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Background: Autosomal dominant polycystic kidney disease (ADPKD) is a common genetic disorder associated with progressive enlargement of the kidneys and liver. ADPKD patients may require renal volume reduction, especially before renal transplantation. The standard treatment is unilateral nephrectomy. However, surgery incurs a risk of blood transfusion and alloimmunization. Furthermore, when patients are treated with peritoneal dialysis (PD), surgery is associated with an increased risk of temporary or definitive switch to haemodialysis (HD). Unilateral renal arterial embolization can be used as an alternative approach to nephrectomy., Methods: We performed a multicentre retrospective study to compare the technique of survival of PD after transcatheter renal artery embolization with that of nephrectomy in an ADPKD population. We included ADPKD patients treated with PD submitted to renal volume reduction by either surgery or arterial embolization. Secondary objectives were to compare the frequency and duration of a temporary switch to HD in both groups and the impact of the procedure on PD adequacy parameters., Results: More than 700 patient files from 12 centres were screened. Only 37 patients met the inclusion criteria (i.e. treated with PD at the time of renal volume reduction) and were included in the study (21 embolized and 16 nephrectomized). Permanent switch to HD was observed in 6 embolized patients (28.6%) versus 11 nephrectomized patients (68.8%) (P = 0.0001). Renal artery embolization was associated with better technique survival: subdistribution hazard ratio (SHR) 0.29 [95% confidence interval (CI) 0.12-0.75; P = 0.01]. By multivariate analysis, renal volume reduction by embolization and male gender were associated with a decreased risk of switching to HD. After embolization, a decrease in PD adequacy parameters was observed but no embolized patients required temporary HD; the duration of hospitalization was significantly lower [5 days [interquartile range (IQR) 4.0-6.0] in the embolization group versus 8.5 days (IQR 6.0-11.0) in the surgery group., Conclusions: Transcatheter renal artery embolization yields better technique survival of PD in ADPKD patients requiring renal volume reduction., (© The Author(s) 2019. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.)

Acute renal failure (ARF) in adults in the intensive care unit (ICU) often evolves in a context of multiple organ failure, which explains the high mortality rate and increase treatment needs. Among, two modalities of renal replacement therapy, peritoneal dialysis (PD) was the first modality used for the treatment of ARF in the 1950s. Today, while PD is generalized for chronic renal failure treatment, its use in the ICU is limited, particularly, due to the advent of new hemodialysis techniques and the development of continuous replacement therapy. Recently, a renewed interest in the use of PD in patients with ARF has manifested in several emerging countries (Brazil, Vietnam). A systematic review in 2013 showed a similar mortality in ARF patients having PD (58%) and those treated by hemodialysis or hemodiafiltration/hemofiltration (56.1%). In the International society of peritoneal dialysis (ISPD)'s guideline (2013), PD may be used in adult ARF as the other blood extracorporeal epuration technics (recommendation with grade 1B). PD is the preferred method in cardiorenal syndromes, in frailty patients with hemodynamic instability and those lacking vascular access; finally PD is also an option in elderly and patients with bleeding tendency. In industrial countries, high volume automated PD with a flexible catheter (usually Tenckhoff) is advocated., (Copyright © 2016 Association Société de néphrologie. Published by Elsevier SAS. All rights reserved.)

The optimal method to assess the adequacy of peritoneal dialysis therapies is controversial. Today, the adequacy must not be considered as a number or a concept assessed only by two parameters (total KT/V urea and total solute clearance) but defined by many more items. In the absence of data, based on theoretical considerations, the reanalysis of the CANUSA study showed that renal kidney function, rather than peritoneal clearance, was associated with improved survival. Residual renal function is considered as a major predictor factor of cardiovascular mortality. Results of this reanalysis were supported by the adequacy data in ADEMEX, EAPOS and ANZDATA studies. Therefore, clinical assessment plays a major role in PD adequacy. The management of fluid balance, the regular monitoring of malnutrition, the control of mineral metabolism and particularly the glucose load, considered as the "corner-stone" of the system, are the main points to be considered in the adequacy of PD patients. The essential goal is to minimize glucose load by glucose-sparing strategies in order to reduce the neoangiogenesis of the peritoneal membrane., (Copyright © 2013. Published by Elsevier SAS.)

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.

The frequency of transfers from peritoneal dialysis to haemodialysis secondary to the catheter-related complications has been estimated between eight to 20% depending the countries. Therefore, it is recommended that the insertion of peritoneal dialysis catheters be made by competent and experienced operators. Indeed, despite the development of new insertion techniques and the availability of new sophisticated catheters, the major prognostic factor remains the quality of the surgical procedure and the postoperative care. As regards the choice between various catheters, there is no consensus for the superiority of one in comparison with others. However it should be noted that a catheter survival rate from 80 to 90% at one year is a recognized index of quality.

In all countries, the number of diabetic patients with end stage renal disease is growing. The question is whether this mode of therapy is the most appropriate for uremic diabetics. The superiority of any type replacement renal therapy (RRT) over another cannot be unequivocally proven in the absence of a truly random long-term prospective study, which for obvious reasons, has not and probably will not be carried out. Today, the decision on the final choice is indeed dependant on patient preferences, medical factors, physician's biais, local facilities and financial aspects. If in most centers, survival analysis results performed in Europe and in North America regarding diabetic patients RRT are conflicting, the interpretation of comparisons of survival rates published in different studies must be treated with great caution. Nevertheless, if diabetic patients survival is significantly lower than that of non diabetic patients independently of the technique chosen there is no argument to assess that survival at 2 years of diabetic patients aged less 55 years is better on PD than on HD. There is no argument to assess that survival at 2 years of diabetic patients aged more 55 years is better or less appropriate on PD than on HD, excepted in the North America where survival seems to be less appropriate on PD. The present report summarizes the major advantages and drawbacks of the PD method in insulin treated diabetic patients.

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.

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.

In a prospective randomized open multicenter study, 107 anemic (Hct < = 28%) peritoneal dialysis (PD) patients were treated with s.c. rhEPO daily. The mean observation period was 299 days (range 14-479 days). Patients were randomly assigned to 3 groups with different initial doses: 5 U/kg (G5), 10 U/kg (G10), 20 U/kg (G20). Initial doses were maintained for at least 8 weeks unless the target Hct (30-35%) was achieved earlier. The weekly increase of Hct was significantly (p < 0.05) dose-dependent: 0.19% in G5, 0.5% in G10 and 0.94% in G20. In case of insufficient response (< 0.5% per week), the dose was doubled every 4 weeks. Final doses on achieving the target Hct ranged from 5 to 40 U/kg (median 20 U/kg). The dose was then reduced to 50% and adjusted individually. The median maintenance dose was 9.9 U/kg/day. No tendency towards higher blood pressure or intensification of antihypertensive treatment was observed. When rhEPO is administered daily, 10 U/kg/day (70 U/kg weekly) is the recommended starting dose. The need for higher doses used in unsatisfactory response, should lead to further examination to rule out iron deficiency and other reasons for non-response. The median maintenance dose reported here is the lowest published in the literature for PD patients and seems to be linked to the daily injections.

From January 1973 to March 1983, 108 IDD patients with a mean age of 46 years were accepted to the dialysis program of the Hôpital de la Pitié. Since January 1973, 67 patients have been treated by hemodialysis. Since August 1978, 38 patients have been treated by CAPD. Three patients have been treated by intermittent peritoneal dialysis. Although diabetic patients remain at a higher risk compared to patients of the same age group, very encouraging results are observed including a 75% survival rate at three years among hemodialyzed patients less than 50 years old. Since 1978, CAPD, when home dialysis was possible, was selected as a first choice treatment. Some severe peritoneal complications still jeopardize the advantages of this method. Diabetics with ESRD, even in the older age group, should not be excluded from treatment. They should be offered within an integrated program all dialysis methods and transplantation.

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.

The pros and cons of CAPD are weighed up on the basis of a 3-year study on 100 patients with renal insufficiency (61 men, 36 women and 3 children). If equal groups are compared, the survival rate corresponds to that of haemodialysis. Continuous detoxication and dehydration lead to a good uraemic metabolic situation (creatinine 960 mumol/l, urea 24 mmol/l, haemoglobin 98 g/l, albumin 31 g/l. The serum electrolytes are well-balanced, anorganic phosphate is normal. The rise in cholesterol and triglycerides observed is a possible negative influence with regard to arterial sclerosis. The functioning of the kidneys is not affected by CAPD. The main risks of this method of therapy are peritonitis and loss of protein via the peritoneal dialysate, which can be favourably influenced by strictly antiseptic handling when changing the dialysate bag and a sufficient protein supply in the diet. In France 10-15% of all patients with terminal renal insufficiency will be treated with CAPD in future.

A study has been carried out to compare over an 18 month period the residual glomerular filtration rate (GFR) measured by the creatinine clearance in two matched groups of 25 patients with end-stage renal disease. One group was treated by continuous ambulatory peritoneal dialysis, the other one by maintenance haemodialysis. GFR was similar in both groups immediately before starting dialysis therapy, respectively 4.3 +/- 2.3 and 4.4 +/- 2.4 ml/min. From the beginning of the dialysis treatment to the eighteenth month there was a significant and progressive decrease of GFR in the group of patients treated by haemodialysis, while in the peritoneal dialysis group GFR and peritoneal clearances remained stable.

Résumé: La méthode optimale pour évaluer l’adéquation en dialyse péritonéale (DP) reste encore controversée. Doit-on considérer aujourd’hui l’adéquation en DP comme un concept, un nombre, un chiffre évalués essentiellement par deux paramètres le KT/Urée global et la clairance de la créatinine globale rapportée à la surface corporelle 1,73m2 (CANUSA, 1996 [1]), ou doit on redéfinir l’adéquation comme étant plus qu’un KT/V ? En effet, depuis la ré-analyse de l’étude CANUSA (Bargman et al., 2001 [2]), confirmée et soutenue par d’autres études ADEMEX study (Paniagua et al., 2005 [3]), EAPOS Study (Brown et al., 2003 [4]), ANZDATA study (Brown et al., 2009 [5]), il a été démontré que les clairances péritonéales ne sont pas corrélées à la survie patient. Seuls les maintiens de la fonction rénale résiduelle et de l’ultrafiltration (UF) péritonéale chez les patients anuriques étaient corrélés à la survie patient et considérés comme des facteurs prédictifs majeurs de morbi-mortalité cardiovasculaire (Brown et al., 2003 [4]). Ces deux facteurs sont devenus dès lors des paramètres incontournables d’adéquation. C’est la raison pour laquelle le KT/V urée et la clairance de la créatinine globale doivent être considérés plus comme des « garde-fous » que comme des paramètres fiables et indiscutables d’adéquation. Aussi, la dimension clinique joue un rôle majeur dans l’adéquation en DP, en particulier la gestion de la balance hydrosodée, le monitoring de la dénutrition, le contrôle du métabolisme phosphocalcique et surtout la charge glucosée, considérée comme la pierre angulaire chez les patients en DP. Le but principal est de minimiser la charge en glucose et de mettre en place toutes les stratégies thérapeutiques d’épargne en glucose possibles, seul moyen de réduire la néovascularisation au sein de la membrane péritonéale. [Copyright &y& Elsevier]

The achievement of euvolemia is essential to the successful management of peritoneal dialysis patients. However, the concern that hypertonic glucose exchanges may have a role in long-term changes to the peritoneal membrane has lead to an alternative strategy to enhance ultrafiltration (UF) over the long dwell by combining crystalloid and colloid osmosis. This review summarizes the experience of mixing glucose or amino acids with polyglucose (icodextrin), with particular focus given to data from studies using glucose/icodextrin in combinations of 1.36%/7.5% and 2.61%/6.8%. Both combinations demonstrate a significant increment of UF volume and sodium removal compared with the component osmotic agents used individually over long dwells, with the 2.61%/6.8% mixture having an effect over dwells extending to 15 h. Hypothetically, the mechanism of the enhanced UF is the attenuation by the colloid osmotic force of the backflow of water through small pores from dialysate to the peritoneal capillary circulation once the crystalloid osmotic force has dissipated. This experience provides promising data that deserves further examination in longer term clinical studies.Kidney International (2008) 73, S102–S111; doi:10.1038/sj.ki.5002610 [ABSTRACT FROM AUTHOR]