icodextrin and Hypertension

Approximately 7%-10% of patients with ESKD worldwide undergo peritoneal dialysis (PD) as kidney replacement therapy. The continuous nature of this dialytic modality and the absence of acute shifts in pressure and volume parameters is an important differentiation between PD and in-center hemodialysis. However, the burden of hypertension and prognostic association of BP with mortality follow comparable patterns in both modalities. Although management of hypertension uses similar therapeutic principles, long-term preservation of residual diuresis and longevity of peritoneal membrane function require particular attention in the prescription of the appropriate dialysis regimen among those on PD. Dietary sodium restriction, appropriate use of icodextrin, and limited exposure of peritoneal membrane to bioincompatible solutions, as well as adaptation of the PD regimen to the peritoneal transport characteristics, are first-line therapeutic strategies to achieve adequate volume control with a potential long-term benefit on technique survival. Antihypertensive drug therapy is a second-line therapeutic approach, used when BP remains unresponsive to the above volume management strategies. In this article, we review the available evidence on epidemiology, diagnosis, and treatment of hypertension among patients on PD and discuss similarities and differences between PD and in-center hemodialysis. We conclude with a call for randomized trials aiming to elucidate several areas of uncertainty in management of hypertension in the PD population.

Topics: Angiotensin-Converting Enzyme Inhibitors; Blood Pressure; Body Water; Dialysis Solutions; Diet, Sodium-Restricted; Diuretics; Humans; Hypertension; Icodextrin; Kidney Failure, Chronic; Mortality; Peritoneal Dialysis, Continuous Ambulatory; Prevalence; Renal Dialysis

Cardiovascular disease remains the leading cause of death in ESRD patients related to long-standing hypertension. Early studies had recognized the favourable effect of PD in controlling hypertension but it was soon realized that such benefit was not sustained. A U shaped trend of hypertension in patients on PD has been recently demonstrated as a result of a steadily increased blood pressure partly attributed to fluid retention resulting from lower sodium removal with time. Effort in selecting the best strategy of ultrafiltration for a single patient along with a careful and frequent monitoring of combined 24 hours sodium elimination coupled with dietician counseling can improve significantly fluid an sodium balance which in turn will result in much better blood pressure control. The contribution of progress in biocompatibility of PD fluid that better preserve renal function and the implementation of the first glucose polymer Icodextrin were key interventions in that aim. Further studies should be conducted to assess the power of innovative PD solutions--Low Sodium PDF and/or Bimodal Ultrafiltration--in enhancing fluid and sodium removal during CAPD/APD programmes.

Topics: Blood Pressure; Blood Pressure Monitoring, Ambulatory; Cardiovascular Diseases; Dialysis Solutions; Glucans; Glucose; Humans; Hypertension; Icodextrin; Kidney Failure, Chronic; Peritoneal Dialysis; Peritoneal Dialysis, Continuous Ambulatory; Sodium; Treatment Outcome; Ultrafiltration; Water-Electrolyte Balance

This paper reviews the most recent clinical data on the volume status of long-term peritoneal dialysis (PD) patients. It appears that many PD patients are volume overloaded, associated with a high prevalence of hypertension and left ventricular hypertrophy. In the presence of the poor results in patients with peritoneal ultrafiltration, the introduction of the polyglucose solution, icodextrin, has ameliorated volume control in some of these patients. In a second part of the review, some of the structural and functional alterations in the peritoneal membrane and the role of glucose degradation products (GDP) in the commonly used dialysates as well as the resulting formation of advanced glycation end products are described. The introduction of low GDP-containing solutions at normal pH has at least in experimental models of PD attenuated the hemodynamic changes observed with the classical solutions. The solutions at normal pH containing either bicarbonate or a mixture of bicarbonate/lactate were clinically associated with less inflow pain.

Topics: Acidosis; Bicarbonates; Blood Volume; Double-Blind Method; Glucans; Glucose; Glycation End Products, Advanced; Hemodialysis Solutions; Humans; Hypertension; Hypertrophy, Left Ventricular; Icodextrin; Kidney Failure, Chronic; Lactates; Multicenter Studies as Topic; Pain; Peritoneal Dialysis; Peritonitis; Randomized Controlled Trials as Topic; Sodium; Treatment Failure

Cardiovascular disease is a leading cause of death in patients with chronic kidney disease. Recent evidence suggests that hypertension and subclinical volume expansion is common in patients on peritoneal dialysis. Moreover, recent studies pointed out that sodium removal is limited in patients on peritoneal dialysis and mortality has been shown to co-relate with fluid and sodium removal. Treatment of sodium and fluid removal includes dietary salt and fluid restriction, use of diuretics, icodextrin, strategies also considered helpful to control hypertension. Despite availability of these measures, prevalence of hypertension remains high in PD patients. Hence, innovative strategies are urgently required to address this common and difficult clinical problem. This article reviews limitations of available measures to manage sodium and fluid overload and hypertension and suggests possible role and place of low sodium dialysis solutions in PD patients.

Topics: Antihypertensive Agents; Diet, Sodium-Restricted; Diuretics; Glucans; Glucose; Hemodialysis Solutions; Humans; Hypertension; Icodextrin; Peritoneal Dialysis; Sodium; Water-Electrolyte Imbalance

Cardiovascular disease is a leading cause of death in patients with end-stage renal disease (ESRD), and hypertension and volume expansion are highly prevalent in long-term peritoneal dialysis (PD) patients. The ADEMEX study made it clear that increased small-solute clearance does not lead to better outcomes. To manage the problem, current clinical practice uses strategies of dietary salt and fluid restriction, diuretics, antihypertensive drugs, icodextrin, extra day dwells, and (as a last resort) PD combined with hemodialysis (HD) or switch to HD. Nevertheless, the prevalence of hypertension remains alarmingly high. In this article, we briefly discuss the therapeutic measures currently available for treating hypertension and volume overload in PD patients, the limitations of those measures, and the possibility of increasing sodium removal by reducing the dialysate sodium level.

Topics: Antihypertensive Agents; Diet, Sodium-Restricted; Diuretics; Glucans; Glucose; Hemodialysis Solutions; Humans; Hypertension; Icodextrin; Kidney Failure, Chronic; Peritoneal Dialysis; Sodium

Little is known about the haemodynamic effects of continuous ambulatory peritoneal dialysis (CAPD) despite its widespread use in the management of end-stage renal failure. We undertook a study to delineate the haemodynamic effects of CAPD using glucose-containing fluids (1.36 and 3.86% glucose) and icodextrin.. Eight CAPD patients were recruited for a prospective crossover study. Patients attended for two investigatory days (in random order). CAPD was carried out using 1.36% followed by 3.86% glucose (buffered with lactate/bicarbonate, Physioneal) on one study day and 1.36% glucose followed by 7.5% icodextrin (Extraneal) on the other day. Dwell times were 150 min. Blood pressure (BP) and a full range of haemodynamic variables including pulse (HR), stroke volume (SV), cardiac output (CO) and total peripheral resistance (TPR) were measured non-invasively using continuous arterial pulse wave analysis.. BP was significantly higher during 3.86% glucose dwells as compared with 1.36% glucose or icodextrin dwells (P<0.0001). TPR during all three dwells was similar; the higher blood pressure was due to an increased HR, SV and, therefore, CO during 3.86% glucose dwells. The higher blood pressure during the 3.86% glucose dwells was present despite the highest ultrafiltration volume and sodium removal.. This study demonstrates large magnitude haemodynamic changes in response to CAPD. In addition to the well-recognized adverse effects on blood glucose and long-term peritoneal membrane viability, CAPD fluids containing high glucose concentrations may also exert undesirable effects on systemic haemodynamics, with potential long-term consequences for patient outcomes.

Topics: Aged; Aged, 80 and over; Cross-Over Studies; Diabetes Mellitus, Type 2; Female; Glucans; Glucose; Hemodialysis Solutions; Hemodynamics; Humans; Hypertension; Icodextrin; Kidney Failure, Chronic; Male; Middle Aged; Peritoneal Dialysis, Continuous Ambulatory

Hypertension is common in peritoneal dialysis (PD) patients and associated with adverse outcomes. Besides solute clearance, PD convective clearance is used to control extracellular water (ECW) volume and sodium balance. Previous studies have reported on hypertension in PD patients treated with continuous ambulatory peritoneal dialysis (CAPD) using hypertonic glucose dialysates. However, increasing numbers of PD patients are now treated with automated peritoneal dialysis (APD) and icodextrin dialysates. As such, we wished to explore factors associated with systolic blood pressure (SBP) in a modern cohort to identify targets to improve blood pressure control in PD patients.. We retrospectively reviewed the results from PD patients attending for peritoneal membrane assessment who had corresponding bioimpedance ECW and brain natriuretic peptide (NT-proBNP) measurements.. We studied 510 PD patients: 317 (72.2%) male, 216 (42.4%) diabetics, median age 59 (47-72) years, and 51% treated by APD with a day-time icodextrin exchange. Mean systolic blood pressure (SBP) was 140 ± 24.8 mmHg. SBP was independently associated with 4-hour dialysate to plasma creatinine ratio (β = 29.5 (95% confidence limits 11.4-47.5, p = 0.001), N-terminal brain natriuretic peptide [β = 11.9 (7.2-16.7), p < 0.001], and daily urine sodium excretion [β = 1.7 (1.0-2.3), p < 0.001].. In the era of APD cyclers and icodextrin, SBP is associated with increased NT-proBNP, a marker of ECW expansion, and faster peritoneal transport, a risk factor for a positive sodium balance, and increased urinary sodium suggestive of higher dietary sodium intake. Patients should be encouraged to restrict sodium intake and PD prescriptions targeted to control ECW to improve SBP control.

Topics: Aged; Dialysis Solutions; Extracellular Fluid; Female; Humans; Hypertension; Icodextrin; Kidney Failure, Chronic; Male; Middle Aged; Peritoneal Dialysis; Retrospective Studies

Psoriasis vulgaris is not frequently seen in patients with renal replacement therapy, especially in patients on peritoneal dialysis. Dialysis also has been reported to improve psoriatic skin lesions with a much higher response rate for peritoneal dialysis than haemodialysis. Conversely, we present a case of a man who developed psoriasis after 16 months of peritoneal dialysis. Discontinuation of icodextrin as a possible factor provoking systemic inflammation had no impact on the course of the disease. In this report, we review the existing studies and counsel caution against optimistic expectations of benefits from dialysis in patients with psoriasis.

Topics: Administration, Topical; Dialysis Solutions; Emollients; Glucans; Glucocorticoids; Glucose; Humans; Hypertension; Icodextrin; Male; Middle Aged; Peritoneal Dialysis; Psoriasis; Renal Insufficiency, Chronic; Treatment Outcome