Peritoneal Dialysis Fluid Research Articles

Improving peritoneal dialysis fluid culture-positivity yield from 2022 to 2023.

Microbiological testing of peritoneal dialysis bags for peritonitis often yields culture-negative results. Culture-negative samples should not exceed > 15% according to the International Society for Peritoneal Dialysis. To reduce this issue, the addition of a blood culture bottle incubation step to the culture process was introduced at the Infection Control Services Laboratory (ICSL) of the National Health Laboratory Services (NHLS). The aim of the study was to ascertain if the change in methodology increased the culture-positivity yield and reduced the culture-negative percentage. Data from the NHLS Central Data Warehouse (CDW) were analysed to compare the culture-positive results over two periods: June-December 2022 when the non-blood culture (B/C) bottle method was used and January-July 2023 when the B/C bottle method was implemented. The non-B/C culture method yielded a 23% culture-positivity yield, whereas the B/C bottle-based method yielded a 51% culture-positivity yield. However, the culture-negative yield for the B/C bottle-based method was high at 49%. The change in dialysis bag processing in 2023 led to a more than doubling in culture-positivity yield. However, the culture-negative percentage remained high. As a result, further modifications to the methodology are needed. The study findings illustrate that the addition of the B/C bottle incubation step significantly improved peritoneal dialysis bag culture yields which directly impacts patient management.

Delaying treatment for peritonitis could be related to longer hospitalization in patients on peritoneal dialysis

Abstract Background When peritoneal dialysis (PD)-related peritonitis occurs in PD patients, diagnostic and therapeutic approaches should be started as soon as possible. However, medical attention may be delayed in patients experiencing minimal symptoms with cloudy PD fluid (PDF). This study investigated differences between the first and later episodes of peritonitis and relationships between interval from peritonitis onset to attending hospital and both duration of hospitalization and medical expenses. Methods We retrospectively investigated 36 patients with multiple episodes of PD-related peritonitis among 125 patients receiving PD therapy from January 2016 during a 6-year period at a single center. Results In 50 episodes of PD-related peritonitis among outpatients, median interval from recognition of cloudy PDF to hospital visit was 4.0 h (interquartile range [IQR] 2.0–12.0 h). With the first episode of peritonitis, the median interval was 8.5 h (IQR 3.6–18.0 h), improving to 2.0 h (IQR2.0–3.3 h) with second and subsequent episodes of peritonitis after patients were provided with education in PD-related issues. Median duration of hospitalization associated with PD-related peritonitis was 16.0 days (IQR 14–22 days) when the interval to hospital visit was < 6 h, significantly shorter than the 20 days (IQR 16–39 days) when the interval from the patient recognizing peritonitis to hospital visit was ≥ 6 h. Conclusions Our results suggest that delaying the hospital visit might lead to longer duration of hospitalization, suggesting that effective educational approaches might be warranted to change behaviors during initial peritonitis.

The future of peritoneal dialysis.

Peritoneal dialysis (PD), long established as the leading form of home dialysis, has comparatively good 5-year outcomes and cost-utility analyses have consistently demonstrated benefits to both patients and payers. Future improvements should still be sought, such as the further development of promising technologies designed to limit PD-associated harm, but given the physical and anatomical constraints of PD, these are unlikely to be transformational through the dialysis process itself. Rather, future focus should be on interventions that are effective across the whole dialysis population, such as mitigating the rate of loss in residual kidney function, pharmacological interventions for symptoms of kidney failure and suppressing inflammation. The greatest future challenge for the modality is inequity of access. In Europe, variation in PD uptake is >10-fold across the continent, with several contributing factors: differing economic drivers, variation in the empowerment of patients, physician attitudes and bias, small centre size, lack of experience, a nursing staff crisis, poor organizational culture and a lack of motivation and educational opportunities. It is time for a collective effort to address this and recently EuroPD convened a policy forum to initiate a multistakeholder approach to the problem, which extends to home haemodialysis. Use of PD worldwide is also highly variable, for some of the same reasons listed above, but with the additional challenges of the high cost of PD fluid and the lack of universal healthcare coverage. In the future, PD could and should play an important part in providing equitable access to dialysis worldwide, but to achieve this-and for the sake of the planet-point-of-care dialysis fluid generation would be transformative.

Genomic characteristics of antimicrobial resistance and virulence factors of carbapenem-resistant Stutzerimonas nitrititolerans isolated from the clinical specimen

BackgroundStutzerimonas nitrititolerans (S. nitrititolerans) is a rare human pathogenic bacterium and has been inadequately explored at the genomic level. Here, we report the first case of carbapenem-resistant S. nitrititolerans isolated from the peritoneal dialysis fluid of a patient with chronic renal failure. This study analyzed the genomic features, antimicrobial resistance, and virulence factors of the isolated strain through whole genome sequencing (WGS).MethodsThe bacterial isolate from the peritoneal dialysis fluid was named PDI170223, and preliminary identification was conducted through Matrix-assisted laser desorption ionization/time of flight mass spectrometry (MALDI-TOF MS). WGS of the strain PDI170223 was performed using the Illumina platform, and a phylogenetic tree was constructed based on the 16S rRNA gene sequences. Antimicrobial susceptibility test (AST) was conducted using the TDR-200B2 automatic bacteria identification/drug sensitivity tester.ResultsS. nitrititolerans may emerge as a human pathogen due to its numerous virulence genes, including those encoding toxins, and those involved in flagellum and biofilm formation. The AST results revealed that the strain is multidrug- and carbapenem-resistant. The antimicrobial resistance genes of S. nitrititolerans are complex and diverse, including efflux pump genes and β⁃lactam resistance genes.ConclusionThe analysis of virulence factors and antimicrobial resistance of S. nitrititolerans provides clinical insight into the pathogenicity and potential risks of this bacterium. It is crucial to explore the mechanisms through which S. nitrititolerans causes diseases and maintains its antimicrobial resistance, thereby contributing to development of effective treatment and prevention strategies.

Linking clinical manifestations and causative organisms may provide clues for the treatment of peritoneal dialysis-associated peritonitis

IntroductionDifferent initial manifestations of peritoneal dialysis-associated peritonitis (PDAP) may depend on the type of pathogenic organism. We investigated the association between the clinical characteristics of PDAP and susceptibility to vancomycin and investigated the possibility of using vancomycin monotherapy alone as an initial treatment regimen for some PDAP patients to avoid unnecessary antibiotic exposure and secondary infection.MethodsPatients with culture-positive PDAP were retrospectively analyzed and divided into two groups: peritonitis with only cloudy effluent (PDAP-cloudy) or with cloudy effluent, abdominal pain and/or fever (PDAP-multi). The bacterial culture of PD effluent and antibiotic sensitivity test results were compared between groups. Logistic regression was used to investigate factors predicting susceptibility to vancomycin.ResultsOf 162 episodes of peritonitis which had a positive bacterial culture of PD fluid, 30 peritonitis were in the PDAP-cloudy group, and 132 peritonitis were in the PDAP-multi group. Thirty (100%) peritonitis in the PDAP-cloudy group had gram-positive bacterial infections, which was significantly greater than that in the PDAP-multi group (51.5%) (P < 0.001). Twenty-nine (96.7%) peritonitis in the PDAP-cloudy group were susceptible to vancomycin, compared to 67 (50.8%) in the PDAP-multi group (P < 0.001). The specificity of PDAP-cloudy for vancomycin-sensitive peritonitis was 98.48%. Only one patient (3.3%) in the PDAP-cloudy group experienced vancomycin-resistant peritonitis caused by Enterococcus gallinarum, which could neither be covered by vancomycin nor by the initial antibiotic regimen recommended by the current ISPD guidelines. The presence of only cloudy effluent was an independent predictor of susceptibility to vancomycin according to multivariate analysis (OR = 27.678, 95% CI 3.191-240.103, p = 0.003), in addition to PD effluent WBC counts (OR = 0.988, 95% CI 0.980–0.996, p = 0.004), diabetes mellitus (OR = 3.646, 95% CI 1.580–8.416, p = 0.002), first episode peritonitis (OR = 0.447, 95% CI 0.207–0.962, p = 0.039) and residual renal creatinine clearance (OR = 0.956, 95% CI 0.918–0.995, p = 0.027). Addition of these characteristics increased the AUC to 0.813 (95% CI 0.0.749–0.878, P < 0.001). The specificity of presenting with only cloudy effluent for vancomycin-sensitive peritonitis was 98.48%.ConclusionsCloudy dialysate, as the only symptom at PDAP onset, was an independent predictor of vancomycin-sensitive PDAP, which is an important new insight that may guide the choice of initial antibiotic treatment.

Pantoea peritonitis in peritoneal dialysis: a report of two cases and literature review

BackgroundPantoea spp., a non-encapsulated, non-spore-forming Gram-negative rod bacterium that belongs to the Erwiniaceae family, can be found as a colonizer in humans, plants, and the environment, such as water and soil. Although it has the pathogenic potential to cause disease in humans, patients infected with this pathogen generally experience favorable outcomes. In this article, we present two cases of peritoneal dialysis (PD)-associated peritonitis caused by Pantoea spp. along with literature review.Case presentationThe first case is a 66-year-old male patient with end-stage kidney disease (ESKD) on PD, admitted for P. dispersa peritonitis. He presented with abdominal pain and cloudy dialysis effluent, responding well to intraperitoneal vancomycin and cefepime. Antibiotics were deescalated to ceftazidime monotherapy on the basis of antibiotic susceptibility testing. Despite initial recovery with a 3-week course of antibiotics, he developed recurrent peritonitis with P. dispersa, necessitating PD catheter removal and transition to hemodialysis. The second case is a 42-year-old male patient with ESKD on PD who was admitted after 6 days of bloody PD fluid without trauma or associated symptoms. With elevated PD fluid cell counts and positive PD fluid culture showing Streptococcus mitis and P. agglomerans, he was empirically treated for PD-associated peritonitis with intraperitoneal vancomycin and cefepime. Due to a suboptimal response in repeat PD fluid cell counts at day 5, the PD catheter was removed, and he was switched to hemodialysis, followed by a 3-week course of intravenous ceftriaxone.ConclusionsWe described two unique cases of Pantoea peritonitis in PD, recurrent P. dispersa peritonitis and refractory P. agglomerans peritonitis, both of which resulted in PD catheter removal. Our cases indicate the formation of bacterial biofilm as a potential reason for recurrence of infection and underscores the importance of vigilant monitoring and need for PD catheter removal in Pantoea peritonitis.

Glucose-Free Solutions Mediated Inhibition of Oxidative Stress and Oxidative Stress-Related Damages in Peritoneal Dialysis: A Promising Solution.

Oxidative stress (OxSt) and inflammation are common in end-stage renal disease and dialysis patients; they are known risk factors for cardiovascular disease and mortality. In peritoneal dialysis (PD), OxSt and inflammation are even further increased compared to the already increased oxidative stress of their pre-dialysis phase. This is due to the high glucose-based solutions currently used, whose continuous contact with the peritoneal membrane can induce significant long-term morphological and functional changes (mesothelial to mesenchymal transition, thickening, neo-angiogenesis and fibrosis) of the peritoneal membrane. Oxidative stress plays a very important role in these processes, which may compromise the peritoneal dialysis procedure. There is, therefore, the need for more biocompatible dialysis fluids with polymers other than glucose to prevent and treat OxSt and inflammation. The most known and used of such glucose-free and more biocompatible peritoneal dialysis solutions is icodextrin, which has shown a protective effect from oxidative stress. This has supported the consideration of the use of glucose-free-based peritoneal dialysis fluids in order to reduce oxidative stress and improve peritoneal membrane survival. Studies investigating peritoneal dialysis with the use of osmo-metabolic agents (L-carnitine, xylitol and their combination) in peritoneal fluids replacing glucose-based fluids are, in fact, ongoing. They represent a promising strategy to reduce OxSt, preserve the peritoneal membrane's integrity and improve patients' outcome.

Rationale and design of ELIXIR, a randomized, controlled trial to evaluate efficacy and safety of XyloCore, a glucose-sparing solution for peritoneal dialysis.

Peritoneal dialysis adoption and technique survival is affected by limitations related to peritoneal membrane longevity and metabolic alterations. Indeed, almost all peritoneal dialysis fluids exploit glucose as an osmotic agent that rapidly diffuses across the peritoneal membrane, potentially resulting in metabolic abnormalities such as hyperglycemia, hyperinsulinemia, obesity, and hyperlipidemia. Moreover, glucose-degradation products generated during heat sterilization, other than glucose itself, induce significant morphological and functional changes in the peritoneum leading to ultrafiltration failure. The partial substitution of glucose with osmotic agents characterized by a better local and systemic biocompatibility has been suggested as a potential strategy to innovate peritoneal dialysis fluids. The approach aims to minimize glucose-associated toxicity, preserving the peritoneal membrane welfare and counteracting common comorbidities. In this work, we report the clinical trial design of ELIXIR, a phase III randomized, controlled, blinded outcome assessment study comparing Xylocore®, an innovative formulation based on Xylitol and l-carnitine, to standard glucose-based regimens, in end-stage kidney disease patients treated with continuous ambulatory peritoneal dialysis; 170 patients will be randomized (1:1) to receive XyloCore® or to continue their pre-randomization peritoneal dialysis (PD) therapy with glucose-only PD solutions, for 6 months. The primary study's objective is to demonstrate the noninferiority of XyloCore® in terms of Kt/V urea, for which a clinically acceptable noninferiority margin of -0.25 has been determined, assuming that all patients will be treated aiming to a minimum target of 1.7 and an optimal target of 2.0.

Peritoneal-dialysis-associated peritonitis due to Staphylococcus sciuri: a case report and literature review

BackgroundPeritoneal-dialysis-associated peritonitis is a serious complication of peritoneal dialysis; prevention and treatment are crucial to reduce patient morbidity and mortality. Staphylococcus sciuri is an organism that, although present in several animal species, rarely causes disease in humans, particularly in patients undergoing peritoneal dialysis.Case presentationA 54-year-old man with end-stage kidney disease on continuous ambulatory peritoneal dialysis was admitted to the emergency department with nausea, vomiting, slight abdominal distention, and cloudy peritoneal dialysis effluent. Relevant medical history included occupational exposure to different animal species. The white blood cell count in the peritoneal dialysis fluid sample was 11,200 cells/mm3 with 90% polymorphonuclear cells. Peritoneal-dialysis-associated peritonitis was diagnosed. Empirical antibiotic treatment was started according to the International Society for Peritoneal Dialysis guidelines. Staphylococcus sciuri was identified in the peritoneal dialysis effluent culture by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. The treatment was modified on the basis of the sensitivity results. Medical cure was established on the basis of the negative result of the dialysate culture and absence of alterations in the cell count with differential after the end of treatment. The patient was instructed to be careful when administering peritoneal dialysis, especially in the care involved in being in contact with animals.ConclusionsThis article highlights the importance of Staphylococcus sciuri as a significant pathogen due to its virulence and antibiotic resistance, especially in patients undergoing peritoneal dialysis. Prevention strategies as well as timely diagnosis and treatment compliance according to the International Society for Peritoneal Dialysis are essential for successful outcomes.

Pathophysiological Mechanisms of Peritoneal Fibrosis and Peritoneal Membrane Dysfunction in Peritoneal Dialysis.

The characteristic feature of chronic peritoneal damage in peritoneal dialysis (PD) is a decline in ultrafiltration capacity associated with pathological fibrosis and angiogenesis. The pathogenesis of peritoneal fibrosis is attributed to bioincompatible factors of PD fluid and peritonitis. Uremia is associated with peritoneal membrane inflammation that affects fibrosis, neoangiogenesis, and baseline peritoneal membrane function. Net ultrafiltration volume is affected by capillary surface area, vasculopathy, peritoneal fibrosis, and lymphangiogenesis. Many inflammatory cytokines induce fibrogenic growth factors, with crosstalk between macrophages and fibroblasts. Transforming growth factor (TGF)-β and vascular endothelial growth factor (VEGF)-A are the key mediators of fibrosis and angiogenesis, respectively. Bioincompatible factors of PD fluid upregulate TGF-β expression by mesothelial cells that contributes to the development of fibrosis. Angiogenesis and lymphangiogenesis can progress during fibrosis via TGF-β-VEGF-A/C pathways. Complement activation occurs in fungal peritonitis and progresses insidiously during PD. Analyses of the human peritoneal membrane have clarified the mechanisms by which encapsulating peritoneal sclerosis develops. Different effects of dialysates on the peritoneal membrane were also recognized, particularly in terms of vascular damage. Understanding the pathophysiologies of the peritoneal membrane will lead to preservation of peritoneal membrane function and improvements in technical survival, mortality, and quality of life for PD patients.

Pressure induces peritoneal fibrosis and inflammation through CD44 signaling

Peritoneal dialysis (PD) is a widely used sustainable kidney replacement therapy. Prolonged use of PD fluids is associated with mesothelial-mesenchymal transition, peritoneal fibrosis, and eventual ultrafiltration (UF) failure. However, the impact of pressure on the peritoneum remains unclear. In the present study, we hypothesized increased pressure is a potential contributing factor to peritoneal fibrosis and investigated the possible mechanisms. In vitro experiments found that pressurization led to a mesenchymal phenotype, the expression of fibrotic markers and inflammatory factors in human mesothelial MeT-5A cells. Pressure also increased cell proliferation and augmented cell migration potential in MeT-5A cells. The mouse PD model and human peritoneum equilibrium test (PET) data both showed a positive association between higher pressure and increased small solute transport, along with decreased net UF. Mechanistically, we found that significant upregulation of CD44 in mesothelial cells upon pressurization. Notably, the treatment of CD44 neutralizing antibodies prevented pressure-induced phenotypic changes in mesothelial cells, while a CD44 inhibitor oligo-fucoidan ameliorated pressure-induced peritoneal thickening, fibrosis, and inflammation in PD mice. To conclude, intraperitoneal pressure results in peritoneal fibrosis in PD via CD44-mediated mesothelial changes and inflammation. CD44 blockage can be utilized as a novel preventive approach for PD-related peritoneal fibrosis and UF failure.

Enterogenic bacterial peritonitis and delayed chylous ascites associated with overheated peritoneal dialysis fluid infusion.

Enterogenic bacterial peritonitis and delayed chylous ascites associated with overheated peritoneal dialysis fluid infusion.

A case of recurrent peritoneal dialysis-related peritonitis caused by Stenotrophomonas maltophilia during ongoing antibiotic treatment for Enterococcus faecalis-induced peritonitis.

Recurrent peritonitis is a serious complication of peritoneal dialysis (PD), which could result in PD withdrawal and mortality. However, cases of recurrent peritonitis occurring during ongoing antimicrobial therapy are rarely reported. Herein, we present a 71-year-old man who experienced initial peritonitis due to Enterococcus faecalis. Despite effective antimicrobial therapy, he developed recurrent peritonitis while on antimicrobial therapy. PD fluid culture analysis yielded Stenotrophomonas maltophilia (S. maltophilia). He was treated with multiple antimicrobials, and the peritoneal catheter was removed. To the best of our knowledge, this is the first case of recurrent peritonitis caused by S. maltophilia, which was developed during antimicrobial treatment. Our report findings suggest the importance of considering S. maltophilia infection in an atypical case of very early recurrent peritonitis.

Detections of Chemicals and Migratory Plastics in Peritoneal Dialysis Fluids

Background: Peritoneal dialysis (PD) is an important modality of renal replacement therapy (RRT). Peritonitis and ultrafiltration failure are complications that have a long-term impact on PD patients. Besides touch contamination, procedural errors and clinical reasons of peritonitis, contaminants, and constituents of peritoneal dialysis fluids (PDFs) have been implicated in causing peritonitis and ultrafiltration failure. This study was aimed to test the PDFs in India for the presence of migratory plastics. Materials and Methods: PDFs from the two manufacturers in India were tested using liquid chromatography mass spectrometry (LCMS) and gas chromatography mass spectrometry (GCMS) with headspace analysis (volatile compounds) and pyrolysis of plastics (polymer compounds). The storage conditions and handling were uniform. Results: The results revealed impurities of acetate compounds and aldehyde derivatives of glucose degradation products (GDPs) with contaminants and leachable plastics. There were high levels of GDP derivative in the form of 5-hydroxymethylfurfural compounds (5-HMF). The analysis revealed the presence of plastic softeners in very high concentrations. Conclusion: The study unmasks the presence of chemicals and GDPs that can be implicated in pathogenesis of sterile peritonitis and ultrafiltration failure. The study demonstrated the presence of leachable plastics. In conclusion, LCMS and GCMS studies can be used to test PDFs for unwanted chemicals prior to human use.

Astragalus polysaccharides augment BMSC homing via SDF-1/CXCR4 modulation: a novel approach to counteract peritoneal mesenchymal transformation and fibrosis

PurposeThis study aimed to evaluate the potential of astragalus polysaccharide (APS) pretreatment in enhancing the homing and anti-peritoneal fibrosis capabilities of bone marrow mesenchymal stromal cells (BMSCs) and to elucidate the underlying mechanisms.MethodsForty male Sprague-Dawley rats were allocated into four groups: control, peritoneal dialysis fluid (PDF), PDF + BMSCs, and PDF + APSBMSCs (APS-pre-treated BMSCs). A peritoneal fibrosis model was induced using PDF. Dil-labeled BMSCs were administered intravenously. Post-transplantation, BMSC homing to the peritoneum and pathological alterations were assessed. Stromal cell-derived factor-1 (SDF-1) levels were quantified via enzyme-linked immunosorbent assay (ELISA), while CXCR4 expression in BMSCs was determined using PCR and immunofluorescence. Additionally, a co-culture system involving BMSCs and peritoneal mesothelial cells (PMCs) was established using a Transwell setup to examine the in vitro effects of APS on BMSC migration and therapeutic efficacy, with the CXCR4 inhibitor AMD3100 deployed to dissect the role of the SDF-1/CXCR4 axis and its downstream impacts.ResultsIn vivo and in vitro experiments confirmed that APS pre-treatment notably facilitated the targeted homing of BMSCs to the peritoneal tissue of PDF-treated rats, thereby amplifying their therapeutic impact. PDF exposure markedly increased SDF-1 levels in peritoneal and serum samples, which encouraged the migration of CXCR4-positive BMSCs. Inhibition of the SDF-1/CXCR4 axis through AMD3100 application diminished BMSC migration, consequently attenuating their therapeutic response to peritoneal mesenchyme-to-mesothelial transition (MMT). Furthermore, APS upregulated CXCR4 expression in BMSCs, intensified the activation of the SDF-1/CXCR4 axis’s downstream pathways, and partially reversed the AMD3100-induced effects.ConclusionAPS augments the SDF-1/CXCR4 axis’s downstream pathway activation by increasing CXCR4 expression in BMSCs. This action bolsters the targeted homing of BMSCs to the peritoneal tissue and amplifies their suppressive influence on MMT, thereby improving peritoneal fibrosis.

#1608 Use of intraperitoneal hydration by peritoneal dialysis fluid as a complementary palliative therapy in peritoneal dialysis patients

Abstract Background and Aims End life care should manage pain, other distressing symptoms and guarantee sufficient hydration. It should also involve psychological, social and spiritual support. Palliative care in peritoneal dialysis is a new and growing clinical question. There are several open questions: Should we stop peritoneal dialysis totally? Should we go on with peritoneal dialysis in a reduced fashion? Hereby we report a new application of CAPD exchanges, intraperitoneal hydration, in end life care of peritoneal dialysis patients. Method In seven peritoneal dialysis patients (2 female, 3 male, age 82 to 90 years) affected by severe heart failure (3 patients), dementia (2 patients) and malnutrition-inflammation syndrome (2 patients) we applied the concept of intraperitoneal hydration as a complementary palliative care. Peritoneal dialysis was switched into a single CAPD bag therapy utilizing a glucose concentration of 1.36% or 1.5%. Depending on the clinical hydration status 1000 ml of dialysis fluid was loaded daily or each other day without prior drainage. None of the patients was on intravenous therapy. Results The duration of the intraperitoneal hydration therapy varied between 5 and 16 days. In two cases, therapy was performed initially at the hospital ward and hereafter at a nursing home, whereas in the latter 5 cases at the patient's home by family members. No case of hypervolemia occurred. The intraperitoneal hydration therapy was well accepted by the family members. Conclusion The transformation of peritoneal dialysis from ultrafiltration and depuration into hydration without depuration seems to be a feasible approach. This approach should be kept in mind in special conditions such as end life palliative care and hypohydration.

#2103 Accuracy of a continuous glucose monitor in people with diabetes on peritoneal dialysis

Abstract Background and Aims Globally 40% of people receiving peritoneal dialysis (PD) have a diagnosis of diabetes. Good glycaemic control can by complicated by the obligate glucose load associated with PD. Monitoring and treatment of people with diabetes (PwD) on PD has been limited by reduced reliability of traditional markers of glycaemia such as HbA1c in end-stage kidney disease. Continuous glucose monitors (CGMs) have been increasingly used in the care of PwD over the last 20 years. Monitors worn on the upper arm or abdomen measure glucose in interstitial fluid at regular intervals over the 24 hour period. CGMs are currently unlicensed in PD populations as they have not been tested in large scale studies. Concerns remain around accuracy in the presence of potentially interfering substances generated by the breakdown of osmotic agents used in PD fluid (e.g. Icodextrin). We aimed to assess the analytical and clinical accuracy of the FreeStyle Libre(FSL) CGM system in PwD on maintenance PD. Method We conducted a single centre observational study of 10 PwD who had been on PD for at least 3 months. For the 10 day study period participants wore a blinded research model FSL monitor which measured interstitial glucose levels every 15 minutes. Results from the FSL were compared with; Analytical accuracy was assessed using three methods; Clinical accuracy was assessed using the Parkes consensus error grid to assign each pair of readings to one of five risk zones and quantify the clinical implications of any difference between the two measurements. The International Organisation for Standardisation guidelines stipulates 99% of pairs should be in zones A and B, denoting little or no effect on clinical actions. Results Of 11 recruited participants, 10 completed the 10 day study period resulting in 76 paired CGM-YSI measurements and 375 paired CGM-CBG measurements. 7 participants were on APD and 3 on CAPD. All participants were prescribed a PD regime that included one daily dwell with Icodextrin. The aggregate MARD was 9.4% (95% CI 7.9, 10.4) for CGM-YSI matched pairs and 17.6% (95% CI 17, 19.3) for CGM-CBG matched pairs. Spearman's r was 0.94 (p &amp;lt; 0.0001) for CGM-YSI and 0.89 (p &amp;lt; 0.0001) for CGM-CBG. From Bland-Altman analysis, the systematic error of the CGM compared with YSI and CBG was −0.81 mmol/l (SD 0.81) and −1.6 mmol/l (SD 1.9) respectively. Parkes consensus error grid analysis showed that compared with YSI and CBG respectively, 100% and 99.9% of sensor values were in the clinically acceptable zones A and B (Fig. 1). Conclusion We have demonstrated satisfactory performance of the FSL monitoring system by both analytical and clinical metrics in this cohort of PD patients using treatment regimens including Icodextrin based fluids. CGMs provide much more information for the PwD and their clinical care team compared with random CBGs (which in themselves have been shown to exhibit significant between user variability) and time averaged markers such as HbA1c. They allow detection of asymptomatic hypoglycaemia and direct monitoring of the systemic effects of any change to the PD prescription resulting in a larger or smaller glucose load. These results should be reassuring for clinicians wishing to utilise the greater depth of information provided by CGMs to improve clinical care for their patients with diabetes on PD.

#1980 Past peritonitis episodes are linked to decreased peritoneal Immune Cell Function and Associated with Chronic Increased Peritoneal Inflammation

Abstract Background and Aims Chronic peritoneal inflammation and infectious complications occur in a significant proportion of PD patients. A relationship between peritoneal IL-6 levels and local immunocompetence is suspected. To analyse local immunocompetence, an ex-vivo stimulation assay of PD effluent was developed. The aim of this study was to analyse peritoneal inflammation and immunocompetence in a PD cohort in relation to clinical outcomes. Method Prospectively, 245 routinely performed 4-hour PETs (143 patients, 2679 patient-months) of patients exclusively receiving 2. generation PD fluids (two-chamber, pH neutral, low amount of glucose degradation products) were analysed. An ex-vivo cell stimulation protocol of the fresh effluents was performed of all PETs. Peritoneal immune cell function was analysed using ex-vivo Toll-like receptor (LPS/Pam3Cys) stimulated IL-6 release as an index of immunocompetence. The molecular effects of effluent components and the addition of alanyl-glutamine to PD fluid were analysed in heterologous cell stimulation experiments and using an effluent proteomics and metabolomics approach. Results IL-6 in the effluent showed no association with various patient characteristics (incl. RRF, underlying disease, peritonitis episodes, time on PD). A significant association of peritoneal IL-6 with solute transport rates and systemic markers of uremic inflammation was found. IL-6 in effluent (HR 2.54) and stimulated 1 h effluent (HR 0.34) was predictive of subsequent peritonitis episodes. An inverse association was observed with ex-vivo stimulated IL-6 release from peritoneal cells (P = .02), most pronounced in patients with a history of peritonitis (P = .008). Patients with above median elevated IL-6 levels showed reduced peritoneal immune cell function. The results were validated in an independent multi-centre PD cohort (n = 48). A proteomics (n = 17) and targeted metabolomics (patients n = 134, 1004 metabolites) analysis of PD effluents show an overrepresentation of apoptosis and neutrophil degranulation pathways in patients with elevated effluent IL-6 levels and reduced response mechanisms to pathogens when compared to effluents from patients with low effluent IL-6 levels. Heterologous donor-PBMC stimulation (4 Healthy donors) with 4h PET PD-effluents of 20 patients showed reduced immunocompetence with elevated IL-6 (P = .038) and improved immunocompetence when 8 mM alanyl-glutamine were added to the PD fluid during the dwell. These results could also be validated in a post-hoc analysis of a RCT testing alanyl-glutamine addition to PD fluid for 8 weeks in PD patients. Conclusion This is the first longitudinal study to show the relationship between peritoneal inflammation and impaired immune function of peritoneal cells, possibly predisposing to infectious complications. The possible underlying mechanistic link may represent the biological correlate (“immune-paralysis”) for PD patients at increased risk for recurrent episodes of peritonitis.

#1319 “Peritoneal volume influence on bedside ultrasound or point-of-care ultrasonography (POCUS) volume assessment in peritoneal dialysis patients”

Abstract Background and Aims To study the variations in hydrosaline overload ultrasound parameters using PoCUS in PD patients with full and drained peritoneum and their correlation with clinical parameters. Method PoCUS and intra-abdominal pressure (IAP) measurements were performed on included patients with a full peritoneum. After drainage, a new PoCUS and a bioimpedance analysis (BIA) were conducted. Results Seventeen patients were included: 70.6% male, mean age 66 ± 9.5 years. 65% had hydrosaline overload &amp;gt;1L as assessed by BIA. The mean IAP was 15 ± 3.9 mmHg. The maximum diameter of the IVC with full and drained peritoneum was 1.44 ± 0.35 cm and 1.53 ± 0.4 cm, respectively, with no significant difference (p = 0.179). The % collapsibility of IVC with full and drained peritoneum was 49 ± 23% and 47 ± 13%, respectively, with no significant difference (p = 0.58). Kerley B-lines with full peritoneum were 1.3 ± 1.5, and with drained peritoneum were 0.71 ± 1.16, with this difference approaching statistical significance (p = 0.063). The same analyses in subgroups of patients with volume overload by BIA (OH&amp;gt;1 or OH/ECW&amp;gt;15%) did not show significant differences. In the correlation analysis of variables, IAP and peritoneal dialysis fluid volume per m2 of body surface did not correlate with the diameters or collapsibility of IVC with full or drained peritoneum. The degree of overhydration by OH (L) correlated with IVC collapsibility with drained peritoneum (Spearman ρ = −0.43; p = 0.08), as did the overhydration by OH/ECW (Spearman ρ = −0.61; p = 0.02). These correlations disappeared with full peritoneum (p &amp;gt; 0.05). The same correlation analyses were performed in subgroups of patients with volume overload by BIA (OH&amp;gt;1L or OH/ECW&amp;gt;15%) and were not significant with either full or drained peritoneum. Conclusion We did not find significant differences in the ultrasound volume overload parameters with full vs. drained peritoneum in PD patients. However, indirect data indicate a lower sensitivity of PoCUS to hydrosaline overload with a full peritoneum.

#1217 Reinsertion of peritoneal dialysis catheter in a patient with Nocardial peritonitis: a case report

Abstract Background and Aims Peritonitis is a major drawback in patients on PD leading to technique failure, change in modality to hemodialysis, mortality. Nocardia infections are rare and occur mainly in immunocompromised individuals. Eleven cases of Nocardial peritonitis only have been reported. Given the rarity of the condition, duration of medical treatment, time at which catheter reinsertion can be done after treatment are not clear. We describe a case of nocardial peritonitis which presented with tunnel abscess and septic shock. Method Our patient is a 65 yr/M, DM &amp; HT, initiated on CAPD due to multiple access failure elsewhere. He was also on treatment with directly acting antiviral for HCV infection. He presented with fever, abdominal pain and cloudy peritoneal fluid. Vitals were HR 98/min, BP 90/ 60 mmHg, temperature 100 F. Abdominal examination showed insertion and exit site pus with tenderness (Fig. 1a,b). USG screening showed tunnel abscess. Labs showed hemoglobin 7.2 g/dL, white blood cell count 6200 cells/cu mm, platelet count 1.4 lakh/cu mm, SGOT 23 U/L, SGPT 15 U/L and peritoneal dialysis fluid count 1570. CT abdomen showed no intraabdominal abscess. He was started on intravenous antibiotic and ionotropic support. Emergent PD catheter removal was done in view of septic shock &amp; was dialysed via femoral tunneled catheter. Pus and peritoneal fluid culture grew Nocardia spp after six days of incubation. Intravenous cotrimoxazole was given for 2 weeks and intravenous ceftriaxone was given for 4 weeks followed by oral cotrimoxazole 960 mg thrice weekly. Results Following 7 months of treatment with cotrimoxazole, PD catheter was inserted laparoscopically after omentectomy and adhesiolysis. Peritoneal biopsy was taken at the time of catheter insertion, histopathology showed fragments of peritoneal tissue with scattered chronic inflammatory cells, culture was negative for Nocardia. PD catheter outflow dysfunction was noted after initiation of exchanges. CT abdomen showed migration of PD catheter tip following which catheter tip repositioning was done laparoscopically. During procedure, nodules were noted over peritoneum and bowel. Biopsy of the nodules were revealed foreign body granuloma and culture did not grow Nocardia (Fig. 2). Patient was initiated on three exchanges with 2.5% dextrose per day after a break-in period of 14 days. He continues to be on PD with good ultrafiltration. Conclusion There is not much data on reinsertion of PD catheter after nocardial peritonitis. One case of Nocardial peritonitis reported in literature, in which PD catheter was reinserted. Jamie Kendrick-Jones et al. [1] reported a case of Nocardial peritonitis in which catheter was reinserted after 1 year. To our knowledge this is the first case of Nocardial peritonitis which presented with tunnel abscess. Catheter was removed due to septic shock. Patient was treated with cotrimoxazole for seven months after which PD catheter insertion was done. Return to PD is feasible if Nocardial infection is identified and treated appropriately.