Adequacy of Peritoneal Dialysis in Children: Consider the Membrane for Optimal Prescription

2007 ◽  
Vol 27 (2_suppl) ◽  
pp. 167-170
Author(s):  
Michel Fischbach ◽  
Celine Dheu ◽  
Laure Seugé–Dargnies ◽  
Jean François Delobbe
Keyword(s):  
Peritoneal Dialysis ◽  
Surface Area ◽  
Degradation Products ◽  
Osmotic Gradient ◽  
Peritoneal Membrane ◽  
Intraperitoneal Pressure ◽  
Membrane Recruitment ◽  
Vascular Area ◽  
Clinical Control ◽  
Fill Volume

The peritoneal dialysis (PD) prescription should be adequate before being optimal. The peritoneal membrane is a dynamic dialyzer: the surface area and the vascular area both have recruitment capacity. At bedside, prescription is based mainly on tolerance of the prescribed fill volume, and therefore a too-small fill volume is often prescribed. A too-small fill volume may lead to a hyperpermeable exchange, with potentially enhanced morbidity—or even mortality—risks. Better understanding of the peritoneal membrane as a dynamic dialysis surface area allows for an individually adapted prescription, which is especially suitable for children on automated PD. Fill volume should be scaled for body surface area (mL/m2) and, to avoid a hyperpermeable exchange, for a not-too-small amount. Fill volume enhancement should be conducted under clinical control and is best determined by intraperitoneal pressure measurement in centimeters of H2O. In children 2 years of age and older, a peak fill volume of 1400 – 1500 mL/m2 can be prescribed in terms of tolerance, efficiency, and peritoneal membrane recruitment. Dwell times should be determined individually with respect to two opposing parameters: • Short dwell times provide adequate small-solute clearance and maintain the crystalloid osmotic gradient (and, thereby, the ultrafiltration capacity). • Long dwell times enhance phosphate clearance, but can lead to dialysate reabsorption. The new PD fluids (that is, those free of glucose degradation products, with a neutral pH, and not exclusively lactate-buffered) appear to be the best choice both in terms of membrane recruitment and of preservation of peritoneal vascular hyperperfusion.

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).

How to Increase Adequacy of Peritoneal Dialysis in Children?

2005 ◽  
Vol 25 (3_suppl) ◽  
pp. 135-136
Author(s):  
Cornelis H. Schröder
Keyword(s):  
Peritoneal Dialysis ◽  
Surface Area ◽  
Body Surface ◽  
Glucose Concentration ◽  
Peritoneal Membrane ◽  
Dialysis Fluid ◽  
Peritoneal Equilibration Test ◽  
Dialysis Adequacy ◽  
Intraperitoneal Pressure ◽  
Dialysis Solution

Since children on dialysis are treated most often with nightly intermittent peritoneal dialysis, adequacy of dialysis is determined by the number and duration of cycles, the volume of the dialysis fluid applied, and the choice of dialysis solution. The number and duration of cycles are dependent on the maximal acceptable duration of night rest and the permeability properties of the peritoneal membrane. The latter can be established by performance of a peritoneal equilibration test. The volume used should be about 1200 mL/m2 body surface area, and intraperitoneal pressure should be between 5 and 15 cm H2O. The dialysis solution administered should have a glucose concentration as low as possible, and an icodextrin daytime dwell may be considered.

Demonstration of Aquaporin-Chip in Peritoneal Tissue of Uremic and Capd Patients

1996 ◽  
Vol 16 (1_suppl) ◽  
pp. 54-57 ◽  
Author(s):  
Marja M. Pannekeet ◽  
Jos B. Mulder ◽  
Jan J. Weening ◽  
Dirk G. Struijk ◽  
Machteld M. Zweers ◽  
...  
Keyword(s):  
Endothelial Cells ◽  
Peritoneal Dialysis ◽  
Sodium Transport ◽  
Water Channels ◽  
Osmotic Gradient ◽  
Peritoneal Membrane ◽  
Specific Staining ◽  
Peritoneal Tissue ◽  
Hyperosmolar Solutions ◽  
Morphological Equivalent

Aquaporin-CHIP is a 28 kD channel forming integral membrane protein. It acts as an osmotically driven, water-selective pore. The presence of aquaporin-CHIP has been demonstrated in the proximal tubule in the kidney and in the pleura, as well as in other tissues. During peritoneal dialysis a dissociation between the transport of water and sodium using hyperosmolar solutions has been reported, suggesting the presence of ultrasmall pores. Water channels, like aquaporin-CHIP, could be the morphological equivalent of these pores. We investigated the possible presence of aquaporinCHIP in cryo-sections of peritoneal tissue using affinity purified human anti-CHIP IgG (P. Agre, Baltimore, MD). Peritoneal biopsies (omenta) were obtained at catheter insertion in 2 uremic patients with end-stage renal disease, and at catheter reimplantation of 1 patient treated with continuous ambulatory peritoneal dialysis (CAPD) for two years. Peritoneal tissue obtained at autopsy from 1 patient who had been on CAPD for four years, but in whom CAPD had been discontinued for five months, was also studied. Aquaporin-CHIP antiserum specific staining was found in the endothelial cells of the peritoneal capillaries in all patients. No obvious difference in the intensity of staining was seen between uremic and CAPD patients. This demonstration of aquaporin-CHIP in human peritoneal endothelial cells supports the hypothesis of the existence of ultrasmall pores within the peritoneal membrane. These water channels facilitate the transcellular transport of water, induced by an osmotic gradient, in the absence of sodium transport. It may be the explanation for the dissociation of water and sodium transport that occurs during hyperosmolar solutions. Aquaporin-CHIP is present in human peritoneal endothelial cells in both uremic and CAPD patients. Aquaporin-CHIP may be the morphological equivalent of the ultrasmall pores within the peritoneal membrane.

Biological Significance of Reducing Glucose Degradation Products in Peritoneal Dialysis Fluids

2000 ◽  
Vol 20 (5_suppl) ◽  
pp. 23-27 ◽  
Author(s):  
Anders Wieslander ◽  
Torbjörn Linden ◽  
Barbara Musi ◽  
Ola Carlsson ◽  
Reinhold Deppisch
Keyword(s):  
Peritoneal Dialysis ◽  
Side Effects ◽  
Host Defense ◽  
Degradation Products ◽  
Biological Significance ◽  
Peritoneal Membrane ◽  
Negative Side ◽  
Glucose Degradation Products ◽  
Negative Side Effects

Carbohydrates are not stable when exposed to energy; they degrade into new molecules. In peritoneal dialysis (PD) fluids, degradation of glucose occurs during the heat sterilization procedure. The biological consequences of this degradation are side effects such as impaired proliferation and impaired host defense mechanisms, demonstrated in vitro for a great variety of cells. Several highly toxic compounds—such as formaldehyde and 3-deoxyglucosone—have been identified in PD fluids. Carbonyl compounds, apart from being cytotoxic, are also well-known promoters of irreversible advanced glycation end-products (AGEs), which might participate in the long-term remodeling of the peritoneal membrane. Various approaches can be used to reduce the formation of glucose degradation products (GDPs) during heat sterilization. Some examples are shortening the sterilization time, lowering the pH, removing catalyzing substances, and increasing glucose concentration. The latter three factors are employed in the multi-compartment bag with a separate chamber containing pure glucose at high concentration and low pH. Gambrosol trio, a PD fluid produced in this way, shows reduced cytotoxicity, normalized host defense reactions, less AGE formation, and reduced concentrations of formaldehyde and 3-deoxyglucosone. Moreover, in the clinical situation, the fluid turns out to be more biocompatible for the patient, causing less mesothelial cell damage, which in the long term could lead to a more intact peritoneal membrane. Conclusion Glucose degradation products in heat-sterilized fluids for peritoneal dialysis are cytotoxic, promote AGE formation, and cause negative side effects for the patient. Using improved and well-controlled manufacturing processes, it is possible to produce sterile PD fluids with glucose as the osmotic agent but without the negative side effects related to GDPs.

scholarly journals Effect ofbalanceSolution on the Peritoneal Membrane in Automated Peritoneal Dialysis

2016 ◽  
Vol 36 (5) ◽  
pp. 569-572 ◽  
Author(s):  
Tatiana De los Ríos ◽  
Juan Pérez-Martínez ◽  
Jose Portoles ◽  
Monika Lichodziejewska-Niemierko ◽  
Maite Rivera ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Degradation Products ◽  
Peritoneal Membrane ◽  
Open Label ◽  
Cell Functions ◽  
Neutral Ph ◽  
Appearance Rate ◽  
Glycation End Products ◽  
Membrane Cell

Interference of conventional peritoneal dialysis fluids (cPDFs) with peritoneal membrane cell functions may be attributed to the dialysis fluid's low pH, high glucose concentration, and/or the presence of glucose degradation products (GDPs), the last of which leads to higher levels of advanced glycation end-products (AGEs). It has been suggested that the peritoneal membrane might be better preserved by using biocompatible solutions, including cancer antigetn 125 (CA125). This prospective, open-label, multicentre, randomized, controlled, cross-over phase IV study compared the in vivo biocompatibility of a neutral-pH, low-GDP peritoneal dialysis (PD) solution ( balance) with a cPDF in automated PD (APD) patients. Our study revealed a significantly increased appearance rate and concentration of CA125 in the peritoneal effluent of APD patients treated with the neutral-pH, low-GDP solution balance versus a conventional PD solution.

scholarly journals Clinical relevance of marginal factors on ultrafiltration in peritoneal dialysis

2020 ◽  
pp. 089686082090455 ◽  
Author(s):  
Vicente Pérez-Díaz ◽  
Alfonso Pérez-Escudero ◽  
Sandra Sanz-Ballesteros ◽  
Luisa Sánchez-García ◽  
Esther Hernández-García ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Body Size ◽  
Clinical Relevance ◽  
The Other ◽  
Clinical Settings ◽  
Osmotic Gradient ◽  
Peritoneal Equilibration Test ◽  
Intraperitoneal Pressure ◽  
Sex Influence ◽  
Peritoneal Permeability

Background: Ultrafiltration (UF) in peritoneal dialysis (PD) is mainly driven by the osmotic gradient and peritoneal permeability, but other factors—such as intraperitoneal pressure (IPP)—also have an influence. Methods: To assess the clinical relevance of these marginal factors, we studied 41 unselected PD patients undergoing two consecutive 2 h, 2.27% glucose exchanges, first with 2.5 L and then with 1.5 L. Results: IPP, higher in the 2.5 L exchange, had a wide interpatient range, was higher in obese and polycystic patients and their increase with infusion volume was higher for women regardless of body size. UF with 2.5 L correlated inversely with IPP and was higher for patients with polycystosis or hernias, while for 1.5 L we found no significant correlations. The effluent had higher glucose and osmolarity in the 2.5 L exchange than in the 1.5 L one, similar for both sexes. In spite of this stronger osmotic gradient, only 21 patients had more UF in the 2.5 L exchange, with differences up to 240 mL. The other 20 patients had more UF in the 1.5 L exchange, with stronger differences (up to 800 mL, and more than 240 mL for 9 patients). The second group, with similar effluent osmolarity and peritoneal equilibration test (PET) parameters than the first, has higher IPP and preponderance of men. The sex influence is so intense that men decreased average UF with 2.5 L with respect to 1.5 L, while women increased it. Conclusions: With 2.27% glucose, sex and IPP—modulated by obesity, polycystosis, hernias, and intraperitoneal volume—significantly affect UF in clinical settings and might be useful for its management.

scholarly journals The Peritoneal Membrane in Peritoneal Dialysis Patients

1999 ◽  
Vol 10 (2) ◽  
pp. 342-346
Author(s):  
AVRY CHAGNAC ◽  
PEARL HERSKOVITZ ◽  
TALIA WEINSTEIN ◽  
SIMCHA ELYASHIV ◽  
JUDITH HIRSH ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Contrast Media ◽  
Surface Area ◽  
Membrane Surface ◽  
Helical Ct ◽  
Peritoneal Membrane ◽  
Dialysis Patients ◽  
Membrane Surface Area ◽  
Random Sections ◽  
High Degree

Abstract. The surface area of the peritoneal membrane in contact with dialysate is an important determinant of solute transport across the peritoneum. Yet there is no method for its estimation in peritoneal dialysis patients. In this study, stereologic methods were applied to computerized tomography (CT) imaging of the peritoneal membrane to estimate the peritoneal membrane surface area. The method was first validated by implementing stereologic methods on a phantom of known surface area. The phantom was a distorted bottle filled with contrast media. Series of thin helical CT sections were performed, and random sections were obtained after reconstruction. A transparent counting grid was placed over the random sections. The surface area was estimated using 9, 18, and 36 random sections. To calculate the coefficient of variation (CV) of the method, 20 different combinations of 9, 18, and 36 random sections were used. With 36 random sections, the error in estimation of the bottle's surface area was - 9.4% to + 8.8%. The CV was 5.0%. Decreasing the number of sections used to 18 and 9 yielded a CV of 7.8 and 12.3%, respectively. This method was then applied to the peritoneal membrane, which was visualized by instilling dialysate containing contrast media into the peritoneal cavity of peritoneal dialysis patients. The estimated peritoneal membrane surface area of six patients was 0.55 ± 0.04 m2. This novel method permits the measurement of the peritoneal membrane surface area with a high degree of accuracy.

scholarly journals The Effect of Far-Infrared Therapy on the Peritoneal Membrane Transport Characteristics of Uremic Patients Undergoing Peritoneal Dialysis: An Open-Prospective Proof-of-Concept Study

Membranes ◽  
2021 ◽  
Vol 11 (9) ◽  
pp. 669
Author(s):  
Ching-Po Li ◽  
Chyong-Mei Chen ◽  
Chia-Hao Chan ◽  
Szu-Yuan Li ◽  
Ming-Tsun Tsai ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Membrane Transport ◽  
Degradation Products ◽  
Far Infrared ◽  
Proof Of Concept ◽  
Peritoneal Membrane ◽  
Membrane Function ◽  
Glucose Degradation Products ◽  
Average Status

Long-term peritoneal dialysis (PD) can lead to detrimental changes in peritoneal membrane function, which may be related to the accumulation of glucose degradation products. A previous study demonstrated that 6 months of far-infrared (FIR) therapy may decrease glucose degradation products in PD dialysate. Due to limited literature on this matter, this study aims to investigate the effect of FIR therapy on the peritoneal membrane transport characteristics of PD patients. Patients were grouped according to baseline peritoneal transport status: lower transporters (low and low-average) and higher transporters (high-average and high). Both groups underwent 40 min of FIR therapy twice daily for 1 year. In lower transporters, FIR therapy increased weekly dialysate creatinine clearance (6.91 L/wk/1.73 m2; p = 0.04) and D/P creatinine (0.05; p = 0.01). In higher transporters, FIR therapy decreased D/P creatinine (−0.05; p = 0.01) and increased D/D0 glucose (0.05; p = 0.006). Fifty percent of high transporter patients shifted to high-average status after FIR therapy. FIR therapy may decrease D/P creatinine for patients in the higher transporter group and cause high transporters to shift to high-average status, which suggests the potential of FIR therapy in improving peritoneal membrane function in PD patients.

scholarly journals Dynamic Changes of the Total Pore Area Available for Peritoneal Exchange in Children

2001 ◽  
Vol 12 (7) ◽  
pp. 1524-1529
Author(s):  
MICHEL FISCHBACH ◽  
BÖRJE HARALDSSON
Keyword(s):  
Peritoneal Dialysis ◽  
Steady State ◽  
Dwell Time ◽  
Chronic Peritoneal Dialysis ◽  
Peritoneal Membrane ◽  
Diffusion Distance ◽  
Dynamic Changes ◽  
Pore Analysis ◽  
Fill Volume ◽  
Pore Area

Abstract. The most important of the parameters that describe exchange across the peritoneal membrane is the total pore area over diffusion distance (A0/Δx). It determines the rate of diffusion and mainly seems to reflect the number of capillaries available for exchange. In the present study, a simplified three-pore analysis was used to estimate A0/Δx from peritoneal equilibration tests. Two groups of children (mean age, 9.5 yr) who were on chronic peritoneal dialysis underwent studies with peritoneal equilibration tests. In the first group of children, three levels of fill volumes were used in each patient. In the second group of patients, the effects of posture and dwell time were analyzed from four consecutive peritoneal dialysis samples obtained after 15, 30, 60, and 90 min. As the fill volume was raised from 800 to 1400 ml/m2 BSA, the steady-state A0/Δx increased significantly by 21%, i.e., from 19,900 ± 1200 to 24,000 ± 1450 cm2/cm per 1.73 m2 (n = 8). A further increase to 2000 ml/m2 did not result in any change of A0/Δx. Moreover, steady-state A0/Δx fell significantly when the patients were standing, 21,900 ± 1400 compared with 29,400 ± 1330 cm2/cm per 1.73m2 (n = 6) obtained in the supine position. There was a transient (<30 min) increase in A0/Δx initially during the dwell, probably reflecting vasodilation and recruitment of capillaries. It is concluded that factors such as the intraperitoneal fill volume, posture, and dwell time all dynamically affect the total pore area available for exchange.

Impact of Fill Volume on Peritoneal Clearances and Cytokine Appearance in Peritoneal Dialysis

2004 ◽  
Vol 24 (2) ◽  
pp. 156-162 ◽  
Author(s):  
Ramón Paniagua ◽  
María de Jesús Ventura ◽  
Ernesto Rodríguez ◽  
Juana Sil ◽  
Teresa Galindo ◽  
...  
Keyword(s):  
Fluid Dynamics ◽  
Peritoneal Dialysis ◽  
Interleukin 6 ◽  
Fluid Absorption ◽  
Necrosis Factor Alpha ◽  
Intraperitoneal Pressure ◽  
Fill Volume ◽  
Dialysate Volume ◽  
Small Solute ◽  
Solute Clearance

Background Current adequacy guidelines for peritoneal dialysis encourage the use of large fill volumes for the attainment of small solute clearance targets. These guidelines have influenced clinical practice in a significant way, and adoption of higher fill volumes has become common in North America. Several studies, however, have challenged the relevance of increasing small solute clearance; this practice may result in untoward consequences in patients. Objective The present study was designed to explore the relationship between dialysate volume and the clearance of different sized molecules, fluid dynamics, and appearance of peritoneal cytokines. Methods Thirteen adult prevalent patients on continuous ambulatory peritoneal dialysis were studied. Three different dialysate volumes (2.0, 2.5, and 3.0 L) were infused on consecutive days in a random order. Several measurements of peritoneal fluid dynamics (intraperitoneal pressure, net ultrafiltration, fluid absorption), solute clearances (urea, creatinine, β2-microglobulin, albumin, IgG, and transferrin), and appearance of interleukin-6 and tumor necrosis factor alpha (TNFα) were assessed. Results Increase in dialysate fill volume (from 2 to 2.5 to 3 L) was examined in relationship to body surface area (BSA). The dialysate volume/BSA (DV/BSA) ratio increased from 1262 to 1566 to 1871 mL/m2 on 2.0, 2.5, and 3.0 L dialysate volumes, respectively. In parallel, diastolic blood pressure increased from 82.7 ± 8.8 to 87.0 ± 9.5 to 92 ± 8.3 mmHg ( p < 0.05). Net ultrafiltration rate also increased, from 0.46 ± 0.48 to 0.72 ± 0.42 to 0.97 ± 0.49 mL/minute ( p < 0.01), despite a concomitant increase in fluid absorption, from 1.05 ± 0.34 to 1.21 ± 0.40 to 1.56 ± 0.22 mL/min ( p < 0.01). Urea peritoneal clearance increased from 8.27 ± 0.68 to 9.92 ± 1.6 to 12.98 ± 4.03 mL/min ( p < 0.01); creatinine peritoneal clearance increased from 6.69 ± 1.01 to 7.64 ± 1.12 to 8.69 ± 1.76 mL/min ( p < 0.01). Clearance of the other measured molecules did not change. Appearance of interleukin-6 increased 17% and 43% ( p < 0.01), and TNFα appearance increased 14% and 50% ( p < 0.01) when dialysate volumes of 2.5 and 3.0 L were used, compared with 2.0 L. Conclusions These results show that, with higher values of DV/BSA ratio, small solute peritoneal clearance is increased, but clearances of large molecules remain unchanged. With the use of higher volumes, fluid absorption rate and the appearance of proinflammatory cytokines in the dialysate are increased.

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