An echocardiography-derived calcium score as a predictor of major adverse cardiovascular events in peritoneal dialysis patients-A prospective cohort study.

BACKGROUND: An echocardiography-derived calcium score (ECS) has been shown to predict cardiovascular (CV) mortality in the general population but has not been utilized in the dialysis population. METHODS: We conducted a prospective cohort study including 125 prevalent PD patients. Two blinded and independent echocardiographers determined the ECS for each subject at baseline. The primary outcome was the three-point major adverse cardiovascular events (MACE) which is a composite outcome comprising CV death, non-fatal myocardial infarction and non-fatal stroke. The secondary outcome was all-cause mortality. RESULTS: The mean age was 61 ± 13 years. The median follow-up duration was 40 months (range 1-50). Seventy six (60.8%) of the subjects had diabetes mellitus (DM). The median duration of dialysis was 32 (IQR 16-54) months. The incidences of MACE and all-cause mortality were 13.0 per 100 patient-years and 18.3 per 100 patient-years. Multivariate Cox regression analysis identified the following three independent predictors of MACE: ECS (HR 1.253/unit increase in ECS, 95% CI 1.014-1.547, p = .036), DM (HR 2.467, 95% CI 1.014-6.005, p = .047) and pre-existing cardiovascular disease (CVD) (HR 2.441, 95% CI 1.261-4.728, p = .008); and the following two predictors of all-cause mortality: pre-existing CVD (HR 2.156, 95% CI 1.251-3.714, p = .006) and serum albumin (HR 0.887/g/L increase in serum albumin, 95% CI 0.839-0.937, p < .001). CONCLUSION: The ECS appears to be a significant predictor of MACE in PD patients independently of DM and pre-existing CVD.

Effectiveness of a brief hope intervention for chronic kidney disease patients on the decisional conflict and quality of life: a pilot randomized controlled trial.

BACKGROUND: Stage 5 chronic kidney disease (CKD) patients often experience decisional conflict when faced with the selection between the initiation of dialysis and conservative care. The study examined the effects of a brief hope intervention (BHI) on the levels of hope, decisional conflict and the quality of life for stage 5 CKD patients. METHODS: This is a single-blinded, randomized controlled trial (ClinicalTrials.gov identifier: NCT03378700). Eligible patients were recruited from the outpatient department renal clinic of a regional hospital. They were randomly assigned to either the intervention or the control group (intervention: n = 35; control: n = 37). All participants underwent a customized pre-dialysis education class, while the intervention group received also BHI. Data were collected prior to the intervention, immediately afterwards, and one month following the intervention. The Generalized Estimating Equation was used to measure the effects in the level of hope, decisional conflict scores (DCS) and Kidney Disease Quality of life (KDQOL-36) scores. Estimated marginal means and standard errors with 95% confidence intervals of these scores were also reported to examine the within group and between group changes. RESULTS: An increase of the hope score was found from time 1 (29.7, 1.64) to time 3 (34.4, 1.27) in the intervention group. The intervention had a significant effect on the KDQOL-36 sub-scores Mental Component Summary (MCS) (Wald χ2 = 6.763, P = 0.009) and effects of kidney disease (Wald χ2 = 3.617, P = 0.004). There was a reduction in decisional conflict in both arms on the DCS total score (Wald χ2 = 7.885, P = 0.005), but the reduction was significantly greater in the control group (effect size 0.64). CONCLUSIONS: The BHI appeared to increase the level of hope within the intervention arm. Nonetheless, differences across the intervention and control arms were not significant. The KDQOL-36 sub-scores on MCS and Effects of kidney disease were found to have increased and be higher in the intervention group. The DCS total score also showed that hope was associated with reducing decisional conflict. TRIAL REGISTRATION: ClinicalTrials.gov Protocol Registration, NCT03378700 . Registered July 12 2017.

The effects of a brief hope intervention on decision-making in chronic kidney disease patients: A study protocol for a randomized controlled trial.

AIMS: This study describes the study protocol of a manualized brief hope intervention that is based on the theoretical proposition - hope theory. BACKGROUND: Patients with stage 5 chronic kidney disease often had decisional regret when facing the tension of treatment alternatives between dialysis initiation and palliative care. Hope has been found to account for therapeutic changes in clients with depressive symptoms, heightens positive expectations, and striving to accomplish chosen goals. Nevertheless, little is known about the effect of hope on decisional conflict and its influences to the quality of life in these chronic kidney disease patients. DESIGN: This study is a single-blinded, randomized controlled trial. METHODS: Participants will be recruited from a regional hospital (approved in April 2018). They will be randomly assigned in equal numbers to either the brief hope intervention or the control arm on completion of the baseline assessment on the possible need of dialysis initiation. Participants in the intervention group will receive the pre-dialysis education and a 4-week Brief Hope Intervention [consisting of four sessions at weekly intervals (two face-to-face sessions and two telephone follow-up sessions in between)], while those allocated to the control arm will receive the renal education and social chats. Outcome measures will be carried out prior to the intervention (baseline), immediately, and 1 month after the intervention. These consist of the hope level, decisional conflict, and quality of life. Healthcare resources use data will be reported. IMPACT: The study results have the potential to add scientific evidence to the research-tested programme when developing renal services integral to multimodal care management to optimize decision-making and attain better health outcomes.

Treatment of HCV in renal transplant patients with peginterferon and ribavirin: long-term follow-up.

BACKGROUND: In addition to the observation of an increased viremia among patients with chronic hepatitis C virus (HCV) infection who undergo renal transplantation, fibrosis and necroinflammatory activity have been noted to worsen comparing pre- and post-renal transplantation liver biopsies in some of these patients. Apart from the reported reduced patient and allograft survival rates, post-transplant diabetes mellitus, de novo glomerulonephritis, and an increased overall risk of infection have been observed. However, antiviral therapy for HCV is generally considered contraindicated among patients with solid organ transplants, with the main worry being the risk of acute rejection in relation to the use of interferon. We reported the long-term outcome of four renal transplant patients with chronic HCV infection who received peginterferon-based therapy. METHODS: We collected the long-term follow-up data of four patients who completed the therapy with peginterferon in combination with ribavirin. Two of them had renal impairment at baseline. RESULTS: With treatment, they had a significant improvement in terms of serum liver transaminase level, and two patients achieved the early virological response and the other two rapid virological response. All four patients achieved sustained virological response, with neither HCV flare up nor renal dysfunction during follow-up for a mean duration of 74.3 months after therapy. CONCLUSIONS: These results suggest that sustained HCV virological response may be achieved without allograft dysfunction, in selected renal transplant patients using a peginterferon-based therapy.

Risk factors and clinical course of hungry bone syndrome after total parathyroidectomy in dialysis patients with secondary hyperparathyroidism.

BACKGROUND: Hungry bone syndrome (HBS) is an important postoperative complication after parathyroidectomy for severe secondary hyperparathyroidism (SHPT). There is, however, little data in the literature on its detailed clinical course, and the associated risk factors remain controversial. METHODS: We did a single-center retrospective study on 62 consecutive dialysis patients who underwent total parathyroidectomy for SHPT to examine the risk factors, clinical course and outcome. Data on demographic characteristics, perioperative laboratory parameters including serum calcium, phosphate, alkaline phosphatase (ALP) and parathyroid hormone (PTH), drug treatment for SHPT and operative details of parathyroidectomy were collected. RESULTS: Seventeen (27.4%) patients developed severe postoperative hypocalcemia with HBS. The serum calcium dropped progressively while serum ALP rose after operation until 2 weeks later when serum calcium reached the trough and serum ALP peaked. Serum phosphate also fell but stabilized between 4 and 14 days. The total postoperative calcium and vitamin D supplementation was significantly larger, and hospital stay was significantly longer in the group with HBS as compared with those without HBS. Young age, high body weight, high preoperative ALP level, and low preoperative calcium level independently predicted the development of HBS while preoperative PTH and use of cinacalcet or paricalcitol did not. CONCLUSION: HBS was common after total parathyroidectomy in patients with SHPT, and it is important to closely monitor the postoperative serum calcium, phosphate and ALP levels in the following 2 weeks, especially for those at risk. The implications of our findings on perioperative management are discussed.

Hepatocellular carcinoma after kidney transplantation: analysis of Hong Kong Renal Registry.

Kidney transplant recipients have increased risk of cancers when compared with the general population. Hepatocellular carcinoma (HCC) is extremely important in Asia where hepatitis B virus (HBV) infection is endemic. The aim is to study the epidemiological and clinical aspects of all de novo HCC in our kidney transplant recipients. Moreover, various preventive strategies which may help to optimize the outcome will also be discussed. A retrospective review of all patients who developed HCC after kidney transplantation between May 1972 and December 2011 in Hong Kong, based on the data from Hong Kong Renal Registry. After a follow-up period of 40,246 person-years, 20 patients (males 15: females 5) developed HCC. The annual incidence was 49.7/100,000 persons per year. Among them, 16 were HBV carriers, 2 were hepatitis C (HCV) carriers and 2 had HBV and HCV co-infection. Presence of HBV infection was associated with 78-fold higher risk for HCC development. Majority (85%) were asymptomatic when HCC was diagnosed by ultrasound or alpha-fetoprotein surveillance. All patients diagnosed by surveillance received active treatment while 2/3 of symptomatic patients could only receive symptomatic care and died rapidly. In conclusion, HBV infection is the major etiological factor for HCC development in kidney transplant recipients in HBV endemic areas. Regular HCC surveillance appeared to be able to detect early stage cancers which are amenable to treatment and offer the best hope of cure.

Dosing regimen and tolerability of methoxy polyethylene glycol-epoetin beta in Chinese dialysis patients.

AIM: To investigate methoxy polyethylene glycol-epoetin beta dosing regimen in treatment naïve subjects and dose conversion in darbepoetin alpha treated subjects, in Chinese dialysis patients. METHODS: Adult Chinese patients on peritoneal dialysis (PD) or haemodialysis (HD), with no prior treatment with erythropoiesis-stimulating agents and haemoglobin below 8 g/dL (Group I) or receiving darbepoetin alpha and had stable haemoglobin at 10-12 g/dL (Group II) were included in this prospective open-label study. In Group I methoxy polyethylene glycol-epoetin beta was started at 0.6 µg/kg subcutaneously fortnightly till haemoglobin reached 10 g/dL, after which it was given monthly. A dose conversion table was devised for Group II. Follow-up was 36 weeks. RESULTS: Forty-five patients were included. Haemoglobin in Group I (n=23, PD/HD:19/4) increased from 7.5 ± 0.9 g/dL at baseline to 10.7 ± 1.0 g/dL after 16 weeks, while it remained stable at 10.4 ± 1.0 g/dL after conversion in Group II (n=22, PD/HD:15/7). Actual dose required after stabilization was 1.7 µg/kg per month in Group I and 2.3 µg/kg per month in Group II. Median number of dose adjustment was three in Group I and one in Group II, while haemoglobin overshoot to 13 g/dL or above occurred in 4.4% and 9.1%, respectively. No significant side-effect was observed. CONCLUSIONS: Our dosing regimen for methoxy polyethylene glycol-epoetin beta, for treatment naïve subjects or for conversion from darbepoetin alpha, is safe and effective. The dose required to achieve a haemoglobin concentration of 10-11 g/dL in Chinese dialysis patients is approximately 2 µg/kg monthly.

Evaluation of the relationship between cardiac calcification and cardiovascular disease using the echocardiographic calcium score in patients undergoing peritoneal dialysis: a cross-sectional study.

Introduction: An echocardiographic calcium score (ECS) predicts cardiovascular disease (CVD) in the general population. Its utility in peritoneal dialysis (PD) patients is unknown. Methods: This cross-sectional study assessed 125 patients on PD. The ECS (range 0-8) was compared between subjects with CVD and those without. Results: Among the subjects, 54 had CVD and 71 did not. Subjects with CVD were older (69 years vs. 56 years, P < 0.001) and had a higher prevalence of diabetes mellitus (DM) (81.5% vs. 45.1%, P < 0.001). They had lower diastolic blood pressure (72 mmHg vs. 81 mmHg, P < 0.001), lower phosphate (1.6 mmol/L vs. 1.9 mmol/L, P = 0.002), albumin (30 g/L vs. 32 g/L, P = 0.001), parathyroid hormone (34.4 pmol/L vs. 55.8 pmol/L, P = 0.002), total cholesterol (4.5 vs. 4.9, P = 0.047), LDL cholesterol (2.4 mmol/L vs. 2.8 mmol/L, P = 0.019) and HDL cholesterol (0.8 mmol/L vs. 1.1 mmol/L, P = 0.002). The ECS was found to be higher in subjects with CVD than in those without (2 vs. 1, P = 0.001). On multivariate analysis, only DM and age were independently associated with CVD. Conclusion: The ECS was significantly higher in PD patients with CVD than in those without, reflecting a higher vascular calcification burden in the former. It is a potentially useful tool to quantify vascular calcification in PD patients.

Treatment of Severe Tumoral Calcinosis with Teriparatide in a Dialysis Patient after Total Parathyroidectomy.

Tumoral calcinosis is a rare but debilitating condition that can affect dialysis patients. Optimal management is largely unknown. We report the clinical course, treatment, and outcome of a peritoneal dialysis (PD) patient who developed tumoral calcinosis refractory to conventional treatment but improved with teriparatide therapy. A 26-year-old lady on PD for 2 years presented to us with tumoral calcinosis involving bilateral hands. Response to surgical excision, parathyroidectomy, and conversion to hemodialysis failed to result in sustained remission, and tumoral calcinosis progressed. After total parathyroidectomy, the patient had transient but partial remission in which her calcinosis deposits remained but were asymptomatic without pain or clinical signs of inflammation. However, she later experienced a relapse with involvement of the left elbow, right shoulder, right hip, and right thigh. Tumoral calcinosis remained uncontrolled resulting in debilitation, likely attributable to poor calcium and phosphate control because of adynamic bone disease after parathyroidectomy despite treatment of superimposed tuberculosis and therapy with sodium thiosulphate and pamidronic acid. Clinical improvement was however evident after the use of teriparatide. Asymptomatic hypocalcemia occurred after teriparatide therapy but resolved after 2 months. In conclusion, teriparatide appears to be useful for treating tumoral calcinosis in the presence of adynamic bone disease. Hypocalcemia can occur in the initial months of therapy.

Efficacy of enteric-coated mycophenolate sodium in patients with active lupus nephritis.

BACKGROUND: The ideal treatment of lupus nephritis has yet to be defined. Both cyclophosphamide and mycophenolate mofetil have been used with encouraging results, but adverse events are frequently seen. There are no data on the use of enteric-coated mycophenolate sodium. METHODS: We retrospectively reviewed 12 patients with active forms of lupus nephritis (1 class III, 7 class IV and 4 class V) treated with enteric-coated mycophenolate sodium combined with corticosteroids. RESULTS: The mean age of the patients was 32.3 +/- 11.2 years and the average length of follow up was 25.9 +/- 8.9 months. The mean serum creatinine clearance was 93 +/- 30.1 mL/min per 1.73 m(2) and the mean proteinuria level was 4.5 +/- 3.6 g/day. All had features that warranted aggressive treatment. Mycophenolate sodium was given for 12.9 +/- 9.7 months with an averaged starting dose of 1350 +/- 163 mg/day. Six patients attained complete remission and six attained partial remission with treatment. The mean interval to attain first remission (complete or partial) was 8.3 +/- 5.7 weeks. At last follow up, all patients were in complete or partial remission. Apart from herpes zoster that developed in one patient, no other significant side-effects were encountered. CONCLUSION: Enteric-coated mycophenolate sodium was effective and well-tolerated in the treatment of active lupus nephritis.

Treatment of fungal peritonitis with a combination of intravenous amphotericin B and oral flucytosine, and delayed catheter replacement in continuous ambulatory peritoneal dialysis.

BACKGROUND: Fungal peritonitis (FP) is associated with significant mortality and high risk of peritoneal failure. The optimum treatment for peritoneal dialysis (PD)-associated FP remains unclear. Since January 2000 we have been treating FP with a combination of intravenous amphotericin B and oral flucytosine, together with deferred catheter replacement. We examined the clinical course and outcome of the FP patients treated with this approach (study group). An outcome comparison was also made to an alternatively treated historic cohort (control group). METHODS: This was a single-center retrospective study. The clinical course and outcome of 13 consecutive episodes of FP occurring in 13 patients treated between January 2000 and April 2005 with the study approach were examined. The patients were treated with an incremental dose of intravenous amphotericin B to a target dose of 0.75 - 1 mg/kg body weight/day, and oral flucytosine 1 g/day upon a diagnosis of FP at 3.77 +/- 0.93 days from presentation. Replacement of the peritoneal catheter was intended after complete clearing of effluent, after which, antifungal chemotherapy was continued for another 1 - 2 weeks. Their outcome was compared with 14 historic controls that were treated between April 1995 and December 1999. RESULTS: Mean age of the study group was 58.7 +/- 13.2 years; male-to-female ratio was 2:11; 6 (46.1%) were diabetic. All FP were caused by Candida species (C. albicans, 2; C. parapsilosis, 8; C. glabrata, 3). Two (15.4%) patients died before resolution of the peritonitis. The dialysate effluent cleared in 11 patients (84.6%) after 13.2 +/- 3.3 days of treatment, but 2 patients died of acute myocardial infarction before catheter replacement. Nine patients had their catheters replaced at day 26.7 +/- 7.7 of treatment; all 9 returned to PD after a total of 31 +/- 12.2 days of antifungal chemotherapy. Reversible liver dysfunction was common with this regimen. When compared with the 14 cases in the historic control group (Candida species, 13; Trichosporon, 1), who were treated with amphotericin B, fluconazole, or a combination of the two, and the majority (78.6%) of whose catheters were removed before day 10 of presentation, the study group appeared to have a lower technique failure rate (30.8% vs 78.6%, p = 0.013) and similar all-cause mortality (30.7% vs 28.5%, p = NS), FP-related mortality (15.4% vs 28.5%, p = NS), and length of hospitalization (48.5 +/- 30.2 vs 57.0 +/- 37.7 days, p = NS). However, a significantly earlier commencement of antifungal treatment in the study group (3.8 +/- 0.9 vs 5.8 +/- 2.4 days, p = 0.012) could be an important confounder of outcome. CONCLUSIONS: Combination of intravenous amphotericin B and oral flucytosine with deferred catheter replacement appears to be associated with a relatively low incidence of PD technique failure, without affecting mortality in patients suffering from FP due to yeasts in this preliminary study. Nonetheless, drug-induced hepatic dysfunction was common; close monitoring during treatment is of paramount importance. The reasons accounting for the observed distinctive outcome remain unclear and further study is required to confirm the results and to investigate for the underlying mechanism.

Renal registry and peritoneal dialysis management: the Hong Kong perspective.

The Hong Kong Renal Registry (HKRR) is an electronic paperless registry that services as database for patients on various renal replacement therapies in the territory. The database consists of demographic data, dialysis and transplant treatments, complications, and inquiries and reports. The HKRR can be helpful for individual patient's management, for renal center management, and for territory-wide management.

Prevention of fungal peritonitis with nystatin prophylaxis in patients receiving CAPD.

OBJECTIVE: Fungal peritonitis (FP) is a serious complication of continuous ambulatory peritoneal dialysis (CAPD), being associated with significant morbidity and mortality. The role of nystatin prophylaxis during antibiotic therapy in the prevention of FP remains controversial, especially in programs with a modest or low baseline FP rate. The aim of the present study was to evaluate the effect of nystatin prophylaxis on the occurrence of FP in programs with a relatively modest baseline FP rate. PATIENTS AND METHODS: Incident and prevalent patients receiving CAPD between April 1995 and April 2005 at our center were included and divided into 2 groups. The control group included 320 patients (total follow-up 8875 patient-months) being treated without nystatin before October 1999; the nystatin group included 481 patients (total follow-up 13725 patient-months) being treated after October 1999. Nystatin tablets (500,000 units, 4 times per day) were given orally during whatever use of antibiotics to cover the whole course of antibiotic therapy. Occurrence of FP and antibiotic-related FP (AR-FP) in patients with and without nystatin prophylaxis was compared. RESULTS: The two groups were of similar age but the nystatin group had a significantly higher percentage of diabetics. In addition, the nystatin group had a higher proportion of patients using disconnecting twin-bag exchange systems and had a significantly lower peritonitis rate compared with the control. There were 13 and 14 episodes of FP in the nystatin and control groups respectively. The fungal peritonitis rate of the nystatin group was slightly lower than that of the control group (0.011 vs 0.019 per patient-year) but it did not reach statistical significance. There was, however, a significant decrease in the incidence and proportion of AR-FP in the nystatin group compared with the control group, which persisted even after adjustment for the peritonitis rate. Kaplan-Meier analysis further demonstrated significantly better AR-FP-free survival in the nystatin group compared with the control group. No significant side effects were observed for nystatin. Subgroup analyses in patients of the 2 different connecting systems revealed a similar but nonsignificant trend toward reduction of AR-FP in patients given nystatin prophylaxis. CONCLUSION: Oral nystatin prophylaxis might prevent the occurrence of AR-FP in CAPD patients, resulting in a trend toward reduction in the incidence of FP even in programs with a modest baseline FP rate. A large scale, prospective, randomized controlled trial is needed to further examine this issue.

Alternating Mupirocin/Gentamicin is Associated with Increased Risk of Fungal Peritonitis as Compared with Gentamicin Alone - Results of a Randomized Open-Label Controlled Trial.

UNLABELLED: ♦ BACKGROUND AND OBJECTIVES: Catheter-related infection, namely exit-site infection (ESI) and peritonitis, is a major infectious complication and remains a main cause of technique failure for patients receiving peritoneal dialysis (PD). Topical application of antibiotic cream might reduce catheter-related infection but emergence of resistant or opportunistic organisms could be a concern. Optimal topical agents and regimens remain to be determined. We did a study to examine the effect of an alternating topical antibiotic regimen in preventing catheter-related infection. ♦ METHOD: We performed a single-center, randomized, open-label study to compare daily topical application of gentamicin cream with a gentamicin/mupirocin alternate regimen to the exit site. Patients randomized to alternating regimen were asked to have daily application of gentamicin cream in odd months and mupirocin cream in even months. Primary outcomes were ESI and peritonitis. Secondary outcomes were catheter removal or death caused by catheter-related infection. A total of 146 patients (71, gentamicin group; 75, alternating regimen group) were enrolled with a total follow-up duration of 174 and 181 patient-years for gentamicin and alternating groups, respectively. All patients were followed up until catheter removal, death, transfer to another unit, transplantation or the end of the study on March 31, 2014. There were no significant differences in the age, sex, dialysis vintage, and rate of diabetes, helper-assisted dialysis and methicillin-resistant Staphylococcus aureus (MRSA) carriage state. ♦ RESULTS: No difference was seen in the time to first ESI or peritonitis. However, the time to first gram-negative peritonitis seemed longer for the gentamicin group (p = 0.055). The 2 groups showed a similar rate of ESI (0.17/yr vs 0.19/yr, p = 0.93) but P. aeruginosa ESI was less common in the gentamicin group (0.06/yr vs 0.11/yr, p < 0.001). There was no difference in the incidence of ESI due to non-tuberculous mycobacteria. Peritonitis rate was significantly lower in the gentamicin group (0.22/yr vs 0.32/yr, p < 0.001), with a striking decrease in gram-negative peritonitis (0.08/yr vs 0.14/yr, p < 0.001), and fungal peritonitis (0.006/yr vs 0.03/yr, p < 0.001), which was all antibiotics-related episodes with antecedent use of systemic antibiotics for the treatment of catheter-related infections. There was no significant difference in the catheter loss or death related to catheter-related infection. ♦ CONCLUSION: Alternating gentamicin/mupirocin cream application appeared as effective as gentamicin alone in preventing ESI except for P. aeruginosa. However, it was inferior to gentamicin in the prevention of peritonitis episodes, especially for those caused by gram-negative organisms. It was also not useful in reducing catheter-related infection due to opportunistic organisms but instead associated with a higher incidence of antibiotic-related fungal peritonitis.

Vibrio vulnificus peritonitis after handling of seafood in a patient receiving CAPD.

Vibrio vulnificus is a marine bacterium and opportunistic human pathogen. Associated infections have contributed to the majority of seafood-related deaths in the United States. In patients with such predisposed clinical conditions as chronic liver disease, immunocompromised state, and end-stage renal disease, this organism has been associated with the development of life-threatening primary septicemia and severe wound infection. However, continuous ambulatory peritonitis dialysis (CAPD)-related peritonitis caused by V vulnificus has not been reported. We describe a patient receiving CAPD who developed peritonitis caused by V vulnificus after handling seafood. This case highlights the importance of strict aseptic technique during CAPD exchanges and calls for an effort in educating our dialysis patients on precautions about seafood handling.

Treatment with cyclophosphamide in elderly-onset nephrotic syndrome.

BACKGROUND: The best treatment of elderly-onset nephrotic syndrome has not been well defined. The use of corticosteroids or combination immunosuppressants may be associated with a significant incidence of side effects in the elderly. There is little data on the use of cyclophosphamide alone. METHODS: We retrospectively reviewed 30 patients with idiopathic elderly-onset nephrotic syndrome treated with cyclophosphamide. RESULTS: Male to female ratio was 2:1, mean age at diagnosis was 72.7 +/- 5.9 years and average length of follow-up was 41.4 +/- 21.3 months. Significant co-morbidities, including hypertension, were present in 57%. A raised serum creatinine level was found in 57%. Biopsy revealed 15 membranous nephropathy, 4 mesangial proliferative Gn, 5 IgA nephropathy, 3 minimal change nephropathy, 2 focal segmental glomerulosclerosis and 1 C1q nephropathy. Cyclophosphamide was given for 32.0 +/- 16.2 weeks with an averaged cumulative dose per patient 177 +/- 84 mg/kg BW. Remission (complete or partial) was attained by 40, 63, 80 and 87% of patients within 12, 24, 36 and 48 weeks of treatment, respectively. Eighteen patients attained complete remission and 9 partial remission after treatment. The mean interval to attain first remission (complete or partial) was 18.9 +/- 14.6 weeks. This was not affected by age (p = NS) or initial albumin level (p = NS). At the time of last follow-up, all but 2 patients were in complete or partial remission with raised serum creatinine levels in 40%. CONCLUSIONS: Cyclophosphamide was effective and well tolerated in the treatment of elderly-onset nephrotic syndrome, with sustained remission and preserved renal function.

Clinical presentation and outcome of severe acute respiratory syndrome in dialysis patients.

There was a major outbreak of severe acute respiratory syndrome (SARS) affecting more than 300 patients occurring in a private housing estate in Hong Kong, in which an infected renal patient was suspected to be the primary source. It is unknown whether renal patients would represent a distinct group of patients who share some characteristics that could predispose them to have higher infectivity. In this context, we have encountered 4 dialysis patients contracting SARS in a minor outbreak, which involved 11 patients and 4 health care workers, in a medical ward of a regional hospital. Of these 4 dialysis patients, 1 patient was receiving hemodialysis while the other 3 patients were on continuous ambulatory peritoneal dialysis. Fever and radiological changes were their dominant presenting features. All were having positive results for SARS-associated coronavirus ribonucleic acid by reverse transcriptase-polymerase chain reaction performed on their nasopharyngeal aspirates or stool samples. It appeared that treatment with high-dose intravenous ribavirin and corticosteroids could only resolve the fever, but it could not stop the disease progression. All 4 patients developed respiratory failure requiring mechanical ventilation on days 9 through 12. At the end, all of the patients died from sudden cardiac arrest, which was associated with acute myocardial infarction in 2 cases. From this small case series, it appeared that dialysis patients might have an aggressive clinical course and poor outcome after contracting SARS. However, a large-scale study is required to further examine this issue, and further investigation into the immunologic abnormalities associated with the uremic state in this group of patients is also warranted.

Tumoral calcinosis after an injection of recombinant human erythropoietin in a dialysis patient.

Tumoral calcinosis is a rare form of soft tissue calcifications, initially described as an idiopathic condition, which could occur in uremic patients. Despite its distinct clinical and morphologic presentations, the underlying pathogenesis is unknown. We present a dialysis patient who developed tumoral calcinosis over the right shoulder after receiving a misplaced injection of human recombinant erythropoietin probably into the periarticular tissue. This case serves as an example highlighting the importance of periarticular inflammatory reaction in precipitating the development of the lesion in predisposed patients.

Efficacy of a 1-week course of proton-pump inhibitor-based triple therapy for eradicating Helicobacter pylori in patients with and without chronic renal failure.

BACKGROUND: The efficacy of short-course triple therapy for the eradication of Helicobacter pylori has been documented in patients with normal renal function. We evaluated the efficacy and safety of a 1-week proton-pump inhibitor-based triple therapy for H pylori eradication in a prospective study of patients with chronic renal failure (CRF). METHODS: Forty-two patients with a creatinine clearance (CrCl) less than 30 mL/min/1.73 m2 or serum creatinine level greater than 2.26 mg/dL (>200 micromol/L; n = 21; CRF group; 12 patients on dialysis therapy) or normal renal function (n = 21; controls) were studied when they had H pylori infection on top of peptic ulcer disease (20 patients) or gastritis (22 patients). The combination of omeprazole, 20 mg twice daily; amoxicillin, 1 g twice daily; and clarithromycin, 500 mg twice daily, was administered for 1 week. All patients underwent repeated endoscopy 4 weeks later for assessment of eradication. Apart from patients on dialysis therapy, all patients had serum creatinine levels and CrCls measured 2 and 4 weeks after treatment. RESULTS: All except 5 patients (2 patients, CRF group; 3 controls) had successful eradication (90.5% versus 85.7%). For patients not on dialysis therapy, serum creatinine levels and CrCls remained stable 4 weeks after treatment (serum creatinine, 3.68 +/- 1.09 versus 3.76 +/- 1.09 mg/dL [325 +/- 96 versus 332 +/- 96 micromol/L]; P = not significant [NS]; CrCl, 21.4 +/- 8.3 versus 22.2 +/- 6.9 mL/min/1.73 m2; P = NS). CONCLUSION: The 1-week course of proton-pump inhibitor-based triple therapy achieved a high eradication rate of H pylori infection in patients with CRF, similar to controls with normal renal function. The regimen was well tolerated.

Long-term follow-up of thoracoscopic pleurodesis for hydrothorax complicating peritoneal dialysis.

BACKGROUND: Massive hydrothorax is a significant complication of continuous ambulatory peritoneal dialysis (CAPD) and its ideal management remains undefined. Conservative management in the form of intermittent peritoneal dialysis had limited success. The use of conventional pleurodesis and open thoracotomy were associated with morbidities and limitations. We retrospectively reviewed the long-term outcome of 8 patients with massive hydrothorax complicating CAPD, 6 of whom received thoracoscopic pleurodesis. METHODS: Among 397 patients undergoing continuous ambulatory peritoneal dialysis during the period from 1994 to 1998, hydrothorax developed in 8 patients. Four patients were first treated with temporary intermittent peritoneal dialysis using 1-L exchange cycles. Three of them had a recurrence of the hydrothorax whereas only one could resume continuous ambulatory peritoneal dialysis successfully. Two patients then underwent conventional pleurodesis but failed. One of them was switched to hemodialysis. Thoracoscopic pleurodesis was performed for the remaining 2 patients together with 4 other patients with hydrothorax once this complication developed. There were no gross abnormalities including pleuroperitoneal communication sites identified. Talc poudrage was performed in 2 patients and mechanical rub pleurodesis in the other 4 patients. All had uncomplicated procedure and uneventful recovery. RESULTS: One patient after thoracoscopic pleurodesis was soon switched to hemodialysis for an unrelated reason. The other 5 patients resumed continuous ambulatory peritoneal dialysis with no recurrence of hydrothorax for a mean period of 50 months (range 19 to 84). CONCLUSIONS: With thoracoscopic pleurodesis, patients resumed continuous ambulatory peritoneal dialysis without recurrence of hydrothorax on long-term follow-up.