Calcified amorphous tumors (CATs) are rare, non-neoplastic intracardiac masses first described by Reynolds et al. in 1997. Although increasingly reported, their pathogenesis remains poorly understood, and they are frequently misdiagnosed as vegetations, cardiac myxomas, or malignant tumors. Proposed mechanisms include abnormalities in calcium-phosphate metabolism and hypercoagulable states. We report a case of CAT formation in a patient receiving peritoneal dialysis with severe, refractory hyperphosphatemia. A 47-year-old woman with type 2 diabetes mellitus, hypertension, heart failure with reduced ejection fraction, and end-stage renal disease on peritoneal dialysis had unremitting hyperphosphatemia (>10 mg/dL). Phosphate control was limited despite having trialed sevelamer and calcium acetate and intolerance to tenapanor due to gastrointestinal adverse effects. She had mixed adherence to dietary recommendations. She presented with leg pain and imaging raised concern for a psoas abscess. As part of an infectious embolic evaluation, transthoracic echocardiography revealed mitral valve dysfunction caused by a mobile intracardiac mass. Surgical resection was performed, and histopathologic examination confirmed a CAT. CATs typically present with symptoms related to valvular obstruction or embolization. Imaging findings on echocardiography, computed tomography, or magnetic resonance imaging are nonspecific, making histopathology essential for definitive diagnosis. Surgical excision remains the treatment of choice, with recurrence reported rarely. Given the propensity for calcium-phosphate deposition in patients with chronic hyperphosphatemia, strict phosphate control may reduce the risk of CAT development in patients with end-stage renal disease, though further studies are needed to clarify preventive strategies.
Thailand has changed its kidney replacement therapy policy in the universal coverage scheme from peritoneal dialysis (PD)-first to free-choice dialysis in February 2022. We aim to compare the incidence rate (IR) of permanent PD transfer to hemodialysis (HD) before and after the national policy change. The records of PD persons in a tertiary hospital in Thailand from February 2020 to January 2023 were reviewed. The time on therapy (TOT) per person-year, the number of PD transfer to HD during the study period were investigated. The incidence of permanent PD transfer to HD was calculated as IR per 100-person-years and the incidence rate ratio (IRR) with a 95% confidence interval (CI) before and after the policy change was analyzed. The IR of PD transfer to HD was 4.31 (95% CI 3.32 to 5.51) per 100 person-years in the PD-first era (TOT of 1483 person-years) and increased to 10.89 (95%CI 8.5-13.74) per 100-person-years (TOT of 652 person-years) after the change to the free-choice dialysis era. The IRR of PD transfer to HD after the change to the free-choice dialysis era significantly increased to 2.52 (95%CI 1.77-3.59, p < 0.001) compared with the PD-first era. The most common reason for PD transfer to HD in the free-choice dialysis era was peritonitis. The cause of transfer to HD by patient preference was only 12.6%. After the change to the free-choice dialysis policy, the IRR of PD transfer to HD significantly increased immediately. The most common cause of PD transfer to HD was peritonitis, not patient preference.
A 50-year-old man with severe presumed gallstone pancreatitis, multiorgan failure, and oliguric stage 3 acute kidney injury underwent bedside acute peritoneal dialysis (PD) for haemodynamically tolerated kidney support and intra peritoneal lavage. Catheter insertion drained a large volume of ascites that rapidly became vivid emerald green. Cultures remained sterile, whereas effluent amylase (11,041 U/L) and lipase (50,750 U/L) were markedly elevated, favouring inflammatory pancreatic leakage over infectious peritonitis or biliary perforation. During PD, effluent enzyme concentrations and cell counts declined, acidosis resolved, and kidney function improved. The patient subsequently died of septic shock. Emerald-green peritoneal effluent is rare and warrants urgent evaluation for serious intra-abdominal pathology.
IntroductionCardiovascular-kidney-metabolic (CKM) syndrome is characterized by chronic inflammation that may drive heart failure. Peritoneal dialysis (PD), while lifesaving, may induce local and systemic inflammation through bioincompatible intraperitoneal solutions, potentially amplifying CKM syndrome. We investigated peritoneal mononuclear phagocyte phenotypes, key-drivers of inflammation, and whether these correlate with systemic inflammation and cardiac function in PD-treated patients.MethodsWe collected patient-matched peripheral blood-derived and PD-effluent (PDE)-derived cells from 13 adult PD-treated patients and characterized peritoneal immune populations by unbiased clustering using a mononuclear phagocyte-selective flow cytometry panel. In a subsequent cohort of 21 PD-treated patients, we correlated cardiac function [left ventricular global longitudinal strain (LV-GLS)] with peritoneal immune profiles and serum inflammatory markers.ResultsMononuclear phagocytes predominated in PDE and exhibited a more differentiated phenotype than blood-derived mononuclear phagocytes. Unbiased clustering revealed substantial overlap between blood- and PDE-derived classical monocytes. A higher PDE-derived differentiated monocyte-to-dendritic cell ratio was related to more impaired LV-GLS. Peritoneal monocytes showed reduced antigen-presenting capacity in patients with impaired cardiac function, potentially influenced by diabetes mellitus. Systemic inflammatory markers were largely undetectable in this stable PD-cohort.ConclusionOur findings suggest a link between peritoneal immune characteristics and cardiac dysfunction, characterized by a shift towards a higher monocyte-to-dendritic cell ratio in PD-treated patients with more pronounced cardiac dysfunction. The directionality and mechanisms underlying this association remain to be established and given the limited patient number and cross-sectional design, these findings should be considered as hypothesis-generating. The applied flow cytometry and unsupervised clustering approach offers a promising and scalable tool for future in-depth investigation of the peritoneal immune microenvironment and its relation to PD-related clinical outcomes, including CKM sequelae.
BackgroundBecause automated peritoneal dialysis (APD) systems are used in the home and operated by patients or their care partners, the human-device interface must be thoughtfully designed to facilitate intuitive operation to reduce the risk of errors that could occur during their use. User-friendly design should also help reduce anxiety to peritoneal dialysis (PD) adoption by patients incident to end-stage kidney disease (ESKD). Usability issues remain a significant barrier to PD adoption and are an important contributor to premature death, serious injuries, and PD technique failure.MethodsA summative human factors usability study was conducted on a novel, gravity-based APD device (Archimedes™) with 15 current or former PD patients and 15 dialysis nurses. Participants were trained for 2 h, followed by a training decay period, then evaluated with critical Use Scenario tasks consisting of Simulated Use tasks and Knowledge tasks reflecting tasks that could result in patient harm if performed incorrectly.ResultsOf the Simulated Use tasks evaluated, 97.3% were deemed successful across all users. This high success rate demonstrates the effectiveness of the Archimedes APD device in facilitating the tasks required for PD. For patients, success outcomes were achieved in 96.8% of Simulated Use tasks. Nurses achieved a success rate of 97.8% for Simulated Use tasks evaluated. For Knowledge tasks, success outcomes were achieved in 99.3% and 98.6% of tasks for patients and nurses.ConclusionIn this summative human factors usability study, the Archimedes APD system usability was found to be safe, accessible and easy for its intended users and use environments after the relatively short training period compared to the status quo.
BackgroundThis study aimed to investigate the clinical characteristics and risk factors of central hypothyroidism (CEH) in peritoneal dialysis (PD) patients treated with roxadustat.MethodsThis retrospective study enrolled maintenance PD patients followed up at Peking University International Hospital. During treatment of renal anemia with roxadustat in these patients, thyroid function [including thyroid-stimulating hormone (TSH), triiodothyronine (T3), thyroxine (T4), free triiodothyronine (FT3), and free thyroxine (FT4)] were assessed and monitored. The severity of hypothyroid symptoms in patients was assessed through questionnaires. The clinical characteristics and risk factors associated with CEH were analyzed.ResultsAmong 76 PD patients with renal anemia treated with roxadustat, 51 were male (67.1%) with the mean age of 58.25 ± 14.58 years. Among the cohort, 12 (15.8%) developed CEH, characterized by FT4, FT3, T4, and T3 levels below the lower reference limits and reduced TSH. All patients returned to baseline thyroid hormone levels after discontinuing roxadustat. Symptom questionnaires revealed mild hypothyroidism symptoms (scores 1-4) in seven patients (58.3%). Multivariate logistic regression identified baseline hypoalbuminemia as a risk factor: each 1 g/L increase albumin reduced the risk of CEH by 16.8%.ConclusionRoxadustat therapy for renal anemia is associated with an increased risk of CEH. Clinically, given the manifestations of hypothyroidism, regular monitoring of thyroid function, particularly changes in TSH levels from baseline, is recommended. Roxadustat should be discontinued if CEH occurs during treatment, and thyroid function generally recovers following drug withdrawal. Multivariate analysis identified hypoalbuminemia as an independent risk factor for CEH. Therefore, thyroid function should be routinely monitored in PD patients before and during roxadustat therapy.
Centre-related factors, in addition to patient-related factors, are known to influence the outcomes of patients on peritoneal dialysis (PD). It is unclear if the nursing staff-to-patient ratios at different PD centres affect peritonitis outcomes. Our study aimed to examine whether full-time equivalent (FTE) PD nurse-patient ratios in individual PD centres were associated with centre-level outcomes of patients on PD. We used a cross-sectional survey of nursing leads of PD units across Australia and multi-centre registry data linkage. Of the 38 PD units in Australia, 28 (73.7%) nursing leads responded to the survey. The overall FTE PD nurse-patient ratio was 1 nurse to 12.7 patients (median; interquartile range 9.8-16.5), with substantial variability between PD units. There was no significant association between the FTE PD nurse-patient ratios and unit-specific peritonitis rates, overnight hospitalisation rates for peritonitis, mortality rates within 30 days of infection, or haemodialysis (HD) transfer rates. However, there was a moderate positive correlation between nurse FTE and transfer to HD rates (r = 0.476, p < 0.01). While our study revealed large variability in FTE PD nurse-patient ratios between PD units across the country, it was not associated with clinically significant PD outcomes between centres. Therefore, PD nurse-patient ratios may not be an important centre-related factor to explain variability in clinically meaningful PD outcomes between centres.
Peritoneal dialysis (PD) is a cornerstone kidney replacement therapy for patients with end-stage kidney disease; however, chronic exposure to bioincompatible dialysis solutions progressively damages the peritoneal membrane, leading to mesothelial-to-mesenchymal transition, fibrosis, and ultimately ultrafiltration failure. Currently, peritoneal membrane dysfunction is detected only at advanced stages through the peritoneal equilibration test, underscoring the need for earlier and more sensitive biomarkers. Extracellular vesicles (EVs) isolated from peritoneal dialysis effluent (PDE) have emerged as promising candidates, given their capacity to carry proteins, lipids, and nucleic acids that reflect local and systemic cellular activity. To date, 12 studies have successfully isolated and characterized PDE-derived EVs, identifying canonical EV markers, such as CD9, CD63, CD81, TSG101, and HSP70, alongside disease-relevant molecules, including galectin-3 binding protein, aquaporin-1, glycoprotein 96, and integrin-linked kinase. These EVs are enriched in signaling components associated with inflammation, angiogenesis, and fibrosis, particularly through TGF-β/p38 and NF-κB pathways. Moreover, specific EV-associated microRNAs (e.g., miR-125a-5p, miR-132-3p, miR-296-3p, miR-432-5p) overlap with molecular signatures observed in kidney and cardiometabolic disorders, suggesting broader systemic relevance. As an original contribution to this review, and to address cross-study comparability, we applied EVqualityMS, a mass spectrometry-based quality assessment tool, to benchmark EV enrichment and contaminant profiles and calculate quality indices across publicly available PDE-EV proteomics datasets. Despite methodological heterogeneity and limited sample sizes, PDE-derived EVs represent a powerful "liquid biopsy" of the peritoneal environment. Their integration into PD monitoring holds promise for the early detection of membrane injury and for supporting a predictive, biomarker-guided, and personalized approach to PD management.
Background Peritoneal fibrosis (PF) limits the long-term use of peritoneal dialysis (PD), with effective therapies lacking. Ferroptosis, an iron-dependent cell death process, has been implicated in organ fibrosis, but its role in PD-related PF remains unexplored. Quercetin, a natural flavonoid, possesses potential anti-fibrotic and anti-ferroptotic properties. Methods PD effluent cells from patients with different dialysis durations were analyzed for the expression of fibrosis markers (α-smooth muscle actin and collagen I) and ferroptosis-related markers (glutathione peroxidase 4 (GPX4) and solute carrier family 7 member 11 (SLC7A11)). In vitro, human peritoneal mesothelial cells (MeT-5A) exposed to high glucose were treated with quercetin to examine its effects on mitochondrial ultrastructure and marker expression. A rat model of PF was established through daily intraperitoneal injection of high-glucose dialysate, with or without quercetin administration, to evaluate histological and molecular changes in the parietal peritoneum. Results Prolonged dialysis duration was associated with upregulated fibrotic markers and downregulated ferroptosis-related genes in patient samples. In vitro, high glucose induced mitochondrial damage and a profibrotic phenotype in MeT-5A cells, which were significantly attenuated by quercetin. Quercetin restored the expression of GPX4 and SLC7A11, comparable to the effects of the ferroptosis inhibitor ferrostatin-1. In vivo, quercetin treatment markedly alleviated high-glucose-induced peritoneal thickening and fibrosis while enhancing the expression of ferroptosis suppressors. Conclusion Our findings demonstrate that ferroptosis contributes to the pathogenesis of PD-associated PF. Quercetin mitigates fibrotic progression by modulating ferroptosis, highlighting its promise as a novel therapeutic agent for preventing or treating this complication.
BackgroundsUnplanned initiation of peritoneal dialysis (PD) is linked to higher risks of complications and transfer to hemodialysis (HD). This study evaluates whether assisted PD was associated with the risk of transitioning to hemodialysis, for the individuals experiencing unplanned PD initiation.MethodsThis retrospective study analyzed data from the French Language Peritoneal Dialysis Registry (RDPLF), including 1009 patients with unplanned PD initiation, defined as a period of <30 days on HD before PD initiation, between January 1, 2002, and December 31, 2018. We compared assisted PD (nurse/family-assisted) versus self-care PD using cause-specific analyses. Time-dependent coefficient Cox regression addressed non-proportional hazards. Mediation analysis was conducted to explore the direct and indirect effects of assisted PD on the risk of transfer to HD, considering early peritonitis as a mediator.ResultsIn unplanned starters, Assisted PD was associated with an increased early risk of transfer to HD within the first six months (cs-HR 2.00, 95% CI 1.30-3.30), but a reduced risk thereafter (cs-HR 0.70, 95% CI 0.50-0.90). Patients on assisted PD had a higher risk of death (cs-HR 2.39, 95% CI 1.77-3.24) and a lower likelihood of transplantation (cs-HR 0.23, 95% CI 0.12-0.42). Mediation analysis revealed no significant indirect effect of assisted PD on the risk of transfer to HD via early peritonitis.ConclusionUnplanned PD initiation presents significant early risks, with assisted PD showing delayed protective effects after six months. Targeted early support (psychological and social) and further research are crucial to optimize outcomes for this patient group.
BackgroundPeritoneal dialysis (PD)-associated peritonitis remains a leading cause of hospitalization, technique failure, and transfer to in-center hemodialysis, with touch contamination during connections accounting for many episodes. Although shrouded connectors and "flush before fill" mechanisms reduce contamination risk, most automated peritoneal dialysis (APD) systems incorporate recessed fluid paths on only one side of the tubing-bag interface, potentially allowing bacterial transfer. We evaluated whether bilateral shrouded connectors with recessed fluid paths reduce bacterial contamination during simulated APD therapy.MethodsIn vitro microbiological testing was performed using three APD systems: Vantive/Baxter Claria™ (System A), Fresenius Liberty™ (System C), and Simergent Archimedes™ (System B). Connectors were deliberately contaminated with Staphylococcus aureus to simulate touch contamination, followed by a simulated APD treatment. Bacterial growth was quantified from pre-therapy flush fluid and the first patient fill ("mock peritoneum"). Agar imprinting was used to assess bacterial distribution relative to connector geometry.ResultsBacterial growth adjacent to the fluid path was observed with contaminated System A connectors but not with System B or System C, where growth was confined to the shroud. Quantitative cultures demonstrated markedly higher bacterial transfer with System A compared with System B and System C across both flush and mock peritoneal samples. Systems B and C employing bilateral shrouded, recessed connectors showed bacterial counts several orders of magnitude lower. All aseptic controls were sterile.ConclusionBilateral shrouded connectors with recessed fluid paths substantially reduce transfer of touch contaminants during simulated APD therapy. This design may mitigate a major mechanism of PD-related peritonitis, warranting clinical evaluation.
