Jan Thomas Kielstein

Background: Currently several registries investigate the structure of the peritoneum in response to uremia and peritoneal dialysis. Those registries using a single peritoneal sample obtained during surgical procedures involving the abdomen. There are no data to support the assumption that a single random sample from the peritoneum is representative of other regions of the peritoneum. The aim of our study was to investigate the potential effect of the sampling site of the parietal peritoneum on peritoneal thickness. Methods: For the study 19 body donors (8 F /11 M), medium [IQR] age 82 [77–88] years were investigated. Peritoneal samples were obtained from five different, predefined sites of the peritoneal cavity involving visceral and parietal peritoneum. Routine histology was performed at the Department of Nephropathology Erlangen. Results: A total number 95 samples from 19 body donors were analyzed. There was a wide intraindividual variation of the peritoneal thickness. In the entire cohort, median [IQR] maximum thickness of the peritoneum did not significantly differ between the four samples of the parietal peritoneum 130 [60–170] µm | 130 [70–200] µm | | 140 [110–240] µm | 140 [110–150] µm. Median [IQR] maximum thickness of the visceral peritoneum was however thinner 90 [60–130] µm than all parietal peritoneal samples ( p = .01). Based on the intraindividual variation in our cohort we calculated a cohort of 24.7 patients needed to detect longitudinal changes of peritoneal thickness at medium effect size with a power of 0.8 at p < .05. Conclusions: The visceral peritoneum differs in thickness form the parietal peritoneum. The sample site of the parietal peritoneum has no effect on the peritoneal thickness. The large intraindividual variation in the peritoneal thickness require large cohorts to detect longitudinal change of the peritoneum. Despite the limitation that it remains uncertain if these results from body donors can be assumed to be true in ex-vivo biopsies, it seems prudent to state that interpreting sequential peritoneal biopsies in single patients or small case series should be interpreted with caution.

Background: Strengthening peritoneal dialysis (PD) utilization in Germany is crucial to ensure dialysis care for patients with kidney failure in an aging population with a predicted decline in the number of health care professionals. PD catheter implantations are a key indicator for the utilization of PD. We performed the first comprehensive study on PD catheter implantation rates and inpatient outcomes in Germany. Methods: For this retrospective study we queried the diagnosis related group statistics of the Federal Statistical Office of Germany for the years 2011 to 2021, which includes demographics and information on the medical course from all German inpatient cases. Results: During the observation period, 14,158 PD catheters were implanted, with an average of 1272 ± 127 (mean ± standard deviation) per year. Nationally, annual implantation rates were stable, without notable changes over time. Notably, there were significant regional differences in implantation rates within Germany. The average patient age at the time of PD catheter implantation was 59.7 years, with a male-to-female ratio of 1.7:1. During the hospital stay for PD catheter implantation, 517 patients (3.7%) died. Centers with higher implantation rates had more favorable outcomes. Age, number of comorbidities and certain comorbidities (e.g., cancer and heart failure) were associated with higher mortality. The length of stay in the hospital for PD catheter implantation was 19.5 (±22.3) days. Conclusion: Our analysis reveals that relatively few PD catheters are implanted in Germany each year. Over the observation period, there was no substantial increase, indicating a continued underutilization of PD in Germany.

Objectives: Cefiderocol is a new siderophore cephalosporin for treating severe bacterial infections by Gram-negative pathogens in adults. Significant elimination of the drug will probably occur as a result of kidney replacement therapy, but there are currently insufficient pharmacokinetic data to guide dosing during prolonged intermittent kidney replacement therapy (PIKRT) or the use of the pathogen adsorber Seraph 100. Materials and methods/case reports: Pharmacokinetic data were obtained from two critically ill patients undergoing PIKRT and hemoperfusion with the pathogen adsorber Seraph 100. Cefiderocol levels in plasma and dialysate samples were quantified using liquid chromatography with tandem mass spectrometry to evaluate the impact of extracorporeal therapy modalities on cefiderocol pharmacokinetics. Results: The median cefiderocol dialyser clearance was 80.94 (38.7–87) mL/min, while the Seraph 100 showed no significant clearance [−1.8 (−7.9 to 3.6) mL/min]. The cefiderocol concentration in the total spent dialysate suggests a total elimination of 1350 and 400 mg of cefiderocol, or 68% and 40% of the administered dose. Conclusion: Cefiderocol is substantially eliminated by PIKRT, but not during hemoperfusion with the Seraph 100. Consequently, dosage adjustments may be necessary depending on the intensity of the PIKRT procedure. Doses used for patients with normal renal function may be required to prevent underdosing during intensive PIKRT.

Introduction: Chlorprothixene is a typical antipsychotic, primarily used in the treatment of psychotic disorders. Overdose may result in severe cardiovascular and central nervous system toxicity. Evidence on the effectiveness of extracorporeal elimination is scarce. Case Presentation: A 19-year-old female ingested 5 g of chlorprothixene in a suicide attempt. Upon admission to the intensive care unit, she was awake, responsive, and oriented. Initial management included 50 g of activated charcoal. As doses of >2 g chlorprothixene can cause severe intoxication and death, attempts to enhance drug elimination by extracorporeal therapy were undertaken. Therapeutic plasma exchange (TPE) was initiated approximately 3 h after admission, exchanging 5,096 mL of plasma with albumin solution and FFP over 3 h 10 min. This was followed by a 10 h 10 min prolonged intermittent kidney replacement therapy (PIKRT). Serial blood, apheresis, and dialyzate samples were collected to quantify drug removal. Both procedures were well tolerated. The patient remained clinically stable and was transferred to a psychiatric facility 24 h post-admission. Conclusion: Although chlorprothixene plasma levels decreased, the amount of chlorprothixene removed by TPE and PIKRT was negligible, classifying the drug as “not dialyzable” per EXTRIP criteria. Given the limited clinical evidence and the pharmacokinetic properties of chlorprothixene, TPE cannot be recommended for the management of chlorprothixene overdose and should not be regarded as a standard treatment option. According to the available literature, this is the first description of chlorprothixene intoxication managed with both TPE and high-flux hemodialysis, highlighting the limited extracorporeal removal of this drug.

Introduction: High‐dose online HDF compared with hemodialysis reduces all‐cause mortality, but increases water consumption. We postulate that the conundrum could be solved by individualizing dialysate flow. Methods: Thirty CKD5D patients undergoing online HDF post‐dilution were changed from fixed dialysate flow (500 mL/min) to individualized dialysate flow, resulting in a dialysate flow that was always 20% higher than the blood flow. Kt / V _urea , K ⁺ , Phos, and pill burden in one quater pre as well as four quarters after the change were evaluated. Results: The practice change resulted in a reduction of the fixed dialysate flow from 500 to 360 (240–383) mL/min. Parameters of dialysis adequacy did not change; neither did the medication. Conclusion: An individualization of the dialysate flow saved about 36 L dialysate per session; hence, even in light of 23 L used for online HDF, the net burden on the environment could be reduced. Neither dialysis adequacy nor pill burden was negatively affected.

Indications for peritoneal dialysis (PD) have undergone a paradigm shift in recent years. Medical barriers previously viewed as contraindications for PD such as anuria, autosomal dominant polycystic kidney disease, cardiovascular diseases or advanced age are increasingly re-examined. We learned that establishing a safe, functional and durable catheter access can be established even in patients with a variety of co-morbidities. Moreover, conditions that predispose to catheter-related infections and peritonitis are not as obvious as we thought. In this case-based review we present patients who have been performing PD for a long time and in whom PD might still be viewed unfeasible. The aim of the paper is to underline the importance of PD as a kidney replacement therapy with fewer medical limits than previously thought. It is also a plaidoyer for interdisciplinary and interprofessional collaboration. This ‘Mission PD-possible’ should be accompanied by a coordinated approach aligning policy, organizational structures and financial resources.

Zusammenfassung Hintergrund Die Weltgesundheitsorganisation (World Health Organization [WHO]) erklärte im Jahre 2019 die antimikrobielle Resistenz zu einer der zehn größten globalen Bedrohungen für die öffentliche Gesundheit. Im gleichen Jahr wurde der erste Adsorber zur Elimination von Pathogenen in der EU zugelassen, der in Kombination zur antiinfektiven Therapie der schnellen und effizienten Entfernung von Bakterien und Viren aus dem Blutstrom dienen soll. Fragestellung Welche präklinischen und klinischen Daten haben zur Zulassung des Seraph® 100 Microbind® Affinity Blood Filter (ExThera Medical Corporation, Martinez, CA, USA) geführt? Ist eine Elimination von Pathogenen mit positiven klinischen Effekten verbunden? Welche Erkrankungen könnten für die Therapie mit Seraph 100® infrage kommen? Material und Methoden Nach einer Einführung in das generelle Konzept der extrakorporalen Pathogenelimination erfolgt eine systematische Übersicht und Zusammenstellung der klinischen und präklinischen Daten zum Seraph® 100 Microbind® Affinity Blood Filter (Seraph® 100). Grundlage sind die in PubMed gelisteten Publikationen bis Februar 2024. Ergebnisse Einzelfallberichte, unkontrollierte Beobachtungsstudien und Registerdaten zeigen die Sicherheit der Therapie mit dem Seraph® 100 und den potenziellen klinischen Nutzen der Pathogenelimination. Das Verfahren kann als alleinige Hämoperfusion, in Kombination mit allen gängigen Nierenersatzverfahren (intermittierende Hämodialyse, verlängerte intermittierende Dialyse und kontinuierliche Nierenersatzverfahren), aber auch mit der extrakorporalen Membranoxygenierung kombiniert werden. Schlussfolgerung Prospektive, randomisierte Studien müssen den klinischen Nutzen der Pathogenadsorption noch belegen.