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postgraduate thesis: Small solute clearance target as an index of adequacy of dialysis in peritoneal dialysis

TitleSmall solute clearance target as an index of adequacy of dialysis in peritoneal dialysis
Authors
Issue Date2016
PublisherThe University of Hong Kong (Pokfulam, Hong Kong)
Citation
Lo, W. [盧維基]. (2016). Small solute clearance target as an index of adequacy of dialysis in peritoneal dialysis. (Thesis). University of Hong Kong, Pokfulam, Hong Kong SAR.
AbstractPeritoneal dialysis (PD) is an important renal replacement therapy for survival of patients with end-stage renal failure. In the 1980s and early 1990s, the standard PD regime was four 2-liter daily exchanges in the western world but was only three 2-liter exchanges in Hong Kong. One important dimension of dialysis is small solute clearance. The formula Kt/V (K = urea clearance, t = time = 1 week, V = volume of distribution of urea = total body water) is a popular index used to represent adequacy of dialysis in terms of small solute clearance. The finding of better patient survival with higher Kt/V in an observational study in North America had led to the recommendation of a target Kt/V of 2.0 for PD by the National Kidney Foundation of the USA in 1997.In this thesis, a series of studies were conducted to better define the adequacy of dialysis in terms of small solute clearance in a stepwise manner. We started with analyzing and comparing the survival of 507 patients received PD in Tung Wah Hospital from 1983-1994 and the Kt/V of the existing 201 PD patients to the western world. The mean Kt/V (1.76+0.36) was substantially lower than the western world, and yet patient survival was not inferior. This casted doubt on the Kt/V target recommended. We then analyzed the Kt/V, nutritional status and subsequent survival of 937 prevalent PD patients in nine hospitals in Hong Kong and found no correlation between Kt/V and nutritional status. Nutritional status predicted patient survival but Kt/V did not. Peritoneal Kt/V in the anuric patients was also not predictive of survival. A randomized control study was conducted in six hospitals from 1996 to 2000. 320 incident PD patients with renal Kt/V less than 1.0 were randomized into three different Kt/V targets: 1.5-<1.7, 1.7-2.0, >2.0. There was no difference in the 2-year patient survival and outcome between groups except that more patients in the lowest Kt/V group were withdrawn for clinical problems and required erythropoietin treatment, suggesting that they had inadequate dialysis. We concluded that the total Kt/V(renal + peritoneal)target should be at least 1.7. To define the peritoneal Kt/V target for anuric patients whose survival is dependent on peritoneal clearance, we retrospectively analyzed the relationship between peritoneal Kt/V and anuric patients’ survival counting from the time of documentation of anuria. We found that baseline peritoneal Kt/V less than 1.67 was associated with worse survival, and patients with peritoneal Kt/V above 1.7 throughout had better survival than those with Kt/V less than 1.7, whether it was corrected to above 1.7 subsequently or not. This suggested that anuric patients should have peritoneal Kt/V maintained above 1.7 at all times. These findings led to the revision or formation of several international guidelines on adequacy of peritoneal dialysis in 2005-6. All recommended Kt/V 1.7 or above being the treatment target, and the peritoneal Kt/V target should also be above 1.7 for anuric patients. These recommendations were subsequently adopted into different national guidelines and quality assurance programs.
DegreeDoctor of Medicine
SubjectPeritoneal dialysis
Dept/ProgramMedicine
Persistent Identifierhttp://hdl.handle.net/10722/237212
HKU Library Item IDb5796664

 

DC FieldValueLanguage
dc.contributor.authorLo, Wai-kei-
dc.contributor.author盧維基-
dc.date.accessioned2016-12-28T02:01:50Z-
dc.date.available2016-12-28T02:01:50Z-
dc.date.issued2016-
dc.identifier.citationLo, W. [盧維基]. (2016). Small solute clearance target as an index of adequacy of dialysis in peritoneal dialysis. (Thesis). University of Hong Kong, Pokfulam, Hong Kong SAR.-
dc.identifier.urihttp://hdl.handle.net/10722/237212-
dc.description.abstractPeritoneal dialysis (PD) is an important renal replacement therapy for survival of patients with end-stage renal failure. In the 1980s and early 1990s, the standard PD regime was four 2-liter daily exchanges in the western world but was only three 2-liter exchanges in Hong Kong. One important dimension of dialysis is small solute clearance. The formula Kt/V (K = urea clearance, t = time = 1 week, V = volume of distribution of urea = total body water) is a popular index used to represent adequacy of dialysis in terms of small solute clearance. The finding of better patient survival with higher Kt/V in an observational study in North America had led to the recommendation of a target Kt/V of 2.0 for PD by the National Kidney Foundation of the USA in 1997.In this thesis, a series of studies were conducted to better define the adequacy of dialysis in terms of small solute clearance in a stepwise manner. We started with analyzing and comparing the survival of 507 patients received PD in Tung Wah Hospital from 1983-1994 and the Kt/V of the existing 201 PD patients to the western world. The mean Kt/V (1.76+0.36) was substantially lower than the western world, and yet patient survival was not inferior. This casted doubt on the Kt/V target recommended. We then analyzed the Kt/V, nutritional status and subsequent survival of 937 prevalent PD patients in nine hospitals in Hong Kong and found no correlation between Kt/V and nutritional status. Nutritional status predicted patient survival but Kt/V did not. Peritoneal Kt/V in the anuric patients was also not predictive of survival. A randomized control study was conducted in six hospitals from 1996 to 2000. 320 incident PD patients with renal Kt/V less than 1.0 were randomized into three different Kt/V targets: 1.5-<1.7, 1.7-2.0, >2.0. There was no difference in the 2-year patient survival and outcome between groups except that more patients in the lowest Kt/V group were withdrawn for clinical problems and required erythropoietin treatment, suggesting that they had inadequate dialysis. We concluded that the total Kt/V(renal + peritoneal)target should be at least 1.7. To define the peritoneal Kt/V target for anuric patients whose survival is dependent on peritoneal clearance, we retrospectively analyzed the relationship between peritoneal Kt/V and anuric patients’ survival counting from the time of documentation of anuria. We found that baseline peritoneal Kt/V less than 1.67 was associated with worse survival, and patients with peritoneal Kt/V above 1.7 throughout had better survival than those with Kt/V less than 1.7, whether it was corrected to above 1.7 subsequently or not. This suggested that anuric patients should have peritoneal Kt/V maintained above 1.7 at all times. These findings led to the revision or formation of several international guidelines on adequacy of peritoneal dialysis in 2005-6. All recommended Kt/V 1.7 or above being the treatment target, and the peritoneal Kt/V target should also be above 1.7 for anuric patients. These recommendations were subsequently adopted into different national guidelines and quality assurance programs.-
dc.languageeng-
dc.publisherThe University of Hong Kong (Pokfulam, Hong Kong)-
dc.relation.ispartofHKU Theses Online (HKUTO)-
dc.rightsThis work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.-
dc.rightsThe author retains all proprietary rights, (such as patent rights) and the right to use in future works.-
dc.subject.lcshPeritoneal dialysis-
dc.titleSmall solute clearance target as an index of adequacy of dialysis in peritoneal dialysis-
dc.typePG_Thesis-
dc.identifier.hkulb5796664-
dc.description.thesisnameDoctor of Medicine-
dc.description.thesislevelMaster-
dc.description.thesisdisciplineMedicine-
dc.description.naturepublished_or_final_version-

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