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Abstract Renal recovery following dialysis-requiring acute kidney injury (AKI-D) is a vital clinical outcome in critical care, yet it remains an understudied area. This retrospective cohort study, conducted in a medical center in Taiwan from 2015 to 2020, enrolled patients with AKI-D during intensive care unit stays. We aimed to develop and temporally test models for predicting dialysis liberation before hospital discharge using machine learning algorithms and explore early predictors. The dataset comprised 90 routinely collected variables within the first three days of dialysis initiation. Out of 1,381 patients who received acute dialysis, 27.3% experienced renal recovery. The cohort was divided into the training group (N = 1135) and temporal testing group (N = 251). The models demonstrated good performance, with an area under the receiver operating characteristic curve of 0.85 (95% CI, 0.81–0.88) and an area under the precision-recall curve of 0.69 (95% CI, 0.62–0.76) for the XGBoost model. Key predictors included urine volume, Charlson comorbidity index, vital sign derivatives (trend of respiratory rate and SpO2), and lactate levels. We successfully developed early prediction models for renal recovery by integrating early changes in vital signs and inputs/outputs, which have the potential to aid clinical decision-making in the ICU.

Abstract Background Transient progressive weakness and disability of lower limb during the early stage after TKR will increase the risk of fall, but the superior postoperative strength training mode have not been elucidated for functional restoration. This study aimed to compare whether the isokinetic lower limb training is superior to either isotonic or home isometric exercise during early stage after TKR in older people. Methods A total of 43 recruited old participants (mean age, 68.40 years old) receiving TKR were divided randomly based on the different four-week training modes into three groups including isokinetic, isotonic, and home isometric exercise (control group). The primary outcome was set as functional performance in terms of Timed Up and Go (TUG) test and the secondary outcomes include the peak torque of knee at 60 and 120 degree/ second, Short-Form 36 Health Survey (SF-36), and Western Ontario and McMaster Universities Arthritis index (WOMAC). Results All of the peak torque measurements of the knee improved significantly in both the isokinetic and the isotonic group, but not in the control group. Although isotonic training resulted in more strength gains, a significant enhancement in TUG test was observed in the isokinetic group only (p = 0.003). However, there were no significantly improvement of TUG test after training in other two groups. SF-36 and WOMAC improved after training in all three groups, with no significant difference in the degree of improvement between groups. Conclusion Isokinetic training for 4 weeks following TKR effectively improved all the outcome parameters in this study, including the TUG test, lower limb strength, and functional scores. However, both isokinetic and isotonic training modes could be recommended after TKR because of no significant difference in the degree of improvement between these two groups. Trial registration Clinical trial registration number: NCT02938416. Level of evidence I

Introduction: No markers have been used to diagnose historical peritoneal dialysis (PD)-related peritonitis. Cyclophilin A (CypA) is associated with glucose toxicity and inflammation. We hypothesize that dialysate CypA can be a marker for historical peritonitis (at least 3 months free from peritonitis). Method: An enzyme-linked immunosorbent assay kit was used to measure the concentration of dialysate CypA. Clinical and laboratory data were collected to correlate with historical peritonitis. Mann-Whitney U test and Chi-square test were used for analysis. Receiver operating characteristic (ROC) analysis was used to evaluate predictive power. Results: Out of a total of 31 patients who had undergone PD for at least 2 years, 18 had no history of PD-related peritonitis, while 13 had experienced PD-related peritonitis at least once. Overall, the patients in this population were in good health (normal white blood cell count, no anemia, normal electrolyte and serum albumin levels). There were no significant differences between patients with and without a history of peritonitis, except for blood white blood cell count (5650.6 ± 1848.4 vs. 7154.6 ± 2056.8, p = 0.032) and dialysate CypA value (24.27 ± 22.715 vs. 54.41 ± 45.63, p = 0.020). In the univariate analysis, only the dialysate CypA level showed a statistically significant association with historical peritonitis (HR = 1.030, 95 % CI = 1.010–1.062, p = 0.046). The AUC for dialysate CypA (>34.83 ng/mL) was 0.748, with a sensitivity of 0.615 and specificity of 0.833. Conclusion: PD peritonitis poses a significant threat to the long-term use of peritoneal dialysis. Based on our study, even in the absence of concurrent infection, dialysate CypA can serve as a predictive marker for historical peritonitis, demonstrating high predictive power along with fair sensitivity and good specificity.

Abstract Background Although combining a low-protein diet (LPD) with oral nutritional supplements increases treatment adherence and nutritional status in patients with chronic kidney disease (CKD), the effect of this combination approach in older adults remains unclear. This study examined the impact of a 6% low-protein formula (6% LPF) with diet counseling in older adults with stage 3–5 CKD. Methods In this three-month randomized controlled study, 66 patients (eGFR

Abstract Validation of the Oxford classification (MEST and MEST-C) for Immunoglobulin A nephropathy (IgAN) in the Taiwanese population is lacking. Our study aimed to validate this classification and assess individual lesion impact. We conducted a retrospective cohort study at Taichung Veterans General Hospital, Taiwan (Jan 2011–Jul 2023). Composite renal outcomes were evaluated using clinical conditions and estimated glomerular filtration rate (eGFR). We used Kaplan–Meier, univariable/multivariable logistic regression and ROC curves. Subgroup analysis considered eGFR

Abstract Background Hemodialysis holds the highest incidence and prevalence rate in Taiwan globally. However, the implementation of advance care planning (ACP), advance directives (AD), and patient self-determination acts (PSDA) remains limited. Our objective was to examine the current status of ACP, AD and PSDA and potential opportunities for enhancement. Methods We developed a novel questionnaire to assess individuals’ knowledge, attitudes, and intentions regarding ACP, AD, and PSDA. We also collected baseline characteristics and additional inquiries for correlation analysis to identify potential factors. Student’s t-test and Analysis of Variance were employed to assess significance. Results Initially, a cohort of 241 patients was initially considered for inclusion in this study. Subsequently, 135 patients agreed to participate in the questionnaire study, resulting in 129 valid questionnaires. Among these respondents, 76 were male (59.9%), and 53 were female (41.1%). Only 13.2% had signed AD. A significant portion (85.3%) indicated that they had not discussed their dialysis prognosis with healthcare providers. Additionally, a mere 14% engaged in conversations about life-threatening decisions. Ninety percent believed that healthcare providers had not furnished information about ACP, and only 30% had discussed such choices with their families. The findings revealed that the average standardized score for ACP and AD goals was 84.97, while the attitude towards PSDA received a standardized score of 69.94. The intention score stood at 69.52 in standardized terms. Potential candidates for ACP initiation included individuals aged 50 to 64, possessing at least a college education, being unmarried, and having no history of diabetes. Conclusion Patients undergoing hemodialysis exhibited a significant knowledge gap concerning ACP, AD, and the PSDA. Notably, a substantial number of dialytic patients had not received adequate information on these subjects. Nevertheless, they displayed a positive attitude, and a considerable proportion expressed a willingness to sign AD. It is imperative for nephrologists to take an active role in initiating ACP discussions with patients from the very beginning.

Cigarette smoking is a critical issue in caring for patients of chronic kidney disease (CKD). However, there is no routine care program designed for combining both smoking cessation and CKD care. The process of our quality improvement (QI) collaboration used data under our routine payment-for-performance for pre-end-stage renal disease (P4P Pre- ESRD) in Taichung Veterans General hospital from 2020 to 2022. We share our experience with a QI project that integrates the Ottawa model for smoking cessation (OMSC) with the Pre-ESRD care program as part of routine CKD care. The electronic health information systems were improved to reduce workload of medical staff. The number was more for both qualified CKD educators and nephrologists for smoking cessation. The access and availability for smoking cessation were immediate and convenient for patients. Specifically, all the actions were performed by CKD educators, with nephrologists overseeing the process in routine care. By combining OMSC with the Pre-ESRD program, we were able to provide smokers with satisfactory access and availability to smoking cessation services within our healthcare facility. The smoker cases found were more in number (206 in 2020, 344 in 2021, and 421 in 2022). Before the integrated OSTC-Pre-ESRD program (in 2020), the proportion of smokers was 3.88%. After implementing the integrated program, smokers increased significantly on a yearly basis (9.69% in 2021 and 9.82% in 2022). Finally, case numbers of on-site smoking cessations increased significantly after implementing the integrated system (0 in 2020, 17 in 2021, and 20 in 2022). All CKD patients for smoking cessation were also more (8 in 2020, 46 in 2021, and 38 in 2022). After implementing the QI program, focusing on the integrated OMSC-Pre- ESRD program, we found more smokers undergoing smoking cessation. This QI program highlighted the importance of better access and availability for smoking cessation.

Background: There is still no consensus about the coronavirus disease 2019 (COVID-19) vaccine-associated glomerular disease (CVAGD). Given the large number of vaccinations administered and the variations in glomerulopathy observed across different countries and regional environments, CVAGD remains an important area of concern. Aim of study: We aimed to elucidate the findings of CVAGD within a Taiwanese cohort using biopsy data. Additionally, we endeavored to clarify the presentation of CVAGD. Methods: We collected data from patients who underwent renal biopsy from June 2021 to October 2022 at Taichung Veterans General Hospital. Two independent nephrologists meticulously reviewed the charts to exclude cases unrelated to vaccination. Results: Initially, a total of 286 patients underwent renal biopsy at our institute. Ultimately, we identified 14 patients with highly suspected CVAGD. All 14 patients exhibited proteinuria and hematuria. The urinary protein-to-creatinine ratio was elevated (median of 2012.1 mg/g; interquartile range (IQR) 25%–IQR 75%: 941.85–3884.1 mg/g) with a median serum creatinine level of 1.71 mg/dL (0.79–5.35). The majority of CVAGD cases were diagnosed as immunoglobulin A (IgA) nephropathy (n = 5, 35.7%), followed by antineutrophil cytoplasmic antibody (ANCA)-related rapidly progressive glomerulonephritis (RPGN) (n = 4, 28.6%). There were only three cases of minimal change disease each: one case of focal segmental glomerulosclerosis, one of membranous glomerulonephritis, and one of lupus nephritis. The culprit of COVID-19 vaccinations was 35.7% (n = 5) of Oxford-AstraZeneca (ChAdOx1-S), 42.9% (n = 6) of Moderna, and 21.4% (n = 3) of BNT162b2. Most patients experienced improvements in renal function. Only two cases of P-ANCA RPGN and one case of IgA nephropathy did not recover. Eighty percent of IgA nephropathy cases had favorable outcomes, but none of the patients with P-ANCA RPGN achieved full recovery. Conclusions: IgA nephropathy and ANCA-related RPGN were the most common CVAGD, and all types of COVID-19 vaccines posed a risk for CVAGD. However, further studies are required to confirm causality.

Background: Heart failure with reduced ejection fraction (HFrEF) poses significant health risks. Midodrine for maintaining blood pressure in HFrEF, requires further safety investigation. This study explores midodrine’s safety in HFrEF through extensive matched analysis.Methods: Patients with HFrEF (LVEF

Background: Admission for renal biopsy is considered the gold standard for diagnosing kidney disease. However, prolonged waiting times for admission can lead to delayed diagnosis. Despite this issue, there are currently no studies demonstrating how to improve the efficiency of renal biopsy procedures. Methods: We initiated a quality improvement project to implement pre-admission testing (PAT) for renal biopsy from 2016 to 2024 (until 15 April). Our evaluation focused on waiting times for admission, length of admission periods, hospitalization expenses, percentage of cases with no renal biopsy performed, incidence of severe bleeding due to renal biopsy, and percentage of cases with adequate tissue samples obtained. Additionally, we highlighted the time periods during the outbreak of SARS-CoV-2. Results: The highest annual case number was observed in time period 1 (168.3/year). Following the outbreak of SARS-CoV-2, there was a notable decrease in case numbers during time period 2 (119.8), which then increased to 143.0 in time period 3 (post-SARS-CoV-2 era). The mean waiting time was 13.72 ± 40.30 days for time period 1 and 10.00 ± 47.80 days for time period 2, without statistical significance. Following the implementation of PAT, patients now only need to wait approximately 0.76 days for admission, representing a significant reduction in waiting time. Subsequently, following the implementation of PAT, the waiting time decreased significantly to 2.09 ± 2.65 days. Additionally, hospitalization expenses per patient significantly decreased from approximately USD 69.62 ± 97.09 to USD 41.66 ± 52.82. The percentage of missed biopsy is significantly low (p < 0.001). Severe bleeding events (indicated as embolization and blood transfusion) were consistent across the three time periods (p = 0.617). Conclusions: The implementation of PAT can improve the pre-admission process for renal biopsy, resulting in decreased waiting times, fewer missed appointments, shorter admission durations, and reduced hospitalization expenses. We propose implementing PAT for outpatient individuals awaiting in-hospital renal biopsy procedures to mitigate delayed diagnosis, reduce pre-admission waiting periods, and streamline admission processes, thereby enhancing overall patient care efficiency.

Summary: Background: This study aimed to evaluate the renal safety and effectiveness of COVID-19 vaccination in patients with immunoglobulin A nephropathy (IgAN). Methods: We conducted a global and retrospective collaborative network analysis using TriNetX data from September 11, 2018 to September 11, 2023, to address this question. The study recorded diagnoses of IgAN, COVID-19 vaccinations, and outcomes of effectiveness using International Classification of Diseases, Tenth Revision, Clinical Modification codes and procedure codes. Propensity score matching (PSM) created matched groups (1:1). Hazard ratios (HR) with 95% confidence intervals (95% CI) were calculated for outcomes of effectiveness, and Kaplan–Meier method assessed survival probability. Safety outcomes regarding renal function were compared with estimated glomerular filtration rate (eGFR), proteinuria, and hematuria. Subgroup analyses were based on sex and age group. Sensitivity analysis was done before the outbreak of Omicron (from September 11, 2018 to October 31, 2021). Findings: The study involved 1010 vaccinated and 2776 unvaccinated patients with IgAN without COVID-19 infection at baseline. After PSM (1:1) with 25 variables, both groups consisted of well-matched 979 patients who were relatively young (around 55 years old) and in good health (eGFR: 78–80 ml/min/1.732 m2). Compared to the non-vaccinated group, vaccinated patients had significantly lower risks of COVID-19 infection and complications, including COVID-19 infection (HR: 0.050, 95% CI: 0.026, 0.093), COVID-19 pneumonia (HR: 0), severe lung complication (0.647, 95% CI: 0.421, 0.994), acute respiratory failure (0.625, 95% CI: 0.400, 0.978), sepsis (0.545, 95% CI: 0.334, 0.890), emergency department visits (0.716, 95% CI: 0.615, 0.833), all hospitalizations (0.573, 95% CI: 0.459, 0.715), and mortality (0.595, 95% CI: 0.366, 0.969). However, one month after the follow-up, the vaccinated group exhibited a slightly, but statistically significantly, lower eGFR compared to the non-vaccinated group (73.58 vs. 83.05 ml/min/1.732 m2, p = 0.047). Nine months after the follow-up, the difference in eGFR between the two groups disappeared. The lower risk of COVID-19 infection was observed across genders (male and female) and age groups (young and old). For the period before Omicron outbreak, results were also similar. Interpretation: In the largest TriNetX matched cohort study of IgAN, COVID-19 vaccination was associated with a reduced risk of COVID-19 infection and associated complications. However, careful monitoring of renal function, especially GFR, is advisable. Funding: This study was supported by grant TCVGH-1103602C, TCVGH-1103601D, and TCVGH-1113602D from Taichung Veterans General Hospital.

Abstract Background This study was to explore the effects of Gan-Lu-Yin (GLY) on the migration of vascular smooth muscle cells (VSMCs) induced by fetal bovine serum and on neointima formation in a rat model of carotid artery balloon injury. Methods VSMCs were treated with different concentrations of GLY, and then analyzed with Flow cytometric analysis, zymography, transwell, and western blotting. SD rats received balloon-injury were analyzed with H&E staining. Results Our results showed that GLY significantly decreased the thickness of neointima. The inhibition by non-cytoxic doses of GLY of VSMCs migration was through its negative regulatory effects on phosphorylated ERK1/2, PI3K/AKT, and FAK. The data showed that GLY can inhibit the migration of VSMCs cells, and might block injury-induced neointima hyperplasia via the inhibition of VSMCs migration, without inducing apoptosis. Conclusions These observations provide a mechanism of GLY in attenuating cell migration, thus as a potential intervention for restenosis.

Abstract Background Although a relationship between chronic obstructive pulmonary disease (COPD) and dementia has been reported, the initial severity upon emergency department (ED) visits and the medications used have not been well evaluated as risk factors for increased dementia occurrence. We aimed to analyze the risks of dementia development over 5 years among patients with COPD compared to matched controls (primary) and the impact of different severities of acute exacerbations (AEs) of COPD and medications on the risk of dementia development among COPD patients (secondary). Method This study used the Taiwanese government deidentified health care database. We enrolled patients during the 10-year study period (January 1, 2000, to December 31, 2010), and each patient was followed up for 5 years. Once these patients received a diagnosis of dementia or died, they were no longer followed up. The study group included 51,318 patients who were diagnosed with COPD and 51,318 matched (in terms of age, sex, and the number of hospital visits) non-COPD patients from the remaining patients as the control group. Each patient was followed up for 5 years to analyze the risk of dementia with Cox regression analysis. Data on medications (antibiotics, bronchodilators, corticosteroids) and severity at the initial ED visit (ED treatment only, hospital admission, or ICU admission) were collected for both groups, as well as demographics and baseline comorbidities, which were considered confounding factors. Results In the study and control groups, 1,025 (2.0%) and 423 (0.8%) patients suffered from dementia, respectively. The unadjusted HR for dementia was 2.51 (95% CI: 2.24–2.81) in the study group. Bronchodilator treatment was associated with the HRs, especially among those who received long-term (> 1 month) treatment (HR = 2.10, 95% CI: 1.91–2.45). Furthermore, among 3,451 AE of COPD patients who initially visited the ED, patients who required ICU admission (n = 164, 4.7%) had a higher risk of dementia occurrence (HR = 11.05, 95% CI: 7.77–15.71). Conclusion Bronchodilator administration might be associated with a decreased risk of dementia development. More importantly, patients who suffered AEs of COPD and initially visited the ED and required ICU admission had a higher risk of developing dementia.

IntroductionLiterature is limited on quantified acute stress reaction, the impact of event scale on medical staff when facing medical malpractice (MMP), and how to individually care for staff.MethodsWe analyzed data in the Taichung Veterans General Hospital from October 2015 to December 2017, using the Stanford Acute Stress Reaction Questionnaire (SASRQ), the Impact of Event Scale-Revised (IES-R), and the medical malpractice stress syndrome (MMSS).Results and DiscussionOf all 98 participants, most (78.8%) were women. Most MMPs (74.5%) did not involve injury to patients, and most staff (85.7%) indicated receiving help from the hospital. The internal-consistency evaluations of the three questionnaires showed good validity and reliability. The highest score of IES-R was the construct of intrusion (30.1); the most severe construct of SASRQ was “Marked symptoms of anxiety or increased arousal,” and the most were having mental and mild physical symptoms for MMES. A higher total IES-R was associated with younger age (

Hepatic events can occur after discontinuing antiviral therapy. We investigated factors associated with hepatitis flares and hepatic decompensation after discontinuing tenofovir disoproxil fumarate (TDF) and entecavir (ETV). Hepatitis flares within 6 months and hepatic decompensation were compared between non-cirrhotic hepatitis B e antigen-negative patients after discontinuing TDF or ETV by using the Cox proportional hazard model. The cumulative rates of hepatitis flare at 6 months after discontinuing ETV and TDF were 2% and 19%, respectively (p < 0.001). The respective rates of hepatic decompensation at 6 months were 0% and 7% (p = 0.009). Higher alanine aminotransferase (ALT) (AASLD criteria) at the end of treatment (EOT) (HR = 4.93; p = 0.001), an off-therapy dynamic change in HBV DNA (rapid rebound of HBV DNA from the nadir, ≥1 log10 IU/mL per month) (HR = 10.7; p < 0.001), and the discontinuation of TDF (HR = 6.44; p = 0.006) were independently associated with hepatitis flares within 6 months. Older age (HR = 1.06; p < 0.001) and an off-therapy dynamic change in HBV DNA (HR = 3.26; p = 0.028) were independently associated with hepatic decompensation after the discontinuation of antiviral therapy. In summary, we demonstrated several factors associated with hepatitis flares and hepatic decompensation after discontinuing antiviral therapy in non-cirrhotic hepatitis B e antigen-negative patients.

The demand for highly sensitive and selective gas sensors has been steadily increasing, driven by applications in various fields such as environmental monitoring, healthcare, and industrial safety. In this context, ternary alloy indium aluminum nitride (InAlN) semiconductors have emerged as a promising material for gas sensing due to their unique properties and tunable material characteristics. This work focuses on the fabrication and characterization of InAlN nanorods grown on sapphire substrates using an ultra-high vacuum magnetron sputter epitaxy with precise control over indium composition and explores their potential for acetone-gas-sensing applications. Various characterization techniques, including XRD, SEM, and TEM, demonstrate the structural and morphological insights of InAlN nanorods, making them suitable for gas-sensing applications. To evaluate the gas-sensing performance of the InAlN nanorods, acetone was chosen as a target analyte due to its relevance in medical diagnostics and industrial processes. The results reveal that the InAlN nanorods exhibit a remarkable sensor response of 2.33% at 600 ppm acetone gas concentration at an operating temperature of 350 °C, with a rapid response time of 18 s. Their high sensor response and rapid response make InAlN a viable candidate for use in medical diagnostics, industrial safety, and environmental monitoring.

Background: We aimed to validate the Japanese histological grading classification (JHGC) in our population of IgA immunoglobulin (IgAN) cases. Methods: We conducted a retrospective cohort study at Taichung Veterans General Hospital in Taiwan from January 2011 to December 2023. The process involved assessing JHGC’s clinical, histological, and merged grading system. Composite renal outcomes based on glomerular filtrate rate (eGFR) were considered. Results: The study included 359 IgAN by renal biopsies. Kidney function at the time of biopsy was suboptimal, with average SCr of 1.3 mg/dL, eGFR of 54.0 mL/min/1.732 m2, and urine protein–creatinine ratio (UPCR) of 1.2 mg/mg. JHGC effectively identified different severity levels of histological and clinical aspects in Taiwanese IgAN. Initial 4-histological classification showed significantly higher MEST-C scores (p < 0.001). Merging grade III and IV was reasonable in Japanese and Taiwanese populations. The clinical grading system (3C) was associated with histological status and proteinuria, but there was no significant trend with SCr, eGFR, and blood urea nitrogen. Significant differences were found among the three groups (log-rank p < 0.01), but C-grade I and II lacked significant difference in long-term renal outcomes. We separated UPCR < 0.5 mg/mg into two groups: eGFR≥ and 2. The new grading system effectively differentiated risk factors for renal outcomes (log-rank p < 0.01), suggesting the need for separation in Taiwanese IgAN. Conclusions: Our study externally validated JHGC in non-Japanese IgAN. Despite applicability to our population, we recommend a new classification specifically for Taiwanese IgAN patients with increased case numbers in eGFR ≥ 60 mL/min/1.732 m2 and UPCR < 0.5 g/day group.

High-energy, low-protein formulas (HE-LPFs) are commonly used as oral nutritional supplements (ONSs) to help provide extra calories to patients who are adhering to a low-protein diet (LPD) after diagnosis with chronic kidney disease (CKD). This randomized controlled trial aimed to evaluate the efficacy and safety of an HE-LPF as either a partial or a total replacement for one meal in pre-dialysis CKD patients. Stage 4–5 CKD patients received either a once-daily HE-LPF (HE-LPF group) or normal food (control group) for a period of 4 weeks while following an LPD. Overall, 73 patients who completed the study were included in the intention-to-treat population. After analyzing the 3-day food records, the HE-LPF group experienced a significant decrease in the percentage of energy derived from protein (p < 0.05) and an increase in the percentage of energy derived from fat (p < 0.05) compared to the control group. The two groups had no significant differences in body weight, body composition, grip strength, renal function, electrolytes, or metabolic markers. The HE-LPF group had a high adherence (94.9% at week 4), and no adverse effects were observed. HE-LPFs are safe to employ as meal replacements for pre-dialysis CKD patients adhering to an LPD.

Abstract Introduction Hyperuricemia and diabetes mellitus (DM) are associated with increased mortality risk in patients with chronic kidney disease (CKD). Here we aimed to evaluate the independent and joint risks of these two conditions on mortality and end stage kidney disease (ESKD) in CKD-patients. Methods This retrospective cohort study enrolled 4380 outpatients (with CKD stage 3–5) with mortality and ESKD linkage during a 7-year period (from 2007 to 2013). All-causes mortality and ESKD risks were analyzed by multivariable-adjusted Cox proportional hazards models (adjusted for age, sex, smoke, previous coronary arterial disease, blood pressure, and medications for hyperlipidemia, hyperuricemia and renin–angiotensin system inhibitors). Results Overall, 40.5% of participants had DM and 66.4% had hyperuricemia. In total, 356 deaths and 932 ESKD events occurred during the 7 years follow-up. With the multivariate analysis, increased risks for all-cause mortality were: hyperuricemia alone, HR = 1.48 (1–2.19); DM alone, and HR = 1.52 (1.02–2.46); DM and hyperuricemia together, HR = 2.12 (1.41–3.19). Similar risks for ESKD were: hyperuricemia alone, HR = 1.34 (1.03–1.73); DM alone, HR = 1.59 (1.15–2.2); DM and hyperuricemia together, HR = 2.46 (1.87–3.22). Conclusions DM and hyperuricemia are strongly associated with higher all-cause mortality and ESKD risk in patients with CKD stage 3–5. Hyperuricemia is similar to DM in terms of risk for all-cause mortality and ESKD. DM and hyperuricemia when occurred together further increase both risks of all-cause mortality and ESKD.

Compared with fully face-to-face or online learning environments, implementation of hybrid learning spaces is costly given the spaces making all learning options available for learners. Therefore, decisions on investments in hybrid learning are critical for institutions. Satisfaction and experience of learners is one of the important indicators for assessing the cost-effectiveness of learning space implementation; thus, predictions of learners' satisfaction and experience can inform institutions' decision making on learning space investments. Moreover, learning competences are found correlated with learners' satisfaction and experience in general and e-learning settings. Therefore, the present study aimed at exploring predictive learning competences for hybrid learners' experience and satisfaction. A hybrid learning space was built upon a proposed model at Shanghai Open University. 211 students' learning competences and their satisfaction and experience in the hybrid learning space were examined. The results showed that except cognitive engagement competence, most predictive competences were not significantly associated with hybrid learners' satisfaction and experience. The findings indicated that since hybrid learning keeps all options available, to experience satisfying learning, students need not have certain competences but cognitive engagement competence, which is correlated with learners' cognitive ability to figure out the right mix of learning options.

Abstract Objective Experimental studies of head-up positioning (HUP) during cardiopulmonary resuscitation (CPR) have had some degree of conflicting published results. The current study aim was to analyze and reconcile those discrepancies in order to better clarify the effects of HUP CPR compared to conventional supine (SUP) CPR. Methods Three databases (PubMed, EMBASE and Cochrane Library) were searched comprehensively (from each respective database's inception to May 2021) for articles addressing HUP CPR. The primary outcome to be observed was cerebral perfusion pressure (CerPP), and secondary outcomes were mean intracranial pressure (ICP), mean arterial pressure (MAP), coronary perfusion pressure (CoPP) and frequencies of return of spontaneous circulation (ROSC). Results Seven key studies involving 131 animals were included for analysis. Compared to SUP CPR, CerPP (MD 10.37; 95% CI 7.11–13.64; p

Abstract We analyzed database from the Taiwan National Health Insurance to investigate whether primary aldosteronism (PA) increases the risk of bladder stones. This retrospective nationwide population-based cohort study during the period of 1998–2011 compared patients with and without PA extracted by propensity score matching. Cox proportional hazard models and competing death risk model were used to estimate the hazard ratios (HRs), sub-hazard ratios (SHRs) and corresponding 95% confidence intervals (CIs). There were 3442 patients with PA and 3442 patients without PA. The incidence rate of bladder stones was 5.36 and 3.76 per 1000 person-years for both groups, respectively. In adjusted Cox hazard proportional regression models, the HR of bladder stones was 1.68 (95% CI 1.20–2.34) for patients with PA compared to individuals without PA. Considering the competing risk of death, the SHR of bladder stones still indicates a higher risk for PA than a comparison cohort (SHR, 1.79; 95% CI 1.30–2.44). PA, age, sex, and fracture number were the variables significantly contributing to the formation of bladder stones. In conclusion, PA is significantly associated with risk of bladder stones.

BackgroundFor patients with Acute Kidney Injury (AKI), a strong and graded relationship exists between AKI severity and mortality. One of the most severe entities of AKI is Dialysis-Requiring Acute Kidney Injury (D-AKI), which is associated with high rates of mortality and end-stage renal disease (ESRD). For this high-risk population group, there is a lack of evidence regarding optimal post-AKI care. We propose that post-AKI care through the combined efforts of the nephrologist and the multidisciplinary care team may improve outcomes. Our aim here is to study for survivors of dialysis-requiring acute kidney injury, the effects of implementing early comprehensive kidney care.MethodsThis is a retrospective longitudinal cohort study of Taiwanese through analyzing the National Health Insurance Research Database (NHIRD). We included patients with acute dialysis during hospitalization from January 1, 2015 to December 31, 2018. Propensity match was done at 1:1, including estimated glomerular filtration rate (eGFR) based on CKD-EPI which was performed due to large initial disparities between these two cohorts.ResultsAfter the propensity match, each cohort had 4,988 patients. The mean eGFR based on CKD-EPI was 27.5 ml/min/1.73 m2, and the mean follow-up period was 1.4 years.The hazard ratio for chronic dialysis or ESRD was 0.55 (95% CI, 0.49–0.62; p < 0.001). The hazard ratio for all-cause mortality was 0.79 (95% CI, 0.57–0.88; p < 0.001). Both outcomes favored early comprehensive kidney care.ConclusionsFor survivors of dialysis-requiring acute kidney injury, early comprehensive kidney care significantly lowered risks of chronic dialysis and all-cause mortality.

The incidence of hypocalcemia is high in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) undergoing denosumab treatment. Since 2018, we have carried out a “multidisciplinary integrated care program for osteoporosis among patients with CKD and ESRD” in our hospital. The aim of this study was to compare the incidence of denosumab-associated hypocalcemia among patients with advanced CKD and ESRD before and after the integrated care program. We retrospectively reviewed the records of patients on their first dose of denosumab treatment from January 2012 to December 2021. A total of 3208 patients were included in our study. Among the 3208 patients, there were 101 dialysis patients, 150 patients with advanced CKD (stage 4 and 5), and 2957 patients with an estimated glomerular filtration rate (eGFR) higher than or equal to 30. The incidence of post-treatment severe hypocalcemia (corrected calcium level less than 7.0 mg/dl) within 30 days was significantly higher in the dialysis and advanced CKD group than in patients with an eGFR higher than or equal to 30 (6.9% vs. 2.0% vs. 0.1%, respectively, p < 0.001). Based on the results of the multivariate regression model, poor renal function (p < 0.05) and lower baseline corrected calcium level (p < 0.05) were associated with severe hypocalcemia within 30 days following the first dose of denosumab treatment. The incidence of post-treatment severe hypocalcemia within 30 days in advanced CKD and dialysis patients was significantly lower after the integrated care program (6.8% vs. 0.8%, p < 0.05). Our study shows that multidisciplinary integrated care may reduce the incidence rate of denosumab-associated severe hypocalcemia among patients with advanced CKD and ESRD.

IntroductionEarly fluid balance has been found to affect short-term mortality in critically ill patients; however, there is little knowledge regarding the association between early cumulative fluid balance (CFB) and long-term mortality. This study aims to determine the distinct association between CFB day 1–3 (CFB 1–3) and day 4–7 (CFB 4–7) and long-term mortality in critically ill patients.Patients and MethodsThis study was conducted at Taichung Veterans General Hospital, a tertiary care referral center in central Taiwan, by linking the hospital critical care data warehouse 2015–2019 and death registry data of the Taiwanese National Health Research Database. The patients followed up until deceased or the end of the study on 31 December 2019. We use the log-rank test to examine the association between CFB 1–3 and CFB 4–7 with long-term mortality and multivariable Cox regression to identify independent predictors during index admission for long-term mortality in critically ill patients.ResultsA total of 4,610 patients were evaluated. The mean age was 66.4 ± 16.4 years, where 63.8% were men. In patients without shock, a positive CFB 4–7, but not CFB 1–3, was associated with 1-year mortality, while a positive CFB 1–3 and CFB 4–7 had a consistent and excess hazard of 1-year mortality among critically ill patients with shock. The multivariate Cox proportional hazard regression model identified that CFB 1–3 and CFB 4–7 (with per 1-liter increment, HR: 1.047 and 1.094; 95% CI 1.037–1.058 and 1.080–1.108, respectively) were independently associated with high long-term mortality in critically ill patients after adjustment of relevant covariates, including disease severity and the presence of shock.ConclusionsWe found that the fluid balance in the first week, especially on days 4–7, appears to be an early predictor for long-term mortality in critically ill patients. More studies are needed to validate our findings and elucidate underlying mechanisms.

Background: Renal transplantation (RTX) is the treatment of choice for end-stage kidney disease (ESKD). Taiwan has the highest incidence and prevalence of ESKD in this world. This is the first study to illustrate the national registry database of RTX. Methods: All patients who received RTX in Taiwan between 2010 and 2018 were enrolled in this study. Demographic data and comorbidities were obtained from the National Health Insurance Research Database and Transplantation Society of Taiwan. Graft and patient survival rates were also analyzed. Results: Men were more likely to receive RTX. During the observation periods, > 30% of the recipients were relatively young (20–44 years). The percentage of preemptive RTX (p = 0.014) and living RTX (p = 0.022) increased annually with statistical significance (linear regression model). Recently, recipients had more cardiovascular disease (p = 0.014), diabetes mellitus (p = 0.097), and hypertension (p = 0.021). The mean duration of graft survival increased yearly (p = 0.001). The proportion of patients surviving till age of ≧65 years increased significantly with time (2.2% in 2010, 33.1% in 2018) (p

Abstract Background Chronic active antibody-mediated rejection is a major etiology of graft loss in renal transplant recipients. However, there is no consensus on the optimal treatment strategies. Methods Computerized records from Taichung Veterans General Hospital were collected to identify renal transplant biopsies performed in the past 7 years with a diagnosis of chronic active antibody-mediated rejection. The patients were divided into two groups according to treatment strategy: Group 1 received aggressive treatment (double filtration plasmapheresis and one of the followings: rituximab, intravenous immunoglobulin, antithymogycte globulin, bortezomib, or methylprednisolone pulse therapy); and group 2 received supportive treatment. Results From February 2009 to December 2017, a total of 82 patients with biopsy-proven chronic antibody mediated rejection were identified. Kaplan-Meier analysis of death-censored graft survival showed a worse survival in group 2 (P = 0.015 by log-rank test). Adverse event-free survival was lower in group 1, whereas patient survival was not significantly different. Proteinuria and supportive treatment were independent risk factors for graft loss in multivariate analysis. Conclusions Aggressive treatment was associated with better graft outcome. However, higher incidence of adverse events merit personalized treatment, especially for those with higher risk of infection. Appropriate prophylactic antibiotics are recommended for patients undergoing aggressive treatment.

In recent studies, much has been discussed about biomarkers used in the evaluation of the transplanted graft function. However, there remains a lack of research regarding the long-term effects of microRNAs (miRNAs) on the different genders for kidney transplant (KTx) patients. In this study, we aim to assess the functions of miRNAs on long term outcomes of KTx patients by extracting differently expressed miRNAs between patients of normal graft function and graft dysfunction, while further analyzing their impact on the different genders. We analyzed the data of 40 patients who had received KTx for a period of more than ten years and included data regarding renal function, immuno-related markers and plasma miRNAs. Data were classified by gender for further studies. Twelve out of 17 females and 8 out of 23 males had undergone graft dysfunction. Renal function analysis showed significantly worse outcomes in the female patients. There were five differently expressed miRNAs between the female control group and female dysfunction group: miR-128-3p, miR-21-5p, miR-150-5p, miR-92a-3p and miR-15a-5p, and five between the male control group and male dysfunction group: miR-23a-3p, miR-126-3p, miR-142-3p, miR-223-3p and miR-26a-5p. Gender differences exist in incidences of kidney graft dysfunction, with male patients displaying better preservation in graft functions. Overall, these differently expressed miRNAs either enhance or suppress host immune responses. They can be predictive markers for graft survival and can also be important factors that lead to worse long term kidney graft function in females when compared to males.

We fabricated a gas sensor with a wide-bandgap ZnGa2O4 (ZGO) epilayer grown on a sapphire substrate by metalorganic chemical vapor deposition. The ZGO presented (111), (222) and (333) phases demonstrated by an X-ray diffraction system. The related material characteristics were also measured by scanning electron microscopy, transmission electron microscopy and X-ray photoelectron spectroscopy. This ZGO gas sensor was used to detect nitric oxide (NO) in the parts-per-billion range. In this study, the structure effect on the response of the NO gas sensor was studied by altering the sensor dimensions. Two approaches were adopted to prove the dimension effect on the sensing mechanism. In the first approach, the sensing area of the sensors was kept constant while both channel length (L) and width (W) were varied with designed dimensions (L × W) of 60 × 200, 80 × 150, and 120 ×100 μm2. In the second, the dimensions of the sensing area were altered (60, 40, and 20 μm) with W kept constant. The performance of the sensors was studied with varying gas concentrations in the range of 500 ppb~10 ppm. The sensor with dimensions of 20 × 200 μm2 exhibited a high response of 11.647 in 10 ppm, and 1.05 in 10 ppb for NO gas. The sensor with a longer width and shorter channel length exhibited the best response. The sensing mechanism was provided to explain the above phenomena. Furthermore, the reaction between NO and the sensor surface was simulated by O exposure of the ZGO surface in air and calculated by first principles.

Chronic allograft dysfunction (CAD) is a major condition affecting long-term kidney graft survival. Serum microRNA (miRNA) has been reported as a biomarker for various conditions of allograft injuries. The upregulation of miR-21 is the best-known miRNA change in graft tissue, urine and plasma. However, the correlation of plasma miR-21 with the severity of CAD remains unclear. In our study, 40 kidney transplantation recipients with late graft survival for more than 10 years were enrolled. The CAD group (n = 20) had either an eGFR between 15 to 60 mL/min or a biopsy-proved chronic allograft nephropathy or rejection. The control group (n = 20) had an eGFR ≥ 60 mL/min without proteinuria and hematuria for a consecutive 3 months before the study. We performed RNA sequencing to profile the miRNAs expression. There were six differentially expressed miRNAs in the CAD group. Among them, miR-21-5p and miR-101-3p were decreased, and miR-20a-5p was increased. We found that miR-21-5p, miR-20a-5p and miR-101-3p all participated in the TGF-beta pathway. We demonstrated that decreased miR-21-5p and miR-101-3p, and increased miR-20a-5p were the novel CAD-associated miRNAs in the TGF-beta pathway. These findings may pave the way for developing early prediction miRNAs biomarkers for CAD, and possibly developing therapeutic tools in the field of kidney transplantation.

Background: Exercise training has positive effects on physical functions and could reduce a sedentary lifestyle for hemodialysis (HD) patients. Given that low-level physical activity increases morbidity and mortality, here, we aimed to determine the effects of an intradialytic exercise program delivered at different frequencies on HD patients in Taiwan. Methods: This study is a prospective, randomized control trial. An intradialytic exercise program will be arranged for patients after receiving their informed consent. Patients will be segregated at random into three groups as follows: (a) three times/week of intradialytic exercise training plus standard care maintenance of HD, (b) two times/week of intradialytic exercise training plus standard care maintenance of HD, or (c) standard care maintenance of HD. Subjects will be followed for 24 weeks. At three time points, 0, 12, and 24 weeks, the primary outcome, the Short-Form 36 score, will be measured. Additional secondary outcomes to be measured are the Beck depression inventory, 6 min walking test, sit-to-stand test, and anthropometric measures such as the body mass index, thigh circumference, and the proportion of fat in the body composition. Conclusions: There is emerging evidence in support of intradialytic exercise improving health-related quality of life for patients on HD. However, the difference in the therapeutic effects between three times per week and twice per week has never been determined. With this study, we anticipate to fill the knowledge gap in the exercise prescription among HD patients.

Diabetic nephropathy (DN) is the main cause of end-stage kidney disease (ESKD). DN-related ESKD has the worst prognosis for survival compared with other causes. Due to the complex mechanisms of DN and the heterogeneous presentations, unmet needs exist for the renal outcome of diabetes mellitus. Clinical evidence for treating DN is rather solid. For example, the first Kidney Disease: Improving Global Outcomes (KDIGO) guideline was published in October 2020: KDIGO Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease. In December of 2020, the International Society of Nephrology published 60 (+1) breakthrough discoveries in nephrology. Among these breakthroughs, four important ones after 1980 were recognized, including glomerular hyperfiltration theory, renal protection by renin-angiotensin system inhibition, hypoxia-inducible factor, and sodium-glucose cotransporter 2 inhibitors. Here, we present a review on the pivotal and new mechanisms of DN from the implications of clinical studies and medications.

Rhabdomyolysis is diagnosed based on the levels of blood biomarkers such as creatine kinase (CK), but the use of CK levels to predict long-term renal function remains controversial. This current report presents a case with a very high CK level with the presentation of acute kidney injury (AKI) who regained full renal function. A 29-year-old man, in a manic mood and presenting with dyspnoea, was admitted to hospital following an episode of ketamine use along with a history of drug abuse. The laboratory analyses identified rhabdomyolysis (CK, 35 266 U/l) and AKI (serum creatinine, 3.96 mg/dl). Despite treatment with intravenous normal saline (4000 ml/day), his CK level reached at least 300 000 U/l. He underwent 13 sessions of haemodialysis and his renal function fully recovered. The final measurements were serum creatinine 1.0 mg/dl and CK 212 U/l. These findings support the view that the predictive power of CK level on AKI is limited, especially regarding long-term renal function. Close follow-up examinations of renal function after haemodialysis are mandatory for patients with rhabdomyolysis.

Background and objectivesImmunoglobulin A Nephropathy (IgAN) is the most common type of glomerulonephritis with variable renal outcome. The association between IgAN and patient survival is limited. The effect of crescents on patient survival was never studied.MaterialsWe conducted a retrospective cohort study between January 2003 and December 2013. All patients with the biopsy-proved IgAN was enrolled for the analysis of patient survival and renal survival. Cox regression model was used analyze the associated factors for patient survival.ResultsAll 388 participants with IgAN were enrolled, in which 45 patients with crescents. The mean percentage of glomeruli involvement was 23±18.9%. After long-term follow-up, crescents group had both worse renal (p = 0.034) and patient survivals (p = 0.016). In univariate Cox regression model, the age (HR = 1.08, 95% CI = 1.05-1.12, pConclusionsThe major strengths of the present study is that crescents IgAN had worse patient survival compared to non-crescents IgAN. Clinicians should be more careful to care patients with crescents IgAN.

Vascular Access (VA) is often referred to as the “Achilles heel” for a Hemodialysis (HD)-dependent patient. Both the patent and sufficient VA provide adequacy for performing dialysis and reducing dialysis-related complications, while on the contrary, insufficient VA is the main reason for recurrent hospitalizations, high morbidity, and high mortality in HD patients. A non-invasive Vascular Wall Motion (VWM) monitoring system, made up of a pulse radar sensor and Support Vector Machine (SVM) classification algorithm, has been developed to detect access flow dysfunction in Arteriovenous Fistula (AVF). The harmonic ratios derived from the Fast Fourier Transform (FFT) spectrum-based signal processing technique were employed as the input features for the SVM classifier. The result of a pilot clinical trial showed that a more accurate prediction of AVF flow dysfunction could be achieved by the VWM monitor as compared with the Ultrasound Dilution (UD) flow monitor. Receiver Operating Characteristic (ROC) curve analysis showed that the SVM classification algorithm achieved a detection specificity of 100% at detection thresholds in the range from 500 to 750 mL/min and a maximum sensitivity of 95.2% at a detection threshold of 750 mL/min.

Acute kidney injury (AKI) refers to rapid decline of kidney function and is manifested by decreasing urine output or abnormal blood test (elevated serum creatinine). Electronic health records (EHRs) is fundamental for clinicians and machine learning algorithms to predict the clinical outcome of patients in the Intensive Care Unit (ICU). Early prediction of AKI could automatically warn the clinicians to review the possible risk factors and act in advance to prevent it. However, the enormous amount of patient data usually consists of a relatively incomplete data set and is very challenging for supervised machine learning process. In this paper, we propose an entropy-based feature engineering framework for vital signs based on their frequency of records. In particular, we address the missing at random (MAR) and missing not at random (MNAR) types of missing data according to different clinical scenarios. Regarding its applicability, we applied it to establish a prediction model for future AKI in ICU patients using 4278 ICU admissions from a tertiary hospital. Our result shows that the proposed entropy-based features are feasible to be used in the AKI prediction model and its performance improves as the data availability increases. In addition, we study the performance of AKI prediction model by comparing different time gaps and feature windows with the proposed vital sign entropy features. This work could be used as a guidance for feature windows selection and missing data processing during the development of a prediction model in ICU.

Background. Since out-of-hospital cardiac arrest- (OHCA-) related dysfunction (ischemic/reperfusion injury and inflammatory response) might result in long-term impairment, we suspect that new-onset heart failure might be common in long-term survivors. However, these relationships had not been well addressed, and we aimed to analyze the impact of emergency interventions and patient characteristics on the risk of new-onset heart failure in patients with nontraumatic OHCA. Methods. The Taiwanese government healthcare database contains data for 49,101 nontraumatic OHCA adult patients from 2011-2012, which were analyzed in this study. Nontraumatic OHCA patients who survived to the intensive care unit (ICU) were included as the study group (n = 7,321). Matched patients (n = 21,963) were recruited as a comparison group. Patients with any history of heart failure or cardiac arrest were not included in either group. All patients were followed-up for 6 months for the identification of new-onset heart failure. Adjustments were made for demographics, age, emergency interventions, and comorbidities as potential risk factors. Results. In all, 3.84% (n = 281) of OHCA patients suffered new-onset heart failure, while only 1.24% (n = 272) of matched patients in the comparison group suffered new-onset heart failure. Strong risk factors for heart failure were age (60–75 years, HR: 11.4; 95% CI: 9–14.4), medical history (myocardial infarction, HR: 2.47; 95% CI: 2.05–2.98 and cardiomyopathy, HR: 2.94; 95% CI: 1.45–5.94), and comorbidities during hospitalization (ischemic heart disease, HR: 4.5; 95% CI: 3.46–5.86). Only extracorporeal membrane oxygenation (ECMO) decreased the risk of heart failure. Most (53.6%) heart failure events occurred within 60 days after OHCA. Conclusion. An age from 61 to 75 years, a history of myocardial infarction or cardiomyopathy, and ischemic heart disease or infection as comorbidities occurring during hospitalization were strong risk factors for new-onset heart failure in OHCA patients. However, ECMO could decrease this risk. More importantly, most heart failure events occurred within 60 days after OHCA.

Over-immunosuppressed kidney transplant recipients are susceptible to malignancies and BK polyomavirus (BKPyV)-associated nephropathy (BKPyVAN). This study aimed to verify the association between BKPyV infection and urinary tract cancers (UTC). A total of 244 kidney transplant recipients were enrolled at Chang Gung Memorial Hospital from June 2000 to February 2020. Biopsy-proven BKPyVAN patients (n = 17) had worse kidney function (eGFR: 26 ± 13.7 vs. 47.8 ± 31.0 mL/min/1.73 m2). The 5-year allograft survival rates for patients with and without BKPyVAN were 67% and 93%, respectively (p = 0.0002), while the 10-year patient survival was not different between the two groups. BKPyVAN patients had a significantly higher incidence of UTC compared to the non-BKPyVAN group (29.4% vs. 6.6%). Kaplan–Meier analysis showed that the UTC-free survival rate was significantly lower in BKPyVAN patients, and the onset of UTC was significantly shorter in BKPyVAN patients (53.4 vs. 108.9 months). The multivariate logistic regression analysis demonstrated that age (RR = 1.062) and BKVAN (RR = 6.459) were the most significant risk factors for the development of UTC. Our study demonstrates that BKPyVAN patients have greater allograft losses, higher incidence, a lower cancer-free survival rate, and an earlier onset with a higher relative risk of developing UTC compared to non-BKPyVAN patients.