Combined Amino-Acid and Glucose Peritoneal Dialysis Solution for ...

Vande Walle et al.229Soon after the introduction of Nutrineal, thosetheoretical considerations were already documentedin clinical practice. Indeed, in almost all of the studieson the use of intraperitoneal AAs, a significantincrease in serum levels of urea were reported, suggestingunsatisfactory utilization of the infused AAs(11,12). Moreover, it is well known that, without anenergy source, nitrogen will not be effectively incorporatedinto proteins.In parenteral nutrition, the combined infusion ofnon protein calories and AAs has been a key factorin ensuring the optimal utilization of the AAs. Totalparenteral nutrition (TPN) solutions with a ratio of150:1 (non protein calories to nitrogen) are consideredappropriate for most patients to incorporate deliveredAAs into new proteins. A mixture of Nutrinealand Dianeal simultaneously achieves three conditionsfavorable for protein synthesis: hyperinsulinemia,hyperaminoacidemia, and an adequate ratio of nonprotein calories to nitrogen (absorbed glucose toAAs).These considerations are of even more importancein intensive care units, where most patients are catabolic,lack enteral nutrition, and require ultrafiltrationfor every parenteral milliliter administered. The useof combined glucose–AA solutions in a peritoneumwith hyperemic dilated vessels will result in significantperitoneal resorption. That resorption may meeta significant percentage of the patient’s nutritionalneeds (AAs and glucose), limiting the need for intravenousadministration of TPN. Limiting intravenousfluid administration helps to eliminate the need forultrafiltration by dialysis.In children in intensive care, who are often alreadyvery sensitive, an AA-containing mixture may helpto control glycemia, subsequently reducing the needfor insulin. Our data demonstrate that the calculatedpercentage reabsorption of glucose and AAs is highand that plasma AA levels remain stable. The reabsorptiondata are comparable with data reported byCanepa et al. and Qamar et al. (13–17).Adequate protein and energy intake are essentialto the maintenance of nitrogen balance and the preventionof malnutrition in intensive care. Treatmentwith oral calorie and protein supplements is oftenimpossible, but intravenous administration of TPN isoften limited by the excessive fluid load imposed on apatient in anuria by the need to reach a given nutritionaltarget. The use of AA-based dialysis fluid combinedwith glucose may provide opportunities to compensatefor dialytic losses of protein and AAs and tosupplement inadequate dietary protein intake, withsubsequent improvement in nutritional status, becauseof the resulting anabolic benefit and limitation of unnecessaryAA metabolism.ConclusionsAlthough our data do not demonstrate a potential influenceon final outcome, they demonstrate the feasibilityand safety of using combined AA–glucosesolution, with a calculated resorption that lends nutritionalsupport.References1 Strazdins V, Watson AR, Harvey AR. Renal replacementtherapy for acute renal failure in children: Europeanguidelines. Pediatr Nephrol 2004; 19:199–207.2 Schroder CH and the European Paediatric PeritonealDialysis Working Group. The choice of dialysis solutionsin pediatric chronic peritoneal dialysis: guidelinesby an ad hoc European committee. Perit Dial Int2001; 21:568–74.3 Kopple JD, Bernard D, Messana J, et al. Treatment ofmalnourished CAPD patients with an amino acidbased dialysate. Kidney Int 1995; 47:1148–57.4 Coleman JE, Watson AR, Rance CH, Moore E. Gastrostomybuttons for nutritional support on chronicdialysis. Nephrol Dial Transplant 1998; 13:2041–6.5 Flynn JT, Kershaw DB, Smoyer WE, Brophy PD,McBryde KD, Bunchman TE. Peritoneal dialysis formanagement of pediatric acute renal failure. PeritDial Int 2001; 21:390–4.6 Vande Walle J, Raes A, Castillo D, Lutz–Dettinger N,Dejaegher A. New perspectives for PD in acute renalfailure related to new catheter techniques and introductionof APD. Adv Perit Dial 1997; 13:190–4.7 Vande Walle J, Raes A, Castillo D, Lutz–Dettinger N,Dejaegher A. Advantages of HCO 3solution with lowsodium concentration over standard lactate solutionsfor acute peritoneal dialysis. Adv Perit Dial 1997; 13:179–82.8 Goldstein SL. Overview of pediatric renal replacementtherapy in acute renal failure. Artif Organs2003; 27:781–5.9 Maxvold NJ, Smoyer WE, Gardner JJ, BunchmanTE. Management of acute renal failure in the pediatricpatient: hemofiltration versus hemodialysis. Am JKidney Dis 1997; 30(Suppl 4):S84–8.10 Symons JM, Brophy PD, Gregory MJ, et al. Continuousrenal replacement therapy in children up to10 kg. Am J Kidney Dis 2003; 41:984–9.