Dialysis
Clinical Benefits of Low-glucose Peritoneal Dialysis Fluid Regimens Pieter M ter Wee
Internist in Nephrology and Professor, Department of Nephrology, VU University Medical Centre, Amsterdam
Abstract
Peritoneal dialysis (PD) is advantageous in the treatment of patients with chronic kidney failure, providing much greater freedom and flexibility than conventional haemodialysis systems, and is more suitable for out-patient use at home. Significant on-going concerns over PD, however, are infections at both the exit site and peritoneal cavity and loss of ultrafiltration capacity in the peritoneal membrane. These problems, particularly loss of ultrafiltration, arise mainly as a result of prolonged exposure to dialysate glucose and its degradation products. Strategies to address this problem include the use of dialysis therapy regimens that contain lower levels of glucose and, in particular, the glucose-based polymer icodextrin and have improved survival in clinical use. Other alternatives are to use dialysis solutions based on amino acids or biocompatible glucose-based fluids, which have shown various advantages in animal studies. Another approach is to use dialysis regimens that combine the use of icodextrin-, amino acid- and biocompatible glucose-based solutions. This combination is promising and appears to be clinically effective and safe, but its value in terms of some aspects of dialytic and cardiovascular function is not yet clear. Further evidence from clinical studies is therefore needed to confirm the clinical benefits of low-glucose therapy regimens in PD.
Keywords Peritoneal dialysis, low-glucose fluids, icodextrin, amino acid, biocompatible glucose-based solutions, chronic kidney disease
Disclosure: Pieter M ter Wee has received research grants from Baxter, is a consultant for Baxter on the IMPENDIA trial data and has served on advisory boards for Amgen, MSD and Roche. Received: 28 January 2012 Accepted: 2 March 2012 Citation: European Nephrology, 2012;6(1):48–52 Correspondence: Pieter M ter Wee, Department of Nephrology, VU University Medical Centre, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands. E:
pm.terwee@vumc.nl
Support: The publication of this article was funded by Baxter Healthcare SA. The views and opinions expressed are those of the author and not necessarily those of Baxter Healthcare SA.
Peritoneal dialysis (PD) has proved to be a valid and useful renal replacement therapy for patients with chronic kidney failure and has, at least during the first years of therapy, a similar outcome to chronic intermittent haemodialysis.1–3
It has the advantage of being a
home-based therapy that gives patients mobility and considerable freedom and can fit around an individual patient’s daily routine. The two most important drawbacks of this renal replacement modality are risk of infection at the exit site and the peritoneal cavity and risk of loss of ultrafiltration capacity of the peritoneal membrane, so-called ultrafiltration failure. The latter results from morphological changes in the peritoneal membrane that occur over time during PD, as demonstrated in biopsy registry studies.4
Such changes are also
found in animal studies, most frequently in rats, in which the peritoneal cavity has been exposed to peritoneal dialysis fluid (PDF). Such models are especially useful to discern the contribution that the different constituents of the PDF have on the changes in the peritoneal membrane. Thus it has been demonstrated that the traditional glucose-containing PDFs cause damage, not only because of the high glucose content but also because of the low pH and high concentrations of glucose degradation products (GDPs).5,6
Indeed, the
newer so-called biocompatible PDFs, characterised by lower concentrations of GDPs and a more biocompatible pH, cause less morphological damage in these animal models.7
Likewise, PDFs that contain another osmotic agent instead of glucose, either amino 48
acid-based or glucose polymer-based, have been shown to be less detrimental to the peritoneal membrane.8
Therefore, PD regimens in
which these newer solutions have been combined could be of potential clinical benefit. In this article, the results of clinical studies that used PD regimens with reduced glucose exposure are discussed. Firstly, studies in which glucose-based regimens are combined with the glucose polymer-based solution icodextrin are discussed. Secondly, studies on the application of an amino acid-based solution are presented. Then, results on studies that cover a regimen with as little glucose and GDP content as possible are reviewed. Finally, some results and possible benefits of combining PD and haemodialysis are discussed.
Icodextrin
Icodextrin is an iso-osmolar glucose polymer-based solution used for long dwell times that results in reduced glucose exposure at the peritoneal membrane during the night dwell in continuous ambulatory peritoneal dialysis (CAPD) and during the daytime dwell in continuous cycling peritoneal dialysis (CCPD). It has been proven to provide better and sustained ultrafiltration compared with glucose-based solutions for the long dwell during CAPD9 CCPD.10–12
and
This effect can be seen in patients with reduced peritoneal membrane transport function, as well as in those with elevated transport function,13
although the most benefit is obtained © TOUCH BRIEFINGS 2012
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