Reducing cardiometabolic risk in peritoneal dialysis patients: role of the dialysis solution

Abstract

Peritoneal dialysis (PD) is a well-established form of therapy for stage 5 chronic kidney disease requiring renal replacement therapy. D-Glucose has been used successfully for several decades as the osmotic agent employed in dialysis solutions to achieve adequate fluid removal. The absorption of 100-200 grams of glucose per day has been suggested as potentially increasing cardiometabolic risk, particularly in patients with diabetes. Supporting and undermining evidence for this hypothesis is reviewed, with a focus on the role of glucose absorption in changes in body composition, dyslipidemia, and glycemic control in diabetic PD patients. Clinical strategies to optimize fluid removal while minimizing the metabolic impact of glucose absorption are also discussed.

Figure 1.

Putative pathways of glucose-associated cardiometabolic risk.

Figure 2.

Effect of nonglucose solutions on glucose control with diabetic PD patients. Modified from Marshall and colleagues.

Figure 3.

Importance of UCP2 gene polymorphisms in changes in body fat during the first year of dialysis. del, deletion; ins, insertion. Modified from Wang and associates.

Figure 4.

Univariate and multivariate fractional polynomial graphs defining the relationship between BMI and mortality risk in the Australian/New Zealand PD population. Shaded areas represent 95% confidence limits. Reproduced with permission from Journal of the American Society of Nephrology.

Figure 5.

Correlation between changes in triglyceride levels and estimated glucose absorption at 3 months from baseline when treated with icodextrin (r = 0.486, p = 0.004, n = 34). Reproduced with permission from Journal of Nephrology.

Figure 6.

Comparison of ultrafiltration efficiency of 4.25% glucose and 7.5% icodextrin during the long dwell in APD patients. Modified from Holmes.

Figure 7.

Mathematical modeling construction depicting the impact of icodextrin on daily carbohydrate (CHO) absorption when using prescriptions that achieve equivalent daily fluid removal. Assumption: two liter fill volumes, daytime dwell of 14 hours, and nighttime therapy of five 2-hour dwells. The model is a mix of transporter types representative of the APD population (15% high, 37% high-average, 33% low-average, 15% low).