• Optimising small solute clearances in peritoneal dialysis. Nephrology 2005 Oct;10(S4):S95-103.



• Optimising small solute clearances in peritoneal dialysis. Westmead NSW (Australia): CARI - Caring for Australasians with Renal Impairment; 2004 Dec. 22 p. [40 references]

This is the current release of the guideline.

Definitions for the levels of evidence (I–IV) can be found at the end of the "Major Recommendations" field.

Guidelines

1. Aim to maintain residual renal function (RRF). Consider the use of ace inhibitors (Level II evidence) to preserve residual renal function and avoidance of nephrotoxins.
2. With automated peritoneal dialysis (APD), consider the use of icodextrin for the long dwell. (Level II evidence)

Suggestions for Clinical Care

(Suggestions are based on Level III and IV sources)

• Aim to maintain RRF. It is a significant contributor to dialysis adequacy. (Level III evidence) Increasing clearance by an increase in peritoneal clearance cannot make up for loss of RRF. (Level III evidence)
• In general, increasing the dialysis volume or increasing the number of daily exchanges will increase the prescribed dialysis dose. The use of APD has not yet been shown to offer a clear advantage in small solute clearances. (Level III evidence)
• Peritoneal dialysis (PD) prescribing should be individualised to the patient, taking into account their body size, peritoneal transport status, RRF and personal preferences. (Levels III and IV evidence)

Optimising Small Solute Clearances

• Increasing the fill volume, the number of exchanges or the amount of ultrafiltration should increase clearances in most patients. Some patient populations may not tolerate increasing dwell volumes in continuous ambulatory peritoneal dialysis (CAPD), especially small patients. Even larger patients often cannot achieve targets set despite the increase in dialysis dose on CAPD. Use of APD should be considered in this group.
• Individualised PD prescriptions are essential, taking into account:
  • Peritoneal transport
  • RRF
  • Body surface area
• Aim to provide the most dialysis possible to a patient given the constraints of lifestyle and quality of life, cost and clinical setting.
• Aim to preserve RRF.
• An increase in peritoneal clearance will be needed as RRF diminishes. Adequate PD should be achievable in nearly all patients, even low-low average transporters as long as they retain some RRF.
• APD patients generally require wet days except some with high transport properties or considerable RRF.
• Low-low average transport patients generally achieve better clearances with continuous regimens such as continuous ambulatory peritoneal dialysis (CAPD) and continuous cyclic peritoneal dialysis (CCPD) whereas high-high average transport patients achieve better small solute clearances with short dwell techniques such as nocturnal peritoneal dialysis (NPD), and nocturnal tidal peritoneal dialysis (NTPD).
• Use of icodextrin will usually increase ultrafiltration and therefore solute removal and should be considered for the long daily dwell.
• Soon after each prescription change, total (renal and peritoneal) clearances should be measured.

Definitions:

Levels of Evidence

Level I: Evidence obtained from a systematic review of all relevant randomized controlled trials (RCTs)

Level II: Evidence obtained from at least one properly designed RCT

Level III: Evidence obtained from well-designed pseudo-randomized controlled trials (alternate allocation or some other method); comparative studies with concurrent controls and allocation not randomized, cohort studies, case-control studies, interrupted time series with a control group; comparative studies with historical control, two or more single arm studies, interrupted time series without a parallel control group

Level IV: Evidence obtained from case series, either post-test or pretest/post-test

None provided

The type of supporting evidence is identified and graded for each recommendation (see "Major Recommendations").

• Optimising small solute clearances in peritoneal dialysis. Nephrology 2005 Oct;10(S4):S95-103.



• Optimising small solute clearances in peritoneal dialysis. Westmead NSW (Australia): CARI - Caring for Australasians with Renal Impairment; 2004 Dec. 22 p. [40 references]

Not applicable: The guideline was not adapted from another source.

2005 Oct

Caring for Australasians with Renal Impairment - Disease Specific Society

Industry-sponsored funding administered through Kidney Health Australia

Not stated

Authors: David Harris, Convenor (Westmead, New South Wales); Merlin Thomas (Prahran, Victoria); David Johnson (Woolloongabba, Queensland); Kathy Nicholls (Parkville, Victoria); Adrian Gillin (Camperdown, New South Wales)

All guideline writers are required to fill out a declaration of conflict of interest.

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI Institute on April 22, 2008.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.