Inflammation is an important risk for mortality in dialysis patients. Extracellular fluid volume (ECFv) expansion, a condition commonly seen in peritoneal dialysis (PD) patients, may be associated with inflammation. However, published support for this relationship is scarce.
Objectives
To quantify the proportion of patients on PD with inflammation and to analyze the role of ECFv expansion and the factors related to these conditions.
Design
A prospective, multicenter cross-sectional study in six hospitals with a PD program.
Patients and Methods
Adult patients on PD were studied. Clinical data, body composition, and sodium and fluid intake were recorded. Biochemical analysis, C-reactive protein (CRP), and peritoneal and urinary fluid and sodium removal were also measured.
Results
CRP values positive (≥ 3.0 mg/L) for inflammation were found in 147 (80.3%) and negative in 36 patients. Patients with positive CRP had higher ECFv/total body water (TBW) ratio (women 47.69 ± 0.69 vs 47.36 ± 0.65, men 43.15 ± 1.14 vs 42.84 ± 0.65; p < 0.05), higher serum glucose (125.09 ± 81.90 vs 103.28 ± 43.30 mg/dL, p < 0.03), and lower serum albumin (2.86 ± 0.54 vs 3.17 ± 0.38 g/dL, p < 0.001) levels. They also had lower ultrafiltration (1003 ± 645 vs 1323 ± 413 mL/day, p < 0.005) and total fluid removal (1260 ± 648 vs 1648 ± 496 mL/day, p < 0.001), and less peritoneal (15.59 ± 162.14 vs 78.11 ± 110.70 mEq/day, p < 0.01) and total sodium removal (42.06 ± 142.49 vs 118.60 ± 69.73 mEq/day, p < 0.001). In the multivariate analysis, only ECFv/TBW was significantly (p < 0.04) and independently associated with inflammation. ECFv/TBW was correlated with fluid removal (r = 0.16, p < 0.03) and renal sodium removal (r = 0.2, p < 0.01).
Conclusion
The data suggest that ECFv expansion may have a significant role as an inflammatory stimulus. The results disclose a relationship between the two variables, ECFv expansion and inflammation, identified as independent risk factors for mortality in PD patients.
Pecoits-FilhoR., StenvinkelP., WangA.Y., HeimburgerO., LindholmB.Chronic inflammation in peritoneal dialysis: the search for the holy grail?Perit Dial Int2004; 24: 327–39.
2.
ChungS.H., HeimburgerO., StenvinkelP., QureshiA.R., LindholmB.Association between residual renal function, inflammation and patient survival in new peritoneal dialysis patients.Nephrol Dial Transplant2003; 18: 590–7.
3.
QureshiA.R., AlvestrandA., Divino-FilhoJ.C., GutierrezA., HeimburgerO., LindholmB.Inflammation, malnutrition, and cardiac disease as predictors of mortality in hemodialysis patients.J Am Soc Nephrol2002; 13(Suppl 1): S28–36.
4.
MallamaciF., TripepiG., CutrupiS., MalatinoL.S., ZoccaliC.Prognostic value of combined use of biomarkers of inflammation, endothelial dysfunction, and myocardiopathy in patients with ESRD.Kidney Int2005; 67: 2330–7.
5.
Pecoits-FilhoR., AraújoM.R.T., LindholmB., StenvinkelP., AbensurH., RomaoJ.E.Jr.. Plasma and dialysate IL-6 and VEGF concentrations are associated with high peritoneal solute transport rate.Nephrol Dial Transplant2002; 17: 1480–6.
6.
AriciM., WallsJ.End-stage renal disease, atherosclerosis, and cardiovascular mortality: is C-reactive protein the missing link?Kidney Int2001; 59: 407–14.
7.
ChungS.H., HeimbürgerO., StenvinkelP., BergstromJ., LindholmB.Association between inflammation and changes in residual renal function and peritoneal transport rate during the first year of dialysis.Nephrol Dial Transplant2001; 11: 2240–5.
8.
ChungS.H., HeimburgerO., StenvinkelP., WangT., LindholmB.Influence of peritoneal transport rate, inflammation, and fluid removal on nutritional status and clinical outcome in prevalent peritoneal dialysis patients.Perit Dial Int2003; 23: 174–83.
9.
PaniaguaR., FríasY., VenturaM.J., RodríguezE., HurtadoM.E., AlcántaraG.C-reactive protein and anti-Chlamydia pneumoniae antibodies as risk factors of cardiovascular death in incident patients on peritoneal dialysis.Perit Dial Int2003; 23: 132–7.
10.
MayrM., KiechlS., WilleitJ., WickG., XuQ.Infection, immunity, and atherosclerosis. Associations of antibodies to Chlamydia pneumoniae, Helicobacter pylori and Cytomegalovirus with immune reactions to heat-shock protein 60 and carotid or femoral atherosclerosis.Circulation2000; 102: 833–9.
11.
HaubitzM., BrunkhorstR.C-reactive protein and chronic Chlamydia pneumoniae infection: long-term predictors for cardiovascular disease and survival in patients on peritoneal dialysis.Nephrol Dial Transplant2001; 16: 809–15.
12.
KredietR.T., Ho-dac-PannekeetM.M., StruijkD.G.Preservation of peritoneal membrane function.Kidney Int Suppl1996; 56: S62–8.
13.
MemoliB., RomanoG., D'ArcangeloR., Del PreteM., EspositoP., ProcinoA.The role of interleukin-6 and of its soluble receptors in the biocompatibility of dialysis treatment.Semin Nephrol2004; 24: 492–4.
14.
PaniaguaR., VenturaM.J., RodríguezE., SilJ., GalindoT., HurtadoM.E.Impact of fill volume on peritoneal clearances and cytokine appearance in peritoneal dialysis.Perit Dial Int2004; 24: 156–62.
15.
Vicenté-MartínezM., Martínez-RamírezL., MuñozR., AvilaM., VenturaM.J., RodríguezE.Inflammation in patients on peritoneal dialysis is associated to increased extracellular fluid volume.Arch Med Res2004; 35: 220–4.
16.
KimS.B., ChangJ.W., LeeS.K., ParkJ.S.Acute systemic inflammation is associated with an increase in peritoneal solute transport rate in chronic peritoneal dialysis patients.Perit Dial Int2004; 24: 597–600.
17.
KoningsC.J., KoomanJ.P., SchonckM., StruijkD.G., GladziwaU., HoorntjeS.J.Fluid status in CAPD patients is related to peritoneal transport and residual renal function: evidence from a longitudinal study.Nephrol Dial Transplant2003; 18: 797–803.
18.
DaviesS.J., WoodrowG., DonovanK., PlumJ., WilliamsP., JohanssonA.C.Icodextrin improves the fluid status of peritoneal dialysis patients: results of a double-blind randomized controlled trial.J Am Soc Nephrol2003; 14: 2338–44.
19.
FineA.Relevance of C-reactive protein levels in peritoneal dialysis patients.Kidney Int2002; 61: 615–20.
20.
OhkumaT., MinagawaT., TakadaN., OhnoM., OdaH., OhashiH.C-reactive protein, lipoprotein(a), homocysteine, and male sex contribute to carotid atherosclerosis in peritoneal dialysis patients.Am J Kidney Dis2003; 42: 355–61.
21.
NascimentoM.M., Pecoits-FilhoR., LindholmB., RiellaM.C., StenvinkelP.Inflammation, malnutrition and atherosclerosis in end-stage renal disease: a global perspective.Blood Purif2002; 20: 454–8.
22.
Su-HernándezL., Abascal-MacíasA., Méndez-BuenoF.J., AmatoD., PaniaguaR.Epidemiologic and demographic aspects of peritoneal dialysis in México.Perit Dial Int1996; 16: 362–5.
23.
Cueto-ManzanoA.M., Correa-RotterR.Is high peritoneal transport rate an independent risk factor for CAPD mortality?Kidney Int2000; 57: 314–20.
24.
Muñoz-de-ChávezM., Ledezma-SolanoJ.A.Los alimentos y sus nutrientes. Tablas de Valor Nutritivo de Alimentos. México, D. F., México: McGraw Hill Interamericana, Health Care Group; 2002.
25.
TwardowskiZ.J.The fast peritoneal equilibration test.Semin Dial1990; 3: 141–2.
26.
PearsonT.A., MensahG.A., AlexanderR.W., AndersonJ.L., CannonRO3rd, CriquiM.Centers for Disease Control and Prevention; American Heart Association. Markers of inflammation and cardiovascular disease: application to clinical and public health practice: a statement for healthcare professionals from the Centers for Disease Control and Prevention and the American Heart Association.Circulation2003; 107: 499–511.
27.
JonesC.H., WellsL., StovesJ., FarquharF., WoodrowG.Can a reduction in extracellular fluid volume result in increased serum albumin in peritoneal dialysis patients?Am J Kidney Dis2002; 39: 872–5.
28.
YonovaC., ValderrabanoF.The influence of extracellular fluid volume on serum proteins in peritoneal dialysis patients.Minerva Urol Nefrol2004; 56: 367–9.
29.
DumlerF.Hypoalbuminemia is a marker of overhydration in chronic maintenance patients on dialysis.ASAIO J2003; 49: 282–6.
30.
WoodrowG., OldroydB., WrightA., CowardW.A., TurneyJ.H., BrownjohnA.M.Abnormalities of body composition in peritoneal dialysis patients.Perit Dial Int2004; 24: 169–75.
31.
PlumJ., SchoenickeG., KleophasW., KulasW., SteffensF., AzemA.Comparison of body fluid distribution between chronic haemodialysis and peritoneal dialysis patients as assessed by biophysical and biochemical methods.Nephrol Dial Transplant2001; 16: 2378–85.
32.
Abu-AlfaA.K., BurkartJ., PirainoB., PulliamJ., MujaisS.Approach to fluid management in peritoneal dialysis: a practical algorithm.Kidney Int Suppl2002; 81: S8–16.
33.
Rodriguez-CarmonaA., Perez-FontanM., Garca-NaveiroR., VillaverdeP., PeteiroJ.Compared time profiles of ultrafiltration, sodium removal, and renal function in incident CAPD and automated peritoneal dialysis patients.Am J Kidney Dis2004; 44: 132–45.
34.
TzamaloukasA.H., SaddlerM.C., MurataG.H., MalhotraD., SenaP., SimonD.Symptomatic fluid retention in patients on continuous peritoneal dialysis.J Am Soc Nephrol1995; 6: 198–206.
35.
FrankenfieldD.L., ProwantB.F., FlaniganM.J., FrederickP.R., BailieG.R., HelgersonS.D.Trends in clinical indicators of care for adult peritoneal dialysis patients in the United States from 1995 to 1997. ESRD Core Indicators Workgroup.Kidney Int1999; 55: 1998–2010.
36.
MistryC.D., GokalR., PeersE.A randomized multicenter clinical trial comparing isosmolar icodextrin with hyperosmolar glucose solutions in CAPD. MIDAS Study Group. Multicenter Investigation of Icodextrin in Ambulatory Peritoneal Dialysis.Kidney Int1994; 46: 496–503.
37.
PlumJ., GentileS., VergerC., BrunkhorstR., BahnerU., FallerB.Efficacy and safety of a 7.5% icodextrin peritoneal dialysis solution in patients treated with automated peritoneal dialysis.Am J Kidney Dis2002; 39: 862–71.
38.
WoodrowG., OldroydB., StablesG., GibsonJ., TurneyJ.H., BrownjohnA.M.Effects of icodextrin in automated peritoneal dialysis on blood pressure and bioelectrical impedance analysis.Nephrol Dial Transplant2000; 15: 862–6.
39.
AsgharR.B., GreenS., EngelB., DaviesS.J.Relationship of demographic, dietary, and clinical factors to the hydration status of patients on peritoneal dialysis.Perit Dial Int2004; 24: 231–9.
40.
AtesK., NergizogluG., KevenK., SenA., KutlayS., ErturkS.Effect of fluid and sodium removal on mortality in peritoneal dialysis patients.Kidney Int2001; 60: 767–76.
41.
BrownE.A., DaviesS.J., RutherfordP., MeeusF., BorrasM., RiegelW.EAPOS Group. Survival of functionally anuric patients on automated peritoneal dialysis: the European APD Outcome Study.J Am Soc Nephrol2003; 14: 2948–57.
42.
SharmaA.P., BlakeP.G.Should “fluid removal” be used as an adequacy target in peritoneal dialysis?Perit Dial Int2003; 23: 107–8.
43.
PaniaguaR., AmatoD., VoneshE., Correa-RotterR., RamosA., MujaisS.Effect of increased peritoneal clearances on mortality in peritoneal dialysis: ADEMEX, a prospective randomized controlled trial.J Am Soc Nephrol2002; 13: 1307–20.
44.
KhandelwalM., KothariJ., KrishnanM., LiakopoulosV., TziviskouE., SahuK.Volume expansion and sodium balance in peritoneal dialysis patients. Part II: Newer insights in management.Adv Perit Dial2003; 19: 44–52.
