Overhydration Is a Strong Predictor of Mortality in Peritoneal Dialysis Patients - Independently of Cardiac Failure

On Whether Ca-125 Is the Answer for Diagnosing Overhydration, Particularly in End-Stage Kidney Disease Patients-A Systematic Review

Overhydration (OH) is a prevalent medical problem that occurs in patients with kidney failure, but a specific marker has still not been found. Patients requiring kidney replacement therapy suffer from a water imbalance, which is correlated with mortality rates in this population. Currently, clinicians employ techniques such as bioimpedance spectroscopy (BIS) and ultrasound (USG) markers of overhydration or markers of heart and kidney function, namely NT-pro-BNP, GFR, or creatinine levels. New serum markers, including but not limited to Ca-125, galectin-3 (Gal-3), adrenomedullin (AMD), and urocortin-2 (UCN-2), are presently under research and have displayed promising results. Ca-125, which is a protein mainly used in ovarian cancer diagnoses, holds great potential to become an OH marker. It is currently being investigated by cardiologists as it corresponds to the volume status in heart failure (HF) and ventricular hypertrophy, which are also associated with OH. The need to ascertain a more precise marker of overhydration is urgent mainly because physical examinations are exceptionally inaccurate. The signs and symptoms of overhydration, such as edema or a gradual increase in body mass, are not always present, notably in patients with chronic kidney disease. Metabolic disruptions and cachexia can give a false picture of the hydration status. This review paper summarizes the existing knowledge on the assessment of a patient's hydration status, focusing specifically on kidney diseases and the role of Ca-125.

SGLT2 inhibitors in peritoneal dialysis: a promising frontier toward improved patient outcomes

Peritoneal dialysis (PD) stands as an important modality among kidney replacement therapies for end-stage kidney disease, offering patients remarkable flexibility and autonomy. Despite its widespread use, challenges such as glucose-related complications, peritoneal membrane fibrosis, declining renal function, and cardiovascular risks persist, necessitating innovative therapeutic approaches. Sodium–glucose cotransporter 2 (SGLT2) inhibitors, originally developed for treating type 2 diabetes mellitus, have recently shown promise as add-on therapy for patients with diabetic and non-diabetic chronic kidney disease (CKD), even in advanced stages. This review describes the potential role of SGLT2 inhibitors as a breakthrough therapeutic option in PD, emphasizing their ability to address unmet clinical needs and improve patient outcomes. The multiple effects of SGLT2 inhibitors in CKD, including metabolic modulation, antihypertensive, diuretic, anemia-reducing, antioxidant, and antiinflammatory properties, are reviewed in the context of PD challenges. Additionally, the potentially protective influence of SGLT2 inhibitors on the integrity of the peritoneal membrane and the transport of solutes and water in the peritoneum are emphasized. Despite these encouraging results, the paper highlights the potential risks associated with SGLT2 inhibitors in PD and emphasizes the need for cautious and thorough investigation of dosing, long-term safety considerations, and patient-specific factors through comprehensive clinical trials. Looking forward, the review argues for well-designed studies to evaluate the expanded safety profile of SGLT2 inhibitors in PD, with particular attention paid to peritoneal membrane integrity and overall patient outcomes.

Association of serum thymosin β4 with malnutrition-inflammation-atherosclerosis syndrome in peritoneal dialysis patients: a cross-sectional study

BACKGROUND

Malnutrition-inflammation-atherosclerosis (MIA) syndrome may worsen the prognosis of peritoneal dialysis (PD) patients. Serum thymosin β4 (sTβ4) protects against inflammation, fibrosis and cardiac dysfunction.

OBJECTIVES

The present study aimed to characterize the association between sTβ4 and MIA syndrome as well as to investigate the potential of regulating sTβ4 to improve the prognosis of PD patients.

METHODS

We performed a cross-sectional, single-center pilot study involving 76 PD patients. Demographic characteristics, clinical characteristics, nutritional profiles, inflammatory mediators, atherosclerosis-related factors and sTβ4 levels were collected and subjected to association analysis for sTβ4 and MIA syndrome.

RESULTS

sTβ4 levels did not significantly vary with sex or primary disease in PD patients. Ages and PD features did not vary between patients with different levels of sTβ4. PD patients with higher levels of sTβ4 had significantly higher levels of nutritional indicators, including subjective global nutritional assessment (SGA) (p < 0.001) and serum albumin (ALB) (p < 0.001) but lower levels of inflammatory and atherosclerotic indicators, including serum C reaction protein (CRP) (p = 0.009), the right common carotid artery (RCCA) intimal thickness (p < 0.001) and the left common carotid artery (LCCA) intimal thickness (p = 0.02). Correlation analysis showed that sTβ4 was positively associated with SGA (p < 0.001) and serum ALB (p < 0.001) but negatively associated with CRP (p = 0.020), RCCA intimal thickness (p < 0.001) and LCCA intimal thickness (p = 0.033). In multiple adjusted models, the prevalence of MIA syndrome was significantly decreased in PD patients with increased levels of sTβ4 when patients without MIA syndrome were compared to those with all indicators of MIA syndrome (OR = 0.996, 95% CI 0.993-0.999, p = 0.003) or those with at least one indicator of MIA syndrome (OR = 0.997, 95% CI 0.995-0.998, p < 0.001).

CONCLUSIONS

The sTβ4 level decreases in PD patients with MIA syndrome. The prevalence of MIA syndrome decreases significantly as the level of sTβ4 increases in PD patients.

Five Things to Know About Volume Overload in Peritoneal Dialysis

Volume overload in peritoneal dialysis (PD) is common and associated with significant morbidity and mortality. If left untreated, it can result in premature technique failure in patients receiving PD. Practitioners should be aware of common causes and formulate a stepwise approach in the management of volume overload.

Optimization of the Chronic Kidney Disease-Peritoneal Dialysis App to Improve Care for Patients on Peritoneal Dialysis in Northeast Thailand: User-Centered Design Study

Background

The prevalence of peritoneal dialysis (PD) in Thailand is increasing rapidly in part because of Thailand’s Peritoneal Dialysis First policy. PD is a home-based renal replacement therapy in which patients with chronic kidney disease perform up to 4 exchanges of dialysate fluid per day in the peritoneal cavity. Overhydration is one of the most common complications in patients on PD and is associated with increased morbidity and mortality. To monitor hydration status, patients collect hydration metrics, including body weight, blood pressure, urine output, and ultrafiltration volume, from each dialysis cycle and enter this information into a PD logbook. This information is reviewed bimonthly at PD clinic appointments. The chronic kidney disease-PD (CKD-PD) app with near-field communication (NFC) and optical character recognition (OCR) was developed to automate hydration metric collection. The information was displayed in the app for self-monitoring and uploaded to a database for real-time monitoring by the PD clinic staff. Early detection and treatment of overhydration could potentially reduce the morbidity and mortality related to overhydration.

Objective

This study aims to identify usability issues and technology adoption barriers for the CKD-PD app with NFC and OCR and a monitoring system and to use this information to make rapid cycle improvements.

Methods

A multidisciplinary team of nephrologists, PD clinic nurses, computer programmers, and engineers trained and observed 2 groups of 5 participants in the use of the CKD-PD app with NFC and OCR and a monitoring system. The participants were observed using technology in their homes in 3 phases. The data collected included the Unified Theory of Acceptance and Use of Technology questionnaire, think-aloud observation, user ratings, completion of hydration metrics, and upload of hydration metrics to the central database. These results were used by the team between phases to improve the functionality and usefulness of the app.

Results

The CKD-PD app with NFC and OCR and a monitoring system underwent 3 rapid improvement cycles. Issues were identified regarding the usability of the NFC and OCR data collection, app stability, user interface, hydration metric calculation, and display. NFC and OCR improved hydration metric capture; however, issues remained with their usability. App stability and user interface issues were corrected, and hydration metrics were successfully uploaded by the end of phase 3. Participants’ scores on technology adoption decreased but were still high, and there was enthusiasm for the self-monitoring and clinical communication features.

Conclusions

Our rapid cycle process improvement methodology identified and resolved key barriers and usability issues for the CKD-PD app with NFC and OCR and a monitoring system. We believe that this methodology can be accomplished with limited training in data collection, statistical analysis, and funding.

Optimised versus standard automated peritoneal dialysis regimens pilot study (OptiStAR): A randomised controlled crossover trial

BACKGROUND

The continuous global rise of end-stage kidney disease creates a growing demand of economically beneficial home-based kidney replacement therapies such as peritoneal dialysis (PD). However, undesirable absorption and exposure of peritoneal tissues to glucose remain major limitations of PD.

METHODS

We compared a reference (standard) automated PD regimen 6 × 2 L 1.36% glucose (76 mmol/L) over 9 h with a novel, theoretically glucose sparing (optimised) prescription consisting of 'ultrafiltration cycles' with high glucose strength (126 mmol/L) and 'clearance cycles' with ultra-low, physiological glucose (5 mmol/L) for approximately 40% of the treatment time. Twenty-one prevalent PD patients underwent the optimised regimen (7 × 2 L 2.27% glucose + 5 × 2 L 0.1% glucose over 8 h) and the standard regimen in a crossover fashion. Six patients were excluded from data analysis.

RESULTS

Median glucose absorption was 43 g (IQR 41-54) and 44 g (40-55) for the standard and optimised intervention, respectively (p = 1). Ultrafiltration volume, weekly Kt/V creatinine and urea were significantly improved during optimised interventions, while no difference in sodium removal was detected. Post hoc analysis showed significantly improved ultrafiltration efficiency (ml ultrafiltration per gram absorbed glucose) during optimised regimens. No adverse events were observed except one incidence of drain pain.

CONCLUSION

Optimised treatments were feasible and well tolerated in this small pilot study. Despite no difference in absorbed glucose, results indicate possible improvements of ultrafiltration efficiency and small solute clearances by optimised regimens. Use of optimised prescriptions as glucose sparing strategy should be evaluated in larger study populations.

Acquired Decline in Ultrafiltration in Peritoneal Dialysis: The Role of Glucose

Ultrafiltration is essential in peritoneal dialysis (PD) for maintenance of euvolemia, making ultrafiltration insufficiency-preferably called ultrafiltration failure-an important complication. The mechanisms of ultrafiltration and ultrafiltration failure are more complex than generally assumed, especially after long-term treatment. Initially, ultrafiltration failure is mainly explained by a large number of perfused peritoneal microvessels, leading to a rapid decline of the crystalloid osmotic gradient, thereby decreasing aquaporin-mediated free water transport. The contribution of peritoneal interstitial tissue to ultrafiltration failure is limited during the first few years of PD, but becomes more important in long-term PD due to the development of interstitial fibrosis, which mainly consists of myofibroblasts. A dual hypothesis has been developed to explain why the continuous exposure of peritoneal tissues to the extremely high dialysate glucose concentrations causes progressive ultrafiltration decline. First, glucose absorption causes an increase of the intracellular NADH/NAD⁺ ratio, also called pseudohypoxia. Intracellular hypoxia stimulates myofibroblasts to produce profibrotic and angiogenetic factors, and the glucose transporter GLUT-1. Second, the increased GLUT-1 expression by myofibroblasts increases glucose uptake in these cells, leading to a reduction of the osmotic gradient for ultrafiltration. Reduction of peritoneal glucose exposure to prevent this vicious circle is essential for high-quality, long-term PD.

Effect of bioimpedance-defined overhydration parameters on mortality and cardiovascular events in patients undergoing dialysis: a systematic review and meta-analysis

OBJECTIVE

To evaluate the role of bioimpedance-defined overhydration (BI-OH) parameters in predicting the risk of mortality and cardiovascular (CV) events in patients undergoing dialysis.

METHODS

We searched multiple electronic databases for studies investigating BI-OH indicators in the prediction of mortality and CV events through 23 May 2020. We assessed the effect of BI-OH indexes using unadjusted hazard ratios (HRs) and 95% confidence intervals (CIs). Sensitivity analysis was used for each outcome.

RESULTS

We included 55 studies with 104,758 patients in the meta-analysis. Extracellular water/total body water (ECW/TBW) >0.4 (HR 5.912, 95% CI: 2.016-17.342), ECW/intracellular water (ICW) for every 0.01 increase (HR 1.041, 95% CI: 1.031-1.051), and OH/ECW >15% (HR 2.722, 95% CI: 2.005-3.439) increased the risk of mortality in patients receiving dialysis. ECW/TBW >0.4 (HR 2.679, 95% CI: 1.345-5.339) and ECW/ICW per increment of 10% (HR 1.032, 95% CI: 1.017-1.047) were associated with an increased risk of CV events in patients undergoing dialysis. A 1-degree increase in phase angle was a protective factor for both mortality (HR 0.676, 95% CI: 0.474-0.879) and CV events (HR 0.736, 95% CI: 0.589-0.920).

CONCLUSIONS

BI-OH parameters might be independent predictors for mortality and CV events in patients undergoing dialysis.

Hemodiafiltration maintains a sustained improvement in blood pressure compared to conventional hemodialysis in children-the HDF, heart and height (3H) study

BACKGROUND

Hypertension is prevalent in children on dialysis and associated with cardiovascular disease. We studied the blood pressure (BP) trends and the evolution of BP over 1 year in children on conventional hemodialysis (HD) vs. hemodiafiltration (HDF).

METHODS

This is a post hoc analysis of the "3H - HDF-Hearts-Height" dataset, a multicenter, parallel-arm observational study. Seventy-eight children on HD and 55 on HDF who had three 24-h ambulatory BP monitoring (ABPM) measures over 1 year were included. Mean arterial pressure (MAP) was calculated and hypertension defined as 24-h MAP standard deviation score (SDS) ≥95th percentile.

RESULTS

Poor agreement between pre-dialysis systolic BP-SDS and 24-h MAP was found (mean difference - 0.6; 95% limits of agreement -4.9-3.8). At baseline, 82% on HD and 44% on HDF were hypertensive, with uncontrolled hypertension in 88% vs. 25% respectively; p < 0.001. At 12 months, children on HDF had consistently lower MAP-SDS compared to those on HD (p < 0.001). Over 1-year follow-up, the HD group had mean MAP-SDS increase of +0.98 (95%CI 0.77-1.20; p < 0.0001), whereas the HDF group had a non-significant increase of +0.15 (95%CI -0.10-0.40; p = 0.23). Significant predictors of MAP-SDS were dialysis modality (β = +0.83 [95%CI +0.51 - +1.15] HD vs. HDF, p < 0.0001) and higher inter-dialytic-weight-gain (IDWG)% (β = 0.13 [95%CI 0.06-0.19]; p = 0.0003).

CONCLUSIONS

Children on HD had a significant and sustained increase in BP over 1 year compared to a stable BP in those on HDF, despite an equivalent dialysis dose. Higher IDWG% was associated with higher 24-h MAP-SDS in both groups.

Impact of extracellular-to-intracellular fluid volume ratio on albuminuria in patients with type 2 diabetes: A cross-sectional and longitudinal cohort study

AIMS/INTRODUCTION

Body fluid volume imbalance is common in patients with kidney failure, and is associated with all-cause mortality. This study aimed to investigate the association between fluid volume imbalance and albuminuria in patients with type 2 diabetes mellitus without kidney failure.

MATERIALS AND METHODS

Using data from one cohort study, a baseline cross-sectional study of 432 participants and a longitudinal cohort study of 368 participants who could follow up was carried out. Body fluid imbalance was determined by measuring the extracellular water (ECW)-to-intracellular water (ICW) ratio (ECW/ICW) using bioelectrical impedance analysis. A change in the urinary albumin-to-creatinine ratio (ACR) was defined as the ratio of urinary ACR at follow up to that at baseline. The ECW/ICW ratio was compared with the level of albuminuria.

RESULTS

In this cross-sectional study, the ECW/ICW ratio increased with the level of albuminuria. There was an association between the ECW/ICW ratio and logarithms of urinary ACR after adjusting for covariates (β = 0.205, P < 0.001). Furthermore, the ECW/ICW ratio was associated with a change in the urinary ACR after adjusting for covariates (β = 0.176, P = 0.004) in this longitudinal study. According to the receiver operating characteristic curve, the optimal cut-off point of the ECW/ICW ratio for incident macroalbuminuria, defined as ACR >300 mg/gCr, was 0.648 (area under the curve 0.78, 95% confidence interval 0.58-0.90).

CONCLUSIONS

The ECW/ICW ratio is independently associated with the level of albuminuria in patients with type 2 diabetes mellitus without kidney failure. This reinforces the importance of monitoring fluid balance in patients with type 2 diabetes mellitus.

Ratio of Overhydration and Extracellular Water Versus Ratio of Extracellular Water and Body Cell Mass in the Assessment of Fluid Status in Patients With Acute Kidney Injury Requiring Kidney Replacement Therapy: A Cohort Study

OBJECTIVES

The aim of this study is to analyze the association between the ratio of overhydration and extracellular water (OH/ECW) and the ratio of extracellular water and body cell mass (ECW/BCM) measured by bioelectrical impedance and outcomes of patients with acute kidney injury (AKI) requiring kidney replacement therapy (KRT).

METHODS

Patients with severe AKI treated with KRT in our hospital between September 2016 and August 2018 were enrolled. These patients were assessed using a body composition monitor before KRT, and on the 3rd day and the 7th day after initiation of KRT. The predictors mainly included OH/ECW and ECW/BCM. The association between all-cause mortality and predictors were analyzed using Cox regression.

RESULTS

A total of 152 patients were included in this study with a median follow-up of 39 (interquartile range 8-742) days. The 28-day mortality, 90-day mortality, and 1-year mortality were 46.7%, 54.6%, and 60.5%, respectively. A high ratio of OH/ECW (adjusted hazard ratio per standard deviation, 1.45; 95% confidence interval = 1.15-1.82, P = .002) and a high ratio of ECW/BCM (adjusted hazard ratio per standard deviation, 1.33, 95% confidence interval = 1.07-1.64, P = .009) before KRT were associated with all-cause mortality during follow-up. Higher ECW/BCM rather than OH/ECW at 7th day was associated with poorer outcomes. Furthermore, a reduction of OH/ECW with an increase of ECW/BCM had higher 1-year mortality as compared to others (85.7% vs. 51.2%, P = .004) in patients who survived 7 days after KRT initiation.

CONCLUSIONS

ECW/BCM performed better than OH/ECW in assessment of fluid status in AKI patients requiring KRT. This study suggested that a simple reduction of OH/ECW without decreasing ECW/BCM may not improve outcomes.

Assessment of Hydration Status in Peritoneal Dialysis Patients: Validity, Prognostic Value, Strengths, and Limitations of Available Techniques

BACKGROUND

The majority of patients undergoing peritoneal dialysis (PD) suffer from volume overload and this overhydration is associated with increased mortality. Thus, optimal assessment of volume status in PD is an issue of paramount importance. Patient symptoms and physical signs are often unreliable indexes of true hydration status.

SUMMARY

Over the past decades, a quest for a valid, reproducible, and easily applicable technique to assess hydration status is taking place. Among existing techniques, inferior vena cava diameter measurements with echocardiography and natriuretic peptides such as brain natriuretic peptide and N-terminal pro-B-type natriuretic peptide were not extensively examined in PD populations; while having certain advantages, their interpretation are complicated by the underlying cardiac status and are not widely available. Bioelectrical impedance analysis (BIA) techniques are the most studied tool assessing volume overload in PD. Volume overload assessed with BIA has been associated with technique failure and increased mortality in observational studies, but the results of randomized trials on the value of BIA-based strategies to improve volume-related outcomes are contradictory. Lung ultrasound (US) is a recent technique with the ability to identify volume excess in the critical lung area. Preliminary evidence in PD showed that B-lines from lung US correlate with echocardiographic parameters but not with BIA measurements. This review presents the methods currently used to assess fluid status in PD patients and discusses existing data on their validity, applicability, limitations, and associations with intermediate and hard outcomes in this population. Key Message: No method has proved its value as an intervening tool affecting cardiovascular events, technique, and overall survival in PD patients. As BIA and lung US estimate fluid overload in different compartments of the body, they can be complementary tools for volume status assessment.

Serum levels of protein carbonyl, a marker of oxidative stress, are associated with overhydration, sarcopenia and mortality in hemodialysis patients

Background

Increased oxidative stress in end-stage renal disease is regarded as one of the important mechanisms in the atherosclerosis and muscle wasting. However, studies examining the clinical significance of oxidative stress by direct measurement of these markers and its association with volume status and sarcopenia are limited.

Methods

A follow-up cross-sectional study was performed in stable hemodialysis (HD) patients and serum protein carbonyl levels were measured as a biomarker of oxidative stress. Additionally, multi-frequency body composition analysis, handgrip strength (HGS) and nutritional assessments were performed at baseline.

Results

Eighty-eight patients undergoing HD were included and 30 (34.1%) patients died during a mean follow-up of 5.2 years. The mean patient age was 60.6 ± 13.5 years, and the mean HD duration was 50.8 ± 41.3 months. In total, 16 patients (18.2%) were overhydrated, 49 (55.7%) had low HGS and 36 (40.9%) had low muscle mass. Serum protein carbonyl levels were associated with serum levels of albumin, prealbumin and transferrin, hydration status and low HGS. Overhydration (odds ratio [OR] 7.01, 95% CI 1.77–27.79, p = 0.006), prealbumin (OR 0.91, 95% CI 0.83–0.99, p = 0.030), subjective global assessment (OR 3.52, 95% CI 1.08–11.46, p = 0.037) and sarcopenia (OR 3.41, 95% CI 1.02–11.32, p = 0.046) were significantly related to increased serum protein carbonyl levels. Multivariate analysis showed that the serum levels of protein carbonyl (Hazard ratio [HR] 2.37, 95% CI 1.02–5.55, p = 0.036), albumin (HR 0.17, 95% CI 0.06–0.46, p = 0.003), prealbumin (HR 0.86, 95% CI 0.80–0.92, p = 0.001), overhydration (HR 2.31, 95% CI 1.26–8.71, p = 0.015) and sarcopenia (HR 2.72, 95% CI 1.11–6.63, p = 0.028) were independent determinants of all-cause mortality.

Conclusions

Serum protein carbonyl was significantly associated with overhydration, nutritional status and sarcopenia, and could be a new predictor of mortality in patients undergoing HD.

Comparative Performance of Body Composition Parameters in Prediction of Death in Hospitalized Patients on Maintenance Hemodialysis: A Cohort Study

We compared the prognostic value of nutritional or volumetric parameters measured by body composition in hospitalized patients on maintenance hemodialysis. We conducted a cohort study to assess the association of different parameters of body composition with all-cause mortality in inpatients admitted to our nephrology department from January 2014 to December 2016. Of the 704 study patients, 160 (22.7%) died during a median follow-up of 33 months. In multivariate adjusted Cox models, higher ratio of extracellular water to body cell mass (ECW/BCM) (adjusted HR per 1-SD, 1.49; 95% CI, 1.19 to 1.85), lower lean tissue index (LTI) (adjusted HR per 1-SD, 0.70; 95% CI, 0.57 to 0.86) and lower body cell mass index (BCMI) (adjusted HR per 1-SD, 0.70; 95% CI, 0.58 to 0.85) were associated with a significantly greater risk of death. When these parameters were added to the fully adjusted model, BCMI performed best in improving the predictability for all-cause mortality (integrated discrimination improvement = 0.02, P = 0.04; net reclassification index = 0.11, P = 0.04). Among body composition indexes, ECW/BCM was the most relevant fluid volume indices to mortality and BCMI and LTI were the most relevant nutritional status indices to mortality in maintenance hemodialysis patients.

Association of NT-proBNP and BNP With Future Clinical Outcomes in Patients With ESKD: A Systematic Review and Meta-analysis

RATIONALE & OBJECTIVE

Use of brain natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) for cardiovascular (CV) risk assessment in patients with end-stage kidney disease (ESKD) remains unclear. We examined the associations between different threshold elevations of these peptide levels and clinical outcomes in patients with ESKD.

STUDY DESIGN

Systematic review and meta-analysis.

SETTING & STUDY POPULATIONS

We searched MEDLINE and EMBASE (through September 2019) for observational studies of adults with ESKD (estimated glomerular filtration rate≤15mL/min/1.73m² or receiving maintenance dialysis).

SELECTION CRITERIA FOR STUDIES

Studies that reported NT-proBNP or BNP levels and future CV events, CV mortality, or all-cause mortality.

DATA EXTRACTION

Cohort characteristics and measures of risk associated with study-specified peptide thresholds.

ANALYTICAL APPROACH

Hazard ratios (HRs) for clinical outcomes associated with different NT-proBNP and BNP ranges were categorized into common thresholds and pooled using random-effects meta-analysis.

RESULTS

We identified 61 studies for inclusion in our review (19,688 people). 49 provided sufficient detail for inclusion in meta-analysis. Pooled unadjusted HRs for CV mortality were progressively greater for greater thresholds of NT-proBNP, from 1.45 (95% CI, 0.91-2.32) for levels>2,000pg/mL to 5.95 (95% CI, 4.23-8.37) for levels>15,000pg/mL. Risk for all-cause mortality was significantly higher at all NT-proBNP thresholds ranging from> 1,000 to> 20,000pg/mL (HR range, 1.53-4.00). BNP levels>550pg/mL were associated with increased risk for CV mortality (HR, 2.54; 95% CI, 1.49-4.33), while the risks for all-cause mortality were 2.04 (95% CI, 0.82-5.12) at BNP levels>100pg/mL and 2.97 (95% CI, 2.21-3.98) at BNP levels>550pg/mL. Adjusted analyses demonstrated similarly greater risks for CV and all-cause mortality with greater NT-proBNP concentrations.

LIMITATIONS

Incomplete outcome reporting and risk for outcome reporting bias. Estimation of risk for CV events for specific thresholds of both peptides were limited by poor precision.

CONCLUSIONS

ESKD-specific NT-proBNP and BNP level thresholds of elevation are associated with increased risk for CV and all-cause mortality. This information may help guide interpretation of NT-proBNP and BNP levels in patients with ESKD.

Volume management as a key dimension of a high-quality PD prescription

BACKGROUND

Appropriate volume control is one of the key goals in a peritoneal dialysis (PD) prescription. As such it is an important component of the International Society of Peritoneal Dialysis (ISPD) guideline for "High-quality PD prescription" necessitating a review of the literature on volume management. The workgroup recognized the importance of including within its scope measures of volume status and blood pressure in prescribing high-quality PD therapy.

METHODS

A Medline and PubMed search for publications addressing volume status and its management in PD since the publication of the 2015 ISPD Adult Cardiovascular and Metabolic Guidelines, from October 2014 through to July 2019, was conducted.

RESULTS

There were no randomized controlled trials on blood pressure intervention and six randomized trials of bioimpedance-guided volume management. Generally, all studies were of small sample size, short duration, and used surrogate markers as primary outcomes. As a consequence, only "practice points" were drawn. High-quality goal-directed PD prescription should aim to achieve and maintain clinical euvolemia taking residual kidney function and its preservation into account, so that both fluid removal from peritoneal ultrafiltration and urine output are considered and residual kidney function is not compromised. Blood pressure should be included as a key objective parameter in assessing the quality of PD prescription but there is currently no evidence for a specific target in PD. Clinical examination remains the keystone of routine clinical care.

CONCLUSIONS

High-quality goal-directed PD prescription should include volume management as one of the key dimensions.

The efficacy of managing fluid overload in chronic peritoneal dialysis patients by a structured nurse-led intervention protocol

Background

Extracellular volume overload is a common problem in peritoneal dialysis (PD) patients and is associated with excessive mortality. We determine the effectiveness of treating PD patients with extracellular volume overload by a structured nurse-led intervention program.

Methods

The hydration status of PD patients was screened by bioimpedance spectroscopy (BIS). Fluid overload was defined as overhydration volume ≥ 2 L. Patients were classified into Symptomatic and Asymptomatic Groups and were managed by a structured nurse-led intervention protocol that focused on education and motivation. Hypertonic cycles were given for short term symptom relief for the Symptomatic group. Patients were followed for 12 weeks for the change in volume status, blood pressure, knowledge and adherence as determined by standard questionnaires.

Results

We recruited 103 patients (53 Symptomatic, 50 Asymptomatic Group. There was a significant reduction in overhydration volume 4 weeks after intervention, which was sustained by week 12; the overall reduction in overhydration volume was 0.96 ± 1.43 L at 4 weeks, and 1.06 ± 1.70 L at 12 weeks (p < 0.001 for both). The improvement was significant for both Symptomatic and Asymptomatic Groups. There was a concomitant reduction in systolic blood pressure in the Asymptomatic (146.9 ± 20.7 to 136.9 ± 19.5 mmHg, p = 0.037) but not Symptomatic group. The scores of knowledge, adherence to dietary control and advices on daily habit at week 4 were all significantly increased, and the improvement was sustained at week 12.

Conclusions

The structured nurse-led intervention protocol has a lasting benefit on the volume status of PD patients with extracellular volume overload. BIS screening allows prompt identification of volume overload in asymptomatic patients, and facilitates a focused effort on this high risk group.

Impact of body mass index on survival in patients undergoing peritoneal dialysis: Analysis of data from the Insan Memorial End-Stage Renal Disease Registry of Korea (1985-2014)

Background

Significant increases in the prevalence of obesity have been observed among patients with peritoneal dialysis (PD). The impact of body mass index (BMI) on survival remains unknown in Korean PD patients.

Methods

Among data of 80,674 patients on PD acquired from the Insan Memorial ESRD Registry database for the years 1985 to 2014, 6,071 cases were analyzed. Subjects were classified by baseline BMI; < 21.19 kg/m² (quartile 1, n = 1,518), 21.19 to 23.18 kg/m² (quartile 2, reference; n = 1,453), 23.19 to 25.71 kg/m² (quartile 3, n = 1,583), and > 25.71 kg/m² (quartile 4, n = 1,517).

Results

Mean age was 65.8 years, and baseline BMI was 23.57 kg/m². Numbers of male and diabetic patients were 3,492 (57.5%) and 2,192 (36.1%), respectively. Among 6,071 cases, 2,229 (36.7%) all-cause deaths occurred. As a whole, Kaplan–Meier survival curves according to BMI quartiles was significantly different (P = 0.001). All-cause mortality was significantly higher in quartile 4 than in the reference (hazard ratio [HR] = 1.154, 95% confidence interval [CI], 1.025–1.300; P = 0.018). There was no statistical difference in all-cause mortality among BMI quartiles in diabetic patients on PD. In non-diabetic patients, all-cause mortality of quartiles 1 and 3 was not different from the reference, but the HR was 1.176 times higher in quartile 4 (95% CI, 1.024–1.350; P = 0.022).

Conclusion

Baseline BMI > 25.71 kg/m² seems to be an important risk factor for all-cause mortality in Korean PD patients.

Evolution Over Time of Volume Status and PD-Related Practice Patterns in an Incident Peritoneal Dialysis Cohort

BACKGROUND AND OBJECTIVES

Volume overload is frequent in prevalent patients on kidney replacement therapies and is associated with outcome. This study was devised to follow-up volume status of an incident population on peritoneal dialysis (PD) and to relate this to patient-relevant outcomes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This prospective cohort study was implemented in 135 study centers from 28 countries. Incident participants on PD were enrolled just before the actual PD treatment was started. Volume status was measured using bioimpedance spectroscopy before start of PD and thereafter in 3-month intervals, together with clinical and laboratory parameters, and PD prescription. The association of volume overload with time to death was tested using a competing risk Cox model.

RESULTS

In this population of 1054 participants incident on PD, volume overload before start of PD amounted to 1.9±2.3 L, and decreased to 1.2±1.8 L during the first year. At all time points, men and participants with diabetes were at higher risk to be volume overloaded. Dropout from PD during 3 years of observation by transfer to hemodialysis or transplantation (23% and 22%) was more prevalent than death (13%). Relative volume overload >17.3% was independently associated with higher risk of death (adjusted hazard ratio, 1.59; 95% confidence interval, 1.08 to 2.33) compared with relative volume overload ≤17.3%. Different practice patterns were observed between regions with respect to proportion of patients on PD versus hemodialysis, selection of PD modality, and prescription of hypertonic solutions.

CONCLUSIONS

In this large cohort of incident participants on PD, with different treatment practices across centers and regions, we found substantial volume overload already at start of dialysis. Volume overload improved over time, and was associated with survival.

Persistent overhydration is associated with a significant risk of peritoneal infection by enteric pathogens in patients treated with peritoneal dialysis

BACKGROUND

Overhydration (OH) complicates frequently the clinical course of Peritoneal Dialysis (PD) patients, and keeps a controversial association with the risk of peritoneal infection. The main objective of this study was to disclose an association between persistent OH and the risk of enteric peritonitis in a relatively large sample of patients undergoing PD.

METHOD

Following a prospective design, we monitorized systematically body composition of patients treated with PD in our unit (2011-2016), searching for a correlation with the ensuing risk of peritonitis, with an emphasis on the association between persistent OH (main study variable) and the risk of infection by enteric pathogens (main outcome). Essential demographic, clinical and laboratory variables with a potential influence on the risk of peritonitis were recorded. We used multivariate survival analysis to clarify the specific effect of different body composition parameters on the main outcome.

MAIN RESULTS

We included 139 patients for analysis (mean follow-up 24 months). Sixty-three patients suffered at least one peritonitis, and 17 had at least one diagnosis of enteric peritonitis. Univariate analysis disclosed a general trend to an increased risk of enteric peritonitis in overhydrated patients, as evidenced by associations of this outcome with mean extracellular water/intracellular water (ECW/ICW) (p=.007), OH/ECW (p=.033) and ECW/total body water (ECW/TBW) (p=.004) ratios, but not with absolute OH values. Multivariate analysis confirmed similar associations or trends (RR: 3.48, 95% CI: 1.03-14.59; p=.046, highest versus lowest tertile of ECW/ICW, RR: 2.31, 95% CI: 0.98-6.56; p=.061, highest versus lowest tertile of OH/ECW, and RR: 6.33, 95% CI: 1.37-19.37; p=.011, highest versus lowest tertile of ECW/TBW). On the contrary, no apparent association was detected between OH and the overall risk of peritoneal infection.

CONCLUSION

Persistent overhydration portends a significant risk of peritoneal infection by enteric pathogens, among patients undergoing chronic PD.

Fluid status assessment in hemodialysis patients and the association with outcome: review of recent literature

PURPOSE OF REVIEW

In this review, we will discuss the most recent literature regarding fluids status assessment in hemodialysis patients, and the associations with outcome.

RECENT FINDINGS

Research toward technique-assisted assessment of fluid status in hemodialysis patients has been going on for many years. However, there is no absolute agreement between techniques, such as bioimpedance, lung ultrasound, biochemical markers or vena caval diameter, likely because they reflect different fluid compartments with potentially altered distribution in hemodialysis patients. Recent studies, mostly based on bioimpedance, have shown not only an association of severe, but also of moderate predialysis fluid overload with overall survival. Also predialysis fluid depletion has been found to associate with and increased mortality risk. Interventional studies with fluid-guided management are scarce and outline the difficulties of achieving dry weight is the dialysis population.

SUMMARY

Optimal estimation of predialysis fluid status remains challenging and may require a combination of clinical and technical derived parameters. There appears to be a narrow window of optimal predialysis fluid status. Further clinical studies are necessary to identify strategies to improve survival in hemodialysis patients with abnormalities in fluid status.

Outcomes and Challenges of a PD-First Program, a South-African Perspective

BACKGROUND

South Africa (SA) currently performs the most peritoneal dialysis (PD) in Africa. Yet outcome data on PD programs on the continent are limited. With the escalating need for renal replacement, PD remains a life-saving modality especially as hemodialysis is limited in the public sector. This study aims to evaluate and report the outcomes of a PD-First program performed in a resource-limited setting and identify factors linked to poor outcomes.

METHODS

This observational cohort study was performed at Groote Schuur Hospital, analyzing all PD patients retrospectively from January 2008 to June 2014 and thereafter prospectively until June 2015. Variables included demographics, adequacy, modality, fluid status, cardiovascular disease, and diabetes. The influence of these variables on peritonitis rate, technique survival, and patient survival was assessed.

RESULTS

In total, 230 patients were initiated on PD, 31 of whom excluded as they were on PD for < 90 days. The mean age was 39.7 ± 10.4 years (standard deviation [SD]), 49.8% were male, 63.8% were mixed ancestry and 9.8 % were diabetic at dialysis initiation. The average length of time on PD was 17 months (interquartile range [IQR] 8 - 32). The peritonitis rate was 0.87 (confidence interval [CI] 7.8 - 9.7) events per patient year. The 1-, 2- and 5-year patient and technique survival was 91.3%, 79.6%, 50.2% and 85.0%, 75.2%, 45.0%, respectively. Diabetes subdistribution hazard ratio (SHR) 3.16 (95% CI 1.34 - 7.45, p = 0.009) strongly predicted an increased cumulative incidence for death when accounting for competing risks. African ethnicity SHR 2.16 (95% CI 1.26 - 3.71, p = 0.005) was a strong predictor of increased cumulative incidence for technique failure.

CONCLUSIONS

In our PD-First program the results are encouraging, despite the lack of home visits due to safety, resource limitations, and a high disease burden. Technique failure in the African race needs further evaluation. Peritoneal dialysis remains a viable, life-saving alternative in an African setting.

Clinical Significance of Phase Angle in Non-Dialysis CKD Stage 5 and Peritoneal Dialysis Patients

Background: Fluid overload and protein-energy wasting (PEW) are common in patients with end-stage renal disease (ESRD) and lead to a poor prognosis. We aimed to evaluate the volume and nutritional status of ESRD patients and to determine the clinical significance of phase angle (PhA). Methods: This study was a cross-sectional comparison of bioimpedance spectroscopy (BIS) findings in patients with non-dialysis chronic kidney disease (CKD) stage 5 (CKD5-ND, N = 80) and age/sex-matched peritoneal dialysis patients (PD, N = 80). PEW was defined as a PhA less than 4.5°. Results: The PhA was found to be positively associated with a geriatric nutritional risk index (GNRI, r = 0.561, p < 0.001), lean tissue index (LTI, r = 0.473, p < 0.001), and albumin (r = 0.565, p < 0.001) while OH/ECW (r = −0.824, p < 0.001) showed an inverse correlation. The CKD5-ND group had more overhydration (p = 0.027). The PD group had significantly higher PhA (p = 0.023), GNRI (p = 0.005), hemoglobin (p < 0.001), and albumin (p = 0.003) than the CKD5-ND group. The cut-off values predicting PEW were found to be 3.55 g/dL for albumin, 94.9 for GNRI, and 12.95 kg/m² for LTI in PD patients. Conclusions: This study demonstrated that PhA could be used as a marker to reflect nutritional status in patients with ESRD. Since BIS can inform both volume and nutritional status, regular monitoring will provide the basis for active correction of fluid overload and nutritional supplementation, which may improve outcomes in patients with ESRD.

Hydration and nutritional status in patients on home-dialysis-A single centre study

BACKGROUND

Over-hydration (OH) and malnutrition are prevalent among patients on dialysis therapy. The prevalence of OH and malnutrition as well as the risk factors associated with OH and malnutrition in our patients on home peritoneal dialysis (PD) and home haemodialysis (HD) are examined.

DESIGN AND METHODS

This was a cross-sectional study. The hydration and nutritional status of the study groups were assessed by a Body Composition Monitor. Patients who were stable on home dialysis therapy for over one year were invited to participate. Univariate and multivariate analyses were performed to identify associated factors and determine the predictors of OH and malnutrition, respectively.

RESULTS

Eighty-eight patients (41 PD and 47 home HD) were recruited. A 32.95% of our patients on home dialysis therapy were in OH status. There was a significance difference in the prevalence of hydration status between patients on PD and home HD (p = 0.014), as overhydration was more common in patients on PD than home HD (46.34 vs. 21.28%). Dehydration was more common in patients on home HD than PD (29.79 vs. 9.76%). Male gender, decreasing haemoglobin level and presence of diabetes mellitus (DM) were risk factors of OH on multivariable analysis. There was no significance difference in the prevalence of malnutrition between patients on PD and home HD (p = 0.27). Increasing Fat Tissue Index (FTI), height and patients on PD therapy were at higher risk of malnutrition.

CONCLUSION

OH and malnutrition were prevalent patients on home dialysis therapy.

Association between OH/ECW and echocardiographic parameters in CKD5 patients not undergoing dialysis

Background

Echocardiography is the most valuable tool for assessing cardiac abnormalities of chronic kidney disease (CKD) patients even though it has its limitations, including high equipment cost and the need for specialized personnel. Assessment of volume status is important not only for volume management, but also for prevention of cardiovascular disease of the CKD patients. Recently, bioimpedance is gaining acceptance as a way to quantitatively assess patient hydration status at bedside.

Methods

127 patients who were admitted for planning their first dialysis treatment were enrolled. The echocardiography and bioimpedance spectroscopy (BIS) were performed. The association between echocardiographic data and clinical values such as NT-proBNP and OH/ECW was examined.

Results

OH/ECW, which indicates relative fluid overload, was positively associated with LA dimension (r = 0.25, P = 0.007), LAVI (r = 0.32, P < 0.001), and E/e´ ratio (r = 0.38, P < 0.001). While OH/ECW was not significantly associated with echocardiographic values such as LVEDD, LVEDV, LVMI, and LVEF, NT-proBNP were significantly associated with all echocardiographic parameters. Multivariate logistic regression analysis showed E/e´ ratio (odds ratio, 1.14 [95% confidence interval (CI), 1.01 to 1.29]; P = 0.031), NT-proBNP (odds ratio, 4.78 [95% CI, 1.51 to 15.11]; P = 0.008), and albumin (odds ratio, 0.22 [95% CI, 0.08 to 0.66]; P = 0.007) were significantly associated with OH/ECW.

Conclusions

Since OH/ECW measured by BIS is associated with echocardiographic parameters related to diastolic dysfunction, preliminary screening through laboratory findings, including serum albumin in conjunction with OH/ECW and NT-proBNP, may find patient with risk of diastolic dysfunction. Our study suggests that a timely detection of fluid overload in patients with CKD as well as their proper treatment may help reduce diastolic dysfunction. Further research may be needed to validate the consistency of this association across other stages of CKD.

Any grade of relative overhydration is associated with long-term mortality in patients with Stages 4 and 5 non-dialysis chronic kidney disease

Background

Overhydration (OH) is associated with mortality in chronic kidney disease (CKD). A relative overhydration adjusted for extracellular water (OH/ECW) measured by bioimpedance >15% has shown an increased mortality risk in haemodialysis but few studies have been developed in advanced CKD. Our objective was to evaluate the effect of OH on mortality in patients with Stage 4 or 5 non-dialysis CKD.

Methods

We performed a prospective study of 356 patients enrolled in 2011 and followed up until 2016. At baseline we collected general characteristics, serum inflammatory and nutrition markers, cardiovascular events (CVEs) and body composition using bioimpedance spectroscopy. During a median follow-up of 50 (24–66) months we collected mortality data.

Results

The mean creatinine was 3.5 ± 1.3 mg/dL, median proteinuria was 0.5 [interquartile range (IQR) 0.2–1.5] g/24 h, median OH was 0.6 (IQR −0.4–1.5) L and mean relative OH (OH/ECW) was 2.3 ± 0.8%. We found that 32% of patients died. The univariate Cox analysis showed an association between mortality and age, diabetes, previous CVEs, Charlson comorbidity index, low albumin and pre-albumin, high C-reactive protein (CRP), low lean tissue and high OH/ECW. Multivariate Cox analysis confirmed an association between mortality and age {exp(B) 1.1 [95% confidence interval (CI) 1.0–1.3]; P = 0.001}, Charlson comorbidity index [exp(B) 1.1 (95% CI 1.0–1.2); P = 0.01], CRP [exp(B) 1.1 (95% CI 1.0–1.2); P = 0.04], OH/ECW [exp(B) 3.18 (95% CI 2.09–4.97); P = 0.031] and low lean tissue [exp(B) 0.82 (95% CI 0.69–0.98); P = 0.002]. Kaplan–Meier analysis confirmed higher mortality in patients with OH/ECW >0% (log rank 11.1; P = 0.001).

Conclusion

Any grade of relative OH measured by OH/ECW >0% is associated with long-term mortality in patients with Stage 4 or 5 non-dialysis CKD.

Bioimpedance-defined overhydration predicts survival in end stage kidney failure (ESKF): systematic review and subgroup meta-analysis

Both overhydration and comorbidity predict mortality in end-stage kidney failure (ESKF) but it is not clear whether these are independent of one another. We undertook a systematic review of studies reporting outcomes in adult dialysis patients in which comorbidity and overhydration, quantified by whole body bioimpedance (BI), were reported. PubMed, EMBASE, PsychInfo and the Cochrane trial database were searched (1990-2017). Independent reviewers appraised studies including methodological quality (assessed using QUIPS). Primary outcome was mortality, with secondary outcomes including hospitalisation and cardiovascular events. Of 4028 citations identified, 46 matched inclusion criteria (42 cohorts; 60790 patients; 8187 deaths; 95% haemodialysis/5% peritoneal dialysis). BI measures included phase angle/BI vector (41%), overhydration index (39%) and extra:intracellular water ratio (20%). 38 of 42 cohorts had multivariable survival analyses (MVSA) adjusting for age (92%), gender (66%), diabetes (63%), albumin (58%), inflammation (CRP/IL6-37%), non-BI nutritional markers (24%) and echocardiographic data (8%). BI-defined overhydration (BI-OH) independently predicted mortality in 32 observational cohorts. Meta-analysis revealed overhydration >15% (HR 2.28, 95% CI 1.56-3.34, P < 0.001) and a 1-degree decrease in phase angle (HR 1.74, 95% CI 1.37-2.21, P < 0.001) predicted mortality. BI-OH predicts mortality in dialysis patients independent of the influence of comorbidity.

Fluid Overload and Inflammation Axis

Extracellular fluid overload (FO), which is assessed using bioimpedance technologies, is an important predictor of outcome in dialysis patients and in patients with early stages of chronic kidney disease. While traditional cardiovascular abnormalities are assumed to mediate this risk, recently also, the importance of noncardiovascular factors, such as systemic inflammation and malnutrition has been shown. While both FO and inflammation are independent risk factors for mortality, recent studies have shown that their combined presence can lead to a cumulative risk profile. From a pathophysiologic viewpoint, FO and inflammation can also be mutually reinforcing. Inflammation could contribute to FO by hypoalbuminemia, capillary leakage, and a (unnoticed) decline in lean and/or fat tissue mass resulting in incorrect estimation of dry weight. Reciprocally, FO could lead to inflammation by the translocation of endotoxins through a congested bowel wall or by a proinflammatory effect of tissue sodium. The relative importance of these putative factors is, however, not clear yet and epidemiological studies have shown no clear temporal direction regarding the relationship between FO and inflammation. FO and inflammation appear to be part of (dynamic) clusters of risk factors, including malnutrition and hyponatremia. Technology-guided fluid management of the often vulnerable dialysis patient with FO and inflammation cannot yet be based on evidence from randomized controlled trials, in which these specific patients were in general not included. In the absence of those trials, treatment should be based on identifying actionable causes of inflammation and on the judicious removal of excess volume based on frequent clinical reassessment.

Total Bilirubin in Prognosis for Mortality in End-Stage Renal Disease Patients on Peritoneal Dialysis Therapy

Background

Evidence regarding bilirubin's antioxidant properties and predictive roles is growing. However, it is unclear whether serum bilirubin would have a prognostic impact on survival of patients with regular peritoneal dialysis.

Methods and Results

We used the Taiwan Renal Registry Data System utilizing its 2005‐2012 data set. Data from patients on regular peritoneal dialysis were retrieved. The primary end point of observation was 3‐year mortality. A total of 3704 patients (mean age 53.5 years, 44% male) were enrolled, and these patients were divided according to baseline serum total bilirubin levels (<0.3, 0.3‐0.4, 0.4‐0.5, 0.5‐0.6, >0.6 mg/dL). Serum total bilirubin level was linearly related to age, incidence of hypertension, and type 2 diabetes mellitus. At the end of the observation period with a mean follow‐up of 2.12±1.07 years, 1095 (30.6%) deaths were detected. Serum total bilirubin level and 3‐year mortality rate presented a U‐shaped relationship. Those with serum total bilirubin 0.5 to 0.6 mg/dL had the lowest 3‐year mortality rate (24%). After adjustment for age, sex, underlying systemic disorders, medications, and laboratory discrepancies, serum total bilirubin still played an independent role for predicting 3‐year mortality.

Conclusions

Baseline serum total bilirubin level is significantly associated with 3‐year mortality among patients receiving regular peritoneal dialysis.

Fluid overload as a major target in management of cardiorenal syndrome: Implications for the practice of peritoneal dialysis

Congestion is an integral component of cardiorenal syndrome and portends an adverse impact on the outcomes. Recent studies suggest that congestion has the ability of modulating the interactions between the kidney and the heart in this setting. Peritoneal dialysis (PD) is a home-based therapeutic modality that is not only offered to patients with end-stage renal disease to provide solute clearance and ultrafiltration, but it has also been used in patients with refractory heart failure and fluid overload to help optimize volume status. Several uncontrolled studies and case series have so far evaluated the role of PD in management of hypervolemia for patients with heart failure. They have generally reported favorable results in this setting. However, the data on the outcomes of patients with end-stage renal disease and concomitant heart failure is mixed, and the proposed theoretical advantages of PD might not translate into improved clinical endpoints. Congestion is prevalent in this patient population and has a significant effect on their survival. As studies suggest that a significant subset of patients with end-stage renal disease who receive PD therapy are hypervolemic, suboptimal management of congestion could at least in part explain these conflicting results. PD is a highly flexible therapeutic modality and the choice of techniques, regimens, and solutions can affect its ability for optimization of fluid status. This article provides an overview of the currently available data on the role and clinical relevance of congestion in patients with cardiorenal syndrome and reviews potential options to enhance decongestion in these patients.