The European Renal Association has recently published the EBPG Guidelines for Peritoneal Dialysis (361 kb) (Nephrol Dial Transplantation (2005) 20 [Suppl 9]: ix1-ix37). The document includes a preface explaining how the process was initiated and conducted and the methodology used for making conclusions. The guidelines consist of nine sections: General aspects, Initiation of dialysis, Peritoneal access, Continuous ambulatory peritoneal dialysis, Peritoneal dialysis solutions, Automated peritoneal dialysis, Adequacy of peritoneal dialysis, Nutrition in peritoneal dialysis, and PD and transplantation.
This document was examined by the ISN Clinical Practice Guidelines (CPG) Committee. The review process included critical appraisal by two independent panels; experts in methodology and medical statistics, and a selected group of international authorities in the field of clinical peritoneal dialysis. Both panels recommended that ISN should acknowledge these guidelines and recommend them for implementation by its members. They did have certain remarks, though, on both the methodology at large, and the applicability in different parts of the world.
There is general agreement that the peritoneal dialysis (PD) facility should have a well articulated organizational structure, incorporating appropriate staff facilities, training and educational programs, and clear protocols to guide the actions of staff and patients. These should be based on internationally recognized guidelines, but should be extended to include the absolute and relative indications and contraindications for PD and clear management plans in the event that PD fails. It is essential that a PD program should have access to back-up hemodialysis program and hospital facilities and preferably to a renal transplantation program. Ideally it should also have access to Automated PD but this is not considered essential. There will clearly be specific regional differences based on available expertise, socioeconomic factors, regulatory requirements and availability of resources. Hence EBPG may be regionally adapted within these constraints.
For international applicability, the following comments address the specific areas in the guidelines which are likely to require regional modification of protocols and management:
Section 1: General guidelines (Guideline: B):
The standards for the equipment used in the delivery and monitoring of therapies should be defined by the local regulatory authorities.
Section 2: The initiation of dialysis (Guidelines: A, B, C):
Recommendations regarding the timing and referral processes of patients with CKD may be defined by external factors such as availability of facilities, personnel and organizational structure. Clearly resources availability will dictate prioritization for nephrology referrals as well as defining a structured approach for the preservation of renal function and the management of associated conditions.
Estimation of glomerular filtration rate using a method based on measurement of serum creatinine or other serum marker has not been adequately validated in many ethnic groups. Hence any recommendation in this regard may not be generally applicable.
Section 3: Peritoneal access (Guideline: D):
Recommendations regarding placement of the dialysis catheter should be individualized. It is agreed that the trochar method should be abandoned, but otherwise acceptable catheter implantation techniques include surgical, mini-laparotomy, laparoscopic approach and Seldinger technique, depending on the available local expertise.
Section 4: Continuous ambulatory peritoneal dialysis delivery systems (Guidelines: A, B, C):
The choice of delivery system should be individualized according to availability and resources. If a spike system is used, the use of disinfectant devices is not universally acceptable: although the EBPG recommend its use, other expert panels� views do not endorse its use because of the association with subsequent encapsulating peritoneal sclerosis.
Section 5: Peritoneal dialysis solutions (Guidelines: B, C):
Because of the lack of the general availability of fluids such as icodextrin and those with low glucose degradation products (GDP), and the absence of convincing trial data with well defined clinically relevant end-points, first line use of low GDP solutions and amino acid based solutions in malnourished patients cannot be universally recommended.
Section 8: Nutrition in peritoneal dialysis:
Guidelines on diagnosis and treatment of malnutrition in patients on PD should be locally developed as cultural differences may influence optimal dietary intervention. Overall management should include defining the cause of malnutrition and then incorporate strategies directed towards improving dietary patterns.
The following are other additional comments, which are not addressed in the guidelines:
An optimal level of ultrafiltration will clearly vary, with no clear data supporting a defined target. Accordingly it is recommended that the amount of ultrafiltration prescribed should be the amount required to achieve optimal fluid balance. Bioelectrical impedance is a well validated method of determination of fluid status, which is not considered in the EBPG. Its use is recommended, if available, to monitor fluid status.
As the Guidelines do not include a section on infection in PD, it is recommended that the ISPD guidelines be consulted for direction on prophylaxis and management of exit site infection and peritonitis. However, clearly regional differences will occur in infectious etiology and local protocols specifying antibiotic use should be developed to reflect this.
Hepatitis-B vaccination is strongly recommended in all regions.
Methodology:
It is noted that the methods used to develop the guidelines were not comprehensively described and were only briefly mentioned in the preface. This may be justified on the grounds that clinicians are not particularly concerned with this aspect. A counter argument is that this may not allow full appraisal and validation. Having a more comprehensive description of the methodology may have strengthened these guidelines and assisted readers in applying them locally.
Overall these guidelines are considered practical, inclusive, and reflect best clinical practice. For the domains of reliability, clinical applicability, clinical flexibility and clarity, they meet accepted standards. An aspect which may not have been adequately addressed is the composition of the development team. A multidisciplinary team is considered the default position for the developing of guidelines. The addition of consumers/patients should ensure that outcomes of relevance to patients are appropriately considered, and patients often have other skills such as writing or advocacy which they can provide. In addition, as guidelines have implications for policy makers, health economists could be considered as part of guidelines-developing teams.
Acknowledgement:
The ISN CPG Committee acknowledges the indispensable contribution made by the Expert Panels involved in reviewing this set of guidelines. The Clinical Experts Panel included Drs. Carol Pollock, Australia (Chair); Javier de Arteaga, Argentina; Bernadette Faller, France; Weike Lo, Hong Kong; Salah Naga, Egypt; Dimitrios Oreopoulos, Canada; and Bengt Rippe, Sweden.
The methodology was reviewed by Dr. Jonathan Craig, Australia and his team from the Cochrane Renal Group.
Omar Abboud, MD
on behalf of the ISN CPG Committee
Rashad Barsoum, Egypt (Chair)
Francois Berthoux, France
Michael Field, Australia
Richard Johnson, USA
Shanyan Lin, China
Pablo Massari, Argentina
Correspondance:
Omar Abboud
Consultant Nephrologist
Hamad Medical Corporation
P O Box 3050, Doha
Qatar
