Start Dialysis With Incremental PD

The majority of patients starting dialysis have residual kidney function (RKF) making them suitable for Incremental PD.

Incremental peritoneal dialysis (IPD) is a strategy by which less than standard “full-dose” PD is prescribed in people initiating PD so that the combination of residual renal and peritoneal clearance achieved is sufficient to achieve individualized clearance goals; it is done with the intention of increasing the peritoneal prescription if and when residual renal clearance subsequently declines​”.1

Chart showing decrease of RKF as PD increases

  • Most patients start IPD with a GFR in the range of 5-12 mL/min/1.73 m2 when moderate uremic symptoms present*2,3
  • Patients are monitored for residual GFR using averages of creatinine and urea clearance3,4
  • The dialysis dose may be gradually increased over time to compensate for any decline in renal function and meet adequacy targets3,4

Incremental PD Offers Many Benefits

Incremental PD strategies ICON

Incremental PD strategies achieve outcomes that are at least as good as full dose PD prescriptions in patients with RKF5

Kidney ICON

RKF preservation without increased risk of peritonitis3,4

Reduction ICON

Lower hospitalisation rates vs standard PD3

Protection ICON

Protection of patient modality goal6

• PD option often low cost GFR if insufficient time for catheter and training • Urgent start PD often not available

Improvement ICON

Benefits may include7,8

• Improvement of ureic symtoms • Reduces burden on patient • Allows more time for the patient to adjust to dialysis therapy • Minimized glucose exposure

Lower cost ICON

Lower cost9

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RKF is associated with better patient survival

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80% of patients survive anuria-free 2+ years longer with incremental PD4

Incremental PD charts

IPD May Preserve Kidney Function Better Than Full-dose PD without Increasing Risk of Peritonitis4

Overall median time to the first peritonitis event was 2.3 years for patients on Incremental PD and full dose4

Study design: A retrospective, randomized study (n=347 patients) between 2007-2015, comparing patients on incremental PD and full dose PD. Primary outcome in the study was anuria-free survival comparing IPD and full dose PD. Inversed probability weighted, adjusted anuria-free survival using time-dependent Cox proportional hazards model.  This was an observational, single-center study, which included only CAPD patients with >200mL daily urine volume.

Potential goals of PD care

Lower hospitalization

  • Maintain individual's quality of life
  • Enable them to meet their life goals
  • Minimize symptoms and treatment burden
  • Ensure delivery of high-quality care
Chart showing time to technique failure by PD intensity

Ease the Transition of Dialysis for Patients

Incremental PD may provide an option for a smoother transition to dialysis

  1. Less burden for patient and carers (with fewer exchanges or dialysis-free days)​
    • Less time spent doing dialysis and more time for normal life activities and goals​
  2. Reduced amount of dialysis fluid normalizes living environment
    • Less storage space required
    • Less waste and improved environmental impact
  3. Symptom burden reduced​
    • Incremental PD clears solutes and achieves adequate dialysis.​
  4. Patients feel able to achieve life goals.​
  5. Maintains independence

We could also add other benefits here and to the table above:

Table showing predictors of drop out to hemodialysis

Extends time on PD

Navaratnarajah Perit Dial Int 2021​

  • Tailoring the PD prescription to RKF enables days off dialysis and reduces therapy burden
  • There was a strong association of the use of this flexible prescription with longer stay on PD​

Multivariate analysis suggested that the incremental approach was associated with a significantly reduced chance of transfer to hemodialysis

Study design: A retrospective, randomized study (n=347 patients) between 2007-2015, comparing patients on incremental PD and full dose PD. Primary outcome in the study was anuria-free survival comparing IPD and full dose PD. Inversed probability weighted, adjusted anuria-free survival using time-dependent Cox proportional hazards model.  This was an observational, single-center study, which included only CAPD patients with >200mL daily urine volume.

THE TIME IS RIGHT FOR PD