Immediate knowledge improvement and long-term teaching confidence after general medicine faculty training program.

BACKGROUND/PURPOSE: This study analyzed the effects of the General Medicine Faculty Training Program (GMFTP), which was implemented in 2009. The training program includes a 7-hour basic training (BT) to introduce ways of teaching and assessing the 6 core competencies identified by the Accreditation Council for Graduate Medical Education, and a 40-hour clinical training program. METHODS: Physicians from different hospitals attended the GMFTPs. Since 2010, we have been using quick tests to assess trainees' familiarity of core competencies. Knowledge improvement (KI) was defined as the difference between post-BT and pre-BT test scores. Since 2013, we have been annually mailing questionnaires to assess trainees' teaching confidence (TC) of core competencies. We analyzed the correlations between trainees' characteristics, KIs, and TCs. RESULTS: Between year 2009 and 2017, a total of 319 attending physicians (257 male, 62 female), with a mean age of 39.1 ± 6.2 years, completed the GMFTPs. Significant KI (32.6-55.4) was noted. There were no correlations between trainees' characteristics and KIs. The mean TCs for the 6 core competences were all above 4.0 (based on a 5-point Likert scale). TCs were positively correlated with age during GMFTP training, age when responding to the questionnaire, and duration between training and the last time responding to the questionnaire. TC showed no correlation with sex, hospitals, departments, or KI. CONCLUSION: Knowledge of teaching core competencies improved immediately after BT, but KIs did not correlate with TCs in long-term follow-up. After the training program, physicians' teaching confidence increased over time.

Old age is a positive modifier of renal outcome in Taiwanese patients with stages 3-5 chronic kidney disease.

BACKGROUND: The incidence of end-stage renal disease (ESRD) is increasing in elderly patients with chronic kidney disease (CKD). This contradicts the general notion that elderly people are more likely to die than to ever reach ESRD. And racial disparity in relation to age on kidney disease outcomes has always been a subject of research interest. AIMS: We investigated the effect of age on outcome in a cohort with stages 3-5 CKD patients by age category. METHODS: A total of 430 patients with a mean age of 65.6 years were enrolled and followed till death, ESRD, or end of 2015. Multivariable Cox regression was used to identify predictors of all-cause mortality. Competing risk-adjusted Cox regression was used to identify determinants of ESRD. The median follow-up was 7.3 (interquartile range 8.8) years. RESULTS: Cox regression showed old age and low mean arterial pressure were predictors of mortality before and after onset of ESRD. Competing risk analysis revealed patients aged 20-39 years and 40-64 years exhibited greater risks of ESRD, compared to those aged over 75 years. These effects of age on outcomes occurred independently of traditional risk factors such as low estimated glomerular filtration rate and high proteinuria. CONCLUSIONS: Age over 75 years is associated with decreased risk for ESRD even after adjustment for competing mortality. Given the global trends in population aging, there is a need to develop age-specific strategies, on top of the existing stage-based measures, to optimize the management of CKD in the elderly.

10-Year Renal Function Trajectories in Community-Dwelling Older Adults: Exploring the Risk Factors for Different Patterns.

Longitudinal changes of renal function help inform patients' clinical courses and improve risk stratification. Rare studies address risk factors predicting changes in estimated glomerular filtration rate (eGFR) over time in older adults, particularly of Chinese ethnicity. We identified prospectively enrolled community-dwelling older adults (≥65 years) receiving annual health examinations between 2005 and 2015 with serum creatinine available continuously in a single institute, and used linear regression to derive individual's annual eGFR changes, followed by multivariate logistic regression analyses to identify features associated with different eGFR change patterns. Among 500 elderly (71.3 ± 4.2 years), their mean annual eGFR changes were 0.84 ± 1.67 mL/min/1.73 m²/year, with 136 (27.2%) and 238 (47.6%) classified as having downward (annual eGFR change <0 mL/min/1.73 m²/year) and upward eGFR (≥1 mL/min/1.73 m²/year) trajectories, respectively. Multivariate logistic regression showed that higher age (odds ratio (OR) 1.08), worse renal function (OR 13.2), and more severe proteinuria (OR 9.86) or hematuria (OR 3.39) were predictive of a declining eGFR while greater waist circumference (OR 1.06) and higher leukocyte counts (OR 1.21) were predictive of an uprising 10-year eGFR. These findings elucidate important features associated with geriatric renal function variations, which are expected to improve their renal care.

Diabetes mellitus, superoxide dismutase and peroxisome proliferator activated receptor gamma polymorphisms modify the outcome of end-stage renal disease patients of Han Chinese origin.

AIM: Increased oxidative stress significantly modifies the outcome of patients with diabetes mellitus (DM) and end-stage renal disease (ESRD), and is counteracted by antioxidative capacity. We aimed to investigate whether antioxidant single nucleotide polymorphisms (SNPs) influence the outcome of ESRD individuals and the influences exerted by DM, which has not been tested before. METHODS: We prospectively enrolled multi-centre ESRD patients of Han Chinese origin between 2002 and 2003, recording their antioxidant (superoxide dismutase [SOD2], glutathione peroxidase [GPX1]) and peroxisome proliferator activated receptor-γ (PPAR-γ) genotyping results, and stratified based on DM. They were followed up until 2008, with risk factors for mortality analyzed by Cox proportional hazard regression. RESULTS: We discovered that diabetic ESRD carriers of CC genotype of SOD2 exon 2 had an increased risk of mortality compared to non-diabetic ones with other genotypes (hazard ratio [HR] 4.04, P = 0.04), while GPX1 SNPs had no influence. Interactions between SOD2 and PPAR-γ SNPs regarding the mortality influence were also detected (for SOD2 CC genotype x PPAR-γ exon 6 CT genotype, HR 3.19, P = 0.008), suggesting the importance of considering a combination panel of SNPs on patient survival. CONCLUSION: This might be the largest study focusing on the relationship between antioxidant SNPs and the outcomes of diabetic ESRD patients of Han Chinese origin. More studies are needed to validate our findings.

Effect of Kidney Dysfunction on Cerebral Cortical Thinning in Elderly Population.

Chronic kidney disease has been linked to cognitive impairment and morphological brain change. However, less is known about the impact of kidney functions on cerebral cortical thickness. This study investigated the relationship between kidney functions and global or lobar cerebral cortical thickness (CTh) in 259 non-demented elderly persons. Forty-three participants (16.7%) had kidney dysfunction, which was defined as either a glomerular filtration rate (GFR) of <60 ml/min/1.73 m2 or presence of proteinuria. Kidney dysfunction was associated with lower global (ß = -0.05, 95% CI = -0.08 to -0.01) as well as frontal, parietal, temporal, occipital, and insular lobar CTh. In the stratified analysis, the associations were more pronounced in women, APOEε4 non-carriers, and participants with a lower cognitive score. Besides, kidney dysfunction significantly increased the risk of cortical thinning, defined as being the lowest CTh tertile, in the insular lobe (adjusted odds ratio = 2.74, 95% CI = 1.31-5.74). Our results suggested that kidney dysfunction should be closely monitored and managed in elderly population to prevent neurodegeneration.

Interplay between Superoxide Dismutase, Glutathione Peroxidase, and Peroxisome Proliferator Activated Receptor Gamma Polymorphisms on the Risk of End-Stage Renal Disease among Han Chinese Patients.

Background. Single nucleotide polymorphisms (SNPs) of antioxidants, including superoxide dismutase 2 (SOD2) and glutathione peroxidase 1 (GPX1), play an important role in the risk for cancer and metabolic disorders. However, little is known regarding the effect of antioxidant SNPs on renal events. Methods. We prospectively enrolled multicenter patients with end-stage renal disease (ESRD) and those without chronic kidney disease (CKD) of Han Chinese origin, with SOD2 (Val16Ala), GPX1 (Pro197Leu), and PPAR-γ (Pro12Ala, C161T) genotyped. Multiple regression analyses were conducted to evaluate the significant risk determinants for ESRD. Results. Compared to ESRD patients, non-CKD subjects were more likely to have T allele at SOD2 Val16Ala (p = 0.036) and CC genotype at PPAR-γ Pro12Ala (p = 0.028). Regression analysis showed that TT genotype of SOD2 Val16Ala conferred significantly lower ESRD risk among patients without diabetes (odds ratio 0.699; p = 0.018). GPX1 SNP alone did not alter the risk. We detected significant interactions between SNPs including PPAR-γ Pro12Ala, C161T, and GPX1 regarding the risk of ESRD. Conclusion. This is the first and largest study on the association between adverse renal outcomes and antioxidant SNPs among Han Chinese population. Determination of SOD2 and PPAR-γ SNPs status might assist in ESRD risk estimation.

Antihypertensive agents and the risk of breast cancer in women aged 55 years and older: a nested case-control study.

OBJECTIVE: The study aimed to investigate the association of long-term use of different antihypertensive agents with incident breast cancer. METHODS: A total of 794 ,533 women aged at least 55 years were identified from Taiwan National Health Insurance claims database during 2001-2011. As of 31 December 2011, incident breast cancer patients were included as cases, and 1 : 4 age-matched controls were selected by risk-set sampling scheme. Logistic regression models were applied to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of breast cancer incidence associated with different durations of use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, ß-blockers, and dihydropyridine calcium channel blockers (DHP CCBs). Different restriction rules were applied to reveal the potential effects of confounding by indication. RESULTS: Among the 9397 incident breast cancer patients and 37 ,588 controls, a significantly elevated risk was found for relatively short-term use of DHP CCBs (<6 years) but not in those observed for more than 6 years. There was no association between either angiotensin-converting enzyme inhibitors/angiotensin receptor blockers or ß-blockers use and breast cancer. Although restricting our analyses to those with any prescription of antihypertensive medications in 2001 or those with diagnosis of hypertension, there was no longer a statistically significant association between any use of DHP CCBs and breast cancer (OR: 1.21, 95% CI: 0.88-1.67 for the former, and OR: 1.71, 95% CI: 0.99-2.95 for the latter). CONCLUSION: The results demonstrated the potential effect of confounding by indication, and thus, did not suggest any association of the use of antihypertensive medication and breast cancer risk.

Ferritin heavy chain mediates the protective effect of heme oxygenase-1 against oxidative stress.

The phenomenon that heme oxygenase-1 (HO-1) protects cell from injury yet its enzymatic product, iron, may facilitate generation of free radical has been long puzzling. Here we establish a functional connection between ferritin heavy chain (FHC) and HO-1. In human lupus nephritis HO-1 and FHC are colocalized within the glomeruli. In rodent anti-Thy1 (thymocyte antigen 1) induced glomerulonephritis, heme oxygenase blockade lowers the expression of FHC and accelerates mesangial cell death. Stimulation of heme oxygenase in cultured rat mesangial cell enhances its resistance to hydrogen peroxide, whereas FHC knockdown by RNA interference compromises this salutary effect. RNA interference of HO-1 makes the cell more susceptible to hydrogen peroxide, which can be rescued by forced expression of wild-type FHC but not mutants that lose the capacity of iron storage and ferroxidase activity. Phosphorylation of JunD was not sustained in these cells. Microarray analysis identifies four candidate transcriptional factors that may regulate the HO-1-induced transcription of FHC. Our results support the role of FHC in neutralizing the iron toxicity as well as mediating the protective effect of HO-1 in response to oxidative stress.

Genome-Wide Association Study for Autism Spectrum Disorder in Taiwanese Han Population.

BACKGROUND: Autism spectrum disorder (ASD) is a neurodevelopmental disorder with strong genetic components. Several recent genome-wide association (GWA) studies in Caucasian samples have reported a number of gene regions and loci correlated with the risk of ASD--albeit with very little consensus across studies. METHODS: A two-stage GWA study was employed to identify common genetic variants for ASD in the Taiwanese Han population. The discovery stage included 315 patients with ASD and 1,115 healthy controls, using the Affymetrix SNP array 6.0 platform for genotyping. Several gene regions were then selected for fine-mapping and top markers were examined in extended samples. Single marker, haplotype, gene-based, and pathway analyses were conducted for associations. RESULTS: Seven SNPs had p-values ranging from 3.4~9.9*10-6, but none reached the genome-wide significant level. Five of them were mapped to three known genes (OR2M4, STYK1, and MNT) with significant empirical gene-based p-values in OR2M4 (p = 3.4*10(-5)) and MNT (p = 0.0008). Results of the fine-mapping study showed single-marker associations in the GLIS1 (rs12082358 and rs12080993) and NAALADL2 (rs3914502 and rs2222447) genes, and gene-based associations for the OR2M3-OR2T5 (olfactory receptor genes, p = 0.02), and GLIPR1/KRR1 gene regions (p = 0.015). Pathway analyses revealed important pathways for ASD, such as olfactory and G protein-coupled receptors signaling pathways. CONCLUSIONS: We reported Taiwanese Han specific susceptibility genes and variants for ASD. However, further replication in other Asian populations is warranted to validate our findings. Investigation in the biological functions of our reported genetic variants might also allow for better understanding on the underlying pathogenesis of autism.

Visceral fat area is associated with HbA1c but not dialysate-related glucose load in nondiabetic PD patients.

Factors associated with increased visceral fat area (VFA) have been well documented in the general population but rarely explored in nondiabetic individuals on peritoneal dialysis (PD). As glycosylated hemoglobin (HbA1c) is positively correlated with VFA in diabetic patients, we hypothesized that the same correlation would exist in nondiabetic PD patients. We enrolled 105 nondiabetic patients who had undergone chronic PD for more than 3 months. Each subject underwent an abdominal computed tomography (CT) scan, and the umbilicus cut was analyzed for VFA. VFA values, corrected for body mass index and subjected to natural logarithm transformations, were examined to determine whether they were correlated with HbA1c and other parameters. PD dialysates prescribed at the time of enrollment were recorded to calculate glucose load. We found that when 105 nondiabetic PD patients were classified according to tertiles of HbA1c, higher HbA1c was associated with larger VFA. Multiple linear regression analysis revealed that HbA1c was an independent determinant of VFA, while glucose load and other PD-specific factors were not. In summary, HbA1c, but not PD-related glucose load, was positively correlated with VFA in nondiabetic PD patients, suggesting clinical utility of HbA1c in the PD population.

Sequence variants of peroxisome proliferator-activated receptor-gamma gene and the clinical courses of patients with end-stage renal disease.

BACKGROUND: PPAR-γ single nucleotide polymorphisms (SNPs) reportedly play an important role in determining metabolic risk among diverse population. Whether PPAR-γ SNPs affect the clinical courses in ESRD patients is unknown. METHODS: From a multicenter cohort, we identified 698 patients with prevalent ESRD between 2002 and 2003, and other 782 healthy subjects as control. Two PPAR-γ SNPs, Pro12Ala (rs1801282) and C161T (rs3856806), were genotyped and their association with ESRD was examined. Both groups were prospectively followed until 2007, and the predictability of genotypes for the long-term survival of ESRD patients was analyzed. RESULTS: After multivariable-adjusted regression, GG genotype of Pro12Ala was significantly more likely to associate with ESRD (P < 0.001) among patients with non-diabetes-related ESRD. Cox's proportional hazard regression showed that both Pro12Ala and C161T polymorphisms were significant predictors of mortality in ESRD patients with DM (Pro12Ala: GG versus other genotypes, hazard ratio [HR] <0.01; P < 0.001; for C161T, CC versus TT genotypes, HR 2.86; P < 0.001; CT versus TT genotypes, HR 1.93; P < 0.001). CONCLUSION: This is the first and largest study to evaluate PPAR-γ SNPs in ESRD patients. Further mechanistic study is needed to elucidate the role of PPAR-γ among ESRD patients.

Intradialytic hypotension and cardiac remodeling: a vicious cycle.

Hemodynamic instability during hemodialysis is a common but often underestimated issue in the nephrologist practice. Intradialytic hypotension, namely, a decrease of systolic or mean blood pressure to a certain level, prohibits the safe and smooth achievement of ultrafiltration and solute removal goal in chronic dialysis patients. Studies have elucidated the potential mechanisms involved in the development of Intradialytic hypotension, including excessive ultrafiltration and loss of compensatory mechanisms for blood pressure maintenance. Cardiac remodeling could also be one important piece of the puzzle. In this review, we intend to discuss the role of cardiac remodeling, including left ventricular hypertrophy, in the development of Intradialytic hypotension. In addition, we will also provide evidence that a bidirectional relationship might exist between Intradialytic hypotension and left ventricular hypertrophy in chronic dialysis patients. A more complete understanding of the complex interactions in between could assist the readers in formulating potential solutions for the reduction of both phenomena.

Pre-surgical Geriatric Syndromes, Frailty, and Risks for Postoperative Delirium in Older Patients Undergoing Gastrointestinal Surgery: Prevalence and Red Flags.

OBJECTIVE: We sought to identify and evaluate red flags for pre-surgical geriatric conditions (geriatric syndromes, frailty, and risks for postoperative delirium) in older patients undergoing gastrointestinal surgery. METHODS: Older individuals (≥65 years) undergoing major elective gastrointestinal surgery from 2009 to 2012 were enrolled and assessed preoperatively. RESULTS: Participants (N=379; mean age=74.5 ± 5.9 years) primarily underwent colorectal (54.3 %), gastric (21.9 %), and pancreatobiliary (12.6 %) surgery. Overall, 30.9 % had existing geriatric syndromes, 26.7 % were frail, and 22.8 % had >3 risk factors for postoperative delirium. The largest proportion (45.7 %) presented with at least one geriatric condition. Patients with or without geriatric conditions were discriminated with adequate sensitivity (67 %), specificity (84 %), and positive predictive value (77 %) by eight red flags: age ≥75 years (OR, 2.86; P<0.001), eating soft food (OR, 3.63; P=0.001), reported hypertension (OR, 2.8; P=0.001), weight loss >3 kg (OR, 4.79; P<0.001), fair-to-weak grip strength (OR, 2.53; P=0.001), sleeplessness (OR, 2.57; P=0.001), no-better-than-peer perceived health (OR, 1.88; P=0.022), and short-term inability to recall two of three common words (OR, 1.81; P=0.025). CONCLUSIONS: Eight red flags covered as part of history and physical examination are well suited to screen patients for geriatric conditions indicating the need for preoperative geriatric assessments and optimization.

Viridans streptococci in peritoneal dialysis peritonitis: clinical courses and long-term outcomes.

BACKGROUND: The clinical courses and long-term outcomes of viridans streptococcus (VS) peritoneal dialysis (PD) peritonitis remain unclear. METHODS: We conducted a retrospective analysis of all PD patients in a single center with gram-positive cocci (GPC) peritonitis between 2005 and 2011, and divided them into 3 groups: VS, other streptococci and other GPC (apart from VS). Clinical characteristics and outcomes of the VS group were compared with the other streptococci and other GPC groups, with prognostic factors determined. RESULTS: A total of 140 patients with 168 episodes of GPC peritonitis (44% of all peritonitis) were identified over 7 years. Among these, 18 patients (13%) developed VS peritonitis, while 14 patients (10%) developed other streptococcal peritonitis. Patients with VS peritonitis had a high cure rate by antibiotic alone (94%), despite a high polymicrobial yield frequency (28%). We found that VS peritonitis carried a lower risk of Tenckhoff catheter removal and relapsing episodes than other GPC peritonitis (6% vs 11%), and a lower mortality than other streptococci peritonitis (0% vs 7%). However, after the index peritonitis episodes, VS, other streptococci, and other GPC group had a significantly increased peritonitis incidence compared with the period before the index peritonitis (all p < 0.01). Patients with VS peritonitis had a significantly higher incidence of refractory peritonitis compared with other streptococci or other GPC peritonitis in the long term (both p < 0.01). CONCLUSIONS: VS poses a higher risk of subsequent refractory peritonitis after the index episode as compared with other streptococcal or GPC peritonitis. It might be prudent to monitor the technique of these patients with VS peritonitis closely to avoid further peritonitis episodes.

Serum free 1,25-dihydroxy-vitamin D is more closely associated with fibroblast growth factor 23 than other vitamin D forms in chronic dialysis patients.

BACKGROUND: Mineral bone disorder (MBD) is prevalent among chronic dialysis patients. However, relationship between different forms of vitamin D and fibroblast growth factor 23 (FGF-23) remains unclear in this population. METHODS: A multicenter hemodialysis cohort was assembled. We evaluated 25-OH-D and 1,25-(OH)2-D, vitamin D-binding protein, and FGF-23, in this cohort. Multiple regression analyses were performed to investigate the relationship and stewardship between different vitamin D forms and FGF-23 concentrations. RESULTS: Chronic dialysis patients presented significantly higher FGF-23 concentrations. 25-OH-D concentrations of <20 ng/ml (deficiency), 20-30 ng/ml (insufficiency), and ≥30 ng/ml (sufficiency) were associated with progressively lower FGF-23 concentrations (p<0.01). Serum FGF-23 concentrations were significantly correlated with total (p=0.02), free (p<0.01) and bioavailable (p<0.01) 25-OH-D and total (p=0.04), free (p=0.02), and bioavailable (p=0.03) 1,25-(OH)2-D concentrations. With all 25-OH-D and 1,25-(OH)2-D forms in the regression model, we found that free 1,25-(OH)2-D outweighed all other vitamin D forms regarding its association with FGF-23 (p=0.03). CONCLUSION: The relationship between FGF-23 and vitamin D is stronger using free forms of 25-OH-D and 1,25-(OH)2-D. Subsequent studies aiming at MBD should consider including free 25-OH-D and 1,25-(OH)2-D in the analysis.

Serum vitamin D levels are positively associated with varicella zoster immunity in chronic dialysis patients.

Uremia results in a relatively immunocompromised status, and patients under chronic dialysis have an elevated risk of developing herpes zoster (HZ). We sought to investigate the relationship between vitamin D status and immunity to varicella-zoster virus (VZV). A multicenter prevalent hemodialysis cohort was assembled between 2012 and 2013. We assayed the biochemical parameters, 25-hydroxy- (25-OH-D) and 1,25-dihydroxyvitamin D, vitamin D-binding protein levels in the sera. VZV immunity was quantitated using VZV-specific glycoprotein IgG and IgM titers. Eighty-eight patients were enrolled and their sera were analyzed. Chronic hemodialysis patients with 25-OH-D < 30 ng/ml (insufficiency or deficiency) had significantly lower VZV-IgG than those with sufficient 25-OH-D (p = 0.04). This discrepancy became more prominent if active vitamin D users alone were analyzed (p = 0.01). Generalized additive modeling showed that those with 25-OH-D higher than 27.8 ng/ml or bioavailable 25-OH-D higher than 3.88 ng/ml had significantly higher VZV-IgG levels than those with lower values. Linear regression suggested that both total and bioavailable 25-OH-D were significantly associated with higher VZV-IgG levels (p = 0.003 [total] and 0.01 [bioavailable]), whereas patients with cancer had lower VZV-IgG. Vitamin D may therefore be a potentially useful choice for raising VZV immunity in chronic dialysis patients.

Acinetobacter peritoneal dialysis peritonitis: a changing landscape over time.

BACKGROUND: Acinetobacter species are assuming an increasingly important role in modern medicine, with their persistent presence in health-care settings and antibiotic resistance. However, clinical reports addressing this issue in patients with peritoneal dialysis (PD) peritonitis are rare. METHODS: All PD peritonitis episodes caused by Acinetobacter that occurred between 1985 and 2012 at a single centre were retrospectively reviewed. Clinical features, microbiological data, and outcomes were analysed, with stratifications based upon temporal periods (before and after 2000). RESULTS: Acinetobacter species were responsible for 26 PD peritonitis episodes (3.5% of all episodes) in 25 patients. A. baumannii was the most common pathogen (54%), followed by A. iwoffii (35%), with the former being predominant after 2000. Significantly more episodes resulted from breaks in exchange sterility after 2000, while those from exit site infections decreased (P = 0.01). The interval between the last and current peritonitis episodes lengthened significantly after 2000 (5 vs. 13.6 months; P = 0.05). All the isolates were susceptible to cefepime, fluoroquinolone, and aminoglycosides, with a low ceftazidime resistance rate (16%). Nearly half of the patients (46%) required hospitalisation for their Acinetobacter PD-associated peritonitis, and 27% required an antibiotic switch. The overall outcome was fair, with no mortality and a 12% technique failure rate, without obvious interval differences. CONCLUSIONS: The temporal change in the microbiology and origin of Acinetobacter PD-associated peritonitis in our cohort suggested an important evolutional trend. Appropriate measures, including technique re-education and sterility maintenance, should be taken to decrease the Acinetobacter peritonitis incidence in PD patients.

High peritoneal KT/V and peritonitis rates are associated with peritoneal calcification.

BACKGROUND: Peritoneal calcification (PC) is a specific finding in patients undergoing peritoneal dialysis (PD), but its prevalence, risk factors, and impacts in PD patients remain unclear. The present study investigated these issues and provided information useful for the management of PC. METHODS: The study included 183 PD patients. The severity of PC was determined using abdominal computed tomography (CT), and we summed up all scores from slices obtained from the diaphragm to the pelvic floor normalized to body surface area. We analyzed the associations between PC and demographic and clinical characteristics, and between PC and levels of biomarkers, including C-reactive protein (CRP), osteoprotegrin and fetuin-A. The determinants of PC were examined using multiple regression analysis. RESULTS: Patients were categorized into group 1 (without PC, n = 133) and group 2 (with PC, n = 50). Group 2 patients showed different degrees of PC with a mean of 160±769 mm(2)/m(2). Group 1 patients had higher fetuin-A levels than group 2 patients (861±309 vs. 760±210 µg/mL; p = 0.021). The independent risk factors for the presence of PC included male gender, previous peritonitis, and PD adequacy (KT/V). Further analysis performed in group 2 patients showed that the dosage of vitamin D, serum levels of CRP, and dialysate calcium load were the independent determinants of PC. However, the presence of PC did not affect patients' technique survival, peritonitis incidence, or mortality in the mean follow up period of 28±12 months. CONCLUSIONS: The presence and severity of PC were associated with inflammation, peritoneal KT/V, and mineral metabolism. The impact of PC on the outcomes of PD patients requires further study with a longer follow-up.

Citrobacter peritoneal dialysis peritonitis: rare occurrence with poor outcomes.

INTRODUCTION: Non-Pseudomonas gram-negative bacteria are responsible for an increasing proportion of cases of peritoneal dialysis (PD)-related peritonitis. The role of Citrobacter species in the etiology of PD-related peritonitis is often underestimated. In the present study, we aimed to describe the clinical features, laboratory findings, and short- and long-term outcomes in PD-related peritonitis caused by Citrobacter. METHODS: A retrospective review of all episodes of PD-related peritonitis caused by Citrobacter from a single center between 1990 and 2010 was performed. Clinical features, microbiological data, and outcomes of these episodes were analyzed. RESULTS: Citrobacter species was responsible for 11 PD-related episodes (1.8% of all peritonitis episodes) in 8 patients. Citrobacter freundii was the most common etiologic species (73%), and mixed growth was found in the other 3 episodes (27%). Approximately half (46%) of the episodes were associated with constipation and/or diarrhea. Of the Citrobacter isolates from all episodes, 54% were resistant to cefazolin, and only 18% were susceptible to cefmetazole. All isolates were susceptible to ceftazidime, cefepime, carbapenem, and aminoglycosides. More than half of the patients (54%) were hospitalized for index peritonitis, and 27% of the episodes involved a change in antibiotic medication. One patient had relapsing peritonitis caused by C. koseri (9%). The mortality rate of PD-related peritonitis caused by Citrobacter was 18%, and 89% of surviving patients developed technique failure requiring a modality switch after an average of 12 months of follow-up (range 1.2-31.2 months). CONCLUSION: PD-related peritonitis caused by Citrobacter is associated with poor outcomes, including high rates of antibiotic resistance, a high mortality rate, and a high rate of technique failure among survivors during the follow-up period.

Effect of age on febrile response in patients with healthcare-associated bloodstream infection.

OBJECTIVE: This study aimed to determine the effect of age on febrile response in patients with healthcare-associated bloodstream infection (BSI). METHODS: This was a retrospective observational study using medical records as the primary source of data. Three indicators measured body temperature changes: basal body temperature (BBT), body temperature at infection onset (onset T), and maximum temperature (max T) during the infection period. RESULTS: In a sample of 230 patients there was no significant correlation between BBT or onset T and age. Max T was significantly correlated with age (r = -.191, p = .004). There was wide variation in onset T in all age groups. CONCLUSIONS: Age showed no effect on BBT and onset T, but blunted max T in patients with bacteremia. This variability in onset T in all age groups emphasizes the need for early recognition of subtle signs of infection and the need to use an individualized definition of fever.