Incremental initiation of peritoneal dialysis: current practice

The Dialysis Outcomes Quality Initiative (DOQI) guidelines define initiation of peritoneal dialysis (PD) as "timely" when dialysis is started using deteriorating renal function and nutritional indices as criteria--before the appearance of frank uremia--and as "incremental" when the initial dose of PD is small, bringing total clearances to or above target values, with the understanding that the dose of PD will be increased as renal function is lost. Current practice regarding timely/incremental PD initiation was studied by analyzing the responses to a questionnaire distributed to 250 U.S. and Canadian nephrologists. A total of 89 responses were received. Only 30 responders (33.7%) practice incremental PD initiation. The more frequent reasons for not practicing incremental PD initiation included anticipated patient noncompliance, the desire to obtain the highest possible clearances, disagreement with the DOQI rationale, and late referral of patients to the nephrologists. Renal clearances were used by 58 responders (65.2%) as independent criteria to start dialysis. Creatinine clearance, at a cut-off level of 9.9 +/- 2.1 mL/minute, was the criterion most frequently used to start PD. Nutritional indices were used by 66 responders (74.2%) as criteria to start PD. Frequently used nutritional indices were serum albumin, body weight, normalized equivalent of protein nitrogen appearance (nPNA), and dietary assessment. The survey provides clues about research studies and educational activities that will be needed in the future.