Changes in the worldwide epidemiology of peritoneal dialysis

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.

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.

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.

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.

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.

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.

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.

Social determinants of health influencing the choice of dialysis modality in advanced chronic kidney disease: Need of an interdisciplinary approach

INTRODUCTION

The influence of socioeconomic and cultural barriers in the choice of renal replacement therapy (RRT) techniques in advanced chronic kidney disease (ACKD) has been scarcely explored, which can generate problems of inequity, frequently unnoticed in health care. The aim of this study is to identify the "non-medical" barriers that influence the choice of RRT in an advanced chronic kidney disease (ACKD) consultation in Spain.

MATERIAL AND METHODS

Retrospective analysis including the total number of patients seen in the ACKD consultation in a tertiary hospital from 2009 to 2020. Inclusion in the ACKD consultation began with an eligibility test and a decision-making process, conducted by a specifically trained nurse. The variables considered for the study were: age, sex, etiology of CKD, level of dependence for basic activities of daily living (Barthel Scale) and instrumental activities of daily living (Lawton and Brody Scale), Spanish versus foreign nationality, socioeconomic level and language barrier. The socioeconomic level was extrapolated according to home and health district by primary care center to which the patients belonged.

RESULTS

A total of 673 persons were seen in the ACKD consultation during the study period, of whom 400 (59.4%) opted for hemodialysis (HD), 156 (23.1%) for peritoneal dialysis (PD), 4 (0.5%) for early living donor renal transplantation (LDRT) and 113 (16.7%) chose conservative care (CC). The choice of PD as the chosen RRT technique (vs. HD) was associated with people with a high socioeconomic level (38.7% vs. 22.5%) (p = 0.002), Spanish nationality (91% vs. 77.7%) (p < 0.001), to a lower language barrier (0.6% vs 10.5%) (p < 0.001), and to a higher score on the Barthel scale (97.4 vs 92.9) and on the Lawton and Brody scale (7 vs 6.1) (p < 0.001). Neither age nor sex showed significant differences in the choice of both techniques. Patients who opted for CC were significantly older (81.1 vs 67.7 years; p < 0.001), more dependent (p < 0.001), with a higher proportion of women (49.6% vs 35.2%; p = 0.006) and a higher proportion of Spaniards (94.7% vs 81%, p = 0.001) in relation to the choice of other techniques (PD and HD). Socioeconomic level did not influence the choice of CC.

CONCLUSION

Despite a regulated decision-making process, there are factors such as socioeconomic status, migration, language barrier and dependency of the population that influence the type of RRT chosen. To address these aspects that may cause inequity, an intersectoral and multilevel intervention is required with interdisciplinary teams that include, among others, social workers, to provide a more holistic and person-centered assessment.

Peritoneal dialysis versus haemodialysis for people commencing dialysis

BACKGROUND

Peritoneal dialysis (PD) and haemodialysis (HD) are two possible modalities for people with kidney failure commencing dialysis. Only a few randomised controlled trials (RCTs) have evaluated PD versus HD. The benefits and harms of the two modalities remain uncertain. This review includes both RCTs and non-randomised studies of interventions (NRSIs).

OBJECTIVES

To evaluate the benefits and harms of PD, compared to HD, in people with kidney failure initiating dialysis.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies from 2000 to June 2024 using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. MEDLINE and EMBASE were searched for NRSIs from 2000 until 28 March 2023.

SELECTION CRITERIA

RCTs and NRSIs evaluating PD compared to HD in people initiating dialysis were eligible.

DATA COLLECTION AND ANALYSIS

Two investigators independently assessed if the studies were eligible and then extracted data. Risk of bias was assessed using standard Cochrane methods, and relevant outcomes were extracted for each report. The primary outcome was residual kidney function (RKF). Secondary outcomes included all-cause, cardiovascular and infection-related death, infection, cardiovascular disease, hospitalisation, technique survival, life participation and fatigue.

MAIN RESULTS

A total of 153 reports of 84 studies (2 RCTs, 82 NRSIs) were included. Studies varied widely in design (small single-centre studies to international registry analyses) and in the included populations (broad inclusion criteria versus restricted to more specific participants). Additionally, treatment delivery (e.g. automated versus continuous ambulatory PD, HD with catheter versus arteriovenous fistula or graft, in-centre versus home HD) and duration of follow-up varied widely. The two included RCTs were deemed to be at high risk of bias in terms of blinding participants and personnel and blinding outcome assessment for outcomes pertaining to quality of life. However, most other criteria were assessed as low risk of bias for both studies. Although the risk of bias (Newcastle-Ottawa Scale) was generally low for most NRSIs, studies were at risk of selection bias and residual confounding due to the constraints of the observational study design. In children, there may be little or no difference between HD and PD on all-cause death (6 studies, 5752 participants: RR 0.81, 95% CI 0.62 to 1.07; I2 = 28%; low certainty) and cardiovascular death (3 studies, 7073 participants: RR 1.23, 95% CI 0.58 to 2.59; I2 = 29%; low certainty), and was unclear for infection-related death (4 studies, 7451 participants: RR 0.98, 95% CI 0.39 to 2.46; I2 = 56%; very low certainty). In adults, compared with HD, PD had an uncertain effect on RKF (mL/min/1.73 m2) at six months (2 studies, 146 participants: MD 0.90, 95% CI 0.23 to 3.60; I2 = 82%; very low certainty), 12 months (3 studies, 606 participants: MD 1.21, 95% CI -0.01 to 2.43; I2 = 81%; very low certainty) and 24 months (3 studies, 334 participants: MD 0.71, 95% CI -0.02 to 1.48; I2 = 72%; very low certainty). PD had uncertain effects on residual urine volume at 12 months (3 studies, 253 participants: MD 344.10 mL/day, 95% CI 168.70 to 519.49; I2 = 69%; very low certainty). PD may reduce the risk of RKF loss (3 studies, 2834 participants: RR 0.55, 95% CI 0.44 to 0.68; I2 = 17%; low certainty). Compared with HD, PD had uncertain effects on all-cause death (42 studies, 700,093 participants: RR 0.87, 95% CI 0.77 to 0.98; I2 = 99%; very low certainty). In an analysis restricted to RCTs, PD may reduce the risk of all-cause death (2 studies, 1120 participants: RR 0.53, 95% CI 0.32 to 0.86; I2 = 0%; moderate certainty). PD had uncertain effects on both cardiovascular (21 studies, 68,492 participants: RR 0.96, 95% CI 0.78 to 1.19; I2 = 92%) and infection-related death (17 studies, 116,333 participants: RR 0.90, 95% CI 0.57 to 1.42; I2 = 98%) (both very low certainty). Compared with HD, PD had uncertain effects on the number of patients experiencing bacteraemia/bloodstream infection (2 studies, 2582 participants: RR 0.34, 95% CI 0.10 to 1.18; I2 = 68%) and the number of patients experiencing infection episodes (3 studies, 277 participants: RR 1.23, 95% CI 0.93 to 1.62; I2 = 20%) (both very low certainty). PD may reduce the number of bacteraemia/bloodstream infection episodes (2 studies, 2637 participants: RR 0.44, 95% CI 0.27 to 0.71; I2 = 24%; low certainty). Compared with HD; It is uncertain whether PD reduces the risk of acute myocardial infarction (4 studies, 110,850 participants: RR 0.90, 95% CI 0.74 to 1.10; I2 = 55%), coronary artery disease (3 studies, 5826 participants: RR 0.95, 95% CI 0.46 to 1.97; I2 = 62%); ischaemic heart disease (2 studies, 58,374 participants: RR 0.86, 95% CI 0.57 to 1.28; I2 = 95%), congestive heart failure (3 studies, 49,511 participants: RR 1.10, 95% CI 0.54 to 2.21; I2 = 89%) and stroke (4 studies, 102,542 participants: RR 0.94, 95% CI 0.90 to 0.99; I2 = 0%) because of low to very low certainty evidence. Compared with HD, PD had uncertain effects on the number of patients experiencing hospitalisation (4 studies, 3282 participants: RR 0.90, 95% CI 0.62 to 1.30; I2 = 97%) and all-cause hospitalisation events (4 studies, 42,582 participants: RR 1.02, 95% CI 0.81 to 1.29; I2 = 91%) (very low certainty). None of the included studies reported specifically on life participation or fatigue. However, two studies evaluated employment. Compared with HD, PD had uncertain effects on employment at one year (2 studies, 593 participants: RR 0.83, 95% CI 0.20 to 3.43; I2 = 97%; very low certainty).

AUTHORS' CONCLUSIONS

The comparative effectiveness of PD and HD on the preservation of RKF, all-cause and cause-specific death risk, the incidence of bacteraemia, other vascular complications (e.g. stroke, cardiovascular events) and patient-reported outcomes (e.g. life participation and fatigue) are uncertain, based on data obtained mostly from NRSIs, as only two RCTs were included.

Informed Dialysis Modality Selection Among Veterans With Advanced CKD: A Community-Level Needs Assessment

Rationale & Objective

The Advancing Americans Kidney Health Executive order has directed substantial increases in home dialysis use for incident kidney replacement therapy (KRT). Clinical guidelines recommend patients' self-selection of KRT modality through a shared decision-making process, which, at the minimum, requires predialysis nephrology care and KRT-directed comprehensive prekidney failure patient education (CoPE). The current state of these essential services among Americans with advanced (stages 4 and 5) chronic kidney disease (CKD) and their informed preferences for home dialysis are unknown.

Study Design

We conducted a community-based, cross-sectional, observational cohort study across a large regional Veteran Healthcare System from October 1, 2020, to September 30, 2021.

Setting & Participants

Of the 928 Veterans with advanced CKD, 287 (30.9%) were invited for needs assessment evaluations. Of the 218 (76% of invited cohort) responding, 178 (81.6%) were receiving nephrology care, with approximately half of those (43.6%) receiving such care from non-Veterans Affairs providers.

Outcomes

The study was targeted to assess the prevalent state of ongoing nephrology care and KRT-directed pre-kidney failure education among Veterans with advanced CKD. The secondary outcome included evaluation of dialysis decision-making state among Veterans with advanced CKD.

Analytical Approach

Veterans with advanced CKD with 2 sustained estimated glomerular filtration rates <30 mL/min/1.73 m2 were identified through an electronic database query, and a randomly selected cohort was invited for their current state of and outstanding needs for predialysis nephrology care and CoPE, essential for informed KRT selection.

Results

Basic awareness of kidney disease was high (92.2%) among Veterans with advanced CKD, although only 38.5% were aware of the severity of their CKD. KRT-directed education during clinical care was reported by 46.8% of Veterans, of which 21.1% reported having received targeted CoPE classes. Three-quarters (74.3%) of Veterans expressed interest in receiving CoPE services. Overall, awareness of CKD and its severity and receipt of KRT-directed education were significantly higher among Veterans with nephrology care than among those without. Of the 61 Veterans providing their KRT preferences, overall decision making was poor, with three-quarters (73.8%) of the cohort unable to choose any KRT modality, irrespective of ongoing nephrology care. Only 8 (13%) felt confident choosing home KRT modalities.

Limitations

The study results are primarily applicable to the Veterans with advanced CKD. Furthermore, a limited numbers of respondents provided data on their KRT decision-making state, prohibiting broad generalizations.

Conclusions

In a first-of-its-kind community-based needs assessment evaluation among Veterans with advanced CKD, we found that awareness of kidney disease is positively associated with nephrology care; however, the informed KRT selection capabilities are universally poor, irrespective of nephrology care. Our results demonstrate a critical gap between the recommended and prevalent nephrology practices such as KRT-directed education and targeted CoPE classes required for informed patient-centered home dialysis selection in advanced CKD.

Trends in Automated Peritoneal Dialysis Prescriptions in a Large Dialysis Organization in the United States

Key Points

This is the largest analysis of incident automated peritoneal dialysis (PD) prescriptions conducted in the United States to date. There was limited variability of automated PD prescriptions across the first 4 months of therapy. PD prescriptions tailored to meet the dialysis needs and lifestyle of patients may make PD a more attractive choice and increase longevity on PD.

Background

Changes in health care policies and recognition of patient benefit have contributed to increases in home-based dialysis, including peritoneal dialysis (PD). Frequent monitoring and early individualization of PD prescriptions are key prerequisites for the delivery of high-quality PD. The present analysis aimed to assess variations in PD prescriptions among incident automated PD (APD) patients who remain on PD for 120+ days.

Methods

This retrospective analysis examined data from patients within a large dialysis organization that initiated PD with APD between 2015 and 2019. PD prescription data were described by calendar year, timing of PD, and residual renal function categories. Changes in prescriptions from PD initiation (day 1) to day 120 were assessed descriptively.

Results

The cohort included 11,659 patients. The mean age at PD initiation increased from 2015 (56 [15] years) through 2019 (58 [15] years), whereas most other variables demonstrated no clear temporal change. Most patients (86%) had nighttime PD prescribed, with an average of 4.9 (1.3) cycles per day, a mean total treatment volume of 9.3 (2.5) L, and a median daily total dwell time of 7 (6–9.5) hours. Relative to day 1 nighttime prescriptions, there were (1 ) small increases in the proportion of patients receiving three or fewer cycles per day and those receiving 6+ cycles per day, (2 ) a 100 ml mean increase in fill volume per exchange, and (3 ) a mean 0.5 L increase in total nighttime treatment volume at day 120. When changes in nighttime APD prescriptions were examined at the patient level, 49% of patients had day 120 prescriptions that were unchanged from their initial prescription.

Conclusions

In the largest analysis of incident APD prescriptions conducted in the United States to date, most patients were prescribed nocturnal PD only with limited variability across the first 4 months of therapy.

Using the concept of food as medicine to mitigate inflammation in patients undergoing peritoneal dialysis

The most common kidney replacement therapy (KRT) worldwide is hemodialysis (HD), and only 5%-10% of patients are prescribed peritoneal dialysis (PD) as KRT. Despite PD being a different method, these patients also present particular complications, such as oxidative stress, gut dysbiosis, premature aging, and mitochondrial dysfunction, leading to an inflammation process and high cardiovascular mortality risk. Although recent studies have reported nutritional strategies in patients undergoing HD with attempts to mitigate these complications, more information must be needed for PD patients. Therefore, this review provides a comprehensive analysis of recent studies of nutritional intervention to mitigate inflammation in PD patients.

A protective role of nintedanib in peritoneal fibrosis through H19-EZH2-KLF2 axis via impeding mesothelial-to-mesenchymal transition

BACKGROUND

Peritoneal fibrosis (PF), a common complication of long-term peritoneal dialysis, accounts for peritoneal ultrafiltration failure to develop into increased mortality. Nintedanib has previously been shown to protect against multi-organ fibrosis, including PF. Unfortunately, the precise molecular mechanism underlying nintedanib in the pathogenesis of PF remains elusive.

METHODS

The mouse model of PF was generated by chlorhexidine gluconate (CG) injection with or without nintedanib administration, either with the simulation for the cell model of PF by constructing high-glucose (HG)-treated human peritoneal mesothelial cells (HPMCs). HE and Masson staining were applied to assess the histopathological changes of peritoneum and collagen deposition. FISH, RT-qPCR, western blot and immunofluorescence were employed to examine distribution or expression of targeted genes. Cell viability was detected using CCK-8 assay. Cell morphology was observed under a microscope. RNA immunoprecipitation (RIP) and chromatin immunoprecipitation (ChIP) assays were applied to validate the H19-EZH2-KLF2 regulatory axis.

RESULTS

Aberrantly overexpressed H19 was observed in both the mouse and cell model of PF, of which knockdown significantly blocked HG-induced mesothelial-to-mesenchymal transition (MMT) of HPMCs. Moreover, loss of H19 further strengthened nintedanib-mediated suppressive effects against MMT process in a mouse model of PF. Mechanistically, H19 could epigenetically repressed KLF2 via recruiting EZH2. Furthermore, TGF-β/Smad pathway was inactivated by nintedanib through mediating H19/KLF2 axis.

CONCLUSION

In summary, nintedanib disrupts MMT process through regulating H19/EZH2/KLF2 axis and TGF-β/Smad pathway, which laid the experimental foundation for nintedanib in the treatment of PF.

Treatment of peritoneal fibrosis: Therapeutic prospects of bioactive Agents from Astragalus membranaceus

Peritoneal dialysis is one of the renal replacement treatments for patients with end-stage renal disease. Peritoneal dialysis-related peritoneal fibrosis is a pathological change in peritoneal tissue of peritoneal dialysis patients with progressive, non-suppurative inflammation accompanied by fibrous tissue hyperplasia, resulting in damage to the original structure and function, leading to peritoneal function failure. Currently, there is no specific drug in the clinic. Therefore, it is necessary to find a drug with good effects and few adverse reactions. Astragalus membranaceus (AMS) is the dried root of the Astragalus membranaceus (Fisch.) Bge. AMS and its active ingredients play a significant role in anti-inflammation, anti-fibrosis, regulation of immune function and regulation of blood pressure. Studies have shown that it can alleviate peritoneal fibrosis by reducing inflammatory response, inhibiting oxidative stress, degrading extracellular matrix deposition, regulating apoptosis, and regulating Transforming Growth Factor-β. The author summarized the relationship between AMS and its active ingredients by referring to relevant literature at home and abroad, in order to provide some theoretical basis for further clinical research.

Sterile inflammation of peritoneal membrane caused by peritoneal dialysis: focus on the communication between immune cells and peritoneal stroma

Peritoneal dialysis is a widely used method for treating kidney failure. However, over time, the peritoneal structure and function can deteriorate, leading to the failure of this therapy. This deterioration is primarily caused by infectious and sterile inflammation. Sterile inflammation, which is inflammation without infection, is particularly concerning as it can be subtle and often goes unnoticed. The onset of sterile inflammation involves various pathological processes. Peritoneal cells detect signals that promote inflammation and release substances that attract immune cells from the bloodstream. These immune cells contribute to the initiation and escalation of the inflammatory response. The existing literature extensively covers the involvement of different cell types in the sterile inflammation, including mesothelial cells, fibroblasts, endothelial cells, and adipocytes, as well as immune cells such as macrophages, lymphocytes, and mast cells. These cells work together to promote the occurrence and progression of sterile inflammation, although the exact mechanisms are not fully understood. This review aims to provide a comprehensive overview of the signals from both stromal cells and components of immune system, as well as the reciprocal interactions between cellular components, during the initiation of sterile inflammation. By understanding the cellular and molecular mechanisms underlying sterile inflammation, we may potentially develop therapeutic interventions to counteract peritoneal membrane damage and restore normal function.

A retrospective study on the efficacy of Roxadustat in peritoneal dialysis patients with erythropoietin hyporesponsiveness

BACKGROUND/AIMS

Roxadustat, an oral medication for treating renal anemia, is a hypoxia-inducible factor prolyl hydroxylase inhibitor used for regulating iron metabolism and promoting erythropoiesis. To investigate the efficacy and safety of roxadustat in patients undergoing peritoneal dialysis (PD) with erythropoietin hyporesponsiveness.

METHODS

Single-center, retrospective study, 81 PD patients (with erythropoietin hyporesponsiveness) were divided into the roxadustat group (n = 61) and erythropoiesis-stimulating agents (ESAs) group (n = 20). Hemoglobin (Hb), total cholesterol, intact parathyroid hormone (iPTH), brain natriuretic peptide (BNP), related indicators of cardiac function and high-sensitivity C-reactive protein (hs-CRP) were collected. Additionally, adverse events were also recorded. The follow-up period was 16 weeks.

RESULTS

The two groups exhibited similar baseline demographic and clinical characteristics. At baseline, the roxadustat group had a mean Hb level of 89.8 ± 18.9 g/L, while the ESAs group had a mean Hb level of 95.2 ± 16.0 g/L. By week 16, the Hb levels had increased to 118 ± 19.8 g/L (p < 0.05) in the roxadustat group and 101 ± 19.3 g/L (p > 0.05) in the ESAs group. The efficacy of roxadustat in improving anemia was not influenced by baseline levels of hs-CRP and iPTH. Cholesterol was decreased in the roxadustat group without statin use. An increase in left ventricular ejection fraction and stabilization of BNP were observed in the roxadustat group.

CONCLUSION

For PD patients with erythropoietin hyporesponsiveness, roxadustat can significantly improve renal anemia. The efficacy of roxadustat in improving renal anemia was not affected by baseline levels of hs-CRP0 and iPTH.

SGLT-2 inhibitors as novel treatments of multiple organ fibrosis

Fibrosis, a significant health issue linked to chronic inflammatory diseases, affects various organs and can lead to serious damage and loss of function. Despite the availability of some treatments, their limitations necessitate the development of new therapeutic options. Sodium-glucose cotransporter 2 inhibitors (SGLT2i), known for their glucose-lowering ability, have shown promise in offering protective effects against fibrosis in multiple organs through glucose-independent mechanisms. This review explores the anti-fibrotic potential of SGLT2i across different tissues, providing insights into their underlying mechanisms and highlighting recent research advancements. The evidence positions SGLT2i as a potential future treatments for fibrotic diseases.

Capacity for the management of kidney failure in the International Society of Nephrology Eastern and Central Europe region: report from the 2023 ISN Global Kidney Health Atlas (ISN-GKHA)

Delivery of care for kidney failure (KF) globally has a significant disparity; even in some countries, it means end of life for the person. The International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA) tries to address gaps in KF care and standardize global nephrology care. From the third iteration of the ISN-GKHA, we present data for countries in the ISN Eastern and Central Europe region. The median prevalences of chronic kidney disease (12.8%) and treated KF (873.5 pmp) were higher than the global rates, respectively. Hemodialysis was the most preferred modality for KF in adults, whereas kidney replacement therapy was more balanced in children. Although most of the countries in the region had lower-middle-income and upper-middle-income levels, health expenditures for kidney health care were almost generally covered publicly. Nephrologists were responsible for the medical kidney care of people with KF in all countries. There was adequate infrastructure to provide all kinds of treatment for kidney care in the region. Regional characteristics such as high levels of obesity, smoking, and Balkan nephropathy as an endemic disease coupled with a shortage of workforce and finance continued to affect kidney care in the region negatively. By making organizational and legislative arrangements, partnerships with national authorities and societies may accelerate the improvement of kidney health care in the region.

Effects of comprehensive nursing interventions on wound pain in patients undergoing catheter insertion for peritoneal dialysis

This study investigates the effects of comprehensive nursing interventions on wound pain in patients undergoing catheter insertion for peritoneal dialysis. Sixty patients who underwent catheter insertion for peritoneal dialysis from January 2021 to January 2023 at our hospital were selected as subjects and randomly divided into an experimental group and a control group using a random number table method. The control group received routine nursing care, while the experimental group was subjected to comprehensive nursing interventions. The study compared the impact of nursing measures on visual analogue scale (VAS), self-rating anxiety scale (SAS), self-rating depression scale (SDS) and nursing satisfaction between the two groups. The analysis revealed that on the third, fifth and seventh days post-intervention, the experimental group's wound VAS scores were significantly lower than those of the control group (p < 0.001). Furthermore, levels of anxiety and depression were markedly lower in the experimental group compared with the control group (p < 0.001). In addition, the nursing satisfaction rate was significantly higher in the experimental group than in the control group (96.67% vs. 73.33%, p = 0.011). This study indicates that the application of comprehensive nursing interventions in patients undergoing catheter insertion for peritoneal dialysis is highly effective. It can alleviate wound pain and negative emotions to a certain extent, while also achieving high patient satisfaction, thus demonstrating significant clinical value.

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.

Longer serum phosphorus time in range associated with lower mortality risk among peritoneal dialysis patients: a multicenter retrospective cohort study

BACKGROUND

Relationship between serum phosphorus time in range and mortality risk in peritoneal dialysis (PD) patients remains uncertain. We aimed to evaluate the association between serum phosphorus time in range and all-cause mortality in Chinese PD population.

METHODS

This was a multicenter, retrospective, cohort study of 1,915 patients collected from January 2008 to October 2020 in 4 Chinese centers. Serum phosphorus time in range was estimated as the months during the first year that a patient's serum phosphorus level was within the target range (defined as 1.13-1.78 mmol/L). The primary outcome was all-cause mortality. The secondary outcomes were cardiovascular (CV) mortality and PD withdrawal. Cox proportional hazards regression model with comprehensive adjustments was used to assess the association.

RESULTS

The primary outcome occurred in 249 (13.0%) PD patients over a median follow-up of 28 months. Overall, the serum phosphorus time in range was negatively associated with all-cause mortality (per 3-month increments, adjusted HR [aHR], 0.83; 95%CI: 0.75-0.92), CV mortality (per 3-month increments, aHR, 0.87; 95%CI: 0.77-0.99), and PD withdrawal (per 3-month increments, aHR, 0.89; 95%CI: 0.83-0.95). Competing-risk model showed that the relationship of serum phosphorus time in range with all-cause mortality remained stable. None of the variables including demographics, history of diabetes and CV disease, as well as several PD-related and clinical indicators modified this association.

CONCLUSIONS

PD patients with longer serum phosphorus time in range in the first year was negatively associated with all-cause mortality and CV mortality. Our findings highlight the importance of maintaining serum phosphorus levels within 1.13-1.78 mmol/L for PD patients.

Nephrologists' perspectives on communication and decision-making regarding technique survival in peritoneal dialysis: an international qualitative interview study

OBJECTIVES

Peritoneal dialysis (PD) allows patients increased autonomy and flexibility; however, both infectious and non-infectious complications may lead to technique failure, which shortens treatment longevity. Maintaining patients on PD remains a major challenge for nephrologists. This study aims to describe nephrologists' perspectives on technique survival in PD.

DESIGN

Qualitative semistructured interview study. Transcripts were thematically analysed.

SETTING AND PARTICIPANTS

30 nephrologists across 11 countries including Australia, the USA, the UK, Hong Kong, Canada, Singapore, Japan, New Zealand, Thailand, Colombia and Uruguay were interviewed from April 2017 to November 2019.

RESULTS

We identified four themes: defining patient suitability (confidence in capacity for self-management, ensuring clinical stability and expected resilience), building endurance (facilitating access to practical support, improving mental well-being, optimising quality of care and training to reduce risk of complications), establishing rapport through effective communications (managing expectations to enhance trust, individualising care and harnessing a multidisciplinary approach) and confronting fear and acknowledging barriers to haemodialysis (preventing crash landing to haemodialysis, facing concerns of losing independence and positive framing of haemodialysis).

CONCLUSION

Nephrologists reported that technique survival in PD is influenced by patients' medical circumstances, psychological motivation and positively influenced by the education and support provided by treating clinicians and families. Strategies to enhance patients' knowledge on PD and communication with patients about technique survival in PD are needed to build trust, set patient expectations of treatment and improve the process of transition off PD.

The association between new inflammation markers and frequent peritoneal dialysis-associated peritonitis

OBJECTIVE

To validate an association between new inflammation and frequent peritoneal dialysis-associated peritonitis (PDAP).

MATERIALS AND METHODS

In China, retrospective clinical data were collected on 208 patients who received continuous ambulatory peritoneal dialysis (CAPD) between 2010 and 2021. The patients were divided into two groups: non-frequent PDAP (the interval between two peritonitis episodes of more than one year) and frequent PDAP (the interval between two peritonitis episodes of less than one year). Patients with their first episode of peritonitis had their age, gender, history of hypertension, diabetic disease, underlying renal disease, bacterial infection, and laboratory data collected. The outcomes of bacterial dispersion, systemic immune-inflammation index (SII), high-density lipoprotein cholesterol (HDL-C), C-reactive protein (CRP), and risk variables associated with frequent PDAP were analyzed.

RESULTS

There are differences between the two groups in dialysis time (p = 0.006), hypertensive nephropathy (p = 0.038), staphylococcus (p = 0.035), white blood cells (p = 0.001), neutrophil (p < 0.01), lymphocyte (p < 0.01), platelet(p = 0.01), SII(p < 0.01), CRP/HDL-C (p = 0.002), CRP (p < 0.001), serum creatinine (p = 0.007), blood urea nitrogen (p = 0.05), serum magnesium (0.03), serum potassium (p = 0.007), and dialysate polymorphonuclear cells (p = 0.004). Multifactorial logistic regression analysis found that SII (p < 0.001), CRP/HDL-C (p = 0.041), and Diabetes mellitus (p = 0.027) were independent risk factors for frequent PDAP. The ROC curve analysis revealed that combining SII with CRP/HDL-C resulted in the largest AUC area (AUC = 0.814).

CONCLUSIONS

Our findings offer clinical proof of the combination of SII and CRP/HDL-C in patients with frequent PDAP.

A landscape of metabolic variation among clinical outcomes of peritoneal dialysis in end-stage renal disease

BACKGROUND

Peritoneal dialysis (PD) helps prevent lethal complications of end-stage renal disease (ESRD). However, the clinical outcomes are affected by PD-related complications. We investigated metabolic biomarkers to estimate the clinical outcomes of PD and identify patients at high risk of downstream complications and recurrent/relapsing infections.

METHODS

Metabolites of normal control and ESRD patient were compared via an untargeted metabolomic analysis. Potential metabolic biomarkers were selected and quantified using a multiple reaction monitoring-based target metabolite detection method. A nomogram was built to predict the clinical outcomes of PD patients using clinical features and potential metabolic biomarkers with the least absolute shrinkage and selection operator Cox regression model.

RESULTS

Twenty-five endogenous metabolites were identified and analyzed. ESRD-poor clinical outcome-related metabolic modules were constructed. Adenine, isoleucine, tyramine, xanthosine, phenylacetyl-L-glutamine, and cholic acid were investigated using the weighted gene correlation network analysis blue module. Potential metabolic biomarkers were differentially expressed between the NC and ESRD groups and the poor and good clinical outcomes of PD groups. A 3-metabolite fingerprint classifier of isoleucine, cholic acid, and adenine was included in a nomogram predicting the clinical outcomes of PD.

CONCLUSION

Metabolic variations can predict the clinical outcomes of PD in ESRD patients.

Center Hemodialysis Versus Peritoneal Dialysis: A Cost-Utility Analysis

Introduction Kidney replacement therapy (KRT) is needed for patients with end-stage kidney disease. While it is clear that kidney transplantation remains the gold standard in KRT, data comparing the cost-utility of peritoneal dialysis (PD) and hemodialysis (HD) are scarce. No such analysis has been performed for German patients.  Methods We used aggregated data generated by the Short Form 36 Health Survey (SF-36) for quality of life and insurance claims to evaluate mortality and economic impact. Quality-adjusted life years (QALY) and cost-utility were calculated accordingly.  Results PD is superior to HD within all dimensions of the SF-36, both in terms of QALY and cost-utility. The difference in cost per QALY between the aggregated physical dimensions (€50,671.54 vs. €39,745.77) is greater than that of the aggregated mental dimensions (€31,638.75 vs. €25,287.63). However, there is considerable variability among patients.  Conclusion From a health-economic point of view, PD should be preferred over HD when deciding on the KRT modality for the patient. This is not reflected in current practice, though. However, interindividual differences and patient preferences should be considered in the decision.

Analysis of a nurse-provided on-call peritoneal dialysis support in an outpatient reference care centre

BACKGROUND

To analyse the nature of medical or technical emergency issues of ambulatory peritoneal dialysis (PD) patients calling a nurse-provided emergency PD support service of a reference centre that is provided all year in the after-hours.

METHODS

We retrospectively analysed patients' chief complaint, urgency, resolution of and association to current PD treatment and modality directed to an on-call nurse-provided PD support service from 2015-2021 based on routinely collected health data. Calls were systematically categorized being technical/procedural-, medical-, material-related or type of correspondence. Call urgency was categorized to have "immediate consequence", inquiry was eligible for "processing next working day" or whether there was "no need for further action". Call outcomes were classified according to whether patients were able to initiate, resume or finalize their treatments or whether additional interventions were required. Unexpected adverse events such as patients' acute hospitalization or need for nurses' home visits were evaluated and quantified.

RESULTS

In total 753 calls were documented. Most calls were made around 7:30 a.m. (5:00-9:00; median, 25-75th CI) and 6:30 p.m. (5:00-8:15). 645 calls were assigned to continuous ambulatory- (CAPD) or automated PD (APD). Of those, 430 calls (66.7%) had an "immediate consequence". Of those 77% (N = 331) were technical/procedural-, 12.8% (N = 55) medical- and 6.3% (N = 27) material related issues. 4% (N = 17) were categorized as other correspondence. Issues disrupting the course of PD were identified in 413 cases. In 77.5% (N = 320) patients were able to initiate, resume or finalize their treatment after phone consultation. Last-bag exchange was used in 6.1% enabling continued therapy in 83.6%. In 35 cases a nurse visit at patients' home or patients' visit to the practice at the earliest possible date were required, while hospitalization was required in seven medical category cases (5.4% and 1.09% of total assessed calls, respectively).

CONCLUSION

The on-call PD-nurse provides patient support for acute and imminent issues enabling them to successfully initiate, resume or finalize their prescribed treatment. Nurses triage of acute conditions facilitated rapid diagnostics and therapy. Maintaining quality PD homecare, the provision of trained personnel is indispensable. The information gathered in this study may therefore be used as a foundation to tailor educational programs for nephrology nurses and doctors to further develop their competencies in PD.

[Neuropsychological impairments in patients undergoing peritoneal dialysis treatment]

BACKGROUND

Patients with chronic kidney disease on hemodialysis (HD) often have cognitive deficits. However, there are few studies that have examined the neuropsychological impairments of patients receiving peritoneal dialysis (PD).

METHODS

Executive functions, processing speed and verbal memory were assessed in 27 PD patients, 42 HD patients, and 42 healthy participants (HP). Systolic blood pressure and total time on renal replacement therapy (RRT) were controlled statistically. Associations between performance and clinical factors were analyzed using correlations and multiple regression.

RESULTS

The DP group showed better performance compared to the HD group in verbal fluency, working memory, cognitive flexibility, planning and decision making. The DP group showed worse execution than the HP group in verbal inhibition and memory. Executive function scores were positively associated with total months on PD, total months on RRT, total months on HD, albumin, total cholesterol, and phosphorus, and negatively with ferritin.

CONCLUSION

Global executive functioning was more optimal in PD patients than in HD patients. The results show the positive effect of PD on executive functions, which must be taken into account when choosing the TRS. The associations observed between biochemical factors and performance show the importance of maintaining an adequate nutritional status in these patients.

Association between sarcopenic obesity and mortality in patients on peritoneal dialysis: a prospective cohort study

Background

Whether sarcopenic obesity had unfavorable effect on survival of peritoneal dialysis (PD) patients is unknown. We aimed to investigate the association between sarcopenic obesity and survival in PD patients.

Methods

This was a prospective observational study. Eligible PD patients from November 2016 to December 2017 were enrolled and followed until August 31, 2023. Sarcopenia was defined following the recommendations of the Asian Working Group for Sarcopenia (AWGS) as low appendicular skeletal muscle mass index (ASMI) and handgrip strength (HGS). Obesity was defined using the percentage of body fat (PBF). Survival analysis was conducted using the Kaplan-Meier and log-rank test. The Cox regression and the cumulative incidence competing risk (CICR) analyzes were used to investigate the association between sarcopenic obesity and all-cause mortality.

Results

A total of 223 patients were enrolled with 133 (59.6%) males, a median age of 57.5 (44.6, 65.7) years, a median dialysis vintage of 20.3 (6.4, 57.7) months and 48 (21.5%) who had comorbid diabetes mellitus. Among them, 46 (20.6%) patients were sarcopenic, and 25 (11.2%) patients were diagnosed with sarcopenic obesity. After followed up for 51.6 (25.6, 73.9) months, the Kaplan-Meier curve showed the sarcopenic obesity (log-rank = 13.527, p < 0.001) group had significant lower survival rate compared to the nonsarcopenic non-obesity group. For multivariate analysis, the CICR method showed patients with sarcopenic obesity had significantly higher mortality rate (HR: 2.190, 95% CI: 1.011-4.743, p = 0.047) compared to those with nonsarcopenic non-obesity.

Conclusion

Sarcopenia is not uncommon in PD patients, with a considerable proportion having sarcopenic obesity. There is a significant association between sarcopenic obesity and an increased risk of mortality in PD patients.

Comparison of different peritoneal dialysis catheters on complication 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.

Omega-3 polyunsaturated fatty acids protect peritoneal mesothelial cells from hyperglycolysis and mesothelial-mesenchymal transition through the FFAR4/CaMKKβ/AMPK/mTOR signaling pathway

Peritoneal fibrosis is a severe clinical complication associated with peritoneal dialysis (PD) and impacts its efficacy and patient outcomes. The process of mesothelial-mesenchymal transition (MMT) in peritoneal mesothelial cells plays a pivotal role in fibrogenesis, whereas metabolic reprogramming, characterized by excessive glycolysis, is essential in MMT development. No reliable therapies are available despite substantial progress made in understanding the mechanisms underlying peritoneal fibrosis. Protective effect of omega-3 polyunsaturated fatty acids (ω3 PUFAs) has been described in PD-induced peritoneal fibrosis, although the detailed mechanisms remain unknown. It is known that ω3 PUFAs bind to and activate the free fatty acid receptor 4 (FFAR4). However, the expression and role of FFAR4 in the peritoneum have not been investigated. Thus, we hypothesized that ω3 PUFAs would alleviate peritoneal fibrosis by inhibiting hyperglycolysis and MMT through FFAR4 activation. First, we determined FFAR4 expression in peritoneal mesothelium in humans and mice. FFAR4 expression was abnormally decreased in patients on PD and mice and HMrSV5 mesothelial cells exposed to PD fluid (PDF); this change was restored by the ω3 PUFAs (EPA and DHA). ω3 PUFAs significantly inhibited peritoneal hyperglycolysis, MMT, and fibrosis in PDF-treated mice and HMrSV5 mesothelial cells; these changes induced by ω3 PUFAs were blunted by treatment with the FFAR4 antagonist AH7614 and FFAR4 siRNA. Additionally, ω3 PUFAs induced FFAR4, Ca2+/calmodulin-dependent protein kinase kinase β (CaMKKβ), and AMPK and suppressed mTOR, leading to the inhibition of hyperglycolysis, demonstrating that the ω3 PUFAs-mediated FFAR4 activation ameliorated peritoneal fibrosis by inhibiting hyperglycolysis and MMT via CaMKKβ/AMPK/mTOR signaling. As natural FFAR4 agonists, ω3 PUFAs may be considered for the treatment of PD-associated peritoneal fibrosis.

Service Utilization Patterns and Direct Medical Costs of Hospitalization in Patients With Renal Failure Before and After Initiating Home Peritoneal Dialysis

OBJECTIVES

This study aimed to determine the hospital service utilization patterns and direct healthcare hospital costs before and during peritoneal dialysis (PD) at home.

METHODS

A retrospective cohort study of patients with kidney failure (KF) was conducted at a Mexican Social Security Institute hospital for the year 2014. Cost categories included inpatient emergency room stays, inpatient services at internal medicine or surgery, and hospital PD. The study groups were (1) patients with KF before initiating home PD, (2) patients with less than 1 year of home PD (incident), and (3) patients with more than 1 year of home PD (prevalent). Costs were actualized to international dollars (Int$) 2023.

RESULTS

We found that 53% of patients with KF used home PD services, 42% had not received any type of PD, and 5% had hospital dialysis while waiting for home PD. The estimated costs adjusting for age and sex were Int$5339 (95% CI 4680-9746) for patients without home PD, Int$17 556 (95% CI 15 314-19 789) for incident patients, and Int$7872 (95% CI 5994-9749) for prevalent patients; with significantly different averages for the 3 groups (P < .001).

CONCLUSIONS

Although the use of services and cost is highest at the time of initiating PD, over time, using home PD leads to a significant reduction in use of hospital services, which translates into institutional cost savings. Our findings, especially considering the high rates of KF in Mexico, suggest a pressing need for interventions that can reduce healthcare costs at the beginning of renal replacement therapy.

Use of lacosamide for focal epilepsy in a child with kidney failure undergoing peritoneal dialysis

BACKGROUND

Lacosamide (LCM) has become commonly used for focal onset seizures due to its high tolerability and low drug interactions. Unlike patients on hemodialysis (HD), pharmacokinetic data and dosing recommendations for patients undergoing peritoneal dialysis (PD) are scant.

CASE REPORT

A 2-year-old girl with end-stage kidney disease undergoing PD suffered prolonged focal onset seizures. The patient had congenital anomalies of the kidney and urinary tract associated with branchio-oto-renal syndrome due to an EYA1 gene mutation. She also had neurological sequelae from post-resuscitation encephalopathy at the age of one month. Antiseizure medication with few drug interactions, less impact on the neurodevelopmental state and possibility of intravenous administration was preferred. LCM met those criteria and was carefully administered. Although the patient had recurrent prolonged seizures during the titration periods, LCM could be continued without any apparent side effects. The blood levels of LCM increased linearly to the optimal level. We confirmed excretion of LCM in the PD fluid. Kidney transplantation was done three months after and her seizures were well controlled.

CONCLUSIONS

LCM might be a promising option for patients undergoing PD. Due to the lower removal efficacy in PD compared with in HD, close attention should be paid to possible drug excess.

Comparative pharmacoeconomic analysis of rituximab and traditional tacrolimus regimens in membranous nephropathy in China

Background: Rituximab (RTX) is a monoclonal antibody that selectively targets CD20 and is frequently used in the treatment of membranous nephropathy (MN). Analysis of the therapeutic efficacy and safety of RTX in treating MN in practice and a comparative pharmacoeconomic analysis of the RTX and traditional tacrolimus (TAC) regimens can provide valuable insights to aid decision-making by the government and relevant medical insurance departments. Methods: We conducted a statistical analysis of medical records from patients diagnosed with MN who underwent RTX treatment between 1 January 2019 and 1 January 2023. The TAC data were obtained from the clinical literature. The efficacy rates and incidence of adverse effects (AEs) were calculated to compare the efficacy and safety of RTX and TAC. Based on the patient's disease status, we developed a Markov model to compare the total cost, remission rate, and incremental cost-effectiveness ratio (ICER) of the two regimens. Both univariate and probability sensitivity analyses were performed to validate the stability of the developed model. Results: The RTX group enrolled 53 patients with MN, and the 12-month overall efficacy rate was not significantly different from that of the TAC group with 35 patients (86.79% vs. 71.4%, p = 0.0131); however, the relapse rate was significantly lower in the RTX group (3.77% vs. 22.8%, p = 0.016). The RTX group demonstrated no severe AEs (SAEs), while the TAC group demonstrated six cases of SAEs, including 4 cases of severe pneumonia, 1 case of lung abscess and 1 case of interstitial lung disease, accounting for 7.89% of traditional tacrolimus-treated patients. The baseline analysis results revealed that over a 5-year post-treatment period, RTX increased quality-adjusted life years (QALYs) by 0.058 and costs by ¥7,341. Assuming three times the 2022 domestic gross domestic product as the willingness-to-pay (WTP) threshold per QALY, the ICER of RTX compared to TAC was ¥124,631.14/QALY, which is less than the WTP threshold of ¥257,094/QALY, indicating that RTX treatment is approximately two times more cost-effective compared to TAC. Conclusion: The current analysis indicates that despite the expensive unit price of RTX, it remains a cost-effective treatment option for MN compared to TAC.

Specific gut microbiome and metabolome changes in patients with continuous ambulatory peritoneal dialysis and comparison between patients with different dialysis vintages

Background

In recent years, the role of gut microbiota and derived metabolites in renal disease has attracted more attention. It has been established that the gut microbiota is a potential target for medical interventions in renal disease including chronic kidney disease (CKD), acute kidney injury (AKI) and renal calculus. Emerging evidence has related dialysis treatment to the microbial composition and function of the intestines, and there are many reports related to HD, but few studies have been related to PD. Previous studies have found that PD patients have intestinal flora disturbances, so we speculate that intestinal flora and its metabolites may be the regulatory factors in long-term therapy of PD. And as far as we know, there have been no studies characterized the gut microbiota in PD patients of different dialysis vintages.

Methods

It is a cross-sectional study based on clinical data and biological samples of 72 patients with CAPD, 13 patients with ESRD and 13 healthy volunteers. The intestinal microecological characteristics of CAPD patients were comprehensively evaluated by combining the intestinal microflora structure, enterotoxin and receptor (serum LPS and LBP), intestinal barrier function index (serum D-Lactate), intestinal uremic toxin (serum IS, PCS, TMAO), fecal SCFAs and other multi-dimensional and multi-omics studies. Furthermore, the changes of intestinal microecology in CAPD patients of different dialysis vintages (≥ 3 and < 12 months, ≥ 12 and < 24 months, ≥ 24 and < 60 months, ≥ 60 months) were further explored, and the correlations between intestinal microecology indicators and some clinical indicators were analyzed. Fecal and serum samples were collected from PD patients (PD group, n = 72), ESRD patients (ESRD group, n = 13) and healthy volunteers (Normal group, n = 13). Fecal samples were subjected to microbiome (16S rDNA) and SCFA (GC-MS) analyses. Serum samples were subjected to LPS, LBP, D-lactate, IS, PCS, and TMAO (ELISA) analyses.

Results

The diversity and richness of intestinal flora in CAPD patients were lower than those in healthy people and ESRD patients, and the microflora structure was different. Anaerobes of Blautia and facultative anaerobes and aerobic bacteria with Bacilli and Lactobacillales those in Firmicutes are the main intestinal flora in CAPD patients. The abundance of Bacteroidaceae, Bacteroides, Faecalibacterium and other dominant bacteria in the intestinal tract of CAPD patients decreased. Proteobacteria, Enterobacteriaceae and Escherichia-Shigella increased their colonization (LDA > 4). In CAPD patients of different dialysis vintages, there was no significant change in the diversity and richness of microflora, and the microflora structure of PDC group was significantly different from that of PDD, which the abnormal expansion of enterobacter group was more prominent in PDC and the abundance of Bacteroides group was relatively higher in PDD. Intestinal barrier damage, intestinal uremic toxin accumulation and short-chain fatty acid reduction were observed in CAPD patients, such as the serum level of D-Lactate, PCS and TMAO were significantly higher than that in the Normal group (P < 0.05),and the fecal levels of BA and CA were significantly lower (P < 0.05). The intestinal microecological disorder of PDC group, while that of PDD group showed a better trend. Such as the PDC group had a significantly higher serum level of LPS, D-Lactate and TMAO (P < 0.01), and significantly lower serum level of LBP (P < 0.01), and lower fecal levels of AA and BA (P > 0.05) than the PDD group.

Conclusion

The intestinal microecology and metabolic system of CAPD patients had changes compared with healthy people and ESRD non-dialysis patients, and there were differences in CAPD patients with different dialysis vintages. PD patients on dialysis for more than 60 months showed a better trend in the intestinal microecology than patients with 24∼36 months, which suggested that the intestinal microecology of PD patients had a certain ability of self-regulation and remodeling under the management of standardized system and it is necessary to strengthen the monitoring of the intestinal status and the occurrence of related complications in PD patients on dialysis of 24∼36 months of dialysis vintage. It is initially considered that the mechanism of intestinal microecology is a potential target for intervention in the diagnosis and treatment of CAPD and incorporating intestinal microecosystem monitoring into the long-term management of CAPD patients is a new strategy.

Association between systemic immune inflammation Index and all-cause mortality in incident peritoneal dialysis-treated CKD patients: a multi-center retrospective cohort study

BACKGROUND

Chronic inflammatory disorders in peritoneal dialysis (PD) contribute to the adverse clinical outcome. Systemic immune inflammation index (SII) is the novel and convenient measurement that is positively associated with various diseases. However, scarce is known regarding the association between SII with all-cause mortality among PD patients.

METHODS

In this multi-center retrospective cohort study, 1,677 incident patients with PD were enrolled. Eligible patients were stratified into groups based on SII level: tertile 1(< 456.76), tertile 2(456.76 to 819.03), and tertile 3(> 819.03). The primary endpoint was the all-cause mortality. Both Cox regression analysis and competing risk models were used to examine the association between SII and all-cause mortality. Subgroup analysis was performed to assess the influence of the SII tertiles on all-cause mortality in different subgroups.

RESULTS

During the follow-up period of 30.5 ± 20.0 months, 26.0% (437/1,677) patients died, of whom the SII tertile 3 group accounted for 39.1% (171/437) of the deaths. Patients in the SII tertile 3 group had a higher all-cause mortality rate than patients in the SII tertile 1 and 2 groups (log-rank = 13.037, P < 0.001). The SII tertile 3 group was significantly associated with 80% greater risk (95% confidence interval:1.13 to 2.85; P = 0.013) compared with the SII tertile 1 group in multivariable Cox regression analysis. The competing risk model also indicated that the relationship between SII tertiles and all-cause mortality remains (subdistribution hazard ratio: 1.86; 95% confidence interval: 1.15 to 2.02, P = 0.011). Furthermore, the relationship between the log-transformed SII and all-cause mortality in patients with PD was nearly linear (P = 0.124).

CONCLUSION

A close relationship was observed between the SII and all-cause mortality in patients undergoing PD, suggesting that more attention should be paid to the SII, which is a convenient and effective measurement in clinical practice.

The influence of different peritoneal dialysis techniques on wound infection in patients with peritoneal dialysis tube

More and more research has started to investigate the effect of peritoneal dialysis treatment on the incidence of pericatheter wound complications in chronic kidney disease (CKD). This meta-study evaluated the effect of emergency peritoneal dialysis (EPD) with conventional peritoneal dialysis (CPD) in patients with catheter-related complications. We looked up 4 databases: PubMed, EMBASE, Cochrane, and Web of Science, and analysed the data with RevMan 5. There were a total of 15 studies with 3034 participants. While the quality of the research included was fairly good, the evidence was mediocre. In the meta-analyses, the risk of leak in the conduit with PD was very high (OR, 2.48; 95% CI, 1.72, 3.59, p < 0.00001). However, for those treated with urgent medical method prior to initiation of PD, the risk for peritonitis, catheter dysfunction and bleeding was similar compared with CPD. Based on limited information, immediate initiation of PDs is advised in order to increase the quality of life for people in urgent need, except if there is no consideration for loss of fluid. The low quality of the evidence is holding up the evidence. This research, however, is also informative because of the large number of available data. Consequently, additional high quality, large, randomized controlled studies are required to establish.

Neutrophil Percentage-to-Albumin Ratio and Risk of Mortality in Patients on Peritoneal Dialysis

Background

Neutrophil percentage-to-albumin ratio (NPAR), a new inflammatory marker, has been shown to be associated with poor prognosis in patients with cardiovascular disease. However, limited evidence is available for its role in peritoneal dialysis (PD) patients. Our study aimed at investigating the prognostic value of NPAR for mortality in PD patients.

Patients and Methods

This was a single center retrospective cohort study. A total of 1966 PD patients were enrolled in our study from January 2006 to December 2016 and were followed up until December 2021. Patients were stratified into tertiles according to baseline NPAR levels. The associations between NPAR levels with all-cause and cardiovascular mortality were estimated using Cox proportional hazards models. Receiver operating characteristic (ROC) analysis was performed to compare the mortality predictive values of NPAR and other known biomarkers, such as NLR (neutrophil-to-lymphocyte ratio), PLR (platelet-to-lymphocyte ratio), LHR (low-density lipoprotein cholesterol-to-high-density lipoprotein cholesterol ratio) and MLR (monocyte-to-lymphocyte ratio).

Results

During a median follow-up of 48.1 months, 503 (25.6%) patients died, in which cardiovascular disease (CVD) death dominated 50.3%. Multivariate Cox regression analysis revealed that the highest NPAR tertile was significantly associated with a higher risk of all-cause and cardiovascular mortality (HR 1.51, 95% CI 1.14-1.98; HR 1.57, 95% CI 1.07-2.31; respectively) compared with tertile 1. The AUC values of NPAR were 0.62 (95% CI 0.60-0.65, P < 0.001) for all-cause mortality and 0.61 (95% CI 0.57-0.65, P < 0.001) for cardiovascular mortality.

Conclusion

Our study showed that higher NPAR levels were independently associated with increased risk of all-cause and cardiovascular mortality in PD patients. Notably, our results demonstrated that NPAR exhibited superior predictive value for mortality compared to NLR, PLR, MLR, and LHR.

Comparison of mortality according to baseline, first year, and mean albumin levels in peritoneal dialysis: a retrospective study

BACKGROUND

The relationship between hypoalbuminemia in peritoneal dialysis (PD) and mortality, risk of peritonitis, and decreased residual renal function (RRF) is known. However, we have not encountered a comprehensive study on which of the mean albumin values, at the beginning of peritoneal dialysis, in the first year, and during the peritoneal dialysis period, provide more predictive predictions regarding mortality, peritonitis risk, and RRF reduction.

METHODS

A total of 407 PD patients in whom PD was initiated and followed up and PD was terminated were included in the study. Albumin levels, peritonitis, and RRF at the beginning of PD and at 3-month periods during PD were recorded.

RESULTS

In the evaluation of the patients, there was a significant relationship between mean, first-year albumin values in RRF loss (p = 0.001, p = 0.006, respectively) and peritonitis (p < 0.001), but no significant correlation was found with baseline albumin values (p = 0.213, p = 0.137, respectively). In the comparison of mortality ROC analysis of PD patients, a significant correlation was found with mortality at baseline, first year, and mean albumin values (p < 0.001). However, in the multivariate Cox regression analysis, it was determined that there was a more significant relationship between first-year albumin and mean albumin values compared to baseline albumin values (HR 0.918 [95% CI 0.302-0.528] (p < 0.001)), (HR 1.161 [95% CI 0.229-0.429] (p < 0.001)), (HR 0.081 [95% CI 0.718-1.184] (p = 0.525)).

CONCLUSIONS

In conclusion, mean and first-year mean albumin levels provide more determinative predictions for mortality, risk of peritonitis, and maintenance of residual renal functions in peritoneal dialysis patients compared to baseline albumin.

Pan-immune-inflammation value is associated with poor prognosis in patients undergoing peritoneal dialysis

BACKGROUND

Immune-inflammatory biomarkers (IIBs) have been shown to be correlated with prognosis in patients undergoing peritoneal dialysis (PD). In this study, we aimed to evaluate the relationship between a novel comprehensive biomarker, the pan-immune-inflammation value (PIV), and the prognosis of patients undergoing PD.

METHODS

We retrospectively analyzed data from a multicenter, large-sample PD database. PIV was calculated as (neutrophil count × platelet count × monocyte count)/lymphocyte count. The prognostic endpoints in this study were all-cause death all-cause, cardiovascular disease (CVD) and infection-related death. The Kaplan-Meier method, a Cox proportional hazards regression, Fine-Gray competing risk model, smooth curve, and subgroup analysis were used to analyze the independent relationship between PIV and the prognosis of patients undergoing PD.

RESULTS

A total of 2796 cases of PD were included, and the study population was divided into Tertiles 1, 2, and 3, according to the tertiles of baseline PIVs. After adjusting for multiple model factors, patients in the Tertile 3 group had a significantly higher risk of all-cause death, CVD death and infection-related death compared with patients with PIV in the Tertile 1 group. Interaction tests showed no positive correlations for subgroup parameters. Regarding all-cause death, compared with the lowest tertile, the multivariable-adjusted hazard ratios (95% confidence intervals) of the highest and middle tertiles were 1.55 (1.25-1.94) and 1.77 (1.43-2.19), respectively; PIV (log2 processing) was associated with 17% excess of mortality in the continuous model.

CONCLUSIONS

A high PIV at baseline was significantly associated with an increased risk of deaths due to all-causes, CVD and infection in patients undergoing PD.

Hyperglycolysis in endothelial cells drives endothelial injury and microvascular alterations in peritoneal dialysis

BACKGROUND

Endothelial cell (EC) dysfunction leading to microvascular alterations is a hallmark of technique failure in peritoneal dialysis (PD). However, the mechanisms underlying EC dysfunction in PD are poorly defined.

METHODS

We combined RNA sequencing with metabolite set analysis to characterize the metabolic profile of peritoneal ECs from a mouse model of PD. This was combined with EC-selective blockade of glycolysis by genetic or pharmacological inhibition of 6-phosphofructo-2-kinase/fructose-2,6-biphosphatase 3 (PFKFB3) in vivo and in vitro. We also investigated the association between peritoneal EC glycolysis and microvascular alterations in human peritoneal samples from patients with end-stage kidney disease (ESKD).

RESULTS

In a mouse model of PD, peritoneal ECs had a hyperglycolytic metabolism that shunts intermediates into nucleotide synthesis. Hyperglycolytic mouse peritoneal ECs displayed a unique active phenotype with increased proliferation, permeability and inflammation. The active phenotype of mouse peritoneal ECs can be recapitulated in human umbilical venous ECs and primary human peritoneal ECs by vascular endothelial growth factor that was released from high glucose-treated mesothelial cells. Importantly, reduction of peritoneal EC glycolysis, via endothelial deficiency of the glycolytic activator PFKFB3, inhibited PD fluid-induced increases in peritoneal capillary density, vascular permeability and monocyte extravasation, thereby protecting the peritoneum from the development of structural and functional damages. Mechanistically, endothelial PFKFB3 deficiency induced the protective effects in part by inhibiting cell proliferation, VE-cadherin endocytosis and monocyte-adhesion molecule expression. Pharmacological PFKFB3 blockade induced a similar therapeutic benefit in this PD model. Human peritoneal tissue from patients with ESKD also demonstrated evidence of increased EC PFKFB3 expression associated with microvascular alterations and peritoneal dysfunction.

CONCLUSIONS

These findings reveal a critical role of glycolysis in ECs in mediating the deterioration of peritoneal function and suggest that strategies targeting glycolysis in peritoneal ECs may be of therapeutic benefit for patients undergoing PD.

Inhibition of EZH2 mitigates peritoneal fibrosis and lipid precipitation in peritoneal mesothelial cells mediated by klotho

BACKGROUND

Peritoneal fibrosis caused by long-term peritoneal dialysis (PD) is the main reason why patients withdraw from PD treatment. Lipid accumulation in the peritoneum was shown to participate in fibrosis, and klotho is a molecule involved in lipid metabolism. GSK343 (enhancer of zeste 2 polycomb repressive complex 2 subunit (EZH2) inhibitor) has been verified to inhibit epithelial mesenchymal transdifferentiation (EMT) and peritoneal fibrosis, but its related mechanism remains unclear. This study aimed to investigate whether lipid accumulation was involved in the effect of GSK343 and its related mechanism.

MATERIALS AND METHODS

First, the expression of EZH2, klotho and EMT indices in human peritoneal mesothelial cells (HMrSV5) incubated with high glucose (HG) levels was detected. After EZH2 was inhibited by GSK343, Western blot (WB), wound healing and Transwell assays were used to explore the effect of GSK343. EZH2 and klotho expression was also detected. Oil red O and Nile red staining and triglyceride (TG) detection kits were used to detect lipid accumulation. A rescue experiment with small interfering RNA specific for klotho (si-klotho) on the basis of GSK343 was also conducted to verify that GSK343 exerted its effect via klotho. In in vivo experiments, rats were administered GSK343, and the related index was assessed.

RESULTS

In our study, we revealed that the expression of EZH2 was significantly upregulated and klotho was significantly downregulated in HMrSV5 cells induced by high glucose. With the aid of GSK343, we found that lipid deposition caused by HG was significantly decreased. In addition, EMT and fibrosis were also significantly alleviated. Moreover, GSK343 could also restore the downregulation of klotho. To further verify whether klotho mediated the effect of EZH2, a rescue experiment with si-klotho was also conducted. The results showed that si-klotho could counteract the protective effect of GSK343 on high glucose-induced lipid accumulation and fibrosis. In vivo experiments also revealed that GSK343 could relieve peritoneal fibrosis, lipid deposition and EMT by mitigating EZH2 and restoring klotho expression.

CONCLUSIONS

Combining these findings, we found that EZH2 regulated lipid deposition, peritoneal fibrosis, and EMT mediated by klotho. To our knowledge, this is the first study to demonstrate the effect of the EZH2-klotho interaction on peritoneal fibrosis. Hence, EZH2 and klotho could act as potential targets for the treatment of peritoneal fibrosis.

The body mass index change is associated with death or hemodialysis transfer in Japanese patients initiating peritoneal dialysis

A decreased body mass index (BMI) over time is associated with a poor prognosis for patients on hemodialysis. We aimed to examine whether this association also applies to patients with peritoneal dialysis (PD). BMI change was defined as the percentage change in the BMI between the time of PD catheter insertion and six months after its insertion. The association between the BMI change and all-cause mortality or PD discontinuation from six months after PD catheter insertion until October 2021 was investigated. This retrospective cohort study included 122 patients (aged 61.1 ± 12.1 years; 90 males) who underwent PD catheter insertion between January 2008 and March 2020. The median follow-up period was 43.1 (21.2-78.8) months. The median six-month percentage change in the BMI was -2.14 (-5.56-1.84)%, and patients were categorized into tertiles based on their BMI changes. The fully-adjusted Cox regression analysis revealed a significantly higher rate of PD discontinuation or all-cause mortality (hazard ratio (HR): 2.48; 95%; confidence interval (CI): 1.41-4.37) in patients with the lowest tertile (T1, BMI change: < -4.13%) compared to patients with the middle tertile (T2, BMI change: -4.13%-0.67%). The risk was not significantly higher in patients with the highest tertile (T3, BMI change: >0.67%) than those in the T2 group (HR: 1.18; 95% CI: 0.66-2.11). A decreased BMI over time is independently associated with HD transfer or all-cause mortality among patients initiating PD, which highlights the importance of the 6-month BMI change as a novel prognostic marker.