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.

BackgroundThe aim of this study was to clarify the current status of assisted peritoneal dialysis (PD) implementation in Japan.MethodsA nationwide, cross-sectional, questionnaire survey was conducted by the Working Group of the Academic Committee of the Japanese Society for Peritoneal Dialysis. A paper-based questionnaire of 22 items was developed based on a literature review and clinical experience. The questionnaires were sent to all 310 facilities that were members of the Japanese Society for Peritoneal Dialysis (JSPD).ResultsResponses were received from 209 facilities (response rate 67.4%). It was found that assisted PD is already being implemented in approximately two-thirds of PD facilities, accounting for 15.9% of all PD patients. Cognitive decline and muscle weakness were the leading reasons for starting assisted PD. Family members, particularly spouses and adult children, were the main caregivers in this cohort, either alone or in collaboration with visiting nurses; cooperation with general practitioners was relatively limited. Facilities with a large number of PD patients made use of collaboration with visiting nurses and respite care facilities, remote monitoring, and medical care-specific social networking sites.ConclusionThis nationwide survey demonstrates that assisted PD is widely practiced in Japan and plays a critical role in sustaining PD therapy for elderly and functionally impaired patients. However, substantial heterogeneity in implementation and insufficient integration with broader medical and social care systems remain major challenges. Addressing these issues through standardization, multidisciplinary collaboration, and policy reform will be essential to meet the needs of Japan's rapidly aging dialysis population.

Percutaneous peritoneal dialysis catheter placement using the Veress needle is considered safe; however, because the needle is usually inserted blindly, there is a risk of visceral or vascular injury. Although ultrasound guidance can reduce this risk, the puncture process has not been described in detail. We therefore illustrate the procedure using ultrasound images and schematic drawings.

BackgroundIntraperitoneal pressure (IPP) may influence ultrafiltration (UF) in peritoneal dialysis (PD), but its clinical relevance under standard peritoneal equilibration test (PET) with 4.25%/3.86% dextrose remains uncertain.MethodsIn 96 unselected PD patients, we performed two 4.25%/3.86% PETs using 1L and 2L fill volumes. IPP, UF, glucose UF efficiency, sodium dip (Na-Dip) as a marker of free water transport (FWT), osmotic conductance to glucose (OCG), and solute transport parameters (D/PCreatinine and diffusion capacities (PS)) were assessed. Associations between IPP, UF parameters, and UF-related abnormalities were analyzed.ResultsThe 2L PET showed higher IPP, dialysate glucose concentration, and PS, and lower D/PCreatinine, as expected. However, an increase in water transport was not consistent: 21%, 66%, 29%, and 40% of patients showed in the 1L PET, respectively, higher UF, glucose UF efficiency, OCG, and Na-Dip. In 2L PET IPP was negatively correlated with UF (r = -0.221; p = 0.03) and Na-Dip (r = -0.210, p = 0.041). About 56% of patients presented at least one of the UF-related abnormalities identified (paradoxically higher UF with 1L, UF insufficiency (UF < 400 mL in 2L PET), and impaired FWT (Na-Dip≤5 mmol/L in 2L PET)). These patients had significantly higher IPP and reduced abdominal distensibility.ConclusionsThis study shows an association between IPP and UF in 4.25%/3.86% dextrose PET that appears clinically relevant. It also raises the hypothesis that IPP may be related to FWT in PD. These findings highlight the importance of IPP monitoring in PD and the need for further studies to characterize changes in FWT across variations in volume and intraperitoneal pressure.

BackgroundSocioeconomic deprivation is an established determinant of adverse health outcomes. However, UK-specific data examining its impact on peritoneal dialysis (PD) outcomes remains generally unknown. This study evaluated associations between socioeconomic deprivation and clinical outcomes among patients receiving PD at a single UK center over a 10-year period.MethodsThis retrospective observational study included 648 adult patients who underwent PD catheter insertion between January 2015 and December 2024. Socioeconomic deprivation was assessed using the Index of Multiple Deprivation (IMD), with study cohorts categorized into quintiles from the least to the most deprived. Primary outcomes included all-cause mortality, transfer to hemodialysis (HD), and kidney transplantation. Secondary outcomes included cardiovascular events and PD-related infections, that is, peritonitis and exit-site infections. A 1:1 propensity score matching was performed to match for age, ethnicity, and smoking history to compare between the most deprived quintiles (MDQ) (i.e., quintiles 1 and 2) and the least deprived quintiles (LDQ) (i.e., quintiles 4 and 5). Cox proportional hazards models were used to evaluate associations between socioeconomic deprivation and outcomes.ResultsOf the 648 patients included, 41.7% resided in quintile 1. Patients in LDQ were significantly younger (median = 54 [IQR 42-67] vs. 64 [51-74] years, p < 0.001) and more likely to belong to ethnic minority backgrounds (24% vs. 7.7%, p < 0.001) compared to those in MDQ. Across all quintiles, no significant associations were observed between deprivation and all-cause mortality, transfer to HD, or kidney transplantation. In the propensity-matched cohort (n = 298), all-cause mortality was significantly higher among patients from MDQ compared to the LDQ (39.6% vs. 24.8%, p = 0.006). Social deprivation was noted to be an independent risk factor associated with all-cause mortality in the matched cohort (adjusted HR 2.08, 95% CI 1.37-3.10, p = 0.001). No significant associations were identified in relation to cardiovascular events, transfer to HD, kidney transplantation, or PD-related infections.ConclusionIn a propensity score-matched cohort from this single-center study, socioeconomic deprivation was independently associated with increased mortality among patients receiving PD. No significant associations were observed between socioeconomic deprivation with transfer to HD or kidney transplantation and PD-related infection complications.

BackgroundChronic kidney disease (CKD) represents a growing public health challenge worldwide, particularly in countries with a medium sociodemographic index such as the Dominican Republic (DR), where both the incidence and prevalence of CKD have shown a sustained increase. In response, the DR government launched a national peritoneal dialysis (PD) program in 2013 to expand access to kidney replacement therapy (KRT).MethodsA retrospective analysis was conducted on the development and implementation of the national continuous ambulatory peritoneal dialysis (CAPD) program over ten years. The model was structured around three pillars: (1) a multidisciplinary team comprising nephrology, nursing, nutrition, psychology, and social work; (2) dedicated infrastructure for PD delivery; and (3) a management system driven by standardized processes and protocols, aligned with ISO certification standards. Patient care involved comprehensive baseline assessments, structured training, monthly follow-up, routine retraining, and home evaluations. Program performance was monitored through predefined clinical indicators.ResultsSince the implementation of the program, the PD penetration in DR increased from 2.7% to 22.4%, reaching 1118 patients by the end of 2024. This growth reflects the program's ability to improve access to KRT through a centralized and standardized care model. This model not only facilitated consistency in care delivery across participating centers but also enhanced the growth of PD.ConclusionsThe 10-year experience of the national PD program in the DR provides evidence for the feasibility and effectiveness of a standardized, patient-centered, and multidisciplinary PD program. The implementation of this program has significantly increased access to kidney replacement therapies and driven the sustained growth of KRT in the DR and provides a scalable model for the implementation of national PD initiatives in similar contexts.