Volume status and fluid overload in peritoneal dialysis

Yousaf khanLecturer Renal dialysisIPMS- KMU

Introduction Fluid overload can manifest in obvious fashion as

hypertension or edema in PD patients. Making it difficult to diagnose clinically chronic

hypervolemia can lead to LVH. Major contributor to cardiovascular disease, in PD patient

with attendant morbidity and mortality. Fluid overload with peritoneal membrane dysfunction is a

common cause for technique failure.

Assessment of fluid status Mechanism of fluid overload Diagnosis of ultrafiltration failure ( UFF)

1: Assessment of fluid status: Clinical examination Laboratory investigation have so far not proven clinically

useful Target body weight for PD is that which gives a well

tolerated normotensive and edema free state

2: Mechanisms of fluid overload: Fluid overload reflects a combination of inappropriate

prescription, noncompliance, loss of residual renal function, mechanical problems and peritoneal membrane dysfunction.

3: Diagnosis of Ultra filtration failure (UFF): High transporter with UFF (type I) Low transporter with UFF (type II)

Diagnosis of Ultra filtration failure (UFF):High transporter with UFF (type I) In this situation the dialysate dextrose concentration falls rapidly after

infusion, resulting in loss of the concentration gradient that drives fluid removal.

Most common cause and is often called type I UFF Develops after 3 or more years on PD. Its reflect an increase membrane vascularity that occurs with time on

PD, to a greater extent in some patients Cause of increase effective surface area may include cumulative

exposure of the membrane to high glucose loads.

Low transporter with UFF (type II) Group of patients has reduced small solute clearance. A normal or reduce glucose absorption profile and reduce fluid

removal Called type II UFF Much less common Its reflects decrease membrane surface and is most often due to

adhesions and scarring after a severe peritonitis or other intra abdominal complication.

Causes of fluid overload in PD patients Inappropriate bag selection Inappropriate prescription for membrane transport status

long, dextrose – containing daytime or nocturnal dwells Failure to optimize APD regimen for transport status Failure to use icodextrin – containing solutions Noncompliance with PD prescription Noncompliance with salt and water restriction Loss of residual renal function Abdominal leak Catheter malfunction Poor blood glucose control Peritoneal membrane dysfunction

Management of fluid overload Sodium restriction Patient education regarding when to select higher dextrose

solutions Good blood glucose control Preserve residual renal function Abdominal leak Catheter malfunction Preservation of peritoneal membrane function

Hypertension and Hypotension in PDHypertension: PD providing better blood pressure control than hemodialysis b/c

of its continuous nature. More recently concern has been raised about blood pressure

control with CAPD It has been demonstrate that antihypertensive medication

requirements with increase duration on CAPD, as compare hemodialysis

Sodium sieving and removal

Management: Initially volume control and antihypertensive should be introduce

only if his approach has been unsuccessful. Preference should be given to agent that have a beneficial effect

on residual renal function, such as loop diuretics, ACE inhibitors and ARB

Hypotension Hypotension is not uncommon in PD population Cause of hypotension is sometimes unclear but

approximately 20% of cases are secondary to heart failure.

40% may due to hypovolemia

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