scholarly journals Ultrafiltration Failure in Peritoneal Dialysis: A Pathophysiologic Approach

2015 ◽  
Vol 39 (1-3) ◽  
pp. 70-73 ◽  
Author(s):  
Isaac Teitelbaum
Keyword(s):  
Peritoneal Dialysis ◽  
Surface Area ◽  
Free Water ◽  
Fluid Loss ◽  
Free Water Clearance ◽  
Peritoneal Surface ◽  
Ultrafiltration Failure ◽  
Rapid Transport ◽  
Technique Failure ◽  
Sodium Sieving

Background: Ultrafiltration failure is a significant cause of technique failure for peritoneal dialysis and subsequent transfer to hemodialysis. Summary: Ultrafiltration failure is defined as failure to achieve at least 400 ml of net ultrafiltration during a 4 h dwell using 4.25% dextrose. Four major causes of ultrafiltration failure have been described. A highly effective peritoneal surface area is characterized by transition to a very rapid transport state with D/P creatinine >0.81. Low osmotic conductance to glucose is characterized by attenuation of sodium sieving and decreased peritoneal free water clearance to <26% of total ultrafiltration in the first hour of a dwell. Low effective peritoneal surface area manifests with decreases in the transport of both solute and water. A high total peritoneal fluid loss rate is the most difficult to diagnose clinically; failure to achieve ultrafiltration with an 8-10 h icodextrin dwell may provide a clue to diagnosis. Key Messages: Knowledge of the specific pathophysiology of the various causes of ultrafiltration failure will aid in the diagnosis thereof.

scholarly journals Ultrafiltration Failure and Impaired Sodium Sieving during Long-Term Peritoneal Dialysis: More than Aquaporin Dysfunction?

2016 ◽  
Vol 36 (2) ◽  
pp. 227-231 ◽  
Author(s):  
Johann Morelle ◽  
Amadou Sow ◽  
Nicolas Hautem ◽  
Olivier Devuyst ◽  
Eric Goffin
Keyword(s):  
Peritoneal Dialysis ◽  
Water Transport ◽  
Free Water ◽  
Peritoneal Fibrosis ◽  
Osmotic Water ◽  
Ultrafiltration Failure ◽  
Normal Expression ◽  
Initial Hypothesis ◽  
Sodium Sieving

Fifteen years ago, our group reported the case of a 67-year-old man on peritoneal dialysis for 11 years, in whom ultrafiltration failure and impaired sodium sieving were associated with an apparently normal expression of aquaporin-1 (AQP1) water channels in peritoneal capillaries. At that time, AQP1 dysfunction was suggested as the cause of impaired free-water transport. However, recent data from computer simulations, and structural and functional analysis of the peritoneal membrane of patients with encapsulating peritoneal sclerosis, demonstrated that changes in the peritoneal interstitium directly alter osmotic water transport. In light of these insights, we challenge the initial hypothesis and provide several lines of evidence supporting the diagnosis of encapsulating peritoneal sclerosis in this patient and suggesting that severe peritoneal fibrosis accounted for the loss of osmotic conductance developed during the course of peritoneal dialysis.

Mass Transfer Area Coefficients in Children

1994 ◽  
Vol 14 (1) ◽  
pp. 30-33 ◽  
Author(s):  
Denis F. Geary ◽  
Elizabeth A. Harvey ◽  
J. Williamson Balfe
Keyword(s):  
Mass Transfer ◽  
Body Weight ◽  
Peritoneal Dialysis ◽  
Solute Transport ◽  
Surface Area ◽  
Peritoneal Surface ◽  
Unit Body Weight ◽  
Rapid Transport ◽  
Sick Children

Objective Measurement of mass transfer area coefficients (MTAC) in children of different sizes to determine if solute transport varies with age and to compare with published adult values. Design Mass transfer area coefficients calculated from prospectively collected data in 28 selected patients. Participants All children starting maintenance peritoneal dialysis at the Hospital for Sick Children. Selected patients were also studied if hospitalized for unrelated reasons. Results Mean MTAC values for creatinine and glucose were 4.0 and 4.5 mL/min, respectively, both considerably lower than adult values. When scaled per 70 kg body weight, these results were greater, and when scaled per 1.73 m2 surface area, they were lower than reported adult values. The MTAC/kg body weight was inversely correlated to age. Conclusions Solute transport in children is directly related to age and does not approach adult values until later childhood. However, more rapid transport per unit body weight is observed in children and may reflect an increased effective peritoneal surface area.

scholarly journals Outcomes of Peritoneal Dialysis Patients and Switching to Hemodialysis: A Competing Risks Analysis

2014 ◽  
Vol 34 (3) ◽  
pp. 289-298 ◽  
Author(s):  
Jernej Pajek ◽  
Alastair J. Hutchison ◽  
Shiv Bhutani ◽  
Paul E.C. Brenchley ◽  
Helen Hurst ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Proportional Hazards ◽  
Proportional Hazards Model ◽  
Residual Renal Function ◽  
Cox Proportional Hazards ◽  
Cox Proportional Hazards Model ◽  
Adjusted Analysis ◽  
Ultrafiltration Failure ◽  
The Impact ◽  
Technique Failure

BackgroundWe performed a review of a large incident peritoneal dialysis cohort to establish the impact of current practice and that of switching to hemodialysis.MethodsPatients starting peritoneal dialysis between 2004 and 2010 were included and clinical data at start of dialysis recorded. Competing risk analysis and Cox proportional hazards model with time-varying covariate (technique failure) were used.ResultsOf 286 patients (median age 57 years) followed for a median of 24.2 months, 76 were transplanted and 102 died. Outcome probabilities at 3 and 5 years respectively were 0.69 and 0.53 for patient survival (or transplantation) and 0.33 and 0.42 for technique failure. Peritonitis caused technique failure in 42%, but ultrafiltration failure accounted only for 6.3%. Davies comorbidity grade, creatinine and obesity (but not residual renal function or age) predicted technique failure. Due to peritonitis deaths, technique failure was an independent predictor of death hazard. When successful switch to hemodialysis (surviving more than 60 days after technique failure) and its timing were analyzed, no adverse impact on survival in adjusted analysis was found. However, hemodialysis via central venous line was associated with an elevated death hazard as compared to staying on peritoneal dialysis, or hemodialysis through a fistula (adjusted analysis hazard ratio 1.97 (1.02 – 3.80)).ConclusionsOnce the patients survive the first 60 days after technique failure, the switch to hemodialysis does not adversely affect patient outcomes. The nature of vascular access has a significant impact on outcome after peritoneal dialysis failure.

The Influence of Peritoneal Surface Area on Dialysis Adequacy

2005 ◽  
Vol 25 (3_suppl) ◽  
pp. 137-140 ◽  
Author(s):  
Michel Fischbach ◽  
Céline Dheu ◽  
Pauline Helms ◽  
Joëlle Terzic ◽  
Anne Cécile Michallat ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Surface Area ◽  
Contact Area ◽  
Peritoneal Membrane ◽  
Dialysis Adequacy ◽  
Peritoneal Surface ◽  
Vascular Area ◽  
Fill Volume ◽  
Peritoneal Dialysis Fluid ◽  
Dialysis Fluids

In children, the prescription of peritoneal dialysis is based mainly on the choice of the peritoneal dialysis fluid, the intraperitoneal fill volume (mL/m2 body surface area (BSA)], and the contact time. The working mode of the peritoneal membrane as a dialysis membrane is more related to a dynamic complex structure than to a static hemodialyzer. Thus, the peritoneal surface area impacts on dialysis adequacy. In fact, the peritoneal surface area may be viewed as composed of three exchange entities: the anatomic area, the contact area, and the vascular area. First, in infants, the anatomic area appears to be twofold larger than in adults when expressed per kilogram body weight. On the other hand, the anatomic area becomes independent of age when expressed per square meter BSA. Therefore, scaling of the intraperitoneal fill volume by BSA (m2) is necessary to prevent a too low ratio of fill volume to exchange area, which would result in a functional “hyperpermeable” peritoneal exchange. Second, the contact area, also called the wetted membrane, is only a portion of the anatomic area, representing 30% to 60% of this area in humans, as measured by computed tomography. Both posture and fill volume may affect the extent of recruitment of contact area. Finally, the vascular area is influenced by the availability of both the anatomic area and the recruited contact area. This surface is governed essentially by both peritoneal vascular perfusion, represented by the mesenteric vascular flow and, hence, by the number of perfused capillaries available for exchange. This vascular area is dynamically affected by different factors, such as composition of the peritoneal fluid, the fill volume, and the production of inflammatory agents. Peritoneal dialysis fluids that will be developed in the future for children should allow an optimization of the fill volume owing to a better tolerance in terms of lower achieved intraperitoneal pressure for a given fill volume. Moreover, future peritoneal dialysis fluids should protect the peritoneal membrane from hyperperfusion (lower glucose degradation products).

Dyslipidemia in Peritoneal Dialysis — Relation to Dialytic Variables

2000 ◽  
Vol 20 (3) ◽  
pp. 306-314 ◽  
Author(s):  
Ann-Cathrine Johansson ◽  
Ola Samuelsson ◽  
Per-Ola Attman ◽  
Börje Haraldsson ◽  
James Moberly ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Creatinine Clearance ◽  
Glucose Uptake ◽  
Surface Area ◽  
Plasma Lipids ◽  
Plasma Concentrations ◽  
University Hospital ◽  
Protein Loss ◽  
Dialysis Unit ◽  
Peritoneal Surface

Objective To investigate whether the specific lipoprotein (LP) abnormalities of peritoneal dialysis (PD) are associated with functional variables of this mode of dialysis. Design A survey of the LP profile in relation to peritoneal dialysis capacity (PDC) variables. The LP profile was compared to that of a group of age- and sex-matched controls. Setting The Peritoneal Dialysis Unit at Sahlgrenska University Hospital in Gothenburg, Sweden. Patients Twenty-two nondiabetic PD patients (5 women, 17 men) who had been on PD for at least 6 months. Main Outcome Measures The LP profile included plasma lipids, apolipoproteins (Apo), and individual ApoA- and ApoB-containing LP. The PDC measurement determined peritoneal glucose uptake, protein losses, effective peritoneal surface area, and total weekly creatinine clearance. Results The patients had been on PD for 6 to 48 months (mean 15.3 months) and had a total weekly creatinine clearance of 69.7 ± 13.3 L/1.73m2 body surface area, an average peritoneal glucose uptake corresponding to 446 ± 162 kcal/24 hour, and a protein loss of 8.1 ± 2.5 g/24 hr. The patients had significantly higher total cholesterol (7.1 mmol/L), VLDL-cholesterol (1.0 mmol/L), LDL-cholesterol (4.7 mmol/L), and triglyceride levels (2.5 mmol/L); whereas the HDL-cholesterol level (1.2 mmol/L) was significantly lower than in controls. The PD patients had increased levels of ApoB-containing LPs, both of the cholesterol-rich LP-B and of the triglyceride-rich LP-B complex, reflected in higher plasma concentrations of ApoB, ApoC-III, and ApoE. Furthermore, they had significantly lower levels of LP-A-I:A-II, as well as of ApoA-I and ApoA-II. The LP-A-I:A-II and ApoA-II levels correlated inversely with the duration of PD treatment ( r = 0.54, p < 0.01 and r = 0.52, p < 0.05, respectively). The ApoA-II level was inversely correlated with the peritoneal surface area ( r = 0.53, p < 0.05). There were no other correlations between LP variables and PDC variables, nor did any of the LP variables correlate with peritoneal glucose uptake or protein losses. Conclusion The proatherogenic lipoprotein profile of patients on PD is characterized by increased concentrations of cholesterol-rich and triglyceride-rich ApoB-containing LPs. While the duration of treatment appears to have some influence on the development of this type of dyslipidemia, the pathophysiological links to the dialysis mode must be further explored.

scholarly journals Analysis of Ultrafiltration Failure Diagnosed at the Initiation of Peritoneal Dialysis with the Help of Peritoneal Equilibration Tests with Complete Drainage at Sixty Minutes. A Longitudinal Study

2016 ◽  
Vol 36 (4) ◽  
pp. 442-447 ◽  
Author(s):  
Daniela Machado Lopes ◽  
Ana Rodríguez-Carmona ◽  
Teresa García Falcón ◽  
Andrés López Muñiz ◽  
Tamara Ferreiro Hermida ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Water Transport ◽  
Time Course ◽  
Free Water ◽  
Control Group ◽  
First Year ◽  
Study Group ◽  
Ultrafiltration Failure ◽  
Small Pore

BackgroundUltrafiltration failure (UFF) diagnosed at the initiation of peritoneal dialysis (PD) has been insufficiently characterized. In particular, few longitudinal studies have analyzed the time course of water transport in patients with this complication.ObjectiveTo investigate the time course of peritoneal water transport during the first year on PD in patients presenting UFF since the initiation of this therapy (study group).MethodProspective, observational, single-center design. We analyzed, at baseline and after 1 year of follow-up, peritoneal water transport in 19 patients incident on PD with UFF. We used incident patients without UFF as a control group. Water transport was characterized with the help of 3.86/4.25% dextrose-based peritoneal equilibration tests (PETs) with complete drainage at 60 minutes.ResultsThe study group revealed a disorder of water transport affecting both small-pore ultrafiltration (SPUF) ( p = 0.054 vs incident without UFF) and free water transport (FW T) ( p = 0.001). After 1 year of follow-up, FWT displayed a general increasing trend in the study group (mean variation 48.9 mL, 95% confidence interval [CI] 15.5, 82.2, p = 0.012), while the behavior of SPUF was less predictable (-4.8 mL, 95% CI -61.4, 71.1, p = 0.85). These changes were not observed in incident patients without UFF. Neither initial clinical characteristics, baseline PET-derived parameters, or suffering peritoneal infections during the first year predicted the time course of the capacity of UF in the study group. Recovery from incident UFF was apparently linked to improvement of SPUF.ConclusionsPatients with UFF at the start of PD suffer a disorder of peritoneal water transport affecting both FWT and SPUF. Free water transport increases systematically in these patients after 1 year of follow-up. The evolution of SPUF is less predictable, and improvement of this parameter marks reversibility of this complication.

Acquired Decline in Ultrafiltration in Peritoneal Dialysis: The Role of Glucose

2021 ◽  
pp. ASN.2021010080
Author(s):  
Raymond Krediet
Keyword(s):  
Peritoneal Dialysis ◽  
Free Water ◽  
Rapid Decline ◽  
Interstitial Tissue ◽  
Continuous Exposure ◽  
Osmotic Gradient ◽  
Glut 1 ◽  
Long Term Treatment ◽  
Ultrafiltration Failure

Ultrafiltration is essential in peritoneal dialysis (PD) for maintenance of euvolemia, making ultrafiltration insufficiency preferably called ultrafiltration failure—an important complication. The mechanisms of ultrafiltration and ultrafiltration failure are more complex than generally assumed, especially after long-term treatment. Initially, ultrafiltration failure is mainly explained by a large number of perfused peritoneal microvessels, leading to a rapid decline of the crystalloid osmotic gradient, thereby decreasing aquaporin-mediated free water transport. The contribution of peritoneal interstitial tissue to ultrafiltration failure is limited during the first few years of PD, but becomes more important in long-term PD due to the development of interstitial fibrosis, which mainly consists of myofibroblasts. A dual hypothesis has been developed to explain why the continuous exposure of peritoneal tissues to the extremely high dialysate glucose concentrations causes progressive ultrafiltration decline. First, glucose absorption causes an increase of the intracellular NADH/NAD+ ratio, also called pseudohypoxia. Intracellular hypoxia stimulates myofibroblasts to produce profibrotic and angiogenetic factors, as well as the glucose transporter GLUT-1. Second, the increased GLUT-1 expression by myofibroblasts increases glucose uptake in these cells, leading to a reduction of the osmotic gradient for ultrafiltration. Reduction of peritoneal glucose exposure to prevent this vicious circle is essential for high-quality long-term PD.

scholarly journals Two-in-One Protocol: Simultaneous Small-Pore and Ultrasmall-Pore Peritoneal Transport Quantification

2012 ◽  
Vol 32 (5) ◽  
pp. 537-544 ◽  
Author(s):  
Ana Paula Bernardo ◽  
M. Auxiliadora Bajo ◽  
Olivia Santos ◽  
Gloria Del Peso ◽  
Maria João Carvalho ◽  
...  
Keyword(s):  
Free Water ◽  
Peritoneal Membrane ◽  
Peritoneal Equilibration Test ◽  
Indirect Measurements ◽  
Ultrafiltration Failure ◽  
Small Pore ◽  
Decisive Parameter ◽  
Sodium Sieving ◽  
Functional Deterioration ◽  
Small Solute

BackgroundReduced free water transport (FWT) through ultrasmall pores contributes to net ultrafiltration failure (UFF) and should be seen as a sign of more severe functional deterioration of the peritoneal membrane. The modified peritoneal equilibration test (PET), measuring the dip in dialysate Na concentration, estimates only FWT. Our aim was to simultaneously quantify small-solute transport, FWT, and small-pore ultrafiltration (SPUF) during a single PET procedure.MethodsWe performed a 4-hour, 3.86% glucose PET, with additional measurement of ultrafiltration (UF) at 60 minutes, in 70 peritoneal dialysis patients (mean age: 50 ± 16 years; 61% women; PD vintage: 26 ± 23 months). We calculated the dialysate-to-plasma ratios (D/P) of creatinine and Na at 0 and 60 minutes, and the Na dip (DipD/PNa60,), the delta dialysate Na 0–60 (ΔDNa0–60), FWT, and SPUF.ResultsSodium sieving (as measured by ΔDNa0–60) correlated strongly with the corrected DipD/PNa60, ( r = 0.85, p < 0.0001) and the corrected FWT ( r = 0.41, p = 0.005). Total UF showed better correlation with FWT than with indirect measurements of Na sieving ( r = 0.46, p < 0.0001 for FWT; r = 0.360, p < 0.0001 for DipD/PNa60,). Corrected FWT fraction was 0.45 ± 0.16. A negative correlation was found between time on PD and both total UF and FWT ( r = -0.253, p = 0.035 and r = -0.272, p = 0.023 respectively). The 11 patients (15.7%) diagnosed with UFF had lower FWT (89 mL vs 164 mL, p < 0.05) and higher D/P creatinine (0.75 vs 0.70, p < 0.05) than did the group with normal UF. The SPUF correlated positively with FWT in the normal UF group, but negatively in UFF patients ( r = -0.709, p = 0.015). Among UFF patients on PD for a longer period, 44.4% had a FWT percentage below 45%.ConclusionsMeasurement of FWT and SPUF is feasible by simultaneous quantification during a modified 3.86% glucose PET, and FWT is a decisive parameter for detecting causes of UFF in addition to increased effective capillary surface.

Determinants of Peritoneal Solute Transport Rates in Newly Started Nondiabetic Peritoneal Dialysis Patients

2004 ◽  
Vol 24 (6) ◽  
pp. 554-561 ◽  
Author(s):  
Sadie van Esch ◽  
Machteld M. Zweers ◽  
Maarten A.M. Jansen ◽  
Dirk R. de Waart ◽  
Jeannette G. van Manen ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Surface Area ◽  
Inflammatory Markers ◽  
Cell Mass ◽  
Mesothelial Cell ◽  
Serum Concentrations ◽  
Peritoneal Surface ◽  
Peritoneal Transport ◽  
Peritoneal Permeability ◽  
Fast Transport

Objective An overrepresentation of a fast peritoneal transport status in new peritoneal dialysis (PD) patients with extensive comorbidity has been reported in some studies. High mass transfer area coefficients (MTACs) of low MW solutes suggest the presence of a large effective peritoneal surface area. The mechanism is unknown. It might include comorbidity, chronic inflammation, or an effect of mesothelial cell mass on peritoneal transport by the production of vasoactive substances. To investigate their relative importance in early PD, peritoneal permeability characteristics in incident PD patients were analyzed for relationships with comorbidity, serum concentrations of inflammatory markers, and products of the mesothelial cells that can be detected in dialysate. Design A cross-sectional study. Setting A university hospital. Methods 46 patients who fulfilled the following inclusion criteria were analyzed: a standard peritoneal permeability analysis (SPA) within 6 months after the start of PD, no peritonitis prior to the SPA, older than 18 years, and without diabetes mellitus as a primary renal disease. The patients were divided into tertiles based on the MTAC creatinine: slow, medium, and fast transport groups. The Davies comorbidity score was used to assess comorbidity. Serum and dialysate samples obtained during the SPA were used to determine hyaluronan, interleukin (IL)-6, vascular endothelial growth factor (VEGF), and cancer antigen 125 (CA125). The dialysate concentrations of these substances were expressed as their dialysate appearance rates. Results No significant differences were present in the three transport groups for comorbidity, serum concentrations of inflammatory markers, or serum VEGF. Interleukin-6 and VEGF concentration attributed to local VEGF production were not different between the tertiles. Levels of VEGF were higher in the medium transport group compared to the slow transport group ( p = 0.02); CA125 was higher in the fast transport group compared to the medium transport group ( p = 0.01). When analyzed as continuous variables, MTAC creatinine was related to VEGF ( r = 0.33, p < 0.05) and CA125 ( r = 0.41, p = 0.03). In linear regression analysis, VEGF influenced the association between CA125 and MTAC creatinine; IL-6 weakened this association only marginally. Conclusion A fast peritoneal transport status in incident nondiabetic PD patients was not related to comorbidity. The relationships found between VEGF, CA125, and MTAC creatinine may suggest a role of VEGF in the regulation of the vascular peritoneal surface area, possibly already before structural abnormalities have developed. Our analyses are consistent with the hypothesis that mesothelial cell mass is an important determinant of the peritoneal transport status in incident nondiabetic PD patients without previous peritonitis. Of the many potential mediators produced by mesothelial cells, VEGF was more important than the inflammation marker IL-6.

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