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      A Simple Method for the Estimation of Peritoneal Fluid Transport

      , , ,

      Blood Purification

      S. Karger AG

      Peritoneal dialysis, Fluid kinetics

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          Background: Evaluating peritoneal fluid kinetics is of great value to the adjustment of peritoneal dialysis prescription. Therefore, in the present study, we developed a simple method, based on a membrane transport model, to evaluate the fluid transport characteristics of the peritoneal membrane in continuous ambulatory peritoneal dialysis (CAPD) patients. Methods: Patients’ peritoneal ultrafiltration (UF) volume was collected for 2 consecutive months. Membrane transport model and nonlinear least-squares regression analyses were applied to the pooled UF volume for the first month for fluid kinetic simulation and the data from the second month were used to evaluate the reliability and precision of simulated UF values. Results: Seventeen chronic peritoneal dialysis (PD) patients were selected for the present study. Simulated UF values based on the pooled UF volume in the first month correlated significantly with the actual measured UF values in the second month. By Bland-Atman plot, the width between the 95% limits of agreement fell within –133.3 to 154.2 ml with a mean difference of 10.5 ml. Conclusion: Our study showed that applying the fluid transport model and nonlinear least-squares regression analysis to the pooled actual UF value might be a good and simple way to predict peritoneal UF.

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          What really happens to people on long-term peritoneal dialysis?

          Several risk factors for patients treated with peritoneal dialysis (PD) have now been identified. These include age, comorbid disease, nutritional status, loss of residual renal function (RRF) and high peritoneal solute transport. This is not the same, however, as knowing what actually happens to these patients, particularly in the long-term. The purpose of this review was to give as complete a description as is currently possible of the long-term PD patient. The literature was surveyed for publications that provide longitudinal cohort data of either selected or unselected patient groups. Detailed data from the Stoke PD Study is presented in the context of these studies. Three principle aspects of what really happens to patients were considered: (1) death, both cause and mode of death; (2) technique failure, with reference to peritoneal function and how the cause of technique failure related to patient survival; and (3) evolution of clinically relevant parameters of patients on PD, such as nutrition and peritoneal function. Sudden death and debilitation were the predominant modes of death, with sepsis playing a contributory role. Debilitation was important regardless of co-existent comorbid disease, and time to death was not influenced by the mode of death. Predominant causes for technique failure remain peritonitis and ultrafiltration, the latter becoming more important with time on treatment. Technical failure is associated with poorer survival, particularly when due to multiple peritonitis or failure to cope with treatment. Cox regression demonstrated that whereas low albumin, loss of RRF and high solute transport predicted patient death, only high solute transport predicted technique failure. Longitudinal changes over the first five years of treatment included loss of RRF, increasing solute transport and following an initial improvement in nutritional state, a decline after two years. Patients surviving long-term PD (at least five years, N = 25) were characterized by prolonged RRF, maintained nutrition and lower solute transport in the medium term. Several studies of long-term PD in the literature now complement each other in providing a picture of what really happens to PD patients. The links between loss of solute clearance and poor peritoneal ultrafiltration combining to exacerbate sudden or debilitated death and technique failure are emerging. For PD to be successful as a long-term therapy, strategies that maintain nutrition and preserve peritoneal membrane function must be developed.
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            Peritoneal transport in CAPD patients with permanent loss of ultrafiltration capacity.

            During a 10 year period, 14 out of 227 patients (6.2%) undergoing continuous ambulatory peritoneal dialysis (CAPD) developed permanent loss of ultrafiltration capacity (UFC). The risk of UFC loss increased from 2.6% after one year to 30.9% after six years of treatment. A six hour, single dwell study with glucose 3.86% dialysis fluid was carried out in nine of the UFC loss patients and in 18 CAPD patients with normal UFC. Intraperitoneal dialysate volumes were calculated using 131I-tagged albumin (RISA) as volume marker with a correction applied for its elimination from the peritoneal cavity. The RISA elimination coefficient (KE), which can serve as an estimation of the upper limit of the lymphatic flow, was also calculated. Diffusive mass transport coefficients (KBD) for investigated solutes (glucose, creatinine, urea, potassium, total protein, albumin and beta 2-microglobulin) were calculated during a period of dialysate isovolemia. Two patterns of UFC loss were observed: (a) seven patients had high KBD values for small solutes resulting in rapid uptake of glucose, whereas KBD values for proteins were normal; (b) two patients had normal KBD values but a threefold increase both in the fluid reabsorption rate and KE. We conclude that loss of the osmotic driving force (due to increased diffusive mass transport for small solutes) and increased fluid reabsorption (possibly due to increased lymphatic reabsorption) are the two major causes of permanent loss of UFC in CAPD patients.
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              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 'Area' parameter (A0/delta X), which determines the diffusion of small solutes and the hydraulic conductance of the membrane (LpS); (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 solutes as well as that of beta 2-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.

                Author and article information

                Blood Purif
                Blood Purification
                S. Karger AG
                March 2007
                29 December 2006
                : 25
                : 2
                : 161-168
                Division of Nephrology, Third Hospital, Peking University, Beijing, PR China
                98319 Blood Purif 2007;25:161–168
                © 2007 S. Karger AG, Basel

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                Page count
                Figures: 6, Tables: 1, References: 11, Pages: 8
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                Original Paper

                Cardiovascular Medicine, Nephrology

                Fluid kinetics, Peritoneal dialysis


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