this topic includes various types of peritoneal solutions.

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.