capd adequacy 2005.doc

NORTH WEST RENAL AUDIT PROGRAMME

:1999 - 2002PERITONEAL DIALYSIS ADEQUACY

PRELIMINARY REPORT

: 2005DATE PRINTED NOVEMBER

AUDIT LEADS: Dr S. Mitra Dr M. Venning

SENIOR REGISTRARS: Dr A. Irtiza-Ali Dr B. Pandya

AUDIT FACILITATOR L. Palmer

:Contact Address NW Renal Audit Programme

Clinical Audit Office

1st Floor ERC

Wythenshawe Hospital

Southmoor Road

23 9M LT

:Telephone 0161 291 5821

PD Adequacy Preliminary Report 1999 - 2002______________________________________________________________

1. Introduction

Adequate peritoneal dialysis has been a widely debated topic in recent times. The symptoms of inadequate dialysis may range from obviously gross underdialysis culminating in death to patients being totally bored with life and on the verge of depression, weakness, anorexia, weight loss, progressing through malnutrition, pericarditis. A minimalist approach would be to just avoid some of these. What we strive to provide however is optimum dialysis, when we have patients looking good, feeling free of uremic symptoms, hopefully eating well and reasonably active with a good quality of life. At this point we can find that our efforts have culminated in a flattening of the curve beyond which the risk/benefit ratio would be not worth proceeding further. As we analyze adequacy and overall well-being of the patient we employ measures of dialysis as a surrogate to quantify this otherwise largely subjective operational definition. Traditionally one of these parameters of adequacy has been based on measuring clearance of predominantly small uremic solutes i.e urea and creatinine.

The Standards Committee of the Renal Association (UK) has identified a number of laboratory and clinical variables that may relate to quality of care or outcomes, and has recommended minimum Standards or target ranges that should be achieved in established dialysis patients. The weekly Kt/V for urea and the weekly creatinine clearance are both used at present as measures of small solute clearance. Each is the sum of the clearance achieved by the dialysis and that due to the residual renl function (RRF). Renal and peritoneal clearance are not equal, although this is assumed when compensating for the loss of RRF by increasing peritoneal clearances.

At present the two measures (Kt/V and creatinine clearance) are regarded as being equivalent and either can be used. Creatinine clearance is greatly affected by RRF and declines more as RRF decreases. A weekly Kt/V <1.65 was reported to be associated with poor outcome. Original DOQI guidelines were predicated on the basis of the Maiorca study and the CANUSA study. They demonstrated the best survival when Kt/V exceeded 1.96. The recently reported ADEMEX study on the other hand is the first randomized, prospective interventional study aimed at assessing whether survival improves with higher Kt/V. It was appropriately designed, and it achieved randomization for age, gender, percent diabetes, hypertension, body surface area, etc. The ADEMEX randomized control trial showed no difference in outcome after two years in patients maintaining a creatinine clearance of 46 litres per week compared with those achieving 57 litres per week. This study therefore provides a firmer evidence base and justifies the minimum target of creatinine clearance of 50 litres per week and a Kt/V greater than 1.7. A revised Renal Standards document was published in autumn 2002 where dialysis adequacy parameters and their monitoring for creatinine clearance and KT/V were set for CAPD: (>50l/week ; 1.7) respectively based on supportive evidence (level B or C).

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November 2005 Page 1

PD Adequacy Preliminary Report 1999 – 2002_______________________________________________________________

2. Aims and Objectives

• To measure achievement of the Renal Association recommendations1 for small solute adequacy

• (Total Kt/V and Total Creatinine Clearance) in peritoneal dialysis (PD) patients in the North West Region.

• To examine the protocols for PD adequacy testing in all the participating renal units.

• To analyse the characteristics of patients failing to achieve the recommended targets for PD adequacy.

3. Renal Association Standards 2002 1

o A total weekly creatinine clearance (dialysis + residual renal function) of greater than 50 l/week/1.73 m2 and/or a weekly dialysis Kt/V urea of greater than 1.7, checked eight weeks after beginning dialysis, are minima. Higher targets are desirable especially for high average and high transporters and APD patients.

o These studies (PD adequacy) should be repeated at least annually, and more

frequently if clinically indicated, particularly if suspicion arises that residual renal function has declined more rapidly than usual.

o At present both Kt/V and creatinine clearance are acceptable measures of adequacy until evidence accumulates to show the superiority of one over the other. Achieving either target is acceptable ; creatinine clearance is more difficult to achieve in anuric patients with below average peritoneal solute transport.

4. Methods• The three audit data sets examined (1999-2000, 2000-2001 and 2001-2002)

were taken from PD patients at Salford Royal Hospital (SRH), Royal Liverpool University Hospital (RLH), Manchester Royal Infirmary (MRI) and Royal Preston Hospital (RPH).

• Data for the 1999-2000 audit were from all patients who had a PD adequacy test performed between 1st July 1999 and 30th June 2000. Data for the 2000-2001 audit were from all patients who had a PD adequacy test performed between 1st

July 2000 and 30th June 2001. Data for the 2001-2002 audit were from all patients who had a PD adequacy test performed between 1st July 2001 and 30th

June 2002.

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• Data were obtained retrospectively from Adequest, a database used by all units to monitor PD adequacy tests. When patients had more than one test in a year, the most recent was used. A small amount of additional data was collected from medical notes.

• Data sets included were under the following main headings:

Patient demographics - Age, gender, weight and ethnic group.

Total Weekly KT/V – Residual and Dialysate Kt/V.

Total Weekly Creatinine clearance - Residual and Dialysate Creatinine Clearance (CCr) (L/Week/1.73sq.m )

Prescribed dialysate volumes & ultrafiltration volumes (mls).

Urine Output (mls) and Residual renal function .

5. RESULTS

5.1 Characteristics of the patient population

Gender, age, ethnicity and weight.

• Regionally, the percentage of males and mean weight of those PD patients tested has remained constant. The percentage of Caucasians has increased by a small amount from 86% to 89% and the mean age has increased from 53 to 57 years between 1999/2000 and 2001/2002 (Table 1).

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No. of patients tested 125 137 115 47 65 51 83 90 165 73 90 126 328 382 457% Male 51 44 49 64 58 49 60 69 61 63 64 66 58 57 58

% Caucasian 90 88 90 92 94 96 80 84 88 84 84 86 86 87 89Age (Mean) 56 57 57 51 48 49 51 50 54 54 57 53 53 52 57

Weight (Mean) 68 68 69 74 76 71 71 72 70 68 69 71 71 70 71

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No. of patients tested 281 316 406% Male 57 62 59

% Caucasian 85 86 88Age (Mean) 53 55 55

Weight (Mean) 69 69 72

Table 1: Gender, ethnic group, age and weight of PD patients tested for dialysis adequacy

5.2 PD Modality distribution

• There was a large variability in the completeness of the PD modality data. As a result, data broken down by PD mode must be interpreted with caution (Table 2).

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Capd (%) 79 91 77 51 65 70 92 87 63 86 91 89 79 86 74Apd (%) 3 8 7 17 33 26 2 9 4 11 9 11 7 12 9

Unknown (%) 18 1 16 32 2 4 6 4 33 3 0 0 14 2 16

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Capd (%) 84 90 75Apd (5%) 5 8 7

Unknown (%) 11 2 18

Table 2: Distribution of PD modality in patients tested for dialysis adequacy

5.3 Protocols for PD adequacy testing

• Throughout the region there were variations in the protocols for PD adequacy testing. SRH had routine yearly tests in 1999. MRI and RPH started yearly tests

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during the 3-year audit period. RLH due to limited staff and resources, only performed PD aadequacy tests when clinically indicated.

• In this report, it must be acknowledged that the RLH data were taken from a selected population with clinical problems and therefore the RLH data does not wholly represent the RLH PD population.

• Regionally, the use of adequacy testing within the PD population has increased steadily between 1999-2002 (Table 3). Throughout the audit period, a high percentage of patients had a PD adequacy test at SRH. MRI and Preston increased testing throughout the audit period. RLH increased the percentage of their PD population tested between 1999 and 2001 but the percentage declined thereafter (Table 3).

SRH RLH MRI RPH Region 1999/2000 95 31 44 54 562000/2001 98 45 49 68 652001/2002 96 36 76 88 74 Table 3: Percentage of patients who had a PD adequacy test

5.4 Small solute adequacy (Total Creatinine clearance )

• Regionally, the percentage of patients achieving a Total CCr > 50 L/week/1.73sq.m remained the same over the 3 year audit period (Table 4).

• SRH consistently had the highest percentage of patients achieving a Total CCr >50 L/week/1.73sq.m. RPH, MRI and RLH ranked behind (Table 4).

SRH RLH MRI RPH Region Region no Liverpool

1999/2000 92 66 69 85 81 842000/2001 95 57 70 91 82 872001/2002 93 69 73 90 82 84

Table 4 : Percentage of patients achieving Total CCr > 50 L/week/1.73m2

5.5 Small solute adequacy ( Total KT/V urea )

• Regionally, the percentage of patients achieving a Total Kt/V > 1.7 initially increased and then reached a plateau over the 3 year audit period (Table 5).

• Over the 3 year audit period, all units increased the percentage of patients achieving a Total Kt/V > 1.7. SRH consistently had the highest percentage of

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patients achieving a Total Kt/V > 1.7. Again RPH, MRI and RLH ranked behind SRH (Table 5).


1999/2000 86 51 64 74 73 772000/2001 90 62 77 90 82 862001/2002 90 67 78 87 82 84

Table 5: Percentage of patients achieving Total Kt/v > 1.7

5.6 Small solute adequacy (Total KT/V urea &/or Creatinine clearance)

• Regionally the percentage of patients achieving the recommendation Total Kt/V > 1.7 and/or Total CCr > 50 L/week/1.73m2 increased over the 3 year audit period (Table 6).

• The percentage of patients achieving either Total Kt/V > 1.7 and/or Total CCr > 50 L/week/1.73m2 over the 3-year audit period increased in all units. SRH started with and maintained the highest level(Table 6)


1999/2000 94 68 78 88 85 882000/2001 98 71 82 92 88 922001/2002 95 77 84 94 89 90

Table 6: Percentage of patients achieving Total Kt/V > 1.7 and/or Total CCr >50 L/week/1.73m2

• Regionally in 1999/2000, the percentage of CAPD patients achieving either Total Kt/V > 1.7 and/or Total CCr > 50 L/week/1.73m2 was greater than the percentage of APD patients achieving the Renal Association Recommendation. In 2000/2001 and 2001/2002, this trend reversed (Table 7)

CAPD APD CAPD no Liverpool

APD noLiverpool

1999/2000 86 82 88 932000/2001 88 94 92 892001/2002 88 98 90 96

Table 7: Percentage of CAPD/APD patients achieving a Total Kt/V > 1.7 and/or Total CCr >50 L/week/1.73m2

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5.7 Prescribed dialysate volumes

• Regionally, the number of patients with prescribed dialysate volumes less than 8000mls decreased. Those with prescribed dialysate volumes greater than or equal to 8000mls increased . The median levels have remained constant (Table 8). Over the 3year audit period mean prescribed dialysate volumes have increased in all units except Liverpool.

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≤6000 (%) 14 13 14 9 5 16 10 9 4 21 20 2 21 12 76500-7500 (%) 3 3 3 6 5 6 1 1 2 0 1 12 2 2 58000 (%) 59 55 50 51 52 57 68 48 68 53 52 48 51 52 57≥ 8000 (%) 24 29 33 34 38 22 21 42 26 26 27 38 26 34 31

LowestHighest

Mean (mls) 8307 8763 8860 9321 9825 8526 8399 9033 8684 8233 8461 8868 8461 8936 8505Median (mls) 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000

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≤6000 (%) 15 14 96500-7500 (%) 1 2 28000 (%) 60 52 57≥ 8000 (%) 24 32 32

Lowest 3000 3000 3000Highest 2050

02200

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Mean (mls) 8432 8743 8252Median (mls) 8000 8000 8000

Table 8: Prescribed dialysate volumes (mls)

5.8 PD Ultrafiltration

• Regionally over the 3 year audit period, there has been a marginal but insignificant increase in mean and median PD ultrafiltration (Table 9).

• Throughout the 3 year audit period, SRH achieved the highest PD ultrafiltrate volumes. PD ultrafiltration had also increased at RLH and MRI .

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Lowest -700 -800 -100 -800 -700 -400 -1800 -920 -1250 -1200 -1560 -1920 -1800 -1560 -1920Highest 3600 3900 3500 2800 3600 2500 4000 3850 3850 3200 3260 3550 4000 3900 3850Mean 1426 1470 1343 766 978 959 757 1152 1026 1037 991 1037 1076 1199 1101

Median 1300 1500 1300 700 1000 1000 800 1005 1100 1100 880 1025 1000 1100 1140

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Lowest -1800 -1560 -1920Highest 4000 3900 3850


Table 9: PD ultrafiltration volumes (mls)

5.9 Urine Output

• Regionally, over the three-year audit period, there has been a small increase in mean and median urine output (Table 10). Over the three-year audit period, there was an increase in urine output at RPH. Changes at RLH, RPH and SRH were variable.

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Lowest 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0Highest 1990 2570 2270 2670 2440 2370 3080 2630 2940 2550 2750 2900 3080 2750 2940Mean 504 539 473 629 558 721 504 539 473 431 574 751 535 555 627

Median 320 390 320 450 310 560 470 345 400 300 400 550 355 380 420

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Lowest 0 0 0Highest 3080 2750 2940


Table 10: Urine output (mls)

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5.10 Residual Renal Function

• Regionally, over the 3-year audit period, the percentage of patients with no residual renal function remained unchanged.

• Over the three year audit period, RPH tended to have more patients with no residual renal function than other centres.

SRH RLH MRI RPH Region RegionNo

Liverpool 1999/2000 27 23 29 45 31 322000/2001 24 34 37 36 31 312001/2002 26 26 33 36 31 32

Table 11: Percentage of patients with no residual renal function

5.11 Ultrafiltration Volumes

• Regionally, mean and median PD ultrafiltration volumes are higher in patients without residual renal function than in patients with residual renal function (Table12 ; table 13).

• Regionally, over the 3 year audit period, there was an increase then a decrease in the mean PD ultrafiltration volumes of patients without residual renal function. At each individual unit, they followed the same pattern although overall, they increased at MRI, RLH and RPH and decreased at SRH (Table12).

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Lowest 100 410 -100 260 500 -200 -450 200 -240 -720 190 -130 -720 190 -240Highest 3500 3900 2200 1400 3600 1700 2650 3850 3850 3200 2700 3500 3500 3900 3850Mean 1534 1622 1340 780 1354 833 871 1414 1268 1029 1310 1292 1128 1432 1260

Median 1300 1600 1400 600 1170 800 770 1410 1250 1100 1225 1230 1050 1335 1250

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Lowest -720 190 -240Highest 3500 3900 3850


Table 12: Ultrafiltration volumes (mls) of patients

with no residual renal function

• Regionally, over the 3 year audit

period, there was little change in the mean PD ultrafiltration volumes of patients with residual renal function (see table14 below). Overall, at MRI and RLH they increased, while at RPH they decreased and at SRH they remained constant (Table 13)

.

Table 13: PD Ultrafiltration volumes (mls) of patients with residual renal function

5.12 Prescribed Dialysate Volumes

• Both regionally and at individual units, throughout the 3 year audit period, the mean prescribed dialysate volumes were higher in patients without renal function, than in patients with renal function (see tables 14 and 15).

• Regionally, throughout the 3 year audit period, there was an increase in the mean prescribed dialysate volumes of patients without renal function, and in patients with renal function (Tables 14 and 15).

• Throughout the 3 year audit period, there was an increase in the mean prescribed dialysate volumes of patients without renal function and in those

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No

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Lowest -1800 -1560 -1920Highest 4000 3600 3550


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Median 1300 1500 1300 700 900 1000 800 900 920 1090 700 896 1000 1100 1060


with renal function at MRI, RPH and SRH. At RLH, the mean prescribed dialysate volumes decreased in both groups of patients (Tables 14 and 15).

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Median 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000

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Table 14: Prescribed Dialysate Volumes (mls) of patients without Residual Renal Function

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Median 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000

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Table 15: Prescribed Dialysate Volumes (mls) of patients with Residual Renal Function____________________________________________________________



6. KT/V urea -- Time trends

• Regionally, there was a small increase in the median Total Kt/V over the 3 year audit period, with similar increases in all 4 units (Table 16).


Liverpool 1999/2000 2.18 1.83 1.88 1.92 2.00 2.022000/2001 2.26 1.95 1.96 2.09 2.10 2.122001/2002 2.23 1.95 2.01 2.16 2.08 2.09

Table 16: Total Kt/V

• Regionally, there was little change in median dialysate Kt/V over the 3 year audit period. Small increases were seen at SRH and MRI, and small decreases at RLH and RPH (Table 17).

Hope Liverpool MRI Preston Regional RegionNo

Liverpool 1999/2000 1.72 1.48 1.51 1.68 1.63 1.662000/2001 1.81 1.56 1.61 1.71 1.68 1.722001/2002 1.78 1.44 1.61 1.65 1.65 1.66

Table 17: Dialysate Kt/V

• Regionally, there was a small increase in median residual Kt/V over the 3-year audit period. An increase was seen at SRH, RLH and RPH and a decrease at MRI (Table 18).

Hope Liverpool MRI Preston Regional RegionNo

Liverpool 1999/2000 0.30 0.13 0.22 0.21 0.24 0.262000/2001 0.40 0.07 0.12 0.34 0.28 0.322001/2002 0.38 0.17 0.16 0.48 0.30 0.31

Table 18: Residual Kt/V

• Regionally, over the 3 year audit period, there has been a small increase in the percentage of the patients with no residual renal function obtaining the RA recommendation for Total Kt/V > 1.7 &/or CCr > 50 (Table 19).

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• SRH started with and maintained the biggest proportion of patients with no residual renal function who obtained the RA recommendation. MRI and RPH increased the proportion of patients in this group over the audit period. RLH remained the same.


Liverpool 1999/2000 91 64 63 73 75 762000/2001 94 50 45 84 70 852001/2002 90 62 69 82 77 78

Table 19: Percentage of patients with no Residual Renal Functionachieving Total Kt/V > 1.7 &/or Total CCr > 50

7 A comparative analysis of patient characteristics in the two groups who are achieving or not achieving the Renal Association standards for PD adequacy

7.1 Body Weight

• Regionally, throughout the 3 year audit period, patients achieving the Renal Association recommendation for Kt/V and CCr have a lower mean weight than patients not achieving the recommendation ( below).

• Patients at MRI, RPH and SRH achieving the Renal Association recommendation for Kt/V and CCr have a lower mean weight than patients not achieving the recommendation. This was only true at RLH in 2001/2002 (table 20,21).

SRH RLH MRI RPH Region RegionNo liverpool

1999/2000 66.4 74.5 68.4 66 67 66.82000/2001 66 75.2 69.7 67.8 72.3 67.852001/2002 66.6 68.6 70 69.5 68.2 68.5

Table 20: Median weight (Kg) of Patients Achieving Renal AssociationRecommendation for Total Kt/V and/or Total CCr

SRH RLH MRI RPH Region Regionno Liverpool

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1999/2000 75.8 72 73.4 76.5 75 75.42000/2001 72.6 73.9 74.2 70 73 72.82001/2002 82.5 72.1 76.7 76.3 76.65 77

Table 21: Median weight (Kg) of patients Not Achieving Renal AssociationRecommendation for Total Kt/V and/or Total CCr

7.2 Urine Output

• Regionally, throughout the 3 year audit period, patients achieving the Renal Association Recommendation for Kt/V and CCr had higher mean urine output levels than patients not achieving the Renal Association Recommendation for Kt/V and CCr. This result was seen at every unit (Table 22,23).

• Regionally, the mean urine output of those patients achieving the Renal Association Recommendation for Kt/V and CCr increased over the 3 years. Conversely, the mean urine output of patients not achieving the Renal Association Recommendation for Kt/V and CCr decreased over the 3 years. The results at the individual units were variable.

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Median 345 430 160 805 690 950 560 470 625 325 500 625 460 470 520

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Table 22: Urine output (mls) in Patients Achieving the RA Recommendation for Total Kt/V and/or Total CCr

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Median 40 0 0 240 0 800 25 50 0 0 0 0 20 0 0

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Table 23: Urine output (mls) in Patients not Achieving RA Recommendation for Total Kt/V and/or Total CCr

7.3 Peritoneal Dialysis Ultrafiltration

• Regionally, throughout the 3-year audit period, the mean PD ultrafiltration was higher in patients achieving the RA recommendation for Total Kt/V and Total CCr than in patients not achieving the recommendation. Results from individual units were variable (Tables 24,25)

• Regionally, over the 3-year audit period, there was little change in the mean PD ultrafiltration of patients achieving the recommendation but in those not achieving the recommendation it increased then decreased. Results from individual units were variable.

Hop

e 99

/00

Hop

e00

/01 H

ope

01/0

2

Liv

erpo

ol99

/00 L

iver

pool

00/0

1 Liv

erpo

ol01

/02

MR

I99

/00 M

RI

00/0

1 MR

I01

/02

Pre

ston

99/0

0 Pre

ston

00/0

1 Pre

ston

01/0

2 Reg

iona

l99

/00 R

egio

nal

00/0

1 Reg

iona

l

01/

02


Median 1300 1500 1150 700 1000 1000 800 1025 1100 1100 860 1025 1080 1150 1200

____________________________________________________________



No

liver

pool

Reg

ion

99/0

0 Reg

ion

00/0

1 Reg

ion

01/0

2

Lowest -1800 -1560 -1920Highest 4000 3900 3850


Table 24: PD Ultrafiltation in Patients Achieving RA Recommendation for Total Kt/V and/or Total CCr

Hop

e 99

/00

Hop

e00

/01 H

ope

01/0

2

Liv

erpo

ol99

/00 L

iver

pool

00/0

1 Liv

erpo

ol01

/02

MR

I99

/00 M

RI

00/0

1 MR

I01

/02

Pre

ston

99/0

0 Pre

ston

00/0

1 Pre

ston

01/0

2 Reg

iona

l99

/00 R

egio

nal

00/0

1 Reg

iona

l

01/

02

Lowest 100 410 -100 -600 200 -200 -450 550 -240 -100 700 130 -450 200 -240Highest 2100 2340 2610 2800 2300 1400 2130 2350 2200 1660 2800 3400 2800 2800 3400Mean 892 1250 1120 750 1030 775 691 1148 958 954 1254 1324 759 1121 977

Median 600 1000 1200 600 900 800 775 925 1075 940 1000 1005 765 950 1000

No

liver

pool

Reg

ion

99/0

0 Reg

ion

00/0

1 Reg

ion

01/0

2

Lowest -450 100 -240Highest 2130 2800 3400


Table 25: PD Ultrafiltation in Patients Not Achieving RA Recommendation for Total Kt/V and/or Total CCr

7.4 Prescribed Dialysate Volumes

• Regionally, in 199/2000 there was little difference in the mean prescribed dialysate volumes of patients achieving the RA recommendation for Total Kt/V and/or Total CCr than in those of patients not achieving the recommendation. In 2000/2001 and 2001/2002, patients achieving the RA recommendation had higher mean prescribed dialysate volumes than patients not achieving the recommendation. Results from individual units were variable (Table 26,27)

____________________________________________________________



• Regionally, over the 3-year audit period, mean prescribed dialysate volumes increased in patients achieving the RA recommendation but there was little change in those of patients not achieving the RA recommendation. Results from individual units were variable.

Hop

e 99

/00

Hop

e00

/01 H

ope

01/0

2

Liv

erpo

ol99

/00 L

iver

pool

00/0

1 Liv

erpo

ol½

MR

I99

/00 M

RI

00/0

1 MR

I01

/02

Pres

ton

99/0

0 Pres

ton

00/0

1 Pres

ton

01/0

2 Reg

iona

l99

/00 R

egio

nal

00/0

1 Reg

iona

l

01/

02


Median 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000 8000

No

Liv

erpo

ol

Reg

ion

99/0

0 Reg

ion

00/0

1 Reg

ion

01/0

2

Lowest 3000 3000 3000Highest 2050

02200

021000


Table 26: Prescribed Dialysate volumes in Patients Achieving the RA recommendation for Total Kt/V and/or Total CCr

Hop

e 99

/00

Hop

e00

/01 H

ope

01/0

2

Liv

erpo

ol99

/00 L

iver

pool

00/0

1 Liv

erpo

ol01

/02

MR

I99

/00 M

RI

00/0

1 MR

I01

/02

Pres

ton

99/0

0 Pre

ston

00/0

1 Pres

ton

01/0

2 Reg

iona

l99

/00 R

egio

nal

00/0

1 Reg

iona

l

01/

02


Median 9000 9000 8000 8000 8000 8000 8000 8000 8000 8000 8000 10000 8000 8000 8000

No

Liv

erpo

ol

Reg

ion

99/0

0 Reg

ion

00/0

1 Reg

ion

01/0

2

Lowest 4500 6000 6000Highest 1200

01250

014000


Table 27: Prescribed Dialysate volumes (mls) in Patients not Achieving RA Recommendation for Total Kt/V and/or Total CCr

____________________________________________________________



8 Summary

8.1 There has been an increase in the mean age of patients accepted on peritoneal dialysis in the region. Regionally and in all individual units the percentage of patients achieving the recommendation Total Kt/V > 1.7 and/or Total CCr > 50 L/week/1.73m2 increased significantly during the 3 year audit period. Overall in the region the Renal Association standard for PD dialysis adequacy is being met in 89 % patients who received a PD adequacy test. There was variation between different centres. Over 70% of the PD population receive a PD adequacy test annually.

8.2 Regionally, at RPH and SRH there is a high level of achievement in the proportion of patients meeting the standard and the trend has reached a plateau. Achievement is increasing at MRI. It is interesting that better results are achieved when the targets aimed for exceed the minimum recommended targets. The early introduction of a protocol for annual PD adequacy tests and a higher target Kt/V and CCr maybe an influence for the high level of achievement at SRH. Missing data could account for some of the observed differences between CAPD and APD.

8.3 The patients failing to achieve the adequacy targets were more likely to be heavier ( > 70 kg ) or with decreasing urine output. The risk of inadequacy is significantly increased if the prescribed dialysate volumes and the ulrafiltrate volumes achieved did not increase with time. This audit suggests that modifications to dialysis prescriptions were variable and insufficient in the failing high risk patients during the 3 yr audit period.

8.4 Across the network there were significant practice variations that could potentially influence the data during the audit period i.e. variations in the protocols for PD adequacy testing as described in results section, variable methods of calculating the ultrafiltration volumes and significant variations observed in the ideal target aimed for at different centres such as :

o MRI aimed for Total Kt/V > 1.7 and a CCr > 50 l/week/1.73 sq.m. (RA standard)

o RLH aimed for Total Kt/V > 2.0 and a CCr > 65 l/week/1.73 sq.m.o RPH aimed for Total Kt/V > 1.7 and a CCr > 50 l/week/1.73 sq.m. (RA

standard)o SRH aimed for Total Kt/V > 1.8 and a Ccr > 60 l/week/1.73 sq.m.

8.5At SRH, there is high level of achievement in the proportion of patients who receive a PD adequacy test and the trend has reached a plateau. Achievement of this target increased at MRI and Preston. Achievement of this target did not increase at RLH during the audit period because of limitations in staff and

____________________________________________________________



resources, resulting in patients having adequacy test only when clinically indicated. RLH data were therefore taken from a selected population with clinical problems and therefore the RLH data does not wholly represent the RLH PD population.

8.6 Prospective cohort studies in which peritoneal dialysis dose was unadjusted have reported reduced survival in patients in whom creatinine and urea clearances were not maintained. In these studies, the influence of clearances on survival could be attributed almost entirely to the maintenance of residual renal function. The implications of the audit findings highlight and reemphasise the fact that PD patients who have lost residual renal function are at increased risk, due to a combination of reduced clearance and fluid removal.

9. Key Recommendations

• To improve standards regionally, units should test dialysis adequacy at least annually in all PD patients.

• The desired adequacy target for each unit may have to be aimed at higher than the minimum recommended target to improve overall performance in individual units.

• Failure to achieve the desired total Kt/v and Ccr targets should trigger a clinical reassessment and modification of the PD prescription especially with regards to the prescribed dialysate volumes and achieved ultrafiltrate volume in these patients.

• Patients with no urine output or above 70 kg are at high risk and should be assessed more carefully, possibly every 6 months.

• To improve accuracy of the data, methods of ultrafiltration calculation should be standardised.

• If adequate dialysis cannot be achieved with PD, patients should be advised early and be able to switch modality, although this will have resource implications.

It is important that clinical aspects be taken into consideration in arriving at targets of small molecule solute clearance, which in general are the basis for measuring dialysis dose. There are many components that might be and should be considered as we discuss adequacy: blood pressure and volume homeostasis-; acid/base homeostasis- are some of the major functions of the kidney; control of lipids and cardiovascular risk; nutritional status; calcium, phosphorus, and bone homeostasis; chronic state of inflammation; middle molecule clearance are all important determinants of dialysis outcomes in addition to small solute clearance. ____________________________________________________________



Adequacy impacts on both morbidity and mortality. Effects of solute clearance on morbidity issues such as hospitalization and peritonitis rates influence patient outcome. Further such analysis could be carried out to provide such clinical information or considered in future audits.

10. References

• Rocco M et al. (2000) Peritoneal dialysis adequacy and risk of death. Kidney International 58(1) 446-457.

• Churchill d, Taylor D, Keshaviah P et al (1996). Adequacy of dialysis and nutrition in continuous peritoneal dialysis. Journal of American Society Nephrology 7 198-207.

• Maiorca R, Brumori G, Zubani R et al (1995). Predictive value of dialysis and nutritional indices for morbidity and mortality in CAPD and HD patients; a longitudinal study. Nephrology Dialysis Transplantation. 10 2295-2305.

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