Peritoneal Dialysis

Intra-abdominal pressure and residual renal function decline in peritoneal dialysis: a threshold-based investigation

BACKGROUND

The potential impact of elevated intra-abdominal pressure (IAP) on residual renal function (RRF) has not been determined. The objective of this study was to investigate the relationship between IAP and the rate of RRF decline in newly initiated peritoneal dialysis (PD) patients, and to identify the optimal IAP threshold value for delaying the deterioration of RRF.

METHODS

A cohort of 62 newly initiated PD patients who completed both 6- and 12-month follow-up evaluations was obtained using the Durand method. A logistic regression model was used to identify variables associated with a rapid decline in RRF. Receiver operating characteristic (ROC) curves were generated to determine the optimal threshold value. Another retrospective cohort analysis was performed to validate the identified critical value.

RESULTS

For each 1 cmH2O increase in IAP, the risk of a rapid decline in the RRF increased by a factor of 1.679. Subsequent analysis revealed that patients in the high IAP group had more significant decreases in residual renal estimated glomerular filtration rate (eGFR) (Z = -3.694, p < 0.001) and urine volume (Z = -3.121, p < 0.001) than did those in the non-high IAP group. Furthermore, an IAP ≥15.65 cmH2O was a robust discriminator for the prediction of the rate of RRF decline.

CONCLUSION

Patients in the high IAP group experienced a more rapid decline in RRF. Additionally, an optimal critical pressure of 15.65 cmH2O was identified for predicting the rate of RRF decline. IAP, as one of the factors contributing to the rapid decline in RRF in the first year of PD, should be given due attention.

Peritoneal Dialysis Aggravates and Accelerates Atherosclerosis in Uremic ApoE-/- Mice

BACKGROUND

Atherosclerosis is highly prevalent in people with chronic kidney disease (CKD), including those receiving peritoneal dialysis (PD). Although it is lifesaving, PD induces profound systemic inflammation, which may aggravate atherosclerosis. Therefore, the hypothesis is that this PD-induced inflammation aggravates atherosclerosis via immune cell activation.

METHODS AND RESULTS

ApoE-/- mice were subjected to a 5/6 nephrectomy to induce CKD. Three weeks later, mice were fed a high-cholesterol diet. Half of the nephrectomized mice then received daily peritoneal infusions of 3.86% Physioneal for 67 further days (CKD+PD) until the end of the experiment, and were compared with mice without CKD. Sham operated and PD-only mice were additional controls. CKD+PD mice displayed more severe atherosclerotic disease than control mice. Plaque area increased, and plaques were more advanced with a vulnerable phenotype typified by decreased collagen content and decreased fibrous cap thickness. Increased CD3+ T-cell numbers were present in plaques and perivascular adipose tissue of CKD and CKD+PD mice. Plaques of CKD+PD mice contained more iNOS+ immune cells. Spleens of CKD+PD mice showed more CD4+ central memory, terminally differentiated type 1 T-helper (Th1), Th17, and CX3C motif chemokine receptor 1+ (CX3CR1) CD4+ T-cells with less regulatory and effector T-cells.

CONCLUSIONS

PD-fluid exposure in uremic mice potentiates systemic and vascular T-cell-driven inflammation and aggravates atherosclerosis. PD polarized CD4+ T-cells toward an inflammatory Th1/Th17 phenotype, and increased CX3CR1+ CD4+ T-cells, which are associated with vascular homing in CKD-associated atherosclerosis. Targeting CD4+ T-cell activation and CX3CR1+ polarization has the potential to attenuate atherosclerosis in PD patients.

Effects of sodium-glucose co-transporter 2 inhibitors on ultrafiltration in patients with peritoneal dialysis: a protocol for a randomized, double-blind, placebo-controlled, crossover trial (EMPOWERED)

BACKGROUND

Volume overload is common and associated with high mortality in patients on peritoneal dialysis (PD). Traditional strategies including diuretics, water/salt restriction, and icodextrin-based solutions cannot always fully correct this condition, necessitating novel alternative strategies. Recent studies confirmed the expression of sodium-glucose cotransporter 2 (SGLT2) in the human peritoneum. Experimental data suggest that SGLT2 inhibitors decrease glucose absorption from the PD solution, thereby increasing the ultrafiltration volume. This trial aims to assess whether SGLT2 inhibitors increase the ultrafiltration volume in patients on PD.

METHODS

The EMPOWERED trial (trial registration: jRCTs051230081) is a multicenter, randomized, double-blind, placebo-controlled, crossover trial. Patients with clinically diagnosed chronic heart failure are eligible regardless of the presence of diabetes if they use at least 3 L/day glucose-based PD solutions. Participants will be randomly assigned (1:1) to receive empagliflozin 10 mg once daily and then placebo or vice versa. Each treatment period will last 8 weeks with a 4-week washout period. This study will recruit at least 36 randomized participants. The primary endpoint is the change in the daily ultrafiltration volume from baseline to week 8 in each intervention period. The key secondary endpoints include changes in the biomarkers of drained PD solutions, renal residual function, and anemia-related parameters.

CONCLUSIONS

This trial aims to assess the benefit of SGLT2 inhibitors in fluid management with a novel mechanism of action in patients on PD. It will also provide insights into the effects of SGLT2 inhibitors on solute transport across the peritoneal membrane and residual renal function.

Nursing management of catheter-related non-infectious complications of PD: Your questions answered

A review from the last seven years (August 2016-July 2023) of questions posted to the International Society for Peritoneal Dialysis (ISPD) website "Questions about PD" by nurses and physicians from around the world revealed that 19 of the questions were associated with optimal approaches for preventing, assessing, and managing issues related to PD catheter non-infectious complications. Our review focused on responses to these questions whereby existing best practice recommendations were considered, if available, relevant literature was cited and differences in international practices discussed. We combined similar questions, revised both the original questions and responses for clarity, as well as updated the references to these questions. PD catheter non-infectious complications can often be prevented or, with early detection, the potential severity of the complication can be minimized. We suggest that the PD nurse is key to educating the patient on PD about PD catheter non-infectious complications, promptly recognize a specific complication and bring that complication to the attention of the Home Dialysis Team. The questions posted to the ISPD website highlight the need for more education and resources for PD nurses worldwide on the important topic of non-infectious complications related to PD catheters, thereby enabling us to prevent such complications as PD catheter malfunction, peri-catheter leakage and infusion or drain pain, as well as recognize and resolve these issues promptly when they do arise, thus allowing patients to extend their time on PD therapy and enhance their quality of life whilst on PD.

Renal health: Evaluation of the spontaneous use of a new m-health technology and validation of its content to support patients undergoing peritoneal dialysis

INTRODUCTION

Chronic kidney disease is a worldwide public health problem, with a high prevalence of patients on dialysis. mHealth technologies can greatly support the treatment and monitoring of these patients. Thus, this study aimed to evaluate the spontaneous use of the application (app) Renal Health, a previously available technology, for patients on hemodialysis and validate content to support patients undergoing peritoneal dialysis.

METHODS

The first stage consisted of evaluating the spontaneous use of the app, and the second stage consisted of methodological research for the development, evaluation, and improvement of a technological instrument for use in clinical practice as a support for patients undergoing peritoneal dialysis (PD). The association between categorical variables was performed using the chi-square test, adopting a significance level of 5%.

RESULTS

The app was accessed by 753 users and of these, 34 % accessed the hemodialysis section. Most accesses were in the state of São Paulo/Brazil and performed by women. The records of biochemical tests did not vary according to gender and age group (p > 0.05). The developed and validated PD section enables section control, allowing the user to manage their sessions. The analysis of the technology by the specialists showed good results for the global content validity index (CVI) regarding objectives (CVI = 0.95), structure (CVI = 0.97), and relevance (CVI = 1.0).

CONCLUSION

It is concluded that the hemodialysis section of the Renal Health app aroused the interest of the population and that the developed peritoneal dialysis section was validated by specialists.

Assisted peritoneal dialysis in Europe: a strategy to increase and maintain home dialysis

Peritoneal dialysis (PD) is a form of kidney replacement therapy with the major advantage that it can be performed at home. This has a positive impact on patients' autonomy and quality of life. However, the dialysis population is ageing and physical and/or cognitive impairments are common. These limitations often form a barrier to PD and contribute to the low incidence and prevalence of PD in Europe. Assisted PD can be a solution to this problem. Assisted PD refers to a patient being assisted by a person or device in performing all or part of their dialysis-related tasks, thereby making PD more accessible to elderly but also younger frail patients. In this way, offering an assisted PD program can help lower the threshold for initiating PD. In this review, we provide an overview of the epidemiology of assisted PD in Europe, we discuss the different categories and clinical outcomes of assisted PD, and we present how assisted PD can be implemented in clinical practice as a possible strategy to increase and maintain home dialysis in Europe.

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.

The Carbon Footprint of Peritoneal Dialysis in Australia

Key Points

Background

As climate change escalates with increasing health impacts, health care must address its carbon footprint. The first critical step is understanding the sources and extent of emissions from commonly utilized clinical care pathways.

Methods

We used attributional process-based life-cycle analysis to quantify CO2 equivalent emissions associated with the delivery of Baxter’s HomeChoice automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD) in Australia.

Results

The annual per-patient carbon emissions attributable to the manufacture and disposal of peritoneal dialysis (PD) fluids and consumables were 1992 kg CO2 equivalent emissions for APD and 1245 kg CO2 equivalent emissions for CAPD. Transport impacts varied depending on the distance between the site of manufacture of PD fluids and consumables and the state of origin of the patient. Therefore, the total impact of providing PD also differed by Australian state, ranging from 2350 to 4503 kg CO2 equivalent emissions for APD and from 1455 to 2716 kg CO2 equivalent emissions for CAPD. Recycling of polyvinyl chloride (PVC) could reduce emissions by up to 14% for APD and 30% for CAPD depending on the distance between the site of PVC waste generation and the recycling center.

Conclusions

This study demonstrated higher per-patient carbon emissions from APD compared with CAPD, owing to both higher fluid and consumable requirements and the consequent higher transport impacts. PVC recycling can partially mitigate PD-associated carbon emissions.

Glycosylation and Characterization of Human Transferrin in an End-Stage Kidney Disease

Chronic kidney disease (CKD) is a global health concern affecting approximately one billion individuals worldwide. End-stage kidney disease (ESKD), the most severe form of CKD, is often accompanied by anemia. Peritoneal dialysis (PD), a common treatment for ESKD, utilizes the peritoneum for solute transfer but is associated with complications including protein loss, including transferrin (Tf) a key protein involved in iron transport. This study investigated Tf characteristics in ESKD patients compared to healthy individuals using lectin microarray, spectroscopic techniques and immunocytochemical analysis to assess Tf interaction with transferrin receptors (TfRs). ESKD patients exhibited altered Tf glycosylation patterns, evidenced by significant changes in lectin reactivity compared to healthy controls. However, structural analyses revealed no significant differences in the Tf secondary or tertiary structures between the two groups. A functional analysis demonstrated comparable Tf-TfR interaction in both PD and healthy samples. Despite significant alterations in Tf glycosylation, structural integrity and Tf-TfR interaction remained preserved in PD patients. These findings suggest that while glycosylation changes may influence iron metabolism, they do not impair Tf function. The study highlights the importance of a glucose-free dialysis solutions in managing anemia exacerbation in PD patients with poorly controlled anemia, potentially offering a targeted therapeutic approach to improve patient outcomes.

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.

Muscularity and adiposity are differently associated with inflammatory and nutritional biomarkers among patients on hemodialysis and peritoneal dialysis

PURPOSE

Nutritional alterations are prevalent in patients undergoing hemodialysis (HD) and peritoneal dialysis (PD). We aimed at evaluating whether body composition parameters in HD vs PD are differently associated with nutritional and inflammatory biomarkers.

METHODS

Body composition was assessed by bioimpedance analysis. Neutrophil to lymphocyte ratio (NLR), serum albumin and C-reactive protein were used as nutritional and inflammatory biomarkers. Multivariable linear regression analysis was used to determine association(s) of body composition parameters with biomarkers.

RESULTS

We enrolled a total of 108 patients, 58 on HD and 50 on PD. Fat free mass percent was higher in HD patients than PD (p = 0.006) and higher extracellular water (ECW)/intracellular water (ICW) in HD compared to PD patients (p = 0.023), as well as fat mass index was greater in PD than HD (p = 0.004). In HD patients, albumin positively correlated with fat free mass (r = 0.42; p = 0.001) and ICW/h2 (r = 0.31; p = 0.02). In PD, NLR positively correlated with fat mass (r = 0.36; p = 0.01), fat mass index (r = 0.37; p = 0.01) and ECW (r = 0.41; p = 0.005), and negatively correlated with fat free mass percent (r = -0.30; p = 0.04) and ICW percent (r = -0.34; p = 0.02). By linear regression analysis, in HD fat free mass index was associated with albumin and the absence of diabetes. In PD, the association of fat free mass index was present with NLR. Regarding adiposity, in HD we found no association of ECW/ICW with NLR and CRP, whereas in PD the ECW/ICW was associated with NLR.

CONCLUSION

Inflammation drives body composition changes with differences according to the type of dialysis, as expressed by the modulation of some circulating biomarkers.

The prognostic values of estimating intraperitoneal pressure in the occurrence of abdominal wall complications in peritoneal dialysis patients

BACKGROUND

Increased intraperitoneal pressure is associated with abdominal wall complications and technical failure of peritoneal dialysis (PD). Several equations have been developed to estimate intraperitoneal pressure. We aimed to assess the prognostic yield of the intraperitoneal pressure as estimated by current equations on the occurrence of abdominal wall complications in peritoneal dialysis patients.

METHODS

This is a retrospective analysis of data from a prospective cohort which recruited 1207 incident PD patients. Estimated intraperitoneal pressure was calculated using four available equations (according to Sigogne, Castellanos, Scanziani and de Jesus Ventura). Abdominal wall complications were recorded during follow-up. Univariate analysis and multivariate analysis with competing risk regression were used to assess the predictive power of the estimates of intraperitoneal pressure in the occurrence of abdominal wall complications.

RESULTS

During a median follow-up of 30 months, 66 (5.5%) patients (1.6/100 patient-years) developed abdominal wall complications. The median time to the occurrence of abdominal wall complications was 5.7 months. Only the estimated intraperitoneal pressure by the de Jesus Ventura equation significantly predicted abdominal wall complications by using univariate analyses. Associations between estimated intraperitoneal pressure by the de Jesus Ventura equation and the occurrence of abdominal wall complications disappeared after adjusting for significant clinical factors.

CONCLUSIONS

We verified the prognostic value of estimation of intraperitoneal pressure by four available equations in predicting abdominal wall complications in our single-center PD cohort. Due to a low diagnostic yield, a novel equation for estimating the intraperitoneal pressure is urgently needed.

Integrative analysis of chromatin accessibility and transcriptome landscapes in the induction of peritoneal fibrosis by high glucose

BACKGROUND

Peritoneal fibrosis is the prevailing complication induced by prolonged exposure to high glucose in patients undergoing peritoneal dialysis.

METHODS

To elucidate the molecular mechanisms underlying this process, we conducted an integrated analysis of the transcriptome and chromatin accessibility profiles of human peritoneal mesothelial cells (HMrSV5) during high-glucose treatment.

RESULTS

Our study identified 2775 differentially expressed genes (DEGs) related to high glucose-triggered pathological changes, including 1164 upregulated and 1611 downregulated genes. Genome-wide DEGs and network analysis revealed enrichment in the epithelial-mesenchymal transition (EMT), inflammatory response, hypoxia, and TGF-beta pathways. The enriched genes included VEGFA, HIF-1α, TGF-β1, EGF, TWIST2, and SNAI2. Using ATAC-seq, we identified 942 hyper (higher ATAC-seq signal in high glucose-treated HMrSV5 cells than in control cells) and 714 hypo (lower ATAC-seq signal in high glucose-treated HMrSV5 cells versus control cells) peaks with differential accessibility in high glucose-treated HMrSV5 cells versus controls. These differentially accessible regions were positively correlated (R = 0.934) with the nearest DEGs. These genes were associated with 566 up- and 398 downregulated genes, including SNAI2, TGF-β1, HIF-1α, FGF2, VEGFA, and VEGFC, which are involved in critical pathways identified by transcriptome analysis. Integrated ATAC-seq and RNA-seq analysis also revealed key transcription factors (TFs), such as HIF-1α, ARNTL, ELF1, SMAD3 and XBP1. Importantly, we demonstrated that HIF-1α is involved in the regulation of several key genes associated with EMT and the TGF-beta pathway. Notably, we predicted and experimentally validated that HIF-1α can exacerbate the expression of TGF-β1 in a high glucose-dependent manner, revealing a novel role of HIF-1α in high glucose-induced pathological changes in human peritoneal mesothelial cells (HPMCs).

CONCLUSIONS

In summary, our study provides a comprehensive view of the role of transcriptome deregulation and chromosome accessibility alterations in high glucose-induced pathological fibrotic changes in HPMCs. This analysis identified hub genes, signaling pathways, and key transcription factors involved in peritoneal fibrosis and highlighted the novel glucose-dependent regulation of TGF-β1 by HIF-1α. This integrated approach has offered a deeper understanding of the pathogenesis of peritoneal fibrosis and has indicated potential therapeutic targets for intervention.

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.

Partial replacement of d-glucose with d-allose ameliorates peritoneal injury and hyperglycaemia induced by peritoneal dialysis fluid in rats

BACKGROUND

Peritoneal dialysis (PD) is a crucial dialysis method for treating end-stage kidney disease. However, its use is restricted due to high glucose-induced peritoneal injury and hyperglycaemia, particularly in patients with diabetes mellitus. In this study, we investigated whether partially replacing d-glucose with the rare sugar d-allose could ameliorate peritoneal injury and hyperglycaemia induced by peritoneal dialysis fluid (PDF).

METHODS

Rat peritoneal mesothelial cells (RPMCs) were exposed to a medium containing d-glucose or d-glucose partially replaced with different concentrations of d-allose. Cell viability, oxidative stress and cytokine production were evaluated. Sprague-Dawley (SD) rats were administrated saline, a PDF containing 4% d-glucose (PDF-G4.0%) or a PDF containing 3.6% d-glucose and 0.4% d-allose (PDF-G3.6%/A0.4%) once a day for 4 weeks. Peritoneal injury and PD efficiency were assessed using immuno-histological staining and peritoneal equilibration test, respectively. Blood glucose levels were measured over 120 min following a single injection of saline or PDFs to 24-h fasted SD rats.

RESULTS

In RPMCs, the partial replacement of d-glucose with d-allose increased cell viability and decreased oxidative stress and cytokine production compared to d-glucose alone. Despite the PDF-G3.6%/A0.4% having a lower d-glucose concentration compared to PDF-G4.0%, there were no significant changes in osmolality. When administered to SD rats, the PDF-G3.6%/A0.4% suppressed the elevation of peritoneal thickness and blood d-glucose levels induced by PDF-G4.0%, without impacting PD efficiency.

CONCLUSIONS

Partial replacement of d-glucose with d-allose ameliorated peritoneal injury and hyperglycaemia induced by high concentration of d-glucose in PDF, indicating that d-allose could be a potential treatment option in PD.

Intercellular communication in peritoneal dialysis

Long-term peritoneal dialysis (PD) causes structural and functional alterations of the peritoneal membrane. Peritoneal deterioration and fibrosis are multicellular and multimolecular processes. Under stimulation by deleterious factors such as non-biocompatibility of PD solution, various cells in the abdominal cavity show differing characteristics, such as the secretion of different cytokines, varying protein expression levels, and transdifferentiation into other cells. In this review, we discuss the role of various cells in the abdominal cavity and their interactions in the pathogenesis of PD. An in-depth understanding of intercellular communication and inter-organ communication in PD will lead to a better understanding of the pathogenesis of this disease, enabling the development of novel therapeutic targets.

Mortality of Peritoneal Dialysis versus Hemodialysis in Older Adults: An Updated Systematic Review and Meta-Analysis

INTRODUCTION

The optimal choice of dialysis modality remains contentious in older adults threatened by advanced age and high risk of comorbidities.

METHODS

We conducted a systematic review and meta-analysis of cohort and case-control studies to assess mortality risk between peritoneal dialysis (PD) and hemodialysis (HD) in older adults using PubMed, Embase, and the Cochrane Library database from inception to June 1, 2022. The outcome of interest is all-cause mortality.

RESULTS

Thirty-one eligible studies with >774,000 older patients were included. Pooled analysis showed that PD had a higher mortality rate than HD in older dialysis population (HR 1.17, 95% CI: 1.10-1.25). When stratified by co-variables, our study showed an increased mortality risk of PD versus HD in older patients with diabetes mellitus or comorbidity who underwent longer dialysis duration (more than 3 years) or who started dialysis before 2010. However, definitive conclusions were constrained by significant heterogeneity.

CONCLUSION

From the survival point of view, caution is needed to employ PD for long-term use in older populations with diabetes mellitus or comorbid conditions. However, a tailored treatment choice needs to take account of what matters to older adults at an individual level, especially in the context of limited survival improvements and loss of quality of life. Further research is still awaited to conclude this topic.

2-Deoxy-glucose ameliorates the peritoneal mesothelial and endothelial barrier function perturbation occurring due to Peritoneal Dialysis fluids exposure

Peritoneal dialysis (PD) and prolonged exposure to PD fluids (PDF) induce peritoneal membrane (PM) fibrosis and hypervascularity, leading to functional PM degeneration. 2-deoxy-glucose (2-DG) has shown potential as PM antifibrotic by inhibiting hyper-glycolysis induced mesothelial-to-mesenchymal transition (MMT). We investigated whether administration of 2-DG with several PDF affects the permeability of mesothelial and endothelial barrier of the PM. The antifibrotic effect of 2-DG was confirmed by the gel contraction assay with embedded mesothelial (MeT-5A) or endothelial (EA.hy926) cells cultured in Dianeal® 2.5 % (CPDF), BicaVera® 2.3 % (BPDF), Balance® 2.3 % (LPDF) with/without 2-DG addition (0.2 mM), and qPCR for αSMA, CDH2 genes. Moreover, 2-DG effect was tested on the permeability of monolayers of mesothelial and endothelial cells by monitoring the transmembrane resistance (RTM), FITC-dextran (10, 70 kDa) diffusion and mRNA expression levels of CLDN-1 to -5, ZO1, SGLT1, and SGLT2 genes. Contractility of MeT-5A cells in CPDF/2-DG was decreased, accompanied by αSMA (0.17 ± 0.03) and CDH2 (2.92 ± 0.29) gene expression fold changes. Changes in αSMA, CDH2 were found in EA.hy926 cells, though αSMA also decreased under LPDF/2-DG incubation (0.42 ± 0.02). Overall, 2-DG mitigated the PDF-induced alterations in mesothelial and endothelial barrier function as shown by RTM, dextran transport and expression levels of the CLDN-1 to -5, ZO1, and SGLT2. Thus, supplementation of PDF with 2-DG not only reduces MMT but also improves functional permeability characteristics of the PM mesothelial and endothelial barrier.

Pleural effusion portends a poor prognosis in patients on continuous ambulatory peritoneal dialysis

AIMS

Pleural effusion is not an infrequent complication in patients undergoing continuous ambulatory peritoneal dialysis. However, there is not adequate data to evaluate pleural effusion and prognosis in clinical practice. In this study, we validated this potential association by a multicenter cohort.

METHODS

We screened 1,162 patients who met the inclusion criteria with PD. According to the existence of pleural effusion on stable dialysis (4-8 weeks after dialysis initiation), the participants were divided into pleural effusion and non-pleural effusion groups. The hazard ratios (HRs) of all-cause and cause-specific death were estimated with adjustment for demographic characteristics and multiple potential clinical confounders. Subgroup analysis and propensity score matching (PSM) were used to further verify the robustness of the correlation between hydrothorax and prognosis.

RESULTS

Pleural effusion was found in 8.9% (104/1162) of PD individuals. After adjusting for the confounding factors, patients with pleural effusion had significantly increased HRs for all-cause death was 3.06 (2.36-3.96) and cardiovascular death was 3.78 (2.67-5.35) compared to those without pleural effusion. However, it was not associated with infectious and other causes of death. After PSM, the HR of all-cause mortality was 3.56 (2.28-5.56). The association trends were consistent in the subgroup sensitivity analysis.

CONCLUSION

Pleural effusion is not rare in PD, and is significantly associated with overall and cardiovascular mortality, which is independent of underlying diseases and clinically relevant indicators.

Network pharmacology, molecular docking and experimental verification of the mechanism of huangqi-jixuecao herb pair in treatment of peritoneal fibrosis

ETHNOPHARMACOLOGICAL RELEVANCE

The Huangqi-Jixuecao herb pair (HQJXCHP) is a traditional herbal formula composed of two widely applied TCM prescriptions, Huangqi (Astragalus membranaceus (Fisch.) Bunge) and Jixuecao (Centella asiatica (L.) Urb.), used for hundreds of years to replenish qi and clear away heat. However, the therapeutic effects of HQJXCHP against peritoneal fibrosis (PF) and potential targets are currently unclear.

AIMS OF THE STUDY

The main objective of this study was preliminary prediction and validation of the effects and molecular mechanisms of action of HQJXCHP against PF based on network pharmacology analysis and experimental verification.

MATERIALS AND METHODS

The ingredients of HQJXCHP were analyzed via HPLC-Q-TOF/MS. Bioactive compounds of HQJXCHP used for network pharmacology analysis were obtained from the TCMSP database. HQJXCHP-related therapeutic targets in PF were obtained from the GeneCards, OMIM, Therapeutic Targets and PharmGkb databases. Therapeutic target-related signaling pathways were predicted via GO and KEGG pathway enrichment analyses. The targets of HQJXCHO were further validated in a PDS-induced PF mouse model in vivo and PMCs MMT model in vitro.

RESULTS

A total of 23 bioactive compounds of HQJXCHP related 188 target genes were retrieved. The HQJXCHP compound-target and PF-related target networks identified 131 common target genes. Subsequent protein-protein interaction (PPI) network analysis results disclosed Akt1, TP53, TNF, VEGFA and CASP3 as the top five key targets of HQJXCHP. Further molecular docking data revealed strong affinity of the two key compounds of HQJXCHP, quercetin and kaempferol, for these key targets. GO and KEGG pathway enrichment analyses further showed that PI3K/Akt, IL-17, TNF and TLR pathways contribute to the therapeutic effects of HQJXCHP on PF. An in vivo PDS-induced PF mouse model and in vitro PMCs mesothelial-to-mesenchymal transition (MMT) model with or without HQJXCHP intervention were used to confirm the effects and mechanisms of action of HQJXCHP. Western blot and qRT-PCR results showed that HQ, JXC and HQJXCHP reduced PDS-induced inflammatory cell aggregation and peritoneal thickening through suppressing the MMT process, among which HQJXCHP exerted the greatest therapeutic effect. Moreover, HQJXCHP inhibited activation of the PI3K/Akt, IL-17, TNF and TLR signaling pathways induced by PDS.

CONCLUSIONS

This is the first study to employ network pharmacology and molecular docking analyses to predict the targets of HQJXCHP with therapeutic effects on PDS-related PF. Data from in vivo and in vitro validation experiments collectively showed that HQJXCHP delays the PF process through inhibiting PI3K/Akt, IL-17, TNF and TLR signaling pathways. Overall, our findings highlight the successful application of network pharmacology theory to provide a scientific basis for clinical utility of HQJXCHP against PF.

Machine learning algorithms for the prediction of adverse prognosis in patients undergoing peritoneal dialysis

BACKGROUND

An appropriate prediction model for adverse prognosis before peritoneal dialysis (PD) is lacking. Thus, we retrospectively analysed patients who underwent PD to construct a predictive model for adverse prognoses using machine learning (ML).

METHODS

A retrospective analysis was conducted on 873 patients who underwent PD from August 2007 to December 2020. A total of 824 patients who met the inclusion criteria were included in the analysis. Five commonly used ML algorithms were used for the initial model training. By using the area under the curve (AUC) and accuracy (ACC), we ranked the indicators with the highest impact and displayed them using the values of Shapley additive explanation (SHAP) version 0.41.0. The top 20 indicators were selected to build a compact model that is conducive to clinical application. All model-building steps were implemented in Python 3.8.3.

RESULTS

At the end of follow-up, 353 patients withdrew from PD (converted to haemodialysis or died), and 471 patients continued receiving PD. In the complete model, the categorical boosting classifier (CatBoost) model exhibited the strongest performance (AUC = 0.80, 95% confidence interval [CI] = 0.76-0.83; ACC: 0.78, 95% CI = 0.72-0.83) and was selected for subsequent analysis. We reconstructed a compression model by extracting 20 key features ranked by the SHAP values, and the CatBoost model still showed the strongest performance (AUC = 0.79, ACC = 0.74).

CONCLUSIONS

The CatBoost model, which was built using the intelligent analysis technology of ML, demonstrated the best predictive performance. Therefore, our developed prediction model has potential value in patient screening before PD and hierarchical management after PD.

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.

Mortality prediction with adaptive feature importance recalibration for peritoneal dialysis patients

The study aims to develop AICare, an interpretable mortality prediction model, using electronic medical records (EMR) from follow-up visits for end-stage renal disease (ESRD) patients. AICare includes a multichannel feature extraction module and an adaptive feature importance recalibration module. It integrates dynamic records and static features to perform personalized health context representation learning. The dataset encompasses 13,091 visits and demographic data of 656 peritoneal dialysis (PD) patients spanning 12 years. An additional public dataset of 4,789 visits from 1,363 hemodialysis (HD) patients is also considered. AICare outperforms traditional deep learning models in mortality prediction while retaining interpretability. It uncovers mortality-feature relationships and variations in feature importance and provides reference values. An AI-doctor interaction system is developed for visualizing patients' health trajectories and risk indicators.

Implementation of artificial intelligence Chatbot in peritoneal dialysis nursing care: Experience from a Taiwan medical center

PURPOSE

Coronavirus disease pandemic makes high requirements in delivering remote and efficient communication, and patient education. Because of the increases of digital and social media applications in Taiwan, we aim to apply Artificial Intelligence of LINE Chatbot to improve the self-care ability of patients undergoing peritoneal dialysis.

MATERIALS AND METHODS

We conducted the project since 1 May 2021 to 30 April 2022. We designed an automatically replied Chatbot system, and divided into six scopes of interaction interfaces, including peritoneal dialysis technique operation video, clinical reminder, home caring, hospital registration service, dietary guideline, and Automatic Peritoneal dialysis guidance. We surveyed patients' satisfaction with the LINE Chatbot 3 months later by the Likert 1-5 score-based questionnaire and the higher score indicated higher satisfaction.

RESULTS

There were 440 patients who joined the PD AI Chatbot study and use the Chatbot, but the satisfaction questionnaire recovery rate was only 297 patients. We found that 91.7% of participants agreed 'Overall satisfaction with patient intelligent Chatbot application'. More than 4 points accounted for 86.6%. We traced every click in each section of the Chatbot and explored the potential scenario patients face. The Chatbot statistically significant reduced infection rate of exit site and tunnel infection before using (p = .049 and .024). Furthermore, peritonitis rate decreased from 0.93 to 0.8/100 patient month after using Artificial Intelligence technique. Peritoneal dialysis Artificial Intelligence Chatbot had similar effect with face-to-face education.

CONCLUSION

The innovative Chatbot allowed delivering remote and digital information's to improve patients' self-care ability. Peritoneal dialysis patients were highly recognized and satisfied with the tools. It deserves to further explore the long-term impact of Artificial Intelligence Chatbot in peritoneal dialysis care.

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.

Effects of Tiaopi Xiezhuo decoction on constipation and gut dysbiosis in patients with peritoneal dialysis

CONTEXT

A Chinese herbal formula, Tiaopi Xiezhuo decoction (TXD), is developed from a classical Chinese prescription Sanhuang Xiexin decoction.

OBJECTIVE

To investigate the regulatory effect of TXD on gut dysbiosis, as a treatment of constipation in patients with peritoneal dialysis (PD).

MATERIALS AND METHODS

The chemical content of TXD was assessed by high-performance liquid chromatography. A total of 29 PD patients were enrolled and treated with TXD orally (3 g crude drug/each/twice/day) for 3 months. Blood and faecal samples were collected at the beginning and end, to determine the changes in biochemical characteristics and gut microbial composition. The stool conditions were asked to be scored. Additional 30 healthy individuals were recruited as a control for the analysis of gut microbiota.

RESULTS

Although having no significant effects on serum biochemical characteristics, 3-month TXD intervention improved constipation in PD patients: decreased 80% abdominal distention (p < 0.01), increased 2.6-fold sloppy stools (p < 0.05) and eliminated hard stool completely (p < 0.01). The analysis of gut microbiota showed that, compared to the healthy group, the microbial richness was reduced in PD patients. After a 3-month TXD treatment, this reduced richness was raised, and Paraprevotella clara, Lachnospiraceae bacterium 2-146FA, Phascolarctobaterium succinatutens, Lachnospiraceae bacterium 2-1-58FAA, Fusobacterium mortiferum, and Prevotella copri were accumulated in the intestinal flora. Furthermore, the bacterial species enriched by TXD correlated with the improvement of constipation.

DISCUSSION AND CONCLUSIONS

TXD treatment may improve constipation by modulating gut dysbiosis in PD patients. These findings provide data to support the further application of TXD in the adjuvant treatment of PD.

The Removal of Uremic Solutes by Peritoneal Dialysis

ABSTRACT

Peritoneal dialysis (PD) is now commonly prescribed to achieve target clearances for urea or creatinine. The International Society for Peritoneal Dialysis has proposed however that such targets should no longer be imposed. The Society's new guidelines suggest rather that the PD prescription should be adjusted to achieve well-being in individual patients. The relaxation of treatment targets could allow increased use of PD. Measurement of solute levels in patients receiving dialysis individualized to relieve uremic symptoms could also help us identify the solutes responsible for those symptoms and then devise new means to limit their accumulation. This possibility has prompted us to review the extent to which different uremic solutes are removed by PD.

Decreased Peripheral Blood Lymphocyte Count Predicts Poor Treatment Response in Peritoneal Dialysis-Associated Peritonitis

Purpose

Peripheral blood lymphocyte counts is a pivotal parameter in assessing the host's immune response during maladies and the equilibrium of the immune system which has been found to correlate with various diseases progression and prognosis. However, there was no study on patients with peritoneal dialysis-associated peritonitis (PDAP). We sought to investigate the prognostic value of baseline peripheral blood lymphocyte count in PDAP patients.

Patients and methods

This retrospective study analyzed data from 286 PDAP patients over nine years. Episodes were categorized according to the tertiles of peripheral blood lymphocyte counts (Very Low Lymphocyte Count (VLLC) Group, <0.72×106/L; Low Lymphocyte Count (LLC) Group, 0.72-1.11×106/L; Normal Lymphocyte Count (NLC) Group, ≥ 1.11×106/L). Demographic, laboratory, and infection-related variables were analyzed. Cox regression and generalized estimating equation (GEE) models were used to estimate the association between lymphocyte counts and PDAP treatment failure, which included PD catheter removal and death.

Results

After adjusting for other potential predictors, decreased lymphocyte counts exhibited an incremental relationship with the risk of treatment failure. The VLLC group indicated a 270% (95% CI, 1.168-6.247, P=0.020) and 273% (95% CI, 1.028-7.269, P=0.044) increased venture of treatment failure in Cox regression and GEE analyses, respectively, compared with the NLC group. As a continuous variable, the restricted cubic spline showed a linear negative correlation between lymphocyte counts and the treatment failure risk (P for overall = 0.026). The multivariate model C (combined lymphocyte count with baseline age, sex, dialysis age, Charlson Comorbidity index (CCI), etiology of kidney failure, hemoglobin, albumin, total bilirubin and infection type) showed an area under the curve of 0.824 (95% CI, 0.767-0.881, P=0.001) for the prediction of treatment failure.

Conclusion

Lower lymphocyte counts are linked to increased PDAP treatment failure risk. This highlights lymphocyte count's potential as a prognostic indicator for PDAP.

Clinical risk factors for peritoneal dialysis withdrawal at different dialysis duration

BACKGROUND

The duration of patients maintained on peritoneal dialysis (PD) varied. This study investigated the clinical risk factors for PD withdrawal at different dialysis duration.

METHODS

Patients who initiated PD from 1994 to 2011 were recruited and followed for at least 10 years until 2021. Patients were grouped into four groups according to dialysis duration or time on treatment (TOT) when withdrew PD.

RESULTS

A cohort of 586 patients were enrolled (mean age of 54.9 years, median dialysis duration or TOT of 47.9 months). Patients who maintained PD for longer than 10 years were younger, with lower prevalence of diabetes, lower serum C-reactive protein (CRP) level and white blood cell (WBC) count, higher serum albumin and pre-albumin level, higher normalized protein catabolic rate (nPCR) and residual kidney function, and more common use of renin-angiotensin system inhibitors (RASi) at baseline (p < 0.05 for all). Peritonitis related death and ultrafiltration failure related HD transferring increased along with time on PD (p < 0.001). Old age, diabetes, low serum albumin, high WBC count, hypertensive nephropathy, and nonuse of RASi were associated with increased risk of non-transplantation related PD withdrawal (p < 0.05 for all). Low baseline CRP and use of RASi were independent predictors for long-term PD maintenance (p < 0.05 for all).

CONCLUSIONS

Long-term PD patients demonstrated young age, low prevalence of diabetes, better nutrition status, absence of inflammation, better residual kidney function, and higher proportion of RASi usage at baseline. Absence of inflammation and use of RASi were independently associated with long-term PD maintenance.

Association of Different Total Bilirubin Levels with Prognosis of Peritoneal Dialysis-Associated Peritonitis

Background and Objectives: Peritoneal dialysis-associated peritonitis (PDAP) poses significant challenges in peritoneal dialysis (PD) patient management and outcomes. Total bilirubin has gained attention due to its antioxidant and immunomodulatory properties. However, its relationship with PDAP prognosis remains underexplored. Materials and Methods: We conducted a retrospective single-center study involving 243 PDAP patients stratified into tertile-based groups according to total bilirubin levels. The association between total bilirubin levels and treatment failure risk was investigated through statistical analyses and restricted cubic spline curve analysis. Results: Our analysis revealed a non-linear correlation between total bilirubin levels and PDAP treatment failure risk. At total bilirubin levels below 8.24 µmol/L, a protective effect was observed, while levels exceeding this threshold heightened the risk of treatment failure. Conclusions: This study unveils a dual role of total bilirubin in PDAP prognosis. Below a certain threshold, it confers protection, while higher levels exacerbate the risk of treatment failure. These findings emphasize the need for further investigation in larger, multicenter prospective studies to validate and elucidate the mechanisms behind bilirubin's impact on PDAP, potentially guiding the development of targeted therapeutic strategies.

Tamoxifen exerts anti-peritoneal fibrosis effects by inhibiting H19-activated VEGFA transcription

BACKGROUND

Peritoneal dialysis (PD) remains limited due to dialysis failure caused by peritoneal fibrosis. Tamoxifen (TAM), an inhibitor of estrogen receptor 1 (ESR1), has been reported to treat fibrosis, but the underlying mechanism remains unknown. In this study, we sought to explore whether tamoxifen played an anti-fibrotic role by affecting transcription factor ESR1.

METHODS

ESR1 expression was detected in the human peritoneum. Mice were daily intraperitoneally injected with 4.25% glucose PD dialysate containing 40 mM methylglyoxal for 2 weeks to establish PD-induced peritoneal fibrosis. Tamoxifen was administrated by daily gavage, at the dose of 10 mg/kg. Chromatin immunoprecipitation (ChIP) and dual-luciferase reporter assay were performed to validate ESR1 bound H19 promoter. Gain-of-function and loss-of-function experiments were performed to investigate the biological roles of H19 on the mesothelial-mesenchymal transition (MMT) of human peritoneal mesothelial cells (HPMCs). Intraperitoneal injection of nanomaterial-wrapped 2'-O-Me-modified small interfering RNA was applied to suppress H19 in the mouse peritoneum. RNA immunoprecipitation and RNA pull-down assays demonstrated binding between H19 and p300. Exfoliated peritoneal cells were obtained from peritoneal dialysis effluent to analyze the correlations between ESR1 (or H19) and peritoneal solute transfer rate (PSTR).

RESULTS

ESR1 was increased significantly in the peritoneum after long-term exposure to PD dialysate. Tamoxifen treatment ameliorated high glucose-induced MMT of HPMCs, improved ultrafiltration rate, and decreased PSTR of mouse peritoneum. Tamoxifen reduced the H19 level by decreasing the ESR1 transcription of H19. Depletion of H19 reversed the pro-fibrotic effect of high glucose while ectopic expression of H19 exacerbated fibrotic pathological changes. Intraperitoneal injection of nanomaterial-wrapped 2'-O-Me-modified siRNAs targeting H19 mitigated PD-related fibrosis in mice. RNA immunoprecipitation (RIP) and RNA pull-down results delineated that H19 activated VEGFA expression by binding p300 to the VEGFA promoter and inducing histone acetylation of the VEGFA promoter. ESR1 and H19 were promising targets to predict peritoneal function.

CONCLUSIONS

High glucose-induced MMT of peritoneal mesothelial cells in peritoneal dialysis via activating ESR1. In peritoneal mesothelial cells, ESR1 transcribed the H19 and H19 binds to transcription cofactor p300 to activate the VEGFA. Targeting ESR1/H19/VEGFA pathway provided new hope for patients undergoing peritoneal dialysis.

High glucose dialysate-induced peritoneal fibrosis: Pathophysiology, underlying mechanisms and potential therapeutic strategies

Peritoneal dialysis is an efficient renal replacement therapy for patients with end-stage kidney disease. However, continuous exposure of the peritoneal membrane to dialysate frequently leads to peritoneal fibrosis, which alters the function of the peritoneal membrane and results in withdrawal from peritoneal dialysis in patients. Among others, high glucose dialysate is considered as a predisposing factor for peritoneal fibrosis in patients on peritoneal dialysis. Glucose-induced inflammation, metabolism disturbance, activation of the renin-angiotensin-aldosterone system, angiogenesis and noninflammation-induced reactive oxygen species are implicated in the pathogenesis of high glucose dialysate-induced peritoneal fibrosis. Specifically, high glucose causes chronic inflammation and recurrent peritonitis, which could cause migration and polarization of inflammatory cells, as well as release of cytokines and fibrosis. High glucose also interferes with lipid metabolism and glycolysis by activating the sterol-regulatory element-binding protein-2/cleavage-activating protein pathway and increasing hypoxia inducible factor-1α expression, leading to angiogenesis and peritoneal fibrosis. Activation of the renin-angiotensin-aldosterone system and Ras-mitogen activated protein kinase signaling pathway is another contributing factor in high glucose dialysate-induced fibrosis. Ultimately, activation of the transforming growth factor-β1/Smad pathway is involved in mesothelial-mesenchymal transition or epithelial-mesenchymal transition, which leads to the development of fibrosis. Although possible intervention strategies for peritoneal dialysate-induced fibrosis by targeting the transforming growth factor-β1/Smad pathway have occasionally been proposed, lack of laboratory evidence renders clinical decision-making difficult. We therefore aim to revisit the upstream pathways of transforming growth factor-beta1/Smad and propose potential therapeutic targets for high glucose-induced peritoneal fibrosis.

A Potential Resuscitation Route on Battlefield: Immediate Intraperitoneal Fluid Administration Post-burn Shows Satisfactory Fluid Absorption and Anti-shock Effects

INTRODUCTION

Timely fluid resuscitation remains the key to the early treatment of severe burns. Intraperitoneal (IP) fluid administration is a simple, rapid resuscitation strategy via a puncture in the abdominal wall. This study aimed to evaluate the fluid absorption and anti-shock effects of IP delivery in the early stage after severe burns.

MATERIALS AND METHODS

A 30% total body surface area full-thickness burn model was established using male C57BL/6 mice. A total of 126 mice were randomly assigned into six groups (n = 21): the sham injury group (SHAM), the burn group without fluid resuscitation (NR), and the four IP resuscitation groups (IP-A/B/C/D, each being intraperitoneally administered with 60, 80, 100, and 120 mL/kg of sodium lactate Ringer's solution post-injury). Three-hour post-burn, six mice in each group were randomly selected and sacrificed for blood and tissue sampling to detect the IP fluid absorption rate and evaluate organ damage because of low perfusion. The remaining 15 mice in each group were observed for the vital signs within 48-h post-injury, and their survival rate was calculated.

RESULTS

The 48-h survival rate increased in the IP-A (40.0%), IP-B (66.7%), IP-C (60.0%), and IP-D (13.3%) groups, compared with the NR group (0%). The mean arterial pressure, body temperature, and heart rate of mice were significantly stabilized in the IP groups. For the first 3-h post-injury, the absorption rates of groups IP-A (74.3% ± 9.5%) and IP-B (73.3% ± 6.9%) were significantly higher than those of groups IP-C (59.7% ± 7.1%) and IP-D (48.7% ± 5.7%). The levels of arterial blood pH, partial pressure of oxygen, partial pressure of carbon dioxide, lactate, and hematocrit were better maintained in the IP groups. Intraperitoneal resuscitation remarkably reduced the injury scores in burn-induced histopathology of the liver, kidneys, lungs, and intestines, accompanied by decreased alanine transaminase, creatinine, interleukin-1, and tumor necrosis factor-α in plasma, and augmented superoxide dismutase 2 and inhibited malondialdehyde in tissues. Group IP-B has the best performance for these indices.

CONCLUSIONS

Intraperitoneal administration of isotonic saline post-burn can be adequately and rapidly absorbed, thereby boosting circulation and perfusion, precluding shock, alleviating organ damage caused by ischemia and hypoxia, and significantly increasing the survival rate. This technique, with a potential to be a supplement to existing resuscitation methods on the battlefield, is worth further investigation.

The Peritoneal Membrane and its Role in Peritoneal Dialysis

A healthy and functional peritoneal membrane is key to achieve sufficient ultrafiltration and to restore fluid balance, a major component of high-quality prescription in patients treated with peritoneal dialysis (PD). Variability in membrane function at the start of PD or changes over time on treatment influence dialysis prescription and outcomes, and dysfunction of the peritoneal membrane contributes to fluid overload and associated complications. In this review, we summarize the current knowledge about the structure, function and pathophysiology of the peritoneal membrane with a focus on clinical implications for patient-centered care. We also discuss the molecular and genetic mechanisms of solute and water transport across the peritoneal membrane, including the role of aquaporin water channels in crystalloid vs. colloid osmosis; why and how to assess membrane function using peritoneal equilibration tests; the etiologies of membrane dysfunction and their specific management; and the impact of genetic variation on membrane function and outcomes in patients treated with PD. This review also identifies the gaps in current knowledge and perspectives for future research to improve our understanding of the peritoneal membrane and, ultimately, to improve the care of patients treated with PD.

Transversus abdominis plane block versus local anesthetic infiltration for anesthetic effect in peritoneal dialysis catheter insertion: A systematic review and meta-analysis

BACKGROUND

The transversus abdominis plane (TAP) block is commonly used in surgical practice for postoperative analgesia in abdominal surgery. However, numerous studies have demonstrated that TAP block is also suitable for intraoperative anesthesia of peritoneal dialysis catheter (PDC) insertion, although its efficacy and safety are still controversial. Local anesthetic infiltration (LAI) is currently the most general anesthesia strategy for PDC insertion. Consequently, we conducted this systematic review and meta-analysis to identify which anesthesia strategy is better between TAP block and LAI.

METHODS

A systematic and comprehensive search was conducted on 5 databases, retrieving published and registered randomized controlled trials as of March 10, 2022, comparing the anesthesia effects of TAP block and LAI. The primary outcomes are the visual analogue scale (VAS) pain score of patients at various time points in the surgery. The secondary outcomes are the VAS pain score at rest at 2 and 24 hours postoperatively, intraoperative rescue anesthesia, general anesthesia switching rate, and PD-related complications.

RESULTS

There were 9 trials with 432 patients identified. TAP block was more effective than LAI at reducing intraoperative and postoperative VAS pain scores in patients. Compared to LAI, TAP block significantly reduces the dosage of anesthetics used to rescue anesthesia during surgery, the general anesthesia switching rate, and the incidence of postoperative PD-related complications in patients.

CONCLUSIONS

Our systematic review and meta-analysis proved that TAP block could be used as the primary anesthetic technique for PDC insertion, with superior anesthetic effects to LAI.

Laparoscopic Techniques in Treatment of Inguinal Hernia in Patients with Peritoneal Dialysis: Experiences from 15 Cases

Objective: This study aimed to investigate the feasibility, efficacy, and safety of laparoscopic transabdominal preperitoneal (TAPP) repair in the treatment of inguinal hernia in patients on peritoneal dialysis, and the optimal timing for initiating postoperative peritoneal dialysis. Methods: We conducted a retrospective analysis of the clinical data pertaining to patients on peritoneal dialysis with inguinal hernias treated with TAPP repair in the First Affiliated Hospital of Shandong First Medical University from July 15, 2020 to December 15, 2022. Follow-up observations of the treatment effect were also analyzed. Results: A total of 15 patients underwent TAPP repair with success. Contralateral occult hernias were found in 3 cases intraoperatively and were treated simultaneously. During the operation, it was found that the peritoneal dialysis tube was completely wrapped in the omentum majus in 1 case and incompletely wrapped in 5 cases and was separated smoothly under laparoscopy. Conclusion: For patients on peritoneal dialysis with inguinal hernia, TAPP repair has the advantages of less trauma, simultaneous treatment of contralateral occult hernias, adjustment and fixation of peritoneal dialysis tubes, lower incision complication rates, and lower recurrence rates, compared with open surgery. With the gradual resumption of peritoneal dialysis 7 days postoperatively, TAPP repair can be performed safely and effectively in this population group; thus it is a procedure worth promoting.

Exosomal lnc-CDHR derived from human umbilical cord mesenchymal stem cells attenuates peritoneal epithelial-mesenchymal transition through AKT/FOXO pathway

OBJECTIVE

Chronic stimulation of peritoneal dialysis (PD) fluid leads to the epithelial-mesenchymal transformation (EMT) of mesothelial cells, peritoneal fibrosis (PF), and ultimately ultrafiltration failure. Some studies have proposed that mesenchymal stem cells (MSCs) can alleviate PF. This study aimed to investigate whether the exosomes from human umbilical cord MSCs (hUMSCs) could alleviate peritoneal EMT.

METHODS

Human peritoneal mesothelial cell line (HMrSV5) were treated with high glucose (HG) for 48 hours to induce the peritoneal EMT model. An inverted fluorescence microscope was used to observe the internalization of exosomes derived from hUMSCs (hUMSC-Exos). Western blot and real-time PCR were used to evaluate the expression of α-SMA, Vimentin, E-cadherin, PTEN, and AKT/FOXO3a. The relationships of lncRNA CDHR and miR-3149, miR-3149 and PTEN were detected by dual luciferase reporter gene assay.

RESULTS

Compared with HG-induced HMrSV5, E-cadherin and PTEN levels significantly increased whereas α-SMA and Vimentin levels significantly decreased after treatment of hUMSC-CM and hUMSC-Exos (P < 0.05). An inverted fluorescence microscope showed HMrSV5 can absorb exosomes to alleviate EMT. Furthermore, exosomes extracted from lnc-CDHR siRNA-transfected hUMSCs can't ameliorate HMrSV5 EMT. Moreover, both CDHR overexpressed and miR-3149 inhibitor in HG-induced HMrSV5 alleviated the expression of α-SMA, and Vimentin, and increased the expression of E-cadherin and PTEN, and AKT/FOXO3a. A rescue experiment showed that CDHR overexpressed expression was repressed by miR-3149 in the HG-induced peritoneal EMT model.

CONCLUSIONS

Exosomal lnc-CDHR derived from hUMSCs may competitively bind to miR-3149 to regulate suppression on target PTEN genes and alleviate EMT of HMrSV5 through AKT/FOXO pathway.

Exosomal lnc-CDHR derived from human umbilical cord mesenchymal stem cells attenuates peritoneal epithelial-mesenchymal transition through AKT/FOXO pathway

OBJECTIVE

Chronic stimulation of peritoneal dialysis (PD) fluid leads to the epithelial-mesenchymal transformation (EMT) of mesothelial cells, peritoneal fibrosis (PF), and ultimately ultrafiltration failure. Some studies have proposed that mesenchymal stem cells (MSCs) can alleviate PF. This study aimed to investigate whether the exosomes from human umbilical cord MSCs (hUMSCs) could alleviate peritoneal EMT.

METHODS

Human peritoneal mesothelial cell line (HMrSV5) were treated with high glucose (HG) for 48 hours to induce the peritoneal EMT model. An inverted fluorescence microscope was used to observe the internalization of exosomes derived from hUMSCs (hUMSC-Exos). Western blot and real-time PCR were used to evaluate the expression of α-SMA, Vimentin, E-cadherin, PTEN, and AKT/FOXO3a. The relationships of lncRNA CDHR and miR-3149, miR-3149 and PTEN were detected by dual luciferase reporter gene assay.

RESULTS

Compared with HG-induced HMrSV5, E-cadherin and PTEN levels significantly increased whereas α-SMA and Vimentin levels significantly decreased after treatment of hUMSC-CM and hUMSC-Exos (P < 0.05). An inverted fluorescence microscope showed HMrSV5 can absorb exosomes to alleviate EMT. Furthermore, exosomes extracted from lnc-CDHR siRNA-transfected hUMSCs can't ameliorate HMrSV5 EMT. Moreover, both CDHR overexpressed and miR-3149 inhibitor in HG-induced HMrSV5 alleviated the expression of α-SMA, and Vimentin, and increased the expression of E-cadherin and PTEN, and AKT/FOXO3a. A rescue experiment showed that CDHR overexpressed expression was repressed by miR-3149 in the HG-induced peritoneal EMT model.

CONCLUSIONS

Exosomal lnc-CDHR derived from hUMSCs may competitively bind to miR-3149 to regulate suppression on target PTEN genes and alleviate EMT of HMrSV5 through AKT/FOXO pathway.

A New Cycler for Automated Peritoneal Dialysis to Provide Efficient Dialysis and Improved Sleep Quality

INTRODUCTION

Automated peritoneal dialysis (APD) employs cyclers to control inflow and outflow of the dialysis fluid to the patient's abdomen. To allow more patients to use this modality, cyclers should support the achievement of an adequate dialysis dose and be easy to use, cost-effective, and silent. The new SILENCIA cycler (Fresenius Medical Care, Bad Homburg, Germany), designed to improve these characteristics in comparison to its predecessor device, was evaluated in this respect in a prospective study.

METHODS

This cross-over study comprised two 2-week study periods, separated by a 3-week training phase. First, patients underwent APD with their current cycler (PD-NIGHT [Fresenius Medical Care, Bad Homburg, Germany] or HomeChoice Pro [Baxter, Deerfield, IL, USA] as control), followed by training on the SILENCIA cycler. Then, patients were switched to the SILENCIA cycler. During each treatment period, we collected data on total Kt/Vurea, ultrafiltration (UF) volume, patient-reported outcomes (sleep quality, among others), and device handling.

RESULTS

Sixteen patients were enrolled; 2 patients terminated the study prematurely before study intervention, 1 patient due to a protocol violation. In 13 patients, total Kt/Vurea and UF could be evaluated. Neither Kt/Vurea nor UF differed significantly between control and SILENCIA cyclers. Out of 10 patients answering the questionnaire on sleep quality after the 2-week phase with the SILENCIA cycler, sleep quality improved in 5 patients; in the other patients, sleep quality was rated unchanged compared to the previously used cycler. The average reported sleep time was 5.9 ± 1.8 h with the PD-NIGHT, 7.2 ± 2.1 h with HomeChoice Pro, and 8.0 ± 1.6 h with the SILENCIA cycler. All patients were much or very much satisfied with the new cycler.

CONCLUSION

The SILENCIA cycler delivers adequate urea clearance and UF. Importantly, sleep quality improved, possibly related to less caution messages and alarms.

TMT quantitative proteomics and network pharmacology reveal the mechanism by which asiaticoside regulates the JAK2/STAT3 signaling pathway to inhibit peritoneal fibrosis

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional Chinese medicine, Centella asiatica (L.) Urb., has been extensively utilized in clinics to treat a variety of fibrotic disorders. Asiaticoside (ASI), as an important active ingredient, has attracted much attention in this field. However, the effect of ASI on peritoneal fibrosis (PF) is still unclear. Therefore, we evaluated the benefits of ASI for PF and mesothelial-mesenchymal transition (MMT) and revealed the underlying mechanisms.

AIM OF STUDY

The objective of this investigation was to anticipate the potential molecular mechanism of ASI against peritoneal mesothelial cells (PMCs) MMT employing proteomics and network pharmacology, and to confirm it using in vivo and in vitro studies.

MATERIALS AND METHODS

The mesentery of peritoneal fibrosis mice and normal mice were analyzed quantitatively for proteins that were differentially expressed using a technique tandem mass tag (TMT). Next, the core target genes of ASI against PF were screened through network pharmacology analysis, and PPI and C-P‒T networks were constructed by Cytoscape Version 3.7.2. According to the findings of a GO and KEGG enrichment analysis of differential proteins and core target genes, the signaling pathway with a high correlation degree was selected as the key signaling pathway of ASI inhibiting the PMCs MMT for further molecular docking analysis and experimental verification.

RESULTS

TMT-based quantitative proteome analysis revealed the identification of 5727 proteins, of which 70 were downregulated and 178 were upregulated. Among them, the levels of STAT1, STAT2, and STAT3 in the mesentery of mice with peritoneal fibrosis were considerably lower than in the control group, indicating a role for the STAT family in the pathogenesis of peritoneal fibrosis. Then, a total of 98 ASI-PF-related targets were identified by network pharmacology analysis. JAK2 is one of the top 10 core target genes representing a potential therapeutic target. JAK/STAT signaling may represent a core pathway mediating PF effects by ASI. Molecular docking studies showed that ASI had the potential to interact favorably with target genes involved in the JAK/STAT signaling pathway, such as JAK2 and STAT3. The experimental results showed that ASI could significantly alleviate Chlorhexidine Gluconate (CG)-induced peritoneal histopathological changes and increase JAK2 and STAT3 phosphorylation levels. In TGF-β1-stimulated HMrSV5 cells, E-cadherin expression levels were dramatically reduced whereas Vimentin, p-JAK2, α-SMA, and p-STAT3 expression levels were considerably increased. ASI inhibited the TGF-β1-induced HMrSV5 cell MMT, decreased the activation of JAK2/STAT3 signaling, and increased the nuclear translocation of p-STAT3, which was consistent with the effect of the JAK2/STAT3 pathway inhibitor AG490.

CONCLUSION

ASI can inhibit PMCs MMT and alleviate PF by regulating the JAK2/STAT3 signaling pathway.

Laparoscopic peritoneal dialysis catheter insertion: an oasis harnessed-experience and results at a tertiary care centre in India

BACKGROUND

Peritoneal dialysis is a life sustaining renal replacement therapy for patients with end stage renal disease. In comparison to hemodialysis it offers better mobility and independence to patients. A number of techniques including open, laparoscopic and fluoroscopy guided, and their modifications, have been described for intraperitoneal catheter insertion. We describe our technique and results of laparoscopic peritoneal dialysis (PD) catheter insertion at a tertiary care centre in India.

CASE SERIES

48 patients were referred from the department of nephrology at our centre for laparoscopic PD catheter insertion. A two port technique was used in 37 patients and three port technique was implemented in the rest for simultaneous adhesiolysis and/or omentectomy. A straight tip catheter was tunneled through the rectus muscle in all patients. Two patients had incisional hernia from a previous abdominal surgery which was repaired concomitantly with onlay meshplasty.

RESULTS

The operative time ranged between 20 and 35 min under general anaesthesia. Three patients were subjected to urgent start dialysis of which one patient developed peridrain leak as an early complication which was managed conservatively. All other patients were commenced on peritoneal dialysis two weeks after surgery. There was no other surgical site occurrence or episodes of peritonitis reported in a 6 month follow up period with the department of nephrology.

CONCLUSION

In the era of minimal access surgery, the laparoscopic approach is feasible for widespread and safe use for PD catheter insertion. The benefits of PD can thus be made available to patients at civil hospitals even with a basic laparoscopy setup.

Intraperitoneally Administered Vancomycin in Patients with Peritoneal Dialysis-Associated Peritonitis: Population Pharmacokinetics and Dosing Implications

Peritonitis is a limiting complication of peritoneal dialysis, which is treated by intraperitoneal administration of antibiotics. Various dosing strategies are recommended for intraperitoneally administered vancomycin, which leads to large differences in intraperitoneal vancomycin exposure. Based on data from therapeutic drug monitoring, we developed the first-ever population pharmacokinetic model for intraperitoneally administered vancomycin to evaluate intraperitoneal and plasma exposure after dosing schedules recommended by the International Society for Peritoneal Dialysis. According to our model, currently recommended dosing schedules lead to possible underdosing of a large proportion of patients. To prevent this, we suggest avoiding intermittent intraperitoneal vancomycin administration, and for the continuous dosing regimen, we suggest a loading dose of 20 mg/kg followed by maintenance doses of 50 mg/L in each dwell to improve the intraperitoneal exposure. Vancomycin plasma level measurement on the fifth day of treatment with subsequent dose adjustment would prevent it from reaching toxic levels in the few patients who are susceptible to overdose.

Urgent-start peritoneal dialysis

Peritoneal dialysis is an important form of kidney replacement therapy. Most patients presenting with an unplanned, urgent need for dialysis are prescribed haemodialysis, leading to peritoneal dialysis underutilisation. Urgent-start peritoneal dialysis refers to treatment that is commenced within 2 weeks of catheter placement. Urgent-start peritoneal dialysis represents an efficacious, cost-effective alternative to the conventional approach of commencing dialysis. There is a paucity of evidence to guide management, however experience with the technique is increasing. This article overviews the rationale and practical application of urgent-start peritoneal dialysis.

Relationship between peritoneal solute transport and dialysate inflammatory markers in peritoneal dialysis patients: A cross-sectional study

BACKGROUND

The associated factors of peritoneal small solute transport was not fully understood. This research aimed to investigate the connection between dialysate inflammatory markers (e.g. macrophage migration inhibitory factor, MIF) in peritoneal dialysis (PD) effluent and peritoneal solute transport rate (PSTR) properties.

SUBJECTS AND DESIGN

A total of 80 stable PD patients in the First ShaoYang Hospital were enrolled in present study. Overnight PD effluent and serum inflammatory markers including MIF, MCP-1, VEGF, IL-6, TNFα and TGFβ were detected. Pearson correlation analysis and Logistic regression was performed to determine the risk factors for the increased PSTR.

RESULTS

A trend toward increased values of MIF, MCP-1 and IL-6 in PD effluent was observed in subjects with high PSTR when compared with those with low PSTR. The Pearson correlation test showed that D/P Cr exhibited positive correlations with dialysis effluent MIF (r=0.32, p=0.01), MCP-1 (r=0.47, p=0.01), IL-6 (r=0.48, p=0.01). Conversely, no significant correlation was found between D/P Cr and TGF-β (r=0.04, p=0.70), TNF-ɑ (r=0.22, p=0.05), VEGF (r=0.02, p=0.86) and serum inflammatory markers. In the unadjusted regression analysis, dialysis effluent MIF (OR 2.41), MCP-1 (OR 1.72), IL-6 (OR 1.55) were associated with high PSTR condition. Multivariate logistic regression analysis showed that the adjusted odds ratios (OR) of dialysis effluent MIF for high PSTR were 2.47 in all subjects (p=0.03).

CONCLUSION

Elevated MIF, MCP-1 and IL-6 levels in PD effluent were associated with increased PSTR. Elevated dialysis effluent MIF levels was an independent risk factor for high PSTR in subjects with PD treatment.

miR-128-3p inhibits high-glucose-induced peritoneal mesothelial cells fibrosis via PAK2/SyK/TGF-β1 axis

AIM

To elucidate the mechanism of miR-128-3p in peritoneal fibrosis (PF).

METHODS

Peritoneal mesothelial cells (PMCs) were dealt with high glucose (HG) for 3 days. The expressions of miR-128-3p, p21-activated kinase 2 (PAK2), spleen tyrosine kinase (SyK), and transforming growth factor-β1 (TGF-β1) were detected with quantitative real-time reverse transcription polymerase chain reaction. The levels of IL-1β, TNF-α, IL-6, and monocyte chemotactic protein-1 in supernatant were measured by ELISA. Proteins of TGF-β1, SyK, PAK2, α-SMA, collagen I, vimentin, ERK/AP-1, and IκBα/NF-κB pathway related proteins were measured by Western blot. The correlation between miR-128-3p and PAK2 was found by bioinformatics analysis and luciferase reporter gene analysis.

RESULTS

miR-128-3p was decreased while PAK2, SyK, and TGF-β1 were increased in HG-induced PMCs. Moreover, miR-128-3p inhibited HG-induced fibrosis and inflammation in PMCs by targeting PAK2. PAK2 activated SyK, which induced TGF-β1 expression through ERK/AP-1 and IκBα/NF-κB pathways to promote HG-induced fibrosis of PMCs.

CONCLUSION

miR-128-3p inhibited HG-induced PMCs fibrosis via PAK2/SyK/TGF-β1 axis.