Problems with solute clearance and ultrafiltration in continuous peritoneal dialysis
- John M Burkart, MD
John M Burkart, MD
- Section Editor — Dialysis
- Professor of Medicine/Nephrology
- Wake Forest University Medical Center
- William L Henrich, MD, MACP
William L Henrich, MD, MACP
- Professor of Medicine
- President of the Health Science Center
- University of Texas Health Science Center School of Medicine
Patients on chronic peritoneal dialysis (including both continuous ambulatory peritoneal dialysis [CAPD] and automated forms of peritoneal dialysis [APD] such as continuous cycler peritoneal dialysis [CCPD]) occasionally have difficulty achieving solute removal goals or maintaining euvolemia. Both inadequate solute removal and volume overload have multiple etiologies.
This topic reviews factors that contribute to inadequate solute removal among peritoneal dialysis patients and discusses the clearance of particular solutes. This topic also reviews volume overload among peritoneal dialysis patients and provides an approach to evaluating such patients.
The factors that regulate solute and water transport across the peritoneal membrane are discussed separately. (See "Mechanisms of solute clearance and ultrafiltration in peritoneal dialysis".)
The following discussion assumes that the peritoneal dialysis prescription was initially adequate and that solute clearance and/or fluid removal have become impaired over time. A review of the factors that must be considered at the initiation of dialysis is presented separately. (See "Choosing a modality for chronic peritoneal dialysis".)
Among peritoneal dialysis patients, total solute removal or clearance consists of the removal of the solute in question by both dialysis and residual renal clearance. The clearance of a particular solute is often used as a measure of the dialysis dose; in such cases, the term clearance refers to the amount of blood that is "cleared" of a substance over a unit of time. The dialysis dose or clearance may also be expressed by normalizing it to the particular solute’s volume of distribution that the solute was cleared from, such as Kt/V.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Burkart JM, Bleyer AJ, Jordan JR, Zeigler NC. An elevated ratio of measured to predicted creatinine production in CAPD patients is not a sensitive predictor of noncompliance with the dialysis prescription. Perit Dial Int 1996; 16:142.
- Tzamaloukas AH. Inadequacy of dialysis and infectious complications of continuous ambulatory peritoneal dialysis (CAPD): Diagnosis, management and prevention. AKF Nephrol 1991; 8:29.
- Smit W, Schouten N, van den Berg N, et al. Analysis of the prevalence and causes of ultrafiltration failure during long-term peritoneal dialysis: a cross-sectional study. Perit Dial Int 2004; 24:562.
- Pollock CA, Ibels LS, Hallett MD, et al. Loss of ultrafiltration in continuous ambulatory peritoneal dialysis (CAPD). Perit Dial Int 1989; 9:107.
- Margetts PJ, Churchill DN. Acquired ultrafiltration dysfunction in peritoneal dialysis patients. J Am Soc Nephrol 2002; 13:2787.
- Albrektsen GE, Widerøe TE, Nilsen TI, et al. Transperitoneal water transport before, during, and after episodes with infectious peritonitis in patients treated with CAPD. Am J Kidney Dis 2004; 43:485.
- van Esch S, Struijk DG, Krediet RT. The Natural Time Course of Membrane Alterations During Peritoneal Dialysis Is Partly Altered by Peritonitis. Perit Dial Int 2016; 36:448.
- Stegmayr BG. Beta-blockers may cause ultrafiltration failure in peritoneal dialysis patients. Perit Dial Int 1997; 17:541.
- Krediet RT. Beta-blockers and ultrafiltration failure. Perit Dial Int 1997; 17:528.
- Davies SJ, Brown EA, Frandsen NE, et al. Longitudinal membrane function in functionally anuric patients treated with APD: data from EAPOS on the effects of glucose and icodextrin prescription. Kidney Int 2005; 67:1609.
- Mikolasevic I, Milic S, Racki S, et al. Nonalcoholic Fatty Liver Disease (NAFLD)-A New Cardiovascular Risk Factor in Peritoneal Dialysis Patients. Perit Dial Int 2016; 36:427.
- Selgas R, Bajo MA, Castro MJ, et al. Managing ultrafiltration failure by peritoneal resting. Perit Dial Int 2000; 20:595.
- Zhe XW, Tian XK, Cheng L, Wang T. Effects of peritoneal resting on peritoneal fluid transport kinetics. Perit Dial Int 2007; 27:575.
- Wilkie ME, Plant MJ, Edwards L, Brown CB. Icodextrin 7.5% dialysate solution (glucose polymer) in patients with ultrafiltration failure: extension of CAPD technique survival. Perit Dial Int 1997; 17:84.
- Konings CJ, Kooman JP, van der Sande FM, Leunissen KM. Fluid status in peritoneal dialysis: what's new? Perit Dial Int 2003; 23:284.
- Finkelstein F, Healy H, Abu-Alfa A, et al. Superiority of icodextrin compared with 4.25% dextrose for peritoneal ultrafiltration. J Am Soc Nephrol 2005; 16:546.
- Mistry CD, Gokal R. Optimal use of glucose polymer (icodextrin) in peritoneal dialysis. Perit Dial Int 1996; 16 Suppl 1:S104.
- Mistry CD, Gokal R, Peers E. A randomized multicenter clinical trial comparing isosmolar icodextrin with hyperosmolar glucose solutions in CAPD. MIDAS Study Group. Multicenter Investigation of Icodextrin in Ambulatory Peritoneal Dialysis. Kidney Int 1994; 46:496.
- Wolfson M, Piraino B, Hamburger RJ, et al. A randomized controlled trial to evaluate the efficacy and safety of icodextrin in peritoneal dialysis. Am J Kidney Dis 2002; 40:1055.
- Davies SJ, Woodrow G, Donovan K, et al. Icodextrin improves the fluid status of peritoneal dialysis patients: results of a double-blind randomized controlled trial. J Am Soc Nephrol 2003; 14:2338.
- Rodríguez-Carmona A, Pérez Fontán M, García López E, et al. Use of icodextrin during nocturnal automated peritoneal dialysis allows sustained ultrafiltration while reducing the peritoneal glucose load: a randomized crossover study. Perit Dial Int 2007; 27:260.
- Lin A, Qian J, Li X, et al. Randomized controlled trial of icodextrin versus glucose containing peritoneal dialysis fluid. Clin J Am Soc Nephrol 2009; 4:1799.
- Takatori Y, Akagi S, Sugiyama H, et al. Icodextrin increases technique survival rate in peritoneal dialysis patients with diabetic nephropathy by improving body fluid management: a randomized controlled trial. Clin J Am Soc Nephrol 2011; 6:1337.
- Cho Y, Johnson DW, Badve S, et al. Impact of icodextrin on clinical outcomes in peritoneal dialysis: a systematic review of randomized controlled trials. Nephrol Dial Transplant 2013; 28:1899.
- Dombros N, Dratwa M, Feriani M, et al. European best practice guidelines for peritoneal dialysis. 2 The initiation of dialysis. Nephrol Dial Transplant 2005; 20 Suppl 9:ix3.
- Jeloka TK, Ersoy FF, Yavuz M, et al. What is the optimal dwell time for maximizing ultrafiltration with icodextrin exchange in automated peritoneal dialysis patients? Perit Dial Int 2006; 26:336.
- Tzamaloukas AH. Avoiding the use of hypertonic dextrose dialysate in peritoneal dialysis. Semin Dial 2000; 13:156.
- Medcalf JF, Harris KP, Walls J. Role of diuretics in the preservation of residual renal function in patients on continuous ambulatory peritoneal dialysis. Kidney Int 2001; 59:1128.
- Dallas F, Jenkins SB, Wilkie ME. Enhanced ultrafiltration using 7.5% icodextrin/1.36% glucose combination dialysate: a pilot study. Perit Dial Int 2004; 24:542.
- Wang T, Cheng HH, Heimbürger O, et al. Hyaluronan decreases peritoneal fluid absorption: effect of molecular weight and concentration of hyaluronan. Kidney Int 1999; 55:667.
- Rosengren BI, Carlsson O, Rippe B. Hyaluronan and peritoneal ultrafiltration: a test of the "filter-cake" hypothesis. Am J Kidney Dis 2001; 37:1277.
- Freida P, Galach M, Divino Filho JC, et al. Combination of crystalloid (glucose) and colloid (icodextrin) osmotic agents markedly enhances peritoneal fluid and solute transport during the long PD dwell. Perit Dial Int 2007; 27:267.
- Dousdampanis P, Trigka K, Chu M, et al. Two icodextrin exchanges per day in peritoneal dialysis patients with ultrafiltration failure: one center's experience and review of the literature. Int Urol Nephrol 2011; 43:203.
- Brown EA, Van Biesen W, Finkelstein FO, et al. Length of time on peritoneal dialysis and encapsulating peritoneal sclerosis: position paper for ISPD. Perit Dial Int 2009; 29:595.
- Kawaguchi Y, Tranaeus A. A historical review of encapsulating peritoneal sclerosis. Perit Dial Int 2005; 25 Suppl 4:S7.
- Levine S, Saltzman A. Abdominal cocoon: an animal model for a complication of peritoneal dialysis. Perit Dial Int 1996; 16:613.
- Io H, Hamada C, Ro Y, et al. Morphologic changes of peritoneum and expression of VEGF in encapsulated peritoneal sclerosis rat models. Kidney Int 2004; 65:1927.
- Kawanishi H, Kawaguchi Y, Fukui H, et al. Encapsulating peritoneal sclerosis in Japan: a prospective, controlled, multicenter study. Am J Kidney Dis 2004; 44:729.
- Nomoto Y, Kawaguchi Y, Kubo H, et al. Sclerosing encapsulating peritonitis in patients undergoing continuous ambulatory peritoneal dialysis: a report of the Japanese Sclerosing Encapsulating Peritonitis Study Group. Am J Kidney Dis 1996; 28:420.
- Rigby RJ, Hawley CM. Sclerosing peritonitis: the experience in Australia. Nephrol Dial Transplant 1998; 13:154.
- Brown MC, Simpson K, Kerssens JJ, et al. Encapsulating peritoneal sclerosis in the new millennium: a national cohort study. Clin J Am Soc Nephrol 2009; 4:1222.
- Johnson DW, Cho Y, Livingston BE, et al. Encapsulating peritoneal sclerosis: incidence, predictors, and outcomes. Kidney Int 2010; 77:904.
- Korte MR, Yo M, Betjes MG, et al. Increasing incidence of severe encapsulating peritoneal sclerosis after kidney transplantation. Nephrol Dial Transplant 2007; 22:2412.
- Fieren MW, Betjes MG, Korte MR, Boer WH. Posttransplant encapsulating peritoneal sclerosis: a worrying new trend? Perit Dial Int 2007; 27:619.
- de Freitas DG, Augustine T, Brown EA, et al. Encapsulating peritoneal sclerosis following renal transplantation - the UK experience. Am J Transplant 2007; 7:163.
- Nakamoto H. Encapsulating peritoneal sclerosis--a clinician's approach to diagnosis and medical treatment. Perit Dial Int 2005; 25 Suppl 4:S30.
- Kawaguchi Y, Saito A, Kawanishi H, et al. Recommendations on the management of encapsulating peritoneal sclerosis in Japan, 2005: diagnosis, predictive markers, treatment, and preventive measures. Perit Dial Int 2005; 25 Suppl 4:S83.
- Tarzi RM, Lim A, Moser S, et al. Assessing the validity of an abdominal CT scoring system in the diagnosis of encapsulating peritoneal sclerosis. Clin J Am Soc Nephrol 2008; 3:1702.
- Junor BJ, McMillan MA. Immunosuppression in sclerosing peritonitis. Adv Perit Dial 1993; 9:187.
- Mori Y, Matsuo S, Sutoh H, et al. A case of a dialysis patient with sclerosing peritonitis successfully treated with corticosteroid therapy alone. Am J Kidney Dis 1997; 30:275.
- Martins LS, Rodrigues AS, Cabrita AN, Guimaraes S. Sclerosing encapsulating peritonitis: a case successfully treated with immunosuppression. Perit Dial Int 1999; 19:478.
- Summers AM, Clancy MJ, Syed F, et al. Single-center experience of encapsulating peritoneal sclerosis in patients on peritoneal dialysis for end-stage renal failure. Kidney Int 2005; 68:2381.
- Wong CF, Beshir S, Khalil A, et al. Successful treatment of encapsulating peritoneal sclerosis with azathioprine and prednisolone. Perit Dial Int 2005; 25:285.
- Eltoum MA, Wright S, Atchley J, Mason JC. Four consecutive cases of peritoneal dialysis-related encapsulating peritoneal sclerosis treated successfully with tamoxifen. Perit Dial Int 2006; 26:203.
- Guest S. Tamoxifen therapy for encapsulating peritoneal sclerosis: mechanism of action and update on clinical experiences. Perit Dial Int 2009; 29:252.
- Korte MR, Fieren MW, Sampimon DE, et al. Tamoxifen is associated with lower mortality of encapsulating peritoneal sclerosis: results of the Dutch Multicentre EPS Study. Nephrol Dial Transplant 2011; 26:691.
- Lee HY, Kim BS, Choi HY, et al. Sclerosing encapsulating peritonitis as a complication of long-term continuous ambulatory peritoneal dialysis in Korea. Nephrology (Carlton) 2003; 8 Suppl:S33.
- Kawanishi H, Watanabe H, Moriishi M, Tsuchiya S. Successful surgical management of encapsulating peritoneal sclerosis. Perit Dial Int 2005; 25 Suppl 4:S39.
- INADEQUATE SOLUTE CLEARANCE
- Poor compliance
- Loss of residual renal clearance
- Decreased peritoneal transport
- Increased peritoneal transport
- INADEQUATE ULTRAFILTRATION
- Icodextrin dialysate
- Use of diuretics
- Novel interventions
- INADEQUATE SOLUTE CLEARANCE AND ULTRAFILTRATION FAILURE
- Encapsulating peritoneal slerosis or sclerosing encapsulating peritonitis
- - Pathogenesis and causes
- - Incidence, clinical features, and diagnosis
- - Treatment
- SUMMARY AND RECOMMENDATIONS