Jyh-Chang Hwang

Reverse Epidemiology of Hypertension-Mortality Associations in Hemodialysis Patients: A Long-Term Population-Based Study

BACKGROUND Although hypertension (HTN) is a predictor of mortality, recent data have questioned the link between baseline HTN and mortality in incident hemodialysis (HD) patients. We used Taiwans National Health Insurance claim data (NHRI-NHIRD-99182) to investigate the association. METHODS In 1999, this longitudinal cohort study enrolled 5752 new HD patients. Follow-up began from the initiation of HD until death, the end of HD, or the end of 2008. A Kaplan-Meier survival analysis was done. Cox proportional hazard analysis was used to identify the risk factors for mortality. RESULTS The prevalence of baseline HTN was 75.47%. Patients with HTN had a higher prevalence of diabetic mellitus (DM) and cardiovascular diseases. The 1-, 5-, and 9-year cumulative survival rates were 95.5, 63.7 and 41.8% in patients with HTN, and 95.5, 71.0, and 52.0% in those without HTN (log-rank test: P <0.001). Multivariate analysis showed that patients with baseline HTN may have a higher survival rate (hazard ratio (HR) 0.901, 95% confidence interval (CI): 0.819-0.992). After stratification by age and DM, only elderly (≥65) patients without DM had a significantly higher survival rate (HR 0.769, 95% CI: 0.637-0.927). HTN predicts lower mortality with increasing age in patients with congestive heart failure (CHF) or coronary artery disease (CAD). CONCLUSIONS There is a reverse (counterintuitive) association between baseline HTN and mortality in elderly HD patients without DM and a clear tendency for a reverse association with increasing age in patients with CHF or CAD. Further study of the association between HTN and mortality in older HD patients may be warranted.

Comparison of low-dose deferoxamine versus standard-dose deferoxamine for treatment of aluminium overload among haemodialysis patients

BACKGROUND Patients on maintenance haemodialysis are at high risk of aluminium overload. While deferoxamine (DFO) has potential adverse effects, lower DFO dosages may afford good efficacy with fewer side effects. We evaluated the therapeutic response of low-dose (2.5 mg/kg/week) DFO among haemodialysis patients with aluminium overload. METHODS We recruited the participants via basal predialysis serum aluminium (Al) levels of >or=20 microg/L with clinical suspicion of aluminium toxicity or hyperparathyroidism indicating parathyroidectomy and positive DFO tests. Patients were randomly divided into standard-dose (5 mg/kg/week) and low-dose (2.5 mg/kg/week) groups. We compared the differences of mineral biochemical and haematological parameters before and after DFO treatment. Successful treatment was defined as a serum aluminium increase of <50 microg/L by DFO test. Adverse events during DFO therapy between the groups were also compared. RESULTS In total, 42 haemodialysis patients completed treatment (standard-dose group, n = 21; low-dose group, n = 21). The demographic characteristics of the groups did not differ. Serum corrected calcium and ferritin decreased in both groups, while serum total alkaline phosphatase increased in both groups. Serum phosphorus increased in low-dose group (P = 0.029), while plasma intact parathyroid hormone increased in standard-dose group (P = 0.004). The successful treatment response rates did not differ between the two groups (standard-dose: 12/21, 57% vs low-dose: 13/21, 62%; P = 0.75). CONCLUSIONS Low-dose DFO may offer similar therapeutic effects as standard-dose DFO therapy.

Long-term survival and predictors for mortality among dialysis patients in an endemic area for chronic liver disease: a national cohort study in Taiwan

BackgroundPatients with end-stage renal disease (ESRD) are at a higher risk for chronic hepatitis, liver cirrhosis (LC) and mortality than the general population. Optimal modalities of renal replacement therapy for ESRD patients with concomitant end-stage liver disease remain controversial. We investigated the long-term outcome for chronic liver disease among dialysis patients in an endemic area.MethodsUsing Taiwan’s National Health Insurance claim data (NHRI-NHIRD-99182), We performed a longitudinal cohort study to investigate the impact of comorbidities on mortality in dialysis patients. We followed up 11293 incident hemodialysis (HD) and 761 peritoneal dialysis (PD) patients from the start of dialysis until the date of death or the end of database period (December 31, 2008). A Cox proportional hazards model was used to identify the risk factors for all-cause mortality.ResultsPatients receiving PD tended to be younger and less likely to have comorbidities than those receiving HD. At the beginning of dialysis, a high prevalence rate (6.16 %) of LC was found. Other than well-known risk factors, LC (hazard ratio [HR] 1.473, 95 % CI: 1.329-1.634) and dementia (HR 1.376, 95 % CI: 1.083-1.750) were also independent predictors of mortality. Hypertension and mortality were inversely associated. Dialysis modality and three individual comorbidities (diabetes mellitus, chronic lung disease, and dementia) interacted significantly on mortality risk.ConclusionsLC is an important predictor of mortality; however, the effect on mortality was not different between HD and PD patients.

Effects of Extract from Solid-State Fermented Cordyceps sinensis on Type 2 Diabetes Mellitus

Diabetes mellitus is the most common chronic disease in the world, and a wide range of drugs, including Chinese herbs, have been evaluated for the treatment of associated metabolic disorders. This study investigated the potential hypoglycemic and renoprotective effects of an extract from the solid-state fermented mycelium of Cordyceps sinensis (CS). We employed the KK/HIJ diabetic mouse model, in which the mice were provided with a high-fat diet for 8 weeks to induce hyperglycemia, followed by the administration of CS or rosiglitazone for 4 consecutive weeks. Several parameters were evaluated, including changes in body weight, plasma lipid profiles, oral glucose tolerance tests, insulin tolerance tests, and plasma insulin concentrations. Our results show that the CS extract significantly elevated HDL/LDL ratios at 4 weeks and decreased body weight gain at 8 weeks. Interestingly, CS treatment did not lead to obvious improvements in hyperglycemia or resistance to insulin, while in vitro MTT assays indicated that CS protects pancreatic beta cells against the toxic effects of STZ. CS also enhanced renal NKA activity and reduced the accumulation of mesangial matrix and collagen deposition. In conclusion, CS extract can potentially preserve β-cell function and offer renoprotection, which may afford a promising therapy for DM.

Sex difference for urologic malignancy risk in uremic patients after kidney transplantation: a population-based study.

Background High urologic malignancy incidence has been reported in end-stage renal disease (ESRD) patients, especially of female sex. This study was undertaken to evaluate whether female recipients still carry an aggravated risk of this malignancy after kidney transplantation (KT). Methods The claims data from the Bureau of National Health Insurance of Taiwan were used for analysis. All KT recipients who developed urologic malignancy from January 1, 1999, to December 31, 2007 (n = 2,245) were enrolled in this study. By means of propensity score, a database of 1:4 ratio random incident ESRD patients with matched age, sex, comorbidity rates, and dialysis to index date was used as control (non-KT group, n = 8,980). The last observation period ended on December 31, 2008. Results The cumulative urologic malignancy incidence rate was significantly higher in female recipients after KT than their female ESRD counterparts without KT (P < 0.001). This gap became more prominent approximately 2 years after transplantation. No similar trend was detected in male KT patients (P = 0.13). Incidence rate ratio of urologic malignancy was significantly higher in female recipients (incidence rate ratio, 2.13; 95% confidence interval [95% CI], 1.53–2.97) than in their male counterparts (incidence rate ratio, 1.43; 95% CI, 0.90–2.25). From multivariate Cox proportional hazard regression tests, female (hazards ratio, 2.10; 95% CI, 1.52–2.95) but not male sex (hazards ratio, 1.47; 95% CI, 0.93–2.32) was determined to be an independent factor for the development of urologic malignancy after KT. After acquiring this malignancy, KT recipients did not have any advantage in cumulative survival compared to ESRD patients without KT (P = 0.07). Conclusion Compared to males, female recipients tended to have a significantly higher urologic malignancy risk after KT.

Impact of HCV Infection on Diabetes Patients for the Risk of End-Stage Renal Failure.

Abstract Both diabetes mellitus (DM) and hepatitis C virus infection (HCVI) are associated with chronic kidney disease (CKD). The aim of this study was to evaluate whether HCVI increases the risk of end-stage renal disease (ESRD) in patients with DM. The National Health Insurance Research database of Taiwan was used to conduct this study. After excluding patients with a prior history of CKD, all patients with a first diagnosis of DM from January 1, 2000 to December 31, 2002 were enrolled. The patients who also had HCVI were defined as index cases (HCV group, n = 9787). A comparison cohort at a 1:1 ratio of random incident patients with DM without HCVI matched by age, sex, age at the diagnosis of DM, duration between the diagnosis of DM and the index date, and various comorbidities through propensity score matching were recruited (non-HCV group, n = 9787). The patients were followed until December 31, 2011. The cumulative incidence rate of developing ESRD was significantly higher in the HCV(+) group than in the non-HCV group (P = 0.008). The incidence rate ratio (IRR) for the risk of ESRD was also significantly higher in the HCV(+) group (IRR: 1.44; 95% CI: 1.09–1.89) than in the non-HCV group, especially for those with a younger age (<50 years; IRR: 2.05; 95% CI: 1.22–3.45) and HCVI within 4 years after the diagnosis of DM (IRR: 1.85; 95% CI: 1.16–2.97). After adjusting for comorbidities in multivariate Cox proportional hazard regression analysis, HCVI (HR: 1.47; 95% CI: 1.11–1.93) was an independent factor for developing ESRD in the patients with DM. After starting dialysis for ESRD, the HCV(+) patients had a similar mortality rate to those without HCVI (P = 0.84). HCVI increases the risk of developing ESRD in patients with DM, especially in younger patients and in those who develop HCVI sooner after a diagnosis of DM.

Aluminum Overload: An Easily-Ignored Problem in Dialysis Patients with Hyperparathyroidism

Wei-Chih Kan1,2, Chih-Chiang Chien1,2, Yi-Hua Lu1, Jyh-Chang Hwang1, Shih-Bin Su3,4 and Hsien-Yi Wang1,5 1Department of Nephrology, Chi-Mei Medical Center, Tainan 2Chung Hwa University of Medical Technology, Tainan 3Department of Family Medicine, Chi-Mei Medical Center, Tainan 4Department of Biotechnology, Southern Taiwan University, Tainan 5Chia Nan University of Pharmacy and Science, Tainan Taiwan, R.O.C.

Outcomes of Monomicrobial Peritoneal Dialysis-Related Peritonitis Caused by Non-Pseudomonas Gram-Negative Pathogens

BACKGROUND: The causative microorganism of peritoneal dialysis (PD)-related peritonitis is an important determinant of patient and technique survival. This retrospective study aimed to investigate the outcomes of monomicrobial peritoneal dialysis-related peritonitis caused by non-Pseudomonas Gramnegative (NPGN) pathogens. METHODS: We analyzed the data of causative microorganisms and outcomes of monomicrobial PDrelated peritonitis in two medical centers in Tainan. The main outcome variables of PD-related peritonitis were the time to dialysate effluent white blood cells ＜ 100/mm^3, length of hospital stay, catheter removal/transfer to hemodialysis, and in-hospital mortality. RESULTS: 104 patients with 151 episodes of monomicrobial Gram-negative PD-related peritonitis were included for final analysis. The overall treatment failure rate was 21%. Escherichia coli and Klebsiella species were the two most common causative pathogens. The risk of peritoneal catheter removal and mortality in NPGN peritonitis was higher than that in Gram-positive peritonitis (40% vs. 10%, P ＜ 0.0001). Among patients with NPGN peritonitis, there was no significant difference between the group of Escherichia coli plus Klebsiella species and the group of other NPGN bacteria in improvement rate, time to dialysate effluent WBC ＜ 100/mm^3, and catheter removal/transfer to hemodialysis. CONCLUSION: This study demonstrated that the outcomes in NPGN peritonitis were significantly worse compared to those in Gram-positive peritonitis. Among patients with NPGN peritonitis, there was no significant difference between the group of E. coli plus Klebsiella species and the group of other Gramnegative bacteria in response to antimicrobial therapy, hospitalization management, and catheter removal/ transfer to hemodialysis.