Ching-Wei Tsai

The 90-day mortality and the subsequent renal recovery in critically ill surgical patients requiring acute renal replacement therapy.

BACKGROUNDnParticular attention should be paid to postoperative patients that suffer from severe acute kidney injury (AKI) requiring renal replacement therapy (RRT).nnnMETHODSnThis multicenter prospective observational study included 342 patients with postoperative AKI requiring RRT from January 2002 to December 2006.nnnRESULTSnThere were 137 (40%) survivors at 90 days after the commencement of RRT. Independent predictors of 90-day mortality were older age, presence of sepsis, status post-cardiopulmonary resuscitation, necessity of continuous renal replacement therapy (CRRT), requirement of total parenteral nutrition, lower body mass index, higher Sequential Organ Failure Assessment score, and higher serum lactate level at the commencement of RRT. Further analysis among the survivors showed that lower serum creatinine at intensive care unit admission, lower Simplified Acute Physiology Score II and inotropic equivalent score at the commencement of RRT, and using CRRT were independent predictors for subsequent renal recovery.nnnCONCLUSIONSnThe development of AKI requiring RRT in postoperative critical patients represents a substantial risk for mortality and morbidity.

Verification and evaluation of aldosteronism demographics in the Taiwan Primary Aldosteronism Investigation Group (TAIPAI Group)

Objective: Current data on primary aldosteronism (PA) from Asian populations are scarce. This cohort study clarifies the attributes of patients with PA in a typical Chinese population. Design: An observational cohort study. Methods: The records of patients referred to the Hypertension Clinic from a multi-centre registration in Taiwan from January 1995 to December 2007 were reviewed. All patients with PA were classified into two subtypes: aldosterone-producing adenomas (APA) and idiopathic hyperaldosteronism (IHA); their characteristics were compared. Results: Our cohort consisted of 346 patients with PA, 255 with APA and 91 with IHA. The initial hypokalaemia (59% in APA vs. 27.5% in IHA, p < 0.0001) and transtubular potassium gradient (TTKG) (6.30 ± 2.41 in APA vs. 4.91 ± 2.03 in IHA, p = 0.01) were higher in the APA group. Baseline plasma aldosterone concentration (PAC) was also significantly different between the two subgroups (49.96 ± 38.15 ng/dl in APA vs. 34.24 ± 21.47 in IHA, p < 0.0001). Conclusions: In typical Chinese PA patients, the APA subgroup had a higher proportion of hypokalaemia with elevated TTKG and higher PAC as compared with the IHA subgroup. This largest Asian database also demonstrated major differences between the Caucasian and Chinese populations including female predilection, frequent hypokalaemia, and common paralytic myopathy.

Relative kidney hyperfiltration in primary aldosteronism: a meta-analysis

Introduction: Since the phenomenon of hyperfiltration in primary aldosteronism (PA) was first noted in 1996, subsequent clinical studies have produced conflicting results. To determine the development of relative hyperfiltration in PA, we performed a meta-analysis. Methods: MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched through to July 2009. Reference sections of original articles, meta-analyses, and reviews on hyperfiltration in PA were reviewed. Hypertensive patients provided the controlled data for hyperfiltration. Two authors independently extracted the data. Results: A total of seven studies were included. One study was from the data of the TAIPAI group. Overall, there was strong evidence that relative kidney hyperfiltration existed in PA (fixed-effects model: standardised mean difference (SMD), 0.13; 95% confidence interval (CI), 0.03—0.22, p = 0.007; random-effects model: SMD, 0.35; 95% CI, -0.01—0.71, p = 0.05), though with a significant heterogeneity (p < 0.0001). In the secondary meta-analysis with five top-quality studies, the relative kidney hyperfiltration was more significant. Mean age in each enrolled study was the only factor significantly associated with the existence of heterogeneity among the selected studies in the meta-regression analysis. Conclusions: Current evidence suggests that relative kidney hyperfiltration is the hallmark in PA and the phenomenon is beyond the effect of hypertension of PA. Clinicians should be aware of the possibility of occult renal damage in patients with PA.

SAPS 3 at dialysis commencement is predictive of hospital mortality in patients supported by extracorporeal membrane oxygenation and acute dialysis

OBJECTIVEnThis study examined the association between hospital mortality and five illness-severity scoring systems evaluated at different time points in the intensive care unit (ICU) as well as clinical variables as predictors in critically ill patients supported by extracorporeal membrane oxygenation (ECMO) and acute dialysis.nnnMETHODSnThis multicenter prospective observational study included 104 patients who received ECMO support and acute dialysis from January 2002 to December 2006. Patients demographic, clinical and laboratory variables were analyzed as predictors of survival. The SAPS 2, APACHE II, SOFA, MODS, and SAPS 3 scores upon ICU admission and at acute dialysis commencement were evaluated to predict the patients hospital mortality.nnnRESULTSnHospital mortality for the study group was 76% (79/104). Among the five scoring systems, only SAPS 3 score showed a significant difference between survivors and non-survivors either upon ICU admission (p=0.038) or at dialysis commencement (p=0.001). SAPS 3 score at dialysis commencement showed the best discrimination ability by using the area under the receiver operating characteristic curve (SOFA, 0.55; SAPS 2, 0.56; MODS, 0.58; APACHE II, 0.59; and SAPS 3, 0.73). Multiple logistic regression analysis indicated that SAPS 3 score at dialysis commencement (OR: 1.070, 95% CI: 1.016-1.216) and IABP usage before ECMO (OR: 4.181, 95% CI: 1.448-12.075) were two independent risk factors for hospital mortality.nnnCONCLUSIONSnAmong five common ICU scoring systems evaluated at different time points, SAPS 3 at dialysis commencement is the best risk adjustment systems to predict hospital mortality in critically ill patients supported by ECMO and acute dialysis. Furthermore, the SAPS 3 score at dialysis commencement and IABP usage before ECMO are two major independent predictors for hospital mortality in patients supported by ECMO and acute dialysis.

Xanthogranulomatous pyelonephritis: critical analysis of 30 patients

Introduction and objectiveXanthogranulomatous pyelonephritis (XGP) is a chronic inflammatory condition of the kidneys. Nevertheless, disparities between the pre-operative and pathological diagnoses are frequently encountered. We reviewed all patients with XGP over a 17-year period to identify and characterize the pre-operative and pathological characteristics of the disease in our patients.MethodsA comprehensive review of all nephrectomy patients with a pre-operative diagnosis of pyelonephritis at National Taiwan University Hospital from 1991 to 2008 with the pathological diagnosis of XGP was conducted to demonstrate the clinical and radiological characteristics of XGP.ResultsXGP was diagnosed in 30 (18.6%) of the 160 nephrectomies performed for pyelonephritis. Of the 30 patients with XGP, 25 were women (83.3%) and 20 (66.7%) were overweight (body mass indexxa0>23). Their mean age was 55.17xa0years. The average serum creatinine level was 1.68xa0mg/dL. The image findings included renal calculi (56.7%), staghorn stones (26.7%), and spread of the disease to the retroperitoneum and psoas muscle (33.3%). Escherichia coli (36.7%) was the most prevalent pathogen. The mortality of the two-stage surgical treatment was zero, and morbidity developed in only 1 patient (4.8%).ConclusionThe key to accurate pre-operative diagnosis is to keep risk factors in mind such as age, sex, and renal calculi. Clinicians should maintain a high suspicion of XGP for early recognition and be aware of the care of chronic kidney disease. Finally, the association between XGP and central obesity warrants further research.

Serum Uric Acid and Progression of Kidney Disease: A Longitudinal Analysis and Mini-Review.

Background Increasing evidence supports the association between hyperuricemia and incident chronic kidney disease (CKD); however, there are conflicting data regarding the role of hyperuricemia in the progression of CKD. This study retrospectively assessed the longitudinal association between uric acid (UA) level and CKD progression in a Chinese population lived in Taiwan. Methods Patients with physician diagnosis of hyperuricemia or receiving urate-lowering therapy between 2003 and 2005 were identified in the electronic medical records (EMR) of a tertiary medical center and were followed up until December 31, 2011. Patients were divided into four UA categories at the cut-off 6, 8, and 10 mg/dL. CKD progression was estimated by the change of estimated glomerular filtration rate (eGFR) in the linear mixed models. Kidney failure was defined as an eGFR less than 15 mL/min/1.73 m2 or requiring renal replacement therapy. Results A total of 739 patients were analyzed. In the full-adjusted model, patients with a baseline UA level ≥6 mg/dL had greater decline in eGFR ((β = -9.6, 95% CI -16.1, -3.1), comparing to those with a UA level less than 6 mg/dL. When stratifying patients into four UA categories, all three hyperuricemia categories (UA6-8, 8–10, ≥10 mg/dL) associated with a greater decline in eGFR over the follow-up period with an increasing dose-response, comparing to the lowest UA category. The risk of progression to renal failure increased 7% (hazard ratio 1.07, 95% CI 1.00, 1.14) for each 1mg/dL increase in baseline UA level. The influences of hyperuricemia on eGFR decline and the risk of kidney failure were more prominent in patients without proteinuria than those with proteinuria. Conclusion Our study showed a higher uric acid level is associated with a significant rapid decline in eGFR and a higher risk of kidney failure, particularly in patients without proteinuria. Our findings suggest hyperuricemia is a potential modifiable factor of CKD progression.

Both rare and common variants in PCSK9 influence plasma low-density lipoprotein cholesterol level in American Indians

CONTEXTnElevated LDL cholesterol (LDL-C) is an important risk factor for atherosclerosis and cardiovascular disease. Variants in the proprotein convertase subtilisin/kexin type 9 (PCSK9) gene have been associated not only with plasma LDL-C concentration, but also with ischemic heart disease. Little is known about the genetic architecture of PCSK9 and its influence on LDL-C in American Indians.nnnOBJECTIVEnWe aimed to investigate the genetic architecture in the 1p32 region encompassing PCSK9 and its influence on LDL-C in American Indians.nnnDESIGNnThe Strong Heart Family Study (SHFS) is a family-based genetic study.nnnPARTICIPANTSnTwo thousand four hundred fifty eight American Indians from Arizona, Oklahoma, North Dakota, and South Dakota, who were genotyped by Illumina MetaboChip.nnnRESULTSnWe genotyped 486 SNPs in a 3.9 Mb region at chromosome 1p32 encompassing PCSK9 in 2458 American Indians. We examined the association between these SNPs and LDL-C. For common variants (MAF ≥ 1%), meta-analysis across the three geographic regions showed common variants in PCSK9 were significantly associated with higher LDL-C. The most significant SNP rs12067569 (MAF = 1.7 %, β = 16.9 ± 3.7, P = 5.9 × 10(-6)) was in complete LD (r(2) = 1) with a nearby missense SNP, rs505151 (E670G) (β = 15.0 ± 3.6, P = 3.6 × 10(-5)). For rare variants (MAF < 1%), rs11591147 (R46L, MAF = 0.9%) was associated with lower LDL-C (β = - 31.1 ± 7.1, P = 1.4 × 10(-5)). The mean (SD) of LDL-C was 76.9 (7.8) and 107.4 (1.0) mg/dL for those with and without the R46L mutation, respectively. One person who was homozygous for R46L had LDL-C levels of 11 mg/dL. In one family, 6 out of 8 members carrying the R46L mutation had LDL-C levels below the lower 10% percentile of LDL-C among all study participants.nnnCONCLUSIONSnBoth rare and common variants in PCSK9 influence plasma LDL-C levels in American Indians. Follow-up studies may disclose the influence of these mutations on the risk of CVD and responses to cholesterol-lowering medications.

Survival analysis of pediatric dialysis patients in Taiwan

Aim:u2003 The long‐term survival of Taiwanese children with end‐stage renal disease (ESRD) has not been reported before. This study aimed to determine the long‐term survival, mortality hazards and causes of death in paediatric patients receiving dialysis.

Longitudinal change in estimated GFR among CKD patients: A 10-year follow-up study of an integrated kidney disease care program in Taiwan

Background This study examined the progression of chronic kidney disease (CKD) by using average annual decline in estimated GFR (eGFR) and its risk factors in a 10-year follow-up CKD cohort. Methods A prospective, observational cohort study, 4600 individuals fulfilled the definition of CKD, with or without proteinuria, were followed for 10 years. The eGFR was estimated by the MDRD equation. Linear regression was used to estimate participants’ annual decline rate in eGFR. We defined subjects with annual eGFR decline rate <1 ml/min/1.73 m2 as non-progression and the decline rate over 3 ml/min/1.73 m2 as rapid progression. Results During the follow-up period, 2870 (62.4%) individuals had annual eGFR decline rate greater than 1 ml/min/1.73 m2. The eGFR decline rate was slower in individuals with CKD diagnosed over the age of 60 years than those with onset at a younger age. Comparing to subjects with decline rate <1 ml/min/1.73 m2/year, the odds ratio (OR) of developing rapid CKD progression for diabetes, proteinuria and late onset of CKD was 1.72 (95% CI: 1.48–2.00), 1.89(1.63–2.20) and 0.68 (0.56–0.81), respectively. When the model was adjusted for the latest CKD stage, comparing to those with CKD stage 1, patients with stage 4 and stage 5 have significantly higher risks for rapid progression (OR, 5.17 (2.60–10.25), 19.83 (10.05–39.10), respectively). However, such risk was not observed among patients with the latest CKD stage 2 and 3. The risk for incident ESRD was 17% higher for each 1 ml/min/1.73 m2 increasing in annual decline rate. Conclusions Not everyone with CKD develops ESRD after a 10-year follow-up. Absolute annual eGFR decline rate can help clinicians to better predict the progression of CKD. Individuals with renal function decline rate over 3 ml/min/1.73 m2/year require intensive CKD care.

Video-assisted thoracoscopic surgery in continuous ambulatory peritoneal dialysis-related hydrothorax

A 50-year-old lady with end-stage renal disease developeddyspnea, nausea, and vomiting soon after commencingcontinuous ambulatory peritoneal dialysis (CAPD) for 1week. The chest X-ray showed massive right-sided pleuraleffusion (Figure 1a), which was transudative in characterwith high sugar levels. To establish the diagnosis ofCAPD-related hydrothorax, a peritoneal–pleural communi-cation was confirmed by Tc-99m peritoneal scintigraphy,where an uptake signal appeared in the right side of thoraxwithin 30min of tracer injection into the peritoneal cavity(Figure 1b). During the video-assisted thoracoscopic surgery,a defect about 0.3cm in diameter on the right diaphragm wasrepaired by direct suture with a mesh (Figure 2). Thepostoperative course was smooth and CAPD was resumed2 weeks later without event. The chest X-ray did not showany recurrence of the pleural effusion up to 5 months later.Both Tc-99m peritoneal scintigraphy and video-assistedthoracoscopic surgery with mesh repair provide a safe,simple, and quick way to diagnose and treat CAPD-relatedhydrothorax.