• Johnson D, Brown F, Lammi H, Walker R. Small solute clearance targets in peritoneal dialysis. Nephrology 2005 Oct;10(S4):81-5.



• Johnson D, Brown F, Lammi H, Walker R. Small solute clearance targets in peritoneal dialysis. Westmead NSW (Australia): CARI - Caring for Australasians with Renal Impairment; 2005 Jul. 13 p. [29 references]

This is the current release of the guideline.

End-stage kidney disease (ESKD)

Evaluation
Management
Treatment

Nephrology
Nursing

Allied Health Personnel
Nurses
Physicians

To review the available evidence for benefit of maintaining small solute clearance targets in peritoneal dialysis

Patients with end-stage kidney disease (ESKD) on continuous ambulatory peritoneal dialysis and automated peritoneal dialysis

Evaluation

1. Kt/V target
2. Minimum weekly corrected creatinine clearance (C_cr) targets
3. Small solute clearance
4. Residual renal function
   • Fluid status: total body water
   • Nutritional status
   • Tolerance of dialysis prescription
5. Physical measurements
   • Body mass index (BMI)
6. Clinical assessment of wellbeing and impact on patient's life

Management/Treatment

Peritoneal dialysis

• Maintain Kt/V target
• Maintain minimum weekly corrected C_cr target
• Modifications according to BMI

• Dialysis adequacy
  • Urea clearance (Kt/V)
  • Minimum weekly corrected creatinine clearance
• Patient wellbeing
• Quality of life
• Mortality

Searches of Electronic Databases

Databases searched: Medical Subject Headings (MeSH) terms and text words for peritoneal dialysis were combined with text words for renal clearance, peritoneal clearance and small solute clearance and then combined with the Cochrane highly sensitive search strategy for randomised controlled trials. The search was carried out in Medline (1966 – October Week 2 2003). The Cochrane Renal Group Trials Register was also searched for trials not indexed in Medline.

Dates of searches: 18 November 2003; 25 November 2003.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

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

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Not stated

Expert Consensus

Not stated

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Comparison with Guidelines from Other Groups
Peer Review

Recommendations of Others. Recommendations regarding small solute clearance targets in peritoneal dialysis from the following groups were discussed: Kidney Disease Outcomes Quality Initiative, British Renal Association, Canadian Society of Nephrology, and European Best Practice Guidelines.

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

Guidelines

For continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD), the weekly urea clearance (Kt/V) target should be ≥ 1.6/week. The minimum weekly corrected creatinine clearance (C_cr) target would be 60 L/week in high and high-average peritoneal transporters; and 50 L/week in low-average and low peritoneal transporters. (Level II evidence)

Suggestions for Clinical Care

(Suggestions are based on Level III and IV sources)

• Peritoneal dialysis (PD) adequacy should involve various measurements including clinical assessment of wellbeing, physical measurements, small solute clearance, fluid removal and the impact of treatment on the individual's life. Small solute clearance measurements should be interpreted in the context of all the clinical and laboratory assessments of dialysis adequacy. Measured clearances that fall short of the recommended targets should not necessarily be interpreted as providing inadequate dialysis, and measured clearances in excess of recommended targets should not necessarily be viewed as representing adequate dialysis.
• These recommendations need to be modified in patients with low body mass index (BMI) or excessive BMI. For patients with a BMI greater than 27.5 kg/m², normalised clearance values may be difficult to achieve (see the discussion in the original guideline document for more information). Adequacy needs to be interpreted in the context of the individual's body size.
• The impact of residual renal function (RRF) appears to be an important determinant of outcome. The contribution of a falling RRF to clearance targets needs to be assessed in the clinical context of the patient's wellbeing, fluid status, nutritional status as well as tolerance of dialysis prescription.

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").

Appropriate management of patients with end-stage kidney disease on peritoneal dialysis

Not stated

Implementation and Audit

1. In reporting to the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), encourage measurements of residual renal function, peritoneal creatinine clearance, renal creatinine clearance, peritoneal Kt/V and renal Kt/V.
2. Encourage identification of patients with body mass indexes (BMIs) outside the accepted normal range to enable separate analysis of the impact of body size on clearances and outcome.
3. Identify peritoneal transporter status at the commencement of continuous ambulatory peritoneal dialysis (CAPD) and in subsequent documentation of outcome.
4. Compare individual unit results with reported national averages.
5. Audit outcomes for CAPD versus automated peritoneal dialysis (APD) at comparable weekly total small solute clearances.

Living with Illness

Effectiveness

• Johnson D, Brown F, Lammi H, Walker R. Small solute clearance targets in peritoneal dialysis. Nephrology 2005 Oct;10(S4):81-5.



• Johnson D, Brown F, Lammi H, Walker R. Small solute clearance targets in peritoneal dialysis. Westmead NSW (Australia): CARI - Caring for Australasians with Renal Impairment; 2005 Jul. 13 p. [29 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.