Association of serum chromium levels with malnutrition in hemodialysis patients.

BACKGROUND: Chromium is an essential trace metal that reduces oxidative stress and inflammation. In patients undergoing maintenance hemodialysis (MHD), a correlation among chromium exposure, inflammation, and malnutrition remains unclear. This study examined the possible effects of serum chromium levels (SCLs) in MHD patients. METHODS: Initially, 732 MHD patients in dialysis centers were recruited. A total of 647 patients met the inclusion criteria and were stratified by SCL into four equal-sized groups: first quartile (< 0.29 µg/L), second quartile (0.29-0.56 µg/L), third quartile (0.57-1.06 µg/L), and fourth quartile (> 1.06 µg/L). Demographic, biochemical, and dialysis-related data were obtained for analyses. The analysis included nutritional and inflammatory markers. RESULTS: As compared with the highest quartile group, more subjects in the lowest quartile group were of an older age; had lower hemoglobin and creatinine levels; had a higher prevalence of DM and malnutrition (serum albumin level < 3.6 g/dL); and higher serum transferrin saturation and ferritin levels. A stepwise multiple linear regression analysis revealed a significant negative correlation between malnutrition and SCL (ß coefficient = - 0.129, p = 0.012) and negative associations among body mass index (ß coefficient = - 0.010, p = 0.041), ferritin (ß coefficient = - 0.107, p = 0.001) and SCL. A multivariate logistic regression analysis also demonstrated a negative correlation between malnutrition and SCL. With a 10-fold increase in SCL, the risk ratio of malnutrition was 0.49 (95% confidence interval: 0.25-0.96; p = 0.039). CONCLUSIONS: SCL is significantly associated with malnutrition in MHD patients. Further evaluation of the relationship between clinical outcomes (morbidity/mortality) and SCL is necessitated.

Acute kidney injury and the risk of mortality in patients with methanol intoxication.

BACKGROUND: Methanol poisoning is a serious public health issue in developing countries, but few data are available in the literature on acute kidney injury (AKI) after methanol intoxication. METHODS: This study examined the clinical features, spectrum and outcomes of AKI in patients with methanol intoxication and evaluated the predictors of mortality after methanol intoxication. A total of 50 patients with methanol intoxication were seen at Chang Gung Memorial Hospital between 2000 and 2013. Patients were grouped according to the status of renal damage as AKI (n = 33) or non-AKI (n = 19). Demographic, clinical, laboratory, and mortality data were obtained for analysis. RESULTS: Most patients were middle-aged (47.8 ± 14.9 years), predominantly male (74.0%), and habitual alcohol consumers (70.0%). Most incidents were oral exposures (96.0%) and unintentional (66.0%). Two (4.0%) patients attempted suicide by intravenous injection of methanol. Five (10.0%) patients suffered methanol intoxication after ingestion of methomyl pesticide that contained methanol as a solvent. Compared to non-AKI patients, the AKI patients were older (50.9 ± 13.7 versus 41.6 ± 15.6 years, P = 0.034), predominantly male (90.9% versus 42.8%, P = 0.000), more habitual alcohol users (84.8% versus 41.2%, P = 0.001) and had more unintentional exposures (82.8% versus 35.3%, P = 0.001). Furthermore, there was a higher incidence of respiratory failure (63.6% versus 29.4%, P = 0.022) in the AKI group than in the non-AKI group, respectively. The laboratory studies revealed that the AKI patients suffered from more severe metabolic acidosis than the non-AKI patients. By the end of this study, 13 (39.5%) AKI patients and 1 (5.9%) non-AKI patient had died. The overall in-hospital hospital mortality rate was 28%. In a multivariate binary logistic regression model, it was demonstrated that AKI (odds ratio 19.670, confidence interval 1.026-377.008, P = 0.048) and Glasgow coma scale score (odds ratio 1.370, confidence interval 1.079-1.739, P = 0.010) were significant factors associated with mortality. The Kaplan-Meier analysis disclosed that AKI patients suffered lower cumulative survival than non-AKI patients (log-rank test, chi-square = 5.115, P = 0.024). CONCLUSIONS: AKI was common (66.0%) after methanol intoxication and was predictive of in-hospital hospital mortality. The development of AKI was associated with a 19.670-fold higher risk of in-hospital mortality.

Identifying risk groups of infectious spondylitis in patients with end-stage renal disease under hemodialysis: a propensity score-matched case-control study.

BACKGROUND: Patients with end-stage renal disease (ESRD) under hemodialysis (HD) are at greater risks of infectious spondylitis (IS), but there is no reliable predictor that facilitate early detection of this relatively rare and insidious disease. METHODS: A retrospective review of the medical records from patients with ESRD under HD over a 12-year period was performed at a tertiary teaching hospital, and those with a first-time diagnosis of IS were identified. A 1:4 propensity score-matched case-control study was carried out, and baseline characteristics, underlying diseases, and laboratory data were compared between the study group and the control group, one month before the date of diagnosis or the index date respectively. RESULTS: A total of 16 patients with IS were compared with 64 controls. After adjustment, recent access operation (odds ratio [OR], 13.27; 95% confidence interval [CI], 3.53 to 49.91; p <  0.001), degenerative spinal disease (OR, 12.87; 95% CI, 1.89 to 87.41; p = 0.009), HD through a tunneled cuffed catheter (OR, 6.75; 95% CI, 1.74 to 26.14; p = 0.006), low serum levels of hemoglobin, albumin, as well as high levels of red blood cell volume distribution width (RDW), alkaline phosphatase (ALP), and high sensitivity C-reactive protein were significant predictors for a IS diagnosis one month later. Receiver operating characteristic curves for hemoglobin, RDW, ALP, and albumin all showed good discrimination. The further multivariate models identified both high serum ALP levels and low serum RDW levels following a recent access intervention in patients with relatively short HD vintages may be indicative of the development of IS. CONCLUSION: Patients under HD with relatively short HD vintages showing either elevated ALP levels or low RDW levels following a recent access intervention should prompt clinical awareness about IS for timely diagnosis.

Blood lead level: an overlooked risk of carpal tunnel syndrome in hemodialysis patients.

Introduction: Carpal tunnel syndrome (CTS) is a severe complication observed in long-term maintenance hemodialysis (MHD) patients. The most common cause of CTS is dialysis-related ß2-microglobulin amyloidosis, which is associated with inflammation and oxidative stress in dialysis patients. Patients on MHD have higher blood lead levels (BLLs) than the general population. Lead (Pb) exposure in chronic dialysis patients has been noted to induce oxidative stress and inflammation. Therefore, lead-related inflammation and oxidative stress might contribute to CTS. Methods: The medical records of 866 MHD patients were reviewed. Two hundred and thirty-four patients with symptoms of CTS were surveyed by senior neurologists via physical examinations and nerve conduction studies. Patients in this study were stratified into groups with low-normal (<10 µg/dL), high-normal (10 to 20 µg/dL), and abnormal (>20 µg/dL) BLLs. The associations between CTS and BLLs and the clinical data were analyzed. Results: Multivariate logistic regression analyses showed that Log BLL (OR: 54.810, 95% CI: 13.622-220.54, p < .001), high-normal BLLs (OR: 4.839, 95% CI: 2.262-10.351, p < .001) with low-normal BLL as a reference, high BLLs (OR: 12.952, 95% CI: 5.391-31.119, p < .001) with low-normal BLL as a reference, and a BLL >12.3 µg/dL (OR: 6.827, 95% CI: 3.737-12.472, p < .001) were positively associated with CTS according to three different analyses. Discussion: In conclusion, blood lead levels were positively associated with CTS in patients on MHD. Dialysis patients should pay more attention to their environmental exposure to Pb. Avoidance of environmental Pb may reduce the incidence of CTS in MHD patients. Future studies will address the role of Pb in the pathophysiology of CTS in this patient population.

Uremic Pruritus is Associated with Two-Year Cardiovascular Mortality in Long Term Hemodialysis Patients.

BACKGROUND/AIMS: Uremic pruritus (UP) is an unpleasant complication in patients undergoing maintenance dialysis. Cardiovascular and infection related deaths are the major causes of mortality in patients undergoing dialysis. Studies on the correlation between cardiovascular or infection related mortality and UP are limited. METHODS: We analyze 866 maintenance hemodialysis (MHD) patients in our hemodialysis centers. Clinical parameters and 24-month cardiovascular and infection-related mortality are recorded. RESULTS: The associations between all-cause, cardiovascular and infection related mortality with clinical data including UP are analyzed. Multivariate Cox regression demonstrated that UP is a significantly predictor for 24-month cardiovascular mortality in the MHD patients (Hazard ratio: 3.164; 95% confidence interval, 1.743-5.744; p < 0.001). CONCLUSION: Uremic pruritus is one of the predictor of 24-month cardiovascular mortality in MHD patients.

Family Aggregation and Heritability of ESRD in Taiwan: A Population-Based Study.

BACKGROUND: Aggregation of end-stage renal disease (ESRD) has been observed in families of European origin, as well as those of African origin. However, it is not well documented if this disease aggregates in Asian families. Furthermore, the contribution of genetic factors and shared environmental factors to family aggregation remains unclear. STUDY DESIGN: Population-based cross-sectional cohort study. SETTING & PARTICIPANTS: All 23,422,955 individuals registered in the Taiwan National Health Insurance Research Database in 2013. Among these, 47.45%, 57.45%, 47.29%, and 1.51% had a known parent, child, sibling, or twin, respectively. We identified 87,849 patients who had a diagnosis of ESRD. PREDICTOR: Family history of ESRD. OUTCOMES & MEASUREMENTS: ESRD and heritability defined as the proportion of phenotypic variance attributable to genetic factors. RESULTS: Having an affected first-degree relative with ESRD was associated with an adjusted relative risk of 2.46 (95% CI, 2.32-2.62). Relative risks were 96.38 (95% CI, 48.3-192.34) for twins of patients with ESRD, 2.15 (95% CI, 2.02-2.29) for parents, 2.78 (95% CI, 2.53-3.05) for offspring, 4.96 (95% CI, 4.19-5.88) for siblings, and 1.66 (95% CI, 1.54-1.78) for spouses without genetic similarities. Heritability in this study was 31.1% to 11.4% for shared environmental factors and 57.5% for nonshared environmental factors. LIMITATIONS: This was a registry database study and we did not have detailed information about clinical findings or the definite causes of ESRD. CONCLUSIONS: This whole population-based family study in Asia confirmed, in a Taiwanese population, that a family history of ESRD is a strong risk factor for this disease. Moderate heritability was noted and environmental factors were related to disease. Family history of ESRD is an important piece of clinical information.

Association Between Environmental Particulate Matter and Carpal Tunnel Syndrome in Patients Undergoing Hemodialysis.

BACKGROUND/AIMS: The deposition of ß2-microglobulin induced by reactive inflammation causing carpal tunnel syndrome (CTS) is one of the complications of dialysis-related amyloidosis in maintenance hemodialysis (MHD) patients. Air pollution levels, especially particulate matter with an aerodynamic diameter of <2.5 mm (PM2.5), have significantly been associated with the elevation of systemic inflammatory markers. There is no previous research on possible associations between CTS and PM2.5. METHODS: This study enrolled 866 MHD patients treated at the outpatient HD centers. Senior neurologists diagnosed the presence of CTS. Air pollution levels were recorded by a network of 27 monitoring stations near or in the patients' living areas throughout Taiwan. The 12- and 24-month average concentrations of PM with an aerodynamic diameter of <10 and <2.5 mm (PM10 and PM2.5, respectively), sulfur dioxide, nitrogen dioxide, carbon monoxide, and ozone were included. RESULTS: Multivariate logistic regression analyses showed that HD duration, the normalized protein catabolic rate (nPCR), hypoalbuminemia (albumin < 4 g/dl), and the mean previous 12-month environmental PM2.5 were positively associated with CTS; HD duration, nPCR, hypoalbuminemia (albumin < 4 g/dl), and the mean previous 24-month environmental PM2.5 were positively associated with CTS; HD duration, hypoalbuminemia (albumin < 4 g/dl), and previous 12-month PM2.5 excess days were positively associated with CTS; and HD duration, nPCR, hypoalbuminemia (albumin < 4 g/dl), and previous 24-month PM2.5 excess days were positively associated with CTS. CONCLUSION: PM2.5 levels and PM2.5 excessing days were positively correlated with CTS.

Conversion to mTOR-inhibitors with calcineurin inhibitor elimination or minimization reduces urinary polyomavirus BK load in kidney transplant recipients.

BACKGROUND/PURPOSE: Polyomavirus BK (BKV) reactivation causes allograft dysfunction in some kidney transplant recipients. The use of mammalian target of rapamycin (mTOR) inhibitor-based immunotherapy is associated with a lower incidence of polyomavirus-associated nephropathy compared with other immunosuppressants. This retrospective study assessed whether conversion to mTOR inhibitor-based immunotherapy directly reduced urinary BKV load. METHODS: A total of 63 kidney recipients were divided into mTOR inhibitor-conversion (21 patients) and nonconversion (42 patients) groups. Urinary BKV loads were determined before and at least 6 months after the conversion. RESULTS: The results demonstrated that urinary BKV titer was significantly reduced in the conversion group (3.94 ± 0.43 copies (log)/mL to 2.49 ± 0.19 copies (log)/mL) and remained unaltered in the nonconversion group (3.19 ± 0.20 copies (log)/mL to 2.90 ± 0.20 copies (log)/mL). In addition, the percentage of patients with reduced urinary BKV load was significantly higher in the conversion group (76.2% vs. 42.9%). The estimated glomerular filtration rate after 24 months mTOR inhibitor conversion was significantly increased compared with that in the nonconversion group. Conversion to mTOR-inhibitor-based immunotherapy was the only factor associated with an increase in estimated glomerular filtration rate. CONCLUSION: This study reveals an association of conversion to mTOR-inhibitor-based immunotherapy with the reduction of urinary BKV load.

Association between environmental particulate matter and arterial stiffness in patients undergoing hemodialysis.

BACKGROUND: Aortic pulse wave velocity (PWV) has been shown to be an independent predictor of cardiovascular mortality in patients with end-stage renal disease and the general population. Atmospheric particulate- matter (PM) concentrations and their effects on cardiovascular system by affecting arterial stiffness and central hemodynamic parameters had been noted. The purpose of this study was to access the correlation of air pollution variables and PWV in patients undergoing hemodialysis (HD). METHODS: This study analyzed 127 HD patients treated at the outpatient HD center. Brachial-ankle pulse wave velocity (baPWV) was measured by using a Vascular Profiler 1000 (VP-1000). Air pollution levels were recorded by a network of 27 monitoring stations near or in the patients' living areas throughout Taiwan. The 12-month average concentrations of PM with an aerodynamic diameter of <10 and <2.5 mm (PM10 and PM2.5, respectively), sulfur dioxide (SO2), nitrogen dioxide (NO2), carbon monoxide(CO), and ozone (O3) were included. RESULTS AND DISCUSSION: Multivariate linear regression analyses indicated that systolic blood pressure (SBP) (ß = 0.589, P < 0.025), age (ß = 0.316, P < 0.001), serum aluminum level (Al) (ß = 0.149, P = 0.020), and PM10 (ß = 0.133, P = 0.036) were positively correlated with baPWV. CONCLUSION: This cross-sectional study shows that in HD patients, the environmental PM10 level is associated with the baPWV.

Polyomavirus BK-encoded microRNA suppresses autoregulation of viral replication.

Polyomavirus BK (BKV) infection is an important cause of renal allograft failure. Viral microRNAs are known to play a crucial role in viral replication. This study investigated the expression of BKV-encoded microRNAs (miR-B1) in patients with polyomavirus-associated nephropathy (PVAN) and their role in viral replication. Following BKV infection in renal proximal tubular cells, the 3p and 5p miR-B1 levels were significantly increased. Cells transfected with the vector containing the miR-B1 precursor (the miR-B1 vector) showed a significant increase in expression of 3p and 5p miR-B1 and decrease in luciferase activity of a reporter containing the 3p and 5p miR-B1 binding sites, compared to cells transfected with the miR-B1-mutated vector. Transfection of the miR-B1 expression vector or the 3p and 5p miR-B1 oligonucleotides inhibited expression of TAg. TAg-enhanced promoter activity and BKV replication were inhibited by miR-B1. In contrast, inhibition of miR-B1 expression by addition of miR-B1 antagomirs or silencing of Dicer upregulated the expression of TAg and VP1 proteins in BKV-infected cells. Importantly, patients with PVAN had significantly higher levels of 3p and 5p miR-B1 compared to renal transplant patients without PVAN. In conclusion, we demonstrated that (1) miR-B1 expression was upregulated during BKV infection and (2) miR-B1 suppressed TAg-mediated autoregulation of BKV replication. Use of miR-B1 can be evaluated as a potential treatment strategy against BKV infection.

Acute large-dose exposure to organophosphates in patients with and without diabetes mellitus: analysis of mortality rate and new-onset diabetes mellitus.

BACKGROUND: We investigated the mortality rates of patients with and without diabetes mellitus after acute large-dose exposure to organophosphate insecticides. All patients without diabetes mellitus were traced to examine the long-term risk of new-onset diabetes mellitus. Previous reports indicated that organophosphate exposure might increase the risk of new-onset diabetes mellitus. METHODS: We analyzed the records of 118 patients referred to Chang Gung Memorial Hospital for management of intentional organophosphate poisoning between 2000 and 2011. Patients were stratified by diabetes mellitus status. Demographic, clinical, laboratory and mortality data were analyzed. RESULTS: Most patients were middle aged (53.45 ± 16.20 years) and male (65.3%) and were referred to our hospital after a relatively short amount of time had elapsed since poisoning (median 3.0 hours). 18 (15.2%) of 118 patients died, including 15 (13.8%) of 109 patients without diabetes mellitus and 3 (33.3%) of 9 with diabetes mellitus. There was no significant difference in mortality between these groups (P = 0.117). In a multivariate Cox regression model, hypotension (P = 0.000), respiratory failure (P = 0.042), coma (P = 0.023), and corrected QT interval prolongation (P = 0.002) were significant risk factors for mortality. Conversely, diabetes mellitus status was not a significant variable in this model. At routine outpatient follow up a median of 1.25 months post exposure, random blood glucose measurements gave no evidence of new-onset diabetes in patients without pre-existing diabetes. CONCLUSIONS: Diabetes mellitus status might not increase mortality risk following acute large-dose exposure to organophosphates, and the risk of new-onset diabetes mellitus also might be minimal in the short term. Larger prospective studies with formal testing for diabetes at later times post-exposure are required.

Presentation of glomerulocystic disease in a young onset diabetes: A case report.

RATIONALE: This case report presents a challenging medical scenario involving a young adult male who exhibited an unusual combination of symptoms, including abrupt weight loss, declining renal function, proteinuria, and concurrent onset of diabetes mellitus. Remarkably, the patient had no previous medical history or family history of similar conditions, necessitating a comprehensive investigation. PATIENT CONCERNS: On March 10, 2021, a 25-year-old male sought medical attention due to the aforementioned symptoms. Initial assessments revealed stage 5 chronic kidney disease, with elevated blood urea nitrogen (BUN) and serum creatinine (Cr) levels, as well as significant proteinuria. The only notable physical finding was obesity, and renal ultrasound showed normal-sized kidneys without cysts. DIAGNOSIS: A treatment plan was initiated to stabilize creatinine levels, including medications such as Glimepiride, Glyxambi, Bisoprolol, Amlodipine, and Valsartan. However, despite diligent medication management, proteinuria persisted, prompting further evaluation. A renal biopsy was performed on April 12th, 2023, leading to the diagnosis of glomerulocystic kidney disease with early-stage changes indicative of diabetic nephropathy. INTERVENTIONS: The patient continues to receive ongoing care and follow-up at our outpatient clinic to optimize therapeutic interventions and elucidate the underlying etiology of this complex clinical scenario. OUTCOMES: Ongoing investigations and therapeutic interventions are crucial to understand the underlying cause and optimize patient care in this intricate clinical scenario. LESSONS: This case underscores the complexity of diagnosing and managing a young adult presenting with concurrent renal dysfunction, proteinuria, and diabetes mellitus in the absence of prior underlying conditions. It highlights the importance of comprehensive evaluation and ongoing care in such challenging cases.

Paraquat poisoning in pediatric patients.

OBJECTIVE: This observational study examined the outcome of Taiwanese pediatric patients with paraquat poisoning and compared these data with the published data on paraquat poisonings from other international poisoning centers. METHODS: We performed a retrospective study on children with acute paraquat poisoning that were admitted to the Chang Gung Memorial Hospital during a period of 10 years (2000-2010). Of the 193 paraquat poisoning patients, only 6 were children. RESULTS: The mean age was 8.85 ± 5.55 (1-15.6) years. Younger patients had accidentally swallowed paraquat, whereas older patients had intentionally ingested paraquat. Most patients were referred within a relatively short period (0.5-2.0 hours). Paraquat poisoning was associated with high morbidity and often resulted in severe complications, including acute respiratory distress syndrome and multiple-organ failure. The complications included shock (50.0%), hypoxemia (33.3%), respiratory failure (33.3%), nausea/vomiting (16.7%), abdominal pain (33.3%), hepatitis (66.7%), gastrointestinal tract bleeding (33.3%), acute renal failure (33.3%), and seizures (16.7%). Patients were treated aggressively with a standard detoxification protocol consisting of gastric lavage, active charcoal, charcoal hemoperfusion, and cyclophosphamide and steroid pulse therapies. Secondary bacterial infections were common after hospitalization and included sepsis (33.3%), pneumonia (33.3%), and urinary tract infection (50.0%). In the end, 2 patients (33.3%) died from multiple-organ failure, despite intensive resuscitation. CONCLUSIONS: Our data (mortality rate, 33.3%) are comparable to the data of other published reports from other international poison centers. Evidently, a prompt diagnosis of paraquat poisoning and an immediate institution of a detoxification protocol is a prerequisite for a favorable outcome.

Assessing Cross-Sectional Association of Uremic Pruritus with Serum Heavy Metal Levels: A Single-Center Study.

(1) Background: Uremic pruritus (UP) is a common and taxing symptom in patients on maintenance hemodialysis (MHD). We have previously shown that blood lead levels (BLLs) and blood aluminum levels (BALs) were separately positively associated with UP in MHD patients. We also found that blood cadmium levels (BCLs) were positively associated with all-cause mortality and cardiovascular-related mortality in MHD patients. We wondered whether there is any correlation between BCLs and UP after adjusting for BLLs and BALs. (2) Methods: Patients enrolled in this study were all from three hemodialysis (HD) centers at Chang Gung Memorial Hospital, Lin-Kou Medical Center, including both the Taipei and Taoyuan branches. Correlations between UP and BLLs, BALs, BCLs, and other clinical data were analyzed. (3) Results: Eight hundred and fifty-three patients were recruited. Univariate logistic regressions showed that diabetes mellitus, hepatitis B virus infection, hepatitis C virus infection, HD duration, hemodiafiltration, dialysis clearance of urea, normalized protein catabolic rate, non-anuria, serum albumin levels, log (intact-parathyroid hormone levels), total serum cholesterol levels, serum low-density lipoprotein levels, log (blood aluminum levels), and log (blood lead levels) were associated with UP. Although log BCLs were not significantly associated with UP (p = 0.136) in univariate analysis, we still included log BCLs in multivariate logistic regression to verify their effect on UP given that our aim in this study was to verify associations between serum heavy metals and UP. Multivariate logistic regressions showed that log BLLs (OR: 27.556, 95% CI: 10.912-69.587, p < 0.001) and log BALs (OR: 5.485, 95% CI: 2.985-10.079, p < 0.001) were positively associated with UP. The other logistic regression, which stratified BLLs and BALs into high and low BLLs and BALs, respectively, showed that high BLLs or high BALs (low BLLs and low BALs as reference) (OR: 3.760, 95% CI: 2.554-5.535, p < 0.001) and high BLLs and high BALs combined (low BLLs and low BALs as reference) (OR: 10.838, 95% CI: 5.381-21.828, p < 0.001) were positively correlated with UP. (4) Conclusions: BLLs and BALs were positively correlated with UP. BCLs were not correlated with UP. Clinicians should pay more attention to the environmental sources of lead and aluminum to prevent UP.

An artificial intelligence algorithm for analyzing globus pallidus necrosis after carbon monoxide intoxication.

Globus pallidus necrosis (GPN) is one of typical neurological imaging features in patients with carbon monoxide (CO) poisoning. Current clinical guideline recommends neurological imaging examination for CO-intoxicated patients with conscious disturbance rather than routine screening, which may lead to undiagnosed GPN. We aimed to develop an artificial intelligence algorithm for predicting GPN in CO intoxication patients. We included CO intoxication patients with neurological images between 2000 and 2019 in Chang Gung Memorial Hospital. We collected 41 clinical and laboratory parameters on the first day of admission for algorithm development. We used fivefold cross validation and applied several machine learning algorithms. Random forest classifier (RFC) provided the best predictive performance in our cohort. Among the 261 patients with CO intoxication, 52 patients presented with GPN. The artificial intelligence algorithm using the RFC-based AI model achieved an accuracy = 79.2 ± 2.6%, sensitivity = 77.7%, precision score = 81.9 ± 3.4%, and F1 score = 73.2 ± 1.8%. The area under receiver operating characteristic was approximately 0.64. Top five weighted variables were Platelet count, carboxyhemoglobin, Glasgow Coma scale, creatinine, and hemoglobin. Our RFC-based algorithm is the first to predict GPN in patients with CO intoxication and provides fair predictive ability. Further studies are needed to validate our findings.

Interferon-alpha and MxA inhibit BK polyomavirus replication by interaction with polyomavirus large T antigen.

INTRODUCTION: BK Polyomavirus (BKPyV) infection is a common complication in kidney transplant recipients and can result in poor outcome and graft failure. Currently, there is no known effective antiviral agent. This study investigated the possible antiviral effects of Interferon alpha (IFNα) and its induced protein, MxA, against BKPyV. METHODS: In vitro cell culture experiments were conducted using human primary renal proximal tubular epithelial cells (HRPTECs). We also did animal studies using Balb/c mice with unilateral kidney ischemic reperfusion injury. RESULTS: Our results demonstrated that IFNα effectively inhibited BKPyV in vitro and murine polyomavirus in animal models. Additionally, IFNα and MxA were found to suppress BKPyV TAg and VP1 production. Silencing MxA attenuated the antiviral efficacy of IFNα.We observed that MxA interacted with BKPyV TAg, causing it to remain in the cytosol and preventing its nuclear translocation. To determine MxA's essential domain for its antiviral activities, different mutant MxA constructs were generated. The MxA mutant K83A retained its interaction with BKPyV TAg, and its antiviral effects were intact. The MxA T103A mutant, on the other hand, abolished GTPase activity and lost its protein-protein interaction with BKPyV TAg, and lost its antiviral effect. CONCLUSION: IFNα and its downstream protein, MxA, have potent antiviral properties against BKPyV. Furthermore, our findings indicate that the interaction between MxA and BKVPyV TAg plays a crucial role in determining the anti-BKPyV effects of MxA.

Giant Pancreatic Pseudocyst after Coronary Artery Bypass Graft in a Hemodialysis Patient: A Case Report.

End-stage renal disease (ESRD) patients have a high prevalence of coronary artery disease, and coronary artery bypass graft (CABG) is one of the essential treatments. ESRD patients undergoing CABG surgery have an increased risk of postoperative complications, including acute pancreatitis. Here, we present the unique case of an exceptionally large pancreatic pseudocyst caused by pancreatitis in an ESRD patient after CABG surgery. A 45-year-old male with ESRD under maintenance hemodialysis received CABG surgery for significant coronary artery disease. Two weeks later, he experienced worsening abdominal pain and a palpable mass was noticed in the epigastric region. Computer tomography revealed an unusually large pseudocyst measuring 21 × 17 cm in the retroperitoneum due to necrotizing pancreatitis. The patient underwent percutaneous cystic drainage, and the symptoms were significantly improved without surgical intervention. Factors such as prolonged cardiopulmonary bypass time, postoperative hypotension, and intradialytic hypotension appeared to have contributed to the development of severe pancreatitis in this case. This report highlights the rarity of a giant pancreatic pseudocyst in an ESRD patient after CABG surgery and emphasizes the importance of vigilant postoperative care.

Hungry bone syndrome in peritoneal dialysis patients after parathyroid surgery.

Secondary hyperparathyroidism (SHPT) is a common complication of end-stage kidney disease (ESKD). Hungry bone syndrome (HBS) occurs frequently in patients on maintenance dialysis receiving parathyroidectomy for refractory SHPT. However, there is scanty study investigating the clinical risk factors that predict postoperative HBS, and its outcome in peritoneal dialysis (PD) patients. We conducted a single-center retrospective study to analyze 66 PD patients who had undergone parathyroidectomy for secondary hyperparathyroidism at Chang Gung Memorial Hospital between 2009 and 2019. The patients were stratified into two groups based on the presence (n=47) or absence (n=19) of HBS after parathyroidectomy. Subtotal parathyroidectomy was the most common surgery performed (74.2%), followed by total parathyroidectomy with autoimplantation (25.8%). Pathological examination of all surgical specimens revealed parathyroid hyperplasia (100%). Patients with HBS had lower levels of postoperative nadir corrected calcium, higher alkaline phosphate (ALP), and higher potassium levels compared with patients without HBS (all P<0.05). A multivariate logistic regression model confirmed that lower preoperative serum calcium level (OR 0.354, 95% CI 0.133-0.940, P=0.037), higher ALP (OR 1.026, 95% CI 1.008-1.044, P=0.004), and higher potassium level (OR 6.894, 95% CI 1.806-26.317, P=0.005) were associated with HBS after parathyroidectomy. Patients were followed for 58.2±30.8 months after the surgery. There was no significant difference between HBS and non-HBS groups in persistence (P=0.496) or recurrence (P=1.000) of hyperparathyroidism. The overall mortality rate was 10.6% with no significant difference found between both groups (P=0.099). We concluded that HBS is a common complication (71.2%) of parathyroidectomy for SHPT and should be managed appropriately.

Human Poisoning with Methomyl and Cypermethrin Pesticide Mixture.

There is limited literature analyzing the outcome of human poisoning with methomyl and cypermethrin pesticide mixture. Between 2002 and 2018, a total of 63 patients intoxicated with methomyl, cypermethrin, or their pesticide mixture were treated at Chang Gung Memorial Hospital. The patients were categorized into three groups based on the type of pesticide, as methomyl (n = 10), cypermethrin (n = 31), or methomyl and cypermethrin (n = 22). Demographic, clinical, laboratory, and mortality data were obtained for analysis. The patients were aged 54.9 ± 18.9 years. Following ingestion, the patients experienced a wide range of clinical symptoms, including aspiration pneumonia (50.8%), acute respiratory failure (41.3%), acute kidney injury (33.3%), multiple organ failure (19.0%), emesis (19.0%), acute hepatitis (12.7%), diarrhea (7.9%), seizures (4.8%), lacrimation (4.8%), etc. After analysis, it was found that patients with methomyl and cypermethrin poisoning suffered higher incidences of acute respiratory failure (p < 0.001), aspiration pneumonia (p = 0.004), acute kidney injury (p = 0.011), and multiple organ failure (p < 0.001) than the other groups. Laboratory analyses revealed that patients with methomyl and cypermethrin poisoning had a higher creatinine level (p = 0.011), white blood cell count (p < 0.001), and neutrophil count (p = 0.019) than the other groups. A total of seven (11.1%) patients died. The average duration of hospitalization was 9.8 ± 10.0 days. In a multivariate logistic regression model, it was revealed that methomyl pesticide (p = 0.045) or methomyl and cypermethrin pesticide mixture (p = 0.013) were significant risk factors for acute respiratory failure. Nevertheless, no mortality risk factor could be identified. Therefore, the analytical results suggest that methomyl pesticide is the major contributor to the toxicity of methomyl and cypermethrin pesticide mixture poisoning. More research is needed.