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Background The blood pressure (BP) of a proportion of chronic hemodialysis (HD) patients rises after HD. We investigated the influence of postdialysis BP rise on long-term outcomes. Methods A total of 115 prevalent HD patients were enrolled. Because of the fluctuating nature of predialysis and postdialysis BP, systolic BP (SBP) and diastolic BP before and after HD were recorded from 25 consecutive HD sessions during a 2-month period. Patients were followed for 4 years or until death or withdrawal. Results Kaplan-Meier estimates revealed that patients with average postdialysis SBP rise of more than 5 mmHg were at the highest risk of both cardiovascular and all-cause mortality as compared to those with an average postdialysis SBP change between -5 to 5 mmHg and those with an average postdialysis SBP drop of more than 5 mmHg. Furthermore, multivariate Cox regression analysis indicated that both postdialysis SBP rise of more than 5 mmHg (HR, 3.925 [95% CI, 1.410-10.846], p = 0.008) and high cardiothoracic (CT) ratio of more than 50% (HR, 7.560 [95% CI, 2.048-27.912], p = 0.002) independently predicted all-cause mortality. We also found that patients with an average postdialysis SBP rise were associated with subclinical volume overload, as evidenced by the significantly higher CT ratio (p = 0.008). Conclusions A postdialysis SBP rise in HD patients independently predicted 4-year cardiovascular and all-cause mortality. Considering postdialysis SBP rise was associated with higher CT ratio, intensive evaluation of cardiac and volume status should be performed in patients with postdialysis SBP rise.

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.

From 2006 to 2010, 20 of 244 patients who underwent placement of a straight two-cuffed Tenckhoff PD catheter experienced acute pericannular bleeding. The first management strategy failed in 6 patients (30%). The second management strategy was applied in those 6 patients, and the bleeding stopped within 24 hours. Blood transfusion was not required, and no exit-site infection was detected during follow-up. Postoperative pericannular bleeding is considered to have both medical and surgical causes. From the medical point of view, patients who undergo PD catheter insertion usually have coagulation dysfunction even if the results of regular blood tests are normal. From the surgical point of view, the bleeders are usually located near the external cuff, because the Dacron cuff easily sticks over the subcutaneous layer, with the bleed developing after tissue rub. Such bleeds are usually too deep to check, and conservative management appears cost effective. Postoperative acute pericannular bleeding is usually regarded as a self-limiting condition, and it is seldom recorded. Pericannular bleeding leading to hematoma formation increases the risk of catheter-related infection and may compromise catheter survival. Although our strategies are effective in stopping bleeding, they still have potential risks for catheter injury and pericatheter infection. Standard skin sterilization and meticulous injection techniques are important.

Ankle-brachial index (ABI) is an accurate tool to diagnose peripheral arterial disease. The aim of this study was to evaluate whether ABI is also a good predictor of renal outcome and cardiovascular events in patients with chronic kidney disease (CKD). We enrolled 436 patients with stage 3–5 CKD who had not been undergoing dialysis. Patients were stratified into two groups according to the ABI value with a cut point of 0.9. The composite renal outcome, including doubling of serum creatinine level and commencement of dialysis, and the incidence of cardiovascular events were compared between the two groups. After a median follow-up period of 13 months, the lower ABI group had a poorer composite renal outcome (OR=2.719,P=0.015) and a higher incidence of cardiovascular events (OR=3.260,P=0.001). Our findings illustrated that ABI is a powerful predictor of cardiovascular events and renal outcome in patients with CKD.

Accessible online at: www.karger.com/journals/nef Dear Sir, Peritonitis is a common complication in patients with end-stage renal disease treated by continuous ambulatory peritoneal dialysis (CAPD). It is usually caused by poor technique, exit-site infection [1, 2], tunnel infection [3, 4], perforation of hollow viscera [5], diverticulitis [6, 7], colitis [8], or cholecystitis [9], etc. It is usually easily treated by effective and adequate antibiotics in most cases. However, it becomes complicated and protracted in some cases if the uncommon abdominal abscesses cannot be found and eradicated completely [10]. However, repeated episodes of peritonitis attributed to isolated lesser sac abscess have never been reported. Herein, we report a rare case of isolated lesser sac abscess formation following repeated episodes of peritonitis in a CAPD patient. The clinical condition improved dramatically after ultrasound-guided aspiration of the lesser sac abscess. A 38-year-old woman was under CAPD therapy for 57 months. She was admitted to hospital because of epigastric pain developed and progressed to diffuse abdominal pain in the morning. It was followed by turbid dialysate effluent. The white cell count (WBC) of the effluent was 480/cm3. The peritoneal effluent culture was positive for coagulase-negative staphylococcus (CNS). Three flushings of heparinized 1.5% Dianeal dialysate were given and followed by IP antibiotics (cefazolin loading 500 mg/l, maintenance 125 mg/l and tobramycin loading 8 mg/l, maintenance 4 mg/l) immediately. The cloudy effluent became clear and WBC decreased to 1/mm3 on the 4th day. The antibiotic therapy was administered for 2 weeks. Two months later, similar symptoms and peritonitis recurred. The WBC of the effluent was 2,900/mm3. The culture of the effluent also showed CNS, which was also sensitive to cefazolin and gentamicin. The three flushings and antibiotics as above were given for 2 weeks, even though the cloudy effluent became clear and WBC of the effluent declined to 37/mm3 on the second day. However, a 3rd episode of peritonitis relapsed 1 month later. Since then, the frequency of relapsing peritonitis has increased and the interval between peritonitis episodes has been shorter even under persistent antibiotic therapy (fig. 1). The symptoms of each episode presented similarly. The pathogen of each episode of peritonitis was CNS with the same bacterial sensitivity test. On physical examination, there was no erythema or discharge from the exit site, no evidence of acute tunnel infection, no rebound pain, and no Murphy’s sign. The WBC was 6,200/mm3 with 62% neutrophils. The hematocrit was 32%. Platelet count was 283,000/mm3. Serum biochemistry showed calcium 8.9 mg/dl (reference range: 8.4– 10.6), inorganic phosphate 4.0 mg/dl (2.1– 4.7), AST 20 U/l (5–45), ALT 3 U/l (0–40), amylase 221 U/l (!190), lipase 178 U/l (!190). Computed tomography (CT) of the whole abdomen before drainage of dialysate showed no evidence of diverticulitis, spaceoccupying lesions or enlarged lymph nodes. The upper gastrointestinal (UGI) and small intestine series did not show peptic ulcer or any abnormality. The subsequent Tc99mlabeled WBC scanning for detection of intraabdominal abscess showed a negative result. Abdominal sonography after dialysate drained out revealed fluid accumulation in the lesser sac. Because there were 4 other episodes of turbid effluents happening under the antibiotic coverage after the above examinations, a 2nd sonography of the whole abdomen after dialysate drained out was arranged which also revealed fluid accumulation, sized 3!2!1.5 cm in the lesser sac (fig. 2). At this time, ultrasound-guided aspiration of the lesser sac fluid was done with the finding of 15 cm3 of turbid aspirate. The aspirated fluid culture was positive for CNS. The bacterial sensitivity test was the same as before. Eight days later, follow-up CT of the whole abdomen after the dialysate drained out showed no evidence of focal fluid accu

Aims We investigated dialysis duration, dose of erythropoietin (EPO), and clinical manifestations in peritoneal dialysis (PD) patients with subclinical hypothyroidism. Methods This cross-sectional study, performed in 3 centers, assessed 122 adult patients on PD for more than 6 months with regard to demographic data, dialysis duration, thyroid function, biochemical data, EPO dose, and clinical manifestations. Thyroid dysfunction was determined by serum thyroid-stimulating hormone, free thyroxine, total thyroxine, total triiodothyronine, antithyroid peroxidase antibodies, and auto-antibodies against thyroglobulin. Results Of the 122 study patients, 98 (80.3%) were assessed as having euthyroidism; 19 (15.6%), subclinical hypothyroidism; and 5 (4.1%), subclinical hyperthyroidism. The proportion of women (74.2% vs. 57.1%, p = 0.038), the mean duration of PD (58.1 months vs. 37.9 months, p = 0.032), and the weighted mean monthly EPO dose (1.22 μg/kg vs. 1.64 μg/kg, p = 0.009) were significantly higher in the subclinical hypothyroidism group than in the euthyroidism group, but the prevalences of coronary artery disease and cerebrovascular disease were not. From the multivariate model, PD duration was more significant than sex as a risk factor for subclinical hypothyroidism ( p = 0.0132). Conclusions Subclinical hypothyroidism is frequent in PD patients, especially female patients and patients with a longer PD duration. Compared with euthyroid patients, patients with subclinical hyperthyroidism need a higher dose of EPO to maintain a stable hemoglobin level.

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.

Overseas kidney transplantation has often been reported to have unsatisfactory outcomes. This study aims to compare post-transplantation outcomes between overseas and domestic kidney transplant (KT) recipients in Taiwan.The Taiwanese National Health Insurance Research Database was used to identify 310 domestic and 643 overseas KT recipients, who survived for longer than 1 month after the transplantation, in a cohort of 45,453 chronic haemodialysis patients in 1997-2002. Cox proportional hazards models were used to assess risks of mortality and graft failure.The 1, 3 and 5 year survival rates for domestic KT recipients were 96.5%, 93.3% and 91.6%, respectively, while those for overseas KT recipients were 94.9%, 87.9% and 77.1%, respectively (P = 0.015). For the overseas group, those who received a KT before 2001 had significantly higher hazard ratios of mortality and graft failure (2.85 and 1.71, respectively). However, for those receiving a KT in 2001-2002, no significant outcome difference could be found between overseas and domestic recipients.The risk disparity between overseas and domestic KT recipients is mainly attributable to when the transplantation was performed. In attempting to dissuade potential recipients from organ trafficking, merely emphasizing the previously acknowledged poor outcomes no longer suffices as a valid reason.

Background and objectives: Matrix metalloproteinases (MMPs) are risk factors for cardiovascular diseases. This study evaluated the association of genotype polymorphisms of MMPs and tissue inhibitors of metalloproteinases (TIMPs) in hemodialysis (HD) patients with arteriovenous fistula (AVF) failure. Design, setting, participants, & measurements: Genotype polymorphism of MMP-1, MMP-2, MMP-3, and MMP-9 and TIMP-1 and TIMP-2 and clinical and laboratory parameters were compared between Chinese HD patients with (n 170) and without (n 426) AVF failure. Results: Significant associations were found between AVF failure and the following factors (hazard ratio): longer HD duration (1.007 per month), lower pump flow (0.991 per ml/min), higher dynamic venous pressure (1.016 per mmHg), location of AVF on right side (1.630 versus left side) and upper arm (2.385 versus forearm), history of cardiovascular disease (1.656 versus absence of history), 1G/1G genotype of MMP-1 1607 1G >2G SNP (2.315 versus 1G/2G 2G/2G genotypes), 6A/6A genotype of MMP-3 1612 5A >6A SNP (1.712 versus 5A/6A 5A/5A), and C/C genotype of MMP-9 1562 C>T SNP (1.650 versus C/TT/T). The positive predictive rates for AVF failure were 63.0% and 6.7% for patients with the highest-risk (1G1G/6A6A/ CC) and lowest-risk (2G2G or 2G1G/5A5A or 6A6A/TT or TC) composite MMP-1/MMP-3/MMP-9 genotype, respectively. The unassisted patency of AVF at 5 years decreased significantly from 93.3% to 38.4% for the composite MMP-1/MMP-3/MMP-9 genotypes (lowest versus highest risk, P < 0.001). Conclusions: Specific genotypes of MMP-1, MMP-3 and MMP-9 with lower transcriptional activity are associated with higher frequencies of AVF failure, which may result from more accumulation of extracellular matrix, leading to AVF stenosis. Clin J Am Soc Nephrol 5: 1805–1814, 2010. doi: 10.2215/CJN.01500210

Background. Glomerular filtration rate (GFR) and comorbidity at dialysis initiation in relation to mortality in end-stage renal disease is still controversial. We studied factors potentially related to the mortality in incident haemodialysis (HD) patients. Methods. A national database included 23 551 incident HD patients from July 2001 to December 2004. Kaplan–Meier and Cox regression analyses were performed to assess the association between GFR estimated by the four-variable Modified Diet in Renal Disease equation and all-cause mortality. Analyses were performed from Day 91 after the start of dialysis. Patients were classified into five groups (quintiles) based on estimated glomerular filtration rate (eGFR) at the start of dialysis. Results. The median eGFR at dialysis initiation was low (4.7 mL/min/1.73 m 2 ), as was the mortality in the first year of dialysis [13.2/100 patient-year, 95% confidence interval (95% CI)=12.8–13.7]. There was an inverse association between lower eGFR and higher survival rate. The Cox regression model revealed an increase in mortality risk in Q5 (hazard ratio [HR]=2.44, 95% CI=2.11–2.81), Q4 (HR= 1.66, 95% CI=1.43–1.93), Q3 (HR=1.21, 95% CI=1.04– 1.41) and Q2 (HR=1.18, 95% CI=1.01–1.37) compared with the reference group of Q1 after adjusting for year of application, primary diseases (chronic glomerulonephritis, diabetic nephropathy, hypertension, chronic tubulointerstitial nephritis and others), demographics (age, sex), presence of co-morbidity (diabetes mellitus, hypertension, congestive heart failure, ischaemic heart diseases, cerebrovascular diseases, malignancies, liver cirrhosis, tuberculosis, other diseases and free of reported of comorbidities) and haematocrit. Propensity score analysis also showed a higher eGFR to be associated with increased mortality risks. Adjustment for all covariates explained a high percentage of excess risk of mortality in the groups with low eGFR, but less risk in the groups with higher eGFR. Conclusions. Lower eGFR at dialysis initiation is associated with lower mortality. Conditions at dialysis initiation explained excess 1-year mortality risk differently in patients who began dialysis at different levels of eGFR. Other factors likely contribute to the mortality of patients initiating dialysis at higher eGFR levels, and further study is needed.

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.

Three methods, i.e., nonspecific radioimmunoassay (RIA; Incstar), fluorescence polarization immunoassay (FPIA; TDx Abbott), and high-performance liquid chromatography (HPLC), have been used for monitoring cyclosporine blood levels in renal transplantation patients. The levels obtained from 135 samples showed a modest correlation between RIA and HPLC, FPIA and HPLC, RIA and FRIA. The mean ratios of RIA to HPLC, FPIA to HPLC, and RIA to FPIA were 2.96, 4.14, and 0.73. The significant variations in cyclosporine levels result from the cross-reaction of antibody with some cyclosporine metabolites, by which these two methods often overestimate the true blood cyclosporine level. HPLC is a more effective and reliable method for pharmacokinetic studies and blood level monitoring of cyclosporine in clinical practice.

arteriovenous fistula; brachiocephalic vein

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 Few patients are able to resume peritoneal dialysis (PD) therapy after an episode of peritonitis that requires catheter removal. PD catheter loss is therefore regarded as an important index of patient morbidity. The aim of the present study was to evaluate factors influencing catheter loss in patients suffering from continuous ambulatory PD (CAPD) peritonitis. Patients and Methods We retrospectively reviewed 579 episodes of CAPD peritonitis from 1999 to 2006 in a tertiary-care referral hospital. Demographic, biochemical, and microbiological characteristics were recorded. Episodes resulting in PD catheter removal ( n = 68; 12%) were compared by both univariate and multivariate analyses with those in which PD catheters were preserved. Results The incidence of PD catheter loss increased as the number of organisms cultured increased ( p = 0.001). Also, PD catheter removal was more likely to occur after peritonitis episodes with low serum albumin level ( p = 0.004), those with long duration of PD effluent leukocyte count remaining above 100/μL ( p < 0.001), those with concomitant tunnel infection ( p < 0.001), those with concomitant exit-site infection ( p = 0.005), and those with presence of catastrophic intra-abdominal visceral events ( p < 0.001). Duration on PD preceding the peritonitis episode was of borderline significance ( p = 0.080). On the contrary, initial PD effluent leukocyte count and serum level of C-reactive protein were not predictive of PD catheter loss. Micro-organisms of the Enterobacteriaceae family were the major pathogens responsible for PD catheter loss following polymicrobial peritonitis. Furthermore, we found that there was no association between polymicrobial peritonitis and the catastrophic intra-abdominal visceral event, although both resulted in a greater incidence of PD catheter loss. Among the single-organism group in our population, the microbiological determinants of PD catheter loss included fungi ( p < 0.001), anaerobes ( p = 0.018), and Pseudomonas sp (borderline significance: p = 0.095). Conclusion PD catheter loss as a consequence of peritonitis is related primarily to hypoalbuminemia, longer duration of PD effluent leukocyte count remaining above 100/μL, the etiologic source of the infection, and the organism causing the infection. Peritonitis associated with concomitant tunnel or exit-site infections and abdominal catastrophes were more likely to proceed to PD catheter loss. The microbiological determinants of PD catheter loss in the present study included polymicrobial infections caused by Enterobacteriaceae as well as monomicrobial pseudomonal, anaerobic, and fungal infections.

Objectives The prevalence of type 2 diabetes, often leading to diabetic nephropathy, has increased globally, especially in Asia. Irbesartan treatment delays the progression of kidney disease at the early (microalbuminuria) and late (proteinuria) stages of nephropathy in hypertensive type 2 diabetics. This treatment has proven to be cost-effective in Western countries. This study assessed the cost-effectiveness of early irbesartan treatment in Asian settings. Methods An existing lifetime model was reprogrammed in Microsoft Excel to compare irbesartan started at an early stage to irbesartan or amlodipine started at a late stage, and standard treatments from a health-care perspective in China, Malaysia, Thailand, South Korea, and Taiwan. The main effectiveness parameters were incidences of end-stage renal disease, time in dialysis, and life expectancy. All costs were converted to 2004 US$ using official purchasing power parity. Local data were obtained for costs, transplantation,dialysis, and mortality rates. Probabilities regarding disease progression after treatment with the investigated drugs were extracted from two published clinical trials. A probabilistic sensitivity analysis was performed. Results Early use of irbesartan yielded the largest clinical and economic benefits reducing need for dialysis by 61% to 63% versus the standard treatment, total costs by 9% (Thailand) to 42% (Taiwan), and increasing life expectancy by 0.31 to 0.48 years. Early irbesartan had a 66% (Thailand) to 95% (Taiwan) probability of being dominant over late irbesartan. Conclusion Although the absolute results varied in different settings, reflecting differences in epidemiology, management, and costs, early irbesartan treatment was a cost-effective alternative in the Asian settings.

SummaryTherapeutic preparations of desmopressin for parenteral use contain the preservative chlorobutanol (5 mg/ml). We show here that chlorobutanol is a potent inhibitor of platelet aggregation and release. It exhibited a significant inhibitory activity toward several aggregation inducers in a concentration- and time-dependent manner. Thromboxane B2 formation, ATP release, and elevation of cytosolic free calcium caused by collagen, ADP, epinephrine, arachidonic acid and thrombin respectively were markedly inhibited by chlorobutanol. Chlorobutanol had no effect on elastase- treated platelets and its antiplatelet effect could be reversed. It is concluded that the antiplatelet effect of chlorobutanol is mainly due to its inhibition on the arachidonic acid pathway but it is unlikely to have a nonspecitic toxic effect. This antiplatelet effect of chlorobutanol suggests that desmopressin, when administered for improving hemostasis, should not contain chlorobutanol as a preservative.

Keywords: angiomyolipoma; computed tomography;focal segmental glomerulosclerosis; kidney cancer;liposarcoma; proteinuriaA 63-year-old man with type 2 diabetes mellitus andhypertension presented with increasing abdominalgirth and foamy urine for the previous 2 years.Impaired renal function (BUN 33mg/dl, serum crea-tinine 2.3mg/dl), hypoalbuminaemia (2.3g/dl), overtproteinuria (11.2g/day), microscopic haematuria(RBC 21-35/HPF) and bilateral perinephric tumourwere noted at a local hospital. Non-contrast enhancedcomputed tomography of the abdomen confirmedgiant bilateral perinephric tumour with fat component(Figure 1). The differential diagnosis included retro-peritoneal liposarcomas or bilateral angiomyolipomaarising from renal capsule. After referral, physicalexamination revealed distended abdomen withoutpalpable mass. Magnetic resonance imaging(T1-weighted) demonstrated a lipomatous tumour ofabout 10cm in size, in the bilateral perinephric space(Figure 2). There was absence of radiological featuresof angiomyolipoma, including linear or branchingappearance of intra-tumoural vessels with evidentcontrast enhancement, aneurysmal dilatation of intra-tumoural vessels, haemorrhage within and outside thetumour, and the bridging vessel or beak signs [1].Hence, bilateral perinephric liposarcoma was favoured.However, a sonography-guided needle biopsy of theleft tumour showed only fibroadipose tissue, withoutidentification of malignant cells. The simultaneousneedle biopsy of left kidney revealed focal segmentalglomerulosclerosis (FSGS). Considering the invasiveclinical course of the tumours, bilateral radicalnephrectomy, with excision of the retroperitonealtumours, was performed. The pathology disclosedwell-differentiated liposarcomas with encasement ofbilateral kidney and involvement of the renal sinus,and further confirmed FSGS. The patient thereafterunderwent regular uneventful haemodialysis. TheFSGS and liposarcomas may just be coincidental inthis patient. However, the probability of bilateralperinephric liposarcoma with secondary FSGS stillcannot be completely excluded.Around 12–40% of liposarcomas occur in theretroperitoneum [2,3], and of these, 35% originate inthe perirenal fat [2]. Although liposarcoma is the mostcommon retroperitoneal soft tissues sarcoma, retro-peritoneal liposarcoma comprises only about 0.1% ofall cancers [2,3]. Liposarcomas tend to grow slowly in

Background The usage of urine protein/creatinine ratio to estimate daily urine protein excretion is prevalent, but relatively little attention has been paid to the influence of urine concentration and its impact on test accuracy. We took advantage of 24-hour urine collection to examine both urine protein/creatinine ratio (UPCR) and daily urine protein excretion, with the latter as the reference standard. Specific gravity from a concomitant urinalysis of the same urine sample was used to indicate the urine concentration. Methods During 2010 to 2014, there were 540 adequately collected 24h urine samples with protein concentration, creatinine concentration, total volume, and a concomitant urinalysis of the same sample. Variables associated with an accurate UPCR estimation were determined by multivariate linear regression analysis. Receiver operating characteristic (ROC) curves were generated to determine the discriminant cut-off values of urine creatinine concentration for predicting an accurate UPCR estimation in either dilute or concentrated urine samples. Results Our findings indicated that for dilute urine, as indicated by a low urine specific gravity, UPCR is more likely to overestimate the actual daily urine protein excretion. On the contrary, UPCR of concentrated urine is more likely to result in an underestimation. By ROC curve analysis, the best cut-off value of urine creatinine concentration for predicting overestimation by UPCR of dilute urine (specific gravity ≦ 1.005) was ≦ 38.8 mg/dL, whereas the best cut-off values of urine creatinine for predicting underestimation by UPCR of thick urine were ≧ 63.6 mg/dL (specific gravity ≧ 1.015), ≧ 62.1 mg/dL (specific gravity ≧ 1.020), ≧ 61.5 mg/dL (specific gravity ≧ 1.025), respectively. We also compared distribution patterns of urine creatinine concentration of 24h urine cohort with a concurrent spot urine cohort and found that the underestimation might be more profound in single voided samples. Conclusions The UPCR in samples with low or high specific gravity is more likely to overestimate or underestimate actual daily urine protein amount, respectively, especially in a dilute urine sample with its creatinine below 38.8 mg/dL or a concentrated sample with its creatinine above 61.5 mg/dL. In particular, UPCR results should be interpreted with caution in cases that involve dilute urine samples because its overestimation may lead to an erroneous diagnosis of proteinuric renal disease or an incorrect staging of chronic kidney disease.

A 41-year-old woman presented with hypokalemic paralysis with non-anion-gap metabolic acidosis and normotension. During the work-up of suspected renal tubular acidosis, a bicarbonate loading test was performed. During the test, the patient developed tetany with severe facial (Figure 1) and carpal spasm (Figure 2). Her venous pH at this time was 7.47 (venous bicarbonate 26 mequiv. per liter) from a baseline of 7.31 (venous bicarbonate 12.2 mequiv. per liter). The infusion was discontinued, and calcium gluconate (9.2 mequiv.) was administered intravenously with complete subsidence of symptoms. The serum ionized calcium level at this event was 0.68 mmol per liter, and the baseline serum total calcium level was 7.8 mg per dl with serum albumin of 3.5 g per dl. Rapid alkalization of plasma may induce acute hypocalcemia leading to tetany; other complications in this setting can include seizures, cardiac dysrhythmias (prolongation of the QT interval), decreased cardiac contractility, hypotension, and heart failure.

A 42-year-old woman underwent hemodialysis secondary to diabetic nephropathy. Total parathyroidectomy with forearm autograft was performed due to secondary hyperparathyroidism (HPT) complicated with calciphylaxis. Rapidly progressive enlargement of autograft with unusual "gourd-shape" developed, and then it was removed. Pathologic examination of the autograft disclosed multinodular hyperplasia. Residual parathyroid gland in the retrothyroid region was found later. Rapidly recurrent HPT originating from both the residual parathyroid tissues and the enlarged autograft within such short time after parathyroidectomy is rare in the literature. The multinodular hyperplasia pattern of the parathyroid gland may be a major factor for such rapid recurrence. In addition to good control of calcium and phosphate, regular follow-up of parathyroid hormone level and imaging studies of not only autografted gland at the forearm but also possibly residual parathyroid tissues at the neck are important for monitoring recurrence in maintenance hemodialysis patients after parathyroidectomy with forearm autograft, especially in those with pathologic type of nodular hyperplasia and calciphylaxis.

A 62-year-old woman presented with sudden onset of lower abdominal pain and lower limb weakness. She had a history of hypertension, hyperlipidemia, diff use atherosclerosis, and renal failure from nephrosclerosis, and had been on peritoneal dialysis for 10 years. A clinical diagnosis of spinal cord infarction with paraplegia was made, and an MRI was arranged. However, she rapidly went into shock with a limited response to intravenous fl uids and vasopressors. Rhabdomyolysis with elevated serum creatine phosphokinase (CK) up to 55,620 U/l was noted. Th e peritoneal dialysis (PD) effl uent, initially clear A B C D B C

Previous studies have shown that urinary calculi are associated with increased risks of urinary tract cancers. However, the association between urinary calculi and overall cancers is a largely undefined body of knowledge. We conducted a nationwide population-based cohort study using Taiwan's National Health Insurance Research Database from 2000 and 2009. Patients were excluded if they had antecedent cancers or urinary calculi before the enrollment. All study subjects were followed until the occurrence of cancer, dropout from the NHI program, death, or the end of 2010. Patterns of cancer incidence in patients with urinary calculi were compared with those of the general population using standardized incidence ratio (SIR). A total of 43,516 patients with urinary calculi were included. After a median follow-up of 5.3 years, 1891 patients developed cancer. The risk of overall cancers was significantly increased (SIR, 1.75; 95% confidence interval [CI], 1.68–1.83). We observed that urinary calculi was associated with higher risk of cancers of kidney (4.24; 95% CI, 3.47–5.13), bladder (3.30; 95% CI, 2.69–4.00), thyroid (2.50; 95% CI, 1.78–3.40), hematologic origin (2.41; 95% CI, 1.92–2.99), breast (1.84; 95% CI, 1.54–2.20), lung (1.82; 95% CI, 1.59–2.07), digestive tract (1.69; 95% CI, 1.57–1.82), and head and neck (1.54; 95% CI, 1.32–1.79), respectively. Our study shows that urinary calculi are associated with higher risk of systemic cancers in addition to urinary tract cancers. Further study is required to validate this association.

Diabetic nephropathy is the major cause of end-stage renal disease. Many studies show that chronic kidney disease can be prevented, or its progression to end-stage renal disease delayed, by effective intervention. The aim of this study was to estimate the prevalence of proteinuria and renal impairment in patients with type 2 diabetes. A community-based screening for chronic kidney disease in type 2 diabetic patients was conducted in 1999-2001. Proteinuria was defined in terms of urine protein-to-creatinine ratio. The glomerular filtration rate per 1.73m(2) body surface area was calculated using an equation from the Modification of Diet in Renal Disease Study. The overall response rate was about 78.6%. Prevalence rates of proteinuria and renal impairment were 29.4% and 15.1%, respectively. Females had higher prevalence of proteinuria and renal impairment than males. And prevalence increased with increasing age. Hypertension was associated with both proteinuria and renal impairment. Only 43.0% of patients with stages 3-5 chronic kidney disease had proteinuria. Proteinuria and renal impairment screening may identify different segments of the diabetic population. Both a glomerular filtration rate and proteinuria test are recommended as screening tools for early detection of chronic kidney disease in type 2 diabetics.

Decreasing vascular access flow (Qa) is an important predictor of future access thrombosis and malfunction for hemodialysis (HD) patients. Among all of the methods for determining Qa, the variable pump flow (VPF) Doppler method measures Qa according to the change in Doppler signal between the arterial and the venous needles under different pump flow. After this technique was combined with spectral analysis of Duplex Doppler imaging, the variable pump flow-based Doppler ultrasound method (VPFDUM) for Qa measurement was developed. This study compared the reproducibility and correlation of Qa measurements for three different methods-VPFDUM, ultrasound dilution method (UDM), and conventional Doppler ultrasound method (CDUM)-in 55 HD patients. The mean value of Qa by VPFDUM (870.8 +/- 412.0 ml/min) was close to that by UDM (868.6 +/- 417.9 ml/min) but higher than that by CDUM (either of the above values versus 685.1 +/- 303.6 ml/min; P0.005). The mean values of coefficient of variation were similar by VPFDUM (1.6%) and UDM (1.4%) but lower than that by CDUM (either of the above values versus 6.8%; P0.01). The correlation coefficient and intraclass correlation coefficient of the repeated Qa measurements by VPFDUM (0.985 and 0.993; P0.001) were also similar to those by UDM (0.992 and 0.995; P0.001) but slightly higher than those by CDUM (0.917 and 0.948; P0.005). Either the reproducibility of VPFDUM (r=0.98, P0.0001) or the correlation between VPFDUM and UDM (r=0.99, P0.0001) in Qa measurements is good. The unassisted patency of vascular access at 6 mo was significantly poorer in patients with Qa500 ml/min than those with Qa500 ml/min (13.6% versus 92.2%; P0.0001). In conclusion, VPFDUM is a noninvasive, accurate, and reliable procedure for Qa measurement and prediction of the prognosis of vascular access in HD patients.

Infective endocarditis (IE) is a serious infectious condition, with high morbidity and mortality in hemodialysis (HD) patients. This study was undertaken to determine the IE risk factors in maintenance HD patients, and the mortality risk factors.We retrospectively reviewed all IE cases of maintenance HD patients at our center over the past 15 yrs (the study group). Regular HD patients without IE in the same period were used as the control group. The basic data of the two groups were analyzed to determine IE risk factors in HD patients. The in-hospital parameters of survival and mortality in the study group patients were used for mortality risk factors analysis.There were 18 definite, and two possible, IE diagnoses in the study group and no cases in the 268 controls. There was no significant difference in age, sex, diabetes, hypertension, underlying malignancy, previous cerebral vascular accident (CVA) history, and calcium multiplied by phosphate product. There was a significant difference between the two groups (study group vs. controls) in pacemaker implant history (15 vs. 1.1%, p0.01), previous heart surgery history (15 vs. 0.4%, p0.01), congestive heart failure (CHF) (50 vs. 10.4%, p0.05), duration on maintenance HD (12.9+/-19.1 vs. 57.9+/-42.3 months, p0.001), serum albumin at the time of admission (2.91+/-0.40 vs. 3.96+/-0.52 g/dL, p0.001). There were more patients dialyzed via non-cuffed dual-lumen catheters in the study group (55 vs. 0%, p0.001), and fewer patients dialyzed via arteriovenous fistula (AVF) (25 vs. 87.7%, p0.001). The mortality in HD patients with IE was high (60%), especially in patients with methicillin-resistant Staphylococcus aureus (MRSA) endocarditis (100%). The most common pathogen was S. aureus (n=12). MRSA was more common than methicillin-susceptible S. aureus (MSSA) (67 vs. 33%). Univariant analysis of in-hospital clinical parameters for mortality revealed no significant difference in age, diabetes, dual-lumen catheter implantation, serum albumin, time to diagnosis, and time to antibiotic use. Borderline statistical significance was noted in serum C-reactive protein (CRP) (p=0.051), and blood glucose level (p=0.056). There were more IE cases due to MRSA in the mortality group than in the survival group (8 vs. 0 cases, p=0.013), but fewer cases due to MSSA (0 vs. 4 cases, p=0.050).IE should be considered in HD patients with the following risk factors, which include previous heart surgery or pacemaker implantation, shorter HD duration, and especially for patients dialyzed via dual-lumen catheters. The in-hospital clinical parameters including CRP and blood sugar level can offer information concerning prognosis. Since MRSA has increased in recent years and is associated with high mortality, strategies for prevention and treatment require development.

The authors report a 49-year-old woman who had been treated with diclofenac for her back pain. Nephrotic syndrome followed by occlusion of the right profound femoral and popliteal arteries occurred. Successful thrombectomy was performed. Another nonsteroidal anti-inflammatory drug (NSAID) was administered by injection during hospitalization. Renal biopsy showed minimal change glomerulopathy (MCG). Remission was delayed despite large-dose steroid administration. The delayed remission in this patient may be caused by impaired renal function and the possible effect of a second period of NSAID administration. The authors present the first case of femoral arterial thrombosis associated with nephrotic syndrome secondary to NSAID-associated MCG. Careful history-taking and physical examination may detect early causes and complications of nephrotic syndrome. Any rechallenge of NSAID should be avoided.

SUMMARY: Clinically relevant renal lesions in rheumatoid arthritis (RA) are not common. More often renal involvement is related to complications of therapy than the disease itself. The most common forms of primary renal disease in RA are membranous glomerulonephropathy and a pure mesangial proliferative glomerulonephritis.[1] Some studies have described the association between crescentic glomerulonephritis (crescentic GN) and RA, but they were all found to be perinuclear antineutrophil cytoplasmic antibody (p-ANCA) positive. However, RA associated with ANCA negative pauci-immue crescentic GN has not been reported. This is a case report of a 37-year-old female with RA who initially presented with general oedema and acute deterioration of renal function. The renal biopsy revealed ANCA negative pauci-immune crescentic GN. The patient was treated with steroid pulse and plasmapheresis, but not cyclophosphamide because of severe urosepsis. Despite the use of aggressive therapy, her renal function was not improved and she underwent maintenance haemodialysis thereafter. Because ANCA negative crescentic GN may occur in RA patients without frank systemic vasculitis, but with severe clinical manifestation, a heightened suspicion for a relatively ‘silent’ crescentic GN would have led to the correct diagnosis and appropriate treatment.

Tacrolimus is an effective organ transplantation immunosuppressant. Hemolytic uremic syndrome (HUS) is a rare but severe complication of tacrolimus.We report a case of tacrolimus-associated HUS and review the 15 previously reported cases.The results of the 16 cases indicated that tacrolimus-associated HUS is more frequent in females (56.3%), with the mean age at onset of 41.3 years. Forty-four percent of cases received renal transplantations. The average time from the first tacrolimus dose to HUS onset was 7.1 months. Prevalence was between 0.14.7%. The tacrolimus trough level did not predict the prognosis. Seven patients (43.7%) had improved graft function after treatment, including anticoagulation and antiplatelet therapy, reduction or discontinuation of tacrolimus, switch to cyclosporine (CyA), plasma exchange (PE) and dialysis. Five patients (31.3%) died and four patients (25%) lost their graft in spite of the above treatment. Mortality risk factors for transplant recipients with tacrolimus-associated HUS included: (1) non-renal transplant recipients (100% vs. 36.4%, p = 0.034); (2) lower peak serum Cr (2.58 +/- 1.23 vs. 6.16 +/- 1.96, p0.002); (3) liver dysfunction (60% vs. 0, p0.02); (4) higher serum lactate dehydrogenase (LDH) level (3119 +/- 1019 vs. 982 +/- 522, p0.001). A lower platelet count carried borderline mortality risk (29500 +/- 14480 vs. 59625 +/- 25584, p = 0.057).HUS should be included in the differential diagnosis of renal function deterioration in patients on tacrolimus post-organ transplantation. Frequent renal function monitoring and appropriate treatment should be performed aggressively to decrease morbidity and mortality, especially in patients with risk factors.

Large-artery derangement is a major risk factor for cardiovascular and all-cause mortality in patients with end-stage renal disease (ESRD). It is not clear how body fluid distribution affects large-artery structure and function in patients with ESRD.One hundred fifty-seven hemodialysis (HD) patients (mean age, 55.9 +/- 15.1 years; 76 men, 81 women) were enrolled. Influence of the extracellular fluid (ECF)-to-intracellular fluid (ICF) ratio derived from bioimpedance spectroscopy on the structure and function of the common carotid artery (CCA) and aorta was analyzed. One hundred forty-four healthy subjects were examined to obtain normal reference values for body fluid compartments. Based on ECF-ICF ratio, 2 groups were identified: ECF-ICF ratio in the 95th percentile or less and ECF-ICF ratio greater than the 95th percentile of age- and sex-stratified normal reference values.ECF-ICF ratio was significantly related to CCA diameter (r2 = 0.26; P0.001), CCA incremental modulus (E(inc); r2 = 0.15; P0.001), carotid augmentation index (AGI; r2 = 0.10; P0.001), and aortic pulse wave velocity (aPWV; r2 = 0.21; P0.001). ECF-ICF ratio remained a significant independent determinant for CCA diameter (model r2 = 0.47; P0.001), E(inc) (r2 = 0.29; P0.001), aPWV (r2 = 0.51; P0.001), and AGI (r2 = 0.40; P0.001) when age, sex, mean blood pressure, anthropometrical parameters, HD duration, and status of diabetes mellitus were accounted for. HD patients with an ECF-ICF ratio greater than the 95th percentile had a greater CCA diameter, E(inc), aPWV, and AGI than their counterparts.ECF-ICF ratio is associated with large-artery structure and function in HD patients. Patients with ESRD with a high ECF-ICF ratio are characterized by significant large-artery derangement.

A 38-year-old woman presented with muscle cramping of 4 extremities and paralysis for months. Laboratory results showed an elevated antinuclear antibody titer; antibodies to the ribonucleoprotein antigen Ro; hypokalemia; hypomagnesemia with hyperreninemia, but abnormally high urine potassium and magnesium levels and low urine calcium levels; and a blunted diuretic effect to thiazide, but not furosemide, which met the criteria for Gitelman's syndrome (GS) and led to the diagnosis of primary Sjogren's syndrome (pSS). She received medical treatment, including a potassium supplement and aldosterone antagonist. GS as a presentation of pSS has never been reported in the literature. The features of renal diseases related to SS are reviewed. SS is the underlying cause of GS, which may precede the onset of the well-known sicca complex.

Lipoprotein glomerulopathy (LPG) is a rare disease, characterized by a special histology, including dilated glomerular capillaries filled with pale-stained and meshlike lipoprotein thrombi. It always presents with proteinuria or nephrotic syndrome. Although hyperlipidemia is not always seen, most patients have type III hyperlipoproteinemia with apolipoprotein (apo) E2/3 phenotyping. Although the clinical feature of LPG is rarely described, LPG associated with other glomerulopathy, including IgA nephropathy, membranous nephropathy, and lupus nephritis, has been documented. Until now, there have been no reports of psoriasis vulgaris associated with LPG. The authors present 2 cases of LPG with apo E3/3 genotyping associated with psoriasis vulgaris. The first patient was a 65-year-old woman who presented with nephrotic syndrome with daily urinary protein loss of 9.05 g and itchy erythematous scaly plaques on her trunk and lower limbs for 1 year. The renal biopsy results showed LPG, and the skin biopsy results showed psoriasis. The second patient was a 50-year-old man with history of psoriasis over his trunk and 4 limbs for 30 years. He also presented with nephrotic syndrome with daily urinary protein loss of 7.55 g. The renal biopsy results also showed LPG. The genotype of apo E showed E3/3, and lipoprotein electrophoresis showed a type III hyperlipoproteinemia-like pattern in both cases. The authors suggest that presence of apo E3/3 genotype cannot rule out the diagnosis of type III hyperlipoproteinemia and LPG. Besides, LPG should be included in the differential diagnosis of psoriatic patients with nephrotic syndrome, especially in Asian patients who show poor response to traditional therapy. Renal biopsy should be performed to make the definitive diagnosis.

Background Fas-mediated apoptosis is important in the regulation of immune response. Human peritoneal mesothelial cells (HPMCs) are able to regulate peritoneal inflammation, but the role of Fas in HPMCs is not clear. This study addresses the mechanisms of Fas-mediated apoptosis in HPMCs. Methods Tumour necrosis factor-alpha (TNF-alpha) primed HPMCs were stimulated with agonistic anti-Fas antibody. The expression of Fas was evaluated by real-time reverse transcription polymerase chain reaction (TaqMan quantitative polymerase chain reaction) and flow cytometry. Apoptosis was assessed by nuclear morphology, TUNEL assay, fractional DNA content and cytokeratin 18 cleavage. Caspase activation and bcl-2 expression were analysed by western blotting. The phagocytosis of apoptotic HPMCs was demonstrated by immunofluorescence and transmission electron microscopy. Results Cultured HPMCs constitutively expressed Fas, and the Fas expression was upregulated by TNF-alpha. TNF-alpha primed HPMCs underwent apoptosis after anti-Fas antibody treatment, and the apoptotic HPMCs could be phagocytosed by macrophages. TNF-alpha was able to downregulate bcl-2 expression. Activation of caspase-3 and caspase-8 was noted during the apoptotic process. The inhibitors of either caspase-3 or caspase-8 could prevent the Fas-induced apoptosis in HPMCs. We also detected increased HPMC apoptosis in dialysate effluent during the recovery phase of peritonitis in peritoneal dialysis patients. Conclusions TNF-alpha directs HPMCs to commit apoptosis via the Fas/Fas ligand pathway through a modulation of Fas and bcl-2. Our study shows that HPMCs undergo apoptosis during peritonitis and suggests that the apoptosis of HPMCs may be related to the resolution of peritoneal inflammation.

Objective To investigate the association of clinical parameters and serum anion gap with thyroid dysfunction and nodular goiter in continuous ambulatory peritoneal dialysis (CAPD) patients. Design Cross-sectional study. Setting Single dialysis unit and outpatient clinic. Patients This study included 89 uremic patients on CAPD. Gender ratio was 50 males to 39 females (M/F = 1.28); mean age was 54.8 years. Main Outcome Measures We investigated the prevalence of nodular goiter and thyroid dysfunction with a 10-MHz high-frequency ultrasound scanner and immunoassay kits. Results Nodular goiter was detected in 52.8% (47/89) of the CAPD patients. Patients with nodular goiter were older than those without goiter (57.7 vs 51.5 years, p < 0.05). Nodular goiter was found more frequently in females than in males (66.7% vs 44.0%, p < 0.05). Patients with nodular goiter had longer duration of CAPD than patients without goiter (51.6 ± 42.9 vs 31.0 ± 28.1 months, p < 0.02). In addition, CAPD patients with goiter had a higher serum anion gap (AG) (16.8 ± 3.3 vs 14.0 ± 4.5 mEq/L, p < 0.02) and a lower weekly creatinine clearance (55.9 ± 12.6 vs 64.6 ± 21.1 L/week/1.73 m2, p < 0.05) than patients without goiter. As serum AG gradually increased, significant alteration of thyroid parameters developed in the following sequence: ( 1 ) reduction of total T3 level at an AG level of 15, ( 2 ) elevation of thyrotropin (TSH) and increased prevalence of goiter at an AG of 18, and ( 3 ) reduction of free T4 and total T4 levels and elevation of TSH, with further increased frequency of goiter at an AG of 20 mEq/L. Conclusion According to this study, age, gender, dialysis duration, serum AG, and weekly creatinine clearance are correlated with prevalence of goiter in CAPD patients. Sequential alteration of thyroid function and increasing frequency of nodular goiter correlated with higher serum AG. There are two explanations for this correlation: the level of serum AG may be an indirect index of the level of serum goitrogens, and higher serum AG and increased frequency of nodular goiters might be a reflection of loss of residual renal function. Therefore, thyroid function screening and goiter detection using ultrasound should be considered when examining CAPD patients with progressively elevating serum anion gap.

Selective immunoglobulin A (IgA) deficiency may result in a predisposition to recurrent sinopulmonary infection and allergic diseases. IgA deficiency may also play a role in the development of autoimmune disorders. Selective IgA deficiency associated with glomerulonephritis was rare, while the clinical presentation in IgA deficiency-associated glomerulonephritis was variable. We report an 83 year-old male with selective IgA deficiency associated with membranous glomerulonephritis. He presented with nephrotic syndrome. Percutaneous renal needle biopsy showed diffuse global thickening and rigidity of glomerular capillary walls, mildly diffuse segmental expansion of mesangial matrix, focal and cortical scar with segmental obsolescence of glomeruli. Heavy IgG and moderate C3 deposits were found on immunofluorescence. We also review the previous cases of IgA deficiency with glomerulonephritis. Several clues were rendered to establish the association between IgA deficiency and membranous glomerulonephritis.

To investigate the relation of leukopenia and thrombocytopenia in hemodialysis (HD) patients with hepatitis C virus (HCV) infection.The study included 86 HD patients with hepatitis B surface antigen-negative and hepatitis C antibody-negative, 28 HD patients with hepatitis C antibody-positive, 22 HD patients with hepatitis B surface antigen-positive, 78 non-HD patients with hepatitis B-induced liver cirrhosis and 38 non-hemodialysis patients with hepatitis C-induced liver cirrhosis. The following parameters were checked: anti-HCV, hepatitis B surface antigen, hemoglobin, hematocrit, white blood cells, platelets, calcium, phosphate, iron, ferritin, albumin, globulin, aspartate transaminase (AST), alanine transaminase (ALT) and C-reactive protein. The history of blood transfusions, medications, erythropoietin doses and adequate dialysis (KTNV) for 6 consecutive months was also recorded from charts.The HD patients with positive serum anti-HCV and non-HD patients with hepatitis B- or C-induced liver cirrhosis had higher prevalences of leukopenia (39.3%, 43.6% and 50% vs. 15.1%; p0.001) and thrombocytopenia (67.9%, 89.7% and 81.6% vs. 34.9%: p0.001) than HD patients with serum anti-HCV(-)HbsAg(-). The WBC (4,432 +/- 1,394, 4,792 +/- 2,263 and 4,624 2,446 vs. 5,590 +/- 1,500/mm3; p0.001) and platelet counts (140 +/- 45, 80 +/- 50 and 89 +/- 65 vs. 186 +/- 62 x 10(3)/mm3; p0.001) of HD patients with positive serum anti-HCV and non-HD patients with hepatitis B- or C-induced cirrhosis were also lower than HD patients without anti-HCV antibody. The liver cirrhosis patients had more thrombocytopenia than the HD patients with anti-HCV(+). The WBC and platelet counts did not vary between HD patients with HbsAg(+) and HD patients with anti-HCV(-)HBsAg(-). The durations of HD, hepatitis and liver cirrhosis were not related to the leukopenia or thrombocytopenia (p0.05).HCV infection associated with leukopenia and/or thrombocytopenia in HD patients is as common as in non-HD patients with liver cirrhosis. This may be due to the direct effect of hemopoiesis rather than the hyperspleenism of liver cirrhosis patients. There is a need for further prospective investigation to ascertain the clinical significance of leukopenia and thrombocytopenia in HD patients with anti-HCV(+). The prevalence of leukopenia and thrombocytopenia was higher in HD patients with hepatitis C than in HD patients with hepatitis B and HD patient without hepatitis.

Divisions of Baxter Novum and Renal Medicine,1 Huddinge University Hospital, Karolinska Institute, Stockholm, Sweden; Department of Nephrology,2 Sri Ramachandra University Hospital, Chennai, India; Tokyo Women’s Medical University,3 Tokyo, Japan; Optimal Dialysis Research Unit,4 London Health Sciences Centre and University of Western Ontario, London, Ontario, Canada; Department of Renal Medicine,5 Manchester Royal Infirmary, Manchester, England; Division of Nephrology,6 Kyung-Hee University Medical Center; Hyonam Kidney Laboratory,7 Soon Chun Hyang University, Seoul, Korea; University Department of Medicine,8 Tung Wah Hospital, Hong Kong, China; Center for Kidney Diseases,9 Mount Elisabeth Hospital, Singapore; Department of Medicine,10 Khon Kaen Medical School, Thailand; Department of Medicine,11 University of Malaya, Kuala Lumpur, Malaysia; Division of Nephrology,12 Chulalongkorn Hospital, Bangkok, Thailand; Division of Nephrology,13 Taipei Veterans General Hospital, Taipei, Taiwan