Rapid transporters on maintenance peritoneal dialysis
- John M Burkart, MD
John M Burkart, MD
- Section Editor — Dialysis
- Professor of Medicine/Nephrology
- Wake Forest University Medical Center
It is now well appreciated that peritoneal dialysis patients have different peritoneal membrane transport characteristics. These differences are best classified and determined by use of the peritoneal equilibration test (PET) . (See "Peritoneal equilibration test".) If the standard PET is done and all recommended measurements obtained, this test has helped characterize the relationship between dwell time, solute transport, glucose absorption, drain volume, and net solute removal. Those patients who have the highest rates of diffusive transport are classified as rapid transporters. According to PET testing in different populations, approximately 15 percent of patients will be rapid transporters at the start of peritoneal dialysis.
As a result of the high rates of diffusive transport, rapid transporters transport small solutes (such as urea, creatinine, and glucose) quickly, leading to equilibration between the dialysate small-solute concentration and that of the blood relatively early in a dwell (figure 1). These patients also rapidly absorb dialysate glucose, leading to early dissolution of the crystalloid osmotic gradient between dialysate and blood that is required to sustain ultrafiltration. Once the osmotic gradient is dissipated, the stimulus for ultrafiltration is gone, and ultrafiltration ceases. However, there is slow but continuous absorption of fluid via the peritoneal lymphatics, potentially leading to poor net ultrafiltration, low drain volume, and potential systemic volume expansion. Lower drain volumes could potentially lead to lower solute clearance.
If one were to design a peritoneal dialysis prescription based upon transport characteristics alone, ignoring patient convenience or lifestyle constraints, attempting to optimize ultrafiltration, drain volumes, and creatinine clearance, rapid transporters would do best with short dwell times (1.5 to 3 hours/dwell). In theory, when using only glucose-containing solutions, such patients would do best with automated therapies (automated peritoneal dialysis [APD]), such as nightly intermittent peritoneal dialysis (NIPD) or nightly cycler therapy with a last bag fill (first morning fill) and a midday exchange when only using glucose-containing solutions. By contrast, low-average or low transporters would do best with prolonged dwells, such as those associated with continuous ambulatory peritoneal dialysis (CAPD) or continuous cycling peritoneal dialysis (CCPD) with less overnight exchanges (figure 1). Low-average or low transporters may need large instilled volumes, which enhance clearance by maximizing contact surface area. In such patients, solute clearance and ultrafiltration tend to be maintained throughout the dwell because of the slow rates of transport for both small solutes and glucose. Patients who are high-average transporters would typically do well with either therapy.
Despite these theoretical concepts, most patients could do either CAPD or APD, if one is knowledgeable in peritoneal dialysis kinetics and peritoneal dialysis fluids and willing to individualize the patient's prescription. This is especially true in patients who have residual renal function, which makes it easier to maintain euvolemia and solute removal. In an extensive observational cohort review of 42,942 patients on CAPD and 23,439 on APD in the United States who started peritoneal dialysis during the years 1996 to 2004 and were followed through September 2006, there was no effect demonstrated of modality on survival risk . In this review, there was no adjustment for transport type. However, in a prior review of patients on peritoneal dialysis in Australia and New Zealand, which adjusted for transport type, there also was no demonstrable difference in risk of death for CAPD or APD . By contrast, an analysis of a more contemporary cohort of patients in peritoneal dialysis in Australia and New Zealand found a lower risk of death in high transporters treated with APD, compared with those on CAPD . At our center, approximately 85 percent of all peritoneal dialysis patients are on APD.
In addition, the removal of larger solutes such as B2-microglobulin is dwell-time dependant even among rapid transporters. Therefore, although these patients could often reach their minimal Kt/V urea targets with NIPD and a dry day, most are on 24 hours a day of peritoneal dialysis dwell. If they were not, they would not be optimizing middle-molecule removal due to the dry day.
- Twardowski ZJ. Clinical value of standardized equilibration tests in CAPD patients. Blood Purif 1989; 7:95.
- Mehrotra R, Chiu YW, Kalantar-Zadeh K, Vonesh E. The outcomes of continuous ambulatory and automated peritoneal dialysis are similar. Kidney Int 2009; 76:97.
- Badve SV, Hawley CM, McDonald SP, et al. Automated and continuous ambulatory peritoneal dialysis have similar outcomes. Kidney Int 2008; 73:480.
- Johnson DW, Hawley CM, McDonald SP, et al. Superior survival of high transporters treated with automated versus continuous ambulatory peritoneal dialysis. Nephrol Dial Transplant 2010; 25:1973.
- Davies SJ, Phillips L, Russell GI. Peritoneal solute transport predicts survival on CAPD independently of residual renal function. Nephrol Dial Transplant 1998; 13:962.
- Churchill DN, Thorpe KE, Nolph KD, et al. Increased peritoneal membrane transport is associated with decreased patient and technique survival for continuous peritoneal dialysis patients. The Canada-USA (CANUSA) Peritoneal Dialysis Study Group. J Am Soc Nephrol 1998; 9:1285.
- Cueto-Manzano AM, Correa-Rotter R. Is high peritoneal transport rate an independent risk factor for CAPD mortality? Kidney Int 2000; 57:314.
- Brimble KS, Walker M, Margetts PJ, et al. Meta-analysis: peritoneal membrane transport, mortality, and technique failure in peritoneal dialysis. J Am Soc Nephrol 2006; 17:2591.
- Blake PG. What is the problem with high transporters? Perit Dial Int 1997; 17:317.
- Wang T, Heimbürger O, Cheng HH, et al. Does a high peritoneal transport rate reflect a state of chronic inflammation? Perit Dial Int 1999; 19:17.
- Tonbul Z, Altintepe L, Sözlü C, et al. The association of peritoneal transport properties with 24-hour blood pressure levels in CAPD patients. Perit Dial Int 2003; 23:46.
- Bieber SD, Burkart J, Golper TA, et al. Comparative outcomes between continuous ambulatory and automated peritoneal dialysis: a narrative review. Am J Kidney Dis 2014; 63:1027.
- Davies SJ. Mitigating peritoneal membrane characteristics in modern peritoneal dialysis therapy. Kidney Int Suppl 2006; :S76.
- Brown EA, Davies SJ, Rutherford P, et al. Survival of functionally anuric patients on automated peritoneal dialysis: the European APD Outcome Study. J Am Soc Nephrol 2003; 14:2948.
- Chung SH, Heimbürger O, Stenvinkel P, et al. Influence of peritoneal transport rate, inflammation, and fluid removal on nutritional status and clinical outcome in prevalent peritoneal dialysis patients. Perit Dial Int 2003; 23:174.
- Yang X, Fang W, Bargman JM, Oreopoulos DG. High peritoneal permeability is not associated with higher mortality or technique failure in patients on automated peritoneal dialysis. Perit Dial Int 2008; 28:82.
- Rumpsfeld M, McDonald SP, Johnson DW. Higher peritoneal transport status is associated with higher mortality and technique failure in the Australian and New Zealand peritoneal dialysis patient populations. J Am Soc Nephrol 2006; 17:271.
- Wiggins KJ, McDonald SP, Brown FG, et al. High membrane transport status on peritoneal dialysis is not associated with reduced survival following transfer to haemodialysis. Nephrol Dial Transplant 2007; 22:3005.
- Blake PG, Abraham G, Sombolos K, et al. Changes in peritoneal membrane transport rates in patients on long term CAPD. Adv Perit Dial 1989; 5:3.
- Dobbie JW, Lloyd JK, Gall CA. Categorization of ultrastructural changes in peritoneal mesothelium, stroma and blood vessels in uremia and CAPD patients. Adv Perit Dial 1990; 6:3.
- Chung SH, Chu WS, Lee HA, et al. Peritoneal transport characteristics, comorbid diseases and survival in CAPD patients. Perit Dial Int 2000; 20:541.
- Rodrigues A, Martins M, Santos MJ, et al. Evaluation of effluent markers cancer antigen 125, vascular endothelial growth factor, and interleukin-6: relationship with peritoneal transport. Adv Perit Dial 2004; 20:8.
- Honda K, Nitta K, Horita S, et al. Morphological changes in the peritoneal vasculature of patients on CAPD with ultrafiltration failure. Nephron 1996; 72:171.
- Heimbürger O, Waniewski J, Werynski A, et al. Peritoneal transport in CAPD patients with permanent loss of ultrafiltration capacity. Kidney Int 1990; 38:495.
- Davies SJ, Phillips L, Naish PF, Russell GI. Peritoneal glucose exposure and changes in membrane solute transport with time on peritoneal dialysis. J Am Soc Nephrol 2001; 12:1046.
- Davies SJ. Longitudinal relationship between solute transport and ultrafiltration capacity in peritoneal dialysis patients. Kidney Int 2004; 66:2437.
- Nakayama M, Kawaguchi Y, Yamada K, et al. Immunohistochemical detection of advanced glycosylation end-products in the peritoneum and its possible pathophysiological role in CAPD. Kidney Int 1997; 51:182.
- De Vriese AS, Flyvbjerg A, Mortier S, et al. Inhibition of the interaction of AGE-RAGE prevents hyperglycemia-induced fibrosis of the peritoneal membrane. J Am Soc Nephrol 2003; 14:2109.
- Linden T, Forsbäck G, Deppisch R, et al. 3-Deoxyglucosone, a promoter of advanced glycation end products in fluids for peritoneal dialysis. Perit Dial Int 1998; 18:290.
- Zimmeck T, Tauer A, Fuenfrocken M, Pischetsrieder M. How to reduce 3-deoxyglucosone and acetaldehyde in peritoneal dialysis fluids. Perit Dial Int 2002; 22:350.
- Ishikawa N, Miyata T, Ueda Y, et al. Affinity adsorption of glucose degradation products improves the biocompatibility of conventional peritoneal dialysis fluid. Kidney Int 2003; 63:331.
- Zeier M, Schwenger V, Deppisch R, et al. Glucose degradation products in PD fluids: do they disappear from the peritoneal cavity and enter the systemic circulation? Kidney Int 2003; 63:298.
- Witowski J, Jörres A. Preventing peritoneal fibrosis--an ace up our sleeve? Perit Dial Int 2005; 25:25.
- Noh H, Ha H, Yu MR, et al. Angiotensin II mediates high glucose-induced TGF-beta1 and fibronectin upregulation in HPMC through reactive oxygen species. Perit Dial Int 2005; 25:38.
- Kolesnyk I, Noordzij M, Dekker FW, et al. A positive effect of AII inhibitors on peritoneal membrane function in long-term PD patients. Nephrol Dial Transplant 2009; 24:272.
- Posthuma N, ter Wee PM, Donker AJ, et al. Icodextrin (I) used in CCPD patients during peritonitis: Serum disaccharide (maltose) levels and ultrafiltration (abstract). J Am Soc Nephrol 1997; 8:270A.
- Tzamaloukas AH, Murata GH, Fox L. Peritoneal catheter loss and death in continuous ambulatory peritoneal dialysis peritonitis: correlation with clinical and biochemical parameters. Perit Dial Int 1993; 13 Suppl 2:S338.
- Dwatwa M, Vladutiu D, Keller J. Nutritional support with Nutrineal for CAPD peritonitis (abstract). Perit Dial Int 1995; 15:39.
- Burkart JM, Jordan J, Rocco MV. Cross sectional analysis of D/P creatinine ratios versus serum albumin levels in NIPD. Perit Dial Int 1994; 14:S18.
- Nolph KD, Moore HL, Prowant B, et al. Continuous ambulatory peritoneal dialysis with a high flux membrane. A preliminary report. ASAIO J 1993; 39:M566.
- Mamoun H, Anderstam B, Lindholm B, et al. Peritoneal dialysis solutions with glucose and amino acids suppress appetite in rats (abstract). J Am Soc Nephrol 1994; 5:498.
- Jones CH, Wells L, Stoves J, et al. Can a reduction in extracellular fluid volume result in increased serum albumin in peritoneal dialysis patients? Am J Kidney Dis 2002; 39:872.
- Burkart JM. Effect of peritoneal dialysis prescription and peritoneal membrane transport characteristics on nutritional status. Perit Dial Int 1995; 15:S20.
- Kathuria P, Moore HL, Khanna R, et al. Effect of dialysis modality and membrane transport characteristics on dialysate protein losses of patients on peritoneal dialysis. Perit Dial Int 1997; 17:449.
- Twardowski ZJ, Nolph KD, Khanna R, et al. Daily clearances with continuous ambulatory peritoneal dialysis and nightly peritoneal dialysis. ASAIO Trans 1986; 32:575.