VOLUME CONTROL
Hypertension in End Stage Renal Disease (ESRD) can be due to extracellular fluid (ECF) volume expansion. Blood pressure control requires optimization of volume status.
Measurement of ECF volume status in ESRD patients currently remains a clinical judgment. A practical approach is to reduce the target “dry” weight gradually until the patient is edema free and normotensive without medication (except for cardioprotective or renoprotective reasons); the process may be limited by postural hypotension, cramps or excess fatigue. Given the proven value of residual kidney function, a falling urine output should prompt one to reconsider target weight reduction. Dyspnea and edema may be due to other causes.
| NON-PERITONEAL APPROACHES INCLUDE:4 | PERITONEAL APPROACHES TO INCREASE ULTRAFILTRATION UTILIZING:4 |
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Target weight in PD can be accomplished by two means: nonperitoneal and peritoneal approaches.
Short, frequent APD cycles can result in hypernatremia as a result of sodium sieving (water removed in excess of sodium). Patients on such therapy should be queried about early morning thirst. Presence of thirst may mandate appropriate adjustment in therapy (e.g., lengthening of APD dwell times).4
Given that reduction of blood pressure is of importance, antihypertensive agents should be added if BP cannot be controlled by extracellular volume reduction. For reasons of renoprotection, ACEIs or ARBs should be the initial antihypertensive agent used.
While a total target volume removal of at least 750 – 1000 mL/day in anuric patients is advocated by some regional and international groups, individual clinical patient assessment is imperative to avoid symptomatic ECF volume depletion or loss of RKF.7, 8
Interventions, such as use of EXTRANEAL (icodextrin) PD Solution, have been shown to improve ECF volume control and left ventricular (LV) mass. However, it should be noted that there is no high-quality clinical evidence to show that aggressive ECF volume management, LV mass reduction, or even that lowering blood pressure improves patient survival in ESRD patients treated with either peritoneal dialysis or hemodialysis (HD).