Incremental peritoneal dialysis: a 10 year single-centre experience

Abstract

IntroductionIncremental dialysis consists in prescribing a dialysis dose aimed towards maintaining total solute clearance (renal + dialysis) near the targets set by guidelines. Incremental peritoneal dialysis (incrPD) is defined as one or two dwell-times per day on CAPD, whereas standard peritoneal dialysis (stPD) consists in three-four dwell-times per day.Patients and methodsSingle-centre cohort study. Enrollement period: January 2002–December 2007; end of follow up (FU): December 2012. Inclusion criteria: incident patients with FU ≥6 months, initial residual renal function (RRF) 3–10 ml/min/1.73 sqm BSA, renal indication for PD.ResultsMedian incrPD duration was 17 months (I–III Q: 10; 30). There were no statistically significant differences between 29 patients on incrPD and 76 on stPD regarding: clinical, demographic and anthropometric characteristics at the beginning of treatment, adequacy indices, peritonitis-free survival (peritonitis incidence: 1/135 months-patients in incrPD vs. 1/52 months-patients in stPD) and patient survival. During the first 6 months, RRF remained stable in incrPD (6.20 ± 2.02 vs. 6.08 ± 1.47 ml/min/1.73 sqm BSA; p = 0.792) whereas it decreased in stPD (4.48 ± 2.12 vs. 5.61 ± 1.49; p < 0.001). Patient survival was affected negatively by ischemic cardiopathy (HR: 4.269; p < 0.001), peripheral and cerebral vascular disease (H2.842; p = 0.006) and cirrhosis (2.982; p = 0.032) and positively by urine output (0.392; p = 0.034). Hospitalization rates were significantly lower in incrPD (p = 0.021). Eight of 29 incrPD patients were transplanted before reaching full dose treatment.ConclusionsIncrPD is a safe modality to start PD; compared to stPD, it shows similar survival rates, significantly less hospitalization, a trend towards lower peritonitis incidence and slower reduction of renal function.

Routine Is the Worst Enemy of the Dialysis Patient

“…The European Best Practice Guidelines recommend measuring RKF in HD patients using the mean of urea and creatinine clearances and offer suggestions to incorporate this into the HD prescription to allow individual adjustments of dialysis prescription to meet minimum dialysis adequacy targets [8]. However, these guidelines do not recommend an incremental transition from less to more frequent HD over time, while, ironically, according to most peritoneal dialysis (PD) guidelines, PD dose should be adjusted upward parallel to decline in RKF, the preservation of which is a high priority target in PD [4,9].…”

Individualized Hemodialysis Treatment: A Perspective on Residual Kidney Function and Precision Medicine in Nephrology

“…This approach has been successfully used for peritoneal dialysis patients, not for hemodialysis patients. Additionally, patients on incremental peritoneal dialysis showed a lower decline in RKF, a similar survival rate, and fewer hospitalizations than standard peritoneal dialysis patients [82]. With incremental hemodialysis, dialysis treatment is initiated once or twice weekly – rather than thrice weekly, as in the conventional regimen – if patients have substantial RKF.…”

Visions in a Crystal Ball: The Future of Peritoneal Dialysis

“…Third, the glucose exposure of the peritoneum can be minimized from the beginning. Finally, there is evidence showing that incrPD might better conserve RKF [19]. Losing RKF not only leads to a reduction in the quality of life, but it is also an important prognostic factor [20].…”

“…Sandrini et al [19] included 105 patients and showed no difference in survival and peritonitis rate over a median time of 17 months when compared to standard PD (stPD; 3–5 exchanges in 24 h). IncrPD was defined by one or 2 dwell times per day.…”

“…Interestingly, there was a reduction in the rate of renal function loss after initiation of incrPD showing that the described preservation of RKF in stPD is the same or even better with incrPD. In both these studies [19, 21], a significant cohort of patients were transplanted before any increase in the dose of PD was necessary.…”