Read Microsoft PowerPoint - Tidal therapy approved 11-11-09.ppt text version

Tidal Therapy in Peritoneal Dialysis

©2009 Fresenius Medical Care North America, All rights reserved.

The first module of this course has been designed to educate the participant in the basic concepts of tidal peritoneal dialysis (TPD). The second module of this course is specific to the renal professional who uses the Liberty peritoneal dialysis (PD) cycler in their practice and focuses on how to program a TPD prescription into the

Liberty cycler for both treatment based and cycle based modes or settings.

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This course is provided by the ADVANCED RENAL EDUCATION PROGRAM® and is designed to support peritoneal dialysis (PD) education within the global renal community

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©2009 Fresenius Medical Care North America, All rights reserved.

This course is provided by the ADVANCED RENAL EDUCATION PROGRAM® and is designed to support PD education within the global renal community.

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Course disclosure

· This educational program is not intended to replace the judgment or experience of the attending physician or other medical professional. The PD treatment prescription is the sole responsibility of the attending physician. · Consult the Liberty cycler user's guide for detailed device description, instructions, contraindications, warnings, and precautions · Please refer to your clinic's policies and procedures for further information

©2009 Fresenius Medical Care North America, All rights reserved.

This educational program is not intended to replace the judgment or experience of the attending physician or other medical professional. The PD treatment prescription is the sole responsibility of the attending physician. Consult the Liberty cycler user's guide for detailed device description, instructions, contraindications, warnings, and precautions. Please refer to your clinic's policies and procedures for further information

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Module 1: Tidal peritoneal dialysis (TPD) overview

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©2009 Fresenius Medical Care North America, All rights reserved.

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Course objectives

The overall objective of Module 1 is to provide a basic understanding of the TPD technique and modality By the end of this module the participant will be able to:

· Define TPD

· Describe the principles of TPD · Calculate tidal fill and drain volumes

©2009 Fresenius Medical Care North America, All rights reserved.

The overall objective of Module 1 is to provide a basic understanding of the TPD technique and modality. By the end of this course the participant will be able to: Define TPD Describe the principles of TPD And calculate tidal fill and drain volumes

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Introduction: Why tidal therapy?

· Continuous cycling peritoneal dialysis (CCPD)

­ Provides a PD option to dialyze during the evening hours ­ Eliminates day time exchanges

· Adequate clearances may not be achieved by all CCPD patients · TPD may increase dialysis efficiency without sacrificing the advantages of CCPD1

©2009 Fresenius Medical Care North America, All rights reserved.

Why was tidal PD therapy conceived? Continuous cycling peritoneal dialysis (CCPD) provides patients with an option to dialyze during the evening, freeing them for activities during the day. However, even with this therapy, not all patients are able to achieve adequate clearances. Therefore, TPD was proposed in an attempt to increase dialysis efficiency without sacrificing the advantages of CCPD1.

1. Flanigan M, Pflederer T, Doyle C, et al. Tidal peritoneal dialysis in children: Initial experiences. Dial Transplant 22:554-563, 1993

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Tidal therapy history

· First introduced in 1978 as reciprocating PD2 · Thought to improve clearances by:

­ Increased mixing of the PD fluid ­ Reduced non-dialytic transit time through the creation of a tidal flow2

©2009 Fresenius Medical Care North America, All rights reserved.

TPD was first introduced in 1978 as reciprocating PD2. The rationale was that TPD would improve small-solute removal through better mixing of the PD fluid by the use of tidal cycles and create a reduction in the non-dialytic transit time through the creation of a tidal flow, whereby dialysate would constantly be in contact with the peritoneal membrane

2. Stephen RL. Reciprocating peritoneal dialysis with a subcutaneous peritoneal catheter. Dial Transplant 7:834-838, 1978

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TPD: A technique and a cycling modality of PD

· Initial fill followed by a partial drain and replacement by fresh dialysate with each cycle · A portion of the dialysate is in constant contact with the peritoneal membrane (reserve volume) · A wave or tide is created by the inflow and outflow of the tidal volume3.

UF

Tidal volume

Tidal drain

Tidal fill

Reserve volume (RV)

Residual volume

Modified from reference 4 ©2009 Fresenius Medical Care North America, All rights reserved.

Exactly what is TPD? TPD is both a technique and a cycling modality of PD. The tidal technique uses an initial fill followed by a partial drain and replacement by fresh dialysate with each cycle. This leaves a portion of the dialysate constantly in contact with the peritoneal membrane (reservoir volume) and a wave or tide created by the inflow and outflow of the tidal volume3.

3. Diaz-Buxo JA. PD modalities. Retrieved August 31, 2009 from http://www.advancedrenaleducation.com/PeritonealDialysis/ModalitiesofTherapy/PDModalities /tabid/83/Default.aspx 4. Diaz-Buxo JA. Automated peritoneal dialysis. A therapy in evolution. In: Ronco C, Amici G, Feriani M, Virga G, eds. Automated Peritoneal Dialysis. Contributions to Nephrology. Basel. Karger,1999:129,1-14

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TPD prescription example3

©2009 Fresenius Medical Care North America, All rights reserved.

As a cycling modality of peritoneal dialysis, the initial fill of dialysate is followed by a series of fills and drains of lesser volume. Only a portion of the dialysate is drained with each tidal drain thereby leaving solution in the peritoneal cavity throughout the night. The tidal drain is replaced with fresh dialysate throughout the night to restore the initial fill volume and at the end of the treatment the entire volume is drained prior to the day fill (if applicable). The example prescription represented in this slide provides an initial fill of 3,000 mL followed by several drains and fills with a residual volume to intraperitoneal volume or exchange volume (Vip) ratio of 0.5, or 1500 mL.

3. Diaz-Buxo JA. PD modalities. Retrieved August 31, 2009 from http://www.advancedrenaleducation.com/PeritonealDialysis/ModalitiesofTherapy/PDModalities/tabid/ 83/Default.aspx

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TPD prescription

· Determined by the physician · Can be based on kinetic modeling programs or patient history on other cyclers · Varies according to the patient body mass and residual renal function

©2009 Fresenius Medical Care North America, All rights reserved.

Remember the TPD prescription is: Determined by the physician Can be based on kinetic modeling programs or patient history on other cyclers and varies according to the patient body mass and residual renal function

TPD concepts

· Continuous contact between the dialysate and the peritoneal membrane

­ Partial exchanges of dialysate keep fresh fluid flowing into the peritoneal cavity creating a tide ­ This hybrid between continuous and intermittent flow techniques bathes the membrane with fluid throughout the night5

· Potentially better fluid flow mechanics and more comfort to the patient; fewer alarms and less pain

­ With intermittent techniques, patients may experience pain at the start of inflow and at the end of outflow due to the empty abdomen ­ In TPD, the presence of at least some fluid in the abdomen during the exchanges may eliminate episodes of pain5

©2009 Fresenius Medical Care North America, All rights reserved.

Next, let's take a look at how TPD works. As mentioned earlier, the TPD modality provides continuous contact between the dialysate and the peritoneal membrane. Partial exchanges of dialysate keeps fresh fluid flowing into the peritoneal cavity creating a tide. This hybrid between continuous and intermittent flow techniques bathes the peritoneal membrane with fluid throughout the night5. Some believe that TPD provides better fluid flow mechanics and more comfort to the patient, thus causing potentially fewer alarms and less pain during inflow and outflow. With intermittent techniques, some patients experience pain at the start of inflow and at the end of outflow due to the empty abdomen. In TPD, the presence of at least some fluid in the abdomen during the exchanges seems to have eliminate these episodes of pain5

5. Agrawal A, Nolph K. Advantages of peritoneal dialysis. Perit Dial Int 20 (Suppl 2):S98-S100, 2000

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Cycler functions during TPD

· Drains the peritoneal cavity · Fills the peritoneal cavity with initial or first fill (based on estimated dry weight) · After the dwell, drains a partial amount of the first fill (tidal drain) leaving a reserve volume of dialysate in the peritoneal cavity · Infuses a tidal fill to mix with the reserve volume · Repeats the tidal exchange (tidal drain, dwell, and tidal fill) until the end of the treatment at which time the abdomen is drained completely6

©2009 Fresenius Medical Care North America, All rights reserved.

During tidal therapy, the cycler performs the following functions: It drains the peritoneal cavity Fills the peritoneal cavity with the initial or first fill, which is based on estimated dry weight After the dwell, the cycler drains a partial amount of the first fill (tidal drain) leaving a reserve volume of dialysate in the peritoneal cavity Next, PD solution is infused (tidal fill) to mix with the reserve volume and This tidal exchange repeats (tidal drain, dwell, and tidal fill) until the end of the treatment, at which time the abdomen is drained completely6.

6. Flanigan MJ, Doyle C, Lim VS, UlrichG. Tidal peritoneal dialysis: Preliminary experience. Perit Dial Int 12:304-308, 1992

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TPD fill volumes defined

· TPD initial fill: First fill upon initiation of treatment on the cycler · TPD fill volume: Amount to be infused for each tidal fill, not to be confused with the first or last fill · Patient's tolerance for total fill volume must be taken into consideration

©2009 Fresenius Medical Care North America, All rights reserved.

Let's take a closer look at each component of the tidal exchange. First, we will review some definitions TPD initial fill is the first fill upon initiation of treatment on the cycler. TPD fill volume is the amount to be infused for each tidal fill, not to be confused with the first or last fill Note that the patient's tolerance for total fill volume must be taken into consideration

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TPD fill volume

· Was initially proposed to be 50% of the initial fill volume1 · A residual volume to intraperitoneal volume or exchange volume (Vip) ratio of 0.5 has consistently outperformed ratios of 0.257-11 · If TPD is used to minimize drain pain upon outflow, the tidal fill volume is most commonly set to 75% of the initial fill (leaving 25% in the reserve volume)12

­ Example, for an initial tidal fill volume of 2000 mL, the tidal fill would be calculated at 1500 mL

©2009 Fresenius Medical Care North America, All rights reserved.

TPD fill volume was initially proposed to be 50% of the initial fill volume1 and despite theoretical predictions, a residual volume to intraperitoneal volume or exchange volume (Vip) ratio of 0.5 has consistently outperformed ratios of 0.257-11. If TPD is used to minimize drain pain upon outflow, the tidal fill volume is most commonly set to 75% of the initial fill (thereby leaving 25% in the reserve volume)12. For example, for an initial tidal fill volume of 2000 mL, the tidal fill would be 1500 mL

7. Rodriguez AMF, Diaz NV, Cubillo LP, Plana JT, Riscos MAG, Delgado RM, et al. Automated peritoneal dialysis: A Spanish multicentre study. Nephrol Dial Transplant 13:2335­ 2340, 1998 8. Piraino B, Bender F, Bernardini J. A comparison of clearances on tidal peritoneal dialysis and intermittent peritoneal dialysis. Perit Dial Int 14:145­148, 1994 9. Shah J, Lane D, Shrivastava D, Berlyne GM, Barth RH. Isovolemic tidal technique does not increase clearances in intermittent peritoneal dialysis (IPD). J Am Soc Nephrol 3:419, 1992 (Abstract) 10. Twardowski ZJ, Prowant BF, Nolph KD, Khanna R, Schmidt LM, Satslowich RJ. Chronic nightly tidal peritoneal dialysis. ASAIO Trans 36:M584­M588, 1990 11. Twardowski ZJ. New approaches to intermittent peritoneal dialysis therapies. In: Nolph KD, ed. Peritoneal Dialysis. Dordrecht: Kluwer Academic Publishers; 1989: 133­151 12. Daugirdas JT, Blake P, Ing TS. Apparatus for peritoneal dialysis. In: Daugirdas JT, Blake P, Ing TS, eds. Handbook of Dialysis. 4th Ed. Philadelphia: Lippincott; 2007: 339-375

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TPD drain volume

· Determined by calculating the TPD ultrafiltration (UF) expected during the treatment · TPD UF is the amount of ultrafiltrate generated during each tidal cycle1

TPD drain volume =TPD fill volume + estimated TPD UF

­ Estimate the expected ultrafiltrate generated for each cycle to prevent the reserve volume at the end of subsequent cycles from gradually changing ­ With gradual changes in the reserve volume, the efficiency of the dialysis and the patient's comfort level may change12

©2009 Fresenius Medical Care North America, All rights reserved.

The TPD drain volume is determined by calculating the tidal ultrafiltration (UF) expected during the treatment. TPD UF is the amount of ultrafiltrate generated during each tidal cycle. TPD drain volume is the sum of the TPD fill volume and the estimated TPD UF. The amount of ultrafiltrate expected to be generated during each cycle should be estimated with accuracy; otherwise, the reserve volume at the end of subsequent cycles will gradually change. With these gradual changes in the reserve volume, the efficiency of the dialysis and the patient's comfort level may change. If UF volumes are overestimated , the reserve volume would gradually be depleted and if the UF volumes are under-estimated, the reserve volume will gradually increase, which could lead to abdominal discomfort.

1. Flanigan M, Pflederer T, Doyle C, et al. Tidal peritoneal dialysis in children: Initial experiences. Dial Transplant 22:554-563, 1993 12. Daugirdas JT, Blake P, Ing TS. Apparatus for peritoneal dialysis. In: Daugirdas JT, Blake P, Ing TS, eds. Handbook of Dialysis. 4th Ed. Philadelphia: Lippincott; 2007: 339-375

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Calculating TPD fill and drain volumes13

©2009 Fresenius Medical Care North America, All rights reserved.

Calculating TPD fill and drain volumes TPD drains must be calculated accurately taking into consideration the usual ultrafiltration amount. To determine the usual ultrafiltration amount, review past treatment records for the patient, and determine the average UF amount for each concentration of dextrose used. Divide the total amount of ultrafiltrate expected by the number of tidal cycles and add it to the tidal fill volume to arrive at the tidal drain volume. Note that UF volume is slightly less with TPD compared to intermittent PD (IPD), since glucose absorption is slightly higher14. Therefore, adjustments in prescription may need to be made during the first several sessions, until satisfactory results are accomplished. If you do not have an average ultrafiltration amount [for example, the patient has been on continuous ambulatory PD (CAPD) and is now transferring to ambulatory PD (APD)], then the amount can be estimated utilizing the idealized ultrafiltration curves proposed by Twardowski, as shown in this graphic.

13. Twardowski ZJ, Khanna R, Nolph KD. Osmotic agents and ultrafiltration in peritoneal dialysis. Nephron 42:93-101, 1986

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Does TPD improve clearances?

· During CCPD/IPD treatment, significant nondialytic transit time may occur · TPD proposed to improve clearances of small molecules through two mechanisms

­ Continuous contact of dialysate with the peritoneal membrane, thus maximizing actual dialysis time2 ­ Drain time in TPD is flow regulated; once programmed inflow and drain volumes are achieved, the cycler automatically moves into the next phase of the exchange, decreasing the transit time seen with CCPD/IPD12

©2009 Fresenius Medical Care North America, All rights reserved.

Does TPD improve clearances? During a typical CCPD/IPD treatment a significant amount of time may be spent instilling and draining dialysis solution, during which time no dialysis occurs (non-dialytic transit time). TPD was proposed to improve clearances of small molecules through two mechanisms. First, with TPD the reserve volume provides continuous contact of dialysate with the peritoneal membrane, therefore it should maximize actual dialysis time2. Secondly, the drain time in TPD is flow regulated; that is, once the programmed inflow and drain volumes are achieved, the cycler automatically moves into the next phase of the exchange. This may decrease the transit time in which there is no dialysate in contact with the peritoneal membrane, as seen with CCPD/IPD12.

2. Stephen RL. Reciprocating peritoneal dialysis with a subcutaneous peritoneal catheter. Dial Transplant 7:834-838, 1978 12. Daugirdas JT, Blake P, Ing TS. Apparatus for peritoneal dialysis. In: Daugirdas JT, Blake P, Ing TS, eds. Handbook of Dialysis. 4th Ed. Philadelphia: Lippincott; 2007: 339-375

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Does TPD improve clearances?

· Several studies suggest better clearances when compared to other PD modalities · When exchange volume and dialysate flow rates were controlled, TPD had no clearance advantage over other intermittent therapies4 · With high dialysate flow rates >20 to 30 liters per night, TPD may be superior or similar to IPD in efficacy, but it is expensive due to the high volumes of dialysis solution needed15 · TPD can be prescribed for patients who experience drain pain12 or for those with slowdraining catheters15

©2009 Fresenius Medical Care North America, All rights reserved.

Although several studies suggest better clearances when compared to other PD modalities, when exchange volume and dialysate flow rates were controlled, TPD had no clearance advantage over other intermittent therapies4. With high dialysate flow rates greater than 20 to 30 liters per night, TPD may be superior or similar to IPD in efficacy, but it is expensive because of the high volumes of dialysis solution used15. TPD may alleviate the drain pain12 that some patients experience when their peritoneum is completely drained. Since TPD leaves a residual amount of dialysate in the peritoneum, the drain pain may be reduced. TPD has also been used for patients who have slowdraining catheters who either cannot or who will not have the catheter replaced15.

4. Diaz-Buxo JA. Automated peritoneal dialysis. A therapy in evolution. In: Ronco C, Amici G, Feriani M, Virga G, eds. Automated Peritoneal Dialysis. Contributions to Nephrology. Basel. Karger,1999:129,1-14 12. Daugirdas JT, Blake P, Ing TS. Apparatus for peritoneal dialysis. In: Daugirdas JT, Blake P, Ing TS, eds. Handbook of Dialysis. 4th Ed. Philadelphia: Lippincott; 2007: 339-375 15. Diaz-Buxo JA. Continuous cycling peritoneal dialysis, PD Plus, and high-flow automated peritoneal dialysis: A spectrum of therapies. Perit Dial Int 20 (Suppl 2): S93-S97, 2000

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Module 2: TPD and the Liberty® Cycler

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©2009 Fresenius Medical Care North America, All rights reserved.

Now, let's look at the TPD programming features of the Liberty® cycler. Please refer to the Liberty cycler user's guide for additional information.

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Course objective

By the end of this module the participant will be able to demonstrate:

· Programming a TPD prescription into the Liberty cycler for both treatment based and cycle based modes or settings

©2009 Fresenius Medical Care North America, All rights reserved.

By the end of this module, the participant will be able to demonstrate:

Programming a TPD prescription into the Liberty cycler for both treatment based and cycle based modes or settings

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Treatment or cycle based TPD

Note: All programming information found in this module is based on the Liberty Cycler User's Guide16

©2009 Fresenius Medical Care North America, All rights reserved.

Prior to programming the Liberty cycler for Tidal PD, decide if the patient will be on treatment or cycle based therapy. Page 5 of the Liberty Cycler User's Guide has the form seen on this slide and can be photocopied to utilize when formulating the patient's prescription.

16. Liberty® Cycler User's Guide, Rev C 08/2009. [Manual] Walnut Creek, CA: Fresenius Medical Care North America

Prescription terms and definitions

Term

# pauses Total volume Pause volume First fill volume Tidal fill volume Total sleep time

Definition

Number of pauses during treatment The total volume of dialysate used for the entire treatment Fill volume of the pause exchange Volume of first fill Fill volume for each exchange Estimated sum of all drain, fill, and dwell time for the treatment

Tidal drain volume Drain volume for each exchange Last fill volume Solution fill volume for the last fill

©2009 Fresenius Medical Care North America, All rights reserved.

Prescription terms and definitions. A majority of these terms were covered in . Module 1. This slide provides an overview of the prescription parameters that will be needed to program the Liberty cycler. As with all prescriptions, the physician determines each parameter to be entered. If the patient will be performing a pause exchange using the cycler during the day, that should be entered. Some patients perform more than one pause exchange. The total volume includes the amount for all fills that the cycler will deliver. The pause volume is the fill volume for the pause exchange(s). The first fill is also known as the initial fill. The tidal fill volume is the fill volume for each exchange. The total sleep time is the total amount of time the patient will be on the cycler (not including time for the pauses). Or you may think of the estimated sum of all drain, fill, and dwell times for the treatment. The tidal drain volume is the drain volume for each exchange. This volume should include the amount of the tidal fill plus the estimated UF for each exchange. The last fill volume equals the fill to be instilled for the day dwell.

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Programming the Liberty cycler for TPD

· Touch the yellow parameter button · The button will turn orange · The parameter can be changed by touching the up and down arrow keys

©2009 Fresenius Medical Care North America, All rights reserved.

Let's discuss how to program the Liberty cycler for TPD. To program the cycler, touch the yellow parameter button to select the value. The button will change to orange color The parameter can be changed by touching the up and down arrow keys as shown in the orange box on the right of the Liberty screen

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Treatment and cycle based modes

©2009 Fresenius Medical Care North America, All rights reserved.

The Liberty cycler can be programmed for tidal dialysis in two different modes; treatment based mode, as shown on the side in the orange box, and cycle based mode. Each of these modes will be discussed in greater detail on the following slides.

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Treatment based modes

User programs: · Total sleep time · Total volume · # of pauses · Pause volume

· The first fill volume · Tidal fill volume · Tidal drain volume · Last fill volume Cycler calculates: · # of fills · Dwell time · Estimates drain and fill times

©2009 Fresenius Medical Care North America, All rights reserved.

In treatment based mode, the total treatment time will be programmed into the cycler (the cycler will deliver the treatment in the time you specify). This method is useful for people that need to finish treatment by a certain time in the morning in order to meet other obligations such as going to work. For this mode, you will need to program the total sleep time, total volume, number of pauses, and pause volume (if applicable), the first fill volume, tidal fill volume, tidal drain volume, and last fill volume. The cycler calculates the number of fills and the dwell time and it estimates the drain times and fill times

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Cycle based programming

©2009 Fresenius Medical Care North America, All rights reserved.

The Liberty cycler can also be programmed to deliver a cycle based treatment, which means that the cycler will always dwell for the amount of time that is prescribed by the physician. This mode is used to ensure that the patient receives the specific amount of dwell time to meet their clearance needs. The total treatment time may vary depending on how the patient drains or fills. When using cycle based programming, the user programs the number of pauses and pause volume (if applicable), the dwell time, the first fill volume, fill time, number of fills, tidal fill volume, drain time, tidal drain volume and last fill volume (if applicable). The Liberty cycler calculates the total volume and the total sleep time values as shown in the light blue boxes, based on the values that have been previously entered. To enter the values for the tidal drain and last fill volume, the user must scroll to the second page. To do this, select "next' to move to page 2.

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Cycle based programming

©2009 Fresenius Medical Care North America, All rights reserved.

You are now ready to finish programming the tidal drain volume and last fill volume. Remember that when programming the tidal drain volume, you need to estimate the average UF (per dextrose concentration) and divide it between the number of tidal exchanges. For each tidal drain you should include the fluid volume of the tidal fill plus the estimated UF per cycle.

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Cycle based programming

©2009 Fresenius Medical Care North America, All rights reserved.

Fast fill/drain are applicable for cycle based programming. If the fast fill/drain option is selected to "yes" the Liberty cycler automatically switches to the next mode when the fill or drain is complete, even if the fill or drain did not require the entire time that was programmed.

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Performing a pause will enhance the clearance achieved with TPD

©2009 Fresenius Medical Care North America, All rights reserved.

The Liberty cycler provides the option of adding one or more pause exchanges to the treatment if prescribed. When the Liberty cycler is on the "Pause" screen, the patient may disconnect from the machine. The cycler will display how long the patient has paused as `Pause time'. When the patient is ready to reconnect to the cycler, they simply touch the "Next" button and follow the directions on the Liberty screen.

Drain cycle

· Drain cycle continues as long as the Liberty cycler is achieving a consistent flow

- Min flow is 50mL if patient is dry during the day

· At the end of the tidal drain, when the amount programmed has been drained, the Liberty cycler begins tidal fill · Switches to fill when:

­ Flow has reached the minimum drain % (default is 85%) programmed, and ­ Flow is less than 30 mL/min for 5 min, or ­ < 1.5 mL/stroke has drained in 4 attempted strokes

· The last drain empties the patient completely

­ Requirement cannot be changed ­ Liberty cycler warns patient if initial fill amount is not drained

©2009 Fresenius Medical Care North America, All rights reserved.

In either mode of programming, drain zero drains the patient completely. As long as the Liberty cycler is achieving a flow, the drain cycle continues If the patient is dry during the day the machine will attempt to drain a minimum of 50 mL. At the end of the tidal drain, when the amount programmed has been drained, the Liberty cycler begins tidal fill. It switches to fill when the flow has reached the minimum drain % (default is 85%) programmed into the cycler and either less than 30 mL/min of fluid has been drained in the last 5 minutes or less than 1.5 mL/stroke of fluid has been drained in 4 attempted strokes of the machine. The last drain of the night, which typically occurs during the early morning, also drains the patient completely. It is important to note that this requirement cannot be changed, and the Liberty cycler will warn the patient if the initial fill amount is not drained.

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Sample tidal prescription: Treatment based (1)

· Utilize the following sample prescription to practice entering data into your Liberty training cycler

©2009 Fresenius Medical Care North America, All rights reserved.

This slide and the next two slides provide an opportunity for you to practice entering data into your Liberty training cycler. Please note that the data on this slide and the next two slides are examples only. The PD prescription is the sole responsibility of the attending physician.

Sample tidal prescription: Treatment based (2)

· Utilize the following sample prescription to practice entering data into your Liberty training cycler

©2009 Fresenius Medical Care North America, All rights reserved.

Please note that the data on this slide is an example only. The PD prescription is the sole responsibility of the attending physician.

Sample tidal prescription: Cycle based

· Utilize the following sample prescription to practice entering data into your Liberty training cycler

©2009 Fresenius Medical Care North America, All rights reserved.

Please note that the data on this slide is an example only. The PD prescription is the sole responsibility of the attending physician.

Summary · Tidal dialysis may be an option for PD patients that:

­ Are not achieving adequate clearances with other PD therapies.

· High dialysate flow rates >20 to 30 liters per night are required, but increases the cost of this therapy

­ Have pain on inflow or outflow during traditional cycling modes12

©2009 Fresenius Medical Care North America, All rights reserved.

Summary Tidal dialysis may be an option for peritoneal dialysis patients that are not achieving adequate clearances with other PD therapies. High dialysate flow rates of >20 to 30 liters per night are required to achieve higher clearance rates than achieved with other traditional therapies, resulting in increased cost for this therapy. Patients that have pain on inflow or outflow during traditional cycling modes may benefit from TPD12

12. Daugirdas JT, Blake P, Ing TS. Apparatus for peritoneal dialysis. In: Daugirdas JT, Blake P, Ing TS, eds. Handbook of Dialysis. 4th Ed. Philadelphia: Lippincott; 2007: 339-375

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Summary · With the option of programming the Liberty cycler for a set drain volume, the patient experiencing multiple drain warnings during the night may find that:

­ Tidal programming decreases the number of warnings encountered ­ Allows a more restful night's sleep

· Contact your Fresenius Sales Representative to learn more about the Liberty cycler

©2009 Fresenius Medical Care North America, All rights reserved.

Summary With the option of programming the Liberty cycler for a set drain volume, the patient experiencing multiple drain warnings during the night may find that tidal programming decreases the number of warnings encountered. Thus allowing a more restful night's sleep.

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References

1. 2. 3. Flanigan M, Pflederer T, Doyle C, et al. Tidal peritoneal dialysis in children: Initial experiences. Dial Transplant 22:554-563, 1993 Stephen RL. Reciprocating peritoneal dialysis with a subcutaneous peritoneal catheter. Dial Transplant 7:834-838, 1978 Diaz-Buxo JA. PD modalities. Retrieved August 31, 2009 from http://www.advancedrenaleducation.com/PeritonealDialysis/ModalitiesofTherapy/PDModalities /tabid/83/Default.aspx Diaz-Buxo JA. Automated peritoneal dialysis. A therapy in evolution. In: Ronco C, Amici G, Feriani M, Virga G, eds. Automated Peritoneal Dialysis. Contributions to Nephrology. Basel. Karger,1999:129,1-14 Agrawal A, Nolph K. Advantages of peritoneal dialysis. Perit Dial Int 20 (Suppl 2):S98-S100, 2000 Flanigan MJ, Doyle C, Lim VS, UlrichG. Tidal peritoneal dialysis: Preliminary experience. Perit Dial Int 12:304-308, 1992 Rodriguez AMF, Diaz NV, Cubillo LP, Plana JT, Riscos MAG, Delgado RM, et al. Automated peritoneal dialysis: A Spanish multicentre study. Nephrol Dial Transplant 13:2335­2340, 1998 Piraino B, Bender F, Bernardini J. A comparison of clearances on tidal peritoneal dialysis and intermittent peritoneal dialysis. Perit Dial Int 14:145­148, 1994

4.

5. 6. 7. 8.

©2009 Fresenius Medical Care North America, All rights reserved.

36

References

9. Shah J, Lane D, Shrivastava D, Berlyne GM, Barth RH. Isovolemic tidal technique does not increase clearances in intermittent peritoneal dialysis (IPD). J Am Soc Nephrol 3:419, 1992 (Abstract) Twardowski ZJ, Prowant BF, Nolph KD, Khanna R, Schmidt LM, Satslowich RJ. Chronic nightly tidal peritoneal dialysis. ASAIO Trans 36:M584­M588, 1990 Twardowski ZJ. New approaches to intermittent peritoneal dialysis therapies. In: Nolph KD, ed. Peritoneal Dialysis. Dordrecht: Kluwer Academic Publishers; 1989: 133­151 Daugirdas JT, Blake P, Ing TS. Apparatus for peritoneal dialysis. In: Daugirdas JT, Blake P, Ing TS, eds. Handbook of Dialysis. 4th Ed. Philadelphia: Lippincott; 2007: 339-375 Twardowski ZJ, Khanna R, Nolph KD. Osmotic agents and ultrafiltration in peritoneal dialysis. Nephron 42:93-101, 1986 Twardowski ZJ. Tidal peritoneal dialysis. In: Nissenson AR, Fine RN, eds. Handbook of Dialysis Therapy. 4th Ed. Philadelphia: Saunders Elsevier; 2008:549-557 Diaz-Buxo JA. Continuous cycling peritoneal dialysis, PD Plus, and high-flow automated peritoneal dialysis: A spectrum of therapies. Perit Dial Int 20 (Suppl 2): S93-S97, 2000 Liberty® Cycler User's Guide, Rev C 08/2009. [Manual] Walnut Creek, CA: Fresenius Medical Care North America

10. 11. 12. 13. 14. 15. 16.

©2009 Fresenius Medical Care North America, All rights reserved.

37

This concludes Tidal Therapy in Peritoneal Dialysis

38

©2009 Fresenius Medical Care North America, All rights reserved.

This concludes Tidal Therapy in Peritoneal Dialysis

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Fresenius Medical Care North America 920 Winter Street, Waltham, MA 02451 (800) 662-1237

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Fresenius Medical Care, the triangle logo, stay safe and Liberty are trademarks of Fresenius Medical Care Holdings, Inc. or its affiliated companies. All other trademarks are the property of their respective owners. P/N 101195-01 Rev00 10/2009

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