2364

Individualising Prescriptions for Peritoneal Dialysis (PD) Patients - Development of a PD Start-Up regime

Jo Whincup, Helen Collinson, Philip Ward

Hull Royal Infirmary

Introduction:

Historically in our renal service, patients commencing peritoneal dialysis (PD) commenced on four 1.5-2.0 litre exchanges daily (continuous ambulatory peritoneal dialysis- CAPD), with an option to switch to Automated PD- (APD), once results of adequacy testing and a Peritoneal Equilibrium Test (PET) were known. Focus was on ensuring achievement of adequate dialysis – maintaining urea and creatinine clearance to Renal Association standards, maintenance of target weight with good fluid balance, and increasing dialysis for patients who were not adequately dialysing.

It was identified that when PD commencement was planned, via the low clearance or transplant clinics, with patients’ eGFRs being 7-10mls/min, results of the first adequacy test showed high numbers of patients with creatinine clearance levels of above 100 litres/week/1.73m2, and very few patients with levels below 80 litres/week/1.73m2. This appeared to indicate early on, that patients often only required very minimal support from a dialysis regime, due to preservation of residual renal function (RRF).

Aim: To reduce the impact of commencing PD on the patient's daily activities, including employment, and avoid starting on full PD until the results of adequacy was known.

Achievement of this with a gradual introduction to PD, increasing as RRF declines.

Approach: An audit of the adequacy results of all patients who commenced PD in the previous year was undertaken and a Start-Up Phase Policy was developed.

Planned commencement onto PD, with eGFR's 7-10mls/min started on a regime of:

  • A Dianeal or Nutrineal 1.5-2.0 litres exchange at 6-7pm
  • An Icodextrin (Extraneal) 1.5-2.0 litres exchange to dwell overnight.
  • Drain out and remain dry throughout the day.

The start-up regime is made possible by; monitoring in the low clearance clinic, timely referral to the surgical team for PD access, regular adequacy testing, close attention to biochemical results, availability of Icodextrin solution, and patient education and awareness of their own health.

Possible benefits of the Start-Up Phase include reduction in glucose exposure (particular advantage to diabetics) - preservation of the peritoneal membrane, reduced risk of fluid absorption in high transporters, reduction in the risk of peritonitis, preservation of RRF, reduced risk of exit site leakage or hernia, PD a more attractive dialysis option, cost effective.

Conclusion: Although we had for several years, reduced a patient’s PD as a response to adequacy testing, this was invariably after they had already started on full CAPD. Our experience is that patients may need to increase PD after weeks or years. Small numbers of patients are however able to decrease to a single Icodextrin exchange overnight. It is hoped that more patients can experience the benefits of reduced dialysis from commencement of PD start for as long as their RRF allows.