Peritoneal dialysis solutions consist of water, osmotic agents like glucose or glucose polymers, electrolytes, and buffers. Glucose is commonly used due to its low cost and safety, but it is easily absorbed and can cause complications over time. Other osmotic agents like amino acids, icodextrin, and glycerol are also used but each has disadvantages. The ideal solution provides adequate solute clearance and ultrafiltration while being non-toxic and non-absorbed. Standard solutions are modified as needed based on individual patient factors.

1. PERITONEAL DIALYSIS SOLUTIONS
Dr. Dinesh Katre
MD Medicine , DNB Nephrology

2. •Peritoneal dialysis solutions consist of
•water,
•osmotic agents,
•electrolytes , minerals
• and buffer

3.  IDEAL SOLUTION —
 Have a sustained and a predictable solute
clearance with minimal absorption of the osmotic
agents
 Provide deficient electrolytes and nutrients, if
required
 Correct acid base problems without interacting
with other solutes in the peritoneal dialysis fluid
 Be free of and inhibit the growth of pyrogens and
microorganisms
 Be free of toxic metals
 Be inert to the peritoneum

4.  Two major types of osmotic agents that are
currently used
 high molecular weight :
 glucose polymers, polypeptides, dextran , gelatin and
polycations
 range in weight from 20,000 to 350,000 DA
 low molecular weight
 dextrose (eg, glucose containing solutions), amino
acids,
xylitol and glycerol
 have weights of 90 to 200 DA.

5.  Glucose-containing solutions —
 Glucose is the most commonly used agent
 It comes in three different dextrose
monohydrate concentrations:
 1.5, 2.5, and 4.25 percent

6.  Composition of standard dextrose PD solution.
 Volume (Liters) 1,2, 2.5, 5,6 (variable in different
countries)
 Sodium (meq/L) 132
 Potassium (meq/L) 0 to 2 mostly 0
 Dextrose (g/dl) 1.5, 2.5, 4.25
 Calcium (meq/L) 2.5 to 3.5
 Magnesium (meq/L) 0.5 to 1.5
 Lactate (meq/L) 35 to 40
 Osmolality (mOsm/kg) 346, 396, 485
 Molecular Weight (Daltons) 182

7.  Buffers:
 the source of bicarbonate for correction of
acidosis.
 acetate, lactate or bicarbonate.
 The first two gets metabolised in the liver to
bicarbonate.
 Acetate frequently causes pain during inflow.
 Bicarbonate is not compatible with calcium and
magnesium containing solutions
 Dextrose solution usually contains lactate as
buffer , which is quite safe.

8. Physiology and Use
•Ultrafiltration with dextrose dialysate
occurs across the aquaporin 1 channels.
• Removes fluid down an osmotic gradient
•Higher the concentration of dextrose,
higher is the ultrafiltration.
•In 4 hours dwell, urea is > 90 %
equilibrated and creatinine is > 60 %
equilibrated.

9.  The ultrafiltration is maximum in the initial
hour of dwell. This leads to ‘sodium sieving’
in the initial hours of dialysis.
 The peritoneal membranes can be classified
into ‘fast’ and ‘slow’ transporters based on
D/P (dialysate to plasma creatinine) ratio in 4
hour dwell with 2.5% dextrose exchange.
 The main advantage - cheap, safer, and easily
available

10. DISADVANTAGES
 Glucose is not the ideal osmotic agent because it is
easily absorbed, leading to short-lived
ultrafiltration.
 absorption can lead to hyperinsulinemia,
hyperglycemia, hyperlipidemia, and weight gain
 the high glucose concentration, low pH, glucose
degradation products (GPDs) of these solutions
can affect peritoneal host defense mechanisms.
 formation of advanced glycation end products
(AGEs) which results in local peritoneal
membrane damage.

11.  Glucose polymer-containing solutions
 Glucose polymers (eg, icodextrin) are
mixtures of oligo/polysaccharides of variable
chain lengths.
 Icodextrin dialysate (Extraneal™) is the major
glucose polymer utilized in peritoneal
dialysis.
 commonly used as a 7.5 percent solution.

12.  Advantages of decreased absorption of solute
and increased ultrafiltration for a longer
period of time.
 Used in patients whose ultrafiltration capacity
may need to be enhanced
 Reduced carbohydrate load may provide
long-term metabolic advantage.
 Substitute for glucose solutions, particularly in
diabetics.

13.  Disadvantages
 Increased concentrations of maltose, maltotriose and
other oligo/polysaccharides possibly resulting in adverse
reactions.
 Several studies have reported incidence of cutaneous reactions
due to its structural similarity to dextran.
 Icodextrin and maltose can interfere with or cause falsely
elevated glucose results, possibly leading to inappropriate
therapy.
 With the enhanced UF provided by icodextrin, patients may be
at risk for hypovolemia and even hypotension.

14.  Incidence of dilutional hyponatremia resulting
from blood levels of icodextrin metabolites.
 The reported incidence of culture-negative
peritonitis .This is thought to be due to
contamination of some batches with a
bacterial wall breakdown product,
peptidoglycan.

15.  Hypertonic in relation to
the plasma
 Transport through the
ultra-small pores , sodium
seiving.
 Removes fluid down an
osmotic gradient
 Isotonic in relation to the
plasma (282 mOsm/kg)
 Transport through small
pores of small solutes
along with water , less
sodium seiving.
 induce transcapillary
ultrafiltration through the
process of colloid osmosis
(principle -water is
transported from the
capillaries in the direction
of relative excess of
impermeable large
solutes)

16.  Amino acid-containing solutions
 Peritoneal dialysis patients tend to lose significant
amounts of protein in the dialysate.
 1.1 percent amino acid solutions are as effective an
osmotic agent as 1.36 percent dextrose solutions
 The pH of this solution is 6.7 and osmolality is
365 mosmol/kg
 improve nutritional status by contributing to protein
synthesis especially when administered with a non-
protein energy source.
 common side effects include worsening of acidosis
and a rise in BUN.

17.  guidelines while prescribing amino acid peritoneal
dialysis solutions
 indicated for use only in malnourished or diabetic
patients, and/or those with recurrent peritonitis.
 1.1 percent amino acid solution consisting of
predominantly essential amino acids (required by
dialysis patients) should be used.
 Sufficient alternative caloric intake should be
guaranteed.

18.  Xylitol-containing solution — Xylitol has
been tried as an osmotic agent in diabetic
patients.
 However, it is not currently used because of
several potentially serious side effects,
including lactic acidosis, hyperuricemia,
carcinogenicity, and deteriorating liver
function

19.  Glycerol-containing solution —
 gained interest because of its smaller
molecular weight, relatively high osmolality
per unit mass, and a higher pH than glucose
solutions
 However, because of rapid diffusion into
blood, it produces less ultrafiltration than
glucose
 Accumulation may cause hyperosmolality of
the plasma and hypertriglyceridemia

20.  Modified solutions
 standard solution has been found to be
associated with hypermagnesemia and
hypercalcemia
 low magnesium (0.5 meq/L) and low calcium
(2.5meq/L) dialysate solutions are used
depending upon patient profile

21.  Other additives
 Insulin is frequently added to control
hyperglycemia and glucose load from the
dextrose containing solutions.
 Heparin frequently added to prevent the
formation of fibrin in the PD fluid
,particularly during peritonitis episodes
 Antibiotics are added to the peritoneal fluid
to treat peritonitis.