Reducing Waiting Times and Admission Periods through Pre-Admission Testing: A Quality Improvement Study on In-Hospital Renal Biopsy.

Background: Admission for renal biopsy is considered the gold standard for diagnosing kidney disease. However, prolonged waiting times for admission can lead to delayed diagnosis. Despite this issue, there are currently no studies demonstrating how to improve the efficiency of renal biopsy procedures. Methods: We initiated a quality improvement project to implement pre-admission testing (PAT) for renal biopsy from 2016 to 2024 (until 15 April). Our evaluation focused on waiting times for admission, length of admission periods, hospitalization expenses, percentage of cases with no renal biopsy performed, incidence of severe bleeding due to renal biopsy, and percentage of cases with adequate tissue samples obtained. Additionally, we highlighted the time periods during the outbreak of SARS-CoV-2. Results: The highest annual case number was observed in time period 1 (168.3/year). Following the outbreak of SARS-CoV-2, there was a notable decrease in case numbers during time period 2 (119.8), which then increased to 143.0 in time period 3 (post-SARS-CoV-2 era). The mean waiting time was 13.72 ± 40.30 days for time period 1 and 10.00 ± 47.80 days for time period 2, without statistical significance. Following the implementation of PAT, patients now only need to wait approximately 0.76 days for admission, representing a significant reduction in waiting time. Subsequently, following the implementation of PAT, the waiting time decreased significantly to 2.09 ± 2.65 days. Additionally, hospitalization expenses per patient significantly decreased from approximately USD 69.62 ± 97.09 to USD 41.66 ± 52.82. The percentage of missed biopsy is significantly low (p < 0.001). Severe bleeding events (indicated as embolization and blood transfusion) were consistent across the three time periods (p = 0.617). Conclusions: The implementation of PAT can improve the pre-admission process for renal biopsy, resulting in decreased waiting times, fewer missed appointments, shorter admission durations, and reduced hospitalization expenses. We propose implementing PAT for outpatient individuals awaiting in-hospital renal biopsy procedures to mitigate delayed diagnosis, reduce pre-admission waiting periods, and streamline admission processes, thereby enhancing overall patient care efficiency.

Pseudohyperkalemia in pediatric patients with newly diagnosed hematological malignancies.

Patients with newly diagnosed hematological malignancies often present with a considerable cellular burden, leading to complications including hyperkalemia. However, pseudohyperkalemia, arising from in vitro cell lysis, can pose challenges in clinical practice. Although pseudohyperkalemia is frequently reported in adult hematological malignancies, its occurrence in pediatric patients is underreported, and its incidence in this demographic remains unclear. We retrospectively reviewed the medical records of pediatric patients who received a new diagnosis of hematological malignancies from 2011 to 2022 at Taichung Veterans General Hospital. Hyperkalemia was defined by a serum or plasma potassium level exceeding 5.5 mEq/L. Pseudohyperkalemia was defined by 1) a potassium decrease of over 1 mEq/L in within 4 h without intervention or 2) the absence of electrocardiography changes indicative of hyperkalemia. Cases with apparent red blood cell hemolysis were excluded. A total of 157 pediatric patients with a new diagnosis of hematological malignancies were included, 14 of whom exhibited hyperkalemia. Among these 14 cases, 7 cases (4.5%) were of pseudohyperkalemia. This rate increased to 21.2% in patients with initial hyperleukocytosis. Pseudohyperkalemia was associated with a higher initial white blood cell count and lower serum sodium level. All episodes of pseudohyperkalemia occurred in the pediatric emergency department, where samples were obtained as plasma, whereas all true hyperkalemia cases were observed in the ordinary ward or intensive care unit, where samples were obtained as serum. Timely recognition of pseudohyperkalemia is crucial to avoiding unnecessary potassium-lowering interventions in pediatric patients with newly diagnosed hematological malignancies.

Dialysate cyclophilin A as a predictive marker for historical peritonitis in patients undergoing peritoneal dialysis.

Introduction: No markers have been used to diagnose historical peritoneal dialysis (PD)-related peritonitis. Cyclophilin A (CypA) is associated with glucose toxicity and inflammation. We hypothesize that dialysate CypA can be a marker for historical peritonitis (at least 3 months free from peritonitis). Method: An enzyme-linked immunosorbent assay kit was used to measure the concentration of dialysate CypA. Clinical and laboratory data were collected to correlate with historical peritonitis. Mann-Whitney U test and Chi-square test were used for analysis. Receiver operating characteristic (ROC) analysis was used to evaluate predictive power. Results: Out of a total of 31 patients who had undergone PD for at least 2 years, 18 had no history of PD-related peritonitis, while 13 had experienced PD-related peritonitis at least once. Overall, the patients in this population were in good health (normal white blood cell count, no anemia, normal electrolyte and serum albumin levels). There were no significant differences between patients with and without a history of peritonitis, except for blood white blood cell count (5650.6 ± 1848.4 vs. 7154.6 ± 2056.8, p = 0.032) and dialysate CypA value (24.27 ± 22.715 vs. 54.41 ± 45.63, p = 0.020). In the univariate analysis, only the dialysate CypA level showed a statistically significant association with historical peritonitis (HR = 1.030, 95 % CI = 1.010-1.062, p = 0.046). The AUC for dialysate CypA (>34.83 ng/mL) was 0.748, with a sensitivity of 0.615 and specificity of 0.833. Conclusion: PD peritonitis poses a significant threat to the long-term use of peritoneal dialysis. Based on our study, even in the absence of concurrent infection, dialysate CypA can serve as a predictive marker for historical peritonitis, demonstrating high predictive power along with fair sensitivity and good specificity.

Effects of down-regulated carbonic anhydrase 8 on cell survival and glucose metabolism in human colorectal cancer cell lines.

Carbonic anhydrase 8 (CA8) is a member of the α-carbonic anhydrase family but does not catalyze the reversible hydration of carbon dioxide. In the present study, we examined the effects of CA8 on two human colon cancer cell lines, SW480 and SW620, by suppressing CA8 expression through shRNA knockdown. Our results showed that knockdown of CA8 decreased cell growth and cell mobility in SW620 cells, but not in SW480 cells. In addition, downregulated CA8 resulted in a significant decrease of glucose uptake in both SW480 and SW620 cells. Interestingly, stable downregulation of CA8 decreased phosphofructokinase-1 expression but increased glucose transporter 3 (GLUT3) levels in SW620 cells. However, transient downregulation of CA8 fails to up-regulate GLUT3 expression, indicating that the increased GLUT3 observed in SW620-shCA8 cells is a compensatory effect. In addition, the interaction between CA8 and GLUT3 was evidenced by pull-down and IP assays. On the other hand, we showed that metformin, a first-line drug for type II diabetes patients, significantly inhibited cell migration of SW620 cells, depending on the expressions of CA8 and focal adhesion kinase. Taken together, our data demonstrate that when compared to primary colon cancer SW480 cells, metastatic colon cancer SW620 cells respond differently to downregulated CA8, indicating that CA8 in more aggressive cancer cells may play a more important role in controlling cell survival and metformin response. CA8 may affect glucose metabolism- and cell invasion-related molecules in colon cancer, suggesting that CA8 may be a potential target in future cancer therapy.

Safety of midodrine in patients with heart failure with reduced ejection fraction: a retrospective cohort study.

Background: Heart failure with reduced ejection fraction (HFrEF) poses significant health risks. Midodrine for maintaining blood pressure in HFrEF, requires further safety investigation. This study explores midodrine's safety in HFrEF through extensive matched analysis. Methods: Patients with HFrEF (LVEF <50%) without malignancy, non-dialysis dependence, or non-orthostatic hypotension, were enrolled between 28 August 2013, and 27 August 2023. Propensity score matching (PSM) created 1:1 matched groups. Outcomes included mortality, stage 4 and 5 chronic kidney disease (CKD), emergency room (ER) visits, intensive care unit (ICU) admissions, hospitalizations, and respiratory failure. Hazard ratios (HR) with 95% confidence intervals (95% CI) were calculated for each outcome, and Kaplan-Meier survival analysis was performed. Subgroup analyses were conducted based on gender, age (20-<65 vs. ≥65), medication refill frequency, and baseline LVEF. Results: After 1:1 PSM, 5813 cases were included in each group. The midodrine group had higher risks of respiratory failure (HR: 1.16, 95% CI: 1.08-1.25), ICU admissions (HR: 1.14, 95% CI: 1.06-1.23), hospitalizations (HR: 1.21, 95% CI: 1.12-1.31), and mortality (HR: 1.090, 95% CI: 1.01-1.17). Interestingly, midodrine use reduced ER visits (HR: 0.77, 95% CI: 0.71-0.83). Similar patterns of lower ER visit risk and higher risks for ICU admissions, respiratory failure, and overall hospitalizations were observed in most subgroups. Conclusion: In this large-scale study, midodrine use was associated with reduced ER visits but increased risks of respiratory failure, prolonged ICU stays, higher hospitalizations, and elevated mortality in HFrEF patients. Further research is needed to clarify midodrine's role in hemodynamic support and strengthen existing evidence.

Effects of AST-120 on mortality in patients with chronic kidney disease modeled by artificial intelligence or traditional statistical analysis.

Chronic kidney disease (CKD) imposes a substantial burden, and patient prognosis remains grim. The impact of AST-120 (AST-120) on the survival of CKD patients lacks a consensus. This study aims to investigate the effects of AST-120 usage on the survival of CKD patients and explore the utility of artificial intelligence models for decision-making. We conducted a retrospective analysis of CKD patients receiving care in the pre-end-stage renal disease (ESRD) program at Taichung Veterans General Hospital from 2000 to 2019. We employed Cox regression models to evaluate the relationship between AST-120 use and patient survival, both before and after propensity score matching. Subsequently, we employed Deep Neural Network (DNN) and Extreme Gradient Boosting (XGBoost) models to assess their performance in predicting AST-120's impact on patient survival. Among the 2584 patients in our cohort, 2199 did not use AST-120, while 385 patients received AST-120. AST-120 users exhibited significantly lower mortality rates compared to non-AST-120 users (13.51% vs. 37.88%, p < 0.0001) and a reduced prevalence of ESRD (44.16% vs. 53.17%, p = 0.0005). Propensity score matching at 1:1 and 1:2 revealed no significant differences, except for dialysis and all-cause mortality, where AST-120 users exhibited significantly lower all-cause mortality (p < 0.0001), with a hazard ratio (HR) of 0.395 (95% CI = 0.295-0.522). This difference remained statistically significant even after propensity matching. In terms of model performance, the XGBoost model demonstrated the highest accuracy (0.72), specificity (0.90), and positive predictive value (0.48), while the logistic regression model showed the highest sensitivity (0.63) and negative predictive value (0.84). The area under the curve (AUC) values for logistic regression, DNN, and XGBoost were 0.73, 0.73, and 0.69, respectively, indicating similar predictive capabilities for mortality. In this cohort of CKD patients, the use of AST-120 is significantly associated with reduced mortality. However, the performance of artificial intelligence models in predicting the impact of AST-120 is not superior to statistical analysis using the current architecture and algorithm.

The association between bone density of lumbar spines and different daily protein intake in different renal function.

BACKGROUND: Low protein intake (LPI) has been suggested as a treatment for chronic kidney disease (CKD). However, protein intake is essential for bone health. METHODS: We studied the database of the National Health and Nutrition Examination Survey, 2005-2010. Basic variables, metabolic diseases, and bone density of different femoral areas were stratified into four subgroups according to different protein intake (DPI) (that is, <0.8, 0.8-1.0, 1.0-1.2, and >1.2 g/kg/day). RESULTS: Significant differences were found among all lumbar area bone mineral density (BMD) and T-scores (p < 0.0001). There was an apparent trend between a decreasing BMD in the CKD groups with increasing DPI in all single lumbar spines (L1, L2, L3, and L4) and all L spines (L1-L4). Compared with DPI (0.8-1.0 g/day/kg), higher risks of osteoporosis were noticed in the subgroup of >1.2 g/day/kg over L2 (relative risk (RR)=1.326, 95% confidence interval (CI)=1.062-1.656), subgroup >1.2 g/day/kg over L3 (RR = 1.31, 95%CI = 1.057-1.622), subgroup <0.8 g/day/kg over L4 (RR = 1.276, 95%CI = 1.015-1.605), subgroup <0.8 g/day/kg over all L spines (RR = 11.275, 95%CI = 1.051-1.548), and subgroup >1.2 g/day/kg over all L spines (RR = 0.333, 95%CI = 1.098-1.618). However, a higher risk of osteoporosis was observed only in the non-CKD group. There was an apparent trend of higher DPI coexisting with lower BMD and T scores in patients with CKD. For osteoporosis (reference:0.8-1.0 g/day/kg), lower (<0.8 g/day/kg) or higher DPI (>1.2 g/day/kg) was associated with higher risks in the non-CKD group, but not in the CKD group. CONCLUSIONS: In the CKD group, LPI for renal protection was safe without threatening L spine bone density and without causing a higher risk of osteoporosis.

A low-protein diet should be encouraged in patients with CKD, but protein is essential for bone health. In this study, we showed that a low-protein diet did not affect lumbar bone density. Therefore, in the care of CKD, a low-protein diet is beneficial for renal function and without harm to lumbar bone health.

Validating the association of Oxford classification and renal function deterioration among Taiwanese individuals with Immunoglobulin A nephropathy.

Validation of the Oxford classification (MEST and MEST-C) for Immunoglobulin A nephropathy (IgAN) in the Taiwanese population is lacking. Our study aimed to validate this classification and assess individual lesion impact. We conducted a retrospective cohort study at Taichung Veterans General Hospital, Taiwan (Jan 2011-Jul 2023). Composite renal outcomes were evaluated using clinical conditions and estimated glomerular filtration rate (eGFR). We used Kaplan-Meier, univariable/multivariable logistic regression and ROC curves. Subgroup analysis considered eGFR < or ≥ 30.0 ml/min/1.73 m2. In 366 renal biopsies, serum creatinine was 1.34 mg/dl, eGFR 53.8 ml/min/1.73 m2, urine protein-creatinine ratio 1159 mg/g. T1/T2 lesions had lowest baseline eGFR (39.6/11.5 ml/min/1.73 m2), correlating with poorest renal survival (median survival 54.7/34.4 months). Univariable analysis linked all individual variables to worse renal outcomes. Multivariable analysis (MEST/MEST-C) showed only T1/T2 linked to worse outcomes. T score had highest predictive power (AUC 0.728, sensitivity 60.2%, specificity 83.6%), with MEST having high AUC (0.758). No extra predictive power was seen transitioning MEST to MEST-C. Subgroup analysis (eGFR < 30.0 ml/min/1.73 m2) associated C1 with improved renal outcomes (odds ratio 0.14, 95% CI 0.03-0.65). T lesion correlated with worse outcomes across subgroups. The T lesion consistently correlated with worse renal outcomes across all groups and baseline statuses. Integrating the C lesion into the transition from MEST to MEST-C did not enhance predictive power. Importantly, the C1 lesion was linked to improved renal outcomes in the eGFR < 30.0 ml/min/1.73 m2 subgroup, likely due to treatment effects.

The Feasibility of Japanese Histological Grade Classification for Predicting Renal Function Deterioration among Taiwanese Individuals with IgA Nephropathy.

BACKGROUND: We aimed to validate the Japanese histological grading classification (JHGC) in our population of IgA immunoglobulin (IgAN) cases. METHODS: We conducted a retrospective cohort study at Taichung Veterans General Hospital in Taiwan from January 2011 to December 2023. The process involved assessing JHGC's clinical, histological, and merged grading system. Composite renal outcomes based on glomerular filtrate rate (eGFR) were considered. RESULTS: The study included 359 IgAN by renal biopsies. Kidney function at the time of biopsy was suboptimal, with average SCr of 1.3 mg/dL, eGFR of 54.0 mL/min/1.732 m2, and urine protein-creatinine ratio (UPCR) of 1.2 mg/mg. JHGC effectively identified different severity levels of histological and clinical aspects in Taiwanese IgAN. Initial 4-histological classification showed significantly higher MEST-C scores (p < 0.001). Merging grade III and IV was reasonable in Japanese and Taiwanese populations. The clinical grading system (3C) was associated with histological status and proteinuria, but there was no significant trend with SCr, eGFR, and blood urea nitrogen. Significant differences were found among the three groups (log-rank p < 0.01), but C-grade I and II lacked significant difference in long-term renal outcomes. We separated UPCR < 0.5 mg/mg into two groups: eGFR≥ and <60 mL/min/1.732 m2. The new grading system effectively differentiated risk factors for renal outcomes (log-rank p < 0.01), suggesting the need for separation in Taiwanese IgAN. CONCLUSIONS: Our study externally validated JHGC in non-Japanese IgAN. Despite applicability to our population, we recommend a new classification specifically for Taiwanese IgAN patients with increased case numbers in eGFR ≥ 60 mL/min/1.732 m2 and UPCR < 0.5 g/day group.

Exploring knowledge, attitude, and intention towards advance care planning, advance directive, and the patient self-determination act among hemodialysis patients.

BACKGROUND: Hemodialysis holds the highest incidence and prevalence rate in Taiwan globally. However, the implementation of advance care planning (ACP), advance directives (AD), and patient self-determination acts (PSDA) remains limited. Our objective was to examine the current status of ACP, AD and PSDA and potential opportunities for enhancement. METHODS: We developed a novel questionnaire to assess individuals' knowledge, attitudes, and intentions regarding ACP, AD, and PSDA. We also collected baseline characteristics and additional inquiries for correlation analysis to identify potential factors. Student's t-test and Analysis of Variance were employed to assess significance. RESULTS: Initially, a cohort of 241 patients was initially considered for inclusion in this study. Subsequently, 135 patients agreed to participate in the questionnaire study, resulting in 129 valid questionnaires. Among these respondents, 76 were male (59.9%), and 53 were female (41.1%). Only 13.2% had signed AD. A significant portion (85.3%) indicated that they had not discussed their dialysis prognosis with healthcare providers. Additionally, a mere 14% engaged in conversations about life-threatening decisions. Ninety percent believed that healthcare providers had not furnished information about ACP, and only 30% had discussed such choices with their families. The findings revealed that the average standardized score for ACP and AD goals was 84.97, while the attitude towards PSDA received a standardized score of 69.94. The intention score stood at 69.52 in standardized terms. Potential candidates for ACP initiation included individuals aged 50 to 64, possessing at least a college education, being unmarried, and having no history of diabetes. CONCLUSION: Patients undergoing hemodialysis exhibited a significant knowledge gap concerning ACP, AD, and the PSDA. Notably, a substantial number of dialytic patients had not received adequate information on these subjects. Nevertheless, they displayed a positive attitude, and a considerable proportion expressed a willingness to sign AD. It is imperative for nephrologists to take an active role in initiating ACP discussions with patients from the very beginning.

Efficacy and Safety of a High-Energy, Low-Protein Formula Replacement Meal for Pre-Dialysis Chronic Kidney Disease Patients: A Randomized Controlled Trial.

High-energy, low-protein formulas (HE-LPFs) are commonly used as oral nutritional supplements (ONSs) to help provide extra calories to patients who are adhering to a low-protein diet (LPD) after diagnosis with chronic kidney disease (CKD). This randomized controlled trial aimed to evaluate the efficacy and safety of an HE-LPF as either a partial or a total replacement for one meal in pre-dialysis CKD patients. Stage 4-5 CKD patients received either a once-daily HE-LPF (HE-LPF group) or normal food (control group) for a period of 4 weeks while following an LPD. Overall, 73 patients who completed the study were included in the intention-to-treat population. After analyzing the 3-day food records, the HE-LPF group experienced a significant decrease in the percentage of energy derived from protein (p < 0.05) and an increase in the percentage of energy derived from fat (p < 0.05) compared to the control group. The two groups had no significant differences in body weight, body composition, grip strength, renal function, electrolytes, or metabolic markers. The HE-LPF group had a high adherence (94.9% at week 4), and no adverse effects were observed. HE-LPFs are safe to employ as meal replacements for pre-dialysis CKD patients adhering to an LPD.

Trace Elements Status and Their Associations With Related Antioxidant Enzyme Activities in Patients Receiving Peritoneal Dialysis and Hemodialysis.

OBJECTIVE: It remains ambiguous as to whether the status of trace elements would affect their related enzyme activities toward defending a possible higher oxidative stress in patients receiving peritoneal dialysis (PD) or hemodialysis (HD) treatment. We investigated copper (Cu), zinc (Zn), and selenium (Se) status in patients receiving PD or HD treatments and further determined the association of these trace elements with their related antioxidant capacities in those patients. METHODS: Sixty PD and 80 HD patients before and after HD treatment had their blood drawn. Demographic, clinical, and 24-hour diet recall data were recorded and collected. Plasma trace elements, oxidative stress indicators, and antioxidant enzyme activities were measured. RESULTS: Patients receiving PD or HD treatments experienced similar Zn and Cu intakes. PD and HD patients displayed adequate mean plasma Cu, Zn, and Se levels. Patients receiving PD treatment showed significantly higher levels of Cu, Zn, advanced oxidation protein products (AOPPs), and superoxide dismutase (SOD) activity, but had significantly lower levels of Se and total antioxidant capacity when compared to levels in the HD patients at the pre-HD session. The levels of 3 trace elements and AOPP increased significantly, while the levels of glutathione (GSH), oxidized glutathione (GSSG), GPx, and SOD activities decreased significantly after receiving HD treatment than did the levels in the pre-HD session. Plasma Cu, Se, and Zn levels had a different correlation with plasma AOPP level, GPx, and SOD activities during PD, pre- or post-HD sessions. Plasma Cu, Zn, and Se levels did not have any association with their associated enzyme activities in patients with PD, while plasma Cu and Zn levels may have influenced SOD activity in HD patients. CONCLUSIONS: An adequate Cu, Zn, and Se status is required in order to help their associated enzyme activity cope with increased oxidative stress during PD or HD sessions.

Safety and effectiveness of COVID-19 vaccines in patients with IgA nephropathy: a retrospective cohort study from the TriNetX global collaborative networks.

Background: This study aimed to evaluate the renal safety and effectiveness of COVID-19 vaccination in patients with immunoglobulin A nephropathy (IgAN). Methods: We conducted a global and retrospective collaborative network analysis using TriNetX data from September 11, 2018 to September 11, 2023, to address this question. The study recorded diagnoses of IgAN, COVID-19 vaccinations, and outcomes of effectiveness using International Classification of Diseases, Tenth Revision, Clinical Modification codes and procedure codes. Propensity score matching (PSM) created matched groups (1:1). Hazard ratios (HR) with 95% confidence intervals (95% CI) were calculated for outcomes of effectiveness, and Kaplan-Meier method assessed survival probability. Safety outcomes regarding renal function were compared with estimated glomerular filtration rate (eGFR), proteinuria, and hematuria. Subgroup analyses were based on sex and age group. Sensitivity analysis was done before the outbreak of Omicron (from September 11, 2018 to October 31, 2021). Findings: The study involved 1010 vaccinated and 2776 unvaccinated patients with IgAN without COVID-19 infection at baseline. After PSM (1:1) with 25 variables, both groups consisted of well-matched 979 patients who were relatively young (around 55 years old) and in good health (eGFR: 78-80 ml/min/1.732 m2). Compared to the non-vaccinated group, vaccinated patients had significantly lower risks of COVID-19 infection and complications, including COVID-19 infection (HR: 0.050, 95% CI: 0.026, 0.093), COVID-19 pneumonia (HR: 0), severe lung complication (0.647, 95% CI: 0.421, 0.994), acute respiratory failure (0.625, 95% CI: 0.400, 0.978), sepsis (0.545, 95% CI: 0.334, 0.890), emergency department visits (0.716, 95% CI: 0.615, 0.833), all hospitalizations (0.573, 95% CI: 0.459, 0.715), and mortality (0.595, 95% CI: 0.366, 0.969). However, one month after the follow-up, the vaccinated group exhibited a slightly, but statistically significantly, lower eGFR compared to the non-vaccinated group (73.58 vs. 83.05 ml/min/1.732 m2, p = 0.047). Nine months after the follow-up, the difference in eGFR between the two groups disappeared. The lower risk of COVID-19 infection was observed across genders (male and female) and age groups (young and old). For the period before Omicron outbreak, results were also similar. Interpretation: In the largest TriNetX matched cohort study of IgAN, COVID-19 vaccination was associated with a reduced risk of COVID-19 infection and associated complications. However, careful monitoring of renal function, especially GFR, is advisable. Funding: This study was supported by grant TCVGH-1103602C, TCVGH-1103601D, and TCVGH-1113602D from Taichung Veterans General Hospital.

A quality improvement initiative for patients with chronic kidney disease to promote their smoking cessation.

Cigarette smoking is a critical issue in caring for patients of chronic kidney disease (CKD). However, there is no routine care program designed for combining both smoking cessation and CKD care. The process of our quality improvement (QI) collaboration used data under our routine payment-for-performance for pre-end-stage renal disease (P4P Pre-ESRD) in Taichung Veterans General hospital from 2020 to 2022. We share our experience with a QI project that integrates the Ottawa model for smoking cessation (OMSC) with the Pre-ESRD care program as part of routine CKD care. The electronic health information systems were improved to reduce workload of medical staff. The number was more for both qualified CKD educators and nephrologists for smoking cessation. The access and availability for smoking cessation were immediate and convenient for patients. Specifically, all the actions were performed by CKD educators, with nephrologists overseeing the process in routine care. By combining OMSC with the Pre-ESRD program, we were able to provide smokers with satisfactory access and availability to smoking cessation services within our healthcare facility. The smoker cases found were more in number (206 in 2020, 344 in 2021, and 421 in 2022). Before the integrated OSTC-Pre-ESRD program (in 2020), the proportion of smokers was 3.88%. After implementing the integrated program, smokers increased significantly on a yearly basis (9.69% in 2021 and 9.82% in 2022). Finally, case numbers of on-site smoking cessations increased significantly after implementing the integrated system (0 in 2020, 17 in 2021, and 20 in 2022). All CKD patients for smoking cessation were also more (8 in 2020, 46 in 2021, and 38 in 2022). After implementing the QI program, focusing on the integrated OMSC-Pre-ESRD program, we found more smokers undergoing smoking cessation. This QI program highlighted the importance of better access and availability for smoking cessation.

Medical malpractice in hospitals-how healthcare staff feel.

Introduction: Literature is limited on quantified acute stress reaction, the impact of event scale on medical staff when facing medical malpractice (MMP), and how to individually care for staff. Methods: We analyzed data in the Taichung Veterans General Hospital from October 2015 to December 2017, using the Stanford Acute Stress Reaction Questionnaire (SASRQ), the Impact of Event Scale-Revised (IES-R), and the medical malpractice stress syndrome (MMSS). Results and Discussion: Of all 98 participants, most (78.8%) were women. Most MMPs (74.5%) did not involve injury to patients, and most staff (85.7%) indicated receiving help from the hospital. The internal-consistency evaluations of the three questionnaires showed good validity and reliability. The highest score of IES-R was the construct of intrusion (30.1); the most severe construct of SASRQ was "Marked symptoms of anxiety or increased arousal," and the most were having mental and mild physical symptoms for MMES. A higher total IES-R was associated with younger age (<40 y/o), and more severe injury on patients (mortality). Those who indicated receiving very much help from the hospital were those having significantly lower SASRQ sores. Our study highlighted that hospital authorities should regularly follow up on staff's response to MMP. With timely interventions, vicious cycles of bad feelings can be avoided, especially in young, non-doctor, and non-administrative staff.

Effects of patient support group on health literacy: a study using the Multidimensional Health Literacy Questionnaire.

Health literacy is important for patient care. Patient support group (PSG) is also crucial for patient education. Little is known about the effect of PSG on health literacy. We studied scores of health literacy before and after the intervention of a PSG. We also collected patient characteristics like age, gender, first-time participation or not, source of participants, and major diseases. We then identified factors associated with improved health literacy. A total of 43 participants (including patients and family) were studied with 100% response rate on questionnaires. Before PSG intervention, the highest score was the subscale 2 (understanding) (12.10 ± 1.53), followed by subclass 4 (application) (10.74 ± 2.34) and subclass 1 (accessing) (10.72 ± 2.32). The lowest score was subclass 3 (appraisal) (9.77 ± 2.39). After the statistical analyses, the final results in difference comparisons were subclass 2 = 5 > 4 = 1 = 3. The improved score of PSG was only noticed in subclass 3 (appraisal) after PSG intervention (9.77 ± 2.39 vs 10.74 ± 2.55, P = .015). Health literacy scores improvements were noticed in "Evaluate whether the health information can be used to solve medical problems" (2.51 ± 0.68 vs 2.74 ± 6.78, P = .048), and in "Evaluate the reliability of medical information from network" (2.28 ± 0.83 vs 2.64 ± 0.78, P = .006) (Table 3). Both scores belonged to subclass 3 (appraisal). We found no factor being associated with improved health literacy. This is the first study regarding the effect of PSG on health literacy. In all 5 dimensions of health literacy, the ability of appraising medical information is lacking in the current era. With suitable design of PSG, the PSG may improve health literacy improved literacy, including the dimension of appraisal.

Outcomes and Effects of Vaccination on Sars-Cov-2 Omicron Infection in Kidney Transplant Recipients.

BACKGROUND: Kidney transplant recipients (KTRs) are at high risk of COVID-19. Vaccination is significantly effective at preventing infection and reducing infection severity. Omicron infections are less severe than infections by previous strains, but breakthrough disease is more common. Thus, we conducted this study to observe the vaccine efficacy in our KTRs. METHODS: During the surge in the Omicron variant, beginning in May 2022, we retrieved data from 365 KTRs who had received at least one dose of various COVID vaccines until June 30, 2022. Outcomes of the KTRs (n = 168) after at least the 2nd vaccination were assessed until September 30, 2022, before the border was opened for tourism. RESULTS: The antibody response in KTRs after the 1st and 2nd doses of SARS-CoV-2 vaccines demonstrated a significant increase from the 1st dose (median: 0.4; IQR: 0.4-8.4 U/mL, P < .001) to the 2nd dose (median: 57.5; IQR: 0.4-799.2 U/mL), and the response rate rose from 32% to 65% (P < .001). SARS-CoV-2 infection was identified in 14/365 (3.8%) patients after at least the 1st dose and 7/187 (3.7%) patients at least 7 days beyond the 2nd dose. Most KTRs had a mild course, but 3 (17%) were hospitalized due to pneumonia. CONCLUSIONS: Our data demonstrate a lower response rate and anti-S titers after 2nd dose vaccination in KTRs than in the general population, but a lower incidence of SARS-CoV-2 infection after vaccination was observed during the Omicron outbreak. Owing to the breakthrough infections found in ordinarily vaccinated KTRs, we must emphasize the importance of vaccination and boosters to prevent severe illness, hospitalizations, and death among those developing infections.

Diagnosis and Management of Fabry Disease in High-Risk Renal Disease Patients in Taiwan: A Single Center Study.

BACKGROUND: Fabry disease (FD) is an X-linked inborn error of lysosomal storage disorder, a deficiency in lysosomal hydrolase α-galactosidase A activity due to pathogenic variants in the GLA gene. Accumulation of globotriaosylceramide in multiple organs contributes to end-stage kidney disease, heart failure, and cerebrovascular accidents. METHODS: We began the FD screening program by involving male patients older than 20 years of age who were on chronic dialysis, had a post-kidney transplantation, and were part of the Pre-End Stage Renal Disease Program in our hospital. α-galactosidase A activity was detected through an initial dried blood spots screen assay, followed by levels of lyso-globotriaosylceramide and sequencing of the GLA gene when screening patients with suspected FD to confirm their diagnosis. RESULTS: A total of 1812 patients had been FD screened, with the prevalence of FD being approximately 0.16 % (3/1812) up until June 2022. Interestingly, we confirmed a family cluster (2 sons and their mother) of having the c.936+919G>A mutation (designated GLA IVS4) with hypertrophic cardiomyopathy in Taiwan and another with the mutation c.644A>G (p.Asn215Ser), a more common later-onset variant reported in people of European or North American descent. Two patients were confirmed with cardiomyopathy through a cardiac biopsy, with their cardiac function later reversed after enzyme replacement therapy. CONCLUSIONS: The FD screening test detects chronic kidney disease due to an unknown etiology and prevents other organ complications. Early detection of FD is crucial for reversing target organ damage with enzyme replacement therapy.

Development and validation of an insulin resistance model for a population without diabetes mellitus and its clinical implication: a prospective cohort study.

Background: Insulin resistance (IR) is associated with diabetes mellitus, cardiovascular disease (CV), and mortality. Few studies have used machine learning to predict IR in the non-diabetic population. Methods: In this prospective cohort study, we trained a predictive model for IR in the non-diabetic populations using the US National Health and Nutrition Examination Survey (NHANES, from JAN 01, 1999 to DEC 31, 2012) database and the Taiwan MAJOR (from JAN 01, 2008 to DEC 31, 2017) database. We analysed participants in the NHANES and MAJOR and participants were excluded if they were aged <18 years old, had incomplete laboratory data, or had DM. To investigate the clinical implications (CV and all-cause mortality) of this trained model, we tested it with the Taiwan biobank (TWB) database from DEC 10, 2008 to NOV 30, 2018. We then used SHapley Additive exPlanation (SHAP) values to explain differences across the machine learning models. Findings: Of all participants (combined NHANES and MJ databases), we randomly selected 14,705 participants for the training group, and 4018 participants for the validation group. In the validation group, their areas under the curve (AUC) were all >0.8 (highest being XGboost, 0.87). In the test group, all AUC were also >0.80 (highest being XGboost, 0.88). Among all 9 features (age, gender, race, body mass index, fasting plasma glucose (FPG), glycohemoglobin, triglyceride, total cholesterol and high-density cholesterol), BMI had the highest value of feature importance on IR (0.43 for XGboost and 0.47 for RF algorithms). All participants from the TWB database were separated into the IR group and the non-IR group according to the XGboost algorithm. The Kaplan-Meier survival curve showed a significant difference between the IR and non-IR groups (p < 0.0001 for CV mortality, and p = 0.0006 for all-cause mortality). Therefore, the XGboost model has clear clinical implications for predicting IR, aside from CV and all-cause mortality. Interpretation: To predict IR in non-diabetic patients with high accuracy, only 9 easily obtained features are needed for prediction accuracy using our machine learning model. Similarly, the model predicts IR patients with significantly higher CV and all-cause mortality. The model can be applied to both Asian and Caucasian populations in clinical practice. Funding: Taichung Veterans General Hospital, Taiwan and Japan Society for the Promotion of Science KAKENHI Grant Number JP21KK0293.

Outcome of Brain Lymphoma in a High Epstein-Barr Virus-Prevalence Country After Kidney Transplantation.

BACKGROUND: The incidence of post-transplant lymphoproliferative disorder (PTLD) in adult kidney transplant (KTx) recipients is less common in Taiwan. In our institute, we observed that brain lymphoma was the most notorious type. METHODS: The study describes the clinical, histologic, and radiological features of primary central nervous lymphoma (PCNSL) and the outcomes and associations with Epstein-Barr virus (EBV) infection in our center. RESULTS: Among 1470 KTx recipients, 5 patients had tissue-proven brain lymphoma (0.34%). The brain pathology disclosed diffuse large B-cell lymphoma in all patients. EBV was detected through in situ hybridization for Epstein-Barr encoding region (EBER) to disclose the EBV inclusion in the nuclei of lymphoma cells. The first treatment step was the reduction of immunosuppressants; 4 patients received whole-brain radiotherapy after complete resection of PCNSL, and 1 received concurrent chemoradiotherapy. Only one patient had poor performance status at the time of diagnosis and had a poor response to treatment with steroids. Four patients survived (mean 36.5 months, range 8.6 to 57.6 months), but one died after rapid neurologic deterioration. CONCLUSION: Epstein-Barr virus inclusion was found in PCNSL in our patients; however, the role of EBV in PCNSL remains to be clarified. Post-transplant lymphoproliferative disorder is a rare malignancy after KTx with a predilection of brain involvement in Taiwan. We report a successful care experience in a patient with primary CNS lymphoma with better survival.