Peritoneal Dialysis Prescription

and Modalities
Maria V. DeVita, M.D.
Associate Director Nephrology Lenox Hill Hospital Clinical
Associate Professor of Medicine NYU School of Medicine
Meghana Gaiki, M.D.
Fellow, Division of Nephrology, Lenox Hill Hospital
Emmanuelle Gilles, M.D.
Fellow, Division of Nephrology, Lenox Hill Hospital
 Goals and Objectives
• Introduction to the different modalities of Peritoneal
Dialysis (PD).
• Clinical implication of Peritoneal Equilibration Test
(PET).
• Chronic Peritoneal Dialysis Prescription.
• Automated versus Ambulatory Peritoneal Dialysis in
terms of –
– Mortality
– Technique survival
– Impact on Residual Renal Function(RRF)
– Volume and blood pressure control
 Continuous Ambulatory
Peritoneal Dialysis
• In 1976, Popovich et al introduced the concept of
continuous ambulatory peritoneal dialysis.
• In 1978, Oreopoulos et al introduced dialysis solutions in
plastic bags and use of a single administration tubing for
one week.
• In 1980, Buoncristiani et al introduced the ‘ Y ‘ set.
• Now, continuous peritoneal dialysis includes continuous
ambulatory and cyclic peritoneal dialysis (CAPD and
CCPD)
CAPD
 Automated Peritoneal Dialysis
Brenner and Rector's The Kidney, 8th edition, 2008

• APD uses a cycler/machine to perform the exchanges.

• For chronic renal failure, APD is traditionally divided into-
• Continuous cycling peritoneal dialysis/CCPD
• Nocturnal intermittent peritoneal dialysis/ NIPD.
• Tidal peritoneal dialysis/ TPD
• Hybrid Systems.
The First Cyclers
The New Cyclers
The New Cyclers
 Modalities of PD
Brenner and Rector's The Kidney, 8th edition, 2008

• Continuous cycled peritoneal dialysis-

3 to 7 cycles of 1.5 to 2.5 L delivered over 9 hours
at nighttime.
Dwell times range from 45 minutes to 3 hours.
Dwell left in at the end of the cycling period and
drained out again before the next cycling
period about 15 hours later.
• Nocturnal intermittent peritoneal
dialysis or day dry APD
– No day dwell because of good residual renal
function or mechanical contraindications.
• High-dose APD or PD plus or APD
with 2 day dwells
– more than one day dwell, requires another
exchange sometime during the day.
• APD with short day dwell-
– leaves some of the day time dry to facilitate
ultrafiltration or for comfort or mechanical
reasons.
• Tidal PD-
– Incomplete drain of a proportion of the
infused fluid before refilling with the next
cycle.
– Used to minimize down time with a poorly
draining catheter or to avoid drain pain.
 Interpretation of the PET test
• High transport implies a structural or
functional alteration of the peritoneum-
– A larger effective peritoneal surface
area
– A higher intrinsic membrane
permeability (for the rapid equilibration
of small solutes including creatinine
and urea).
• High transporters are prone to lose the
osmotic gradient required for sustained
ultrafiltration because of rapid absorption of
glucose from the dialysate.
– Subsequent decrease in ultrafiltration
capacity
– Tendency to have greater systemic
exposure to glucose than low
transporters do.
 Clinical implications of
transporter type
• High transporters tend to have problems
achieving ultrafiltration goals but are efficient
with clearance.
• Low transporters tend to achieve ultrafiltration
goals but have difficulty with clearance targets.
• Traditionally, high transporters were thought to
do best on regimens that involve frequent short
duration dwells (APD) maximizing ultrafiltration,
and low transporters needed longer dwell times
(CAPD) to maximize clearances.
 Typical PD Regimens Required to Achieve Adequate Solute Clearances

Peritoneal Solute Transport Characteristics‐D/P Creatinine at 4 Hours

Patient
Body
Surface Area Low Low Average High Average High
(m2) (<0.5) (0.5 to <0.65) (0.65‐0.82) (>0.83)

CAPD/APD CAPD/APD+ APD+* APD*

<1.7 10‐12.5 liters 10‐12.5 liters 10‐12.5 liters 10‐12.5 liters

CAPD+/APD APD+ APD+* APD+*

1.7‐2.0 12.5‐15 liters 12.5‐15 liters 12.5‐15 liters 12.5‐15 liters

APD+ APD+* APD+*

>2.0 CAPD+,HD 15‐20 liters 15‐20 liters 15‐20 liters

Adapted From Comprehensive Clinical Nephrology- John Feehally, Jurgen Floege, Richard
J. Johnson, 3rd edition, 2007.
+ an additional exchange , * use of icodextrin solution .
Peritoneal Dialysis Prescription
Handbook of Dialysis, fourth edition, 2006, John T. Daugirdas, Peter G. Blake, Todd S. Ing

 Clearance Targets-
A consensus target Kt/V for all modalities of PD is 1.7 per week. KDOQI guidelines
suggest that peritoneal and renal Kt/V can be added to achieve the target.
Greater residual renal function has repeatedly been shown to be associated with
superior survival.
 Incremental versus maximal prescription-
 In the incremental approach PD is used to make up the differences between
residual renal clearance and targeted clearances.
 In the maximal approach a sufficient prescription of PD is given to meet their
targets with PD alone.
 Empirical versus Modeled approach-
 With the empirical approach a reasonable prescription is chosen and
prescription is adjusted to achieve clearance targets.
 The computer program uses anthropometric data, results of PET test and
RRF to predict clearances achieved with various prescriptions.
 Factors determining clearance in peritoneal
dialysis patients
Handbook of Dialysis, fourth edition, 2006, John T. Daugirdas, Peter G. Blake, Todd S. Ing

• Nonprescription factors-
– Residual renal function
– Body size
– Peritoneal transport characteristics
 Prescription factors-
 CAPD- frequency of exchanges, dwell volumes,
tonicity of dialysis solution.
 APD- Number of day dwells, volume of day dwells,
tonicity of day dwells, time on cycler, cycle frequency,
cycler dwell volumes and tonicity of cycler solution.
 Typical CAPD Prescription
Handbook of Dialysis, fourth edition, 2006, John T. Daugirdas, Peter G. Blake, Todd S. Ing

1) Dwell Volumes and Frequency of daily exchanges

4 ( number of exchanges) x 2L ( dwell volumes) is the typical
prescription.
4 x 2.5L in larger patients with small RRF or anuric patients who
weigh >75 kg.
3 x 2L in smaller patients or in patients with good RRF.
Problems of increasing dwell volumes- back pain, abdominal
distension and even shortness of breath.
Increasing frequency of dwells is less effective than increased
volumes for improvement of creatinine clearance as equilibration
curve for creatinine is rising 4 hours after the dwell. It is also more
expensive and may interfere with patient’s lifestyle.
2) Increasing tonicity of dialysis solution increases both ultrafiltration
and clearance but may lead to hyperglycemia, hyperlipidemia, obesity
and long term peritoneal membrane damage.
 Typical APD Prescription
Handbook of Dialysis, fourth edition, 2006, John T. Daugirdas, Peter G. Blake, Todd S. Ing

• Number of day dwells- Can start with NIPD if patient has good residual
volume. Adding a day dwell increases Kt/V by 25%. In high transporters a
long day dwell can result in net fluid absorption. This can be countered by
shortening the day dwell.
• Tonicity of day dwells- Net fluid absorption occurring in day dwells can be
countered by using icodextrin dialysis solutions.
• Time on cycler – 8 to 10 hrs. The longer the time the patient spends on
the cycler the better the clearance.
• Cycle frequency- 3 to 5 cycles per 9 hour cycling session. Each cycle
lasting 1.5 to 3 hrs. More frequent cycles increases clearance, but a greater
proportion of the time is spent draining and filling. Some dialysis time is lost.
• Cycler dwell volumes - 2 to 2.5 L. As patients are supine in APD they can
tolerate larger dwell volumes more easily. A typical starting volume is 10 to
15 l depending on the patient size.
• Tonicity of cycler solution- As with CAPD increasing tonicity increases
ultrafiltration , but the same concerns about glucose related complications
arise.
 Factors taken into account before
choosing PD modality
In the past Current thinking
• Long term outcomes • Patient preference.
– Technique failure • Transporter status?
– Mortality
– Volume and BP Control
• Residual Renal Function.
• Risk of peritonitis.
• Transporter Status.
• Patient preference.
 Increasing use of APD
Mehrotra et al, Kidney Int 2009; 76,97-
76,97-107

• In the 1980s and early 1990s APD was largely used to

optimize volume status in high average and high
transporters.
• With the advent of smaller, portable machines; APD use
has increased due to physician and patient choice,
irrespective of the transport type.
• Percentage of patients on PD using APD in different
countries-
– 59%: US ( 2007)
– 60%: Belgium, Denmark and Finland 60%
– 42%: Australia and New Zealand.
 CAPD versus APD
Mehrotra et al, Kidney Int 2009; 76,97-
76,97-107

• Since 1996, the 1 year mortality outcomes have improved for PD but
remained the same for maintenance HD.
• Reasons
– Decrease in infectious complications.
– Publication of clinical practice guidelines that may improve
prescription management.
– Increased use of APD- Lower rates of peritonitis with APD.

• APD also associated with-

– Lower daily sodium removal. (worse volume and BP control )
– Rapid loss of residual renal function.
– Higher protein losses with multiple night time exchanges.
– More expensive
 CAPD versus APD
Mehrotra et al, Kidney Int 2009:76,97-
2009:76,97-107

• These differences highlight the need to compare

outcomes of CAPD and APD.
• Data from USRDS on 66,381 incident patients
on chronic PD from 1996 to 2004 was used.
• The risk of death and technique failure between
the two modalities was compared.
• Also wanted to study the impact of APD on the
improved outcomes in PD.
• The adjusted median life expectancy improved
by approximately 8 years from 1996–1998 to
1999-2001, irrespective of the modality of PD.
 The outcomes of continuous ambulatory and
automated peritoneal dialysis are similar
Mehrotra et al, Kidney Int 2009; 76,97-
76,97-107

There were no significant differences There were no significant

in adjusted mortality rates in patients differences in either time dependent
treated with CAPD or APD for virtually or overall relative risk for technique
all the time periods examined failure between CAPD and APD
patients
 Conclusions
• There have been substantial reductions in the
adjusted risk for death and technique failure
among incident PD patients since 1996.
• The outcomes of CAPD and APD patients are
remarkably similar and the improvement in PD
outcomes cannot be attributed to a greater use
of APD.
• Centers with a higher PD utilization had a
significantly lower risk of technique failure and
marginally lower risk of death.
 NECOSAD
Study Group
Michels WM et al
Clin J Am Soc Nephrol 2009; 4: 943-
943-949

Netherlands Cooperative Study

on the Adequacy of Dialysis.
 Prospective, Multicenter cohort
of ESRD patients (562 on CAPD
and 87 on APD)
Patient preference main reason
to be on APD.
No short-term or long term effect
of PD modality on overall mortality
or technique failure
Findings similar to the ANZDATA
registry.
Two large observational studies
showed survival benefit with APD.
The choice to start APD versus
CAPD should be based on factors
such as quality of life, partner’s
preference or available resources.
 Sodium Removal in Patients Undergoing
CAPD and APD
Rodriguez-
Rodriguez-Carmona A et al, Perit Dial Int 2002; 22:705–
22:705–713

• Study in three steps. Cross-sectional observational (Study A), and longitudinal

interventional (Studies B and C).
– Study A was a cross-sectional survey of Na removal in 63 patients on CAPD and
78 patients on APD.
– Study B- studied Na removal in 32 patients before and after changing from
CAPD to APD therapy.
– Study C analyzed the impact on Na removal of introducing icodextrin for the long
dwell in 16 patients undergoing CAPD or APD.
• Standard APD schedules are frequently associated with poor Na removal rates.
• For any degree of ultrafiltration, Na removal is better in CAPD than in APD.
• Icodextrin, supplementary diurnal exchanges, and longer nocturnal dwell times
improve Na removal in APD.
• Patients on APD may have more frequent hypertension because of lower sodium
removal.
– Sodium sieving in the short duration dwells of APD.
– Less ultrafiltration in the long duration day dwells.
 Blood Pressure, Volume and Sodium Control in an
Automated Peritoneal Dialysis Population.
Boudville NC et al, Perit Dial Int 2007; 27:537–
27:537–543
• An observational cross-sectional study with 56 APD patients using
icodextrin assessed sodium removal with APD and its association with BP
and volume control.

• Mean total sodium removal was 102.9 ± 64.6 mmol/day. 68% had a sodium
removal of >120 mmol/day.

• Total sodium removal correlated with total body water (TBW), extracellular
water (ECW) and intracellular water (ICW).
• No significant correlation was found between sodium removal and the
ECW/ICW ratio in those with sodium removal ≤120 mmol/day compared to
those with sodium removal>120 mmol/day.

• Mean SBP 111.9 ± 18.2 mmHg and mean DBP 63.3 ±11.9 mmHg. Only 4
(7%) patients had SBP >140 mmHg and only 1 (2%) had DBP >90 mmHg.
• Blood pressure control was similar in the group of patients with sodium
removal ≤120 mmol/day compared to those with >120 mmol/day.
 Impact of PD modality on residual renal function
Long term outcomes in automated peritoneal dialysis: Similar or better than in
continuous ambulatory peritoneal dialysis?
Mehrotra R, Perit Dial Int 2009; 29(S2):111-
29(S2):111-114

• Faster decline of RRF in APD patients : four

single-center observational studies (103 CAPD
and 108 APD subjects in total)
• Numerous other studies have been unable to
demonstrate a more rapid loss of RRF in APD
patients (1141 CAPD and 484 APD subjects
total). Three of those studies were large
multicenter trials.
• There is probably no difference in the rate of
loss of RRF between CAPD and APD
patients.
 Predictors of Loss of Residual Renal Function among
New Dialysis Patients
Moist LM,
LM, J Am Soc Nephrol 2000; 11:556-
11:556-564

• The Dialysis Morbidity and Mortality Study (DMMS) is a U.S. Renal

Data System (USRDS) special study, including more than 20,000
randomly selected dialysis patients. ( HD and PD)
• The study included 33 baseline variables for evaluation as possible
independent predictors of residual renal function.
• Loss of residual renal function was defined as an estimated urine
output <200 ml/24h at the time of follow-up (8 to 18 mo from
initiation of dialysis).
• Patients receiving treatment with PD had a reduced risk of RRF loss
when compared to HD-treated patients
• Factors associated with increased loss of RRF on PD-
– Increasing duration of time on PD, higher eGFR at time of
initiation of PD, female gender, Non-white race , presence of DM
and CHF were all associated with loss of residual renal function.
• Lower risk of loss of RRF among ESRD patients on PD being
treated with ACE inhibitors and/or calcium channel blockers.
• No significant difference in loss of RRF by PD modality type
 Impact of PD modality on Peritonitis rates
Long term outcomes in automated peritoneal dialysis: Similar or better than in continuous ambulatory peritoneal dialysis? Perit Dial Int
29(Supplement 2): 111-114 2009

• Single center nonrandomized observational studies

showed that APD patients had significantly lower peritonitis
rates than CAPD patients did .
• In a recent meta-analysis of data from two randomized
controlled trials APD patients had a 46% lower peritonitis
rate compared to CAPD.
• Data seems to suggest that APD patients may experience
lower peritonitis rates than CAPD patients do.
• Use of connection-assist devices to spike the cycler bags is
probably important to maintain this advantage in favor of
APD.
• Use of CAPD twin-bag systems and of exit-site antibiotic
prophylaxis are far more important in lowering peritonitis
rates in a PD program than is a greater use of APD.
 PD modality and Technique Success
Mehrotra,
Mehrotra, Perit Dial Int 2009; 29(S2):111-
29(S2):111-114

• "Technique success" is defined as the proportion of patients who did not

need to transfer to HD.

• Two randomized controlled clinical trials – underpowered.

• Three observational studies-

– Two of these (one each from the United States and Mexico) have shown better
technique success with APD.
– The ANZDATA registry (Australia and New Zealand) was unable to demonstrate
any difference in technique success.

• In the largest study with 40,869 patients , APD had a lower incidence of
transfer to maintenance hemodialysis for a variety of reasons:
– A lower chance of transfer secondary to infection
– Catheter problem
– Adequacy considerations
– Other medical reasons
– Psychosocial causes However,
– The advantage of higher technique success with APD was limited to the
first year of therapy
 Meta-Analysis: Peritoneal Membrane Transport, Mortality, and
Technique Failure in Peritoneal Dialysis
Brimble et al, J Am Soc Nephrol 2006 ;(17): 2591-2598.

Increasing peritoneal membrane solute transport Use of CCPD seemed to offset some
rate was associated with an increasing risk for
mortality with a trend to increased technique of this negative effect on mortality.
failure.
Peritoneal Protein
Clearance and not
Peritoneal Membrane
Transport Status Predicts
Survival
A prospective, single-center cohort
study by Perl J et al in 192 PD
patients suggested that increased
peritoneal protein clearance (Pcl) at
the start of PD therapy, age and
comorbidity grade were predictors
of death, independent of baseline
small solute transport status.

Patients with baseline Pcl values

were included in the study
( 192 /341).They had higher
baseline small solute clearance and
greater initial use of APD.

Even after inclusion of all 341

patients, transport status (D/Pcr)
did not remain a predictor of
survival on unadjusted analysis.

Perl J et al. CJASN 2009;4:1201-1206

 Problems Faced by High Transporters
Kam-Tao LI P et al, Perit Dial Int 2007; 27(S2): 148-
148-152

• Ultra-Filtration problems
• Hypoalbuminemia
• Rapid satiety
• Marker for inflammation
– Canusa Study
• The relative risk of technique failure or death for high vs. low
transporters was 4.
– ANZDATA Registry subanalysis
• High transport status is independently predictive of death-censored
technique failure for patients on CAPD, but not for those on APD.
– Meta-Analysis of 19 studies
• High transporters were estimated to have a 77% higher risk for
mortality after adjusting for age, diabetes & albumin.
 Modeling Prescription for High Transport Status
MAXIMIZING THE SUCCESS OF PERITONEAL DIALYSIS IN HIGH TRANSPORTERS TRANSPORTERS
Philip Kam-
Kam-Tao Li and Kai Ming Chow , Perit Dial Int 2007:27(S2): 148-
148-152

• Frequent, Shorter dwell times- APD

– The osmotic gradient is dissipated after excessive
dwell time. Short dwell times as used in APD
maximize small solute clearance and net
ultrafiltration.
– Use of short-dwell therapy at night or NIPD keeps a
dry abdomen during the day thus minimizing protein
losses not attributable to glucose absorption.
• Use of icodextrin-containing PD solution to achieve
volume control in high transporters.
• The association of survival disadvantage and high
transport status is confined to patients on CAPD and
does not appear to affect those on APD.
Automated Peritoneal Dialysis: A spanish
Multicenter Study
Rodriguez A, Nephrol Dial transplant 1998; 13:2335-
13:2335-2340
 Patient Preference
QUALITY OF LIFE IN AUTOMATED AND CONTINUOUS AMBULATORY PERITONEAL DIALYSIS. Michels et al.
Perit Dial Int. 2011 Mar;31(2):138-147

• Advantages of CAPD
– Cheaper
– Freedom from machine
– Easier to be trained.
• Advantages of APD
– More time available for work, family and social activities as most
of the fluid exchanges are at night.

• In a recent study, Michels et al used the prospective cohort of the

Netherlands Cooperative Study on the Adequacy of Dialysis
(NECOSAD) and showed no differences in quality of life between
patients starting on CAPD versus APD.
 Summary
• Thus all evidence so far seems to suggest that the choice of the
initial PD modality should be based on patient preference, as
neither modality has any advantage over the other in terms of
survival advantage, preserving renal function, technique success,
risk of peritonitis or blood pressure control.
• APD is associated with lower risk of transfer to maintainence
hemodialysis early during the course of renal replacement.
• There is data suggesting that APD may have a survival advantage
over CAPD in high transporters, but newer data suggests that the
peritoneal protein clearance and not the peritoneal membrane
transport status may predict survival outcomes.
• Choice of PD modality should mainly be based on Patient
preferences.
 Additional References
Brenner and Rector's The Kidney, 8th ed.
Comprehensive Clinical Nephrology- John Feehally, Jurgen Floege, Richard J.
Johnson,
3rd edition, 2007.
Burkart JM Effect of peritoneal dialysis prescription and peritoneal membrane
transport characteristics on nutritional status, Perit. Dial. Int. 1995;
15(S5):S20-35
Churchill DN, Thorpe KE, Nolph KD, Keshaviah PF, Oreopoulos DG, Pagé D,
Increased peritoneal membrane transport is associated with decreased
patient and technique survival for continuous peritoneal dialysis patients.
(CANUSA); J Am Soc Nephrol 1998; 9 :1285-92.
Badve SV, Hawley CM, Mcdonald SP, Mudge DW, et al, for The ANZDATA
Registry PD Working Group. Automated and continuous ambulatory
peritoneal dialysis have similar outcomes Kidney Int 2008; 73:480-488
Google.com-images
 Question 1
• A 44yo African-American woman has CKD-stage 5 due to
hypertension and diabetes mellitus. She is on a kidney transplant
list, but has no living donor. She has decided to proceed with
peritoneal dialysis but is concerned for her overall health and well-
being. She wants to know if it is better to proceed with CAPD or
APD. You advise her that:

• A. Patients who undergo CAPD are at a higher risk for death and
technique failure than APD patients
• B. Patients who undergo CAPD are at a lower risk for death and
technique failure than APD patients.
• C. Both CAPD and APD patients have a high risk for technique
failure and transfer to hemodialysis.
• D. There is no difference in risk of death or technique failure in
CAPD patients when compared to APD patients.
 Correct Answer: D

Shown in Mehrotra et al. KI 2009 (slides

20 and 21) When analysis subdivided into
earlier and more recent cohorts, no
differences were found between the 2 PD
techniques.
 Question 2
• In the above patient, factors that will
increase her rate of loss of residual renal
function include all but:

• A. Gender
• B. Ethnicity
• C. Use of PD instead of HD
• D. Use of APD instead of CAPD
 Correct Answer: C
Factors associated with an increased loss
of residual renal function include female
gender, non-white, history of diabetes,
history of CHF. There is no effect of PD
modality on rate of loss of residual renal
function (e.g. CAPD and APD are equal).
Patients on PD have a slower rate of
change in RRF.