Icodextrin-induced acute generalized exanthematous pustulosis in a patient with peritoneal dialysis.

Icodextrin has been widely prescribed for peritoneal dialysis (PD) patients with inadequate ultrafiltration, but icodextrin induced acute generalized exanthematous pustulosis (AGEP) has been not well recognized in clinical practice. We described a young-aged female with IgA nephropathy and end stage kidney disease under continuous automated peritoneal dialysis. She developed skin erythema with exfoliation over the groin 7th day after initiation of icodextrin based PD dialysate. Initially, her scaling skin lesion with pinhead-sized pustules affected the bilateral inguinal folds, and then it extended to general trunk accompanied by pruritus. She was admitted because of deterioration of skin lesion on 14th day of icodextrin exposure. She was afebrile and physical examination was notable for widespread erythematous papules with pruritus extending over her groins and trunk. Pertinent laboratory examination showed leukocytosis of 18 970 cells/µL with neutrophile count of 17 642 cells/µL (92.3%), and c-reactive-protein: 3.39 mg/dL. Skin biopsy revealed multifocal sub corneal abscess with papillary dermal edema, and upper-dermal neutrophilia with perivascular accentuation, consistent with the diagnosis of AGEP. After discontinuation of PD, she underwent temporary high-flux haemodialysis with treatment of steroid and antihistamine. Her dermatologic lesion resolved without any skin sequalae completely within 4 days, and she underwent icodextrin-free peritoneal dialysis at 17th day. This case highlighted the fact that icodextrin-induced AGEP should be early recognized to avoid inappropriate management.

Artificial intelligence-enabled electrocardiography contributes to hyperthyroidism detection and outcome prediction.

BACKGROUND: Hyperthyroidism is frequently under-recognized and leads to heart failure and mortality. Timely identification of high-risk patients is a prerequisite to effective antithyroid therapy. Since the heart is very sensitive to hyperthyroidism and its electrical signature can be demonstrated by electrocardiography, we developed an artificial intelligence model to detect hyperthyroidism by electrocardiography and examined its potential for outcome prediction. METHODS: The deep learning model was trained using a large dataset of 47,245 electrocardiograms from 33,246 patients at an academic medical center. Patients were included if electrocardiograms and measurements of serum thyroid-stimulating hormone were available that had been obtained within a three day period. Serum thyroid-stimulating hormone and free thyroxine were used to define overt and subclinical hyperthyroidism. We tested the model internally using 14,420 patients and externally using two additional test sets comprising 11,498 and 596 patients, respectively. RESULTS: The performance of the deep learning model achieves areas under the receiver operating characteristic curves (AUCs) of 0.725-0.761 for hyperthyroidism detection, AUCs of 0.867-0.876 for overt hyperthyroidism, and AUC of 0.631-0.701 for subclinical hyperthyroidism, superior to a traditional features-based machine learning model. Patients identified as hyperthyroidism-positive by the deep learning model have a significantly higher risk (1.97-2.94 fold) of all-cause mortality and new-onset heart failure compared to hyperthyroidism-negative patients. This cardiovascular disease stratification is particularly pronounced in subclinical hyperthyroidism, surpassing that observed in overt hyperthyroidism. CONCLUSIONS: An innovative algorithm effectively identifies overt and subclinical hyperthyroidism and contributes to cardiovascular risk assessment.

Hyperthyroidism occurs when the thyroid gland produces too much hormone and can cause various symptoms including faster heartbeat, weight loss, and nervousness. Diagnosis is often missed, which can lead to heart problems and even death. Measurements of the heart's electrical activity can be obtained using Electrocardiograms (ECGs). We made a computational model that can detect hyperthyroidism from ECGs. Our model was better able to identify people with hyperthyroidism than currently available methods, especially the more severe forms of the condition. If future work demonstrates our model is safe and accurate, it could potentially be used to detect hyperthyroidism sooner, enabling faster treatment and improved health of people with hyperthyroidism.

Acute kidney disease following COVID-19 vaccination: a single-center retrospective study.

Background: Rare cases of de novo or relapsed kidney diseases associated with vaccination against coronavirus disease 2019 (COVID-19) have been increasingly reported. The aim of this study was to report the incidence, etiologies, and outcomes of acute kidney disease (AKD) following COVID-19 vaccination. Methods: This retrospective study extracted cases from renal registry of a single medical center from 1 March 2021 to 30 April 2022, prior to the significant surge in cases of the Omicron variant of COVID-19 infection in Taiwan. Adult patients who developed AKD after COVID-19 vaccination were included. We utilized the Naranjo score as a causality assessment tool for adverse vaccination reactions and charts review by peer nephrologists to exclude other causes. The etiologies, characteristics, and outcomes of AKD were examined. Results: Twenty-seven patients (aged 23 to 80 years) with AKD were identified from 1,897 vaccines (estimated rate of 13.6 per 1000 patient-years within the renal registry). A majority (77.8%) of vaccine received messenger RNA-based regimens. Their median (IQR) Naranjo score was 8 (6-9) points, while 14 of them (51.9%) had a definite probability (Naranjo score ≥ 9). The etiologies of AKD included glomerular disease (n = 16) consisting of seven IgA nephropathy, four anti-neutrophil cytoplasmic antibodies-associated glomerulonephritis (AAN), three membranous glomerulonephritis, two minimal change diseases, and chronic kidney disease (CKD) with acute deterioration (n = 11). Extra-renal manifestations were found in four patients. Over a median (IQR) follow-up period of 42 (36.5-49.5) weeks, six patients progressed to end-stage kidney disease (ESKD). Conclusion: Besides glomerulonephritis (GN), the occurrence of AKD following COVID-19 vaccination may be more concerning in high-risk CKD patients receiving multiple doses. Patients with the development of de novo AAN, concurrent extra-renal manifestations, or pre-existing moderate to severe CKD may exhibit poorer kidney prognosis.

Pioglitazone use increases risk of Alzheimer's disease in patients with type 2 diabetes receiving insulin.

Pioglitazone is an insulin resistance inhibitor widely used as monotherapy or combined with metformin or insulin in treating type 2 diabetes mellitus (T2DM). This study further investigated the relationship between pioglitazone use and the risk of developing Alzheimer's disease (AD) in patients newly diagnosed with T2DM, and examined the potential impact of insulin use on this association. Data were extracted from the National Health Insurance Research Database (NHIRD) of Taiwan. Our data exhibited that the risk of developing AD in the pioglitazone group was 1.584-fold (aHR = 1.584, 95% CI 1.203-1.967, p < 0.05) higher than that in the non-pioglitazone controls. Compared to patients without both insulin and pioglitazone, higher cumulative risk of developing AD was found in patients receiving both insulin and pioglitazone (aHR = 2.004, 95% CI = 1.702-2.498), pioglitazone alone (aHR = 1.596, 95% CI = 1.398-1.803), and insulin alone (aHR = 1.365, 95% CI = 1.125-1.572), respectively (all p < 0.05). A similar observation also found in the evaluation the use of diabetic drugs with a cumulative defined daily dose (cDDD). No interaction between pioglitazone and major risk factors (comorbidities) of AD was observed. In conclusion, alternative drug therapies may be an effective strategy for reducing risk of developing AD in T2DM patients.

Incorporating knowledge of disease-defining hub genes and regulatory network into a machine learning-based model for predicting treatment response in lupus nephritis after the first renal flare.

BACKGROUND: Identifying candidates responsive to treatment is important in lupus nephritis (LN) at the renal flare (RF) because an effective treatment can lower the risk of progression to end-stage kidney disease. However, machine learning (ML)-based models that address this issue are lacking. METHODS: Transcriptomic profiles based on DNA microarray data were extracted from the GSE32591 and GSE112943 datasets. Comprehensive bioinformatics analyses were performed to identify disease-defining genes (DDGs). Peripheral blood samples (GSE81622, GSE99967, and GSE72326) were used to evaluate the effect of DDGs. Single-sample gene set enrichment analysis (ssGSEA) scores of the DDGs were calculated and correlated with specific immunology genes listed in the nCounter panel. GSE60681 and GSE69438 were used to examine the ability of the DDGs to discriminate LN from other renal diseases. K-means clustering was used to obtain the separate gene sets. The clustering results were extended to data derived using the nCounter technique. The least absolute shrinkage and selection operator (LASSO) algorithm was used to identify genes with high predictive value for treatment response after the first RF in each cluster. LASSO models with tenfold validation were built in GSE200306 and assessed by receiver operating characteristic (ROC) analysis with area under curve (AUC). The models were validated by using an independent dataset (GSE113342). RESULTS: Forty-five hub genes specific to LN were identified. Eight optimal disease-defining clusters (DDCs) were identified in this study. Th1 and Th2 cell differentiation pathway was significantly enriched in DDC-6. LCK in DDC-6, whose expression positively correlated with various subsets of T cell infiltrations, was found to be differentially expressed between responders and non-responders and was ranked high in regulatory network analysis. Based on DDC-6, the prediction model had the best performance (AUC: 0.75; 95% confidence interval: 0.44-1 in the testing set) and high precision (0.83), recall (0.71), and F1 score (0.77) in the validation dataset. CONCLUSIONS: Our study demonstrates that incorporating knowledge of biological phenotypes into the ML model is feasible for evaluating treatment response after the first RF in LN. This knowledge-based incorporation improves the model's transparency and performance. In addition, LCK may serve as a biomarker for T-cell infiltration and a therapeutic target in LN.

Inactivation of mitochondrial pyruvate carrier promotes NLRP3 inflammasome activation and gout development via metabolic reprogramming.

The nucleotide-binding and oligomerization domain, leucine-rich repeats, and pyrin domain-containing protein 3 (NLRP3) inflammasome plays a crucial role in innate immunity and is involved in the pathogenesis of autoinflammatory diseases. Glycolysis regulates NLRP3 inflammasome activation in macrophages. However, how lactic acid fermentation and pyruvate oxidation controlled by the mitochondrial pyruvate carrier (MPC) affect NLRP3 inflammasome activation and autoinflammatory disease remains elusive. We found that the inactivation of MPC with genetic depletion or pharmacological inhibitors, MSDC-0160 or pioglitazone, increased NLRP3 inflammasome activation and IL-1ß secretion in macrophages. Glycolytic reprogramming induced by MPC inhibition skewed mitochondrial ATP-associated oxygen consumption into cytosolic lactate production, which enhanced NLRP3 inflammasome activation in response to monosodium urate (MSU) crystals. As pioglitazone is an insulin sens MSDC-itizer used for diabetes, its MPC inhibitory effect in diabetic individuals was investigated. The results showed that MPC inhibition exacerbated MSU-induced peritonitis in diabetic mice and increased the risk of gout in patients with diabetes. Altogether, we found that glycolysis controlled by MPC regulated NLRP3 inflammasome activation and gout development. Accordingly, prescriptions for medications targeting MPC should consider the increased risk of NLRP3-related autoinflammatory diseases.

Reversible cefazolin-induced status epilepticus in a peritoneal dialysis patient.

Cefazolin-induced neurotoxicity with the documented toxic concentration has not been reported in uremic patients on continuous ambulatory peritoneal dialysis (CAPD). We described an elderly female on CAPD for years presented with newly-onset status epilepticus. Her body weight was 60 kg. And she had received intraperitoneal ceftazidime and cefazolin 1.5 g once daily for her CAPD peritonitis 5 days earlier. She was disoriented but afebrile with normal blood pressure. Laboratory data showed WBC 18,480/uL, pH 6.93, HCO3 - 8.5 mmol/L, free Ca2+ 3.5 mmol/L, and albumin 2.8 g/dL. Although antiepileptic drugs and hypocalcemia correction ceased the seizure, her consciousness remained semi-coma. Image studies of brain were unremarkable. Despite undetectable serum ceftazidime, her cefazolin trough level was 149.5 µg/mL. Emergent hemodialysis rapidly resolved her neurological features accompanied by a markedly declined serum cefazolin concentration (28.6 µg/mL). Higher intraperitoneal cefazolin dosing in patients on CAPD may cause drug-induced neurotoxicity with status epilepticus which could be rapidly corrected by hemodialysis.

Mycophenolate-Induced Hepatotoxicity Precipitates Tacrolimus Nephrotoxicity in a Kidney Transplant Recipient: A Case Report.

Mycophenolate (mycophenolate mofetil [MMF]; mycophenolate sodium [MPS]) and tacrolimus (FK-506) are commonly and concomitantly used to prevent rejection in organ transplant. Mycophenolate-induced hepatotoxicity causing the reduced FK-506 metabolism with nephrotoxicity may be less appreciated, leading to inappropriate management. We describe a new living donor kidney recipient receiving pretransplant and post-transplant immunosuppressants including oral mycophenolate (MMF 1 g daily) and tacrolimus (FK-506 4-8 mg daily) who developed progressive liver dysfunction (up to 10-fold increase) despite the reduced FK-506 dosage (6 mg daily). A thorough investigation including infection, inflammation, and autoimmune hepatitis were unremarkable. With a withdrawal of MMF, his liver function improved, but persistently higher trough serum FK-506 level (12-15 ng/mL) and increased serum creatinine were notable. Moreover, the reintroduction of MPS with the reduced FK-506 dosage (4 mg daily) worsened liver function along with FK-506 nephrotoxicity (serum creatinine from 1.4-2.4 mg/dL). The replacement of MPS with mammalian target of rapamycin inhibitor not only resolved liver injury but also normalized serum FK-506 level and kidney function. Mycophenolate should be kept in mind as a cause of drug-induced hepatotoxicity that can reduce tacrolimus metabolism, leading to FK-506 nephrotoxicity and acute kidney injury in organ transplant.

Effect of Dialysis Modalities on All-Cause Mortality and Cardiovascular Mortality in End-Stage Kidney Disease: A Taiwan Renal Registry Data System (TWRDS) 2005-2012 Study.

Introduction: End-stage kidney disease (ESKD) patients who need renal replacement therapy need to face a dialysis modality decision: the choice between hemodialysis (HD) and peritoneal dialysis (PD). Although the global differences in HD/PD penetration are affected by health-care policies, these two modalities may exert different effects on survival in patients with ESKD. Although Taiwan did not implicate PD as first policy, we still need to compare patients' outcomes using two modalities in a nation-wise database to determine future patients' care and health policies. Methods: We used the nationwide Taiwan Renal Registry Data System (TWRDS) database from 2005 to 2012 and included 52,900 patients (48,371 on HD and 4529 on PD) to determine all-cause and cardiovascular mortality among ESKD patients. Results: Age-matched survival probability from all-cause mortality was significantly lower in patients on PD than in those on HD (p < 0.05). The adjusted hazard ratios of 3-year and 5-year all-cause and cardiovascular mortality were significantly higher in PD compared with HD. The presence of comorbid conditions including myocardial infarction, coronary artery disease (CAD), diabetes mellitus (DM), hypoalbuminemia, hyperferritinemia and hypophosphatemia was related with significantly higher all-cause and CV mortality in PD patients. No significant difference was noted among younger patients <45 years of age regardless of DM and/or comorbid conditions. Conclusion: Although PD did not have the survival advantage compared to HD in all dialysis populations, PD was related with superior survival in younger non-DM patients, regardless of the presence of comorbidities. Similarly, for younger ESKD patients without the risk of CV disease, both PD and HD would be suitable dialysis modalities.

Association between trichomoniasis and prostate and bladder diseases: a population-based case-control study.

Trichomonas vaginalis infection is one of the most widespread sexually transmitted infections in the world. There are approximately 276 million cases worldwide. Most men remain undiagnosed and untreated because they are asymptomatic. The chronic inflammation induced by persistent infection may increase the risk of developing genitourinary cancers. In this study, we aimed to investigate the association between trichomoniasis and benign prostate hyperplasia (BPH), prostate cancer (PCa), and bladder cancer (BC) in Taiwan. We designed a case-control study by using the database of the National Health Insurance program in Taiwan. We used the International Classification of Diseases, 9th Revision classifications to classify all the medical conditions in the case and control groups. All odds ratios (ORs) and 95% confidence intervals (CIs) were analyzed using multivariable logistic regression to adjust for all comorbidities and variables. From 2000 to 2015, we enrolled a total of 62,544 individuals as the case group and 187,632 as the control group. Trichomoniasis exposure had a significant association with BPH and PCa (adjusted OR: BPH = 2.685, 95% CI = 1.233-4.286, P = 0.013; PCa = 5.801, 95% CI = 1.296-26.035, P = 0.016). The relative risk was much higher if patients had both trichomoniasis and depression (adjusted OR = 7.682, 95% CI = 5.730-9.451, P < 0.001). Men with trichomoniasis had a significantly higher risk of developing BPH and PCa than those without. Healthcare professionals should not only pay more attention to disease treatment, but also to public health education.

Artificial intelligence-enabled electrocardiography identifies severe dyscalcemias and has prognostic value.

CONTEXT: Abnormal serum calcium concentrations affect the heart and may alter the electrocardiogram (ECG), but the detection of hypocalcemia and hypercalcemia (collectively dyscalcemia) relies on blood laboratory tests requiring turnaround time. OBJECTIVE: The study aimed to develop a bloodless artificial intelligence (AI)-enabled (ECG) method to rapidly detect dyscalcemia and analyze its possible utility for outcome prediction. METHODS: This study collected 86,731 development, 15,611 tuning, 11,105 internal validation, and 8401 external validation ECGs from electronic medical records with at least 1 ECG associated with an albumin-adjusted calcium (aCa) value within 4 h. The main outcomes were to assess the accuracy of AI-ECG to predict aCa and follow up these patients for all-cause mortality, new-onset acute myocardial infraction (AMI), and new-onset heart failure (HF) to validate the ability of AI-ECG-aCa for previvor identification. RESULTS: ECG-aCa had mean absolute errors (MAE) of 0.78/0.98 mg/dL and achieved an area under receiver operating characteristic curves (AUCs) 0.9219/0.8447 and 0.8948/0.7723 to detect severe hypercalcemia and hypocalcemia in the internal/external validation sets, respectively. Although < 20 % variance of ECG-aCa could be explained by traditional ECG features, the ECG-aCa was found to be associated with more complications. Patients with ECG-hypercalcemia but initially normal aCa were found to have a higher risk of subsequent all-cause mortality [hazard ratio (HR): 2.05, 95 % conference interval (CI): 1.55-2.70], new-onset AMI (HR: 2.88, 95 % CI: 1.72-4.83), and new-onset HF (HR: 2.02, 95 % CI: 1.38-2.97) in the internal validation set, which were also seen in external validation. CONCLUSION: The AI-ECG-aCa may help detecting severe dyscalcemia for early diagnosis and ECG-hypercalcemia also has prognostic value for clinical outcomes (all-cause mortality and new-onset AMI and HF).

Case report: Severe rhabdomyolysis and acute liver injury in a high-altitude mountain climber.

Concurrent severe rhabdomyolysis and acute liver damage are rarely reported in the setting of acute high-altitude illness (AHAI). We described a 53-year-old healthy mountain climber who experienced headache and dyspnea at the summit of Snow Mountain (Xueshan; 3,886 m above sea level) and presented to the emergency room with generalized malaise, diffuse muscle pain, and tea-colored urine. His consciousness was alert, and he had a blood pressure of 114/74 mmHg, heart rate of 66/min, and body temperature of 36.8°C. Myalgia of the bilateral lower limbs, diminished skin turgor, dry oral mucosa, and tea-colored urine were notable. Urinalysis showed positive occult blood without red blood cells. The most striking blood laboratory data included creatine kinase (CK) 33,765 IU/L, inappropriately high aspartate aminotransferase (AST) 2,882 IU/L and alanine aminotransferase (ALT) 2,259 IU/L (CK/AST ratio 11.7, CK/ALT ratio 14.9), creatinine 1.5 mg/dl, serum urea nitrogen (BUN) 26 mg/dl, total bilirubin 1.7 mg/dl, ammonia 147 µg/ml, lactate 2.5 mmol/L, and prothrombin time 17.8 s. The meticulous search for the underlying causes of acute liver injury was non-revealing. With volume repletion, mannitol use, and urine alkalization coupled with avoidance of nephrotoxic and hepatotoxic agents, his clinical features and laboratory abnormality completely resolved in 3 weeks. Despite rarity, severe rhabdomyolysis and/oracute liver injury as a potential life-threatening condition requiring urgent management may occur in high-altitude hypobaric hypoxia.

SARS-CoV-2 versus other minor viral infection on kidney injury in asymptomatic and mildly symptomatic patients.

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and has become a global pandemic since December 2019. Most of the patients are mild or asymptomatic and recovered well as those suffered from other respiratory viruses. SARS-CoV-2 infection is supposed to demonstrate more sequelae. Acute kidney injury (AKI) is common among COVID-19 patients and is associated with disease severity and outcomes. Only a few studies focused on a detailed analysis of kidney damage in asymptomatic or mildly symptomatic COVID-19 patients. Whether any minor viral infection is likely to exhibit similar minor effect on renal function as COVID-19 is still unclear, and the definite pathophysiology of viral invasion is not fully understood. Currently, the proposed mechanisms of AKI include direct effects of virus on kidney, dysregulated immune response, or as a result of multi-organs failure have been proposed. This study will discuss the difference between COVID-19 and other viruses, focusing on proposed mechanisms, biomarkers and whether it matters with clinical significance.

Spatial Analysis on Supply and Demand of Adult Surgical Masks in Taipei Metropolitan Areas in the Early Phase of the COVID-19 Pandemic.

This study aimed to assess the gap between the supply and demand of adult surgical masks under limited resources. Owing to the implementation of the real-name mask rationing system, the historical inventory data of aggregated mask consumption in a pharmacy during the early period of the COVID-19 outbreak (April and May 2020) in Taiwan were analyzed for supply-side analysis. We applied the Voronoi diagram and areal interpolation methods to delineate the average supply of customer counts from a pharmacy to a village (administrative level). On the other hand, the expected number of demand counts was estimated from the population data. The relative risk (RR) of supply, which is the average number of adults served per day divided by the expected number in a village, was modeled under a Bayesian hierarchical framework, including Poisson, negative binomial, Poisson spatial, and negative binomial spatial models. We observed that the number of pharmacies in a village is associated with an increasing supply, whereas the median annual per capita income of the village has an inverse relationship. Regarding land use percentages, percentages of the residential and the mixed areas in a village are negatively associated, while the school area percentage is positively associated with the supply in the Poisson spatial model. The corresponding uncertainty measurement: villages where the probability exceeds the risk of undersupply, that is, Pr (RR < 1), were also identified. The findings of the study may help health authorities to evaluate the spatial allocation of anti-epidemic resources, such as masks and rapid test kits, in small areas while identifying priority areas with the suspicion of undersupply in the beginning stages of outbreaks.

Quantified Facial Rejuvenation Utilizing High Intense Focus Ultrasound with Multiple Penetrative Depths.

Background: Multiple penetration depths of high-intensity focused ultrasound (HIFU) treatment for facial rejuvenation have not been quantified. Methods: We enrolled 12 participants (n=24) to undergo one session of HIFU rejuvenation between January 1, 2019, and January 10, 2020. We used a 2-, 4.5-, and 6-mm focal depth transducer on the upper and middle face. We evaluated efficacy on days 60 and 90 by using our specific assessment system. Results: The average eyebrow peak and pupil-eyebrow peak angles significantly increased by 2° (p < 0.0005) and decreased by 1° (p < 0.0001), respectively, at day 90. The shortened eyebrow-iris length indicated that the forehead tissues had lifted and moved medially to the central face. Supraorbital tissues were also vertically elevated, marked by the eyebrow-orbital (p = 0.0016) and vertical palpebral fissure lengths (p = 0.0052), which both exhibited a 0.8-cm elevation. For the midface, the increased canthus-oral-nasal angle (p = 0.5881) and decreased tragus-oral length (p = 0.5881) indicated that laxity had been corrected through lifted oral commissure, though the data were not statistically significant. No serious side effects were observed. Conclusion: HIFU treatment with multiple depths quantitatively improved both upper-facial rejuvenation and midface rejuvenation after a single session.

Trichomonas infection in pregnant women: a nationwide cohort study.

Trichomoniasis is the most prevalent sexually transmitted infection worldwide, and is associated with adverse pregnancy outcomes. However, Trichomonas vaginalis (TV) has received little public health attention, and only limited data are available on prevalence of TV and other Trichomonas-associated syndromes in pregnant women. This study aimed to determine associations between pregnancy and incident trichomoniasis-related diseases. Data of pregnant women were extracted from the National Health Insurance Research Database (NHIRD) of Taiwan. The pregnant cohort included 113,781 women, and cases were randomly matched by age, and index year with those of non-pregnant women (n = 113,781). Risk of incident trichomoniasis-related diseases was also not significantly different between pregnant and non-pregnant women. However, after stratifying by age or level of care, the younger subgroup among pregnant women had a higher risk of incident trichomoniasis-related diseases than did the younger subgroup in non-pregnant women, while the elder subgroup among pregnant women had a lower risk of incident trichomoniasis-related diseases than did the same subgroup in non-pregnant women (all p < 0.05). The higher level of care (medical center) subgroup among pregnant women had a lower risk of incident trichomoniasis-related diseases than did the same subgroup in non-pregnant women. In conclusions, although pregnancy is not significantly associated with risk of trichomoniasis-related diseases, data of the present study support an enhanced high level of medical care for pregnant women, emphasizing the potential of high medical care in reduced incidence of trichomoniasis-related diseases. This may be an effective strategy for reducing various pregnancy complications associated with trichomoniasis-related diseases.

Relationship between metformin use and lactic acidosis in advanced chronic kidney disease: The REMIND-TMU study.

BACKGROUND: Evidence of metformin-associated lactic acidosis (MALA) in advanced chronic kidney disease (CKD) has been limited due to high mortality rate but rare incidence rate. The mechanism of increased MALA in advanced CKD is mainly based on the hypothesis of decreased drug elimination, which might also be confounded by increased comorbidities as CKD progresses. The goal of the study is to analyze the incidence and associated factors of lactic acidosis between metformin user and non-user with advanced CKD. METHODS: This study used a three million population-based, propensity score-matched cohort from 2008 to 2016. The primary outcome was laboratory-defined lactic acidosis. Relationships between the probability of lactic acidosis and various estimated glomerular filtration rate (eGFR) values in advanced CKD patients were also presented in regression analysis. RESULTS: Adults with type 2 diabetes whose eGFR was <30 mL/min/1.73 m2 were enrolled in this study. After the process of propensity score matching, 7707 patients were divided into metformin and non-metformin groups. In linear regression model, metformin significantly increased the risk of lactic acidosis (p=0.0204) as the eGFR declined in advanced CKD over a mean follow up of over 600 days even after confounder adjustment with age, sex and comorbidities. CONCLUSIONS: Metformin was associated with a significant increased risk of laboratory-defined lactic acidosis (p=0.0204) even after adjusting confounder such as age, sex and underlying comorbidities. This "REMIND" study reminds us that metformin-associated lactic acidosis is mainly caused by decreased drug renal elimination other than underlying comorbidities in advanced CKD patients.

Lactic acidosis associated with standard dose linezolid in a kidney recipient with impaired renal function.

Severe lactic acidosis, a mitochondrial toxicity caused by the recommended standard dosage of linezolid (LZD), may occur in patients with impaired renal function. We describe an adult male who underwent kidney transplantation with stably impaired renal function, severe dyspnea, and abdominal discomfort. He received a standard oral dose of LZD (600 mg twice daily) and azithromycin for three weeks with a reduced immunosuppressant dose due to pulmonary non-tuberculosis mycobacterial infection. He was alert and afebrile, with a blood pressure of 140/60 mmHg. Pertinent laboratory data showed: pH 7.12, PaCO2 13.6 mmHg; HCO3- 4.3 mmol/L and serum lactate 18.4 mmol/L. His trough serum LZD concentration reached toxic levels (21.4 µg/mL). With hemodialysis, his clinical symptoms improved, with a decline in serum LZD (9.8µg/mL) and lactate (3.2 mmol/L). Chronic standard dose LZD in patients with impaired renal function can lead to life-threatening lactic acidosis, especially in coexisting conditions that reduce LZD metabolism.