The Patient Receiving Automated Peritoneal Dialysis with Volume Overload

Abstract

A 54-year-old man with polycystic kidney disease on automated peritoneal dialysis (APD) was seen for peripheral edema. His BP was 165/93 mm Hg and his weight was 85 kg (previously 82 kg). Jugular venous distension, peripheral edema, normal cardiac and respiratory examinations were noted. He received a peritoneal dialysis (PD) prescription of five 2-L overnight exchanges of 2.5% dextrose (over 9 hours) and a 2-L all-day dwell of 2.5% dextrose. His residual urine output was 600 ml/d, with furosemide 80 mg daily. A peritoneal equilibration test (4.25%) demonstrated high-average transport status, and ultrafiltration (UF) of 750 ml.

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

“…Fischbach and colleagues used a total treatment time of 540 min. [ 6 , 17 ] which is consistent with a recently published guidance document for APD in volume overloaded patients that recommends a 9-hour total treatment period with a maximum of 5 overnight cycles in high (fast) and high-average and a maximum of 4 cycles in low and low-average transporters [ 18 ]. Among the participants of this study, the average prescribed treatment times were considerably shorter, with more than half of the patients treated for 7 hours or less.…”

“…Due to the time required for filling and draining, too rapid exchanges limit active treatment time and thus bear the risk of overhydration and sodium sieving [ 18 ]. Whereas in the early phase of the dwell mainly free water is removed via aquaporin-1 channels, removal of sodium-coupled water occurs only later during the dwell via the small pores of the peritoneum, a process which is essential for adequate sodium and water balance and for blood pressure control [ 19 , 20 ].…”

The impact of volume overload on technique failure in incident peritoneal dialysis patients

“…In addition, fluid overload was independently associated with faster loss of residual renal function in PD patients, which may contribute to higher rate of technique failure [ 26 ]. Here, various approaches to control fluid balance might be suggested, including dietary counselling to control fluid and sodium intake, appropriate pharmacological treatment to support residual renal fluid excretion and, eventually, to optimize the prescription by PD modality, dialysis schedule and fluid composition to ensure adequate peritoneal fluid removal [ 27 , 28 ]. Consequent monitoring of patients’ fluid status from the beginning of PD is a prerequisite to acknowledge volume status and to initiate the appropriate measures.…”

Blood pressure and volume management in dialysis: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference

“…solutions (high transporter), using higher tonicity glucosebased solutions (but this is less preferable), using icodextrin for long day dwell for APD or long overnight dwell for continuous ambulatory PD, restricting dietary salt, and in those with RKF, using diuretics to increase urine volume ( Figure 3). 55,100 Experimental approaches include using a low-sodium dialysate, 101 a bimodal solution with glucose and icodextrin, 102 2 icodextrin exchanges per day, 103 and incorporating intermittent hybrid therapy, all of which require further evaluation. Assessment of membrane function may be considered as adjunctive to clinical measures of UF volume.…”