Volume control in diabetic and nondiabetic peritoneal dialysis patients

Perspective: Multiomics and Artificial Intelligence for Personalized Nutritional Management of Diabetes in Patients Undergoing Peritoneal Dialysis

Managing diabetes in patients on peritoneal dialysis (PD) is challenging due to the combined effects of dietary glucose, glucose from dialysate, and other medical complications. Advances in technology that enable continuous biological data collection are transforming traditional management approaches. This review explores how multiomics technologies and artificial intelligence (AI) are enhancing glucose management in this patient population. Continuous glucose monitoring (CGM) offers significant advantages over traditional markers, such as hemoglobin A1c (HbA1c). Unlike HbA1c, which reflects an mean glucose level, CGM provides real-time, dynamic glucose data that allow clinicians to make timely adjustments, leading to better glycemic control and outcomes. Multiomics approaches are valuable for understanding genetic factors that influence susceptibility to diabetic complications, particularly those related to advanced glycation end products (AGEs). Identifying genetic polymorphisms that modify a patient's response to AGEs allows for personalized treatments, potentially reducing the severity of diabetes-related pathologies. Metabolomic analyses of PD effluent are also promising, as they help identify early biomarkers of metabolic dysregulation. Early detection can lead to timely interventions and more tailored treatment strategies, improving long-term patient care. AI integration is revolutionizing diabetes management for PD patients by processing vast datasets from CGM, genetic, metabolic, and microbiome profiles. AI can identify patterns and predict outcomes that may be difficult for humans to detect, enabling highly personalized recommendations for diet, medication, and dialysis management. Furthermore, AI can assist clinicians by automating data interpretation, improving treatment plans, and enhancing patient education. Despite the promise of these technologies, there are limitations. CGM, multiomics, and AI require significant investment in infrastructure, training, and validation studies. Additionally, integrating these approaches into clinical practice presents logistical and financial challenges. Nevertheless, personalized, data-driven strategies offer great potential for improving outcomes in diabetes management for PD patients.

Predictors and prognostic significance of the volume load trajectory: a longitudinal study in patients on peritoneal dialysis

Volume overload in peritoneal dialysis patients is a common issue that can lead to poor prognosis. We employed a group trajectory model to categorize volume load trajectories and examined the factors associated with each trajectory class to explore the impact of different trajectory groups on clinical prognosis and residual renal function (RRF). This single-center prospective cohort study included 214 patients on maintenance peritoneal dialysis within a tertiary hospital. The ratio of extracellular water to total body water was measured using Bioimpedance analysis. The SAS 9.4 PROC Traj procedure was used to examine the group-based trajectory of the patients. A multivariate logistic regression model was used to calculate the adjusted odds ratios (aOR) of the associated factors to predict the trajectory class of participants. The average age of the included patients was 53.56 (SD: 11.77) years, with a male proportion of 46.7% and a median follow-up time of 6 months. The normal stable group accounted for 35.05% of the total population and maintained a normal and stable level, the moderate stable group accounted for 52.8% of the total population and showed a slightly higher and stable level, and the high fluctuation group accounted for 12.15% of the total population and showed a high and fluctuating level. A multivariate logistic regression analysis revealed that age, diabetes, and albumin levels are significant factors influencing the categorization of volume load trajectories. There were statistically significant differences in both the technical survival rate and the loss of residual renal function among the three trajectory groups.

Effect of Time Interval and Frequency of Hospitalization Because of Fluid Overload on Survival in Peritoneal Dialysis: Thailand Experience

Key Points

Background

Fluid overload (FO) is common and linked to high mortality in patients undergoing peritoneal dialysis (PD). This study evaluates the effect of time interval and frequency of FO-related hospitalizations on mortality and patient survival rates in patients on PD.

Methods

Data from patients on PD voluntarily registered in the Database of Peritoneal Dialysis in EXcel were reviewed. We included patients who started PD between January 2008 and December 2018, had a history of FO-related hospitalizations after starting PD, and were followed until December 2020 or death. We analyzed the time interval to the first FO-related hospitalization after starting PD, number of such hospitalizations, and cumulative FO-free time. Mortality and patient survival rates were calculated, and multiple Cox regression identified factors associated with mortality.

Results

Among 1858 patients hospitalized because of FO, those hospitalized within 12 months of starting PD or with <12 months of cumulative FO-free time had high mortality rates of 38.8 and 40.3 per 100 patient-years, respectively. One-year survival rates were 70.1% for those with a time to first FO-related hospitalization within 12 months of starting PD and 68.7% for those with <12 months of cumulative FO-free time. Adjusted hazard ratios were 2.92 (2.31–3.69) for a cumulative FO-free time of <12 months, 1.53 (1.18–1.99) for time to first FO-related hospitalization within 12 months and 1.05 (1.03–1.07) per FO-related hospitalization.

Conclusions

The time interval to the development of FO significantly affects mortality in patients undergoing PD.

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Association of overhydration and serum pigment epithelium-derived factor with CKD progression in diabetic kidney disease: A prospective cohort study

AIM

Little is known about whether overhydration (OH), measured using bioimpedance assay (BIA), is associated with CKD progression in patients with type 2 diabetes mellitus (T2DM). We hypothesised that OH was a predictor, and pigment epithelium-derived factor (PEDF) was a modifiable risk factor of CKD progression.

METHODS

We conducted a prospective cohort study of 1,065 patients with clinically euvolemic T2DM who attended the diabetes centre in a tertiary hospital or primary care clinic. CKD progression was defined as a combination of the worsening of the KDIGO defined CKD category by eGFR and a ≥25% decline in eGFR compared to baseline.

RESULTS

Patients with T2DM in the highest tertile of OH and relative OH (OH/ extracellular water > 7%) were positively associated with CKD progression (hazard ratio [HR] 1.45 [95% confidence interval (CI) 1.14-1.85; p = 0.003 and HR 1.29 [95%CI 1.05-1.59; p = 0.017]). There were positive associations between PEDF and CKD progression (β = 1.10; p = 0.001) and between OH and CKD progression (β = 0.21; p = 0.036). OH remained positively associated with CKD progression mediated by PEDF.

CONCLUSIONS

OH is an independent risk factor for CKD progression in patients with T2DM. Our study supports the novel definition of PEDF as a positive mediator between OH and CKD progression.

Negotiated Care Improves Fluid Status in Diabetic Peritoneal Dialysis Patients

Background

Volume overload is common in diabetic patients on continuous ambulatory peritoneal dialysis (PD), especially when the patient's residual renal function decreases with time on PD. Due to the higher dietary salt and fluid intake, diabetic PD patients tend to use more hyper-tonic glucose solution to remove excess fluid, which in turn may lead to increased membrane permeability. In the present study, we investigated the effect of negotiated care on fluid status in diabetic PD patients.

Methods

All diabetic PD patients who had been on PD for at least 3 months by the end of year 2002 in the First Hospital of Peking University were included in the present study. A primary nurse was assigned to each patient and intensive patient education was implemented, focusing on the importance of dietary salt and fluid restriction, the detrimental effect of using more hypertonic glucose solution, and the consequence of fluid overload. Decisions on dialysis prescriptions were made after extensive discussion among the primary nurse, nephrologists, patients, and patients’ families. A patient support group was also involved when it was necessary. All the patients were followed for 1 year and fluid status, compliance to dietary restriction, and dialysis prescription were evaluated before the start and at the end of the study.

Results

There were 30 diabetic PD patients (age 65.4 ± 10.3 years; on PD for 24.5 ± 19.9 months, range 3 – 66 months) included in the study when it was started. During the 1 year of follow-up, 4 patients died of diabetic complications, 3 patients were transferred to hemodialysis due to resistant peritonitis, and 2 patients were transplanted. By the end of follow-up, 21 patients remained on PD, among whom 15 had improved fluid status, 4 did not change, and 2 had worsened fluid status as assessed by clinical and bio-impedance evaluation. Patient compliance to dietary salt and fluid restriction had increased from 19.5% to 76.2%. During the follow-up, 8 patients were anuric at the beginning of the study and the remaining 22 patients had declining residual renal function. Only 4 patients increased their use of hypertonic solution including 2.5% (3 patients) and 4.25% (1 patient) glucose, whereas 5 patients decreased their use of 2.5% dialysis solution. By the end of follow-up, only 1 of the 21 patients was using 4.25% glucose solution and all the patients had good blood glucose control.

Conclusions

Our results suggest that negotiated care can be successfully used in diabetic PD patients. It helps to minimize the use of hypertonic glucose solution and improves patient compliance to dietary restriction of salt and fluid intake, and thus improves their fluid status.

Analyzing the concept of fluid overload in Chronic Kidney Disease patients in dialysis therapy: an integrative review

Objective To analyze the concept of fluid overload in Chronic Kidney Disease patients undergoing dialysis therapy and comparing it to the Nursing Diagnosis of Excess fluid volume present in the NANDA International. Method An integrative literature review carried out in the LILACS, CINAHL and SCOPUS databases. Results The sample was comprised of 22 articles. The defining attributes of the concept were: fluid retention, fluid buildup in the body, and weight gain over a short period; while the attributes composing the definition were: fluid retention in the body (intracellular/extracellular space) expressed by weight gain over short period of time. Twenty-one (21) antecedents and 22 consequents of fluid overload in patients with renal disease in dialysis therapy were identified. Conclusion The definition evidenced by the NANDA International taxonomy for the Excess fluid volume Nursing Diagnosis and the components of this diagnosis need to be complemented in order to better target the care of patients with kidney disease undergoing dialysis therapy.

DETERMINATION OF VOLUME OVERLOAD BY BIOELECTRICAL IMPEDANCE ANALYSIS AND NT-PROBNP IN DIABETIC PRE-DIALYSIS PATIENTS

Introduction

Diabetic chronic kidney disease has more fatal clinical progresses and this situation can be related to volume overload, which is seen more commonly in diabetic chronic kidney disease patients than in non-diabetic chronic kidney disease patients. Therefore, we examined the effect of diabetes mellitus on volume overload in newly diagnosed stage 5 chronic kidney disease patients whose volume overloads were not showing signs of improvement from renal replacement therapy.

Method

One hundred and five patients (46 diabetic, 59 non-diabetic) with end-stage chronic kidney disease, who had glomerular filtration rate (GFR) under 15 mL/min for at least three months were enrolled in this prospective study. We determined the body volume overload and configuration using a bioimpedance device. NT-proBNP levels were recorded.

Results

There was a statistically significant difference between diabetic and non-diabetic groups according to overhydration (OH, p=0.003), extracellular water (ECW, p=0.045), intracellular water (ICW, p<0.001) and OH/ECW (p=0.003). In addition, there was a statistically significant difference between groups in terms of N-terminal Pro-brain Natriuretic Peptide (NT-proBNP levels, p=0.008).

Discussion

We compared diabetic and non-diabetic end-stage chronic kidney disease patients who were not in renal replacement therapy yet. We found more volume overload and extracellular fluid volume in the diabetic group.

Influence of peritoneal transport characteristics on nutritional status and clinical outcome in Chinese diabetic nephropathy patients on peritoneal dialysis

Background:

High peritoneal transport status was previously thought to be a poor prognostic factor in peritoneal dialysis (PD) patients. However, its effect on diabetic nephropathy PD patients is unclear in consideration of the adverse impact of diabetes itself. The purpose of this study was to investigate the influence of peritoneal transport characteristics on nutritional status and clinical outcome in diabetic nephropathy patients on PD.

Methods:

One hundred and two diabetic nephropathy patients on PD were enrolled in this observational cohort study. According to the initial peritoneal equilibration test result, patients were divided into two groups: Higher transport group (HT, including high and high average transport) and lower transport group (LT, including low and low-average transport). Demographic characteristics, biochemical data, dialysis adequacy, and nutritional status were evaluated. Clinical outcomes were compared. Risk factors for death-censored technique failure and mortality were analyzed.

Results:

Compared with LT group (n = 37), serum albumin was significantly lower and the incidence of malnutrition by subjective global assessment was significantly higher in HT group (n = 65) (P < 0.05). Kaplan–Meier analyses showed that death-censored technique failure and mortality were significantly increased in HT group compared with that in LT group. On multivariate Cox analyses, higher peritoneal transport status and lower residual renal function (RRF) were independent predictors of death-censored technique failure when adjusted for serum albumin and total weekly urea clearance (Kt/V). Independent predictors of mortality were advanced age, anemia, hypoalbuminemia, and lower RRF, but not higher peritoneal transport status.

Conclusions:

Higher peritoneal transport status has an adverse influence on nutrition for diabetic nephropathy patients on PD. Higher peritoneal transport status is a significant independent risk factor for death-censored technique failure, but not for mortality in diabetic nephropathy patients on PD.

Is fluid overload more important than diabetes in renal progression in late chronic kidney disease?

Fluid overload is one of the major presentations in patients with late stage chronic kidney disease (CKD). Diabetes is the leading cause of renal failure, and progression of diabetic nephropathy has been associated with changes in extracellular fluid volume. The aim of the study was to assess the association of fluid overload and diabetes in commencing dialysis and rapid renal function decline (the slope of estimated glomerular filtration rate (eGFR) less than -3 ml/min per 1.73 m(2)/y) in 472 patients with stages 4-5 CKD. Fluid status was determined by bioimpedance spectroscopy method, Body Composition Monitor. The study population was further classified into four groups according to the median of relative hydration status (△HS =fluid overload/extracellular water) and the presence or absence of diabetes. The median level of relative hydration status was 7%. Among all patients, 207(43.9 %) were diabetic. 71 (15.0%) subjects had commencing dialysis, and 187 (39.6%) subjects presented rapid renal function decline during a median 17.3-month follow-up. Patients with fluid overload had a significantly increased risk for commencing dialysis and renal function decline independent of the presence or absence of diabetes. No significantly increased risk for renal progression was found between diabetes and non-diabetes in late CKD without fluid overload. In conclusion, fluid overload has a higher predictive value of an elevated risk for renal progression than diabetes in late CKD.

High glucose concentrations in peritoneal dialysate are associated with all-cause and cardiovascular disease mortality in continuous ambulatory peritoneal dialysis patients

BACKGROUND

The effect of high peritoneal dialysate glucose concentration (PDGC) on all-cause and cardiovascular disease (CVD) mortality in peritoneal dialysis (PD) patients is unclear.

OBJECTIVE

Our study aimed to investigate the effect of high PDGC on all-cause and CVD mortality in continuous ambulatory PD (CAPD) patients.

METHODS

The study enrolled 716 patients newly initiated on CAPD therapy between January 2006 and December 2010. We allocated the patients to low (< 1.56%), medium (≥ 1.56% to < 1.74%), and high (≥ 1.74%) average PDGC groups according to the tertile of average PDGC in the first 6 months after PD initiation. Cox regression and ordinal logistic regression were used to analyze determinants of mortality and of PDGC use respectively.

RESULTS

Mean follow-up in the study cohort was 31 ± 15 months. The all-cause mortality was 4.7 events per 100 patient-years, and the leading cause of death was CVD. Patients with a higher PDGC had significantly higher cumulative rates of all-cause (log-rank p < 0.001) and CVD mortality (log-rank p < 0.001). In Cox regression analysis, high PDGC independently predicted higher all-cause (hazard ratio: 2.63; p = 0.004) and CVD mortality (hazard ratio: 2.78; p = 0.01). Compared with a lower PDGC, a higher PDGC was significantly associated with older age [odds ratio (OR): 1.02; p < 0.001], low residual renal function (OR: 0.91; p < 0.001), and high dialysate-to-plasma ratio of creatinine (OR: 28.61; p < 0.001) in ordinal logistic regression.

CONCLUSIONS

Higher PDGC is associated with higher allcause and CVD mortality in CAPD patients.

Risk factors for high dialysate glucose use in PD patients--a retrospective 5-year cohort study

BACKGROUND

Use of high concentrations of glucose for peritoneal dialysis (PD) may produce unfavorable results. Our previous study showed that high initial glucose load is associated with poor PD technique survival.

OBJECTIVE

This retrospective cohort study at a medical center in Taiwan aimed to understand the factors associated with high glucose load in long-term PD patients.

PATIENTS AND METHODS

We reviewed 90 newly started PD patients over 5 years. We determined glucose load by calculating annual glucose weight and dialysate volume administered. Multiple linear regression analyses with time-dependent covariates were used to determine factors that influence the annual average dialysate glucose concentration.

RESULTS

The study group included 47 men and 43 women with a mean age of 53.4 +/- 13.9 years. Technique survival rates were 91.0%, 84.1%, and 77.6% at the beginning of the second, third, and fourth year of PD therapy respectively. The presence of diabetes mellitus (DM), high body mass index (BMI), and low weekly renal Kt/V were significantly correlated with high average dialysate glucose concentration during the first, second, and third years. For patients undergoing PD for more than 3 years, residual renal function (RRF) deteriorated, and only DM significantly affected higher dialysate glucose concentration in the fourth year.

CONCLUSIONS

Patients with DM, high BMI, and low RRF were more likely to require a high glucose load for PD therapy, especially during the first 3 years. After those 3 years of PD, DM was the only significant factor in the need for higher glucose load. To reduce the glucose load in chronic PD patients, alternative osmotic agents such as icodextrin or amino acids should be considered in the daily PD regimen.