Quantification of free water transport in peritoneal dialysis

Quantification of free water transport in peritoneal dialysis.BackgroundIn peritoneal dialysis (PD) total net ultrafiltration (NUF) is dependent on transport through small pores and through water channels in the peritoneum. These channels are impermeable to solutes, and therefore, crystalloid osmotic-induced free water transport occurs through them. Several indirect methods to assess free water transport have been suggested. The difference in NUF between a 3.86% and a 1.36% solution gives a rough indication, but is very time consuming. The magnitude of the dip in dialysate/plasma (D/P) sodium in the initial phase of a 3.86% exchange is another way to estimate free water transport. In the present study, a method was applied to calculate free water transport by calculating sodium-associated water transport in one single 3.86% glucose dwell.MethodsForty PD patients underwent one standard peritoneal permeability analysis (SPA) with a 1.36% glucose solution, and another with a 3.86% glucose solution. At different time points intraperitoneal volume and sodium concentration were assessed. This made it possible to calculate total sodium transport. By subtracting this transport (which must have occurred through the small pores) from the total fluid transport, free water transport remained. These results were compared with the other methods to estimate free water transport.ResultsFor the 1.36% glucose dwell, total transcapillary ultrafiltration in the first hour (TCUF0-60) was 164 mL, transport through the small pores was 129 mL, and free water transport was 35 mL (21%). For the 3.86% glucose solution, total TCUF0-60 was 404 mL, transport through the small pores was 269 mL, and free water transport was 135 mL (34%). The contribution of free water transport in the first minute (TCUF0-1) was 39% of the total fluid transport. From the 40 patients, 11 patients had ultrafiltration failure (NUF <400 mL after 4 hours). For these patients the contribution of free water to TCUF0-1 was significantly lower than for those with normal ultrafiltration (20% vs. 48%, P < 0.05). A strong correlation was present between free water transport as a percentage of total fluid transport and the maximum dip in D/P sodium (r = 0.84). The correlation was not significant with the difference in net ultrafiltration of 3.86% and 1.36% solutions (r = 0.24, P = 0.3).ConclusionThe method applied here is the first direct quantification of free water transport, calculated from a single standard peritoneal function test. It offers a quick possibility to evaluate patients suffering from ultrafiltration failure. In these patients free water transport was impaired, but the origin of this impairment is still to be determined

The difference in causes of early and late ultrafiltration failure in peritoneal dialysis

OBJECTIVE: Ultrafiltration failure (UFF) is a major complication of peritoneal dialysis. Although it seems associated with long-term treatment, it can also occur in recently started patients. To identify the causes of this complication in patients with early and late UFF we studied a group of 48 patients. Patients were classified as early if they had been treated for less than 2 years and as late if they had been treated for more than 4 years. METHOD: The patients were studied using a standard peritoneal permeability analysis. They all had a net ultrafiltration of less than 400 mL after a 4-hour dwell with 3.86% glucose. As possible causes for UFF, the solute transport parameters dialysate-to-plasma ratio (D/P) and mass transfer area coefficient of creatinine were compared, as well as the effective lymphatic absorption rate (ELAR) and the maximum dip in D/P sodium as an assessment of osmotic conductance to glucose. RESULTS: 25 short-term patients were compared with 23 long-term patients. Both groups showed an equal distribution of high small solute transport rates as a cause of UFF. The chi-square test showed that a high ELAR was a more frequent cause in early UFF compared to late UFF. However, a decreased osmotic conductance to glucose was significantly more often observed in late UFF. Some patients showed more than one cause of the complication. CONCLUSION: This study has shown that UFF in long-term patients is often caused by a decreased osmotic conductance to glucose, most likely caused by a dysfunction of peritoneal water channels in combination with increased peritoneal surface area. In short-term patients, aquaporin dysfunction is rare, but a high ELAR was a very important factor in the occurrence of UF

Dry Body Weight and Ultrafiltration Targets in Peritoneal Dialysis

A review is given on methods that can be used for the assessment of dry body weight in peritoneal dialysis patients. Besides clinical examination, the use of natriuretic hormone concentrations in plasma, and the value of multifrequency bio-impedance analysis is discussed. Ultrafiltration targets as formulated in various guidelines are reviewed. Finally, it is concluded that the ultrafiltration target is the amount required to keep patients euvolemic with an exposure to glucose that is as low as possibl

Free water transport in patients starting with peritoneal dialysis: a comparison between diabetic and non diabetic patients

Peritoneal transport rates and net drained volume are reported to be different for peritoneal dialysis (PD) patients with diabetes mellitus (DM) as compared with patients without DM. The difference has been considered to be caused by exposure to high plasma glucose levels before PD initiation. However, the results of previous studies conflict. Transport of small solutes has been reported to be either higher than or similar to that seen in patients without DM, and ultrafiltration to be either similar or lower. No information on free water transport is available. The main problem in earlier reports is the wide variation in duration of PD, which may have influenced the outcomes. In the present study, we compared the results of peritoneal function tests in 10 patients with DM to results in 10 patients without DM. All patients were investigated within the first 4 months of PD treatment. No differences were observed in transcapillary ultrafiltration rate, net ultrafiltration, or lymphatic absorption. Free water transport, estimated using the maximum dip in the dialysate-to-plasma ratio of sodium and quantified by calculating the transport through the ultrasmall pores, showed no differences. Small-solute transport was also similar. These findings imply that a mild chronic hyperglycemic state in the peritoneal vessels does not contribute to important peritoneal changes or to changes in aquaporin-1 function. The influence of continuous treatment with hyperosmolar glucose solutions on the latter is worth investigatin

Fluid Transport with Time on Peritoneal Dialysis: The Contribution of Free Water Transport and Solute Coupled Water Transport

Ultrafiltration in peritoneal dialysis occurs through endothelial water channels (free water transport) and together with solutes across small pores: solute coupled water transport. A review is given of cross-sectional studies and on the results of longitudinal follow-u

Quantification of free water transport in peritoneal dialysis

BACKGROUND: In peritoneal dialysis (PD) total net ultrafiltration (NUF) is dependent on transport through small pores and through water channels in the peritoneum. These channels are impermeable to solutes, and therefore, crystalloid osmotic-induced free water transport occurs through them. Several indirect methods to assess free water transport have been suggested. The difference in NUF between a 3.86% and a 1.36% solution gives a rough indication, but is very time consuming. The magnitude of the dip in dialysate/plasma (D/P) sodium in the initial phase of a 3.86% exchange is another way to estimate free water transport. In the present study, a method was applied to calculate free water transport by calculating sodium-associated water transport in one single 3.86% glucose dwell. METHODS: Forty PD patients underwent one standard peritoneal permeability analysis (SPA) with a 1.36% glucose solution, and another with a 3.86% glucose solution. At different time points intraperitoneal volume and sodium concentration were assessed. This made it possible to calculate total sodium transport. By subtracting this transport (which must have occurred through the small pores) from the total fluid transport, free water transport remained. These results were compared with the other methods to estimate free water transport. RESULTS: For the 1.36% glucose dwell, total transcapillary ultrafiltration in the first hour (TCUF(0-60)) was 164 mL, transport through the small pores was 129 mL, and free water transport was 35 mL (21%). For the 3.86% glucose solution, total TCUF(0-60) was 404 mL, transport through the small pores was 269 mL, and free water transport was 135 mL (34%). The contribution of free water transport in the first minute (TCUF(0-1)) was 39% of the total fluid transport. From the 40 patients, 11 patients had ultrafiltration failure (NUF <400 mL after 4 hours). For these patients the contribution of free water to TCUF(0-1) was significantly lower than for those with normal ultrafiltration (20% vs. 48%, P < 0.05). A strong correlation was present between free water transport as a percentage of total fluid transport and the maximum dip in D/P sodium (r= 0.84). The correlation was not significant with the difference in net ultrafiltration of 3.86% and 1.36% solutions (r= 0.24, P= 0.3). CONCLUSION: The method applied here is the first direct quantification of free water transport, calculated from a single standard peritoneal function test. It offers a quick possibility to evaluate patients suffering from ultrafiltration failure. In these patients free water transport was impaired, but the origin of this impairment is still to be determine

Longitudinal analysis of peritoneal fluid transport and its determinants in a cohort of incident peritoneal dialysis patients

There is a paucity of large longitudinal studies on the time course of peritoneal fluid transport. The aim of the present study was to longitudinally analyze changes in fluid transport and relevant solute transport parameters in patients treated with a conventional peritoneal dialysis (PD) fluid and, to mimic clinical reality, not selected for the presence or absence of ultrafiltration (UF) failure. This prospective single-center cohort study followed 138 consecutive incident PD patients from July 1994 until censoring in August 2004. The design was longitudinal, with repeated measures over time in each patient. Patients had undergone at least 1 and a maximum of 5 annual standard peritoneal permeability analyses (SPAs) using 3.86% glucose dialysate. A linear mixed model was used to analyze the longitudinal data. No differences in patient characteristics were present at baseline in relation to the number of available SPAs. There were also no differences in patient withdrawal during the years of follow-up. A gradual decline in fluid transport, expressed as free water transport (FWT), small-pore fluid transport (SPFT), and transcapillary UF (TCUF), was observed with duration of PD. The decline was mainly attributable to patients who developed UF failure. The time courses for the determinants of fluid transport, such as the reflection coefficient (σ) and the UF coefficient (LpA), were not different. However, they were associated with an increase in the mass transfer area coefficient of creatinine, reflecting the peritoneal vascular surface area. Fluid profiles for FWT and SPFT during a dwell can be explained by current knowledge of the three-pore model. Fluid transport declines with the duration of PD because of an increase in the vascular surface area, leading to a rapid dissipation of glucose as the osmotic agent. The absence of a trend in the time course of osmotic conductance and its constituents-that is, LpA and σ-suggests that, in an unselected population, these parameters are affected only late in the time course of P

Free water transport, small pore transport and the osmotic pressure gradient

BACKGROUND: Water transport in peritoneal dialysis (PD) patients occurs through the small pores and water channels, the latter allowing free water transport (FWT). The osmotic gradient is known to be one of the major determinants of water transport. The objective of the study was to analyse the relation between each transport route and the osmotic gradient. METHODS: The 4-h standard peritoneal permeability analyses of 80 stable PD patients were studied. Small pore transport (SPT) was calculated based on the transported amount of sodium. FWT was calculated by subtracting SPT from transcapillary ultrafiltration (TCUF). Water transport rates were determined. The osmotic gradient was calculated. The slope of the relation between FWT rate and osmotic gradient (slope(FWT)), and the elimination constant (K(e)) of the exponential relation between SPT rate and osmotic gradient (K(SPT)) were calculated for every patient. RESULTS: The FWT rate was related to the osmotic gradient (P = 0.001). A similar correlation was also found between the SPT rate and osmotic gradient when fitted exponentially (P = 0.005). The rates of FWT decreased significantly between each time point during the whole dwell. The SPT rates decreased significantly within the first half of the dwell and levelled off thereafter. No correlations were found between the slope(FWT), K(SPT) and PD duration. The slope(FWT) of the relationship between the FWT and the osmotic gradient is an indirect measurement of the amount of functioning water channels. Similarly, the K(SPT) value represents the number of functioning small pores. The absence of a relationship of these parameters with the duration of PD suggests opposing mechanisms, for instance a lower number of functioning pores in combination with an increased vascular surface area. Conclusion. The curves of the relationship between FWR, SPT and OG support the assumption that FWR is much more dependent on the OG than SPT. Non-osmotic determinants are likely to be important in small pore fluid transpor

The cellular contribution to effluent potassium and its relation to free water transport during peritoneal dialysis

BACKGROUND: Aquaporin-1 (AQP-1) dysfunction is one of the valid theories for decreased free water transport (FWT) in long-term peritoneal dialysis (PD) ultrafiltration failure (UFF). We questioned whether apoptosis of peritoneal cells could be reflected in an increased release of cellular (CR) K(+) and explain AQP-1 dysfunction. If so, negative relationships between CR-K(+) and FWT would be expected. Therefore, we analysed CR-K(+) to total peritoneal K(+) removal, for possible relationships with FWT, the duration of PD, the presence of late UFF and effluent cancer antigen (CA) 125. METHODS: Standard peritoneal permeability analyses done with 3.86% glucose were investigated cross-sectionally in three extreme groups: group I: 19 patients 4 years on PD without UFF; group III: 19 patients >4 years on PD with UFF. RESULTS: Group III had the lowest values of FWT and CR-K(+) (P < 0.01). CR-K(+) had a positive correlation with FWT in groups I and II, but not in group III. These correlations were also present using much simpler methodologies: replacement of CR-K(+) by mass transfer area coefficient (MTAC)-K(+)/MTAC-creatinine ratio or dialysate over plasma (D/P)-K(+)/D/P-creatinine ratio and replacement of FWT by Na(+)-sieving. No relationship with CA125 was present. CONCLUSIONS: This study shows that other than diffusive and convectional, K(+) transport is not excluded in patients treated with conventional glucose-based PD solutions. We found evidence for release of K(+) from cells. In general, CR-K(+) was related to parameters of FWT, except for long-term patients with UFF. This suggests glucose-induced hypertonic cell shrinkage as a basic physiological phenomenon during PD. The absence of this relationship in long-term PD patients with UFF either suggests a reduction or inhibition of K(+)-channels and may be due to another mechanism than AQP-1 dysfunction. Most likely, CR-K(+) in UFF does not reflect apoptosis. However, the D/P-K(+)/D/P-creatinine ratio may be useful in detecting peritoneal change