In addition to the maintenance of normal extracellular
electrolyte composition, the prescription of continuous
peritoneal dialysis (CPD) should address four other specific issues: (i) prevention of
uremia by achievement of adequate clearance of azotemic substances, (ii) prevention of progressive expansion of the extracellular volume by adequate peritoneal ultrafiltration, (iii) prevention of loss of residual renal function, and (iv) prevention of deterioration of the peritoneal membrane structure and function.
Urea clearance, in the form of Kt/V(
Urea), is the index of removal of azotemic substances proposed by current guidelines. The target total (renal plus peritoneal) Kt/V(
Urea) is >or=1.7 weekly. To provide the desired peritoneal Kt/V(
Urea) (K(p)t/V(
Urea)), the prescription of
peritoneal dialysis must provide a daily drain volume (Dv) defined by the clearance equations as Dv = V x (K(p)t/V(
Urea))/(D/P(
Urea)), where V is body water obtained from published anthropometric formulas, K(p)t/V(
Urea) = (1.7 - renal Kt/V(
Urea))/7 and D/P(
Urea) is the
dialysate-to-plasma
urea concentration ratio at the dwell time prescribed. Computer programs obtain the relevant D/P(
Urea) values from formal studies of peritoneal transport. In the absence of these studies (for example, at initiation of CPD), D/P(
Urea) values can be obtained from published studies with similar dwell times. Body size, indicated by V, is the major determinant of the K(p)t/V(
Urea) limit provided by a given CPD schedule. Other obstacles to achievement of adequate
urea clearance are created by poor patient compliance, inaccuracies of the anthropometric formulas estimating V, and mechanical complications of CPD that lead to retention of
dialysate in the body. The main requirements for the prescription of adequate ultrafiltration are knowledge of the individual peritoneal transport characteristics, monitoring of urinary volume, and restriction of
dietary sodium intake. Excessive
dietary sodium intake is the major cause of extracellular volume expansion in CPD. Ideally,
sodium intake should be kept at the level of total (peritoneal plus renal)
sodium removal. Preventing the loss of residual renal function involves avoidance of nephrotoxic influences in the form of medications,
radiocontrast agents, urinary obstruction and
infection, and possibly other influences, such an elevated
calcium-
phosphorus product and
anemia. Use of the lowest
dialysate dextrose concentration that will allow adequate ultrafiltration is currently the most widespread practical measure of prevention of peritoneal membrane deterioration. Formulation of biocompatible
dialysate is a major ongoing research effort and may greatly enhance the success of CPD in the future.