From the Guidelines
Worsening uremia significantly exacerbates edema and complicates peritoneal dialysis by increasing fluid retention and reducing dialysis efficiency, necessitating close monitoring and adjustments in dialysis prescriptions to manage fluid overload and prevent further complications. As kidney function deteriorates, waste products like urea accumulate in the blood, causing increased capillary permeability and sodium retention, which leads to fluid shifting into tissues and worsening edema 1. This fluid overload makes peritoneal dialysis less effective because the concentration gradient between the dialysate and blood decreases, reducing ultrafiltration capacity. Additionally, uremia damages the peritoneal membrane over time, decreasing its efficiency as a dialysis surface 1.
Some key considerations for managing edema in patients with worsening uremia include:
- Dietary sodium restriction (less than 2g daily) to reduce fluid retention
- Fluid limitation (often 500-1000mL plus urine output) to manage fluid balance
- Use of diuretics like furosemide (40-240mg daily) to enhance fluid removal if residual kidney function remains 1
- Regular monitoring of weight, blood pressure, and assessment of edema to adjust dialysis prescriptions promptly as uremia worsens
- Consideration of higher glucose concentrations in dialysate (1.5%, 2.5%, or 4.25%) to improve fluid removal, more frequent exchanges, or even temporary hemodialysis to manage severe fluid overload 1.
It is essential to note that the initiation of dialysis should be based on the patient's overall clinical condition, including signs of uremia, fluid overload, and electrolyte imbalances, rather than solely on the level of kidney function 1. The decision to start dialysis should be individualized, taking into account the patient's quality of life, comorbidities, and potential risks and benefits of dialysis therapy.
From the Research
Worsening Uremia and Edema
- Worsening uremia can lead to increased symptoms such as fatigue, anorexia, insomnia, pruritus, and nausea 2
- Edema is a common complication of uremia, particularly in patients with declining renal function
- Increasing daily dialysate volume in patients on chronic peritoneal dialysis can improve uremic symptoms, including edema 2
Peritoneal Dialysis and Uremia
- Peritoneal dialysis is a treatment option for patients with end-stage renal disease, and its effectiveness can be impacted by worsening uremia 3, 2
- The use of angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) has been shown to improve survival in patients on peritoneal dialysis 3
- Increasing the dose of dialysis in patients with declining renal function can improve uremic symptoms and reduce the risk of complications 2
Management of Edema in Peritoneal Dialysis
- Intensive monitoring of urine output can help detect acute kidney injury and improve fluid management, reducing the risk of edema 4
- The use of ACEIs or ARBs can help reduce the risk of cardiovascular events, including heart failure, which can contribute to edema 5
- Increasing daily dialysate volume and adjusting the dialysis prescription can help improve uremic symptoms, including edema, in patients on peritoneal dialysis 2