Yuliang Zhao

Is hyperuricemia an independent risk factor for new-onset chronic kidney disease?: a systematic review and meta-analysis based on observational cohort studies

BackgroundHyperuricemia has been reported to be associated with chronic kidney disease (CKD). However whether an elevated serum uric acid level is an independent risk factor for new-onset CKD remained controversial.MethodsA systematic review and meta-analysis using a literature search of online databases including PubMed, Embase, Ovid and ISI Web/Web of Science was conducted. Summary adjusted odds ratios with corresponding 95% confidence intervals (95% CI) were calculated to evaluate the risk estimates of hyperuricemia for new-onset CKD.ResultsThirteen studies containing 190,718 participants were included. A significant positive association was found between elevated serum uric acid levels and new-onset CKD at follow-up (summary OR, 1.15; 95% CI, 1.05–1.25). Hyperuricemia was found be an independent predictor for the development of newly diagnosed CKD in non-CKD patients (summary OR, 2.35; 95% CI, 1.59–3.46). This association increased with increasing length of follow-up. No significant differences were found for risk estimates of the associations between elevated serum uric acid levels and developing CKD between males and females.ConclusionsWith long-term follow-up of non-CKD individuals, elevated serum uric acid levels showed an increased risk for the development of chronic renal dysfunction.

Citrate Versus Heparin Lock for Hemodialysis Catheters: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND Citrate solution has been suggested as an effective and safe catheter lock in hemodialysis. However, whether a citrate lock is superior to a heparin lock in preventing catheter-related infections and maintaining catheter patency is inconclusive. STUDY DESIGN A systematic review and meta-analysis was performed by searching in PubMed, EMBASE, Ovid, the Cochrane Library, and Web of Science databases and major nephrology journals. SETTING & POPULATION Patients receiving hemodialysis with central venous catheters. SELECTION CRITERIA FOR STUDIES Randomized controlled trials comparing citrate locks with heparin locks in hemodialysis patients with central venous catheters. INTERVENTION Locking central venous catheters with citrate locks. OUTCOMES Primary outcomes include catheter-related bloodstream infection (CRBSI), exit-site infection, catheter removal for poor flow, and thrombolytic treatment. RESULTS 13 randomized controlled trials (1,770 patients, 221,064 catheter-days) met the inclusion criteria. Pooled analyses found that citrate locks could significantly reduce the incidence of CRBSI (risk ratio [RR], 0.39; 95% CI, 0.27-0.56; P < 0.001). Subgroup analysis showed that antimicrobial-containing citrate locks (citrate + gentamicin, citrate + taurolidine, and citrate + methylene blue + methylparaben + propylparaben) were superior to heparin locks in the prevention of CRBSI (P < 0.001, P = 0.003, and P = 0.008, respectively), whereas citrate alone failed to show a similar advantage (P = 0.2). Low- (1.04%-4%) to moderate-concentration (4.6%-7%) citrate locks were associated with decreased CRBSI incidence (P < 0.001 and P = 0.003, respectively), but patients receiving high-concentration (30%-46.7%) citrate and heparin locks had similar incidences (P = 0.3). The incidence of bleeding episodes (RR, 0.48; 95% CI, 0.30-0.76; P = 0.002) was significantly lower in patients receiving citrate locks, whereas both groups were similar in terms of exit-site infection (P = 0.2), catheter removal for poor flow (P = 0.9), thrombolytic treatment (P = 0.8), all-cause death (P = 0.3), catheter thrombosis (P = 0.9), mean catheter duration (P = 0.2), CRBSI-free catheter survival (P = 0.2), and catheter-related readmission (P = 0.5). LIMITATIONS All studies used in the meta-analysis were performed in Western countries. The applicability of our findings to other regions remains to be clarified. CONCLUSIONS An antimicrobial-containing citrate lock is better than a heparin lock in the prevention of catheter-related infection, while citrate alone fails to show a similar advantage. Citrate locks of low to moderate concentrations, rather than high concentration, were superior to heparin locks in preventing CRBSI. Citrate locks also might decrease bleeding episodes. No difference has been identified in the efficacy to prevent exit-site infection or preserve catheter patency between citrate and heparin locks.

Recovery from AKI Following Multiple Wasp Stings: A Case Series

BACKGROUND AND OBJECTIVE To observe the outcomes of AKI following multiple wasp stings. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Eighty-one patients (mean age ± SD, 45.5 ± 14.7 years; 55 men and 26 women; mean Acute Physiology and Chronic Health Evaluation II score, 16.85 ± 2.78) with AKI following multiple wasp stings between 1997 and 2011 were retrospectively analyzed. Data on their demographic characteristics, initial modalities of renal replacement therapy (RRT), urine output, serum creatinine, bilirubin, myoglobin, and other variables were collected. Renal outcomes included complete recovery of kidney function, CKD, and death. Subgroup analysis was performed according to initial modality of RRT in the first 48 hours, including continuous veno-venous hemofiltration (CVVH), intermittent hemodialysis (IHD), and CVVH plus plasma exchange (PE). RESULTS Of the 75 patients available for follow-up, 7 (9.3%) died, and 8 (10.7%, all in the IHD group) developed CKD. The average RRT time was 18.2 ± 8.4 days, and the average kidney function recovery time was 36.0 (29.0, 41.0) days. Subgroup analysis showed no difference in the mortality rates between the CVVH, CVVH + PE, and IHD groups (8.0%, 7.1%, and 11.1%, respectively; P>0.99). The recovery time for kidney function was significantly shorter in the CVVH and CVVH + PE groups than in the IHD group (31.9 ± 8.5 days, 28.6 ± 9.4 days, and 41.6 ± 8.1 days, respectively; P<0.001). CONCLUSIONS This is a large case series report on the outcomes of patients with AKI following multiple wasp stings. Most patients survived with complete recovery of their kidney function. Despite the lack of difference in mortality rates, the patients who began RRT with CVVH and CVVH + PE experienced a better and more rapid recovery of kidney function than those initiated with IHD.

Biomarkers upon discontinuation of renal replacement therapy predict 60-day survival and renal recovery in critically ill patients with acute kidney injury: Biomarkers upon discontinuation of RRT

Introduction: There is no consensus on the specific indications for weaning critically ill patients with acute kidney injury (AKI) off renal replacement therapy (RRT). This study aimed to explore the prognostic value of several biomarkers measured upon discontinuation of RRT for their value in predicting 60‐day survival and renal recovery in an effort to add knowledge to the decision‐making process regarding RRT withdrawal.

Portal Vein Thrombosis Secondary to Embolization of Superior Mesenteric Arteriovenous Fistula

Superior mesenteric arteriovenous fistula is a rare vascular disorder. Endovascular embolization has been widely used to treat this disease. Patients receiving successful fistula embolization generally have good prognoses. We present a man with iatrogenic superior mesenteric arteriovenous fistula who received endovascular embolization. Portal thrombus was detected on postoperative day 2, and the patient eventually died of multiple organ failure on postoperative day 13 despite having received antithrombotic and antiplatelet therapy. We identified portal thrombosis as a serious complication of transcatheter superior mesenteric arteriovenous fistula embolization.

Predictive Factors Upon Discontinuation of Renal Replacement Therapy for Long-Term Chronic Dialysis and Death in Acute Kidney Injury Patients

The specific timing for discontinuing renal replacement therapy (RRT) in acute kidney injury (AKI) patients is debatable. The predictive abilities of variables at the time of discontinuation of RRT for the long-term prognoses of patients have not been explored. This study aimed to explore the prognostic factors upon discontinuation of RRT for long-term chronic dialysis and death of patients with acute RRT-requiring AKI, thus improving decision making regarding the discontinuation of RRT and the follow-up of patients thereafter. A cohort of 302 AKI patients who required acute RRT and remained alive and free of dialysis for at least 30 days after discharge from January 2009 to December 2012 were followed up. The predictive abilities of general characteristics, RRT details, and variables upon discontinuation of RRT for long-term chronic dialysis and all-cause death were evaluated using Cox proportional hazards models. Kaplan-Meier analysis with a log-rank test was used to compare the survival curves between the strata of levels of good predictors upon discontinuation of RRT. After a median follow-up time of 4.1 years, 20 (6.6%) patients initiated chronic dialysis and 56 (18.5%) patients died. A higher CysC level upon discontinuation of RRT (HR 1.520, 95% CI 1.082-2.135; P = 0.016), comorbid chronic kidney disease, and a higher non-renal Charlson comorbidity index (CCI) were independently predictive for chronic dialysis. The hemoglobin level upon discontinuation of RRT was inversely predictive of death (HR 0.986, 95% CI 0.973-0.999; P = 0.035), and comorbid malignancy, the presence of multiple organ dysfunction syndrome, and a higher non-renal CCI also predicted death. Urine output upon discontinuation of RRT was marginally inversely predictive of death (HR 0.997, 95% CI 0.994-1.000; P = 0.056). Patients who discontinued RRT with CysC levels <2.97 mg/L, hemoglobin levels >85 g/L, and urine output >1130 mL/24 h showed significantly higher non-chronic dialysis and survival rates according to a log-rank test. Our study suggested that upon discontinuation of RRT, higher serum CysC levels had the most promising predictive value for long-term chronic dialysis, and lower hemoglobin levels predicted long-term death; lower urine output also marginally predicted long-term death. Based on the remission of the comprehensive condition, lower CysC levels and higher hemoglobin levels and urine output should be considered in the decision to stop RRT. Patients showing worse levels of these indices upon discontinuation of RRT should undergo stricter follow-up and treatment to improve long-term outcomes.

Prognostic Biomarkers at Discontinuation of Renal Replacement Therapy in Acute Kidney Injury Patients in the Intensive Care Unit

obtained 16–48 h after the discontinuation of RRT. The levels of serum osteopontin (sOPN), interleukin-6 (IL-6), IL-18, neutrophil gelatinase-associated lipocalin and cystatin C were measured by sandwich enzyme-linked immunosorbent assay or immunoturbidimetric assay. Patients were followed up for 90-day survival. Eleven (26.2%) patients died during follow-up. The mean levels of all biomarkers were higher in death group. Diabetes, Charlson comorbidity index, sepsis, APACHE II score, all biomarkers, sCr and UO were included in the primary logistic regression analysis. By the enter method, the final model identified no sepsis (OR Dear Editor, There remains uncertainty about the optimal timing of discontinuing renal replacement therapy (RRT) in acute kidney injury (AKI) patients in the intensive care unit (ICU) [1] . Conventional indicators such as serum creatinine (sCr) and urine output (UO) may be susceptible and not accurate enough to reflect the progress or repair. Biomarkers are involved in the pathogenesis of AKI [2] . Sensitive and specific novel biomarkers at an early stage of AKI have been reported to be early predictors of the need for RRT [3] . Nevertheless, the predictive values of biomarkers at the time of discontinuing RRT for mid-term survival-related successful weaning of RRT are unknown. To seek biomarker reference indicators for the discontinuation of RRT, we performed a preliminary prospective observational study in the ICUs of West China Hospital of Sichuan University, China. The study was approved by the local ethics Committee and written informed consent was obtained from participants. The study enrolled 42 RRT-requiring AKI patients who weaned and remained independent from RRT or died without requirement of acute re-initiation. RRT was stopped when azotemia, oliguria, acidosis and hyperkalemia were significantly improved. In order to reduce the possible influence of clearance effect of RRT, blood samples were Received: April 28, 2016 Accepted: October 3, 2016 Published online: November 11, 2016

Successful tunneled catheter placement in a hemodialysis patient with idiopathic multiple central venous stenoses

Central venous stenosis (CVS) in hemodialysis patients could be secondary to central venous catheterization, high flow arteriovenous fistula, as well as extrinsic compression. However, we report a senile hemodialysis patient of left internal jugular vein stenosis and right innominate vein occlusion unrelated to any known risk factors. Aided by computed tomography and digital subtraction angiography, we managed to dilate the stenosis by percutaneous balloon angioplasty, followed by successful tunneled catheter placement. Nephrologists should be aware of idiopathic CVS and its impact on the creation and preservation of vascular access. When confronted with difficulties in catheter placement, practitioners need to consider the possibilities of idiopathic CVS and refer to radiological tests.

Systemic sclerosis with thrombotic thrombocytopenia purpura and malignant hypertension.

Thrombotic thrombocytopenia purpura (TTP) is a rare clinical syndrome characterized by microangiopathic hemolytic anemia (MAHA), thrombocytopenia, neurologic symptoms, acute renal impairment, and fever. It has been seldom reported in systemic sclerosis (SSc). Systemic renal crisis is an infrequent complication of SSc, and is characterized by new onset malignant hypertension, rapidly progressive oliguric renal failure, and MAHA. In this study, we present a case of SSc of 1 month duration, with TTP accompanied by new onset malignant hypertension. The patient responded to plasmapheresis but still died of septic shock.