Usefulness of assessment of the Clinical Frailty Scale and the Dementia Assessment Sheet for Community-based Integrated Care System 21-items at the time of initiation of maintenance hemodialysis in older patients with chronic kidney disease.

INTRODUCTION: We examined whether the Clinical Frailty Scale (CFS), a widely adopted tool for stratifying the degree of frailty, and the Dementia Assessment Sheet for Community-based Integrated Care System 21-items (DASC-21), a simple tool for simultaneous assessment of impaired cognition and impaired ADL, at the time of initiation of hemodialysis is useful tool of older patients for the outcome and prognosis. METHODS: Data for 101 patients aged 75 years or older (mean age, 84.3 years) with ESRD who were initiated on hemodialysis and could be followed up for a period of 6 months were reviewed. RESULTS: The 6-month survival curves showed a significantly higher number of deaths in the frailty (CFS≥5) group than in the normal to vulnerable (CFS<5) group (p<0.01). The CFS level was also significantly higher (6.5±1.5) in patients who died within 6 months of dialysis initiation as compared with that (4.6±1.7) in patients who survived (p<0.01). On the other hand, the total score of DASC-21 was related to need for inpatient maintenance dialysis (p<0.01). The total score on the DASC-21 were found as showing significant correlations with the CFS level. The IADL outside the home was identified in the DASC-21 sub-analyses as being correlated with CFS. CONCLUSIONS: The CFS and the DASC-21 appeared to be a useful predictive tool of outcome and prognosis for older patients being initiated on hemodialysis. Assessment by the CFS or the DASC-21 might be useful for selecting the renal replacement therapy by shared decision-making and for advance care planning.

Dementia knowledge and attitudes of nursing undergraduate students-association between lifestyle background and practical training experience.

Objective: To clarify the association between dementia knowledge and attitudes, lifestyle backgrounds, and practical training experiences of nursing students, and examine the basic nursing education for dementia. Participants and Methods: A total of 412 first-to-fourth-year students at Nursing College A participated in the study. A cross-sectional survey was conducted regarding knowledge (15 questions) and attitudes (15 questions) related to dementia. Results: Consent was obtained from 158 individuals (The response rate was 38.3%). Significant items regarding dementia attitudes and cohabitation experiences were identified. Additionally, significant items regarding attitude toward dementia and care providing experiences were identified. Conclusion: Associations among attitude toward dementia, cohabitation experiences, and care providing experiences were determined. Knowledge and attitudes regarding dementia improved with practical training experience.

Urate-lowering therapy for CKD patients with asymptomatic hyperuricemia without proteinuria elucidated by attribute-based research in the FEATHER Study.

Attribute-based medicine is essential for patient-centered medicine. To date, the groups of patients with chronic kidney disease (CKD) requiring urate-lowering therapy are clinically unknown. Herein, we evaluated the efficacy of febuxostat using a cross-classification, attribute-based research approach. We performed post hoc analysis of multicenter, randomized, double-blind, placebo-controlled trial data for 395 patients with stage 3 CKD and asymptomatic hyperuricemia. Participants were divided into febuxostat or placebo groups and subcohorts stratified and cross-classified by proteinuria and serum creatinine concentrations. In patients stratified based on proteinuria, the mean eGFR slopes were significantly higher in the febuxostat group than in the placebo group (P = 0.007) in the subcohort without proteinuria. The interaction between febuxostat treatment and presence of proteinuria in terms of eGFR slope was significant (P for interaction = 0.019). When cross-classified by the presence of proteinuria and serum creatinine level, the mean eGFR slopes significantly differed between the febuxostat and placebo groups (P = 0.040) in cross-classified subcohorts without proteinuria and with serum creatinine level ≥ median, but not in the cross-classified subcohorts with proteinuria and serum creatinine level < median. Febuxostat mitigated the decline in kidney function among stage 3 CKD patients with asymptomatic hyperuricemia without proteinuria.

Breast Shape Evaluation After Free Flap Breast Reconstruction After More Than 10 Years Follow-up Using 3-Dimensional Imaging Device.

BACKGROUND: Breast reconstruction using autologous tissue has been widely performed, and its safety and usefulness have been reported. However, there are few reports on the long-term morphological evaluation of autologous breast reconstruction cases. We evaluated long-term change of breast shape using Vectra, a 3-dimensional imaging device, for breast reconstruction cases with more than 10 years of follow-up. METHODS: The subjects had undergone autologous tissue breast reconstruction between 2007 and 2009. Sixteen deep inferior epigastric perforator flap cases were included in this study. For each patient, 4 items were measured as indicators: breast width, distance from the sternal notch to the nipple, distance from the nipple to the inframammary fold, and breast volume. The ratio of reconstructed breast to healthy breast was calculated for these 4 items. RESULTS: The long-term average ratio of breast width was 0.99, that of distance from the sternal notch to the nipple was 0.98, that of distance from the nipple to the inframammary fold was 0.94, and that of breast volume was 1.13. We evaluated the influence of body mass index and age at the time of the primary reconstructive surgery, but there was no significant difference in 2 body mass index groups (obese and nonobese groups) and 2 age groups (less than and more than 50 years old). CONCLUSION: We assumed that the balance between the reconstructed breast and the contralateral native breast would become worse over time because of breast sagging and changes in breast elasticity. According to our study, the shape balance of left and right breasts was maintained over time. Limitation of this study is the fact that more than half of the cases included in this study had undergone small to moderate revision surgery during the course of follow-up.

Utility of serological tumor biomarkers for surveillance of hepatocellular carcinoma in patients undergoing dialysis.

BACKGROUND: Patients undergoing dialysis are at risk of hepatocellular carcinoma (HCC) and preferably should undergo HCC surveillance. We investigated the utility of HCC tumor markers for HCC surveillance in patients undergoing dialysis. METHODS: Three serum markers specific for HCC, namely alpha-fetoprotein (AFP), Lens culinaris agglutinin A-reactive fraction of AFP (AFP-L3) and des-gamma-carboxy prothrombin (DCP), were measured in dialysis patients with and without a diagnosis of HCC (n = 60 and 507, respectively). The predictive value of each marker and that of a diagnostic score (GALAD score) based on patient age and gender as well as the same three markers were evaluated by receiver-operating characteristic (ROC) analysis, as well as sensitivity and specificity. RESULTS: AFP, DCP and the GALAD scores showed high predictive values for HCC, with areas under the ROC curve of >0.85. This effectiveness remained when focusing on small HCC (≤3 cm or ≤2 cm) or early-stage HCC (Stage I), as well as after propensity score matching of background characteristics of HCC and non-HCC patients. In particular, DCP and GALAD score had excellent predictive abilities for HCC. CONCLUSIONS: Measuring serum tumor markers for HCC can serve as a complement to imaging studies in the surveillance of HCC in patients undergoing dialysis, and reduce the likelihood of advanced HCC at detection and diagnosis.

An Idea of Hemi-abdominal Free Flap for Breast Reconstruction: A Case Report.

A deep inferior epigastric perforator (DIEP) flap is one of the gold standards for autologous breast reconstructions. However, this flap cannot be chosen again if asynchronous contralateral breast cancer occurs in the future. To solve this problem, we propose an idea and design for a hemi-abdominal DIEP flap. The patient was a 50-year-old woman who was suffering from right invasive ductal carcinoma. In using a hemi-abdominal DIEP flap, the poor postoperative appearance of the donor site might be a problem. To obtain a good donor site shape, we use a specific design to make the appearance of the donor site as good as possible. Specifically, we make an oblique spindle-shaped flap that can cover the deep inferior epigastric perforators, the superficial circumflex iliac artery, and the superficial inferior epigastric artery and avoid dog-ears, without passing over the median line. The flap weight was 800 g, the operating time was 6 hours and 22 minutes, and the bleeding amount was 110 ml. The patient had a minor wound infection in the donor site, and it was treated with a local wound treatment. The patient is satisfied with the result. We believe our flap design could minimize the unfavorable appearance of the donor site. This method might be suited to cases where the patients present with excess skin and fat on the abdomen, and half the abdominal tissue is enough to create the necessary volume of the breast. Although more cases and studies will be required to justify our technique, this case may show the possibility of a new option for breast reconstructions.

The Reconstruction after a Giant Phyllodes Tumor Resection Using a DIEP Flap.

A phyllodes tumor of the breast is a rare neoplasm, accounting for 0.3%-1% of all breast cancers. The size is 4-5 cm on average but sometimes the tumor grows more and involves the entire breast. As for treatment, complete surgical resection is the standard for localized breast phyllodes tumors. The reconstruction of a large defect is challenging. Herein, we present a case where a deep inferior epigastric artery perforator (DIEP) flap was used in breast reconstruction for a 48-year-old woman who was suffering from a giant phyllodes tumor. Immediate reconstruction was performed after tumor excision; the specimen weighed 4,230 g and the skin defect was 22 × 24 cm. The deep inferior epigastric artery and vein were anastomosed to the right internal mammary artery and vein, and the superficial inferior epigastric vein was anastomosed to the right lateral thoracic vein. The postoperative course was uneventful and the DIEP flap survived completely. In the setting of the reconstruction for a large defect, we must make maximum use of the limited human tissue available and ensure minimum damage, while also considering the functional and aesthetic outcome of the donor site. Various ideas and technologies have been reported that can assist in achieving this goal, but few reports have commented especially on the reconstruction of giant phyllodes tumor using autologous tissues. There were some other options for the way of the reconstruction such as a latissimus dorsi flap and a rectus abdominis flap. Compared with these approaches, using a DIEP flap has some disadvantages such as the need for the microsurgical skill and the risk of postoperative hernia. However, a DIEP flap provides the enough tissue to cover the large defect without any damage of the muscle. To our knowledge, this case was the largest phyllodes tumor reconstruction ever, in terms of the amount of the skin needed and resected tissue involved. Although more studies and longer follow-up will be required in the future, this case may show the usefulness of DIEP flaps for reconstruction of a giant phyllodes tumor.

Application of explainable ensemble artificial intelligence model to categorization of hemodialysis-patient and treatment using nationwide-real-world data in Japan.

BACKGROUND: Although dialysis patients are at a high risk of death, it is difficult for medical practitioners to simultaneously evaluate many inter-related risk factors. In this study, we evaluated the characteristics of hemodialysis patients using machine learning model, and its usefulness for screening hemodialysis patients at a high risk of one-year death using the nation-wide database of the Japanese Society for Dialysis Therapy. MATERIALS AND METHODS: The patients were separated into two datasets (n = 39,930, 39,930, respectively). We categorized hemodialysis patients in Japan into new clusters generated by the K-means clustering method using the development dataset. The association between a cluster and the risk of death was evaluated using multivariate Cox proportional hazards models. Then, we developed an ensemble model composed of the clusters and support vector machine models in the model development phase, and compared the accuracy of the prediction of mortality between the machine learning models in the model validation phase. RESULTS: Average age of the subjects was 65.7±12.2 years; 32.7% had diabetes mellitus. The five clusters clearly distinguished the groups on the basis of their characteristics: Cluster 1, young male, and chronic glomerulonephritis; Cluster 2, female, and chronic glomerulonephritis; Cluster 3, diabetes mellitus; Cluster 4, elderly and nephrosclerosis; Cluster 5, elderly and protein energy wasting. These clusters were associated with the risk of death; Cluster 5 compared with Cluster 1, hazard ratio 8.86 (95% CI 7.68, 10.21). The accuracy of the ensemble model for the prediction of 1-year death was 0.948 and higher than those of logistic regression model (0.938), support vector machine model (0.937), and deep learning model (0.936). CONCLUSIONS: The clusters clearly categorized patient on their characteristics, and reflected their prognosis. Our real-world-data-based machine learning system is applicable to identifying high-risk hemodialysis patients in clinical settings, and has a strong potential to guide treatments and improve their prognosis.

23-valent pneumococcal polysaccharide vaccine improves survival in dialysis patients by preventing cardiac events.

BACKGROUND: Immunodeficient patients are recommended to receive pneumococcal vaccination. However, there is limited evidence showing effectiveness of the polysaccharide vaccine. Polysaccharide vaccination has shown an association with cardiovascular event risk reduction. We assessed the efficacy of the 23-valent pneumococcal polysaccharide vaccine (PPSV23) in relation to the risk of hospitalization and death due to pneumonia and acute cardiac events. METHODS: The medical records of all dialysis patients attending our 8 study centers in 2010 were studied, and we selected 1038 consecutive patients. One-to-one propensity score matching was used to correct for potential selection bias in a PPSV23-vaccinated group versus a non-vaccinated group, and a total of 510 patients were identified for outcome analysis. Time to first admission, or deaths due to all-cause pneumonia or cardiac events until 2015 were compared between both groups. RESULTS: The all-cause death rate was significantly decreased in the PPSV23-vaccinated group, (hazard ratio [HR] 0.62, 95% confidence interval [CI]; 0.46-0.83, P = 0.002). All-cause death was considered to be a competing risk for the other outcomes. Further outcomes were evaluated by competing risk analysis adjusting for mortality. There was no statistically significant difference in the hospitalization rate for pneumonia; however, the hospitalization rate due to cardiac events was significantly lower in the PPSV23-vaccinated group than in the non-vaccinated group (HR 0.44, 95% CI; 0.20-0.96, P = 0.040). There was no statistically significant difference in the death rate due to pneumonia; however, the rate of cardiac death was significantly lower in the PPSV23-vaccinated group than in the non-vaccinated group (HR 0.36, 95% CI; 0.18-0.71, P = 0.003). CONCLUSIONS: The PPSV23 vaccination is associated with a good prognosis and a low-risk of cardiac events in dialysis patients; however, there was no evidence indicating enhanced protective efficacy against pneumonia, suggesting the PPSV23 vaccination might improve the prognosis by directly preventing cardiovascular events.

Use of vasopressor for dialysis-related hypotension is a risk factor for death in hemodialysis patients: Nationwide cohort study.

Because hypotension during hemodialysis (HD) makes continuation of HD difficult and is associated with mortality, pressor approaches are necessary for patients with hypotension. However, the relationships between the pressor approaches and the risk of death have not been clarified yet. We analyzed data from a nationwide prospective cohort study of the Japanese Society for Dialysis Therapy Renal Data Registry (n = 29,309). The outcome was all-cause one-year death. The association between the use of pressor approaches and the outcome was examined using Cox proportional hazards models adjusted for baseline characteristics, propensity score matched analysis and Bayesian networks. The background features of the patients were as follows: male, 59.6%; average age, 64.5 ± 12.5 years; and patients with diabetes mellitus, 31.5%. The pressor group showed a higher risk of the outcome than the control group [adjusted hazard ratio (aHR) 1.33 (95% CI: 1.21, 1.47), p = 0.0001]. Propensity score matched analysis also showed that the matched-pressor group had a higher risk of the outcome than the matched-control group [aHR 1.30 (95% CI: 1.17, 1.45), p = 0.0001]. Moreover, the Bayesian network showed a direct causal relationship from the use of pressor approaches to the outcome. The use of oral vasopressors [aHR 1.20 (95% CI: 1.07, 1.35), p = 0.0018], intravenous injection of vasopressors [aHR 1.54 (95% CI: 1.32, 1.79), p = 0.0001] and normal saline [aHR 1.18 (95% CI: 1.05, 1.33), p = 0.0066] were associated with a high risk of the outcome. In conclusion, this study showed that the use of pressor approaches during HD may be an independent risk factor for death.

Eicosapentaenoic Acid (EPA) Decreases the All-Cause Mortality in Hemodialysis Patients.

OBJECTIVE: Atherosclerosis, which causes cardiovascular disease, is a major cause of death in hemodialysis (HD) patients. Eicosapentaenoic acid (EPA), an anti-hyperlipidemic agent, is known to have antioxidative or anti-inflammatory effects, resulting in improvements in atherosclerosis. In the present study, we examined whether EPA improves the all-cause mortality in patients receiving regular HD therapy. METHODS: We enrolled 176 patients treated with maintenance HD therapy and performed a longitudinal observational cohort study for three years. We divided the patients into two groups based on whether or not the received EPA treatment [EPA(+) and EPA(-), respectively]. The primary end-point was all-cause death. We also matched the two groups using propensity score matching and examined the effect of EPA. RESULTS: Before matching, the all-cause mortality rates were 24.0% in the EPA(+) and 11.8% in the EPA(-) groups, which were significantly different (p=0.044). After propensity score matching, the EPA(+) group still showed a significantly better prognosis than the EPA(-) group (p=0.038). A multivariate analysis showed that EPA treatment significantly reduced the risk of all-cause mortality both before and after propensity score matching. CONCLUSION: EPA treatment is independently associated with lower mortality in HD patients.

Febuxostat improves endothelial function in hemodialysis patients with hyperuricemia: A randomized controlled study.

Endothelial dysfunction is often found in both hyperuricemia and hemodialysis patients. Recent studies have shown that treating hyperuricemia with allopurinol improves endothelial dysfunction. This study is performed to assess the effect of febuxostat on endothelial dysfunction in hemodialysis patients with hyperuricemia. We randomly assigned 53 hemodialysis patients with hyperuricemia to a febuxostat (10 mg daily) group and a control group and measured flow-mediated dilation, serum uric acid (UA) levels, systolic and diastolic blood pressure, malondialdehyde-modified low-density lipoprotein (MDA-LDL), and highly sensitive C-reactive protein (hsCRP) at baseline and at the end of a 4-week study period. Flow-mediated dilation increased from 5.3% ± 2.4% to 8.9% ± 3.6% in the febuxostat group but did not change significantly in the control group. Treatment with febuxostat resulted in a significant decrease in serum UA level and a significant decrease in MDA-LDL compared with baseline, but no significant difference was observed in hsCRP level or blood pressure. No significant differences were observed in the control group. Febuxostat improved endothelial dysfunction and reduced serum UA levels and oxidative stress in hemodialysis patients with hyperuricemia.

Switching from allopurinol to febuxostat for the treatment of hyperuricemia and renal function in patients with chronic kidney disease.

Hyperuricemia is a frequent complication of chronic kidney disease (CKD). Febuxostat is a novel xanthine oxidase inhibitor that is metabolized by many metabolic pathways in the kidney and the liver. We performed a 1-year cohort study of 73 hyperuricemic patients who had an estimated glomerular filtration rate (eGFR) below 45 ml/min and were being treated with urate-lowering therapy. In 51 patients, treatment was changed from allopurinol to febuxostat, and the other 22 patients were continued on allopurinol. The serum levels of uric acid (UA) level, creatinine, and other biochemical parameters were measured at baseline and after 3, 6, 9, and 12 months of treatment. The serum UA levels significantly decreased from 6.1 ± 1.0 to 5.7 ± 1.2 mg/dl in the febuxostat group and significantly increased from 6.2 ± 1.1 to 6.6 ± 1.1 mg/dl in the allopurinol group. The eGFR decreased 27.3 to 25.7 ml/min in the febuxostat group and from 26.1 to 19.9 ml/min in the allopurinol group. The switch from allopurinol to febuxostat was significantly associated with the changes in eGFR according to a multiple regression analysis (ß = -0.22145, P < 0.05). Febuxostat reduced the serum UA levels and slowed the progression of renal disease in our CKD cohort in comparison with allopurinol.

Association between allopurinol and mortality among Japanese hemodialysis patients: results from the DOPPS.

PURPOSE: Allopurinol, for treating hyperuricemia, is associated with lower mortality among hyperuricemic patients without chronic kidney disease (CKD). Greater allopurinol utilization in hemodialysis (HD) in Japan versus other countries provides an opportunity for understanding allopurinol-related HD outcomes. METHODS: Data from 6,252 Japanese HD patients from phases 1-3 of the Dialysis Outcomes and Practice Patterns Study (1999-2008) at ~60 facilities per phase were analyzed. Mortality was compared for patients prescribed (25 %) versus not-prescribed allopurinol using Cox regression, overall, and in patient subgroups. RESULTS: Patients prescribed allopurinol were more likely to be younger, male, and non-diabetic, and had higher serum creatinine and lower (treated) serum uric acid levels (mean = 7.0 vs. 8.0 mg/dL, p < 0.001). The inverse association between allopurinol prescription and mortality in unadjusted analyses (HR 0.65, 95 % CI 0.52-0.81) was attenuated by covariate adjustment (HR 0.84, 0.66-1.06). In subgroup analyses, allopurinol was associated with lower mortality among patients with no history of cardiovascular disease (CVD) (HR 0.48, 0.28-0.83), but not among patients with CVD (HR 1.00, 0.76-1.32). A similar pattern was seen outside Japan and for cardiovascular (CV)-related mortality. CONCLUSIONS: Allopurinol prescription was not significantly associated with case-mix-adjusted mortality in Japanese HD patients overall, but was associated with lower all-cause and CV-related mortality in the subgroup of patients with no prior CVD history. These findings in HD patients may be related to findings in non-dialysis CKD patients showing lower CV event rates and mortality, and improved endothelial function with allopurinol prescription. These results are useful for designing future trials of allopurinol use in HD patients.

Long-term damage assessment in patients with microscopic polyangiitis and renal-limited vasculitis using the Vasculitis Damage Index.

OBJECTIVES: The Vasculitis Damage Index (VDI) is used to define the degree of damage occurring in patients with systemic vasculitis. We conducted a retrospective study of 30 patients with microscopic polyangiitis (MPA) and renal-limited vasculitis (RLV). METHODS: The clinical data and VDI of the 30 patients enrolled in the study were collected and assessed for a period of 5 years. RESULT: The VDI score, which was 2.5 at 1 year after the initial diagnosis, increased gradually to 4.3 at 5 years post-diagnosis. The degrees of musculoskeletal and ocular damage significantly increased during the 5-year period (p = 0.001 and p = 0.002, respectively). The most frequent damage items in the VDI were cataract (13 %), hypertension (12 %), diabetes mellitus (9 %), and osteoporosis (6 %). The VDI score was significantly higher in the groups of patients who showed relapse or MPA than in the groups of patients who did not show relapse or RLV at 5 years (p = 0.02 and p = 0.03, respectively). In addition, a significant correlation was found between the VDI score at 5 years and the Birmingham Vasculitis Activity Score at diagnosis (p = 0.04, r = 0.4). CONCLUSION: The VDI was found to be a useful tool for determining the severity of damage caused by disease and the effects of treatment. The individual contributions of the VDI items may also be applied to treatment decisions.

Effects of cinacalcet on bone mineral density and bone markers in hemodialysis patients with secondary hyperparathyroidism.

BACKGROUND: Cinacalcet markedly reduces the serum intact parathyroid hormone (PTH) level of hemodialysis (HD) patients with secondary hyperparathyroidism. Parathyroidectomy also reduces the serum intact PTH level of HD patients and it increases their bone mineral density (BMD). However, there is little information about the effect of cinacalcet on BMD or on the associations between bone markers and BMD in HD patients. METHODS: We performed a 1-year cohort study of 25 HD patients who had a serum intact PTH level above 300 pg/ml during treatment by conventional therapies, such as with active vitamin D, and cinacalcet was prescribed for 14 of them. BMD of the femoral neck and the serum levels of two circulating bone markers, alkaline phosphatase (ALP) and bone-specific alkaline phosphatase (BSAP), were measured before and after treatment. The other 11 HD patients without cinacalcet treatment were defined as control group. RESULTS: BMD significantly increased by 7.3 % during the 1 year of treatment in the cinacalcet group and decreased by 6.2 % during the same period in the control group, and cinacalcet therapy was independently associated with the changes in BMD after multiple regression analysis that included intact PTH (ß = 7.57, P < 0.01). In the cinacalcet group, the serum ALP levels (R(2) = 0.315, P < 0.05) and BSAP levels (R(2) = 0.682, P < 0.01) levels were significantly negatively correlated with the changes in BMD, but the serum intact PTH levels were not significantly associated with the changes in BMD (R(2) = 0.011, P = 0.72). CONCLUSIONS: One year of treatment with cinacalcet increased the BMD of the femoral neck in the HD cohort, especially in the patients who had higher serum ALP and BSAP levels at baseline.

Serum osteocalcin levels are useful as a predictor of cardiovascular events in maintenance hemodialysis patients.

BACKGROUNDS: Osteocalcin (OC) is a known bone metabolic marker and a regulator of glucose and fat metabolisms. Although bone and energy metabolisms are known risk factors for cardiovascular disease (CVD) in hemodialysis (HD) patients, few studies have examined the correlation between OC and CVD. The purpose of this study was to investigate the impact of serum OC levels on the emergence of new CVD events in HD patients. METHODS: We designed a longitudinal, observational cohort study in which the study patients were divided into low- and high-serum OC groups based on a median serum OC level of 71.5 ng/ml. RESULTS: Cardiovascular disease events were observed in 29 of 126 patients (23.0 %). The number of cumulative CVD events in the low-serum OC group was significantly higher than that in the high-serum OC group, as evaluated by the Kaplan-Meier method (p = 0.0021, log-rank test). Multivariate Cox proportional hazards analysis demonstrated that a low level of serum OC is a significant predictor of a higher incidence of CVD events [hazard ratio, 2.925; 95 % confidence interval, 1.048-9.066; p = 0.0401] after adjustment. CONCLUSION: Serum OC level is a significant, independent prognostic factor for CVD events in maintenance HD patients. OC may be useful in predicting new CVD events in HD patients.

Effect of single-dose rituximab on steroid-dependent minimal-change nephrotic syndrome in adults.

BACKGROUND: Steroid-dependent minimal-change nephrotic syndrome (MCNS) requires administration of prolonged courses of prednisolone (PSL); therefore, a paradigm shift from such toxic 'non-specific' therapies to selective immunomodulating regimens is necessary for these cases. METHODS: To assess the therapeutic effects of rituximab (an anti-CD20 antibody) in adult patients with steroid-dependent MCNS, we performed a prospective trial of the effects of a single dose of rituximab administered twice at an interval of 6 months in 25 MCNS patients. We evaluated the biochemical parameters and compared the clinical findings between the 12-month period before and 12-month period after the first rituximab infusion. RESULTS: A significant reduction in the number of relapses and the total dose and the maintenance dose of PSL administered was observed during the 12-month period after the first rituximab infusion when compared with the findings during the 12-month period before the first rituximab infusion [25 (100%) versus 4 (16%), P < 0.001; 8.2 versus 3.3 g, P < 0.001; 26.4 mg/day at baseline versus 1.1 mg/day at 12-month, P < 0.0001]. Complete remission was achieved/maintained in all patients undergoing B-cell depletion. Four of 17 patients with B-cell repletion developed relapse. CONCLUSIONS: Our results revealed that rituximab therapy was associated with a reduction in the number of relapses and in the total dose of PSL needed. Therefore, rituximab appears to be a useful therapeutic agent for adult patients with steroid-dependent MCNS. These results suggest that this treatment is rational and should be considered as an important option in the management of adult patients with steroid-dependent MCNS.

Positive C1q staining associated with poor renal outcome in membranoproliferative glomerulonephritis.

BACKGROUND: Pathogenesis and clinical prognosis of membranoproliferative glomerulonephritis (MPGN) has not yet been established. METHODS: We conducted a retrospective study of 41 patients with MPGN (type I and III) and examined the renal survival. In addition, factors contributing to survival time were analyzed. RESULTS: Fourteen patients (34 %) were classified into the renal death group. Patients with nephrotic syndrome and positive C1q staining of glomerular deposits showed a particularly poor prognosis. Significantly higher frequency of nephrotic syndrome and higher urinary protein excretion were observed in the renal death group (p = 0.0002, p = 0.0002) than in the renal survival group. The intensity of C1q staining was positively correlated with the severity of the proteinuria (p = 0.004). Factors that influenced the survival time were positive C1q staining of glomerular deposits (p = 0.003), presence of nephrotic syndrome (p = 0.004), serum albumin (p = 0.02), and proteinuria (p = 0.04). CONCLUSIONS: C1q staining in glomerular deposits and nephrotic syndrome were important factors influencing the prognosis and outcome in MPGN patients. C1q deposition may play a key role in the pathogenesis of MPGN, as evidenced by numerous observations, such as induction of proteinuria.

Rituximab treatment for adult patients with focal segmental glomerulosclerosis.

We present two cases with steroid-resistant nephrotic syndrome (SRNS) and two cases with steroid-dependent nephrotic syndrome (SDNS) due to focal segmental glomerulonephritis (FSGS) who were treated with a single dose of rituximab (375 mg/m(2)). Although the two cases with SRNS showed no response, the two cases with SDNS achieved complete remission. The patients in whom the peripheral B-cell counts subsequently increased after the administration of rituximab demonstrated a relapse. Rituximab may be an effective treatment agent for SDNS with FSGS and the peripheral B-cell count may be a useful marker in such patients for preventing disease relapse.