Randomized Trial on the Effects of Dialysate Potassium Concentration on Intradialytic Hypertension.

Introduction: Intradialytic hypertension is not an uncommon condition during chronic hemodialysis. It is associated with unfavorable cardiovascular outcomes, including hospitalization and mortality. Several small studies have demonstrated the contradictory effects of different dialysate potassium concentrations on intradialytic blood pressure. This study is a randomized crossover trial aiming to evaluate the effects of different dialysate potassium concentrations on intradialytic hypertension. Methods: A 24-week, 2-treatment, 4-sequence, multicenter, double-blinded, randomized, crossover study was conducted at Maharaj Nakorn Chiang Mai Hospital and Lampang Hospital in Thailand among stable patients receiving chronic hemodialysis who experienced intradialytic hypertension >30% of their sessions over the past 3 months. Each participant was randomly assigned to 1 of 4 treatment sequences. During each intervention period, patients were dialyzed with dialysate potassium of either 2 mmol/l (D-K2) or 3 mmol/l (D-K3) for 4 weeks according to their preassigned sequence, separated by a 2-week washout period. The primary outcome was the incidence of intradialytic hypertension. Results: Forty eligible patients were recruited. The mean age was 61.4 ± 14.2 years and the mean systolic blood pressure (SBP) was 146.6 ± 11.2 mm Hg. Of the 40 patients, 95.5% had hypertension and their average number of antihypertensive drugs was 2.8 ± 1.9. A total of 1380 dialysis sessions were included in the analysis (695 sessions for D-K2 and 685 sessions for D-K3). The incidence of intradialytic hypertension was not significantly different between different dialysate potassium concentrations (D-K2 54.7% vs. D-K3 53.1%, P = 0.788). The changes in SBP, diastolic blood pressure (DBP), and mean arterial pressure (MAP) were not different between the 2 dialysate potassium groups. Conclusion: Dialysate potassium concentration of 2 or 3 mmol/l did not affect the incidence of intradialytic hypertension in patients receiving chronic hemodialysis who frequently developed intradialytic hypertension.

Modification of immunosuppressive agents in a kidney transplant recipient with COVID-19 and acute kidney injury.

INTRODUCTION: An outbreak of coronavirus disease-19 (COVID-19) has occurred in different parts of the world. Although a large piece of information regarding the epidemiology, clinical features, and management of COVID-19 has been reported in the general population, there is very limited data regarding organ transplant recipients, particularly regarding the management of maintenance immunosuppressive agents during infection. METHODOLOGY: We described a case of kidney transplant recipient from Thailand who had COVID-19 pneumonia and severe acute kidney injury. RESULTS: The patient's serum creatinine peaked at 7.0 mg/dL on day 15 of illness and returned to baseline value of 2.0 mg/dL on day 26 of illness. We have shown how we modified tacrolimus, mycophenolate, and steroids in the patient who had received favipiravir and lopinavir/ritonavir for COVID-19 pneumonia. CONCLUSIONS: In this case, successful modification of this immunosuppressive regimen was accomplished to reduce drug interaction complications, aiming to avoid calcineurin inhibitor nephrotoxicity while maintaining appropriate levels of immunosuppression to prevent organ rejection and to promote the patient's recovery from infection.

Differences in clinical presentation and incidence of cardiopulmonary involvement in late-onset versus early-onset systemic sclerosis: inception cohort study.

INTRODUCTION: Data regarding the incidence rate (IR) of cardiopulmonary involvement in comparison between late-onset SSc and early-onset SSc are limited. OBJECTIVE: To compare the prevalence of clinical manifestations and the IR of cardiopulmonary involvement compared between the two subgroups. METHODS: An inception cohort of SSc patients seen at the Rheumatology Clinic, Maharaj Nakorn Chiang Mai Hospital, between January 2010 and June 2016, was used. All patients were assessed for clinical manifestations and underwent electrocardiograph, echocardiography and high-resolution computed tomography at the study entry and every 12 months thereafter. RESULT: One hundred and fifteen patients (69 female and 90 diffuse cutaneous SSc [dcSSc]) with a mean (SD) disease duration of 11.6 months (8.8) at cohort entry were enrolled during a mean (SD) observation period of 3.8 years (1.6). Patients were classified into two groups: age ≥ 50 years (late onset) and age < 50 years (early onset). The late-onset group included 78 patients (67.8%). At enrollment, the late-onset group had higher prevalence of digital pitting scars (60.3% vs. 35.1%, P = 0.012), dry eye symptoms (17.9% vs. 2.7%, P = 0.035), and hypertension (20.5% vs. 5.4%, P = 0.037) compared to the early-onset group. In the last visit, it was found that the late-onset group had higher cumulative prevalence of joint contracture (61.5% vs. 37.8%, P = 0.017) compared to the early-onset group. The late-onset group had no significant IR of left ventricular ejection fraction < 50% (3.04 vs. 4.45 per 100 person-years, P = 0.486), right ventricular dysfunction (5.17 vs. 2.73 per 100 person-years, P = 0.269), interstitial lung disease (49.45 vs. 42.03 per 100 person-years, P = 0.462), and systolic pulmonary arterial pressure ≥ 50 mmHg (2.57 vs. 1.07 per 100 person-years, P = 0.267) compared to the early-onset group. CONCLUSION: Our study cohort found that digital pitting scar, xerophthalmia, hypo-hyperpigmentation, joint contracture, and hypertension are more prevalent in late-onset SSc than early-onset SSc. However, no significant differences regarding the IR of cardiopulmonary involvement between the two subgroups, the majority of which were dcSSc, in the early phase of the disease.