Response to: International Society for Peritoneal Dialysis practice recommendations: Prescribing high-quality goal-directed peritoneal dialysis.

Abstract

I read with great interest the recently published ‘International Society for Peritoneal Dialysis practice recommendations: prescribing high-quality goal-directed peritoneal dialysis’ Peritoneal Dialysis International, 1–10, 2020, DOI: 10.1177/0896860819895364, where the authors/ working group have very nicely summarized and informatively updated the 2006 International Society for Peritoneal Dialysis guidelines. It was noticed in these recommendations that the description of the section ‘Which dialysis solution? – B. Use of neutral pH, low GDP PD solutions’ was so concise, that is, focusing only on preservation of residual renal function (RRF) and improving urine output despite the low certainty evidence that use of these fluids may have little or no effect on technique survival or mortality. However, there were no comments and/or clarifying the strength of evidence on (a) preservation of peritoneal membrane, (b) peritonitis or (c) peritoneal ultrafiltration (UF), which presumably all are very much related to the technique survival and time-on-therapy. This is especially the case in patients who lost their RRF, and where cost implications need to be taken in consideration! Most of previous studies, including randomized clinical trials and meta-analysis, didn’t show any effect of the neutral pH low glucose degradation product peritoneal dialysis solutions on improving peritoneal UF, if not decreasing it. While the mechanism of improving the RRF and urine output by these solutions is not clear, the RRF and peritoneal UF are interdependent. For example, higher peritoneal UF and the resultant relative volume contraction could directly promote a transient or permanent decrease in urine output and measured RRF, while increases in RRF may actually be due to relative volume expansion as a result of diminished peritoneal UF.