Cheng-Hao Weng

Spectrum of toxic hepatitis following intentional paraquat ingestion: analysis of 187 cases

This retrospective observational study examined the clinical features, the degrees of toxic hepatitis, physiological markers and clinical outcomes after intentional paraquat poisoning and sought to determine what association, if any, might exist between these findings.

Sequential organ failure assessment score can predict mortality in patients with paraquat intoxication.

Introduction Paraquat poisoning is characterized by multi-organ failure and pulmonary fibrosis with respiratory failure, resulting in high mortality and morbidity. The objective of this study was to identify predictors of mortality in cases of paraquat poisoning. Furthermore, we sought to determine the association between these parameters. Methods A total of 187 patients were referred for management of intentional paraquat ingestion between January 2000 and December 2010. Demographic, clinical, and laboratory data were recorded. Sequential organ failure assessment (SOFA) and acute kidney injury network (AKIN) scores were collected, and predictors of mortality were analyzed. Results Overall hospital mortality for the entire population was 54% (101/187). Using a multivariate logistic regression model, it was found that age, time to hospitalization, blood paraquat level, estimated glomerular filtration rate at admission (eGFR first day), and the SOFA48-h score, but not the AKIN48-h score, were significant predictors of mortality. For predicting the in-hospital mortality, SOFA48-h scores displayed a good area under the receiver operating characteristic curve (AUROC) (0.795±0.033, P<0.001). The cumulative survival rate differed significantly between patients with SOFA48-h scores <3 and those ≥3 (P<0.001). A modified SOFA (mSOFA) score was further developed by using the blood paraquat level, and this new score also demonstrated a better AUROC (0.848±0.029, P<0.001) than the original SOFA score. Finally, the cumulative survival rate also differed significantly between patients with mSOFA scores <4 and ≥4 (P<0.001). Conclusion The analytical data demonstrate that SOFA and mSOFA scores, which are based on the extent of organ function or rate of organ failure, help to predict mortality after intentional paraquat poisoning.

Spectrum of corrosive esophageal injury after intentional paraquat ingestion

INTRODUCTIONnThis is an observational study that examines the clinical features, the degrees of esophageal injury, physiological markers, and clinical outcomes after paraquat ingestion and seeks to determine what association, if any, may exist between these findings.nnnMETHODSnThe study included 16 of 1410 paraquat subjects who underwent endoscopies at Chang Gung Memorial Hospital between 1980 and 2007.nnnRESULTSnCorrosive esophageal injuries were classified as grade 1 in 8, 2a in 5, and 2b in 3 patients. No patients had grade 0, 3a, or 3b esophageal injuries. After paraquat ingestion, systemic toxicity occurred, with rapid development of hypoxia, hepatitis, and renal failure in many cases. Hypoxia occurred in 1 (12.5%), 5 (100%), and 3 (100%) patients with grades 1, 2a, and 2b esophageal injury, respectively. There were more hypoxic patients with grades 2a and 2b than those with grade 1 esophageal injury (P < .05). The nadir Pao(2) was lower in patients with grades 2a and 2b than those with grade 1 esophageal injury (P < .05). However, there were no significant differences in terms of acute hepatitis, peak serum alanine aminotransferase, acute renal failure, and peak serum creatinine between the 3 groups (P > .05). Kaplan-Meier analysis did not find any difference in survival between the groups (P > .05).nnnCONCLUSIONnParaquat, a mild caustic agent, produces only grades 1, 2a, and 2b esophageal injury. Our findings showed a potential relationship between the degree of hypoxia, mortality, and degree of esophageal injury, although such a low number of study subjects limits the conclusions that can be made by this study.

Paraquat poisoning in pediatric patients.

Objective This observational study examined the outcome of Taiwanese pediatric patients with paraquat poisoning and compared these data with the published data on paraquat poisonings from other international poisoning centers. Methods We performed a retrospective study on children with acute paraquat poisoning that were admitted to the Chang Gung Memorial Hospital during a period of 10 years (2000–2010). Of the 193 paraquat poisoning patients, only 6 were children. Results The mean age was 8.85 ± 5.55 (1–15.6) years. Younger patients had accidentally swallowed paraquat, whereas older patients had intentionally ingested paraquat. Most patients were referred within a relatively short period (0.5–2.0 hours). Paraquat poisoning was associated with high morbidity and often resulted in severe complications, including acute respiratory distress syndrome and multiple-organ failure. The complications included shock (50.0%), hypoxemia (33.3%), respiratory failure (33.3%), nausea/vomiting (16.7%), abdominal pain (33.3%), hepatitis (66.7%), gastrointestinal tract bleeding (33.3%), acute renal failure (33.3%), and seizures (16.7%). Patients were treated aggressively with a standard detoxification protocol consisting of gastric lavage, active charcoal, charcoal hemoperfusion, and cyclophosphamide and steroid pulse therapies. Secondary bacterial infections were common after hospitalization and included sepsis (33.3%), pneumonia (33.3%), and urinary tract infection (50.0%). In the end, 2 patients (33.3%) died from multiple-organ failure, despite intensive resuscitation. Conclusions Our data (mortality rate, 33.3%) are comparable to the data of other published reports from other international poison centers. Evidently, a prompt diagnosis of paraquat poisoning and an immediate institution of a detoxification protocol is a prerequisite for a favorable outcome.

Polyomavirus BK-encoded microRNA suppresses autoregulation of viral replication.

Polyomavirus BK (BKV) infection is an important cause of renal allograft failure. Viral microRNAs are known to play a crucial role in viral replication. This study investigated the expression of BKV-encoded microRNAs (miR-B1) in patients with polyomavirus-associated nephropathy (PVAN) and their role in viral replication. Following BKV infection in renal proximal tubular cells, the 3p and 5p miR-B1 levels were significantly increased. Cells transfected with the vector containing the miR-B1 precursor (the miR-B1 vector) showed a significant increase in expression of 3p and 5p miR-B1 and decrease in luciferase activity of a reporter containing the 3p and 5p miR-B1 binding sites, compared to cells transfected with the miR-B1-mutated vector. Transfection of the miR-B1 expression vector or the 3p and 5p miR-B1 oligonucleotides inhibited expression of TAg. TAg-enhanced promoter activity and BKV replication were inhibited by miR-B1. In contrast, inhibition of miR-B1 expression by addition of miR-B1 antagomirs or silencing of Dicer upregulated the expression of TAg and VP1 proteins in BKV-infected cells. Importantly, patients with PVAN had significantly higher levels of 3p and 5p miR-B1 compared to renal transplant patients without PVAN. In conclusion, we demonstrated that (1) miR-B1 expression was upregulated during BKV infection and (2) miR-B1 suppressed TAg-mediated autoregulation of BKV replication. Use of miR-B1 can be evaluated as a potential treatment strategy against BKV infection.

Predictors of Acute Respiratory Distress Syndrome in Patients with Paraquat Intoxication

Introduction Paraquat poisoning is characterized by acute lung injury, pulmonary fibrosis, respiratory failure, and multi-organ failure, resulting in a high rate of mortality and morbidity. The objectives of this study were to identify predictors of acute respiratory distress syndrome (ARDS) in cases of paraquat poisoning and determine the association between these parameters. Materials and Methods In total, 187 patients were referred for management of intentional paraquat ingestion between 2000 and 2010. Demographic, clinical, and laboratory data were recorded. Sequential organ failure assessment (SOFA) and Acute Kidney Injury Network (AKIN) scores were collected, and predictors of ARDS were analyzed. Results The overall mortality rate for the entire population was 54% (101/187). Furthermore, the mortality rate was higher in the ARDS patients than in the non-ARDS patients (80% vs. 43.80%, P<0.001). Additionally, the ARDS patients not only had higher AKIN48-h scores (P<0.009), SOFA48-h scores (P<0.001), and time to ARDS/nadir PaO2 (P=0.008) but also suffered from lower nadir PaO2 (P<0.001), nadir AaDO2 (P<0.001), and nadir eGFR (P=0.001) compared to those in the non-ARDS patients. Moreover, pneumomediastinum episodes were more frequent in the ARDS patients than in the non-ARDS patients (P<0.001). A multivariate Cox regression model revealed that blood paraquat concentrations (P<0.001), SOFA48-h scores (P=0.001), and steroid and cyclophosphamide pulse therapies (P=0.024) were significant predictors of ARDS. The cumulative survival rates differed significantly (P<0.001) between patients with SOFA48-h scores <3 and SOFA48-h scores ≥3, with a sensitivity of 95.8%, specificity of 58.4%, and overall correctness of 67.6%. Finally, the area under the receiver operating characteristic (AUROC) analysis showed that SOFA48-h scores (P<0.001) had a better discriminatory power than blood paraquat concentrations (P=0.01) for predicting ARDS. Conclusions The analytical results indicate that SOFA48-h scores, blood paraquat concentrations, and steroid and cyclophosphamide pulse therapies are significantly associated with ARDS complications after paraquat intoxication.

Course and Outcome of Dialysis Pericarditis in Diabetic Patients Treated with Maintenance Hemodialysis

Introduction: This observational study investigated the course and outcome of dialysis pericarditis in diabetic dialysis patients, as previous reports found that in contrast to uremic pericarditis, which responds in most cases to intensive hemodialysis, dialysis pericarditis resolves with intensification of hemodialysis in fewer cases. Methods: From 2002 through 2006, 88 maintenance hemodialysis patients (47 diabetic and 41 non-diabetic) were referred for management of dialysis pericarditis. Results: Dialysis pericarditis in 85.1% of diabetic and 82.9% of non-diabetic patients improved following institution of intensive hemodialysis. For the few unresponsive and critical cases, 8.5% of diabetic and 7.3% of non-diabetic patients received pericardiocentesis, whereas 6.4% of diabetic and 9.8% of non-diabetic patients received surgical drainage. In terms of outcome, 85.1, 4.3 and 10.6% of diabetic patients were alive without recurrence, alive with recurrence and deceased, respectively. There was no significant difference with their non-diabetic counterparts, for which the percentages were 87.8, 4.9 and 7.3%, respectively (p > 0.05). Kaplan-Meier analysis did not find any significant difference in survival as well (p > 0.05). Conclusion: Whether used in diabetics or not, intensive hemodialysis remains the primary and most effective dialysis pericarditis treatment, whereas pericardiocentesis or surgical drainage should be reserved for the few unresponsive and critical cases.

Impact of renal survival on the course and outcome of systemic lupus erythematosus patients treated with chronic peritoneal dialysis.

This longitudinal study investigated whether renal survival can affect the course and outcome of systemic lupus erythematosus (SLE) patients treated with chronic peritoneal dialysis (PD). Thirty‐five SLE patients, out of 1115 end‐stage renal disease (ESRD) patients treated with chronic PD, were seen between 1990 and 2007 at the Chang Gung Memorial Hospital. Patients were followed up for a mean of 38.8u2003±u200322.9u2003months. There were no significant differences between patients with short renal survival (<3 years) and long renal survival (>3u2003years) for the various demographic variables such as age, sex, PD duration, immunosuppressive drug administration, or exchange system (Pu2003>u20030.05). Interestingly, before PD, patients with short renal survival had lower serum complement levels than patients with long renal survival (C3, 40.2u2003±u200314.4 vs 76.3u2003±u200318.5u2003mg/dL, Pu2003<u20030.001; and C4, 14.8u2003±u20034.7 vs 22.4u2003±u20038.1u2003mg/dL, Pu2003<u20030.05). However, the differences in complement levels between the groups disappeared after PD (C3, 76.5u2003±u200327.3 vs 84.2u2003±u200327.8u2003mg/dL; and C4, 26.7u2003±u200311.3 vs 22.6u2003±u200310.8u2003mg/dL, both Pu2003>u20030.05). Patients with short renal survival were more likely to have a high peritoneal solute transporter rate (PSTR) than their long renal survival counterparts (χ2‐test, Pu2003=u20030.02, and AUROCu2003=u20030.744 and Pu2003=u20030.040); however, there were no significant differences for other variables such as cardiothoracic ratio (CTR), Kt/V, residual renal function, exit site infection, and peritonitis (Pu2003>u20030.05). Finally, Kaplan–Meier analysis revealed that the two groups did not differ in patient and technical survival (Pu2003>u20030.05). Therefore it was concluded that renal survival might be associated with PSTR, but not with patient and technical survival in SLE patients treated with PD.

Oral Tori in Chronic Hemodialysis Patients

Background. This study investigated the epidemiology of torus palatinus (TP) and torus mandibularis (TM) in hemodialysis patients and analyzed the influences of hyperparathyroidism on the formation of oral tori. Method. During 2013, 119 hemodialysis patients were recruited for dental examinations for this study. Results. The prevalence of oral tori in our sample group was high at 33.6% (40 of 119). The most common location of tori was TP (70.0%), followed by TM (20.0%), and then both TP and TM (10.0%). Of the 40 tori cases, most (67.5%) were <2u2009cm in size; moreover, the majority (52.5%) were flat in shape. In symmetry, most (70.0%) occurred in the midline, followed by bilateral sides (20.0%). Notably, the levels of intact parathyroid hormone did not differ in patients with or without tori (P = 0.611). Furthermore, patients with tori did not differ from patients without tori in inflammatory variables such as log high-sensitivity C-reactive protein (P = 1.000) or nutritional variables such as albumin (P = 0.247). Finally, there were no differences between patients with and without tori in adequacy of dialysis (P = 0.577). Conclusions. Neither hyperparathyroidism nor inflammation malnutrition syndrome was found to contribute to the formation of oral tori in chronic hemodialysis patients. Further studies are warranted.

Association between environmental particulate matter and arterial stiffness in patients undergoing hemodialysis

BackgroundAortic pulse wave velocity (PWV) has been shown to be an independent predictor of cardiovascular mortality in patients with end-stage renal disease and the general population. Atmospheric particulate- matter (PM) concentrations and their effects on cardiovascular system by affecting arterial stiffness and central hemodynamic parameters had been noted. The purpose of this study was to access the correlation of air pollution variables and PWV in patients undergoing hemodialysis (HD).MethodsThis study analyzed 127 HD patients treated at the outpatient HD center. Brachial-ankle pulse wave velocity (baPWV) was measured by using a Vascular Profiler 1000 (VP-1000). Air pollution levels were recorded by a network of 27 monitoring stations near or in the patients’ living areas throughout Taiwan. The 12-month average concentrations of PM with an aerodynamic diameter of <10 and <2.5xa0mm (PM10 and PM2.5, respectively), sulfur dioxide (SO2), nitrogen dioxide (NO2), carbon monoxide(CO), and ozone (O3) were included.Results and DiscussionMultivariate linear regression analyses indicated that systolic blood pressure (SBP) (βu2009=u20090.589, Pu2009<u20090.025), age (βu2009=u20090.316, Pu2009<u20090.001), serum aluminum level (Al) (βu2009=u20090.149, Pu2009=u20090.020), and PM10 (βu2009=u20090.133, Pu2009=u20090.036) were positively correlated with baPWV.ConclusionThis cross-sectional study shows that in HD patients, the environmental PM10 level is associated with the baPWV.