Prolong

Fluid Status in Peritoneal Dialysis Patients: The European Body Composition Monitoring (EuroBCM) Study Cohort

Wim Van Biesen1*, John D. Williams2, Adrian C. Covic3, Stanley Fan4, Kathleen Claes5, Monika Lichodziejewska-Niemierko6, Christian Verger7, Jurg Steiger8, Volker Schoder9, Peter Wabel9, Adelheid Gauly9, Rainer Himmele9, on behalf of the EuroBCM study group

1 University Hospital Ghent, Ghent, Belgium, 2 University Hospital of Wales College of Medicine, Cardiff, United Kingdom, 3 University ‘‘Gr T Popa’’ and University Hospital ‘‘C I Pharon’’, Iasi, Romania, 4 The Royal London Hospital, London, United Kingdom, 5 University Hospital Leuven, Leuven, Belgium, 6 Dialysis Center NephroCare, Gdansk University, Gdansk, Poland, 7 University Hospital Rene´ Dubos, Pontoise, France, 8 University Hospital Basel, Basel, Switzerland, 9 Fresenius Medical Care Deutschland GmbH, Bad Homburg, Germany

Abstract

Background: Euvolemia is an important adequacy parameter in peritoneal dialysis (PD) patients. However, accurate tools to evaluate volume status in clinical practice and data on volume status in PD patients as compared to healthy population, and the associated factors, have not been available so far.

Methods: We used a bio-impedance spectroscopy device, the Body Composition Monitor (BCM) to assess volume status in a cross-sectional cohort of prevalent PD patients in different European countries. The results were compared to an age and gender matched healthy population.

Results: Only 40% out of 639 patients from 28 centres in 6 countries were normovolemic. Severe fluid overload was present in 25.2%. There was a wide scatter in the relation between blood pressure and volume status. In a multivariate analysis in the subgroup of patients from countries with unrestricted availability of all PD modalities and fluid types, older age, male gender, lower serum albumin, lower BMI, diabetes, higher systolic blood pressure, and use of at least one exchange per day with the highest hypertonic glucose were associated with higher relative tissue hydration. Neither urinary output nor ultrafiltration, PD fluid type or PD modality were retained in the model (total R2 of the model = 0.57).

Conclusions: The EuroBCM study demonstrates some interesting issues regarding volume status in PD. As in HD patients, hypervolemia is a frequent condition in PD patients and blood pressure can be a misleading clinical tool to evaluate volume status. To monitor fluid balance, not only fluid output but also dietary input should be considered. Close monitoring of volume status, a correct dialysis prescription adapted to the needs of the patient and dietary measures seem to be warranted to avoid hypervolemia.

 PLoS ONE  - www.plosone.org  February 2011 | Volume 6 | Issue 2 | e17148

THE BENEFICIAL INFLUENCE ON THE EFFECTIVENESS OF AUTOMATED PERITONEAL DIALYSIS OF VARYING THE DWELL TIME (SHORT/LONG) AND FILL VOLUME (SMALL/LARGE): A RANDOMIZED CONTROLLED TRIAL

Michel Fischbach,1 Belkacem Issad,2 Vincent Dubois,3 and Redouane Taamma3

Nephrology Dialysis Transplantation Children’s Unit,1 University Hospital Hautepierre, Strasbourg; Nephrology,2 Pitié–Salpétrière, Paris; and Fresenius Medical Care–Nephrocare France,3 Fresnes, France

Abstract

Background: It is well known that the efficiency of peritoneal dialysis (PD) varies with the duration of the dwell and with the prescribed fill volume. Automated PD (APD) is classically given as a series of recurrent exchanges, each having the same dwell time and fill volume—that is, conventional APD (APD-C). We propose a new way of giving PD, using a modified version of APD-C. This method first uses a short dwell time with a small fill volume to promote ultrafiltration (UF) and subsequently uses a longer dwell time and a larger fill volume to promote removal of uremic toxins from the blood. We use the term “adapted APD” (APD-A) to describe this modified form of PD.
Methods: We designed a multicenter prospective randomized crossover trial to assess the impact of APD-A in comparison with APD-C on the efficacy of dialysis. The parameters investigated were overnight UF; weekly peritoneal Kt/Vurea; weekly peritoneal creatinine clearance corrected to 1.73 m2 body surface area (Kcreat); and phosphate (PDR) and sodium dialytic removal (SDR) in millimoles per session, corrected for glucose absorption, which provides an estimate of metabolic cost. Blood pressure was also regularly monitored. Initially, 25 patients were identified for inclusion in the study. There were 6 withdrawals in total: 2 at enrolment, 1 at day 75 (transplantation), 2 at day 30 (catheter dysfunction), and 1 for drainage alarms. All patients received the same duration of overnight APD, using the same total volume of dialysate, with the same 1.5% glucose, lactate-buffered dialysate (Balance: Fresenius Medical Care, Bad Homburg, Germany).
Results: Tolerance was good. Compared with APD-C, APD-A resulted in a significant enhancement of Kt/Vurea, Kcreat, and PDR. The metabolic cost, in terms of glucose absorption, required to achieve dialytic capacity for urea, creatinine, and phosphate blood purification was significantly lower for APD-A than for APD-C, and UF increased during APD-A. With APD-A, each gram of glucose absorbed contributed to 18.25 ± 15.82 mL UF; in APD-C, each gram of glucose ab­sorbed contributed to 15.79 ± 11.24 mL UF. However, that difference was not found to be significant (p = 0.1218). The SDR was significantly higher with APD-A than with APD-C: 35.23 ± 52.00 mmol and 18.35 ± 48.68 mmol per session respectively (p < 0.01). The mean blood pressure recorded at the end of each PD period (on day 45) was significantly lower when patients received APD-A than when they receivedAPD-C.
Conclusions: Our study provides evidence that, compared with the uniform dwell times and fill volumes used throughout an APD-C dialysis session, the varying dwell times and fill volumes as described for an APD-A dialysis session result in improved dialysis efficiency in terms of UF, Kt/Vurea, Kcreat, PDR, and SDR. Those results were achieved without incurring any extra financial costs and with a reduction in the metabolic cost (assessed using glucose absorption).

Personalization of Automated Peritoneal Dialysis Treatment Using a Computer Modeling System

Emilio G. Galli, Carlo Taietti, Marcello Borghi

Nephrology and Dialysis, Azienda Ospedaliera di Treviglio, Bergamo, Italy

Abstract

The use of almost standardized dialysis programs—and the absence of any adjustment over time in these program to match the progressive decline in residual kidney function, in addition to the reduction in peri­toneal depuration because of the frequency of perito­nitis and the use of solutions containing high glucose concentrations—often leads to technique drop-out and transfer to hemodialysis.
Our study enrolled 15 clinically stable patients (13 white men, 2 white women; average age: 67.3 ± 12.99 years; average dialysis vintage: 32.25 ± 25.10 months) who had been on automated peritoneal dialysis treatment with a standard treatment profile for at least 6 months (dwell time per cycle and solutions fixed at various glucose concentrations in all exchanges). After a peritoneal equilibration test had been performed and clearances (peritoneal and renal) were measured, the dialysis program was modified, individualizing it to the patient’s peritoneal membrane transport by the Twardowski system of classification and taking into account the patient’s residual diuresis and need for ultrafiltration. The change was implemented using the Patient on Line software created by Fresenius Medical Care (Bad Homburg, Germany).
After a month of personalized dialysis treatment, weekly peritoneal Kt/V in the study group increased significantly (to 1.47 ± 0.61 from 1.02 ± 0.37, p = 0.001); no difference in renal Kt/V was observed. Total Kt/V reached levels of optimum dialysis adequacy (to 2.21 ± 0.28 from 1.62 ± 0.33, p = 0.0001). Weekly peritoneal creatinine clearance also increased to 32.86 ± 16.94 L/1.73 m2 from 22.27 ± 9.16 L/1.73 m2 (p = 0.005), with renal creatinine clearance essentially stable, and total weekly clearance increasing to 67.58 ± 14.52 L/1.73 m2 from 53.51 ± 16.86 L/1.73 m2 (p < 0.0001).
The dialysis adequacy improvements obtained involved no statistically significant differences in the total infused volume of dialysis solution, ultrafiltration, or the duration of dialysis treatment. It should also be noted that no changes in residual diuresis occurred.

Advances in Peritoneal Dialysis, Vol. 27, 2011