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To lower the charge leakage of a floating gate device and improve the operation performance of memory devices toward a smaller structure size and a higher component capability, two new types of floating gates composed of pn-type polysilicon or np-type polysilicon were developed in this study. Their microstructure and elemental compositions were investigated, and the sheet resistance, threshold voltages and erasing voltages were measured. The experimental results and charge simulation indicated that, by forming an n-p junction in the floating gate, the sheet resistance was increased, and the charge leakage was reduced because of the formation of a carrier depletion zone at the junction interface serving as an intrinsic potential barrier. Additionally, the threshold voltage and erasing voltage of the np-type floating gate were elevated, suggesting that the performance of the floating gate in the operation of memory devices can be effectively improved without the application of new materials or changes to the physical structure.

Background/Aims: We examined the association between markers of chronic kidney disease - mineral and bone disorder (CKD-MBD) and mortality in hemodialysis (HD) patients. Methods: We retrospectively reviewed the association between markers of CKD-MBD and mortality in 1,126 HD patients from 2009 to 2013 with baseline (B), time-average (TA), and time-dependent (TD) Cox regression models. Results: Hypercalcemia (10.9-11.9 mg/dL) indicated an increased risk of all-cause mortality (TA: hazard ratio [HR] 3.49; p = 0.01). Hypophosphatemia (2.0-2.5 mg/dL) was significantly associated with an increased risk of all-cause mortality (TA: HR 5.18; p = 0.01). Hypophosphatemia (1,500 pg/mL indicated an increased risk of all-cause mortality (TA: HR 1.64; p = 0.02; TD: HR 2.26; p = 0.02). Conclusion: Extreme values of CKD-MBD markers are associated with mortality risk in HD patients. Video Journal Club ‘Cappuccino with Claudio Ronco' at http://www.karger.com/?doi=478972.

This multicenter study was designed to assess the hemoglobin (Hb) stability and conversion ratio of the switch from epoetin beta to darbepoetin alfa in Taiwanese hemodialysis (HD) patients. A total of 135 HD patients were enrolled and randomized with intravenous darbepoetin alfa or epoetin beta. The study duration was 24 weeks. Equivalent doses and conversion ratios were assessed with respect to Hb stratification: low Hb (≥8.0 g/dL to ≤10.0 g/dL) and high Hb (>10.0 g/dL to ≤11.0 g/dL). The results showed stable Hb levels in the study period. At week 24, the conversion ratio was higher for high Hb than low Hb (296.4 IU/dose epoetin beta: 1 µg/dose darbepoetin alfa. vs. 277.2 IU/dose epoetin beta: 1 µg/dose darbepoetin alfa). In conclusion, the conversion ratio in the present study was higher than 1 µg: 200 IU for darbepoetin alfa: epoetin for treating anemia in Taiwanese HD patients.

The relationship between serum alkaline phosphatase (ALP) concentrations and mortality in peritoneal dialysis (PD) patients is rarely reported. We enrolled 667 PD patients in one PD centre in Taiwan to retrospectively examine the association between three ALP concentrations (baseline, time-averaged, time-dependent) and mortality over a 5-year period (2011-2015). Baseline data collection included demographics, clinical, and laboratory parameters. Multivariable-adjusted Cox models were used to analyse the association. Four ALP quartiles were defined at the baseline: ≤62, 63-82, 83-118, and ≥119 U/L. Of 667 patients, 65 patients died, of which 8 patients died due to cardiovascular disease. Females were predominant in the higher ALP quartiles, and 24-h urine volume was significantly proportionately decreased in the higher ALP quartiles. ALP quartiles expressed by the three models were not associated with all-cause or cardiovascular mortalities after adjusting for demographics, liver function, bone metabolism, mortality, hemoglobin, and 24-h urine volume. In conclusion, ALP concentrations were not associated with death risk in PD patients over the 5-year period.

Background Chronic kidney disease is a significant complication after liver transplantation (LT), but the role of pre-existing renal insufficiency and proteinuria remains unclear among LT recipients receiving sirolimus. Methods We assessed the effects of proteinuria and baseline renal function on long-term renal and survival outcomes among 576 LT recipients who received SRL in a medical center between 2005 and 2014. Renal outcomes were the incidences of >50% reduction in their baseline estimated glomerular filtration rate and end stage kidney disease requiring renal replacement therapy. Proteinuria was identified using morning dipstick results (≥30 mg/dL) at baseline and within the first year after the initiation of SRL therapy. A Kaplan-Meier analysis was performed to estimate time to event. Factors associated with the outcomes were determined using the Cox proportional hazards model with a significance level set at P

The relationship between serum alkaline phosphatase (ALP) concentrations and mortality in peritoneal dialysis (PD) patients is rarely reported. We enrolled 667 PD patients in one PD centre in Taiwan to retrospectively examine the association between three ALP concentrations (baseline, time-averaged, time-dependent) and mortality over a 5-year period (2011–2015). Baseline data collection included demographics, clinical, and laboratory parameters. Multivariable-adjusted Cox models were used to analyse the association. Four ALP quartiles were defined at the baseline: ≤62, 63–82, 83–118, and ≥119 U/L. Of 667 patients, 65 patients died, of which 8 patients died due to cardiovascular disease. Females were predominant in the higher ALP quartiles, and 24-h urine volume was significantly proportionately decreased in the higher ALP quartiles. ALP quartiles expressed by the three models were not associated with all-cause or cardiovascular mortalities after adjusting for demographics, liver function, bone metabolism, mortality, hemoglobin, and 24-h urine volume. In conclusion, ALP concentrations were not associated with death risk in PD patients over the 5-year period.

Background/Aims: Abnormal potassium profiles are common in peritoneal dialysis (PD) patients. We studied the factors associated with serum potassium profiles in incident PD patients. Methods: Patients were enrolled from two hospital-facilitated PD centers from May 2013 to May 2016 and January 2009 to December 2015. A total of 319 incident PD patients were examined for factors associated with serum potassium profile. Average serum potassium levels were obtained for analysis during the first 3 months after PD initiation. Clinically factors and parameters associated with PD were assessed by logistic regression. Results: There were 168 men and 151 women (mean age, 50.8 years). Blood urea nitrogen (BUN), creatinine (Cr), and intact parathyroid hormone levels were significantly increased in patients in the higher serum potassium group. There were no significant risk factors for hypokalemia, including sex, age, diabetes, blood examination parameters, medication use, or PD-related parameters by multivariate logistic regression analysis. BUN (adjusted odds ratio [OR] 1.02, 95% CI 1.01-1.03, p = 0.001) and Cr (adjusted OR 1.08, 95% CI 1.01-1.16, p = 0.029) levels were significant risk factors for hyperkalemia by multivariate logistic regression analysis. Conclusion: Hyperkalemia and blood BUN and Cr levels were significantly associated in incident PD patients.

Background/Aims: Although high serum alkaline phosphatase (ALP) levels were reported as predictive factors for death risk in dialysis patients on the basis of large databank analyses, the real scenario in a single hemodialysis (HD) center is unknown. Methods: In this study, a 5-year cohort of 1126 prevalent HD patients in the largest HD center in Taiwan was studied. The associations of ALP levels expressed as baseline, time-average, and time-dependent with all-cause mortality and cardiovascular mortality were evaluated by using adjusted Cox regression models. Results: At baseline, levels of serum parathyroid hormone, calcium, and liver enzymes are increased in parallel with ALP quartiles. The hazard ratio (HR) for all-cause mortality was significantly increased in time-average and time-dependent ALP quartile in the unadjusted Cox analysis. The significance disappeared when multivariate adjusted Cox analysis was used. Similarly, HR was not significantly increased for cardiovascular mortality with ALP quartile expressed as baseline, time-average, and time-dependent in three models of Cox analyses. Conclusion: Our study demonstrated that serum ALP levels were not associated with increased death risk in prevalent HD patients over a 5-year interval.

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

A novel low-voltage low-power programming method for NAND Flash cell is presented. By utilizing the self-channel boosting technique, a sufficiently high local field is established in a NAND string that causes efficient hot-carrier injection. This method has been successfully demonstrated in the 75-nm-node floating-gate NAND cells, along with comprehensive studies on bias and timing effects. Requirements for high-voltage supporting devices, circuitry, and process in conventional Fowler-Nordheim programmed NAND cells are greatly mitigated. It would be very attractive for scaled NAND Flash technology in the future.

Aims: Vascular calcification is a common complication among dialysis patients and its pathogenesis involves a variety of factors. The roles of pro-inflammatory cytokines and residual kidney function (RKF) in peritoneal dialysis (PD) patients with vascular calcification have not been investigated. Materials and methods: 157 stable PD patients were enrolled. All patients had plain X-ray film examination including chest (posterior-anterior view, CXR) and pelvis. Vascular calcification was interpreted as calcified deposit over aortic arch and linear calcification of pelvic arteries. Relevant biochemical data, pro-inflammatory markers, and PD-related factors were measured and collected. Results: Vascular calcification prevalence in CXRs was higher than that in pelvis films (38.2% vs. 22.3%, p < 0.05). Patients with vascular calcification in CXR had higher incidence of calcification in pelvis films (p < 0.05). Only a minor portion (14.6%) had two calcification sites. Regression analysis revealed that age, PD duration, body mass index, and RKF were independent factors associated with vascular calcification in CXR. Age, diabetes, IL-10 and RKF were factors associated in pelvis films. Factors independently related to vascular calcification in both films were age, duration, diabetes, IL-10, and RKF. Conclusions: Besides traditional risk factors, IL-10 and RKF were important factors associated with vascular calcification in PD patients.

Objectives: To report the success of treatment with low- molecular-weight heparins (LMWHs) in a case of nephrotic syndrome complicated by mesenteric vein thrombosis (MVT) and portal vein thrombosis (PVT). Clinical Presentation and Intervention: A 53-year-old man with nephrotic syndrome developed persistent mild abdominal pain for 3 days. Hepatic-portal venous system thrombosis of nephrotic syndrome was suspected due to new-onset superficial vein engorgement of the abdomen without liver cirrhosis. Abdominal computed tomography revealed MVT concomitant with PVT. He was successfully treated with LMWH without thrombolytic therapy. After discharge on day 9, he received continuous anticoagulation by LWMH on an outpatient basis at the nephrology clinic. Venous thromboembolic events or proteinuria did not recur within the 6-month follow-up. Conclusion: This report showed a case of MVT concomitant with PVT, a critical complication of nephrotic syndrome that was diagnosed in time and successfully treated with LMWH. A high index of clinical suspicion and timely management are crucial to tackle thrombotic complications in nephrotic syndrome.

To date, there is convincing evidence for the preservation of residual renal function (RRF) in peritoneal dialysis (PD) patients; however, substantially variable data exist on the incidence rate of infectious complications and the decline of RRF for automated peritoneal dialysis (APD) and continuous ambulatory peritoneal dialysis (CAPD). The purpose of our study was to investigate the relative merits or demerits of APD compared with CAPD.From November 1998 to November 2007, we retrospectively reviewed 32 patients on APD and 140 patients on CAPD. We compared incidences of infectious complications during the entry period. RRF and other PD parameters were determined and compared over 2 years of therapy. In addition, the period of hospitalization was also included for clinical outcome analysis.There were no significant differences between the two modalities with regard to the incidence of peritonitis (1.42/100 patient-months for APD vs. 1.23/100 patient-months for CAPD, p = 0.66). At the end of the second year, there were no significant differences between APD and CAPD with regard to the decline of RRF (14.8 vs. 15.3 L/week/1.73 m(2), p = 0.84). However, APD significantly increased the value of total weekly Kt/V during this period. Furthermore, we observed a significant reduction in hospitalized days of APD compared with CAPD.We concluded that the selection of the PD modality is not a major determinant of the decline in RRF. APD can be adapted to the targeted adequacy and is at least as efficacious as CAPD when it is expertly applied.

Nephropathy associated with contrast medium exposure is a well-known complication of IVP. However, it is uncertain whether iso-osmolar non-iodinated contrast medium (iodixanol) is less nephrotoxic than low-osmolar contrast medium (iohexol).In this single-center, double-blind, prospective study, 50 patients undergoing IVP were randomized into two groups receiving different contrast medium: iodixanol and iohexol. Patients in high risk for contrast nephropathy were included, 28 with renal insufficiency and 19 with diabetes mellitus. We compared the nephrotoxic effect (contrast nephropathy), complement and cytokines profile between the iodixanol and iohexol groups. The mean volume of contrast medium in each IVP procedure was 0.8 mL/kg.The incidence of contrast nephropathy was 4 percent among all patients (one iodixanol and one iohexol). We found no significant differences in contrast nephropathy and allergic reactions between the two groups. There was no significant difference in cytokine profiles in both groups (p0.05).The incidence of allergic reaction was 16 percent among all patients. Twelve percent (3/25) had late reaction after iohexol exposure compared to four percent (2/25) with iodixanol (p = 1.0). One patient had severe skin rash due to late adverse reaction after iodixanol. No mortality was found.New iodixanol and iohexol contrast medium for routine IVP examination are safe and have low nephrotoxicity profile, especially in elderly or high-risk patients. Iodixanol contrast medium has an increased risk to induce severe late adverse reaction compared to iohexol. Allergic reaction may be the main adverse effect after contrast medium infusion.

To evaluate the benefits of dialyzer reuse for hemodialysis (HD) patients, including the cost of HD treatment and patient's survival, a comparison was made regarding the standard practice of single-use dialysis.From January 1, 2005, to December 31, 2005, a total of 128,232 successive HD treatments in 822 patients in Chang Gung Memorial Hospital-Kaohsiung Medical Center were included in this study.Approximately 54.25% (446/822) of patients reused dialyzers. The average times of dialyzer reuse was 2.54. The annual hollow fiber cost is reduced by $241,054.08 U.S. dollars (NT $7,834,257.60). The annual cost of hollow fiber was reduced by $540.48 U.S. dollars (NT $17,565.60) in one patient with dialyzer reuse. The mortality rates in dialyzer reuse and single use groups were 3.1% and 10.9% within one year (p0.0001). Multiple logistic regressions showed that single use compared with reuse was associated with higher mortality after adjusting co-morbid conditions including age, diabetes mellitus, etc. CONCLUSIONS. We concluded that the benefits of dialyzer reuse included safety in our center and reduction in cost during a 12-month period. Dialyzer reuse may be a safe alternative.

Intravenous and oral labedipinedilol-C showed a dose-dependent long-lasting hypotension and a decrease of heart rate in normotensive and conscious spontaneously hypertensive rats (SHR). In isolated Wistar rat and guinea pig tissues, labedipinedilol-C competitively antagonized (-)isoproterenol-induced cardiac stimulation, tracheal relaxation, and phenylephrine-, CaCl2-, and high-K-induced aorta contractions in a concentration-dependent manner. The estimated pA2 and pKCa values were 8.22+/-0.04 and 7.11+/-0.52, respectively. [H]CGP-12177 binding to ventricle and lung tissues as well as [H]prazosin and [H]nitrendipine binding to brain membranes were inhibited by labedipinedilol-C with Ki values of 2.86, 9.03, 0.39, and 0.05 muM, respectively. The vasorelaxant effects of labedipinedilol-C on phenylephrine (10 microM)-induced contractions were attenuated by removing endothelium, by pretreatment with soluble guanylyl cyclase (sGC) inhibitors ODQ (10 microM) and methylene blue (10 microM), a NOS inhibitor L-NAME (100 microM), a K channel blocker TEA (10 mM), a KATP channel blocker glibenclamide (1 microM), and Ca-dependent K channel blockers apamin (1 microM) and charybdotoxin (0.1 microM). In human umbilical vein endothelial cells (HUVECs), labedipinedilol-C increased NO release, which was significantly inhibited by L-NAME. The Western blot analysis on HUVECs indicated that labedipinedilol-C increased the expression of eNOS. These results indicate that hypotension effects of labedipinedilol-C result from alpha-adrenoceptor and Ca entry-blocking activities and release of NO or NO-related substance from vascular endothelium. The endothelium-independent relaxation of vascular smooth muscle is probably linked to K channel opening and alpha-adrenoceptor-blocking activities.

Despite advances in modern technology of dialysis, prognosis of patients with acute renal failure (ARF) remains poor. To give the clinicians the most useful information, a model that accurately predicts outcome early in the course of ARF is required. However, because ARF is a heterogeneous syndrome and occurs in patients with diverse etiologies and some coexisting diseases, predicting outcome early is hard. The aim of this study is to evaluate prospectively the Acute Physiology and Chronic Health Evaluation (APACHE II) and organ system failure (OSF) models, evaluated prior to dialysis, in predicting hospital mortality.From June 2002 to March 2004, ARF patients requiring dialysis at Chang Gung Memorial Hospital, Chiayi, were prospectively recruited for this study. The worst clinical and laboratory data in the 24 hours before initiation of dialysis were prospectively evaluated, and the patients' APACHE II score and OSF number were assessed.A total of 61 patients (40 male and 21 female) were enrolled, of whom 38 (62.3%) died before discharge. By multivariate logistic regression, the APACHE II score (odds ratio 1.3 per increase in one score; P0.001), or OSF number (odds ratio 1.9 per increase in one OSF; P0.01) and oliguria (odds ratio 4.2; P=0.04), were found to be statistically significant prognostic factors for hospital mortality. Mortality increased progressively and significantly as OSF number (chi-square for trend; P=0.001) or the APACHE II score (chi-square for trend; P0.001) increased. By using Youden's index, the best cut-off value for APACHE II was 24, with 63% sensitivity and 96% specificity. The best cut-off value for OSF number was 2, with a sensitivity of 81.6% and a specificity of 60.9%. The areas under the receiver operating characteristic curves for APACHE II and OSF number were 0.847 (95% confidence interval (CI)=0.752-0.942; P0.01) and 0.769 (95% CI=0.646-892; P0.001), respectively, indicating good model discrimination.This study concludes that APACHE II and OSF number measured prior to initiation of dialysis reliably predict outcomes of ARF patients requiring dialysis. The mortality rates increase as the APACHE II score or OSF number increases. For predicting mortality, the APACHE II scoreor = 24 was found to have 63% sensitivity and 96% specificity, and OSF numberor = 2 had 81.6% sensitivity and 60.9% specificity.

The purpose of this study is to find out whether basiliximab administration will improve postoperative renal function by delaying the start of tacrolimus and decreasing of dosage requirement for tacrolimus in adult living donor liver transplantation (LDLT). Forty-five adult LDLT recipients were enrolled in the study. The induction group (n = 27) was given basiliximab 20 mg on days 0 and 4; tacrolimus administration was delayed until renal function improved. The control group (n = 18) did not receive basiliximab; tacrolimus was given on the first postoperative day. Trough levels of tacrolimus in the induction and control groups were aimed to be maintained at 5-10 ng/ml and 10-15 ng/ml during the first week after transplant, respectively. The median follow-up was 22 months (range 10-34 months). The preoperative conditions were poorer in the induction group (Child C, 56% vs. 33%, P = 0.01; UNOS 2a, 15% vs. 0%, P = 0.02). The intraoperative blood loss was also higher in the induction group than in the control group (median 2,180 ml vs. 495 ml, P < 0.01). The median delay in tacrolimus administration in the induction group was 36 hours (range 24-108 hours). Serum creatinine levels at second and third postoperative months were significantly lower in the induction group. The creatinine clearance rate in the induction group was higher at the third month posttransplant (median 72 vs. 57 ml/minute, P = 0.04). The incidence of renal insufficiency was significantly lower in the induction group at the third month posttransplant (26% vs. 67%, P < 0.01). Blood cholesterol level at the sixth month posttransplant was lower in the induction group (median 152 vs. 196 mg/dl P = 0.03). The incidences of acute cellular rejection, bacteremia, and cytomegalovirus (CMV) infection were similar in both groups. In conclusion, for pretransplant critical patients with more intraoperative blood loss, basiliximab induction could prevent early renal dysfunction by delaying the start of tacrolimus and reducing the dose requirement of tacrolimus without increasing graft rejection and infection. Furthermore, it also improved renal function as well as lowered cholesterol levels within 6 months after transplantation.

Vascular access failure is a major cause of morbidity in chronic hemodialysis (HD) patients. Elevated immunoglobulin-M anticardiolipin antibody (IgM-aCL) titer is associated with stenosis of vascular access in HD patients. The clinical significance of elevated IgM-aCL titer relative to recurrent vascular access thrombosis (VAT) in patients with HD is less clear. However, little information has been available until now about the clinical influence of elevated IgM-aCL titer with recurrent VAT in HD patients from Western countries, and no report exists for Taiwan. This study attempted to determine whether elevated IgM-aCL titer was associated with recurrent VAT in HD patients.This study enrolled 483 patients undergoing HD. IgM-aCL titer and hepatitis C marker were measured for all subjects.Elevated IgM-aCL titer was present in 17.4% (84/483) of patients. There was no association recurrent VAT between elevated and normal IgM-aCL titers (P=0.90). Presence of hepatitis C had significant differences between elevated and normal IgM-aCL titers (P=0.027).We found no significant differences in recurrent VAT between elevated and normal IgM-aCL titer in chronic HD patients. Our results suggest recurrent VAT of synthetic or native fistula may not be caused by elevated IgM-aCL titer in these patients. Presence of hepatitis C may be a cofactor.

While hospitalized for pneumonia with ventilator-dependent respiratory failure, a 45-year-old man on continuous ambulatory peritoneal dialysis (CAPD) had nosocomial peritonitis secondary to infection by expanded spectrum beta-lactamase producing Klebsiella pneumoniae (ESBL-Kp). He was treated successfully with a 3-week course of intraperitoneal (IP) flomoxef therapy without subsequent relapse, loss of peritoneal catheter, ultrafiltration failure, or dialysis inadequacy. The International Consensus Panel recommends IP ceftazidime as the treatment of choice for CAPD patients suffering Klebsiella species-related peritonitis. However, the most appropriate form of IP antibiotic therapy and the outcomes for expanded-spectrum beta-lactamase (ESBL)-producing bacteria-related peritonitis for CAPD patients have not been established yet. Further, the ability to correctly report minimal inhibitory concentrations (MICs) of ceftazidime for ESBL bacteria in the resistant range varies between laboratories, making the diagnosis of ESBL-Kp-related CAPD peritonitis more complex and difficult. Thus, it appears reasonable to suggest that its incidence is probably underestimated and its significance ignored. The authors suggest that a 3-week IP treatment with flomoxef, a synthesized oxacephem, with loading and maintenance doses of 250 and 125 mg/L, respectively, is effective and safe for ESBL-Kp-related peritonitis in these patients. ESBL producing bacterial infection should be considered as a possible cause of overt CAPD-related peritonitis. Early detection of ESBLB pathogens and institution of effective antibiotic treatment may improve the prognosis.

The antihypertensive effect of vanylidilol, a new α/β-adrenoceptor antagonist with endothelium-dependent and K+-channel-opening activities, was investigated in normotensive and hypertensive Wistar rats. Vanylidilol competitively antagonized (–)isoproterenol-induced positive chronotropic effects, inotropic effects, and tracheal relaxation effects in isolated rat right atria, left atria, and guinea pig tracheal strips in a concentration-dependent manner. Vanylidilol’s apparent pA2 values were 6.36 ± 0.08 (right atria), 6.41 ± 0.07 (left atria), and 6.31 ± 0.06 (trachea). Vanylidilol also produced a competitive antagonism of phenylephrine-induced contraction in the isolated rat aorta with pA2 values of 6.79 ± 0.18. In the radioligand binding assay, vanylidilol inhibited [3H]CGP-12177 binding to rat ventricle and lung tissues and [3H]prazosin binding to brain membranes with Ki values of 535.17, 2,066.69, and 431.11, respectively. In isolated rat thoracic aorta, vanylidilol’s vasorelaxant effects on phenylephrine (10 µmol/l)-induced contractions were attenuated by removing endothelium and by the presence of L-NG-nitro arginine methyl ester (L-NAME; 100 µmol/l), methylene blue (10 µmol/l), 1H-[1,2,4]oxadiazolol[4,3,-a] quinoxalin-1-one (ODQ; 10 µmol/l), tetraethylammonium (10 mmol/l), glibenclamide (1 µmol/l), apamin (1 µmol/l), and charybdotoxin (0.1 µmol/l). In addition, vanylidilol, in an equally antagonistic activity, inhibited phenylephrine-induced phasic and tonic contractions. Intravenous vanylidilol further reduced mean blood pressure in pentobarbital-anesthetized normotensive Wistar rats in a dose-dependent manner. The oral administration of vanylidilol to conscious spontaneously hypertensive rats had a long-lasting hypotensive effect on the heart rate and decreased it in a dose-dependent manner. Furthermore, vanylidilol’s vasodilator effect can be attributed in part to the release of NO or NO-related substance from vascular endothelium, while the endothelium-independent mechanism involved in vanylidilol’s relaxation is probably linked to the activation of the K+ channels and the α-adrenoceptor blocking activity in these vessels.

Aims To identify clinical features and treatment response of tuberculous peritonitis (TBP) in a uremic population, a retrospective case-control study was performed. Materials and methods Thirteen uremic patients with TBP (Group I: 62.7 +/- 6.8 years, male 54%) collected between January 1986 and January 2002 were compared with another two age- and sex-matched controls: 19 non-azotemic patients with TBP (Group II: 62.9 +/- 7.3 years, male 47%) and 30 uremic patients without TBP (Group III: 61.1 +/- 8.7 years, male 47%). Clinical information and data of ascites and blood examinations were evaluated. Results Significant differences between Groups I and II were found in comorbidity, hypertension, anorexia, percentages of neutrophil and lymphocyte from blood and ascites, and serum calcium (sCa), phosphorus and albumin-adjusted calcium (sAACa). However, no significant differences in duration of symptoms, coexistent pulmonary tuberculosis (p = 0.061), duration or complications of therapy and mortality (p = 0.13) were detected. Significant differences between Groups I and III were found in peripheral white cell counts and percentages of neutrophil and lymphocyte as well as in serum creatinine (sCr), albumin, sCa, sAACa and intact parathyroid hormone (iPTH). Conclusions Non-specific symptoms make the diagnosis of TBP in a uremic population difficult. However, neutrophil predominance in blood and ascites, hypoalbuminemia, relatively lower sCr and hypercalcemia with suppressed serum iPTH were found to be characteristic. In TBP uremic patients, therapy complications were not common and there was a tendency for higher mortality, largely due to septic shock.

The incidence of extrapulmonary tuberculosis is higher in dialysis than general population. The aim of the study was to characterize clinical picture in dialysis patients, who developed extrapulmonary tuberculosis.We retrospectively investigated the hemodialysis patients with extrapulmonary tuberculosis. 2208 hemodialysis patients were reviewed for extrapulmonary tuberculosis from October 1986 to January 2001.Seventeen patients (10 male, 7 female) were enrolled. The mean age was 57.4 +/- 12.4 years. The sites for extrapulmonary tuberculosis were peritoneum (35.3%, 6/17), cervical lymph node (17.6%. 3/17), bone marrow (5.9%, 1/17), spine (5.9%, 1/17), knee (5.9%, 1/17), brain (5.9%, 1/17), pericardium (5.9%, 1/17), cutaneous tissue (5.9%, 1/17) and genitourinary system (5.9%, 1/17). Fourteen of 15 tissue-biopsy specimens from suspicious sites revealed granulomatous inflammation. There were low yield in mycobacteria culture (11.1%, 1/9) and PCR (33.3%, 2/6). Three patients died during the treatment of the disease.Extrapulmonary tuberculosis constitutes a major part of tuberculosis in dialysis patients. Tissue biopsy with invasive procedures, such as laparoscopy or laparotomy, may be necessary if clinical presentations are suspicious.

Uterine prolapse resulting in hydronephrosis was uncommon. We report two cases of complete uterine prolapse and bilateral moderate hydronephrosis. Case 1, she was admitted due to fever with pyuria. Uterine prolapse was noted by incidental finding. Urine culture showed Escherichia coli. She received total vaginal hysterectomy, which corrected the obstruction and bladder dysfunction. Case 2, she had a history of liver cirrhosis and was denied further operation due to bleeding tendency. Renal echo and intravenous pyelography showed bilateral moderate hydronephrosis with hydroureter in the two cases. Normal renal function was found in the two cases. We suggest early diagnosis and management are necessary in order to prevent renal failure and urinary tract infection.

Acute renal artery thromboembolism (ARAT), a rare event in native kidneys, potentially result in severe renal injury if it is not appropriately managed. The optimal therapy still remains controversial today even though various methods of managements for ARTA were applied in these decades including surgical intervention and medical approach such as thrombolytic therapy. Recombinant tissue plasminogen activator (rt-PA) reveals a better bioavailability and lower incidence of adverse effects and it has been widely used to treat a number of clinical conditions but only very few cases have been reported where rt-PA was used to treat ARAT. We described a case of ARAT, which was successfully treated by the administration of rt-PA via intra-arterial infusion within a period of 60 min without residual renal impairment. It may be a useful choice for ARAT and renal infarction sufferers.

Objective: To report a potential salvage therapy for refractory renal cyst infection secondary to Salmonellaenterica serotype choleraesuis (S. choleraesuis).Clinical Presentation and Intervention: A 52-year-old male with autosomal dominant polycystic kidney disease undergoing hemodialysis experienced an episode of S. choleraesuis-related gastroenteritis subsequently complicated by bloodstream and refractory renal cyst infection with formation of multiple pyocysts. The patient was treated with intracystic indwelling diluted ciprofloxacin solution. Conclusion: In this patient, intracystic infusion of ciprofloxacin achieved a sufficient antibiotic level in infected renal cysts and hence completely eradicated S. choleraesuis. Therefore, intracystic antiobiotic infusion could be a potential salvage therapy for refractory renal cyst infection.

We propose a new hot-electron programming method with a low drain-to-source voltage in a buried-diffusion (BD) bit-line SONOS memory array. In this method, channel electrons are preaccelerated in a cell preceding a program cell. For a small bit-line width, some energetic electrons will traverse an n+ BD region and enter a program cell with residual energy due to nonequilibrium transport. Our measurement result shows that this residual energy can significantly enhance hot-electron programming efficiency even at a V ds of 2.5 V. The concept of this method is verified by means of a Monte Carlo analysis. Our study shows that this method is more effective as a bit-line width reduces.

Tuberculosis remains an important cause of infection in chronic haemodialysis patients. Frequent extrapulmonary involvement, non-specific presentation and limited diagnostic tools usually make early diagnosis difficult. Herein, we report on an 83-year-old female patient who had been on regular heamodialysis therapy for 15 years, who presented with asymptomatic hypercalcaemia and pancytopenia. Haemophagocytic syndrome was documented during the admission period. Mycobacterium tuberculosis was cultured from bone marrow 1 month after her demise. This case report highlights the non-specific manifestations of extrapulmonary tuberculosis in dialysis patients and the limited value of conventional diagnostic methods. We would like to recommend aggressive intervention and early tissue aspiration from possible infectious sites when tuberculosis cannot be completely ruled out. Disseminated tuberculosis should be considered as an indication of hypercalcaemia where haemophagocytic syndrome occurs simultaneously.

Background Hemodialysis (HD) patients are susceptible to extended spectrum beta-lactamase (ESBL)-producing bacterial infections. Because the optimal treatment and clinical significance of ESBL-producing Klebsiella pneumoniae (ESBL-Kp) HD access-related bacteremia remain unclear, we conducted this retrospective study to determine the clinical outcomes of patients treated with either flomoxef or a carbapenem. Methods The eligibility criterion was fistula or graft- or catheter- related ESBL-Kp bacteremia in patients on maintenance HD. The clinical characteristics and antibiotic management were analyzed. Outcome was determined by mortality resulting from bacteremia during the 14‐day period after the first positive blood culture for flomoxef-susceptible ESBL-Kp. Results The 57 patients studied were predominantly elderly, malnourished, with a history of severe illnesses and broad-spectrum antibiotic use before the onset of bacteremia, and with severe septicemia as determined by the Pitt bacteremia score (PBS). The study population comprised 7 fistula, 8 graft, and 42 HD catheter-related bacteremia (CRB) cases, and the mortality rate was high (36/57, 63.2%) in these 57 patients. Of 42 patients with CRB, those in the deceased group (27/42, 64.3%) had significantly lower levels of serum albumin, longer prior hospital stay and duration of catheter-dependent HD, and higher PBS than patients in the survived group. Failure to receive effective antibiotics (flomoxef or a carbapenem) within 5 days after onset of bacteremia and treatment with flomoxef both significantly contributed to higher mortality. Multivariate analyses revealed that flomoxef use, PBS, and catheter-dependent HD >30 days were independently associated with increased mortality (OR, 3.52; 95% CI, 1.19–58.17, OR, 2.92; 95% CI, 1.36–6.26 and OR, 5.73; 95% CI, 1.21–63.2, respectively). Conclusions Considering the high mortality rate, ESBL-Kp should be recognized as a possible pathogen in patients on maintenance HD at high risk of acquiring HD access infections associated with ESBL-producing bacteria. Carbapenems rather than flomoxef should be the therapy of choice in these critically vulnerable patients.

Leptospirosis is the most common zoonosis in the world but remains underreported, owing to protean manifestations and ignorance about the disease among health care providers in Taiwan. From September 2000 to March 2006, surveillance of 455 patients with multiple organ dysfunction syndrome with unclear cause or clinical suspicion of leptospirosis was performed. Diagnosis was further confirmed by microscopic agglutination test or isolation of Leptospira. Cases were classified as excluded based on confirmed etiology other than leptospirosis or negative paired serologic test. Forty-two patients were confirmed as having leptospirosis, which accounted for 9.2% of total patients with multiple organ dysfunction syndrome. Forty-nine excluded cases were identified for a case-control analysis for clinical distinction. The most common presentations of leptospirosis were fever (97.6%), acute kidney injury (85.7%), and jaundice (61.9%). The leptospirosis group showed lower urine specific gravity (cutoff value, 1.0145) and enlarged kidney size (cutoff value, 11.05 cm) as compared with the excluded cases by multivariate logistics regression. Delayed antibiotic administration prolongs the duration of hospitalization (R2 = 0.486, P0.01). No mortality has been found in the leptospirosis group after initiation in 2003 of rapid immunoglobulin M serology assay that showed considerably high sensitivity and specificity. Leptospirosis accounts for a salient cause of multiple organ dysfunctions in Taiwan. Early awareness of leptospirosis by distinct presentations, followed by prompt antibiotics therapy, can dramatically save the patients. The easily performed rapid immunoglobulin M serology assay is suitable as a rapid screening test for the diagnosis of leptospirosis.

Patients with nephrotic syndrome frequently have renal-vein thrombosis (RVThromb) without overt clinical manifestations. At the onset of the condition only 10% of these patients have acute signs and symptoms such as flank pain, haematuria, proteinuria and a rapid decline of renal function [1]. Patients experiencing severe flank pain, a rapid deterioration of renal function and concomitant pulmonary emboli or multiple thrombi have been successfully managed with thrombolytic agents [3], despite the fact that the risk associated with thrombolytic therapy seems to be greater than that of anticoagulant therapy, which would appear to be a more appropriate choice of treatment. Since low-molecular-weight heparins (LMWHep) have a longer half-life and better bioavailability than unfractionated heparin, they are widely used for treating many clinical conditions [4]. This case report confirms that LMWHep can be used successfully to treat the RVThromb of a nephrotic patient. It also suggests that such therapy may be applied even when thrombolytic or other anticoagulation therapy has previously failed.

Aim: The aim of this analysis was to know whether these three cytokine polymorphisms, including interleukin-6 (IL-6; −572 G/C), tumour necrosis factor-α (TNF-α; −308 G/A), and IL-10 (–592 A/C) have an effect on baseline peritoneal transport property and longitudinal evolution of peritoneal function. Methods: A total of 141 stable peritoneal dialysis (PD) patients with mean treatment duration of 84.4 ± 34.2 months were enrolled. We genotyped these three cytokine polymorphisms, together with clinical parameters that were included as factors affecting longitudinal change of property of peritoneal transport over the first 3 year period after commencing therapy. Results: There was no significant association between genotypes and baseline peritoneal transport property. The −592 A/C polymorphism of IL-10 was associated with longitudinal change of peritoneal transport. The ratio of D/P creatinine was significantly higher in patients with AA than those with CC/CA genotypes at 12 months (0.65 ± 0.11 vs 0.62 ± 0.09, P = 0.048) and 24 months (0.64 ± 0.12 vs 0.59 ± 0.09, P = 0.018). In addition, patients with increased peritoneal transport have greater frequency distribution of AA genotype and A allele. Logistic regression analysis revealed that −592 A allele was an independent predictor for the increase in D/P creatinine over the first 12 month period (odds ratio: 2.482, P = 0.017). There was no correlation between either polymorphism of IL-6 −572 (G/C) or TNF-α−308 (G/A) and longitudinal change of peritoneal function. Conclusions: Single nucleotide polymorphism of IL-10 −592 (A/C) was associated with longitudinal evolution of peritoneal transport rate in PD patients rather than the baseline peritoneal characteristics.

Patients with gout often have concurrent chronic kidney disease (CKD); the relationship between the two conditions is still unclear. Previous studies have identified an association between low level of urinary uromodulin (UMOD) and CKD within the setting of diabetes and lupus. The aim of this study was to examine the association between urinary UMOD excretion and CKD in patients with gout. A total of 53 Taiwanese gout patients with stable disease activity were enrolled. Patients were divided into a CKD group (n = 25) and a non-CKD group (n = 28). Using Pearson correlation analysis, urinary UMOD excretion was positively correlated with estimated glomerular filtration rate (Ha: ρ0, p = 0.004). Using multivariate analysis, patients with CKD and gout were associated with lower urinary UMOD excretion than those who have gout alone [odds ratio (95% CI): 0.826 (0.694-0.985), p0.001]. Patients with CKD and gout were also more likely to be older (p0.001) and have higher uric acid levels (p0.001). This study implicates that UMOD might play a role in the relationship between gout and CKD. Further studies with animal models of gout and CKD would be recommended.

Nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD) clinically resembles scleromyxedema which develops in the setting of advanced chronic kidney diseases. Limited data exist about its epidemiology in Asian countries. A total of 153 magnetic resonance imaging (MRI) examinations, including 81 contrast-enhancement, were identified in 127 patients with advanced chronic kidney disease at stage five undergoing MRI or angiography examination between January 2005 and July 2007, in our hospital. The diagnosis of NFD/NSF was established based on clinical manifestation and histopathology. NFD/NSF was diagnosed in none of the 105 patients on haemodialysis but in one of the 22 patients on peritoneal dialysis. This 24-year-old woman was a case of systemic lupus erythematosus since age 15 and who developed skin lesions two months before the initiation of peritoneal dialysis but nine months after four exposures to gadodiamide during MRI study. The skin condition had significantly improved within three months under a combination regimen of systemic pentoxifylline and topical clobetasol propionate ointment, with further amelioration during subsequent treatment with colchicine. Our results lend support to the predisposition of gadolinium-containing contrast agents to the development of NFD/NSF in patients with advanced renal failure, even before the initiation of dialysis. The cause of a lower incidence rate in our series remains to be determined.

Dialysis disequilibrium syndrome (DDS) is usually seen in severely uremic patients who are dialyzed aggressively. DDS mostly appeared within 24 hours after hemodialysis (HD) and may last for a few hours. This diagnosis is made by the exclusion of other causes including metabolic and intracranial events and has been recognized for more than 40 years. Few reports described the cerebral radiographic features associated with DDS. We present an 83-year-old uremic patient experiencing DDS at initial HD. DDS-related cerebral radiographic manifestations reported in the literature are reviewed, along with a discussion of the role of neuroimaging in the diagnosis of DDS.

Introduction: Chronic cutaneous lesions are common in immunocompromised patients and are attributable to a wide range of potential microbial pathogens. Common infections may have a variety of unusual manifestations, and unusual pathogens can also play an important role in these infections. Therefore, “how to approach” these lesions becomes a difficult problem. Case Report: A 42-year-old male had medical history of immune thrombocytopenic purpura (ITP), chronic hepatitis C with liver cirrhosis, Child’s-Pugh-Turcotte score A, and end stage renal disease requiring maintenance hemodialysis. The patient also suffered from multiple ecchymoses and tender plaques on all four limbs for one month. A pathology of skin biopsy showed lobular panniculitis and a strong positive finding of acid-fast bacilli (AFB). A bone marrow biopsy also showed a strong positive finding of AFB but no granulomatous inflammation. The patient was treated as disseminated tuberculosis infection and experienced anti-tuberculosis (TB) drug

Leptospirosis is the most widespread zoonosis. Leptospirosis remains underreported in Taiwan because of ignorance and the broad spectrum of clinical manifestations. Acute renal failure (ARF) is a prominent feature of leptospirosis. This investigation conducted a case-control study to obtain information to distinguish leptospirosis from other conditions with similar presentations.Leptospirosis surveillance was performed at Chang Gung Memorial Hospital, Taiwan, between September 2000 and December 2001. Suspected clinical cases were included in the sample and investigated. Diagnosis was confirmed with four-fold or greater increase of microscopic agglutination test (MAT) titer in paired sera; positive immunoglobulin M (IgM) dipstick with single MATor =400; or isolation of leptospira. Cases were classified as excluded based on confirmed etiology other than leptospirosis or negative paired serologic test.Twenty-two confirmed cases and 21 excluded cases of leptospirosis were identified from among 169 suspected cases. An outbreak was observed during the flooding from Typhoon Nali. L. shermani, the most common serovar in Taiwan, was identified in 78.5% of confirmed cases. In the confirmed group, mean age was 44 +/- 14.5 (21-66) yrs similar to that of the excluded group, with male predominance (86.4 vs. 57.1%, p0.05). The most common presentations in the confirmed group were fever (95.5%), ARF (86.4%), myalgia (72.7%) and jaundice (63.6%). Ten patients were infected through occupational or recreational exposure, and in six patients, the infection was associated with flooding. The most distinct presentations of leptospirosis cases compared with excluded cases were increased incidence of hemorrhagic diathesis (odds ratio (OR): 10, p=0.04), myalgia (OR: 8.0, p=0.02), bilateral enlarged kidneys (OR: 7.5, p=0.0004), risk factor exposure (OR: 6.9, p=0.005), sterile pyuria (OR: 6.3, p=0.017), hypokalemia (OR: 5.0, p=0.035) and thrombocytopenia (OR: 4.8, p=0.04). Hospitalization days correlated well with levels of peak creatinine (Cr) (p=0.0362) and platelet nadir (p=0.0039) reached. Penicillin treatment was followed by rapid symptoms and renal function improvement.Prompt recognition of the characteristic presentations of leptospirosis, followed by timely antibiotic treatment, can dramatically save the patients even with severe multiple organ damage.

Chronic inflammation is prevalent in dialysis patients. We investigated the relationship between inflammation and newly identified adipokines: leptin and adiponectin in this population. A total of 129 chronic hemodialysis patients were collected. Serum high sensitivity C-reactive protein (CRP), interleukin-6 (IL-6), leptin and adiponectin levels were determined as well as other metabolic variables. Correlation studies and multiple regression analysis were performed among variables. Our results showed that hemodialysis patients had elevated levels of inflammatory markers, leptin and adiponectin. Diabetic subjects had higher serum CRP and lower albumin levels than non-diabetics. Serum CRP levels were positively correlated with IL-6 levels and negatively correlated with albumin levels. Serum leptin levels were directly related to CRP levels while adiponectin levels were inversely related to CRP levels. A significant negative correlation was observed between serum leptin and adiponectin levels. Serum IL-6 levels were the single independent factor affecting CRP levels. Body mass index can predict both serum leptin and adiponectin levels. We conclude that hemodialysis patients are at an increased risk of chronic inflammation and diabetes patients are even more susceptible to this status. Both serum leptin and adiponectin levels are associated with inflammatory markers. As adipose tissue is the major secreting site of these adipokines, our results suggest that adipose tissue plays an important role in the pathogenesis of chronic inflammation in dialysis patients.