<% 'if (Session("Type") <> 1 and Session("Type") <> 5 and Session("Type") <> 28) then Response.Redirect "../Msg.asp?Messaggio1=Restricted access area!!!&Messaggio2=Return to HomePage" 'if Session("UserCount") = "" then Response.Redirect "../Msg.asp?Messaggio1=Error while initialising the quiz!!!&Messaggio2=Return to HomePage" a_capo = chr(13) + chr(10) NumQuestions = 4 RightAnswer1 = "f" RightAnswer2 = "e" RightAnswer3 = "d" RightAnswer4 = "h" currentID = Request("currentID") if currentID = "" then currentID = 1 Answer1 = Request("Question1") if Request("Answer1") <> "" then Answer1 = Request("Answer1") Answer2 = Request("Question2") if Request("Answer2") <> "" then Answer2 = Request("Answer2") Answer3 = Request("Question3") if Request("Answer3") <> "" then Answer3 = Request("Answer3") Answer4 = Request("Question4") if Request("Answer4") <> "" then Answer4= Request("Answer4") if currentID = 11 or currentID = 22 or currentID = 33 then Label = "Next" elseif currentID = 44 then Label = "Continue" else Label = "Evaluate" end if %> Erwin Fleischmann - Case study




A patient on peritoneal dialysis with weight gain and edema

by Dr. E. Fleischmann
Department of Clinical Medicine IV, Division of Nephrology and Hypertensiology,
Friedrich-Alexander University Erlangen-Nuremberg
Erlangen, Germany

 

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A 57 year old woman treated with CAPD for ESRD due to FSGS presented with complaints of weight gain, edema, reduced physical well-being and loss of appetite. She started CAPD 42 months ago. Concomitant diseases were arterial hypertension, goiter and hysterectomy due to myoma.
On examination her blood pressure was 142/87 mm HG, heart rate 73 bpm, bodyweight 81,5 kg, normal SI and SII, without murmur, respiration was unremarkable, she had + peripheral edema. At present she was using as PD prescription a fill volume of 2000 ml with glucose concentration of 1x 2,27 %, 2 x 3,86% and 1 x icodextrin revealing an ultrafiltration of 1350 mls per day with residual urine volume of 200 ml.

Laboratory: Hemoglobin 10,3 g/L, Erythrocytes 3,25 mio/µl, wbc 8,62 x 10 3/µl, thrombocytes 398 8,62 x 10 3/µl, creatinine 9,48 mg/dl, urea 56 mg/dl, albumin 3,13 g/dl, sodium 139 mmol/l, potassium 3,92 mmol/l, calcium 2,51 mmol/l, phosphate 4,49 mmol/l , CaxPo4 45,1, iPTH 239 pg/ml, CRP 0,90 mg/dl

References:




* Mujais S. Ultrafiltration Management in Automated Peritoneal Dialysis. In: Ronco C., Amici G., Feriani M., Virag G. (eds): Automated Pertoneal Dialysis. Contrib Nephrol. Basel. Karger 1999, vol 129, pp 255 - 266

**Posthuma N., ter Wee P.M., Verbruh H.A., Oe PL., Peers E., Sayers J., Donker A.J.M. Icodextrin instead of glucose during daytime dwell in CCPD increases ultrafiltration and 24 h dialysis creatinine clearance. Nephrol Dial Transplant 1997: 12 ( suppl 1 ): 550 - 553

***Li FK, Chan LY, Woo JC, Ho SK, Lo WK, Lai KN, Chan TM. A 3-year, prospective, randomized, controlled study on amino acid dialysate in patients on CAPD. Am J Kidney Dis. 2003 Jul;42(1):173-83.

****le Poole CY, van Ittersum FJ, Weijmer MC, Valentijn RM, ter Wee PM. Clinical effects of a peritoneal dialysis regimen low in glucose in new peritoneal dialysis patients: a randomized crossover study. Adv Perit Dial. 2004;20:170-6.

---------------------------------------------------------------

NKF-DOQI clinical practice guidelines for peritoneal dialysis adequacy. Am J Kidney Dis 1997 30 (suppl) S 67 - 136

Twardorski, ZJ. Clinical value of standardized equilibrium tests in CAPD patients. Blood Purif 1989; 7: 95-108

Mujais S. Ultrafiltration failure. In: Gokal R., Khanna R., Krediet R.Th. and Nolph K.D: (eds) Textbook of Peritoneal dialysis, 2 nd Edition, 499 – 513, 2000, Kluwer Academic Publishers, Dordrecht

Mujais S. Ultrafiltration Management in Automated Peritoneal Dialysis. In: Ronco C., Amici G., Feriani M., Virag G. (eds): Automated Pertoneal Dialysis. Contrib Nephrol. Basel. Karger 1999, vol 129, pp 255 - 266

Posthuma N., ter Wee P.M., Verbruh H.A., Oe PL., Peers E., Sayers J., Donker A.J.M. Icodextrin instead of glucose during daytime dwell in CCPD increases ultrafiltration and 24 h dialysis creatinine clearance. Nephrol Dial Transplant 1997: 12 ( suppl 1 ): 550 - 553

Li FK, Chan LY, Woo JC, Ho SK, Lo WK, Lai KN, Chan TM. A 3-year, prospective, randomized, controlled study on amino acid dialysate in patients on CAPD.

Am J Kidney Dis. 2003 Jul;42(1):173-83.

le Poole CY, van Ittersum FJ, Weijmer MC, Valentijn RM, ter Wee PM. Clinical effects of a peritoneal dialysis regimen low in glucose in new peritoneal dialysis patients: a randomized crossover study. Adv Perit Dial. 2004;20:170-6.

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Question 1) - What information is needed for further work up of the patient?

> a) Ultrafiltration rate
> b) Residual renal function
> c) History of fluid and salt intake
> d) clearance of urea and creatinine
> e) peritoneal equilibrium test
> f) all of the above
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Knowledge of the history of the patient’ s peritoneal dialysis prescription, ultrafiltration rate and residual renal function, a clearance of urea and creatinine and peritoneal equilibrium test (PET), as well as an detailed history of dietary habits, especially salt and fluid intake, is needed to analyze the patients situation.

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History of fluid and salt intake:
The patient reported no major changes in her fluid or salt intake, averaging approximately 1500 ml fluid per day.

History of ultrafiltration and urine output:

Months

-26

-14

-11

Present

Prescription

2000 ml

2 x 1,36%

2 x 2,27%

3 x 2,27%

1 x icodextrin

2 x 2,27%

1 x 3,86%

1x icodextrin

1 x 2,27%

2 x 3,86%

1x icodextrin

Ultrafiltration (ml)

700

1050

1050

1350

Urine volume (ml)

1700

1300

700

200

Weight (kg)

77.0

79.8

80

81.5

The clearance of urea and creatinine can be determined by determining urea and creatinine concentrations in all exchanges over 24 hours, as well in a 24 hour urine collection. A weekly Kt/V (Urea) and a weekly creatinine clearance can be calculated, both Kt/V and creatinine clearance consist of a peritoneal and a renal part. DOQI guidelines suggest for CAPD a weekly Kt/V > 2,0 and a creatinine clearance > ml/week / 1,73 m 2 body surface area*. In addition the above collection of dialysate and urine enables us by assuming a metabolic steady state to calculate the daily protein intake expressed as normalized protein catabolic rate (nPCR) g/kg/24h. For patients on peritoneal dialysis a nPCR of > 1,2 g/kg/24h is recommended.

Previous clearance:
Total creatinine clearance: 65,6 ml/week/1,73 m 2 bsa. Peritoneal creatinine clearance 38,8 ml/week/1,73 m 2/bsa, renal creatinine clearance 4,2 ml/week/1,73 m 2/ BSA bsa.
Total Kt/V 2,26, peritoneal Kt/V 2,05, renal Kt/V 0,21.
nPCR: 0,49 g/kg/24h

*Literature:
NKF-DOQI clinical practice guidelines for peritoneal dialysis adequacy. Am J Kidney Dis 1997 30 (suppl) S 67 - 136

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Question 2) - Considering the information above, how can the complaints of the CAPD patient be explained?

> a) Insufficient clearance of urea and creatinine
> b) Fluid excess due to loss of renal function
> c) Fluid excess due to ultrafiltration failure
> d) Fluid excess due to increased salt and fluid intake
> e) b and c
> f) b and d
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Fluid excess in patients on peritoneal dialysis can be caused by three major entities: excess intake of salt and fluids, loss of renal function or ultrafiltration failure. True ultrafiltration failure is characterized by ultrafiltration less than 200 ml after an exchange of 2000 ml of a solution with 3.86% glucose.

The patient’s history clearly illustrates the loss of urine output over the previous years. Fluid balance was maintained by gradually adjusting the concentration of glucose and early use of icodextrin. The dietary history was not suggestive for increased intake of salt and water. Thus edema and an increase in weight suggest a ultrafiltration problem in this anuric patient.

The use of two exchanges with 3,86% glucose concentration leads to increased loss of appetite and protein malnourishment as indicated by a low serum albumin and the low nPCR.

The peritoneal equilibrium test (PET) is a standardized exchange performed under defined conditions as described by Twadorski**. At 0, 1, 2, and 4 hours after start of the exchange dialysate probes for analysis of creatinine, urea and glucose, at 2 hours a blood sample for creatinine and urea are obtained. The relation of dialysate and plasma concentration of creatinine (D/P Crea) and dialysate to dialysate 0 concentration of glucose (D/D 0 Glucose) will provide information about transport properties of the peritoneum. Patients are characterized as low, low average, high average and high transporters. A low transport characteristic is characterized by a high ultrafiltration rate, because glucose is not readily absorbed by the peritoneum and therefore the osmotic gradient is longer preserved. On the other hand, glucose will be readily absorbed in a high transport status, which will lead to a reduced osmotic load and reduced ultrafiltration.

Last 4 hour PET performed 11 months before using 2000 ml glucose concentration 2,23%, 2000 ml fill volume.
Drain volume: 2200 ml
D/P creatinine: 0,59
D/D 0 glucose: 0,31

Therefore: This patient had a low average transport status 11 months before the complaints

** Twardorski, ZJ. Clinical value of standardized equilibrium tests in CAPD patients. Blood Purif 1989; 7: 95-108

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Question 3) - What is needed for further differential diagnosis of ultrafiltration in this patient?

> a) urine volumes
> b) Exchange volumes
> c) PET
> d) D/P creatinine
> e) 24 h protein loss with exchanges
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a) Urine volume was already low, a repeat measurement will be of no diagnostic benefit.
b) Exchange volumes will confirm the need for high glucose solutions thus confirming the ultrafiltration failure, but they will add no further information.
c) Clearance is not the problem in this particular patient
d) The D/P creatinine ratio obtained by a PET test will provide information about the cause of ultrafiltration failure.
e) Analysis of protein content of the exchanges is irrelevant for this problem.

A recent PET is necessary to further address the patient’s condition.

A D/P creatinine ratio less then 0,5 suggests a peritoneal leakage. Because by loss of fluids through the leak not only water, but also solutes will be reduced in the exchange. Therefore, in addition to ultrafiltration failure there is a loss of peritoneal clearance expressed as low D/P creatinine.

A D/P creatinine > 0,5 < 0,81 is associated with aquaporine loss or increased mechanical reabsorption, no decrease of peritoneal clearance is noted. In contrast, a D/P creatinine > 0,81 suggests increased reabsorption due to peritonitis, long term peritoneal dialysis or inherent high transport status. In the latter, peritoneal clearance is higher due to accelerated clearance during exchange time***.

Recent PET using 2000 ml glucose concentration 2,23% concentration, 2000 ml fill volume.
Draine volume: 2020
D/P creatinine 0,91 , D/D 0 glucose: 0,14

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Now this patient has a high transport status .

The recent PET demonstrated a change of membrane transport characteristics from previous low average to high transport status.


*** Mujais S. Ultrafiltration failure. In: Gokal R., Khanna R., Krediet R.Th. and Nolph K.D: (eds) Textbook of Peritoneal dialysis, 2 nd Edition, 499 – 513, 2000, Kluwer Academic Publishers, Dordrecht

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Question 4) - Which therapeutic approach is feasible?

> a) Administer high dose diuretics
> b) Reduce fluid and salt intake
> c) Increase fill volume
> d) Increase frequency of exchanges
> e) Switch to APD
> f) Switch in PD fluids
> g) Switch to hemodialysis
> h) d, e, f, g
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  • a) In any patients on PD with decreasing urine output a trial with high dose loop diuretics, f.e. furosemide or torasemide is justified to maintain urinary output. This should be considered before even prescribing 3,86% glucose solutions. In this particular patient, diuretics were prescribed earlier. No additional benefit was observed at this time.
  • b) The restriction of fluid and salt intake can be debated in this case. But a restriction in fluid intake always presents major inconveniences to the patient. In addition, there was no change in dietary intakes suggesting that another factor was responsible for the patient’s complaints.
  • c) An increase of fill volume in a patient with high transport status will not significantly increase ultrafiltration; it would increase glucose absorption even more.
  • d) An increase in the frequency of exchanges will improve ultrafiltration, because by removing the exchange earlier less glucose will be absorbed. A higher osmotic gradient will be maintained inside the peritoneum to actually remove fluid from the body. Increasing the exchange frequency will be a major inconvenience to the patient with a massive loss of quality of life because of increased time needed to perform exchanges.
  • e) A switch to automated PD will perform the needed increased exchange frequency during the night, thus not compromising the patient’s daily activities. APD might re-establish peritoneal ultrafiltration and reduce the glucose load by a change of lower glucose concentrations. Ultrafiltration in PD patients can be modified by altering the osmotic gradient (glucose concentration), dwell time, and fill volume*. The reduced dwell time due to short cycles has the advantage of the high initial ultrafiltration rate. The shorter the dwell the more preservation of the osmotic gradient can be observed. Under this condition the ultrafiltration will be similar in different peritoneal membrane conditions. The clearance will be affected inversely, because the less time for diffusion of solutes the more important is the transport status of the membrane. In addition, the more cycles are applied during time the more drainage and fill time will increase and a reduction in dialysis time with reduction in clearance will occur. Usually a one time exchange during day time can be easily included in the patient’s life.
  • f) A switch in PD fluids should be considered, if there is an improvement in ultrafiltration or an improvement in the nutritional status achievable.

To maintain ultrafiltration in a high transport status in the long dwell, icodextrin is recommended**. Icodextrin is only suitable for an exchange longer then 8 hours. Therefore it can be only used once a day. It is already incorporated in the patient’s dialysis prescription.

To increase nitrogen balance the patient should be treated with an amino acid based, glucose free PD solution, which will lead to absorption of essential amino acids***. Thereby the protein metabolism can be improved. This solution should be given with carbohydrates, which can be administered by a meal or by adding the solution during APD treatment, thus using a mixture of glucose and amino acids as PD solution.

  • g) A switch to hemodialysis is always within options but in this particular case not necessary. The patient expressed the strong wish to continue with PD.

In the patient, the PD prescription was changed to CCPD with a dwell time of 80 min, total time 9 hours, total exchange volume 15000 ml solution of 2,23% glucose concentration, last bag 2000 ml amino acid based solution (Nutrineal®, one day time exchange with icodextrine.

Ultrafiltration rose to 1500 ml per cycler treatment and 400 ml per icodextrine exchange. Clearance was sufficiently maintained. This regimen consisting of aminmo acid solution (N), icodextrin (E) and physiologic solution (P) twice daily was recently investigated in a randomized cross over study by le Poole et al****. Compared to a standard regimen, this NEPP regimen was no different with regard to ultrafiltration and dialysis efficacy, but markedly reduced glucose load.

In our patient a marked improvement of the nutritional status was documented by a rise of albumin to 4,3 g/dl and a nPCR of 0,85. The clinical condition improved, edema resolved. The patient is now dialyzing with CCPD using the described prescription for more then three years.

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