Identification of the Factors Associated With Intraperitoneal Pressure in ADPKD Patients Treated With Peritoneal Dialysis

Introduction

Peritoneal dialysis (PD) is reported to be underused in the autosomal dominant polycystic kidney disease (ADPKD) population because doctors fear technical failure caused by reduced abdominal space and high intraperitoneal pressure (IPP).

Methods

We designed a multicenter retrospective study to be carried out in 15 French centers recruiting 60 patients with ADPKD treated with PD to identify factors associated with IPP. Inclusion criteria were start of PD between 2010 and 2017, available tomodensitometry, and IPP measurement in the first year of dialysis. The clinical and radiological data for each patient were reviewed by the same operator. Total kidney volume (TKV), liver volume, and the volume of the abdominal cavity were measured using contouring.

Results

TKV and the volume of the abdominal cavity in women and men were, respectively, 2397 ml versus 3758 ml and 9402 ml versus 12,920 ml. In the univariate analysis, IPP was significantly and positively associated with body surface area (P = 0.0024), body mass index (BMI) (P < 0.0001), the volume of the abdominal cavity (P = 0.0005), and the volume of the dialysate infused in the peritoneal cavity (IPV) (P = 0.0108). In the multivariate analysis, only BMI was still significantly associated with IPP (P = 0.0004)

Conclusions

Our results identified BMI as the main factor linked to IPP in patients with ADPKD. Despite a reliable assessment of the volume of their organs we did not find any correlation between liver and kidney volumes and IPP. To our knowledge, this is the first study designed to identify factors associated with IPP in patients with ADPKD on PD.

Clinical Relevance of Intraperitoneal Pressure in Peritoneal Dialysis Patients

Introduction

Intraperitoneal pressure (IPP) in peritoneal dialysis (PD) increases in sitting and upright positions and is related to some individual characteristics. Adverse effects can appear with IPP > 20 cm H2O. Few studies about peritoneal transport or abdominal wall problems have directly measured IPP. We measured IPP in our prevalent PD patients to identify the clinical factors related to its variability and its possible association with peritoneal transport and abdominal wall complications.

Methods

We performed a retrospective, observational study of our stable PD patients. Intraperitoneal pressure was measured using the Durand's method in supine, sitting, and upright position.

Results

Forty-nine patients were included, 70% males, mean age 61.1 ± 15 years, body mass index (BMI) 27.9 ± 5.2 kg/m2. The mean of supine IPP was 18.0 ± 4.4 cm H2O. Intraperitoneal pressure in sitting and upright positions were similar and higher than in supine. Supine IPP showed a positive correlation with BMI ( p < 0.0005) and comorbidity ( p < 0.05). A multivariate linear regression analysis showed that BMI and comorbidity ( p < 0.005) had a positive correlation with IPP; time on PD and daily total ultrafiltration (UF) (p < 0.005) showed a negative correlation. Patients with an IPP ≥ 20 cm H2O had more hernias (35% vs 17%) and leakages (21% vs 8%) without statistical significance.

Conclusion

Our supine IPPs were higher than others published in adults. Intraperitoneal pressure has an individual value associated with body size. Greater IPP was correlated with lower daily total UF and more hernias and leakages. The measurement of IPP is a simple technique and can help with PD prescription, especially in obese patients.

Intraperitoneal pressure in peritoneal dialysis

The measure of intraperitoneal pressure in peritoneal dialysis is easy and provides clear therapeutic benefits. However it is measured only rarely in adult peritoneal dialysis units. This review aims to disseminate the usefulness of measuring intraperitoneal pressure. This measurement is performed in supine before initiating the drain of a manual exchange with "Y" system, by raising the drain bag and measuring from the mid-axillary line the height of the liquid column that rises from the patient. With typical values of 10-16 cmH₂O, intraperitoneal pressure should never exceed 18 cmH₂O. With basal values that depend on body mass index, it increases 1-3 cmH₂O/L of intraperitoneal volume, and varies with posture and physical activity. Its increase causes discomfort, sleep and breathing disturbances, and has been linked to the occurrence of leaks, hernias, hydrothorax, gastro-esophageal reflux and enteric peritonitis. Less known and valued is its ability to decrease the effectiveness of dialysis significantly counteracting ultrafiltration and decreasing solute clearance to a smaller degree. Because of its easy measurement and potential utility, should be monitored in case of ultrafiltration failure to rule out its eventual contribution in some patients. Although not yet mentioned in the clinical practice guidelines for PD, its clear benefits justify its inclusion among the periodic measurements to consider for prescribing and monitoring peritoneal dialysis.