Simultaneous occurrence of fibrillary glomerulonephritis and renal lesions in nonmalignant monoclonal IgM gammopathy.

BACKGROUND: Fibrillary glomerulonephritis (FGN) is a rare primary glomerular disease that seldom coexists with other diseases. Membranoproliferative glomerulonephritis is a pathologic finding of renal lesions associated with IgM-secreting monoclonal proliferations. We present a case study of a patient with unusual simultaneous FGN and IgM-related renal disorder in nonmalignant monoclonal IgM gammopathy. CASE PRESENTATION: A 63-year-old male presented with nephrotic syndrome and elevated serum creatinine levels. Laboratory examination revealed elevated levels of serum IgM and low C3 levels. Serum and urine immunofixation electrophoresis showed a monoclonal IgM with a kappa light chain. A bone marrow biopsy revealed less than 5 % bone marrow infiltration by lymphoplasmacytic lymphoma, and a renal biopsy revealed mesangiocapillary glomerulonephritis on light microscopy. Immunofluorescent and immunohistochemical staining indicated granular deposits of immunoglobulin G in the mesangium and granular deposits of immunoglobulin M and κ light chains along the capillary wall. Electron microscopy revealed randomly arranged nonbranching fibrils of approximately 15 nm in diameter in the glomerular mesangium and subendothelial electron-dense deposits. According to these results, we confirmed FGN and membranoproliferative glomerulonephritis, which were attributed to monoclonal IgM deposits. CONCLUSION: To the best of our knowledge, this is the first report of simultaneous FGN and membranoproliferative glomerulonephritis in nonmalignant IgM monoclonal gammopathy.

Effect of oral ferric citrate on serum phosphorus in hemodialysis patients: multicenter, randomized, double-blind, placebo-controlled study.

BACKGROUND: Hyperphosphatemia is a common complication in dialysis patients that can be treated by oral phosphate binders. We investigated the efficacy and safety of oral ferric citrate as a phosphate binder for Taiwanese patients with end stage renal disease and with hyperphosphatemia who were undergoing hemodialysis. METHODS: This was a prospective, double-blind, placebo-controlled, randomized trial carried out in 5 hospitals in Taiwan. Ferric citrate (4 or 6 g/day) or placebo was administered for 56 days. Serum calcium, phosphorous levels, calcium × phosphorus product, serum ferritin level, transferrin saturation, and adverse events were recorded. RESULTS: A total of 166 patients completed the trial. The placebo group had relatively constant serum data. Serum phosphorus declined significantly in the 6 g/day group (p < 0.05 for 4 and 8 weeks) and the 4 g/day group (p < 0.05 for 4 and 8 weeks). There were similar changes in the calcium × phosphorus product. The serum ferritin level increased significantly in the 6 g/day group (p < 0.05) and the 4 g/day group (p < 0.05). There were similar changes in transferrin saturation. Most adverse events were mild to moderate and were comparable among the three groups. CONCLUSIONS: A 56-day treatment with ferric citrate effectively controlled hyperphosphatemia and was well tolerated in maintenance hemodialysis patients. There were also moderate increases in serum ferritin and transferrin saturation.

The immediate and one-year outcomes of dialysis patients with refractory angina treated by enhanced external counterpulsation.

Adult dialysis patients with angina pectoris refractory to medical treatment or revascularization are not uncommon. Enhanced external counterpulsation (EECP) has been proven to be effective in reducing myocardial ischemia and refractory angina. The objective of this study was to assess the immediate and 1-year effects of EECP treatment in dialysis patients with refractory angina. Thirty-six consecutive dialysis patients were treated with EECP, and a follow-up was conducted after 1 year. The Canadian Cardiovascular Society (CCS) Angina Grading Scale was used to measure angina severity. Medications were recorded before EECP treatment, at the end of treatment, and at 1-year follow-up. Adverse events and risk factors of cardiovascular disease were recorded and analyzed. At 1-year follow-up, data from patients improving by at least one CCS class after treatment were compared with data from patients showing no improvement. The improvement rates in CCS class were 85% immediately after EECP and 66% at 1-year follow-up. Thallium-201 myocardial perfusion imaging demonstrated a reversible resolution of 40% and improvement of 25% immediately after EECP treatment. Diabetes mellitus and high serum phosphate levels were risk factors affecting whether the beneficial effects of EECP treatment could be sustained (p < 0.05). Major adverse events were rare. EECP shows potential for refractory angina in dialysis patients. The beneficial effects were sustained for more than 1 year in 66% patients. Diabetes mellitus and high serum phosphate levels were major factors impacting the sustained effectiveness of EECP treatment. Nonetheless, adequately powered future studies are necessary to assess safety and efficacy of this procedure.

Cola-colored dialysate as a gastrointestinal sequelae of cardiac surgery in a patient who underwent peritoneal dialysis.

The discoloration of effluent peritoneal dialysate, which is transparent in origin, is seen in some particular conditions including chyloperitoneum, calcium channel blocker usage, hemoperitoneum, perforated cholecystitis, iron administration, and hemorrhagic pancreatitis. We report a case of a 60-year-old woman who underwent peritoneal dialysis for 3 years and presented with conspicuous cola-colored (brownish-black) dialysate after a cardiac surgery. The findings of the dialysate analysis and the abdominal computed tomography showed that this discoloration could be due to the presence of methemalbumin caused by pancreatitis (not hemorrhagic) combined with intra-abdominal bleeding-both of which are rare gastrointestinal complications of cardiac surgery. She eventually died of pulseless electrical activity due to severe sepsis with profound shock. Therefore, the rare event of cola-colored peritoneal dialysate could present as severe gastrointestinal sequelae of cardiac surgery and may indicate a poor prognosis.

Efficacy and safety of SBR759, a novel calcium-free, iron(III)-based phosphate binder, in Asian patients undergoing hemodialysis: A 12-week, randomized, open-label, dose-titration study versus sevelamer hydrochloride.

AIM: SBR759 is a calcium-free, polymeric, iron(III)-based oral phosphate binder, in development for the treatment of hyperphosphatemia. The efficacy and safety of SBR759 was compared with sevelamer hydrochloride in chronic kidney dialysis patients on hemodialysis. METHODS: Japanese and Taiwanese hyperphosphatemic patients who were on hemodialysis (n = 203) received starting doses of 3.0 or 4.5 g/day SBR759 or 2.4 or 4.8 g/day sevelamer-hydrochloride (HCl) based on baseline phosphate levels. Daily doses were up-titrated every 2 weeks to reach the Kidney Disease Outcomes Quality Initiative (K/DOQI) recommended target serum phosphate concentration ≤1.7 mmol/L. The key endpoints were proportion of patients achieving target serum phosphate and the safety at week 12. RESULTS: SBR759 showed a superior phosphate response at week 12 compared with sevelamer-HCl (83% vs 54% patients; P < 0.0001). Mean serum calcium concentrations were unaffected by either treatment. Similar incidences of adverse events and serious adverse events were seen with SBR759 and sevelamer-HCl (90.3% vs 94.1% and 5.2% vs 4.4%, respectively), but overall discontinuation rates were lower with SBR759 (11.9% vs 20.6%). The proportion of patients experiencing gastrointestinal disorders was lower in SBR759 versus sevelamer-HCl. No treatment-related serious adverse events were reported. CONCLUSIONS: SBR759 showed superior phosphate control with a favorable tolerability profile compared to sevelamer-HCl in hemodialysis patients.

Assessment of reasons for not intensifying antihypertensive treatment in the Taiwanese population.

BACKGROUND/PURPOSE: Despite availability of effective antihypertensives, blood pressure (BP) control is usually inadequate. The Reasons for not Intensifying Antihypertensive Treatment (RIAT) registry evaluated the reasons behind not modifying treatment in an international, cross-sectional study in 16 countries. METHODS AND RESULTS: The Taiwanese cohort of RIAT consisted of 8922 patients with untreated/uncontrolled essential hypertension recruited from 22 centers in the country. At the first visit, physicians selected target BP and antihypertensive treatment, and at the next three visits they measured BP and modified treatment/provided justification for not modifying treatment. Mean target BP selected by physicians was 134.6/84.6 ± 5.1/5.0 mmHg, respectively. Patients' individual risk stratification determined the BP goals. More patients achieved targets according to the physicians' opinion than based on actual BP measurements: visit 2-50.6% vs. 48.6%; visit 3-58.4% vs. 55.2%; and visit 4-61.2% vs. 57.0%. At each visit, treatment remained unchanged for >60% patients not reaching target; the most common reason for this at visit 2 was the assumption that the time was too short to assess new drug therapy and at visits 3 and 4 was the assumption that target was reached/had almost been reached. CONCLUSION: About 40% Taiwanese hypertensive patients in RIAT did not reach BP targets after an average of 4 months' follow-up. The most common reason for not modifying treatment was the assumption that the target had been reached or had almost been reached.

Micronutrients and lifestyles in Taiwanese patients with stage 3 to 5 chronic kidney disease.

OBJECTIVE: Lycopene is an antioxidant that reduces oxidative stress. Analgesics are commonly used and may impair kidney function. However, the associations among plasma lycopene, analgesic use, and chronic kidney disease (CKD) are unknown. A hospital-based, case-control study was conducted to determine the association among plasma lycopene, analgesic use, and CKD. METHODS: Two hundred one patients with CKD and 313 controls were recruited, and CKD was defined as an estimated glomerular filtration rate <60 mL/min per 1.73 m(2), as calculated by the Modification of Diet in Renal Disease formula. Plasma antioxidants were measured by high-performance liquid chromatography. RESULTS: This study showed that the higher the plasma lycopene was, the lower the CKD risk. Specifically, in subjects with a plasma lycopene level >or=17.97 or 7.72-17.97 microg/dL, the adjusted odds ratio of CKD was 0.32 (95% confidence interval 0.18-0.58) or 0.49 (95% confidence interval 0.29-0.83), respectively, compared with subjects with a plasma lycopene level <7.72 microg/dL, independent of age, gender, level of education, paternal and maternal ethnicities, cigarette smoking, analgesic use, hypertension, and diabetes history. In contrast, the higher the plasma retinol level, the higher the risk of CKD. A significantly higher risk was demonstrated in analgesic users than in non-users (odds ratio 3.83, 95% confidence interval 1.75-8.40), but a significantly lower risk was shown in subjects who used analgesics on an as-needed basis than in non-users. Plasma lycopene tended to interact additively with analgesic consumption in modifying the CKD risk; however, the interactions were statistically insignificant. CONCLUSION: This is the first study showing that a low plasma lycopene level is associated with CKD risk.

Urinary arsenic species and CKD in a Taiwanese population: a case-control study.

BACKGROUND: Inorganic arsenic has been linked to decreased kidney function through oxidative damage. Arsenic methylation is believed to be a pathway for arsenic metabolism. Lycopene is an antioxidant that reduces oxidative stress; however, the association between urinary arsenic species, plasma lycopene level, and chronic kidney disease (CKD) has seldom been evaluated. STUDY DESIGN: Case-control study. SETTING & PARTICIPANTS: 125 patients with CKD and 229 controls were recruited from a hospital-based pool. PREDICTOR: Urinary arsenic species and plasma lycopene level. OUTCOMES & MEASUREMENTS: CKD was defined as estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m(2), calculated by using the Modification of Diet in Renal Disease Study equation. Plasma lycopene was measured by means of high-performance liquid chromatography. Urinary arsenic species, including arsenite, arsenate, monomethylarsonic acid, and dimethylarsinic acid, were determined by means of high-performance liquid chromatography and hydride generator-atomic absorption spectrometry. RESULTS: Lycopene level was associated positively with eGFR, and participants with a high serum lycopene level had a significant, inverse association with CKD (odds ratio, 0.41; 95% confidence interval, 0.21 to 0.81). Total arsenic level was associated significantly with CKD in a dose-response relationship, especially in participants with a total arsenic level greater than 20.74 compared with 11.78 microg/g creatinine or less (odds ratio, 4.34; 95% confidence interval, 1.94 to 9.69). Furthermore, participants with a high urinary total arsenic level or participants with a low percentage of dimethylarsinic acid had a positive association with CKD when their plasma lycopene level was low. LIMITATIONS: Because of the single spot evaluation of plasma antioxidants and urinary arsenic species and the small sample size, statistical significance should be interpreted with caution. CONCLUSIONS: This study shows that high urinary total arsenic or low plasma lycopene level is associated positively with CKD. Results suggest that the capacity for arsenic methylation may be associated with CKD in individuals who ingest low arsenic levels in drinking water and also have a low plasma lycopene level.

Correlation of intraoperative blood flow measurement with autogenous arteriovenous fistula outcome.

BACKGROUND: Autogenous arteriovenous fistula (AVF) has proven to be the optimal vascular access for the majority of hemodialysis patients due to its durability and low complication rates. The purpose of this study is to determine the value of intraoperative blood flow measurement with respect to AVF short-term outcome. METHODS: A prospective cohort study enrolled patients undergoing first time AVF creation surgery for hemodialysis from November 2001 to April 2007. Intraoperative blood flow measurements were collected using transit time flowmeter, and primary and secondary patency rates of AVF were examined. Other variables including age, sex, the presence of diabetes, hypertension, or cerebrovascular disease, current smoking, systolic and diastolic blood pressure, heart rate, serum calcium-phosphate product, and triglyceride and cholesterol level were analyzed. RESULTS: Autogenous radiocephalic AVFs (n = 109) in 109 patients were constructed and followed up for an average of 21 months. Among these, 54% of patients were 60 years or older, 51% were male, and 56% were diabetics. One-year primary and secondary patency rates for the high-flow group (> or =200 mL/min) were 69% and 94%, respectively. One-year primary and secondary patency rates for the low-flow group (<200 mL/min) was 52% and 80%, respectively. Using hazard analysis, intraoperative blood flow was the most important determinant of primary and secondary patency, in addition to the presence of diabetes. CONCLUSION: Intraoperative blood flow measurement is a predictor of the primary and secondary patency of autogenous radiocephalic AVFs. Awareness of the significant correlation between intraoperative AVF blood flow and the short-term outcome would enhance the surgical efficiency and maximize the usefulness of autogenous AVF.

Variable pump flow-based Doppler ultrasound method: a novel approach to the measurement of access flow in hemodialysis patients.

Decreasing vascular access flow (Qa) is an important predictor of future access thrombosis and malfunction for hemodialysis (HD) patients. Among all of the methods for determining Qa, the variable pump flow (VPF) Doppler method measures Qa according to the change in Doppler signal between the arterial and the venous needles under different pump flow. After this technique was combined with spectral analysis of Duplex Doppler imaging, the variable pump flow-based Doppler ultrasound method (VPFDUM) for Qa measurement was developed. This study compared the reproducibility and correlation of Qa measurements for three different methods-VPFDUM, ultrasound dilution method (UDM), and conventional Doppler ultrasound method (CDUM)-in 55 HD patients. The mean value of Qa by VPFDUM (870.8 +/- 412.0 ml/min) was close to that by UDM (868.6 +/- 417.9 ml/min) but higher than that by CDUM (either of the above values versus 685.1 +/- 303.6 ml/min; P < 0.005). The mean values of coefficient of variation were similar by VPFDUM (1.6%) and UDM (1.4%) but lower than that by CDUM (either of the above values versus 6.8%; P < 0.01). The correlation coefficient and intraclass correlation coefficient of the repeated Qa measurements by VPFDUM (0.985 and 0.993; P < 0.001) were also similar to those by UDM (0.992 and 0.995; P < 0.001) but slightly higher than those by CDUM (0.917 and 0.948; P < 0.005). Either the reproducibility of VPFDUM (r=0.98, P < 0.0001) or the correlation between VPFDUM and UDM (r=0.99, P < 0.0001) in Qa measurements is good. The unassisted patency of vascular access at 6 mo was significantly poorer in patients with Qa <500 ml/min than those with Qa >500 ml/min (13.6% versus 92.2%; P < 0.0001). In conclusion, VPFDUM is a noninvasive, accurate, and reliable procedure for Qa measurement and prediction of the prognosis of vascular access in HD patients.

Health-related quality of life of hemodialysis patients in Taiwan: a multicenter study.

BACKGROUND/AIMS: Health-related quality of life (HRQOL) is an important determinant of treatment effectiveness in dialysis patients. To our knowledge, there are no reports evaluating HRQOL of hemodialysis (HD) in Chinese patients. The purpose of this study is to present our results about HRQOL using the 36-Item Short-Form (SF-36) questionnaire on Taiwanese hemodialysis patients. METHODS: HRQOL was measured by using the SF-36 questionnaire in 497 HD patients in five hospitals. RESULTS: The following attributes, male gender, age <50 years old, higher education level (HEL), marriage status, employment status (EPS), less comorbid medical condition (CMC), and non-diabetic patients (NDP) were all predicted on a better Physical Component Scale (PCS). Age <50 years old, body mass index >18.5, HEL, EPS and NDP were all predicted on a higher Mental Component Scale (MCS). Scales contributing to a summary measure of physical health, the PCS score was significantly lower in women (35.0 +/- 12.3) than in men (37.9 +/- 12.3). However, there was no difference in the MCS score between women and men. In multivariate analysis, age, CMC, diabetes, serum creatinine (SCr), and erythropoietin responsiveness were significant independent predictors of PCS. Diabetes, educational level, SCr, and erythropoietin responsiveness were significant independent predictors of MCS. All of the individual scales were lower in Taiwanese HD patients than in both the general Taiwanese and US population. Each of the individual scales and MCS scores were substantially lower in the Taiwan HD group than in the US HD cohort. However, the bodily pain of PCS was significantly higher in the Taiwan HD group, although the mean PCS scores for the Taiwan HD group and the US HD study participants were nearly equal at 36.3 and 36.1, respectively. CONCLUSION: The physical and mental aspects of quality of life are substantially lower for Taiwanese HD patients, except for higher bodily pain tolerance. A number of demographic and clinical characteristics have a significant impact on HRQOL in Taiwanese HD patients.