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Incremental initiation of dialysis: one center's experience over a two-year period
1Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157-1053, USA.
Objective:
This pilot study describes our center's experience with peritoneal dialysis (PD) over the past 2 years using a "healthy start" dialysis protocol with an incremental approach to prescription management.
Design:
Nonrandomized, prospective pilot study.
Setting:
Single PD unit of a university teaching hospital.
Patients:
Thirteen PD patients who initiated dialysis at our center from April 1997 to June 1999.
Methods:
Patients initiating PD with residual renal Kt/V of 1.0 - 2.0/week were invited to participate. They were given an initial dialysis prescription so that total (residual renal + dialysis) weekly Kt/V exceeded 2.0. The dialysis prescription was "incrementally" increased as residual renal function (RRF) declined. Data collected for all patients included monthly serum chemistries, residual renal weekly Kt/V and creatinine clearance (CCr) at 1- to 2-month intervals, and peritoneal weekly Kt/V and CCr at 3-month intervals and 1 month after each prescription change.
Results:
To date, we have followed 13 patients on our incremental PD protocol for a total of 159.3 patient-months. Mean serum albumin concentration and mean normalized protein equivalent of nitrogen appearance (nPNA) were stable throughout the study. Mean total Kt/V and CCr remained above the recommended targets of 2.0/wk and 60 L/wk, respectively. Residual renal function declined rather slowly in our PD patients. One patient died from complications of aortic valve surgery and a second died from pneumonia. A third patient died from peritonitis. One patient required a new Tenckhoff catheter after catheter migration. Three patients were temporarily switched to hemodialysis after a hernia repair, a pleural leak, and elective native/transplant nephrectomies, respectively. Two patients were permanently switched to hemodialysis: one after an episode of peritonitis, the second after accidentally damaging his PD catheter.
Conclusions:
Providing incremental dialysis to maintain adequate total small solute clearance has been technically feasible in our patient population. However, a larger than expected number of complications was seen in our study. Fortunately, complications were easier to manage due to the presence of RRF. Because this study was not designed to compare outcome with that observed after traditional initiation of dialysis, further large-scale studies are needed.