ABSTRACT
BACKGROUND: Ultrafiltration (UF) in peritoneal dialysis (PD) is mainly driven by the osmotic gradient and peritoneal permeability, but other factors-such as intraperitoneal pressure (IPP)-also have an influence. METHODS: To assess the clinical relevance of these marginal factors, we studied 41 unselected PD patients undergoing two consecutive 2 h, 2.27% glucose exchanges, first with 2.5 L and then with 1.5 L. RESULTS: IPP, higher in the 2.5 L exchange, had a wide interpatient range, was higher in obese and polycystic patients and their increase with infusion volume was higher for women regardless of body size. UF with 2.5 L correlated inversely with IPP and was higher for patients with polycystosis or hernias, while for 1.5 L we found no significant correlations. The effluent had higher glucose and osmolarity in the 2.5 L exchange than in the 1.5 L one, similar for both sexes. In spite of this stronger osmotic gradient, only 21 patients had more UF in the 2.5 L exchange, with differences up to 240 mL. The other 20 patients had more UF in the 1.5 L exchange, with stronger differences (up to 800 mL, and more than 240 mL for 9 patients). The second group, with similar effluent osmolarity and peritoneal equilibration test (PET) parameters than the first, has higher IPP and preponderance of men. The sex influence is so intense that men decreased average UF with 2.5 L with respect to 1.5 L, while women increased it. CONCLUSIONS: With 2.27% glucose, sex and IPP-modulated by obesity, polycystosis, hernias, and intraperitoneal volume-significantly affect UF in clinical settings and might be useful for its management.
Subject(s)
Peritoneal Dialysis , Ultrafiltration , Dialysis Solutions , Female , Glucose , Hernia , Humans , Male , PeritoneumABSTRACT
La medida de la presión intraperitoneal en diálisis peritoneal es muy sencilla y aporta claros beneficios terapéuticos. Sin embargo, su monitorización todavía no se ha generalizado en las unidades de diálisis peritoneal de adultos. Esta revisión pretende divulgar su conocimiento y la utilidad de su medida. Se realiza en decúbito antes de iniciar el drenaje de un intercambio manual con bolsa en Y, elevando la bolsa de drenaje y midiendo la altura que alcanza la columna de líquido desde la línea medio-axilar. Los valores habituales son 10 a 16 cmH2O y nunca debe superar los 18 cmH2O. Aumenta de 1 a 3 cmH2O por litro de volumen intraperitoneal sobre valores basales que dependen del índice de masa corporal y varía con la postura y la actividad física. Su aumento provoca malestar, alteraciones del sueño y de la respiración, y se ha relacionado con la aparición de fugas de líquido, hernias, hidrotórax, reflujo gastroesofágico y peritonitis por gérmenes intestinales. Menos conocida y valorada es su capacidad para disminuir la eficacia de la diálisis contrarrestando, sobre todo, la ultrafiltración y, en menor grado, el aclaramiento de solutos. Por su facilidad de medida y potencial utilidad, debería ser uno de los factores que investigar en los fallos de ultrafiltración, pues su elevación podría contribuir a ellos en algunos pacientes. Aunque todavía no se menciona en las guías de actuación en diálisis peritoneal, sus claros beneficios justifican su inclusión entre las mediciones periódicas que considerar para la prescripción y seguimiento de la diálisis peritoneal (AU)
The measure of intraperitoneal pressure in peritoneal dialysis is easy and provides clear therapeutic benefits. However it is measured only rarely in adult peritoneal dialysis units. This review aims to disseminate the usefulness of measuring intraperitoneal pressure. This measurement is performed in supine before initiating the drain of a manual exchange with 'Y' system, by raising the drain bag and measuring from the mid-axillary line the height of the liquid column that rises from the patient. With typical values of 10-16 cmH2O, intraperitoneal pressure should never exceed 18 cmH2O. With basal values that depend on body mass index, it increases 1-3 cmH2O/L of intraperitoneal volume, and varies with posture and physical activity. Its increase causes discomfort, sleep and breathing disturbances, and has been linked to the occurrence of leaks, hernias, hydrothorax, gastro-esophageal reflux and enteric peritonitis. Less known and valued is its ability to decrease the effectiveness of dialysis significantly counteracting ultrafiltration and decreasing solute clearance to a smaller degree. Because of its easy measurement and potential utility, should be monitored in case of ultrafiltration failure to rule out its eventual contribution in some patients. Although not yet mentioned in the clinical practice guidelines for PD, its clear benefits justify its inclusion among the periodic measurements to consider for prescribing and monitoring peritoneal dialysis (AU)
Subject(s)
Humans , Peritoneal Dialysis/methods , Hydrostatic Pressure , Ultrafiltration/methods , Ascitic Fluid/chemistry , Ascitic Fluid/pathologyABSTRACT
The measure of intraperitoneal pressure in peritoneal dialysis is easy and provides clear therapeutic benefits. However it is measured only rarely in adult peritoneal dialysis units. This review aims to disseminate the usefulness of measuring intraperitoneal pressure. This measurement is performed in supine before initiating the drain of a manual exchange with "Y" system, by raising the drain bag and measuring from the mid-axillary line the height of the liquid column that rises from the patient. With typical values of 10-16 cmH2O, intraperitoneal pressure should never exceed 18 cmH2O. With basal values that depend on body mass index, it increases 1-3 cmH2O/L of intraperitoneal volume, and varies with posture and physical activity. Its increase causes discomfort, sleep and breathing disturbances, and has been linked to the occurrence of leaks, hernias, hydrothorax, gastro-esophageal reflux and enteric peritonitis. Less known and valued is its ability to decrease the effectiveness of dialysis significantly counteracting ultrafiltration and decreasing solute clearance to a smaller degree. Because of its easy measurement and potential utility, should be monitored in case of ultrafiltration failure to rule out its eventual contribution in some patients. Although not yet mentioned in the clinical practice guidelines for PD, its clear benefits justify its inclusion among the periodic measurements to consider for prescribing and monitoring peritoneal dialysis.
Subject(s)
Ascitic Fluid/physiology , Peritoneal Dialysis/methods , Pressure , Adult , Body Mass Index , Dialysis Solutions/administration & dosage , Dialysis Solutions/adverse effects , Dialysis Solutions/pharmacokinetics , Humans , Hydrostatic Pressure , Kidney Failure, Chronic/therapy , Manometry/methods , Peritoneal Dialysis/adverse effects , Reference Values , Supine Position , UltrafiltrationABSTRACT
UNLABELLED: ⦠BACKGROUND: Peritoneal dialysis (PD) has limited power for liquid extraction (ultrafiltration), so fluid overload remains a major cause of treatment failure. ⦠METHODS: We present steady concentration peritonal dialysis (SCPD), which increases ultrafiltration of PD exchanges by maintaining a constant peritoneal glucose concentration. This is achieved by infusing 50% glucose solution at a constant rate (typically 40 mL/h) during the 4-hour dwell of a 2-L 1.36% glucose exchange. We treated 21 fluid overload episodes on 6 PD patients with high or average-high peritoneal transport characteristics who refused hemodialysis as an alternative. Each treatment consisted of a single session with 1 to 4 SCPD exchanges (as needed). ⦠RESULTS: Ultrafiltration averaged 653 ± 363 mL/4 h - twice the ultrafiltration of the peritoneal equilibration test (PET) (300 ± 251 mL/4 h, p < 0.001) and 6-fold the daily ultrafiltration (100 ± 123 mL/4 h, p < 0.001). Serum and peritoneal glucose stability and dialysis efficacy were excellent (glycemia 126 ± 25 mg/dL, peritoneal glucose 1,830 ± 365 mg/dL, D/P creatinine 0.77 ± 0.08). The treatment reversed all episodes of fluid overload, avoiding transfer to hemodialysis. Ultrafiltration was proportional to fluid overload (p < 0.01) and inversely proportional to final peritoneal glucose concentration (p < 0.05). ⦠CONCLUSION: This preliminary clinical experience confirms the potential of SCPD to safely and effectively increase ultrafiltration of PD exchanges. It also shows peritoneal transport in a new dynamic context, enhancing the influence of factors unrelated to the osmotic gradient.
Subject(s)
Glucose/metabolism , Hemofiltration/methods , Kidney Failure, Chronic/therapy , Peritoneal Dialysis/methods , Aged , Aged, 80 and over , Biological Transport/physiology , Combined Modality Therapy , Dialysis Solutions/metabolism , Dialysis Solutions/pharmacology , Female , Humans , Kidney Failure, Chronic/diagnosis , Male , Middle Aged , Osmosis , Patient Safety , Peritoneal Dialysis/adverse effects , Peritoneum/metabolism , Pilot Projects , Quality Improvement , Risk Assessment , Sampling Studies , Treatment OutcomeABSTRACT
Las úlceras por presión son un problema de salud de primer orden dado el elevadísimo coste de su incidencia y prevalencia, que repercute de manera global sobre los sistemas de salud. El éxito terapéutico dependerá de la adecuada identificación y control de las causas que favorecieron la aparición de la úlcera y, por otra parte, de la correcta elección del tratamiento local que empleemos. Los cambios posturales, el estado de nutrición y el cuidado diario de la piel son los pilares de la prevención. El cuidado adecuado en el domicilio de los pacientes inmovilizados previene de forma importante la aparición de úlceras por presión. Es necesaria la colaboración estrecha entre el cuidador y los profesionales. En el caso de presentar úlceras de gran tamaño que no mejoran tras un tiempo de cuidados o signos de infección generalizada, es necesario derivar al hospital. Antes de iniciar el tratamiento va a ser necesaria una valoración general del paciente, de su situación física-psicosocial y de la úlcera. Los cuidados locales de las úlceras incluyen: limpieza, desbridamiento, prevención, diagnóstico y tratamiento de la infección y selección de apósito (AU)
Pressure ulcers are a basic health problem given its high-cost incidence and prevalence, which, in a global way, has an effect on health systems. Therapeutic success will depend on the right identification and control of the causes that created a favourable atmosphere to develop the ulcer and, on the other hand, selecting the right local treatment. Postural changes, state of nutrition and daily skin care are the basis for prevention. The adequate care at the residence of immobilized patients prevents the apparition of pressure ulcers in a significant way. Close collaboration between caregiver and professionals is necessary. When showing large ulcers that do not get better after some time of care or signs of widespread infection, it is necessary to refer to the hospital. Before starting treatment, assessing the patient in a general way, his physical-psychosocial situation and the ulcer will be necessary. Local cares for ulcers: cleaning, debridement, prevention, diagnosis and treatment of infection and selection of dressing (AU)