Peritoneal Dialysis Population Research Articles

#510 Evaluating tolvaptan as a protective agent for cardiac insufficiency in peritoneal dialysis patients

Abstract Introduction Peritoneal dialysis serves as a highly effective renal replacement therapy, offering prolonged preservation of residual renal function, improved blood pressure regulation, and enhanced quality of life. While diuretics are generally considered safe and beneficial in this context, their efficacy may be limited in certain cases. Background and Aims The rationale behind investigating the potential benefits of tolvaptan in peritoneal dialysis stems from existing studies in Asia, where the use of tolvaptan has been approved in this population. These studies, conducted on patients undergoing peritoneal dialysis, indicate notable improvements in urine output and key heart failure indicators such as Left Ventricular Mass Index (LVMI) and Brain Natriuretic Peptide (BNP). Materials & Methods Recognizing the significance of these findings, a recent meta-analysis was conducted to comprehensively assess the collective data. The meta-analysis encompassed data from five pertinent studies involving a total of 70 peritoneal dialysis patients, with an average age of 66.1 ± 15 years. Participants received tolvaptan in doses of up to 15 mg, and the mean follow-up period was 8.2 ± 3.9 months. Results Results from the meta-analysis revealed a significant increase in urine volume in two out of four instances (Mean Difference [MD]= +554.5 cc [379,730], I²=61.5). While most studies did not indicate substantial changes in body weight or renal kt/V, a notable reduction in Left Ventricular Mass Index was evident in two studies (MD= -43.28 [-84.9,-1.6], I²=80.6%). Additionally, a substantial reduction in BNP was reported in one study, with no documented adverse events across the studies. Conclusion As an adjunct therapy, tolvaptan exhibits potential benefits in volume control, potentially contributing to improved cardiac function in peritoneal dialysis patients. The findings of this study align with existing research, highlighting the positive impact of tolvaptan on heart failure markers. Nevertheless, further high-quality studies are imperative to consolidate and validate these observed benefits in the peritoneal dialysis population.

#521 Increasing levels of aortic peak wave velocity along with prolonged higher CaxP product is associated with mortality in peritoneal dialysis

Abstract Background and Aims Valvular calcification is concordant with vascular calcification and develops faster in end-stage renal disease patients than in the average population. There are contradictory reports about the pathophysiology and the predictive value of valvular calcification regarding mortality in this patient population. Aortic peak wave velocity (Vmax) measurement is a non-invasive and reliable marker for the diagnosis of valve calcification. Our study analyzes cardiovascular risk prediction effect of increasing levels of Vmax at different time points in peritoneal dialysis (PD) patients. Method We conducted a retrospective, single-center study of incident PD patients under follow-up between January 1992 and January 2023 in our clinic. Demographics, laboratory, and echocardiographic findings were obtained from medical records. Patients without a baseline echocardiography were excluded. ΔVmax is defined as the last Vmax minus baseline Vmax levels. The patients were divided into two subgroups: Vmax-stable and Vmax-increased. Results The baseline demographics, laboratory, and clinical characteristics, including daily elemental calcium and calcitriol usage, were similar between Vmax-stable and Vmax-increased groups. Baseline calcium (Ca), phosphate (P), and annual CaXP levels were significantly higher in Vmax-increased group [p = 0.01, p = 0.02, and (F(1,27) = 10.415, p = 0.003), respectively]. Cardiovascular mortality was 9.8% in Vmax-stable group and 26.8% in Vmax-increased group (p = 0.02). Conclusion During a follow-up of 20 years, increasing Vmax values were associated with higher CaxP levels in PD patients. Increased Vmax levels, along with higher CaxP levels, are associated with cardiovascular mortality. Even without clinical manifestations, Vmax follow-up is a non-invasive, easily accessible method and might identify the high-risk group regarding cardiovascular mortality in the PD population.

#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 < 0.0001) for CGM-YSI and 0.89 (p < 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.

#2234 A new formula for total body water in peritoneal dialysis patients

Abstract Background and Aims Peritoneal dialysis (PD) adequacy, assessed primarily by Kt/V, is crucial in routine clinical practice for detecting issues with PD treatment. This metric relies on urea levels and its volume (V) distribution, classically equivalent to total body water (TBW). TBW estimation, commonly achieved through the Watson and Watson (WW) formula, lacks dialysis patients in its original study, it also excluded patients with water metabolism disturbances, raising concerns about its generalizability to this population. Despite limitations, WW has been widely used in trials assessing optimal dialysis dosage in the PD population. Body composition monitoring (BCM) with bioimpedance (BI) offers a more reliable method for TBW determination, commonly used in dialysis programs for quantifying overhydration. However, its higher cost and limited availability compared to estimate formulas pose challenges. Thereby, this study aims to compare TBW values derived from the WW formula and BCM analysis with BI. Additionally, intends to create a new, patient-specific TBW formula based on biometric measurements for PD. Method We retrospectively analyzed adequacy measurements and BCM data from a Portuguese PD center. Patient information included age, sex, height, weight, and BCM-TBW and Percentage Body Fat (PBF). Derived parameters encompassed WW-derived TBW, Body Surface Area (BSA) via the DuBois formula and Body Mass Index (BMI). Statistical analysis, using Microsoft Excel 2017 and IBM SPSS version 25, with a p-value<0.05 considered significant, followed by a step-wise approach: Results 400 measurements were collected from 90 chronic PD patients. 25.1% (n = 23) were female (101 measurements), with a mean age of 56.2 ± 11.9 years. Mean weight was 74.0 ± 12.5 kg, BMI 26.4 ± 4.1 and BSA 1.80 ± 0.80. BCM TBW obtained was significantly lower compared to WW-TBW (33.7 and 38.4 litters respectively, mean difference −4.65 ± 4.17, P < .001). This difference correlated positively with increased PBF (ρ = 0.73, P < .001). BCM TBW correlated positively with weight, height, BMI and BSA (ρ = 0.62, ρ = 0.68, ρ = 0.28 and ρ = 0.62, respectively, with P < .001 overall), without correlation with age (ρ = 0.0, P = .99). For linear regression analysis, the first step was to exclude outlier values for BCM TBW using median ± 1.5 x interquartile range resulting in 383 measurements comprised between 22.15 and 44.95 L. A multiple linear regression using BSA, height, weight and sex to predict BCM TBW. The overall regression model was statistically significant (R2 = 0.59, F (4 378) = 138.17, P < .001). All the variables significantly contributed to the model at predicting BCM TBW (BSA: β = −0.283, P < .001; Height: β = 0.495, P < .001; Weight: β = 0.56, P < .001; Sex: β = 0.237, P < .001). Two formulas were extrapolated from this regression: Conclusion We present a pivotal formula for TBW calculation in PD patients, aiming to improve the correlation between provided Kt/V and clinical outcomes. This addresses the exclusion of diverse patient characteristics in previous studies. However, given the new evidence challenging the association between Kt/V and clinical outcomes in PD, it becomes imperative to appropriate measures for PD adequacy and subject them to examination in novel randomized clinical trials.

#1085 Prediction models for hospitalization in patients with advanced chronic kidney disease: systematic review, external validation and development study

Abstract Background and Aims Hospitalization is a common complication in patients with advanced chronic kidney disease (CKD). Predicting hospitalization would be beneficial for clinicians and patients. Clinicians may be assisted in adequate healthcare planning by being able to anticipate hospitalizations. Additionally, patients have indicated wanting more information about their risk of hospitalization. By providing patients a personal indication of their risk of hospitalization, they better know what to expect of the future which can foster a feeling of control. Especially for incident dialysis patients this might help, as they enter a new and to them still largely unknown stage of their disease. Moreover, if a patient knows they have a high risk of hospitalization, they may better cope with the hospitalization if it occurs, as it is less unexpected. Therefore, we aimed to 1) identify and give an overview of current prediction models for hospitalization in CKD patients, 2) externally validate these models, and 3) develop a new model if no well-performing models were identified. Method We performed a systematic review in PubMed to identify prediction models for hospitalization, length of stay (LOS), and readmission. Identified models were appraised using the Prediction model Risk of Bias Assessment Tool. We targeted three external validations in hemodialysis (HD), peritoneal dialysis (PD), and pre-dialysis patients in a Dutch dialysis and European pre-dialysis cohort. Prediction models were externally validated on discrimination (C-statistic) and calibration (calibration plot, slope, and calibration-in-the-large). We developed a Fine-Gray model for hospitalization within one year in patients initiating HD, taking into account the competing risk of death. Informed by model performance, we also investigated Cox and logistic regression as modeling strategies. We performed a sensitivity analysis, redefining the outcome to be predicted as the 1-year risk of hospitalization of 3 days or longer. Results From the systematic search, we identified 17 models in 6 studies. All models were developed in the USA or in China. Two models predicted hospitalization rate in incident PD patients and 3 models predicted 30-day readmission in maintenance HD patients and in CKD stage 3-5 patients not on dialysis discharged after a heart failure hospitalization. The risk of 1 and 6 hospitalizations within one year in prevalent HD patients were predicted by one model each. Prolonged LOS in PD patients was predicted by ten models. All models were of low quality with a high risk of bias. The most common shortcomings were using future information to make predictions, inadequate handling of missing data, and model overfitting. Due to underreporting and unavailability of predictors, we could only externally validate 3 models. These models were poorly calibrated and had poor discrimination. We developed a new model in 1,020 incident HD patients predicting 1-year risk of hospitalization. We used age, cardiovascular disease, diabetes mellitus, malignancy, estimated glomerular filtration rate, and body mass index as predictors, selected based on literature and clinical expertise. The model discriminated poorly (C-statistic, 95% confidence interval [CI]; 0.55, 0.53-0.58), also in targeted external validations in 620 PD patients (0.55, 0.52-0.58) and 1,718 pre-dialysis patients (0.52, 0.52-0.54). Calibration was poor for all models. Using different modelling strategies, model performance did not improve. In the sensitivity analysis, discrimination improved but was still low (HD population: 0.58, 0.55-0.62; PD population: 0.59, 0.54-0.63; pre-dialysis: 0.55, 0.52-0.57). Conclusion Hospitalizations are important but difficult to predict for patients with advanced CKD. Current models are insufficient to predict hospitalizations. We offer two main suggestions to improve future predictions of hospitalizations. First, the outcome of hospitalization should be more specific (e.g., cardiovascular hospitalizations) to reduce outcome heterogeneity. Second, the selection of predictors should be extended with more patient-centered factors, such as patient-reported outcomes.

#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 < .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 > 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 < .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<.0001) (Fig. 1). The percentage of AnnexinV-binding RBCs was significantly higher in PD patients with peritonitis than in healthy CTR (P < .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<.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.

#2241 Validation of a new formula for total body water in peritoneal dialysis patients

Abstract Background and Aims Peritoneal dialysis (PD) adequacy, assessed primarily by Kt/V, is crucial in routine clinical practice for detecting issues with PD treatment. This metric relies on urea levels and its volume (V) distribution, classically equivalent to total body water (TBW). TBW estimation, commonly achieved through the Watson and Watson (WW) formula, lacks dialysis patients in its original study, it also excluded patients with water metabolism disturbances, raising concerns about its generalizability to this population. Responding to this need, a new formula (NF) for calculating TBW in PD patients was developed in our center, with the aim of improving the correlation between administered Kt/V and clinical outcomes. Consequently, this study seeks to validate the proposed formula by applying it to a population. Method A prospective study conducted at a single center within PD program involved the collection of data on adequacy and Body Composition Monitoring (BCM) spanning from May 2023 to January 2024. TBW was calculated using the WW formula and the proposed new formula (TBW BI=0.36*Height+0.241*weight−9.675*BSA−26.234 for man and TBW BI=0.36*Height+0.241*weight−9.675*BSA−28.926 for woman). Categorical variables are presented as frequencies and percentages, continuous variables as means and standard deviations, or medians and interquartile ranges for variables with skewed distributions. A p-value < 0.05 was considered significant. Both formulas were subjected to correlation analysis with BCM TBW to assess mean differences using a paired-samples T test. Additionally, the resulting Kt/V values were compared, along with an examination of concordance in the detection of Kt/V values below 1.7. Results 66 measurements were collected from 36 PD patients. 29.2% (n = 10) were female, and the mean age was 59.7 years. Both formulas exhibited strong correlations with BCM TBW (WW: ρ = 0.949 and NF: ρ = 0.953, p < 0.001). BCM TBW showed a significant difference from WW TBW (34.8 vs. 38.1 liters, p < 0.001), but not when compared to the new formula (34.8 vs. 33.9, p = 0.06). The resulting BCM-derived Kt/V significantly differed from both formulas, with a larger mean difference compared to the WW formula (BCM: 2.71 vs. WW: 2.42, p < 0.001, and vs. the new formula: 2.77, p = 0.04). There was a perfect association between the use of NF and identification of BCM derived KtV measurements under the 1.7 target (Phi = 1, p < 0.001), an association that was strong for WW (Phi = 0.69, p < 0.001). Conclusion Errors in quantifying PD adequacy can lead to delayed detection of technical issues or inappropriate adjustments to already adequate prescriptions. We present a novel formula, specific for the PD population, reducing errors in PD quantification, particularly in settings where BCM is not available.

Association between beta-blocker utilization and heart failure mortality in the peritoneal dialysis population: a cohort study.

The prognostic significance of beta(β)-blocker therapy in patients at end-stage renal disease, specifically those receiving peritoneal dialysis (PD) and presenting with heart failure, remains inadequately elucidated due to limited research conducted thus far. A retrospective analysis was performed on a cohort comprising 608 patients receiving PD between September 2007 and March 2019, with a subsequent follow-up period extending until December 2020. Cox regression and propensity score matching weighted analysis was used to model adjusted hazard ratios for β-blocker use with heart failure-related mortality. Competing risk analysis and subgroup analysis were carried out to further elucidate the correlation. β-blockers were prescribed for 56.1% of the peritoneal dialysis patients. Heart failure occurred in 43.4% of the total population and 15.5% of deaths were due to heart failure. The prescription of β-blockers was associated with a 43% lower adjusted hazard ratio (HR) for heart failure death within the cohort (95% confidence interval [CI] = 0.36-0.89; P=0.013). Even after accounting for competing risk events, patients in the group using β-blockers demonstrated a significantly lower cumulative risk of heart failure-related mortality compared to those not using β-blockers (P=0.007). This protective effect of β-blockers was also observed in subgroup analyses. Conversely, β-blocker use had no statistically significant associations with all-cause mortality. The use of β-blockers was associated with a reduced risk of heart failure-related mortality in the PD population. Future randomized clinical trials are warranted to confirm the beneficial effect of β-blockers in the context of PD.

Why should we use a low sodium dialysis solution for peritoneal dialysis?

Overhydration is highly prevalent in patients on peritoneal dialysis (PD), with inappropriately high sodium load supposedly playing a central role in the pathophysiology of the conditions. Recent studies have revealed the novel role of the interstitium as a buffer system for sodium ions, and it has been reported that patients on dialysis, including PD, present increased levels of sodium in the interstitium, such as in subcutaneous tissue and muscle. Hence, therapy for correction of overhydration should target the excess extracellular volume and the excess sodium storage in the interstitium. The ultrafiltrate obtained using the currently available PD solutions is hypo- to isonatric as compared to serum, which is disadvantageous for prompt and efficient sodium removal from the body in patients with overhydration. In contrast, use of low sodium PD solutions is characterised by iso- to hypernatric ultrafiltrate, which may beneficial for reducing sodium storage in the interstitium. Trials of low sodium PD solutions have reported possible clinical merits, for example, decreased blood pressure, reduced dryness of mouth and decreased body water content as assessed using bioimpedance methods. Given these observations and the high prevalence of overhydration in current PD populations, it makes medical sense that low sodium solutions be positioned as the new standard solution in the future. However, for medical safety, that is, to avoid hyponatremia and excessive decreases in blood pressure, further studies are needed to establish the appropriate compositions and applications of low sodium solutions.

Apparent Treatment-Resistant Hypertension in the First Year Associated With Cardiovascular Mortality in Peritoneal Dialysis Patients.

Few reports have focused on the association between apparent treatment-resistant hypertension (aTRH) and cardiovascular (CV) mortality in peritoneal dialysis (PD) population, thus we conducted this retrospective cohort to explore it. This was a retrospective cohort study conducted from January 2011 to January 2020 with PD patients in 4 Chinese dialysis centers. aTRH was defined according to the American College of Cardiology and American Heart Association guidelines. aTRH duration was calculated as the total number of months when patients met the diagnostic criteria in the first PD year. The primary outcome was CV mortality, and the secondary outcomes were CV events, all-cause mortality, combined endpoint (all-cause mortality and transferred to hemodialysis [HD]), and PD withdrawal (all-cause mortality, transferred to HD, and kidney transplantation). Cox proportional hazards models were used to assess the association. A total of 1,422 patients were finally included in the analysis. During a median follow-up period of 26 months, 83 (5.8%) PD patients incurred CV mortality. The prevalence of aTRH was 24.1%, 19.9%, and 24.6% at 0, 3, and 12 months after PD initiation, respectively. Overall, aTRH duration in the first PD year positively associated with CV mortality (per 3 months increment, adjusted hazards ratio [HR], 1.29; 95% confidence interval 1.10, 1.53; P = 0.002). After categorized, those with aTRH duration more than 6 months presented the highest adjusted HR of 2.92. Similar results were found for secondary outcomes, except for the CV event. Longer aTRH duration in the first PD year is associated with higher CV mortality and worse long-term clinical outcomes. Larger studies are warranted to confirm these findings. There is no clinical trial registration for this retrospective study.

Ongoing Peritoneal Dialysis Training at Home Allows for the Improvement of Patients' Empowerment: A Single Center Experience.

Peritoneal dialysis (PD), as a home treatment, ensures better patient autonomy and lower intrusiveness compared to hemodialysis. However, choosing PD comes with an increased burden of responsibility that the patient may not always be able to bear, due to advanced age and deteriorating health condition. Various approaches have been explored to address this issue and mitigate its primary complications. In this study, we aim to present the ongoing PD training at-home program implemented by the Vicenza PD Center, and evaluate its impact on patients' prognoses. We enrolled 210 patients who underwent PD at Vicenza Hospital between 1 January 2019 and 1 January 2022 for a minimum of 90 days. Each patient was observed retrospectively for one year. We categorized the patients into three groups based on their level of autonomy regarding their PD management: completely independent patients; patients able to perform some parts of the PD method on their own, while the remaining aspects were carried out by a caregiver; and patients who required complete assistance from a caregiver, like in the assisted PD program (asPD). A total of 70% of the PD population were autonomous regarding their PD therapy, 14% had an intermediate degree of autonomy, and 16% were entirely dependent on caregivers. The PD nurses performed a median of four home visits per patient per year, with a tendency to make more visits to patients with a lower degree of autonomy. All the groups achieved similar clinical outcomes. At the end of the year of observation, only 6% of the patients witnessed a decline in their autonomy level, whereas 7% demonstrated an enhancement in their level of autonomy, and 87% remained stable. A home care assistance program ensures clinical support to a household with the purpose of improving the empowerment of the PD population and reducing the prevalence of assisted PD. Ongoing PD training at home helps patients to maintain a stable degree of autonomy and stay in their home setting, even though they present with relative attitudinal or social barriers.

Characterizing Interventions Used to Promote Life Participation in Adults on Peritoneal Dialysis Therapy: A Scoping Review.

Living with kidney failure can interfere with life participation (ie, participation in valued life activities). Life participation has recently been identified as a top-priority health outcome of people on peritoneal dialysis therapy, but it is a relatively unexplored topic in peritoneal dialysis. The objective is to describe the interventions that have been used to promote life participation in the peritoneal dialysis population and highlight research gaps warranting further investigation. A scoping review was conducted according to the Joanna Briggs Institute methodology. Six electronic databases (MEDLINE [OVID], EMBASE, PsycINFO, Cochrane Central Register of Controlled Trials, CINAHL Plus, SCOPUS) were searched. Adults aged 18+ years on peritoneal dialysis therapy. Any dedicated scale or subscale that measured life participation as an isolated outcome. Title/abstract screening was completed independently after adequate inter-rater reliability (kappa > 0.8) was achieved among reviewers. Full-text review and data extraction were conducted in duplicate. Extracted data were analyzed using counts, percentages, and narrative synthesis to describe patterns in the literature. After identifying 13 874 results, 17 studies met eligibility criteria. Eight studies were conducted within the past 5 years, with China as the most common study location. Only 2 studies investigated life participation as a primary study outcome. Eight studies targeted personal-physical barriers to life participation, 8 targeted multiple barriers, and 1 targeted an environmental-institutional barrier. Life participation was assessed within a subdomain of a broader quality of life assessment (The Kidney Disease Quality of Life [KDQOL]-36 or the 36-Item Short-Form Health Survey [SF-36]) in 11 studies. The majority of assessments captured life participation in all major domains of participation (self-care, work, and leisure). Eligibility screening at title/abstract stage was not performed in duplicate; articles not available in English were excluded. Life participation has infrequently been prioritized as a health outcome in peritoneal dialysis (PD). Interventions have been narrow in focus given the range of challenges faced by people on PD and the holistic approaches used in other clinical populations. Future research should prioritize life participation as a key health outcome in PD and investigate the impact of interventions that address cognitive, affective, and environmental barriers to participation.

Dietary Micronutrient Intake and Its Relationship with the Malnutrition–Inflammation–Frailty Complex in Patients Undergoing Peritoneal Dialysis

Background: The relationship between dietary patterns and the malnutrition–inflammation–frailty complex in patients undergoing peritoneal dialysis (PD) is currently unknown. Our objective was to measure dietary nutrient intake and evaluate its association with malnutrition, inflammation, and frailty. Methods: We prospectively recruited adult PD patients. We assessed their dietary nutrient intake using a food frequency questionnaire. Frailty, malnutrition, and inflammation were evaluated by validated Frailty Score (FQ), Subjective Global Assessment (SGA), and Malnutrition-Inflammation Score (MIS). Results: A total of 209 patients were recruited for the study. Among them, 89 patients (42.6%) had an insufficient protein intake, and 104 patients (49.8%) had an insufficient energy intake. Additionally, 127 subjects were identified as frail, characterized by being older (61.9 ± 9.5 vs. 55.6 ± 12.8, p < 0.001), malnourished (SGA: 21.0 ± 2.7 vs. 22.7 ± 3.1, p < 0.001), and having a high inflammation burden (MIS: 10.55 ± 3.72 vs. 7.18 ± 3.61, p < 0.001). There was a significant correlation between dietary zinc intake and body mass index (r = 0.31, p < 0.001), SGA (r = 0.22, p = 0.01), and MIS (r = −0.22, p = 0.01). In the multivariate model, a higher dietary zinc intake predicted a higher SGA (beta 0.03, p = 0.003) and lower FQ (beta −0.38, p < 0.001) and MIS (beta −0.14, p < 0.001), indicating a better nutrition, less frail and inflamed state. A higher dietary zinc intake was also associated with a lower odds of being frail (adjusted odds ratio 0.96, p = 0.009). Conclusion: Dietary inadequacy and micronutrient deficiency are common among the PD population. Dietary zinc intake is independently associated with an improved nutrition, physical condition, and reduced inflammatory state.

Constipation and clinical outcomes in peritoneal dialysis: Results from Thailand PDOPPS.

Patient-reported outcome measures (PROMs) are widely recognized as valuable predictors of clinical outcomes in peritoneal dialysis (PD). Our study aimed to explore the connections between patient-reported constipation and clinical outcomes. We assessed constipation in patients across 22 facilities participating in the Thailand Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) from 2014 to 2017. Constipation diagnosis utilized objective assessment tools such as the Bristol stool form scale (BSFS) and a self-reported questionnaire known as the constipation severity score (CSS). The BSFS is a 7-level scale that visually inspects feces based on texture and morphology, while the CSS measures constipation duration and severity using a 5-point Likert scale for various factors. We employed Cox proportional hazards model regression to determine the associations between constipation and clinical outcomes, including mortality, hemodialysis (HD) transfer and peritonitis. Among 975 randomly selected PD patients from 22 facilities, 845 provided written informed consent, and 729 completed CSS questionnaire. Constipation was prevalent in the PD population (13%), particularly among older patients, those who were caregiver dependent, had diabetes and poorer nutritional status (indicated by lower time-averaged serum albumin, potassium, creatinine and phosphate concentrations). Twenty-seven percent of which experiencing symptoms of constipation for over a year. Notably, self-reported constipation at baseline was significantly associated with a shorter time to first peritonitis and higher rates of peritonitis and death. However, no significant association was found between constipation and HD transfer after adjusting for various factors, including age, gender, PD vintage, comorbidities, shared frailty by study sites and serum albumin. Patient-reported constipation independently correlated with increased risks of peritonitis and all-cause mortality, though no such correlation was observed with HD transfer. These findings underscore the need for further investigation to identify effective interventions for constipation in PD patients.

Enhancing healthcare quality and outcomes for peritoneal dialysis patients in Thailand: An evaluation of key performance indicators and PDOPPS cohort representativeness.

To assess whether the peritoneal dialysis (PD) centres included in the Peritoneal Dialysis Outcomes and Practise Patterns Study (PDOPPS) in Thailand are representative of other PD centres in the country, based on 8 key performance indicators (KPIs 1-8). A retrospective analysis was conducted comparing PD-related clinical outcomes between PD centres included in the PDOPPS (the PDOPPS group) and those not included (the non-PDOPPS group) from January 2018 to December 2019. Logistic regression analysis was used to identify predictors associated with achieving the target KPIs. Of 181 PD centres, 22 (12%) were included in the PDOPPS. PD centres in the PDOPPS group were larger and tended to serve more PD patients than those in the non-PDOPPS group. However, the process and outcome KPIs (KPIs 1-8) were comparable between the 2 groups. Large hospitals (≥120 beds), providing care to ≥100 PD cases and having experience for >10 years were independent predictors of achieving the peritonitis rate target of <0.5 episodes/year. Most PD centres in Thailand showed weaknesses in off-target haemoglobin levels and culture-negative peritonitis rate. The PD centres included in Thai PDOPPS were found to be representative of other PD centres in Thailand in terms of clinical outcomes. Thus, Thai PDOPPS findings may apply to the broader PD population in Thailand.

Increased Access, Persistent Disparities: Trends in Disparities in Peritoneal Dialysis (PD) Use, 2009-2019.

Peritoneal dialysis (PD) use has increased in the United States since 2009, but how this has affected disparities in PD use is unclear. We used data from the United States Renal Data System to identify a cohort of incident dialysis patients from 2009 to 2019. We used logistic regression models to examine how odds of PD use changed by demographic characteristics. The incident PD population increased by 203% from 2009 to 2019, and the odds of PD use increased in every subgroup. PD use increased more among older people because the odds for those aged 75 years or older increased 15% more per 5-year period compared with individuals aged 18-44 years (odds ratio [OR] 1.68, 95% confidence interval [CI], 1.64 to 1.73 versus OR 1.46, 95% CI, 1.42 to 1.50). The odds of PD use increased 5% more per 5-year period among Hispanic people compared with White people (OR 1.58, 95% CI, 1.53 to 1.63 versus OR 1.51, 95% CI, 1.48 to 1.53). There was no difference in odds of PD initiation among people who were Black, Asian, or of another race. The odds of PD use increased 5% more for people living in urban areas compared with people living in nonurban areas (5-year OR 1.54, 95% CI, 1.52 to 1.56 versus 5-year OR 1.46, 95% CI, 1.42 to 1.50). The odds of PD use increased 7% more for people living in socioeconomically advantaged areas compared with people living in more deprived areas (5-year OR 1.60, 95% CI, 1.56 to 1.63 for neighborhoods with lowest Social Deprivation Index versus 5-year OR 1.50, 95% CI, 1.48 to 1.53 in the most deprived areas). Expansion of PD use led to a reduction in disparities for older people and for Hispanic people. Although PD use increased across all strata of socioeconomic deprivation, the gap in PD use between people living in the least deprived areas and those living in the most deprived areas widened.

Phosphate Control in Peritoneal Dialysis Patients: Issues, Solutions, and Open Questions.

Hyperphosphatemia is a common complication in advanced chronic kidney disease and contributes to cardiovascular morbidity and mortality. The present narrative review focuses on the management of phosphatemia in uremic patients receiving peritoneal dialysis. These patients frequently develop hyperphosphatemia since phosphate anion behaves as a middle-size molecule despite its low molecular weight. Accordingly, patient transporter characteristics and peritoneal dialysis modalities and prescriptions remarkably influence serum phosphate control. Given that phosphate peritoneal removal is often insufficient, especially in lower transporters, patients are often prescribed phosphate binders whose use in peritoneal dialysis is primarily based on clinical trials conducted in hemodialysis because very few studies have been performed solely in peritoneal dialysis populations. A crucial role in phosphate control among peritoneal dialysis patients is played by diet, which must help in reducing phosphorous intake while preventing malnutrition. Moreover, residual renal function, which is preserved in most peritoneal dialysis patients, significantly contributes to maintaining phosphate balance. The inadequate serum phosphate control observed in many patients on peritoneal dialysis highlights the need for large and well-designed clinical trials including exclusively peritoneal dialysis patients to evaluate the effects of a multiple therapeutic approach on serum phosphate control and on hard clinical outcomes in this high-risk population.

Pediatric peritoneal dialysis training program andits relationship to peritonitis: a study of the International Pediatric Peritoneal Dialysis Network.

The guidelines for training of patients and caregivers to perform home peritoneal dialysis (PD) uniformly include recommendations pertaining to the prevention of peritonitis. The objective of this study conducted by the International Pediatric Peritoneal Dialysis Network (IPPN) was to investigate the training practices for pediatric PD and to evaluate the impact of these practices on the peritonitis and exit-site infection (ESI) rate. A questionnaire regarding details of the PD program and training practices was distributed to IPPN member centers, while peritonitis and ESI rates were either derived from the IPPN registry or obtained directly from the centers. Poisson univariate and multivariate regression was used to determine the training-related peritonitis and ESI risk factors. Sixty-two of 137 centers responded. Information on peritonitis and ESI rates were available from fifty centers. Training was conducted by a PD nurse in 93.5% of centers, most commonly (50%) as an in-hospital program. The median total training time was 24hours, with a formal assessment conducted in 88.7% and skills demonstration in 71% of centers. Home visits were performed by 58% of centers. Shorter (< 20hours) training duration and lower number of training tools (both p < 0.02) were associated with higher peritonitis rate, after adjustment for proportion of treated infants and income of country of residence. An association between training duration and the number of training tools represent potentially modifiable risk factors to reduce peritonitis rates within the pediatric PD population. A higher resolution version of the Graphical abstract is available as Supplementary information.

#6717 IS PERITONEAL DIALYSIS RELATED PERITONITIS A MAJOR RISK FACTOR FOR CARDIOVASCULAR EVENTS?

Abstract Background and Aims Cardiovascular (CV) disease remains the leading cause of death in peritoneal dialysis (PD) patients and traditional CV risk factors are unable to fully account for this high incidence. The aim of our study was to establish the incidence of CV events such as acute myocardial infarction (AMI) in the PD population and assess possible risk factors for its occurrence. Method We retrospectively studied patients on PD in our unit with a minimum 3-years dialysis vintage, between January 1st 2015 and April 30th 2022. Patients with previous CV disease were excluded. Demographic and clinical data were collected, such as traditional CV risk factors, AMI, peripheral artery disease, cerebrovascular events, as well as dialysis efficiency, hydration status obtained by Body Composition Monitor (Fresenius Medical Care) and PD-related infections before AMI or end of follow-up. Univariate analysis was performed and logistic regression was applied to access predictors of AMI. Results Of the 43 patients recruited, 53.5% were male, with a mean age of 56.4 ± 11.8 years. About 98% of patients were hypertensive, 21% were diabetic, 19% were obese, and 54% had dyslipidemia. Five (11.6%) patients had a CV event while on PD, 4 suffered AMI and 1 patient had an ischemic stroke. Patients’ characteristics are presented in Table 1. In the follow-up, peripheral arterial disease (p = 0.037), hyperphosphatemia (p = 0.035) and the cumulative number of peritonitis (p = 0.018) were associated with the occurrence of AMI. In our population we found a higher frequency of peritonitis in the year prior to the AMI (p = 0.024). In logistic regression, the cumulative number of peritonitis was a predictor of AMI (OR 4.918, CI 95%:1.093-22.132). In the mean follow-up time of 4.7 ± 1.4 years, the overall mortality was 21,7%, with CV disease accounting for 60% of the observed deaths. AMI and peritonitis were associated with higher mortality in PD patients (p = 0.016 and p = 0.009, respectively). Conclusion PD-related peritonitis was a predictor of AMI in these population. The risk is higher in the year following a peritonitis episode. This may be due to a chronic inflammatory state that persists after successful treatment of peritonitis which may predispose to enhanced CV risk. Similar to previous studies, we found that cumulative episodes of peritonitis were associated with increased mortality in PD population.

#5529 RED BLOOD CELL TRANSFUSION RATES IN THE INTERNATIONAL DOPPS PROGRAM (2012–2022): HEMODIALYSIS, PERITONEAL DIALYSIS, AND NON-DIALYSIS CKD POPULATIONS

Abstract Background and Aims Anemia is a common complication of chronic kidney disease (CKD), and affects the majority of patients on hemodialysis (HD) and peritoneal dialysis (PD). Consequences of anemia include lower quality of life, increased healthcare utilization, and greater mortality risk. Current international guidelines recommend treating patients with iron and erythropoiesis-stimulating agents (ESAs) to a target hemoglobin (Hb) range, and avoiding red blood cell transfusions (RBCT) when possible, given the associated short- and long-term adverse consequences including hyperkalemia and allosensitization. A description of contemporary RBCT rates – after the 2012 KDIGO guideline changes – across the spectrum of CKD and different geographies is lacking. In this analysis, we estimated RBCT rates in non-dialysis CKD (ND-CKD), PD, and HD patients in a multinational setting, overall and stratified by Hb levels. Method We used data from 3 ongoing prospective cohort studies from the Dialysis Outcomes and Practice Patterns Study (DOPPS) Program: 2443 Stage 3–4 ND-CKD patients from 2 countries in CKDopps phases 1–2 (2013–2022), 3557 PD patients from 6 countries in PDOPPS phase 1 (2014–2018), and 22,771 HD patients from 20 countries in DOPPS phases 5–7 (2012–2022). Within each study, patients were randomly selected from stratified national samples of clinics, representative of a snapshot in time at study entry. Prospective information on RBCT receipt (yes/no) was captured at the patient-month level; thus, multiple events per patient were considered in the rate calculation, if they occurred in different months. RBCT rates were calculated as a count of the total patient-months with an RBCT event divided by the total patient-months with RBCT data available. Rates (per patient-month) were converted to per 100 patient-years, with 95% confidence intervals estimated by Poisson regression. RBCT rates are presented in each population (ND-CKD, PD, HD) across strata of interest, including CKD stage, country/region, and baseline Hb levels. Results Mean age (years) of the cohort was 68.6 for ND-CKD, 59.1 for PD, and 63.2 for HD. Mean (std dev) baseline Hb levels (g/dL) were 12.1 (1.9) in ND-CKD compared to 10.9 (1.7) in PD and 10.9 (1.5) in HD. Median [IQR] months of follow up (with RBCT data available) was 17 [6, 27] for ND-CKD, 16 [9, 20] for PD, and 8 [4, 19] for HD. Table 1 shows crude RBCT rates (per 100 patient-years) in the ND-CKD, PD, and HD populations, overall, by CKD stage and country/region. For ND-CKD, the RBCT rate was 6.7 (95% CI: 5.9, 7.6) overall, including 7.0 in the US and 5.5 in Brazil. RBCT rates increased with ND-CKD stage, from 2.2 in Stage 3a to 4.5 in Stage 3b to 8.5 in Stage 4. For PD, the RBCT rate was 20.3 (95% CI: 19.1, 21.6), higher than in ND-CKD, with substantial variation across countries, from 7.3 in the UK to 45.6 in Thailand. For HD, the RBCT rate was 23.9 (95% CI: 23.3, 24.5), also higher than in ND-CKD, with international variation observed. In the HD cohort, RBCT rates were lower in China (6.3) compared to the US (21.9), Canada (34.4), and the Gulf Cooperation Council region (34.8). Within HD-Europe, RBCT rates were highest in Belgium (48.1) and Sweden (42.4), and lowest in Germany (15.4), France (19.0), and Italy (20.4). Table 2 shows crude RBCT rates by baseline Hb levels. In all 3 cohorts (ND-CKD, PD, HD), RBCT rates appeared higher among patients with lower versus higher baseline Hb levels. In the PD and HD populations, patients with baseline Hb &amp;lt;8 g/dL had RBCT rates &amp;gt;100. Conclusion Our multinational study used uniform and standardized data collection tools, procedures, and processes to estimate RBCT rates in the post-2012 era following the revision of international guidelines. As expected, we observed higher RBCT rates in the PD and HD (vs. ND-CKD) populations, and higher RBCT rates among patients with lower baseline Hb levels. Interestingly, we also observed substantial international variation in RBCT rates in all 3 cohorts (ND-CKD, PD, HD). Further research is needed to better understand the reasons why RBCT use is higher or lower in certain countries, and to investigate predisposing and modifiable risk factors for RBCT. Funding: GSK (study 218930)