icodextrin and Anuria

The development of APD technologies enables physician to customize PD treatment for optimal dialysis. Dialysis dose can be increased with APD alone or in conjunction with daytime dwells. Although there is no strong evidence of the advantage over CAPD, APD is generally recommended for patients having a high peritoneal transport, outflow problems or high intraperitoneal pressure (IPP) and those who depend on caregivers for their dialysis. The benefits of APD over CAPD depends on the problems and treatment results among dialysis centers. Before starting the APD, medical, psychosocial and financial aspects, catheter function, residual renal function (RRF), body surface area and peritoneal transport characteristic must be evaluated. The recommended starting prescription for APD is the dwell volume of 1,500 ml/m2, 2 hours/cycle, and 5 cycles/session, which will provides 10-15 L of total volume and 10 hours per session. The IPP should be monitored and kept below 18 cmH2O. NIPD is accepted for patients with significant RRF. Anuric patients usually require 15-20 L of total fill volume and may need 1-2 day-dwells of 2L icodextrin or hypertonic glucose solutions. Small solute clearances and ultrafiltration depend on the peritoneal catheter function and dialysis schedule. The clinical outcomes and small solute clearances must be monitored and adjusted accordingly to meet the weekly total Kt/V urea > or = 1.7 and in low peritoneal transporters, the weekly total CCr should be > or = 45 L/1.73 m2. The volume status must be normal. To diagnose the peritonitis in NIPD patients, 1 L of PDF should be infused and permitted to dwell for 2 hours before sending for analysis. The differential of white cell count may be more useful than the total cell counts. In Siriraj Hospital, APD patients had 1.5-3 times less peritonitis than CAPD patients and most of our anuric patients can achieve the weekly total Kt/V urea target with 10 L of NIPD.

Topics: Anuria; Biological Transport; Body Surface Area; Creatinine; Dialysis Solutions; Dose-Response Relationship, Drug; Glucans; Glucose; Humans; Icodextrin; Kidney Failure, Chronic; Peritoneal Dialysis; Peritoneum; Practice Guidelines as Topic; Urea

Peritoneal dialysis is associated with changes in membrane function that can lead eventually to ultrafiltration (UF) failure. Factors driving these changes are thought to include hypertonic glucose exposure, but previously reported associations are confounded by the presence of residual renal function.. Longitudinal membrane function (solute transport and UF capacity) were measured annually in a prospective cohort of 177 functionally anuric patients as part of the European Automated Peritoneal Dialysis Outcomes Study (EAPOS). Subgroup analysis was performed according to glucose exposure and icodextrin use at baseline.. The whole cohort experienced an increase in solute transport and reduction in UF capacity at 12 and 24 months that could not be explained by informative censoring. These changes were accelerated and more severe in patients using either 2.27% or 3.86% glucose, or those not using icodextrin at baseline. These differences could not be explained by age, comorbidity score, previous time spent on renal replacement, differential dropout from the study, peritonitis rates, or, by definition, residual renal function. Patients using icodextrin at baseline had worse membrane function and were more likely to be diabetic. There was an association between membrane function changes and achieved 24-hour ultrafiltration over the 2-year study period.. Anuric automated peritoneal dialysis (APD) patients experience significant detrimental changes in membrane function over a relatively short time period. Glucose appears to enhance these changes independent of residual renal function. Icodextrin use in these circumstances is associated with less deterioration in membrane function.

Topics: Anuria; Automation; Female; Glucans; Glucose; Hemodialysis Solutions; Humans; Icodextrin; Male; Membranes, Artificial; Middle Aged; Multicenter Studies as Topic; Peritoneal Dialysis; Ultrafiltration

Using changes in cell counts and levels of cancer antigen 125 (CA125), fibrinogen degradation product (FDP), and interleukin-6 (IL-6) in effluent before and after the use of icodextrin-based peritoneal dialysis solution (icodextrin), we evaluated the effects of icodextrin on peritoneal membrane. The subjects were 8 anuric patients (4 men, 4 women) who had been using a 2.5% glucose-based dialysis solution (glucose solution) for the overnight dwell. The mean age of the patients was 57.9 +/- 6.1 years, and their mean duration of continuous ambulatory peritoneal dialysis was 61.6 +/- 44.3 months. In all patients, chronic glomerulonephritis was the cause of end-stage renal disease. We changed the 2.5% glucose solution used for the 8-hour dwell to an icodextrin, and we compared cell counts in effluent and levels of IL-6, FDP, and CA125 in the overnight effluent before, and 12 and 36 weeks after, the switch to the icodextrin. When 2.5% glucose solution was used for the overnight 8-hour dwell, the mean cell count in the effluent was 5.5 +/- 3 cells/mm3. However, 12 and 36 weeks after the start of icodextrin, mean cell counts in effluent were significantly increased to 15.3 +/- 7.7 cells/mm3 (p < 0.01) and 16.5 +/- 11.2 cells/mm3 (p < 0.01) respectively. Values of effluent CA125, FDP, and IL-6 obtained during the use of a glucose solution were compared to values obtained 12 and 36 weeks after the start of icodextrin. Effluent levels of CA125 and IL-6 did not vary before and after the use of the icodextrin, but levels of FDP in the icodextrin effluent were higher than the levels found in the effluent of a 2.5% glucose solution (7278.8 +/- 2915 ng/mL before the start of icodextrin; 29,875 +/- 13,227 ng/mL 12 weeks after icodextrin introduction, p < 0.01; and 12,062.9 +/- 5684.6 ng/mL 36 weeks after icodextrin introduction). Icodextrin induced a subclinical inflammatory response in the peritoneum. Therefore, biocompatibility of an icodextrin solution is not always superior to that of a glucose solution, and further research is needed to clarify the influence of long-term icodextrin use on the peritoneum.

Topics: Anuria; CA-125 Antigen; Cell Count; Eosinophils; Female; Fibrin Fibrinogen Degradation Products; Glucans; Glucose; Hemodialysis Solutions; Humans; Icodextrin; Interleukin-6; Leukocyte Count; Male; Middle Aged; Peritoneal Dialysis, Continuous Ambulatory; Peritoneum

In the present study, we evaluated peritoneal transport characteristics during the use of icodextrin-based peritoneal dialysis (PD) solution, determining ultrafiltration (UF) and dialysate-to-plasma creatinine (D/P(Cr)) in a peritoneal equilibration test (PET). The subjects of the study were 8 anuric patients who, at the time of enrollment into the study, were receiving continuous ambulatory peritoneal dialysis (CAPD) and using a 2.5% glucose-based dialysis solution overnight. The mean age of the patients was 57.9 +/- 6.1 years (range: 45.2 - 64.1 years), and their mean duration of CAPD was 61.6 +/- 44.3 months (range: 5.6 - 140.1 months). We changed the 2.5% glucose solution that the patients were using for the 8-hour overnight dwell to icodextrin and measured the resulting UF. We also performed a PET before and 12 weeks after the start of icodextrin. After the start of icodextrin, PETs were carried out immediately after the icodextrin dwell; after rinsing twice with 2.5% glucose solution following an icodextrin dwell; and after an 8-hour dwell with glucose solution. The UF for 8-hour dwells increased significantly 12 weeks after the start of icodextrin (356.3 +/- 102.9 mL with 2.5% glucose at baseline vs. 517.5 +/- 102.8 mL with icodextrin, p < 0.001). However, the daily total UF was unchanged after the start of icodextrin (924.3 +/- 281.3 mL vs. 934.6 +/- 263.4 mL). As compared with the D/P(Cr) before the start of icodextrin, the D/P(Cr) after the start of icodextrin was significantly increased immediately after an icodextrin dwell (0.57 +/- 0.1 vs. 0.63 +/- 0.1, p < 0.01) and after twice rinsing with 2.5% glucose solution following an icodextrin dwell (0.57 +/- 0.1 vs. 0.66 +/- 0.2, p < 0.01). However, before or after the start of icodextrin, the D/P(Cr) after an 8-hour dwell with glucose solution did not change (0.57 +/- 0.1 vs. 0.57 +/- 0.1, p < 0.01). The D/P(Cr) measured in a PET was high immediately after a dwell with icodextrin. Those results may reflect an effect of icodextrin on the small pores. Before a PET, dialysis should be performed using a glucose solution.

Topics: Anuria; Biological Transport; Creatinine; Female; Glucans; Glucose; Hemodialysis Solutions; Humans; Icodextrin; Male; Middle Aged; Peritoneal Dialysis, Continuous Ambulatory; Peritoneum; Permeability; Ultrafiltration