1
|
Affiliation(s)
- Raymond T. Krediet
- Division of Nephrology, Department of Medicine, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Bengt Lindholm
- Department of Clinical Science, Karolinska Institute, Division of Baxter Novum, Huddinge University Hospital, Huddinge, Lund, Sweden
| | - Bengt Rippe
- Department of Nephrology, University Hospital of Lund, Lund, Sweden
| |
Collapse
|
2
|
Ronco C, Feriani M, Chiaramonte S, Brendolan A, Bragantini L, Conz P, Dell'Aquila R, Milan M, La Greca G. Pathophysiology of Ultrafiltration in Peritoneal Dialysis. Perit Dial Int 2020. [DOI: 10.1177/089686089001000201] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Pathophysiology of peritoneal ultrafiltration is analyzed in the present study. Peritoneal equilibration test is the easiest procedure to study in detail the possible causes of failure to control the ultrafiltration rate in patients undergoing peritoneal dialysis. Membrane failure, reduction in peritoneal blood flow, excessive lymphatic reabsorption catheter malposition, and fluid sequestration are the most common causes of ultrafiltration loss. Pharmacologic manipulation of peritoneal membrane, correction of mechanical inconvenients, reduction in peritonitis rate and in the level of immunostimulation of the mesotelial macrophages, together with a careful policy in terms of glucose concentration in the dialysate and dwell times may contribute not only to treat different forms of ultrafiltration loss but also to prevent their incidence.
Collapse
Affiliation(s)
- Claudio Ronco
- Department of Nephrology, St. Bortolo Hospital, Vicenza, Italy
| | - Mariano Feriani
- Department of Nephrology, St. Bortolo Hospital, Vicenza, Italy
| | | | | | | | - Piero Conz
- Department of Nephrology, St. Bortolo Hospital, Vicenza, Italy
| | | | - Massimo Milan
- Department of Nephrology, St. Bortolo Hospital, Vicenza, Italy
| | | |
Collapse
|
3
|
Zakaria ER, Spain DA, Harris PD, Garrison RN. Generalized Dilation of the Visceral Microvasculature by Peritoneal Dialysis Solutions. Perit Dial Int 2020. [DOI: 10.1177/089686080202200510] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives Conventional peritoneal dialysis solutions are vasoactive. This vasoactivity is attributed to hyperosmolality and lactate buffer system. This study was conducted to determine if the vasodilator property of commercial peritoneal dialysis solutions is a global phenomenon across microvascular levels, or if this vasodilation property is localized to certain vessel types in the small intestine. Design Experimental study in a standard laboratory facility. Interventions Hemodynamics of anesthetized rats were monitored while the terminal ileum was prepared for in vivo intravital microscopy. Vascular reactivity of inflow arterioles (A1), branching (A2), and arcade, as well as pre-mucosal (A3) arterioles was assessed after suffusion of the terminal ileum with a non-vasoactive solution or a commercial 4.25% glucose-based solution (Delflex; Fresenius USA, Ogden, Utah, USA). Vascular reactivity of three different level venules was also assessed. Maximum dilation response was obtained from sequential applications of the endothelial-dependent dilator, acetylcholine (10–5 mol/L), and the endothelial-independent nitric oxide donor, sodium nitroprusside (NTP; 10–4mol/L). Results Delflex induced an instant and sustained vasodilation that averaged 28.2% ± 2.4% of baseline diameter in five different-level arterioles, ranging in size between 7 μ and 100 μ. No significant vascular reactivity was observed in three different-level venules. Delflex increased intestinal A1 blood flow from baseline 568 ± 31 nL/second to 1049 ± 46 nL/sec ( F = 24.7, p < 0.001). Similarly, intestinal venous outflow increased to 435 ± 17 nL/sec from a baseline outflow of 253 ± 59 nL/sec ( F = 4.7, p < 0.05). Adjustment of the initial pH of Delflex from 5.5 to 7.4 resulted in similar microvascular responses before pH adjustment. Conclusions Ex vivo exposure of intestinal arterioles to conventional peritoneal dialysis solutions produces a sustained and generalized vasodilation. This vasoactivity is independent of arteriolar level and the pH of the solution. Dialysis solution-mediated vasodilation is associated with doubling of A1 intestinal arteriolar blood flow. Addition of NTP at an apparent clinical dose does not appear to produce any further significant arteriolar dilation than that induced by dialysis solution alone. Experimental data that estimate the exchange vessel surface area per unit volume of tissue will be required to make a correlation with permeability in order to extrapolate our findings to clinical in vivo conditions.
Collapse
Affiliation(s)
| | - David A. Spain
- Surgery, University of Louisville Louisville, Kentucky, USA
- Veterans Affairs Medical Center, Louisville, Kentucky, USA
| | | | - R. Neal Garrison
- Surgery, University of Louisville Louisville, Kentucky, USA
- Veterans Affairs Medical Center, Louisville, Kentucky, USA
| |
Collapse
|
4
|
Handa SP, Scarth H. Hemorrhagic Luteal Cyst with Massive Hemoperitoneum in a Patient on Capd. Perit Dial Int 2020. [DOI: 10.1177/089686089301300115] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- S. P. Handa
- Division of Nephrology Saint John Regional Hospital Saint John, New Brunswick
| | - H. Scarth
- Department of Surgery Saint John Regional Hospital Saint John, New Brunswick
| |
Collapse
|
5
|
Goodkin DA, Benning MG. An Outpatient Maneuver to Treat Bloody Effluent during Continuous Ambulatory Peritoneal Dialysis (CAPD). Perit Dial Int 2020. [DOI: 10.1177/089686089001000308] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Asymptomatic episodes of grossly bloody effluent during continuous ambulatory peritoneal dialysis (CAPD) can be treated by following a simple therapeutic maneuver. The patient performs one to three rapid exchanges using unwarmed (room temperature), 1.5% dextrose containing dialysate. No dwell time is employed. This treatment proves successful in a variety of clinical settings, and no adverse effects have been noted. Infusion of unwarmed dialysate likely induces peritoneal vasoconstriction and thus favors hemostasis. Bleeding of nonperitoneal etiology, such as renal cyst hemorrhage or retrograde menstruation, proves resistant.
Collapse
Affiliation(s)
| | - Mary G. Benning
- Houston Northwest Medical Center Dialysis Unit, Houston, Texas
| |
Collapse
|
6
|
Zakaria ER, Patel AA, Li N, Matheson PJ, Garrison RN. Vasoactive Components of Dialysis Solution. Perit Dial Int 2020. [DOI: 10.1177/089686080802800316] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BackgroundConventional peritoneal dialysis (PD) solutions elicit vasodilation, which is implicated in the variable rate of solute transport during the dwell. The components causing such vasoactivity are still controversial. This study was conducted to define the vasoactive components of conventional and new PD solutions.MethodsThree visceral peritoneal microvascular levels were visualized by intravital video microscopy of the terminal ileum of anesthetized rats. Anesthesia-free decerebrate conscious rats served as control. Microvascular diameter and blood flow by Doppler measurements were conducted after topical peritoneal exposure to 4 clinical PD solutions and 6 prepared solutions designed to isolate potential vasoactive components of the PD solution.ResultsAll clinically available PD solutions produced a rapid and generalized vasodilation at all intestinal microvascular levels, regardless of the osmotic solute. The pattern and magnitude of this dilation was not affected by anesthesia but was determined by arteriolar size, the osmotic solute, and the solution's buffer anion system. The greatest dilation occurred in the small precapillary arterioles and was elicited by conventional PD solution and heat re-sterilized solution containing low glucose degradation products (GDPs). Hypertonic mannitol solutions produced a dilation that was approximately 50% less than the dilation obtained with glucose solutions with identical osmolarity and buffer. Increasing a solution's osmolarity did not produce a parallel increase in the magnitude of dilation, suggesting a nonlinear relationship between the two variables. Lactate dissolved in an isotonic solution was completely non-vasoactive unless the solution's H+concentration was increased. At low pH, isotonic lactate produced a rapid but transient vasodilation. This vascular reactivity was similar in magnitude and pattern to that obtained with the isotonic 7.5% icodextrin solution (Extraneal; Baxter Healthcare, Deerfield, Illinois, USA).Conclusions( 1 ) Hyperosmolarity is the major vasoactive component of PD solution. ( 2 ) Hyperosmolarity and active intracellular glucose uptake account together for approximately 75% of PD solution-induced dilation, whereas GDPs contribute to approximately 25%. ( 3 ) Lactate is vasoactive only at low pH (high [H+]). ( 4 ) The magnitude of PD solution-mediated vasodilation is partially dependent on the nature of the osmotic solute, the GDP contents, and the [H+], which determine the vasoactivity of the lactate-buffer anion system. Studies are required to define the molecular mechanisms of PD-induced vasodilation and to determine the vasoactive properties of these solutions after chronic infusion.
Collapse
Affiliation(s)
| | - Anuj A. Patel
- Department of Physiology and Biophysics Louisville, Kentucky, USA
| | - Na Li
- Department of Physiology and Biophysics Louisville, Kentucky, USA
| | - Paul J. Matheson
- Department of Surgery, University of Louisville Louisville, Kentucky, USA
| | - Richard N. Garrison
- Department of Physiology and Biophysics Louisville, Kentucky, USA
- Department of Surgery, University of Louisville Louisville, Kentucky, USA
- Veterans Affairs Medical Center, Louisville, Kentucky, USA
| |
Collapse
|
7
|
Zakaria ER, Hunt CM, Li N, Harris PD, Garrison RN. Disparity in osmolarity-induced vascular reactivity. J Am Soc Nephrol 2005; 16:2931-40. [PMID: 16079269 PMCID: PMC1538639 DOI: 10.1681/asn.2004090764] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Conventional peritoneal dialysis solutions (PDS) are vasoactive. This study was conducted to identify vasoactive components of PDS and to describe quantitatively such vasoactivity. Anesthetized nonheparinized rats were monitored continuously for hemodynamics while the microvasculature of the jejunum was studied with in vivo intravital microscopy. In separate experiments, vascular reactivity of rat endothelium-intact and -denuded aortic rings (2 mm) was studied ex vivo in a standard tissue bath. In both studies, suffusion of the vessels was performed with filter-sterilized isotonic and hypertonic solutions that contained glucose or mannitol as osmotic agents. PDS served as a control (Delflex 2.25%). Hypertonic glucose and mannitol solutions produced a significant vascular reactivity in aortic rings and instantaneous and sustained vascular relaxation at all levels of the intestinal microvasculature. Similarly, lactate that was dissolved in a low-pH isotonic physiologic salt solution produced significant force generation in aortic rings. Whereas isotonic glucose and mannitol solutions had no vasoactivity in aortic rings, isotonic glucose produced a selective, insidious, and time-dependent vasodilation in the intestinal premucosal arterioles (18 +/- 0.2% of baseline), which was not observed in the larger inflow arterioles (100 mum). This isotonic glucose-mediated vascular relaxation can be attenuated by approximately 50% with combined adenosine A(2a) and A(2b) receptor antagonists and completely abolished by adenosine A(1) receptor inhibition. By using two different experimental techniques, this study demonstrates that hyperosmolality and lactate are the major vasoactive components of clinical peritoneal dialysis solutions. The pattern and the magnitude of such reactivity are dependent on vessel size and on the solutes' metabolic activity. Low pH of conventional PDS is not a vasoactive component by itself but renders lactate vasoactive. Energy-dependent transport of glucose into cells mediates vasodilation of small visceral arterioles by an adenosine receptor-mediated mechanism and constitutes a significant fraction of PDS-mediated vascular reactivity in the visceral microvasculature.
Collapse
Affiliation(s)
- El Rasheid Zakaria
- Department of Physiology and Biophysics, Health Sciences Center A-1115, University of Louisville, Louisville, KY 40292, USA.
| | | | | | | | | |
Collapse
|
8
|
Davenport A, Fernando RL, Robson R, Varghese Z. Nitric oxide production by human peritoneal mesothelial cells. Int J Artif Organs 2004; 27:15-23. [PMID: 14984179 DOI: 10.1177/039139880402700105] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Nitric oxide (NO) has multiple actions, ranging from immunomodulation to regulation of vascular tone and capillary flow. Thus NO generation within the peritoneum could potentially affect peritoneal transport by increasing capillary vasodilatation, and regulate the response to bacterial invasion. Peritoneal mesothelial cells have a common embryological derivation with endothelial cells. As mesothelial cells are the predominant cell type lining the peritoneal cavity, they could potentially be a major source of locally produced nitric oxide. Nitric oxide was measured using the Griess reaction, as total nitrite and nitrate, in fresh unused and spent dialysate effluent (SPDE) from both healthy peritoneal dialysis patients, and during episodes of bacterial peritonitis. Whereas fresh CAPD dialysate was nitrite free (5 +/- 0.1 microM), SPDE from a standard 4 h day time exchange contained 10.2 +/- 0.6 microM/L/h, and that from the overnight dwell 9.1 +/- 0.7 microM/L/h. During an episode of peritonitis, dialysate nitrite and nitrate increased significantly from 9.0 +/- 1.0 microM/L/h, when not infected to 17.5 +/- 2.4, from the first CAPD bag drained at presentation, and 15.2 +/- 1.8 for the second and 16.0 +/- 2.5 for the third exchange (p<0.01). By the following day nitrite levels had returned to baseline, 7.0 +/- 1.0 microM/L/h. Human peritoneal mesothelial cells (HPMC) were cultured and found to produce nitric oxide (261 nmol/mg cell protein), which increased in a dose dependent manner with the addition of spent uninfected CAPD dialysate. The addition of L-arginine, a NO substrate resulted in a 10% increase in nitric oxide production, whereas the addition of the blocker L-NMMA produced a 10% reduction. RNA for inducible nitric oxide synthase (iNOS) was sought using northern blotting technique following combination stimulation with lipopolysaccharide and cytokines (IL-1beta, TNFalpha and gamma-INF, and/or spent dialysate from patients with bacterial peritonitis). However, we could not demonstrate RNA production for iNOS. Peritoneal mesothelial cells may be an important source of locally generated nitric oxide within the peritoneal cavity under basal conditions, but as they do not contain iNOS, the markedly increased NO production observed with episodes of acute bacterial peritonitis is more likely due to a combination of increased NO production by peritoneal macrophages and endothelial cells.
Collapse
Affiliation(s)
- A Davenport
- Renal Research Laboratories, Centre for Nephrology, Royal Free Hospital, London, UK.
| | | | | | | |
Collapse
|
9
|
Douma CE, Hiralall JK, de Waart DR, Struijk DG, Krediet RT. Icodextrin with nitroprusside increases ultrafiltration and peritoneal transport during long CAPD dwells. Kidney Int 1998; 53:1014-21. [PMID: 9551412 DOI: 10.1111/j.1523-1755.1998.00821.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Addition of the nitric oxide (NO) donor nitroprusside to 1.36% glucose dialysate enlarges the effective peritoneal surface area during four-hour dwells. The theoretical positive effect on ultrafiltration is, however, counteracted by an increase in glucose absorption. The absorption of the glucose polymer icodextrin is much lower in comparison with glucose-based dialysis solutions, due to its high molecular weight. In the present study 7.5% icodextrin dialysis solution with and without the addition of 4.5 mg/liter nitroprusside was studied during eight-hour CAPD dwells. Two Standard Peritoneal permeability Analyses, adapted for eight-hour dwells, were performed in 10 stable CAPD patients. Nitrate and cGMP were measured as parameters of NO synthesis. The transcapillary ultrafiltration increased in a linear way with icodextrin (ICO) and was even higher after the addition of nitroprusside (NP): 666 (ICO) versus 834 (NP) ml/8 hr, P = 0.03. The effective lymphatic absorption rate was not different. The resulting net ultrafiltration increased with nitroprusside: 344 (ICO) versus 540 (NP) ml/8 hr, P < 0.01. The mass transfer area coefficient of urea increased 15% and that of creatinine 26% with nitroprusside, consistent with the expected enlargement of the vascular peritoneal surface area. The increase in protein clearances was more pronounced the larger the protein: beta 2-microglobulin 19%, albumin 47%, IgG 63% and alpha 2-macroglobulin 95%. Dialysate/plasma (D/P) ratios of nitrate were not higher than the expected values on the basis of its molecular weight (P < 0.001). They increased 19% with nitroprusside. Also, the D/P ratio cyclic guanosine monophosphate (cGMP) after four hours increased with nitroprusside (0.39, range 0.13 to 0.55 ICO, and 0.82, range 0.36 to 1.39 NP, P = 0.01). With nitroprusside the D/P ratio cGMP was higher than expected after four and eight hours (P < 0.001). This points to local generation of NO after addition of nitroprusside. The nitroprusside induced increase in the mass transfer area coefficients (MTAC) of creatinine and in the ultrafiltration caused an increase in the creatinine clearance from 4.2 ml/min to 5.0 ml/min during the eight-hour dwell. This means that nitroprusside adds 3 liters/week to the peritoneal clearance of creatinine. The adequacy of peritoneal dialysis can therefore be improved by the addition of nitroprusside to 7.5% icodextrin, used for the long exchange.
Collapse
Affiliation(s)
- C E Douma
- Department of Medicine, University of Amsterdam, The Netherlands
| | | | | | | | | |
Collapse
|
10
|
|
11
|
Abstract
The major restrictions to the transport of solute and solvent across the peritoneum are the limited peritoneal blood flow, area and permeability. Recent investigations have demonstrated that several vasoactive drugs influence transport parameters. Isoproterenol, nitroprusside, dipyridamole and dopamine exemplify drugs that dilate the splanchnic vasculature, thereby augmenting transport, whereas vasoconstriction induced by l-norepinephrine decreases clearances. The tissue prostaglandins affect peritoneal mass transport in accord with their known vasoactive effects, suggesting a role in modulating peritoneal blood flow. The gastrointestinal hormones vasodilate the splanchnic circulation. Exposure of the endothelial surface to glucagon markedly increases peritoneal mass transport, while secretin increases the ultrafiltration rate significantly. These preliminary studies suggest the possible future clinical use of drugs and hormones to augment the efficiency of peritoneal dialysis.
Collapse
|