Peritoneal Dialysis Patients And Residual Kidney Function

Although a large number of studies have shown that there is no difference in long-term survival between peritoneal dialysis (PD) and hemodialysis (HD) patients, most national and regional registries show that after 2 to 3 years of PD treatment, the patient dropout rate is significantly higher than HD, the main reason is that with the extension of dialysis years, the residual renal function of patients gradually declines, resulting in a decline in the ability of patients to remove water and toxins.

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It is undeniable that good residual renal function in PD patients is helpful for the removal of toxins and water. Residual renal function can also secrete other endocrine hormones such as erythropoietin, which is beneficial to correct anemia, control blood pressure, and correct calcium and phosphorus metabolism. More importantly, a certain residual renal function can reduce the number of dialyses and save the cost of dialysis treatment. Therefore, nephrologists often need to do their best to preserve residual renal function.

In response to the question of whether PD is dependent on residual renal function, we have studied dialysis patients without residual renal function and found that the existing standard HD technology (3 times/week, 4h/time) and standard PD technology (4 bags/ d) In comparison, PD is not inferior to HD in removing toxins, and for some toxins, PD is better. If it is changed to HD 2 times/week and PD 3 bags/d, the ability of PD to remove toxins is much higher than that of HD. However, PD is less efficient in removing water than HD. It requires medical staff to truly understand PD and provide individualized guidance. Otherwise, it is more likely to have excess water in the body than HD, but this does not mean that PD removes less water than HD; a large number of studies showed that many PD patients removed more water than HD patients. Therefore, the high dropout rate of PD should not theoretically be due to poorer clearance of toxins and water than HD. After several years of research, we finally found that residual renal function is a double-edged sword for PD treatment. The high dropout rate in PD actually stems from our iatrogenic harm in the treatment of patients with residual renal function.

It is well known that adequate clearance of solutes (toxins) in dialysis patients depends on the patient's protein intake. The protein intake of dialysis patients has been a research hotspot for many years. The K/DOQI guidelines recommend that the daily dietary protein intake of PD patients should be 1.2-1.3 g/(kg d), and the energy intake should be >35 keal/(kg d) to maintain a good nutritional status of patients. However, a large number of clinical observations have found that the daily protein intake of PD patients in my country is maintained at 0.8 g/(kg·d), which can maintain nitrogen balance and good nutritional status. In recent years, many Western scholars have also proposed that the recommended protein intake value of K/D0QI may be too high. They believe that the protein intake of PD patients is 0.9~1.1g/(kg·d). In view of the daily protein intake of 0.6g/(kg·d) in non-dialysis uremic patients can maintain good nutrition, we believe that on this basis, the daily protein loss in the dialysate is added (about 100% of PD patients in my country). 6g/d), that is, in a stable PD patient weighing 60kg, the protein intake can maintain its nutritional status at 0.7g/(kgd). When the protein intake of the patient has reached the minimum requirement of the body, increasing the protein intake will bring more disadvantages. The intake of a high-protein diet can lead to insufficient dialysis and aggravate uremia symptoms. Kinetic studies show that if anuria patients consume 1.2g/(kg·d) of protein, 4 bags of dialysis per day cannot ensure adequate dialysis.

Therefore, we found that under the recommendation of traditional guidelines (high protein diet), when the patient has a residual renal function, the dual channel clearance of dialysis and residual renal function makes the patient's solute clearance adequate; as renal function declines, maintaining the same At the dialysis dose (4 bags/d), the solute removal efficiency decreased and dialysis was insufficient.

In addition, recent studies have found that water balance disorders may be the main factor affecting the prognosis of PD patients. PD patients are prone to water balance disorders, which is related to the fact that we have been overemphasizing that PD patients can drink water relatively freely, and the changes in patient's residual renal function. With the increase of dialysis years, the residual urine volume of patients gradually decreases. At this time, even if there is no change in peritoneal function (on the contrary, the permeability of the peritoneum of many patients can be increased to a certain extent, resulting in a decrease in the ability to remove ascites), The patient's total water clearance decreases. If the patient's water and salt intake do not decrease accordingly, the blood volume in the body will inevitably increase with the decrease of residual renal function. More importantly, when the dialysis patients still have a considerable amount of urine, we often inadvertently generate a large amount of ultrafiltration from the 4 bags of dialysis per day, which leads to the removal of water (residual urine + ultrafiltration) in the early dialysis patients. Much more water than normal human urination removes, forcing patients to drink more water than normal. Therefore, water balance disorders are more common in PD patients when residual renal function declines.

In previous PD treatment, when patients still had their own residual renal function, due to our inappropriate recommendations, the patients ate and drank more than normal people; and when the residual renal function of the patients declined, dialysis could not remove a large amount of ingested by the patients. The resulting waste and moisture cause iatrogenic injuries and ultimately lead to a high dropout rate.

The adverse effect of residual renal function on patients is also that when the patient has a good residual renal function, the amount of bicarbonate ion scavenging is large, which is likely to cause metabolic acidosis in the patient. This phenomenon increases with the urine output of the patient. disappear and gradually disappear. Patients with high residual renal function are more likely to develop hypokalemia due to the clearance of potassium by the residual kidney when they have a poor diet. The loss of a large amount of albumin in the residual kidney of some diabetic nephropathy patients is also one of the problems of the residual kidney. Therefore, residual renal function is not always beneficial in PD patients.

In conclusion, although a large number of literatures suggest that residual renal function in PD treatment plays a crucial role in the prognosis of patients, our research and practice show that the influence of this residual renal function is largely different from that of our traditional PD treatment. iatrogenic injury caused by the method. Residual renal function has its own advantages, especially to reduce the dose and cost of dialysis treatment, and we need to vigorously protect it. However, it should also be recognized that PD does not depend on residual renal function, and residual renal function also has many negative effects, especially the high dropout rate of current PD therapy is related to it.

for more information:Ali.ma@wecistanche.com