Decreasing the Burden: A Single-Centre Experience of Decremental Peritoneal Dialysis (PD) in Toronto, Canada
Bibliographic record
Abstract
Background: The 2020 International Society of Peritoneal Dialysis (ISPD) recommendations on providing high-quality peritoneal dialyis (PD) prescriptions highlight shared-decision making principles that deemphasize the focus on Kt/V clearance targets. As a result, incremental PD has gained popularity amongst care providers in recent history. However, “decremental PD”, a practice in which PD dose is reduced after patients are started on high dose PD (>10L/day), has not been well described in the literature. Decremental PD utilizes the principles of goal-directed therapy as outlined by the ISPD to reduce prescriptions where possible; particularly when treatment is burdensome for patients. We describe our experience with this approach and potential benefits to both patients and the healthcare system. Methods: Nine prevalent patients on high-dose automated PD prescriptions seen between August 1-December 31, 2019, were included in this analysis. All patients reported prescriptions were burdensome. Patients were offered a reduced dose in their prescription after clinical assessment and laboratory investigations were reviewed. Patients were compared 6 months before and after the change in prescription for any significant differences in hospitalization, peritonitis rates and technique failure. Small solute clearance using Kt/V and creatinine clearance along with residual urine output were also compared. Results: Total dialysis volume and time on cycler were significantly reduced from a mean of 12.6 L to 9.2L (p <0.001) and from 8.7 to 8.2 hours (p <0.035). No statistically significant differences in Kt/V and CrCl values 6 months after the change in prescription were observed. There were no observed peritonitis episodes or hospitalizations six months after prescription change. All patients remained on PD 12 months after the intervention with no further prescription changes. The reduced prescription resulted in a 19.2% cost reduction per patient at six months compared to high-dose prescription. Conclusions: We demonstrate that decremental PD prescriptions align with ISPD recommendations in maintaining patient-centered care while reducing cost.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.000 | 0.002 |
| Meta-epidemiology (narrow) | 0.000 | 0.000 |
| Meta-epidemiology (broad) | 0.000 | 0.000 |
| Bibliometrics | 0.000 | 0.002 |
| Science and technology studies | 0.005 | 0.001 |
| Scholarly communication | 0.001 | 0.000 |
| Open science | 0.001 | 0.002 |
| Research integrity | 0.001 | 0.001 |
| Insufficient payload (model declined to judge) | 0.002 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".