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  1. 1. PART FIVE Pediatrics
  2. 2. Advances in Peritoneal Dialysis, Vol. 13, 1997 Variability of Peritoneal Equilibration Test in Children on Continuous Peritoneal Dialysis By Repeated Testing With Solutions of Different Christiane Laux, Klaus-Eugen Bonzel, Friederike Rubbert- Osmolarity Lauterbach, Rainer Biischer, Anne-Margret Wingen To evaluate (1) differences in the peritoneal equilibration test Key words (PET) achieved using continuous peritoneal dialysis (CPD) Peritoneal dialysis in children, peritoneal equilibration test, solutions containing d~ ferent amounts of glucose and (2) intra dialysis fluid, glucose content in dialysis fluid individual reproducibility of PEn performed twice within an in- terval of 8 months on CPD, we investigated 39 PETs in 13 Introduction children aged 2.4-19.0years (median 10.6 years) on stable CPD A standardized peritoneal equilibration test (PET) has been used regimens. The fill volume was 1 L/ml body surface area. We used in continuous peritoneal dialysis (CPD) patients since 1986 to a standard CPD solution (Fresenius) with a 2.3% glucose content evaluate peritoneal transport kinetics (1,2). Later, the PET was (groups 2.3a and 2.3b) two times within an interval of 1 -8 adapted for study in children (3-5), and reference values for months. A third test was done between the two with a children were developed (6). CPDsolution ofl.5%glucose (group 1.5). Equilibration quotients, that is, substrate concentration in dialysis fluid divided by substrate concentration in plasma (D/P), did not show any Subjects statistically significant differences between groups 1.5 and 2.3a Thirteen children (8 boys, 5 girls) on stable CPO were studied. or between groups 2.3a and 2.3b. A significant d~ ference was The patients' age ranged between 2.4 and 19.0 years (median seen in the decline of glucose content of dialysate between groups 10.6 years). Underlying renal diseases were congenital in 5 1.5 and 2.3 but not between groups 2.3a and 2.3b. Ultrafiltration patients (dysplasia in 2, prunebelly syndrome in 1, nephrotic was higher in groups 2.3a and 2.3b compared with group 1.5. In- syndrome in I, and nephrocalcinosis in I) and acquired in 8 cases ter and intraindividual variability between solute transfer was (different kinds of glomerulonephritis in 6, hemolytic uremic small during follow-up in stable CPD patients. Different glucose syndrome in 1, and shock in I ). Total number of PETs was 39; contents of 1.5 and 2.3 g/dL dialysis fluid had no measurable 15 were performed on patients on continuous ambulatory influence on PET results of stable CPD patients. For standard peritoneal dialysis (CAPD) and 24 on patients on continuous PETs, reducing the glucose content of dialysis fluid to iso- cyclic peritoneal dialysis (CCPD). Mean time on CPO was 22.4 osmolarity is not necessary. months at the first, 24.0 at the second, and 28.5 months at the third PET. At time of testing all patients were free from peritonitis (at least 4 weeks after termination of antibiotic treatment). Three patients suffered from peritonitis during follow-up. Methods From: Department of Pediatric Nephrology, Universitiits- The PET was performed in the morning after an overnight dwell kinderklinik Essen, Germany. by CAPO or a usual nighttime exchange
  3. 3. 264 Laux et al. regimen in CCPD patients. After a complete drainage, the peritoneal cavity was filled with I Llm2 body surface area of solution. We used a commercially available CPD solution (Fresenius) containing 1.5% (group 1.5) and 2.3% (group 2.3) glucose. The first and the third PETs were done with standard CPD solution containing 2.3% (groups 2.3a and 2.3b) within an interval of I -8 months, and the second PET was performed with CPD solution containing 1.5% glucose (group 1.5) between the others. Glucose, volume, potassium, urea, creatinine, and phosphorus were measured in dialysate (D) six times during a 6-hour dwell by a complete drainage technique and in plasma (P) two times (dwell time 0 and 4). The concentrations of glucose, urea, and phosphorus (enzymatic reactions), creatinine (modified Jaffe reaction, corrected for glucose concentration in dialysate ), and potassium (ion-selective electrode method) were de- termined in each dialysate and plasma sample (6). For each patient at each dwell time DIP was calculated for urea, phosphorus, creatinine, and potassium, D t ID o for high and high-average transporters up to 70% (5). This is glucose, and V t N o for ultrafiltration. All data are given in agreement with our findings (not shown here). But the as mean:1:SD. Student's t-test for paired data was used variability ofPET results in the literature is rather large. for statistical evaluation. The results are considered By selecting patients strictly according to stable clinical statistically significant for p < 0.01. conditions without signs of active peritonitis, we found an interindividual variance much smaller than shown before (5,6). In contrast to our previous data, intra individual Results variance was also small, if short time influences near a Different glucose contents of dialysis fluid of 2.3% and preceding episode of peritonitis were excluded. Glucose 1.5% glucose do not influence PET results in stable CPD resorption profiles of our follow-up only hint at increasing patients (Table I). This is even more important when permeability of the peritoneal membrane by time. But loss realizing the small inter and intraindividual variance of ultrafiltration was not detectable in the absence of ofPET results. Also, repeated testing of all patients after I peritonitis. Unlike others (7), we did not observe a -8 months showed intraindividually stable equilibration decrease in DIP creatinine following peritonitis, albeit 6 curves even after a cured intercurrent peritonitis episode of our 13 patients had between one and four episodes of (Figure I ). In 2 of the 3 patients who developed peritonitis before the tests, and 3 patients each had one peritonitis between the tests, PETs after one month episode during the test. We know that our follow-up time showed steeper equilibration curves for potassium and was somewhat short. We think that even repeated phosphorus, which reversed later on (Figure 2). DIP of episodes of peritonitis will not necessarily influence urea always showed the steepest curves and was never in- peritoneal function in a negative way, if the intervals fluenced by peritonitis. between episodes of peritonitis are long enough and healing is complete. Two of the 3 patients with peritonitis between the tests and who underwent PETs one month Discussion after peritonitis was cured showed a reversible increase in CPD is an extensively used dialysis method in children. DIP values for potassium and phosphorus. Variability of Peritoneal membrane mass transfer is both diffusive and PETs seems to be much smaller than expected and not convective. The considerable individual variability in the detectable by changing the osmolarity of dialysis fluid. handling of different solutes is well known (6). The Therefore, the PET can be experience with pediatric PET curves differed from those in adults by showing many more
  4. 4. Variability of PET 265
  5. 5. Laux et at. 266 performed with reasonable accuracy, without reducing the dialysis. Toronto: Peritoneal Dialysis Bulletin, 1991; glucose content of dialysis fluid to isoosmolarity. The 7:262-5. reason for this might be that measuring the DIP ratio is 4 Hanna ill, Foreman JW, Gehr TWB, Chan JCM, Worfrum J, Ruddley J. The peritoneal equilibration test in children. only an approximate method of testing peritoneal Pediatr Nephrol1993; 7:731--4. function. We need more refined methods to really detect 5 Geary DF, Harvey EA, MacMillan JH, Goodman Y, Scott membrane dysfunction in a predictive sense. M, Balfe JW. The peritoneal equilibration test in children. Kidney Int 1992; 42:102~5. 6 Schaefer F, Langenbeck D, Heckert, KH, Schiirer K, Mehls References 0. Evaluation of peritoneal solute transfer by the peritoneal 1 Verger C, Larpent L, Dumontet M. Prognostic value equilibration test in children. In: Khanna R, Nolph KD, of peritoneal equilibration curves in CAPD patients. Prowant BF, Twardowski ZJ, Oreopoulos Do, eds. In: Maher JF, Winchester JF, eds. Frontiers in Advances in peritoneal dialysis. Toronto: Peritoneal Dialysis peritoneal dialysis. New York: Field, Rich and Associates, Bulletin, 1992; 8:410-15. 1986:88~93. 7 Nishi A, Ito Y, Amamoto Y, Aida K, Kato H. Longitudinal 2 Twardowski ZJ, Nolph KD, Khanna R, et al. Peritoneal changes in peritoneal equilibration test with or without equilibration test. Perit Dial Bull 1987 ; 7: 138--47. peritonitis in children. Pediatr Nephrol1995; 9:562-5. 3 Fischbach M, Mengus J, Birmele B, Hamel a, Simeioni U, Geisert J. Solute equilibration curves, crossing time for urea and glucose during peritoneal dialysis: A function of age in children. In: Khanna R, Nolph KD, Prowant BF, Corresponding author: Twardowski ZJ, Oreopoulos Do, eds. Advances in Klaus-Eugen Bonzel, MD, Pediatric Nephrology, Universitiitskinderklinik peritoneal Essen, Hufelandstr. 55, 45122 Essen, Germany.