Wen-Yi Li

The 90-day mortality and the subsequent renal recovery in critically ill surgical patients requiring acute renal replacement therapy.

BACKGROUND Particular attention should be paid to postoperative patients that suffer from severe acute kidney injury (AKI) requiring renal replacement therapy (RRT). METHODS This multicenter prospective observational study included 342 patients with postoperative AKI requiring RRT from January 2002 to December 2006. RESULTS There were 137 (40%) survivors at 90 days after the commencement of RRT. Independent predictors of 90-day mortality were older age, presence of sepsis, status post-cardiopulmonary resuscitation, necessity of continuous renal replacement therapy (CRRT), requirement of total parenteral nutrition, lower body mass index, higher Sequential Organ Failure Assessment score, and higher serum lactate level at the commencement of RRT. Further analysis among the survivors showed that lower serum creatinine at intensive care unit admission, lower Simplified Acute Physiology Score II and inotropic equivalent score at the commencement of RRT, and using CRRT were independent predictors for subsequent renal recovery. CONCLUSIONS The development of AKI requiring RRT in postoperative critical patients represents a substantial risk for mortality and morbidity.

Restless legs syndrome in end‐stage renal disease: a multicenter study in Taiwan

Restless legs syndrome (RLS) is an underestimated movement disorder in patients with end‐stage renal disease (ESRD). Several clinical and laboratory factors were inconsistently reported to associate with RLS. We aim to perform a large‐scale multicenter study to investigate the possible associated risk factors of RLS in patients with ESRD in Taiwan, a country with the highest incidence of uremia in the world.

Restless legs syndrome is associated with cardio/cerebrovascular events and mortality in end‐stage renal disease

Earlier studies suggested an association between idiopathic restless legs syndrome (RLS) and cardiovascular diseases. However, the risk of cardiovascular events in patients with secondary RLS due to end‐stage renal disease (ESRD) is unclear. Our aim was to examine whether ESRD patients with RLS had an increased risk of cardio/cerebrovascular events and mortality.

Association of candidate genetic variants with restless legs syndrome in end stage renal disease: a multicenter case−control study in Taiwan

Recent genome‐wide association studies have shown associations between multiple genetic variants and primary restless legs syndrome (RLS). Their roles in end stage renal disease (ESRD) related secondary RLS are not clear and studies in Asian populations are scarce. The association between candidate genetic variants and uremic RLS was investigated in a large cohort of Taiwanese dialysis patients.

A Modified Sequential Organ Failure Assessment Score to Predict Hospital Mortality of Postoperative Acute Renal Failure Patients Requiring Renal Replacement Therapy

Background: A predictive model for hospital mortality in postoperative acute renal failure (ARF) patients requiring renal replacement therapy (RRT) may aid clinicians’ therapeutic decision-making and research design. Methods: A prospective observational study of 398 postoperative ARF patients requiring RRT was conducted in four hospitals. The derivation cohort consisted of 334 patients recruited between January 2002 and December 2005. The validation cohort consisted of 64 patients recruited between January 2006 and December 2006. Results: The hospital mortality rates for the derivation and validation cohorts were 65.6 and 62.5%, respectively. A modified Sequential Organ Failure Assessment (SOFA) score was constructed at the commencement of RRT by a formula of serum lactate level (mM) + 2 × (generic SOFA score) + 3 × (age per decade) + 8 (if mechanical circulatory support required) + 10 (if total parenteral nutrition required) + 11 (if status postcardiopulmonary resuscitation) + 13 (if positive sepsis sign). The area under the receiver operating characteristic curve of the model for the derivation and validation cohorts was 0.804 and 0.839, respectively. Conclusion: This validated score at dialysis commencement might assist clinicians in estimating hospital mortality, planning future clinical trials, and providing quantitative guidance for decision making in postoperative ARF patients requiring RRT.

Randomized Study of Darbepoetin Alfa and Recombinant Human Erythropoietin for Treatment of Renal Anemia in Chronic Renal Failure Patients Receiving Peritoneal Dialysis

BACKGROUND/PURPOSE Darbepoetin alfa can be administered less frequently than recombinant human erythropoietin (r-HuEPO) for the treatment of anemia in chronic renal failure (CRF) patients. We aimed to confirm that darbepoetin alfa at a reduced dosing schedule can safely maintain a target hemoglobin level in CRF patients undergoing peritoneal dialysis. METHODS Forty-five PD patients receiving r-HuEPO were randomized in a 1:1 ratio to continue r-HuEPO or to change to darbepoetin alfa (open-label). Patients were maintained within a target range of haemoglobin for 5.5 months by adjusting the dose and then the frequency of darbepoetin alfa and r-HuEPO over the initial 4 months. The evaluation period was the final 1.5 months. A total of 37 patients completed the study. RESULTS During the evaluation period, the hemoglobin of the darbepoetin alfa group was higher than that in the baseline period (10.46 +/- 0.22 g/dL vs. 9.98 +/- 0.18 g/dL, p < 0.05). Hemoglobin remained similar in the r-HuEPO group. The average dose in the darbepoetin alfa group was 93.0 microg/month, while the average dose in the r-HuEPO group was 18,339.9 units/month. The dosing frequency was less in the darbepoetin alfa group (3.9 times/month vs. 9.2 times/month). We divided the darbepoetin alfa group into low-dose (< 70 microg/month) and high-dose (> or = 70 microg/month) subgroups. The body weight in the high-dose group was higher than that in the low-dose group (66 +/- 11 kg vs. 52 +/- 4.4 kg, p < 0.01). CONCLUSION Both darbepoetin alfa and r-HuEPO safely maintain hemoglobin levels within the target range in peritoneal dialysis patients.

Candida tropicalis-associated bilateral renal papillary necrosis and emphysematous pyelonephritis.

Although the kidney is often involved in disseminated and localized candidiasis, bilateral emphysematous pyelonephritis (EPN) is infrequently reported. Renal papillary necrosis (RPN) caused by fungi is also rare. We describe a patient with bilateral RPN and EPN caused by Candida tropicalis, who suffered from recurrent hematuria, flank pain, acute fulminant renal failure, and obstruction by a sloughed papilla. He was treated successfully with antifungal therapy and percutaneous nephrostomy (PCN). This is the first case report of C. tropicalis-associated EPN and RPN.

Residual Urine Output and Postoperative Mortality in Maintenance Hemodialysis Patients

BACKGROUND The relationship between residual urine output and postoperative survival in maintenance hemodialysis patients is unknown. OBJECTIVE To explore the relationship between amount of urine before surgery and postoperative mortality and differences between postoperative nonanuria and anuria in maintenance hemodialysis patients. METHODS A total of 109 maintenance hemodialysis patients underwent major operations. Anuria was defined as urine output <30 mL in the 8 hours before the first session of postoperative dialysis. Propensity scores for postoperative anuria were developed. RESULTS Postoperative residual urine output was 159.2 mL/8 h (SD, 115.1) in 33 patients; 76 patients were anuric. Preoperative residual urine output and adequate perioperative blood transfusion were positively related to postoperative urine output. Propensity-adjusted 30-day mortality was associated with postoperative anuria (odds ratio [OR], 4.56; 95% confidence interval [CI], 1.16-17.96; P = .03), prior stroke (OR, 4.46; 95% CI, 1.43-13.89; P = .01) and higher disease severity (OR, 1.10; 95% CI, 1.00-1.21; P = .049) at the first postoperative dialysis. OR of 30-day mortality was 5.38 for nonanuria to anuria vs nonanuria to nonanuria (P = .03) and 5.13 for preoperative anuria vs nonanuria to nonanuria (P = .01). By Kaplan-Meier analysis, 30-day mortality differed significantly among patients for nonanuria to nonanuria, anuria, and nonanuria to anuria (log rank, P = .045). CONCLUSION Patients with preoperative nonanuria and postoperative anuria had higher mortality than did patients with no anuria before and after surgery and patients with anuria before surgery. Postoperative residual urine output is an important surrogate marker for disease severity.

Impact of weaning from acute dialytic therapy on outcomes of chronic kidney disease following urgent-start dialysis.

Discontinuation of acute, unplanned dialysis is always an important therapeutic goal in dialysis-requiring patients with existing chronic kidney disease. Only a limited proportion of patients could be weaned off dialysis and remained dialysis-free. Here we performed a multicenter, observational study to investigate factors associated with successful weaning from acute dialysis, and to explore the potential impact of weaning itself on outcomes of patients with chronic kidney disease following urgent-start dialysis. We recruited 440 chronic kidney disease patients with a baseline estimated glomerular filtration rate <45 ml/min per 1/73 m2, and used propensity score-adjusted Cox regression analysis to measure the effect of weaning from acute dialysis on death during the index hospitalization and death or readmission after discharge. Over 2 years, 64 of 421 (15.2%) patients who survived >1 month died, and 36 (8.6%) were removed from dialysis, with 26 (6.2%) remaining alive and dialysis-free. Logistic regression analysis found that age ≧ 65 years, ischemic acute tubular necrosis, nephrotoxic exposure, urinary obstruction, and higher predialysis estimated glomerular filtration rate and serum hemoglobin were predictors of weaning off dialysis. After adjustment for propensity scores for dialysis weaning, Cox proportional hazards models showed successful weaning from dialysis (adjusted hazard ratio 0.06; 95% confidence interval 0.01 to 0.35), along with a history of hypertension and serum albumin, were independent protectors for early death. Conversely, a history of stroke, peripheral arterial disease and cancer predicted the occurrence of early mortality. In conclusion, this prospective cohort study shows that compared to patients with chronic kidney disease who became end-stage renal disease after acute dialysis, patients who could be weaned off acute dialytic therapy were associated with reduced risk of premature death over a 2-year observation period.

Primary renal lymphoma.

A 55-year-old woman presented with low grade fever and frequent night sweating of one month’s duration. Laboratory data showed severe anaemia (haemoglobin: 74 g/l) with low reticulocyte count 67Æ54 · 10/l (2Æ2%) and elevated lactate dehydrogenase (1174 U/l) without leukocytosis (white blood cell count: 6Æ56 · 10/l). There was no history or evidence of recent blood loss. Microbiological studies and immunological profiles were unremarkable. Abdominal computed tomography with contrast enhancement (left figure) demonstrated a heterogenous hypodense renal tumour occupying the right renal sinus. In addition, right renal vein encasement and inferior vena cava invasion (arrow) were noted, accompanied by multiple enlarged para-aortic lymph nodes (arrow heads). Doppler sonography (right figure) showed a hypovascular mass (arrow heads) with surrounding hydrocalyces (arrows). Tissue sampling was achieved by open laparotomy. Histopathology with immunochemical staining revealed a diffuse large B-cell lymphoma with positive CD20 expression, confirming the diagnosis of primary renal lymphoma. One month after rituximab-based chemotherapy, the patient became apyrexial with concurrent regression of the renal tumour. Primary renal lymphoma is rare and may present with acute renal failure of flank pain or as an incidental renal mass. Typical image findings on a colour Doppler ultrasound consist of a hypoechoic mass with hypovascularity, in contrast to the hypervascular pattern of most renal cell carcinomas. Most primary renal lymphomas are highly chemo-sensitive as demonstrated in this case.