Response to Inadequate Peritoneal Dialysis

Since the publication of the initial National Kidney Foundations Dialysis Outcomes Quality Initiatives (KDOQI) Guidelines for Adequacy of Peritoneal Dialysis (PD)¹ there has been a positive trend to increase the frequency of monitoring and the dose of delivered dialysis among PD patients in the US.  Data from the Centers for Medicare and Medicaid for the year 2000 and the ESRD Clinical Performance Measures Project Annual Report for 2004 were used to obtain information on dialysis prescriptions and adequacy^2,3.  

The dose of dialysis prescribed and delivered has significantly increased since the original publication of the KDOQI guidelines in 1997.  The percentage of CAPD patients that met the guidelines for Kt/V or that the dialysis prescription was changed if the adequacy measurements were less than these thresholds during the six month study period increased from 23% in 1995 to 70% in 2004^2,4.  Similarly, cycler patients have increased from 28 to 65% during that period of time.

 Percent of patients meeting KDOQI guidelines

The principal means to increase the PD dose include an increase in the number of daily exchanges, higher exchange volumes and a combination of these two maneuvers.  As of March 2004, only 11% of all patients used less than 8,000 ml of PD solution per day, 33% used 8,000 ml and 66% more than 8,000 ml.  Among adult CAPD patients the single dwell volume was < 2,000 ml in 50% of the patients and exceeded 2,000 ml in the other 50%.  The mean single night-time dwell volume for adult patients on cycler therapy exceeded 2,500 ml in 42%. 

 Distribution of 24-hour total infused dialysate volumes for adult CAPD patients, Oct 2003 - Mar 2004 (2004 ESRD CPM Project)

Distribution of single dwell volumes for adult CAPD patients, Oct 2003 - Mar 2004 (2004 ESRD CPM Project)

Among adult cycler patients the mean number of night-time exchanges was three exchanges in 13%, four in 43% and five or more in 37% and the mean number of day-time exchanges was two or more in 42%.  These trends towards utilization of larger volumes of dialysate, particularly at night and in the supine position, reflect the emphasis on good dialysis practices.  There are insufficient data to establish trends on volume control and net ultrafiltration.

Distribution of mean number of day-time exchanges for adult cycler patients with a day-time dwell, Oct 2003 - Mar 2004 (2004 ESRD CPM Project)

Distribution of mean single day-time dwell volumes for adult cycler patients with a day-time dwell, Oct 2003 - Mar 2004 (2004 ESRD CPM Project)

Distribution of mean number of nighttime exchanges for adult cycler patients, Oct 2003 - Mar 2004 (2004 ESRD CPM Project)

 Distribution of mean single nighttime dwell volumes for adult cycler patients, Oct 2003 - Mar 2004 (2004 ESRD CPM Project)

References:

1. NKF DOQI. Clinical Practice Guidelines for Peritoneal Dialysis Adequacy. Am J Kidney Dis 30:S67-S136, 1997
2. Rocco MV, Frankenfield DL, Prowant B, et al.  Response to inadequate dialysis in chronic peritoneal dialysis patients.  Results from the 2000 centers for Medicare and Medicaid (CMS) ESRD Peritoneal Dialysis Clinical Performance Measures (PD-CPM) Project. Am J Kidney Dis 41:840-848, 2003
3. Centers for Medicare & Medicaid Services: 2004 Annual Report, End-Stage Renal Disease Clinical Performance Measures Project. Am J Kidney Dis 46 (Suppl 2):1-100, 2005
4. Health Care Financing Administration: 2000 Annual Report, End-Stage Renal Disease Clinical Performance Measures Project, Baltimore, MD-44, Department of Health and Human Services, Health Care Financing Administration, Office of Clinical Standards and Quality, 2000