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Background Previous studies have assessed note quality and the use of electronic medical record (EMR) as a part of medical training. However, a generalized and user-friendly note quality assessment tool is required for quick clinical assessment. We held a medical record writing competition and developed a checklist for assessing the note quality of participants’ medical records. Using the checklist, this study aims to explore note quality between residents of different specialties and offer pedagogical implications. Methods The authors created an inpatient checklist that examined fundamental EMR requirements through six note types and twenty items. A total of 149 records created by residents from 32 departments/stations were randomly selected. Seven senior physicians rated the EMRs using a checklist. Medical records were grouped as general medicine, surgery, paediatric, obstetrics and gynaecology, and other departments. The overall and group performances were analysed using analysis of variance (ANOVA). Results Overall performance was rated as fair to good. Regarding the six note types, discharge notes (0.81) gained the highest scores, followed by admission notes (0.79), problem list (0.73), overall performance (0.73), progress notes (0.71), and weekly summaries (0.66). Among the five groups, other departments (80.20) had the highest total score, followed by obstetrics and gynaecology (78.02), paediatrics (77.47), general medicine (75.58), and surgery (73.92). Conclusions This study suggested that duplication in medical notes and the documentation abilities of residents affect the quality of medical records in different departments. Further research is required to apply the insights obtained in this study to improve the quality of notes and, thereby, the effectiveness of resident training.

Encapsulating peritoneal sclerosis (EPS) is a catastrophic complication of peritoneal dialysis (PD) with high mortality. Our aim is to develop a novel noninvasive microRNA (miRNA) test for EPS.We collected 142 PD effluents (EPS: 62 and non-EPS:80). MiRNA profiles of PD effluents were examined by a high-throughput real-time polymerase chain reaction (PCR) array to first screen. Candidate miRNAs were verified by single real-time PCR. The model for EPS prediction was evaluated by multiple logistic regression and machine learning.Seven candidate miRNAs were identified from the screening of PCR-array of 377 miRNAs. The top five area under the curve (AUC) values with 5 miRNA-ratios were selected using 127 samples (EPS: 56 vs non-EPS: 71) to produce a receiver operating characteristic curve. After considering clinical characteristics and 5 miRNA-ratios, the accuracies of the machine learning model of Random Forest and multiple logistic regression were boosted to AUC 0.97 and 0.99, respectively. Furthermore, the pathway analysis of miRNA associated targeting genes and miRNA-compound interaction network revealed that these five miRNAs played the roles in TGF-β signaling pathway.The model-based miRNA expressions in PD effluents may help determine the probability of EPS and provide further therapeutic opinion for EPS.

A novel assay platform consisting of a microfluidic sliding double-track paper-based chip and a hand-held Raspberry Pi detection system is proposed for determining the albumin-to-creatine ratio (ACR) in human urine. It is a clinically important parameter and can be used for the early detection of related diseases, such as renal insufficiency. In the proposed method, the sliding layer of the microchip is applied and the sample diffuses through two parallel filtration channels to the reaction/detection areas of the microchip to complete the detection reaction, which is a simple method well suited for self-diagnosis of ACR index in human urine. The RGB (red, green, and blue) value intensity signals of the reaction complexes in these two reaction zones are analyzed by a Raspberry Pi computer to derive the ACR value (ALB and CRE concentrations). It is shown that the G + B value intensity signal is linearly related to the ALB and CRE concentrations with the correlation coefficients of R2 = 0.9919 and R2 = 0.9923, respectively. It is additionally shown that the ALB and CRE concentration results determined using the proposed method for 23 urine samples were collected from real suffering chronic kidney disease (CKD) patients are in fine agreement with those acquired operating a traditional high-reliability macroscale method. Overall, for point-of-care (POC) CKD diagnosis and monitoring in clinical applications, the results prove that the proposed method offers a convenient, real time, reliable, and low-spending solution for POC CKD diagnosis.

An electrochemical-biosensor (EC-biosensor) microchip consisting of screen-printed electrodes and a double-layer reagent paper detection zone impregnated with amaranth is proposed for the rapid determination of microalbuminuria (MAU) in human urine samples. Under the action of an applied deposition potential, the amaranth is adsorbed on the electrode surface and the subsequent reaction between the modified surface and the MAU content in the urine sample prompts the formation of an inert layer on the electrode surface. The inert layer impedes the transfer of electrons and hence produces a drop in the response peak current, from which the MAU concentration can then be determined. The measurement results obtained for seven artificial urine samples with known MAU concentrations in the range of 0.1–40 mg/dL show that the measured response peak current is related to the MAU concentration with a determination coefficient of R2 = 0.991 in the low concentration range of 0.1–10 mg/dL and R2 = 0.996 in the high concentration range of 10–40 mg/dL. Furthermore, the detection results obtained for 82 actual chronic kidney disease (CKD) patients show an excellent agreement (R2 = 0.988) with the hospital analysis results. Overall, the results confirm that the proposed detection platform provides a convenient and reliable approach for performing sensitive point-of-care testing (POCT) of the MAU content in human urine samples.

Background. Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication of peritoneal dialysis (PD). So far, there is no biomarker-based prediction tool available for EPS. Matrix metalloproteinase-2 (MMP-2) is a protein involved in the breakdown of the extracellular matrix, and the effluent MMP-2 can be a potential biomarker of EPS. This study is aimed at developing a nomogram for EPS based on effluent MMP-2 levels. Patients and Methods. We enrolled 18 EPS patients and 90 gender-matched PD patients without EPS in this cross-sectional case-controlled study. The effluent MMP-2 levels and possible risk factors for EPS were analyzed using multivariable logistic regression, and a nomogram was developed. The nomogram was validated using 200 bootstrap resamples to reduce overfit bias. Results. The effluent MMP-2 levels in EPS patients were significantly higher than those in normal PD patients (p<0.001, Manny-WhitneyUtest). Effluent MMP-2 levels and PD duration were independently associated with EPS risks (p<0.001andp=0.001) in multivariate logistic regression. A nomogram based on MMP-2 levels and PD duration was proposed. The AUC of MMP-2 was 0.824, and the AUC of the nomogram was 0.907 (p=0.05). Conclusion. A nomogram based on effluent MMP-2 levels and PD duration may predict EPS with high accuracy.

Escherichia coli is the most common cause of urinary tract infections (UTIs). It is widely accepted that uropathogenic E. coli (UPEC) mainly emerge from the distal gut microbiota. Identification of bacterial characteristics that are able to differentiate UPEC from fecal commensal strains will facilitate the development of novel strategies to detect and monitor the spread of UPEC.Fifty fecal commensal, 83 UTI-associated and 40 biliary tract infection (BTI)-associated E. coli isolates were analyzed. The NotI restriction patterns of chromosomal DNA in the isolates were determined by pulse-field gel electrophoresis. The phylogenetic types and the presence of 9 known virulence genes of each isolate were determined by PCR analyses. Additionally, the susceptibilities of the isolates to antibiotics were revealed. Then the associations of NotI resistance with UTI-associated isolates, phylotypes, and antibiotic resistance were assessed.NotI resistance was correlated with UTI-associated isolates, compared to the fecal isolates. Consistently, NotI-resistant isolates harbored a greater number of virulence factors and mainly belonged to phylotype B2. Additionally NotI resistance was correlated with chloramphenicol resistance among the bacteria. Among the fecal, UTI-associated and BTI-associated groups, the distribution of NotI-resistant group B2 isolates was correlated with UTI-associated bacteria.NotI resistance alone is a potential marker for distinguishing fecal strains and UPEC, while the combination of NotI resistance and B2 phylogeny is a candidate marker to differentiate UPEC from fecal and other extraintestinal pathogenic E. coli. Additionally, NotI resistance may be valuable for assessing the potential of chloramphenicol resistance of E. coli.

A microfluidic colorimetric detection (MCD) platform consisting of a sliding hybrid PMMA/paper microchip and a smart analysis system is proposed for the convenient, low-cost and rapid analysis of human urine and whole blood samples. The sliding PMMA/paper microchip comprises a PMMA microfluidic chip for sample injection and transportation, a paper strip for sample filtration (urine) or separation (blood), and a sealed paper-chip detection zone for sample reaction and detection. In the proposed device, the paper-chip is coated with bicinchoninic acid (BCA) and biuret reagent and is then assembled into the PMMA microchip and packaged in aluminum housing. In the detection process, the PMMA/paper microchip is slid partially out of the housing, and 2 μL of sample (urine or whole blood) is dripped onto the sample injection zone. The chip is then slid back into the housing and the sample is filtered/separated by the paper strip and transferred under the effects of capillary action to the sealed paper-chip detection zone. The housing is inserted into the color analysis system and heated at 45 °C for 5 min to produce a purple-colored reaction complex. The complex is imaged using a CCD camera and the RGB color intensity of the image is then analyzed using a smartphone to determine the total protein (TP) concentration of the sample. The effectiveness of the proposed method is demonstrated using TP control samples with known concentrations in the range of 0.03–5.0 g/dL. The detection results obtained for 50 human urine samples obtained from random volunteers are shown to be consistent with those obtained from a conventional hospital analysis system (R2 = 0.992). Moreover, the detection results obtained for the albumin (ALB) and creatine (CRE) concentrations of 50 whole blood samples are also shown to be in good agreement with the results obtained from the hospital analysis system (R2 = 0.982 and 0.988, respectively).

An integrated microfluidic Au nanoparticle (AuNP) aptasensor device is proposed for monitoring the concentration of potassium (K

Peritonitis is a serious complication and major cause of treatment failure in patients undergoing peritoneal dialysis (PD). Escherichia coli is the major pathogen in extraintestinal Gram-negative infections, including PD-related peritonitis. The outcomes of E. coli peritonitis in PD varied from relatively favorable outcomes to a higher incidence of treatment failure. The aim of this study was to investigate the impact of bacterial virulence and host characteristics on the outcomes of PD-related peritonitis caused by E. coli. From January 2000 to June 2016, a total of 47 episodes of monomicrobial and 10 episodes of polymicrobial E. coli PD-related peritonitis, as well as 89 episodes of monomicrobial Gram-positive (56 Staphylococcus spp. and 33 Streptococcus spp.) PD-related peritonitis cases, were retrospectively enrolled. Clinical features, E. coli bacterial virulence, and outcomes were analyzed. Compared to Streptococcus spp. peritonitis, E. coli peritonitis had a higher peritoneal catheter removal rate (38 versus 12%; P = 0.0115). Compared to the monomicrobial group, patients in polymicrobial group were older and had higher peritoneal catheter removal rate (80 versus 38%; P = 0.0324). Treatment failure of E. coli peritonitis was associated with more polymicrobial peritonitis and immunocompromised comorbidity, longer duration of PD therapy, and more antimicrobial resistance. E. coli isolates with more iron-related genes had higher prevalence of phylogenetic group B2 and papG II, iha, ompT, and usp genes. This study demonstrates the important roles of clinical and bacterial characteristics in the outcomes of monomicrobial and polymicrobial E. coli PD-related peritonitis.

Background Sclerostin, an antagonist of the Wingless-type mouse mammary tumor virus integration site (Wnt) pathway that regulates bone metabolism, is a potential contributor of chronic kidney disease (CKD)–mineral and bone disorder (MBD), which has various forms of presentation, from osteoporosis to vascular calcification. The positive association of sclerostin with bone mineral density (BMD) has been demonstrated in CKD and hemodialysis (HD) patients but not in peritoneal dialysis (PD) patients. This study assessed the association between sclerostin and BMD in PD patients. Methods Eighty-nine PD patients were enrolled; their sera were collected for measurement of sclerostin and other CKD–MBD-related markers. BMD was also assessed simultaneously. We examined the relationship between sclerostin and each parameter through Spearman correlation analysis and by comparing group data between patients with above- and below-median sclerostin levels. Univariate and multiple logistic regression models were employed to define the most predictive of sclerostin levels in the above-median category. Results Bivariate analysis revealed that sclerostin was correlated with spine BMD (r = 0.271, P = 0.011), spine BMD T-score (r = 0.274, P = 0.010), spine BMD Z-score (r = 0.237, P = 0.027), and intact parathyroid hormone (PTH; r = − 0.357, P

Patients with end-stage renal disease (ESRD) have higher risks of subdural hemorrhage (SDH) and subsequent 30-day mortality. However, evidences regarding optimal mode of dialysis therapy during acute management are sparse. We aimed to compare the outcomes of ESRD patients who received continuous peritoneal dialysis (CPD) or extended hemodialysis (EHD) after SDH and determined factors associated with 30-day mortality.We retrospectively reviewed consecutive patients with SDH and ESRD in a medical center. The clinical parameters and outcomes were compared between CPD and EHD groups. Factors associated with 30-day mortality were analyzed.We reviewed 32 patients, including 22 received EHD, 8 received CPD, and 2 received continuous veno-venous hemodialysis. Neurosurgery was done in 9 (28%) of them. There was no significant difference in baseline parameters and outcomes between EHD and CPD groups. The overall 30-day mortality rate was 19%. Lower Glasgow coma scale (GCS, median [interquartile range]: 10 [7-12] vs. 15 [11-15], p = 0.02) and larger changes in absolute mean arterial pressure (MAP: 26.5 [10.5-46.0] vs. 7.5 [2.0-17.8] mmHg, p = 0.01) during the first dialysis therapy were noted in patients with 30-day mortality. In multivariate analysis, consciousness disturbance at presentation was an independent risk factor for 30-day mortality.Among ESRD patients with SDH, the 30-day mortality rates were similar between EHD and CPD groups. MAP change during dialysis might be an important modifiable risk factor for 30-day mortality, though the effect was not significant in multivariate analysis. Further prospective studies with larger sample size are warranted.

Background Encapsulating peritoneal sclerosis (EPS) is a rare but serious complication of long-term peritoneal dialysis (PD). However, previous studies reported large variations in its mortality rates that may associate with a different degree of EPS severity. This study reports the incidence and outcomes of EPS and identifies the risk factors associated with severe EPS. Methods We retrospectively analyzed clinical data of EPS patients from 3 medical centers in Taiwan from January 1982 to September 2015, and classified patients as having mild/moderate or severe EPS. Patients with intractable intestinal obstruction/gut-related sepsis that needed surgical intervention or resulted in mortality were in severe EPS group. Follow-up for outcome was through December 31, 2015. Clinical characteristics, peritoneal dialysis (PD)-related parameters, biochemical and imaging results were analyzed and compared between groups. Results Fifty-eight of 3202 patients undergoing PD during the study period had EPS (prevalence 1.8%). The incidence of EPS increased for patients on PD for >6–8 years (≤6 yrs. vs. >6–8 yrs., 0.0% vs. 1.8%, p = 0.001). Relative to those on PD for >6–8 years, the risk of EPS significantly increased with PD duration longer than 10 years (>10–12 years vs. >6–8 years: OR: 5.5, 95% CI: 1.7–17.1, p < 0.01). Twenty-three patients fulfilled the criteria for severe EPS. The overall mortality rate of EPS was 35% (20/58), and was 74% (17/23) in the severe EPS group. The average serum levels of C-reactive protein (CRP) and intact-parathyroid hormone (i-PTH), which were checked every 3~6 months within one year before diagnosis of EPS, were higher in severe EPS group than in mild/moderate group (p = 0.02, p = 0.08, respectively). Multivariate analysis revealed severe EPS was independently associated with bowel tethering (based on CT), presentation with bloody ascites, diagnosis of EPS after withdrawal from PD, and i-PTH ≥ 384 pg/mL. Receiver operating characteristic analysis indicated that presentation with 2 or more of the 5 risk factors (EPS diagnosis after PD withdrawal, bloody ascites, bowel tethering, CRP ≥ 29 mg/L, and i-PTH ≥ 384 pg/mL) had a good accuracy (AUC = 0.80, p = 0.001) for prediction of severe EPS. Conclusions The incidence of EPS increases with PD duration. Severe EPS has high mortality rate and is associated with bowel tethering, presentation of bloody ascites, diagnosis after PD withdrawal, and higher serum levels of i-PTH before EPS diagnosis. Having 2 or more of the 5 risk factors can provide a good accuracy for prediction of severe EPS.

Background Matrix-assisted laser desorption/ionization–time of flight mass spectrometry (MALDI-TOF MS) is a valuable method for rapid identification of blood stream infection (BSI) pathogens. Integration of MALDI-TOF MS and blood culture system can speed the identification of causative BSI microorganisms. Materials and methods We investigated the minimal microorganism concentrations of common BSI pathogens required for positive blood culture using BACTEC FX and for positive identification using MALDI-TOF MS. The time to detection with positive BACTEC FX and minimal incubation time with positive MALDI-TOF MS identification were determined for earlier identification of common BSI pathogens. Results The minimal microorganism concentrations required for positive blood culture using BACTEC FX were >10 7 –10 8 colony forming units/mL for most of the BSI pathogens. The minimal microorganism concentrations required for identification using MALDI-TOF MS were > 10 7 colony forming units/mL. Using simulated BSI models, one can obtain enough bacterial concentration from blood culture bottles for successful identification of five common Gram-positive and Gram-negative bacteria using MALDI-TOF MS 1.7–2.3 hours earlier than the usual time to detection in blood culture systems. Conclusion This study provides an approach to earlier identification of BSI pathogens prior to the detection of a positive signal in the blood culture system using MALDI-TOF MS, compared to current methods. It can speed the time for identification of BSI pathogens and may have benefits of earlier therapy choice and on patient outcome.

Background/Purpose(s) Gram-negative peritonitis is a frequent and serious complication of peritoneal dialysis (PD). No previous reports have focused on Klebsiella pneumoniae infection. The aim of this study was to investigate the host and bacterial factors associated with K. pneumoniae PD-related peritonitis. Methods We retrospectively studied K. pneumoniae PD-peritonitis cases treated at a university hospital in southern Taiwan during 1990–2011, and analyzed the clinical features and outcomes and bacterial characteristics of serotypes, hypermucoviscosity (HV), and virulence-associated genes such as wabG, uge, and rmpA in K. pneumoniae PD-related peritonitis. Fifty-four isolates of K. pneumoniae -related community-acquired urinary tract infection (UTI) and 76 morphologically different nonpathogenic K. pneumoniae isolates from healthy adults were used as controls. Results K. pneumoniae was the second most common monomicrobial pathogen causing Gram-negative PD-related peritonitis ( n = 13, 2.7%), and the most common pathogen involved in polymicrobial peritonitis (16/43, 37.2%) and associated with high catheter removal rate (7/16, 43.8%). Compared with Escherichia coli peritonitis cases, patients with monomicrobial K. pneumoniae peritonitis also had insignificantly higher incidence of sepsis/bacteremia [ n = 5 (38%), p = 0.11] and a higher mortality rate [ n = 3 (23%), p = 0.36]. The prevalence of K1/K2 ( n = 1, 7.7%) serotypes was low, but there was a higher prevalence of serotype K20 ( n = 3, 23.1%) in K. pneumoniae isolates derived from monomicrobial PD-related peritonitis compared with control groups. HV phenotype ( p rmpA genotype ( p = 0.007) were absent in the peritonitis group. Conclusion This is the first study focused on clinical and microbiological characteristics of K. pneumoniae PD-related peritonitis. K. pneumoniae was a common Gram-negative pathogen causing monomicrobial and polymicrobial PD-related peritonitis in southern Taiwan. The bacterial characteristics with low percentage of capsular serotype K1/K2, no significant HV, and absence of rmpA suggest a different pathogenesis in K. pneumoniae PD-related peritonitis compared with that in UTI and liver abscess.

Background: Compliance index derived from digital volume pulse (CI-DVP), measuring the relationship between volume and pressure changes in fingertip, is a surrogate marker of peripheral arterial stiffness. This study investigated if CI-DVP can predict renal function deterioration, cardiovascular events and mortality in patients with chronic kidney disease (CKD). Methods: In this prospective observational study, 149 CKD patients were included for final analysis. CI-DVP and brachial-ankle pulse wave velocity (baPWV) were measured, decline in renal function was assessed by the estimated glomerular filtration rate (eGFR) slope. Composite renal and cardiovascular outcomes were evaluated, including ≥50% eGFR decline, start of renal replacement therapy, and major adverse events. Results: Patients in CKD stages 3b to 5 had higher baPWV and lower CI-DVP values than those in patients with CKD stages 1 to 3a. Stepwise multivariate linear regression analysis showed that lower CI-DVP (p =0.0001) and greater proteinuria (p =0.0023) were independent determinants of higher eGFR decline rate. Multivariate Cox regression analysis revealed that CI-DVP (HR 0.68, 95% CI 0.46-1.00), baseline eGFR (HR 0.96, 95% CI 0.94-0.98) and serum albumin (HR 0.17, 95% CI 0.07-0.42) were independent predictors for composite renal and cardiovascular outcomes. Conclusions: Compliance index, CI-DVP, was significantly associated with renal function decline in patients with CKD. A higher CI-DVP may have independent prognostic value in slower renal function decline and better composite renal and cardiovascular outcomes in CKD patients.

Motility mediated by the flagella of Escherichia coli is important for the bacteria to move toward host cells. Here, we present the relationship among bacterial motility, virulence factors, antimicrobial susceptibility, and types of infection. A total of 231 clinical E. coli isolates from different infections were collected and analyzed. Higher-motility strains (motility diameter ≥6.6 mm) were more common in spontaneous bacterial peritonitis (SBP) (SBP 59 %, colonization 32 %, urinary tract infection 16 %, urosepsis 34 %, and biliary tract infection 29 %; p < 0.0001). Compared with the higher-motility group, there was a higher prevalence of afa and ompT genes (p = 0.0160 and p = 0.0497, respectively) in E. coli strains with lower motility. E. coli isolates with higher and lower motility were in different phylogenetic groups (p = 0.018), with a lower prevalence of A and B1 subgroups in higher-motility strains. Also, the patterns of virulence factors and antibiotic susceptibility of E. coli isolates derived from various infections were significantly different. This study demonstrates that the prevalence of higher-motility strains was greater in E. coli isolates from SBP compared to other types of infection. Various types of E. coli infection were associated with differences in bacterial motility, virulence factors, and antibiotic susceptibility. More bacterial virulence factors may be necessary for the development of extraintestinal infections caused by E. coli isolates with lower motility.

Understanding the pathogenesis of recurrent urinary tract infection (RUTI) and whether it is attributable to reinfection with a new strain or relapse with the primary infecting strain is of considerable importance. Because previous studies regarding community-acquired Klebsiella pneumoniae RUTI are inconclusive, we undertook this study to evaluate the characteristics of the host and the bacterial agent K. pneumoniae in RUTI. A prospective study was designed, using consecutive patients diagnosed with community-acquired K. pneumoniae-related UTI from January 2007 to December 2009. Of the total 468 consecutive episodes, we found 7 patients with RUTI. All the patients with RUTI were elderly (median, 74 years), with diabetes (100 %, 7 out of 7). Clinical K. pneumoniae isolates derived from the same patients with RUTI revealed identical genomic fingerprints, indicating that K. pneumoniae UTI relapsed despite appropriate antibiotic therapy. The antimicrobial resistance, growth curve and biofilm formation of the recurrent isolates did not change. K. pneumoniae strains causing RUTI had more adhesion and invasiveness than the colonization strains (p < 0.01). When we compared the recurrent strains with the community-acquired UTI strains, the prevalence of diabetes mellitus was significant (100 % vs 53.7 %, p = 0.03) in the RUTI group. Our data suggest that K. pneumoniae strains might be able to persist within the urinary tract despite appropriate antibiotic treatment, and the greater adhesion and invasiveness in the recurrent strains may play an important role in recurrent infections.

Objective Malnutrition is common in patients with chronic kidney disease (CKD) who are on low-protein diets and is a powerful predictor of morbidity and mortality in CKD. Studies have shown that patients on low-protein diets often have difficulty meeting nutritional energy requirements. Our study evaluated the effects of a nonprotein calorie (NPC) supplement on renal function and nutritional status in patients on a low-protein diet. Design This was a prospective, randomized, open-label, controlled clinical trial. Subjects A total of 109 patients with CKD (men, 67%; mean age, 54.5 ± 13 years) with stage 3 to 4 disease were randomly assigned to the intervention group (n = 55) or the control group (n = 54). Intervention All participants received individualized dietary counseling aimed at achieving a daily protein intake of 0.6 to 0.8 g and a daily energy intake of 30 to 35 kcal/kg. The intervention group consumed a 200-kcal NPC supplement daily. The control group received dietary counseling only. Main Outcome Measure The estimated glomerular filtration rate (eGFR) was calculated using the 4-variable Modification of Diet in Renal Disease (MDRD) Study equation. Urine protein excretion, dietary protein and energy intake, and serum levels of creatinine, urea nitrogen, cholesterol, triglycerides, and albumin were assessed at baseline, at 12 weeks, and at 24 weeks. Results Dietary protein intake and urine protein excretion levels decreased significantly in the intervention group and were significantly lower than those of the control group. In addition, serum levels of creatinine and urea nitrogen decreased significantly, and eGFR increased significantly in the intervention group compared with baseline assessments. No significant differences were observed in the control group. Conclusions The NPC supplement improved patient adherence to the low-protein diet and reduced urine protein excretion in patients with CKD.

The macrophage migration inhibitory factor (MIF), a pro-inflammatory cytokine, is deregulated in acute kidney injury (AKI) through an unknown mechanism. In the present study, we used a previously described mouse model of ascending urinary tract infection in which uropathogenic Escherichia coli (UPEC) were transurethrally inoculated to induce kidney infections. Here, we show that urinary MIF was upregulated during AKI while MIF was abundantly expressed in the renal cortical tubules and that UPEC infection caused a decrease in tubular MIF. Infections with UPEC in vitro caused MIF release in a cell type-dependent manner, which was independent of receptor-mediated internalization, signal transduction, and transcription. Indeed, UPEC infection-induced necrotic cell death in vitro and in vivo correlated with extracellular acidification and processed MIF secretion. These data suggest that MIF is released by necrotic renal cortical tubular cells during UPEC infection.

The aim of this study was to characterize fluoroquinolone (FQ)-resistant Escherichia coli isolates from bacteremia in Taiwan in 2001–2015. During the study period, 248 (21.2%) of 1171 isolates were identified as levofloxacin-resistant. The results of phylogenetic group analysis showed that 38.7% of the FQ-resistant isolates belonged to phylogenetic group B2, 23.4% to group B1, 22.6% to groupA, 14.9% to group D and 0.4% belonged to group F. FQ-resistant isolates were highly susceptible to cefepime (91.5%), imipenem (96.0%), meropenem (98.8%), amikacin (98.0%) and fosfomycin (99.6%), as determined by the agar dilution method. β-lactamases, including blaTEM (66.1%), blaCMY-2 (16.5%), blaCTX-M (5.2%), blaDHA-1 (1.6%) and blaSHV-12 (1.6%), were found in FQ-resistant isolates. The results of PCR and direct sequencing showed that 37 isolates (14.9%) harbored plasmid-mediated quinolone resistance (PMQR) genes. qnrB2, qnrB4, qnrS1, coexistence of qnrB4 and qnrS1, oqxAB and aac(6′)-Ib-cr were found in 1, 4, 4, 1, 15 and 14 isolates, respectively. PMQR genes were successfully transfered for 11 (29.7%) of the 37 PMQR-harboring isolates by conjugation to E. coli C600. These findings indicate that qnr genes remained rare in E. coli but demonstrate the potential spread of oqxAB and aac(6′)-Ib-c in Taiwan.

Matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) and conventional standard methods were compared for time to pathogen identification and impact on clinical outcomes in peritoneal dialysis-related peritonitis patients. The MALDI-TOF MS method identified the causative microorganisms earlier (average time saved, 64 h for all pathogens), and patients had a shorter hospital stay (mean ± standard deviation, 5.2 ± 4.8 days versus 8.2 ± 4.5 days, P = 0.001).

Background. In dialysis patients, protein-energy wasting (PEW) is associated with high mortality, and some indicators of PEW, such as serum albumin value, subjective global assessment (SGA) score and handgrip strength (HGS), may predict mortality. However, whether PEW is associated with poor renal outcomes and whether the indicators of PEW can predict renal outcomes in patients with non-dialysis-dependent chronic kidney disease (CKD-ND) is still unclear.Methods. We enrolled 128 clinically stable patients with CKD-ND and followed up for 33.8 +/- 9.2 months. Baseline characteristics, echocardiographic information, laboratory data, HGS, SGA scores, anthropometric parameters, bio-impedance analyses and other indicators of PEW were examined in relation to the risk of reaching renal composite end points of pre-dialysis mortality or dialysis-dependent end-stage renal disease.Results. Twenty-six patients reached composite renal end points. Multivariate Cox regression analyses showed that HGS was an independent predictor of renal outcome in patients with CKD-ND of Stages 1-5 [CKD(1-5), hazard ratio (HR) = 0.90, P = 0.004] or advanced CKD-ND of Stages 3b [defined as estimated glomerular filtration rate (eGFR) of 30-44 mL/min/1.73m(2)] to 5 (CKD(3b-5), HR 0.91, P = 0.031), but not serum albumin, SGA score or other indicators of PEW. When the cutoffs were set at 24.65 kg in men with CKD(1-5), 20.15 kg in men with CKD(3b-5) and 10.15 kg in women with CKD(1-5) or CKD(3b-5), which were deduced from receiver-operating characteristics analyses, patients with lower HGS had significantly poor renal outcomes in Kaplan-Meier survival analyses in all subgroups and higher HR for reaching renal end points in multivariate Cox regression analyses in all subgroups except for women with CKD(3b-5), whose HR had marginal significance (HR = 3.78, P = 0.068) after adjusting for age and eGFR.Conclusions. This is the first study demonstrating that HGS is an independent predictor of composite renal outcomes in CKD-ND patients. HGS can be incorporated to clinical practice for assessing nutrition status and renal prognosis in patients with CKD-ND.

PCR coupled with electrospray ionization mass spectrometry (PCR/ESI-MS) was compared with culture for pathogen detection in peritoneal dialysis (PD)-related peritonitis. Of 21 samples of PD effluent, PCR/ESI-MS identified microorganisms in 18 (86%) samples, including Mycobacterium tuberculosis in 1 culture-negative sample. Of 15 double-positive samples, PCR/ESI-MS and culture reached levels of agreement of 100% (15/15) and 87.5% (7/8) at the genus and species levels, respectively. PCR/ESI-MS can be used for rapid pathogen detection in PD-related peritonitis.

Background/Aims: The optimal mode of dialysis for end-stage renal disease (ESRD) patients with spontaneous intracerebral hemorrhage (ICH) remains controversial. We compared the outcomes of ESRD patients who received continuous peritoneal dialysis (CPD) or extended hemodialysis (EHD) after ICH, and investigated the factors determining prognosis.Methods: We incorporated our ICH patients with ESRD, requiring dialysis from January 2005 to December 2009. Patients were allocated to the CPD or EHD group according to the dialysis mode after ICH. We compared the 30-day mortality rate and modified Rankin Scale (mRS) of the two groups and analyzed the factors associated with mortality. Results: There were 40 patients with 16 episodes in CPD and 27 episodes in EHD group, without significant differences in baseline demographic data. The 30-day mortality rate and mRS were not different between the two groups. The patients who died within 30 days had higher ICH scores (4 ± 1 vs. 1 ± 1, p < 0.001) and outcome scores (5 ± 2 vs. 1 ± 1, p < 0.001). Dialysis-related complications occurred more frequently in the PD group (p = 0.07), but were unrelated to mortality. Conclusion: Among ESRD patients with ICH, EHD had a similar 30-day mortality rate and 30-day mRS to those receiving CPD. The mortality was significantly related to the severity of ICH.

Many host and bacterial factors contribute to the development of different Escherichia coli extra-intestinal infections. The aim of this study was to evaluate the roles of host and bacterial factors in different extra-intestinal E. coli infections. A total of 221 E. coli isolates collected from urine, bile and peritoneal fluid were included in this retrospective study. Four main phylogenetic groups of E. coli, 14 genetic determinants, static biofilm formation and antimicrobial resistance data were assessed, as well as the immunological status of the hosts. Group B2 was the most common phylogenetic group (30%), especially in cases of asymptomatic bacteriuria (ABU), urinary tract infection (UTI), acute appendicitis/gastrointestinal perforation, and spontaneous bacterial peritonitis (SBP), and was associated with elevated prevalence of papG III, fimH, sfa, iha, hlyA, cnf1, ompT and usp. Phylogenetic group A was most common in the isolates from asymptomatic bacteriocholia, biliary tract infection, and peritoneal dialysis (PD)-related peritonitis. There was similarity with respect to both phylogenetic groups and virulence factors in strains from faeces and ABU, and in strains from faeces and SBP/PD-related peritonitis. Host characteristics were important in patients with ABU, UTI, and SBP/PD-related peritonitis. Immunocompetence of hosts was associated with a relatively high prevalence of papG II, afa and iha, and relatively low antimicrobial resistance to fluoroquinolones. This study demonstrates that, in most E. coli extra-intestinal infections, phylogenetic group B2 was predominant and was more virulent than the three other phylogenetic groups in the Taiwanese population studied. The diverse patterns of host and bacterial factors demonstrate that there were different host and bacterial factors dominating in different extra-intestinal E. coli infections.

Parathyroidectomy is recommended by the clinical guidelines for dialysis patients with unremitting secondary hyperparathyroidism (SHPT). However, the survival advantage of parathyroidectomy is debated because of the selection bias in previous studies. To minimize potential bias in the present nationwide cohort study, we enrolled only dialysis patients who had undergone radionuclide parathyroid scanning to ensure all patients had severe SHPT. The parathyroidectomized patients were matched with the controls based on propensity score for parathyroidectomy. Mortality hazard was estimated using multivariate Cox proportional hazard models adjusting for comorbidities before scanning (model 1) or over the whole study period (model 2). Our results showed that among the 2786 enrolled patients, 1707 underwent parathyroidectomy and the other 1079 were controls. The crude mortality rates were lower in the parathyroidectomized patients than in the controls. In adjusted analyses for the population matched on propensity score, parathyroidectomy was associated with a significant 20% to 25% lower risk for all-cause mortality (model 1: hazard ratio 0.76, 95% confidence interval 0.61 to 0.94; model 2: hazard ratio 0.80, 95% confidence internal 0.64 to 0.98). We concluded that parathyroidectomy was associated with a reduced long-term mortality risk in dialysis patients with severe SHPT.

● Background: Emphysematous pyelonephritis (EPN) is a rare, severe, gas-forming infection of the kidney, and its precise pathogenesis remains obscure. Methods: To investigate the roles of host and bacterial virulence factors in the pathogenesis of EPN, we compared: (1) host factors in patients with EPN (n 47) with those in patients with acute renal infections without gas formation (non-EPN; n 79), (2) the prevalence of virulence gene in causative Escherichia coli strains from 16 of the 47 EPN cases with all 79 non-EPN cases by means of polymerase chain reaction analysis, and (3) gas volumes produced by EPN and non-EPN strains cultured in broths at 3 glucose concentrations (100, 180, and 250 mg/dL [5.6, 10.0, and 13.9 mmol/L]). Results: Diabetes mellitus (DM) with poor glycemic control (ie, hemoglobin A1c level > 11%) and urinary tract obstruction were more prevalent in the EPN group. However, DM with poor glycemic control was the only host factor independently associated with EPN (odds ratio, 4.9; P 0.018). EPN strains had a greater prevalence of the uropathogenic-specific protein (usp) genes. Multivariate analyses also showed the association between usp and EPN with borderline significance (odds ratio, 8.4; P 0.057). There was no significant difference in gas production by E coli isolated from patients with or without EPN. Conclusion: DM with poor glycemic control and urinary tract obstruction are host factors predisposing to EPN. There was no difference in gas production between EPN and non-EPN E coli strains. The distribution of E coli virulence genes was remarkably similar between the 2 groups. However, the PapG II adhesin (papG II) gene is significantly decreased and the usp gene is increased with borderline significance in EPN E coli strains. Am J Kidney Dis 46:432-439. © 2005 by the National Kidney Foundation, Inc.

Spontaneous bacterial peritonitis (SBP) is one of the most serious complications in patients with cirrhosis. This study aimed to investigate the prevalence of SBP caused by Escherichia coli isolates with or without the K1 capsule antigen in cirrhotic patients and the outcome. From January 2004 to January 2012, a total of 54 and 41 E. coli strains derived from patients with SBP and intestinal perforation (IP), respectively, were included for comparison in this study. Bacterial characteristics including phylogenetic groups, K1 capsule antigen, and 14 virulence factor genetic determinants, as well as data regarding patient characteristics, clinical manifestations, and in-hospital deaths, were collected and analyzed. The prevalence of the K1 capsule antigen gene neuA was more common in SBP isolates compared to IP isolates (28 % vs. 10 %, p = 0.0385). Phylogenetic groups B2 and group D were dominant in E. coli isolates with and without the K1 capsule antigen, respectively. The prevalence of virulence factors genes papG II, ompT, and usp was higher in E. coli K1 strains. There were 26 deaths (48 %) during hospitalization. Presence of the K1 capsule antigen in E. coli isolates was significantly associated with in-hospital death in cirrhotic patients with SBP (42 % vs. 14 %, p = 0.0331). This study demonstrates a higher prevalence of the K1 capsule antigen in E. coli SBP compared to E. coli peritonitis caused by IP. There were significant associations between the K1 capsule antigen and in-hospital mortality and bacterial virulence in cirrhotic patients with E. coli SBP.

Outer membrane proteins (OMPs) serve as the permeability channels for nutrients, toxins, and antibiotics. In Escherichia coli , OmpA has been shown to be involved in bacterial virulence, and OmpC is related to multidrug resistance. However, it is unclear whether OmpC also has a role in the virulence of E. coli . The aims of this study were to characterize the role of OmpC in antimicrobial resistance and bacterial virulence in E. coli . The ompC deletion mutant showed significantly decreased susceptibility to carbapenems and cefepime. To investigate the survival of E. coli exposed to the innate immune system, a human blood bactericidal assay showed that the ompC mutant increased survival in blood and serum but not in complement-inactivated serum. These effects were also demonstrated in the natural selection of OmpC mutants. Also, C1q interacted with E. coli through a complex of antibodies bound to OmpC as a major target. Bacterial survival was increased in the wild-type strain in a dose-dependent manner by adding free recombinant OmpC protein or anti-C1q antibody to human serum. These results demonstrated that the interaction of OmpC-specific antibody and C1q was the key step in initiating the antibody-dependent classical pathway for the clearance of OmpC-expressing E. coli . Anti-OmpC antibody was detected in human sera, indicating that OmpC is an immunogen. These data indicate that the loss of OmpC in E. coli is resistant to not only antibiotics, but also the serum bactericidal effect, which is mediated from the C1q and anti-OmpC antibody-dependent classical pathway.

Conventional markers of kidney function that are familiar to clinicians, including the serum creatinine and blood urea nitrogen levels, are unable to reveal genuine injury to the kidney, and their use may delay treatment. Macrophage migration inhibitory factor (MIF) is a proinflammatory cytokine, and the predictive role and pathogenic mechanism of MIF deregulation during kidney infections involving acute kidney injury (AKI) are not currently known. In this study, we showed that elevated urinary MIF levels accompanied the development of AKI during kidney infection in patients with acute pyelonephritis (APN). In addition to the MIF level, the urinary levels of interleukin (IL)-1βand kidney injury molecule (KIM)-1 were also upregulated and were positively correlated with the levels of urinary MIF. An elevated urinary MIF level, along with elevated IL-1βand KIM-1 levels, is speculated to be a potential biomarker for the presence of AKI in APN patients.

A 72-year-old non-diabetic uremic woman underwent right nephrectomy for urolithiasis at the age of 50. Because pyuria, fever, chilliness and left flank pain developed during preparing for arteriovenous fistula, she was admitted to National Cheng Kung University Hospital. Renal cell carcinoma (RCC) complicated with emphysematous pyelonephritis (EPN) was diagnosed and immediately treated with antibiotics and CT-guided percutaneous catheter drainage. Cultures of pus and blood yielded Escherichia coli. She received left radical nephrectomy later for the control of persistent sepsis and removal of left renal tumor. The pathology of the tumor was composed of a glandular arrangement of granular cells with the occasional atypism, and renal parenchyma had been totally replaced by RCC. The non-tumor part of the kidney showed chronic pyelonephritis. Five months later, multiple metastases developed. We reported this first uremic case with EPN and RCC, but without diabetes mellitus and urinary tract obstruction. The gas formation may be due to large RCC, which caused impaired tissue perfusion and E. coli infection.

Background Patients with diabetes mellitus have an increased risk of infection. The roles of bacterial characteristics and glycemic control in diabetic patients with Escherichia coli infection have not been well investigated. The aims of this study were to examine the bacterial characteristics and glycemic control in diabetic patients with E. coli infections arising in the urinary tract. Methods A total of 271 E. coli isolates were collected from urine and bloodstream. Phylogenetic groups, the presence of virulence genes, and antimicrobial susceptibility of E. coli isolates were determined. Results There were few differences in E. coli bacterial characteristics between 190 diabetic and 81 nondiabetic patients. In diabetic patients with urosepsis, there was a higher hemoglobin A 1C level, and the related E. coli strains had more neuA , papG II , afa and hlyA genes, and a lower prevalence of antimicrobial resistance to cephalosporins and fluoroquinolones than those with asymptomatic bacteriuria and urinary tract infection. Multivariate logistic regression analysis revealed that increased hemoglobin A 1C and presence of papG II and afa genes were independent factors associated with development of urosepsis in diabetic patients. Conclusion This study demonstrated that more virulent E. coli isolates, especially with papG II and afa genes, and poorer glycemic control were important determinants for development of urosepsis in diabetic patients.

Most Staphylococcus lugdunensis strains (49/59, 83%) were related to clinical infections, were susceptible to most antimicrobial agents with an overall oxacillin-resistant rate of 5% (3/58), and carried relatively great genetic diversity. Community-acquired infections (41/49, 84%) were dominant, often developed in patients with comorbidity, and had rather benign clinical courses without mortality.

This study presents an integrated microfluidic chip for non-immunologically determining the concentrations of albumin in clinical urine samples. This microchip integrates membrane-type micromixers and a fan-shaped micropump capable of simultaneously and precisely delivering assay reagents to react with 6 urine samples in one single operation. The experimental results show that the coefficient of variation in the pumping rate is 2.42%. More importantly, using this unique chip design, only 2 electromagnetic valves are required for the actuation of the micromixer and the micropump. The working range of the proposed microchip is 2–200 mg/L of albumin, which covers the range of interest for the determination of microalbuminuria. Moreover, statistical analysis show that the results obtained by the proposed microchip are in good agreement with the conventional detection method, based on immunological assays. This simple, inexpensive and microchip-based platform presents a promising alternative to conventional immunological assays for measurement of urinary albumin, and is well suited for clinical applications.

Klebsiella pneumoniae is the second most common species causing urinary tract infections (UTI). However, the host factors and virulence genes of K. pneumoniae related to UTI are poorly understood. The aim of this study was to analyze the capsular phenotype and virulence genes of K. pneumoniae isolates and host factors potentially relevant to community-acquired UTI. Fifty-four K. pneumoniae isolates from patients with community-acquired UTI, 76 isolates from healthy adults, and 29 from patients with community-acquired pneumonia were compared. The virulence genes (rmpA, magA, uge, and wabG) and serotype (K1, K2, K5, K20, K54, or K57) were characterized by polymerase chain reaction (PCR). The modified string test was used to determine the hypermucoviscosity. Diabetes mellitus was the most frequent underlying disease among UTI patients (53.7%, 29/54). No predominant K serotype was found in UTI strains. The hypermucoviscosity phenotype and rmpA gene were more often found in UTI isolates than in those from healthy adults (27.8 vs. 2.6%, P

We evaluated the influence of patient factors and virulence factors of uropathogenic Escherichia coli on the occurrence of acute pyelonephritis and subsequent renal parenchymal scarring.We evaluated 80 boys and 45 girls 1 to 180 months old with febrile urinary tract infections who underwent renal scan to diagnose acute pyelonephritis and followup dimercapto-succinic acid scintigraphy at least 6 months later. Urinalysis, white blood cell count, uropathogenic E. coli genotype and vesicoureteral reflux were measured. Voiding cystourethrogram was investigated after acute pyelonephritis was confirmed by renal scan and acute inflammation subsided, about 2 to 4 weeks later.Acute pyelonephritis was significantly more likely to develop in children with urinary tract infections and persistent fever before and after hospitalization, elevated C-reactive protein or positive renal ultrasound findings. E. coli strains with the papG II and iha genes were significantly more likely to occur in patients with acute pyelonephritis. Patients with a fever for more than 3 days and C-reactive protein levels greater than 90.8 mg/l were significantly more likely to have renal scarring. Age was not an independent predictor of acute pyelonephritis, but modified the effect of virulence factors on the development of acute pyelonephritis.Bacterial virulence factors and host factors are associated with the occurrence of acute pyelonephritis. Host factors such as patient age and vesicoureteral reflux severity modify the influence of virulence factors, although only host factors are associated with the occurrence of renal scarring.

lung metastases; parathyroid carcinoma; nodules with calcification. A Tl-201 and Tc-99m sub-parathyroidectomy; tertiary hyperparathyroidism traction parathyroid scan revealed hot spots in theupper poles of both thyroid lobes. Serum aluminumconcentrations were within the normal range (pre-DFO 6.9 mg/dl, post-DFO 9.4 mg/dl). Based on these

We studied the pathogenic role of host and Escherichia coli virulence factors in the development of E. coli bacteremia in patients with acute cholangitis (AC) or upper urinary tract infection (UTI). Isolates recovered from 75 adult patients consecutively admitted to the hospital with E. coli bacteremia caused by AC (n=24) or upper UTI (n=51) were evaluated, as were 30 fecal strains isolated from healthy control individuals. Virulence genes of E. coli were detected by polymerase chain reaction analysis, including papG genes (classes I-III), sfa/foc, fimH, afa, hlyA, cnf1, and iutA. Our results show that biliary tract obstruction and urinary tract obstruction are important host factors for the development of E. coli bacteremia in patients with AC and upper UTI, respectively. With regard to E. coli virulence factors, the papG class II gene might play a more important role in the development of E. coli bacteremia in patients with upper UTI than in those with AC.

Emphysematous pyelonephritis and double cancers of the kidney and urinary tract are rare. We describe here a case of a diabetic man who had simultaneous renal cell carcinoma of the right kidney and transitional cell carcinoma of the right ureter complicated with emphysematous pyelonephritis within the tumour parenchyma of renal cell carcinoma. Imaging and pathology are demonstrated.

Microfluidics has attracted considerable attention since its early development in the 1980s and has experienced rapid growth in the past three decades due to advantages associated with miniaturization, integration and automation. Urine analysis is a common, fast and inexpensive clinical diagnostic tool in health care. In this article, we will be reviewing recent works starting from 2005 to the present for urine analysis using microfluidic devices or systems and to provide in-depth commentary about these techniques. Moreover, commercial strips that are often treated as chips and their readers for urine analysis will also be briefly discussed. We start with an introduction to the physiological significance of various components or measurement standards in urine analysis, followed by a brief introduction to enabling microfluidic technologies. Then, microfluidic devices or systems for sample pretreatments and for sensing urinary macromolecules, micromolecules, as well as multiplexed analysis are reviewed, in this sequence. Moreover, a microfluidic chip for urinary proteome profiling is also discussed, followed by a section discussing commercial products. Finally, the authors' perspectives on microfluidic-based urine analysis are provided. These advancements in microfluidic techniques for urine analysis may improve current routine clinical practices, particularly for point-of-care (POC) applications.

Emphysematous pyelonephritis (EPN) is a rare, severe gas-forming infection of renal parenchyma and its surrounding areas. The radiological classification and adequate therapeutic regimen are controversial and the prognostic factors and pathogenesis remain uncertain.To elucidate the clinical features, radiological classification, and prognostic factors of EPN; to compare the modalities of management (ie, antibiotic treatment alone, percutaneous catheter drainage combined with antibiotic treatment, or nephrectomy) and outcome among the various radiological classes of EPN; and to clarify the gas-forming mechanism and pathogenesis of EPN by gas analysis and pathological findings.Forty-eight EPN cases from our institution were enrolled between August 1,1989, and November 30, 1997. According to the radiological findings on computed tomographic scan, they were classified into the following classes: (1) class 1: gas in the collecting system only; (2) class 2: gas in the renal parenchyma without extension to extrarenal space; (3) class 3A: extension of gas or abscess to perinephric space; class 3B: extension of gas or abscess to pararenal space; and (4) class 4: bilateral EPN or solitary kidney with EPN. The clinical manifestations, management, and outcome were compared. The gas contents of specimens from 6 patients were analyzed. The pathological findings from 8 patients who received nephrectomy were reviewed. The statistical methods consisted of the Fisher exact test (2 tailed) for categorical variables and Wilcoxon rank sum test for continuous variables to test the predictors of poor prognosis.Forty-six patients (96%) had diabetes mellitus, and 10 (22%) of the 46 also had urinary tract obstruction in the corresponding renoureteral unit. The other 2 nondiabetic patients (4%) had severe hydronephrosis. Twenty-one (72%) of the 29 patients with diabetes mellitus also had a glycosylated hemoglobin A(1c) level higher than 0.08. Escherichia coli (69%) and Klebsiella pneumoniae (29%) were the most common pathogens. The mortality rate in patients who received antibiotic treatment alone was 40% (2 of 5 patients). The success rate of management by percutaneous catheter drainage (PCD) combined with antibiotic treatment was 66% (27 of 41 patients). In classes 1 and 2 EPN, all the patients who were treated using a PCD or ureteral catheter combined with antibiotic treatment survived. In extensive EPN (classes 3 and 4), 17 (85%) of the 20 patients with fewer than 2 risk factors (ie, thrombocytopenia, acute renal function impairment, disturbance of consciousness, or shock) were successfully treated using PCD combined with antibiotic treatment; and the patients with 2 or more risk factors had a significantly higher failure rate than those with no or only 1 risk factors (92% vs 15%, P.001). Eight of the 14 patients who had an unsuccessful treatment using a PCD underwent subsequent nephrectomy, 7 of whom survived. Only 2 patients were managed by direct nephrectomy and survived. The overall success rate of nephrectomy was 90% (9 of 10 patients). The total mortality was 18.8% (9 of 48 patients). Five of the 6 gas samples contained hydrogen (average, 12.8%), and all had carbon dioxide (average, 14.4%). The pathological findings from 8 of 10 who underwent nephrectomy revealed poor perfusion in most cases (ie, infarction, 5 patients; vascular thrombosis, 3 patients; and arteriosclerosis and/or glomerulosclerosis, 4 patients).Acute renal infection with E coli or K pneumoniae in patients with diabetes mellitus and/or urinary tract obstruction is the cornerstone for the development of EPN. Mixed acid fermentation of glucose by Enterobacteriaceae is the major pathway of gas formation. For localized EPN (classes 1 and 2), PCD combined with antibiotic treatment can provide a good outcome. (ABSTRACT TRUNCATED)

Aims of this study are to identify host and Escherichia coli virulence factors associated with upper urinary tract infection (UTI) by comparing them with those for lower UTI and determining the association between major predisposing host factors for upper UTI and urovirulence genes for E coli. Host factors and urovirulence genes of E coli associated with bacteremia in patients with upper UTI and their interactions also were studied. One hundred thirty-nine adult patients who fulfilled clinical diagnostic criteria for upper (n = 81) or lower UTI (n = 58) caused by E coli between January 1997 and December 1999 were retrospectively enrolled into this study. Old age (or =60 years), male sex, diabetes with poor blood glucose control (ie, glycosylated hemoglobin A1Cor = 8.1%), immunosuppression, and urinary tract obstruction were more frequently associated host factors for patients with upper UTI than for those with lower UTI. Using polymerase chain reaction, the papG class II allele was detected more frequently for E coli strains isolated from patients with upper UTI than for those from patients with lower UTI (85% versus 52%; P0.0001). Multivariate analysis showed that diabetes with poor blood glucose control, immunosuppression, urinary tract obstruction, and papG class II allele were independently associated with upper UTI. For patients without these three predisposing host factors, the prevalence of papG class II allele was significantly greater in those with upper UTI than those with lower UTI. However, the papG class II allele was less prevalent in strains isolated from patients with upper UTI with urinary tract obstruction or with two of the three predisposing host factors. In addition, both univariate and multivariate analyses showed that old age and papG class II allele were risk factors for the development of E coli bacteremia in patients with upper UTI. In conclusion, both host and E coli virulence factors contribute to the development of upper UTI, and less virulent strains can cause upper UTI in hosts with predisposing factors.