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The letter criticizes inconsistent definitions of incremental PD and proposes a quantitative, mechanism-based approach targeting adequacy goals while minimizing cumulative dialysate glucose exposure, supported by center 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is also linked to accelerated decline in residual kidney function.",{"name":70,"@type":61,"acceptedAnswer":71},"What definition of incremental peritoneal dialysis does the letter propose?",{"text":72,"@type":64},"Incremental PD is defined as a prescription that meets International Society for Peritoneal Dialysis adequacy targets while using the minimum feasible cumulative dialysate glucose exposure, determined by the patient’s RKF, peritoneal transport characteristics, and clinical status.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},434751,1790792087,{"code":4,"msg":82,"data":83},"success",[84,88,92,96,101,106,109,114,119,122,126],{"id":22,"doc_module":4,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Story & 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1, sfaf365  \n[https:/doi.org/10.1093/ckj/sfaf365](https:/doi.org/10.1093/ckj/sfaf365)  \nAdvance Access Publication Date: 28 November 2025 Letter to the Editor  \nLETTER TO THE EDITOR  \nReframing incremental peritoneal dialysis: prioritizing minimum glucose exposure to preserve residual kidney function  \nHacı Hasan Yeter   \nHacettepe University, Department of Nephrology, ANKARA, TURK˙IYE  \nCorrespondence to: Hacı Hasan YETER; [E-mail:](E-mail: hasanyeter@hotmail.com)[ hasanyeter@hotmail.com](E-mail: hasanyeter@hotmail.com)  \nTo the Editor,  \nResidual kidney function (RKF) is a major contributor to survival in patients undergoing peritoneal dialysis (PD) . Therefore, any PD approach that aims to optimize outcomes must place the protection of RKF at its core.  \nRepeated and cumulative exposure of the peritoneal membrane to glucose-based dialysis solutions is a primary driver of peritoneal membrane injury and progressive ultrafiltration loss [1] . In addition, glucose exposure also contributes to accelerated decline in RKF. Thus, peritoneal membrane integrity and RKF preservation are interconnected therapeutic priorities, both directly influenced by glucose burden.  \nWhile international guidelines from the International Society for Peritoneal Dialysis acknowledge incremental PD as a rational and patient-centered approach, they currently provide no quantitative or mechanistic definition based on measurable parameters such as glucose exposure, solute clearance, or preservation of RKF [2]. Also, the incremental PD term has been inconsistently defined across the literature. Some studies have described incremental PD as a reduction in the number of daily exchanges, variation in fill volumes, or as flexible treatment schedules. Although these approaches generally share the goal of personalizing PD intensity, they do not guarantee the most biologically meaningful target, namely, reduction of cumulative glucose exposure that would protect the RKF and peritoneal membrane.  \nOn the other hand, the kinetic modeling work by Guest et al. demonstrated, using a modified three-pore model across all peritoneal transport types, that adequacy targets (weekly Kt/V ≥ 1.7) can be achieved in incident PD patients with residual glomerular filtration rate (GFR) values as low as 4–6 ml/min/  \n1.73 m² using only one to three low-tonicity (1.36%) glucose oricodextrin exchanges per day [3] . These regimens not only met clearance goals but also minimized carbohydrate absorption, highlighting that dialysis adequacy and low glucose exposure are not mutually exclusive. Complementary review literature on incremental PD emphases that the biological aim of incremental PD is not just achieving operational metrics but preserving RKFand reducing cumulative metabolic and peritoneal stress as part of a strategy of aligning solute and volume control with membrane and RKF protection [4]. Beyond reducing the dialysate refill volume or dwell time, peritoneal rest also contribute favorable effect on peritoneal membrane recovery by reducing ongoing injurious exposure. This effect has documented in the rat studies and clinical and translational reports [5] .  \nOur center has applied the proposed glucose-minimizing incremental PD strategy in a cohort of 28 incident PD patients. The median follow-up durations were 39 months (range 30–50) for the continuous ambulatory PD(CAPD) group and 27 months (range 10–74) for the automated PD[automated peritoneal dialysis (APD)] group (Table 1) . Whereas all CAPD patients retained measurable RKF, 21 out of 23 APD patients (91%) maintained RKF during the observation period.  \nIn this context, incremental PD could be defined as a PD prescription that achieves International Society for Peritoneal Dialysis adequacy targets with the minimum feasible cumulative dialysate glucose exposure, determined by the patient’s RKF, peritoneal transport characteristics, and clinical status.  \nKey components of increme","cbCaiv3wi13Q4BJI","https://ap.wps.com/l/cbCaiv3wi13Q4BJI","pdf",177909,"English","# Letter to the Editor\n## Rationale: RKF and glucose-driven injury\n## Limitations of current guideline definitions\n## Mechanistic framework and adequacy targets\n## Proposed definition and patient selection\n## Center cohort experience and outcomes","[{\"question\":\"Why does the letter emphasize protecting residual kidney function in peritoneal dialysis?\",\"answer\":\"Because residual kidney function is described as a major contributor to survival in patients undergoing peritoneal dialysis, and protecting it should be central to any approach that optimizes outcomes.\"},{\"question\":\"How does glucose exposure relate to peritoneal membrane injury and RKF decline?\",\"answer\":\"Repeated and cumulative exposure of the peritoneal membrane to glucose-based solutions is presented as a primary driver of membrane injury and ultrafiltration loss, and glucose exposure is also linked to accelerated decline in residual kidney function.\"},{\"question\":\"What definition of incremental peritoneal dialysis does the letter propose?\",\"answer\":\"Incremental PD is defined as a prescription that meets International Society for Peritoneal Dialysis adequacy targets while using the minimum feasible cumulative dialysate glucose exposure, determined by the patient’s RKF, peritoneal transport characteristics, and clinical status.\"}]","Reframing incremental peritoneal dialysis: prioritizing minimum glucose exposure to preserve residual kidney function - Letter to the Editor | PDF",1790670471]