The Removal of Uremic Solutes by Peritoneal Dialysis

ABSTRACT

Peritoneal dialysis (PD) is now commonly prescribed to achieve target clearances for urea or creatinine. The International Society for Peritoneal Dialysis has proposed however that such targets should no longer be imposed. The Society's new guidelines suggest rather that the PD prescription should be adjusted to achieve well-being in individual patients. The relaxation of treatment targets could allow increased use of PD. Measurement of solute levels in patients receiving dialysis individualized to relieve uremic symptoms could also help us identify the solutes responsible for those symptoms and then devise new means to limit their accumulation. This possibility has prompted us to review the extent to which different uremic solutes are removed by PD.

Mechanisms of Peritoneal Acid-Base Kinetics During Peritoneal Dialysis: A Mathematical Model Study

To investigate mechanisms of acid-base changes during peritoneal dialysis (PD), a mathematical model was developed that describes kinetics of peritoneal bicarbonate, CO2, and pH during the dwell with both high and low lactate-containing dialysis fluids. The model was based on a previous modification of the Rippe 3-Pore model of water and solute kinetic transport across the peritoneal membrane during the PD dwell. A central feature of the present modification is an electroneutrality constraint on peritoneal-fluid ion concentrations, which results in the conclusion that peritoneal bicarbonate-concentration kinetics are entirely dependent on the kinetics of the other ions. This new model was able to closely predict peritoneal bicarbonate-concentration kinetics during the dwell. Predictions of total peritoneal bicarbonate-mass kinetics were greater than those of porous, transmembrane bicarbonate transport, suggesting that a portion of bicarbonate comes from CO2 transport, both porous and nonporous and then a partial conversion to bicarbonate. Fitting the model to experimental pH data during the dwell, required addition of a peritoneal CO2 mass-conservation constraint, coupled with the description for peritoneal bicarbonate kinetics. Predicted pH kinetics during the dwell, closely mimicked the experimental data. The conclusion was that the mechanisms describing peritoneal bicarbonate and pH kinetics during PD must include 1) electroneutrality of peritoneal fluid, 2) porous transport of bicarbonate and CO2, 3) nonporous transport of CO2, and 4) CO2 conversion to bicarbonate. These mechanisms are quite different and more complex than the bicarbonate-centered, lactate to acid-generation mechanisms previously proposed.

Peritoneal physicochemical transport mechanisms: Hypotheses, models and controversies

This study answers criticisms by Waniewski et al. of the recent paper by Wolf on peritoneal transport kinetic models. Their criticisms centre on the accuracy of the data used for model fits, the hypothesis presented, which involves changes in glucose membrane parameters at high peritoneal glucose concentration and on the necessary techniques required to achieve accurate model parameter estimation. In response, this article shows that (1) the mean values previously captured from graphical depictions of Heimburger et al. are not different than those captured from the recent Waniewski et al. graphs, (2) a much simpler hypothesis is proposed, which centres on intraperitoneal pressure-induced lymph flow during the dialysis dwell and (3) the finding that the new model predictions, with only two constant parameter values, as estimated by the Powell algorithm, give a closer fit than the Waniewski model, which uses many time-varying parameters. The current findings again bring into question of the validity of their vasodilation hypothesis, leading to transient changes in capillary surface area during the dwell.

On the change of transport parameters with dwell time during peritoneal dialysis

The transitory change of fluid and solute transport parameters occurring during the initial phase of a peritoneal dialysis dwell is a well-documented phenomenon; however, its physiological interpretation is rather hypothetical and has been disputed. Two different explanations were proposed: (1) the prevailing view-supported by several experimental and clinical studies-is that a vasodilatory effect of dialysis fluid affects the capillary surface area available for dialysis, and (2) a recently presented alternative explanation is that the molecular radius of glucose increases due to the high glucose concentration in fresh dialysis fluid and that this change affects peritoneal transport parameters. The experimental bases for both phenomena are discussed as well as the problem of the accuracy necessary for a satisfactory description of clinical data when the three-pore model of peritoneal transport is applied. We show that the correction for the change of transport parameters with dwell time provides a better fit with clinical data when applying the three-pore model. Our conclusion is in favor of the traditional interpretation namely that the transitory change of transport parameters with dwell time during peritoneal dialysis is primarily due to the vasodilatory effect of dialysis fluids.

Are transient changes in capillary surface area required to explain peritoneal transport in renal failure patients?

BACKGROUND

Waniewski postulated a transient increase in peritoneal capillary surface area to fit their model predictions to experimental data of Heimburger measured in renal failure (RF) patients undergoing peritoneal dialysis (PD) but with only a 3.86% glucose dialysis fluid. The present aim is to propose a new mathematical model of the patient PD procedure that could closely fit the complete Heimburger measurement set without this postulate.

METHODS

The three-pore model of Rippe was used to describe transient changes in peritoneal volume and solute concentrations during a PD dwell. The predialysis, RF patient, plasma solute concentrations were assumed to remain constant during the dwell. The model was validated using the 3.86% glucose Heimburger measurements. Permeability surface area product parameters were chosen to match only the end-dwell peritoneal fluid glucose concentration and the end-dwell amounts of urea, creatinine, and Na⁺ removed from this simulated patient group. Then, this model was used to predict additional measurements by Heimburger on two other patient groups dialyzed with glucose concentrations of 2.27% and 1.36%, respectively. Parameters were unchanged when simulating these other patient groups.

RESULTS

To match the shape of the transient changes in drained volume and dialysis fluid glucose concentration for the 3.86% glucose group, it was necessary for only one parameter, the effective radius of glucose, to vary linearly in proportion to the dialysis fluid glucose concentration. This description was unchanged in the other two groups.

CONCLUSION

Postulated transient increases in peritoneal capillary surface area were unnecessary to predict the entire Heimburger measurements.

Sodium removal in peritoneal dialysis: is there room for a new parameter in dialysis adequacy?

In peritoneal dialysis (PD) (as well as in hemodialysis) small solute clearance measured as Kt/v urea has long been used as a surrogate of dialysis adequacy. A better urea clearance was initially thought to increase survival in dialysis patients (as shown in the CANUSA trial)(1), but  reanalysis of the data showed a superior contribution of residual renal function as a predictor of patient survival. Two randomized controlled trials (RCT)(2, 3)  supported this observation, demonstrating no survival benefit in patients with higher achieved Kt/v. Then guidelines were revised and a minimum Kt/v of 1,7/week was recommended but little emphasis was given to additional parameters of dialysis adequacy. As such, volume overload and sodium removal have gained major attention, since their optimization has been associated with decreased mortality in PD patients(4, 5). Inadequate sodium removal is associated with fluid overload which leads to ventricular hypertrophy and increased cardiovascular mortality(6). Individualized prescription is key for optimal sodium removal as there are differences between PD techniques (CAPD versus APD) and new strategies for sodium removal have emerged (low sodium solutions and adapted PD). In conclusion, future guidelines should address parameters associated with increased survival outcomes (sodium removal playing an important role) and abandon the current one fit all prescription model.

Fluid Tonicity Affects Peritoneal Characteristics Derived by 3-PORE Model

Background

It is typically assumed that within short time-frames, patient-specific peritoneal membrane characteristics are constant and do not depend on the initial fluid tonicity and dwell duration. The aim of this study was to check whether this assumption holds when membrane properties are estimated using the 3-pore model (3PM).

Methods

Thirty-two stable peritoneal dialysis (PD) patients underwent 3 8-hour peritoneal equilibration tests (PETs) with different glucose-based solutions (1.36%, 2.27%, and 3.86%). Temporary drainage was performed at 1 and 4 hours. Glucose, urea, creatinine, sodium, and phosphate concentrations were measured in dialysate and blood samples. Three-pore model parameters were estimated for each patient and each 8-hour PET separately. In addition, model parameters were estimated using data truncated to the initial 4 hours of peritoneal dwell.

Results

In all cases, model-estimated parameter values were within previously reported ranges. The peritoneal absorption (PA) and diffusive permeability for all solutes except sodium increased with fluid tonicity, with about 18% increase when switching from glucose 2.27% to 3.86%. Glucose peritoneal reflection coefficient and osmotic conductance (OsmCond), and fraction of hydraulic conductance for ultrasmall pores decreased with fluid tonicity (over 40% when switching from glucose 1.36%). Model fitting to the truncated 4-hour data resulted in little change in the parameters, except for PA, peritoneal hydraulic conductance, and OsmCond, for which higher values for the 4-hour dwell were found.

Conclusion

Initial fluid tonicity has a substantial impact on the 3PM-estimated characteristics of the peritoneal membrane, whereas the impact of dwell duration was relatively small and possibly influenced by the change in the patient's activity.

Is Adapted APD Theoretically More Efficient than Conventional APD?

Background

A modified version of automated peritoneal dialysis (APD) using not only variable dwell times but also variable fill volumes has been tested against conventional APD (cAPD) with fixed dwell volumes in a randomized controlled clinical study. The results have indicated that the modified schedule for APD, denoted adapted APD (aAPD), can lead to improved small solute clearances, and, above all, a markedly increased sodium removal (NaR). To theoretically test these results, we have modeled aAPD vs cAPD in computer simulations using the 3-pore model (TPM).

Methods

The TPM, modified by including a transient, initial inflation of small solute mass transfer area coefficients (PS values), was employed. For simulations of osmotic ultrafiltration (UF), the TPM uses a constantly inflated value for PS for glucose and also a reduced value for PS for Na+, setting the peritoneal lymphatic reabsorption term at 0.3 mL/min. The simulations were performed by assuming that increases in intraperitoneal hydrostatic pressure (IPP) are transmitted to the capillary level ( via vein compression) and therefore do not significantly affect the Starling balance. Furthermore, the effective peritoneal surface area (A) was set to be variable as a function of intraperitoneal volume (IPV).

Results

The simulations demonstrated a minor improvement of small solute clearances (∼0.7 – 1.6%) and a very small improvement of UF and NaR in aAPD compared to cAPD.

Conclusions

Due mainly to the increased fill volumes in 3 out of 5 dwells in aAPD, this modality caused minor increases in small solute clearances and marginal effects on UF and NaR. The computer simulations point to a need for accurate sodium determinations in aAPD, considering all the methodological problems and pitfalls relevant to determining dialysate Na+ concentrations and peritoneal sodium mass balance.

Peritoneal Fluid Transport rather than Peritoneal Solute Transport Associates with Dialysis Vintage and Age of Peritoneal Dialysis Patients

During peritoneal dialysis (PD), the peritoneal membrane undergoes ageing processes that affect its function. Here we analyzed associations of patient age and dialysis vintage with parameters of peritoneal transport of fluid and solutes, directly measured and estimated based on the pore model, for individual patients. Thirty-three patients (15 females; age 60 (21–87) years; median time on PD 19 (3–100) months) underwent sequential peritoneal equilibration test. Dialysis vintage and patient age did not correlate. Estimation of parameters of the two-pore model of peritoneal transport was performed. The estimated fluid transport parameters, including hydraulic permeability (LpS), fraction of ultrasmall pores (α_u), osmotic conductance for glucose (OCG), and peritoneal absorption, were generally independent of solute transport parameters (diffusive mass transport parameters). Fluid transport parameters correlated whereas transport parameters for small solutes and proteins did not correlate with dialysis vintage and patient age. Although LpS and OCG were lower for older patients and those with long dialysis vintage, α_u was higher. Thus, fluid transport parameters—rather than solute transport parameters—are linked to dialysis vintage and patient age and should therefore be included when monitoring processes linked to ageing of the peritoneal membrane.

Erythrocytes as Volume Markers in Experimental PD Show that Albumin Transport in the Extracellular Space Depends on PD Fluid Osmolarity

♦

BACKGROUND

Macromolecules, when used as intraperitoneal volume markers, have the disadvantage of leaking into the surrounding tissue. Therefore, (51)Cr-labeled erythrocytes were evaluated as markers of intraperitoneal volume and used in combination with (125)I-labeled bovine serum albumin to study albumin transport into peritoneal tissues in a rat model of peritoneal dialysis (PD). ♦

METHODS

Single dwells of 20 mL of lactate-buffered filter-sterilized PD fluid at glucose concentrations of 0.5%, 2.5%, and 3.9% were performed for 1 or 4 hours. Tissue biopsies from abdominal muscle, diaphragm, liver, and intestine, and blood and dialysate samples, were analyzed for radioactivity. ♦

RESULTS

The dialysate distribution volume of labeled erythrocytes, measured after correction for lymphatic clearance to blood, was strongly correlated with, but constantly 3.3 mL larger than, drained volumes. Erythrocyte activity of rinsed peritoneal tissue biopsies corresponded to only 1 mL of dialysate, supporting our utilization of erythrocytes as markers of intraperitoneal volume. The difference between the distribution volumes of albumin and erythrocytes was analyzed to represent the albumin loss into the peritoneal tissues, which increased rapidly during the first few minutes of the dwell and then leveled out at 2.5 mL. It resumed when osmotic ultrafiltration turned into reabsorption and, at the end of the dwell, it was significantly lower for the highest osmolarity PD fluid (3.9% glucose). Biopsy data showed the lowest albumin accumulation and edema formation in abdominal muscle for the 3.9% fluid. ♦

CONCLUSION

Labeled erythrocytes are acceptable markers of intraperitoneal volume and, combined with labeled albumin, provided novel kinetic data on albumin transport in peritoneal tissues.

Peritoneal fluid transport: mechanisms, pathways, methods of assessment

Fluid removal during peritoneal dialysis is controlled by many mutually dependent factors and therefore its analysis is more complex than that of the removal of small solutes used as markers of dialysis adequacy. Many new tests have been proposed to assess quantitatively different components of fluid transport (transcapillary ultrafiltration, peritoneal absorption, free water, etc.) and to estimate the factors that influence the rate of fluid transport (osmotic conductance). These tests provide detailed information about indices and parameters that describe fluid transport, especially those concerning the problem of the permanent loss of ultrafiltration capacity (ultrafiltration failure). Different theories and respective mathematical models of mechanisms and pathways of fluid transport are presently discussed and applied, and some fluid transport issues are still debated.

Sequential peritoneal equilibration test: a new method for assessment and modelling of peritoneal transport

BACKGROUND

In spite of many peritoneal tests proposed, there is still a need for a simple and reliable new approach for deriving detailed information about peritoneal membrane characteristics, especially those related to fluid transport.

METHODS

The sequential peritoneal equilibration test (sPET) that includes PET (glucose 2.27%, 4 h) followed by miniPET (glucose 3.86%, 1 h) was performed in 27 stable continuous ambulatory peritoneal dialysis patients. Ultrafiltration volumes, glucose absorption, ratio of concentration in dialysis fluid to concentration in plasma (D/P), sodium dip (Dip D/P Sodium), free water fraction (FWF60) and the ultrafiltration passing through small pores at 60 min (UFSP60), were calculated using clinical data. Peritoneal transport parameters were estimated using the three-pore model (3p model) and clinical data. Osmotic conductance for glucose was calculated from the parameters of the model.

RESULTS

D/P creatinine correlated with diffusive mass transport parameters for all considered solutes, but not with fluid transport characteristics. Hydraulic permeability (L(p)S) correlated with net ultrafiltration from miniPET, UFSP60, FWF60 and sodium dip. The fraction of ultrasmall pores correlated with FWF60 and sodium dip.

CONCLUSIONS

The sequential PET described and interpreted mechanisms of ultrafiltration and solute transport. Fluid transport parameters from the 3p model were independent of the PET D/P creatinine, but correlated with fluid transport characteristics from PET and miniPET.

Threefold peritoneal test of osmotic conductance, ultrafiltration efficiency, and fluid absorption

BACKGROUND

Fluid removal during peritoneal dialysis depends on modifiable factors such as tonicity of dialysis fluids and intrinsic characteristics of the peritoneal transport barrier and the osmotic agent-for example, osmotic conductance, ultrafiltration efficiency, and peritoneal fluid absorption. The latter parameters cannot be derived from tests of the small-solute transport rate. We here propose a simple test that may provide information about those parameters.

METHODS

Volumes and glucose concentrations of drained dialysate obtained with 3 different combinations of glucose-based dialysis fluid (3 exchanges of 1.36% glucose during the day and 1 overnight exchange of either 1.36%, 2.27%, or 3.86% glucose) were measured in 83 continuous ambulatory peritoneal dialysis (CAPD) patients. Linear regression analyses of daily net ultrafiltration in relation to the average dialysate-to-plasma concentration gradient of glucose allowed for an estimation of the osmotic conductance of glucose and the peritoneal fluid absorption rate, and net ultrafiltration in relation to glucose absorption allowed for an estimation of the ultrafiltration effectiveness of glucose.

RESULTS

The osmotic conductance of glucose was 0.067 ± 0.042 (milliliters per minute divided by millimoles per milliliter), the ultrafiltration effectiveness of glucose was 16.77 ± 7.97 mL/g of absorbed glucose, and the peritoneal fluid absorption rate was 0.94 ± 0.97 mL/min (if estimated concomitantly with osmotic conductance) or 0.93 ± 0.75 mL/min (if estimated concomitantly with ultrafiltration effectiveness). These fluid transport parameters were independent of small-solute transport characteristics, but proportional to total body water estimated by bioimpedance.

CONCLUSIONS

By varying the glucose concentration in 1 of 4 daily exchanges, osmotic conductance, ultrafiltration efficiency, and peritoneal fluid absorption could be estimated in CAPD patients, yielding transport parameter values that were similar to those obtained by other, more sophisticated, methods.

Two-in-one protocol: simultaneous small-pore and ultrasmall-pore peritoneal transport quantification

BACKGROUND

Reduced free water transport (FWT) through ultrasmall pores contributes to net ultrafiltration failure (UFF) and should be seen as a sign of more severe functional deterioration of the peritoneal membrane. The modified peritoneal equilibration test (PET), measuring the dip in dialysate Na concentration, estimates only FWT. Our aim was to simultaneously quantify small-solute transport, FWT, and small-pore ultrafiltration (SPUF) during a single PET procedure.

METHODS

We performed a 4-hour, 3.86% glucose PET, with additional measurement of ultrafiltration (UF) at 60 minutes, in 70 peritoneal dialysis patients (mean age: 50 ± 16 years; 61% women; PD vintage: 26 ± 23 months). We calculated the dialysate-to-plasma ratios (D/P) of creatinine and Na at 0 and 60 minutes, and the Na dip (Dip(D/PNa60')), the delta dialysate Na 0-60 (ΔDNa(0-60)), FWT, and SPUF.

RESULTS

Sodium sieving (as measured by ΔDNa(0-60)) correlated strongly with the corrected Dip(D/PNa60') (r = 0.85, p < 0.0001) and the corrected FWT (r = 0.41, p = 0.005). Total UF showed better correlation with FWT than with indirect measurements of Na sieving (r = 0.46, p < 0.0001 for FWT; r = 0.360, p < 0.0001 for Dip(D/PNa60')). Corrected FWT fraction was 0.45 ± 0.16. A negative correlation was found between time on PD and both total UF and FWT (r = -0.253, p = 0.035 and r = -0.272, p = 0.023 respectively). The 11 patients (15.7%) diagnosed with UFF had lower FWT (89 mL vs 164 mL, p < 0.05) and higher D/P creatinine (0.75 vs 0.70, p < 0.05) than did the group with normal UF. The SPUF correlated positively with FWT in the normal UF group, but negatively in UFF patients (r = -0.709, p = 0.015). Among UFF patients on PD for a longer period, 44.4% had a FWT percentage below 45%.

CONCLUSIONS

Measurement of FWT and SPUF is feasible by simultaneous quantification during a modified 3.86% glucose PET, and FWT is a decisive parameter for detecting causes of UFF in addition to increased effective capillary surface.

Computer simulations of osmotic ultrafiltration and small-solute transport in peritoneal dialysis: a spatially distributed approach

The aim of this study was to simulate clinically observed intraperitoneal kinetics of dialysis fluid volume and solute concentrations during peritoneal dialysis. We were also interested in analyzing relationships between processes in the peritoneal cavity and processes occurring in the peritoneal tissue and microcirculation. A spatially distributed model was formulated for the combined description of volume and solute mass balances in the peritoneal cavity and flows across the interstitium and the capillary wall. Tissue local parameters were assumed dependent on the interstitial hydration and vasodilatation induced by glucose. The model was fitted to the average volume and solute concentration profiles from dwell studies in 40 clinically stable patients on chronic ambulatory peritoneal dialysis using a 3.86% glucose dialysis solution. The model was able to describe the clinical data with high accuracy. An increase in the local interstitial pressure and tissue hydration within the distance of 2.5 mm from the peritoneal surface of the tissue was observed. The penetration of glucose into the tissue and removal of urea, creatinine, and sodium from the tissue were restricted to a layer located within 2 mm from the peritoneal surface. The initial decline of sodium concentration (sodium dip) was observed not only in intraperitoneal fluid but also in the tissue. The distributed model can provide a precise description of the relationship between changes in the peritoneal tissue and intraperitoneal dialysate volume and solute concentration kinetics. Computer simulations suggest that only a thin layer of the tissue within 2-3 mm from the peritoneal surface participates in the exchange of fluid and small solutes between the intraperitoneal dialysate and blood.

Three-pore model predictions of 24-hour automated peritoneal dialysis therapy using bimodal solutions

BACKGROUND

Recently, bimodal peritoneal dialysis (PD) solutions containing low concentrations of Na have been shown to increase 24-hour ultrafiltration (UF) or UF efficiency (UF volume per gram of carbohydrate or CHO absorbed) and Na removal in high ("fast") transport patients during automated PD therapy. We used computer simulations to compare UF efficiency and Na removal at equivalent 24-hour UF volumes using either a generic bimodal solution (2.27% glucose + 7.5% icodextrin) during the long dwell or an increase in the glucose concentration during the short dwells, with all solutions containing Na at the conventional concentration (132 mEq/L).

METHODS

The 3-pore model has been shown to accurately predict peritoneal transport for PD solutions containing glucose or icodextrin, or both. Here, we used that model to calculate 24-hour UF volume, CHO absorption, and Na removal for high (H), high-average (HA), and low-average (LA) transport patients on automated PD. Nighttime therapy consisted of 1.36% or 2.27% glucose solution (or both), and daytime therapy consisted of either Extraneal (Baxter Healthcare Corporation, Deerfield, IL, USA) or a bimodal solution.

RESULTS

As expected, addition of glucose to either the long dwell or the short dwells resulted in increased UF volume and glucose absorption. The increase in UF was a function of patient transport type (bimodal range: 288 - 490 mL; short-dwell range: 323 - 350 mL), and the increase in CHO absorption was smaller with glucose added to short dwells than with bimodal solution (range: 18 - 30 g vs. 34 - 39 g). The 24-hour UF efficiency was higher when high glucose concentrations were used during short-dwell exchanges than when a bimodal PD solution was used for the long dwell (0.6 to 1.2 mL/g vs. -0.1 to 0.5 mL/g). By contrast, Na removal was lower with the short-dwell exchanges (28.3 - 30.7 mmol vs. 36.2 - 53.3 mmol), likely because of more pronounced Na sieving.

CONCLUSIONS

Our modeling studies predict that generic bimodal PD solutions will provide higher Na removal but not higher 24-hour UF efficiency compared with current automated PD prescriptions using Extraneal for the long dwell and glucose-containing solutions for the short dwells. The modeling predictions from this study require clinical validation.

Changes in free water fraction and aquaporin function with dwell time during continuous ambulatory peritoneal dialysis

Diffusive (K(BD), A₀/Δx(t)) transport parameters and sieving coefficients (S) for small solutes and free water fraction (FWF), that is, the fraction of total water flow that is transported through aquaporins, were assessed as functions of dwell time t for 35 continuous ambulatory peritoneal dialysis patients using glucose 3.86% dialysis fluid.The individual values of the unrestricted pore area over diffusion distance, A₀/Δx(t), were estimated using the mixed effects nonlinear regression and applied for evaluation of S(t) for sodium and FWF(t). FWF decreased on average from the initial 51% of the total transcapillary water flow to 36% at 120 min, whereas the small pore water fraction and sodium sieving coefficient increased. Our results were consistent with the three-pore model if the contribution of the transcellular pores (α(TP)) at the beginning of dwell study was doubled and later decreased to the standard value of 0.02.We conclude that transport characteristics of fluid and small solutes should be considered as time-dependent variables during the peritoneal dialysis.

Water and Solute Transport through Different Types of Pores in Peritoneal Membrane in Capd Patients with Ultrafiltration Failure

Free water transport, an estimate of aquaporin function, was evaluated in 7 continuous ambulatory peritoneal dialysis (CAPD) patients with permanent ultrafiltration failure. In 3 patients, peritoneal transport was studied also before the onset of ultrafiltration failure. Transcapillary ultrafiltration and fluid absorption rates were assessed using radiolabeled albumin, and free water transport by kinetics of sodium concentration in dialysis fluid. Diffusive and convective transport rates of small solutes were estimated using the modified Babb–Randerson–Farrell model. Increased diffusive transport of small solutes was found in 5 patients and increased peritoneal fluid absorption in 2 patients. The 3-pore model was fitted to these data. Overall, hydraulic conductivity and the fractional contributions of aquaporins to hydraulic conductivity were either decreased or normal. We conclude that the quantitative role of aquaporins in overall fluid transport may vary substantially in normal patients as well in patients with ultrafiltration failure.

Kinetic Analysis of Peritoneal Fluid and Solute Transport with Combination of Glucose and Icodextrin as Osmotic Agents

Background

Controlling extracellular volume and plasma sodium concentration are two crucial objectives of dialysis therapy, as inadequate sodium and fluid removal by dialysis may result in extracellular volume overload, hypertension, and increased cardiovascular morbidity and mortality in end-stage renal disease patients. A new concept to enhance sodium and fluid removal during peritoneal dialysis (PD) is the use of dialysis solutions with two different osmotic agents.

Aim

To investigate and compare, with the help of mathematical modeling and computer simulations, fluid and solute transport during PD with conventional dialysis fluids (3.86% glucose and 7.5% icodextrin; both with standard sodium concentration) and a new combination fluid with both icodextrin and glucose (CIG; 2.6% glucose/6.8% icodextrin; low sodium concentration). In particular, this paper is devoted to improving mathematical modeling based on critical appraisal of the ability of the original three-pore model to reproduce clinical data and check its validity across different types of osmotic agents.

Methods

Theoretical investigations of possible causes of the improved fluid and sodium removal during PD with the combination solution (CIG) were carried out using the three-pore model. The results of computer simulations were compared with clinical data from dwell studies in 7 PD patients. To fit the model to the low net ultrafiltration (366 ± 234 mL) obtained after a 4-hour dwell with 3.86% glucose, some of the original parameters proposed in the three-pore model (Rippe & Levin. Kidney Int 2000; 57:2546-56) had to be modified. In particular, the aquaporin-mediated fractional contribution to hydraulic permeability was decreased by 25% and small pore radius increased by 18%.

Results

The simulations described well clinical data that showed a dramatic increase in ultrafiltration and sodium removal with the CIG fluid in comparison with the two other dialysis fluids. However, to adapt the three-pore model to the selected group of PD patients (fast transporters with small ultrafiltration capacity on average), the peritoneal pore structure had to be modified. As the mathematical model was capable of reproducing the clinical data, this shows that the enhanced ultrafiltration with the combination fluid is caused by the additive effect of the two different osmotic agents and not by a specific impact of the new dialysis fluid on the transport characteristics of the peritoneum.