Shuo-Chun Weng

In-hospital mortality risk estimation in patients with acute nonvariceal upper gastrointestinal bleeding undergoing hemodialysis: a retrospective cohort study.

Background: Upper gastrointestinal bleeding (UGIB) is a major cause of clinical bleeding among patients with end-stage renal disease (ESRD). This study aimed to investigate the association between mortality and UGIB in patients with uremia. Methods: From 2004 to 2010, a tertiary hospital-based retrospective cohort comprising 322 patients undergoing hemodialysis was investigated. All the patients were diagnosed with UGIB according to the International Classification of Diseases, 9th Revision (ICD-9) that included peptic ulcer bleeding, duodenal ulcer bleeding, and other symptoms. UGIB was required to be one of the first three discharge diagnoses. Rehospitalization within 3 days after discharge was regarded as the same course. Exclusion criteria were age <20 years, previous gastric resection or vagotomy, esophageal and gastric variceal bleeding, or gastric cancer within the first 2 years of the index hospitalization. Results: The all-cause in-hospital mortality rate of patients with UGIB undergoing hemodialysis was high, with the first-month mortality rate of 13.7%, sixth-month mortality rate of 26.7%, and first-year mortality rate of 27.0%. Using Cox regression models, we found that the high mortality rate of the UGIB group was significantly correlated with older age [adjusted hazard ratio (HR) = 1.02, 95% confidence interval (CI) = 1.01–1.04], female sex (adjusted HR = 1.62, 95% CI = 1.05–2.51), infection during hospitalization (adjusted HR = 1.85, 95% CI = 1.13–3.03), single episodic UGIB (adjusted HR = 2.00, 95% CI = 1.08–3.70), abnormal white blood cell (WBC) count (adjusted HR = 1.59, 95% CI = 1.03–2.45), and albumin level ≤3 g/dL (adjusted HR = 2.67, 95% CI = 1.51–4.72). Conclusion: In conclusion, patients with ESRD who are admitted with primary UGIB have a profoundly increased risk of all-cause in-hospital mortality during the follow-up period.

Estimated Glomerular Filtration Rate Decline Is a Better Risk Factor for Outcomes of Systemic Disease-Related Nephropathy than for Outcomes of Primary Renal Diseases

Background Currently, the contribution of kidney function decline in renal and patient outcomes is unclear. There are few data on the associations of different etiologies of estimated glomerular filtration rate (eGFR) decline with outcomes in multidisciplinary care. The purpose of this investigation was to establish whether eGFR decline in patients with disease is an important risk factor for developing end-stage renal disease (ESRD) and death. Methods From December 1, 2001 to December 31, 2011, 5097 adults with chronic kidney disease (CKD) received biochemical tests, physical examinations, a pathological examination, and a comprehensive questionnaire. We used linear regression models and multivariate Cox proportional hazards model to examine the outcome of eGFR decline in renal diseases with different etiologies. Results Mean age was 68.1±16.1 (standard deviation, SD) years, and 63.3% patients were male. In the studied cohort, 58.2% of the patients had systemic disease-related nephropathy (SDRN), 29.4% had primary renal diseases (PRDs), and 12.4% had other etiologies. The eGFR decline in SDRN had a significant association with dialysis in the Cox proportional hazards model [crude hazard ratio (HR) = 1.07, 95% confidence interval (CI), 1.04 to 1.10; adjusted HR 1.05, 95% CI, 1.02 to 1.08]. Diabetic nephropathy (DN) had the most severe eGFR decline in CKD stages 3, 4, and 5, and all contributed to the initiation of dialysis and death regardless of whether DN with or without eGFR decline was considered to be the cause. Although hypertensive nephropathy (HN) was related to significant acceleration of eGFR decline, it did not lead to poor outcome. There were still discrepancies between eGFR decline and outcomes in PRDs, hypertensive nephropathy, and lupus nephritis. Conclusions eGFR decline and CKD staging provide an informative guide for physicians to make proper clinical judgments in the treatment of CKD, especially SDRN. Poor control of the underlying systemic disease will thus lead to more rapid progression of SDRN.

Severe Decline of Estimated Glomerular Filtration Rate Associates with Progressive Cognitive Deterioration in the Elderly: A Community-Based Cohort Study

Cognitive dysfunction is closely related to aging and chronic kidney disease (CKD). However, the association between renal function changes and the risk of developing cognitive impairment has not been elucidated. This longitudinal cohort study was to determine the influence of annual percentage change in estimated glomerular filtration rate (eGFR) on subsequent cognitive deterioration or death of the elderly within the community. A total of 33,654 elders with eGFR measurements were extracted from the Taipei City Elderly Health Examination Database. The Short Portable Mental Status Questionnaire was used to assess their cognitive progression at least twice during follow-up visits. Multivariable Cox regression models were used to estimate the hazard ratio (HR) for cognitive deterioration or all-cause mortality with the percentage change in eGFR. During a median follow-up of 5.4 years, the participants with severe decline in eGFR (>20% per year) had an increased risk of cognitive deterioration (HR, 1.33; 95% confidence interval [CI], 1.08–1.72) and the composite outcome (HR, 1.17; 95% CI, 1.03–1.35) when compared with those who had stable eGFR. Severe eGFR decline could be a possible predictor for cognitive deterioration or death among the elderly. Early detection of severe eGFR decline is a critical issue and needs clinical attentions.

Expression of decoy receptor 3 in kidneys is associated with allograft survival after kidney transplant rejection.

Decoy receptor 3 (DcR3) expression in kidneys has been shown to predict progression of chronic kidney disease. We prospectively investigated a cohort comprising 96 renal transplant recipients (RTRs) undergoing graft kidney biopsies. Computer-assisted quantitative immunohistochemical staining value of DcR3 in renal tubular epithelial cells (RTECs) was used to determine the predictive role of DcR3 in kidney disease progression. The primary end point was doubling of serum creatinine and/or graft failure. A multivariate Cox proportional hazards model was used to assess the risk of DcR3 expression in rejected kidney grafts toward the renal end point. In total, RTRs with kidney allograft rejection were evaluated and the median follow-up was 30.9 months. The greater expression of DcR3 immunoreactivity in RTECs was correlated with a higher rate of the histopathological concordance of acute T cell-mediated rejection. Compared with 65 non-progressors, 31 progressors had higher DcR3 expression (HDE) regardless of the traditional risk factors. Cox regression analysis showed HDE was significantly associated with the risk of renal end point with a hazard ratio of 3.19 (95% confidence interval, 1.40 to 7.27; P = 0.006) after adjusting for other variables. In repetitive biopsies, HDE in tissue showed rapid kidney disease progression due to persistent inflammation.

Migraine and subsequent chronic kidney disease risk: a nationwide population-based cohort study

Objective We compared the incidence and risk of chronic kidney disease (CKD) between subjects with new-onset migraine and matched controls without migraine in this large-scale retrospective cohort study. Design Population-based cohort study. Setting 8880 subjects with migraine and 503 070 subjects without migraine were enrolled between January 1, 2000 and December 31, 2013, all diagnosed to be without kidney disease. All the participants were registered in the National Health Insurance Research Database. Participants Finally, data from 7156 subjects with migraine and 7156 propensity-score-matched control subjects were analysed. Primary outcome measure We used Cox proportional hazards regression to estimate adjusted HRs for incident CKD; subgroup analyses were performed to assess the interactive effects of migraine with demographics, comorbidities and long-term medications. Results The incidence of CKD was higher in the migraine group than in the control group. The risk of developing CKD was significantly higher in subjects with migraine than without migraine (P=0.031). Subjects with migraine aged <65 years (age 40–64 (adjusted HR (aHR) 1.35; 95% CI 1.05 to 1.73); age <40 (aHR 1.55; 95% CI 1.02 to 2.36)), with ≥1 comorbid diseases (1–2 diseases (aHR 1.30; 95% CI 1.01 to 1.68); ≥3 diseases (aHR 1.45; 95% CI 1.01 to 2.07)), and not receiving anti-migraine agents (aHR 1.26; 95% CI 1.04 to 1.54) were at a higher risk of developing CKD compared with the control subjects. The interaction between migraine and comorbidities was not significant; age, male gender and long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) were independent risk factors for CKD in subjects with migraine. Conclusion Migraine may be an independent risk factor for CKD. Young subjects with migraine, and those with comorbid conditions or without medical control, are likely to be at higher risk for CKD. Ageing, male sex and NSAIDs tend to have an association with CKD in subjects with migraine.

Application of qualitative response models in a relevance study of older adults' health depreciation and medical care demand.

The effect of health depreciation in older people on medical care demand is not well understood. We tried to assess the medical care demand with length of hospitalization and their impact on profits as a result of health depreciation.

Interaction between protein-energy wasting and geriatric nutritional risk index in elderly patients on dialysis.

Proteineenergy malnutrition has been proposed to be a cause of refractory anemia that accompanies the malnutritioneinflammation complex (or cachexia) syndrome in dialysis patients. Malnutritioneinflammation complex syndrome and the obesity paradox are also the main etiology for “reverse epidemiology” of cardiovascular risk factors and outcomes in dialysis patients. However, in some dialysis patients, protein-energy wasting (PEW) is not related to inadequate nutrient intake. The 2013 International Society of Renal Nutrition and Metabolism meeting report notes that PEW is responsible for loss of protein mass and fuel reserve, and that PEW is a nonspecific inflammatory process. The term kidney disease wasting emphasizes the strong association between kidney diseases and PEW. However, kidney disease wasting does not provide any insight into the different causes of PEW in kidney disease. Moreover, the lack of association between kidney disease (acute kidney injury and chronic kidney disease) and PEW may be found between young (pancreatitis) and elderly individuals (chronic obstructive pulmonary disease) with different etiologies. Therefore, the expert panel reached the conclusion that the term kidney disease wasting is not a suitable substitute for PEW. There is a wide variety of causes of PEWand frailty in elderly patients with end-stage renal disease, including genotype, phenotype, comorbid conditions, duration and severity of renal failure, psychosocial problems, and lifestyle, in addition to low anabolic (insulin, growth hormone, and insulin growth factor-1) but high catabolic hormones (parathyroid hormone and glucagon), and age-related mitochondrial dysfunction and oxidative stress. Numerous different terminologies have been used to describe the phenomena of malnutrition and inflammatory wasting coexisting in patients with kidney diseases, such as uremic malnutrition, proteineenergy malnutrition, malnutritioneinflammation atherosclerosis syndrome, and malnutritioneinflammation complex syndrome. Several inflammatory markers, such as C-reactive protein, interleukin-6, tumor necrosis factor-a, interleukin-1, and serum amyloid A, have recently been shown to be associated with concomitant malnutrition and inflammatory wasting. Geriatric Nutritional Risk Index (GNRI) was first used to evaluate malnutrition and related morbidity and mortality in

Febuxostat is superior to traditional urate-lowering agents in reducing the progression of kidney function in chronic kidney disease patients

Abstract The prevalence of hyperuricemia in patients with chronic kidney disease (CKD) is high, but the management is suboptimal under traditional treatment. This study was conducted to clarify whether febuxostat achieves better renal survival and patient outcome compared with traditional urate-lowering agents (ULAs). In total, 2,460 adults who had continuously received ULAs for at least three months before enrollment were investigated. Three groups were compared prospectively including non-conversion (n = 2,214), conversion (n = 206), and febuxostat first (n = 40). We evaluated laboratory changes, estimated glomerular filtration rate (eGFR) change, eGFR decline, renal survival, and all-cause mortality. The Cox proportional hazard risk analysis were also used for risk prediction. Multiple prescriptions for ULAs were found in both the non-conversion and conversion groups. However, improved median eGFR was noted in the febuxostat group (p < 0.001), median serum uric acid (SUA) level decreased from 9.45 to 6.7 mg/dL in the febuxostat group (p = 0.010), and median SUA decreased from 8.5 to 6.3 mg/dL in the conversion group (p < 0.001). Decline rate was retarded in the conversion (p = 0.050). Using the Cox proportional model, the multivariate analysis showed conversion group, young age, and relatively good baseline eGFR were associated with better renal outcome [Hazard ratio (HR) = 0.51, 95% confidence interval (CI) = 0.39–0.69]. Febuxostat had a beneficial effect on renal outcome and hyperuricemia in CKD patients. In summary, our results support the use of aggressive treatment with febuxostat in CKD patients.

In-Hospital Mortality Risk Estimation in Single Episodic Upper Gastrointestinal Bleeding Patients Undergoing Hemodialysis: A Retrospective Cohort Study

BACKGROUND: Upper gastrointestinal bleeding (UGIB) is a major cause of clinical bleeding among patients with end-stage renal disease (ESRD). The purpose of this study was to investigate the association of mortality in uremic patients with single UGIB.METHODS: From 2004 to 2010, a tertiary hospital-based retrospective cohort comprising 244 patients undergoing hemodialysis was investigated. All patients were diagnosed with UGIB according to ICD-9 codes which included peptic ulcer bleeding, duodenal ulcer bleeding, among other symptoms. UGIB was required to be one of the first three discharge diagnoses. Rehospitalization within 3 days after discharge was regarded as the same course. Exclusion criteria were UGI re-bleeding, patients younger than 20 y/o, previous gastric resection or vagotomy, or gastric cancer within the first 2 years of the index hospitalization.RESULTS: The mean age in the group with single UGIB was 71.3 ± 14.7 years. The all-cause mortality was 31.1% (76/244). Using Cox regression models, we found the higher mortality of the single UGIB group was significantly correlated with older age (adjusted hazard ratio [HR] = 1.02, 95% confidence interval [CI] = 1.00-1.04), hepatitis (adjusted HR = 1.96, 95% CI = 1.03-3.71) and albumin ＜ 3 g/dL (adjusted HR = 2.61, 95% CI = 1.44-4.72). Patients with a greater number of infection events during hospitalization were more likely to have poor outcome (crude HR = 1.70, 95% CI = 1.07-2.71). However, after adjustment for covariates, the number of infection episodes was not significantly related to poor outcome.CONCLUSION: In conclusion, single episodic UGIB was correlated with significantly higher mortality in uremic patients during the follow-up. Older age, hepatitis, and albumin ＜ 3 g/dL appeared to worsen all-cause mortality in patients with single UGIB.