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Lab-on-paper, or microfluidic paper-based analytical devices (μPADs), use paper as a substrate material, and are patterned with a system of microchannels, reaction zones and sensing elements to perform analysis and detection. The sample transfer in such devices is performed by capillary action. As a result, external driving forces are not required, and hence the size and cost of the device are significantly reduced. Lab-on-paper devices have thus attracted significant attention for point-of-care medical diagnostic purposes in recent years, particularly in less-developed regions of the world lacking medical resources and infrastructures. This review discusses the major advances in lab-on-paper technology for blood analysis and diagnosis in the past five years. The review focuses particularly on the many clinical applications of lab-on-paper devices, including diabetes diagnosis, acute myocardial infarction (AMI) detection, kidney function diagnosis, liver function diagnosis, cholesterol and triglyceride (TG) analysis, sickle-cell disease (SCD) and phenylketonuria (PKU) analysis, virus analysis, C-reactive protein (CRP) analysis, blood ion analysis, cancer factor analysis, and drug analysis. The review commences by introducing the basic transmission principles, fabrication methods, structural characteristics, detection techniques, and sample pretreatment process of modern lab-on-paper devices. A comprehensive review of the most recent applications of lab-on-paper devices to the diagnosis of common human diseases using blood samples is then presented. The review concludes with a brief summary of the main challenges and opportunities facing the lab-on-paper technology field in the coming years.

The prevalence of metabolic syndrome (MetS) is increasing, and patients with MetS are at an increased risk of cardiovascular disease and diabetes. There is a close link between hypomagnesemia and MetS. Administration of sodium-glucose transporter 2 (SGLT2) inhibitors has been reported to increase serum magnesium levels in patients with diabetes. We investigated the alterations in renal magnesium handling in an animal model of MetS and analyzed the effects of SGLT2 inhibitors. Adult rats were fed a fructose-rich diet to induce MetS in the first 3 months and were then treated with either dapagliflozin or magnesium sulfate-containing drinking water for another 3 months. Fructose-fed animals had increased insulin resistance, hypomagnesemia, and decreased urinary magnesium excretion. Dapagliflozin treatment improved insulin resistance by decreasing glucose and insulin levels, increased serum magnesium levels, and reduced urinary magnesium excretion. Serum vitamin D and parathyroid hormone levels were decreased in fructose-fed animals, and the levels remained low despite dapagliflozin and magnesium supplementation. In the kidney, claudin-16, TRPM6/7, and FXDY expression was increased in fructose-fed animals. Dapagliflozin increased intracellular magnesium concentration, and this effect was inhibited by TRPM6 blockade and the EGFR antagonist. We concluded that high fructose intake combined with a low-magnesium diet induced MetS and hypomagnesemia. Both dapagliflozin and magnesium sulfate supplementation improved the features of MetS and increased serum magnesium levels. Expression levels of magnesium transporters such as claudin-16, TRPM6/7, and FXYD2 were increased in fructose-fed animals and in those administered dapagliflozin and magnesium sulfate. Dapagliflozin enhances TRPM6-mediated trans-epithelial magnesium transport in renal tubule cells.

Disturbance in glucose and uric acid metabolism is the major disorder of metabolic syndrome (MetS). The kidneys play an important role in the management of glucose and uric acid. The aim of our study was to investigate alterations in renal glucose and uric acid transporters in animals with MetS after treatment with dapagliflozin and xanthine oxidase inhibitors (allopurinol and febuxostat). Sprague-Dawley rats were fed normal chow or a high fructose diet for the first 3 months. The fructose-fed animals were then treated with dapagliflozin, allopurinol, febuxostat, or no treatment for the next 3 months. Fasting glucose, insulin resistance, and hyperuricaemia were improved in all treatment groups except that in the fructose group (all p < 0.05). Both allopurinol and febuxostat reversed the increase in levels of sodium glucose cotransporter (SGLT) 1, SGLT2, and glucose transporter (GLUT) 2 (all p < 0.05). Dapagliflozin alleviated hyperuricaemia and induced uricosuria without affecting serum xanthine oxidase activity. Dapagliflozin suppressed the expression of GLUT9, urate transporter, and urate anion exchanger 1 (all p < 0.05), which was similar to the effects of allopurinol and febuxostat. The results suggest that treatment with dapagliflozin and xanthine oxidase inhibitors improved insulin resistance and reversed the increased expression of glucose and urate transporters in the kidney.

Hepatitis B virus (HBV) reactivation is a well-known complication after rituximab-based chemotherapy in patients with B cell lymphoma (BCL) who have resolved HBV infection. This retrospective cohort study used electronic medical records from the Kaohsiung Chang Gung Memorial Hospital. There were 128 patients with BCL and resolved HBV infection treated with 1st-line rituximab-containing therapy from 2008 to 2013. No patient received antiviral prophylaxis. Patients with high pretreatment hepatitis B surface antibody (anti-HBs titer ≥100 mIU/mL), had significantly less HBV reactivation (2.0%, 1/49) than patients with low (10-100 mIU/mL, 10.8%, 4/37) or negative anti-HBs (

BackgroundDialysis-related myofascial pain in hemodialysis (HD) patients is an important issue that is associated with many other psychosomatic problems. Effective interventions are required to alleviate pain in this group. Chinese herbal medicine (CHM) may be a potential therapeutic treatment to reduce pain. The aim of this study is to evaluate the effect of a CHM formula intervention on pain intensity, daily function, quality of life, and safety among patients receiving HD in a dialysis center within a southern Taiwan context. MethodsThis will be a randomized, open label, cross-over trial with two parallel groups in a pre- and post-test study. Forty patients with myofascial pain related to their arteriovenous fistula in the arm during regular HD sessions will be recruited. Participants will receive 4 weeks of treatment with Juan Bi Tang (JBT) and 4 weeks of no treatment in a random order, separated by a washout period of 2 weeks. Treatment doses (3 g JBT) will be consumed thrice daily. The primary outcome measure will be the Kidney Disease Quality of Life 36-Item Short-Form Survey. Secondary outcomes will include the Fugl-Meyer Assessment–arm, Visual Analogue Scale of pain, and grip strength. Outcomes will be collected before and after each intervention, for a total of four times per participant. The safety evaluation will focus on adverse events. DiscussionThis study will be the first to use CHM to treat patients receiving HD with dialysis-related myofascial pain in their fistula arm and to perform a complete assessment of the treatment, including records of quality of life, arm function and muscle power, severity of pain, and safety. The results of the study will provide convincing evidence on the use of JBT as an adjuvant treatment for dialysis-related myofascial pain. TRIAL REGISTRATION:Clinicaltrials.gov registry (NCT04417101) registered 30 May 2020.

Objectives Severe hyperkalemia can cause life-threatening arrhythmia, cardiac arrest, or death. This study aimed to investigate the incidence and the associated factors relevant to critical hyperkalemia (≥6 mmol/L) among inpatients, outpatients, and emergency department. Their clinical outcomes were also analyzed. Methods All patients whose high serum potassium values had been reported as critical laboratory values in 2016 were enrolled. Their demographic data, comorbidities, clinical symptoms, biochemical data, and outcomes were reviewed and collected. The Charlson comorbidity score (CCS) and glomerular filtration rate (GFR) were computed to assess the comorbidity burden and renal function. Patients were divided into groups according to different settings, potassium and GFR levels, and their survival. Results Of the 293,830 total serum potassium tests, 1,382 (0.47%) reports were listed as critical laboratory values. The average reply time was 6.3 min. Their mean age was 67.2 years, while the average GFR was 12.2 mL/min/1.73 m2. The overall mortality rate was 34%. Patients in the emergency department had the highest incidence (0.92%), while inpatients had the worst outcome (51% mortality). The leading cause of mortality was septic shock. The fatal group had higher rates of clinical symptoms, higher potassium values, CCS, and eGFR (all p Conclusions Most of the responses for the reports were obtained within a short period of time. Patients with reported high critical serum potassium values were characterized by high rates of comorbidity, reduced eGFR, and mortality. The incidence, clinical manifestations, and outcomes varied in the different clinical settings.

Background and Aims Hyperphosphatemia and secondary hyperparathyroidism are frequent complications in chronic kidney disease (CKD) which both contribute to increased morbidity and mortality in CKD. Osteogenic factor-1 (OP-1) is an important member of BMPs subfamily and its effects on CKD-associated mineral and bone disorders (MBD) is controversial. The study examined whether exogenous OP-1 administration can modulate disturbed CKD-MBD in adenine-induced chronic uremic rats Method Chronic renal failure was induced in adult male SD rats by feeding adenine-containing diet. After adenine diet feeding 3 weeks, animals were injected with OP-1 (5μg/kg/day) intraperitoneally for 2 weeks. The serum and urine phosphorus levels and associated mineral parameters, including fibroblast growth factor 23(FGF-23), DKK-1 and sclerostin were measured. Vascular calcification was assessed by immunohistochemistry staining on aortic tissue. Bony structure was evaluated by microCT (Bruker-microCT, Kontich, Belgium). Results A significant decrease of body weight and deteriorated renal function was observed in adenine and OP-1 treatment groups during study period and serum creatinine levels were similar (5.23 ±1.1 mg/dL vs. 5.4 ±1.2 mg/dL, p>0.05). Animals in OP-1 group had lower serum phosphorous (18.7±5.1 vs. 29.0±9.6 mg/dL, p Conclusion Our data indicated administration of exogenous OP-1 improved hyperparathyroidism and attenuated vascular calcification. OP-1 treatment was also associated with beneficial effects on bony structure in animals with renal failure.

Background and Aims Vascular calcification is a common complication in patients with chronic kidney disease (CKD) and associated with increased morbidity and mortality. Pathogenesis of vascular calcification in CKD is multiple and phenotypic transformation of vascular smooth muscle cell (VSMC) is of critical importance. TRPM7 is a magnesium channel that regulate magnesium transport. The role of TRPM7 in VSMC transformation during vascular calcification is not clear. We aim to investigate the effects of phosphate and indoxyl sulphate on the expression of TRPM7 in VSMC and 2-APB, the TRPM7 blocker was used to evaluate the alteration of calcification-related molecules. Method Human aortic smooth muscle cells (HASMC) were used and treated either with phosphate (3.3mM) or indoxyl sulphate (500uM) for 7 days. 2-APB, a channel blocker of TRPM7 was added simultaneously in blocking experiment. Cells were then examined grossly and alizarin red solution was employed for calcification staining assessment. For calcification process study, cells were harvested for gene expression and protein abundance analysis. Results Gross examination did not find evidence of cell death during experiment on both treatments. Alizarin staining revealed apparent calcification in phosphate-treated HASMC but it was unremarkable in indoxyl sulphate. Phosphate treatment induced significant increase in RUNX2(151±35.8% of control), BMP2(124±10.1%), BMP7(155±9.3%), vitamin D receptor (VDR, 138±21%), calcium sensing receptor (CaSR, 185± 39%) and TRPM7(172±33.7%, all p< 0.05), but DKK1 and sclerostin were not changed. The addition of 2-APB prevented the increase of RUNX2(107±31.2%), BMP2(80±4.9%), BMP7(72±32.9%), VDR (94±43.2%), CaSR (83±17%) and TRPM7(118±23.9%). Indoxyl sulphate treatment was associated with decrease in TRPM7 (45±22%, p Conclusion We concluded that both phosphate and indoxyl sulphate induced calcification in VSMC but it was less in indoxyl sulphate. TRPM7 was upregulated by phosphate but decreased in indoxyl sulphate treatment. Blocking TRPM7 with 2-APB can prevent phosphate-induced calcification but partially attenuated calcification during indoxyl sulphate administration.

Aims Vascular calcification is a common complication in patients with chronic kidney disease and associated with increased morbidity and mortality. The role of TRPM7 in vascular smooth muscle cell (VSMC) transformation during vascular calcification is not clear. We aim to investigate the effects of phosphate and indoxyl sulphate on the expression of TRPM7 and calcification-related molecules in VSMC. Main methods Human aortic smooth muscle cells (HASMC) were treated with phosphate (3.3 mM) or indoxyl sulphate (500 μM and 1000 μM). 2-APB, a channel blocker of TRPM7 was added simultaneously in blocking experiment. Cells were then examined grossly and alizarin red solution was employed for calcification assessment. Lastly, cells were harvested for gene expression and protein abundance analysis. Key findings Phosphate treatment induced significant increase in BMP2, RUNX2, BMP7, vitamin D receptor (VDR), calcium sensing receptor (CaSR) and TRPM7, but 1-alpha hydroxylase, klotho, DKK1 and sclerostin were not changed. The addition of 2-APB prevented increase of BMP2, RUNX2, BMP7, VDR, CaSR and TRPM7. Indoxyl sulphate treatment was associated with decrease in TRPM7 and DKK1, but increase in RUNX2, BMP2 and VDR were noted. There were no significant alterations in BMP7, CaSR, klotho,1-alpha hydroxylase and sclerostin. Co-treatment with 2-APB reversed the increase in VDR. Significance Both phosphate and indoxyl sulphate induced calcification in VSMC but it was more prominent in phosphate. TRPM7 was upregulated by phosphate but downregulated in indoxyl sulphate treatment. Vascular calcification was reduced by blocking TRPM7 with 2-APB and there was partial anti-calcification effect in indoxyl sulphate.

Diabetic kidney disease (DKD) is the leading cause of chronic kidney disease (CKD). Elucidating the mechanisms underlying proteinuria in DKD is crucial because it is a common problem in DKD-related mortality and morbidity. MicroRNAs (miRs) associated with DKD have been detected in experimental diabetes models and in patients with both diabetes and CKD. Here, we aimed to investigate pathologic miRs in diabetic nephropathy (DN) by prospectively following six nephrotic, biopsy-proven isolated DN patients (enrolled between August 2015 and July 2017) for one year. The urinary exosomes were isolated at the time of the biopsy and the contained miRs were analyzed by next-generation sequencing. The results were compared to the control group, composed of age-, gender-, and CKD stage-matched patients with proteinuric CKD who did not present diabetes. Among the 72 identified miRs, we investigated eight (miR-188-5p, miR-150-3p, miR-760, miR-3677-3p, miR-548ah-3p, miR-548p, miR-320e, and miR-23c) exhibiting the strongest upregulation (13&ndash, 15 fold) and two (miR-133a-3p and miR-153-3p) with the strongest downregulation (7&ndash, 9 fold). The functional analysis of these miRs showed that they were involved in known and novel pathways of DN, supporting their pathologic roles. The bioinformatics-based prediction of the target genes of these miRs will inspire future research on the mechanisms underlying DN pathogenesis.

Previous studies have indicated diabetes was associated with lower serum magnesium (Mg) level. Patients with renal impairment usually have higher Mg concentration due to reduced renal excretion. Whether Mg level in diabetics with chronic kidney disease (CKD) is altered remains undermined. In this study, we analyzed serum Mg concentration in patients with CKD and also compared diabetics with non-diabetics. Factors associated with Mg levels were explored. A total of 939 patients were included and 717 were with CKD. Their serum Mg concentration increased progressively, as their glomerular filtration rate (GFR) decreased in both diabetics and non-diabetics. Compared with non-diabetics, diabetes was significantly associated with lower serum Mg concentration in patients without CKD than in patients with CKD in all stages of disease. Multivariate regression analysis identified that both diabetes and serum albumin were independent factors of serum Mg concentration in patients without CKD. Age, diabetes, serum albumin concentration, GFR and macroproteinuria were significantly associated with serum Mg concentration in patients with early-stage CKD. In patients with moderate-to-severe CKD, diabetes, serum albumin and GFR were independent factors related to the serum Mg level.

Objective Vascular calcification is common in chronic dialysis patients and is associated with increased morbidity and mortality. However, the role of circulating microRNAs (miRs) in vascular calcification has rarely been investigated. We aimed to determine circulating levels of miRs in hemodialysis patients, and analyzed their relationship with vascular calcification. Methods Sixty-one stable hemodialysis patients were enrolled, including 31 with vascular calcification and 30 without. Demographic and biochemical data were collected and reviewed. The presence and severity of vascular calcification were determined by lumber spine X-ray. Blood levels of miR29a/b, miR223, miR9, and miR21 were determined. Results Patients with vascular calcification were older (65.6 ± 9.0 vs. 59.1 ± 7.1 years) with a higher proportion of vascular disease (55% vs. 23%) than those without vascular calcification. Additionally, high-sensitivity C-reactive protein (3.90 vs 2.09 mg/dL) and fibroblast growth factor 23 (17311 vs. 6306 pg/mL) were significantly higher. Patients with vascular calcification also had higher levels of miR29a/b and miR223. Regression analysis indicated that age and miR29a were significant associates of the calcification score. Conclusions Hemodialysis patients with vascular calcification had higher levels of miR 29a/b and miR223 than those without vascular calcification, and circulating miR29a was associated with calcification severity.

Background/Aim: Angiotensin converting enzyme-related carboxypeptidase 2/angiotensin (Ang)-(1-7)/Mas receptor axis is protective in the development of chronic kidney disease and cardiovascular disease. This study is aimed at investigating whether indoxyl sulfate (IS) affects Mas receptor expression, cell proliferation and tissue factor expression in vascular smooth muscle cells, and if Ang-(1-7), an activator of Mas receptor, counteracts the IS-induced effects. Methods: IS was administered to normotensive and hypertensive rats. Human aortic smooth muscle cells (HASMCs) were cultured with IS. Results: IS reduced the expression of Mas receptor in the aorta of normotensive and hypertensive rats. IS downregulated the Mas receptor expression in a time- and dose-dependent manner in HASMCs. Knockdown of aryl hydrocarbon receptor (AhR) and nuclear factor-kappa B (NF-κB) inhibited IS-induced downregulation of Mas receptor. Further, IS stimulated cell proliferation and tissue factor expression in HASMCs. Ang-(1-7) attenuated IS-induced cell proliferation and tissue factor expression in HASMCs. Ang-(1-7) suppressed phosphorylation of extracellular signal-regulated kinase 1/2 (ERK1/2) and NF-κB in HASMCs. Conclusion: IS downregulated the expression of Mas receptor via AhR/NF-κB, and induced cell proliferation and tissue factor expression in HASMCs. Ang-(1-7) inhibited IS-induced cell proliferation and tissue factor expression by suppressing the phosphorylation of ERK1/2 and NF-κB p65.

Background: Vascular calcification (VC) is a key process associated with cardiovascular mortality in dialysis patients. Gelsolin is an actin-binding protein that can modulate inflammation, correlated inversely with hemodialysis (HD) mortality and involved in bone calcification homeostasis. In this report, we aim to characterize progression in aortic arch calcification (AAC) and investigate its association with gelsolin. Methods: 184 HD patients were enrolled and their annual posterior-anterior chest X-ray films (CXR) in 2009 and 2013 were examined. The severity of AAC was classified as grade 0 to 3. Blood levels of gelsolin were measured by ELISA kits. Biographic and biochemical data at baseline were analyzed with status of AAC at baseline and changes after 4 years. Results: At baseline, 60% of the patients had detectable AAC on CXR. After 4 years, 77% had AAC. Patients with grade 1 and 2 AAC had increased risk of progression (Odds ratio [OR] 2~3, P=0.001) compared to those with grade 0 at baseline. Compared to those with no AAC, patients with AAC progression had older age, lower gelsolin, higher waist circumference and prevalence of vascular disease. Regression analysis confirmed baseline gelsolin (odds ratio 0.845, 95% confidence interval [0.734-0.974]) and waist circumference as the independent factors associated with AAC progression. Gelsolin is positively correlated with serum albumin and negatively with tumor necrosis factor-alpha. Conclusion: Our study demonstrated that HD patients with grades 1 or 2 baseline AAC are at increased risk of further progression compared to those with grade 0. We also found lower blood levels of gelsolin associated with progressive AAC. Further investigation into the mechanistic roles of gelsolin in vascular calcification may provide new understanding of this key process.

Introduction. Nonalcoholic fatty liver disease (NAFLD) is becoming more common around the world and it may progress to cirrhosis and liver failure, increasing mortality risk. In hemodialysis (HD) patients, NAFLD may be a novel risk factor for their high cardiovascular mortality. Heightened oxidative stress is highly prevalent in HD patients. However, the relationship between oxidative stress and NAFLD in HD patients is not well defined.Methods. We studied seventy-one stable nondiabetic HD patients. Nineteen patients had the diagnosis of NAFLD by ultrasonography. Blood levels of oxidative stress markers were measured in each patient, including thiobarbituric acid reactive substances (TBARS), free thiols, superoxide dismutase (SOD) activities, and glutathione peroxidase (GPx) activity. The copy numbers of mitochondrial DNA (mtDNA) in peripheral leukocytes were also determined. Demographic, biochemistry, and hemogram data were recorded. The two groups of patients were compared in order to determine the factors associated with NAFLD in HD patients.Findings. Compared to those without NAFLD, nondiabetic HD patients with NAFLD had significantly higher mtDNA copy number and GPx levels. The two groups did not differ significantly in dialysis adequacy, hemoglobin, serum calcium, phosphorus, albumin, liver function tests, or lipid profiles. Regression analysis confirmed mtDNA copy numbers and GPx levels as two independent factors associated with NAFLD. Compared to those with polysulfone, patients dialyzed with cellulose membrane have significantly higher levels of TBARS. However, patients with or without NAFLD did not differ in their use of either dialysis membrane.Discussion. Oxidative stress (represented by antioxidant defense, GPx) and mitochondrial DNA copy numbers are independently associated with fatty liver disease in nondiabetic HD patients. The diagnostic and therapeutic implications of this key observation warrant further exploration.

Hypotension during hemodialysis (HD) is the most common complication that negatively affects the quality of life of patients. The objective of the current study was to evaluate the preliminary efficacy and safety of herbal acupoint therapy (HAT) for intradialytic hypotension (IDH).A randomized, placebo-controlled trial was performed in 32 HD patients to determine whether HAT was more effective than a sham treatment for the treatment of IDH. The outcomes were frequency of IDH episodes and number of nursing interventions during HD sessions, pre- and post-dialysis BP, subjective change in fatigue as measured by the Visual Analogue Scale (VAS), and recovery time from fatigue after dialysis at the 0th and 4th week. Data analyses were performed using per-protocol population.In all, 27 patients (84%) completed the entire study. At the end of the intervention, the patients in the HAT group were found to have a significantly lower frequency of IDH episodes, fewer nursing interventions, a lower intervention failure rate, and earlier discontinuation of dialysis than those in the sham group (p .05). The improvement in degree of fatigue (p = .001) was greater and recovery time from fatigue after dialysis (p = .03) was shorter in the group treated with HAT than in the sham group. HAT was safe, with 2 withdrawal cases due to local erythema caused by the patch.HAT appears to be safe and efficacious for improving IDH-related symptoms and intervention in HD patients. Larger studies are needed to confirm the benefit of this technique for IDH.

Background. Apheresis treatment includes plasmapheresis (PP) and plasma exchange (PE), and these terms are commonly used interchangeably. Nevertheless, the two procedures are carried out differently. The aims of this study were to investigate the mortality rate of patients who underwent therapeutic apheresis and compare the mortality rate between PP and PE. Methods. We conducted a medical chart review retrospective study. All identified subjects (n=436) were over 20 years old with at least one ICD-9-CM intervention code plasmapheresis or plasma exchange and at least one diagnosis code with rheumatic disease. All of them were hospitalized to Chang Gung Memorial Hospital between 1st of January, 2000, and 31st of December, 2014. Results. 436 nonoverlapping patients had never received PE and/or PP before 1 Jan, 2000. Among all the patients, 350 received PE, 63 received PP, and 23 received both therapies. Female patients accounted for 85.09% of patients. The overall mortality rate was 4.65% in the PE subgroup, 4.76% with combination therapy, and 13.46% in the PP subgroup. There were 374 patients diagnosed as SLE, which is the majority of overall patients who received PE and/or PE. In multivariate analysis, PE was the sole independent factor predictor of survival in SLE subgroup patients (p=0.02, exp(B)=0.314, 95% CI 0.12–0.81). Conclusions. We showed that both PP and PE were used in treating a variety of autoimmune disorders. Plasmapheresis was preferentially carried out in patients with peripheral neuropathy. In 374 lupus patients treated with either PE or PP, PE is superior to PP in reducing in-hospital mortality.

OBJECTIVE To analyze the effects of chronic kidney disease (CKD) care programs on clinical outcomes. DESIGN An observational, retrospective study with medical record review. SETTING Kaohsiung Chang Gung Memorial Hospital. PARTICIPANTS Patients diagnosed with CKD. INTERVENTIONS CKD care programs conducted by nephrologists-based team from 2006 to 2013 in our hospital. MAIN OUTCOME MEASURES We set 10 goals with treatment target ranges based on the guidelines suggested by the following organizations: Kidney Disease Improving Global Outcomes (2012) and the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (2003). RESULTS In total, 1486 patients were enrolled. Their average estimated glomerular filtration rate (ml/min/1.73 m2) was 31.9 at baseline and declined to 28.9 in Year 3 (P < 0.001). The all-goals attainment rate increased from 59.4% at baseline to 60.5% in Year 3, with an especially significant improvement for low-density lipoprotein (from 46.8% to 67.0%) and glycated hemoglobin (from 55.0% to 64.0%). Achievement rates decreased for hemoglobin (from 34.2% to 31.0%), calcium (from 94.6% to 92.3%) and phosphate (from 89.9% to 82.5%) between baseline and Year 3. Albuminuria was the least achieved goal (from 23.4% to 24.0%). Subgroup analysis revealed that estimated glomerular filtration rate did not decline in patients who had a good achievement rate, but decreased significantly in patients with a poor achievement rate. CONCLUSION Enrolment in CKD care programs resulted in a significant improvement in goal attainment by patients. Further, a good achievement rate was associated with better preservation of residual renal function.

Summary Indoxyl sulphate is a protein-bound uraemic toxin that has deleterious effects on the cardiovascular system. Rosiglitazone (RGZ) is an insulin sensitizer used for glycaemic control in type 2 diabetes. Rosiglitazone has been shown to be beneficial for cardiovascular disease because of its pleiotropic effects. Whether RGZ can improve indoxyl sulphate-induced endothelial damage has not been investigated. In the present in vitro study, we examined the effects of RGZ on indoxyl sulphate-induced endothelial injury. Endothelial cells were exposed to RGZ (5 and 10 μmol/L) and then treated with indoxyl sulphate (100 and 1000 μmol/L) for 48 h. Indoxyl sulphate upregulated intracellular cell adhesion molecule-1, vascular cell adhesion molecule-1 and monocyte chemotactic protein-1 expression. Indoxyl sulphate also increased the abundance of NADPH oxidase 4 (NOX4) and nuclear factor (NF)-κB. Both extracellular signal-regulated kinase (ERK) 1/2 and p38 mitogen-activated protein kinase (MAPK) signalling pathways were activated after 48 h treatment with indoxyl sulphate. Pretreatment of cells with both concentrations of RGZ improved indices of endothelial injury. In addition, RGZ attenuated the increase in NOX4 and NF-κB and prevented the activation of the ERK1/2 and p38 MAPK signalling pathways. We conclude that RGZ ameliorates indoxyl sulphate-induced endothelial injury.

Background: Both cardiovascular calcification and autonomic dysfunction are frequently encountered in hemodialysis patients. We aimed to investigate the relationship between cardiovascular calcification and heart rate variability (HRV) and their influence on long-term outcome. Methods: Seventy-eight hemodialysis patients underwent echocardiogram and radiography of the pelvis and hands to identify valvular and vascular calcification. HRV was evaluated using a commercial machine. Results: Based on the average, the patients were divided into higher and lower subgroups of high frequency (HF) and low frequency (LF) respectively. Patients with higher LF were younger and were found to have a lower proportion of diabetes. Their hemoglobin, albumin, and bone morphogenic protein (BMP)-7 levels were significantly higher and both high-sensitive C-reactive protein (hs-CRP) and osteoprotegerin levels were lower (all p < 0.05). In patients of the higher HF group, the proportion of diabetes was lower but they were found to have higher levels of BMP-7 and lower levels of hs-CRP, interleukin-6 (all p < 0.05). Significantly higher LF and HF were noted in patients without vascular calcification, but only hand artery (HA) calcification was negatively correlated with both LF and HF in multivariate analysis. Low LF and high hs-CRP were the independent predictors of mortality. Coexistence of low LF band and HA calcification was associated with the worse outcome. Conclusions: Abnormal autonomic nervous function was closely related to inflammation and mortality in hemodialysis patients. Calcification of HA was associated with autonomic dysfunction and patients with lower autonomic tone and HA calcification had the highest mortality rate in this population.

Background/Aims: Interleukin-6 (IL-6) is one of the inflammation biomarkers with highest predictive value for outcome in chronic kidney disease (CKD) patients. The present study aimed to determine the effects of indoxyl sulfate (IS) on IL-6 expression in vascular cells. Methods: IS was administered to normo- and hypertensive rats. Human umbilical vein endothelial cells (HUVECs) and human aortic smooth muscle cells (HASMCs) were incubated with or without IS. Results: Immunohistochemistry revealed that IS-administered rats showed increased expression of IL-6 in the aortic tissues. IS increased IL-6 expression in HUVECs and HASMCs in a time- and dose-dependent manner. Knockdown of organic anion transporter 3 (OAT3) using small interfering RNA (siRNA) inhibited IS-induced expression of IL-6 in HUVECs and HASMCs. IS induced activation of aryl hydrocarbon receptor (AhR) and nuclear factor-κB (NF-κB) subunit p65 in HUVECs and HASMCs. Both AhR siRNA and p65 siRNA inhibited IS-induced expression of IL-6. AhR siRNA inhibited IS-induced phosphorylation and nuclear translocation of p65 without change in total p65 level. However, p65 siRNA did not inhibit IS-induced nuclear translocation of AhR. Thus, AhR is responsible for IS-induced p65 signaling transduction. Conclusion: IS induces IL-6 expression in vascular endothelial and smooth muscle cells through OAT3/AhR/NF-κB pathway.

Protein-energy wasting (PEW) contributes to mortality in hemodialysis (HD) patients. Adipokines regulate energy homeostasis and body weight. Circulating gelsolin can modulate inflammation and is correlated with HD mortality. Whether adipokines and gelsolin play important roles in PEW remains unclear. Based on the criteria proposed by the International Society of Renal Nutrition and Metabolism, we examined the associations between PEW and biomarkers (gelsolin, leptin, adiponectin, interleukin-6, tumor necrosis factor alpha [TNF-α]) in 188 stable HD patients. Patients with PEW had significantly lower serum leptin levels, and tended to have higher adiponectin, TNF-α, and lower gelsolin levels. Logistic regression analysis revealed that gelsolin, leptin, adiponectin, and blood urea nitrogen were independently associated with PEW score. Serum creatinine, TNF-α, gender, renin-angiotensin system (RAS) blockade, and lipid-lowering agents were not associated with PEW score. Patients on lipid-lowering agents had lower PEW scores and those with RAS blockade had higher PEW scores. Our study confirms that gelsolin, adiponectin, and leptin are significant associates with PEW in HD patients. Further understanding of how these factors contribute to PEW may help design novel therapeutic strategies for PEW in chronic kidney disease.

Background: Cardiovascular calcification represents a marker of cardiovascular risk in chronic dialysis patients. In the general population, aortic arch calcification (AAC) can predict cardiovascular mortality. We conducted a prospective study to investigate factors associated with AAC in hemodialysis patients and examined its prognostic value in long-term outcome. Methods: A total of 712 hemodialysis patients were enrolled. AAC was identified on postero-anterior chest X-ray films and classified as grade (Gr.) 0, 1, 2 or 3. Demographic data including age, gender, dialysis vintage, co-morbidity and biochemical data were reviewed and recorded. The patients were followed for 10 years. Results: AAC was present in 164 patients (23%) as Gr. 1, in 116 patients (16.3%) as Gr. 2 and in 126 patients (17.7%) as Gr. 3. An increase in the severity of calcification was associated with older patients who had lower albumin, higher calcium and glucose levels. During the follow-up period of 10 years, we found that the grade of AAC was directly related to cardiovascular mortality (Gr. 0: 5.3%; Gr. 1: 12.7%; Gr. 2: 18.9%, and Gr. 3: 24.4%; p < 0.05) and all-cause mortality (Gr. 0: 19.9%; Gr. 1: 31.1%; Gr. 2: 44.8%, and Gr. 3: 53.2%; p < 0.001). Multivariate Cox proportional hazards analysis revealed that high-grade calcification was associated with cardiovascular and all-cause mortality. Patients with AAC were associated with a worse outcome in survival analysis. The severity of AAC also influenced their survival. Conclusion: Calcification of the aortic arch detected in plain chest radiography was an important determinant of cardiovascular as well as all-cause mortality in chronic hemodialysis patients. The presence and severity of AAC predicted long-term survival.

Lead intoxication is usually insidious and may cause a variety of complications such as kidney damage and hypertension. The role of intrarenal renin-angiotensin system (RAS) in lead-induced nephropathy has not been investigated. Adult male Sprague-Dawley rats were fed with water containing 250ppm of lead acetate (lead group) and deionized water (control group) for 4weeks. Another two groups started to receive intraperitoneal captopril (50mg/kg/d) or losartan (10mg/kg/d) after 2weeks of lead feeding and continued for another 2weeks. Immunoblotting was used to analyze the protein amount of intrarenal RAS components and transforming growth factor-beta (TGF-β). Compared with control group, lead exposure resulted in increased proteinuria after 2-week treatment (4.2±0.9mg/100g vs. 1.8±0.8mg/100g, p

Background Hemodialysis (HD) vascular access failure is one of the most important causes of morbidity and contributes to the cost of dialysis care. There is paucity of data evaluating long-term monitoring of C-reactive protein (CRP) on outcome of HD vascular access. Methods We conducted a retrospective study to investigate whether variability of serum CRP level was associated with vascular access failure rate over a 7-year period. A total of 318 HD patients were included. Their demographic data, co-morbidities and biochemical data were reviewed and collected. Serum high-sensitivity CRP (hs-CRP) level was measured every 6 months. Patients were divided into three groups according to their serial hs-CRP levels. Patients with their hs-CRP below 2 mg/L were defined as low group (n=65, 20.4%) and those with higher than 4 mg/L were defined as high (n=39, 12.3%). The rest were classified as fluctuated hs-CRP group (n=214, 67.3%). Treatment of vascular access failure includes angioplasty and access re-creation. Results Their body mass index, indicators of dialysis adequacy and serum albumin and hs-CRP levels differed significantly among three groups. The annual vascular access failure rate was significantly higher in fluctuated hs-CRP group than in high hs-CRP group (0.41 vs 0.36, P=.037). Serum albumin was a significant associate of vascular access failure. Kaplan-Meier survival analysis indicated patients with high or fluctuated hs-CRP had shorter free interval of vascular access failure than low hs-CRP group. Conclusions HD patients with fluctuated hs-CRP levels were associated with increased vascular access failure.

High prevalence of depression has been reported in patients with end stage kidney disease and depression is associated with increased morbidity and mortality. We aimed to investigate the prevalence of depression in patients receiving standard hemodialysis (SHD) and hemodiafiltration (HDF) and compare the associated factors between these treatment modalities. The Beck Depression Inventory (BDI) was used to survey for major depressive symptoms. Demographic and biochemical data were reviewed and collected. Point prevalence of depression in HDF patients was significantly lower than SHD patients (23.9% vs. 43.1%, P < 0.05). The BDI score was also higher in SHD than HDF group (13.2 ± 11.6 vs. 8.7 ± 11.2, P < 0.05). SHD patients with major depressive symptoms had significantly lower levels of hemoglobin, albumin, creatinine, sodium and hand grip strength but had higher prevalence of diabetes and high sensitivity C-reactive protein (hs-CRP) levels. In HDF patients, phosphorus level was significantly lower in patients with major depressive symptoms. Logistic regression analysis revealed that hs-CRP, serum sodium and hand grip strength were significantly associated with major depressive symptoms in patients treated with SHD; while serum phosphorus was identified in HDF groups. We concluded that prevalence of depression was high in dialysis patients. Patients receiving HDF had a lower mean BDI score and a nearly 50% lower prevalence rate of major depressive symptoms than that of SHD. Factors associated with depression were different between two modalities.

Background Both albuminuria and proteinuria are important disease markers of chronic kidney disease (CKD). Their relationship and the ratio between urinary albumin and protein in patients with CKD have not been investigated. Whether clinical features can affect these measurements is not clear. Methods We conducted a cross-sectional study in 602 CKD patients. Demographic data, including age, gender, and co-morbidity such as diabetes, hypertension, hyperuricemia, and hyperlipidemia, were reviewed and recorded. Their urinary albumin, total protein, and creatinine were determined and urinary albumin to creatinine ratio (UACR), total protein to creatinine ratio (UPCR), and albumin to total protein ratio (UAPR) were calculated. Their estimated glomerular filtration rate (eGFR) was calculated according to serum creatinine. The correlation between UACR and UPCR was thus analyzed. We also investigated factors associated with these urinary measurements. Results UACR and UPCR increased progressively as renal function deteriorated, while UAPR increased to a plateau in CKD stage 4. There was direct relationship between UACR and UPCR. UAPR rose exponentially with the increase of both UACR and UPCR when UACR

In many countries low-molecular-weight heparins (LMWHs) are increasingly used for hemodialysis (HD). Low-range activated clotting time (ACT-LR) values and anti-Xa activity had been used to monitor the degree of anticoagulation caused by LMWH. However, the facilities are not easily available at most hospitals. Such data are limited in Taiwan.A total of 76 patients receiving maintenance HD were prospectively enrolled. The HD patients were randomized to receive either nadroparin or enoxaparin and checked the ACT-LR values and anti-Xa activity. We aimed to analyze ACT-LR values and anti-Xa activity along with the clotting of the dialyzer or bleeding events associated with two LMWHs after they were administered. We also aimed to determine the dose necessary to reach maximum safety and efficacy.We found no significant differences in LMWH dosage, ACT-LR values, and anti-Xa activity between the two groups. There were no significant differences in bleeding/adverse events and extracorporeal circuit thrombosis between the two groups. Most of the bleeding and adverse events were subcutaneous minor bleeding. No major bleeding or mortality was found. We found significant differences in mean dosage, cost, bleeding/adverse effect, and extracorporeal circuit thrombosis between excessive and reduced nadroparin dosage groups.LMWH is not still routinely used due to its high cost in Taiwan. In our clinical experience, nadroparin and enoxaparin exhibited high levels of safety and efficacy in chronic HD patients. Reduced LMWHs dosage could promote patient's safety and decreased HD cost in HD patients with excessive dosage of LMWHs.

Background: Abnormalities in mineral metabolism are common complications of organ transplantation. The role of immunosuppressive agents in alteration of mineral metabolism is not clear. Methods: We conducted an animal study to investigate the effects of cyclosporine A (CsA), tacrolimus, and sirolimus on renal calcium, magnesium and vitamin D metabolism. Results: CsA and tacrolimus induced a 2- to 3-fold and 1.6- to 1.8-fold increase in urinary calcium and magnesium excretion, respectively, while rapamycin had no effects on calcium, but doubled the urinary magnesium excretion. CsA and tacrolimus, but not rapamycin, elevated serum 1,25(OH)2 vitamin D without affecting the parathyroid hormone level. CsA and tacrolimus reduced mRNA abundance in TRPV5 (CsA: 64 ± 3% of control; tacrolimus: 50 ± 3%) calbindin-D28k (CsA: 62 ± 4%; tacrolimus: 43 ± 3%), and vitamin D receptor (CsA: 52 ± 3%; tacrolimus: 58 ± 2%, all p < 0.05). Rapamycin did not affect gene expression in any of studied proteins. The immunofluorescence staining study demonstrated a 50% reduction of TRPV5 and calbindin-D28k by CsA and tacrolimus. Conclusion: The suppression of VDR by calcineurin inhibitors is probably the underlying mechanism of renal calcium wasting. In spite of an increased 1,25(OH)2 vitamin D level, the kidney is not able to reserve calcium, suggesting a role of vitamin D resistance that may be related to bone loss.

Mucosa associated lymphoid tissue lymphoma (MALT lymphoma) is mostly seen in the gastrointestinal tract; origin from the kidney is extremely rare. Waldenström macroglobulinemia (WM) is a clinicopathologic syndrome denoted by the presence of monoclonal gammopathy in the serum, typically caused by lymphoproliferative disorder. Literature review did not find any report of renal MALT lymphoma accompanied by WM. Herein, for the first time, we report a 72 year-old female patient with a history of chronic kidney disease, presenting with solitary renal mass; MALT lymphoma was confirmed by pathological examination. A serology study identified the presence of WM. No manifestation of hyperviscosity syndrome was noted. Bone marrow biopsy disclosed the concurrent systemic involvement. Her treatment response was uneventful and the renal mass responded with regressive change in size after chemotherapy. The renal function remained stable during follow-up. MALT lymphoma should be considered as an underlying pathology of isolated renal mass. Furthermore, patients with MALT lymphoma should be screened for Waldenström macroglobulinemia and hyperviscosity syndrome.

Background: Chronic kidney disease (CKD) is a global health threat affecting approximately 10% of the adult population worldwide. Multimorbidity is common in CKD, but its impacts on disease outcomes are seldom investigated. Methods: This prospective cohort analysis followed patients, who were part of a multidisciplinary CKD care program, for 10 years. We aimed to determine the impact of multimorbidity on renal outcomes. Results: Overall, 1463 patients with stage 3&ndash, 5 CKD were enrolled and stratified by the number of comorbidities. Mean follow-up time was 6.39 &plusmn, 1.19 years. We found that stage 3&ndash, 5 CKD patients with at least three comorbidities at enrollment initiated dialysis earlier (hazard ratio (HR): 2.971) than patients without comorbidities. Risk factors for multimorbidity included old age, smoking, and proteinuria. Conclusions: By analyzing the number of comorbidities, a simple and readily applicable method, we demonstrated an association between multimorbidity and poor renal outcomes in stage 3&ndash, 5 CKD patients. In addition to current guideline-based approaches, our results suggest an urgent need for tailored CKD care strategies for high-risk groups.

Chronic inflammation is a well-recognized complication in dialysis patients and a potential role of the adipose tissue as an important tissue of origin contributing to inflammation has been proposed. Stable peritoneal dialysis (PD) patients were enrolled to investigate the relationship between serum levels of proinflammatory cytokines and adipokines. Our results revealed that there was a strong association between high sensitivity C-reactive protein and interleukin (IL)-6 and tumor necrosis factor-alpha (TNF-alpha) but not with IL-10 and IL-18. IL-6 correlated with TNF-alpha, IL-10, and IL-18. No association was found between IL-10 and IL-18. Adiponectin was positively correlated with all proinflammatory cytokines, except IL-10. No significant association was found between resistin and proinflammatory cytokines. Hepatocyte growth factor (HGF) was directly related to proinflammatory cytokines but not with adipokines. The presence of residual kidney function (RKF) affected IL-6, TNF-alpha, and HGF levels. The peritoneal transport property did not influence inflammatory cytokine and adipokine levels. In conclusion, there was a close relationship between proinflammatory cytokines and adipokines. HGF correlated with proinflammatory cytokines but not with adipokines. The PD-related factors such as RKF, peritoneal property and dialysis glucose load affected levels of proinflammatory cytokines. Body mass index was an important determinant of leptin and adiponectin in PD patients.

Objective: Both chronic inflammation and dysregulation of bone and mineral metabolism are closely related with long-term outcomes of dialysis patients. Our objective was to investigate the relationship between these two abnormalities. Design: This was a cross-sectional study. Setting: This study was performed at a hospital-based hemodialysis center. Patients: We enrolled 448 (male, 198; female, 250) clinically stable hemodialysis patients. Patients with chronic inflammatory disease, malignancy, or viral hepatitis were excluded. Their age (mean 6 SD) was 57.4 6 12.5 years. MainOutcome Measures:Biomarkers,including high-sensitivity C-reactive protein (hsCRP), totalcalcium, phosphate, and intact parathyroid hormone levels, were measured and compared with the recommended range in the K/ DOQI guidelines. Correlations between these parameters were analyzed, and factors independently associated with hsCRP and the calcium phosphate product (Ca 3 P) were identified by regression analysis. Results: Most patients did not achieve the K/DOQI recommended therapeutic range in the four parameters, and only 50 patients (11%) met their treatment goals. ThehsCRP level was directly related to calcium, phosphate, andCa 3 P. Patients who achieved the guidelines’ range had lower hsCRP levels (1.97 mg/L vs. 2.71 mg/L, P , .05). A high hsCRP level (S 10 mg/L) was associated with higher calcium, phosphate, and Ca 3 P levels, and lower albumin levels. Serum albumin, Ca 3 P, alkaline phosphatase, and diabetes independently predicted hsCRP levels. Conclusion: There is a strong association between chronic inflammation and the disturbance of bone mineral metabolism in chronic hemodialysis patients.

Background Abdominal aortic calcification (AAC) is commonly observed in chronic dialysis patients and is associated with cardiovascular and all-cause mortality. We investigated the factors associated with AAC and analyze the relationship between bone-derived biomarkers and AAC. Methods We enrolled 227 stable hemodialysis patients. Vascular calcifications were assessed using lateral lumbar radiography of the abdominal aorta. Demographic data were collected and serum levels of biochemical and bone-derived biomarkers, including sclerostin, Dickkopf-1 (DKK-1), and fibroblast growth factor 23 (FGF23), were measured. Results One hundred sixty-one patients (71.0%) had AAC. Patients with AAC score ≧ 13 were older, with higher body mass index (BMI), serum calcium, calcium phosphate product, high-sensitivity C-reactive protein (hsCRP), and FGF23 levels. Sclerostin and DKK-1 levels were inversely associated with AAC severity, and FGF23 was directly related to vascular calcification. Hypertension, vascular disease, hsCRP, FGF23, and sclerostin were independent AAC determinants. Conclusions Chronic hemodialysis patients have a high prevalence of vascular calcifications. Levels of circulating sclerostin, DKK-1, and FGF23 were related to AAC severity. Sclerostin and FGF23 were independently associated with AAC.

Calbindin-D28k (CBD-28k) is a calcium binding protein located in the distal convoluted tubule (DCT) and plays an important role in active calcium transport in the kidney. Loop and thiazide diuretics affect renal Ca and Mg handling: both cause Mg wasting, but have opposite effects on Ca excretion as loop diuretics increase, but thiazides decrease, Ca excretion. To understand the role of CBD-28k in renal Ca and Mg handling in response to diuretics treatment, we investigated renal Ca and Mg excretion and gene expression of DCT Ca and Mg transport molecules in wild-type (WT) and CBD-28k knockout (KO) mice. Mice were treated with chlorothiazide (CTZ; 50 mg·kg−1·day−1) or furosemide (FSM; 30 mg·kg−1·day−1) for 3 days. To avoid volume depletion, salt was supplemented in the drinking water. Urine Ca excretion was reduced in WT, but not in KO mice, by CTZ. FSM induced similar hypercalciuria in both groups. DCT Ca transport molecules, including transient receptor potential vanilloid 5 (TRPV5), TRPV6, and CBD-9k, were upregulated by CTZ and FSM in WT, but not in KO mice. Urine Mg excretion was increased and transient receptor potential subfamily M, member 6 (TRPM6) was upregulated by both CTZ and FSM in WT and KO mice. In conclusion, CBD-28k plays an important role in gene expression of DCT Ca, but not Mg, transport molecules, which may be related to its being a Ca, but not a Mg, intracellular sensor. The lack of upregulation of DCT Ca transport molecules by thiazides in the KO mice indicates that the DCT Ca transport system is critical for Ca conservation by thiazides.

Purpose: To evaluate the clinical manifestations of Cushing’s Syndrome (CS) and associated genetic mutation in patients with Primary Pigmented Nodular Adrenocortical Disease (PPNAD). Methods: Seven family members were screened for mutations of the PRKAR1A gene. Gene mutation screening used genomic DNA (from peripheral blood leukocytes and, in some cases, adrenal gland tissue) and subsequent DNA sequencing. The five patients showing genetic mutation were assessed clinically for baseline cortisol and adrenocorticotropic hormone and adrenal imaging studies (abdominal computed tomography and adrenal scintigraphy). Low-dose and high-low dexamethasone suppression tests were performed in these five patients. Results: PRKAR1A gene mutation was detected in five of the seven family members. Four of the five gene mutation-positive patients presented with overt CS due to pathology-proven PPNAD. After unilateral adrenalectomy in these four patients, overt CS persisted for two patients and CS symptoms abated for the other two. The remission period of CS was >11 years in one instance (case III-2) and continues for >12 years in the other (case II-4), with no observable disease of the contralateral non-resected adrenal gland. For each of the two remission patients, one adrenal gland had been larger (by abdominal computed tomography) and had had stronger function (by 131I-6β- iodomethyl-19-norcholesterol scintigraphy) than the other. In one (case III-2) of the two remission patients, one adrenal displayed focal PPNAD while the other displayed diffuse PPNAD. The clinical manifestations of CS did not resolve after unilateral adrenalectomy in case II-2 and III-7. The fifth gene mutation-positive patient (case III-4) is still in the latent stage of CS. Conclusions: The clinical manifestations of CS and adrenal image features in patients with PPNAD are heterogeneous. Detailed adrenal imaging of these patients is necessary to assist with the decision to perform unilateral adrenalectomy.

Renin-angiotensin system (RAS) plays a pivotal role in chronic kidney disease (CKD). Angiotensin converting enzyme-related carboxypeptidase 2 (ACE2)/angiotensin (Ang)-(1–7)/Mas receptor axis counteracts the deleterious actions of Ang II. ACE2 exerts its actions by cleaving Ang II into Ang-(1–7) which activates Mas receptor. This study aimed to determine if the expression of Mas receptor is altered in the kidneys of CKD rats, and if indoxyl sulfate (IS), a uremic toxin, affects the expression of Mas receptor in rat kidneys and cultured human proximal tubular cells (HK-2 cells). The expression of Mas receptor was examined in the kidneys of CKD and AST-120-treated CKD rats using immunohistochemistry. Further, the effects of IS on Mas receptor expression in the kidneys of normotensive and hypertensive rats were examined. The effects of IS on the expression of Mas receptor and phosphorylation of endothelial nitric oxide synthase (eNOS) in HK-2 cells were examined using immunoblotting. CKD rats showed reduced renal expression of Mas receptor, while AST-120 restored its expression. Administration of IS downregulated Mas receptor expression in the kidneys of normotensive and hypertensive rats. IS downregulated Mas receptor expression in HK-2 cells in a time- and dose-dependent manner. Knockdown of organic anion transporter 3 (OAT3), aryl hydrocarbon receptor (AhR), and signal transducer and activator of transcription 3 (Stat3) inhibited IS-induced downregulation of Mas receptor and phosphorylated eNOS. N-acetylcysteine, an antioxidant, also inhibited IS-induced downregulation of Mas receptor and phosphorylated eNOS. Ang-(1–7) attenuated IS-induced transforming growth factor-β1 (TGF-β1) expression. Conclusion Mas receptor expression is reduced in the kidneys of CKD rats. IS downregulates renal expression of Mas receptor via OAT3/AhR/Stat3 pathway in proximal tubular cells. IS-induced downregulation of Mas receptor might be involved in upregulation of TGF-β1 in proximal tubular cells.

Residual kidney function (RKF) contributes significantly to solute clearance and fluid removal for dialysis patients, and the presence of RKF is associated with less morbidity and better long-term outcome. Most studies demonstrate that peritoneal dialysis preserves RKF better than hemodialysis (HD). Herein, we report a 55-year-old man with end stage renal failure who had been on chronic HD for 12 years. His RKF is preserved with very slow decline during the past years. Without specific intervention, delicate fluid management, minimal ultrafiltration, and stable hemodynamics during HD may help maintain his RKF. He is currently normotensive with good nutritional status. Although unexpected, we report this HD patient can preserve his RKF for at least 12 years.

Background: Removal of protein-bound uremic toxins by dialysis therapy is limited. The effect of oral adsorbent AST-120 in chronic dialysis patients has rarely been investigated. Methods: AST-120 was administered 6.0 g/day for 3 months in 69 chronic dialysis patients. The blood concentrations of indoxyl sulfate, p-cresol sulfate and biomarkers of cardiovascular risk were determined before and after AST-120 treatment. Results: AST-120 significantly decreased both the total and free forms of indoxyl sulfate and p-cresol sulfate ranging from 21.9 to 58.3%. There were significant simultaneous changes of the soluble tumor necrosis factor-like weak inducer of apoptosis (sTWEAK, 24% increase), malondialdehyde (14% decrease) and interleukin-6 (19% decrease). A significant association between the decrease of indoxyl sulfate and changes of sTWEAK and interleukin-6 was noted. Conclusions: AST-120 effectively decreased indoxyl sulfate and p-cresol sulfate levels in both total and free forms. AST-120 also improved the profile of cardiovascular biomarkers.

Aim: Uremic hyperparathyroidism (UHPT) has been shown to contribute to the development and progression of chronic kidney disease—mineral bone disorder. UHPT is frequently observed in chronic dialysis patients, and patients with UHPT are associated with increased risk of all-cause and cardiovascular mortality. Cinacalcet is a novel agent that increases sensitivity to the calcium-sensing receptor and is approved for control of UHPT. Nevertheless, cinacalcet is costly and information regarding efficacy of low-dose cinacalcet on UHPT is limited. Methods: We conducted a retrospective study to evaluate treatment with either low-dose calcitriol combined with low-dose cinacalcet (25 mg) (d-Cinacalcet) or calcitriol alone (VitD) in dialysis patients with moderate to severe UHPT. A total of 81 dialysis patients were enrolled (40 subjects in d-Cinacalcet group and 41 subjects in VitD group). Demographic data including age, gender, duration on dialysis and biochemical data were reviewed and recorded. Results: At the end of the study, the intact parathyroid hormone (iPTH) levels of the d-Cinacalcet group declined significantly (from 1166.0 ± 469.3 pg/mL to 679.8 ± 421.6 pg/mL, p &lt, 0.0001), while there was no significant change in the VitD group. Significant decrease of serum calcium (Ca: 9.9 ± 0.6 mg/dL vs. 9.6 ± 0.8 mg/dL, p = 0.002), phosphorus (P: 5.9 ± 1.3 mg/dL vs. 4.9 ± 0.9 mg/dL, p &lt, 0.0001) and calcium phosphate product (Ca × P: 58.7 ± 15.0 mg2/dL2 vs. 46.9 ± 8.9 mg2/dL2, p &lt, 0.0001) were observed in the d-Cinacalcet group. In addition, the subjects in the d-Cinacalcet group had a greater proportion to achieve Kidney Disease Outcomes Quality Initiative (KDOQI)-recommended biochemical targets than the subjects in the VitD group (Ca: 48% vs. 24%, P: 78% vs. 32%, Ca × P: 85% vs. 37%, iPTH: 15% vs. 0%). Conclusions: We conclude that combination therapy of low-dose cinacalcet and calcitriol is more effective than calcitriol alone as a treatment for moderate and severe UHPT in chronic dialysis patients. Furthermore, this therapy is associated with improvement in hyperphosphatemia and hypercalcemia.

Introduction Intradialytic hypotension (IDH) is the most frequent complication of haemodialysis (HD) and may contribute to cardiovascular events and high mortality. The aetiology of IDH is multifactorial; therefore, it remains a challenging problem in the management of patients with HD. Since the application of Tianjiu at specific points can influence haemodynamics, we hypothesise that Tianjiu therapy at the traditionally used meridian points will reduce the severity of hypotension in patients who undergo HD. Methods/analysis In this clinical trial, eligible patients with IDH will be divided randomly and equally into a Tianjiu group and a control group for 4 weeks. In the Tianjiu group, the patients will have Tianjiu applied at three points (conception vessel 4, and bilateral kidney 1) during each HD session. In the control group, patients will have clay patches applied in the same way as those in the Tianjiu treatment group. Both groups will be followed up for 2 weeks. The primary outcome measure will be the percentage of target ultrafiltration achieved, defined as the actual ultrafiltration volume divided by the target ultrafiltration volume. Secondary outcome measures, including frequency of IDH episodes and number of nursing interventions during HD sessions, predialysis and postdialysis blood pressure (BP), patient9s participative assessment of the degree of fatigue after dialysis (scale from 0, not at all, to 10, extremely), and recovery time from fatigue after dialysis will be recorded at the 0th and 4th weeks. Ethics/dissemination This trial has undergone ethical scrutiny and been approved by the ethics review board of Chang Gung Memorial Hospital (Permission number: 102-4749A3 and 104-3156C). The pre-results of this trial will help to determine whether Tianjiu is an effective and safe treatment for IDH, and, if so, whether it is a therapeutic effect rather than a placebo effect. Trial registration number NCT02210377; Pre-results.

Background: The renal distal tubule fine-tunes renal epithelial calcium transport. Dietary intake of salt and fluid varies day-to-day and the kidney adapts accordingly to maintain homeostasis. The alternations in salt and fluid balance affect calcium and magnesium transport in the distal tubule, but the mechanisms are not fully understood. Methods: Sprague-Dawley rats were grouped into high-salt, low-salt and dehydration treatment. Daily intake, water consumption and urine output were recorded. At the end of the experiment, blood and urine samples were collected for hormonal and biochemical tests. Genetic analysis, immunoblotting and immunofluorescence studies were then performed to assess the alterations of calcium and magnesium transport-related molecules. Results: High-salt treatment increased urinary sodium, calcium and magnesium excretion. Low-salt treatment and dehydration were associated with decreased urinary excretion of all electrolytes. High-salt treatment was associated with increased intact parathyroid hormone levels. A significant increase in gene expression of TRPV5, TRPV6, calbindin-D28k and TRPM6 was found during high-salt treatment, while low salt and dehydration diminished expression. These findings were confirmed with immunofluorescence studies. High-salt and low-salt intake or dehydration did not cause any significant changes in WNK1, WNK3 and WNK4. Conclusions: Alternations in salt and water intake affect renal calcium and magnesium handling. High-salt intake increases the distal delivery of the divalent cations which upregulates distal tubule calcium and magnesium transport molecules, while the opposite effects are associated with low-salt intake or dehydration.

Background: Gentamicin, a well-known nephrotoxic drug, affects calcium and magnesium homeostasis. Although gentamicin induces urinary calcium and magnesium wasting immediately, it rarely causes significant hypocalcemia or hypomagnesemia clinically. Methods: We conducted an animal study to investigate the renal adaptation in calcium and magnesium handling after gentamicin treatment and effects on the expression of calcium and magnesium transport molecules in distal tubule. Gentamicin (40 mg/kg) was injected daily in male Sprague-Dawley rats (220–250 g) for up to 7 days. Results: This treatment did not affect serum creatinine, calcium, or magnesium levels. Gentamicin induced significant hypercalciuria (14-fold) and hypermagnesiuria (10-fold) in 6 h, which was associated with upregulation of TRPV5 (175 ± 3%), TRPV6 (170 ± 4%), TRPM6 (156 ± 4%) and calbindin-D28k (174 ± 3%; all p < 0.05 vs. control). This gene upregulation was maintained with daily injection of gentamicin for 7 days. The gentamicin-induced urinary calcium loss was reduced by 80% at days 3 and 7, while magnesium loss was reduced by 52 and 57% at days 3 and 7, respectively. On the other hand, urinary loss of potassium became worse on day 7 (2-fold), and phosphorus loss worse from day 3 to day 7 (3-fold). Conclusion: There is a rapid adaptation to gentamicin-induced hypercalciuria and hypermagnesiuria. The upregulation of distal tubule transport molecules, TRPV5, TRPV6, TRPM6 and calbindin-D28k occurs within 6 h of gentamicin treatment. This renal adaptation prevents further mineral loss due to gentamicin treatment.

Aims Endothelial dysfunction is a common manifestation of chronic kidney disease (CKD). The protein-bound uremic toxins have emerged as important factors associated with cardiovascular disease and the outcome of CKD. The effect of indoxyl sulfate (IS) on endothelial cells remains unclear. Main methods Human umbilical endothelial cells (HUVEC) were incubated using IS at two concentrations: 100 μM and 1000 μM over two periods of time: 16 and 48 h. HUVEC were also pre-treated with simvastatin to examine its effect. RT-PCR was used to assess changes in the gene expression of intracellular cell adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), Monocyte chemotactic protein-1 (MCP-1), E-selectin, and angiotensin receptor type 1 (AT1R). Protein abundance of the investigated molecules was assessed by immunoblotting. Key findings Treatment with 100 μM IS for 16 h induced a 2-fold increase in the expression of ICAM-1, VCAM-1, and MCP-1. At a concentration of 1000 μM, there was a 2–3-fold increase. An extended treatment period at low concentrations was associated with a 2–3 fold increase and the increase of ICAM-1 and VCAM-1 was more prominent under high concentration. Results of immunoblotting confirmed an increase in the abundance of ICAM-1, VCAM-1 and MCP-1. No significant change was noted in E-selectin and AT1R according to concentration or treatment duration. Pre-treatment with simvastatin did not alter IS-induced changes. Significance IS increased the expression of adhesion molecules of endothelial cells exhibiting a concentration and duration dependent pattern. Simvastatin did not demonstrate any effect on IS-associated endothelial activation.

Background: Chronic metabolic acidosis is a common metabolic disturbance and its clinical impact can be severe and extensive. The role and the change of the intrarenal renin-angiotensin system (RAS) during metabolic acidosis are uncertain, and whether acidosis can evoke inflammation remains unclear. Methods: Male Sprague-Dawley rats were fed with water containing 0.14 M NH4Cl to induce metabolic acidosis for 1 and 8 weeks, respectively. They were compared with animals fed with deionized water (control) and equimolar sodium chloride water (NaCl). Gene expression analysis of RAS components included renin, renin/prorenin receptor, angiotensinogen, angiotensin-converting enzyme (ACE), and angiotensin II type 1 and 2 receptors (AT1R and AT2R). Histological examination was also performed to detect morphological change. Results: Acidosis was found in 1-week NH4Cl-treated rats but not in the 8-week group. More than twofold proteinuria and a significant decline of glomerular filtration rate (GFR) were observed in acid-loaded rats. Compared to the control and NaCl groups, angiotensinogen, ACE, AT1R and AT2R were significantly increased in the 1-week acidosis group (all p < 0.05). Sustained increase of AT1R expression was found as NH4Cl was continued for 8 weeks. There was no significant change in transforming growth factor-β and nuclear factor-ĸB. The architecture of tubular epithelial cells was affected during our experiment. Conclusion: Metabolic acidosis induced proteinuria and decline of GFR in association with activation of intrarenal RAS.

Primary aldosteronism is an important cause of secondary hypertension, because it is potentially curable, especially in case of unilateral aldosterone-producing adrenal adenoma (APA). However, the information is limited concerning the cardiovascular and renal outcomes in this patient population. We studied 52 patients with APA in order to determine the pre-operative and post-operative factors predicting cardiovascular and renal outcomes. All 52 patients were hypertensive before the operation. Among 35 patients who underwent pre-operative electrocardiogram, 23 patients had left ventricular hypertrophy (LVH). Patients with LVH had lower estimated glomerular filtration rate (eGFR). Adrenalectomy successfully normalized or improved hypertension, hypokalemia, and aldosterone excess. One month after the adrenalectomy, 32 patients (62%) became normotensive, but 20 patients (38%) remained hypertensive. However, after an average follow-up period of 51 months, only 18 patients remained normotensive, while 34 patients were hypertensive. Thus, the rate of recurrent hypertension after adrenalectomy was high (14/32, 43%). Pre-operative systolic blood pressure (BP), diastolic BP, and post-operative plasma aldosterone concentrations were the only variables significantly different between the hypertensive and normotensive patients. Using pre-operative BP 165/110 mmHg as a cutoff has good positive predictive values (73-92%) for post-operative long-term hypertension. Patients whose renal function worsened after adrenalectomy had significantly higher pre-operative plasma active renin levels. Thus, in patients with APA, the presence of LVH is correlated with impaired renal function (lower eGFR). In conclusion, pre-operative BP and post-operative plasma aldosterone are important in predicting post-adrenalectomy hypertension, and a lower pre-operative plasma renin predicts the improvement in renal function after adrenalectomy.

Emphysematous pyelonephritis (EPN) is a severe and complicated renal infection characterized by gas formation within the infected kidney and its surrounding tissues. Early diagnosis with a high index of suspicion and aggressive treatment are important for improving outcome. Bilateral involvement is rare, and surgical intervention is usually required because of its high mortality rate. A literature review found that EPN has rarely been noted in chronic dialysis patients, and those who show bilateral EPN have demonstrated no survival at all until now. Herein, we presented a 51-year-old diabetic uremic woman who developed right emphysematous pyelitis initially and then progressed to bilateral EPN when hospitalized. Percutaneous drainage (PCD) with simultaneous antibiotic therapy successfully eradicated her renal infection. In this study, all reported cases of EPN in chronic dialysis patients were also reviewed.

Background: Iron deficiency is the most common factor associated with erythropoietin (EPO) hyporesponsiveness. Current iron indices are inadequate to demonstrate the status or utility of iron in erythropoiesis. The aims of this study are to investigate the value of the reticulocyte hemoglobin content, RET-Y, in hemodialysis (HD) patients and compare the levels with conventional iron indices. Methods: HD patients (n = 289) were divided into 4 groups according to serum ferritin (cutoff value 100 ng/ml) and transferrin saturation (TSAT, cutoff value 20%). The RET-Y value, hemogram and biochemical data were determined and compared between groups. Factors associated with RET-Y were examined. Results: The mean RET-Y value was 1,716 ± 125 AU. Patients with absolute iron deficiency had lower RET-Y levels and mean corpuscular volume (MCV). Patients with functional iron deficiency had a lower reticulocyte production index and serum albumin levels. MCV, mean corpuscular hemoglobin concentration (MCHC) and albumin were independently correlated with the RET-Y level (all p < 0.001). EPO-independent patients had low iron indices and low RET-Y levels, but a higher reticulocyte production index and albumin levels were noted. Conclusion: RET-Y levels in HD patients were close to that of the normal population. Low RET-Y levels were observed in patients with absolute iron deficiency and also in EPO-independent patients with low ferritin and low TSAT. There was a strong association between the serum albumin and RET-Y levels in chronic HD patients.