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Abstract The frequency of percutaneous transluminal angioplasty (PTA) procedures has substantially increased, but its effect on vascular access recreation (VAR) remains inconclusive. We conducted a population-based retrospective analysis of Taiwan hemodialysis (HD) centers from 2004 to 2012. Data was accumulated into center-level characteristics, including patients' demographics, baseline characteristics, PTA procedures, and VAR. Center-level characteristics were summarized annually using appropriate measures. A mixed model assessed the association between PTA frequency and VAR rates, considering within-center correlation and adjusting for potential confounders. A total of 82,005 patients (mean age 62.7 ± 13.9 years, 50.5% male, 48.5% with diabetes mellitus) from 820 HD centers were analyzed. From 2004 to 2012, PTA frequency significantly increased from 1.24 to 3.23 per 1000 HD sessions, while VAR rates did not decline as expected (0.5–0.8 per 1000 HD sessions). Compared with the HD centers of infrequent use of PTA (annual lowest quartile, range 0.39–1.20 per 1000 HD sessions), the ones of frequent use (annual highest quartile, range 2.52–5.10 per 1000 HD sessions) didn't have lower VAR (range 0.54–0.99 vs. 0.50–0.91 per 1000 HD sessions, respectively). After controlling the potential confounders, the HD centers' PTA rates were not significantly associated with lower VAR rates (− 2.6, 95% confidence interval: − 30.3; 25.0, p = 0.85). Frequent use of PTA does not seem to improve VA patency at the center level, with no significant association identified with lower VAR. The indication of PTA in daily practice should be re-evaluated in terms of its efficiency in lowering VAR.

Abstract This study investigated the moderating effect of financial strain or social support on depressive symptoms among older people living alone in Taiwan. Data were collected from the “Taiwan Longitudinal Study on Aging (TLSA),” which included 1513 participants aged 65 and over, among them, 153 (10.1%) were living alone, while 1360 (89.9%) were living with others. Measurement tools included the Depression scale (CES-D), financial stress scale, social support scale, ADL scale, IADL scale, and stress scale, with Cronbach’s α coefficients were 0.85, 0.78, 0.67, 0.91, 0.90, and 0.70 respectively. Hierarchical multiple regression was used to examine the moderator effect. The findings revealed that (1) Financial strain was found to moderate the relationship between living alone and depressive symptoms, acting as a promotive moderator among older men living alone. For older women, financial stress does not moderate the relationship between living alone and depressive symptoms. However, financial strain was also identified as a significant factor associated with depressive symptoms among older women living alone. (2) Social support does not moderate effect on the relationship between living alone and depressive symptoms in older men or older women. These results underscore the importance of considering financial stress in mental health policy development by government agencies. It is imperative to address the unique challenges faced by older individuals living alone, particularly in relation to financial strain, in order to promote their mental well-being.

Abstract The incidence and prevalence of dialysis in Taiwan are high compared to other regions. Consequently, mitigating chronic kidney disease (CKD) and the worsening of kidney function have emerged as critical healthcare priorities in Taiwan. Heat stress is known to be a significant risk factor for CKD and kidney function impairment. However, differences in the impact of heat stress between males and females remains unexplored. We conducted this retrospective cross-sectional analysis using data from the Taiwan Biobank (TWB), incorporating records of the wet bulb globe temperature (WBGT) during midday (11 AM–2 PM) and working hours (8 AM–5 PM) periods based on the participants’ residential address. Average 1-, 3-, and 5-year WBGT values prior to the survey year were calculated and analyzed using a geospatial artificial intelligence-based ensemble mixed spatial model, covering the period from 2010 to 2020. A total of 114,483 participants from the TWB were included in this study, of whom 35.9% were male and 1053 had impaired kidney function (defined as estimated glomerular filtration rate

AbstractIntroduction Chronic kidney disease is related to neurodegeneration and structural changes in the brain which might lead to cognitive decline. The Fazekas scale used for assessing white matter hyperintensities (WMHs) was associated with poor cognitive performance. Therefore, this study investigated the associations between the mini-mental status examination (MMSE), Montreal cognitive assessment (MoCA), cognitive abilities screening instrument (CASI), and Fazekas scale in patients under hemodialysis (HD).Methods The periventricular (PV) WMHs and deep WMHs (DWMHs) in brain magnetic resonance images of 59 patients under dialysis were graded using the Fazekas scale. Three cognition function tests were also performed, then multivariable ordinal regression and logistic regression were used to identify the associations between cognitive performance and the Fazekas scale.Results There were inverse associations between the three cognitive function tests across the Fazekas scale of PVWMHs (p = .037, .006, and .008 for MMSE, MoCA, and CASI, respectively), but the associations were attenuated in the DWMHs group. In CASI, significant differences were identified in short-term memory, mental manipulation, abstract thinking, language, spatial construction, and name fluency in the PVWMHs group. However, DWMHs were only significantly correlated with abstract thinking and short-term memory.Conclusion An inverse correlation existed between the Fazekas scale, predominantly in PVWMHs, and cognition in patients undergoing HD. The PVWMHs were associated with cognitive performance assessed by MMSE, MoCA, and CASI, as well as with subdomains of CASI such as memory, language and name fluency in patients undergoing HD.

Abstract Background Current healthcare trends emphasize the use of shared decision-making (SDM) for renal replacement treatment (RRT) in patients with chronic kidney disease (CKD). This is crucial to understand the relationship between SDM and illness perception of CKD patients. Few studies have focused on SDM and illness perception status of CKD patients and the impact of illness perception on RRT after SDM. Methods In this cross-sectional study, we used a questionnaire with purposive sampling from March 2019 to February 2020 at the nephrology outpatient department of a medical center in southern Taiwan. The nephrology medical team in this study used the SHARE five-step model of SDM to communicate with the patients about RRT and Brief Illness Perception Questionnaire (BIPQ) was applied to evaluate illness perception of these patients at the beginning of SDM. According to the SDM decision time, the study participants were classified general and delayed SDM groups. The distribution between SDM groups was estimated using independent two sample t-test, chi-squared test or Fisher’s exact test. The correlation between illness perception and SDM decision time were illustrated and evaluated using Spearman’s correlation test. A p-value less than 0.05 is statistically significant. Results A total of 75 patients were enrolled in this study. The average time to make a dialysis decision after initiating SDM was 166.2 ± 178.1 days. 51 patients were classified as general group, and 24 patients were classified as delayed group. The median SDM decision time of delayed group were significantly longer than general group (56 vs. 361 days, P

Microbiota tryptophan metabolism and the biosynthesis of indole derivatives play an important role in homeostasis and pathogenesis in the human body and can be affected by the gut microbiota. However, studies on the interplay between gut microbiota and tryptophan metabolites in patients undergoing dialysis are lacking. This study aimed to identify the gut microbiota, the indole pathway in tryptophan metabolism, and significant functional differences in ESRD patients with regular hemodialysis. We performed the shotgun metagenome sequencing of stool samples from 85 hemodialysis patients. Using the linear discriminant analysis effect size (LEfSe), we examined the composition of the gut microbiota and metabolic features across varying concentrations of tryptophan and indole metabolites. Higher tryptophan levels promoted tyrosine degradation I and pectin degradation I metabolic modules; lower tryptophan levels were associated with glutamate degradation I, fructose degradation, and valine degradation modules. Higher 3-indoxyl sulfate concentrations were characterized by alanine degradation I, anaerobic fatty acid beta-oxidation, sulfate reduction, and acetyl-CoA to crotonyl-CoA. Contrarily, lower 3-indoxyl sulfate levels were related to propionate production III, arabinoxylan degradation, the Entner–Doudoroff pathway, and glutamate degradation II. The present study provides a better understanding of the interaction between tryptophan, indole metabolites, and the gut microbiota as well as their gut metabolic modules in ESRD patients with regular hemodialysis.

Indole-3-acetic acid (IAA), a protein-bound uremic toxin resulting from gut microbiota-driven tryptophan metabolism, increases in hemodialysis (HD) patients. IAA may induce endothelial dysfunction, inflammation, and oxidative stress, elevating cardiovascular and cognitive risk in HD patients. However, research on the microbiome–IAA association is limited. This study aimed to explore the gut microbiome’s relationship with plasma IAA levels in 72 chronic HD patients aged over 18 (August 2016–January 2017). IAA levels were measured using tandem mass spectrometry, and gut microbiome analysis utilized 16s rRNA next-generation sequencing. Linear discriminative analysis effect size and random forest analysis distinguished microbial species linked to IAA levels. Patients with higher IAA levels had reduced microbial diversity. Six microbial species significantly associated with IAA levels were identified; Bacteroides clarus, Bacteroides coprocola, Bacteroides massiliensi, and Alisteps shahii were enriched in low-IAA individuals, while Bacteroides thetaiotaomicron and Fusobacterium varium were enriched in high-IAA individuals. This study sheds light on specific gut microbiota species influencing IAA levels, enhancing our understanding of the intricate interactions between the gut microbiota and IAA metabolism.

Abstract Autosomal Dominant polycystic kidney disease (ADPKD) is the most common inherited adult kidney disease. Although ADPKD is primarily caused by PKD1 and PKD2, the identification of several novel causative genes in recent years has revealed more complex genetic heterogeneity than previously thought. To study the disease-causing mutations of ADPKD, a total of 920 families were collected and their diagnoses were established via clinical and image studies by Taiwan PKD Consortium investigators. Amplicon-based library preparation with next-generation sequencing, variant calling, and bioinformatic analysis was used to identify disease-causing mutations in the cohort. Microsatellite analysis along with genotyping and haplotype analysis was performed in the PKD2 p.Arg803* family members. The age of mutation was calculated to estimate the time at which the mutation occurred or the founder arrived in Taiwan. Disease-causing mutations were identified in 634 families (68.9%) by detection of 364 PKD1, 239 PKD2, 18 PKHD1, 7 GANAB, and 6 ALG8 pathogenic variants. 162 families (17.6%) had likely causative but non-diagnostic variants of unknown significance (VUS). A single PKD2 p.Arg803* mutation was found in 17.8% (164/920) of the cohort in Taiwan. Microsatellite and array analysis showed that 80% of the PKD2 p.Arg803* families shared the same haplotype in a 250 kb region, indicating those families may originate from a common ancestor 300 years ago. Our findings provide a mutation landscape as well as evidence that a founder effect exists and has contributed to a major percentage of the ADPKD population in Taiwan.

Abstract Background Precision is crucial in determining the appropriate procedure for implementing further trials. We conducted a study to explore the reliability of a novel measuring system for human skin color. Methods The novel skin color measuring system was used to capture the skin color of four volunteers (2 males and 2 females) from the same location on each subject by the same operator. The measurement was repeated for different poses and instrument factors (camera and shooting protocol) in the red, green, and blue (RGB) system. The average color depth in each image was calculated and converted from 0 to 255. The spread of measures and the Bland‐Altman plot was displayed to determine each variance source's random error, with the interclass correlation coefficients applied to reflect the reliability. Result The RGB color depth in the experiment ranged from 190, 152, and 122 to 208, 170, and 142. The 95% confidential interval of the differences from the means in RGB colors for the different protocols were ±2.8, ±2.6, and ±2.1, respectively. The largest variation in the replicate trials was observed when subjects were in a supine position (standard deviation: 2). The interclass correlation coefficients were greater than 90%, suggesting that the developed system is highly precise. Conclusion This study demonstrated that the developed device could stably and reliably detect human skin color across different common sources of variation, and thus could be applied clinically to explore relationships between health/disease and skin color changes.

Background: Vitamin D is essential in the host defense against tuberculosis (TB). Suboptimal vitamin D status is common in the hemodialysis population. Hemodialysis patients have an increased risk compared to the general population latent tuberculosis infection (LTBI). However, the association between vitamin D deficiency and LTBI in this population remains unclear. Materials and methods: We conducted a cross-sectional study between March and May 2017. Interferon-gamma release assay (IGRA) through QuantiFERON-TB Gold In-Tube was used to assess LTBI. Plasma 25-hydroxycholecalciferol (25-OHD) levels were measured by Elecsys Vitamin D Total assay. Suboptimal vitamin D levels included vitamin D insufficiency 20–29 ng/mg and vitamin D deficiency 65 years old (odds ratio (OR), 1.89; 95% CI, 1.08–3.31; p = 0.026) and TB history (OR, 3.51; 95% CI, 1.38–8.91; p = 0.008) were independent predictors of IGRA positivity. Conclusion: This is the first study to report that vitamin D deficiency was not associated with IGRA positivity in a hemodialysis population. Aging and TB history were both independent predictors for LTBI.

Abstract The factors associated with the timely creation of distal vascular access for hemodialysis initiation are unclear. We aimed to explore the association between the slope of estimated glomerular filtration rate (eGFR) and the successful usage of vascular access upon hemodialysis initiation. This single center retrospective cohort study enrolled chronic kidney disease patients who undertook a multidisciplinary care program from 2003 to 2016. Using eGFR slope as predictor, we evaluated the vascular access created timely upon hemodialysis initiation. Among the 987 patients, vascular access was created at a median eGFR of 5.8 min/ml/1.73 m2, with a median duration of 3.1 months before hemodialysis. The proportions of vascular access created timely, created not timely (vascular access immature), and not created were 68.5%, 8.8%, and 22.7%, respectively. There was a significant negative association of eGFR upon vascular access creation with eGFR slope (r = − 0.182, P

Rationale & Objective: Taiwan implemented national pay-for-performance programs for chronic kidney disease (CKD) care in 2006 and 2011; however, it is unknown whether this affected trends in maintenance dialysis. This study assessed the temporal trends in the incidence, prevalence, and mortality of individuals treated with maintenance dialysis from 2002-2016 in Taiwan. Study Design: Follow-up study using Taiwan Renal Disease System Databases. Setting & Participants: Participants who received dialysis for ≥90 days. Predictors: Age, sex, and calendar year. Outcomes: Incidence, prevalence of maintenance dialysis, or death, ascertained using the National Death Registry database. Analytical Approach: The estimated annual percentage change was assessed by a generalized linear model, and the association of the programs with changes in the incidence of maintenance dialysis was evaluated using an age-period-cohort model. Results: A total of 144,258 incident cases with a follow-up of 346 million person-years were analyzed during the observed periods. The estimated annual percentage change of the expected crude incidence rate was slightly reduced by 0.41% (95% CI, −1.06 to 0.24) and was more obvious in women and patients aged greater than 70 years; whereas, it was significantly increased in those aged greater than 75 years. After disentangling age and cohort effects, the implementation of the care programs was associated with an overall net drift of −1.09% (95% CI, −1.65 to −0.52) per year and a significant linear reduction in the period rate ratio from 1.06 (95% CI, 1.02-1.09) in the years 2002-2006 to 0.95 (95% CI, 0.92-0.98) in 2012-2016, using years 2007-2011 as reference. Limitations: The findings of the study may have limited inferences to other countries with different health care systems. Conclusions: The implementation of universal CKD care programs in Taiwan has significantly reduced the long-term trends in the incidence of maintenance dialysis; hence, devoting governmental resources to CKD care and prevention is advocated.

BackgroundAlthough the bio-incompatibility of glucose-based peritoneal dialysis (PD) solution is well documented, it is used worldwide. How PD duration and the amount of dialyzate glucose exposure affect survival in patients with end-stage renal disease remain inconclusive due to improper study designs in the extant literature.MethodsAll incident patients with PD from 2004 to 2007 who were older than 18 years in Taiwan were included. Patients were censored when they received a transplant or at the end of 2012. Glucose exposure through PD solution was calculated by the mean glucose contained per liter when receiving PD. For those who had already shifted to hemodialysis (HD) and survived longer than 2, 3, and 4 years (the index dates), the cause-specific Cox regression model was used to make the survival comparison by PD duration and mean glucose concentration in these three cohorts, respectively. The model was adjusted by demographics, case-mix, time cohort (2004–2005 vs. 2006–2007), peritonitis episode (none vs. ≥once), and mean PD solution glucose exposure (tertile).ResultsA total of 3,226 patients were included, with a mean age of 53.4 ± 15.2 years, 44.6% being male, and 34.2% having diabetes mellitus. The 1, 2, 3, and 4-year survival rates were 94, 87, 80, and 74%, while technical survival rates were 86, 70, 56, and 45%, respectively. The overall transplant events were 309 (9.6%) only. There were 389, 495, and 553 incident patients with PD shifting to HD included in 2-, 3-, and 4-year cohort, respectively. The population with moderate glucose concentration exposure had the highest mortality, and the high glucose concentration exposure had non-significant lower mortality in each cohort. In various fixed time-window cohorts, the duration of PD treatment did not increase mortality risk after adjustments. In addition, glucose exposure did not affect the mortality rate.ConclusionFor incident PD patients with PD duration no longer than 4 years, neither PD duration nor glucose exposure amount increases the long-term mortality risk.

Abstract Low transferrin saturation (TSAT), calculated by serum iron divided by total iron-binding capacity (TIBC), indicates iron deficiency. Because malnutrition and inflammation are associated with low TIBC in chronic kidney disease (CKD), TSAT might not reflect iron status or risk for anemia. We examined whether low serum iron was a risk factor for anemia in CKD patients with normal TSAT. Thus we compare the risk for anemia in 2500 CKD stage 1–4 patients divided by TSAT (cutoff: 20%) and serum iron (cutoff: 70 μg/dL in men, 60 μg/dL in women). Our results confirmed low TIBC (

Abstract Protein-bound uremic toxins (Indoxyl sulfate [IS] and p-cresyl sulfate [PCS]) are both associated with cardiovascular (CV) and all-cause mortality in subjects with chronic kidney disease (CKD). Possible mechanisms have not been elucidated. In hemodialysis patients, we investigated the relationship between the free form of IS and PCS and 181 CV-related proteins. First, IS or PCS concentrations were checked, and high levels were associated with an increased risk of acute coronary syndrome (ACS) in 333 stable HD patients. CV proteins were further quantified by a proximity extension assay. We examined associations between the free form protein-bound uremic toxins and the quantified proteins with correction for multiple testing in the discovery process. In the second step, the independent association was evaluated by multivariable-adjusted models. We rank the CV proteins related to protein-bound uremic toxins by bootstrapped confidence intervals and ascending p-value. Six proteins (signaling lymphocytic activation molecule family member 5, complement component C1q receptor, C–C motif chemokine 15 [CCL15], bleomycin hydrolase, perlecan, and cluster of differentiation 166 antigen) were negatively associated with IS. Fibroblast growth factor 23 [FGF23] was the only CV protein positively associated with IS. Three proteins (complement component C1q receptor, CCL15, and interleukin-1 receptor-like 2) were negatively associated with PCS. Similar findings were obtained after adjusting for classical CV risk factors. However, only higher levels of FGF23 was related to increased risk of ACS. In conclusion, IS and PCS were associated with several CV-related proteins involved in endothelial barrier function, complement system, cell adhesion, phosphate homeostasis, and inflammation. Multiplex proteomics seems to be a promising way to discover novel pathophysiology of the uremic toxin.

Background/Aims Direct‐acting antivirals (DAAs) have been approved for hepatitis C virus (HCV) treatment in patients with end-stage renal disease (ESRD) on hemodialysis. Nevertheless, the complicated comedications and their potential drug-drug interactions (DDIs) with DAAs might limit clinical practice in this special population. Methods The number, class, and characteristics of comedications and their potential DDIs with five DAA regimens were analyzed among HCV-viremic patients from 23 hemodialysis centers in Taiwan. Results Of 2,015 hemodialysis patients screened in 2019, 169 patients seropositive for HCV RNA were enrolled (mean age, 65.6 years; median duration of hemodialysis, 5.8 years). All patients received at least one comedication (median number, 6; mean class number, 3.4). The most common comedication classes were ESRD-associated medications (94.1%), cardiovascular drugs (69.8%) and antidiabetic drugs (43.2%). ESRD-associated medications were excluded from DDI analysis. Sofosbuvir/velpatasvir/voxilaprevir had the highest frequency of potential contraindicated DDIs (red, 5.6%), followed by glecaprevir/pibrentasvir (4.0%), sofosbuvir/ledipasvir (1.3%), sofosbuvir/velpatasvir (1.3%), and elbasvir/grazoprevir (0.3%). For potentially significant DDIs (orange, requiring close monitoring or dose adjustments), sofosbuvir/velpatasvir/voxilaprevir had the highest frequency (19.9%), followed by sofosbuvir/ledipasvir (18.2%), glecaprevir/pibrentasvir (12.6%), sofosbuvir/velpatasvir (12.6%), and elbasvir/grazoprevir (7.3%). Overall, lipid-lowering agents were the most common comedication class with red-category DDIs to all DAA regimens (n=62), followed by cardiovascular agents (n=15), and central nervous system agents (n=10). Conclusions HCV-viremic patients on hemodialysis had a very high prevalence of comedications with a broad spectrum, which had varied DDIs with currently available DAA regimens. Elbasvir/grazoprevir had the fewest potential DDIs, and sofosbuvir/velpatasvir/voxilaprevir had the most potential DDIs.

Abstract Multidisciplinary care can improve the outcomes of chronic kidney disease (CKD), however the contribution of self-care behavior and knowledge about CKD is unclear. This study enrolled 454 participants with CKD stages 1–5 not on dialysis. Structured questionnaires were used to evaluate self-care behavior and kidney disease knowledge. Rapid decline in renal function was defined as the decline in estimated filtration rate > 3 ml/min per 1.73 m2/year within 1-year prior to enrollment. The mean age of all study participants was 65.8 ± 12.1 years and 55.9% were male. The elderly had better self-care behavior while younger participants had better disease knowledge. Both high self-care and high disease knowledge scores were significantly associated with and had a synergistic effect on decreasing the risk of rapid decline in renal function. CKD patients with better self-care behavior and better kidney disease knowledge had lower risk of rapid decline in renal function.

Abstract This animal study aimed to elucidate the relationship of low-dose, narrow-band UVB at 308 nm with vitamin D synthesis. C57BL/6 female mice, at 3 weeks-of-age, were randomly divided into the following six groups (n = 6 at each time point of vitamin D measurement), which were: (1) normal diet without UVB irradiation; (2) VDd diet without UVB irradiation; and (3)–(6) VDd diet with 308 nm-UVB irradiation of 12.5, 25, 50, and 100 μω/cm2, respectively. All of the groups needing UVB irradiation received an exposure of 10 min per day, five days per week, and a duration of 3–5 weeks. The mice recovering from severe VDd (plasma total 25-hydroxyvitamin D level increasing from approximately 3 to over 30 ng/mL) only occurred in groups with a UVB irradiation dosage of either 50 or 100 μω/cm2. The optimal, estimated dosage for mice to recover from severe VDd was 355 mJ/cm2 within 3 weeks. Low-dose, narrow-band UVB irradiation at 308 nm is effective in improving VDd in mice. The results obtained, in addition to the especially small side effects of the above UVB irradiation formula, could be further translated to treating VDd-related disorders.

BackgroundFracture Risk Assessment Tool (FRAX) and bone turnover markers (BTMs) predict fractures in the general population. However, the role of FRAX and BTMs in predicting mortality remains uncertain in hemodialysis (HD) patients.MethodsOne hundred and sixty-four HD patients stratified by low or high risk of 10-year fracture probability using FRAX. High risk of fracture was defined as 10-year probability of hip fracture ≥3% or major osteoporotic fracture ≥20%. The association of high risk of fracture and BTMs with all-cause mortality and cardiovascular (CV) mortality were evaluated using multivariate-adjusted Cox regression analysis.ResultsEighty-five (51.8%) patients were classified as high risk of fracture based on FRAX among 164 HD patients. During a mean follow-up period of 3.5 ± 1.0 years, there were 39 all-cause deaths and 23 CV deaths. In multivariate-adjusted Cox regression, high risk of fracture based on FRAX was independently associated with all-cause mortality [hazard ratio (HR): 2.493, 95% confidence interval (CI): 1.026–6.056, p = 0.044) but not with CV mortality (HR: 2.129, 95% CI: 0.677–6.700, p = 0.196). There were no associations between BTMs and mortality risk. Furthermore, lower geriatric nutritional risk index (GNRI) was significantly associated with increased CV mortality (HR: 0.888, 95% CI: 0.802–0.983, p = 0.022) after adjusting by confounding variables.ConclusionHigh risk of fracture using FRAX was an independent predictor of all-cause mortality in patients undergoing HD. FRAX, rather than BTMs, has an important role of prognostic significance in HD patients.

Background: The Taiwanese government launched a universal pay-for-performance (P4P) program in 2006 to promote multidisciplinary care for patients with stage 3b–5 chronic kidney disease (CKD). This study aimed to understand the enrollments, care processes, and outcomes of the P4P program between 2010 and 2018. Methods: We conducted a population-based study using the Taiwan National Health Insurance Research Data. We divided the incident dialysis population into joining and not joining P4P groups based on whether patients had joined the pre-ESRD program before dialysis or not. Trends in the medications prescribed, anemia correction, vascular access preparation before dialysis initiation, and cumulative survival rate were compared. Results: The program included more than 100,000 patients with late-stage CKD. Enrollment increased by almost 100% from 2010 to 2018, with increases seen in those over 75 years old (127.5%), male (96.7%), and earlier CKD stages (≥35% stage 3b in 2018). Females were more likely to stay being enrolled. The joining P4P group was prescribed more appropriate medications, such as erythropoietin-stimulating agents and statins. However, a high number of patients were still prescribed metformin (≥40%) and non-steroidal anti-inflammatory drugs (≥20%). Compared to the not joining P4P group, the patients in the P4P group had better anemia management, dialysis preparation, and post-dialysis survival. Conclusion: The patients in the joining P4P program group were delivered more appropriate CKD care and were associated with better survival outcomes. Polices and action plans are needed to extend the coverage of and enrollment in the P4P program.

Exercise and sport practitioners frequently utilize rating of perceived exertion (RPE) to evaluate the players' psychophysiological strains during training sessions. The subjective rating of physical exertion level during sports training has been shown to have a reciprocal relationship with wellness status during periodic training or competitive seasons. However, the relationship between subjective physical exertions and wellness status during short-term overseas training camps (OTCs) has not been extensively investigated. This study aimed to examine the perceived responses of physical exertions [session-RPE (sRPE), training monotony, and training strain] and wellness status (fatigue, sleep, delayed onset muscle soreness, stress, and mood) measures in elite young adult futsal players from four separate OTCs with different training tasks. Twenty-seven U-20 male national team futsal players voluntarily participated in this study. The players recruited for OTCs were based on their performance during domestic training camps and the tactical demand of the team. The task of each OTCs was defined as: 1) 1st OTC = game-based camp (n = 14); 2) 2nd and 3rd OTC = training-based camp (n = 20 and n = 17, respectively); and 3) 4th OTC = pre-tournament camp (n = 14). The OTCs consisted of 11 training sessions (18.9 hours) and 16 friendly matches (23.8 hours). During daily training sessions and friendly matches, sRPE was used to quantify training load (TL). Additionally, a five-elements general wellness questionnaire was used to evaluate daily wellness status in the morning. The results demonstrated that the mean and sum sRPE in the game-based OTCs were significantly lower compared to the mean sRPE [p < 0.01, effect size (ES) = -4.8; p < 0.01, ES = -2.9] and sum sRPE in the training-based OTCs (p < 0.01, ES = -3.6; p < 0.01, ES = -3.1). The mean (p = 0.01; ES = -2.0) and sum sRPE (p < 0.01; ES = -3.4) in the game-based OTC were also lower than that in the pre-tournament OTC. Conversely, the wellness scores in the game-based OTC were higher compared to the training-based (p = 0.01; ES = 1.8) and the pre-tournament OTCs (p < 0.01; ES = 1.6). There was a negative relationship between mean and sum sRPE and all wellness scores (mean sRPE = r = -0.441 ~ -0.575, p < 0.001; sum sRPE = r = -0.41 ~ -0.559, p < 0.001). Our findings suggested that responses to training sessions, derived from mean and sum sRPE and wellness scores, are dependent upon the task-specific nature of OTCs among elite futsal players. Utilization of mean and sum sRPE and wellness measures to monitor the psychophysiological health during short-term OTCs is recommended.

Background We explored the long-term safety and efficacy of ferric citrate in hemodialysis patients in Taiwan, and further evaluated the iron repletion effect and change of iron parameters by different baseline groups. Methods This was a 12-month, Phase IV, multicenter, open-label study. The initial dose of ferric citrate was administered by patients’ clinical condition and further adjusted to maintain serum phosphorus at 3.5–5.5 mg/dL. The primary endpoint was to assess the safety profiles of ferric citrate. The secondary endpoints were to evaluate the efficacy by the time-course changes and the number of subjects who achieved the target range of serum phosphorus. Results A total of 202 patients were enrolled. No apparent or unexpected safety concerns were observed. The most common treatment-emergent adverse events were gastrointestinal-related with discolored feces (41.6%). Serum phosphorus was well controlled, with a mean dose of 3.35±1.49 g/day, ranging from 1.5 to 6.0 g/day. Iron parameters were significantly improved. The change from baseline of ferritin and TSAT were 227.17 ng/mL and 7.53%, respectively (p-trendConclusions Ferric citrate is an effective phosphate binder with favorable safety profile in ESRD patients. The iron-repletion by ferric citrate is effective, and the increase is limited in patients with a higher baseline. In addition to controlling hyperphosphatemia, ferric citrate also shows additional benefits in the treatment of renal anemia. Clinical trial registration ClinicalTrials.gov ID: NCT03256838; 12/04/2017.

Human induced pluripotent stem cells (iPSCs), since their discovery in 2007, open a broad array of opportunities for research and potential therapeutic uses. The substantial progress in iPSC reprogramming, maintenance, differentiation, and characterization technologies since then has supported their applications from disease modeling and preclinical experimental platforms to the initiation of cell therapies. In this review, we started with a background introduction about stem cells and the discovery of iPSCs, examined the developing technologies in reprogramming and characterization, and provided the updated list of stem cell biobanks. We highlighted several important iPSC-based research including that on autosomal dominant kidney disease and SARS-CoV-2 kidney involvement and discussed challenges and future perspectives.

Environmental melamine exposure has been associated with deteriorating kidney function in early-stage chronic kidney disease patients. In this study, a benchmark dose (BMD) approach was used to establish melamine exposure threshold in 293 patients with eGFR≥30 ml/min per 1.73 m2. The patients were enrolled 2006–2010 and followed-up for a median of 7.0 years to monitor kidney outcomes. Average daily intakes (AvDI) of melamine were estimated using one-spot urine samples collected at enrollment. BMDs and corresponding one-sided 95% lower bound (BMDLs) were derived using established dose–response models relating estimated AvDIs and dichotomous kidney outcomes: doubling of serum creatine levels, eGFR decreased > 3 ml/min per 1.73 m2 per year, and >30% decline in eGFR during the first 2 years. In addition, survival time to doubling of serum creatinine and eGFR decline over time were assessed as continuous endpoints. Given a benchmark response of 0.10, BMDLs ranged from 0.74 to 2.03 μg/kg_bw/day after Bayesian model averaging, a range one to two orders lower than the current WHO recommended tolerable daily intake of 200 μg/kg_bw/day and the US FDA’s 63 μg/kg_bw/day. Our results suggest that early-stage CKD patients should strictly refrain from using melamine tableware and related melamine-made products.

Bardet-Biedl syndrome is a autosomal recessive hereditary disorder characterized by polydactyly, multiple renal cysts, retinal cone-rod dystrophy, obesity, and variable neural development or cognitive impairment. We reported the generation and characterization of an iPS cell line, IBMS-iPSC-063-06, from a patient carrying the BBS2 homologous c534 + 1G > T mutation. The generated iPS cell line retains the mutation and exhibits pluripotency and differentiation ability both in vivo and in vitro condition.

Background: Peritoneal dialysis (PD)-related infection is a serious complication of patients with PD. Refractory peritonitis may lead to failure of PD, shift to hemodialysis (HD) or death. Besides, microbiologic resistance increased worldwide that might impact the treatment choice for such infections. Investigating the causative pathogens and risk factors of PD-related infections in Taiwan was warranted. Methods: This is a retrospective study involving patients with PD from 2007 to 2016 in a southern Taiwan hospital. Patient characteristics, microbiological data, outcomes, and factors associated with refractory peritonitis were analyzed. Results: There were 190 episodes of PD-related peritonitis in 110 patients from this cohort. Gram-positive organisms were the leading cause of PD-related peritonitis, but gram-negative organisms, esp. Pseudomonas aeruginosa, were predominant for exit site infection and tunnel infection. The incidence of peritonitis was 0.25 episode per patient-year (1 episode per 47.69 months). The refractory rate was 14.2% (27/190). Methicillin resistance was noted in 2 (13.3%) of 15 Staphylococcus aureus isolates. Of 114 isolates, 72.8% (83) were susceptible to either cefazolin or gentamicin. Staphylococcus spp. and Escherichia coli infections were significantly associated with refractory peritonitis. Baseline hyponatremia (

Abstract Background Incidence of renal dysfunction and risks of progression to end-stage renal disease (ESRD) were reported higher in upper urinary tract urothelial carcinoma (UTUC) than in renal cell carcinoma (RCC) patients after unilateral nephrectomy. Methods Totally 193 renal cancer patients, including 132 UTUC and 61 RCC, were studied to clarify whether the pathological changes of the kidney remnant removed from nephrectomy and the clinical factors might predict the risk of ESRD. Renal tubulointerstitial (TI) score and global glomerulosclerosis (GGS) rate were examined by one pathologist and two nephrologists independently under same histopathological criteria. Results The glomerular filtration rates at the time of surgery were lower in UTUC than RCC groups (p

The consequences of once-weekly rifapentine plus isoniazid for 3 months (3HP) against latent tuberculosis infections in hemodialysis patients have not been studied before. This is the first study to evaluate the safety and tolerability of 3HP in this population and revealed a completion rate of 65.4%. The therapy was not associated with hepatotoxicity, but with high rates of adverse events (69.2%). Keywords: Rifapentine, 3HP, Latent tuberculosis, LTBI, Hemodialysis

Uric acid (UA) is elevated in metabolic syndrome (MS) and diabetes (DM). UA is associated with central obesity and blood glucose and is proposed as a criterion of MS. Previous reports showed that UA could predict renal outcome in CKD. However, recent clinical trials did not demonstrate the benefits of urate-lowering agents (ULA) for renal outcome. Whether the prognostic value of UA for renal outcome is independent of MS or secondary to MS in CKD patients is unknown. Our study included 2500 CKD stage 1–4 Asian patients divided by UA tertiles and MS/DM. In linear regression, UA was associated with obesity, C-reactive protein, and renal function. In Cox regression, high UA was associated with worse renal outcome in non-MS/DM, but not in MS/DM: hazard ratio (95% confidence interval) of UA tertile 3 was 3.86 (1.87–7.97) in non-MS/DM and 1.00 (0.77–1.30) in MS/DM (p for interaction < 0.05). MS was associated with worse renal outcome, but redefined MS (including hyperuricemia as the 6th criteria) was not. In conclusion, hyperuricemia is associated with worse renal outcome in non-MS/DM and is not an independent component of MS in CKD stage 1–4 patients. Hyperuricemia secondary to MS could not predict renal outcome.

Objective: Harmonizing formulas are associated with beneficial renal outcomes in chronic kidney disease (CKD), but the therapeutic mechanisms are unclear. The study aims to explore the associations of intentions and independent factors with harmonizing formulas prescriptions for patients with CKD.Methods: We conducted a population-based cross-sectional study to explore factors associated with harmonizing formulas prescription. Patients who had been prescribed harmonizing formulas after CKD diagnosis was defined as the using harmonizing formulas group. Disease diagnoses when having harmonizing formula prescriptions and patient characteristics related to these prescriptions were collected.Results: In total, 24,971 patients were enrolled in this analysis, and 5,237 (21%) patients were prescribed harmonizing formulas after CKD diagnosis. The three most frequent systematic diseases and related health problems for which harmonizing formula prescriptions were issued in CKD were symptoms, signs, and ill-defined conditions (24.5%), diseases of the digestive system (20.67%), and diseases of the musculoskeletal system (12.9%). Higher likelihoods of harmonizing formula prescriptions were associated with young age (adjusted odds ratio: 0.98, 95% confidence interval: 0.97–0.98), female sex (1.79, 1.68–1.91), no diabetes (1.20, 1.06–1.36), no hypertension (1.38, 1.27–1.50), no cerebrovascular disease (1.34, 1.14–1.56), less disease severity (0.85, 0.83–0.88), using nonsteroidal anti-inflammatory drugs (NSAIDs) (1.65, 1.54–1.78), and using analgesic drugs other than NSAIDs (1.47, 1.35–1.59).Conclusion: Harmonizing formulas are commonly used for treating symptoms of the digestive and musculoskeletal systems in CKD cases. Further research on harmonizing formula effectiveness with regard to particular characteristics of CKD patients is warranted.

Digoxin is commonly prescribed for heart failure and atrial fibrillation, but there is limited data on its safety in patients with chronic kidney disease (CKD). We conducted a population-based cohort study using the pre-end stage renal disease (ESRD) care program registry and the National Health Insurance Research Database in Taiwan. Of advanced CKD patient cohort (N = 31,933), we identified the digoxin user group (N = 400) matched with age and sex non-user group (N = 2,220). Multivariable Cox proportional hazards and sub-distribution hazards models were used to evaluate the association between digoxin use and the risk of death, cardiovascular events (acute coronary syndrome, ischemic stroke, or hemorrhagic stroke) and renal outcomes (ESRD, rapid decline in estimated glomerular filtration rate-eGFR, or acute kidney injury). Results showed that all-cause mortality was higher in the digoxin user group than in the non-user group, after adjusting for covariates (adjusted hazard ratio, aHR 1.63; 95% CI 1.23-2.17). The risk for acute coronary syndrome (sub-distribution hazard ratio, sHR 1.18; 95% CI 0.75-1.86), ischemic stroke (sHR 1.42; 95% CI 0.85-2.37), and rapid eGFR decline (sHR 1.00 95% CI 0.78-1.27) was not significantly different between two groups. In conclusion, our study demonstrated that digoxin use was associated with increased mortality, but not cardiovascular events or renal function decline in advanced CKD patients. This finding warns the safety of prescribing digoxin in this population. Future prospective studies are needed to overcome the limitations of cohort study design.

The incidence of hepatic steatosis is increasing globally, and it is important to identify those at risk to prevent comorbidities. Complete blood count is a simple, convenient, and inexpensive laboratory examination which can be used to obtain white blood cell (WBC) and platelet counts. The aims of this study were to investigate the relationships between WBC and platelet counts with hepatic steatosis, and whether WBC and platelet counts were associated with the severity of hepatic steatosis. We enrolled 1969 participants residing in southern Taiwan who took part in a health survey from June 2016 to September 2018 in this cross-sectional study. None of the participants were heavy alcohol users or had a history of hepatitis B or C. We collected laboratory data, and the severity of hepatic steatosis was determined by abdominal ultrasound. The overall prevalence rate of hepatic steatosis was 42.0%. There were significant trends of stepwise increases in WBC count (p < 0.001) corresponding to the severity of hepatic steatosis. After multivariable linear regression analysis, hepatic steatosis was significantly associated with high WBC count (coefficient β, 0.209; 95% confidence interval (CI), 0.055 to 0.364; p = 0.008) and high platelet count (coefficient β, 12.213; 95% CI, 6.092 to 18.334; p < 0.001); also, higher WBC counts corresponded with the severity of hepatic steatosis.

Background: Many elderly people in Taiwan move to institutional care due to disability or insufficient family resources. This study aimed to understand the place identity and life adaptation of institutional residents and their influencing factors, and to explore the correlation between these two. Methods: This study adopted a cross-sectional survey method. A total of 120 cases were collected with structured questionnaires, and SPSS 22.0 software package was used for statistical analysis. Results: The place identity was the highest in the sense of belonging, while the sense of participation was the worst; adaptation to life was the best in terms of care management, and the worst in terms of adaptation to life and assistive devices. The length of stay in the institution, daily activities, and the number of chronic diseases were significantly different from place identity, and the number of chronic diseases was significantly different from life adaptation. Conclusions: The results of this study can be used as a reference for institutions to improve the quality of care. It is suggested that institutions can organize more activities to promote interaction and participation among residents, to strengthen their local identity and life adaptation.

The aim of this study was two-fold: (i) analyze the variations in the physical fitness of selected and non-selected under-20 male national futsal players; and (ii) analyze the variations in training intensity monitored during training camps. Thirty-three Taiwan under-20 national futsal players were monitored for training intensity during 18 training camps. They were divided into two groups: selected (n = 14) and non-selected (n = 17) players. The physical assessments included the following measures: body mass, distance covered at Yo-Yo intermittent recovery test Level 1, final velocity at 30-15 Intermittent Fitness Test (30-15 IFT), standing long jump, maximum heart rate (HR), and 1-min sit-up. The training intensity was monitored using the rate of perceived exertion (RPE), HR at different intensity zones, and locomotor demands measured at different speed thresholds. The results revealed that the selected players were significantly faster in the 15-m sprint with ball (p = 0.001) and 30-m sprint (p = 0.001). Additionally, the selected players presented significantly greater HRaverage and time spent above 90% maximum HR during the three-to-six-day training camps (p < 0.05) compared to the non-selected players. Interestingly, the NS demonstrated a greater number of sprints during the training camps (p = 0.001), while the selected players presented greater distance/minute and average speed (p = 0.001). A regression analysis showed that the distance/minute and average speed was a significant predictor of maximum HR in the selected players. As conclusions, the physical fitness outcomes are different between the selected and non-selected national futsal players. The selected players spent more time in high intensity HR demands in training sessions.

Background Glycemia is related to energy production during exercise. Coenzyme Q10 is an antioxidant that participates in adenosine triphosphate synthesis in mitochondria. The aim of this study was to investigate the level of coenzyme Q10, glucose parameters, and antioxidant capacity in athletes. Methods This study was designed as a cross-sectional study. Well-trained college athletes (n = 43) and age-gender matched healthy subjects (n = 25) were recruited from a college. The levels of glucose parameters, oxidative stress, antioxidant enzymes activity, Trolox equivalent antioxidant capacity (TAC), and coenzyme Q10 status were measured in the present study. Results The athletes had a significantly lower level of white blood cells (WBC) coenzyme Q10 than the healthy subjects (0.34 ± 0.24 vs. 0.65 ± 0.43 nmol/g, p

BackgroundThe accurate assessment of liver fibrosis among hemodialysis patients with chronic hepatitis C (CHC) is important for both treatment and for follow up strategies. Applying the non-invasive methods in general population with viral hepatitis have been successful but the applicability of the aminotransferase/platelet ratio index (APRI) or the fibrosis-4 index (FIB-4) in hemodialysis patients need further evaluation.Materials and methodsWe conducted a prospective, multi-center, uremic cohort to verify the applicability of APRI and FIB-4 in identifying liver fibrosis by reference with the standard transient elastography (TE) measures.ResultsThere were 116 CHC cases with valid TE were enrolled in our analysis. 46 cases (39.6%) were classified as F1, 35 cases (30.2%) as F2, 11 cases (9.5%) as F3, and 24 cases (20.7%) as F4, respectively. The traditional APRI and FIB-4 criteria did not correctly identify liver fibrosis. The optimal cut-off value of APRI was 0.28 and of FIB-4 was 1.91 to best excluding liver cirrhosis with AUC of 76% and 77%, respectively. The subgroup analysis showed that female CHC hemodialysis patients had better diagnostic accuracy with 74.1% by APRI. And CHC hemodialysis patients without hypertension had better diagnostic accuracy with 78.6% by FIB-4.ConclusionsThis study confirmed the traditional category level of APRI and FIB-4 were unable to identify liver fibrosis of CHC hemodialysis patients. With the adjusted cut-off value, APRI and FIB-4 still showed suboptimal diagnostic accuracy. Our results suggest the necessary of TE measures for liver fibrosis in the CHC uremic population.

Background/Aims: Fluid overload is common and associated with morbidity and mortality in patients with end-stage renal disease. The relationship between fluid overload and cardiac function is complex, and whether fluid overload is associated with adverse outcomes in patients undergoing hemodialysis (HD) independently of systolic and diastolic function of the left ventricle (LV) remains unclear. Methods: The present study aimed to investigate the relationship between overhydration and all-cause and cardiovascular (CV) mortality after adjusting for LV function in 178 maintenance HD patients. The relative hydration status (overhydration/ extracellular water, ∆HS) was measured using a body composition monitor, and then used to assess the fluid status. A ∆HS ≥7% was defined as fluid overload. Global left ventricular longitudinal systolic strain (GLS), and the early filling and early diastolic mitral annular velocity (E/E’) ratio were assessed using speckle-tracking and tissue Doppler echocardiography. Results: During a mean follow-up period of 2.7 years, 24 patients died, including 11 CV deaths. An increased ∆HS was significantly associated with all-cause and CV mortality in the univariate analysis. This prognostic significance remains after multivariate adjusting for GLS and E/E’ ratio for all-cause (HR, 1.123; 95% CI, 1.063–1.186; p-value < 0.001) and CV (HR, 1.088; 95% CI, 1.005–1.178; p-value =0.037) mortality. Moreover, ∆HS significantly improved the prognostic value beyond conventional clinical and echocardiographic parameters. Conclusion: A higher ∆HS was independently associated with increased all-cause and CV mortality after adjusting for systolic and diastolic function of the LV. This suggests that ∆HS may be a relevant target for improving outcomes in maintenance HD patients.

Background/Aims: Diabetic nephropathy is the leading cause of end-stage renal disease and accounts for 30∼40% of patients requiring maintenance dialysis, thereby increasing the burden on health insurance programs. Diabetic nephropathy is also the strongest predictor of cardiovascular morbidity and mortality. The aim of this study was to examine whether angiopoietin-2 (Angpt2), a modulator of endothelial function, affects the clinical outcomes of diabetic patients. Methods: This study enrolled 236 patients with diabetes mellitus with estimated glomerular filtration rate (eGFR) < 60ml/min/1.73m2 from January 2006 to December 2011, who were followed until June 2017. Clinical outcomes included renal outcomes (commencing dialysis and rapid decline in renal function (eGFR decline > 3 ml/min per 1.73 m2/year)), major adverse cardiovascular events (MACEs), and all-cause mortality. Results: Over a mean follow-up period of 3.9±2.7 years, 135 (57.2%) patients commenced dialysis, 106 (44.9%) had rapid decline in renal function, and 50 (21.2%) had MACEs or died from all-causes. Log-formed Angpt2 was significantly associated with increased risks of commencing dialysis (HR: 3.91, 95% CI: 1.56-9.76), rapid renal function decline (OR: 6.81, 95% CI: 1.06-43.88), and MACEs or all-cause mortality (HR: 6.34, 95% CI: 1.18-33.97) in the adjusted analysis. Patients in the highest quartile had hazard ratios of 2.90 and 3.11 for commencing dialysis and rapid renal function decline, respectively, compared to those in the lowest quartile after adjustments. Similar significant dose-response results were found in composite outcomes of either MACEs or all-cause mortality. Conclusion: Angpt2 is an independent predictor of adverse clinical outcomes in diabetic patients. Further studies are needed to identify the pathogenic role of Angpt2 in renal deterioration and cardiovascular complications of diabetes mellitus.

(1) Background: A disease prediction model derived from real-world data is an important tool for managing type 2 diabetes mellitus (T2D). However, an appropriate prediction model for the Asian T2D population has not yet been developed. Hence, this study described construction details of the T2D Holistic Care model via estimating the probability of diabetes-related complications and the time-to-occurrence from a population-based database. (2) Methods: The model was based on the database of a Taiwan pay-for-performance reimbursement scheme for T2D between November 2002 and July 2017. A nonhomogeneous Markov model was applied to simulate multistate (7 main complications and death) transition probability after considering the sequential and repeated difficulties. (3) Results: The Markov model was constructed based on clinical care information from 163,452 patients with T2D, with a mean follow-up time of 5.5 years. After simulating a cohort of 100,000 hypothetical patients over a 10-year time horizon based on selected patient characteristics at baseline, a good predicted complication and mortality rates with a small range of absolute error (0.3–3.2%) were validated in the original cohort. Better and optimal predictabilities were further confirmed compared to the UKPDS Outcomes model and applied the model to other Asian populations, respectively. (4) Contribution: The study provides well-elucidated evidence to apply real-world data to the estimation of the occurrence and time point of major diabetes-related complications over a patient’s lifetime. Further applications in health decision science are encouraged.

Diastolic dysfunction is an emerging challenge among hemodialysis (HD) patients, and the associations between serum zinc with echocardiographic parameters and diastolic function remain uncertain. A total of 185 maintenance HD patients were stratified by the tertiles of serum zinc level to compare their clinical characteristics and echocardiography. Correlations of serum zinc levels with echocardiographic parameters were examined using Pearson’s analysis. Univariate and multivariate logistic regression analyses were performed to investigate the determinants of E/e’ ratio >15 and left atrial volume index (LAVI) > 34 mL/m2, both indicators of diastolic dysfunction. Patients belonging to the first tertile of serum zinc level had a significantly higher E/e’ ratio and LAVI. Serum zinc levels were negatively correlated with E (r = −0.204, p = 0.005), E/e’ ratio (r = −0.217, p = 0.003), and LAVI (r = −0.197, p = 0.007). In a multivariate analysis, older age, diabetes, coronary artery disease, and lower serum zinc levels (OR = 0.974, 95% CI = 0.950–0.999, p = 0.039) were significantly associated with E/e’ ratio >15. Furthermore, diabetes and lower serum zinc levels (OR = 0.978, 95% CI = 0.958–0.999, p = 0.041) were significantly associated with LAVI >34 mL/m2. Reduced serum zinc level was significantly associated with diastolic dysfunction among HD patients. Further prospective studies are warranted to investigate whether zinc supplementation can attenuate cardiac dysfunction in maintenance HD patients.

Abstract Diabetes duration, diabetic retinopathy (DR), and a diagnostic model have been proposed as clinical parameters favoring the presence of diabetic nephropathy (DN) in biopsied patients with diabetic kidney disease. DN, compared with non-diabetic renal disease, had poorer renal outcomes. We tested whether these clinical parameters favoring DN are associated with poorer renal outcomes in non-biopsied patients. In this study, 1330 patients with type 2 diabetes and chronic kidney disease stages 1–4 were included and divided according to diabetes mellitus (DM) duration >8 years, DR, or a diagnostic model for DN. These clinical parameters favoring DN were found in 62–77% of patients and associated with higher levels of proteinuria. In a Cox survival analysis, DR and the diagnostic model favoring DN were associated with an increased risk for end-stage renal disease with adjusted hazard ratios of 1.69 (95% CI: 1.16–2.45, P = 0.006) and 1.66 (95% CI: 1.05–2.61, P = 0.029), respectively. DR was associated with an increased risk for rapid renal disease progression. DM >8 years was not associated with renal outcome. Propensity score-matched analyses also showed similar results. In conclusion, DR and the diagnostic model favoring DN were associated with poorer renal outcomes.

Background/Aims: Heart rate variability (HRV) has been linked to mortality in maintenance hemodialysis (HD) patients, but it is less clear whether HRV is associated with major adverse cardiovascular events (MACEs) and hospitalization. Methods: This study enrolled 179 maintenance HD patients. HRV was measured to assess its prognostic significance in relation to MACEs and hospitalization. Results: During the follow-up period of 33.3 ± 6.7 months, 36 (20.1%) patients had a MACE, and 98 (54.7%) experienced hospitalization. In multivariate adjusted Cox regression analysis, low very low frequency (VLF) power (hazard ratio [HR], 0.727; 95% confidence interval [CI], 0.624–0.848; p < 0.001), a history of coronary artery disease, high ultrafiltration rate, the use of angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, and the use of beta-blockers were all significantly associated with MACEs. Low VLF power (HR, 0.873; 95% CI, 0.785–0.971; p = 0.012), low serum albumin, low serum creatinine, low Kt/V levels, and high serum calcium-phosphorus product levels significantly predicted hospitalization in maintenance HD patients. Conclusions: Reduced VLF power is linked to an increased risk of MACEs and hospitalization in maintenance HD patients. Assessing cardiac autonomic function through HRV is of pivotal prognostic significance for this patient population.

Adiponectin is the most abundant circulating adipokine, and it has insulin-sensitizing and anti-inflammatory properties. Although it has been speculated that kidney function decline associated with elevated adiponectin is attributable to decreased renal clearance and compensatory responses to adiponectin resistance, it is unclear how elevated adiponectin affects clinical outcomes in chronic kidney disease (CKD) patients and whether the effects are the same as those in the general population. Therefore, the aim of this study is to examine whether the association between serum adiponectin levels and clinical outcomes in non-diabetic CKD patients is independent of adiposity and metabolic syndrome. We enrolled 196 non-diabetic CKD patients with eGFR ranging between 10 and 60 mL/min/1.73 m2, these patients were divided into two groups based on the presence of metabolic syndrome. The primary endpoint was all-cause mortality or renal events (renal failure requiring renal replacement therapy [RRT] or 50% reduction in eGFR). During the mean follow-up period of 5 years, 48 (24.5%) incident cases of end-stage renal disease (ESRD) were observed, and 33 (16.8%) deaths occurred. The mean eGFR was 29.8 ± 12.8 mL/min/1.73m2. The baseline median adiponectin concentration in the cohort was 29.4(interquartile range, 13.3-108.7) μg/ml. Adiponectin levels were inversely related to body mass index (BMI) (r = -0.29; P < 0.001) and waist circumference (r = -0.35; P < 0.001). In the fully adjusted Cox regression model, the hazard ratios (HRs) were 2.08 (95% confidence interval [CI], 1.08-4.02; P = 0.03) for RRT and 1.66 (95% CI, 1.03-2.65; P = 0.04) for composite renal outcome. The risks remained consistent within different subgroups. However, no association was observed with mortality risk. In conclusion, higher adiponectin levels are associated with a higher risk of ESRD independent of conventional risk factors, BMI, and metabolic syndrome components.

BackgroundDepression is common in dialysis patients, but the clinical impact of this condition is poorly defined.MethodsOut of 57,703 patients starting dialysis during 2000-2007 recorded in the National Health Insurance Research Database of Taiwan, we identified 2,475 patients with a clinical diagnosis of depression, and compared them with 1:5 age- and sex-matched patients without a depression diagnosis (n = 12,375). Patients were followed up for hospitalisation due to severe infections, major adverse cardiovascular events (MACE) and death. Multivariable Cox regression and competing risk analyses (accounting for death when appropriate) were used to estimate risk associations.ResultsPatients with depression had a higher frequency of comorbidities. During a mean follow-up of 3.2 years, 1,140 severe infections, 806 MACE, and 1,121 deaths were recorded. Compared to controls, patients with depression were at increased risk of death (adjusted hazard ratio 1.24; 95%CI 1.16-1.33). Patients with depression were also at higher risk of severe (1.14; 1.06-1.22) and fatal infections (death within 30 days, 1.22; 1.09-1.35), attributed mainly to sepsis (1.19; 1.08-1.31), septic shock (1.36; 1.13-1.62) and pneumonia (1.19; 1.07-1.33). Conversely, no association was observed between depression and the MACE risk (1.04; 0.94-1.15).ConclusionDialysis patients with depression are associated with increased risk of infections and death.

Anti-acid drugs, proton pump inhibitor (PPI) and histamine-2 blocker (H2-blocker), are commonly prescribed to treat gastrointestinal disorders. These anti-acid drugs alter gut microbiota in the general population, but their effects are not known in hemodialysis patients. Hence, we investigated the microbiota composition in hemodialysis patients treated with PPIs or H2-blocker. Among 193 hemodialysis patients, we identified 32 H2-blocker users, 23 PPI users, and 138 no anti-acid drug subjects. Fecal samples were obtained to analyze the gut microbiome using 16S RNA amplicon sequencing. Differences in the microbial composition of the H2-blocker users, PPI users, and controls were assessed using linear discriminant analysis effect size and the random forest algorithm. The species richness or evenness (α-diversity) was similar among the three groups, whereas the inter-individual diversity (β-diversity) was different between H2-blocker users, PPI users, and controls. Hemodialysis patients treated with H2-blocker and PPIs had a higher microbial dysbiosis index than the controls, with a significant increase in the genera Provetella 2, Phascolarctobacterium, Christensenellaceae R-7 group, and Eubacterium oxidoreducens group in H2-blocker users, and Streptococcus and Veillonella in PPI users. In addition, compared to the H2-blocker users, there was a significant enrichment of the genera Streptococcus in PPI users, as confirmed by the random forest analysis and the confounder-adjusted regression model. In conclusion, PPIs significantly changed the gut microbiota composition in hemodialysis patients compared to H2-blocker users or controls. Importantly, the Streptococcus genus was significantly increased in PPI treatment. These findings caution against the overuse of PPIs.

Gut dysbiosis in patients with chronic kidney disease (CKD) may induce chronic inflammation and increase morbidity. Phosphate-binding agents, generally used in patients with CKD, may potentially change the composition of the gut microbiota. This study aimed to compare the microbiota composition in hemodialysis patients treated with ferric citrate or calcium carbonate. The stool microbiota was investigated in hemodialysis patients treated with ferric citrate (n = 8) and calcium carbonate (n = 46) using 16S rRNA gene amplicon sequencing profiling using linear discriminant analysis of effect size. Further predictive functional profiling of microbial communities was obtained with Tax4Fun in R. Hemodialysis patients treated with calcium carbonate had a significantly reduced microbial species diversity (Shannon index and Simpson index) and an increased microbial alteration ratio compared with patients treated with ferric citrate. A distinct microbial community structure was found in patients treated with ferric citrate, with an increased abundance of the Bacteroidetes phylum and a decreased abundance of the phylum Firmicutes. Members of the order Lactobacillales were enriched in patients treated with calcium carbonate, whereas taxa of the genera Ruminococcaceae UCG-004, Flavonifractor, and Cronobacter were enriched in patients treated with ferric citrate phosphate binder. In conclusion, Ferric citrate therapy results in a more diverse microbiome community compared to calcium carbonate therapy in hemodialysis patients with phosphate binder treatment. The gut microbiome reflects the phosphate binder choice in hemodialysis patients, further affecting the physiological environment in the gastrointestinal tract.

Background: Understanding factors associated with the quality of life (QoL) of patients with type 2 diabetes (T2DM) is an important health issue. This study aimed to explore the correlation between continuity of care and quality of life in patients with T2DM and to probe for important explanatory factors affecting quality of life. Methods: This study used a cross-sectional correlation research design. Convenience sampling was adopted to recruit 157 patients, aged 20–80 years and diagnosed with T2DM in the medical ward of a regional hospital in central Taiwan. Results: The overall mean (standard deviation, SD) QOL score was 53.42 (9.48). Hierarchical regression linear analysis showed that age, depression, two variables of potential disability (movement and depression), and the inability to see a specific physician or maintain relational continuity with medical providers were important predictors that could effectively explain 62.0% of the variance of the overall QoL. Conclusions: The relationship between patients and physicians and maintaining relational continuity with the medical providers directly affect patients’ QoL during hospitalization and should be prioritized clinically. Timely interventions should be provided for older adult patients with T2DM, depression, or an inability to exercise to maintain their QoL.

Background: Heart rate variability (HRV) represents changes in the time between successive heart beats, and it has been used to assess the autonomic nervous system. Previous studies have reported autonomic dysfunction in diabetic patients undergoing hemodialysis (HD), however, no studies have evaluated the effects of age on changes in HRV in these patients. The aim of this study was to examine the effects of age on changes in HRV in diabetic HD patients.Methods: We enrolled 84 diabetic patients receiving maintenance HD. HRV was measured before and after HD to assess changes in HRV (ΔHRV). The patients were divided into two groups based on their age (65 years< or ≥65 years).Results: Compared to the patients aged

OBJECTIVES:Methicillin-resistant Staphylococcus aureus (MRSA) infections in the hemodialysis (HD) population are epidemiologically classified as healthcare-associated infections. The data about the clinical impact and bacterial characteristics of hospital-onset (HO)- and community-onset (CO)-MRSA in HD patients are scarce. The current study analyzed the difference in the clinical and molecular characteristics of HO-MRSA and CO-MRSA. METHODS:We performed a retrospective review and molecular analysis of clinical isolates from 106 HD patients with MRSA bacteremia from 2009 to 2014. CA genotypes were defined as isolates carrying the SCCmec type IV or V, and HA genotypes were defined as isolates harboring SCCmec type I, II, or III. RESULTS:CO-MRSA infections occurred in 76 patients, and 30 patients had HO-MRSA infections. There was no significant difference in the treatment failure rates between patients with CO-MRSA infections and those with HO-MRSA infections. CA genotypes were associated with less treatment failure (odds ratio [OR]: 0.18; 95% confidence interval [95% CI], 0.07-0.49; p = 0.001). For isolates with a vancomycin minimum inhibitory concentration (MIC) < 1.5 mg/L, the multivariate analysis revealed that HA genotypes and cuffed tunneled catheter use were associated with treatment failure. For isolates with a vancomycin MIC ≥1.5 mg/L, the only risk factor for treatment failure was a higher Pitt score (OR: 1.76; 95% CI, 1.02-3.05; p = 0.043). CONCLUSION:CA genotypes, but not the epidemiological classification of CO-MRSA, impacted the clinical outcome of MRSA bacteremia in the HD population.