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Introduction: Results on the association between the use of renin-angiotensin system blockades (RASBs) and vascular access-related outcomes are inconsistent. We aimed to compare vascular access-related outcomes according to the use of RASBs in hemodialysis patients., Methods: This study used data from a national hemodialysis quality assessment program of the Republic of Korea (n = 54,903). Group 1 was not prescribed any blood pressure-lowering drugs (n = 28,521). Group 2 was prescribed other blood pressure-lowering agents except for RASBs (n = 9571). Group 3 was prescribed RASBs (n = 16,811). Vascular access-related outcomes were classified into intervention-free survival (IFS), thrombosis-free survival (TFS), and vascular access survival (VAS)., Results: No significant difference in the three access survival rates was identified among the three groups. The multivariate Cox regression analyses indicated that Group 3 had better outcomes in IFS and TFS than Group 1. The numbers of angioplasties performed were significantly greater in Group 1 than in the other two groups. The numbers of thrombectomies performed were significantly the lowest in Group 3 among all the groups., Conclusions: Our study revealed different results according to types of access survival in univariate or multivariate analyses. The association of RASBs with favorable outcomes in vascular access remains unclear., (© 2023 Wiley Periodicals LLC.)

Background: In case of intractable exit site and/or tunnel infections, peritoneal dialysis (PD) catheter removal and re-insertion are recommended. Previous studies have reported the possibility of catheter salvage before removal, but they were either case-series or had a small sample size., Methods: We identified all incident patients with PD who underwent revision at a tertiary medical center. In intractable exit site and/or tunnel infections, we tried catheter revision using a method with cuff shaving, using an original catheter, and creating a new tunnel. Revision success was defined as complete remission over more than 1 month after revision. We evaluated the infection-free and catheter survival rates., Results: In total, 52 patients with PD underwent revision. The median age at the time of revision in the patients undergoing PD was 51 (21) years. There were 43 (82.7%) cases of revision success. Infection-free survival rates at 6 and 12 months were 57.0% and 35.1%, respectively. Catheter survival rates at 12 and 36 months were 72.5% and 56.2%, respectively., Conclusion: The present study demonstrated that catheter revision can be a useful bridging method for original catheter salvage before catheter removal in intractable exit site and/or tunnel infections., (© 2022 Wiley Periodicals LLC.)

A 57-year-old male patient visited our center owing to abnormal tunneled cuffed hemodialysis catheter (TC-HDC). He had been undergoing hemodialysis for 44 months. Hemodialysis was performed using a TC-HDC, which became dilatated between the hub and exit site 19 months after the initiation of hemodialysis. The first TC-HDC was exchanged using over the guidewire method. The second TC-HDC was maintained for 25 months after catheter exchange. However, the second TC-HDC was repeatedly dilatated 25 months later from the first catheter exchange. We re-exchanged the dilatated TC-HDC to the new TC-HDC using over the guidewire method. Our case presented general dilatation of both lumens without leakage. The portion of catheter dilatation was limited between the hub and exit site. The embedded segment of the catheter was preserved owing to encasement of the adjacent tissue. Our case showed that clinicians should inspect both exposed and embedded segments to prevent further catheter injury and exchange the catheter before the development of complications., (© 2022 Wiley Periodicals LLC.)

Background: The aim of the present study was to perform a comparative analysis of peritoneal dialysis catheter (PDC) insertion between blind and surgical methods by nephrologists., Patients and Methods: The present study enrolled 249 peritoneal dialysis patients who received first-time PDC insertion. All PDC insertions were performed using either the blind or surgical method. In our hospital during the study period, two of three nephrologists performed the blind method routinely in all eligible patients (blind group), and one of three nephrologists performed the surgical method in all eligible patients (surgical group). Catheter outcomes, including infectious or mechanical complications, functional parameters, and catheter survival, were evaluated., Results: The numbers of patients underwent surgical or blind methods were 105 and 144, respectively. The use of systemic analgesics in the surgical group was higher than that in the blind group. The operation time was longer in the blind group than in the surgical group. The D0 level and peritoneal Kt/V were similar between the two groups. There was no significant difference in infectious and mechanical complications between the two groups. The catheter survival and intervention-free survival were similar between the two groups (P = .995 for catheter survival and P = .723 for intervention-free survival)., Conclusion: Our study shows that catheter outcomes are similar between blind and surgical insertion techniques performed by nephrologists. These findings reveal that patients without previous major abdominal surgery would be suitable to receive any one of the two methods according to the operator-friendly technique., (© 2020 Wiley Periodicals LLC.)

Aim: The intrarenal renin-angiotensin system (RAS) has been reported to be activated in chronic proteinuria patients. This study aimed to compare intrarenal RAS activity between diabetic nephropathy (DN) and non-diabetic nephropathy (NDN) patients with overt proteinuria., Methods: A multicenter, cross-sectional study was conducted in 116 patients with overt proteinuria (urinary protein/creatinine ratio [uPCR] > 1 mg/mg Cr). To estimate intrarenal RAS activity we measured urinary excretion of angiotensinogen (uAGT) and renin (uRenin) in patients with DN (n = 38) and NDN (n = 78)., Results: Both natural logarithms of uAGT/urinary creatinine (ln[uAGT/uCr]) and uRenin (ln[uRenin/uCr]) levels were significantly higher in patients with DN compared with those with NDN (ln[uAGT/uCr]: 4.16 ± 1.13 in DN vs. 3.52 ± 1.21 in NDN, P = 0.007; ln[uRenin/uCr]: 5.66 ± 1.60 in DN vs. 4.29 ± 1.48 in NDN, P < 0.001), when estimated glomerular filtration rate (eGFR) and uPCR showed no significant difference between the two groups. In a subgroup analysis, according to amount of proteinuria, both uAGT and uRenin were higher in DN in patients with subnephrotic-range proteinuria (uPCR < 3.5 mg/mg Cr). However, in patients with nephrotic-range proteinuria (uPCR ≥ 3.5 mg/mg Cr), only uRenin was higher in DN compared to NDN. In a multiple regression analysis, diabetes showed independent association with uRenin., Conclusion: Consistently elevated uRenin in DN, regardless of the amount of proteinuria, indicates that intrarenal RAS activity may be higher in DN compared to NDN in patients with overt proteinuria., (© 2014 Asian Pacific Society of Nephrology.)

The presence of peritoneal dialysate when performing bioimpedance analysis may affect body composition measurements. The aim of this study was to evaluate the impact of dialysate on body composition measurements in Asians. Forty-one patients undergoing maintenance peritoneal dialysis in our hospital peritoneal dialysis unit were included in this study. Dialysate was drained from the abdomen prior to measurement, and bioimpedance analysis was performed using multi-frequency bioimpedance analysis, with each subject in a standing position (D-). Dialysate was then administered and the measurement was repeated (D+). The presence of peritoneal dialysate led to an increase in intracellular water (ICW), extracellular water (ECW), and total body water (D-: 20.33 ± 3.72 L for ICW and 13.53 ± 2.54 L for ECW; D+: 20.96 ± 3.78 L for ICW and 14.10 ± 2.59 L for ECW; P < 0.001 for both variables). Total and trunk oedema indices were higher in the presence of peritoneal dialysate. In addition, the presence of peritoneal dialysate led to an overestimation of mineral content and free fat mass (FFM) for the total body; but led to an underestimation of body fat (D-: 45.80 ± 8.26 kg for FFM and 19.30 ± 6.27 kg for body fat; D+: 47.51 ± 8.38 kg for FFM and 17.59 ± 6.47 kg for body fat; P < 0.001 for both variables). Our results demonstrate that the presence of peritoneal dialysate leads to an overestimation of FFM and an underestimation of fat mass. An empty abdomen is recommended when evaluating body composition using bioimpedance analysis., (© 2014 Asian Pacific Society of Nephrology.)

Aim: There are few reports on the incidence, aetiology, and mortality of peritoneal dialysis (PD) patients with hyponatraemia., Methods: We identified all adults (>18-years-of-age) who received PD between May 2001 and March 2010. The patients were divided into two groups according to the presence of hyponatraemia (<135 mmol/L) during follow-up. Total body water (TBW) was obtained from bioimpedance analysis. Appropriate water gain was defined as a more than 3.6% increase of the mean TBW during normonatraemia in the same patient. Aetiologies of hyponatraemia were divided into two classes according to TBW., Results: Three hundred and eighty seven patients were enrolled in this study. Ninety nine had normonatraemia and 288 developed hyponatraemia during follow-up. Among 241 episodes with simultaneous bioelectrical impedance analysis measurement, there were 71 cases with appropriate water gain and 170 cases with non-appropriate water gain. Low residual renal function and long duration of PD were associated with development of hyponatraemia by appropriate water gain. On multivariate analysis, old age (≥65-years-of-age), hypoalbuminaemia (<35 g/L), low residual renal function (<2 mL/min per 1.73(2) ) and a high comorbid condition were associated with mortality in the PD patients. The patients with intermediate and high Davies index had an odds ratio of 3.25 for development of hyponatraemia during the follow-up period (95% confidence interval, 2.025-5.215; P < 0.001)., Conclusion: The prevalence of hyponatraemia increases along with the increased comorbidity status. The comorbidity conditions may be more important than hyponatraemia per se for predicting mortality. Additionally, the preservation of residual renal function may play a role in preventing hyponatraemia., (© 2012 The Authors. Nephrology © 2012 Asian Pacific Society of Nephrology.)

Aim: Catheter-related infection is a major cause of catheter loss in peritoneal dialysis (PD). We evaluated the effect of catheter revision on the treatment of intractable exit site infection (ESI)/tunnel infection (TI) in PD patients who required catheter removal., Methods: We reviewed the medical records of 764 continuous ambulatory peritoneal dialysis (CAPD) patients from May 1995 to April 2011 at our hospital. One hundred and twenty six patients had more than one occurrence of ESI. Catheter revision was performed to treat intractable ESI/TI. Incidence of ESI, causative organisms and the outcomes of catheter revision were analyzed., Results: The total PD duration of all patients was 32,581 months. Three hundred and twelve ESI episodes occurred in 126 patients and the incidence of ESI was 1/104 patient-months (0.12/patient-year). The most common causative organism was methicillin-sensitive Staphylococcus aureus (MSSA) (98 episodes), followed by Pseudomonas aeruginosa (63 episodes) and methicillin-resistant S. aureus (MRSA) (28 episodes). Among these, catheter revision was required due to intractable ESI/TI in 36 patients. The most common causative organism was MSSA (14 episodes) followed by P. aeruginosa (10 episodes) and MRSA (six episodes) in catheter revision cases. The outcomes of catheter revision were as follows: ESI relapsed in 11 patients (30.6%) after catheter revision. Among them, five patients were treated with antibiotic treatment, two patients required secondary catheter revision, four patients required catheter removal due to ESI/TI accompanying peritonitis. The catheter survival rate after catheter revision was 89.7% in one year. There were no statistical differences in the rates of ESI relapse after catheter revision between ESI caused by P. aeruginosa (5/10, 50%) and ESI caused by S.aureus (6/21, 28.6%)., Conclusion: Catheter revision may be an alternative treatment option to treat intractable ESI/TI before catheter removal is considered in PD patients., (© 2012 The Authors. Nephrology © 2012 Asian Pacific Society of Nephrology.)

Aim: Blind peritoneal dialysis (PD) catheter instrumentation with a Tenckhoff trocar is performed without direct visualization of the peritoneum. This method requires the least equipment, it is safe and it can be performed mainly by nephrologists. We report here on our long-term experience with this method as performed by nephrologists., Methods: We reviewed the medical records at Yeungnam University Hospital in Korea and identified all the patients who had undergone blind PD catheter instrumentation with a Tenckhoff trocar by nephrologists. Four hundred and three patients were enrolled., Results: Early complications occurred in 7.7% (four patients with pericatheter bleeding, one patient with pleural leakage, two patients with migration, two patients with omental wrapping, three patients with exit site/tunnel infection and 19 patients with peritonitis). The late mechanical complications included eight cases of hernia, three cases of catheter extrusion, five cases of leakage, four cases of migration and five cases of omental wrapping. Exit site/tunnel infection and peritonitis occurred at a rate of 0.067 and 0.40 episodes/year, respectively. The intervention free survival rate was 84.5% at one year and 63.3% at 5 years. The catheter survival rate was 96.5% at one year and 83.6% at 5 years., Conclusion: This study provides evidence that blind PD catheter placement with a Tenckhoff trocar requires the least equipments, and it is easy to perform. Therefore, if the general anesthesia is impossible or equipment, such as fluoroscopy and laparoscopy, were not available, this method may be an alternative choice for PD catheter placement., (© 2011 The Authors. Nephrology © 2011 Asian Pacific Society of Nephrology.)

Aim: The renoprotective effects of angiotensin receptor blockers vary considerably among individuals. We investigated the renoprotective effects of valsartan according to polymorphisms of the renin-angiotensin system and transforming growth factor-b1 (TGFB1) genes in patients with chronic non-diabetic proteinuric nephropathies., Methods: Two hundred and thirty-nine non-diabetic patients with proteinuria of at least 1 g/day were enrolled. Patients received 80 g of valsartan daily, followed by 160 mg/day after 6 weeks. The follow-up period was 18 months. The status of the angiotensin-converting enzyme (ACE) insertion/deletion, angiotensinogen (AGT) M235T, type 1 angiotensin II receptor (ATR1) A1166C, and TGFB1 C509 and T869C polymorphisms was determined in 162 patients., Results: Valsartan treatment caused a significant reduction in proteinuria from baseline throughout the study in patients with each genotype of the ACE, AGT and TGFB1 genes. However, patients with the ATR1 AC genotype had no significant reduction in proteinuria from baseline throughout the study course. The median reductions in proteinuria after 6 months were 45.7% and 10.8% in the patients with the ATR1 AA and AC genotypes, respectively (P = 0.034). The annual change in the estimated glomerular filtration rate did not differ significantly among the genotypes for each gene. On multiple regression analysis, the change in proteinuria after 6 months of treatment was independently associated with the ATR1 genotype and the change in blood pressure (P = 0.005 and 0.019, respectively)., Conclusion: Valsartan treatment significantly reduced the blood pressure and urinary protein excretion of patients with chronic non-diabetic proteinuric nephropathies. Interindividual differences in the anti-proteinuric effect of valsartan may be related partly to the ATR1 A1166C polymorphism., (© 2011 The Authors. Nephrology © 2011 Asian Pacific Society of Nephrology.)

Aim: The doses of darbepoetin alfa required to maintain target haemoglobin levels after s.c. or i.v. administration when recombinant human erythropoietin (rHuEpo) treatment was replaced by darbepoetin alfa treatment in haemodialysis (HD) patients were compared., Methods: In this prospective, randomized, open-label study, 65 HD patients who were receiving stable SC doses of rHuEpo were switched to an equivalent dose of darbepoetin alfa at a reduced frequency by s.c. or i.v. administration. Patients were randomly assigned to the s.c. group (n = 32) or the i.v. group (n = 33). Darbepoetin alfa doses were titrated to maintain target haemoglobin levels of 8.0-11.0 g/dL for up to 24 weeks. A period of 20 weeks was used for dose titration and haemoglobin stabilization. This was followed by a 4 week evaluation period., Results: The mean haemoglobin concentration during the evaluation period was similar in the s.c. and i.v. groups. The mean dose and mean weight-standardized dose of darbepoetin alfa during the evaluation period tended to be lower in the s.c. group than the i.v. group, although these differences were not statistically significant. The mean weekly darbepoetin alfa dose requirements during the evaluation period significantly decreased in both groups compared to the dose requirements at randomization., Conclusion: There is a possibility that s.c. administration of darbepoetin alfa is more efficacious than i.v. administration, but a definite benefit cannot be demonstrated with the current sample size. A bigger sample size is needed to confirm the result.