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Abstract: FR-PO567

Compounded Amino Acid Peritoneal Dialysate as an Alternative Volume Management Strategy in a Diabetic Patient

Session Information

Category: Trainee Case Report

  • 703 Dialysis: Peritoneal Dialysis

Authors

  • Ajuria, Michael, Stanford University, Palo Alto, California, United States
  • Abra, Graham E., Stanford University, Palo Alto, California, United States
  • Schiller, Brigitte, Satellite Healthcare, San Jose, California, United States
Introduction

Volume control in diabetic patients with end stage renal disease (ESRD) on peritoneal dialysis (PD) can be challenging. Common glucose sparing volume control strategies for these patients include dietary sodium restriction, diuretics, and the use of icodextrin dialysate. Another potential strategy is the use of amino acid based dialysate, which may maintain ultrafiltration by avoiding hyperglycemia and loss of the osmotic gradient between dialysate and blood. In the United States amino acid peritoneal dialysate is often not covered by insurance, leading to limited experience.

Case Description

A 63 year old female diabetic with history of ESRD treated with continuous cycler PD developed increasing challenges to maintain dry weight with frequent use of 4.25% dextrose along with a 2L icodextrin day dwell.
On exam the weight was 86.5 kg (dry weight 83 kg) and blood pressure was 173/59, with bilateral crackles and trace edema in the extremities. Daily peritoneal ultrafiltration was between 500-700 ml with no residual urine output.
Labs showed BUN 47, creatinine 12.4 mg/dl, albumin 3.4 g/dl, glucose 104 mg/dl, sodium 136 meq/L, HgA1c 6.0%, total weekly Kt/V 2.45.
Given hypoalbuminemia and worsening volume status despite frequent use of 4.25% dextrose and icodextrin, the decision was made to substitute a compounded dialysate with amino acids (1.0% amino acids in 5L of 2.5% dextrose) during CCPD with continued daytime 2L icodextrin dwells.
Daily ultrafiltration improved to an average of 1L per day. Weight decreased to 79.2 kg, edema resolved, and blood pressure improved with a reduction from 5 to 4 antihypertensives.
Due to insurance, the amino acid supplemented dialysate was lost in September with a subsequent increase in weight and blood pressure. In October the next year, insurance reauthorized the amino acid solution, which was restarted with similar improvement in weight and blood pressure.

Discussion

Volume control can be challenging despite typical glucose sparing strategies in diabetic PD patients. Our patient had improvements in volume control during periods when an amino acid based solution was used in place of standard dextrose solutions. We hypothesize that the tonicity of the above solution allowed for superior ultrafiltration and volume control compared to 4.25% dextrose due to avoidance of hyperglycemia and loss of osmotic gradient.