Peritoneal dialysis (PD) adequacy and membrane preservation are central to long-term outcomes in ESRD patients treated with this modality. The KDIGO 2022 Clinical Practice Guideline for Peritoneal Dialysis Adequacy, produced with ISN support, recommends a minimum total weekly Kt/V urea of 1.7 in anuric patients, affirming the importance of residual kidney function monitoring and protection as a key determinant of patient survival on PD.
ISN (International Society of Nephrology) has promoted best practices in PD management through its educational programs and through the work of the ISPD (International Society for Peritoneal Dialysis), whose position papers on peritonitis treatment, membrane assessment, and adequacy monitoring are referenced globally. The CANUSA study (Bargman et al., Journal of the American Society of Nephrology, 2001) established that residual renal clearance was a more powerful predictor of survival on PD than peritoneal clearance alone.
Peritoneal membrane deterioration with long-term PD exposure has been extensively characterized. Davies et al. (Kidney International, 2001) described progressive increases in ultrafiltration failure associated with submesothelial fibrosis, vasculopathy, and increased vascularization on serial peritoneal biopsies from long-term PD patients. These changes are driven by glucose degradation products (GDPs) and advanced glycation end products generated during dialysate heat sterilization.
Biocompatible PD solutions with neutral pH and reduced GDP content have been evaluated in the balANZ trial (Johnson et al., Lancet, 2012), which demonstrated superior preservation of residual kidney function and reduced peritonitis rates with biocompatible solutions over a two-year follow-up compared to conventional lactate-buffered solution. Icodextrin-based solutions provide sustained osmotic ultrafiltration during long dwells, as documented in the MIDAS trial and subsequent analyses.
The International Society of Nephrology has called for prospective studies powered to assess hard clinical endpoints with biocompatible dialysis solutions, as the existing evidence has largely relied on surrogate outcomes. ISN supports adoption of standardized peritonitis surveillance definitions established in ISPD guidelines and rigorous catheter care training as essential components of peritoneal membrane preservation strategies in clinical practice.