Incremental peritoneal dialysis

Abstract

<jats:p> Incremental peritoneal dialysis (PD) has been variably defined. It involves taking advantage of the residual renal function that is usually present at initiation of dialysis to initially prescribe less onerous lower doses of PD while still achieving individualized clearance goals. We propose that incremental PD be defined as a strategy, rather than a particular regime, in which: (1) less than standard “full-dose” PD is initially prescribed in recognition of the value of residual renal function; (2) peritoneal clearance is initially less than the individualized clearance goal but the combination of peritoneal plus renal clearance achieves or exceeds that goal clearance; and (3) there is a clear intention to increase dose of PD as renal clearance declines and/or symptoms appear. </jats:p><jats:p> Incremental PD by its nature lessens the workload of dialysis for those doing PD, reduces cost and exposure of the peritoneal membrane to glucose, and may lessen mechanical symptoms. Evidence that incremental PD improves clinical outcomes compared to the use of full-dose PD is lacking but one randomized controlled trial, multiple observational studies, and a systematic review all suggest that outcomes are at least as good. Given that incremental PD costs less and is inherently less onerous, it is reasonable, pending larger randomized trials, to adopt this strategy. </jats:p>

The osmo-metabolic approach: a novel and tantalizing glucose-sparing strategy in peritoneal dialysis

“…Likewise, any PD treatment aimed to reduce, among others, glucose exposure may further benefit in using osmo-metabolic agents. This is the case of incremental PD, a dialysis strategy that is in keeping with the issue of green nephrology [106], and may offer several advantages with no evidence of any harmful effect [107,108].…”

Foreign Perspective on Achieving a Successful Peritoneal Dialysis-First Program

“…The gradual incremental dialysis dose is adjusted based on the clinical condition of patients. The use of incremental PD is supported by a recent ISPD guideline in which less than the standard "full-dose" PD is prescribed to people initiating PD so that the combination of residual renal and peritoneal clearance achieved is sufficient to achieve individualized clearance goals (14).…”

The Role of Incremental Peritoneal Dialysis in the Era of the Advancing American Kidney Health Initiative

“…The ISPD suggests using innovative PD care delivery strategies, such as incremental PDa strategy with the potential to improve patient experience while lowering complication rates and costs. Incremental PD refers to the strategy of prescribing less than the standard "full dose" of PD when initiating PD so that the combination of residual kidney function (RKF) and peritoneal clearance is sufficient to achieve individualized clearance goals; the prescription is increased if (and when) RKF declines (2). An incremental PD prescription consists of any of the following: (1) continuous ambulatory peritoneal dialysis (CAPD) with fewer than four dwells daily, ,2-L dwell volume, or ,7 d/wk or (2) automated PD with no day dwell, ,10-L total daily dose, or ,7 d/wk (2).…”

“…Incremental PD refers to the strategy of prescribing less than the standard "full dose" of PD when initiating PD so that the combination of residual kidney function (RKF) and peritoneal clearance is sufficient to achieve individualized clearance goals; the prescription is increased if (and when) RKF declines (2). An incremental PD prescription consists of any of the following: (1) continuous ambulatory peritoneal dialysis (CAPD) with fewer than four dwells daily, ,2-L dwell volume, or ,7 d/wk or (2) automated PD with no day dwell, ,10-L total daily dose, or ,7 d/wk (2). Notably, incremental PD is initiated at the same time as "full-dose" PD and is not a strategy that favors the early initiation of dialysis.…”

“…As a result, to achieve the AAKH home goal, nearly 80,000 patients with incident kidney failure may need to choose to initiate PD every year (1). For this to occur, the expansion of patient-centered strategies such as incremental PD should be explored, along with parallel efforts to overcome barriers to kidney transplantation and home HD (1,2). This perspective aims to provide an overview of incremental PD, including advantages and limitations of implementing this strategy to help achieve the AAKH goal of optimizing patient-centered home therapies in the United States (2,3).…”