This document discusses volume management in peritoneal dialysis (PD) patients. It notes that fluid overload is common in PD patients and associated with adverse outcomes. It recommends assessing factors contributing to fluid overload like salt intake, glucose control, cardiac status, residual renal function, and adherence. Tools to evaluate fluid status include bioimpedance, tracer dilution techniques, imaging, and clinical exams. Salt intake should be restricted to less than 1500 mg daily in patients with hypervolemia. Visible and invisible fluid intake must be considered. Ultrafiltration is affected by peritoneal membrane function and posture. Residual renal function and high-dose diuretics can help with fluid removal in some cases. Careful evaluation of volume status is needed

1. “ Volume management in PD patient”
นพ.กมล โฆษิตรังสิกุล
โรงพยาบาลมหาราชนครศรีธรรมราช

2. REASONS FOR DISCONTINUATION

3. HEAD TO TOE
Brain
Mouth
Abdomen
Legs

4. FLUID OVERLOAD
Common in contemporary PD populations and has
been associated with adverse clinical outcomes
hypertension
left ventricular hypertrophy
congestive heart failure
hospitalization

5. APPROACH FOR FLUID OVERLOAD
salt & water intake
blood glucose control
cardiac status
change in RRF
adherence to prescription
appropriateness of prescription
mechanical complication
change in peritoneal membrane function

6. FLUID ASSESSMENT TOOLS
• Bioelectrical impedance analysis (BIA)
• Tracer dilution technique (Deuterium oxide, Sodium bromide)
• Dual-energy x-ray absorptiometry (DEXA)
• Biochemical markers( Cardiac natriuretic peptides level)
• Cardiothoracic ratio (CTR) & Vascular pedicle width(VPW)
• Inferior vena cava diameter (IVCD)
• Clinical syndrome( BP, Edema)

7. TOOLS TO EVALUATE
G. Woodrow, Perit Dial Int 2007; 27(S2):S143–S147
Body weight alterations
Daily weighing by patients
is a routine part of PD
management, and weighing
is valuable in detecting
changes in body fluid
content.

8. FLUID BALANCE
The most appropriate way to control fluid balance in
diabetic PD patients should be control of dietary salt
and fluid intake.
Lei Quan, Perit Dial Int 2006; 26:95–100

9. PHYSIOLOGY OF VOLUME CONTROL
Input Output
สิริภา ช้างศิริกุลชัย, 2007 Update on CAPD, P111

10. PHYSIOLOGY OF VOLUME CONTROL
Input Salt
Fluid

11. SALT INTAKE IN PD
Blake G.,Perit Dial Int 2011;31:224

12. SALT INTAKE IN PD
• Sodium intake should be restricted to 65 mmol
(1500 mg) or less daily in patients with
hypervolemia (grade C).
Blake G.,Perit Dial Int 2011;31:224

13. WATER MEASUREMENT

14. FLUID
Visible fluid
Invisible fluid

15. VISIBLE FLUID
น้ำสำหรับทานยา
น้ำดื่มแก้กระหาย
น้ำแข็งอมแก้คอแห้ง

16. INTRAVENOUS MEDICATION

17. PERITONEAL MEMBRANE
The total surface of interchange of the
peritoneal cavity is approximately 1 m2.

18. PERITONEAL MEMBRANE

19. FLUID ABSORPTION
• Via Lymphatic ducts & Tissue absorption
• Usually occurs in a fixed rate (0.2-1 ml/min)
• Affected by posture associated intra-abdominal
pressure

20. ULTRAFILTRATION CURVE

21. PERITONEAL MEMBRANE
Unlike liquids and most solutes, larger particles are eliminated through the
larger orifices that exist between the specialized mesothelial cells that
cover the lymphatic conduits on the diaphragmatic surface of the
peritoneal cavity. These intracellular orifices correspond to fenestrations of
the basal membrane, and together serve as conduits of the peritoneal
cavity to the underlying lymphatic drainage system of the diaphragm,
called “lakes” or “lagoons.” The reabsorption of particles or bacteria is only
possible in the subdiaphragmatic peritoneal surface through numerous
stomas or intracellular lagoons, to which a network of lymphatic vessels
flows into the diaphragmatic lacunas. These lacunas have a diameter of 8
to 12 microns, subject to variations depending on the diaphragmatic
movements and the changes of thoraco- abdominal pressure. Smaller
particles, such as bacteria that by general are approximately 2 microns in
diameter, are readily absorbed through diaphragmatic lacunes into the
thoracic duct. Intra-peritoneal fluid and exudates circulate constantly in the
cavity toward the decanting zones via gravity, and toward the subphrenic
spaces by the suction caused by diaphragmatic contraction. This works
like a suction pump. It accelerates the flow during inspiration, and
diminishes or restrains it during expiration, and it is probably the most
important mechanism in charge of the “defensive” cleansing of the
peritoneum [1,4].

22. POSTURE & INTRA-ABDOMINAL PRESSURE
Intra abdominal pressure (cm H 2 O)
Exchange volume (ml/kg)
Sitting
Upright
Supine
Via Lymphatic ducts & Tissue absorption
Usually occurs in a fixed rate (0.2-1 ml/min)
Affected by posture associated intra-abdominal pressure
Supine < Standing < Sitting

23. PERITONEAL EQUILIBRATION TEST

24. Evaluation of peritoneal membrane function test ( modified PET)
modified PET -4.25%
High Low HA/LA
• Idiopathic
• Peritonitis
• Peritoneal
membrane
change
Adhesion
< 5 mEq/L
Sodium dipping
>5 mEq/L
Aquaporin
deficiency
Increase
Lymphatic
absorption
จิรายุทธ จันทร์มา, 2008 Optimal Care on CAPD in Thailand, P125

25. UF FAILURE
Blake G.,Perit Dial Int 2011;31:224

26. ABDOMEN

27. FLUIDS MANAGEMENT
Kidney International 20002 (62) Supplement 81: S8-S16

28. DIFFERENT MODE OF PD

29. DIALYSIS FLUID : OSMOLARITY
1.5% dextrose : 346 mOsm/L
2.5% dextrose : 396 mOsm/L (hypertonic)
4.25% dextrose : 485 mOsm/L (hypertonic)
7.5 % icodextrin (Extraneal) : 282-286 mOsm/L
http://www.baxter.com/downloads/patients_and_caregivers/products/dianeal_ultrapd2.pdf
http://www.baxter.com/downloads/patients_and_caregivers/products/extraneal_pi.pdf

30. ULTRAFILTRATION
1.5% Glucose 2000 ml
Max UF 330 + 187 ml
Time to max UF 140 + 48 min (2.3 hr)
4.25% Glucose 2000 ml
Max UF 1028 + 258 ml
Time to max UF 247 + 61 min (4 hr)

31. ULTRAFILTRATION CURVE

32. ICODEXTRIN

33. ABDOMEN

34. PD RELATED PERITONITIS
Defined as the presence of at least 2 of the
following conditions:
• Abdominal pain or tenderness
• Presence of white blood cells in peritoneal
effluent in excess of 100 cells/mL,
comprising at least 50% PMN
• Positive dialysate culture results
Perit Dial Int : July/August 2010 vol. 30 no. 4, 440-447

35. STABILITY OF DRUGS
Perit Dial Int 2009; 29:5–15

36. STABILITY OF SINGLE DRUGS IN PD
SOLUTIONS IN PVC CONTAINER
Perit Dial Int 2009; 29:5–15

37. Perit Dial Int 2009; 29:5–15
STABILITY OF SINGLE DRUGS IN PD
SOLUTIONS IN PVC CONTAINER

38. STABILITY OF DRUGS

39. PERITONITIS - APD
Ideally the patient should convert to a CAPD regime
with the help of the nursing staff.
When the fluid has cleared, the patient may return to
a more typical APD regimen (i.e. short nightly cycles
and a prolonged daytime dwell).
If the daytime dwell contains antibiotics, this must be
a full exchange (at least 6 hours).

40. LAPAROSCOPIC VIEW

41. ABDOMEN

42. PHYSIOLOGY OF VOLUME CONTROL
Output
• Urine (RRF)
• PD fluid
ultrafiltration
สิริภา ช้างศิริกุลชัย, 2007 Update on CAPD, P111
Urine
(RRF)
PD fluid
ultrafiltration

43. CAREFUL EVALUATION OF VOLUME STATUS
Blake G.,Perit Dial Int 2011;31:224
• Low net daily peritoneal UF volume
• <750 mL in anuric patients
• <250 mL in patients with RRF

44. RESIDUAL RENAL FUNCTION
Marron B, Kidney Int 2008; 108:S42-51

45. HIGH-DOSE DIURETICS
Medcalf JF,et al.Kidney Int 2001; 59:1128–33.
• RCT conducted in incident 61 CAPD patients
• Furosemide 250 mg daily (plus metolazone 5 mg
daily) followed for 12 months.
• Increase in urine output and urinary sodium
excretion with no difference in the rate of loss of RRF.
• Thiazide diuretics alone are generally ineffective in
promoting diuresis in PD patients.

46. LEGS