Treatment of severe ultrafiltration failure with nonglucose dialysis solutions in patients with and without peritoneal sclerosis

Abstract

Introduction. Ultrafiltration failure (UFF) in peritoneal dialysis (PD) patients is a reflection of changes in the peritoneal membrane, which can include mesothelial damage, neoangiogenesis, and occasionally, peritoneal fibrosis. These structural changes are probably induced by the use of bioincompatible dialysis solutions. Therefore, we investigated the effects of the treatment with a combination of nonglucose dialysis solutions in patients with severe UFF.Methods. Ten patients with UFF (net ultrafiltration <400 mL/4 h on 3.86% glucose) were treated with a combination of glycerol and icodextrin with or without amino acid-based dialysis solutions for 3 months. Four of them were diagnosed with encapsulating peritoneal sclerosis (PS), proven by peritoneal biopsies. Standard peritoneal permeability analyses (SPA), using 3.86% glucose, were performed, and dialysate CA125 appearance rate (AR-CA125) was analysed at the start, after 6 weeks and after 12 weeks. PS and non-PS patients were compared.Results. One patient underwent transplant after 6 weeks, one was withdrawn from PD because of clinical signs of encapsulating PS before the 3-month period ended. PS patients had been treated with PD for a longer duration than the non-PS patients (102 versus 52 months, P = 0.05), but no differences in baseline transport parameters or AR-CA125 were present. During the study, no differences were observed for transport characteristics when the results of the whole group at 6 and 12 weeks were compared to baseline. For the non-PS patients, however, a significant increase in the transcapillary ultrafiltration rate (from 2.2 mL/min to 2.6 mL/min, P < 0.05) and a decrease in the MTAC creatinine (from 14.3 mL/min to 12.6 mL/min, P < 0.05) were found after 6 weeks of glucose-free treatment. Free-water transport, measured as the maximum dip in the dialysate-to-plasma ratio of sodium and as the transport through the ultrasmall pores in the first minute, tended to improve, but this difference did not reach significance. In addition, the AR-CA125 increased significantly (from 2.8 U/min to 16.1 U/min, P < 0.05). Continued treatment did not reach statistical difference even after 3 months. No changes were observed in the PS patients.Conclusions. In the present study, an improvement of UFF in the non-PS patients was obtained by withdrawal of glucose-based dialysis solutions. The abnormalities in PS patients are probably irreversible. Early withdrawal of glucose-based dialysis solutions or at least a marked reduction in glucose exposure should be considered in UFF patients, but the identification of the patients who would benefit most needs further studies.

How to Improve the Biocompatibility of Peritoneal Dialysis Solutions (without Jeopardizing the Patient’s Health)

“…From the systemic standpoint, however, it remains to be established if a daily peritoneal glycerol load would further increase hepatic glucose and VLDL-TG production over time, particularly in insulin resistant and/or diabetic PD patients [ 98 ]. Smit et al [ 101 ] switched 10 PD patients with UF failure from glucose-based dialysis solutions to a dialysis regime consisting of two to three exchanges (according to the patients’ needs) with a 2.5% glycerol-based dialysate, one exchange with a 1.1% amino acid-based dialysate, and one exchange with 7.5% icodextrin-containing dialysate for 3 months. Four patients were diagnosed with encapsulating peritoneal sclerosis (PS), proven by peritoneal biopsies.…”

“…Four patients were diagnosed with encapsulating peritoneal sclerosis (PS), proven by peritoneal biopsies. In the whole cohort, no statistically significant changes were observed for transport characteristics after 6 weeks or 3 months of glucose-free treatment, compared to the baseline levels [ 101 ]. However, after 6 weeks of glucose-free treatment, non-PS patients showed a significant increase in the transcapillary ultrafiltration rate and a decrease in the mass transfer area coefficient of creatinine.…”

“…By contrast, no significant changes were found in patients suffering from PS. These results suggest that early withdrawal of glucose-based dialysis solutions, or at least a marked reduction in glucose exposure, may improve peritoneal function in PD patients with UF failure, but the identification of the patients who would benefit most warrants further studies [ 101 ]. In this regard, and in a broader sense to improve the clinical outcomes of PD, it is necessary to identify new biomarkers of the health of the peritoneal membrane in relation to dialytic prescription as tools in guiding personalized interventions in patients who are at risk of PD-related complications [ 102 ].…”

Peritoneal Resting with Heparinized Lavage Reverses Peritoneal Type I Membrane Failure. A Comparative Study of the Resting Effects on Normal Membranes

“…34, NO. 7 PERITONEAL REST IN ULTRAFILTRATION FAILURE PD (APD) and electively switching to hemodialysis (HD) (1,2,10).…”

“…The contribution and potential reversibility of each of these processes remain to be determined, but once UFF is established, the therapeutic options are limited. These options include the use of nonglucose-based PD fluids such as icodextrin, transitioning to automated PD (APD) and electively switching to hemodialysis (HD) (1,2,10).…”