Response to Inadequate Peritoneal Dialysis

Jose A. Diaz-Buxo, MD, FACP Despite the general acceptance of the National Kidney Foundations Dialysis Outcomes Quality Initiatives (K/DOQI) guidelines for adequacy of peritoneal dialysis (PD) and the regular monitoring of delivered dialysis among PD patients in the US, it is not known if patient prescriptions are being changed in response to a diagnosis of inadequate dose. Data from the Centers for Medicare and Medicaid for the year 2000 were used to obtain information on dialysis prescriptions and adequacy1. The results of this study are herein summarized. The dose of dialysis prescribed and delivered has significantly increased since the publication of the K/DOQI guidelines in 19972. The percentage of CAPD patients that met the guidelines for Kt/V has increased from 23% in 1995 to 65% in 20003. Similarly, cycler patients have increased from 28 to 60% during that period of time. Despite this progress in the dose of PD provided, in the year 2000, 38% of all PD patients had an inadequate Kt/V and 56% did not reach the creatinine clearance (Ccr) target recommended by K/DOQI (Figure 1). Figure 1. Percent of patients meeting K/DOQI guidelines3 Detailed descriptions of the Centers for Medicare & Medicaid Services Clinical Performance Measures (CPM) Project for peritoneal dialysis have been published4,5. A random sample of 1,735 adult PD patients alive on December 31, 1999 (approximately 5% of the adult PD population of the US) was identified for inclusion in the 2000 PD-CPM cohort. An analysis of PD patients who did not receive hemodialysis (HD) during the study period (October 1999-March 2000) was done to detect inadequate dialysis (n=1,268 patients). The criteria for inadequate dialysis were: – Total weekly Kt/V<2.0 – Total weekly Ccr<60 L/1.73 m2 Twenty eight percent of the patients studied were considered inadequately dialyzed (359/1268). Among these, 47% were treated with CAPD and 53% with APD. Of the CAPD patients, 43% had inadequate dialysis and a change in prescription within 6 months of the initial adequacy evaluation. Of these, 78% had an improvement in weekly Kt/V and 76% experienced an improvement in weekly Ccr. Among the APD patients, 54% had inadequate dialysis and a change in prescription within 6 months of the initial adequacy evaluation. Of these, 86% had an improvement in weekly Kt/V and 79% experienced an improvement in weekly Ccr. For all the patients who were initially inadequately dialyzed (CAPD and APD) and had a prescription change, total weekly Kt/V increased from 1.6±0.3 to 2.1±0.5 with an increase in the peritoneal Kt/V (Kt/Vp) from 1.5±0.3 to 1.9±0.4. Similarly, total weekly Ccr increased from 46.3±7.5 to 59.1±10.6 L/1.73 m2 with an increase in the peritoneal Ccr (Ccrp) from 42.0±9.1 to 52.7±9.9 L/1.73 m2 (Figure 2). Figure 2. Response to prescription change in terms of Kt/V and Ccr In conclusion, approximately 28% of PD patients in the US remain inadequately dialyzed according to this study. About half of the patients with inadequate dialysis had a prescription change and significant improvements in the mean weekly Kt/V and Ccr. About half of the patients with inadequate dialysis did not have a prescription change and could have benefited from modifications in their prescription. References 1. Rocco MV, Frankenfield DL, Prowant B, et al. Response to inadequate dialysis in chronic peritoneal dialysis patients. Results from the 2000 centers for Medicare and Medicaid (CMS) ESRD Peritoneal Dialysis Clinical Performance Measures (PD-CPM) Project. Am J Kidney Dis 41:840-848, 2003 2. NKF DOQI: Clinical Practice Guidelines for Peritoneal Dialysis Adequacy. Am J Kidney Dis 30:S67-S136, 1997 3. Health Care Financing Administration: 2000 Annual Report, End-Stage Renal Disease Clinical Performance Measures Project, Baltimore, MD-44, Department of Health and Human Services, Health Care Financing Administration, Office of Clinical Standards and Quality, 2000 4. Frankenfield DL, Prowant BF, Flanigan MJ, et al. Trends in clinical indicators of care for adult peritoneal dialysis patients in the US. Kidney Int 55:1998-2010, 1999 5. Rocco MV, Flanigan MJ, Prowant B, et al., Health Care Financing Administration Peritoneal Dialysis Core. Cycler adequacy and prescription data in a national cohort sample: The 1997 core indicators report. Kidney Int 55:2030-2039, 1999