Ultrafiltration Management

in Peritoneal Dialysis

桃園醫院 腎臟科
丁瑞聰

仁心仁術 優質服務 團隊榮譽 追求卓越

 案例一～基本資料
姓名：楊先生 學歷：國中
年齡： 38 歲 職業：廚師
診斷： 1.CAD with CHF ,FC II-III 2.HTN
3. CGN to ESRD
婚姻：未婚
生活習性：抽菸、喝酒的習性
透析年資：三年

仁心仁術 優質服務 團隊榮譽 追求卓越

 案例一
疾病治療過程：
原在他院就診， 102.06.09 ：因呼吸喘、頭暈、胸
悶來本院急診，

Lab data: BUN/Cr: 124/20.9 mg/dl, Hct: 28% ,

Troponin-i: 0.20 ng/ml , CK/CKMB: 484/28 IU/L

102.06.10 ： on femoral DLC 急 H/D ，爾後入院

仁心仁術 優質服務 團隊榮譽 追求卓越

 案例一
102.06.19 ： check WCC ： 48.19, KT/V ： 1.59 ,
PET ： Low /0.49
更改透析處方為
Total Volume ： 10000cc
Filling Volume ： 2500cc
Last Filling ： 2000cc
Treatment Time ： 10hrs
Wet day ： Extraneal 2L
HD ： QW
仁心仁術 優質服務 團隊榮譽 追求卓越
 案例一
re-check WCC ： 62.94 KT/V ： 2.01
一天的脫水量約為 1500-2000 ㏄

38y/o B+ 男 開始透析日期 :99/11

項目 KT/V WCC 其他
Urine Dialysate Total Urine Dialysate Total
日期 Cr/4hrs/DP nPCR nPNA
KT/V KT/V KT/V WCC WCC WCC
102/6/19 0 1.59 1.59 0 48.19 48.19 L/0.49 1.41 1.4
102/10/22 0 2.01 2.01 0 62.94 62.94 1.25 1.25
103/5/19 0 1.85 1.85 0 59.81 59.81 LA/0.55 1.2 1.2

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 案例二～基本資料
姓名：石小姐 學歷：高中
年齡： 54 歲 職業：家庭主婦
診斷 ： 1.ESRD under PD ,with pulmonary edema s/p emergent HD
2.DM 3.HTN 4. CAD,2VD
婚姻：已婚
生活習性：無抽菸、喝酒的習性
開始透析日： 99.08.03

仁心仁術 優質服務 團隊榮譽 追求卓越

 案例二
疾病治療過程：
103.06.09 ：因呼吸喘、頭暈、胸悶來本院急診
103.06.25 check PET 為 LA/0.58 ， 7/4 日回診將透析
處方調整為：
Total Volume ： 12000cc →8500cc
Filling Volume ： 1900cc →2000cc
Last Filling ： 2000cc
Treatment Time ： 10hrs
Wet day ： Extraneal 2L
仁心仁術 優質服務 團隊榮譽 追求卓越
 案例二
54 y/o O+ 女 開始透析日期 :99/8/3
項 KT/V WCC 其他
目
Urine Dialysate Total Urine Dialysate Total
Cr/4hrs/DP nPCR nPNA
日期 KT/V KT/V KT/V WCC WCC WCC
99/9/16 0.44/450 1.85 2.29 63.4 53.95 117.36 H/0.82 0.63 0.63
99/11/30 0.31/350 2.25 2.57 12.48 50.82 63.3 0.93 0.93
100/4/26 0.02/20 2.67 2.69 1.31 49.18 50.48 HA/0.66 0.65 0.65
100/9/29 0.02/50 2.74 2.76 1.98 48.77 50.74 HA/0.67 0.9 0.9
101/3/28 0 2.54 2.54 0 47.01 47.01 LA/0.62 0.81 0.8
101/9/25 0 2.84 2.84 0 60.89 60.89 LA/0.61 0.96 0.96
102/3/28 0 2.76 2.76 0 55.99 55.99 LA/0.63 0.76 0.76
102/9/25 0 2.45 2.45 0 45.17 45.17 LA/0.62 0.79 0.78
103/5/28 0 2.42 2.42 0 42.69 42.69 LA/0.58 0.81 0.81
仁心仁術 優質服務 團隊榮譽 追求卓越
 案例二～疾病治療過程
→ 三天後 check 脫水狀況，個案表示：以前
洗 5 個週期時可脫水 1100-1400 ㏄ ，現在改成 3
個週期一天脫水 700-800 ㏄ 。於是再將透析處方
更改為
Total Volume ： 8500cc →10000cc
Filling Volume ： 2000cc →2000cc
Last Filling ： 2000cc
Treatment Time ： 10hrs
Wet day ： Extraneal 2L
仁心仁術 優質服務 團隊榮譽 追求卓越
 案例二～疾病治療過程
• 7/15 日因呼吸喘來院急診急 HD 一次，爾後入院
治療。住院期間改 CAPD 一天脫水量約 1000-1200
㏄，下肢仍有水腫現象，故於 7/22 、 7/24 日再
度行 HD ，將體重下調 2.6 公斤， 7/28 日出院

• 7/29 日早上再度因呼吸喘來院急診，以 4.25% 透

析液脫水只脫 600 ㏄，於當日再急 HD 連續二天
，之後 regular HD ，將體重再下調 3 公斤。與個
案討論避免上述情況再度發生，故決定每週加洗
一次 HD
仁心仁術 優質服務 團隊榮譽 追求卓越
Ultrafiltration Management
in Peritoneal Dialysis

仁心仁術 優質服務 團隊榮譽 追求卓越

Effective Fluid Management
Established Clinical Benefits
Controls blood pressure
Lowers cardiovascular risk
- LVH
- CHF
- Stroke
Preserves GFR
Prevents uremia-like symptoms
Avoids acceleration of malnutrition,
inflammation and atherosclerosis syndrome
仁心仁術 優質服務 團隊榮譽 追求卓越
Fluid Balance

A Clinical Challenge
Maintaining edema-free state
Dynamic nature of target weight
Reliance on clinical judgment and
indicators of volume status
Individualized approach to fluid removal

Mujais, et al. Perit. Dial Int. 2000;20(suppl 4):S5-S21.

仁心仁術 優質服務 團隊榮譽 追求卓越
Fluid Overload in PD

• Symptomatic fluid retention noted in 25% of PD patients1:

• Lower extremity edema 98.6%
• Pleural effusions 76.1%
• Pulmonary congestion 80.3%

• Similar clinical observations in Japan,2 the Netherlands,3

and Sweden4
1
Tzamaloukas, et al. J Am Soc Nephrol. 1995;6:198-206.
2
Kawaguchi, et al. Kidney Int. 1997;52:S105-S107.
3
Ho-dac-Pannekeet, et al. Perit Dial Int. 1997;17:144-150.
4
Heimbürger, et al. Perit Dial Int. 1999;19:S83-S90.
仁心仁術 優質服務 團隊榮譽 追求卓越
 kidney.org.uk
仁心仁術 優質服務 團隊榮譽 追求卓越
Fluid Overload
An Underappreciated Cause of CV Mortality

• The majority of dialysis Causes of Death in Dialysis Patients1

patients die of cardiac
causes; 36% present 20% Cardiac
with CHF1,2 Other known
• Hypervolemia and 7% 47% Infection
hypertension remain 4% Unknown
important underlying Cerebrovascular
causes3 16% Malignancy
6%

1
USRDS 1997 Annual Report Data.
2
Stack, et al. Am J Kidney Dis. 2001;38:992-1000.
3
Lamiere, et al. Perit Dial Int. 2000;21:206-211.
仁心仁術 優質服務 團隊榮譽 追求卓越
Fluid Overload vs UF Failure
An Important Distinction

• Fluid overload is a common clinical syndrome

with multiple causes
• It is the inability to maintain target weight and
edema free state
• UF failure is a pathophysiologic characterisation
of one of the causes of the clinical syndrome
• Distinction between syndrome and cause
determines the intervention to be taken

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Mujais, et al. Perit. Dial Int. 2000;20(suppl 4):S5-S21.

 Causes of Fluid Overload in PD

• Excessive salt & water intake

• Loss of residual renal urine volume
• Cardiac disease
• Non compliance with PD prescription
• Insufficient use of hypertonic exchanges
• Dialysate leak
• Catheter malfunction
• Hyperglycaemia
• UF failure
仁心仁術 優質服務 團隊榮譽 追求卓越
Current UF Management
Hampered by Complexity

Dietary counseling
 Compliance issues
 may complicate management

Limiting renal excretion

 Gradual decline to anuria
 Failure to respond to diuretics

Peritoneal Ultrafiltration (UF)

 Challenge of the long dwell
仁心仁術 優質服務 團隊榮譽 追求卓越

Medcalf, et al. Kidney Int. 2001;59:1128-

 The Long Dwell in PD

APD Long dwell

Cycles 1 to 4

Manual Manual Manual

CAPD Long dwell
exchange exchange exchange

Night-time Daytime

APD and CAPD both have long dwells

In APD, even high-dose night-time exchanges involve long
dwells of 8-12 hours
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Value of the Long Dwell
Toxin removal
 Small solutes fluid flow-dependent
 Middle and large MW toxins time-dependent
 Continuously wet abdomen required for
therapy success

Lifestyle
 Logistic burden and compliance
 Realistic therapy imperative

仁心仁術 優質服務 團隊榮譽 追求卓越

Assessing Volume Status
Proactive Monitoring and Evaluation

Achieving and maintaining target weight

(goal: normal BP, with euvolemia)
Review of dietary compliance/guidelines
Monitoring residual renal function
Evaluating solute clearance
Awareness of peritoneal function

仁心仁術 優質服務 團隊榮譽 追求卓越

Mujais, et al. Perit. Dial Int. 2000;20(suppl 4):S5-S21.

Redefining what is a “dry weight”
Minimal definition
 Edema-free body weight

Maximal definition
 Weight below which further fluid removal results in signs
and symptoms of hypovolemia

Clinical definition
 Between minimal and maximal definitions with resolution
of volume-dependent derangements in homeostasis
(explained – please make notes on this!)

仁心仁術 優質服務 團隊榮譽 追求卓越

Mujais, et al. Perit. Dial Int. 2000;20(suppl 4):S5-S21.

 ISPD Guidelines
Optimal Fluid Management in PD

RRF ‡, but not peritoneal clearance, is predictive of survival

in prospective observational studies
Loop diuretics if RRF present
Routine standardized monitoring and awareness of PET†
Ultrafiltration was predictive of survival in anuric APD
patients in the prospective observational EAPOS study
UF below 750 mL/day was associated with poor survival
Patient education for enhanced compliance
*International Society for Peritoneal Dialysis;
†
Peritoneal equilibration test;
‡
Residual renal function.
仁心仁術 優質服務 團隊榮譽 追求卓越

2006 International Society for Peritoneal Dialysis

Criteria of PD adequacy

仁心仁術 優質服務 團隊榮譽 追求卓越

2006 International Society for Peritoneal Dialysis

 Fluid
UF overload / UF Failure
Failure
AAStructured
structured diagnostic
Diagnosticapproach
Approachto managing a patient

RRF* REVERSIBLE CAUSES PERITONEUM

Appropriate Dietary Mechanical Low transport

Rx indiscretion, causes
compliance
Low-average or
Dwell Leaks high-average
time Deficient transport
education Obstructions
Dialysate High transport
tonicity Complex Entrapment
regimen

*Residual renal function Malposition

Burn-out

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Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

Peritoneal Equilibration Tests (PET)

仁心仁術 優質服務 團隊榮譽 追求卓越

Principles and Practice of Dialysis, 4th ed. 2009

Initial Approach to Patients with
Fluid Overload

Principles and Practice of Dialysis, 4th ed. 2009

仁心仁術 優質服務 團隊榮譽 追求卓越

 Factors assumed to affect
the decline of Residual Renal Function

Kjaergaard K D et al. NDT Plus 2011;ndtplus.sfr035

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Fluid Overload
Identifying Reversible Causes

Clinical Syndrome

Initial Evaluation for

Reversible Causes

Dietary Non-Compliance

Appropriate Prescription

Mechanical Problems

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Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

Patients with unexplained Fluid Overload
modified (4.25%) peritoneal equilibration test (PET)

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Principles and Practice of Dialysis, 4th ed. 2009

UF Failure
Assessing UF Response

Clinical Syndrome

Initial Evaluation for

Reversible Causes

Evaluation of Peritoneal
Membrane Function

UF Response

Drain Volume Drain Volume

<2400 mL / 4 hr >2400 mL / 4 hr

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Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

 Definition of UF Failure
• Drain volume <2400ml after 4 hour dwell with 2L 4.25%
glucose

• 4.25% is preferred to 2.5% PET because the greater

osmotic challenge of a 4.25% dwell is more likely to be
discriminating in the assessment of UF

仁心仁術 優質服務 團隊榮譽 追求卓越

Principles and Practice of Dialysis, 4th ed. 2009

 UFF Classification
Type I Type III
 High transport status  Low transport status
 Rapid loss of glucose osmotic  Loss of peritoneal surface
gradient area
 Commonest; increases with  Not common
time
Type II Type IV
 decrease in osmotic  High lymphatic flow rate
conductance of glucose  By exclusion of other types
→ inadequate water removal
only
 Aquaporin dysfunction
 Prevalence unknown
 Rare 仁心仁術 優質服務 團隊榮譽 追求卓越
Overall, UFF occurs in <3% of patients in Year
1, Principles and Practice of Dialysis, 4th ed. 2009
 PET helps diagnose UF failure (UFF) ?
UF good:
Compliance w Reduced RKF
PET w 4.25 >400 ml
low Na diet and
dextrose Noncompliance
PD regimen
UF low: D/P creat
<400 ml low: <0.5 Type 2 UFF:
Low transporter
Reduced surface
D/P creat
>0.5
Type 1 UFF
High or normal D/P creat >0.8 (R/o inflammation):
transporter Na2/Na0 <0.93
Osmotic force ↓
D/P creat <0.8
Na2/Na0 >0.93 Aquaporin 1
UF Failure Function ↓
Na2/Na0 <0.93
• Type 1: >50%
• Type 2: <10% Normal PET Lymphatic
solute kinetics Reabsorption ↑
1. Smit et al: Analysis of the prevalence and causes of ultrafiltration failure PDI 2004; 24:562–70
2. Coester M: Peritoneal function in clinical practice… NDT Plus (2009) 2: 104–110 仁心仁術 優質服務 團隊榮譽 追求卓越
3. Gomes et al: Categorization of sodium sieving…NDT 2009; 0: gfp319v1-gfp319
UF Failure
Peritoneal Membrane Function

UF Response

Drain Volume
<2400 mL/4 hr

PET
transport results

Low Transport High-Avg or Low-Avg High Transport

D/P Cr <0.5 0.81> D/P Cr >0.5 D/P Cr >0.81

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Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

UF Failure
Low Drain, High Transport

Drain Volume
<2400 mL/4 hr

Small Solute Profile

High Transport
D/P Cr >0.81

 Inherent high transport

 Recent peritonitis
 High transport of long-term PD → Type I UFF

仁心仁術 優質服務 團隊榮譽 追求卓越

Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

UF Failure
Low Drain, High-Avg or Low-Avg Transport

Drain Volume
<2400 mL/4 hr

PET
transport results

High-Avg or Low-Avg Transport

0.5< D/P Cr <0.81

 Mechanical problems
 Tissue absorption
 Aquaporin deficiency → Type II UFF
 ↑ Lymphatic absorption → Type IV UFF

仁心仁術 優質服務 團隊榮譽 追求卓越

Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

UF Failure
Low Drain, Low Transport

Drain Volume
<2400 mL/4 hr

PET
transport results

Low Transport
D/P Cr <0.5

 Disruption of peritoneal space, adhesions, etc.

→ Type III UFF
 Peritoneography

仁心仁術 優質服務 團隊榮譽 追求卓越

Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

Therapeutic Approaches
Universal Measures
Low Drain, – CAPDAPD
High Transport – Icodextrin for long dwells

Low Drain, – Icodextrin for long dwells

High-Avg or Low-Avg – Dextrose for short dwells
Transport

Low Drain, – High-dose loop diuretics with RRF

Low Transport – Adjunctive HD or transfer to HD

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Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

Volume Control Algorithm

Interventions

Dietary Residual Peritoneal

Evaluation Renal Function Prescription

Salt Volum e Long dw ell

Fluid Trend Total UF
M eds/effects PET

仁心仁術 優質服務 團隊榮譽 追求卓越

Volume Control Algorithm

Interventions

Evaluate Characterize Catheter

Com pliance Edema Function

QOL issues localized vs. Outflow obs

Inventory control generalized Leaks/hernia
Delivered dose Trend

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 Volume Control Algorithm
P e rit. P re s c rip tio n

R e v ie w
P ET

E v a lu a te 24 hr UF
L o n g d w e ll U F

N e g a tiv e P o s itiv e
net UF net UF

M o d ify M o d ify A lte rn a te O p tio n al

d w e ll tim e to n ic ity o s m o tic a g e n t m in im iz e 4 .2 5 %
仁心仁術 優質服務 團隊榮譽 追求卓越
Volume Control Algorithm
O p t im iz e
s h o r t d w e ll U F

C y c le r CAPD

In cre a se M o d ify
c y c le n u m b e r t o n ic ity

M o d ify C o n s id e r
t o n ic ity a d d it io n a l e x c h a n g e

In cre a se C o n s id e r
c y c le r t im e fill v o lu m e

C o n s id e r
fill v o lu m e
仁心仁術 優質服務 團隊榮譽 追求卓越
Volume Control Algorithm

U rine
O u tp ut

N ep h roto xin s?

<200 m l/d ay >200 m l/d ay

C o n sid er
D iu retics
仁心仁術 優質服務 團隊榮譽 追求卓越
High transport & outcome
High transporters:
Efficient membranes for small solute clearance
but may have difficulty with ultrafiltration, especially during
the long dwell Recent studies
(Davis1 and
Impact on outcomes in PD Churchill2) have
shown that high
100 transporters
% Surviving

had a worse
90 prognosis probably
due to a more
High
80 difficult fluid balance
High Average
management
Low Average
70 Low

60
0 6 12 18 24
Time in Months
仁心仁術 優質服務 團隊榮譽 追求卓越
1 Davis et al. KI 1999 Vol 54 p 2207 – 2217
2 Churchill et al JASN 1998 - Vol 9 1285 - 1292
 Therapeutic approaches for
High transporters
Inherent high transporters
• APD & icodextrin for the long dwell is the
recommended therapeutic approach

Recent peritonitis
• “Several studies have indicated that UF during an
episode of peritonitis can be satisfactorily achieved with
the use of icodextrin”

High transport during long term PD

• For patients with a net UF less than 400 mL/4 hours and
a high transport profile of small solute clearance, APD
and icodextrin for the long dwell are the recommended
therapeutic approaches
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Mujais, et al. Perit Dial Int. 2000;20(suppl 4):S5-S21.

 Summary:
12 Strategies to improve Volume Management in PD

1. Start PD earlier
2. Protect residual renal function
3. Use high-dose loop diuretics on maintain urine output
4. Educate patients regarding salt and water intake and
regarding significance of oedema, weight gain, etc
5. Appropriate use of hypertonic solutions
6. Awareness of PET status

仁心仁術 優質服務 團隊榮譽 追求卓越

 Summary:
12 Strategies to improve Volume Management in PD

7. Consider APD in high and high average transporters

8. Night exchange device in CAPD if night –time dwell is
reabsorbed
9. Short day indwell on APD – long enough to give good
clearance and short enough to give good UF
10. Icodextrin for long dwell in CAPD & APD
11. Frequent reassessment of the patient’s target weight
12. Anti-hypertensives only when volume removal has
failed to reduce BP.

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謝謝聆聽
歡迎指教

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