Improved Acidosis Correction and Recovery of Mesothelial Cell Mass with Neutral-pH Bicarbonate Dialysis Solution among Children Undergoing Automated Peritoneal Dialysis

Abstract

Abstract. Acid-base balance and peritoneal membrane longevity are of utmost relevance for pediatric patients undergoing peritoneal dialysis (PD). PD fluids with neutral pH and reduced glucose degradation product contents are considered more biocompatible, because they preserve peritoneal cell functions in vitro. To investigate the clinical effects of a novel PD fluid buffered with 34 mM pure bicarbonate at neutral pH, a randomized, prospective, crossover comparison with conventional, acidic, 35 mM lactate PD fluid was performed for two consecutive 12-wk periods with 28 children (age, 6 mo to 15 yr) undergoing automated PD (APD). Blood bicarbonate levels and arterial pH were significantly higher after 3 mo of bicarbonate PD (24.6 Ϯ 2.3 mM and 7.43 Ϯ 0.06, respectively), compared with lactate PD (22.8 Ϯ 3.9 mM and 7.38 Ϯ 0.05, respectively; P Ͻ 0.05). This effect was reversible among patients who returned from bicarbonate to lactate fluid. Low initial pH and young patient age independently predicted increased blood pH during bicarbonate APD. Peritoneal equilibration tests revealed subtle changes in solute transport, with a less steep creatinine equilibration curve during bicarbonate dialysis, suggesting reduced peritoneal vasodilation. The peritoneal release of carcinogen antigen-125 increased twofold during bicarbonate APD (29 Ϯ 15 versus 15 Ϯ 8 U/ml per 4 h, P Ͻ 0.01), which is consistent with recovery of the mesothelial cell layer. This effect was fully reversed when the patients returned to lactate fluid. Effluent carcinogen antigen-125 levels were inversely correlated with peritoneal glucose exposure during lactate but not bicarbonate APD, indicating improved in vivo mesothelial cell tolerance of high-dose glucose with the neutral-pH PD fluid with reduced glucose degradation product content. Among children undergoing APD, neutral-pH, bicarbonate-buffered PD fluid provides more effective correction of metabolic acidosis and better preservation of peritoneal cell mass than do conventional, acidic, lactate-based fluids.

Effect of Neutral-pH, Low–Glucose Degradation Product Peritoneal Dialysis Solutions on Residual Renal Function, Urine Volume, and Ultrafiltration

“…Additionally, we excluded two trials that did not meet our inclusion criteria. First, a study by Haas et al (26) was of pediatric patients, and thus, it was excluded on the basis of our inclusion criteria. Second, a randomized study conducted by Fan et al (27) was not included, because it reported only baseline measurements and the change in these measurements during the study period rather than final values.…”

Biocompatible Peritoneal Dialysis Solutions

“…The primary advantages of the bicarbonate-based solution are: (1) a physiologic pH; (2) a buffer that is physiologic in nature and at a physiologic concentration; (3) reduced GDPs; and (4) reduced lactate concentration. The bicarbonate buffered PD solutions have been shown to cause less peritoneal damage both in vitro and in vivo (75). In a crossover study of 12 stable PD patients who were switched to neutral pH, bicarbonate buffered solutions for 6 months, the level of CA125 at baseline was 15.07 Ϯ 5.72 U/ml, which after 6 months of treatment with bicarbonate PD solutions increased to 111.97 Ϯ 66.21 U/ml, whereas the mean values after the patients' return for another 6 months to the conventional solution use dropped again to 22.72 Ϯ 16.06 U/ml (76).…”

Association of Biocompatible Peritoneal Dialysis Solutions with Peritonitis Risk, Treatment, and Outcomes

“…In contrast, data from randomized controlled trials (RCTs) are conflicting. Of the 13 RCTs that reported peritonitis (17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30), only 2 showed significant benefit with the use of biocompatible PD solutions (19,22); the remainder reported a neutral effect. However, most trials examined peritonitis as a secondary outcome only; they can therefore not be regarded as providing definitive evidence.…”