BackgroundCritically ill children on peritoneal dialysis (PD) are at an increased risk of raised intra-abdominal pressure (IAP). The aim of this study was to describe IAP and complications with a standard PD fill volume, using conventional PD and continuous flow PD (CFPD) in critically ill children with acute kidney injury. A secondary objective was to compare two IAP measurement techniques, which were direct measurement from the PD catheter via a manometer and indirect measurement via the bladder catheter to a transducer.MethodThis study was a secondary analysis of a previously published randomized controlled crossover trial. Within- and between-group changes in IAP, blood pressure and ventilation parameters were analysed using paired t-tests. Bland-Altman and intraclass correlation tests were used to assess agreement between direct and intravesicular measurement of IAP.ResultsFifteen participants (median (range) age and weight 6.0 (0.2-14) months and 5.8 (2.3-14.0) kg) were included, of which 9 (60%) had raised IAP (>10 mmHg) after filling. No children developed compartment syndrome or other complications. Mean ± standard deviation IAP on conventional versus CFPD was 9.35 ± 2.97 and 11.5 ± 2.96 versus 9.3 ± 3.35 and 11.2 ± 3.62 when measured directly and indirectly, respectively (p > 0.5). Intravesicular measurement of IAP was constantly significantly higher compared to the direct method (p = 0.002); however, there was good correlation (Pearson correlation coefficient 0.7; p < 0.001) and moderate reliability (ICC = 0.6) between the methods.ConclusionIncreased IAP (>10 mmHg) was common, although not associated with serious adverse events, and warrants monitoring in these patients. The pressures measured are different with the two techniques used, although they do correlate well. More studies are needed to define increased IAP depending on the measuring technique and inform IAP measurement practice in children with acute PD.

Centre-related factors, in addition to patient-related factors, are known to influence the outcomes of patients on peritoneal dialysis (PD). It is unclear if the nursing staff-to-patient ratios at different PD centres affect peritonitis outcomes. Our study aimed to examine whether full-time equivalent (FTE) PD nurse-patient ratios in individual PD centres were associated with centre-level outcomes of patients on PD. We used a cross-sectional survey of nursing leads of PD units across Australia and multi-centre registry data linkage. Of the 38 PD units in Australia, 28 (73.7%) nursing leads responded to the survey. The overall FTE PD nurse-patient ratio was 1 nurse to 12.7 patients (median; interquartile range 9.8-16.5), with substantial variability between PD units. There was no significant association between the FTE PD nurse-patient ratios and unit-specific peritonitis rates, overnight hospitalisation rates for peritonitis, mortality rates within 30 days of infection, or haemodialysis (HD) transfer rates. However, there was a moderate positive correlation between nurse FTE and transfer to HD rates (r = 0.476, p < 0.01). While our study revealed large variability in FTE PD nurse-patient ratios between PD units across the country, it was not associated with clinically significant PD outcomes between centres. Therefore, PD nurse-patient ratios may not be an important centre-related factor to explain variability in clinically meaningful PD outcomes between centres.

Peritoneal dialysis (PD) is a cornerstone kidney replacement therapy for patients with end-stage kidney disease; however, chronic exposure to bioincompatible dialysis solutions progressively damages the peritoneal membrane, leading to mesothelial-to-mesenchymal transition, fibrosis, and ultimately ultrafiltration failure. Currently, peritoneal membrane dysfunction is detected only at advanced stages through the peritoneal equilibration test, underscoring the need for earlier and more sensitive biomarkers. Extracellular vesicles (EVs) isolated from peritoneal dialysis effluent (PDE) have emerged as promising candidates, given their capacity to carry proteins, lipids, and nucleic acids that reflect local and systemic cellular activity. To date, 12 studies have successfully isolated and characterized PDE-derived EVs, identifying canonical EV markers, such as CD9, CD63, CD81, TSG101, and HSP70, alongside disease-relevant molecules, including galectin-3 binding protein, aquaporin-1, glycoprotein 96, and integrin-linked kinase. These EVs are enriched in signaling components associated with inflammation, angiogenesis, and fibrosis, particularly through TGF-β/p38 and NF-κB pathways. Moreover, specific EV-associated microRNAs (e.g., miR-125a-5p, miR-132-3p, miR-296-3p, miR-432-5p) overlap with molecular signatures observed in kidney and cardiometabolic disorders, suggesting broader systemic relevance. As an original contribution to this review, and to address cross-study comparability, we applied EVqualityMS, a mass spectrometry-based quality assessment tool, to benchmark EV enrichment and contaminant profiles and calculate quality indices across publicly available PDE-EV proteomics datasets. Despite methodological heterogeneity and limited sample sizes, PDE-derived EVs represent a powerful "liquid biopsy" of the peritoneal environment. Their integration into PD monitoring holds promise for the early detection of membrane injury and for supporting a predictive, biomarker-guided, and personalized approach to PD management.

BackgroundPeritoneal fibrosis (PF) limits the long-term use of peritoneal dialysis (PD), with effective therapies lacking. Ferroptosis, an iron-dependent cell death process, has been implicated in organ fibrosis, but its role in PD-related PF remains unexplored. Quercetin, a natural flavonoid, possesses potential anti-fibrotic and anti-ferroptotic properties.MethodsPD effluent cells from patients with different dialysis durations were analyzed for the expression of fibrosis markers (α-smooth muscle actin and collagen I) and ferroptosis-related markers (glutathione peroxidase 4 (GPX4) and solute carrier family 7 member 11 (SLC7A11)). In vitro, human peritoneal mesothelial cells (MeT-5A) exposed to high glucose were treated with quercetin to examine its effects on mitochondrial ultrastructure and marker expression. A rat model of PF was established through daily intraperitoneal injection of high-glucose dialysate, with or without quercetin administration, to evaluate histological and molecular changes in the parietal peritoneum.ResultsProlonged dialysis duration was associated with upregulated fibrotic markers and downregulated ferroptosis-related genes in patient samples. In vitro, high glucose induced mitochondrial damage and a profibrotic phenotype in MeT-5A cells, which were significantly attenuated by quercetin. Quercetin restored the expression of GPX4 and SLC7A11, comparable to the effects of the ferroptosis inhibitor ferrostatin-1. In vivo, quercetin treatment markedly alleviated high-glucose-induced peritoneal thickening and fibrosis while enhancing the expression of ferroptosis suppressors.ConclusionOur findings demonstrate that ferroptosis contributes to the pathogenesis of PD-associated PF. Quercetin mitigates fibrotic progression by modulating ferroptosis, highlighting its promise as a novel therapeutic agent for preventing or treating this complication.

BackgroundPeritoneal dialysis (PD)-associated peritonitis remains a leading cause of hospitalization, technique failure, and transfer to in-center hemodialysis, with touch contamination during connections accounting for many episodes. Although shrouded connectors and "flush before fill" mechanisms reduce contamination risk, most automated peritoneal dialysis (APD) systems incorporate recessed fluid paths on only one side of the tubing-bag interface, potentially allowing bacterial transfer. We evaluated whether bilateral shrouded connectors with recessed fluid paths reduce bacterial contamination during simulated APD therapy.MethodsIn vitro microbiological testing was performed using three APD systems: Vantive/Baxter Claria™ (System A), Fresenius Liberty™ (System C), and Simergent Archimedes™ (System B). Connectors were deliberately contaminated with Staphylococcus aureus to simulate touch contamination, followed by a simulated APD treatment. Bacterial growth was quantified from pre-therapy flush fluid and the first patient fill ("mock peritoneum"). Agar imprinting was used to assess bacterial distribution relative to connector geometry.ResultsBacterial growth adjacent to the fluid path was observed with contaminated System A connectors but not with System B or System C, where growth was confined to the shroud. Quantitative cultures demonstrated markedly higher bacterial transfer with System A compared with System B and System C across both flush and mock peritoneal samples. Systems B and C employing bilateral shrouded, recessed connectors showed bacterial counts several orders of magnitude lower. All aseptic controls were sterile.ConclusionBilateral shrouded connectors with recessed fluid paths substantially reduce transfer of touch contaminants during simulated APD therapy. This design may mitigate a major mechanism of PD-related peritonitis, warranting clinical evaluation.

BackgroundsUnplanned initiation of peritoneal dialysis (PD) is linked to higher risks of complications and transfer to hemodialysis (HD). This study evaluates whether assisted PD was associated with the risk of transitioning to hemodialysis, for the individuals experiencing unplanned PD initiation.MethodsThis retrospective study analyzed data from the French Language Peritoneal Dialysis Registry (RDPLF), including 1009 patients with unplanned PD initiation, defined as a period of <30 days on HD before PD initiation, between January 1, 2002, and December 31, 2018. We compared assisted PD (nurse/family-assisted) versus self-care PD using cause-specific analyses. Time-dependent coefficient Cox regression addressed non-proportional hazards. Mediation analysis was conducted to explore the direct and indirect effects of assisted PD on the risk of transfer to HD, considering early peritonitis as a mediator.ResultsIn unplanned starters, Assisted PD was associated with an increased early risk of transfer to HD within the first six months (cs-HR 2.00, 95% CI 1.30-3.30), but a reduced risk thereafter (cs-HR 0.70, 95% CI 0.50-0.90). Patients on assisted PD had a higher risk of death (cs-HR 2.39, 95% CI 1.77-3.24) and a lower likelihood of transplantation (cs-HR 0.23, 95% CI 0.12-0.42). Mediation analysis revealed no significant indirect effect of assisted PD on the risk of transfer to HD via early peritonitis.ConclusionUnplanned PD initiation presents significant early risks, with assisted PD showing delayed protective effects after six months. Targeted early support (psychological and social) and further research are crucial to optimize outcomes for this patient group.

Peritoneal dialysis (PD) is being promoted worldwide, but nearly half of all patients who start PD will no longer be on therapy at two years, representing an important barrier to maximizing the safe and effective use of the therapy. Loss most commonly occurs due to HD transfer, death, or the receipt of a kidney transplant, but can also occur because patients recover kidney function, transfer to another dialysis program, or are lost to follow-up. Historically, the term "technique failure" has been used to describe loss from PD, but there has been no consistent definition, and as a consequence, it has been unclear whether the observed variability in the reported risk is related to differences in patient characteristics, practice patterns, or simply differences in the way it was defined, measured, analyzed, or reported. The International Society for Peritoneal Dialysis (ISPD) convened a working group to provide recommendations around key issues related to measuring time on PD therapy. These included standardizing definitions for causes of loss, as well as their measurement, analysis, and reporting. Key performance indicators were proposed for the purpose of benchmarking and to facilitate quality improvement and research. The target audience of this document includes physicians and other healthcare providers, dialysis programs, researchers, and national registries.

BackgroundThe Standardized Outcomes in Nephrology-Peritoneal Dialysis (SONG-PD) initiative identified core outcomes for patients receiving peritoneal dialysis (PD). However, this study included very few Japanese participants, raising concerns whether their findings applied to Japanese patients. This study aimed to identify important factors in the choice of dialysis modality from the SONG-PD list.MethodsParticipants comprised 199 patients receiving dialysis (mean age, 61 ± 12 years; male, 71.9%) who initiated PD between January 1, 2018, and September 30, 2024. Important factors in the choice of dialysis modality were investigated using a questionnaire and clinical data were obtained from medical records.ResultsImportant factors with high voting percentages included "Flexibility with time (ability to schedule dialysis according to one's day)" "Life participation (ability to work, study, do home duties)," "Mobility/fitness (ability to move without assistance, and to train to achieve physical goals)" and "Ability to travel." These findings, except for "Life participation," differed from the core outcomes identified in the SONG-PD study. Subgroup analysis showed that "Death" had a higher voting percentage in patients with diabetic nephropathy. Additionally, important factors varied partly depending on age and employment status.ConclusionImportant factors in the choice of dialysis modality among Japanese patients initiating PD, particularly regarding flexibility, daily activities, mobility, and travel, highlight specific needs that may not be fully captured by the internationally derived SONG-PD core outcomes, except for life participation itself. Important factors identified in this study may be included in clinical trials involving Japanese patients to support shared decision making.

Neutral-pH, low-glucose degradation product peritoneal dialysis (PD) solutions are widely used because of their favorable biocompatibility. These solutions are typically packaged in dual-chamber bags and must be mixed immediately before use. Although the mixing procedure is simple, improper preparation may occur, particularly in patients with cognitive impairment, potentially resulting in unintended electrolyte exposure. We report a case of severe hyponatremia with altered mental status associated with inadvertent infusion of an unmixed neutral-pH PD solution in an elderly patient undergoing automated peritoneal dialysis (APD). A man in his eighth decade with diabetic nephropathy and progressive cognitive decline presented with somnolence and severe hyponatremia after a dual-chamber PD bag with an unopened septum was connected. Based on the clinical course and the finding that a PD solution bag with an unopened inter-chamber septum had been connected, hyponatremia due to exposure to an unmixed dialysate compartment was diagnosed. Management consisted of immediate discontinuation of the improperly prepared dialysate and correction using appropriately mixed PD solutions, without administration of hypertonic saline. Serum sodium levels improved gradually without neurological complications, accompanied by recovery of mental status. This case highlights a rare but serious complication related to improper preparation of dual-chamber PD solutions. Increased awareness of this risk and careful monitoring of vulnerable patients, particularly those with cognitive impairment, are essential to ensure safe home PD therapy.