Preserving residual kidney function in peritoneal dialysis: from conventional approaches to contemporary practice

Residual kidney function (RKF) is a key determinant of outcomes in patients undergoing peritoneal dialysis (PD), contributing to solute clearance, volume regulation, reduced inflammation, and improved survival. Nevertheless, RKF commonly declines after PD initiation, often due to potentially modifiable clinical and treatment-related factors. This narrative review summarizes current evidence on the mechanisms underlying RKF loss in PD and evaluates established and emerging strategies to preserve RKF in contemporary practice. Major contributors to RKF decline include hemodynamic instability, cumulative glucose exposure, inflammation and peritonitis, nephrotoxic medications, dialysis-related volume shifts, and kidney disease-specific conditions. Conventional strategies such as incremental and individualized PD prescriptions, use of biocompatible and glucose-sparing solutions, careful volume and blood pressure management, renin-angiotensin-aldosterone system blockade, infection prevention, and tailored management after kidney allograft failure are reviewed. Importantly, current guideline-based strategies largely address these factors in isolation. We propose that RKF preservation should be approached through an integrated, mechanism-based framework, in which cumulative glucose exposure represents a central modifiable mediator linking multiple pathways of kidney injury. In this context, remote monitoring and artificial intelligence-based tools may serve as enabling platforms that integrate longitudinal clinical and treatment data, supporting individualized and proactive care. Preserving RKF should remain a central therapeutic goal in PD, and combining established physiological principles with modern digital technologies may provide a more effective framework for improving long-term patient outcomes.