The effect of low glucose degradation product, neutral pH versus standard peritoneal dialysis solutions on peritoneal membrane function: the balANZ trial (original) (raw)
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Assessing the peritoneal dialysis capacities of individual patients
Kidney International, 1995
Assessing the peritoneal dialysis capacities of individual patients. A method for measuring the peritoneal dialysis capacity (PDC) of the individual patient has been developed as an aid to treatment of patients with renal failure and peritoneal dialysis. The patient collects the data him or herself during an almost normal CAPD day using a carefully designed protocol whereby the nursing time is kept to a minimum. The three-pore model is used to describe the PDC with three physiological parameters: (1.) the 'Aiea' parameter (Ajx), which determines the diffusion of small solutes and the hydraulic conductance of the membrane (LS); (2.) the final reabsorption rate of fluid from the abdominal cavity to blood (JvAR) when the glucose gradient has dissipated; and (3.) the large pore fluid flux (of plasma, JvL), which determines the loss of protein to the PD fluid. In the adult PD population (age 60, N = 97) the normal 'Area' parameter was 23,600 cm/1.73 m2, with an SEM of 650. The JVAR was 1.49 ml/min/1.73 m2 and JvL was 0.078 ml/min/1.73 m2. The PDC parameters were reproducible and could adequately predict the concentrations of the test sQiutes as well as that of 132-microglobulin. The results in terms of clearance, 'UF volume' and nutritional consequences were presented on easily understandable graphs, whereby patient compliance was improved, These physiological parameters are highly dynamic, as evidenced by the marked increases observed during peritonitis. It seems safe to conclude that PDC is a useful tool to achieve adequate dialysis and to enhance the understanding of PD exchange. Peritoneal dialysis (PD) is an increasingly popular life-supporting therapy for patients with chronic renal failure. In contrast to the membranes used in hemodialysis, the functional characteristics of the individual PD membrane are unknown. indeed, it was recognized early that there are large differences in solute and fluid exchange between individual patients treated with continuous ambulatory peritoneal dialysis (CAPD) [1]. Moreover, the consequences of inadequate, or rather insufficient, dialysis appear gradually over a long period of time and include the reappearing uremic symptoms as well as increased morbidity and mortality. The effects appear in patients as the residual renal function declines, a phenomenon often denoted "the end of the honeymoon period." Previously, infections were the major complications of PD. However, the risk of peritonitis has been reduced in the last few years and other problems such as underdialysis are now evident. Against this background, it is not surprising that there is growing interest in methods of measuring PD exchange and providing adequate dialysis. In 1987, Twardowski et al introduced a simple peritoneal equilibration test (PET) which greatly improved our knowledge of
Peritoneal dialysis adequacy: A model to assess feasibility with various modalities
Kidney International, 1999
Background. The current standard of adequacy for peritoor more [3]. Recognized weaknesses of these guidelines neal dialysis (PD) is to provide a weekly normalized urea include: (a) the lack of evidence to establish equivalency clearance (Kt/V) of 2.0 or more and a creatinine clearance between the renal and peritoneal contributions of small (C Cr) of 60 liter/1.73 m 2 or more. As native renal function is lost, it is important to determine the effectiveness of the available solute removal to clinical outcome; and (b) the uncertain therapeutic modalities in achieving these goals. value of urea versus creatinine as markers of uremia Methods. A model to assess our ability to provide a weekly [4, 5]. Most clinical outcome studies have included pa-Kt/V urea of 2.0 or more and a C Cr of 60 liter/1.73 m 2 or more tients at various stages of uremia therapy with different to anuric patients undergoing continuous ambulatory PD degrees of residual renal function (RRF). The most (CAPD) and automated PD (PD Plus) was developed. The body surface area (BSA) distribution was obtained from 38,768 quoted prospective study, CANUSA, was not designed patients undergoing dialysis during January 1997. The distributo evaluate the relative effect of RRF and the peritoneal tion of peritoneal transport rates (PTRs) was obtained from clearance on patient outcome [2, 6, 7]. Furthermore, 2531 peritoneal equilibration tests performed during 1996. The patients with significant RRF are more likely to achieve weekly K p t/V urea was calculated for the various PTR groups higher clearances of creatinine than anuric patients beand the range of BSA with four PD prescriptions: CAPD 8 liters, CAPD 10 liters, PD Plus 12 liters, and PD Plus 15 liters, cause of tubular secretion of creatinine in advanced renal using a previously validated kinetic program (PackPD). failure. Few prospective studies have been performed in Results. The predicted percentage of patients capable of anuric patients undergoing PD. However, Selgas et al achieving the adequacy goals for Kt/V and C Cr , respectively, studied patients who had a minimum of three years on
Nephrology Dialysis Transplantation, 2006
Background. Chronic utilization of a bio-incompatible peritoneal dialysis (PD) solution with acidic pH and a high content of glucose degradation product (GDP) has been implicated as a contributing cause of peritoneal failure. We compared a newly formulated solution of neutral pH and low levels of GDP to a standard PD solution. Methods. Fifty new PD patients were randomized to a conventional lactate-buffered fluid (control) and a pH neutral, lactate-buffered, low GDP solution (balance). Patients were followed for 12 months. Serum samples were assayed for C-reactive protein (CRP). PD effluent was collected and assayed for cancer antigen-125 (CA125) and hyaluronan (HA). Clinical end points were the residual renal function and dialysis adequacy indices. Results. After 52 weeks of treatment, PD fluid CA125 rose from 2.45 AE 0.96 to 14.30 AE 2.17 U/ml (P < 0.001), and HA declined from 2.26 AE 0.60 to 1.45 AE 0.32 mg/ml (P ¼ 0.07) in the balance group. The balance group had a higher PD fluid CA-125 (14.30 AE 2.17 vs 7.36 AE 2.23 U/ml, P ¼ 0.007), lower HA (1.45 AE 0.32 vs 2.55 AE 0.32 mg/ml, P ¼ 0.007), and lower serum CRP level (1.77 AE 0.42 vs 7.73 AE 2.42 mg/l, P ¼ 0.026) than the control group at 52 weeks. There was no difference in dialysis adequacy indices, ultrafiltration volume, urine output, residual renal function, peritonitis rate or need of hospitalization in 1 year. Conclusion. As compared to conventional PD solution, the use of balance, a neutral pH, low GDP solution resulted in a superior profile of PDE mesothelial cell marker and a lower degree of systemic inflammation, and the difference was maintained for 1 year.
BMC Nephrology, 2010
Background: The main hypothesis of this study is that neutral pH, low glucose degradation product (GDP) peritoneal dialysis (PD) fluid better preserves residual renal function in PD patients over time compared with conventional dialysate. Methods/Design: Inclusion criteria are adult PD patients (CAPD or APD) aged 18-81 years whose first dialysis was within 90 days prior to or following enrolment and who have a residual GFR ≥ 5 ml/min/1.73 m 2 , a urine output ≥ 400 ml/day and an ability to understand the nature and requirements of this trial. Pregnant or lactating patients or individuals with an active infection at the time of enrolment, a contra-indication to PD or participation in any other clinical trial where an intervention is designed to moderate rate of change of residual renal function are excluded. Patients will be randomized 1:1 to receive either neutral pH, low GDP dialysis solution (Balance®) or conventional dialysis solution (Stay.safe®) for a period of 2 years. During this 2 year study period, urinary urea and clearance measurements will be performed at 0, 3, 6, 9, 12, 18 and 24 months. The primary outcome measure will be the slope of residual renal function decline, adjusted for centre and presence of diabetic nephropathy. Secondary outcome measures will include time from initiation of peritoneal dialysis to anuria, peritoneal small solute clearance, peritoneal transport status, peritoneal ultrafiltration, technique survival, patient survival, peritonitis rates and adverse events. A total of 185 patients has been recruited into the trial. Discussion: This investigator-initiated study has been designed to provide evidence to help nephrologists determine the optimal dialysis solution for preserving residual renal function in PD patients.
Assessment of Peritoneal Dialysis Adequacy – Does it Impact on Patient Outcomes?
2017
The provision of adequate dialysis is important for the survival of Peritoneal Dialysis (PD) patients. Small solute clearance indices of urea and creatinine are widely used as markers of PD adequacy although several other factors are also known to affect optimal outcome in PD patients. Recently there is continued debate on the interpretation and precise prognostic value of small solute clearance in PD patients despite issuance of clinical practice guidelines and recommendations based on the solute clearance indices. We reviewed available literature on solute clearance indices in the assessment of PD adequacy and its association with patient outcome. Electronic data base such as the EMBASE, MEDLINE, OVID and Google internet search engines were used for the search as well as relevant textbooks. Several prospective cohort studies have been published on the effects of small solute clearance and other factors on mortality, morbidity and quality of life of PD patients. There are also some...
Recent advances in the management of peritoneal dialysis patients
F1000prime reports, 2015
Peritoneal dialysis is a form of kidney dialysis that is used to remove accumulated metabolic waste products and water in patients with end stage kidney disease. Long-term exposure to high concentrations of glucose and its by-products, both found in peritoneal dialysis fluid, has been implicated in contributing to peritoneal damage over time, in turn limiting long-term use of the technique. Newer peritoneal dialysis solutions have been developed in the hope of reducing the unfavorable effects of peritoneal dialysis solutions. In vitro and in vivo studies have suggested that newer peritoneal dialysis fluids have salutary effects on the peritoneal membrane. Short-term clinical studies have also found some metabolic benefits of glucose-sparing regimens in chronic peritoneal dialysis. Mixed results have been found in studies examining whether newer peritoneal dialysis fluids reduce peritonitis rates. Long-term studies are needed to investigate whether newer peritoneal dialysis fluids pr...
Can peritoneal dialysis be used as a long term therapy for end stage renal disease
International Urology and Nephrology, 2003
Over the last 25 years, since the introductionof CAPD, the use of PD has increased greatlyand over this period many advances intechnique have been made. As is well known,that home and self-dialysis, such as PD, costless than in-center HD and can provideexcellent survival and a high level of patientrehabilitation. To date however, thedemonstration that PD can provide long termdialysis has been limited to a small number ofpatients.The next few decades will see a markedincrease in the worldwide dialysis population,particularly as older and sicker patients areaccepted into dialysis. It is likely thatworldwide pressures related to costcontainment will favour the use ofcost effective therapies, such as PD. However,the increased use of PD will continue, only ifwe continue to improve its efficacy and do notwaste the economic benefits gained over HD. Weare challenged to improve and develop PD in away that optimises patient medical andpsychosocial outcomes while minimizing costs.This may be achieved by using morebiocompatible solutions, hopefullyinexpensive, that will maintain the peritonealmembrane intact for long periods, will betterpreserve the membrane's transportcharacteristics over time, and thus reduce themain causes of drop out from dialysis.