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Contributions To Nephrology 2017Glucose-based peritoneal dialysis (PD) solutions are the mainstay of therapy for PD patients, yet are accompanied by a number of adverse effects and potential... (Review)
Review
Glucose-based peritoneal dialysis (PD) solutions are the mainstay of therapy for PD patients, yet are accompanied by a number of adverse effects and potential complications. The high glucose content can cause both systemic effects, such as hyperglycaemia, as well as local effects on the peritoneal membrane, which can interfere with its function. In addition, glucose degradation products (GDPs) generated during heat sterilization of the solutions and the acidic pH at which these solutions are kept have been shown to cause peritoneal membrane injury and precipitate inflow pain, respectively. As a result, biocompatible PD solutions, characterized by neutral pH and low GDP concentrations, have been developed. However, the published evidence supporting their use has often been conflicting and of variable methodological quality. This review aims to discuss the relevant literature and up-to-date evidence for the use of biocompatible PD solutions.
Topics: Biocompatible Materials; Dialysis Solutions; Glucose; Humans; Peritoneal Dialysis; Peritoneum; Sterilization
PubMed: 27951555
DOI: 10.1159/000450690 -
Biomolecules May 2020One of the main limitations to successful long-term use of peritoneal dialysis (PD) as a renal replacement therapy is the harmful effects of PD solutions to the... (Review)
Review
One of the main limitations to successful long-term use of peritoneal dialysis (PD) as a renal replacement therapy is the harmful effects of PD solutions to the structure and function of the peritoneal membrane (PM). In PD, the PM serves as a semipermeable membrane that, due to exposure to PD solutions, undergoes structural alterations, including peritoneal fibrosis, vasculopathy, and neoangiogenesis. In recent decades, oxidative stress (OS) has emerged as a novel risk factor for mortality and cardiovascular disease in PD patients. Moreover, it has become evident that OS plays a pivotal role in the pathogenesis and development of the chronic, progressive injury of the PM. In this review, we aimed to present several aspects of OS in PD patients, including the pathophysiologic effects on the PM, clinical implications, and possible therapeutic antioxidant strategies that might protect the integrity of PM during PD therapy.
Topics: Animals; Dialysis Solutions; Epithelial Cells; Glycation End Products, Advanced; Humans; Oxidative Stress; Peritoneal Dialysis; Peritoneum
PubMed: 32423139
DOI: 10.3390/biom10050768 -
Nephrology Nursing Journal : Journal of... 2004The composition of peritoneal dialysis solutions to a great extent, determine their effectiveness and safety. Many of the factors that determine the bioincompatibility... (Comparative Study)
Comparative Study Review
The composition of peritoneal dialysis solutions to a great extent, determine their effectiveness and safety. Many of the factors that determine the bioincompatibility of peritoneal dialysis fluids have been recently identified. This knowledge is essential to modify the manufacturing processes and in the quest for more biocompatible solutions. A description of the available peritoneal dialysis fluids in the United States and a comparison of their formulations are provided.
Topics: Biocompatible Materials; Buffers; Dialysis Solutions; Equipment Design; Glucans; Glucose; Humans; Hydrogen-Ion Concentration; Peritoneal Dialysis; United States
PubMed: 15518252
DOI: No ID Found -
Advances in Renal Replacement Therapy Oct 2000Currently available peritoneal dialysis (PD) solutions provide for adequate removal of metabolic waste and manage fluid and electrolyte imbalances. They are, however,... (Review)
Review
Currently available peritoneal dialysis (PD) solutions provide for adequate removal of metabolic waste and manage fluid and electrolyte imbalances. They are, however, bioincompatible and do lead to peritoneal membrane changes with long-term use. Glucose is now strongly implicated in this. Newer solutions (icodextrin, bicarbonate, those with reduced glucose degradation products, amino acids) provide for greater biocompatibility and also address the question of fluid removal and retention. The future of PD solutions lies in combinations and additives.
Topics: Dialysis Solutions; Humans; Kidney Failure, Chronic; Peritoneal Dialysis
PubMed: 11073562
DOI: 10.1053/jarr.2000.16267 -
The Cochrane Database of Systematic... Jul 2014The high mortality rate among critically ill patients with acute kidney injury (AKI) remains an unsolved problem in intensive care medicine, despite the use of renal... (Review)
Review
BACKGROUND
The high mortality rate among critically ill patients with acute kidney injury (AKI) remains an unsolved problem in intensive care medicine, despite the use of renal replacement therapy (RRT). Increasing evidence from clinical studies in adults and children suggests that the new peritoneal dialysis (PD) fluids may allow for better long-term preservation of peritoneal morphology and function. Formation of glucose degradation products (GDPs) can be reduced and even avoided with the use of newer "biocompatible" solutions. However, it is still unclear if there are any differences in using conventional (lactate) solutions compared with low GDP (bicarbonate) solutions for acute PD.
OBJECTIVES
To look at the benefits and harms of bicarbonate versus lactate solutions in acute PD.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1966), EMBASE (from 1980), Latin American and Caribbean Health Sciences Literature Database LILACS (from 1982), and reference lists of articles.Date of last search: 6 May 2014.
SELECTION CRITERIA
Randomised controlled trials (RCTs) comparing bicarbonate to lactate solution for acute PD.
DATA COLLECTION AND ANALYSIS
Two authors independently assess the methodological quality of studies. One author abstracted data onto a standard form, and a second author checked data extraction. We used the random-effects model and expressed the results as relative risk (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with 95% confidence intervals (CI).
MAIN RESULTS
We included one study (20 patients) in this review. In shock patients, bicarbonate did not differ from lactate with respect to mortality (RR 0.50, 95% CI 0.06 to 3.91); however there were significant differences in blood lactate (MD -1.60 mmol/L, 95% CI -2.04 to -1.16), serum bicarbonate (MD 5.00 mmol/L, 95% CI 3.26 to 6.74) and blood pH (MD 0.12, 95% CI 0.06 to 0.18). In non-shock patients there was a significance difference in blood lactate (MD -0.60 mmol/L, 95% CI -0.85 to -0.35) but not in serum bicarbonate (MD 1.10 mmol/L, 95% CI -0.27 to 2.47) or blood pH (MD -0.02, 95% CI -0.02 to -0.06). Other outcomes could not be analysed because of the limited data available.
AUTHORS' CONCLUSIONS
There is no strong evidence that any clinical advantage for patients requiring acute PD for AKI when comparing conventional (lactate) with low GDP dialysis solutions (bicarbonate).
Topics: Acute Kidney Injury; Adult; Bicarbonates; Dialysis Solutions; Humans; Lactic Acid; Peritoneal Dialysis; Randomized Controlled Trials as Topic
PubMed: 24992903
DOI: 10.1002/14651858.CD007034.pub3 -
International Journal of Molecular... Jul 2021Peritoneal dialysis (PD) is an important, if underprescribed, modality for the treatment of patients with end-stage kidney disease. Among the barriers to its wider use... (Review)
Review
Peritoneal dialysis (PD) is an important, if underprescribed, modality for the treatment of patients with end-stage kidney disease. Among the barriers to its wider use are the deleterious effects of currently commercially available glucose-based PD solutions on the morphological integrity and function of the peritoneal membrane due to fibrosis. This is primarily driven by hyperglycaemia due to its effects, through multiple cytokine and transcription factor signalling-and their metabolic sequelae-on the synthesis of collagen and other extracellular membrane components. In this review, we outline these interactions and explore how novel PD solution formulations are aimed at utilizing this knowledge to minimise the complications associated with fibrosis, while maintaining adequate rates of ultrafiltration across the peritoneal membrane and preservation of patient urinary volumes. We discuss the development of a new generation of reduced-glucose PD solutions that employ a variety of osmotically active constituents and highlight the biochemical rationale underlying optimization of oxidative metabolism within the peritoneal membrane. They are aimed at achieving optimal clinical outcomes and improving the whole-body metabolic profile of patients, particularly those who are glucose-intolerant, insulin-resistant, or diabetic, and for whom daily exposure to high doses of glucose is contraindicated.
Topics: Diabetes Mellitus; Dialysis Solutions; Glucose; Glucose Intolerance; Humans; Insulin Resistance; Kidney Failure, Chronic; Peritoneal Dialysis; Peritoneum
PubMed: 34360717
DOI: 10.3390/ijms22157955 -
Clinical Journal of the American... Apr 2010Clinical experience and literature evidence suggest that peritoneal dialysis (PD) is a safe and effective treatment in short term (3 to 5 years) for stage 5 chronic... (Review)
Review
Clinical experience and literature evidence suggest that peritoneal dialysis (PD) is a safe and effective treatment in short term (3 to 5 years) for stage 5 chronic kidney disease patients. A major limitation to long-term PD has been peritoneal membrane structural and functional alterations over time, resulting in significant technique failure. Much evidence implicates glucose contained in conventional PD solutions as the major cause of membrane changes. Other harmful characteristics of glucose or its degradation products are thought to cause systemic undesirable metabolic and cardiovascular effects. This led to the search for more "biocompatible" PD solutions to ameliorate complications associated with conventional glucose solutions. Studies in animals and humans show that newer biocompatible solutions may preserve membrane functions better, lead to less therapy failure, and avoid the undesirable metabolic and cardiovascular effects of systemic glucose exposure. There is evidence in specific, clinical, short-term situations of biochemical and metabolic benefits of biocompatible solutions. However, are these solutions superior to glucose in preserving peritoneal membrane long term? Are they truly more biocompatible? Clinical and experimental data suggest that newer solutions, albeit most of them glucose based, are less toxic compared with the current PD solution; however, there is currently no osmotic agent that can safely replace glucose. The future appears to be in using combinations of different osmotic agents in a more biocompatible solution, whether they are mixtures in a single bag or daily exchanges of different osmotic agents. This review discusses the current status of these biocompatible solutions in PD patients.
Topics: Animals; Biocompatible Materials; Cardiovascular System; Dialysis Solutions; Evidence-Based Medicine; Glucose; Humans; Kidney Failure, Chronic; Peritoneal Dialysis; Peritoneum; Risk Assessment; Time Factors; Treatment Outcome
PubMed: 20093342
DOI: 10.2215/CJN.05720809 -
BMC Nephrology Oct 2019This guideline is written primarily for doctors and nurses working in dialysis units and related areas of medicine in the UK, and is an update of a previous version...
This guideline is written primarily for doctors and nurses working in dialysis units and related areas of medicine in the UK, and is an update of a previous version written in 2009. It aims to provide guidance on how to look after patients and how to run dialysis units, and provides standards which units should in general aim to achieve. We would not advise patients to interpret the guideline as a rulebook, but perhaps to answer the question: "what does good quality haemodialysis look like?"The guideline is split into sections: each begins with a few statements which are graded by strength (1 is a firm recommendation, 2 is more like a sensible suggestion), and the type of research available to back up the statement, ranging from A (good quality trials so we are pretty sure this is right) to D (more like the opinion of experts than known for sure). After the statements there is a short summary explaining why we think this, often including a discussion of some of the most helpful research. There is then a list of the most important medical articles so that you can read further if you want to - most of this is freely available online, at least in summary form.A few notes on the individual sections: 1. This section is about how much dialysis a patient should have. The effectiveness of dialysis varies between patients because of differences in body size and age etc., so different people need different amounts, and this section gives guidance on what defines "enough" dialysis and how to make sure each person is getting that. Quite a bit of this section is very technical, for example, the term "eKt/V" is often used: this is a calculation based on blood tests before and after dialysis, which measures the effectiveness of a single dialysis session in a particular patient. 2. This section deals with "non-standard" dialysis, which basically means anything other than 3 times per week. For example, a few people need 4 or more sessions per week to keep healthy, and some people are fine with only 2 sessions per week - this is usually people who are older, or those who have only just started dialysis. Special considerations for children and pregnant patients are also covered here. 3. This section deals with membranes (the type of "filter" used in the dialysis machine) and "HDF" (haemodiafiltration) which is a more complex kind of dialysis which some doctors think is better. Studies are still being done, but at the moment we think it's as good as but not better than regular dialysis. 4. This section deals with fluid removal during dialysis sessions: how to remove enough fluid without causing cramps and low blood pressure. Amongst other recommendations we advise close collaboration with patients over this. 5. This section deals with dialysate, which is the fluid used to "pull" toxins out of the blood (it is sometimes called the "bath"). The level of things like potassium in the dialysate is important, otherwise too much or too little may be removed. There is a section on dialysate buffer (bicarbonate) and also a section on phosphate, which occasionally needs to be added into the dialysate. 6. This section is about anticoagulation (blood thinning) which is needed to stop the circuit from clotting, but sometimes causes side effects. 7. This section is about certain safety aspects of dialysis, not seeking to replace well-established local protocols, but focussing on just a few where we thought some national-level guidance would be useful. 8. This section draws together a few aspects of dialysis which don't easily fit elsewhere, and which impact on how dialysis feels to patients, rather than the medical outcome, though of course these are linked. This is where home haemodialysis and exercise are covered. There is an appendix at the end which covers a few aspects in more detail, especially the mathematical ideas. Several aspects of dialysis are not included in this guideline since they are covered elsewhere, often because they are aspects which affect non-dialysis patients too. This includes: anaemia, calcium and bone health, high blood pressure, nutrition, infection control, vascular access, transplant planning, and when dialysis should be started.
Topics: Ambulatory Care Facilities; Anticoagulants; Dialysis Solutions; Humans; Membranes, Artificial; Renal Dialysis; Renal Insufficiency; United Kingdom
PubMed: 31623578
DOI: 10.1186/s12882-019-1527-3 -
Journal of the American Society of... Jan 2002On-line preparation, i.e., continuous mixing and immediate use, was introduced for dialysis fluid in 1964, and it contributed significantly to the expansion of dialysis... (Review)
Review
On-line preparation, i.e., continuous mixing and immediate use, was introduced for dialysis fluid in 1964, and it contributed significantly to the expansion of dialysis therapy through simplified handling, improved microbiology, and enhanced efficiency. On-line prepared replacement solution for hemofiltration was shown to be clinically safe as early as 1978, but the implementation was delayed for 20 yr because of regulatory conservatism. On-line preparation of sterile and pyrogen-free solutions for infusion is based on the use of water and concentrates that contribute a minimum of microorganisms and are mixed and distributed in a hygienically designed and maintained flow path. Ultrafilters with known retention capacity are placed in strategic positions and dimensioned to remove bacteria and endotoxins, which gives a sterility assurance level of at least six magnitudes, as required by the Pharmacopoeia for sterile products. Microbiologic testing of the fluid should be applied when designing, validating, and troubleshooting on-line systems but not for routine quality control, because it only gives retrospective information. Quality assurance has to be built into a system and the way it is operated. On-line fluid preparation, when properly performed, is safe, simple, and cost-effective and enhances the efficiency as well as the biocompatibility of dialysis therapy.
Topics: Dialysis Solutions; Drug Compounding; Drug and Narcotic Control; Humans; Online Systems; Safety
PubMed: 11792766
DOI: No ID Found -
The Cochrane Database of Systematic... Sep 2010The high mortality rate among critically ill patients with acute kidney injury (AKI) remains an unsolved problem in intensive care medicine, despite the use of renal... (Review)
Review
BACKGROUND
The high mortality rate among critically ill patients with acute kidney injury (AKI) remains an unsolved problem in intensive care medicine, despite the use of renal replacement therapy (RRT). Increasing evidence from clinical studies in adults and children suggests that the new peritoneal dialysis (PD) fluids may allow for better long-term preservation of peritoneal morphology and function. Formation of glucose degradation products (GDPs) can be reduced and even avoided with the use of newer "biocompatible" solutions. However, it is still unclear if there are any differences in using conventional (lactate) solutions compared with low GDP (bicarbonate) solutions for acute PD.
OBJECTIVES
To look at the benefits and harms of bicarbonate versus lactate solutions in acute PD.
SEARCH STRATEGY
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1966), EMBASE (from 1980), Latin American and Caribbean Health Sciences Literature Database LILACS (from 1982), and reference lists of articles.
SELECTION CRITERIA
Randomised controlled trials (RCTs) comparing bicarbonate to lactate solution for acute PD.
DATA COLLECTION AND ANALYSIS
Two authors independently assess the methodological quality of studies. One author abstracted data onto a standard form, and a second author checked data extraction. We used the random-effects model and expressed the results as relative risk (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with 95% confidence intervals (CI).
MAIN RESULTS
We included one study (20 patients) in this review. In shock patients, bicarbonate did not differ from lactate with respect to mortality (RR 0.50, 95% CI 0.06 to 3.91); however there were significant differences in blood lactate (MD -1.60 mmol/L, 95% CI -2.04 to -1.16), serum bicarbonate (MD 5.00 mmol/L, 95% CI 3.26 to 6.74) and blood pH (MD 0.12, 95% CI 0.06 to 0.18). In non-shock patients there was a significance difference in blood lactate (MD -0.60 mmol/L, 95% CI -0.85 to -0.35) but not in serum bicarbonate (MD 1.10 mmol/L, 95% CI -0.27 to 2.47) or blood pH (MD -0.02, 95% CI -0.02 to -0.06). Other outcomes could not be analysed because of the limited data available.
AUTHORS' CONCLUSIONS
There is no strong evidence that any clinical advantage for patients requiring acute PD for AKI when comparing conventional (lactate) with low GDP dialysis solutions (bicarbonate).
Topics: Acute Kidney Injury; Adult; Bicarbonates; Dialysis Solutions; Humans; Lactic Acid; Peritoneal Dialysis
PubMed: 20824854
DOI: 10.1002/14651858.CD007034.pub2