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Moncrief developed a new surgical technique to prevent infection. In this technique, a peritoneal dialysis (PD) catheter is first inserted, then an exit site is created only after 3–5 weeks. Planning of PD initiation reportedly has a large influence on avoiding complications and life prognosis. For these reasons, stepwise initiation of PD using Moncrief Popovich technique (SMAP) has been used in many patients in Japan for safe PD initiation at the appropriate time. The Moncrief-Popovich catheter creates an exit site after 3-5 weeks of operation, but SMAP creates it when the symptoms appear.
In 2005, M Kubota et al. reported that PD initiation by SMAP suppressed chronic kidney disease (CKD) progression in nine patients; subsequently, several physicians experienced the same. There are some reports in HD patients, but there are few reports about PD patients. In this study, we compared the preoperative and postoperative rates of kidney function decline in patients who undewent SMAP and compared the influence on kidney function between SMAP and direct method.
Study Design
This retrospective study included 110 patients who were initiated on PD at five centers from April 2015 to July 2024. The patients who were referred to other hospitals during follow-up were excluded. This study was approved by the ethics committee of our institution (MH2023-116), which waived the requirement for individual patient consent, considering the retrospective observation study design. Patients were divided into those who underwent SMAP (SMAP group, n = 51) and those who in whom PD was initiated immediately or urgently (direct method group, n = 59). We compared the rate of kidney function decline before and after operation in the SMAP group and between the SMAP and direct method groups. We used estimated glomerular filtration rate (eGFR) slope as the measure of the rate of kidney function decline. In the SMAP group, we evaluated eGFR slope from the first visit to surgery (preoperative) and from surgery to PD initiation (postoperative). In the direct method group, we evaluated eGFR slope from the first visit to PD initiation. Calculation of eGFR slope was as follows:
SMAP group
Pre-operative =((eGFR at operation-eGFR at first visit))/((Time from first visit to operation (month))) × 12(mi/min/1.73 m2/year )
Post-operative =((eGFR at peritoneal dialysis initiation-eGFR at operation))/((Time from operation to peritoneal dialysis initiation (month))) × 12(ml/min/1.73 m2/year)
Direct method group
((eGFR at peritoneal dialysis initiation-eGFR at first visit))/((Time from first visit to peritoneal dialysis initiation (month)))/ × 12(ml/min/1.73 m2/year)
Statistical analysis
The rate of kidney function decline was compared between the preoperative and postoperative periods using paired t-test and between the SMAP and direct method groups using t-test and chi-square test. All statistical analyses were performed using EZR ver1.64 (Saitama Medical Center, Jichi Medical University, Saitama, Japan). EZR (The R Foundation for Statistical Computing, Vienna, Austria) is a statistical program that extends the foundation of R or R Commander. Statistical significance was defined as a p value <0.05.
The patient characteristics were as follows. The population had a median (interquartile range) age of 60.0 years (47.5–67.0 years), and men accounted for 65.4% (n = 72). The primary kidney disease with the highest prevalence rate was diabetic nephropathy (39.0%, n = 43), followed by benign nephrosclerosis (10.9%, n = 12) and glomerulonephritis (10.0%, n = 11). The median age (in years) was significantly lower in the SMAP group than in the direct method group [60.0 (47.5–67.0) vs. 63.0 (55.0–73.5), p = 0.03]. There were no significant differences between the two groups in terms of sex and primary kidney disease.
Evaluation of the transition of kidney function in the SMAP group showed median eGFR (mL/min/1.73 m2) values of 10.4 (8.4–13.4) at first visit, 7.0 (6.1–8.2) at operation, and 5.1 (4.3–6.7) at the time of PD initiation. As shown in Fig. 1, the postoperative eGFR slope was significantly lower than the preoperative eGFR slope [8.2 (5.0–13.8) mL/min/1.73 m2/year vs. 4.1 (1.5–7.0) mL/min/1.73 m2/year, p <0.01]. Compared with the SMAP group, the direct method group did not significantly differ in terms of the median eGFR at PD initiation [5.6 (4.4–6.8) mL/min/1.73 m2, p = 0.54] and median eGFR slope [6.8 (3.3–12.0) mL/min/1.73 m2/year, p = 0.58 compared with the preoperative eGFR slope in the SMAP group] (Fig. 2). Hb and Alb levels increased slightly from 9.5 to 10.0 g/dL and 3.6 to 3.9 g/dL, respectively, but remained relatively stable; there were no differences between the preoperative and postoperative transition of Hb and Alb levels in the SMAP group.
The SMAP approach may contribute to the preservation of kidney function after surgery. This effect could be partially attributed to psychological factors, although further studies are needed to confirm this.
