Who wants to be just “adequate”? Redefining the goals for PD treatment

Written by Richard Booth, Medical Lead, Chronic Therapies A/NZ

In an inspirational presentation to this year’s PD Academy class, Prof. Jeff Perl from University of Toronto outlined what it takes to achieve PD excellence and how patients deserve excellence and not just adequacy. He shared that the days of looking at small solute clearance as the key measure of PD are gone and that we now need to shift our focus from the PD of the past to the modern PD. We know that the survival and mortality are similar between PD and HD so let’s move away from that as the reason behind choosing one modality over another. Prof. Perl also highlighted that this research has been done “to death” and we don’t need to do it anymore.

Prof. Perl discussed how in the past the focus was choosing a ‘good PD candidate’, and now it is critical that the patient selects the right treatment for them, after discussion, education and a shared decision-making process.

A less is more approach compared with a ‘one size fits all’ to the prescription should be part of today’s PD therapy. Prof. Perl reminded people that when people start on PD it’s the “golden age”: their membrane is fresh, there can be significant residual kidney function, and the patient may be able to do CAPD or APD. It’s during this “golden age” that they may not need a lot of dialysis and incremental or tidal PD can achieve the same level of clearance as a full prescription and maintain residual kidney function.

Urea clearance or PD adequacy has long been how we measured PD performance, and this has not considered other measures that are more important to the patient. When was the last time you had a patient complain of a low Kt/V? Performance measures are multi-factorial and away from urea. Prof. Perl discussed how the SONG initiative has highlighted a range of other measures that deserve more attention: peritonitis rates and transition to HD, to name just two.

The COVID-19 pandemic taught us that not all clinic visits and assessments need to be in person. We heard Prof. Perl’s perspective on how a mix of virtual, telehealth and in person can work as well as in-person only. The use of remote patient monitoring provides peace of mind for clinicians and patients, knowing that they can see what’s happening.

For some patients who are keen to do PD yet have one or more limitations (physical, cognitive, psychological), Assisted PD may provide the necessary support to help these patients achieve PD excellence. The PD Academy audience heard that while not widely available in ANZ, the Canadian experience highlights how a little help can get patients over the line onto PD. Sometimes it’s just a helping hand until the patient is confident enough to do it themselves.

Prof. Perl’s final discussion point is that we need to be aware of the environmental impact of the therapy we choose and here, recycling of the waste from PD is one way of reducing the carbon footprint and improving sustainability.

Prof. Perl closed his talk with a couple of patient photos: one of a man sitting on the balcony overlooking the sea in glorious sunshine, his drain bag on the ground as he completed a CAPD exchange, and the other man sitting on camp chair in front of his motorcycle as he rode across Canada. His PD solution bag hung off the handlebars. Prof. Perl reminded us that this is what PD excellence looks like: patients living their best lives and managing the therapy.

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Using Kt/V as a marker for dialysis adequacy in PD is liking trying to use Euros to pay for something in Australia

Prof. Jeff Perl