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Background: Diabetic nephropathy (DN) can affect quality of life (QoL) because it requires arduous lifelong management. This study analyzed QoL differences between DN patients and patients with other chronic kidney diseases (CKDs). Methods: The analysis included subjects (n = 1,766) from the KNOW-CKD (Korean Cohort Study for Outcomes in Patients with Chronic Kidney Disease) cohort who completed the Kidney Disease Quality of Life Short Form questionnaire. After implementing propensity score matching (PSM) using factors that affect the QoL of DN patients, QoL differences between DN and non-DN participants were examined. Results: Among all DN patients (n = 390), higher QoL scores were found for taller subjects, and lower scores were found for those who were unemployed or unmarried, received Medical Aid, had lower economic status, had higher platelet counts or alkaline phosphatase levels, or used clopidogrel or insulin. After PSM, the 239 matched DN subjects reported significantly lower patient satisfaction (59.9 vs. 64.5, p = 0.02) and general health (35.3 vs. 39.1, p = 0.04) than the 239 non-DN subjects. Scores decreased in both groups during the 5-year follow-up, and the scores in the work status, sexual function, and role-physical domains were lower among DN patients than non-DN patients, though those differences were not statistically significant. Conclusion: Among the DN subjects, socioeconomic factors were strong risk factors for impaired QoL, as were high platelet counts, high alkaline phosphatase levels, and clopidogrel and insulin use. Clinicians should keep in mind that the QoL of DN patients might decrease in some domains compared with that in patients with other CKDs.

Introduction Despite of the routine use of erythropoietin in hemodialysis patients to correct anemia, its administration route's effects on hemoglobin variability and cardiovascular events remain elusive. Herein, we determined different erythropoietin administration routes' effects on hemoglobin variability in hemodialysis patients and the associated factors of hemoglobin variability and cardiovascular events. Methods This is a post hoc analysis of a prospective, controlled, randomized, unblinded study with 78 Korean hemodialysis patients receiving intravenous (n = 40) or subcutaneous (n = 38) erythropoietin therapy. We evaluated hemoglobin variability by calculating the frequency of hemoglobin measurements outside the target range during all visits. The high-frequency group was defined by those with hemoglobin variability over the median value (25%) while the low-frequency group was defined by those with hemoglobin variability of Results In this analysis, 37 patients (51.1%) were males, and the mean age was 50.6 ± 12.5 years. The frequency of the value being outside the target hemoglobin range was higher in the subcutaneous group compared to the intravenous group (p = 0.03). The low-frequency group required significantly lower erythropoietin doses compared to the high-frequency group. In the adjusted Cox analysis, the parameter high group was a significant independent risk factor for cardiovascular events (p = 0.03). Conclusion The risk out of the target hemoglobin range increased with subcutaneous administration compared with intravenous erythropoietin administration in hemodialysis patients. An increased frequency of the value being outside the target hemoglobin range was also associated with an increased risk of cardiovascular events.

High-volume online hemodiafiltration (HDF) has been reported to reduce the patient's mortality. However, achieving a high convection volume is challenging. In this prospective study, we investigated the feasibility of achieving high-volume HDF with ≥21 L substitution volume via modification of blood flow rate (BFR), needle size, and dialysis membrane. In 30 patients undergoing hemodialysis, we followed a stepwise protocol and gradually increased the BFR (280→300→330 ml/min; steps 1, 2, and 3) and needle size (16→15 G; step 4). After changing dialyzer surface area (1.8 m2 →2.5 m2 ), the BFR and needle size were similarly increased stepwise (steps 5, 6, 7, and 8). The mean substitution volume was 18.7 ± 2.2 L at step 1 and it significantly increased to 25.1 ± 2.6 L by step 8. A substitution volume of 21 L was achieved by 13.3% of patients in step 1 and by 96.7% after step 8. The substitution volume was higher for the dialyzer with a large surface area and for the larger needle (15 G). Between steps 1 and 8, the Kt/V and β2 microglobulin reduction ratios also improved significantly. High-volume HDF is feasible through a stepwise increase in the BFR, needle size, and surface area of the dialysis membrane.

Background As hemodialysis is administered with the patient lying down, the distribution of body fluid is stable in the lying position, which is why this position is recommended for bioimpedance analysis (BIA). Although the InBody S10 is widely used for hemodialysis patients in the lying position, clinicians must make the measurements in person. In contrast, patients can use the InBody 770 to obtain measurements by themselves in the standing position, which may be more convenient. Therefore, this study compared the measurements of hemodialysis patients’ estimated target weight and ECW/TBW obtained lying down using the S10 to those obtained in the standing position using the 770. Methods This study was conducted among maintenance hemodialysis patients at Chuncheon Sacred Heart Hospital in October 2020. Measurements from 56 patients before and after hemodialysis were obtained using the 2 machines. Each (S10 or 770) estimated target weight, both pre- and post-hemodialysis, was considered ideal when the ECW/TBW ratio was 0.380. R2 was calculated and the Bland-Altman test was performed. Results The patients’ median age was 64 years old, and 51% were men. The actual ultrafiltration was 2 kg, and the mean TBW change measured using the InBody devices was 1.5 L (R2 = 0.718) for the S10 and 1.7 L (R2 = 0.616) for the 770. The estimated target weight at pre- and post-hemodialysis showed a remarkably high correlation with the patients’ actual pre- and post-hemodialysis weight (R2 > 0.095). The correlation between these measurements (lying vs. standing) before and after hemodialysis was also very close (R2 = 1.0000). In addition, ECW/TBW had a good correlation (R2 ≥ 0.970) The Bland-Altman test of dry weight and ECW/TBW yielded similar results. Conclusions This study showed that patients’ estimated target weights in the lying position using the InBody S10 device and in the standing position using the InBody 770 device were consistent in both pre- and post-hemodialysis states.

Background/Aims Hepatitis A virus (HAV) is a self-limiting infectious disease, but 1% of subjects develop fulminant hepatitis. The prevalence of the anti-HAV immunoglobulin G (IgG) antibody in hemodialysis subjects in Korea remains unknown. The purpose of this study was to describe and compare the seropositive rate of anti-HAV antibody among hemodialysis subjects in two hospitals according to age group. Methods A total of 170 hemodialysis subjects were evaluated for the seropositive rate of the anti-HAV IgG antibody and its titer. Results Of the 170 maintenance hemodialysis subjects in two hospitals (Kangnam 92 vs. Chuncheon 78), 79 (46.5%) were male. The mean age was 53.2 years old, and 94.1% of the subjects were over 40 years old. The median vintage of hemodialysis was 29.0 months. Anti-HAV antibody was found in 163 subjects (95.9%), with no significant difference between the two areas (Kangnam 97.8% [n = 90] vs. Chuncheon 93.6% [n = 73]). Subjects younger than 40 years old showed a seropositive rate of 50%, while the seropositive rate increased with age for subjects aged 40 or older (p for trend < 0.001). Seropositive subjects from Kangnam showed a higher anti-HAV antibody titer than those from Chuncheon (median: Kangnam 14.2 vs. Chuncheon 11.7). Only age influenced seropositivity. The only factor that influenced the antibody level was the location of hospital (p < 0.001). Conclusions The seropositive rate of the anti-HAV antibody in hemodialysis subjects was 95%, which is similar to findings in the general population. Active immunization against hepatitis A is strongly recommended for hemodialysis subjects under 40 years of age after anti-HAV testing.

Background/aims Maintaining the patency of vascular access (VA) in hemodialysis (HD) patients is important and can be life-saving. We investigated the effects of aspirin resistance and mean platelet volume (MPV) on VA failure in HD patients. Methods We enrolled 163 patients on maintenance HD. VA failure was defined as thrombosis or a decrease of > 50% of the normal vessel diameter, as revealed by angiography. Results Aspirin resistance was observed in 17 of 109 patients in whom this parameter was measured, and was not significantly associated with VA failure (p = 0.051). The mean MPV was 9.15 ± 0.05 fL. The 163 patients were grouped by the median MPV value (9.08 fL) at baseline; patients with higher MPVs (n = 82) had lower platelet counts (p = 0.002) and albumin levels (p = 0.009). During 34 months of follow-up, 65 VA failures (39.9%) occurred. The Kaplan-Meier curve revealed significant differences between the two groups in terms of cumulative VA failure (54.1% vs. 35.3%, p = 0.018). On multivariate analysis, the MPV (hazard ratio [HR], 1.794; 95% confidence interval [CI], 1.066 to 3.020; p = 0.028), platelet count (HR, 1.003; 95% CI, 1.001 to 1.006; p = 0.01), and smoking status (HR, 1.894; 95% CI, 1.019 to 3.519; p = 0.043) independently predicted VA failure. Conclusion A high MPV was associated with an increased risk of VA failure, whereas aspirin resistance showed only a weak association. The MPV may predict VA survival in HD patients.

Background: Plastic cannulae have attracted increasing interest as an alternative to traditional metal needles with the aim of reducingcannulation-related complications. We investigated whether the substitution volumes during hemodiafiltration differ using thesetwo types of needles in dialysis patients.Methods: An intervention study involving 26 hemodialysis patients was conducted in Korea between March and September in 2021.Patients first received online hemodiafiltration using traditional metal needles, and thereafter plastic cannulae were used in a stepwiseprotocol. Repeated-measures design and linear mixed-effect models were used to compare substitution volumes between thetwo needle types with the same inner diameter.Results: The mean patient age was 62.7 years, and their mean dialysis vintage was 95.2 months. Most patients (92.3%) had an arteriovenousfistula as the vascular access. The substitution volume increased as blood flow and needle size increased for both plasticcannulae and metal needles. The substitution volume was significantly higher with 17-gauge (G) plastic cannulae than with 16-G metalneedles at blood flow rates of 280, 300, and 330 mL/min. Similar results were obtained for 15-G metal needles and 16-G plasticcannulae at a blood flow rate of 330 mL/min. However, the patient ratings of pain on a visual analogue scale were higher for plasticcannulae.Conclusion: Higher substitution volumes were obtained at the same prescribed blood flow rate with plastic cannulae than with metalneedles during online hemodiafiltration. Plastic cannulae are an option for achieving high-volume hemodiafiltration for patients withlow blood flow rates.

Background: Sarcopenia involves an age-related decline in skeletal muscle mass with functional disability or low muscle strength. Vascular calcification (VC) occurs commonly in patients with chronic kidney disease, in whom it is associated with cardiovascular disease. We aimed to investigate the correlations of low muscle mass with the quantified vascular calcification score (VCS) of the arm of vascular access, as well as whether low muscle mass is associated with the incidence of vascular access failure. Methods: The VCS was measured on non-contrast, arm computed tomography using the Agatston method. The lower muscle mass (LMM) group comprised subjects whose skeletal muscle mass of the lower extremities, as measured using bioelectrical impedance, was lower than the median. Higher VC was defined as a score of 500 or above, corresponding to the highest 40% of VCS. The relationship between LMM and VC was explored using univariate and multivariate logistic regression analyses. Results: Seventy-five patients were included, of whom forty-two (56.0%) were men. The median age was 64 years (interquartile range 58–72 years). Of the 75 patients, 73 satisfied the diagnostic criteria for sarcopenia. The median hemodialysis vintage was 49.4 months (range 32.1–99.2 months). No significant differences were found between the non-LMM and LMM groups in sex, end-stage renal disease etiology, and type of vascular access, although the LMM group showed significantly older age and hemodialysis vintage. LMM presented a significant association with VC (hazard ratio (HR) 3.562, 95% CI, 1.341–9.463, p = 0.011). Upon adjustment for hemodialysis vintage, diabetes, and systolic blood pressure, LMM demonstrated an independent association with VC (HR, 10.415, 95% CI, 2.357–46.024, p = 0.002). The risk of vascular access failure was higher in the LMM group (HR, 3.652, 95%, CI 1.135–11.749, p = 0.03). VC was a full mediator in the relationship of LMM with recurrent vascular access failure. Conclusions: We quantified LMM via bioimpedance analysis and found a heretofore-unreported association between LMM and vascular access failure. LMM increases the risk of VC and has the potential to predict vascular access failure.

Background Chronic stimulation of the mineralocorticoid receptor has been suggested as one of the potential causes of cardiovascular events and death in patients with end-stage renal disease. This observational cohort study was performed to demonstrate that serum cortisol might be a predictive marker for patient mortality and to evaluate its association with oxidized low-density lipoprotein (oxLDL) in hemodialysis (HD) patients. Methods Patients receiving HD three times a week were screened for enrollment at two institutions. Baseline cortisol levels were measured before each HD session, and the patients were divided into two groups according to the median value of serum cortisol before analysis. The baseline characteristics and laboratory values of the high and low cortisol groups were compared. Serum cortisol, adrenocorticotropic hormone, renin, aldosterone, and oxLDL were measured in 52 patients to evaluate the effect of oxidative stress on serum cortisol levels. Results A total of 133 HD patients were enrolled in this cohort study. Compared to the patients with low serum cortisol levels, the patients with high serum cortisol levels (baseline cortisol ≥ 10 μg/dL) showed higher rates of cardiovascular disease (59.7% vs. 39.4%, P=0.019) and left ventricular systolic dysfunction (LVSD) (25.9% vs. 8.0%, P=0.016). The patients in the high cortisol group demonstrated higher all-cause mortality than those in the low cortisol group. The serum cortisol level was an independent risk factor for patient mortality (hazard ratio 1.234, 95% confidence interval 1.022-1.49, P=0.029). Among the 52 patients with oxLDL measurements, oxLDL was an independent risk factor for elevated serum cortisol levels (Exp(B) 1.114, P=0.013) and LVSD (Exp(B) 12.308, P=0.045). However, plasma aldosterone levels did not affect serum cortisol levels. Conclusions Serum cortisol is a useful predictive marker for all-cause death among patients receiving HD. OxLDL is an independent marker for elevated serum cortisol among HD patients.

Background : Elevated serum alkaline phosphatase (AP) and γ-glutamyl transferase (γ-GT) are commonly observed in patients with acute pyelonephritis. The goal of this study was to examine the clinical significance of elevated serum AP and γ-GT levels and to explore the mechanisms underlying these changes. Methods : We examined serum AP and γ-GT levels in 438 patients with acute pyelonephritis. Urine AP/creatinine (Cr), urine γ-GT/Cr, fractional excretion of AP, and fractional excretion of γ-GT (FEγ-GT) were evaluated in patients with elevated and normal serum levels. AP isoenzymes were also examined. Results : We identified 77 patients (17.6%) with elevated serum AP and 134 patients (30.6%) with elevated serum γ-GT. Among them, both enzymes were elevated in 64 patients (14.6%). Older age, longer hospital stay, elevated baseline serum Cr, and complicated pyelonephritis were associated with increases in serum AP and γ-GT. Multivariate analysis showed that high serum AP levels were significantly correlated with renal impairment (odds ratio, 2.13; 95% confidence interval, 1.08-4.19; P = 0.029). FEγ-GT was significantly lower in patients with elevated serum enzyme levels. The liver fraction for AP isoenzyme profile did not increase in patients with elevated serum AP. Conclusion : Our results demonstrated that elevated serum AP and γ-GT levels are associated with complicated pyelonephritis and renal impairment. Lower FEγ-GT levels in patients with elevated serum enzymes may be the result of decreased urinary excretion of these enzymes.

Background : This study compared nutritional parameters in hemodialysis (HD) subjects and controls using bioimpedance analysis (BIA) and investigated how BIA components changed before and after HD. Methods : This cross-sectional study included 147 subjects on maintenance HD from two hospitals and 298 propensity score-matched controls from one healthcare center. BIA was performed pre- and post-HD at mid-week dialysis sessions. Results : Extracellular water/total body water (ECW/TBW) and waist-hip ratio were higher in the HD patients’ the other variables were higher in the control group. The cardiothoracic ratio correlated best with overhydration (r = 0.425, P < 0.01) in HD subjects. Blood pressure, hemoglobin, creatinine, and uric acid positively correlated with the lean tissue index in controls; however, most of these nutritional markers did not show significant correlations in HD subjects. Normal hydrated weight was predicted to be higher in the pre-HD than post-HD measurements. Predicted ultrafiltration (UF) volume difference based on pre- and post-HD ECW/TBW and measured UF volume difference showed a close correlation (r2 = 0.924, P < 0.01). Remarkably, the leg phase angle increased in the post-HD period. Conclusion : The estimated normal hydrated weight using ECW/TBW can be a good marker for determining dry weight. HD subjects had higher ECW/TBW but most nutritional indices were inferior to those of controls. It was possible to predict UF volume differences using BIA, but the post-HD increase in leg phase angle, a nutritional marker, must be interpreted with caution.

Background and Aims Patients with end-stage renal disease have an increased risk of cardiovascular (CV) mortality and left ventricular diastolic dysfunction (LVDD) is known to contribute to its high occurrence. Although high serum aldosterone level is involved in the development of CV complications in general population, this association is unclear in patients undergoing hemodialysis (HD). We aimed to determine the impact of serum aldosterone on LVDD and CV mortality among HD patients. Method We performed a prospective cohort study of maintenance HD patients without CV disease. Patients were divided into two groups according to the median level of serum aldosterone (44 ng/dL). All patients underwent echocardiography to evaluate diastolic dysfunction. Proportions of LVDD and CV mortality were compared between high and low aldosterone groups. Results We enrolled a total of 60 adult patients (mean age 57.9±12.1 years, male 30.0%). Low aldosterone group had an increased left ventricular diastolic dimension compared with high aldosterone group (52.2±8.4 vs. 50.3±5.2 mm, p=0.033). The E/è ratio (19.5±7.5 vs. 14.6±5.2, p=0.024) was significantly higher among patients in low aldosterone group compared to high aldosterone group. There were no significant differences either in ejection fraction, LVMI, or the proportion of LVH between two groups. Low log-aldosterone (odds ratio 0.403; 95% confidence interval 0.188-0.862) and large left atrial dimension (1.308; 1.114-1.536) were independent risk factors for LVDD. In addition, cox regression analysis demonstrated that low log-aldosterone was an independent predictor of CV mortality in HD patients (hazard ratio 0.505; 95% confidence interval 0.294-0.869, p=0.014). Conclusion Low serum aldosterone was not only associated with LVDD but also an independent predictor of CV mortality among HD patients.

Supplemental Digital Content is available in the text, Renal cell carcinoma (RCC) is known to be more prevalent in autosomal dominant polycystic kidney disease (ADPKD) patients than in the general population. However, little is known about genetic alterations or changes in signaling pathways in RCC in patients with ADPKD. In the current report, whole-exome and transcriptome sequencing was performed for paired samples of tumor tissue, cyst tissue, and peripheral blood (triple set) from a patient diagnosed with ADPKD and RCC. A 68-year-old man with ADPKD underwent left partial nephrectomy and was diagnosed with RCC. DNA and RNA were extracted from the triple set of the patient. A nonsense mutation in PKD2 (p.Arg742X), which is well known as a pathogenic variant in ADPKD, was identified in the paired triple set. In the tumor sample, a somatic missense mutation of VHL (p.S65L) was found, which is known as a pathogenic mutation in Von Hippel-Lindau syndrome and RCC. Furthermore, loss of chromosome 3p, where VHL is located, was detected. Upregulated VEGFA was found in the analysis of RCC mRNA, which might be caused by the loss of VHL and accelerate angiogenesis in RCC. Proliferation was also expected to be activated by the MAPK signaling pathway, including NRAS and MAPK1 expression.

Static intra-access pressure ratio (SIAPR) measurement, using haemodialysis machine transducers, is the vascular access surveillance method in patients undergoing haemodialysis. However, little is known about the relationship between the SIAPR and arterial stiffness, and the clinical usefulness of the SIAPR in predicting cardiovascular events. A total of 209 patients undergoing maintenance haemodialysis were evaluated. The SIAPRs ranged from 0.01 to 0.52 (median: 0.23). When the patients were divided into two groups according to their median of SIAPR, the incidence of previous cardiovascular disease, E/E′ ratio, and brachial-ankle pulse wave velocity were significantly higher in the patients with SIAPRs of ≤0.23 than in those with SIAPRs of >0.23. Conversely, patients with worse comorbid status had a lower SIAPR than patients without it. In the Kaplan-Meier analysis, the cumulative incidence of cardiovascular events was significantly higher in the patients with SIAPRs of ≤0.23 than in those with SIAPRs of >0.23 (P

A 47-year-old female previously diagnosed with ADPKD visited the hospital due to sudden pain in her upper abdomen and back. Esophagogastroduodenoscopy, contrast-enhanced abdominal computed tomography (CT), and CT angiography identified an esophageal artery pseudoaneurysm and hematoma in the esophagus. Urgent angiography and embolization were performed. After the procedure, CT angiography and positron emission tomography were performed due to differences in blood pressure between the arms. The patient was also found to have Takayasu arteritis and subsequently received outpatient follow-up care. The possible mechanisms that cause vascular abnormalities in ADPKD patients include damaged vascular integrity due to abnormal polycystin expression caused by PKD mutations and connective tissue abnormalities. Further research is needed to confirm these mechanisms, and ADPKD patients should be assessed for vascular abnormalities.

Background End-stage renal disease is a common predisposing condition for the development of hypoglycaemia. Aim To determine the effect of hypoglycaemia on the mortality of patients undergoing maintenance dialysis. Methods Retrospective and descriptive analyses were performed in five dialysis centres in the Republic of Korea between June 2002 and August 2008. We enrolled 1685 patients who had undergone dialysis for at least 1 month. Results We identified 453 episodes of hypoglycaemia in 256 of 1685 patients (15.2%); 189 patients (73.8%) had diabetes, whereas the other patients did not. The occurrence of hypoglycaemia in patients receiving dialysis appeared to be a life-threatening complication because 27.0% of patients died within two days of the onset of a hypoglycaemic episode. Older age, low serum albumin levels and infections were independent risk factors for total mortality in these patients. Furthermore, the absence of diabetes, age and serum glucose levels were independent factors associated with early mortality within two days of the development of hypoglycaemia. Conclusion Although several factors were associated with mortality, the degree of hypoglycaemia, absence of diabetes and old age were associated with early mortality. Elderly hypoglycaemic patients, especially those without diabetes, should be closely monitored.

Background and aimsMalnutrition and inflammation are closely linked to vascular calcification (VC), the severity of which correlate with adverse outcome. However, there were few studies on the interplay between malnutrition, inflammation and VC progression, rather than VC presence per se. We aimed to determine the relationship of malnutrition, inflammation, abdominal aortic calcification (AAC) progression with survival in hemodialysis (HD) patients.MethodsMalnutrition and inflammation were defined as low serum albumin (< 40 g/L) and high hs-CRP (≥ 28.57 nmol/L), respectively. We defined AAC progression as an increase in AAC score using lateral lumbar radiography at both baseline and one year later. Patients were followed up to investigate the impact of AAC progression on all-cause and cardiovascular mortality.ResultsAAC progressed in 54.6% of 97 patients (mean age 58.2±11.7 years, 41.2% men) at 1-year follow-up. Hypoalbuminemia (Odds ratio 3.296; 95% confidence interval 1.178-9.222), hs-CRP (1.561; 1.038-2.348), low LDL-cholesterol (0.976; 0.955-0.996), and the presence of baseline AAC (10.136; 3.173-32.386) were significant risk factors for AAC progression. During the mean follow-up period of 5.9 years, 38(39.2%) patients died and 27(71.0%) of them died of cardiovascular disease. Multivariate Cox regression analysis adjusted for old age, diabetes, cardiovascular history, and hypoalbuminemia determined that AAC progression was an independent predictor of all-cause mortality (2.294; 1.054-4.994).ConclusionsMalnutrition and inflammation were significantly associated with AAC progression. AAC progression is more informative than AAC presence at a given time-point as a predictor of all-cause mortality in patients on maintenance HD.

Encapsulating peritoneal sclerosis (EPS) is a potentially fatal complication after long-term peritoneal dialysis, and tamoxifen can be used for its prevention and treatment. However, tamoxifen is known to increase the risk of venous thromboembolism. A 49-year-old woman was admitted with sudden abdominal pain. The patient had received peritoneal dialysis for 20 years and switched to hemodialysis after the diagnosis of EPS. Tamoxifen (10mg) and prednisolone (20mg) had been administered for 8 months. On computed tomography, the left hepatic lobe was hardly illuminated, leading to a diagnosis of liver infarction. A month later, she was re-admitted due to abdominal pain and extensive deep vein thrombosis of the leg. The administration of tamoxifen was stopped and prednisolone was reduced to 10mg. As her malnutrition progressed, she succumbed to death of gram negative sepsis. The patient was concluded to have liver infarction and extensive venous thrombosis as a side effect of tamoxifen.

Background The Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines recommend intra-access flow (Qa) measurement as the preferred vascular access surveillance method over static intra-access pressure ratio (SIAPR). Recently, it has become possible to perform Qa measurement during hemodialysis using thermodilution method called blood temperature monitoring (BTM) with the Twister device. The aim of this study was to investigate the correlation between Qa by BTM and SIAPR and to compare the performance of two tests in prediction of vascular access stenosis. Methods The study was performed from January 2016 to November 2017 and included 97 patients with arteriovenous fistulas (AVF). Qa by BTM and SIAPR were simultaneously measured every 1~3 months with a total of 449 measurements during study period. Results In our study population, mean age was 59.9±10.0 years and 61.9% were diabetes. The mean Qa obtained by BTM was 1186±588 mL/min. There was no correlation between Qa by BTM and venous SIAPR (r = 0.061, P = 0.196). Angiography identified 36 stenotic AVFs (37.1%) among the study subjects. They included 13 cases with only inflow stenosis, 6 with only outflow stenosis, and 17 with stenosis on both sides. Receiver-operating characteristic (ROC) curve analysis showed that Qa by BTM had higher discriminative ability to diagnose vascular access stenosis compared to SIAPR (P

Diabetic bladder dysfunction (DBD) is a common complication of type 2 diabetes mellitus (T2DM). The association between DBD and progression of diabetic nephropathy has not been clarified. In this study, we investigated the relationship between post-voiding residual urine (PVR) with decline in renal function in patients with type 2 diabetes. This retrospective study included 164 patients at a single center. We collected medical histories and laboratory findings of patients undergoing uroflowmetry from January 1, 2008 to October 30, 2013. Renal function was assessed by calculating the estimated glomerular filtration rate (eGFR) using the Modification of Diet in Renal Disease (MDRD) study equation. We evaluated whether greater PVR was a risk factor for faster decline of GFR during a 1-year follow-up. The subjects' mean age was 65±12 years, duration of diabetes 12.8±8.8 years, baseline serum creatinine level 106.1±53.0 μmol/L, and eGFR was 64.6±25.2 mL/min/1.73 m(2). Mean PVR was 69.8±96.3 mL and in 17.7% of subjects, PVR>100 mL. In linear regression analysis, PVR was independently associated with GFR decrease (standardized β coefficient=0.2, P=0.009). Multiple logistic analysis showed that subjects with PVR>100 mL had a 2.8-fold higher risk of an eGFR change during 1 year higher than the median value of all subjects (95% confidence interval, 1.1-6.8; P=0.03). Increased PVR was independently associated with a more rapid decline in renal function in patients with type 2 diabetes.

Background/Aims Diabetic cystopathy is a frequent complication of diabetes mellitus. This study assessed the association between the post-voiding residual (PVR) urine volume and diabetic nephropathy in type 2 diabetics with no voiding symptoms. Methods This study investigated 42 patients with type 2 diabetes who were followed regularly at our outpatient clinic between July 1, 2008 and June 30, 2009. No patient had voiding problems or International Prostate Symptom Scores (IPSSs) ≥ 12. An urologist performed the urological evaluations and the PVR was measured using a bladder scan. A PVR > 50 mL on two consecutive voids was considered abnormal, which was the primary study outcome. Results The mean patient age was 60 ± 10 years; the IPSS score was 3.7 ± 3.3; and the diabetes duration was 11.9 ± 7.8 years. Seven of the 42 patients (16.7%) had a PVR > 50 mL. The presence of overt proteinuria or microalbuminuria was associated with an increased risk of a PVR > 50 mL (p < 0.01). Patients with a PVR > 50 mL had a significantly lower estimated glomerular filtration rate (eGFR) compared with those with a PVR ≤ 50 mL (59.2 ± 27.1 mL/min/1.73 m2 vs. 28.7 ± 23.3 mL/min/1.73 m2; p < 0.001). Multivariate logistic analysis revealed that a lower eGFR (odds ratio, 0.94; 95% confidence interval, 0.88 to 0.99; p = 0.04) was a significant risk factor for a PVR > 50 mL. Conclusions Patients with diabetic nephropathy had a significantly higher PVR and a lower eGFR was associated with an abnormal PVR.

Background Vascular calcification is associated with structural and functional abnormality of the heart and blood vessels. We investigated the relationship between intradialytic hypotension (IDH) and vascular calcification in hemodialysis (HD) patients, and their impacts on cardiovascular events (CVEs). Method We enrolled 191 maintenance HD patients who underwent plain abdomen radiography for abdominal aortic calcification score (AACS). A nadir systolic blood pressure (BP) < 90 mm Hg or the requirement of bolus fluid administration was required to quantify the hypotension diagnosis. IDH was defined as > 2 hypotension episodes during 10 HD treatments. Results Among the 191 patients, IDH occurred in 32. AACS was higher in the IDH group compared with the no-IDH group (8.4 ± 6.0 vs. 4.9 ± 5.2, respectively; P = 0.001). High AACS was an independent risk factor after adjustment for age, diabetes mellitus, ultrafiltration, diastolic BP, and calcium level (odds ratio (OR) = 1.09, 95% CI = 1.01–1.18; P = 0.03). Patients with both IDH and AACS ≧ 4 had the highest cumulative CVE rate (27.9%, P = 0.008) compared with 11.2%, 12.5%, and 6% for those with AACS ≧ 4 only, with IDH only, and neither, respectively. In multivariate analysis, the presence of both IDH and AACS ≧ 4 was a significant predictor of CVE (hazard ratio (HR) = 2.84, 95% CI = 1.04–7.74, P = 0.04). Conclusion IDH is associated with abdominal aortic calcification and is an independent risk factor for IDH. Both IDH and high AACS were significant predictors of CVE.

Background Periprocedural (6h pre- and 24h post-angiography) hemofiltration appears to effectively prevent contrast-induced nephropathy (CIN) in chronic kidney disease (CKD) patients undergoing coronary angiography. However, this procedure over-uses medical resources, and the cessation of hemofiltration during coronary angiography results in persistent renal injury. In comparison, simultaneous hemofiltration performed only during coronary angiography requires fewer medical resources and can provide instantaneous protection against CIN. Methods Sixty-eight CKD patients (serum creatinine, 2.51±1.15mg/dL) undergoing coronary angiography were randomized in a 1:2 ratio to receive either periprocedural (n=23) or simultaneous (n=45) hemofiltration. The expected CIN rate was similar for the two groups (41.3% versus 40.0%, p=0.769). Results On day 3 after contrast exposure, four and seven patients in the periprocedural and simultaneous groups, respectively experienced CIN (17.4% versus 15.6%, p=0.846). On days 5–30, seven and three patients in the periprocedural and simultaneous groups, respectively experienced CIN (30.4% versus 6.7%, p=0.009). The serum creatinine levels of patients in the periprocedural group transiently decreased on day 1 and persistently increased during days 5–30 compared with the simultaneous group. This difference between the two groups in terms of creatinine levels over time was statistically significant (F statistic=6.830; p=0.001, by ANCOVA). The cost of hemofiltration was doubled in the periprocedural group ($1066±83 versus $504±40, p Conclusions Simultaneous hemofiltration provide equal early (day 3) and better late-stage (days 5–30) renal protection against CIN at a significantly lower cost compared with periprocedural hemofiltration.

Background: In chronic hemodialysis patients, malnutrition, inflammation, depression and arteriosclerosis are pathogenetically associated suggesting the presence of malnutrition-inflammation-depression-arteriosclerosis (MIDA) complex acting as a risk factor for cardiovascular disease (CVD). Methods: Nutritional status was assessed by serum albumin, subjective global assessment and normalized protein catabolic rate (nPCR). Inflammation was assessed by serum high-sensitivity C-reactive protein (hsCRP). Depression was assessed with the Beck Depression Inventory and DSM-IV criteria. The severity of arteriosclerosis was measured by pulse wave velocity (PWV). Results: Among 81 hemodialysis patients, 44 (54.3%) had malnutrition (albumin 1 mg/l). The prevalence of depression was 50.6% (n = 41). Fifty-nine (73.8%) had arteriosclerosis (measured PWV > expected PWV based on age/blood pressure/gender adjustment). The severity of the all four individual MIDA components correlated well with each other. The average number of the MIDA complication (MIDA score) was 2.27 ± 1.33. -During the 5-year follow-up, 40 cases of CVD and 26 cases of all-cause death occurred. In Cox analysis adjusted for -previous CVD, age, diabetes, blood pressure, pulse pressure, intradialytic hypotension, B-type natriuretic peptide, -hemoglobin and hemodialysis incompliance, the MIDA score was an independent predictor of CVD and all-cause death: hazard ratio (95% confidence interval); 1.89 (1.13-3.17) and 3.48 (1.32-9.21) for an increase of 1 MIDA score. Conclusions: This study suggests the presence of MIDA complex, which is composed of malnutrition, inflammation, depression and arteriosclerosis. The MIDA complex syndrome was an independent risk factor for CVD and all-cause death in chronic hemodialysis patients.

Background In hemodialysis patients, fluid overload and malnutrition are accompanied by extracellular fluid (ECF) expansion and intracellular fluid (ICF) depletion, respectively. We investigated the relationship between ECF/ICF ratio (as an integrated marker reflecting both fluid overload and malnutrition) and survival and cardiovascular disease (CVD) in the context of malnutrition-inflammation-arteriosclerosis (MIA) complex. Methods Seventy-seven patients from a single hemodialysis unit were prospectively enrolled. The ECF/ICF volume was measured by segmental multi-frequency bioimpedance analysis. MIA and volume status were measured by serum albumin, C-reactive protein (CRP), pulse wave velocity (PWV) and plasma B-type natriuretic peptide (BNP), respectively. Results The mean ECF/ICF ratio was 0.56±0.06 and the cut-off value for maximum discrimination of survival was 0.57. Compared with the low ECF/ICF group, the high ECF/ICF group (ratio≥0.57, 42%) had higher all-cause mortality, CVD, CRP, PWV, and BNP, but lower serum albumin. During the 5-year follow-up, 24 all-cause mortality and 38 CVD occurred (18 and 24, respectively, in the high ECF/ICF group versus 6 and 14 respectively in the low ECF/ICF group, P

Background Paraquat poisoning can be lethal, and aggressive treatments might have little or no effect on severely poisoned patients. Accordingly, a convenient prognostic test is necessary to guide therapy for acute paraquat poisoning. Sodium dithionite reduces paraquat to a blue radical form in alkaline plasma with a paraquat detection sensitivity of 2.0 mg/L, which is a 100% lethal concentration at 10 to 12 hours postingestion. The prognostic utility of this simple reaction was examined prospectively. Methods Of 233 paraquat-poisoned patients, who were taken to the hospital within 12 hours after ingestion, the plasma samples obtained on arrival were tested using the sodium dithionite reaction. Standard saline containing 2.0 mg/L paraquat was used as the positive control. The test result was interpreted as being positive when the plasma test yielded a blue color darker than that of the positive control. The effects of aggressive treatment, including cyclophosphamide pulse and continuous venovenous hemofiltration, were evaluated retrospectively. Results The discharge survival rate was 41.6% (97 of 233). Ninety-seven of 142 patients with negative or equivocal plasma dithionite test survived. However, all 91 patients with positive plasma dithionite test died of multiorgan failure. Cyclophosphamide and/or continuous venovenous hemofiltration could not improve survival. conclusion In this single-center study, a positive plasma dithionite test was associated with 100% mortality, despite aggressive treatment. In contrast, negative or equivocal tests were associated with a 68% survival rate. It is believed that after further verification, this test can be used to guide therapy and predict the outcomes of patients suffering acute paraquat poisoning.

We investigated the effect of rapamycin, a specific inhibitor of the mammalian serine/threonine kinase, mammalian target of rapamycin (mTOR), on the expression of inducible nitric oxide synthase (iNOS) in lipopolysaccharide (LPS)-stimulated RAW 264.7 cells. Pretreatment of cells with rapamycin significantly inhibited LPS-induced nitrite production and the expression of iNOS protein in a dose-dependent manner. However, LPS-induced mRNA expression of iNOS and its concomitant activation of nuclear factor (NF)-kappaB remained unchanged by rapamycin. Intriguingly, LPS-induced nitrite production and iNOS protein expression were partially blocked at nanomolar concentrations of rapamycin, whereas phosphorylation of both p70 S6 kinase and 4E-BP1 was completely abolished. The suppression of LPS-induced iNOS expression by rapamycin was reversed by the protease inhibitor lactacystin. Furthermore, rapamycin treatment stimulated 20S proteasome activity, which was slightly elevated by LPS. Taken together, our findings strongly suggest that rapamycin down-regulates LPS-induced iNOS protein expression via proteasomal activation, as well as through inhibition of the mTOR signaling pathway.

Background.Inpatientswithchronicrenalfailure,theability to reduce the administration frequency of subcutaneous (SC) erythropoietin (epoetin) could provide benefits and may improve compliance. The study investigated whether once-weekly SC epoetin alfa was equivalent to twice- or thrice-weekly SC administration in maintaining anaemia correction in haemodialysis patients. Methods. Eighty-three patients were randomly assigned to either once-weekly epoetin alfa (n = 44) or their original dose twice- or thrice-weekly regimen (control, n = 39) for 12 weeks. The haemoglobin concentration was maintained within the target range of 9.0–12.0 g/dL by adjusting the dose of epoetin alfa. All patients received intravenous iron supplementation, as required. Results. Stable haemoglobin levels were maintained without epoetin dose increases in the majority of patients in both groups (once-weekly group, 95.0%, control group, 91.4%). The mean haemoglobin levels at randomization at weeks 4, 8 and 12 were 10.7, 11.1, 11.3 and 11.0 g/dL, respectively, in the once-weekly group, and 10.5, 11.3, 11.5 and 11.3 g/dL, respectively, in the control group. The mean weekly dose of epoetin alfa at randomization at weeks 4, 8 and 12 was 142.8, 114.5, 108.6 and 104.5 IU/kg, respectively, in the once-weekly group, and 128.4, 116.0, 101.0 and 96.1 IU/kg/week, respectively, in the control group. No statistically significant between-group differences were apparent for changes in haemoglobin levels or epoetin alfa dosages at week 12. Conclusions. This study demonstrates that once-weekly SC administration of epoetin alfa is as effective and safe as two or three times weekly administration in maintaining haemoglobinlevels.Therefore,theonce-weeklytherapyusing high dose of epoetin alfa is considered to be an efficient method in stable haemodialysis patients.