scholarly journals Removal of Different Classes of Uremic Toxins in APD vs CAPD: A Randomized Cross-Over Study

2015 ◽  
Vol 35 (4) ◽  
pp. 436-442 ◽  
Author(s):  
Sunny Eloot ◽  
Raymond Vanholder ◽  
Clement Dequidt ◽  
Wim Van Biesen
Keyword(s):  
Peritoneal Dialysis ◽  
Indole Acetic Acid ◽  
Residual Renal Function ◽  
Uremic Toxins ◽  
Water Soluble ◽  
Automated Peritoneal Dialysis ◽  
Mass Removal ◽  
Blood And Urine Samples ◽  
Dialysate Volume ◽  
Solute Clearance

♦AimIn this study, we investigated, and this for the different classes of uremic toxins, whether increasing dialysate volume by shifting from continuous ambulatory peritoneal dialysis (CAPD) to higher volume automated peritoneal dialysis (APD) increases total solute clearance.♦MethodsPatients on peritoneal dialysis were randomized in a cross-over design to one 24-hour session of first a CAPD regimen (3*2 L of Physioneal 1.36% and 1*2 L of icodextrin) or APD (consisting of 5 cycles of 2 L Physioneal 1.36 and 1 cycle of 2 L Extraneal), and the other week the alternate regime, each patient serving as his/her own control. Dialysate, blood and urine samples were collected and frozen for later batch analysis of concentrations of urea, creatinine, phosphorus, uric acid, hippuric acid, 3-carboxy-4-methyl-5-propyl-2-furanpropionic acid, indoxyl sulfate, indole acetic acid, and p-cresyl sulfate. For the protein-bound solutes, total and free fractions were determined. Total, peritoneal and renal clearance (K) and mass removal (MR) of each solute were calculated, using validated models.♦ResultsIn 15 patients (11 male, 3 diabetics, 56 ± 16 years, 8 on CAPD, time on peritoneal dialysis 12 ± 14 months, and residual renal function of 9.9 ± 5.4 mL/min) dialysate over plasma ratio for creatinine (D/Pcrea) was 0.62 ± 0.10. Drained volume and obtained ultrafiltration were higher with APD vs CAPD (13.3 ± 0.5 L vs 8.5 ± 0.7 L and 1.3 ± 0.5 L vs 0.5 ± 0.7 L), whereas urine output was lower (1.0 ± 0.5 L vs 1.4 ± 0.6 L). Total clearance and MR tended to be higher for CAPD vs APD for all small and water soluble solutes, but mainly because of higher renal contribution, with no difference in the peritoneal contribution. For the protein-bound solutes, no differences in clearance or mass removal were observed.♦ConclusionAlthough the drained dialysate volume nearly doubled, APD did not result in better peritoneal clearance or solute removal vs classic CAPD. APD resulted in better ultrafiltration, but at the expense of residual urinary output and clearance.

scholarly journals Sodium removal in peritoneal dialysis: is there room for a new parameter in dialysis adequacy?

2019 ◽  
Vol 2 (3) ◽  
pp. 151-157
Author(s):  
Anna Lima ◽  
Joana Tavares ◽  
Nicole Pestana ◽  
Maria João Carvalho ◽  
António Cabrita ◽  
...  
Keyword(s):  
Peritoneal Dialysis ◽  
Volume Overload ◽  
Residual Renal Function ◽  
Dialysis Adequacy ◽  
Sodium Removal ◽  
Low Sodium ◽  
Major Attention ◽  
New Strategies ◽  
Small Solute ◽  
Solute Clearance

In peritoneal dialysis (PD) (as well as in hemodialysis) small solute clearance measured as Kt/v urea has long been used as a surrogate of dialysis adequacy. A better urea clearance was initially thought to increase survival in dialysis patients (as shown in the CANUSA trial)(1), but  reanalysis of the data showed a superior contribution of residual renal function as a predictor of patient survival. Two randomized controlled trials (RCT)(2, 3)  supported this observation, demonstrating no survival benefit in patients with higher achieved Kt/v. Then guidelines were revised and a minimum Kt/v of 1,7/week was recommended but little emphasis was given to additional parameters of dialysis adequacy. As such, volume overload and sodium removal have gained major attention, since their optimization has been associated with decreased mortality in PD patients(4, 5). Inadequate sodium removal is associated with fluid overload which leads to ventricular hypertrophy and increased cardiovascular mortality(6). Individualized prescription is key for optimal sodium removal as there are differences between PD techniques (CAPD versus APD) and new strategies for sodium removal have emerged (low sodium solutions and adapted PD). In conclusion, future guidelines should address parameters associated with increased survival outcomes (sodium removal playing an important role) and abandon the current one fit all prescription model.

Continuous Ambulatory Peritoneal Dialysis is Better than Automated Peritoneal Dialysis as First-Line Treatment in Renal Replacement Therapy

2007 ◽  
Vol 27 (2_suppl) ◽  
pp. 153-157
Author(s):  
Philip Kam-Tao Li ◽  
Kwok Yi Chung ◽  
Kai Ming Chow
Keyword(s):  
Peritoneal Dialysis ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Continuous Ambulatory Peritoneal Dialysis ◽  
Large Scale ◽  
Residual Renal Function ◽  
Health Care Economics ◽  
Automated Peritoneal Dialysis ◽  
First Line ◽  
Randomized Controlled Studies

This article examines the roles of continuous ambulatory peritoneal dialysis (CAPD) versus automated peritoneal dialysis (APD) as first-line renal replacement therapy. To date, no high-quality large-scale randomized controlled studies have compared CAPD with APD as first-line therapy. However, a discussion on this issue is important so that nephrologists can decide and patients can have a choice of modality on which to start dialysis, especially in the context of health care economics. We review the literature and present Hong Kong as the model of a “CAPD first” policy, an appealing, cost-effective approach for any country. An ideal renal replacement therapy should provide optimal survival, lowest possible risk for comorbidity, highest level of quality of life, and equally important, acceptable cost to society. When we consider this subject in the context that all patients should be started on one first-line modality, the data suggest that a “CAPD first” policy has all these advantages, with APD probably having the edge only with regard to patient preference. The present review highlights preservation of residual renal function, removal and balancing of sodium, incidence of peritonitis, peritoneal membrane transport status, patient rehabilitation, and financial issues in demonstrating that a “CAPD first” policy is the model that should be adopted.

Rapid Decline of Residual Renal Function in Patients on Automated Peritoneal Dialysis

1996 ◽  
Vol 16 (3) ◽  
pp. 307-315 ◽  
Author(s):  
Kinya Hiroshige ◽  
Kougi Yuu ◽  
Masasuke Soejima ◽  
Masayuki Takasugi ◽  
Akio Kuroiwa
Keyword(s):  
Renal Function ◽  
Peritoneal Dialysis ◽  
Renal Disease ◽  
Creatinine Clearance ◽  
Experimental Period ◽  
Residual Renal Function ◽  
University Hospital ◽  
Rapid Decline ◽  
Automated Peritoneal Dialysis ◽  
Stage Renal Disease

Objective To determine the effect of peritoneal dialysis modalities such as nightly intermittent peritoneal dialysis (NIPD), continuous cyclic peritoneal dialysis (CCPD), and continuous ambulatory peritoneal dialysis (CAPD) on residual renal function. Design A six-month prospective, nonrandomized comparison study. Setting Outpatient CAPD unit of a university hospital. Participants Eighteen end-stage renal disease patients treated by peritoneal dialysis (8 by NIPD, 5 by CCPD, and 5 by CAPD). Interventions Samples from the total dialysate, blood, and 24hour urine collection were obtained monthly. Measurements Urea, creatinine, and beta2-microglobulin concentrations were measured. Renal and peritoneal clearances of each substance and KT/V urea were calculated. Residual renal function (RRF) was estimated by renal creatinine clearance (RCcr). Results No significant differences in age, sex, and primary renal disease among the three groups were noted. In all groups, anemic and hypertensive states were controlled identically, and mean weekly total (renal + peritoneal) KT/V urea (over 2.1/wk) and total creatinine clearance (over 60 L/wk/1.73 m2) were maintained during the whole experimental period. Starting mean RCcr was near 4.0 mL/min/1.73 m2 in all groups. Thereafter, a rapid and significant decline in RRF was demonstrated on NIPD and CCPD. The declining rates of RCcr values at 6 months after starting NIPD and CCPD were -0.29 and -0.34 mL/min/month, respectively, which were much greater than those of CAPD (+0.01 mL/min/month). Conclusion Because of a possibly characteristic progressive loss of RRF in automated peritoneal dialysis (APD), strict regular assessment of RRF should be performed from the start of APD.

Patient Selection for Automated Peritoneal Dialysis: For Whom, When?

2009 ◽  
Vol 29 (2_suppl) ◽  
pp. 102-107 ◽  
Author(s):  
Vassilios Liakopoulos ◽  
Nicholas Dombros
Keyword(s):  
Peritoneal Dialysis ◽  
Residual Renal Function ◽  
Patient Choice ◽  
Rapid Decline ◽  
Automated Peritoneal Dialysis ◽  
Contributing Factors ◽  
Dialysis Dose ◽  
Intraperitoneal Pressure ◽  
Sodium Removal ◽  
Disturbed Sleep

The use of the various forms of automated peritoneal dialysis (APD) has increased considerably in the past few years. This increase has in part been driven by technology, through improved cycler design. Other contributing factors include better adjustment of APD to patient lifestyle, the flexibility that APD offers to patients, and the increased ability of APD to achieve adequacy and ultrafiltration targets. For high transporters and for patients unable to perform peritoneal dialysis (PD) on their own (for example, pediatric and elderly patients), APD is considered the most suitable PD modality. Furthermore, APD has been associated with improved compliance, lower intraperitoneal pressure, and lower incidences of peritonitis. On the other hand, concerns have been raised regarding increased complexity and cost, a more rapid decline in residual renal function, inadequate sodium removal, and disturbed sleep. Automated PD is an alternative to continuous ambulatory PD when a higher dialysis dose is needed, and it could be a reliable alternative for unplanned or urgent dialysis start. Other than beneficial results in high transporters, the medical advantages of APD remain controversial. Individual patient choice therefore remains the main indication for the application of APD, which should be made available to all patients starting PD.

Adequacy Targets Can be Met in Anuric Patients by Automated Peritoneal Dialysis: Baseline Data from Eapos

2001 ◽  
Vol 21 (3_suppl) ◽  
pp. 133-137 ◽  
Author(s):  
Edwina A. Brown ◽  
Simon J. Davies ◽  
Olof Heimbürger ◽  
Frederique Meeus ◽  
George Mellotte ◽  
...  
Keyword(s):  
Renal Function ◽  
Peritoneal Dialysis ◽  
Creatinine Clearance ◽  
Solute Transport ◽  
Clinical Outcomes ◽  
Residual Renal Function ◽  
Baseline Data ◽  
Automated Peritoneal Dialysis ◽  
Treatment Optimization ◽  
Dialysis Outcomes

♦ Objective Conventional continuous ambulatory peritoneal dialysis (CAPD) in patients without residual renal function and with high solute transport is associated with worse clinical outcomes. Automated peritoneal dialysis (APD) has the potential to improve both solute clearance and ultrafiltration in these circumstances, but its efficacy as a treatment modality is unknown. The European Automated Peritoneal Dialysis Outcomes Study (EAPOS) is a 2-year, prospective, European multi-center study designed to determine APD feasibility and clinical outcomes in anuric patients. The present article describes the baseline data for patients recruited into the study. ♦ Design All PD patients treated in the participating centers were screened for inclusion criteria [urinary output < 100 mL/24 h, or residual renal function (RRF) < 1 mL/min, or both]. After enrollment, changes were made to the dialysis prescription to achieve a weekly creatinine clearance above 60 L per 1.73 m2 and an ultrafiltration rate above 750 mL in 24 hours. ♦ Setting The study is being conducted in 26 dialysis centers in 13 European countries. ♦ Baseline Data Collection The information collected includes patient demographics, dialysis prescription, achieved weekly creatinine clearance, and 24-hour ultra-filtration (UF). ♦ Results The study enrolled 177 anuric patients. Median dialysis duration before enrollment was 22.5 months (range: 0 – 285 months). Mean solute transport measured as the dialysate-to-plasma ratio of creatinine (D/PCr) was 0.74 ± 0.12. Patients received APD for a median of 9.0 hours overnight (range: 7 – 12 hours) using a median of 11.0 L of fluid (range: 6 – 28.75 L). Median daytime volume was 4.0 L (range: 0.0 – 9.0 L). Tidal dialysis was used in 26 patients, and icodextrin in 86 patients. At baseline, before treatment optimization, the weekly mean total creatinine clearance was 65.2 ± 14.4 L/1.73 m2, with 105 patients (60%) achieving the target of more than 60 L/1.73 m2. At baseline, 81% of patients with high transport, 69% with high-average transport, and 40% with low-average transport met the target. At baseline, 70% of patients with a body surface area (BSA) below 1.7 m2, 60% with a BSA of 1.7 – 2.0 m2, and 56% with a BSA above 2.0 m2 achieved 60 L/1.73 m2 weekly. Median UF was 1090 mL/24 h, and 75% of patients achieved the UF target of more than 750 mL/24 h. ♦ Conclusion This baseline analysis of anuric patients recruited into the EAPOS study demonstrates that a high proportion of anuric patients on APD can achieve dialysis and ultrafiltration targets using a variety of regimes. This 2-year follow-up study aims to optimize APD prescription to reach predefined clearance and ultrafiltration targets, and to observe the resulting clinical outcomes.

Automated Peritoneal Dialysis: An alternative to Continuous Ambulatory or a First Choice Treatment?

2014 ◽  
Vol 12 (2) ◽  
pp. 77-83
Author(s):  
Evangelia Dounousi ◽  
Anila Duni ◽  
Konstantinos Leivaditis ◽  
Vassilios Liakopoulos
Keyword(s):  
Peritoneal Dialysis ◽  
Residual Renal Function ◽  
Rapid Decline ◽  
Automated Peritoneal Dialysis ◽  
Intraperitoneal Pressure ◽  
The Past ◽  
Sodium Removal ◽  
Disturbed Sleep ◽  
First Choice ◽  
Important Indication

Abstract The use of the various forms of Automated Peritoneal Dialysis (APD) has considerably increased in the past few years. This increase is driven by improved cycler design, apparent lifestyle advantages, and the increased ability to achieve adequacy and ultrafiltration targets. It is therefore reasonable to raise the question whether APD is superior to Continuous Ambulatory Peritoneal Dialysis (CAPD). APD is considered the most suitable Peritoneal Dialysis (PD) modality for high transporters as well as for assisted PD. It has also been associated with improved compliance, lower intraperitoneal pressure and possibly lower incidence of peritonitis. On the other hand, there are concerns regarding increased cost, a more rapid decline in residual renal function, inadequate sodium removal and disturbed sleep. Besides its beneficial results in high transporters, other medical advantages of APD still remain unclear. Individual patient’s choice remains the most important indication for applying APD, which should be made available to all patients starting PD.

What is the Optimal Frequency of Cycling in Automated Peritoneal Dialysis?

2000 ◽  
Vol 20 (5) ◽  
pp. 548-556 ◽  
Author(s):  
Rafael A. Perez ◽  
Peter G. Blake ◽  
Susan McMurray ◽  
Lou Mupas ◽  
Dimitrios G. Oreopoulos
Keyword(s):  
Peritoneal Dialysis ◽  
Residual Renal Function ◽  
Glucose Absorption ◽  
Published Data ◽  
Automated Peritoneal Dialysis ◽  
Optimal Frequency ◽  
Urea Clearance ◽  
Protein Excretion ◽  
The Individual ◽  
Sodium And Potassium

Objective The recent increase in the use of automated peritoneal dialysis (APD) has led to concerns about the adequacy of clearances delivered by this modality. Few clinical studies looking at the effects of varying the individual components of the APD prescription on delivered clearance have been done, and most published data are derived from computer modeling. Most controversial is the optimal frequency of exchanges per APD session. Many centers prescribe 4 to 6 cycles per night but it is unclear if this is optimal. The purpose of this study was to address at what point the beneficial effect of more frequent cycles is outweighed by the concomitant increase in the proportion of the total cycling time spent draining and filling. Methods A comparison was made between the urea and creatinine clearances (CCrs) achieved by 4 different APD prescriptions, used for 7 days each, in 18 patients. The prescriptions were for 9 hours each and were all based on 2-L dwell volumes, but differed in the frequency of exchanges. They were 5 x 2 L, 7 x 2 L, and 9 x 2 L, as well as a 50% tidal peritoneal dialysis (TPD) prescription using 14 L. Ultrafiltration, dwell time, glucose absorption, sodium and potassium removal, protein excretion, and relative cost were also compared. Clearances due to day dwells and residual renal function were not included in the calculation. Results Mean urea clearances were 7.5, 8.6, 9.1, and 8.3 L/night for the four prescriptions respectively. Urea clearance with 9 x 2 L was significantly greater than with the other three prescriptions ( p < 0 0.05). Urea clearance with 7 x 2 L and TPD were superior to 5 x 2 L ( p < 0.05). Mean CCr was 5.1, 6.1, 6.4, and 5.6 L/night, respectively. Compared to 5 x 2-L, the 7 x 2-L, 9 x 2-L, and TPD prescriptions achieved greater CCr ( p < 0.05). Taking both urea and CCr into account, 9 x 2 L was the optimal prescription in 12 of the 18 patients. Ultrafiltration and sodium and potassium removals were all significantly greater with the higher frequency prescriptions. Conclusion The 5 x 2-L prescription significantly underutilizes the potential of APD to deliver high clearances, and 7 x 2 L is a consistently superior prescription if 2-L dwells are being used. Although more costly, 9 x 2 L should be considered if higher clearances are required.

scholarly journals Current clinical practice in adapted automated peritoneal dialysis (aAPD)—A prospective, non-interventional study

PLoS ONE ◽  
2021 ◽  
Vol 16 (12) ◽  
pp. e0258440
Author(s):  
Manel Vera ◽  
Bee Boon Cheak ◽  
Hana Chmelíčková ◽  
Sunita Bavanandan ◽  
Bak Leong Goh ◽  
...  
Keyword(s):  
Renal Function ◽  
Peritoneal Dialysis ◽  
Clinical Practice ◽  
Laboratory Data ◽  
Residual Renal Function ◽  
Volume Status ◽  
Automated Peritoneal Dialysis ◽  
Interventional Study ◽  
Mean Values ◽  
Prescription Patterns

Adapted automated peritoneal dialysis (aAPD), comprising a sequence of dwells with different durations and fill volumes, has been shown to enhance both ultrafiltration and solute clearance compared to standard peritoneal dialysis with constant time and volume dwells. The aim of this non-interventional study was to describe the different prescription patterns used in aAPD in clinical practice and to observe outcomes characterizing volume status, dialysis efficiency, and residual renal function over 1 year. Prevalent and incident, adult aAPD patients were recruited during routine clinic visits, and aAPD prescription, volume status, residual renal function and laboratory data were documented at baseline and every quarter thereafter for 1 year. Treatments were prescribed according to the nephrologist’s medical judgement in accordance with each center’s clinical routine. Of 180 recruited patients, 160 were analyzed. 27 different aAPD prescription patterns were identified. 79 patients (49.4%) received 2 small, short dwells followed by 3 long, large dwells. During follow-up, volume status changed only marginally, with visit mean values ranging between 1.59 (95% confidence interval: 1.19; 1.99) and 1.97 (1.33; 2.61) L. Urine output and creatinine clearance decreased significantly, accompanied by reductions in ultrafiltration and Kt/V. 25 patients (15.6%) received a renal transplant and 15 (9.4%) were changed to hemodialysis. Options for individualization offered by aAPD are actually used in practice for optimized treatment. Changes observed in renal function and dialysis efficiency measures reflect the natural course of chronic kidney disease. No safety events were observed during the study period.

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