Peritoneal Equilibration Test Reference Values Using A 3.86% Glucose Solution during the First Year of Peritoneal Dialysis: Results of a Multicenter Study of a Large Patient Population

Milia, Vincenzo La; Cabiddu, Gianfranca; Virga, Giovambattista; Vizzardi, Valerio; Giuliani, Anna; Finato, Viviana; Feriani, M; Filippini, A; Neri, Loris; Lisi, Lucia

doi:10.3747/pdi.2017.00004

Cited by 15 publications

(16 citation statements)

References 27 publications

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“…A close positive association between peritoneal transport rates and glucose absorption has also been reported, both when using 2.27% (2.5%) or 3.86% (4.5%) PD fluid (e.g. patients with fast peritoneal transport rates also have faster glucose absorption) (31)(32)(33). During a 4-h peritoneal equilibration test (using 2 L of 2.5% PD fluid) glucose absorption was 20.3 AE 0.4 g in patients with low peritoneal transport rates, 26.0 AE 0.1 g in the low-average transporter group, 31.1 AE 0.1 g in the high-average transporter group, and 35.4 AE 0.3 g in patients with high peritoneal transport rates (27).…”

Section: Glucose Load and Effect On Nodm In Pd Patientsmentioning

confidence: 63%

New‐Onset Diabetes Mellitus in Peritoneal Dialysis and Hemodialysis Patients: Frequency, Risk Factors, and Prognosis—A Review

2019

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New‐onset diabetes mellitus (NODM) is observed in both hemodialysis (HD) and peritoneal dialysis (PD) patients. The prevalence of NODM in dialysis patients is slightly higher compared to subjects of the general population. Based on currently published data there is no convincing evidence that the risk of NODM is different between HD and PD patients. Data on the effect of glucose load on risk of NODM in dialysis patients remain controversial. PD modality (automated or continuous ambulatory PD) has no significant influence on NODM incidence. Chronic inflammation is associated with NODM in dialysis patients. Reported differences in NODM between PD and HD patients are possibly also influenced by differences in demographic factors between these patient groups. Mortality in NODM patients is lower than mortality in patients with preexisting DM. This may be partly explained by the younger age and lower number of comorbidities in patients with NODM.

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Section: Glucose Load and Effect On Nodm In Pd Patientsmentioning

confidence: 63%

New‐Onset Diabetes Mellitus in Peritoneal Dialysis and Hemodialysis Patients: Frequency, Risk Factors, and Prognosis—A Review

2019

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“…(2) Intrinsic low UF -variation in FWT Clinical evidence and implications. PSTR explains less than 20% of the variation in the inter-individual differences in 50 Australia/New Zealand 3702 0.69 +0.12 Smit et al 51 Netherlands 154 0.73 +0.10 Lambie et al 42 UK, Canada, Korea 595 0.71 +0.12 Mehrotra et al 45 USA 10,142 0.65 +0.12 La Milia et al 53 Italy 758 0.73 +0.12 Shi et al 52 China 320 0.62 +0.11…”

Section: Clinical Evidence and Implicationsmentioning

confidence: 99%

“…It is not possible to give a generally applicable cut-off value, however, as multicenter studies, such as those shown in Table 2, show that there is a clear centre effect, and possible a regional effect seen when measuring PSTR, likely due to different methods for measuring blood and dialysate creatinine levels, including adjustment for glucose concentration in the dialysate. 42,[45][46][47][48][49][50][51][52][53] Ideally, centres would establish their own normal range (a further argument for undertaking routine measurements in all newly established patients at a standardized time point), but it is recognized that this may not be practical, especially for many smaller centres. One solution to this would be the national reporting of membrane function tests, as is achieved by the ANZDATA registry.…”

Section: ) Fast Pstr -Local Inflammation But Recognition Of Other Mec...mentioning

confidence: 99%

ISPD recommendations for the evaluation of peritoneal membrane dysfunction in adults: Classification, measurement, interpretation and rationale for intervention

et al. 2021

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Peritoneal dialysis (PD) uses the peritoneal membrane for dialysis. The peritoneal membrane is a thin layer of tissue that lines the abdomen. The lining is used as a filter to help remove extra fluid and poisonous waste from the blood. Everybody is unique. What is normal for one person’s membrane may be very different from another person’s. The kidney care team wants to provide each person with the best dialysis prescription for them and to do this they must evaluate the person’s peritoneal lining. Sometimes dialysis treatment itself can cause the membrane to change after some years. This means more assessments (evaluations) will be needed to determine whether the person’s peritoneal membrane has changed. Changes in the membrane may require changes to the dialysis prescription. This is needed to achieve the best dialysis outcomes. A key tool for these assessments is the peritoneal equilibration test (PET). It is a simple, standardized and reproducible tool. This tool is used to measure the peritoneal function soon after the start of dialysis. The goal is to understand how well the peritoneal membrane works at the start of dialysis. Later on in treatment, the PET helps to monitor changes in peritoneal function. If there are changes between assessments causing problems, the PET data may explain the cause of the dysfunction. This may be used to change the dialysis prescription to achieve the best outcomes. The most common problem with the peritoneal membrane occurs when fluid is not removed as well as it should be. This happens when toxins (poisons) in the blood cross the membrane more quickly than they should. This is referred to as a fast peritoneal solute transfer rate (PSTR). Since more efficient fluid removal is associated with better outcomes, developing a personal PD prescription based on the person’s PSTR is critically important. A less common problem happens when the membrane fails to work properly (also called membrane dysfunction) because the peritoneal membrane is less efficient, either at the start of treatment or developing after some years. If membrane dysfunction gets worse over time, then this is associated with progressive damage, scarring and thickening of the membrane. This problem can be identified through another change of the PET. It is called reduced ‘sodium dip’. Membrane dysfunction of this type is more difficult to treat and has many implications for the individual. If the damage is major, the person may need to stop PD. They would need to begin haemodialysis treatment (also spelled hemodialysis). This is a very important and emotional decision for individuals with kidney failure. Any decision that involves stopping PD therapy or transitioning to haemodialysis therapy should be made jointly between the clinical team, the person on dialysis and a caregiver, if requested. Although evidence is lacking about how often tests should be performed to determine peritoneal function, it seems reasonable to repeat them whenever there is difficulty in removing the amount of fluid necessary for maintaining the health and well-being of the individual. Whether routine evaluation of membrane function is associated with better outcomes has not been studied. Further research is needed to answer this important question as national policies in many parts of the world and the COVID-19 has placed a greater emphasis and new incentives encouraging the greater adoption of home dialysis therapies, especially PD. For Chinese and Spanish Translation of the Lay Summary, see Online Supplement Appendix 1. Guideline 1: A pathophysiological taxonomy: A pathophysiological classification of membrane dysfunction, which provides mechanistic links to functional characteristics, should be used when prescribing individualized dialysis or when planning modality transfer (e.g. to automated peritoneal dialysis (PD) or haemodialysis) in the context of shared and informed decision-making with the person on PD, taking individual circumstances and treatment goals into account. (practice point) Guideline 2a: Identification of fast peritoneal solute transfer rate (PSTR): It is recommended that the PSTR is determined from a 4-h peritoneal equilibration test (PET), using either 2.5%/2.27% or 4.25%/3.86% dextrose/glucose concentration and creatinine as the index solute. (practice point) This should be done early in the course dialysis treatment (between 6 weeks and 12 weeks) (GRADE 1A) and subsequently when clinically indicated. (practice point) Guideline 2b: Clinical implications and mitigation of fast solute transfer: A faster PSTR is associated with lower survival on PD. (GRADE 1A) This risk is in part due to the lower ultrafiltration (UF) and increased net fluid reabsorption that occurs when the PSTR is above the average value. The resulting lower net UF can be avoided by shortening glucose-based exchanges, using a polyglucose solution (icodextrin), and/or prescribing higher glucose concentrations. (GRADE 1A) Compared to glucose, use of icodextrin can translate into improved fluid status and fewer episodes of fluid overload. (GRADE 1A) Use of automated PD and icodextrin may mitigate the mortality risk associated with fast PSTR. (practice point) Guideline 3: Recognizing low UF capacity: This is easy to measure and a valuable screening test. Insufficient UF should be suspected when either (a) the net UF from a 4-h PET is <400 ml (3.86% glucose/4.25% dextrose) or <100 ml (2.27% glucose /2.5% dextrose), (GRADE 1B) and/or (b) the daily UF is insufficient to maintain adequate fluid status. (practice point) Besides membrane dysfunction, low UF capacity can also result from mechanical problems, leaks or increased fluid absorption across the peritoneal membrane not explained by fast PSTR. Guideline 4a: Diagnosing intrinsic membrane dysfunction (manifesting as low osmotic conductance to glucose) as a cause of UF insufficiency: When insufficient UF is suspected, the 4-h PET should be supplemented by measurement of the sodium dip at 1 h using a 3.86% glucose/4.25% dextrose exchange for diagnostic purposes. A sodium dip ≤5 mmol/L and/or a sodium sieving ratio ≤0.03 at 1 h indicates UF insufficiency. (GRADE 2B) Guideline 4b: Clinical implications of intrinsic membrane dysfunction (de novo or acquired): in the absence of residual kidney function, this is likely to necessitate the use of hypertonic glucose exchanges and possible transfer to haemodialysis. Acquired membrane injury, especially in the context of prolonged time on treatment, should prompt discussions about the risk of encapsulating peritoneal sclerosis. (practice point) Guideline 5: Additional membrane function tests: measures of peritoneal protein loss, intraperitoneal pressure and more complex tests that estimate osmotic conductance and ‘lymphatic’ reabsorption are not recommended for routine clinical practice but remain valuable research methods. (practice point) Guideline 6: Socioeconomic considerations: When resource constraints prevent the use of routine tests, consideration of membrane function should still be part of the clinical management and may be inferred from the daily UF in response to the prescription. (practice point)

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“…Incidence rate of the outcome measure "peritoneal membrane deterioration" could not be identified in registry reports and this outcome was therefore individually searched in published clinical reports on repeated peritoneal equilibration tests (PET). The PET assesses time-dependent changes in dialysate volume and solute levels (e.g., creatinine or sodium) during the dwell, given as ultrafiltration, as ratios of dialysate to plasma (D/P) solute levels (e.g., creatinine), and as sodium sieving or free water transport (17)(18)(19)(20)(21)(22). "Peritoneal membrane deterioration" was defined as ultrafiltration loss, increase of D/P creatinine transport ratio, and/or decrease of sodium dip.…”

Section: Methodsmentioning

confidence: 99%

Composite Outcome Improves Feasibility of Clinical Trials in Peritoneal Dialysis

et al. 2019

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Background Peritoneal dialysis (PD) is complicated by a high rate of adverse events that might be attributed to cytotoxicity of currently used PD fluids. However, clinical development of novel PD fluids is virtually non-existent, in part due to difficulties in recruiting sufficiently large populations for adequately powered trials. The aim of this study is to understand the potential impact of introducing composite outcomes on clinical trial feasibility in PD. Methods A composite outcome “major adverse peritoneal events (MAPE)” was designed to combine clinically relevant complications of PD, such as ( 1 ) technical failure (cause-specific for peritonitis and/or insufficient dialysis), ( 2 ) peritonitis, and ( 3 ) peritoneal membrane deterioration. Incidence rates of individual endpoints were obtained from the literature and expert panel estimations, and population sizes were computed based on Chi-square test for adequately powered confirmatory randomized controlled clinical trials with 2 parallel arms. Results Incidence rates for technical failure, peritonitis, and peritoneal membrane deterioration were estimated at 15%, 50%, and 23%, respectively, at 2 years follow-up, with adequate agreement between the literature and expert opinion. Assuming that a given intervention reduces adverse outcomes by 30%, an adequately powered clinical trial needs to recruit up to 1,720 patients when studying individual outcomes. Combining endpoints increases power in simulated trials despite considerable overlap, and the composite outcome MAPE reduces the required population to 202 patients aiming for 80% power. Conclusion Introduction of the composite outcome MAPE, covering relevant major adverse peritoneal events, may improve the feasibility of clinical trials to adequately test novel PD fluids.

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Peritoneal Equilibration Test Reference Values Using A 3.86% Glucose Solution during the First Year of Peritoneal Dialysis: Results of a Multicenter Study of a Large Patient Population

Abstract: The results of the study provide PET-3.86% reference values for the beginning of PD that can be used to classify PD patients into transport classes and monitor them over time.

Cited by 15 publications

References 27 publications

New‐Onset Diabetes Mellitus in Peritoneal Dialysis and Hemodialysis Patients: Frequency, Risk Factors, and Prognosis—A Review

New‐Onset Diabetes Mellitus in Peritoneal Dialysis and Hemodialysis Patients: Frequency, Risk Factors, and Prognosis—A Review

ISPD recommendations for the evaluation of peritoneal membrane dysfunction in adults: Classification, measurement, interpretation and rationale for intervention

Composite Outcome Improves Feasibility of Clinical Trials in Peritoneal Dialysis

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