A patient with hemodialysis-related hyperammonemic encephalopathy: a delayed presentation of congenital arterioportal fistulas.

We present a 32-year-old woman who developed hyperammonemic encephalopathy during hemodialysis. She was rather well before 2009 when receiving peritoneal dialysis due to chronic interstitial nephritis. Due to a refractory peritonitis, the treatment was shifted to hemodialysis in January 2009. About 1 year later, she was found with consciousness disturbance during hemodialysis then admitted to the hospital because of hyperammonemia (165 µg/dl). During hospitalization, the patient's abdominal Doppler sonography showed a hepatofugal flow in the portal trunk while the hepatic artery angiography demonstrated multiple intrahepatic arterioportal fistulas. Her general condition was improved after the treatment of lactulose and hepatic artery embolization. With the occurrence of arterioportal fistulas induced portal hypertension, we speculated that the portal-systemic shunt was enhanced during hemodialysis because of venous hypotension which then resulted in the transient hyperammonemia. To the best of our knowledge, this is the first patient who developed hemodialysis- related hyperammonemic encephalopathy due to multiple arterioportal fistulas.

Key pathological features characterize minimal change disease-like IgA nephropathy.

AIMS: A subset of IgA nephropathy (IgAN) patients exhibiting minimal change disease (MCD) like features present with nephrotic-range proteinuria and warrants immunosuppressive therapy (IST). However, the diagnosis of MCD-like IgAN varied by reports. We aimed to identify the key pathological features of MCD-like IgAN. METHODS: In this cohort, 228 patients had biopsy-proven IgAN from 2009 to 2021, of which 44 without segmental sclerosis were enrolled. Patients were classified into segmental (< 50% glomerular capillary loop involvement) or global (> 50%) foot process effacement (FPE) groups. We further stratified them according to the usage of immunosuppressant therapy after biopsy. Clinical manifestations, treatment response, and renal outcome were compared. RESULTS: 26 cases (59.1%) were classified as segmental FPE group and 18 cases (40.9%) as global FPE group. The global FPE group had more severe proteinuria (11.48 [2.60, 15.29] vs. 0.97 [0.14, 1.67] g/g, p = 0.001) and had a higher proportion of complete remission (81.8% vs. 20%, p = 0.018). In the global FPE group, patients without IST experienced more rapid downward eGFR change than the IST-treated population (-0.38 [-1.24, 0.06] vs. 1.26 [-0.17, 3.20]mL/min/1.73 m2/month, p = 0.004). CONCLUSIONS: The absence of segmental sclerosis and the presence of global FPE are valuable pathological features that assist in identifying MCD-like IgAN.

Survival benefit of a third dose of the COVID-19 vaccine among hemodialysis patients: A prospective cohort study.

BACKGROUND: Hemodialysis (HD) patients are particularly vulnerable to severe coronavirus disease 2019 (COVID-19) due to their immunocompromised state and comorbid conditions. Timely vaccination could be the most effective strategy to reduce morbidity and mortality. However, data on the survival benefit of the COVID-19 vaccine against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and death among HD patients are limited, especially during the Omicron-dominant period. METHODS: In this prospective hospital-based cohort study, we identified HD patients from July 1, 2021, to April 29, 2022. The patients were divided into fully vaccinated and partially vaccinated groups. We compared the humoral response, risk of developing SARS-CoV-2 infection, and all-cause mortality between the two groups. RESULTS: Among the 440 HD patients included, 152 patients were fully vaccinated, and 288 patients were partially vaccinated. Patients in the fully vaccinated group exhibited higher anti-spike protein receptor-binding domain (S protein RBD) antibody levels and lower risks of all-cause mortality (adjusted hazard ratio, 0.35; 95% confidence interval, 0.17-0.73; p = 0.005) than the partially vaccinated group. However, the risk for SARS-CoV-2 infection did not significantly differ between the two groups. Irrespective of the number of vaccinations, the risk of all-cause mortality was lower in patients with anti-S protein RBD antibody levels in the higher tertile. CONCLUSION: A third dose of the COVID-19 vaccine was associated with a decreased risk of all-cause mortality among HD patients during the Omicron-dominant period. A higher post-vaccination anti-S protein RBD antibody level was also associated with a lower risk of mortality.

Peritoneal dialysis as compared with hemodialysis is associated with higher overhydration but non-inferior blood pressure control and heart function.

BACKGROUND/AIMS: Fluid overload is an important factor causing cardiovascular complications in dialysis patients. We compared fluid status, blood pressure (BP) and heart function between peritoneal dialysis (PD) patients and hemodialysis (HD) patients. METHODS: We recruited 94 PD and 75 HD patients in our hospital. Fluid status was assessed by bioimpedance spectroscopy. Home BP was recorded. Use of antihypertensives was retrieved by chart review. In each group, 39 patients received echocardiographic examinations. RESULTS: PD patients' fluid status was similar to that of predialysis HD patients. PD patients had lower systolic BP. E/E' and left ventricular mass index (LVMI) showed no significant intergroup difference. In multiple linear regression analyses, overhydration (OH)/extracellular water ratio >0.15 was associated with higher systolic BP, E/E' and LVMI. CONCLUSIONS: While PD was associated with higher OH but non-inferior BP control and heart function, OH was indeed related to poor BP control, diastolic dysfunction and left ventricular hypertrophy.

Ankle-brachial index is a powerful predictor of renal outcome and cardiovascular events in patients with chronic kidney disease.

Ankle-brachial index (ABI) is an accurate tool to diagnose peripheral arterial disease. The aim of this study was to evaluate whether ABI is also a good predictor of renal outcome and cardiovascular events in patients with chronic kidney disease (CKD). We enrolled 436 patients with stage 3-5 CKD who had not been undergoing dialysis. Patients were stratified into two groups according to the ABI value with a cut point of 0.9. The composite renal outcome, including doubling of serum creatinine level and commencement of dialysis, and the incidence of cardiovascular events were compared between the two groups. After a median follow-up period of 13 months, the lower ABI group had a poorer composite renal outcome (OR = 2.719, P = 0.015) and a higher incidence of cardiovascular events (OR = 3.260, P = 0.001). Our findings illustrated that ABI is a powerful predictor of cardiovascular events and renal outcome in patients with CKD.

Baseline Peritoneal Membrane Transport Characteristics Are Associated with Peritonitis Risk in Incident Peritoneal Dialysis Patients.

The peritoneal equilibration test (PET) is a semi-quantitative measurement that characterizes the rate of transfer of solutes and the water transfer rate across the peritoneum in patients treated with peritoneal dialysis (PD). The results of the PET are used to maximize daily peritoneal ultrafiltration and solute clearances. Previous studies have shown that high transport status is associated with ultrafiltration failure, malnutrition, and reduced survival; however, the way in which peritoneum transport characteristics affect peritonitis risk is unknown. In the current cohort study, we recruited 898 incident-PD patients and used intention-to-treat analysis to test if baseline PET affected the subsequent 3-year peritonitis rate. Among all recruited PD patients, 308 (34.2%) developed peritonitis within three years. Multivariate Cox regression analysis showed that the high-transport group has the greatest peritonitis risk (HR 1.98, 95% CI: 1.08-3.62) even after an adjustment for demographics, comorbid diseases, and biochemical measurements. We concluded that a baseline high peritoneal membrane transport rate is an independent risk factor for peritonitis in incident PD patients.

Far-Infrared Therapy Improves Arteriovenous Fistula Patency and Decreases Plasma Asymmetric Dimethylarginine in Patients with Advanced Diabetic Kidney Disease: A Prospective Randomized Controlled Trial.

Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of nitric oxide synthase and plays a significant role in the pathogenesis of arteriovenous fistula (AVF) dysfunction. The aim of this study is to evaluate the effect of far-infrared (FIR) therapy on the maturation and patency of newly-created AVFs in patients with advanced diabetic kidney disease (DKD) as well as the concurrent change in plasma ADMA. The study enrolled 144 participants with advanced DKD where 101 patients were randomly allocated to the FIR therapy group (N = 50) and control group (N = 51). Patients receiving FIR therapy had a decreased AVF failure rate within 12 months (16% versus 35.3%; p = 0.027); decreased incremental change of ADMA concentration at the 3rd and 12th month; increased AVF blood flow at the 1st, 3rd, and 12th month; increased 3-month physiologic maturation rate (88% versus 68.6%; p = 0.034); increased 1-year unassisted AVF patency rate (84% versus 64.7%; p = 0.017); and increased clinical AVF maturation rate within 12 months (84% versus 62.7%; p = 0.029) compared to the control group. The study demonstrates that FIR therapy can reduce the incremental changes in plasma ADMA concentration, which may be associated with the improvement of AVF prognosis in patients with advanced DKD.

Peritoneal-Membrane Characteristics and Hypervolemia Management in Peritoneal Dialysis: A Randomized Control Trial.

Excessive bodily-fluid retention is the major cause of hypertension and congestive heart failure in patients with end-stage renal disease. Compared to hemodialysis, peritoneal dialysis (PD) uses the abdominal peritoneum as a semipermeable dialysis membrane, providing continuous therapy as natural kidneys, and having fewer hemodynamic changes. One major challenge of PD treatment is to determine the dry weight, especially considering that the speed of small solutes and fluid across the peritoneal membrane varies among individuals; considerable between-patient variability is expected in both solute transportation and ultrafiltration capacity. This study explores the influence of peritoneal-membrane characteristics in the hydration status in patients on PD. A randomized control trial compares the bioimpedance-assessed dry weight with clinical judgment alone. A high peritoneal membrane D/P ratio was associated with the extracellular/total body water ratio, dialysate protein loss, and poor nutritional status in patients on PD. After a six-month intervention, patients with monthly bioimpedance analysis (BIA) assistance had better fluid (-1.2 ± 0.4 vs. 0.1 ± 0.4 kg, p = 0.014) and blood-pressure (124.7 ± 2.7 vs. 136.8 ± 2.8 mmHg, p < 0.001) control; however, hydration status and blood pressure returned to the baseline after we prolonged BIA assistance to a 3-month interval. The dry-weight reduction process had no negative effect on residual renal function or peritoneal-membrane function. We concluded that peritoneal-membrane characteristics affect fluid and nutritional status in patients on PD, and BIA is a helpful objective technique for fluid assessment for PD.

Diabetes Is the Most Critical Risk Factor of Adverse Complications After Peritoneal Dialysis Catheter Placement.

Introduction: Peritoneal dialysis (PD) is a kind of renal replacement therapy for end-stage renal disease (ESRD). While PD has many advantages, various complications may arise. Methods: This retrospective study analyzed the complications of ESRD patients who received PD catheter implantation in a single medical center within 15 years. Results: This study collected 707 patients. In the first 14 days after PD implantation, 54 patients experienced bleeding complications, while 47 patients experienced wound infection. Among all complications, catheter-related infections were the most common complication 14 days after PD implantation (incidence: 38.8%). A total of 323 patients experienced PD catheter removal, of which 162 patients were due to infection, while 96 were intentional due to kidney transplantation. Excluding those whose catheters were removed due to transplantation, the median survival of the PD catheter was 4.1 years; among them, patients without diabetes mellitus (DM) were 7.4 years and patients with DM were 2.5 years (p < 0.001). Further, 50% probability of surviving was beyond 3.5 years in DM patients with HbA1CC < 7 and 1.6 years in DM patients with HbA1C <7 (p ≥ 0.001). Conclusions: Catheter-related infections were the most common complications following PD catheter implantation. DM, especially with HbA1C ≥7, significantly impacted on the catheter-related infection and the survival probability of the PD catheter.

Comparison of peptic ulcer disease risk between peritoneal and hemodialysis patients.

BACKGROUND: Compared to the general population, patients with end-stage renal disease (ESRD) have increased peptic ulcer and upper GI bleeding complication rates. However, the risk factors for peptic ulcer among ESRD patients are unknown. METHODS: In this retrospective study, we enrolled 827 incident dialysis patients and diagnosed peptic ulcer on the basis of endoscopic findings; information on the morbidities and medical prescription were obtained directly from medical records. A Cox regression hazard model was used to identify risk factors for peptic ulcer. RESULTS: During the 10-year study period, 481 patients underwent an endoscopic exam. Peptic ulcers were detected in 153 patients. Age (p = 0.025), peritoneal dialysis (p = 0.022), diabetes mellitus (p = 0.020), congestive heart failure (p = 0.015), low serum albumin (p = 0.008) and high gamma-glutamyl transpeptidase (γ-GT) levels (p = 0.002) are risk factors for peptic ulcers among ESRD patients. Ulcer severity (p = 0.004) and aspirin prescription (p = 0.043), but not Helicobacter pylori infection, influenced the ulcer recurrence rate. CONCLUSION: The risk factors for peptic ulcer have some differences between ESRD patients and general population. In patients with high risk of upper GI bleeding, peritoneal dialysis and aspirin should be prescribed with caution.

Incidence of soft tissue sarcoma in Taiwan: A nationwide population-based study (2007-2013).

BACKGROUND: Asian studies on soft tissue sarcoma (STS) incidence, irrespective of the primary site, are scant. METHODS: STS data were acquired from the population-based 2007-2013 Taiwan Cancer Registry of the Health and Welfare Data Science Center, Taiwan. Histological subtype-, site-, sex-, and age-specific STS incidence rates were analyzed according to the 2013 classification of the World Health Organization. RESULTS: In total, 11,393 patients with an age-standardized incidence rate (ASIR) of 5.62 (95% confidence interval, 5.51-5.73) per 100,000 person-years were identified. Overall, a male predominance (sex-standardized incidence rate ratio, 1.2) was noted, and the rate increased with age, peaking at >75 years. Approximately 30% of STSs occurred in connective, subcutaneous, and other soft tissues and 70% in other sites. In addition to connective, subcutaneous, and other soft tissues, the three most common primary sites were the stomach (15.9%), skin (14.3%), and small intestines (10.5%). Gastrointestinal stromal tumor was the most common subtype (29.2%; ASIR, 1.55/100,000 person-years), followed by liposarcoma (11.5%; ASIR, 0.63/100,000 person-years) and leiomyosarcoma (9.7%; ASIR, 0.53/100,000 person-years). Compared with relevant data from Western countries, the incidence rate of angiosarcomas was higher than that in other regions, whereas the incidence rates of leiomyosarcoma and Kaposi sarcoma were lower than those in other regions. CONCLUSION: STS incidence varied by histological subtype, sex, age, and primary site in an Asian population. Our results suggested regional and racial discrepancies in the incidence rates of certain STS subtypes.

Seasonal variations in serum sodium levels and other biochemical parameters among peritoneal dialysis patients.

BACKGROUND: Although modest seasonal variations in blood biochemical composition have been reported in end-stage renal disease patients treated with haemodialysis, there have been no adequate explanations. The current study aimed to explore whether these phenomena are present in peritoneal dialysis patients and to discuss these variations. METHODS: This was a retrospective study with an enrollment of 44 anuric PD patients. Serum biochemical parameters, peritoneal function, dialysis adequacy, peritoneal ultrafiltration volume and body weight were analysed in relation to climate variables for a study period of 2 years. RESULTS: PD patients exhibited cyclic variations in blood biochemical concentrations. Monthly mean outdoor temperature was inversely correlated with serum concentrations of sodium (r = -0.712, P < 0.001), potassium (r = -0.697, P < 0.001), bicarbonate (r = -0.642, P < 0.001), BUN (r = -0.654, P < 0.001), albumin (r = -0.496, P = 0.012), peritoneal ultrafiltration volume (r = -0.723, P = 0.001) and body weight (r = -0.623, P < 0.001). Serum chloride and creatinine concentrations were not correlated with temperature or other climate variables. CONCLUSIONS: PD patients showed seasonal variations in serum electrolyte concentration and peritoneal ultrafiltration volume. Monthly outdoor mean temperature was inversely correlated with serum electrolytes and ultrafiltration volume. A likely explanation is loss of these electrolytes through perspiration. Neglect of this annual cycle in PD patients may lead to biases in interpretation of clinical study and individual laboratory data.

Training of peritoneal dialysis patients--Taiwan's experiences.

In Taiwan, peritoneal dialysis (PD) was launched in 1984. Since then, the Taiwan Society of Nephrology (TSN) has taken the responsibility for supervising PD programs. All PD programs are required to pass evaluations from the TSN before inception. Every new PD patient receives individual training from a qualified PD nurse. The training, accompanied by a review test, is usually provided in the hospital during the week right after catheter implantation. To evaluate the effect of the patient training program on PD outcomes, we designed a retrospective observation study and reviewed the post-training tests of 100 new PD patients. The post-training test has 10 parts: anatomy and physiology, overview of chronic kidney disease, overview of PD, complications of peritonitis and exit-site infection, diet control, cardiovascular complications, PD skills and procedures, aseptic techniques, management of peritonitis, and routine tasks. The relationship between the post-training test scores and peritonitis was analyzed. Results showed that risk of peritonitis is not related to the post-training test score. However, based on our experiences, we believe that PD patient training should be lengthened and repeated periodically as suggested by the International Survey of Peritoneal Dialysis Training Programs. Training on certain issues such as the signs and symptoms of peritonitis should be especially enhanced.

Determinants of catheter loss following continuous ambulatory peritoneal dialysis peritonitis.

BACKGROUND: Few patients are able to resume peritoneal dialysis (PD) therapy after an episode of peritonitis that requires catheter removal. PD catheter loss is therefore regarded as an important index of patient morbidity. The aim of the present study was to evaluate factors influencing catheter loss in patients suffering from continuous ambulatory PD (CAPD) peritonitis. PATIENTS AND METHODS: We retrospectively reviewed 579 episodes of CAPD peritonitis from 1999 to 2006 in a tertiary-care referral hospital. Demographic, biochemical, and microbiological characteristics were recorded. Episodes resulting in PD catheter removal (n = 68; 12%) were compared by both univariate and multivariate analyses with those in which PD catheters were preserved. RESULTS: The incidence of PD catheter loss increased as the number of organisms cultured increased (p = 0.001). Also, PD catheter removal was more likely to occur after peritonitis episodes with low serum albumin level (p = 0.004), those with long duration of PD effluent leukocyte count remaining above 100/microL (p < 0.001), those with concomitant tunnel infection (p < 0.001), those with concomitant exit-site infection (p = 0.005), and those with presence of catastrophic intra-abdominal visceral events (p < 0.001). Duration on PD preceding the peritonitis episode was of borderline significance (p = 0.080). On the contrary, initial PD effluent leukocyte count and serum level of C-reactive protein were not predictive of PD catheter loss. Micro-organisms of the Enterobacteriaceae family were the major pathogens responsible for PD catheter loss following polymicrobial peritonitis. Furthermore, we found that there was no association between polymicrobial peritonitis and the catastrophic intra-abdominal visceral event, although both resulted in a greater incidence of PD catheter loss. Among the single-organism group in our population, the microbiological determinants of PD catheter loss included fungi (p < 0.001), anaerobes (p = 0.018), and Pseudomonas sp (borderline significance: p = 0.095). CONCLUSION: PD catheter loss as a consequence of peritonitis is related primarily to hypoalbuminemia, longer duration of PD effluent leukocyte count remaining above 100/muL, the etiologic source of the infection, and the organism causing the infection. Peritonitis associated with concomitant tunnel or exit-site infections and abdominal catastrophes were more likely to proceed to PD catheter loss. The microbiological determinants of PD catheter loss in the present study included polymicrobial infections caused by Enterobacteriaceae as well as monomicrobial pseudomonal, anaerobic, and fungal infections.

Subfascial hematoma progressed to arm compartment syndrome due to a nontransposed brachiobasilic fistula.

Vascular access-associated compartment syndrome is reported rarely in hemodialysis patients. A 62-year-old female hemodialysis patient experienced left-arm compartment syndrome caused by a nontransposed brachiobasilic arteriovenous fistula. A subfascial hematoma that developed because of perforation of the posterior wall of the basilic vein was not detected by Doppler ultrasound initially, and subsequent heparinized hemodialysis caused progression of the hematoma. Neuromuscular sequelae were prevented by performing an emergent fasciotomy, and transposition of the arterialized basilic vein was performed later to prevent similar complications in the future. This case report shows the risk for the occurrence of such a devastating complication if the nontransposed brachiobasilic fistula is used for hemodialysis vascular access.

Adipocytes play an etiological role in the podocytopathy of high-fat diet-fed rats.

Obesity is a risk factor that promotes progressive kidney disease. Studies have shown that an adipocytokine imbalance contributes to impaired renal function in humans and animals, but the underlying interplay between adipocytokines and renal injury remains to be elucidated. We aimed to investigate the mechanisms linking obesity to chronic kidney disease. We assessed renal function in high-fat (HF) diet-fed and normal diet-fed rats, and the effects of preadipocyte- and adipocyte-conditioned medium on cultured podocytes. HF diet-fed and normal diet-fed Sprague Dawley rats were used to analyze the changes in plasma BUN, creatinine, urine protein and renal histology. Additionally, podocytes were incubated with preadipocyte- or adipocyte-conditioned medium to investigate the effects on podocyte morphology and protein expression. In the HF diet group, 24 h urinary protein excretion (357.5 ± 64.2 mg/day vs 115.9 ± 12.4 mg/day, P < 0.05) and the urine protein/creatinine ratio were significantly higher (1.76 ± 0.22 vs 1.09 ± 0.15, P < 0.05), increased kidney weight (3.54 ± 0.04 g vs 3.38 ± 0.04 g, P < 0.05) and the glomerular volume and podocyte effacement increased by electron microscopy. Increased renal expression of desmin and decreased renal expression of CD2AP and nephrin were also seen in the HF diet group (P < 0.05). Furthermore, we found that adipocyte-conditioned medium-treated podocytes showed increased desmin expression and decreased CD2AP and nephrin expression compared with that in preadipocyte-conditioned medium-treated controls (P < 0.05). These findings show that adipocyte-derived factor(s) can modulate renal function. Adipocyte-derived factors play an important role in obesity-related podocytopathy.

Lipoprotein glomerulopathy associated with psoriasis vulgaris: report of 2 cases with apolipoprotein E3/3.

Lipoprotein glomerulopathy (LPG) is a rare disease, characterized by a special histology, including dilated glomerular capillaries filled with pale-stained and meshlike lipoprotein thrombi. It always presents with proteinuria or nephrotic syndrome. Although hyperlipidemia is not always seen, most patients have type III hyperlipoproteinemia with apolipoprotein (apo) E2/3 phenotyping. Although the clinical feature of LPG is rarely described, LPG associated with other glomerulopathy, including IgA nephropathy, membranous nephropathy, and lupus nephritis, has been documented. Until now, there have been no reports of psoriasis vulgaris associated with LPG. The authors present 2 cases of LPG with apo E3/3 genotyping associated with psoriasis vulgaris. The first patient was a 65-year-old woman who presented with nephrotic syndrome with daily urinary protein loss of 9.05 g and itchy erythematous scaly plaques on her trunk and lower limbs for 1 year. The renal biopsy results showed LPG, and the skin biopsy results showed psoriasis. The second patient was a 50-year-old man with history of psoriasis over his trunk and 4 limbs for 30 years. He also presented with nephrotic syndrome with daily urinary protein loss of 7.55 g. The renal biopsy results also showed LPG. The genotype of apo E showed E3/3, and lipoprotein electrophoresis showed a type III hyperlipoproteinemia-like pattern in both cases. The authors suggest that presence of apo E3/3 genotype cannot rule out the diagnosis of type III hyperlipoproteinemia and LPG. Besides, LPG should be included in the differential diagnosis of psoriatic patients with nephrotic syndrome, especially in Asian patients who show poor response to traditional therapy. Renal biopsy should be performed to make the definitive diagnosis.

The dysregulated glomerular cell growth in Denys-Drash syndrome.

While diffuse mesangial sclerosis is traditionally described as being the glomerulopathy of Denys-Drash syndrome (DDS), the podocyte proliferative lesions may be overlooked in these DDS cases. In the present study, an evolving process is extrapolated from a selected case of DDS that demonstrated glomerulopathy with conspicuous podocyte proliferation. The observation that podocytes express proliferation markers (Ki67, proliferating-cell nuclear antigen and topoisomerase IIalpha) in non-proliferative, mature-looking glomeruli suggests an initial pathogenic act to activate or to keep podocytes from quiescence. The subsequent proliferation of podocytes is in keeping with downregulation of WT1 and cyclin kinase inhibitors of p16 and p21. The emergence of cytokeratin-positive cells in glomeruli that show typical mesangial sclerosis implies elimination of podocytes and replacement with tubular and/or parietal epithelial cells. The final scene of evolving glomerulopathy displays apoptosis and expression of Fas-L and Bax in sclerotic mesangial lesions, which eventually end up with global sclerosis. This novel concept of DDS glomerulopathy implies complex molecular mechanisms involved in glomerular injury.

The association of non-small-cell lung cancer, focal segmental glomerulosclerosis, and platelet dysfunction.

Neoplasm-related nephrotic syndrome exhibiting focal segmental glomerulosclerosis (FSGS) has been reported mainly in patients with hematologic malignancies. The association of FSGS with carcinoma is very rare and nephrotic syndrome caused by FSGS has not yet been reported in patients with lung cancer. We report a case of nephrotic syndrome caused by FSGS in a 61-year-old man with advanced non-small-cell lung cancer. In addition, platelet dysfunction evidenced by prolonged bleeding time was noted. The renal problem and prolonged bleeding time resolved dramatically during radiotherapy for lung cancer. We speculate that both FSGS and prolonged bleeding time are paraneoplastic syndromes associated with lung cancer, although the underlying mechanisms of both conditions remain to be elucidated.

A comorbidity index for mortality prediction in Chinese patients with ESRD receiving hemodialysis.

BACKGROUND AND OBJECTIVES: Chinese patients with ESRD have different comorbidity patterns than white patients with ESRD and require a validated comorbidity index. The objective of this study was to develop a new index for mortality prediction in 2006-2009 Taiwanese incident hemodialysis patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Data were retrieved from 2005 to 2010 Taiwan National Health Insurance claim records, and follow-up was available until December 31, 2010. The same comorbid conditions as the US Renal Data System (USRDS) index that occurred during a 12-month period from 9 months before to 3 months after dialysis initiation were used to construct the index. Integer weight of the comorbid conditions was derived from coefficient estimates of Cox regression for all-cause mortality, and the index was internally validated. The performance of the index was assessed by discrimination, calibration, and reclassification. RESULTS: A total of 30,303 hemodialysis patients were included in this study. The weight for individual comorbid conditions of this index differed from that of the USRDS index. The performance of this index was similar to that of USRDS and Charlson indices in terms of model fit statistics, overall predictive ability, discrimination, and calibration. Hosmer-Lemeshow test showed that all three indices demonstrated significant differences between predicted and observed mortality rates. When patients were categorized by the predicted 2.5-year survival probabilities, the index achieved a net reclassification improvement of 4.71% (P<0.001), referenced to USRDS index. CONCLUSIONS: Compared with USRDS index, this new index demonstrated better reclassification ability, but future studies should address the clinical significance.