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Background This article is a duplicated publication from the Japanese version of “2019 JSDT Guidelines for Peritoneal Dialysis” with permission from the Japanese Society for Dialysis Therapy (JSDT). This clinical practice guideline (CPG) was developed primarily by the Working Group on Revision of Peritoneal Dialysis (PD) Guidelines of the Japanese Society for Dialysis Therapy. Recently, the definition and creation process for CPGs have become far more rigorous; traditional methods and formats no longer adhere to current standards. To improve the reliability of international transmission of our findings, CPGs are created in compliance with the methodologies developed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) working group. Part 2 of this PD guideline is the first CPG developed by our society that conforms to the GRADE approach. Methods Detailed processes were created in accordance with the Cochrane handbook and the GRADE approach developed by the GRADE working group. Results Clinical question (CQ)1: Is the use of renin-angiotensin system inhibitors (RAS inhibitors), such as angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB), effective in PD patients? Recommendation: We suggest the usage of RAS inhibitors (ACEI and ARB) in PD patients (GRADE 2C). CQ2: Icodextrin or glucose solution: which is more useful as a dialysate among patients with PD? Recommendation: We suggest using icodextrin when managing body fluids in PD patients (GRADE 2C). CQ3: Is it better to apply or not apply mupirocin/gentamicin ointment to the exit site? Recommendation: We suggest not applying mupirocin/gentamicin ointment to the exit sites of PD patients (GRADE 2C). CQ4: Which surgical approach is more desirable when a PD catheter is placed, open surgery or laparoscopic surgery? No recommendation. CQ5: Which administration route of antibiotics is better in PD patients with peritonitis, intravenous or intraperitoneal? Recommendation: We suggest intraperitoneal administration of antibiotics in PD patients with peritonitis (GRADE 2C). Note: The National Insurance does not currently cover intraperitoneal administration. CQ6: Is peritoneal dialysis or hemodialysis better as the first renal replacement therapy in diabetic patients? No recommendation. Conclusions In the future, we suggest that society members construct their own evidence to answer CQs not brought up in this guideline, and thereby show the achievements of Japan worldwide.

Background and Aims Iron-based phosphate binder (IPB) is a noncalcium phosphate binder that demonstrated sustained serum phosphorus control, good tolerability and lower pill burden compared with sevelamer carbonate in a Phase 3 study conducted in dialysis patients. These efficacy of IPB has been demonstrated for hemodialysis (HD) patients, but few studies have focused on patients undergoing peritoneal dialysis (PD). We evaluated efficacy of IPB and focused on effects for anemia and iron metabolism in patients on PD. Method This study was a cross-sectional, longitudinal multicenter study conducted by PD OASIS, organized committee in Kanagawa Japan. We analyzed the effects of IPB during a 6 months observation period in chronic kidney disease patients on PD who had administrated IPB, Ferric citrate hydrate and Sucroferric oxyhydroxide, between 2017 and 2019. The primary endpoint was the changes of phosphate, and several secondary endpoints were assessed: calcium, intact PTH, RBC, hemoglobin, MCH, RDW-VC, Fe, TSAT, Ferritin, albumin, CRP, monthly dosage of Erythropoietin stimulating agents (ESA) and ESA resistance index (ERI). In addition, we assessed the association between these markers and iron metabolism utilizing multivariate logistic regression analysis. Results A total of 102 patients were registered in the study who had received IPB. The initial doses of Ferric citrate hydrate and Sucroferric oxyhydroxide were 1010.9 ±400.9 mg and 941.7 ±502.9 mg daily, finally increased to 1213.6 ±559.9 mg and 1310.0 ±521.8 mg respectively at the end of the observation. We observed a significant reduction of serum phosphate to 5.27 ± 0.98 mg/dL from 6.56 ± 1.52 mg/dL with follow-up of six months (p < 0.01). At the end of the study, 76.4% of participants had achieved the target of less than 6 mg/dL. The hemoglobin, TSAT and Ferritin increased significantly from 10.47 ±1.26 g/dl, 27.95 ±11.05 % and 139.0 ±147.6 ng/mL to 11.17 ±1.16 g/dl, 40.46 ±15.00 % and 305.9 ±232.0 ng/mL respectively in six months (p < 0.01). No significant changes of serum calcium, intact parathyroid hormone (PTH) and CRP occurred over the study period. The monthly dosage of ESA was significantly decreased after administration with IPB and ERI significantly improved to 0.11±0.12 (μg/month/kg/g Hb) from 0.21±0.16 (μg/month/kg/g Hb) (p Additionally, we assessed the factors of ferritin increase because it was remarkable in follow-up six months compared to HD patients. In multivariate analysis, phosphate (Odds ratio 5.85, 95%CI 1.18-91.77, p=0.027), intact PTH (0.99, 0.97-1.15, p=0.015), hemoglobin (Odds ratio 0.10, 95%CI 0.05-0.59, p=0.025), RBC (Odds ratio 1.16, 95%CI 1.04-1.41, p=0.003), and RDW-CV (Odds ratio 0.44, 95%CI 0.10-0.99, p=0.046) were significantly associated with ferritin increase more than 300 ng/ml ,after adjusted. Conclusion This study confirmed the efficacy of Iron-based phosphate binder, Ferric citrate hydrate and Sucroferric oxyhydroxide, in the treatment of hyperphosphatemia in PD patients. In addition, IBP caused secondary effects of anemia improvement and ESA dosage reduction resulting in ERI improvement. However, in this study, the increase in ferritin levels was remarkable. It may be because PD does not lose iron by treatment compared to HD. Therefore, we should check iron metabolism more frequently for PD patients taking IPB than HD patients. It is necessary to further investigate the effects of IPB on anemia and iron metabolism in PD patients.

Success in peritoneal dialysis (PD) requires a well-functioning catheter, and catheter placement at PD initiation is extremely important for long-term PD. Although several randomized, controlled trials (RCTs) have compared open surgery with laparoscopic surgery, there is controversy regarding which surgical approach is desirable. The present systematic review and meta-analysis was performed to clarify which surgical approach is superior. A systematic literature search for RCTs was performed using the Cochrane Central Register of Controlled Trials and the MEDLINE database, and a meta-analysis was performed using Review Manager Version 5.3.5 (Cochrane Collaboration, Oxford, UK). Catheter survival was the primary outcome, and leakage, hernia, requirement for reoperation, catheter-related infection, postoperative pain, hospitalization period associated with catheter placement, and catheter migration were the secondary outcomes. After screening 913 references, seven RCTs were analyzed. Laparoscopic surgery was found to have no favorable effect on catheter survival (5 trials, 424 patients; risk ratio [RR] 1.02; 95% confidence interval [CI] 0.92–1.13; p = 0.68; low-quality evidence]. The incidence of catheter migration was significantly lower with laparoscopic surgery (6 trials, 526 patients; RR 0.42; 95% CI 0.18–0.96; p = 0.04; moderate-quality evidence). However, the significance decreased on limiting the analysis to RCTs involving laparoscopic surgery without secured suture of the PD catheter (4 trials, 431 patients; RR 0.58; 95% CI 0.27–1.25; p = 0.17; moderate-quality evidence). Other outcomes were similar between open surgery and laparoscopic surgery. The present findings indicate that laparoscopic surgery has a limited advantage over open surgery with respect to PD patients’ outcomes.

Pulmonary involvement in cryoglobulinemia usually is mild. We present a rare case of severe lung involvement in mixed cryoglobulinemia. A 73-year-old woman with cryoglobulinemic glomerulonephritis was admitted. Dyspnea appeared suddenly two days later. She received the diagnosis of acute lung injury according to the concept proposed by the American-European Consensus Conference. Management required corticosteroid pulse therapy and plasma exchange. This case is the first description of successful early and long-term management of severe lung involvement observed in cryoglobulinemia. Although she has been free of chest symptoms for seven months, further follow-up may be necessary to assess the potential danger of relapse.