Prevalence and prognosis of hypoglycaemia in patients receiving maintenance dialysis.

BACKGROUND: End-stage renal disease is a common predisposing condition for the development of hypoglycaemia. AIM: To determine the effect of hypoglycaemia on the mortality of patients undergoing maintenance dialysis. METHODS: Retrospective and descriptive analyses were performed in five dialysis centres in the Republic of Korea between June 2002 and August 2008. We enrolled 1685 patients who had undergone dialysis for at least 1 month. RESULTS: We identified 453 episodes of hypoglycaemia in 256 of 1685 patients (15.2%); 189 patients (73.8%) had diabetes, whereas the other patients did not. The occurrence of hypoglycaemia in patients receiving dialysis appeared to be a life-threatening complication because 27.0% of patients died within two days of the onset of a hypoglycaemic episode. Older age, low serum albumin levels and infections were independent risk factors for total mortality in these patients. Furthermore, the absence of diabetes, age and serum glucose levels were independent factors associated with early mortality within two days of the development of hypoglycaemia. CONCLUSION: Although several factors were associated with mortality, the degree of hypoglycaemia, absence of diabetes and old age were associated with early mortality. Elderly hypoglycaemic patients, especially those without diabetes, should be closely monitored.

Internal and external environmental factors affecting the performance of hospital-based home nursing care.

BACKGROUND: Numerous studies on HNC services have been carried out by signifying their needs, efficiency and effectiveness. However, no study has ever been performed to determine the critical factors associated with HNC's positive results despite the deluge of positive studies on the service. METHODS: This study included all of the 89 training hospitals that were practising HNC service in Korea as of November 2006. The input factors affecting the performance were classified as either internal or external environmental factors. This analysis was conducted to understand the impact that the corresponding factors had on performance. Data were analysed by using multiple linear regressions. RESULTS: The internal and external environment variables affected the performance of HNC based on univariate analysis. The meaningful variables were internal environmental factors. Specifically, managerial resource (the number of operating beds and the outpatient/inpatient ratio) were meaningful when the multiple linear regression analysis was performed. Indeed, the importance of organizational culture (the passion of HNC nurses) was significant. CONCLUSION: This study, considering the limited market size of Korea, illustrates that the critical factor for the development of hospital-led HNC lies with internal environmental factors rather than external ones. Among the internal environmental factors, the hospitals' managerial resource-related factors (specifically, the passion of nurses) were the most important contributing element.

Successful antibiotic lock therapy in patients with refractory peritonitis.

We describe two patients receiving peritoneal dialysis who experienced refractory peritonitis caused each by Gram-negative bacteria: Acinetobacter baumannii and Stenotrophomonas maltophilia. These patients did not respond to appropriate intraperitoneal antibiotic therapy. We assumed bacterial colonization in the intra-abdominal portion of the catheter with biofilm. Therefore, patients were treated with additional instillation of a ceftazidime-heparin lock into the catheter lumen after each exchange, as an adjunct to systemic antibiotic treatment which was successful. This study suggests that antibiotic lock therapy in the treatment of refractory peritonitis can be an effective method without catheter removal.

Screening of the anticoccidial effects of herb extracts against Eimeria tenella.

Ionophorous antibiotics have been popularly used in the treatment of avian coccidiosis. Tissue residue of these antibiotics may be found in poultry, we have sought safe alternative anticoccidial herbal materials for the control of avian coccidiosis. Efficacy of extracts from 15 different herbs, including Bupleurum chinese DC, Sophora flavescens Aiton, and Artemisia annua Linne was tested against Eimeria tenella. One-day-old broiler chicks were infected with a USDA reference book of E. tenella, and administered various herbal extracts. Survival rates, lesion scores, body weight gains, bloody diarrhea, and oocysts excretions were investigated at the first and the second week after infection. Bloody diarrhea in the S. flavescens and Sinomenium acutum treated groups was milder than that of the other infected groups. Survival rates in the groups treated with Ulmus macrocarpa (100%), Pulsatilla koreana, Torilis japonica, Artemisia asiatica and S. flavescens (90%) were higher than that of the infected control group (70%). Lesion scores in the groups treated with U. macrocarpa (1.40+/-1.14) or Pulsatilla koreana (1.60+/-1.82) were significantly lower than those of the infected control group (3.00+/-1.10). During the first week after infection, the weight gains in the groups treated with Quisqualis indica (232.9+/-43.5 g), S. flavescens (214.4+/-46.1 g) and S. acutum (211.3+/-29.4 g) were significantly higher than the infected control group (172.4+/-17.6 g). In conclusion, the data of the survival rates, bloody diarrhea symptoms, lesion scores, body weight gains and oocyst excretions indicate that the extract of S. flavescens was the most effective. P. koreana, S. acutum, U. macrocarpa and Q. indica were also effective. Further research on the above herbal materials will be carried out by the authors by chemical analysis of the extracts.

Identification of Acanthocephala discovered in changran-pickles and myungran-pickles.

To identify acanthocephala found in 'Changran-pickles' and 'Myungran-pickles' each organ was measured in permanent slides. In the present report, the results obtained were as follows: 1. Morphology of male worms: Worms possessed 18-19 longitudinal rows, with 4 hooks per row, which became smaller towards the base of proboscis. Each worm contained two testis and six cement glands arranged linearly. Body 22.0 by 0.8-0.6 mm and 15.0 by 0.6-0.4 mm, proboscis 284.8 by 227.6 micro m and 524.9 by 151.4 micro m, proboscis sheath 1570.7 by 72.7 micro m and 751.9 by 280.4 micro m, lemnisci length 2566.7 and 1085.6, testis 2202.9-1860.5 by 737.0-575.7 micro m and 1033.8-981.1 by 463.1-351.6 micro m, cement glands 940.2 by 441.2 micro m and 610.0 by 369.1 micro m. 2. Morphology of female worms: Worms possessed 14-18 longitudinal rows, with 6-10 hooks per row and become smaller toward the base of proboscis. Each worm contained an uterine bell and uterus in the posterior portion and the eggs filled the body cavity. Body, approximately 14.0 - 51.0 mm by 0.7-0.5 - 2.2-1.4 mm, proboscis 466.1-268.9 micro m by 259.9-252.0 micro m, proboscis sheath 1550.7-506.0 by 298.8-231.1 micro m, lemnisci length 1325.7-473.1 micro m, eggs approximately 112.4 by 28.5 micro m - 51.7 by 14.0 micro m. In this present study, the acanthocephala collected in 'Changran-pickles' and 'Myungran-pickles' were identified as Echinorhynchus gadi by morphological features.

Urine transforming growth factor-beta activity is related to the degree of scarring in crescentic nephritis in the rabbit.

Crescentic nephritis was induced in rabbits by injection of antirabbit glomerular basement membrane (GBM) antibodies. Urine samples were obtained by catheterization and assayed for transforming growth factor-beta (TGF-beta) activity. On day 31, all animals were sacrificed for evaluation of renal cortical histopathology and collagen content. The results show that control rabbit urine contains measurable amounts of TGF-beta. Urine TGF-beta activity was expressed in relation to urine creatinine concentration to correct for variation in urine concentration. When expressed in this manner, urine TGF-beta activity increased from day 2 onwards, peaked on day 7 and returned to normal levels after day 14. This time course is identical to that previously seen for the cortical and glomerular production of TGF-beta in the same model. Furthermore, when the normalized TGF-beta values for each animal were compared to their respective fibrosis parameters on day 31, significant correlations were observed for the values of urine TGF-beta activities on day 7 and all indices of fibrosis. These results suggest that measurements of urine TGF-beta activity at certain critical stages of disease could be useful in predicting the progression to end-stage renal disease with fibrosis and might serve as a helpful noninvasive adjunct in monitoring response to therapy.

Transforming growth factor-beta production in anti-glomerular basement membrane disease in the rabbit.

The purpose of this study was to assay for the presence of collagen synthesis stimulatory activity in the kidney during immune-induced renal injury that results in severe fibrosis in both glomerular and interstitial compartments. A model of antiglomerular basement (anti-GBM) disease in the rabbit was induced on day 0 by the injection of anti-GBM antibody and renal cortex tissues were then sampled at various time points. Only conditioned media prepared from diseased renal cortical samples showed collagen synthesis stimulatory activity when tested on rabbit mesangial cells. The activity had an estimated molecular weight range of 16 to 25 kd and was neutralized by antibody to transforming growth factor-beta (TGF-beta). A standard assay for TGF-beta using a mink lung epithelial cell line confirmed the increase in TGF-beta activity in conditioned media of diseased cortex from day 7 and day 14 animals, which was not significantly activated by previous acidification. This suggests that most of the TGF-beta present in renal conditioned media was in the active form. The increase in renal cortical secretion of active TGF-beta was accompanied by increases in renal cortical TGF-beta mRNA content on days 4 and 7 after induction, with subsequent return to control levels. A similar increase in TGF-beta activity was present in nonacidified conditioned media of purified glomeruli from diseased days 7 and 14 animals, which was also accompanied by significant increases in TGF-beta mRNA. However with acidification no significant differences were noted between control and diseased samples, suggesting the presence of substantial latent TGF-beta activity in control glomerular conditioned media. These same control-conditioned media contained inhibitor activity for added exogenous TGF-beta. These results support the conclusion that the association between increased TGF-beta secretion and increased renal cortical collagen synthesis in this model is consistent with a role for this cytokine in directing fibrogenesis in the kidney.

Evaluation of quantitative magnetic resonance imaging as a noninvasive technique for measuring renal scarring in a rabbit model of antiglomerular basement membrane disease.

Renal function tests are an insensitive means of detecting progressive scarring of the kidney such as occurs in chronic allograft rejection and lupus nephritis. Alternative approaches for the measurement of small progressive changes in renal structure on a repetitive basis are needed. Quantitative magnetic resonance imaging (proton T1 relaxation time) was assessed for this purpose. A rabbit model of antiglomerular basement membrane disease that develops glomerular and interstitial inflammation followed by scarring of the renal cortex was used. Longitudinal studies of cortical T1 showed a marked prolongation of T1 during the initial inflammation and edema associated with glomerular crescent formation (Day 7). The T1 remained prolonged up to Day 120 in animals with significant fibrosis and crescent formation when the wet/dry weight ratio (a measure of edema) had returned to baseline. T1 was a more sensitive index of renal injury than was serum creatinine for all of the end points measured (cortical hydroxyproline per dry weight, percent crescent formation, or histologic fibrosis score). It was concluded from these studies that measurement of renal cortical T1 is quite a sensitive index of renal injury, probably more sensitive than the measurement of serum creatinine, but that this method does not discriminate between edema and scarring.

The relationship between plasma leptin and nutritional status in chronic hemodialysis patients.

Leptin serves an important role in suppressing appetite in mice and is known to be elevated in chronic renal failure (CRF) patients. But clinical significance of leptin as an appetite-reducing uremic toxin, remains to be determined. So we studied the relationship between plasma leptin and nutritional status in 46 chronic hemodialysis (HD) patients. Pre HD leptin was measured and divided by body mass index (BMI) to give adjusted leptin levels. KT/Vurea (K, dialyzer urea clearance; T, duration of HD; V, volume of distribution of urea), C-reactive protein (CRP), plasma insulin and nutritional parameters such as serum albumin, normalized protein catabolic rate (nPCR), subjective global assessment (SGA), BMI and mid-arm muscle circumference (MAMC) were also measured. Mean plasma leptin levels were 8.13+/-2.91 ng/mL (male 3.15+/-0.70; female 14.07+/-6.14, p<0.05). Adjusted leptin levels were positively correlated with nPCR (male r=0.47, p<0.05; female r=0.46, p<0.05), SGA (male r=0.43, p<0.05; female r=0.51, p<0.05) and MAMC (male r=0.60, p<0.005; female r=0.61, p<0.05). They did not correlate with KT/Vurea, serum albumin, hematocrit, bicarbonate, insulin and CRP. Presence of DM and erythropoietin therapy had no effect on leptin levels. These results suggest that leptin is a marker of good nutritional status rather than a cause of protein energy malnutrition in chronic HD patients.

Th1/Th2 predominance and proinflammatory cytokines determine the clinicopathological severity of IgA nephropathy.

BACKGROUND: IgA nephropathy is one of the most common forms of primary glomerulonephritis in adults. Its pathogenesis is complex. The nature of infiltrating and proliferating cells and of cellular mediators could contribute to the progression of IgA nephropathy towards end-stage renal failure. METHODS: To evaluate this hypothesis, we attempted to quantify the magnitude of intrarenal gene expression of various cytokines (IL-1 beta, TNF-alpha, IL-6, IL-15, IL-2, IFN-gamma, IL-10) and chemokines (IL-8, RANTES, MCP-1) in 48 renal core biopsy specimens, diagnosed as IgA nephropathy by immunofluorescence microscopy. Semi-quantitative reverse-transcriptase polymerase chain reaction using internal competitors was used for the quantification of gene transcripts. RESULTS: The expression of intrarenal gene transcripts of various cytokines and chemokines was closely interrelated, but not associated with the pathological grading system. The IFN-gamma/IL-10 ratio was higher in patients with renal dysfunction than in those with normal renal function (P=0.0483). Gene transcript levels of proinflammatory cytokines were related to the amount of proteinuria. In patients with severe glomerular sclerosis, the ratio of IFN-gamma/IL-10 gene transcripts was high (P=0.04). IL-10 gene transcript level was related to the severity of tubulointerstitial damage. The levels of gene expression of IL-10 (P=0.009), IFN-gamma (P=0.03), and TNF-alpha (P=0.005) were related to the degree of mesangial matrix expansion and the extent of intrarenal arteriolar changes correlated with the expression of the IL-8 gene transcript (r=0.43, P=0.004). CONCLUSIONS: We propose that Th1/Th2 predominance and the level of proinflammatory cytokines could determine the pathogenetic processes and the severity of the clinical manifestations of IgA nephropathy.