Kt as control and follow-up of the dose at a hemodialysis unit

To ensure our patients are receiving an adequate dose in every dialysis session there must be a target to achieve this in the short or medium term. The incorporation during the last years of the ionic dialysance (ID) in the monitors, has provided monitoring of the dialysis dose in real time and in every dialysis session. Lowrie y cols., recommend monitoring the dose with Kt, recommending at least 40 L in women and 45 L in men or individualizing the dose according to the body surface area. The target of this study was to monitor the dose with Kt in every dialysis session for 3 months, and to compare it with the monthly blood test. 51 patients (58% of our hemodialysis unit), 32 men and 19 women, 60.7+/-14 years old, in the hemodialysis programme for 37.7+/-52 months, were dialysed with a monitor with IC. The etiology of their chronic renal failure was: 3 tubulo-interstitial nephropathy, 9 glomerulonephritis, 12 vascular disease, 7 polycystic kidney disease, 7 diabetic nephropathy and 13 unknown. 1,606 sessions were analysed during a 3 month period. Every patient was treated with the usual parameters of dialysis with 2.1 m2 cellulose diacetate (33.3%), 1.9 m2 polisulfone (33.3%) or 1.8 m2 helixone, dialysis time of 263+/-32 minutes, blood flow of 405+/-66, with dialysate flow of 712+/-138 and body weight of 66.7+/-14 kg. Initial ID, final ID and Kt were measured in each session. URR and Kt/V were obtained by means of a monthly blood test. The initial ID was 232+/-41 ml/min, the final ID was 197+/-44 ml/min, the mean of Kt determinations was 56.6+/-14 L, the mean of Kt/V was 1.98+/-0.5 and the mean of URR was 79.2+/-7%. Although all patients were treated with a minimum recommended dose of Kt/V and URR when we used the Kt according to gender, we observed that 31% of patients do not get the minimum dose prescribed (48.1+/-2.4 L), 34.4% of the men and 26.3% of the women. If we use the Kt individualized for the body surface area, we observe that 43.1% of the patients do not get the minimum dose prescribed with 4.6+/-3.4 L less than the dose prescribed. We conclude that the monitoring of dialysis dose with the Kt provides a better discrimination detecting that between 30 and 40% of the patients perhaps do not get an adequate dose for their gender or body surface area.     

维持性血液透析患者的血压与透析充分性及相关因素分析

目的观察维持性血液透析(MHD)患者血压与透析充分性及其它相关因素间的关系。方法 56例MHD连续12次记录透析前后血压、体重、超滤量(FV),分别计算收缩压(SBP)、舒张压(DBP)和平均动脉压(MAP)的均值,第0、1、2、3个月透析前后测定血液生化值、甲状旁腺激素(PTH)、血红蛋白(Hb)、红细胞压积(Hct),计算尿素清除指数(Kt/V)、尿素下降率(URR)。结果透析充分组(Kt/V≥1.2、URR≥0.65)MHD患者血压明显低于透析不充分组(Kt/V<1.2、URR<0.65)差异有统计学意义(P<0.05);Hct≥0.22组与Hct<0.22组比较MAP差异有统计学意义(P<0.05);Logistic回归分析显示透析间期体重增加量、体重增加率、透析不充分及血清PTH水平与透析前收缩压密切相关(OR=1.98~3.50,P<0.05)。结论充分透析、减少容量负荷是控制MHD患者高血压的关键,透析不充分、透析间期体重增长过多、高血清甲状旁腺激素水平与透析前收缩压升高有密切关系。     

Treatment time and ultrafiltration rate are more important in dialysis prescription than small molecule clearance

Chronic hemodialysis sessions, as developed in Seattle in the 1960s, were long procedures with minimal intra- and interdialytic symptoms. Over the next three decades, dialysis duration was shorten to 4, 3, even 2 h in thrice weekly schedules. This method spread rapidly, particularly in the United States, after the National Cooperative Dialysis Study suggested that the time of dialysis is of minor importance as long as urea clearance multiplied by dialysis time and scaled to total body water (Kt/V(urea)) equals 0.95-1.0. This number was later increased to 1.3, but the assumption that hemodialysis time is of minimal importance remained unchanged. However, Kt/V(urea) measures only the removal of low molecular weight substances and does not consider the removal of larger molecules. Nor does it correlate with the other important function of hemodialysis, namely ultrafiltration. Rapid ultrafiltration is associated with cramps, nausea, vomiting, headache, fatigue, hypotensive episodes during dialysis, and hangover after dialysis; patients remain fluid overloaded with subsequent poor blood pressure control leading to left ventricular hypertrophy, diastolic dysfunction, and high cardiovascular mortality. Kt/V(urea) should be abandoned as a measure of dialysis quality. The formula suggests that it is possible to decrease t as long as K is proportionately increased, but this is not true. Time of dialysis should be adjusted in such a way that patients would not suffer from symptoms related to rapid ultrafiltration, would not have other uremic symptoms and most patients would have blood pressure controlled without antihypertensive drugs.     

Ionic dialysance to control the dose of dialysis. One year experience

The Diascan equipment (Hospal) measures ionic dialysane which it derives the K and the Kt. If we divide the Kt obtained with Diascan between the Kt/V obtained by a simplified formula, it result a value of V for every patient. Entering this V in the Diascan software we can obtain a Kt/V (Diascan Kt/V), similar in theory to the simplified Kt/V. In the year 2002 we have controlled the delivered dialysis in our unit with the Diascan Kt/V. The aim of the present study was to study the agreement between de Diascan Kt/V and the Lowrie Kt/V. During the year 2002, 63 patients have been dialyzed in monitors with Diascan equipment. We calculated the V of each patient by dividing the Kt Diascan between the Lowrie Kt/V in the same dialysis session. The mea of the two consecutive measurements was considered the V value. Throughout the year 2002, 7 agreement studies were realized. The inter-method variability was assessed by the relative difference (absolute difference Diascan Kt/V-Lowrie Kt/V, divided by the average of both tests). A good agreement was considered when the relative difference was equal or lower than 10%. In the 7 agreement studies realized, the mean of the relative difference oscilled between 5.2 and 6.6%, and the percentage of patients with a relative difference equal or lower than 10% oscilled between 83 and 91%. During a month, the Diascan Kt/V was controlled in all dialysis sessions in 41 patients (554 sessions in total). Failure in the lecture of Kt/V Diascan was observed in 41 sessions (7%). A Diascan Kt/V greater than 1 (the minimum delivered dialysis considered in our unit) was obtained in 93% of the valid sessions. 38 of 41 patients had a mean monthly Diascan Kt/V greater than 1. The coefficient of variability of any patient oscilled between 2.1 and 12.4% (mean 5.1%). Diascan Kt/V is good procedure for the monitoring the delivered dialysis without blood sampling or any additional costs.     

残余肾功能状态对腹膜透析效能的影响

目的:前瞻性观察终末期肾衰(ESRF)患者在腹膜透析(PD)治疗后残余肾功能(RRF)对透析效能及相关临床指标之间的影响。方法:所有患者按残余肾小球滤过率(rGFR)水平将其分为A组(GFR0~2ml/min)、B组(GFR2·1~4ml/min)和C组(GFR>4ml/min)。每3个月进行一次临床随访,全面评估患者的全身情况及透析状态,包括血压、身高、体重、体重指数(BMI)、尿量(UV)、残余肾肌酐清除率(Ccr)、每周总尿素氮表现率(Kt/Vtotal)、每周肌酐总清除率(WCcrtotal)、蛋白氮呈现率(nPNA)、残余肾尿素及Ccr。对比观察不同RRF状态患者透析状况和部分临床及生化指标变化。尿量<100ml/d或Ccr<1·0ml/min视为无尿。结果:三组不同残肾状态患者Kt/vtotal和Ccr分别为1·75±0·35、2·07±0·54、2·46±0·50和53·4±11·2、66·6±11·2、97·6±22·1(L/Wks),各组之间差异非常显著(P<0·001)。三组不同残余肾Kt/v和Ccr分别占总体kt/v的12·4%、27%、45·7%及总体Ccr的18·3%、47·3%和65·3%,三组间相比差异亦显著(P<0·01)。此外,三组间高血压发生率、心胸比例及左心室肥厚(LVH)亦存在一定差异,C组心脏增大的病例明显低于A、B两组。RRF状态与透析效能呈正相关。本组患者除2例在透析治疗时即无尿,128例患者中有31例(24·2%)发生无尿,其中原发病为血管炎综合征及糖尿病肾病各占4例和7例,其无尿发生率分别占本病种的66·7%及25·9%;另20例无尿患者为肾小球肾炎或其它疾病,占此类疾病的20·6%。此外,发生无尿患者中有5例(16·1%)透析时尿量<300ml/d。结论:PD患者的残余肾仍然是清除体内代谢产物的重要途径,同时也影响血压及心血管系统并发症。     

Monitoring hemodialysis dose with ionic dialisance in on-line hemodiafiltration

Until now, with the ionic dialysance measurement, it has been possible to determine hemodialysis dose in each session of hemodialysis (HD) and in the conventional hemofiltration (HDF) but not in the modality of on-line HDF. Recently it is possible with a new biosensor that allows to measure the dose in on-line HDF. The aim of this study was to evaluate the value of this biosensor in different dialysis situations comparing the dialysis dose measured in blood in comparison with the values obtained from the sensor. We have analysed 192 hemodialysis sessions performed in 24 patients, 15 male and 9 female, mean age of 70.2 +/- 12 years, included in on-line HDF. All treatments were done using 4008H (Fresenius) monitor equipped with on-line clearance monitoring (OCM), that measure, with non invasive monitoring, the effective ionic dialysance equivalent to urea clearance. Every patient received eight dialysis sessions: one with dialysate flow (Qd) 500 ml/min, two with HD and Qd 800 ml/min and five with on-line HDF. Other habitual haemodialysis parameters were no changed, dialysis time 200 +/- 63 min (135-300) and blood flow 421 +/- 29 ml/min (350-450). Initial and final ionic dialysance values (K), final Kt, Kt/V measured with OCM using V of Watson, and Kt/V determined in blood pre and postdialysis concentrations of urea (Daugirdas second generation), were measured. The mean of initial K was 251 +/- 21 ml/min and the final K was 234 +/- 24 ml/min. The Kt measured with OCM was 50.6 +/- 17 L, 51.2 +/- 17 in men and 49.7 +/- 16 in women. The V (Watson) was 34.5 +/- 6 L. The Kt/V measured with the Kt of OCM and V was 1,499 +/- 0.54 and Kt/V measured in blood samples was 1,742 +/- 0.58. The correlation between both values was 0.956. The Kt was different according to dialysis modality used: in HD and Qd 500 was 44.7 +/- 15 L, in HD and Qd 800 was 50.7 +/- 17 and in on-line HDF (22.1 +/- 7 L of reposition volume), was 51.8 +/- 17 L. The Kt/V from blood samples also shows variation: in HD and QD 500 was 1.60 +/- 0.55, in HD and Qd 800 was 1,726 +/- 0.56 and in on-line HDF was 1,776 +/- 0.59. In this study has been observed a close correlation between the new biosensor OCM with the measures obtained from the blood samples. For this reason this sensor it is useful in all modalities of dialysis treatment, included on-line HDF. The sensor was able to discriminate the efficacy of different dialysis modalities used in this study.     

Correlates of urea kinetic modeling during hemodialysis in patients with acute renal failure

The current guidelines on dialysis adequacy in acute renal failure (ARF) are loosely defined and have been extrapolated from patients with end-stage renal disease. The objectives of this study were (1) to compare three methods of urea kinetic modeling measurement in patients with ARF receiving intermittent hemodialysis, (2) to compare prescribed to delivered dose of dialysis, and (3) to explore the factors that are associated with dialysis delivery. 'Single-pool' urea kinetic modeling was assessed by the Ureakin) software and the second-generation equation which uses a logarithmic estimate of spKt/V. 'Equilibrated' Kt/V (eKt/V) was calculated using the rate adjustment equation. The prescribed dose was derived using the manufacturer's specifications of the dialyzer clearance, prescribed time, actual delivered blood and dialysate flow, and estimates of volume of urea distribution. A total of 78 consecutive spKt/V measurements were obtained in 24 patients. The mean urea reduction ratio was 51 +/- 1%. The delivered spKt/V was significantly lower than that prescribed (0.87 +/- 0.03 or 0.83 +/- 0.03 vs. 1.28 +/- 0.05; p = 0.0001). The equilibrated Kt/V was markedly lower than the delivered spKt/V (0.73 +/- 0.03 vs. 0.83 +/- 0.03; p = 0.0001). Univariate analyses demonstrated that female gender, low body mass index, low predialysis weight, use of cellulose acetate dialyzers, and increased prescribed time were associated with increased odds of prescribed spKt/V > or =1.2. Similarly, old age, increased delivered time, and high cytokine production were associated with increased odds of delivered spKt/V > or =1.2. In summary, while the impact of delivered intermittent hemodialysis on the survival of patients with ARF remains to be determined, these results indicate that dialysis delivery is suboptimal in ARF, and empiric dosing should strongly consider factors related to lean body mass, including age and gender.     

Bedeutung von PET und Kt/V für die Peritonealdialyse

PET should be monitored 4 weeks after the start of peritoneal dialysis (PD) and then yearly, and Kt/V every 3 months. PET makes it possible to determine different velocities of glucose absorption (from the dialysate) and of the transport of such low-molecular-weight substances as creatinine and urea (from blood to dialysate), and in particular to calculate the prognosis of the long-term ultrafiltration capacity of the peritoneum in each PD patient. Kt/V is a measure of the urea clearance both of the peritoneum and of the actual kidneys; it seems that preservation of any residual renal function has a more significant positive influence on patient survival and on the technical course than does an increase of the dialysis dose. It is accepted that PD is working efficiently when Kt/V is over 1.7. Besides PET and Kt/V clinical (well-being, eating behaviour, whether body weight is steady, functional capacity) and other (blood pressure, neurological status, degree of anaemia, calcium/phosphate ratio) criteria are also important in the evaluation of whether PD treatment is adequate.     

Conventional blood sampling versus On-Line Clearance Monitoring

On-line Clearance Monitoring (OCM) calculates the Kt/V during a dialysis session using a module incorporated into the Fresenius 4008 H/S haemodialysis machine (1). The method is based on repeated increments in dialysate sodium concentrations followed by measuring the change of dialysate sodium concentration after the dialysate has passed through the kidney. OCM is a patient friendly, non-invasive and easy method for measuring Kt/V. Kt/V calculated on single-pool urea kinetics according to Daugirdas was compared to Kt/V measured by OCM in thirty stable patients on chronic haemodialysis. Patients were dialysed using a dialyser with either a high-flux polysulfone or a haemophane membrane. In four patients OCM was measured in ten consecutive sessions to assess the intra-individual variation in OCM. The calculated Kt/V was compared to Kt/Vocm in three patients at five consecutive dialysis sessions to measure the intra-individual correlation. A linear correlation was present between Kt/Vocal and Kt/Vac for both the polysulfone and haemophane membrane. Intra-individual Kt/Vocm showed very stable values with an average variation of less than 5%. Intra-individual correlation between calculated Kt/V and Kt/Vocm was high.     

Improving adequacy improves haemodialysis outcome

Our goal of maintenance dialysis for the coming millennium is optimal rather than just adequate dialysis. Delivering a large amount of dialysis expressed in terms of urea Kt/V is a necessary but insufficient measure to improve clinical outcome. Cardiovascular morbidity and mortality remain very high in haemodialysis. This is due in great part to the insufficient control of extra cellular volume and blood pressure. Ours, as well as published data, indicate that up to now, only increasing dialysis time either by prolonging the session or increasing its frequency has proven value in overcoming this critical issue.     

透析液流量对血液透析充分性的影响

目的：观察增加透析液流量（Qd）对维持性血液透析（MHD）患者透析充分性的影响。方法：随机选择稳定透析6个月以上的MHD患者38例。血透透析液流量定于500ml／min和800ml／min各透析4周，其他透析参数[透析时间，血流量（Qb），超滤量和透析器型号与面积]不变。每种Qd量于第3周和第4周分别测定透析前后血尿素氮（BUN）、血肌酐（SCr）水平，记录每次透析的透析时间、超滤量及透析后体重（W），并根据Kt／V的自然对数公式计算Kt／V、尿素下降率（URR），取2次测定值的平均值作为患者该透析液流量的Kt／V。同时检测第4周及第8周透析前的血红蛋白（Hb）和红细胞压积（Hct）水平。采用成对t检验和卡方检验进行统计学分析。结果：本研究中每例患者构成自身对照，研究前后一般情况完全一致。Qd为800ml／min时URR及Kt／V值均较Qd流量为500ml／min时增加，具有统计学意义（P〈0．05），而SCr下降率、Hb和Hct水平略有增加趋势，无显著性差异。Qd为800ml／min时透析后URR〉65％的百分数明显高于Qd为500ml／min时，具有显著统计学意义（P〈0．001）。结论：将Qd从500ml／min增加至800ml／min，可显著增加URR、增加Kt／V，提高透析充分性达标率。800ml／min透析液流量的MHD可选择性用于不便于延长治疗时间和提高血流量达到透析充分性的患者。     

Ionic dialysance and quality control in hemodialysis

Quantification of dialysis is based on the measurement of effective urea clearance (K), dialysis dose (Kt) or normalized dialysis dose (Kt/V). During the last 20 years, Kt/V was the single parameter actually useful for quantifying dialysis efficiency, because it can be calculated from just blood or dialysate urea concentrations at the beginning and at the end of the dialysis session. However the calculation of the normalized dialysis dose (Kt/V) actually delivered to the patient cannot be performed during each dialysis session, because of the need of urea concentration measurements. Ionic dialysance is a new parameter easily measured on-line, non-invasively, automatically and without any cost during each dialysis session by a conductivity method. Because ionic dialysance has been proved equal to the effective urea clearance taking into account cardiopulmonary and access recirculation, it is becoming an actual quality-assurance parameter of the dialysis efficiency.     

On line UV-adsorbance measurements. Summary of the EDTNA/ERCA journal club discussion. Summer 2006

The discussion was initiated by a paper comparing the measurement of dialysis dose (Kt/V) and solute clearance using on‐line ultra‐violet absorbance, blood and dialysate urea and ionic dialysance by Uhlin et al (NDT 2006). Participants from 14 countries discussed the theory behind the UV absorbance technique and the potential for its use in routine practice, the correlation between Kt/V measured using different methods, the use of ionic dialysance and the optimisation of dose monitoring. The ‘take‐home’ messages from the discussion were that UV‐absorbance could help ensure the delivery of dialysis dose as it provides real time feedback on the effect interventions such as repositioning of needles. The technology is relatively inexpensive and requires no consumables but changes in the dialysis machine settings could lead to misleading measurements if not communicated to the UV monitor. Session‐to‐session variation in dialysis dose can be measured using on‐line clearance monitoring. If it is already on the machine and costs nothing, why not use it? Alternatively, regular access recirculation checks and a record of the total blood volume processed at each session allow problems with delivered dialysis dose to be picked up between routine blood tests.     

Determination of the dose of dialysis with integrated modules in the same monitor

The "gold standard" method to measure the mass balance achieved during dialysis for a given solute is based on the total dialysate collection. This procedure is unfeasible and too cumbersome. For this reason, alternative methods have been proposed including the urea kinetic modelling (Kt/V), the measurement of effective ionic dialysance (Diascan), and the continuous spent sampling of dialysate (Quantiscan). The aim of this study was to compare the reliability and agreement of these two methods with the formulas proposed by the urea kinetic modelling for measuring the dialysis dose and others haemodialysis parameters. We studied 20 stable patients (16 men/4 women) dialyzed with a monitor equipped with the modules Diascan (DC) and Quantiscan (QC) (Integra. Hospal). The urea distribution volume (VD) was determined using anthropometric data (Watson equation) and QC data. Kt/V value was calculated according to Daurgidas 2nd generation formula corrected for the rebound (eKt/V), and using DC (Kt/VDC) and QC (Kt/VQC) data. The total mass of urea removed was calculated as 37,93 +/- 16 g/session. The VD calculated using Watson equation was 35.7 +/- 6.6 and the VDQC was 35.06 +/- 9.9. And they showed an significative correlation (r:0,82 p < 0.001). The (VDQC-VDWatson) difference was -0.64 +/- 5.8L (ns). Kt/VDC was equivalent to those of eKt/V (1.64 +/- 0.33 and 1.61 +/- 0.26, mean difference -0.02 +/- 0.29). However, Kt/VQC value was higher than eKt/V (1.67 +/- 0.22 and 1.61 +/- 0.26 mean difference 0.06 +/- 0.07 p < 0.01). Both values correlated highly (R2: 0.92 p < 0.001). Urea generation (C) calculated using UCM was 8.75 +/- 3.4 g/24 h and those calculated using QC was 8.64 +/- 3.21 g/24 h. Mean difference 0.10 +/- 1.14 (ns). G calculated by UCM correlated highly with that derived from QC (R2: 0.88 p < 0.001). In conclusion, Kt/VDC and Kt/VQC should be considered as valid measures for dialysis efficiency. However, the limits of agreement between Kt/VQC and eKt/V were closer than Kt/VDC.     

ON‐LINE CLEARANCE MONITORING FOR BLOOD ACCESS MANAGEMENT

On‐line Clearance Monitoring (OCM) provides frequent and precise information about urea clearance values during haemodialysis. In the case of blood access recirculation, it is presumed that urea clearance values on OCM would be lower and suspect to blood access malfunction. In order to check the relation between significantly lower urea clearance values and blood access recirculation, the Kt value (Clearance × time/min) for fifteen patients on OCM, including the patients with a low Kt/V in spite of their small urea distribution volume (V) was observed. Average urea clearance was calculated indirectly using Kt value (Kt/time in minutes = average clearance ml/min) and blood access recirculation tests performed using slow/stop flow two‐needle, three samples method (urea method). After comparison of the recirculation percentage to clearance value, positive correlation between high recirculation and clearance reduction was noted. OCM alongside detection of haemodialysis inefficiency is also a practical instrument for blood access management between regular monitoring. Lower OCM urea clearance values demonstrate a possible blood access problem that can be confirmed with another method. When an OCM urea clearance reading is decreased by more than 25%, undiscovered access recirculation can be suspected.     

On-line clearance monitoring for blood access management

On-line Clearance Monitoring (OCM) provides frequent and precise information about urea clearance values during haemodialysis. In the case of blood access recirculation, it is presumed that urea clearance values on OCM would be lower and suspect to blood access malfunction. In order to check the relation between significantly lower urea clearance values and blood access recirculation, the Kt value (Clearance x time/min) for fifteen patients on OCM, including the patients with a low Kt/V in spite of their small urea distribution volume (V) was observed. Average urea clearance was calculated indirectly using Kt value (Kt/time in minutes = average clearance ml/min) and blood access recirculation tests performed using slow/stop flow two-needle, three samples method (urea method). After comparison of the recirculation percentage to clearance value, positive correlation between high recirculation and clearance reduction was noted. OCM alongside detection of haemodialysis inefficiency is also a practical instrument for blood access management between regular monitoring. Lower OCM urea clearance values demonstrate a possible blood access problem that can be confirmed with another method. When an OCM urea clearance reading is decreased by more than 25%, undiscovered access recirculation can be suspected.     

Evaluation of methods to calculate dialysis dose in daily hemodialysis

Daily dialysis has shown excellent clinical results because a higher frequency of dialysis is more physiological. Different methods have been described to calculate dialysis dose which take into consideration change in frequency. The aim of this study was to calculate all dialysis dose possibilities and evaluate the better and practical options. Eight patients, 6 males and 2 females, on standard 4 to 5 hours thrice weekly on-line hemodiafiltration (S-OL-HDF) were switched to daily on-line hemodiafiltration (D-OL-HDF) 2 to 2.5 hours six times per week. Dialysis parameters were identical during both periods and only frequency and dialysis time of each session were changed. Time average concentration (TAC), time average deviation (TAD), normalized protein catabolic rate (nPCR), Kt/V, equilibrated Kt/V (eKt/V), equivalent renal urea clearance (EKR), standard Kt/V (stdKt/V), urea reduction ratio (URR), hemodialysis product and time off dialysis were measured. Daily on-line hemodiafiltration was well accepted and tolerated. Patients maintained the same TAC although TAD decreased from 9.7 +/- 2 in baseline to a 6.2 +/- 2 mg/dl after six months, p < 0.01. No significant changes were observed in weekly Kt/V and eKt/V throughout the study. However EKR, stdKt/V and weekly URR were increased during D-OL-HDF in 24-34%, 46% and 50%, respectively. Hemodialysis product was raised in a 95% and time off dialysis was reduced to half. CONCLUSION: Dialysis frequency is an important urea kinetic parameter which there are to take in consideration. It's necessary to use EKR, stdKt/V or weekly URR to calculate dialysis dose for an adequate comparison between different frequency dialysis schedules.     

Incremental peritoneal dialysis - yes

The incremental modality at the start of peritoneal dialysis (Incr-DP) is implicit in the definition of adequacy, which is expressed as the sum of dialysis clearance and renal clearance.Theoretically, it is possible to demonstrate that with a glomerular filtration rate at the start of dialysis of 6 mL/min, the minimum Kt/V target of 1.70 indicated by the current guidelines is easily exceeded with both 2-exchange of CAPD (incremental CAPD) and APD of 3 or 4 weekly sessions (Incr-APD), with a daytime icodextrin dwell. The GSDP (Peritoneal Dialysis Study Group) census data suggest that Incr-DP favors the choice of peritoneal dialysis. Although limited to a few studies with a relatively small number of patients, data show that Incr- CAPD is associated with a better quality of life, the achievement of Kt/V targets, and satisfactory ultrafiltration. The clearance of medium molecules is equivalent in Incr-DP and full-dose PD as it depends on the duration of the dwell and not on the number of exchanges. The maintenance of body weight, protein intake and peritoneal permeability may be explained by the lower glucose load with Incr-DP. The preservation of residual renal function is similar to that recorded with full-dose PD, while the peritonitis rate seems to be lower. The favorable results reported in the literature and the indications of the most recent guidelines about the importance of reducing the exposure to glucose to a minimum and safeguarding the patient's quality of life in our opinion further justify the use of Incr-DP.     

腹膜透析治疗充分性评估与影响因素干预

腹膜透析(PD)充分性是PD患者预后的关键因素,目前国内外常用的小分子溶质清除指标为每周尿素清除指数(Kt/V)。Kt/V已经由既往指南的＞2.0,降低到≥1.7即可。除了小分子溶质清除外,容量平衡、营养状态、临床症状等也是透析充分性的评估指标。因此,PD充分性评估既有小分子溶质的清除,也包括其他综合性因素。影响透析充分性的因素中,残余肾功能、腹膜转运特性为主要因素,应予以足够重视并定期监测。