Morbidity and mortality in redefining adequacy of peritoneal dialysis: A step beyond the National Kidney Foundation Dialysis Outcomes Quality Initiative

The National Kidney Foundation Dialysis Outcomes Quality Initiative (NKF-DO QI) Peritoneal Dialysis (PD) Adequacy Work Group intentionally limited the scope of its work to address adequacy in terms of small-solute removal, Thi s decision was based on the need for rigorous evidence and that mortality i s the most objective parameter in the literature. This review attempts to m ore broadly redefine the concept of the adequacy of PD, particularly as it relates to the most common general medical problems that PD patients experi ence; namely, cardiovascular disease and malnutrition, Whereas we are sensi tive to the developmental process of the NKF-DOQI, we are critical that the definition of adequacy may be too narrow, leading clinicians to overlook o ther important morbidities. We have reiterated the evidence that suggests a weekly solute clearance (Kt/V-urea) of 1.7 or greater is associated with b etter patient survival. The arguments to target a greater Kt/V-urea of 2.0 are challenged, yet the concept is ultimately supported. Because cardiovasc ular disease is the cause of death in half of all patients with end-stage r enal disease, dialysis adequacy must be defined, in part, by the potential of that therapy to diminish cardiovascular maladies. Blood pressure, volume , left ventricular hypertrophy, and dyslipidemias are discussed in this con text. Lastly, assumptions that increasing total solute clearance leads to i mproved nutrition in PD patients are challenged. We have attempted to expan d on what the NKF-DOQI did not include, and we urge the dialysis community to seek the answers to the many controversies that remain. We need to redef ine the adequacy of PD in a holistic manner and find outcome parameters tha t are not as final as death. (C) 1999 by the National Kidney Foundation, In c.