A 66-year-old male at the beginning of PD as a treatment for long-standing TCRF due to severe hypertension and hyperuricemia.
At the beginning of the treatment, the patient had the following profile regarding his acidosis status.
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Since her general condition was good and she maintained residual diuresis (2000 ml/d), it was decided to start the purifying treatment with three daily exchanges of 2l, (4 l to 1’26% recambium at night).
Two months after PD, the patient was included in a multicenter study evaluating dialysis fluid with bicarbonate-only®.
The dialysis characteristics of the patient at the beginning of this study are shown in Table 2.
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Shortly after using this solution, the patient reports some discomfort, such as:
• Increase in thirst sensation and mild abdominal discomfort during the first days.
• Manifestation that occasionally and at the end of drainage feels pain, which is attributed to the position of the catheter.
• Appearance of fibrin clots in the drained fluid.
No importance is given to these manifestations that are attributed, on the one hand, to the non-compliance of the diet by the patient, since he had high sodium (141mEq/L), and on the other hand, to the discomfort that occasionally causes the treatment.
To prevent clot formation, 15 mg of heparin sodium was administered into the dialysis fluid.
These symptoms disappeared and the patient's general condition was satisfactory.
The study lasted three months; at the end of the study, the patient's analytical values and dialysis characteristics are shown in Table 3.
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Usual treatment is restarted with 4 l of glucose 1’5%, normal Ca and 2 l of solution with Icodextrin for nocturnal replacement.
After these three months with the bicarbonate solution, the patient's clinical situation was good (although he had manifested some discomfort) and the analytical values were acceptable, but it was noted that in a short period of time the patient had been transported.
Five months later, it was decided to restart the treatment with bicarbonate.
The patient wanted to reuse the new solution because it seemed to her that it was better" (less asthenia and better mood).
Although Kt/V was slightly lower than recommended values, maintaining diuresis, good creatinine clearance and good general condition, it was decided not to increase the dialysis dose.
HCO3 values were not considered important.
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In the control performed three months after restarting treatment with bicarbonate solution, the results are shown in Table 5.
The patient had very good general condition, even wished to leave vacation so it was decided to continue with the same treatment regimen
1.
Three months later, the patient continued feeling well and decided to leave vacation.
However, his diuresis and Kt/V have decreased and he is hypertensive.
A higher dose of hypotensive drugs was prescribed and it was decided to increase peritoneal flow to four replacements/day: 6 l to 1.36% and Icodextrine 2 l, in the night shift.
One month later, she came to the hospital urgently, for presenting an episode of turbid liquid with negative culture and abdominal pain, which is believed to be the result of a peritoneal irritation caused by excessive UF of Icodext (3
Antibiotics are given and the volume of Icodextrin infusion is reduced to 1’5 l.
The situation is favorable.
Fifteen days later, the patient came to the hospital with a significant change in general condition without signs of infection, highlighting:
• Sudden decrease in hematocrit
Hypercholesterolaemia
• Hyperhydration (increased weight with the presence of malignant oedema)
• Dyspnoea
• Significant spatial-time disorientation
• Increase in diaphragms on chest X-ray, with reduction in lung fields
The analytical results shown in Table 6 show a METABOLIC ALCALOSIS.
1.
Establishing this situation, the infusion of liquid with bicarbonate is suspended and the PD starts with lactated liquid PD1, increasing the frequency of replacements to 10 l/day.
For the treatment it is decided to use a cycling run, for which the patient's wife is instructed, since the patient's state of consciousness does not allow optimization of cycling.
One week after starting the new treatment with hospital cycling, the patient's condition, as well as acidosis. With the support of his wife, he is able to start peritoneal dialysis (PD) at home.
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One month after starting peritoneal dialysis with cycling, the analytical values and blood pressure figures were normalized, and the patient's general condition was good.
The most notable parameters are shown in Table 8.
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Currently (30 months after starting PD), the patient has not presented any complication, no new episode of turbid liquid and its general condition is correct, with a tendency to weight gain without the presence of edema.
