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PERITONEAL DIALYSIS CLINICAL PERFORMANCE MEASURES DATA COLLECTION FORM 2005 (CONTINUED)

21E: Check the method used to calculate the V in the Kt/V

measurement; % BW = percent of body weight; Hume and Watson are two

urea

nomograms used to calculate V based on several of these parameters - weight, height, age, gender. If method used to calculate V is not

known, please call lab to ascertain method. Please do not leave blank.

21F: Enter the TOTAL WEEKLY CREATININE CLEARANCE for the first adequacy measurement indicated on 21A between OCT 1, 2004

through MAR 31, 2005. NOTE: Whether or not you have a value for weekly creatinine clearance for this adequacy assessment, please

complete the corresponding values for questions 21H and 21J for 24-hour dialysate volume, 24-hour dialysate creatinine and question

21K for 24-hour urine volume. If the patient is not anuric, complete the corresponding value for question 21M, the 24-hour urine

creatinine, if this value is available. Enter NF/NP for all values when not found or not performed. If your unit calculates a daily creatinine

clearance multiply this result by 7.0 and enter the result in the appropriate space(s). If this patient did not dialyze each day of the week,

then multiply the daily creatinine clearance by the number of days the patient did dialyze.

21G: Check Yes or No if the weekly creatinine clearance was normalized for body surface area (i.e., the result is multiplied by 1.73m

and

divided by the patient’s body surface area [BSA]). Standard methods for establishing BSA are: the DuBois and DuBois method; the

Gehan and George method; and the Haycock method. If you do not have this information, call the laboratory that provided the creatinine

clearance value for this information. Please do not leave blank.

21H, I, and J: Enter the measured 24-hour DIALYSATE volume (includes prescribed and ultrafiltration volumes), urea nitrogen and creatinine

obtained for the first adequacy measurement obtained between OCT 1, 2004 through MAR 31, 2005. If a 24-hour dialysate volume, urea

nitrogen or creatinine were NOT measured in this time period, enter NF/NP (for not found or not performed) in the appropriate spaces.

ONLY ENTER ACTUAL MEASURED 24-HOUR DIALYSATE VOLUME. DO NOT ENTER AN EXTRAPOLATED DIALYSATE

VOLUME. Please report the 24-hour dialysate volume as a combination of the prescribed fill volume and the ultrafiltration volume.

21K, L, and M: Enter the 24-hour URINE volume, urea nitrogen and creatinine obtained for the first adequacy assessment obtained between

OCT 1, 2004 through MAR 31, 2005. ONLY ENTER ACTUAL MEASURED 24-HOUR URINE VOLUME—DO NOT ENTER AN

EXTRAPOLATED URINE VOLUME. If 24-hour urine volume was not collected check NF/NP for not found or not performed. If NF/NP

is checked, SKIP TO QUESTION 21N. If urine urea nitrogen and creatinine were not found or not measured in this time period, enter

NF/NP in the appropriate spaces.

21N, O: Enter the SERUM BUN and SERUM CREATININE obtained for the first PD adequacy assessment obtained between OCT 1, 2004

through MAR 31, 2005. Enter NF/NP in the appropriate spaces for all time periods when not found or not performed.

21P: (1) Enter the most recent four hour dialysate/plasma creatinine ratio (D/P Cr) from a peritoneal equilibration test (PET).

(2) Enter the date of the most recent D/P Cr. The test result and corresponding date of the most recent D/P Cr may be outside the 6-month

study period. If never found or performed record NF/NP. Date cannot be after 3/31/04 or prior to the first day of peritoneal dialysis.

22:

To respond to questions 22A through 22C record the peritoneal dialysis (PD) prescription in effect at the time of the first adequacy

measures/results recorded in question 21 performed between OCT 1, 2004 through MAR 31, 2005. Complete all items that are applicable.

22A: CAPD PRESCRIPTION. Use the CAPD prescription category for all CAPD patients including patients with one overnight exchange

using an assist device. (1) Enter the number of days per week for which this patient underwent peritoneal dialysis. (2) Enter the total

dialysate volume in mL infused over a 24-hour period and (3) the number of exchanges per 24-hour period PRESCRIBED for CAPD at

the time the first adequacy measurements were performed.

22B: CYCLER PRESCRIPTION. (1) Enter the number of days per week for which this patient underwent peritoneal dialysis. (2) Enter the

total dialysate volume in mL infused over a 24-hour period. (3) Total dialysis time - (Note: 2a+b+c = 24 hours): (3a) Enter the total

nighttime dialysis time, (3b) the total daytime dialysis dwell time, and (3c) the total amount of time the patient is dry during 24 hours. If

the patient is never dry in 24 hours enter a value of 0 hours. The hours entered in 2a, b, & c should equal 24 hours. (4) Nighttime

Prescription (excluding last bag fill): (4a) Enter the volume of a single nighttime exchange and (4b) the number of dialysis exchanges

during the nighttime PRESCRIBED for CYCLER NIGHTTIME at the time the first adequacy measurements were performed. Include in

the CYCLER NIGHTTIME prescription only those exchanges provided by an automated device. DO NOT include in this category any

last bag fill or option that the patient carries after unhooking from the cycler or any daytime dwells as these exchanges are recorded in the

DAYTIME PRESCRIPTION information. If different inflow volumes are used, report average inflow volume. (5) Daytime Prescription

(including last bag fill): (5a) Enter the volume of a single daytime exchange and (5b) the number of dialysis exchanges during the

daytime PRESCRIBED for CYCLER DAYTIME at the time the first adequacy measurements were performed. Include in the CYCLER

DAYTIME prescription only those exchanges performed after the patient disconnects from the cycler and/or a last bag fill or option that

the patient carries during the day. ANY OTHER EXCHANGES PERFORMED USING THE CYCLER SHOULD BE INCLUDED

UNDER CYCLER NIGHTTIME PRESCRIPTION. If different inflow volumes are used, report average inflow volume.

(6) Check the appropriate box, “yes” or “no”, indicating whether this patient’s peritoneal dialysis prescription included TIDAL dialysis.

TIDAL patients are cycler patients for whom the dialysate is partially drained between some exchanges.

22C: (1) Check the appropriate box, “yes” or “no”, indicating whether the adequacy collection was repeated, and (2) check the appropriate box

“yes” or “no”, indicating whether the prescription changed following the first PD adequacy measurement performed between OCT 1,

2004 through MAR 31, 2005.

23:

Check “yes”, “no”, or “unknown” to indicate if a PD adequacy measurement was done between NOV 1, 2004 through MAR 31, 2005.

23A-O: See instructions for 21A-21O and complete for second PD adequacy measurement performed between NOV 1, 2004 through MAR 31,

2005. DO NOT record more than one PD adequacy measurement done for any one month.

23P: Record the value and date of the patient’s PET if a new one was performed since the time of the first adequacy test. If not performed enter NP.

24A-C: See instructions for 22A-22C and complete for the peritoneal dialysis (PD) prescription in effect at the time of the second adequacy

measures/results recorded in question 23 performed between NOV 1, 2004 through MAR 31, 2005.

CMS – 821 (Rev.1/20/05)

Form Cms-821 - Peritoneal Dialysis Clinical Performance Measures Data Collection - 2005 Page 6

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