Courivaud Cecile, Davenport Andrew
Department of Nephrology, Dialysis and Renal Transplantation, Besançon University Hospital, Besançon, France
UCL Centre for Nephrology, Royal Free Hospital, London, UK.
Perit Dial Int. 2016 Jan-Feb;36(1):85-93. doi: 10.3747/pdi.2014.00173. Epub 2015 Jul 29.
♦
Interventional trials failed to demonstrate that increasing urea clearance improved peritoneal dialysis (PD) patient survival. Hyperphosphatemia is a well-recognized predictor of cardiovascular and all-cause mortality in PD patients. Simplification of PD small solute clearance targets focuses away from larger solutes, including phosphate. In the US and UK, increasing use of automated peritoneal dialysis (APD) cyclers with shorter dwell times could also potentially reduce peritoneal phosphate removal compared to continuous ambulatory peritoneal dialysis (CAPD). ♦
Total phosphate and peritoneal phosphate clearances were measured in a prospective observational cohort of 380 adult PD patients attending a tertiary university hospital between 1996 and 2013 for routine assessment of PD adequacy. ♦
Eighty-seven patients (22.9%) were hyperphosphatemic. Taking the mean 4-hour dialysate to plasma (D/P) ratio for phosphate, 193 (50.8%) were fast and fast-average transporters and 187 (49.2%) were slow and slow-average transporters (compared to 276 [72.6%] and 104 [27.4%], respectively, for peritoneal creatinine transporter status). Faster peritoneal phosphate transporter status was associated with over-hydration (odds ratio [OR] = 2.45 [1.43 - 4.20], p = 0.001). Whereas the 4-hour D/P creatinine and peritoneal weekly creatinine clearance did not differ between those who were hyperphosphatemic or not, the hyperphosphatemic patients had lower 4-hour D/P phosphate and lower peritoneal weekly phosphate clearance (p = 0.019, and p = 0.06 respectively). We found greater peritoneal phosphate clearance for patients choosing CAPD compared to APD, irrespective of the peritoneal phosphate transporter status. ♦
Peritoneal creatinine transporter status and creatinine clearance cannot be used as surrogate markers of peritoneal phosphate transport and clearance. Hyperphosphatemia was more common in PD patients with slower peritoneal transporter status and lower peritoneal phosphate clearance. Greater peritoneal phosphate clearance was achieved with CAPD prescriptions. Slower peritoneal transporters should be advised to choose CAPD to improve serum phosphate control.
♦
干预性试验未能证明增加尿素清除率可改善腹膜透析（PD）患者的生存率。高磷血症是PD患者心血管疾病和全因死亡率的公认预测指标。简化PD小溶质清除目标会使关注点从包括磷酸盐在内的较大溶质上转移。在美国和英国，与持续非卧床腹膜透析（CAPD）相比，使用停留时间更短的自动腹膜透析（APD）循环器的情况增多，这也可能会减少腹膜对磷酸盐的清除。♦
对1996年至2013年间在一家三级大学医院就诊的380例成年PD患者进行前瞻性观察队列研究，测量其总磷和腹膜磷清除率，以进行PD充分性的常规评估。♦
87例患者（22.9%）存在高磷血症。以磷酸盐的平均4小时透析液与血浆（D/P）比值计算，193例（50.8%）为快速和快速-平均转运者，187例（49.2%）为缓慢和缓慢-平均转运者（相比之下，腹膜肌酐转运状态分别为276例[72.6%]和104例[27.4%]）。更快的腹膜磷转运状态与水合过度相关（优势比[OR]=2.45[1.43 - 4.20]，p = 0.001）。虽然高磷血症患者与非高磷血症患者的4小时D/P肌酐和腹膜每周肌酐清除率无差异，但高磷血症患者的4小时D/P磷酸盐和腹膜每周磷清除率较低（分别为p = 0.019和p = 0.06）。我们发现，无论腹膜磷转运状态如何，选择CAPD的患者腹膜磷清除率更高。♦
腹膜肌酐转运状态和肌酐清除率不能用作腹膜磷转运和清除的替代标志物。高磷血症在腹膜转运状态较慢且腹膜磷清除率较低的PD患者中更为常见。CAPD方案可实现更高的腹膜磷清除率。对于腹膜转运较慢的患者，建议选择CAPD以改善血清磷控制。
