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Purpose The combination of vancomycin and piperacillin/tazobactam (VAN + PTZ) provides a broad spectrum of activity against multiple pathogens. However, a major issue in previous research concerned significant nephrotoxicity associated with this drug combination, and most studies have been conducted in American and European countries, with no similar data available from China. Therefore, this study evaluated the nephrotoxic effects of VAN + PTZ in a large-scale Chinese cohort to determine the prevalence of acute kidney injury (AKI) in this population by comparing PTZ and vancomycin monotherapies and the combined use of vancomycin and β-lactam antibiotics. Methods This retrospective cohort study identified adult patients who received vancomycin either as monotherapy or in combination with PTZ or carbapenem (VAN + CAR) for at least 48 hours at Jiangsu Province Hospital from January 1, 2017, to December 31, 2018. Patients were also evaluated for the development of AKI, defined according to the Kidney Disease Improving Global Outcome criteria. Duration of vancomycin exposure, steady-state trough vancomycin concentrations, and other risk factors for AKI were assessed. A Bayesian network meta-analysis was conducted to validate our results and comparatively evaluate the nephrotoxicity of β-lactam antibiotics in combination with vancomycin. Findings In all, 752 patients were included in the present study. The prevalence of AKI was higher in the VAN + PTZ group than in the VAN and VAN + CAR groups (15.2% vs 4.0% and 6.0%, respectively). After adjustment for confounding factors, VAN + PTZ was still related to AKI (odds ratio [OR] = 4.37; 95% CI, 1.65–11.59; P = 0.003). The network meta-analysis indicated that VAN + PTZ was associated with a significantly higher risk for AKI than was VAN (OR = 3.23; 95% CI, 2.50–4.35), PTZ (OR = 2.86; 95% CI, 1.92–4.12), VAN + cefepime (FEP) (OR = 2.37; 95% CI, 1.80–3.19), or VAN + CAR (OR = 2.28; 95% CI, 1.64–3.21). However, there was no significant difference with respect to AKI prevalence among the VAN, PTZ, VAN + FEP, and VAN + CAR groups. Implications The prevalence of AKI was higher with VAN + PTZ therapy than with VAN or PTZ monotherapy or with the concurrent use of VAN and FEP or CAR in our study. Clinicians should adequately assess renal function and consider this differential risk for nephrotoxicity when choosing empiric antibiotics in hospitalized patients to minimize the rates of AKI.

Objective: The objective of this study is to investigate the association between the serum sclerostin, the coronary artery calcification (CAC), and patient outcomes in maintenance dialysis patients. Methods: We performed a prospective cohort study of 65 maintenance dialysis patients in 2014, including 39 patients on peritoneal dialysis and 26 on hemodialysis, and followed up for 5 years. Parameters of mineral metabolism including bone-specific alkaline phosphatase, fibroblast growth factor 23, sclerostin, and other biochemical factors were determined at the baseline. Meanwhile, the CAC score was analyzed by cardiac computed tomography. Results: Serum sclerostin in hemodialysis patients was significantly higher than that in peritoneal dialysis patients (632.35 ± 369.18 vs. 228.85 ± 188.92, p < 0.001). The patients with CAC were older, receiving hemodialysis, lower Kt/V, and had longer dialysis vintage, as well as higher levels of serum 25-(OH)-vit D and sclerostin. In multivariate logistic regression analysis, older age and lower Kt/V were risk factors for CAC. The area under the receiver operating characteristic curves for prediction of CAC by sclerostin was 0.74 (95% confidence interval 0.605–0.878, p = 0.03), and the cutoff value of sclerostin is 217.55 pg/mL with the sensitivity 0.829 and specificity 0.619. After 5 years of follow-up, 51 patients survived. The patients in the survival group had significantly lower age, sclerostin levels, and low CAC scores than the nonsurvival group. Old age (≥60 years, p < 0.001) and high CAC score (≥50 Agatston unit, p = 0.031) were significant risk factors for the patient survival. Conclusions: Sclerostin is significantly elevated in dialysis patients with CAC. But sclerostin is not a risk factor for CAC. After 5 years of follow-up, patients in the survival group are younger and have lower sclerostin levels and CAC scores. But sclerostin levels are not independent risk factors for high mortality in dialysis patients.

The current study aimed to assess the dietary salt intake in patients with CKD in Jiangsu province and investigate the relationship of urinary sodium excretion with blood pressure. A total of 800 patients with CKD stages 1–4 were recruited. All enrolled patients were asked to collect complete 24‐h urine specimen. At the same time, patient's demographic and laboratory data were recorded. The mean age was 47.45 ± 15.25 years old, including 423 men and 377 women. There was no significant difference in urinary sodium excretion among different stages of CKD (p = .748). This study revealed that the median urinary sodium excretion of all patients was 127.20 mmol/d (IQR 91.03–172.06), corresponding to a salt intake of 7.4 g/d. Among them, only 167 (20.9%) cases had salt intake

BACKGROUND Hematopoietic stem cell transplantation (HSCT) is widely used in the treatment of hematological diseases. However, complications after transplantation, such as acute and chronic graft-vs-host disease (GVHD), still seriously affect the quality of life and even threaten the lives of patients. There is evidence that glomerular diseases can manifest as GVHD. However, GVHD should not occur as a result of syngeneic HSCT. CASE SUMMARY A 20-year-old male diagnosed with T lymphoblastic lymphoma (stage IIIA, aaIPI 1) in September 2013 was treated with six cycles of hyper-CVAD and achieved complete remission. He underwent syngeneic HSCT in June 2014, and had no kidney disease history before the transplant. However, nephrotic syndrome occurred 24 mo later in the patient after syngeneic HSCT. Renal biopsy was performed, which led to a diagnosis of atypical membranous nephropathy. After treatment with glucocorticoids combined with cyclophosphamide and cyclosporine, the nephrotic syndrome was completely relieved. CONCLUSION We report a case of delayed nephrotic syndrome after syngeneic HSCT. Antibody-mediated autoimmune glomerular disease may be the underlying mechanism. After treatment with immunosuppressive agents, the nephrotic syndrome was completely relieved but further long-term follow-up is still needed.

We compared the prognostic value of nutritional or volumetric parameters measured by body composition in hospitalized patients on maintenance hemodialysis. We conducted a cohort study to assess the association of different parameters of body composition with all-cause mortality in inpatients admitted to our nephrology department from January 2014 to December 2016. Of the 704 study patients, 160 (22.7%) died during a median follow-up of 33 months. In multivariate adjusted Cox models, higher ratio of extracellular water to body cell mass (ECW/BCM) (adjusted HR per 1-SD, 1.49; 95% CI, 1.19 to 1.85), lower lean tissue index (LTI) (adjusted HR per 1-SD, 0.70; 95% CI, 0.57 to 0.86) and lower body cell mass index (BCMI) (adjusted HR per 1-SD, 0.70; 95% CI, 0.58 to 0.85) were associated with a significantly greater risk of death. When these parameters were added to the fully adjusted model, BCMI performed best in improving the predictability for all-cause mortality (integrated discrimination improvement = 0.02, P = 0.04; net reclassification index = 0.11, P = 0.04). Among body composition indexes, ECW/BCM was the most relevant fluid volume indices to mortality and BCMI and LTI were the most relevant nutritional status indices to mortality in maintenance hemodialysis patients.

Objective To search all available sources to find incontrovertible scientific explanation of the meridian system and mechanism of acupuncture action. Methods Extensive search of electronic databases was carried out to identify all published scientific articles, research papers and experimental findings regarding meridian system, acupuncture points and mechanisms of acupuncture action, from both English and Chinese language journals, from inception till date. Results There are many hypotheses and studies about meridian system such as, primovascular system as meridian, nuclear tracers study to locate the track of meridian, infrared imaging studies to prove existence of meridians, investigations about anatomical structure of acupoints, etc. There are many researches and theories about mechanism of acupuncture action such as gate control theory of acupuncture analgesia, neurotransmitters, neuro-endocrine-immune network, fMRI evidences of brain's processing of pain signal etc. Conclusion Researchers over half a century discovered many factual information about meridian system, acupoints, neuro-transmitters and acupuncture analgesia, neuro-hormonal mechanism etc. All these important discoveries contributed to clarify the mysteries of meridian system and acupuncture action, but they still fell short of providing an incontrovertible scientific explanation. Further coordinated studies are warranted to explore more plausible and scientifically valid explanation of meridian system and acupuncture action.

Continuous renal replacement therapy (CRRT) has become an important multiple organ support therapy and it is widely used in the intensive care unit (ICU). The aim of this study was to clarify the association between CRRT and 28-day mortality in critically ill coronavirus disease 2019 (-COVID-19) patients receiving mechanical ventilation.112 respiratory decompensated critically ill adult patients with COVID-19 admitted to a COVID-19-designated ICU were included in this retrospective cohort study. Data on demographic information, comorbidities, laboratory findings upon ICU admission, and clinical outcomes were collected. The Kaplan-Meier method and Cox proportional hazard model were applied to determine the potential risk factors associated with 28-day mortality.The median age was 65.7 years, 67.8% were males, and 58.9% patients had at least one comorbidity. The median scores of the Charlson Comorbidity Index and Sequential Organ Failure Assessment (SOFA) were 3 and 7, respectively. Acute kidney injury (AKI) occurred in 57 critically ill patients upon ICU admission; 43 patients were classified as stage 2 - 3 AKI, and 36 patients were treated with CRRT. Age 65 years, high SOFA score, damaged cardiac function, poor nutrition, and severe infection were significantly associated with increased 28-day mortality. AKI patients receiving CRRT had lower 28-day mortality compared with those not receiving CRRT (HR = 0.35, 95% CI: 0.21 - 0.58, p 0.001). Initiating CRRT within 72 hours after mechanical ventilation did not improve survival after CRRT initiation.AKI prevalence and 28-day mortality are high in critically ill patients with COVID-19 receiving mechanical ventilation. CRRT plays a part in decreasing the mortality of critically ill COVID-19 patients with AKI receiving mechanical ventilation.

To explore the short-term variation in bone metabolic markers and the characteristics of hungry bone syndrome (HBS) after parathyroidectomy (PTX) with forearm autotransplantation in uremic patients with secondary hyperparathyroidism (SHPT) and to provide a basis for the pathogenesis, diagnosis and treatment of metabolic bone disease in SHPT. A total of 115 patients with SHPT receiving PTX from July 2015 to December 2017, hospitalized at the First Affiliated Hospital of Nanjing Medical University, were enrolled in our study. We retrospectively analyzed the baseline clinical data, the levels of bone metabolism markers before and on the third day after PTX, and the risk factors predicting HBS. Preoperative baseline data showed that the levels of bone metabolic markers such as bone metabolism-regulating hormones: iPTH, calcitonin (CT); bone formation markers: phosphatase (ALP), osteocalcin (OC); bone resorption markers: type I collagen cross-linked N-telopeptides (NTX), type I collagen cross-linked C-telopeptides (CTX), tartrate-resistant acid phosphatase 5b (TRAP-5b) were all increased compared to normal levels. The levels of postoperative serum iPTH, CT, CTX and TRAP-5b decreased significantly compared to preoperative levels, while the levels of OC and ALP increased significantly. Of the 115 patients, 101 (87.8%) developed HBS after PTX. High preoperative serum ALP and low preoperative serum calcium level independently predicted the occurrence of HBS. Younger preoperative age, high preoperative serum ALP and iPTH level independently predicted the severity of HBS. In severe SHPT, both bone formation and resorption were active, which suggested the presence of high-turnover bone diseases characterized by up-regulation of osteoclasts-osteoblasts functionally coupling activation in the patients. PTX could promote osteoblast activity and reduce osteoclast activity. HBS was common after PTX. Preoperative higher serum ALP and lower calcium were independent predictors of the occurrence of HBS. Younger patients with higher preoperative ALP and PTH may need to closely monitor serum calcium levels and intensive calcium supplementation after PTX.

AIM To understand the agreement, precision, and accuracy between other estimated glomerular filtration rate (eGFR) equations and the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) creatinine-cystatin C equation (EPI_Cr_CysC). MATERIALS AND METHODS We conducted a cross-sectional study of 1,913 CKD patients. The eGFRs were calculated separately by creatinine clearance rate and Cockcroft-Gault equation corrected for standard body surface area (Ccr_BSA and eCcr_BSA); CKD-EPI creatinine equation (EPI_Cr); CKD-EPI cystatin C equation (EPI_CysC); EPI_Cr_CysC equation; Modification of Diet in Renal Disease (MDRD) Study equation with standardized serum creatinine; and full-age spectrum creatinine equation (FAS). The EPI_Cr_CysC equation was used as the reference. RESULTS When compared with the EPI_Cr_CysC equation, the EPI_Cr equation achieved the highest agreement in eGFRs (Lin's concordance correlation coefficient = 0.936, 95% confidence interval (CI) = 0.930, 0.941). eCcr_BSA and EPI_Cr equations achieved the first and second highest percentage agreement in the accurate classification of CKD stage (72.55 vs. 71.25%). The MDRD equation had minimal bias and was closely followed by the EPI_Cr equation (median difference = -1.3, 95% CI = -2.0, -0.8 vs. median difference = 2.5, 95% CI = 1.7, 3.3 mL/min/1.73m2). The EPI_CysC and EPI_Cr equations achieved the first and second highest precision (interquartile range (IQR) of the difference = 12.2, 95% CI = 11.6, 12.9 vs. IQR of the difference = 15.5, 95% CI = 14.7, 16.3 mL/min/1.73m2). The EPI_Cr and MDRD equations performed similarly and both had the highest accuracy at 30% (1 - P30 = 18.6, 95% CI = 16.9, 20.4 vs. 1 - P30 = 18.6, 95% CI = 16.8, 20.3%). CONCLUSION For assessment of renal function, the EPI_Cr equation performed the best and remained an acceptable alternative to the EPI_Cr_CysC equation in the absence of cystatin C. .

Uraemic cardiomyopathy (UCM) is one of the most common complications in chronic kidney disease (CKD). Our aim was to compare characteristics of various UCM mouse models. Mice were assigned to the following groups: the pole ligation group, 5/6 nephrectomy group (5/6Nx), uninephrectomy plus contralateral ischemia followed by reperfusion group (IR), adenine group, and sham group. Mice were sacrificed at 4, 8, and 16 weeks after surgery in the pole ligation, 5/6Nx, and IR groups, respectively. In the adenine group, mice were sacrificed at 16 weeks after the adenine diet. The structure and function of the heart and the expression of fibroblast growth factor 23 (FGF-23) and growth differentiation factor 15 (GDF-15) in hearts were assessed. The mortality in the 5/6 Nx group was significantly higher than that in the pole ligation, IR, and adenine groups. Echocardiogram and histological examination showed cardiac hypertrophy in the adenine,5/6Nx, ligation group, and IR group. In addition, cardiac fibrosis occurred in all CKD modeling groups. Interestingly, cardiac fibrosis was more serious in the IR and adenine groups. FGF-23 expression in sham mice was similar to that in modeling groups; however, the GDF-15 level was decreased in modeling groups. Our results suggest that the four models of UCM show different phenotypical features, molding time and mortality. GDF-15 expression in the hearts of UCM mice was downregulated compared with sham group mice.

ObjectiveTo determine the prognostic values of histopathologic classification of myeloperoxidase-anti-neutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis and other clinical and laboratory features at the time of presentation on renal and patient survival associated with myeloperoxidase-ANCA-associated glomerulonephritis (MPO-ANCA-GN).MethodsA total of 112 patients diagnosed with MPO-ANCA-GN from October 2005 to December 2018 were enrolled. The baseline clinical characteristics, renal histopathological data, and risk factors predictive of renal and patient survival were retrospectively analyzed.ResultsAll 112 patients underwent renal biopsy. Disease in 32 patients was classified as focal, 26 as mixed, 29 as crescentic, and 25 as sclerotic. Over a median follow-up period of 41.5 months, there were 44 patients dialysis-dependent. The renal survival rate was significantly higher in the focal group than the other groups (p < 0.001) and significantly lower in the sclerotic group (p < 0.05). In addition, disease histopathologically classified as sclerotic (p = 0.044), high serum creatinine level (≥320 μmol/L, p < 0.001), low albumin (p = 0.024) and hemoglobin level (p = 0.044) were associated with a greater risk of ESRD. After follow-up, 70 (62.5%) of 112 patients survived. Old age (≥60 years, p = 0.018) and low serum albumin (p = 0.006) was significant risk factor for patient survival.ConclusionAmong patients with MPO-ANCA-GN, those with poor renal function, disease histopathologically classified as sclerotic, and lower albumin and hemoglobin levels were risk factors for ESRD, while older age and low serum albumin level were associated with a greater risk for all-cause mortality.

Background: An early net ultrafiltration (NUF) rate may be associated with prognosis in patients receiving continuous kidney replacement therapy (CKRT). In this study, we tested whether high or low early NUF rates in patients treated with CKRT were associated with increased mortality.Methods: We conducted a retrospective, observational study among all patients in the Medical Information Mart for Intensive Care IV database who received CKRT for more than 24 hours within 14 days after intensive care unit admission. We defined the early (initial 48 hours) NUF rate as the amount of fluid removal per hour adjusted by the patients’ weight and took it as a classified variable (low rate: < 1.6, moderate rate: 1.6–3.1 and high rate: > 3.1 mL/kg/h). The association between 28-day mortality and the NUF rate was analyzed by logistic regression and mediation analyses. Results: A total of 911 patients were included in our study. The median NUF rate was 2.71 (interquartile range 1.90–3.86) mL/kg/h and the 28-day mortality was 40.1%. Compared with the moderate NUF rate, the low NUF rate (adjusted odds ratio 1.56, 95% CI 1.04–2.35, p = 0.032) and high NUF rate (adjusted odds ratio 1.43, 95% CI 1.02–2.01, p = 0.040) were associated with higher 28-day mortality. The putative effect of a low or high NUF rate on 28-day mortality was possibly direct [adjusted average direct effects (ADE) 1.03, p = 0.096 for a low NUF rate; adjusted ADE 0.92, p = 0.064 for a high NUF rate], and also mediated by effects of the NUF rate on fluid balance during the same period [adjusted average causal mediation effects (ACME) 0.96, p = 0.010 for a low NUF rate; adjusted ACME 0.99, p = 0.042 for a high NUF rate]. Moreover, we found an increase trend in the NUF rate corresponding to the lowest mortality when fluid input increased. Conclusion: Compared with NUF rates between 1.6–3.1 mL/kg/h in the first 48 hours of CKRT, NUF rates > 3.1 mL/kg/h and < 1.6 mL/kg/h were associated with higher mortality.

Electroacupuncture (EA) is a promising clinical approach to treating posttraumatic stress disorder (PTSD), yet the mechanisms whereby EA can alleviate anxiety and other PTSD symptoms have yet to be clarified. In the present report, rats underwent EA for 14 consecutive days following modified single prolonged stress (MSPS) exposure. These animals were then evaluated in open field and elevated plus maze tests (OFT and EPM), while Fos immunohistochemical staining was performed to assess ventromedial prefrontal cortex (vmPFC) functional activation. In addition, an extracellular recording and stimulation system was used to analyze vmPFC inputs into the ventral tegmental area (VTA) in these rats. Temporary vmPFC inactivation was further performed to assess whether this was sufficient to reverse the anxiolytic effects of EA. Overall, rats that underwent EA treatment spent more time in the central region (OFT) and the open arm (EPM) relative to MSPS model animals (P < 0.05). These MSPS model animals also exhibited significantly fewer activated Fos-positive nuclei in the vmPFC following behavioral testing, while EA was associated with a significant relative increase in c-Fos expression in this region. The transient inactivation of the vmPFC was sufficient to reverse the effects of EA treatment on anxiety-like behaviors in MSPS model rats. MSPS and SEA rats exhibiting no differences in bursting activity between baseline and vmPFC stimulation, whereas bursting activity rose relative to baseline upon ventral mPFC stimulation in EA treated and control rats. Together, these findings indicate that the vmPFC and its inputs into the VTA are functionally linked to the anxiolytic activity of EA, implicating this pathway in the EA-mediated treatment of PTSD.

BackgroundImmune checkpoint inhibitors (ICIs) have brought a paradigm shift to cancer treatment. However, little is known about the risk of renal adverse events (RAEs) of ICI-based regimens, especially ICI combination therapy.MethodsWe carried out a network meta-analysis of randomized controlled trials (RCTs) to compare the risk of RAEs between ICI-based regimens and traditional cancer therapy, including chemotherapy and targeted therapy. Subgroup analysis was conducted based on tumor types.ResultsNinety-five eligible RCTs involving 40,552 participants were included. The overall incidence of RAEs, grade 3–5 RAEs, acute kidney injury (AKI), and grade 3–5 AKI was 4.3%, 1.2%, 1.3%, and 0.8%, respectively. Both ICI-based treatment regimens and traditional cancer therapy showed significantly higher risk of RAEs and AKI than the placebo. Among ICI monotherapy, anti-PD-1 (RR: 0.51, 95%CI: 0.29–0.91) was significantly safer than anti-CTLA-4 in terms of RAEs. Anti-CTLA-4 showed significantly higher toxicity than anti-PD-1 (RR: 0.33, 95%CI: 0.14-0.77), anti-PD-L1 (RR: 0.38, 95%CI:0.16-0.91), and anti-PD-1 plus anti-CTLA-4 (RR: 0.32, 95%CI: 0.12-0.87) in terms of grade 3-5 RAEs. The difference was not significant between ICI monotherapy and traditional cancer therapy, except that targeted therapy seemed the least toxic therapy in terms of the incidence of AKI. Anti-CTLA-4 plus anti-PD-1 were associated with higher risk of RAEs than anti-PD-1 (RR: 1.61, 95%CI: 1.02–2.56). The difference was not significant between other dual ICI regimens and ICI monotherapy in terms of RAEs and AKI. ICI plus chemotherapy showed increased risk of both RAEs and AKI compared with ICI monotherapy, chemotherapy, and targeted therapy. The overall results remained robust in the meta-regression and sensitivity analyses.ConclusionsAmong ICI monotherapy, anti-CTLA-4 appeared to be associated with increased toxicity, especially in terms of grade 3–5 RAEs. Anti-CTLA-4 plus anti-PD-1 were associated with higher risk of RAEs than anti-PD-1. However, the difference was not significant between other dual ICI regimens and ICI monotherapy in terms of RAEs and AKI. ICIs plus chemotherapy seemed to be the most toxic treatment regimen in terms of RAEs, AKI, and grade 3–5 AKI.Systematic Review RegistrationPROSPERO, identifier CRD42020197039.

Abnormal blood pressure variability (BPV) is associated with various organ injuries, high risk of cardio-cerebrovascular events and mortality. To investigate the association between mean perfusion pressure variability (MPPV) and mortality in critically ill patients admitted to the Intensive Care Unit (ICU), we analyzed data stored in the eICU-CRD database. MPPV was measured as the standard deviation (SD), coefficient of variation (CV), average real variability (ARV) and variation independent of the mean (VIM) of the first 24 hours MPP data within the first 72 hours in the first ICU stay. A total of 6049 patients were included. Apart from SD, survivors had significantly lower MPPV in ARV, CV but higher VIM compared with non-survivors. After accounting for confounders, highest MPPV in decile using four measurements were associated with increased risk of hospital mortality compared with those in the fifth and sixth decile. In addition, lowest MPPV with dimension (mmHg) in decile also correlated to an increase in the risk of hospital mortality compared with the fifth and sixth decile. These relationships remained remarkable in the sensitive analyses. Increased MPPV and decreased MPPV with dimension were associated with short-term mortality in critically ill patients.

Introduction: Acute kidney injury has been identified as a common complication of cardiac surgery. To date, the effect of the time interval from coronary angiography to cardiac surgery on postoperative acute kidney injury is still controversial. The aim of this study was to investigate the relationship between the timing of coronary angiography and cardiac surgery associated acute kidney injury.Methods: Eight hundred thirteen patients who underwent coronary angiography and cardiac surgery successively from January 2017 to December 2018 were included in this retrospective cohort study. We applied multivariate logistic regression, propensity score analysis, and subgroup analysis to evaluate the association between the time interval and postoperative acute kidney injury incidence and prognosis. Meta-analysis was conducted to verify the results.Results: The overall incidence of the cardiac surgery associated acute kidney injury was 28.8%. Age (OR = 1.046, 95%CI: 1.017–1.075), cardiopulmonary bypass (OR = 3.439, 95%CI: 1.316–8.986) and diabetes (OR = 2.522, 95%CI: 1.439–4.417) were found to be independent risk factors of postoperative acute kidney injury in multivariate logistic regression and propensity score analysis. Undergoing cardiac surgery within 7 days after coronary angiography was not associated with increased incidence of postoperative acute kidney injury or worse prognosis. Meta-analysis obtained consistent results.Conclusions: The time interval shorter than 7 days had no influence on cardiac surgery associated acute kidney injury incidence and prognosis. The decision of delaying the surgery should be made after comprehensive evaluation of the patient.

Background: The optimal perfusion pressure target for acute kidney injury (AKI) in critically ill patients remains uncertain. We investigated the association between mean perfusion pressure (MPP) and AKI among critically ill patients and estimated its optimal range.Methods: We analyzed data stored in the Medical Information Mart for Intensive Care (MIMIC) -III, eICU Collaborative Research Database (eICU-CRD), and MIMIC-IV databases. Critically ill patients receiving invasive measurements of MPP for at least 12 hours within the first 24 hours of ICU stay were included. The exposure of interest was the time-weighted average MPP (TWA-MPP) in the first 24 hours. The primary outcome was the incidence of AKI in the next 48 hours. Results: We enrolled 7,992, 8,604, and 6,730 patients from the MIMIC-III, eICU-CRD, and MIMIC-IV databases, respectively. TWA-MPP had higher areas under the curve than mean arterial pressure in predicting AKI in the next 48 hours (0.63 vs 0.57, 0.62 vs 0.58, and 0.64 vs 0.58 in three databases, all p < 0.001). We observed the lowest adjusted risk of AKI when TWA-MPP above 72, 65, and 69 mmHg in the MIMIC-III, eICU-CRD, and MIMIC-IV databases, respectively. Pooled analyses indicated that per 10% increase of proportion of MPP above 65 mmHg was associated with decreased incidence of AKI (adjusted odds ratio = 0.93, 95% confidence interval = 0.92–0.94, p < 0.001). Furthermore, pooled analyses showed that the lowest risk of new-onset, persistence, and progression of AKI was estimated when TWA-MPP above 74, 70 and 65 mmHg, respectively. Conclusions: MPP outperformed mean arterial pressure as a perfusion predictor of AKI. MPP of 65 mmHg or higher may be the optimal target for managing AKI in critically ill patients. The target rises to higher when reversing or preventing AKI.

ObjectiveTo determine the relationship between obesity and the risk of AKI after cardiac surgery (CS-AKI) in a cohort study.MethodsA total of 1,601 patients undergoing cardiac surgery were collected and their incidence of CS-AKI was recorded. They were divided into underweight, normal weight, overweight, and obese groups. Logistic regression was used to estimate the association between BMI (body mass index) and CS-AKI risk. Then, a meta-analysis of published cohort studies was conducted to confirm this result using PubMed and Embase databases.ResultsA significant association was observed in this independent cohort after adjusting age, gender, hypertension and New York Heart Association classification (NYHA) class. Compared with normal BMI group (18.5 ≤ BMI < 24.0), the individuals with aberrant BMI level had an increased AKI risk (OR: 1.68, 95% CI: 1.01–2.78) for BMI < 18.5 group and (OR: 1.43, 95% CI: 0.96–2.15) for BMI ≥ 28.0. Interestingly, the U-shape curve showed the CS-AKI risk reduced with the increasing of BMI when BMI ≤ 24.0. As BMI increases with BMI > 24.0, the risk of developing CS-AKI increased significantly. In the confirmed meta-analysis, compared with normal weight, overweight group with cardiac surgery had higher AKI risk (OR: 1.28, 95% CI: 1.16–1.41, Pheterogeneity = 0.49). The similar association was found in obesity subgroup (OR: 1.79, 95% CI: 1.57–2.03, Pheterogeneity = 0.42).ConclusionIn conclusion, the results suggested that abnormal BMI was a risk factor for CS-AKI independently.

OBJECTIVE To determine the prognostic values of clinical and laboratory features at the time of presentation on renal function and survival of patients with myeloperoxidase anti-neutrophil cytoplasmic antibody-associated glomerulonephritis. (MPO-ANCA GN). MATERIALS AND METHODS A total of 119 patients (52 males and 67 females) with MPO-ANCA GN and hospitalized at the First Affiliated Hospital of Nanjing Medical University from January 2010 to April 2018 were enrolled. The baseline clinical characteristics, renal biopsy pathological data, and risk factors predictive of renal and patient survival were retrospectively analyzed. RESULTS Among these 119 patients, the median serum creatinine at diagnosis was 354.30 (range, 216.10 - 637.30) mmol/L and the median estimated glomerular filtration rate (eGFR) was 14.78 (range, 7.23 - 29.21) mL/min. In total, 58 (48.7%) patients received initial renal replacement therapy (RRT). During a median follow-up duration of 32 (range, 3 - 113) months, 57 (47.9%) patients progressed to end-stage renal disease (ESRD). Initial renal function status (i.e., initial RRT, serum creatinine, and eGFR) (p < 0.001) and hemoglobin level (p = 0.027) were significant risk factors for renal survival. During the follow-up, 69 (57.6%) of 119 patients survived. Age (p = 0.009) and urine red blood cell count (p = 0.012) were predictive of patient survival. CONCLUSION Among patients with MPO-ANCA GN, poor renal function and lower hemoglobin level were predictive of ESRD, while older age and higher urinary red blood cell count were associated with a higher risk for all-cause mortality.

The aim of this study was to investigate the effect of 10.6-μm laser moxibustion and electroacupuncture in 5-fluorouracil (5-Fu)-induced diarrhea model rats. Forty-eight Sprague Dawley rats were randomly divided into 4 groups: a normal group, model group, 10.6-μm laser moxibustion (LM) group, and electroacupuncture (EA) group. Diarrhea was induced by 5-Fu (50 mg/kg) injection in 36 rats; the LM and EA groups received treatment at acupoint ST36 (Zusanli) on hind limbs once a day for 6 days. 5-Fu injection caused body weight decline and diarrhea. From the 5th to 7th day, the LM group showed higher body weights than the model group (P < 0.05). On the 6th day, diarrhea score of the LM group was better than that of the EA group (P < 0.05). Both scores of the LM group and EA group were better than that of model group (P < 0.05). The LM group and EA group both had better intestine pathological scores and lower endotoxin (ET) and diamine oxide (DAO) activity than the model group (P < 0.01). The LM group got better pathological scores than the EA group (P < 0.01). Ultramicroscopic structures of the model group showed severe damage while the LM group and EA group remained good in their small intestines. The model group had obviously decreased occludin protein in intestine tissues than the control group (P < 0.01), while occludin expressions in the LM group and EA group were both obviously increased compared with the model group (P < 0.01). LM and EA treatment on ST36 could alleviate damage to intestinal barrier function and alleviate diarrhea caused by 5-Fu.

Purpose: Accurate preoperative parathyroid localization is important for successful parathyroidectomy (PTX). The aim of our study was to investigate whether SPECT/CT has enhanced effect in preoperative localization of parathyroids. Methods: In our retrospective cohort study, we evaluated the effects of technetium-99m methoxyisobutylisonitrile-single-photon emission computed tomography/computed tomography (99mTc-MIBI SPECT/CT) on preoperative parathyroid localization for 645 secondary hyperparathyroidism (SHPT) patients. Among them, 569 successful PTX patients were divided into group A (received 99mTc-MIBI scintigraphy, n = 175) and group B (received 99mTc-MIBI scintigraphy and SPECT/CT imaging, n = 394). Sensitivity, specificity, and consistency of two imaging methods in preoperative localization of parathyroids were compared. Results: Overall sensitivity and consistency were higher in group B, while there was no difference in specificity between the two groups. In group A, the sensitivity of 99mTc-MIBI was 50.00%, 77.11%, 61.76%, and 76.54% in the right upper gland (RU), right lower gland (RL), left upper gland (LU), and left lower gland (LL) subgroups, while the consistency was 52.00%, 76.57%, 61.71%, and 75.43%, respectively. In group B, the sensitivity of 99mTc-MIBI with SPECT/CT was 69.39%, 90.03%, 78.07%, and 84.27%, and the consistency was 69.54%, 88.32%, 78.43%, and 84.26%, respectively. The sensitivity and consistency in lower glands were higher than in upper glands in both groups. Sensitivity for eutopic parathyroid was higher in group B, while there was no difference for ectopic parathyroid. Conclusions: 99mTc-MIBI SPECT/CT can increase the sensitivity and consistency of preoperative localization of eutopic parathyroid glands, and it can accurately locate ectopic parathyroid without sensitivity improvement.

BACKGROUND The predictive value of Doppler-based renal resistive index (RRI) for acute kidney injury (AKI) has not been fully elucidated. The present meta-analysis was carried out to disclose the correlation between AKI and RRI, and to investigate the predictive value of RRI for the onset of AKI and its recovery. MATERIALS AND METHODS We searched PubMed, Embase, and Cochrane Library databases from inception to March 2019. The weighted mean difference (WMD) with a 95% confidence interval (CI) was used to assess the difference in RRIs between AKI and non-AKI patients. Moreover, the sensitivity and specificity were calculated, and summary receiver operating characteristic (SROC) curves were constructed. Meta-Disc and STATA were used for all statistical analyses. RESULTS A total of 20 studies (14 for prediction of the onset of AKI and 6 for prediction of AKI short-term non-recovery) were included in our meta-analysis. The values of RRI (WMD = 0.07; 95% CI: 0.05 - 0.09; p < 0.0001) were significantly higher in AKI patients compared with non-AKI patients. The overall sensitivity and specificity of RRI for prediction of the onset of AKI were 72% (95% CI, 64 - 80%) and 79% (95% CI, 71 - 85%), respectively. As for prediction of AKI short-term non-recovery, the pooled sensitivity was 81% (95% CI: 64 - 91), and the pooled specificity was 80% (95% CI: 72 - 85). For the onset of AKI, the best predictive performance was observed for the RRI measured immediately after major surgery, and a cut-off value ≥ 0.715 also achieved superior predictive value. CONCLUSION This study showed that the elevation of RRI may be related to the progression of AKI, and RRI could have good overall predictive value for the onset of AKI and its short-term non-recovery. Further studies in different clinical settings and patient groups are warranted before it could be widely used in clinical practice.

Acute kidney injury (AKI) is a common disease, but diagnosis is usually delayed or missed in hospitalized patients. The aim of this study was to investigate the impact of under-recognition of AKI (beyond 3 days after AKI onset) on short-time prognosis. Of 785 patients with under-recognition of AKI and 616 patients with timely-recognition of AKI were propensity matched in a 1:1 ratio. The two groups, with a total of 482 matched patients (241:241), were comparable in baseline covariates. Under-recognition of AKI was not associated with 30-day all-cause mortality in the logistic regression model with covariate adjustment (OR = 1.01, 95% CI = 0.62–1.64, p = 0.967). Sensitivity analyses and subgroup analyses also proved the association. There were also no significant differences in causes of 30-day mortality, in-hospital mortality, recovery of renal function at discharge, length of hospital stay, length of intensive care unit stay or hospitalization costs between the two groups, although timely-recognition group had more chance of renal consult and a little more interventions for AKI. In conclusion, under-recognition of AKI may not be associated with poor short-term outcomes of adult hospitalized patients via these propensity-score-matched analyses.

Objective This study was performed to explore the risk factors for hungry bone syndrome (HBS) and establish prediction equations for calcium supplementation after parathyroidectomy in hemodialysis patients with secondary hyperparathyroidism. Methods We retrospectively analyzed data from 252 hemodialysis patients undergoing successful total parathyroidectomy with autotransplantation. HBS was defined according to a minimum postoperative serum corrected calcium (PcCa) concentration of Conclusions Establishment of prediction equations for HBS may contribute to a new individualized therapy for patients with HBS.

Background Renal replacement therapy (RRT) with regional citrate anticoagulation (RCA) is an important therapeutic approach for refractory hypercalcemia complicated with renal failure. However, RCA has the potential to induce arrhythmia caused by rapid calcium loss. We report a case of arrhythmia associated with rapid calcium loss during RCA-RRT. Case presentation A 51-year-old man with hypercalcemia, primary hyperparathyroidism, and acute kidney injury was treated by predilutional-RCA-hemofiltration at a rate of 4.3 L/h. The effect of lowering serum calcium was unsatisfactory despite reducing calcium substitution gradually from 5.3 to 2.2 mmol/h in the first 8-h session of RCA-hemofiltration. New-onset sinus tachycardia with a prolonged QT interval occurred when calcium substitution was infused at rate of 1.1 mmol/h after 15 min of starting the second RCA-hemofiltration session (estimated net calcium loss was 7.54 mmol/h). When the calcium substitution was increased to usual rate of 5.6 mmol/h, the arrhythmia disappeared after 2 min. Arrhythmia did not recur when the calcium substitution rate was 2.2 mmol/h during the third session (estimated net calcium loss was 6.44 mmol/L). After the third RCA-hemofiltration session, the patient underwent parathyroidectomy and serum calcium returned to normal. Conclusions This case indicated that rapid calcium loss may cause arrhythmia in RCA-hemofiltration, and the rate of net calcium loss should be limited below a threshold value to prevent similar adverse effect during RCA-RRT.

The aim of this study is to investigate the association between body composition, measured by bioelectrical impedance analysis, and outcomes in patients with acute kidney injury (AKI) receiving kidney replacement therapy (KRT).Patients with severe AKI treated with KRT in our hospital between September 2016 and August 2018 were enrolled. These patients were assessed by body composition analysis before KRT, and on the 3rd day and the 7th day after initiation of KRT. The predictors included lean tissue index (LTI), fat tissue index, and body cell mass index (BCMI). The association between all-cause mortality and predictors was analyzed using Cox regression.A total of 152 patients were included in this study, with a 28-day mortality of 46.7% and 1-year mortality of 60.5%. LTI (adjusted hazard ratio per standard deviation: 0.37; 95% confidence interval = 0.21-0.66, P .001) and BCMI (adjusted hazard ratio per standard deviation: 0.37; 95% confidence interval = 0.21-0.67, P .001) on day 7 after initiation of KRT, rather than before KRT, were associated with mortality during follow-up. LTI and BCMI before KRT were associated with 28-day mortality rather than 1-year mortality.LTI and BCMI before KRT were associated with short-term prognosis, and those on day 7 after KRT initiation were associated with intermediate mortality in patients with AKI requiring KRT.

Long‐term peritoneal dialysis is accompanied by functional and histopathological alterations in the peritoneal membrane. In the long process of peritoneal dialysis, high‐glucose peritoneal dialysis solution (HGPDS) will aggravate the peritoneal fibrosis, leading to decreased effectiveness of peritoneal dialysis and ultrafiltration failure. In this study, we found that the coincidence of elevated TGF‐β1 expression, autophagy, apoptosis and fibrosis in peritoneal membrane from patients with peritoneal dialysis. The peritoneal membranes from patients were performed with immunocytochemistry and transmission electron microscopy. Human peritoneal mesothelial cells were treated with 1.5%, 2.5% and 4.25% HGPDS for 24 hrs; Human peritoneal mesothelial cells pre‐treated with TGF‐β1 (10 ng/ml) or transfected with siRNA Beclin1 were treated with 4.25% HGPDS or vehicle for 24 hrs. We further detected the production of TGF‐β1, activation of TGF‐β1/Smad2/3 signalling, induction of autophagy, EMT, fibrosis and apoptosis. We also explored whether autophagy inhibition by siRNA targeting Beclin 1 reduces EMT, fibrosis and apoptosis in human peritoneal mesothelial cells. HGPDS increased TGF‐β1 production, activated TGF‐β1/Smad2/3 signalling and induced autophagy, fibrosis and apoptosis hallmarks in human peritoneal mesothelial cells; HGPDS‐induced Beclin 1‐dependent autophagy in human peritoneal mesothelial cells; Autophagy inhibition by siRNA Beclin 1 reduced EMT, fibrosis and apoptosis in human peritoneal mesothelial cells. Taken all together, these studies are expected to open a new avenue in the understanding of peritoneal fibrosis, which may guide us to explore the compounds targeting autophagy and achieve the therapeutic improvement of PD.

// Chuanyan Zhao 1, * , Zhuyun Chen 1, * , Jia Qi 2 , Suyan Duan 1 , Zhimin Huang 1 , Chengning Zhang 1 , Lin Wu 1 , Ming Zeng 1 , Bo Zhang 1 , Ningning Wang 1 , Huijuan Mao 1 , Aihua Zhang 3, 4 , Changying Xing 1 , Yanggang Yuan 1 1 Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China 2 Department of Pharmacy, Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China 3 Department of Nephrology, Nanjing Children's Hospital, Nanjing Medical University, Nanjing, China 4 Institute of Pediatrics, Nanjing Medical University, Nanjing, China * These authors are contributed equally to this work Correspondence to: Yanggang Yuan, email: ygyuan@njmu.edu.cn Changying Xing, email: cyxing1962@163.com Keywords: Drp1, mitophagy, mitochondrial dysfunction, mitochondrial fission, cisplatin Received: July 10, 2016 Accepted: February 07, 2017 Published: February 18, 2017 ABSTRACT Cisplatin chemotherapy often causes acute kidney injury (AKI) in cancer patients. There is increasing evidence that mitochondrial dysfunction plays an important role in cisplatin-induced nephrotoxicity. Degradation of damaged mitochondria is carried out by mitophagy. Although mitophagy is considered of particular importance in protecting against AKI, little is known of the precise role of mitophagy and its molecular mechanisms during cisplatin-induced nephrotoxicity. Also, evidence that activation of mitophagy improved mitochondrial function is lacking. Furthermore, several evidences have shown that mitochondrial fission coordinates with mitophagy. The aim of this study was to investigate whether activation of mitophagy protects against mitochondrial dysfunction and renal proximal tubular cells injury during cisplatin treatment. The effect of mitochondrial fission on mitophagy was also investigated. In cultured human renal proximal tubular cells, we observed that 3-methyladenine, a pharmacological inhibitor of autophagy, blocked mitophagy and exacerbated cisplatin-induced mitochondrial dysfunction and cells injury. In contrast, autophagy activator rapamycin enhanced mitophagy and protected against the harmful effects of cisplatin on mitochondrial function and cells viability. Suppression of mitochondrial fission by knockdown of its main regulator dynamin-related protein-1 (Drp1) decreased cisplatin-induced mitophagy. Meanwhile, Drp1 suppression protected against cisplatin-induced cells injury by inhibiting mitochondrial dysfunction. Our results provide evidence that Drp1-depedent mitophagy has potential as renoprotective targets for the treatment of cisplatin-induced AKI.

Objective. Coronary slow/no reflow is not rare after successfully undergoing primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI), and shock index (SI) is an important factor for adverse cardiovascular prognosis. In this study, we are to explore whether SI is associated with coronary slow/no reflow in patients with AMI following primary PCI. Methods. A total of 153 consecutive AMI patients undergoing primary PCI within 24 hours of symptom onset were included in this study. The participants were divided into normal flow group (n=124) and slow/no reflow group (n=29) according to cineangiograms recorded during the period of PCI. Cardiovascular risk factors, hematologic parameters, preoperative management of antithrombotic therapy, and baseline angiography were collected. Results. SI, plasma glucose, white blood cells (WBC) and neutrophil count, neutrophil to lymphocyte ratio (PLR), high sensitivity C-reactive protein (hs-CRP), probrain natriuretic peptide (pro-BNP), and Killip classification on admission and thrombus burden on initial angiography were significantly different between patients with and without slow/no reflow. Multivariate analysis revealed that SI≥0.66, thrombus burden, and plasma glucose on admission were independent predictors for coronary slow/no reflow. Preoperative management of tirofiban therapy improves initial thrombolysis in myocardial infarction (TIMI). However, it has no effect on prognosis of slow/no reflow. Conclusion. Our findings demonstrated that slow/no reflow in patients with AMI following primary PCI was more likely associated with SI≥0.66, thrombus burden, and plasma glucose on admission. SI as a predictor for coronary slow/no reflow should be further confirmed in the following more large-scale and prospective studies. The clinical registration number is ChiCTR1900024447.

BACKGROUND Fatigue is the most common symptom negatively affecting the quality of life of patients with cancer. The objective of the current study was to evaluate the preliminary efficacy and safety of 10.6‐μm infrared laser moxibustion for cancer‐related fatigue (CRF). METHODS The authors conducted a randomized, placebo‐controlled trial among 78 patients with cancer who were diagnosed with CRF. The group treated with infrared laser moxibustion received 10.6 μm of infrared laser moxibustion on the ST36 (bilateral), CV4, and CV6 acupoints. Each participant received a 20‐minute treatment session 3 times per week for 4 weeks. The sham group received the same treatment duration on the same acupoints, but without infrared laser output. The outcome was change in fatigue as measured by the Chinese version of the Brief Fatigue Inventory between groups at week 4 with additional evaluation at week 8 for durability of treatment effects. A mixed effects model was used to evaluate the difference in treatment effect over time. RESULTS Among those randomized, 61 patients (78%) completed the entire study. At the end of the intervention, the individuals in the group treated with the laser were found to have significantly less fatigue than those in the sham group (3.01 vs 4.40; P = .002). The improvement in fatigue persisted to week 8, favoring the group treated with laser moxibustion (3.03 vs 4.26; P = .006). Laser moxibustion was safe, with 3 cases of mild local erythema that resolved without medical intervention reported. CONCLUSIONS Infrared laser moxibustion appeared to be safe and efficacious for improving CRF in a Chinese patient population. Larger studies in more racial/ethnically diverse populations are needed to confirm the benefit of this technique for fatigue in patients with cancer. Cancer 2016;122:3667‐72. © 2016 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes., The current study is a randomized, double‐blind, placebo‐controlled trial of infrared laser moxibustion for the treatment of cancer‐related fatigue. Infrared moxibustion appears to be a promising new therapy for this complication.

It is unclear whether clinical courses of hungry bone syndrome (HBS) after parathyroidectomy (PTX) in peritoneal dialysis (PD) and hemodialysis (HD) patients are different. The present study aimed to investigate the possible differences of postoperative hypocalcemia and hyperkalemia between PD and HD patients. We performed retrospectively 29 PD patients as the PD group and 169 HD patients as the HD group undergoing successful total PTX with autotransplantation. Calcium supplement after surgery was recorded. Higher levels of serum potassium during and immediately after surgery were recorded as K+d0. K+d3 was recorded as peak pre-dialysis serum potassium level 3 days post-surgery. There were 157 (92.90%) patients in HD group and 22 (75.86%) patients in PD group suffered from HBS after surgery, with significant difference between the groups (P = 0.004). Patients in PD group had significantly shorter intravenous calcium supplement duration (P = 0.037) and significantly smaller intravenous calcium supplement dosage (P = 0.042) and total calcium supplement dosage during hospitalization (P = 0.012) than patients in HD group. The levels of serum K+d0 (P

The Src homology and collagen A (ShcA) adaptor protein that binds to tyrosine kinase receptors. ShcA plays a role in insulin signaling, stress resistance and energy metabolism. The 66-kDa Src homology 2 domain-containing protein (p66shc) belongs to the ShcA family and has been associated with reactive oxygen species (ROS); increased ROS is involved in the pathology of lupus nephritis (LN). However, whether ShcA can act as a biomarker for oxidative injury in LN is unknown. This study is aimed to investigate the ShcA expression in kidney tissues from patients presenting with LN and the association between ShcA expression and clinical parameters. Renal biopsy tissues were obtained from 62 LN, 20 primary membranous nephropathy (MN) and 10 other secondary MN patients. ShcA was measured by immunofluorescence. The expression of ShcA in the membranous lupus nephritis (class V) group showed a higher trend but there were no significant differences compared with pure mesangial disease (class II) and proliferative (Class III/IV) lupus nephritis. ShcA deposits were negative in primary and other secondary MN. ShcA might act as a new biomarker and a diagnostic tool to identify membranous lupus nephritis with other MN.

PURPOSE: Fatigue is the most common and distressing symptom experienced by cancer survivors. This study sought to determine the prevalence and risk factors for fatigue among breast cancer (BC) survivors receiving aromatase inhibitors (AIs). MATERIAL AND METHODS: We conducted a cross-sectional survey study among postmenopausal women with stage 0 to III BC receiving adjuvant AI therapy at the outpatient breast oncology clinic of a large university hospital. Participants with a score ≥4 on the “worst fatigue” item of the Brief Fatigue Inventory (BFI) were classified as having moderate or severe fatigue. Multivariate logistic regression analyses were performed to evaluate risk factors. RESULTS: Among 1,103 participants, 616 (55.8%) had moderate or severe fatigue. In the multivariate logistic regression model, women younger than 55 years were significantly more likely to report moderate-severe fatigue than women older than 65 years (adjusted odds ratio (AOR), 1.58, 95% confidence interval (CI) 1.07–2.35; p=0.023). Compared to women with high school or less education, women with college or more education were significantly more likely to report moderate-severe fatigue (AOR, 1.40, 95% CI 1.02–1.91; p=0.037). Increasing body mass index (BMI) was significantly associated with increased risk of experiencing moderate-severe fatigue (overweight: AOR, 1.37, 95% CI 1.01–1.84; p=0.042; obesity: AOR, 2.08, 95% CI 1.53–2.81; p

Background: In chronic kidney disease (CKD) patients, decreased heart rate variability (HRV) reflects impaired cardiac automatic nervous function and high risk of cardiovascular disease (CVD). Lower HRV in patients with severe secondary hyperparathyroidism (SHPT), a clinical manifestation of CKD-mineral and bone disorder (CKD-MBD), could be reversed by parathyroidectomy (PTX). It has been proved that leptin interacts with the autonomic nervous function. However, the associations between leptin and HRV in CKD patients and their longitudinal changes in SHPT patients after PTX are still unknown. Methods: This was a cross-sectional study including 141 stage 5 CKD patients, and a prospective study in 36 severe SHPT patients with PTX. HRV was measured by Holter and serum leptin was measured by ELISA. Serum leptin levels were adjusted for body mass index (BMI) and transformed using natural logarithm (lnleptin/BMI). Results: With a gradient of lnleptin/BMI across quartiles from Q1 to Q4 in CKD patients, HRV indices showed no differences among quartiles. Patients in Q1 group had higher mean 24 h heart rates, and lower ln(very low frequency) (lnVLF) than other quartiles, although there were no statistically significant difference. In multivariate stepwise regression, serum leptin/BMI was an independent predictor for low frequency/high frequency. HRV indices and lnleptin/BMI levels were increased in severe SHPT patients after PTX. Compared to other quartiles, SHPT patients in Q1 group had larger improvement of lnVLF after PTX. Conclusion: Circulating leptin levels may be a novel treatment target to reduce CVD risk in advanced CKD-MBD patients.

The aim of the present study was to investigate the effect of the serum of patients with secondary hyperparathyroidism (SHPT) on endothelial cells and to examine the protective effect and the possible mechanism of Klotho. A total of three types of mixed serum from 15 patients with SHPT scheduled for parathyroidectomy, 10 chronic kidney disease (CKD) patients at stage 5 without SHPT and 15 healthy volunteers were collected. Initially, human umbilical vein endothelial cells (HUVECs) were incubated in vitro with the three types of serum and levels of proliferation were compared by assessing viable cell numbers with cell counting kit-8 (CCK-8). Subsequently, HUVECs were divided into three groups: Control group (healthy serum medium), SHPT group (SHPT serum) and Klotho treatment group (SHPT serum and Klotho). The proliferative and apoptotic levels of endothelial cells were evaluated by CCK-8 and flow cytometry, respectively. The levels of extracellular signal-regulated kinase (ERK1/2) and phosphorylated forms of ERK1/2 (p-ERK1/2) were detected using western blotting (with or without ERK1/2 inhibitor PD98059). The synthesis of nitric oxide (NO) was measured using the nitrate reduction method. The proliferation of HUVECs was inhibited by the serum from SHPT patients and CKD-5 patients without SHPT and the inhibitory effects of the SHPT serum were the most marked (P

Background/Aims: To evaluate the long-term outcomes of Chinese patients with cardiac surgery-associated acute kidney injury (CSA-AKI). Methods: Patients who underwent cardiac surgery with a median 3-year follow-up were enrolled. The long-term survival rate and the incidence of chronic kidney disease (CKD) were recorded, and related risk factors were analyzed. Results: Of all 1,363 patients, 457 (33.5%) developed CSA-AKI. The AKI patients had a lower 3-year survival rate (88.8 vs. 97.2%, respectively, p < 0.001) and a higher incidence of CKD stages 3-5 (9.9 vs. 2.3%, respectively, p < 0.001) than the non-AKI patients. Cox regression analysis showed that AKI, atrial fibrillation, chronic cardiac insufficiency, longer surgical duration, respiratory failure after surgery, and longer mechanical ventilation time were associated with long-term mortality, while AKI, older age, and lower baseline kidney function were associated with incident CKD stages 3-5. Conclusion: CSA-AKI increased the risk of 3-year mortality and incident CKD stages 3-5.

To explore the relationship between ambulatory blood pressure and arterial atherosclerosis and provide simple and easy reference indicators for the prediction, prevention and prognosis of cardiovascular events in end-stage renal disease (ESRD) patients.This prospective study consecutively collected clinical data of 114 ESRD hospitalized patients in the Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University during August 2012 to December 2012. The data included laboratory data, the ambulatory blood pressure monitoring (ABPM), carotid ultrasound, two-dimensional echocardiography and the prognosis scores of the death risk.(1) A series of ABPM parameters were closely associated with atherosclerosis (p ≤ 0.05). Ambulatory Arterial Stiffness Index (AASI) was the most representative parameter of ABPM and also the best indicator for atherosclerosis (logistic regression analysis, p = 0.005). (2) AASI was a comprehensive index of atherosclerosis (p 0.001), which was associated with the increase of left ventricular diameter (p = 0.028) and the risk of death (p 0.001). The independent risk factors of AASI were the growth of the age (p 0.001), elevated serum fibrinogen (p = 0.009) and reduced serum albumin (p = 0.022).AASI, as the representative of ABPM parameters, related well to atherosclerosis, which implied a broader application of ABPM in ESRD patients.

Fibroblast growth factor 23(FGF23) is a bone-derived hormone which regulates mineral homeostasis but may also have a role in cardiovascular disease. Here, we found that higher plasma FGF23 was independently associated with decreased heart rate variability in stage 5 CKD patients and parathyroidectomy may reverse these abnormal indicators. Lower heart rate variability (HRV) in patients with chronic kidney disease (CKD) compared with healthy controls is associated with increased risk of cardiovascular disease (CVD). Higher levels of plasma FGF23 also predict higher risk of CVD. Here, we aimed to evaluate the relationship between plasma FGF23 levels and HRV in patients with stage 5 CKD and to investigate longitudinal changes of them together with the correlation between their changes in two severe secondary hyperparathyroidism (SHPT) subgroups with successful parathyroidectomy (PTX) and persistent SHPT. This cross-sectional study included 100 stage 5 CKD patients, 78 controls, and a prospective study in two PTX subgroups classified as successful PTX (n = 24) and persistent SHPT (n = 4) follow-up. Blood examination and 24-h Holter monitoring for HRV were measured. Most HRV indices were lower in stage 5 CKD patients than in healthy controls, and plasma FGF23 levels were higher. In multivariate stepwise regression models, levels of plasma FGF23 and serum parathyroid hormone (PTH) were correlated with HRV. The successful PTX subgroup had significant improvements over baseline in HRV indices. Persistent SHPT subgroup had numerically similar changes in HRV indices. However, plasma FGF23 levels decreased in both subgroups. Plasma FGF23 levels were higher in CKD patients than in controls, much higher in patients with severe SHPT. FGF23 was independently associated with decreased HRV in stage 5 CKD. Successful PTX may reverse these abnormal indicators and contribute to decreases in the risk of cardiovascular disease.

Background Cancer-related fatigue (CRF) is the most common and distressing symptom associated with cancer treatment that breast cancer survivors (BCS) experience. We previously found that laser moxibustion may be efficacious for CRF. The primary aim of this study is to determine the specific efficacy of 10.6 μm infrared laser moxibustion on CRF. The secondary aim is to evaluate the effect of infrared laser moxibustion on co-existing symptoms that BCS experience. Methods We will conduct a randomized, sham-controlled, three-arm trial of infrared laser moxibustion (ILM) against sham ILM (SILM) and waitlist control (WLC) among BCS with moderate to severe fatigue. The two intervention groups will receive either real or sham infrared laser moxibustion on four acupoints (i.e., ST36 [bilateral], CV4, and CV6) for 20 minutes each session for 6 weeks (twice per week). The primary endpoint is the change in fatigue score from Baseline to Week 6 as measured by the Chinese version of the Brief Fatigue Inventory (BFI-C). Our secondary aim is to compare the severity of co-morbidities (e.g., depression, insomnia, and pain) among the 3 groups. Discussion The results of our trial will establish evidence for the efficacy of infrared laser moxibustion for CRF, a very common and challenging symptom. Trial registration number NCT03553355.

The use of left ventricular assist devices (LVADs) in treating patients with advanced heart failure restores cardiac output resulting in improved perfusion to multiple organ systems with important clinical benefits. Renal pathophysiology during LVAD support remains an evolving, poorly understood, and potentially dynamic problem. Changes in renal function after LVAD placement have been investigated in multiple studies with contradictory results. Renal dysfunction is common prior to LVAD placement, which complicates postoperative clinical outcomes. The purpose of this review is to assess the latest information regarding the effects of LVADs on renal function with regard to hemodynamics, physiology, pathology and clinical issues prior to and after placement of the devices. The review should then aid in identifying patients best suited to benefit from this technology and to refine the therapy to reduce associated risks.

Aims: The aims of this study were to investigate the efficacy and identify the prognostic factors of continuous hemofiltration in patients with cardiorenal syndrome (CRS) and, finally, to optimally select patients who could benefit more from this therapy. Methods: A total of 59 patients with CRS type 1 or type 2 treated with continuous hemofiltration were enrolled. We collected their clinical data and divided them into 2 groups according to their survival or death during hospitalization to conduct a retrospective analysis on factors affecting mortality. Results: The following items were significantly different between the survival (n = 30) and death (n = 29) groups: serum creatinine, serum total bilirubin, direct bilirubin, white blood cells, hemoglobin, hematocrit, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, systolic blood pressure and mean arterial pressure before hemofiltration, and average dehydration volume during the hemofiltration process. Leukocytosis was a risk factor for death (OR 1.242, 95% CI 1.242-1.480), and elevated sCr was not a key negative factor in the prognosis of CRS (OR 0.994, 95% CI 0.989-1.000). Conclusions: Cardiac function before hemofiltration and the amount of dehydration during the hemofiltration process both affected the prognosis. Infection and fluid overload condition at the beginning of hemofiltration were independently associated with mortality during hospitalization.

Summary Background and objectives Lower heart rate variability implies increased risk of cardiovascular disease. This study aimed to evaluate the relationship between mineral metabolism and heart rate variability and longitudinal changes of heart rate variability after parathyroidectomy in stage 5 CKD patients. Design, setting, participants, & measurements This cross-sectional study included 118 stage 5 CKD patients, 87 controls, and a prospective study in two subgroups classified as successful ( n =17) and unsuccessful ( n =4) parathyroidectomy follow-up enrolled from March of 2011 to December of 2012. Blood examination and 24-hour Holter for heart rate variability were measured. Results Most heart rate variability indices were lower in stage 5 CKD patients. In multivariate stepwise regression models, serum intact parathyroid hormone was correlated with mean normal-to-normal R–R intervals, mean heart rate, and very low frequency, serum calcium was correlated with SD of 5-minute average of normal R–R intervals, and serum phosphorus was correlated with very low frequency and low frequency/high frequency. Compared with baseline, the successful parathyroidectomy subgroup had significant improvements in mean normal-to-normal R–R intervals, mean heart rate, SD of normal-to-normal R–R intervals, SD of 5-minute average of normal R–R intervals, very low frequency, high frequency, and low frequency/high frequency. There was no significant change of heart rate variability in patients after unsuccessful parathyroidectomy. Conclusions Disorders of mineral metabolism are associated with decreased heart rate variability in stage 5 CKD. Successful parathyroidectomy may contribute to reverse this cardiovascular disease risk in severe secondary hyperparathyroidism patients.

Objective To observe the specificity of reinforcing and reducing methods of mild moxibustion and explore its clinical significance.

Background/Aims: Renal replacement therapy (RRT) is a rescue therapy for patients with type 1 cardiorenal syndrome (CRS) with poor prognoses. However, the optimal timing for initiation and cessation of RRT remains controversial. The purpose of this study was to determine the optimal timing of initiation and cessation of RRT for patients with type 1 CRS. Methods: In this retrospective analysis, patients with refractory type 1 CRS receiving RRT were divided into 3 groups according to weaning from RRT and death within 90 days. Baseline characteristics, underlying heart disease, comorbidities, drug use before RRT, indicators of RRT initiation, and prognosis were compared between the 3 groups. Results: Fifty-two patients were enrolled, which included 27 males and 25 females with a mean age of 70.7 ± 16.1 years and a 90-day mortality rate of 65.4%. The mean urine output before RRT initiation was 800 mL/ 24 h in the RRT-independent group, 650 mL/24 h in the RRT-dependent group, and 345 mL/ 24 h in the death group (p = 0.021). Additionally, there were obvious differences in fluid balance between the 3 groups (167, 250, and 1,270 mL, respectively, p = 0.016). Patients could be successfully weaned from RRT when urine output was >880 mL and fluid balance volume was Conclusion: The mean fluid balance of survivors was remarkably less than that of the death group at RRT initiation. RRT termination can be considered when urine output is >880 mL/24 h and volume balance is

Ventricular assist devices (VADs) are used to improve the systemic circulation and to decrease ventricular loading in patients with hemodynamic instability that is refractory to pharmacologic therapies. During an acute critical event, percutaneous devices are preferred because of their rapid deployment, since implantable devices require more extensive procedures. Implantable devices are used for patients with established end-stage heart failure as a bridge to heart transplantation, recovery or destination therapy. This report reviews mechanical principles and clinical studies regarding percutaneous VAD to address their potential renal effects. Since the focus of this study is set on devices that are dedicated to cardiac support only, extracorporeal membrane oxygenation systems are not included.

Background Acute kidney injury (AKI) places a heavy burden on the healthcare system in China and is usually misdiagnosed. However, there are limited studies that have described the epidemiology and diagnosis of AKI in China. The aim of this study was to describe the incidence and diagnosis of AKI in hospitalized adult patients in a tertiary teaching hospital in southeast China. Methods All adult patients hospitalized from October 1, 2013 to September 30, 2014 in the First Affiliated Hospital of Nanjing Medical University were screened using the Lab Administration Network. AKI definition and staging were based on the KDIGO AKI criteria. Demographic characteristics, laboratory examination, clinical data, and clinical outcomes of AKI patients were recorded and analyzed. Results The incidence of AKI was 1.6% (1401/87196). The 30-day mortality was 35.3%. AKI stage 1, 2, 3 and RRT accounted for 38.0% (532/1401), 22.0% (309/1401), 40.0% (560/1401), and 16.3% (228/1401) of patients, respectively. The Renal, other Internal Medicine, Surgery, and ICU Departments accounted for 7.4%, 37.1%, 30.1%, and 25.4% of AKI patients, respectively. The timely diagnosis rate, delayed diagnosis rate, and missed diagnosis rate were 44% (616/1401), 3.3% (46/1401), and 52.7% (739/1401), respectively. Patients hospitalized in the Renal Department had the highest AKI diagnosis rate (89.3%, 88/103), while missed diagnosis rate of the surgical patients was as high as 75.1% (317/422). Multivariable logistic regression analysis indicated that presence of tumors, higher serum albumin, and AKI stage 1 were associated with failure to timely diagnose AKI, whereas presence of chronic kidney disease, oliguria, higher blood urea nitrogen, and greater number of organ failures correlated with earlier diagnosis. Conclusions AKI was characterized by a high incidence, high short-term mortality, and high missed diagnosis rate in hospitalized adult patients in our hospital. Interventions for improving diagnosis of AKI are urgently needed. Electronic supplementary material The online version of this article (doi:10.1186/s12882-017-0622-6) contains supplementary material, which is available to authorized users.

Background/Aims: The study aimed to investigate the relationship among mortality of patients with cardiac surgery-associated acute kidney injury (CSA-AKI), fluid balance, and ultrafiltration of renal replacement therapy (RRT). Methods: From January 2009 to October 2015, hospitalized patients with CSA-AKI receiving continuous or prolonged intermittent RRT were screened. The effects of fluid balance and ultrafiltration of RRT on clinical outcome were analyzed. Results: The 30-day mortality of all the 63 patients in the study was 58.6%. Compared with the death group, the survival group had a significantly lower fluid balance, larger ultrafiltration volume, and similar ultrafiltration rate during the first 3 days of RRT. Multivariate Cox regression analysis revealed that positive fluid balance during the first day of RRT, cardiac function of grade IV, and higher Sequential Organ Failure Assessment score were independent risk factors of 30-day mortality. Conclusion: Fluid balance was more relevant to short-term prognosis of CSA-AKI-RRT patients than ultrafiltration volume or ultrafiltration rate.