Nephrology · Medical Literature
Therapeutic potential of amino acid-based peritoneal dialysis solutions: a systematic review.
Abstract
Peritoneal dialysis (PD) offers many advantages over hemodialysis but chronic exposure to bio-incompatible glucose-based PD solutions and continuous absorption of glucose from the dialysate may lead to peritoneal membrane (PM) dysfunction and systemic metabolic complications such as hyperglycemia, insulin resistance, dyslipidemia, and obesity. Replacing one daily exchange of 1.36% glucose-based solution with one 1.1% amino acid-based PD solution may provide nutritional benefits of amino acid supplementation, improve biocompatibility, and reduce the peritoneal glucose load while maintaining similar ultrafiltration and solute removal capacity. Randomized clinical trials and mechanistic studies show beneficial effects of amino acid-based PD solutions on peritoneal homeostasis, preserved viability of the PM, and favorable nutritional and metabolic effects. This systematic review highlights the clinical rationale for implementing use of amino acid-based PD solutions as an integral part of glucose-sparing strategies in PD to reduce the cumulative intraperitoneal glucose load and mitigate its well-documented adverse effects. Amino acid-based PD solutions emerge as a clinically viable, glucose-free alternative and a nutritionally beneficial option that can improve the nutritional status of PD patients by providing essential amino acids when used as part of a comprehensive glucose-sparing strategy. Targeted use of these solutions, particularly in malnourished or high-risk patients, represents a personalized approach to optimizing peritoneal dialysis outcomes.Clinical trial number: Not applicable.
Clinical relevance
Chronic exposure to glucose-based peritoneal dialysis (PD) solutions contributes to peritoneal membrane dysfunction and systemic metabolic complications — including hyperglycemia, insulin resistance, dyslipidemia, and obesity — representing a critical unmet need in the long-term management of PD patients. This systematic review synthesizes evidence from randomized clinical trials and mechanistic studies evaluating 1.1% amino acid-based PD solutions as a glucose-sparing alternative, directly addressing the dual burden of bio-incompatibility and malnutrition in this population. Given the growing prevalence of end-stage kidney disease and increasing utilization of home-based PD, clinicians need evidence-based strategies to preserve peritoneal membrane integrity and optimize nutritional outcomes over time.
Key findings
1. Substituting one daily exchange of standard 1.36% glucose-based PD solution with a 1.1% amino acid-based PD solution maintained comparable ultrafiltration and solute removal capacity, supporting clinical non-inferiority for dialysis adequacy endpoints. 2. Amino acid-based PD solutions demonstrated preserved peritoneal membrane viability and favorable effects on peritoneal homeostasis across randomized clinical trials and mechanistic studies included in this review. 3. Use of amino acid-based solutions reduced the cumulative intraperitoneal glucose load by replacing at least one glucose-containing exchange per day, thereby mitigating glucose-mediated peritoneal and systemic toxicity. 4. Nutritional benefits were documented, with amino acid supplementation via dialysate providing essential amino acids and improving nutritional status — particularly relevant in malnourished or high-risk PD patients. 5. Systemic metabolic complications associated with glucose-based PD solutions — including hyperglycemia, insulin resistance, dyslipidemia, and obesity — represent the mechanistic rationale for glucose-sparing strategies supported by this review, though specific quantitative effect sizes (e.g., confidence intervals, p-values, NNT) were not reported in the available abstract. 6. Targeted use in malnourished or high-risk patient subgroups was identified as a personalized, clinically viable approach to optimizing PD outcomes within a comprehensive glucose-sparing strategy.
Practice implications
Nephrologists should consider prescribing one daily exchange of 1.1% amino acid-based PD solution in place of the standard 1.36% glucose-based exchange — particularly in PD patients with evidence of malnutrition, hyperglycemia, insulin resistance, or dyslipidemia — as part of a structured glucose-sparing regimen. This strategy should be implemented as a component of a comprehensive approach that may also include icodextrin-based solutions, with ongoing monitoring of nutritional markers (e.g., serum albumin, prealbumin, subjective global assessment), dialysis adequacy (Kt/V, ultrafiltration volume), and metabolic parameters. Patient selection should prioritize those at highest risk for glucose-related peritoneal membrane deterioration or protein-energy wasting, and clinical teams should ensure that amino acid supplementation via dialysate is integrated with dietary counseling to avoid over-reliance on dialysate as the sole nutritional intervention.