Background and objective: During peritoneal dialysis (PD), the period of effective net peritoneal ultrafiltration during long dwells can be extended by using the colloidal osmotic agent icodextrin but there are few detailed studies on ultrafiltration with icodextrin solution exceeding 12 h. We analyzed kinetics of peritoneal ultrafiltration in relation to icodextrin and its metabolites for 16-h dwells with icodextrin.Design, setting, participants, and measurements: In 20 clinically stable patients (mean age 54 years; 8 women; mean preceding time on PD 26 months), intraperitoneal dialysate volume (VD) was estimated from dilution of 125I-human serum albumin during 16-h dwell studies with icodextrin 7.5% solution. Sodium was measured in dialysate and plasma. In 11 patients, fractional absorption of icodextrin from dialysate, dialysate, and plasma amylase and high and low (Mw <2 kDa) Mw icodextrin fractions were analyzed.Results: Average VD increased linearly with no difference between transport types. At 16 h, the cumulative net ultrafiltration was 729 ± 337 ml (range −18 to 1,360 ml) and negative in only one patient. Average transcapillary ultrafiltration rate was 1.40 ± 0.36 ml/min, and peritoneal fluid absorption rate was 0.68 ± 0.38 ml/min. During 16 h, 41% of the initial mass of icodextrin was absorbed. Plasma sodium decreased from 138.7 ± 2.4 to 136.5 ± 3.0 mmol/L (p < 0.05). Dialysate glucose G2–G7 oligomers increased due to increase of G2–G4 metabolites while G6–G7 metabolites and higher Mw icodextrin fractions decreased. In plasma maltose and maltotriose (G2–G3 metabolites) increased while higher Mw icodextrin oligomers were almost undetectable. Dialysate amylase increased while plasma amylase decreased.Conclusions: Icodextrin resulted in linear increase of VD with sustained net UF lasting 16 h and with no significant difference between peritoneal transport types. In plasma, sodium and amylase declined, G2–G3 increased whereas larger icodextrin fractions were not detectable. In dialysate, icodextrin mass declined due to decrease of high Mw icodextrin fractions while low Mw metabolites, especially G2–G3, increased. The ability of icodextrin to provide sustained UF during very long dwells – which is usually not possible with glucose-based solutions – is especially important in anuric patients and in patients with fast peritoneal transport.
Objective To evaluate peritoneal transport of fluid and solutes in continuous ambulatory peritoneal dialysis (CAPD) patients using amino acid (AA)-based versus glucose-based dialysis solutions. Methods Using iodine-labeled human serum albumin (125I-HSA) as intraperitoneal volume marker, peritoneal transport was investigated in a group of 20 clinically stable patients (11 females and 9 men, age 53 ± 15 years) on CAPD for 15 – 101 months. Two paired 4-hour dwells, one with 1.36% glucose and one with 1.1% AA dialysis solution, were performed in each patient. Intraperitoneal dialysate volume, fluid absorption rate, and diffusive mass transport coefficients (KBD) and sieving coefficients (S) for glucose, creatinine, urea, potassium, and total protein were estimated for each dwell study. Dwell studies with AA solution were used to estimate KBD values for individual AAs. Results Intraperitoneal dialysate volume was higher for AA solution in comparison with glucose solution due to the higher osmolality of the AA solution. No statistically significant difference was found for KBD or S for creatinine, urea, potassium, or total protein in the dwell studies with either solution, whereas KBD for glucose was higher with AA than with glucose solution. Mean values of KBD of AA were similar but with high standard deviation, reflecting inter-individual variations in peritoneal transport rate. Conclusion Our results indicate that the AA peritoneal transport rate is strongly dependent on transport characteristics of the individual peritoneal membrane.
kinetics of water transperitoneal transport during long-term peritoneal… 305 INTROduCTION Our studies on peritoneal dialysis (PD), full of surprises and unexpected findings, began more than 40 years ago. At that time, Zofia Górko-Wańkowicz was trained in a newly introduced method of inter mittent PD at the First Department of Internal Diseases of the Warsaw Medical Academy, which an associate professor, Tadeusz Orłowski was in charge of. 1 Until the end of the 1970s, the approach was used only in hospitalized patients. In November 1979, Zofia Wańkowicz was one of the first in Europe to apply continuous ambulatory PD (CAPD) at our center using the equipment designed by us. In subsequent years, we developed our own schedule of CAPD and the method of auto matic PD (APD). Since 1990s, we have conducted a number of studies both on PD adequacy and the kinetics of peritoneal transport of water and substances. The present paper presents our current scientific work. Even in the 1990s, because of its continuous character PD was considered an effective method for treating overhydration in patients with end-stage renal disease subjected to extended dialysis therapy. 2 However, at the beginning of the 21st century, a number of papers were published, which indicated overhydration as a major clinical challenge in PD. 3-5 Overhydration in PD is associated with excessive supply of salt and fluids, and low removal of water from the organism on the one hand, and with real ultrafiltration
SummaryDiuretic-resistant congestive heart failure in the form of type 2 cardiorenal syndrome is a problem of growing significance in everyday clinical practice because of high morbidity and mortality. There has been scant progress in the treatment of overhydration, the main cause of symptoms in this group of patients. The aim of our review is to present recent advances in the ultrafiltration therapy of congestive heart failure, with special attention to the new dedicated device for extracorporeal isolated ultrafiltration, as well as modifications of peritoneal dialysis in the form of peritoneal ultrafiltration with icodextrin solution and incremental peritoneal dialysis. Technical and clinical features, costs and potential risks of available devices for isolated ultrafiltration are presented. This method should be reserved for patients with true diuretic resistance as part of a more complex strategy aiming at the adequate control of fluid retention. Peritoneal ultrafiltration is presented as a viable alternative to extracorporeal ultrafiltration because of medical and psychosocial benefits of home-based therapy, lower costs and more effective daily ultrafiltration. In conclusion, large, properly randomized and controlled clinical trials with long-term follow-up will be essential in assessing the logistics and cost-effectiveness of both methods. Most importantly, however, they should be able to evaluate the impact of both methods on preservation of renal function and delaying the progression of heart failure by interrupting the vicious circle of cardiorenal syndrome. Our review is supplemented with the case report of the use of peritoneal ultrafiltration with a single 12-hour nighttime icodextrin exchange as a life-saving procedure in a patient with congestive heart failure resistant to pharmacological treatment.
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