RESUMO
Abstract The peritoneal effects of low-glucose degradation product (GDP)-containing peritoneal dialysis (PD) solutions have been extensively described. To systematically evaluate the efficacy and safety of low GDP solution for PD patients, specifically the effect on residual renal function (RRF) and dialysis adequacy, we conducted a meta-analysis of the published randomized controlled trials (RCTs). Different databases were searched for RCTs that compared low GDP-PD solutions with conventional PD solutions in the treatment of PD patients with continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD). The outcomes of RCTs should include RRF and may include small solute clearance, peritoneal transport status, nutritional status, and all-cause mortality. Seven studies (632 patients) were included. Compared with the conventional solution, low-GDP solution preserved RRF in PD patients over time (MD 0.66 mL/min, 95% CI 0.34 to 0.99; p<0.0001), particularly in one year of treatment (p<0.01), and improved weekly Kt/V (MD 0.11, 95% CI 0.05 to 0.17; p=0.0007) without an increased 4-hour D/Pcr (MD 0.00, 95% CI -0.02 to 0.02; p=1.00). Notably, the MD of RRF and urine volume between the two groups tended to decrease as time on PD progressed up to 24 months. Patients using low GDP PD solutions did not have an increased risk of all-cause mortality (MD 0.97, 95% CI 0.50 to 1.88; p=0.93). Our meta-analysis confirms that the low GDP PD solution preserves RRF, improves the dialysis adequacy without increasing the peritoneal solute transport rate and all-cause mortality. Further trials are needed to determine whether this beneficial effect can affect long-term clinical outcomes.
Resumen Los efectos peritoneales de las soluciones de diálisis peritoneal (DP) que contienen productos de degradación bajos en glucosa (PIB) se han descrito ampliamente. Para evaluar sistemáticamente la eficacia y la seguridad de la solución de PIB bajo para pacientes en DP, específicamente el efecto sobre la función renal residual (RRF) y la adecuación de la diálisis, realizamos un metanálisis de los ensayos controlados aleatorios (ECA) publicados. Se realizaron búsquedas en diferentes bases de datos de ECA que compararan la solución de DP de bajo PIB con la solución de DP convencional en el tratamiento de pacientes con EP con CAPD y APD. Los resultados de los ECA deben incluir la RRF y pueden incluir la depuración de solutos pequeños, el estado nutricional, el estado del transporte peritoneal y la mortalidad por todas las causas. Se incluyeron siete estudios (632 pacientes). En comparación con la solución convencional, la solución de bajo PIB preservó la FRR en pacientes con EP a lo largo del tiempo (DM 0,66 mL/min, IC del 95%: 0,34 a 0,99; p<0,0001), particularmente en un año de tratamiento (p<0,01), y mejoró el Kt/V semanal (DM 0,11, IC del 95%: 0,05 a 0,17; p = 0,0007), sin un aumento de D/Pcr a las 4 horas (DM 0,00, IC del 95%: -0,02 a 0,02; p = 1,00). Los pacientes que usaron una solución para DP con bajo contenido de GDP no tuvieron un mayor riesgo de mortalidad por todas las causas (DM 0,97; IC del 95%: 0,50 a 1,88; p = 0,93). Nuestro metanálisis confirma que la solución de DP de bajo PIB preserva la FRR, mejora la adecuación de la diálisis sin aumentar la tasa de transporte peritoneal de solutos y la mortalidad por todas las causas. Se necesitan más ensayos para determinar si este efecto beneficioso puede afectar los resultados clínicos a largo plazo.
RESUMO
Objectives To study the efficacy of the two-compartment peritoneal dialysis fluid with low glucose degradation products in peritoneal dialysis (PD) patients.Methods Pubmed,EBMASE,Cochrane Library,Wanfang,VIP,CNKI,CBM and other databases were searched,at the same time the information form relevant literatures until December 2013 were searched by hand.To be eligible,studies had to be randomized controlled trials that allocated PD patients to two-compartment peritoneal dialysis fluid with low glucose degradation products (low-GPDs group) or to traditional dialysis fluid (control group).The qualities of included articles were assessed and then a meta-analysis was conducted by using RevMan 5.2 software.Results A total of 12 documents,11 studies met the inclusion criteria,and 1 059 cases were included.Meta-analysis results were as follows:(1)the low-GPDs group had higher level of CA125 in peritoneal dialysis effluent,higher residual renal function compared with that in the control group and the weighted mean difference were 19.61 (95％CI 12.04-27.18,P ＜ 0.01) and 0.78 (0.14-1.43,P=0.02),respectively; (2)There was no statistically significant difference between control and low-GPDs group in the ultrafiltration,peritonitis and plasma bicarbonate (all P ＞ 0.05); (3)Four studies showed no difference in peritoneal dialysis technique survival between the two group (P ＞ 0.05).Conclusions The two-compartment peritoneal dialysis fluid with low glucose degradation products is effective and safe,has no negative effects on the frequency of peritonitis,patient' s peritoneal member transport function and plasma bicarbonate,but it causes less mesothelial damage and has higher residual renal function in patients than conventional ones,and does not affect the technique survival time.
RESUMO
Peritoneal membrane shows progressive thickening, fibrotic changes and neovascularization with time on PD. Peritonitis, uremia and bioincompatible dialysate solution are important causes of peritoneal fibrosis in CAPD patients. Epithelial to mesenchymal transition (EMT) is one of the important etiologic factors for the peritoneal fibrosis in CAPD patients. Low GDP group showed less EMT than conventional PD group. Adjustment of peritoneal growth factor for dialysate CA125 revealed significant association with EMT suggesting that fibroblastoid transition from HPMC could be affected by the amount of intraperitoneal VEGF per unit mass of HPMC. There was significant improvement in both degree of EMT and D-CA125 at 6th and 12th months after switching from high GDP solution to low GDP solution. Application of icodextrin solution showed preservation of the peritoneum, like less EMT and high mesothelial bulk mass. In conclusion, therapy with low GDP solution including icodextrin may positively impact on preservation of the peritoneal membrane via reduced EMT.
Assuntos
Humanos , Glucanos , Glucose , Guanosina Difosfato , Membranas , Diálise Peritoneal Ambulatorial Contínua , Fibrose Peritoneal , Peritônio , Peritonite , Uremia , Fator A de Crescimento do Endotélio VascularRESUMO
BACKGROUND: We reported the beneficial effect of low GDP solution on rapid remesothelialization and less EMT in the peritoneum with time on CAPD. In a prospective study, we investigated the effect of switching solution from high GDP to low GDP on the restoration of EMT from human peritoneal mesothelial cells (HPMCs) in CAPD patients via ex vivo. METHODS: 21 patients (11 females, DM:11, mean age: 52.1+/-13.4 years old) who had used high GDP solution (pH 5.5, stay-safe(R), FMC) for more than 1 year (mean 14+/-6.4 months) were treated with the low GDPs solution (pH 7.0, stay-safe Balance(R), FMC) at least additional 12 months. Drained HPMCs from overnight effluent were cultured on T25 flask at the 6 months before switching to low GDPs solution (Time -6), just before switching (Time 0), 3 months after switching (Time +3), 6 months after switching (Time +6) and 12 months after switching (Time +12). When they had nearly reached to confluence, cell scores were blindly measured by the same person (Score 1: cobble stone shaped HPMCs, Score 2: mixed, Score 3:fibroblast dominant). Cell scores and clinical indices were compared between Time 0 and the others. We analyzed data with paired t-test. RESULTS: Cell score was a significantly lower at Time -6 than Time 0 (1.63+/-0.8 vs. 2.06+/-0.85, p= 0.014). But, there was no difference of level of D-CA125 between two groups (23.4+/-13.0 vs. 23.7+/-13.4 (IU/mL), p=N.S., N=16). There was no difference of cell scores between Time +3 and Time 0 (2.24+/-0.94 vs. 2.19+/-0.87, p=N.S., N=21). There were significantly lower cell score (1.71+/-0.90 vs. 2.19+/-0.87, p=0.038) and significantly higher level of D-CA125 (37.4+/-20.3 vs. 24.4+/-13.4 (IU/mL), p=0.004) at Time +6 than Time 0 (N=17). There were significantly lower cell score (1.60+/-0.88 vs. 2.20+/-0.89, p=0.014) and significantly higher level of D-CA125 (46.2+/-20.9 vs. 20.1+/-11.5 (IU/mL), p=0.000) in Time +12 than Time 0 (N=17). CONCLUSION: Our study suggests that, although restoration of EMT took some time, the switching into GDP solution from conventional solution might be helpful to pre-Jong-Won Park, et al.: Restoration of Epithelial to Mesenchymal Transition in CAPD Patients-serve the peritoneal membrane with time on PD.