Changes in the worldwide epidemiology of peritoneal dialysis

Role of macrophages in peritoneal dialysis-associated peritoneal fibrosis

Peritoneal dialysis (PD) can be used as renal replacement therapy when chronic kidney disease (CKD) progresses to end-stage renal disease. However, peritoneal fibrosis (PF) is a major cause of PD failure. Studies have demonstrated that PD fluid contains a significantly larger numbers of macrophages compared with the healthy individuals. During PD, macrophages can secrete cytokines to keep peritoneal tissue in sustained low-grade inflammation, and participate in the regulation of fibrosis-related signaling pathways, such as NF-κB, TGF-β/Smad, IL4/STAT6, and PI3K/AKT. A series of basic pathological changes occurs in peritoneal tissues, including epithelial mesenchymal transformation, overgeneration of neovasculature, and abnormal deposition of extracellular matrix. This review focuses on the role of macrophages in promoting PF during PD, summarizes the targets of macrophage-related inhibition of fibrosis, and provides new ideas for clinical research on delaying PF, maintaining the function and integrity of peritoneum, prolonging duration of PD as a renal replacement modality, and achieving longer survival in CKD patients.

Anxiety as a mediator between symptom distress and quality of life in peritoneal dialysis patients: insights from mediation analysis and nonlinear models

OBJECTIVES

This study investigates anxiety's role as a mediator between symptom burden and quality of life in patients undergoing peritoneal dialysis, emphasizing the potential for targeted interventions to enhance patient outcomes.

METHODS

In a cross-sectional design, 320 peritoneal dialysis patients were recruited, with 305 providing valid responses (response rate: 95.31%). Symptom burden (occurrence and distress), anxiety levels, and quality of life were measured using validated tools. Multiple linear regression and restricted cubic spline models assessed associations, using β with a 95% confidence interval (95% CI), while mediation analysis with 1000 bootstrap samples quantified anxiety's mediating effects.

RESULTS

Participants reported an average of 8.2 ± 2.3 concurrent symptoms, with 'worry,', 'tiredness', and 'dry skin' being the most severe. Both symptom number (β = -0.90; 95%CI: -1.26 to -0.55) and distress (β = -1.20; 95%CI: -1.41 to -0.98) negatively correlated with quality of life. Anxiety mediated these relationships significantly, explaining 38.9% (95%CI: 18%-62%) and 33.3% (95%CI: 19%-49%) of the total effects for symptom number and distress, respectively. Restricted cubic spline models revealed an 'L-shaped' relationship between symptom burden and quality of life.

CONCLUSIONS

Anxiety significantly mediates the relationship between symptom burden and quality of life in peritoneal dialysis patients. These findings underline the importance of integrating psychological interventions and routine symptom screening into patient care to enhance quality of life. Future research should explore longitudinal designs and standardized intervention strategies.

The combination of left ventricular ejection fraction and end-diastolic diameter and outcomes in peritoneal dialysis patients: a multicenter retrospective study

End-stage renal disease (ESRD) is often complicated by left ventricular dysfunction, which is associated with a poor prognosis. This study aims to investigate the association between baseline left ventricular ejection fraction (LVEF) plus left ventricular end-diastolic diameter (LVEDD) with outcomes in peritoneal dialysis (PD) patients. In this multicenter retrospective study, 1,511 incident Chinese patients on PD between 1 January 2005 and 31 December 2021 were enrolled. Restricted cubic splines (RCS) were used to explore the non-linear associations between LVEF+LVEDD and the risk of mortality. Parametric models for interval-censored survival-time data (stintreg) were used to examine the association between LVEF+LVEDD quartiles and the outcomes. During 6,451.11 person-years of follow-up [median 4.81 (IQR 3.61-6.81) years], 247 (17.8%) patients died, including 88 cardiovascular deaths. RCS showed a U-shaped association between LVEF+LVEDD and the risks of all-cause and CV mortality. According to the quartiles, the optimal range of LVEF+LVEDD associated with the lowest risk of all-cause and CV mortality was 103-107, which was set as the reference range. Both higher (≥115) and lower (<103) levels of LVEF+LVEDD were associated with increased risks of all-cause mortality (hazard ratio [HR] 2.20, 95% confidence interval [CI] 1.58-3.07; HR 1.68, 95% CI 1.19-2.36) and cardiovascular mortality (HR 2.51, 95% CI 1.33-4.75; HR 1.86, 95% CI 0.96-3.61). Low and high levels of baseline LVEF+LVEDD were associated with increased risks of all-cause and cardiovascular mortality in PD patients.

Peritoneal membrane transport characteristics in patients undergoing peritoneal Dialysis are associated with systemic IL-8 levels

BACKGROUND

Several cytokine levels in dialysate, particularly interleukin-6 (IL-6), have been investigated as potential biomarkers for peritoneal solute transport rate (PSTR). However, studies examining the relationship between systemic cytokine levels and PSTR have yielded contradictory results. In this study, we aimed to assess 12 kinds of cytokines in serum and explore their potential relationship with peritoneal transport function.

METHODS

Patients undergoing peritoneal dialysis (PD) from September 2022 to September 2024 were retrospectively analyzed at our PD center. The patients were categorized into fast and non-fast PSTR groups based on the 4-h dialysate creatinine /plasma creatinine ratio (D/P Cr). The systemic levels of 12 cytokines (IL-1β, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p70, IL-17 A, TNF-α, IFN-α, and IFN-γ) in both groups were measured using flow cytometry and compared. The relationship between serum cytokine levels and baseline peritoneal transport status was analyzed by univariate and multivariate logistic regression analyses.

RESULTS

A total of 284 patients were enrolled in this study. According to the D/P Cr, 171 patients (60.2 %) were classified as non-fast PSTR group, while 113 patients (39.8 %) were classified as fast PSTR group. Among the 12 cytokines analyzed, serum IL-8 exhibited a significant difference between the two groups (P = 0.01). IL-8/IL-10 and IL-12p70/IL-10 ratios were also significantly higher in fast PSTR group. In the subgroup of incident PD patients, multivariate analysis revealed that total cholesterol (OR 0.559, 95 % CI 0.323-0.966, P = 0.037) and serum IL-8 (OR 1.040, 95 % CI 1.006-1.075, P = 0.021) were significantly and independently associated with baseline fast PSTR.

CONCLUSION

The systemic IL-8 level is positively correlated with PSTR in patients undergoing PD, which may serve as an indicator of baseline peritoneal transport function.

Sacubitril/valsartan affects pulmonary arterial pressure in heart failure with preserved ejection fraction and pulmonary hypertension among PD patients

PURPOSE

Pulmonary hypertension is an independent risk factor for all-cause mortality and cardiovascular events in peritoneal dialysis (PD) patients with heart failure with preserved ejection fraction (HFpEF). However, there is still no effective treatment. The aim of this study is to evaluate the efficacy and safety of sacubitril/valsartan in PD patients with HFpEF and pulmonary hypertension.

PATIENTS AND METHODS

145 PD patients with HFpEF and pulmonary hypertension receiving sacubitril/valsartan were recruited in this study. 38 PD patients with HFpEF and pulmonary hypertension treated with angiotensin receptor blocker (ARB) were enrolled as the control group. The follow-up time was 3 months. We evaluate efficacy and safety of sacubitril/valsartan through biochemical parameters, and echocardiographic indicators, and adverse reactions.

RESULTS

At the end of follow-up, the pulmonary artery pressure was significantly lower [33.00 (23.00, 45.50) vs 48.00 (40.00, 54.00) mmHg, P < 0.001] after the treatment of sacubitril/valsartan. The percentage change of pulmonary artery pressure after the treatment of sacubitril/valsartan was significantly higher than that of ARB [-30.00 (-48.78, -8.23) vs -8.57 (-12.80, -0.85) %, P < 0.001]. As the biomarkers of heart failure, the levels N-terminal B-type natriuretic peptide precursor and cardiac troponin I were remarkably reduced after the treatment with sacubitril/valsartan. Sacubitril/valsartan can also attenuate left-ventricular remodeling among PD patients. While, ARB does not show significant advantages compared to sacubitril/valsartan.

CONCLUSION

Our study suggested that sacubitril/valsartan treatment might be an effective treatment for PD patients with HFpEF and pulmonary hypertension.

Engagement and usability of a mobile health app for peritoneal dialysis patients: A pilot randomized controlled trial

BackgroundRemote monitoring programs for peritoneal dialysis (PD) have emerged with evidence of improved clinical and system-related outcomes in automated PD (APD) patients. The digital revolution now includes digital applications (apps) for mobile devices in healthcare. We evaluated the usability and patient engagement of using a newly developed mobile health app, MyPD app, for the care of continuous ambulatory PD (CAPD) and APD patients.MethodsThis randomized controlled, open-label, parallel-group trial was conducted in adult prevalent CAPD and APD patients. One arm used the MyPD app in addition to standard of care, while the other followed the standard of care in PD only. The follow-up was for six months. The primary outcome was engagement measured as frequency of communication between clinic and patient and, vice versa, number of preemptive visits and changes in dialysis prescription. Secondary outcomes included usability, peritonitis events, and number of hospitalizations, emergency room visits, and antihypertensive medicationsResultsA total of 140 patients were included in this study, 70 in the MyPD group and 70 in the standard care group. Their mean age was 52 ± 17 years; 68 (49%) patients received CAPD, while 72 (51%) received APD with remote monitoring based on the Sharesource platform.The mean number of communications between the clinic and patients during follow-up was 4.3 ± 5.2 for MyPD group and 1.2 ± 2.3 for standard of care, p < 0.01. The overall usability score was 6.5 ± 0.7, the maximum possible score is 7.ConclusionsThe use of MyPD app was associated with increased engagement between PD clinic and patients and high usability. The findings from the study are encouraging for integration of mobile health apps like MyPD into routine care in PD as tools to improve communication.

Effect of the Chronic Kidney Disease-Peritoneal Dialysis (CKD-PD) App on Improvement of Overhydration Treatment in Patients on Peritoneal Dialysis: Randomized Controlled Trial

BACKGROUND

Overhydration is associated with increased morbidity and mortality in patients on peritoneal dialysis (PD). Early detection of overhydration is possible by monitoring hydration metrics, but the critical gap for treatment is obtaining timely and actionable data.

OBJECTIVE

This study compares the detection of overhydration and clinical outcomes in patients on PD using the Chronic Kidney Disease-Peritoneal Dialysis (CKD-PD) smartphone app with standard monitoring and management.

METHODS

An open-label randomized controlled trial was conducted at 3 hospitals in northeast Thailand. Enrolled participants from PD clinics were randomized into 2 equal groups: CKD-PD (App users) and usual management (No-App). Participants or their caregivers in the App group recorded hydration metrics in the CKD-PD app, which were uploaded to a central database monitored by nephrology staff. The No-App group used a handwritten logbook. Both groups had bimonthly clinic visits. The primary outcome was the incidence rate ratio (IRR) for clinical interventions for overhydration. Secondary outcomes included hospitalizations, technique failure, and death.

RESULTS

A total of 208 participants were randomized into App (N=103) and No-App (N=105) groups with the median follow-up time of 11.2 months. Hydration metric upload compliance in the App group was 85.7% (IQR 71.4-95.6). The IRR of overall interventions for overhydration was 2.51 times higher in the App group (95% CI 2.18-2.89; P<.001). Types of clinical interventions for overhydration differed between groups with dietary change and prescription of antihypertensive drugs more frequent in App users and diuretics and change of dialysis prescription more frequent in the No-App group. Hospitalizations were significantly higher in the No-App group due to any cause (adjusted IRR 1.58) and volume overload (adjusted IRR 4.07). There was no significant difference in survival analysis and technique failure between the 2 groups.

CONCLUSIONS

Use of the CKD-PD app improved early detection of overhydration and early treatment interventions, resulting in fewer all-cause and volume overload hospitalizations.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04797195; https://clinicaltrials.gov/study/NCT04797195.

Development and validation of a nomogram for predicting low Kt/Vurea in peritoneal dialysis patients

BACKGROUND

This study aimed to develop a nomogram to predict peritoneal dialysis (PD) adequacy in incident PD patients and identify those at high risk for low Kt/Vurea PD function.

METHODS

We retrospectively analyzed 141 incident PD patients from January 2021 to January 2024. Baseline characteristics, including BMI, hemoglobin levels, and high transport PD membrane, were compared between patients with and without adequate PD function. Univariate logistic regression, LASSO analysis, and Random Forest (RF) algorithms were employed to identify potential biomarkers. Significant predictors were integrated into a multivariable logistic regression model to construct a predictive nomogram.

RESULTS

The study found that 32.1% of patients had low total Kt/Vurea. Significant predictors of low Kt/Vurea included smoking (OR 2.23, CI 1.47-5.85), BMI (OR 1.35, CI 1.17-1.59), hemoglobin levels (OR 0.98, CI 0.95-0.99), and High transport (OR 0.2., CI 0.04-0.72). These factors were incorporated into a nomogram, which demonstrated strong predictive accuracy, with a C-Index of 0.802 in the main study group. The model's AUC was 0.778 (95% CI: 0.686-0.870), and Decision Curve Analysis (DCA) confirmed its clinical utility across a wide range of threshold probabilities.

CONCLUSIONS

We developed a nomogram that accurately predicts PD total Kt/Vurea in incident PD patients. This model can be a valuable tool for identifying patients at risk of low PD total Kt/Vurea, facilitating timely interventions to improve patient outcomes.

The burden of chronic kidney disease in Asia region: a review of the evidence, current challenges, and future directions

The disease burden of chronic kidney disease (CKD) and its impact on healthcare systems has been poorly studied in Asia, a socioeconomically diverse region with wide variations in availability, access, and quality of CKD care. The high CKD burden in this region is predominantly driven by an increased prevalence of risk factors including diabetes mellitus, hypertension, obesity, and use of traditional medicines and is further aggravated by challenges associated with effective implementation of population-based screening and surveillance systems in early detection and intervention of CKD. The Asian continent mostly comprised of low- and middle-income countries with resource restraints lacks robust population-based CKD registries resulting in a paucity of data on CKD incidence and prevalence, various treatment modalities, uptake of current guidelines, and the overall impact of implementation of developmental programs. There is an urgent need for a collaborative action plan between the healthcare community and governments in this region to detect CKD in its early stages and prevent its complications including kidney failure, cardiovascular disease, and death. Research- based evidence on the impact of early detection, sustainable treatment options, quality of life, delay or avoidance of dialysis, and related cost analysis is the need of the hour. We highlight successful implementation of strategic and policy-sharing programs adopted in a few countries; also, consolidate available region-specific data, quantify estimates of CKD burden and propose strategies with a multidisciplinary approach involving patients, the healthcare community and governmental bodies to combat CKD and its complications.

Targeting MLL1/WDR5-Mediated Epigenetic Regulation Mitigates Peritoneal Fibrosis by Reducing p16INK4a

Peritoneal fibrosis poses a significant challenge to the long-term efficacy of peritoneal dialysis (PD), with emerging evidence highlighting the role of cellular senescence in its pathogenesis. p16INK4a is a cell cycle regulator that has been implicated in cellular senescence. Mixed-lineage leukemia 1 (MLL1) forms a complex with WD-40 repeat protein 5 (WDR5) and exhibits histone H3K4 methyltransferase activity. We have previously shown that inhibition of the MLL1/WDR5 complex reduces p16INK4a expression and attenuates renal senescence after injury in mice. This study aimed to investigate whether inhibiting MLL1/WDR5 attenuates peritoneal senescence, inflammation, and fibrosis in both human samples and in mice with methylglyoxal (MGO)-induced peritoneal fibrosis (MGO-injected mice), while also exploring the associated underlying mechanisms. MLL1/WDR5, histone 3 lysine 4 trimethylation (H3K4me3), and p16INK4a expression were elevated in TGF-β1-stimulated human peritoneal mesothelial cells (HPMCs), non-adherent cells obtained from patients undergoing PD, and the submesothelial compact zones of MGO-injected mice. Notably, p16INK4a expression in these cells was positively correlated with the dialysate/plasma creatinine ratio. Treatment with the MLL1/WDR5 protein-protein interaction inhibitors MM-102 and OICR-9429 reduced H3K4me3 levels and p16INK4a expression, suppressing fibrosis in HPMCs as well as peritoneal fibrosis and inflammation in MGO-injected mice. These inhibitors also improved peritoneal function in MGO-injected mice. Additionally, we demonstrated that MLL1/WDR5-induced H3K4me3 directly regulates p16INK4a gene transcription, and that inhibiting MLL1/WDR5 reduces H3K4me3, thereby suppressing p16INK4a gene transcription. These findings suggest that targeting MLL1/WDR5 activation alleviates peritoneal senescence, inflammation, and fibrosis, highlighting its potential as a promising therapeutic strategy for peritoneal fibrosis.

A complicated case of refractory multiple drug-resistant peritoneal dialysis-associated peritonitis due to teratoma

Peritoneal dialysis-associated peritonitis is a leading cause of treatment discontinuation and mortality among peritoneal dialysis patients. The presence of multidrug-resistant organisms further complicates management, particularly in patients with complex intra-abdominal conditions. This paper presents a complicated case of refractory multidrug-resistant peritoneal dialysis-associated peritonitis, which was ultimately diagnosed as being caused by a teratoma. Following adequate drainage and the administration of sensitive antibiotics, the patient successfully underwent teratoma excision and transitioned to hemodialysis.

Realtime particulate matter and bacteria analysis of peritoneal dialysis fluid using digital inline holography

This study developed a digital inline holography (DIH) system integrated with deep learning algorithms for real-time detection of particulate matter (PM) and bacterial contamination in peritoneal dialysis (PD) fluids. The system comprises a microfluidic sample delivery module and a DIH imaging module that captures holograms using a pulsed laser and a digital camera with a 40 × objective. Our data processing pipeline enhances holograms, reconstructs images, and employs a YOLOv8n-based deep learning model for particle identification and classification, trained on labeled holograms of generic PD particles, Escherichia coli (E. coli), and Pseudomonas aeruginosa (P. aeruginosa). The system effectively detected and classified generic particles in sterile PD fluids, revealing diverse morphologies predominantly sized 1-5 µm with an average concentration of 61 particles/µL. In PD fluid samples spiked with high concentrations of E. coli and P. aeruginosa, our system achieved high sensitivity (>90 %) in detecting and classifying these bacteria at clinically relevant low false positive rates (∼0.5 %). Further validation against standard colony-forming unit (CFU) methods using PD fluid spiked with bacterial concentrations from approximately 100 to 10,000 bacteria/mL demonstrated a clear one-to-one correspondence between our measurements and CFU counts. Our DIH system provides a rapid, accurate alternative to traditional culture-based methods for assessing bacterial contamination in PD fluids. By enabling real-time sterility monitoring, it can significantly improve patient outcomes in PD treatment, facilitate point-of-care fluid production, reduce logistical challenges, and be extended to quality control in pharmaceutical production.

Roxadustat effectiveness versus ESAs in peritoneal dialysis patients during the COVID-19 pandemic: A retrospective study

BACKGROUND

The COVID-19 pandemic has made treating renal anemia in chronic kidney disease (CKD) patients undergoing peritoneal dialysis (PD) difficult. The current study aims to compare roxadustat with erythropoiesis-stimulating agents (ESAs) during the COVID-19 pandemic.

METHODS

We conducted a single-center, retrospective study during the COVID-19 outbreak in China, from December 7, 2022, to January 31, 2023. The study involved patients undergoing PD who were divided based on the medication used to treat renal anemia; the roxadustat group (n = 34) and the ESAs group (n = 120). We analyzed the effectiveness of treating anemia, cost, medication adherence, and clinical outcomes related to COVID-19. Patients were followed up for 9 months.

RESULTS

The baseline of hemoglobin levels was (110.03 ± 1.71 g/L in the roxadustat and 110.1 ± 1.52 g/L in the ESAs groups, respectively), after 9 months of inspections, the levels of hemoglobin were (121.26 ± 2.03 g/L in the roxadustat and 118.49 ± 1.35 g/L in the ESAs groups, respectively). The roxadustat subgroup analysis indicated that total cholesterol and low-density lipoprotein levels in the roxadustat group decreased from baseline in subjects not receiving statins (3.39 ± 0.12 vs. 4.2 ± 0.21 mmol/L and 2.21 ± 0.23 vs. 3.65 ± 0.37 mmol/L, P < 0.05). The Morisky score of the roxadustat group was higher [7 (5, 8) vs. 6 (4, 8), P < 0.01]. The drug cost of the roxadustat group was higher, but another additional cost for correcting anemia was significantly reduced. The infection rate of COVID-19 and the mortality rate caused by COVID-19 were lower in roxadustat group.

CONCLUSION

During the COVID-19 pandemic, both roxadustat and ESAs effectively improved renal anemia in PD patients, however, the roxadustat group experienced less additional costs for anemia correction and better medication compliance.

Adipose Tissue Stem Cells (ASCs) and ASC-Derived Extracellular Vesicles Prevent the Development of Experimental Peritoneal Fibrosis

Cell therapy utilizing mesenchymal stromal cells (MSCs) through paracrine mechanisms holds promise for regenerative purposes. Peritoneal fibrosis (PF) is a significant complication of peritoneal dialysis. Various strategies have been proposed to protect the peritoneal membrane (PM). This study explores the effectiveness of adipose-tissue-derived stem cells (ASCs) and extracellular vesicles (EVs) at mitigating PF using a rat model of PF induced by chlorhexidine gluconate. ASC and EV treatments effectively prevented an increase in the thickness of the PM and diminished the number of myofibroblasts, fibronectin expression, collagen III expression, and PF-related factors such as TGF-β and FSP-1. Smad3 gene expression decreased in the treatment groups, whereas Smad7 gene expression increased in treated animals. In addition, ASC and EV injections showed potent anti-inflammatory effects. Glucose transport through the PM remained unaffected in relation to the PF group; both treatments promoted an increase in ultrafiltration (UF) capacity. The PF+EVs treated group showed the highest increase in UF capacity. Another critical aspect of ASC and EV treatments was their impact on neoangiogenesis in the PM which is vital for UF capacity. Although the treated groups displayed a significant decrease in VEGF expression in the PM, peritoneal function remained effective. In conclusion, within the experimental PF model, both ASC and EV treatments demonstrated anti-inflammatory effects and comparably hindered the progression of PF. The EV treatment exhibited superior preservation of peritoneal function, along with enhanced UF capacity. These findings suggest the potential of ASCs and EVs as novel therapeutic approaches to prevent the development of PF associated with peritoneal dialysis.

Dietary energy intake predicts mortality in Chinese patients with peritoneal dialysis: a single-center 18 years' follow-up study

BACKGROUND

Lower dietary energy intake (DEI) may be associated with increased mortality risk. This study aims to analyze the influence of baseline DEI, time average DEI, and other factors on survival in peritoneal dialysis (PD) patients.

METHOD

It was a single-center retrospective cohort study. Patients who started PD from January 2006 to June 2021 were included in this study and followed up until June 2023. Their baseline (six months after the beginning of PD) demographic, dietary intake, laboratory data, and time varying dietary intake data were collected and analyzed. The relationships between these data and survival were examined using Cox model to estimate death hazard ratios.

RESULT

A total of 794 patients were included in this study, 424 males and 370 females, with a mean age of 58.87 ± 16.02 years. Their mean normalize baseline dietary energy intake (nDEI) was 25.46 ± 6.72 kcal/kg/day, time average nDEI was 24.87 ± 4.74 kcal/kg/day. The median follow-up duration was 46.58 (27.38, 78.52) months in the overall cohort. Based on multivariate Cox proportional hazard analysis, age (HR = 1.056, 95% Cl = 1.047-1.065, p < 0.001), diabetes (HR = 1.364, 95% Cl = 1.114-1.671, p = 0.003), serum albumin (HR = 0.945, 95% Cl = 0.923-0.967, p < 0.001), blood sodium (HR = 0.973, 95% Cl = 0.954-0.992, p = 0.002), serum urea (HR = 0.974, 95% Cl = 0.953-0.994, p = 0.025), and baseline nDEI (HR = 0.980, 95% Cl = 0.964-0.996, p = 0.017) were significantly associated with mortality. Baseline DPI, BMI and time average nDEI were not related to PD patients' survival. When classified baseline nDEI into 4 groups (< 25 kcal/kg/day, 25-29.99 kcal/kg/day, 30-34.99 kcal/kg/day, and ≥ 35 kcal/kg/day), the univariate and multivariate Cox proportional hazard analysis showed that the patients with nDEI 30-34.99 kcal/kg/day had the lowest mortality risk (using the DEI < 25 kcal/kg/day group as reference, p < 0.05).

CONCLUSION

Our study revealed that DEI 30-34.99 kcal/kg/day might be beneficial to the long-term outcome for the Chinese PD population.

CLINICAL TRIAL NUMBER

Not applicable.

Daily Treatment Monitoring for Patients Receiving Home-Based Peritoneal Dialysis and Prediction of Heart Failure Risk: mHealth Tool Development and Modeling Study

BACKGROUND

Peritoneal dialysis is one of the major renal replacement modalities for patients with end-stage renal disease. Heart failure is a common adverse event among patients who undergo peritoneal dialysis treatment, especially for those who undergo continuous ambulatory peritoneal dialysis at home, because of the lack of professional input-output volume monitoring and management during treatment.

OBJECTIVE

This study aims to develop novel mobile health (mHealth) tools to improve the quality of home-based continuous ambulatory peritoneal dialysis treatment and to build a prediction model of heart failure based on the system's daily treatment monitoring data.

METHODS

The mHealth tools with a 4-layer system were designed and developed using Spring Boot, MyBatis Plus, MySQL, and Redis as backend technology stack, and Vue, Element User Interface, and WeChat Mini Program as front-end technology stack. Patients were recruited to use the tool during daily peritoneal dialysis treatment from January 1, 2017, to April 20, 2023. Logistic regression models based on real-time treatment monitoring data were used for heart failure prediction. The sensitivity, specificity, accuracy, and Youden index were calculated to evaluate the performance of the prediction model. In the sensitivity analysis, the ratio of patients with and without heart failure was set to 1:4 and 1:10, respectively, to better evaluate the stability of the prediction model.

RESULTS

A WeChat Mini Program named Futou Bao for patients and a patient data management platform for doctors was developed. Futou Bao included an intelligent data upload function module and an auxiliary function module. The doctor's data management platform consisted of 4 function modules, that is, patient management, data visualization and marking, data statistics, and system management. During the study period, the records of 6635 patients who received peritoneal dialysis treatment were uploaded in Futou Bao, with 0.71% (47/6635) of them experiencing heart failure. The prediction model that included sex, age, and diastolic blood pressure was considered as the optimal model, wherein the sensitivity, specificity, accuracy, and Youden index were 0.75, 0.91, 0.89, and 0.66, respectively, with an area under the curve value of 0.879 (95% CI 0.772-0.986) using the validation dataset. The sensitivity analysis showed stable results.

CONCLUSIONS

This study provides a new home-based peritoneal dialysis management paradigm that enables the daily monitoring and early warning of heart failure risk. This novel paradigm is of great value for improving the efficiency, security, and personalization of peritoneal dialysis.

Reduction of peritoneal dialysis associated infections using a novel exit-site care practice

INTRODUCTION

Peritoneal dialysis (PD) related infections are a significant obstacle leading to PD discontinuation. Since catheter related infections (CRI), defined as exit site infections and/or tunnel infection, can progress to peritonitis, vigorous efforts are implemented in CRI prevention. Following an increased CRI rate in our institution, partially related to environmental organisms found in water distribution systems, we hypothesized that exit site care that includes prevention of water exposure-related pathogens may reduce CRI.

METHODS

In this prospective single center study, we compared a contemporary cohort consisting of PD patients who implemented the modified exit-site care protocol, mainly including water avoidance during shower with stoma bag usage and local Mupirocin ointment against a historical control group before the protocol implementation. The historical cohort was allowed water exposure and used local gentamicin ointment. The primary outcome was the development of a CRI. Secondary outcomes were PD associated peritonitis and infection related outcomes.

RESULTS

There were 55 patients in contemporary cohort and 58 in historical group. The CRI rate was significantly lower in study group (0.11/episodes per patient year [EPP]) compared to control group (0.71 EPP), p < 0.001. A multivariate Cox regression analysis demonstrated a protective effect of being in the contemporary cohort compared to historical group (HR for first CRI = 12.0 95%CI: 4.0-35.7, p < 0.001). Peritonitis rate was significantly lower in contemporary cohort (0.19/EPP) compared to the historical group (0.40/EPP), p = 0.011. Transfer to hemodialysis was significantly lower in contemporary cohort than historical group (7.3% vs 31.0% in contemporary and historical group respectively, HR = 0.2, 95%CI; 0.05-0.6, p = 0.001).

CONCLUSION

An exit site care protocol that includes water avoidance and local Mupirocin use reduced substantially both CRI and peritonitis rate in patients treated with PD.

Immediate-start peritoneal dialysis without break-in-period: an 18-year retrospective cohort study on patient survival

BACKGROUND

Immediate-start peritoneal dialysis (ISPD) is an effective renal replacement therapy that can prevent central venous catheterization due to its immediate initiation of peritoneal dialysis (PD) after catheter insertion without a break-in period. This study aimed to investigate the effect of ISPD on long-term patient survival.

METHODS

In this retrospective single-center cohort study, 178 consecutive patients who started PD from August 2005 to March 2023 were enrolled, from whom 144 patients with ISPD were analyzed. PD was initiated without a break-in period within 24 hours of catheter insertion using percutaneous needle-guidewire technique. The primary outcome was patient survival, estimated using the Kaplan-Meier method. A Cox proportional hazard regression model was used to identify factors independently associated with patient survival.

RESULTS

The median follow-up period was 4.00 years (interquartile range, 1.23-5.75 years). The mean age of patients was 61.6 ± 13.6 years; 58 patients (40.3%) were male and 93 patients (64.6%) were diabetic. Overall patient survival rates at 1, 3, 5, and 10 years were 98.5%, 93.5%, 92.1%, and 65.6%, respectively. The technique survival rates at 1, 3, 5, and 10 years were 88.1%, 74.9%, 63.2%, and 40.2%, respectively. The peritonitis-free survival rates at 1, 3, 5, and 10 years were 92.3%, 76.0%, 59.4%, and 28.0%, respectively. In the multivariate analysis, diabetes was the only factor associated with patient survival and technique survival.

CONCLUSION

Our study demonstrated that patient survival and technique survival rates were relatively high in ISPD patients who were catheterized using percutaneous needle-guidewire technique.

Assessing the Value of Further Investment in R&D Using Mixed Methods: A Case Study of Biosensor-Integrated Arteriovenous Grafts

This study illustrates the utility of a mixed-methods approach in assessing the value of an example novel technology-biosensor-integrated self-reporting arteriovenous grafts (smart AVGs). Currently in preclinical development, the device will detect arteriovenous graft stenosis (surveillance-only use case) and treat stenosis (interventional use case). The approach to value assessment adopted in this study was multifaceted, with one stage informing the next and comprised a stakeholder engagement with clinical experts to explore the device's clinical value, a cost-utility analysis (CUA) from a US Medicare perspective to estimate pricing headroom, and an investment model estimating risk-adjusted net present value analysis (rNPVs) to determine commercial viability. The stakeholder engagement suggested that it would currently be difficult to establish the current value of the surveillance-only use case due to the lack of well-established interventions for preclinical stenosis. Based on this, the CUA focused on the interventional use case and estimated economically justifiable prices at assumed effectiveness levels. Using these prices, rNPVs were estimated over a range of scenarios. This value assessment informs early decision-making on health technology R&D by identifying the conditions (including clinical study success, potential market size and penetration, market access strategies, and assumptions associated with CUA) under which investment may be considered attractive.

Unveiling risk factors: a prognostic model of frequent peritonitis in peritoneal dialysis patients

INTRODUCTION

Peritoneal dialysis-associated peritonitis (PDAP) is a serious complication of peritoneal dialysis (PD) patients. The aim of this study was to construct a risk prediction model for frequent episodes in PDAP patients.

METHODS

This retrospective cohort study included PDAP patients in our center from January 1, 2010 to December 31, 2021. The risk prediction model for frequent episodes in PDAP patients was constructed by the binary logistic regression.

RESULTS

We included 371 PDAP patients, of which 235 patients had single episode and 136 had frequent episodes. We randomly allocated the patients into training set (296 patients) and test set (75 patients) in the ratio of 8:2. In the training set, we found several independent risk factors significantly associated with frequent episodes in PDAP patients, including diabetes mellitus (DM), hemoglobin (HB), serum albumin (ALB), lactatic dehydrogenase (LDH), serum potassium (K), N-terminal pro-brain natriuretic peptide (NT-proBNP) and peritoneal dialysate white cell counts on day 1. And we constructed a prediction model with an area under curve (AUC) values of 0.75 in the training set and 0.76 in the test set, which showed excellent predictive performance.

CONCLUSION

We constructed a predictive model that demonstrated excellent predictive performance for identifying high-risk frequent episodes in PDAP patients and developed a more intuitive nomogram for evaluating the risk. However, multicenter studies with a larger sample size are warranted to validate the model in the future.

Dynamic changes in serum albumin and ferritin indicate higher risk of early-onset peritonitis in peritoneal dialysis patients

INTRODUCTION

The objective of this study is to investigate the dynamic changes in serum albumin and ferritin as potential predictors for early-onset peritoneal dialysis-related peritonitis (PDRP) in patients undergoing peritoneal dialysis (PD).

METHODS

This retrospective study included 215 patients with end-stage renal disease who initiated PD at Huadong Hospital. Patients were followed up to 24 months, during which episodes of PDRP were recorded. The dynamic changes in serum albumin and ferritin levels were evaluated within the first 6 months of PD initiation. Data were analyzed to assess the relationship between these biomarkers and early-onset PDRP.

RESULTS

Among the 215 patients, 33.49% developed PDRP, and 28.93% experienced early-onset PDRP. Patients with lower baseline serum albumin levels (<35 g/L) and higher baseline ferritin levels (≥400 μg/L) had an increased risk of developing early-onset PDRP. Importantly, the risk associated with low initial albumin was not significant when serum albumin levels remained stable within the first 6 months (-5% to 5% change). Similarly, although higher baseline ferritin was associated with a higher risk of early-onset PDRP, patients with fluctuating ferritin levels (more than 35% change) showed no significant increase in the risk. Kaplan-Meier analysis revealed a lower cumulative technical survival rate in patients with early-onset PDRP.

CONCLUSION

Dynamic changes in serum albumin and ferritin levels within the first 6 months of PD can serve as significant predictors of early-onset PDRP, but stable levels of these markers mitigate their predictive value. Close monitoring of these biomarkers may help in identifying high-risk patients and improving PD outcomes.

Comparison of different peritoneal dialysis catheters on complications and catheter survival: A network meta-analysis of randomised controlled trials

BACKGROUND

This network meta-analysis (NMA) aimed to compare the clinical advantage of four commonly used peritoneal dialysis catheters (PDCs) including the Swan neck segment with straight tip (Swan neck + S), Tenckhoff segment with straight tip (Tenckhoff + S), Swan neck segment with coiled tip (Swan neck + C) and Tenckhoff segment with coiled tip (Tenckhoff + C).

METHODS

Randomised clinical trials were searched from PubMed, Embase, the Cochrane Register of clinical trials, China National Knowledge Infrastructure (CNKI) and ChinaInfo from their inception until July 31, 2022. Meta-analysis was performed using Stata 14.0 and RevMan 5.3.5 software to evaluate the four commonly used PDCs.

RESULTS

Seventeen studies involved 1578 participants were included. NMA showed that compared with Swan neck + C, Swan neck + S significantly reduced catheter tip migration (OR 0.47 95% CI 0.22-0.99). Tenckhoff + S was more effective in reducing catheter dysfunction (OR 0.42, 95% CI 0.23-0.79), catheter tip migration with dysfunction (OR 0.19, 95% CI 0.05-0.78) and catheter removal (OR 0.56, 95% CI 0.34-0.93) which were consistent with the pairwise meta-analysis. According to the surface under the cumulative ranking curve, Swan neck + S emerged as the best PDC in the reduction of catheter tip migration (83.3%), followed by Tenckhoff + S (79.4%). Moreover, Tenckhoff + S (86.5%, 76.3%) and Swan neck + S (72.3, 86.9%) ranked as the first and second PDC for 1 and 2-year technique survival which was significantly higher than those of the other two PDCs.

CONCLUSION

Our NMA showed Swan neck + S and Tenckhoff + S tended to be more efficacious than Swan neck + C and Tenckhoff + C in lowering the mechanical dysfunction and prolonging the technique survival, which may contribute to better clinical decisions. More randomised controlled trials with larger scales and higher quality are needed in order to obtain more credible evidence.

Mechanisms underlying the involvement of peritoneal macrophages in the pathogenesis and novel therapeutic strategies for dialysis-induced peritoneal fibrosis

Long-term exposure of the peritoneum to peritoneal dialysate results in pathophysiological changes in the anatomical organization of the peritoneum and progressive development of peritoneal fibrosis. This leads to a decline in peritoneal function and ultrafiltration failure, ultimately necessitating the discontinuation of peritoneal dialysis, severely limiting the potential for long-term maintenance. Additionally, encapsulating peritoneal sclerosis, a serious consequence of peritoneal fibrosis, resulting in patients discontinuing PD and significant mortality. The causes and mechanisms underlying peritoneal fibrosis in patients undergoing peritoneal dialysis remain unknown, with no definitive treatment available. However, abnormal activation of the immune system appears to be involved in altering the structure of the peritoneum and promoting fibrotic changes. Macrophage infiltration and polarization are key contributors to pathological injury within the peritoneum, showing a strong correlation with the epithelial-to-mesenchymal transition of mesothelial cells and driving the process of fibrosis. This article discusses the role and mechanisms underlying macrophage activation-induced peritoneal fibrosis resulting from PD by analyzing relevant literature from the past decade and provides an overview of recent therapeutic approaches targeting macrophages to treat this condition.

Tunnel Infection and Peritonitis Induced by Staphylococcus aureus Due to Decubitus Change of the Anterior Abdominal Wall in a Patient on Peritoneal Dialysis: Case Report

The occurrence of anterior abdominal wall ulcer at the site of the peritoneal catheter (PC) is one of the rarest complications of peritoneal dialysis (PD). When present, it is mainly caused by staphylococci which respond well to vancomycin therapy. Despite well-conducted therapy, there is a tendency to relapse and induce peritonitis, which makes it necessary to remove the PC and change the dialysis model of treatment and/or re-insert the catheter at another place to preserve PD as a treatment method. In the present study, we discuss a case of a 53-year-old patient with end-stage kidney disease treated with PD and with decubitus changes at the PC exit site; the change occurred due to migration of the catheter middle part by protruding from the abdominal cavity to the skin, thus allowing ulcer appearance. Although the PC site was treated with antibiotics, as advised by the surgeon, the patient was finally transferred to hemodialysis as the repositioning of the catheter was not performed. This leads to the conclusion that the antibiotic treatment and catheter repositioning are mandatory to preserve peritoneal dialysis as an end-stage kidney disease (ESKD) treatment model.

Inflammatory Burden Index: A Superior Prognostic Biomarker of Systemic Inflammation in Patients on Peritoneal Dialysis

Purpose

Systemic inflammation biomarkers, derived from routine blood tests, have been demonstrated to be associated with prognosis of patients undergoing peritoneal dialysis (PD). However, studies focusing on the comparisons of their role on predictive efficacy for prognosis of PD patient are limited and results are inconsistent. The purpose of this study was to evaluate the prognostic value of various systemic inflammation biomarkers and to identify the optimal one in PD patients.

Patients and Methods

This longitudinal study involved 3,225 patients undergoing PD across China. The prognostic accuracy of systemic inflammatory biomarkers was evaluated using C-statistics. Independent prognostic biomarkers of outcomes were determined using multivariate Cox proportional hazards regression analysis.

Results

During a 46-month follow-up, 829 (25.7%) patients died, with 458 (55.3%) deaths attributed to cardiovascular disease (CVD). The highest C-statistics were observed for the IBI, with 0.619 and 0.621 for all-cause and CVD mortality, respectively. The optimal threshold of the IBI for predicting prognosis in patients undergoing PD was 50.0. An elevated IBI was a significant independent predictor of all-cause mortality, with a 1-SD increase associated with higher risks of all-cause and CVD mortality. Participants in the upper two quartiles of IBI exhibited increased risks of all-cause mortality by 41.2% and 67.6%, respectively, compared to those in the lowest quartile. Similar results were observed for CVD mortality.

Conclusion

The IBI is a superior prognostic indicator of survival and could be broadly applied for prognosis of patients undergoing PD. Elevated IBI is an independent risk factor for all-cause and CVD mortality.

Effects of Ketoanalogue Supplements on Patients Receiving Continuous Ambulatory Peritoneal Dialysis: A Multicenter, Randomized, Double-Blinded, Placebo-Controlled Study

OBJECTIVES

Evidence of the effects of ketoanalogue supplements on residual kidney function (RKF) in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) is limited. This study aimed to evaluate the efficacy and safety of ketoanalogues in preserving RKF in CAPD patients.

METHODS

This 1-year multicenter, randomized, double-blinded, placebo (PBO)-controlled trial involved 153 CAPD patients across 6 centers. Patients were randomly assigned to either the keto acid (KA, 100 mg/kg per day) or PBO group, both with a protein intake of 1.0 g/kg ideal body weight. The primary outcome was the changes in RKF, evaluated based on 24-hour creatinine and urea clearance, and secondary outcomes included dialysis adequacy, peritoneal function, nutritional status, and quality-of-life scores.

RESULTS

The decline in RKF was 1.89 (0.44, 2.98) and 1.56 (0.35, 3.14) mL/min/1.73 m2 in the KA and PBO groups, respectively, with no difference observed (P = .89). There were no differences in dialysis adequacy, peritoneal function, nutritional status, or quality-of-life scores between the groups. In subgroup analyses, for patients with early peritoneal dialysis (PD) initiation, patients in the KA group had a significantly lower decline in RKF compared with the PBO group (1.34 vs. 4.79 mL/min/1.73 m2, P = .02); however, there is no significant difference between the groups in patients with late PD initiation (1.89 vs. 1.23 mL/min/1.73 m2, P = .17).

CONCLUSIONS

Ketoanalogues did not reduce the decline in RKF on the basis of a protein-restricted diet in patients receiving CAPD; however, its effect on patients with early PD initiation needs further investigation.

A case of a peritoneal dialysis patient with left pleuroperitoneal communication caused by a pericardial defect after coronary artery bypass surgery

A 74-year-old woman with reduced kidney and cardiac function and a history of coronary artery bypass surgery involving the gastroepiploic artery to the right coronary artery and posterior descending artery #4 presented with dyspnea on exertion. Shortly after the induction of peritoneal dialysis (PD), an increase in the left pleural effusion was observed, and a diagnosis of left pleuroperitoneal communication was made by puncture drainage. The pleuroperitoneal communication hole was not detected under thoracoscopic observation; however, a 10 mm-sized hole in the pericardium was found, confirming leakage of ICG-loaded peritoneal dialysate fluid (PDF). CT peritoneography using PDF mixed with iodine contrast medium revealed that the gastroepiploic artery-to-right coronary artery pathway was defective on the abdominal side. We concluded that the left pleuroperitoneal communication was caused by a two-stage fistulous pathway between the abdominal and pleural cavities through the pericardial cavity after coronary artery bypass graft surgery. Although closure of the diaphragmatic hole around the gastroepiploic artery graft should have been performed to restart PD, the patient did not wish to undergo further invasive procedures. Identification of the fistulous pathway is extremely important for prompt diagnosis and treatment of pleuroperitoneal communication.

The impact of angiotensin-receptor neprilysin inhibitors on cardiovascular events and solute transport function in peritoneal dialysis patients: a multicenter retrospective controlled study

BACKGROUND

Whether angiotensin receptor-neprilysin inhibitor (ARNI) can reduce the incidence of cardiovascular events and improve peritoneal function in peritoneal dialysis (PD) patients remains unclear. Thus, this study aims to clarify the role of ARNI in PD patients.

METHODS

This was a multicenter retrospective study. A total of 102 patients were enrolled for analysis. Patients who continuously used ARNI for 12 months were assigned to the ARNI group (n = 55), while those who never used ARNI to the control group (n = 47). Clinical indicators and cardiovascular risk factors were analyzed, along with in vitro experiments on neoangiogenesis to investigate the underlying molecular mechanisms of peritoneal protection by ARNI.

RESULTS

Systolic blood pressure (p = 0.001), diastolic blood pressure (p = 0.001), and left ventricular ejection fraction (p = 0.008) were statistically improved after 12 months of ARNI therapy, whereas these metrics did not change in control patients. The risk factors for the occurrence of cardiac events in PD patients included the use of ARNI [hazard ratio (HR) 0.053; 95% confidence interval (CI), 0.006-0.492] and NT-proBNP level (HR 2.317; 95% CI, 1.179-4.554). Additionally, there was a decrease in 4-hour ratio of creatinine concentration in dialysate to plasma (4h Scr D/P) in the ARNI group (p = 0.020). The in vitro experiments showed that LCZ696, a combination of sacubitril and valsartan, inhibited neoangiogenesis via the VEGFR2/ERK1/2 and Notch1 pathways.

CONCLUSIONS

ARNI may play a protective role in reducing the incidence of cardiovascular events and decreasing solute transport in PD patients.

The potential for reducing greenhouse gas emissions through disease prevention: a secondary analysis of data from the CREDENCE trial

BACKGROUND

The health-care sector is responsible for 5·2% of global emissions, however, little data exist regarding the environmental impact of disease management strategies. SGLT2 inhibitors are now widely used to reduce the risk of hospital admission and kidney failure in people with type 2 diabetes and chronic kidney disease. This study aimed to estimate the impact of SGLT2 inhibitors on greenhouse gas emissions using data from the CREDENCE trial.

METHODS

For this modelling analysis, we used data from the randomised, double-blind, placebo-controlled, CREDENCE trial, which compared the effect of canagliflozin versus placebo on kidney and cardiovascular outcomes in patients with type 2 diabetes and albuminuric chronic kidney disease. For this secondary analysis, we included all participants randomly assigned to canagliflozin or placebo at baseline in the CREDENCE trial. Data on greenhouse gas emissions resulting from hospital inpatient days, maintenance dialysis therapy, and SGLT2 inhibitor tablet production were derived from published reports and used to model greenhouse gas emissions from total number of hospital inpatient days, total number of days of maintenance dialysis therapy, and from SGLT2 inhibitor treatment over the course of the CREDENCE trial. We compared greenhouse gas emission estimates for participants in the canagliflozin group and placebo group of the CREDENCE trial. We used bootstrapping analyses to calculate uncertainty estimates and permutation tests to generate p values for the difference in number of days on dialysis and inpatient bed days between treatment groups.

FINDINGS

4401 participants who were randomly assigned to the canagliflozin (n=2202) or placebo group (n=2199) were included in the secondary analyses. During a median follow-up of 2·62 years (IQR 0·02 to 4·53), SGLT2 inhibitor production for 2202 participants resulted in greenhouse gas emissions of 63 tonnes of CO2 equivalent (CO2e; 95% CI 62 to 64). The total number of inpatient bed days was 17 002 days in the placebo group versus 13 672 days in the canagliflozin group; the 3330 fewer inpatient days (95% CI 1037 to 5686; p=0·042) with SGLT2 inhibitor treatment equated to a reduction of approximately 126 tonnes of CO2e (95% CI 39 to 216). Participants in the placebo group required 24 877 days of maintenance dialysis compared with 16 605 days in the treatment group; 8272 fewer days of dialysis ( -168 to 16 755; p=0·16), equated to a reduction of 161 tonnes of CO2e (-3 to 327). Overall, mean greenhouse gas emissions per-participant-year were reduced from 196 kg of CO2e per-participant-year to 157 kg of CO2e per-participant-year.

INTERPRETATION

The addition of an SGLT2 inhibitor to routine therapy for people with type 2 diabetes and chronic kidney disease has the potential to reduce greenhouse gas emissions through the prevention of hospital admissions and need for dialysis.

FUNDING

None.

Exploring symptom clusters in Chinese patients with peritoneal dialysis: a network analysis

BACKGROUND

In recent years, the research on symptom management in peritoneal dialysis (PD) patients has shifted from a single symptom to symptom clusters and network analysis. This study collected and evaluated unpleasant symptoms in PD patients and explored groups of symptoms that may affect PD patients with a view to higher symptom management.

METHODS

The symptoms of PD patients were measured using the modified Dialysis Symptom Index. The symptom network and node characteristics were assessed by network analysis, and symptom clusters were explored by factor analysis.

RESULTS

In this study of 602 PD patients (mean age 47.8 ± 16.8 years, 47.34% male), most had less than 2 years of dialysis experience. Five symptom clusters were obtained from factor analysis, which were body symptom cluster, gastrointestinal symptom cluster, mood symptom cluster, sexual disorder symptom cluster, and skin-sleep symptom cluster. Itching and decreased interest in sex may be sentinel symptoms, and being tired or lack of energy and feeling anxious are core symptoms in PD patients.

CONCLUSIONS

This study emphasizes the importance of recognizing symptom clusters in PD patients for better symptom management. Five clusters were identified, with key symptoms including itching, decreased interest in sex, fatigue, and anxiety. Early intervention focused on these symptom clusters in PD patients holds promise for alleviating the burden of symptoms.

Pressure induces peritoneal fibrosis and inflammation through CD44 signaling

Peritoneal dialysis (PD) is a widely used sustainable kidney replacement therapy. Prolonged use of PD fluids is associated with mesothelial-mesenchymal transition, peritoneal fibrosis, and eventual ultrafiltration (UF) failure. However, the impact of pressure on the peritoneum remains unclear. In the present study, we hypothesized increased pressure is a potential contributing factor to peritoneal fibrosis and investigated the possible mechanisms. In vitro experiments found that pressurization led to a mesenchymal phenotype, the expression of fibrotic markers and inflammatory factors in human mesothelial MeT-5A cells. Pressure also increased cell proliferation and augmented cell migration potential in MeT-5A cells. The mouse PD model and human peritoneum equilibrium test (PET) data both showed a positive association between higher pressure and increased small solute transport, along with decreased net UF. Mechanistically, we found that significant upregulation of CD44 in mesothelial cells upon pressurization. Notably, the treatment of CD44 neutralizing antibodies prevented pressure-induced phenotypic changes in mesothelial cells, while a CD44 inhibitor oligo-fucoidan ameliorated pressure-induced peritoneal thickening, fibrosis, and inflammation in PD mice. To conclude, intraperitoneal pressure results in peritoneal fibrosis in PD via CD44-mediated mesothelial changes and inflammation. CD44 blockage can be utilized as a novel preventive approach for PD-related peritoneal fibrosis and UF failure.

The neutrophil percentage-to-albumin ratio is an independent risk factor for poor prognosis in peritoneal dialysis patients

AIM

This study aimed to investigate the predictive ability of the neutrophil percentage-to-albumin Ratio (NPAR) concerning all-cause mortality and cardio-cerebrovascular mortality in patients undergoing peritoneal dialysis (PD).

METHODS

We included a total of 807 PD patients from the Peritoneal Dialysis Center of the Second Affiliated Hospital of Soochow University between January 2009 and December 2019 in this study. Patients were categorized into three groups based on their baseline NPAR. The Kaplan-Meier method, multivariate Cox proportional hazard model, and Fine-Gray competing risk model were employed to examine the relationship between NPAR level and all-cause mortality and cardio-cerebrovascular mortality among PD patients. Furthermore, the ROC curve and calibration plots were utilized to compare the performance between NPAR and other conventional indicators.

RESULTS

The mean follow-up period was 38.2 months. A total of 243 (30.1%) patients passed away, with 128 (52.7%) succumbing to cardio-cerebrovascular diseases. The mortality rates of the Middle and High NPAR groups were significantly greater than that of the Low NPAR group (p < 0.001), and NPAR was independently associated with all-cause mortality and cardio-cerebrovascular mortality. Receiver Operating Characteristic (ROC) analysis indicated that the Area Under the Curve (AUC) of NPAR (0.714) was significantly superior to those of C-reactive protein (CRP) (0.597), neutrophil to lymphocyte ratio (NLR) (0.589), C-reactive protein to albumin ratio (CAR) (0.698) and platelet to lymphocyte ratio (PLR) (0.533).

CONCLUSION

NPAR served as an independent predictive marker for all-cause mortality and cardio-cerebrovascular mortality in PD patients. Moreover, NPAR demonstrated superior predictive potential compared to CRP, CAR, NLR, and PLR.

Therapeutic Potential of Oligo-Fucoidan in Mitigating Peritoneal Dialysis-Associated Fibrosis

Peritoneal dialysis (PD) serves as a home-based kidney replacement therapy with increasing utilization across the globe. However, long-term use of high-glucose-based PD solution incites repeated peritoneal injury and inevitable peritoneal fibrosis, thus compromising treatment efficacy and resulting in ultrafiltration failure eventually. In the present study, we utilized human mesothelial MeT-5A cells for the in vitro experiments and a PD mouse model for in vivo validation to study the pathophysiological mechanisms underneath PD-associated peritoneal fibrosis. High-glucose PD solution (Dianeal 4.25%, Baxter) increased protein expression of mesothelial-mesenchymal transition (MMT) markers, such as N-cadherin and α-SMA in MeT-5A cells, whereas it decreased catalase expression and stimulated the production of reactive oxygen species (ROS). Furthermore, macrophage influx and increased serum pro-inflammatory cytokines, such as IL-1β, MCP-1, and TNF-α, were observed in the PD mouse model. Interestingly, we discovered that oligo-fucoidan, an oligosaccharide extract from brown seaweed, successfully prevented PD-associated peritoneal thickening and fibrosis through antioxidant effect, downregulation of MMT markers, and attenuation of peritoneal and systemic inflammation. Hence, oligo-fucoidan has the potential to be developed into a novel preventive strategy for PD-associated peritoneal fibrosis.

Efficacy and safety of daprodustat in patients on peritoneal dialysis in the ASCEND-D trial

BACKGROUND AND HYPOTHESIS

Daprodustat, an oral hypoxia-inducible factor prolyl hydroxylase inhibitor, is approved for treatment of anemia in dialysis patients with CKD in some parts of the world. This subgroup analysis examined the efficacy and safety of daprodustat versus darbepoetin alfa in patients with anemia of CKD undergoing peritoneal dialysis (PD).

METHODS

ASCEND-D (NCT02879305) was an open-label, Phase 3 trial; patients with CKD were randomized to daprodustat daily and epoetin alfa (HD patients) or darbepoetin alfa (PD patients). In PD patients, prespecified analyses of the co-primary endpoints of mean change in hemoglobin from baseline to Weeks 28-52 using an ANOVA model and first occurrence of a major cardiovascular event (MACE) using a Cox proportional hazards model were conducted. The secondary endpoints were average monthly intravenous iron dose to Week 52 and treatment-emergent adverse events. Additional post hoc analyses were conducted.

RESULTS

Overall, 340 PD patients (daprodustat n = 171, darbepoetin alfa n = 169) were randomized. Mean age was 53.6 years (±14 SD), 55% male, 56% White. For daprodustat and darbepoetin alfa groups respectively, mean change in hemoglobin was 0.38 and 0.23 g/dL [adjusted mean difference 0.15, 95% confidence interval (CI), -0.04, 0.34], and first occurrence of adjudicated MACE occurred in 40 (23.4%) and 46 (27.2%) patients (HR 0.84; 95% CI, 0.55-1.28). No heterogeneity was observed between PD and HD patients for these endpoints in ASCEND-D. Serum hepcidin was lower with daprodustat; there was no difference in other iron parameters, intravenous iron usage, transfusion requirement, blood pressure, or quality of life. There were no differences in adverse events or incidence of peritonitis between the groups.

CONCLUSIONS

This subgroup analysis of the ASCEND-D trial demonstrated comparable efficacy and safety of daprodustat versus darbepoetin alfa in PD patients, supporting its use in the treatment of anemia in these patients.

Roxadustat Efficacy and Safety in Patients Receiving Peritoneal Dialysis: Pooled Analysis of Four Phase 3 Studies

Background/Objectives: Roxadustat is an oral hypoxia-inducible factor prolyl hydroxylase inhibitor approved to treat anemia of chronic kidney disease (CKD). The efficacy and safety of roxadustat compared with parenteral erythropoiesis-stimulating agents (ESAs) were evaluated in patients with anemia of CKD receiving peritoneal dialysis (PD). Methods: This analysis pooled data from four phase 3, multicenter, randomized, open-label, active-comparator studies (PYRENEES, SIERRAS, HIMALAYAS, ROCKIES). The primary endpoints evaluated were hemoglobin change from baseline (CFB) to Weeks 28-36 without rescue therapy and hemoglobin CFB to Weeks 28-52 regardless of rescue therapy use. Safety data were reported. Results: This analysis included 422 patients (215 roxadustat, 207 ESA). Hemoglobin CFB to Weeks 28-36 without rescue therapy and hemoglobin CFB to Weeks 28-52 regardless of rescue therapy achieved non-inferiority for roxadustat vs. ESAs. The mean weekly dose of roxadustat was maintained over time (Weeks 1-4, 3.86 mg/kg/week; Weeks 101-104, 3.27 mg/kg/week), whereas the mean weekly ESA dose increased by 24% (Weeks 1-4, 115.70 IU/kg/week; Weeks 101-104, 143.40 IU/kg/week). Fewer patients treated with roxadustat received intravenous iron supplementation and rescue therapy, and patients treated with an ESA required blood transfusions sooner. Roxadustat-treated patients experienced a greater decrease in low-density lipoprotein cholesterol levels relative to baseline vs. ESA-treated patients. Treatment-emergent adverse events were similar in both treatment groups. Major adverse cardiovascular event (MACE), MACE plus unstable angina or congestive heart failure, and all-cause mortality hazard ratios were <1; the lower limit of the 95% CIs was <0.6, and the upper limit was >1.3. Conclusions: Roxadustat was non-inferior to ESAs in correcting and maintaining hemoglobin levels, with stable dosing and a comparable safety profile, in anemic patients receiving PD.

Loading Self-Assembly Siliceous Zeolites for Affordable Next-Generation Wearable Artificial Kidney Technology

The global demand for dialysis among patients with end-stage kidney disease has surpassed the capacity of public healthcare, a trend that has intensified. While wearable artificial kidney (WAK) technology is seen as a crucial solution to address this demand, there is an urgent need for both efficient and renewable toxin-adsorbent materials to overcome the long-standing technological challenges in terms of cost, device size, and sustainability. In this study, we employed screening experiments for adsorbent materials, multimodal characterization, and Monte Carlo adsorption simulations to identify a synthetic self-assembly silicalite-1 zeolite that exhibits highly ordered crystal arrays along the [010] face (b-axis) direction, demonstrating exceptional adsorption capabilities for small molecular toxins such as creatinine and urea associated with uremia. Moreover, this metal-free, cost-effective, easily synthesized, and highly efficient toxin adsorbent could be regenerated through calcination without compromising the performance. The simulated toxin adsorption experiments and comprehensive biocompatibility verification position it as an auxiliary adsorbent to reduce dialysate dosages in WAK devices as well as a potential adsorbent for small-molecule toxins in dialysis. This work is poised to propel the development of next-generation WAK devices by providing siliceous adsorbent solutions for small-molecule toxins.

Aquaporin-1 and Osmosis: From Physiology to Precision in Peritoneal Dialysis

The discovery of the aquaporin family of water channels has provided a molecular counterpart to the movement of water across biological membranes. The distribution of aquaporins in specific cell types, their selectivity and very high capacity for water permeation, and the control of their expression and/or trafficking are key to sustain osmosis in multiple tissues. Here, we review the convergent evidence demonstrating that aquaporin-1 (AQP1) facilitates water transport across endothelial cells in the peritoneal membrane, a key process for peritoneal dialysis-the leading modality of home-based dialysis therapy for patients with kidney failure. Genetic and pharmacologic studies in mouse and cell models indicated that AQP1 plays a critical role in crystalloid osmosis, with clinically relevant effects on water transport and risk of death and technique failure for patients on dialysis. By contrast, AQP1 plays no role in colloid osmosis. These studies substantiate potential strategies to improve free water transport and ultrafiltration in patients treated by peritoneal dialysis.

Intraperitoneal MASP-1 Levels are Associated with Peritoneal Solute Transport Rate in Peritoneal Dialysis Patients: A Retrospective Cohort Study

Purpose

A major limitation of long-term peritoneal dialysis (PD) is peritoneal membrane dysfunction characterized by faster peritoneal solute-transport rate (PSTR). This study aimed to identify efficient complement factors in peritoneal effluents of continuous ambulatory peritoneal dialysis (CAPD) patients that can predict the PSTR.

Methods

A multiplex suspension protein array was used to screened related complement pathways in overnight peritoneal effluents among 58 CAPD patients. Then the related complement factors in lectin and classical pathways in effluents were analyzed using ELISA kits among another cohort of 129 CAPD patients. Logistic regression modeling was fitted to predict the PSTR of PD patients.

Results

The multiplex suspension protein array showed complement factors including C2, C4b, C5, C5a, Factor D, Factor I, and MBL were detected in effluents of CAPD patients, and the effluent C2 Appearance rate (Ar) and C4b Ar levels were significantly correlated with D/P Cr and D/D0 glucose. The levels of effluents MASP-1 Ar, M-Ficolin Ar, C2 Ar and C4b Ar, which belong to the lectin pathway were also positively correlated with D/P Cr according the ELISA results and these parameters were expressed higher in the high and high-average (H/HA) groups according to the PET results. Moreover, effluent Masp-1 was independently associated with increased PSTR and adverse events related peritoneal transport function failure.

Conclusion

This study suggested that the lectin pathway may be involved in local complement activation and peritoneal injury of PD patients, intraperitoneal level of Masp-1 was an independent predictor of increased PSTR in PD patients.

Platelet-to-albumin ratio: a potential biomarker for predicting all-cause and cardiovascular mortality in patients undergoing peritoneal dialysis

BACKGROUND

Although peritoneal dialysis (PD) is an efficient therapy for renal replacement, the long-term survival rate of patients undergoing PD remains low. The platelet-to-albumin ratio (PAR), recently identified as a parameter of inflammatory and nutritional status, is associated with an adverse prognosis for various diseases. However, the association between the serum PAR and prognosis of patients undergoing PD is poorly understood. This study aimed to evaluate whether the PAR is a reliable predictor of cardiovascular disease (CVD) and all-cause mortality in patients undergoing PD.

METHODS

This multicenter cohort study enrolled patients undergoing PD from January 1, 2009, to September 30, 2018. The patients were divided into four groups according to the quartiles of their baseline PAR. The primary endpoint was all-cause and CVD-related mortality. Cox proportional hazard models were used to determine the association between the PAR and all-cause or CVD-related mortality. The receiver operating characteristic (ROC) curve was utilized to compare the performance among PAR and other inflammatory indicators. C-statistic, net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were applied to examine the incremental prognostic value of PAR compared with baseline model for predicting all-cause and CVD mortality.

RESULTS

A total of 2825 patients were included. During the follow-up period of 47.5 ± 28.3 months, 747 (26.4%) mortality cases were observed, of which 415 (55.6%) were CVD-related. Compared with the Q1 (PAR < 4.43), placement in Q4 (PAR > 7.27) was associated with an increased risk of all-cause mortality and CVD mortality (p < 0.001). The adjusted restricted cubic spline analysis indicated that the relationship of the PAR with all-cause and cardiovascular mortality was linear (p for nonlinearity = 0.289 and 0.422, respectively). No positive correlations were shown in the interaction tests. PAR exhibited superior predictive value for mortality compared to other inflammatory indicators, with a respective AUC value of 0.611 (P < 0.001) for all-cause mortality and 0.609 (P < 0.001) for cardiovascular mortality. According to the C-statistic, continuous NRI and IDI, the addition of PAR to the baseline model yielded a moderate but significant improvement in outcome prediction.

CONCLUSIONS

The PAR is an independent prognostic factor associated with all-cause and cardiovascular mortality in patients undergoing PD.

Barriers and facilitators for the adoption of peritoneal dialysis: protocol for a systematic review of qualitative studies

INTRODUCTION

Peritoneal dialysis (PD) is an effective home-based treatment for end-stage kidney disease (ESKD) that offers several advantages over in-centre haemodialysis, including better quality of life, increased autonomy and lower costs. Despite these benefits, PD remains underused globally, with wide variations in adoption rates across countries. Qualitative studies have explored the experiences, perceptions and decision-making processes of patients, caregivers and healthcare providers regarding PD, but their findings have not been systematically synthesised. This protocol outlines a systematic review of qualitative studies to identify and synthesise the multilevel factors that influence PD adoption.

METHODS AND ANALYSIS

We will conduct a comprehensive search of electronic databases (PubMed, Web of Science, Embase, CINAHL, MEDLINE, The Cochrane Library, PsycINFO, Scopus) and grey literature sources for qualitative studies published in English from each database inception to June 2024 that explore barriers and facilitators to PD adoption. Two reviewers will independently screen titles, abstracts and full texts for eligibility based on predefined criteria. Eligible studies will include those that use qualitative methods (eg, interviews, focus groups, observations) to explore the perspectives of adult ESKD patients, their caregivers and/or healthcare providers on factors influencing PD adoption, initiation or maintenance. Data will be extracted using a standardised form and synthesised using thematic analysis. The methodological quality of included studies will be appraised using the Critical Appraisal Skills Programme Qualitative Checklist. Confidence in the review findings will be assessed using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research approach.

ETHICS AND DISSEMINATION

Ethics approval is not required as this study will merely synthesise data from published studies. The results will be disseminated through peer-reviewed publications as well as conference presentations.

STUDY REGISTRATION

PROSPERO, CRD42024570521.

A retrospective study of the safety and efficacy of peritoneal dialysis catheter placement under combined local infiltration anesthesia and monitored anesthesia care

OBJECTIVE

Given the lack of global consensus on anesthesia selection for peritoneal dialysis catheter (PDC) placement via open surgery, this study investigates the safety and efficacy of combining local infiltration anesthesia (LIA) with monitored anesthesia care (MAC) in patients with end-stage renal disease (ESRD).

METHODS

This retrospective analysis of ESRD patients who underwent open surgical placement of PDC in the Department of Nephrology, the First Affiliated Hospital of the Army Medical University from 1 August 2020 to 31 May 2022. Patients were categorized into two groups based on anesthesia method: LIA group and LIA + MA group. MA was defined as preoperative sedation (0.2-0.7 µg/kg/h) with dexmedetomidine injection (Huidrican trade name, DEX), and intraoperative analgesia with dexrazoxane injection (Garonin trade name, DEZ) as appropriate according to the patients' pain scores. We compared the general clinical data of the two groups of patients, the changes in blood pressure and heart rate during the whole operation, the intraoperative and postoperative pain, the total duration of the operation and the immediate postoperative complications.

RESULTS

The study included 123 patients (59 in the LIA + MAC group and 64 in the LIA group). The LIA + MA group exhibited lower pain scores measured by Visual Analogue Scale(VAS) during surgery (skin incision, subcutaneous adipose tissue dissection, anterior fascia, muscle traction, posterior fascia, peritoneum, and catheterization) compared to the LIA group(p<0.05). In terms of surgical incisions, to intraoperative pain scores (VRS), the LIA + MA group showed higher score level I and lower score level II compared to the LIA group (p = 0.002, 0.004, respectively). The LIA + MA group experienced lower postoperative resting pain (NRS) and VAS than the LIA group (p = 0.001,0.003, respectively). The surgical duration for the LIA + MA group was shorter than that of the LIA group (p<0.001). Preoperative systolic and diastolic blood pressures (SBP and DBP) were higher in the LIA + MA group compared to the LIA group (p<0.001,<0.001, respectively). Postoperative heart rate and DBP were lower in the LIA + MA group (p<0.001, 0.004, respectively). The LIA + MA group exhibited greater changes in heart rate, SBP, and DBP during and after surgery compared to the LIA group (p = 0.009, <0.001,<0.001, respectively). In terms of immediate postoperative complications, the proportion of patients requiring analgesics within 24 h post-surgery was significantly lower in the LIA + MA group (p = 0.031).

CONCLUSION

Open surgery for PDC placement under LIA + MAC is both safe and effective.

Effects of Illness Perception and Coping Style on Self-Management in Peritoneal Dialysis Patients: A Cross-Sectional Study

Aim

Chronic disease self-management is critical to disease prognosis and patient quality of life. Several psychological factors influence this process of self-management. In this background, the present study investigated the impact of illness perceptions and coping style on self-management in people with peritoneal dialysis (PD).

Methods

The study is a cross-sectional study. From May 2022 to January 2023, a convenience sampling method was used to recruit 246 peritoneal dialysis patients. General information questionnaire, brief illness perception questionnaire, medical coping style modes questionnaire and the self-management scale for peritoneal dialysis patients were used in this study. We used SPSS 24.0 to analyze the data, and the statistical methods included descriptive analysis, single factor analysis, Pearson correlation analysis and multiple linear regression analysis.

Results

A total of 246 patients were included in this study (93.89% response rate). Cognitive representations and emotional representations were 30.40, 14.18, respectively. However, illness comprehensibility was 2.87. Illness perceptions were negative significantly correlated with self-management. With regard to coping style, our patients were more likely to adopt avoidance and resignation coping style. Confrontation and avoidance were positively related to self-management, while acceptance-resignation was negatively related.

Conclusion

Self-management of peritoneal dialysis patients needs to be improved. Age, female sex, monthly income, illness perceptions and coping style were independently associated with self-management.

Impact

These findings suggest that interventions that improve illness perceptions and coping style should be explored to ultimately improve their self-management. For example, patients can be provided with psychological counseling so that they can face the disease correctly, and we should pay attention to the positive role of social support.

Preserved fertility of a young woman with bilateral peritoneal dialysis catheter fimbrial adhesions, a priority to consider

Peritoneal dialysis (PD) has become an established treatment modality for end-stage kidney disease (ESKD) in recent years, though catheter dysfunction remains a common issue, often due to adhesions or migration. Laparoscopic surgery is an effective method for addressing these problems with precision and minimal trauma. A rare cause of catheter dysfunction is fimbriae adhesions, where the fimbriae of the fallopian tubes obstruct the catheter. We present a case of a 23-year-old woman with ESKD who transitioned to PD, complicated by catheter blockage within days. Radiographs suggested adhesions and diagnostic laparoscopy revealed fimbriae entangling the catheter. Laparoscopic adhesiolysis and catheter replacement were performed, with the fallopian tubes secured to the ipsilateral ovary to prevent recurrence. Post-surgery, catheter function was restored, and an 18-month follow-up showed no complications. This case highlights the importance of considering fertility preservation in cases of fimbrial adhesions and underscores the value of laparoscopic intervention.

Mitigating Social Isolation Among Peritoneal Dialysis Patients: The Impact of Educational Level, Physical Activity, and Familial Support

Objective

This study investigates the prevalence and determinants of social isolation in peritoneal dialysis (PD) patients, focusing on the influence of environmental systems and individual behaviors on their social well-being.

Methods

We conducted a cross-sectional study from December 2023 to February 2024 at Shenzhen Traditional Chinese Medicine Hospital. A total of 259 PD patients were enrolled using a consecutive sampling method. Data were collected via validated tools including the Pittsburgh Sleep Quality Index (PSQI), Lubben Social Network Scale-6 (LSNS-6), Family APGAR Questionnaire, and Social Anxiety Subscale of Self-Consciousness Scale (SASS-CS). Statistical analyses utilized Spearman correlation and multiple linear regression to identify factors associated with social isolation.

Results

The average score for social isolation was 11 (range 7-15). Significant predictors of social isolation included education level, physical inactivity, and normal hemoglobin concentrations. Social isolation was negatively correlated with family functionality and positively correlated with social anxiety. Regression analysis confirmed education, family functionality, and social anxiety as significant independent predictors of social isolation.

Conclusion

Social isolation is common among PD patients, driven by factors such as education level, physical inactivity, and unexpectedly, normal hemoglobin levels linked to greater family isolation. Targeted interventions like education, physical activity promotion, and innovative therapies such as animal-assisted activities and social gardening can help reduce isolation and improve patient well-being.

Global structures, practices, and tools for provision of chronic peritoneal dialysis

BACKGROUND

Worldwide, the uptake of peritoneal dialysis (PD) compared with hemodialysis remains limited. This study assessed organizational structures, availability, accessibility, affordability and quality of PD worldwide.

METHODS

This cross-sectional study relied on data from kidney registries as well as survey data from stakeholders (clinicians, policymakers and advocates for people living with kidney disease) from countries affiliated with the International Society of Nephrology (ISN) from July to September 2022.

RESULTS

Overall, 167 countries participated in the survey. PD was available in 79% of countries with a median global prevalence of 21.0 [interquartile range (IQR) 1.5-62.4] per million population (pmp). High-income countries (HICs) had an 80-fold higher prevalence of PD than low-income countries (LICs) (56.2 pmp vs 0.7 pmp). In 53% of countries, adults had greater PD access than children. Only 29% of countries used public funding (and free) reimbursement for PD with Oceania and South East Asia (6%), Africa (10%) and South Asia (14%) having the lowest proportions of countries in this category. Overall, the annual median cost of PD was US$18 959.2 (IQR US$10 891.4-US$31 013.8) with full private out-of-pocket payment in 4% of countries and the highest median cost in LICs (US$30 064.4) compared with other country income levels (e.g. HICs US$27 206.0).

CONCLUSIONS

Ongoing large gaps and variability in the availability, access and affordability of PD across countries and world regions were observed. Of note, there is significant inequity in access to PD by children and for people in LICs.

11 cases of peritoneal dialysis catheter penetrating into the intestinal cavity: case series

The penetration of a peritoneal dialysis catheter into the intestinal cavity is a clinically rare complication. In the present retrospective clinical case series, 11 patients with uraemia who received continuous ambulatory peritoneal dialysis and attended hospital between 2019 and 2023 are described. The median patient age was 61.91 ± 11.33 years. All patients had previously experienced peritoneal dialysis-related peritonitis and were clinically cured by infusing sensitive antibiotics into the abdominal cavity. Colonoscopy was utilised to locate the penetrating catheter and close the perforation with a titanium clip once the catheter had been removed via an external approach. Following a 2-4-week fast, the perforations healed in all 11 patients. The present authors' experience illustrates that directly removing the catheter and clamping the perforation opening under the guidance of colonoscopy is simple to operate with few complications compared with traditional open surgery.

Retroperitoneal leakage as an important cause of acquired ultrafiltration decline in peritoneal dialysis: clinical characteristics and related risk factors

BACKGROUND

Peritoneal dialysis (PD) is a widely-used renal replacement therapy while low ultrafiltration volume usually results in technique failure. Retroperitoneal leakage has been reported to be one of the causes of acquired decline in ultrafiltration. The present study investigated retroperitoneal leakage in PD patients and explored related risk factors.

METHODS

This study was designed as a prospective, observational study. A total of 420 PD patients regularly followed up at our center were enrolled from May 2011 to July 2021 and followed until December 2021. Retroperitoneal leakage was determined by magnetic resonance peritoneography and was used as the endpoint. Patients with retroperitoneal leakage were given intermittent PD or temporary hemodialysis (HD) as therapy. Cox regression models were used to identify risk factors for retroperitoneal leakage.

RESULTS

The cohort was followed up for up to 125.0 months (median: 46.4 months; interquartile range: 16.6 months). During the follow-up, 68 patients developed retroperitoneal leakage, with 31 (45.6%) cases occurring within the first year after PD initiation. A total of 62 (91.2%) patients recovered from retroperitoneal leakage and resumed their original PD regimen. Multivariate Cox regression analysis revealed that age and gender were independent predictors for retroperitoneal leakage. Younger males were more likely to develop retroperitoneal leakage. In females, waistline and body mass index (BMI) were found to be risk factors for retroperitoneal leakage.

CONCLUSIONS

Retroperitoneal leakage was common in PD patients with ultrafiltration insufficiency and was usually reversible after appropriate treatment. Age and gender were independent risk factors for retroperitoneal leakage.

Immune-metabolic marker of albumin-to-fibrinogen ratio based prognostic nomogram for patients following peritoneal dialysis

Background

The nutritional status and coagulation function of peritoneal dialysis (PD) patients are closely associated with their prognosis. This study aims to investigate the prognostic value of the albumin-to-fibrinogen ratio (AFR) on mortality in PD patients and to establish a prognostic prediction model based on AFR.

Methods

We retrospectively collected data from 148 PD patients treated at our hospital between Oct. 2011 and Dec. 2021. Using the "survminer" package in R, we determined the optimal cutoff value for AFR and divided the patients into low-AFR and high-AFR groups. The primary endpoint of this study was overall survival (OS). Univariate and multivariate Cox analyses were used to assess the impact of AFR and other factors on prognosis, and a corresponding prognostic prediction model was constructed using a nomogram, which was evaluated through ROC curves, the c-index, and calibration plots.

Results

The optimal cutoff value for AFR was 9.06. In the entire cohort, 30 patients (20.2%) were classified into the low-AFR group. Compared to the high-AFR group, patients in the low-AFR group were older, had lower total urine output over 24 h, higher blood urea nitrogen, higher total protein and urinary microalbumin levels, and longer remission times (p < 0.05). They also had a poorer OS (HR: 1.824, 95%CI: 1.282-2.594, p < 0.05). Multivariate Cox analysis indicated that AFR was an independent prognostic factor for OS (HR: 1.824, 95% CI: 1.282-2.594, p < 0.05). A prognostic prediction model based on AFR, age, and cause of ESRD was successfully validated for predicting OS in PD patients.

Conclusion

AFR represents a potential prognostic biomarker for PD patients. The prognostic prediction model based on AFR can provide accurate OS predictions for PD patients, aiding clinicians in making better-informed decisions.

Inflammation and all-cause mortality in patients undergoing peritoneal dialysis

OBJECTIVE

This study aimed to evaluate inflammatory biomarkers in patients undergoing peritoneal dialysis and investigate their association with all-cause mortality or transfer to hemodialysis.

METHODS

This prospective cohort study included 43 patients undergoing peritoneal dialysis. Plasma levels of cytokines were measured using flow cytometry and capture enzyme-linked immunosorbent assay. Biomarkers were categorized based on their respective median values. Survival analysis was conducted using the Kaplan-Meier estimator, considering two outcomes: all-cause mortality and transfer to hemodialysis.

RESULTS

After adjusting for confounding factors, plasma levels above the median of the levels of CCL2 and plasma, as well as below the median of TNF-α, and the median of dialysate IL-17 levels, were associated with an increased risk of experiencing the specified outcomes after approximately 16 months of follow-up.

CONCLUSION

These findings suggest that inflammatory biomarkers may be a valuable tool for predicting all-cause mortality and transfer to hemodialysis in patients undergoing peritoneal dialysis.

Pathophysiological Mechanisms of Peritoneal Fibrosis and Peritoneal Membrane Dysfunction in Peritoneal Dialysis

The characteristic feature of chronic peritoneal damage in peritoneal dialysis (PD) is a decline in ultrafiltration capacity associated with pathological fibrosis and angiogenesis. The pathogenesis of peritoneal fibrosis is attributed to bioincompatible factors of PD fluid and peritonitis. Uremia is associated with peritoneal membrane inflammation that affects fibrosis, neoangiogenesis, and baseline peritoneal membrane function. Net ultrafiltration volume is affected by capillary surface area, vasculopathy, peritoneal fibrosis, and lymphangiogenesis. Many inflammatory cytokines induce fibrogenic growth factors, with crosstalk between macrophages and fibroblasts. Transforming growth factor (TGF)-β and vascular endothelial growth factor (VEGF)-A are the key mediators of fibrosis and angiogenesis, respectively. Bioincompatible factors of PD fluid upregulate TGF-β expression by mesothelial cells that contributes to the development of fibrosis. Angiogenesis and lymphangiogenesis can progress during fibrosis via TGF-β-VEGF-A/C pathways. Complement activation occurs in fungal peritonitis and progresses insidiously during PD. Analyses of the human peritoneal membrane have clarified the mechanisms by which encapsulating peritoneal sclerosis develops. Different effects of dialysates on the peritoneal membrane were also recognized, particularly in terms of vascular damage. Understanding the pathophysiologies of the peritoneal membrane will lead to preservation of peritoneal membrane function and improvements in technical survival, mortality, and quality of life for PD patients.