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PET and Adequacy
Atma Gunawan
PET (peritoneal equilibrum
test)
Information on the rate of
peritoneal transport of small solute
and ultrafiltration capacity
Peritoneal Dialysis
Applications of the PET
•
•
•
•
•
•
peritoneal membrane transport classification
predict dialysis dose
choose peritoneal dialysis regime
monitor peritoneal membrane function
diagnose causes of inadequate ultrafiltration
diagnose causes of inadequate solute clearance
When PET performed ?
• PET should be performed approximately 4 weeks
after initiating peritoneal dialysis, but no earlier
• PETs should be repeated at 2 years and then
annualy.
The CARI Guidelines – Caring for Australians with Renal Impairment
Aquaporine channel
PRINCIPLES OF PERITONEAL DIALYSIS
( the three pores model of peritoneal transport)
Ultrapores (4-6 An). Water sieving,Aquaporin water Channel.
(Natrium, Urea N, Kreatinin tidak lolos)
Small pores (40-60An),celah di endotel meloloskan small
solute,air
Large pores (100-200 An), celah di endotel,meloloskan
macromolecules
Persiapan PET
• Malam : dwell dengan dialisat 2.5%
• Dwell time : 8-12 jam
• Drain out di di klinik CAPD
1. Posisi
duduk : drain out
dialisat 2.5% setelah dwell 810 jam (malam)
2. Posisi baring  drain in dialisat 2.5% 2 liter, sekitar
10 menit. Setiap 400 ml masuk, pasien posisi pasien
miring kanan-miring kiri
3. Drain out dialisat 200 cc ke dalam kantong 
dibalik-balik.
4. Bersihkan medication port dengan
bethadine selama 5 menit, aspirasi 10cc cairan
dialisat dengan spuit, taruh kedalam red top
tube. Masukkan sisanya 190 cc ke rongga
peritoneum
= Dialisat
0 jam
5. Setelah dwell 2 jam, ulangi prosedur
no 4. konektor transfer set boleh dilepas
= Darah 2
jam
= Dialisat
2 jam
6. Ambil darah 5cc.
7. Jam ke-4: drain out semua dialisat,
lakukan seperti protokol no 4. Lanjutkan
dengan cairan dialisat sehari-harinya.
= Dialisat
4 jam
0 jam (PET 1)
2 jam (PET 2
•Kreatinin
•Glukosa
4 jam (PET 3)
PERHITUNGAN
PET
D/P = KONSENTRASI
DIALISAT
KONSENTRASI PLASMA
4,2 = .68
6.1
D/P = 1,0 berarti bahwa dialisat mempunyai konsentrasi solut yang sama dengan plasma, atau men
capai 100 % keseimbangan.
0.68 berarti dialisat dalam 68 % keseimbangan
CORRECTION FACTOR
• TINGGINYA KONSENTRASI GLUKOSA PADA CAIRAN
DIALISAT DAPAT MEMPENGARUHI HASIL PENILAIAN
LABORATORIUM DARI KREATININ (menghasilkan
kreatinin tinggi palsu)
• PERLU FAKTOR KOREKSI
KREATININ TERKOREKSI
• KREATININ TERKOREKSI mg/dl = KREATININ mg/dl (GLUKOSA X CORRECTION FACTOR)
CORRECTION FACTOR FROM FRESH 2.5% DIANEAL = .000210526
Contoh :
SERUM kreatinin =12
GLUKOSA = 95
CORRECTED SERUM CREATININE = 12 - (95 X .000210526)= 12-.0199975= 11.9
Peritoneal Equilibration Test
Copyright of Baxter Healthcare
Peritoneal Dialysis
Relationship Between Dwell Time
and Transport
Transport
Rapid
High A
Low A
Low
Solute Cl
++++
+++
++
+
UF Prescription
+
Short dwell
++
CAPD/CCPD
+++
CAPD/CCPD
++++
Long Dwells
Peritoneal membrane characteristics according to PET result
Membrane type 4-hr D/P
creatinine
Australian
Non-diabetics
(ANZDATA 2003)
Australian
Diabetics
(ANZDATA 2003)
High
0.81 – 1.03
9%
10%
High Average
0.65 – 1.80
56%
51%
Low Average
0.50 – 1.64
32%
37%
Low
0.34 – 1.49
3%
2%
The CARI Guidelines – Caring for Australians with Renal Impairment
PROFIL PASIEN CAPD DI RSSA MALANG
2015
Karakteristik (n = 68 pasien)
Usia (tahun)
Hasil (mean ± SD atau %)
47.79 ± 11.25
Jenis Kelamin (n %)
- Laki-Laki
40 (58.8%)
- Perempuan
28 (41.2%)
BMI (kg/m2)
23.84 ± 4.7
BSA (m2)
1.6 ± 0.19
Lama CAPD (bulan)
24.47 ± 29.2
Total Urine (mL)
289.41 ± 371.76
Total Drain (mL)
8730 ± 1226.45
D/P H4Cr
0.68 ± 0.12
DM (n %)
- DM
23(33.8%)
- Non DM
45(66.2%)
Peritonitis (n %)
- Peritonitis
11(16.2%)
- Non Peritonitis
57 (83.8%)
Tipe Membran Peritoneal
Pasien CAPD di RSSA Malang
Adequacy of PD
What is Clearance?
• Clearance is the total amount of body fluid
completely cleared of a solute during a certain
time
• ml/min
• L/week
• Ex: Creatinine clearance = 50 l/week means:
50 L of body fluid is totally cleared for creatinine
during a week
• Other indicator urea clearance : KT/V
Patient survival according to Kt/V group
(Hongkong Trial)
p value of the difference was 0.0582 at 12
months, and 0.295 at 24 months
Peritoneal Dialysis International, Vol. 21, pp. 441–447
Targets for solute clearance (2005 European Best
Practices Guidelines and the 2006 International Society for Peritoneal
Dialysis (ISPD) Guidelines/Recommendations)
CrCl
50
60
1.7
2.0
Kt/V
Suggested impact on outcome
Calculation of Peritoneal Creat. Clearance
Drain No Dwell
time
1
285
Drain Vol.
2500
Drain
creatinine
804
2
285
2500
800
3
315
2625
817
4
597
2500
1017
Plasma
1091
creatinine umol/l
Body
1.737 m2
surface
area
Total drain vol = 10125 ml
Ave drain creat = 859.5 umol/l
Calculation of Peritoneal Creat Clearance
dialysate creatinine
weekly creatinine clearance(l )  total drain volume x
x7
plasma creatinine
= 10.7 x 0.788 x 7
= 59 l/wk
Normalise to BSA
= CCl x 1.73/ patients BSA
Normalised weekly CCl = 59 l/wk/1.73 m2
Calculation of Peritoneal Urea Clearance
Drain No
Dwell time Drain Vol.
Drain urea
1
285
2500
11.9
2
285
2500
12.2
3
315
2625
10.0
4
597
2500
14.3
Plasma urea 14.4 mmol/l Total drain vol = 10125 ml
Volume of 31595 ml
distribution
Average drain urea = 12.7
Calculation of peritoneal urea clearance
weekly Kt / v  (
drain volume
diaysate urea
x
)x 7
volume of distribution plasma urea
10125 12.7
weekly Kt / v 
x
x7
31595 14.1
= 0.288 x 7
= 2.02
Volume distribution urea
V(men)=55% BW
V(women)=50% BW
Adekuasi pasien CAPD RSSA Malang (n=68), th
2015

Klirens urea (wKT/V) : 1,84 ± 0,56 liter/minggu

Klirens kreatinin (wCCr) : 61,51 ± 23,69 liter/minggu/m2

Standar NKF/K- DOQI : wKT/V ≥ 1.7 liter/minggu
wCCr ≥ 60 liter/minggu/m2
Peritoneal Dialysis
Gambar Perbedaan Kt/V pada Masing-Masing Type Membran
1.800
1.650
Kt/V HA <> Kt/V H
(t=2,380 P=0,026)
1.500
1.350
Mean=1,125
1.200
KT/V
1.050
0.900
0.750
Mean=0,876
Mean=0,818
0.600
0.450
0.300
0.150
0.000
Low Average
High Average
Type Membran
High
Peritoneal Dialysis
Kontribusi renal terhadap total kliren kreatinin
(pasien CAPD RSSA Malang 2006, n=37)
Renal
Cr
3.59%
Cl.Cr
96.41%
Optimizing peritoneal dialysis dose
Increase dialysis
dose by increasing
drain volumes
Schedule dwell
times to
maximise
clearance
drain volu me D
target urea clearance 
x x7
distr volu me P
Problems
arise for
large body
weights
Main principles behind
the PD guidelines
•
•
•
•
Patients with higher D/P require an increased number of exchanges during
the night
Patients with higher BSA require higher fill volume per exchange
Anuric patients are advised to have an extra day exchange (OCPD)
Extraneal is encouraged to be used in all patients during a long day well
as it can improve the UF and clearance of patients
L
(D /P < 0 .5 )
LA
(D /P 0 .5 -0 .6 5 )
HA
(D /P 0 .6 5 -0 .8 1 )
H
(D /P > 0 .8 1 )
S m a ll (< 1 .7 1 B S A )
Increase number of exchanges
M e d iu m (1 .7 1 - 2 .0 B S A )
L a r g e (> 2 .0 B S A )
Increase
fill
volume
Treatment guidelines – a summary
• Patients with BSA> 1.7m2 or body weight >65 kg
• Routinely prescribed 2.5L fill volume
• Patients with BSA> 2 m2 or body weight >80 kg
• Routinely prescribed 3 L fill volume
• Patients requiring 5 day exchanges should use a
night time exchange device to deliver the 5th
exchange
• Patients on APD should do one or more day time
exchanges (unless small BSA or high RRF)
Clinical Practice Guidelines of the Canadian Society of Nephrology for treatments of Patients with CRF
JASN 10: S287-S321, 1999
2006 K/DOQI guidelines
For patients with RKF (if urine volume is >100 mL/day):
• The minimal delivered dose of small solute clearance
should be a total (PD and RKF) Kt/Vurea of at least
1.7/week.
For patients without RKF (if urine volume is <100 mL/day):
• The minimal delivered dose of small solute clearance
should be a peritoneal Kt/Vurea of at least 1.7/week.
The dose should be measured within the first month of
starting dialysis and at least every four months
Wassalam