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Background The Taiwan Health Insurance Bureau has conducted a bundled payment system for hemodialysis reimbursement since 1995. The maximum dose of erythropoiesis-stimulating agents allowed by insurance is capped at 20 000 U of epoetin or 100 μg of darbepoetin alfa per month. Nephrologists have avoided the use of high dosages of erythropoiesis-stimulating agents to achieve a hemoglobin level of 10 to 11 g/dL by iron supplementation. The clinical impact of these policies on patients' outcomes is unknown. The authors aimed to assess the AIM-HD (Association of Anemia, Iron parameters, and Mortality among the prevalent Hemodialysis patients) Study in Taiwan. Methods and Results The AIM-HD study was conducted based on the Taiwan Renal Registry Data System. From 2001 to 2008, the authors enrolled 42 230 patients undergoing hemodialysis who were older than 20 years and had received hemodialysis for more than 12 months. Patient follow-ups occurred until death or December 31, 2008. During a study period of 8 years, 12 653 (30.0%) patients died. After multivariate adjustment, the authors found that a hemoglobin level <10 g/dL was significantly associated with higher risk for all-cause and cardiovascular deaths. Moreover, a serum ferritin level between 300 and 800 ng/mL and transferrin saturation value between 30% and 50% were associated with the lowest all-cause mortality. Conclusions The authors recommend avoiding a low hemoglobin level and maintaining serum ferritin between 300 and 800 ng/mL and transferrin saturation between 30% and 50%, which were associated with lower risks of all-cause mortality among patients undergoing hemodialysis receiving the restricted erythropoiesis-stimulating agent doses but prompt intravenous iron supplementation in Taiwan.

Cutaneous mucinoses encompass a variety of cutaneous disorders. Cutaneous focal mucinosis (CFM) was originally described as an asymptomatic solitary lesion characterized by abundant focal cutaneous mucin deposits. However, multiple focal mucinous lesions associated with systemic diseases have also been designated as CFM. Our clinicopathological study of 11 cases of solitary lesions confirmed that CFM is a unique primary cutaneous mucinosis unrelated to mucinosis-associated systemic diseases. We suggest calling this group of CFM lesions "solitary CFM" to distinguish them from multiple CFM associated with mucinosis associated systemic diseases. Our cases showed slight male predominance with a median age of 50 years. They occurred most often on the extremities (45%), presented as asymptomatic solitary, white to erythematous, small, soft, fibroma-like lesions. None of the clinical impressions were of CFM. We call attention to include solitary CFM in clinical differential diagnosis of polypoid skin lesions., (© 2016 Japanese Dermatological Association.)

Background: Volume overload is frequently encountered and is associated with cardiovascular risk factors in patients with chronic kidney disease (CKD). However, the relationship between volume overload and adverse outcomes in CKD is not fully understood., Methods and Results: A prospective cohort of 338 patients with stage 3 to 5 CKD was followed for a median of 2.1 years. The study participants were stratified by the presence or absence of volume overload, defined as an overhydration index assessed by bioimpedance spectroscopy exceeding 7%, the 90th percentile for the healthy population. The primary outcome was the composite of estimated glomerular filtration rate decline ≥50% or end-stage renal disease. The secondary outcome included a composite of morbidity and mortality from cardiovascular causes. Animal models were used to simulate fluid retention observed in human CKD. We found that patients with volume overload were at a higher risk of the primary and secondary end points in the adjusted Cox models. Furthermore, overhydration appears to be more important than hypertension in predicting an elevated risk. In rats subjected to unilateral nephrectomy and a high-salt diet, the extracellular water significantly increased. This fluid retention was associated with an increase in blood pressure, proteinuria, renal inflammation with macrophage infiltration and tumor necrosis factor-α overexpression, glomerular sclerosis, and cardiac fibrosis. Diuretic treatment with indapamide attenuated these changes, suggesting that fluid retention might play a role in the development of adverse outcomes., Conclusions: Volume overload contributes to CKD progression and cardiovascular diseases. Further research is warranted to clarify whether the correction of volume overload would improve outcomes for CKD patients., (© 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)

Background: Observational studies have demonstrated an association between anemia and adverse outcomes in patients with chronic kidney disease (CKD). However, randomized trials failed to identify a benefit of higher hemoglobin concentrations, suggesting that the anemia-outcome association may be confounded by unknown factors., Methods and Results: We evaluated the influence of fluid status on hemoglobin concentrations and the cardiovascular and renal outcomes in a prospective cohort of 326 patients with stage 3 to 5 CKD. Fluid status, as defined by overhydration (OH) level measured with bioimpedance, was negatively correlated with hemoglobin concentrations at baseline (r=-0.438, P<0.001). In multivariate regression analysis, OH remained an independent predictor of hemoglobin, second only to estimated glomerular filtration rate. Patients were stratified into 3 groups: no anemia (n=105), true anemia (n=82), and anemia with excess OH (n=139) (relative OH level ≥7%, the 90th percentile for the healthy population). During a median follow-up of 2.2 years, there was no difference in cardiovascular and renal risks between patients with true anemia and those with no anemia in the adjusted Cox proportional hazards models. However, patients with anemia with excess OH had a significantly increased risk of cardiovascular morbidity and mortality and CKD progression relative to those with true anemia and those with no anemia, respectively., Conclusions: Fluid retention is associated with the severity of anemia and adverse cardiovascular and renal outcomes in patients with CKD. Further research is warranted to clarify whether the correction of fluid retention, instead of increasing erythropoiesis, would improve outcomes of CKD-associated anemia., (© 2015 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.)