Meng-Fu Cheng

Arterial stiffness correlated with cardiac remodelling in patients with chronic kidney disease

Background:u2003 It is well known that both pressure and volume overloads contribute to left ventricular hypertrophy (LVH) and left ventricular dilatation in patients with chronic kidney disease (CKD). Few studies have evaluated the association between increased pulse wave velocity (PWV) and LVH in CKD patients not yet receiving dialysis. The purpose of this study was to assess the relationship between arterial stiffness and cardiac remodelling in patients with CKD, and to determine the independent factors associated with increased left ventricular mass index (LVMI) and left ventricular volume index (LVVI).

Peritoneal Dialysis-Related Fungal Peritonitis: Twenty-Year Experience of a Medical Center in Southern Taiwan

BACKGROUND: Fungal peritonitis is a rare but frequently lethal peritonitis in patients with endstage renal disease (ESRD) receiving peritoneal dialysis (PD). We reported our twenty-year experience of fungal peritonitis, management and outcome, and identified the risk factors associated with mortality.METHODS: We retrospectively screened all patients with ESRD receiving PD at our PD center between 1 January 1990 and 31 December 2009, and identified the patients diagnosed with fungal peritonitis from 1990 to 2009. Records of all patients with fungal peritonitis were carefully reviewed. Clinical information was collected, including age, gender, clinical presentation, causative pathogens, management, and outcomes. Risk factors associated with mortality were also analyzed.RESULTS: The incidence of fungal peritonitis in our series was 0.13 episodes per 100 patientmonths. Candida species were the most common pathogens, accounting for 72% of fungal peritonitis, and Candida tropicalis (27%) was the most common Candida species. All patients with fungal peritonitis had the catheter removed except one who was transferred to the local hospital, and all received antifungal therapy. Three-month mortality was 20%, but technique survival was 15%. The presence of diabetes mellitus (P = 0.032) and advanced age (P = 0.036) predicted mortality. Gender, previous antibiotics use, previous bacterial peritonitis, and serum albumin had no influence on mortality.CONCLUSION: For patients with PD-related fungal peritonitis, attention should be paid to those with diabetes and advanced age owing to higher risk of mortality.

Clinical characteristics and outcomes of new uremic patients with extreme azotemia in southern Taiwan

Serum creatinine (SCr) had been considered to be an important predictor of mortality in end‐stage renal disease (ESRD) patients at the start of renal replacement therapy (RRT). However, the data were limited about initially extreme azotemia (EA), exclusively defined as blood urea nitrogen (BUN)≥300u2003mg/dL, SCr≥30u2003mg/dL, or both. This retrospective study was conducted to clarify the characteristics and outcome in our EA patients. We had 1682 new ESRD patients from July 1988 to December 1996. With frequency match for age, gender, and starting RRT in the same period, 20 EA patients and 60 controls were included. Fifty percent of our EA patients had unknown etiology. The EA patients had significantly lower prevalence of underlying diabetic nephropathy, and comorbid hypertension. All the EA patients had late referral to nephrologists within 4 weeks before the initiation of RRT, and 90% of them had taken Chinese herbals. The EA group had significantly higher BUN, SCr, and iron storage as well as a higher prevalence of severe anemia, hyperkalemia, hypocalcemia, and acidemia. However, the similar prevalence of cardiomegaly and left ventricular hypertrophy as well as the similar early mortality rate and long‐term survival were noted. Age over 40 years, comorbid diabetes mellitus, and hypoalbuminemia were independent predictors of poor survival. Our EA patients had different initial presentations from other uremic ones at the start of RRT. However, the short‐term and long‐term mortality rates were similar. The lower prevalence of underlying diabetic nephropathy and comorbid hypertension among the EA patients might contribute to their fair outcome.

Diffuse Calcinosis and Intradermal Tophi in a Uremic Patient: Effect of Low-Calcium Hemodialysis and Mechanism of Hypercalcemia

Soft tissue calcification is a frequent complication in end-stage renal disease (ESRD) patients with a high serum calcium-phosphate product, but systemic involvement of both the visceral organs and skin is rarely seen. We report on a newly diagnosed ESRD patient with gouty nephropathy who had initial presentations of extensive intradermal tophi, diffuse calcinosis, and hypercalcemia. He received maintenance hemodialysis (HD) with low-calcium dialysate (1.25 mEq/l) for 11 months. Although the above complications diminished, serum calcium remained elevated. Thereafter, unexpected cervical lymphadenitis from a Mycobacterium tuberculosis (TB) infection with high extra-renal production of calcitriol was found. Serum calcium levels normalized only after anti-TB treatment for 2 months. We thought that this patient might have had occult TB infection before the start of HD, which resulted in calcitriol production and hypercalcemia. In addition, concomitant hyperphosphatemia in chronic renal failure contributed to severe diffuse calcinosis. After the initiation of HD therapy, both the elevated serum calcitriol levels and accelerated resolution and mobilization of diffuse calcinosis from low-calcium HD contributed to persistent hypercalcemia.

Portal Vein Gas in a Diabetic Patient with Gas-forming Pararenal Abscess

The incidence of portal vein gas (PVG), which used to be an ominous sign of intestinal sepsis, has increased with progressive improvements in imaging modalities. Therefore, the clinical significance of PVG has changed. Emphysematous pyelonephritis (EPN) is a rare, potentially life-threatening and gas-forming infection of the renal parenchyma and/or its surroundings. Gas-forming pararenal abscess presenting with PVG is even rarer. We hereby present the case of a diabetic female with poor glycemic control, who was diagnosed to have EPN and PVG concurrently by computed tomography. She underwent percutaneous catheter drainage (PCD) of the pyelonephritis. Both cultures of blood and pus grew Klebsiella pneumoniae. Her subsequent clinical course was uneventful. In summary, EPN is a rare but potentially fatal urinary tract infection in diabetic patients, and finding PVG on computed tomography can aid in diagnosis. Conservative treatment with intravenous antibiotics and PCD of pus may be adequate for the patient with EPN. However, nephrectomy may be necessary if the patient deteriorates and PCD fails to contain the infection.