hemodialysis, continuous ambulatory peritoneal di- alysis (CAP D) ..... Home peritoneal dialysis: a major advance in promoting home dialysis. Trans Am Soc Artif ...
Advances in Peritoneal Dialysis, Vol. 10. 1994
Hariprasad S. Trivedi, Zbylut J. Twardowski
We report a case of polycystic kidney disease, successfully dialyzed using nocturnal intermittent peritoneal dialysis (NJPD) for ten years. Other forms of renal replacement therapy, which {ncluded hemodialysis, continuous ambulatory peritoneal dialysis (CAPD), intermittentperitoneal dialysis (IPD), and renal transplantation, were unsuitable for the patient. A peritoneal equilibration test revealed a 4-h DIP creatinine (Cr) ratio of 0.54. In January }984, the patient began NIPD for 12 h, using a dialysis solution dose of14 Llday, and 2 Llexchange. In January 1986, because of clinical under-dialysis, the dialysis solution dose was increased to 20 Llday, with an exchange volume of 1.57 L. The prescribed outflow time was 20 min. Dialysis was still inadequate with a weekly corrected Cr clearance (CoCrCI/w) of 33.6 L.Jn August 1986, the outflow time was reduced to 14 min and the total dialysis time to 11 h. Despite the latter, the efficiency of dialysis was greater because of longer full contact between dialysate and peritoneum. The last change resulted in marked clinical improvement and CoCrC/Iw increased to 39.9 L. Over the years, the patient's peritoneal transport changed to high average (4-h DIP Cr = 0.74) and NIPD provided even better clearances (CoCrC/Iw = 59.96L in 1994 ). The report emphasizes that NIPD, if properly tailored, can provide clinically adequate long-term dialysis. Keywords Peritoneal transport, dialysis adequacy, long-tenn peritoneal dialysis, nocturnal intennittent peritoneal dialysis
Long-Term Successful Nocturnal IntermittentPeritoneal Dialysis: A Ten-Year Case Study Introduction Intennittent peritoneal dialysis (IPD) therapy for chronic renal failure, in spite of early enthusiasm (16), did not stand the test of time for long-tenn treatment of end-stage renal disease (ESRO). Insufficient dialysis clearances and failure to extend treatment times in patients with no residual renal function has been one of the major factors responsible for its failure (7). Continuous ambulatory peritoneal dialysis (CAPO) became the most commonly used regimen of peritoneal dialysis (PO) (8). However, psychosocial and noninfectious medical problems led to a significant number of patients being transferred from CAPO (9). In 1985, Belding Scribner predicted that some type of nightly peritoneal dialysis may evolve as the best fonn ofPD therapy (10). Nocturnal (or nightly) intennittent peritoneal dialysis (NIPD) is a dialysis regimen that is beneficial for patients having complications due to high intra-abdominal pressure or inadequate ultrafiltration on CAPO. Another advantage of NIPD is convenient treatment times for patients and helpers working during the day. Some patients have distorted body image on CAPD due to protuberance of the abdomen with the intraperitoneal fluid during the daytime. This problem is obviated in patients on NIPD. Patients having high peritoneal solute transport characteristics are those that are most suitable for this modality. On NIPD, the duration of dialysis, exchange volume, outflow time, and dialysis solution dose need to be adjusted according to the patient's need. We report successful dialysis of a patient using this regimen for ten years, highlighting the importance of these aspects.
Case History
From: The Division of Nephrology. Department of A white woman, born in 1960. has Caroli 's disease Internal Medicine, University of Missouri-Columbia. and end-stage renal disease secondary to polycystic Dalton Research Center and Dialysis Clinic Inc.• _ _kidney disease. She began hemodialysis (HD) therapy Columbia. Missouri, U.S.A. 195
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Trivedi et at.
in 1979. She did not tolerate HD well because of poor cardiac function. Her left ventricular ejection fraction was 17%. Symptoms of fluid overload before dialysis and hypotension after dialysis were a frequent occurrence. The patient had great difficulty in maintaining a functioning vascular access and had four access failures through December 1982. Renal transplantations perfonned three times in May 1980, November 1980, and August 1982 were unsuccessful. All grafts were lost due to acute rejections. In the latter half of 1982, she became an uric. In December 1982, she elected a transfer to peritoneal dialysis. CAPD was initiated but the clinical course was complicated by repeated hospitalizations for the treatment of leaks and/or hernias. She was hospitalized nine times in 1983 for this purpose. A peritoneal equilibration test revealed a 4-h dialysate to plasma ratio of creatinine equal to 0.54. The patient lost her peritoneal access two times during surgical treatment of leaks and/or hernias. The large native kidneys and the three failed allografts (none of which was removed) undoubtedly contributed to high intraabdominal pressure and perpetuated the problem. IPD, 40 h per week, was tried during this period but provided inadequate dialysis (weekly creatinine clearance of 20 L per 1. 73 m2 of body surface area). She refused to retry HD. NIPD was the only reasonable option of therapy and was begun in January 1984. The serial dialysis prescriptions are shown in Table I. Table II depicts clinical and laboratory data over the years. As seen from Tables I and II, the initial prescription of 14 L of dialysis solution dose and outflow time of 25 min provided an inadequate corrected creatinine clearance. The patient had uremic symptoms and rising serum creatinine. Therefore, in January 1986, the dialysis solution dose was increased to 20.4 L per day and outflow time was maintained at 20 min. The patient sometimes kept an even longer outflow time, up to 35 min. A repeated peritoneal equilibration test in February 1986 showed that her solute transport characteristics had not changed (4-h dialysate to plasma creatinine ratio of 0.54). Since the creatinine clearance was still inadequate, in August 1986, the outflow time was decreased to 14 min and the total dialysis duration was decreased to 11 h per day. The reduction in outflow time increased the full contact time between the peritoneum and dialysate.
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Full contact time (hours/day)= total treatment time (hours/day)-[(inflow time per exchange in hours+ outflow time per exchange in hours) x number of exchanges per day] Dialysis is most efficient when there is a full contact between the peritoneum and dialysate. The clearance of a given regimen, in a given patient, would then be directly related to the "full contact dialysis." The full contact dialysis is directly related to the full contact time and the dialysis solution dose; thus: Full contact dialysis (FCD) in liters-hours/day = full contact time (hours/day) x dialysis solution dose (liters). It can be observed from Tables I and II that the increase in dialysis solution dose in January 1986 by itself did not result in adequate creatinine clearance, as reflected by the laboratory data in August 1986. TABLE 1
Serial dialysis prescription
Jan 84 Feb 86. Sept 86. Jan 89 Jan 93 Jan 94 Treatment time (hr/D)
12
12
11
11
11
II
Dialysis solution dose (L/D)
14
20.4
20.4
20.4
20.4
20.4
Exchange volume (L)
2
Number of exchanges
7
13
13
13
13
13
Outflow time (min)
25
20
14
14
14
14
6
6
6
6
122.4
122.4
122.4
122.4
FuJI contact time (hrs/D"")
7.7
1.57
5.7
FulJ contact dialysis (L-hrs/0"") 107.8 116.3
1.57
1.57
1.57
1.57
hrs=hours: D=day; L=liter "prescription changed in the preceding month, as described in the text see text for calculations (inflow time not shown)
..
LOng·Tenn NIPD- A Case Study TABLE 0
83 Clinical and iabOratory data Dec83•
Jan 86•• Aug 86••
Jan89
Jan 93
Jan94
54.8
56.5
56.9
63.2
56.8
56.2
1o8n6
98n6
90/64
120/80
101/63
90/56
Hematocrit
33.0
36.0
36.0
37.0
38.0
45
Blood urea nitrogen (mg'dL)
63
77
72
52
43
33
Serum creatinine (Cr) (mg'dL) ...
13.1
18.3
16.9
13.1
12.8
11.1
Corrected Cr Cl (L/wk ···) 39.9
29.4
33.6
39.9
54
59.96
Corrected ureaCI (L/wk···) 53.9
64.4
71.4
76.3
84.6
89.4
Body weight (kg) Blood pressure (mm Hg)
·Dec 83: subject on CAPD ··data obtained before the change in prescription, as described in the text corrected to 1.73 square meter body surface area
...
The adjustment in outflow time was crucial in providing greater FCD, by 6.1 liter-hours/day (42.7 liter-hours per week). This resulted in an improvement in corrected creatinine clearance, from 33.6 L per week to 39.9 L per week. After the last change, the patient showed marked clinical improvement, which has been maintained through the years. Her left ventricular ejection fraction improved to 54%. There were no recurrences of leaks and hernias, and the last inserted peritoneal dialysis access in January 1984, a Toronto Western Hospital catheter, is still functioning well to date, although it had to be spliced and rejoined three times because of material breakdown. The patient has had three exit-site infections and one episode of peritonitis, all having been successfully treated. Over the· years, her transport characteristics changed to high average (a 4-h dialysate to plasma creatinine ratio = 0.74), and NIPD provided even higher clearances. The weekly corrected creatinine clearance was 59.96 Lin January 1994.
reviewed (8). The reported patient failed other fonns of renal replacement therapy such as hemodialysis, CAPD, IPD, and renal transplantation. Thus, NIPD remained as the only viable option. She had low average peritoneal transport characteristics, not ideal for NIPD. However, tailoring of the dialysis prescription allowed clinically adequate long-tenn dialysis. The case study highlights the importance of estimating the "full contact dialysis" which is a function of the full contact time and dialysis solution dose. In January 1986, the increased dialysis solution dose was not enough to provide adequate creatinine clearance. The reduction in outflow time proved critical to provide enough FCD, the latter being supported by clinical improvement and improved creatinine clearance (Table I, II). Estimation of the FCD is a simple means of comparing serial dialysis prescriptions in NIPD in a given patient and could assist the clinician in making appropriate adjustments. Obviously, because of differing solute transport characteristics, comparisons between different Discussion patients would not be valid. The FCD and full contact Nightly intermittent peritoneal dialysis has been time are likely to be relevant only in peritoneal increasingly used for dialysis of suitable patients dialysis regimens with short exchange times. The since 1982 (8). The evolution, advantages, and dis- principle of full contact dialysis is optimized in a tidal advantages .of NIPD have been previously peritoneal dialysis technique (8). -197-
Trivedi et a/.
84 The change in solute transport characteristics observed in the reported case is worth noting. We are uncertain of the exact significance of this observation. No data are available regarding repeated assessment of peritoneal solute transport characteristics in a large number of patients on long-tenn PD (ten years or more). Such information would be of great interest. Lo eta/. ( 11) have described a centripetal change in transport in the initial 18 months of PD, followed by a slow increase thereafter. If patients do change peritoneal transport to fall within the extremes of transport characterization [as categorized by Twardowski et al. ( 12)], they may lose the long-tenn (greater than ten years) utility of the peritoneum for dialysis. To conclude, it is possible to provide clinically adequate long-tenn dialysis therapy using NIPD. Adjustment of the prescription on a patient-to-patient basis is essential for peritoneal dialysis therapy in general and seems to be even more important in
5
6 7
8
9
10
NIPD. References
11
1 Tenckhoff H. Peritoneal dialysis today: a new look. Nephron 1974; 12:420--36. 2 Von Hartitzch B, Medlock TR. Chronic peritoneal dialysis-a regime comparable to conventional hemodialysis. Trans Am Soc Artif Intern Organs 1976; 22:595-7. 3 Diaz-Buxo JA, Chandler IT, Fanner CD, et al. Chronic peritoneal dialysis at home-a comparison with hemodialysis. Trans Am Soc Artif Intern Organs 1977; 23:191-3. 4 Diaz-Buxo JA, Haas VF. The influence of auto-
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mated peritoneal dialysis in an established dialysis program. Dialysis and Transplant 1979; 8:531-3. Fenton SSA, Cattran DC, Barnes NM, et al. Home peritoneal dialysis: a major advance in promoting home dialysis. Trans Am Soc Artif Intern Organs 1977; 23: 194-200. Gutman RA. Automated peritoneal dialysis for home use. Q J Med 1978; 47:261-80. Ahmad S, Shen FH, Blagg CR. Intermittent peritoneal dialysis as renal replacement therapy. In: Nolph KD, ed. Peritoneal dialysis, 2nd ed. Dordrecht: The Martin us Nijhoff Publishers, 1985: 179-208. Twardowski ZJ. Nightly peritoneal dialysis: why, who, how, and when? Trans Am Soc Artif Intern Organs 1990; 36(1 ):8-16. Lindblad AS, Novak JW, Nolph KD, eds. Continuous ambulatory peritoneal dialysis in the U.S.A. Final Repon of the National CAPO Registry 19811988. Dordrecht: Kluwer Academic Publishers, 1989; 43-60. Scribner BH. Foreword to second edition. In: Nolph KD, ed. Peritoneal dialysis, 2nd ed. Dordrecht: The Maninus Nijhoff Publishers, 1985: xi-xii. Lo W-K, Brendolan A, Prowant BF, et al. Changes in the peritoneal equilibration test in selected chronic peritoneal dialysis patients. J Am Soc Nephrol 1994; 4: 1466-74. Twardowski ZJ, Nolph KD, Khanna R, et al. Peritoneal equilibration test. Perit Dial Bull 1987; 7:138-47.
Corresponding author: Zbylut J. Twardowski. MD, MA436 Health Sciences Center, Division of Nephrology, Department of Internal Medicine, Columbia, Missouri 65212 U.S.A.
