Prognostic superiority of global longitudinal strain beyond four-tiered ventricular hypertrophy in asymptomatic individuals.

BACKGROUND: This study aims to explore the clinical correlates of myocardial deformations using speckle-tracking algorithm and to determine the prognostic utility of such measures in asymptomatic ethnic Chinese population. METHODS: Global longitudinal (GLS), circumferential strain (GCS), and torsion were analyzed using featured tissue-tracking algorithm among 4049 symptom-free ethnic Chinese population. Hypertrophy (LVH) was classified into 4 tiers: indeterminate, dilated, thick and thick/dilated, by gender-stratified partition of end-diastolic volume index (EDVi) and LV mass/EDV0.67. RESULTS: LVH (7.3%) showed substantially lower GLS (-20.3 ± 1.82% vs. -18.9 ± 2.08%) yet higher torsion (2.20 ± 0.90 vs. 2.39 ± 1.01, p < 0.001) than non-LVH participants. Those with thick LVH (n = 123) were more obese, had higher blood pressure and increased high-sensitivity C-reactive protein (hs-CRP); with dilated/thick LVH (n = 26) group demonstrating highest pro-brain natriuretic peptide (NT-proBNP) and worse GLS compared to indeterminate-/non-LVH groups. There were independent associations among larger EDVi, higher NT-proBNP and decreased torsion, and among greater LV mass/EDV0.67, worse GLS, greater GCS/torsion and hs-CRP. Over a median of 2.3 years (IQR: 1.2-4.8), the dilated, thick, and dilated/thick LVH categorizations were associated with higher risk of composite all-cause death and heart failure (HF) compared to non-LVH (adjusted hazard ratio [HR]: 3.65, 3.72, 6.01, respectively, all p < 0.05). Per 1% GLS reduction was independently associated with higher risk (adjusted HR: 1.31, p < 0.001) and improved risk prediction (p ≤ 0.001 by integrated discrimination improvement [IDI]: 3.5%, 95% CI: 1.5%-5.6%, and continuous net reclassification improvement [NRI]: 42.3%, 95% CI: 24.0%-60.6%) over LVH. CONCLUSION: GLS improved risk stratification of four-tiered classification of LVH in asymptomatic ethnic Chinese.

Associations of obesity and malnutrition with cardiac remodeling and cardiovascular outcomes in Asian adults: A cohort study.

BACKGROUND: Obesity, a known risk factor for cardiovascular disease and heart failure (HF), is associated with adverse cardiac remodeling in the general population. Little is known about how nutritional status modifies the relationship between obesity and outcomes. We aimed to investigate the association of obesity and nutritional status with clinical characteristics, echocardiographic changes, and clinical outcomes in the general community. METHODS AND FINDINGS: We examined 5,300 consecutive asymptomatic Asian participants who were prospectively recruited in a cardiovascular health screening program (mean age 49.6 ± 11.4 years, 64.8% male) between June 2009 to December 2012. Clinical and echocardiographic characteristics were described in participants, stratified by combined subgroups of obesity and nutritional status. Obesity was indexed by body mass index (BMI) (low, ≤25 kg/m2 [lean]; high, >25 kg/m2 [obese]) (WHO-recommended Asian cutoffs). Nutritional status was defined primarily by serum albumin (SA) concentration (low, <45 g/L [malnourished]; high, ≥45 g/L [well-nourished]), and secondarily by the prognostic nutritional index (PNI) and Global Leadership Initiative on Malnutrition (GLIM) criteria. Cox proportional hazard models were used to examine a 1-year composite outcome of hospitalization for HF or all-cause mortality while adjusting for age, sex, and other clinical confounders. Our community-based cohort consisted of 2,096 (39.0%) lean-well-nourished (low BMI, high SA), 1,369 (25.8%) obese-well-nourished (high BMI, high SA), 1,154 (21.8%) lean-malnourished (low BMI, low SA), and 681 (12.8%) obese-malnourished (high BMI, low SA) individuals. Obese-malnourished participants were on average older (54.5 ± 11.4 years) and more often women (41%), with a higher mean waist circumference (91.7 ± 8.8 cm), the highest percentage of body fat (32%), and the highest prevalence of hypertension (32%), diabetes (12%), and history of cardiovascular disease (11%), compared to all other subgroups (all p < 0.001). N-terminal pro B-type natriuretic peptide (NT-proBNP) levels were substantially increased in the malnourished (versus well-nourished) groups, to a similar extent in lean (70.7 ± 177.3 versus 36.8 ± 40.4 pg/mL) and obese (73.1 ± 216.8 versus 33.2 ± 40.8 pg/mL) (p < 0.001 in both) participants. The obese-malnourished (high BMI, low SA) group also had greater left ventricular remodeling (left ventricular mass index, 44.2 ± 1.52 versus 33.8 ± 8.28 gm/m2; relative wall thickness 0.39 ± 0.05 versus 0.38 ± 0.06) and worse diastolic function (TDI-e' 7.97 ± 2.16 versus 9.87 ± 2.47 cm/s; E/e' 9.19 ± 3.01 versus 7.36 ± 2.31; left atrial volume index 19.5 ± 7.66 versus 14.9 ± 5.49 mL/m2) compared to the lean-well-nourished (low BMI, high SA) group, as well as all other subgroups (p < 0.001 for all). Over a median 3.6 years (interquartile range 2.5 to 4.8 years) of follow-up, the obese-malnourished group had the highest multivariable-adjusted risk of the composite outcome (hazard ratio [HR] 2.49, 95% CI 1.43 to 4.34, p = 0.001), followed by the lean-malnourished (HR 1.78, 95% CI 1.04 to 3.04, p = 0.034) and obese-well-nourished (HR 1.41, 95% CI 0.77 to 2.58, p = 0.27) groups (with lean-well-nourished group as reference). Results were similar when indexed by other anthropometric indices (waist circumference and body fat) and other measures of nutritional status (PNI and GLIM criteria). Potential selection bias and residual confounding were the main limitations of the study. CONCLUSIONS: In our cohort study among asymptomatic community-based adults in Taiwan, we found that obese individuals with poor nutritional status have the highest comorbidity burden, the most adverse cardiac remodeling, and the least favorable composite outcome.

Correction: Associations of obesity and malnutrition with cardiac remodeling and cardiovascular outcomes in Asian adults: A cohort study.

[This corrects the article DOI: 10.1371/journal.pmed.1003661.].

Sex, racial differences and healthy aging in normative reference ranges on diastolic function in Ethnic Asians: 2016 ASE guideline revisited.

BACKGROUND: Diastolic dysfunction (DD) has shown to be a hallmark pathological intermediate in the development of heart failure with preserved ejection fraction (HFpEF). We aim to establish age- and sex-stratified normal reference values of diastolic indices and to explore racial-differences. METHODS: We explored age- and sex-related structural/functional alterations from 6023 healthy ethnic Asians (47.1 ± 10.9 years, 61.3% men) according to 2016 American Society of Echocardiography (ASE) diastolic dysfunction (DD) criteria. Racial comparisons were made using data from London Life Sciences Prospective Population (LOLIPOP) study. RESULTS: Age- and sex-based normative ranges (including mean, median, 10% and 90% lower and upper reference values) were extracted from our large healthy population. In fully adjusted models, advanced age was independently associated with cardiac structural remodeling and worsened diastolic parameters including larger indexed LA volume (LAVi), lower e', higher E/e', and higher TR velocity; all p < 0.001), which were more prominent in women (P interaction: <0.05). Broadly, markedly lower e', higher E/e' and smaller LAVi were observed in ethnic Asians compared to Whites. DD defined by 2016 ASE criteria, despite at low prevalence (0.42%) in current healthy population, increased drastically with advanced age and performed perfectly in excluding abnormal NT-proBNP (≥125 pg/mL) (Specificity: 99.8%, NPV: 97.6%). CONCLUSION: This is to date the largest cohort exploring the normative reference values using guideline-centered diastolic parameters from healthy Asians, with aging played as central role in diastolic dysfunction. Our observed sex and ethnic differences in defining healthy diastolic cut-offs likely impact future clinical definition for DD in Asians.

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.

Clinical and Echocardiography Features of Diagnosed in Adulthood Isolated Left Ventricular Noncompaction: A Case Series Study.

BACKGROUND: Left ventricular noncompaction cardiomyopathy (LVNC) is a primary genetic cardiomyopathy with morphologically unique characteristics, including loose "spongy" meshwork. Subjects carrying these disorders were typically presented with triad of heart failure, cardiac arrhythmias, and consequences of mural thrombi formation. The clinical and echocardiographic features regarding LVNC, however, are not widely known. METHODS: A retrospective survey involving 11 patients who fulfilled echocardiographic criteria for LVNC defined by Jenni et al. was conducted at MacKay Memorial Hospital from January 2009 to March 2017. Parameters assessed by echocardiography and clinical data were further analyzed. RESULTS: Significantly depressed left ventricular systolic function assessed by echocardiography was noticed in a majority of our adult study cases. CONCLUSION: Considering the fatal complications LVNC may lead to, it is essential for clinical cardiologists to early identify suspicious individuals, and the establishment of definitive criteria and early treatment is essential.

Improving the regenerative potential of olfactory ensheathing cells by overexpressing prostacyclin synthetase and its application in spinal cord repair.

BACKGROUND: Olfactory ensheathing cells (OEC), specialized glia that ensheathe bundles of olfactory nerves, have been reported as a favorable substrate for axonal regeneration. Grafting OEC to injured spinal cord appears to facilitate axonal regeneration although the functional recovery is limited. In an attempt to improve the growth-promoting properties of OEC, we transduced prostacyclin synthase (PGIS) to OEC via adenoviral (Ad) gene transfer and examined the effect of OEC with enhanced prostacyclin synthesis in co-culture and in vivo. Prostacyclin is a vasodilator, platelet anti-aggregatory and cytoprotective agent. RESULTS: Cultured OEC expressed high level of cyclooxygneases, but not PGIS. Infection of AdPGIS to OEC could selectively augument prostacyclin synthesis. When cocultured with either OEC or AdPGIS-OEC, neuronal cells were resistant to OGD-induced damage. The resulted OEC were further transplanted to the transected cavity of thoracic spinal cord injured (SCI) rats. By 6 weeks post-surgery, significant functional recovery in hind limbs occurred in OEC or AdPGIS-OEC transplanted SCI rats compared with nontreated SCI rats. At 10-12 weeks postgraft, AdPGIS-OEC transplanted SCI rats showed significantly better motor restoration than OEC transplanted SCI rats. Futhermore, regenerating fiber tracts in the distal spinal cord stump were found in 40-60% of AdPGIS-OEC transplanted SCI rats. CONCLUSIONS: Enhanced synthesis of prostacyclin in grafted OEC improved fiber tract regeneration and functional restoration in spinal cord injured rats. These results suggest an important potential of prostacyclin in stimulating OEC therapeutic properties that are relevant for neural transplant therapies.

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.

The immunomodulator decoy receptor 3 improves locomotor functional recovery after spinal cord injury.

BACKGROUND: Spinal cord injury (SCI) causes loss of neurons and axons and results in motor and sensory function impairments. SCI elicits an inflammatory response and induces the infiltration of immune cells, predominantly macrophages, to the injured site. Decoy receptor 3 (DcR3), also known as tumor necrosis factor receptor superfamily member (TNFRSF)-6B, is a pleiotropic immunomodulator capable of inducing macrophage differentiation into the M2 phenotype and enhancing angiogenesis. Because M2 macrophages are crucial for the recovery of impaired motor functions, we ask whether DcR3 is beneficial for the functional recovery of locomotion in Sprague-Dawley (SD) rats after SCI. METHODS: Contusion injury of the spinal cord was performed using a New York University impactor at the ninth thoracic vertebrae, followed by intrathecal injection of 15 µg recombinant protein comprising DcR3 (DcR3.Fc) in 5 µl of normal saline as the treatment, or 5 µl of normal saline as the control, into the injury epicenter. Functional recovery was evaluated using an open-field test weekly up to 6 weeks after injury. The cavity size and myelin sparing in the rostral-to-caudal region, including the epicenter of the injury, were then examined in SCI rats by histological staining. The expression of anti-inflammatory cytokines and the presence of M2 macrophages were determined by quantitative real-time polymerase chain reaction (qPCR) and immunohistochemistry at 7 day after SCI. Statistical analysis was performed using a two-tailed Student's t test. RESULTS: Intrathecal administration of DcR3.Fc significantly improved locomotor function and reduced secondary injury with a smaller wound cavity and increased myelin sparing at the lesion site. Compared with the control group, DcR3.Fc-treated rats had increased vascularization at the injury epicenter along with higher levels of interleukin (IL)-4 and IL-10 and lower level of IL-1ß on DcR3.Fc-treated rats at day 7 after SCI. Moreover, higher levels of arginase I (Arg I) and CD206 (M2 macrophage markers) and RECA-1 (endothelial marker) were observed in the epicenter on day 7 after SCI by immunofluorescence staining. CONCLUSIONS: These results indicated that DcR3.Fc may promote the M2 macrophage infiltration and enhanced angiogenesis at the lesion site, thus preserving a greater amount of spinal cord tissues and enhancing functional recovery after SCI.

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.

Association between management of metabolic syndrome and progression of early-stage chronic kidney disease: an observational cohort study.

OBJECTIVES: To analyze the effect of treating metabolic syndrome (MetS) on further kidney function decline in patients with early-stage chronic kidney disease (CKD). METHODS: In a study period of 24 months, 162 patients with early stage CKD were enrolled. Baseline and follow-up data related to the occurrence of MetS and glomerular filtration rate (GFR) were assessed. Subjects were classified into controlled MetS (group 1) and uncontrolled MetS (group 2). Furthermore, they were subdivided into four subgroups: (A) controlled MetS at baseline and at follow-up, (B) uncontrolled MetS at baseline but controlled MetS at follow-up visits, (C) controlled MetS at baseline but uncontrolled MetS at follow-up visits, and (D) uncontrolled MetS at baseline and follow-up visits. RESULTS: Final GFR was lower in group 2 versus group 1 (69.21 ± 20.20 vs. 82.86 ± 22.33 mL/min/1.73 m(2), p <0.001). The presence of MetS had high risk to develop late-stage CKD (HR = 3.279, 95% CI: 1.545-6.958, p = 0.002). Moreover, subgroup D (HR = 2.982, 95% CI: 1.287-6.908, p = 0.011) and the presence of three (p = 0.026) or four (p = 0.049) metabolic components had high risk to develop late-stage CKD. CONCLUSION: Treating MetS slows CKD progression in patients with early-stage of CKD.

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.

Association between blood cadmium levels and malnutrition in peritoneal dialysis.

BACKGROUND: Malnutrition is associated with an increased risk of cardiovascular death and may cause protein-energy wasting in individuals with chronic kidney disease. A previous study demonstrated that blood cadmium levels (BCLs) were associated with malnutrition in maintenance hemodialysis (MHD) patients. However, the correlation between cadmium exposure and malnutrition remains unclear in chronic peritoneal dialysis (CPD) patients. This study examined the possible adverse effects of environmental cadmium exposure in CPD patients. METHODS: A total of 301 CPD patients were enrolled and divided into 3 study groups based on the following BCL tertiles: low (<0.19 µg/L), middle (0.19-0.39 µg/L), and high (>0.39 µg/L). Demographic, hematological, biochemical, and dialysis-related data were obtained for analysis. The analysis also included values of nutritional and inflammatory markers. RESULTS: The BCLs of CPD patients were lower than those of MHD patients. At baseline, patients in the high BCL group were older and had a higher prevalence of diabetes mellitus but lower serum albumin, creatinine, and phosphate levels than the patients in the other 2 groups. After adjusting for potential variables, stepwise backward multiple linear regression analysis revealed that age and alanine aminotransferase levels were positively associated with logarithmic transformation of BCLs (log BCLs), while serum albumin levels were negatively associated with log BCLs in CPD patients. The log BCLs were a significant determinant (beta coefficient ± standard error = -0.185 ± 0.074; P = 0.013) of nutritional status and significantly associated with the presence of malnutrition (odds ratio = 2.64; 95% confidence interval: 1.07-6.48; P = 0.035) in CPD patients after adjustment for related variables. CONCLUSIONS: BCL is significantly associated with nutritional status and malnutrition in CPD patients. Therefore, it is important for CPD patients to avoid environmental exposure to cadmium such as through smoking and consumption of cadmium-rich foods.

Non-tuberculous and tuberculous mycobacterial peritonitis in peritoneal dialysis patients.

INTRODUCTION: Peritoneal dialysis (pd)-associated mycobacterium peritonitis is an important clinical entity in patients with end stage renal disease. They present a significant diagnostic and therapeutic challenge for clinicians because clinical findings and laboratory investigations can not be differentiated from symptoms caused by non-tuberculous mycobacterium (ntm), Mycobacterium tuberculosis (tb) or other bacteria. The aim of the present article is to know the differences between the clinical manifestations and laboratory investigations, the appropriate diagnosis, treatment strategies and prognosis for tb and ntm disease in patients with pd-associated mycobacterial infections. METHODS: This was a retrospective observational study conducted over a period of 25 years. Out of 1737 patients, only 7 were diagnosed with mycobacterial peritonitis. RESULT: Evaluable data showed that there were three patients diagnosed with ntm peritonitis and four patients with tuberculous peritonitis. The mean age of the patients was 53.9 ± 11.8 years. Although all patients developed abdominal pain and cloudy dialysate, only four patients (57.1%) had fever. Two patients (28.6%) suffered severe sepsis and septic shock. Therefore, the patient survival rates for ntm and tuberculous peritonitis were 100.0% and 75.0%, respectively. Two patients were shifted to long-term hemodialysis; therefore, the technical survival rates for ntm and tuberculous peritonitis were 66.7% and 50.0%, respectively. Notably, recurrence of mycobacterial infection was found in one patient with both pulmonary tuberculosis and tuberculous peritonitis. CONCLUSION: The diagnosis of mycobacterial peritonitis remains a challenge to medical staffs because of its insidious nature, the variability of its presentation and the limitations of available diagnostic test.

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.