Mitigating peritoneal membrane characteristics in modern peritoneal dialysis therapy (original) (raw)
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Peritoneal Dialysis International, 2016
♦ Background: Peritoneal dialysis (PD) has limited power for liquid extraction (ultrafiltration), so fluid overload remains a major cause of treatment failure. ♦ Methods: We present steady concentration peritonal dialysis (SCPD), which increases ultrafiltration of PD exchanges by maintaining a constant peritoneal glucose concentration. This is achieved by infusing 50% glucose solution at a constant rate (typically 40 mL/h) during the 4-hour dwell of a 2-L 1.36% glucose exchange. We treated 21 fluid overload episodes on 6 PD patients with high or average-high peritoneal transport characteristics who refused hemodialysis as an alternative. Each treatment consisted of a single session with 1 to 4 SCPD exchanges (as needed). ♦ Results: Ultrafiltration averaged 653 ± 363 mL/4 h — twice the ultrafiltration of the peritoneal equilibration test (PET) (300 ± 251 mL/4 h, p < 0.001) and 6-fold the daily ultrafiltration (100 ± 123 mL/4 h, p < 0.001). Serum and peritoneal glucose stability...
Kidney International, 2004
Longitudinal relationship between solute transport and ultrafiltration capacity in peritoneal dialysis patients. Background. Time on treatment is associated with a greater risk of impaired ultrafiltration (UF) in peritoneal dialysis (PD) patients. In addition to increasing solute transport, a potentially treatable cause of impaired ultrafiltration, cross-sectional studies suggest that there is also reduced osmotic conductance of the membrane. If this were the case then it would be expected that the UF capacity for a given rate of solute transport would change with time. The purpose of this analysis was to establish how solute transport and UF capacity change relative to one another with time on therapy. Methods. Membrane function, using a standard peritoneal equilibration test, was measured at least annually in a wellcharacterized, single-center observational cohort of PD patients between 1990 and 2003. Demography included age, gender, original cause of renal failure, body surface area (BSA), validated comorbidity score, residual urine volume and urea clearances, peritoneal urea clearances, and plasma albumin. Results. Data from 574 new PD patients were available for analysis. Independent demographic factors associated with higher solute transport at baseline were male gender and higher residual urine volume. Throughout time on therapy there was a negative relationship between solute transport and UF capacity and a significant increase and decrease in these parameters, respectively. During the first 12 months of treatment, the increase in solute transport was not associated with the expected fall in UF capacity, a phenomenon that was not explained by informative censoring, but was associated with an increased, albeit weak, correlation with BSA. In contrast, later in treatment there was a disproportionate fall in UF capacity, more accelerated in patients developing UF failure. Early exposure to higher intraperitoneal glucose concentrations, in the context of more comorbidity and relative lack of residual renal function, was associated with more rapid deterioration in membrane function. Conclusion. Despite a causal link between solute transport and UF capacity of the membrane, due to the effect of the former on the osmotic gradient, there is evidence of their longitudinal dissociation. This implies a change in the structure-function
NDT Plus, 2008
Introduction. Ultrafiltration failure (UFF) in peritoneal dialysis (PD) patients is a reflection of changes in the peritoneal membrane, which can include mesothelial damage, neoangiogenesis, and occasionally, peritoneal fibrosis. These structural changes are probably induced by the use of bioincompatible dialysis solutions. Therefore, we investigated the effects of the treatment with a combination of nonglucose dialysis solutions in patients with severe UFF. Methods. Ten patients with UFF (net ultrafiltration <400 mL/4 h on 3.86% glucose) were treated with a combination of glycerol and icodextrin with or without amino acid-based dialysis solutions for 3 months. Four of them were diagnosed with encapsulating peritoneal sclerosis (PS), proven by peritoneal biopsies. Standard peritoneal permeability analyses (SPA), using 3.86% glucose, were performed, and dialysate CA125 appearance rate (AR-CA125) was analysed at the start, after 6 weeks and after 12 weeks. PS and non-PS patients were compared. Results. One patient underwent transplant after 6 weeks, one was withdrawn from PD because of clinical signs of encapsulating PS before the 3-month period ended. PS patients had been treated with PD for a longer duration than the non-PS patients (102 versus 52 months, P = 0.05), but no differences in baseline transport parameters or AR-CA125 were present. During the study, no differences were observed for transport characteristics when the results of the whole group at 6 and 12 weeks were compared to baseline. For the non-PS patients, however, a significant increase in the transcapillary ultrafiltration rate (from 2.2 mL/min to 2.6 mL/min, P < 0.05) and a decrease in the MTAC creatinine (from 14.3 mL/min to 12.6 mL/min, P < 0.05) were found after 6 weeks of glucose-free treatment. Free-water transport, measured as the maximum dip in the dialysateto-plasma ratio of sodium and as the transport through the ultrasmall pores in the first minute, tended to improve, but this difference did not reach significance. In addition, the AR-CA125 increased significantly (from 2.8 U/min to 16.1 U/min, P < 0.05). Continued treatment did not reach statistical difference even after 3 months. No changes were observed in the PS patients. Conclusions. In the present study, an improvement of UFF in the non-PS patients was obtained by withdrawal of glucose-based dialysis solutions. The abnormalities in PS patients are probably irreversible. Early withdrawal of glucose-based dialysis solutions or at least a marked reduction in glucose exposure should be considered in UFF patients, but the identification of the patients who would benefit most needs further studies.
Peritoneal dialysis international : journal of the International Society for Peritoneal Dialysis
Evidence is accumulating that the continuous exposure to high glucose concentrations during peritoneal dialysis (PD) is an important cause of ultrafiltration (UF) failure. The cornerstone of prevention and treatment of UF failure is reduction of glucose exposure, which will also alleviate the systemic impact of significant free glucose absorption. The challenge for the future is to discover new therapeutic strategies to enhance fluid and sodium removal while diminishing glucose load and exposure using combinations of available osmotic agents. To investigate in patients on automated PD (APD) with a fast transport pattern whether there is a glucose-sparing advantage to replacing 7.5% icodextrin (ICO) during the long dwell with a mixed crystalloid and colloid PD fluid (bimodal UF) in an attempt to promote daytime UF and sodium removal while diminishing the glucose strength of the dialysate at night. A 2 parallel arm, 4 month, prospective nonrandomized study. PD units or university hosp...
Peritoneal dialysis international: journal of the International Society for Peritoneal Dialysis
Objective: In response to recent randomized controlled trials, 2006 Kidney Disease Outcomes Quality Initiative (K/DOQI) revised the peritoneal dialysis (PD) adequacy guidelines to a minimum level total Kt/V of 1.7. Observational studies suggest that mortality may be higher in those with Kt/V below 1.8. We evaluated the association of Kt/V with outcomes in anuric PD patients. Methods: Adult anuric PD patients receiving dialysis care in Dialysis Clinics, Inc. unit or the New Haven CAPD unit were selected for study. The clearance for analysis was within 60 days of anuria. Kt/V was classified as <1.7, 1.7-2.0, and >2.0. Mortality and time to first hospitalization were analyzed using Cox proportional hazards. Results: The study population was 1429 individuals, mean age 54, 62% white, 30% black, 8% other, 50% women, 45% diabetes, median end-stage renal disease (ESRD) time prior to anuria 21.3 months (range 0-27 years), median follow-up time 10 months (range 0.03-90). In unadjusted analysis, both Kt/V <1.7 and Kt/V 1.7-2.0 were associated with higher mortality . After adjustment, Kt/V <1.7 remained associated with increased mortality although Kt/V 1.7-2.0 was no longer statistically significant. Kt/V <1.7 was associated with time to first hospitalization, which persisted after adjustment .
Nocturnal ultrafiltration profiles in patients on APD: Impact on fluid and solute transport
Kidney International, 2008
In order to prevent morbidity and mortality in peritoneal dialysis (PD), sodium and water balance as well as a minimal level of small-solute clearances are needed. The impact of three nocturnal peritoneal ultrafiltration (UF) profiles on UF and small solute clearance in patients on automated PD (APD) was studied: constant glucose concentration of 1.36% (flat) or modifying the glucose concentration of the heater bag (descendant: 3.86-1.36%; ascendant: 1.36-3.86%). Sixty-two patients were enrolled in the study and received each profile within a four-month period, thus serving as their own controls. UF was lower with the flat profile (3677420 ml; Po0.01), but no difference was seen between the two higher glucose concentration profiles. Peritoneal Kt/V (pKt/V) and peritoneal creatinine clearance (CrpC) showed statistically higher values from the descendant vs ascendant vs flat profiles (pKt/V: 1.5470.30 vs 1.4570.30 vs 1.3870.27, and CrpC: 36.977.9 vs 33.577.48 vs 29.9277.5 ml min À1). Multivariate analysis showed statistical significance for the following: in the intrasubject comparisons, the profile for pKt/ V (F=9.109, Po0.001) and CrpC (F=11.697, Po0.001), and in the intersubjects comparisons, the effects of both gender (F=14.334, Po0.01) for pKt/V and peritoneal permeability for both parameters (pKt/V: F=4.37, Po0.05; CrpC: F=11.697, Po0.001). In conclusion, the application of ascendant and descendant UF profiles in automated PD is feasible and results in better UF and small solute clearances, thus preventing inadequate dialysis and volume overload.