#5231 INCREMENTAL PERITONEAL DIALYSIS VERSUS CONSERVATIVE MANAGEMENT IN PATIENTS WITH ESRD
Authors: Elshabrawy Nehal Atef , Gambaro Giovanni , Sayed-Ahmed Nagy 
Published: June 2023

Abstract

Background and Aims
At its start, Peritoneal dialysis (PD) was implemented only in advanced renal disease with a myriad of symptoms and signs. However, many subsequent literatures have highlighted possible benefits of early rather than late start of PD. Nevertheless, when to start PD has been a matter of controversy. This debate has created a new era of starting dialysis early during the course of the disease, in a small dose that was termed ‘incremental’ dialysis. By this modality, the dose of PD, is low at the initiation of RRT, and could be progressively increased over time in parallel with the reduction of RKF. Although incremental dialysis is growing worldwide, there has been no substantial agreement on the benefits of this approach. Moreover, the few available observational studies have compared incremental versus full-dose PD, with controversial results. On the other hand, studies comparing incremental dialysis with the conservative management for non-symptomatic ESRD patients are mostly deficient in the published literature. The present work is a retrospective, case-control, longitudinal study, aimed to evaluate the adequacy of incremental peritoneal dialysis as a modality of renal replacement therapy in ESRD patients, and whether it adds superior benefits over the conservative and the standard peritoneal dialysis (STPD) managements.

Method
Data were collected retrospectively from Complesso Integrato Columbus Policlinico Gemelli, nephrology and dialysis unit archives. The study comprising three groups: first included 23 patients who were treated with IPD and second group included 30 patients who were managed with the standard dose of PD (STPD), and a third group include 19 ESRD patients who had GFR values of &lt; 15ml/min and were off dialysis and received only conservative treatment. The collected data for each patient included demographic, clinical assessment (volume excess and nutritional state), pharmacological data, laboratory records (Hb concentration, and sodium, potassium, phosphorus), creatinine clearance and rate of hospitalization, in addition to dialysis regimen and rate of dialysis related infection in IPD and STPD patients, data from these patients were collected at the baseline (time just before starting PD), and every 6 months for 24 months or whenever there is cessation of PD, whichever occurs first.

Results
In the present study all IPD group patients started PD with increment dose 1 or 2 exchanges per day, with a solution volume 1.5 to 2 L/ exchange for 8 to 16 hours/day. Data analysis revealed improvement in the nutritional state, a better control of the blood electrolyte and body volume in IPD and STPD groups while they deteriorated significantly in the conservative group (P = 0.005, P = 0.001 & P = 0.001, respectively). Dialysis groups succeed in maintain the Hb level within target level with smaller dose of ESA therapy and also ESA Resistive Index (ERI) decreased in this groups while it significantly increased in the conservative group (P1 = 0.019).There was no statistically significant differences between the rate of decline of creatinine clearance between the patients on conservative, those on IPD and STPD (P = 0.295), Also there was no statistically significant difference in the rate of hospitalization between study groups (P = 0.69).Those who had a mean creatinine clearance (CrCl) more than 9.4±2.8 ml/min/1.73m2 could be managed with one exchange to achieve the target Kt/V, a mean CrCl of less than 3.6±0.8 ml/min/1.73m2 failed to reach adequacy even with two exchanges a day and needed to be transferred to full dose while those with a mean CrCl in between the above values could only achieve Kt/V above 1.7 with two exchanges per day.

Conclusion
Incremental peritoneal dialysis, a rapidly growing new modality, is superior to the conservative treatment in patients with end-stage renal disease that can be adequately applied to patients with a GFR of 4 ml/min or more without adding the burden of full dose dialysis.