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A 65-year-old woman on peritoneal dialysis (PD) was admitted due to abdominal pain with cloudy PD effluent. The white blood cell count in PD effluent was 5860/µL with 85% polymorphonuclear neutrophils. Therefore, she was clinically diagnosed with peritonitis. The cultures of PD effluent were negative. Initial abdominal computed tomography did not find suggest any intraabdominal pathology. The patient was treated with empirical intraperitoneal antibiotics. Because abdominal pain with cloudy PD effluent persisted, the PD catheter was removed eventually. The culture of the removed PD catheter grew Klebsiella pneumoniae . However, intermittent fever was noted over the following days and empyema developed approximately 2 weeks after PD catheter removal. The culture of pleural fluid also grew K. pneumoniae . Another computed tomography revealed multiple intraabdominal abscesses that was assumed to come from a complication of PD-associated peritonitis. We postulate that the empyema might be caused by transdiaphragmatic extension of the intraabdominal abscesses into the pleural space., Competing Interests: Declaration of conflicting interestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Decreased functional capacity and reduced cardiac function were the main symptoms in patients with heart failure (HF) and the incidence increases with advanced age. The guidelines recommend that exercise training should be considered for medically stable HF outpatients. Studies have confirmed that exercise can improve functional capacity, prognosis, and reduced hospitalization rates; however, very few studies have investigated the elderly. It is not clear whether exercise could be feasible in elderly HF. The aim of this study was to evaluate the effect of the 6-month heart failure post-acute care program focused on home-based cardiac telerehabilitation (HCTR) on functional capacity, cardiac function, and readmission rates in HF patients. A prospective longitudinal study was conducted. Study duration was from January 2018 to December 2019. HF patients with a left ventricular ejection fraction <40% and age ≧65 years were included and divided into intervention (n = 40) and control group (n = 41). We arranged a 6-month heart failure post-acute care program that included outpatient cardiac rehabilitation and home exercise for the intervention group. The response to home exercise was followed by telemonitor. The exercise parameters were recorded on the HF health management mobile application system platform by each patient and daily transmission to hospital's cloud database as HCTR, usual care program for the control group. Information such as general data, laboratory data, six-minute walk test, cardiac function, and admission record was collected from all patients. Eighty one patients between the ages of 65 and 92 completed the study. The mean age was 73.3 ± 5.0 and 75.6 ± 6.0 years in control and intervention group, respectively. The intervention group showed a statistically significant improvement in functional capacity, percentage change in the of six-minute walk distance (51.2% vs 17.7%, P < .05, 95% confidence interval -45.9 to -6.3). Left ventricular ejection fraction increased by 7.7%, which corresponds to 25.6% in relative terms (P < .05, 95% confidence interval -7.8 to -0.5). The readmission rate was 4.6% in the intervention group. Six months of post-acute HF focused on HCTR programs was safe, improved functional capacity, cardiac function, and decreased readmission rate in elderly patients with HF patients., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Macrophages are critical players in regulating innate and adaptive immunity in the tumor microenvironment (TME). The prognostic value of macrophages and their heterogeneous phenotypes in non-small cell lung cancer (NSCLC) is still uncertain., Methods: Surgically-resected samples of 681 NSCLC cases were stained by multiplex immunofluorescence to examine macrophage phenotypes as well as the expression levels of program death-ligand 1 (PD-L1) on them in both tumor nest and tumor stroma, including pan-macrophage (CD68+), M1 (CD68+CD163-), and M2 macrophages (CD68+CD163+). Various other immune cell markers, including CD4, CD8, CD20, CD38, CD66B, FOXP3, and CD133, were also evaluated. Machine learning algorithm by Random Forest (RF) model was utilized to screen the robust prognostic markers and construct the CD68-based immune-related risk score (IRRS) for predicting disease-free survival (DFS)., Results: The expression levels of CD68 were moderately correlated with the levels of PD-L1 (P<0.001), CD133 (P<0.001), and CD8 (P<0.001). Higher levels of CD68 (OR 1.03, 95% CI: 1.01-1.05, P<0.001) as well as M1 macrophage (OR 1.04, 95% CI: 1.01-1.06, P<0.001) indicated shorter DFS. Despite without statiscial significance, intratumoral M2 macrophage (OR 1.05, 95% CI: 0.99-1.10, P=0.081) was also associated with worse DFS. IRRS incorporating three intratumoral CD68-related markers and four intrastromal markers was constructed and validated to predict recurrence (high-risk group vs. low-risk group: OR 2.52, 95% CI: 1.89-3.38, P<0.001). The IRRS model showed good accuracy [area under the curve (AUC) =0.670, 0.709, 0.695, 0.718 for 1-, 3-, 5-year, and overall DFS survival, respectively] and the predictive performance was better than the single-marker model (area under the curve 0.718 vs. 0.500-0.654). A nomogram based on clinical characteristics and IRRS for relapse prediction was then established and exhibited better performance than the tumor-node-metastasis (TNM) classification and IRRS system (C-index 0.76 vs. 0.69 vs. 0.60, 0.74 vs. 0.67 vs. 0.60, 0.81 vs. 0.74 vs. 0.60 of the entire, training, testing cohort, respectively)., Conclusions: Our study suggested close interactions between CD68 and other immune markers in TME, demonstrating the prognostic value of CD68 in relapse prediction in resectable NSCLC., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tlcr.amegroups.com/article/view/10.21037/tlcr-21-916/coif). WHL serves as an unpaid Associate Editors-in-Chief of Translational Lung Cancer Research. TY, HBZ, and YHC are employed by Genecast Biotechnology Co., Ltd. The other authors have no conflicts of interest to declare., (2022 Translational Lung Cancer Research. All rights reserved.)

Background: Significantly rising plasma circulating C-reaction protein (CRP) concentrations are pervasive in lung cancer (LC) development, demonstrating a bidirectional relation. However, it remains uncertain whether the causation between them exists, and the degree to which the effect varies across different ethnic ancestries remains unknown. Therefore, we attempted to investigate the causal relationship between these two phenotypes., Methods: With summary statistics of CRP-related single nucleotide polymorphisms (SNPs) identified by several large-scale genome-wide association studies (GWAS) datasets based on five ethnic ancestries coverage worldwide, we implemented bidirectional two-sample Mendelian randomization (MR) analyses. Genetic summary data of 11,348 LC cases and 15,861 controls from the International Lung Cancer Consortium (ILCCO) were applied. The inverse-variance weighted (IVW) approach was utilized as the principal analysis, supplemented by various complementary methods., Results: MR study did not reveal the causal relationship shared across genetically predisposed CRP blood concentrations and LC risk (OR =1.022, 95% CI: 0.965-1.083, P=0.455) including pathological subtypes (OR =1.026, 95% CI: 0.947-1.112, P=0.534 for lung adenocarcinoma; OR =1.060, 95% CI: 0.970-1.158, P=0.201 for squamous cell lung cancer). Further analyses among East Asian, Hispanic/Latin American, European, African American/Afro-Caribbean, and South Asian populations revealed consistent null causation. Additionally, the causal effects of LC on CRP concentrations were not statically significant (OR =0.999, 95% CI: 0.977-1.021, P=0.923)., Conclusions: We did not observe a bidirectional causal association between CRP blood concentrations on LC among East Asian, Hispanic/Latin American, European, African American/Afro-Caribbean, and South Asian ancestry individuals., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://dx.doi.org/10.21037/tlcr-21-750). The authors have no conflicts of interest to declare., (2021 Translational Lung Cancer Research. All rights reserved.)

We report a 73-year-old male with no relevant past medical history who presented with nephrotic syndrome and jaundice. Subsequent studies revealed immunoglobulinM (IgM) monoclonal gammopathy. Kidney biopsy revealed monoclonal Ig deposition disease and amyloidosis. Bone marrow biopsy demonstrated <10% infiltration by lymphoplasmacytic cells. However, rapidly progressive hypergammaglobulinemia of IgM and hyperbilirubinemia were noted. Despite aggressive treatment, the patient developed acute kidney injury and complications of hepatic failure. He eventually died of pneumonia, just two months after diagnosis.

Background: Exercise tolerance and cardiac output have a major impact on the quality of life (QOL) of patients experiencing heart failure (HF). Home-based cardiac rehabilitation can significantly improve not only exercise tolerance but also peak oxygen uptake ((Equation is included in full-text article.)peak), and the QOL in patients with HF. The aim of this prospective study was to evaluate the beneficial effects of home-based cardiac rehabilitation on the quality of medical care in patients with chronic HF., Methods: This study was a randomized prospective trial. HF patients with a left ventricular ejection fraction (LVEF) of less than 50% were included in this study. We randomly assigned patients to the control group (n = 18) and the interventional group (n = 19). Within the interventional group, we arranged individualized rehabilitation programs, including home-based cardiac rehabilitation, diet education, and management of daily activity over a 3-month period. Information such as general data, laboratory data, Cardiopulmonary Exercise Test (CPET) results, Six-minute Walk Test (6MWT) results, and the scores for the Minnesota Living with Heart Failure Questionnaire (MLHFQ) before and after the intervention, was collected from all patients in this study., Results: Patients enrolled in the home-based cardiac rehabilitation programs displayed statistically significant improvement in (Equation is included in full-text article.)peak (18.2 ± 4.1 vs 20.9 ± 6.6 mL/kg/min, P = .02), maximal 6-Minute Walking Distance (6MWD) (421 ± 90 vs 462 ± 74 m, P = .03), anaerobic threshold (12.4 ± 2.5 vs 13.4 ± 2.6 mL/kg/min, P = .005), and QOL. In summary, patients receiving home-based cardiac rehabilitation experienced a 14.2% increase in (Equation is included in full-text article.)peak, a 37% increase in QOL score, and an improvement of 41 m on the 6MWD test. The 90-day readmission rate for patients reduced to 5% from 14% after receiving cardiac rehabilitation., Conclusion: Home-based cardiac rehabilitation offered the most improved results in functional capacity, QOL, and a reduced the rate of readmission within 90 days.

Aim: There is little information on the relationship between uric acid (UA) and residual renal function (RRF) in continuous ambulatory peritoneal dialysis (CAPD). The aim of this research is to study the influence of UA on RRF decline in CAPD patients., Methods: A retrospective observational cohort study of 304 patients who started CAPD without anuria between 2001 and 2010 was conducted at a single medical center. The outcomes measured in the study included the rate of RRF decline and anuria. A multiple ordinal logistic regression model with backward elimination was conducted to determine the independent factors of the slope of RRF decline. A Cox proportional hazard model was conducted to determine the independent variables of time to anuria., Results: The average rate of RRF decline was -0.12 ± 0.22 mL/min per month. Multivariate analysis showed that lower UA group (<0.372 mmol/L), higher UA group (≧0.421 mmol/L), male gender, diabetes mellitus (DM), the use of calcium channel blocker (CCB), and RRF at baseline were linked positively with the rate of RRF decline; on the other hand, independence in dialysate exchanges and BUN were negatively associated with the risk of RRF decline. In addition, male gender, DM, diuretics, and CCB were associated with a higher risk of progression to anuria, whereas 24-h urine amount at baseline conferred a protective role in the development of anuria., Conclusions: A U-shaped relationship was found between UA levels and the rate of RRF decline in patients on CAPD, with a faster decline rate in those of higher and lower UA groups., (© 2015 Asian Pacific Society of Nephrology.)

Aim: Chronic kidney disease (CKD) is always associated with hyperuricaemia. However, the studies evaluating the clinical implications of hyperuricaemia have shown conflicting results in these patients., Methods: A retrospective observational study was conducted in 2408 stage 3-5 CKD patients. Instead of one baseline uric acid (UA) level, the averaged level of the two consecutive measurements for each participant was used as the predictor for the outcomes of the study, which included mortality, renal outcomes, and hospitalization risk. A multivariate Cox proportional hazards model and logistic regression model were performed to determine the independent risk factor., Results: The mean UA level was 0.46 ± 0.106 mmol/L. Of the 2408 patients, there were 563 (23.3%) deaths, 143 (5.9%) cardiovascular deaths, 652 (27%) subjects commencing renal replacement therapy (RRT), 664 (27.5%) subjects with rapid renal progression, 1937 (58%) patients requiring hospitalization and 404 (16.7%) patients with CVD hospitalization during a mean follow-up of approximately 3.03 years. After multivariate adjustments, a 1-mg/dL increase in uric acid level was associated with a hazard ratio (HR) of 1.26 for RRT (P = 0.002), an odds ratio (OR) of 1.27 for rapid renal progression (P = 0.001), an HR of 1.19 for all-cause hospitalization (P < 0.001), and an HR of 1.12 for cardiovascular disease (CVD) hospitalization (P = 0.02), but not significantly with all-cause mortality and cardiovascular death at the end of follow-up., Conclusions: In stage 3-5 CKD patients, hyperuricaemia was associated with a higher risk of renal replacement therapy, rapid renal progression and hospitalization for all causes or CVD, but not with all-cause mortality or cardiovascular mortality., (© 2015 Asian Pacific Society of Nephrology.)

Objectives: Uric acid (UA) is the product of purine or nucleotide metabolism via the pathway of xanthine oxidase or xanthine dehydrogenase. Although epidemiological studies assessing the role of UA in cardiovascular disease or mortality have produced inconsistent results, the correlation between UA and technique failure in patients on continuous ambulatory peritoneal dialysis (CAPD) remains to be assessed., Design: A retrospective cohort study., Setting: Patients starting CAPD between 2001 and 2009 in a single centre in Taiwan., Participants: A total of 371 patients on CAPD., Primary Outcome Measures: All-cause and peritonitis-related technique failure., Results: A cohort of 371 participants (43.9% male) was enrolled in the study with a mean age of 55.7±15.9 years at the start of CAPD. During the study period, technique failure occurred in 41 (34.4%) patients in the hyperuricaemia group compared with 49 (19.4%) in the normouricaemia group (p=0.003). In the multivariate Cox regression models, hyperuricaemia at baseline was significantly associated with both a higher risk of technique failure (HR 1.24; 95% CI 1.09 to 1.42, p=0.001) and peritonitis-related technique failure (HR 1.29; 95% CI 1.07 to 1.57, p=0.008)., Conclusions: UA was shown to be associated with all-cause and peritonitis-related technique failure in our study. Patients on CAPD with hyperuricaemia should be closely monitored and strategies of increasing survival on CAPD should be taken., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background and Objectives: Mean corpuscular volume is the measure of the average size of the circulatory erythrocyte, and it is principally used as an index for the differential diagnosis of anemia. Recently, mean corpuscular volume has been associated with mortality in many clinical settings. However, the association of mean corpuscular volume with mortality in patients with CKD has not been fully addressed., Design, Setting, Participants, & Measurements: We conducted a retrospective observational cohort study of 1439 patients with stages 3-5 CKD and baseline mean corpuscular volume values from 2004 to 2012 in a medical center. The study cohort was divided into the high-mean corpuscular volume group and the low-mean corpuscular volume group by the median value (90.8 fl) of mean corpuscular volume. The baseline patient information included demographic data, laboratory parameters, medications, and comorbid conditions. The independent association of mean corpuscular volume with mortality was examined using multivariate Cox regression analysis., Results: Of the 1439 participants, 234 patients (16.2%) died during a median follow-up of 1.9 years (interquartile range, 1.1-3.8 years). The crude overall mortality rate was significantly higher in the high-mean corpuscular volume group (high-mean corpuscular volume group, 22.7%; low-mean corpuscular volume group, 9.7%; P<0.001). In the fully adjusted models, the high-mean corpuscular volume group was associated with higher risks of all-cause mortality (hazard ratio, 2.19; 95% confidence interval, 1.62 to 2.96; P<0.001), cardiovascular mortality (hazard ratio, 3.57; 95% confidence interval, 1.80 to 7.06; P<0.001), and infection-related mortality (hazard ratio, 2.22; 95% confidence interval, 1.41 to 3.49; P=0.001) compared with the low-mean corpuscular volume group., Conclusions: In patients with stages 3-5 CKD, mean corpuscular volume was associated with all-cause mortality, cardiovascular disease mortality, and infection-associated mortality, independent of other factors. The underlying pathophysiologic mechanisms warrant additional investigation., (Copyright © 2017 by the American Society of Nephrology.)

Background: Recently, accumulating evidence has demonstrated that RDW independently predicts clinically important outcomes in many populations. However, the role of RDW has not been elucidated in chronic kidney disease (CKD) patients. We conducted the present study with the aim to evaluate the predictive value of RDW in CKD patients., Methods: A retrospective observational cohort study of 1075 stage 3-5 CKD patients was conducted in a medical center. The patients' baseline information included demographic data, laboratory values, medications, and comorbid conditions. The upper limit of normal RDW value (14.9%) was used to divide the whole population. Multivariate Cox regression analysis was used to determine the independent predictors of mortality., Results: Of the 1075 participants, 158 patients (14.7%) died over a mean follow-up of approximately 2.35 years. The crude mortality rate was significantly higher in the high RDW group (high RDW group, 22.4%; low RDW group 11%, p <0.001). From the adjusted model, the high RDW group was correlated with a hazard ratio of 2.19 for overall mortality as compared with the low RDW group (95% CI = 1.53-3.09, p<0.001). In addition, the high RDW group was also associated with an increased risk for cardiovascular disease (HR = 2.28, 95% CI = 1.14-4.25, p = 0.019) and infection (HR = 1.9, 95% CI = 1.15-3.14, p = 0.012)) related mortality in comparison with the low RDW group., Conclusions: In stage 3-5 CKD patients, RDW was associated with patient mortality of all-cause, cardiovascular disease and infection. RDW should be considered as a clinical predictor for mortality when providing healthcare to CKD patients., Competing Interests: The authors have declared that no competing interests exist.

Aim: The influence of high peritonitis rate (HPR) on clinical outcomes of continuous ambulatory peritoneal dialysis (CAPD) patients has been far less studied in the Chinese population than in those of the USA, Australia and Europe. Furthermore, concerning the peritonitis risk, most studies primarily examined the risk of developing the first peritonitis episode, rather than a HPR., Methods: A single-center, retrospective, observational study was carried out over 10 years in Taiwan. A total of 124 patients with at least one peritonitis episode were the study subjects. The Cox proportional hazard model was used to assess the impact of HPR on clinical outcomes. Multivariate logistic regression was conducted to determine the independent factors associated with a HPR., Results: In the multivariate Cox regression model, HPR was still a significant predictor for technique failure, patient mortality and dropout from peritoneal dialysis (PD). Factors independently associated with a HPR were peritonitis occurrence during the first year after the start of CAPD and the first peritonitis infected with streptococcus species., Conclusion: Peritonitis during the first year after PD commencement and the first peritonitis infected by streptococcus species were significantly associated with an increased risk of a HPR. Our data also indicate that HPR was correlated with technique failure, patient mortality and dropout from PD, thus highlighting the need and role of future studies to reduce this complication.

Background: Peritonitis rate has been reported to be associated with technique failure and overall mortality in previous literatures. However, information on the impact of the timing of the first peritonitis episode on continuous ambulatory peritoneal dialysis (CAPD) patients is sparse. The aim of this research is to study the influence of time to first peritonitis on clinical outcomes, including technique failure, patient mortality and dropout from peritoneal dialysis (PD)., Methods: A retrospective observational cohort study was conducted over 10 years at a single PD unit in Taiwan. A total of 124 patients on CAPD with at least one peritonitis episode comprised the study subjects, which were dichotomized by the median of time to first peritonitis into either early peritonitis patients or late peritonitis patients. Cox proportional hazard model was used to analyze the correlation of the timing of first peritonitis with clinical outcomes., Results: Early peritonitis patients were older, more diabetic and had lower serum levels of creatinine than the late peritonitis patients. Early peritonitis patients were associated with worse technique survival, patient survival and stay on PD than late peritonitis patients, as indicated by Kaplan-Meier analysis (log-rank test, p = 0.04, p < 0.001, p < 0.001, respectively). In the multivariate Cox regression model, early peritonitis was still a significant predictor for technique failure (hazard ratio (HR), 0.54; 95% confidence interval (CI), 0.30 - 0.98), patient mortality (HR, 0.34; 95% CI, 0.13 - 0.92) and dropout from PD (HR, 0.50; 95% CI, 0.30 - 0.82). In continuous analyses, a 1-month increase in the time to the first peritonitis episode was associated with a 2% decreased risk of technique failure (HR, 0.98; 95% CI, 0.97 - 0.99), a 3% decreased risk of patient mortality (HR, 0.97; 95% CI, 0.95 - 0.99), and a 2% decreased risk of dropout from PD (HR, 98%; 95% CI, 0.97 - 0.99). Peritonitis rate was inversely correlated with time to first peritonitis according to the Spearman analysis (r = -0.64, p < 0.001)., Conclusions: Time to first peritonitis is significantly correlated with clinical outcomes of peritonitis patients with early peritonitis patients having poor prognosis. Patients with shorter time to first peritonitis were prone to having a higher peritonitis rate., (Copyright © 2014 International Society for Peritoneal Dialysis.)

Objective: Peritoneal dialysis (PD) has become more prevalent as a treatment modality for end-stage renal disease, and peritonitis remains one of its most devastating complications. The aim of the present investigation was to examine the frequency and predictors of peritonitis and the impact of peritonitis on clinical outcomes. ♢, Methods: Our retrospective observational cohort study enrolled 391 patients who had been treated with continuous ambulatory PD (CAPD) for at least 90 days. Relevant demographic, biochemical, and clinical data were collected for an analysis of CAPD-associated peritonitis, technique failure, drop-out from PD, and patient mortality. ♢, Results: The peritonitis rate was 0.196 episodes per patient-year. Older age (>65 years) was the only identified risk factor associated with peritonitis. A multivariate Cox regression model demonstrated that technique failure occurred more often in patients experiencing peritonitis than in those free of peritonitis (p < 0.001). Kaplan-Meier analysis revealed that the group experiencing peritonitis tended to survive longer than the group that was peritonitis-free (p = 0.11). After multivariate adjustment, the survival advantage reached significance (hazard ratio: 0.64; 95% confidence interval: 0.46 to 0.89; p = 0.006). Compared with the peritonitis-free group, the group experiencing peritonitis also had more drop-out from PD (p = 0.03). ♢, Conclusions: The peritonitis rate was relatively low in the present investigation. Elderly patients were at higher risk of peritonitis episodes. Peritonitis independently predicted technique failure, in agreement with other reports. However, contrary to previous studies, all-cause mortality was better in patients experiencing peritonitis than in those free of peritonitis. The underlying mechanisms of this presumptive "peritonitis paradox" remain to be clarified.

We report a 48-year-old woman with end-stage renal disease receiving continuous ambulatory peritoneal dialysis who presented with polyarthritis. Painless cloudy peritoneal dialysis effluent was also noted incidentally. Analyses of the effluent dialysate showed increased leukocyte count with a predominance of lymphocytes. Empirical intraperitoneal cefazolin was given initially. Routine cultures of effluent dialysate were negative for bacteria, fungi, and mycobacteria. Cytology revealed no malignant cells. However, the turbidity of effluent dialysate was still increased after 1 week of antibiotic treatment. In the meantime, laboratory tests showed significant antinuclear antibody positivity. Additional serology testing found positive antihistone antibody. On reviewing the patient's current medications, we found that she had been taking hydralazine for the past 3 months. Because drug-induced lupus was suspected, hydralazine was discontinued and low-dose steroids were initiated. Clinical symptoms and cloudy dialysate rapidly abated afterwards. There was no relapse of arthralgia during the next 1-year period of follow-up.

We report a 64-year-old man who was referred with gross hematuria and acute renal failure. Initial laboratory data showed marked lymphocytosis. A diagnosis of chronic lymphocytic leukemia was made by bone marrow biopsy. In the mean time, kidney biopsy showed crescentic glomerulonephritis and interstitial infiltration with leukemic cells. To our knowledge, there are only three previous reports of rapidly progressive glomerulonephritis that occurred simultaneously with chronic lymphocytic leukemia.

A 72-year-old man with ESRD on hemodialysis was referred to the hospital because of hemoptysis. A chest radiograph showed diffuse infiltration in the right lung field. Laboratory data showed hematuria and proteinuria. A kidney biopsy revealed diffuse crescentic glomerulonephritis with linear staining of IgG along the glomerular basement membrane (GBM). However, circulating IgG anti-GBM antibodies were not detected. Because the findings of renal biopsy suggested Goodpasture's disease, the patient was treated with plasmapheresis and pulse steroid therapy, which resulted in a rapid resolution of his pulmonary symptoms and chest radiograph abnormalities. However, sputum culture on admission yielded Mycobacterium tuberculosis 3 weeks later. Therefore, immuosuppressive agents were discontinued and antituberculous agents were administered. There was no relapse of pulmonary hemorrhage during the next 1-year period of follow-up, but the patient did not regain renal function and remained on hemodialysis.

Anti-glomerular basement membrane (GBM) disease is mediated by circulating autoantibodies, principally IgG, targeted at the type IV collagen of GBM. The IgA variant of anti-GBM disease has rarely been described. We report a 65-year-old man with uremia, undergoing hemodialysis, who was referred because of hemoptysis. A chest X-ray showed diffuse infiltration in the right lung field. Laboratory data were remarkable for renal failure, anemia, and thrombocytopenia. Furthermore, laboratory evidence of microangiopathic hemolytic anemia was present. A kidney biopsy revealed diffuse crescentic glomerulonephritis. Circulating IgA anti-GBM antibody was found, as well as the presence of significant IgA deposition in a linear pattern along the GBM, suggesting an anti-GBM antibody-mediated disease. The patient was treated with plasmapheresis and pulse steroid therapy, which resulted in an immediate improvement in the pulmonary hemorrhage and hematological abnormalities. However, the patient did not regain renal function and remained on hemodialysis.

Necrotizing fasciitis is an uncommon complication of nephrotic syndrome. There have been only four cases of necrotizing fasciitis complicating nephrotic syndrome reported in the English literature. We report a 40-year-old woman with minimal-change nephrotic syndrome receiving cyclosporine therapy, who suffered from necrotizing fasciitis of her left leg. Cultures of blood and surgical specimens yielded Serratia marcescens. Despite aggressive treatment, the patient expired shortly after surgery. We review the literature and find eight cases of necrotizing fasciitis caused by S. marcescens. Most of these patients had an immunocompromised background, and the mortality rate was high.

Background: The goal of this study is to determine the value of early renal biopsy as a therapeutic guide in systemic lupus erythematosus (SLE) patients presenting with renal involvement., Methods: We retrospectively analyzed renal biopsies findings in SLE patients between January 2000 and December 2009 encountered at a medical center in Taiwan. An additional criterion for inclusion in this study was kidney biopsy done within 3 months of the first detection of sign(s) of renal disease., Results: There were 131 patients enrolled in this study. In patients presenting with acute renal failure, 91% of patients had proliferative lupus nephritis (Class IV, mixed Class V+III) and 9% had non-proliferative lupus nephropathy (pure Class V). In patients presenting with nephrotic range proteinuria, proliferative lupus nephritis (Class III, IV, mixed Class V+III) and non-proliferative lupus nephropathy (Class II, pure Class V) accounted for 55% and 36% of patients, respectively; and 9% had non-lupus nephropathy. In this group, except that elevated anti-double-stranded DNA antibody levels were more common in proliferative lupus nephritis (p = 0.043), no clinical findings could predict the renal morphology. In patients presenting with subnephrotic proteinuria, 49% of patients had proliferative lupus nephritis (Class III, IV, mixed Class V+III) and 51% had non-proliferative lupus nephropathy (Class II, pure Class V), and decreased C4 levels were more common in patients with proliferative lupus nephritis (p = 0.031). In patients presenting with isolated hematuria, all were not active forms of nephropathy. Immunosuppressive therapy was intensified because of biopsy findings in 29% of patients presenting with acute renal failure, 43% with nephrotic range proteinuria, and 53% with sub-nephrotic proteinuria., Conclusions: Our data suggested that similar clinical renal manifestations may be observed despite very different classes of lupus nephritis. Clinicians tended to wait for histological identification of severe lupus nephritis before initiating potential harmful treatment with aggressive immunosuppressive therapy. Therefore, in SLE patients with clinical sign(s) of renal disease, early renal biopsy may be helpful in planning treatment.

We reported a case of a 41-year-old woman who had been diagnosed with Gitelman's syndrome since the age of 31 years. The diagnosis was established by the typical biochemical pictures including renal wasting hypokalemia, hypomagnesemia, hypocalciuria, metabolic alkalosis, and hyperreninemic hyperaldosteronism. She had normal blood pressure and had never used diuretics. She had a sibling with similar syndrome. The patient was treated with oral potassium and magnesium supplementation. She began to have hypercalcemia at the age of 39 years. The diagnostic approach to hypercalcemia became more complicated because of normal parathyroid hormone levels and underlying hypocalciuria due to Gitelman's syndrome. Thorough evaluation eventually identified primary hyperparathyroidism as the cause of hypercalcemia. To our best knowledge, this is the first report of combined occurrence of Gitelman's syndrome and primary hyperparathyroidism in the literature.

A 66-year-old man with uremia and on hemodialysis was referred to our hospital because of hemoptysis. A chest radiograph showed diffuse infiltration in the right lung field. Laboratory data were remarkable for renal failure accompanied by hematuria and proteinuria. A kidney biopsy revealed diffuse crescentic glomerulonephritis with linear staining of IgG along the glomerular basement membrane (GBM). Circulating IgG anti-GBM antibody was not detected. Because the findings of renal biopsy suggested anti-GBM disease, the patient was treated with plasmapheresis and pulse steroid therapy, which resulted in a rapid resolution of his pulmonary symptoms and chest radiograph abnormalities. However, sputum culture submitted on admission yielded Mycobacterium tuberculosis 3 weeks later. Therefore, immunosuppressive agents were discontinued and antituberculous agents were administrated. No relapse of pulmonary hemorrhage occurred during the next 1-year period of follow-up, but the patient did not regain renal function and remained on hemodialysis.

A 70-year-old man with uremia was referred because of hemoptysis. A chest X-ray showed diffuse infiltration in the right lung field. Laboratory data were remarkable for renal failure, anemia, and thrombocytopenia. Furthermore, laboratory evidence of microangiopathic hemolytic anemia was present. A kidney biopsy revealed diffuse crescentic glomerulonephritis with linear staining of IgA along the glomerular basement membrane (GBM). No thrombotic microangiopathy was noted on renal biopsy. Circulating IgG anti-GBM antibody was not detected, and IgA anti-GBM antibody was not tested. The patient was treated with plasmapheresis and pulse steroid therapy, which resulted in an immediate improvement in the pulmonary hemorrhage and hematological abnormalities. However, the patient did not regain renal function and remained on hemodialysis.

Objective: To examine the effects of foot orthosis intervention during a 60-minute running test in pronated-foot runners with overuse knee or foot pain during running., Design: A randomized, controlled design., Setting: Sports gym., Participants: Twenty-four runners with pronated foot who experienced pain over anterior knee or foot region during running were recruited and randomized into the treatment, or the control, group., Interventions: A soft insole with a semi-rigid rearfoot medial wedge was given to the treatment group, and a soft insole without corrective posting was applied to the control group., Outcome Measures: The immediate and short-term effects of orthosis application on incidence of pain, pain intensity and onset time were evaluated using the 60-minutes treadmill test., Results: Immediately after wearing the foot orthosis, pain incidence reduced in the treatment group but not in the control group (P = 0.04). After two weeks, seven (58%) subjects in the treatment group and one (8%) in the control group were free of pain during the test (P = 0.01). The pain intensity score decreased significantly after orthosis application, from 35.5 to 17.2 (immediate effect, P = 0.014), then to 12.3 (short-term effect, P < 0.001)., Conclusion: The rearfoot medially-wedged insole was a useful intervention for preventing or reducing painful knee or foot symptoms during running in runners with pronated foot.

Objectives: Renal biopsy has been used extensively in systemic lupus erythematosus (SLE) with renal involvement. However, there is no complete agreement about the need for renal biopsy at presentation. The goal of this study is to define the role of renal biopsy as a therapeutic guide in new-onset SLE with renal involvement., Methods: We retrospectively analyzed renal biopsy findings in 131 SLE patients who received renal biopsy within 3 months from the diagnosis of SLE., Results: In patients presenting with acute renal failure, 91% of patients had proliferative lupus nephritis (LN) (class IV, mixed class V + III) and 9% had non-proliferative lupus nephropathy (pure class V). In patients presenting with nephrotic range proteinuria, proliferative LN (class III, IV, mixed class V + III) and non-proliferative lupus nephropathy (class II, pure class V) accounted for 55% and 36% of patients, respectively, whereas 9% had non-lupus nephropathy. With the exception of anti-double-stranded DNA, no clinical findings correlated with pathology. In patients presenting with sub-nephrotic proteinuria, 49% of patients had proliferative LN (class III, IV, mixed class V + III) and 51% had non-proliferative lupus nephropathy (class II, pure class V). Decreased C4 levels were more common in patients with proliferative LN (P = 0.031). In patients presenting with isolated hematuria, all were not active form nephropathy., Conclusions: Our data suggested that similar clinical features may be observed despite very different classes of LN. Therefore, in new-onset SLE patients with clinical renal disease, early renal biopsy may be helpful in planning the treatment.

Over the past decade, star fruit (Averrhoa carambola) intoxication decreased in the Taiwanese society due to improved public education on chronic kidney disease (CKD). Various complications including hiccups, altered levels of consciousness, coma, and seizures have been reported in individuals with renal failure who ingested fresh star fruit or star fruit juice. A high mortality rate (from 33 to 80%) was observed in patients with altered levels of consciousness, despite prompt dialysis and supportive care. According to previous case reports, the proposed treatment of choice for severe star fruit intoxication may be continuous renal replacement therapy with or without hemoperfusion. We report two cases of star fruit intoxication with stage V CKD (one case is predialysis) presenting with coma and generalized tonic-clonic seizures. The two patients were treated with sustained low-efficiency daily diafiltration (SLEDD-f) and charcoal hemoperfusion. Status epilepticus was controlled fairly quickly after treatment with SLEDD-f and hemoperfusion. However, the outcomes in this report are still poor (both remained comatose; one of two patients died). Currently, there are no data for the use of SLEDD-f with hemoperfusion for severe star fruit intoxication. SLEDD-f with charcoal hemoperfusion may play a role in managing refractory status epilepticus in patients with severe star fruit poisoning.

Dominant or codominant IgA deposits in the setting of proliferative glomerulonephritis usually indicate IgA nephropathy, Henoch-Schönlein purpura nephritis, or, sometimes, lupus nephritis. However, a new type of poststaphylococcal glomerulonephritis with predominantly IgA deposition has been increasingly reported. Herein, we report an unusual case of rapidly progressive glomerulonephritis following methicillin-resistant Staphylococcus aureus infection. Renal biopsy showed crescentic IgA nephropathy. The renal function improved after eradication of infection and administration of immunosuppressive therapy. Although the limited data support the use of immunosuppressive agents in this setting, one must proceed with caution. We suggest that immunosuppressive therapy should only be an option if the underlying infection has definitely been well controlled while the renal disease still progresses.

Background: IgA-dominant postinfectious glomerulonephritis (PIGN) is a unique form of PIGN. It has been linked to staphylococcal infection and underlying diabetic glomerulosclerosis. However, the significance of glomerular IgA-dominant deposition in PIGN remains unclear., Methods: We reported 10 patients with IgA-dominant PIGN encountered at a single center, each characterized by subepithelial humps. Their demographic, clinical, and renal biopsy findings were summarized and compared with the data of 32 patients with non-IgA-dominant PIGN., Results: The mean age was 57 years. An immunocompromised background was present in 70% of patients; only one patient had diabetes mellitus. The causative infectious agents included Staphylococcus (30%), Streptococcus (20%), and gram-negative organisms (50%). Decreased serum complement was present in 60%. Increased serum IgA was noted in 75%. The mean peak serum creatinine was 5.1 mg/dL, and 20% required acute dialysis. Diffuse endocapillary-proliferative glomerulonephritis was found in all cases, and three patients also had crescentic glomerulonephritis. Electron microscopy revealed large subepithelial hump-shaped deposits in all cases. At the last follow-up, one patient had died, five had achieved complete recovery, three had persistent renal insufficiency, and one was on chronic dialysis. Compared to patients with non-IgA-dominant PIGN, increased serum IgA was more commonly present in IgA-dominant group (p = 0.007). There were no significant differences in other clinical parameters and outcome between the two groups., Conclusions: IgA-dominant PIGN resembles poststreptococcal glomerulonephritis in its histological spectrum and ultrastructural appearance. Increasing serum IgA may be involved in the pathogenesis of this form of PIGN. Our data suggested that IgA-dominant PIGN was not peculiar to staphylococcal infection and diabetic patients.

Objectives: The goal of this study was to define the differences between prominent glomerular injury and prominent tubular injury in immunoglobulin (Ig) A nephropathy patients presenting with acute renal failure., Methods: In our experience of 236 patients with biopsy-proven IgA nephropathy from 2000 to 2009 at a medical center in Taiwan, 20 cases of acute renal failure were identified. The patients' records were retrospectively reviewed with respect to clinical presentation, morphology of renal biopsy, and outcomes., Results: We subdivided the 20 patients into two groups: group 1 included 9 patients with prominent glomerular injury (≥30% of glomeruli affected by crescents) and group 2 included 11 patients with prominent tubular injury (tubules filled with red blood cell casts/acute tubular necrosis/or acute interstitial nephritis). Regarding clinical parameters, the glomerular injury group had a greater urinary protein excretion (P = 0.014), a higher level of peak serum creatinine (P = 0.025), and more frequently had requirement for dialysis support (P = 0.022). Concerning histological parameters, the glomerular injury group had a higher degree of mesangial hypercellularity (P = 0.009). Regarding renal outcome, the tubular injury group had a higher remission rate than the glomerular injury group (P = 0.022)., Conclusions: Histological characteristics showed two distinct mechanisms of acute kidney injury associated with IgA nephropathy, including prominent glomerular injury and prominent tubular injury. The clinical presentation and prognosis largely depended on the histological presentation.

Background: A unique form of postinfectious glomerulonephritis (PIGN) with IgA-dominant deposition mimicking IgA nephropathy has been increasingly reported., Methods: We compared the clinical and histological features of 12 patients with postinfectious IgA-dominant glomerulonephritis to 134 patients with idiopathic IgA nephropathy., Results: In addition to hypocomplementemia and subepithelial hump-shaped deposits characteristic of PIGN, patients with postinfectious IgA-dominant glomerulonephritis had older age (62.3 +/- 16.9 vs. 37.9 +/- 16.3 years; p < 0.001) and more frequently presented with acute renal failure (83.3% vs. 10.4%; p < 0.001) than patients with idiopathic IgA nephropathy. Moreover, glomerular changes including endocapillary proliferation, neutrophil infiltration, and capillary loops deposits by immunofluorescence were more commonly present in postinfectious IgA-dominant glomerulonephritis group (p < 0.001)., Conclusions: PIGN could be characterized by glomerular IgA-dominant deposition resembling idiopathic IgA nephropathy. It is essential to differentiate postinfectious IgA-dominant glomerulonephritis from idiopathic IgA nephropathy because of the different treatments and prognosis of the two diseases.

Objectives: Infection-associated glomerulonephritis is uncommon in adults. In the present study, we have tried to determine the mode of presentation, the spectrum of morphology, and the prognostic factors for renal outcome in adult patients with infection-associated glomerulonephritis., Methods: Between July 2000 and June 2008, 20 adults (14 males, 6 females) with infection-associated glomerulonephritis were managed at a medical center in Taiwan. The patients' records were retrospectively reviewed with respect to clinical presentation, microbiology, serology, morphology of renal biopsy, and clinical course., Results: All patients developed acute renal failure and the majority required dialysis support. The most frequently identified infectious agent was Staphylococcus (60%). Histological characteristics showed two distinct patterns of glomerulonephritis. One was diffuse endocapillary proliferative glomerulonephritis (65%) and the other was focal mesangial proliferative glomerulonephritis (35%). There were no significant differences in the clinical presentation and outcome between the two groups. However, glomerular neutrophil infiltration and subepithelial hump-shaped deposits were more commonly present in diffuse endocapillary proliferative pattern (P = 0.017, 0.004, respectively). Moreover, the percentage of patients with focal mesangial proliferative pattern significantly increased over time (P < 0.001). At the end of follow-up, 6 patients (30%) had died, 6 (30%) were in remission, 4 (20%) had renal insufficiency, and 4 (20%) were on chronic dialysis. The prognostic factors for renal outcome were peak serum creatinine, percentage of glomeruli affected by crescents, and interstitial infiltration (P = 0.02, 0.05, 0.01, respectively)., Conclusions: Our data suggested that Staphylococcus had become the leading pathogen in adult infection-associated glomerulonephritis over the past 10 years. Furthermore, atypical histological feature with focal mesangial proliferative pattern was increasingly identified over time. The prognosis was still guarded, with a considerable mortality rate and risk for developing chronic renal failure.

Background: Acute renal failure rarely complicates the course of IgA nephropathy. In this study, we have tried to define the mode of presentation, the spectrum of morphology, and the prognostic factors for renal outcome., Methods: Twenty patients with biopsy-proven IgA nephropathy who developed acute renal failure were identified from 2000 to 2009 at a medical center in Taiwan. The patients' records were retrospectively reviewed with respect to clinical presentation, morphology of renal biopsy, and outcomes., Results: On histology, glomerular crescents were present in 11 patients (55%), acute tubular necrosis was identified in 11 patients (55%), acute interstitial nephritis was seen in 4 patients (20%), and extensive tubular red blood cell casts were present in 4 patients (20%). At the end of follow-up, 2 patients (10%) had died, 11 patients (55%) were in remission, and 7 patients (35%) developed end-stage renal disease. The prognostic factors for renal outcome were peak serum creatinine, dialysis support requirement, morphology (prominent glomerular/tubular injury), percentage of glomeruli affected by crescents, and interstitial infiltration (p = 0.04, <0.001, 0.013, 0.05, 0.02, respectively)., Conclusions: Our findings suggested that there were four pathogenic mechanisms involved in IgA nephropathy with acute renal failure including (1) crescentic IgA nephropathy; (2) acute tubular necrosis associated with microhematuria and red blood cell casts occluding tubules; (3) acute tubular necrosis not related to microhematuria; and (4) acute interstitial nephritis, apparently induced by drugs. In general, patients with prominent tubular injury had a much higher remission rate than patients with prominent glomerular injury.

Background: The goal of this study was to define the clinical and histological differences in new-onset IgA nephropathy between young adults and the elderly., Methods: We retrospectively examined renal biopsy findings, clinical features at presentation and outcomes in 82 young adults (mean age 30.3+/-10.2 years) and 17 elderly patients (mean age 71.9+/-4.5 years) with IgA nephropathy whose renal biopsies were taken within 1 year from the onset of renal manifestations., Results: The elderly group more frequently had hypertension (p<0.001), acute renal failure (p<0.001), and nephrotic range proteinuria (p=0.001) at presentation than the young adults group. On histology, a higher percentage of globally sclerotic glomeruli (p<0.001) was present in the elderly group. In patients presenting with acute renal failure, the elderly group more frequently had an intercurrent disease (p=0.02), mostly infection, and a higher mortality rate (p=0.033). On histology, the young adults group had a higher percentage of glomeruli affected by crescents (p=0.027); in contrast, the elderly group more commonly had acute tubular injury (p=0.02)., Conclusions: The elderly patients affected by IgA nephropathy had more severe renal manifestations at presentation (acute renal failure in 52.9% and nephrotic syndrome in 41.2% of patients). In cases of acute renal failure, the elderly patients had more predominant tubular rather than glomerular injury. Moreover, the considerable mortality rate (44.4%) might be associated with the intercurrent disease, mostly infection, which was more commonly present in the elderly patients.