Clinical Experience with a New Bicarbonate (25 Mmol/L)/Lactate (10 Mmol/L) Peritoneal Dialysis Solution

Objective

Physiological bicarbonate/lactate-based solutions may correct acidosis in a better way than standard lactate-based solutions. In this study, a new 25 mmol/L bicarbonate/10 mmol/L lactate peritoneal dialysis (PD) solution was compared with a standard 35 mmol/L lactate solution.

Design

This was a prospective open label study. All patients had a 2-week baseline period using the standard lactate solution, followed by 8 weeks on the bicarbonate/lactate solution and 2 weeks on the lactate-basedsolution.

Setting

Four Danish and four Spanish nephrology centers.

Patients

40 well-dialyzed (creatinine clearance > 55 L/week/1.73 m2 body surface area) patients on continuous ambulatory PD.

Interventions

Blood samples were taken for biochemistry (including venous blood gases) at week –2, day 1, weeks 2, 4, and 8, and at follow-up. A physical examination, a peritoneal equilibration test (PET), and quality of life (K/DQOL), ultrafiltration, and adequacy assessments were performed at baseline and at week 8. Vital signs and other safety parameters were followed at each visit. Extraneal (Baxter Healthcare, Castlebar, Ireland) was used by all patients for the long dwell.

Main Outcome Measure

Effect on the venous plasma bicarbonate level.

Results

Venous plasma bicarbonate levels rose from 24.4 mmol/L when patients were on the pure lactate to 26.1 mmol/L when using the bicarbonate/lactate solution ( p < 0.001). When patients were using the bicarbonate/lactate solution, 66% of values were maintained within the venous normal range of 24 – 30 mmol/L, versus 46.2% when patients were on the pure lactate solution ( p < 0.001). There were no adverse findings with respect to clinical symptoms, vital signs, or physical examination. The PET and adequacy, ultrafiltration, and K/DQOL assessment results were unchanged.

Conclusions

The new 25 mmol/L bicarbonate/10 mmol/L lactate solution provided better correction of acidosis than an equivalent 35 mmol/L standard lactate solution, without any safety issues.

A Long-Term Study of a Bicarbonate/Lactate-Based Peritoneal Dialysis Solution — Clinical Benefits

Objective

A bicarbonate/lactate peritoneal dialysis solution (Bic/Lac) has been developed based on in vitro and ex vivo data showing better preservation of cell function and correction of pain on infusion.

Design

This was a randomized, prospective, controlled, open-label study comparing a new 25 mmol/L bicarbonate/15 mmol/L lactate with a standard 40 mmol/L lactate-buffered peritoneal dialysis solution (Lac) over a 12-month treatment period.

Setting

17 European nephrology centers.

Patients

106 (70 Bic/Lac and 36 Lac) well-dialyzed continuous ambulatory peritoneal dialysis (CAPD) patients.

Interventions

Dialysis adequacy and peritoneal equilibration test (PET, week –4, months 3, 6, and 12); 24-hour ultrafiltration (week –4, months 1, 3, and 6); blood biochemistry (week –2, day 0, months 1, 2, 3,6, 9, and 12); and a product acceptability questionnaire (months 1 and 6).

Results

88 patients completed the first 6 months, and 44 the full year. The solutions were shown to be therapeutically equivalent with respect to plasma bicarbonate and peritoneal urea and creatinine clearances. Ultrafiltration in the Bic/Lac group increased significantly from baseline by about 150 mL/day for the whole of the 6-month treatment period ( p < 0.05). The biochemistry profile, adverse events, and physical examination (except body weight where there was a statistically significant increase in the Bic/Lac group) results did not differ significantly between the two groups. Reduced pain/discomfort on infusion or an increased sense of well-being was reported by 41% of patients on the Bic/Lac fluid.

Conclusions

The Bic/Lac solution is safe and effective in correcting uremic acidosis, provides relief of inflow pain/discomfort, and improves ultrafiltration and body weight.

Acidosis Correction with a new 25 Mmol/L Bicarbonate/15 Mmol/L Lactate Peritoneal Dialysis Solution

Objective

The aim of this study was to evaluate the effects of a combined 25 mmol/L bicarbonate/15 mmol/L lactate-based solution (Bic/Lac), compared to a 35 mmol/L lactate solution (Lac) — the most commonly used solution for patients in southern Europe — on the venous plasma bicarbonate level in patients treated with continuous ambulatory peritoneal dialysis (CAPD).

Design

This was a randomized, parallel, controlled, open-label study, with patients studied for a period of 3 months preceded by a 1-month baseline and followed by a 1-month follow-up. Patients used the 35 mmol/L lactate solution during baseline and follow-up periods.

Setting

Four Spanish nephrology centers.

Patients

Thirty-one (20 Bic/Lac, 11 Lac) well-dialyzed (creatinine clearance > 55 L/week/1.73 m2body surface area) CAPD patients.

Interventions

Blood samples were taken for biochemistry tests at all visits. A physical examination was completed at baseline and month 3, and a medical update was completed after 1, 2, and 3 months, and at the follow-up visit. Adverse-event monitoring and notation of prescription changes were carried out continuously.

Main Outcome Measure

Effect on venous plasma bicarbonate level.

Results

Venous plasma bicarbonate rose by 3.1 mmol/L (confidence intervals 1.6 – 4.8), from a baseline level of 23.0 mmol/L during the treatment period in those patients treated with Bic/Lac ( p < 0.05 vs Lac). The number of acidotic patients (venous plasma bicarbonate < 24 mmol/L) was statistically significantly reduced at every treatment period visit in the Bic/Lac group ( p < 0.05). There were no adverse findings with respect to vital signs, physical examination, or clinical symptoms, apart from one death in the control group.

Conclusions

The new Bic/Lac solution allowed better correction of acid–base status than the lactate solution.

Clinical Evaluation of a Peritoneal Dialysis Solution with 33 mmol/L Bicarbonate

Objective

To evaluate the efficacy and safety of a new peritoneal dialysis solution with 33 mmol/L bicarbonate.

Design

In an acute, prospective, randomized crossover study, 8 patients were randomized in two groups of 4. On the first study day, the first group performed two consecutive 4-hour exchanges with a dialysis solution containing 35 mmol/L lactate: the first exchange with 13.6 g/L and the second with 38.6 g/L dextrose. On the second study day, the same type of exchanges were performed with bicarbonate. The second group underwent the same treatment, but used bicarbonate solutions on the first day and control solutions on the second study day. Thirty-three patients participated in a 2-month prospective and randomized study. After a 4-week baseline period using solutions containing 40 mmol/L lactate, the patients were dialyzed with either 33 mmol/L bicarbonate solutions or 40 mmol/L lactate solutions.

Setting

Peritoneal dialysis units at the University Hospital of Brescia and the Niguarda Hospital of Milan, Italy.

Results

Acute study: Control and bicarbonate solutions had similar effects on blood chemistries and peritoneal transport. Chronic study: Mean venous bicarbonate concentrations remained unchanged in the control group (26.6 -27.2 mmol/L), but decreased significantly in the bicarbonate group from 28.8 mmol/L at the start of the study to 23.0 mmol/L after 2 months of bicarbonate administration. Other biochemical parameters remained unchanged.

Conclusion

A peritoneal dialysis solution with a bicarbonate level of 33 mmol/L does not adequately correct uremic acidosis.

Ten Years’ Experience with Capd in a Nursing Home Setting

Objective

We reviewed our experience with end-stage renal disease (ESRD) patients treated with continuous ambulatory peritoneal dialysis (CAPD) in a nursing home with the aims of describing their demographic and clinical characteristics, evaluating CAPD technique success and patient outcomes.

Setting

University-based, teaching nursing home.

Design

Retrospective review of patients in our nursing home treated with CAPD between 1 June 1986 and 1 June 1996.

Patients

One hundred and nine patients: 66 (60.5%) were female and 59 (54%) were white. Their mean age was 62.7 years ± 12.8 SD (range 31 -88). Females were significantly older than males (64.9 years ± 10.7 SD vs 59.1 years ± 14.6 SD, p < 0.05). Sixty-eight (62.4%) were diabetics. Main outcomes studied:Cox -adjusted patient survival. Cause of death. Peritonitis and hospitalization rates. Logistic analysis of predictors of discharge home.

Results

Six and 12-month survival rates were 51.7% and 37.2%, respectively. Age greater than 75, poor functional status, coronary artery disease (CAD), and decubitus ulcers were significant mortality risks. Vascular disease was the leading cause (41.7%) of death. The peritonitis rate in the nursing home was 1.19 episodes per patient year. Gram-positive organisms predominated. The hospitalization rate was 22.4 days per patient year. Gangrene/ stump infections and peritonitis accounted for 14% and 10% of admissions. Those patients admitted for rehabilitation and with higher activity of daily living (ADL) scores were more likely, and those with diabetes, age ≥75, and CAD less likely to be discharged.

Conclusions

We continue to believe that peritoneal dialysis is a reasonable option for ESRD patients placed in nursing homes. Technical problems do not limit its use, but overall poor patient outcomes are an important issue. Patients, their families, and referring physicians should be informed of the limited survival expectations particularly for the very old and/or severely functionally impaired patient. Patients whose discharge is anticipated on admission are those most likely to return to the community and are the most likely to truly benefit from nursing home placement.

Chronic kidney disease: issues and establishing programs and clinics for improved patient outcomes

The spectrum of chronic kidney disease (CKD) extends from the point at which there is slight kidney damage, but normal function, to the point at which patients require either a renal transplant or renal replacement therapy to survive. Epidemiological studies suggest there are approximately 20,000,000 patients with various stages of CKD. These patients have many comorbidities, including cardiovascular disease, hypertension, diabetes, anemia, nutritional and metabolic derangements, and fluid overload. Unfortunately, evidence shows that current CKD care in the United States is suboptimal, and late referral to a nephrologist is often the rule and not the exception. Roles of primary care physicians (PCPs) and nephrologists in the care of patients with CKD remain undefined. Several studies have suggested that care provided by multidisciplinary nephrology teams can improve patient outcomes. Currently, there are published evidence-based clinical practice guidelines for anemia management, nutritional therapy, and vascular access placement, with other CKD guidelines under development. The intent of this review includes providing compelling evidence for earlier screening, identification, and management of patients with CKD; showing that current CKD care is suboptimal; encouraging the development of multidisciplinary teams that provide collaborative care to patients with CKD, suggesting roles for PCPs and nephrologists in the care of these patients; describing CKD initiatives from national organizations; and providing a comprehensive checklist that can guide the development of CKD clinics and programs.

Complications of chronic renal insufficiency: beyond cardiovascular disease

The less rigorous attention to the management of the complications of chronic renal insufficiency (CRI) and its comorbid conditions has potentially tragic consequences. In fact, with early recognition and intervention, many of the complications of CRI and its comorbid conditions can be ameliorated or prevented. We review here the most prevalent, troublesome, and potentially preventable complications and comorbidities of CRI with a view toward developing high-quality, cost-effective strategies for delivering early interventional care. Complications of CRI include malnutrition, anemia, disorders of divalent ion metabolism and osteodystrophy, metabolic acidosis, and dyslipidemia. Important comorbid conditions of CRI are hypertension, diabetes mellitus, and cardiovascular disease. Clinical intuition suggests that early intervention will avert morbidity related to the hypoalbuminemia and other nutritional disorders of CRI, the metabolic acidosis, and the dyslipidemias, but prospective data are lacking at present. Correction of anemia, usually with recombinant human erythropoietin, may be key to the prevention of cardiac disease and other comorbidities of CRI. Incipient disorders of bone and mineral metabolism are managed prospectively using such measures as protein restriction to reduce phosphorus intake, phosphate binders, calcium supplementation, and vitamin D analogues. Hypertension, whatever its original etiology, is clearly an important risk factor for the progression of kidney failure and for the development of diffuse vascular disease; appropriate and aggressive treatment is essential. In patients with diabetic nephropathy, the principles of both primary and secondary prevention have been validated in several large trials of glycemic and blood pressure control. The seeds of these insidious, challenging, and costly comorbid conditions are sown very early in CRI, at a time when they are-in theory-most amenable to intervention. We therefore must be as proactive as possible in the timely implementation of relatively simple therapies that have the potential to prevent some of these adverse outcomes of CRI.