What types of peritoneal dialysis (PD) bags are prescribed for a patient with hypertension?

Peritoneal Dialysis Prescription for Hypertensive Patients

For patients with hypertension, the optimal peritoneal dialysis (PD) prescription should include icodextrin for long dwells, shorter dwell times with glucose-based solutions for high transporters, and minimization of hypertonic glucose solutions to achieve euvolemia while controlling blood pressure. 1, 2

Volume Management Strategies in PD for Hypertension

Volume overload is the primary contributor to hypertension in PD patients. The following strategies should be implemented:

• Maximize peritoneal ultrafiltration by optimizing the PD prescription to achieve euvolemia 1, 2
• Use icodextrin solution for long dwells (nocturnal dwell in CAPD patients and day dwell in APD patients) to increase ultrafiltration and decrease extracellular fluid volume 1
• Consider shortening dwell times with glucose-based solutions, especially for high transporters, to prevent fluid reabsorption 1
• Avoid long-duration dwells that are associated with ineffective fluid removal or net fluid resorption 1
• In APD patients, consider either shortening the day dwell or draining out the day dwell and replacing it with fresh dialysis solution partway through the day 1
• In CAPD patients, consider switching to APD without a long day dwell or using a night-exchange device to divide the nocturnal dwell into 2 shorter dwells 1

Specific PD Solution Recommendations

Icodextrin Solutions

• Use icodextrin for the long dwell (day dwell in APD, overnight dwell in CAPD) 1, 2
• Randomized controlled trials have shown icodextrin both increases peritoneal ultrafiltration and decreases extracellular fluid volume 1
• With icodextrin in place, there is no need to drain a day dwell early to optimize ultrafiltration 1
• Monitor for potential increased peritoneal permeability with long-term use of icodextrin 3

Glucose-Based Solutions

• Minimize use of hypertonic glucose solutions due to concerns about peritoneal membrane damage and adverse metabolic effects 1
• When necessary, use more hypertonic glucose solutions strategically for shorter dwells rather than long dwells 1
• Consider biocompatible, neutral pH, or low glucose degradation product solutions which may help preserve residual kidney function and maintain peritoneal membrane function 1

Modality Considerations (APD vs CAPD)

• APD may provide better blood pressure control compared to CAPD in some patients, with studies showing a 4 mmHg decrease in systolic blood pressure when transitioning from CAPD to APD 4
• Pay close attention to sodium sieving effect in APD patients with multiple short overnight dwells, which may compromise BP control 1
• Consider using fewer than four overnight exchanges during 8 hours in APD to minimize sodium sieving 1
• No definitive evidence suggests one PD modality is superior to the other for volume control; selection should consider patient-specific factors 1

Additional Management Strategies

• Preserve residual kidney function (RKF) as it is strongly associated with better BP control 5
• For patients with RKF, consider high-dose loop diuretics to enhance urinary sodium and water removal 1
• ACE inhibitors and ARBs may help maintain urinary volume and clearance in patients with RKF 1
• Restrict dietary sodium intake if persistent hypertension and fluid overload are present 1
• Monitor salt and water removal by measuring daily urinary volume/sodium content and the difference between dialysate effluent and infused dialysis solution 1
• Consider experimental approaches such as low-sodium dialysate, though these require further evaluation and may increase risk of hypotensive episodes 1, 6

Monitoring and Assessment

• Assess blood pressure and volume status monthly 1
• Evaluate drain volume, residual kidney function, and dietary salt/water intake monthly 1
• More frequent clinical examination may be needed in the initial weeks of PD therapy when target weight is being established 1
• Pay particular attention to net peritoneal fluid absorption during long duration dwells 1

By implementing these strategies, hypertension can be effectively managed in PD patients while minimizing complications and preserving peritoneal membrane function and residual kidney function.