Han-Hsiang Chen

Difference between CKD-EPI and MDRD equations in calculating glomerular filtration rate in patients with cirrhosis

AIM To evaluate the difference between the performance of the (CKD-EPI) and Modification of Diet in Renal Disease (MDRD) equations in cirrhotic patients. METHODS From Jan 2004 to Oct 2008, 4127 cirrhotic patients were reviewed. Patients with incomplete data with respect to renal function were excluded; thus, a total of 3791 patients were included in the study. The glomerular filtration rate (GFR) was estimated by the 4-variable MDRD (MDRD-4), 6-variable MDRD (MDRD-6), and CKD-EPI equations. RESULTS When serum creatinine was 0.7-6.8 mg/dL and 0.6-5.3 mg/dL in men and women, respectively, a significantly lower GFR was estimated by the MDRD-6 than by the CKD-EPI. Similar GFRs were calculated by both equations when creatinine was > 6.9 mg/dL and > 5.4 mg/dL in men and women, respectively. In predicting in-hospital mortality, estimated GFR obtained by the MDRD-6 showed better accuracy [81.72%; 95% confidence interval (CI), 0.94-0.95] than that obtained by the MDRD-4 (80.22%; 95%CI, 0.96-0.97), CKD-EPI (79.93%; 95%CI, 0.96-0.96), and creatinine (77.50%; 95%CI, 2.27-2.63). CONCLUSION GFR calculated by the 6-variable MDRD equation may be closer to the true GFR than that calculated by the CKD-EPI equation.

Primary hyperparathyroidism in Taiwan: clinical features and prevalence in a single-center experience

In Taiwan, urolithiasis remains a common manifestation of primary hyperparathyroidism (PHPT). We designed this study to estimate the prevalence of PHPT in asymptomatic adults and to assess the complications already present when the disease was diagnosed. In the first phase of the study, we retrospectively reviewed 50 patients diagnosed with surgically or biochemically proven PHPT between April 1995 and April 2007. In the second phase, we reviewed the records of 4,359 asymptomatic subjects who had undergone a health examination between August 2002 and January 2007. Of the 50 patients reviewed in the first phase, hypercalcemia was the presenting complication in 33 patients (64%) followed by symptomatic recurrent solitary urolithiasis in 10 patients (20%). Of the 43 patients who underwent urologic imaging, 29 (67%) had urolithiasis and 7 (16%) had nephrocalcinosis, indicating that urinary stone disease is common. In the second phase, 28 of the 4,359 asymptomatic adults (0.64%) were found to have hypercalcemia; of these 28, 4 (0.092%) were diagnosed with PHPT. In Taiwan, PHPT remains underdiagnosed, and complications manifest in most patients upon admission. Although still relatively uncommon, screening serum calcium levels helps diagnose PHPT at an asymptomatic stage.

THE MORTALITY SURVEY OF OLDER PATIENTS WITH CIRRHOSIS IN TAIWAN—A SINGLE-CENTER EXPERIENCE

tered survey and once by telephone. This may have influenced patients’ responses and thereby reduced the reliability of the instrument. It was attempted to minimize this by using a scale with numbers ranging from 1 to 10 and providing visualization instructions over the phone at the second administration. Exclusion of patients with cognitive impairment may also have improved reliability but also limits generalization of the results to all older persons living in the community. A third limitation is the use of a onedimensional scale to measure the multidimensional construct of FOF.

Multiorgan failure following mass wasp stings.

Wasp bites usually bring temporary discomfort and pain, but on occasion, they can cause serious infections and fatal allergic reactions. We report on a patient who experienced massive wasp stings and developed multiple organ failure, including acute kidney, hepatic failure, and circulatory collapse 4 days later. He was treated with aggressive fluid resuscitation, inotropic agent, intravenous injection of steroids, broad-spectrum antibiotics, and hemodialysis. After intensive treatment, his liver function recovered one month later. Recovery of renal function was delayed, and the patient needed temporary regular hemodialysis. The pathology of kidney biopsy showed acute tubulointerstitial nephritis. This case shows that toxic reactions following massive wasp attacks may happen several days after the fact and result in severe, multiorgan system dysfunction.

Effects of percutaneous ethanol injection therapy on subsequent parathyroidectomy

BACKGROUND Although percutaneous ethanol injection therapy (PEIT) is an alternative to surgery for patients with secondary or tertiary hyperparathyroidism, it also has been conjectured to make subsequent parathyroidectomy more difficult. METHODS The records of 37 patients with end-stage renal disease managed between September 2000 and August 2005 were reviewed retrospectively. All patients had hyperparathyroidism intractable to medical treatment, and all eventually underwent parathyroidectomy. Of the 37 patients, 20 initially underwent PEIT, whereas 17 did not. Surgical and biochemical outcomes were compared between the 2 groups. RESULTS i-PTH and biochemical markers before and after surgery did not differ significantly between the 2 groups, nor did the outcome, defined as persistent hypocalcemia, persistent hyperphosphatemia, persistent low or high i-PTH, persistent hoarseness, or residual parathyroid mass. Parathyroidectomy in the PEIT group proceeded smoothly and was not hindered by inflammation or tissue adhesion. CONCLUSIONS Using PEIT to treat hyperparathyroidism in patients with end-stage renal disease does not make subsequent parathyroidectomy more difficult.

Is an estimated glomerular filtration rate better than creatinine to be incorporated into the end-stage liver disease score?

AIM To incorporate estimated glomerular filtration rate (eGFR) into the model for end-stage liver disease (MELD) score to evaluate the predictive value. METHODS From January 2004 to October 2008, the records of 4127 admitted cirrhotic patients were reviewed. Patients who survived and were followed up as outpatients were defined as survivors and their most recent available laboratory data were collected. Patients whose records indicated death at any time during the hospital stay were defined as non-survivors (in-hospital mortality). Patients with incomplete data or with cirrhosis due to a congenital abnormality such as primary biliary cirrhosis were excluded; thus, a total of 3857 patients were enrolled in the present study. The eGFR, which was calculated by using either the modification of diet in renal disease (MDRD) equation or the chronic kidney disease epidemiology collaboration (CKD-EPI) equation, was incorporated into the MELD score after adjustment with the original MELD equation by logistic regression analysis [bilirubin and international normalized ratio (INR) were set at 1.0 for values less than 1.0]. RESULTS Patients defined as survivors were significantly younger, had a lower incidence of hepatoma, lower Child-Pugh and MELD scores, and better renal function. The underlying causes of cirrhosis were very different from those in Western countries. In Taiwan, most cirrhotic patients were associated with the hepatitis virus, especially hepatitis B. There were 16 parameters included in univariate logistic regression analysis to predict in-hospital mortality and those with significant predicting values were included in further multivariate analysis. Both 4-variable MDRD eGFR and 6-variable MDRD eGFR, rather than creatinine, were significant predictors of in-hospital mortality. Three new equations were constructed (MELD-MDRD-4, MELD-MDRD-6, MELD-CKD-EPI). As expected, original MELD score was a significant predictor of in-hospital mortality (odds ratio = 1.25, P < 0.001). MELD-MDRD-4 excluded serum creatinine, with the coefficients refit among the remaining 3 variables, i.e., total bilirubin, INR and 4-variable MDRD eGFR. This model represented an exacerbated outcome over MELD score, as suggested by a decrease in chi-square (2161.45 vs 2198.32) and an increase in -2 log (likelihood) (2810.77 vs 2773.90). MELD-MDRD-6 included 6-variable MDRD eGFR as one of the variables and showed an improvement over MELD score, as suggested by an increase in chi-square (2293.82 vs 2198.32) and a decrease in -2 log (likelihood) (2810.77 vs 2664.79). Finally, when serum creatinine was replaced by CKD-EPI eGFR, it showed a slight improvement compared to the original MELD score (chi-square: 2199.16, -2 log (likelihood): 2773.07). In the receiver-operating characteristic curve, the MELD-MDRD-6 score showed a marginal improvement in area under the curve (0.909 vs 0.902), sensitivity (0.854 vs 0.819) and specificity (0.818 vs 0.839) compared to the original MELD equation. In patients with a different eGFR, the MELD-MDRD-6 equation showed a better predictive value in patients with eGFR ≥ 90, 60-89, 30-59 and 15-29. CONCLUSION Incorporating eGFR obtained by the 6-variable MDRD equation into the MELD score showed an equal predictive performance in in-hospital mortality compared to a creatinine-based MELD score.

Massive bilateral pleural effusion associated with use of pioglitazone

BACKGROUND Pioglitazone is a peroxisome proliferator-activated receptor-gamma agonist that decreases insulin resistance in type 2 diabetes mellitus. However, it has been associated with fluid retention, peripheral edema, and congestive heart failure, which has become of particular concern. There are no reports in the literature of severe pleural effusions in a patient with normal cardiac function. CASE SUMMARY A 54-year-old Asian woman weighing 77 kg developed massive bilateral pleural effusion after receiving pioglitazone (30 mg QD) in combination with glimepiride 2 mg BID and metformin 500 mg TID. Despite treatment with furosemide (20 mg intravenously at 12-hour intervals for 4 days) and a decrease in weight from 77 to 72 kg, the effusion persisted. However, it began to decrease after pioglitazone was discontinued, and it had resolved completely when the patient was evaluated on follow-up 1 month later in the outpatient department. CONCLUSIONS This article reports a case of massive bilateral pleural effusion found in a patient with normal cardiac function who was receiving pioglitazone. After the drug was discontinued, the effusion resolved completely, indicating a probable adverse drug reaction.

A giant gastric ulcer mimicking carcinoma in a renal transplant recipient with CMV infection.

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