Kidney function trajectories, associated factors, and outcomes in multiethnic Asian patients with type 2 diabetes.

BACKGROUND: We examined the trajectory of estimated glomerular filtrate rate (eGFR), associated risk factors, and its relationship with end-stage kidney disease (ESKD) among a multiethnic patient population with type 2 diabetes in Singapore. METHODS: A follow-up study included 62 080 individuals with type 2 diabetes aged ≥18 years in a multi-institutional SingHealth Diabetes Registry between 2013 and 2019. eGFR trajectories were analyzed using latent class linear mixed models. Factors associated with eGFR trajectories were evaluated using multinomial logistic regression. The association of eGFR trajectories with ESKD was assessed via competing risk models. RESULTS: Trajectory of kidney function, determined by eGFR, was nonlinear. The trajectory pattern was classified as stable initially then gradual decline (75%), progressive decline (21.9%), and rapid decline (3.1%). Younger age, female sex, Malay ethnicity, lower-income housing type, current smoking, higher glycated hemoglobin, lower low-density lipoprotein, higher triglyceride, uncontrolled blood pressure, albuminuria, cardiovascular disease, hypertension, and higher eGFR levels each were associated with progressive or rapid decline. Compared with the trajectory of stable initially then gradual eGFR decline, progressive decline increased the hazard of ESKD by 6.14-fold (95% confidence interval [CI]: 4.96-7.61)) and rapid decline by 82.55 folds (95% CI: 55.90-121.89). CONCLUSIONS: Three nonlinear trajectory classes of kidney function were identified among multiethnic individuals with type 2 diabetes in Singapore. About one in four individuals had a progressive or rapid decline in eGFR. Our results suggest that eGFR trajectories are correlated with multiple social and modifiable risk factors and inform the risk of ESKD.

Heterogeneity by age and gender in the association of kidney function with mortality among patients with diabetes - analysis of diabetes registry in Singapore.

BACKGROUND: We aimed to explore the three-way interaction among age, gender, and kidney function on the risk of all-cause mortality and cardiovascular mortality among patients with type 2 diabetes (T2D). METHODS: In a retrospective cohort study, patients aged > 40 years with T2D with serum creatinine and urine albumin measured from 2013 to 2019 were included from a multi-institutional diabetes registry. The exposure was estimated glomerular filtration rate (eGFR), outcomes were all-cause mortality (primary outcome) and cardiovascular disease (CVD) mortality (secondary outcome). We applied multivariable cox proportional hazards regression analysis to compute the association between eGFR and mortality. RESULTS: A total of 36,556 patients were followed for up to 6 years during which 2492 (6.82%) died from all causes, and 690 (1.9%) died from CVD. We observed a significant three-way interaction (p = 0.021) among age (younger, < 65; older, ≥65 years), gender and eGFR for the risk of all-cause mortality. Using age- and gender-specific eGFR of 90 ml/min/1.73m2 as the reference point, the adjusted hazard rate (HR) (95% CI) for all-cause mortality at eGFR of 40 ml/min/1.73m2 was 3.70 (2.29 to 5.99) in younger women and 1.86 (1.08 to 3.19) in younger men. The corresponding adjusted HRs in older women and older men were 2.38 (2.02 to 2.82) and 2.18 (1.85 to 2.57), respectively. Similar results were observed for CVD deaths, although the three-way interaction was not statistically significant. Sensitivity analysis yielded similar results. CONCLUSIONS: In this T2D population, younger women with reduced kidney function might be more susceptible to higher risks of all-cause mortality and CVD mortality than younger men.

Impact of focal segmental glomerulosclerosis over the past decade.

OBJECTIVE: This is a study on the demographics and clinical outcomes including the response to therapy of patients with focal segmental glomerulosclerosis (FSGS) over the past decade. MATERIALS AND METHODS: All histologically proven FSGS cases diagnosed between 2008 and 2018 were analyzed for their clinical, laboratory, and histological characteristics including treatment that could influence the disease progression and renal outcome of these patients. We used the Columbia Classification for FSGS for the renal biopsy. RESULTS: There were two subgroups of FSGS patients; those with nephrotic syndrome and those without nephrotic syndrome. Patients with FSGS with non-nephrotic syndrome had poorer survival rates compared to the nephrotic group. For those without nephrotic syndrome, the indices responsible for progression involved more tubular and blood vessel lesions in addition to glomerular pathology compared to those with nephrotic syndrome. Patients with FSGS with nephrotic syndrome responded to immunosuppressants more favorably compared to the non-nephrotic group, though both groups responded with decreasing proteinuria. The nephrotic group had a better 10-year long-term survival rate of 92 vs. 72% for the non-nephrotic group (log-rank 0.002). The 10-year survival for the whole group of FSGS patients was 64%. CONCLUSION: Our data suggest that in FSGS, one of the significant components of the disease is the vascular and tubular damage, apart from the underlying glomerular pathology, resulting in varying responses to therapy, and the difference is reflected in inherently poorer response to immunosuppressant therapy in those without nephrotic syndrome as opposed to those with nephrotic syndrome, who responded to immunosuppressant therapy (IST) with stabilization of renal function and had less blood vessel and tubular lesions.

Development and validation of a novel nomogram to predict diabetic kidney disease in patients with type 2 diabetic mellitus and proteinuric kidney disease.

PURPOSE: Differentiating between diabetic kidney disease (DKD) and non-diabetic kidney disease (NDKD) in patients with Type 2 diabetes mellitus (T2DM) is important due to implications on treatment and prognosis. Clinical methods to accurately distinguish DKD from NDKD are lacking. We aimed to develop and validate a novel nomogram to predict DKD in patients with T2DM and proteinuric kidney disease to guide decision for kidney biopsy. METHODS: A hundred and two patients with Type 2 Diabetes Mellitus (T2DM) who underwent kidney biopsy from 1st January 2007 to 31st December 2016 were analysed. Univariate and multivariate analyses were performed to identify predictive variables and construct a nomogram. The discriminative ability of the nomogram was assessed by calculating the area under the receiver operating characteristic curve (AUROC), while calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test and calibration plot. Internal validation of the nomogram was assessed using bootstrap resampling. RESULTS: Duration of T2DM, HbA1c, absence of hematuria, presence of diabetic retinopathy and absence of positive systemic biomarkers were found to be independent predictors of DKD in multivariate analysis and were represented as a nomogram. The nomogram showed excellent discrimination, with a bootstrap-corrected C statistic of 0.886 (95% CI 0.815-0.956). Both the calibration curve and the Hosmer-Lemeshow goodness-of-fit test (p = 0.242) showed high degree of agreement between the prediction and actual outcome, with the bootstrap bias-corrected curve similarly indicating excellent calibration. CONCLUSIONS: A novel nomogram incorporating 5 clinical parameters is useful in predicting DKD in type 2 diabetes mellitus patients with proteinuric kidney disease.

Validation of the kidney failure risk equation in predicting the risk of progression to kidney failure in a multi-ethnic Singapore chronic kidney disease cohort.

INTRODUCTION: The Kidney Failure Risk Equation (KFRE) was developed to predict the risk of progression to end-stage kidney disease (ESKD). Although the KFRE has been validated in multinational cohorts, the Southeast Asian population was under-represented. This study aimed to validate the KFRE in a multi-ethnic Singapore chronic kidney disease (CKD) cohort. METHODS: Stage 3-5 CKD patients referred to the renal medicine department at Singapore General Hospital in 2009 were included. The primary outcome (time to ESKD) was traced until 30 June 2017. The eight- and four-variable KFRE (non-North America) models using age, gender, estimated glomerular filtration rate, urine albumin-creatinine ratio, serum albumin, phosphate, bicarbonate and calcium were validated in our cohort. Cox regression, likelihood ratio (Χ2), adequacy index, Harrell's C-index and calibration curves were calculated to assess the predictive performance, discrimination and calibration of these models on the cohort. RESULTS: A total of 1,128 patients were included. During the study period, 252 (22.3%) patients reached ESKD at a median time to ESKD of 84.8 (range 0.1-104.7) months. Both the eight- and four-variable KFRE models showed excellent predictive performance and discrimination (eight-variable: C-index 0.872, 95% confidence interval [CI] 0.850-0.894, adequacy index 97.3%; four-variable: C-index 0.874, 95% CI 0.852-0.896, adequacy index 97.9%). There was no incremental improvement in the prediction ability of the eight-variable model over the four-variable model in this cohort. CONCLUSION: The KFRE was validated in a multi-ethnic Singapore CKD cohort. This risk score may help to identify patients requiring early renal care.

Native kidney biopsies in older adults: disease spectrum, long-term kidney and patient survival and safety.

PURPOSE: Patients undergoing kidney biopsy are increasingly older. We aimed to evaluate the clinical utility of kidney biopsy, long-term clinical outcomes, and safety of high-risk biopsies in older adults undergoing kidney biopsy in a multi-ethnic Southeast Asian cohort. METHODS: We performed a single-center retrospective study of older patients (age ≥ 60 years) who underwent native kidney biopsies between June 2011 and March 2015. The primary long-term outcome of interest was a composite of ESKD or death. The safety outcome of interest was post-biopsy bleeding in the high-risk subgroup, defined by serum creatinine > 150 µmol/l. RESULTS: Older adults accounted for 153 of 545 (28.1%) native renal biopsies performed. The median age of these older adults was 66.6 (IQR 63.0, 70.6) years. Kidney dysfunction was frequent and severe in this cohort, with 41.2% having eGFR < 30 ml/min/m2 and 71.2% having nephrotic-range proteinuria at presentation. A significant proportion (124 patients; 81.0%) had treatable diagnoses. Of these, 90 (72.6%) received immunosuppressive therapy. On Kaplan-Meier analysis, patients with pauci-immune glomerulonephritis (p = 0.004) and diabetic nephropathy (p = 0.005) were at a significantly increased risk of the composite outcome of ESKD or death. On multivariate analysis, older age and lower eGFR were independently associated with ESKD or death and ESKD alone. Lupus nephritis and diabetic nephropathy were independently associated with ESKD or death, while immunosuppressant therapy was associated with reduced ESKD alone. In the high-risk subgroup, post-biopsy bleeding occurred in 19 (22.8%) patients. Desmopressin use was not associated with reduced bleeding complications. CONCLUSION: Our study confirmed the utility of kidney biopsy in older adult patients for diagnosis and management, although risk counselling and close monitoring for bleeding complications is necessary.

Preliminary safety study of the Automated Wearable Artificial Kidney (AWAK) in Peritoneal Dialysis patients.

BACKGROUND: Regeneration of peritoneal dialysis (PD) fluid using sorbent technology can provide flexibility and improve quality of life. This study examined the safety and efficacy of the automated wearable artificial kidney (AWAK) device in PD patients. METHODS: This pilot study included prevalent PD patients from a single center in Singapore between 2016 and 2018. Participants underwent up to nine AWAK therapies over 72 h and were followed up for 1 month. Primary outcomes were serious adverse events (SAEs) and completion of nine therapies without device deficiency. Secondary outcomes were weekly peritoneal Kt/Vurea, solutes clearance and adverse events (AEs). RESULTS: Twenty-one patients were screened and 15 were included in the study. Device alterations were required to overcome issues including flow occlusions initially, which resulted in three cohorts (n = 2, 2 and 11 respectively). No SAEs were observed during the study and at the follow-ups. Common AEs were abdominal pain/discomfort (60%) and bloatedness (47%). The median estimated peritoneal weekly Kt/Vurea was 3.0 (interquartile range: 2.2-4.8). There were significant reductions in pre- and post-study median serum urea (20.8 vs. 14.9 mmol/L; p = 0.001), creatinine (976.0 vs. 667.5 µmol/L; p = 0.001), phosphate (1.7 vs. 1.5 mmol/L; p = 0.03), and ß2-microglobulin (29114.0 vs. 26339.0 µg/L; p = 0.048). Fluid reabsorption occurred among patients with residual kidney function. However, median body weights were not significantly different pre- and post-study (66.4 vs. 65.7 kg; p = 0.83). CONCLUSIONS: This preliminary study demonstrated that no SAEs were observed with the AWAK-PD device; however, 60% of participants developed abdominal pain/discomfort. Further device enhancements are needed to improve ultrafiltration and reduce AEs.

Changes in metabolic parameters and adverse kidney and cardiovascular events during glomerulonephritis and renal vasculitis treatment in patients with and without diabetes mellitus.

BACKGROUND: Cardiovascular disease causes significant morbidity and mortality in patients with glomerulonephritis, which is increasingly diagnosed in older individuals who may have diabetes mellitus (DM). We evaluated the impact of DM on metabolic profile, renal and cardiovascular outcomes during treatment and follow-up of individuals with glomerulonephritis. METHODS: We performed a retrospective cohort study of 601 consecutive adults with biopsy-proven glomerulonephritis for factors associated with kidney failure, hospitalization for cardiovascular events, and death. Biopsies with isolated diabetic nephropathy were excluded. RESULTS: The median patient age was 49.8 years (36.7-60.9 years) with estimated glomerular filtration rate of 56.7 mL/min/1.73 m2 (27.7-93.2 mL/min/1.73 m2). DM was present in 25.4%. The most frequent diagnoses were minimal change disease (MCD) or focal segmental glomerulosclerosis (FSGS) (29.5%), lupus nephritis (21.3%), immunoglobulin A (IgA) nephropathy (19.1%), and membranous nephropathy (12.1%). The median follow-up was 38.8 months (interquartile range [IQR], 26.8-55.8 months). Among 511 individuals with lupus nephritis, anti-neutrophil cytoplasmic antibody-associated vasculitis, MCD/FSGS, membranous nephropathy, and IgA nephropathy, 52 (10.2%) developed kidney failure at a median 16.4 months (IQR, 2.3-32.2 months), while 29 (5.7%) had cardiovascular-related hospitalizations at 12.9 months (IQR, 4.8-31.8 months) and 31 (6.1%) died at 13.5 months (IQR, 2.5-42.9 months) after diagnosis. Cox regression analysis found that baseline DM was independently associated with kidney failure (adjusted hazard ratio [HR], 2.07; 95% confidence interval [CI], 1.06-4.05, p = 0.03) and cardiovascular-related hospitalization (adjusted HR, 2.69; 95% CI, 1.21-5.98, p = 0.02) but not with mortality. CONCLUSION: DM was strongly associated with kidney failure and hospitalization for cardiovascular events in patients with biopsy-proven glomerulonephritis.

Evolution of IgA nephropathy in Singapore over four decades and a comparison of two cohorts from the first and fourth decade.

OBJECTIVE: In this study, we trace the changes in the clinical and histological pattern of IgA nephritis (IgAN) in Singapore as it has evolved over 4 decades and compare the clinical, demographic, histological, and renal outcome of patients with IgAN from the 1st decade and the 4th decade. MATERIALS AND METHODS: This is a retrospective study of all histologically proven IgAN diagnosed between 1976 and 2018. Clinical, laboratory, and histological characteristics between the 1st and the 4th decade, including treatment which could influence the disease progression and renal outcome of these two groups, were compared. We used the Oxford classification to compare the renal biopsy changes for these 2 decades as we were able to retrieve 125 renal biopsy tissues for the 1st cohort of IgAN studied in the 1970s for the comparative study. RESULTS: The commonest clinical presentation throughout the first 3 decades was asymptomatic hematuria and proteinuria (63, 52, and 49%, respectively). In the 4th decade, nephrotic syndrome (31%) was the commonest followed by asymptomatic hematuria and proteinuria (30%), hypertension (21%), and chronic renal failure (11%). The data showed that treatment can modify the Oxford MEST - Crescent scores. Renin-angiotensin system (RAS) blockers modified the S scores, immunosuppressants modified the T and C scores, and combination therapy with RAS blockers and immunosuppressants modified the E, S, and T scores. CONCLUSION: The Oxford MEST classification offers a robust and expressive classification for early and late disease progression with respect to the development of end-stage renal disease (ESRD). E and S seem to be indices of continuing disease activity with progressive glomerulosclerosis, probably still amenable to therapy, but T was a predictive indicator for those destined for ESRD and no longer amenable to therapy.

Comparison of outcomes of urgent-start and conventional-start peritoneal dialysis: a single-centre experience.

BACKGROUND: There has been a growing interest in urgent-start peritoneal dialysis (PD) in patients with end-stage kidney disease to avoid central venous catheter use and its complications. This study aimed to compare clinical outcomes between urgent-start PD (defined as PD commencement within 2 weeks of PD catheter insertion) and conventional-start PD. METHODS: This was a single-centre retrospective cohort study of all incident PD patients at Singapore General Hospital between January 2017 and February 2018. The primary outcome was dialysate leak. Secondary outcomes included catheter malfunction, catheter readjustment, exit-site infection, peritonitis, technique and patient survival. RESULTS: A total of 187 incident PD patients were included. Of these, 66 (35%) initiated urgent-start PD. Dialysate leak was significantly higher in urgent-start PD compared with conventional-start PD groups (7.6% versus 0.8%; p = 0.02) whilst catheter malfunction (4.5% vs. 3.3%; p = 0.70) and catheter readjustment (1.5% vs. 2.5%; p = 1.00) were comparable between the two groups. Exit-site infection was comparable (IRR: 0.66 95% CI 0.25-1.74) whilst peritonitis was significantly higher in urgent-start PD compared with conventional-start PD (incidence risk ratio (IRR) 3.10, 95% confidence interval (CI) 1.29-7.44). Time to first episode of peritonitis, particularly Gram-positive peritonitis was significantly shorter with urgent-start PD. Technique survival (hazards ratio (HR) 1.95, 95% CI 0.89-4.31) and patient survival (HR 1.46, 95% CI 0.44-4.87) were comparable between the two groups. CONCLUSION: Urgent-start PD was associated with higher risks of dialysate leak and peritonitis but comparable technique and patient survival compared to conventional-start PD.

The Value of Renal Biopsy in Non-Insulin-Dependent Diabetes Mellitus in Singapore over the Past Two Decades.

OBJECTIVE: This study on the prevalence of diabetic nephropathy (DN) and coexistence of non-diabetic renal disease (NDRD) in a cohort of 255 non-insulin-dependent diabetes mellitus (NIDDM) patients aims to determine the value of performing renal biopsies in these patients and elucidate the factors which could affect their progression to end-stage renal disease (ESRD). METHODS: Among 255 NIDDM patients, 93 had DN alone, 69 had NDRD alone, and the remaining 93 had DN plus NDRD (mixed group). The indications for renal biopsy were based on clinical suspicion of superimposed NDRD, including heavy or rapidly increasing proteinuria, renal impairment even though diabetes is of relatively short duration, rapidly declining renal function, and presence of hematuria with dysmorphic red blood cells suggesting presence of glomerulonephritis. RESULTS: The following were predictors of ESRD: high systolic BP at biopsy, longer duration of diabetes, heavy proteinuria, and presence of diabetic retinopathy. Comparing patients in the NDRD group with the DN group and the mixed group, the NDRD group had lower serum creatinine and higher eGFR with lower urinary proteinuria and higher serum albumin at presentation and on follow-up. Kimmelstiel-Wilson nodules were associated with a poorer prognosis leading to a higher occurrence of ESRD among patients with DN. CONCLUSION: Renal biopsy is of value in indicating the prognosis of NIDDM patients with DN based on the diabetic lesions. For NIDDM patients with atypical course and suspicion of associated NDRD, a renal biopsy would enable us to diagnose the underlying NDRD and offer appropriate therapy. Most nephrologists would consider renal biopsy for an NIDDM patient based on clinical indications like atypical clinical course and suspicion of an associated NDRD, but they would not perform a routine renal biopsy like for a CKD patient, unless it is for a research indication.

A Global Evolutionary Trend of the Frequency of Primary Glomerulonephritis over the Past Four Decades.

OBJECTIVE: The pattern of glomerulonephritis (GN) in Singapore is compared with that of 19 other countries to review changing trends in the evolution of GN in Asian, Eastern, and Western countries. METHOD: Three thousand two hundred and eighty-nine renal biopsies in Singapore were reviewed and compared with that of 19 other countries. RESULTS: IgA nephritis is on the decline in many countries, including Singapore, though it still remains the commonest GN in Singapore. Membranous GN that if used to be more frequently present in Western countries has also declined though it continues a rising trend in countries such as Singapore and China. Worldwide, the frequency of focal sclerosing glomerulosclerosis (FSGS) continues to increase in many countries, but in some countries, the frequency is still low with mesangiocapillary GN remaining indigenous. CONCLUSION: Urbanization and socioeconomic changes and less exposure to parasitic and other infestations have transformed Singapore's pattern, which is tending toward that of more developed countries. Antigenic exposure due to lifestyle changes, environmental, and industrial pollution are significant contributory factors that affect the evolutionary trend of GN in many countries. The rising trend in the frequency of FSGS may reflect aging and obesity.

Evaluating Burden and Quality of Life among Caregivers of Patients Receiving Peritoneal Dialysis.

Peritoneal dialysis (PD) is advocated as treatment of choice for most end-stage renal disease (ESRD) patients, including elderly and frail patients. It typically requires caregiver involvement to support care at home. The purpose of this study was to examine changes in burden and quality of life (QOL) in caregivers of prevalent PD patients over 12 months. Data were collected in 44 caregivers of PD patients (mean age 38.4 ± 6.3 years; 60% female) in Singapore at baseline and 12 months. Measures included demographics, the Lay Care-Giving for Adults Receiving Dialysis (LC-GAD), Zarit Burden Interview (ZBI), and the World Health Organization Quality of Life instrument (WHOQOL-BREF). Paired t-tests indicate a significant decrease in task-related aspects of caregiving (p = 0.04), particularly in relation to personal hygiene (p < 0.01), over time. Cognitive aspects of caregiving remained unchanged. Perceived burden, however, significantly increased (p < 0.01), with significantly more caregivers reporting moderate to severe caregiver burden at follow-up (28%) relative to baseline (13%; p < 0.01). There was a significant reduction in psychological health (under WHOQOL) (p = 0.01). Study findings indicate an increase in caregiver burden and a reduction in psychological health despite a reduction in task-related aspects of caregiving, supporting a further exploration of the "wear-and-tear" hypothesis among this population. Intervention strategies are needed.

Changes in primary glomerulonephritis in Singapore over four decades
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This review of 3,289 native kidney biopsies over the past four decades in Singapore documents the changing pattern of biopsy-proven glomerulonephritis (GN)from that of a third world country to that of a developed nation. In the 1st decade, mesangial proliferative GN was the most common form of primary GN, similar to the Asian region. In the 2nd decade, the percentage of mesangial proliferative GN decreased, but membranous GN became more common, as was seen in China and Thailand. In the 3rd decade, focal segmental glomerulosclerosis (FSGS) and membranous nephropathy continued to rise, but it was only recently, in the 4th decade, that FSGS prevalence increased dramatically, although membranous nephropathy continues to increase in some Asian countries. In the last decade in Singapore, Malaysia, and Japan, prevalence of IgA nephritis has decreased but remains the most common GN. The percentage of FSGS continues to increase in many countries like in Italy, United States of America, United Kingdom, China, and Malaysia. We surmise that socioeconomic factors play significant roles in the evolution of the renal biopsy pattern.
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Comparison of Clinical Presentation and Outcomes of Peritonitis in the Elderly and Younger Peritoneal Dialysis Patients.

BACKGROUND: The incidence of elderly patients receiving peritoneal dialysis (PD) has increased. This study aimed to examine the clinical presentation and outcomes of peritonitis in elderly PD patients compared with younger PD patients. METHODS: This single-center, retrospective, observational cohort study included all adult PD patients who developed peritonitis between January 2011 and December 2014. Elderly was defined as ≥ 65 years old at PD initiation. The primary outcome was medical cure, defined as a peritonitis episode cured by antibiotics without being complicated by catheter removal, transfer to hemodialysis (HD), relapsing peritonitis,or death. The secondary outcomes were clinical manifestations (fever, cloudy dialysate) and complications (catheter removal, transfer to HD, relapse, hospitalization, and mortality). Peritonitis outcomes were compared using multivariable logistic regression. RESULTS: Overall, 377 peritonitis episodes occurred in 247 patients. Of these, 126 episodes occurred in 79 elderly patients and 251 episodes occurred in 168 younger patients. Baseline demographic data were comparable between the 2 groups, except that elderly patients were significantly more likely to have diabetes mellitus (66% vs 46%), diabetic nephropathy (55% vs 39%), and a lower serum albumin than younger patients. Medical cure was comparable between the 2 groups (71% vs 72%, respectively, p = 0.67, adjusted odds ratio [AOR] 0.89, 95% confidence interval [CI]: 0.52 - 1.53). Compared with younger patients, elderly patients experiencing peritonitis had lower odds of fever (OR 0.53, 95% CI: 0.30 - 0.94), cloudy dialysate (OR 0.45, 95% CI: 0.23 - 0.88), and catheter removal (AOR 0.50, 95% CI: 0.26 - 0.98), but similar odds of transfer to HD (AOR 0.70, 95% CI: 0.32 - 1.51), relapse (AOR 1.57, 95% CI: 0.46 - 5.40), hospitalization (AOR 1.55, 95% CI: 0.52 - 4.56), and all-cause mortality (AOR 1.88, 95% CI: 0.83 - 4.26). CONCLUSIONS: Compared with younger patients, elderly PD patients with peritonitis achieved similar medical cure rates, a lower catheter removal rate, and comparable rates of HD transfer, relapse, hospitalization, and death. Elderly PD patients experiencing peritonitis were less likely to present with fever or cloudy dialysate.

Severe infections in patients with lupus nephritis treated with immunosuppressants: A retrospective cohort study.

AIM: Lupus nephritis (LN) is associated with significant morbidity and mortality and hence usually treated aggressively with immunosuppressants. This predisposes LN patients to increased infections, yet few studies have evaluated LN patients for infective complications. We aimed to describe the epidemiology and identify risk factors for infections requiring hospitalization among patients with biopsy-proven LN. METHODS: This was a single-centre retrospective cohort study of patients with biopsy-proven LN between 1 January 2000 and 31 May 2009. Patients were excluded if they were <16 years old at time of biopsy, had previous kidney transplant or if pharmacotherapy data were incomplete. Hospitalizations for infections, bacteraemia and polymicrobial infections were recorded until patients' last visit or when they received immunosuppression for non-glomerulonephritis indications, such as solid organ transplant or chemotherapy. RESULTS: We studied 189 patients who had biopsy-proven lupus nephritis. Median age at diagnosis was 36.9 (IQR: 27.4, 47.5) years and 82% were female. Most patients received at least one immunosuppressant after LN diagnosis, including glucocorticosteroids in 94.2%. One hundred and four patients (60.3%) had at least one hospitalization for infection at 11 (1, 53) months from diagnosis. Bacteraemia occurred in 26 patients (13.8%) and 32 patients (16.9%) had polymicrobial infections. On multivariate analysis, LN relapse was associated with hospitalization for infection (OR 2.33 (1.18, 4.60), P = 0.01) and bacteraemia (OR 3.47 (1.05, 11.45), P = 0.04). Infection-related mortality occurred in 10 patients (5.3%). CONCLUSION: Serious infections are common among patients with LN and are associated with mortality.

30-year follow-up study of IgA nephritis in a Southeast Asian population: an evaluation of the Oxford histological classification
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BACKGROUND: In 1985 we reported that 11% of a cohort of 151 patients with IgA nephritis (IgAN) had developed end-stage renal disease (ESRD) after a follow-up period of 5 years. 15 years later, 35% had developed ESRD. METHODS: We retrieved 125 stored renal biopsy paraffin blocks of the original cohort. From these, 102 patients were included in the present study and scored according to the Oxford classification as 21 specimens with less than 8 glomeruli were excluded and in 2 others, tissue samples were too tiny for a re-block. ESRD was ascertained by linking the study cohort to the Singapore Renal Registry at the National Registry of Diseases Office. RESULTS: Renal survival curves for each of the Oxford MEST lesions: endocapillary proliferation (E) (p < 0.04), segmental glomerulosclerosis (S) (p < 0.05), tubular atrophy/interstitial fibrosis (p < 0.0001) were significantly associated with ESRD. Mesangial hypercellularity, less commonly associated with progressive chronic kidney disease (CKD) in the study, was independently associated with ESRD at 30 years (p < 0.03). In this cohort, E and S were associated with lower eGFR at presentation and doubling of serum creatinine in the first 5 years. This study's initial 5 years was representative of the "natural history" of IgAN since no renin-angiotensin system (RAS) blockers or immunosuppression were administered. This represents the early phase of disease progression. E and S may be considered "early disease activity predictors". CONCLUSION: Mesangial hypercellularity and tubular atrophy/interstitial fibrosis (M1 and T1/T2 lesion) of the Oxford classification independently predicted long term ESRD.
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A cluster of Epoetin-associated pure red cell aplasia: clinical features and the possible association of HLA-DRB1*12:02.

Antibody-mediated pure red cell aplasia is a rare but serious complication in chronic kidney disease patients receiving recombinant human erythropoietin (r-HuEpo). Between April 2012 and May 2013, eight such cases were reported in our institution. Their clinical features were reviewed and their HLA alleles were compared with those of healthy controls. All patients were exposed to epoetin alfa (Eprex®) with polysorbate-80 as stabilizer via subcutaneous route with a mean age of 61.9 years and mean exposure of 11.2 months of r-HuEpo before loss of efficacy. 87.5% of the cases were male and Chinese and received immunosuppression as treatment for pure red cell aplasia. All three of the successfully treated patients are alive compared with only 40% of the transfusion-dependent patients. DRB1*12:02 was more frequently expressed among the cases than healthy controls suggesting a plausible molecular link.