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Osama El Shamy @osamaelshamy88

Osama El Shamy MD is an assistant professor of medicine at the George Washington University. He is co-chair of the International Society for Peritoneal Dialysis (ISPD) Program Committee, both an author and reviewer for UpToDate’s peritoneal dialysis section, a hub committee member on the NKF Home Dialysis Project ECHO, and faculty member of Home Dialysis University.

Competitors for the Peritoneal Dialysis Region

Team 1: PD First vs Team 2: Beyond Kt/V

Image generated by Evan Zeitler using Image Creator from Microsoft Designer, accessed via https://www.bing.com/images/create, January, 2024. After using the tool to generate the image, Zeitler and the NephMadness Executive Team reviewed and take full responsibility for the final graphic image.

While aspirational, the goal of achieving 80% home dialysis or kidney transplant in incident patients with kidney failure by 2025 – as set out by the Advancing American Kidney Health Initiative (AAKHI) – is arbitrary at best. While approaches have differed over time, the ultimate target for both patients and the clinical team has always been the safety of kidney failure patients whatever the outcome; medical management, in-center or home dialysis.

Whether it is a byproduct of AAKHI, adjustments to the End-Stage Renal Disease Treatment Choices (ETC) payment model, or other factors, there has been a steady growth in PD utilization in the United States since 2016.

Many countries/regions have adopted a PD-first policy, including Hong Kong, Denmark, Latvia, Thailand, Malaysia, and the Philippines. While it is a welcome approach to expanding PD utilization, its implementation is dependent on multiple factors, such as the cost of PD consumables, the location of PD solution production, government reimbursement rates for PD, and so on. For example, the United States was affected by a PD solution shortage in 2014 owing to limited manufacturing capacity and increased overall demand for sterile solutions which lasted many months.

When I think of PD-first, I do not think of it in the typical sense of, “All patients who are starting dialysis should be started on PD”, but moreso, “Patients who would like to be on PD should be started on PD first.” We know from the National Pre-ESRD Education Initiative that approximately 45% of kidney failure patients choose PD as their preferred dialysis treatment. Our job should be to help bridge the gap between the patients’ intended modality of choice (45% PD) and the actual modality prevalence (17.4% PD) in the United States. This can be achieved by minimizing the rate of unplanned dialysis initiation – also known as “crashing” into dialysis – as well as increasing the implementation of acute urgent start PD, urgent start PD, and incremental PD.

That being said, you can have all the players that you want in the game: LeBron James, Kevin Durant, Steph Curry, Nikola Jokic and Giannis Antetokounmpo. However, it won’t matter as long as the rules are the way that they are in the United States. Buoyed by the findings of the CANUSA study, which did not show a survival difference between patients who achieved Kt/V values of 2.27 and 1.80, the 2006 ISPD guidelines recommended and the Centers for Medicare and Medicaid Services (CMS) require a minimum total Kt/V_urea of 1.7. CMS also requires that there is a Kt/V value within 4 months of the date of a patient’s monthly visit.

While urea clearance can be extrapolated to reflect the clearance of larger molecules, it’s use as a cornerstone metric for dialysis quality (or “adequacy”) is slowly become more of a hindrance, rather than a facilitator for the delivery of high quality, goal-directed PD care. In its 2020 update, the ISPD tracked back from its prior recommendation of a Kt/V-driven approach, instead focusing more on the whole picture:

“PD should be prescribed using shared decision-making between the person doing PD/their caregivers and the care team with the aim of achieving realistic care goals to maximize quality of life and satisfaction for the individual, minimize their symptoms and provide high quality care.”

Patient choice, acid-base status, electrolyte control, albumin level, blood pressure control, anemia management, mineral bone disease metrics, and volume status are all complementary and contributing metrics that should be more robustly weighted in the assessment of quality of care delivered. Until then, we can spend our time recruiting patients to the “PD team”, but the rules will remain stacked against us. For this reason, the Beyond Kt/V team is my bracket winner. Let’s focus on fixing the regulations by which we are bound, to reflect what is truly in our patients’ best interest.

Copyright: Canities/Shutterstock

– Guest Post written by Osama El Shamy @osamaelshamy88

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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