1. Therapy Modality: Automated Peritoneal Dialysis (APD)
Renal Division
Baxter Healthcare

2. APD – prescription basics
Automated (cycler) therapy
Flexible prescription volumes
Recommended – (European APD Advanced Club)
9 hour total therapy time (CCPD, NIPD)
12-14L. total therapy volume
‘Wet’ days, i.e. long day dwell of hr (Extraneal)
4-8 nightly cycles, with (optional) 1-2 additional day exchanges /cycles
Daily therapy, 7 days week
30 minute – 120 minute dwell times each cycle (depending on PET result)

3. Types of PD

4. APD benefits
Optimum dialysis for high transporters, large body surface area, and minimal residual renal function
Offers potential for better clearances than in CAPD
Volumetric control of fill, drain and therapy volume delivery
Supine positions at night permit larger fill volumes, a major determinant of treatment adequacy
Short dwells may increase ultrafiltration & clearance

5. APD benefits
Reduced risk of intra-peritoneal pressure complications:hernias, leak, back pain, reduced appetite
8. Reported lower incidence of peritonitis than CAPD
9. Treatment of choice for children – avoids school interruptions and encourages peer integration (“normality”)
10. Daytime freedom and comfort

6. APD benefits Employment and school uninterrupted
Improved patient compliance
13. Increased patient comfort
14. Possible to monitor patient compliance at home

7. Clinical Practice Guidelines of the Canadian Society of Nephrology for treatments of Patients with CRF JASN 10: S287-S321, 1999
‘A prescription that is compatible with the patient’s preferences and lifestyle is likely to reduce the risk of patient « burnout » and noncompliance’

8. APD regimens

9. APD Nightly Intermittent PD (NIPD)
APD performed nightly only, with complete fill and drain of the peritoneal cavity
Most patients cannot be maintained on NIPD alone without diurnal additions
Limitations:
Not efficient in anuric patients
Inadequate in large BSA patients (>2m2)
Inadequate in low – low average Transporters
High cost may be prohibitive

10. APD modalities TIDAL PD
Dialysis fill volume is only partly drained, leaving a ‘reserve’ volume in contact with peritoneum
Tidal fill volume brings fresh fluid to mix with the reserve volume each cycle
Tidal therapy increases dialysate flow and reduces drain and fill times (therapy rationale)
Combined with larger fill volumes, it will raise clearances in ‘High’ to ‘High Average’ transporters
Only option for anephric patient clearance
Less ‘drain-pain’ an added advantage

11. APD modalities
CCPD – Continuous Cyclic PD
Nocturnal therapy, with day time long dwell (only realistic if Icodextrin containing solution used for day dwell)
5-8 exchanges in relatively short dwell periods, maximising U/F and clearances
Therapy most used in practice

12. APD modalities IPD - Intermittent PD
PD prescribed mainly 2-3 times per week for hours each session
Large volumes (20-40 litres) are cycled each session, short dwells, fill volumes litres
IPD fails to deliver sufficient quantity dialysis if BSA, RRF
Mostly used in elderly; acute patients; new catheter conditioning – N.B. no longer a preferred modality for majority of patients
Only adequate for high transport patients
Reduced protein losses, glucose absorption and fluid retention

13. APD - therapy programming
Inputs required:
Total therapy volume
Total therapy time
Fill volume
Last fill: volume, and same or different dextrose
Machine calculates:
Number of cycles
Estimated Dwell time per cycle

14. Programming the HomeChoice System
Example therapy:
Total therapy volume = ml
Total therapy time = Nine hours
Fill volume = 2000 ml
Last bag = 2000 ml, same dextrose
Machine calculates:
Number of cycles = 5 cycles
Estimated Dwell time per cycle = 1:19
1. HomeChoice assumes 'typical' flow rates to calculate Drain and Fill times.
2. Dwell times are updated throughout the therapy depending on actual time required for Fill and Drain.
3. HomeChoice ALWAYS DELIVERS THE MAXIMUM AMOUNT OF DWELL TIME WITHIN THE PROGRAMMED THERAPY TIME!

15. How does it work ? 5 litre 5 2.5 SETUP of system (example):
A. One 5000ml bag on the heater plate
B. Other bags connected to the HomeChoice
set:
5 litre 5
2.5
Press go to start
Baxter

16. APD made easier PRO Card PATIENT’S HOME HOSPITAL
PD LINKä
software
PRO Card
The PRO Card is used to download therapy information from the HomeChoice PRO and is read, at the hospital, using the PD Link software

17. How does it work? 1 Write a Prescription
2 Program HomeChoice PRO with Pro Card
3 HomeChoice PRO records therapy results
4 Retrieve therapy results or
5 Analyze therapy results

18. Managing Patients on Home Therapies
Balancing Clinical and Lifestyle Needs:
Dialysate Clearances
Quality of Life
The balance results in Improved Outcomes

19. Procedural Modifications - to improve UF1 2 3 4

20. Procedural Modifications - fill (dwell) volume
Increasing fill volumes maximises the peritoneal capacity and improves solute clearances. You will notice that the time between exchanges however does NOT change.

21. Procedural Modification - no. of exchanges

22. Procedural Modifications - partial day fill

23. APD - Increasing Clearance
Programme an increase in fill volume
Effective means of improving clearance
Minimum impact on patient lifestyle
Adjust nighttime exchanges first
Use 2.0L or greater whenever possible
Add a daytime exchange
Increase Time on Cycler
Increase Number of Nighttime Exchanges

24. APD - Increasing Clearance
Increase fill volumes
Add a daytime exchange
This is a very effective means of improving clearance
HomeChoice can be programmed to deliver an exchange at midday
Increase Time on Cycler
Increase Number of Nighttime Exchanges

25. APD - Increasing Clearance
Increase fill volumes
Add a daytime exchange
Increase Programmed Time on Cycler
Cycler time can be extended to 10 hours
Increasing cycler time with a constant number of exchanges increases dwell time which increases clearance
Increase Number of Night-time Exchanges
- May increase clearance, but only if dwell
time on cycler is also increased

26. The Importance of “Wet Days”
> 85% of APD patients - all except High Transporters – will
require a daytime dwell to achieve adequate dialysis
> High transporters need daytime dwells with Icodextrin to
achieve ultrafiltration targets
> 85%
Wet Day Dry Day 0% 5%
10%
15%
20%
25%
30%
35%
Low
Average
High
CCPD+CAPD CCPD NIPD

27. Fluid Balance - General Guidelines for APD
Evaluation and Management of Ultrafiltration problems in PD, ISPD Recommendations, PDI Vol 20, suppl 4, 2000
Avoidance of long dwells with low glucose
Use of mid-day drain even when no additional exchange is needed for clearance
“The most frequently ignored principles in PD that lead to UF difficulties are the need to avoid long glucose dwells in high transporters and balancing glucose concentration and dwell time”

28. Designing the Optimal APD Therapy
Fact: APD utilizes shorter dwell times, relative to CAPD. Therefore, more solution volume is needed to provide adequate clearance
Fiction: More total solution volume will always provide better clearance for APD patients
The Key to success with APD is a balance of:
Solution Volume and Dwell Time
Excessive solution volume = too many cycles =
wasted time filling and draining = reduced clearances

29. CAPD or APD? CAPD Easy technique
Daytime exchanges can be difficult if working or for carer
Poor UF if high transporter resulting in use of high dextrose fluids
APD
More difficult technique
No or only 1 daytime exchange
Easier to achieve high UF independent of transporter status

30. CAPD or APD? CAPD Difficult to  adeq by  exchange number or volume
 exchange volume  intraperitoneal pressure when patient ambulant
 risk of herniae and leaks
APD
Easy to  adequacy by  exchange number overnight
Intraperitoneal pressure lower when patient supine
 risk of herniae and leaks

31. CAPD or APD?
CAPD
Adequacy  in low transporters by 5th exchange - ‘Quantum’ or 1/wk HD
Ease of travel
Peritonitis 1/20-24 mths
APD
Difficult to achieve adequacy in low transporters
Can travel with machine or revert to CAPD
Peritonitis 1/30-40 mths