CAPD : praktek terkini dan hambatan

Dr. Atma Gunawan SpPD.KGH

Malang CAPD Center

Chronic renal disease

Chronic renal failure

End-stage renal disease

Renal replacement therapy

Hemodialysis

Peritoneal Dialysis Renal transplantation

Late referral

Late renal replacement therapy

Kondisi pasien yang dikirim ke rumah sakit

• 95% need hemodialysis urgent : lung edema, encephalopathy, severe uremia, hyperkalemia, metabolic acidosis

• 5% elective dialysis

Shift HD Patients

HD survival in RSSA (2009; n=107)

HD survival in RSSA (2009; n=107

6

Note : one year survival probability 49.6%

(95% CI 0.36 - 0.62)

Kidney Int. 2000 Jan;57(1):307-13

How we respond the problem ?

CONTINUOS AMBULATORY PERITONEAL DIALYSIS (CAPD)

Ruang GantiCairan

Ruang TungguPasien

Ruang PeriksaDokter

Kamar Operasi

PLB

Total pasien CAPD per Des 2016 : 1994

6

1717

45

16

9

18

60

76

55

13

16

25

CAPD Px

Mapping

58

35

51

290

95

94

135

324

COE

RSSA MALANG RS SANGLAH

RSHS

RS CIKINI

RSPAD

70

496 (64%)

290 (34%)

13 (2%)

HD CAPD Renal Transplant

PATIENT PROPORTION IN 2016 (RSSA Malang)

CAPD patients adequation in Malang CAPD Center (n=68)

Urea clearance (wKT/V) : 1,84 ± 0,56 litre/week

Creatinine clearance (wCCr) : 61,51 ± 23,69 litre/week/m2

Standard NKF/K- DOQI : wKT/V ≥ 1.7 litre/week

wCCr ≥ 60 litre/week/m2

Membran type in Malang CAPD Center (n=68)

Tipe membran Hasil

Low 8 (12%)

Low average 32 (47%)

High average 22 (32%)

High 6 (9%)12 %

47 %

32%

9 %

Low

Low Average

High Average

High

12% pasien CAPD tidak terakomodir dengan regimen saat ini

Membran type Preferred regimen Distribution in RSSA Malang

High APD regimen 12 %

High-average Any regimen 47%

Low-average Standard dose CAPD 32%

Low High dose, long dwell CAPD 9 %

• Dari 1994 pasien CAPD di Indonesia, diduga 240 pasien dengan tipe High Membran Type.

• Pasien ini tidak terakomodir dengan APD regimen, karena tidak disediakan dalam fornas.

Causes of drop out (2013)

Economic reason

5%Recovery of RF 5%

Death 77%

Infection 7%

Transfer to other PD units

7%

• Drop Out occured in (65 dari 176) (36 %)CAPD patient

CAPD Infections (2013)

JAN FEB MAR APR MEI JUN JUL AGUST SEP OKT

3.52%

5.28%

10.56%

1.76%

3.52%

17.65%

7.04%

3.52%

10.56%

3.52%

1.76% 1.76%1.76%

Peritonitis

Tunnel

Exit site

Proportion of peritonitis in Malang CAPD Center

Year Proportion with peritonitis

Proportion without peritonitis

Peritonitis rate(episode/month)

2013 19 % 81% 77.4 months

2014 14 % 86 % 43.8 months

2015 16% 84% 17.8 months

Gram Mapping Based on Culture Result

14.21%

28.50%

12.20%

35%

73.40%

36.20%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

2015 2016 ( untillAugust )

Gram Positive

Gram Negative

No Culture

• Negative culture still high

• ISPD : Culture-negative peritonitis should not be greater than 20% of episodes

Data source : CAPD Centre RSSA

Analisa Mortalitas (CAPD Center Malang)

22

Mean survival time 20.63 bulan (95% CI 18.778 – 22.49)Angka mortalitas dengan penyebab apapun : 24/68 (35.2%)

Grafik Hazard Kematian

Korelasi Kejadian Mortalitas danStatus Nutrisi Berdasarkan Skor CNI

23

Skor CNI > 11 : RR=2.12 (95% CI 1.05-4.28),

p=0.027

*Menggunakan uji Chi-Square dengan p<0.05

Mean survival time :Skor CNI > 11 : 17.1 bulan

(95% CI 13.6 – 21.6)Skor CNI ≤ 11 : 21.7 bulan

(95% CI 19.2 – 24.2

Survival rate patients start on PD or HD

Nefrologia (Madr.) 2012;32:335-42

Masalah lain

• Biaya belum tersedia atau tidak memadai di Ina-CBGs : pemeriksaan rutin, adequacy dan PET test, repair malposisi kateter CAPD, aff catheter CAPD, home visite, edukasi.

• Finance interest lebih rendah dibandingkan HD

Messages

• Telat dirujuk mendominasi pasien kiriman

• Sebagian besar pasien CAPD adalah start on HD

• Survival pasien CAPD masih rendah

• Nutrisi buruk, peritonitis rate, negative culture , pembiayaan yang belum tercover, masih jadi masalah yang penting

Wassalam