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Incremental PD Escalation RRF Decline — ESENeph MCQ

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ModeratePeritoneal DialysisIncremental PD Escalation RRF DeclineESENeph

A 50-year-old man on peritoneal dialysis develops gradual loss of residual renal function over 3 years. His urine output has fallen from 800 to 150 mL/day. His weekly Kt/V is now 1.5 (target ≥1.7). He was initially on incremental PD (2 exchanges/day). What is the MOST appropriate adjustment?

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Correct answer: A — Increase to full-dose PD (4 exchanges daily or APD)

Incremental PD is an evidence-based strategy that starts with fewer exchanges (1-2/day) when significant residual renal function (RRF) exists, gradually increasing PD dose as RRF declines. This approach preserves RRF longer (by avoiding volume depletion from excessive UF) and improves quality of life. As RRF falls (urine output <500 mL/day, renal Kt/V contribution diminishing), PD dose must be escalated to maintain total clearance target. The transition from 2 to 4 exchanges (CAPD) or to APD maintains adequacy. High-dose furosemide (250-500 mg) can help maintain RRF but becomes less effective as function declines. Switching to HD is premature if PD adequacy can be achieved with prescription changes.

Reference: ISPD 2020 – Incremental PD; UKKA 2019 – PD Guidelines; Ankawi et al 2016 – Incremental PD