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Care of the Pediatric Patienton Peritoneal Dialysis
Clinical Process for Optimal Outcomes
PediatricCovers.QX 2/17/04 1:55 PM Page 1
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Cover art by Morgan Ghosey, age 16
C O N T R I B U T I N G A U T H O R S
Bradley A. Warady, M.D.
Franz Schaefer, M.D.
Steven R. Alexander, M.D.
Catherine Firanek, B.S.N.
Salim Mujais, M.D.
PediatricCovers.QX 2/17/04 1:55 PM Page 2
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Ensuring adequate dialysis and optimal patient care is a multifaceted process in children
with end stage renal disease who receive peritoneal dialysis. Whereas clinicians typically
utilize clinical and laboratory indices when attempting to define and achieve adequate
dialysis, optimal care cannot be achieved by focusing on solute clearances alone. Attention
to nutrition therapy, correction of anemia and growth retardation, control of osteodys-
trophy, prevention/treatment of peritonitis and preparation for transplantation are also
mandatory, and excellence in each aspect of management is necessary if an optimal
patient outcome is to be achieved.
Care of the Pediatric Patient on Peritoneal Dialysis was developed based on a review
of the current medical literature and the authors clinical experience. It has been designed
to serve as a resource that can be easily integrated into clinical programs caring for
children, with the discussion of each major topic consisting of a treatment algorithm
and a brief but pertinent review of associated background material. An appendix with a
variety of clinical tools and list of references is also included. By its nature, this guide
cannot be considered to be exhaustive, and users are encouraged to pursue specific issues
that may not be covered herein. This guide is also not intended to be the practice of
medicine, nor does it replace sound medical clinical judgment.
Children who receive peritoneal dialysis and their families are deserving of the best care
we can possibly provide, in order to give them every opportunity to achieve their desired
goals. The authors hope that the information contained within this guide assists you to
that end.
Care of the Pediatric Patienton Peritoneal Dialysis
Clinical Process for Optimal Outcomes
Introduction
Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 3
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Care of the Pediatric Patienton Peritoneal Dialysis
Clinical Process for Optimal Outcomes
Predialytic Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Modality Selection and Preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
PD Prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Automated Peritoneal Dialysis (APD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Continuous Ambulatory Peritoneal Dialysis (CAPD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Ultrafiltration Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
Peritonitis Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Management of Growth Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Recombinant Growth Hormone Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Management of Malnutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Mineral Metabolism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Management of Anemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Preparation for Transplantation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Appendix:
Guidelines for 24-Hr Dialysate Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Guidelines for 24-Hr Urine Collection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Clearance Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Residual Renal Clearance Calculations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
PET in Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Measurement of Intraperitoneal Pressure (IPP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Table of Contents
Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 5
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Predialytic Monitoring
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
Pred
ialy
tic M
onito
ring
Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 7
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TREATMENT GOAL
Full compensation for the complications of chronic kidney disease Timely preparation for transplantation Seamless transition to dialysis
DIALYSIS INITIATION: ABSOLUTE INDICATIONS
GFR
-
9 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
oodmatocrit,ur urine
every
choice
g
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
PREDIALYTIC MONITORING
Select dialysis modality.Initiate dialysis
Child with advanced chronic renal failure (calculated GFR
-
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 10
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Modality Selectionand Preparation
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
Mod
ality
Sel
ectio
n an
dPr
epar
atio
n
Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 11
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PD TRAIN
Theory (>15 Functions
Practical/Tech Aseptic te
exchangesfeeding (in
Peritonitis an Recognitio
treatment
Noninfectiou Hypotensi
HOME V
Psychosocial Family stru
Environment Presence o
formula pfor treatm
Safety Asses Locked me
Equipment A Blood pres
Treatment As Dressing c
blood pres
Cycler Manag Average st
plan for an
TREATMENT GOAL
Improvement of patients physical and mental well-being Adequate performance of home dialysis by caregivers Minimal interference with family/school/social life
INDICATIONS FOR PD IN PREFERENCE TO HD
Patient/caregiver choice if the modality is medically suitable Very small/very young patients Lack of vascular access Contraindications to anticoagulation Cardiovascular instability Poorly controlled hypertension/hypertensive cardiomyopathy (relative) Lack of proximity to a pediatric HD center (relative) Desire for normal school attendance More liberal fluid intake
ABSOLUTE CONTRAINDICATIONS TO PD
Omphalocoele Gastroschisis Bladder extrophy Diaphragmatic hernia Obliterated peritoneal cavity and peritoneal membrane failure
RELATIVE CONTRAINDICATIONS TO PD
Imminent living-related transplantation Impending/recent major abdominal surgery Lack of an appropriate caregiver Patient/caregiver choice if an alternate modality is available and medically suitable
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.12
Modality Selection MCLINICAL PROCESS FOR OPTIMAL OUTCOMES
Mod
ality
Sel
ectio
n an
dPr
epar
atio
nPediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 12
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PD TRAINING CONTENT
Theory (>15 hours) Functions of the kidney, pathophysiology of renal failure, osmosis, diffusion, fluid balance
Practical/Technical (>15 hours) Aseptic technique, blood pressure monitoring, exit site care, performance of PD
exchanges, setup and function of cycler, problem-solving alarms, NG/gastrostomy tubefeeding (infants/small children)
Peritonitis and Exit site/Tunnel Infection Recognition of signs and symptoms, initiating treatment, medicating bags for ongoing
treatment
Noninfectious Complications Hypotension/hypertension, catheter flow problems, hernias
HOME VISIT CONTENT
Psychosocial Assessment Family structure, financial status, school schedule
Environmental Assessment Presence of heat, running water and electricity, function of smoke detector and telephone,
formula preparation facilities (infants/small children), purity of water supply, isolated areafor treatment
Safety Assessment Locked medicine cabinet, storage of needles, location of local hospital
Equipment Assessment Blood pressure monitor, scale, thermometer, cycler, tube feeding pump
Treatment Assessment Dressing care, medications, dialysis supply location, hand washing station, home records,
blood pressure assessment
Cycler Management Average start/end time for dialysis, proximity of caregiver bedroom to treatment area,
plan for answering alarms
13 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
able
Modality PreparationCLINICAL PROCESS FOR OPTIMAL OUTCOMES
Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 13
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Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 14
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PD Prescription
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
PDPr
escr
iptio
n
Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 15
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INITIATE
Initiate diapage 33 (C
MEASUR
Document(See pages
ADJUST
Adjust thedialysis doPrescriptio
This section prescriptionare based on
DETERMINE BSA
Determine BSA by using the patients height and weight on the BSA chart located onpages 18-19. Prescription recommendations are based on patient size.
SELECT MODALITY
Based on the patients lifestyle, physical condition and physicians recommendation,patients may be started on either APD or CAPD. Each therapy offers distinct lifestyle andclinical advantages.
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.16
PD PrescriptionCLINICAL PROCESS FOR OPTIMAL OUTCOMES
PDPr
escr
iptio
nPediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 16
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INITIATE THERAPY
Initiate dialysis therapy by using the prescription options offered on page 23 (APD) andpage 33 (CAPD).
MEASURE CLEARANCES
Document an adequate dose of dialysis by measuring the actual clearances achieved.(See pages 8285.)
ADJUST PRESCRIPTION
Adjust the prescription if the patient is not achieving desired clearance or an increase indialysis dose is required by clinical evaluation, using the guidelines in the AdjustPrescription sections on pages 27 (APD) and 36 (CAPD).
17 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
This section of the guide was designed to assist you in integrating a simple peritoneal dialysisprescription process into the management of individual patients. Recommended prescriptionsare based on patient Body Surface Area (BSA) and residual creatinine clearance (CrCl), if available.
ated on
ation,festyle and
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 17
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Tailoring theBSA can be d
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.18
Determine Body Surface Area (BSA)
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
50 0.18
0.22
0.25
0.28
0.31
0.33
0.36
0.38
0.40
0.42
0.44
0.46
0.48
0.49
0.51
0.53
0.54
0.56
0.57
54 0.18
0.22
0.26
0.29
0.32
0.34
0.37
0.39
0.41
0.44
0.46
0.47
0.49
0.51
0.53
0.54
0.56
0.58
0.59
58 0.19
0.23
0.27
0.30
0.33
0.36
0.38
0.40
0.43
0.45
0.47
0.49
0.51
0.53
0.54
0.56
0.58
0.59
0.61
62 0.19
0.24
0.27
0.31
0.34
0.37
0.39
0.42
0.44
0.46
0.48
0.50
0.52
0.54
0.56
0.58
0.59
0.61
0.63
66 0.20
0.24
0.28
0.32
0.35
0.38
0.40
0.43
0.45
0.47
0.50
0.52
0.54
0.56
0.57
0.59
0.61
0.63
0.64
70 0.20
0.25
0.29
0.32
0.36
0.38
0.41
0.44
0.46
0.49
0.51
0.53
0.55
0.57
0.59
0.61
0.63
0.64
0.66
74 0.21
0.25
0.30
0.33
0.36
0.39
0.42
0.45
0.47
0.50
0.52
0.54
0.56
0.58
0.60
0.62
0.64
0.66
0.68
78 0.21
0.26
0.30
0.34
0.37
0.40
0.43
0.46
0.48
0.51
0.53
0.55
0.58
0.60
0.62
0.64
0.66
0.67
0.69
82 0.22
0.27
0.31
0.35
0.38
0.41
0.44
0.47
0.49
0.52
0.54
0.57
0.59
0.61
0.63
0.65
0.67
0.69
0.71
86 0.22
0.27
0.31
0.35
0.39
0.42
0.45
0.48
0.50
0.53
0.55
0.58
0.60
0.62
0.64
0.66
0.68
0.70
0.72
90 0.22
0.28
0.32
0.36
0.40
0.43
0.46
0.49
0.51
0.54
0.56
0.59
0.61
0.63
0.66
0.68
0.70
0.72
0.73
94 0.23
0.28
0.33
0.37
0.40
0.44
0.47
0.50
0.52
0.55
0.58
0.60
0.62
0.65
0.67
0.69
0.71
0.73
0.75
98 0.23
0.29
0.33
0.37
0.41
0.44
0.48
0.51
0.53
0.56
0.59
0.61
0.63
0.66
0.68
0.70
0.72
0.74
0.76
102
0.24
0.29
0.34
0.38
0.42
0.45
0.48
0.51
0.54
0.57
0.60
0.62
0.64
0.67
0.69
0.71
0.73
0.75
0.77
106
0.24
0.30
0.34
0.39
0.42
0.46
0.49
0.52
0.55
0.58
0.61
0.63
0.66
0.68
0.70
0.72
0.75
0.77
0.79
110
0.24
0.30
0.35
0.39
0.43
0.47
0.50
0.53
0.56
0.59
0.61
0.64
0.67
0.69
0.71
0.74
0.76
0.78
0.80
114
0.25
0.31
0.35
0.40
0.44
0.47
0.51
0.54
0.57
0.60
0.62
0.65
0.68
0.70
0.72
0.75
0.77
0.79
0.81
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Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 18
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19 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
Tailoring the prescription to patient size is essential to achieve desired peritoneal clearances.BSA can be determined from height and weight by referring to the tables below.
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 60
106
0.79
0.83
0.86
0.90
0.94
0.97
1.00
1.03
1.07
1.10
1.12
1.15
1.18
1.21
1.24
1.26
1.29
1.31
1.34
1.36
1.39
110
0.80
0.84
0.88
0.92
0.95
0.99
1.02
1.05
1.08
1.11
1.14
1.17
1.20
1.23
1.25
1.28
1.31
1.33
1.36
1.38
1.41
114
0.81
0.85
0.89
0.93
0.97
1.00
1.03
1.07
1.10
1.13
1.16
1.19
1.22
1.25
1.27
1.30
1.33
1.35
1.38
1.40
1.43
118
0.82
0.87
0.90
0.94
0.98
1.01
1.05
1.08
1.11
1.15
1.18
1.21
1.24
1.26
1.29
1.32
1.35
1.37
1.40
1.42
1.45
122
0.84
0.88
0.92
0.96
0.99
1.03
1.06
1.10
1.13
1.16
1.19
1.22
1.25
1.28
1.31
1.34
1.37
1.39
1.42
1.44
1.47
126
0.85
0.89
0.93
0.97
1.01
1.04
1.08
1.11
1.15
1.18
1.21
1.24
1.27
1.30
1.33
1.36
1.38
1.41
1.44
1.46
1.49
130
0.86
0.90
0.94
0.98
1.02
1.06
1.09
1.13
1.16
1.19
1.23
1.26
1.29
1.32
1.35
1.38
1.40
1.43
1.46
1.48
1.51
134
0.87
0.91
0.95
0.99
1.03
1.07
1.11
1.14
1.18
1.21
1.24
1.27
1.30
1.33
1.36
1.39
1.42
1.45
1.48
1.50
1.53
138
0.88
0.92
0.97
1.01
1.05
1.08
1.12
1.16
1.19
1.22
1.26
1.29
1.32
1.35
1.38
1.41
1.44
1.47
1.49
1.52
1.55
142
0.89
0.94
0.98
1.02
1.06
1.10
1.13
1.17
1.21
1.24
1.27
1.30
1.34
1.37
1.40
1.43
1.46
1.49
1.51
1.54
1.57
146
0.90
0.95
0.99
1.03
1.07
1.11
1.15
1.18
1.22
1.25
1.29
1.32
1.35
1.38
1.41
1.44
1.47
1.50
1.53
1.56
1.59
150
0.91
0.96
1.00
1.04
1.08
1.12
1.16
1.20
1.23
1.27
1.30
1.34
1.37
1.40
1.43
1.46
1.49
1.52
1.55
1.58
1.60
154
0.92
0.97
1.01
1.06
1.10
1.14
1.17
1.21
1.25
1.28
1.32
1.35
1.38
1.42
1.45
1.48
1.51
1.54
1.57
1.59
1.62
158
0.93
0.98
1.02
1.07
1.11
1.15
1.19
1.22
1.26
1.30
1.33
1.37
1.40
1.43
1.46
1.49
1.52
1.55
1.58
1.61
1.64
162
0.94
0.99
1.03
1.08
1.12
1.16
1.20
1.24
1.27
1.31
1.35
1.38
1.41
1.45
1.48
1.51
1.54
1.57
1.60
1.63
1.66
166
0.95
1.00
1.05
1.09
1.13
1.17
1.21
1.25
1.29
1.32
1.36
1.39
1.43
1.46
1.49
1.52
1.56
1.59
1.62
1.65
1.67
170
0.96
1.01
1.06
1.10
1.14
1.18
1.22
1.26
1.30
1.34
1.37
1.41
1.44
1.48
1.51
1.54
1.57
1.60
1.63
1.66
1.69
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Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 19
-
A Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
APD is perforexchanges pexchange in
This therapyultrafiltratiopatients are
Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 20
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Automated PeritonealDialysis (APD)
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
APD is performed at night with the help of a cycler. A typical APD prescription includes fiveexchanges performed by the cycler while the patient is sleeping. The cycler instills a final (sixth)exchange in the morning. This final exchange dwells in the peritoneal cavity during the day.
This therapy is especially well-suited for pediatric patients. Additional benefits include betterultrafiltration due to shorter nighttime dwells, and decreased intra-abdominal pressure sincepatients are supine.
Auto
mat
ed P
erito
neal
Dial
ysis
Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 21
-
The following APD prescription principles improve the efficiency of APD therapy:
STEP 1 ADEQUATE TIME ON CYCLER
Actual time on the cycler may vary by patient and should be adapted to the patients clinical needs and lifestyle. A starting time of 10 hours is generally recommended.
STEP 2 ANURIC APD PATIENTS REQUIRE WET DAYS
All functionally anuric (CrCl
-
23 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
herapy:
ients d.
a daytimean
ge.
ount ofes at night.
igher mber ofecause of
ples
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
INITIATION OF APD
Implant catheter
Initial prescription: 56 90120 min cycles with maximally tolerable fill volume (usually ~1100 mL/m2 BSA) + 1 daytime cycle with >50% of nocturnal fill volume (CCPD)
or
-
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.24
Management of APD Prescriptions
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
FACTORS
Insufficien Loss of res Prescriptio Reduced p Loss of me Noncomp Poorly fun
CRITERIA
CCPD (APTotal KTotal Caverag
NIPD (APDTotal KTotal Caverag
Clearancepressure, g
TREATMENT GOAL
Physical and mental well-being, absence of uremic symptoms Minimal interference with family/school/social life
MANIFESTATIONS OF INADEQUATE DIALYSIS
Overt uremia (uremic pericarditis, pleuritis) Manifest edema Clinical or biochemical signs of malnutrition, wasting Congestive heart failure Arterial hypertension requiring more than one antihypertensive agent Absolute BUN value Weekly Kt/Vurea and CrCl below K/DOQI recommendations Hyperkalemic episodes Hyperphosphatemia, excessive serum calcium-phosphate product
Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 24
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25 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
FACTORS CONTRIBUTING TO INADEQUATE DIALYSIS
Insufficient time on cycler Loss of residual renal function Prescription not adequate for membrane characteristics Reduced peritoneal surface area due to extensive intra-abdominal adhesions Loss of membrane solute transport/ultrafiltration capacity due to peritonitis Noncompliance with PD prescription Poorly functioning PD catheter
CRITERIA OF APD ADEQUACY
CCPD (APD with daytime dwell):Total Kt/Vurea >2.1/weekTotal CrCl >63 L/1.73m2/week in high/high average transporters, >52.5 in low/lowaverage transporters
NIPD (APD with dry day): Total Kt/Vurea >2.2/weekTotal CrCl >66 L/1.73m2/week in high/high average transporters, >55 in low/lowaverage transporters
Clearance associated with normal status for hydration, electrolyte balance, blood pressure, growth, nutrition and psychomotor development
Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 25
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OUTCOME EVALUATION
Monthly assessment of growth and weight gain, head circumference (infants); bloodpressure, acid-base status, electrolytes, serum creatinine, BUN, hemoglobin/hematocrit,serum albumin, record urine output and daily ultrafiltration
Serum ferritin, serum iron, total iron binding capacity (monthly until stable, then every 23 months)
Every 3 months assessment of intact PTH, alkaline phosphatase Every 4 months assessment of 24-hour dialysate and urine collection for CrCl, Kt/Vurea;
possibly more frequent if prior assessment reveals failure to achieve adequacy targets;school evaluation
Every 6 months neurodevelopmental assessment in infants
-
27 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
bloodmatocrit,
en every
Kt/Vurea;targets;
quently
tic range)
ate 82,
rance totion
n a defined
mpleted
Adjust APD Prescription
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
There are four basic options to adjust an APD prescription. The options must beweighed with regard to improvements in clearance and the patients comfort andlifestyle.
STEP 1 INCREASE FILL VOLUMES
Maximizing the fill volume is an effective means of improving clearance with a minimumimpact on patient lifestyle. Since patients tolerate larger fill volumes when supine, adjustprescriptions first by increasing the volume of the nighttime exchanges.
STEP 2 ADD A DAYTIME EXCHANGE
Adding a daytime exchange is an effective means of improving clearance. For patientsusing a dry day prescription, add a wet day. For patients using a wet day prescription,add a daytime exchange after school.
HomeChoice High Dose Therapy, combining conventional CCPD with additional daytimeexchange(s), minimizes impact on lifestyle by utilizing one cycler setup per day for allexchanges. HomeChoice can be programmed to deliver the daytime exchange.
STEP 3 INCREASE TIME ON THE CYCLER
Cycler time can be extended to increase clearances, but this must be balanced with thepatients lifestyle needs.
Increasing cycler time while keeping the same number of exchanges increases the dwelltime, which results in increased clearance.
STEP 4 INCREASE NUMBER OF NIGHTTIME EXCHANGES
An increase in nighttime exchanges may increase clearance in high transporters. Inpatients with a different transport profile, a simultaneous increase in the time on cyclermay be required.
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-
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.28
Adjust APD Prescription
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
MAINTENANCE PD PRESCRIPTION IN NIPD
Measure dialytic and urinary CrCl and Kt/Vurea every 4 months
Switch to CCPD (daytime dwell)
Low, low-average transporters
Adequacy targets met?
Adequacy targets met?
Total weekly Kt/Vurea < 2.2 and/or CrCl
-
29 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
on
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
inue close onitoring
MAINTENANCE PD PRESCRIPTION IN CCPD
Measure dialytic and urinary CrCl and Kt/Vurea every 4 months
Consider adding afternoon cycle or change to hemodialysis
Low, low-average transporters
Adequacy targets met?
Adequacy targets met?
Total weekly Kt/Vurea
-
CoPer
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
CAPD is perfoexchanges, tbedtime and
Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 30
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Continuous AmbulatoryPeritoneal Dialysis (CAPD)
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
CAPD is performed evenly over the entire course of a 24-hour period. It usually consists of fourexchanges, three of which are completed during the waking hours, and the last is performed beforebedtime and allowed to dwell overnight.
Cont
inuo
us A
mbu
lato
ryPe
riton
eal D
ialy
sis
(CAP
D)
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The following CAPD prescription principles improve the efficiency of the therapy:
STEP 1 OPTIMIZE FILL VOLUMES
Fill volumes appropriate for patient body size are used in the recommended prescriptions.These can be increased further if clearance targets are not met. When adjusting fill volumes, care should be taken to account for patient tolerance.
STEP 2 DISTRIBUTE DAYTIME EXCHANGES EVENLY OVER THE COURSE OFTHE DAY
Dwell times during the waking hours should be of approximately the same duration (46 hours).
STEP 3 USE APPROPRIATE TONICITY FOR ULTRAFILTRATION
Proper fluid balance improves the effectiveness of the therapy. Guidelines for ultrafiltrationmanagement are listed on pages 4045.
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.32
CAPD PrescriptionPrinciples
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
U
2then s
usincre
Cont
inuo
us A
mbu
lato
ryPe
riton
eal D
ialy
sis
(CAP
D)Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 32
-
33 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
herapy:
scriptions.fill
OURSE OF
ation
trafiltration
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
INITIATION OF CAPD
Implant catheter
Initial prescription: 3 3- to 5-hour daytime + 1 9- to 12-hour nighttime cycles with maximally tolerable fill volume (usually ~1100 mL/m2 BSA)
Provide educational materials to caregivers, patients
Establish maximally tolerable fill volume by either repeated IPP measurements or clinical judgment. Adjust to maximally tolerable fill volume
Perform PET, measure urinary and dialysate creatinine and urea clearancesat the end of training (preferaby 4 weeks after start of PD)
Use PD dosing tables or software (PD Adequest or RenalSoft PD Rx Management) to adjust PD prescription
* ~200 mL/m2 BSA during infancy
Immediate PD required?no yes
2- to 6-week healing period,then start dialysis with 48 exchanges
using 300 mL/m2 BSA volume,*increase fill volume to ~1100 mL/m2
BSA within 714 days
Start supine dialysis with 1224 exchangesusing 300 mL/m2 BSA volume* for 7 days,
increase fill volume to ~1100 mL/m2
BSA within 1421 days
Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 33
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OUTCOM
Monthly apressure, aserum alb
Serum fer23 mont
Every 3 mo Every 4 mo
possibly mschool eva
Every 6 mo Consider a
Ambor
Han
MEASUR
Measuring thadequate the
Assess thecollection.and Cleara
For patiendetermine83, and Re
Measuremprescriptio
Once a paevery 4 mo
TREATMENT GOAL
Physical and mental well-being, absence of uremic symptoms Minimal interference with family/school/social life
MANIFESTATIONS OF INADEQUATE DIALYSIS
Overt uremia (uremic pericarditis, pleuritis) Manifest edema Clinical or biochemical signs of malnutrition, wasting Congestive heart failure Arterial hypertension requiring more than one antihypertensive agent Absolute BUN value Weekly Kt/Vurea and CrCl below K/DOQI recommendations Hyperkalemic episodes Hyperphosphatemia, excessive serum calcium-phosphate product
FACTORS CONTRIBUTING TO INADEQUATE DIALYSIS
Loss of residual renal function Prescription not adequate for membrane characteristics Reduced peritoneal surface area due to extensive intra-abdominal adhesions Loss of membrane solute transport/ultrafiltration capacity due to peritonitis Noncompliance with PD prescription Poorly functioning PD catheter
CRITERIA OF CAPD ADEQUACY
Total Kt/Vurea >2.0/week Total CrCl >60 L/1.73m2/week in high/high average transporters, >50 in low/low average
transporters Clearance associated with normal status for hydration, electrolyte balance, blood
pressure, growth, nutrition and psychomotor development
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.34
Management of CAPD Prescriptions
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
Pediatric Guide-SC3.qxd 2/17/04 1:30 PM Page 34
-
OUTCOME EVALUATION
Monthly assessment of growth and weight gain, head circumference (infants); bloodpressure, acid-base status, electrolytes, serum creatinine, BUN, hemoglobin/hematocrit,serum albumin, record urine output and daily ultrafiltration
Serum ferritin, serum iron, total iron binding capacity (monthly until stable, then every 23 months)
Every 3 months assessment of intact PTH, alkaline phosphatase Every 4 months assessment of 24-hour dialysate and urine collection for CrCl, Kt/Vurea;
possibly more frequent if prior assessment reveals failure to achieve adequacy targets;school evaluation
Every 6 months neurodevelopmental assessment in infants
-
There are two basic options for adjusting the CAPD prescription. These options mustbe weighed with regard to improvements in clearance and the patients comfort andlifestyle. Increasing fill volumes is preferred over adding additional exchanges.
INCREASE FILL VOLUMES
Maximizing fill volume is THE most effective means of improving clearance.
Start patients on the recommended prescription, and increase fill volumes if targets arenot met. You may elect to increase only two of the exchanges when first adjusting theprescription. If targets are still not met, proceed by increasing the fill volume of all fourexchanges.
ADD AN ADDITIONAL EXCHANGE
A fifth exchange may be added manually during the daytime or at nighttime by the useof an exchange device. The latter is feasible only with fill volumes greater than 1500 mL.
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.36
Adjust CAPD Prescription
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 36
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37 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
tions mustomfort andnges.
rgets aresting thef all four
by the use1500 mL.
ion
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
MAINTENANCE PD PRESCRIPTION IN CAPD
Measure dialytic and urinary CrCl and Kt/Vurea every 4 months
Low, low-average transporters
Adequacy targets met?
Total weekly Kt/Vurea
-
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 38
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UltrafiltrationManagement
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
Ultra
filtra
tion
Man
agem
ent
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 39
-
Adjusting a patients prescription to achieve and maintain fluid balance is an essential component of PD prescription management. Peritoneal dialysis, due to its continuousnature, offers some distinct advantages such as avoiding fluctuating volume status andoffering better homeostatic stability than an intermittent therapy.
In PD, ultrafiltration is driven by the osmotic gradient between the plasma and dialysatecompartments. The two key factors to consider when adjusting the patients prescriptionfor fluid removal are the nature of the osmotic agent used, concentration and dwell time.These are interrelated and need to be considered jointly. Dextrose performs adequately inshort dwells, but for the long nighttime dwell in CAPD and the daytime dwell in APD, asignificant proportion of patients manifest fluid retention with dextrose-based solutions.
Ultrafiltration is time dependent. The net ultrafiltration rate with dextrose-based solutionsis greatest at the beginning of an exchange and peaks at about 2-3 hours. Because theglucose osmotic gradient dissipates with time, and lymphatic absorption continues, netultrafiltration then begins to decrease. An alternate osmotic agent may be more appropriatefor the long dwell.
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.40
Ultrafiltration Management
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
FACTO
Dietary Inappro Decreas Mechan Transpo
reabsor
COMPO
Determ Dietary Protecti Optiona Ultrafilt
DETER
Peritonthat theremova
Dwell tin UF be
Tonicityincrease
The usenegative
TREATMENT GOAL
Adjust a patients prescription to achieve and maintain fluid balance Patient edema free Achieve normotension with minimal use of or need for antihypertensive medications.
MANIFESTATIONS OF INADEQUATE DIALYSIS
Peripheral edema Systolic hypertension Diastolic hypertension Pulmonary congestion Pleural effusions
Ultra
filtra
tion
Man
agem
ent
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 40
-
41 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
tial ouss and
lysateriptionell time.ately in
APD, autions.
olutionse thes, netpropriate
Ultrafiltration Management
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
FACTORS CONTRIBUTING TO INADEQUATE FLUID BALANCE
Dietary noncompliance with salt and water Inappropriate/noncompliance to PD prescription Decreased residual renal function Mechanical PD catheter issues Transport characteristics: Reduced membrane function/high permeability/lymphatic
reabsorption
COMPONENTS OF FLUID BALANCE MANAGEMENT
Determination of appropriate target weight, Dietary counseling concerning appropriate salt and water intake, Protection of residual renal function by avoiding nephrotoxic agents, Optional use of loop diuretics if residual function is present, Ultrafiltration management utilizing the appropriate PD prescription.
DETERMINANTS OF ULTRAFILTRATION IN PD
Peritoneal transport status: the dependence of UF on the osmotic gradient impliesthat the transport properties of the peritoneal membrane can significantly affect fluidremoval when dextrose solutions are used
Dwell time: an increase in dwell time with dextrose-based solutions leads to a decreasein UF because of dissipation of the osmotic gradient.
Tonicity: with dextrose-based solutions, an increase in tonicity is associated with anincrease in ultrafiltration.
The use of an alternate osmotic agent may allow for a long dwell without the risk ofnegative ultrafiltration.
cations.
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 41
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UltrafilSTRATEGIES TO MAXIMIZE LONG DWELL UF CAPD/APD
If the patient manifests negative UF during the long dwell Utilize alternate osmotic agent Shorten dwell time Replace single long dwell exchange with two exchanges Increase dextrose concentration
If the patient has adequate UF during the long dwell:
Minimize use of 4.25% dextrose preparations to protect the peritoneal membraneand avoid the metabolic complications of very hypertonic dextrose.
STRATEGIES TO MAXIMIZE SHORT DWELL UF
APD Increase the number of cycles Increase dextrose concentration Increase overall cycler treatment time Consider increasing the fill volume
CAPD Increase dextrose concentration Decrease dwell time/increase number of exchanges Consider increasing fill volume
Figures:
Dependence of UF on peritoneal transport status and dialysis solution tonicity for dextrose based solutions.
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.42
Ultrafiltration Management
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
Ultrafiltr
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 42
-
Ultrafiltration response to 1.5% dextrose based on peritoneal transport type
43 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
embrane
utions.
Ultrafiltration Management
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
Ultrafiltration response to 2.5% dextrose based on peritoneal transport type
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 43
-
Ultrafiltration response to 4.25% dextrose based on peritoneal transport type
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.44
Ultrafiltration Management
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 44
-
ort type
45 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
Ultrafiltration Management
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
Ultrafiltration response to dextrose
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 45
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Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
Pe
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 46
-
Peritonitis Management
Perit
oniti
s M
anag
emen
t
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 47
-
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.48
STEP 1 KEY ASSESSMENTS
Cloudy effluent Abdominal pain and/or fever
An empiric diagnosis of peritonitis should be made if: Peritoneal effluent is cloudy and Effluent with WBC >100/mm3 of which at least 50% are polymorphonuclear neutrophils (PMN)
STEP 2 KEY ACTIVITIES
Initiate the following (Performed by the patient or by the PD nurse in the dialysis unit): Disconnect drained bag and send sample to laboratory for cell count with differential, Gram stain and
culture prior to administration of antibiotics In presence of cloudy effluent,add heparin 500 U/L to new bag until effluent clears (usually 4872 hours) In asymptomatic patients with only cloudy effluent, initiation of therapy may be delayed 23 hours until
laboratory results are available In presence of cloudy effluent with pain and/or fever:
Begin 23 rapid exchanges to relieve discomfort Initiate empiric antibiotic therapy within 1 hour while waiting for test results
Consider antifungal prophylaxis to accompany antibiotic therapy After peritonitis resolved, schedule re-evaluation of total (dialysis plus residual renal function) creatinine
clearance and Kt/V urea
STEP 3 PATIENT/PARENTS EDUCATION
Immediately report cloudy effluent, abdominal pain and/or fever to PD unit Obtain specimen of effluent for laboratory testing prior to administration of antibiotics Initiate palliative steps
In presence of pain, begin 23 rapid exchanges Add intraperitoneal antibiotics for duration of required therapy Add heparin 500 U/L to each bag until clear Report persistent cloudiness to PD unit Schedule retraining for technique issues
STEP 4 OUTCOMES EVALUATION
Date of culture, organism, drug therapy Date infection resolved Recurrent organisms, date of drug therapy Method of interim renal replacement therapy Date of catheter removal Date of new catheter reinsertion Document contributing factors
Break-in technique, patient factors, exit site infections, tunnel infections
STEP 4 CONTINUES ON THE TOP OF PAGE 49...
Optimal long-tPrevention of most importanfollowing the prompt interv
* Continuetables fo For p
(244clearineeds
In patinfection,
ommhistory
CefazCepha
Ceftaz
Vanco
Teico
an
STEP 4 ...
Date of re Re-evalua Enter data
Peritonitis ManagementINITIAL EMPIRIC MANAGEMENT OF PERITONITIS
Perit
oniti
s M
anag
emen
t CLINICAL PROCESS FOR OPTIMAL OUTCOMES
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 48
-
49 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
MN)
stain and
72 hours)3 hours until
) creatinine
OF PAGE 49...
Optimal long-term management of the peritoneal dialysis patient hinges on prevention of peritonitis.Prevention of peritonitis includes proper catheter placement, use of advanced disconnect systems andmost importantly, the patients adherence to aseptic technique during the exchange procedure and following the protocol for exit site care. Early identification of the signs and symptoms of peritonitis andprompt intervention should be emphasized in the patient training program and follow-up care.
* Continued assessment and modification of therapy are based on culture and sensitivity results; refer to subsequenttables for specific organisms cultured and antibiotic dosing recommendations. For patients on automated peritoneal dialysis (APD) with short dwell times for routine therapy, the initial
(2448 hours) treatment of peritonitis should include a prolongation of dwell time to 36 hours, until there is clearing of the peritoneal effluent. This does not apply to asymptomatic patients or those with ultrafiltrationneeds requiring more frequent exchanges.
In patients with cloudy effluent, without fever and/or severe abdominal pain, and no risk factors for severeinfection, the combined intraperitoneal administration of a first-generation cephalosporin and ceftazidime is rec-
ommended. In patients with fever and/or severe abdominal pain, a history of MRSA infection, a recent history or current evidence of an exit site/tunnel or nasal/exit site colonization with S. aureus, and in patients
younger than 2 years, a glycopeptide combined with ceftazidime should be administered.
0 hour
Cefazolin orCephalothin
Ceftazidime
Vancomycin
Teicoplanin
250 mg/L load, then 125mg/L in each exchange
250 mg/L load, then125 mg/L in
each exchange
500 mg/L load, then30 mg/L in each
exchange
200 mg/L load, then20 mg/L in each exchange
15 mg/kg in single exchange q day
15 mg/kg in single exchange q day
30 mg/kg in single exchange q 57 days
15 mg/kg in single exchange q 57 days
Intermittent DosingContinuous Dosing
Initiate Empiric Therapy* with Cefazolin or Cephalothinand Ceftazidime or Glycopeptide (Vancomycin or Teicoplanin)
and Ceftazidime
THERAPEUTICSEMPIRIC THERAPY
STEP 4 ... CONTINUED
Date of re-education/training Re-evaluation of total (dialysis plus residual renal function) creatinine clearance and Kt/V urea Enter data into catheter management database (e.g., RenalSoft Access Management, POET 2.1 software)
entNITIS
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
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-
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.50
Peritonitis Management
STEP 1 KEY ASSESSMENTS
Cloudy effluent Abdominal pain and/or fever
An empiric diagnosis of peritonitis should be made if: Peritoneal effluent is cloudy and Effluent with WBC >100/mm3, of which at least 50% are polymorphonuclear neutrophils (PMN)
STEP 2 KEY ACTIVITIES
Initiate the following (Performed by the patient or by the PD nurse in the dialysis unit): Disconnect drained bag and send sample to laboratory for cell count with differential,
Gram stain and culture In presence of cloudy effluent add heparin 500 U/L to new bag until effluent clears (usually 48 to 72 hours) In asymptomatic patients with only cloudy effluent, initiation of therapy may be delayed 2 to 3 hours until
laboratory results are available In presence of cloudy effluent with pain and/or fever:
Begin 23 rapid exchanges to relieve discomfort Initiate empiric antibiotic therapy within one 1 while waiting for test results
Consider antifungal prophylaxis to accompany antibiotic therapy After peritonitis is resolved, schedule re-evaluation of total (dialysis plus residual renal function) creatinine
clearance and Kt/V urea
STEP 3 PATIENT/PARENTS EDUCATION
Immediately report cloudy effluent, abdominal pain and/or fever to PD unit Obtain specimen of effluent for laboratory testing prior to administration of antibiotics Initiate palliative steps
In presence of pain, begin 23 rapid exchanges Add intraperitoneal antibiotics for duration of required therapy Add heparin 500 U/L to each bag until clear Report persistent cloudiness to PD unit Schedule retraining for technique issues
STEP 4 OUTCOMES EVALUATION
Date of culture, organism, drug therapy Date infection resolved Recurrent organisms, date of drug therapy Method of interim renal replacement therapy Date of catheter removal Date of new catheter reinsertion Document contributing factors
Break-in technique, patient factors, exit site infections, tunnel infections
STEP 4 CONTINUES ON THE TOP OF PAGE 51...
an
*Refer to
STEP 4 ... C
Date of re-e Re-evaluatio Enter data in
ES
Discontiglycope
start a
**A secoaminogbased o
pVancom
may be u
** NOTICon Peritontivation ofantibioticsto exerciseHandbook
GRAM POSITIVE AND GRAM NEGATIVE PERITONITIS
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
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51 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
ent
PMN)
to 72 hours)o 3 hours until
on) creatinine
OF PAGE 51...
0 hour
Initiate Empiric Therapy* with Cefazolin or Cephalothinand Ceftazidime or Glycopeptide (Vancomycin or Teicoplanin)
and Ceftazidime2448 hours
Gram Positive Organism on Culture(Choice of therapy guided by sensitivity patterns)
Duration of Therapy
96 hours
If no improvement, reculture and evaluate Consider ultrasound evaluating for occult tunnel infection For peritonitis with exit site or tunnel infection, consider catheter removal
14 Days 21 Days 14 Days
*Refer to Initial Empiric Management of Peritonitis and antibiotic dosing recommendations (page 49)
THERAPEUTICS GRAM POSITIVE PERITONITIS
STEP 4 ... CONTINUED
Date of re-education/training Re-evaluation of total (dialysis plus residual renal function) creatinine clearance and Kt/V urea Enter data into catheter management database (e.g., RenalSoft Access Management, POET 2.1 software)
EnterococcusStreptococcus
Discontinue cephalosporin orglycopeptide and ceftazidime;
start ampicillin 125 mg/L
**A second antibiotic such as anaminoglycoside may be addedbased on sensitivity results and
patient responseVancomycin or clindamycin
may be used in case of ampicillinresistance
Staphylococcus aureus
Methicillin sensitive:Continue cephalosporin
Discontinueceftazidime and glycopeptide;
consider addition of rifampin20 mg/kg/day PO in divided doses
(maximum 600 mg/day)
Methicillin resistant:Discontinue ceftazidime
Continue or substitute glycopeptide or clindamycin
Other Gram PositiveOrganisms
Methicillin sensitive:Discontinue ceftazidime
and glycopeptide; continue cephalosporin
** NOTICE: The therapeutic recommendations provided above are those recommended by the ISPD Advisory Committeeon Peritonitis Management in Pediatric Patients. Baxter Healthcare is aware of literature which documents the potential inac-tivation of aminoglycosides by ampicillin in parenteral solution. The manufacturers precaution labeling states that theseantibiotics should not be mixed together in the same solution container (see references). Baxter Healthcare urges physiciansto exercise good medical judgment in selecting antibiotic combinations in the treatment of peritonitis. Ref. Trissel, LA,Handbook on Injectable Drugs, 12th ed. Macmillan Publishers LTD, ASHP, 2002; Physicians Desk Reference, 58th ed.
ONITIS
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
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52 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
2448 hours
Gram Negative Organism on Culture(Choice of therapy guided by sensitivity patterns)
96 hours
Clinical improvement: continue above therapy No clinical improvement: repeat cell count, culture and Gram stain If culture remains positive, remove catheter If no clinical improvement and exit site infection present, remove catheter
* Refer to Initial Empiric Management of Peritonitis and Antibiotic Dosing Recommendations (page 49).** Additional agents may include piperacillin, ciprofloxacin, aminoglycoside or aztreonam as susceptibility
indicates.*** Duration may need to be adjusted on clinical grounds but never shorter than recommended.
Duration of Therapy***
14 Days 21 Days 21 Days
Initiate Empiric Therapy* with Cefazolin or Cephalothinand Ceftazidime or Glycopeptide (Vancomycin or Teicoplanin)
and Ceftazidime
THERAPEUTICS GRAM NEGATIVE PERITONITIS
0 hour
Single Gram NegativeOrganism
(Non-Stenotrophomonas)
Adjust antibiotics to sensitivity patterns.
May continue ceftazidime
Pseudomonas/Stenotrophomonas
Discontinue cephalosporinor glycopeptide; continue
ceftazidime; add agent withactivity against this
pseudomonas/stenotrophomonas**
Multiple Organismsand/or Anaerobes
Consider surgical intervention and add
metronidazole15 mg/kg/day in divided
doses every 8 hours (maximum dose 1.5 gm/day),
PO, IV or rectally
Peritonitis ManagementGRAM NEGATIVE PERITONITIS
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
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Management of Growth Failure
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
er
.ity
n)
mses
l dd
dedrs
m/day),y
ent
Man
agem
ent o
fGr
owth
Fai
lure
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 53
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TREATMENT GOAL
Optimal: final adult height = midparental height (i.e., mean of parents heights +6.5 cm for boys, 6.5 cm for girls)
Minimal: final adult height above third percentile (i.e., > 1.88 SDS) Goal while still growing: target height standard deviation score (SDS) (= midparental
height SDS)
PATTERNS OF GROWTH FAILURE
Loss of relative height (downward crossing of percentiles) Percentile-parallel growth below third percentile Subnormal pubertal growth spurt
FACTORS CONTRIBUTING TO UREMIC GROWTH FAILURE
Malnutrition (most important factor in infants) Electrolyte imbalance (sodium, potassium deficiency; metabolic acidosis) Impaired growth hormone/IGF-1 action (most important factor beyond infancy) In adolescents: delayed onset of puberty Infection/inflammation (occult or overt) Medications (glucocorticoids) Complete loss of residual renal function Inadequate dialysis Excessive dialytic protein losses Low-turnover bone disease/severe secondary hyperparathyroidism Severe psychosocial stress/depression/anorexia
OUTCOME EVALUATION
Monthly measurement of supine length/standing height Annual bone age assessment
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.54
Management of Growth Failure
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
Check
S(g
acid-bas
Evide
Ina
Excessivor low-
Siinfec
Heigh
Man
agem
ent o
fGr
owth
Fai
lure
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-
55 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
arental
y)
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
MANAGEMENT OF GROWTH FAILURE DURING DIALYSIS
yes
yes
yes
yes
yesyes
no
Check anthropometric status
Start rGH treatment(go to rGH algorithm)
Evidence ofacid-base/electrolyte imbalance?
no
Evidence of malnutrition?
no
Inadequate dialysis?
no
no
Excessive renal osteodystrophyor low-turnover bone disease?
no
Signs of subclinicalinfection/inflammation?
Correct by supplementationto total CO2 22mEq/L
Go to malnutrition algorithm
Go to NIPD/CCPD/CAPD maintenance prescription
algorithms
Monitor growthfor 3 months
after correctionof problem
Continuecurrent
management
Growth rateimproved?
Go to uremic hyperparathyroidism
algorithm
Find and treat underlying cause
Check labsCheck nutritional intake
Height
-
BASELIN
Monthly: m Every 3 mo Every 12 m
SAFETY
Baseline: h Initial 12 At least ev Before and
funduscop
TREATMENT GOAL
Optimal: final adult height = midparental height(i.e., mean of parents heights +6.5 cm for boys, 6.5 cm for girls)
Minimal: final adult height above third percentile (i.e., >1.88 SDS) Goal while still growing: target height SDS (= midparental height SDS)
RESPONSE CRITERIA
Increase in annual height velocity by >2 cm/year above baseline height velocity in first 2treatment years
Change in standardized height by >0.1 SDS /treatment year in subsequent years (as longas height SDS < 1.88)
rGH DOSE
0.05 mg/kg/day by once daily subcutaneous injection Consider dose doubling in primary or secondary nonresponders
STRATEGIES FOR OPTIMIZED USE OF rGH
Correct/treat causes of growth failure before start of rGH: Electrolyte imbalance (sodium, potassium deficiency; metabolic acidosis) Hypothyroidism (frequent in patients with cystinosis!) Latent or overt inflammation (consider focal, systemic causes) Glucocorticoid medication Inadequate dialysis Inadequate treatment of renal osteodystrophy
Start early in the course of chronic renal failure Start before growth retardation is severe Never use less than standard dose Regularly adjust dose to body weight Assure compliance with daily s.c. injections Continue therapy until transplantation or attainment of target height SDS Be alert to possibility of catch-down growth after discontinuation Discontinue rGH if persistently ineffective (height velocity
-
BASELINE/OUTCOME EVALUATION
Monthly: measurement of supine length/standing height Every 3 months: puberty staging in peripubertal patients Every 12 months: hand and wrist X-ray
SAFETY EVALUATION
Baseline: hip X-rays Initial 12 months: intensified monitoring of blood pressure and fluid status At least every 3 months: intact PTH, alkaline phosphatase Before and at least every 12 months after start of treatment: glycosylated hemoglobin,
funduscopy (exclude benign intracranial hypertension)
57 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
y in first 2
ars (as long
)
hCLINICAL PROCESS FOR OPTIMAL OUTCOMES
MANAGEMENT OF rGH THERAPY
yes
yes
yes
yes
yes yes
Continue treatment. Perform regular safety checks
Consider doubling rGH dose
no
no
no
Discontinue rGH.Re-evaluate
growth after 12months
Transplantation
Discontinue rGH.Evaluate heightvelocity every 34 months
Resume rGHtreatment
Continue monitoring
Find and treat underlying disorder
Continue treatment. Perform regularsafety checks
Improve nutritional status
Increasedialysis dose
Target heightSDS exceeded
Secondary nonresponsiveness(drop of 6-month height velocity
to pretreatment level)
Signs of subclinical inflammation ?
no
New evidence of malnutrition?
no
no
Rapid loss of residual GFR/signsof inadequate dialysis?
Annualized height velocityincreased by >2 cm/year 3months after intervention?
Catch-down growth?
Administer rGH once daily; start with 0.025 mg/kg/day, increase within 4 weeks to 0.05 mg/kg/day
Monitor growth monthly for 6 months
Annualized height velocity increased by >2 cm/year?
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Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 58
-
Management ofMalnutrition
Man
agem
ent o
f M
alnu
tritio
n
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-
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.60
Management ofMalnutrition
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
RESPONS
Percentile-height per
Energy intdietary ass
STRATEG
Suppleme Institute co Consider c Maintain r
OUTCOM
Monthly: mand skinfo
Every 3 mo
TREATMENT GOAL
Energy intake 100% RDA Protein intake 120% RDA Water soluble vitamin intake 100% RDA BMI, skinfolds within normal range for height age Linear growth at target height SDS
MANIFESTATIONS
Poor weight gain Poor growth Poor brain growth during infancy Poor school performance Impaired exercise activity Impaired wound healing Impaired sense of well-being/quality of life
CONTRIBUTING FACTORS
Anorexia Emesis Food refusal Food preference Peritonitis Inadequate dialysis Constipation Gastroesophageal reflux Pica Economic factors Impaired physical eating skills
Man
agem
ent o
f M
alnu
tritio
nPediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 60
-
61 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
RESPONSE CRITERIA
Percentile-parallel growth and weight gain (catch-up pattern if below target height percentile)
Energy intake = 100%, protein intake 120% of individual requirement (RDA) by dietary assessment
STRATEGIES FOR ENTERAL TUBE SUPPORT
Supplement may be provided by bolus or continuous infusion Institute continuous feedings at rate of approximately 12 mL/kg/hr Consider concomitant use of antiemetic/motility agents if emesis present Maintain regular oral stimulation during infancy to enhance oral-motor development
OUTCOMES EVALUATION
Monthly: measurement of supine length/standing height, weight, head circumferenceand skinfolds (if available); calculation of BMI; biochemical assessment
Every 3 months: head circumference until age 36 months
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-
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.62
Management ofMalnutrition
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
MANAGEMENT OF MALNUTRITION WITH GROWTH FAILURE IN INFANTS
no
no no
no Nutritional status improved?
Nutritional status improved? Growth rate improved?
Nutritional status improved?
yes
yes
yes
yes
yes
Frequent vomiting?Start rGH treatment
(see growthhormone
algorithm)
Continuecurrent
management
Evidence of malnutrition based on dietary history,anthropometric status and biochemistry
Review dietary (formula) prescription.Monitor nutritional status for 12 months
Start PEG/NG tube feeding.* Monitor nutritional status for 12 months
Modify feeding patterns (continuous nocturnalpump; frequent small-volume feeding)
*Malnourished infants/small children should receive NG feeds for 34 months prior to PEG placement to decrease risk of leak, infection.
Psychosocial assessment andintervention if necessary.
Consider jejunal PEG, fundoplication.
Consider rGH treatment
GR
Apply K/DOQI Pediatric
NutritionalGuidelines
no
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-
63 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
.
MANAGEMENT OF MALNUTRITION WITH GROWTH FAILURE IN SCHOOLCHILDREN AND ADOLESCENTS
no no
Nutritional status improved? Growth rate improved?
yes
yes
yes
Consider rGH treatment
Evidence of malnutrition based on dietary history,anthropometric status and biochemistry
Intensify dietary counseling. Increase energy intake if insufficient, consider psychosocial assessment
Monitor nutritional status for 23 months
Monitor nutritional status for 23 months
Consider PEG/NG tube feeding. Consider psychosocial intervention
no
Nutritional status improved?
Apply K/DOQI Pediatric
NutritionalGuidelines
Start rGH treatment
(see growthhormone
algorithm)
Continuecurrent
management
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 63
-
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
M
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-
Mineral Metabolism
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
Min
eral
Met
abol
ism
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 65
-
MANIFES
Uremic os gro bon ske abn den red
Myocardia Myopathy Vascular a Hypercalce
CONTRIB
Hyperpho ina- ina
Decreased Hypocalce
hyp dec ske
TREATM
Dietary ph Phosphate
calc sev
Oral calcit com
hyp
RESPONS
Serum pho Serum inta
OUTCOM
Serum calc Serum inta Serum alk
TREATMENT GOAL
Normal bone turnover Prevention of vascular and soft tissue calcifications Control of hyperparathyroidism Normal growth Prevention of skeletal deformities (rickets)
Hyperphosphatemia
MANIFESTATIONS
Hyperparathyroidism Soft tissue and vascular calcifications
CONTRIBUTING FACTORS
Impaired renal phosphate excretion Dietary phosphorus intake (meat, milk products) Inadequate dialysis:
low fill volume, lack of daytime dwell(s) in APD
Insufficient dietary phosphate binder therapy or Nonadherence to phosphate binder prescription
Hypercalcemia
MANIFESTATIONS
Low-turnover bone disease Soft tissue and vascular calcifications
CONTRIBUTING FACTORS
Severe hyperparathyroidism Vitamin D toxicity Low turnover bone disease Use of calcium containing phosphate binders Use of high calcium PD fluid (1.75 mM/3.5 mEq/L Ca2+)
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.66
Management of Calcium-phosphate Metabolism
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
H
Min
eral
Met
abol
ism
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 66
-
MANIFESTATIONS
Uremic osteodystrophy growth failure bone pain skeletal deformities abnormal gait dental abnormalities red eye syndrome
Myocardial fibrosis Myopathy, neuropathy Vascular and soft tissue calcifications Hypercalcemia
CONTRIBUTING FACTORS
Hyperphosphatemia due to: inadequate dietary phosphorus restriction - inadequate oral phosphate binder therapy
Decreased levels of calcitriol due to impaired renal calcitriol synthesis Hypocalcemia due to:
hyperphosphatemia, decreased GI calcium absorption skeletal resistance to PTH
TREATMENT STRATEGIES
Dietary phosphorus restriction Phosphate binder therapy
calcium carbonate/acetate if serum calcium low or normal sevelamer if hypercalcemia present or Ca intake with binders >200% RDA
Oral calcitriol therapy combined with low-calcium PD fluid and/or sevelamer in the presence of
hypercalcemia
RESPONSE CRITERIA
Serum phosphorus, calcium and calcium-phosphorus ion product in normal range for age Serum intact PTH 150300 pg/mL (normal 1065 pg/mL)
OUTCOMES EVALUATION
Serum calcium, phosphorus every 4 weeks Serum intact PTH at least every 23 months Serum alkaline phosphatase activity every 6 months
67 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
m-m Hyperparathyroidism
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 67
-
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
Ma
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
MANAGEMENT OF UREMIC HYPERPARATHYROIDISM IN CHILDREN ON PD
PTH 2.5 mmol/L (10mg/dl)
Pi normal or elevated
PTH
-
Management of Anemia
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
Man
agem
ent o
f Ane
mia
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 69
-
TREATMENT GOAL
Hemoglobin 1112 g/dL Hematocrit 3336%
MANIFESTATIONS
Anorexia Fatigue Decreased exercise capacity Increased risk for patient mortality Left ventricular hypertrophy Poor cardiac function Impaired school performance
CONTRIBUTING FACTORS
Iron deficiency (absolute, functional) Blood loss Vitamin B12, B6 and folate deficiency Carnitine deficiency Secondary hyperparathyroidism Infection/inflammation Surgery Trauma Hemolysis Medications (e.g., ACE inhibitors) Hemoglobinopathies (alpha & beta thalassemia, sickle cell anemia) Malnutrition Inadequate dialysis Aluminum toxicity
OUTCOME EVALUATION
Hemoglobin/hematocrit at least monthly Serum ferritin/TSAT monthly until stable, then every 3 months
IRON PREPARATIONS
Oral iron (35 mg/kg/day elemental iron) Ferrous gluconate (tablets) 12% elemental iron Ferrous sulfate (syrup, elixir, drops, tablets, capsules) powder 20% elemental iron,
dried 30% elemental iron Ferrous fumarate (drops, suspension, tablets) 33% elemental iron Polysaccharide iron complex (capsules, elixir, tablets)
Intravenous Iron dextran Ferric gluconate Iron sucrose
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.70
Management of Anemia
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
If using d
Man
agem
ent o
f Ane
mia
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-
71 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
mental iron,
mia
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
INITIATION OF ERYTHROPOIETIN (EPO) THERAPY
no
no
noIron replete or receiving iron therapy?
Hgb increase 0.50.75 g/dL weeklyup to target Hgb of 1112 g/dL?
Factors presentthat decrease EPO effect?
yes
yes
yes
See iron administration algorithm
Identify and correct factors
Increase EPOdosage 25%.Repeat Hgb in
12 weeks
Continuecurrent therapy
Hgb 5 yrs)
or100 u/kg/dose twice weekly (
-
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.72
Management of Anemia
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
MAINTENANCE ERYTHROPOIETIN (EPO) THERAPY
no
no
yes
yes
Iron replete?
See iron managementalgorithm
Identify and correct other factors
Increase EPOdosage by
25%. RepeatHgb in
12 weeks
Receiving Maintenance EPO
Hgb 12 g/dL and increasing
Increase dosage by 2550%.
Repeat Hgb in 12 weeks
Decrease dosage by 25%.Repeat Hgb in 12 weeks
Continue current therapyFactors present thatdecrease EPO effect?
Monitor Hgb every 12 weeks following initiation and monthly during maintenance therapy.If using darbepoetin alfa, provide weekly equivalent epoetin dose; if epoetin dosing 23 times weekly, convert to darbepoetin alfa dosing once weekly;
if epoetin dosing once weekly, convert to darbepoetin alfa dosing every other week [100 IU epoetin = 0.5 g darbepoetin alfa].
yes
Factors presthat decreaEPO effec
TSAT >20ser
>100 ng/m
Hgb
-
73 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
mia
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
g surgeryinfection
ge by .
2 weeks
weekly;
IRON ADMINISTRATION
no
no
yes
yes
Factors presentthat decreaseEPO effect?
Consider course of IV iron
Identify and correct
Continue current therapy
Baseline TSAT* and serum ferritin
Initiate oral iron therapy 35 mg/kg/day elemental iron
TSAT and serum ferritin
TSAT >20% to 100 ng/mL to 50%and/or
serum ferritin >800 ng/mL
TSAT
-
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 74
-
Preparation forTransplantation
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
Prep
arat
ion
for
Tran
spla
ntat
ion
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 75
-
COMPON
Physical Exam Height, we
evaluationMedical Histo
Detailed pLaboratory S
BUN, creaALT, GGTP
Serology Stu Serology f
Immunizatio DPT, Hep A
months ofHistocompat
Blood typeRadiologic
In infants patency of
Consultation Urology ev
obstructive
TREATMENT GOALS
Thorough evaluation to determine patient suitability/readiness for transplantation Detect and treat reversible medical conditions that may influence transplant outcome Complete all live attenuated viral vaccinations (if possible) 612 weeks prior to transplant
TIMING OF EVALUATION
When progression toward end stage renal disease becomes evident When patient/family is medically/psychologically prepared for evaluation and subsequent
transplant
INDICATION FOR TRANSPLANTATION
Symptoms of uremia not responsive to standard medical therapies Failure to thrive due to limitations in total caloric intake Delayed psychomotor development Hypervolemia Hyperkalemia Metabolic bone disease due to renal osteodystrophy not responsive to standard medical
therapies
CONTRAINDICATION FOR TRANSPLANTATION
Active or untreated malignancy HIV infection Chronic active infection with Hepatitis B Severe multiorgan failure that precludes a combined transplant with a kidney Severe, irreversible neurologic impairment/persistent vegetative state
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.76
Preparation forTransplantation
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
Prep
arat
ion
for
Tran
spla
ntat
ion
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 76
-
COMPONENTS OF EVALUATION
Physical Exam Height, weight, dental evaluation, pelvic examination (if applicable), ophthalmologic
evaluationMedical History
Detailed patient and family medical history, record of all blood transfusionsLaboratory Studies
BUN, creatinine, electrolytes, calcium, magnesium, glucose, phosphorus, albumin, AST,ALT, GGTP, PT, PTT, CBC with differential/platelets, monthly PRA
Serology Studies Serology for CMV, EBV, VZV, HZV, HIV and Hepatitis A,B,C
Immunizations DPT, Hep A and B, HIB, IPV, pneumococcal, influenza; VZV and MMR (not within 2
months of transplant)Histocompatibility
Blood type, HLA, PRA, cross-matchRadiologic
In infants and small children with history of central venous access, CT/MRI evaluation forpatency of abdominal and pelvic vasculature
Consultation Urology evaluation for assessment of children with history of bladder dysfunction,
obstructive uropathy
77 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
ionutcometransplant
ubsequent
d medical
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
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-
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.78
Preparation forTransplantation
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
yes
yes
yes
yes
yes
yes
Recipient Evaluation
Medical/nutritional history andphysical examination completed?
Psychosocial assessment ofpatient and family complete?
Laboratory and serologic evaluation completed
and satisfactory?
Genitourinary evaluation completed and satisfactory?
Immunizations up-to-date?
Histocompatibility testing completed?
Complete assessment.Dietary consult if indicated
Refer to Psychologist/Social Worker
Obtain outstanding laboratory data
Refer to pediatric urologist. Review GU history and
radiologic/urodynamic results
Provide immunizations. Delay transplant following live
virus vaccines
Complete testing
no
no
no
no
no
no
Recipient Preparation Complete
Preparation for Transplant
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 78
-
79 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
yes
yes no
Proceed with LD transplant evaluation or
list for cadaveric donation
Continue decisionprocess
no
Donor selection
Decision made?
Donor options discussed with patient/family?
Conference with patient/family and transplant personnel
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 79
-
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 80
-
Appendix
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
Appe
ndix
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-
CAPD Have the patient drain and discard dialysate. Collect all dialysate for the next 24 hours. Dialysate does not require refrigeration OR a
preservative. Draw a blood sample in close proximity to the 24-hr collection period. Send blood
sample to lab for creatinine and urea nitrogen (BUN) measurement. Two methods are common for dialysate collection:
Batch method Pool the entire volume of dialysate and mix thoroughly. Measure the 24-hr. dialysate volume. Draw a final sample of mixed dialysate. Send dialysate sample to lab for creatinine and urea nitrogen (DUN)
measurement. or
Aliquot Method Empty each dialysate bag into a measuring container. Record the individual bag volume. Move the decimal point 3 places to the left. Draw this amount in mL from that
sample of effluent and place in a red top test tube. (i.e., if effluent volume is2350 mL, 2.35 mL are placed in the test tube).
Repeat the process for all bags. Mix all dialysate samples in single container. Send dialysate sample to lab for creatinine and urea nitrogen (DUN).
APD Begin the cycler treatment by draining the patient and saving the drained volume. Collect all dialysate during the cycler treatment using a 15-liter drain bag. If a daytime
exchange is performed, it must be included in the total collection. Instruct the patient to mix the solution thoroughly and obtain a sample. Record the total volume drained. Draw a blood sample in close proximity to the 24-hr collection period. Send to lab for
creatinine and urea nitrogen (BUN) measurement. Send dialysate sample to lab for creatinine and urea nitrogen (DUN) measurement.
Note: When performing 24-hr. collections, standard precautions should be taken when handlingblood or drained dialysate.
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.82
Guidelines for 24-HrDialysate Collection
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
Twenty-fourcollection (ththe growth oits protocol.
To perform t First, have Collect all
bacterial b End the te
complete Draw a blo
to lab for c Measure 2 Send urine
Note: For patrecommendedby 2 to create
G
Appe
ndix
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 82
-
ion OR a
ood
)
L from thatolume is
).
me.daytime
o lab for
ment.
when handling
r
Twenty-four-hour urine collection requires either a preservative be added to thecollection (thymol is the recommended preservative) or refrigeration to inhibit the growth of bacteria that can break down urea. Check with your laboratory forits protocol.
To perform the 24-hr collection: First, have the patient empty his/her bladder and discard urine. Collect all urine for the next 24 hours. Refrigerate urine OR add thymol to prevent
bacterial breakdown of urea End the test by having the patient empty his/her bladder. Save the urine to
complete the 24-hr collection Draw a blood sample in close proximity to the 24-hr collection period. Send blood sample
to lab for creatinine and urea nitrogen (BUN) measurement Measure 24-hr urine volume Send urine sample to lab for creatinine and urea nitrogen (UUN) measurement
Note: For patients who void infrequently (less than 3 times per 24 hours), a 48-hr collection isrecommended. If the sample is a 48-hr collection, the total volume collected should be dividedby 2 to create a 24-hr volume result.
83 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
Guidelines for 24-Hr Urine Collection
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
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-
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.84
Clearance Calculations
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
Cl
Residual renaclearance. Ca
Renal Clearan
Urea Clearan
Creatinine Cle
It is important to measure achieved clearances to document the actual dialysis dosereceived. The following are simplified formulas to calculate patient clearance.
Creatinine Clearance (CrCl) calculation is normalized to BSA. (Refer to the Body Surface Area chart on pages 1819.)
Dialysis CrCl L/week = 24-Hr D/P Cr x 24-Hr Drained Volume x 7 x 1.73m2 BSA
Patients BSA
*D/P = Dialysate concentration/Plasma concentration
Kt/Vurea is the urea clearance normalized for the urea distribution space. Kt is the ureaclearance during the sampling period, and V is the distribution volume of urea. A simplemethod for determining the volume of urea distribution is to estimate the patientstotal body water. It is important to note that different equations exist for estimatingtotal body water, and using a different equation may give different values.
V can be estimated by the following pediatric total body water prediction equation(Morgenstern et al.*):
TBW ( V ) = 0.098 x ( Ht x Wt )0.63
Dialysis Kt/V = 24-Hr D/P Urea x 24-Hr Drained Volume x 7
V
For those patients with renal function, clearance from their residual function is added tothe calculated dialysate clearance for a total combined clearance.
Renal Kt/V = mL/min Urea clearance x 1440 min/day x 7
1000 mL x V
*Morgenstern BZ, Mahoney DW, Wuhl E, Schaefer F and Warady BA. Total Body Water (TBW) in Children on PeritonealDialysis. J Am Soc Nephrol (abst) 2002; 13: 2A
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 84
-
85 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
ns Residual Renal Clearance Calculations
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
Residual renal clearance is calculated as the average of creatinine clearance and ureaclearance. Calculate residual renal clearance using the following formulas.
Renal Clearance:
Urea Clearance mL/min = Volume of 24-Hr Urine in mL x Urine Urea Nitrogen Concentration
1440 min/day x Blood Urea Nitrogen Concentration
Creatinine Clearance mL/min = Volume of 24-Hr Urine in mL x Urine Creatinine Concentration
1440 min/day x Serum Creatinine Concentration
ysis dosece.
m2 BSA
is the urearea. A simplepatientsstimating
quation
s added to
on Peritoneal
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 85
-
Dwell period: 4 hours Fill volume: 1100 mL/m2 BSA* 2.32.4% anhydrous glucose dialysis solution (Europe) 2.5% dextrose dialysis solution (North America, Japan)
Test exchange after prolonged (8 hours) dwell, if possible as follows: Drain the overnight dwell Record the length of the dwell and the volume drained. Also note the dextrose
and volume infused Infuse the calculated fill volume, note infusion time Keep patient in supine position Drain
-
87 Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
dextrose
minutesnt
dialysate
curves
evaluation.
g Method of Performing a PET in Children
CLINICAL PROCESS FOR OPTIMAL OUTCOMES
PEDIATRIC CREATININE PET CURVE
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
D/P
Crea
tinin
e
0 2 4
Time in Hours
High High Average Low Average Low
Source: Warady, et al., Peritoneal Membrane Transport Function in Children Receiving Long-Term DialysisJournal of the American Society of Nephrology, Vol.7, Number 11, 1996 p.2385-2391
PEDIATRIC GLUCOSE PET CURVE
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
D/D0
Glu
cose
0 2 4
Time in Hours
High High Average Low Average Low
Source: Warady, et al., Peritoneal Membrane Transport Function in Children Receiving Long-Term DialysisJournal of the American Society of Nephrology, Vol.7, Number 11, 1996 p.2385-2391
Pediatric Guide-SC3.qxd 2/17/04 1:31 PM Page 87
-
Copyright 2004, Baxter Healthcare Corporation. All rights reserved.
1. Schroder CH
peritoneal d
2. Fischbach M
a useful too
3. Sanchez CP
disease. Sem4. Schroder CH
patients. Gu
5. Davis ID, Bu
transplantat
of Transplan
6. Haffner D, S
with chronic
343(13):923
7. Wuhl E, Wit
Reusz GS, R
children nor
8. Warady BA,
Verrina E; In
Patients. Co