Chronic kidney disease-related osteoporosis is associated with incident frailty among patients with diabetic kidney disease: a propensity score-matched cohort study.

Chronic kidney disease (CKD)-related osteoporosis is a major complication in patients with CKD, conferring a higher risk of adverse outcomes. We found that among those with diabetic kidney disease, this complication increased the risk of incident frailty, an important mediator of adverse outcomes. INTRODUCTION: Renal osteodystrophy and chronic kidney disease (CKD)-related osteoporosis increases complications for patients with diabetic kidney disease (DKD). Since musculoskeletal degeneration is central to frailty development, we investigated the relationship between baseline osteoporosis and the subsequent frailty risk in patients with DKD. METHODS: From the Longitudinal Cohort of Diabetes Patients in Taiwan (n = 840,000), we identified 12,027 patients having DKD with osteoporosis and 24,054 propensity score-matched controls having DKD but without osteoporosis. The primary endpoint was incident frailty on the basis of a modified FRAIL scale. Patients were prospectively followed-up until the development of endpoints or the end of this study. The Kaplan-Meier technique and Cox proportional hazard regression were used to analyze the association between osteoporosis at baseline and incident frailty in these patients. RESULTS: The mean age of the DKD patients was 67.2 years, with 55.4% female and a 12.6% prevalence of osteoporosis at baseline. After 3.5 ± 2.2 years of follow up, the incidence rate of frailty in patients having DKD with osteoporosis was higher than that in DKD patients without (6.6 vs. 5.7 per 1000 patient-year, p = 0.04). A Cox proportional hazard regression showed that after accounting for age, gender, obesity, comorbidities, and medications, patients having DKD with osteoporosis had a significantly higher risk of developing frailty (hazard ratio, 1.19; 95% confidence interval, 1.02-1.38) than those without osteoporosis. CONCLUSIONS: CKD-related osteoporosis is associated with a higher risk of incident frailty in patients with DKD.

Osteoprotegerin, inflammation and dyslipidemia are associated with abdominal aortic calcification in non-diabetic patients on peritoneal dialysis.

BACKGROUND AND AIMS: Abdominal aortic calcification (AC) has been reported to be associated with cardiovascular disease (CVD) in hemodialysis patients but is rarely discussed in peritoneal dialysis (PD) patients. We examined the independent predictors and predictive power for survival of AC in prevalent PD patients. METHODS AND RESULTS: AC was detected by computed tomography (CT) and represented as the percentage of the total aortic cross-section area affected by AC (%AC). The predictors of %AC ≥ 15 were examined by multiple logistic regression analysis. Cox proportional hazard analysis was used to determine the hazard ratios associated with high %AC. A total of 183 PD patients were recruited to receive CT scans and divided into group 1 (%AC < 15, n = 97), group 2 (%AC ≥ 15, n = 41), and group 3 (diabetic patients, n = 45). Group 1 patients had lower osteoprotegerin (OPG) levels than group 2 patients (798 ± 378 vs. 1308 ± 1350 pg/mL, p < 0.05). The independent predictors for %AC ≥ 15 included the atherogenic index, OPG, and C-reactive protein (CRP). The age-adjusted hazard ratios associated with %AC ≥ 15 were 3.46 (p = 0.043) for mortality and 1.90 (p = 0.007) for hospitalization. CONCLUSIONS: %AC can predict mortality and morbidity in non-diabetic PD patients, and 15% is a good cut-off value for such predictions. There are complex associations among mineral metabolism, inflammation, and dyslipidemia in the pathogenesis of AC.

Campylobacter jejuni peritonitis and bacteremia in a patient undergoing continuous ambulatory peritoneal dialysis.

Gram-negative pathogen-induced continuous ambulatory peritoneal dialysis- (CAPD) related peritonitis is increasing, especially that caused by enteric pathogens. We describe a 54-year-old Taiwanese man with a case of Campylobacter jejuni-mediated CAPD-related peritonitis and bacteremia. Positive Campylobacter jejuni dialysate and blood cultures confirmed the diagnosis of CAPD-mediated systemic infection. We initially administered intraperitoneal ceftazidime, amikacin and oral azithromycin, but the patient did not recover. We then administered i.v. ciprofloxacin and replaced the hemodialysis (HD). The patient recovered and was discharged with maintenance HD. Treatment of Campylobacter jejuni-mediated CAPD peritonitis is a challenge in areas with high antibiotic resistance.

Rupture of pectoralis major muscle in an elderly patient receiving long-term hemodialysis: case report and literature review.

Total or near-total rupture of the pectoralis major muscle is rare. It has mainly occurred in male patients between 20 - 40 years of age while performing weight-lifting. Major tendon rupture is a rare but well-documented complication of long-term dialysis. However, rupture of pectoralis major in dialysis patients had never been reported before. Here, we present a pectoralis major rupture in an elderly patient receiving maintenance hemodialysis. Both old age and long-term dialysis could be risk factors of rupture. The clinicians should pay more attention to this complication when taking care of elderly patients on hemodialysis.

Zona fasciculata-like cells determine the response of plasma aldosterone to metoclopramide and aldosterone synthase messenger ribonucleic acid level in aldosterone-producing adenoma.

The different responses of plasma aldosterone to ACTH and angiotensin II in aldosterone-producing adenoma (APA) is thought to be due to the various cellular compositions of the tumors. To investigate whether the dopaminergic regulation of aldosterone in APA is also dependent on the cellular types, we studied the effects of metoclopramide on plasma aldosterone in six patients with APA. The messenger RNA (mRNA) levels of aldosterone synthase (P450aldo), 11 beta-hydroxylase (P450(11) beta), and 17 alpha-hydroxylase (P450(17) alpha) of APA and normal adrenal glands were determined by competitive polymerase chain reaction. After administration of metoclopramide (an antagonist of dopamine-2 receptor), the increment of plasma aldosterone correlated inversely with the percentage of zona fasciculata cells of APA. The mRNA level of P450aldo in the tumorous portion was much higher, whereas the levels of P450(11) beta and P450(17) alpha mRNAs were lower, than those of the nontumorous portion and normal adrenals. There was a correlation of the percentage of zona fasciculata cells in APA with the levels of P450aldo and P450(11) beta mRNAs, but not with P450(17) alpha mRNA. These results suggest that differential responsiveness of plasma aldosterone to metoclopramide may be due to various proportions of different cell types in APA that may have different expression of dopamine-2 receptor. In addition, this histologically dependent expression was present at the transcriptional level of the gene responsible for aldosterone biosynthesis.

Quantitative analysis of messenger ribonucleic acid encoding natriuretic peptide receptors in aldosterone-producing adenoma.

There exist conflicting data regarding the inhibitory effect of atrial natriuretic peptide on aldosterone production from aldosterone-producing adenoma (APA). Natriuretic peptides mediate their actions through natriuretic peptide receptors (NPRs). Whether or not NPRs are present in the tumors remains controversial. To elucidate this paradox, gene expression of NPRs was examined by Northern blot analysis and competitive polymerase chain reaction in tumorous and non-tumorous portions of APA, and in normal adrenal gland from patients with renal cell carcinoma. The results of Northern blot analysis showed the presence of messenger ribonucleic acid (mRNA) of three NPRs in all adrenal tissues, including APA. The proportional expression of NPR gene transcripts in APA was type A (0.6%), type B (18.7%), and type C (80.7%). The levels, but not the proportions, of type C and possibly type B NPR mRNAs were lower in tumorous and non-tumorous portions of APA compared to those in normal adrenal gland (type C 190.2 +/- 24.5 [means +/- SEM, normal adrenal gland] > 168.1 +/- 20.8 [non-tumorous portion] > 112.2 +/- 15.5 [tumorous portion] pg/10 micrograms total RNA, F = 3.82, P < 0.05; type B 45.2 +/- 8.5 [normal adrenal gland] > 30.0 +/- 5.2 [non-tumorous portion] > 25.1 +/- 4.1 [tumorous portion] pg/10 micrograms total RNA, F = 3.03, P = 0.065). The mRNA levels of type C, rather than type A or type B, NPR were correlated with the percentage of zona fasciculata-like cells in APA (r = 0.90, P < 0.05). In conclusion we have demonstrated the presence of mRNA encoding the three NPRs in APA.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult primary IgA nephropathy and common viral infections.

Serum samples obtained from 69 histopathologically proven IgA nephropathy (IgAN) patients and 563 healthy controls were examined to evaluate the association between IgAN and common viral infections. Antibody titres to cytomegalovirus (CMV), herpes simplex virus (HSV), Vericella-Zoster virus (VZV), Influenza A (Inf. A) and Influenza B (Inf. B) viruses were determined, using a complement fixation test. The viral antibody titres were considered to be positive with dilutions of 1:8 or greater except for Epstein-Barr virus (EBV), studied using immunofluorescence, which was considered to be positive with dilutions of 1:10 or greater. The positive rate of Inf. B antibody in IgAN patients was significantly lower than that in controls. The frequency of positive CMV antibody titres was higher than for controls, but with only borderline statistical significance (P = 0.059). The frequency of positive CMV and Inf. B titres was compared by age in IgAN patients and controls. but showed no statistically significant difference. Comparisons of percentage distributions at each antibody dilution level to the common virus of IgAN patients and controls, but showed no statistically significant difference. Comparisons of percentage distributions at each antibody dilution level to the common virus of IgAN patients and controls were made; however, none showed a statistically significant difference. In conclusion, no absolutely higher frequency of positive antibody titres for common viruses was demonstrated in IgAN patients in this study.

Relationship between dialysis adequacy and quality of life in long-term peritoneal dialysis patients.

OBJECTIVE: The purpose of this study was to compare quality of life (QOL) between peritoneal dialysis (PD) patients with adequate and inadequate total solute clearance (TSC). We also tried to determine the relationship between QOL and TSC. DESIGN: A cross-sectional study design was used in which QOL was evaluated and compared between PD patients with adequate and inadequate TSC. SETTING: The PD unit of a university teaching hospital. PATIENTS: Sixty-seven patients were recruited, 38 on continuous ambulatory PD and 29 on continuous cyclerassisted PD. METHODS: Patients were divided into adequate and inadequate groups, based on the results of either total urea clearance (Kt/Vurea) or total creatinine clearance (weekly CCr). The demographic data, dialysis variables, and clinical parameters of these patients were all collected. QOL was evaluated using the SF-36 questionnaire, which contains eight domains and is a comprehensive and validated instrument for QOL evaluation. QOL of patients in adequate and inadequate groups was compared. The relationship between QOL and TSC was also examined. RESULTS: Among patients grouped by Kt/Vurea, patients in the adequate group had significantly higher scores in two domains of the SF-36, that is, physical and emotional role functioning, than did those in the inadequate group. The total SF-36 scores were positively correlated with Kt/Vurea when all patients were pooled together. However, among patients grouped by weekly CCr, there was no significant difference in any of the eight domains of the SF-36 between patients in the adequate and inadequate groups. No correlation was found between the total SF-36 scores and weekly CCr. CONCLUSION: Our study had two important findings: First, PD patients with adequate total solute clearance, based on Kt/Vurea and not on weekly CCr, had a better QOL. Second, Kt/Vurea is better correlated with QOL than weekly CCr. These findings suggest that Kt/Vurea is a better parameter for the clinical evaluation of total solute clearance from the viewpoint of QOL.

Systemic lupus erythematosus and peritoneal dialysis: outcomes and infectious complications.

OBJECTIVE: Systemic lupus erythematosus (SLE) is the most common secondary glomerulonephritis resulting in end-stage renal disease (ESRD) among young adults in Taiwan. Studies of the infectious complications and outcomes among such SLE patients undergoing peritoneal dialysis (PD) are limited. DESIGN: A retrospective age- and gender-matched case control study. SETTING: A university teaching hospital. PATIENTS: There were 23 SLE patients with ESRD receiving PD for more than 3 months during the past 15 years. Another 46 age- and gender-matched non-SLE nondiabetic patients receiving PD were selected as the control group in this study. INTERVENTION: All patients underwent PD as renal replacement therapy and were regularly followed up at this hospital. MAIN OUTCOME MEASURES: Technique survival and incidences of exit-site infection (ESI) and peritonitis in these patients. RESULTS: The SLE patients had a lower predialysis serum albumin than the control group (3.16 +/- 0.50 g/dL vs 3.52 +/- 0.50 g/dL, p < 0.01). The incidences of exit-site infection (ESI) and peritonitis were higher for SLE patients than for control patients (p < 0.01 and p < 0.001, respectively). Kaplan-Meier survival analysis indicated that SLE patients had shorter time intervals to first infectious complications, and poorer technique survival. Infection was the major cause of dropout and mortality in the SLE patients. The SLE patients had a reduced chance of receiving a renal transplant. The use of steroids by SLE patients was associated with a higher incidence of peritonitis (p = 0.04), but association with ESI was insignificant. In a Cox regression model, the underlying SLE was the only risk factor for technique failure and time interval to first infectious complication. CONCLUSION: SLE patients undergoing PD are more susceptible to infection than age- and gender-matched non-SLE nondiabetic patients and have poorer technique survival. Systemic lupus erythematosus itself may further compromise the immunity of uremic patients.

Impact of peritoneal membrane transport on technique failure and patient survival in a population on automated peritoneal dialysis.

The peritoneal equilibration test (PET) is well established as a tool for classifying patients as low (L), low average (LA), high average (HA), or high (H) peritoneal transporters. We performed this retrospective 6 year cohort survey to evaluate the impact of different types of PET results on technique survival and patient survival on automated peritoneal dialysis (APD) therapy. From March 1992 to May 1998, 50 patients (20 men, 30 women) receiving APD were enrolled. The mean follow-up period was 25.2 +/- 9.2 months. Basic data and PET results of each patient at the initiation of APD therapy were retrospectively obtained for analysis. Adequacy of dialysis was estimated by measurement of total weekly urea clearance (Kt) normalized to total body water (V) and total weekly creatinine clearance (Ccr) per 1.73 m2 body surface area. The clinical outcomes evaluated were technique survival and patient survival. For statistical analyses we used the Kruskal-Wallis test, Friedman test, Kaplan-Meier life table analysis, and Cox's proportional hazards regression model. There were no differences in age, gender, prevalence of diabetes mellitus (DM), duration of APD, or the initial value of serum albumin between the four subgroups (H, HA, LA, and L). There were 11 (22%) deaths and 8 (16%) technique failures. The 2 year patient survival probability was significantly higher (100%) in the L subgroup than in the LA (62.6%), HA (48.4%), or H (46.2%) subgroups. Patients with DM had a lower patient survival rate than patients without DM; however, there was no statistical significance in technique survival rate between them. Diabetes mellitus (RR = 2.898) and the final albumin value (RR = 0.2099 per increase of 1 gm/dl) had a significant influence on patient survival. By stepwise regression analysis of final serum albumin levels, we found that patients with lower serum albumin values (< or = 3.0 gm/dl vs. >3.0 gm/dl) had a significantly lower probability of patient survival (p = 0.0156). We conclusively demonstrate four important findings in this work: 1) patients with H peritoneal transport had a lower probability of patient survival, but not a decreased rate of technique survival; 2) patients with L peritoneal transport can tolerate APD well; 3) there was no significant difference in technique survival rate between the different PET subgroups; and 4) DM and a lower serum albumin, implicating malnutrition, may contribute to the lower probability of patient survival among H peritoneal transporters.

Trace elements burden in geriatric hemodialysis patients: a prospective multicenter collaborative study.

INTRODUCTION: Hemodialysis therapy and the aging process have been reported to interfere with the trace element (TE) status in the body. This multicenter collaborative study on blood levels of TE in geriatric hemodialysis (HD) patients was carried out with an aim to clarify the impact of the aging process and HD therapy on the TE status in such patients. METHODS: One hundred and fifty-one HD patients (65 male, 86 female), all aged over 60 (68.2+/-3.86 y), and 112 elderly controls (58 male, 54 female) with a mean age of 67.5+/-3.03 were enrolled. All patients underwent standard HD for at least 6 months. The artificial kidneys used were hollow-fiber dialyzers of cellulose membranes. Water used for HD was prepared by reverse osmosis. Blood was collected in the morning prior to dialysis and after fasting. Atomic absorption spectrophotometry was applied to measure blood levels of Pb, Cd and Hg as well as plasma levels of Cu, Zn and Al. Data are presented as mean +/- SEM. Student's t-test and linear regression were applied for statistics. RESULTS: Our geriatric chronic HD patients showed a marked elevation of blood Al and decreased plasma Zn concentrations. The blood levels of Cu, Cd, Pb and Hg were within normal limits. The blood concentrations of Al, Cu and Pb were significantly higher in HD patients than in the normal elderly controls, whereas Cd and Hg were similar in both groups, and Zn were lower in HD patients. Plasma Zn value decreased as dialysis duration increased, however there was a reversely linear correlation between plasma Zn and age. CONCLUSIONS: This data reported can be regarded as a starting point and may serve as an insight to further studies on TE imbalances in geriatric and chronic HD populations.

Incidence of exit-site infection with various exchange systems in continuous ambulatory peritoneal dialysis.

BACKGROUND AND PURPOSE: The disconnect twin-bag (TB) system was first introduced in Taiwan for use as an exchange system in continuous ambulatory peritoneal dialysis (CAPD) in 1995. Following its introduction, the incidence of CAPD-associated peritonitis declined, but the incidence of exit-site infection (ESI) increased. To determine the cause of the increase in ESI incidence after the introduction of the TB system, this study compared the incidence of ESI among patients using the O set, ultraviolet antiseptic (UV) device, and the TB system. METHODS: A total of 170 patients who had received CAPD for more than 3 months were enrolled in this study. Poisson test and Kaplan-Meier survival analysis were used to compare the ESI incidence and ESI-free catheter survival among patients using the O set, UV device, or TB system. Cox stepwise forward proportional hazard analysis was used to assess the impact of sex, education, cause of uremia, age, and type of exchange system on ESI. RESULTS: The incidences of ESI differed significantly among patients using the three exchange systems, with 20.9, 13.8, and 4.0 episodes per 100 patient-years for patients using the TB system, O set, and UV device, respectively. New patients using the TB system also had a shorter mean interval of ESI-free catheter survival than those using the UV device (26.9 vs 58.8 months, p = 0.002). In the Cox stepwise forward proportional hazard analysis, non-lupus patients had a lower risk of developing ESI than lupus patients (relative risk [RR] 0.40, p = 0.03). The RR of ESI in patients using the UV device was also lower than in those using the TB system (RR 0.15, p < 0.01). CONCLUSION: In this study, use of the TB system was associated with a higher incidence of ESI. The increased ESI incidence may be related to the heavier mini-transfer set of the TB system. Therefore, special attention should be given to fastening the mini-transfer set tightly during the exchanging procedure to prevent traction on the exit-site, which is associated with an increased incidence of subsequent ESI.

Clinical features of and risk factors for fungal peritonitis in peritoneal dialysis patients.

BACKGROUND AND PURPOSE: Fungal peritonitis (FP) is a serious complication for peritoneal dialysis (PD) patients and can result in technical failure and mortality. Catheter removal remains the mainstay of treatment. This study sought to identify the risk factors for FP in order to facilitate the prevention of this catastrophic complication. METHODS: A total of 246 patients who received long-term PD from 1985 to 1998 were included in this retrospective study. Twenty episodes of FP occurred in 19 patients. The clinical characteristics, pathogens, treatment modalities, and outcomes of the FP episodes were retrospectively reviewed. The FP incidence in various demographic and clinical groups, classified according to sex, age, education, and underlying cause of uremia, were compared with the Poisson test. RESULTS: Thirteen episodes of FP were caused by yeast, and the remaining episodes were caused by Aspergillus spp. Age, sex, and education did not affect the FP incidence. Lupus patients (969 patient-months) had a higher incidence of FP than patients with other underlying diseases (p < 0.05). The 19 FP patients also had a higher incidence of bacterial peritonitis than other PD patients (p < 0.01). Among the 20 FP episodes, 14 (70%) were preceded by antibiotic use, and eight (40%) developed during hospitalization. Steroids were used at the time of FP in five of six lupus patients. Seven patients (37%) died within 1 month after diagnosis of FP. Five patients were able to remain on PD after FP, but only three patients were able to maintain catheter placement. CONCLUSION: The risk factors for FP identified in this study include the use of antibiotics and steroids, underlying lupus, frequent occurrence of bacterial peritonitis, and hospitalization. Antifungal therapy may allow the catheter to be kept in place in a few patients, but catheter removal should be considered in patients whose FP is refractory to medical treatment.

Necrotizing fasciitis caused by Serratia marcescens in two patients receiving corticosteroid therapy.

Necrotizing fasciitis (NF), a devastating soft tissue infection, is rarely attributed to Serratia marcescens. We here report two patients with S. marcescens NF, both of whom had underlying renal disease and had been receiving corticosteroid therapy. The first patient, a 40-year-old man with systemic lupus erythematosus and uremia on prednisolone therapy, developed fulminant cellulitis and septic shock 1 month after a skin biopsy for cutaneous vasculitis of the left foot. The cellulitis evolved to NF, and blood and necrotic tissue cultures both grew S. marcescens. The patient completely recovered after debridement and ceftazidime therapy. The second patient, a 73-year-old man receiving prednisolone therapy for nephrotic syndrome, developed right leg cellulitis that evolved to NF. Blood and necrotic tissue cultures both grew S. marcescens. After aggressive debridement and ciprofloaxcin therapy, the NF improved. However, the patient died of aspiration pneumonia and massive gastrointestinal bleeding 1 month later. These findings illustrate that S. marcescens should be considered as a potential pathogen causing NF in susceptible hosts.

Honokiol, a small molecular weight natural product, alleviates experimental mesangial proliferative glomerulonephritis.

Glomerulonephritis (GN) is still the most common cause of end-stage renal disease. Accumulation of glomerular macrophages, proliferation of mesangial cells, and deposition of extracellular matrix proteins are pathobiological hallmarks of GN. Pharmacological interventions that can inhibit these insults may be beneficial in the retardation of the progression of GN. Honokiol originally isolated from Magnolia officinalis, shows antioxidative, anti-inflammatory, and antiproliferative activities in a variety of inflammation models. In this study, we first investigated the in vivo effects of honokiol on rat anti-Thy1 nephritis. Anti-Thy1 nephritis was induced in Wistar rats by injecting mouse anti-rat Thy1 antibodies intravenously. Nephritic rats were randomly assigned to receive honokiol (2.5 mg/kg, twice a day) or vehicle and were killed at various time points. Glomerular histology and immunohistopathology and urine protein excretion were studied. Western blotting was conducted for markers of proliferation. Adhesion molecules, chemokine, and extracellular matrix gene expression were evaluated by Northern blotting. Honokiol-treated nephritic rats excreted less urinary protein and had lower glomerular cellularity and sclerosis. The increased intraglomerular proliferating cell nuclear antigen and Akt phosphorylation in nephritic rats could be abolished by the treatment of honokiol. Honokiol also alleviated glomerular monocyte chemoattractant protein-1 and intracellular adhesion molecule-1, similar to type I (alpha1) collagen and fibronectin mRNA levels of nephritic rats. These results indicate that honokiol may have therapeutic potential in mesangial proliferative GN.

Infection associated with double lumen catheterization for temporary haemodialysis: experience of 168 cases.

A total of 227 patients with renal failure requiring acute haemodialysis with placement of a total of 260 Medcorp double lumen catheters at National Taiwan University Hospital from July 1992 to July 1993 were reviewed. Among them, only 135 patients receiving a total of 168 catheter placements and a complete infectious work-up were selected for this study. The mean age of the patients was 55 years (range 15-89 years); 63 (46.7%) were male and 75 (53.3%) were female. The three major reasons for dialysis were chronic glomerular disease (CGN; 49%), diabetic nephropathy (13%) and nephritis associated with systemic lupus erythematosus (SLE; 11%). The catheters remained in place for an average of 27.8 days (9-73 days) and each catheter was used for an average of eight treatments (2-26). The reasons for catheter removal were classified as: availability of permanent vascular access (48%), recovery of renal function (10%), scheduled duration (30 days, not every case; 4%), expiration of patient (10%), suspicion of catheter-related infections (15%), and catheter thrombosis/occlusion (9%). Seven cases with local haematoma and one case of pneumothorax were also identified (total 5%). In total, a 21.4% catheter-related infection rate was observed and micro-organisms such as Staphylococcus aureus (33%), coagulase-negative staphylococci (36%) and Enterococcus (19%) were isolated. The cumulative probability of patients remaining free from catheter-related infections was about 75% by the end of the fourth week post-catheter insertion, and decreased to less than 50% near the end of the second month of persistent catheterization.(ABSTRACT TRUNCATED AT 250 WORDS)

Viral hepatitis infection should be considered for evaluating uremic pruritus in continuous ambulatory peritoneal dialysis patients.

Determining the possible association of viral hepatitis infection and degree of pruritus is the primary concern of this study. Ninety-six adequately dialyzed CAPD patients (47 male and 49 female) and 526 normal controls (266 male and 260 female) were enrolled. Blood hemoglobin, ferritin, electrolytes, calcium, phosphate, albumin, urea, creatinine, aspartate transaminase (AST), alanine transaminase (ALT), alkaline phosphatase, and bilirubin were analyzed by routine methods. Serum HBsAg was examined, using a radioimmunoassay method and the anti-HCV, an enzyme immunoassay method. All cases were interviewed with a standardized questionnaire. The highest possible pruritus score (PS) was 22. The prevalences of HBsAg(+) and anti-HCV(+) were 14.6% and 17.7%, respectively. The mean PS in all 96 CAPD patients was 11.6 (range 7-22). The mean PS were 11.8 +/- 0.6 and 12.5 +/- 1.0 for patients infected with HBV and HCV, respectively. Both were significantly higher than that (10 +/- 0.9) of patients without hepatitis infection. AST and ALT were significantly higher in patients infected with viral hepatitis than those without. The other biochemical parameters were not significant. Thirty-seven (38.5%) of our 96 patients had mild pruritus (PS < or = 7) and 11 (15.9%) had severe pruritus (PS > or = 15). Of the 83.9% (26/31) patients with viral hepatitis, the grades of skin itching were moderate to severe; whereas those of the patients without viral hepatitis, 53.6% (37/69) belonged to the group of moderate to severe pruritus (p = 0.003, chi 2 test with Yates' correction). The authors recommended screening of viral hepatitis infection to be undertaken for uremic patients with unexplained skin itching.

Natural changes in peritoneal equilibration test results in continuous ambulatory peritoneal dialysis patients: a retrospective, seven year cohort survey.

We conducted a retrospective, 7 year cohort survey to examine the natural changes in peritoneal equilibration test (PET) results in patients with long-term uneventful continuous ambulatory peritoneal dialysis (CAPD). Thirty-two (17 males, 15 females) patients on CAPD with two or more standard PETs performed more than 6 months apart, in the absence of peritoneal insult, were included. Changes and pattern of PET results were evaluated by the dialysate to plasma ratio of creatinine (D:P-cre), the fourth h dialysate to instilled glucose ratio (D4:Do) and ultrafiltration volume (UF, ml). The subgroups included high (H), high-average (HA), low-average (LA), or low (L) transporters with the dividing ratios (D:P-cre) of >0.81, >0. 65 to 0.81, >0.5 to 0.65, and <0.5, respectively. The median D:P-cre significantly decreased (p = 0.04), but neither the D4:Do nor the final median UF significantly decreased. The change in D:P-cre was strongly and inversely correlated with the initial D:P-cre value (r = -0.68; p < 0.05). A similar relationship was found between the change in the final D4:Do and the initial D4:Do (r = -0.752; p < 0. 01) and between the change in the final UF and the initial UF (r = -0.875; p < 0.01). No correlation was found between the change in D:P-cre and the age of the patient, the time interval between PETs, monthly dialysate glucose exposure, or underlying diabetes/non-diabetes. The final peritoneal transport pattern was altered with 5 (15.6%) patients remaining in the extreme subgroups (H or L) and, by contrast, 84.4% (27/32) of the patients now in the averaged (HA or LA) groups (p < 0.01, chi2 test). We demonstrated a natural "centralization" migration of PET results after long-term uneventful CAPD, which may help to explain why patients with extreme PET characteristics, that is, H or L, continued to do well on CAPD.

Non-excretory myeloma with diffuse osteolytic lesions caused by tumor necrosis factor: report of a case.

A 63-year-old male patient was admitted to the hospital after a six-month complaint of low back pain. Anemia, hypercalcemia and 5 to 18% giant abnormal binucleated plasma cells infiltrations in the bone marrow suggested a diagnosis of multiple myeloma. However, repeated serum and urine immunofixation electrophoresis failed to demonstrate any abnormal monoclonal band. Diagnosis of non-excretory myeloma was verified by immunocytochemical stains demonstrating intracellular kappa chain in these neoplastic cells. Some authors have claimed that there were fewer bone lytic changes, less bone marrow infiltration, more preservation of normal immunoglobulin but with more neurological presentations among non-excretors. However, this patient had severely generalized bone lytic lesions and high serum level of tumor necrosis factor. The former might be attributed to the latter. Literatures about multiple myeloma and the tumor necrosis factor are also reviewed.