A 50-year-old woman who had been on maintenance hemodialysis for 5 years developed severe anemia resistant to treatment with iron supplements and erythropoietin 4 months prior to hospital admission. Her stool occult blood test was positive, and an initial panendoscopy revealed evidence of possible antral gastritis. However, repeated administration of sucralfate, H2 blockers and a proton pump inhibitor was not effective in preventing further gastrointestinal tract blood loss and subsequent refractory anemia. She required multiple blood transfusions and hospital admissions during this period. There was no obvious coagulopathy or thrombocytopenia. After her third admission, a second panendoscopy demonstrated the typical picture of watermelon stomach. A trial of hormone therapy with estrogen and progesterone increased the hemoglobin level within a month without further evidence of active gastrointestinal bleeding. From our experience with this case, we found that the diagnosis of antral vascular ectasia (watermelon stomach) with bleeding requires a high degree of clinical alertness and careful endoscopic examination. Estrogen and progesterone therapy may provide a good option for treating the disease in uremic patients without an obvious complication. To the best of our knowledge, this is the first report demonstrating the use of maintenance hormone therapy in a female uremic patient to successfully treat watermelon gastric bleeding.
Tubulointerstitial involvement is well recognized in systemic lupus erythematosus. The tubular dysfunction is usually latent and usually presents after diagnosis of systemic lupus erythematosus. We report a case presenting that she is well previously and initially diagnosed as periodic paralysis of hypokalemia at emergency room and final diagnosis is systemic lupus erythematosus with H+-ATPase pump defect of distal type renal tubular acidosis. Kidney biopsy showed lupus nephritis classified as mesangial proliferative glomerulonephritis WHO class II B. Her renal tubular acidosis was subsided after steroid therapy was administered.
Liver transplantation can prolong survival in patients with end-stage liver disease. We have proposed that the Sequential Organ Failure Assessment (SOFA) score calculated on post-transplant day 7 has a great discriminative power for predicting 1-year mortality after liver transplantation. The Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) score, a modified SOFA score, is a newly developed scoring system exclusively for patients with end-stage liver disease. This study was designed to compare the CLIF-SOFA score with other main scoring systems in outcome prediction for liver transplant patients.We retrospectively reviewed medical records of 323 patients who had received liver transplants in a tertiary care university hospital from October 2002 to December 2010. Demographic parameters and clinical characteristic variables were recorded on the first day of admission before transplantation and on post-transplantation days 1, 3, 7, and 14.The overall 1-year survival rate was 78.3% (253/323). Liver diseases were mostly attributed to hepatitis B virus infection (34%). The CLIF-SOFA score had better discriminatory power than the Child-Pugh points, Model for End-Stage Liver Disease (MELD) score, RIFLE (risk of renal dysfunction, injury to the kidney, failure of the kidney, loss of kidney function, and end-stage kidney disease) criteria, and SOFA score. The AUROC curves were highest for CLIF-SOFA score on post-liver transplant day 7 for predicting 1-year mortality. The cumulative survival rates differed significantly for patients with a CLIF-SOFA score ≤8 and those with a CLIF-SOFA score >8 on post-liver transplant day 7.The CLIF-SOFA score can increase the prediction accuracy of prognosis after transplantation. Moreover, the CLIF-SOFA score on post-transplantation day 7 had the best discriminative power for predicting 1-year mortality after liver transplantation.
Abstract: Background: Controversy still persists regarding the impact of HCV infection on renal transplant recipients. This study aimed to evaluate the effect of anti‐HCV antibody status on patients and grafts of renal transplants at a single center. Methods: We examined 299 first cadaveric renal transplants performed between July 1981 and May 2000 at our hospital, including 129 patients with anti‐HCV antibody positive (HCV+ group) and 170 patients with anti‐HCV antibody negative (HCV− group). The HBsAg of the 299 patients were all negative throughout the follow‐up period. Causes of graft failure and patient death were analyzed. Patient and graft cumulative survival were compared between HCV+ and HCV− groups. Multivariate analysis with Cox proportional hazard model were calculated for risk hazards of outcome. Results: Overall cumulative patient survival was 97.72, 85.63 and 71.31% at 1, 10, and 15 yr, respectively, in the HCV+ group, compared with 95.02, 67.85 and 59.83% at 1, 10 and 15 yr, respectively, in the HCV− group (p = 0.014). The major cause of patient death in both groups was infection with 26.67% in HCV+ group and 60.87% in HCV− group. Cumulative graft survival in the HCV+ group revealed 92.26, 55.97 and 26.16% at 1, 10 and 15 yr, respectively, compared with 88.07, 58.34 and 58.32% at 1, 10 and 15 yr, respectively, in the HCV− group (p = 0.700). The major cause of graft failure was chronic allograft dysfunction (56.82%) in HCV+ group, and patient death (32.43%) in the HCV− group. Multivariate analysis of patient survival revealed anti‐HCV antibody+ had lesser risk hazard (aRR: 0.30, p = 0.002), chronic hepatitis had higher risk hazard (aRR: 1.90, p = 0.135), male recipient had higher risk hazard (aRR: 2.18, p = 0.051), and older recipients (age >55) also had higher risk hazard (aRR: 4.21, p = 0.063). Analysis of graft survival revealed only older donors (age >35) had higher risk hazard (aRR: 1.90, p = 0.081). Conclusions: The study revealed that patients with anti‐HCV antibody had higher incidence of chronic hepatitis, chronic allograft dysfunction and post‐transplantation nephrotic syndrome. Graft survival tended lower in the very long time. However, patients with anti‐HCV antibodies had better patient survival when compared with patients without HCV antibodies up to 15 yr follow up. Patients of hepatitis C group without clinical chronic hepatitis was associated with best patient survival.
Anemia is a component of the pathological triangle in cardiorenal anemia syndrome and is a risk factor for mortality in acute respiratory distress syndrome. This study assessed the predictive value of anemia for outcomes in critically ill patients receiving extracorporeal membrane oxygenation (ECMO) support. This retrospective study analyzed patients who received ECMO support at the cardiovascular surgery intensive care unit in the study institute between July 2003 and March 2012. Patient data, such as demographic information, etiologies of ECMO implementation, clinical parameters, and in-hospital and 6-month mortality rates, were statistically analyzed. The overall in-hospital mortality rate among the enrolled 295 patients was 55.6%. Multivariate logistical regression analysis indicated that age, albumin levels, sequential organ failure assessment (SOFA) score, and hemoglobin (Hb) level on ECMO day 1 exhibited independent prognostic significance for predicting in-hospital mortality rate. The SOFA score exhibited the highest areas under the receiver operating characteristic curve value (0.812 ± 0.025). The Hb level on ECMO day 1 exhibited satisfactory calibration and discriminatory power. The cumulative 6-month survival rates differed significantly between patients with Hb levels less than and more than 8.85 g/dL (30.6 vs. 54.0%, respectively, P < 0.001). This study indicated that old age, low albumin levels, low Hb levels, and higher SOFA scores on ECMO day 1 increased the risk of mortality. The Hb level is a readily measurable parameter and with good predictive power for critical patients on ECMO.
Background. Star fruit is a fruit originating is Southeast Asia and readily available in Taiwan. Star fruit causes several symptoms in patients with chronic renal failure or end stage renal disease. The symptoms vary, and include insomnia, intractable hiccup, agitation, muscle weakness, confusion, conscious disturbance of various degrees, seizure and cardiorespiratory arrest. The various star fruit subspecies contain different toxins, and a powerful neurotoxin that is suspected to accumulate in blood, cross the blood-brain barrier in chronic renal failure patients, and eventually cause irreversible damage. Mothods. We investigated three patients who suffered from star fruit intoxication, with different renal function status, clinical presentations and outcomes, and response to different management. We studied the star fruit intoxication with electroencephalography, and treated with plasma exchange. Results. Star fruit intoxication cannot be treated effectively. Our case suggests plasma exchange is an effective treatment in status seizure, but not in conscious disturbance. Conclusions. This results require further study of effectiveness, timing, frequency, and dosage of plasma exchange in star fruit intoxication to confirm this conclusion. Star fruit intoxication is a neglected but serious fruit intoxication which is frequently observed in patients with chronic renal failure. Because no effective treatment is available now, patients, especially those who are newly diagnosed with chronic renal failure and end stage renal disease, must be warned not to take star fruit, even a small amount.
The Chang Gung University School of Medicine adopted problem-based learning (PBL) education 3 years ago. A questionnaire was designed to evaluate the effectiveness of this teaching method, and the results were analyzed to determine statistical significance.In June 2001, all the interns in the Medical and Surgical departments of the Chang Gung Memorial Hospital were compulsorily assessed using a newly developed questionnaire, which was provided to the residents, chief resident, and attending doctors. The questions involved the interns' ability to perform 10 essential skills, namely (1) problem searching, (2) problem solving, (3) initiative learning, (4) thinking process, (5) establishing the patient-doctor relationship, (6) establishing the doctor-nurse relationship, (7) interaction with peers, (8) professional knowledge, (9) clinical techniques, and (10) medical notes writing. Forty-three completed questionnaires, evaluating 25 interns, were returned. Of these 25 individuals, 14 had participated in PBL education and 11 had been taught using the conventional variant.No statistically significant differences were demonstrated for gender or average school records between the interns who had been taught using the PBL and conventional methods. Statistically significant superiority was demonstrated for interns educated using PBL in three of 10 areas including, thinking process, professional knowledge, and clinical techniques.Analysis of the questionnaire results clearly demonstrated that the introduction of the PBL method of teaching at the university was efficacious in terms of the competence demonstrated by the interns when entering clinical practice.
Background Renal dysfunction is an established predictor of all-cause mortality in intensive care units. This study analyzed the outcomes of coronary care unit (CCU) patients and evaluated several biomarkers of acute kidney injury (AKI), including neutrophil gelatinase-associated lipocalin (NGAL), interleukin-18 (IL-18) and cystatin C (CysC) on the first day of CCU admission. Methodology/Principal Findings Serum and urinary samples collected from 150 patients in the coronary care unit of a tertiary care university hospital between September 2009 and August 2010 were tested for NGAL, IL-18 and CysC. Prospective demographic, clinical and laboratory data were evaluated as predictors of survival in this patient group. The most common cause of CCU admission was acute myocardial infarction (80%). According to Acute Kidney Injury Network criteria, 28.7% (43/150) of CCU patients had AKI of varying severity. Cumulative survival rates at 6-month follow-up following hospital discharge differed significantly (p<0.05) between patients with AKI versus those without AKI. For predicting AKI, serum CysC displayed an excellent areas under the receiver operating characteristic curve (AUROC) (0.895±0.031, p<0.001). The overall 180-day survival rate was 88.7% (133/150). Multiple Cox logistic regression hazard analysis revealed that urinary NGAL, serum IL-18, Acute Physiology, Age and Chronic Health Evaluation II (APACHE II) and sodium on CCU admission day one were independent risk factors for 6-month mortality. In terms of 6-month mortality, urinary NGAL had the best discriminatory power, the best Youden index, and the highest overall correctness of prediction. Conclusions Our data showed that serum CysC has the best discriminative power for predicting AKI in CCU patients. However, urinary NGAL and serum IL-18 are associated with short-term mortality in these critically ill patients.
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