Article

Kontinuierliche ambulante und automatisierte Peritonealdialyse

Authors:
  • Hospital Straubing
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Abstract

Grundstzlich sind die Peritonealdialyse (PD) und Hmodialyse (HD) als unterschiedliche, aber gleichwertige Dialyseverfahren anzusehen. Mehrere Studien beschreiben ein besseres berleben der PD- im Vergleich zur HD-Patienten in den ersten 2–3 Behandlungsjahren. Bei Langzeit-PD-Patienten steigt jedoch die Mortalitt im Vergleich zu HD-Patienten an. Das in den letzten Jahren entwickelte Konzept der integrated care (primr PD-Beginn, spterer Wechsel an die HD) wird auch in jngeren Studien untersttzt. Der bessere Erhalt der Nierenrestfunktion, die Schonung der Armgefe fr eine sptere Shuntanlage und die fehlende kardiale Belastung durch einen Shunt sprechen fr eine grozgigere Wahl der PD als initiales Dialyseverfahren. Wichtig ist es, fr den einzelnen Patienten den richtigen Zeitpunkt zum Wechsel an die HD zu finden; Kriterien dabei sind unzureichende Ultrafiltration, inadquate Clearance von Urmietoxinen, Versagen der Peritonealmembran. Es gibt nur wenig absolute Kontraindikationen fr die PD.Peritoneal dialysis (PD) and hemodialysis (HD) are different but equivalent dialysis methods. Several studies have shown better survival using PD compared to HD in the first 2–3years of treatment. After several years, mortality increases for PD compared to HD patients. Several recent studies support the concept of integrated care (starting with PD and switching to HD). Better preservation of residual renal function using PD and sparing of the veins of the arm for later use for a shunt, and lack of cardiac stress with an AV-shunt are important arguments for starting dialysis with PD. It is very important to find the right time for switching to HD for each individual patient. Criteria for switching are inadequate ultrafiltration and clearance of uremic toxins. There are few contra-indications for PD.

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Thesis
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Der Wasserhaushalt von Dialysepatienten bewegt sich ondulierend zwischen Überwässerung vor der Behandlung und gezielter Dehydratation nach der Dialyse. Das Ziel der Behandlung ist ein e Flüssigkeitsbalance. Das Gewicht nach der Dialyse bei dem dieser Zustand erreicht ist, wird als Trockengewicht oder Dialysezielgewicht bezeichnet. Zur Zeit ist kein einzelner Parameter verfügbar, von dem sich ein adäquates Trockengewicht der Dialysepatienten ableiten ließe. Die Einschätzung des Trockengewichtes von dialysepflichtigen Kindern stützt sich auf die sorgfältige klinische Untersuchung. Die Bioimpedanzanalyse und die Messung des Durchmessers der Vena cava inferior sind zwei nicht invasive Verfahren, die bereits an erwachsenen Dialysepatienten untersucht und zur Beurteilung des Trockengewichtes sowie des Extrazellulärvolumens angewandt werden. Für Kinder sind keine Referenzwerte für beide Verfahren verfügbar. Aus diesen Grund entschlossen wir uns, Normalwerte für diese Altersgruppe (6,8 bis 16 Jahre) zu erheben. Es zeigte sich ein enger Zusammenhang zwischen Resistanz (BIA) und Durchmesser der Vena cava inferior auf der einen und Werten wie z.B. Alter, Gewicht und Körperoberfläche auf der andren Seite. Resistanz und Durchmesser stehen ebenfalls in enger Beziehung zueinander. Bei der Untersuchung von 31 Dialysepatienten zeigten sich Wachstumsverzögerung und verspätete Pubertät. Daraus wird deutlich das altersbezogene Referenzwerte zu einer falschen Einschätzung des Wasserhaushaltes führen würden. Die kombinierte Anwendung beider Verfahren mit der Körperoberfläche als Bezugswert, kann im Vergleich zu den Veränderungen des Körpergewichtes wertvolle Informationen zur Optimierung des Trockengewichtes geben.
Article
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Article
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Article
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Article
The peritoneal barrier exchange characteristics are in this article described in terms of a three-pore model of membrane permselectivity. The peritoneal membrane during continuous ambulatory peritoneal dialysis (CAPD) is thus simulated to have a large number of small pores of radius 40-55 A, a small number of large pores of radius 200-300 A, and an abundance of transcellular pores of radius 4-5 A. Due to the heteroporous nature of the peritoneal membrane, peritoneal small solute sieving coefficients are of the order of 0.5-0.6, and not near unity, as predicted for a homoporous membrane having 50 A (radius) equivalent pores, but lacking transcellular pores. As a consequence, the dialysate during CAPD is diluted during the first 50-100 minutes of the dwell. Furthermore, there is a marked coupling between the increased net transperitoneal volume flow, occurring early in the cycle, and the transfer of "small" macromolecules, such as beta 2-microglobulin and albumin, across the peritoneal membrane. This coupling is, however, small for "large" macromolecules, such as IgG and IgM, or for small solutes. Increasing the peritoneal surface area, in computer simulations of peritoneal transport according to the three-pore model, causes the simulated intraperitoneal (i.p.) volume vs. time (V(t)) curves to peak earlier than during control, while the maximum volume ultrafiltered is not markedly affected. However, selectively increasing the glucose PS (mass transfer area coefficient) causes a reduction both in the peak time and the peak "height" of the V(t) curves. The latter pattern is also seen when the dialysate volume is reduced. It is concluded that a three-pore model of membrane permselectivity selectivity can adequately describe the kinetics of peritoneal transport of small and large solutes and of fluid.
Article
Despite the availability of calcitriol and recombinant erythropoietin to replace two major endocrine functions of the kidneys, mortality in chronic hemodialysis patients remains substantially higher than that in the general population. This suggests that most, if not all, patients are underdialyzed. While increasing small solute clearance by dialysis using urea kinetics as a guide improves clinical outcome, 'adequate' treatment using current techniques is only an arbitrary definition, since solute removal by dialysis remains far inferior to that of the normal native kidneys. In recent years, significant advances have been made in the structural and functional characterization of toxic uremic solutes that are in the higher molecular size range ('middle molecules'). Several lines of evidence suggest that, in addition to small solutes, removal of middle molecules is also advantageous. The potential beneficial effects of synthetic high flux hemodialysis membranes are probably attributed to both their solute clearance profiles as well as their biocompatibility characteristics.
Article
Tidal peritoneal dialysis (TPD) was introduced to increase the efficacy of peritoneal dialysis. We measured peritoneal clearances of small solutes and beta2-microglobulin, peritoneal protein loss, and efficacy of ultrafiltration in 30 patients during TPD and intermittent peritoneal dialysis (IPD) with low-dialysate flow (1.7 L/h) and, in addition, in 17 of these patients using a high-dialysate flow (3 L/h). Using a low-dialysate flow, patients with low/low average peritoneal transport rates showed significantly better peritoneal creatinine and urea nitrogen clearances during IPD compared with TPD, whereas there was no difference between these two treatment modalities in high/high average transporters. With high-dialysate flow, peritoneal clearances of creatinine and urea nitrogen were similar between TPD and IPD independent of peritoneal transport type. Clearances of phosphate and beta2-microglobulin were similar between TPD and IPD independent of dialysate flow or peritoneal transport type. Increasing the dialysate flow rate led to a significant increase in small-solute clearances, but not beta2-microglobulin clearances, in both peritoneal transport types. Total peritoneal protein and albumin losses were similar between TPD and IPD only with low-dialysate flow. However, using a high-dialysate flow, total protein losses tended to increase in both transport types during IPD compared with TPD. In conclusion, up to a dialysate flow of 3 L/h, TPD did not provide better small-solute or middle-molecule clearances compared with IPD. Moreover, using a low-dialysate flow, IPD was superior to TPD in low/low average transporters.
Article
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Long survival is now common in patients with end-stage renal disease owing to improvement in dialysis techniques and kidney transplantation. As malnutrition is commonly reported in dialysis patients, we evaluated the nutritional status of patients treated with haemodialysis (HD) for more than 20 years. Ten patients (59.5 years old; 4F/6M; HD treatment for 304 months; group A) underwent an extensive nutritional examination and were compared to a control group of 10 patients treated with HD for an average of 51 months and strictly matched for age (58.6 years old), gender, and height (group B). The patients were treated on a similar basis (long-duration HD, cellulosic membranes, Daugirdas index >2). The body weight (BW) in group A had decreased gradually from the 11th year of HD treatment, whereas it had increased by an average of 1.9+/-4.4% since the beginning of the HD treatment in group B. The body mass index (BMI) was lower in group A (19.3 +/- 2.3 vs 21.4 +/- 2.8 kg/m(2); P = 0.05). The arm-muscle circumference (AMC), the arm-muscle area (AMA), and triceps skinfold (TSF) were lower in group A than in group B. The fat mass assessed with anthropometry (10.8 +/- 4.0 vs 14.8 +/- 4.2 kg) was significantly lower in group A. The deviation of actual BW from ideal BW (IBW) was significantly lower in group A than in group B (80.6 +/- 10.7% vs 89.6 +/- 9.0%; P = 0.028); The deviations of actual BW, TSF, and AMA from standard values of the NHANES II study were more marked in group A than in group B. On the other hand, daily energy and protein intakes (DEI and DPI) were identical in both groups and met the recommendations for dialysis patients when normalized to the actual BW. When normalized to the IBW, the DEI appeared low. Energy expenditure was not different between groups, and not different from the resting metabolism calculated from the Harris and Benedict formula. Average albumin, prealbumin, and IgF-1 were normal and not different between groups. Branched-chain amino acids (BCAA), and especially leucine, were correlated with BMI in group A but not in group B. Serum total and free carnitine were low in both groups. Three patients had ascorbic acid deficiency in group A but none in group B. Hence, despite adequate dialysis dose and protein intake, patients treated with HD for a long period of time became malnourished, whereas the classical nutritional markers remained in normal ranges. Among the potential causes leading to malnutrition, inadequate energy intake and micronutrient deficiencies were found in these patients.
Article
This paper reviews the rationale behind the proposed policy of using peritoneal dialysis (PD) as the initial treatment modality in patients with end-stage renal disease (ESRD). The better preservation of residual renal function associated with PD is emphasized along with its potential cardiovascular benefits. The superior patient survival on PD, relative to hemodialysis, during the first 2 years on dialysis in both the United States and Canada is discussed, as are the potential advantages of PD in terms of hepatitis C prevention, anaemia management and quality of life. The lower cost of PD in association with these clinical advantages lead to the modality being more cost-effective in the early years on dialysis. The relatively high technique failure rate on PD, however, subsequently leads to an increasing need for haemodialysis. A policy of integrated dialysis care with PD first and then haemodialysis, as required, is advocated as a more cost-effective approach to ESRD in suitable patients.
Article
Long-term peritoneal dialysis is associated with changes in the peritoneal membrane. Conventional dialysate solutions are bioincompatible because of their low pH, high glucose content, hyperosmolality and increased concentration of glucose degradation products. The development of double-compartment systems has made it possible to separate glucose from the buffer during heat sterilization, resulting in a higher or even physiologic pH of the solution with reduced concentration of glucose degradation products. These new solutions are less toxic for several cell groups and are better than conventional solutions in preserving membrane function, as demonstrated by experiments in rats. Glucose degradation products promote formation of advanced glycation end-products, and plasma levels of these are markedly reduced when double-compartment systems are used. Clinical studies with these more physiologic dialysis solutions have demonstrated better correction of acidosis, less inflow pain, significantly elevated CA-125 dialysate levels and lower concentrations of markers for inflammation and fibrosis in the effluent. In a retrospective study, a lower rate of mortality was observed in patients who were treated using a double-compartment system than in those treated with standard dialysis solution. Amino acids (in the low-molecular-weight range) and icodextrin (in the high-molecular-weight range) are newer osmotic agents that have been developed as alternatives to glucose. Several clinical studies have shown that amino-acid solution improves various nutritional parameters in patients with malnutrition and is more biocompatible than standard glucose solution. Icodextrin is an iso-osmolar dialysis solution. Ultrafiltration takes place via colloid osmotic pressure and is sufficient in all types of peritoneal transport. Clinical studies using icodextrin have shown better fluid control, especially in high transporters, reduced carbohydrate load and fewer patients with ultrafiltration failure compared with those treated with conventional dialysis solutions. However, allergic skin reactions have been observed in up to 10% of patients treated with icodextrin. Icodextrin may induce a fall of sodium plasma levels. Because of cross-reaction with elevated plasma levels of maltose, serum amylase is determined falsely low and glucose (using the glucose-dehydrogenase method) is measured falsely high, but high plasma levels of maltose do not affect measurement of lipase or measurement of glucose using the glucose-oxidase method. New dialysate solutions will have a positive influence on both survival and technical drop-out rates in patients receiving peritoneal dialysis treatment.
Article
In older textbooks the use of peritoneal dialysis (PD) in patients with liver cirrhosis and/or ascites was contraindicated. Only a small number of papers have focused on this problem and they mainly consist of case reports and retrospective studies of small numbers of patients. In addition, most nephrologists' experience of performing PD in patients with liver diseases is rather limited. Nevertheless, for these patients PD offers a wide range of advantages, such as a simplified ascites management, since repeated abdominal punctures become unnecessary. Furthermore, because of continuous peritoneal ultrafiltration, hemodynamic tolerance during PD is significantly better than in hemodialysis and results in a markedly lower frequency of hypotensive episodes. The risk of nosocomial infection with hepatitis B or C viruses can also be reduced by treating these patients with home PD. Although some authors suggest that PD patients with liver cirrhosis have an especially increased risk of Gram-negative peritonitis, currently available data show controversial results. There is also little information in the literature on the impact of increased peritoneal protein loss on malnutrition and outcome of these patients. Nevertheless, recent studies have shown that protein loss into the peritoneal cavity in PD patients with liver cirrhosis is high only initially, stabilizing at a lower level in the further course of treatment. In conclusion, in patients with end-stage renal disease suffering from liver cirrhosis and/or ascites, PD can be considered as a good or adequate treatment option.
Article
Most physicians do not consider peritoneal dialysis (PD) to be the treatment of choice in obese patients with end-stage renal failure. In some but not all studies the incidence of infectious complications (catheter-associated infections and peritonitis) is higher than in patients with normal body mass index (BMI). Although mathematical models show that even continuous ambulatory PD with a daily dialysate treatment volume of 12 litres does not provide sufficient clearances in patients weighing 80 kg, adequate dialysis has been achieved in clinical studies in patients with BMI up to 46 kg/m2. Residual renal function is a very important factor for survival in patients undergoing PD and might be influenced by body weight; however, data are controversial, showing either a negative influence of high BMI on renal clearance or no association. The incidence of peritoneal leaks in PD is higher in obese patients than in other patients, because of the raised intra-abdominal pressure. In contrast, hernias do not occur more frequently in overweight PD patients and the risk of hernias seems to be greater in patients with lower BMI. It is well known that mortality rates of overweight patients on hemodialysis are lower than in those with normal body weight, but data on the influence of BMI on survival in PD patients are more controversial. In conclusion, there is no evidence that PD is absolutely contraindicated in patients with high BMI, especially if patients have a strong preference for this type of treatment.
Article
Patients with chronic kidney-graft failure who are starting peritoneal dialysis (PD) treatment need special consideration. The question of whether mortality is higher in these patients than in those who have not received a transplant is controversial. However, some studies suggest that differences in mortality between these groups are mainly explained by variations in age, duration of dialysis and comorbidity. One study showed similar survival between patients with chronic graft failure treated with hemodialysis (HD) and those on PD, but there is some evidence that residual renal function in PD patients with chronic graft failure declines faster than in PD-patients without transplants. Until now there have been no data on whether PD has a positive influence on the course of residual renal clearances compared with the influence of HD. The fact that PD patients with transplants show significantly higher peritoneal transport rates than patients without transplants may have an influence on technique survival. In patients with chronic graft failure, the type and dose of immunosuppressive therapy, as well as its influence on the incidence of acute rejections, residual renal function and infection rates, are also controversial. Immunosuppressive therapy may preserve residual graft function, but these patients have a higher risk of Gram-negative peritonitis, a shorter interval between start of dialysis and first episode of peritonitis, and a higher risk of catheter infections with Staphylococcus aureus than PD patients without transplants. In conclusion, PD is an acceptable treatment option for patients with chronic kidney-graft failure provided that the above clinical aspects are considered (e.g., intensified monitoring of infections and residual renal function).
Article
In Austria, patients with end-stage renal disease caused by polycystic kidney disease are less frequently treated with peritoneal dialysis (PD) than patients with noncystic renal diseases (6% versus 8%). In contrast, the United States renal data system reports that more than one fifth of patients with polycystic kidney disease choose PD as their initial form of renal replacement therapy. The reasons for this difference are unknown. Extrarenal manifestations of the disease, such as diverticulosis, development of hernias or vascular aneurysms, may theoretically promote the occurrence of complications typically related to PD. However, studies undertaken to clarify these questions did not find any difference in the rates of peritonitis caused by diverticulosis or Gram-negative bacteria, and no differences were seen with respect to vascular complications. Nevertheless, in comparison with the general population, patients with polycystic kidney disease are more likely to develop hernias, and the incidence of herniation may be further increased by PD. In conclusion, patients with polycystic kidney disease who also have abdominal complaints such as meteorism and discomfort, or lumbago resulting from the markedly enlarged kidneys, should not be actively advised to have PD treatment. The same is true for patients with recurrent hernias. However, the technical survival, quality of dialysis, duration of therapy and rates of complications in PD are comparable in patients with cystic or noncystic kidney disease, and therefore all patients with polycystic kidney disease who do not have abdominal complaints or history of recurrent hernias should be informed that PD is an adequate form of renal replacement therapy, equally effective as hemodialysis.
Peritonealdialyse bei Patienten mit Polyzystischer Nierendegeneration
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