Alexander L.T. Imholz

Fluid Kinetics in CAPD Patients during Dialysis with a Bicarbonate-Based Hypoosmolar Solution

The magnitude of transcapillary backfiltration by the colloidosmotic pressure within the peritoneal capillaries compared to the effective lymphatic absorption was investigated in continuous ambulatory peritoneal dialysis patients. This was done during a 4-hour dwell period, using a hypoosmolar dialysis fluid (280 mosm/kg H2O) in 8 patients and compared to 5 of these patients using a 1.36% glucose (GS; 324 mosm/kg H2O). The low molecular weight solute transport did not differ between the two solutions. The intraperitoneal dextran 70 concentration increased during the dwell with the hypoosmolar dialysis fluid (from 770 to 945 mg/l; p = 0.000002) and decreased with the GS (from 859 to 719 mg/l; p = 0.007). With the GS the transcapillary ultrafiltration was directed towards the abdominal cavity during the dwell period. With the hypoosmolar fluid, the transcapillary ultrafiltration was continuously directed towards the circulation. In this solution, the magnitude of transcapillary backfiltration due to colloidosmotic pressure within the peritoneal capillaries was 0.4 +/- 0.1 ml/min. In conclusion, intraperitoneal markers can be used in continuous ambulatory peritoneal dialysis patients for determination of effective lymphatic absorption and transcapillary fluid passage in both transport directions.

Effects of Tracer, Volume, Osmolarity and Infection on Fluid Kinetics during CAPD

A review is given on various aspects of using the disappearance rate of intraperitoneally administered macromolecules for the determination of fluid kinetics in CAPD patients. The rationale and mathematics for the calculation of transcapillary ultrafiltration and of indirect measurement of lymphatic absorption are described. A comparison is made between autologous haemoglobin, human albumin and dextran 70. Dextran 70 appeared most useful; one brand of human albumin increased solute transport. Lymphatic absorption was higher after the installation of a 3-litre dialysate volume than after a 2-litre one, and also higher during peritonitis than after recovery from infection. A gradual increase in intraperitoneal volume, as obtained with glucose 3.86% dialysate, had no apparent effect on the disappearance rate of dextran 70. It is concluded that intraperitoneally administered dextran 70 is a clinically useful marker for the description of fluid kinetics in CAPD patients under various conditions.

Similarities and Differences between the Effects of Amino Acids and Nitroprusside on Peritoneal Permeability during CAPD

Objective: Intraperitoneal administration of amino acid based dialysis solutions affects the surface area available for diffusion, with almost no effect on the intrinsic permeability to macromolecules. Intraperitoneally administered nitroprusside affects the vascular surface area and the intrinsic permeability without effect on the peritoneal blood flow. In the present study, these differences were translated into different effects on the radii of the pores in the peritoneal membrane. Methods: Effects of amino acid based dialysate and nitroprusside on peritoneal permeability characteristics were evaluated in standard peritoneal permeability analyses with L-arginine-containing amino acid dialysate (10 patients) or with 1.36% glucose dialysate with nitroprusside (10 patients). In each patient a control experiment with 1.36% glucose was performed. Kinetic modeling was done to analyze the effects in terms of the pore theory. Results: Both interventions increased the mass transfer area coefficients of low molecular weight solutes. This is in accordance with an increase in the unrestricted area over diffusion distance found with modeling. With amino acids almost no effect was found on the protein clearances; the increase in the large-pore radius was only small. Nitroprusside induced a marked increase in protein clearances. This was in accordance with an evident increase in the average large-pore radius. Conclusions: Amino acids affect the radii of the small pores and the large pores to the same extent. Nitroprusside influences especially the large pores. Both amino acids and nitroprusside are vasoactive, although the effects on the peritoneal microcirculation are different.

Use of the disappearance rate for the estimation of lymphatic absorption during CAPD.

Several studies are discussed which investigated the usefulness of the disappearance rate of macromolecules from the peritoneal cavity for estimating convective fluid loss from the peritoneal cavity into the peritoneal lymphatic system. It is shown that dextrans are removed from the peritoneal cavity by a size-independent process at a mean rate of 1.37 +/- 0.15 ml/min, whereas the clearance from blood to dialysate of dextrans is size-dependent. The fluid removal rate estimated by the difference in bidirectional transport of inulin (1.79 +/- 0.38 ml/min; p < 0.0005) was of the same order of magnitude as has been found using the removal rate of macromolecules from the peritoneal cavity. Also, the role of local accumulation of macromolecules was studied during continuous administration of dextrans. No differences were found in the dextran disappearance rate before and after saturation of the peritoneal interstitium with dextran (1.1 +/- 0.6 vs. 1.0 +/- 0.4 ml/min). During a study using a hypoosmotic solution we calculated a net transcapillary backfiltration of fluid, whereas the dextran removal rate was in the same order of magnitude as found using commercially available dialysate. In our opinion, the disappearance rate of macromolecules is an estimate of convective fluid loss from the peritoneal cavity into the peritoneal lymphatic system.

Clinical significance and detection of individual differences and changes in transperitoneal transport.

A review is given on the pathophysiology of the transport of solutes and fluid during continuous ambulatory peritoneal dialysis. Special attention is paid to the assessment of peritoneal permeability in individual patients, its inter- and intraindividual variability, the effect of systemic disease, some regulatory mechanisms, and alterations observed during long-term continuous ambulatory peritoneal dialysis.