Past, present and future of incremental peritoneal dialysis

Abstract Peritoneal dialysis (PD) provides an effective, home-based and cost-efficient treatment option, but is underutilised owing to concerns about treatment burden and complications. Contemporary priorities from international guidelines emphasise quality of life, attainment of life goals and reduced treatment burden, particularly during the first months after PD initiation, when risks of complications, haemodialysis transfer and death are the highest. Despite this, most patients begin PD on standardised ‘full-dose’ regimens, imposing substantial time demands, potential for accelerated glucose‑related metabolic harm, peritoneal inflammation and loss of residual kidney function (RKF). Incremental PD can be defined as the initiation of PD at a lower than standard ‘full dose’ supported by residual kidney function and has garnered PD clinician interest worldwide. Incremental PD has been proposed as an approach to reduce early treatment burden, limit exposure to glucose degradation products (GDP), decrease environmental waste and improve resource utilisation. However, the current evidence base is heterogeneous and predominantly observational, with inconsistent definitions of ‘incremental’ versus ‘full‑dose’ PD that limit cross-study comparability. Consequently, the purported advantages of incremental PD, including improved preservation of residual kidney function and enhanced patient experience through greater life participation, remain uncertain. This review synthesises the conceptual rationale, current evidence and patient‑important considerations for incremental PD and outlines priorities for rigorous, adequately powered randomised trials to determine when, how and for whom incremental PD should be implemented.