Automated Peritoneal Dialysis Research Articles

Comparison of clinical outcomes based on dialysis modality and icodextrin usage in patients on peritoneal dialysis.

There is no conclusive evidence regarding the survival benefits of automated peritoneal dialysis (APD) or the use of icodextrin. This study aimed to evaluate patient and technique survival among four groups divided based on peritoneal dialysis modality and icodextrin use over 1 year. We specifically included patients who underwent a single peritoneal dialysis modality for at least 1 year during that period (n = 148). The participants were categorized into four groups for comparison: continuous ambulatory peritoneal dialysis (CAPD) without icodextrin (CAPD-ET, n = 39); CAPD with icodextrin (CAPD+ET, n = 35); APD without icodextrin (APD-ET, n = 40); and APD with icodextrin (APD+ET, n = 34). The CAPD+ET group had a higher patient survival rate than that of the APD-ET group and also had a higher technique survival trend than that of the APD-ET group, despite no statistical significance. In patients without diabetes mellitus (DM), the APD-ET group had a poorer patient survival trend than those of the APD+ET or CAPD+ET groups. In patients without DM, the APD+ET group had a higher technique survival than the APD-ET group. In addition, the APD+ET group showed a higher technique survival trend than did the CAPD-ET group, despite non-statistical significance. The edema index after 1 year of follow-up was higher in the APD-ET group than in the other groups. The present study demonstrated that patients undergoing APD without icodextrin had poor patient and technique survival trends, which may be caused by poor volume control.

Lost dwell time and cycler alarms in inpatient automated peritoneal dialysis at a tertiary care hospital

Background and aims Dwell time is a critical component of automated peritoneal dialysis (APD) prescription, the stage at which transmembrane mass and fluid transfer occur. Loss of prescribed dwell time (LDT) can negatively influence the efficiency of APD. We investigated the incidence of LDT and related causes using APD in the acute care setting at a tertiary care center. Methods Retrospective analysis was conducted of all inpatients receiving APD treatments from 1 December 2021 to 1 June 2023. Patient demographics, comorbidities, laboratory, and treatment data were extracted from electronic medical records and a propriety database. Results N = 235 cycler treatments completed by 32 patients were included for analysis. The total LDT per treatment exceeding 30 minutes and 60 minutes occurred in 27% and 20% of all treatments. LDT of more than 10 minutes per each cycle exchange occurred in 26%. Session disruptions were caused by slow out-flow (55%), inadequate drain volumes (32%), patient line occlusions (20%), and priming errors (23%). The slow flow alarm requiring user intervention was reported to occur in about one-third of all treatments (31%). Conclusion There was significant LDT and inadequate drain volume seen in about one-quarter and one-third of all inpatient APD treatments respectively. This can impact solute clearance and ultrafiltration. Slow flow alarms were the most prevalent and the leading cause of LDT followed by inadequate drain volume. Future studies are required to investigate measures to reduce slow drain and improve drain volume in the hospital setting.

Automated peritoneal dialysis versus continuous ambulatory peritoneal dialysis for people with kidney failure.

Peritoneal dialysis (PD) is a home-based kidney replacement therapy (KRT) performed in people with kidney failure. PD can be performed by manual filling and draining of the abdominal cavity, i.e. continuous ambulatory PD (CAPD), or using a device connected to the PD catheter that is programmed to perform PD exchanges, i.e. automated PD (APD). APD is considered to have several advantages over CAPD, such as a lower incidence of peritonitis, fewer mechanical complications, and greater psychosocial acceptability. Acknowledging the increasing uptake of APD in incident and prevalent patients undergoing PD, it is important to re-evaluate the evidence on the comparative clinical and patient-reported outcomes of APD compared to CAPD. This is an update of a Cochrane review published in 2007. To compare clinical and patient-reported outcomes of APD to CAPD in people with kidney failure. In this update, we searched the Cochrane Kidney and Transplant Register of Studies until 29 August 2024. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. Randomised controlled trials (RCTs) comparing APD with CAPD in adults (≥ 18 years) with kidney failure. Two authors independently screened the search results and extracted data. Data synthesis was performed using random-effects meta-analyses, expressing effect estimates as risk ratios (RR) with 95% confidence intervals (CI) for dichotomous data and mean differences (MD) with 95% CIs for continuous data. Certainty in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. Two RCTs (131 randomised people) comparing APD with CAPD were included in this update. One RCT had a follow-up of six months, and one RCT had a follow-up of 24 months. The risk of bias in the included studies was mostly low, except for the high risk of performance bias for subjective outcomes. The evidence is very uncertain about the effect of APD compared to CAPD on death, hospitalisations, PD-related peritonitis, change of dialysis modality, residual kidney function, health-related quality of life (HRQoL), overhydration, blood pressure, exit-site infections, tunnel infections, mechanical complications, PD catheter removal, or dialysis adequacy measures. These results were largely based on low to very low certainty evidence; hence, caution is warranted when drawing conclusions. Insufficient evidence exists to decide between APD and CAPD in kidney failure patients with regard to clinical and patient-reported outcomes. Therefore, current evidence is insufficient as a guide for clinical practice. Given that the sample sizes of existing studies are generally small with insufficient follow-up, there is a need for large-scale, multicentre studies. Future research should focus on possible differences between APD and CAPD in residual kidney function, euvolaemia, and patient-reported outcomes such as HRQoL, symptoms, patient satisfaction and life participation.

Remote monitoring of automated peritoneal dialysis reduces mortality, adverse events, and hospitalizations: a cluster randomized controlled trial.

Remote monitoring (RM) of patients on automated peritoneal dialysis (APD) prevent complications and improve treatment quality. We analyzed the effect of RM-APD on mortality and complications related to cardiovascular disease (VD), fluid overload and insufficient dialysis efficiency. In a cluster-randomized, open-label, controlled trial, 21 hospitals with APD programs were assigned to use either RM-APD (10 hospitals; 403 patients) or conventional APD (11 hospitals; 398 patients) for the treatment of adult patients starting PD. Primary outcomes were time to first event of: 1) Composite Index-1 comprising all-cause mortality, first adverse events and hospitalizations of any cause, and 2) Composite Index-2 comprising cardiovascular mortality, first adverse event and hospitalizations related to CVD, fluid overload and insufficient dialysis efficiency. Secondary outcomes were time to first event of individual components of the two composite indices, and rates of adverse events, hospitalizations, unplanned visits, and transfer to hemodialysis. Patients were followed for a median of 9.5 months. Primary outcomes were evaluated by competing-risk analysis and restricted mean survival time (RMST) analysis. While time to reach Composite Index-1 did not differ between the groups, Composite Index-2 was reached earlier (ΔRMST: -0.85 months; p=0.02), and all-cause mortality (55 vs. 33 deaths, p=0.01; sHR 1.69 (95%CI 1.39-2.05), p<0.001) and hospitalizations of any cause were higher in APD group than in RM-APD as were cardiovascular deaths (24 vs. 13 deaths, p=0.05; sHR 2.44 (95%CI 1.72 - 3.45), p<0.001) and rates of adverse events and hospitalizations related to CVD, fluid overload or insufficient dialysis efficiency. Dropouts were more common in the APD group (131 vs. 110, p=0.048). This randomized controlled trial shows that remote monitoring may add significant advantages to APD, including improved survival and reduced rate of adverse events and hospitalizations, which can favorably impact the acceptance and adoption of the therapy.

Gut Microbiome Is Related to Cognitive Impairment in Peritoneal Dialysis Patients.

Gut microbiota disturbances may influence cognitive function, increasing uremic toxins and inflammation in dialysis patients; therefore, we aimed to evaluate the association of the gut microbiota profile with cognitive impairment (CI) in patients on automated peritoneal dialysis (APD). In a cross-sectional study, cognitive function was evaluated using the Montreal Cognitive Assessment in 39 APD patients and classified as normal cognitive function and CI. The gut microbiota was analyzed using the 16S rRNA gene sequencing approach. All patients had clinical, biochemical and urea clearance evaluations. Eighty-two percent of patients were men, with a mean age of 47 ± 24 years and 11 (7-48) months on PD therapy; 64% had mild CI. Patients with CI were older (53 ± 16 vs. 38 ± 14, p = 0.006) and had a higher frequency of diabetes mellitus (56% vs. 21%, p = 0.04) and constipation (7% vs. 48%, p = 0.04) and lower creatinine concentrations (11.3 ± 3.7 vs. 14.9 ± 5.4, p = 0.02) compared to normal cognitive function patients. Patients with CI showed a preponderance of S24_7, Rikenellaceae, Odoribacteraceae, Odoribacter and Anaerotruncus, while patients without CI had a greater abundance of Dorea, Ruminococcus, Sutterella and Fusobacteria (LDA score (Log10) > 2.5; p < 0.05). After glucose and age adjustment, Odoribacter was still associated with CI. In conclusion, patients with CI had a different gut microbiota characterized by the higher abundance of indole-producing and mucin-fermenting bacteria compared to normal cognitive function patients.

Precision Medicine in Peritoneal Dialysis: An Expert Opinion on the Application of the Sharesource Platform for the Remote Management of Patients.

The management of end-stage kidney disease (ESKD) has been constantly evolving over the last decade with the development of targeted approaches. In this field, telemedicine and remote monitoring are based on the availability of new cyclers that allow for bidirectional communication (between patient and physician) and for the application of the Sharesource cloud-based platform. These technologies allow patients with ESKD to undergo automated peritoneal dialysis (APD) at home. However, these approaches are not well standardized and largely applied yet. Therefore, this study aimed to elaborate a protocol for the utilization of the Sharesource platform to facilitate the practical management of patients treated with APD. A series of expert meetings were held between September 2022 and January 2023 in Italy. The participants (ten nephrologists and five nurses) from nine Italian public dialysis centers shared their opinions, examined the current scientific literature in the field, and reviewed the key characteristics of the Sharesource system to achieve a common position on this topic. A detailed and practical document containing experts' opinions and suggestions on the use of the Sharesource platform for the management of patients treated with APD was produced. This expert opinion might represent a new useful instrument in clinical practice for managing patients undergoing home-based peritoneal dialysis (PD) through the Sharesource platform, which is valid not only for Italy. These recommendations pave the way to novel patient-centered and personalized therapeutic approaches for ESKD and highlight the advantages of telemedicine and remote monitoring in the management of patients with ESKD undergoing PD and its positive impact on their quality of life.

Ultrafiltration Patterns during Automated Peritoneal Dialysis: Findings and Insights to Peritoneal Physiology.

With the growing use of automated peritoneal dialysis (APD), it is important to improve our knowledge of the clinical patterns and physiology of APD treatment sessions. The ultrafiltration (UF) achieved during each cycle of an APD treatment is assumed to be relatively linear if the delivered prescription is the same. We set out to determine if that is indeed the case. Single-center, cross-sectional study of prevalent PD patients. All adult APD patients (> 18 years of age), who had been on PD for >3 months, and >3 months on APD were included. Continuous ambulatory PD patients or those with peritonitis within 3 months of the consent date were excluded. Individual treatment data from 7 consecutive APD treatment sessions with consistent dialysate composition for each cycler exchange were collected for each subject. Thirty-nine subjects met the inclusion criteria and were enrolled. The probability of yielding a positive UF was 48.9% for cycle 1, rising to 90.5% by cycle 6. Adjusting for average dextrose concentration, dwell time, fill volume, solute transfer rate, and number of cycles, we observed that cycles 2 through 6 achieved progressively higher UF volumes than cycle 1 (p < 0.001). The first and last cycles demonstrated significantly different cycle UF volumes compared to a middle cycle (-230 ml and 277 ml, respectively, p < 0.001). We observed a consistent increase in UF volumes achieved per cycle over the course of an APD treatment session with numerous clinical and physiologic implications. This provides the foundation for future studies investigating peritoneal inter-cycle variations and membrane physiology.

A Randomized Controlled Trial Comparing Automated Peritoneal Dialysis and Hemodialysis for Urgent-Start Dialysis in ESRD

Peritoneal dialysis (PD) shows promise for urgent-start dialysis in end-stage renal disease (ESRD), with automated PD (APD) having advantages. However, there is limited multicenter randomized controlled trial (RCT) evidence comparing APD with temporary hemodialysis (HD) for this indication in China. This multicenter RCT enrolled 116 patients with ESRD requiring urgent dialysis from 11 hospitals, randomized to APD or HD. Patients underwent a 2-week treatment with APD or HD via a temporary central venous catheter (CVC), followed by a maintenance PD. Outcomes were assessed over 12 months during 8 visits. The primary outcome was dialysis-related complications. The 1-year incidence of dialysis-related complications was significantly lower in the APD group than in the HD group (25.9% vs. 56.9%, P= 0.001). No significant differences were found between the groups in terms of PD catheter survival rates (P= 0.388), peritonitis-free survival rates (P= 0.335), and patient survival rates (P= 0.329). In terms of health economics, the total direct medical cost of the initial hospitalization for patients with ESRD was significantly lower in the APD group (27,008.39 CNY) than in the HD group (42,597.54 CNY) (P= 0.001), whereas the duration of the first hospital stay showed no significant difference (P= 0.424). For patients with ESRD needing urgent initiation of dialysis, APD was associated with a lower incidence of dialysis-related complications and lower initial hospitalization costs compared with HD, with no significant differences in PD catheter survival rate, peritonitis-free survival rates, or patient survival rates. These findings can guide clinical decision-making for the optimal dialysis modality for patients requiring urgent dialysis initiation.

Assessment of the perceptions of health-related quality of life in Greek patients undergoing automated peritoneal dialysis with remote monitoring: A qualitative study.

This study aimed to explore in depth the lived experience and quality of life outcomes in patients receiving automated peritoneal dialysis (APD) treatment. The study adhered to the standards of the Consolidated Criteria for Reporting Qualitative Research. A total of 19 APD patients were recruited and assessed using in-depth semi-structured interviews on various aspects of life with respect to APD modality. The interviews were transcribed verbatim and analyzed using Interpretive Phenomenological Analysis. Study findings generated five superordinate themes: (a) treatment-free daily routine, (b) sleep disturbances, (c) remote care, (d) limitations of peritoneal dialysis, and (e) the dimension of chronic disease. Further analysis of the material revealed the relationship of these themes with individual patient characteristics. Overall, our findings suggest that APD characteristics contribute to the perceptions of quality of life in patients under dialysis considerably.

Improving self-dependency in Pakistan: Experience of a locally prepared automated PD machine.

The increasing burden of haemodialysis on healthcare systems merits efforts to make peritoneal dialysis (PD) more accessible to the population in need of kidney replacement therapy. Automated PD (APD) may be a suitable alternative to continuous ambulatory peritoneal dialysis for home dialysis especially for children, elderly and patients who lead a busy schedule in their jobs thus leaving more time for personal and family activities during the day. Recently, a local bioengineering company took the initiative to develop a locally manufactured, low-cost APD cycler in Pakistan, with an aim to improve the self-dependency and home-based kidney replacement therapy. We herein present our first experience of APD on this locally manufactured APD cycler. It was an investigator-led study on the utility of a locally manufactured APD cycler and the safety and efficacy of the standard operating procedures developed and adopted by the study authors. A total of eight patients agreed to participate in this study extending from September 2021 to August 2022. There were four male and four female patients, and the mean age was 52.5 + 19.71 years. The locally manufactured cycler provided more than 1600 h of APD sessions. The APD sessions were well tolerated with only a few instances of minor mechanical and software issues that did not require termination of therapy. There were no episodes of peritonitis; however, one of the patients had an episode of exit site and tunnel infection that did not seem to be related to the procedure. Our experience with locally manufactured APD cycler was successful and without major adverse events. We believe the locally produced APD cycler is a viable cost-effective option for patients requiring PD and may herald a new era of self-dependency for patients considering or undergoing PD in Pakistan.

Successful pregnancy in peritoneal dialysis: a case report

Introduction: Conception in dialysis patients is a rare event. In peritoneal dialysis (PD), it is exceptional due to the technique’s short half-life, as these are young women who are often waiting for a transplant project. Clinical observation: We report a case of successful pregnancy conducted exclusively on peritoneal dialysis in a patient on PD for 2 years with preserved residual renal function. At the beginning of pregnancy, our patient was on continuous ambulatory peritoneal dialysis (CAPD), and at 12 weeks of amenorrhea (WA), we indicated automated peritoneal dialysis (APD) for better fluid and sodium depletion and adequate dialysis. The delivery was programmed at 35 WA per caesarian section, which gave birth to a newborn weighing 3.5 kg and with an Apgar index of 10/10. CAPD was resumed 2 weeks later. After 4 years of follow-up, the child is in good health, and our patient is on APD. Discussion: In peritoneal dialysis, pregnancy remains a rare but possible event. It requires regular adaptation of the prescription of dialysis and a close clinical and biological follow-up to improve the maternal-fetal prognosis. Conclusion: Successful pregnancy in PD requires multidisciplinary care. The prognosis has improved thanks to advances in the technique (APD, extrarenal) and the introduction of erythropoietin. However, the data are insufficient, and more recent studies on larger numbers are needed.

Use of eHealth and remote patient monitoring: a tool to support home dialysis patients, with an emphasis on peritoneal dialysis

ABSTRACT Implementing eHealth requires technological advancement, universal broadband and internet access, and devices to conduct telemedicine and remote patient monitoring in end-stage kidney disease patients receiving home dialysis. Although eHealth was beginning to make inroads in this patient population, the COVID-19 pandemic spurred telemedicine usage when many regulations were waived during the Public Health Emergency to limit the spread of infection by endorsing social distancing. At the same time, two-way communication automatic peritoneal dialysis cyclers were introduced to advance remote patient monitoring. Despite the numerous advantages and potential benefits afforded by both procedures, challenges and untapped resources remain to be addressed. Continuing research to assess the use of eHealth and technological innovation can make eHealth a powerful tool in home dialysis. We review the past, present and future of eHealth and remote patient monitoring in supporting home dialysis.

Automated peritoneal dialysis: Challenge and hope for Indonesia.

Peritoneal dialysis utilisation in Indonesia decreased yearly from 6.6% in 2014 to 1.6% in 2018. Various efforts have been made by the government and the Indonesian Nephrologist Organization (PERNEFRI) through education and regulation to optimise the use of peritoneal dialysis, but have yet to succeed. The simplicity of automated peritoneal dialysis (APD) made it worth considering as another solution to optimise peritoneal dialysis in Indonesia. Several advantages are offered by using APD, such as providing more time for activities compared to continuous ambulatory peritoneal dialysis, cheaper cost than haemodialysis and allowing remote monitoring. The advantages of APD make it a promising kidney replacement therapy (KRT) modality for developing countries like Indonesia, but the application is scarce. Some of the challenges in implementing APD in Indonesia include APD machines and fluids that are not available in the Indonesian market; the price of machines and fluids is still high; health workers are not familiar with APD; patients and their families not knowing APD as one of KRT; and APD machines distribution in archipelagic country is challenging.

#2784 Deep learning algorithm predicts individual ultrafiltration trajectories for patients on automated peritoneal dialysis 12 weeks ahead

Abstract Background and Aims Adequate small solute clearance and ultrafiltration (UF) are the main requirements for fluid and salt homeostasis on peritoneal dialysis (PD). New automated peritoneal dialysis (APD) systems that allow remote patient monitoring in terms of PD treatment analysis have the potential to improve clinical outcomes. UF on APD although dependent on PD prescription, i.e. fill volumes and glucose concentration, exhibits substantial intra- and interindividual variation, even day-by-day. As conventional statistical methods are not able to assess these complex non-linear relationships adequately, we aimed to build a deep learning algorithm to predict ultrafiltration trajectories of individual patients 12 weeks ahead. Method Data on daily UF and PD prescriptions (i.e., glucose concentration, fill volumes) was extracted from the APD cycler management software (PD Link, Baxter, IL, USA) and patient charts at the Medical University of Vienna, for a secondary analysis of this cohort. The Keras high-level API for TensorFlow in R software (R Core Team 2023) was used to create a Long Short-Term Memory (LSTM) recurrent neural network based on historic prescription and gcUF data of 26 weeks (after the first 90 days of APD) to predict individual UF trajectories for the following 12 weeks. Results APD machine readouts from a total of 123 patients, with a mean time on PD of 117 (±73) days, were retrieved. The final recurrent neural network consisted of four LSTM layers with 64 cells each, sigmoid activation. The final model was fit using 30 epochs, 49 steps per epoch, and recurrent dropout to avoid overfitting. A 40-40-20% data split was used to train, validate, and test the model adequately. This deep learning algorithm was able to predict individual UF values, for each day of the upcoming 12 weeks, with an accuracy of at mean 201ml. Upon visual inspection, predicted individual UF trajectories smoothly resemble the overall day-by-day trajectory of the patient but fail to account for extreme spikes in either direction. Conclusion In conclusion, historic daily APD cycler and prescription data in coalescence with respective daily measurements of membrane function (i.e., gcUF) can be used to predict individual daily ultrafiltration values and trajectories of APD patients 12 weeks ahead using a deep learning algorithm. Therefore, continuous collection of PD prescription data and UF measurements may be used to monitor peritoneal membrane function of patients on APD and alert clinical teams upon detection of relevant changes of UF trajectories already 12 weeks ahead to facilitate early intervention. In contrast to current “screening” methods on PD, i.e., Peritoneal Equilibrium Test, these methods could reduce treatment burden.

#2249 Morning blood pressure and heart rate surge in peritoneal dialysis patients

Abstract Background and Aims The increased surge of blood pressure (BP) early in the morning and the parallel increase of heart rate (HR) are risk factors for cardiovascular disease in general and CKD populations. Early morning changes in these parameters have not been investigated in peritoneal dialysis (PD) patients. The aim of the study is to correlate the morning fluctuations of BP and HR with left ventricular hypertrophy and cardiovascular risk. Method This was a cross-sectional study of PD patients followed-up in our Peritoneal Dialysis Unit (PDU). At their regular visit to our PDU, a 24-hour ambulatory BP measurement (Mobil-o-graph®) was performed. A diary was given to the patients in order to record the time they performed their evening exchange (continuous ambulatory peritoneal dialysis- CAPD) or connection to the automated peritoneal dialysis (APD) machine, the time they laid down, the time they approximately fell asleep, when they woke up in the morning, when they inclined from the bed and the time they performed the morning exchange or disconnection. The 24-hour BP recordings were analyzed in the available software and calculations were done based on the diary information; pre-awakening BP, HR surges, nocturnal dipping, weighted 24 h systolic BP and HR variability. Demographic, laboratory data and left heart hypertrophy parameters of the patients were also recorded. 35 patients were eligible for participation in the study; 2 denied participation, 1 was rejected due to ongoing cancer therapy and two patients were declined due to invalid BP measurements. Finally 30 patients (10 males and 20 females) were analyzed, 9 were on CAPD and 21 were on APD. Results The mean age of the patients was 60.5 ± 12.6 years old and the median PD vintage was 21.5 months (8.25-58) (Table 1). Left Ventricular Mass index (LVMi) was 99.01 ± 28 g/m2 (Table 1). The 24h systolic BP was 125.66 ± 10.9 mmHg and the diastolic BP was 79.59 ± 7.7 mmHg (Table 2). The mean pre-awaking Systolic BP surge was 10.76 ± 9.7 mmHg, the median non-dipping blood pressure 8.6 (IQR 1.11-12.86), the mean heart rate surge was 3.3 ± 4.7 /min and the mean non-dipping HR was 9.7 ± 5.9/min (Table 2). There was no statistically significant correlation of the parameters above with the LVMi. Patients with high cardiovascular risk (diabetes, coronary heart disease, heart failure) had statistically higher non-dipping BP (27 vs 12.3 mmHg, p = 0.034) and higher nighttime SPB (27 vs 20.74 mmHg, p = 0.024). When compared patients in CAPD vs APD, there were no differences in the pre-awaking BP or the rest of the measurements performed, although APD patients recorded interrupted sleep due to the alarms of the APD machine. Conclusion PD patients with high cardiovascular risk had higher nondipping BP and nighttime systolic BP compared with patients without cardiovascular disease. There were no correlations of BP and heart rate morning surge with left ventricular hypertrophy or PD mode.

#1325 Patients reporting not “sleeping normally” are more likely to transition to in-center hemodialysis within 90 days of peritoneal dialysis start

Abstract Background and Aims Although there are many advantages to home dialysis therapies such as peritoneal dialysis (PD), many patients drop out of PD and transition to in-center hemodialysis (ICHD). Reasons for this transition are varied and may be multifactorial. The current analysis aims to assess whether self-reported abnormal sleep is associated with transition to ICHD within 90 days of starting automated peritoneal dialysis (APD). Method Patients initiating APD at any Fresenius Kidney Care dialysis clinic between 2017-2019 were eligible for inclusion in this retrospective database analysis (n = 11 668). Monthly, various health-related questions are asked to patients as part of routine care through a home therapy nursing assessment (HTNA). One question asks if the patient is “sleeping normally”. After removing patients without completed HTNA questions on sleep, there were 11 449 patients included. We assessed patients for the first 90 days of PD for transition to ICHD through survival analysis with other reasons for discontinuing PD treated as competing events. Results On average, patients were aged 57 (15) years with BMI of 31 (14.5) and 42% were female. Approximately 5% of patients described their sleep as not normal (553/11449) in their first HTNA. Patients who reported abnormal sleep had 4.4 times the rate of switching to ICHD when compared to patients who reported normal sleep (Hazard Ratio (HR): 4.4; 95% CI: 3.5-5.5, p &amp;lt; 0.0001). After controlling for case mix variables, the HR was 3.7 (95% CI: 2.9-4.7, p &amp;lt; 0.0001). Case mix variables included gender, dialysis vintage, age, race, ethnicity, body size, residual renal function, Charlson Co-morbidity Index, diabetes status, geographic region, size of PD program, insurance primary payor, relationship status, and primary language spoken. Conclusion Among patients dialyzing at home with APD, abnormal sleep may be a risk factor for transitioning from home therapy to ICHD. Identifying root causes of sleep disturbances may help to prevent modality change.

#2292 Incremental peritoneal dialysis: an individualized therapy with better clinical outcomes and reduced environmental and economic impact

Abstract Background and Aims Incremental peritoneal dialysis (IPD) is based on the prescription of a dose lower than the standard “full dose” (SPD). The achievement of individualized clearance goals is based on the combination of peritoneal and renal clearance. IPD as the initial PD strategy seems to be a convenient and resource-sparing technique, but its impact in long term outcomes and in the environment lacks evidence. The aim of this study is to evaluate IPD outcomes and to analyze the potential impact of this initial approach on costs, total and plastic waste, and water consumption. Method Single-center observational retrospective study that included a cohort of 87 prevalent PD adults. Patients were assigned in two groups according to their initial PD prescription—IPD group [continuous ambulatory PD (CAPD): less than 4 dwells daily, less than 2L dwell volume, and/or PD less than 7 days/week; automated PD (APD): without a long dwell, less than 10 L delivered, and/or PD for less than 7 days/week] and SPD group. Primary outcomes were residual kidney function preservation, technique survival and mortality. Secondary outcomes were peritonitis rate and hospitalizations. The reductions related to costs, total and plastic waste, and water usage were also compared between groups. Results In 57 (65%) of the patients IPD was the initial therapy, while 30 (35%) patients were prescribed SPD. The median follow-up was 23 months and the median transition time from 2 to 3 and from 3 to 4 exchanges were 6 and 14 months in CAPD, respectively. APD patients transitioned to SPD after a median of 9 months. Patients in IPD group had a higher glomerular filtration rate (7 vs. 3.7, mL/min/1.73 m2, p &amp;lt; 0.001) in the first 6 months, and after 24 months (4.8 vs. 1.9, mL/min/1.73 m2, p = 0.002. IPD was also associated with a longer technique survival (p = 0.026), lower hospital admissions per year (0.23 vs. 0.5, p = 0.001), and lower mortality (1.8% vs. 13.3%, p = 0.027). Compared to SPD, 2 and 3 exchanges per day led to a reduction in costs of approximately 8500 or 4100 euros/patient-year, total waste of 266 or 143 kg/year/patient, in plastic waste of 159 or 69 kg/year/patient, and water savings of 28,620 or 12,420 L/year/patient, respectively. In APD, IPD led to a reduction of 4400 euros/ patient-year in cost, 211 kg/year/patient in total and of 139 kg/year/patient in plastic waste, and water savings of 25,020 L/year/patient. Conclusion Prescription of initial individualized IPD is associated with better clinical outcomes in patients with substantial RKF. This approach was a significant economic and environmental impact, with a reduction in total and plastic waste, and water consumption.

#1814 Infection associated pancreatitis in peritoneal dialysis, a case report

Abstract Background and Aims Peritoneal dialysis (PD) patients seem to have a higher incidence of acute alithiasic pancreatitis. Though rare and with some suggested triggers described in the literature, this is still a poorly understood and potentially life-threatening complication. We present a 60 years old woman concluding antimicrobial therapy with an icodextrin night-dwell regimen for peritonitis presenting with epigastric pain. This work reviews our approach to cloudy effluent from non-infectious causes during an infection while managing acute pancreatitis in the PD setting. We report diagnostic difficulties and treatment considerations with a positive outcome. Method We present a 60 years old woman on PD for one year presenting to the emergency room in November of 2023 with severe epigastric pain, nausea and emesis. She suffered from stage 5 chronic kidney disease due to autosomal dominant polycystic kidney disease and had disease complications as anemia and secondary hyperthyroidism controlled within targets. She was on automated PD (APD) with glucose based solutions. She was on the 17th of 21 days antibiogram guided treatment (ceftazidime) for a Enterobacter ludwigii PD-related peritonitis with good clinical evolution and peritoneal effluent (PE) leukocyte count per μl from 1258 to 91 in 5 days. In the previous 3 months she had had 2 other infectious episodes. A bacteremic urinary tract infection to E. coli associated with peritonitis treated with antibiogram guided therapy (ceftazidime) followed by C. difficile colitis treated with oral vancomycin. During each infection period she transitioned from APD to continuous ambulatory peritoneal dialysis with an icodextrin night dwell. On admission she presented with normal vital signs, no fever, and abdominal distention with severe epigastric tenderness to palpation without muscular guarding. Her dwell exchange showed blood-tinged cloudy PE. She had hemoglobin of 11.3 g/dl, otherwise normal blood cell counts, and raised amylase (213 UI/l) and lipase (1467 UI/l). There was no elevation of transaminases, cholestatic enzymes, C-reactive protein or procalcitonin and lipidemia or hyperbilirubinemia were normal. PE cell count showed 213/μl leukocytes and 202/μl erythrocytes. Abdominal ultrasound showed no evidence of an obstructive cause. She was admitted in the surgical care unit for a conservative and watchful approach. Results On presentation we accounted for the peritonitis still under treatment, acute pancreatitis, drug therapy and recently introduced icodextrin solution. The acute alithiasic pancreatitis diagnosis was established but there was still a possible causative role of icodextrin or infection and refractory peritonitis could also not be promptly excluded. The literature suggests icodextrin and other drugs as causes for acute pancreatitis in some patients but also mentions the possibility of cloudy or hemorrhagic effluent due to abdominal inflammation processes. Considering the clinical stability, the multiple possible contributing causative agents and the differential diagnosis of refractory peritonitis we closely monitored PE cell count evolution keeping the icodextrin dwell and ceftazidime prescriptions and collected samples for bacterial and fungal culture. The cultures were negative and stability of leukocyte count and mononuclear cell predominance (Fig. 1) helped us exclude the peritonitis hypothesis and attribute the PE changes to the pancreatitis process. Conclusion Inpatient monitoring and identifying all possible causes are essential to ensure good outcomes in PD patients suffering from acute pancreatitis. Full anamnesis, physical examination and close attention to laboratory findings were key in allowing adequate antibiotic therapy and resolution of the abdominal inflammatory process at hand while maintaining an adequate PD prescription.

#2355 Eradication of Staphylococcus aureus carriage in patients undergoing peritoneal dialysis

Abstract Background and Aims Peritonitis is a common and serious complication of peritoneal dialysis (PD). A single episode of severe peritonitis or multiple peritonitis episodes frequently leads to diminished peritoneal ultrafiltration capacity, hospitalization, and a switch to hemodialysis. Prevention of infection is the mainstay for the reduction of peritonitis rate. According to the current guidelines, we use nasal antibiotic prophylaxis if patients are identified as nasal Staphylococcus aureus carriers on screening prior to PD beginning. Eradication of S. aureus Regular with nasal mupirocin reduces the rate of exit-site infections but has uncertain effects on the risk of peritonitis. The aim of this study was to evaluate the rate of S. aureus peritonitis in our cohort of patients receiving PD. Method A retrospective single-center study was conducted in a large Italian PD center. We reviewed all cases of bacterial peritonitis from 1999 to 2023. Demographic and clinical characteristics of the patients and microbiological features of the bacteria identified in cultures were extracted from electronic health record. From 2011, all patients were screened before surgery for Methicillin-resistant S. aureus (MRSA) and methicillin-sensitive S. aureus (MSSA) with nares swabs. All patients with positive nasal colonization for MSSA and MRSA were treated with nasal mupirocin (nasal ointment twice daily for 5 consecutive days every 4 weeks) until eradication was confirmed by a nasal swab. According to our protocol, from 2011, screening for S. aureus carriage along peritoneal fluid culture was performed in all patients on PD with an episode of peritonitis to verify nasal colonization with S. aureus. The study was approved by the regional ethical committee of Emilia Romagna (507/2021/OSS/AOUMO SIRER ID 2845). Results Overall, 345 cases of peritonitis were reviewed in 214 patients who received peritoneal dialysis. In our center, the rate of peritonitis was 0.23 episodes/patient-year. After the introduction of nasal screening for S. aureus carriage, the episodes of S. aureus peritonitis decreased in frequency (0.0093 episodes/patient-year vs. 0.034 episodes/patient-year) and as absolute number (17.8% vs 3.6%; p = 0.001). No differences were observed in the rate of catheter removal in the two populations (p = 0.99). The age of 109 patients screened for S. aureus carriage was 64.1 ± 17 years. Males accounted for 58.9% and automated PD (APD) was chosen by 66% of the subjects. After an average period of 1.6 years from the start of PD, 7 patients experienced S. aureus peritonitis in the absence of exit-site or tunnel catheter infection. Nasal screening at the time of peritonitis showed that half of them were carriers of S. aureus and half were negative (one patient was not screened). Colonization from S. aureus was found in another 9 patients whose peritonitis was caused by a different type of bacteria (44% S. epidermidis, 33.3% Enterobacteriaceae, 11.1% Acinetobacter, and 11.1% culture-negative peritonitis). Conclusion Our data document that screening for S. aureus, along with other preventive measures, contributes to significantly reducing the rate of S. aureus peritonitis in patients screened and treated for S. aureus carriage at the time of PD start. Routine screening and the use of a mask during connection are required because recolonization occurs frequently in this population.

#897 Peritoneal inflammation in PD-related peritonitis induces systemic eryptosis: in vitro and in vivo assessments

Abstract Background and Aims Erythrocytes (RBCs) have a highly specialized and organized membrane structure and undergo programmed cell death, known as eryptosis ( = stress-induced RBC death mechanism). Triggers of eryptosis include oxidative stress, inflammation and several uremic toxins. Our preliminary data show a significant increase of eryptosis during peritoneal dialysis (PD) -associated peritonitis in PD patients. The aims of this study were: assessment of incrementation of eryptosis in PD patients with peritonitis, evaluation of the relationship between systemic eryptosis in peritonitis and specific peritonitis biomarkers in PD effluent (PDE), and confirmation of the induction of eryptosis by peritonitis in a vitro setting. Method We enrolled 34 PD patients in stable condition (without systemic inflammation nor PD-related peritonitis in the last 3 months), 31 PD patients with acute peritonitis, and 17 healthy subjects (CTR). For PD stable patients, blood samples for eryptosis evaluation were drawn during the regular outpatient. For PD patients with peritonitis, blood samples and PDE samples were collected at the time of peritonitis diagnosis. PDE samples were used for peritoneal White Blood Cell count (pWBC), peritoneal Neutrophil Gelatinase-associated Lipocalin (pNGAL) and peritoneal cytokines levels (IL-1β and IL-6) measurements. For in vitro study, healthy RBCs were exposed to plasma of 31 PD patients with peritonitis and plasma of CTR group for 2, 4 and 24 hours. Morphological markers of eryptosis (cell membrane scrambling, cell shrinkage) and eryptosis percentage (based on PS exposure at RBC surface and AnnexinV-binding) were evaluated by flow cytometric analyses in vivo and in vitro. Results Totally, 65 chronic PD patients were included in this study. 57% of patients were treated with continuous ambulatory PD (CAPD) and 43% with automated PD (APD). The median PD vintage was 38 months (IQR 3.6–124.9 months). Table 1 reports clinical data for our PD population (Table 1). The percentage of AnnexinV-binding RBCs was significantly higher in PD patients than in CTR (2.7%; IQR 1.6–3.9 vs CTR: 0.8; IQR 0.7–1.3 P &amp;lt; .05). Eryptosis levels did not differ significantly between PD pts with and without diabetes, with and without hypertension, with and without cardiovascular disease. Eryptosis showed no significant differences between patients treated by CAPD/APD, and with Kt/Vurea values ≤ 1.7 and &amp;gt; 1.7. Generally, RBCs of all 65 PD patients were dramatically deranged in their morphology. In particular, RBCs from PD patients with peritonitis were characterized by dramatically deranged morphology and increased median cell volume in comparison with PD stable patients (P &amp;lt; .001). The percentages of AnnexinV-binding RBCs were significantly increased in the PD-associated peritonitis group (9.6%; IQR 4.2–16.7 versus 2.7%; IQR 1.6–3.9) (P&amp;lt;.0001) (Fig. 1). The percentage of AnnexinV-binding RBCs was significantly higher in PD patients with peritonitis than in healthy CTR (P &amp;lt; .001). We confirmed these in vivo data by in vitro results: healthy RBCs incubated with plasma from PD patients with peritonitis demonstrated a significant increase of eryptosis compared to healthy RBCs exposed to plasma from control group at all times (Fig. 2). Furthermore, significant positive strong correlations were observed between eryptosis level and all analysed peritoneal biomarkers of peritonitis (Spearman's rho pWBC = 0.77, P&amp;lt;.001, Spearman's rho pNGAL = 0.64, P = .001, Spearman's rho IL-6 = 0.61, P = .003 and Spearman's rho IL-1β = 0.64, P = .001,) (Fig. 3). Conclusion We investigated a potential connection between systemic eryptosis and peritoneal biomarkers of peritonitis. In particular, we theorized that the eryptosis enhancement is directly connected with peritonitis, and, based on the results, we hypothesized that the peritoneal membrane injury could be related to eryptosis. Upregulation of inflammatory markers could explain the increased rate of systemic eryptosis during PD-related peritonitis. In particular, we corroborated this point with our observations about in vitro induction of eryptosis by plasma from PD patients on the first day of peritonitis.