腹膜透析充分性的国际指南解读.ppt

腹膜透析充分性的国际指南ShijunbaoShijunbao腹膜透析充分性的国际指南ISPDGUIDELINE ON TARGETS FOR SOLUTE AND FLUID REMOVAL IN ADULT PATIENTS ON CHRONIC PERITONEAL DIALYSISKDOQICLINICAL PRACTICE GUIDELINES AND CLINICAL PRACTICE RECOMMENDATIONS 2006 UPDATESERA-EDTAEUROPEAN BEST PRACTICE GUIDELINES FOR PERITONEAL DIALYSISGUIDELINE ON TARGETS FOR SOLUTE AND FLUID REMOVAL IN ADULT PATIENTS ON CHRONIC PERITONEAL DIALYSISISPD GUIDELINES/RECOMMENDATIONSRECOMMENDATIONS 1Adequacy of dialysis should be interpreted clinicallyrather than by targeting only solute and fluid removal.Clinical AssessmentClinical and laboratory resultsPeritoneal and renal clearancesHydration statusAppetite and nutritional statusEnergy levelHemoglobin concentrationResponsiveness to erythropoietin therapyElectrolytes and acidbase balanceCalcium phosphate homeostasisBlood pressure controlRECOMMENDATIONS 2In order to emphasize that there is more to adequate dialysis than a focus on small solute kinetics and ultrafiltration targets,the Committee decided to name this guidelineGuideline on Targets for Solute and Fluid Removal in Adult Patients on Chronic Peritoneal Dialysis instead of Guideline on Adequacy of Peritoneal Dialysis.RECOMMENDATIONS 3For small solute removal,the total(renal+peritoneal)Kt/V urea should not be less than 1.7 at any time(Evidence level A).That means,in anuric patients,peritoneal Kt/V urea has to be above 1.7.RECOMMENDATIONS 3In the presence of residual renal function,the contributions of renal and peritoneal clearances may be added for practical purposes,although,as mentioned previously,renal and peritoneal clearances may not be truly additive(Opinion).Solute removal above this level should not be equated with“adequate dialysis.”RECOMMENDATIONS 3Knowledge of the transport characteristics of the patients peritoneal membrane by peritoneal equilibration test or other testsmay help to optimize the prescription to meet this target.RECOMMENDATIONS 4A separate target for creatinine clearance is not required in CAPD.In APD,due to a more variable relationship between urea and creatinine clearancean additional target of 45 L/week/1.73 m2 for creatinine clearance is recommended(Evidence level C).RECOMMENDATIONS 5For patients who rely significantly on residual renal function to achieve the minimal target level of small solute clearance,residual renal function should be monitored regularly and at an appropriate frequencyso that the PD prescription can be adjusted in a timely manner(Evidence level C).Every 1 2 months if practicable,otherwise no less frequently than every 4 6 months RECOMMENDATIONS 5If there is a decrease in urine volume or a change in blood chemistries suggesting a decline in residual renal function,it should be measured sooner.RECOMMENDATIONS 6A continuous around-the-clock PD regime is preferred to an intermittent schedule whenever possible(Evidence level B)RECOMMENDATIONS 7Attention should be paid to both urine volume and the amount of ultrafiltration,with the goal of maintaining euvolemia.RECOMMENDATIONS 7A small ultrafiltered volume despite the use of dialysis solutions with a high glucose concentration should be regarded as a warning sign for the presence of ultrafiltration failure.This should be investigated further with a peritoneal equilibration test according to the ISPD recommendations on evaluation and management of ultrafiltration problems(Evidence level B).RECOMMENDATIONS 8For patients with signs and symptoms suggestive of underdialysis,a trial of increasing dialysis should be provided even if Kt/V urea is well above the minimal target(Evidence level C).RECOMMENDATIONS 9The benefit of increasing the amount of peritoneal dialysate(either number of exchanges or volume of each exchange),or change to hemodialysis,when these targets cannot be met should be balanced againstThe potential side effectsEffects on the patients lifestyle Cost consideration(Evidence level C).Peritoneal Dialysis AdequacyClinical Practice Guidelines and Clinical Practice Recommendations2006 UpdatesPERITONEAL DIALYSIS SOLUTE CLEARANCE TARGETS AND MEASUREMENTSGUIDELINE 2.GUIDELINE 2.Data from RCTs suggested that the minimally acceptable small-solute clearance for PD is less than the prior recommended level of a weekly Kt/Vurea of 2.0.Furthermore,increasing evidence indicates the importance of RKF as opposed to peritoneal small-solute clearance with respect to predicting patient survival.Therefore,prior targets have been revised as indicated next.GUIDELINE 2.2.1 For patients with RKF(considered to be significant when urine volume is 100 mL/d):2.1.1 The minimal“delivered”dose of total small-solute clearance should be a total(peritoneal and kidney)Kt/Vurea of at least 1.7 per week.(B)GUIDELINE 2.2.1 For patients with RKF(considered to be significant when urine volume is 100 mL/d):2.1.2 Total solute clearance(residual kidney and peritoneal,in terms of Kt/Vurea)should be measured within the first month after initiating dialysis therapy and at least once every 4 months there