Incremental Versus Standard (Full-Dose) Peritoneal Dialysis

Abstract

Incremental peritoneal dialysis (PD), defined as less than “standard dose” PD prescription, has a number of possible benefits, including better preservation of residual kidney function (RKF), reduced risk of peritonitis, lower peritoneal glucose exposure, lesser environmental impact, and reduced costs. Patients commencing PD are often new to kidney replacement therapy and possess substantial RKF, which may allow safe delivery of an incremental prescription, often in the form of lower frequency or duration of PD. This has the potential to help improve quality of life (QOL) and life participation through reducing time requirements and burden of treatment. Alternatively, incremental PD could potentially contribute to reduced small solute clearance, fluid overload, or patient reluctance to increase dialysis prescription when later needed. This review discusses the definition, rationale, uptake, potential advantages and disadvantages, and clinical trial evidence pertaining to the use of incremental PD. Incremental peritoneal dialysis (PD), defined as less than “standard dose” PD prescription, has a number of possible benefits, including better preservation of residual kidney function (RKF), reduced risk of peritonitis, lower peritoneal glucose exposure, lesser environmental impact, and reduced costs. Patients commencing PD are often new to kidney replacement therapy and possess substantial RKF, which may allow safe delivery of an incremental prescription, often in the form of lower frequency or duration of PD. This has the potential to help improve quality of life (QOL) and life participation through reducing time requirements and burden of treatment. Alternatively, incremental PD could potentially contribute to reduced small solute clearance, fluid overload, or patient reluctance to increase dialysis prescription when later needed. This review discusses the definition, rationale, uptake, potential advantages and disadvantages, and clinical trial evidence pertaining to the use of incremental PD. PD is chosen as the first modality of dialysis by many patients newly diagnosed with having kidney failure and is currently used to treat approximately 11% of patients on dialysis worldwide.1Fresenius annual report 2020Fresenius Medical Care.https://www.fresenius.com/media_library/Fresenius_Annual_Report_2020.pdfGoogle Scholar Frequently, PD is the first form of kidney replacement therapy for patients with kidney failure in whom substantial RKF supports fluid and solute removal. In these circumstances, it is reasonable to contend that these patients may not require “standard dose” PD to maintain health. There are many purported advantages of incremental PD, including reduced peritonitis risk, glucose exposure, environmental waste and cost, preservation of RKF, and improved QOL. However, there are also possible disadvantages, including reduced small solute clearance, increased risk of fluid overload, increased mortality risk, and reluctance to increase PD prescription over time. The practice of incremental PD aligns closely to the latest guideline from the International Society for Peritoneal Dialysis on prescribing high-quality, goal-directed PD, which emphasizes that dialysis should be prescribed using shared decision-making, with the aim of minimizing symptoms and treatment burden and maintaining QOL, in light of the lack of evidence that small solute clearance affects patient outcomes.2Brown E.A. Blake P.G. Boudville N. et al.International Society for Peritoneal Dialysis practice recommendations: prescribing high-quality goal-directed peritoneal dialysis.Perit Dial Int. 2020; 40: 244-253https://doi.org/10.1177/0896860819895364Crossref PubMed Scopus (56) Google Scholar Thus, the aim of this review is to provide a comprehensive update on incremental PD, including its definition, uptake, potential advantages and disadvantages, and outcomes. Although the concept of incremental PD has been recognized by national bodies since the 1990s3NKF-DOQI clinical practice guidelines for peritoneal dialysis adequacy. National Kidney Foundation.Am J Kidney Dis. 1997; 30: S67-S136https://doi.org/10.1016/s0272-6386(97)70028-3Abstract Full Text PDF Scopus (196) Google Scholar and has been used by health practitioners ad hoc before this, the definition of incremental PD is not clearly established. In general terms, incremental PD may be considered as any PD prescription that is less than the “standard dose,” achieves a combined peritoneal and kidney clearance target, and is intended to increase as needed if and when RKF declines.4Blake P.G. Dong J. Davies S.J. Incremental peritoneal dialysis.Perit Dial Int. 2020; 40: 320-326https://doi.org/10.1177/0896860819895362Crossref PubMed Scopus (16) Google Scholar However, what is considered a standard PD prescription is subject to regional variation, often in the context of differences in the population, particularly body habitus. In China and Hong Kong, a standard prescription may be considered to be 3 exchanges of 2 l/d.5Lai K.N. Lo W.K. Optimal peritoneal dialysis for patients from Hong Kong.Perit Dial Int. 1999; 19: S26-S34Crossref PubMed Google Scholar,6Yu X. Chen J. Ni Z. et al.Number of daily peritoneal dialysis exchanges and mortality risk in a Chinese population.Perit Dial Int. 2018; 38: S53-S63https://doi.org/10.3747/pdi.2017.00283Crossref PubMed Scopus (4) Google Scholar However, in many western countries, a standard PD prescription is typically 4 exchanges of 2 l/d on continuous ambulatory PD (CAPD)7Gillis L. Wilkie M. Peritoneal dialysis.Medicine. 2019; 47: 603-608https://doi.org/10.1016/j.mpmed.2019.06.003Abstract Full Text Full Text PDF Scopus (1) Google Scholar,8Kidney Health AustraliaAn Introduction to Peritoneal Dialysis. Kidney Health Australia, 2016Google Scholar or equivalent on automated PD, incorporating a long dwell.9Dombros N. Dratwa M. Feriani M. et al.European best practice guidelines for peritoneal dialysis. 6 Automated peritoneal dialysis.Nephrol Dial Transplant. 2005; 20: ix21-ix23https://doi.org/10.1093/ndt/gfi1120Crossref PubMed Scopus (14) Google Scholar As such, incremental PD has been defined using both of these values as a threshold across various studies10Ankawi G.A. Woodcock N.I. Jain A.K. Garg A.X. Blake P.G. The use of incremental peritoneal dialysis in a large contemporary peritoneal dialysis program.Can J Kidney Health Dis. Scopus (14) Google L. Ni Z. J. 4 daily exchanges and residual kidney function in a J Kidney Dis. Full Text Full Text PDF PubMed Scopus Google et peritoneal dialysis may be for residual function to peritoneal 2019; PubMed Scopus Google M. et peritoneal a PubMed Scopus Google L. to peritoneal dialysis in patients with residual J PubMed Scopus Google Scholar and Incremental PD be in including number of or incorporating or G.A. Woodcock N.I. Jain A.K. Garg A.X. Blake P.G. The use of incremental peritoneal dialysis in a large contemporary peritoneal dialysis program.Can J Kidney Health Dis. Scopus (14) Google M. et peritoneal a PubMed Scopus Google Scholar often with a to and clinical of and PD PD on incremental et G.A. Woodcock N.I. Jain A.K. Garg A.X. Blake P.G. The use of incremental peritoneal dialysis in a large contemporary peritoneal dialysis program.Can J Kidney Health Dis. Scopus (14) Google patients on PD of with l/d or with or and peritoneal and with with and et L. to peritoneal dialysis in patients with residual J PubMed Scopus Google patients with of approximately incremental PD on patients with and patients to if or on exchanges of et et peritoneal dialysis may be for residual function to peritoneal 2019; PubMed Scopus Google on dialysis time of or to patients on PD, 6 patients with with peritoneal and of et M. et peritoneal a PubMed Scopus Google on dialysis to kidney or of patients on PD, RKF et L. Ni Z. J. 4 daily exchanges and residual kidney function in a J Kidney Dis. Full Text Full Text PDF PubMed Scopus Google Chinese to kidney or 2 on patients on PD on 2 patients with or kidney life or 3 4 patients to to the et X. Chen J. Ni Z. et al.Number of daily peritoneal dialysis exchanges and mortality risk in a Chinese population.Perit Dial Int. 2018; 38: S53-S63https://doi.org/10.3747/pdi.2017.00283Crossref PubMed Scopus (4) Google of Chinese patient on PD and in on PD and not automated peritoneal continuous ambulatory peritoneal incremental not PD, peritoneal RKF, residual kidney standard PD. in a new in and et G.A. Woodcock N.I. Jain A.K. Garg A.X. Blake P.G. The use of incremental peritoneal dialysis in a large contemporary peritoneal dialysis program.Can J Kidney Health Dis. Scopus (14) Google peritonitis for the 3 before the and for of the for residual clearance in in peritoneal on PD less in incremental et L. to peritoneal dialysis in patients with residual J PubMed Scopus Google in the et et peritoneal dialysis may be for residual function to peritoneal 2019; PubMed Scopus Google in of first peritonitis of peritonitis time to first of peritonitis for in of risk of in incremental in time to failure in from any et M. et peritoneal a PubMed Scopus Google of peritonitis in in in of function lower in the 6 and the of treatment in 6 of treatment in patient by or et L. Ni Z. J. 4 daily exchanges and residual kidney function in a J Kidney Dis. Full Text Full Text PDF PubMed Scopus Google lower of patients peritonitis in lower in the in in in in less in in in patient et X. Chen J. Ni Z. et al.Number of daily peritoneal dialysis exchanges and mortality risk in a Chinese population.Perit Dial Int. 2018; 38: S53-S63https://doi.org/10.3747/pdi.2017.00283Crossref PubMed Scopus (4) Google lower mortality risk in standard incremental not PD, peritoneal QOL, quality of RKF, residual kidney standard in a new of using incremental PD P.G. Dong J. Davies S.J. Incremental peritoneal dialysis.Perit Dial Int. 2020; 40: 320-326https://doi.org/10.1177/0896860819895362Crossref PubMed Scopus (16) Google number of exchanges long or a number of exchanges on including use of peritoneal dialysis automated peritoneal continuous ambulatory peritoneal peritoneal PD, peritoneal dialysis. in a new automated peritoneal continuous ambulatory peritoneal incremental not PD, peritoneal RKF, residual kidney standard PD. incremental not PD, peritoneal QOL, quality of RKF, residual kidney standard automated peritoneal continuous ambulatory peritoneal peritoneal PD, peritoneal dialysis. Incremental PD is currently used in as G.A. Woodcock N.I. Jain A.K. Garg A.X. Blake P.G. The use of incremental peritoneal dialysis in a large contemporary peritoneal dialysis program.Can J Kidney Health Dis. Scopus (14) Google M. et peritoneal a PubMed Scopus Google Incremental peritoneal dialysis in kidney Dial Int. its use is not and is by practice and patient Incremental PD to be over with a of that the of patients using incremental PD, defined as to 2 exchanges or automated PD 3 to 4 increased from of patients in to in L. et to PD as in of from to 30: PubMed Scopus Google Scholar The of incremental PD use are not its may be by in The Kidney Health from and that of not to provide PD, defined as 3 to 4 exchanges or equivalent on automated A.K. et dialysis use and practice an J Kidney Dis. 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