Élimination du sodium en dialyse péritonéale : existe-t-il de la place pour un nouveau paramètre dans l'adéquation de la dialyse ?

  • Anna Lima Nephrology Department, Hospital Prof Fernando Fonseca
  • Joana Tavares
  • Nicole Pestana
  • Maria João Carvalho
  • António Cabrita
  • Anabela Rodrigues
Mots-clés: dialyse péritonéale, dialyse adéquate, soustraction sodium

Résumé

En dialyse péritonéale (DP), ainsi qu'en hémodialyse (HD), une faible clairance du soluté mesurée par le Kt/ V urée a longtemps été utilisée comme représentant l'adéquation de la dialyse. On pensait initialement que l'amélioration de la clairance de l'urée augmentait la survie des patients dialysés (comme le montrait l'essai CANUSA) (1), mais la réanalyse des données a montré une contribution supérieure de la fonction rénale résiduelle en tant que facteur prédictif de la survie du patient. Deux essais contrôlés randomisés (ECR) (2, 3)ont confirmé cette observation, ne montrant aucun bénéfice en termes de survie chez les patients présentant un Kt/ V supérieur. Ensuite, les recommandations ont été révisées et un Kt/ V minimum de 1,7 / semaine a été recommandé, mais peu d'attention a été accordée aux paramètres supplémentaires de l'adéquation de la dialyse. En tant que telles, la surcharge volumique et l'élimination du sodium ont retenu l'attention, leur optimisation étant associée à une diminution de la mortalité chez les patients en DP(4, 5). Une élimination inadéquate du sodium est associée à une surcharge liquidienne qui conduit à une hypertrophie ventriculaire et à une mortalité cardiovasculaire accrue(6). La prescription individualisée est essentielle pour une élimination optimale du sodium car il existe des différences entre les techniques de DP, dialyse péritonéale continue ambulatoire et dialyse péritonéale automatisée (DPCA et DPA), et de nouvelles stratégies d'élimination du sodium ont émergé (solutions à faible teneur en sodium et DP adaptée). En conclusion, les futures recommandations devraient traiter des paramètres associés à des résultats de survie améliorés (l'élimination du sodium jouant un rôle important) et abandonner le modèle actuel de prescription unique.

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Publiée
2019-09-18