Evaluation of hypervolemia in peritoneal dialysis patients
- John M Burkart, MD
John M Burkart, MD
- Section Editor — Dialysis
- Professor of Medicine/Nephrology
- Wake Forest University Medical Center
Maintenance of euvolemia is of primary importance in the treatment of patients with chronic kidney disease (CKD) and is a principal goal of renal replacement therapies. Achievement of this goal is dependent upon a complex interplay between the intake and loss of fluid, which relies upon patient- and treatment-related features.
Due to its continuous nature, which potentially allows for a steady state and the avoidance of fluctuating volume status, peritoneal dialysis has historically been considered superior to hemodialysis with respect to maintaining adequate volume control among patients with end-stage renal disease (ESRD) . Despite this advantage, many patients on peritoneal dialysis are hypertensive and volume overloaded . This is most frequently due to a preventable or treatable process.
With peritoneal dialysis patients, attainment of euvolemia or "target weight" is usually based upon clinical judgment. However, because peritoneal dialysis is a home therapy, this clinical judgment is often determined by the patient. Since the target weight is usually set during peritoneal dialysis training, the importance of the dynamic nature of a patient's actual body mass (eg, muscle mass, fat mass) and, therefore, the person's target weight cannot be underestimated.
In standard clinical practice, since patients may lose or gain weight while on peritoneal dialysis, their target weight is not based upon a measurement obtained from a scale during training. Instead, it results from the compilation of clinical parameters such as blood pressure, presence of peripheral edema, and body weight. During monthly clinic visits, reevaluation of target weight is indicated and guided by changes in cardiovascular or nutritional status. Investigators are looking at more precise measurements of true body weight such as body impedance studies, but these can be used only during the clinical visit, are time consuming, and, in most countries, are non-reimbursable.
If the patient is found to be volume overloaded based upon clinical assessment, one needs to consider the following pathophysiologic processes as causes: too much sodium or water intake, too little sodium or water removal, or a new comorbid condition. Based on this approach, the following questions should be asked:
- Gokal R. Fluid management and cardiovascular outcome in peritoneal dialysis patients. Semin Dial 1999; 12:126.
- Coles GA. Have we underestimated the importance of fluid balance for the survival of PD patients? Perit Dial Int 1997; 17:321.
- K/DOQI Clinical Practice Guidelines for Peritoneal Dialysis Adequacy. Am J Kidney Dis 2006; 47(Suppl 4):S1.
- Mujais S, Nolph K, Gokal R, et al. Evaluation and management of ultrafiltration problems in peritoneal dialysis. International Society for Peritoneal Dialysis Ad Hoc Committee on Ultrafiltration Management in Peritoneal Dialysis. Perit Dial Int 2000; 20 Suppl 4:S5.
- Pannekeet MM, Imholz AL, Struijk DG, et al. The standard peritoneal permeability analysis: a tool for the assessment of peritoneal permeability characteristics in CAPD patients. Kidney Int 1995; 48:866.
- Pride ET, Gustafson J, Graham A, et al. Comparison of a 2.5% and a 4.25% dextrose peritoneal equilibration test. Perit Dial Int 2002; 22:365.
- Lam MF, Lo WK, Chu FS, et al. Retroperitoneal leakage as a cause of ultrafiltration failure. Perit Dial Int 2004; 24:466.
- Abu-Alfa AK, Burkart J, Piraino B, et al. Approach to fluid management in peritoneal dialysis: a practical algorithm. Kidney Int Suppl 2002; :S8.
- Michels WM, Zweers MM, Smit W, et al. Does lymphatic absorption change with the duration of peritoneal dialysis? Perit Dial Int 2004; 24:347.
- Akonur A, Holmes CJ, Leypoldt JK. Peritoneal residual volume induces variability of ultrafiltration with icodextrin. Perit Dial Int 2014; 34:95.
- Posthuma N, ter Wee PM, Verbrugh HA, et al. Icodextrin instead of glucose during the daytime dwell in CCPD increases ultrafiltration and 24-h dialysate creatinine clearance. Nephrol Dial Transplant 1997; 12:550.
- Teitelbaum I, Burkart J. Peritoneal dialysis. Am J Kidney Dis 2003; 42:1082.
- Davison SN, Jhangri GS, Jindal K, Pannu N. Comparison of volume overload with cycler-assisted versus continuous ambulatory peritoneal dialysis. Clin J Am Soc Nephrol 2009; 4:1044.
- Chan PC, Tam SC, Robinson JD, et al. Effect of phosphatidylcholine on ultrafiltration in patients on continuous ambulatory peritoneal dialysis. Nephron 1991; 59:100.
- Clinical history
- Physical examination
- Fill and drain test
- Peritoneal equilibration test
- Radiographic studies
- OVERVIEW OF DIFFERENT DISEASE STATES OR CONDITIONS
- Comorbid disease
- Input-dependent states
- Output-dependent states
- - Inadequate provision of conditions that result in ultrafiltration
- - Increased lymphatic reabsorption
- - Peritoneal membrane failure
- - Incomplete drain
- - Mechanical failure
- MONITORING AND PREVENTION
- OVERVIEW OF MANAGEMENT AND RECOMMENDATIONS
- SUMMARY AND RECOMMENDATIONS