Effect of Orthostatic Hypotension on Kidney Function.

BACKGROUND: The association between orthostatic hypotension (OH) and long-term changes in kidney function in the general population is not yet well known. METHODS: We performed a population-based cohort study based on data from the Korean Genome and Epidemiology Study (KoGES). The primary exposure was the presence of classic OH, defined as a postural drop in blood pressure (systolic blood pressure ≥20 mm Hg and/or diastolic blood pressure ≥10 mm Hg) at 2 min of standing after 5 min of supine rest. The primary outcome was a 12-year change in kidney function, assessed by subtracting the baseline estimated glomerular filtration rate (eGFR) from the eGFR at 12 years of follow-up. RESULTS: Our study included 5,905 participants (median [interquartile range] age, 49 [44-58] years; 46% males) who met inclusion and exclusion criteria. Classic OH was detected in 268 (4.5%) of the total participants. In the regression analyses, participants with classic OH had a greater decline in eGFR over 12 years compared with those without classic OH; the fully adjusted beta coefficient and 95% confidence intervals (95% CIs) were -1.74 (-3.07, -0.40). Furthermore, classic OH was associated with 27% greater risk of a 30% decline in kidney function compared with those without classic OH; fully adjusted hazard ratio and 95% CIs were 1.27 (1.07, 1.49). CONCLUSIONS: Classic OH can negatively affect long-term kidney function in the general population.

Serum Phosphorus Levels are Associated with Intradialytic Hypotension in Hemodialysis Patients.

BACKGROUND: Intradialytic hypotension (IDH) is a common serious complication in hemodialysis (HD) patients. Hyperphosphatemia is also common in HD patients and promotes vascular calcification. Given the association between vascular calcification and IDH, we investigated the association between IDH and serum phosphorus in HD patients. METHODS: We enrolled 173 patients who received HD for 3 months or more. IDH was defined as a nadir systolic blood pressure (SBP) <90 mm Hg or as a decrease in SBP ≥20 mm Hg or a decrease in mean arterial pressure by 10 mm Hg with the occurrence of hypotension-related symptoms requiring intervention. Serum phosphorus levels were analyzed both as a continuous variable and as a categorical variable. RESULTS: IDH occurred in 40 (23.1%) of the 173 patients. The mean phosphorus level was 4.9 mg/dL. A 1 mg/dL higher serum phosphorus resulted in a 2.1-fold greater odds of IDH. The fully adjusted odds ratio (OR) and 95% confidence interval (CI) were 2.11 (1.48-3.01). High categorized phosphorus levels were also associated with IDH. The highest tertile of serum phosphorus was associated with 6.5-fold greater odds of developing IDH compared to the referent group (the middle tertile of serum phosphorus, 4.0-<5.3 mg/dL); the fully adjusted OR (95% CIs) were 6.53 (2.23-19.09). In subgroup analyses, diabetes and pre-dialysis SBP modified the association between IDH and phosphorus levels, with a more pronounced association in diabetic patients and pre-dialysis SBP ≥140 mm Hg. CONCLUSION: In HD patients, higher phosphorus levels were associated with an increased occurrence of IDH.

Effect of alcohol consumption on kidney function: population-based cohort study.

The association between alcohol consumption and kidney function is intriguing, but study results are mixed and controversial. We examined the association of alcohol consumption with the overall change in kidney function over 12 years. We analyzed data from a population-based cohort that was part of the Korean Genome and Epidemiology Study. Primary exposure was total alcohol intake (non-drinkers, 0 to < 10 g/day, 10 to < 30 g/day, and ≥ 30 g/day). Main outcome was decline in kidney function over 12 years. Our study included 5729 participants (mean [SD] age, 51 [8] years; 46% males). Compared to non-drinkers, higher alcohol intake groups had lesser reduction in estimated glomerular filtration rate (eGFR) over 12 years; fully adjusted beta coefficients and 95% confidence intervals were 0.45 (- 0.27, 1.18), 1.87 (0.88, 2.87), and 3.08 (1.93, 4.24) for participants with alcohol intake of < 10, 10 to < 30, and ≥ 30 g/day, respectively. However, this association was attenuated among women, smoker, and age ≥ 60 year. Compared with not drinking, more frequent alcohol consumption and binge drinking were associated with lesser reduction in eGFR. Our findings suggest that alcohol consumption may have a favorable effect on kidney function among the general population.

Potassium intake, skeletal muscle mass, and effect modification by sex: data from the 2008-2011 KNHANES.

BACKGROUND: A loss of muscle mass may be influenced by multiple factors. Insulin sensitivity and metabolic acidosis are associated with muscle wasting and may be improved with potassium intake. This study evaluated the association between dietary potassium intake and skeletal muscle mass. METHODS: We performed a cross-sectional study with data obtained from the Korean National Health and Nutrition Examination Survey (KNHANES) (2008-2011). Participant's daily food intake was assessed using a 24-h recall method. Appendicular skeletal muscle mass (ASM) was calculated as the sum of muscle mass in both arms and legs, measured using dual energy X-ray absorptiometry. The skeletal muscle index (SMI) was calculated as ASM divided by height2 (kg/m2). Low muscle mass was defined as a SMI < 7.0 kg/m2 for men and < 5.4 kg/m2 for women. RESULTS: Data from 16,558 participants (age ≥ 19 years) were analyzed. Participants were categorized into quintiles according to their potassium intake. Sex-specific differences were found in the association between potassium intake and muscle mass (PInteraction < 0.001). In men, higher potassium intake was associated with lower odds for low muscle mass; the fully adjusted odds ratios (95% confidence intervals) were 0.78 (0.60-1.03), 0.71 (0.54-0.93), 0.68 (0.51-0.90), and 0.71 (0.51-0.98) for the top four quintiles (referenced against the lowest quintile), respectively. However, this association was attenuated in women after adjusting for total energy intake. Higher potassium intakes were also associated with a greater SMI. CONCLUSIONS: Higher dietary potassium intake decreased the odds of low muscle mass in men but not in women.

Association between Ultrafiltration Rate and Clinical Outcome Is Modified by Muscle Mass in Hemodialysis Patients.

BACKGROUND: The association between ultrafiltration rate (UFR) and mortality may be affected by the muscle mass or volume status in hemodialysis (HD) patients. However, there is an absence of data regarding this association. METHODS: We performed an observational study on patients (≥18 years old) who had been on HD for at least 3 months. A body composition monitor (BCM) was used for baseline bioimpedance analysis measurement. The primary composite outcome was defined as the time to death or the first cardiovascular event. RESULTS: The median (interquartile range) UFR, volume excess measured by the BCM, and lean tissue index (LTI) (calculated as lean tissue mass/height2) were 11.4 (8.0-15.0) mL/h/kg, 2.4 (1.4-4.1) L, and 12.5 (10.4-14.4) kg/m2, respectively. During 284 person-years of follow-up, the primary outcome occurred in 44 of the 167 patients (26%). Higher UFR was associated with an increased outcome of death or cardiovascular event; the adjusted hazard ratio (HR) was 1.044 (95% confidence interval [CI]: 1.006-1.083). This association remained consistent even after adjusting for volume excess. However, the association between UFR and the primary outcome was modified by LTI (pinteraction = 0.027); the association was significant in patients with LTI < 12.5 kg/m2, and the HR (95% CI) was 1.050 (1.001-1.102). CONCLUSION: Higher UFR was associated with an increased risk of a composite outcome of death or cardiovascular event regardless of volume status in HD patients. However, muscle mass may modify the association between higher UFR and increased risk of a composite outcome.

Ultrafiltration Rate Effects Declines in Residual Kidney Function in Hemodialysis Patients.

BACKGROUND: High ultrafiltration rate (UFR) has been associated with increased mortality in hemodialysis (HD) patients. However, the impact of UFR on decline of residual kidney function (RKF) has not been elucidated among patients receiving conventional HD. METHODS: We performed a retrospective cohort study of 7,753 patients who initiated conventional HD from 2007 to 2011 and survived the first year of dialysis with baseline UFR and renal urea clearance (KRU) data at baseline and 1 year (5th patient-quarter). The primary exposure was average UFR at the 1st patient-quarter from dialysis initiation (<4, 4 to <6, 6 to <9, 9 to <13, and ≥13 mL/h/kg). Decline in RKF was defined as the percent change in KRU and decline in urine output during the first year after initiation of dialysis. We used a logistic regression model for rapid decline in RKF and a linear regression model for change in urine volume. RESULTS: In our HD cohort, mean baseline UFR was 7.0 ± 3.1 mL/h/kg, and median (interquartile range) baseline KRU was 3.5 (2.1-5.3) mL/min/1.73 m2. There was a graded association between UFR and a rapid decline in RKF; the expanded case mix-adjusted ORs and 95% CIs were 1.21 (1.04-1.40), 1.34 (1.16-1.55), 1.73 (1.46-2.04), and 1.93 (1.48-2.52) for baseline UFR 4 to <6, 6 to <9, 9 to <13, and ≥13  mL/h/kg, respectively (reference: <4 mL/h/kg). KRU trajectories showed a greater KRU decline over time in higher UFR categories. Higher UFR was also associated with a greater decline in urine output after 1 year. CONCLUSION: Higher UFR was associated with a rapid decline in RKF among conventional HD patients. Further clinical trials are needed to elucidate a causal effect of UFR on RKF among HD patients.

Value of Doppler evaluation of physically abnormal fistula: hemodynamic guidelines and access outcomes.

BACKGROUND/AIMS: The strategy of access care at out center involves the use of ultrasound (USG) in case of physical examination (PE) abnormality. USG determines the need of angiography. This study investigated the possible association between the need for percutaneous transluminal angioplasty (PTA) and hemodynamic parameters of USG. The study also assessed the effects of this monitoring strategy on outcomes in comparison with a historical control. METHODS: A retrospective study of the medical records of 127 patients (65 PTA, 62 non-PTA) was conducted. Data were analyzed using logistic regression analysis and receiver operating characteristic curve. Fistula outcomes and intervention rates were calculated and compared with 100 historic controls. RESULTS: Logistic regression analysis showed that brachial artery flow volume (FV) < 612.9 mL/min or brachial artery resistance index (RI) > 0.63 was independently associated with the need for PTA. This monitoring strategy showed an a reduction in thromboses (0.02 ± 0.11 events/arteriovenous fistula [AVF]-year vs. 0.07 ± 0.23 events/AVF-year, p = 0.046), reduction in central venous catheter placement (0.01 ± 0.05 events/AVF-year vs. 0.06 ± 0.22 events/AVF-year, p = 0.010), reduction in access loss (0.02 ± 0.13 events/AVF-year vs. 0.19 ± 0.34 events/AVF-year, p = 0.015), and increase in access selective repair (0.49 ± 0.66 events/AVF-year vs. 0.21 ± 0.69 events/AVF-year, p = 0.003), compared to historic control. CONCLUSION: There was significant stenosis if brachial artery FV was < 612.9 mL/min or RI was > 0.63 for PE abnormality. These parameters should be used as markers for assessing PTA risk in hemodialysis patients. Addition of USG to determine the need of angiography after detection of PE abnormality leads to decreases in access thrombosis, catheter placement, and access loss despite increasing access intervention rates compared to clinical monitoring.

Multicenter, cross-sectional observational study of the impact of neuropathic pain on quality of life in cancer patients.

PURPOSE: Neuropathic cancer pain (NCP) is a common and potentially debilitating symptom in cancer patients. We investigated the prevalence of NCP, as well as its management and association with QOL. METHODS: Cancer patients with pain ≥1 on the visual analogue scale (VAS) were surveyed with the Douleur Neuropathique (DN4) questionnaire, the Brief Pain Inventory-Short Form (BPI-SF), and the EuroQOL five dimensions (EQ-5D) questionnaire. The associations between NCP and pain severity or NCP and QOL, while controlling for variables relevant to QOL, were then analyzed. RESULTS: A total of 2003 patients were enrolled in this survey; the prevalence of NCP was 36.0% (n = 722, 95% CI, 32.5-39.5). We found that NCP in cancer patients was closely correlated to a higher pain severity (BPI-SF; 4.96 ± 1.94 versus 4.24 ± 2.02, p < 0.001), and in patients with NCP, pain more severely interfered with daily living, as compared to those without NCP (BPI-SF; 4.86 ± 2.71 versus 4.41 ± 2.87, p < 0.001). Patients with NCP also had worse QOL than those without NCP, as measured by EQ-5D index score (0.47 ± 0.30 vs. 0.51 ± 0.30, p = 0.005), and this was confirmed using multivariate analysis (p < 0.001), even after controlling for other variables such as age, sex, disease stage, cancer duration, radiotherapy, chemotherapy, and comorbidities. Importantly, adjuvant analgesics were used in less than half of patients with NCP (n = 358, 46.4%). CONCLUSIONS: We found that NCP in cancer patients was significantly associated with a worsened QOL, and current management is inadequate. Therefore, future research aimed at developing improved strategies for management of NCP is required.

Clinical experience with ultrasound guided angioplasty for vascular access.

BACKGROUND: The use of ultrasound guided percutaneous transluminal angioplasty (UG-PTA), which use ultrasound as an imaging modality, is an evolving strategy. But, in Korea, this method is rarely used. We report our experiences with UG-PTA with respect to technical success rates and complication rates compared to conventional PTA (C-PTA), performed between 2010 and 2015 at Samsung Changwon Hospital, Korea. METHODS: In our series, 53 cases of UG-PTA and 90 cases of C-PTA were reviewed, respectively. Cases of central vein stenosis, cephalic arch stenosis, arterial stenosis and thrombosis were excluded. However, cases of juxta-anastomotic stenosis and outflow vein stenosis were included. RESULTS: Technical success was achieved in 96.2% (51 of 53) of cases in the UG-PTA group and in 93.3% (84 of 90) of cases in the C-PTA group, respectively (P = 0.710). Technical failure was experienced in a total 8 cases (UG-PTA group: 2/53, 3.8%; C-PTA group: 6/90, 6.7%). No differences were observed in complications. CONCLUSION: Duplex ultrasound-guided angioplasty for dialysis access in the outpatient setting is feasible, safe, and effective for peripheral venous stenotic lesions. It offers many advantages over conventional angiographic procedures, and, in the future, it has great potential to play a significant role in the management of these challenging patients.

Acute Peritoneal Dialysis in Patients with Acute Kidney Injury.

BACKGROUND: The purpose of this study was to evaluate the efficacy, complications, and mortality rate associated with acute peritoneal dialysis (PD) in patients with acute kidney injury (AKI). METHODS: A total of 75 patients who were treated at Samsung Changwon Hospital between February 2005 and March 2016 were included in the study sample. The outcomes included in-hospital survival, renal recovery, metabolic and fluid control rates, and technical success rates. RESULTS: Refractory heart failure was the most frequent cause of acute PD (49.3%), followed by hepatic failure (20.0%), septic shock (14.7%), acute pancreatitis (9.3%), and unknown causes (6.7%). The hospital survival of patients in the acute PD was 48.0%. Etiologies of acute kidney injury (AKI) (refractory heart failure, acute pancreatitis compared with hepatic failure, septic shock or miscellaneous causes), use of inotropes, use of a ventilator, and simplified acute physiology score (SAPS) II were associated with survival differences. Maintenance dialysis required after survival was high (80.1% [29/36]) due to AKI etiologies (heart or hepatic failures). Metabolic and fluid control rates were 77.3%. The technical success rate for acute PD was 93.3%. CONCLUSION: Acute PD remains a suitable treatment modality for patients with AKI in the era of continuous renal replacement therapy (CRRT). Nearly all patients who require dialysis can be dialyzed with acute PD without mechanical difficulties. This is particularly true in patients with refractory heart failure and acute pancreatitis who had a weak requirement for inotropes.

Comparison of Gait Speed and Peripheral Nerve Function Between Chronic Kidney Disease Patients With and Without Diabetes.

OBJECTIVE: To compare overall physical function, including gait speed and peripheral nerve function, between diabetic chronic kidney disease (CKD) patients and nondiabetic CKD patients and to investigate the association between gait speed and peripheral nerve function in CKD patients. METHODS: Sixty adult CKD patients (35 with and 25 without diabetes), who received maintenance hemodialysis (HD), were included in this study. Demographic data, past medical history, current medical condition and functional data-usual gait speed, vibration perception threshold for the index finger (VPT-F) and the great toe (VPT-T), activity of daily living (ADL) difficulty, and peripheral neuropathy (PN) along with the degree of its severity-were collected and compared between the two groups. Correlations between the severity of PN and the impairment of other functions were identified. RESULTS: Diabetic CKD patients showed significantly slower gait speed (p=0.029), impaired sensory function (VPT-F, p=0.011; VPT-T, p=0.023), and more frequent and severe PN (number of PN, p<0.001; severity of PN, p<0.001) as compared to those without diabetes. Usual gait speed had a significant negative correlation with the severity of PN (rho=-0.249, p=0.013). By contrast, VPT-F (rho=0.286, p=0.014) and VPT-T (rho=0.332, p=0.035) were positively correlated with the severity of PN. ADL difficulty was comparatively more frequent in the patients with more severe PN (p=0.031). CONCLUSION: In CKD patients with maintenance HD, their gait speed, sensory functions, and peripheral nerve functions were all significantly impaired when they have diabetes, and the severity of PN was negatively correlated with their gait speed, sensory function, and ADL function. Adverse effects of diabetes impacted physical performance of CKD patients. The physical disability of those patients might be attributable to PN and its severity.

Triplet cytotoxic chemotherapy with gemcitabine, 5-fluorouracil and cisplatin for advanced pancreatic cancer.

In advanced or relapsed pancreatic cancer, mono- or duo-therapy has shown modest efficacy at best. The present study evaluated the efficacy of a triplet combination in relapsed or advanced pancreatic cancer. A total of 37 patients with adenocarcinoma of the pancreas in stage III/IV or with relapsed disease were treated with a gemcitabine, 5-fluorouracil and cisplatin (GFP) regimen every 3 weeks. Only 29 out of 37 patients were evaluable for response due to early treatment interruption in 8 patients. The overall response rate was 24.1% and the disease control rate was 68.9%. The progression-free survival (PFS) rate was 61.5, 30.9 and 17.6% at 3, 6 and 9 months, respectively, and the overall survival (OS) rate was 46.5 and 30.6% at 6 and 12 months, respectively. Grade 3/4 leukopenia, neutropenia and thrombocytopenia occurred in 18.4, 29.9 and 24.5% of 147 cycles, respectively. Old age and a poor performance status (PS) were associated with the early discontinuation of chemotherapy (P=0.038 and P=0.036, respectively). In patients <65 years old and with a PS of <2, the median PFS and OS times were 5.3 months and 10.3 months, respectively. Overall, although GFP resulted in acceptable response and survival rates, it does not appear to have marked superiority to gemcitabine-based single or duplet chemotherapy.

Multinational Randomized Phase III Trial With or Without Consolidation Chemotherapy Using Docetaxel and Cisplatin After Concurrent Chemoradiation in Inoperable Stage III Non-Small-Cell Lung Cancer: KCSG-LU05-04.

PURPOSE: To determine the efficacy of consolidation chemotherapy (CC) with docetaxel and cisplatin (DP) after concurrent chemoradiotherapy (CCRT) with the same agents in locally advanced non-small-cell lung cancer (LA-NSCLC). PATIENT AND METHODS: Patients were randomly assigned to either CCRT alone (observation arm) or CCRT followed by CC (consolidation arm). CCRT with docetaxel (20 mg/m(2)) and cisplatin (20 mg/m(2)) was administered every week for 6 weeks with a total dose of 66 Gy of thoracic radiotherapy in 33 fractions. In the consolidation arm, patients were further treated with three cycles of DP (35 mg/m(2) each on days 1 and 8, every 3 weeks). The primary end point was 40% improvement in progression-free survival (PFS) compared with observation. RESULTS: From October 2005 to April 2011, 437 patients were randomly assigned. Seventeen patients did not start CCRT as a result of consent withdrawal or ineligibility reasons after random assignment, leaving 420 patients for this analysis (n = 211 for observation; n = 209 for consolidation). Patient characteristics were similar in both arms. In the consolidation arm, 143 patients (68%) received CC, of whom 88 (62%) completed three planned cycles. The median PFS was 8.1 months in the observation arm and 9.1 months in the consolidation arm (hazard ratio, 0.91; 95% CI, 0.73 to 1.12; P = .36). Median overall survival times were 20.6 and 21.8 months in the observation and consolidation arms, respectively (HR, 0.91; 95% CI, 0.72 to 1.25; P = .44). CONCLUSION: CC with DP after CCRT with weekly DP in LA-NSCLC failed to further prolong PFS. CCRT alone should remain the standard of care.

Association between colistin dose and development of nephrotoxicity.

OBJECTIVE: To investigate the development of nephrotoxicity associated with colistin dose, and whether this relationship differs depending on renal function. DESIGN: A retrospective cohort study of patients who received intravenous colistin to treat infections caused by extensively drug-resistant Gram-negative microorganisms. Adult patients receiving colistin for 72 hours or longer were included in this study. Patients who received renal replacement therapy at baseline or were administered colistin for less than 3 days were excluded. Colistin-induced nephrotoxicity was defined as a doubling of baseline serum creatinine. Colistin dosing was evaluated based on both actual body weight and ideal body weight. SETTING: Single general hospital between 2010 and 2013. PATIENTS: A total number of 475 patients received colistin therapy. Of these patients, 329 met the inclusion criteria and were included in the analysis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred forty-three patients (43.5%) experienced nephrotoxicity during colistin treatment. The median onset time of nephrotoxicity was 6 days (interquartile range, 4-8 days). The patients with nephrotoxicity were older. Hematocrit and serum albumin levels were lower in patients with nephrotoxicity. Median daily dosing of colistin based on ideal body weight was significantly higher in patients with nephrotoxicity than in those without nephrotoxicity (4.55 vs 4.43 mg/kg/d, respectively; p=0.021). The cumulative dose was not different between patients with and without nephrotoxicity. In multiple logistic regression analysis, daily colistin dosing based on ideal body weight was only significantly associated with the development of nephrotoxicity in patients with an estimated glomerular filtration rate<60 mL/min/1.73 m2 (odds ratio, 2.34; 95% CI, 1.22-4.5). In these affected patients, based on a receiver operating characteristic plot, the optimal predictive cutoff of colistin dose for the development of nephrotoxicity was 2.87 mg/kg/d of colistin, with a sensitivity of 92.3% and a specificity of 76.7%. In patients with estimated glomerular filtration rate≥60 mL/min/1.73 m, age, serum albumin, hematocrit, and use of glycopeptide were associated with the development of nephrotoxicity. CONCLUSIONS: Development of nephrotoxicity was significantly more strongly associated with the dose of colistin, but only in patients with an estimated glomerular filtration rate<60 mL/min/1.73 m2 and not in those with normal renal function.

The intracavitary ECG method for insertion of a tunneled dialysis catheter without using fluoroscopy.

PURPOSE: Recently, there have been many reports that exact central vein catheter tip positioning was possible using intracardiac electrocardiographic (ECG) monitoring. Ultrasonic guidance in combination with intracardiac ECG monitoring may allow for a tunneled dialysis catheter to be inserted at the bedside without using fluoroscopy. Therefore we report on the intracavitary ECG method for insertion of a tunneled dialysis catheter with ultrasound guidance and the feasibility, safety, effectiveness, complications and limitations of this method. METHODS: From April 2012 to June 2014, we evaluated 142 hemodialysis (HD) patients who were dialyzed by a tunneled dialysis catheter that was inserted using intracardiac ECG monitoring without fluoroscopic usage. We checked the intracardiac P wave and the point at which it gradually rose to the highest P wave morphology, we stopped inserting the catheter. RESULTS: Catheter flow during dialysis was adequate in 139 cases. There were three cases where it malfunctioned. Catheter malposition occurred in 6 out of 142 cases. The correct matching rate between the intracardiac ECG and chest posteroanterior (PA) view was 98.5%. No significant complications developed. CONCLUSIONS: To conclude, in this single-center study, the intracavitary ECG method for assessing the position of the tip of tunneled dialysis catheter was proven to be safe and feasible in virtually all adult patients who had an evident P wave at the basal ECG tracking.

Association between serum bicarbonate levels and albuminuria in stage 3 and stage 4 chronic kidney disease: a cross-sectional study.

AIMS: Metabolic acidosis is a common manifestation of chronic kidney disease (CKD) and appears to be associated with CKD progression and mortality. We evaluated whether serum bicarbonate level is associated with albuminuria in patients with stage 3 and 4 CKD. METHODS: This was a retrospective cross-sectional study of outpatients with CKD stages 3 - 4 (estimated glomerular filtration rate 15 - 59 mL/minutes/1.73 m2). Serum bicarbonate levels, serum creatinine levels, and random urinary albumin-to-creatinine ratios (UA/Cr) examined on the same day were required for enrollment. Significant albuminuria was defined as UA/Cr >= 300 mg/g. Serum bicarbonate was analyzed as both a continuous variable and a categorical variable after it was divided into categories of < 23, 23 - 25.9, and >= 26 mmol/L. RESULTS: 151 patients were included in this study. Their mean age was 59.1 ± 13.9 years, and 60.9% were men. The mean serum bicarbonate level was 23.7 ± 3.3 mmol/L. In a multiple logistic regression analysis to determine the factors associated with significant albuminuria, the serum bicarbonate categories were independent factors associated with significant albuminuria after adjustments were made for relevant covariates (p = 0.028). In a subgroup analysis according to CKD stage, the association between bicarbonate categories and significant albuminuria was significant only for patients with stage 3 disease, regardless of renal function or blood pressure (p = 0.014 and 0.706 in stage 3 and 4 diseases, respectively). CONCLUSIONS: Low serum bicarbonate levels were ssociated with significant albuminuria, even at levels in the normal range, in CKD patients, especially with stage 3 disease.

Unilateral and bilateral acute pyelonephritis: differences in clinical presentation, progress and outcome.

PURPOSE: Acute pyelonephritis (APN) generally involves a single kidney, but it can be bilateral. The aim of the present study was to evaluate differences in clinical presentation, progress and outcome for bilateral APN compared with unilateral APN. STUDY DESIGN: The medical records of all patients over 19 years of age, hospitalised for APN and who underwent abdominal enhanced CT at Samsung Changwon Hospital between January 2009 and August 2012 were retrospectively reviewed. Patients were divided into two groups according to whether unilateral or bilateral lesions were identified on the CT scan. RESULTS: Of the 296 patients, 99 had bilateral APN. Only 64/86 (74.4%) patients with clear tenderness in the bilateral APN group had bilateral tenderness. Patients with bilateral APN had more severe abnormalities, based on the results of laboratory tests. Leukocytosis, thrombocytopenia, bacteraemia, acute kidney injury, shock and death occurred more frequently in bilateral than in unilateral APN. In the bilateral APN group, broad spectrum antibiotics were used more frequently as an initial antibiotic treatment. A history of stroke or diabetes mellitus, and duration of symptoms before admission, were independent risk factors associated with bilateral APN. CONCLUSIONS: Patients with bilateral APN experienced more severe clinical and laboratory manifestations and had a poorer outcome than those with unilateral APN. Early imaging tests can be considered to discriminate unilateral from bilateral APN, especially in those with a history of stroke or diabetes and with a longer duration of symptoms. Moreover, initial use of broader spectrum antibiotics can be considered in patients with bilateral APN.

Phase II trial of combination chemotherapy with gemcitabine, 5-fluorouracil and cisplatin for advanced cancers of the bile duct, gallbladder, and ampulla of Vater.

AIMS AND BACKGROUND: For advanced cancers of the bile duct, gallbladder and ampulla of Vater, there are only a few treatment options. We explored the efficacy of the combination of gemcitabine, 5-fluorouracil and cisplatin for advanced biliary cancers. METHODS: From September 2003 to April 2010, 28 patients with recurrent or metastatic biliary tract cancer were enrolled. A treatment regimen consisting of gemcitabine (800 mg/m² at a fixed dose rate on days 1 and 8), 5-fluorouracil (1 g/m²/day continuous infusion for 4 days) and cisplatin (60 mg/m² on day 2) was repeated every 3 weeks. RESULTS: One (3.6%) patient showed complete response, 8 (28.6%) partial response, 14 (50%) stable disease and 5 (17.9%) disease progression. Overall, the objective response rate was 32.1% (95% CI, 17.9-50.6%) and the disease control rate was 82.1% (95% CI, 64.4-92.1%). Median progression-free survival and overall survival were 7.6 months (95% CI, 5.5-9.7) and 11.2 months (95% CI, 6.8-15.5), respectively. G3/4 neutropenia was observed in 44 (24.3%) of 181 cycles and G3/4 thrombocytopenia in 48 (26.5%) of 181 cycles. There was no treatment-related mortality. CONCLUSIONS: The combined regimen of gemcitabine, 5-fluorouracil and cisplatin has comparable activity for patients with advanced cancer of the bile duct, gallbladder and ampulla of Vater. Toxicity was tolerable but substantial.

Interaction of malnutrition, N-terminal pro-B-type natriuretic peptide and ventricular remodeling in patients on maintenance hemodialysis.

AIMS: The aim of the present study was to investigate the interaction of nutritional status, N-terminal probrain-type natriuretic peptide (NT-proBNP) and ventricular remodeling in hemodialysis patients. METHODS: NT-proBNP was measured by immunoassay. Nutritional status was assessed using the subjective global assessment (SGA) and malnutrition-inflammation score (MIS). Transthoracic echocardiographic examinations were performed on all patients. RESULTS: 44 patients undergoing maintenance hemodialysis were enrolled in this study. Malnourished patients had higher levels of extracellular water (ECW) per kg body weight (BWt) than well-nourished patients and higher levels of NT-proBNP. MIS was positively correlated with left ventricular mass index (LVMI), log NT-proBNP and ECW/BWt, and negatively correlated with fat mass and LV systolic dysfunction. LV systolic dysfunction, LVMI and MIS were independently associated with log NT-proBNP levels. Multiple regression analysis showed that log NT-proBNP, mean arterial pressure and ECW/BWt were independently associated with LVMI. However, MIS did not have an independent relationship to LVMI. CONCLUSIONS: Malnutrition in hemodialysis patients is accompanied by volume overload and associated with increased log NT-proBNP levels independent of volume status, and these levels are independently associated with increased LVMI. This suggests a possibility that nutritional status may affect ventricular remodeling in hemodialysis patients.

Health-related quality of life in adults with metabolic syndrome: the Korea national health and nutrition examination survey, 2007-2008.

BACKGROUND/AIMS: An association between metabolic syndrome and impaired health-related quality of life (HRQoL) is still controversial. We investigated the association between metabolic syndrome in itself and HRQoL in the Korean adult population. METHODS: The study is a cross-sectional analysis of 8,941 adults ≥19 years of age who participated in the 2007 and 2008 Korean National Health and Nutrition Examination Survey. EuroQoL five-dimension (EQ-5D), the EQ-5D index and the EQ visual analogue scale (EQ VAS) were used to assess HRQoL. RESULTS: The prevalence of metabolic syndrome was 26.2%. Compared to the participants without metabolic syndrome, those with metabolic syndrome were older and comprised a higher proportion of men. Moreover, participants with metabolic syndrome were more likely to have a lower education level, to be current smokers, to have activity limitation and to have more frequent metabolic abnormalities and comorbidities. Metabolic syndrome was associated with HRQoL based on EQ-5D and EQ VAS in simple regression analysis. However, metabolic syndrome was not significantly associated with HRQoL after adjusting for age, sex, smoking status, income, education level, marital status, obesity, diabetes mellitus, stroke, history of heart disease and chronic kidney disease for EQ-5D, and in addition history of depression for EQ VAS. CONCLUSION: Metabolic syndrome in itself was not associated with impaired HRQoL after adjusting for confounding variables such as socio-demographic factors, medical comorbidities and obesity.