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International Society for Peritoneal Dialysis (ISPD) practice recommendations: Prescribing high-quality goal-directed peritoneal dialysis
Edwina A Brown, Peter G Blake, Neil Boudville, Simon Davies, Javier de Arteaga, Jie Dong, Fred Finkelstein, Marjorie Foo, Helen Hurst, David W Johnson, Mark Johnson, Adrian Liew, Thyago Moraes, Jeff Perl, Rukshana Shroff, Isaac Teitelbaum, Angela Yee-Moon Wang and Bradley Warady
Full text is free at Peritoneal Dialysis International
Introduction
Peritoneal Dialysis (PD) is an increasingly popular modality of kidney replacement therapy (KRT) for end stage kidney disease (ESKD). There is renewed interest in promoting home dialysis therapies and peritoneal dialysis is the most commonly prescribed home therapy.
PD can be prescribed in almost any population, including
Patients in remote locations.
Patients from economically emerging countries
Children
Frail and older people
But there are certain aspects that need to be taken into account:
PD requires a certain level of commitment, on the part of people practicing this modality, as well as their care-givers and prescribers need to respect their lifestyles and limitations
As these people may not be visiting their physicians regularly, they need to be guided about when to seek help
It is not always feasible for people on PD to measure solute and fluid clearances and they need to know if and when they need a change in prescription or modality
The International Society for Peritoneal Dialysis (ISPD) is a multinational organization focussed on promotion of peritoneal dialysis and provides guidance on how best to provide PD in various populations. The ISPD regularly organizes a review of all aspects of current PD practices and develops guidelines to help prescribers. These ISPD guidelines can be accessed here.
Guidelines on adequacy of PD were last published in 2006. These guidelines emphasize small solute clearance and fluid removal. Healthcare providers interpreted these suggestions to be the "mandatory minimum clearance" and provided prescriptions aiming for this clearance target, often at the cost of the persons choosing PD as a KRT and their caregivers as well as their lifestyles, convenience, and quality of life.
Much has been learned since the last guidelines, from people doing PD themselves, their caregivers and health care professionals as well as from discussions in conferences like the KDIGO Controversies Conference on Dialysis Initiation, Modality Choices and Prescription in 2018 ,and the SONG - Initiative.
Consequently, for the current set of guidelines, the approach changed from “adequate dialysis “ to a ‘goal-directed dialysis”
‘using shared decision-making between the patient and care team to establish realistic care goals that will allow the patient to meet his/her own life goals and allow the clinician to provide individualized, high quality dialysis care’
This approach stems from the Standardised Outcomes in Nephrology - PD (SONG-PD) initiative, which involved people doing PD, caregivers and health professionals and identified core outcomes for this special population. (Fig 1.)
SONG-PD core outcomes for people on PD
Landmark Trials in Peritoneal Dialysis
Below is a timeline from Landmark Trials in nephrology
Timeline of landmark trials in PD
Some more details in a tabular form:
Solute clearance, measured in terms of Kt/V and CCr, is but one parameter of measurement of adequacy. ’Goal Directed dialysis’ therapy has the person doing PD at the center of the adequacy discussion and changes the question from “How to achieve a Kt/V of x?” to “How can we best provide a PD prescription that accommodates the person’s values and goals for therapy”.
Several measures and goals need to be considered in determining the adequacy of dialysis -
Symptoms
Individual experiences and goals
Residual kidney function (RKF)
Volume status
Biochemical measures
Nutritional status
Cardiovascular function
Small solute clearance and
Sense of well-being and satisfaction
Methods
The guideline committee set out to update the 2006 PD dialysis adequacy paper with renewed emphasis on the “Person on Peritoneal Dialysis”. International PD experts were tasked with updating the guidelines and to consider the following factors in the new position paper.
Table 1 from Brown et al, PDI 2020
These recommendations strongly agree with the core outcomes identified by the SONG-PD Initiative. Evidence supporting the recommendations was graded using the standard GRADE system - as follows
Unique to this exercise was continuous representation and participation of people on PD, right from conception to the final product.
Key recommendations include the following:
Key Recommendations
Key recommendations are presented within the main document, while the supporting evidence is included in a series of accompanying papers in the same issue of the journal.
Recommendation One
PD should be prescribed using shared decision-making between the person doing PD and the care team. The aim is to establish realistic care goals that:
Maintain quality of life for the person doing PD as much as possible by enabling them to meet their life goals
Minimize symptoms and treatment burden while
Ensuring high-quality care is provided
Key points
The principles of person-centred care and shared decision-making should be applied to the care of people who are reaching end-stage kidney disease (practice point)
People doing PD should be educated and given choice as far as is possible concerning the PD prescription they receive (practice point)
People doing PD should be educated about their conditions and be informed about their prognosis and given the opportunity to define their goals of care (practice point)
Patient reported experience of care is a crucial measure of how effective person centred care is in PD and should be surveyed and used to improve the delivery of care (practice point)
My take
Ultimately, any form of dialysis is a means of enabling a person to lead a healthy, happy and productive life. So it makes sense that any regime that is prescribed to these people, should be developed with their collaboration.
Recommendation Two
The PD prescription should take into account the local country resources, the wishes and lifestyle considerations of people needing treatment, including those of their families/caregivers’, especially if providing assistance in their care.
Key Points
PD is prescribed in a variety of ways depending on local country resources, availability of PD solutions and devices, modalities, reimbursement, clinicians’ preferences and other local constraints, as well as patients’ characteristics and preferences regarding lifestyle and family/caregiver wishes if providing assistance (practice point)
My take
Again, there is emphasis on treating the person and not the disease alone. . Your prescription may be textbook perfect, but is the person being treated really happy? Do they have the resources to follow your advice? It is truly an unfortunate case when someone started on PD is simply unable to follow through. We must make sure the prescription is practical!
Recommendation Three
A number of assessments should be used to help ensure the delivery of high-quality PD care.
Patient reported outcome measures – this is a measure of how a person doing PD is experiencing life and his/her feeling of well-being. It should take into account the person’s symptoms, impact of the dialysis regimen on the person’s life, mental health and social circumstances.
Fluid status is an important part of dialysis delivery. Urine output and fluid removed by dialysis both contribute to maintaining good fluid status. Regular assessment of fluid status, including blood pressure and clinical examination, should be part of routine care.
Nutrition status should be assessed regularly through evaluation of the patient’s appetite, clinical examination, body weight measurements and blood tests (potassium, bicarbonate, phosphate, albumin). Dietary intake of potassium, phosphate, sodium, protein, carbohydrate and fat may need to be assessed and adjusted as well.
Removal of toxins. This can be estimated using a calculation called Kt/Vurea and/or creatinine clearance. Both are measures of the amount of dialysis delivered. There is no high-quality evidence regarding the need or benefit associated with the achievement of a specific target value for these measures.
Key Points
Health related quality of life (HRQOL)
The person’s perception of their health-related quality of life should be assessed routinely. This should take into account assessment of symptoms, the impact of dialysis treatment prescription on life participation and psychosocial status. Appropriate adjustments in care should be made based on these assessments (practice point).
Assessing the patient’s perception of their HRQOL should be integrated into routine care assessments and taken into account when prescribing the optimal treatment regimen for each patient (practice point)
Utilizing Patient Reported Outcome Measures (PROM) to assess patients’ experiences, symptoms and domains of difficulty requires that appropriate approaches be utilized, such as the incorporation of various questionnaires into routine patient care, addressing a wide variety of domains (practice point)
It is suggested that PD regimen should be adjusted and modified using a person-centred, shared decision-making individualized approach, based on patients’ symptoms and medical/clinical needs, HRQOL, sense of well-being and satisfaction and life participation with clearly defined goals of care (practice point)
Fluid Status
High-quality PD prescription should aim to achieve and maintain clinical euvolaemia taking residual kidney function and its preservation into account, so that both fluid removal from peritoneal ultrafiltration and urine output are considered and residual kidney function is not compromised (practice point).
Blood pressure should be included as one of the key objective parameters in assessing quality of PD prescription. However, there is currently no evidence for a specific blood pressure target in PD (practice point).
Regular assessment of volume status including blood pressure and clinical examination should be part of the routine clinical care (practice point).
Nutrition Status
Nutritional status should be regularly assessed and monitored with attention to appetite and dietary protein intake to maintain a normal nutrition status with restriction of phosphorus, sodium and potassium as indicated (practice point).
Biochemical plasma markers including potassium, bicarbonate, albumin, phosphate should be regularly measured as markers of nutrition (practice point).
Hypokalemia is associated with poor nutritional intake and adverse outcomes including peritonitis. Dietary and/or oral potassium supplementation should be considered (practice point)
Hypoalbuminemia is more common in PD compared to HD and is associated with protein energy wasting and peritoneal protein losses. Interventions are of limited utility in increasing serum albumin alone (practice point)
Hyperphosphatemia is multifactorial and associated with adverse outcomes in PD. Dietary interventions, phosphate binders and modifying the PD prescription should be considered to control hyperphosphatemia (practice point)
Poor nutritional status and protein energy wasting should be evaluated when assessing the need to increase the dose of peritoneal dialysis (practice point)
My take
Is the person doing PD satisfied with their life on PD? Is the therapy in concordance with their personal values? Has PD helped maintain/improve their QoL? Is the PD regime interfering with their personal or professional life? Is therapy really 'therapeutic'? Asking these questions critically is important to ensure the well-being of people undergoing PD.
Removal of toxins
Small solute clearance should be routinely measured using Kt/Vurea or creatinine clearance to provide a quantitative measure of the amount of dialysis delivered. This can guide the amount of dialysis prescribed, while recognizing the limitations of accuracy of these measurements in individuals (practice point).
There is no specific clearance target that guarantees sufficient dialysis for an individual. Increasing small solute clearance to a Kt/V > 1.7 may improve uraemia related symptoms, if present, but there is only low certainty evidence showing that increasing urea clearance has any impact on quality of life, technique survival or mortality (practice point).
The presence of residual kidney function at the start of PD may enable individuals to start on a low dose prescription that may be increased incrementally as residual kidney function declines or as clinically indicated. This may allow patients more time for life participation, less treatment burden and better quality of life (practice point).
If symptoms, nutrition and volume are all controlled, no PD prescription change is needed for the sole purpose of reaching an arbitrary clearance target (practice point).
Critique of previous targets for small solute clearance
There is very low certainty evidence that residual kidney function may be more important than peritoneal clearance (practice point)
There appears to be no survival advantage in aiming routinely for a weekly Kt/V > 1.70 (practice point)
There is very low certainty evidence that a weekly Kt/V less than 1.7 may be associated with increased morbidity (practice point)
Other factors beyond urea clearance
Patients who remain symptomatic despite a Kt/Vurea > 1.7 should have other dialysis and non-dialysis-related factors considered as possible contributing factors. A trial of increasing dialysis dose may be indicated (practice point)
Incremental dialysis
Incremental peritoneal dialysis is a strategy by which less than standard ‘full-dose’ PD is prescribed in people initiating PD; it is done with the intention of increasing the peritoneal prescription if and when residual kidney clearance declines (DEFINITION)
Incremental PD strategies use less PD solution than standard full-dose PD prescription and so cost less (GRADE 1A)
Incremental PD strategies achieve outcomes that are at least as good as full dose PD prescription in patients with residual kidney function (practice point)
My take
The above mentioned trials suggest that Kt/V is really just one of a number of factors that needs to be assessed for dialysis adequacy. It is probably a good idea to measure the kt/v occasionally and aim for a kt/v of 1.7, there is nothing to suggest that a higher value leads to a better outcomes. Moral of the story - treat the person and not the lab report! Don't let the numbers dictate your prescription. And the statement where it suggests that “if the patient is well, no PD prescription change is necessary to achieve an arbitrary number” is particularly important. It is up to us to take this guideline to our front line staff who frequently worry about marginally low kt/v in a perfectly well patient.
Recommendation Four
The amount of kidney function that continues to remove waste products and the remaining urine volume should be known for all individuals doing PD. Management should focus on preserving this as long as possible.
Key Points
RKF is an important component of the overall well-being and survival of dialysis patients (practice point)
There is low certainty evidence demonstrating that different PD modalities may make little or no difference to preservation of RKF (practice point)
Caution should be taken to avoid volume depletion and hypotension based on low certainty evidence that this may adversely affect RKF (practice point)
Urine output is increased by a variable, but small, amount when using neutral pH, low glucose degradation product dialysate for the first 12–24 months after starting PD (GRADE 1A), though there is low certainty evidence of associated reduction in ultrafiltration
My take
Residual renal function often gets overlooked once the patient is on dialysis. The effort needed to preserve this needs to be conscious and continuous. Patients need to be educated on keeping an eye on the urine output as dramatic drops in the urine output may require a change in the PD prescription.
Recommendation Five
For some people who require dialysis and who are old, frail or have a poor prognosis, there may be a quality of life benefit from a reduced dialysis prescription to minimize the burden of treatment.
Key Points
PD is only one component of overall care (practice point)
It is suggested that goals of care and care needs are determined after appropriate geriatric and palliative care assessments with shared decision-making approach (practice point)
Management should consider people’s life goals, quality of life and symptom control (practice point)
Residual kidney function enables PD prescription to be reduced; this enables reduction in treatment burden in line with other existing multimorbidity guidelines (practice point)
My take
The elderly comprise a unique segment of the PD population. They may have multiple co-morbidities and PD often becomes an additional burden. They also have limitations like low visual acuity and impaired physical dexterity and may not always have the benefit of a dedicated caregiver. The PD prescription must take all these factors into account. Balancing a prescription to match the patient’s values plays a key role.
Here again a shared decision making approach is called for, involving both the elderly people and their care-givers.
Recommendation Six
In low and lower middle-income countries, every effort should be made to conform to the framework of these statements, taking into account resource limitations.
Key Points
The initial PD prescription should take into consideration the amount of residual renal function and be aimed at achieving clinical euvolemia, clinical and biochemical well-being of patients at the lowest cost, through the use of incremental PD with fewer bags and PD free days (practice point)
All efforts should be made to preserve residual kidney function and peritoneal membrane function, and in so doing, maintain PD ultrafiltration for an extended period without the need to intensify PD prescription (practice point)
Greater emphasis be made to utilize low-cost adjunctive management strategies in low low middle income countries (LLMICs), such as dietary and life-style modification, in reducing the generation of uremic toxins and achieving euvolemia, with the aim to minimize the need to intensify the PD prescription prematurely (practice point)
PET and weekly Kt/V should be encouraged if the cost of these tests do not compromise the affordability of PD treatment in LLMICs. Where facility-performed PET or Kt/V is unavailable or unaffordable, it is reasonable to assess quality and adequacy of PD prescription based on clinical, biochemical parameters and clinical well-being of patients (practice point)
PD programs should monitor the outcomes of these clinical interventions, focusing on inexpensive clinical indicators, to determine efficacy, trends and progression and for international comparison (practice point)
My take
PD has the potential to be an economical and sustainable renal replacement therapy for resource poor societies. For these to be successful, clinical judgement and innovative practices need to be adopted. For emerging economies, all attempts must be made to optimize utilization of the limited resources available. Incremental dialysis appears to be an attractive option, starting with fewer bags and cheaper solutions. Obviously, it helps to have a good RKF, and all efforts must be made to promote dietary and lifestyle changes which can help in its preservation. Measurement of Kt/V may not always be possible in these LLMICs and physicians must rely on other parameters to determine adequacy.
Recommendation Seven
The principles of prescribing and assessing delivery of high-quality PD to children are the same as for adults. In all cases, the PD prescription should be designed to meet the medical, mental health social and financial needs of the individual child and family
Key Points
In children, selection of the dialysis modality should be based upon the child’s age and size, presence of comorbidities, family support available, modality contraindications, expertise of the dialysis team and the child’s and parents’/caregivers’ choice. Preserving dialysis access, both peritoneal and vascular access, must be considered when selecting the optimal dialysis modality for a child (practice point)
While the goal of PD therapy is to optimize fluid management and solute clearance, this must be considered in the context of the child’s and family’s expectations of dialysis and quality of life, encouraging the child to participate at school and free time with family and friends as much as possible (practice point)
My take
The advantages of PD in children are manifold including the comfort of home dialysis, provision for regular school attendance, lesser dietary restrictions, avoiding need for vascular access and even a reported slower rate of decline in renal function. However, children may be too young to understand or perform the procedure and require the commitment of a parent or caregiver. It is also important to ensure that the child grows happily with active involvement in scholastic activities and also that he/she has some good old fashioned fun!
Recommendation Eight
A. Once-daily icodextrin should be considered as an alternative to hypertonic glucose solutions for long dwells in people doing PD who are experiencing difficulties maintaining euvolemia due to insufficient peritoneal ultrafiltration, taking into account the individual’s peritoneal transport state (GRADE 1B).
B. Use of neutral pH, low GDP PD solutions improves preservation of residual kidney function and urine output (GRADE 1A). There is low certainty evidence that use of these fluids may have little or no effect on technique survival or mortality.
Key Points
PDOPPS shows significant variability in the use of PD solutions across programs, and more studies with longer follow ups and relevant outcomes assessment is required.
The ISPD Cardiovascular guideline 2015 and Cochrane Review 2018 have reviewed and there may be an advantage to specific solutions in specific situations.
My Take
There are many types of fluids available and these fluids can be quite expensive. As with other recommendations there needs to be a balance between clinical utility, cost to the patient and the system and expected benefit.
Practical Implementation
The guideline also provides a very comprehensive flowchart to help prescribe “Goal Directed” PD or person centered PD. It is obvious from this that there is no one solution or one correct answer.
Figure 1 from Brown et al, PDI 2020
Failing to Thrive
All of us have seen patients not doing well on PD - but this guideline encourages us to recognize that this failure to thrive is not exclusively “poor” or “inadequate” dialysis. There can be many reasons - personal, physical, psycho-social, mental, financial, that may be the reason for a person not doing well. A “one size fits all” - increase the amount of dialysis to make the patient feel better is destined to fail if the other aspects of the patient’s life are not addressed!
The guideline provides a framework for recognizing and assessing the “failing to thrive” patient in the following table.
Table 3 from Brown et al, PDI 2020
At the end it may be obvious that it is the dialysis dose itself that needs to be adjusted, and the following table identifies the factors that support increasing dialysis dose delivery.
Table 4 from Brown et al, PDI 2020
Summary
The bottom line is that PD needs to be personalized. Each aspect of the prescription and ESRD management needs to be in concordance with the patient's values, situation and potential burden of care. Caring for the whole person is critical for successful uptake of PD, keeping patients on PD and reducing technique failure.
Kudos to the ISPD Guideline Committee and the guideline authors for making an excellent effort to change the narrative of dialysis adequacy from small solute clearance to the whole person.
Can we ask our hemodialysis colleagues to step up and do the same for our hemodialysis patients as well?
As several home dialysis patients point out - Don't live to dialyze, dialyze to live!
Summary by Namrata Parikh
Nephrologist, Hyderabad, India
NSMC Intern, Class of 2020