Diagnostic accuracy of fibroblast growth factor 23 for predicting acute kidney injury in patients with acute decompensated heart failure.

BACKGROUND: Elevated plasma levels of fibroblast growth factor 23 (FGF23) have emerged as a predictor for the development of acute kidney injury (AKI) in patients undergoing cardiac surgery and those with critical illnesses. However, accurate data in cases involving acute decompensated heart failure (ADHF) remains limited. METHODS: Single centre cohort study was performed in patients admitted for ADHF. Plasma c-terminal FGF23 (c-FGF23) was measured at baseline and 24 hours after being diagnosed with ADHF. AKI was defined by KDIGO 2012 criteria. RESULTS: The study enrolled 62 patients diagnosed with ADHF. The incidence of AKI was 45% and significantly increased the risk of death. Patients developing AKI had significantly higher levels of plasma c-FGF23 at baseline in comparison with those not developing AKI [median value 1258.5 (57.2, 15 850) vs 230.2 (68.515 850) RU/mL, P = .005]. During the first 24 hours, plasma c-FGF23 levels decreased in both groups, and the levels of c-FGF23 at 24 hours were consistent with the baseline [861.8 (75.7, 15 850) vs 226.3 (56, 5450.8) RU/mL, P = .006]. Receiver operating characteristic analysis of both first time and second time for plasma c-FGF23 collection yielded an area under curve of 0.71 for the prediction of AKI incidence. With the cut-off point at 450 RU/mL, the sensitivity and specificity of plasma c-FGF23 at the baseline for predicting AKI were 71.4% and 61.8% respectively. CONCLUSION: Plasma c-FGF23 may serve as a novel biomarker for development of AKI in patients with ADHF. These results should be revalidated in larger-scale, cohort studies.

National feasibility survey of peritoneal dialysis key performance indicators in Thailand from provider perspective.

BACKGROUND: Peritoneal dialysis (PD) has been the main method of renal replacement therapy under the "PD First" policy in Thailand since 2008. Initially, the proposed 13 key performance indicators (KPIs) raised feasibility concerns because of inequitable distribution of resources such as laboratory facilities and/or specialized health-care staff for PD care throughout the country. METHODS: Data availability and goals from the health-care providers' perspective were explored using an online questionnaire survey for all PD centers registered with the Nephrology Society of Thailand from May to June 2016. The availability of essential data required for each KPI indicator to achieve the desired target was assessed using a 5-point Likert scale. RESULTS: Of the 197 centers, 119 responded to the survey (response rate of 60.41%). PD indicators with a high percentage of strongly disagree or disagree were "PD adequacy measured in the last 12 months" (26.83%), "Total weekly Kt/V ≥ 1.7" (24.59%), "3-year PD technique survival" (21.31%), "Serum parathyroid levels within 150 to 500 pg/mL" (16.94%), and a "3-year PD patient survival" (19.01%). As many as 34.17%, 39.19%, 27.27%, 28.93%, and 22.00%, respectively, did not anticipate that the targets could be achieved. Based on the findings from this survey, the national committee concluded that these indicators be removed, and only eight PD indicators were launched. CONCLUSION: Given the importance of KPIs for quality assurance and financial reimbursement, inputs from health-care providers especially data availability and achievement of targets should be considered to ensure feasibility before the final list of indicators are launched.

Major adverse kidney events in multidisciplinary chronic kidney disease care compared with usual outpatient care: a propensity score matched analysis.

BACKGROUND: Chronic kidney disease (CKD) is a public health problem worldwide. Multidisciplinary care has been recommended in clinical practice to delay disease progression and minimize complications. However, the effectiveness of multidisciplinary care on major adverse kidney events in CKD patients is still inconclusive. METHODS: We conducted a cohort study in patients with CKD stages G3b to 4 who were followed up at Bhumibol Adulyadej Hospital from 2014 to 2020. Propensity score matching by age, sex, CKD staging, Diabetes Mellitus (DM), blood pressure and rate of estimated Glomerular Filtration Rate (eGFR) decline before inclusion between patients in multidisciplinary CKD care (MDC) and usual outpatient care (UOC) was performed. The primary outcome was a composite of cardiovascular or renal mortality, 40% eGFR decline and initiation of long-term kidney replacement therapy. RESULTS: After 1:1 propensity score matching, 822 patients were included. Mean age was 70.9 years, 64% had diabetes. During the mean follow-up of 3.3 years, rate of reaching the primary endpoint was lower in the multidisciplinary CKD care group than in the usual outpatient care group (24.1% vs. 38.9%; hazard ratio [HR], 0.66; 95% confidence interval [CI], 0.52-0.86; P = 0.002). The multidisciplinary CKD care group benefited more than the usual outpatient care group with regard to 40% eGFR decline (21.7% vs. 35.0%; HR, 0.67; 95%CI 0.52-0.88; P = 0.004), all-cause mortality (8.5% vs. 19.5%; HR, 0.60; 95%CI 0.40-0.90; P = 0.014), non-cardiovascular death (6.1% vs. 15.1%; HR, 0.56; 95%CI 0.35-0.90; P = 0.015) and hospitalizations per year (1.0 ± 1.5 vs. 1.6 ± 2.0; P < 0.001). According to subgroup analysis, diabetes mellitus patients benefited the most from multidisciplinary CKD care. CONCLUSIONS: In a tertiary care hospital, multidisciplinary CKD care showed benefits over usual outpatient care on kidney outcomes in patients with CKD stages G3b and 4. The benefit was enhanced in DM patients.

Safety and efficacy of proactive versus reactive administration of desmopressin in severe symptomatic hyponatremia: a randomized controlled trial.

This randomized controlled trial aimed to evaluate the safety and efficacy of proactive versus reactive desmopressin (DDAVP) strategies in treating severe symptomatic hyponatremia. Conducted from June 20, 2022, to February 20, 2023, it involved 49 patients with serum sodium levels below 125 mmol/L. Patients were assigned to either the proactive group, receiving DDAVP immediately upon diagnosis, or the reactive group, receiving DDAVP only if the serum sodium level tended to be overcorrected. The primary outcome was the incidence of overcorrection. The study revealed no significant difference in the overcorrection incidence between the proactive (16.7%) and reactive (28%) groups (p = 0.54). The change in serum sodium levels at 1, 6, 12, and 24 h were not different, however, at 48 h, the proactive group exhibited a higher but still safe change in serum sodium levels compared to the reactive group (10.3 ± 3.6 mmol/L vs. 7.7 ± 3.6 mmol/L, p = 0.013). Other parameters including time to symptom improvement, total intravenous fluid administered, DDAVP dose, urine volume, hospital stay duration, osmotic demyelination syndrome incidence, and 28-day mortality did not significantly differ between the groups. In conclusion, our findings suggest that there was no significant disparity in overcorrection rates between proactive and reactive DDAVP strategies for treating severe symptomatic hyponatremia. However, further large-scale studies are warranted to validate these results.

Immunogenicity and safety of heterologous versus homologous prime-boost schedules with inactivated and adenoviral vectored SARS-CoV-2 vaccines - A prospective multi-center study.

Background: During the peak of Coronavirus disease (COVID-19) pandemic in Thailand when the emergence of delta variant reduced the efficacy of inactivated vaccine, Thailand had abundance of inactivated vaccine but mRNA vaccine was not available and the supply of adenoviral-vectored vaccine was limited. The heterologous vaccination using CoronaVac and ChAdOx1-nCoV-19 vaccines was applied. We aim to compare the immunogenicity of immune response of primary vaccination with homologous ChAdOx1 nCoV-19 and heterologous vaccination with CoronaVac and ChAdOx1 nCoV-19. Methods: A total of 430 adults, scheduled to receive ChAdOx1-nCoV-19 as their second dose of primary COVID-19 vaccination, were enrolled. Participants were classified into two groups based on the first dose vaccine as CoronaVac (heterologous group) or ChAdOx1 nCoV-19 (homologous group). The primary outcome was antibodies to the SARS-CoV-2 spike protein receptor binding domain (anti-RBD) titres at 28 days after the second dose of vaccination. Secondary outcomes were anti-RBD titres at 90 days, surrogate viral neutralizing test (sVNT) at 28 and 90 days, and adverse events. Findings: In 358 participants with correct vaccine interval, the anti-RBD geometric mean titre ratio for the heterologous versus homologous group was 0.55 (95%CI; 0.44-0.067); p < 0.001 at day 28, and 0.80 (95%CI; 0.65-1.00); P = 0.05 at day 90. Median sVNT neutralizing activity was not significantly different in the heterologous versus homologous group at 28 days (93.5 vs 92.7 %); p = 0.13, but significantly higher in the heterologous group at day 90 (82.9 vs 76.4 %); p = 0.01. Interpretation: The homologous vaccination resulted in higher anti-RBD titres at 28 days after vaccination, but titres in the homologous group showed more rapid decline at 90 days. In the sVNT assay, median neutralization was similar at 28 days, but was longer-lasting and higher in the heterologous group at 90 days. Funding: This research received funding from the Royal College of Physicians of Thailand special grant 2021 for research initiative during COVID-19 pandemic.

The changing profile of PD-related peritonitis in Thailand: a single centers experience.

OBJECTIVE: The percentage of utilizing peritoneal dialysis (PD) in Thailand was increased dramatically since the implementation of PD-First policy in 2008. However, peritonitis remains a major obstacle to achieve success of this modality. The aim of the present study, was to assess the clinical characteristics of PD peritonitis in the PD-first policy era. MATERIAL AND METHOD: The PD peritonitis patients in Bhumibol Adulyadej Hospital between October 2008 and December 2010 were reviewed. Microbiological diagnosis, treatment responses, technique, and patient survival were analyzed. RESULTS: Since October 2008, 93 peritoneal dialysis patients were followed-up in Bhumibol Adulyadej Hospital including 75 new cases. During the present study period of 1,560 patient-months, 51 episodes of peritonitis from 33 cases were recorded and analyzed. The mean age of the peritonitis patients was 57.9 +/- 16.1 years and 63.6% were females. The most common isolates were gram negative organisms (33.3%) followed by gram positive (17.6%) and fungi (5.9%). Nocardiosis was diagnosed in 1 patient. However, 43.1% of episodes were culture-negative peritonitis. Treatment of peritonitis resulted in a complete cure in 74.5% of patients while 7.8% of patients required catheter removal, and 17.6% died. Event-free survival was better in gram positive organisms (43.3 months) compared with those infected with gram negative (26.8 months) and culture negative peritonitis (16.1 months). CONCLUSION: The proportions of peritonitis due to gram negative organisms were increased and associated with less favorable outcome. These findings suggest that it is necessary to prepare the appropriate protocol for prevention and treatment of PD peritonitis under national PD-First policy scheme.

Efficacy and safety of enoxaparin during hemodialysis: results from the HENOX study.

BACKGROUND: Low molecular weight heparins (LMWHs) have been suggested as an anticoagulant in hemodialysis (HD) since they provide convenient usage, safety and effective outcomes. OBJECTIVE: Determine clinical efficacy and safety of enoxaparin sodium for the anticoagulation effect during HD in 99 clinically stable end-stage renal disease (ESRD) patients. MATERIAL AND METHOD: This prospective open-label study was conducted in seven hemodialysis centers in Thailand HD prescription during the present study was similar to the previous prescriptions including the type of dialyzer. Enoxaparin sodium 0.7 mg/kg was administered into a pre-dialyzer arterial line at the beginning of the HD session. The anticoagulation effect was monitored by visual inspection of the HD line hourly and inspection of the dialyzer at the end of HD session. Vascular access compression time was monitored at both arterial and venous sites separately at the end of the HD. RESULTS: HD with enoxaparin sodium resulted in no fibrin/clot formation in a hemodialysis line in 97 cases (98%), and no significant clot formation in a dialyzer in 96 cases (97%). The mean vascular compression time was 5.63 +/- 1.90 minutes at the arterial site and 5.72 +/- 2.61 minutes at the venous site. Neither major adverse events nor major hemorrhages were reported Prolonged activated partial thromboplastin times (aPTT) at 30 minutes after hemodialysis were reported in two cases. These abnormal aPTT cases returned to normal levels within 24 hours and 72 hours, respectively. CONCLUSION: The present study suggests that a single-dose regimen of enoxaparin sodium 0.7 mg/kg is an effective, well-tolerated, and convenient alternative to sodium heparin.

Efficacy of low-dose cinacalcet on alternate days for the treatment of secondary hyperparathyroidism in hemodialysis patients: a single-center study.

INTRODUCTION: Cinacalcet is effective in reducing serum parathyroid hormone (PTH) in patients with secondary hyperparathyroidism (HPT). This study focused on testing whether a prescription of low-dose cinacalcet on alternate days could be an option for treatment of secondary HPT. MATERIALS AND METHODS: A retrospective clinical study was conducted on chronic maintenance hemodialysis patients. Patients with secondary HPT who received cinacalcet at a starting dose of 25 mg on alternate days were reviewed (low-dose group). Patients who were being treated with a standard dose of cinacalcet in the same period of time were selected as the control group. The primary outcome was difference in the percentage of patients achieving >30% reduction of intact parathyroid hormone (iPTH) levels at 16 weeks. The changes of serum iPTH and other biochemical data were also tested. RESULTS: A total of 30 patients (16 low doses and 14 controls) took part in the study. Baseline iPTH levels in the low-dose and control group were 1,065.9±477.7 and 1,214.1±497.6 pg/mL, respectively (p=0.413). The analysis showed that the percentage of patients who achieved the primary outcome showed little or no difference (33.3% in the low-dose group compared with 38.5% in the control group, p=1.0). Serum iPTH reduction during 16 weeks of study period in the low-dose and control group was 253.5±316.1 and 243.4±561.3 pg/mL, respectively (p=0.957). There was no difference in the adverse events between both groups. CONCLUSION: Among patients with secondary HPT, initial treatment with cinacalcet 25 mg on alternate days can decrease serum PTH levels. The role of low-dose cinacalcet in secondary HPT should be further determined in large-scale, randomized controlled trials.

Continuous veno-venous hemofiltration in Bhumibol Adulyadej Hospital.

OBJECTIVE: Continuous veno-venous hemofiltration (CVVH) is a mode of renal replacement therapy in critically ill patients that has gained popularity all over the world. The authors reviewed one-year experience with CVVH in intensive care units (ICUs) of Bhumibol Adulyadej Hospital. The objectives of this study were to describe the characteristics of the patients and demonstrate the association between various factors and outcome. MATERIAL AND METHOD: The medical records of 45 patients who underwent CVVH treatment were analyzed. All patients had been admitted into the ICUs of Bhumibol Adulyadej Hospital between 1 January 2005 and 31 December 2005. RESULTS: Average age of patients was 67.7 +/- 13.3 years (range from 27.0 years to 88.4 years). The male: female ratio was 1.4:1. Twenty-four patients were admitted to the medical ICU, 17 to the coronary care unit (CCU) and 4 to the surgical ICU. All of them needed mechanical ventilator support and 91.1% required vasopressor. Sixty percent of the patients had sepsis. Most of them had comorbidity including, cardiovascular (66.7%), hepatobilliary (35.6%) and neurological comorbidity (13.3%). Half of them had been diagnosed with chronic kidney disease (CKD) with pre-dialysis CKD in 40% and end stage renal disease (ESRD) in 11.1%. The mean number of organ failure was 3.18 +/- 0.1 and 95.6% had more than 2 organ failures. The range of APACHE II score was 15-50 (mean 30.8 +/- 9.5) with a predicted death rate of 21.0-97.8% (mean 66.4 +/- 23.4). The indications for renal replacement were 80% for level of nitrogenous waste product, 75.6% for volume overload, 42.2% for severe metabolic acidosis, 35.6% for hyperkalemia and 2.2% for toxic substance removal. Eighty percent of the patients had 2 or more indications. Mean blood urea nitrogen (BUN) and creatinine (Cr) level before starting CVVH was 78.8 +/- 36.5 mg/dl (10.0 to 187.0) and 5.3 +/- 3.3 mg/dl (2.0 to 20.2) respectively. Duration of CVVH was 1.5 to 251.0 hours (mean 57.8 +/- 58.9) and the average CVVH dose was 36.6 +/- 7.5 ml/kg/hr (24.6 to 55.6). The overall mortality was 80%. The two most frequent causes of death were sepsis (44.4%) and cardiovascular disease (15.6%). The significant difference between the survival and nonsurvival groups were surgical ICU admission (p = 0.021), sepsis (p = 0.019), APACHE II score (p = 0.011), volume indication for CVVH (p = 0.028), number of dialysis indication (p = 0.019), duration of hospitalization (p = 0.004), systolic blood pressure (p = 0.012) and serum albumin level (p = 0.009). By logistic regression analysis, there was only statistical significance for serum albumin level less than 3 g/dl. CONCLUSION: One-year experience of CVVH in Bhumibol Adulyadej Hospital showed high mortality rate but it is comparable to previous publications. The only factor that was associated with death by multivariate analysis was lower serum albumin level at the time of initiating CVVH. Prospective studies are required to explore this issue in the future.

Prevalence of chronic kidney disease in Thai adult population.

OBJECTIVE: Chronic kidney disease (CKD) is a major public health problem worldwide. Until now, no large-scale data about the prevalence of pre-dialysis CKD has been reported in Thailand. MATERIAL AND METHOD: The clinical and laboratory data from the ground air force personnel who were routinely checked up during 2002-2003 were collected and descriptively analyzed. The pilots and air crews were excluded. All personnel were working in Bangkok. RESULTS: 15,612 RTAF personnel completed the annual check up. Eighty-two percent were male. The average age was 45.7 +/- 8 (19-65) years. According to the classification of stages of CKD by Kidney Disease Outcome Quality Initiative (K/DOQI), the prevalence of CKD is 9.1% by Cockcroft Gault formula and 4.6% by Modification of Diet in Renal Disease. Patients with diabetes mellitus, hypertension, hypercholesterolemia and proteinuria were found in 8.2%, 45.8 %, 28.2 % and 1.8% respectively. CKD patients were older had higher body weight, Body Mass Index (BMI), blood pressure and blood sugar than non CKD personnel. CONCLUSION: CKD were not uncommon among RTAF personnel. The Cockcroft-Gault and MDRD equations were different in detecting CKD in the present study. The appropriate equation to determine GFR in Thai population should be evaluated. Low sensitivity of dipstick proteinuria may cause the low prevalence of stage 1 and 2 CKD.

Anemia and survival in Thai hemodialysis patients: evidence from national registry data.

BACKGROUND: Anemia is a major contributor to morbidity and mortality in chronic dialysis patients. The K/DOQI guideline recommends the target hemoglobin of 11-12 g/dl (hematocrit of 33-36%). However the appropriate hematocrit level for Thai hemodialysis patients has been controversial. OBJECTIVE: To investigate the influence of anemia on mortality in Thai chronic hemodialysis patients who initiated their dialysis from 1999 through 2003. MATERIAL AND METHOD: The data from the Thailand Renal Replacement Therapy Registry who has conducted an annual report of chronic dialysis patients throughout Thailand since 1997 was used. Data of twice- and thrice-weekly hemodialysis patients who had recorded hematocrit from 1999 through 2003 were processed and confirmed before final analysis. Records of 3,211 hemodialysis patients from 301 centers were included. RESULT: The original kidney diseases were diabetes mellitus (31.5%) and hypertension (20.9%). Most patients received twice-weekly hemodialysis (86.3%). The mean hematocrit was 29.3 +/- 5.5%. Most patients (72.8%) had hematocrits of less than 33%. Kaplan-Meier analysis showed patients with hematocrit of ?33% or more had better survival than patients with hematocrits of less than 33% (p <0.01). Patients with hematocrits of less than 27, 27-29.9, 30-32.9 and 36% or more had mortality risks of 1.90 (95% CI: 1.31-2.76, p <0.01), 2.10 (95% CI: 1.42-3.09, p <0.01), 1.74 (95% CI: 1.18-2.56, p <0.01) and 1.174 (95% CI: 0.73-1.90, p = 0.51) respectively, compared to those with hematocrit of 33-35.9%. CONCLUSION: The best survival can be achieved in Thai patients with hematocrits of at least 33%.

Prevalence and risk factors of microalbuminuria in Thai nondiabetic hypertensive patients.

PURPOSE: To assess the prevalence and risk factors of microalbuminuria in nondiabetic hypertensive patients in Thailand. PATIENTS AND METHODS: A cross-sectional study was performed during January to December 2007 at outpatients departments of Bhumibol Adulyadej hospital. Nondiabetic hypertensive patients without a history of pre-existing kidney diseases participated in this study. A questionnaire was used for collecting information on demographics, lifestyle, and family history of cardiovascular and kidney disease. Spot morning urine samples were collected for albuminuria estimation. Albuminuria thresholds were evaluated and defined using albumin-creatinine ratio (ACR). RESULTS: A total of 559 hypertensive patients (283 males, 276 females), aged 58.0 +/- 11.6 years were enrolled in this study. Microalbuminuria (ACR 17 to 299 mg/g in males and 25 to 299 mg/g in females) was found in 93 cases (16.6%) [15.0%-18.2%]. The independent determinants of elevated urinary albumin excretion in a multiple logistic regression model were; body mass index > or =30 (odds ratio (OR) = 2.24, 95% confidence intervals (CI): 1.33-3.76) and dihydropyridine calcium channel blockers (DCCB) use (OR = 1.92, 95% CI: 1.22-3.02). CONCLUSION: In Thai nondiabetic hypertensive patients, microalbuminuria was not uncommon. Obesity and use of dihydropyridine calcium channel blocker were found to be the important predictors. Prognostic value of the occurrence of microalbuminuria in this population remains to be determined in prospective cohort studies.