**8. Diagnosis of peritoneal fibrosis**


### **9. Conventional PD fluids**

First generation Fluids: contain 35–40 mM lactate buffer with an acidic pH of 5.5. The low pH will be aggravating the detrimental effects of the high lactate on peritoneal mesothelium. During heat sterilization and storage, more of (GDPs) (e.g., formaldehyde, acetaldehyde, glyoxal, methylglyoxal, 5-hydroxymethylfurfural (5-HMF), 3-Deoxyglucosone (3-DG) and 3,4-dideoxyglucosone3-ene (3,4-DGE)) are formed, leading to membrane damage (shown in **Figure 7**).

Second generation Fluids: The buffers (such as lactate ± bicarbonate) are in separate chamber and are kept in very low pH to prevent formation of GDPs. Prior to use, they are mixed to a pH of 7–7.5 and are administered. They are detailed below.

Icodextrin: is an osmotic agent (Mol.wt-16,800 Da) derived from the starch, used in long night dwell with very low GDP, since they are absorbed into the

#### **Figure 7.**

*Potential beneficial effects of newer peritoneal dialysis solutions [16]. (Courtesy: Garcia nature reviews 2012). Abbreviations: RRF—residual renal function; LV—left ventricle; and AGE—advanced glycosylated end products).*

circulation, with no sodium sieving. It has an UF capacity comparable to 4.25% dextrose fluid. Despite this, acidic PD fluid has been associated with increased local and systemic inflammation with increased permeability and IL-6. Even though this reaction is reaction, long term exposure may irreversibly change peritoneal morphology. The ISPD guidelines recommends use of icodextrin in high transporters for better volume control.

Amino acid solutions: A bag of 1.1% 21 amino acid PD fluid used in one exchange a day provide 22gm of amino acids (2/3rd essential & 1/3rd nonessential) which is 25% of daily requirement and generate an UF equal to 2 L 1.5% dextrose. It has an acidic pH of 6.6 with very low GDPs and low VEGF. For optimized nutrition of malnourished patients and to prevent increased serum nitrogen levels and metabolic acidosis, they should be applied at a ratio of 1:4 with glucose-containing PD fluids [17]. Nutrineal in one exchange with icodextrin (Extraneal) and Physioneal (Baxter) for other exchange as a regimen (NEPP regimen) has shown to preserve mesothelial integrity but with increased VEGF.
