Article

Association of Tubular Solute Clearance with Symptom

Burden in Incident Peritoneal Dialysis
Ke Wang,1,2 Michelle Nguyen,2 Yan Chen,2,3 Andrew N. Hoofnagle,2,4 Jessica O. Becker,4 Leila R. Zelnick ,1,2
John Kundzins,2,3 Anne Goodling,2 Jonathan Himmelfarb,1,2 and Bryan Kestenbaum1,2

Abstract
Background and objectives Residual kidney function is important to the health and wellbeing of patients with 1
Division of
ESKD. We tested whether the kidney clearances of proximal tubular secretory solutes are associated with burden Nephrology,
of uremic and heart failure symptoms among patients on peritoneal dialysis with residual kidney function. Department of
Medicine, University
Design, setting, participants, & measurements We enrolled 29 patients on incident peritoneal dialysis with residual of Washington, Seattle
Washington; 2Division
urine output .250 ml daily. We used targeted liquid chromatography-mass spectrometry to quantify plasma, 24-
of Nephrology,
hour urine, and peritoneal dialysate concentrations of ten tubular secretory solutes. We calculated the kidney and Department of
peritoneal dialysis clearances of each secretory solute, creatinine, and urea, and we estimated a composite kidney Medicine, University
and peritoneal secretion score. We assessed for uremic symptoms using the Dialysis Symptom Index and heart of Washington, Kidney
failure–related symptoms using the Kansas City Cardiomyopathy Questionnaire. We used linear regression to Research Institute,
Seattle, Washington;
determine associations of composite secretory solute clearances and GFRurea1Cr with Dialysis Symptom Index 3
Department of
symptom score and Kansas City Cardiomyopathy Questionnaire summary score. Epidemiology,
University of
Results Mean residual kidney clearances of creatinine and urea were 865 and 966 ml/min per 1.73 m2, Washington, Seattle
Washington; and
respectively, and mean GFRurea1Cr was 865 ml/min per 1.73 m2. The residual kidney clearances of most secretory 4
Department of
solutes were considerably higher than creatinine and urea clearance, and also, they were higher than their Laboratory Medicine,
respective peritoneal dialysis clearances. After adjustments for age and sex, each SD higher composite kidney University of
secretion score was associated with an 11-point lower Dialysis Symptom Index score (95% confidence interval, 220 Washington, Seattle,
to 21; P50.03) and a 12-point higher Kansas City Cardiomyopathy Questionnaire score (95% confidence interval, Washington
0.5- to 23-point higher score; P50.04). Composite peritoneal dialysis secretion score was not associated with either
Correspondence:
symptom assessment.
Dr. Ke Wang, Kidney
Research Institute,
Conclusions Residual kidney clearances of secretory solutes are higher than peritoneal dialysis clearances. Kidney Harborview Medical
clearances of secretory solutes are associated with patient-reported uremic and heart failure–related symptoms. Center, 325 9th
Avenue, Box 359606,
CJASN 15: 530–538, 2020. doi: https://doi.org/10.2215/CJN.11120919
Seattle, WA 98104.
Email: kewang@
uw.edu
Introduction ESKD because many secreted solutes are highly pro-
Among patients receiving maintenance dialysis, the tein bound, preventing adequate clearance by glo-
contribution of residual kidney function (RKF) toward merular filtration or by currently available dialysis
health and wellbeing is well established. Observa- treatments. Many solutes that are eliminated pre-
tional studies consistently demonstrate associations dominantly by tubular secretion are uremic toxins that
of RKF with improved survival and better quality of accumulate and are suspected to contribute to adverse
life (1–6). The physiologic importance of RKF is clinical outcomes (9–11). Moreover, proximal tubular
highlighted by recognized limitations of currently secretion is an active process requiring cellular energy
available dialysis therapies, which cannot remove and coordination of numerous transporters, suggest-
protein-bound solutes or maintain minute-to-min- ing potential contrasts with glomerular filtration
ute electrolyte homeostasis. Consequently, estima- (12,13). Despite its potential importance, tubular
tion of RKF remains an important component of secretory clearance is rarely estimated in ESKD.
dialysis clinical care. We used a novel targeted mass spectrometric assay to
Current assessment of RKF is on the basis of the measure the kidney and peritoneal clearances of tubular
GFR, which can be measured by the average of secretory solutes in an incident cohort of patients on
creatinine and urea clearance in ESKD (7,8). However, peritoneal dialysis (PD). We compared residual kidney
GFR incompletely describes the multifaceted biologic and PD clearances of secretory solutes, creatinine, and
functions of the kidneys. The secretion of organic urea, and we tested whether residual clearances of these
solutes by the proximal tubules is a vital intrinsic solutes were associated with the severity of uremic and
kidney function that may be particularly important in heart failure symptoms.

530 Copyright © 2020 by the American Society of Nephrology www.cjasn.org Vol 15 April, 2020
CJASN 15: 530–538, April, 2020
Materials and Methods
Patient Recruitment and Data Collection
Between June 2017 and October 2018, we recruited 29
patients on incident PD from outpatient units affiliated
with the Northwest Kidney Centers (Seattle, WA). Eligi-
bility criteria included PD initiation within the previous
1 year and self-reported residual urine output .250 ml
daily. Major exclusions were a history of kidney trans-
plantation, previous hemodialysis (HD), age ,18 years old,
non-English speaking, and inability to provide informed
consent. We further excluded persons who regularly used
medications that could interfere with tubular secretion:
probenecid, cimetidine, ranitidine, mycophenolate, olme-
sartan, indomethacin, trimethoprim-sulfamethoxazole, and
procainamide. The University of Washington’s institu-
tional review board approved the study, and all partici-
pants provided informed consent. During the visit, each
patient brought in clinical collections of 24-hour urine and
dialysate drainage. Clinical staff collected a blood sample,
an aliquot from the 24-hour urine specimen, and an aliquot
containing equal proportions (1/1000 of drainage volume)
of dialysate effluent from each exchange over the pre-
ceding 24 hours. We centrifuged all blood samples imme-
diately after collection and stored all specimens at 280°C
until assay.
Measurement of Tubular Secretory Solutes
Through literature review, we initially selected a panel of
secretory solutes on the basis of specificity for known
proximal tubular transporters, an increase in circulating
concentrations following transporter knockout in experi-
mental models, a high reported protein binding percent-
age, and reported kidney clearances that substantially
exceed GFR (9,10,14–18). We developed a targeted liquid
chromatography-tandem mass spectrometry assay for
these solutes in plasma and urine using labeled internal
standards as previously described (19,20). Briefly, we
extracted plasma solutes from bound proteins using pro-
tein precipitation with acidified acetonitrile and solid-
phase extraction through phospholipid removal. We
extracted urine solutes using solid-phase extraction using
either a mixed cation exchange extraction plate or a
hydrophilic-lipophilic binding extraction plate. We recon-
stituted dried extracts in acetonitrile/formic acid and
injected solution onto a Restek PFPP chromatographic
column. The column eluate was subsequently introduced
into a triple quadrupole tandem mass spectrometer (Sciex
6500). To maximize the accuracy of the calibration and
minimize laboratory imprecision, we used standard addi-
tion of purified analytes that were quantified using nuclear
magnetic resonance to determine the concentration of the
analytes in the calibrator. We performed further validation
experiments to maximize precision. Inter- and intra-assay
coefficients of variation for individual solutes in plasma and
urine range from 3.4% to 14.7% (Supplemental Table 1).
We were unable to determine the lower limits of de-
tection for three solutes due to isobaric interference (adipic
acid, suberic acid, and succinic acid), and therefore, we
excluded these solutes from further analyses. We further
excluded pantothenic acid from consideration on the basis
of previous studies demonstrating glomerular filtration
Tubular Solute Clearance in Incident ESKD, Wang et al. 531
and tubular reabsorption of this compound (21,22), and we
excluded 3-hydroxy hippurate due to implausibly high
kidney clearance. Subsequent protein binding studies
performed in our laboratory revealed that three additional
solutes (isovalerylglycine, tiglylglycine, and xanthosine)
had lower binding percentages than previously reported
(Supplemental Table 1). However, we retained these
solutes in this study because their kidney clearances greatly
exceeded GFR, suggesting tubular secretion as the major
kidney pathway of elimination.
Symptom Assessment
We administered the Dialysis Symptom Index (DSI) (23)
to evaluate uremic symptoms and a modified version of the
Kansas City Cardiomyopathy Questionnaire (KCCQ) (24)
to further elicit specific symptoms of dyspnea, fatigue, and
lower-extremity swelling. The DSI queries regarding the
presence and severity of 30 physical or emotional symp-
toms during the past week. Participants rated each symp-
tom using a five-point severity scale. The overall DSI
symptom score ranges from 0 to 150, with higher scores
indicating worse symptom burden. The DSI was system-
ically developed and validated among patients on long-
term dialysis and demonstrates good test-retest reliability
and content validity in HD. The questionnaire assesses
numerous symptoms that are both highly prevalent and
clinically relevant in ESKD on the basis of literature review,
dedicated focus groups consisting of patients and pro-
viders, and experts’ assessments (23). However, we cur-
rently know very little regarding which specific symptoms
are causally related to the retention of protein-bound
solutes. Therefore, we assessed the association of secretory
solute clearance with overall DSI severity.
The KCCQ is a 23-item questionnaire that evaluates the
severity of dyspnea, fatigue, and lower-extremity swelling
and the effect of these symptoms on physical functioning
and quality of life. The KCCQ was developed and vali-
dated in heart failure populations (24), and it has been
modified for use in CKD (25,26). However, this instrument
has not been validated in ESKD. We transformed raw
KCCQ scores into a summary score ranging from 0 to 100,
with higher scores indicating better overall function (24).
Prior studies have suggested that a KCCQ summary score
,75 indicates clinically significant symptoms (24,27,28).
The KCCQ has been well validated and carries prognostic
significance in patients with established heart failure and in
patients with CKD but no history of heart failure (25,27,29).
One participant did not complete the questionnaires and
was excluded from subsequent analyses involving symp-
tom assessment.
Measurement of Other Study Data
Study participants provided self-reported demographics
and medical conditions via study questionnaires. We used
the electronic medical record to ascertain active medica-
tions, modality of PD, and the clinically suspected cause of
ESKD. Clinical staff measured height, weight, 24-hour
urine volume, and 24-hour dialysate volume during the
adequacy visit. We measured serum and urine creatinine
concentrations using the modified Jaffe method and urine
532 CJASN

urea concentration using enzymatic conductivity on the
Beckman Coulter DxC 600.
Calculations
We calculated the kidney and peritoneal clearances of
urea, creatinine, and each secretory solute as the volume of
blood that is cleared of the solute per minute (milliliters
per minute):
hemoglobin, bicarbonate, parathyroid hormone, and phos-
phorus levels were within target ranges for ESKD. The
mean 24-hour ultrafiltration volume was 6526840 ml
(Supplemental Table 2). Higher kidney clearances of
secretory solutes, reflected by the composite secretion
score, were correlated with higher residual urine volume
(Rho50.66; P50.001) and with lower 24-hour ultrafiltration
volume (Rho520.62; P,0.001).

Clearance½kidney5urine½x 3 V =plasma½x
Comparison of Residual Kidney and PD Solute Clearances
Clearance½dialysate5dialysate½x 3 V =plasma½x; The mean residual kidney clearances of creatinine and
urea were 865 and 966 ml/min per 1.73 m2, respectively
where [x] represents the solute concentration in urine, (Table 2). The kidney clearances of most secretory solutes
plasma, or dialysate and V represents the urine or dialysate were considerably higher than that of creatinine or urea,
volume per minute over the collection period. All clearances with the highest values observed for hippurate (mean of
represent total urinary clearances, which include the bound 95672 ml/min per 1.73 m2) and dimethyluric acid (mean of
and unbound fractions. We measured GFRurea1Cr by cal- 57667 ml/min per 1.73 m2). In contrast, the kidney
culating the average of urea and creatinine clearances and
standardizing to 1.73 m2 body surface area (milliliters per
minute per 1.73 m2) according to clinical guidelines estab-
lished by the National Kidney Foundation (30). We also Table 1. Participant characteristics
standardized all clearance values to the same units.
Mean (SD) or
Characteristic
N (%)
Statistical Analyses
Age, yr 55 (12)
We expressed kidney and peritoneal solute clearances as Men 20 (69)
means and 95% confidence intervals (95% CI). We com- Race
puted a composite score for kidney and peritoneal secre- White 15 (51)
tory clearance, which represents a scaled average of the ten Black 4 (14)
Asian 4 (14)
individual secretory clearances. We first standardized log-
Other 6 (21)
transformed secretory clearance of each individual solute Medical history
to a 0–100 scale as described below: Hypertension 26 (96)
Diabetes 13 (48)
Standardized solute clearance Coronary artery disease 10 (34)
Congestive heart failure 3 (11)
logðsecretory clearanceÞ–min½logðsecretory clearanceÞ 3 100 Clinical characteristics
5 :
Range½logðsecretory clearanceÞ BMI, kg/m2 28 (5)
Dialysis duration, mo 4 (3)
24-h urine volume, ml 1350 (946)
We then determined the average of the ten standardized PD-related data
secretory clearances to create a composite secretion score. Continuous cycler–assisted PD 27 (93)
Continuous ambulatory PD 2 (7)
We used scatter plots, Pearson correlation coefficients, and D/PCr Peritoneal Equilibration Test 0.7 (0.1)
linear regression to determine associations of secretory 24-h PD drain volume, ml 8551 (2990)
solute clearances and GFRurea1Cr with DSI and KCCQ Mean fill volume continuous ambulatory 1750 (354)
scores. Given the small sample size, we were parsimonious PD, ml
Mean fill volume continuous 2067 (408)
in the selection of covariates: age, sex, and GFRurea1Cr. P
cycler–assisted PD, ml
values are presented without correction for multiple com- Total Kt/V 2.25 (0.70)
parisons. A nominal P value of 0.05 was taken as evidence of Laboratory parameters
statistical significance for regression analyses. Analyses GFRurea1Cr, ml/min per 1.73 m2 8 (5)
were conducted using STATA 14 (StataCorp, College Albumin, g/dl 3.2 (0.6)
Hemoglobin, g/dl 10.5 (1.3)
Station, TX). Bicarbonate, mEq/L 22 (3)
Parathyroid hormone, pg/ml 396 (254)
Phosphorous, mg/dl 5.5 (1.7)
Results Medication use
Diuretics 8 (33)
Description of the Study Population ACE-I/ARB 9 (37)
Among the 29 study participants, the mean duration of Phosphorous binders 20 (83)
PD was 4.062.9 months. The mean measured residual Erythropoietin-stimulating agents 18 (72)
GFRurea1Cr was 865 ml/min per 1.73 m2 (Table 1). Mean
age of the study cohort was 55612 years old; 69% of Values are mean (SD) or number (percentage). BMI, body mass
participants were men, and 52% were white. Hyperten- index; PD, peritoneal dialysis; D/PCr, ratio of dialysate to
plasma creatinine concentration; ACE-I, angiotensin-
sion (96%) and diabetes (48%) were the most prevalent converting enzyme inhibitor; ARB, angiotensin
comorbidities. Detailed dialysis prescriptions are pro- receptor blocker.
vided in Supplemental Table 2. Metabolic parameters of
 CJASN 15: 530–538, April, 2020
Table 2. Residual kidney and peritoneal dialysis solute clearance (n529)

Clearance, ml/min per 1.73 m2 Ratios

Molecular
Solutes Protein Binding, %a Peritoneal Solute
Weight, g/mol Kidney to Peritoneal Kidney Solute
Kidney Peritoneal Clearance to Peritonealurea1Cr
Clearance Clearance to GFRurea1Cr
Clearance

Filtration
Urea 60 — 9.0 [6.8 to 11.2] 8.4 [7.3 to 9.4] 1.2 [0.9 to 1.6] — —
Creatinine 113 — 8.2 [6.3 to 10.2] 2.8 [2.3 to 3.2] 3.7 [2.6 to 4.9] — —
Secretion
Cinnamoylglycine 205 94.9 9.5 [6.7 to 12.2] 0.5 [0.3 to 0.6] 22.4 [7.2 to 55.6] 1.2 [1.0 to 1.4] 0.08 [0.06 to 0.10]
Dimethyluric acid 196 63.6 57.2 [31.7 to 82.7] 3.4 [2.4 to 4.4] 17.4 [4.3 to 28.6] 7.7 [3.2 to 12.2] 0.59 [0.4 to 0.7]
Hippurate 179 65.7 94.6 [67.3 to 121.9] 8.8 [5.2 to 12.3] 15.6 [5.1 to 30.2] 13.7 [10.0 to 17.3] 1.5 [1.0 to 1.9]
Indoxyl sulfate 213 92.9 6.6 [5.0 to 8.2] 1.0 [0.5 to 1.5] 9.9 [3.3 to 19.9] 1.03 [0.7 to 1.3] 0.2 [0.1 to 0.2]
Isovalerylglycine 159 ND 29.3 [21.1 to 37.6] 3.8 [3.1 to 4.5] 8.4 [2.4 to 13.3] 3.6 [3.2 to 4.1] 0.7 [0.6 to 0.7]
Kynurenic acid 189 97 18.7 [14.0 to 23.4] 0.9 [0.6 to 1.1] 23.0 [7.8 to 42.9] 2.6 [2.1 to 3.1] 0.2 [0.1 to 0.2]
p-cresol sulfate 188 88.5 1.3 [1.0 to 1.6] 0.3 [0.2 to 0.4] 5.4 [1.7 to 9.5] 0.2 [0.1 to 0.2] 0.05 [0.04 to 0.06]
Pyridoxic acid 183 80.2 48.7 [34.3 to 63.2] 4.0 [2.8 to 5.2] 12.9 [3.8 to 22.2] 6.0 [4.9 to 7.1] 0.7 [0.5 to 0.9]

Tubular Solute Clearance in Incident ESKD, Wang et al.

Tiglylglycine 157 18.3 21.5 [14.8 to 28.3] 2.1 [1.5 to 2.6] 10.8 [3.5 to 16.3] 2.7 [2.2 to 3.1] 0.3 [0.3 to 0.4]
Xanthosine 284 29.5 9.1 [5.8 to 12.3] 1.6 [1.2 to 1.9] 6.3 [2.2 to 14.8] 1.2 [0.9 to 1.4] 0.3 [0.2 to 0.3]

Values are expressed as mean [95% confidence interval]. ND, protein binding not detected; MWCO, molecular weight cut-off.
a
To evaluate the extent of protein binding, we performed ultrafiltration experiments. Briefly, plasma was filtered using a centrifugal filter (Amicon Ultra; 3-kD MWCO) at 11,2003g for 30 min at
room temperature. The concentration of solutes in the filtrate was then determined using the same method as for plasma and compared with the concentration of solutes in unfiltered plasma. The
proportion of the solutes in the filtrate was assumed to be unbound in plasma. Preliminary experiments were performed to confirm that observed differences between the filtrate and unfiltered
plasma could not be attributed to adsorption to the Amicon Ultra filtration units (data not shown).

533
534 CJASN

clearance of p-cresol sulfate (mean of 160.8 ml/min per
1.73 m2) was lower than that of creatinine and urea. With
the exception of p-cresol sulfate, the kidney clearance of all
other solutes exceeded GFR, with the ratio of residual
secretory clearance to glomerular filtration ranging from
1.03 for indoxyl sulfate to 13.7 for hippurate. The residual
kidney clearance of each secretory solute was substantially
higher than its respective PD clearance, ranging up to
23-fold higher for kynurenic acid clearance. The peritoneal
clearance of most secretory solutes was lower than the
average of peritoneal urea and creatinine clearances.
Correlations between kidney secretory clearances and
GFRurea1Cr ranged from 0.38 for dimethyluric acid to
0.91 for isovalerylglycine (Supplemental Table 3). Secretory
solute concentrations in urine were substantially higher
compared with concentrations in dialysate and plasma
(Supplemental Table 4). Composite kidney solute clearance
was inversely correlated with composite peritoneal solute
clearance (Supplemental Figure 1).
Associations of Residual Kidney and Peritoneal Solute
Clearances with DSI Symptom Score
The median overall DSI symptom severity score was 25
(interquartile range [IQR], 10–44), and the median number
of symptoms was 9 (IQR, 4–14). The most prevalent
symptoms were muscle cramps (61%), leg swelling
(59%), fatigue (57%), and difficulty with sexual arousal
(57%) (Supplemental Table 5). Higher residual GFRurea1Cr
and higher composite kidney solute clearance were corre-
lated with lower DSI scores. This correlation tended to be
modestly higher for composite kidney solute clearance
compared with GFRurea1Cr (Figure 1, Table 3). Among the
individual solutes, the residual kidney clearances of tiglyl-
glycine, kynurenic acid, and isovalerylglycine were most
strongly correlated with DSI scores. After adjustments for
age and sex, each SD higher composite kidney secretion
score was associated with an estimated 11-point lower DSI
score (95% CI, 20- to 1-point lower; P50.03) (Table 5). This
association was similar in magnitude after adjustment for
residual GFRurea1Cr. Conversely, composite peritoneal
solute clearance was not associated with uremic symptom
severity (Figure 1, Tables 4 and 5). In examining individual
symptoms, higher kidney secretory clearance and GFR
were most strongly associated with decreased appetite, leg
swelling, and insomnia (Supplemental Table 6).
Associations of Residual Secretory Clearances with KCCQ
Summary Score
The median overall KCCQ score was 80 (IQR, 51–91),
and 43% of participants had overall KCCQ scores ,75.
Higher residual GFRurea1Cr and higher residual kidney
solute clearances tended to track with higher (better)
KCCQ scores (Figure 1, Table 3); however, correlations
were weaker than those observed for DSI scores. After
adjustment for age and sex, each SD higher composite
kidney secretion score was associated with an estimated 12-
point higher KCCQ score (95% CI, 0.5- to 23-point higher
score; P50.04). However, this association was weakened
by adjustment for residual GFRurea1Cr. Higher peritoneal
solute clearance was correlated with lower KCCQ scores

80 80 80
r = -0.35 p-value=0.06
DSI symptom score

60 60 60
r = -0.49 p-value=0.007 r = 0.06 p-value=0.76

40 40 40

20 20 20

0 0 0
0 5 10 15 20 0 20 40 60 80 100 0 20 40 60 80 100
GFRurea+Cr Composite secretion score (kidney) Composite secretion score (peritoneal)

150 150 150

r = 0.32 p-value=0.09
r = -0.34 p-value=0.07
KCCQ summary score

100 100 100

50 50 50
r = 0.41 p-value=0.02

0 0 0
0 5 10 15 20 0 20 40 60 80 100 0 20 40 60 80 100
GFRurea+Cr Composite secretion score (kidney) Composite secretion score (peritoneal)

Figure 1. | Kidney tubular soute clearance correlates with severity of uremic and heart failure symptoms. Scatter plots with fitted least squares
regression lines are shown. Rho and P values generated from Pearson regression are shown. GFRurea1Cr is expressed in milliliters per minute per
1.73 m2. Composite secretion score is standardized on a scale of 1–100.
CJASN 15: 530–538, April, 2020 Tubular Solute Clearance in Incident ESKD, Wang et al. 535

Table 3. Correlations of kidney solute clearances with symptoms (n528)

DSI Symptom Scorea KCCQ Summary Scoreb

Solute
Rho P Valuec Rho P Valuec

GFRurea1Cr 20.35 0.06 0.32 0.09

Composite secretion score (kidney) 20.49 0.007 0.41 0.02
Secretory solutes
Cinnamoylglycine 20.19 0.32 0.31 0.10
Dimethyluric acid 20.33 0.08 0.27 0.15
Hippurate 20.38 0.05 0.42 0.02
Indoxyl sulfate 20.42 0.02 0.26 0.18
Isovalerylglycine 20.45 0.01 0.36 0.06
Kynurenic acid 20.49 0.008 0.32 0.09
p-cresol sulfate 20.26 0.17 0.08 0.68
Pyridoxic acid 20.40 0.03 0.28 0.14
Tiglylglycine 20.50 0.006 0.30 0.11
Xanthosine 20.39 0.04 0.22 0.25

GFRurea1Cr is calculated as the mean of urea and creatinine clearance standardized to body surface area. DSI, Dialysis Symptom Index;
KCCQ, Kansas City Cardiomyopathy Questionnaire.
a
Lower DSI scores indicate fewer uremic symptoms.
b
Higher KCCQ scores indicate fewer dyspnea and fatigue symptoms.
c
Raw P values are uncorrected for multiple comparisons.

(Figure 1, Table 4); however, this association was not
statistically significant (Table 5). Correlations of combined
kidney and PD solute clearances were comparable with
correlations with kidney solute clearances alone given the
relatively small contribution of PD clearance toward total
clearance (Supplemental Table 7).
Discussion
In a primary cohort of patients recently initiating PD, we
observed substantially higher residual kidney clearances of
tubular secretory solutes compared with their respective
peritoneal dialytic clearances. The residual kidney clearances
of most secretory solutes were also considerably higher than
the clearances of creatinine and urea. Higher kidney secretory
clearances but not PD clearances were correlated with a lower
burden of uremic and heart failure symptoms. Taken together,
our findings suggest that the residual kidney clearance of
tubular secretory solutes is an important component of RKF
that may hold clinical significance.
Consistent with our findings, two prior studies of PD
have shown the superiority of residual kidney clearance
compared with dialytic clearance in eliminating p-cresol
sulfate, a small protein-bound molecule that is primarily
cleared by proximal tubular secretory transport. These
studies found a four-times higher residual kidney clearance
of p-cresol sulfate compared with its peritoneal clearance
(31,32). Similarly, among patients on HD with RKF, the
fraction of p-cresol sulfate, indoxyl sulfate, and hippurate
that is removed by residual kidney clearance was two to

Table 4. Correlations of peritoneal solute clearances with symptoms (n528)

DSI Symptom Scorea KCCQ Summary Scoreb

Solute
Rho P Valuec Rho P Valuec

Uread 20.003 0.98 20.17 0.39

Creatinined 0.05 0.80 20.29 0.14
Cinnamoylglycine 0.11 0.56 20.31 0.10
Dimethyluric acid 20.02 0.93 20.11 0.56
Hippurate 0.15 0.43 20.37 0.05
Indoxyl sulfate 0.17 0.39 20.41 0.03
Isovalerylglycine 20.01 0.93 20.27 0.16
Kynurenic acid 0.17 0.39 20.51 0.005
p-cresol sulfate 0.31 0.11 20.53 0.003
Pyridoxic acid 20.09 0.63 20.10 0.61
Tiglylglycine 20.22 0.27 20.21 0.28
Xanthosine 0.22 0.25 20.45 0.01
Composite secretion score (peritoneal) 0.06 0.76 20.34 0.07

DSI, Dialysis Symptom Index; KCCQ, Kansas City Cardiomyopathy Questionnaire.

a
Lower DSI scores indicate fewer uremic symptoms.
b
Higher KCCQ scores indicate fewer dyspnea and fatigue symptoms.
c
Raw P values are uncorrected for multiple comparisons.
d
Urea and creatinine clearances are standardized to body surface area.
 536
CJASN
Table 5. Association of kidney solute clearances with symptoms (n528)

DSI Symptom Score KCCQ Overall Score

Kidney/Peritoneal Unadjusted Model 1 Model 2 Unadjusted Model 1 Model 2

Solute Clearance
P P P P P P
b (95% CI) b (95% CI) b (95% CI) b (95% CI) b (95% CI) b (95% CI)
Value Value Value Value Value Value

GFRurea1Cr 28 (217 to 0.5) 0.06 27 (217 to 4) 0.22 NA NA 8 (21 to 18) 0.09 9 (23 to 21) 0.14 NA NA
Kidney secretion 211 (220 to 23) 0.007a 211 (220 to 21) 0.03a 215 (230 to 1) 0.06 11 (1 to 21) 0.03a 12 (0.5 to 23) 0.04a 13 (25 to 31) 0.16
score (composite)
Peritoneal secretion 1 (28 to 11) 0.76 1 (29 to 11) 0.80 21 (211 to 10) 0.90 29 (220 to 1) 0.07 29 (220 to 2) 0.12 27 (219 to 5) 0.23
score (composite)

Model 1 includes age and sex. Model 2 includes age, sex, and GFRurea1Cr. Values are expressed as the change in DSI or KCCQ summary scores per SD increase in GFRurea1Cr or composite solute
clearance. DSI, Dialysis Symptom Index; KCCQ, Kansas City Cardiomyopathy Questionnaire; 95% CI, 95% confidence interval; NA, not applicable.
a
Statistical significance at P value threshold of 0.05.
CJASN 15: 530–538, April, 2020
three times higher than that of urea. Higher RKF, measured
by 24-hour kidney creatinine and urea clearance, was also
associated with lower plasma levels of the three protein-
bound solutes (33).
The relatively low PD clearance of secretory solutes
likely reflects their larger size and high degree of protein
binding. The peritoneal capillary membrane is the principal
determinant of solute transport into the peritoneal cavity.
Small and water-soluble solutes diffuse through protein-
restrictive pores, which account for most of the capillary
exchange membrane. Larger protein-bound solutes are carried
by convection through larger pores, which exist in substan-
tially fewer numbers (34,35). Intriguingly, we observed rela-
tively low dialytic clearances of solutes that demonstrated a
low-protein binding percentage (isovalerylglycine, tiglylgly-
cine, and xanthosine), suggesting that laboratory assessment of
protein binding on the basis of equilibrium dialysis or
centrifugation may not fully correspond with the free move-
ment of these solutes across the peritoneal membrane in
uremia. Additionally, the molecular weight of the evaluated
secretory solutes is 1.4–2.5 times higher than that of creatinine
and 2.6–4.7 times higher than that of urea, potentially
contributing to their slower dialytic clearances.
We found that the composite residual kidney clearance
but not peritoneal clearance of secretory solutes is associ-
ated with lower uremic and heart failure symptom burden.
The pathogenesis underlying the clinical syndrome of
uremia remains unclear because only a few small studies
have directly examined relationships between candidate
solutes and uremic symptomology. In a study of 30 patients
on incident PD, the severity of gastrointestinal and neuro-
logic symptoms was significantly correlated with blood
levels of p-cresol sulfate but not with urea or creatinine (32).
Among 141 patients on maintenance HD, circulating
concentrations of phenylacetylglutamine and hippurate
were most strongly associated with impaired executive
function (36). Furthermore, we currently know very little
regarding which specific solutes of the .150 candidate
uremic solutes actually exhibit clinical toxicity (14). The
association between kidney clearance of secretory solutes
with heart failure–related symptoms may be partially
explained by improved volume control because higher
kidney clearances of secretory solutes were correlated with
higher 24-hour urine volume and with lower ultrafiltration
volume. Our findings are an important addition to the existing
literature, suggesting that the accumulation of protein-bound
solutes may contribute to symptom development in ESKD and
motivate future larger metabolomics studies to identify clinical
consequences of individual solutes.
Our study has several strengths. We used a targeted
mass spectrometry assay that was specifically developed
for the secretory solutes of interest using labeled internal
standards and external calibration. We calculate solute
clearances using 24-hour urine and dialysate samples,
which are theoretically independent of characteristics
that might influence their production. We also assessed
for symptom burden using well validated questionnaires.
However, we are not powered to examine associations with
individual symptoms. Another limitation of our study is
that DSI and KCCQ scores may not be specific for uremic
toxicity because the symptoms elicited by these instru-
ments may be caused by conditions other than uremia. The
Tubular Solute Clearance in Incident ESKD, Wang et al. 537
KCCQ also has not been validated in patients with ESKD.
Furthermore, given the known diurnal variations of plasma
concentrations of secretory solutes (20), estimation of
kidney clearance from a single plasma level may be prone
toward error. For instance, the 24-hour clearance of a solute
may be falsely high if its plasma concentration obtained on a
single occasion is lower than the true average plasma value
over the 24-hour collection period. Therefore, further refine-
ments of laboratory assessments of secretory solutes may
strengthen the association between solute clearance and
symptoms. Despite these limitations, our results suggest a
potential mechanism underlying the pathogenesis of uremic
symptomology and motivate future larger studies to explore
associations between tubular secretory clearance with de-
tailed symptom assessments.
In summary, we found residual kidney clearances of
tubular secretory solutes to be substantially higher than
their respective peritoneal clearances among patients ini-
tiating PD. Higher residual kidney secretory clearances
were associated with fewer uremic and heart failure
symptoms. The inclusion of tubular secretory clearances
into the assessment of RKF could enhance assessment of
RKF and uniquely inform uremic toxicity. Future strategies
to improve the dialytic clearance of secretory solutes may
improve patient-reported symptom burden in ESKD.
Disclosures
Dr. Hoofnagle reports receiving grants from Waters, Inc. during
the conduct of the study. Dr. Kestenbaum reports personal fees from
Reata Pharmaceuticals outside the submitted work. Dr. Becker,
Dr. Chen, Dr. Goodling, Dr. Himmelfarb, Dr. Kundzins, Dr. Nguyen,
Dr. Wang, and Dr. Zelnick have nothing to disclose.
Funding
This work was supported by National Institutes of Health,
National Institute of Diabetes and Digestive and Kidney Diseases
grants R01 DK107931 (to Dr. Kestenbaum) and R01 DK 103986 (to
Dr. Kestenbaum) and an unrestricted gift from the Northwest
Kidney Centers (to the Kidney Research Institute). Dr. Wang is
supported by the American Society of Nephrology Ben J. Lipps
Research Fellowship.
Supplemental Material
This article contains the following supplemental material online at
http://cjasn.asnjournals.org/lookup/suppl/doi:10.2215/CJN.
11120919/-/DCSupplemental.
Supplemental Figure 1. Correlation between composite secretion
scores (peritoneal versus kidney).
Supplemental Table 1. Detection limits, laboratory variability, and
characteristics of candidate secretory solutes.
Supplemental Table 2. Peritoneal dialysis prescriptions for study
participants.
Supplemental Table 3. Correlations of kidney and peritoneal
solute clearances.
Supplemental Table 4. Solute concentrations in urine, dialysate,
and plasma.
Supplemental Table 5. Dialysis Symptom Index symp-
tom summary.
Supplemental Table 6. Correlations of kidney functions with
Individual Dialysis Symptom Index symptoms.
Supplemental Table 7. Correlations of combined residual kidney
and peritoneal solute clearance with symptoms.
538 CJASN
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Received: September 15, 2019 Accepted: February 7, 2020
Published online ahead of print. Publication date available at
www.cjasn.org.