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Background: It is well known that the efficiency of peritoneal dialysis (PD) varies with the duration of the dwell and with the prescribed fill volume. Automated PD (APD) is classically given as a series of recurrent exchanges, each having the same dwell time and fill volume-that is, conventional APD (APD-C). We propose a new way of giving PD, using a modified version of APD-C. This method first uses a short dwell time with a small fill volume to promote ultrafiltration (UF) and subsequently uses a longer dwell time and a larger fill volume to promote removal of uremic toxins from the blood. We use the term "adapted APD" (APD-A) to describe this modified form of PD., Methods: We designed a multicenter prospective randomized crossover trial to assess the impact of APD-A in comparison with APD-C on the efficacy of dialysis. The parameters investigated were overnight UF; weekly peritoneal Kt/V(urea); weekly peritoneal creatinine clearance corrected to 1.73 m(2) body surface area (K(creat)); and phosphate (PDR) and sodium dialytic removal (SDR) in millimoles per session, corrected for glucose absorption, which provides an estimate of metabolic cost. Blood pressure was also regularly monitored. Initially, 25 patients were identified for inclusion in the study. There were 6 withdrawals in total: 2 at enrolment, 1 at day 75 (transplantation), 2 at day 30 (catheter dysfunction), and 1 for drainage alarms. All patients received the same duration of overnight APD, using the same total volume of dialysate, with the same 1.5% glucose, lactate-buffered dialysate (Balance: Fresenius Medical Care, Bad Homburg, Germany)., Results: Tolerance was good. Compared with APD-C, APD-A resulted in a significant enhancement of Kt/V(urea), K(creat), and PDR. The metabolic cost, in terms of glucose absorption, required to achieve dialytic capacity for urea, creatinine, and phosphate blood purification was significantly lower for APD-A than for APD-C, and UF increased during APD-A. With APD-A, each gram of glucose absorbed contributed to 18.25 ± 15.82 mL UF; in APD-C, each gram of glucose absorbed contributed to 15.79 ± 11.24 mL UF. However, that difference was not found to be significant (p=0.1218). The SDR was significantly higher with APD-A than with APD-C: 35.23 ± 52.00 mmol and 18.35 ± 48.68 mmol per session respectively (p<0.01). The mean blood pressure recorded at the end of each PD period (on day 45) was significantly lower when patients received APD-A than when they received APD-C., Conclusions: Our study provides evidence that, compared with the uniform dwell times and fill volumes used throughout an APD-C dialysis session, the varying dwell times and fill volumes as described for an APD-A dialysis session result in improved dialysis efficiency in terms of UF, Kt/V(urea), K(creat), PDR, and SDR. Those results were achieved without incurring any extra financial costs and with a reduction in the metabolic cost (assessed using glucose absorption)., (Copyright © 2011 International Society for Peritoneal Dialysis)

Background: Evidence is accumulating that the continuous exposure to high glucose concentrations during peritoneal dialysis (PD) is an important cause of ultrafiltration (UF) failure. The cornerstone of prevention and treatment of UF failure is reduction of glucose exposure, which will also alleviate the systemic impact of significant free glucose absorption. The challenge for the future is to discover new therapeutic strategies to enhance fluid and sodium removal while diminishing glucose load and exposure using combinations of available osmotic agents., Objectives: To investigate in patients on automated PD (APD) with a fast transport pattern whether there is a glucose-sparing advantage to replacing 7.5% icodextrin (ICO) during the long dwell with a mixed crystalloid and colloid PD fluid (bimodal UF) in an attempt to promote daytime UF and sodium removal while diminishing the glucose strength of the dialysate at night., Design: A 2 parallel arm, 4 month, prospective nonrandomized study., Setting: PD units or university hospitals in 4 French and Belgian districts., Results: During the 4-month intervention period, net UF and peritoneal sodium removal during the long dwell when treated by bimodal UF was about 2-fold higher than baseline (with ICO). The estimated percent change (95% confidence interval) from baseline in net daytime UF for the bimodal solution was 150% (106% - 193%), versus 18% (-7% - 43%) for ICO (p < 0.001). The estimated percent change from baseline in peritoneal sodium removal for the bimodal solution was 147% (112% - 183%), versus 23% (-2% - 48%) for ICO (p < 0.001). The estimated percent change from baseline in UF efficiency (24-hour net UF divided by the amount of glucose absorbed) was significantly higher (p < 0.001) when using the bimodal solution was 71%, versus -5% for ICO., Conclusion: Prescription of bimodal UF during the day in APD patients offers the opportunity to optimize the long dwell exchange in a complete 24-hour APD cycle. The current study demonstrated that a bimodal solution based on the mixing of glucose (2.6%) and icodextrin (6.8%) achieved the double target of significantly improving UF and peritoneal sodium removal by exploring a new concept of glucose-sparing PD therapy.

Background: Growing concern over the limited capacity of the peritoneal dialysis (PD) system has revived interest in continuous flow peritoneal dialysis (CFPD), a modality in which continuous circulation of PD fluid is maintained at a high flow rate using two separate catheters or one dual-lumen catheter. The CFPD regimen contrasts the "inflow/outflow" regimen, which requires specific times devoted to filling and draining the peritoneum via a single-lumen catheter. Historical data established CFPD capabilities in providing higher solute clearance and ultrafiltration rate (UFR) using either an open loop system with a single pass of fresh PD fluid, or various external purifications of the spent dialysate., Objective: To compare, in patients with various peritoneal transport patterns, fluid and solute removal achieved during a standardized program of CFPD versus two control schedules: nightly intermittent peritoneal dialysis (NIPD) and nightly tidal peritoneal dialysis (NTPD). This study focused on small solute clearances and UFR using only isotonic PD solution (Dianeal PD1 1.36%; Baxter Healthcare, Castlebar, Ireland). The model of fresh dialysate, single pass, was used to optimize solute gradients and to characterize the impact of a continuous flow regimen on peritoneal transport characteristics., Methods: In a crossover trial, 4-hour CFPD sessions were performed at a fixed dialysate flow rate (100 mL/ minute) in 5 patients being treated with automated PD. A hemofiltration monitor (BM25; Baxter Healthcare, Brussels, Belgium) was adapted to the CFPD technique. The peritoneal cavity was filled through a temporary second catheter and simultaneously drained using the permanent peritoneal access. Fluid and solute removal were compared to data obtained from a control period based on 8-hour sessions of NIPD or NTPD using 13 L of isotonic dialysate., Results: High-flow CFPD enhanced the diffusive transport coefficient compared with the alternative flow regimen in patients ranging from low to high transporters. Weekly creatinine clearance increased from 36.9 L (22.3 - 49.6 L) and 37.3 L (27.5 - 45.0 L) with NIPD and NTPD respectively, to 74.9 L (42.3 - 107.5 L) with CFPD. Mean UFR was 2.44 mL/min with CFPD versus 0.92 and 0.89 mL/min with NIPD and NTPD respectively. The mass transfer area coefficient (MTAC) of creatinine with CFPD was 2.5-fold that obtained from the peritoneal equilibration test data., Conclusion: Our results confirm that CFPD is highly effective in increasing fluid and solute removal. Furthermore, consistent with historical data, our findings indicate that the enhanced solute transfer is not due only to steeper solute gradients, but also depends on increased MTAC in a wide range of peritoneum transport characteristics.

Unlabelled: We report our experience in 213 elderly patients over 75 years treated by peritoneal dialysis (PD) as first and exclusive dialysis therapy. The mean age at start of PD was 79.4 +/- 3.6 years, and the cumulative time on PD was 4551 months (mean time: 21.4 +/- 19.8 months). Twenty-six patients lived in institutions and 187 lived at home. Thirty patients had an effective autonomy with the ability to carry on normal activities. One hundred and two patients were cared for by a private nurse at home, and 46 patients were cared for in a family environment. Most cases were treated by three exchanges per day (152 cases) and used a nondisconnect system (175 cases) on account of absence of autonomy. The rate of peritonitis per patient-month was one episode per 16.8 patient-months. Patient survival (Kaplan-Meier curves) was 74%, 59%, 45%, and 19% at one, two, three, and five years, respectively. The causes of death were various with a higher frequency of cardiovascular causes (48.3% of the 116 deaths). Thirty-three patients died in less than six months including 18 patients in less than three months., In Conclusion: elderly uremic patients can be treated with long-term PD with relatively good results. Mortality is high but essentially due to age and poor general status-the dedication of private home nursing is very important in treating elderly PD patients. This fact often is a necessary condition in maintaining these elderly patients at home.

This paper summarizes the basis of prescription for automated peritoneal dialysis (APD) established during a French national conference on APD. Clinical results and literature data show that peritoneal clearances are closely determined by peritoneal permeability and hourly dialysate flow rate, independently of dwell time or number of cycles. With APD, peritoneal creatinine clearance increases according to the hourly dialysate flow rate to a maximum (plateau), then decreases because of the multiplication of the drain-fill times. The hourly dialysate flow giving the maximum peritoneal creatinine clearance is defined as the "maximal effective dialysate flow" (MEDF). MEDF is higher for high peritoneal permeabilities: MEDF is 1.8 and 4.2 L/hr with nocturnal tidal peritoneal dialysis (TPD) for a 4-hr creatinine dialysate-to-plasma ratio (D/P) of 0.50 and 0.80, respectively. With nightly intermittent peritoneal dialysis (NIPD), MEDF is 1.6 and 2.3 L/hr for a D/P of 0.50 and 0.78, respectively. Under these conditions, tidal modalities can only be considered as a way to increase the MEDF. Using the MEDF concept for an identical APD session duration, the maximal weekly normalized peritoneal creatinine clearance can vary by 340% when 4-hr D/P varies from 0.41 to 0.78. APD is not recommended when 4-hr creatinine D/P is lower than 0.50. However, the limits of this technique may be reached at higher peritoneal permeabilities in anurics because of the duration of sessions and/or the additional exchanges required by these patients.

A total of 127 patients from 8 hospitals were randomized into 1 of 2 exit-site care regimes to evaluate their effect on rate of exit-site infection (ESI). Group 1 used povidone iodine and nonocclusive dressings changed 2 to 3 times weekly; Group 2 simply cleansed the exit site with nondisinfectant soap and water. Incidence, cause, duration, and treatment of ESI and peritonitis (P) were noted. Groups were analysed for age, sex, end-stage renal disease (ESRD), catheter, and systems. Total cumulative follow up time was 95.6 years. There was a significantly higher rate (p = 0.0183) of ESI in Group 2 (soap and water). The mean rate of ESI was 0.27 episodes/patient year for Group 1 versus 0.71 episodes/patient year for Group 2. Rates of P for the two groups were not significantly different (p greater than 0.50): 0.446 episodes/year for Group 1 versus 0.574 episodes/year for Group 2. S. aureus was responsible for 83% of ESI in Group 1 and 67% of ESI in Group 2. Protective dressing with a disinfectant is associated with significantly less ESI than minimum care. However, further research in exit-site care aimed specifically at reducing S. aureus infection is still required.

The treatment of end-stage renal diabetic nephropathy remains a challenge. A large experience allows us to clearly outline the advantages and the drawbacks of continuous ambulatory peritoneal dialysis (CAPD) and continuous cyclic peritoneal dialysis (CCPD). Eighty-one patients, mean age 51.3 years, were treated over the last 9 years by CAPD-CCPD. Extrarenal complications, mainly vascular lesions, were present in this high-risk group of patients. The technique was modified in order to inject intraperitoneally, 4 times per day, insulin to control blood glucose level in CAPD patients. Actuarial survival was 92% at 1 year, 50% at 4 years mainly influenced by age: 85% survival at 2 years in 35 patients aged less than 50 years old and 62% at 2 years in 46 patients aged more than 50 years old. The main causes of death were of cardiovascular origin: myocardial infarction, stroke, atherosclerotic vasculopathy. The main causes of transfer to hemodialysis were due to technical complications. Peritonitis rate was one episode every 14 patient-months. Control of blood pressure, blood glucose levels, main biological parameters, and visual status were the clear advantages of the method. Peripheral vascular disease is not influenced by the technique. CAPD-CCPD is the technique of first choice in young diabetics and the preferential technique for home dialysis.