Acute kidney injury (AKI) is a common complication in hospitalized patients. The International Society of Nephrology implemented the "0 by 25" initiative aimed at preventing deaths from treatable AKI worldwide by 2025 and conducted a global snapshot survey in 2014. We joined in the project and conducted this study to compare the epidemiology, risk factors, and prognosis between patients with pure AKI and those with acute-on-chronic kidney disease (ACKD). In this study, we prospectively collected demographic parameters and data on clinical characteristics, baseline comorbidities, management, and outcomes of 201 AKI patients in 18 hospitals in Taiwan from September 2014 to November 2014. The in-hospital mortality rate was 16%. AKI was mostly attributed to sepsis (52%). Multivariate logistic regression indicated that oliguria was a positive independent predictor of in-hospital mortality, whereas preexisting CKD and exposure to nephrotoxic agents were negative independent predictors. The prevalence of vasopressor use, intensive care unit care, and mortality were significantly higher in pure AKI patients than in ACKD patients. Moreover, serum creatinine (SCr) levels significantly increased within 7 days after AKI diagnosis in nonsurvivors but not in survivors in the pure AKI group. By contrast, SCr levels were persistently lower in nonsurvivors than in survivors in the ACKD group during the same period. We thus determined that the prognosis of ACKD patients differed from that of pure AKI patients. Considering the CKD history in the future AKI staging system may improve prognosis prediction.
Background. The thrombotic thrombocytopenic purpura (TTP) is a rare disorder with a high mortality rate if untreated or delayed therapy. Whether immediate diagnosis and promptly treated with plasma exchange can change the grave prognosis? Method. Retrospective analysis was performed on clinical characteristics and treatment outcome of 13 patients diagnosed and treated during a 6-year period, from 08 1994 to 08 2000, in a tertiary care university hospital in Taiwan. Results. Among the patients, 8 were males and 5 were females, 10 were idiopathic, 2 were ticlopidine, and 1 was SLE-induced; 12 (92.3%) had neurological abnormalities, 11 (84.6%) had ecchymosis, 8 (61.5%) had fever, and 6 (46.2%) had renal impairment (creatinine ≥ 1.5 mg/dL) at initial presentation of the syndrome. Excluding the SLE patient, 6 of 10 (60%) had shown antinuclear antibody (ANA) non-specific positive (titer ≥ 1:40). All patients were initially treated with plasma exchange plus steroids. Of these 13 patients, 11 (84.6%) achieved complete remission, one had partial remission, and one, which was ticlopidine-induced, had no response and died of a progressive disease complicated with pneumonia. Within a median follow-up period of 31 months, 4 of 11 patients who achieved complete remission relapsed after one week, two weeks, three weeks, and three months, respectively. In the four relapsing patients, three late relapsing patients received FFP infusion, increased steroid dosages, added cyclophosphamide plus vincristine; and one early relapsing patient, relapsing twice, received an additional two courses of plasma exchange and added cyclophosphamide plus vincristine. All of the four patients achieved complete remission again. The patient who had partial remission relapsed early and responded promptly to another course of plasma exchange plus cyclophosphamide and vincristine and achieved complete remission. and Conclusion. Based on the results in this study, we conclude that plasma exchange plus steroids can effectively treat TTP. For patients with a refractory or relapsing disease, immunosuppressive therapy with cyclophosphamide plus vincristine should be administered as well.
To evaluate the influence of body iron stores on the serum aluminum (Al) level, we studied the correlation between iron status (the serum ferritin, serum iron and transferrin saturation) and serum Al levels in 68 severely anemic hemodialysis patients. Among them, 36 underwent the desferrioxamine (DFO) mobilization test. These 68 patients were divided into three groups according to their serum ferritin level. The basal Al level in the patient group was 41.4 ± 37.4 μg/l (control, 4.1 ± 2.4 μg/l). The serum Al level after DFO infusion of the patient group was Ill.1 ± 86.8 μg/l. A significantly higher basal Al and peak Al level after DFO infusion were found in group 1 patients (serum ferritin < 300 μg/l) when compared to group 2 (serum ferritin 300-1,000 μg/l) and group 3 (serum ferritin > 1,000 μg/l) patients. A significant negative correlation between serum ferritin and basal serum Al (r = -0.544, p = 0.0001), as well as peak serum Al after DFO infusion (r =-0.556, p = 0.0001), was noted. Similarly, a negative relationship between serum Al (both basal and peak) and either serum iron or transferrin saturation was noted. However, there was no correlation between the serum Al level and the dosage of aluminum hydroxide. In conclusion, serum ferritin, serum iron and transferrin saturation were inversely correlated with serum Al in our hemodialysis patients. Iron deficiency may probably increase Al accumulation in these patients.
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.
Nitric oxide plays an important role in mediating the inflammatory process. The aim of this study was to evaluate if nitric oxide production was increased during peritonitis in patients receiving continuous ambulatory peritoneal dialysis (CAPD), and the association with the prognosis. The study population comprised 21 patients with 22 episodes of peritonitis. Fifteen patients without peritonitis were controls. Nitrate was measured by HPLC and nitrite by the Griess method, to reflect nitric oxide production. Peritoneal dialysate effluent and plasma were collected from six patients during peritonitis and 1 week after treatment to study changes in dialysate:plasma ratio. In 15 patients, nitrite was measured during peritonitis and every 3 days for 2 weeks or until normalized for evolutional changes. The dialysate plasma ratios of nitrate and nitrite during peritonitis were reduced 26% and 41.5%, respectively, after 1 week of treatment, indicating the peritoneal production of nitric oxide during peritonitis. In the evolutional study, a 5.1-fold increase of peak nitrite levels in bacterial peritonitis (n=13) and a 2.5-fold increase in fungal peritonitis (n=3) were observed compared to controls. Nitrite gradually declined to control levels (9.3±7.2 days) after effective antibiotic treatment, but took longer than to normalize leukocyte count in the peritoneal dialysate effluent (3.9±1.9 days). In four patients with refractory peritonitis (Candida infection in three, Acinetobacter infection in one), the nitrite levels remained elevated 2-fold despite treatment, and the catheters were removed. It is concluded that nitrite levels in peritoneal dialysate effluent may serve as a marker to assess treatment efficacy in CAPD patients with peritonitis.
To establish the impact of cyclosporine on the development of chronic hepatitis in hepatitis B surface antigen (HBsAg)—positive renal allograft recipients, the incidence and outcome of chronic hepatitis in 20 cyclosporine-treated patients (CsA group) were compared with 13 azathioprine-treated patients (AZA group). All 33 patients had a functioning graft for 2 years or longer. Twenty-nine of the 33 patients were HBsAg-positive prior to the initiation of hemodialysis. The difference in the incidence of chronic hepatitis between these 2 groups was not statistically significant (78.6% in the AZA group vs. 52.4% in the CsA group, P = 0.12). In the CsA group, 3 patients (15%) developed liver cirrhosis, and there was a 5% mortality. The AZA group had a 7.7% mortality, and 4 patients (30.8%) developed liver cirrhosis. Serial serum samples obtained from these 33 HBsAg-positive renal allograft recipients were analyzed for antibody to hepatitis D virus (anti-HD). Anti-HD was found in 3 patients. Two of them developed anti-HD seroconversion after renal transplantation during a mean follow-up of 4 years. All 3 patients developed chronic hepatitis and 2 of them have subsequently developed liver cirrhosis. There was a mortality of 6.1% in 33 HBsAg-positive patients compared with a 5.3% mortality in 57 HBsAg-negative renal allograft recipients. The difference was not statistically significant. We conclude from this study that (1) CsA-treated HBsAg-positive renal allograft recipients have a tendency to develop chronic hepatitis like AZA-treated patients; (2) HBsAg-positive patients have an increased risk of HDV superinfection after renal transplantation, and this may result in rapid progression to liver cirrhosis; (3) HBsAg-positive patients who acquire HBsAg prior to renal transplantation have a low overall mortality, including death due to liver disease, for a mean follow-up of 4 years.
Abstract BACKGROUND Chronic hepatitis is associated with increased hemoglobin level in patients with end‐stage renal disease. The aim of this study was to define the individual and combined influence of chronic hepatitis B and C infections on red blood cell status. METHODS A total of 524 chronic hemodialysis patients at 5 hemodialysis centers were retrospectively reviewed for the period from March 1 to June 31, 2005. The results of testing using a third‐generation enzyme‐linked immunosorbent assay showed that 345 patients (65.8%) had neither HBV nor HCV (NBC), 55 patients (10.5%) had HBV, 108 (20.6%) had HCV, and 16 (3.1%) had concurrent HBV and HCV infection (BBC). Differences between the 4 groups of patients in the parameters studied were investigated using a multivariate general linear model with the Sidak post hoc test. RESULTS The hemoglobin and hematocrit of patients with HCV were 10.5 ± 1.6 g/dL and 31.6% ± 4.7%, respectively, which were significantly higher than the 9.9 ± 1.4 g/dL and 29.7% ± 4% of NBC patients ( p = 0.002 and p = 0.001). The erythropoietin (EPO) dose given to patients with HCV was 39.3 ± 40.3 IU/kg/week, significantly lower than the 58.1 ± 40.6 IU/kg/week for those with NBC. The results of the multivariate linear regression analysis suggested that erythropoietin dose, elevated liver functional test results, and HCV infection were major factors affecting red cell production ( p < 0.001, p < 0.02, and p < 0.05, respectively). CONCLUSION Hepatitis C virus infection was associated with an increased number of red blood cells, which led to a lowering of the necessary EPO dose, whereas hepatitis B virus infection was not.
Nephrologists commonly recommend continuous ambulatory peritoneal dialysis (CAPD) with break-in periods of at least 2 weeks. We investigated the safety and feasibility of shorter break-in periods following surgical implantation of Tenckhoff catheters.We retrospectively examined 310 patients that underwent Tenckhoff catheter implantation for the first time. The early group comprised 226 patients that started CAPD ≤ 14 days after implantation; the late group comprised 84 patients that started CAPD > 14 days after implantation. Catheter-related complications within 6 months were analyzed.A total of 310 patients were enrolled. Time to CAPD initiation was shorter in the early group (2.0 ± 2.7 days) than in the late group (40.6 ± 42.8 days) (p < 0.001). The bridge hemodialysis rate was higher in the late group (57.1%) than in the early group (31.4%) (p < 0.001). Overall, 33 early-group (14.6%) and 11 late-group patients (13.1%) developed catheter-related complications within 6 months. The early-group complications were leakage (n = 5), diminished outflow volume (n = 7), migration (n = 7), pericatheter hernia (n = 1), hemoperitoneum (n = 1), pericatheter infection (n = 3), and peritonitis (n = 9). The late-group complications were leakage (n = 2), diminished outflow volume (n = 5), migration (n = 2), and peritonitis (n = 2). Actuarial freedom from catheter-related complications was similar in both groups (log rank, p = 0.76).Early initiation of CAPD with surgically implanted Tenckhoff catheters is feasible and safe. Shorter break-in periods are not associated with more catheter-related complications. The data from our peritoneal dialysis population suggest that early initiation is not associated with an increased number of complications. This needs to be confirmed in a randomized trial.
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