Peritoneal Protein Clearance and not Peritoneal Membrane Transport Status Predicts Survival in a Contemporary Cohort of Peritoneal Dialysis Patients
Perl J, Huckvale K, Chellar M, John B, Davies SJ. Clin J Am Soc Nephrol. 2009 Jul;4(7):1201-6
In this observational study of patients receiving peritoneal dialysis, peritoneal protein clearance rather than peritoneal transport status was found to predict patient survival.
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Abstract:
BACKGROUND AND OBJECTIVES: Fast peritoneal membrane transport status may be due to inflammation or increased peritoneal membrane surface area. We evaluated the ability of peritoneal protein clearance (Pcl) to distinguish fast peritoneal membrane transport status as a consequence of peritoneal membrane inflammation and assess its impact on patient survival. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Patients who initiated peritoneal dialysis at our center since January 1998 and had a baseline peritoneal equilibration test, measurement of dialysis adequacy, and 24-h dialysate Pcl were included. Demography, comorbidities, and biochemical data were prospectively collected. Follow-up was until death or the end of the period studied. Multivariate regression analysis identified factors that were associated with Pcl. A Cox proportional hazards model was used to identify factors that were associated with survival. RESULTS: A total of 192 patients (56% men, mean age 54.3 +/- 15.3; 32% with diabetes) were included. On univariate analysis, Pcl was negatively correlated with serum albumin and positively correlated with age, dialysate/plasma creatinine ratio (D/Pcr), the presence of peripheral vascular disease, and urine volume. On multivariate analysis, serum albumin, D/Pcr, urine volume, and peripheral vascular disease remained significant. Predictors of mortality were age, comorbidity grade, and Pcl but not D/Pcr. CONCLUSIONS: In this cohort, peritoneal transport status no longer predicted survival, whereas Pcl remained a predictor. Increased large-pore protein loss may reflect the severity of underlying cardiovascular disease, portending a poor prognosis for these patients.
July 16th, 2009 at 10:27 am
This is a fascinating article which further supports recent data suggesting that fast transporter status is not associated with worse outcomes.
Given that the cohort in this study used a lot of icodextrin, this would suggest that the historical poor outcomes in fast transporters may be minimized by the use of icodextrin. Would others agree? Are there other more current patient cohorts that do not use icodextrin where these findings have been replicated?
Anyone know?
August 12th, 2009 at 8:57 am
These findings have not been replicated, however, there is RCT data to suggest that icodextrin-use improves fluid status and is associated with greater technique survival.
Having said that, while Icodextrin may improve patient and technique survival via enhanced ultrafiltration in rapid transporters, it may also impact on the progressive changes in peritoneal membrane function seen with time.
In a sub-cohort of patients in the EAPOS study, slower deterioration of peritoneal membrane function over time was seen in icodextrin-treated patients compared to those not treated with icodextrin. While baseline transport status does not predict survival, it is likely that progressive changes in transport status may be more informative as a marker of progressive and structural alterations in membrane function. While there are several methodologic limitations in the interpretation of the EAPOS data, it does suggest that ID and other glucose minimization strategies may play a role in augmenting peritoneal membrane injury and inflammation.
August 17th, 2009 at 9:25 am
An interesting paper. I think it could be useful to have informations on the rate of peritonitis episodes, in comparison with a control group without significative modifications of PCl , because the important influence of peritonitis on peritoneum functions, beyond the undoubted etiology by the vascular disease.