#NephMadness 2018: Brimble Breaks Down the PD Region

Scott Brimble, MD

Dr. Brimble is Associate Professor of Medicine and Divisional Director of Nephrology in the Department of Medicine at McMaster University and a staff nephrologist at St. Joseph’s Healthcare. He is also Provincial Lead for Chronic Kidney Disease Care as well as First Nations, Inuit, and Métis Kidney Health at the Ontario Renal Network (ORN). His clinical interests focus on the management of patients with advanced CKD, hypertension, and peritoneal dialysis. Follow him @S_brimble.

Competitors for the Peritoneal Dialysis Region

Volume Issues in PD vs Solute Issues in PD

Culture-Negative Peritonitis vs Catheter Dysfunction in PD

Since the beginning of time, peritoneal dialysis (PD), a home-based therapy for end-stage kidney disease (ESKD), has been the poor cousin to hemodialysis (HD). Two of the three most cited original research publications in PD of the past 10 years are studies comparing outcomes in PD and HD (JAMA, JASN). Those of us with a clinical and/or research interest in PD seem to have a bit of an inferiority complex compared to our HD colleagues. Having been around probably too many of them over the years I have no idea why.

I recently prepared this summary of the strength of evidence for the ISPD guidelines on the management of cardiovascular disease in patients on PD:

As you can see, it is very sad. Not much has changed in PD; there continues to be a paucity of important clinical trials and technological innovations have been generally lacking. With that in mind, I will dive into the Peritoneal Dialysis region and try to make some sense of it all.

Volume Issues in PD

Many have argued that this is the Holy Grail in PD. Forget solute clearance! Patients are volume overloaded and this leads to premature cardiovascular disease. Finally, something we can do for our patients! If you have ever been to a PD conference you have probably heard Dr. Joanne Bargman making this point.

The region writer makes a valiant effort to convince us of the importance of volume control and to consider the use of fancy methods such as bioelectrical impedance analysis to improve the detection of volume control. Sadly, the level of evidence to support sub-clinical volume overload as a mediator of bad outcomes in patients on PD is poor. Furthermore, interventions to correct volume overload have generally not been successful in improving clinical outcomes. There may still be something here but my suspicion is that, much like solute clearance, its importance has been overstated.

Solute Issues in PD

Groan…Yes, if your patient on PD is anuric, some amount of solute clearance is needed. Which solute? I have no idea. How much solute clearance? I have only an inkling of an idea. Until better evidence comes along, I am going to ask my patients how they are feeling and work from there. Sorry, but this topic is dead to me…

Culture-Negative Peritonitis

Peritonitis is wickedly important for PD programs and more importantly, for the patients that they care for. The region writer makes a concerted effort to pique our interest in the rather specific sub-topic of culture-negative peritonitis. Mostly a problem in sample collection technique with an outcome that is probably intermediate to culture-positive peritonitis and the absence of peritonitis, it is hard to imagine how this topic is going to capture the imagination of NephMadness participants. It certainly hasn’t captured mine.

Catheter Dysfunction in PD

Now we’re getting somewhere! The catheter is the Achilles’ heel of PD. Having been medical director of a PD program at a time when less than 8% of our dialysis patients were on PD and catheter insertion success rates were < 60%, to a time when our PD prevalence rate is now over 20% and success rates are at 90+%, I know that the catheter will make or break a program. For a patient it can be devastating when the catheter does not work. The North American chapter of ISPD considers it sufficiently important that their first collaborative study, led by Canadians Matt Oliver and Rob Quinn, is examining the factors that contribute to PD catheter function success or failure. Stay tuned.

In the end my vote is with Catheter Dysfunction in PD. While an important topic, this list makes it clear that we have a long way to go in the PD community despite our best efforts. Work is underway to identify outcomes of importance to all stakeholders that should be included in future trials in PD. This is a start. But there is still a great need to develop new therapies and technologies that will improve their life expectancy and their ability to continue on PD with a high quality of life. Little has changed in PD in the past 20 years; here’s hoping the next 20 years will not be more of the same.

– Post written by Scott Brimble. Follow him @S_brimble

As with all content on the AJKD Blog, the opinions expressed are those of the author of each post, and are not necessarily shared or endorsed by the AJKD Blog, AJKD, the National Kidney Foundation, Elsevier, or any other entity unless explicitly stated.

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