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Background: Studies in hemodialysis patients suggest that the "surprise" question can help to identify a group of patients with a high mortality risk who should receive priority for palliative care interventions. However, the same instrument has not been tested in peritoneal dialysis (PD) patients., Method: We studied 367 prevalent PD patients from a single dialysis center. Three clinicians independently answered the "surprise" question (Would I be surprised if this patient died within the next 12 months?) according to their clinical impression of the individual patient. Patients are then classified into "yes" (yes, surprised) and "no" (no, not surprised) groups. All patients were followed for 12 months., Results: In this cohort, 109 patients (29.7%) were allocated to the "no" group, and 258 (70.3%), to the "yes" group. Patients in the "no" group were older and had high prevalences of pre-existing ischemic heart disease, cerebrovascular disease, and peripheral vascular disease. The "no" group had a higher score on the Charlson comorbidity index and a higher malnutrition-inflammation score. At 12 months, 44 patients had died. Mortality was 24.8% in the "no" group and 6.6% in the "yes" group. Multivariate analysis showed that an opinion of "Not surprised if dies in the next 12 months" was an independent predictor of 12-month mortality, with an associated 3.594 excess mortality risk (95% confidence interval: 1.411 to 9.151; p = 0.007). The positive predictive value of this opinion was 24.8%, and its negative predictive value was 93.4%., Conclusions: The "surprise" question has the potential to help identify a group of PD patients with high short-term mortality. Its use may contribute to a decision to refer PD patients for early palliative care assessment.

Unlabelled: We quantified the urine sediment and supernatant levels of microRNA (miRNA) targets related to epithelial-mesenchymal transition in 51 patients with bladder cancer and in 24 controls. We found that patients with bladder cancer had depressed levels of the miR-200 family, miR-192, and miR-155 in urinary sediment. The urinary level of these miRNAs may be developed as noninvasive markers for bladder cancer., Background: MicroRNAs (miRNA) have been implicated to play an important role in the pathogenesis of a variety of cancers. We studied the levels of miRNAs related to epithelial-mesenchymal transition (EMT) in the urine of patients with bladder cancer., Method: The expression of the miR-200 family, miR-205, miR-192, miR-155, and miR-146a in the urine sediment and supernatant of 51 patients with bladder cancer and in 24 controls was determined by real-time quantitative polymerase chain reaction., Results: Compared with controls, the patients with bladder cancer had a lower expression of the miR-200 family, miR-192, and miR-155 in the urinary sediment; lower expression of miR-192; and higher expression of miR-155 in the urinary supernatant. The expression of the miR-200 family, miR-205, and miR-192 in the urine sediment significantly correlated with urinary expression of EMT markers, including zinc finger E-box-binding homeobox 1, vimentin, transforming growth factor β1, and Ras homolog gene family, member A. Furthermore, the levels of miR-200c and miR-141 in the urine sediment became normalized after surgery., Conclusion: We found that the urinary miR-200 family, miR-155, miR-192, and miR-205 levels are depressed in patients with bladder cancer. The level of these miRNA targets in urine has the potential to be developed as noninvasive markers for bladder cancer., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Aim: MicroRNAs (miRNAs) play important roles in the pathogenesis of autoimmune diseases. We studied the intra-renal expression of miRNA targets that were reported to be differentially expressed in peripheral blood or urine between lupus nephritis (LN) patients and normal controls., Methods: We quantified the expression of in glomerulus and tubulointerstitium of miR-146a, miR-155, miR-198 miR-638 and miR-663 in 42 patients with LN and 10 healthy controls., Results: As compared with controls, LN patients had lower glomerular expression of miR-638 (P < 0.001) but higher tubulointerstitial expression of this target (P = 0.001). Both glomerular and tubulointerstitial expression of miR-198 were higher in LN patients than controls (P < 0.001). For miR-146a, LN patients only had higher expression in glomerulus (P = 0.005) but not in tubulointerstitium. Tubulointerstitial miR-638 expression was significantly correlated with proteinuria (r = 0.404; P = 0.022) and disease activity score (r = 0.454; P = 0.008), while glomerular miR-146a expressions were correlated with estimated GFR (r = 0.453; P = 0.028) and histological activity index (r = 0.494; P = 0.027)., Conclusion: We found that intra-renal expression of miR-638, miR-198 and miR-146a are differentially expressed between LN patients and normal controls. Furthermore, the degree of change in glomerular miR-146a and tubulointerstitial miR-638 expression correlated with clinical disease severity. The results suggested that these miRNA targets may play a role in the pathogenesis of lupus nephritis., (© 2012 The Authors. Nephrology © 2012 Asian Pacific Society of Nephrology.)

We studied the levels of miR-146a and miR-155 in the urine sediment of SLE patients. The levels of miR-146a and miR-155 in the urine sediment of 40 SLE patients who were receiving calcitriol treatment and 13 healthy controls were determined with real-time quantitative polymerase chain reaction. The levels of urinary miR-146a and miR-155 in patients with SLE were significantly higher than that in healthy controls. Calcitriol treatment reduced the levels of urinary miR-155 in patients with SLE. The level of urinary miR-146a significantly correlated with estimated glomerular filtration rate (r = 0.242, P = 0.008). The level of urinary miR-155 significantly correlated with proteinuria (r = 0.407, P < 0.001) and systemic lupus erythematosus disease activity index (r = 0.278, P = 0.002). The level of urinary miR-146a reversely correlated with the urinary expression of TNF-α (r = -0.247, P = 0.012). Our results suggested that miR-146a and miR-155 might play important roles in the pathophysiology of SLE and the levels of urinary miR-146a and miR-155 could be used as potential markers for diagnosis, disease activity, and therapeutic response.

Background and Objectives: The single-nucleotide polymorphism (SNP) -717A→G substitution, rs2794521, was found in the promoter of the C-reactive protein (CRP) gene. Functional studies showed that A allele promoter has higher transcriptional activity than the G allele. This study investigated the association between this SNP and the outcome of Chinese patients undergoing peritoneal dialysis (PD)., Design, Setting, Participants, & Measurements: The study included 441 new PD patients (232 men; mean age ± SD, 56.7±13.5 years). CRP genotyping was determined; patients were followed for 41.3±18.3 months for cardiovascular events., Results: For the entire cohort, 5-year event-free survival rates did not differ between the AA and AG/GG groups (35.7% and 31.9%, respectively; P=0.64). However, there was significant interaction between plasma cholesterol levels and CRP genotype groups on event-free survival (P=0.04 for interaction). For patients with cholesterol levels of 200 mg/dl or greater, the 5-year event-free survival rate in the AG/GG group was significantly better than that in the AA group (54.7% versus 40.0%; P=0.04), whereas there was no difference in event-free survival between genotype groups for patients with cholesterol levels less than 200 mg/dl., Conclusions: CRP gene -717AG or GG genotypes is associated with cardiovascular benefit to Chinese PD patients with cholesterol levels of 200 mg/dl or greater. These findings suggest a complex interaction among cholesterol, CRP, and cardiovascular disease in PD patients.

Aim: Long term dialysis is life-saving for patients with end stage renal disease (ESRD). However, in ESRD patients with multiple comorbid conditions, dialysis may actually be futile, and conservative management is advisable. We studied the life expectancy of Chinese ESRD patients treated conservatively., Methods: We reviewed 63 consecutive ESRD patients who were treated conservatively in our centre. Duration of survival was calculated from the date of initial assessment for dialysis, as well as the expected date of needing dialysis based on previous trend of renal function decline., Results: At the end of the observation period, 55 patients died. Twelve patients died before the expected date of needing dialysis because of unrelated reasons, while 36 deaths were directly attributed to uraemia. The median overall survival after initial assessment for dialysis was 41.3 months (95% confidence interval (CI), 33.2 to 49.4 months). The median overall survival was 6.58 months (inter-quartile range, 0.92 to 9.33 months) from the theoretical date of needing dialysis. The survival from the theoretical date of needing dialysis did not correlate with patient age, sex, diabetic status, or baseline renal function., Conclusions: In Chinese ESRD patients treated conservatively, the median survival is around 6 months after the theoretical date of needing dialysis. Our result provides an important piece of information for the decision of dialysis and patient counselling., (© 2011 The Authors. Nephrology © 2011 Asian Pacific Society of Nephrology.)

Background: Although originally described in dialysis patients treated with recombinant human erythropoietin (rHuEPO), haemoglobin variability has recently also been noted to be increased in patients who have chronic kidney disease (CKD) without dialysis. In our country, pre-dialysis CKD patients generally would not receive rHuEPO treatment. We studied the degree of haemoglobin variability and its prognostic implication in this group of patients., Methods: We reviewed 332 patients with Stages 3 through 5 CKD; patients with overt iron deficiency or requiring blood transfusion were excluded. Patients were followed for up to 5 years. End points include all-cause mortality, progression to dialysis-dependent renal failure and hospitalization., Results: The average haemoglobin level was 11.4 ± 2.8 g/dL; intra-individual SD of haemoglobin was 0.76 ± 0.61 g/dL. Haemoglobin variability, as represented by intra-individual SD of haemoglobin, was significantly associated with the average haemoglobin level (r = -0.130, P = 0.017), Charlson's comorbidity score (r = 0.113, P = 0.040) and proteinuria (r = 0.151, P = 0.044). Univariate analysis showed that patients with high haemoglobin variability had a significantly higher all-cause mortality (log-rank test, P = 0.030) and risk of progression to end-stage renal disease (log-rank test, P = 0.021) and was associated with the adjusted duration of hospitalization (r = 0.134, P = 0.015). However, all associations become statistically insignificant after multivariate analysis to control for confounding factors., Conclusions: Fluctuation of haemoglobin level is common and substantial in Chinese pre-dialysis CKD patients. Our results suggests that the observed clinical effect of haemoglobin variability in this patient population is an epiphenomenon secondary to the association between haemoglobin variability and other clinical factors.

Aim: The role of the tumour necrosis factor-like weak inducer of apoptosis (TWEAK)/Fn14 and interferon-inducible protein (IP-10)/CXCR3 axis in the pathogenesis of lupus nephritis were studied., Methods: The mRNA expression of TWEAK, Fn14, IP-10 and CXCR3 were quantified in the glomerulus and tubulointerstitium of 42 patients with lupus nephritis (LN group) and 10 healthy controls., Results: As compared to controls, LN patients had higher glomerular expression of TWEAK and Fn14, but glomerular CXCR3 expression was lower in the LN group. Similarly, the LN group had higher tubulointerstitial expression of TWEAK and Fn14, but lower tubulointerstitial expression of CXCR3, than controls. Glomerular TWEAK expression of class V nephritis was significantly higher than class IV nephritis. Glomerular expression of CXCR3 significantly correlated with proteinuria (r = -0.532; P = 0.019), whereas tubulointerstitial CXCR3 significantly correlated with serum creatinine (r = -0.447; P = 0.029)., Conclusion: In patients with lupus nephritis, there is an increase in intra-renal expression of TWEAK and Fn14, and a decrease in CXCR3 expression. Intra-renal expression of CXCR3 correlates with proteinuria and renal function. Our findings suggest that the TWEAK/Fn14 and IP-10/CXCR3 axis may contribute to the pathogenesis of lupus nephritis., (© 2011 The Authors. Nephrology © 2011 Asian Pacific Society of Nephrology.)

Background and Objectives: The clinical behavior of repeat-peritonitis episodes, defined as peritonitis with the same organism occurring more than 4 weeks after completion of therapy for a prior episode, is poorly understood., Design, Setting, Participants, & Measurements: We compared outcomes of 181 episodes of repeat peritonitis from 1995 to 2009 (Repeat Group) with 91 episodes of relapsing peritonitis (Relapsing Group) and 125 episodes of peritonitis preceded 4 weeks or longer by another episode with a different organism (Control Group)., Results: In Repeat Group, 24% were due to Staphylococcus aureus, as compared with 5.5% in Relapsing Group and 15% in Control Group. The majority of the organisms causing relapsing peritonitis were Gram negative (62%), whereas the majority of that in Repeat Group were Gram positive (56%). Repeat Group had a lower complete-cure rate (70.7% versus 54.9%) than Relapsing Group, but rates of primary response, catheter removal, and mortality were similar. Repeat Group had a higher primary response rate (89.0% versus 73.6%) and a lower rate of catheter removal (6.1% versus 15.2%) than Control Group, whereas the complete-cure rate and mortality were similar. Repeat Group had a higher risk of developing relapsing (14.3% versus 2.2%) and repeat peritonitis (26.1% versus 5.4%) than Control Group, whereas the risk of recurrent peritonitis was similar., Conclusions: Repeat peritonitis is a distinct clinical entity. Although repeat-peritonitis episodes generally have a satisfactory response to antibiotic, they have a substantial risk of developing further relapsing or repeat peritonitis., (© 2011 by the American Society of Nephrology)

Background: Peritoneal dialysis (PD) patients with severe peritonitis require catheter removal. It is often assumed that this approach, together with antibiotics, would eradicate the infection; however, some patients continue to have problems despite catheter removal., Method: We reviewed 30 consecutive PD patients in our center from 1997 to 2008 with recurrent loculated peritoneal collection after catheter removal for severe peritonitis., Results: Of the 1928 episodes of peritonitis that occurred in 702 patients during the study period, 11.1% required catheter removal and 1.6% developed recurrent peritoneal collection that required percutaneous drainage. Median time to diagnosis of intra-abdominal collection was 12 days after catheter removal (interquartile range 7 - 61 days). In 25 patients (83.3%), aspirate of the abdominal collection was culture negative. In 17 patients (56.7%), the abdominal collection was recurrent and required repeated percutaneous aspiration. Only 3 patients had successful reinsertion of the peritoneal catheter but all had reduced small solute clearance after returning to PD., Conclusion: A small but not negligible proportion of patients with PD-related peritonitis develop recurrent intra-abdominal collection that requires percutaneous drainage after catheter removal. The chance of a successful return to PD is very low in this group of patients. Direct conversion to long-term hemodialysis may avoid unnecessary attempts at peritoneal catheter reinsertion.

Background: The practice of Tenckhoff catheter insertion by nephrologists remains uncommon in most countries. ♢, Methods: We report our single-center experience of Tenckhoff catheter insertion by nephrologists using the open dissection surgical technique in a dedicated ward-based procedure room. ♢, Results: Between November 2005 and September 2008, 250 peritoneal catheters were inserted by 6 nephrologists with varying levels of experience. Surgical dissection followed by exposure of the peritoneum under direct vision was performed under local anesthesia. Primary catheter failure, as defined by catheters that failed to function within 1 month after insertion, occurred in 2.8% of cases. Within 1 month of catheter insertion, 20 patients developed infectious complications: 9 (3.6%) peritonitis, and 11 (4.4%) exit-site infections; none of these complications led to catheter removal. Mean technique survival for the catheters was 41.2 months (95% confidence interval: 39.5 months to 42.9 months). Catheter survival rates at 1 and 2 years were 92.7% and 87.2% respectively. ♢, Conclusions: We reported an encouraging outcome for Tenckhoff catheters inserted by nephrologists in an open surgical manner, with a 2-year catheter survival of 87.2% and a good safety profile.

Background: Although the clinico-pathological entity of uremic pleuritis has long been recognized, its clinical significance remains poorly defined. ♢, Methods: We retrospectively studied 82 chronic peritoneal dialysis (PD) patients that had pleural effusion. The pattern of diagnosis and clinical outcome were reviewed. ♢, Results: 10 patients had overt fluid overload and thoracocentesis was not performed, 23 had other specific diagnoses, 15 had transudative effusion due to fluid overload, 12 had unexplained transudative effusion, and 22 patients had unexplained exudative effusion. The 3-year actuarial survival was 40.9% and 83.3% for patients with unexplained exudative and transudative effusion respectively (p = 0.012); technique survival was 74.2% and 90.9% respectively (p = 0.006). For patients with unexplained exudative effusion, 11 patients had their PD regimen intensified: they had a higher 3-year actuarial survival than those with their dialysis regimen unchanged (100.0% vs 52.6%, p = 0.04). ♢, Conclusion: Unexplained exudative pleural effusion is not uncommon in chronic PD patients. These patients have a high mortality; an intensive dialysis regimen may be considered.

Background: The response to recombinant hepatitis B vaccine remains suboptimal among the dialysis population., Methods: In this multi-centre randomized controlled trial, we studied the factors that modify the response to intramuscular Engerix-B vaccination in patients on peritoneal dialysis. The primary aim was to study if a three-dose schedule of extra-high dose (80 microg) of Engerix-B would offer better primary seroconversion and more persistent serological protection than the conventional 40-microg dose., Results: Forty-two peritoneal dialysis patients were randomized to receive the conventional 40-microg Engerix-B dose and 45 patients to 80-microg dose. Seroconversion [hepatitis B surface antibody (anti-HBs) level > or =10 IU/l 3 months after completion of the third dose] occurred in 78.6% of patients after 40-microg Engerix-B dosage treatment versus 62.2% for those receiving 80-microg Engerix-B treatment (P = 0.11). After 12 months, the persistence of protective anti-HBs also did not differ between 40- (45.2%) and 80-microg (51.1%) treatment groups (P = 0.67). In contrast, patients with seroconversion 3 months after the third dose of Engerix-B had a higher normalized protein nitrogen appearance (nPNA) than patients without seroconversion (1.16 +/- 0.25 versus 0.96 +/- 0.23 g/kg/day, P = 0.001). Conclusions. We found no evidence of a worthwhile clinical benefit from increasing the three-dose intramuscular Engerix-B vaccine from 40- to 80-microg dose. An unplanned analysis suggested a role of improved protein intake to improve the immune response to hepatitis B vaccine in peritoneal dialysis patients.

Aim: Activation of beta1-adrenergic receptor (beta1AR) enhances contractility and heart rate. The polymorphism Arg389Gly in the beta1AR gene was found to be functionally important in determining receptor activity. The relationship between this polymorphism and the risk of cardiovascular disease was investigated in Chinese subjects with overt diabetic nephropathy., Methods: A total of 219 type 2 diabetic subjects with nephropathy were recruited. Genotyping of the beta1AR Arg389Gly polymorphism was determined. Patients were followed up to 96 months for the development of cardiovascular events., Results: There were 122, 86 and 11 patients with Arg/Arg, Arg/Gly and Gly/Gly genotype, respectively. At 96 months, the event-free survival of primary composite cardiovascular end-point was 33.0% and 44.3% for Gly(+) and Gly(-) groups, respectively (log-rank test, P = 0.105), while the event-free survival for first ischaemic heart disease was 62.4% and 75.9%, respectively (log-rank test, P = 0.038). However, with multivariate analysis by the Cox proportional hazard model to adjust for confounders, only low-density lipoprotein and baseline glomerular filtration rate were independent predictors of first ischaemic heart event., Conclusion: The beta1AR Arg389Gly polymorphism is not an independent predictor of cardiovascular events in subjects with overt diabetic nephropathy.

Background: Endotoxemia is common in peritoneal dialysis (PD) patients; circulating lipopolysaccharide (LPS) level is related to the degree of systemic inflammation and atherosclerosis. We examine whether baseline plasma LPS level represents a prognostic marker in new PD patients., Methods: We studied 158 new Chinese PD patients (80 males). Baseline plasma LPS level at initiation of PD was measured. Patients were stratified into quartiles according to plasma LPS level: quartile I, <0.45 EU/mL; II, 0.45 - <0.70 EU/mL; III, 0.70 - <0.95 EU/mL; and IV, ≥ 0.95 EU/mL. The patients were then prospectively followed for the development of cardiovascular events. All-cause mortality and duration of hospitalization were also recorded., Results: Average age was 55.6 +/- 14.7 years; average endotoxin concentration was 0.70 +/- 0.30 EU/mL; average follow-up was 55.5 +/- 36.9 months. At 60 months, event-free survival was 41.0%, 52.5%, 65.0%, and 61.5% for LPS level quartiles I, II, III, and IV, respectively (log rank test p = 0.066). By multivariate analysis with the Cox proportional hazard model to adjust for confounders, plasma LPS level had no independent effect. At 60 months, technique survival was 20.5%, 20.0%, 32.5%, and 51.3% for LPS level quartiles I, II, III, and IV, respectively (log rank test p = 0.0009). By Cox proportional hazard model, each higher quartile of LPS conferred 28.6% protection (95% confidence interval 15.6% - 40.3%, p = 0.0002) from developing technique failure. A higher plasma LPS level had a lower all-cause mortality (unadjusted hazard ratio 0.486, p = 0.046) and cardiovascular mortality (unadjusted hazard ratio 0.251, p = 0.025), but the result became insignificant after adjusting for potential confounders., Conclusion: A higher baseline plasma LPS level is an independent predictor of better technique survival in new Chinese PD patients, with an insignificant trend of fewer cardiovascular events. The observation seems to conform to the phenomenon of reverse epidemiology for other traditional cardiovascular risk factors in dialysis patients but the exact reason for this paradoxical phenomenon requires further investigation.

Objective: Cardiovascular disease (CVD) is the most common cause of mortality in chronic peritoneal dialysis (PD) patients. Increased arterial stiffness may be related to a high peritoneal permeability resulting in fluid overload in PD patients. We studied the relations between arterial stiffness, peritoneal transport, and radiographic parameters of systemic fluid overload in a cohort of Chinese PD patients., Design: Prospective cohort study., Setting: University referral center., Patients: We studied 107 PD patients. Vascular pedicle width and cardiothoracic ratio were measured from a plain postero-anterior chest radiograph. Pulse wave velocity (PWV) was determined at carotid-femoral (C-F) and carotid-radial sites. Peritoneal transport was determined by the dialysate-to-plasma ratio (D/P) of creatinine at 4 hours of dwell. Patients were followed for 9.4 +/- 4.6 months., Outcome Measures: Duration of hospitalization; actuarial and technique survival., Results: There were no relationships between radiographic measures, arterial PWV, and D/P creatinine. However, both C-F PWV and D/P creatinine were independent predictors of the number of hospitalizations for CVD. None of the parameters correlated with mortality in this study., Conclusions: There were no relationships between radiological parameters of fluid overload, peritoneal transport characteristics, and arterial PWV. Both C-F PWV and D/P creatinine were independent predictors of the number of hospitalizations for CVD. Our result suggests that arterial stiffness and high peritoneal transport each contribute to the development of CVD in this group of patients.

Background: MicroRNAs (miRNAs) are non-coding, single-stranded RNA molecules that play important roles in a number of physiological and pathological processes. Previous studies showed that miRNAs targeting transcription factors ZEB1 and ZEB2 may repress epithelial-mesenchymal transition (EMT)., Methods: We studied 34 consecutive patients with biopsy-proven hypertensive nephrosclerosis. Intrarenal expression of miR-200 family, miR-205, and miR-192 were determined. We also studied normal renal tissue from 20 patients with nephrectomy for kidney cancer as controls., Results: The level of intrarenal of miR-200a, miR-200b, miR-141, miR-429, miR-205, and miR-192 were significantly higher in patients with hypertensive nephrosclerosis than controls. Proteinuria correlated with intrarenal expression of miR-200a (r = 0.594, P < 0.001), miR-200b (r = 0.395, P = 0.004), miR-141 (r = 0.377, P = 0.007), miR-429 (r = 0.346, P = 0.013), miR-205 (r = 0.636, P < 0.001), and miR-192 (r = 0.306, P = 0.029). Estimated glomerular filtration rate (GFR) correlated with intrarenal expression of miR-200a (r = -0.374, P = 0.007) and miR-205 (r = -0.400, P = 0.005). Intrarenal expression of ZEB1 inversely correlated with intrarenal expression of miR-429, whereas expression of ZEB2 inversely correlated with miR-200a, miR-200b, and miR-429., Conclusions: The results show that intrarenal expression of miR-200a, miR-200b, miR-141, miR-429, miR-205, and miR-192 were increased in hypertensive nephrosclerosis, and the degree of upregulation correlated with disease severity. The results suggested that these miRNA species may play important roles in the pathogenesis of hypertensive nephrosclerosis.

Background: Malnutrition is common among peritoneal dialysis (PD) patients. Recently, the Geriatric Nutrition Risk Index (GNRI) was found to be a reliable tool for screening malnutrition in hemodialysis patients. However, the GNRI has not been validated in PD patients., Methods: We studied 314 unselected, adult PD patients from a single dialysis unit. We compared their GNRI scores with their comprehensive Malnutrition-Inflammation Scores (MIS) and 7-point Subjective Global Assessment (SGA) scores. We randomly selected 106 patients for a repeated assessment, and the changes in their three indices were compared., Results: Baseline GNRI was significantly correlated with MIS (r = -0.487, P < .0001) and SGA (r = 0.234, P < .0001). When MIS >or=6 was defined as malnutrition, the sensitivity and specificity of GNRI

Objective: We studied the role of type 17 Th cells (TH17) in the pathogenesis of SLE., Methods: We quantified the mRNA expression of IL-17, -23, -27 and retinoic-acid-related orphan receptor (ROR)-gamma, the regulator for the development and function of TH17, in the urinary sediment of 23 subjects with active lupus nephritis, 25 subjects with a history of lupus nephritis in remission, 30 SLE patients with no history of renal involvement and 8 healthy subjects., Results: All three groups of lupus patients had a higher urinary expression of TH17-related cytokines than the controls. However, urinary expression of IL-17 and -27 was found to be inversely correlated with the SLEDAI score (r = -0.252 and -0.258, respectively; P < 0.05 for both). For patients with active lupus nephritis, the histological activity index of kidney biopsy was also found to be inversely correlated with the urinary expression of ROR-gamma (r = -0.447; P = 0.032), IL-17 (r = -0.454; P = 0.029) and IL-23 (r = -0.455; P = 0.029). Urinary expression of IL-17, -23, -27 and ROR was also found to be inversely correlated with the urinary expression of IFN-gamma and T-bet, the key transcription factor of type 1 Th cells. After 6 months of treatment, urinary IL-27 expression rose significantly in patients with complete response (from 2.07 +/- 1.62 to 3.70 +/- 1.69; P = 0.028) but remained unchanged in those with partial or no response (from 2.60 +/- 1.87 to 2.52 +/- 1.94; P = 0.9)., Conclusions: The urinary expression of TH17-related genes is increased in SLE patients. The degree of up-regulation, however, is inversely related to systemic and renal lupus activity, as well as urinary expression of TH1-related genes. Urinary expression of TH17-related genes increased again after successful immunosuppressive treatment of active disease. Our findings suggest a regulatory role of TH17-related cytokines in pathogenesis of lupus nephritis.

Background: The clinical behavior and optimal treatment of relapsing and recurrent peritonitis episodes in patients undergoing long-term peritoneal dialysis are poorly understood., Study Design: Retrospective study over 14 years., Setting & Participants: University dialysis unit; 157 relapsing episodes (same organism or culture-negative episode occurring within 4 weeks of completion of therapy for a prior episode), 125 recurrent episodes (different organism, occurs within 4 weeks of completion of therapy for a prior episode), and 764 control episodes (first peritonitis episode without relapse or recurrence)., Predictors: Exit-site infection, empirical antibiotics., Outcome Measures: Primary response (resolution of abdominal pain, clearing of dialysate, and peritoneal dialysis effluent neutrophil count < 100 cells/mL after 10 days of antibiotic therapy), complete cure (resolution by using antibiotics without relapse/recurrence), catheter removal (for any cause while on antibiotic therapy), and mortality., Results: Compared with the control group, more relapsing episodes were caused by Pseudomonas species (16.6% versus 9.4%) and were culture negative (29.9% versus 16.4%); recurrent infections commonly were caused by Enterococcus species (3.2% versus 1.2%) or other Gram-negative organisms (27.2% versus 11.1%) or had mixed bacterial growth (17.6% versus 12.7%). There were significant differences in primary response, complete cure, and mortality rates among groups (P < 0.001 for all comparisons). Compared with the control and relapsing groups, post hoc analysis showed that the recurrent group had a significantly lower primary response rate (86.4%, 88.5%, and 71.2%, respectively), lower complete cure rate (72.3%, 62.4%, and 42.4%, respectively), and higher mortality rate (7.7%, 7.0%, and 20.8%, respectively)., Limitations: Retrospective analysis., Conclusion: Relapsing and recurrent peritonitis episodes are caused by different spectra of bacteria and probably represent 2 distinct clinical entities. Recurrent peritonitis episodes had a worse prognosis than relapsing ones.

We report a 56-year-old male hemodialysis patient who developed fatal pancytopenia after treatment with low-dose methotrexate for psoriasis and psoriatic arthropathy. Risk factors identified included impaired renal function, concurrent use of nonsteroidal anti-inflammatory drugs, low serum albumin, and relatively low serum folate level. Literature review found similar risk factors in 12 other cases. Therefore, methotrexate, even as a single dose, should not be used to treat rheumatic conditions in dialysis patients.

Background: Podocyte injury probably plays important roles in the pathogenesis of hypertensive nephropathy, but human data are limited. We studied glomerular podocyte count and intrarenal expression of podocyte-associated molecules in patients with hypertensive nephrosclerosis., Methods: We studied 41 consecutive patients with biopsy-proven hypertensive nephropathy, 10 cadaveric kidney donors, and 9 healthy subjects. Intrarenal and urinary mRNA expression of podocyte-associated molecules was quantified and podocyte number was determined by stereological method., Results: Intrarenal mRNA expression levels of nephrin, podocin, and synaptopodin were lower, and urinary mRNA expression levels were higher in patients with hypertensive nephropathy than controls. Glomerular podocyte number was significantly lower in patients with hypertensive nephrosclerosis than kidney donors (545 +/- 237 vs. 773 +/- 296 per glomeruli, P < 0.02). Podocyte density and intrarenal gene expression of podocyte-associated molecules significantly correlated with estimated glomerular filtration rate (GFR) and inversely correlated with blood pressure and the degree of renal fibrosis. Intrarenal gene expression of nephrin significantly correlated with change in renal function decline., Conclusion: This study demonstrates a decrease in podocyte number and intrarenal gene expression of podocyte-associated molecules in patients with hypertensive nephrosclerosis. We observed correlations between glomerular podocyte density and intrarenal expression of podocyte-associated molecules with renal function and the degree of renal fibrosis, suggesting podocyte loss may play an important role in the pathogenesis of hypertensive nephrosclerosis.

Metabolic syndrome (MetS) occurs in about 50% of peritoneal dialysis (PD) patients. It encompasses a cluster of major risk factors for cardiovascular diseases. A modified National Cholesterol Education Program Third Adult Treatment Panel guideline for the diagnosis of MetS in PD patients has been proposed. Preliminary data suggest that PD patients with MetS in our cohort have an increased risk of cardiovascular mortality. The proinflammatory effects of adipose tissue are one of the reasons for poor outcome in obese PD patients. Lifestyle modification, including appropriate dietary restriction and exercise, especially reduction of fat mass in obese patients, has been one of the major areas proposed for managing patients with MetS. Individual therapeutic trials are treating hyperglycemia, hypertension, and dyslipidemia in dialysis patients. Evidence in PD patients that interventions targeting MetS can improve outcomes is still lacking. Large-scale studies with data on the clinical outcome for MetS intervention in PD patients are needed.

Background: Volume overload is an important contributing factor of cardiovascular disease (CVD) in peritoneal dialysis (PD) patients. Vascular pedicle width (VPW) and cardiothoracic ratio (CTR) in routine chest radiograph are indicators of intravascular volume. Longitudinal changes of VPW and CTR may be important prognostic factors of PD patients., Method: We studied 212 PD patients. Longitudinal changes in VPW (DeltaVPW) and CTR (DeltaCTR) were calculated. The relationship between radiologic measurements and clinical outcome was analyzed., Results: During the 12 months prior to enrollment, VPW rose from 53.35 +/- 5.66 to 55.40 +/- 6.30 mm (p < 0.001) and CTR rose from 53.3 +/- 7.1 to 56.0 +/- 7.8% (p < 0.001). After adjusting for confounding variables by Cox regression model, DeltaCTR is an independent predictor of hospitalization-free survival; 1% increase in CTR confers 2.9% higher risk of hospitalization (95% confidence interval 0.2-5.7%, p = 0.034). None of the radiologic measurements correlated with actuarial patient survival., Conclusions: In chronic PD patients, DeltaCTR is an independent predictor of hospitalization-free survival. This simple radiological parameter may serve as an important parameter for the risk stratification of PD patients., (Copyright 2009 S. Karger AG, Basel.)

Background: Relatively little is known of the epidemiology and predictors of sudden death in peritoneal dialysis (PD) populations. We aimed to identify the risk factors of sudden death among PD subjects., Methods: To explore clinical correlates of sudden death in PD patients, we conducted a population-based case-control study using data from a single dialysis unit. Cases (n=24) were defined as all PD patients that met the criteria for sudden death during January 2003 through December 2006. We also selected 48 control subjects that were selected from the prevalent PD patient name list compiled in alphabetical order. Data on the hemoglobin, potassium, and calcium levels, residual renal function, dialysis adequacy, cardiovascular risks, comorbid conditions, concurrent use of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors, and erythropoietin, electrocardiographic and echocardiographic findings were extracted from case notes and computer records. Confounders were controlled by logistic regression., Results: Over a period of 4 years, 24 PD patients (mean age 61.4+/-9.5 years, median duration of dialysis 3.1 years) experienced sudden death. Univariate analyses showed that patients that died suddenly were more likely to be male and to have diabetes mellitus, a history of smoking, and a lower small solute clearance as measured by Kt/V. Cases of sudden death were also more likely to have received blood transfusion within the previous 1 year. There were no significant differences between patients and controls for residual renal function, serum potassium levels, control of blood pressure and mineral metabolism, or hemoglobin levels. Multivariate regression analysis confirmed independent association between recent blood transfusion and increased odds of sudden death [adjusted odds ratio (OR) 5.18, 95% confidence interval (CI) 1.44-18.6]. Two other factors significantly associated with risk of sudden death were male gender (adjusted OR 4.16, 95% CI 1.14-15.2) and diabetes mellitus (adjusted OR 5.33, 95% CI 1.53-18.6)., Conclusion: This study shows that recent blood transfusion is associated with an increased likelihood of sudden death in PD patients. The mechanisms that underlie this observation are unclear.

Background: After prolonged peritoneal dialysis (PD) and exposure to a non-physiological dialysis solution, peritoneal mesothelial cells undergo the epithelial-to-mesenchymal transition. In other biological systems, bone morphogenic protein-7 (BMP-7) is a key factor that controls this process. However, the role of BMP-7 in peritoneal physiology has not been studied., Methods: We studied the peritoneal transport characteristics of 50 consecutive new PD patients at 4 and 52 weeks after PD. Peritoneal permeability will be determined by the standard peritoneal equilibration test (PET). BMP-7 in PD effluent (PDE) at mRNA and protein level at 4 weeks was quantified., Results: At 4 weeks, the mRNA expression of BMP-7 in PDE significantly correlated with peritoneal transport characteristics, including the dialysate-to-plasma creatinine ratio at 4 h (D/P4) (r = 0.422, P = 0.015) and mass transfer area coefficient (MTAC) of creatinine (r = 0.457, P = 0.008). The PDE BMP-7 level by ELISA also had marginal correlation with D/P4 (r = 0.287, P = 0.072) and MTAC creatinine (r = 0.287, P = 0.073), although the result did not reach statistical significance. For the subgroup of patients who remained free of peritonitis, the PDE BMP-7 level by ELISA had significant correlation with the change in D/P4 (r = 0.441, P = 0.017) and MTAC creatinine in 52 weeks (r = 0.415, P = 0.025). The PDE BMP-7 level remained independently associated with the change in peritoneal transport adjusting for age, sex, serum C-reactive protein and PDE transforming growth factor-beta level. In patients who had peritonitis during the study period, the PDE BMP-7 level did not affect the change in peritoneal transport. Conclusion. We find that the peritoneal BMP-7 level correlates with peritoneal transport characteristics, and a high PDE BMP-7 level is associated with a gradual increase in peritoneal transport parameters with time. It remains unclear, however, whether this effect is beneficial, and the therapeutic role of exogenous BMP-7 on peritoneal transport requires a further study.

Objectives: Several studies have examined the possible association between late referral to a nephrologist and mortality on maintenance hemodialysis. However, we lack information on the benefit of early nephrologist referral in patients receiving peritoneal dialysis (PD)., Patients and Methods: In an inception cohort of 102 consecutive PD patients identified in a single center between 2003 and 2004, we sought to determine whether late nephrologist referral was associated with poor outcomes. The primary end point was all-cause mortality. The effects of early referral to a multidisciplinary low clearance clinic on cardiovascular mortality and length of hospitalization were also evaluated., Results: Of 102 incident PD patients, 61 subjects (59.8%) were referred early to the nephrologist (more than 3 months) before dialysis initiation. During the study period of 284.9 patient-years (median follow-up period 36.8 months), 25 patients died, 12 due to cardiovascular causes. Both cardiovascular and all-cause mortality were significantly increased among PD patients with late referral, but the relationship between late referral and all-cause mortality was mitigated substantially by adjusting for relevant factors. In univariate analysis, late nephrology referral was associated with increased cardiovascular mortality, with a hazard ratio of 5.43 (95% confidence interval 1.46 - 20.21, p = 0.012). Annual adjusted days of hospitalization were similar between the early and late nephrology referral groups., Conclusions: A comprehensive analysis of incident PD subjects confirmed the significant relationship between late nephrology referral and all-cause and cardiovascular mortality. A causal relationship remains to be established and validated.

Background: Laboratory research and previous retrospective study suggest that vitamin D and its analogues have profound effects on immune system function and glomerular mesangial cell proliferation. We conducted an open-label study to evaluate the antiproteinuric effect of calcitriol on proteinuria in patients with immunoglobulin A (IgA) nephropathy., Study Design: Open-label prospective uncontrolled trial., Setting & Participants: 10 patients (3 men) with biopsy-proven IgA nephropathy and persistent proteinuria despite angiotensin-converting enzyme-inhibitor or angiotensin receptor blocker therapy in a tertiary referral center., Intervention: Calcitriol, 0.5 microg, twice weekly for 12 weeks., Outcome Measures: Changes in proteinuria, renal function, serum transforming growth factor beta (TGF-beta) and angiotensin II levels., Results: After calcitriol treatment, there was a significant overall decrease in proteinuria with time by using a general linear model with repeated measures (P = 0.03). There was a progressive decrease in urine protein-creatinine ratio from 1.98 +/- 0.74 to 1.48 +/- 0.81 g/g (P = 0.007) during the first 6 weeks that persisted throughout the study period. No significant change in blood pressure or renal function was noted. There was a simultaneous decrease in serum TGF-beta level, and percentage of decrease in serum TGF-beta level significantly correlated with percentage of change in proteinuria (Spearman r = 0.643; P = 0.02). Serum angiotensin II level did not change throughout the study. One patient experienced transient hypercalcemia that normalized after a dosage decrease. No other major adverse effect was reported., Limitations: This small study is uncontrolled and does not examine the long-term effect of calcitriol therapy., Conclusion: Twice-weekly oral calcitriol has a modest antiproteinuric effect in patients with IgA nephropathy and persistent proteinuria despite angiotensin-converting enzyme-inhibitor or angiotensin receptor blocker therapy. Additional studies are needed to confirm the renal protecting effect of calcitriol in patients with chronic proteinuric kidney diseases.

Background: Social support is an independent risk factor for mortality among new hemodialysis patients. We evaluated the effect of social support on the outcome of Chinese peritoneal dialysis (PD) patients., Methods: We studied 167 prevalent PD patients. They completed the Medical Outcomes Study Social Support Survey, Chinese Version (MOS-SSS-C) questionnaire. Patients were followed for 1 year. Outcome measures included change in nutritional status, hospitalization, and technique and actuarial patient survival., Results: Actuarial survival was 57.1%, 72.7%, 85.3%, and 88.6% for MOS-SSS-C total score quartiles I, II, III, and IV, respectively (log rank test, p = 0.037). Technique survival was 57.1%, 81.9%, 91.9%, and 91.4% (log rank test, p = 0.0044). By multivariate analysis with the Cox proportional hazard model to adjust for confounders, every 1 point increase in MOS-SSS-C total score was associated with a 0.6% [95% confidence interval (CI) 0.2%-0.9%, p = 0.003] reduction in the risk of death and a 0.5% (95%CI 0.1%-1.0%, p = 0.037) reduction in the risk of technique failure. The MOS-SSS-C score had no significant effect on change in nutritional or dialysis adequacy indices, hospitalization, or number of peritonitis episodes in 1 year., Conclusion: The degree of social support is an important predictor of actuarial and technique survival in Chinese PD patients. Measures to enhance social support may represent an easily achievable means of improving the clinical outcome of PD patients.

Background and Objectives: Coagulase-negative Staphylococcus species is the most common cause of peritoneal dialysis-related peritonitis; however, the optimal treatment strategy of coagulase-negative Staphylococcus species peritonitis remains controversial., Design, Setting, Participants, & Measurements: All of the coagulase-negative Staphylococcus species peritonitis in a dialysis unit from 1995 to 2006 were reviewed. During this period, there were 2037 episodes of peritonitis recorded; 232 episodes (11.4%) in 155 patients were caused by coagulase-negative Staphylococcus species., Results: The overall primary response rate was 95.3%; the complete cure rate was 71.1%. Patients with a history of recent hospitalization or recent antibiotic therapy had a higher risk for developing methicillin-resistant strains. Episodes that were treated initially with cefazolin or vancomycin had similar primary response rate and complete cure rate. There were 33 (14.2%) episodes of relapse and 29 (12.5%) episodes of repeat peritonitis; 12 (60.6%) of the repeat episodes developed within 3 mo after completion of antibiotics. Relapse or repeat episodes had a significantly lower complete cure rate than the other episodes. For relapse or repeat episodes, treatment with effective antibiotics for 3 wk was associated with a significantly higher complete cure rate than the conventional 2-wk treatment., Conclusions: Coagulase-negative Staphylococcus species peritonitis remains a common complication of peritoneal dialysis. Methicillin resistance is common, but the treatment outcome remains favorable when cefazolin is used as the first-line antibiotic. A 3-wk course of antibiotic can probably achieve a higher cure rate in relapse or repeat episodes.

Background: Diabetic patients often have reduced insulin requirements when they progress to renal failure. Since peritoneal dialysis (PD) solution contains glucose, the insulin requirement of these patients often increases after commenced on PD. However, the change in insulin requirement has not been studied systematically., Methods: We study 60 consecutive patients (32 male) with diabetic nephropathy newly started on PD. Their insulin requirement before and 6 months after initiation of dialysis is compared. Clinical factors affecting insulin requirement are explored., Results: All patients received a standard 6 l/day dialysis exchange. The mean age was 60.3 +/- 8.9 years. Twelve patients did not require insulin before PD; four of them were started on insulin 6 months after dialysis. The average dosages of insulin 6 months before and after PD were 0.27 +/- 0.28 and 0.37 +/- 0.29 unit/kg/day, respectively (paired t-test, P < 0.001). The increment in dosage was 0.103 +/- 0.216 unit/kg/day. The dosage of insulin requirement correlates with the small solute transport of the peritoneal membrane, as represented by the mass transfer area coefficient (MTAC) of creatinine (r = -0.307, P = 0.017) and haemoglobin level (r = 0.284, P = 0.028), but not with body mass index (BMI). The change in insulin dosage correlates with the number of 2.5% dialysis cycle required per day (r = 0.433, P = 0.001), but not with peritoneal transport status or BMI. In patients who did not receive hypertonic exchange, the dosage of insulin increased by 1.5 +/- 11.1 unit/day. Each extra 2.5% 2 l exchange results in a 7.5 unit/day (95%CI 3.2-11.8, P = 0.001) increase in insulin requirement., Conclusion: Diabetic patients have a minimal increase in insulin requirement after initiation of PD per se, but the dosage of insulin increased markedly after exposure to hypertonic glucose solution. Our result provides a basis for the dosage adjustment of insulin in diabetic patients newly commenced on PD.

The aging population has significant implications for the community. The increasing number of elderly end-stage renal disease (ESRD) patients presses the renal team to find an appropriate management plan. We used a retrospective analysis to study the effectiveness of continuous ambulatory peritoneal dialysis (CAPD) in elderly ESRD patients. Of the 328 CAPD patients recruited for the study, 121 were in the elderly group (>or=65 years of age), and 207 were in the control group (under 65 years of age). Median age in the elderly group was 71 years, and in the control group, 51 years. The elderly group had a higher prevalence (54.5%) of diabetes mellitus. The 2-year and 5-year rates of patient survival were 89.3% and 54.8% respectively in the elderly group and 92.2% and 62.9% in the control group (p=0.19). The 2-year and 5-year rates of technique survival were 84.0% and 45.7% respectively in the elderly group and 80.9% and 49.1% in the control group (p=0.75). The probability of a 12-month peritonitis-free period was 76.6% in the elderly group and 76.5% in the control group (p=0.75). One hundred elderly patients (82.6% of the group) performed their CAPD exchanges by themselves. We observed no significant difference in clinical outcome-including patient survival, technique survival, and peritonitis-free period-between the elderly self-care CAPD and the elderly assisted CAPD groups. In elderly ESRD patients, CAPD is an effective dialysis modality. A slightly longer training time is to be expected for elderly patients. Self-care CAPD for elderly patients who are capable of performing their own exchanges provides them with an independent home life.

Background: Glucose has been used as the osmotic agent added to standard peritoneal dialysis (PD) solutions since its inception. Patients who have no history of glucose intolerance may develop hyperglycemia after the initiation of PD therapy. However, the prevalence and long-term implications of new-onset hyperglycemia in PD patients has not been studied., Methods: We studied 405 consecutive patients with renal failure newly started on PD therapy. Fasting plasma glucose levels 1 month after being stable on PD therapy were reviewed. Clinical factors affecting fasting plasma glucose levels were explored. Patients were followed up for 49.7 +/- 28.4 months., Results: Of 405 patients, 136 had underlying diabetic nephropathy and another 17 had preexisting diabetes before starting PD therapy. Of the remaining 252 patients, fasting plasma glucose levels were greater than 200 mg/dL (>11.1 mmol/L) in 21 (8.3%) and 126 to 200 mg/dL (7.0 to 11.1 mmol/L) in 48 patients (19.0%). Seven patients required insulin therapy, 3 required low-dose sulfonylurea therapy, and all other patients had glucose levels controlled by means of dietary restriction only. Fasting plasma glucose levels significantly correlated with patient age (Pearson r = 0.278; P < 0.001), Charlson comorbidity score (r = 0.484; P < 0.001), baseline serum C-reactive protein level (r = 0.390; P < 0.001), and serum albumin level (r = -0.182; P < 0.001). However, patients with new-onset hyperglycemia had similar values for body weight, body mass index, peritoneal transport parameters, and ultrafiltration profile compared with other patients. At 36 months, actuarial survival rates were 93.7%, 85.3%, 81.6%, and 66.7% for patients with fasting glucose levels less than 100, 100 to less than 126, 126 to less than 200, and 200 mg/dL or greater (5.6, 5.6 to <7.0, 7.0 to <11.1, and >or=11.1 mmol/L) and 65.9% for patients with preexisting diabetes, respectively (overall log rank test, P < 0.001)., Conclusion: New-onset hyperglycemia is common in patients without diabetes started on PD therapy. Contrary to common belief, obese patients do not appear to have a greater risk of hyperglycemia. Our results suggest that even mild hyperglycemia, with fasting plasma glucose level greater than 100 mg/dL (>5.6 mmol/L), is associated with worse survival in PD patients.

Background: Shortening behaviour during peritoneal dialysis training can be easily measured, and likened to the skipping behaviour in haemodialysis subjects, although its effect on peritoneal dialysis outcomes is now well understood. We studied the clinical impact of failing to adhere to a peritoneal dialysis training programme among incident dialysis patients., Methods: This study included 159 consecutive inception peritoneal dialysis patients in a single centre from September 1999 through November 2002. We evaluated the effects of behavioural compliance quantified by the per cent time arriving late for scheduled peritoneal dialysis training. The patients were categorized by whether they arrived late in >20% of their peritoneal dialysis training sessions., Results: Of the 159 incident peritoneal dialysis patients (mean age 57 +/- 13 years) who attended peritoneal dialysis training, 70 subjects (44%) arrived late in >20% of the sessions. They were younger by 5 years than patients who arrived late < or =20%. Mean peritonitis-free time for subjects who arrived late for training in >20% the of sessions was 30.9 months, as compared with 41.8 months in subjects with < or =20% late attendance behaviour (log rank test, P = 0.038). Multivariable Cox proportional hazards analysis showed that late attendance behaviour and baseline serum albumin were the only independent risk factors for the time to a first peritonitis after adjustment for diabetes mellitus and relevant coexisting medical factors. Late arrival in >20% of the peritoneal dialysis training sessions was associated with >50% increased likelihood of subsequent peritonitis, with an adjusted risk ratio of 1.56 (95% confidence interval, 1.02-2.39; P = 0.04)., Conclusion: These findings show that the behavioural measure of late attendance for peritoneal dialysis training has a crucial role in predicting peritonitis. It may therefore represent a practical strategy for identifying poor adherence or predicting medical outcomes.

Background: Study of messenger RNA (mRNA) expression of target genes in urinary sediment was suggested as a noninvasive marker of renal damage in patients with chronic kidney diseases (CKDs). We studied the relationship between urinary mRNA expression of target genes and risk for renal function deterioration in patients with CKD., Methods: We studied 131 patients with CKD with kidney biopsy. mRNA expression of 11 target genes in urinary sediment was measured by means of quantitative polymerase chain reaction. Patients then were followed up for 27.4 +/- 10.1 months. The primary end point is doubling of serum creatinine concentration or end-stage renal disease., Results: Thirty-six patients (27.5%) reached the primary end point during follow-up. Univariate analysis showed that sex, age, proteinuria, estimated glomerular filtration rate, histological diagnosis, degree of tubulointerstitial scarring, percentage of glomerulosclerosis, and urinary mRNA expression of hepatocyte growth factor (HGF) were predictors of the primary end point. At 24 months, event-free survival rates were 90.9% and 64.3% for patients with low and high urinary HGF expression, respectively (log rank test, P = 0.002). After adjusting for other confounding factors by using a Cox proportional hazard model, urinary HGF expression remained an independent predictor of the primary end point, and a 1-fold increase in expression was associated with a 4.0% (95% confidence interval, 0.5 to 7.5; P = 0.024) increase in risk., Conclusion: In the target genes examined, urinary HGF expression is an independent prognostic indicator of CKD after adjusting for confounding clinical and histological factors. Measurement of urinary HGF mRNA expression may be a useful noninvasive tool for risk stratification of patients with CKD.

Objective: We hypothesized that patients with hepatitis B virus infection and cirrhosis are more susceptible to peritonitis as a complication of peritoneal dialysis (PD)., Methods: A retrospective study was carried out to compare peritonitis rates between cirrhotic and non-cirrhotic patients with hepatitis B virus infection., Results: Between 1994 and 2004, 25 PD patients with hepatitis B cirrhosis and 36 patients with hepatitis B without cirrhosis were included for analysis. Mean follow-up duration was 52 months. Subjects with hepatitis B cirrhosis consisted of more males and had higher total body weight. No cirrhotic patients (20 of them being Child-Pugh class A, 2 class B, and 3 class C) had undergone portosystemic shunting or liver transplantation. Cirrhotic patients had slightly higher bilirubin concentration than the non-cirrhotic group (22 +/- 50 vs 9 +/- 4 micromol/L, p = 0.16). There was no difference in median peritonitis-free survival between cirrhotic and non-cirrhotic patients (40 vs 37 months, p = 0.64 by log-rank test). The average peritonitis rate was 1 episode every 19.2 patient-months in the cirrhotic group and 1 episode every 20.5 patient-months in the non-cirrhotic group. Time to first peritonitis did not differ between the two groups with respect to gram-negative organisms (p = 0.88) or gram-positive organisms (p = 0.52). Cirrhotic patients had more frequent Streptococcus species peritonitis, which accounted for 13% of all peritonitis episodes, as opposed to 2% among the non-cirrhotic patients (p = 0.01). Overall treatment response rate and outcome did not differ between patients with and patients without cirrhosis., Conclusions: Peritonitis-free survival of cirrhosis patients infected by hepatitis B virus compares favorably with thatin patients without cirrhosis. The presence of liver cirrhosis does not appear to compromise PD outcome.

Background: Microalbuminuria is a marker of systemic endothelial dysfunction. We hypothesize that peritoneal albumin excretion in peritoneal dialysis (PD) patients, which is conceptually analogous to microalbuminuria in non-uremic patients, can predict cardiovascular disease in new PD patients., Method: We studied peritoneal albumin excretion in 43 new PD patients. They were then followed prospectively for the development of cardiovascular events. All-cause mortality and duration of hospitalization for cardiovascular diseases were also recorded., Result: The average duration of follow-up was 26.5 +/- 17.6 months. During the follow-up period, 15 patients developed cardiovascular events. Event-free survival at 36 months was 81.4% and 53.6% for low (< 300 mg/L) and high (> 300 mg/L) peritoneal albumin excretion groups respectively (log rank test, p = 0.042). By Cox regression analysis, the only independent factors for event-free survival were diabetic status and peritoneal albumin excretion rate. For every 100 mg/L increase in peritoneal albumin excretion, the adjusted hazard ratio of developing a cardiovascular event was 1.83 [95% confidence interval (CI) 1.11 - 3.02, p = 0.018]. Actuarial patient survival at 36 months was 85.7% and 59.1% for low and high peritoneal albumin excretion groups respectively (log rank test, p = 0.10). After adjusting for the duration of follow-up for individual patients, the average duration of hospitalization was 9.1 +/- 16.2 and 21.7 +/- 25.7 days per year of follow-up for low and high peritoneal albumin excretion groups respectively (Mann-Whitney U test, p = 0.012)., Conclusion: Although the sample size of our present study is small and does not have adequate statistical power, we conclude that peritoneal albumin excretion may be an important predictor of cardiovascular disease. Further studies are needed to examine the role of dialysate albumin excretion as a means of cardiovascular risk stratification in PD patients.

Objective: We studied the clinical characteristics that influence the risk of dialysis-related peritonitis complication in incident Chinese patients undergoing continuous ambulatory peritoneal dialysis (CAPD)., Methods: A single center, retrospective, observational cohort study was carried out to examine the risk factors of developing a first episode of dialysis-related peritonitis., Results: Between 1995 and 2004, 246 incident CAPD patients were recruited for analysis. During the study period of 897.1 patient-years, 85 initial episodes of peritonitis were recorded. The median peritonitis-free time for diabetic subjects was significantly worse than for nondiabetic subjects (49.0 +/- 10.5 vs 82.3 +/- 12.6 months, p = 0.0019). The difference was due mainly to a higher likelihood of developing peritonitis with gram-negative organisms in patients with diabetes mellitus (p = 0.038). Low serum albumin concentration was also associated with worse peritonitis-free survival. There was a nonsignificant trend toward an increased risk for peritonitis in the group of patients with cerebrovascular disease. According to multivariate Cox proportional hazards model for the analysis of time to first peritonitis episode, the two independent risk factors were presence of diabetes mellitus and initial serum albumin concentration. In particular, diabetes mellitus was associated with a hazard ratio of 1.50 and a 95% confidence interval of 1.05 - 2.40 (p = 0.030) to develop an initial peritonitis. Lower serum albumin level at the start of CAPD was a significant predictor of peritonitis, with hazard ratio of 1.67 for every decrease of 10 g/L, and 95% confidence interval 1.08 - 2.60 (p = 0.021)., Conclusions: Our results confirm the susceptibility of diabetic CAPD and hypoalbuminemic patients to peritonitis, and highlight the role of further studies in reducing this complication.

Background: End-stage renal disease (ESRD) is epidemic worldwide. In Hong Kong, the annual incidence of ESRD has risen from 100 pmp (per million population) in 1996 to 140 pmp in 2003. SHARE (Screening for Hong Kong Asymptomatic Renal Population and Evaluation program) is a population-based screening program aimed at identifying the prevalence of unrecognized renal disease in asymptomatic individuals, allowing further evaluation and disease-modifying interventions., Methods: From November to December 2003, SHARE was conducted in several large residential communities in Hong Kong. The screening tool included a questionnaire documenting demographics and history or family history of diabetes mellitus (DM), hypertension (HT), and chronic kidney disease (CKD), together with on-site measurements of blood pressure (BP) and urine dipstick for protein, blood, and glucose., Results: There were a total of 1811 participants. One thousand two hundred and one subjects were entered into the final analysis. Among the 1201 who were apparently "healthy" (asymptomatic and without history of DM, HT, or CKD), the prevalence of positive (> or =1+) urine dipstick for protein, glucose, blood, protein or blood, any urine abnormality, and HT (BP> or =140/90) was 3.2%, 1.7%, 13.8%, 16%, 17.4%, and 8.7%, respectively. Thirty three percent of the age over 60 years old group had either hypertension or urine abnormalities, compared with 24.0% in the 41- to 60-year-old group and 9.7% in the 20- to 40-year-old group. Having a family history of diabetes or hypertension increases the risk of having urine abnormalities, while a family history of hypertension also increases the risk of high blood pressure., Conclusion: It is concluded that subclinical abnormalities in urinalysis or BP readings are prevalent across all age groups in the adult population. An effective screening program at the primary care level that identifies these subjects for further evaluation is warranted, and the public in Hong Kong should be educated toward the significance of such findings in order to have regular health check for asymptomatic renal diseases.

To determine the prevalence and vulnerability of symptoms from thiazide-induced hyponatremia, we reviewed 223 cases of symptomatic hyponatremia enrolled between January 1996 and April 2002. There was a high frequency of neurologic manifestation of thiazide-induced hyponatremia, whereas clinical dehydration was not a discernible feature. Female patients presented with lower serum sodium levels than male counterparts (114+/-8 versus 117+/-8 mmol/L, P=0.02), although the frequency of central nervous system manifestation was comparable between two gender groups. The most frequent symptoms were malaise and lethargy (49%), followed by dizzy spells (47%) and vomiting (35%). Degree of hyponatremia upon presentation predicted the development of confusion and vomiting symptoms. Serum sodium concentration < or =115 mmol/L was significantly associated with the development of confusion (odds ratio 2.6, 95% confidence interval 1.3 to 5.1, P=0.004). Our results show that symptoms from thiazide-induced hyponatremia primarily reflect osmotic water shift into brain cells rather than extracellular fluid volume depletion.

Background: Peritonitis is a serious complication of peritoneal dialysis (PD). We studied the efficacy of imipenem/cilastatin monotherapy in the treatment of PD-related peritonitis., Methods: We performed an open-label, randomized control study comparing imipenem/cilastatin monotherapy (treatment group) versus cefazolin plus ceftazidime (control group) in the treatment of PD peritonitis. The result was further compared to a historic group treated with cefazolin plus netilmycin. Outcome measures were primary response rate at day 10 and complete cure rate., Results: We enrolled 51 patients in the treatment group, 51 in the control group, and identified 96 in the historic group. The primary response rate to the assigned antibiotics was 49.0%, 51.0%, and 49.0% for the treatment, control, and historic groups, respectively (p = 0.97). The primary response rate allowing for change in antibiotic was 82.4%, 90.2%, and 82.3%, respectively, for the three groups (p = 0.41). The complete cure rate was 72.5%, 80.4%, and 82.3%, respectively (p = 0.60). Tenckhoff catheter removal was needed in 6 cases in the treatment group, 6 cases in the control group, and 13 cases in the historic group (p = 0.90)., Conclusions: We concluded that monotherapy of imipenem/cilastatin has similar efficacy compared to the two standard regimens of cefazolin plus ceftazidime or netilmycin in the treatment of PD peritonitis.

Background: We prospectively studied changes in the perception of health-related quality of life, pruritus, and degree of left ventricular hypertrophy in end-stage renal disease patients with tertiary hyperparathyroid disorder, before and 6 months after total parathyroidectomy treatment., Methods: A series of 12 consecutive patients were enrolled. Throughout the follow-up period, all subjects completed the Kidney Disease Quality of Life Short Form-36 (KDQOL SF-36) questionnaire at inclusion and after 6 months. Serial clinical and physiological parameters including uremic pruritus, blood pressure control and left ventricular hypertrophy measured by echocardiography were recorded., Results: Mean scores of the KDQOL SF-36 questionnaires were substantially higher 6 months after parathyroidectomy, with reference to physical functioning, bodily pain, role-physical, role-emotional, symptom list and burden of kidney disease. Parathyroidectomy resulted in a 22% reduction in left ventricular mass index, with significant improvement from the baseline value of 246 +/- 131 to 192 +/- 131 g/m2 (p = 0.03)., Conclusion: Our findings highlight the potential importance of parathyroidectomy in improving health-related quality of life and left ventricular hypertrophy among dialysis patients with tertiary hyperparathyroidism.