Incremental Versus Standard (Full-Dose) Peritoneal Dialysis

Incremental compared with full-dose peritoneal dialysis: A cost analysis from a third-party payer perspective in Australia

IntroductionIncremental peritoneal dialysis (PD) prescriptions, tailored to individual patient needs and residual kidney function, may offer patients greater dialysis-free time than full-dose PD and has the potential to yield substantial cost savings. We aimed to quantify the direct healthcare costs and resource utilization associated with incremental and full-dose PD from a third-party health service payer's perspective and estimate dialysis-free time and dialysis waste saved.MethodsWe recruited patients from a large dialysis service provider in Australia. We retrospectively analysed prospectively collected hospital data from 203 incident patients receiving PD over a 24-month period. Incremental PD was compared to full dose, considering costs related to consumables, multidisciplinary reviews, pathology, and in-patient costs.ResultsOf the 204 incident patients recruited in the study, 123 (60%) were prescribed incremental PD, with mean age of 62 years, and 66% being male. The total mean monthly outpatient cost ($AUD) for any dose of incremental PD was $339 (95% CI $152, -$526, p< .001) less than full dose, with PD consumables as the greatest contributor to the cost difference. At the end of the study, the mean dwell and exchange procedure times were 5065 h (4222-5908) and 455 h (403-507) lower in incremental PD than full dose, respectively, and incremental PD prescriptions saved >2 million litres of water, >9000 kg plastic and >8000 kg cardboard.ConclusionCompared to full dose, incremental PD minimizes dialysis time and is associated with lower costs and dialysis waste, driven largely by reduction in consumables use.

Effects of initial peritoneal dialysis prescription on clinical outcomes in Japanese peritoneal dialysis patients: a cohort study

Effects of the initial peritoneal dialysis (PD) prescription on clinical outcomes are unknown in Japan. We conducted a cohort study using data from Peritoneal Dialysis Outcomes and Practice Patterns Study. The patients were divided into two groups by the volume of the initial PD prescription (≤ 4 L/day or > 4 L/day). Cause-specific Cox proportional hazards survival models were used to model the association between different PD prescriptions and the clinical outcomes. The outcomes included transfer to HD, mortality, the composite of mortality and transfer to HD, peritonitis, hospitalization, and the patient-reported outcomes (PROs). Of the 342 patients, 98 were prescribed ≤ 4 L/day, and 244 were prescribed > 4 L/day. Patients prescribed ≤ 4 L/day were older with a lower percentage being male, had more cardiovascular and cerebrovascular disease but lower diabetes prevalence, were more likely to be receiving CAPD, used more assisted PD, and had lower BMI and mean serum creatinine levels. There were no significant differences between groups in terms of transfer to HD, mortality, transfer to HD or mortality, hospitalization, incidence of peritonitis, and PROs. Patients with initial PD prescriptions of ≤ 4 L/day compared to > 4 L/day had similar clinical outcomes. This practice may provide health economic benefits in Japan.

Comparison of outcomes of incremental vs. standard peritoneal dialysis: a systematic review and meta-analysis

BACKGROUND

Incremental peritoneal dialysis (IPD) refers to the use of less than standard full-dose peritoneal dialysis (SPD) in end-stage renal disease patients. While the use of IPD is being reported in the literature, its safety and efficacy vs. SPD is unclear. We hereby performed a systematic review of studies comparing mortality, peritonitis, technique survival, anuria-free survival and residual renal function (RRF) between IPD and SPD.

METHODS

All comparative studies published on PubMed, Embase, CENTRAL, Scopus, and Web of Science databases from inception to 5th September 2023 and reporting on given outcomes were eligible.

RESULTS

Ten studies were included. Definitions of IPD were heterogenous and hence mostly a qualitative synthesis was undertaken. Majority of studies found no difference in patient survival between IPD and SPD. Meta-analysis of crude mortality data also presented no significant difference. Peritonitis and technique survival were also not significantly different between IPD and SPD in the majority of studies. Data on RRF was conflicting. Some studies showed that IPD was associated with the preservation of RRF while others found no such difference.

CONCLUSION

IPD may be a safe alternative to SPD in incident dialysis patients. There seems to be no difference in patient survival, peritonitis, and technique survival between the two modalities. However, the impact of IPD on RRF is still questionable. Evidence is heterogeneous and conflicting to derive firm conclusions.

Global structures, practices, and tools for provision of chronic peritoneal dialysis

BACKGROUND

Worldwide, the uptake of peritoneal dialysis (PD) compared with hemodialysis remains limited. This study assessed organizational structures, availability, accessibility, affordability and quality of PD worldwide.

METHODS

This cross-sectional study relied on data from kidney registries as well as survey data from stakeholders (clinicians, policymakers and advocates for people living with kidney disease) from countries affiliated with the International Society of Nephrology (ISN) from July to September 2022.

RESULTS

Overall, 167 countries participated in the survey. PD was available in 79% of countries with a median global prevalence of 21.0 [interquartile range (IQR) 1.5-62.4] per million population (pmp). High-income countries (HICs) had an 80-fold higher prevalence of PD than low-income countries (LICs) (56.2 pmp vs 0.7 pmp). In 53% of countries, adults had greater PD access than children. Only 29% of countries used public funding (and free) reimbursement for PD with Oceania and South East Asia (6%), Africa (10%) and South Asia (14%) having the lowest proportions of countries in this category. Overall, the annual median cost of PD was US$18 959.2 (IQR US$10 891.4-US$31 013.8) with full private out-of-pocket payment in 4% of countries and the highest median cost in LICs (US$30 064.4) compared with other country income levels (e.g. HICs US$27 206.0).

CONCLUSIONS

Ongoing large gaps and variability in the availability, access and affordability of PD across countries and world regions were observed. Of note, there is significant inequity in access to PD by children and for people in LICs.

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

PURPOSE

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.

METHODS

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.

RESULTS

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).

CONCLUSION

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.

The Carbon Footprint of Peritoneal Dialysis in Australia

Key Points

Background

As climate change escalates with increasing health impacts, health care must address its carbon footprint. The first critical step is understanding the sources and extent of emissions from commonly utilized clinical care pathways.

Methods

We used attributional process-based life-cycle analysis to quantify CO2 equivalent emissions associated with the delivery of Baxter’s HomeChoice automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD) in Australia.

Results

The annual per-patient carbon emissions attributable to the manufacture and disposal of peritoneal dialysis (PD) fluids and consumables were 1992 kg CO2 equivalent emissions for APD and 1245 kg CO2 equivalent emissions for CAPD. Transport impacts varied depending on the distance between the site of manufacture of PD fluids and consumables and the state of origin of the patient. Therefore, the total impact of providing PD also differed by Australian state, ranging from 2350 to 4503 kg CO2 equivalent emissions for APD and from 1455 to 2716 kg CO2 equivalent emissions for CAPD. Recycling of polyvinyl chloride (PVC) could reduce emissions by up to 14% for APD and 30% for CAPD depending on the distance between the site of PVC waste generation and the recycling center.

Conclusions

This study demonstrated higher per-patient carbon emissions from APD compared with CAPD, owing to both higher fluid and consumable requirements and the consequent higher transport impacts. PVC recycling can partially mitigate PD-associated carbon emissions.

Management of Chronic Heart Failure in Dialysis Patients: A Challenging but Rewarding Path

Chronic heart failure (CHF) is a common complication and cause of death in dialysis patients. Although several clinical guidelines and expert consensus on heart failure (HF) in the general population have been issued in China and abroad, due to abnormal renal function or even no residual renal function (RRF) in dialysis patients, the high number of chronic complications, as well as the specificity, variability, and limitations of hemodialysis (HD) and peritoneal dialysis (PD) treatments, there are significant differences between dialysis patients and the general population in terms of the treatment and management of HF. The current studies are not relevant to all dialysis-combined HF populations, and there is an urgent need for high-quality studies on managing HF in dialysis patients to guide and standardize treatment. After reviewing the existing guidelines and literature, we focused on the staging and diagnosis of HF, management of risk factors, pharmacotherapy, and dialysis treatment in patients on dialysis. Based on evidence-based medicine and clinical trial data, this report reflects new perspectives and future trends in the diagnosis and treatment of HF in dialysis patients, which will further enhance the clinicians' understanding of HF in dialysis patients.

Integrated home dialysis model: facilitating home-to-home transition

Peritoneal dialysis (PD) and home hemodialysis (HHD) are the two home dialysis modalities offered to patients. They promote patient autonomy, enhance independence, and are generally associated with better quality of life compared to facility hemodialysis. PD offers some advantages (enhanced flexibility, ability to travel, preservation of residual kidney function, and vascular access sites) but few patients remain on PD indefinitely due to peritonitis and other complications. By contrast, HHD incurs longer and more intensive training combined with increased upfront health costs compared to PD, but is easier to sustain in the long term. As a result, the integrated home dialysis model was proposed to combine the advantages of both home-based dialysis modalities. In this paradigm, patients are encouraged to initiate dialysis on PD and transfer to HHD after PD termination. Available evidence demonstrates the feasibility and safety of this approach and some observational studies have shown that patients who undergo the PD-to-HHD transition have clinical outcomes comparable to patients who initiate dialysis directly on HHD. Nevertheless, the prevalence of PD-to-HHD transfers remains low, reflecting the multiple barriers that prevent the full uptake of home-to-home transitions, notably a lack of awareness about the model, home-care "burnout," clinical inertia after a transfer to facility HD, suboptimal integration of PD and HHD centers, and insufficient funding for home dialysis programs. In this review, we will examine the conceptual advantages and disadvantages of integrated home dialysis, present the evidence that underlies it, identify challenges that prevent its success and finally, propose solutions to increase its adoption.

Personalized peritoneal dialysis prescription-beyond clinical or analytical values

Traditionally, dialysis adequacy has been assessed primarily by determining the clearance of a single small solute, urea. Nevertheless, it has become increasingly evident that numerous other factors play a crucial role in the overall well-being, outcomes and quality of life of dialysis patients. Consequently, in recent years, there has been a notable paradigm shift in guidelines and recommendations regarding dialysis adequacy. This shift represents a departure from a narrow focus only on the removal of specific toxins, embracing a more holistic, person-centered approach. This new perspective underscores the critical importance of improving the well-being of individuals undergoing dialysis while simultaneously minimizing the overall treatment burden. It is based on a double focus on both clinical outcomes and a comprehensive patient experience. To achieve this, a person-centered approach must be embraced when devising care strategies for each individual. This requires a close collaboration between the healthcare team and the patient, facilitating an in-depth understanding of the patient's unique goals, priorities and preferences while striving for the highest quality of care during treatment. The aim of this publication is to address the existing evidence on this all-encompassing approach to treatment care for patients undergoing peritoneal dialysis and provide a concise overview to promote a deeper understanding of this person-centered approach.

Delivering Person-Centered Peritoneal Dialysis

Peritoneal dialysis (PD) enables people to have a home-based therapy, permitting greater autonomy for individuals along with enhanced treatment satisfaction compared with in-center dialysis care. The burden of treatment on PD, however, remains considerable and underpins the need for person-centered care. This reflects the need to address the patient as a person with needs and preferences beyond just the medical perspective. Shared decision making is central to the recent International Society for Peritoneal Dialysis recommendations for prescribing PD, balancing the potential benefits of PD on patient well-being with the burden associated with treatment. This review considers the role of high-quality goal-directed prescribing, incremental dialysis, and remote patient monitoring in reducing the burden of dialysis, including an approach to implementing incremental PD. Although patient-related outcomes are important in assessing the response to treatment and, particularly life participation, the corollary of dialysis burden, there are no clear routes to the clinical implementation of patient-related outcome measures. Delivering person-centered care is dependent on treating people both as individuals and as equal partners in their care.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

Compared with Full-dose PD start, Incremental PD start is associated with similar declines in RKF and UV.

Multicentre registry analysis of incremental peritoneal dialysis incidence and associations with patient outcomes

BACKGROUND

Incremental peritoneal dialysis (PD) is increasingly advocated to reduce treatment burden and costs, with potential to better preserve residual kidney function. Global prevalence of incremental PD use is unknown and use in Australia and New Zealand has not been reported.

METHODS

Binational registry analysis including incident adult PD patients in Australia and New Zealand (2007-2017), examining incidence of and outcomes associated with incremental PD (first recorded PD exchange volume <42 L/week (incremental) vs. ≥42 L/week (standard)).

RESULTS

Incremental PD use significantly increased from 2.7% of all incident PD in 2007 to 11.1% in 2017 (mean increase 0.84%/year). Duration of incremental PD use was 1 year or less in 67% of cases. Male sex, Aboriginal and Torres Strait Islander (ATSI) or Māori ethnicities, age 45-59 years, medical comorbidities or treatment at a centre with low use of automated PD or icodextrin was associated with lower incidence of incremental PD use. Low body mass index and higher estimated glomerular filtration rate was associated with higher incidence. After accounting for patient and centre variables, commencing PD with an incremental prescription was associated with reduced peritonitis risk (adjusted hazard ratio 0.73, 95% confidence interval (CI) 0.61-0.86).When kidney transplantation and death were considered as competing risks, the association between incremental PD and peritonitis was not significant (sub-hazard ratio [SHR] 0.91, 95%CI 0.71-1.17, p = 0.5), however cumulative incidence of 30-day transfer to haemodialysis was lower in those receiving incremental PD (SHR 0.73, 95%CI 0.56-0.94, p = 0.01). There was no association between incremental PD and death.

CONCLUSIONS

Incremental PD use is increasing in Australia and New Zealand and is not associated with patient harm.

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

BACKGROUND

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.

METHODS

We considered adult patients initiating peritoneal dialysis between 31 July, 2015 and 31 May, 2019 within a single dialysis organization. Patients with body weight < 40 kg, amputation, or an estimated glomerular filtration rate > 20 mL/min during the first 4 weeks 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 12 months 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).

RESULTS

Among continuous ambulatory peritoneal dialysis patients, compared to full-dose peritoneal 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.

CONCLUSION

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.

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.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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 60 months 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 11.8 months, 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 8.3 kg/patient-year, free lifetime gain of 18.1, 13.1 or 7.4 day/patient-year, a decrease in cost of 8700, 6300 or 3540 €/patient-year, a reduction in plastic waste of 139.2, 100.8 or 56.6 kg/patient-year, and a decline in water use of 25,056, 18,144 or 10,196 L/patient-year.

CONCLUSIONS

In comparison with full-dose PD, incPD allows to reduce the time spent for managing dialysis, glucose exposure, economic cost, plastic waste, and water consumption.

Managing Transition between dialysis modalities: a call for Integrated care In Dialysis Units

Summary Patients with chronic kidney disease have three main possible groups of dialysis techniques: in-center hemodialysis, peritoneal dialysis, and home hemodialysis. Home dialysis techniques have been associated with clinical outcomes that are equivalent and sometimes superior to those of in-center hemodialysisTransitions between treatment modalities are crucial moments. Transition periods are known as periods of disruption in the patient’s life associated with major complications, greater vulnerability, greater mortality, and direct implications for quality of life. Currently, it is imperative to offer a personalized treatment adapted to the patient and adjusted over time.An integrated treatment unit with all dialysis treatments and a multidisciplinary team can improve results by establishing a life plan, promoting health education, medical and psychosocial stabilization, and the reinforcement of health self-care. These units will result in gains for the patient’s journey and will encourage home treatments and better transitions.Peritoneal dialysis as the initial treatment modality seems appropriate for many reasons and the limitations of the technique are largely overcome by the advantages (namely autonomy, preservation of veins, and preservation of residual renal function).The transition after peritoneal dialysis can (and should) be carried out with the primacy of home treatments. Assisted dialysis must be considered and countries must organize themselves to provide an assisted dialysis program with paid caregivers.The anticipation of the transition is essential to improve outcomes, although there are no predictive models that have high accuracy; this is particularly important in the transition to hemodialysis (at home or in-center) in order to plan autologous access that allows a smooth transition.

On the importance of the interplay of residual renal function with clinical outcomes in end-stage kidney disease

Chronic kidney disease (CKD) is one of the most important public health concerns of the century, and is associated with high rates of morbidity, mortality and social costs. CKD evolving towards end-stage kidney disease (ESKD) is on the rise resulting in a greater number of patients requiring peritoneal dialysis (PD) and hemodialysis (HD). The aim of this manuscript is to review the current literature on the interplay of residual renal function (RRF) with clinical outcomes in ESKD. The persistence of RRF is one of the most important predictors of decreased morbidity, mortality, and better quality of life in both PD and HD patients. RRF contributes to the well-being of ESKD patients through various mechanisms including higher clearance of solutes, maintenance of fluid balance, removal of uremic toxins and control of electrolytes. Furthermore, RRF has beneficial effects on inflammation, anemia, malnutrition, diabetes mellitus, obesity, changes in the microbiota, and cardiac diseases. Several strategies have been proposed to preserve RRF, such as blockade of the renin-angiotensin-aldosterone system, better blood pressure control, incremental PD and HD. Several clinical trials investigating the issue of preservation of RRF are ongoing. They are needed to broaden our understanding of the interplay of RRF with clinical outcomes in ESKD.

Incremental peritoneal dialysis after unplanned start initiation

Incremental peritoneal dialysis (PD) is characterized as less than a "standard dose" PD prescription. Compared to standard treatment, it has many potential advantages, including better preservation of residual renal function, a lower risk of peritonitis, and a decreased care delivery burden while reducing the environmental impact and economic cost. Unplanned PD can be defined when treatment starts up to 14 days after catheter insertion and is recognized as a safe and feasible clinical approach. In this perspective paper, we briefly discuss both strategies and share our experience and clinical routine in managing incremental PD after unplanned initiation.

Outcomes of incident patients treated with incremental haemodialysis as compared with standard haemodialysis and peritoneal dialysis

BACKGROUND

Residual kidney function is considered better preserved with incremental haemodialysis (I-HD) or peritoneal dialysis (PD) as compared with conventional thrice-weekly HD (TW-HD) and is associated with improved survival. We aimed to describe outcomes of patients initiating dialysis with I-HD, TW-HD or PD.

METHODS

We conducted a retrospective analysis of a prospectively assembled cohort in a single university centre including all adults initiating dialysis from January 2013 to December 2020. Primary and secondary endpoints were overall survival and hospitalization days at 1 year, respectively.

RESULTS

We included 313 patients with 234 starting on HD (166 TW-HD and 68 I-HD) and 79 on PD. At the end of the study, 10 were still on I-HD while 45 transitioned to TW-HD after a mean duration of 9.8 ± 9.1 months. Patients who stayed on I-HD were less frequently diabetics (P = .007). Mean follow-up was 33.1 ± 30.8 months during which 124 (39.6%) patients died. Compared with patients on TW-HD, those on I-HD had improved survival (hazard ratio 0.49, 95% confidence interval 0.26-0.93, P = .029), while those on PD had similar survival. Initial kidney replacement therapy modality was not significantly associated with hospitalization days at 1 year.

CONCLUSIONS

I-HD is suitable for selected patients starting dialysis and can be maintained for a significant amount of time before transition to TW-HD, with diabetes being a risk factor. Although hospitalization days at 1 year are similar, initiation with I-HD is associated with improved survival as compared with TW-HD or PD. Results of randomized controlled trials are awaited prior to large-scale implementation of I-HD programmes.

The Peritoneal Membrane—A Potential Mediator of Fibrosis and Inflammation among Heart Failure Patients on Peritoneal Dialysis

Peritoneal dialysis is a feasible, cost-effective, home-based treatment of renal replacement therapy, based on the dialytic properties of the peritoneal membrane. As compared with hemodialysis, peritoneal dialysis is cheaper, survival rate is similar, residual kidney function is better preserved, fluid and solutes are removed more gradually and continuously leading to minimal impact on hemodynamics, and risks related to a vascular access are avoided. Those features of peritoneal dialysis are useful to treat refractory congestive heart failure patients with fluid overload. It was shown that in such patients, peritoneal dialysis improves functional status and quality of life, reduces hospitalization rate, and may decrease mortality rate. High levels of serum proinflammatory cytokines and fibrosis markers, among other factors, play an important part in congestive heart failure pathogenesis and progression. We demonstrated that those levels decreased following peritoneal dialysis treatment in refractory congestive heart failure patients. The exact mechanism of beneficial effect of peritoneal dialysis in refractory congestive heart failure is currently unknown. Maintenance of fluid balance, leading to resetting of neurohumoral activation towards a more physiological condition, reduced remodeling due to the decrease in mechanical pressure on the heart, decreased inflammatory cytokine levels and oxidative stress, and a potential impact on uremic toxins could play a role in this regard. In this paper, we describe the unique characteristics of the peritoneal membrane, principals of peritoneal dialysis and its role in heart failure patients.