Evaluation and Management of Ultrafiltration Problems in Peritoneal Dialysis (original) (raw)
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Turkish Nephrology Dialysis Transplantation, 2013
OBJECTIVE: Most patients on peritoneal dialysis (PD) consume a normal Western diet that contains a large amount of salt. This causes increase in extracellular volume ("fl uid overload") that has to be removed mostly with the dialysis fl uid, as residual renal function (if present) cannot cope with it. In the present study, we prospectively investigated whether an increased extracellular volume (corrected for height) predicted technique survival in PD patients. MATERIAL and METHODS: Ninety-fi ve prevalent PD patients from one center (mean age 50±13 years, 10 of them diabetic) were studied. Extracellular water (ECW), total body water (TBW), and intracellular water (ICW) were measured by multi-frequency bioimpedance analysis (m-BIA). Echocardiography was performed in all patients. Volume status was also evaluated by measuring left atrium diameter (LAD) and left ventricular end-diastolic diameter (LVEDD). Demographical, biochemical analyses, peritoneal equilibration test, weekly total Kt/V urea and weekly total creatinine clearance (CCr) results were obtained from patient chart. We identifi ed a cutoff value for ECW/height by drawing ROC curves that differentiate patients with FO and those without, using LAD and LVEDD measured by echocardiography as confi rmatory parameters. Technique survival (TS) was defi ned as the time on PD treatment until transfer to hemodialysis. Technique survival (TS) was assessed at the end of the follow-up and signifi cant predictors of technique survival were investigated. RESULTS: During the follow-up, 62 patients dropped out. Thirty-six patients were switched to hemodialysis (severe peritonitis in twelve, hernia in one, peritoneal leaks in fi ve, inadequate dialysis in seventeen and unwillingness in one patient), twelve patients received transplants, fi ve patients were transferred to other center and nine patients died (4 patients from infection, 4 patients from cardiovascular disease and 1 patient from malignancy). Patients switched to hemodialysis were older and had higher duration of PD treatment, body mass index, ECW/height and LAD than patients that stayed on PD. Patients that switched to HD also had signifi cantly lower weekly total KT/V urea , weekly total CCr and daily total urine volume than patients that stayed on PD. On ROC analysis, we found a cutoff value for ECW/height of 10.5 liters/m with specifi city of 78 % and sensitivity of 75% for the diagnosis of FO. Patients with the ratio of ECW/height values above the cutoff values had signifi cantly worse technique survival than those with ECW/height below 10.5 L/m (mean survival, 28.7±2.6 vs. 35.1± 1.9 months; p=0.016). On multivariate analysis, weekly total CCr, serum CRP level and ECW/height above 10.5 L/m were independent predictors of technique failure. CONCLUSION: An increased extracellular volume corrected for height as a fl uid overload marker is associated with decreased technique survival in PD patients.
Hemodialysis International, 2009
Excessive interdialytic weight gain (IWG) and ultrafiltration rates (UFR) above 10 mL/h/kg body weight imply higher morbidity and mortality. This study aimed to estimate the prevalence of high fluid consumers, describe UFR patterns, and describe patient characteristics associated with IWG and UFR. The Swedish Dialysis DataBase and The Swedish Renal Registry of Active Treatment of Uremia were used as data sources. Data were analyzed from patients aged ≥18 on regular treatment with hemodialysis (HD) and registered during 2002 to 2006. Interdialytic weight gain and dialytic UFR were examined in annual cohorts and the records were based on 9693 HD sessions in 4498 patients. Differences in proportions were analyzed with the chi‐square test and differences in means were tested using the ANOVA or the t test. About 30% of the patients had IWG that exceed 3.5% of dry body weight and 5% had IWG ≥5.7%. The volume removed during HD was >10 mL/h/kg for 15% to 23% of the patients, and this rat...
Assessment of Volume Status in Peritoneal Dialysis Patients
Some Special Problems in Peritoneal Dialysis, 2016
Ideal volume status of patients with end-stage renal disease is one of the main goals of adequate dialysis. Volume overload has been associated with heart failure, left ventricular hypertrophy, and mortality, both in hemodialysis (HD) and peritoneal dialysis (PD) populations. The assessment of normal volume status is traditionally based on clinical parameters such as blood pressure, edema, lung auscultation, and chest X-ray. However, these parameters cannot be trustworthy to direct treatment decisions. Gold standard methods of assessing volume status are mainly isotope dilution analysis techniques. However, these methods are invasive and impractical in clinical routine. A number of handy bedside methods have been developed focusing on objective fluid status assessment, both in HD and PD patients. Bioimpedance techniques can estimate extracellular volume, intracellular volume, and total body water, whereas inferior vena cava diameter measurements, biochemical markers, and lung ultrasound provide information about the intravascular filling state and blood volume. Various studies have used the values of the above-mentioned techniques as tools for determining the overhydration of dialysis patients as well as predictors of mortality. Yet, randomized intervention studies based on these methods with hard end points (like echocardiographic parameters modification) have not been published so far in PD patients.
Comparison of volume status in asymptomatic haemodialysis and peritoneal dialysis outpatients
Nephron extra, 2012
The majority of haemodialysis (HD) patients gain weight between dialysis sessions and thereby become volume overloaded, whereas peritoneal dialysis (PD) is a more continuous technique. Cardiovascular mortality and hypertension is increased with both treatment modalities. We therefore wished to compare volume status in PD and HD to determine whether PD patients are chronically volume overloaded, as a risk factor for cardiovascular mortality. Study Design, Setting and Participants:We retrospectively audited 72 healthy HD patients and 115 healthy PD patients attending a university hospital dialysis centre for routine outpatient treatment, who had multi-frequency bioimpedance measurements of extracellular water to total body water (ECW/TBW). The groups were well matched for age, sex, weight and ethnicity, PD patients had greater urine output [1,075 (485-1,613) vs. 42.5 (0-1,020) ml/day, p < 0.001], but there was no difference in antihypertensive prescription (63.5 vs. 76.4%), mean ar...
Clinical Journal of the American Society of Nephrology
Background and objectivesVolume overload is frequent in prevalent patients on kidney replacement therapies and is associated with outcome. This study was devised to follow-up volume status of an incident population on peritoneal dialysis (PD) and to relate this to patient-relevant outcomes.Design, setting, participants, & measurementsThis prospective cohort study was implemented in 135 study centers from 28 countries. Incident participants on PD were enrolled just before the actual PD treatment was started. Volume status was measured using bioimpedance spectroscopy before start of PD and thereafter in 3-month intervals, together with clinical and laboratory parameters, and PD prescription. The association of volume overload with time to death was tested using a competing risk Cox model.ResultsIn this population of 1054 participants incident on PD, volume overload before start of PD amounted to 1.9±2.3 L, and decreased to 1.2±1.8 L during the first year. At all time points, men and p...
Volume management as a key dimension of a high-quality PD prescription
Peritoneal Dialysis International: Journal of the International Society for Peritoneal Dialysis
Background: Appropriate volume control is one of the key goals in a peritoneal dialysis (PD) prescription. As such it is an important component of the International Society of Peritoneal Dialysis (ISPD) guideline for “High-quality PD prescription” necessitating a review of the literature on volume management. The workgroup recognized the importance of including within its scope measures of volume status and blood pressure in prescribing high-quality PD therapy. Methods: A Medline and PubMed search for publications addressing volume status and its management in PD since the publication of the 2015 ISPD Adult Cardiovascular and Metabolic Guidelines, from October 2014 through to July 2019, was conducted. Results: There were no randomized controlled trials on blood pressure intervention and six randomized trials of bioimpedance-guided volume management. Generally, all studies were of small sample size, short duration, and used surrogate markers as primary outcomes. As a consequence, onl...
Maintaining Peritoneal Dialysis Adequacy: The Process of Incremental Prescription
2018
Urea kinetics (weekly Kt/V) greater than 1.7 generally define adequate peritoneal dialysis (PD). Adequacy of PD depends on residual renal function and PD clearance. Preserving residual renal function and peritoneal membrane characteristics helps to maintain PD adequacy.The dose of PD can be augmented by increasing the total dialysate volume. Greater volume can be achieved by increasing either the fill volume per exchange or the number of exchanges. Increased time on dialysis can be achieved by keeping PD fluid in the peritoneal cavity at all times. Increasing the convective force enhances solute removal with ultrafiltration.Incremental PD is used during urgent starts and in patients who are newly starting or who have been on PD. Urgent starts require use of frequent low-volume exchanges to avoid leaks at surgical sites. The dialysate volume can be gradually increased provided that no leakage occurs, up to approximately 2 L per exchange on day 14 for an average-size adult. New-start ...
Plasma Volume, Albumin, and Fluid Status in Peritoneal Dialysis Patients
Clinical Journal of the American Society of Nephrology, 2010
Background and objectives: Peritoneal dialysis (PD) patients may be overhydrated especially when inflammation is present. We hypothesized that patients with a plasma albumin below the median value would have measurable overhydration without a proportional increase in plasma volume (PV). Design, setting, participants, & measurements: We investigated a cross-sectional sample of 46 prevalent PD patients powered to detect a proportional increase in PV associated with whole body overhydration and hypoalbuminemia. PV was determined from 125 I-labeled albumin dilution, absolute total body water from D dilution (TBW D), and relative hydration from multifrequency bioimpedance analysis (BIA; Xitron 4200) expressed as the extracellular water (ECW):TBW BIA ratio. Results: Whereas patients with plasma albumin below the median (31.4 g/dl) were overhydrated as determined both by BIA alone (ECW:TBW BIA 0.49 versus 0.47, P < 0.036) and the difference between estimated TBW BIA and measured TBW D (3.55 versus 0.94 L, P ؍ 0.012), corrected PV was not different (1463 versus 1482 ml/m 2 , NS). Mean PV was not different from predicted, and its variance did not correlate with any other clinical measures. Multivariate analysis showed that the only independent predictor of whole body overhydration was reduced plasma albumin. Conclusions: Hypoalbuminemia is an important determinant of tissue overhydration in PD patients. This overhydration is not associated with an increased plasma volume. Attempts to normalize the ECW:TBW ratio in hypoalbuminemic, inflamed PD patients may lead to hypovolemia and loss of residual renal function.