Incremental Peritoneal Dialysis Research Articles

#2292 Incremental peritoneal dialysis: an individualized therapy with better clinical outcomes and reduced environmental and economic impact

Abstract Background and Aims Incremental peritoneal dialysis (IPD) is based on the prescription of a dose lower than the standard “full dose” (SPD). The achievement of individualized clearance goals is based on the combination of peritoneal and renal clearance. IPD as the initial PD strategy seems to be a convenient and resource-sparing technique, but its impact in long term outcomes and in the environment lacks evidence. The aim of this study is to evaluate IPD outcomes and to analyze the potential impact of this initial approach on costs, total and plastic waste, and water consumption. Method Single-center observational retrospective study that included a cohort of 87 prevalent PD adults. Patients were assigned in two groups according to their initial PD prescription—IPD group [continuous ambulatory PD (CAPD): less than 4 dwells daily, less than 2L dwell volume, and/or PD less than 7 days/week; automated PD (APD): without a long dwell, less than 10 L delivered, and/or PD for less than 7 days/week] and SPD group. Primary outcomes were residual kidney function preservation, technique survival and mortality. Secondary outcomes were peritonitis rate and hospitalizations. The reductions related to costs, total and plastic waste, and water usage were also compared between groups. Results In 57 (65%) of the patients IPD was the initial therapy, while 30 (35%) patients were prescribed SPD. The median follow-up was 23 months and the median transition time from 2 to 3 and from 3 to 4 exchanges were 6 and 14 months in CAPD, respectively. APD patients transitioned to SPD after a median of 9 months. Patients in IPD group had a higher glomerular filtration rate (7 vs. 3.7, mL/min/1.73 m2, p < 0.001) in the first 6 months, and after 24 months (4.8 vs. 1.9, mL/min/1.73 m2, p = 0.002. IPD was also associated with a longer technique survival (p = 0.026), lower hospital admissions per year (0.23 vs. 0.5, p = 0.001), and lower mortality (1.8% vs. 13.3%, p = 0.027). Compared to SPD, 2 and 3 exchanges per day led to a reduction in costs of approximately 8500 or 4100 euros/patient-year, total waste of 266 or 143 kg/year/patient, in plastic waste of 159 or 69 kg/year/patient, and water savings of 28,620 or 12,420 L/year/patient, respectively. In APD, IPD led to a reduction of 4400 euros/ patient-year in cost, 211 kg/year/patient in total and of 139 kg/year/patient in plastic waste, and water savings of 25,020 L/year/patient. Conclusion Prescription of initial individualized IPD is associated with better clinical outcomes in patients with substantial RKF. This approach was a significant economic and environmental impact, with a reduction in total and plastic waste, and water consumption.

#2752 Decline of residual renal function in peritoneal patients: in search of the lost kidney?

Abstract Background and Aims The latest (2020) recommendations of the International Society of Peritoneal Dialysis have proposed a new paradigm of adequacy. In this context, preserving residual renal function (RRF) is considered one of the most important therapeutic targets to reduce cardiovascular risk and mortality. Incremental peritoneal dialysis can contribute to preserving RRF. The goal of this study is to evaluate factors which are associated with a decline in RRF in APD patients. Method We conducted a retrospective study of incidental peritoneal dialysis patients between 2020 and 2022. We started considering 62 patients who underwent APD. 23 were excluded due to lack of data, follow-up of less than 1 year, need for haemodialysis sessions before or during follow-up, interfering surgery (bariatric surgery and nephrectomy) and treatment using the CAPD technique. We analyzed data from 39 APD patients (see Table 1) and classified them into two groups based on their RRF decline using the cut-off of 1 ml/min/year (calculated as the mean of urea and creatinine clearance). They were distinguished into slow progressors and fast progressors and we identified any differences in clinical and dialysis parameters at baseline and 12-month follow-up. We calculated dialytic, renal and total Kt/V in both groups and looked for possible predictors of faster RRF loss. For statistical analysis, we used ANOVA for continuous variables, Kruskal-Wallis for non-continuous variables and Fisher for qualitative variables. Finally, predictive data were extracted using logistic regression. Results We found 22 slow progressors and 17 fast progressors. A significant difference was found in the prevalence of cardiovascular disease (18.2% vs 47.1%, p 0.028), residual renal function (5.71 ml/min vs 6.85 ml/min, p 0,03) and dialysing solution volumes (13.2 L vs 14.1 L, p 0.05) between the two groups, with higher values in the fast progressors. In this group, more male patients were also observed (p 0.11), treated with 2 or more antihypertensive drugs (p 0.30) and exposed to higher weekly dialysate glucose (p 0.23) and daily ultrafiltration rates (p 0.23). At the 12-month follow-up, the mean decline in renal function was -1, 56 ml/min in the entire sample, -3.03 ml/min in the fast progressors group and -0.43 ml/min in the slow progressors group; the change in daily Uf inversely correlated with the change in RRF (p 0.025; r -0.35, Fig. 1). There was a mean reduction in ultrafiltrate volume (-22.7 ml vs +123.5 ml, p 0.028) and in the amount of glucose in the dialysing solutions (-138.6 g vs +100.5 g, p 0.007) compared to baseline values in patients who preserved RRF. In contrast, the difference between the two groups in the number of patients who started PD with<5 sessions per week is borderline (p 0.099). Weekly dialysis Kt/V is higher in fast-progressor patients (1 vs 0.88; p 0.205) with a total weekly Kt/V in both cases above the recommended target of 1.7. On multivariate regression analysis, baseline renal function and the presence of heart disease correlate with a more rapid decline in RRF (p 0.047; p 0.021 respectively). Conclusion With the limitations of low sample size and short follow-up time, we observed that ultrafiltration and peritoneal exposure to dialysate glucose may play a role in RRF loss, but more research is needed to confirm this. We found that patients with heart disease and higher baseline RRF were more likely to experience a faster decline in RRF. Overall findings suggest that maintaining RRF is crucial in APD patients, and incremental dialysis can help preserve it. We recommend further studies with longer follow-up times to better understand the relationship between RRF and APD.

#2969 One-year longitudinal changes in nutritional parameters associated with low-protein diets in patients starting with incremental PD

Abstract Background and Aims Starting peritoneal dialysis (PD) with an incremental approach, that is, a low dose of PD (1-2 dwells a day in continuous ambulatory PD and until 5 sessions a week in automated PD) based on residual kidney function, is a common strategy to increase the acceptance of dialysis for patients affected by advanced chronic kidney disease (CKD) requiring renal replacement therapy. However, no study has provided evidence on the optimal protein intake in patients treated with a low dose of PD. Indeed, patients starting dialysis require an increased protein intake to supply protein loss by dialysis. On the other hand, patients beginning with a low dose of dialysis and a high protein intake may lead to toxins accumulation and metabolic acidosis. Therefore, the maintenance of protein restriction could be indicated as long as malnutrition does not occur. Method The I-COPE study was designed to assess in 24 PD units in Italy the time to full-dose PD in patients undergoing integrated conservative therapy with low-dose PD. Patients who reached full-dose, switched to hemodialysis, received transplant, or died were censored. No specific recommendation on protein intake was included in the study protocol due to the lack of guidelines on this issue, so the prescription was left to decision of each participating center. This is an ad-interim analysis of the I-COPE study aimed at evaluating the longitudinal changes at one year of BMI and serum albumin. Two groups of nutritional interventions were identified a posteriori: non-low protein diet (NLPD, dietary protein intake > 0.6 g/Kg/day) vs low protein diet (LPD, dietary protein intake ≤ 0.6 g/Kg/day) on two visits after baseline (months 6 and 12). We used a mixed linear regression model to evaluate changes in variables over time in the two diet groups, assuming an unstructured covariance matrix; this was done to consider the correlation between repeated measures and missing points for patients not completing the analysis. Results The I-COPE study included 222 patients (age 63.6 ± 14.2 ys, males 65.3%, diabetes 29.2%). LPD was prescribed in 46.3%, while NLPD in 53.7%. At baseline, no intergroup difference was reported for age (P = 0.51), gender (P = 0.94), and diabetes (P = 0.11). 150 patients had at least an evaluation after baseline. The mixed regression model showed no difference in BMI (P = 0.668) and serum albumin (P = 0.297) adjusted for age, gender, diabetes, and GFR at the start of dialysis. As depicted in Fig. 1, serum albumin level was maintained at 12 months in either group. Conclusion We provide first-time observation that LPD may be safely associated with stable serum albumin and BMI over one year of incremental PD treatment. Therefore, in patients with advanced CKD requiring renal replacement therapy, LPD combined with a low dose of PD may provide a suitable nutritional approach to reduce waste metabolic products without increasing the risk of malnutrition.

#2253 The gender influence on peritoneal membrane transport

Abstract Background and Aims The classification of peritoneal dialysis (PD) patients based on their peritoneal transport was introduced by Twardowski in 1987, analysing a cohort of 86 PD patients, where gender was not specified. Method Aiming to analyze gender differences in the interpretation of peritoneal transport outcomes, we completed a single-center cross-sectional study of 143 incident patients in PD between 2015 and 2022. We also, assessed differences in their follow-up outcomes until PD cessation (21.2 ± 17 months). Results We analyzed 143 patients (55.3 ± 15.5 years, 92% hypertension, 25.5% diabetic, Charlson index 5.9 ± 2.4 points), corresponding to 85 men (M) and 58 women (W). M were older (M 56.4 ± 15.4 years vs. W 53.7 ± 15.7 years, NS) and associated higher comorbidity (hypertension M 95.8% vs. W 86.4%, p = 0.04 and diabetes M 33.7% vs. W 13.6%, P = 0.007, NS on Charlson index) compared to W. Creatinine transport in W is slower than in M (D/P Cr M 0.73 ± 0.1 vs W 0.69 ± 0.1, p = 0.017), but no differences in glucose transport were observed. Although most patients were classified as medium-high transporters, the percentage of M was significantly higher than W (H 71.1% vs M 52.6%). In our cohort, initial adequacy tests using incremental PD reveal that W have a higher total Kt/v (M 2.2 ± 0.5 vs W 2.8 ± 1.9, p = 0.021) attributed to a higher peritoneal Kt/v (M 0. 95 ± 0.41 vs. W 1.3 ± 1.1, p = 0.035) and renal Kt/v (NS). Despite W presented lower residual renal function (NS) and lower residual diuresis (H 1.5 ± 0.7 L vs. M 1.3 ± 0.6 L) compared with M. There was no gender difference in average duration of PD (M 22.4 vs. W 21.5 months). However, most W ended PD to receive a kidney transplant (46.8%), while most M transitioned to haemodialysis (41.3%). Nineteen patients died during follow-up, with 68.4% being M (NS). Conclusion Differences in D/P Cr and normal distribution curves between M and W suggest significant differences in peritoneal membrane transport. Classical methods of assess PD quality and adequacy may need to be corrected by gender, further studies are needed to determine these differences.

Effects of incremental peritoneal dialysis with low glucose-degradation product neutral pH solution on clinical outcomes.

Incremental peritoneal dialysis (IPD) could decrease unfavorable glucose exposure results and preserve (RKF). However, there is no standardization of dialysis prescriptions for patients undergoing IPD. We designed a prospective observational multi-center study with a standardized IPD prescription to evaluate the effect of IPD on RKF, metabolic alterations, blood pressure control, and adverse outcomes. All patients used low GDP product (GDP) neutral pH solutions in both the incremental continuous ambulatory peritoneal dialysis (ICAPD) group and the retrospective standard PD (sPD) group. IPD patients started treatment with three daily exchanges five days a week. Control-group patients performed four changes per day, seven days a week. A total of 94 patients (47 IPD and 47 sPD) were included in this study. The small-solute clearance and mean blood pressures were similar between both groups during follow-up. The weekly mean glucose exposure was significantly higher in sPD group than IPD during the follow-up (p < 0.001). The patients with sPD required more phosphate-binding medications compared to the IPD group (p = 0.05). The rates of peritonitis, tunnel infection, and hospitalization frequencies were similar between groups. Patients in the sPD group experienced more episodes of hypervolemia compared to the IPD group (p = 0.007). The slope in RKF in the 6th month was significantly higher in the sPD group compared to the IPD group (65% vs. 95%, p = 0.001). IPD could be a rational dialysis method and provide non-inferior dialysis adequacy compared to full-dose PD. This regimen may contribute to preserving RKF for a longer period.

WCN24-2514 Cost-Effectiveness of Less Frequent Hemodialysis Compared with Incremental Peritoneal Dialysis in Colombia

WCN24-2514 Cost-Effectiveness of Less Frequent Hemodialysis Compared with Incremental Peritoneal Dialysis in Colombia

Is the cost of the new home dialysis techniques still advantageous compared to in-center hemodialysis? An Italian single center analysis and comparison with experiences from western countries.

Potential advantages of home dialysis remained a questionable issue. Three main factors have to be considered: the progressive reduction in the cost of consumables for in-Center hemodialysis (IC-HD), the widespread use of incremental Peritoneal Dialysis (PD), and the renewed interest in home hemodialysis (H-HD) in the pandemic era. Registries data on prevalence of dialysis modalities generally report widespread underemployment of home dialysis despite PD and H-HD could potentially provide clinical benefits, improve quality of life, and contrast the diffusion of new infection among immunocompromised patients. We examined the economic impact of home dialysis by comparing the direct and indirect costs of PD (53 patients), H-HD (21 patients) and IC-HD (180 patients) in a single hospital of North-west Italy. In order to achieve comparable weekly costs, the average weekly frequency of dialysis sessions based on the dialysis modality was calculated, the cost of individual sessions per patient per week normalized, and the monthly and yearly costs were derived. As expected, PD resulted the least expensive procedure (€ 23,314.79 per patient per year), but, notably, H-HD has a lower average cost than IC-HD (€ 35,535.00 vs. € 40,798.98). A cost analysis of the different dialysis procedures confirms the lower cost of PD, especially continuous ambulatory PD, compared to any extracorporeal technique. Among the hemodialysis techniques, home bicarbonate HD showed the lowest costs, while the weekly cost of Frequent Home Hemodialysis was found to be comparable to In-Center Bicarbonate Hemodialysis.

The Beauty of Individualize Peritoneal Dialysis Prescription by Using Incremental Peritoneal Dialysis during Ramadan Fasting

The Beauty of Individualize Peritoneal Dialysis Prescription by Using Incremental Peritoneal Dialysis during Ramadan Fasting

Relationship between number of daily exchanges at CAPD start with clinical outcomes.

Peritoneal dialysis (PD) continues to be demanding for patients affected by kidney failure. In kidney failure patients with residual kidney function, the employment of incremental PD, a less onerous dialytic prescription, could translate into a decrease burden on both health systems and patients. Between 1st January 2009 and 31st December 2021, 182 patients who started continuous ambulatory peritoneal dialysis (CAPD) at our institution were included in the study. The CAPD population was divided into three groups according to the initial number of daily CAPD exchanges prescribed: one or two (50 patients, CAPD-1/2 group), three (97 patients, CAPD-3 group) and four (35 patients, CAPD-4 group), respectively. Multivariate analysis showed a difference in term of peritonitis free survival in CAPD-1/2 in comparison to CAPD-3 (hazard ratio (HR): 2.20, p = 0.014) and CAPD-4 (HR: 2.98, p < 0.01). A tendency towards a lower hospitalisation rate (CAPD-3 and CAPD-4 vs. CAPD-1/2, p = 0.11 and 0.13, respectively) and decreased mortality (CAPD-3 and CAPD-4 vs. CAPD-1/2, p = 0.13 and 0.22, respectively) in patients who started PD with less than three daily exchanges was detected. No discrepancy of the difference of the mean values between baseline and 24 months residual kidney function was observed among the three groups (p = 0.33). One- or two-exchange CAPD start was associated with a lower risk of peritonitis in comparison to three- or four-exchange start. Furthermore, an initial PD prescription with less than three exchanges may be associated with an advantage in term of hospitalisation rate and patient survival.

Use of incremental peritoneal dialysis: impact on clinical outcomes and quality of life measure.

Incremental peritoneal dialysis (PD)can be defined as a PD prescription that is less than the standard, full dose prescription and is typically used for patients initiating PD with residual kidney function. It has been suggested that use of incremental peritoneal dialysis may help preserve residual kidney function and may offer better quality of life due to the lower treatment burden, however published evidence is limited. In this study we assessed the associations between incremental peritoneal dialysis use and both clinical outcomes and quality of life measures in a large cohort of incident peritoneal dialysis patients in the US. We considered adult patients initiating peritoneal dialysis between 31 July, 2015 and 31 May, 2019 within a single dialysis organization. Patients with body weight < 40kg, amputation, or an estimated glomerular filtration rate > 20mL/min during the first 4weeks on peritoneal dialysis were excluded. Patients were assigned to exposure groups based on peritoneal dialysis prescription during dialysis weeks 5-8. Incremental peritoneal dialysis was defined by treatment frequency, number of exchanges/day, and exchange volume (for continuous ambulatory peritoneal dialysis patients) or by treatment frequency and presence/absence of last fill (for automated peritoneal dialysis patients). Analyses were performed separately for continuous ambulatory peritoneal dialysis and automated peritoneal dialysis. For each analysis, incremental peritoneal dialysis patients were propensity score matched to eligible full-dose peritoneal dialysis patients. Patients were followed for a maximum of 12months until censoring for loss to follow-up or study end. Outcomes were compared using Poisson models (mortality, hospitalization, peritoneal dialysis discontinuation), linear mixed models (estimated glomerular filtration rate), and paired t tests (KDQOL domain scores). Among continuous ambulatory peritoneal dialysis patients, compared to full-doseperitoneal dialysis, incremental peritoneal dialysis use was associated with better KDQOL scores on 3 domains: physical composite score (42.5 vs 37.7, p = 0.03), burden of kidney disease (60.2 vs 45.6, p = 0.003), effects of kidney disease (79.4 vs 72.3, p = 0.05). Hospitalization and mortality rates were numerically lower (0.77 vs 1.12 admits/pt-year, p = 0.09 and 5.0 vs 10.2 deaths/100 pt-years, p = 0.22), while no associations were found with estimated glomerular filtration rate or peritoneal dialysis discontinuation rate. Use of incremental peritoneal dialysis was not associated with any discernable effects on outcomes in automated peritoneal dialysis patients. These results suggest that there may be benefits of using incremental PD in the context of continuous ambulatory peritoneal dialysis, particularly with respect to quality of life as a prescription strategy when initiating peritoneal dialysis. While no significant benefits of incremental peritoneal dialysis were detected among patients initiating automated peritoneal dialysis, no detrimental effects of using incremental schedules were observed for either peritoneal dialysis type.

Incremental peritoneal dialysis and survival outcomes: a propensity-matched cohort study.

The advantages of an incremental dialysis start are not fully clear.We aimed to evaluate the association of incremental initiation of peritoneal dialysis with mortality. Incident peritoneal dialysis patients with a catheter placed at our hospital between 2008 and 2017 were included. All patients were followed up until December 31, 2019. Patients were categorized into different groups according to the initial daily dialysis exchanges, and were matched at a ratio of 1:2 with propensity score matching. Multiple variables including age, sex, residual kidney function, urine volume, hemoglobin, serum albumin and other important variables were included for the matching. Primary outcomes were all-cause and cardiovascular mortality. A total of 1315 patients with a mean age of 45.9years were enrolled. The mean glomerular filtration rate was 4.32ml/min/1.73 m2 at start ofdialysis. Two hundred eighty-fivepatientsin the incremental group and 502 in the full dose group were matched for age, sex, residual kidney function, urine volume, hemoglobin, serum albumin and other important variables. Patient survival and cardiovascular event-free survival were similar between the two groups. However, during the first 6 years of peritoneal dialysis, patients inthe incremental group had bettersurvival (P = 0.011) and cardiovascular event-free survival (P = 0.044) than the full dose group, while such advantages disappeared when dialysis vintage became longer. Further analysis showed that the incremental group (vs full dose dialysis) had a 39% lower risk (95% CI 0.42-0.90, P = 0.012) of all-cause mortality and a 41% decreased risk (95% CI 0.35-0.99, P = 0.047) of cardiovascular mortality during the first 6 years of dialysis. Additionally, the cumulative hazard for anuria was significantly lower in the incremental group versus the full dose group (P = 0.006). Our study shows a time-related survival advantage for incremental peritoneal dialysis patients, suggesting that an incremental regimen for startingperitoneal dialysis is feasibleand is not associated with worse outcomes. Graphical Abstract presenting schematically the measurements of the solvation response function by processing the relevant streak camera images and the time-correlated photon counting (TCSPC) data and appropriately combining them together.

The feasibility of incremental peritoneal dialysis for older patients on peritoneal dialysis.

This study was performed to investigate the feasibility of incremental peritoneal dialysis (iPD) in older patients. In this retrospective cohort study, we enrolled peritoneal dialysis (PD) patients with age ≥ 60 years old at our center from 2008 to 2017. The patients were divided into two groups based on the daily PD exchanges: iPD group (≤3 × 2 L exchanges), and full dose group (≥4 × 2 L exchanges). Kaplan-Meier curves and multivariate Cox regression models were applied to evaluate the risks of anuria and mortalities between groups. A total of 238 patients (186 in full dose group and 52 in iPD group) were enrolled. The mean age was 67.8 ± 5.7 years, and 45.8% were females. The baseline glomerular filtration rate was 4.15 ± 2.39 mL/min/1.73 m2 . Multivariate Cox regression models showed that patients in the iPD group patients had significantly decreased risk of anuria (hazard ratio [HR], 0.44; 95% confidence interval [CI], 0.24-0.81; p = 0.008), and all-cause mortality (HR, 0.59; 95% CI, 0.36-0.98; p = 0.04). Additionally, the incidence of peritonitis was significantly lower in the iPD group than that in the full dose group (0.115 vs. 0.197 episodes per person-year, p = 0.03) during the 36 months of PD commencement. Older patients with iPD were independently associated with better preservation of residual kidney function and survival outcomes. Moreover, iPD regimens are also associated with reduced incidence of peritonitis. The iPD strategy might offer a feasible option for older patients.

#5231 INCREMENTAL PERITONEAL DIALYSIS VERSUS CONSERVATIVE MANAGEMENT IN PATIENTS WITH ESRD

Abstract Background and Aims At its start, Peritoneal dialysis (PD) was implemented only in advanced renal disease with a myriad of symptoms and signs. However, many subsequent literatures have highlighted possible benefits of early rather than late start of PD. Nevertheless, when to start PD has been a matter of controversy. This debate has created a new era of starting dialysis early during the course of the disease, in a small dose that was termed ‘incremental’ dialysis. By this modality, the dose of PD, is low at the initiation of RRT, and could be progressively increased over time in parallel with the reduction of RKF. Although incremental dialysis is growing worldwide, there has been no substantial agreement on the benefits of this approach. Moreover, the few available observational studies have compared incremental versus full-dose PD, with controversial results. On the other hand, studies comparing incremental dialysis with the conservative management for non-symptomatic ESRD patients are mostly deficient in the published literature. The present work is a retrospective, case-control, longitudinal study, aimed to evaluate the adequacy of incremental peritoneal dialysis as a modality of renal replacement therapy in ESRD patients, and whether it adds superior benefits over the conservative and the standard peritoneal dialysis (STPD) managements. Method Data were collected retrospectively from Complesso Integrato Columbus Policlinico Gemelli, nephrology and dialysis unit archives. The study comprising three groups: first included 23 patients who were treated with IPD and second group included 30 patients who were managed with the standard dose of PD (STPD), and a third group include 19 ESRD patients who had GFR values of &amp;lt; 15ml/min and were off dialysis and received only conservative treatment. The collected data for each patient included demographic, clinical assessment (volume excess and nutritional state), pharmacological data, laboratory records (Hb concentration, and sodium, potassium, phosphorus), creatinine clearance and rate of hospitalization, in addition to dialysis regimen and rate of dialysis related infection in IPD and STPD patients, data from these patients were collected at the baseline (time just before starting PD), and every 6 months for 24 months or whenever there is cessation of PD, whichever occurs first. Results In the present study all IPD group patients started PD with increment dose 1 or 2 exchanges per day, with a solution volume 1.5 to 2 L/ exchange for 8 to 16 hours/day. Data analysis revealed improvement in the nutritional state, a better control of the blood electrolyte and body volume in IPD and STPD groups while they deteriorated significantly in the conservative group (P = 0.005, P = 0.001 &amp; P = 0.001, respectively). Dialysis groups succeed in maintain the Hb level within target level with smaller dose of ESA therapy and also ESA Resistive Index (ERI) decreased in this groups while it significantly increased in the conservative group (P1 = 0.019).There was no statistically significant differences between the rate of decline of creatinine clearance between the patients on conservative, those on IPD and STPD (P = 0.295), Also there was no statistically significant difference in the rate of hospitalization between study groups (P = 0.69).Those who had a mean creatinine clearance (CrCl) more than 9.4±2.8 ml/min/1.73m2 could be managed with one exchange to achieve the target Kt/V, a mean CrCl of less than 3.6±0.8 ml/min/1.73m2 failed to reach adequacy even with two exchanges a day and needed to be transferred to full dose while those with a mean CrCl in between the above values could only achieve Kt/V above 1.7 with two exchanges per day. Conclusion Incremental peritoneal dialysis, a rapidly growing new modality, is superior to the conservative treatment in patients with end-stage renal disease that can be adequately applied to patients with a GFR of 4 ml/min or more without adding the burden of full dose dialysis.

Association of Incremental peritoneal dialysis with residual kidney function decline in patients on peritoneal dialysis: The balANZ trial.

Incremental peritoneal dialysis (PD), defined as less than Full-dose PD prescription, has several possible merits, including better preservation of residual kidney function (RKF), lower peritoneal glucose exposure and reduced risk of peritonitis. The aims of this study were to analyse the association of Incremental and Full-dose PD strategy with RKF and urine volume (UV) decline in patients commencing PD. Incident PD patients who participated in the balANZ randomised controlled trial (RCT) (2004-2010) and had at least one post-baseline RKF and UV measurement was included in this study. Patients receiving <56 L/week and ≥56 L/week of PD fluid at PD commencement were classified as Incremental and Full-dose PD, respectively. An alternative cut-point of 42 L/week was used in a sensitivity analysis. The primary and secondary outcomes were changes in measured RKF and daily UV, respectively. The study included 154 patients (mean age 57.9 ± 14.1 years, 44% female, 34% diabetic, mean follow-up 19.5 ± 6.6 months). Incremental and Full-dose PD was commenced by 45 (29.2%) and 109 (70.8%) participants, respectively. RKF declined in the Incremental group from 7.9 ± 3.2 mL/min/1.73 m2 at baseline to 3.2 ± 2.9 mL/min/1.73 m2 at 24 months (p < 0.001), and in the Full-dose PD group from 7.3 ± 2.7 mL/min/1.73 m2 at baseline to 3.4 ± 2.8 mL/min/1.73 m2 at 24 months (p < 0.001). There was no difference in the slope of RKF decline between Incremental and Full-dose PD (p = 0.78). UV declined from 1.81 ± 0.73 L/day at baseline to 0.64 ± 0.63 L/day at 24 months in the Incremental PD group (p < 0.001) and from 1.38 ± 0.61 L/day to 0.71 ± 0.46 L/day in the Full-dose PD group (p < 0.001). There was no difference in the slope of UV decline between Incremental and Full-dose PD (p = 0.18). Compared with Full-dose PD start, Incremental PD start is associated with similar declines in RKF and UV.

Questioning one-size-fits-all dialysis prescription: balancing dialysis prescription and residual kidney function

Recent awareness of the viability and benefits of incremental hemodialysis is an opportunity to review clinical practices and improve the process of dialysis induction. Incremental dialysis is a standard approach in peritoneal dialysis prescription, with a focus on the quality parameter of nephroprotection. The same should apply in hemodialysis, with individualization of the prescribed extracorporeal technique: frequency, duration and intensity, in either home or center hemodialysis, are prescription variables to adjust according to the patient’s residual renal function, medical condition and psycho-social priorities. Considering that fluid balance and smooth ultrafiltration critically impact patient survival, incremental dialysis schedules need to be carefully tailored and grounded in routine residual kidney function measurement. This paper raises concerns about both the benefits of incremental dialysis and its putative detrimental effects, these being mainly dependent on the quality of the hemodialysis prescription and external economic constraints. As a comparator, incremental peritoneal dialysis is a scientifically based model to pursue, whichever the modality, based on updated concepts of patient-centered prescription and adequacy in dialytic renal replacement therapies.

Incremental peritoneal dialysis: Is it better for preservation of residual kidney function and clinical outcomes?

Incremental peritoneal dialysis (IPD) is based on the prescription of a dose lower than the standard (SPD). The combination of residual kidney function (RKF) and peritoneal clearance achieves clearance goals. The aim of this study is to compare the outcomes of IPD with SPD. This was a single-center, retrospective study that included a cohort of prevalent peritoneal dialysis (PD) adults. Patients were assigned according to their first PD protocol in two groups - group A: IPD protocol (continuous ambulatory PD: less than 4 dwells daily, less than 2 L dwell volume, and/or treatment less than 7 days/week; automated PD: without a long dwell, less than 10 L daily delivered, and/or treatment for less than 7 days/week); group B: SPD protocol. 87 PD patients were included, 65.5% underwent IPD. The median follow-up time was 23 months (IQR 15-35). IPD had a higher glomerular filtration ratio (7 vs. 3.7, mL/min/1.73m2, p<0.001) in the first 6 months, and after 24 months (4.8 vs. 1.9, mL/min/1.73m2, p=0.002). IPD protocol was independently associated with GFR≥5 mL/min/1.73m2 at 24 months (OR 13 per point, 95% CI 1.48-114.36, p=0.021). IPD was also associated with a longer technique survival (log-rank test=4.928, p=0.026), lower hospital admissions per year (0.23 vs. 0.5, p=0.001), and lower mortality (1.8% vs. 13.3%, p=0.027). Cox regression demonstrated that IPD (HR 0.30; 95% CI 0.098-0.93); p=0.036) was associated with a decrease in the risk of technique failure. The prescription of IPD seems to be beneficial, in terms of outcomes, for patients with substantial RKF.

Five Things to Know About Incremental Peritoneal Dialysis.

Incremental peritoneal dialysis (PD) offers patients newly starting dialysis less than the standard "full dose" of PD, reducing treatment burden and intrusiveness while minimizing symptoms of renal failure. Incremental PD is a cost-effective approach that has been associated with slower rates of decline in residual kidney function. This approach also produces less waste and in turn reduces environmental footprint compared to standard PD prescriptions. It also aligns with the International Society of Peritoneal Dialysis (ISPD) Practice Recommendations for high-quality, goal-oriented therapy. Awareness of incremental PD along with its advantages and limitations provides practitioners with the tools to provide more patient-centered dialysis prescriptions in appropriate populations.

A Review of Residual Kidney Function in Peritoneal Dialysis Patients.

Residual kidney function (RKF) has been associated with better survival, less morbidity, and improved quality of life in peritoneal dialysis (PD) patients. Since higher peritoneal clearance does not lead to better outcomes, more emphasis should be put on preserving kidney function. Many other benefits have been reported, including better volume and blood pressure control, better nutritional status, lower rates of PD peritonitis, preserved erythropoietin and vitamin D production, middle molecule clearance, lower Left Ventricular Hypertrophy, and better serum phosphate level. The most practical method of assessing RKF is the mean of 24-h urinary urea and creatinine clearance. Incremental PD prescription is an ideal option to supplement RKF in PD patients, which also offers more flexibility to the patient and, possibly, improved adherence. Angiotensin converting enzyme inhibitors and angiotensin receptor blockers should be used when possible in PD patients to preserve RKF. Loop diuretics are underutilized in PD patients despite providing an additional means of maintaining fluid balance and reducing the need for higher glucose-containing PD solutions. In this paper, we outline the importance of RKF in PD patients and the different strategies for its preservation.

Incremental peritoneal dialysis allows to reduce the time spent for dialysis, glucose exposure, economic cost, plastic waste and water consumption.

Incremental peritoneal dialysis (incPD) as the initial PD strategy represents a convenient and resource-sparing approach, but its impact on patient, healthcare and environment has not been thoroughly evaluated. This study includes 147 patients who started incPD at our institution between 1st January, 2009 and 31st December, 2021. Adequacy measures, peritoneal permeability parameters, peritonitis episodes, hospitalizations and increase in CAPD dose prescriptions were recorded. The savings related to cost, patient glucose exposure, time needed to perform dialysis, plastic waste, and water usage were compared to full-dose PD treatment. During the study follow-up 11.9% of the patients transitioned from incremental to full dose PD. Patient cumulative probability of remaining on PD at 12, 24, 36, 48 and 60months was 87.6, 65.4, 46.1, 30.1 and 17.5%, respectively. The median transition time from 1 to 2 exchanges, from 2 to 3 and 3 to 4 exchanges were 5, 9 and 11.8months, respectively. Compared to full dose PD, 1, 2, and 3 exchanges per day led to reduction in glucose exposure of 20.4, 14.8 or 8.3kg/patient-year, free lifetime gain of 18.1, 13.1 or 7.4day/patient-year, a decrease in cost of 8700, 6300 or 3540 €/patient-year, a reduction in plastic waste of 139.2, 100.8 or 56.6kg/patient-year, and a decline in water use of 25,056, 18,144 or 10,196 L/patient-year. In comparison with full-dose PD, incPD allows to reduce the time spent for managingdialysis, glucose exposure, economic cost, plastic waste, and water consumption.

Epidemiology of peritoneal dialysis outcomes.

Peritoneal dialysis (PD) is an important home-based treatment for kidney failure and accounts for 11% of all dialysis and 9% of all kidney replacement therapy globally. Although PD is available in 81% of countries, this provision ranges from 96% in high-income countries to 32% in low-income countries. Compared with haemodialysis, PD has numerous potential advantages, including a simpler technique, greater feasibility of use in remote communities, generally lower cost, lesser need for trained staff, fewer management challenges during natural disasters, possibly better survival in the first few years, greater ability to travel, fewer dietary restrictions, better preservation of residual kidney function, greater treatment satisfaction, better quality of life, better outcomes following subsequent kidney transplantation, delayed need for vascular access (especially in small children), reduced need for erythropoiesis-stimulating agents, and lower risk of blood-borne virus infections and of SARS-CoV-2 infection. PD outcomes have been improving over time but with great variability, driven by individual and system-level inequities and by centre effects; this variation is exacerbated by a lack of standardized outcome definitions. Potential strategies for outcome improvement include enhanced standardization, monitoring and reporting of PD outcomes, and the implementation of continuous quality improvement programmes and of PD-specific interventions, such as incremental PD, the use of biocompatible PD solutions and remote PD monitoring.