Yu-Ji Lee

Health-related quality of life in adults with metabolic syndrome: the Korea national health and nutrition examination survey, 2007-2008.

Background/Aims: An association between metabolic syndrome and impaired health-related quality of life (HRQoL) is still controversial. We investigated the association between metabolic syndrome in itself and HRQoL in the Korean adult population. Methods: The study is a cross-sectional analysis of 8,941 adults ≥19 years of age who participated in the 2007 and 2008 Korean National Health and Nutrition Examination Survey. EuroQoL five-dimension (EQ-5D), the EQ-5D index and the EQ visual analogue scale (EQ VAS) were used to assess HRQoL. Results: The prevalence of metabolic syndrome was 26.2%. Compared to the participants without metabolic syndrome, those with metabolic syndrome were older and comprised a higher proportion of men. Moreover, participants with metabolic syndrome were more likely to have a lower education level, to be current smokers, to have activity limitation and to have more frequent metabolic abnormalities and comorbidities. Metabolic syndrome was associated with HRQoL based on EQ-5D and EQ VAS in simple regression analysis. However, metabolic syndrome was not significantly associated with HRQoL after adjusting for age, sex, smoking status, income, education level, marital status, obesity, diabetes mellitus, stroke, history of heart disease and chronic kidney disease for EQ-5D, and in addition history of depression for EQ VAS. Conclusion: Metabolic syndrome in itself was not associated with impaired HRQoL after adjusting for confounding variables such as socio-demographic factors, medical comorbidities and obesity.

Association between colistin dose and development of nephrotoxicity.

Objective:To investigate the development of nephrotoxicity associated with colistin dose, and whether this relationship differs depending on renal function. Design:A retrospective cohort study of patients who received intravenous colistin to treat infections caused by extensively drug-resistant Gram-negative microorganisms. Adult patients receiving colistin for 72 hours or longer were included in this study. Patients who received renal replacement therapy at baseline or were administered colistin for less than 3 days were excluded. Colistin-induced nephrotoxicity was defined as a doubling of baseline serum creatinine. Colistin dosing was evaluated based on both actual body weight and ideal body weight. Setting:Single general hospital between 2010 and 2013. Patients:A total number of 475 patients received colistin therapy. Of these patients, 329 met the inclusion criteria and were included in the analysis. Interventions:None. Measurements and Main Results:One hundred forty-three patients (43.5%) experienced nephrotoxicity during colistin treatment. The median onset time of nephrotoxicity was 6 days (interquartile range, 4–8 days). The patients with nephrotoxicity were older. Hematocrit and serum albumin levels were lower in patients with nephrotoxicity. Median daily dosing of colistin based on ideal body weight was significantly higher in patients with nephrotoxicity than in those without nephrotoxicity (4.55 vs 4.43 mg/kg/d, respectively; p = 0.021). The cumulative dose was not different between patients with and without nephrotoxicity. In multiple logistic regression analysis, daily colistin dosing based on ideal body weight was only significantly associated with the development of nephrotoxicity in patients with an estimated glomerular filtration rate < 60 mL/min/1.73 m2 (odds ratio, 2.34; 95% CI, 1.22–4.5). In these affected patients, based on a receiver operating characteristic plot, the optimal predictive cutoff of colistin dose for the development of nephrotoxicity was 2.87 mg/kg/d of colistin, with a sensitivity of 92.3% and a specificity of 76.7%. In patients with estimated glomerular filtration rate ≥ 60 mL/min/1.73 m2, age, serum albumin, hematocrit, and use of glycopeptide were associated with the development of nephrotoxicity. Conclusions:Development of nephrotoxicity was significantly more strongly associated with the dose of colistin, but only in patients with an estimated glomerular filtration rate < 60 mL/min/1.73 m2 and not in those with normal renal function.

Randomized trial of cyclosporine and tacrolimus therapy with steroid withdrawal in living-donor renal transplantation: 5-year follow-up

The aim of this study was to compare the long‐term safety and efficacy of immunosuppressive regimens consisting of cyclosporine (CsA) plus mycophenolate mofetil (MMF) or tacrolimus (TAC) plus MMF after steroid withdrawal 6 months after kidney transplantation in low‐risk patients. One hundred and thirty‐one patients were randomized to receive either CsA (n = 63) or TAC (n = 68). Of these, 117 patients satisfied the criteria for steroid withdrawal (no biopsy‐proven rejection episode and serum creatinine level <2.0 mg/dl 6 months after transplantation). Fifty‐five recipients were of the CsA group, and 62 were of the TAC group. The 5‐year graft survival rate did not differ between groups (90.5% vs. 93.3% respectively; P = 0.55). The cumulative incidence of acute rejection 5 years after transplantation was 16.4% and 8.1% for the CsA and TAC groups respectively (P = 0.15). Post‐transplantation diabetes mellitus was more frequent in the TAC group than in the CsA group (P = 0.05), but the incidence of other side‐effects did not differ between groups. In conclusion, CsA‐ and TAC‐based regimens in conjunction with MMF have similar patient‐ and graft survival rates in low‐risk patients who underwent steroid withdrawal 6 months after kidney transplantation.

Potential role of urinary angiotensinogen in predicting antiproteinuric effects of angiotensin receptor blocker in non-diabetic chronic kidney disease patients: a preliminary report.

Objectives Many chronic kidney disease (CKD) patients have persistent overt proteinuria despite angiotensin receptor blocker (ARB) treatment. This study investigated whether the initial difference in intrarenal renin–angiotensin system activity measured with urinary angiotensinogen would affect the antiproteinuric effects of ARB. Methods Between September 2005 and September 2008, in 50 non-diabetic proteinuric CKD patients not taking renin–angiotensin system inhibitors, the urinary protein/creatinine ratio (P/Cr), angiotensinogen/creatinine ratio (AGT/Cr), plasma renin and aldosterone were measured before starting valsartan, and were followed for 18 months. Results Patients were divided into three groups according to their initial urinary AGT/Cr. The urinary P/Cr was lower in the low angiotensinogen group, but similar in the high and extremely high angiotensinogen groups (1.3±0.38 vs 2.0±0.92 vs 2.2±0.78). In all groups, the urinary P/Cr was decreased most for the first 6 months. The urinary P/Cr reduction at 6 months was greatest in the high angiotensinogen group (−24.2% vs −46.2% vs −16.4%). The urinary AGT/Cr was decreased most in the high angiotensinogen group. Renal functional deterioration was attenuated in the high angiotensinogen group compared with the extremely high angiotensinogen group. Conclusions The antiproteinuric effects of ARB were different according to the initial urinary angiotensinogen levels. These results suggest the potential value of the initial urinary AGT/Cr for predicting the therapeutic effect of ARB in proteinuric non-diabetic CKD patients.

Effect of losartan on proteinuria and urinary angiotensinogen excretion in non-diabetic patients with chronic kidney disease

Purpose Activation of the rennin–angiotensin system (RAS) is thought to contribute to hypertension and proteinuria, and eventually to the progression of chronic kidney disease (CKD). Recent evidence suggests that urinary angiotensinogen (UAGT) excretion reflects activation of the intrarenal RAS. This study was performed to determine the effect of losartan on proteinuria and UAGT excretion in non-diabetic patients with CKD with non-nephrotic-range proteinuria. Study design Thirty-two patients with non-nephrotic-range proteinuria (0.045–0.23 g/mmol creatinine) and normal renal function between April 2005 and April 2006 were randomised to a losartan (n=17) or a control (n=15) group. Patients in the losartan group received losartan 50 mg/day, and the doses were titrated up to 100 mg/day after 6 weeks. Serum and urinary angiotensinogen concentrations were measured by sandwich ELISA. The primary end point was the percentage change in proteinuria. The secondary end points were changes in estimated glomerular filtration rate and UAGT excretion. The follow-up period was 24 months. Results Baseline characteristics in the two groups were similar. After 24 months, losartan had reduced urinary protein excretion by 43% (from mean±SD 0.13±0.04 to 0.073±0.03 g/mmol, p<0.0001), but proteinuria had not changed in the control group. The percentage change in mean arterial pressure did not differ between the groups. Losartan decreased logarithmically converted UAGT excretion (from 1.58±0.47 to 1.00±0.52, p=0.001). Estimated glomerular filtration rate decreased significantly only in the control group. Conclusion Losartan significantly decreased proteinuria and UAGT excretion, and preserved renal function in non-diabetic patients with CKD.

The intracavitary ECG method for insertion of a tunneled dialysis catheter without using fluoroscopy.

Purpose Recently, there have been many reports that exact central vein catheter tip positioning was possible using intracardiac electrocardiographic (ECG) monitoring. Ultrasonic guidance in combination with intracardiac ECG monitoring may allow for a tunneled dialysis catheter to be inserted at the bedside without using fluoroscopy. Therefore we report on the intracavitary ECG method for insertion of a tunneled dialysis catheter with ultrasound guidance and the feasibility, safety, effectiveness, complications and limitations of this method. Methods From April 2012 to June 2014, we evaluated 142 hemodialysis (HD) patients who were dialyzed by a tunneled dialysis catheter that was inserted using intracardiac ECG monitoring without fluoroscopic usage. We checked the intracardiac P wave and the point at which it gradually rose to the highest P wave morphology, we stopped inserting the catheter. Results Catheter flow during dialysis was adequate in 139 cases. There were three cases where it malfunctioned. Catheter malposition occurred in 6 out of 142 cases. The correct matching rate between the intracardiac ECG and chest posteroanterior (PA) view was 98.5%. No significant complications developed. Conclusions To conclude, in this single-center study, the intracavitary ECG method for assessing the position of the tip of tunneled dialysis catheter was proven to be safe and feasible in virtually all adult patients who had an evident P wave at the basal ECG tracking.

Evolving appendicitis presenting as culture-negative peritonitis with minimal symptoms in a patient on continuous ambulatory peritoneal dialysis

Culture-negative peritonitis, which results from a variety of etiologies, such as problems in culture techniques, prior use of antibiotics, infection caused by unusual organisms, and noninfectious causes, accounts for up to 20% of cases of peritonitis in peritoneal dialysis patients and sometimes poses diagnostic and therapeutic dilemmas. A 62-year-old woman on continuous ambulatory peritoneal dialysis (CAPD) presented with minimal abdominal pain and a turbid dialysate. Under the impression of infectious peritonitis, empirical intraperitoneal (IP) antibiotic treatment was administered. All cultures from the effluent were negative, although the white blood cell count in the effluent was elevated. Despite initial clinical improvement and resolution of abdominal pain, mild fever persisted, even after removal of the CAPD catheter. The first CT scan before removal of the catheter demonstrated no evidence of intra-abdominal pathology, except for the possibility of peritonitis, but a follow-up CT scan after removal of the catheter demonstrated a perforated appendix with a peri-appendiceal abscess. The patient recovered completely after removal of the appendix and the abscess. This case suggests that a follow-up CT scan and/or surgical exploration should be considered to identify the intra-abdominal pathology in patients with culture-negative refractory peritonitis, even after removal of CAPD catheter.

Value of Doppler evaluation of physically abnormal fistula: hemodynamic guidelines and access outcomes

Background/Aims The strategy of access care at out center involves the use of ultrasound (USG) in case of physical examination (PE) abnormality. USG determines the need of angiography. This study investigated the possible association between the need for percutaneous transluminal angioplasty (PTA) and hemodynamic parameters of USG. The study also assessed the effects of this monitoring strategy on outcomes in comparison with a historical control. Methods A retrospective study of the medical records of 127 patients (65 PTA, 62 non-PTA) was conducted. Data were analyzed using logistic regression analysis and receiver operating characteristic curve. Fistula outcomes and intervention rates were calculated and compared with 100 historic controls. Results Logistic regression analysis showed that brachial artery flow volume (FV) < 612.9 mL/min or brachial artery resistance index (RI) > 0.63 was independently associated with the need for PTA. This monitoring strategy showed an a reduction in thromboses (0.02 ± 0.11 events/arteriovenous fistula [AVF]-year vs. 0.07 ± 0.23 events/AVF-year, p = 0.046), reduction in central venous catheter placement (0.01 ± 0.05 events/AVF-year vs. 0.06 ± 0.22 events/AVF-year, p = 0.010), reduction in access loss (0.02 ± 0.13 events/AVF-year vs. 0.19 ± 0.34 events/AVF-year, p = 0.015), and increase in access selective repair (0.49 ± 0.66 events/AVF-year vs. 0.21 ± 0.69 events/AVF-year, p = 0.003), compared to historic control. Conclusions There was significant stenosis if brachial artery FV was < 612.9 mL/min or RI was > 0.63 for PE abnormality. These parameters should be used as markers for assessing PTA risk in hemodialysis patients. Addition of USG to determine the need of angiography after detection of PE abnormality leads to decreases in access thrombosis, catheter placement, and access loss despite increasing access intervention rates compared to clinical monitoring.

Independent Contributions of Obstructive Sleep Apnea and the Metabolic Syndrome to the Risk of Chronic Kidney Disease

STUDY OBJECTIVES This retrospective study was conducted to evaluate the associations and interactions among obstructive sleep apnea (OSA), chronic kidney disease (CKD), and metabolic syndrome (MS). METHODS This study included 1,732 subjects (1,482 male and 250 female) in whom OSA was diagnosed by polysomnography. The severity of OSA was defined as mild, moderate, or severe with an apnea-hypopnea index (AHI) score of 5 to < 15, 15 to < 30, and ≥ 30 events/h, respectively. CKD was defined as an estimated glomerular filtration rate < 60 mL/min/1.73 m2 or albuminuria. RESULTS The prevalence of MS was 29.2% (n = 505). One hundred twenty-nine subjects (7.4%) had CKD. In subjects with MS, CKD prevalence increased progressively with OSA severity: 7.4%, 12.5%, and 15.8% in those with mild, moderate, or severe OSA, respectively (P = .025). Each 10-point increment in AHI score was independently associated with a 1.15-fold higher prevalence of CKD [95% confidence interval (CI), 1.036-1.280; P = .009] after adjustment for all individual components of MS. On the contrary, in those without MS, AHI was not associated with increased odds for CKD [odds ratio, 1.054; 95% CI, 0.930-1.195]. CONCLUSIONS The independent association between OSA severity and CKD prevalence was observed only in subjects with MS. Further studies are needed to ascertain if OSA contributes to the development of CKD in subjects with MS.

[PP.16.23] REVISED DEFINITION OF PREDICTED LEFT VENTRICULAR MASS USING AMBULATORY BLOOD PRESSURE IN HEALTHY KOREAN ADULTS

Objective: The left ventricular is known to be influenced by both hemodynamic and non-hemodynamic factors. Body size and gender are the most representative non-hemodynamic factors. This study was performed to establish the influences of these variables including ambulatory BP on the variation of the left ventricular mass in healthy Korean adults. Design and method: 627 subjects (male = 270, female = 357), with a normal body mass index and blood pressure, were included in the analysis form database of the Yangpyung Epidemiologic cohort. The left ventricular mass was calculated using the equation: [1.04 × (IVSd + LVDd + PWTd)3-(LDVs3)] × 0.8 + 0.6. The stroke volume was calculated (mL/beat) using Teichholzs formula. The stroke work (SW in gram-meters/beat [g-m/beat]) was computed as ambulatory systolic BP × stroke volume × 0.0144. Results: The stroke work (SW) was the most important factor associated with the LV mass (adjusted R2 = 0.422, p < 0.001), and body weight, age and gender were independent factors (adjusted R2 = 0.524). In a regression model, including stroke work, gender and height2.7, the LV mass was predicted by the equation: 79.4 + 6.35 × height (m2.7) + 0.45 × SW (g-m/beat)-15.6 × gender (male = 1, female = 2)(constant = 79.3 ± 14.7 g, adjusted R2 = 0.517, p = 0.001). Figure. No caption available. Conclusions: In this study using ambulatory BP, as with the previous studies, the stroke work, gender and height2.7 were important determinants of the left ventricular mass in Korean adults with a normal weight and normal blood pressure.