Characteristics According to Frailty Status Among Older Korean Patients With Hypertension.

BACKGROUND: As the prevalence of hypertension increases with age and the proportion of the older population is also on the rise, research on the characteristics of older hypertensive patients and the importance of frailty is necessary. This study aimed to identify clinical characteristics of older hypertension in Korea and to investigate these characteristics based on frailty status. METHODS: The HOW to Optimize eLDerly systolic BP (HOWOLD-BP) is a prospective, multicenter, open-label, randomized clinical trial that aims to compare intensive (target systolic blood pressure [SBP] ≤ 130 mmHg) with standard (target SBP ≤ 140 mmHg) treatment to reduce cardiovascular events in older hypertensive Korean patients aged ≥ 65 years. Data were analyzed through a screening assessment of 2,085 patients recruited from 11 university hospitals. Demographic, functional (physical and cognitive), medical history, laboratory data, quality of life, and medication history of antihypertensive drugs were assessed. RESULTS: The mean age was 73.2 years (standard deviation ± 5.60), and 48.0% (n = 1,001) were male. Prevalent conditions included dyslipidemia (66.5%), obesity (body mass index ≥ 25 kg/m², 53.6%), and diabetes (28.9%). Dizziness and orthostatic hypotension were self-reported by 1.6% (n = 33) and 1.2% (n = 24), respectively. The majority of patients were on two antihypertensive drugs (48.4%), while 27.5% (n = 574) and 20.8% (n = 433) were on 1 and 3 antihypertensive medications, respectively. Frail to pre-frail patients were older and also tended to have dependent instrumental activities of daily living, slower gait speed, weaker grip strength, lower quality of life, and lower cognitive function. The frail to pre-frail group reported more dizziness (2.6% vs. 1.2%, P < 0.001) and had concerning clinical factors, including lower glomerular filtration rate, more comorbidities such as diabetes, stroke, and a history of admission. Frail to pre-frail older hypertensive patients used slightly more antihypertensive medications than robust older hypertensive patients (1.95 vs. 2.06, P = 0.003). Pre-frail to frail patients often chose beta-blockers as a third medication over diuretics. CONCLUSION: This study described the general clinical characteristics of older hypertensive patients in Korea. Frail hypertensive patients face challenges in achieving positive clinical outcomes because of multifactorial causes: they are older, have more morbidities, decreased function, lower quality of life and cognitive function, and take more antihypertensive medications. Therefore, it is essential to comprehensively evaluate and monitor disease-related or drug-related adverse events more frequently during regular check-ups, which is necessary for pre-frail to frail older patients with hypertension. TRIAL REGISTRATION: Clinical Research Information Service Identifier: KCT0003787.

Nurse Caseload and Patient Survival in Hemodialysis Units: A Korean Nationwide Cohort Study.

INTRODUCTION: The patient-to-nurse ratio is highly variable among dialysis facilities. However, there is little known about the association between nurse caseload and hemodialysis (HD) patient outcomes. We evaluated the association between patient-to-nurse ratio and mortality in the Korean patients undergoing HD. METHODS: We used HD quality assessment data and National Health Insurance Service claim data from the year of 2013 for collecting demographic and clinical data. Altogether, 21,817 patients who participated in the HD quality assessment in 2013 were included in the study. Nurse caseload was defined as the number of HD sessions performed by a nurse per working day. The patients were divided into two groups according to the nurse caseload as follows: low nurse caseload group (≤6.0) and high nurse caseload group (>6.0). We analyzed mortality risk based on nurse caseload using the Cox proportional hazard model. RESULTS: The mean age was 59.1 years, and males accounted for 58.5%. The mean hemoglobin was 10.6 g/dL and albumin was 3.99 g/dL. At the mean follow-up duration of 51.7 (20.6) months, the ratio between low and high groups was 69.6% (15,184 patients) versus 30.4% (6,633 patients). The patients in the high nurse caseload group were older and showed lower levels of hemoglobin, albumin, calcium, and iron saturation and higher levels of phosphorus than those in the low nurse caseload group. A high nurse caseload was associated with a lower survival rate. In the adjusted Cox analysis, a high nurse caseload was an independent risk factor for all-cause mortality (hazard ratio 1.08; 95% confidence interval, 1.02-1.14; p = 0.01). CONCLUSION: High nurse caseload was associated with an increased mortality risk among the patients undergoing HD. Further prospective studies are needed to determine whether a caseload of nursing staff can improve the prognosis of HD patients.

Impact of Total Ischemic Time on the Recovery of Regional Wall Motion Abnormality after STEMI in the Modern Reperfusion Era.

BACKGROUND: Total ischemic time (TIT) is an important factor for predicting mortality among patients with ST-segment elevation myocardial infarction (STEMI). However, the correlation between TIT and the extent of wall motion abnormality has not been well studied. Therefore, we investigated changes in the wall motion score index (WMSI) value based on TIT in STEMI patients who underwent primary percutaneous coronary intervention (PCI) and subsequent transthoracic echocardiography. METHODS: STEMI patients who underwent primary PCI and follow-up coronary angiography were analyzed after the exclusion of cases of in-stent restenosis (ISR). WMSI values were calculated by dividing the sum of scores by the number of segments visualized. RESULTS: A total of 189 patients underwent primary PCI for STEMI, and 151 had no ISR with a median follow-up of 12.3 months. TIT was 180 (117-369) minutes in a subset of 151 patients (mean age of 62 years; 76% male). Among patients without ISR, 109 (72%) demonstrated a decrease in the WMSI value during the follow-up period. The WMSI values of patients with TITs of 180 minutes or less were significantly decreased relative to those among patients with TITs of greater than 180 minutes (p=0.020). Among patients with TITs of 180 minutes or less, the TIT was significantly shorter among those with a reduction in the WMSI value than among those with an increase in the WMSI value (106 [81-124] vs. 133 [100-151] minutes; p=0.018). TIT was an independent predictor for a reduction in the WMSI value among these patients (adjusted hazard ratio: 0.976 (0.957-0.995); p=0.016). CONCLUSIONS: In the modern reperfusion era of STEMI, patients with TITs of 180 minutes or less experienced a significant degree of recovery from regional wall motion abnormalities.

Predictive value of mesangial C3 and C4d deposition in IgA nephropathy.

We aimed to determine the relative contribution of each complement (C3 and C4d) deposition to the progression of IgA nephropathy (IgAN). We enrolled a total of 380 patients with biopsy-confirmed IgAN. Mesangial deposition of C3(<2+ vs. ≥2+) and C4d(positive vs. negative) was evaluated by immunofluorescence staining and immunohistochemistry, respectively. Study endpoint was the composite of a 30% decline in eGFR or ESRD. The risk of reaching the primary outcome was significantly higher in patients having C3 ≥ 2+ and C4d(+) than in corresponding counterparts. Adding C3 deposition to clinical data acquired at kidney biopsy modestly increased the area under the receiver-operating characteristic curve, net reclassification improvement, and integrated discrimination improvement (IDI); adding C4d increased IDI only. In conclusion, mesangial C3 and C4d deposition was an independent risk factor for progression of IgAN. C3 showed better predictability than C4d, suggesting that lectin pathway alone has limited clinical prognostic value.

Health Insurance Status Is Related to Risk of Mortality and Hospitalization in Korean Maintenance Hemodialysis Patients: A Longitudinal Cohort Study.

BACKGROUND: There has been an increasing incidence of hemodialysis (HD) due to old age and comorbid condition such as diabetes. In general, socioeconomic status (SES) is known as one of the most important risk factors for patient mortality and morbidity. Whether low SES is associated with poorer outcome in HD patients is controversial. This study was performed to evaluate the association of health insurance status as a proxy indicator for SES upon mortality and hospitalization in maintenance HD patients. METHODS: We used HD-quality assessment data from the year of 2015 for collecting demographic and clinical data. The subjects were classified into Medical Aid (MA) recipients (low SES) and National Health Insurance (NHI) beneficiary (high SES). We analyzed mortality and hospitalization risk based on health insurance status using Cox proportional hazard model. A total of 35,454 adult HD patients ≥18 years old who received HD treatment more than twice weekly were included in the analysis. RESULTS: The ratio between MA recipient and NHI beneficiary was 76.7 versus 23.3%. The MA recipient group demonstrated younger age and lower proportion of female, diabetes, hypertension, and cerebrovascular accidents compared to the NHI beneficiary group. After adjusting for age, gender, comorbidity, and laboratory parameters, the MA recipient group showed a significantly higher mortality risk compared to the NHI beneficiary group (hazard ratio 1.073 [1.009-1.14], p = 0.025). The MA recipient group was also an independent risk factor for hospitalization after adjusting for age, gender, comorbidities, and laboratory parameters (hazard ratio 1.142 [1.108-1.178], p < 0.001). CONCLUSION: Low SES as measured by health insurance status was associated with an increased risk of patient mortality and hospitalization in Korean maintenance HD patients.

Relationship between complement deposition and the Oxford classification score and their combined effects on renal outcome in immunoglobulin A nephropathy.

BACKGROUND: Complement activation has been highlighted in immunoglobulin (Ig) A nephropathy pathogenesis. However, whether the complement system can affect the downstream phenotype of IgA nephropathy remains unknown. Herein, we investigated the association of mesangial C3 deposition with the Oxford classification and their joint effects on worsening kidney function. METHODS: We investigated 453 patients with biopsy-proven IgA nephropathy. C3 deposition was defined as an immunofluorescence intensity of C3 ≥2+ within the mesangium. The subjects were classified according to the combination of C3 deposition and Oxford classification lesions. The primary endpoint was a composite of ≥30% decline in the estimated glomerular filtration rate or an increase in proteinuria ≥3.5 g/g during follow-up. RESULTS: Among the Oxford classification lesions, mesangial hypercellularity (M1), segmental glomerulosclerosis (S1) and tubulointerstitial fibrosis (T1-2) and crescentic lesion significantly correlated with C3 deposition. During a median follow-up of 33.0 months, the primary endpoint occurred more in patients with M1, S1, T1-2 and mesangial C3 deposition than in those without. In individual multivariable-adjusted Cox analyses, the presence of M1, S1, T1-2 and C3 deposition was significantly associated with higher risk of reaching primary endpoint. In the combined analyses of C3 deposition and the Oxford classification lesions, the hazard ratios for the composite outcome were significantly higher in the presence of C3/M1, C3/S1 and C3/crescent than in the presence of each lesion alone. CONCLUSIONS: Complement deposition can strengthen the significance of the Oxford classification, and the presence of both components portends a poorer prognosis in IgA nephropathy.

Estimation of population-based utility weights for health states of chronic kidney disease, dialysis and kidney transplantation.

AIM: This study aimed to determine the utility of chronic kidney disease (CKD)-related health states in the Korean general population by using the standard gamble (SG) method. METHODS: Seven hypothetical CKD-related health states were developed and revised based on previous publications. Data from 242 individuals from the Korean general population were obtained via computer-assisted personal interviews and used to evaluate the CKD-related health states by using the visual analogue scale (VAS) and SG methods. Mean and median utility values were calculated for each health state. To assess the reliability of the valuation, some samples were retested and evaluated using intraclass correlation coefficients (ICC). RESULTS: In all health states, the utility weights from SG were higher than those from VAS. The difference in utility values between the two valuation methods ranged from 0.258 to 0.308. The utility value of CKD grade 3 was the highest and that of peritoneal dialysis (PD) was the lowest. The utility weights tended to decrease in accordance with the progression of CKD. CKD grade 3 was assigned a SG utility value of 0.878, whereas PD was assigned 0.507. The SG utility values of predialysis end-stage renal disease, haemodialysis, kidney transplantation (KT), and post-KT recovery states were 0.666, 0.547, 0.748 and 0.827, respectively. The mean ICC (SD) at the individual level was 0.746 (0.281) for the SG scores. CONCLUSION: Our results could be used to measure the burden of kidney disease or to evaluate the economic efficiency of CKD-related interventions.

Noninvasive indices for predicting nonalcoholic fatty liver disease in patients with chronic kidney disease.

BACKGROUND: Data on clinical characteristics of nonalcoholic fatty liver disease (NAFLD) in patients with chronic kidney disease (CKD) are scarce. We investigated the clinical features and risk factors of NAFLD using noninvasive serum markers in CKD patients and attempted the temporal validation of a predictive model for CKD based on NAFLD. METHODS: This retrospective cross-sectional study was conducted in a single tertiary center. We enrolled 819 CKD patients and evaluated the predictive performance of relevant clinical and laboratory markers for the presence of NAFLD in both derivation (data from 2011 to 2014, n = 567) and validation (data from 2015 to 2016, n = 252) groups. RESULTS: In the derivation group, NAFLD was observed in 89 patients (15.7%; mean body mass index (BMI), 24.6 kg/m2; median estimated glomerular filtration rate (eGFR), 28.0 ml/min). BMI, hemoglobin, serum alanine aminotransferase, eGFR, and triglyceride-glucose index were used to derive a prediction model for the presence of NAFLD. Using the cutoff value of 0.146, the area under the receiver operating characteristic curve (AUROC) for the prediction of NAFLD was 0.850. In the validation group, NAFLD was observed in 51 patients (20.2%; mean BMI, 25.4 kg/m2; median eGFR, 36.0 ml/min). Using the same prediction model and cutoff value, the AUROC was 0.842. NAFLD prevalence in CKD patients was comparable to that in the general population, increasing over time. CONCLUSIONS: Our model using BMI, renal function, triglyceride-glucose index, serum alanine aminotransferase, and hemoglobin accurately predicted the presence of NAFLD in CKD patients.

Comparison of hemodialysis and peritoneal dialysis patients' dietary behaviors.

BACKGROUND: Nutritional factors are associated with high mortality and morbidity in dialysis patients, and protein-energy wasting is regarded as an important one. The modality of dialysis may affect patients' dietary behavior and nutritional status, but no study has compared the dietary behavior, nutrient intake, and nutritional adequacy of hemodialysis (HD) and peritoneal dialysis (PD) patients. METHODS: From December 2016 to May 2017, a dietary behavior survey and Semi-quantitative Food Frequency Questionnaire (Semi-FFQ) were conducted on 30 HD patients and 30 PD patients in Ewha Womans University Mokdong Hospital, and laboratory parameters were obtained. The results of prevalent HD and PD patients were then compared. RESULTS: The mean age of HD patients was higher than that of PD patients; HD: 58.5 ± 9.1 years, PD: 49.3 ± 9.7 years (p = 0.001). In the dietary behavior survey, HD patients showed more appropriate dietary behavior patterns overall than PD patients. In the dietary intake analysis with the Semi-FFQ, energy intake was significantly lower in the PD group than in the HD group due to the lower intake of carbohydrates, fat, and protein. A comparison of nutrient intake-to-recommended allowance ratio between the HD and PD groups revealed that the HD group showed higher nutrient intake than the PD group. Serum albumin and potassium levels were significantly higher in HD than in PD patients. CONCLUSION: According to this study, the dietary behavior and nutritional intake of prevalent PD patients were worse than those of HD patients.

Biobanking for glomerular diseases: a study design and protocol for KOrea Renal biobank NEtwoRk System TOward NExt-generation analysis (KORNERSTONE).

BACKGROUNDS: Glomerular diseases, a set of debilitating and complex disease entities, are related to mortality and morbidity. To gain insight into pathophysiology and novel treatment targets of glomerular disease, various types of biospecimens linked to deep clinical phenotyping including clinical information, digital pathology, and well-defined outcomes are required. We provide the rationale and design of the KOrea Renal biobank NEtwoRk System TOward Next-generation analysis (KORNERSTONE). METHODS: The KORNERSTONE, which has been initiated by Korea Centres for Disease Control and Prevention, is designed as a multi-centre, prospective cohort study and biobank for glomerular diseases. Clinical data, questionnaires will be collected at the time of kidney biopsy and subsequently every 1 year after kidney biopsy. All of the clinical data will be extracted from the electrical health record and automatically uploaded to the web-based database. High-quality digital pathologies are obtained and connected in the database. Various types of biospecimens are collected at baseline and during follow-up: serum, urine, buffy coat, stool, glomerular complementary DNA (cDNA), tubulointerstitial cDNA. All data and biospecimens are processed and stored in a standardised manner. The primary outcomes are mortality and end-stage renal disease. The secondary outcomes will be deterioration renal function, remission of proteinuria, cardiovascular events and quality of life. DISCUSSION: Ethical approval has been obtained from the institutional review board of each participating centre and ethics oversight committee. The KORNERSTONE is designed to deliver pioneer insights into glomerular diseases. The study design allows comprehensive, integrated and high-quality data collection on baseline laboratory findings, clinical outcomes including administrative data and digital pathologic images. This may provide various biospecimens and information to many researchers, establish the rationale for future more individualised treatment strategies for glomerular diseases. TRIAL REGISTRATION: NCT03929887 .

The protective effect of klotho against contrast-associated acute kidney injury via the antioxidative effect.

As oxidative stress is one major factor behind contrast-associated acute kidney injury (CA-AKI), we investigated the protective effect of klotho against CA-AKI via the antioxidative effect. In in vitro experiments, cells (NRK-52E) were divided into the following three groups: control, iopamidol, or iopamidol + recombinant klotho (rKL) groups. Moreover, cell viability was measured with the Cell Counting Kit-8 assay, and oxidative stress was examined with 2',7'-dichlorodihydrofluorescein diacetate fluorescence intensity. RT-PCR and Western blot analysis were performed to assess propidium iodide klotho expression, and Bax-to-Bcl-2 and apoptosis ratios were evaluated with annexin V/Hoechst 33342 staining. Furthermore, we knocked down the klotho gene using siRNA to verify the endogenous effect of klotho. In our in vivo experiments, oxidative stress was evaluated with the thiobarbituric acid-reactive substance assay, and apoptosis was evaluated with the Bax-to-Bcl-2 ratio and cleaved caspase-3 immunohistochemistry. Additionally, cell and tissue morphology were investigated with transmission electron microscopy. In both in vitro and in vivo experiments, mRNA and protein expression of klotho significantly decreased in CA-AKI mice compared with control mice, whereas oxidative stress and apoptosis markers were significantly increased in CA-AKI mice. However, rKL supplementation mitigated the elevated apoptotic markers and oxidative stress in the CA-AKI mouse model and improved cell viability. In contrast, oxidative stress and apoptotic markers were more aggravated when the klotho gene was knocked down. Moreover, we found more cytoplasmic vacuoles in the CA-AKI mouse model using transmission electron microscopy but fewer cytoplasmic vacuoles in rKL-supplemented cells. The present study shows that klotho in proximal tubular cells can protect against CA-AKI via an antioxidative effect.

The interactive effects of input and output on managing fluid balance in patients with acute kidney injury requiring continuous renal replacement therapy.

BACKGROUND: The interactive effect of cumulative input and output on achieving optimal fluid balance has not been well elucidated in patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT). This study evaluated the interrelation of fluid components with mortality in patients with AKI requiring CRRT. METHODS: This is a retrospective observational study conducted with a total of 258 patients who were treated with CRRT due to AKI between 2016 and 2018 in the intensive care unit of Ewha Womans University Mokdong Hospital. The amounts of fluid input and output were assessed at 24-h and 72-h from the initiation of CRRT. The study endpoints were 7- and 28-day all-cause mortality. RESULTS: The mean patient age was 64.7 ± 15.8 years, and 165 (64.0%) patients were male. During the follow-up, 7- and 28-day mortalities were observed in 120 (46.5%) and 157 (60.9%) cases. The patients were stratified into two groups (28-day survivors vs. non-survivors), and the cumulative fluid balances (CFBs) at 24 h and 72 h were significantly higher in the 28-day non-survivors compared with the survivors. The increase in 24-h and 72-h CFB was significantly associated with an increase in 7- and 28-day mortality risks. To examine the interactive effect of cumulative input or output on the impact of CFB on mortality, we also stratified patients into three groups based on the tertile of 24-h and 72-h cumulative input or output. The increases in 24-h and 72-h CFBs were still significantly related to the increases in 7-day and 28-day mortality, irrespective of the cumulative input. However, we did not find significant associations between increase in 24-h and 72-h CFB and increase in mortality risk in the groups according to cumulative output tertile. CONCLUSIONS: The impact of cumulative fluid balance on mortality might be more dependent on cumulative output. The physicians need to decrease the cumulative fluid balance of CRRT patients as much as possible and consider increasing patient removal.

Clinical Significance of Crescent Formation in IgA Nephropathy - a Multicenter Validation Study.

BACKGROUND/AIMS: Additional validation study was warranted to confirm the clinical significance of C score, which was recently added to the Oxford classification for immunoglobulin A nephropathy (IgAN). METHODS: We performed a multicenter retrospective cohort study in four hospitals in Korea. Patients who had biopsied glomeruli less than eight or inadequate follow-up information were excluded. Clinicopathologic parameters, including the degree of cellular or fibrocellular crescents, were collected and included in multivariable models for Cox regression analysis. The main outcome was a composite renal outcome, defined as a merge of progression to end-stage renal disease (ESRD) and halving of estimated glomerular filtration rate (eGFR) from baseline. RESULTS: Among included 3,380 biopsy-confirmed IgAN patients, there were 664 (19.6%) patients with C1 and 60 (1.8%) patients with C2 scores in the study population. Although C0 and C1 patients shared similar baseline characteristics, C2 patients frequently had more clinicopathologic risk factors for poor prognosis of IgAN. Both C1 [adjusted HR 1.33 (1.11-1.58), P=0.002] and C2 [adjusted HR 2.24 (1.46-3.43), P< 0.001] scores were associated with an increased risk of the composite outcome. C2 was a strong predictive parameter associated with both progression to ESRD and halving of eGFR, whereas C1 was mainly associated with the increased risk of halving of eGFR. Notably, the proportion of crescent showed a linear association with the risk of adverse renal outcome. CONCLUSION: The C score in the Oxford classification is a valid predictive parameter for IgAN prognosis. Additional clinical attention is necessary for IgAN patients with identified cellular or fibrocellular crescents.

The anticholinergic drug oxybutynin inhibits voltage-dependent K+ channels in coronary arterial smooth muscle cells.

This study demonstrates the inhibitory effect of anticholinergic drug oxybutynin on voltage-dependent K+ (Kv) channels in rabbit coronary arterial smooth muscle cells. Oxybutynin inhibited vascular Kv channels in a concentration-dependent manner, with an IC50 value of 11.51 ± 0.38 µmol/L and a Hill coefficient (n) of 2.25 ± 0.12. Application of oxybutynin shifted the activation curve to the right and the inactivation curve to the left. Pretreatment with the Kv1.5 subtype inhibitor DPO-1 and the Kv2.1 subtype inhibitor guangxitoxin suppressed the oxybutynin-induced inhibition of the Kv current. However, application of the Kv7 subtype inhibitor linopirdine did not affect the inhibition by oxybutynin of the Kv current. The anticholinergic drug atropine did not inhibit the Kv current nor influence oxybutynin-induced inhibition of the Kv current. From these results, we concluded that oxybutynin inhibited the vascular Kv current in a concentration-dependent manner by influencing the steady-state activation and inactivation curves independent of its anticholinergic effect.

Cost-utility analysis of the National Health Screening Program for chronic kidney disease in Korea.

AIM: Although a National Health Screening Program (NHSP) for chronic kidney disease (CKD) has been implemented in Korea since 2002, its cost-effectiveness has never been determined. This study aimed to estimate the cost-utility of NHSP for CKD in Korea. METHODS: A Markov decision analytic model was constructed to compare CKD screening strategies of the NHSP with no screening. We developed a model that simulated disease progression in a cohort aged 20-120 years or death from the societal perspective. RESULTS: Biannual screening starting at age 40 for CKD by proteinuria (dipstick) and estimated glomerular filtration ratio had an ICUR of $66 874/QALY relative to no screening. The targeted screening strategy had an ICUR of $37 812/QALY and $40 787/QALY for persons with diabetes and hypertension, respectively. ICURs improved with lower cost strategies. The most influential parameter that might make screening more cost-effective was the effectiveness of treatment on CKD to decrease disease progression and mortality. CONCLUSIONS: The Korean NHSP for CKD is more cost-effective for patients with diabetes or hypertension than the general population, consistent with prior studies. Although it is too early to conclude the cost-effectiveness of the Korean NHSP for CKD, this study provides evidence that is useful in evaluating the cost-effectiveness of CKD interventions.

Three-year income trends in Korean adults commencing haemodialysis: A prospective cohort.

AIM: This study aimed to explore the trends in individual income and to estimate the change in average monthly income for patients undergoing haemodialysis therapy. METHODS: The main data source was the Clinical Research Center (CRC) for End-Stage Renal Disease in Korea. In addition to the cohort data, a survey was conducted to capture personal income for 3 years. To estimate the change in monthly income over time using repeated measures, a random coefficient model using penalized quasi-likelihood methods based on restricted or residual maximum likelihood estimation was used. RESULTS: During the 3-year study period, 138 subjects aged 20 and over who answered the question about pre-dialysis income were traced and analyzed. The median value of monthly income was $US564.4 in the 1st year, $470.4 in the 2nd year, and $733.8 in the 3rd year, representing a 70%, 75%, and 61% decrease compared to pre-dialysis income ($1881.5), respectively. By using mixed analysis, we found that monthly income change was $1283 (95% CI, -1621.5, -945.1), $1182 USD (95% CI, -1540.8, -823.1), and $1041 (95% CI, -1457.6, -623.6) in the 1st , 2nd , and 3rd year, respectively, compared to pre-dialysis income after controlling for other covariates. Women and less educated patients had a relatively higher reduction of income, despite the low starting point. CONCLUSIONS: The monthly income of dialysis patients reduced substantially over the study period, especially at the time of the first survey. Considering the social security system, haemodialysis patients face significant personal financial burdens due to their ESRD unrelated to the direct costs of dialysis treatment.

The locally activated renin-angiotensin system is involved in albumin permeability in glomerular endothelial cells under high glucose conditions.

Background: Although the diabetic milieu per se , hemodynamic changes, oxidative stress and local growth factors such as angiotensin II (AII) are considered to be mediators in the pathogenesis of diabetic nephropathy, the underlying pathways mediating the changes in glomerular endothelial cells (GECs) are not well understood. Therefore, we investigated changes in the renin-angiotensin system (RAS) components in high glucose (HG)-stimulated GECs and the role of the local RAS in morphological and functional changes in GECs under diabetic conditions. Methods: We stimulated GECs with 5.6 mM glucose or 30 mM glucose with or without an angiotensin II type I receptor blocker (ARB) in vitro and also performed experiments with Sprague-Dawley rats injected with diluent ( n = 16) or streptozotocin [ n = 16, diabetes (DM)]. Eight rats from each group were treated with ARB for 3 months in vivo . Real-time polymerase chain reaction, western blot analysis, enzyme-linked immunosorbent assay and immunofluorescent staining using cultured GECs were performed. The permeability of GECs to macromolecules was assessed by measuring the passage of fluorescein isothiocyanate-labeled bovine serum albumin. Morphological changes were also evaluated by scanning and transmission electron microscopy. Results: There were significant increases in angiotensinogen expression in HG-stimulated GECs along with significant increases in AI and AII levels. Moreover, the expression of heparan sulfate glycosaminoglycans (HS-GAG) assessed by immunofluorescent staining was significantly lower and the permeability to albumin was significantly higher in GECs exposed to HG medium, and ARB treatment significantly abrogated these changes. Upon electron microscopy examination, the mean size of the GEC fenestrae was significantly greater in HG-stimulated GECs and DM rats, and these increases were significantly ameliorated by ARB. Conclusions: The local RAS within GECs was activated under HG conditions, and this activation may be associated with both an alteration in GEC fenestration and a decrease in HS-GAG, resulting in the development of albuminuria in diabetic nephropathy.

Dementia is a risk factor for major adverse cardiac and cerebrovascular events in elderly Korean patients initiating hemodialysis: a Korean national population-based study.

BACKGROUND: Dementia is common in end-stage renal disease (ESRD) patients on hemodialysis (HD) and is associated with worse outcomes. This study aimed to investigate the risk of major adverse cardiac and cerebrovascular event (MACCE) in elderly patients with dementia initiating HD. METHODS: Using the database from the Health Insurance Review & Assessment Service, we analyzed 10,171 patients aged 65 years or older who had initiated dialysis from 2005 to 2008. MACCE was defined as a composite outcome of all-cause mortality, nonfatal acute myocardial infarction, target vessel revascularization, and nonfatal ischemic and hemorrhagic stroke. The Kaplan-Meier method and Cox proportional hazards model were used, and further comparisons using propensity-score matching at 1:2 ratio were also performed. RESULTS: A total of 303 elderly patients (3.0%) had dementia at initiating HD. During follow-up, dementia was a significant predictor of MACCE after adjustment for confounding variables. In addition, further analyzed in the propensity-score matched groups, dementia was an independent predictor of both nonfatal ischemic stroke and all-cause mortality. CONCLUSIONS: Dementia is an independent risk factor for mortality and ischemic stroke in elderly ESRD patients initiating HD. Patients with dementia who start dialysis should be closely monitored to reduce the risk of mortality and ischemic stroke.

Risk of Stroke in Elderly Dialysis Patients.

Despite the current knowledge about the risk of stroke and its related factors in general population, this issue in elderly patients receiving dialysis remains unresolved. Firstly, to compare the risk of stroke between hemodialysis (HD) and peritoneal dialysis (PD), data on 13,065 incident dialysis patients (aged ≥ 65 years; 10,675 in HD and 2,390 in PD) were retrieved from the Korean Health Insurance dataset. Secondly, to identify the risk factors of stroke amongst various clinical and laboratory parameters in HD, 980 elderly patients were retrospectively analyzed using an independent prospective cohort from 31 dialysis centers. For a mean duration of 1.8 years (maximum of 5 years), the risk of all cardiovascular diseases (ischemic heart disease and stroke) did not differ between HD and PD. However, when analyses were conducted separately by subtype, the risk of stroke, not ischemic heart disease, was significantly higher in HD patients than in PD patients. When the risk factors of stroke were probed after HD for a mean duration of 2.6 years (maximum of 7 years), the absolute dependence on social support, a previous history of cardiovascular disease, high levels of low-density lipoprotein cholesterol, and the use of a high number of anti-hypertensive drugs were identified as being significant. Based on the discrepancy of stroke risk between modalities and the HD-tailored risk factors of stroke, the monitoring and management of these factors may be a key strategy to reduce the risk of stroke in elderly patients receiving dialysis.