IntroductionIncremental peritoneal dialysis (PD) may confer environmental benefits compared to full-dose PD due to reduced resource use. We aimed to quantify and compare carbon emissions, water consumption, and waste generation between incremental and full-dose PD in a cohort of incident PD patients.MethodsWe compared environmental metrics, including carbon emissions, water consumption, and waste generation between incremental and full-dose PD, using prospectively collected data between June 2019 and May 2024 at the Western Renal Service, Sydney, Australia. Carbon emissions were quantified using standardized coefficients from a published life-cycle analysis, while water and waste volumes were estimated using literature-based assumptions. Group comparisons were conducted using the Mann-Whitney test, with a two-sided -value <0.05 considered statistically significant.ResultsAmong 365 incident patients (187 incremental, 178 full-dose), followed for a median of 20 months (interquartile range 13-37), incremental PD had lower median annual per-patient carbon dioxide equivalent emissions (1016 vs. 1360 kg), blue water consumption (24,090 vs. 25,548 L), landfill waste (212 vs. 271 kg), gray water generation (8213 vs. 10,549 L), and recycling volume (73 vs. 131 kg), compared to full-dose PD (all  < 0.001). Incremental PD yielded estimated savings of 201,087 kg carbon dioxide equivalent emissions, over 5 million liters of blue water, 1.8 million liters of gray water, 27,223 kg of landfill waste, and 16,219 kg of recyclable materials.ConclusionIncremental PD was associated with a lower environmental impact than full-dose PD, highlighting its potential contribution to environmentally sustainable dialysis care.

Peritoneal dialysis-associated peritonitis (peritoneal dialysis (PD) peritonitis) is a common complication of peritoneal dialysis associated with adverse events and mortality. Outcomes are poorer when two or more organisms are isolated in the dialysis effluent culture, known as polymicrobial PD peritonitis, which can be caused by an underlying secondary process, such as gastrointestinal tract pathology and, rarely, a foreign body. Here, we report a case of polymicrobial PD peritonitis due to a vegetable matter foreign body perforating the colon. The patient was conservatively managed with antibiotic treatment and subsequent colonoscopic removal of the foreign body without the need for peritoneal dialysis catheter removal. She continues to remain on peritoneal dialysis 18 months after the PD peritonitis episode.

Peritoneal dialysis (PD) provides independence and quality of life comparable to in-center hemodialysis, but its long-term success depends on comprehensive training and sustained support. This editorial underscores the pivotal role of PD nurses as educators, partners, and motivators in empowering patients and caregivers. Beyond clinical skills, effective training must also address psychosocial stressors, as patient and caregiver burnout is an overlooked barrier to technique survival and adherence. Drawing on ISPD and NKF-KDOQI guidance, we highlight strategies such as early education, routine assessment of well-being, peer mentorship, retraining, and remote patient monitoring to foster resilience, prevent isolation, and reduce dropout. By prioritizing holistic, patient-centered training, healthcare systems can strengthen outcomes, enhance sustainability, and ensure PD remains a lifestyle-enabling therapy.

Increasingly, nephrologists struggle with providing care to patients with complex diseases who are heading towards the end of life. In this vignette, we illustrate how to recognize and acknowledge disease progression, tailor treatments to frailty status, and extend high-quality kidney care through to the time of death. Questions answered include how to discuss prognosis while retaining feelings of hope, and tips on how to recognize that the end-of-life may be approaching are included as part of the case discussion. We advocate for modest changes to nephrology care guidelines that promote integration of both high clinical standards and holistic and practical kidney care.

Peritoneal dialysis (PD) catheter dysfunction is an important mechanical complication in patients undergoing PD. Although there are many causes of mechanical obstruction causing PD catheter dysfunction, very rarely the obstruction can be caused by fallopian tubes. We report a case of a 42-year-old female who experienced PD catheter dysfunction at 6 weeks post-PD catheter insertion from fallopian tube invasion of the PD catheter. Diagnosis was confirmed using laparoscopy with intraoperative interventions to release the fimbriae from the drainage holes and no further recurrence at 3 months of follow up. Right fallopian tube involvement was more commonly seen in previous reports however our case was the first to be reported to involve both fallopian tubes.

Peritoneal dialysis (PD) is a preferred dialysis modality in many patients and healthcare settings, as it enables patient independence, reduces hospital visits, and health costs when compared to center-based hemodialysis (HD). However, PD technique failure due to loss of residual kidney function and/or loss of peritoneal membrane function may require patients to transition to HD, where hybrid dialysis (combining PD and HD) may be a viable alternative to thrice-weekly HD, while also promoting patient-centered care. However, hybrid dialysis is not advocated in current clinical practice guidelines, potentially due to a lack of clinician experience or high certainty evidence on the benefits, safety, and cost of combining PD and HD. In this narrative review, we summarize the existing data on health and economic outcomes in patients transitioning from PD alone to combined PD and HD, which may inform patient selection, dialysis prescription, and evaluation of dialysis quality for clinicians and patients considering hybrid dialysis.

BackgroundProtein-energy-wasting (PEW) is a prevalent condition in patients undergoing peritoneal dialysis (PD) associated with poor outcomes and anthropometry assessment is necessary for its diagnosis. The aim of this study was to compare whether anthropometry or bioimpedance spectroscopy (BIS) in the diagnosis of PEW differ in predicting all-cause mortality in PD patients.MethodsProspective, multicenter and observational study. The diagnosis of PEW was performed using the criteria of the International Society of Renal Nutrition and Metabolism (ISRNM). The measurement of muscle and fat mass was done using both anthropometry and BIS. Patients were followed for up to two years for adverse events. The survival rates of the patients identified with PEW according to both methods were compared. Patient survival was analyzed using a competing risk approach as proposed by Fine and Gray.ResultsWe included 121 patients with mean age of 58.9 ± 14.2 years, almost half of them with diabetes as the primary kidney disease (48.4%) and 52.5% were males. We identified 16 (13.2%) patients with PEW using anthropometry and 25 (20.7%) using BIS. In 92 (76%) patients there was no diagnosis of PEW independent of the method used to measure muscle mass and fat. PEW was a strong predictor of death. After adjustments for confounders the diagnosis of PEW using anthropometry was a better predictor of patient survival comparing to BIS.ConclusionPEW was associate with all-cause mortality either using anthropometry or BIS. Both assessment tools have clinical utility; however, in this study, anthropometry demonstrated greater effectiveness in identifying patients at increased risk of mortality.

We appreciate Dr Akcay's insightful comments. His observations provide valuable context and highlight important considerations for future research. We hope our work will serve as a foundation for further investigation into sex-associated risks in peritoneal dialysis and contribute to optimizing high-quality patient care for all individuals. Looking ahead, future studies should integrate dialysis-specific measures, explore mechanistic pathways, and incorporate patient-centered outcomes to better characterize sex-associated differences in peritoneal dialysis.

IntroductionThe clinical outcomes of starting peritoneal dialysis (PD) in kidney failure patients according to different break-in periods are not well established. Our aim was to assess whether the strategy of PD initiation interferes with clinical outcomes over the initial 180 days.MethodsThis retrospective study included incident kidney failure patients starting PD at a single center (November 2016-July 2022). Patients were divided into three groups: (1) Urgent-start (US-PD), initiated within 3 days after catheter insertion without prior hemodialysis (HD); (2) Early-start (ES-PD), initiated between 3-14 days, including those with ≤30 days of prior HD; (3) Planned-start (Plan-PD), initiated after 15 days without prior HD. Mechanical and infectious complications, hospitalizations, mortality, and time on PD were compared at 180 days. Patient dropout was defined as the discontinuation of PD due to death or transfer to HD.ResultsA total of 211 patients were included: 118 (55.9%) US-PD, 46 (21.9%) ES-PD, and 47 (22.2%) Plan-PD. Among ES-PD patients, 15 (32.6%) had prior HD (<30 days - median time 19 days). Catheter insertion was mostly performed by nephrologists (60.6%) using the modified Seldinger technique (59.2%). Early complications included catheter dysfunction, which occurred in 12.7% of the overall cohort (17.8% in US-PD vs. 4.3% in ES-PD vs. 8.5% in Plan-PD; p = 0.04), and leakage, observed in 7.1% of the overall cohort (9.3% in US-PD vs. 6.5% in ES-PD vs. 2.1% in Plan-PD; p = 0.26). Later complications, hospitalizations, mortality, and time on PD did not differ significantly between groups. Peritonitis, poor education, and hospitalization were associated with dropout.ConclusionAlthough initiating PD within 72 h of catheter insertion was associated with more mechanical complications in our study, it resulted in similar clinical outcomes to Planned-start PD patients within the first 6 months of therapy, making it a viable option for urgent dialysis initiation in kidney failure patients.

This case report describes a 66-year-old male on continuous cycling peritoneal dialysis (PD) with polycythemia vera and type 2 diabetes. He presented with culture-negative PD-associated peritonitis secondary to splenic infarcts and further accompanied by a splenic vein thrombosis and posterior brain circulation infarcts. His abdominal pain was atypical for peritonitis, being mild and localized to the left side, with an unremitting course despite several treatment attempts with appropriate antimicrobial coverage. An extensive workup for thromboembolic causes was unremarkable. Initially, the patient was started on aspirin and later treated with hydroxyurea and long-term warfarin. His PD catheter was removed due to concerns about an underlying biofilm, and a new one was inserted one month later, while on temporary hemodialysis, without recurrence. This case highlights that non-infectious, culture-negative PD peritonitis related to splenic infarction should be considered in patients with left-sided abdominal pain, poor clinical response to appropriate antibiotics and significant risk factors for thromboembolic events, such as hematologic disorders like polycythemia vera and splenomegaly. Maintaining a high clinical suspicion can prevent unnecessary antibiotic use and reduce repeated exposure to intravenous contrast for imaging studies. Early initiation of long-term anticoagulation might also prevent futile PD catheter removal if subsequent clinical improvement is obtained.

BackgroundThe impact of incremental peritoneal dialysis (PD) on outcomes is poorly understood, and there is a paucity of evidence informing best practices regarding the dialysis dose at the commencement of PD. This international prospective cohort study aimed to compare PD prescription practices at dialysis commencement and their subsequent association with clinical outcomes.MethodsAdult patients who started PD for less than three months at the time of enrolment in the Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS) between 1 January 2014 and 31 December 2017 were included. Patients were defined as initiating incremental PD if prescribed a total of <4 exchanges/day for continuous ambulatory peritoneal dialysis (CAPD) or, with dry days or having PD less than seven days per week for automated peritoneal dialysis (APD). All other prescriptions were considered standard PD. The primary outcome was the transfer to haemodialysis (HD). Secondary outcomes included peritonitis rate, time to first peritonitis and mortality. Logistic regression analysed PD uptake and the Cox proportional hazards regression model analysed HD transfer, peritonitis and patient survival.ResultsOverall, 1365 PD patients from 128 facilities across seven countries were included. Fewer individuals started on incremental PD than standard PD (37% vs 63%,  < 0.001). Higher incremental PD uptake was associated with receiving treatment in Japan (odds ratio [OR] 2.35, 95% CI 1.05-5.26,  = 0.04; ref: Canada), age >75 years (OR 1.51, 95% CI 1.02-2.24,  = 0.04), icodextrin use (OR 8.54, 95% CI 6.26-11.64,  < 0.001), lower serum creatinine concentration at PD start (OR 1.01, 95% CI 1.01-1.01,  = 0.007) and higher number of PD patients at a facility (OR 1.01, 95% CI 1.00-1.01,  = 0.02). Crude HD transfer rates for the incremental and standard PD groups were 0.14 (95% CI, 0.12-0.16) and 0.15 (95% CI, 0.13-0.17) per patient-year of follow-up, respectively (incidence rate ratio [IRR], 0.93; 95% CI, 0.75-1.15;  = 0.49). There was no significant difference in the hazard of HD transfer between the incremental and standard PD groups (hazard ratio [HR] 0.87, 95% CI 0.68-1.12,  = 0.29). There were also no differences between the two groups concerning peritonitis and mortality.ConclusionsIncremental PD start was prescribed in approximately one-third of patients and, in low certainty evidence, was associated with comparable risks of HD transfer, peritonitis and death.

BackgroundInfections can make it difficult to continue peritoneal dialysis (PD). Nontuberculous mycobacteria-associated PD (NTM-PD) infections, while rare, frequently pose a treatment challenge due to their intractable nature and the lack of established therapeutic guidelines. As a result, we aimed to investigate the clinical characteristics of NTM infections in patients undergoing PD.MethodsWe retrospectively examined consecutive patients with NTM-PD infections from 2012 to 2022. The cases were identified through microbiological records. The primary outcomes were all-cause mortality and transition to hemodialysis. Secondary outcomes included treatment duration and antimicrobial regimens. Outcomes were compared across different NTM species and between cases with and without infectious disease (ID) consultation.ResultsAmong 177 patients undergoing PD, we identified 22 NTM infections in 20 patients. The predominant species were (36%), (36%), and (23%). Twelve patients were transitioned to hemodialysis, with no mortality. All infections (5) required transition to hemodialysis, compared to 46% in other species. ID consultation (15) was linked to more frequent antimicrobial susceptibility testing (60% vs. 0%, .05), longer treatment duration (5.7 vs. 1.2 months, .05), and increased use of combination therapies (100% vs. 43%, .05). However, ID consultation did not affect the frequency of transition to hemodialysis.ConclusionEarly identification of NTM species and timely ID consultation can help optimize management strategies for these challenging infections.

BackgroundPeritoneal dialysis (PD)-associated peritonitis is a major complication in PD and may require abdominal imaging to identify the intra-abdominal pathology, though its clinical utility remains unclear.MethodsThis retrospective, single-center study included all episodes of PD-associated peritonitis that occurred between January 2013 and July 2024. The primary objective was to identify factors predicting the use of abdominal imaging during peritonitis episodes.ResultsA total of 691 episodes of peritonitis occurred in 376 PD patients during the study period. Of these, 354 episodes (51%) were subjected to abdominal imaging, which revealed 102 episodes (29%) suggestive of enteric or other secondary peritonitis. The most common abnormal imaging findings were colitis or enteritis, followed by ileus or intestinal obstruction. Imaging findings indicating the need for urgent medical or surgical attention were observed in 27 episodes of peritonitis (7.6%). Imaging was more frequently performed in peritonitis episodes caused by polymicrobial enteric bacteria (adjusted odds ratio [AOR]: 4.49; 95% CI [2.13-9.48]), single enteric bacteria (AOR: 2.02; 95% CI [1.31-3.13]), and fungi (AOR: 7.77; 95% CI [2.48-24.29]), compared to nonenteric bacteria. Hypotension (AOR: 6.19; 95% CI [2.81-13.66]), cloudy effluent (AOR: 1.91; 95% CI [1.30-2.80]), and higher PD effluent cell counts at presentation (AOR: 1.03; 95% CI [1.01-1.05]) were all significantly associated with imaging. Only polymicrobial infection involving enteric bacteria (AOR: 2.65; 95% CI [1.28-5.50]) was significantly associated with abnormal imaging findings suggestive of secondary or enteric peritonitis. Furthermore, polymicrobial infections with enteric bacteria (AOR: 9.17; 95% CI [3.29-25.50]), fungal infections (AOR: 5.25; 95% CI [1.26-21.96]), and hypotension (AOR: 2.77; 95% CI [1.08-7.07];  = .03) were significantly associated with critical imaging findings.ConclusionImaging in PD peritonitis was primarily performed based on causative organisms or clinical features. Only polymicrobial enteric peritonitis, fungal infections, and hypotension were significantly associated with critical imaging findings. Future prospective studies are required to improve diagnostic accuracy and guide imaging decisions in PD-related peritonitis.

IntroductionTherapy alerts during automated peritoneal dialysis (APD) can cause significant disruptions to patients' sleep and quality of life and may portend poorer outcomes. Understanding the relationship between alert frequency during this early period and longer-term PD outcomes is important.MethodsFollowing the probabilistic linkage of Vantive's Sharesource database to the Australian and New Zealand Dialysis and Transplant (ANZDATA) Registry, we examined the relationship between alert frequency in the first 30 days of APD and PD discontinuation. We included adult patients in Australia and New Zealand who commenced APD with the Vantive Homechoice Claria cycler over 2019-2023 and continued for at least 30 days. The average alerts per treatment in the first 30 days were divided into quartiles and time to PD discontinuation (inclusive of HD transfer and death), HD transfer only, and infective and non-infective HD transfer were modelled as outcomes.ResultsThe cohort was 1880 patients, 65% male, and median age at PD commencement of 58 years. Overall PD continuation at 1,2, and 3 years was 78%, 56% and 41%, with HD transfer rates at 14%, 23% and 27%. Higher rates of HD transfer in the first 12 months were seen in the groups with a higher average alert number. Within 12 months, there was a progressive risk of non-infective HD transfer with increasing 30-day alert quartile.ConclusionAlert burden in the first 30 days is a risk factor for HD transfer in the first 12 months, and resolving underlying issues early may help to improve PD continuation.

Women with kidney failure have impaired fertility challenges due to disruption of the hypothalamic gonadal axis and hormonal dysregulation, with pregnancy rates on home dialysis being much lower than those with normal kidney function. Pregnant women on dialysis are at high risk of hypertensive disorders, preterm birth, and fetal growth restriction, but intensified dialysis can mitigate these risks. Home dialysis offers advantages like flexibility, better hemodynamic stability, and improved fetal outcomes, but logistical and training challenges remain. Hybrid approaches combining hemodialysis and peritoneal dialysis may benefit select women during pregnancy. Effective management of pregnancy on dialysis requires treatment of anemia, optimized nutrition, close obstetric monitoring, and multi-disciplinary care. Postpartum care should focus on breastfeeding support, home dialysis prescription adjustment, and contraception counseling. Systematic capacity-building in home dialysis can lead to better pregnancy outcomes while alleviating in-center dialysis burdens.

Peritoneal dialysis (PD) has important disadvantages compared to hemodialysis, including low plasma clearance and limited technique survival. A new device for sorbent-assisted (continuous flow) peritoneal dialysis (SAPD) has been designed that is based on continuous recirculation of peritoneal dialysate a single-lumen peritoneal catheter with regeneration of spent dialysate by sorbents. SAPD treatment may enhance plasma clearance of uremic solutes by increasing the mass transfer area coefficient and maintenance of a high plasma-to-dialysate concentration gradient. In addition, SAPD treatment may preserve integrity of the peritoneal membrane for a longer period of time by avoiding the need for high initial glucose concentrations and by reducing the number of exchanges and (dis)connections of the peritoneal catheter, which may lower the risk of peritonitis. The primary aim of this first-in-human clinical trial is to evaluate the (short-term) clinical safety and performance of SAPD treatment in a small group ( = 12) of stable adult PD patients in a clinical setting (proof of concept). Key secondary objectives include an evaluation of efficacy in terms of plasma clearance, ultrafiltration, and patient tolerance.