Volume-Based Peritoneal Dialysis Prescription Guide to Achieve Adequacy Targets

Trends in Automated Peritoneal Dialysis Prescriptions in a Large Dialysis Organization in the United States

Key Points

This is the largest analysis of incident automated peritoneal dialysis (PD) prescriptions conducted in the United States to date. There was limited variability of automated PD prescriptions across the first 4 months of therapy. PD prescriptions tailored to meet the dialysis needs and lifestyle of patients may make PD a more attractive choice and increase longevity on PD.

Background

Changes in health care policies and recognition of patient benefit have contributed to increases in home-based dialysis, including peritoneal dialysis (PD). Frequent monitoring and early individualization of PD prescriptions are key prerequisites for the delivery of high-quality PD. The present analysis aimed to assess variations in PD prescriptions among incident automated PD (APD) patients who remain on PD for 120+ days.

Methods

This retrospective analysis examined data from patients within a large dialysis organization that initiated PD with APD between 2015 and 2019. PD prescription data were described by calendar year, timing of PD, and residual renal function categories. Changes in prescriptions from PD initiation (day 1) to day 120 were assessed descriptively.

Results

The cohort included 11,659 patients. The mean age at PD initiation increased from 2015 (56 [15] years) through 2019 (58 [15] years), whereas most other variables demonstrated no clear temporal change. Most patients (86%) had nighttime PD prescribed, with an average of 4.9 (1.3) cycles per day, a mean total treatment volume of 9.3 (2.5) L, and a median daily total dwell time of 7 (6–9.5) hours. Relative to day 1 nighttime prescriptions, there were (1 ) small increases in the proportion of patients receiving three or fewer cycles per day and those receiving 6+ cycles per day, (2 ) a 100 ml mean increase in fill volume per exchange, and (3 ) a mean 0.5 L increase in total nighttime treatment volume at day 120. When changes in nighttime APD prescriptions were examined at the patient level, 49% of patients had day 120 prescriptions that were unchanged from their initial prescription.

Conclusions

In the largest analysis of incident APD prescriptions conducted in the United States to date, most patients were prescribed nocturnal PD only with limited variability across the first 4 months of therapy.

Optimization of bimodal automated peritoneal dialysis prescription using the three-pore model

BACKGROUND

Previous studies suggested that automated peritoneal dialysis (APD) could be improved in terms of shorter treatment times and lower glucose absorption using bimodal treatment regimens, having 'ultrafiltration (UF) cycles' using a high glucose concentration and 'clearance cycles' using low or no glucose. The purpose of this study is to explore such regimes further using mathematical optimization techniques based on the three-pore model.

METHODS

A linear model with constraints is applied to find the shortest possible treatment time given a set of clinical treatment goals. For bimodal regimes, an exact analytical solution often exists which is herein used to construct optimal regimes giving the same Kt/V urea and/or weekly creatinine clearance and UF as a 6 × 2 L 1.36% glucose regime and an 'adapted' (2 × 1.5 L 1.36% + 3 × 3 L 1.36%) regime.

RESULTS

Compared to the non-optimized (standard and adapted regimes), the optimized regimens demonstrated marked reductions (>40%) in glucose absorption while having an identical weekly creatinine clearance (35 L) and UF (0.5 L). Larger fill volumes of 1200 mL/m² (UF cycles) and 1400 mL/m² (clearance cycles) can be used to shorten the total treatment time.

CONCLUSION

These theoretical results imply substantial improvements in glucose absorption using optimized APD regimens while achieving similar water and solute removal as non-optimized APD regimens. While the current results are based on a well-established theoretical model for peritoneal dialysis, experimental and clinical studies need to be performed to validate the current findings.

APD or CAPD: one glove does not fit all

The use of Automated Peritoneal Dialysis (APD) in its various forms has increased over the past few years mainly in developed countries. This could be attributed to improved cycler design, apparent lifestyle benefits and the ability to achieve adequacy and ultrafiltration targets. However, the dilemma of choosing the superior modality between APD and Continuous Ambulatory Peritoneal Dialysis (CAPD) has not yet been resolved. When it comes to fast transporters and assisted PD, APD is certainly considered the most suitable Peritoneal Dialysis (PD) modality. Improved patients’ compliance, lower intraperitoneal pressure and possibly lower incidence of peritonitis have been also associated with APD. However, concerns regarding increased cost, a more rapid decline in residual renal function, inadequate sodium removal and disturbed sleep are APD’s setbacks. Besides APD superiority over CAPD in fast transporters, the other medical advantages of APD still remain controversial. In any case, APD should be readily available for all patients starting PD and the most important indication for its implementation remains patient’s choice.

Economic costs of automated and continuous ambulatory peritoneal dialysis in Taiwan: a combined survey and retrospective cohort analysis

OBJECTIVES

Taiwan succeeded in raising the proportion of peritoneal dialysis (PD) usage after the National Health Insurance (NHI) payment scheme introduced financial incentives in 2005. This study aims to compare the economic costs between automated PD (APD) and continuous ambulatory PD (CAPD) modalities from a societal perspective.

DESIGN AND SETTING

A retrospective cohort of patients receiving PD from the NHI Research Database was identified during 2004-2011. The 1:1 propensity score matched 1749 APD patients and 1749 CAPD patients who were analysed on their NHI-financed medical costs and utilisation. A multicentre study by face-to-face interviews on 117 APD and 129 CAPD patients from five hospitals located in four regions of Taiwan was further carried out to collect data on their out-of-pocket payments, productivity losses and quality of life with EuroQol-5D-5L.

OUTCOME MEASURES

The NHI-financed medical costs, out-of-pocket payments and productivity losses of APD and CAPD patients.

RESULTS

The total NHI-financed medical costs per patient-year after 5 years of follow-up were significantly higher with APD than CAPD (US$23 005 vs US$19 237; p<0.01). In terms of dialysis-related costs, APD had higher costs resulting from the use of APD machines (US$795) and APD sets (US$2913). Significantly lower productivity losses were found with APD (US$2619) than CAPD (US$6443), but the out-of-pocket payments were not significantly different. The differences in NHI-financed medical costs and productivity losses between APD and CAPD remained robust in the bootstrap analysis. The total economic costs of APD (US$30 401) were similar to those of CAPD (US$29 939), even after bootstrap analysis (APD, US$28 399; CAPD, US$27 960). No discernable differences were found in the results of mortality and quality of life between the APD and CAPD patients.

CONCLUSIONS

APD had higher annual dialysis-related costs and lower annual productivity losses than CAPD, which made the economic costs of APD very close to those of CAPD in Taiwan.

Changing Landscape for Peritoneal Dialysis: Optimizing Utilization

The future growth of peritoneal dialysis (PD) will be directly linked to the shift in US healthcare to a value-based payment model due to PD's lower yearly cost, early survival advantage over in-center hemodialysis, and improved quality of life for patients treating their kidney disease in the home. Under this model, nephrology practices will need an increased focus on managing the transition from chronic kidney disease to end-stage renal disease (ESRD), providing patient education with the aim of accomplishing modality selection and access placement ahead of dialysis initiation. Physicians must expand their knowledge base in home therapies and work toward increased technique survival through implementation of specific practice initiatives that highlight PD catheter placement success, preservation of residual renal function, consideration of incremental PD, and competence in urgent start PD. Avoidance of both early and late PD technique failures is also critical to PD program growth. Large dialysis organizations must continue to measure and improve quality metrics for PD, expand their focus beyond the sole provision of PD to holistic patient care, and initiate programs to reduce PD hospitalization rates and encourage physicians to consider the benefits of PD as an initial modality for appropriate patients. New and innovative strategies are needed to address the main reasons for PD technique failure, improve the connectivity of the patient in the home, leverage home biometric data to improve overall outcomes, and develop PD cycler devices that lower patient treatment burden and reduce both treatment fatigue and treatment-dependent complications.