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Background: Cross-sectional studies showed that fluid overload (FO) measured by bioimpedance spectroscopy (BIS) predicted adverse outcomes in patients on peritoneal dialysis (PD). We aimed to describe the longitudinal change in volume status in Chinese PD patients and determine its relation with clinical outcomes., Methods: We performed a single-centre, retrospective analysis of all PD patients who underwent repeated BIS from 2010 to 2015. FO was defined by relative hydration index (RHI; volume of overhydration adjusted by extracellular water >7%). Variability of volume status (VVS) was denoted by the standard deviation of all RHI. The association of time-averaged RHI and VVS on patient and technique survival was explored by a competing risk model., Results: A total of 269 patients were followed for a median of 47.1 months. Mean time-averaged RHI was 17.6 ± 10.2%. Multivariable mixed linear regression revealed that RHI was significantly associated with diabetes, time-varying systolic blood pressure, and inversely with time-varying albumin level, lean tissue index and fat tissue index ( p <0.0001 for all). Time-averaged RHI independently predicted patient survival (subdistribution hazard ratio (SHR) 1.05, 95% CI 1.03-1.07, p <0.0001) and technique survival (SHR 1.04, 95% CI 1.02-1.06, p <0.0001), whereas VVS did not. The mortality risk for patients with persistent FO was consistently higher than the corresponding risk estimated from baseline FO of the same extent., Conclusions: Persistent FO was a strong predictor of patient and technique failure. Repeated bioimpedance measurements to monitor volume status may provide additional prognostic information in PD patients.

Background: Patients with refractory to optimal pharmacological treatment heart failure (HF) require frequent hospitalization. Peritoneal dialysis (PD) has been part of the management of such patients mainly for promoting ultrafiltration and management of overhydration independently of kidney function. The aim of this study was to evaluate the efficacy of PD, especially the use of icodextrin solutions and intermittent PD, in the hospitalization rate and cardiac functional status of patients with HF., Methods: We conducted a retrospective study involving patients with New York Heart Association (NYHA) class IV HF and preserved renal function (estimated glomerular filtration rate (eGFR) > 25 ml/min), who were refractory to conservative treatment. Clinical data on weight loss, hospitalization rate before and after PD initiation, cardiac functional status, and technique complications during a 6-month observational period were analyzed., Results: PD treatment was performed in 32 patients with a mean age of 63.8 ± 11.9 years and a follow-up of 20.78 ± 14.24 months. Hospitalizations were significantly reduced from 20.7 ± 13.7 to 7.7 ± 8.9 days/patients at 6 months. All patients showed improvement in NYHA class as well as in left ventricular ejection fraction. Overall, eGFR showed a significant decrease but only six patients reached end-stage renal disease. Complications included 18 cases of peritonitis. PD was well tolerated and no patient dropped out of the method. Survival rate reached 72% at 12 months but mortality rate was high with 23 patients dying at 16.65 ± 12.3 months after the initiation of treatment. Patients survival was not influenced by the type of PD modality or weight reduction achieved., Conclusions: PD showed to be a viable option for the treatment of patients with refractory HF leading to a better cardiac functional status and diminishing the number of hospital admissions.

Background: This 6-month prospective longitudinal study investigates the association between hydration status changes using bioimpedance spectroscopy (BIS) and systolic blood pressure (SBP), pulse pressure (PP), and serum albumin (sAlb) changes in children on peritoneal dialysis (PD)., Methods: Thirteen patients (median age: 12.58 years) were enrolled. Normal hydration, moderate hydration, severe overhydration, and dehydration were defined as -7% ≤ relative overhydration (Re-OH) < +7%, +7% ≤ Re-OH < +15%, Re-OH ≥ +15%, and Re-OH < -7%, respectively. Automated office blood pressure z -score, sAlb, and weight z -score were recorded., Results: Fifty-two Re-OH measurements were recorded: three in five, four in five, five in two, and seven in one patient, respectively. SBP was higher and sAlb lower in cases with severe overhydration (9 readings) ( p < 0.001, p < 0.001), but distribution of these parameters did not differ between normal hydration/dehydration (28 readings) and moderate overhydration (15 readings) cases. In patients with hydration status change, SBP and PP were higher while sAlb lower in cases with higher hydration status level ( p = 0.026, p = 0.05, and p = 0.109, respectively). In all patients, visit-to-visit SBP, PP, and sAlb changes were correlated to Re-OH changes ( r s = 0.693, p < 0.001; r s = 0.643, p < 0.001; r s = -0.444, p = 0.008, respectively) but not to weight changes ( r s = 0.052, p = 0.754; r s = 0.034, p = 0.838; r s = -0.156, p = 0.378, respectively). Visit-to-visit Re-OH changes, which were >+4% or <-4%, were linearly correlated to SBP ( r = 0.858, p < 0.001), PP ( r = 0.757, p < 0.001), and sAlb ( r = -0.699, p = 0.002) changes., Conclusion: In children on PD, longitudinal Re-OH changes are superior to weight changes in assessing volume-dependent variations of SBP, PP, and sAlb. Routine BIS application, rather than single BIS measurements, seems useful in the intra-patient monitoring of hydration status.

Introduction: In peritoneal dialysis (PD) patients, volume overload is related to cardiac dysfunction and mortality, while intravascular volume depletion is associated with a rapid decline in the residual renal function (RRF). This study sought to determine the clinical usefulness of bioimpedance spectroscopy (BIS)-guided fluid management for preserving RRF and cardiac function in PD patients., Subjects and Methods: This is a multicenter, prospective, open-label study that was conducted over a 1-year period (NCT01887262). Non-anuric (urine volume > 500 mL/day) subjects on PD were enrolled. Subjects in the control group received fluid management based on the clinical information alone. Those in the BIS group received BIS-guided fluid management along with clinical information., Results: The subjects ( N = 137, mean age 51.3 ± 12.8 years, 54% male) were randomly assigned to the BIS group ( n = 67) or to the control group ( n = 70). There were no significant differences between the 2 groups with regard to age, sex ratio, cause of kidney failure, duration of PD, baseline comorbidity, RRF, PD method, or peritoneal transport type. At baseline, the 2 groups were not different in terms of RRF (glomerular filtration rate [GFR], 5.1 ± 2.9 vs 5.5 ± 3.7 mL/min/1.73 m 2 ). After follow-up, changes in the GFR between the 2 groups were not different (-1.5 ± 2.4 vs -1.3 ± 2.6 mL/min/1.73 m 2 , p = 0.593). Over the 1-year study period, both groups maintained stability of various fluid status parameters. Between the 2 groups, there were no differences in the net change of various fluid status parameters such as overhydration (OH) and extracellular water/total body water (ECW/TBW). A net change in ECW over 1 year was slightly but significantly higher in the control group (net increase, 0.57 ± 1.27 vs 0.05 ± 1.63 L, p = 0.047). However, this difference was not translated into an improvement in RRF in the BIS group. There were no differences in echocardiographic parameters or arterial stiffness at the end of follow-up., Conclusion: Routine BIS-guided fluid management in non-anuric PD patients did not provide additional benefit in volume control, RRF preservation, or cardiovascular (CV) parameters. However, our study cannot be generalized to the whole PD population. Further research is warranted in order to investigate the subpopulation of PD patients who may benefit from routine BIS-guided fluid management., (Copyright © 2018 International Society for Peritoneal Dialysis.)

Objectives: In this study our aim was to evaluate the relationship between degree of fluid status and arterial stiffness measured by pulse wave velocity (PWV) in peritoneal dialysis (PD) patients. Fluid status was determined by different methods including fluid overload measured by bioimpedance (Body Composition Monitor, BCM), calf normalized resistivity (CNR), plasma N-terminal fragment of B-type natriuretic peptide (NT-proBNP) and extracellular to intracellular water ratio (ECW/ICW)., Methods: Sixty PD patients were evaluated. They were stratified into normo- and hypervolemic groups according to their fluid overload (FO). CNR was calculated from resistance at 5 kHz using calf bioimpedance spectroscopy. Arterial stiffness was assessed by PWV. Additionally, all patients underwent transthoracic echocardiography and had levels of NT-proBNP measured., Results: PWV was higher in the hypervolemic compared to normovolemic patients (9.99 ± 2.4 m/sec vs 7.48 ± 2.3 m/sec, p < 0.001). Hypervolemic patients had higher NT-proBNP levels (3065 ± 981 pg/mL vs 1095 ± 502 pg/mL, p < 0.001), a higher ratio of ECW/ICW; (0.93 ± 0.11 vs 0.81 ± 0.08, p < 0.001) and lower CNR (13.7 ± 2.4 vs 16.0 ± 3.3 W m(3)/kg(*)10(-2), p = 0.005). NT-pro BNP level, ECW/ICW ratio, relative FO, and left ventricular (LV) mass index were positively and CNR negatively correlated with PWV. Relative FO and CNR independently predicted PWV in multivariate analysis adjusted for age, duration of PD, body mass index and mean arterial pressure., Conclusions: Arterial stiffness is increased in fluid-overloaded PD patients. Our results indicated that fluid status is an independent predictor of PWV., (Copyright © 2014 International Society for Peritoneal Dialysis.)

Objective: In dialysis patients, volume overhydration is common and is related to increased risk of cardiovascular morbidity and mortality. However, it remains unclear whether volume overload imposes those detrimental effects through endothelial dysfunction., Methods: In this cross-sectional study, 81 stable patients on continuous ambulatory peritoneal dialysis in a single center were recruited. Volume status was evaluated by extracellular water, assessed by bioimpedance analysis, and normalized to individual height (nECW). Endothelial function was estimated by endothelial-dependent flow-mediated dilatation (FMD) of the brachial artery and expressed as percentage change relative to baseline diameter., Results: There were 37 male and 44 female patients (mean age 61 +/- 12 years, dialysis vintage 20 +/- 23 months). FMD in female patients was significantly higher than that in male patients (9.17% +/- 6.23% vs 6.31% +/- 5.01%, p < 0.05). FMD was negatively correlated with weight (r = -0.308, p < 0.01), body mass index (r = -0.242, p < 0.05), systolic blood pressure (r = -0.228, p < 0.05), ECW (r = -0.404, p < 0.001), and nECW (r = -0.418, p < 0.001). No correlation was found between FMD and other variables. In multiple stepwise regression analysis, calcium x phosphate product (beta = 0.422, p < 0.001), nECW (beta = -0.343, p < 0.01), and dialysis vintage (beta = -0.237, p < 0.05) were independent determinants of FMD (adjusted R(2) = 0.327 for this model)., Conclusion: There was independent correlation between index of volume status and FMD, and higher nECW was related to worse endothelial function. The results of this study may help us understand the underlying mechanism of volume overhydration leading to increased cardiovascular morbidity and mortality in dialysis patients.

This article reviews published studies related to fluid status of Japanese peritoneal dialysis (PD) patients and its impact on technique and patient survival. In addition, some specifics related to clinical background that potentially influence fluid status are described. According to a multicenter survey conducted in Japan, nearly 25% of Japanese PD patients are overhydrated. Available data indicate that a high salt diet may conceivably play an important role in the pathogenesis of fluid overload in Japanese PD patients, and it in turn negatively impacts patient prognosis. Because of the generally adopted policy among Japanese PD experts to avoid regular use of 3.86% glucose solution, icodextrin solution is now used in more than one third of all patients. Other means of managing fluid overload, such as drug therapy, combination (complementary) therapy with hemodialysis, and low sodium PD solution, are also explored and summarized in this article.

Objective: A reliable assessment of nutritional state in peritoneal dialysis (PD) patients is of great importance. Nevertheless, techniques used to assess body composition in patients on PD may be affected by abnormalities in fluid status. The primary aim of the present study was to compare different techniques used to evaluate body composition and to assess the influence of fluid status on the assessment of body composition. The secondary aim was to assess the relevance of handgrip muscle strength in the nutritional evaluation of the patient., Methods: In 40 PD patients, dual-energy x-ray absorptiometry (DEXA), multifrequency bioimpedance analysis (MF-BIA), and anthropometry were compared with respect to the evaluation of body composition [fat mass and lean body mass (LBM; by DEXA), and fat-free mass (FFM; by MF-BIA, anthropometry]. The influence of fluid status on the measurement of LBM/FFM by the various techniques was assessed by their relation to left ventricular end-diastolic diameter (LVEDD), assessed by echocardiography, and by estimating the ratio between extracellular water (ECW) and total body water (TBW), assessed by bromide and deuterium dilution, with LBM (DEXA). The relevance of handgrip muscle strength as a nutritional parameter was assessed by its relation to LBM and other nutritional parameters., Results: Despite highly significant correlations, wide limits of agreement between the various techniques were present with respect to assessment of body composition (expressed as % body weight) and were most pronounced for anthropometry: LBM (DEXA) - FFM (MF-BIA) = 3.4% +/- 12.2%; LBM (DEXA) - FFM (anthropometry) = -5.7% +/- 7.8%; fat mass (DEXA - MF-BIA) = -4.2% +/- 7.9%; fat mass (DEXA - anthropometry) = 2.9% +/- 7.2%. The ratio between ECW and LBM (DEXA) was 0.36 +/- 0.08 L/kg (range 0.25 - 0.67 L/kg), and the ratio between TBW and LBM was 0.75 +/- 0.06 L/kg (range 0.63 - 0.86 L/kg), which shows the variability in hydration state of LBM/FFM between individual patients. LBM/FFM measured by all three techniques was significantly related to LVEDD, suggesting an important influence of hydration state on this parameter. Handgrip muscle strength was significantly related to LBM/FFM, as measured by all three techniques, but not to other nutritional parameters., Conclusion: Wide limits of agreement were found between various techniques used to assess body composition in PD patients. The assessment of body composition was strongly influenced by hydration state. The handgrip test is related to body composition, but not to other nutritional parameters.

Objectives: To assess the influence of abnormalities in fluid status and body composition on agreement between multifrequency bioimpedance analysis (MF-BIA), segmental BIA (sigmaBIA), the Watson formula, and tracer dilution techniques., Design: Cross-sectional., Setting: Multicenter., Patients: 40 patients (29 males, 11 females) on peritoneal dialysis (PD)., Main Outcome Measures: Agreement between the various techniques used to assess total body water (TBW) [MF-BIA, deuterium oxide (D2O), and the Watson formula] and extracellular water (ECW) [MF-BIA, bromide dilution (NaBr), and sigmaBIA], also in relation to the relative magnitude of the body water compartments [ECW (NaBr):body weight (BW) and TBW (D2O):BW] and body composition (DEXA). Second, the relation between body water compartments with echocardiographic parameters., Results: Wide limits of agreement were observed between tracer dilution techniques and MF-BIA [TBW (D2O - MF-BIA) 2.0 +/- 3.9 L; ECW (NaBr - MF-BIA) -2.8 +/- 3.9 L], which were related to the relative magnitude of the body water compartments: r = 0.70 for ECW and r = 0.40 for TBW. sigmaBIA did not improve the agreement [ECW (NaBr-sigmaBIA): 3.7 +/- 2.9 L]. Also, wide limits of agreement were observed between D2O and the Watson formula (-2.3 +/- 3.3 L). The difference between D2O and Watson was related to hydration state and to percentage of fat mass (r = 0.70 and r = -0.53, p < 0.05). Both ECW and TBW as assessed by BIA and tracer dilution were related to echocardiographic parameters., Conclusion: Wide limits of agreement were found between MF-BIA and sigmaBIA with dilution methods in PD patients, which were related to hydration state itself. The disagreement between the Watson formula and dilution methods was related to both hydration state and body composition.

Objective: Hypertension, reduced arterial distensibility, and left ventricular hypertrophy (LVH) are risk factors for mortality in hemodialysis patients. However, few studies have focused on the relation between fluid status, blood pressure (BP), and cardiovascular abnormalities in peritoneal dialysis (PD) patients. This study was designed, first, to assess, using tracer dilution techniques, fluid status in PD patients compared to a control population of stable renal transplant (RTx) patients; second, to study the relation between fluid status, BP, and arterial wall abnormalities; third, to assess the determinants of cardiac structure; and last, to compare office and ambulatory BP measurements with respect to cardiac abnormalities., Design: Cross-sectional study., Setting: Multicenter study., Patients: 41 stable PD patients with a mean Kt/V urea of 2.4 +/- 0.7, and 77 stable RTx patients., Intervention: Fluid status was assessed by tracer dilution techniques: extracellular volume (ECV) with bromide dilution; total body water (TBW) with deuterium oxide; and plasma volume (PV) with dextran 70. Echocardiography was performed to assess left ventricular mass (LVM), left ventricular end diastolic diameter (LVEDD), and relative wall thickness as indicators of LVH. Echography of the common carotid artery was performed to assess arterial distensibility. Both office and 24-hour ambulatory BP measurements were performed., Results: Fluid status, as assessed by ECV corrected for body surface area (BSA) (ECV:BSA), was significantly different between PD and RTx patients (9.4 +/- 2.6 vs 8.6 +/- 1.2 L/m2, p < 0.05). In 36.6% of the PD patients, ECV:BSA was above the 90th percentile of the RTx patients. Fluid status corrected for BSA, assessed by TBW (TBW:BSA), ECV (ECV:BSA), or plasma volume (PV:BSA), was significantly related to diastolic BP (DBP) (r = 0.35, r = 0.37, r = 0.53; p < 0.05). Arterial distensibility of the common carotid artery was related to systolic BP (SBP) (r = -0.36, p < 0.05). ECV was significantly related to LVEDD (r = 0.41, p < 0.05) as a marker of eccentric LVH, whereas arterial distensibility was related to relative wall thickness (r = -0.53, p < 0.001) as a marker of concentric LVH. An abnormal day-night BP rhythm, which was not related to fluid status, was observed in 68.4% of patients. Ambulatory DBP and SBP but not office DBP and SBP were related to LVM (r = 0.43, r = 0.46; p < 0.01)., Conclusions: A large proportion of PD patients whose treatment prescriptions are in accordance with the Dialysis Outcomes Quality Initiative guidelines were found to be overhydrated compared with a population of stable RTx patients. Fluid status was significantly related to DBP and eccentric LVH, whereas arterial distensibility of the common carotid artery was significantly related to SBP and concentric LVH. In contrast to ambulatory BP, office BP was not related to LVM.

Objective: Our current programs (CPs) were compared to PD Adequest 2.0 (PD-A) for calculations of peritoneal membrane transport and dialysis adequacy., Design: Thirty peritoneal equilibration tests (PETs) and 24-hour balances (24hBs) were conducted and calculated using our CPs and PD-A., Patients and Methods: Thirty hospital-controlled peritoneal dialysis (PD) patients were studied. The inclusion of correction factors (for glucose or plasmatic water) and of residual volume, and the use of 3 or 6 peritoneal samples were analyzed to discover the differences between programs. The main outcome measures were peritoneal permeability and adequacy parameters, evaluated by Student t-test (mean and paired comparisons) and linear regression for correlation., Results: No significant differences were found in D/P values for small solutes. At the first step, mass transfer area coefficient (MTAC) urea and MTAC creatinine were significantly higher in DP-A than in CP, but MTAC glucose did not differ. The causes of differences were: (1) inclusion of a correction factor for aqueous plasmatic concentration of small solutes in CP; (2) lack of Inclusion of residual volume in peritoneal volumes in CP; and (3) use of 6 peritoneal samples in CP versus 3 in PD-A. At the second step, when the input data were made equivalent for both programs, the differences disappeared for MTAC urea, creatinine, and glucose (mean comparison), but creatinine and glucose remained different by paired comparison. Similar results were obtained when a correction for plasmatic aqueous concentration was applied to the data in both programs [MTAC urea: 22.60 +/- 4.27 ml/min (CP) vs 22.43 +/- 4.61 mL/min (PD-A), nonsignificant, r= 0.97; MTAC creatinine: 9.76 +/- 3.83 mL/min (CP) vs 10.61 +/- 3.07 mL/min (PD-A), nonsignificant, r = 0.98; MTAC glucose: 13.30 +/- 3.12 mL/min (CP) vs 11.87 +/- 3.41 m/min (PD-A), nonsignificant, r= 0.92]. Creatinine and glucose were different by paired t-test. No significant differences were found in Kt/V and urea generation rate. Weekly creatinine clearance [WCCr: 70.71 +/- 16.71 L (CP) versus 79.33 +/- 18.73 L (PD-A), p < 0.001] and creatinine generation rate [CrGR: 0.56 +/- 0.18 mg/min (CP) versus 0.61 +/- 0.19 mg/min (PD-A), p < 0.001) were significantly higher in PD-A than In CP owing to the lack of creatinine correction according to glucose concentration In the PD-A adequacy program. Finally, normalized protein nitrogen appearance according to Bergström [1.09 +/- 0.20 g/kg/d (CP) versus 1.03 +/- 0.21 g/kg/d (PD-A), p = 0.01] was different owing to the different algorithms and normalization method: standardized body weight in CP and actual body weight in PD-A., Conclusions: Provided that equivalent data are used, PD-A and CP yield similar results. The PD-A program needs external correction of data input: (1) for plasmatic water concentration in MTAC calculations, and (2) for peritoneal glucose interference with creatinine analysis (Jaffé method) In WCCr and CrGR calculations; otherwise, It may give falsely optimistic results.

Objective: While most hypertensive patients with end-stage renal disease normalize high blood pressure with fluid removal by continuous ambulatory peritoneal dialysis (CAPD), there is a significant proportion of CAPD patients whose blood pressure can be controlled only by antihypertensive drugs., Method and Patients: To study the hypothesis that such patients are still volume overloaded, we used plasma cyclic guanosine monophosphate (cGMP) as a marker for hydration status. Thirty-two CAPD patients were divided into 3 groups: group 1, normotensive patients (n = 12); group 2, hypertensive patients who normalized their blood pressure with fluid removal (n = 12); group 3, hypertensive patients whose blood pressure was refractory to intensified fluid removal (n = 8)., Results: Mean cGMP levels were significantly higher in dialysis-sensitive hypertension (27 +/- 5 pmol/mL) than in dialysis-refractory hypertension (15 +/- 2 pmol/mL), or in normotensive patients (13 +/- 4 pmol/mL). Reduction of excess fluid in volume overloaded hypertensive CAPD patients resulted in a normalization of cGMP levels (14 +/- 8 pmol/mL), but did not affect this volume marker in patients with dialysis-resistant hypertension (10 +/- 4 pmol/mL)., Conclusion: Plasma cGMP levels are elevated in volume overload-induced hypertension complicating CAPD. Hypertensive CAPD patients whose plasma cGMP levels are within normal limits have raised blood pressure refractory to volume removal. Our findings are consistent with the hypothesis that inadequate removal of excess volume plays a major role in a subset of patients with CAPD hypertension.

In regard to the question posed in the title of this review, the answer is mixed. IPN is possible today but only on a limited basis and at high cost with uncertain benefit. A 1.1% amino acid dialysis solution for IPAA therapy is available in several European countries but has not yet been approved for use in the United States. When it becomes more widely available, IPAA should become an important tool, along with other types of therapy, for use in the maintenance of good nutritional status in PD patients.

Hypotension and orthostatic hypotension are frequently observed in CAPD patients. In the present paper the possible causes of these complications were reviewed, and the roles of sodium and water were pointed out. In addition, we reported our experience using different sodium concentrations in CAPD dialysis fluid. In 38 CAPD patients sodium concentration in the dialysate was changed from 132 to 137 mEq/L. At first, arterial blood pressure increased in 4 patients (10%), and they were switched to 132 mEq/L sodium. Of the other 34 patients, 3 required larger doses of antihypertensive agents, while 9 reduced the number and/or dose of antihypertensive drugs. Thirst, body weight, residual renal function, 24-hour ultrafiltration, and biochemical examinations did not change using 137 mEq/L sodium concentrations for 6 months. In the 21 patients who did not change their antihypertensive treatment, upright blood pressure tended to increase, but the difference was not statistically significant. In 3 hypotensive patients sodium concentration was increased to 142 mEq/L. Thirst increased in 2 of the 3, one observed a transient increase in 24-hour ultrafiltration, and none showed changes in plasma sodium level. One patient developed reversible hypertension, one became normotensive, and the third had no changes in blood pressure.