Adequacy of peritoneal dialysis.

The National Kidney Foundation-Dialysis Outcomes Quality Initiatives guidelines have standardized many aspects of treating end-stage renal disease patients with peritoneal dialysis in an attempt to improve overall patient outcome. While recommending certain total solute clearance goals, the guidelines have also pointed out deficiencies in our knowledge base and precipitated many controversies. Some of these controversies have been resolved while others may have been interpreted wrongly, unnecessarily resulting in transfer of patients from peritoneal dialysis to hemodialysis due to "failure to meet adequacy targets" even when doing well clinically. This report reviews the rationale for the original guidelines and their subsequent modification. It also outlines a rational approach toward prescription modification based on peritoneal physiology. Specific solute clearance target goals discussed are the modifications for continuous ambulatory peritoneal dialysis (CAPD) and cycler peritoneal dialysis (CCPD), and a review of what solute clearance targets subsequent guidelines from other countries have used. Some examples are as follows: new guidelines suggest that solute clearance goals for creatine clearance should differ for low and low-average transporters than for high and high-average transporters (weekly clearance of 50 and 60 1/1.73 m(2), respectively) while Kt/V targets remain unchanged. Also discussed is the rationale for having the same target for patients on CCPD with a mid-day exchange as those for patients on CAPD. We are also reminded that solute clearance is only one aspect of "adequate" dialysis-blood pressure and volume control are equally important, and ways to maintain euvolemia and blood pressure control are discussed in the context of prescription management.