The optimization of continuous ambulatory peritoneal dialysis.

medication, but he required medication thereafter. He had no episodes of peritonitis and gained 5 kg. However, his urine output gradually declined despite large doses of furosemide. At the beginning of the third year, despite an increasing dose and number of antihypertensive medications, he complained of progressive fatigue, anorexia, and ankle swelling. He was hypertensive (blood pressure, 180/100 mm Hg), and his urine output was negligible. His serum albumin had decreased to 3.0 g/dl, the blood urea had decreased to 12 mm/liter, and the serum creatinine was 1100 mm/liter (12.5 mg/dl). On repeat assessment, his clearances were KT/V, 1.55 (1.45 peritoneal and 0.1 renal), and WCC, 48 liters (42 liters peritoneal and 6 liters renal). His NPNA had decreased to 0.65 g/kg/day. His weight had increased by 3 kg and he was edematous. His CAPD prescription was increased to 2.5 liters 4 times daily, after which his KT/V increased to 1.75 (1.65 peritoneal CASE PRESENTATION and 0.1 renal) and his weekly creatinine clearance to 58 liters A 55-year-old Greek Canadian, a restaurant owner, devel(52 liters peritoneal and 6 liters renal). After 3 months, his oped end-stage renal disease secondary to proliferative glomerNPNA remained low at 0.60 g/kg/day. His uremic symptoms ulonephritis of 3 years’ duration. Because he was fatigued, had and hypertension became worse, and he could not achieve a poor appetite with occasional morning nausea, and could not his target weight despite three hypertonic exchanges per day. sleep well, he began continuous ambulatory peritoneal dialysis Average ultrafiltration with 2.5% glucose at four hours was 25 (CAPD) 5 years ago through a surgically implanted Toronto ml, and with 4.25% glucose was 180 ml. Dialysate protein losses Western peritoneal catheter. At that time his weight was 71 kg were 12 g/day and his serum albumin fell to 2.8 g/dl. Because his and body surface area 1.76 m. He had substantial residual renal condition was getting worse, he was transferred to automated function, with a 24-hour creatinine clearance of 9.0 ml/min, a peritoneal dialysis (APD) with 4 3 2.8 liter exchange over nine urea clearance of 4.3 ml/min, and a urine volume of 1100 ml/ hours each night and a three-hour 2.5 liter exchange each day. Initial biochemical investigations showed a serum albumin evening. of 3.5 g/dl (Bromcresol green method); hemoglobin, 10.1 g/dl; On this regimen, his KT/V was 2.1 and creatinine clearance and hematocrit, 33%. He was started on a “standard” CAPD 60 liters/week. Furthermore, his net ultrafiltration increased, regimen of 2-liter exchanges four times daily. At the end of he attained his target weight and, after six months, his NPNA the second week, clearance measurements with the Adequestt had increased to 0.8 g/kg/day, but his serum albumin remained program were as follows: D/P creatinine, 0.85; KT/V (urea), low at 3.1 g/dl. Clinically he felt better. He was able to sleep 2.57 (1.07 renal and 1.5 peritoneal); weekly creatinine clearance well and he resumed working part-time work in his restaurant. (WCC) corrected for 1.73 m BSA, 113 liters (65 liters renal Three months later he received a successful transplant with a and 48 liters peritoneal); and normalized equivalent of protein cadaveric kidney. nitrogen appearance (NPNA), 0.8 g/kg/day. The blood urea was 20 mm/liter; serum creatinine, 416 mm/liter (4.7 mg/dl); and blood pressure, 150/80 mm Hg. DISCUSSION For the next two years he did well on CAPD. He felt well and continued working in his restaurant. His appetite was good, Dr. Dimitrios G. Oreopoulos (Director, Peritoneal he slept well, and he had an active sexual life. For the first Dialysis Program, The Toronto Hospital—Western Diviyear, his blood pressure was normal without antihypertensive sion, and Professor of Medicine, University of Toronto, Toronto, Ontario, Canada): A Nephrology Forum given in 1983 by Dr. Stephen Vas [1] was devoted to the diagPresentation of this Forum is made possible by grants from Merck & Company, Incorporated; Astra Pharmaceuticals; Hoechst Marion nosis and treatment of peritonitis—at that time, the main Roussel, Incorporated; Dialysis Clinic, Incorporated; and R & D Labocomplication of CAPD. Since then, the introduction of ratories, Incorporated. several disconnect systems has decreased the rate of peri