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We investigated the predictors of serum albumin and the relationship between serum albumin and urea kinetic indices in continuous peritoneal dialysis (CPD). In a training set (TS) of 143 urea kinetic studies performed in 92 CPD patients, stepwise logistic regression identified high/high-average peritoneal solute transport, diabetes, advanced age and high daily drain volume normalized by body water as predictors of low serum albumin (< 35 g/liter). This analysis was then substantiated in a validation set (VS) of 187 kinetic studies performed in another 102 CPD patients. The calculated area under the receiver operating characteristic (ROC) curve by this logistic regression model was 0.782 (95% CI, 0.745 to 0.819). Logistic regression was repeated in the TS using only the first kinetic study from each patient, and it identified high/high-average peritoneal solute transport, diabetes, and advanced age as predictors of low albumin. Using only the first kinetic study from each patient in the VS, the second logistic regression model calculated an area under the ROC curve equal to 0.850 (95% CI, 0.810 to 0.890). The relative risk (RR) of serum albumin < 35 g/liter was computed for all kinetic studies after combining the TS and the VS and using non-diabetic CPD subjects aged < or = 61 years with low/low average peritoneal solute transport as the reference group. The RR with only one risk factor present ranged from 1.076 (age > 61 years) to 6.792 (high/high-average transport). The RR with two risk factors present ranged from 5.200 to 9.729. The RR with all three risk factors present was 9.100 (95% CI, range 3.923 to 21.111). A subset of 37 CPD patients had a second urea kinetic study 8 +/- 5 months after an increase in the amount of dialysis due to low urea clearance and/or uremic symptoms. The weekly KT/V urea increased from 1.40 +/- 0.24 to 2.10 +/- 0.31 after the increase in the CPD dose. With the increase in dialysis, the protein catabolic rate increased substantially; however, the mean serum albumin remained stable (from 33.9 +/- 4.6 to 33.3 +/- 6.2 g/liter; decrease 18; increase 15; same 4). In comparison to the subjects who had a decrease in serum albumin after the increase in KT/V, those with the increase in serum albumin were younger (44.2 +/- 11.2 vs. 54.3 +/- 16.2 years, P = 0.044) and had a higher serum urea after the increase in the dose of CPD (22.4 +/- 7.8 vs. 17.0 +/- 6.0 mmol/liter, P = 0.037). We conclude that the major predictors of low serum albumin in CPD are advanced age, diabetes, and high/high-average peritoneal solute transport, but not urea kinetic studies. An increase in the dose of dialysis does not cause a consistent rise in serum albumin in underdialyzed CPD subjects. However, a subset of younger patients may be able to increase their serum albumin in response to the increase in KT/V.

Anionic sites have been demonstrated in the basement membranes of peritubular capillaries. The anionic barrier function of peritubular capillary wall has been ascribed to these sites. Fenestrated capillaries in other organs have anionic sites in the endothelial cell glycocalyx and at the luminal surface of the fenestral diaphragms. The purpose of this study was to map anionic sites at the luminal surface of peritubular capillaries and to assess whether a concentration gradient for albumin exists across the endothelium. Partial chemical characterization of these anionic sites was done by in vivo enzymatic degradation. The difference in distribution of albumin following enzyme digestion was also studied. The binding of cationized ferritin to the luminal surface indicated that the rat peritubular capillaries have anionic sites along the entire luminal surface of the endothelial cell, including the fenestral diaphragms. Partial biochemical characterization of these sites shows that the sites in the glycocalyx are mainly from neuraminic acid, while the fenestral diaphragms have mainly heparan sulfate proteoglycans. Intravascular albumin extended to the endothelial luminal plasmalemma and to the luminal surface of fenestral diaphragms. Digestion with heparitinase was associated with the leakage of albumin outside the capillary wall. These findings suggest that the anionic surface of fenestrae constitutes a charge barrier of the peritubular capillaries.

Noninvasive characterization of renal artery blood flow variables in the human has not been reported. Using a unique dual-frequency real-time two-dimensional echo Doppler (Duplex scanner) that was calibrated in vitro, we characterized renal artery blood flow patterns in 16 normal subjects (6 females). Calculated mean values of systolic diameter (Ds), maximal spatial average blood velocity (Vmsa), and volume flow rate (Q) were as follows: 4.5 +/- 0.6 mm right, 4.4 +/- 0.6 mm left; 67.6 +/- 9.4 cm . sec-1 right, 69.6 +/- 12.0 cm . sec-1 left; and 403 +/- 127 ml . min-1 right, 395 +/- 98 ml . min-1 left; respectively. Direct linear regression correlation of body surface area (BSA) with Ds and Q were statistically significant (P less than 0.01, r = 0.70; and P less than 0.01, r = 0.72, respectively). In a blind prospective series, six of seven angiographically normal renal arteries were noninvasively identified by normal geometry and blood velocity patterns. One angiographically normal artery was incorrectly classified as mildly stenotic. Eleven angiographically documented abnormal renal arteries were noninvasively identified by their abnormal blood flow patterns and/or geometry. This study suggests that dual-frequency Duplex scanning with careful sample volume control and Doppler audio spectra/blood velocity waveform analysis can be used to characterize blood flow variables in normal and diseased human renal arteries.

We evaluated the diagnostic accuracy of ultrasonic echo-Doppler velocimetry for the noninvasive diagnosis of renal artery stenosis. Renal artery stenosis was diagnosed if one or more of the following four abnormal hemodynamic parameters were found by Doppler velocimetry: (1) peak blood velocity greater than 100 cm . sec-1 in a focal area along the length of a renal artery, (2) absence of blood velocity during diastole, (3) absence of any detectable blood velocity denoting occlusion, or (4) broad-band Doppler frequency spectra due to focal blood velocity disturbances. With these criteria, the presence or absence of renal artery stenosis was blindly evaluated in 26 patients (52 arteries) who underwent standard or digital subtraction angiography. Compared to arteriography (reduction in diameter greater than or equal to 50%), the sensitivity of Doppler method was 89%, while its specificity was 73%. This noninvasive method may be useful in selecting patients for radiographic evaluation of renal artery stenosis and in the long term follow-up of these patients. Furthermore, echo-Doppler velocimetry may have the unique capability of assessing the hemodynamic consequences of renal artery stenosis.