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End stage renal disease (ESRD) is followed by disturbed adaptive immunity, together with alterations in T cell subsets, including CD4+CD25+FoxP3+ cells (Tregs). In the present study, we assessed the effect of haemodialysis (HD) on the Treg population. CD3+CD4+, CD3+CD8+ and CD4+CD25+FoxP3+ cells were estimated by flow cytometry in 142 ESRD patients (45 ESRD-preHD, 97 on HD) and 30 healthy controls (HC). Patients on HD were classified into three groups according to time on dialysis (HD vintage - HDV): A 2 years, B: 2-5 years and C:5 years on HD. The mean age of patients on HD (M/F 53/44) was 54.8 ± 14 years and the median HDV 58 (78) months. We observed a significant progressive reduction in the percentage and count of lymphocytes (p .001, p .001, respectively), CD3+CD4+ (p = .003 and, p .001, respectively) and Tregs (p = .001 and, p .001, respectively), between HC, ESRD-preHD and HD patients. HDV had a significant inverse correlation with total lymphocyte, CD3+CD4+ and Treg cell counts (p = .001, p .001, p .001, respectively) and, the percentage of lymphocytes and CD3+CD4+ cells (p = .005, p = .01, respectively). Furthermore, we stratified patients on HD into three groups according to HDV: A 2 years, B: 2-5 years and C:5 years on HD. Total lymphocytes and Tregs were significantly different among the three vintage groups (Kruskal-Wallis H test, p .001, p .001 respectively). CD3+CD4+ and CD3+CD8+ cells were also significantly affected (p .001 and p = .001, respectively), after at least 2 years of HD. Tregs show prompt and significant reduction at the pre-dialysis stage, and continue to decrease gradually even after long-term HD, in a context of total lymphocyte reduction.

Background T-cell immunity is affected in end stage renal disease (ESRD). However, whether this happens at pre- or post-dialysis stage and what is the impact of different renal replacement methods, remains unclear. We investigated the alterations of T-cell subtypes in patients at pre-dialysis ESRD and their further changes during dialysis. Methods CD4+, CD8+, CD4 + CD28null and CD8 + CD28null T-cells were analysed in 40 ESRD patients at two different time points, (a) the day started on dialysis (ESRD-T0) and (b) 6 months later (ESRD-T6), while being on haemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD). Twenty-five age matched healthy volunteers served as controls. Results CD4+ and CD8+ T-cells were significantly reduced in ESRD-T0 patients compared to controls, 604 (105-3551) vs 943 (584-1867)μ/L, P = .001, and 352 (103-1561) vs 422.4 (263-1453)μ/L, P = .05, respectively. However, proportions of CD4 + CD28null and CD8 + CD28null cells were significantly increased, 6.4 (0.3-30)% vs 2.7 (0.1-7.8)%, P = .04 and 58.2 (12.8-85.4)% vs 39 (7.8-57.1)%, P = .01, respectively. Proportion of CD4 + CD28null cells showed significant correlation with serum CRP (r = .4, P = .04) and albumin levels (r = -.5, P = .007) in ERSD patients. ESRD-T0 patients with cardiovascular disease (CVD) had increased CD4 + CD28null and CD8 + CD28null proportions, 8.6 (1-30)% vs 2.1 (0.1-19.8)%, P = .04 and 62.5 (12.8-85.4)% vs 45.5 (5.7-73.7)%, P = .02, respectively, compared to those without. Six months later, both CD4 + CD28null and CD8 + CD28null T-cells were increased in HD compared to CAPD patients, by +110.11 (-27.1 to 311.4)% vs -28.1 (-100 to 30)%, P = .003 and +55.23 (-29.06 to 197.93)% vs -8.34 (-54.99 to 66.72)%, P = .05, respectively. Conclusions CD4 + CD28null and CD8 + CD28null T-cells are increased at pre-dialysis ESRD, and correlate with chronic inflammatory markers and the presence of CVD. Dialysis methods seem to have different impact on these subpopulations.

AIM Vascular calcification has played a vital role in increasing the prevalence of cardiovascular disease (CVD) and mortality in maintenance haemodialysis (MHD) patients. This study is aimed at exploring the prognostic value of abdominal aortic calcification (AAC) estimated by plain lateral abdominal radiography in MHD patients. METHODS Lateral abdominal radiography was used to determine the abdominal aortic calcification score (AACS). The serum level of fibroblast growth factor-23 was tested by enzyme-linked immunosorbent assay. Patients were divided into two groups: no or minor calcification group (AACS

AIM Laboratory deficit-based frailty index (LFI) exhibited outcome-prediction ability in the elderly, but not in those with end-stage renal disease (ESRD). We hypothesized that LFI results might have outcome correlation and correlate closely with other instruments in ESRD patients. METHODS We prospectively enroled ESRD patients between 2014 and 2015 and administered self-report frailty instruments (Strawbridge questionnaire, Edmonton frail scale (EFS), Groningen frailty indicator (GFI), Tilburg frailty indicator, G8 questionnaire and FRAIL scale), and Cardiovascular Health Study (CHS) scale, with two types of LFI calculated. They were followed up until June 30, 2017. Correlations between the results of six instruments, CHS scale, and those of LFI were identified, followed by Kaplan-Meier survival analyses and logistic regression analyses to compare those with high and low LFI. RESULTS The frailty prevalence was 33.3% (CHS), 78.8% Strawbridge questionnaire, 45.5% (EFS), 57.6% (GFI), 27.3% (Tilburg frailty indicator), 84.8% (G8) and 18.2% (FRAIL) among ESRD participants. LFI-1 results were significantly correlated with those of LFI-2 (P

Aim To investigate if calcification and intimal media thickness (IMT) of arteries are present in children and adolescents with end-stage renal disease and to describe the risk factors associated with these alterations. Methods In an observational, cross-sectional prospective study, 68 patients were evaluated at the time of renal transplantation. A fragment of the inferior epigastric artery was removed during surgery for histopathological analysis to verify the presence or not of arterial calcification. Two outcomes were considered: the presence of calcium deposition and the measurement of the IMT of the artery. The potential exposure variables were: age, chronic kidney disease aetiology, diagnosis time, systolic blood pressure (SBP), use of oral active vitamin D, homocysteine and C-reactive protein. Results No arterial calcification was observed in the studied sample. The median value of the IMT of the inferior epigastric artery was 166 μm (interquartile range = 130-208). SBP standard deviation score and age were the only factors associated with this outcome. There was no statistical interaction between SBP and age with the IMT (P = 0.280). Conclusion Arterial calcification is rare in children and adolescents with end-stage renal disease. The factors associated with IMT were age and SBP.

In Singapore, most elderly end-stage renal disease (ESRD) patients choose dialysis over palliative management. However, dialysis may not be the optimal treatment option given only moderate survival benefits and high costs and treatment burden compared to non-dialysis management. Elderly patients may therefore come to regret this decision. This study investigated: (i) extent of patients' decision regret after starting dialysis, and (ii) potentially modifiable predictors of regret: satisfaction with chronic kidney disease education, decisional conflict, and decision-making involvement.The present study was a cross-sectional study of 103 dialysis patients above 70 years of age, surveyed at Singapore General Hospital's renal medicine clinics between March and June 2017. Participants reported their levels of decision regret on the Decision Regret Scale (DRS), retrospective decisional conflict on the Decisional Conflict Scale, information satisfaction, and decision-making involvement.In total, 81% of participants reported no decision regret (DRS score 50), 11% ambivalence (DRS = 50), and 8% regret (DRS50). In individual DRS items, 19% felt dialysis had done them harm and 16% would not make the same decision again. In multivariable analyses, lower information satisfaction [b = -0.07 (95% CI: -0.13, -0.01)] and decisional conflict [b = 0.004 (95% CI: 0.002, 0.006)] were significantly associated with decision regret.Although the majority of elderly dialysis patients were comfortable with their decision to start dialysis, a proportion was ambivalent or regretted this choice. Regret was more likely among those who experienced decisional conflict and/or expressed poorer information satisfaction. Healthcare professionals should recognize these risk factors and take steps to minimize chances of regret among this population subset.

Aim Data on the changing levels in renal morbidity and mortality are scant globally. We sought to assess trends in renal disease mortality and attributable causes over a 20 year period in Ghana. Methods A retrospective analysis of 20 year autopsy records of the Pathology Departments of leading teaching hospitals in Ghana, (Korle-Bu Teaching Hospital (KBTH) in Accra and Komfo Anokye Teaching Hospital (KATH) in Kumasi) from January 1994 to December 2013. Data comprising autopsies from in-patients, community cases and coroners' cases were used. We defined primary cause of death as death directly due to renal disease and secondary cause of death as death in which renal disease was a comorbid or contributing factor. Results Over the period, there were a total of 94 309 deaths, of which 5608 were attributed to renal disease (5.9/100). Mortality rate remained fairly the same from 1994 to 2009 (5.0%), but doubled from 2010 to 2013 (10.8%). Similar trends were observed among males and females during the same period. However, males had slightly higher mortality rates (6.6%; 95% CI: 46.1%-6.8%) compared to females (5.6%; 95% CI: 5.4%-5.8%; P = 0.271). The major leading attributable causes of renal disease death include end stage renal disease 45.0% and acute pyelonephritis accounting for 20.9% of the cases. Hypertensive heart disease accounted for 30.0% of all secondary cause of death while congestive heart disease and septicaemia accounted for 13.0% and 12.0%, respectively. Conclusions We observed marked increase in the renal disease mortality rate during the last few years predominantly driven by chronic and infectious related renal diseases as a main cause, and hypertensive heart disease and congestive heart failure as the main secondary causes. Measures geared towards prevention, treatment and managing such conditions may impact on the reduction of renal disease mortality rate among Ghanaian populations.

Aim There is conflicting evidence regarding the safety and effectiveness of warfarin for atrial fibrillation (AF) treatment among older end-stage renal disease (ESRD) patients, and differences among subgroups are unclear. Methods Older dialysis patients who were newly diagnosed with AF (7/2007-12/2011) were identified in the United States Renal Data System. The adjusted hazard ratios (HR) of the outcomes (any stroke, ischaemic stroke, major bleeding, severe gastrointestinal bleeding, and death) by time-varying warfarin use were estimated using Cox regression accounting for the inverse probability of treatment weight. Results Among 5765 older dialysis patients with incident AF, warfarin was associated with significantly increased risk of major bleeding (HR = 1.50, 95% CI 1.33-1.68), but was not statistically associated with any stroke (HR = 0.92, 95% CI 0.75-1.12), ischaemic stroke (HR = 0.88, 95%CI 0.70-1.11) or gastrointestinal bleeding (HR = 1.03, 95% CI 0.80-1.32). Warfarin use was associated with a reduced risk of mortality (HR = 0.72, 95%CI 0.65-0.80). The association between warfarin and major bleeding differed by sex (male: HR = 1.29; 95%CI 1.08-1.55; female: HR = 1.67; 95%CI 1.44-1.93; P-value for interaction = 0.03). Conclusion Older ESRD patients with AF who were treated with warfarin had a no difference in stroke risk, lower mortality risk, but increased major bleeding risk. The bleeding risk associated with warfarin was greater among women than men. The risk/benefit ratio of warfarin may be less favourable among older women.

Aims: Cardiovascular disease (CVD) is the leading cause of mortality in patients with end‐stage renal disease (ESRD) receiving maintenance hemodialysis treatment. This study investigated the effect of a 12‐week intradialytic progressive resistance training (PRT) intervention on pulse wave velocity (PWV) and associated hemodynamic, anthropometric, and hematologic outcomes in patients with ESRD. Method: Twenty‐two patients with ESRD (59% men, 71.3 ± 11.0 years) were recruited. Supervised PRT (3 sets of 11 exercises) was prescribed three times per week during routine dialysis. The primary outcome was brachial‐ankle PWV via applanation tonometry. Secondary outcomes included augmentation index, brachial and aortic blood pressures, endothelial progenitor cells, C‐reactive protein, blood lipids and anthropometrics. Results: The intradialytic PRT regimen resulted in no significant change in PWV between control and intervention periods [mean difference = 0 (95% CI = ‐0.1 to 0.1); P=0.58]. Similarly, no significant change was noted in any secondary outcome measures between the control and intervention periods. Post‐hoc analyses limited to high adherers (≥75% attendance; n=11) did not differ from the primary analysis, indicating no dose‐response effect of our intervention Conclusion: Our 12‐week PRT intervention did not change PWV or any secondary outcomes. Future studies should determine if higher dosages of intradialytic PRT (i.e. longer duration and/or higher intensity) can be applied as a method improve arterial stiffness to potentially reduce cardiovascular disease and associated mortality this cohort Refereed/Peer-reviewed

Aim This study was designed to investigate the impact of pediatric end-stage renal disease (ESRD) on parents, based on the PedsQL™ Family Impact Module (FIM), and the relationship to the quality of life (QOL) of pediatric ESRD patients measured by PedsQLTM 3.0 ESRD module. Methods We performed a cross-sectional study using Korean translations of the PedsQLTM FIM and the PedsQLTM 3.0 ESRD module. In all, 79 patients were enrolled, including 47 children receiving dialysis and 32 children who underwent renal transplant. Results FIM scores, analyzed for every category according to treatment modality, were significantly lower in hemodialysis (HD) than in peritoneal dialysis (PD) or renal transplant patients. Mother's age, duration since diagnosis of ESRD and the existence of comorbidity were variables to have significant effects on FIM scores. The correlation between total FIM and QOL scores of pediatric patients were significant, in both parent-proxy and child-self report. Conclusions The PedsQL™ FIM appears to be a useful tool for the assessment of family impact on children with ESRD. Further prospective studies focused on the QOL of parents and caregivers should be performed with the goal of improving clinical outcomes for pediatric ESRD patients.

Aim Patients with diabetic end-stage renal disease (ESRD) are at increased risk of lower extremity amputation (LEA) and postoperative complications compared to those without diabetic ESRD. This study sought to determine the factors that influence complications following LEA in patients with diabetic ESRD. Methods A total of 41 patients with diabetic ESRD (total of 46 amputations) who underwent LEA were enrolled in this study. The electronic medical records were retrospectively reviewed to identify the predictors of postoperative complications. The outcomes were divided into three categories: no complications, minor complications (wounds requiring only local care or oral antibiotics), and major complications (requiring surgical intervention, further amputations, or inducing life-threatening morbidities and mortalities). Results Multivariate logistic regression analysis demonstrated that underlying sepsis (p = 0.007) was the only significant risk factor for major complications, with an odds ratio demonstrating an 8.16 times increased risk of requiring another surgery or mortality compared to those without sepsis. Conclusion Preoperative sepsis is an independent risk factor for major complications after LEA in patients with diabetic ESRD. We advise particular caution when performing LEA in diabetic ESRD patients who are also septic. Early amputation, prior to the development of sepsis, is preferable.

AIM Anti-glomerular basement membrane (GBM) disease is an autoimmune disorder with rapidly progressive glomerulonephritis and alveolar haemorrhage. Fever symptoms and prodromal infections have been reported in many cases, but still not been elucidated. METHODS Our study enrolled 140 consecutive patients with anti-GBM disease and retrospectively analyzed the characteristics of fever symptoms and the possible reasons. RESULTS Among the 140 patients, 94 (67.1%) patients presented with fever (over 37.5°C) prior to admission or within 48 h of hospitalization. Among those with fever, 74 (78.7%) patients had infections, 15 (16.0%) patients had positive serum anti-neutrophil cytoplasmic antibodies, all towards myeloperoxidase, which was comparable to the patients without fever (17.4%, P = 0.830). There were 93/140 patients suffered from infections, with 47.3% in lungs and 31.2% on upper respiratory tract. In some cases, we identified the microbes of infections, including Candida albicans, Escherichia coli, Acinetobacter baumannii, Enterococcus faecalis, Klebsiella pneumoniae, Hemolytic staphylococci, Pseudomonas aeruginosa and Citrobacter braakii. Patients with fever had higher levels of serum anti-GBM antibodies (154.9 ± 58.4 vs. 106.0 ± 63.2 IU/mL, P < 0.001), higher serum creatinine (733.4 ± 402.5 vs. 580.6 ± 368.1 μmol/L, P = 0.032), higher percentage of crescents (87.0 ± 15.6 vs. 67.4 ± 37.6%, P = 0.021), and higher frequency of progression to end stage renal disease (ESRD) (80.9% vs. 60.9%, P = 0.011). CONCLUSION We concluded that fever is a common symptom in anti-GBM disease and associates with more severe glomerulonephritis. The majority of patients at presentation had fever with respiratory tract infections, which needs further investigation to reveal their role in the pathogenesis of anti-GBM disease.

Aim The TTC21B gene is now known as causative of nephronophthisis-related ciliopathies (NPHP-RC). We reported two Chinese pediatric cases with end-stage renal disease and other phenotypes caused by the TTC21B gene mutations. Methods The clinical features of Chinese pediatric cases with NPHP-RC were summarized. Mutation analysis of the TTC21B gene was performed using next-generation sequencing. Results The two cases both had nephrotic proteinuria, renal failure, hypertension and abnormal liver function (or hepatic fibrosis). One case also presented situs inversus and short phalanges. They developed end-stage renal disease (ESRD) at 1 year old and 8 years old, respectively, when renal pathology both showed focal segmental glomerular sclerosis (FSGS) with tubulointerstitial lesions including interstitial fibrosis and atrophic tubules. Three novel disease-causing TTC21B mutations were identified. One case carried homozygous mutation c.2211 + 3A > G, while the other case carried compound heterozygous mutations c.1552 T > C (p.C518R) and c.1456dupA (p.R486KfsX22). Conclusion Mutations in TTC21B cause a range of ciliopathy phenotypes in humans. We identified 3 novel TTC21B mutations in two Chinese pediatric cases that both presented end-stage renal disease and other different features. This is the first TTC21B mutations ever reported in China.

Aim This study aimed to investigate sensitive factors involved in left ventricular mass reduction in children with end-stage renal disease (ESRD) undergoing peritoneal dialysis. Methods Thirty-five subjects on peritoneal dialysis were enrolled. Two successive echocardiographic and clinical data for each subject were obtained. Blood pressure and left ventricular mass index (LVMI) were indexed through a division with the normal 95th percentile value. Differences in numeric data between two datasets were calculated. Results The mean age was 12.9 ± 4.6 years. Predictors of left ventricular hypertrophy and its persistence were systolic blood pressure index (P = 0.019 and P = 0.046) and E' velocity (P = 0.035 and P = 0.031) in univariate analysis. However, differences in these predictors between the datasets were not related to the change in indexed LVMI. Reduction in indexed LVMI was correlated to a reduction of indexed left atrial volume (R = 0.638, P = 0.001), trans-mitral A velocity (R = 0.443, P = 0.011), and serum blood urea nitrogen level (R = 0.372, P = 0.028) and an elevation of haemoglobin level (R = -0.374, P = 0.027). Conclusion The extent of circulating volume expansion is potentially the main predictive factor for change of LVMI, because the volume dependent diastolic functional variables correlate to the change of LVMI. Further study with a large number of ESRD children including a group under fluid volume control is needed to investigate the role of volume expansion on the change of LVMI.

Aim Proteinuria is known to be an independent risk factor of end-stage renal disease (ESRD). But the associations between changes in dipstick proteinuria and the risk of ESRD in the general population and its appropriate observation period to predict incident ESRD are unknown. Methods We assessed the changes in dipstick proteinuria in 69021 subject aged ≥20 years who participated in health check-up from 1993 and more than once until 1996 in Okinawa, Japan. Development of ESRD until 2011 was identified using dialysis registry. Cox proportional hazards model and receiver operating characteristic (ROC) curve were used. Results At baseline, proteinuria (±) and ≥(1+) were observed in 2.4% and 1.2% of total subjects. 1.5% of subjects had decreased and 9.4% of subjects had increased their proteinuria level after 2-year. After adjustment for confounding factors, hazard ratios (95% confidence interval) of ESRD for subjects with proteinuria change ≤-1, +1, +2, +3, and +4 level during 2-year compared to subjects with no change were 0.89 (0.43-1.87), 3.18 (2.21-4.60), 8.01 (5.55-11.55), 11.17 (6.59-19.95), and 16.59 (5.95-46.25), respectively. Heterogeneity existed between changes in proteinuria level during 1- or 3-year and the risk of ESRD among baseline proteinuria. Area under the ROC curve (95%CI) to predict ESRD by increase in proteinuria level during 1-, 2-, and 3-year were 0.650 (0.623-0.679), 0.779 (0.751-0.808), and 0.778 (0.748-0.808), respectively. Conclusions The changes in dipstick proteinuria were an independent predictor of ESRD in the general population. Changes in proteinuria during 2-year may be appropriate for the risk prediction of ESRD.

International audience; Aim: Daily haemodialysis improves patients' quality of life and blood purification, but its effect on survival remains controversial. The aim of this study was to analyze the association between daily haemodialysis and renal transplantation and survival in France.Methods: This was an observational cohort study based on the French REIN registry. All incident patients 18 years old who started daily haemodialysis in France between 2003 and 2012 were included. Using a propensity score, 575 patients on daily haemodialysis were matched with 1696 patients receiving thrice-weekly haemodialysis. Survival analysis was performed using the Cox model. Access to the renal transplant waiting list and renal transplantation were analyzed using the Fine and Gray model.Results: Daily haemodialysis was not independently associated with reduced access to transplant waiting list, whereas, major comorbidities remained associated with restricted waitlisting after multivariate analysis adjusted for confounding factors. After being waitlisted, the cumulative incidence of renal transplantation was lower for the daily haemodialysis than for the thrice-weekly haemodialysis group (SHR=0.72, 95%CI 0.56-0.91). The risk of death was significantly higher in the daily haemodialysis group (HRadjusted=1.58, 95%CI 1.4-1.8). Major comorbidities were associated with higher risk of death and lower likelihood of receiving a renal transplant during the follow-up period.Conclusion: Our study showed that in France, the likelihood of undergoing renal transplantation after being waitlisted was lower for patients on daily haemodialysis than those on thrice-weekly haemodialysis. Moreover, daily haemodialysis was associated with higher risk of death, even after taking into account age and all major comorbidities.

Aim Catheter malfunction is the main reason for early peritoneal dialysis (PD) technique failure. This study aimed to evaluate the effect of a new surgery technique with catheter fixation to the lower abdominal wall combined with straight upward tunnel and low implant position in reducing catheter malfunction. Methods Patients with end stage renal disease who received PD in our centre from January 2013 to December 2015 were involved in this study. They were randomly divided into three groups according to surgical technique: traditional open surgery group, modified open surgery group and modified open surgery with catheter fixation group. All patients were followed up for six months after surgery. Catheter- related complications were analyzed. Results A total of 152 patients were involved. Among them, 49 received traditional open surgery (TOS group), 49 received modified open surgery (MOS group), and 54 received modified open surgery with catheter fixation (MOS-F group). During follow-up, no patients (0%) in MOS-F group developed catheter malfunction which was significantly lower than that of the TOS group (0 vs 16.33%, P = 0.002). Although not statistically significant, the incidence of catheter malfunction was lower in MOS-F group than that in MOS group (0 vs 4.08%, P = 0.134). No significant difference was observed in the episodes of infection, bleeding, leakage, inflow or outflow pain, hernia and delayed wound healing among the three groups (all P > 0.05). Conclusions Catheter fixation combined with straight upward tunnel and low implant position can effectively prevent catheter malfunction in PD catheter placement.

AIM Increased oxidative stress significantly modifies the outcome of patients with diabetes mellitus (DM) and end-stage renal disease (ESRD), and is counteracted by antioxidative capacity. We aimed to investigate whether antioxidant single nucleotide polymorphisms (SNPs) influence the outcome of ESRD individuals and the influences exerted by DM, which has not been tested before. METHODS We prospectively enrolled multi-centre ESRD patients of Han Chinese origin between 2002 and 2003, recording their antioxidant (superoxide dismutase [SOD2], glutathione peroxidase [GPX1]) and peroxisome proliferator activated receptor-γ (PPAR-γ) genotyping results, and stratified based on DM. They were followed up until 2008, with risk factors for mortality analyzed by Cox proportional hazard regression. RESULTS We discovered that diabetic ESRD carriers of CC genotype of SOD2 exon 2 had an increased risk of mortality compared to non-diabetic ones with other genotypes (hazard ratio [HR] 4.04, P = 0.04), while GPX1 SNPs had no influence. Interactions between SOD2 and PPAR-γ SNPs regarding the mortality influence were also detected (for SOD2 CC genotype x PPAR-γ exon 6 CT genotype, HR 3.19, P = 0.008), suggesting the importance of considering a combination panel of SNPs on patient survival. CONCLUSION This might be the largest study focusing on the relationship between antioxidant SNPs and the outcomes of diabetic ESRD patients of Han Chinese origin. More studies are needed to validate our findings.

Background Patients with end-stage renal disease (ESRD) who received parathyroidectomy (PTX) had persistently reduced levels of parathyroid hormone. The study investigated the risk of acute coronary syndrome (ACS) in patients with ESRD who underwent PTX using a nationwide health insurance claims database. Methods Of all ESRD patients, we selected 1047 individuals who had undergone PTX between 2000 and 2008 as the PTX group and 4188 patients who did not undergo PTX (non-PTX group) matched by propensity score. Multivariable Cox proportional hazards regression analysis was conducted for assessing the excess ACS risk for the PTX group compared to the non-PTX group. Results The mean follow-up periods were 4.63 and 4.04 years for the PTX and non- PTX groups, respectively. A significant reduction in the risk of ACS (adjusted hazard ratio = 0.74, 95% confidence interval = 0.57-0.96) was observed for the ESRD patients after PTX. Conclusions PTX is associated with reduced risk of ACS in patients with ESRD.

Aim Autosomal dominant polycystic kidney disease (ADPKD), a systemic disorder caused by mutation in genes encoding polycystins, has been reported to lead to metabolic derangements including new-onset diabetes mellitus after kidney transplantation. We analyzed markers of insulin resistance (IR), inflammation, nutritional status and insulin-like growth factor-1 (IGF-1) in end-stage renal disease (ESRD) patients with ADPKD and ESRD patients with other primary kidney diseases. Methods In a post hoc cross-sectional analysis in 254 non-diabetic CKD 5 patients starting on dialysis, glucose metabolism (insulin, IGF-1, homeostasis model assessment of IR, HOMA-IR), inflammation (high sensitivity C-reactive protein, interleukin-6, and tumor necrosis factor), nutritional status, and bone mineral density (BMD), were assessed. Survival was recorded for median time of 28 months (IQR 15–48 months). Results Neither indices of IR, nor IGF-1, inflammatory status, nutritional status, or BMD were different in patients with ADPKD as compared to other etiologies of ESRD. Kaplan-Meier curves showed better survival among ADPKD group versus other etiologies, even after an exclusion of diabetic patients. Conclusions The ESRD phenotype did not differ in ADPKD versus other primary kidney diseases in terms of markers of IR, inflammation, and nutritional status. This argues against the proposition that ADPKD patients are more prone to develop metabolic derangements beyond those generally observed in advanced CKD. However, additional studies are warranted to further elucidate systemic metabolic aspects of ADPKD. This article is protected by copyright. All rights reserved.

AIM We used insurance claims data of Taiwan to compare the risk of non-traumatic lower extremity amputation between haemodialysis (HD) and peritoneal dialysis (PD) patients. METHODS We identified 77 669 HD patients and 10 035 PD patients without prior amputation from 2000 to 2010. Incidence rates and hazard ratios (HRs) of lower extremity amputation, and subsequent 30-day mortality after amputation were evaluated up to 31 December 2011. RESULTS There were 2427 and 216 patients undergoing lower extremity amputation during follow-up in the HD and PD groups with incidence rates of 8.35 and 5.79 per 1000 person-years, respectively. Compared with the HD group, the overall adjusted HR of lower extremity amputation for the PD group was 1.27 (95% CI = 1.10-1.46). The impact of diabetes status on the risk of lower extremity amputation interacted with dialysis modality significantly (P

To address the issue of heavy dialysis burden due to the rising prevalence of end-stage renal disease around the world, a roundtable discussion on the sustainability of managing dialysis burden around the world was held in Hong Kong during the First International Congress of Chinese Nephrologists in December 2015. The roundtable discussion was attended by experts from Hong Kong, China, Canada, England, Malaysia, Singapore, Taiwan and United States. Potential solutions to cope with the heavy burden on dialysis include the prevention and retardation of the progression of CKD; wider use of home-based dialysis therapy, particularly PD; promotion of kidney transplantation; and the use of renal palliative care service.

The global burden of chronic kidney disease (CKD) has increased substantially in recent years, partly attributed to the global epidemic of diabetes mellitus. In many countries including China, glomerulonephritis was the most common cause of end stage renal disease (ESRD). The mortality rate of dialysis patients can be as high as patients with colon, breast and prostate cancers. CKD has important socio-economic impact on the healthcare system and society. Increasing awareness and early detection of CKD cannot be overemphasized. In places where healthcare resources are limited, peritoneal dialysis first policy has allowed local governments and health authorities to maximize healthcare resources to provide renal replacement therapy for more ESRD patients. In conclusion, management of CKD remains a global health challenge and continued medical research is most important.

Adolescents make up a quarter of the world's population and are important users of health services. In South Africa little is known about the extent of renal disease or outcomes in this group. Adolescents are a vulnerable age group, due to their neurocognitive development, engagement in high-risk social activities, prevalence of mental illness and increasing rates of HIV infection. In Africa access to renal replacement therapy is rationed, therefore the focus of renal disease must be one of prevention rather than dealing with the management of end stage renal disease. Treating adolescents is a challenging field, as compliance is essential as a preventative strategy. This review will outline how a cost effective adolescent service was established in a resource limited setting. The adolescent friendly clinic aims to ease transition of adolescents, improve engagement within the health service and ultimately aims to improve compliance. In order to treat adolescents it is important to deliver age appropriate treatment that can be implemented in any chronic disease setting to give the adolescent the greatest chance of success.

AIM There is little information on the relationship between uric acid (UA) and residual renal function (RRF) in continuous ambulatory peritoneal dialysis (CAPD). The aim of this research is to study the influence of UA on RRF decline in CAPD patients. METHODS A retrospective observational cohort study of 304 patients who started CAPD without anuria between 2001 and 2010 was conducted at a single medical center. The outcomes measured in the study included the rate of RRF decline and anuria. A multiple ordinal logistic regression model with backward elimination was conducted to determine the independent factors of the slope of RRF decline. A Cox proportional hazard model was conducted to determine the independent variables of time to anuria. RESULTS The average rate of RRF decline was -0.12 ± 0.22 mL/min per month. Multivariate analysis showed that lower UA group (

Aim The study evaluated the risk of sudden sensorineural hearing loss (SSHR) in patients with end-stage renal disease (ESRD) undergoing dialysis METHODS: We identified 18 905 patients newly diagnosed with ESRD, comprising 6382 patients on peritoneal dialysis (PD) and 12 523 patients on hemodialysis (HD) using Taiwan's National Health Insurance claims data from 2000 to 2010. A total of 76 520 controls without kidney disease were randomly selected with frequency matched with the ESRD group by age and sex. We further established additional cohorts with 6375 patients on PD and 6375 patients on HD matched by their propensity scores. Cox proportional hazards models were used to examine the effect of ESRD and dialysis modality on the risk of sudden sensorineural hearing loss (SSHL) by the end of 2011. Results The incidences for SSHR were 0.49, 2.37, 2.95, and 2.12 per 1000 person-years in the control, ESRD (PD and HD), PD, and HD cohorts, respectively. The adjusted HRs of SSHR was 2.71, 3.60, and 2.33 for ESRD, PD, and HD groups (95% CI = 2.17-3.38, 2.71-4.78 and 1.81-2.99, respectively) compared with the control cohort. Patients on PD exhibited 1.53-fold (95% CI = 1.14-2.04) and 1.64-fold (95% CI = 1.19-2.27) higher SSHL risk than their age- and sex-matched and propensity score-matched patients on HD, respectively. Conclusion Patients with ESRD exhibit a higher risk of SSHL than people without kidney disease. The SSHL risk is greater for patients on PD than on HD.

AIM Despite increase global prevalence of End stage renal disease (ESRD) and subsequent need for renal replacement therapy (RRT), relatively little is known about disease progression and prognosis of earlier stages of CKD. Current study was conducted to examine rate of CKD progression, predictors of ESRD and death. METHODS A total 621 patients with estimated glomerular filtration rate (eGFR) of 15-59ml/min/1.73m2 (CKD stage 3 & 4) were selected and followed up for 10 years or until ESRD or death, whichever occurred first. Subjects who did not meet inclusion criteria were excluded (n=1474). RESULTS Annual cumulative decline in eGFR was 3.01±0.40 ml/min/1.73m2 . Overall disease progression was observed in 60% patients while 18% died. Among patients with CKD stage 3, 21% progressed to stage 4, 10% to stage 5ND (non-dialysis) and 31% to RRT while mortality was observed in 16% patients. On the other hand, 8% patients with CKD stage 4 progressed to stage 5ND, 31% to RRT and mortality was observed in 24% cases. Patients with CVD, higher systolic blood pressure, elevated phosphate levels, heavy proteinuria, microscopic hematuria and use of diuretics were more likely to develop ESRD. Advancing age, low eGFR, low systolic blood pressure, low hemoglobin and baseline diabetes were found to be significant predictors of mortality while being female reduced risk of mortality. CONCLUSION Our data suggest that, in this CKD cohort, patients were more likely to develop ESRD than death. Prime importance should be given to mild forms of CKD to retard and even reverse CKD progression.

AIM Studies investigating the association between blood phosphorus and renal outcomes yielded inconsistent results, and studies from Asian population are extremely limited. We initiated the present cohort study, aiming to prospectively examine the association between blood phosphorus and adverse renal outcomes in a prospective chronic kidney disease (CKD) cohort of Chinese patients majorly with glomerulonephritis. METHODS A total of 1430 patients were involved in the study. Linear regression analyses were used to assess the relationship between phosphorus and the slope of estimated glomerular filtration rate (eGFR). Cox regression analyses were used to assess the association between phosphorus and composite outcomes, which were defined as the presence of at least one of: eGFR halving, end stage renal disease, or death. RESULTS During follow-up for an average of 41.4 months, 196 patients developed composite outcomes. The time-average plasma phosphorus was independently associated with the slope of eGFR (β = -0.18, 95% CI: -4.42 to -2.19, P

Aim Acoustic radiation force impulse is a noninvasive method for evaluating tissue elasticity on ultrasound. Renal shear wave velocity measured by this technique has not been fully investigated in patients with renal disease. The aim of the present study was to compare renal shear wave velocity in end-stage renal disease patients and that in patients without chronic kidney disease and to investigate influencing factors. Methods Renal shear wave velocities were measured in 59 healthy young subjects (control group), 31 subjects without chronic kidney disease (non-CKD group), and 39 end-stage renal disease patients (ESRD group). Each measurement was performed 10 times at both kidneys, and the mean value of eight of 10 measurements, excluding the maximum and minimum values, was compared. Results Renal shear wave velocity could be measured in all subjects. Renal shear wave velocity in the control group was higher than in the non-CKD group and in the ESRD group, and no difference was found between the non-CKD group and the ESRD group. Age and depth were negatively correlated to the renal shear wave velocity. In multiple regression analysis, age and depth were independent factors for renal shear wave velocity, while renal impairment was not. There was no difference between the non-CKD group and the ESRD group, even when ages were matched and depth was adjusted. Conclusion Renal shear wave velocity was not associated with advanced renal impairment. However, it reflected alteration of renal aging, and this technique may be useful to detect renal impairment in the earlier stages.

AIM Hepatitis B virus (HBV) infection is an important risk factor for morbidity and mortality in the general population. However, limited data are available on the progression of HBV infection in patients with end-stage renal disease (ESRD), and available data are controversial. Therefore, we investigated the association between hepatitis B surface antigen (HBsAg) seropositivity and mortality in patients with incident ESRD. METHODS All adult patients (≥18 years of age) starting dialysis for ESRD from January 2000 to December 2011 were included. A total of 1090 patients with ESRD were analyzed. HBsAg-positive patients were paired 1:6 with HBsAg-negative patients using propensity score matching. RESULTS Eighty one (7.4%) patients were HBsAg positive. No differences in the survival rates of the HBsAg-positive and HBsAg-negative patients with ESRD were detected in either the entire cohort or the propensity score matched cohort. No differences in survival were detected between the groups of HBsAg-positive patients based on the hepatitis B envelope antigen, hepatitis B envelope antibody, HBV DNA status, or use of antiviral agents. No difference in mortality was found between the haemodialysis (HD) and peritoneal dialysis (PD) subgroups among HBsAg-positive patients. CONCLUSION Our results suggest that hepatitis B surface antigenaemia is not related to increased mortality in patients with incident ESRD. Survival of HBsAg-positive patients undergoing PD was comparable to that of patients undergoing HD.

A 54 year old male with b-Thalassemia major developed ESRD and was managed with continuous ambulatory peritoneal dialysis. Although not able to be transfused due to high titre red cell antibodies he did require management of iron overload. Deferasirox (Exjade) was administered orally. There was concern that excretion of iron via the peritoneal dialysate may raise the risk of iron-dependent infections (Yersinia and Rhizopus).Whilst receiving Exjade 1000mg /day, a total collection of 12.7L of peritoneal dialysate was collected over a 24 hour period by the patient. The dialysate total iron levels were measured by ICP-MS at 0.46mmol/L which equates to 0.33mg of Fe in total. Over a 6 month period his serum ferritin fell from 3869μg/l to 1545μg/l. There were no episodes of peritonitis. Since only 7-8% of the deferasirox and iron complex is excreted through the urine, the amount of Fe seen in the patient's dialysate might be expected to be up to 1.5-1.6mg. Yet, the results of the Fe levels in the patient's PD fluid was a meagre 0.33mg, about five times lower than expected.Whilst only moderately effective at a dosage of 1000mg/day, deferasirox may be a safe agent for iron removal in iron overloaded peritoneal dialysis patients, as relatively low dialysate iron levels reduces the risk of Yersinia and Rhizopus infection.

Aim Acute kidney injury (AKI) carries an increasing incidence rate worldwide and increases the risk of developing end-stage renal disease (ESRD) as well as the medical expenses during the post-AKI course. The Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKs) has thus launched a nationwide epidemiology and prognosis of dialysis-requiring acute kidney injury (NEP-AKI-D) study, which prospectively enrols critically ill patients with AKI. Through thoroughly evaluating the risk and prognostic factors of AKI, we hope to lower the incidence of AKI and ESRD from the perspective of AKI-ESRD interaction. Methods The CAKs includes 30 hospitals which distribute widely through the four geographical regions (north, middle, south, and east) of Taiwan, and have a 1:1 ratio of medical centres to regional hospitals in each region. The NEP-AKI-D study enrols intensive care unit-based AKI patients who receive dialysis in the four seasonal sampled months (October 2014, along with January, April, and July 2015) in the included hospitals. The collected data include demographic information, pertaining laboratory results, dialysis settings and patient outcomes. The data are uploaded in a centre website and will be audited by on-site principal investigators, computer logic gates, and the CAKs staffs. The outcomes of interest are in-hospital mortality, dialysis-dependency and readmission rate within 90 days after discharge. Conclusion The NEP-AKI-D study enrols a large number of representative AKI patients throughout Taiwan. The results of the current study are expected to provide more insight into the risk and prognostic factors of AKI and further attenuated further chronic kidney disease transition.

Aim This study aimed to evaluate the cost-effectiveness of haemodialysis (HD), continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD) for patients with end-stage renal disease (ESRD) in Singapore. Methods A Markov model was developed to examine the incremental cost-effectiveness ratios (ICERs) of HD, CAPD and APD over the 10-year time horizon from the societal perspective, using clinical data from an observational study and the national renal registry, utilities from published studies and costs from dialysis services providers. The base-case analysis was for a hypothetical cohort of 60-year-old non-diabetic ESRD patients. A high-risk group of 60-year-old diabetic ESRD patients was also studied. Results In the base-case analysis, the quality-adjusted life-years (QALYs) were 3.27 with CAPD, 3.48 with APD and 4.69 with HD. The total costs were Singapore dollar $169 872 for CAPD, $201 509 for APD and $306 827 for HD. CAPD and HD had extended dominance over APD. The ICER of HD versus CAPD was $96 447 (US$69 121) per QALY. One-way sensitivity analyses indicated that the results were most sensitive to the utility of HD. Probabilistic sensitivity analyses demonstrated that CAPD had the maximum probability of being cost-effective among treatments under evaluation at a willingness-to-pay (WTP) threshold of $60 000 (US$43 000) per QALY. The high-risk group analyses showed similar results. The ICER of HD versus CAPD was $106 281 (US$76 168) per QALY and the probability of CAPD being optimal was the highest using the same WTP threshold. Conclusions Our analysis suggested that starting dialysis with CAPD is most cost-effective for ESRD patients in Singapore.

AIM Involvement of pro-inflammatory genes has been correlated with basic kidney diseases and end stage renal disease (ESRD). However, results at odds were often noted from such independent association studies. This study proposes a genome wide analysis approach to predict ESRD risk associated genes. METHODS We included 42 single nucleotide polymorphisms (SNPs) showing association among north Indian ESRD cases and controls. ESRD cases comprised chronic glomerulonephritis (CGN), chronic interstitial nephritis (CIN), hypertension (HTN) and autosomal dominant polycystic kidney disease (ADPKD). Genotyping data obtained from our prior published reports were compared with Genome-Wide Association Studies (GWAS) SNPs retrieved from HapMap and GWASCentral databases using R-statistical package SNPAssoc. Linkage disequilibrium (LD), gene-gene interaction, classification and regression tree (CART) and pathway analysis were carried out in the present study supplemented with IL-6 and TNF-α levels estimation using enzyme linked immunosorbent assay (ELISA). RESULTS Comparison of genotyping data with GWAS SNPs revealed significant associations for interleukin (IL)1-RN, IL-6, MTHFR, tumour necrosis factor-α (TNF-α) and CCR3 genes with ESRD. Nine SNPs were commonly associated with CGN, CIN, HTN, ADPKD and ESRD. LD (D = 0.9) and gene-gene interaction (P = 0.0002) analyses revealed significant associations for IL-6 and TNF-α genes. In a consistent manner, CART analysis and functional analysis servers predict predisposing effects for TNF-α and IL-6 with ESRD. Finally, higher body circulating levels were observed for mutant TNF-α and IL-6 alleles among ESRD. CONCLUSION The study indicates significance for IL-6 and TNF-α gene with basic kidney diseases and ESRD. Extensive statistical tests, pathway analysis and functional assays also reflect attenuated level of significance for these SNPs. In future these may be brought from bench side to clinical practice as diagnostic biomarkers upon external and prospective replication and confirmation among other cohorts.

Aim Elderly people comprise a large and growing proportion of the global dialysis population. Regional differences in rates of dialysis in the elderly suggest multiple factors influence treatment decision-making including beliefs about the relative benefits and harms of dialysis and supportive (non-dialysis) care. We therefore systematically reviewed the literature reporting survival of elderly patients treated with either treatment pathway. Methods Systematic review and meta-analysis of cohort studies or randomized controlled trials identified in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials published before July 2014. Survival by treatment modality was calculated. Subgroup analyses by study design, study size, patient age and cohort era were conducted. Results Eighty-nine studies published between 1976 and 2014 reported on 294 921 elderly end-stage kidney disease (ESKD) patients. There was a paucity of data for supportive care (724 patients or 0.2% of the total patients) and supportive care studies were susceptible to lead-time bias. One-year survival for elderly patients treated with undifferentiated dialysis was 73.0% (95% confidence interval (CI) 66.3–79.7%), 78.4% (95% CI 75.2–81.6) for haemodialysis and 77.9% (95% CI 73.8–81.9) for peritoneal dialysis. Supportive care patients had a 1-year survival of 70.6% (95% CI 63.3–78.0%). Residual heterogeneity remained within individual treatment modalities despite subgroup analyses. Conclusions While the available literature demonstrates a broadly similar 1-year survival in elderly ESKD patients, it does not allow a confident estimate of the relative survival benefits of dialysis or supportive care. This uncertainty needs urgent attendance by further prospective data, which avoid bias and allow comparisons of quality of life and survival.