Handbook of Dialysis by Daugirdas John T. & Blake Peter G. & Ing Todd S

Author:Daugirdas, John T. & Blake, Peter G. & Ing, Todd S.
Language: eng
Format: epub
Publisher: LWW
Published: 2014-11-23T16:00:00+00:00

22.1

These may differ slightly in name and in formulation from region to region.

All glucose-based solutions are available in three strengths (1.36, 2.27, and 3.86 mg/dL of glucose, equivalent to 1.5, 2.5, and 4.25 mg/dL of dextrose as glucose monohydrate.

To convert calcium from mmol/L (mM) to mg/dL multiply by 4.

To convert magnesium from mmol/L (mM) to mg/dL multiply by 2.43.

FMC, Fresenius Medical Care.

        5.  Non-glucose solutions. Glucose as an osmotic agent in PD has the advantage of being familiar, relatively safe, and inexpensive, and also is a source of calories. There is concern, however, that instillation of large amounts of glucose into the peritoneal cavity predisposes patients to hyperglycemia, dyslipidemia, obesity, and to long-term peritoneal membrane damage, both directly and via GDPs and the formation of advanced glycosylation end products. Glucose-based solutions are not very effective in high transporters, and inadequate ultrafiltration may result. Alternative osmotic agents are available.

            a.  Icodextrin. This is a polyglucose solution and is widely used. It is iso-osmolar and induces ultrafiltration by its oncotic effect (Mistry, 1994). Absorption of polyglucose is by the lymphatics and so is much slower compared with glucose. The oncotic effect and the associated ultrafiltration are therefore more sustained than with glucose. For this reason, the main indication to use icodextrin is for the long nocturnal dwell in CAPD and for the long day dwell in automated peritoneal dialysis (APD), especially in patients with ultrafiltration failure. It is generally used for just one dwell daily as it is no more effective than glucose for short dwell times. Icodextrin use is associated with unphysiologic blood levels of maltose and maltotriose, but no associated toxicity has been identified. The increased maltose levels will cause interference with the glucose dehydrogenase pyrroquinolinequinone assay (which reacts with both glucose and maltose) for blood glucose measurements. Therefore, blood glucose should be measured with other methods in patients using icodextrin. In addition, use of icodextrin is associated with mild translocational hyponatremia (owing to movement of sodium-poor fluid from cells to the extracellular fluid). Measured amylase levels can be factitiously low, as a result of interaction between metabolites of icodextrin and commonly used amylase assays.

    Icodextrin has been shown in randomized controlled trials to improve ultrafiltration and volume status in PD patients, though not convincingly to reduce blood pressure (Davies, 2003). It has also been shown to improve glycemic control, decrease weight gain, and lessen glucose-induced lipid abnormalities (Cho, 2013; Li, 2013). There is some evidence of better long-term preservation of peritoneal membrane function (Davies, 2005). Disadvantages are its extra cost, occasional skin reactions, and rare sterile peritonitis episodes.

            b.  Amino acid–based solutions. These are used for nutritional supplementation as they are largely absorbed by the end of a 4- to 6-hour dwell (Jones, 1998). Studies have shown them to be modestly effective in nutritionally compromised patients (Lo, 2003). They are reasonably effective osmotically (comparable to the 1.36% glucose solution) but can be used only once daily because in larger amounts they tend to cause acidosis, as well as a rise in the blood urea. These side effects can be addressed with oral alkali therapy and more dialysis, respectively.

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