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Volume Management

Sagar Nigwekar MD, MMSc

Massachusetts General Hospital

E-mail: snigwekar@mgh.harvard.edu

March 14, 2017

Disclosures statement:

• Consultant: Allena, Becker Professional Education

• Grant support: Sanofi-Aventis

• Speaker honoraria: Sanofi-Aventis

Objectives

• To discuss evaluation of hypervolemia in peritoneal dialysis patients

• To review prevention and treatment of hypervolemia in peritoneal dialysis patients

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Peritoneal dialysis: ultrafiltration basics

Peritoneal membrane barrier

Flessner et al. Am J Physiol Renal Physiol. 2005 Mar;288(3):F433-42

Three-pore model of peritoneal transport

Agarwal et al. Indian J Nephrol. 2008 Jul;18(3):95-100

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Effect of aquaporin-1 (AQP1) deletion on the transport of water across the peritoneal membrane

Devuyst and Rippe. Kidney International (2014) 85, 750–758

Endothelial barrier to water transport during peritoneal dialysis

Flessner et al. Kidney International (2006) 69, 1494–1495

Peritoneal dialysis: hypertension and heart failure

epidemiology

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Hypertension: prevalence in peritoneal dialysis patients and association with GFR

Ortega and Materson. J Am Soc Hypertens. 2011 May-Jun;5(3):128-36.

Symptomatic fluid retention in 1 out of every 4 PD patients:

• Lower extremity edema 98.6%

• Pleural effusions 76.1%

• Pulmonary congestion 80.3%

Fluid retention in PD patients

Tzamaloukas, et al. J Am Soc Nephrol. 1995;6:198-206.

Mean arterial pressure over time from initiation of peritoneal dialysis.

Menon M K et al. Nephrol. Dial. Transplant. 2001;16:2207-2213

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Mean antihypertensive use over time from initiation of peritoneal dialysis.

Menon M K et al. Nephrol. Dial. Transplant. 2001;16:2207-2213

Residual renal function over time from initiation of peritoneal dialysis.

Menon M K et al. Nephrol. Dial. Transplant. 2001;16:2207-2213

Event rates of cardiovascular diagnoses & procedures, by modality, 2009–2011

January 1, 2009 point prevalent ESRD patients with Medicare as primary payer; January 1, 2009 point prevalent ESRD patients with Medicare as primary payer; follow can occur up to three years.

USRDS, 2013 ADR

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Heart failure in prevalent dialysis patients, by modality, 2011

January 1, 2011 point prevalent ESRD dialysis patients with Medicare Parts A, B,& D coverage, diagnosed with heart failure in 2011, & surviving & staying on the same modality for all of 2011.

USRDS, 2013 ADR

Prevalence of left ventricular hypertrophy (a), and relative frequency of the concentric and eccentric pattern (b) in CAPD and in HD patients

Enia G et al. Nephrol. Dial. Transplant. 2001;16:1459-1464

Three-year patient survival rates in PD patients according to total fluid removal. The four groups are defined as: group I, <1265 mL/24 h/1.73 m2; group II, 1265 to 1570 mL/24 h/1.73

m2; group III, 1570 to 2035 mL/24 h/1.73 m2; and group IV,> 2035 mL/24 h/1.73 m2.

Kidney International (2001) 60, 767–776

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Peritoneal dialysis: causes and evaluation of volume overload

Am J Kidney Dis. 2006; 47(Suppl 4):S1.

• Adherence with salt and fluid intake

• PD prescription: adequate osmotic stimulus

Too much in

• Loss of residual renal function

• PD prescription: adequate osmotic stimulus

• Peritoneal membrane failure

Too little out

• New or worsening heart disease

• Hypoalbuminemia

• Mechanical problem

Co-morbidity

Volume overload in PD patients is preventable

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Target weight ?

Residual renal function over time from initiation of peritoneal dialysis.

Menon M K et al. Nephrol. Dial. Transplant. 2001;16:2207-2213

Thirst profiles for control and PD. Profiles show mean thirst score for each group at each

time point±SEM.

Wright M et al. Nephrol. Dial. Transplant. 2004;19:1581-1586

Polydipsia in PD patients?

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Box and whisker plot showing calculated fluid balance.

Under-reporting of water intake by PD patients?

Wright M et al. Nephrol. Dial. Transplant. 2004;19:1581-1586

Improvement in BP with salt and fluid restriction in PD

Gunal et al. Am J Kidney Dis. 2001 Mar;37(3):588-93.Abu-Alfa et al. Kidney Int Suppl. 2002 Oct;(81):S8-16.

CAPD patients with diabetes are more fluid overloaded than non-diabetic patients

Gan et al. Int Urol Nephrol. 2005;37(3):575-9.

Empty bars, diabetics; Black bars, non-diabetics

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Fluid status improvement in diabetic CAPD patients after dietary salt and fluid

restriction

Gan et al. Int Urol Nephrol. 2005;37(3):575-9.

Empty bars, before dietary restriction; Black bars, after dietary restriction

Sodium removal in APD is lower than in CAPD

Rodriguez-Carmona et al. Perit Dial Int. 2002 Nov-Dec;22(6):705-13.

PD catheter mal-position

Jheng et al. Kidney International (2012) 82, 827

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2 liter fill and drain test

• Inflow difficulty

• Fibrin clot

• Incomplete drainage

• Positional drainage

PD: mechanical complications Problem Details Management considerations

Leaks Typically seen early after catheter placement

-Reduce fill volume and intraperitoneal pressure-Can accomplish this with bed rest

Inflow problem Pain can result from low pH of PD solution or from peritonitis

-Test for peritonitis-Can slow infusion rate, add bicarbonate or lidocaine to bag

Outflow problem From clots, fibrin, or constipation

-Treat constipation-Leaving fluid incompletely drained after prior dwell reduces outflow pain

Pleural effusion From congenital or acquired defects in diaphragm; more common on right side, in women, and in PKD patients

-Diagnose by testing glucose on pleural fluid and or with radio-labeled albumin or methylene blue-Treat with PD holiday, VATS, or open surgery-Can suffer from under-dialysis-Must achieve drain volume > 9 L/24 hrs

Courtesy Dr. Eliot Heher, MGH

Peritoneal Equilibration TestingType Frequency,

%D/P Creatinine at 4 hours

Comments

High 10 0.82-1.03 -Best managed with cycler-Can experience “UF” failure -Albumin often low

High Average > 50 0.65-0.81 -Can be managed with CAPD or cycler-7.5 to 9 L/24 hrs

Low Average > 30 0.50-0.64 -Standard PD high dose needed for larger patients

Low 5 0.34-0.49 -Manage with long dwell CAPD-Can suffer from underdialysis-Must achieve drain volume > 9 L/24 hrs

Courtesy Dr. Eliot Heher, MGH

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Peritoneal dialysis: monitoring and prevention of volume

overload

Monitoring for volume overload

• Active surveillance

• Monthly review of PD prescription

• Urine volume measurement on every 1-2 month basis

• Overnight drain volume review in CAPD patients

• Day time drain volume review in APD patients

• PET testing as indicated

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Potential areas of intervention

• Dietary salt and fluid intake• Residual renal function

– Diuretics– Avoid nephrotoxic agents– Angiotensin inhibition– Control of HTN– Treatment of urinary obstruction

• Adherence to PD prescription• PD catheter function• Matching dwell time to transport type

Adapted from Abu-Alfa et al. Kidney Int Suppl. 2002 Oct;(81):S8-16 and UpToDate.

Diuretics in PD

Evolution of urine volume (UV) over one year of peritoneal dialysis (PD). UV at randomization was comparable between groups. In the diuretic group (), it remained constant over one year of CAPD, whereas in the control group (), UV declined. Data presented are mean SEM at each time point.

Medcalf et al. Kidney Int. 2001 Mar;59(3):1128-33.

Long dwell UF

Abu-Alfa et al. Kidney Int Suppl. 2002 Oct;(81):S8-16.

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Short dwell UF

Abu-Alfa et al. Kidney Int Suppl. 2002 Oct;(81):S8-16.

Net drained UF volume (ml) during a 15-h long dwell with 3.86% glucose (black bars), 7.5% icodextrin (gray bars), or a mix of 6.8% icodextrin and 2.6% glucose (white bars) (n=7).

Freida et al. Kidney International (2008) 73, S102–S111.

Net Na+ removal during a 15-h long dwell with 3.86% glucose (black bars), 7.5% icodextrin(gray bars), or a mix of 6.8% icodextrin and 2.6% glucose (white bars) (n=7).

Freida et al. Kidney International (2008) 73, S102–S111.

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Negative UF with different dextrose solutions

Abu-Alfa et al. Kidney Int Suppl. 2002 Oct;(81):S8-16.

Summary

• Evaluating and managing volume is critical part of PD management

• Focus should be on prevention and early detection of volume overload in PD patients

• Treatment options for impaired ultrafiltration

– dwell time shortening

– frequent hypertonic exchanges

– icodextrin

– use of diuretics in patients with residual renal function

Acknowledgements

• MGH CAPD Unit

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Questions

Fluid Overload vs UF Failure

An Important Distinction

• Fluid overload is a common clinical syndrome with multiple causes

• It is the inability to maintain target weight and oedema free state

• UF failure is a pathophysiologic characterisation of one of the

causes of the clinical syndrome

• Distinction between syndrome and cause determines the

intervention to be taken

Mujais, et al. Perit. Dial Int. 2000;20(suppl 4):S5-S21.