Approach to fluid management in peritoneal dialysis: A practical algorithm  Ali K. Abu-Alfa, John Burkart, Beth Piraino, Joe Pulliam, Salim Mujais  Kidney International  Volume 62, Pages S8-S16 (October 2002) DOI: 10.1046/j.1523-1755.62.s81.3.x Copyright © 2002 International Society of Nephrology Terms and Conditions

Figure 1 Prevalence of congestive heart failure (CHF) in patients initiating dialysis in the United States of America in the years 1996, 1998, and 2000 showing persistently high proportions. Symbols represent ages: () 45 to 64; () 65 to 74; (▪) 75+. The prevalence of CHF was age dependent. Data are from the 2001 USRDS Report. Kidney International 2002 62, S8-S16DOI: (10.1046/j.1523-1755.62.s81.3.x) Copyright © 2002 International Society of Nephrology Terms and Conditions

Figure 2 Profile of blood pressure control in patients on peritoneal dialysis in the United States of America and Italy classified by the criteria of the Sixth Joint National Committee on Hypertension (JNC6). A high prevalence of poorly controlled hypertension is clearly demonstrated. Data are from references2,3. Kidney International 2002 62, S8-S16DOI: (10.1046/j.1523-1755.62.s81.3.x) Copyright © 2002 International Society of Nephrology Terms and Conditions

Figure 3 Success in control of hypertension in PD patient by strict fluid management is illustrated by the study of Günal et al6. The number of patients requiring antihypertensive medications for blood pressure control was progressively reduced and those requiring oral antihypertensives were controlled by a single agent. Kidney International 2002 62, S8-S16DOI: (10.1046/j.1523-1755.62.s81.3.x) Copyright © 2002 International Society of Nephrology Terms and Conditions

Figure 4 Differential effects of dwell time or drain volume on peritoneal clearance of β2-microglobulin. Increasing dwell time from 12 to 24 hours and not drain volume (by increasing the number of exchanges of 2 L each) was effective in increasing clearance. Data are from reference10. Kidney International 2002 62, S8-S16DOI: (10.1046/j.1523-1755.62.s81.3.x) Copyright © 2002 International Society of Nephrology Terms and Conditions

Figure 5 Prevalence of negative net ultrafiltration (drain volume less than fill volume) in (A) CAPD and (B) APD patients treated with glucose based dialysate with various concentrations. Data are from references11,13,47. Kidney International 2002 62, S8-S16DOI: (10.1046/j.1523-1755.62.s81.3.x) Copyright © 2002 International Society of Nephrology Terms and Conditions

Figure 6 Algorithm for fluid management in patients on PD. Therapeutic goals. Kidney International 2002 62, S8-S16DOI: (10.1046/j.1523-1755.62.s81.3.x) Copyright © 2002 International Society of Nephrology Terms and Conditions

Figure 7 Algorithm for fluid management in patients on PD. Therapeutic goals and management of the long dwell. Kidney International 2002 62, S8-S16DOI: (10.1046/j.1523-1755.62.s81.3.x) Copyright © 2002 International Society of Nephrology Terms and Conditions

Figure 8 Algorithm for fluid management in patients on PD. Management of the short dwell. Kidney International 2002 62, S8-S16DOI: (10.1046/j.1523-1755.62.s81.3.x) Copyright © 2002 International Society of Nephrology Terms and Conditions

Figure 9 Relationship between cycle number and cycle duration during the nighttime phase of APD. With increasing cycle number, the duration of a dwell is shortened. This effect is due to the proportional requirements for fill and drain. The curves illustrate the changes in cycle duration by differing therapy times. Kidney International 2002 62, S8-S16DOI: (10.1046/j.1523-1755.62.s81.3.x) Copyright © 2002 International Society of Nephrology Terms and Conditions

Figure 10 Correspondence between dwell time with different cycle number (A) and the corresponding decline in osmotic gradient (B) as illustrated by the changes in dialysate glucose concentration ratio (D) compared to baseline glucose (D0). The four peritoneal transport types are represented by the different areas in the right hand panel: Low transport (L), low average transport (LA), high average transport (HA), and high transport (H). Kidney International 2002 62, S8-S16DOI: (10.1046/j.1523-1755.62.s81.3.x) Copyright © 2002 International Society of Nephrology Terms and Conditions

Figure 11 Nighttime ultrafiltration in patients on APD with variations in number of cycles. Increasing cycle number beyond 5 is associated with diminishing net UF because of the disproportional increase in relative “no therapy time” during fill/drain periods. Profiles for patients with high average (HA) and low average (LA) transport are illustrated. Kidney International 2002 62, S8-S16DOI: (10.1046/j.1523-1755.62.s81.3.x) Copyright © 2002 International Society of Nephrology Terms and Conditions

Figure 12 Net ultrafiltration per cycle declines with increasing cycle number because of the reduced time for ultrafiltration. Although shorter cycles operate at higher ultrafiltration rates, the cumulative ultrafiltration tends to be lower. Kidney International 2002 62, S8-S16DOI: (10.1046/j.1523-1755.62.s81.3.x) Copyright © 2002 International Society of Nephrology Terms and Conditions

Figure 13 Nighttime ultrafiltration in APD increases with increasing tonicity. Symbols are: (▪) 1.50%; (▵) 2.00%; (○) 2.50%. It is more efficacious to increase UF by increasing tonicity than by increasing cycle number. Curves for a high average (HA) transport patient are illustrated. Kidney International 2002 62, S8-S16DOI: (10.1046/j.1523-1755.62.s81.3.x) Copyright © 2002 International Society of Nephrology Terms and Conditions

Figure 14 Caloric gain per milliliter of ultrafiltration. Symbols are: (▪) 1.50%; (○) 2.50%. Fewer calories from glucose are gained per mL of net ultrafiltration with the use of higher tonicity solutions. Kidney International 2002 62, S8-S16DOI: (10.1046/j.1523-1755.62.s81.3.x) Copyright © 2002 International Society of Nephrology Terms and Conditions