Optimised versus standard automated peritoneal dialysis regimens pilot study (OptiStAR): A randomised controlled crossover trial

Abstract

Background: The continuous global rise of end-stage kidney disease creates a growing demand of economically beneficial home-based kidney replacement therapies such as peritoneal dialysis (PD). However, undesirable absorption and exposure of peritoneal tissues to glucose remain major limitations of PD. Methods: We compared a reference (standard) automated PD regimen 6 × 2 L 1.36% glucose (76 mmol/L) over 9 h with a novel, theoretically glucose sparing (optimised) prescription consisting of ‘ultrafiltration cycles’ with high glucose strength (126 mmol/L) and ‘clearance cycles’ with ultra-low, physiological glucose (5 mmol/L) for approximately 40% of the treatment time. Twenty-one prevalent PD patients underwent the optimised regimen (7 × 2 L 2.27% glucose + 5 × 2 L 0.1% glucose over 8 h) and the standard regimen in a crossover fashion. Six patients were excluded from data analysis. Results: Median glucose absorption was 43 g (IQR 41–54) and 44 g (40–55) for the standard and optimised intervention, respectively ( p = 1). Ultrafiltration volume, weekly Kt/V creatinine and urea were significantly improved during optimised interventions, while no difference in sodium removal was detected. Post hoc analysis showed significantly improved ultrafiltration efficiency (ml ultrafiltration per gram absorbed glucose) during optimised regimens. No adverse events were observed except one incidence of drain pain. Conclusion: Optimised treatments were feasible and well tolerated in this small pilot study. Despite no difference in absorbed glucose, results indicate possible improvements of ultrafiltration efficiency and small solute clearances by optimised regimens. Use of optimised prescriptions as glucose sparing strategy should be evaluated in larger study populations.

Phloretin Improves Ultrafiltration and Reduces Glucose Absorption during Peritoneal Dialysis in Rats

“…2 Other than pharmacologic interventions, several strategies exist to reduce glucose absorption and increase UF efficiency in PD: for example, by the use of icodextrin or by altering the prescription. 3,22,23 However, several studies have shown that sodium removal in relation to the UF volume (i.e., millimoles of sodium removed per liter of UF volume) is lower with automated PD, 24,25 which could potentially limit net sodium removal in clinical practice. Phloretin exposure here improved sodium removal, yet there was no effect on sodium removal per liter UF, indicating that the observed improvements are due to enhanced UF rates because sodium transport in PD occurs mainly via convection.…”

“…Similarly, increasing evidence shows that glucose absorption is associated with worse outcomes in PD 3 and is responsible for significant weight gain and metabolic side effects 2 . Other than pharmacologic interventions, several strategies exist to reduce glucose absorption and increase UF efficiency in PD: for example, by the use of icodextrin or by altering the prescription 3 , 22 , 23 . However, several studies have shown that sodium removal in relation to the UF volume ( i .…”

Evidence on continuous flow peritoneal dialysis: A review

“…Findings by Htay and Van Gelder suggest only a limited increase in PD efficacy using this configuration, but results are too preliminary to draw conclusions, and studies providing a direct comparison with a two‐catheter setup are lacking. In a recent clinical study, Bergling et al 50 compared a standard PD regimen (6 × 2 L 1.36% glucose) over 9 h with a novel prescription (7 × 2 L 2.27% glucose + 5 × 2 L 0.1% glucose over 8 h) in 21 patients. The rapid static dwells (via a single‐lumen catheter) seemed to increase small solute diffusion capacities and hydraulic conductance by 27%, probably related to a stirring effect or a vasodilatation effect due to the high time‐averaged dialysate flow rate.…”

Modelling of icodextrin hydrolysis and kinetics during peritoneal dialysis

“…Various mathematical approaches have been proposed to model peritoneal transport. Their ability to describe and predict fluid and solute transport has been validated based on clinical and experimental data for glucose-based dialysis fluids [6][7][8][9][10][11] . In contrast, there are few studies published so far attempting to model fluid and solute transport during peritoneal dwells with icodextrin used as an osmotic agent.…”