PD and hemo to rest the membrane


I am worried about preserving my membrane. I am a Type II in control diabetic and have been on PD for two years. I do have some fibrin and use Heparin at times. What is the best fluid to use? I use baxter dianeal pd-2 now. What else can I do, e.g. adrenaline, Heparin to help preserve my membrane. I am in a smaller town and while we do have a Davita PD clinic there are not many docs here or none that champion PD. I am the one that put myself on a low protein diet and informed my doc prior to my renal failure. I chose to do PD and it seems like most docs just say well, go to hemo. I do not want to do hemo and enjoy being able ot travel and live some what normally using home PD.

What is the lowest clearance number that can provide life support? Davita has stated it is 1.7. My number has never been much higherr and urine output has declined a bit. I feel very good and do projects and my other numbers are good. Doesn’t how you feel mean anything, as I am not just a number, right?

If I am forced that direction can you do PD and use hemo once a week to help with clearance and live normally for 6 days or more a week. I want to stay on PD unless it becomes absolutely required to switch. I was told to lose 50lbs and then reconsider a transplant and I have lost 30 lbs and have a ways to go to even complete evaluation. I may be on treatment for ever and want to use PD.

Dear spatterson

Thanks for your inquiry … and while our unit has a strong home PD service and I manage many of those patients - my major interest has been in home HD. Recognizing this, Judith Bernadini has long been the PD oracle here at HDC. She has an extraordinary breadth of knowledge about PD, the fluids available and the best options to use … a knowledge that I think far outstrips my own. As this is a question that should be asked primarily of Judith, can I suggest you re-direct it there … or maybe Dori can.

That said, I suspect she will discuss some of the newer bio-compatible fluids - as have been recently reported to be of significant benefit in the BALANZ trial out of Australia and New Zealand: a trial with which I now Judith is familiar.

ON the issue of membrane preservation - this is a key issue in PD. However, we still don’t know enough about the mesothelial layer that forms the PD membrane. We still know only some of the effects of the differing fluids - be they glucose based, non-glucose-based, bio-compatible, bicarbonate, nutrient-delivering etc. - that also have a dorect influence on the health and sustainability of the peritoneal membrane. We are still learning about the effects of ‘advanced glycation end-products’ (AGE’s) … where the cells that make up the membrane are slowly ‘caramelized’, over time, by glucose and the cells thicken in response … and why this happens more in some patients than others. Obviously, too, there are the effects of peritonitis - should it occur. In my own unit, we have a quite a low peritonitis rate (stable between 1 in 50 and 1 in 60 months of therapy) - but in services where the rate is more frequent, the influence of recurrent infection on the membrane and it’s durability as a functioning dialysis membrane plays and important role as well.

As for combination PD/HD therapies - yes, this is a concept that has been around for some 3-4 decades. Indeed, John Moran, now Medical Director of Davita and previously from Satellite Health and an avowed proponent of home therapies, is, like me, an Australian and, once in his earlier days, was a recognized expert in PD. Incidentlally, echoes of his formative PD experience emerged in his contribution to the development of the NxStage system. John wrote back in the 70’s of his experience with hybrid therapy (PD + HD) at St Vincents Hospital, Melbourne, his ‘Alma Mater’ … as have others, from time to time since … and there is a (very) limited place for considering it is exceptional circumstances … but I would not consider it as a mainstream option.

All these issues are best discussed, though, with Judith. I am sure she will be of some help to you - more, I am sure, than I am likely to be.