Volume Management 2/25/2017. Disclosures statement: Objectives. To discuss evaluation of hypervolemia in peritoneal dialysis patients

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1 Volume Management Sagar Nigwekar MD, MMSc Massachusetts General Hospital March 14, 2017 Disclosures statement: Consultant: Allena, Becker Professional Education Grant support: Sanofi-Aventis Speaker honoraria: Sanofi-Aventis Objectives To discuss evaluation of hypervolemia in peritoneal dialysis patients To review prevention and treatment of hypervolemia in peritoneal dialysis patients 1

2 Peritoneal dialysis: ultrafiltration basics Peritoneal membrane barrier Flessner et al. Am J Physiol Renal Physiol Mar;288(3):F Three-pore model of peritoneal transport Agarwal et al. Indian J Nephrol Jul;18(3):

3 Effect of aquaporin-1 (AQP1) deletion on the transport of water across the peritoneal membrane Devuyst and Rippe. Kidney International (2014) 85, Endothelial barrier to water transport during peritoneal dialysis Flessner et al. Kidney International (2006) 69, Peritoneal dialysis: hypertension and heart failure epidemiology 3

4 Hypertension: prevalence in peritoneal dialysis patients and association with GFR Ortega and Materson. J Am Soc Hypertens May-Jun;5(3): Fluid retention in PD patients Symptomatic fluid retention in 1 out of every 4 PD patients: Lower extremity edema 98.6% Pleural effusions 76.1% Pulmonary congestion 80.3% Tzamaloukas, et al. J Am Soc Nephrol. 1995;6: Mean arterial pressure over time from initiation of peritoneal dialysis. Menon M K et al. Nephrol. Dial. Transplant. 2001;16:

5 Mean antihypertensive use over time from initiation of peritoneal dialysis. Menon M K et al. Nephrol. Dial. Transplant. 2001;16: Residual renal function over time from initiation of peritoneal dialysis. Menon M K et al. Nephrol. Dial. Transplant. 2001;16: Event rates of cardiovascular diagnoses & procedures, by modality, January 1, 2009 point prevalent ESRD patients with Medicare as primary payer; January 1, 2009 point prevalent ESRD patients with Medicare as primary payer; follow can occur up to three years. USRDS, 2013 ADR 5

6 Heart failure in prevalent dialysis patients, by modality, 2011 January 1, 2011 point prevalent ESRD dialysis patients with Medicare Parts A, B,& D coverage, diagnosed with heart failure in 2011, & surviving & staying on the same modality for all of USRDS, 2013 ADR Prevalence of left ventricular hypertrophy (a), and relative frequency of the concentric and eccentric pattern (b) in CAPD and in HD patients Enia G et al. Nephrol. Dial. Transplant. 2001;16: Three-year patient survival rates in PD patients according to total fluid removal. The four groups are defined as: group I, <1265 ml/24 h/1.73 m 2 ; group II, 1265 to 1570 ml/24 h/1.73 m 2 ; group III, 1570 to 2035 ml/24 h/1.73 m 2 ; and group IV,> 2035 ml/24 h/1.73 m 2. Kidney International (2001) 60,

7 Peritoneal dialysis: causes and evaluation of volume overload Volume overload in PD patients is preventable Too much in Too little out Comorbidity Adherence with salt and fluid intake PD prescription: adequate osmotic stimulus Loss of residual renal function PD prescription: adequate osmotic stimulus Peritoneal membrane failure New or worsening heart disease Hypoalbuminemia Mechanical problem Am J Kidney Dis. 2006; 47(Suppl 4):S1. 7

8 Target weight? Residual renal function over time from initiation of peritoneal dialysis. Menon M K et al. Nephrol. Dial. Transplant. 2001;16: Polydipsia in PD patients? Thirst profiles for control and PD. Profiles show mean thirst score for each group at each time point±sem. Wright M et al. Nephrol. Dial. Transplant. 2004;19:

9 Under-reporting of water intake by PD patients? Box and whisker plot showing calculated fluid balance. Wright M et al. Nephrol. Dial. Transplant. 2004;19: Improvement in BP with salt and fluid restriction in PD Gunal et al. Am J Kidney Dis Mar;37(3): Abu-Alfa et al. Kidney Int Suppl Oct;(81):S8-16. CAPD patients with diabetes are more fluid overloaded than non-diabetic patients Empty bars, diabetics; Black bars, non-diabetics Gan et al. Int Urol Nephrol. 2005;37(3):

10 Fluid status improvement in diabetic CAPD patients after dietary salt and fluid restriction Empty bars, before dietary restriction; Black bars, after dietary restriction Gan et al. Int Urol Nephrol. 2005;37(3): Sodium removal in APD is lower than in CAPD Rodriguez-Carmona et al. Perit Dial Int Nov-Dec;22(6): PD catheter mal-position Jheng et al. Kidney International (2012) 82,

11 2 liter fill and drain test Inflow difficulty Fibrin clot Incomplete drainage Positional drainage Leaks PD: mechanical complications Problem Details Management considerations Inflow problem Outflow problem Pleural effusion Typically seen early after catheter placement Pain can result from low ph of PD solution or from peritonitis From clots, fibrin, or constipation From congenital or acquired defects in diaphragm; more common on right side, in women, and in PKD patients -Reduce fill volume and intraperitoneal pressure -Can accomplish this with bed rest -Test for peritonitis -Can slow infusion rate, add bicarbonate or lidocaine to bag -Treat constipation -Leaving fluid incompletely drained after prior dwell reduces outflow pain -Diagnose by testing glucose on pleural fluid and or with radio-labeled albumin or methylene blue -Treat with PD holiday, VATS, or open surgery -Can suffer from under-dialysis -Must achieve drain volume > 9 L/24 hrs Courtesy Dr. Eliot Heher, MGH Peritoneal Equilibration Testing Type Frequency, % D/P Creatinine at 4 hours Comments High Best managed with cycler -Can experience UF failure -Albumin often low High Average > Can be managed with CAPD or cycler-7.5 to 9 L/24 hrs Low Average > Standard PD high dose needed for larger patients Low Manage with long dwell CAPD -Can suffer from underdialysis -Must achieve drain volume > 9 L/24 hrs Courtesy Dr. Eliot Heher, MGH 11

12 Peritoneal dialysis: monitoring and prevention of volume overload Monitoring for volume overload Active surveillance Monthly review of PD prescription Urine volume measurement on every 1-2 month basis Overnight drain volume review in CAPD patients Day time drain volume review in APD patients PET testing as indicated 12

13 Potential areas of intervention Dietary salt and fluid intake Residual renal function Diuretics Avoid nephrotoxic agents Angiotensin inhibition Control of HTN Treatment of urinary obstruction Adherence to PD prescription PD catheter function Matching dwell time to transport type Adapted from Abu-Alfa et al. Kidney Int Suppl Oct;(81):S8-16 and UpToDate. Diuretics in PD Evolution of urine volume (UV) over one year of peritoneal dialysis (PD). UV at randomization was comparable between groups. In the diuretic group ( ), it remained constant over one year of CAPD, whereas in the control group ( ), UV declined. Data presented are mean SEM at each time point. Medcalf et al. Kidney Int Mar;59(3): Long dwell UF Abu-Alfa et al. Kidney Int Suppl Oct;(81):S

14 Short dwell UF Abu-Alfa et al. Kidney Int Suppl Oct;(81):S8-16. Net drained UF volume (ml) during a 15-h long dwell with 3.86% glucose (black bars), 7.5% icodextrin (gray bars), or a mix of 6.8% icodextrin and 2.6% glucose (white bars) (n=7). Freida et al. Kidney International (2008) 73, S102 S111. Net Na + removal during a 15-h long dwell with 3.86% glucose (black bars), 7.5% icodextrin (gray bars), or a mix of 6.8% icodextrin and 2.6% glucose (white bars) (n=7). Freida et al. Kidney International (2008) 73, S102 S

15 Negative UF with different dextrose solutions Abu-Alfa et al. Kidney Int Suppl Oct;(81):S8-16. Summary Evaluating and managing volume is critical part of PD management Focus should be on prevention and early detection of volume overload in PD patients Treatment options for impaired ultrafiltration dwell time shortening frequent hypertonic exchanges icodextrin use of diuretics in patients with residual renal function MGH CAPD Unit Acknowledgements 15

16 Questions Fluid Overload vs UF Failure An Important Distinction Fluid overload is a common clinical syndrome with multiple causes It is the inability to maintain target weight and oedema free state UF failure is a pathophysiologic characterisation of one of the causes of the clinical syndrome Distinction between syndrome and cause determines the intervention to be taken Mujais, et al. Perit. Dial Int. 2000;20(suppl 4):S5-S21. 16