Kajohnsak Noppakun

Efficacy and safety of warfarin in dialysis patients with atrial fibrillation: a systematic review and meta-analysis

Objective To systematically review and meta-analyse the risk–benefit ratio of warfarin users compared with non-warfarin users in patients with atrial fibrillation (AF), who are undergoing dialysis. Methods We searched PubMed/MEDLINE, EMBASE, SCOPUS, Web of Science, Cochrane Library, grey literature, conference proceedings, trial registrations and also did handsearch. Cohort studies without language restrictions were included. Two investigators independently conducted a full abstraction of data, risk of bias and graded evidence. Effect estimates were pooled using random-effect models. Main outcome measure All-cause mortality, total stroke/thromboembolism and bleeding complications. Results 14 studies included 37 349 dialysis patients with AF, of whom 12 529 (33.5%) were warfarin users. For all-cause mortality: adjusted HR=0.99 (95% CI 0.89 to 1.10; p=0.825), unadjusted risk ratio (RR)=1.00 (95% CI 0.96 to 1.04; p=0.847). For stroke/thromboembolism: adjusted HR=1.06 (95% CI 0.82 to 1.36; p=0.676), unadjusted incidence rate ratio (IRR)=1.23 (95% CI 0.94 to 1.61; p=0.133). For ischaemic stroke/transient ischaemic attack, adjusted HR=0.91 (95% CI 0.57 to 1.45; p=0.698), unadjusted IRR=1.16 (95% CI 0.84 to 1.62; p=0.370). For haemorrhagic stroke, adjusted HR=1.60 (95% CI 0.91 to 2.81; p=0.100), unadjusted IRR=1.48 (95% CI 0.92 to 2.36; p=0.102). Major bleeding was increased among warfarin users; adjusted HR=1.35 (95% CI 1.11 to 1.64; p=0.003) and unadjusted IRR=1.22 (95% CI 1.07 to 1.40; p=0.003). Conclusions Among dialysis patients with AF, warfarin therapy was not associated with mortality and stroke/thromboembolism, but significantly increased the risk of major bleeding. More rigorous studies are essential to demonstrate the effect of warfarin for stroke prophylaxis in dialysis patients with AF.

Development of a multidimensional assessment tool for uraemic pruritus: Uraemic Pruritus in Dialysis Patients (UP‐Dial)

Dialysis patients with uraemic pruritus (UP) have significantly impaired quality of life. To assess the therapeutic effect of UP treatments, a well‐validated comprehensive and multidimensional instrument needed to be established.

A Clinical Risk Prediction Tool for Peritonitis-Associated Treatment Failure in Peritoneal Dialysis Patients

A tool to predict peritonitis-associated treatment failure among peritoneal dialysis (PD) patients has not yet been established. We conducted a multicentre, retrospective cohort study among 1,025 PD patients between 2006 and 2016 in Thailand to develop and internally validate such a tool. Treatment failure was defined as either a requirement for catheter removal, a switch to haemodialysis, or peritonitis-associated mortality. Prediction model performances were analysed using discrimination (C-statistics) and calibration (Hosmer-Lemeshow test) tests. Predictors were weighted to calculate a risk score. In total, 435 patients with 855 episodes of peritonitis were identified; 215 (25.2%) episodes resulted in treatment failure. A total risk score of 11.5 was developed including, diabetes, systolic blood pressure <90 mmHg, and dialysate leukocyte count >1,000/mm3 and >100/mm3 on days 3–4 and day 5, respectively. The discrimination (C-statistic = 0.92; 95%CI, 0.89–0.94) and calibration (P > 0.05) indicated an excellent performance. No significant difference was observed in the internal validation cohort. The rate of treatment failure in the different groups was 3.0% (low-risk, <1.5 points), 54.4% (moderate-risk, 1.5–9 points), and 89.5% (high-risk, >9 points). A simplified risk-scoring scheme to predict treatment failure may be useful for clinical decision making regarding PD patients with peritonitis. External validation studies are needed.

Clinical interpretation of the Uremic Pruritus in Dialysis Patients (UP‐Dial) scale: a novel instrument for the assessment of uremic pruritus

The Uremic Pruritus in Dialysis Patients (UP‐Dial) scale is valid and reliable for uremic pruritus (UP) assessment. However, it remains unknown how the scores should be interpreted in clinical practices.

Risk factors and outcome of Thai patients with scleroderma renal crisis: a disease duration‐matched case control study

Data regarding the prevalence, risk factors and outcome of scleroderma renal crisis (SRC) in Asian patients with systemic sclerosis (SSc) are limited.

Potential impact of Thai Kidney Transplant program on immunosuppressive utilization: an analysis of the national transplant registry.

BACKGROUND The Thai Kidney Transplant (TKT) program was launched in October 2008 to promote transplantation among previously disadvantaged populations, using fixed-rate provider payment. This study investigated if the introduction of this program could alter the natural practice trends of immunosuppressive drug use. METHODS Data from the Thai Transplantation Registry were analyzed. The change in trend of immunosuppressive use was assessed using the multivariate adaptive regression splines (MARS) technique. RESULTS During 1987-2012, 3975 kidney transplantations were done. The average age of patients was 42 years and 62% were male. Chronic glomerulonephritis accounted for one third of those with known causes of end-stage renal disease (ESRD). Eighty-six percent were on hemodialysis before transplantation. Prednisolone was used in 95.87% of all transplant recipients, whereas calcineurin inhibitors (CNIs), mycophenolates (MPAs), azathioprine (AZA), and mammalian target of rapamycin inhibitors (mTORis) were used in 95.67%, 64.22%, 12.25%, and 2.31%, respectively. Overall use after 2008 was decreased for AZA (18.16% to 3.40%) and mTORis (2.86% to 1.5%) but increased for MPAs (50.80% to 84.34%), CNIs (95.43% to 96.04%), and prednisolone (95.60% to 96.29%), as compared with before the program inception. The slopes of use trends of AZA, MPAs, and CNIs did not significantly marginally differ from their natural trends before the program inception (P = .496, .108, and .741, respectively). However, the natural increasing use trend of mTORis significantly changed to a decreasing pattern after the introduction of the TKT program (P = .018). CONCLUSION Fixed-rate provider payment might interfere with the natural practice trends of immunosuppressive drug use.

Comparison between visual assessment and digital image analysis in evaluating renal interstitial fibrosis in lupus nephritis

Background: Prediction of the renal outcomes is crucial for patients with lupus nephritis due to high morbidity and mortality. Renal interstitial fibrosis is correlated with progression to renal failure. However evaluation of interstitial fibrosis by subjective visual assessment comparing with digital image analysis has not been well studied. Method: All kidney core biopsies diagnosed with lupus nephritis at Chiang Mai University hospital during July 1 2011 to December 31 2012 were retrieved from the database. Interstitial fibrosis in percentage was assessed on scanned Picrosirius red-stained histological images (Aperio) using software analysis. Visual assessment was performed under a light microscope by two pathologists (SS, SL). Clinical, laboratory data and renal outcomes [dialysis, doubling of serum creatinine (DSC), end-stage renal disease (ESRD) and complete remission (CR)] were collected retrospectively from the time of biopsy to the last follow-up. Result: Interstitial fibrosis evaluating by digital image analysis (IF-IA) showed better intraobserver (Pearson correlation coefficient: r = 0.98, p < 0.001) and interobserver reliability (r = 0.79, p < 0.001) compared with interstitial fibrosis evaluating by visual assessment (IF-VA) (intraobserver reliability: r = 0.85, p < 0.001 and interobserver reliability: r = 0.61, p = 0.001) while IF-VA was more negatively correlated with baseline estimated glomerular filtration rate (r = -0.50, p =  < 0.001) compared with IF-IA (r = -0.235, p = 0.034). A significantly greater degree of interstitial fibrosis evaluated by visual assessment was observed in patients with subsequent dialysis, DSC and ESRD; and a significantly lesser degree of interstitial fibrosis was observed in patients with CR compared with patients without these outcomes. There is no difference in IF-IA between patients with and without such renal outcomes. IF-VA but not IF-IA was positively correlated with incidence of dialysis, DSC and ESRD [Spearman correlation coefficient (rs) = 0.309, 0.366, 0.459 and p = 0.005, 0.001, <0.001, respectively] and was negatively correlated with CR (rs = -0.306, p = 0.005). For Kaplan-Meier survival analysis, IF-VA greater than percentile 75th (P75, interstitial fibrosis = 20%) had significantly higher incidence of dialysis, DSC and ESRD and significantly lower incidence of CR compared with IF-VA lesser than P75. However IF-IA had no difference. Conclusion: Renal interstitial fibrosis evaluating by digital image analysis is more reliable and precise, however assessing by visual assessment is more predictive of renal outcomes in lupus nephritis patients.