We report a rare case of peritoneal dialysis (PD)-associated peritonitis caused by Coxiella burnetii, an intracellular pathogen typically associated with Q fever. A 28-year-old female with lupus nephritis and end-stage kidney disease on PD presented with cloudy effluent and abdominal pain after consuming undercooked lamb. Despite initial empirical broad-spectrum antibiotic therapy (cefazolin/ceftazidime protocol), clinical symptoms persisted. Conventional bacterial, fungal, and mycobacterial cultures were negative. Metagenomic next-generation sequencing (mNGS) of the peritoneal effluent identified C. burnetii DNA. The treatment was transitioned to doxycycline and hydroxychloroquine resulted in clinical improvement and normalization of inflammatory markers. This case underscores the diagnostic value of mNGS in culture-negative peritonitis and emphasizes C. burnetii as an emerging pathogen in immunocompromised PD patients, particularly with zoonotic exposure histories.

INTRODUCTION:There is a great burden of cerebral small-vessel disease (CSVD) in dialysis population. Arterial stiffness, normally assessed by pulse-wave velocity (PWV), is an important risk factor for CSVD. We aimed to investigate the effect of PWV on CSVD and related consequences, including cognitive function, cardiovascular disease (CVD), and mortality in dialysis. METHODS:In a prospective cohort of maintenance dialysis adults, 3 features of CSVD including cerebral microbleed (CMB), lacunae, and white matter hyperintensity (WMH) were measured. PWV was assessed by sequential recording of electrocardiogram-gated carotid and femoral artery pressure waves. The effect of PWV on CSVD and cognitive impairment were investigated by multivariate regression analysis. Cox proportional hazards model was used to assess the risk of CVD and mortality up to 10 years follow-up. RESULTS:In the 178 study subjects, the frequency of CMB, lacunae, and WMH was 32.6%, 25.3%, and 34.8%. PWV was related to the risk of lacunae in subcortical white matter (odds ratio [OR], 1.11; 95% confidence interval [CI], 1.02-1.20) and WMH (OR, 1.11; 95% CI, 1.02-1.20) in crude analyses. Unadjusted associations between PWV and cognitive impairment, which were reflected in loss of global function, verbal memory, and executive function, were also detected. At follow-up, PWV was associated with CVD (hazard ratio [HR], 1.13; 95% CI, 1.08-1.18) and all-cause mortality (HR, 1.11; 95% CI, 1.06-1.16) after confounder adjustment. Restricted cubic splines depicted a linear relationship between PWV and the outcome events. CONCLUSION:PWV was associated with all-cause mortality and CVD, independent of age and sex. PWV was associated with CVSD and cognitive decline in unadjusted analyses. PWV is a widely available measurement and could be an early biomarker and provide predictive value in this population.

BackgroundDiabetic kidney disease (DKD) and diabetic retinopathy (DR) represent two major microvascular complications of diabetes mellitus (DM). Previous studies have suggested that renin-angiotensin system inhibitors (RASi) exert protective effects on both DKD and DR. However, their specific impact on retinal microvascular parameters (RMPs), as well as the association between changes in fundus microvasculature and alterations in renal clinical parameters, remains unclear. This pilot study aimed to quantitatively assess the short-term effects of RASi on retinal microvasculature in patients with DKD using an artificial intelligence (AI)-based analysis of ultra-wide-field (UWF) fundus images.MethodsIn this prospective cohort study, 27 patients with DKD were enrolled between July 2023 and September 2024. UWF fundus images were acquired at baseline and 12 weeks after initiation of RASi therapy. A validated deep learning AI model was employed to segment retinal vessels and quantify RMPs, including fractal dimension (Df) and tortuosity (TORT), in both the central and peripheral retinal regions. Statistical analyses for pre- and post-treatment comparisons were performed using a linear mixed-effects model with patient ID as a random intercept. or a Wilcoxon signed-rank test, as appropriate. Changes in these parameters post-treatment were analyzed and correlated with alterations in clinical renal indicators.ResultsAmong the enrolled patients, 21 patients (77.8%) were male, with a mean age of 55.7 ± 14.2 years, a mean diabetes duration of 9.9 ± 6.6 years, a baseline estimated glomerular filtration rate (eGFR) of 73.7 ± 18.5 mL/min/1.73 m², and a median proteinuria of 0.57 (0.25, 0.97) g/24h. Fifteen patients (55.6%) had diabetic retinopathy (DR). After 12 weeks of RASi treatment, significant decreases were observed within the UWF images in venous Df (adjusted p = 0.0389) for the overall cohort, and venous TORT (adjusted p = 0.0496) for No-DR and NPDR groups. These significant changes were not observed in parameters derived from the central retinal region.ConclusionRASi therapy might be associated with retinal peripheral venous alterations, providing clues to a vascular- and topography-specific therapeutic response and shedding light on a potential imaging biomarker for diabetes management.

Peritoneal dialysis-associated peritonitis is the primary cause of technical failure and infection-related mortality in PD patients. Culture-negative peritonitis poses unique management challenges. The reported incidence of culture-negative peritonitis varies substantially across regions and centers, likely reflecting differences in patient characteristics, microbiological practices, and treatment protocols. In this study, we aimed to investigate the risk factors, treatment strategies, and clinical outcomes of culture-negative peritonitis in a large peritoneal dialysis center in northern China. In this single-center retrospective cohort study, we included consecutive peritonitis episodes from January 2013 to December 2023. We assessed patient demographics, medical history, peritonitis presentation, antibiotic use, and treatment pathways. The primary outcomes were culture-negativity and outcomes of medical cure. Logistic regression was used to identify independent risk factors for culture negativity and failure to achieve a medical cure. The overall incidence of peritonitis during the study period was 0.15 episodes per patient-year and the culture-negative peritonitis rate was 25.5

Peritonitis is the leading cause of technical failure in peritoneal dialysis (PD), often resulting in the cessation of home dialysis. Culture-negative peritonitis poses unique management challenges with limited evidence on optimal strategies. This retrospective cohort study included consecutive cases of PD-associated peritonitis from 2013 to 2023 in the PD center of Peking Union Medical College Hospital. The clinical data were extracted from electronic health records. The diagnosis, classification, and outcomes of peritonitis were consistent with ISPD guidelines. Depending on the characteristics of the data, comparisons between groups were conducted using t-tests, Mann–Whitney tests, or Fisher’s exact test. Logistic regression was used to analyze the correlation between various factors and outcomes. Culture-negative (CN) peritonitis accounted for 25.5% (63/247) of all peritonitis. Compared with culture-positive (CP) peritonitis, patients with CN peritonitis were more likely to have smoked (P = 0.031) and had significantly higher rates of antibiotic use before culture collection (47.6% vs. 9.2%, P < 0.0001). Baseline characteristics, including age, diabetes status, BMI, PD modality, and pre-peritonitis bloodwork, were comparable. In multivariate logistic regression, only smoking history (OR = 2.01, 95% CI: [1.024, 3.945], P = 0.042) and the use of antibiotics before culture collection (OR = 58.59, 95% CI: [3.942, 19.54], P < 0.0001) were independently associated with negative culture peritonitis. The patients initially presented to the emergency room (ER) experienced higher rates of antibiotic use (27.55% vs. 9.85%, P = 0.0007) and delays in effluent culture collection (average 12.7 hours vs. 1.2 hours, P < 0.0001) than those presented to the PD unit. Multivariate logistic regression analysis indicated that CP peritonitis, automated peritoneal dialysis (APD), and non-first episodes of peritonitis independently predicted the poor prognosis of not being medically cured. CN peritonitis generally had better outcomes with higher medically cured rates and fewer refractory cases. However, a subgroup of patients with comorbidities requiring antibiotics (N = 9) use before culture had the worst prognosis: 4 of them died during peritonitis treatment, and the survivors had a catheter removal rate of 60%. Cultural negativity is influenced by the initial presentation’s location and sample collection delays. CN peritonitis generally has favorable outcomes. Special attention is needed for CN peritonitis patients with comorbid infections, as their prognoses are significantly worse. These findings highlight the importance of tailored management strategies for patients with peritonitis, particularly for those with a history of antibiotic use or recurrent episodes.

Introduction: Currently, no consensus on optimal renal replacement modality has been reached for end -stage renal disease (ESRD) patients complicated with hemophilia. They may require infusion of coagu-lation factors during each hemodialysis session. In comparison, peritoneal dialysis (PD) might be preferred considering that coagulation replacement is only required for catheter placement. However, limited data on the safety and efficacy of PD for treating ESRD patients with hemophilia were reported.Methods: This is a single-center retrospective cohort study. ESRD patients diagnosed with hemophilia under PD in Peking Union Medical College Hospital from January 1, 1996 to December 31, 2021 were included and followed-up with every month. Their baseline clinical data, catheter insertion procedure, coagulation factor replacement, complications, and outcome were analyzed and compared with general PD patients.Results: In total, 8 patients diagnosed with hemophilia were included, all-male, with a mean age of 50.3 +/- 13.3 years old. Two were acquired hemophilia A, whereas the rest were hereditary hemophilia A (HHA). Seven patients experienced significant hemoglobin (Hgb) increment after PD. Peritoneal hemor-rhage only consisted of a small portion of all hemorrhage. Patients with hemophilia seemed to have lower small solute clearance despite higher baseline peritoneal permeability, and appeared to have increased peritonitis rate than other male PD patients, yet this study is not powered to prove this.Conclusion: PD is a safe and effective choice for patients with hemophilia and ESRD requiring dialysis. More studies are required to evaluate this certain rare group of patients.

Background: Previous study consistently showed that lower serum sodium (SNa) was associated with a greater risk of mortality in hemodialysis (HD) patients. However, few studies have focused on the change in SNa (Delta SNa = post-HD SNa - pre-HD SNa) during an HD session. Methods: In a retrospective cohort of maintenance HD adults, all-cause mortality and cardio-cerebrovascular event (CCVE) were followed up for a medium of 82 months. Baseline pre-HD SNa and Delta SNa were collected; time-averaged pre-HD SNa and Delta SNa were computed as the mean values within 1-year, 2-year and 3-year intervals after enrollment. Cox proportional hazards models were used to evaluate the relationships of pre-HD and Delta SNa with outcomes. Results: Time-averaged pre-HD SNa were associated with all-cause mortality (2-year pre-HD SNa: HR [95% CI] 0.86 [0.74-0.99], p = 0.042) and CCVE (3-year pre-HD SNa: HR [95% CI] 0.83 [0.72-0.96], p = 0.012) with full adjustment. Time-averaged Delta SNa also demonstrated an association with all-cause mortality (3-year Delta SNa: HR [95% CI] 1.26 [1.03-1.55], p = 0.026) as well as with CCVE (3-year Delta SNa: HR [95% CI] 1.51 [1.21-1.88], p = <0.001) when fully adjusted. Baseline pre-HD SNa and Delta SNa didn't exhibit association with both outcomes. Conclusions: Lower time-averaged pre-HD SNa and higher time-averaged Delta SNa were associated with a greater risk of all-cause mortality and CCVE in HD patients.

Age-associated deterioration of physiological functions occur at heterogeneous rates across individual organs. A granular evaluation of systemic metabolic mediators of aging in a healthy human cohort (n = 225) identified prominent increases in circulating uremic toxins that were recapitulated in mice, on which we further characterized the aging phenome across five peripheral organs. Our multi-omics analyses connected systemic aging profiles primarily to kidney metabolism, uncovering a metabolic association between localized glucosylceramide (GluCer) accretion and renal functional decline. Elevated GluCers were also associated with higher risk of deaths in an independent cohort of aged individuals (n = 271). We report GluCer-mTOR signaling commencing at late middle-age that disrupts mitophagy and undermines mitochondrial respiration in kidney. Conserved between human and mice, GluCer-mediated renal dysfunction is female-biased and modulated by intracellular purines. Our work provides molecular basis for the sexually disparate effects of mTOR inhibition on mammalian lifespan, possibly ascribed to the evolutionary cost of female reproduction.

Parvovirus B19 infection can cause chronic pure red cell aplasia in immunosuppressed hosts or acute and transient aplastic crisis in immunocompetent hosts. In dialysis patients, only transient aplastic crisis induced by parvovirus B19 infection has been reported. We herein report the first case of an adult dialysis patient who developed chronic pure red cell aplasia associated with parvovirus B19 infection. Repeated pneumonia and heart failure may contribute to an immunocompromised status, making the patient more vulnerable to parvovirus B19 infection. This case expands on the differential diagnosis of chronic anemia in patients undergoing dialysis.

[This corrects the article DOI: 10.1016/j.ekir.2022.09.030.].

AbstractBackgroundIntensity‐Modulated Radiation Therapy (IMRT) has been the standard of care for many types of tumors. However, treatment planning for IMRT is a time‐consuming and labor‐intensive process.PurposeTo alleviate this tedious planning process, a novel deep learning based dose prediction algorithm (TrDosePred) was developed for head and neck cancers.MethodsThe proposed TrDosePred, which generated the dose distribution from a contoured CT image, was a U‐shape network constructed with a convolutional patch embedding and several local self‐attention based transformers. Data augmentation and ensemble approach were used for further improvement. It was trained based on the dataset from Open Knowledge‐Based Planning Challenge (OpenKBP). The performance of TrDosePred was evaluated with two mean absolute error (MAE) based scores utilized by OpenKBP challenge (i.e., Dose score and DVH score) and compared to the top three approaches of the challenge. In addition, several state‐of‐the‐art methods were implemented and compared to TrDosePred.ResultsThe TrDosePred ensemble achieved the dose score of 2.426 Gy and the DVH score of 1.592 Gy on the test dataset, ranking at 3rd and 9th respectively in the leaderboard on CodaLab as of writing. In terms of DVH metrics, on average, the relative MAE against the clinical plans was 2.25% for targets and 2.17% for organs at risk.ConclusionsA transformer‐based framework TrDosePred was developed for dose prediction. The results showed a comparable or superior performance as compared to the previous state‐of‐the‐art approaches, demonstrating the potential of transformer to boost the treatment planning procedures.

ABSTRACT Background Increasing evidence suggests a high prevalence of cerebral small-vessel disease (CSVD) in hemodialysis patients. Variable ultrafiltration during hemodialysis may contribute to brain lesions by inducing hemodynamic instability. We aimed to investigate the effect of ultrafiltration on CSVD and relative outcome in this population. Methods In a prospective cohort of maintenance hemodialysis adults, three features of CSVD including cerebral microbleed (CMB), lacunae and white matter hyperintensity (WMH) were measured by brain magnetic resonance imaging. Ultrafiltration parameters included the difference between annual average ultrafiltration volume (UV, kg) and 3%–6% of dry weight (kg), respectively, and the percentage of UV to dry weight (UV/W). The effect of ultrafiltration on CSVD and the risk of cognitive decline were investigated by multivariate regression analysis. Cox proportional hazards model was used to assess mortality over 7 years of follow-up. Results In the 119 study subjects, the frequency of CMB, lacunae and WMH was 35.3%, 28.6% and 38.7%, respectively. All ultrafiltration parameters were associated with the risk of CSVD in the adjusted model. There was a 37%, 47% and 41% greater risk of CMB, lacunae, and WMH, respectively, per 1% increment of UV/W. Ultrafiltration showed different effects on different distributions of CSVD. Restricted cubic splines depicted a linear relationship between UV/W and the risk of CSVD. At follow-up, lacunae and WMH were associated with cognitive decline, CMB and lacunae were associated with all-cause mortality. Conclusions UV/W was associated with the risk of CSVD in hemodialysis. Reducing UV/W might protect hemodialysis patients from CSVD and subsequent cognitive decline and mortality.

Background The chronic kidney disease-mineral and bone disorder(CKD-MBD) is known to be associated with increased mortality in dialysis patients, but whether current global guidelines for CKD-MBD, which were primarily developed from hemodialysis, are suitable for peritoneal dialysis (PD) patients practice require further investigation.Methods This is a single-center retrospective cohort study. In total 491 prevalent PD patients (median follow-ups: 34 months) from Peking Union Medical College Hospital (PUMCH) from January 2004 to December 2017 were included and followed until 30 June 2018. In the first dialysis year, the average levels of serum calcium, albumin-corrected calcium (CorCa), phosphorus, and parathyroid hormone (PTH) levels were the interested predictors in Cox proportional regression model.Results Of these PD patients (age 58 ± 17 years), 52% were male and 36% had diabetic nephropathy. In Cox regression over first-year mean parameters, PTH <100 pg/mL (HR = 1.97, 95% CI 1.32 to 2.94, p < 0.001) and ≥300 pg/mL (HR = 2.24, 95% CI 1.32 to 3.81, p = 0.003) were associated with increased all-cause mortality than that of PTH 100–200 pg/mL. Patients with albumin-corrected serum calcium level < 2.13 mmol/L also had higher risk of death than patients with level of 2.13 to 2.38 mmol/L (HR = 2.06, 95% CI 1.06 to 4.01, p = 0.02). Serum phosphorus ≥1.45 mmol/L were associated with increased all-cause mortality. However, lacking of data on 25-hydroxy vitamin D, alkaline phosphatase, and activated vitamin-D are limitations of our analysis.Conclusions As one of the largest PD cohort study focusing on CKD-MBD, we demonstrated that the level of CKD-MBD markers in the first PD year are independent predictors of all-cause mortality. PTH 100–300 pg/mL might be the best target for Chinese PD patients.

Background: Growing data indicate a higher prevalence of cerebrovascular diseases in patients with ESRD. Cerebral small-vessel disease (CSVD) is an important risk factor of stroke and dementia. A comprehensive assessment of CSVD in a dialysis population is needed. Methods: In this retrospective cross-sectional study, we enrolled 179 dialysis patients and 351 controls matched by sex and age with normal serum creatinine. The presence and locations of 3 main features of CSVD in dialysis patients, including lacunes, cerebral microbleeds (CMBs), and white matter hyperintensities (WMHs), were evaluated with brain magnetic resonance imaging and compared with controls. Univariate and multivariate analyses were performed to identify risk factors. Results: Compared with controls, the prevalence of CSVD was significantly increased in dialysis patients (odds ratio [OR] 2.66, 95% confidence interval [CI] 1.26–5.62). Among them, risks of CMBs and WMHs were increased in dialysis (OR 4.01, 95% CI 1.78–9.42; 3.91, 95% CI 1.67–9.15), except for lacunes. The age of subjects with CSVD detected was significantly younger in the dialysis group (p = 0.002). Unlike controls, basal ganglia were most affected by lacunes and CMBs in dialysis patients. In dialysis patients, multivariate analysis further revealed that aging, smoking, and hyperlipidemia were significantly associated with CSVD, while dialysis modality was not significant. Conclusion: We demonstrated a higher prevalence and early-onset tendency of CSVD in dialysis patients, especially for CMBs and WMHs. Dialysis patients showed different patterns and associated factors for CSVD.

Since the outbreak of the coronavirus epidemic, the "virtual" telemedicine has become a critical substitute for patient-provider interactions. However, virtual encounters often face challenges in the care of patients in high-risk categories such as chronic kidney disease (CKD) patients. In this study, we explore the patient's satisfaction and the practical effects of a newly established telemedicine program on CKD patients' care during the COVID-19 pandemic. Based on a prior version of an online patient care platform established in 2017, we developed a customized and improved online telemedicine program designed to specifically address the challenges emerging from the pandemic. This included an online, smart phone-based strategy for triage and medical care delivery and psychological support. We invited a total of 278 CKD patients to join the new platform during the pandemic. The subjects in group A were patients utilizing our old online CKD system and were historical users registered at least 3 months before the pandemic. A pilot survey interrogating medical and psychological conditions was conducted. Feedback on the program as well as a psychological assessment were collected after 1 month. In total, 181 patients showed active responses to the program, with 289 person-time medical consultations occurring during the study. The virtual care program provided a rapid triage for 17% (30 out of 181) patients, with timely referral to in-patient medical encounters for their worsening medical conditions or severe psychological problems. Nearly all patients (97.4%) believed the program was helpful. The number of symptoms (OR 1.309, 95%CI 1.113-1.541; P = 0.001) and being enrolled during the pandemic (OR 3.939, 95% CI 1.174-13.221; P = 0.026) were associated with high stress. During the follow-up, the high-stress CKD group at baseline showed a significant decrease in avoidance score (6.9 ± 4.7 vs. 9.8 ± 1.9, P = 0.015). In conclusion, during the pandemic, we established an online telemedicine care program for CKD patients that provides a rapid triage function, effective CKD disease management, and potentially essential psychological support.

Background: Pemphigus is a group of rare and severe autoimmune blistering disease mediated by pathogenic autoantibodies against desmogleins. Plasmapheresis can directly remove autoantibodies from circulation, which has been applied to the treatment of pemphigus as an adjuvant therapy. But the results of the researches are controversial. This study aims to evaluate the efficacy and safety of double filtration plasmapheresis (DFPP) combined with immunosuppressive treatment for patients with severe pemphigus in our single center. Methods: We retrospectively analyzed 17 patients with severe pemphigus who were unresponsive to high-dose corticosteroid and received DFPP treatment between January 2010 and January 2020. The information on demographic characteristics, clinical and laboratory data, treatment regimens, and clinical outcomes were collected. Results: All the patients were diagnosed as severe pemphigus and had a period of at least 1 week of high-dose prednisone (1-1.5 mg/kg/day), but they were unresponsive to corticosteroid and immunosuppressants treatment. They received DFPP treatment as an adjuvant therapy. After DFPP treatment, the titers of desmogleins antibodies significantly decreased (P < .001), Nikolsky's sign became negative and no new blisters appeared. The dosage of corticosteroid could begin to taper down rapidly in 9 +/- 4 days. On discharge, the dosage of prednisone decreased significantly (51 +/- 3 mg/day,P < .001). No major adverse events happened that could lead to the termination of DFPP treatment. Conclusion: Double filtration plasmapheresis combined with immunosuppressive treatment is an effective and safe therapeutic regimen for severe pemphigus. DFPP can also contribute to the dosage reduction of steroid to avoid more drug-related side effect.

Cerebral microbleeds (CMBs) in dialysis patients have recently attracted much attention, and the different locations of CMBs indicate different pathological processes. Previous studies on the relationship between CMBs and cognitive impairment (CI) in the general population and in dialysis patients have reported controversial results. A total of 180 chronic dialysis patients were enrolled in our study. Based on brain magnetic resonance imaging (MRI) analysis of CMBs, the patients were divided into 4 groups (without-CMBs group, strictly lobar group, strictly deep group, and mixed group). A wide range of cognitive tests was administered to evaluate cognitive function. The risk factors for CMBs were explored, and the correlation between CMB distribution and CI was investigated by regression analysis. The prevalence of CMBs was 32.8% in the total study population, 36.1% in the haemodialysis (HD) subgroup and 26.2% in the peritoneal dialysis (PD) PD subgroup. Sixteen subjects (8.9%) were classified as the lobar group, 12 subjects (6.7%) as the mixed group, and 31 subjects (17.2%) as the deep group. A significant association was shown between deep CMBs and impaired cognitive function, involving overall cognitive function, memory, language ability and executive function. Deep CMBs were significantly associated with dialysis vintage, mean arterial pressure (MAP) and lacunar infarcts number, while deep CMBs showed no correlation with dialysis modality and current heparin medication. Deep CMBs are closely associated with global and specific CI in dialysis patients. Blood pressure control may prevent deep CMBs and their associated CI.