Effects of overhydration, Kt/Vurea, ß2-microglobulin on coronary artery calcification and mortality in haemodialysis patients.

AIM: We studied the effects of overhydration (OH), Kt/Vurea and ß2-microglobulin (ß2-MG) on coronary artery calcification and mortality in patients undergoing haemodialysis (HD). METHODS: The Agatston coronary artery calcium score (CACS), postdialysis body composition using bioimpedance analysis, single-pool Kt/Vurea and predialysis ß2-MG at baseline were assessed and followed up for 3 years in patients undergoing HD. We performed logistic regression analyses for a CACS ≥400 and Cox proportional hazard analyses for all-cause and cardiovascular mortality. RESULTS: The study involved 338 patients with a median age of 67 (56-74) years, dialysis duration of 70 (33-141) months and diabetes prevalence of 39.1% (132/338). Patients with a CACS ≥400 (n = 222) had significantly higher age, dialysis duration, male prevalence, diabetes prevalence, C-reactive protein, predialysis ß2-MG, OH, extracellular water/total body water and overhydration/extracellular water (OH/ECW) but significantly lower Kt/Vurea than patients with a CACS <400 (n = 116) (p < .05). OH/ECW, Kt/Vurea and predialysis ß2-MG were significant predictors of a CACS ≥400 (p < .05) after adjusting for age, dialysis duration, serum phosphate and magnesium. In all patients, cut-off values of OH/ECW, Kt/Vurea and predialysis ß2-MG for a CACS ≥400 were 16%, 1.74 and 28 mg/L, respectively. After adjusting for dialysis duration, OH/ECW ≥16%, Kt/Vurea ≥1.74 and ß2-MG ≥28 mg/L were significant predictors of 3-year all-cause mortality but not 3-year cardiovascular mortality. CONCLUSION: Higher OH/ECW, higher predialysis ß2-MG and lower Kt/Vurea values are significant risk factors for a CACS ≥400 and 3-year all-cause mortality in patients undergoing maintenance HD.

Absolute iron deficiency, coronary artery calcification and cardiovascular mortality in maintenance haemodialysis patients.

AIM: The effects of iron on vascular calcification in rats and vascular smooth muscle cells were recently reported, but clinical studies on iron and vascular calcification are scant. We studied the associations of absolute iron deficiency, coronary artery calcification and mortality in patients with maintenance haemodialysis (MHD). METHODS: Transferrin saturation (TSAT), ferritin, mean corpuscular haemoglobin (MCH) and Agatston coronary artery calcium score (CACS) were studied at baseline in MHD patients and followed up for 3 years. Cox proportional hazard analyses for mortality and linear regression analyses for CACS were performed. RESULTS: In 306 patients, the median age was 67 (56-81) years, dialysis duration was 76 (38-142) months, and diabetes prevalence was 42.5%. Fifty-two patients had died by 3 years. Patients with absolute iron deficiency (TSAT <20% and ferritin <100 ng/mL) (n = 102) showed significantly higher CACS (p = .0266) and C-reactive protein (p = .0011), but a lower frequency of iron formulation administration compared with patients without absolute iron deficiency at baseline (n = 204). Absolute iron deficiency was a significant predictor for 3-year cardiovascular (CV) mortality (hazard ratio: 2.08; p = .0466), but not for 3-year all-cause mortality. CACS was significant predictor for both 3-year CV and all-cause mortality (p <.05). Absolute iron deficiency and MCH were significant determinants of CACS (p < .05). CONCLUSION: MHD patients with absolute iron deficiency showed significantly higher CACS than others, and absolute iron deficiency was a significant risk factor for coronary artery calcification and 3-year CV mortality in MHD patients, but was not a significant predictor for 3-year all-cause mortality.

α1- and ß2-Microglobulin reduction ratios and survival in patients on predilution online haemodiafiltration.

AIM: ß2-Microglobulin (ß2-MG) and α1-microglobulin (α1-MG) have molecular weights of 11,800 and 33,000 Da, respectively. We studied the α1-MG and ß2-MG reduction ratios (RRs) and survival in patients on predilution online haemodiafiltration (Pre-OL-HDF). METHODS: Participants were 247 Pre-OL-HDF patients. α1-MG and ß2-MG RRs were assessed at baseline. Kaplan-Meier survival and Cox proportional hazard analyses were used. RESULTS: In 247 patients, the median age was 67 (56-73) years, the dialysis duration was 77 (46-150) months, and the diabetes prevalence was 47.4%. Twenty-two patients died over the 450-day study period. The mortality cut-off values using receiver-operating characteristic curves for the α1-MG and ß2-MG RRs were 20% and 80%, respectively. Survival rates were significantly (p < 0.05) higher in patients with α1-MG RRs ≥20% (n = 134) compared with patients with α1-MG RRs <20% (n = 113) and in patients with ß2-MG RRs ≥80% (n = 87) compared with patients with ß2-MG RRs <80% (n = 160). Cox models adjusting for diabetes and dialysis duration showed that α1-MG RR, ß2-MG RR, and pre- and postdialysis ß2-MG were risk factors for all-cause mortality; however, after additional adjustment for age, sex, and serum albumin, only ß2-MG RR and pre- and postdialysis ß2-MG were significant predictors of mortality (p < 0.05). α1-MG RRs were significantly correlated with ß2-MG RRs (ρ = 0.73, p < 0.0001) and serum albumin levels (ρ = 0.13, p < 0.05). CONCLUSION: In patients on Pre-OL-HDF, α1-MG RRs ≥20% and ß2-MG RRs ≥80% were associated with better survival, ß2-MG RR ≥80% and pre-and postdialysis ß2-MG levels were significant predictors of all-cause mortality, and α1-MG RR ≥20% may predict mortality.

Nurturing Basic Societal Competencies in Speech-Language-Hearing Therapy Training Education: Effects of Coaching Classes.

INTRODUCTION: Nurturing "basic societal competencies" is important in the training education of speech-language-hearing therapists (SLHTs) to enable them to respond to fluctuating medical treatment scenarios. However, in the current training education for SLHTs, some students need assistance in terms of basic societal competencies, such as initiative, planning, and communication. In this study, the focus was on coaching theory, a method of interpersonal support through dialog, as a strategy for addressing the issues. The objective was to clarify whether coaching theory-based classes for SLHT students improve their basic societal competencies. METHODS: The participants were first- and third-year undergraduate SLHT students in Japan. The coaching and control groups comprised students enrolled in 2021 and 2020, respectively. The observation period for this prospective cohort study was from April to September 2020 and from April to September 2021. The coaching and control groups received 90-min coaching and remedial education classes, respectively, 11 times in 3 months. To establish students' knowledge and skills, follow-up sessions were conducted four times a month, and assignments were given during the subsequent summer vacation. The effects of the classes were based on Kirkpatrick's four-level evaluation model, with Levels 1, 2, 3, and 4 evaluating satisfaction with the class, learning proficiency, behavior modification, and result attainment, respectively. RESULTS: The coaching and control groups comprised 40 and 48 participants, respectively. In the evaluation of behavior modification (level 3) using the "PROG (progress report on generic skills) competency test (RIASEC Inc., Tokyo)," the interactions between time and group and the main effects of time were significant for the basic societal competencies of "relating with others" and "self-confidence." Multiple comparisons showed that the post-class scores were significantly higher than the pre-class scores in the coaching group (change of 0.9 for relating with others and 0.7 for self-confidence) and that the scores in the coaching group were significantly higher than those in the control group at the post-class. The interaction between time and group was significant for those "planning solutions," and the post-class score was significantly higher than the pre-class score in the coaching group (change of 0.8). CONCLUSION AND IMPLICATION: The coaching classes improved the students' basic societal competencies of relating with others, self-confidence, and planning solutions. This suggests that coaching classes are useful in the training education for SLHTs. Ultimately, nurturing students' basic societal competencies will develop human resources who could achieve quality clinical performance.

Utility of CHA2DS2-VASc Score to Predict Mid-Term Clinical Outcomes in Hemodialysis Patients.

BACKGROUND: The CHA2DS2-VASc score has been widely used to predict stroke in patients with atrial fibrillation (AF). Recently, it was reported that the CHA2DS2-VASc score helps predict cardiovascular disease (CVD) or all-cause mortality in patients with or without AF. However, few reports have examined the association between this score and mortality in hemodialysis (HD) patients. METHODS: We analyzed 557 consecutive patients who initiated HD at our facilities between February 2005 and October 2017. The CHA2DS2-VASc score was calculated at the time of initiation of HD. Patients were then categorized into three groups according to their CHA2DS2-VASc scores: 0-1 (low), 2-3 (intermediate), and 4-9 (high). Multivariate Cox proportional hazards analysis was used to assess independent risk factors for 3-year all-cause mortality. RESULTS: During the 3-year follow-up period, 153 (27.5%) patients died (cardiovascular death: n = 88). According to multivariate analysis, serum albumin (hazard ratio [HR] 0.60, 95% confidence interval [CI] 0.43-0.85, p = 0.003), creatinine (HR 0.91, 95% CI 0.84-0.99, p = 0.049), and CHA2DS2-VASc score (HR 1.33, 95% CI 1.20-1.46, p < 0.001) were associated with 3-year all-cause mortality. Compared with patients in the low CHA2DS2-VASc score group, those in the intermediate- and high-score groups had a higher risk for all-cause and CVD mortality (all-cause mortality: HR 1.77, 95% CI 1.23-2.55, p = 0.002 and HR 2.94, 95% CI 1.90-4.53, p < 0.001, respectively; CVD mortality: HR 1.82, 95% CI 1.27-2.59, p = 0.001 and HR 2.85, 95% CI 1.88-4.31, p < 0.001, respectively). CONCLUSION: The CHA2DS2-VASc score is a valuable predictor of 3-year all-cause and CVD mortality in incident HD patients.

Convection volume, ß2-microglobulin and α1-microglobulin reduction ratios, and body composition in pre-dilution online haemodiafiltration.

AIM: The effect of convection volume (CV) in patients on pre-dilution online haemodiafiltration (Pre-OL-HDF) was evaluated. METHODS: We conducted a retrospective, cross-sectional study in 126 patients on Pre-OL-HDF. Dialysis conditions, laboratory data, and same day post-dialysis body composition measurements using bioimpedance spectroscopy were assessed. Patients were divided into two groups according to their CV: ≥ median value and < median value. Linear regression analyses for reduction ratios (RRs) of ß2-microglobulin and α1-microglobulin, and body composition, were conducted. RESULTS: Age, dialysis vintage, and CVs of the study patients were 64 ± 12 years, 81 (48-154) months, and 43.2 (38.5-55.9) L/session, respectively. The higher CV (≥ 43 L/session) group (n = 66) had significantly higher RRs of ß2-microglobulin and α1-microglobulin, lean tissue index, body cell mass index, total body water (TBW), extracellular water (ECW), and intracellular water (ICW) compared with the lower CV (< 43 L/session) group (n = 60, p <  .01). Serum albumin and fat tissue index were not significantly different between the groups. CV/ECW, CV/TBW, and CV/ICW but not un-adjusted CV, were significant determinants for ß2-microglobulin and α1-microglobulin RRs (p <  .05). Lean tissue and body cell mass indexes, but not the fat tissue index, showed significant associations with CV, and RRs of ß2-microglobulin and α1-microglobulin (p < kb.05). CONCLUSIONS: Among patients on Pre-OL-HDF, higher values in the lean tissue index and body cell mass index were observed in those with higher CV versus lower CV, and CV adjusted to body water may be useful to prescribe individualized conditions for Pre-OL-HDF.

Association and predictive value of geriatric nutritional risk index, body composition, or bone mineral density in haemodialysis patients.

AIM: Assess the association and predictive value of geriatric nutritional risk index (GNRI), body composition, and bone mineral density (BMD) in haemodialysis (HD) patients. METHODS: Laboratory data, body composition parameters measured via body composition monitor, and radius, lumbar spine, femoral neck BMD measured using dual energy X-ray absorptiometry were assessed in all subjects on HD or online haemodiafiltration (HDF) at baseline. Regression analysis for GNRI, Cox proportional hazard analyses and comparison of multiple receiver operating characteristic (ROC) curves were performed. RESULTS: Among all 264 patients, age was 65 ± 12 years and dialysis vintage was 79 (39-144) months. GNRI tertile (T)1, T2, and T3 were 88 (85-91), 94 (93-95), and 98 (97-101), respectively. Patients in GNRI T1 had lower fat tissue index (FTI), lean tissue index, and femoral neck, lumbar spine, and distal mid-third radius BMD, but higher overhydration/extracellular fluid than patients in GNRI T2 or T3 (P < .05). GNRI was significantly associated with FTI, lean tissue index, and femoral neck, lumbar spine, and distal mid-third radius BMD (P < .01). GNRI was a significant predictor of 2-year all-cause mortality (HR 0.92, P < .05). Area under the ROC curve for all-cause mortality using traditional risk factors (age, sex, diabetes mellitus, cardiovascular disease, use of vasopressors for dialysis-related hypotension, and C-reactive protein) was 0.67 and changed by adding GNRI (0.78, P < .05), FTI (0.75), or femoral neck BMD (0.66), respectively. CONCLUSION: Associations between GNRI, body composition, and BMD were confirmed in HD patients. Combining GNRI with traditional risk factors improved mortality prediction in HD patients.

Iron, coronary artery calcification, and mortality in patients undergoing hemodialysis.

OBJECTIVE: A high coronary artery calcification score (CACS) may be associated with high mortality in patients undergoing hemodialysis (HD). Recently, effects of iron on vascular smooth muscle cell calcification have been described. We aimed to investigate the relationships between iron, CACS, and mortality in HD patients. METHODS: We studied 173 consecutive patients who were undergoing maintenance HD. Laboratory data and Agatston's CACS were obtained at baseline for two groups of patients: those with CACS ≥400 (n = 109) and those with CACS <400 (n = 64). Logistic regression analyses for CACS ≥400 and Cox proportional hazard analyses for mortality were conducted. RESULTS: The median (interquartile range) age and duration of dialysis of the participants were 67 (60-75) years and 73 (37-138) months, respectively. Serum iron (Fe) and transferrin saturation (TSAT) levels were significantly lower in participants with CACS ≥400 than in those with CACS <400, although the serum ferritin concentration did not differ between the groups. TSAT ≥21% was significantly associated with CACS ≥400 (odds ratio 0.46, p<0.05). TSAT ≥17%, Fe ≥63 µg/dL, and ferritin ≥200 ng/mL appear to protect against 5-year all-cause mortality in HD patients, independent of conventional risk factors of all-cause mortality (p < 0.05). CONCLUSION: We have identified associations between iron, CACS, and mortality in HD patients. Lower TSAT was found to be an independent predictor of CACS ≥400, and iron deficiency (low TSAT, iron, or ferritin) was a significant predictor of 5-year all-cause mortality in HD patients.

Relationship of matrix Gla protein and vitamin K with vascular calcification in hemodialysis patients.

Objective: This study evaluated associations of serum matrix Gla protein (MGP), plasma vitamin K1, and plasma vitamin K2 with coronary artery calcium score (CACS) and cardiovascular disease (CVD) in maintenance hemodialysis (MHD) patients. Methods: Subjects comprised 112 MHD patients aged 30-60 years and 40 age-matched healthy subjects. Total MGP, vitamin K1, vitamin K2, and lipid profile were examined in all subjects; other clinical data, medication use, and CACS were assessed only in MHD patients. Determinants of MGP in all subjects were identified by regression analysis. Factors associated with CACS and CVD in MHD patients were identified by regression analysis and logistic analysis, respectively. Results: Lower plasma levels of vitamin K1 corrected for triglycerides [0.39 (0.24-0.70) vs. 0.77 (0.48-1.34) ng/mg, p < 0.001], higher frequency of plasma vitamin K2 ≤ 0.05 ng/ml (p = 0.23), and higher serum total MGP (288.4 ± 44.2 vs. 159.7 ± 40.6 ng/ml, p < 0.0001) were observed in MHD patients than in healthy controls. Total MGP level was significantly associated with levels of vitamin K1 corrected for triglycerides (p <0 .001) and vitamin K2 ≤ 0.05 ng/ml (p < 0.05) in all subjects. Total MGP level was significantly associated with presence of CVD (p <0 .05), but not CACS, in MHD patients. Conclusion: The end-stage renal disease on hemodialysis is a deficiency state of vitamin K. Total MGP was significantly higher in MHD patients compared to healthy subjects and total MGP was associated with the presence of CVD, but not CACS, in MHD patients.

Coronary artery calcification score and common iliac artery calcification score in non-dialysis CKD patients.

AIM: Many studies have validated Agatston's coronary artery calcification score (CACS) for assessing vascular calcification (VC) in chronic kidney disease (CKD) patients. This study aimed to evaluate the CACS and common iliac artery calcification score (IACS) and to examine the variables related to each score. METHODS: The subjects were 145 non-dialysis CKD patients. The CACS and IACS were determined using the same thoracicoabdominal multi-detector computed tomography. Multiple regression analyses were performed to assess the factors associated with the CACS or IACS. The associations between progression to renal replacement therapy (RRT) and the CACS or IACS were studied using Cox hazards models. RESULTS: The subjects' median age, estimated glomerular filtration rate (eGFR), and follow-up period were 72 (62-78) years, 32 (18-50) mL/min/1.73m2 , and 864 (550-1425) days, respectively. Age, diabetes, the serum phosphate level, and the eGFR were found to be significant factors of the CACS [ß (95% CI): 0.38 (0.02-0.04), P < 0.0001, 0.28 (0.19-0.50), P < 0.0001, 0.16 (0.03-0.45), P < 0.05 and -0.15 (-0.02-0.00), P < 0.05, respectively]. Age and diabetes were shown to be significant factors of the IACS [ß (95% CI): 0.53 (0.04-0.06), P < 0.0001, and 0.18 (0.07-0.40), P < 0.01, respectively]. Progression to RRT occurred in 31 patients and was significantly associated with the CACS (hazard ratio: 1.01, P < 0.01), urinary protein level and eGFR, but not the IACS. CONCLUSION: Chronic kidney disease related risk factors for VC, such as the eGFR and hyperphosphataemia, are significantly associated with a high CACS, but not a high IACS, and the CACS is a significant predictor of progression to RRT.

Oral iron supplementation with sodium ferrous citrate reduces the serum intact and c-terminal fibroblast growth factor 23 levels of maintenance haemodialysis patients.

AIM: Iron deficiency stimulates fibroblast growth factor 23 (FGF23) transcription. This study aimed to determine whether oral ferrous iron (Fe2+ ) reduces the serum FGF23 levels of iron-deficient maintenance haemodialysis (MHD) patients in the same way as oral ferric iron (Fe3+ ) METHODS: Thirty-one MHD patients with iron deficiency were enrolled in this prospective study. Patients who had taken iron supplements during the 8 weeks before the study were excluded. The patients' iron stores and their serum FGF23, phosphate, intact parathyroid hormone (iPTH), albumin, C-reactive protein (CRP), and albumin-adjusted calcium (Ca) levels were examined at the baseline and after 3 months' treatment with sodium ferrous citrate (Fe2+ ). RESULTS: The patients' transferrin saturation values and serum iron and ferritin levels were significantly increased after 3 months' treatment (P < 0.01), as were their serum albumin levels (P < 0.05). Conversely, their serum intact FGF23 (iFGF23) [1820 (342-4370) vs 1240 (214-2940) pg/mL, P < 0.05], C-terminal FGF23 (cFGF23) [309 (120-1211) vs 259 (99-600) pg/mL, P < 0.05)], and CRP levels (P < 0.01) were significantly reduced after 3 months' treatment. No changes were detected in the patients' serum iFGF23:cFGF23 ratios or their serum phosphate, Ca, or iPTH levels. The changes in the patients' serum iFGF23 and cFGF23 levels induced by sodium ferrous citrate supplementation were shown to be attributable to changes in their serum ferritin levels (P < 0.05). CONCLUSION: Short-term oral iron supplementation with sodium ferrous citrate replenished the iron stores and reduced the serum iFGF23 and cFGF23 levels of MHD patients with iron deficiency without affecting their serum phosphate, Ca, or iPTH levels.

Determinants of coronary artery calcification in maintenance hemodialysis patients.

In addition to the well-known traditional risk factors, uremia-related so-called novel risk factors and medications appear to affect coronary artery calcification in hemodialysis patients. This study was performed to evaluate coronary artery calcification score (CACS) in maintenance hemodialysis (MHD) patients, and to identify significantly related factors. We assessed CACS using Agatston Score by MDCT, sex, age, dialysis vintage, presence of diabetes mellitus, smoking history, presence of ≥100 ml urine volume/day, normalized protein catabolic rate, geriatric nutritional risk index, administration of active vitamin D3, cinacalcet, phosphate binders or antihypertensive agents, and circulation parameters including creatinine, albumin, corrected calcium and phosphate in 207 MHD patients. Coronary artery calcifications were observed in 192 patients (92.8%). In multivariate analysis, CACS showed direct associations with age (p < 0.001), dialysis vintage (p < 0.001) and presence of diabetes mellitus (p < 0.01), and an inverse association only with active vitamin D3 administration (p < 0.001) in MHD patients. Patients with active vitamin D3 showed significantly lower CACS than in those without it (1349.6 ± 1635.0 vs. 2475.6 ± 2646.6 H, p < 0.05). Older age, longer duration of dialysis and diabetes mellitus are risk factors and administration of active vitamin D3 is protective factor for coronary artery calcification in MHD patients.

Lower serum fibroblast growth factor-23 levels may suggest malnutrition in maintenance haemodialysis patients.

AIM: It is reported that high serum fibroblast growth factor-23 (FGF-23) levels are associated with increased mortality in haemodialysis patients, and can be caused by hyperphosphataemia and loss of residual renal function. However, hypophosphataemia is also associated with increased mortality in maintenance haemodialysis (MHD) patients. We studied the determinants of the serum FGF-23 levels in MHD patients, focusing on nutritional status and residual renal function. METHODS: A total of 332 Japanese MHD patients with a median age of 69 years, and median dialysis vintage of 66 months, were studied. The serum levels of intact FGF-23, albumin, phosphate, and intact parathyroid hormone (iPTH), corrected serum calcium (Ca) levels, urine volume, (creatinine clearance+urea clearance)/2, phosphate clearance, Kt/Vurea, body mass index (BMI), normalized protein catabolic rate (nPCR), normalized protein equivalent of nitrogen appearance (nPNA), geriatric nutritional risk index (GNRI), and the prescribed dosages of active vitamin D and phosphate binders were assessed. RESULTS: The significant independent factors for InFGF-23 by multivariate analysis were age, GNRI, serum phosphate, Ca, iPTH levels and dosage of active vitamin D in patients without residual renal function (P<0.05). Among all MHD patients, the lowest BMI, nPNA, nPCR, GNRI, serum albumin, creatinine, phosphate, Ca, Ca x P product and iPTH values were seen in the lowest serum FGF-23 quartile (FGF-23<311 pg/mL). CONCLUSIONS: The determinants of the serum FGF-23 level in MHD patients without residual renal function were age, serum phosphate, Ca, iPTH levels, the active vitamin D dose and the GNRI. The lower serum FGF-23 levels may suggest malnutrition in MHD patients.

Free air on CT and the risk of peritonitis in peritoneal dialysis patients: a retrospective study.

BACKGROUND: Intra-abdominal free air is found frequently in patients undergoing peritoneal dialysis (PD). Some studies have investigated an association between intra-abdominal free air and peritonitis in PD patients. However, most used chest X-rays, which are of limited sensitivity, and the association was not made clear. We conducted a retrospective study of the association between peritonitis and intra-abdominal free air using computed tomography. METHODS: The presence and volume of free air, and its relationship with other variables, were assessed on review of routine examinations in 108 patients. Correlations between the presence of free air and age, duration of PD, continuous ambulatory versus automated PD, presence or absence of a person who assisted in bag changes, exit-site infection, tunnel infection and peritonitis were assessed. RESULTS: Free air was detected in 29 patients (27.1%). The prevalence of peritonitis was higher in the free air (+) group than in the free air (-) group: 1/40.2 patient-months for free air (+) versus 1/96.9 patient-months for free air (-). The risk ratio of free air for peritonitis was 2.41 (95% confidence interval: 2.28-2.55) and was similar when corrected for age, gender, albumin, diabetes mellitus and body mass index. CONCLUSION: Free air is an independent risk factor for peritonitis in PD patients. This suggests that bag change procedures should be re-evaluated, and patients re-educated, when necessary.

Membranous nephropathy after multiple Hymenoptera stings: a case report.

An association between Hymenoptera (bee and wasp) stings and nephrotic syndrome has been rarely reported. We report a case of nephrotic syndrome after multiple Hymenoptera stings, and membranous nephropathy was later diagnosed by a kidney biopsy. The patient was a 79-year-old woman who was stung by Hymenoptera at seven sites on her body. A weight gain of 3.7 kg was observed in the patient at 1 week after being stung, and she had considerable edema in both lower extremities. A urine protein concentration of 14.8 g/g creatinine and a serum albumin concentration of 1.7 g/dL led to the diagnosis of nephrotic syndrome. A percutaneous kidney biopsy 8 days after the Hymenoptera stings showed stage I membranous nephropathy. She was in complete remission 1 week after the administration of oral prednisolone 40 mg/day, which was started 14 days after Hymenoptera stings, and had no relapse of nephrotic syndrome. To the best of our knowledge, this is the first report of biopsy-proven membranous nephropathy caused by Hymenoptera stings.

Early arteriovenous fistula failure associated with mortality and major adverse cardiovascular events in patients undergoing incident hemodialysis.

BACKGROUND: Arteriovenous fistula (AVF) patency is important for patients undergoing hemodialysis. The association between early AVF failure and the prognosis, including all-cause mortality and major adverse cardiovascular events (MACE), has not been fully investigated. The present study was performed to investigate the association between early AVF failure and 3-year mortality, cardiovascular disease (CVD) mortality, and MACE. METHODS: We analyzed 358 patients who started hemodialysis in our institution from October 2008 to February 2020. We defined early AVF failure as cases requiring percutaneous transluminal angioplasty or reoperation within 1 year after AVF surgery. The patients were divided into two groups according to the presence or absence of early AVF failure, and the prognosis of each group was examined. The association between early AVF failure and outcomes (3-year all-cause mortality, CVD mortality, and MACE) was determined using Cox proportional hazards regression analysis. RESULTS: During the 3-year follow-up, 75 (20.9%) patients died (cardiovascular death: n = 39) and 145 patients developed MACE. According to the multivariable analysis, the early AVF failure group had a significantly higher risk of 3-year all-cause mortality (hazard ratio [HR], 1.42; 95% confidence interval [CI], 1.09-1.83; p = 0.009), CVD mortality (HR, 1.54; 95% CI, 1.29-2.08; p < 0.001), and MACE (HR, 1.68; 95% CI, 1.25-2.26; p < 0.001). When the patients were stratified by age, early AVF failure was associated with 3-year all-cause mortality in all groups except for the younger group (<65 years of age). CONCLUSIONS: Early AVF failure was associated with an increased risk of 3-year all-cause mortality, CVD mortality, and MACE.

A multi-institutional, observational study of outcomes after catheter placement for peritoneal dialysis in Japan.

BACKGROUND: This multi-institutional, observational study examined whether the outcomes after peritoneal dialysis (PD) catheter placement in Japan meet the audit criteria of the International Society for Peritoneal Dialysis (ISPD) guideline and identified factors affecting technique survival and perioperative complications. METHODS: Adult patients who underwent first PD catheter placement for end-stage kidney disease between April 2019 and March 2021 were followed until PD withdrawal, kidney transplantation, transfer to other facilities, death, 1 year after PD start or March 2022, whichever came first. Primary outcomes were time to catheter patency failure and technique failure, and perioperative infectious complications within 30 days of catheter placement. Secondary outcomes were perioperative complications. Appropriate statistical analyses were performed to identify factors associated with the outcomes of interest. RESULTS: Of the total 409 patients, 8 who underwent the embedded catheter technique did not have externalised catheters. Of the 401 remaining patients, catheter patency failure occurred in 25 (6.2%). Technical failure at 12 months after PD catheter placement calculated from cumulative incidence function was 15.3%. On Cox proportional hazards model analysis, serum albumin (hazard ratio (HR) 0.44; 95% confidence interval (CI) 0.27-0.70) and straight type catheter (HR 2.14; 95% CI 1.24-3.69) were the independent risk factors for technique failure. On logistic regression analysis, diabetes mellitus was the only independent risk factor for perioperative infectious complications (odds ratio 2.70, 95% CI 1.30-5.58). The occurrence rate of perioperative complications generally met the audit criteria of the ISPD guidelines. CONCLUSION: PD catheter placement in Japan was proven to be safe and appropriate.

Coronary artery calcification is a risk factor for intradialytic hypotension in patients undergoing hemodialysis.

INTRODUCTION: We investigated the association between intradialytic hypotension (IDH) and coronary artery calcification and their effects on mortality in hemodialysis (HD) patients. METHODS: Consecutive patients undergoing maintenance HD were enrolled. The study timeline included the baseline (day 1), exposure assessment (day 1-day 22), and outcome assessment (day 23-3 years) periods. IDH was defined as a nadir systolic blood pressure (SBP) of <100 mmHg or vasopressor use during at least 2 of 10 HD sessions in the exposure assessment period. The clinical data at baseline and the Agatston coronary artery calcium score (CACS) were assessed in the exposure assessment period. FINDINGS: The median age and dialysis vintage were 67 years [60-75 years] and 73 months [37-138 months], respectively. IDH occurred in 37 patients (21.4%), and the CACS was higher in the IDH group than in the non-IDH group (p = 0.08). IDH was associated with CACS, diabetes mellitus, mean predialysis SBP, and mean ultrafiltration volume (p < 0.05). The cutoff CACS for mortality was 1829 (sensitivity: 69%, specificity: 77%). In all, 45 all-cause deaths and 19 cardiovascular deaths occurred over 3 years. Patients with both IDH and a CACS of ≥1829 had a lower 3-year cumulative survival from cardiovascular death (66.7%) than those with a CACS of ≥1829 (80.3%), IDH (88.5%), or neither (95.5%) (p < 0.01). IDH, a CACS of ≥1829, and IDH + CACS of ≥1829 were predictors of 3-year all-cause and cardiovascular mortality (p < 0.05). The hazard ratio for cardiovascular mortality was highest in the group with IDH + CACS ≥ 1829. DISCUSSION: A high CACS may be a biomarker for IDH. Both IDH and CACS were risk factors for all-cause and cardiovascular mortality in patients undergoing HD, and there was a synergistic interaction between IDH and high CACS for cardiovascular mortality.

Synergistic Effects of the Geriatric Nutritional Risk Index and the Modified Creatinine Index for Predicting Mortality in Patients on Hemodialysis.

This study aimed to investigate whether a combined estimation of the geriatric nutritional risk index (GNRI) and the modified creatinine index (mCI) provides synergistic information for mortality in patients treated by chronic hemodialysis. We analyzed 499 patients on hemodialysis for five years. We set each cut-off value as the high (≥92) and low (<92) GNRI groups and the high (≥21 mg/kg/day) and low (<21 mg/kg/day) mCI groups, and divided them into four subgroups: G1, high GNRI + high mCI; G2, high GNRI + low mCI; G3, low GNRI + high mCI; and G4, low GNRI + low mCI. The survival rate was evaluated and time-to-event analysis was performed. All-cause death occurred in 142 (28%) patients. Kaplan−Meier curves showed that G2 and G4 had a significantly worse outcome (p < 0.05) than G1 but not G3. Using the multivariable-adjusted model, only G4 was significantly associated with all-cause mortality compared with G1. Our study suggests that the synergistic effects of the GNRI and the mCI are helpful in predicting all-cause mortality. The combination of these indices may be superior to a single method to distinguish patients who are well or moderately ill from potentially severely ill.

Different risk factors are associated with vascular access patency after construction and percutaneous transluminal angioplasty in patients starting hemodialysis.

BACKGROUND: The objective of this multicenter, prospective observational study was to determine the factors related to patency rates after construction of vascular access (VA) and the first percutaneous transluminal angioplasty (PTA). METHODS: The 24-month primary and secondary patency rates after construction of a radiocephalic arteriovenous fistula (RC-AVF) and arteriovenous graft (AVG) were evaluated using the Kaplan-Meier method and log-rank test. The 12-month post-PTA patency rate was also investigated. A Cox proportional hazard model was used to identify clinical parameters associated with the primary patency rate and the post-PTA patency rate. RESULTS: A total of 611 patients were enrolled in the study. The primary patency rate after VA construction was lower in hemodialysis (HD) patients with an AVG than in those with an AVF. Aging (hazard ratio [HR], 1.02 per 1 year; p < 0.001), female sex (HR, 1.41; p = 0.03), diabetes mellitus (HR, 1.37; p = 0.03), low serum albumin (HR, 0.76 per 1-g/dL decrease; p = 0.02), and use of an erythropoietin-stimulating agent (HR, 1.62; p = 0.02) were risk factors for VA problems. The post-PTA patency rate was associated with aging (HR, 1.02; p < 0.001), diabetes mellitus (HR, 1.49; p = 0.02), polycystic kidney disease (HR, 2.14; p = 0.01), temporary catheter use for initiation of HD (HR, 1.60; p = 0.02), and period from VA construction to use (HR, 0.99; p = 0.04). CONCLUSION: Although a poor patency rate is commonly associated with advanced age and diabetes, different risk factors affect patency between VA construction and the first PTA.