A recent multicenter, prospective cohort study conducted in Japan has shed light on the impact of initial peritoneal dialysis (PD) prescriptions on clinical outcomes. The study, which examined Japanese PD patients, found no significant differences in key clinical outcomes between patients initiated on PD volumes of ≤4 L/day and those started on >4 L/day. This suggests that a lower initial PD volume may be a safe and effective approach for certain patients.
The research, published in Nature, addressed the ongoing debate regarding the optimal initial PD prescription. The primary outcomes assessed included transfer to hemodialysis, mortality, incidence of peritonitis, and hospitalization rates. Patient-reported outcomes were also evaluated.
Key Findings
The study revealed that despite the >4 L/day group receiving approximately twice the PD volume as the ≤4 L/day group during the first two years of dialysis, there were no significant differences in the clinical outcomes assessed. Specifically, the hazard ratios for death were similar between the two groups after adjusting for confounding factors such as age and comorbidity burden.
Furthermore, the study found no significant difference in the incidence of peritonitis between the two groups. The hazard ratio for peritonitis was consistently lower in the ≤4 L/day group across various adjusted models, although the difference did not reach statistical significance. Both groups exhibited peritonitis rates below the targets outlined in the new International Society for Peritoneal Dialysis (ISPD) guidelines.
Incremental PD
The concept of incremental PD (incrPD) has been gaining traction, with numerous studies conducted globally to compare incrPD and standard PD. These studies have explored various outcomes, including patient survival, technique survival, peritonitis incidence, hospitalization rates, and preservation of residual kidney function (RKF).
While some studies have suggested potential benefits of incrPD in terms of RKF preservation and reduced peritonitis rates, the overall evidence remains mixed. The definitions of incrPD and standard PD also vary across studies, making direct comparisons challenging.
Study Limitations
The authors acknowledge several limitations to their study, including its observational design, relatively small sample size, and the potential for residual confounding factors. The inability to analyze changes in RKF due to missing data was also noted as a significant limitation. Additionally, the reasons for choosing lower PD prescriptions in some patients were not clear, and data on dwell time were not available.
Clinical Implications
Despite these limitations, the study provides valuable insights into the safety and efficacy of lower initial PD volumes. The findings suggest that initiating PD with a volume of ≤4 L/day may be a reasonable option for selected patients, potentially reducing medical costs without compromising clinical outcomes. However, the authors emphasize the need for larger, randomized controlled trials to confirm these findings and further refine PD prescription strategies.
In conclusion, this study contributes to the growing body of evidence supporting the feasibility of individualized PD prescriptions tailored to patient needs and characteristics. While further research is warranted, the results suggest that a one-size-fits-all approach to initial PD volume may not be necessary, paving the way for more personalized and cost-effective dialysis strategies.
