Effects of Peritoneal Dialysis with an Overnight Icodextrin Dwell on Parameters of Glucose and LIPID Metabolism

Objective

To examine whether a reduced daily glucose load by overnight application of the less-absorbed glucose polymer icodextrin would have favorable effects on lipid profiles of continuous ambulatory peritoneal dialysis (CAPD) patients.

Study Design

Randomized crossover study with two subsequent periods of 6 weeks.

Setting

Home PD unit of a secondary-care hospital.

Patients

Twenty-one nondiabetic CAPD patients (15 male, 6 female; mean age 50.3 ± 11.8 years).

Intervention

Participants were randomly assigned to receive an overnight dwell with either standard glucose solution or with a 7.5% icodextrin-containing solution.

Main Outcome Measures

Relation between reduction in the total amount of intraperitoneal infused glucose and parameters of glucose (plasma glucose, insulin, and HbA1C) and lipid metabolism [free fatty acids, plasma lip-ids, lipoproteins, and low density lipoprotein (LDL) sub-fraction profile].

Results

After the icodextrin dwells, a reduction of plasma total cholesterol (from 5.43 ± 0.85 to 4.86 ± 0.70 mmol/L, p < 0.001) and LDL cholesterol (from 3.38 ± 0.87 to 2.93 ± 0.73 mmol/L, p = 0.001) was observed. Also, high density lipoprotein (HDL) cholesterol (from 0.95 ± 0.27 to 0.90 ± 0.24 mmol/L, p = 0.029) was reduced, but the plasma total cholesterol-to-HDL ratio remained similar. Plasma free fatty acids and triglyceride levels tended to decrease (from 0.16 ± 0.10 to 0.13 ± 0.08 mmol/L, p = 0.06, and from 2.14 ± 1.96 to 1.92 ± 1.03 mmol/L, respectively). Evaluation of LDL subfraction profiles after ultra-centrifugation showed a more buoyant LDL subfraction profile with fewer dense LDL particles in 6 patients and no changes in 14 patients after icodextrin. The effects on lipids were not accompanied by a decrease in fasting plasma glucose (from 5.76 ± 1.29 to 5.86 ± 0.80 mmol/L) or insulin levels (from 19.5 ± 14.4 to 20.3 ± 13.0 mU/L).

Conclusion

These results suggest a beneficial effect on lipid profiles of CAPD patients with the use of an overnight dwell with icodextrin.

Peritoneal protein leakage, systemic inflammation, and peritonitis risk in patients on peritoneal dialysis

BACKGROUND

Whether peritoneal protein leakage predicts risk for peritonitis in patients on peritoneal dialysis (PD) is unknown. In this observational cohort study, we aimed to determine that association and, further, to explore if it might be explained by systemic inflammation. ♢

METHODS

We prospectively followed 305 incident PD patients to first-episode peritonitis, censoring, or the end of the study. Demographics, comorbidity score, biochemistry, and peritoneal protein clearance (PrC) were collected at baseline. The predictors of first-episode peritonitis were analyzed prospectively. ♢

RESULTS

During follow-up, 14 868 patient months and 251 episodes of peritonitis were observed. The baseline PrC was 73.2 mL/day (range: 53.2 - 102 mL/day). Patients with a high PrC were prone to be older and malnourished. They also had a higher comorbidity score and higher C-reactive protein values. In 132 first episodes of peritonitis, baseline PrC was shown to be a significant independent predictor after adjustment for age, sex, body mass index, diabetes, residual renal function, hemoglobin, and peritoneal transport rate. Systemic inflammatory markers such as serum albumin, C-reactive protein, and interleukin-6 could not explain the association of PrC and high risk for peritonitis. ♢

CONCLUSIONS

Baseline peritoneal protein leakage was able to independently predict risk for peritonitis, which is not explained by systemic inflammation. The underlying mechanisms should be explored in future.

Effect of Peritoneal Dialysis Solution Type on Serum Lipid Levels in End-Stage Renal Disease

Among the different cardiovascular risk factors, lipid abnormalities dominate the high mortality in chronic ambulatory peritoneal dialysis patients. So far, no data comparing the effect of standard glucose-containing, amino acid-containing, and icodextrin-containing peritoneal dialysis solutions on serum lipid concentrations in a chronic ambulatory peritoneal dialysis population are available. To determine the effect of peritoneal dialysis solutions on parameters of lipid metabolism, 67 subjects who had continued their usual dialysis for the last six months were enrolled in the study. Group A consisted of 18 patients who were receiving only glucose-based peritoneal dialysis solutions, group B consisted of 18 patients who were receiving glucose and amino acid-based peritoneal dialysis solutions, and group C consisted of 31 patients who were receiving glucose and icodextrin-based peritoneal dialysis solutions. Serum lipid parameters including total cholesterol, low-density lipoprotein, high-density lipoprotein, triglyceride, and lipoprotein (a) were determined in all groups. No significant difference in serum lipid parameters was found between groups A, B, and C. These results demonstrate the lack of the effect of amino acid or icodextrin-based peritoneal solutions on dyslipidemia of CAPD patients.

Comparative effects of carvedilol and lercanidipine on ultrafiltration and solute transport in CAPD patients

BACKGROUND

Peritonitis, the type of buffer used in the dialysate, continue ambulatory peritoneal dialysis (CAPD) of greater than two years duration, increased exposure to dialysate glucose, diabetes mellitus, and the use of beta blockers may contribute to impaired ultrafiltration.

OBJECTIVES

The aim of the present study is to compare the effects of a calcium-channel blocker and a beta-blocker on the peritoneal transport and clearance.

METHODS

We studied 48 patients with ESRD on chronic peritoneal dialysis, included 27 females and 19 males with mean age 42.6 +/- 16.4 years. Two patients were excluded from the study due to peritonitis. Patients were treated either with carvedilol or lercanidipine. In all patients; peritoneal equilibration test (PET), ultrafiltration (UF), Kt/V ratio, creatinine clearance (CrCl), systolic blood pressure, diastolic blood pressure, serum BUN, creatinine, glucose, sodium, potassium, albumin, cholesterol, and triglyceride values were obtained before and after 8 weeks from the start of the drug treatment.

RESULTS

Lercanidipine and carvedilol showed a good antihypertensive effect in CAPD patients. Both drugs had a good tolerability profile and showed no effect on plasma lipids. There were no differences in terms of PET, ultrafiltration, Kt/V ratio, CrCl, systolic blood pressure, diastolic blood pressure, serum BUN, creatinine, glucose, sodium, and potassium values between both patient groups. After antihypertensive treatment, neither group showed a difference in the above-mentioned parameters (p > 0.05) except potassium, which was significantly higher in the carvedilol group (p < 0.05).

CONCLUSIONS

In CAPD patients. short-term usage of carvedilol has no effect on ultrafiltration and solute transport like lercanidipine. Both drugs showed a good antihypertensive effect.

Evaluation of peritoneal transport properties at onset of peritoneal dialysis and longitudinal follow-up

BACKGROUND

The clinical determinants of baseline peritoneal membrane (PM) transport characteristics, as evaluated by a hypertonic peritoneal equilibration test (PET), remain ill-defined. Likewise, the longitudinal evolution of PM transport properties in peritoneal dialysis (PD) patients given automated PD (APD) and icodextrin still needs to be determined precisely. The aims of the present study were (1) to determine the clinical and biological factors affecting PM transport characteristics at PD onset and (2) to assess the longitudinal evolution of these markers.

METHODS

Seventy-two consecutive patients performed a baseline 3.86% glucose dialysate PET and were enrolled. Subgroups of 35 and 18 patients underwent another PET 1 and 2 year(s) later, respectively, and were included in the longitudinal part. For each patient, clinical and biological data were reviewed and PM transport markers calculated.

RESULTS

At onset of PD, angiotensin-converting enzyme (ACE) inhibitor intake (r = 0.31, P = 0.01), presence of a diabetes (r = 0.26, P = 0.03) and body surface area (BSA) (r = 0.26, P = 0.03) independently affected the mass transfer area coefficient (MTAC) of creatinine. Serum albumin (r = -0.46, P<0.001) and net ultrafiltration (r = -0.33, P = 0.009) inversely correlated with MTAC creatinine. Sodium sieving was inversely correlated with BSA (r = -0.33, P = 0.01). Serum albumin also inversely correlated with albumin clearance (r = -0.39, P = 0.02). Finally, the independent covariates that affected alpha2-macroglobulin clearance were age (P = 0.03), diabetes (P = 0.01) and the level of residual renal function (P<0.01). Serum albumin decreased with time on PD (P = 0.02). A rise in small solute transport and a decrease in net ultrafiltration, but no change in protein clearances, were also observed after 2 years of PD.

CONCLUSIONS

Transport properties across the PM, as evaluated by MTAC creatinine and sodium sieving determinations, are correlated with anthropometric characteristics (BSA) and by comorbid conditions (witnessed by the presence of diabetes, a low serum albumin concentration and the prescription of an ACE inhibitor). The short-term evolution (2 years) of the PM transport properties of patients on APD and icodextrin is still characterized by a progressive increase in small solute transport and a loss of ultrafiltration capacity, as documented in ancient studies, but not with a modification in protein clearances. This conclusion merits, however, to be further evaluated in a larger cohort of PD patients after a longer follow-up.

Effect of valsartan versus lisinopril on peritoneal sclerosis in rats

BACKGROUND

Peritoneal sclerosis (PS) is one of the most serious causes of failure in long-term peritoneal dialysis. Angiotensin II is known to promote fibrosis and inflammation in various tissues. We previously showed that ACE inhibitors (ACEIs) have beneficial effects on hypertonic PD solutions (3.86% PD) induced peritoneal alterations. The aim of this study is to compare the effects of an ACEI and a receptor blocker on peritoneal alterations induced by hypertonic PD solutions in rats.

METHODS

Forty-three non-uremic rats were divided into four groups: group I (Sham) rats received no treatment (n=11), group II received hypertonic (3.86%, 10 ml/day) PD solution (n = 10) and groups III and IV received hypertonic PD solution (10 ml/day) plus 640 mg/L valsartan (n=11) and 100 mg/L lisinopril in drinking water (n = 11). After four weeks, a one-hour peritoneal equilibration test (PET) was performed with 3.86% PD solution. Dialysate-to-plasma urea ratio (D/P urea), glucose reabsorption (D 1 /D 0 glucose), ultrafiltration volume (UF), dialysate protein, TGFbeta 1 and VEGF levels were determined.

RESULTS

Administration of valsartan or lisinopril resulted in preserved UF (8+/-0.8 and 6.7+/-0.7 vs 4.9+/-0.8 mL), D1/D0 glucose (0.69+/-0.05 and 0.62+/-0.05 vs 0.56+/-0.04) and peritoneal thickness (19.4+/-2.9 and 28.5+/-5.2 vs 53+/-3 microm), respectively. Both higher level of TGF beta 1 (206+/-40 vs 474+/-120 pg/mL, p<0.05), and VEGF in dialysate effluent (4+/-0.4 vs 7.9+/-3 pg/mL, p>0.05), was determined in the dextrose group. Both cytokines are partially inhibited by valsartan or lisinopril (p >0.05)

CONCLUSION

Exposure to hypertonic glucose solution resulted in alterations in peritoneal transport manifested by a rapid dissipation of the glucose gradient and resultant impaired UF response. Administration of valsartan or lisinopril led to attenuation of these alterations. We suggest that the equal protection of the peritoneal membrane from the effects of hypertonic glucose was achieved by receptor blockers and ACE inhibitors.

Economic evaluation of centre haemodialysis and continuous ambulatory peritoneal dialysis in Ministry of Health hospitals, Malaysia

BACKGROUND

This is a multi-centre study to determine cost efficiency and cost effectiveness of the Ministry of Health centre haemodialysis and continuous ambulatory peritoneal dialysis (CAPD) programme.

METHODS

Forty-four haemodialysis and 11 CAPD centres were enrolled in this study in 2001. Sixty patients, 30 from each modality, were evaluated. Micro-costing was used to determine costs.

RESULTS

The number of haemodialyses conducted ranged from 402 to 23,000 procedures per year, while for CAPD, output ranged from 70 to 2300 patient months/year. Cost ranged from RM79.61 to RM475.79 per haemodialysis treatment, with a mean cost of RM169 per HD (USD 1 = RM 3.80). The cost of CAPD treatment ranged from RM1400 to RM3200 per patient month, with a mean of RM2186. Both modalities incurred similar outpatient costs. The cost of erythropoeitin per year is RM4500 and RM2500 for haemodialysis and CAPD, respectively. The number of life years saved is 10.96 years for haemodialysis and 5.21 years for CAPD. Cost per life year saved is RM33 642 for haemodialysis and RM31 635 for CAPD. The cost for land, building, equipment, overheads, and staff were higher for haemodialysis, while consumables and hospitalization cost more for CAPD. Sensitivity analysis was performed for two discount rates (3 and 5%), varying erythropoietin doses and maximum and minimum overheads. Relative cost effectiveness of haemodialysis and CAPD was unchanged in all sensitivity scenarios, except for overhead costs, which influenced the cost effectiveness of HD.

CONCLUSION

It is economically viable to promote the use of both CAPD and haemodialysis because the cost effectiveness of both are nearly equal.

Dialysis therapies for end-stage renal disease

End-stage renal disease (ESRD) has various causes that may differ according to country and racial group. Whatever the cause, unless the water, salt, electrolytes, and waste products excreted by normal kidneys are removed, their accumulation will result in death. Removal of these products can be variably achieved by either hemodialysis or peritoneal dialysis. The principles and outcomes of these techniques are described, as are their complications. It is important that these two different methods of treatment are not regarded as competitive, but are integrated, together with renal transplantation where appropriate, into the management of patients with ESRD to optimize both outcome and quality of life.