Chia Chen Wang

Renin-angiotensin system blockade in heart failure patients on long-term haemodialysis in Taiwan

Heart failure is among the most frequent complications of patients on long‐term haemodialysis. The benefits of renin–angiotensin system (RAS) blockade on the outcomes of these patients have yet to be determined.

Treatment of Cosmetic Tattoos Using Carbon Dioxide Ablative Fractional Resurfacing in an Animal Model: A Novel Method Confirmed Histopathologically

BACKGROUND Treating cosmetic tattoos using quality‐switched lasers is difficult. OBJECTIVE We used carbon dioxide ablative fractional resurfacing (CO2 AFR) to remove cosmetic tattoos and examined the pathophysiologic mechanisms involved in this technique in an animal model. METHODS AND MATERIALS Twelve rats were tattooed on their backs with white and flesh‐colored pigments. Half of each tattoo was treated with CO2 AFR (5 sessions at 1‐month intervals), and the other half was the untreated control. An independent observer reviewed photographic documentation of clinical response. Serial skin samples obtained at baseline and at various times after laser treatment were evaluated using histologic and immunohistochemical methods. RESULTS Four rats had excellent responses to laser treatment and eight had good responses. White and flesh‐colored tattoos had similar clearance rates and tissue reactions. Histologic analysis showed immediate ablation of tattoo pigments in the microscopic ablation zones. Tattoo pigments in the microscopic coagulation zones migrated to the epidermis and became part of the microscopic exudative necrotic debris appearing on day 2 that was exfoliated after 5 days. Increased fibronectin expression around the microscopic treatment zones during the extrusion of tattoo pigments indicated that wound healing facilitates this action. CONCLUSION CO2 AFR successfully removes cosmetic tattoos.

Treatment of cosmetic tattoos with nonablative fractional laser in an animal model: a novel method with histopathologic evidence.

Cosmetic tattoos are difficult to treat using Q‐switched lasers. We introduce a novel method for the treatment of cosmetic tattoos using a nonablative fractional laser and investigate the underlying pathophysiological mechanisms in an animal model.

Prognostic Benefits of Carvedilol, Bisoprolol, and Metoprolol Controlled Release/Extended Release in Hemodialysis Patients with Heart Failure: A 10‐Year Cohort

Background Heart failure is a highly prevalent cardiovascular complication among patients receiving long‐term hemodialysis, but the benefits of carvedilol, bisoprolol, and metoprolol controlled release/extended release on the outcomes of these patients remain unclear. In this study, we address the use of these 3 β‐blockers and their associations with mortality. Methods and Results Long‐term hemodialysis patients, aged ≥35 years, with new‐onset heart failure and receiving various medications were identified through the use of 1999–2010 data from the Taiwan National Health Insurance Research Database. From the total of 4435 heart failure patients, we selected 1700 new users of the 3 β‐blockers (study group) and 1700 nonusers (control group), by using matched cohorts according to their propensity scores, and then compared the 5‐year all‐cause mortality rates by using Cox proportional hazard regressions and time‐dependent covariate adjustment. During 3944 person‐years of follow‐up, 666 (39.2%) deaths occurred within the study group, compared with 918 (54%) deaths during 2893 person‐years of follow‐up in the control group. The 5‐year mortality rate for the study (control) group was 54.5% (70.3%); P<0.001. Adjusted hazard regression analyses revealed that the therapeutic effects of β‐blockers remained significant for all‐cause mortality (hazard ratio 0.80, 95% CI 0.72 to 0.90). Subgroup analyses revealed that patients in the study group receiving β‐blockers plus renin‐angiotensin system antagonists exhibited the lowest mortality rate, while the highest mortality rate was found among patients in the control group receiving neither β‐blockers nor renin‐angiotensin system antagonists. Conclusions This study demonstrates that the 3 β‐blockers were associated with improved survival in long‐term hemodialysis patients with heart failure.

Do Automated Peritoneal Dialysis and Continuous Ambulatory Peritoneal Dialysis Have the Same Clinical Outcomes? A Ten-year Cohort Study in Taiwan

This paper reports a comprehensive comparison for mortality and technique failure rates between automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD) in Taiwan. A propensity-score matched cohort study was conducted by retrieving APD and CAPD patients identified from the Taiwan National Health Insurance Research Database between 2001 and 2010. The main outcomes were the 5-year mortality and technique failure rates. Further analyses were then carried out based upon the first (2001–2004), second (2005–2007), and third (2008–2010) sub-periods. Similar baseline characteristics were identified for APD (n = 2,287) and CAPD (n = 2,287) patients. The proportion on APD therapy increased rapidly in the second sub-period. As compared to CAPD patients of this sub-period, APD patients had a significantly higher risk of mortality (HR, 1.37; 95% CI 1.09–1.72; p < 0.01) and technique failure (HR, 1.43; 95% CI, 1.10–1.86; p < 0.01), particularly in the first year after peritoneal dialysis commencement. However, APD patients had similar mortality and technique failure rates to those of CAPD patients throughout the full sample period and the first and third sub-periods. These findings do not suggest the presence of a clear advantage of CAPD over APD. Differences observed between these two modalities might be attributed to specials circumstances of sub-periods.

Risk of non-melanoma skin cancer in patients with chronic kidney disease and its relationship to uraemic pruritus

This study investigated the risk of non-melanoma skin cancer (NMSC) in pre-dialysis patients with chronic kidney disease (CKD) and explored associated risk factors. A population-based cohort of 1,515,858 Taiwanese CKD patients was included. The standardized incidence ratio (SIR) for incident NMSC was determined. Compared with the general population, a 1.14-fold risk of NMSC was found in the CKD cohort. NMSC risk was significant in patients with pre-dialysis stage 5 CKD and anaemia (1.48-fold), and in those with uraemic pruritus after long-term antihistamine treatment (1.38-fold). A higher SIR for NMSC was found in younger patients with CKD (age < 70 years, 1.34-fold; age 20-39 years, 1.63-fold), stage 5 CKD with anaemia (age < 70 years, 2.09-fold), and uraemic pruritus (age <70 years, 2.22-fold). Pre-dialysis patients with CKD are at higher risk of NMSC, especially those with advanced-stage CKD, and those with uraemic pruritus.

The Case | Hexadactyly, blindness, obesity, and end-stage renal disease

A 39-year-old man with mental retardation, diabetes mellitus (DM), and end-stage renal disease (ESRD) on chronic hemodialysis was referred for blood-glucose control. His medical history indicated congenital hexadactyly and developmental delay, with speech and walking delay at the age of 5 and 6 years, respectively. He had degraded vision since 17 years old, which progressed to blindness at 28 years of age. At 18 years of age, impaired renal function (serum creatinine, 1.9 mg/dl) without proteinuria was noted, and kidney echography revealed bilateral increased echogenicity and decreased size. Renal function deteriorated gradually to ESRD, with daily proteinuria of 0.9 g, at 37 years of age. No kidney biopsy was performed. He had obese features since childhood and developed type II DM at 34 years of age. On examination, it was found that he had a high body mass index at 33.3 kg/m2, showed postaxial hexadactyly and brachydactyly of the four limbs (Figure 1), and a 2.5-cm micropenis. Fundus examination revealed retinitis pigmentosa (Figure 2). Echocardiogram and brain computed tomography were unremarkable.