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J Am Soc Nephrol 13:2554-2559, 2002
© 2002 American Society of Nephrology

Effect of Increased Dialysate Volume on Peritoneal Surface Area among Peritoneal Dialysis Patients

Avry Chagnac*, Pearl Herskovitz{dagger}, Yaacov Ori*, Tali Weinstein*, Judith Hirsh*, Miriam Katz{dagger} and Uzi Gafter*

Departments of *Nephrology and {dagger}Radiology, Rabin Medical Center-Golda Campus, Petah Tikva, Tel Aviv University Medical School, Tel Aviv, Israel.

Correspondence to Dr. Avry Chagnac, Department of Nephrology, Rabin Medical Center-Golda Campus, 7 Keren Kayemet St., Petah Tikva 49372, Israel. Phone: 972-3-9372224; Fax: 972-3-9372311;


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
ABSTRACT. Large dialysate volumes are often required to increase solute clearance for peritoneal dialysis patients. The resulting increase in solute clearance might be attributable to an increased plasma-to-dialysate concentration gradient and/or to an increased effective peritoneal surface area. One of the factors affecting the latter is the peritoneal surface area in contact with dialysate (PSA-CD). The aim of this study was to estimate the change in PSA-CD after a 50% increase in the instilled dialysate volume for patients undergoing peritoneal dialysis. PSA-CD was estimated by using a method applying stereologic techniques to computed tomographic (CT) scans of the peritoneal space. The peritoneal cavity of 10 peritoneal dialysis patients was filled with a solution containing dialysate, half-isotonic saline solution, and contrast medium. Peritoneal function tests and CT scanning of the abdomen were performed twice for each patient (with an interval of 1 wk), after instillation of a 2- or 3-L solution. Scanning of thin helical CT sections was performed, and 36 random sections of the abdomen were obtained after reconstruction. A grid was superimposed on the sections. The surface area was estimated by using stereologic methods. After instillation of the 2-L solution, the volume of the peritoneal solution at the time of CT scanning was 2.32 ± 0.05 L. The PSA-CD was 0.57 ± 0.03 m2, ranging from 0.41 to 0.76 m2. The use of the 3-L solution increased the peritoneal volume by 46 ± 2%. PSA-CD increased by 18 ± 2.3% to 0.67 ± 0.04 m2 (range, 0.49 to 0.84 m2; P < 0.01). Creatinine mass transfer increased from 112 ± 10 mg to 142 ± 11 mg (P < 0.0001). The slope of the change of the plasma-to-dialysate creatinine concentration gradient with time decreased from -2.26 ± 0.23 x 10-2 to -1.97 ± 0.16 x 10-2 (P = 0.01). KBD-0 (permeability-surface area product or mass area transfer coefficient at time 0 of the dwell) increased from 10.6 ± 0.7 to 13.6 ± 1.2 ml/min (P < 0.02). These data demonstrate that increasing the instilled dialysate volume by 50% for peritoneal dialysis patients results in significant increases in the PSA-CD and KBD. E-mail: uzig@clalit.org.il


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Large dialysate volumes are often required to increase solute clearance for patients undergoing peritoneal dialysis (1,2). Theoretically, the increased solute clearance obtained with the use of large volumes (2–4) could be attributable either to an increased blood/dialysate solute concentration gradient or to an increase in the effective peritoneal surface area. Experimental studies have demonstrated that increasing the instilled dialysate volume from 2 to 3 L results in inconsistent changes in small-solute mass transfer area coefficients among peritoneal dialysis patients (3,4). A 250% increase in dialysate fill volume did not affect the diffusive mass transfer coefficients for urea and glucose in rats (5). The mass transfer area coefficient, or permeability-surface area product, is the solute clearance via diffusion per unit of concentration gradient (KBD). KBD provides information on the effective peritoneal surface area, i.e., the vascular peritoneal surface area (6,7) times the effective peritoneal solute permeability. The vascular peritoneal surface area is itself dependent on the peritoneal surface area in contact with dialysate (PSA-CD) and on the density of the pores of the perfused capillaries.

Studies in rodents by Flessner and co-workers (8,9) demonstrated that the PSA-CD during dialysis exchange was significantly less than that of the anatomic peritoneum and that this contact area could be increased with animal agitation or administration of surfactant (9). In a subsequent study, those authors demonstrated that increasing the peritoneal surface contact area with a surfactant resulted in increased peritoneal transport (10). A study performed with human subjects in our laboratory (11) confirmed the findings of Flessner’s group in rodents, demonstrating that the PSA-CD during a 2-L dialysis exchange was approximately 0.55 m2. This value is lower than the estimates of the anatomic peritoneal surface area obtained from post mortem studies in human subjects (12–14). To estimate the PSA-CD, we have developed a method applying stereologic techniques to computed tomographic (CT) imaging of the peritoneal membrane (11). CT peritoneography allows visualization of the peritoneal space (15,16). The boundaries of the peritoneal space represent the mesothelial aspect of the peritoneal membrane in contact with dialysate. The surface area of these boundaries is the PSA-CD. Stereologic techniques enable quantitative estimation of three-dimensional structures from two-dimensional sections, irrespective of their shape (17). Surfaces in three dimensions are observed as lines in two dimensions. Therefore, a method of quantifying the lines in two-dimensional sections would permit estimation of the corresponding surface area. We have validated the application of these methods to CT imaging (11).

Because the peritoneum is not used at its maximal capacity during 2-L dialysis exchanges (8–11), we hypothesized that increasing the dialysate fill volume from 2 to 3 L would result in an increase in the peritoneal contact area. In addition, we performed solute transport studies, in an attempt to clarify the relationships between peritoneal volume, surface area, and diffusion capacity.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Patients and Dialysis
Ten peritoneal dialysis patients participated in the study. They were 55 ± 6 yr of age (range, 38 to 78 yr). Three patients were female and seven were male. All except two had been treated with peritoneal dialysis for >1 yr (median, 3.2 yr; range, 0.8 to 4.7 yr). Five patients were undergoing chronic ambulatory peritoneal dialysis, and five were undergoing automated peritoneal dialysis. All patients were treated with a large dialysate volume (>=2.5 L). The height and weight of the patients were 1.67 ± 0.04 m and 74 ± 3 kg, respectively. Their body surface area was 1.82 ± 0.04 m2. Studies were performed in the morning, after drainage of the fluid from the peritoneal cavity. Patients were studied twice (with an interval of 1 wk), after instillation of a 2-L solution (first study) or a 3-L solution (second study). Each 1 L of solution contained 790 ml of 1.36% Dianeal glucose (Teva Medical, Ashdod, Israel), 160 ml of 0.45% NaCl, and 50 ml of contrast material (Ultravist 300, containing 623 mg/ml iopromide; Schering, Berlin, Germany). 2.5 µCi of radiolabeled serum 125I-albumin (RISA) (Seralb-125; CIS Biointernational, France) was added for estimation of the peritoneal dialysate volume (18). This addition was performed after priming of the bag with 1 ml of a salt-free 20% albumin solution, to minimize adhesion of the radiolabeled albumin to the surfaces of the plastic material. Peritoneal function studies were followed by CT imaging of the peritoneal space.

Study 1
The 2-L solution was infused through an infusion set. The patients rolled from side to side, and 200 ml were drained out and mixed. Ten milliliters were sampled for radioactivity counting and measurement of creatinine levels (time 0), and the remainder of the solution was instilled back into the peritoneal cavity. Blood was sampled at 0, 90, and 180 min, and dialysate was sampled eight times, at 4, 30, 60, 90, 120, 150, 180, and 205 min. The last sample was drawn just before CT scanning. Series of helical scans of the patient were then obtained, from the level of the diaphragm to the level of the symphysis pubis (Helicat II CT scanner; Marconi, Haifa, Israel). Scan parameters were as follows: for thin patients, slice width, 2.7 mm; slice interval, 1.4 mm (50% overlap); pitch, 1.5; for other patients, slice width, 3.2 mm; slice interval, 1.6 mm (50% overlap); pitch, 1.0. Image parameters were as follows: window center, 0; window width, 350. Dialysate and blood samples were withdrawn before and after each series. After scanning, the images were reconstructed and sets of 36 systematic, isotropic, uniform, random sections of the whole peritoneum were obtained.

Study 2
The same steps were followed as in study 1, using 3 L of solution.

Data Analysis
Estimation of the Intraperitoneal Dialysate Volume.
The intraperitoneal dialysate volume was calculated by using RISA as a volume marker, with a correction applied for its elimination from the peritoneal cavity (18), based on the timed dialysate samples obtained during the peritoneal function tests and CT scanning. The repeated sampling was used to estimate the changes in intraperitoneal fluid volume during the peritoneal function tests and CT scanning (which lasted approximately 40 min). The dialysate volume during CT scanning was calculated as the mean of the four measurements. The peritoneal space volume at time t of each sampling [VD(t)] was calculated as follows:Go



(1)

where VA(t) is the apparent volume of dialysate calculated from the dilution of RISA at time t and CF(t) is a correction factor at time t.Go



(2)

where VA(T) is the apparent volume of dialysate estimated from the dilution of RISA at the end of the dwell time (i.e., at time T), Vout is the volume of dialysate drained after termination of the dwell, and Vres is the residual dialysate volume after drainage, calculated from the equation



(3)

where RISADIAL-T is the concentration of RISA at the end of the dwell time, Vrinse in is 1 L of fresh dialysate (1.36%, without RISA), and RISADIAL-rinse out is the concentration of RISA in the drained rinsing fluid.

Stereologic Measurements.
A transparent counting grid formed of test lines (multipurpose test system) (17) was placed over the CT images. The test line length, after correction for the scale, was 13.9 mm for patients 1 to 3, 13.5 mm for patients 4 and 5, and 13.0 mm for patients 6 to 10. The PSA-CD was estimated by counting the number of intersections of the test lines with the boundaries of the peritoneal fluid and the number of lines passing over the reference volume. The intraperitoneal dialysate volume was used as the reference volume. The ratio estimate of the PSA-CD (SV-PSA-CD) was generated by using the relationship SV-PSA-CD (m2/m3) = 2I/L, where I is the number of intersections with the surface of interest and L is the total length of test lines within the reference volume, after correction for the scale of the print. The ratio estimate of the PSA-CD was converted to an absolute value (PSA-CD) by multiplication by the peritoneal volume (Vperit), as follows: PSA-CD (m2) = SV-PSA-CD (m2/m3) x Vperit (m3).

Peritoneal Function Tests.
Dialysate creatinine concentrations were corrected for the effects of the glucose concentration by using the formula CrDIAL = (1.021 x CrDIAL-meas) - (0.00008 x GlucDIAL) - 0.065, where CrDIAL is the corrected dialysate creatinine concentration (mg/dl), CrDIAL-meas is the measured dialysate creatinine concentration (mg/dl), and GlucDIAL is the dialysate glucose concentration (mg/dl). The plasma creatinine concentration was calculated as the mean of the plasma creatinine concentrations (mg/dl) measured at 0, 90, and 180 min.

KBD, i.e., the rate of creatinine transfer from plasma to dialysate via diffusion per unit of plasma-to-dialysate concentration gradient, is not constant during the dialysis dwell. It varies with time, being higher during the initial phase of the dwell (19–21) and decreasing exponentially with time (20). In this study, KBD was calculated for time 0 of the dwell (KBD-0) from the regression equation of log KBD with timeGo



(4)

Where a is the regression coefficient. Equation 4 indicates that, at t = 0, log KBD equals the constant of the regression equation (log KBD-0 = constant). Therefore, KBD-0 = econstant.

KBD(t) was determined during seven time periods, the first starting at 4 min and the last ending at 205 min; the sampling times are listed above. Each period was defined by the times of two consecutive samplings of dialysate. The time t for each KBD determination was defined as the average time of each time period. KBD(t) was calculated as the rate of creatinine mass transfer from plasma to the peritoneal solution via diffusion (Crdiff) divided by the mean concentration gradient between plasma and dialysate during period n (CrP-D gradient).Go



(5)

CrP-D gradient was calculated as CrP-D gradient = CrPL (mg/ml) - CrDIAL (mg/ml), where CrPL is the plasma creatinine concentration and CrDIAL is the mean of the dialysate creatinine concentrations at the beginning and the end of period n.

The creatinine mass cleared via diffusion (Crdiff) was calculated for each period as Crdiff = Crtotal - Crnet uf + Crabs, where Crtotal is the creatinine mass transferred from plasma to dialysate during period n, Crnet uf is the creatinine mass transferred from blood to the peritoneal cavity by convection via net ultrafiltration during period n, and Crabs is the creatinine mass transferred from plasma to the peritoneal cavity via diffusion and eliminated from the peritoneal cavity via tissue absorption and lymphatic vessels during period n.

Crtotal was calculated as Crtotal = [CrDIAL-final (mg/ml) x VDIAL-final (ml)] - [CrDIAL-initial (mg/ml) x VDIAL-initial (ml)], where CrDIAL is the creatinine concentration in the dialysate and VDIAL is the dialysate volume, obtained from Equation 1. Initial and final refer to the values at the beginning and the end of period n, respectively.

Crnet uf was calculated as Crnet uf = [VDIAL-final (ml) - VDIAL-initial (ml)] x CrPL (mg/ml) x SievCR, where CrPL is the plasma creatinine concentration and SievCR is the sieving coefficient for creatinine. An assumed value of 0.55 was used for SievCR; this value is the mean of the minimal and maximal values noted in animal studies for sieving coefficients for small solutes (range, 0.3 to 0.8) (22).

Crabs was calculated as Crabs = CrDIAL (mg/ml) x Vabs-n (ml), where CrDIAL is the mean creatinine concentration in the dialysate during period n. Vabs-n is the volume of dialysate absorbed into peritoneal tissues and lymphatic vessels during period n. Vabs-n was calculated asGo



(6)

RISADIAL-initial and RISADIAL-final refer to the dialysate concentrations of RISA at the beginning and the end of period n, respectively. RISADIAL-mean refers to the mean concentration of RISA during period n.

The creatinine mass transfer was calculated as the sum of Crtotal for all n periods. The change in CrP-D gradient with time was estimated by linear regression analysis of CrP-D gradient versus time during the n periods and was expressed as the slope of the regression line.

Statistical Analyses
Data are expressed as mean ± SEM. The significance of differences between the 2-L and 3-L groups was evaluated by using a two-tailed paired t test.

Informed consent was obtained from all participants. The study was approved by the Rabin Medical Center Ethics Committee.


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Peritoneal Membrane Surface Area
After instillation of the 2-L solution, the volume of peritoneal solution at the time of CT scanning was 2.32 ± 0.05 L. SV-PSA-CD was 2.43 ± 0.12 m2/m3. PSA-CD was 0.57 ± 0.03 m2, ranging from 0.41 to 0.76 m2.

Use of the 3-L solution increased the peritoneal volume by 46 ± 2%, to 3.38 ± 0.06 L (P < 0.0001). SV-PSA-CD decreased by 19 ± 3%, to 1.97 ± 0.10 m2/m3 (P < 0.001). PSA-CD increased by 18 ± 2%, to 0.67 ± 0.04 m2 (range, 0.49 to 0.84 m2; P < 0.001) (Figure 1).



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  		Figure 1. Peritoneal surface area in contact with dialysate (PSA-CD) for the 2-L and 3-L groups.

 
Peritoneal Function Tests
Creatinine mass transfer was 112 ± 10 mg with the 2-L solution and increased to 142 ± 11 mg with the 3-L solution (P < 0.0001). This represents the solute mass transferred from blood to the peritoneal space via diffusion and convection, not including the absorbed solute mass. The slope of the change in the plasma-to-dialysate creatinine concentration gradient with time was -2.26 ± 0.23 x 10-2 with the 2-L solution and decreased to -1.97 ± 0.16 x 10-2 with the 3-L solution (P = 0.01). This decrease is attributable to an enlarged distribution volume for creatinine with the 3-L solution, resulting in a wider plasma-to-dialysate creatinine concentration gradient during the dwell time. KBD-0 was 10.6 ± 0.7 ml/min with the 2-L solution and increased to 13.6 ± 1.2 ml/min with the 3-L solution (P < 0.02), reflecting the increased diffusing capacity of the peritoneal membrane.


   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
This study demonstrated that increasing the peritoneal dialysate volume by 46% resulted in an 18% increase in PSA-CD. PSA-CD was estimated by using a method previously validated by our group (11). The present estimate of PSA-CD with a 2-L solution (0.57 m2) confirmed the findings of our initial study (0.55 m2) (11). The larger number of patients studied revealed large interindividual variations (0.41 to 0.76 m2).

PSA-CD was determined as SV times the actual dialysate volume. The latter variable was also used for the estimation of KBD-0. The actual dialysate volume was assessed with the tracer dilution technique, using RISA as a macromolecular marker. This method assumes the disappearance of RISA to be linear during the dwell time. In fact, Zakaria and Rippe (23) demonstrated that the disappearance of RISA was faster during the first 30 min of the dwell period and then followed a nearly linear course. Those authors demonstrated that the assumption of linear disappearance led to a slight overestimation of the dialysate volume at the beginning of the dwell time (approximately 4% in rats) and this overestimation decreased with time. Therefore, the use of this method for the estimation of KBD-0 and PMSA-CD leads to minimal overestimation of these parameters.

The results of this study confirm that the PSA-CD after instillation of a 2-L peritoneal solution is smaller than the surface area of the anatomic peritoneum. The latter value was estimated in early studies to range between 1.8 and 2.1 m2 (12,13) and was determined in more recent studies to approximate 0.8 to 1 m2 (13,14). The results presented here are in accordance with rodent studies reported by Flessner et al. (8–10), which demonstrated that only approximately 25 to 40% of the peritoneal surface area was in contact with dialysate after instillation of a dialysis solution scaled to 2 to 3 L for a 70-kg human subject. Interestingly, those experimental data and the findings of our study confirm the theoretical estimations proposed in 1973 by Henderson (24), who reasoned that the functional surface area of the peritoneum must be substantially less than 1 m2. In light of these experimental studies and the difference observed between the PSA-CD with a 2-L dialysis solution and the surface area of the anatomic peritoneum (11), we hypothesized that increasing the peritoneal volume would result in a larger PSA-CD.

This study demonstrates that, after a 50% increase in the instilled dialysate volume, the peritoneal fluid volume increased by 46%. This difference is accounted for by the presence of a residual dialysate volume. PSA-CD increased by 18%, reaching 0.67 m2, which is still less than the estimated surface area of the anatomic peritoneum (12–14). This increase was associated with an increase in the small-solute KBD-0. KBD, the permeability-surface area product or mass area transfer coefficient, is the solute clearance via diffusion per unit of concentration gradient. It is not influenced by the decrease in the solute concentration gradient that occurs during dialysis (7). However, it varies with time, being higher during the initial dwell phase (19–21). Carlsson and Rippe (21) demonstrated, in a rat model, that peritoneal arteriolar vasodilation is a major factor accounting for this early increase, although the authors could not exclude a role played by the macroscopic stirring that occurs when fluid is instilled into the peritoneal cavity. In this study, the KBD values reported are those calculated at time 0 of the dwell (KBD-0).

The changes in KBD reflect changes in membrane and non-membrane factors affecting the effective surface area and the effective permeability of the peritoneal membrane. Therefore, the increase in PSA-CD associated with the increase in the instilled volume may not be the only factor accounting for the increase in KBD-0. Other factors, affecting the effective permeability, might also account for the augmented KBD-0 associated with the increase in volume. One of these factors might be a differential increase in the contact area of the visceral and parietal peritoneum. It was demonstrated that the effective permeability of the visceral peritoneum is poor, compared with that of the parietal peritoneum (25–29). Zakaria et al. (29) suggested that the relatively low efficiency of the visceral peritoneum with respect to transport might be attributable to the presence of unmixed or poorly mixed fluid trapped in the many pouches formed by the complex shape of the peritoneal space (30). This assumption is supported by the findings of improved contact area (9) and solute clearance (29,31) resulting from agitation or vibration applied to the abdomen of experimental animals, suggesting that lack of mixing is a main factor limiting solute transport by the visceral peritoneum. Despite these limitations, the data collected in this study may provide a unique method to estimate in vivo the effective peritoneal surface area and effective permeability determining KBD in human subjects.

This study demonstrates that the 3-L solution increases the peritoneal surface area exposed to dialysate. However, this large volume does not make contact with the entire anatomic peritoneal surface. This suggests that an additional increase in dialysate volume might recruit a larger peritoneal surface area, resulting in a higher KBD. However, the associated increase in hydrostatic pressure in the peritoneal space would be expected to increase fluid absorption by peritoneal tissues and lymphatic vessels, thus decreasing net ultrafiltration (3,5,32–36) and consequently solute removal. Nevertheless, the fact that the PSA-CD with the 3-L solution was still less than the estimated anatomic peritoneal surface area suggests that methods should be sought to provide an additional increase in PSA-CD without increasing the hydrostatic pressure inside the peritoneal cavity. Flessner et al. (9,10) demonstrated that surfactant enhanced the PSA-CD in mice and rats, probably by decreasing the surface tension between peritoneal surfaces. This effect was associated with an increase in solute mass transfer (10). The use of surfactants for human subjects (if such treatment is proved to be nontoxic) might provide a method for enhancing PSA-CD without increasing hydrostatic pressure.

In addition to peritoneal dialysis, the intraperitoneal administration of solutions has been used for regional chemotherapy for the treatment of metastatic cancer (37,38). Such concentrations are not achievable via intravenous administration without severe systemic side effects (39). The rationale behind this treatment is that it provides high tissue concentrations of the therapeutic agent. Two physiologic determinants of the efficacy of this treatment are surface exposure (i.e., PSA-CD) and tissue penetration (40). The 18% augmentation in PSA-CD after an increase in the volume of the peritoneal solution from 2 to 3 L suggests that the use of large volumes may improve the efficiency of intraperitoneal chemotherapy. The increase in peritoneal hydrostatic pressure associated with the use of large-volume solutions is a limiting factor in peritoneal dialysis, resulting in decreases in net ultrafiltration and solute removal (3,5,32–36). This effect would not be a drawback for peritoneal chemotherapy, because such treatment is not aimed at removing fluid and solutes. In fact, as demonstrated by Flessner (41), the increased pressure associated with large volumes might be an advantage in intraperitoneal regional therapy, because increased hydrostatic pressure results in improved tissue penetration of macromolecules. Therefore, the administration of intraperitoneal regional therapy with large-volume solutions might improve efficiency by increasing both surface exposure and tissue penetration.

In conclusion, this study demonstrates that increasing the instilled dialysate volume from 2 to 3 L among patients undergoing peritoneal dialysis increases the PSA-CD. This increase results in an augmented KBD. These findings might have important applications in the fields of peritoneal dialysis and intraperitoneal chemotherapy.


   Acknowledgments
 
We thank Miki Grazutis and Miriam Yuran, radiographers of the Department of Radiology, Rabin Medical Center-Golda Campus, for invaluable help in performing this study.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Blake P, Burkart JM, Churchill DN, Daugirdas J, Depner T, Hamburger RJ, Hull AR, Korbet SM, Moran J, Nolph KD: Recommended clinical practices for maximizing peritoneal dialysis clearances. Perit Dial Int 16: 448–456, 1996[Abstract/Free Full Text]
  2. Krediet RT, Douma CE, van Olden RW, Ho-dac-Pannekeet MM, Struijk DG: Augmenting solute clearance in peritoneal dialysis. Kidney Int 54: 2218–2225, 1998[CrossRef][Medline]
  3. Krediet RT, Boeschoten EW, Struijk DG, Arisz L: Differences in the peritoneal transport of water, solutes and proteins between dialysis with two- and with three-litre exchanges. Nephrol Dial Transplant 2: 198–204, 1988
  4. Keshaviah P, Emerson PF, Vonesh EF, Brandes JC: Relationship between body size, fill volume and mass transfer area coefficient in peritoneal dialysis. J Am Soc Nephrol 4: 1820–1826, 1994[Abstract]
  5. Wang T, Heimbürger O, Cheng HH, Waniewski J, Bergström J, Lindholm B: Effect of increased dialysate fill volume on peritoneal fluid and solute transport. Kidney Int 52: 1068–1076, 1997[Medline]
  6. Krediet RT, Zemel D, Imholz ALT, Koomen GCM, Struijk DG, Arisz L: Indices of peritoneal permeability and surface area. Perit Dial Int 13 [Suppl 2]: S31–S34, 1993
  7. Krediet RT, Zemel D, Imholz ALT, Struijk DG: Impact of surface area and permeability on solute clearances. Perit Dial Int 14 [Suppl 3]: S70–S77, 1994
  8. Flessner MF: Small-solute transport across specific peritoneal tissue surfaces in the rat. J Am Soc Nephrol 7: 225–233, 1996[Abstract]
  9. Flessner MF, Lofthouse J, Zakaria ER: Improving contact area between the peritoneum and intraperitoneal therapeutic solutions. J Am Soc Nephrol 12: 807–813, 2001[Abstract/Free Full Text]
  10. Flessner MF, Lofthouse J, Williams A: Increasing peritoneal contact during dialysis improves mass transfer. J Am Soc Nephrol 12: 2139–2145, 2001[Abstract/Free Full Text]
  11. Chagnac A, Herskovitz P, Weinstein T, Elyashiv S, Hirsh J, Hammel I: The peritoneal membrane in peritoneal dialysis patients: Estimation of its functional surface area by applying stereologic methods to computerized tomography scans. J Am Soc Nephrol 10: 342–346, 1999[Abstract/Free Full Text]
  12. Wegner G: Chirurgische Bermekungen uber die Peritonealhole, mit besonderer Berucksichtung der Ovariotomie. Arch Klin Chir 20: 51–147, 1877
  13. Esperanca MJ, Collins DL: Peritoneal dialysis efficiency in relation to body weight. J Pediat Surg 1: 162–169, 1966
  14. Rubin J, Clawson M, Planch A, Jones Q: Measurements of peritoneal surface area in man and rat. Am J Med Sci 295: 453–458, 1988[Medline]
  15. Twardowski ZJ, Tully RJ, Ersoy FF, Dedhia NM: Computerized tomography with and without intraperitoneal contrast for determination of intraabdominal fluid distribution and diagnosis of complications in peritoneal dialysis patients. ASAIO Trans 36: 95–103, 1990[Medline]
  16. Caimi F, Roveroe G, Phillipson M, Battaglia E: Contribution of peritoneography combined with computerized tomography in the assessment of abdominal complications in patients undergoing continuous peritoneal dialysis. Radiol Med 81: 656–659, 1991
  17. Weibel ER: Stereological Methods, Vol. 1, Practical Methods for Biological Morphometry, New York, Academic Press, 1979
  18. Lindholm B, Heimburger O, Waniewski A, Werynski A, Bergstrom J: Peritoneal ultrafiltration and fluid reabsorption during peritoneal dialysis. Nephrol Dial Transplant 4: 805–813, 1989[Abstract/Free Full Text]
  19. Simonsen O, Carlsson O, Zakaria ER, Rippe B: High peritoneal mass transport coefficients during the early (0–30 min) phase of PD dwells: Role of the interstitium. Perit Dial Int 16 [Suppl 2]: S12, 1996
  20. Wanieski J, Heimburger O, Werynski A, Lindholm B: Diffusive mass transport coefficients are not constant during a single exchange in continuous ambulatory peritoneal dialysis. ASAIO J 42: M518–M523, 1996[Medline]
  21. Carlsson O, Rippe B: Enhanced peritoneal diffusion capacity of 51Cr-EDTA during the initial phase of peritoneal dialysis dwells: Role of vasodilatation, dialysate stirring and of interstitial factors. Blood Purif 16: 162–170, 1998[CrossRef][Medline]
  22. Leypoldt JK, Mistry CD: Ultrafiltration in peritoneal dialysis.In: Textbook of Peritoneal Dialysis,edited by Gokal R, Nolph K, Dordrecht, Kluwer Academic Publishers, 1994,pp 135–160
  23. Zakaria ER, Rippe B: Intraperitoneal fluid volume changes during peritoneal dialysis in the rat: Indicator dilution vs. volumetric measurements. Blood Purif 13: 255–270, 1995[Medline]
  24. Henderson LW: The problem of peritoneal membrane area and permeability. Kidney Int 3: 409–410, 1973[Medline]
  25. Rubin J, Jones Q, Planch A, Rushton F, Bower JD: The importance of the abdominal viscera to peritoneal transport during peritoneal dialysis in the dog. Med Sci 292: 203–208, 1986
  26. Rubin J, Jones Q, Planch A, Bower JD: The minimal importance of the hollow viscera to peritoneal transport during peritoneal dialysis in the rat. Trans Am Soc Artif Intern Organs 34: 912–915, 1988
  27. Fox SD, Leopoldt JK, Henderson LW: Visceral peritoneum is not essential for solute transport during peritoneal dialysis. Kidney Int 40: 612–620, 1991[Medline]
  28. Albert A, Takamatsu H, Fonkalsrud EW: Absorption of glucose solutions from the peritoneal cavity in rabbits. Arch Surg 119: 1247–1251, 1984[Abstract]
  29. Zakaria ER, Carlsson O, Rippe B: Limitation of small-solute exchange across the visceral peritoneum. Perit Dial Int 17: 72–79, 1997[Abstract/Free Full Text]
  30. Bouchet Y, Voilin C, Yver R: The peritoneum and its anatomy.In: The Peritoneum and Peritoneal Access,edited by Bengmark S, London, Butterworth Scientific, 1989, pp 1–13
  31. Levitt MD, Kneip JM, Overdahl MC: Influence of shaking on peritoneal transfer in rats. Kidney Int 35: 1145–1150, 1989[Medline]
  32. Flessner MF, Parker RJ, Sieber SM: Peritoneal lymphatic uptake of fibrinogen and erythrocytes in the rat. Am J Physiol 244: H89–H96, 1983
  33. Durand PY, Chanliau J, Gamberoni J, Hestin D, Kessler M: Intraperitoneal pressure, peritoneal permeability and volume of ultrafiltration in CAPD. Adv Perit Dial 8: 22–25, 1992[Medline]
  34. Imholz AL, Koomen GC, Struijk DG, Arisz L, Krediet RT: Effect of an increased intraperitoneal pressure on fluid and solute transport during CAPD. Kidney Int 44: 1078–1085, 1993[Medline]
  35. Zakaria ER, Rippe B: Peritoneal fluid kinetics in the rat: Effects of increases in intraperitoneal hydrostatic pressures. Perit Dial Int 15: 118–128, 1995
  36. Flessner MF, Schwab A: Pressure threshold for fluid loss from the peritoneal cavity. Am J Physiol 270: F377–F390, 1996
  37. Alberts DS, Liu PY, Hannigan EV, O’Toole R, Williams SD, Young JA, Franklin EW, Clarke-Pearson DL, Malviya VK, DuBeshter B: Intraperitoneal cisplatin plus intravenous cyclophosphamide versus intravenous cisplatin plus intravenous cyclophosphamide for stage III ovarian cancer. N Engl J Med 335: 1950–1955, 1996[Abstract/Free Full Text]
  38. Markman M: Intraperitoneal drug delivery of antineoplastics. Drugs 61: 1057–1065, 2001[CrossRef][Medline]
  39. Dedrick RL, Myers CE, Bungay PM, De Vita VT Jr: Pharmacokinetic rationale for peritoneal drug administration in the treatment of ovarian cancer. Cancer Treat Rep 62: 1–11, 1978[Medline]
  40. Flessner MF, Dedrick RL: Intraperitoneal chemotherapy.In: Textbook of Peritoneal Dialysis, 2nd Ed., edited by Gokal R, Khanna R, Krediet RT, Nolph KD, Dordrecht, Kluwer Academic Publishers, 2000, pp 829–848
  41. Flessner MF: Transport of protein in the abdominal wall during intraperitoneal therapy. I. Theoretical approach. Am J Physiol 281: G424–G437, 2001
Received for publication April 29, 2002. Accepted for publication May 21, 2002.




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