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: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:
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- 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