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

This study aimed to evaluate and compare the usefulness of four indices—arm circumference, thigh circumference, mid-arm muscle circumference (MAMC), and thigh muscle circumference (TMC)—with that of other classical indicators of body composition in the prediction of sarcopenia and two sarcopenia-related components in patients receiving peritoneal dialysis (PD) grouped by sex. The data of all patients receiving PD who visited a tertiary medical center were collected (n = 214); of them 199 patients undergoing PD were included in the final analyses. Data on baseline characteristics and measurements, including circumferences of appendicular sites, handgrip strength (HGS), and appendicular lean mass (ALM) index, were obtained during a routine peritoneal membrane equilibration test. Body composition was evaluated using dual-energy X-ray absorptiometry. The ALM index (kg/m2) was defined as the sum of lean mass in the upper and lower extremities divided by height squared. Sarcopenia was defined as low HGS and low muscle mass based on the cut-off values in the Asian Working Group for Sarcopenia guideline. The circumferences of the lower extremities showed the greatest association with the ALM index in both sexes. Prediction of HGS was better with the MAMC than with the other indices in the male patients, whereas none of the indices were associated with HGS in the female patients. Moreover, the MAMC in the male patients and TMC in the female patients were the strongest predictors of sarcopenia among the six anthropometric indices. This study showed that the MAMC in male PD patients and TMC in female PD patients might be the best predictors of sarcopenia. However, the TMC was associated with sarcopenia regardless of HGS in the female PD patients. These findings suggest that, in PD patients, different indices should be considered in predicting sarcopenia or its components based on the sex.

Many peritoneal dialysis (PD) patients are malnourished, which leads to weakening owing to a decrease in muscle mass. However, this straightforward association could differ based on the sex of individuals. Further, studies on the sex-based association among nutrition, muscle mass, and strength would be helpful in choosing optimal interventions to improve the strength of patients on dialysis. The study aimed to assess the association between these three variables using mediation analysis. This retrospective study included prevalent PD patients (n = 199). Mediation analysis was conducted to investigate the effect of the appendicular lean mass (ALM) index on the association between the geriatric nutritional risk index (GNRI) and handgrip strength (HGS). The numbers of PD patients with a low ALM index, low HGS, or low GNRI score were 121 (60.8%), 109 (54.8%), and 70 (35.2%), respectively. The proportion of patients with a low ALM index was lower in females than in males, and those with a low HGS were less in patients without diabetes than that in those with diabetes. Patients ≥ 65 years old had a higher proportion of low ALM index or HGS than those

Serial follow-up data of body composition from peritoneal dialysis (PD) initiation until 1 year after kidney transplantation (KT) would be useful in identifying pathologic or physiologic changes, related to each modality or during the exchange of the modality. Body composition analysis was performed 1 month after PD initiation, repeated annually, immediately before KT, 1 month and 1 year after KT (n = 43). Body composition analysis was performed using a bioimpedance analysis (BIA) machine. The body composition parameters measured using BIA included the water contents, fat mass index (FMI), appendicular muscle mass index (aMMI), and bone mineral content (BMC). The aMMI values 1 month and 1 year after PD initiation, immediately before KT, and 1 month and 1 year after KT were 7.6 ± 1.5, 7.8 ± 1.4, 8.0 ± 1.4, 6.8 ± 0.9, and 7.0 ± 1.0 kg/m2, respectively. The aMMI increased during the first year of PD (P = 0.029) and was maintained during the remaining period of PD (P = 0.413). The value decreased during the first month after KT (P

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

Objective Peritoneal dialysis (PD) peritonitis is a common complication in PD patients. The remission of peritonitis is easily achieved, but its presence is associated with local/systemic inflammation in PD patients, which would lead to decreases in muscle mass. Here, we hypothesized that the history of PD peritonitis is associated with low muscle mass (LMM) in PD patients. Methods We identified incident PD patients for whom body composition measurements at baseline and 1 year after PD initiation were available. Finally, we analyzed 230 incident PD patients. The PDP group was defined as patients with a PD peritonitis event during the period and the Non-PDP group was defined as patients without a PD peritonitis event during the period. Body compositions were calculated using bioimpedance and includes regional lean mass (LM), fat mass (FM), and sarcopenia index. Results There were no significant intergroup differences in baseline limb LM, total LM, or total FM. Total FM and body mass index at follow-up (FU) increased in both groups compared to that at baseline. There was no significant difference in total LM between baseline and FU in either group. Limb LM at FU increased in only the Non-PDP group compared to that at baseline. Sarcopenia index at FU decreased in only the PDP group compared to that at baseline. The prevalence of LMM at FU was higher in the PDP group than in the Non-PDP group. Among the participants without LMM at baseline, those in the PDP group had a higher prevalence of LMM at FU. Logistic regression showed that the PDP group was associated with a higher odds ratio for LMM at FU in the multivariate analyses. Conclusion LMM was found to be associated with the presence of PD peritonitis in incident PD patients.

Background Health care-associated infections during previous coronavirus epidemics involving severe acute respiratory syndrome and Middle East respiratory syndrome resulted from human-to-human transmission in hemodialysis (HD) facilities. The effect of a strategy of HD with cohort isolation-separate dialysis sessions for close contacts of patients with confirmed coronavirus disease 2019 (COVID-19)-on the prevention of secondary transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in HD units is unknown. Methods Our multicenter cohort study of an HD with cohort isolation strategy enrolled close contacts of patients with confirmed COVID-19, including patients on HD and health care workers in HD units. Close contacts had been identified by epidemiologic investigation and tested negative on an immediate screening test for SARS-CoV-2. Results As of March 14, 11 patients on HD and 7 health care workers from 11 HD centers were diagnosed as having COVID-19. The immediate screening test was performed in 306 people, and among them, 302 close contacts with negative test results were enrolled. HD with cohort isolation was performed among all close contacts for a median of 14 days in seven centers. During cohort isolation, nine patients showed symptoms but tested negative for SARS-CoV-2. Two health care workers in the HD units (0.66% of the total group) were diagnosed at the termination test for SARS-CoV-2. Conclusions The transmission of COVID-19 can be controlled without closure of HD centers by implementing preemptive activities, including early detection with rapid testing, cohort isolation, collaboration between institutions, and continuous monitoring of infection. Our strategy and experience may provide helpful guidance for circumstances involving the rapid spread of infectious diseases such as COVID-19.

Background Tunnel exposure, a non-infectious complication, is a rare finding in peritoneal dialysis (PD) patients, which has been described in some case reports. Our study aimed to present catheter salvage therapy using a revision procedure of tunnel exposure by nephrologists. Methods Our retrospective study was conducted between July 1998 and October 2021. We identified all PD patients with tunnel exposure from a database of a tertiary medical center. Tunnel exposure was diagnosed following gross inspection by clinicians during outpatient consultations. We attempted revision with partial external cuff shaving and creating a new tunnel without catheter change. Results Fourteen cases in 12 patients were diagnosed as tunnel exposure. The median age at presentation of tunnel exposure was 51 years. Eleven patients underwent revision, and the PD catheter was removed in one patient. The patients who underwent revision were followed up for 6 months. The catheter salvage rate was 72.7%. Conclusions The present study demonstrated that catheter revision performed by nephrologists could be a valuable alternative for original catheter salvage before considering catheter removal in tunnel exposure management.

Neck circumference (NC), per se, includes muscle mass beyond simple fat mass and mainly subcutaneous fat. We aimed to investigate the clinical usefulness of NC for predicting muscle mass, strength, or sarcopenia in patients undergoing peritoneal dialysis (PD).We retrospectively analyzed the data of patients undergoing PD (n = 199). NC, body compositions, and handgrip strength (HGS) were measured in all patients. Appendicular lean mass (ALM) was evaluated using dual-energy x-ray absorptiometry at the time of dry abdomen. Sarcopenia and metabolic syndrome were diagnosed using the definitions from previous guidelines. We analyzed the data divided by sex.In male patients, the discrimination performance of BMI or NC for sarcopenia was similar, but BMI was more closely associated with the prediction of metabolic syndrome than NC. Linear and logistic regression analyses showed that, in males, BMI was associated with the ALM index and metabolic syndrome, but NC was associated with sarcopenia and HGS. In addition, the addition of NC in the multivariate model was associated with better predictability of sarcopenia in men. In female patients, the discrimination performance of BMI or NC for sarcopenia or metabolic syndrome was similar.The present study demonstrated that NC is associated with HGS and sarcopenia in male patients undergoing PD. NC may be a useful option for screening for sarcopenia beyond simple BMI and may be helpful in identifying whether further evaluation for a diagnosis of sarcopenia is required.

Introduction We aimed to evaluate the association between the phase angle and muscle mass, muscle strength, physical performance tests, quality-of-life scales, mood scales, or patient and hospitalization-free survival rates in hemodialysis (HD) patients. Methods We included 83 HD patients. The patients were divided into tertiles based on phase angle value. The phase angle was measured using a bioimpedance analysis machine. Thigh muscle area per height squared (TMA/Ht2), handgrip strength (HGS), nutritional indicators, physical performance, quality-of-life, depression or anxiety status, and the presence of hospitalization or death regardless of cause were evaluated. Results In our study, no significant differences were observed in the serum albumin level and body mass index according to tertiles of phase angle. The phase angle tertiles were associated with TMA/Ht2 and HGS. The phase angle was also associated with physical performance measurements and depression or anxiety status. Subgroup analyses according to sex, age, and diabetes mellitus showed similar trends to those of the total cohort. Furthermore, the hospitalization-free survival rate and patient survival rate were favorable in patients with high values for the phase angle. Conclusion The present study demonstrated that the phase angle is associated with muscle mass, strength, physical performance, quality-of-life scale, and hospitalization-free survival in maintenance HD patients.

Data regarding the status of physical activity or understanding of the importance of exercise, such as barriers of exercise or enablers of exercise, in dialysis patients were insufficient. This study aimed to evaluate the status of physical activity and the understanding of the importance of exercise in Korean dialysis patients. The study participants were recruited from 27 hospitals or dialysis centers (n = 1611). Physical activity was evaluated using the Korean version of the International Physical Activity Questionnaire-Short Form. High physical activity was defined as ≥ 600 metabolic equivalent of task (MET). Knowledge about the importance of exercise, enabler for regular exercise, benefits of exercise, and barrier to exercise was evaluated. Health-related quality of life (HRQoL) was assessed by the Kidney Disease Quality of Life version 1.3. The number of participants in the hemodialysis (HD) and peritoneal dialysis (PD) groups was 1247 and 364, respectively. The intensity of physical activity did not differ between the two modalities. The time of physical activity was longer in HD patients than in PD patients, which resulted in greater MET values and the number of high physical activity. There were 762 (61.1%) HD patients and 281 (77.2%) PD patients who heard of the importance of exercise (P

Background The prevalence of sarcopenia is increased with declining renal function. Elevated serum indoxyl sulfate levels are associated with poor skeletal muscle conditions. We aimed to determine the effects of AST‐120, the oral adsorbent of indoxyl sulfate, on sarcopenia and sarcopenia‐associated factors in chronic kidney disease patients. Methods This was a 48 week, randomized controlled, parallel group, open‐label, multicentre trial (n = 150). The participants were randomly assigned in a 1:1 ratio to the control (CON) and AST‐120 (Renamezin®, REN) groups. Outcome measurements were performed at baseline and every 24 weeks for 48 weeks. The primary outcome was gait speed difference ≥0.1 m/s between the two groups, and secondary outcomes included hand grip strength, muscle mass, and health‐related quality of life. Results A difference of gait speed ≥0.1 m/s was not observed during the study period. The mean dynamic‐start gait speed in the REN group increased from baseline to 48 weeks (1.04 ± 0.31 to 1.08 ± 0.32 m/s, P = 0.019). The static‐start gait speed changed by −0.024 and 0.04 m/s (P = 0.049) in the CON and REN groups over 48 weeks, respectively. Hand grip strength decreased during the first 24 weeks and did not significantly change over the next 24 weeks in either group. The proportion of low muscle mass or sarcopenia at baseline was larger in the REN group than in the CON group, but the difference attenuated over the study period [low muscle mass and sarcopenia in the CON and REN groups at baseline, 4.0% vs. 18.9% (P = 0.004) and 2.7% vs. 13.5% (P = 0.017); at 24 weeks, 2.9% vs. 13.6% (P = 0.021) and 1.4% vs. 10.5% (P = 0.029); and at 48 weeks, 7.6% vs. 12.9% (P = 0.319) and 4.5% vs. 8.1% (P = 0.482), respectively]. Bodily pain, vitality, symptoms/problems, and cognitive function in the REN group improved, while the quality of social interactions and the kidney disease effects in the CON group aggravated from baseline to 48 weeks. Interaction between time and group was evident only in symptoms/problems, cognitive function, and kidney disease effects. Conclusions The addition of AST‐120 to standard treatment in chronic kidney disease patients did not make a significant difference in gait speed, although AST‐120 modestly had beneficial effects on gait speed change and quality of life and showed the potential to improve sarcopenia. (clinicaltrials.gov: NCT03788252).

We investigated the effectiveness of the transforming growth factor beta-1 (TGF-β) receptor inhibitor GW788388 on the epithelial to mesenchymal transition (EMT) using human peritoneal mesothelial cells (HPMCs) and examined the effectiveness of GW788388 on the peritoneal membrane using a peritoneal fibrosis mouse model. HPMCs were treated with TGF-β with or without GW788388. Animal experiments were conducted on male C57/BL6 mice. Peritoneal fibrosis was induced by intraperitoneal injection of chlorhexidine gluconate. GW788388 was administered by once-daily oral gavage. The morphological change, cell migration, and invasion resulted from TGF-β treatment, but these changes were attenuated by cotreatment with GW788388. TGF-β-treated HPMCs decreased the level of the epithelial cell marker and increased the levels of the mesenchymal cell markers. Cotreatment with GW788388 reversed these changes. Phosphorylated Smad2 and Smad3 protein levels were stimulated with TGF-β and the change was attenuated by cotreatment with GW788388. For the peritoneal fibrosis mice, thickness and collagen deposition of parietal peritoneum was increased, but this change was attenuated by cotreatment with GW788388. GW788388, an orally available potent TGF-β receptor type 1 inhibitor, effectively attenuated TGF-β-induced EMT in HPMCs. Cotreatment with GW788388 improved peritoneal thickness and fibrosis, and recovered peritoneal membrane function in a peritoneal fibrosis mouse model.

Background Few studies have considered optimal adjusted lean mass indices for prediction of clinical outcomes in peritoneal dialysis (PD) patients. We aimed to evaluate clinical variables using various adjusted indices in PD patients. Methods Total 528 incident PD patients were included. Lean mass was measured using dual energy X-ray absorptiometry. Appendicular lean mass (ALM) was calculated using the sum for both upper and lower extremities. Each ALM index was calculated using ALM per body weight (ALM/BW), height squared (ALM/Ht2), or body mass index (ALM/BMI). Limb/trunk lean mass (LTLM) ratio was defined as the sum for both upper and lower extremities divided by trunk lean mass. Results A total of 528 patients were analyzed men: 286, women: 242. In area under the receiver operating characteristic curve analyses, LTLM alone was associated with 1 year mortality. In the LTLM ratio, the cut-off value for 1-year mortality was ≤ 0.829 in men and ≤ 0.717 in women, respectively. In both sexes, LTLM ratio alone showed statistical significance in all-cause mortality in both univariate and multivariate Cox-regression analyses. Compared with other indices, the LTLM ratio was independent of edema and fat in both sexes. Edema- and C-reactive protein-adjusted correlation analysis showed that LTLM ratio alone was associated with serum albumin in men. Although statistical significance was not obtained for women, the correlation coefficient was highest for the LTLM ratio compared with other indices. Conclusion Among various indices using lean mass, LTLM ratio was independent of volume status and fat mass and was associated with mortality in incident PD patients.

Background Some sea anemone toxins cause renal injuries resembling hemolytic uremic syndrome (HUS). To date, only a few cases of HUS caused by sea anemone stings have been reported. In this case report, we have described an HUS case caused by a sea anemone sting. Case presentation In November 2019, a 37-year-old man with no underlying disease was admitted to our hospital. He presented with intense pain, a rash on, and swelling in his right thigh. Two days prior, he had been stung by a sea anemone while scuba diving in Cebu, Philippines. His blood tests revealed renal dysfunction, and his platelet count was normal. However, on day three, the platelet count decreased rapidly. His blood haptoglobin level decreased, and schistocytes were identified on the peripheral blood smear. We suspected thrombotic microangiopathy and started the conventional treatment, comprising hemodialysis, blood transfusion, and antibiotic administration. ADAMTS-13 and genetic test results associated with atypical HUS were normal. Therefore, the patient was diagnosed with HUS caused by a sea anemone toxin. Conclusions HUS caused by a sea anemone toxin is rare, but it is a serious medical disease. Clinicians should consider HUS in patients with such clinical presentations, and they should make prompt treatment-related decisions.

Background A population-based study would be useful to identify the association between chronic kidney disease (CKD) or acute kidney injury (AKI) and prognosis of coronavirus disease 2019 (COVID-19) patients. Methods This retrospective study utilized the claim data from Korea. Patients who underwent COVID-19 testing and were confirmed to be positive were included and divided into the following three groups based on the presence of CKD or requirement of maintenance dialysis: Non-CKD (participants without CKD), non-dialysis CKD (ND-CKD), and dialysis-dependent CKD (DD-CKD) patients. We collected data on the development of severe clinical outcomes and death during follow-up. Severe clinical outcomes were defined as the use of inotropics, conventional oxygen therapy, high-flow nasal cannula, mechanical ventilation, or extracorporeal membrane oxygenation and the development of AKI, cardiac arrest, myocardial infarction, or acute heart failure after the diagnosis of COVID-19. AKI was defined as the initiation of renal replacement therapy after the diagnosis of COVID-19 in patients not requiring maintenance dialysis. Death was evaluated according to survival at the end of follow-up. Results Altogether, 7,341 patients were included. The median duration of data collection was 19 (interquartile range, 11–28) days. On multivariate analyses, odds ratio (OR) for severe clinical outcomes in the ND-CKD group was 0.88 (95% confidence interval [CI], 0.64–1.20; P = 0.422) compared to the Non-CKD group. The DD-CKD group had ORs of 7.32 (95% CI, 2.14–33.90; P = 0.004) and 8.32 (95% CI, 2.37–39.21; P = 0.002) compared to the Non-CKD and ND-CKD groups, respectively. Hazard ratio (HR) for death in the ND-CKD group was 0.79 (95% CI, 0.49–1.26; P = 0.318) compared to the Non-CKD group. The DD-CKD group had HRs of 2.96 (95% CI, 1.09–8.06; P = 0.033) and 3.77 (95% CI, 1.29–11.06; P = 0.016) compared to the Non-CKD and ND-CKD groups, respectively. DD-CKD alone was associated with severe clinical outcomes and higher mortality. There was no significant difference in frequency of severe clinical outcomes or mortality rates between the Non-CKD and ND-CKD groups. In patients not requiring maintenance dialysis, AKI was associated with old age, male sex, and high Charlson's comorbidity index score but not with the presence of CKD. HRs for patients with AKI were 11.26 (95% CI, 7.26–17.45; P < 0.001) compared to those for patients without AKI in the multivariate analysis. AKI was associated with severe clinical outcomes and patient survival, rather than underlying CKD. Conclusion CKD requiring dialysis is associated with severe clinical outcomes and mortality in patients with COVID-19; however, the development of AKI is more strongly associated with severe clinical outcomes and mortality., Graphical Abstract

Background The use of human intravenous immunoglobulin gamma (IVIG) is associated with thromboembolic events as a complication. There are few reported cases of renal infarction during IVIG use in the general population, but transplant kidney may be more susceptible to thromboembolic events following IVIG use. Case presentation A 41-year-old woman visited with fever and pain at the transplant kidney. Six years ago, she underwent kidney transplantation from a deceased donor. Laboratory and radiologic findings were compatible to septic condition, secondary to acute pyelonephritis. We started antibiotics, inotropics, and IVIG. The patient abruptly developed gross hematuria and urine output decreased to 100 cc/day during IVIG administration. Renal doppler and pathologic findings revealed renal infarction. Oliguria and azotemia persisted and she is undergoing maintenance hemodialysis. Conclusion Our case shows that infarction of transplant kidney can be caused by IVIG use in a patient with severe infection. Thus, when using IVIG for kidney transplant patients with high risk of thromboembolic events, we may be careful to prevent the thromboembolic events.

Proper screening or diagnosis of sarcopenia (SP) is important to obtain favorable outcomes in patients on peritoneal dialysis (PD). Previous studies have shown that the SARC-F is associated with various parameters of SP in elderly populations. In this study, we aimed to validate the SARC-F questionnaire for predicting SP in patients on PD.This cross-sectional study was conducted at a tertiary medical center. We identified all patients prevalent on PD patients (n = 127). A version of the original SARC-F was used to assess the questionnaire. Patients with a total score of ≥4 points were defined as the high group and those with4 points were defined as the normal group. The hand grip strength and appendicular skeletal muscle mass index were measured in all patients. SP was defined as previously reported.Of the 127 total patients, 29 (22.8%, high group) had an SARC-F score of ≥4. The sensitivity and specificity of the SARC-F for predicting SP were 70.0% and 81.2%, respectively. The negative predictive and positive predictive values were 96.9% and 24.1%, respectively. The area under curve of the SARC-F score for SP was 0.791 (0.709-0.858, P .001). The hand grip strength of the normal and high groups was 26.4 ± 8.5 and 19.5 ± 6.8 kg, respectively (P .001). The appendicular skeletal muscle mass index in the normal and high groups was 7.6 ± 1.3 and 7.2 ± 1.8 kg/mThe SARC-F has a high negative predictive value and a high specificity for predicting SP in patients on PD.

Background Gastric antral vascular ectasia (GAVE), associated with autoimmune diseases, such as systemic lupus erythematosus, and hepatic or renal disorders, is a rare cause of gastrointestinal bleeding. We report the case of a patient with lupus erythematosus undergoing hemodialysis with an uncorrectable anemia caused by GAVE. Case presentation A 76-year-old Korean woman with lupus undergoing hemodialysis frequently complained of symptoms or signs associated with anemia, such as dizziness, dyspnea, hypotension, melena, and hematemesis. Gastrointerstinal endoscopy revealed multiple erythematous and hyperemic mucosal lesions at the distal antrum without active bleeding, a finding compatible with GAVE. Although she frequently complained of symptoms or signs associated with anemia and had frequent gastrointestinal endoscopies with or without pre-emptive argon plasma coagulation, her clinical status is relatively stable, and she is undergoing maintenance hemodialysis without anticoagulants. Conclusion This clinical case suggests that GAVE should be considered as a cause of the anemia resistant to erythropoiesis-stimulating agents and iron supplementation in patients with chronic kidney disease and lupus.

Highlights • At present, the association between metformin use and mortality in DM patients with COVID-19 remains uncertain. • Our data have revealed more favourable survival in patients not taking DM drugs compared with patients taking DM drugs other than metformin. • This study showed no definite association between metformin use and clinical outcomes, including survival. • Further studies are needed to determine whether the use of metformin may have favourable or unfavourable effects in DM patients with COVID-19., Aim Previous studies have reported inconsistent results regarding the association between metformin use and clinical outcomes in diabetes mellitus (DM) patients with coronavirus disease 2019 (COVID-19). This study aimed to evaluate the association between metformin use and clinical outcomes in DM patients with COVID-19. Methods This retrospective study was based on claims data. All diseases, including COVID-19, were defined using International Classification of Diseases 10th Revision (ICD-10) codes. Patients were divided into three groups depending on metformin use: CON (those not taking DM medication); N-MFOM (those taking DM medications other than metformin); and MFOM (those taking metformin for DM). Ultimately, 1865 patients were included; CON, N-MFOM and MFOM groups comprised 1301, 95 and 469 patients, respectively. Results Kaplan–Meier analyses showed that MFOM patients had poorer survival rates than those in the CON group, but there were no significant differences in survival rates between MFOM and N-MFOM groups. Multivariate Cox regression analyses revealed more favourable survival in CON than in N-MFOM patients, but there was no statistically significant difference in MFOM vs the other groups. Also, there were no significant differences in rates of use of inotropes, extracorporeal membrane oxygenation, conventional oxygen therapy, high-flow nasal cannulas or mechanical ventilators, nor in the rates of acute kidney injury or cardiac events across all study groups. Conclusion No definite association could be found between metformin use and clinical outcomes, including survival. However, given the disproportionate participant numbers in our groups and small number of events, further studies are needed to determine whether the use of metformin has favourable or unfavourable effects in DM patients with COVID-19.

Background: Non-alcoholic fatty liver disease (NAFLD) is associated with the dysregulation of multiple metabolic and inflammatory pathways. These can lead to extrahepatic disorders involving the kidney, a vulnerable organ responsible for extra-renal complications. Evaluating the association between NAFLD and low-grade albuminuria as a renal complication would be helpful to better understand the pathophysiology and extra-hepatic complications of NAFLD. Patients and Methods: Our study extracted data from database obtained a representative population sample. Overall, 3867 men were included in this survey. Our study included only men without diabetes mellitus, with a urinary albumin/creatinine ratio < 30 mg/g (n = 1390). Low-grade albuminuria was defined by a urinary albumin/creatinine ratio within the highest quartile. The fatty liver index was calculated in accordance with Bedogni's equation. We defined the NAFLD group as patients with a fatty liver index of ≥ 60. Results: In the multivariate analysis, the urinary albumin/creatinine ratio in the non-NAFLD and NAFLD groups was 3.05 ± 0.14 and 5.19 ± 0.42, respectively (P < 0.001). The correlation coefficients between the fatty liver index and urinary albumin/creatinine ratio were 0.124 in the Pearson's correlation test and 0.084 in the partial correlation test (P < 0.001 and P = 0.002, respectively). Linear regression analysis showed a positive association between the fatty liver index and the urinary albumin/creatinine ratio on multivariate analysis. Logistic regression analysis showed that the odds ratio for low-grade albuminuria with NAFLD was 2.31 (95% confidence interval, 1.47-3.61; P < 0.001) on the multivariate analysis. Subgroup analyses according to the presence of metabolic syndrome or age (< 50 or ≥ 50 years) showed that the association between NAFLD and the urinary albumin/creatinine ratio was stronger for participants without metabolic syndrome and in those aged < 50 years. Conclusion: NAFLD was associated with low-grade albuminuria in men without diabetes mellitus in this study. Therefore, men with a relatively high fatty liver index or NAFLD should be closely monitored for low-grade albuminuria, especially in absence of metabolic syndrome.

Few studies have examined the optimal adjustment indices for predicting low muscle strength or physical performance in hemodialysis (HD) patients. Thus, the present study aimed to identify optimal adjustment indices for predicting strength and/or physical performance in HD patients. Our study was performed at an HD center (n = 84). Appendicular lean mass (ALM; kg) was calculated using dual-energy X-ray absorptiometry. ALM were adjusted to body weight, height2 (Ht2), body surface area, or body mass index. Physical performance tests (sit-to-stand test performed 5 times test, sit-to-stand for 30 second test, 6-minute walk test, timed up and go test, gait speed, hand grip strength, average steps per day (AST), and short physical performance battery) were also evaluated. Participants with a below median value for each physical performance test were defined as the low group. The mean participant age was 55.6 ± 12.8 years; 44 (52.4%) were men. The univariate analysis revealed a significant difference in ALM/Ht2 values between the low and normal physical performance group in all physical performance tests except short physical performance battery. The multivariate analysis revealed a significant difference in ALM/Ht2 between the low and normal physical performance groups in hand grip strength, 5 times sit-to-stand test, sit-to-stand for 30-second test, and AST. In women on HD, most indices were not associated with physical performance or strength. We demonstrated that, in men on HD, ALM/Ht2 may be the most valuable among various variables adjusted for ALM for predicting physical performance or strength.

Background/Aims: Our study aims to evaluate the association between thigh muscle cross-sectional area (TMA) using computed tomography (CT), or appendicular skeletal muscle mass (ASM) using dual energy X-ray absorptiometry (DEXA), and physical performance levels in hemodialysis (HD) patients. Methods: Patients were included if they were on HD for ≥6 months (n = 84). ASM and TMA were adjusted to body weight (BW, kg) or height2 (Ht2, m2). Each participant performed a short physical performance battery test (SPPB), a sit-to-stand for 30 second test (STS30), a 6-minute walk test (6-MWT), a timed up and go test (TUG), and hand grip strength (HGS) test. Results: Correlation coefficients for SPPB, GS, 5STS, STS30, 6-MWT, and TUG were highest in TMA/BW. Results from partial correlation or linear regression analyses displayed similar trends to those derived from Pearson’s correlation analyses. An increase in TMA/BW or TMA/Ht2 was associated with a decreased odds ratio of low SPPB, GS, or HGS in multivariate analyses. Indices using DEXA were associated with a decreased odds ratio of a low HGS only in multivariate analysis. Conclusion: TMA indices using CT may be more valuable in predicting physical performance or strength in HD patients.

Background: The aim of the present study was to evaluate the effects of physical activity on various aspects in Asian dialysis patients. Methods: This was a retrospective cohort study. Study participants were recruited from 27 hospitals or dialysis centers in Korea (n = 1611). The participants were divided into 3 groups according to the degree of regular exercise: Inactive group, Intermediate group, and Active group. Results: The proportions of patients with frailty and the presence of each component decreased as physical activity increased. The presence and numbers of disabilities decreased as physical activity increased. The number of participants with a history of fall during the last 12 months was 149 (20.5%) in the Inactive group, 88 (16.9%) in the Intermediate group, and 48 (13.2%) in the Active group. Physical component scale and mental component scale scores increased as physical activity increased. The survival rate for all-cause death at 500 days was 95.5% in the Active group, 95.2% in the Intermediate group, and 93.5% in the Inactive group. Conclusion: High physical activity was associated with favorable results for most health-related quality of life scale scores, including frailty, disability, and exhaustion, in Korean dialysis patients.

Introduction: Identification of the risk factors and treatment of the decrease in muscle mass or strength are important to improve the prognosis of patients undergoing hemodialysis (HD). Previous studies have investigated the association between vitamin D level and muscle mass or strength in patients undergoing HD. However, there are conflicting results regarding this association. Objective: To evaluate the association between vitamin D level and muscle mass indices, strength, or physical performance in patients undergoing HD. Methods: This study was performed in a tertiary medical center. We included patients undergoing HD aged ≥20 years. A total of 84 patients were enrolled. The patients were divided into tertiles based on the 25-hydroxy (25-OH) vitamin D level as follows: lowest tertile (Lowest T, n = 28), middle tertile (Middle T, n = 28), and highest tertile (Highest T, n = 28). We evaluated the association between the tertiles and clinical outcomes including nutritional status, muscle mass, muscle function, handgrip strength (HGS), physical performance, and health-related quality of life (HRQoL) scales. Results: There were no significant differences in the muscle mass indices and nutritional markers according to tertiles of 25-OH vitamin D level. However, 25-OH vitamin D level as a continuous variable or the tertile of 25-OH vitamin D level as a categorical variable was positively associated with HGS. Logistic and linear regression analyses showed a consistent superiority of the Highest T in HGS compared with the Lowest or Middle T. Although the statistical significance was weak, the scores of various physical performance tests and the HRQoL scales were highest in the Highest T among the 3 tertiles. Conclusion: The present study demonstrated that serum vitamin D level is associated with HGS in patients undergoing HD regardless of muscle mass indices or nutritional status.

Inadequate fluid removal or high water intake leads to overhydration, which results in malnutrition. The aim of the present study was to evaluate the effects of volume status on body composition in incident peritoneal dialysis (PD) patients. All incident PD patients who survived ≥1 year after PD initiation were considered eligible. A total of 366 incident PD patients were finally included and divided into three tertiles according to the time-averaged-edema index (TA-EI). The body composition parameters measured using bioimpedance analysis included the EI, fat mass index (FMI, kg/m2), and appendicular muscle mass index (AMMI, kg/m2). dFMI and dAMMI were defined as delta values for each variable. The cutoff value for sarcopenia (SP) was defined as previously reported. Patients with AMMI below the cutoff values were defined as having SP. The number of participants in the low, middle, and high tertiles was 126, 100, and 140, respectively. A high volume status was associated with high solute clearance, albumin loss, and glucose absorption through the peritoneal membrane, which led to high dialysate glucose. In addition, volume status was inversely associated with increases in AMMI, but was not associated with changes in FMI. SP as a categorical variable was positively associated with a high volume status. On subgroup analyses, TA-EI had the greatest negative correlation coefficients for dAMMI. Overhydration in PD patients was associated with decrease in muscle mass indices and the development of SP.

The aim of this study was to determine and evaluate the association between potassium intake and hearing thresholds in the Korean adult population. Data from the Korean National Health and Nutrition Examination Survey were analyzed. Participants were divided into tertiles on the basis of their potassium intake as follows: low, middle, and high. Pure-tone audiometry was performed using an automated audiometer. We calculated as the average threshold at the low-frequency pure-tone average (0.5 and 1 kHz), mid-frequency pure-tone average (2 and 3 kHz), and high-frequency pure-tone average (4 and 6 kHz). The average hearing threshold (AHT) was calculated as the pure-tone average of the thresholds at 0.5~3 kHz. Hearing loss (HL) was defined as an AHT of >40 dB in the better ear. There were 1975 participants each in the low, middle, and high tertile groups. The four different average hearing thresholds significantly decreased with an increase in the potassium intake tertile. Multivariate analysis revealed that the four different average hearing thresholds were significantly lower in the high tertile group than in the other two groups. In addition, univariate and multivariate linear regression analyses showed that the potassium intake level was inversely associated with each of the four different average hearing thresholds. Analyses of participants matched based on propensity scores and participants not matched based on propensity scores yielded similar results. The results of this study suggest that high potassium intake levels were associated with a lower prevalence of HL and lower hearing thresholds in the Korean adult population.

BackgroundPeriodontitis and cardiovascular disease (CVD) share inflammation as common pathogenesis. Evaluating the association between periodontitis and CVD would be helpful to better understand the pathophysiology and various complications of periodontitis. We aimed to determine whether there is an independent relationship between periodontitis and various CVD risk indicators or prevalence.Patients and methodsOur study used representative data from the Korea National Health and Nutrition Examination Survey. Finally, data from 26,097 participants were used for analysis. Periodontitis was defined as a community periodontal index (CPI) ≥3. Participants were classified into 3 groups according to CPI score: Non-PO (participants without periodontitis, CPI score ResultsThe numbers of participants in Non-PO, NS-PO, and Severe PO groups were 17,237, 6,738, and 2,122, respectively. The proportions of participants with high FRS and/or prevalent CVD increased as the severity of periodontitis increased. In participants without prevalent CVD, the FRS according to severity of periodontitis increased in both univariate and multivariate analyses as the severity of periodontitis increased. Logistic regression showed that the odds ratio for metabolic syndrome increased as the severity of periodontitis increased on univariate analysis and that the presence of periodontitis was associated with a higher odds ratio for metabolic syndrome on multivariate analysis. Trends for prevalent CVD were similar to those of metabolic syndrome. For participants without prevalent CVD, the odds ratio for high FRS increased as the severity of periodontitis increased in both univariate and multivariate analyses. Subgroup analyses according to sex and age showed similar trends.ConclusionPeriodontitis was associated with CVD in the Korean population. Therefore, those with periodontitis, especially young adults with severe periodontitis, may be closely monitored for CVD.

The aim of our study was to evaluate the association between the dietary approaches to stop hypertension (DASH) and metabolic syndrome in postmenopausal Korean women without diabetes.Our study enrolled postmenopaual women without diabetes (n = 6826). We used the DASH-Korean quartile (KQ) model using six nutrients. For protein, fiber, calcium, and potassium, we scored 1 for the first quartile (1Q), 2 for the second quartile (2Q), 3 for the third quartile (3Q), and 4 for the fourth quartile (4Q). For fat and sodium, we scored 4 for the 1Q, 3 for the 2Q, 2 for the 3Q, and 1 for the 4Q. We defined the sum of the six scores as the DASH-KQ score. Participants were divided into four quartiles (DASH-1Q, DASH-2Q, DASH-3Q, and DASH-4Q), according to the sum of the six DASH-KQ scores.The number of participants with metabolic syndrome in DASH-1Q, DASH-2Q, DASH-3Q, or DASH-4Q was 601 (37.4%), 671 (31.1%), 440 (30.5%), and 492 (30.3%), respectively. The proportion of participants with metabolic syndrome was greatest in DASH-1Q (P 0.001). Multivariate logistic regression analyses showed that every increase in the DASH-KQ score by 1 exhibited a 0.977-fold odds for metabolic syndrome. DASH-1Q, by DASH-KQ score, had higher odds for metabolic syndrome than the other groups.The lowest quartile of the DASH-KQ score was associated with a higher prevalence of metabolic syndrome in postmenopausal Korean women without diabetes.

The objective of the present study was to examine the association between low-grade albuminuria and hearing impairment in the non-diabetic population.Data from the Korean National Health and Nutrition Examination Survey 2011-2013 were used in the analyses. Participants were excluded from this study if they were younger than 19 years old, or had urine albumin/creatinine ratio (UACR) ≥ 30 mg/g or diabetes mellitus. There were 10,608 participants included in this study. The participants were divided into three groups according to their UACR tertiles.There were 1560; 1561; and 1552 male and 1982; 1975; and 1978, female participants in the low, middle, and high tertile groups, respectively. The results indicated the association between low-grade albuminuria and the numbers of metabolic syndrome (MetS) components or Framingham risk score, and the presence of MetS or the proportions of participants at high cardiovascular risk. Univariate and multivariate linear regression analyses demonstrated an association between the UACR and average hearing threshold (AHT) that was observed in both sexes. Multivariate analyses showed that mean AHTs in the low, middle, and high tertile groups were, respectively, 16.127 dB, 17.139 dB, and 18.604 dB for men, and 14.842 dB, 15.100 dB, and 16.353 dB, respectively, for women. Low-frequency, mid-frequency, and high-frequency hearing thresholds according to UACR tertiles showed similar trends. In both sexes, multivariate logistic regression analyses revealed that participants in the low and middle tertile groups had a decreased risk for hearing loss compared to participants in the high tertile group.Low-grade albuminuria was associated with hearing impairment in the non-diabetic participants of this study.

The aim of the present study was to evaluate the clinical association between triglyceride (TG)/high-density lipoprotein cholesterol (HDL-C) ratio and hearing impairment in a Korean population.This was a cross-sectional study (n = 18,004). Participants were divided into 4 quartiles based on their TG/HDL-C ratio: first quartile (1Q), second quartile (2Q), third quartile (3Q), and fourth quartile (4Q). The threshold values at 0.5, 1, and 2 kHz were averaged to obtain the low- or mid-frequency pure-tone average (Low/Mid-Freq), and the values at 3, 4, and 6 kHz were averaged to obtain the high-frequency pure-tone average (High-Freq). The average hearing threshold (AHT) was calculated as the pure-tone average of the thresholds at 0.5, 1, 2, and 3 kHz. Hearing loss (HL) was defined as an AHT of40 dB.The Low/Mid-Freq, High-Freq, and AHT values were the highest among participants in 4Q than among those in the other quartiles. Compared with those in 1Q, 2Q, or 3Q, participants in 4Q exhibited a 1.32, 1.27, and 1.16-fold higher odds for HL, respectively. Partial correlation coefficients for TG/HDL-C ratio were 0.065 for Low/Mid-Freq, 0.041 for High-Freq, and 0.060 for AHT (P 0.001 for all). Linear regression analyses showed that β ± SE for TG/HDL-C ratio was 0.293 ± 0.038 on multivariate analysis. In addition, all subgroup analyses except diabetes participants showed statistically significant association between TG/HDL-C ratio and HL.High TG/HDL-C ratio was associated with hearing impairment in a Korean population.

The aim of this study was to determine whether chronic kidney disease (CKD) is associated with vestibular dysfunction in a general population.Of the total participants, 7,799 of participants were included in this study. The data collected from the participants during the health examination included an estimated glomerular filtration rate (eGFR) and balancing test results. Mild CKD was defined as an eGFR of 60-90 mL/min/1.73 m2 or an eGFR ≥ 90 mL/min/1.73 m2 with dipstick proteinuria (≥ 1+). Moderate CKD was defined as an eGFR of 45-59 mL/min/1.73 m2. Severe CKD was defined as an eGFR of 30-44 mL/min/1.73 m2. Very severe CKD was defined as an eGFR30 mL/min/1.73 m2.The number of participants with vestibular dysfunction was 268. Univariate and multivariate linear regression analyses showed that eGFR levels were inversely associated with the presence of vestibular dysfunction. Multivariate analysis revealed that those with moderate, severe, and very severe CKD had a 1.830-, 4.496-, and 6.055-fold increased risk of vestibular dysfunction, respectively, compared to the participants without CKD.CKD was found to be associated with vestibular dysfunction in the general population. Therefore, the participants with CKD may be closely monitored for vestibular dysfunction.

Background: The purpose of the present study was to examine the effectiveness of paricalcitol for the prevention of epithelial-to-mesenchymal transition (EMT). Materials and Methods: Human peritoneal mesothelial cells (HPMCs) were cultured in media containing transforming growth factor β1 (TGF-β1) with or without paricalcitol. Forty-two male Sprague-Dawley rats were divided into three groups. In the control group, the catheter was inserted but no dialysate was infused. The peritoneal dialysis (PD) group was infused with a conventional 4.25% dialysis solution. The paricalcitol group was infused with 4.25% dialysis solution and cotreated with paricalcitol. Results: Exposure of HPMCs to TGF-β1 decreased the protein level of the epithelial cell marker and increased the expression levels of the mesenchymal markers. Cotreatment with paricalcitol increased the protein levels of the epithelial cell marker and decreased those of mesenchymal markers compared with their levels in cells treated with TGF-β1 alone. Exposure of HPMCs to TGF-β1 significantly increased the phosphorylation of Smad2 and Smad3. Cotreatment with paricalcitol significantly decreased the phosphorylation of Smad2 and Smad3 compared with that of cells treated with TGF-β1 alone. After 8 weeks of experimental PD in rats, the thickness of the peritoneal membrane in the PD group was significantly increased compared with that of the control group. Cotreatment with paricalcitol decreased peritoneal thickness. Conclusion: The present study showed that paricalcitol attenuates the TGF-β1-induced EMT in peritoneal mesothelial cells. We suggest that paricalcitol may preserve peritoneal mesothelial cells during PD and could thus be of value for the success of long-term PD.

Objectives The aim of this study is to evaluate changes in body composition in accordance with residual renal function (RRF). Subjects and Methods Two hundred forty-four patients with more than 1 year of follow-up were enrolled. The mean value of RRF at peritoneal dialysis (PD) initiation and 1 year after PD initiation was used as an indicator of the time-averaged RRF (TA-RRF). The patients were divided into 3 groups with respect to the tertile of the TA-RRF level: low tertile (n = 81), middle tertile (n = 82), and high tertile (n = 81). Body composition measurement was determined from dual-energy X-ray absorptiometry and bioimpedance analysis. This analysis was performed at PD initiation and 1 year after PD initiation. Results Multivariate analysis showed that the high TA-RRF tertile was associated with an increase in lean mass index. Fat mass index in all tertiles and bone mineral content index in the middle and high TA-RRF tertiles were increased, but no significant difference were observed in these changes among the 3 tertiles. The edema index decreased over the 1-year PD period. The high TA-RRF tertile was associated with a lower edema index. Although there was no statistical significance, the increase in fat mass/lean mass ratio (FM/LM) attenuated as the grade of TA-RRF tertile increased. The increase in fat mass index was similar to the trend in FM/LM. Conclusion TA-RRF was associated with an increase in total lean mass and a decrease in edema index.

Background Health-related quality of life (HRQoL) surveys are needed to evaluate regional and ethnic specificies. The aim of the present study was to evaluate the differences in HRQoL, frailty, and disability according to dialysis modality in the Korean population. Patients and methods We enrolled relatively stable maintenance dialysis patients. A total of 1,616 patients were recruited into our study. The demographic and laboratory data collected at enrollment included age, sex, comorbidities, frailty, disability, and HRQoL scales. Results A total of 1,250 and 366 participants underwent hemodialysis (HD) and peritoneal dialysis (PD), respectively. The numbers of participants with pre-frailty and frailty were 578 (46.2%) and 422 (33.8%) in HD patients, and 165 (45.1%) and 137 (37.4%) in PD patients, respectively (P = 0.349). Participants with a disability included 195 (15.6%) HD patients and 109 (29.8%) PD patients (P < 0.001). On multivariate analysis, the mean physical component scale (PCS) and mental component scale (MCS), symptom/problems, and sleep scores were higher in HD patients than in PD patients. Cox regression analyses showed that an increased PCS in both HD and PD patients was positively associated with patient survival and first hospitalization–free survival. An increased MCS in both HD and PD patients was positively associated with first hospitalization–free survival only. Conclusion There was no significant difference in frailty between patients treated with the two dialysis modalities; however, disability was more common in PD patients than in HD patients. The MCS and PCS were more favorable in HD patients than in PD patients. Symptom/problems, sleep, quality of social interaction, and social support were more favorable in HD patients than in PD patients; however, patient satisfaction and dialysis staff encouragement were more favorable in PD patients than in HD patients.

Renal involvement in the form of glomerulonephritis in Sjögren's syndrome (SS) is less common and usually a latent sequel in the course of the disease. We report a patient with Type III membarnoproliferative glomerulonephritis (MPGN) with hypothyroidism, which precedes the onset of the clinical manifestation of SS. She received immunosuppressions consisting of i.v. cyclophosphamide and high-dose corticosteroid and subsequently oral corticosteroid resulting in complete remission of nephrotic syndrome. To our knowledge, this is the first report of successfully treated Type III MPGN associated with SS.

Background: Given the association between metabolic disturbance and sarcopenia, sarcopenia may be intrinsically associated with the prevalence of HL. However, few studies describe the association between sarcopenia and HL. The aim of this study was to evaluate the clinical association between sarcopenia and HL in postmenopausal Korean women. Patients and Methods: A total of 4,038 women were ultimately included in this study. All participants were postmenopausal. Participants were divided into two groups based on criteria from the Foundation for the National Institute of Health Sarcopenia Project: a normal group (sarcopenia index ≥ 0.512) and a sarcopenia group (sarcopenia index < 0.512). Low-frequency (Low-Freq), mid-frequency (Mid-Freq), and high-frequency (High-Freq) values were obtained. The average hearing threshold (AHT) was calculated as the pure tone average at the 4 frequencies of 0.5 kHz, 1 kHz, 2 kHz, and 3 kHz. Mild HL was as an AHT of 24 to 40 dB; moderate-to-profound HL was defined as an AHT of 40 dB or greater. Results: Of the 4,038 participants, 272 (6.7%) were allocated to the sarcopenia group, leaving 3,766 (93.3%) in the normal group. The groups differed significantly in terms of having hypertension (775 [20.6%] vs. 108 [39.7%]; P < 0.001) or metabolic syndrome (817 [21.7%] vs. 110 [40.4%]; P < 0.001) in the normal and sarcopenia groups, respectively. Visceral fat area (cm3) in the normal and sarcopenia groups was 99.0 ± 21.9 cm3 and 117.0 ± 21.8 cm3 , respectively (P < 0.001). The hsCRP level was higher in the sarcopenia group than in the normal group. For univariate and multivariate analyses, all 4 hearing thresholds were higher in the sarcopenia group than in the normal group. In addition, linear regression analyses showed Low-Freq, Mid-Freq, and High-Freq to be inversely correlated with the sarcopenia index. The unadjusted OR for mild HL was 2.692 (95% CI, 1.963-3.692; P < 0.001) in the sarcopenia group relative to the normal group, with an adjusted OR of 1.584 (95% CI, 1.131-2.217; P = 0.007). The unadjusted OR for moderate-to-profound HL in the sarcopenia group relative to the normal group was 6.246 (95% CI, 4.530-8.612; P < 0.001); the adjusted OR was 2.667 (95% CI, 1.866-3.812; P < 0.001). Conclusion: Sarcopenia may be associated with HL. It may be beneficial to perform screening audiometry in patients with sarcopenia.

Background/Aims: The objective of the present study was to evaluate the clinical association between periodontitis and a high urinary albumin/creatinine ratio (UACR) in individuals without diabetes mellitus. Methods: Data from the Korean National Health and Nutrition Examination Survey were used for this analysis. A high UACR was defined as UACR≥3.9 mg/g for men and UACR≥7.5 mg/g for women. The WHO community periodontal index (CPI) was used to define periodontitis and assess its severity. Results: The numbers of participants without and with periodontitis were 3,046 and 8,571, respectively. The UACR values were higher in participants with periodontitis than in those without periodontitis. Logistic regression showed that the OR for a high UACR with the presence of periodontitis was 1.14 (P=0.044) on multivariate analysis. CPI score was positively associated with UACR. Conclusions: Periodontitis was associated with UACR in the non-diabetic participants in this study. Therefore, participants with periodontitis should be closely monitored for UACR, which can function as an early marker for renal injury.

Regarding the association between glycated hemoglobin A1c (HbA1c) levels and microvascular complications, high HbA1c level in participants without diabetes mellitus (DM) may be associated with a high urinary albumin-to-creatinine ratio (UACR).Twelve thousand seven hundred and seventy four participants without DM were included in this study. The participants were divided into three groups according to HbA1c levels: a Low group (5.7%), Middle group (5.7-6.0%), and High group (6.0%). A high UACR was defined as UACR ≥3.9 mg/g for men and UACR ≥7.5 mg/g for women.The proportions of participants with a high UACR in the Low, Middle, and High groups were 22.4%, 27.9%, and 38.1%, respectively. Both univariate and multivariate analyses showed that logUACR was greatest in the High group compared to the other groups. For participants without metabolic syndrome (MetS), the proportions of participants with high UACR and logUACR values were greatest in the High group compared to the other groups. For participants with MetS, no differences were found for proportions of participants with high UACR and logUACR values in the Low, Middle, and High groups.Non-DM participants with relatively high HbA1c levels should be closely monitored for UACR, especially if participants do not have MetS. KEY MESSAGES HbA1c level was positively associated with the proportion of participants with a high UACR and logUACR in participants without DM. For participants without MetS, the proportion of participants with a high UACR was greater in the High group than in the other groups and logUACR was greatest in the High group compared to the other groups. For participants with MetS, there were significant associations between HbA1c and the proportion of participants with a high UACR as a categorical variable or logUACR as a continuous variable, but the statistical significance of this finding was weak. No differences were found for proportions of participants with high UACR and logUACR values in the Low, Middle, and High groups.

Few studies have linked changes in bone mineral density (BMD) in peritoneal dialysis (PD) patients to the calcium concentration in peritoneal dialysate.In total, 236 incident patients who underwent an annual BMD determination for 2 years were enrolled. The patients were divided into two groups: the standard calcium dialysate (SCD) group (n = 190; 1.75 mmol/l) and the low-calcium dialysate (LCD) group (n = 46; 1.25 mmol/l).There were no significant differences between the baseline demographics of the two groups, such as age, diabetes, calcium, phosphorus, alkaline phosphatase (ALP), intact parathyroid hormone (i-PTH) levels or variables related to BMD. Univariate and multivariate analyses [adjusted for age, gender and time-averaged 25(OH)-vitamin D] determined that the LCD group had higher time-averaged i-PTH and ALP and a greater decrease in bone mineral content, lumbar spine BMD, subtotal BMD and total BMD compared to the SCD group.LCD is associated with a more rapid decline in BMD, higher i-PTH and higher ALP in PD patients. It is suggested that LCD be avoided for PD patients at risk of osteoporosis and hyperparathyroidism.

Introduction: Severe hypo- natremia is a serious medical condition that is associated with morbidity and mortality. Controversy still exists regarding the preva- lence, cause and mortality of hyponatremia. Patients and methods: Of the hyponatremic patients, we studied 116 severe hyponatremic patients. Severe hyponatremia was defined as a serum sodium concentration equal to or less than 120 mmol/l at least twice. Results: The mean age of the patients was 67.3 ± 14.9 years. The mean sodium level at the time of diagnosis was 114.9 ± 5.2 mmol/l. Normal ex- tracelluar fluid volume (ECFV) was reported in 44 patients (37.9%). 24 (20.7%) of 44 pa- tients were diagnosed with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). Excess ECFV and depleted ECFV were reported in 37 (31.9%) and 18 patients (15.5%), respectively. In 17 patients (14.7%), the exact causes could not be determined due to incomplete laboratory studies. On the uni- variate analysis, age (p = 0.030), the Charl- son's risk index (p = 0.000) and the correc- tion rate (p = 0.000) were associated with the 1-year survival. The time of onset (p = 0.051) and the initial serum sodium level (p = 0.986) were not associated with the 1-year survival. On the multivariate analysis, the Charlson's risk index (p = 0.003) and the correction rate (p = 0.033) were independently associated with 1-year survival. Conclusion: This study showed that the sodium level per se is not re- lated to mortality, but a higher Charlson's risk index and a slow rate of correcting the sodium are related with mortality. For improving the survival of patients with severe hyponatremia, we should pay more attention to correct the underlying comorbidity.

BACKGROUND Renal dysfunction after allogeneic hematopoietic stem cell transplantation (HSCT) has been increasingly reported. However, there are few reports on the changes of the estimated glomerular filtration rate (eGFR) in long-term survivors after allogeneic HSCT. PATIENTS AND METHODS The medical records at Seoul St. Mary's Hospital in Korea were reviewed to identify all adult (> 18-years-of-age) patients who had undergone high-dose chemotherapy and allogeneic HSCT between January 2001 and December 2005. Among these patients, those with < 5 years of follow-up and relapse within 5 years after HSCT were excluded. 85 patients were enrolled. RESULTS The mean follow-up was 76.0 ± 13.5 months. The eGFR recorded 3 months after HSCT was significantly decreased compared with the eGFR recorded before HSCT. Subsequently, early decreased eGFR was maintained during the 60 months after HSCT. Multivariate analysis showed that acute kidney injury (AKI) during HSCT, hypertension (HTN) and eGFR before HSCT was differently associated with changes in eGFR. The eGFR in patients who had AKI decreased significantly at 3 months after HSCT. After 3 months, the eGFR recovered to reach a lower level than in patients without AKI. The level was maintained during the 60 months after HSCT. The eGFR in patients who had low eGFR before HSCT (< 90 ml/min) decreased significantly at 3 months after HSCT, which was also maintained during the 60 months after HSCT. The eGFR in patients who had HTN also decreased significantly at 3 months after HSCT. By contrast, the eGFR decreased consistently and slowly from 3 to 60 months. CONCLUSION AKI and low baseline eGFR are associated with early renal dysfunction in patients after HSCT, but are not closely associated with long-term decline in eGFR. In contrast, eGFR in patients with HTN continuously decrease after 3 months of HSCT. Therefore, HTN seems to play a major role in the long-term decline in eGFR. These findings suggest that eGFR at 3 months after HSCT should be monitored closely for all patients who have undergone HSCT. Additionally, long-term follow-up of renal function is needed to prevent further renal damage for patients with HTN.

Background. In 2009, the Oxford classification was developed as a pathological classification system for immunoglobulin A nephropathy (IgAN) to predict the risk of disease progression. The aim of this retrospective study was to evaluate the clinical and pathologic relevance of the Oxford classification in Korean patients with a pathologic diagnosis of IgAN. Patients and methods. We reviewed the renal pathology archives from January 2000 to December 2006 at Seoul St Mary’s Hospital in Korea and identified 273 patients, who were diagnosed as having IgAN. We enrolled 197 patients who were available for further clinicopathologic analysis. All cases of IgAN were categorized according to the WHO classification, the semiquantitative classification and the Oxford classification. These pathologic classifications were compared. The clinical and laboratory findings at the time of biopsy were compared with those at the end of the follow-up according to the Oxford classification. Results. When three pathologic classifications were compared, M1, S1, E1, T1 or T2 were associated with a higher score in the activity index. S1, T1 or T2 were associated with a higher score in the chronicity index and a higher grade in the WHO classification. The clinical and laboratory findings were compared according to the Oxford classification. At the time of biopsy, the proteinuria in patients with M1 was more than that of M0 (P ¼ 0.035). At the end of follow-up, the number of antihypertensive drugs taken among patients with M1 was greater than that of patients with M0 (P ¼ 0.001). At the time of biopsy, the proteinuria of patients with S1 was greater than that of S0 patients (P ¼ 0.009). At the end of follow-up, the number of patients who received immunosuppressants was increased as the grade of T increased (P ¼ 0.000). At the end point of the followup, the estimated glomerular filtration rate (eGFR) decreased as the grade of T increased (P ¼ 0.008). The time-average proteinuria after adjusting the initial proteinuria increased significantly with increasing degree of T( P¼ 0.000). Levels of tubular atrophy/interstitial fibrosis were predictive for survival from end-stage renal disease or of having a 50% reduction of eGFR. Conclusion. The pathologic variables of the Oxford classification correlated significantly with other classifications (the WHO classification and the semiquantitative classification). The Oxford classification is a simple method for predicting renal outcome and differentiating between active and chronic lesions. We suggest that the Oxford classification offers an advantage for determining treatment policy for patients with IgAN.

The aim of this study is to investigate the clinical course of patients with failed allograft according to the type of renal replacement modality. Three hundred sixty-eight patients with failed allograft were included. Of these, 233 patients started hemodialysis (HD-PSKT), 64 patients started peritoneal dialysis (PD-PSKT), and 71 patients underwent second transplantation (ReKT). At baseline, age, sex, laboratory findings, and comorbidity did not differ significantly among three groups. Chronic rejection was the most common cause of allograft failure (81.6%) followed by acute rejection (10.7%). During the observation period, 96 patients died. The most common cause of death was cardiovascular disease (39.6%) followed by infection (34.4%) and malignancy (8.3%). Infection was important cause of death within 10 years from allograft failure, but cardiovascular disease and malignancy occupied significant portion of death after 10 years from allograft failure. Significant difference was not found among the three groups in the cause of allograft failure and the cause of death. The patient outcome was better in the ReKT than in the other two groups and it did not differ significantly between the PD-PSKT and HD-PSKT. In multivariate analysis, old age, hypoalbuminemia, and high comorbidity were proved to be the independent risk factors for mortality and the ReKT was still significantly superior to the HD-PSKT and PD-PSKT after adjustment for other confounding factors. In conclusion, second transplantation may result in survival benefit, and proper management of nutrition and comorbidity may help to improve outcome in patients with failed allograft.

Background/Aims Many studies have compared patients with systemic lupus erythematosus (SLE) on renal replacement therapy (RRT) with non-lupus patients. However, few data are available on the long-term outcome of patients with end-stage renal disease (ESRD) secondary to SLE who are managed by different types of RRTs. Methods We conducted a retrospective multicenter study on 59 patients with ESRD who underwent maintenance RRT between 1990 and 2007 for SLE. Of these patients, 28 underwent hemodialysis (HD), 14 underwent peritoneal dialysis (PD), and 17 patients received kidney transplantation (KT). We analyzed the clinical outcomes in these patients to determine the best treatment modality. Results The mean follow-up period was 5 ± 3 years in the HD group, 5 ± 3 years in the PD group, and 10 ± 5 years in the KT group (p = 0.005). Disease flare-up was more common in the HD group than in the KT group (p = 0.012). Infection was more common in the PD and HD groups than in the KT group (HD vs. KT, p = 0.027; PD vs. KT, p = 0.033). Cardiovascular complications were more common in the HD group than in the other groups (p = 0.049). Orthopedic complications were more common in the PD group than in the other groups (p = 0.028). Bleeding was more common in the HD group than in the other groups (p = 0.026). Patient survival was greater in the KT group than in the HD group (p = 0.029). Technique survival was lower in the PD group than in the HD group (p = 0.019). Conclusions Among patients with ESRD secondary to SLE, KT had better patient survival and lower complication rates than HD and lower complication rates than PD. The prognosis between the HD and PD groups was similar. We conclude that if KT is not a viable treatment option, any alternative treatment should take into account the patient's general condition and preference.

High baseline anti-ABO antibody titer is still an important obstacle for successful ABO-incompatible kidney transplantation (ABO IKT). This study aims to investigate the clinical outcome of ABO IKT in patients with a high baseline titer in comparison with patients with a low baseline titer. Fourteen patients who received ABO IKT at our center were classified as the high-titer group (≥1:256, n = 8) or the low-titer group (≤1:128, n = 6). We used a protocol composed of rituximab, plasmapheresis, and intravenous immunoglobulin (RTX/PP/IVIG). We compared the intensity of preparation, complications, and clinical outcome between the two groups. The high-titer group required more sessions of pretransplant (10.5 ± 3.5 vs. 6.0 ± 1.3 times, p = 0.01) and posttransplant (1.6 ± 1.8 vs. 0 ± 0 times) PP/IVIG than the low-titer group did. All patients from both groups showed immediate recovery of graft function. The antibody titer and allograft function in the high-titer group were stable and did not differ significantly from those of the low-titer group up to 1 year after kidney transplantation. There was no antibody-mediated rejection in either group during follow-up, but three cases of acute cellular rejection developed in the high-titer group. The high-titer group showed two cases of opportunistic viral infection (herpes gingivitis and cytomegalovirus viremia) and one case of graft loss due to postoperative bleeding. ABO IKT can be safely performed even in patients with a high baseline anti-ABO antibody titer, but the risk for infection and bleeding should be considered before transplantation.

Background/Aims: It is undetermined whether the effect of uric acid (UA) on graft outcome is independent of graft dysfunction. This study was designed to explore whether early-onset hyperuricemia has clinical significance regardless of graft function. Methods: This study was conducted based on a retrospective chart review. We calculated time-averaged UA and estimated glomerular filtration rate from the values at 3, 6, and 9 months after transplantation. Cardiovascular complications during follow-up and long-term graft survival were assessed according to UA levels and graft function. Results: 351 patients were enrolled into this study. Hyperuricemia increased the risk of cardiovascular complications (HR = 2.8, 95% CI 1.1–7.1; p = 0.02), but reduced graft function did not. In the hyperuricemia group, 5- and 10-year graft survival was significantly lower than in the normouricemia group (89 and 81% vs. 96 and 92%, respectively; p = 0.02). In the reduced graft function group, these values were also lower than in the normal graft function group (89 and 81% vs. 96 and 93%, respectively; p = 0.02). In the multivariate analysis, both hyperuricemia and reduced graft function were independent risk factors for graft failure and the presence of both factors presented the highest risk. Conclusion: Early-onset hyperuricemia is a significant predictor of cardiovascular complications and graft survival independently of graft function.

Background. The clinical significance of slow recovery of graft function (SGF) in living donor kidney transplantation is unclear. We evaluated the incidence, risk factors, and clinical outcome of SGF in living donor transplantation. Methods.Threehundredtenlivingdonorkidneyrecipientswereincludedandcategorizedintoimmediaterecoveryof graft function (IGF; n239) and SGF (n71), according to estimated glomerular filtration rate (60 mL/min/1.73 m 2 ) at posttransplant day 14. We compared the clinical parameters, protocol biopsy findings, acute rejection (AR), and 10-year graft survival between the two groups. Results. The SGF group had an older recipient age, lower ratio of donor to recipient body mass index, and higher incidence of AR than IGF group, as shown by protocol biopsies. The SGF group had significantly more AR episodes thanIGFgroupwithin12months(21.1%vs.13.4%,P0.05)andduringfollow-upperiod(32.4%vs.20.1%,P0.05). The 10-year graft survival rate did not differ between groups, but AR presence was significantly associated with a lower graft survival in the SGF group than the IGF group (64.9% vs. 78.9%, P0.05). Conclusions. SGF in the early posttransplant period is immunologically active and should be considered as one of the risk factors for determining long-term graft survival in living donor kidney transplantation.