Free-water transport in fast transport status: A comparison between CAPD peritonitis and long-term PD

Abstract

Ultrafiltration failure (UFF) in continuous ambulatory peritoneal dialysis (CAPD) is a transient phenomenon during acute peritonitis and a permanent complication in long-term peritoneal dialysis (PD). The high solute transport rates during acute peritonitis are probably caused by an increased number of perfused peritoneal capillaries. Long-term PD is associated with an increased number of peritoneal microvessels, leading to an enlargement of the anatomic vascular surface area. This leads to high mass transfer area coefficients (MTAC) and to UFF. Impaired conductance to glucose, leading to a reduction in free-water transport, may be a contributing factor to UFF in long-term PD. We hypothesized that UFF during acute peritonitis is, in the absence of permanent structural changes, only caused by an increased vascular surface area, while in long-term patients it is often the result of an increased surface area in combination with an impaired conductance to glucose. Therefore, the peritoneal transport parameters of patients with acute peritonitis were compared to those in long-term PD patients. A standard peritoneal permeability analysis (SPA) was done in 10 PD patients during the first 48 hours after the diagnosis of peritonitis. The results were compared to those obtained in 10 long-term PD patients matched for the MTAC creatinine. In addition, the results of 8 peritonitis patients were compared with SPA results of 8 recently started PD patients, matched for MTAC creatinine. Peritonitis patients had a deeper maximal dip in D/P sodium, corrected for diffusion, than long-term patients (0.058 vs. 0.039, P < 0.05). Most parameters of peritoneal fluid transport were not different, except that t50 (i.e., the time to reach 50% of the maximum transcapillary ultrafiltration) was reached earlier during the dwell in peritonitis than in long-term PD-128 versus 175 minutes, P < 0.05. This confirmed the difference in the shape of the intraperitoneal volume versus time curve, which was blunted in the long-term patients. No differences were found for the parameters of solute transport between peritonitis patients and recently started patients. In contrast to patients with long-term PD, the osmotic conductance to glucose is unaffected in peritonitis, despite the lower net ultrafiltration caused by high solute transport. This implies that impaired free- water transport in chronic PD must be regarded as a contributing factor to UFF.