Management of chronic kidney disease: a Hong Kong consensus recommendation.

Chronic kidney disease (CKD) imposes a significant burden on healthcare systems worldwide, and diabetes is a major risk factor for CKD. There is currently no consensus in Hong Kong regarding the prioritisation of early identification and intervention for CKD. A comprehensive and Hong Kong-specific diabetes and CKD treatment guideline is also lacking. A multidisciplinary group of experts discussed issues surrounding the current management of CKD and reviewed evidence in the context of local experience to support recommendations. The experts used a modified Delphi approach to finalise recommendations. Consensus was regarded as ≥75% acceptability among all expert panel members. The panel members finalised 14 CKD-focused consensus statements addressing disease definition, screening, disease monitoring, lifestyle management, and treatment strategies. The recommendations provided are relevant to the Hong Kong healthcare setting and can be used as a guide by physicians across various specialties to facilitate the appropriate management of CKD.

Characteristics and clinical outcomes of living renal donors in Hong Kong.

INTRODUCTION: In Asia, few reports are available on the outcomes for living renal donors. We report the short- and long-term clinical outcomes of individuals following living donor nephrectomy in Hong Kong. METHODS: We retrospectively reviewed the characteristics and clinical outcomes of all living renal donors who underwent surgery from January 1990 to December 2015 at a teaching hospital in Hong Kong. Information was obtained from hospital records and territory-wide electronic patient records. RESULTS: During the study period, 83 individuals underwent donor nephrectomy. The mean (± standard deviation) follow-up time was 12.0 ± 8.3 years, and the mean age at nephrectomy was 37.3 ± 10.0 years. A total of 44 (53.0%), four (4.8%), and 35 (42.2%) donors underwent living donor nephrectomy via an open, hand-port assisted laparoscopic, and laparoscopic approach, respectively. The overall incidence of complications was 36.6%, with most being grade 1 or 2. There were three (9.4%) grade 3a complications; all were related to open donor nephrectomy. The mean glomerular filtration rate was 96.0 ± 17.5 mL/min/1.73 m2 at baseline and significantly lower at 66.8 ± 13.5 mL/min/1.73 m2 at first annual follow-up (P<0.01). The latest mean glomerular filtration rate was 75.6% ± 15.1% of baseline. No donor died or developed renal failure. Of the donors, 14 (18.2%) developed hypertension, two (2.6%) had diabetes mellitus, and three (4.0%) had experienced proteinuria. CONCLUSION: The overall perioperative outcomes are good, with very few serious complications. The introduction of a laparoscopic approach has decreased perioperative blood loss and also shortened hospital stay. Long-term kidney function is satisfactory and no patients developed end-stage renal disease. The incidences of new-onset medical diseases and pregnancy-related complications were also low.

Public lacks knowledge on chronic kidney disease: telephone survey.

OBJECTIVES: To examine knowledge of chronic kidney disease in the general public. DESIGN: Cross-sectional telephone survey. SETTING: Hong Kong. PARTICIPANTS: Community-dwelling adults who spoke Chinese in Hong Kong. RESULTS: The response rate was 47.3% (516/1091) out of all subjects who were eligible to participate. The final survey population included 516 adults (55.6% female), of whom over 80% had received a secondary level of education or higher. Close to 20% of the participants self-reported a diagnosis of hypertension. Few (17.8%) realised the asymptomatic nature of chronic kidney disease. Less than half of these individuals identified hypertension (43.8%) or diabetes (44.0%) as risk factors of kidney disease. Awareness of high dietary sodium as a risk factor for chronic kidney disease was high (79.5%). CONCLUSIONS: The public in Hong Kong is poorly informed about chronic kidney disease, with major knowledge gaps regarding the influence of hypertension on kidney disease. We are concerned about the public's unawareness of hypertension being a risk factor for kidney disease. Future health education should target areas of knowledge deficits.

Fracture risk after thiazide-associated hyponatraemia.

BACKGROUND/AIM: Although thiazide-type diuretics can promote a positive calcium balance, thiazide can be associated with hyponatraemia, which is recently linked with heightened fracture risk. We examine the chance of developing fracture in patients with and without hyponatraemia after taking thiazide diuretics. METHODS: In this single-centre retrospective study, we followed up a previously published cohort of patients with (n= 223) and without (n= 216) thiazide-induced hyponatraemia. RESULTS: A total of 61 osteoporotic fractures was recorded during a mean follow-up period of 82 months. Using univariate regression analysis, the hazard ratio of thiazide-induced hyponatraemia was 1.78 (95% confidence interval (CI), 1.05-3.03; P= 0.033). Cox proportional hazards regression analysis, however, showed that age, body mass index and diabetes mellitus were the only independent predictors of osteoporotic fractures. No association of a history of thiazide-induced hyponatraemia and risk of fracture was evident in the final model. CONCLUSION: Since a history of thiazide-induced hyponatraemia is associated with osteoporotic fracture in univariate but not multivariate analyses, an alternative explanation is that confounding factors of older age and low body mass index accounted for the apparently increased risk of osteoporotic fracture in patients with thiazide-induced hyponatraemia.

Polypharmacy Predicts Onset and Transition of Frailty, Malnutrition, and Adverse Outcomes in Peritoneal Dialysis Patient.

BACKGROUND: Polypharmacy, frailty and malnutrition are known predictors of adverse outcomes in dialysis patients. Little has reported about their interaction and composite prognostic values. We aimed to describe the interaction between polypharmacy, frailty, nutrition, hospitalization, and survival in peritoneal dialysis patients. METHODS: In this prospective cohort study, we recruited 573 peritoneal dialysis patients. Drug burden was measured by medication number and daily pill load. Frailty and nutrition were assessed by the validated Frailty Score (FQ) and Subjective Global Assessment (SGA) respectively. All patients were followed for two years. Primary outcome was all-cause mortality. Secondary outcomes were fall and fracture episodes, hospitalization, change in FQ and SGA. RESULTS: At baseline, each patient took 7.5 ± 2.6 medications with 15.5 ± 8.5 tablets per day. Medication number, but not daily pill load predicted baseline FQ (p = 0.004) and SGA (p = 0.03). Over 2 years, there were 69 fall and 1,606 hospitalization episodes. In addition, 148 (25.8%) patients died, while FQ and SGA changed by 0.73 ± 4.23 and -0.07 ± 1.06 respectively in survivors. Medication number (hospitalization: p = 0.02, survival: p = 0.005), FQ (hospitalization: p < 0.001; survival: p = 0.01) predicted hospitalization and survival. Medication number also predicted fall episodes (p = 0.02) and frailty progression (p = 0.002). Daily pill load did not predict any of these outcomes. CONCLUSIONS: Drug burden is high in peritoneal dialysis patients, and it carries important prognostic implication. Medication number but not pill load significantly predicted onset and progression of frailty, malnutrition, fall, hospitalization, and mortality.

Measurements on the routine chest radiograph as prognostic markers in Chinese peritoneal dialysis patients.

BACKGROUND: Fluid overload is a common problem in peritoneal dialysis (PD) patients. Cardiothoracic ratio (CTR) and vascular pedicle width (VPW) in routine chest radiograph are useful indicators of intravascular volume status and may represent important prognostic factors of PD patients. METHODS: We measured VPW and CTR in 286 unselected prevalent PD patients. VPW was further adjusted for the thoracic diameter (VPWR). One-year actuarial survival, technique survival, and duration of hospitalization were analyzed. RESULTS: The mean values of VPW, CTR, VPWR were 47.31 ± 4.73 mm, 0.542 ± 0.074, 0.170 ± 0.024, respectively. VPW correlated with age (r = 0.143; p = 0.016), body weight (r = 0.371; p < 0.001), body height (r = 0.271; p < 0.001), and Charlson's index score (r = 0.153; p = 0.01). One-year patient survival was 87.8%, and technique survival was 82.2%. None of the radiological measurements had an independent effect on one-year actuarial or technique survival by multivariate analysis. Both CTR and VPWR correlated with the duration of hospitalization (r = 0.192 and 0.186, respectively (p = 0.001 and 0.002). Multivariate regression analysis by log-linear modeling showed that independent predictors of one-year hospitalization were VPWR, serum albumin, and SGA overall score. CONCLUSIONS: In Chinese PD patients, VPW was significantly correlated with age, body weight, body height and Charlson's index score. VPWR was an independent predictor of the duration of hospitalization. Further studies are needed to confirm the prognostic value of these radiographic measurements in PD patients.

A major outbreak of severe acute respiratory syndrome in Hong Kong.

BACKGROUND: There has been an outbreak of the severe acute respiratory syndrome (SARS) worldwide. We report the clinical, laboratory, and radiologic features of 138 cases of suspected SARS during a hospital outbreak in Hong Kong. METHODS: From March 11 to 25, 2003, all patients with suspected SARS after exposure to an index patient or ward were admitted to the isolation wards of the Prince of Wales Hospital. Their demographic, clinical, laboratory, and radiologic characteristics were analyzed. Clinical end points included the need for intensive care and death. Univariate and multivariate analyses were performed. RESULTS: There were 66 male patients and 72 female patients in this cohort, 69 of whom were health care workers. The most common symptoms included fever (in 100 percent of the patients); chills, rigors, or both (73.2 percent); and myalgia (60.9 percent). Cough and headache were also reported in more than 50 percent of the patients. Other common findings were lymphopenia (in 69.6 percent), thrombocytopenia (44.8 percent), and elevated lactate dehydrogenase and creatine kinase levels (71.0 percent and 32.1 percent, respectively). Peripheral air-space consolidation was commonly observed on thoracic computed tomographic scanning. A total of 32 patients (23.2 percent) were admitted to the intensive care unit; 5 patients died, all of whom had coexisting conditions. In a multivariate analysis, the independent predictors of an adverse outcome were advanced age (odds ratio per decade of life, 1.80; 95 percent confidence interval, 1.16 to 2.81; P=0.009), a high peak lactate dehydrogenase level (odds ratio per 100 U per liter, 2.09; 95 percent confidence interval, 1.28 to 3.42; P=0.003), and an absolute neutrophil count that exceeded the upper limit of the normal range on presentation (odds ratio, 1.60; 95 percent confidence interval, 1.03 to 2.50; P=0.04). CONCLUSIONS: SARS is a serious respiratory illness that led to significant morbidity and mortality in our cohort.

Sevelamer treatment strategy in peritoneal dialysis patients: conventional dose does not make best use of resources.

BACKGROUND: The significant incremental expense in the use of conventional sevelamer dose prompted us to evaluate the role of prescribing a lower dose of sevelamer. METHODS: To determine the optimum strategy for prescribing sevelamer in peritoneal dialysis patients, we conducted an open-label randomized study comparing the treat-to-goal strategy (4.0-g daily sevelamer dose) with lower sevelamer dose (1.2-g daily dose). RESULTS: Twenty-seven peritoneal dialysis patients with serum calcium x phosphorus product above 55 mg2/dL2 were recruited. Eighteen were randomized to the low-dose treatment group (1.2 g daily), and 9 to the treat-to-goal (4.0 g daily) group. Overall, significantly lower calcium x phosphorus product and serum phosphorus levels at 6 months were achieved by the treat-to-goal treatment. The proportions of patients who attained the Kidney Disease Outcomes Quality Initiative (K/DOQI) treatment target, however, did not differ significantly between the treat-to-goal and low-dose treatment groups (66.7% +/- 30.8% vs. 33.3% +/- 21.8%, p=0.10). The numbers needed to treat to benefit 1 patient who attains the K/DOQI recommendation are 1.5 patients (95% confidence interval [95% CI], 1.0-2.8) in the 4.0-g daily dose and 3 patients (95% CI, 1.8-8.7) in the 1.2-g daily dose group. Therefore, an extra 66.7% of subjects would be able to attain the treatment recommendation within the same budget if the daily dose of sevelamer used was 1.2 g instead of the usual 4.0 g. Compared with a 1.2-g daily dose of sevelamer, the 4.0-g daily dose had an incremental cost-effectiveness ratio (ICER) of US $2,353 per additional patient achieving the K/DOQI target. Multivariate analysis showed that only the calcium x phosphorus product after 1 month of sevelamer treatment was predictive of treatment response. CONCLUSIONS: Low-dose sevelamer treatment might be a cost-effective approach, which is "good for many rather than best for a few."

Relation between number of prescribed medication and outcome in peritoneal dialysis patients.

BACKGROUND: Many patients with end-stage renal disease need to take a large number of medications. In the present study, we studied the magnitude of problem and explored the relationship between the number of prescribed medications and the clinical outcome of a large cohort of prevalent peritoneal dialysis (PD) patients. METHODS: We studied the medication list of 266 prevalent PD patients. Dialysis adequacy, residual renal function and nutritional assessment were also performed. The patients were followed for 33.7 +/- 20.7 months. RESULTS: On average, each patient required 4.7 +/- 1.8 type of medications or 10.0 +/- 4.9 tablets per day. 40 patients (15.0%) needed at least 7 types of medication; 33 patients (12.4%) had to take more than 15 tablets each day. There is a significant but weak correlation between the number of types of medication and the Charlson's comorbidity score (r = 0.252, p < 0.001). Despite the large number of medication prescribed, the blood pressure control, serum cholesterol level, and the use of aspirin after atherosclerotic disease remained suboptimal in many patients. By multivariate analysis, independent factors for patient survival were Charlson's comorbidity score, number of types of medication, duration of dialysis, overall SGA score, and mean arterial blood pressure. Each additional type of medication conferred 20% increase in risk of death (95% CI, 1.6-41.7%, p = 0.032), and the effect is independent on the Charlson's comorbidity score. The actual number of pills taken by a patient did not influence survival in this model. CONCLUSION: Our results indicate that the number of prescribed medications is related to the clinical outcome of PD patients. The number of prescribed medication may reflect the severity of uremic complications and comorbid diseases not reflected by the Charlson's comorbidity score. Nevertheless, dialysis physicians should carefully balance the clinical need of treating multiple medical conditions with the potential problems of a complicated therapeutic regimen.

Cardiovascular complications of severe acute respiratory syndrome.

BACKGROUND AND AIMS: Severe acute respiratory syndrome (SARS) is a virulent viral infection that affects a number of organs and systems. This study examined if SARS may result in cardiovascular complications. METHODS AND RESULTS: 121 patients (37.5 (SD13.2) years, 36% male) diagnosed to have SARS were assessed continuously for blood pressure, pulse, and temperature during their stay in hospital. Hypotension occurred in 61 (50.4%) patients in hospital, and was found in 28.1%, 21.5%, and 14.8% of patients during the first, second, and third week, respectively. Only one patient who had transient echocardiographic evidence of impaired left ventricular systolic function required temporary inotropic support. Tachycardia was present in 87 (71.9%) patients, and was found in 62.8%, 45.4%, and 35.5% of patients from the first to third week. It occurred independent of hypotension, and could not be explained by the presence of fever. Tachycardia was also present in 38.8% of patients at follow up. Bradycardia only occurred in 18 (14.9%) patients as a transient event. Reversible cardiomegaly was reported in 13 (10.7%) patients, but without clinical evidence of heart failure. Transient atrial fibrillation was present in one patient. Corticosteroid therapy was weakly associated with tachycardia during the second (chi(2) = 3.99, p = 0.046) and third week (chi(2) = 6.53, p = 0.01), although it could not explain tachycardia during follow up. CONCLUSIONS: In patients with SARS, cardiovascular complications including hypotension and tachycardia were common but usually self limiting. Bradycardia and cardiomegaly were less common, while cardiac arrhythmia was rare. However, only tachycardia persisted even when corticosteroid therapy was withdrawn.

Change in bacterial aetiology of peritoneal dialysis-related peritonitis over 10 years: experience from a centre in South-East Asia.

This study reviewed 1787 episodes of peritoneal dialysis (PD)-related peritonitis in 544 patients between 1994 and 2003. The overall rate of peritonitis was 0.68 episodes/year of PD, but decreased from 1.10 to 0.46 episodes/year between 1994 and 2003. The incidence of peritonitis caused by coagulase-negative staphylococci declined between 1994 and 1998 from 0.21 to 0.06 episodes/year of PD, coinciding with a reduction in the use of spike PD sets. There was a 60.1% response rate to antibiotics throughout the period, but the percentage of cases that required modification of the initial empirical antibiotic regimen rose from 13.6% to 58.7%, indicating that treatment should be individualised.

Peritoneal transport status correlates with morbidity but not longitudinal change of nutritional status of continuous ambulatory peritoneal dialysis patients: a 2-year prospective study.

Cross-sectional studies show that peritoneal transport status is associated with nutritional status and clinical outcome of continuous ambulatory peritoneal dialysis (CAPD) patients. High transporters often are assumed to have progressive malnutrition as a result of fluid overload and nutrient loss in dialysis effluent. There are few prospective data to confirm this assumption, however. We studied 235 unselected CAPD patients to examine this possibility. There were 58 new cases and 177 prevalent cases. A standard peritoneal equilibration test was performed at enrollment. All patients were followed for 2 years. Dialysis adequacy and nutritional assessment, including serum albumin, protein nitrogen appearance, and lean body mass, were performed at 0, 12, and 24 months. Clinical outcome included hospitalization, actuarial patient survival, and technique survival. The mean age was 51.6 +/- 12.4 years. The mean 4-hour dialysate-to-plasma ratio of creatinine was 0.57 +/- 0.12 for all cases (0.60 +/- 0.12 for new cases). Patients were classified into three groups: high/high-average (H/HA) (63 cases), low-average (LA) (105 cases), and low (L) (67 cases) transporters. Baseline demographic data and total Kt/V were similar in all transport groups. There were weak correlations between 4-hour dialysate-to-plasma ratio of creatinine and baseline serum albumin (r = -0.249, P: < 0.001), protein nitrogen appearance (r = -0.190, P: < 0.01), and percentage of lean body mass (r = -0.194, P: < 0.01). The H/HA group was a specific but not a sensitive predictor of poor baseline nutritional status. There was no significant change in any nutritional indices after 2 years in new cases and prevalent cases, regardless of transport status. The differences in nutritional indices between groups remained unchanged during the study period. There was a significant difference in hospitalization rate among peritoneal transport groups (median 12 versus 7 versus 3 days per year for H/HA, LA, and L groups, Kruskal-Wallis test, P: < 0.05). The difference remained similar when new cases and prevalent cases were analyzed separately. The L group had slightly better 2-year patient survival than the H/HA group (90.2% versus 83.3%), but the result was not statistically significant. We conclude that peritoneal transport status is not associated with longitudinal change of nutritional parameters, although transport status is associated with short-term patient morbidity. Further study is needed to identify the mechanisms of poor clinical outcome in high peritoneal transporters.

Clinical and biochemical characteristics of type 2 diabetic patients on continuous ambulatory peritoneal dialysis: relationships with insulin requirement.

Although glycemic control has an important impact on the clinical outcomes of patients with diabetes undergoing dialysis, there is a paucity of data on the relationship between glucose metabolism and clinical parameters in these patients. In this study, we compared a cohort of 48 patients with type II diabetes undergoing continuous ambulatory peritoneal dialysis (CAPD) with 84 age- and sex-matched patients with type II diabetes with similar disease duration but normal renal function. Compared with those with normal renal function, patients with type 2 diabetes undergoing CAPD had greater serum angiotensin-converting enzyme activity (median, 57.4 U/L; range, 33.5 to 100.0 U/L v 46.9 U/L; range, 11.6 to 111.2 U/L; P < 0.005), fasting C-peptide (median, 9.1 ng/mL; range, 0.9 to 30.0 ng/mL v 2.2 ng/mL; range, 0.2 to 20.3 ng/mL; P < 0.0001) and triglyceride levels, and lower serum albumin concentrations. Among the patients undergoing CAPD, there was a preponderance of men in the insulin-treated group. Insulin-treated patients also had greater plasma albumin levels and body weights and lower fasting serum C-peptide levels (2.81 +/- 1.77 v 3.12 +/- 2.04 ng/mL; analysis of variance, P = 0.007 adjusted for fasting glucose concentration). Multivariate analysis showed duration of diabetes, hemoglobin A(1c) (HbA(1c)) level, and body weight were independent determinants of insulin requirement in patients undergoing CAPD. The daily insulin dosage required was related to the duration of diabetes (r = 0.5; P = 0.007). In summary, among patients with end-stage renal failure, insulin-treated patients had greater body weights and plasma albumin levels but lower cholesterol levels. Plasma C-peptide concentration and duration of diabetes were the main determinants of insulin requirement, reflecting a decrease in beta-cell reserve, whereas the daily insulin dose correlated mainly with body weight, HbA(1c) level, and duration of diabetes. Kt/V had no effect on insulin resistance or insulin requirement of the patients.

Effective treatment of high-grade lymphoproliferative disorder after renal transplantation using autologous lymphocyte activated killer cell therapy.

Posttransplantation lymphoproliferative disorders (PTLD) is not uncommon and can occur in 2% to 5% of solid organ recipients on immunosuppression. Epstein-Barr virus (EBV) infection or reactivation and intensive anti-T lymphocyte treatment are important pathogenetic factors for a large proportion of these disorders. Nonclonal lesions with polymorphous histology have a potential for regressing when the immunosuppressants are reduced or stopped. Clonal tumors with a monomorphous histology carry a poor prognosis, and the mortality rate for monoclonal lymphoma has been reported as high as 80%. We report a renal transplant recipient who developed high-grade monoclonal lymphoma only 4 months after a live-donor transplantation. The tumor was EBV positive. Reduction of immunosuppressants resulted in minimal regression of the tumor. The patient was treated with adoptive immunotherapy using ex vivo generation of autologous lymphocyte activated killer (LAK) cells. She had leukapheresis, and autologous peripheral blood mononuclear cells were obtained and cultured in interleukin-2 (IL-2)-rich medium for 9 to 10 days. The IL-2-activated LAK cells were reinfused into the patient without any systemic administration of IL-2. The patient experienced no side effects during the infusion. There was no rejection episode, and the renal function of the patient remained stable after treatment. Computed tomography scan performed 2 months after the infusion showed marked regression of the lesions in the liver and spleen. Five months later, magnetic resonance imaging showed complete resolution of the tumor lesions. Ultrasonography 13 months after the LAK cell infusion showed no lesion. The allograft function was not affected after treatment. Adoptive immunotherapy using IL-2-activated autologous LAK cells was effective in treating this renal transplant patient with EBV-positive high-grade lymphoma. The patient's kidney allograft functioned well without any rejection.

Factors predicting outcome of fungal peritonitis in peritoneal dialysis: analysis of a 9-year experience of fungal peritonitis in a single center.

Fungal peritonitis causes significant morbidity and mortality for patients undergoing continuous ambulatory peritoneal dialysis (CAPD). We retrospectively reviewed 70 episodes of fungal peritonitis in a single center over the last 9 years in 896 CAPD patients. Seventy percent of the episodes of fungal peritonitis were caused by Candida species, among which 50% were Candida parapsilosis. As a result of fungal peritonitis, 44% of the patients died, whereas further peritoneal dialysis failed in 14%, requiring a change to long-term hemodialysis. Only 37% managed to continue CAPD. The remaining 5% either underwent transplantation or were lost to follow-up. We identified the factors associated with poor outcome, namely mortality and technique failure. The presence of abdominal pain, bowel obstruction, and a catheter remaining in situ were significantly associated with greater mortality. Abdominal pain, antibiotic use within 3 months before fungal peritonitis, and complication by bowel obstruction were associated with greater technique failure. In choosing antifungal agents with catheter removal, oral fluconazole alone appears equally as effective as combined oral fluconazole with 5-flucytosine for peritonitis caused by Candida species. For peritonitis caused by species other than Candida, the choice of antifungal therapy needs to be individualized, based on fungal species and sensitivities.

Independent effects of residual renal function and dialysis adequacy on nutritional status and patient outcome in continuous ambulatory peritoneal dialysis.

Dialysis adequacy has a major impact on outcome of continuous ambulatory peritoneal dialysis (CAPD) patients. However, there is a substantial confounding effect by residual renal function in most studies. We differentiated the effects of dialysis adequacy from those of residual renal function on nutritional status and outcome of CAPD patients. We identified 168 CAPD patients treated in our center between September 1995 and December 1996 and categorized them into three groups: 49 patients with an average total Kt/V of 1.93 +/- 0.18 and a median residual glomerular filtration rate (GFR) of 0. 07 mL/min/1.73 m(2) in the dialysis-dependent (DD) group; 48 patients with an average total Kt/V of 2.03 +/- 0.25 and a residual GFR of 2. 33 mL/min/1.73 m(2) in the residual renal function (RRF) group; and 71 patients with an average total Kt/V of 1.38 +/- 0.22 and a residual GFR of 0.05 mL/min/1.73 m(2) in the control (CTL) group. They were followed-up for 1 year to compare baseline nutritional status and 1-year morbidity. Baseline normalized protein catabolic rates (NPCR) are 1.00 +/- 0.20 and 0.96 +/- 0.19 (for RRF and DD, respectively) versus 0.89 +/- 0.16 g/kg/d for CTL (P < 0.01). Percentage lean body mass (%LBM) was 71.6 +/- 9.8 and 71.5 +/- 10.0 (for RRF and DD, respectively) versus 65.2 +/- 8.5% for CTL (P < 0. 001). No difference was seen in the nutritional status between RRF and DD groups. Duration of hospitalization for 1 year was 6.9 +/- 11. 8 days in the RRF group versus 14.9 +/- 25.1 in the DD and 10.6 +/- 11.6 days in the CTL groups (P < 0.05). The peritonitis rate was 44. 4 patient-months for the RRF group, versus 13.6 for the DD and 12.9 for the CTL groups (P < 0.05). There also was a trend toward superior 1-year technique survival in the RRF group, but the number of observations was small. There was no difference in duration of hospitalization, peritonitis rate, and technique survival between the DD and CTL groups. Short-term morbidity in patients without residual renal function appears to be independent of total Kt/V, although Kt/V may have some effects on nutritional status. The assumption that renal and peritoneal clearances are equivalent must be carefully reexamined. Further studies on the effect of dialysis adequacy in patients without residual renal function are urgently needed.

Parvovirus B19 infection causing red cell aplasia in renal transplantation on tacrolimus.

Parvovirus B19 infection is known to cause chronic anemia in immunocompromised hosts, including organ transplant recipients. Most reported cases of parvovirus B19-associated aplastic anemia in renal transplant recipients responded to intravenous immunoglobulin (IVIG) infusion. Tacrolimus is of special interest; it was proposed to be associated with pure red cell aplasia (PRCA) on its own because resolution of anemia on withdrawal of tacrolimus was previously observed. Interaction between parvovirus B19 infection and tacrolimus has not been reported. We report a case of parvovirus B19-associated PRCA in a renal transplant recipient treated with tacrolimus who failed to clear the virus despite repeated courses of IVIG. She showed complete recovery promptly after tacrolimus was switched to cyclosporine A. A well-documented concomitant decrease in serum parvovirus DNA polymerase chain reaction titer was also observed. This shows another mechanism by which tacrolimus can aggravate PRCA because of impaired clearance of parvovirus B19 infection in transplant recipients. For those patients receiving tacrolimus who have parvovirus B19 infection with refractory anemia and who fail to recover with IVIG, replacement of tacrolimus with cyclosporine A can be considered.