Te Chao Fang

A Cohort Study of Subjective Global Assessment and Mortality in Taiwanese Hemodialysis Patients

Many patients with end-stage renal disease are malnourished, and cross-sectional studies have shown that markers of malnutrition may predict death. In this study, we investigated the possible association of Subjective Global Assessment and mortality in a small cohort of Taiwanese hemodialysis patients. Fifty hemodialysis patients at a hemodialysis center in eastern Taiwan were enrolled in June 2002. Height and weight were used to determine the body mass index. Bioelectrical impedance analysis of body fat mass was performed before and after a mid-week dialysis session. Biochemical indexes of the nutritional status included serum albumin, creatinine, transferrin, cholesterol, and the normalized protein catabolic rate. Mortality data during 42 months after enrollment were obtained. Twenty-six hemodialysis patients were classified as well-nourished and twenty-four as malnourished based on Subjective Global Assessment. Decreased body mass index (pu2009=u20090.006), increased body fat mass (pu2009=u20090.019 before hemodialysis; pu2009=u20090.007 after hemodialysis), decreased serum albumin (pu2009=u20090.011), and decreased serum creatinine (pu2009=u20090.006) were significantly higher in the malnourished group. Older age (pu2009=u20090.042), decreased serum albumin (pu2009=u20090.028), decreased serum transferrin (pu2009=u20090.041), and malnourishment (pu2009=u20090.004) were significantly higher in the mortality group. Multivariate forward stepwise linear regression analysis of mortality and nutrition profiles show that Subjective Global Assessment is the independent predictor of mortality (R2u2009=u20090.20). Malnourished hemodialysis patients had a higher mortality rate than well-nourished hemodialysis patients in Taiwan. Subjective Global Assessment of the nutritional status appears to be a simple tool for assessing the nutritional status of hemodialysis patients in long-term care. This assessment tool is also beneficial for hemodialysis patients who are at a greater risk of nutritional-associated mortality.

The Association of Serum Osteoprotegerin and Osteoporosis in Postmenopausal Hemodialysis Patients: A Pilot Study

AIMnOsteoprotegerin (OPG) is a potent inhibitor of osteoclasts and plays an important role in bone metabolism. Relatively high serum levels of OPG have been observed in postmenopausal women with osteoporosis compared with age-matched controls. No data, however, are available on the relationship between low bone density and serum OPG levels in postmenopausal hemodialysis (HD) patients.nnnMETHODSnThe enrolled subjects included 28 postmenopausal HD patients and 28 age-matched postmenopausal women with normal renal function as controls. Bone mineral density (BMD) was measured by dual energy x-ray absorptiometry (DEXA) in both hips. Low BMD was defined as femoral neck T-score <-2.5. Serum OPG levels were measured using a commercial enzyme-linked immunosorbent assay (ELISA) kit.nnnRESULTSnEight of the age-matched postmenopausal controls (28.6%) and 12 of the postmenopausal HD patients (42.9%) had low BMD. There was no statistically significant difference in low BMD between postmenopausal HD patients and age-matched postmenopausal patients (p = 0.263). The serum OPG level was significantly higher in the postmenopausal HD group (p < 0.001). Increased serum OPG (p = 0.017) and decreased serum albumin (p = 0.021) were significantly correlated with low BMD in postmenopausal HD patients. Univariate linear regression analysis showed that serum albumin (r = -0.455, p = 0.015) was negatively correlated, whereas age (r = 0.423, p = 0.025) and the length of time since menopause (r = 0.397, p = 0.036) were positively correlated with the serum OPG level in postmenopausal HD patients. Multivariate forward stepwise linear regression analysis showed that serum OPG (adjusted R(2) = 0.262, p = 0.003) was an independent predictor of low BMD in postmenopausal HD patients and explained 26.2% of the variance.nnnCONCLUSIONSnSerum OPG is associated with low BMD in postmenopausal HD patients.

Conn's Syndrome with an Unusual Presentation of Rhabdomyolysis Secondary to Severe Hypokalemia

Abstract Conns syndrome is one of the major causes of secondary hypertension. Premature hypertension, metabolic alkalosis, and hypokalemia usually lead clinicians to suspect the diagnosis. We describe a case of Conns syndrome in a 28-year-old woman with an unusual presentation of rhabdomyolysis secondary to hypokalemia and complete bilateral lower limb paralysis. An elevated transtubular potassium concentration gradient, asymptomatic severe hypertension, and metabolic alkalosis pointed to possible primary hyperaldosteronism, which was confirmed by a decrease in plasma renin activity (PRA), elevation in plasma aldosterone level and elevation of the plasma aldosterone to PRA ratio. Computed tomography showed an adrenal tumor in the adrenal gland. Her blood pressure, hypokalemia, and plasma aldosterone level returned to normal after left adrenalectomy, further confirming the diagnosis. Histologic examination showed an adrenal gland adenoma.

Arterial Stiffness in Hemodialysis Patients

Abstract Objectives Increased arterial stiffness is an independent predictor of death from cardiovascular disease, and cardiovascular disease is the leading cause of death among patients with end-stage renal disease. The aim of this study was to compare arterial stiffness in hemodialysis patients. Patients and Methods Serum samples were taken from 42 hemodialy-sis patients with the same high flux artificial kidney. Brachial-ankle pulse wave velocity (baPWV) was measured in the right or left brachial artery to the ankle segments that did not have arteriovenous fistula using an automatic pulse wave analyzer. Plasma adiponectin levels were measured using a commercial enzyme-linked immunosorbent assay kit. Body fat mass was determined using bioelectrical impedance analysis. Results Arterial stiffness was higher in hemodialysis patients (85.7%). Age ( p = 0.018), systolic blood pressure ( p p = 0.007) were higher, and hematocrit ( p = 0.016) was lower in hemo-dialysis patients with arterial stiffness. Plasma homocystine ( p = 0.899), adiponectin ( p = 0.204), C-reactive protein ( p = 0.276), body fat mass ( p = 0.756), total cholesterol ( p = 0.607), triglyceride ( p = 0.737), calcium ( p = 0.698) and phosphorous ( p = 0.629) metabolism were not associated with arterial stiffness in hemodialysis patients. Multivariate forward step-wise linear regression analysis of arterial stiffness showed that systolic blood pressure and age were independent predictors of arterial stiffness in hemodialysis patients and explained 45.8% of the variance in patients with arterial stiffness ( R 2 = 0.458). Conclusion The incidence of arterial stiffness was higher in hemodialy-sis patients. Systolic blood pressure and age were independent predictors of arterial stiffness in hemodialysis patients.

TT Virus Infection in Patients on Peritoneal Dialysis in Taiwan

Many studies have reported the prevalence of transfusion-transmitted virus (TTV) infection in hemodialysis patients, but few reports studied the prevalence of TTV infection in peritoneal dialysis patients. In this study, we determined the prevalence of TTV in a peritoneal dialysis population in Taiwan and related its prevalence with history of blood transfusion, serum hepatitis B surface antigen (HBsAg), antibody to hepatitis C virus (anti-HCV), and serum aminotransferases (AST and ALT) levels. Serum samples from 47 peritoneal dialysis patients and a control group of 43 patients at health examination were studied for TTV viremia by using polymerase chain reaction. The rate of blood transfusion exposure (p < 0.0001), female gender (p = 0.001), younger age (pu2009=u20090.0014), and serum AST level (pu2009=u20090.012) were significantly higher in peritoneal dialysis patients. The prevalence of TTV viremia was not significantly different between peritoneal dialysis patients and the control group (23.4% vs. 37.2%). TTV infection was not associated with evident liver diseases in peritoneal dialysis patients, and the infection rate was not different between automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD) patients. There was no statistically significant association between TTV infection and age, gender, transfusion history, duration of peritoneal dialysis, AST level, ALT level, HBsAg, or anti-HCV seropositivity in peritoneal dialysis patients. Our results suggest that TTV infection is not associated with evident liver diseases, and there is no difference between TTV infection in healthy individuals and peritoneal dialysis patients. TTV transmission probably occurs via routes unrelated to peritoneal dialysis.

Salmonella Emphysematous Pyelonephritis in a Nondiabetic and Non-Obstructive End-Stage Renal Disease Patient

Emphysematous pyelonephritis (EPN) is a rare, severe, and gas-forming infection of the kidney. EPN is common in patients with diabetes mellitus and/or urinary tract obstruction. EPN rarely occurs in patients with end-stage renal disease, and is rarely caused by non-typhoidal Salmonella. This is a case report of end-stage renal disease in a 28-year-old woman who refused regular hemodialysis. She presented with fever, abdominal pain and right flank pain. Unenhanced computed tomography showed air within the right kidney. Salmonella group D was isolated from the drainage. The patient was successfully treated with antibiotics and percutaneous catheter drainage. To our knowledge, this is the first case report in the literature of EPN caused by Salmonella in a patient with end-stage renal disease who did not have diabetes mellitus or urinary tract obstruction.

Bone marrow stem cell therapy for renal regeneration after acute tubular necrosis: A dream or a reality?

Bone marrow transplantation and organ transplantation studies suggest that bone marrow cells can differentiate into a variety of non-hematological tissues, including renal cells. The results of a number of experimental animal studies also showed that cell therapy (bone marrow cells [BMCs], hematopoietic stem cells [HSCs], mesenchymal stem cells [MSCs]) might have the potential to rescue animals from organ injuries. However, when BMCs or HSCs were injected into rodents subjected to ischemic or toxin- induced acute tubular necrosis (ATN), the results with regard to whether they could rescue rodents from ATN were inconsistent. The reasons for the conflicting results of BMC or HSC therapy in ATN are unknown, but may be due to the different types of cells injected, number of cells injected, route of injection, or injury model of acute renal failure. It is known that MSCs can contribute to renal tubular regeneration after ATN, although the exact mechanism, either transdifferentiation or effects of paracrine/cytokines, is uncertain. In the future, the most pertinent issue is to determine how MSCs protect the renal tubule from injury, and then to imitate this protective or reparative effect pharmacologically.

Transfusion-transmitted virus infection in renal transplant recipients in eastern Taiwan

Objective: Many studies have reported the prevalence of transfusion-transmitted virus (TTV) infection in hemodialysis patients but only a few reports have studied the prevalence of TTV infection in renal transplant recipients and none from Taiwan. In this study, we have determined the prevalence of TTV in renal transplant recipients and related its prevalence to history of blood transfusion, serum hepatitis B surface antigen (HBsAg), antibodies to hepatitis C virus (anti-HCV) and serum aminotransferase (AST and ALT) levels in eastern Taiwan. Patients and Methods: Serum samples from 23 renal transplant recipients and a control group of 43 subjects at health examination were studied for TTV viremia using polymerase chain reaction. Results: The proportion of blood transfusions (p＜0.0001) and HCV infection (p=0.048) were significantly higher in renal transplant recipients. Renal transplant recipients had higher mean levels of serum AST (p=0.013) and ALT (p=0.019) than the control group. The prevalence rate of TTV viremia was not significantly different between renal transplant recipients and the control group (34.8% vs 37.2%). TTV infection was not associated with evident liver disease in renal transplant recipients. There was no statistically significant association between TTV infection and age, gender, transfusion history, duration of transplantation, AST level, ALT level, HBsAg or anti-HCV status in renal transplant recipients. Conclusions: These results suggest that TTV infection is not associated with evident liver disease, and the prevalence rate is not different between healthy individuals and renal transplant recipients.