Understanding the Korean dialysis cohort for mineral, vascular calcification, and fracture (ORCHESTRA) Study: Design, method, and baseline characteristics

INTRODUCTION

End-stage renal disease (ESRD) is a growing disease in Korea and worldwide and is an important condition that affects patient outcomes. In order to provide optimal management for mineral disturbance, vascular calcification, and bone disease of ESRD patients, the ORCHESTRA study (Korean dialysis cohort for mineral, vascular calcification, and fracture) was conducted and enrolled Korean dialysis patients.

METHODS

Sixteen university-affiliated hospitals and one Veterans Health Service Medical Center participated in this study. This prospective cohort study enrolled approximately 900 consecutive dialysis patients between May 2019 and January 2021. Enrolled subjects were evaluated at baseline for demographic information, laboratory tests, radiologic imaging, and bone mineral densitometry (BMD) scans. After enrollment, regular assessments of patients were performed and their biospecimens were collected according to the study protocol. Primary outcomes were occurrence of major adverse cardiovascular events (MACE), invasive treatment for peripheral artery disease (PAD), and osteoporotic fractures. Secondary outcomes were hospitalization for cerebro-cardiovascular disease or progression of abdominal aortic calcification (AAC). Participants will be assessed for up to three years to determine whether primary or secondary outcomes occur.

RESULTS

From May 2019 to January 2021, all participating centers recruited 900 consecutive dialysis patients, including 786 undergoing hemodialysis (HD) and 114 undergoing peritoneal dialysis (PD). The mean age of subjects was 60.4 ± 12.3 years. Males accounted for 57.7%. The mean dialysis vintage was 6.1 ± 6.0 years. The HD group was significantly older, had a longer dialysis vintage, and more comorbidities. Overall, the severity of vascular calcification was higher and the level of BMD was lower in the HD group than in the PD group.

CONCLUSION

This is a nationwide, multicenter, prospective cohort study that focuses on CKD-mineral and bone disorder (CKD-MBD) and aims to provide clinical evidence to establish optimal treatment guidelines for Asian dialysis patients.

Clinical significance of neutrophil-to-lymphocyte ratio on the risk of abdominal aortic calcification and decreased bone mineral density in patients with end-stage kidney disease

Inflammation plays a major role in the pathogenesis of chronic kidney disease (CKD), but the relationship between systemic inflammation and CKD-mineral bone disease is unclear. We aimed to investigate whether the neutrophil-to-lymphocyte ratio (NLR) is related to abdominal aortic calcification (AAC) and bone mineral density (BMD) in dialysis patients. In this cross-sectional analysis using baseline data of a multicenter cohort, a total of 759 patients were divided into three groups according to NLR level, and the associations between NLR and Kauppila AAC score (AACS) and BMD were assessed. The highest tertile NLR group had more males, alcohol consumers, higher diabetes prevalence, and higher comorbidity index than the lowest tertile NLR group. Fasting glucose and C-reactive protein levels were higher, while serum albumin, serum iron, and lipid profiles except triglycerides were lower in the highest tertile group. AACS was significantly higher in the highest tertile group than in the lowest and middle tertile groups (p = 0.017), but the mean areal BMD and T-score of the lumbar spine and femur were not different between groups. NLR level was positively correlated with AACS in all aortic wall segments except L1 and L3 anterior. In multivariable logistic regression analysis, the highest tertile NLR group was independently associated with AAC (odds ratio 2.876, 95% confidence interval 1.250-6.619, p = 0.013) but was not associated with osteoporosis in the lumbar spine and femur after adjusting for confounding factors. The NLR can be used as a potential indicator of AAC in dialysis patients.

Association between Blood Pressure and Renal Progression in Korean Adults with Normal Renal Function

BACKGROUND

Although hypertension (HTN) is a well-established major risk factor for renal progression in patients with chronic kidney disease (CKD), few studies investigating its role in renal deterioration in the general population with normal renal function (NRF) have been published. Here, we analyzed the correlation between blood pressure (BP) and impaired renal function (IRF) in Korean adults with NRF.

METHODS

Data for the study were collected from the national health screening database of the Korean National Health Insurance Service. Patients whose baseline estimated glomerular filtration rate (eGFR) was less than 60 mL/min/1.73 m² or whose baseline urinalysis showed evidence of proteinuria were excluded. IRF was defined as an eGFR below 60 mL/min/1.73 m². We performed follow up for eGFR for 6 years from 2009 to 2015 and investigated IRF incidence according to baseline BP status. We categorized our study population into two groups of IRF and NRF according to eGFR level in 2015.

RESULTS

During 6 years of follow-up examinations, IRF developed in 161,044 (2.86%) of 5,638,320 subjects. The IRF group was largely older, and the incidence was higher in females and patients with low income, HTN, diabetes mellitus, dyslipidemia, and obesity compared with the NRF group. Subjects whose systolic BP was more than 120 mmHg or whose diastolic BP was more than 70 mmHg had an increased risk of developing IRF compared with subjects with lower BP (odds ratio [OR], 1.037; 95% confidence interval [CI], 1.014-1.061 vs. OR, 1.021; 95% CI, 1.004-1.038).

CONCLUSION

BP played a major role in renal progression in the general population with NRF. Strict BP control may help prevent CKD in the general population.

Identifying different types of microorganisms with terahertz spectroscopy

Most microbial detection techniques require pretreatment, such as fluorescent labeling and cultivation processes. Here, we propose novel tools for classifying and identifying microorganisms such as molds, yeasts, and bacteria based on their intrinsic dielectric constants in the THz frequency range. We first measured the dielectric constant of films that consisted of a wide range of microbial species, and extracted the values for the individual microbes using the effective medium theory. The dielectric constant of the molds was 1.24-1.85, which was lower than that of bacteria ranging from 2.75-4.11. The yeasts exhibited particularly high dielectric constants reaching 5.63-5.97, which were even higher than that of water. These values were consistent with the results of low-density measurements in an aqueous environment using microfluidic metamaterials. In particular, a blue shift in the metamaterial resonance occurred for molds and bacteria, whereas the molds have higher contrast relative to bacteria in the aqueous environment. By contrast, the deposition of the yeasts induced a red shift because their dielectric constant was higher than that of water. Finally, we measured the dielectric constants of peptidoglycan and polysaccharides such as chitin, α-glucan, and β-glucans (with short and long branches), and confirmed that cell wall composition was the main cause of the observed differences in dielectric constants for different types of microorganisms.

Circulating renalase predicts all-cause mortality and renal outcomes in patients with advanced chronic kidney disease

BACKGROUND/AIMS

Patients with chronic kidney disease (CKD) have been found to show markedly increased rates of end-stage renal disease, major adverse cardiovascular and cerebrovascular events (MACCEs), and mortality. Therefore, new biomarkers are required for the early detection of such clinical outcomes in patients with CKD. We aimed to determine whether the level of circulating renalase was associated with CKD progression, MACCEs, and all-cause mortality, using data from a prospective randomized controlled study, Kremezin STudy Against Renal disease progression in Korea (K-STAR; NCT00860431).

METHODS

A retrospective analysis of the K-STAR data was performed including 383 patients with CKD (mean age, 56.4 years; male/female, 252/131). We measured circulating renalase levels and examined the effects of these levels on clinical outcomes.

RESULTS

The mean level of serum renalase was 75.8 ± 34.8 μg/mL. In the multivariable analysis, lower hemoglobin levels, higher serum creatinine levels, and diabetes mellitus were significantly associated with a higher renalase levels. Over the course of a mean follow-up period of 56 months, 25 deaths and 61 MACCEs occurred. Among 322 patients in whom these outcomes were assessed, 137 adverse renal outcomes occurred after a mean follow-up period of 27.8 months. Each 10- μg/mL increase in serum renalase was associated with significantly greater hazards of all-cause mortality and adverse renal outcomes (hazard ratio [HR] = 1.112, p = 0.049; HR = 1.052, p = 0.045). However, serum renalase level was not associated with the rate of MACCEs in patients with CKD.

CONCLUSION

Our results indicated that circulating renalase might be a predictor of mortality and adverse renal outcomes in patients with CKD.

Higher Serum Levels of Osteoglycin Are Associated with All-Cause Mortality and Cardiovascular and Cerebrovascular Events in Patients with Advanced Chronic Kidney Disease

Patients with chronic kidney disease (CKD) have markedly increased rates of major adverse cardiovascular and cerebrovascular events (MACCEs) and mortality. Therefore, identifying early biomarkers predicting clinical outcomes in patients with CKD is critical. We aimed to determine whether osteoglycin, a basic component of the vascular extracellular matrix, was associated with MACCEs or all-cause mortality, using data from a prospective randomized controlled study, K-STAR (Kremezin STudy Against Renal disease progression in Korea: NCT 00860431). A total of 383 patients (mean age: 56.4 years, men/women = 252/131) with CKD stage 3 to 4 from the original trial were enrolled in the present study. We measured serum osteoglycin level and examined the impact of osteoglycin on clinical outcomes. The mean value of osteoglycin levels was 13.3 ± 9.4 ng/mL (healthy control: 5.3 ± 2.1 ng/mL). In multivariable analysis, lower levels of proteinuria and hemoglobin and higher levels of C-reactive protein were significantly associated with higher osteoglycin levels. Estimated glomerular filtration rate was not related to osteoglycin level. During a mean follow-up period of 56 months, 25 deaths, 61 MACCEs, and 76 composite outcomes (all-cause mortality or MACCEs) occurred. In the non-diabetic group, each 1-ng/mL increase in serum osteoglycin was associated with all-cause mortality and composite outcome (hazard ratio [HR] = 1.058, P = 0.031; HR = 1.041, P = 0.036). However, osteoglycin levels were not associated with mortality, MACCEs, or composite outcome in the diabetic group. Our results indicate that serum osteoglycin is a potential predictor of adverse outcomes in patients with CKD.

Comparative efficacy and safety of gemigliptin versus linagliptin in type 2 diabetes patients with renal impairment: A 40-week extension of the GUARD randomized study

AIMS

The long-term safety and efficacy of gemigliptin was evaluated in the present extension study after a 12-week study during a 40-week follow-up period.

METHODS

The main study was a randomized, placebo-controlled, double-blinded, phase IIIb study in which 50 mg of gemigliptin (N = 66) or placebo (N = 66) was administered to patients with type 2 diabetes mellitus (T2DM) and moderate or severe renal impairment over a 12-week period. Patients with a glycated haemoglobin (HbA1c) level of 7% to 11% and an estimated glomerular filtration rate (eGFR) of 15 to 59 mL/min/1.73 m² were enrolled in the main study. After 12 weeks, patients in the gemigliptin group continued to receive gemigliptin (N = 50), whereas patients in the placebo group were transitioned from placebo to linagliptin (N = 52). Each group received the indicated treatment over the subsequent 40-week period. A total of 102 patients consented to participate in the extension study, and 79 patients ultimately completed the study.

RESULTS

The HbA1c levels of both groups were significantly reduced at week 52 compared with baseline. Specifically, the adjusted mean change ± standard error in HbA1c level in the gemigliptin and placebo/linagliptin groups was 1.00% ± 0.21% and 0.65% ± 0.22% lower at week 52 than at baseline (P < .001 and P = .003), respectively. No significant difference in the change in HbA1c level was found between the 2 groups (P = .148). Trends in fasting plasma glucose, fructosamine and glycated albumin levels in the 2 groups were similar to trends in HbA1c levels. The eGFR of both groups was also significantly lower at week 52 than at baseline, and no significant difference in change in eGFR was found between the 2 groups. In contrast, both drugs had little effect on urinary albumin excretion, although both drugs significantly reduced the urinary type IV collagen level. The overall rates of adverse events were similar between the 2 groups.

CONCLUSIONS

Gemigliptin and linagliptin did not differ with respect to safety and efficacy in patients with T2DM and renal impairment. The 2 drugs had similar glucose-lowering effects, and the changes in eGFR and albuminuria were also similar. Additionally, the risk of side effects, including hypoglycaemia, was similar between the 2 groups.

Sudden bilateral vision loss as the sole manifestation of posterior reversible encephalopathy syndrome from acute uremia: Clinical case report

RATIONALE

Posterior reversible encephalopathy syndrome (PRES) is a cliniconeuroradiological entity associated with vasogenic edema. Symptoms may include headache, seizures, altered mental status, and visual impairment. Patients with PRES generally present with neurological deficits.

PATIENT CONCERNS

Here, we report an unusual case of a 42-year-old man who presented with sudden bilateral vision loss without any other neurologic symptoms.

DIAGNOSES

He was diagnosed with PRES secondary to acute uremia.

INTERVENTIONS AND OUTCOMES

Our patient experienced a dramatic improvement in visual acuity, blood chemistry values, and magnetic resonance imaging findings following repeated hemodialysis.

LESSONS

Sudden bilateral vision loss may be the sole manifestation of PRES, particularly in patient with risk factors for PRES. Awareness of this variation of the clinical symptoms of PRES is important to facilitate its recognition.

Sustained uremic toxin control improves renal and cardiovascular outcomes in patients with advanced renal dysfunction: post-hoc analysis of the Kremezin Study against renal disease progression in Korea

Background

We investigated the long-term effect of AST-120, which has been proposed as a therapeutic option against renal disease progression, in patients with advanced chronic kidney disease (CKD).

Methods

We performed post-hoc analysis with a per-protocol group of the K-STAR study (Kremezin study against renal disease progression in Korea) that randomized participants into an AST-120 and a control arm. Patients in the AST-120 arm were given 6 g of AST-120 in three divided doses, and those in both arms received standard conventional treatment.

Results

The two arms did not differ significantly in the occurrence of composite primary outcomes (log-rank P = 0.41). For AST-120 patients with higher compliance, there were fewer composite primary outcomes: intermediate tertile hazard ratio (HR) 0.62, 95% confidence interval (CI) 0.38 to 1.01, P = 0.05; highest tertile HR 0.436, 95% CI 0.25 to 0.76, P = 0.003. The estimated glomerular filtration rate level was more stable in the AST-120 arm, especially in diabetic patients. At one year, the AST-120-induced decrease in the serum indoxyl sulfate concentration inversely correlated with the occurrence of composite primary outcomes: second tertile HR 1.59, 95% CI 0.82 to 3.07, P = 0.17; third tertile HR 2.11, 95% CI 1.07 to 4.17, P = 0.031. Furthermore, AST-120 showed a protective effect against the major cardiovascular adverse events (HR 0.51, 95% CI 0.26 to 0.99, P = 0.046).

Conclusion

Long-term use of AST-120 has potential for renal protection, especially in diabetic patients, as well as cardiovascular benefits. Reduction of the serum indoxyl sulfate level may be used to identify patients who would benefit from AST-120 administration.

Prediction of clinical outcomes after kidney transplantation from deceased donors with acute kidney injury: a comparison of the KDIGO and AKIN criteria

Background

Acute kidney injury (AKI) is frequently detected in deceased donors (DDs), and it could be associated with adverse clinical outcomes in corresponding kidney transplant recipients (KTRs). In this regard, we sought to identify which criteria is better between the KDIGO and AKIN criteria for the diagnosis of AKI in DDs in the prediction of clinical outcomes after kidney transplantation (KT).

Methods

Two hundred eighty-five cases of deceased donor kidney transplantation (DDKT) were included. We divided them into three groups; the non-AKI by both KDIGO and AKIN criteria group (n = 120), the AKI by KDIGO only group (n = 61), and the AKI by both criteria group (n = 104) according to the diagnosis of AKI using the KDIGO and AKIN criteria in the corresponding 205 DDs. We compared the development of delayed graft function (DGF), the change in allograft function, the allograft survival among the three groups.

Results

The incidence of DGF was significantly higher in the AKI by KDIGO only and the AKI by both criteria groups than in the non-AKI by both criteria group (P < 0.05 each). But no difference was detected between the AKI by KDIGO only group and the AKI by both criteria group (P > 0.05). Therefore, the KDIGO criteria had a better predictive value for DGF occurrence than the AKIN criteria (Area under the curve = 0.72 versus 0.63, P < 0.05) in Receiver Operation Characteristic analysis. On comparison of allograft function, the AKI by KDIGO only and the AKI by both criteria groups showed a significantly deteriorating pattern by 6 months after KT in comparison with the non-AKI by both criteria group (P < 0.05). However, the differences disappeared at 1 year from KT and long-term allograft survival did not differ among the three groups. AKI stage either by KDIGO or AKIN in DDs did not affect long-term allograft survival in corresponding KTRs as well.

Conclusions

The KDIGO criteria may be more useful for predicting DGF than the AKIN criteria. However, AKI or AKI stage by either criteria in DDs failed to affect long-term allograft outcomes in KTRs.

Serum Anion Gap Predicts All-Cause Mortality in Patients with Advanced Chronic Kidney Disease: A Retrospective Analysis of a Randomized Controlled Study

Background and Objectives

Cardiovascular outcomes and mortality rates are poor in advanced chronic kidney disease (CKD) patients. Novel risk factors related to clinical outcomes should be identified.

Methods

A retrospective analysis of data from a randomized controlled study was performed in 440 CKD patients aged > 18 years, with estimated glomerular filtration rate 15–60 mL/min/1.73m². Clinical data were available, and the albumin-adjusted serum anion gap (A-SAG) could be calculated. The outcome analyzed was all-cause mortality.

Results

Of 440 participants, the median (interquartile range, IQR) follow-up duration was 5.1 (3.0–5.5) years. During the follow-up duration, 29 participants died (all-cause mortality 6.6%). The area under the receiver operating characteristic curve of A-SAG for all-cause mortality was 0.616 (95% CI 0.520–0.712, P = 0.037). The best threshold of A-SAG for all-cause mortality was 9.48 mmol/L, with sensitivity 0.793 and specificity 0.431. After adjusting for confounders, A-SAG above 9.48 mmol/L was independently associated with increased risk of all-cause mortality, with hazard ratio 2.968 (95% CI 1.143–7.708, P = 0.025). In our study, serum levels of beta-2 microglobulin and blood urea nitrogen (BUN) were positively associated with A-SAG.

Conclusions

A-SAG is an independent risk factor for all-cause mortality in advanced CKD patients. The positive correlation between A-SAG and serum beta-2 microglobulin or BUN might be a potential reason. Future study is needed.

Trial Registration

Clinicaltrials.gov NCT 00860431

Disorganized attachment in infancy predicts greater amygdala volume in adulthood

Early life stress in rodents is associated with increased amygdala volume in adulthood. In humans, the amygdala develops rapidly during the first two years of life. Thus, disturbed care during this period may be particularly important to amygdala development. In the context of a 30-year longitudinal study of impoverished, highly stressed families, we assessed whether disorganization of the attachment relationship in infancy was related to amygdala volume in adulthood. Amygdala volumes were assessed among 18 low-income young adults (8M/10F, 29.33±0.49years) first observed in infancy (8.5±5.6months) and followed longitudinally to age 29. In infancy (18.58±1.02mos), both disorganized infant attachment behavior and disrupted maternal communication were assessed in the standard Strange Situation Procedure (SSP). Increased left amygdala volume in adulthood was associated with both maternal and infant components of disorganized attachment interactions at 18 months of age (overall r=0.679, p<0.004). Later stressors, including childhood maltreatment and attachment disturbance in adolescence, were not significantly related to left amygdala volume. Left amygdala volume was further associated with dissociation and limbic irritability in adulthood. Finally, left amygdala volume mediated the prediction from attachment disturbance in infancy to limbic irritability in adulthood. Results point to the likely importance of quality of early care for amygdala development in human children as well as in rodents. The long-term prediction found here suggests that the first two years of life may be an early sensitive period for amygdala development during which clinical intervention could have particularly important consequences for later child outcomes.

A Randomized, Controlled Trial of Oral Intestinal Sorbent AST-120 on Renal Function Deterioration in Patients with Advanced Renal Dysfunction

BACKGROUND AND OBJECTIVES

The notion that oral intestinal sorbent AST-120 slows renal disease progression has not been evaluated thoroughly. In this study, we investigated the long-term effect of AST-120 on renal disease progression (doubling of serum creatinine, eGFR decrease >50%, or initiation of RRT) in patients with advanced CKD.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We prospectively recruited 579 patients (CKD stage 3 or 4) from 11 medical centers in Korea from March 4, 2009 to August 31, 2010 and randomized them into an AST-120 arm and a control arm. Patients in the AST-120 arm were given 6 g AST-120 in three divided doses per day, and those in the control arm received only standard conventional treatment (open-label design) for 36 months or until the occurrence of primary outcomes.

RESULTS

Levels of serum and urine indoxyl sulfate and β2-microglobulin decreased throughout the study period in both treatment arms; however, there was not a significant difference in change in uremic toxins in the AST-120 and control arms. The two arms were not different in the occurrence of composite primary outcomes (100 events in 272 individuals in the AST-120 arm and 100 events in 266 individuals in the control arm; hazard ratio, 1.12; 95% confidence interval, 0.85 to 1.48; log-rank P=0.45). The decline in eGFR and change in proteinuria were similar in the two treatment arms over time (Prandomization-time=0.64 and Prandomization-time=0.16, respectively). There was no difference in mortality (nine deaths in the AST-120 arm and 11 deaths in the control arm; log-rank P=0.73) or unplanned hospitalizations (102 in the AST-120 arm and 109 in the control arm; log-rank P=0.76) in the two treatment arms. There was no significant difference of the health-related quality of life score between the two arms.

CONCLUSIONS

Long-term use of AST-120 added to standard treatment did not change renal disease progression, proteinuria, mortality, and health-related quality of life in patients with advanced renal dysfunction.

Angiotensin III increases monocyte chemoattractant protein-1 expression in cultured human proximal tubular epithelial cells

BACKGROUND/AIMS

We investigated whether angiotensin III (Ang III) is involved in monocyte recruitment through regulation of the chemokine monocyte chemoattractant protein-1 (MCP-1) in cultured human proximal tubular epithelial cells (HK-2 cells).

METHODS

We measured MCP-1 levels in HK-2 cells that had been treated with various concentrations of Ang III and Ang II type-1 (AT1) receptor antagonists at various time points. The phosphorylation states of p38, c-Jun N-terminal kinases (JNK), and extracellular-signal-regulated kinases were measured in Ang III-treated cells to explore the mitogen-activated protein kinase (MAPK) pathway. MCP-1 levels in HK-2 cell-conditioned media were measured after pre-treatment with the transcription factor inhibitors curcumin or pyrrolidine dithiocarbamate.

RESULTS

Ang III increased MCP-1 protein production in dose- and time-dependent manners in HK-2 cells, which was inhibited by the AT1 receptor blocker losartan. p38 MAPK activity increased significantly in HK-2 cells exposed to Ang III for 30 minutes, and was sustained at higher levels after 60 minutes (p < 0.05). Total phosphorylated JNK protein levels tended to increase 20 minutes after stimulation with Ang III. Pre-treatment with a p38 inhibitor, a JNK inhibitor, or curcumin significantly inhibited Ang III-induced MCP-1 production.

CONCLUSIONS

Ang III increases MCP-1 synthesis via stimulation of intracellular p38 and JNK MAPK signaling activity and subsequent activated protein-1 transcriptional activity in HK-2 cells.

Time points for obtaining representative values of 24-hour blood pressure in chronic kidney disease

BACKGROUND/AIMS

Ambulatory blood pressure (BP) monitoring has been widely recommended for evaluating the status of BP, but is lacking in practicality. Determination of the specific time points for BP measurement that are representative of 24-hour mean BP could be useful and convenient in hypertensive patients with chronic kidney disease (CKD).

METHODS

A total of 1,317 patients for whom 24-hour ambulatory BP monitoring was performed were enrolled in a multicenter study on hypertensive CKD. We analyzed the time points at which systolic blood pressure (SBP) values exhibited the smallest differences from 24-hour mean SBP (mSBP). We included office mSBP and analyzed the relationships between SBPs at the office and the time points with the smallest differences from 24-hour mSBP using several methods.

RESULTS

The time points with the smallest differences from 24-hour mSBP were 7:00 AM, 2:00 PM, and 9:30 PM. In regression analysis, SBPs at 7:00 AM and 9:30 PM were better correlated with 24-hour mSBP than SBPs at 2:00 PM and the office. The proportions of patients with SBPs within 30% of 24-hour mSBP were higher at 7:00 AM and 9:30 PM. The best consistency between the uncontrolled hypertensive groups, defined as ≥ 135 mmHg of 24-hour mSBP and higher values of SBPs corresponding to 135 mmHg of 24-hour mSBP, were observed at the 7:00 AM and 9:30 PM time points.

CONCLUSIONS

The specific time points for SBPs that correlated well with 24-hour mSBP in hypertensive CKD patients were 7:00 AM and 9:30 PM.

Benefits of a continuous ambulatory peritoneal dialysis (CAPD) technique with one icodextrin-containing and two biocompatible glucose-containing dialysates for preservation of residual renal function and biocompatibility in incident CAPD patients

In a prospective randomized controlled study, the efficacy and safety of a continuous ambulatory peritoneal dialysis (CAPD) technique has been evaluated using one icodextrin-containing and two glucose-containing dialysates a day. Eighty incident CAPD patients were randomized to two groups; GLU group continuously using four glucose-containing dialysates (n=39) and ICO group using one icodextrin-containing and two glucose-containing dialysates (n=41). Variables related to residual renal function (RRF), metabolic and fluid control, dialysis adequacy, and dialysate effluent cancer antigen 125 (CA125) and interleukin 6 (IL-6) levels were measured. The GLU group showed a significant decrease in mean renal urea and creatinine clearance (-Δ1.2 ± 2.9 mL/min/1.73 m(2), P=0.027) and urine volume (-Δ363.6 ± 543.0 mL/day, P=0.001) during 12 months, but the ICO group did not (-Δ0.5 ± 2.7 mL/min/1.73 m(2), P=0.266; -Δ108.6 ± 543.3 mL/day, P=0.246). Peritoneal glucose absorption and dialysate calorie load were significantly lower in the ICO group than the GLU group. The dialysate CA125 and IL-6 levels were significantly higher in the ICO group than the GLU group. Dialysis adequacy, β2-microglobulin clearance and blood pressure did not differ between the two groups. The CAPD technique using one icodextrin-containing and two glucose-containing dialysates tends to better preserve RRF and is more biocompatible, with similar dialysis adequacy compared to that using four glucose-containing dialysates in incident CAPD patients. [Clincal Trial Registry, ISRCTN23727549].

The clinical association of the blood pressure variability with the target organ damage in hypertensive patients with chronic kidney disease

It is known that blood pressure variability (BPV) can independently affect target organ damage (TOD), even with normal blood pressure. There have been few studieson chronic kidney disease (CKD) patients. We evaluated the relationship between BPV and TOD in a cross-sectional, multicenter study on hypertensive CKD patients. We evaluated 1,173 patients using 24-hr ambulatory blood pressure monitoring. BPV was defined as the average real variability, with a mean value of the absolute differences between consecutive readings of systolic blood pressure. TOD was defined as left ventricular hypertrophy (LVH) (by the Romhilt-Estes score ≥4 in electrocardiography) and kidney injury (as determined from an estimated glomerular filtration rate [eGFR]<30 mL/min/1.73 m(2) and proteinuria).The mean BPV of the subjects was 15.9±4.63 mmHg. BPV displayed a positive relationship with LVH in a univariate analysis and after adjustment for multi-variables (odds ratio per 1 mmHg increase in BPV: 1.053, P=0.006). In contrast, BPV had no relationship with kidney injury. These data suggest that BPV may be positively associated with LVH in hypertensive CKD patients.

Arterial micro-calcification of vascular access is associated with aortic arch calcification and arterial stiffness in hemodialysis patients

Vascular calcification of the coronary arteries or aorta is an independent risk factor for cardiovascular outcome, but clinical significance of arterial micro-calcification (AMC) of vascular access is unclear in hemodialysis (HD) patients. Sixty-five patients awaiting vascular access operation were enrolled. We compared surrogate markers of cardiovascular morbidity such as aortic arch calcification (AoAC) by chest radiography, arterial stiffness by brachial-ankle pulse wave velocity (baPWV) and endothelial dysfunction by flow-mediated dilatation (FMD) between patients with and without AMC of vascular access on von Kossa staining. AMC of vascular access was detected in 36 (55.4%). The AMC-positive group had significantly higher incidence of AoAC (63.9% vs. 20.7%, p < 0.001) and higher baPWV (26.5 ± 9.4 m/s vs. 19.8 ± 6.6 m/s, p = 0.006) than the AMC-negative group. There was no significant difference in FMD between the two groups (5.4 ± 2.6% vs. 5.7 ± 3.5%, p = 0.764). The AMC-positive group had higher incidence of diabetes mellitus, higher systolic blood pressure and wider pulse pressure than the AMC-negative group. This study suggests that AMC of vascular access may be associated with cardiovascular morbidity via AoAC and arterial stiffness in HD patients.

A case of cytomegalovirus colitis in an immunocompetent hemodialysis patient

Symptomatic cytomegalovirus (CMV) infection in immunocompetent patients has traditionally been considered to have a benign and self-limited course. Moreover, current concept is that CMV infection in immunocompetent patients does not require treatment. However, recent studies reveal that CMV infection in immunocompetent patient with clinical manifestation is not a rare condition as thought previously. Here, we report a case of CMV colitis, which occurred in an immunocompetent hemodialysis patient who neither had HIV infection nor had medication that could cause immunosuppression. Our case revealed that the conservative treatment was not enough, and the administration of ganciclovir was essential for improving the disease course.

Clinical impact of renal biopsy on outcomes in elderly patients with nephrotic syndrome

BACKGROUND/AIMS

The number of elderly patients with nephrotic syndrome (NS) is increasing. This study aimed to assess the implications of renal biopsy on the outcomes in elderly patients with NS.

METHODS

Ninety-nine patients diagnosed with NS who were over 60 years of age were reviewed. Secondary NS related to diabetes was excluded. Histopathological diagnosis, comparison of outcomes between the biopsied group (n = 64) and the nonbiopsied group (n = 35) and factors affecting renal survival were evaluated.

RESULTS

The biopsied group was significantly younger and had better renal function than the nonbiopsied group. More patients in the biopsied group than in the nonbiopsied group received immunosuppressive treatment (76.6 vs. 42.9%, p < 0.005), and achieved complete remission (45.3 vs. 26.5%, p = 0.013). The complication rates and renal survival rates were not different between the two groups, but the patient survival rates were significantly higher in the biopsied group (p < 0.005). Predictors for renal survival were renal function at diagnosis and response to treatment.

CONCLUSION

Renal biopsy is essential for a correct diagnosis and directed therapeutic approach in elderly patients with NS and may improve the clinical outcomes of these patients.

Small dose contrast venography as venous mapping in predialysis patients

PURPOSE

This study was designed to evaluate radiocontrast-induced nephrotoxicity (RIN), and the image quality and findings of venography using small doses of radiocontrast as a venous mapping method in pre-dialysis patients.

METHODS

Twenty-eight patients with stage 4 and 5 chronic kidney disease underwent arm venography with 10-15 ml of dilute contrast medium. Image quality, venographic findings and glomerular filtration rate (GFR) before and after the procedure were evaluated.

RESULTS

Mean GFR was 19.3+/-5.8 ml/min/1.73 m2 (7-30 ml/min/1.73 m2). Image quality of venography in the forearm and upper arm veins was good in all patients. Central veins were visualized well in 26 (92.8%) patients. Eight (28.5%) patients showed cephalic veins inadequate for creation of radiocephalic arteriovenous fistula (AVF) because of occlusion or small diameter veins. There was no significant difference in GFR between the pre- and post-study (19.3+/-5.8 vs. 19.2+/-6.2 ml/min/1.73 m2, p=0.693). RIN developed (GFR: 17 to 13 ml/min/1.73 m2) in only one patient but without sequelae, and the GFR completely recovered to baseline level 7 days after the study.

CONCLUSION

Small dose venography is safe and effective for venous mapping in pre-dialysis patients.

Hepatic subcapsular steatosis in a diabetic CAPD patient receiving intraperitoneal insulin

Hepatic subcapsular steatosis is a rare and specific form of fatty change in the liver. It is a unique finding in diabetic patients receiving continuous ambulatory peritoneal dialysis (CAPD) and intraperitoneal insulin treatment. Intraperitoneal administration of insulin causes a unique pattern of fatty infiltration in the subcapsular location of the liver. Here we report a case of hepatic subcapsular steatosis in a diabetic CAPD patient who received intraperitoneal insulin. A 46-year-old diabetic woman on CAPD presented with general weakness. The patient received a total amount of 110 units of regular insulin via intraperitoneal and subcutaneous injection. Her initial blood chemistry showed increased serum lipid and liver enzyme profiles. Abdominal CT scan images and MRI revealed characteristic findings consistent with hepatic subcapsular steatosis. We assumed that the cause was CAPD and concomitant intraperitoneal insulin treatment; therefore, the patient was switched from CAPD to hemodialysis (HD) and began to receive insulin subcutaneously. Two months after the beginning of HD, the hepatic subcapsular steatosis completely resolved.

The impact of intima-media thickness of radial artery on early failure of radiocephalic arteriovenous fistula in hemodialysis patients

This study was performed to investigate the impact of intima-media thickness (IMT) of radial artery on early failure of radiocephalic arteriovenous fistula (AVF) in hemodialysis (HD) patients. Ninety uremic patients undergoing radiocephalic AVF operation were included in this study. During the operation, 10-mm long partial arterial walls were removed with elliptical form for microscopic analysis. Specimens were stained with trichrome and examined by a pathologist blinded to the clinical data. And then AVF patency was followed up for 1 yr after the operation. Of the total 90 patients, 31 patients (34%) had AVF failure within 1 yr after the operation. Mean IMT was thicker in failed group (n=31) than in patent group (n=59) (486+/-130 micrometer vs. 398+/-130 micrometer, p=0.004). The AVF patency rate within 1 yr after the operation was lower in patients with IMT > or = 500 micrometer (n=26) than in patients with IMT <500 micrometer (n=64) (p=0.017). Age was an independent risk factor of IMT. Diabetes mellitus tended to be independent risk factor but not statistically significant. Our data suggest that increased radial artery IMT is closely associated with early failure of radiocephalic AVF in HD patients.

Ultrasonographic measurement of intima-media thickness of radial artery in pre-dialysis uraemic patients: comparison with histological examination

BACKGROUND

Increased intima-media thickness (IMT) of the radial artery is associated with early failure of radiocephalic arteriovenous fistula (AVF) in haemodialysis patients. Therefore, non-invasive measurements of radial artery IMT before AVF operations are very important in predicting AVF patency. This study was designed to evaluate the accuracy of high-resolution ultrasonography in measuring radial artery IMT in pre-dialysis uraemic patients.

METHODS

This study enrolled 43 pre-dialysis uraemic patients awaiting radiocephalic AVF operations for the first time. In this study, 17 age- and sex-matched uncomplicated hypertensive patients and 15 healthy subjects were included as a control. We measured the internal diameter (ID) and IMT of the radial artery using high-resolution ultrasonography on the wrists of uraemic patients as well as the control group before the AVF operation. We obtained specimens of the radial artery during the AVF operation and directly measured the IMT by histological examination.

RESULTS

The radial artery IMT of the uraemic patients (0.41 +/- 0.09 mm) was significantly thicker, compared to both those of the hypertensive (0.33 +/- 0.05 mm, P < 0.001) and the healthy patients (0.25 +/- 0.04 mm, P = 0.002). In contrast, the radial artery ID in the uraemic patients (1.85 +/- 0.48 mm) was smaller than both that of the hypertensive patients (2.08 +/- 0.31 mm, P = 0.023) and the healthy persons (2.34 +/- 0.37 mm, P = 0.001). Radial artery IMT had a negative correlation with radial artery ID in a total of 73 subjects (r = -0.290, P = 0.012). The value of the radial arterial IMT measured by sonographic examination correlated significantly with that by histological examination in 43 uraemic patients (r = 0.786, P < 0.001) and it correlated significantly with early AVF failure (r = 0.358, P = 0.027).

CONCLUSION

Our data suggest that high-resolution ultrasonography is an effective tool in measuring radial artery IMT in uraemic patients before AVF operation.

Clinical role of interstitial pneumonia in patients with scrub typhus: a possible marker of disease severity

Interstitial pneumonia (IP) frequently occurs in patients with scrub typhus, but its clinical significance is not well known. This study was designed to evaluate interstitial pneumonia as a marker of severity of the disease for patients with scrub typhus. We investigated clinical parameters representing the severity of the disease, and the chest radiographic findings for 101 patients with scrub typhus. We then compared these clinical factors between patients with and without IP. We also studied the relationship between IP and other chest radiographic findings. The chest radiography showed IP (51.4%), pleural effusion (42.6%), cardiomegaly (14.9%), pulmonary alveolar edema (20.8%), hilar lymphadenopathy (13.8%) and focal atelectasis (11.8%), respectively. The patients with IP (n=52) had higher incidences in episode of hypoxia (p=0.030), hypotension (p=0.024), severe thrombocytopenia (p=0.036) and hypoalbuminemia (p=0.013) than the patients without IP (n=49). The patients with IP also had higher incidences of pleural effusion (p<0.001), focal atelectasis (p=0.019), cardiomegaly (p<0.001), pulmonary alveolar edema (p=0.011) and hilar lymphadenopathy (p<0.001) than the patients without IP. Our data suggest that IP frequently occurs for patients with scrub typhus and its presence is closely associated with the disease severity of scrub typhus.

Minimally dilated obstructive nephropathy initially suspected as pre-renal azotemia in a kidney donor with volume depletion

Although ultrasonography is regarded as the gold standard in the diagnosis of obstructive nephropathy, dilatation is sometimes not observed by ultrasonography. We report upon a case of minimally dilated obstructive nephropathy due to an ureter stone in a kidney donor with volume depletion. A 54-year-old man was admitted due to anuria and abdominal pain of 2 days duration. Ten years previously, his right kidney was donated for transplantation, and one month before admission, he abstained from all food except water and salt, for 30 days for religious reasons. He had lost 8 kg of body weight. On admission, he had clinical signs of volume depletion, i.e., a dehydrated tongue and decreased skin turgor. Laboratory data confirmed severe renal failure, his blood urea nitrogen level was 107.3 mg/dL, and his serum creatinine 16.5 mg/dL. The plain X-ray was unremarkable and ultrasonography showed only minimal dilatation of the renal collecting system. On follow-up ultrasonography, performed on the 5th hospital day, the dilatation of the collecting system had slightly progressed and a small stone was found at ureter orifice by cystoscopy. Removal of stone initiated dramatic diuresis with a rapid return of renal function to normal by the third day.

Serum albumin level correlates with disease severity in patients with Hemorrhagic Fever with Renal Syndrome

Hypoalbuminemia frequently occurs in Hemorrhagic Fever with Renal Syndrome (HFRS), but clinical significance of hypoalbuminemia is not well known. This study was designed to evaluate hypoalbuminemia as a marker of severity of disease in patients with HFRS. We evaluated the relationship between the level of serum albumin and clinical parameters representing the severity of disease in 144 patients with HFRS. The patients were divided into three groups based on the level of serum albumin; Group I (normal serum albumin), Group II (serum albumin <3.5 g/dL and >/=3.0 g/dL), and Group III (serum albumin <3.0 g/dL). Of the total of 144 patients, 42 patients (29.2%) were categorized as Group I, 39 patients (27.1%) as Group II, and 63 patients (43.8%) as Group III. Group III had a higher rate of incidence in episode of hypotension, pulmonary edema than did Group I and Group II. The lowest level of serum albumin was positively correlated with platelet count (r=0.505, p<0.001) and was negatively correlated with leukocyte count (r=-0.329, p<0.001), BUN (r=-0.484, p<0.001), serum creatinine (r=-0.394, p<0.001), and AST (r=-0.251, p=0.002). Our data suggest that hypoalbuminemia frequently occurs in the acute stage of HFRS, and level of serum albumin is associated with the disease severity of HFRS.

Synergistic effects of mycophenolate mofetil and losartan in a model of chronic cyclosporine nephropathy

BACKGROUND

Combined treatments of mycophenolate mofetil (MMF) and losartan (LSRT) have synergistic effects on various renal diseases through their hemodynamic and anti-inflammatory effects. This study investigated whether MMF treatment is effective in inhibiting inflammatory processes in chronic cyclosporine A (CsA) nephrotoxicity, and whether combined treatment using MMF and LSRT affords superior protection compared with the respective monotherapies.

METHODS

Rats on a low-salt diet were given vehicle (VH group, olive oil, 1 mg/kg per day), CsA (15 mg/kg per day), CsA and LSRT (CsA+LSRT group, 100 mg/L per day), CsA and MMF (CsA+MMF group; 40 mg/kg per day), or CsA, LSRT and MMF (CsA+LSRT MMF group). Control groups received each drug without CsA treatment. Renal function, histologic parameters (arteriolopathy, tubulointerstitial fibrosis, and inflammatory cell infiltration), and mediators of CsA-induced nephrotoxicity (angiotensin-II, osteopontin, and transforming growth factor [TGF]-beta1) were studied.

RESULTS

The CsA-treated rats showed decreased renal function and increased histologic parameters compared with the VH-treated rats. The CsA+MMF treatment significantly improved renal function and histopathologic parameters compared with the CsA group, and combined treatment with MMF and LSRT further improved those parameters compared with the CsA+LSRT and CsA+MMF groups. At a molecular level, increased expression of angiotensin II protein, osteopontin, and TGF-beta1 mRNAs in the CsA group were significantly decreased with MMF, and further decrease was observed with the combined treatment using MMF and LSRT.

CONCLUSIONS

MMF treatment decreases CsA-induced nephrotoxicity, and combined treatment with LSRT has a synergistic effect in preventing chronic CsA nephrotoxicity.

Preexisting intimal hyperplasia of radial artery is associated with early failure of radiocephalic arteriovenous fistula in hemodialysis patients

BACKGROUND

The radiocephalic arteriovenous fistula (AVF), which provides the best vascular access for hemodialysis, continues to have a high incidence of early failure. Intimal hyperplasia (IH) of the radial artery is observed commonly in uremic patients before hemodialysis, but the impact of this preexisting IH on the early failure of radiocephalic AVFs has not been reported yet. Therefore, we designed this study to: (1) investigate clinical risk factors for IH, and (2) determine whether preexisting IH of the radial artery is associated with early failure of a radiocephalic AVF.

METHODS

Specimens from the radial artery were obtained during the radiocephalic AVF operation. IH was measured with trichrome staining, and AVF patency was prospectively followed up for 12 months after the operation.

RESULTS

Of the 59 patients, 45 patients had evidence of IH in their radial artery (76.2%). Patients with IH (n = 45) were older than those without IH (n = 14; 58 +/- 12 versus 44 +/- 17 years; P = 0.003). The incidence of diabetes mellitus in patients with IH was greater than that in patients without IH (60.0% versus 28.6%; P = 0.004). Of the 57 patients, except for 2 patients who died before the end point of the study with patent AVFs, fistula failure was observed only in patients with IH (22 of 44 patients; 50% versus 0%; P < 0.001). The intima was thicker in the failed-AVF group than the patent-AVF group (93.1 +/- 37.5 versus 45.6 +/- 17.4 micrometer P < 0.001).

CONCLUSION

This study suggests that early failure of radiocephalic AVFs in hemodialysis patients is closely associated with preexisting IH of the radial artery.

Sonographic evaluation of gallbladder-wall thickening in hemorrhagic fever with renal syndrome: prediction of disease severity

PURPOSE

Gallbladder-wall thickening (GBWT) frequently occurs in patients with hemorrhagic fever with renal syndrome (HFRS), an acute infectious disease caused by hantaviruses. HFRS is manifested by fever, hemorrhage, renal failure, and in many cases gastrointestinal symptoms, such as abdominal pain and tenderness. The clinical significance of GBWT in HFRS has not been reported. The purpose of this study was to investigate the incidence of GBWT and the relationship between GBWT and the severity of HFRS.

METHODS

We retrospectively reviewed the medical records and sonograms of 68 patients with HFRS (47 males and 21 females, with an age range of 10-76 years) who underwent abdominal sonography in the acute stage of the disease. We measured the gallbladder-wall thickness on the sonograms and reviewed other sonographic and radiographic findings. Clinical factors that reflect the severity of HFRS were compared between the patients with GBWT (defined as thickness of 4 mm or more) and those without GBWT.

RESULTS

Of the 68 patients, 29 (43%) had GBWT, which was even and diffuse in all cases. The patients with GBWT had a significantly lower mean platelet count and serum albumin level and significantly higher serum aspartate aminotransferase and serum lactate dehydrogenase levels than did the patients without GBWT. In addition, the incidence of renal failure requiring hemodialysis and the incidences of ascites and pleural effusion were higher in the patients with GBWT than in those without GBWT. Five patients died of HFRS; all 5 had GBWT (p = 0.011 for comparison with patients without GBWT).

CONCLUSIONS

Our results suggest that the sonographic measurement of gallbladder-wall thickness during the acute stage of HFRS is useful for determining the severity of HFRS.

Access blood flow as a predictor of early failures of native arteriovenous fistulas in hemodialysis patients

Blood flow imaging using color doppler has proven effective in predicting graft failures in hemodialysis patients, but its effect on native arteriovenous fistulas (AVF) is not well known. This study was performed to investigate whether measurements of the access blood flow can be used as predictors of an early failure of a native AVF in hemodialysis patients. Fifty-three consecutive patients who received native AVF operations were included in this study. Access blood flow was measured at 1 week after operations, and AVF function was followed for 4 months. During the follow-up, access failures developed in 10 patients at 9.8 +/- 3.5 weeks. AVF blood flow was significantly lower in the failure group (n = 10) than in the patent group (n = 43) (450 +/- 214 vs. 814 +/- 348 ml/min, p = 0.003). The incidence of access failures was higher in the patients with a flow <350 ml/min (n = 9) compared to the patients with a flow >350 ml/min (n = 44) (55.5 vs. 11.3%, p = 0.008). The diameters of veins were significantly smaller in the failure group than in the patent group (3.5 +/- 0.5 vs. 4.1 +/- 0.7 mm, p = 0.018). The incidence of diabetes mellitus was higher in the failure group than in the patent group (90 vs. 51%, p = 0.025). However, age, sex, duration from an operation to first cannulation, and different AVF sites did not make a significant difference between the two groups. Our data suggest that access blood flow measurements using color doppler ultrasound during early postoperative periods are useful parameters in predicting an early failure of a native AVF in hemodialysis patients.

Intestinal protein loss in patients with haemorrhagic fever with renal syndrome

BACKGROUND

In haemorrhagic fever with renal syndrome (HFRS) vascular dysfunction has been observed in various organs, but the involvement of the intestine has not yet been reported. This study was performed to evaluate the association of intestinal protein loss in this disease with other clinical parameters reflecting vascular permeability or disease severity.

METHODS

Twenty patients with HFRS were included in this study. Intestinal protein loss was measured by (99m)Tc-human serum albumin ((99m)Tc-HSA) scintigraphy in the acute stage, and quantitative analysis of protein loss was measured by the faecal clearance of alpha 1-antitrypsin (C(AT)) in the acute and the recovery stages. C(AT) was then compared with clinical parameters reflecting disease activity and vascular permeability.

RESULTS

(99m)Tc-HSA scintigraphy was positive in 13 (65%) patients, and C(AT) in the acute stage was significantly increased as compared with C(AT) in the recovery stage (40.5+/-24.1 vs 9.2+/-4.2 ml/day, P<0.001). C(AT) was associated with serum albumin levels, frequency of hypotensive episodes, severity of acute renal failure, and degree of thrombocytopenia.

CONCLUSIONS

Our data suggest that the increased vascular permeability of HFRS is associated with the increased intestinal loss of plasma proteins, which might represent one of the parameters of disease severity in HFRS.

A case of Goodpasture's syndrome with massive pulmonary hemorrhage

We present a typical case of Goodpasture's syndrome with massive pulmonary hemorrhage and acute deterioration of renal function. A 20-year-old male was admitted due to severe azotemia (blood urea nitrogen 214.7 mg/dL, serum creatinine 30.2 mg/dL) and was treated with emergency hemodialysis. On the 4th hospital day, a sudden onset of pulmonary hemorrhage developed. The circulating level of anti-glomerular basement membrane antibody was then elevated highly, and the kidney biopsy showed crescentic glomerulonephritis and linear deposition of IgG along the glomerular capillary. The patient was treated with intravenous high dose-steroid, oral cyclophosphamide and plasma exchanges. The pulmonary hemorrhage improved with the therapy, however, his renal function did not improve. He is currently on a regular schedule of hemodialysis.

Comparison of acquired cystic kidney disease between hemodialysis and continuous ambulatory peritoneal dialysis

OBJECTIVES

ACKD has been described mainly in patients treated with hemodialysis(HD), and there are only a few reports about the prevalence of ACKD in continuous ambulatory peritoneal dialysis (CAPD) patients. Therefore, we compared the prevalence of ACKD in patients receiving HD and CAPD, and evaluated the possible factors which may affect the development of ACKD.

METHODS

Forty nine HD and 49 CAPD patients who had received dialysis therapy for at least 12 months were enrolled in this cross-sectional study. Patients who had a past history of polycystic kidney disease and had acquired cystic kidney disease on predialysis sonographic exam were excluded. Detection of ACKD was made by ultrasonography and ACKD was defined as 3 or more cysts in each kidney.

RESULTS

The prevalence of ACKD was about 31% (30/98) and there was no significant difference between HD and CAPD patients(27% vs. 34%, p > 0.05). The prevalence of ACKD was not associated with age, sex, primary renal disease, the levels of hemoglobin, BUN, and serum creatinine. However, the duration of dialysis was significantly related to the development of ACKD (presence of ACKD, 74.4 +/- 42.4 months vs. absence of ACKD, 37.8 +/- 24.1 months, p < 0.05).

CONCLUSION

The prevalence of ACKD is not different according to the mode of dialysis, and the major determinant of acquired cyst formation is duration of dialysis.

High-frequency, in vitro reversible switching of Candida lusitaniae clinical isolates from amphotericin B susceptibility to resistance

Recent studies have revealed an increase in the incidence of serious infections caused by non-albicans Candida species. Candida lusitaniae is of special interest because of its sporadic resistance to amphotericin B (AmB). The present in vitro study demonstrated that, unlike other Candida species, C. lusitaniae isolates frequently generated AmB-resistant lineages form previously susceptible colonies. Cells switching from a resistant colony to a susceptible phenotype were also detected after treatment with either UV light, heat shock, or exposure to whole blood, all of which increased the frequency of switching. In some C. lusitaniae lineages, after a cell switched to a resistant phenotype, the resistant phenotype was stable; in other lineages, colonies were composed primarily of AmB-susceptible cells. Although resistant and susceptible lineages were identical in many aspects, their cellular morphologies were dramatically different. Switching mechanisms that involve exposure to antifungals may have an impact on antifungal therapeutic strategies as well as on standardized susceptibility testing of clinical yeast specimens.

Factors on graft survival of living donor kidney transplantation in a single center

We analyzed the potential factors that could influence the survival of graft, focused on primary graft living-donor kidney transplantation with cyclosporine (CsA) therapy. 680 cases were enrolled in this study. Patients and graft survival rates were calculated by a Kaplan-Meier product limit estimate with a 1-day time interval. The analyzed variables were donor relationship, HLA matching, recipient age and sex, donor age and sex, ABO blood type compatibility, diabetic status, hepatitis virus infection, donor specific or non-specific blood transfusion and acute rejection episode. The results suggested that acute rejection episode was the most prognostic factor in graft survival. An HLA-matched donor and a young male donor, i.e. a greater donor nephron mass for less recipient body mass, will show better long-term survival. Diabetes and hepatitis B infection have some negative effects on the long-term survival of graft kidney, but age of recipient, donor-specific transfusion and donor-recipient relationship have little effect.

Prevalence and clinical course of hepatitis B and hepatitis C liver disease in ciclosporin-treated renal allograft recipients

We performed this study to evaluate prevalence and clinical course of hepatitis B surface antigen (HBsAg)-positive and anti-hepatitis C virus (HCV)-positive renal transplant recipients. HBsAg positivity was 13.7 and anti-HCV positivity 12.8%. Before transplantation, the HBsAg positivity was observed in in 83.5% of the patients, and 16.4% of the patients acquired HBsAg after renal transplantation. In the HCV group, anti-HCV positivity was observed in 47.1% before transplantation, and 19.6% acquired anti-HCV after renal transplantation. The prevalence of chronic hepatitis in the hepatitis B virus (HBV) and in the HCV groups was not different (25.7 vs. 25.5%). Among those with chronic hepatitis in the HBV group, 4 cases progressed to fulminant hepatic failure, 1 case progressed to the end-stage liver cirrhosis, and 1 case to hepatocellular carcinoma. However, in the HCV group, no case showed progression of chronic hepatitis. The overall mortality in the HBV and HCV groups was 25.3 and 7.8%, respectively (p = 0.001). Among 20 fatal cases in the HBV group 9, cases were liver disease related, but no liver disease related death occurred in the HCV group. In conclusion, HCV as well as HBV infections are quite prevalent and important causes of posttransplant chronic hepatitis, and the clinical course of anti-HCV-positive recipients is less aggressive than that of HBsAg-positive recipients.

'Pauci-immune' rapidly progressive glomerulonephritis associated with systemic vasculitis

'Pauci-immune' glomerulonephritis has been recognized as an important cause of rapidly progressive glomerulonephritis. The paucity of immune deposits can be separated from the other two major immunohistologic variants of crescentic glomerulonephritis, ie, antiglomerular basement membrane (GBM) antibody-mediated and immune complex-mediated glomerulonephritis. Here we describe the case of a 42-year-old woman with pauci-immune' glomerulonephritis and vasculitis presenting as rapidly progressive renal failure with characteristic pathologic and immunohistologic findings. And in this case, despite oliguria and rapid deterioration of renal function, the renal function recovered partially and continued to be stabilized with a favourable response to hemodialysis and combined system immunosuppressive therapy.