The contribution of combined crystalloid and colloid osmosis to fluid and sodium management in peritoneal dialysis.

The achievement of euvolemia is essential to the successful management of peritoneal dialysis patients. However, the concern that hypertonic glucose exchanges may have a role in long-term changes to the peritoneal membrane has lead to an alternative strategy to enhance ultrafiltration (UF) over the long dwell by combining crystalloid and colloid osmosis. This review summarizes the experience of mixing glucose or amino acids with polyglucose (icodextrin), with particular focus given to data from studies using glucose/icodextrin in combinations of 1.36%/7.5% and 2.61%/6.8%. Both combinations demonstrate a significant increment of UF volume and sodium removal compared with the component osmotic agents used individually over long dwells, with the 2.61%/6.8% mixture having an effect over dwells extending to 15 h. Hypothetically, the mechanism of the enhanced UF is the attenuation by the colloid osmotic force of the backflow of water through small pores from dialysate to the peritoneal capillary circulation once the crystalloid osmotic force has dissipated. This experience provides promising data that deserves further examination in longer term clinical studies.

[Fluid and sodium balance and blood pressure control in APD/CAPD]. / Equilibre de la balance hydrosodée et contrôle de la pression artérielle en DPA/DPCA.

Cardiovascular disease remains the leading cause of death in ESRD patients related to long-standing hypertension. Early studies had recognized the favourable effect of PD in controlling hypertension but it was soon realized that such benefit was not sustained. A U shaped trend of hypertension in patients on PD has been recently demonstrated as a result of a steadily increased blood pressure partly attributed to fluid retention resulting from lower sodium removal with time. Effort in selecting the best strategy of ultrafiltration for a single patient along with a careful and frequent monitoring of combined 24 hours sodium elimination coupled with dietician counseling can improve significantly fluid an sodium balance which in turn will result in much better blood pressure control. The contribution of progress in biocompatibility of PD fluid that better preserve renal function and the implementation of the first glucose polymer Icodextrin were key interventions in that aim. Further studies should be conducted to assess the power of innovative PD solutions--Low Sodium PDF and/or Bimodal Ultrafiltration--in enhancing fluid and sodium removal during CAPD/APD programmes.

How to reach optimal creatinine clearances in automated peritoneal dialysis.

This paper summarizes the basis of prescription for automated peritoneal dialysis (APD) established during a French national conference on APD. Clinical results and literature data show that peritoneal clearances are closely determined by peritoneal permeability and hourly dialysate flow rate, independently of dwell time or number of cycles. With APD, peritoneal creatinine clearance increases according to the hourly dialysate flow rate to a maximum (plateau), then decreases because of the multiplication of the drain-fill times. The hourly dialysate flow giving the maximum peritoneal creatinine clearance is defined as the "maximal effective dialysate flow" (MEDF). MEDF is higher for high peritoneal permeabilities: MEDF is 1.8 and 4.2 L/hr with nocturnal tidal peritoneal dialysis (TPD) for a 4-hr creatinine dialysate-to-plasma ratio (D/P) of 0.50 and 0.80, respectively. With nightly intermittent peritoneal dialysis (NIPD), MEDF is 1.6 and 2.3 L/hr for a D/P of 0.50 and 0.78, respectively. Under these conditions, tidal modalities can only be considered as a way to increase the MEDF. Using the MEDF concept for an identical APD session duration, the maximal weekly normalized peritoneal creatinine clearance can vary by 340% when 4-hr D/P varies from 0.41 to 0.78. APD is not recommended when 4-hr creatinine D/P is lower than 0.50. However, the limits of this technique may be reached at higher peritoneal permeabilities in anurics because of the duration of sessions and/or the additional exchanges required by these patients.

[Association of mixed connective tissue disease with Sjogren's syndrome and lupus in 2 HLA- and DR-identical sisters]. / Association d'une connectivite mixte avec syndrome de Sjögren et d'une maladie lupique chez deux sceurs HLA ET DR identiques.

Different connective tissue diseases were observed in two HLA--and DR--identical sisters. The daughter of one of the index patients and their father exhibited closely related symptoms. With reference to this familial observation the authors discuss the significance of DR3 which is correlated with immunologic disturbances producing multiple clinical and biological manifestations.