There are many measures to protect the peritoneum, however, each only to contribute somewhat to a prologed function.

Avoidance of peritonitis, avoidance of high glucose concentrations, use of biocompatible dialysis solution i.e. bicarbonate buffered, low in glucose degradation endproducts etc. are some.

Input from Friedrich is correct. There are details in the elements cited. It all started with a proper selection of patient to be treated with PD to reduce or avoid potential complications arising from social ( home environment , facilities, suitability and commitment of assistant in case of assisted PD) ,technical (available of highly dedicated ,reliable and effective PD catheter insertion services provided by competent providers to ensure high primary catheter success and longevity of function to avoid leaks,exit site and tunnel infection,catheter malposition or malfunction ), clinical (effective post catheter insertion management including post-op nursing management, catheter break-in policy, catheter care education and protocol,effective PD training module or program and retraining program at intervals or as indicated by adverse events,highly trained and dedicated nursing and clinical team to provide prompt treatment of peritonitis, availability of excellent laboratory support to enable rapid and accurate diagnosis of infective peritonitis yielding positive culture -hence low culture negative- to enable prompt and effective treatment, clear and effective protocol with regard to choice,dose and duration of antimicrobials and the timing of catheter removal if indicated, avoiding factors which lead to rapid loss of residual renal function including avoidance of exposure to nephrotoxins and judicious use of loop diuretics to optimise urine output ) , effective support program to deal with burnout syndrome and ensure persistence of adherence to low dietary salt , glucose and fluid intake which will avoid prolonged or repeated needs for increased ultrafiltration leading to exposures to dialysates with higher glucose concentrations . Such a program which include a regular home visit program, re education, motivational program , group outings etc may provide additional strengths to sustain health and avoid PD related complications. Use of more biocompatible PD solutions and better , easier connectology will add to factors which will reduce complications that finally result in ultrafiltration or peritoneal failure including the dreaded and fatal encapsulating peritoneal sclerosis or fibrosis.

I can recommend a recent article: Fernandez-Reyes MJ; Ossorio M; Bajo MA et al. Peritoneal dialysis international 2012;32(6):636-44. The influence of initial peritoneal transport characteristics, inflammation, and high glucose exposure on prognosis for peritoneal membrane function.

They analyze factors as:

- Initial fast transport characteristics of patient at starting PD

- Peritonitis

- high exposure to glucose

In patients using new liquids with bicarbonate buffer, neutral pH and low GDP (and also Icodextrin), membrane prognosis and technique survival were independent of baseline transport characteristics.

So fast transport and low ultrafiltration rates seems to be reversible conditions, provided that peritonitis and high glucose exposure are avoided during the early dialysis period.

They suggest that first year on PD is a main determining factor for the membrane's future.

A high peritoneal infection rate on the first PD year are related with more infections and a bad survival of technique.

After 5 years on dialysis, permeability frequently increases, and UF decreases.

Icodextrin is associated with peritoneal protection

There is some experimental evidence to support the idea that RAS-blockade can preserve the peritoneum (e.g Miyata JASN 2002; 13:2478, Perez-Martinez PLoS One 2012; 7:e36268). There is also some clinical evidence (Kolesnyk PDI 2007; 27:446, Oseto PDI 2006; 26Suppl2:9, Jing Nephrology 2010; 15:27). Since PD patients rarely suffer from hyperkalemia, the treatment has relatively few side effects.

Prevent infection and ensuing peritonitis and exposure of peritoneal membrane to higher concentrations of glucose.

I dissent somewhat and think that a protective effect of biocompatible solutions has not been proven. Studies in this respect differ and those that claim a beneficial effect of the newer biocompatible solutions all suffer from flaws. i think the singlemost important factor is prevention of peritonitis.

I would agree with agree with Johan Rosman, the biocompatible solutions have not proven to protect the membrane in long term. Other factors for preserving the membrane are preventing infection, avoiding high glucose fluids and preserving residual renal function as long as possible.

The factors for preserving the peritoneal membrane are, avoiding high glucose fluids prevening infections and preserving residual renal function as long as possible.

There is also some experimental and cinical evidence to support the idea that RAS-blockade can preserve the peritoneum

I agree with most of colleagues that prevention of peritonitis and Icodextrin solution as a main step and otherwise RAS blocker may be useful.

I agree with Taner Camsari

Recently read three journal articles that may be of interest to you. One is regarding the early loss of osmotic gradient relating to losses of peritoneal protein resulting in peritonitis / "systemic infection". Mitigating peritoneal membrane characteristics in modern peritoneal dialysis therapy- International Society of Nephrology (2006) 70, S76-S83. Second article, Insulin resistance and lower plasma adiponectin increase malignancy risk in nondiabetic continuous ambulatory peritoneal dialysis patients - published in Metabolism Clinical and Experimental (2011) 60, 121-126; proposes it is the, "persistent metabolic derangements," that may alter DNA repair. I found this fascinating, as I could not find other articles approaching the subject from a DNA angle. Last article, Peritoneal accumulation of age and peritoneal membrane permeability (2000) - published in Peritoneal Dialysis International, vol. 20, pp.452-460 suggests that it "is the "thickening" of capillary and submesothelial basement membranes," that accounts for less ultrafiltration (volume). If you would like the full references, I can provide them.

Hi Jennifer

It would be very helpful to have full references, so that I can read and completely understand your explanations. Thank you. Latha

References are below and the articles are attached for your convenience.

Park, J., Yoo, T., Chang, T., Lee, D., Lee, J., Lee, J., ... Ryu, D. (2011). Insulin resistance and lower plasma adiponectin increase malignancy risk in nondiabetic continuous ambulatory peritoneal dialysis patients. Metabolism Clinical and Experimental, (60), 121-126. doi: 10.1016/j.metbol.2010.02.006

Park, M., Lee, H., Chu, W., Yang, D., & Hwang, S. (2000). Peritoneal accumulation of age and peritoneal membrane permeability. Peritoneal Dialysis International, 20(4), 452-460.

Davies, S. J. (2006). Mitigating peritoneal membrane characteristics in modern peritoneal dialysis therapy. Kidney International, 70, S76-S83. doi: 10.1038/sj.ki.5001920

Thank you Jennifer

Thank you everybody for your contributions!

You are most welcome! I would love to know of your outcomes/ findings

The first step to preserve peritoneum in peritoneal dialysis is to avoid the incidence of peritonitis , this target can be attained 1) by a very careful training in connecting the dialysis system ( bags or automatic device ) , letting the patient go home in self-dialysis only when evaluated to be really sufficiently skilled. 2) teaching the patent the correct care of the exit site. The achieving of these targets bases fundamentally in the availability of accurately trained nurses , which have to be fully dedicated to peritoneal dialysis. The second step is to carefully limit the use of high glucose concentrations and to choice solutions based on bicarbonate - lactate. The possibility to limit the use of high glucose concentrations is strictly linked to the education of patient to avoid the use of excessive input of fluids and salty foods , this particularly in anuric patients or patients having less than 500 ml/day of urine .The resort to high glucose concentrations allows to decrease the fluid retention but it causes hyperglycemia , this resulting in thirsty with a consequent stimulus to increase water input. The use of icodextrin should be limited to the cases of high transporter with loss of or severe reduction of ultrafiltration : the researches on icodextrin biocompatibility have shown important damages to the peritoneal mesothelium due to icodextrin. The absolute need to use icodextrin each day even with two exchanges as proposed should suggest a very carefully and frequent observations of the peritoneum conditions , and eventually to shift the patent to hemodialysis , if possible, to avoid the possible appearance of an Encapsulating Peritoneal Sclerosis, or if the shift to HD impossible, to consider the suitability to start a medical treatment of the peritoneal conditions.

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These are very useful and practical informations . I totally agree and appreciate the opinion of Giancarlo Ruggieri.

Thank you Giancairo for the rich information you provided!