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How to Improve the Biocompatibility of Peritoneal Dialysis Solutions (without Jeopardizing the Patient's Health). Int J Mol Sci 2021; 22:ijms22157955. [PMID: 34360717 PMCID: PMC8347640 DOI: 10.3390/ijms22157955] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 07/21/2021] [Accepted: 07/24/2021] [Indexed: 12/23/2022] Open
Abstract
Peritoneal dialysis (PD) is an important, if underprescribed, modality for the treatment of patients with end-stage kidney disease. Among the barriers to its wider use are the deleterious effects of currently commercially available glucose-based PD solutions on the morphological integrity and function of the peritoneal membrane due to fibrosis. This is primarily driven by hyperglycaemia due to its effects, through multiple cytokine and transcription factor signalling-and their metabolic sequelae-on the synthesis of collagen and other extracellular membrane components. In this review, we outline these interactions and explore how novel PD solution formulations are aimed at utilizing this knowledge to minimise the complications associated with fibrosis, while maintaining adequate rates of ultrafiltration across the peritoneal membrane and preservation of patient urinary volumes. We discuss the development of a new generation of reduced-glucose PD solutions that employ a variety of osmotically active constituents and highlight the biochemical rationale underlying optimization of oxidative metabolism within the peritoneal membrane. They are aimed at achieving optimal clinical outcomes and improving the whole-body metabolic profile of patients, particularly those who are glucose-intolerant, insulin-resistant, or diabetic, and for whom daily exposure to high doses of glucose is contraindicated.
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The osmo-metabolic approach: a novel and tantalizing glucose-sparing strategy in peritoneal dialysis. J Nephrol 2020; 34:503-519. [PMID: 32767274 PMCID: PMC8036224 DOI: 10.1007/s40620-020-00804-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 07/09/2020] [Indexed: 02/07/2023]
Abstract
Peritoneal dialysis (PD) is a viable but under-prescribed treatment for uremic patients. Concerns about its use include the bio-incompatibility of PD fluids, due to their potential for altering the functional and anatomical integrity of the peritoneal membrane. Many of these effects are thought to be due to the high glucose content of these solutions, with attendant issues of products generated during heat treatment of glucose-containing solutions. Moreover, excessive intraperitoneal absorption of glucose from the dialysate has many potential systemic metabolic effects. This article reviews the efforts to develop alternative PD solutions that obviate some of these side effects, through the replacement of part of their glucose content with other osmolytes which are at least as efficient in removing fluids as glucose, but less impactful on patient metabolism. In particular, we will summarize clinical studies on the use of alternative osmotic ingredients that are commercially available (icodextrin and amino acids) and preclinical studies on alternative solutions under development (taurine, polyglycerol, carnitine and xylitol). In addition to the expected benefit of a glucose-sparing approach, we describe an ‘osmo-metabolic’ approach in formulating novel PD solutions, in which there is the possibility of exploiting the pharmaco-metabolic properties of some of the osmolytes to attenuate the systemic side effects due to glucose. This approach has the potential to ameliorate pre-existing co-morbidities, including insulin resistance and type-2 diabetes, which have a high prevalence in the dialysis population, including in PD patients.
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Schröder CH. The Choice of Dialysis Solutions in Pediatric Chronic Peritoneal Dialysis: Guidelines by AnAD HOCEuropean Committee. Perit Dial Int 2020. [DOI: 10.1177/089686080102100606] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
ObjectiveTo provide guidelines on choosing dialysis solutions for children on chronic peritoneal dialysis (PD).SettingEuropean Paediatric Peritoneal Dialysis Working Group.Data SourceLiterature on the application of PD solutions in children ( Evidence), and discussions within the group ( Opinion).ConclusionsGlucose is the standard osmotic agent for PD in children ( Evidence). The lowest glucose concentration needed should be used ( Opinion). Low calcium solution (1.25 mmol/L) should be applied, wherever possible, with careful monitoring of parathyroid hormone levels ( Opinion). The use of amino acid-containing dialysis fluids can be considered in malnourished children, although aggressive enteral nutrition is preferred ( Opinion). There is insufficient evidence documenting the efficacy of intraperitoneally administered amino acids ( Evidence). When ultrafiltration and/or solute removal are insufficient, poly-glucose solutions are a welcome addition to the treatment of children on nocturnal intermittent PD ( Evidence). However, in the absence of any reported long-term experience with children, their use must be closely monitored ( Opinion). Bicarbonate would appear to be the preferred buffer for PD in children, but more in vivo studies are required before it replaces the present lactate-containing solutions ( Evidence/Opinion).
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Kari JA, El-Desoky S, Abuduhair AA, Habib H. Sterile Peritonitis with High-Dose Amino Acid–Containing Peritoneal Dialysis Solution in Children. Perit Dial Int 2012; 32:204-6. [DOI: 10.3747/pdi.2011.00250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jameela A. Kari
- Department of Pediatrics, Abdul Aziz University Hospital Jeddah, Saudi Arabia
- Dialysis Unit King Abdul Aziz University Hospital Jeddah, Saudi Arabia
| | - Sherif El-Desoky
- Department of Pediatrics, Abdul Aziz University Hospital Jeddah, Saudi Arabia
- Dialysis Unit King Abdul Aziz University Hospital Jeddah, Saudi Arabia
| | | | - Hamid Habib
- Dialysis Unit King Abdul Aziz University Hospital Jeddah, Saudi Arabia
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Abstract
Although end-stage renal disease is rare in infants and young children, its development can be associated with significant morbidity and mortality and only through the provision of experienced, multidisciplinary care can a favorable outcome be anticipated. Peritoneal dialysis is the renal replacement modality of choice for this age group and serves as an essential bridge until successful renal transplantation can occur. In this review, we discuss the practice of peritoneal dialysis in infants including the unique ethical and technical considerations facing pediatric nephrologists and caregivers. In addition, we review current guidelines concerning nutrition, growth, and adequacy, as well as the literature on complications and outcomes.
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Affiliation(s)
- Joshua Zaritsky
- Department of Pediatrics, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA, USA
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Verrina E, Cappelli V, Perfumo F. Selection of modalities, prescription, and technical issues in children on peritoneal dialysis. Pediatr Nephrol 2009; 24:1453-64. [PMID: 18521632 PMCID: PMC2697927 DOI: 10.1007/s00467-008-0848-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2007] [Revised: 03/31/2008] [Accepted: 03/31/2008] [Indexed: 11/08/2022]
Abstract
Peritoneal dialysis (PD) is widely employed as a dialytic therapy for uraemic children, especially in its automated form (APD), that is associated with less burden of care on patient and family than continuous ambulatory PD. Since APD offers a wide range of treatment options, based on intermittent and continuous regimens, prescription can be individualized according to patient's age, body size, residual renal function, nutritional intake, and growth-related metabolic needs. Transport capacity of the peritoneal membrane of each individual patient should be assessed, and regularly monitored, by means of standardized peritoneal function tests validated in pediatric patients. To ensure maximum recruitment of peritoneal exchange area, fill volume should be scaled to body surface area and adapted to each patient, according to clinical tolerance and intraperitoneal pressure. PD solutions should be employed according to their biocompatibility and potential ultrafiltration capacity; new pH-neutral, glucose-free solutions can be used in an integrated way in separate dwells, or by appropriately mixing during the same dialytic session. Kinetic modelling software programs may help in the tailoring of PD prescription to individual patients' characteristics and needs. Owing to advances in the technology of new APD machines, greater programming flexibility, memorized delivery control, and tele-dialysis are currently possible.
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Affiliation(s)
- Enrico Verrina
- Dialysis Unit, Nephrology and Dialysis Division, Giannina Gaslini Institute, Largo G. Gaslini, 5, 16148, Genoa, Italy.
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Paglialonga F, Edefonti A. Nutrition assessment and management in children on peritoneal dialysis. Pediatr Nephrol 2009; 24:721-30. [PMID: 18253763 PMCID: PMC6904418 DOI: 10.1007/s00467-007-0719-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2007] [Revised: 11/18/2007] [Accepted: 11/19/2007] [Indexed: 11/27/2022]
Abstract
Protein-calorie malnutrition, otherwise known as cachexia, is a common problem in children undergoing chronic peritoneal dialysis (PD) and is a frequent source of significant morbidity and mortality. Recent evidence suggests that the main factors involved in the pathogenesis are metabolic acidosis, a decreased response to anabolic hormones, and chronic inflammation, associated with hormonal imbalances and an increased metabolic rate. Given the complexity and multifactorial nature of cachexia, the assessment of nutritional status in children on PD requires a complete history and physical examination; assessment of dietary intake, biochemical indices, and anthropometry; and possibly bioimpedance analysis and combined score systems. Its management should likewise be multidisciplinary and include ensuring an adequate energy and protein intake; optimal metabolic control, with the correction of acidosis, anaemia, and hyperparathyroidism; an optimal (or at least adequate) dialysis dose; and, if necessary, prescription of specific drugs such as recombinant human growth hormone.
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Affiliation(s)
- Fabio Paglialonga
- Pediatric Nephrology and Dialysis Unit, Clinica Pediatrica G. e D. D Marchi, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Via Commenda, 9, Milan, 20122 Italy
| | - Alberto Edefonti
- Pediatric Nephrology and Dialysis Unit, Clinica Pediatrica G. e D. D Marchi, Fondazione IRCCS Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Via Commenda, 9, Milan, 20122 Italy
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Fischbach M, Warady BA. Peritoneal dialysis prescription in children: bedside principles for optimal practice. Pediatr Nephrol 2009; 24:1633-42; quiz 1640, 1642. [PMID: 18807074 PMCID: PMC2719743 DOI: 10.1007/s00467-008-0979-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2008] [Revised: 08/01/2008] [Accepted: 08/01/2008] [Indexed: 11/15/2022]
Abstract
There is no unique optimal peritoneal dialysis prescription for all children, although the goals of ultrafiltration and blood purification are universal. In turn, a better understanding of the physiology of the peritoneal membrane, as a dynamic dialysis membrane with an exchange surface area recruitment capacity and unique permeability characteristics, results in the transition from an empirical prescription process based on clinical experience alone to the potential for a personalized prescription with individually adapted fill volumes and dwell times. In all cases, the prescribed exchange fill volume should be scaled for body surface area (ml/m(2)), and volume enhancement should be conducted based on clinical tolerance and intraperitoneal pressure measurements (IPP; cmH(2)O). The exchange dwell times should be determined individually and adapted to the needs of the patient, with particular attention to phosphate clearance and ultrafiltration capacity. The evolution of residual kidney function and the availability of new, more physiologic, peritoneal dialysis fluids (PDFs) also influence the prescription process. An understanding of all of these principles is integral to the provision of clinically optimal PD.
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Affiliation(s)
- Michel Fischbach
- Pediatry 1, University Hospital, Avenue Molière, 67098 Strasbourg Cedex, France
| | - Bradley A. Warady
- Section of Pediatric Nephrology, Children’s Mercy Hospital, 2041 Gillham Road, Kansas City, MO 64108–4698 USA
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Abstract
Standard peritoneal dialysis (PD) solutions with low pH and containing high concentrations of lactate and glucose have been demonstrated to negatively affect the peritoneal membrane, mesothelial cell viability, residential peritoneal cells, and also to inhibit phagocytic functions. An increasing body of experimental evidence supports the idea that the peritoneal hypervascularization and fibrosis observed in long-term PD are causally related to the acute and chronic toxicity of conventional PD solutions. A Physioneal (lactate/bicarbonate mixed buffer pH 7-7.4), Physioneal, Extraneal (7.5% icodextrin), Nutrineal (1.1% amino-acid-containing solution) regimen, for example, offers a significant reduction in carbohydrate load (approximately 40-50%), lower exposure to and absorption of glucose degradation products, reduced oxidative stress, and improved volume control when compared with a first-generation DDDD (4 x Dianeal) regimen. The positive aspects of each solution that we have observed in our patients allow a recommendation on the potential benefit of using these solutions in children treated with PD. In fact, data from the literature as well as the results of the studies reported in this paper show that in children the application of neutral pH bicarbonate/lactate-buffered solution for the standard nighttime APD prescription, icodextrin solution for a long daytime dwell, and AA-based solution in malnourished patients is safe and effective. Extended clinical trials should be encouraged to better define the PD schedules for the combined use of these solutions that may be associated with the best clinical efficacy and the highest level of biocompatibility.
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Saxena R. Pathogenesis and treatment of peritoneal membrane failure. Pediatr Nephrol 2008; 23:695-703. [PMID: 17891546 DOI: 10.1007/s00467-007-0580-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2007] [Revised: 07/08/2007] [Accepted: 07/09/2007] [Indexed: 10/22/2022]
Abstract
Peritoneal dialysis (PD) is a viable treatment option for end stage renal disease (ESRD) patients worldwide. PD may provide a survival advantages over hemodialysis (HD) in the early years of treatment. However, the benefits of PD are short-lived, as peritoneal membrane failure ensues in many patients, owing mainly to structural and functional changes in the peritoneal membrane from the use of conventional bio-incompatible PD solutions, which are hyperosmolar, acidic, have lactate buffer and contain high concentrations of glucose and glucose degradation products (GDPs). Current data suggest that chronic exposure of the peritoneum to contemporary PD fluids provokes activation of various inflammatory, fibrogenic and angiogenic cytokines, interplay of which leads to progressive peritoneal fibrosis, vasculopathy and neoangiogenesis. There is emerging evidence that peritoneal vascular changes are mainly responsible for increased solute transport and ultrafiltration failure in long-term PD. However, the precise pathophysiologic mechanisms initiating and propagating peritoneal fibrosis and angiogenesis remain elusive. The protection of the peritoneal membrane from long-term toxic and metabolic effects of high GDP-containing, conventional, glucose-based solutions is a prime objective to improve PD outcome. Recent development of new, more biocompatible, PD solutions should help to preserve peritoneal membrane function, promote ultrafiltration, improve nutritional status and, hopefully, preserve peritoneal membrane and improve overall PD outcomes. Elucidation of molecular mechanisms involved in the cellular responses leading to peritoneal fibrosis and angiogenesis spurs new therapeutic strategies that might protect the peritoneal membrane against the consequences of longstanding PD.
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Affiliation(s)
- Ramesh Saxena
- Department of Internal Medicine, Division of Nephrology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390-8856, USA.
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Rönnholm KAR, Holmberg C. Peritoneal dialysis in infants. Pediatr Nephrol 2006; 21:751-6. [PMID: 16583242 DOI: 10.1007/s00467-006-0084-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2005] [Revised: 12/28/2005] [Accepted: 01/03/2006] [Indexed: 11/29/2022]
Abstract
The need for maintenance dialysis for infants is rare, but peritoneal dialysis has been the modality of choice in cases of end-stage renal failure, for technical reasons. Problems include higher mortality rates and an inferior long-term outcome compared with that in older children. Also, no internationally accepted guidelines exist for dialysis in infants. Many children on maintenance peritoneal dialysis in Finland have congenital nephrotic syndrome of the Finnish type (NPHS1), and dialysis is started during infancy. In this commentary we discuss our practice of performing peritoneal dialysis in infants and experiences gathered from the literature.
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Fischbach M, Stefanidis CJ, Watson AR. Guidelines by an ad hoc European committee on adequacy of the paediatric peritoneal dialysis prescription. Nephrol Dial Transplant 2002; 17:380-5. [PMID: 11865081 DOI: 10.1093/ndt/17.3.380] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Michel Fischbach
- Centre Hospitalier Regional et Universitaire, Hopital de Hautepierre, Strasbourg, France
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