• 1.

    Mehrotra R, et al. The current state of peritoneal dialysis. J Am Soc Nephrol 2016; 27:32383252. doi: 10.1681/ASN.2016010112

  • 2.

    Michels WM, et al. Similar survival on automated peritoneal dialysis and continuous ambulatory peritoneal dialysis in a large prospective cohort. Clin J Am Soc Nephrol 2009; 4:943949. doi: 10.2215/CJN.04440908

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3.

    Shah A, Dave N. History of adequacy trials in perito-neal dialysis. ASN Kidney News 2020; 12:1617. https://www.kidneynews.org/view/journals/kidney-news/12/7/article-p16_10.xml?rskey=u49qNM&result=6&tab_body=fulltext

    • Search Google Scholar
    • Export Citation
  • 4.

    NKF-DOQI clinical practice guidelines for perito-neal dialysis adequacy. National Kidney Foundation. Am J Kidney Dis 1997; 30 (3 Suppl 2):S67S136. doi: 10.1016/s0272-6386(97)70028-3

    • Search Google Scholar
    • Export Citation
  • 5.

    Daugirdas JT, et al. Handbook of Dialysis. Lippincott Williams (Baltimore, MD), 2015.

  • 6.

    Teitelbaum I. Crafting the prescription for patients starting peritoneal dialysis. Clin J Am Soc Nephrol 2018; 13:483485. doi: 10.2215/CJN.10770917

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    • Search Google Scholar
    • Export Citation

A Practical Patient-Centric Approach to the Peritoneal Dialysis Prescription

  • 1 Sehrish Ali, DO, is an assistant professor of medicine at Baylor College of Medicine in Houston, TX. Natasha Dave, MD, is a nephrologist at the Bruce W. Carter VA Medical Center in Miami, FL. Ankur Shah, MD, is an assistant professor of medicine at Warren Alpert Medical School at Brown University in Providence, RI.
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Once the decision to pursue peritoneal dialysis (PD) is made, two primary modalities are available from which patients can choose: continuous ambulatory PD (CAPD) and ambulatory PD (APD). CAPD involves manually performed exchanges using gravity to fill and drain the peritoneal cavity, and APD involves exchanges that are performed using a cycler over several hours, typically during the night. The selection of a PD modality is dependent on an individual's lifestyle because there is no difference in patient and technique survival (1).

Subtypes of APD include continuous cycling PD (CCPD), nightly intermittent PD (NIPD), and tidal PD (TPD) (2). CCPD consists of overnight exchanges with a day dwell, and NIPD encompasses only overnight exchanges without a day dwell. TPD is an alternative form of APD in which the peritoneum is not completely drained between exchanges (Figure 1).

Figure 1.
Figure 1.

Overview of PD modality types

Citation: Kidney News 13, 5

We use the following approach to determine modality and initial prescription. We begin with an assessment of the patient's lifestyle. Given that CCPD is a predominantly nocturnal therapy, a detailed sleep history is critical. This should include the average times when the patient goes to bed, falls asleep, and wakes up. This history can help determine the total amount of time available for cycler-assisted dialysis. In patients who report shorter sleep periods, the history is expanded to include activities immediately before and after bedtime, because some may be amenable to being performed during cycler-assisted dialysis. After understanding the patient's sleep schedule, the nephrologist and patient can work together to determine whether it would be feasible to perform exchanges during the day. This typically depends on the employment status, field, and lifestyle of the patient. The adept nephrologist will develop a prescription that works around the patient's lifestyle, allowing the patient to maintain a maximal quality of life. For example, a patient may report sleeping only 6.5 hours per night, but further history taking reveals that the patient reads for 1 hour before falling asleep and has a sleep latency of 30 minutes. This patient could reasonably receive 8 hours of cycler-assisted dialysis overnight. Volumes are titrated to tolerance, and dwell time typically targets 2 hours per exchange, which can be adjusted when transport status is determined by peritoneal equilibrium testing. Patients who are rapid transporters will benefit from shortened exchanges and slow transporters from longer exchanges (Figure 2).

Figure 2.
Figure 2.

Chronology for determining the peritoneal dialysis prescription

Citation: Kidney News 13, 5

Example prescriptions

  • 32-year-old, 104-kg man, rapid transporter, works 9 to 5, sleeps 10 to 7; CCPD with four cycles over 9 hours of 3 L with a 2-L last fill

  • 58-year-old, 78-kg woman, slow transporter, works from home, sleeps 9 to 7; CAPD with four manual exchanges of 2 L daily, scheduled at 8 am, noon, 4 pm, and 8 pm

  • 36-year-old, 74-kg woman, slow transporter, works an office job, sleeps 10 to 6; CCPD with two exchanges over 8 hours of 2 L, last fill of 2 L, and midday exchange when home from work

  • 46-year-old, 66-kg man, rapid transporter, works service job with variable hours, sleeps 11 to 6; CCPD with four cycles over 7 hours of 2 L with a 1.5-L icodextrin last fill.

We determine dialysis adequacy by using a holistic approach, including assessment of volume status, nutrition, electrolyte derangements, uremic symptoms, burden of therapy, and small solute clearance, as recommended by the 2020 International Society for Peritoneal Dialysis guideline. The evidence supporting this recommendation was reviewed in a prior Kidney News article (3). However, the Centers for Medicare & Medicaid Services quality metrics in the United States require that combined peritoneal and residual kidney Kt/V urea (whereby K is the clearance, t is time on dialysis, and V is the volume of distribution of urea) in PD patients be >1.7. If the prescription is deemed inadequate, then the prescription is adjusted to increase clearance, either by increasing dialysate fluid quantity or time or by adding an exchange (4).

Regardless of modality, dialysate composition in the United States is dextrose based and typically includes a sodium concentration of 132 mM, potassium 0 mEq/L, calcium 2.5 to 3.5 mEq/L, magnesium 0.25 to 0.75 mM, and lactate 35 to 40 mM. The dextrose concentrations available include 1.5, 2.5, and 4.25 g/dL (5). The tonicity of the dialysate may be increased to improve ultrafiltration and clearance. Attention should be given to uncontrolled hyperglycemia and hyperlipidemia and changes in peritoneal membrane function. Icodextrin, a branched glucose polymer derived from maltodextrin with minimal absorption that functions through colloid osmosis rather than crystalloid osmosis, may be used for the day dwell to improve ultrafiltration without worsening the hyperglycemia and limiting peritoneal absorption.

Writing a prescription requires a good foundation of knowledge of PD modalities and comprehension of your patient's daily life and transporter status. Understanding the patient's sleep patterns, lifestyle, occupation, and preferences for PD modality type will help in writing the appropriate prescription (6). Thankfully, prescriptions can be adjusted, and modalities can be switched if necessary. It is important to approach PD in a holistic fashion to ensure that dialysis is adequate and quality of life is upheld.

This article is part of a series about peritoneal dialysis. Additional articles will appear in upcoming issues.

References

  • 1.

    Mehrotra R, et al. The current state of peritoneal dialysis. J Am Soc Nephrol 2016; 27:32383252. doi: 10.1681/ASN.2016010112

  • 2.

    Michels WM, et al. Similar survival on automated peritoneal dialysis and continuous ambulatory peritoneal dialysis in a large prospective cohort. Clin J Am Soc Nephrol 2009; 4:943949. doi: 10.2215/CJN.04440908

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 3.

    Shah A, Dave N. History of adequacy trials in perito-neal dialysis. ASN Kidney News 2020; 12:1617. https://www.kidneynews.org/view/journals/kidney-news/12/7/article-p16_10.xml?rskey=u49qNM&result=6&tab_body=fulltext

    • Search Google Scholar
    • Export Citation
  • 4.

    NKF-DOQI clinical practice guidelines for perito-neal dialysis adequacy. National Kidney Foundation. Am J Kidney Dis 1997; 30 (3 Suppl 2):S67S136. doi: 10.1016/s0272-6386(97)70028-3

    • Search Google Scholar
    • Export Citation
  • 5.

    Daugirdas JT, et al. Handbook of Dialysis. Lippincott Williams (Baltimore, MD), 2015.

  • 6.

    Teitelbaum I. Crafting the prescription for patients starting peritoneal dialysis. Clin J Am Soc Nephrol 2018; 13:483485. doi: 10.2215/CJN.10770917

    • Crossref
    • Search Google Scholar
    • Export Citation
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