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Peritoneal dialysis: a primary care perspective
1Department of Internal Medicine, Division of Nephrology, University of Texas, Southwestern Medical Center; Dallas, TX 75390-8856, USA. Ramesh.saxena@utsouthwestern.edu
Insights
Primary care physicians play a key role in managing chronic kidney disease (CKD) and end-stage renal disease (ESRD). Preserving residual renal function (RRF) is crucial for patients undergoing peritoneal dialysis (PD), and new solutions like icodextrin offer benefits but require careful monitoring.
Area of Science:
- Nephrology
- Internal Medicine
- Dialysis Therapy
Background:
- Growing prevalence of chronic kidney disease (CKD) and end-stage renal disease (ESRD) necessitates increased primary care physician involvement.
- Early CKD recognition and timely nephrologist referral are vital for improving ESRD outcomes and dialysis modality selection.
- Peritoneal dialysis (PD) is a cost-effective ESRD treatment option, potentially offering survival advantages over hemodialysis in the initial years.
Purpose of the Study:
- To highlight the importance of preserving residual renal function (RRF) in peritoneal dialysis (PD) patients for improved survival.
- To guide primary care physicians on managing PD patients, including avoiding nephrotoxic agents and judicious antibiotic use.
- To inform about the benefits and unique metabolic effects of icodextrin, a novel PD solution, for primary care physicians.
Main Methods:
- Review of current literature and clinical guidelines regarding CKD and ESRD management.
- Analysis of the role of peritoneal dialysis (PD) in ESRD treatment and its comparison with hemodialysis.
- Examination of strategies for preserving residual renal function (RRF) in PD patients.
- Evaluation of the properties and clinical implications of icodextrin in PD therapy.
Main Results:
- Preservation of RRF is critical for enhancing survival outcomes in PD patients.
- Avoiding nephrotoxic drugs (aminoglycosides, NSAIDs) and limiting radiocontrast agents are essential for RRF protection.
- Icodextrin, a new PD solution, is safe but presents unique metabolic effects, including falsely elevated blood glucose and altered serum amylase levels.
Conclusions:
- Primary care physicians must be aware of CKD/ESRD management principles and PD-specific care.
- Protecting RRF and peritoneal membrane health are key objectives in PD patient management.
- Understanding icodextrin's metabolic effects is crucial for accurate patient monitoring and avoiding misdiagnosis of conditions like pancreatitis.
Abstract:
As the population of chronic kidney disease (CKD) and end-stage renal disease (ESRD) grows at an alarming rate, primary care physicians will increasingly be involved in the management of these patients. Early recognition of CKD and timely referral to a nephrologist when glomerular filtration rate approaches 30 mL/min/1.73 m(2) is extremely important to improve ESRD outcome and appropriate selection of dialysis modality. Peritoneal dialysis (PD) remains a viable treatment option for ESRD patients. PD is less expensive dialysis modality and may provide a survival advantages over hemodialysis in first 2 to 4 years of treatment. Preserving residual renal function (RRF) is of paramount importance to prolong the survival outcomes in PD patients. Thus preservation of RRF is an important goal in the management of PD patients. Every effort should be made to avoid nephrotoxic drugs like aminoglycosides and nonsteroidal anti-inflammatory drugs, and limit the use of radiocontrast agents in PD patients with RRF. Judicious use of prophylactic antibiotics to prevent peritonitis would further help to reduce morbidity from PD. Protecting peritoneal membrane from long-term toxic and metabolic effects of the conventional glucose-based solutions is another objective to further improve PD outcome. Development of new, more biocompatible PD solutions holds promise for the future. One such solution, icodextrin, is now approved for use in the United States. Although extremely safe to use, it is associated with unique metabolic effects that may concern primary care physicians. They include false elevation of blood glucose, a reversible increase in serum alkaline phosphatase and a false decline in serum amylase. Monitoring of glycemia by assays that use glucose dehydrogenase pyrroloquinoline quinone enzymes should be avoided and serum amylase alone should not be relied on in diagnosing pancreatitis in patients on icodextrin.
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