Left ventricular strain and myocardial work in short-term peritoneal dialysis patients.

BACKGROUND: Initiation of dialysis encompasses new cardiovascular challenges on patients with end-stage renal disease (ESRD). This study used two-dimensional speckle-tracking echocardiography (2D-STE) to investigate the change of left ventricular (LV) myocardial function undergoing peritoneal dialysis (PD) within 1-3 months. METHODS: A total of 56 patients with ESRD and 27 healthy controls were enrolled in this prospective study. Mean duration of PD was 44.41 ± 16.44 days. We evaluated LV myocardial function of patients with ESRD in baseline and within 1-3 months after PD by 2D-STE with global longitudinal strains (GLS) and myocardial work (MW). Based on the level of serum phosphate before PD, patients were divided into two groups: the group with normal serum phosphate or hyperphosphatemia. RESULTS: Compared with healthy controls, patients with ESRD had impaired GLS (p < .001) and increased global work index (GWI) (p = .034), global constructive work (GCW) (p < .001), global wasted work (GWW) (p < .001), and lower global work efficiency (GWE) (p = .002). After PD therapy, GWI (p = .001), GCW (p < .001), and GWW (p = .023) decreased and closed to healthy subjects (p > .05) and no significant improvement was observed in GLS (p = .387). GLS of basal segments worsened in the hyperphosphatemia group (p = .005) and GWW reduced remarkably in the group with normal serum phosphate after PD treatment (p = .008). The change of left ventricular internal diameter in diastole (LVIDd) was the only parameter influenced GWI in post-dialysis patients (ß = 0.324, p = .013). CONCLUSIONS: Short-term PD treatment improved LV MW in ESRD patients. They benefited more when receiving treatment before the increase of serum phosphorus.

Association between serum chloride levels with mortality in incident peritoneal dialysis patients.

BACKGROUND AND AIMS: Lower serum chloride (Cl) levels have been associated with excess mortality in pre-dialysis chronic kidney disease patients. However, the relationship between serum Cl levels and clinical outcomes in continuous ambulatory peritoneal dialysis (CAPD) patients is unclear. METHODS AND RESULTS: In this retrospective cohort study, we enrolled 1656 eligible incident patients undergoing CAPD from 2006 to 2013, and followed until December 2018. Cox regression analyses were used to examine the association between baseline and time-varying serum Cl levels and mortality. During a median follow-up of 46 months, 503 patients (30.4%) died. In analyses of baseline serum Cl, the adjusted hazard ratios (HR) for tertile 1 (<100.0 mmol/L), tertile 2 (100.0-103.0 mmol/L) versus tertile 3 (>103.0 mmol/L) were 2.34 [95% confidence interval (CI) 1.43-3.82] and 1.73 (95% CI 1.24-2.42) for all-cause mortality, 2.86 (95% CI 1.47-5.56) and 1.90 (95% CI 1.19-3.02) for cardiovascular disease (CVD) mortality, respectively. And a linear relationship was observed between serum Cl and mortality. Further, the inverse association between serum Cl and CVD mortality was particularly accentuated in the patients who were ≥50 years or with a history of diabetes. Similarly, lower time-varying serum Cl levels were also associated with a significant increased risk of all-cause and CVD death. CONCLUSION: Lower serum Cl levels predicted higher risk of all-cause and CVD mortality in CAPD patients.

Upregulation of C/EBP Homologous Protein induced by ER Stress Mediates Epithelial to Myofibroblast Transformation in ADTKD-UMOD.

Autosomal dominant tubulointerstitial kidney disease due to UMOD mutations (ADTKD-UMOD) results in chronic interstitial nephritis, which gradually develops into end-stage renal disease. It is believed that the accumulation of mutant uromodulin causes the endoplasmic reticulum (ER) stress, then leads to the kidney damage. But the underlying mechanism remains unclear. To find the ADTKD-UMOD patients, UMOD gene screening was performed in 26 patients with unexplained chronic interstitial nephritis, during the past 10 years in our department, and among them three ADTKD-UMOD cases were discovered. Routine pathological staining and electron microscopy sections were reviewed again to confirm their kidney lesions. Immunostaining of UMOD and ER stress marker GRP78, as well as CHOP have all been done. The strong colocalization of UMOD with GRP78 and CHOP in ADTKD-UMOD patients but not in other chronic interstitial nephritis patients had been found. Moreover in vitro experiments, ER stress induced by tunicamycin (TM) not only significantly increased the expression of GRP78 and CHOP, but also caused the epithelial to myofibroblast transformation (EMT) of renal tubular epithelial cells, evidenced by decreased expression of E-cadherin and increased expression of vimentin, and extracellular matrix (ECM) deposition, evidenced by increased expression of fibronectin (FN). CHOP knockdown could restore the upregulation of vimentin and FN induced by TM. Thus, specific activation of CHOP in renal tubular epithelial cells induced by UMOD protein might be the key reason of renal interstitial fibrosis in ADTKD-UMOD patients.

Sexual Effect of Platelet-to-Lymphocyte Ratio in Predicting Cardiovascular Mortality of Peritoneal Dialysis Patients.

BACKGROUND: The study is aimed at exploring the relationship of platelet-to-lymphocyte (PLR), all-cause, and cardiovascular disease (CVD) mortality in peritoneal dialysis (PD) patients based on gender. METHODS: A total of 1438 PD patients from January 1,2007 to December 31, 2014 in PD center at The First Affiliated Hospital, Sun Yat-sen University, were included. Patients were followed up until December 31, 2019. The endpoint was all-cause mortality and CVD mortality. Cox proportional hazards regression models were used to evaluate the association of PLR with all-cause and CVD mortality to calculate hazard ratios (HR) and 95% confidence intervals (CI). RESULTS: After a median of 48.9 (interquartile range [IQR]: 23.4-79.3) months of follow-up, 406 (28.2%) patients died based on all-cause death, among which 200 (49.3%) patients died from CVD. In the multivariate Cox regression model, we found that PLR was independently related to an increased risk of CVD mortality only in female PD patients, with HR of 1.003 (95% CI: 1.001-1.006). Interaction test showed that the correlation between PLR level for all-cause and CVD mortality varied with gender (p = 0.042 and p = 0.012, respectively). CONCLUSION: Higher PLR was associated with a higher risk of CVD mortality in female PD patients.

Clinical characteristics and outcomes of antibiotic-associated encephalopathy in patients with end-stage kidney disease.

OBJECTIVE: End-stage kidney disease (ESKD) patients have a higher risk of antibiotic-associated encephalopathy (AAE) than other patients. We aimed to evaluate the prevalence, risk factors and outcomes of AAE in ESKD patients. METHOD: A retrospective study of ESKD patients treated with intravenous antibiotics in our hospital from Jan. 1, 2006, to Dec. 31, 2015 was performed. AAE was diagnosed by the modified Delphi method. Control individuals were randomly selected from the remaining patients who did not exhibit neurologic symptoms. Logistic regression analysis was used to identify risk factors for AAE as well as the association between AAE and outcome. RESULT: A total of 2104 patients were included in the study. The prevalence of AAE in our study was 4.4% (92/2104). The multivariate logistic regression analysis revealed that anuria (OR = 8.04, 95% CI: 4.13-15.65, p < 0.001), history of central nervous system disorder (OR = 3.03, 95% CI: 1.21-7.56, p = 0.018) and hypoalbuminemia (OR= 1.87, 95% CI: 1.01-3.47, p = 0.046) were independent factors associated with AAE in ESKD patients. After adjustment for confounders, AAE was associated with composite outcomes of in-hospital mortality and treatment withdrawal (OR = 4.36, 95% CI: 2.09-9.10, p < 0.001). CONCLUSION: The prevalence of AAE was 4.4% in ESKD patients and varied among different antibiotics. Anuria, history of central nervous system disorder and hypoalbuminemia were associated with AAE in ESKD patients. AAE is associated with worse outcomes in ESKD patients.

Risk Factors and Clinical Outcomes of Cognitive Impairment in Diabetic Patients Undergoing Peritoneal Dialysis.

INTRODUCTION: Cognitive impairment (CI) is common in patients with CKD or diabetes mellitus (DM). However, the relevance between DM and CI in diabetic patients undergoing peritoneal dialysis (PD) has not been clearly established. This study aimed to explore the role of DM in CI, the association of glycemic control with CI, and clinical outcomes of CI in diabetic PD patients. METHODS: Continuous ambulatory PD (CAPD) patients followed up in our PD center between 2014 and 2016 were enrolled. The participants were followed until an endpoint was reached or December 2017. Demographic data and clinical characteristics were collected, and laboratory parameters were measured. The Montreal Cognitive Assessment (MoCA) was used to evaluate global cognitive function, and a score of <26 was considered to indicate CI. A propensity score matching according to age, gender, and mean arterial pressure was conducted between the DM and non-DM groups. RESULTS: A total of 913 CAPD patients were enrolled, of whom 186 (20.4%) had diabetes. After appropriate matching, 175 patients in the DM group and 270 patients in the non-DM group were included. Patients with diabetes had a higher prevalence of CI and lower scores for visuospatial/executive function, naming, language, delayed recall, and orientation. Higher HbA1c (odds ratio [OR], 1.547; 95% confidence interval [95% CI], 1.013-2.362) and cardiovascular disease (CVD; OR, 2.926; 95% CI, 1.139-7.516) significantly correlated with a risk of CI in diabetic patients. During a median of 26.0 (interquartile range 13.5-35.6) months of follow-up, diabetic patients with CI demonstrated a significantly lower survival rate than those without CI, and CI was an independent risk factor for mortality after adjustment (hazard ratio, 7.224; 95% CI, 1.694-30.806). However, they did not show worse technique survival or higher peritonitis rate than patients without CI. CONCLUSIONS: HbA1c and CVD are independent risk factors for CI in diabetic patients undergoing CAPD, and CI is independently associated with a higher risk of mortality.

Abnormal iron status is associated with an increased risk of mortality in patients on peritoneal dialysis.

BACKGROUND AND AIMS: Iron deficiency is prevalent, but there is limited data about the relationship between iron status and poor outcomes in chronic kidney disease patients undergoing peritoneal dialysis (PD). We aimed to investigate the association between iron status and mortality in PD patients. METHODS AND RESULTS: This retrospective study was conducted on incident PD patients from January 2006 to December 2016 and followed up until December 2018. Patients were categorized into four groups according to baseline serum transferrin saturation (percent) and ferritin levels (ng/ml): reference (20-30%, 100-500 ng/ml), absolute iron deficiency (<20%, <100 ng/ml), function iron deficiency (FID) (<20%, >100 ng/ml), and high iron (>30%, >500 ng/ml). Among the 1173 patients, 77.5% had iron deficiency. During a median follow-up period of 43.7 months, compared with the reference group, the FID group was associated with increased risk for all-cause [adjusted hazard ratio (aHR) 1.87, 95% confidence interval (95% CI) 1.05-3.31, P = 0.032], but not cardiovascular (CV) mortality. Additionally, the high iron group had a more than four-fold increased risk of both all-cause and CV mortality [aHR 4.32 (95% CI 1.90-9.81), P < 0.001; aHR 4.41 (95% CI 1.47-13.27), P = 0.008; respectively]. CONCLUSION: FID and high iron predict worse prognosis of patients on PD.

Clinical and pathological characteristics of ANA/anti-dsDNA positive patients with antineutrophil cytoplasmic autoantibody-associated vasculitis.

Antineutrophil cytoplasmic autoantibodies (ANCA) associated vasculitis (AAV) consists of a group of systemic autoimmune diseases. The roles of serum anti-nuclear antibodies (ANA) and anti-double-stranded DNA (anti-dsDNA) antibodies in AAV patients remain unknown. This study investigated the prevalence of serum ANAs and anti-dsDNA antibodies in AAV patients and characterized the clinical and pathological features of these patients. A total of 218 AAV patients were enrolled. Clinical and pathological data of patients were analyzed retrospectively. Of the 218 AAV patients, 109 (50.0%) were positive for ANA, 45 (20.6%) were positive for anti-dsDNA, and 43 (19.7%) were positive for both. The AAV patients with ANA had severer kidney damage and more chronic renal histopathological changes compared to those who were negative for ANA. Specifically, patients positive for ANA had more hypertension, higher levels of urea nitrogen and serum creatinine, lower estimated glomerular filtration rate (eGFR), more end-stage renal disease (ESRD), severer proteinuria, glomerular sclerosis, tubular interstitial fibrosis and tubular atrophy, and were more likely to receive renal biopsies compared to ANA negative patients. The study found ANA and anti-dsDNA in AVV patients were not rare, ANA-positive AAV patients had severer kidney damage and more chronic renal histopathological changes compared to ANA-negative AAV patients. Renal biopsy is strongly recommended for differential diagnosis in such cases.

Serum Sodium Modifies the Association of Systolic Blood Pressure with Mortality in Peritoneal Dialysis Patients.

INTRODUCTION: High serum sodium is associated with increased blood pressure (BP) in dialysis patients, which is a risk factor for cardiovascular (CV) disease. However, the interaction between serum sodium and BP and their association with clinical outcomes in peritoneal dialysis (PD) patients is uncertain. METHODS: We analyzed a retrospective cohort of 1,656 incident PD patients from January 2006 to December 2013, who were followed up until December 2018. Cox proportional hazards regression models were used to evaluate the association of serum sodium and BP with all-cause and CV mortality. A priori interaction between serum sodium and systolic BP (SBP) was explored, and a subgroup analysis was performed by stratifying SBP into the following 3 groups: <110, 110-130, and >130 mm Hg. RESULTS: Mean baseline serum sodium was 140.2 ± 3.6 mmol/L, mean SBP was 137 ± 20 mm Hg, and diastolic BP was 85 ± 14 mm Hg. During a median (range) follow-up time of 46.5 (2.6-154.3) months, 507 patients died, 252 of whom died due to CV disease. SBP did not predict all-cause and CV mortality when BP was assessed as a continuous variable. However, SBP >130 or <110 mm Hg was associated with higher risk of all-cause and CV mortality compared with SBP of 110-130 mm Hg. There was a significant interaction between baseline serum sodium and SBP for all-cause mortality (p for interaction = 0.016). In subgroup analysis, among those with SBP >130 mm Hg, the risk of all-cause mortality was elevated in those with serum sodium ≥140 mmol/L (adjusted hazard ratio [aHR] 1.45 [95% confidence interval (CI): 1.07-1.98]), but not for those with serum sodium <140 mmol/L (aHR 1.27 [95% CI: 0.89-1.82]). Conversely, among those with SBP <110 mm Hg, those with serum sodium <140 mmol/L had an elevated risk of mortality (aHR 1.99 [95% CI: 1.31-3.02]), but not those with serum sodium ≥140 mmol/L (aHR 1.15 [95% CI: 0.74-1.79]) (p for interaction = 0.028). CONCLUSION: The association of BP with mortality was modified by serum sodium levels in PD patients. Further studies are needed to evaluate whether individualized BP control based on serum sodium levels contributes to improve patient outcomes.

The predictive study of the relation between elevated low-density lipoprotein cholesterol to high-density lipoprotein cholesterol ratio and mortality in peritoneal dialysis.

BACKGROUND: The low-density lipoprotein cholesterol to high-density lipoprotein cholesterol (LDL-C/HDL-C) ratio constitutes a strong risk predictor of cardiovascular events. However, the association between this ratio and cardiovascular death in peritoneal dialysis (PD) patients is uncertain. The study aimed to investigate whether a high LDL-C/HDL-C ratio could predict both cardiovascular and all-cause mortalities in patients on PD. METHODS: A total of 1616 incident patients on PD included from January 1, 2006 to December 31, 2013 were followed up with until 31 December 2018 in this single-center prospective cohort study. Participants were divided into three categories according to LDL-C/HDL-C ratio tertile. The primary endpoint was cardiovascular mortality; the secondary endpoint was all-cause mortality. RESULTS: The mean age of the study cohort was 47.5 years and the mean body mass index (BMI) was 21.6 kg/m2. During a median follow-up period of 47.6 months, 492 patients died, including 246 (50.0%) due to cardiovascular disease (CVD). A multivariate analysis revealed that the highest LDL-C/HDL-C ratio tertile was significantly associated with increased CVD mortality [hazard ratio (HR): 1.69, 95% CI: 1.24-2.29; P = 0.001] and all-cause mortality (HR: 1.46, 95% CI: 1.18-1.81; P = 0.001) relative to the lowest tertile. After adjusting for covariates, the HRs of cardiovascular and all-cause mortalities were 1.84 (95% CI: 1.25-2.71; P = 0.002) and 1.35 (95% CI: 1.03-1.77; P = 0.032). Subgroup analysis showed that the risk of CVD death rose with a higher LDL-C/HDL-C ratio among PD patients who were female, younger than 65 years old, without being malnourished (BMI ≥ 18.5 kg/m2 or albumin ≥35 g/L), and with a history of diabetes or CVD, respectively. CONCLUSIONS: A high LDL-C/HDL-C ratio is an independent risk factor for both cardiovascular and all-cause mortalities among PD patients.

Age Difference in the Association between Hyponatremia and Infection-Related Mortality in Peritoneal Dialysis Patients.

OBJECTIVES: This study aimed to examine the association of serum sodium with infection-related mortality and its age difference among continuous ambulatory peritoneal dialysis (CAPD) patients. METHODS: A total of 1,656 CAPD patients from January 2006 to December 2013 were included in this study. All patients were followed up until December 2018. Hyponatremia was defined as serum sodium <135 mmol/L. Cox proportional hazards regression model was used to investigate the relationship between baseline serum sodium levels and infection-related mortality. RESULTS: Participants were aged 47.5 ± 15.3 years, 666 (40.2%) patients were female. Glomerulonephritis was the main cause of end-stage renal disease (61.1%). After a median of 46 months of follow-up, 507 patients died. Among the deaths, 252 (49.7%) died from cardiovascular diseases, 105 (20.7%) from infections, and 150 (29.6%) from other causes. The overall infection-related mortality was 14.8 events per 1,000 patients-year, which was higher in patients aged ≥50 years than those younger than 50 years (28.3 vs. 5.3 events per 1,000 patients-year). In the entire cohort, hyponatremia at was not associated with infection-related (hazards ratios [HR] 1.66, 95% CI 0.91-3.02) and all-cause mortality (HR 1.14, 95% CI 0.83-1.57) after adjusting for potential confounders. There was a significant interaction by age of association of serum sodium with infection-related (p = 0.002) and all-cause (p = 0.0002) death. Age-stratified analysis showed that compared with control group, hyponatremia was independently related to increased risks of infection-related death, but not all-cause mortality in patients aged ≥50 years, with HR of 2.32 (95% CI 1.25-4.32) and 1.33 (95% CI 0.95-1.87), respectively. CONCLUSIONS: Hyponatremia was associated with increased risk of infection-related mortality in CAPD patients aged ≥50 years.

Plasma fibrinogen and mortality in patients undergoing peritoneal dialysis: a prospective cohort study.

BACKGROUND: Plasma fibrinogen is significantly associated with cardiovascular (CV) events and mortality in the general population. However, the association between plasma fibrinogen and mortality in patients undergoing peritoneal dialysis (PD) is unclear. METHODS: This was a prospective cohort study. A total of 1603 incident PD patients from a single center in South China were followed for a median of 46.7 months. A Cox regression analysis was used to evaluate the independent association of plasma fibrinogen with CV and all-cause mortality. Models were adjusted for age, sex, smoking, a history of CV events, diabetes, body mass index, systolic blood pressure, hemoglobin, blood platelet count, serum potassium, serum albumin, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, hypersensitive C-reactive protein, estimated glomerular filtration rate, antiplatelet agents and lipid-lowering drugs. RESULTS: The mean age was 47.4 ± 15.3 years, 955 (59.6%) patients were male, 319 (19.9%) had a history of CV events, and 410 (25.6%) had diabetes. The average plasma fibrinogen level was 4.12 ± 1.38 g/L. Of the 474 (29.6%) patients who died during follow-up, 235 (49.6%) died due to CV events. In multivariable models, the adjusted hazard ratios (HRs) for quartile 1, quartile 3, and quartile 4 versus quartile 2 were 1.18 (95% confidence interval [CI], 0.72-1.95, P = 0.51), 1.47 (95% CI, 0.93-2.33, P = 0.10), and 1.78 (95% CI, 1.15-2.77, P = 0.01) for CV mortality and 1.20 (95% CI, 0.86-1.68, P = 0.28), 1.29 (95% CI, 0.93-1.78, P = 0.13), and 1.53 (95% CI, 1.12-2.09, P = 0.007) for all-cause mortality, respectively. A nonlinear relationship between plasma fibrinogen and CV and all-cause mortality was observed. CONCLUSIONS: An elevated plasma fibrinogen level was significantly associated with an increased risk of CV and all-cause mortality in patients undergoing PD.

Infection-related hospitalization after intensive immunosuppressive therapy among lupus nephritis and ANCA glomerulonephritis patients.

Introduction: This study aimed to investigate the clinical characteristics, risk factors, and outcomes of infection-related hospitalization (IRH) in patients with lupus nephritis (LN) and ANCA glomerulonephritis after intensive immunosuppressive therapy.Methods: Patients diagnosed with LN or ANCA glomerulonephritis who received intensive immunosuppressive therapy at the First Affiliated Hospital of Sun Yat-sen University from 2005 to 2014 were enrolled. Demographics, laboratory parameters, immunosuppressive agents, and IRH details were collected. Multivariable Cox regression was used, and hazard ratios (HRs) and 95% confidence intervals (CIs) were reported.Results: Totally, 872 patients with 806 LN and 66 ANCA glomerulonephritis were enrolled, and 304 (34.9%) patients with 433 episodes of IRH were recorded. ANCA glomerulonephritis patients were more vulnerable to IRH than LN patients (53.0% vs. 33.4%, p = .001). Multivariable Cox regression analysis showed that ANCA glomerulonephritis (HR = 1.62, 95% CI: 1.06-2.49, p = .027), diabetes (HR = 1.82, 95% CI: 1.03-3.22, p = .039) and a higher initial dose of prednisone (HR = 1.01, 95% CI: 1.00-1.02, p = .013) were associated with a higher likelihood of IRH. Higher albumin (HR = 0.96, 95% CI: 0.94-0.98, p < .001), globulin (HR = 0.98, 95% CI: 0.96-0.99, p = .008), and eGFR (HR = 0.99, 95% CI: 0.99-1.00, p < .001), were associated with a lower likelihood of IRH. The rates of transfer to ICU and mortality for ANCA glomerulonephritis patients were higher than those for LN patients (22.9% vs. 1.9%, p < .001, and 20.0% vs. 0.7%, p < .001, respectively).Conclusions: ANCA glomerulonephritis patients had a higher risk of IRH and poorer outcome once infected after intensive immunosuppressive therapy than LN patients. More strict control for infection risks is required for ANCA glomerulonephritis patients who undergo intensive immunosuppressive therapy.

Urgent-start peritoneal dialysis for patients with end stage renal disease: a 10-year retrospective study.

BACKGROUND: Urgent-start peritoneal dialysis (PD) can help patients with end-stage renal diseases (ESRD) that are referred late to dialysis. However, catheter patency and related complications of urgent-start PD have not been thoroughly clarified. We investigated the clinical outcomes of urgent-start PD in a Chinese cohort. METHODS: We enrolled ESRD patients who received urgent-start PD (starting PD within 14 days after catheter insertion) in our center from January 1, 2006 to December 31, 2014, and followed them up for 10 years. The primary outcome was catheter failure. Secondary outcomes included short-term and long-term complications related to urgent-start PD. RESULTS: Totally 2059 patients (58.9% male, mean age 47.6 ± 15.9 years) were enrolled. Few perioperative complications were observed, including significant hemorrhage (n = 3, 0.1%) and bowel perforation (n = 0). Early peritonitis occurred in 24 (1.2%) patients (0.28 episodes per patient-year). Within the first month after catheter insertion, functional catheter malfunction occurred in 85 (4.1%) patients, and abdominal wall complications (including hernia, hydrothorax, hydrocele, and leakage) in 36 (1.7%) patients. During a median 36.5 (17.7-61.4) months of follow-up, 75 (3.6%) patients experienced catheter failure, and 291 (14.1%) had death-censoring technique failure. At the end of 1-month, 1 -year, 3-year, and 5-year, catheter patency rate was 97.6, 96.4, 96.2, 96.2%; and technique survival rate was 99.5, 97.0, 90.3, 82.7%, respectively. After adjusting for confounders, every 5-year increase in age was associated with 19% decrease of risk for catheter failure (hazard ratio [HR]: 0.81, 95% confidence interval [CI]: 0.73-0.89). Male sex (HR: 1.43, 95% CI: 1.00-2.04), diabetic nephropathy (HR: 1.56, 95% CI: 1.08-2.25) and low hemoglobin levels (HR: 0.89, 95% CI: 0.81-0.98) were independent risk factors for abdominal wall complications. CONCLUSIONS: Urgent-start PD is a safe and efficacious option for unplanned ESRD patients. A well-trained PD team, a standardized catheter insertion procedure by experienced nephrologists, and a carefully designed initial PD prescription as well as comprehensive follow-up care, might be essential for the successful urgent-start PD program.

Maintained Folic Acid Supplementation Reduces the Risk of Mortality in Continuous Ambulatory Peritoneal Dialysis Patients.

BACKGROUND: The association between folic acid (FA) supplementation and mortality in continuous ambulatory peritoneal dialysis (CAPD) patients is unclear. METHODS: FA exposure was calculated as a percentage of cumulative duration of drug usage to total follow-up duration (FA%). A total of 1,358 patients were classified by a cutoff value of FA%. The association of FA with mortality was evaluated using Cox proportional hazards models. RESULTS: The cutoff value of FA% for predicting mortality was <34% at a median follow-up of 40.7 months. FA ≥34% was associated with decreased risk for all-cause (adjusted hazard ratios [HRs] 95% CI 0.64 [0.48-0.85] and cardiovascular mortality 0.67 (95% CI 0.47-0.97). Moreover, the adjusted HRs per 10% higher FA for all-cause and cardiovascular mortality were 0.925 (95% CI 0.879-0.973) and 0.926 (95% CI 0.869-0.988), respectively. CONCLUSIONS: Longer period of FA supplementation led to a reduction in risk of both all-cause and cardiovascular mortality in CAPD patients.

Association of left ventricular systolic dysfunction with mortality in incident peritoneal dialysis patients.

AIM: Cardiovascular disease is associated with morbidity and mortality in peritoneal dialysis patients but the relationship between left ventricular ejection fraction (LVEF) and outcomes is unclear. This study aimed to explore the association between LVEF and mortality in incident continuous ambulatory peritoneal dialysis (CAPD) patients. METHODS: The patients were divided into three groups according to LVEF levels (>0.6, 0.5 to 0.6, and <0.5). Kaplan-Meier analysis and the Cox proportional hazards models were used to evaluate association of LVEF with mortality. RESULTS: Among the 594 patients, LVEF levels of >0.6, 0.5 to 0.6, and <0.5 were detected in 428 (72.0%), 127 (21.4%) and 39 (6.6%) patients, respectively. During a median follow-up of 39.6 months, 127 (21.4%) patients died, of the deaths, 57.5% were attributable to cardiovascular causes. Patients with LVEF <0.5 had worst overall rates of survival and cardiovascular death-free survival among groups. Compared with LVEF >0.6, adjusted all-cause mortality hazard ratio (HR) and 95% confidence interval (CI) for patients with LVEF 0.5 to 0.6 and <0.5 were 1.62 (1.09-2.43) and 1.93 (1.06-3.52), respectively. The corresponding adjusted cardiovascular mortality HR were 1.60 (0.94-2.47) and 2.16 (1.04-4.74), respectively. CONCLUSION: Reduced LVEF is significantly associated with increased all-cause and cardiovascular mortality in incident CAPD patients.

Association of baseline, longitudinal serum high-sensitive C-reactive protein and its change with mortality in peritoneal dialysis patients.

BACKGROUND: The prognostic values of baseline, longitudinal high-sensitivity C-reactive protein (hs-CRP) and its change over time on mortality in patients undergoing continuous ambulatory peritoneal dialysis (CAPD) remain uncertain. METHODS: We retrospectively studied 1228 consecutive CAPD patients from 2007 to 2012, and followed up through December 2014. Cox regression models were performed to assess the association of hs-CRP on outcomes using serum hs-CRP levels as: (1) stratified by tertile of baseline or longitudinal hs-CRP levels; (2) baseline or longitudinal hs-CRP levels as continuous variables; and (3) categorized by tertile of slopes of hs-CRP change per year for each subject. RESULTS: Higher baseline hs-CRP levels were not associated with clinical outcomes after adjustment for potential confounders. However, patients with the upper tertile of longitudinal hs-CRP had a nearly twice-fold increased risk of both all-cause and cardiovascular mortality [adjusted hazard ratio (HR) 1.77; (95% CI 1.16-2.70) and 2.08 (1.17-3.71), respectively], as compared with those with lower tertile. Results were similar when baseline or longitudinal hs-CRP was assessed as continuous variable. Additionally, the risk of all-cause and cardiovascular mortality in patients with increased trend in serum hs-CRP levels over time (tertile 3) was significantly higher [adjusted HR 2.48 (1.58-3.87) and 1.99 (1.11-3.56), respectively] when compared to those with relatively stable hs-CRP levels during follow-up period. These associations persisted after excluding subjects with less than 1-year follow up. CONCLUSIONS: Higher longitudinal serum hs-CRP levels and its elevated trend over time, but not baseline levels were predictive of worse prognosis among CAPD patients.

Group 3 Innate Lymphoid Cells Exacerbate Lupus Nephritis by Promoting B Cell Activation in Kidney Ectopic Lymphoid Structures.

Group 3 innate lymphoid cells (ILC3s) represent a new population in immune regulation, yet their role in lupus nephritis (LN) remains elusive. In the present work, systemic increases in ILC3s, particularly in the kidney, are observed to correlate strongly with disease severity in both human and murine LN. Using MRL/lpr lupus mice and a nephrotoxic serum-induced LN model, this study demonstrates that ILC3s accumulated in the kidney migrate predominantly from the intestine. Furthermore, intestinal ILC3s accelerate LN progression, manifested by exacerbated autoimmunity and kidney injuries. In LN kidneys, ILC3s are located adjacent to B cells within ectopic lymphoid structures (ELS), directly activating B cell differentiation into plasma cells and antibody production in a Delta-like1 (DLL1)/Notch-dependent manner. Blocking DLL1 attenuates ILC3s' effects and protects against LN. Altogether, these findings reveal a novel pathogenic role of ILC3s in B cell activation, renal ELS formation and autoimmune injuries during LN, shedding light on the therapeutic value of targeting ILC3s for LN.

Prognostic significance of hypertension at the onset of lupus nephritis in Chinese patients: prevalence and clinical outcomes.

The demographic features, and clinical and histological characteristics of lupus nephritis (LN) patients with hypertension in the Chinese population remain unclear. Hence, the clinical characteristics of LN with and without hypertension were retrospectively analyzed. A total of 764 LN patients (53.1%) were hypertensive. These hypertensive patients had higher levels of serum creatinine and blood urea nitrogen, and lower estimated glomerular filtration rates, when compared to their normotensive counterparts (P < 0.05). Furthermore, these hypertensive patients had higher median acuity index and chronicity index scores, when compared to normotensives (P < 0.001). In terms of histology, hypertensive patients were more likely to develop glomerular sclerosis, thickened glomerular capillary loops, or crescent formations, and had more severe endothelial cell proliferation, when compared to normotensive patients (P < 0.001). Hypertensive patients also had a higher percentage for more severe tubular atrophy, interstitial inflammatory cell infiltration and interstitial fibrosis (P < 0.001). Compared with normotensive patients, hypertensive patients exhibited a significant decline in survival time and rate for all end points (P < 0.01). The presence of hypertension was an independent predictor of mortality (P = 0.009), ESRD (P = 0.026), and doubling of serum creatinine (P = 0.017). In conclusion, hypertension is associated with poor clinical and renal outcome in LN patients. The monitoring and control of hypertension should be considered an important clinical goal in the treatment of LN patients.

Association of Ratio of Apolipoprotein B to Apolipoprotein A1 With Survival in Peritoneal Dialysis.

Background: Although the ratio of apolipoprotein B (apo B) to apolipoprotein A1 (apo A1) (apo B/apo A1) seems to be associated with mortality in hemodialysis (HD) patients, the association of apo B/apo A1 ratio with death remains not clear in peritoneal dialysis (PD) patients. Aims: The study targets to examine the relationship of apo B/apo A1 ratio with survival in patients receiving PD treatment. Methods: In this single-center prospective observational cohort study, we enrolled 1,616 patients receiving PD treatment with a median follow-up time of 47.6 months. We used a multivariable Cox proportional hazards model to examine the relationship between apo B/apo A1 ratio and cardiovascular (CV) and all-cause mortality. The association of apo B/apo A1 ratio with atherosclerotic and non-atherosclerotic CV mortality was further evaluated by competing risk regression models. Results: During the follow-up, 508 (31.4%) patients died, 249 (49.0%) died from CV events, of which 149 (59.8%) were atherosclerotic CV mortality. In multivariable models, for 1-SD increase in apo B/apo A1 ratio level, the adjusted hazard ratios for CV and all-cause mortality were 1.26 [95% confidence interval (CI), 1.07-1.47; P = 0.005] and 1.20 (95% CI, 1.07-1.35; P = 0.003), respectively. The adjusted subdistribution hazard ratios for atherosclerotic and non-atherosclerotic CV mortality were 1.43 (95% CI, 1.19-1.73; P < 0.001) and 0.85 (95% CI, 0.64-1.13; P = 0.256), respectively. For quartile analysis, patients in quartile 4 had higher CV, all-cause, and atherosclerotic CV mortality compared with those in quartile 1. Moreover, apo B/apo A1 ratio had a diabetes-related difference in CV, all-cause, and atherosclerotic CV mortality. Conclusion: Elevated apo B/apo A1 ratio level was significantly associated with CV, all-cause, and atherosclerotic CV mortality in patients undergoing PD. Moreover, the association was especially statistically significant in patients with diabetes.