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Peritoneal dialysis (PD) is a treatment modality for end-stage renal disease (ESRD) patients. Dextrose is a common osmotic agent used in PD solutions and its absorption may exacerbate diabetes mellitus, a common complication of ESRD. PD solutions also contain glucose degradation products (GDPs) that may lead to encapsulating peritoneal sclerosis (EPS), a severe complication of PD. A previous study showed that far-infrared (FIR) therapy improved a patient’s gastrointestinal symptoms due to EPS. Due to limited literature on the matter, this study aims to investigate dialysate GDPs and peritoneal function in diabetic patients on PD. Thirty-one PD patients were enrolled and underwent 40 min of FIR therapy twice daily for six months. We demonstrated the effect of FIR therapy on the following: (1) decrease of methylglyoxal (p = 0.02), furfural (p = 0.005), and 5-hydroxymethylfurfural (p = 0.03), (2) increase of D/D0 glucose ratio (p = 0.03), and (3) decrease of potassium levels (p = 0.008) in both DM and non-DM patients, as well as (4) maintenance and increase of peritoneal Kt/V in DM and non-DM patients, respectively (p = 0.03). FIR therapy is a non-invasive intervention that can decrease dialysate GDPs in PD patients by improving peritoneal transport rate and solute removal clearance, while also maintaining dialysis adequacy.

Background Colistin is widely used in the treatment of nosocomial infections caused by carbapenem-resistant gram-negative bacilli (CR-GNB). Colistin-induced nephrotoxicity is one of the major adverse reactions during colistin treatment. Comparisons of colistin-induced nephrotoxicity between different formulations of colistin are rarely reported. Methods In this retrospective cohort study, we enrolled intensive care unit–admitted patients if they had culture isolates of CR-GNB and underwent intravenous treatment with colistin. The occurrence of acute kidney injury (AKI) during intravenous treatment with colistin was recorded. The occurrence of colistin-induced nephrotoxicity was compared between two formulations of colistin, Locolin®, and Colimycin®. Treatment outcomes associated with the occurrence of colistin-induced nephrotoxicity were also investigated. Results Among 195 patients, 95 who were treated with Locolin® and 100 who were treated with Colimycin® were included for analysis. Patients treated with Locolin® had a higher rate of occurrence of stage 2 (46.3% vs. 32%, p = 0.040) and stage 3 (29.5% vs. 13%, p = 0.005) AKI than did those treated with Colimycin®. In multivariate analysis, the presence of septic shock (adjusted odds ratio [aOR] 2.17, 95% confidence interval [CI] 1.10–4.26) and inappropriate colistin dosage (aOR 2.52, 95% CI 1.00–6.33) were clinical factors associated with colistin-induced nephrotoxicity. Treatment with Colimycin® was an independent factor associated with a lower risk of colistin-induced nephrotoxicity (aOR 0.37, 95% CI 0.18–0.77). The mortality rate was comparable between patients with and without colistin-induced nephrotoxicity. Conclusions The risk of colistin-induced nephrotoxicity significantly varied in different formulations of colistin in critically ill patients. Colistin-induced nephrotoxicity was not associated with increased mortality rate.

Patients with systemic lupus erythematosus (SLE) have a higher risk of vascular complications. This retrospective cohort study aimed to analyze the differences in the risk of arteriovenous fistula or graft (AVF/AVG) dysfunction in hemodialysis patients with and without SLE from Taiwan’s National Health Insurance Database over a 10-year period. AVF/AVG dysfunction is defined as the occurrence of the first episode of intervention after vascular access creation. A total of 1366 HD patients with SLE had higher incidence rates of AVF/AVG dysfunction than 4098 non-SLE HD patients in the following 4 periods: (1) after 1 year (incidence rates = 15.21% and 13.01%, respectively; subdistribution hazard ratio (SHR) = 1.16; P = 0.007), (2) 1st-to-10th-year period (15.36% and 13.25%; SHR = 1.16; P = 0.007), (3) 5th-to-10th-year period (11.91% and 8.1%; SHR = 1.42; P = 0.003), and (4) overall period (23.53% and 21.66%; SHR = 1.09; P = 0.027). In conclusion, there were significantly higher incidence rates of AVF/AVG dysfunction in SLE patients during the long-term follow-up period. Vascular access function should be monitored regularly by clinical examinations, especially after 1 year and during 5 to 10 years, to improve AVF/AVG patency and dialysis adequacy in SLE patients undergoing maintenance hemodialysis.

Background The clinical effect of atrial fibrillation (AF)-related ischemic cardiovascular events in patients undergoing peritoneal dialysis (PD) remains uncertain. This study aimed to investigate the risk of ischemic events in patients undergoing PD with new-onset AF compared with that in patients without AF and ascertain the association between the CHA2DS2-VASc score and risk of ischemic stroke. Methods This nationwide, population-based cohort study used data from Taiwan's National Health Insurance Research Database from 1998 to 2011 for patients receiving PD with or without new-onset AF. The clinical endpoints included ischemic stroke, all-cause death, and in-hospital cardiovascular death. Results Patients undergoing PD with new-onset AF (N = 505) had significantly higher risks of ischemic stroke (adjusted hazard ratio [aHR], 1.98; 95% CI, 1.40-2.80), all-cause death (aHR, 1.61; 95% CI, 1.40-1.85), and in-hospital cardiovascular death (aHR, 1.82; 95% CI, 1.50.2.21) compared with those in patients undergoing PD without AF. After considering in-hospital death as a competing risk, AF remained associated with an increased risk of ischemic stroke (hazard ratio [HR], 1.67; 95% CI, 1.17-2.37). The CHA2DS2-VASc score was associated with the risk of ischemic stroke (HR, 1.28; 95% CI, 1.12-1.46). Conclusion The risks of ischemic stroke, all-cause death, and in-hospital cardiovascular death were significantly higher in patients undergoing PD with AF than those in patients without AF. The CHA2DS2-VASc score remained associated with the risk of ischemic stroke in patients undergoing PD with AF.

Background: The effect of warfarin on the risk of cardiovascular (CV) disease is unknown among chronic hemodialysis patients with atrial fibrillation (HD-AF). Methods: Population-based propensity score and prescription time-distribution matched cohort study including 6719 HD-AF patients with CHA2DS2-VASc score ≥ 2 were divided into warfarin users and nonusers and followed-up for CV events and death. Results: Warfarin treatment in HD-AF patients with AF preceding HD was associated with higher risks of developing congestive heart failure [hazard ratio (HR) = 1.82, 95% confidence interval (CI) = 1.29–2.58, p

Anaemia is an important issue in patients undergoing haemodialysis. We aimed to identify a better dosing schedule of a fixed monthly dose of continuous erythropoietin receptor activator (CERA) in patients with chronic kidney disease (CKD) on haemodialysis. The CERA dosing schedule included 100 μg once monthly for 2 months, 50 μg twice monthly for 2 months and then 100 μg once monthly for two months. The effectiveness was determined by comparing haematocrit, nutritional status (serum protein and albumin) and inflammatory markers (tumour necrosis factor (TNF)-α, interleukin (IL)-1, IL-6 and Hepcidin) at the beginning of the study with those at the end of the study. Forty-seven out of 67 patients completed the trial. At the end, haematocrit was significantly higher (34.51 vs 33.22%, P=.004), levels of inflammatory markers were significantly lower (TNF-α (30.71 vs 35.67 ng/mL, P=.007), IL-6 (5.12 vs 7.95 ng/mL, P=.033), hepcidin (60.39 vs 74.39 ng/mL, P=.002)), blood glucose levels were significantly lower (112.40 vs 139.02 mg/dL, P=.003) and albumin was significantly higher (4.11 vs 3.98, P=.001). Patients with a better than average response had a lower initial number of red blood cells (3.3 vs 3.6 × 10(6) /mm(3) , P=.025) and a lower IL-1 (3.8 vs 12.9 ng/mL, P=.01). They also had significantly lower blood glucose levels at the end. (91.3 vs 124.0 mg/dL, P=.03). We demonstrate that a fixed monthly dose of CERA at a twice monthly dosing schedule improves nutrition, reduces the inflammation and corrects anaemia in patients on haemodialysis. This finding may provide a new strategy for treating CKD-related anaemia.

To evaluate the long-term survival rate of critically ill sepsis survivors following cardiopulmonary resuscitation on a national scale.Retrospective and observational cohort study.Data were extracted from Taiwan's National Health Insurance Research Database.A total of 272,897 ICU patients with sepsis were identified during 2000-2010. Patients who survived to hospital discharge were enrolled. Post-discharge survival outcomes of ICU sepsis survivors who received cardiopulmonary resuscitation were compared with those of patients who did not experience cardiopulmonary arrest using propensity score matching with a 1:1 ratio.None.Only 7% (n = 3,207) of sepsis patients who received cardiopulmonary resuscitation survived to discharge. The overall 1-, 2-, and 5-year postdischarge survival rates following cardiopulmonary resuscitation were 28%, 23%, and 14%, respectively. Compared with sepsis survivors without cardiopulmonary arrest, sepsis survivors who received cardiopulmonary resuscitation had a greater risk of all-cause mortality after discharge (hazard ratio, 1.38; 95% CI, 1.34-1.46). This difference in mortality risk diminished after 2 years (hazard ratio, 1.11; 95% CI, 0.96-1.28). Multivariable analysis showed that independent risk factors for long-term mortality following cardiopulmonary resuscitation were male sex, older age, receipt of care in a nonmedical center, higher Charlson Comorbidity Index score, chronic kidney disease, cancer, respiratory infection, vasoactive agent use, and receipt of renal replacement therapy during ICU stay.The long-term outcome was worse in ICU survivors of sepsis who received in-hospital cardiopulmonary resuscitation than in those who did not, but this increased risk of mortality diminished at 2 years after discharge.

Renin-angiotensin-aldosterone system blockers are the preferred antihypertensive medications in patients with diabetes and prior stroke. This study aimed to compare the effects of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) in terms of major adverse cardiac events (MACEs) in patients with diabetes who survived ischemic stroke.We conducted an observational, nationwide, propensity score-matched cohort study using Taiwan's National Health Insurance Research Database. Patients aged at least 20 years with type 2 diabetes who initiated ACEI (n = 15,959) or ARB (n = 23,929) use within 90 days after discharge for first ischemic stroke between January 2000 and December 2011 were allocated to ACEI and ARB groups, respectively. The primary outcomes were MACEs (myocardial infarction, ischemic stroke, and cardiovascular mortality). The secondary outcomes were hospitalization for acute kidney injury and hyperkalemia. Intention-to-treat and as-treated models were used.Intention-to-treat analysis showed no significant difference between the ACEI and ARB groups in the outcomes of MACEs [hazard ratio (HR), 0.99; 95% confidence interval (CI), 0.95-1.04], including ischemic stroke (HR, 1.01; 95% CI, 0.97-1.06), myocardial infarction (HR, 1.06; 95% CI, 0.95-1.18), and cardiovascular mortality (HR, 0.98; 95% CI, 0.91-1.06). As-treated analysis produced similar results. Additionally, the groups showed no difference in the risk of hospitalization for acute kidney injury or hyperkalemia.Our study supports the hypothesis that the risks of MACEs and two additional secondary outcomes in patients with diabetes who survived ischemic stroke did not differ according to ACEI versus ARB use.

Background— Whether oral anticoagulant use should be considered in patients undergoing hemodialysis with atrial fibrillation (AF) remains controversial because of the uncertainty regarding risk-benefit assessments. The purpose of this study was to investigate the risk of ischemic stroke in patients undergoing hemodialysis with new-onset AF, in comparison with those without arrhythmia. Methods and Results— This nationwide, population-based, propensity score–matched cohort study used data from Taiwan’s National Health Insurance Research Database during 1998 to 2011 for patients on hemodialysis with new-onset nonvalvular AF and matched subjects without arrhythmia. The clinical end points were ischemic stroke (fatal or nonfatal), all-cause death, and other serious adverse cardiovascular events. In comparison with the matched cohort, patients with AF (n=6772) had higher risks of ischemic stroke (adjusted hazard ratio [aHR], 1.27; 95% confidence interval [CI], 1.13–1.43), all-cause death (aHR, 1.59; 95% CI, 1.52–1.67), in-hospital cardiovascular death (aHR, 1.83; 95% CI, 1.71–1.94), myocardial infarction (aHR, 1.33; 95% CI, 1.17–1.51), and hospitalization for heart failure (aHR, 1.90; 95% CI, 1.76–2.05). After considering in-hospital death as a competing risk, AF significantly increased the risk of heart failure (HR, 1.56; 95% CI, 1.45–1.68), but not those of ischemic stroke and myocardial infarction. Additionally, the predictive value of the CHA 2 DS 2 –VASc score for ischemic stroke was diminished in the competing-risk model. Conclusions— The risk of stroke was only modestly higher in patients undergoing hemodialysis with new-onset AF than in those without AF, and it became insignificant when accounting for the competing risk of in-hospital death.

Background The comorbidity profile, especially cancer risk, of narcoleptic patients has seldom been explored. We used a nationwide database to evaluate the risk of cancer among adult narcoleptic patients. Methods We conducted the cohort study using National Health Insurance Research Database from 2000 to 2009. Standardized incidence ratios (SIRs) of cancers were calculated to compare the cancer incidence of the study cohort with that of the general population. Results 2833 narcoleptic patients were identified after excluding patients with antecedent malignancy and age younger than 18 years old. The study cohort was observed for 15,913 person-years during a 10-year period. The median follow-up interval was 5.6 ± 3.0 years. Seventy-four cancers occurred in during the follow-up. The risk of all cancers was found significantly increased in adult narcoleptic patients (SIR 1.32; 95% CI, 1.04–1.66, p = 0.0248). Regarding sex, the overall cancer risk was increased in female patients (SIR 1.52; 95% CI, 1.05–2.13, p = 0.026). Furthermore, females were found to have more head and neck cancers (SIR 6.17; 95% CI, 1.66-15.80, p = 0.009) and gastric cancers (SIR 4.87; 95% CI, 1.31–12.48, p = 0.02). For males, the incidence of overall and specific cancer types was not significantly increased. Conclusions Adult narcoleptic patients had a higher risk for cancer. Further research is warranted to elucidate the mechanism underlying its association.

Introduction Proprotein convertase subtilisin/kexin-6 (PCSK6) is a secretory protein that activates corin in the heart. Higher circulating levels of corin are associated with improved cardiovascular outcomes in patients with acute myocardial infarction. This study aimed to determine the role of serum PCSK6 and corin levels in predicting cardiovascular outcomes in patients with suspected coronary artery disease (CAD). Materials and methods In total, 565 patients who had undergone coronary angiography were enrolled. Serum PCSK6 and corin levels were determined before the administration of contrast media. In this study, coronary revascularization, acute myocardial infarction, acute stroke, and death were defined as cardiovascular outcomes. All patients were followed up for at least one year after coronary angiography or until the occurrence of death. Results During a median follow-up of 691 days, 67 patients (15.7%) developed composite cardiovascular outcomes after coronary angiography, including 51 incidents of coronary revascularization, 7 instances of acute myocardial infarction, 2 acute strokes, and 15 deaths. After adjustment for demographic characteristics and all significant variables in the univariate analysis, serum levels of neither PCSK6 nor corin were associated with increased risk for cardiovascular outcomes. This correlation remained insignificant in patients with underlying hypertension, diabetes mellitus, CAD, heart failure, or chronic kidney disease (CKD). However, in patients without CKD, higher serum PCSK6 levels were associated with increased risk for cardiovascular outcomes (hazard ratio 1.380; 95% confidence interval 1.023–1.862). Conclusions We found no association between cardiovascular outcomes and pre-procedural serum levels of PCSK6 or corin in patients undergoing coronary angiography. However, an increased risk was seen in non-CKD patients with higher PCSK6 levels. Further studies are needed to verify these results.

Background Higher circulatory corin in patients with cardiac diseases is associated with improved cardiovascular outcomes, and chronic cardiac dysfunction is a well‐known cause of progressive renal dysfunction. This study aimed to determine the role of serum corin in predicting short‐term and long‐term renal outcomes after contrast exposure in patients with suspected coronary artery disease. Methods and Results Four hundred one patients who had received coronary angiography were enrolled. Serum corin levels were determined before administration of contrast media. Contrast‐induced nephropathy was defined as a rise in serum creatinine of 0.5 mg/dL or a 25% increase from baseline within 48 hours after the procedure. Progressive renal dysfunction was defined as >50% decrease in estimated glomerular filtration rate after discharge. All patients were followed up for at least 1 year or until the occurrence of death after coronary angiography. Overall, contrast‐induced nephropathy occurred in 23 (5.7%) patients. During a median follow‐up of 529 days, 44 (11.0%) cases had subsequent decline in renal function. After adjustment for demographic characteristics, kidney function, traditional risk factors, and medications, lower corin level was found to be independently associated with higher risk for progressive renal dysfunction (hazard ratio, 0.23; 95% confidence interval, 0.12–0.44) but not for contrast‐induced nephropathy. This inverse correlation remained evident in patients with underlying chronic kidney disease, coronary artery disease, or heart failure. Conclusions Lower baseline serum corin was associated with higher risk of renal function decline in patients undergoing coronary angiography. Further studies are needed to verify these results.

Perfluorooctanesulfonate (PFOS) and perfluorooctanoic acid (PFOA) are commonly used perfluorinated chemicals (PFCs). PFCs are mainly excreted by urine. Uremic patients tend to accumulate toxins in their body and have poor functional status. We investigated the associations between PFCs and the clinical profile of uremic patients under hemodialysis (HD). Liquid chromatography tandem mass spectrometry coupled with isotope dilution was used to quantify PFOA and PFOS. We enrolled 126 patients under regular HD. Compared with previous research, the concentration of PFOA was lower, but that of PFOS was higher in uremic patients than in the general population. The levels of PFOA and PFOS in uremic patients before dialysis were 0.52 (ng/ml) and 21.84 (ng/ml) respectively. The PFOA level remained unchanged but that of PFOS decreased to1.85 ng/mL after dialysis. PFOS can be removed by HD. Patients using hypertensive medication had a lower PFOS then those who did not. The PFOS level was negatively correlated with the duration of the HD session and patient performance status, but positively correlated with levels of cholesterol, chloride (an indicator of acidemia), ferritin, and total protein. (p

Objectives There is a lack of consensus on the risk factors for hernia formation, and the impact on peritoneal dialysis (PD) survival has seldom been studied. Methods This was a population-based study and all collected data were retrieved from the National Health Insurance Research Database of Taiwan. Patients who commenced PD between January 1998 and December 2006 were screened for inclusion. Multiple logistic regression and Cox proportional hazards models were applied to estimate the predictors for hernia formation and determine the predictors of PD withdrawal. Results A total of 6,928 PD patients were enrolled and followed until December 2009, with 631 hernia events and 391 hernioplasties being registered in 530 patients (7.7%). The incidence rate was 0.04 hernias/patient/year. Longer PD duration (per 1 month increase, hazard ratio (HR) 1.019) and history of mitral valve prolapse (MVP) (HR 1.584) were independent risk factors for hernia formation during PD, and female gender (HR 0.617) was a protective factor. On the other hand, there were 4,468 PD withdrawals, with cumulative incidence rates of 41% at 1 year, 66% at 3 years, and 82% at 5 years. Independent determinants for cumulative PD withdrawal included hernia formation during PD (HR 1.154), age (per 1 year increase, HR 1.014), larger dialysate volume (per 1 liter increase, HR 0.496), female gender (HR 0.763), heart failure (HR 1.092), hypertension (HR 1.207), myocardial infarction (HR 1.292), chronic obstructive pulmonary disease (COPD) (HR 1.227), cerebrovascular accident (CVA) (HR 1.364), and history of MVP (HR 0.712) Conclusions Prolonged PD duration was a risk factor for hernia formation, and female gender was protective. Hernia formation during PD therapy may increase the risk of PD withdrawal.

Objective Acute kidney injury is a common and serious problem after cardiac surgery. Postoperative acute kidney injury is independently associated with in-hospital mortality and long-term morbidity, even after adjustment for comorbid diseases. Chronic kidney disease has been recognized as a strong risk factor of acute kidney injury after cardiac surgery. The association between proteinuria and postcardiotomy acute kidney injury in patients with preserved glomerular filtration rate remains uncertain. Methods Patients with an estimated glomerular filtration rate greater than 60 mL/min/1.73 m 2 who underwent cardiac surgery between January 2003 and December 2007 in a tertiary medical center were retrospectively analyzed. Dipstick urinalysis was performed before surgery. Proteinuria was categorized into negative, trace, 1+, 2+, or 3+. Postoperative acute kidney injury was defined by the Acute Kidney Injury Network criteria. Multinomial logistic regression was used to clarify whether proteinuria is an independent risk factor of postoperative acute kidney injury. Results A total of 1246 patients were included in this study, with a mean estimated glomerular filtration rate of 80 ± 13 mL/min/1.73 m 2 . Proteinuria was present in 290 patients (23.4%). Postoperative acute kidney injury developed in 434 patients (34.8%), and 36 patients (2.9%) required renal replacement therapy. Proteinuria was independently associated with all stages of postcardiotomy acute kidney injury and dialysis-requiring acute kidney injury. The crude risk of acute kidney injury was greater in patients with a higher grade of proteinuria. In subgroup analysis for gender, diabetes, and surgical type, preoperative proteinuria remains a strong risk factor of acute kidney injury after cardiac surgery. Conclusions Urine analysis is usually neglected before cardiac surgery despite the fact that proteinuria is the earliest manifestation of kidney dysfunction. In the current study, we show that urine protein is strongly and independently associated with postoperative acute kidney injury in subjects with preserved estimated glomerular filtration rate. These data suggest that such a relatively simple and clinically easy to use tool as a urinary dipstick may be useful to identify patients at high risk of acute kidney injury before cardiac surgery.

Background— Substantial infective endocarditis (IE)–related morbidity and mortality may occur even after successful treatment. However, no previous study has explored long-term hard end points (ie, stroke, myocardial infarction, heart failure, cardiovascular death) in addition to all-cause mortality in IE survivors. Methods and Results— A nationwide population-based cohort study was conducted among IE survivors identified with the use of the Taiwan National Health Insurance Research Database during 2000 to 2009. IE survivors were defined as those who survived after discharge from first hospitalization with a diagnosis of IE. A total of 10 116 IE survivors were identified. IE survivors were matched to control subjects without IE at a 1:1 ratio through the use of propensity scores. The primary outcomes were stroke, myocardial infarction, readmission for heart failure, and sudden cardiac death or ventricular arrhythmia. The secondary outcomes were repeat IE and all-cause mortality. Compared with the matched cohort, IE survivors had higher risks of ischemic stroke (adjusted hazard ratio [aHR], 1.59; 95% confidence interval [CI], 1.40–1.80), hemorrhagic stroke (aHR, 2.37; 95% CI, 1.90–2.96), myocardial infarction (aHR, 1.44; 95% CI, 1.17–1.79), readmission for heart failure (aHR, 2.24; 95% CI, 2.05–2.43), sudden death or ventricular arrhythmia (aHR, 1.69; 95% CI, 1.44–1.98), and all-cause death (aHR, 2.27; 95% CI, 2.14–2.40). Risk factors for repeat IE were older age, male sex, drug abuse, and valvular replacement after an initial episode of IE. Conclusion— Despite treatment, the risk of long-term major adverse cardiac events was substantially increased in IE survivors.

Background Headaches resulting from proton pump inhibitor (PPI) use could cause discontinuation of PPI in as many as 40% of patients who experience such headaches. Previous studies focusing on acute headache risk from PPI use are rare and limited to clinical trials of a single PPI. Objectives To investigate the association between PPI use and headache with a nationwide population-based case-crossover study. Methods Records containing the first diagnosis of any headache, including migraine and tension-type headaches, were retrieved from Taiwan National Health Insurance Database (1998–2010). We compared the rates of PPI use for cases and controls during time windows of 7, 14, and 28 days. The adjusted self-matched odds ratios (ORs) and 95% confidence intervals (CIs) from a conditional logistic regression model were used to determine the association between PPI use and headache. Results Overall, 314,210 patients with an initial diagnosis of any headache during the study period were enrolled. The adjusted ORs for headache risk after PPI exposure were calculated for three time periods (within 7 days = 1.41, p = 0.002, 95% CI 1.14–1.74; within 14 days = 1.36, p < 0.001, 95% CI 1.16–1.59; within 28 days = 1.20, p = 0.002, 95% CI 1.07–1.35). Subgroup analyses showed female patients had an increased risk of headache. Among PPIs, lansoprazole and esomeprazole had the highest risks of headache incidence, which were similar to that of nitrates. Conclusion PPI usage is associated with an increased risk for acute headache. Female patients and use of lansoprazole or esomeprazole present the greatest risks of headache.

The association between selective serotonin receptor inhibitors (SSRIs) and risk of upper gastrointestinal bleeding remains controversial. Previous studies have generally evaluated the issue for approximately 3 months, even though the SSRI-mediated inhibition of platelet serotonin concentrations occurs within 7-14 days. The authors explored the risk of upper gastrointestinal bleeding after short-term SSRI exposure by a case-crossover design.The records of psychiatric inpatients with upper gastrointestinal bleeding were retrieved from the Taiwan National Health Insurance Database (1998-2009). Rates of antidepressant use were compared for case and control periods with time windows of 7, 14, and 28 days. The adjusted self-matched odds ratios from a conditional logistic regression model were used to determine the association between SSRI use and upper gastrointestinal bleeding.A total of 5,377 patients with upper gastrointestinal bleeding were enrolled. The adjusted odds ratio for the risk of upper gastrointestinal bleeding after SSRI exposure was 1.67 (95% CI=1.23-2.26) for the 7-day window, 1.84 (95% CI=1.42-2.40) for the 14-day window, and 1.67 (95% CI=1.34-2.08) for the 28-day window. SSRIs with high and intermediate, but not low, affinity for serotonin transporter were associated with upper gastrointestinal bleeding. An elevated risk of upper gastrointestinal bleeding after SSRI exposure was seen in male but not female patients.Short-term SSRI use (7-28 days) is significantly associated with upper gastrointestinal bleeding. Gender differences may exist in the relationship between SSRI use and upper gastrointestinal bleeding. Physicians should carefully monitor signs of upper gastrointestinal bleeding even after short-term exposure to SSRIs, as is done with nonsteroidal anti-inflammatory drugs and aspirin.

High uric acid (UA) can act as a pro-oxidant in normal physiological conditions; however, emerging evidence is still debatable with regard to the association between high UA and poor outcomes among chronic hemodialysis (HD) patients. In the present study, 27,229 stable prevalent HD patients were enrolled and divided into four groups according to the quartiles of baseline UA concentration, and 5737 died during a median follow-up of 38 months. Multivariate Cox regression analysis showed that a UA level of 8.1 mg/dL [HR, 1.20, 95% CI (1.10–1.31)] adjusting for baseline demographic and biochemical parameters. Moreover, a UA level of

Introduction: Perfluoro-octanesulfonate (PFOS) and perfluoro-octanoic acid (PFOA) are two toxic perfluorochemicals (PFCs) commonly used as surfactants. PFCs are difficult to be eliminated from the body. We investigated the influence of different dialysis membranes on the concentrations of PFCs in patients under hemodialysis. Method: We enrolled 98 patients. Of these, 58 patients used hydrophobic polysulfone (PS) dialysis membranes, and the other 40 had hydrophilic membranes made by poly-methyl methacrylate (PMMA) or cellulose triacetate (CTA). Liquid chromatography tandem mass spectrometry coupled was used with isotope dilution to quantify PFOA and PFOS. Results: The predialysis concentrations of PFOA and PFOS in patients with hydrophobic PS dialysis membranes were 0.50 and 15.77 ng/mL, respectively, lower than the concentrations of 0.81 and 22.70 ng/mL, respectively, in those who used hydrophilic membranes (such as CTA or PMMA). Older patients have higher PFOS and poorer body function, with lower Karnofsky Performance Status Scale (KPSS) scores. The demographic data of the two groups were similar. However, patients with hydrophobic PS dialysis membranes had lower predialysis aspartate transaminase (AST) (p = 0.036), lower glucose levels (p = 0.017), and better body function (nonsignificantly higher KPSS scores, p = 0.091) compared with patients who used other membranes. These differences may be associated with the effects of different membranes, because PFOA positively correlated with AST, while PFOS negatively correlated with body function. Conclusions: This is the first study comparing PFC levels in uremic patients with different dialysis membrane. PS membrane may provide better clearance of PFCs and may, therefore, be beneficial for patients.

The objective of this study was to evaluate the risks of acute cholecystitis among end-stage renal disease patients and compare the incidence between two dialysis modality.In this retrospective cohort study, records of fifty thousand end-stage renal disease patients older than 20 years of age from 1998 to 2007 and an age, gender, Charlson's score, diabetes, and dyslipidemia matched control cohort were retrieved from Taiwan National Health Insurance Research Database. Hospitalizations for acute cholecystitis were retrieved using ICD-9-CM diagnosis codes and ICD-9-CM operation codes from in-patient claims.The incidence rates were 5.8 per 1000 patient-years in the end-stage renal disease patients and 0.92 per 1000 patient-years in the control group. End-stage renal disease was an independent risk factor for acute cholecystitis. In the end-stage renal disease patients, independent risk factors were old age, higher Charlson's score, diabetes, severe liver disease, atrial fibrillation, and haemodialysis (all p0.05). However, the peritoneal dialysis patients had a higher mortality rate after developing acute cholecystitis.Acute cholecystitis is not uncommon in end-stage renal disease patients. The independent risk factors were older age, higher Charlson's score, atrial fibrillation, severe liver disease, diabetes, and dialysis modality. Haemodialysis patients had a higher risk of acute cholecystitis than PD patients.

Background There has been no large-scale population-based study on the incidence and clinical manifestations of second primary cancer (SPC) after diagnosis of hepatocellular carcinoma (HCC). Aims This study aimed to evaluate the incidence and the risk factors of SPC following HCC diagnosis. Method This study used data from the National Health Insurance Research Database of Taiwan to identify all HCC patients from 1 January 1997 to 31 December 2006. Cases of SPC were gathered using the ICD9-CM codes of 140–208.91. Standardized incidence ratios (SIRs) were conducted for incidence of SPC in HCC survivors. Competing-risks regression with adjustment of death was used to analyse the risk factors of SPC. Results From 45 976 HCC patients, 749 (1.6%) developed SPC after 90 days of HCC diagnosis. Male HCC patients had higher risks of gastric, biliary, urinary bladder, kidney and haematological cancers compared to the general male population. Female patients had higher incidences of biliary tract, kidney and bone and soft tissue cancers. Older age and chronic kidney disease (CKD) were independent factors predicting SPC. Conclusions SPC in patients with HCC is not rare in Taiwan. Urinary bladder cancer and renal cancer are more specific SPC for HCC patients. Better surveillance strategies for SPC should be established for HCC survivors, especially in the elderly or those with CKD.

Background Patients with end-stage renal disease (ESRD) are at high risk of cardiovascular disease and elevated serum homocysteine levels. Although folic acid supplementation has been documented to reduce serum homocysteine levels in ESRD patients, most trials of folic acid therapy for reducing cardiovascular diseases in ESRD patients have failed, mainly because of limited patient numbers. Methods We used the Taiwan National Health Insurance Research Database (NHIRD) to conduct a matched-pair retrospective cohort study to clarify whether folic acid supplementation benefits ESRD patient survival. Patients were divided into a folic acid supplementation group and a control group. All-cause and cardiovascular-related mortality rates between groups were compared. Results In total, 55,636 stable incident hemodialysis patients were identified from the database. Using a propensity score-matched method and intention-to-treat analysis, the survival rate of 17,000 patients with folic acid supplementation was compared with a 1:1 matched control group. The baseline demographic data and comorbid disease incidence between the 2 groups were comparable. During the study period, the mortality rate in the matched pair cohort was 35.5% (n = 6,030) over a mean follow-up period of 3.0 years, corresponding to a mortality rate of 12.8/100 patient-years. The all-cause mortality rates were 12.3 and 13.4/100 patient-years in the folic acid group and control group, respectively (p = 0.005). Conclusions In adult hemodialysis patients, folic acid supplementation improves cardiovascular and all-cause mortality rates.

Background Pleiotropic effects on cardiovascular protection have been suggested in several oral antidiabetic drugs (OAD). The impacts of OADs on aortic aneurysm (AA) growth have been found in animal studies, but the evidence of their beneficial effects for AA protection in human are lacking. We investigated the relationship between OAD therapy and the risk of developing AA. Methods We conducted a nested case–control analysis using the database extracted from Taiwan’s National Health Insurance Research Database. The database consists of 1.2 million diabetic patients representing the majority of the type 2 diabetes population in Taiwan from 2000 to 2013. Cases were identified as those with either inpatient or outpatient diagnosis code of AA. One control was selected for each case matching on duration of follow-up, age, sex, urbanization, monthly income, severity of diabetes, and risk factor for AA. We identified variable classes of OADs, including metformin, sulfonylureas, thiazolidinedione (TZD), alpha-glucosidase inhibitors, meglitinide, dipeptidyl peptidase-4 (DPP-4) inhibitors prior to the development of AA. Results A total of 4468 cases diagnosed with AA and 4468 matched controls were identified. Metformin use, sulfonylurea use, and TZD were associated with lower risk of developing AA, odds ratio [OR] 0.72 (95 % confidence interval [CI] 0.64–0.80), 0.82 (95 % CI 0.74–0.92), and 0.82 (95 % CI 0.69–0.98), respectively. The effects of metformin and sulfonylurea on AA were dose responsive. Neither alpha-glucosidase inhibitors (OR 0.95; 95 % CI 0.81–1.11) nor DPP-4 inhibitors (OR 0.85; 95 % CI 0.68–1.07) was significantly associated with AA events. Conclusions Metformin, sulfonylurea, and TZD treated patients were associated with lower risks of AA development, but not DPP-4 inhibitors or alpha-glucosidase inhibitor. The protective effects of hypoglycemic agents are further confirmed by the dose responsive relations in metformin and sulfonylurea groups.

Background: Angiotensin-converting-enzyme (ACE) inhibitors and angiotensin II receptor blockers (ARBs) are effective treatments for diabetic retinopathy, but randomized trials and meta-analyses comparing their effects on macrovascular complications have yielded conflicting results. We compared the effectiveness of these drugs in patients with pre-existing diabetic retinopathy in a large population-based cohort. Methods: We conducted a propensity score–matched cohort study using Taiwan’s National Health Insurance Research Database. We included adult patients prescribed an ACE inhibitor or ARB within 90 days after diagnosis of diabetic retinopathy between 2000 and 2010. Primary outcomes were all-cause death and major adverse cardiovascular events (myocardial infarction, ischemic stroke or cardiovascular death). Secondary outcomes were hospital admissions with acute kidney injury or hyperkalemia. Results: We identified 11 246 patients receiving ACE inhibitors and 15 173 receiving ARBs, of whom 9769 patients in each group were matched successfully by propensity scores. In the intention-to-treat analyses, ARBs were similar to ACE inhibitors in risk of all-cause death (hazard ratio [HR] 0.94, 95% confidence interval [CI] 0.87–1.01) and major adverse cardiovascular events (HR 0.95, 95% CI 0.87–1.04), including myocardial infarction (HR 1.03, 95% CI 0.88–1.20), ischemic stroke (HR 0.94, 95% CI 0.85–1.04) and cardiovascular death (HR 1.01, 95% CI 0.88–1.16). They also did not differ from ACE inhibitors in risk of hospital admission with acute kidney injury (HR 1.01, 95% CI 0.91–1.13) and hospital admission with hyperkalemia (HR 1.01, 95% CI 0.86–1.18). Results were similar in as-treated analyses. Interpretation: Our study showed that ACE inhibitors were similar to ARBs in risk of all-cause death, major adverse cardiovascular events and adverse effects among patients with pre-existing diabetic retinopathy.

Acute appendicitis in patients with end-stage renal disease (ESRD) poses a diagnostic challenge. Delayed surgery can contribute to higher morbidity and mortality rates. However, few studies have evaluated this disease among ESRD patients. Our study focused on the lack of data on the incidence and risk factors of acute appendicitis among ESRD patients and compared the outcomes in patients who underwent different dialysis modalities. This national survey was conducted between 1997 and 2005 and included ESRD patients identified from the Taiwan National Health Insurance database. The incidence rate of acute appendicitis in ESRD patients was compared with that in randomly selected age-, sex-, and Charlson comorbidity score-matched non-dialysis controls. A Cox regression hazard model was used to identify risk factors. Among 59,781 incident ESRD patients, matched one-to-one with controls, there were 328 events of acute appendicitis. The incidence rate of 16.9 per 10,000 person-years in the ESRD cohort was higher than that in the control cohort (p = 0.003). The independent risk factors were atrial fibrillation (hazard ratio [HR], 2.08), severe liver disease (HR, 1.74), diabetes mellitus (HR, 1.58), and hemodialysis (HR, 1.74). Compared with the control cohort, subsequent perforation and mortality rates of acute appendicitis were also higher in the ESRD cohorts. There was no effect of dialysis modality on the patient outcomes. ESRD patients had a higher risk for acute appendicitis and poorer outcomes than non-dialysis populations. A careful examination of ESRD patients presenting with atypical abdominal pain to avoid misdiagnosis is extremely important to prevent delayed surgery.

Objectives. Erythropoiesis-stimulating agents (ESA) are the main treatment for anemia in hemodialysis (HD) patients. We evaluated factors determining the response after treatment of a new ESA (continuous erythropoietin erythropoietin receptor activator (CERA)).Methods. 61 HD patients were classified by their response at two different timings. First, patients whose hematocrit (Hct) increased 1.5% in the first week were defined as initial responders (IR,n=16). We compared several parameters between IR and the rest of the study subjects (non-IR,n=45). Second, patients whose Hct increased 2% in the 4th week were defined as sustained responders (SR,n=12), and we did a similar comparison.Results. The Hct showed a waveform fluctuation. Compared with the rest, IR had significantly lower platelet counts and higher levels of ferritin, total protein, total bilirubin, and serum sodium, while SR had significantly lower levels of C-reactive protein and low-density lipoprotein (AllP<0.05). In comparison with the rest, higher Hct persisted for 10 weeks in SR but only for two separate weeks (the 1st and 7th week) in IR.Conclusions. The initial and sustained erythropoietic responses are independent from each other and are associated with different factors. Treatment focusing on these factors may improve the response.

Objective The response of erythropoietic stimulating agents (ESA) in uremic patients may be associated with the changes of biochemical parameters, metal elements and inflammation status during the shift from one ESA to another. Method We compared changes in above mentioned factors after switching from darbepoetin-α (DPO) 20 μg weekly for 10 weeks to continuous erythropoietin receptor activator (CERA) 100 μg monthly for 10 weeks in uremic patients on hemodialysis. The haematocrit (Hct), metal elements and inflammation status are the primary outcome. Subjects included 54 patients without transfusion or bleeding or additional ESAs. Responders (IR, n = 36) were defined as patients with an increase in Hct after the swtich. Result Although there was no significant difference in overall mean Hct after the switch (p = 0.135), there are significantly greater mean number of red blood cells (RBC) (p = 0.006), higher platelet numbers (p = 0.001), larger RBCs (p = 0.017) and higher creatinine (p = 0.04) and total cholesterol (T-CHOL) (p = 0.003) levels. Mean overall aluminium (Al) level decreased significantly (p = 0.001). C-reactive protein (CRP) also decreased (p = 0.016). The overall LDH increased (p = 0.049) and potassium decreased significantly (p = 0.036), which indicating active erythropoiesis. The calcium (Ca) level was significantly higher (p = 0.034) and phosphate was significantly lower (p = 0.028) after the shift. Although there was no significant increase in overall levels of parathyroid hormone (PTH) after the shift (p = 0.061), but the pre-shift and post-shift PTH level was significantly higher in IRs than in non-IRs (p = 0.003 and p = 0.027, respectively). IRs had a significantly lower initial T-CHOL (p = 0.03) and initial CRP (p = 0.012) than non-responders, which may be related to lower inflammation. Conclusion We found the shift from DPO to CERA results in lower Al levels, a reduced inflammatory response, and an increase in RBC number and PTH level in uremic patients on hemodialysis.

Catheter-related blood stream infection (CRBSI) is a major complication in hemodialysis patients. We assessed the efficacy of systemic daptomycin (DPT) plus DPT antibiotic lock therapy (DPT-ALT) for catheter salvage in patients with Gram-positive CRBSIs. This is a retrospective study of hemodialysis patients with tunneled and cuffed hemodialysis catheters. All patients were from a single institution in Taipei and received systemic DPT plus DPT-ALT for the treatment of Gram-positive CRBSI. Successful resolution of CRBSI was implemented. Resolution of fever within 48 hours, negative result of repeated blood cultures after resolution of fever, no clinical evidence of CRBSI relapse and no need for catheter removal were measured. Fifteen hemodialysis patients received DPT-ALT for CRBSI, nine with coagulase-negative Staphylococcus (CONS), two with methicillin-resistant Staphylococcus aureus (MRSA), three with methicillin-sensitive Staphylococcus aureus (MSSA) and one with polymicrobial infections. Systemic DPT plus DPT-ALT cured 11 patients (73.3%). Treatment failed in all three MRSA cases (two with MRSA and one with MRSA + Enterococcus faecalis). Retrospective design and small sample size were the limitations of this study. Systemic DPT plus DPT-ALT appears to be a promising treatment for CRBSI from CONS and MSSA, but not for MRSA CRBSI. Systemic DPT plus DPT-ALT should be considered for patients with CRBSIs caused by certain species.

Although the association of hyperuricemia and cardiovascular diseases is well established by previous research studies, the relationship between gout and deep vein thrombosis (DVT) remains unclear. We conducted a nationwide longitudinal cohort study to investigate the relationship between gout and DVT. We used the Taiwan National Health Insurance Research Database to identify patients with gout diagnosed in Taiwan during 2000–2011, and we followed up these patients to determine the incidence of DVT among them. The association between gout and DVT was analyzed by cox proportional hazard model. The study cohort included 35,959 patients with history of gout attack and 35,959 matched controls without gout attack. During the median follow-up of 7.5 ± 3.6 years, the incidence rate of DVT was significantly higher in patients with gout than that in control group (13.48 versus 9.77 per 104 person-years, p

Background: Compared to the general population, patients with end-stage renal disease (ESRD) have increased peptic ulcer and upper GI bleeding complication rates. However, the risk factors for peptic ulcer among ESRD patients are unknown. Methods: In this retrospective study, we enrolled 827 incident dialysis patients and diagnosed peptic ulcer on the basis of endoscopic findings; information on the morbidities and medical prescription were obtained directly from medical records. A Cox regression hazard model was used to identify risk factors for peptic ulcer. Results: During the 10-year study period, 481 patients underwent an endoscopic exam. Peptic ulcers were detected in 153 patients. Age (p = 0.025), peritoneal dialysis (p = 0.022), diabetes mellitus (p = 0.020), congestive heart failure (p = 0.015), low serum albumin (p = 0.008) and high gamma-glutamyl transpeptidase (γ-GT) levels (p = 0.002) are risk factors for peptic ulcers among ESRD patients. Ulcer severity (p = 0.004) and aspirin prescription (p = 0.043), but not Helicobacter pylori infection, influenced the ulcer recurrence rate. Conclusion: The risk factors for peptic ulcer have some differences between ESRD patients and general population. In patients with high risk of upper GI bleeding, peritoneal dialysis and aspirin should be prescribed with caution.

Dual renin angiotensin system (RAS) blockade using angiotensin-receptor blockers (ARBs) in combination with angiotensin converting enzyme inhibitors (ACEIs) is reported to improve proteinuria in both diabetic and non-diabetic patients. However, its renoprotective effect and safety remain uncertain in patients with advanced chronic kidney disease (CKD). From January 1, 2000 through June 30, 2009, we enrolled 14,117 pre-dialytic stage 5 CKD patients with serum creatinine >6mg/dL and hematocrit

Thiazide diuretics are associated with an increased risk of hyponatremia. The aim of this study was to investigate possible predictors of thiazide-induced hyponatremia. A total of 48 patients admitted to the ward or to the emergency department due to severe thiazide-induced hyponatremia (Na

Although oral antidiabetic drugs (OADs) have been associated with immunomodulation in preclinical studies, little is still known about the association between the use of OADs and the risk of sepsis. Using a cohort of patients, extracted from Taiwan’s National Health Insurance Research Database, with type 2 diabetes who were newly diagnosed between 2010 and 2012 and treated with OADs, we conducted a nested case-control study involving 43,015 cases (patients who were first hospitalized for sepsis) and 43,015 matched controls. Compared with non-use, metformin use was associated with a decreased risk of developing sepsis (adjusted odds ratio [OR] 0.80, 95% confidence interval [CI] 0.77–0.83, P P

Background The spot urine protein/creatinine ratio (UPCR) is proposed to be a substitute for 24-hour urinary protein (24 h-UP). This study is aimed to determine whether the predictive accuracy of 24 h-UP using UPCR can be improved by simply multiplying estimated daily urine creatinine excretion (eUCr) and UPCR together. Methods This study enrolled 120 participants to investigate the correlation between spot UPCR and 24 h-UP. Three sets of spot urine samples were randomly collected throughout the day and night, along with the first morning void. UPCR was weighted by eUCr to investigate the improvement of accuracy in using spot urine samples to predict 24 h-UP. Results There were strong correlation and concordance between UPCR and 24 h-UP irrespective of the time of spot urine sampling, and the correlation, concordance and agreement were improved after multiplying the UPCR value by the eUCr. Greater improvement was found in the subgroups with measured daily urine creatinine excretion ≤ 0.8 g/d and ≥ 1.2 g/d. Conclusions This investigation demonstrated that multiplying UPCR by eUCr can improve the accuracy of only using UPCR to predict 24 h-UP.

Background & Aims Studies concerning seasonal variations and the impact of air temperature on oesophageal variceal bleeding have yielded conflicting results. We aimed to explore the impact of air temperature on the occurrence of variceal bleeding. Methods A case-crossover study design was employed, and two cohorts were used, including the NHI-EVB cohort from the National Health Insurance Research Database of Taiwan from 1 January 1999 to 31 December 2010, and the VGH-EVB cohort from the Taipei Veterans General Hospital, from 4 May 2002 to 31 December 2010. A conditional logistic regression model was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs). Results In total, 2542 cases from the NHI-EVB cohort and 220 cases from the VGH-EVB cohort were analysed. Our analysis showed that low air temperature (LAT) increased the risk of variceal bleeding regardless of age, sex, decompensated cirrhosis, Child-Pugh classification, aetiology of liver disease and concomitant hepatocellular carcinoma; the lag effect was also observed. The ORs per 5°C decrease in daily mean air temperature were 1.144 (95% CI, 1.060–1.235) for the NHI-EVB cohort and 1.307 (95% CI: 1.031–1.658) for the VGH-EVB cohort. Oesophageal variceal bleeding in patients with small varices, end-stage liver disease score ≧15 or those using non-selective beta blockers was not influenced by air temperature. Conclusions Patients have higher risk of oesophageal variceal bleeding at low air temperature regardless of age, sex, aetiology of cirrhosis, Child-Pugh classification, decompensated cirrhosis and concomitant hepatocellular carcinoma and can be protected by use non-selective beta blockers.

Background There is substantial debate regarding the development of acute coronary syndrome in patients using proton pump inhibitors (PPIs) combined with clopidogrel. However, data remain limited to address the effect of PPIs alone on the subsequent risk of myocardial infarction (MI). We aimed to explore the subsequent risk of MI in PPI users who had no previous history of MI. Methods The records of inpatients and outpatients with PPI prescriptions were retrieved from the Taiwan National Health Insurance Research Database between 2000 and 2009. We conducted two different study designs, the first using propensity score (PS)-matching analyses and the second using case-crossover analyses. The risk of developing MI for PPI users was analyzed in the PS-matched study. The association between risk of MI and prior PPI exposure was further validated in the case-crossover study. Results In the PS-matched study, we included 126,367 PPI users and 126,367 PS-matched PPI non-users. After 120days of follow-up, PPI use was associated with a 1.58-fold greater risk of MI (adjusted hazard ratio [HR]=1.58, 95% confidence interval [CI]=1.11 to 2.25). In the case-crossover study, adjusted odds ratios of PPI for MI risk were 4.61 (95% CI=1.76 to 12.07) for the 7-day window and 3.47 (95% CI=1.76 to 6.83) for the 14-day window. Conclusions Use of PPIs may be independently associated with an increased risk of MI. However, the benefits of PPIs may greatly outweigh the risks of adverse cardiovascular effects, with number needed to harm of 4357.

End-stage renal disease (ESRD) patients are more prone to infectious disease because of their immunocompromised status. However, the association between pyogenic liver abscess (PLA) and ESRD remains not clear. The aim of our study is to evaluate the incidence, risk factors, and outcomes of PLA in ESRD patients. We recruited all incident ESRD patients from the Taiwan National Health Insurance database from 1998 to 2006. The incidence rate of PLA in ESRD patients was compared with that of a randomly selected non-ESRD control group matched for age, sex gender, Charlson comorbidity score, diabetes mellitus, and cirrhosis. Among the 57,761 incident dialysis patients, there were 538 cases of PLA. The incidence rate of PLA was 18.20 per 10,000 person-years in the ESRD cohort and 6.34 per 10,000 person-years in matched control cohort. The rate of PLA was significantly higher in the ESRD cohort (hazard ratio 3.63, 95% confidence interval 2.83-4.65, P 0.001). The mortality rates of PLA were higher in the ESRD cohort than those in matched control cohort. Diabetes mellitus was an independent risk factor for mortality of PLA. Compared with non-ESRD patients, ESRD patients have a higher risk of PLA and poorer outcomes.

The aim of our study was to determine whether pre-emptive statin therapy was associated with improved outcome of infective endocarditis (IE). We conducted a nationwide, population-based, propensity score-matched cohort study with the Taiwan's National Health Insurance Research Database. All patients with IE between January 2000 and December 2010 were enrolled. The primary outcome was in-hospital mortality. The secondary outcome included all-cause mortality within the first 3 months, 6 months, and one year after the diagnosis of IE. Among 13,584 patients with IE, we applied propensity score-matching on a 1:4 ratio, in which 370 statin users were matched to 1,480 statin non-users. Compared with statin non-users, statin users had a significantly lower risk of in-hospital mortality (adjusted hazard ratio [aHR] 0.65, 95% confidence interval [CI], 0.49–0.86). The reduction in mortality from IE remained significant for follow-up 3 months (aHR 0.68, 95% CI, 0.53–0.88), 6 months (aHR 0.73, 95% CI, 0.58–0.91), and 12 months (aHR 0.68, 95% CI, 0.55–0.84). Statin therapy was associated with a reduced risk of ICU admission rates, shock events, the need for mechanical ventilation, but not significantly with the need for heart valvular replacement surgery. In conclusion, our study found that statin therapy is associated with a reduced risk of in-hospital and subsequent mortality of IE.

Background To control tuberculosis (TB), it is critical to identify at risk populations. Schizophrenia is recognized as an important risk factor for TB. However, previous studies have been confounded by comorbidities, and reports of TB infection outcomes are rare. Therefore, the current nation-wide study aimed to compare the adjusted incidence and outcome of TB diseases in schizophrenics and the general population. Method Using the National Health Insurance Research Database from 1998 to 2009, this retrospective longitudinal study included 60,409 schizophrenics and general population matched for age, Charlson’s score, and comorbidities. Diagnosis of TB was based on the international classification of disease, ninth revision and use of anti-TB drugs. Unfavorable outcome for TB was defined as death, loss to follow-up, or use of anti-TB treatment for more than 9 months. Results The adjusted incidence of TB in schizophrenics was significantly higher than in the general population [hazard ratio, 1.52; 95% confidence interval (CI), 1.29-1.79; p < 0.001; Kaplan-Meier log-rank test, p < 0.001]. Cox regression revealed age and male gender as risk factors for newly-diagnosed TB. The outcome of TB was comparable in schizophrenics and the general population [odds ratio (OR), 0.78; 95% CI, 0.55-1.09; p =0.144]. Logistic regression revealed a statistical trend for diabetes mellitus to predict poor outcome in schizophrenics with TB (OR, 2.30; 95% CI, 0.96-5.74; p = 0.062). Conclusions Schizophrenics are at increased risk for TB, and screening may be warranted for those living in areas with high prevalence of TB.

Previous studies have shown that nonsteroidal anti-inflammatory drug (NSAID) use might be associated with a lower risk of developing cancer in the general population. Patients on dialysis have increased risk for cancer, but there are no studies to determine the relationship between NSAID use and cancer risk in these patients. To identify any association between NSAID use and cancer risk in patients with end-stage renal disease on dialysis, we used Taiwan's National Health Insurance database to conduct a nationwide population-based, propensity score–matched cohort study. All cancers between groups were compared by Cox proportional hazards models. Compared to nonuse of NSAIDs, the use of non-COX-2-selective inhibitors (hazard ratio 0.81, 95% confidence interval 0.67–0.97) or COX-2-selective inhibitors (0.78, 0.62–0.98) was associated with a lower risk of developing cancer. NSAID use reduced the risk of respiratory (0.39, 0.19–0.79), breast (0.41, 0.19–0.89), kidney (0.58, 0.38–0.88), digestive tract (0.64, 0.49–0.85), and bladder cancers (0.73, 0.55–0.96). NSAID use, however, significantly increased risk for upper gastrointestinal bleeding (odds ratio, 1.15, 1.07–1.23) but not adverse cardiac or cerebrovascular events. Thus, NSAID use was associated with a lower risk of developing cancer in chronic dialysis patients; however, they should still be used with caution due to the side effects of gastrointestinal bleeding.

Background and Aims: Mesenteric ischemia is an uncommon disorder associated with an extremely high mortality rate. Only limited studies have evaluated this lethal disease among patients with end-stage renal disease (ESRD). The objective of this study was to evaluate the risks of mesenteric ischemia among ESRD patients and compare the incidence between two dialysis modalities. Methods: Records of all ESRD patients older than 20 years of age from 1998 to 2007 and a control group consisting of 1 million records were retrieved from the Taiwan National Health Insurance Research Database. Hospitalizations for mesenteric ischemic events were retrieved using ICD-9-CM diagnosis codes and ICD-9-CM operation codes from inpatient claims. Results: Among 55,807 incident ESRD patients who received hemodialysis or peritoneal dialysis, there were 458 mesenteric ischemic events, corresponding to an incidence rate of 2.7 per 1,000 patient-years. Multivariate Cox regression analysis indicated that the independent risk factors were old age (HR 1.42 per 10 years), diabetes (HR 2.85), peripheral vascular disease (HR 2.66), atrial fibrillation (HR 2.15), heart failure (HR 1.65), chronic pulmonary disease (HR 1.41), neoplasm (HR 1.54), peptic ulcer disease (HR 1.86), and peritoneal dialysis (HR 1.51, all p < 0.05). There was no effect of dialysis modality on the mesenteric ischemia mortality rate. Conclusion: The risk of mesenteric ischemia for ESRD patients was 44.1 (95% confidence interval 13.4–106.2, p < 0.001) times higher than that of the general population. Compared to hemodialysis, peritoneal dialysis was associated with a higher risk of mesenteric ischemia.

Summary Background & aims Essential trace elements are involved in many biological processes for normal cell function including immunological defense against oxidation and infection. Deficiency of these elements generally leads to illness or even death in the general population. Therefore, we investigated the predictive values of trace element status on clinical outcomes in dialysis patients, who are more prone to trace element deficiency. Methods We enrolled 111 prevalent patients on maintenance dialysis from a Taipei tertiary-care referral hospital and measured serum levels of selenium, copper, and zinc. Patients were followed for 2 years or until death or withdrawal. Results Multivariate Cox regression analysis indicated that patients with diabetes mellitus (HR, 2.162 [95% CI, 1.105–4.232], p =0.024), prior stroke (HR, 3.876 [95% CI, 1.136–13.221], p =0.030), and zinc deficiency (HR, 0.979 [95% CI, 0.966–0.992], p =0.002) were more likely to be hospitalized for infectious diseases. Furthermore, beyond traditional risk factors, such as old age and hypoalbuminemia, multivariate Cox regression also indicated that lower serum level of zinc independently predicts overall mortality (HR, 0.973 [95% CI, 0.948–0.999], p =0.046). Conclusions In long-term dialysis patients, the serum level of zinc was an independent predictor of future hospitalization due to infectious diseases and of overall mortality.

Objective: Acute kidney injury (AKI) is a highly prevalent complication after cardiac surgery. It is associated with substantial morbidity and mortality. However, the definition of AKI has not been well established until the Acute Kidney Injury Network group outlined an easily used consentaneous staging system. The study aims to evaluate the association between this determination and in-hospital as well as long-term mortalityin patients receivingelective coronaryarterybypass grafting (CABG)surgery. Methods:PatientsundergoingelectiveCABG surgery from January 2003 to December 2007 in a tertiary medical center were studied. The Acute Kidney Injury Network classification was applied for the diagnosis of perioperative AKI. Medical history and intra-operative variables were collected retrospectively. Multivariate analysis was used to identify the independent risk factors of in-hospital and long-term mortality. Long-term survival rates were calculated using the Kaplan—Meier method. Results: This study included 964 patients. The incidence of AKI following elective CABG was 19.8%. Only 7% of the study population developed AKI requiring renal replacement therapy after surgery. The overall in-hospital mortality rate was 5.1%. Significant independent risk factors for in-hospital mortality include increasing age, higher serum uric acid, postoperative requirement of intra-aortic balloon pumping (IABP) and extracorporeal membrane oxygenation (ECMO), perioperative AKI, and chronic dialysis (all p < 0.05). Significant independent risk factors for long-term mortality include increasing age, lower serum albumin, higher serum uric acid, postoperative requirement of IABP and ECMO, perioperative AKI, and chronic dialysis (all p < 0.005). Conclusions: Acute Kidney Injury Network classification is a powerful tool to evaluate the prognostic impact of AKI on both in-hospital and long-term mortality among patients undergoing elective CABG surgery. # 2010 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Patients with autosomal dominant polycystic kidney disease (ADPKD) usually have extrarenal manifestations. We report the case of a 53-year-old man with ADPKD who presented with a retroperitoneal abscess of the left side after undergoing bilateral nephrectomy for a cyst that had repeatedly bled for 1 year. The abscess recurred despite drainage with a pig-tail catheter and antibiotic treatment. Fistulography with injection of diluted contrast medium via the pig-tail catheter showed an accumulation of contrast medium in the descending colon, which indicated a fistula between the abscess and the descending colon. A portion of the descending colon was resected, and multiple diverticulitis with 1 perforation in the resected specimen was observed. The findings support a diagnosis of retroperitoneal abscess caused by a perforated diverticulum---an extrarenal manifestation of ADPKD.

In Taiwan, peritoneal dialysis (PD) was launched in 1984. Since then, the Taiwan Society of Nephrology (TSN) has taken the responsibility for supervising PD programs. All PD programs are required to pass evaluations from the TSN before inception. Every new PD patient receives individual training from a qualified PD nurse. The training, accompanied by a review test, is usually provided in the hospital during the week right after catheter implantation. To evaluate the effect of the patient training program on PD outcomes, we designed a retrospective observation study and reviewed the post-training tests of 100 new PD patients. The post-training test has 10 parts: anatomy and physiology, overview of chronic kidney disease, overview of PD, complications of peritonitis and exit-site infection, diet control, cardiovascular complications, PD skills and procedures, aseptic techniques, management of peritonitis, and routine tasks. The relationship between the post-training test scores and peritonitis was analyzed. Results showed that risk of peritonitis is not related to the post-training test score. However, based on our experiences, we believe that PD patient training should be lengthened and repeated periodically as suggested by the International Survey of Peritoneal Dialysis Training Programs. Training on certain issues such as the signs and symptoms of peritonitis should be especially enhanced.

Background. Although modest seasonal variations in blood biochemical composition have been reported in end-stage renal disease patients treated with haemodialysis, there have been no adequate explanations. The current study aimed to explore whether these phenomena are present in peritoneal dialysis patients and to discuss these variations. Methods. This was a retrospective study with an enrollment of 44 anuric PD patients. Serum biochemical parameters, peritoneal function, dialysis adequacy, peritoneal ultrafiltration volume and body weight were analysed in relation to climate variables for a study period of 2 years. Results. PD patients exhibited cyclic variations in blood biochemical concentrations. Monthly mean outdoor temperature was inversely correlated with serum concentrations of sodium (r ¼� 0.712, P < 0.001), potassium (r ¼� 0.697, P < 0.001), bicarbonate (r ¼� 0.642, P < 0.001), BUN (r ¼� 0.654, P < 0.001), albumin (r ¼� 0.496, P ¼ 0.012), peritoneal ultrafiltration volume (r ¼� 0.723, P ¼ 0.001) and body weight (r ¼� 0.623, P < 0.001). Serum chloride and creatinine concentrations were not correlated with temperature or other climate variables. Conclusions. PD patients showed seasonal variations in serum electrolyte concentration and peritoneal ultrafiltration volume. Monthly outdoor mean temperature was inversely correlated with serum electrolytes and ultrafiltration volume. A likely explanation is loss of these electrolytes through perspiration. Neglect of this annual cycle in PD patients may lead to biases in interpretation of clinical study and individual laboratory data.

Vascular access–associated compartment syndrome is reported rarely in hemodialysis patients. A 62-year-old female hemodialysis patient experienced left-arm compartment syndrome caused by a nontransposed brachiobasilic arteriovenous fistula. A subfascial hematoma that developed because of perforation of the posterior wall of the basilic vein was not detected by Doppler ultrasound initially, and subsequent heparinized hemodialysis caused progression of the hematoma. Neuromuscular sequelae were prevented by performing an emergent fasciotomy, and transposition of the arterialized basilic vein was performed later to prevent similar complications in the future. This case report shows the risk for the occurrence of such a devastating complication if the nontransposed brachiobasilic fistula is used for hemodialysis vascular access.

A 54-year-old man developed a progressively enlarging painless mass on both forearms with limited range of flexion following 8 years of continuous ambulatory peritoneal dialysis (Figure 1, A.). Computed tomography showed amorphous, cystic, and multilobulated calcification at the medial aspect of his elbow joints, about 6 × 4 × 9 cm in size (Figure 1, B). His serum calcium, phosphate, and intact parathyroid hormone levels were 10.5 mg/dL, 6.0 mg/dL, and 1257 pg/mL, respectively. A sonogram disclosed evidence of 4 heterogeneous hypoechoic nodules ranging from 0.7 to 2.2 cm in the bilateral retrothyroid gland region. Conservative therapy with dietary phosphate restriction, noncalcemic phosphate binders, and vitamin D did not alleviate its progression. With a diagnosis of tertiary hyperparathyroidism with tumoral calcinosis, the patient underwent parathyroidectomy, and the calcified mass disappeared within 2 months (Figure 2).