Therapy Modality:Automated Peritoneal
Dialysis (APD)
Renal DivisionBaxter Healthcare
2APD
APD – prescription basics
• Automated (cycler) therapy• Flexible prescription volumes
Recommended – (European APD Advanced Club)• 9 hour total therapy time (CCPD, NIPD)• 12-14L. total therapy volume• ‘Wet’ days, i.e. long day dwell of 12-15 hr (Extraneal) • 4-8 nightly cycles, with (optional) 1-2 additional day
exchanges /cycles• Daily therapy, 7 days week• 30 minute – 120 minute dwell times each cycle
(depending on PET result)
3APD
Types of PD
CAPD APD CCPD NIPD OCPD IPD
Continuous Ambulatory PD Ambulatory PD Continuous Cycling PD Nightly Intermittent PD Optimised Continuous PD Intermittent PD
4APD
APD benefitsAPD benefits
1. Optimum dialysis for high transporters, large body surface area, and minimal residual renal function
2. Offers potential for better clearances than in CAPD3. Volumetric control of fill, drain and therapy volume
delivery4. Supine positions at night permit larger fill volumes, a
major determinant of treatment adequacy5. Short dwells may increase ultrafiltration & clearance
5APD
APD benefitsAPD benefits
7. Reduced risk of intra-peritoneal pressure complications:hernias, leak, back pain, reduced appetite
8. Reported lower incidence of peritonitis than CAPD9. Treatment of choice for children – avoids school
interruptions and encourages peer integration (“normality”)
10. Daytime freedom and comfort
6APD
APD benefitsAPD benefits
11. Employment and school uninterrupted
12. Improved patient compliance
13. Increased patient comfort
14. Possible to monitor patient compliance at home
7APD
‘A prescription that is compatible with the patient’s preferences and lifestyle is
likely to reduce the risk of patient « burnout » and noncompliance’
Clinical Practice Guidelines of the Canadian Society of Nephrology for treatments of Patients with CRF JASN 10: S287-S321, 1999
8APD
APD regimens
CCPD “wet day” orlong day dwell
shortday dwell
shortday dwell
Night dwells
Night dwells
OCPD(Optimized Continuous Peritoneal Dialysis)
(long) day dwell
(long) day dwell
day dwell day dwell
(short)day dwell
(short)day dwell
Night dwells
9APD
APD APD Nightly Intermittent PD (NIPD)Nightly Intermittent PD (NIPD)
• APD performed nightly only, with complete fill and drain of the peritoneal cavity
• Most patients cannot be maintained on NIPD alone without diurnal additions
Limitations:1. Not efficient in anuric patients2. Inadequate in large BSA patients (>2m2)3. Inadequate in low – low average Transporters4. High cost may be prohibitive
10APD
APD modalitiesAPD modalities
• Dialysis fill volume is only partly drained, leaving a ‘reserve’ volume in contact with peritoneum
• Tidal fill volume brings fresh fluid to mix with the reserve volume each cycle
• Tidal therapy increases dialysate flow and reduces drain and fill times (therapy rationale)
• Combined with larger fill volumes, it will raise clearances in ‘High’ to ‘High Average’ transporters
• Only option for anephric patient clearance• Less ‘drain-pain’ an added advantage
TIDAL PD
11APD
APD modalitiesAPD modalities
• Nocturnal therapy, with day time long dwell (only realistic if Icodextrin containing solution used for day dwell)
• 5-8 exchanges in relatively short dwell periods, maximising U/F and clearances
• Therapy most used in practice
CCPD – Continuous Cyclic PD
12APD
APD modalitiesAPD modalities
• PD prescribed mainly 2-3 times per week for 12-20 hours each session
• Large volumes (20-40 litres) are cycled each session, short dwells, fill volumes 1.5-3.0 litres
• IPD fails to deliver sufficient quantity dialysis if BSA, RRF
• Mostly used in elderly; acute patients; new catheter conditioning – N.B. no longer a preferred modality for majority of patients
• Only adequate for high transport patients
• Reduced protein losses, glucose absorption and fluid retention
IPD - Intermittent PD
13APD
APD - therapy programming
Inputs required:
Total therapy volume Total therapy time Fill volume Last fill: volume, and same or different dextrose
Machine calculates: Number of cycles Estimated Dwell time per cycle
14APD
Programming the HomeChoice SystemExample therapy:
Total therapy volume = 12000 ml Total therapy time = Nine hours Fill volume = 2000 ml Last bag = 2000 ml, same dextrose
Machine calculates: Number of cycles = 5 cycles Estimated Dwell time per cycle = 1:19
1. HomeChoice assumes 'typical' flow rates to calculate Drain and Fill times. 2. Dwell times are updated throughout the therapy depending on actual time required for Fill and Drain.3. HomeChoice ALWAYS DELIVERS THE MAXIMUM AMOUNT OF DWELL TIME WITHIN THE
PROGRAMMED THERAPY TIME!
15APD
How does it work ?
SETUP of system (example):– A. One 5000ml bag on the heater plate – B. Other bags connected to the HomeChoice set:
Baxter
Press go to start
5 litre
5 2.5
16APD
APD made easier
PD LINKäsoftware
PRO Card
PATIENT’S HOME HOSPITAL
The PRO Card is used to download therapy information from the HomeChoice PRO and is read, at the hospital, using the PD Link software
17APD
How does it work?
1 Write a Prescription
2 Program HomeChoice PRO with Pro Card
4 Retrieve therapy results
5 Analyze therapy results
or
3 HomeChoice PRO records therapy results
18APD
The balance results in Improved Outcomes
Dialysate Clearances Quality of Life
Balancing Clinical and Lifestyle Needs:
Managing Patients on Home Therapies
19APD
1
2
3
Procedural Modifications- to improve UF
I ncreasecycle num ber
Modifyton icity
I ncreasecycler tim e
Considerfi ll vo lum e
Cycler
O ptim izeshort dw ell U F
4
20APD
Procedural Modifications - fill (dwell) volume
21APD
Procedural Modification- no. of exchanges
22APD
Procedural Modifications- partial day fill
23APD
APD - Increasing Clearance
• Programme an increase in fill volume– Effective means of improving clearance– Minimum impact on patient lifestyle– Adjust nighttime exchanges first– Use 2.0L or greater whenever possible
• Add a daytime exchange • Increase Time on Cycler• Increase Number of Nighttime Exchanges
24APD
APD - Increasing Clearance
• Increase fill volumes• Add a daytime exchange
– This is a very effective means of improving clearance
– HomeChoice can be programmed to deliver an exchange at midday
• Increase Time on Cycler• Increase Number of Nighttime Exchanges
25APD
APD - Increasing Clearance
• Increase fill volumes• Add a daytime exchange• Increase Programmed Time on Cycler
– Cycler time can be extended to 10 hours– Increasing cycler time with a constant number of
exchanges increases dwell time which increases clearance
• Increase Number of Night-time Exchanges - May increase clearance, but only if dwell time on cycler is also increased
26APD
The Importance of “Wet Days”
• > 85% of APD patients - all except High Transporters – will require a daytime dwell to achieve adequate dialysis• > High transporters need daytime dwells with Icodextrin to achieve ultrafiltration targets
> 85%
Wet Day Dry Day
0%5%
10%15%20%25%30%35%
Low LowAverage
HighAverage
High
CCPD+CAPD CCPD NIPD
27APD
Fluid Balance - General Guidelines for APD
• Avoidance of long dwells with low glucose• Use of mid-day drain even when no additional exchange is
needed for clearance
• “The most frequently ignored principles in PD that lead to UF difficulties are the need to avoid long glucose dwells in high transporters and balancing glucose concentration and dwell time”
Evaluation and Management of Ultrafiltration problems in PD, ISPD Recommendations, PDI Vol 20, suppl 4, 2000
28APD
Designing the Optimal APD Therapy
Fact: APD utilizes shorter dwell times, relative to CAPD. Therefore, more solution volume is needed to provide adequate clearance
Fiction: More total solution volume will always provide better clearance for APD patients
The Key to success with APD is a balance of:Solution Volume and Dwell Time
Excessive solution volume = too many cycles = wasted time filling and draining = reduced clearances
29APD
CAPD or APD?
CAPD Easy technique Daytime exchanges can
be difficult if working or for carer
Poor UF if high transporter resulting in use of high dextrose fluids
APD More difficult technique No or only 1 daytime
exchange Easier to achieve high
UF independent of transporter status
30APD
CAPD or APD?
CAPD Difficult to adeq by
exchange number or volume
exchange volume intraperitoneal pressure when patient ambulant
risk of herniae and leaks
APD Easy to adequacy by
exchange number overnight
Intraperitoneal pressure lower when patient supine
risk of herniae and leaks
31APD
CAPD or APD?
CAPD Adequacy in low
transporters by 5th exchange - ‘Quantum’ or 1/wk HD
Ease of travel Peritonitis 1/20-24 mths
APD Difficult to achieve
adequacy in low transporters
Can travel with machine or revert to CAPD
Peritonitis 1/30-40 mths