Immunogenicity and safety of heterologous versus homologous prime-boost schedules with inactivated and adenoviral vectored SARS-CoV-2 vaccines - A prospective multi-center study.

Background: During the peak of Coronavirus disease (COVID-19) pandemic in Thailand when the emergence of delta variant reduced the efficacy of inactivated vaccine, Thailand had abundance of inactivated vaccine but mRNA vaccine was not available and the supply of adenoviral-vectored vaccine was limited. The heterologous vaccination using CoronaVac and ChAdOx1-nCoV-19 vaccines was applied. We aim to compare the immunogenicity of immune response of primary vaccination with homologous ChAdOx1 nCoV-19 and heterologous vaccination with CoronaVac and ChAdOx1 nCoV-19. Methods: A total of 430 adults, scheduled to receive ChAdOx1-nCoV-19 as their second dose of primary COVID-19 vaccination, were enrolled. Participants were classified into two groups based on the first dose vaccine as CoronaVac (heterologous group) or ChAdOx1 nCoV-19 (homologous group). The primary outcome was antibodies to the SARS-CoV-2 spike protein receptor binding domain (anti-RBD) titres at 28 days after the second dose of vaccination. Secondary outcomes were anti-RBD titres at 90 days, surrogate viral neutralizing test (sVNT) at 28 and 90 days, and adverse events. Findings: In 358 participants with correct vaccine interval, the anti-RBD geometric mean titre ratio for the heterologous versus homologous group was 0.55 (95%CI; 0.44-0.067); p < 0.001 at day 28, and 0.80 (95%CI; 0.65-1.00); P = 0.05 at day 90. Median sVNT neutralizing activity was not significantly different in the heterologous versus homologous group at 28 days (93.5 vs 92.7 %); p = 0.13, but significantly higher in the heterologous group at day 90 (82.9 vs 76.4 %); p = 0.01. Interpretation: The homologous vaccination resulted in higher anti-RBD titres at 28 days after vaccination, but titres in the homologous group showed more rapid decline at 90 days. In the sVNT assay, median neutralization was similar at 28 days, but was longer-lasting and higher in the heterologous group at 90 days. Funding: This research received funding from the Royal College of Physicians of Thailand special grant 2021 for research initiative during COVID-19 pandemic.

Biosimilar erythropoietin in anemia treatment (BEAT)-Efficacy and safety of a 1:1 dose conversion from EPREX® to EPIAO® in patients with end-stage renal disease on hemodialysis: A prospective, randomized, double blind, parallel group study.

BACKGROUND: EPREX®/ERYPO®/PROCRIT® (epoetin alfa, Janssen-Cilag GmbH) was the first available recombinant human erythropoietin (rHuEPO) and was universally reference product as per the recommendation provided by European Medicines Agency. EPIAO® is a biosimilar formulation of EPREX®, and making it a 1:1 dose conversion from EPREX® according to recommendation of European Medicines Agency. This study evaluated the clinical efficacy and safety of EPIAO® in subjects with end-stage renal disease receiving hemodialysis after intravenous administration. METHODS: This study was a multicenter, prospective, randomized, double-blind, parallel-group, 2-cohort, maintenance phase, therapeutic equivalence study to evaluate a 1:1 dose conversion from EPREX® to EPIAO® in terms of clinical efficacy and safety that was conducted at 20 sites in 2 countries in patients with end-stage renal disease on hemodialysis. Eligible subjects were treated with EPREX® (reference product of epoetin) for a period of at least 3 months before the treatment period, and then were randomly assigned to the group of EPREX® or EPIAO®. Primary endpoints were mean absolute change in hemoglobin level and mean absolute change in weekly epoetin dosage from baseline to 6 months after treatment with EPIAO®/EPREX® in parallel groups. RESULTS: A total of 200 people received the random intervention and were included in the safety set. After 6, 9, and 12 months of treatment with EPIAO® or EPREX®, there were no significant differences in the hemoglobin levels of the 2 groups compared with baseline. The 95% confidence interval for the treatment difference was within the predetermined acceptable range: ±0.5 g/dL. There were no significant differences in the epoetin dosage of the 2 groups compared with the baseline. The 95% confidence interval for the treatment difference was within the predetermined acceptable range: ± 45 IU/kg. There were no significant differences in the incidence of adverse events between the EPIAO® and EPREX® groups. Most adverse events were mild to moderate and were reverted/resolved. CONCLUSION: EPIAO® demonstrated promising effectiveness and manageable safety in patients with end-stage renal disease on hemodialysis.

Economic evaluation of peritoneal dialysis and hemodialysis in Thai population with End-stage Kidney Disease.

BACKGROUND: This study aimed to conduct a cost-utility analysis of the "Peritoneal Dialysis (PD)-First" policy in 2008 under a universal health coverage scheme and hemodialysis (HD) in Thai patients with End-stage Kidney Disease (ESKD) using updated real-practice data. METHODS: Markov model was used to evaluate the cost-utility of two modalities, stratified into five age groups based on the first modality taken at 20, 30, 40, 50, and 60 years old from government and societal perspectives. Input parameters related to clinical aspects and cost were obtained from 15 hospitals throughout Thailand and Thai Renal Replacement Therapy databases. Both costs and outcomes were discounted at 3%, adjusted to 2021, and converted to USD (1 USD = 33.57 Thai Baht). One-way analysis and probabilistic sensitivity analysis were performed to assess the uncertainty surrounding model parameters. RESULTS: From the government perspective, compared to PD-first policy, the incremental cost-effectiveness ratio (ICER) was between 19,434 and 23,796 USD per QALY. Conversely, from a societal perspective, the ICER was between 31,913 and 39,912 USD per QALY. Both are higher than the willingness to pay threshold of 4,766 USD per QALY. CONCLUSION: By applying the updated real-practice data, PD-first policy still remains more cost-effective than HD-first policy at the current willingness to pay. However, HD gained more quality-adjusted life years than PD. This information will assist clinicians and policymakers in determining the future direction of dialysis modality selection and kidney replacement therapy reimbursement policies for ESKD patients.

Cost-Utility Analysis of Dapagliflozin as an Add-on to Standard of Care for Patients with Chronic Kidney Disease in Thailand.

INTRODUCTION: Chronic kidney disease (CKD) creates a significant economic burden on patients and society. The DAPA-CKD trial reports the benefit of dapagliflozin in CKD patients; however, its cost-effectiveness is unknown in Thailand. This study evaluated the cost-utility of dapagliflozin in addition to standard of care (SoC) compared with SoC alone in CKD patients. METHODS: A Markov model was employed to estimate lifetime costs, life-years, and quality-adjusted life-year (QALY), with the modeled population aligned to the baseline characteristics of a DAPA-CKD trial, from a societal perspective. Effectiveness inputs were obtained from the DAPA-CKD trial. Costs and most utility data were gathered from published studies conducted in Thailand. Costs and benefits were discounted at 3% per annum. A series of sensitivity analyses were performed. RESULTS: Over a lifetime horizon, add-on dapagliflozin was estimated to increase life-years by 0.34 and QALY by 0.30 in comparison with SoC alone (7.13 vs. 6.78 years, 5.10 vs. 4.80 QALYs). Total cost was lower under dapagliflozin treatment than SoC treatment (648,413 THB vs. 689,284 THB or 20,947.64 USD vs. 22,268.01 USD). Cost saving occurred as a result of the lower costs of dialysis and KT. The findings were robust to the changes of inputs. CONCLUSIONS: On the basis of the DAPA-CKD trial, the add-on dapagliflozin results in cost saving compared favorably with SoC alone in Thailand. The benefit of dapagliflozin in delayed CKD progression is that it reduces the requirement for dialysis and KT, which can offset the costs of dapagliflozin and early CKD treatment.

Interventional nephrology and vascular access practice: A perspective from South and Southeast Asia.

South and Southeast Asia is the most populated, heterogeneous part of the world. The Association of Vascular Access and InTerventionAl Renal physicians (AVATAR Foundation), India, gathered trends on epidemiology and Interventional Nephrology (IN) for this region. The countries were divided as upper-middle- and higher-income countries as Group-1 and lower and lower-middle-income countries as Group-2. Forty-three percent and 70% patients in the Group 1 and 2 countries had unplanned hemodialysis (HD) initiation. Among the incident HD patients, the dominant Vascular Access (VA) was non-tunneled central catheter (non-TCC) in 70% of Group 2 and tunneled central catheter (TCC) in 32.5% in Group 1 countries. Arterio-Venous Fistula (AVF) in the incident HD patients was observed in 24.5% and 35% of patients in Group-2 and Group-1, respectively. Eight percent and 68.7% of the prevalent HD patients in Group-2 and Group-1 received HD through an AVF respectively. Nephrologists performing any IN procedure were 90% and 60% in Group-2 and Group 1, respectively. The common procedures performed by nephrologists include renal biopsy (93.3%), peritoneal dialysis (PD) catheter insertion (80%), TCC (66.7%) and non-TCC (100%). Constraints for IN include lack of time (73.3%), lack of back-up (40%), lack of training (73.3%), economic issues (33.3%), medico-legal problems (46.6%), no incentive (20%), other interests (46.6%) and institution not supportive (26%). Routine VA surveillance is performed in 12.5% and 83.3% of Group-2 and Group-1, respectively. To conclude, non-TCC and TCC are the most common vascular access in incident HD patients in Group-2 and Group-1, respectively. Lack of training, back-up support and economic constraints were main constraints for IN growth in Group-2 countries.

Peritoneal dialysis: Status report in South and South East Asia.

BACKGROUND: Peritoneal dialysis (PD) as a modality of kidney replacement therapy (KRT) is largely underutilized globally. We analyzed PD utilization, impact of economic status, projected growth and impact of state policy(s) on PD growth in South Asia and Southeast Asia (SA&SEA) region. METHODS: The National Nephrology Societies of the region responded to a questionnaire on KRT practices. The responses were based on the latest registry data, acceptable community-based studies and societal perceptions. The representative countries were divided into high income and higher-middle income (HI & HMI) and low income and lower-middle income (LI & LMI) groups. RESULTS: Data provided by 15 countries showed almost similar percentage of GDP as health expenditure (4%-7%). But there was a significant difference in per capita income (HI & HMI -US$ 28 129 vs. LI & LMI - US$ 1710.2) between the groups. Even after having no significant difference in monthly cost of haemodialysis (HD) and PD in LI & LMI countries, they have poorer PD utilization as compared to HI & HMI countries (3.4% vs. 10.1%); the reason being lack of formal training/incentives and time constraints for the nephrologist while lack of reimbursement and poor general awareness of modalities has been a snag for the patients. The region expects ≥10% PD growth in the near future. Hong Kong and Thailand with 'PD first' policy have the highest PD utilization. CONCLUSION: Important deterrents to PD underutilization were lack of PD centric policies, lackadaisical patient/physician's attitude, lack of structured patient awareness programs, formal training programs and affordability.

Cost-Utility Analysis of Dapagliflozin as an Add-On to Standard Treatment for Patients with Type 2 Diabetes and High Risk of Cardiovascular Disease in Thailand.

INTRODUCTION: Diabetes treatment has incurred financial burden. We examined the cost-utility of adding dapagliflozin to the standard treatment for treating type 2 diabetes (T2DM) with cardiovascular risk in a Thai context. METHODS: A two-part model, decision tree and Markov models, was developed to capture the benefits in terms of heart failure (HF) and chronic kidney disease. The model was used to estimate the lifetime costs and outcomes from a societal perspective. Costs were based on local data while the transitional probabilities and utilities were derived from the DECLARE-TIMI 58 clinical trial and published studies. Future costs and outcomes were discounted at an annual rate of 3%. The results were reported as incremental cost-effectiveness ratios (ICER). One-way and probabilistic sensitivity analyses were performed to investigate parameter uncertainty. RESULTS: The increased cost of adding dapagliflozin from 8707 USD to 14,455 USD was associated with an increase in quality-adjusted life years (QALYs) from 9.28 to 9.58, yielding an ICER of 18,988 USD/QALY. Compared with the standard treatment, the dapagliflozin group acquired more clinical benefits in terms of fewer HF hospitalizations and macroalbuminuria. Sensitivity analyses revealed that with high prevalence of diabetic nephropathy of 29.4-43.9%, the ICER would decline to 5591-8014 USD/QALY. CONCLUSION: On the basis of the DECLARE study with low incidence of T2DM complications and 4.2 years of median follow-up duration, the add-on dapagliflozin results in an ICER of 18,988 USD/QALY, which exceeds the local threshold of 5310 USD/QALY. Dapagliflozin would show better value for money in the context of high prevalence of T2DM complications.

Impact of National Economy and Policies on End-Stage Kidney Care in South Asia and Southeast Asia.

BACKGROUND: The association between economic status and kidney disease is incompletely explored even in countries with higher economy (HE); the situation is complex in lower economies (LE) of South Asia and Southeast Asia (SA and SEA). METHODS: Fifteen countries of SA and SEA categorized as HE and LE, represented by the representatives of the national nephrology societies, participated in this questionnaire and interview-based assessment of the impact of economic status on renal care. RESULTS: Average incidence and prevalence of end-stage kidney disease (ESKD) per million population (pmp) are 1.8 times and 3.3 times higher in HE. Hemodialysis is the main renal replacement therapy (RRT) (HE-68%, LE-63%). Funding of dialysis in HE is mainly by state (65%) or insurance bodies (30%); out of pocket expenses (OOPE) are high in LE (41%). Highest cost for hemodialysis is in Brunei and Singapore, and lowest in Myanmar and Nepal. Median number of dialysis machines/1000 ESKD population is 110 in HE and 53 in LE. Average number of machines/dialysis units in HE is 2.7 times higher than LE. The HE countries have 9 times more dialysis centers pmp (median HE-17, LE-02) and 16 times more nephrologist density (median HE-14.8 ppm, LE-0.94 ppm). Dialysis sessions >2/week is frequently followed in HE (84%) and <2/week in LE (64%). "On-demand" hemodialysis (<2 sessions/week) is prevalent in LE. Hemodialysis dropout rates at one year are lower in HE (12.3%; LE 53.4%), death being the major cause (HE-93.6%; LE-43.8%); renal transplants constitute 4% (Brunei) to 39% (Hong Kong) of the RRT in HE. ESKD burden is expected to increase >10% in all the HE countries except Taiwan, 10%-20% in the majority of LE countries. CONCLUSION: Economic disparity in SA and SEA is reflected by poor dialysis infrastructure and penetration, inadequate manpower, higher OOPE, higher dialysis dropout rates, and lesser renal transplantations in LE countries. Utility of RRT can be improved by state funding and better insurance coverage.

Aetiology, practice patterns and burden of end-stage kidney disease in South Asia and South-East Asia: A questionnaire-based survey.

AIM: There is paucity of data on the epidemiology of end-stage kidney disease (ESKD) from South Asia and South-East Asia. The objective of this study was to assess the aetiology, practice patterns and disease burden and growth of ESKD in the region comparing the economies. METHODS: The national nephrology societies of the region; responded to the questionnaire; based on latest registries, acceptable community-based studies and society perceptions. The countries in the region were classified into Group 1 (High|higher-middle-income) and Group 2 (lower|lowermiddle income). Student t-test, Mann-Whitney U test and Fisher's exact test were used for comparison. RESULTS: Fifteen countries provided the data. The average incidence of ESKD was estimated at 226.7 per million population (pmp), (Group 1 vs. Group 2, 305.8 vs. 167.8 pmp) and average prevalence at 940.8 pmp (Group 1 vs. Group 2, 1306 vs. 321 pmp). Group 1 countries had a higher incidence and prevalence of ESKD. Diabetes, hypertension and chronic glomerulonephritis were most common causes. The mean age in Group 2 was lower by a decade (Group 1 vs. Group 2-59.45 vs 47.7 years). CONCLUSION: Haemodialysis was the most common kidney replacement therapy in both groups and conservative management of ESKD was the second commonest available treatment option within Group 2. The disease burden was expected to grow >20% in 50% of Group 1 countries and 78% of Group 2 countries along with the parallel growth in haemodialysis and peritoneal dialysis.

Recommendations by the Asian Pacific society of nephrology (APSN) on the appropriate use of HIF-PH inhibitors.

Renal anaemia is a common and important complication in patients with chronic kidney disease (CKD). The current standard-of-care treatment for renal anaemia in CKD patients involves ensuring adequate iron stores and administration of erythropoietin stimulating agents (ESA). Hypoxia inducible factor (HIF) is a key transcription factor primarily involved in the cellular regulation and efficiency of oxygen delivery. Manipulation of the HIF pathway by the use of HIF-prolyl hydroxylase inhibitors (HIF-PHI) has emerged as a novel approach for renal anaemia management. Despite it being approved for clinical use in various Asia-Pacific countries, its novelty mandates the need for nephrologists and clinicians generally in the region to well understand potential benefits and harms when prescribing this class of drug. The Asian Pacific society of nephrology HIF-PHI Recommendation Committee, formed by a panel of 11 nephrologists from the Asia-Pacific region who have clinical experience or have been investigators in HIF-PHI studies, reviewed and deliberated on the clinical and preclinical data concerning HIF-PHI. This recommendation summarizes the consensus views of the committee regarding the use of HIF-PHI, taking into account both available data and expert opinion in areas where evidence remains scarce.

Non-steroidal anti-inflammatory drug (NSAID) therapy in patients with hypertension, cardiovascular, renal or gastrointestinal comorbidities: joint APAGE/APLAR/APSDE/APSH/APSN/PoA recommendations.

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) are one of the most commonly prescribed medications, but they are associated with a number of serious adverse effects, including hypertension, cardiovascular disease, kidney injury and GI complications. OBJECTIVE: To develop a set of multidisciplinary recommendations for the safe prescription of NSAIDs. METHODS: Randomised control trials and observational studies published before January 2018 were reviewed, with 329 papers included for the synthesis of evidence-based recommendations. RESULTS: Whenever possible, a NSAID should be avoided in patients with treatment-resistant hypertension, high risk of cardiovascular disease and severe chronic kidney disease (CKD). Before treatment with a NSAID is started, blood pressure should be measured, unrecognised CKD should be screened in high risk cases, and unexplained iron-deficiency anaemia should be investigated. For patients with high cardiovascular risk, and if NSAID treatment cannot be avoided, naproxen or celecoxib are preferred. For patients with a moderate risk of peptic ulcer disease, monotherapy with a non-selective NSAID plus a proton pump inhibitor (PPI), or a selective cyclo-oxygenase-2 (COX-2) inhibitor should be used; for those with a high risk of peptic ulcer disease, a selective COX-2 inhibitor plus PPI are needed. For patients with pre-existing hypertension receiving renin-angiotensin system blockers, empirical addition (or increase in the dose) of an antihypertensive agent of a different class should be considered. Blood pressure and renal function should be monitored in most cases. CONCLUSION: NSAIDs are a valuable armamentarium in clinical medicine, but appropriate recognition of high-risk cases, selection of a specific agent, choice of ulcer prophylaxis and monitoring after therapy are necessary to minimise the risk of adverse events.

National feasibility survey of peritoneal dialysis key performance indicators in Thailand from provider perspective.

BACKGROUND: Peritoneal dialysis (PD) has been the main method of renal replacement therapy under the "PD First" policy in Thailand since 2008. Initially, the proposed 13 key performance indicators (KPIs) raised feasibility concerns because of inequitable distribution of resources such as laboratory facilities and/or specialized health-care staff for PD care throughout the country. METHODS: Data availability and goals from the health-care providers' perspective were explored using an online questionnaire survey for all PD centers registered with the Nephrology Society of Thailand from May to June 2016. The availability of essential data required for each KPI indicator to achieve the desired target was assessed using a 5-point Likert scale. RESULTS: Of the 197 centers, 119 responded to the survey (response rate of 60.41%). PD indicators with a high percentage of strongly disagree or disagree were "PD adequacy measured in the last 12 months" (26.83%), "Total weekly Kt/V ≥ 1.7" (24.59%), "3-year PD technique survival" (21.31%), "Serum parathyroid levels within 150 to 500 pg/mL" (16.94%), and a "3-year PD patient survival" (19.01%). As many as 34.17%, 39.19%, 27.27%, 28.93%, and 22.00%, respectively, did not anticipate that the targets could be achieved. Based on the findings from this survey, the national committee concluded that these indicators be removed, and only eight PD indicators were launched. CONCLUSION: Given the importance of KPIs for quality assurance and financial reimbursement, inputs from health-care providers especially data availability and achievement of targets should be considered to ensure feasibility before the final list of indicators are launched.

Prevalence of and Predictive Factor for Abdominal Aortic Calcification in Thai Chronic Kidney Disease Patients.

Presence and severity of cardiovascular calcifications strongly predict cardiovascular morbidity and mortality in patients with CKD. This multicenter, cross-sectional study primarily aimed to determine prevalence of abdominal aortic calcification (AAC) detected by plain lateral abdominal radiograph, and secondarily aimed to assess predictive factors for AAC. Patients (N = 1500), aged 18-70 years, with CKD stages 3-5D for ≥3 months prior to evaluation, were enrolled at 24 study centers in Thailand; 54.3% were non-dialysis patients. The prevalence of AAC was 70.6% and 70.8% in non-dialysis and dialysis patients, respectively. Patient's advanced age and widening pulse pressure were identified as predictive factors for AAC ≥ 5 in non-dialysis patients, while patient's age, history of coronary heart disease or diabetes, longer dialysis vintage, and increasing corrected serum calcium or high-sensitivity C-reactive protein were identified as such in dialysis patients. With additional regression having covariates in binary, corrected serum calcium ≥9.5 mg/dL gave an OR 1.974 (95% CI: 1.324-2.943) for AAC ≥ 5 among the dialysis patients. AAC in diabetes subgroup (N = 692) was additionally evaluated and found that it was prevalent at 84.7% with increased phosphorus as predictive factor (OR, 1.178; 95% CI: 1.032-1.344) and 1,25 (OH)2 vitamin D as protective factor (OR, 0.983; 95% CI, 0.970-0.996). The prevalence of AAC in the Thai CKD population is lower than that reported in the literature, and yet the burden is prominent in patients coexisting with diabetes. Variable relationships identified in this study may guide preventive measures against cardiovascular complications in CKD patients.

Warfarin related nephropathy: the first case report in Thailand.

Warfarin is the most prescribed oral anticoagulant. Adverse renal effect from warfarin therapy are uncommon and Thailand is not acquainted. Warfarin-related nephropathy (WRN) is a newly recognized complication of warfarin treatment, especially in patients with chronic kidney disease. The authors hereby report a 56-year-old man who developed gross hematuria and severe acute kidney injury (AKI) necessitating hemodialysis, following supra-therapeutic INR level. Renal pathology revealed extensive intratubular obstruction with red blood cell casts. From the literature, there were only twelve case reports of WRN, which were confirmed by renal histopatology. Renal survival of this condition was unsatisfactory. However, our patient was dialysis-independent after vitamin K treatment and temporary warfarin discontinuation. To the best of our knowledge, this is the first case report of biopsy-proven WRN in Thailand.

Role of meditation in reducing sympathetic hyperactivity and improving quality of life in lupus nephritis patients with chronic kidney disease.

BACKGROUND: Lupus nephritis is an important leading cause of chronic kidney disease (CKD) among the young population in Thailand. Systemic lupus erythematosus (SLE) is often characterized by the presence of sympathetic hyperactivity, which results in a perishing outcome. Some physiological studies reveal that meditation may reduce this autonomic dysfunction. The authors hypothesized that meditation could be beneficial in alleviating the sympathetic hyperactivity and improving quality of life in lupus nephritis patients with CKD. MATERIAL AND METHOD: The authors performed a prospective pilot study, which enrolled lupus nephritis patients and categorized enrollees into meditation group and control group. Method of meditation was instructed by an expert in Buddhist studies for a duration of 60 minutes every month. Participants in the intervention group were advised to meditate every day for 24 weeks. To evaluate change in sympathetic activity, normetanephrine level was measured at beginning and the end of study and compared between both groups. Quality of life was determined by SF-36. Heart rate variability was also assessed in meditation group. RESULTS: Thirty eligible patients were recruited into the study. Fifteen patients were stratified in the meditation group and 15 patients in the control group. After meditation for 6 months, serum normetanephrine level decreased, but without statistical significance (0.105 vs. 0.059, p = 0.28). The reduction in normetanephrine level was also observed in the control group (p = 0.11). In the aspect of quality of life, scores of physical and mental components improved significantly. In meditation group, physical component score increased from 21.4 (5.0-50.2) to 62.2 (51.8-88.4) points (p < 0.01) and mental score increased from 16.9 (4.4-46.0) to 72.4 (45.1-81.6) points (p < 0.01). Quality of life score in the meditation group significantly increased more than in control group (p < 0.01). The parameter of heart rate variability in time and frequency domain also improved in the meditation group. CONCLUSION: In lupus nephritis patients with CKD, meditation shows a trend of benefits in reducing sympathetic overactivity and improving quality of life. Our results support the important role of meditation as a valuable adjunctive treatment of lupus nephritis with CKD.

Nephrotic syndrome in elderly patients: three years experience at Siriraj Hospital.

BACKGROUND: The population age is being high and nephotic syndrome is a common renal disease. OBJECTIVE: To find the etiology and clinical manifestations of nephrotic syndrome in the elderly patients who underwent renal biopsy at Siriraj hospital including management and outcome. MATERIAL AND METHOD: Retrospective study in 76 nephrotic patients whose age > or =50 years and underwent renal biopsy between 2005-2007. RESULTS: Seventy six nephrotic patients with age ranged from 50-84 years were analysed. Primary glomerulonephritis diseases were found more than secondary causes (5:2). The two most common glomerulonephritis were membranous GN and focal/segmental glomerulosclerosis. The etiology of common secondary GN was lupus nephtitis 11.84% following by diabetic nephropathy and amyloidosis. The patients received immunosuppressive drugs and complete response was found in 51%, partial response 10.2%, no response was 2% and no immunosuppressive therapy 36.7%. There was 1 patient died of septicaemia. CONCLUSION: Nephrotic syndrome in the elderly patients were not uncommon. The causes should be identified for prompt management and excellent outcome.

Acute kidney injury in primary nephrotic syndrome: report of nine cases in Siriraj Hospital.

Acute kidney injury is a rare but important complication of nephrotic syndrome. We demonstrated here nine patients with nephrotic syndrome and oliguric renal failure in Siriraj Hospital during 2007-2009. Renal biopsy was done in every patient. The results were focal and segmental glomerulosclerosis (FSGS) in three patients, minimal change disease in four patients and collapsing focal segmental glomerulosclerosis in two patients. Seven patients had dramatic response to corticosteroid treatment within a few weeks and had rapid recovery of renal function. The exact mechanism of idiopathic renal failure is not well understood but it might be related to reduction in ultrafiltration coefficient of the glomeruli.

Efficacy and safety of enoxaparin during hemodialysis: results from the HENOX study.

BACKGROUND: Low molecular weight heparins (LMWHs) have been suggested as an anticoagulant in hemodialysis (HD) since they provide convenient usage, safety and effective outcomes. OBJECTIVE: Determine clinical efficacy and safety of enoxaparin sodium for the anticoagulation effect during HD in 99 clinically stable end-stage renal disease (ESRD) patients. MATERIAL AND METHOD: This prospective open-label study was conducted in seven hemodialysis centers in Thailand HD prescription during the present study was similar to the previous prescriptions including the type of dialyzer. Enoxaparin sodium 0.7 mg/kg was administered into a pre-dialyzer arterial line at the beginning of the HD session. The anticoagulation effect was monitored by visual inspection of the HD line hourly and inspection of the dialyzer at the end of HD session. Vascular access compression time was monitored at both arterial and venous sites separately at the end of the HD. RESULTS: HD with enoxaparin sodium resulted in no fibrin/clot formation in a hemodialysis line in 97 cases (98%), and no significant clot formation in a dialyzer in 96 cases (97%). The mean vascular compression time was 5.63 +/- 1.90 minutes at the arterial site and 5.72 +/- 2.61 minutes at the venous site. Neither major adverse events nor major hemorrhages were reported Prolonged activated partial thromboplastin times (aPTT) at 30 minutes after hemodialysis were reported in two cases. These abnormal aPTT cases returned to normal levels within 24 hours and 72 hours, respectively. CONCLUSION: The present study suggests that a single-dose regimen of enoxaparin sodium 0.7 mg/kg is an effective, well-tolerated, and convenient alternative to sodium heparin.

Prevalence of chronic kidney disease in Thai adults: a national health survey.

BACKGROUND: The prevalence of patients with end stage renal disease (ESRD) who need dialysis and/or transplantation has more than doubled in Thailand during the past two decades. It has been suggested that therapeutic strategies to reduce the risk of ESRD and other complications in CKD are now available, thus the early recognition and the institution of proven therapeutic strategies are important and beneficial. We, therefore, aimed to determine the prevalence of CKD in Thai adults from the National Health Examination Survey of 2004. METHODS: Data from a nationally representative sample of 3,117 individuals aged 15 years and older was collected using questionnaires, physical examination and blood samples. Serum creatinine was measured by Jaffé method. GFR was estimated using the Chinese modified Modification of Diet in Renal Disease Study equation. Chronic kidney Disease (CKD) stages were classified based on Kidney Disease Outcome Quality Initiative (K/DOQI). RESULTS: The prevalence of CKD in Thai adults weighted to the 2004 Thai population by stage was 8.1% for stage 3, 0.2% and 0.15% for stage 4 and 5 respectively. Compared to non-CKD, individuals with CKD were older, had a higher level of cholesterol, and higher blood pressure. Those with cardiovascular risk factors were more likely to have CKD (stage 3-5) than those without, including hypertension (OR 1.6, 95%CI 1.1, 3.4), diabetes (OR 1.87, 95%CI 1.0, 3.4). CKD was more common in northeast (OR 2.1, 95%CI 1.3, 3.3) compared to central region. Urinalysis was not performed, therefore, we could not have data on CKD stage 1 and 2. We have no specific GFR formula for Thai population. CONCLUSION: The identification of CKD patients should be evaluated and monitored for appropriate intervention for progression to kidney disease from this screening.

Non-diabetic glomerular disease in type II DM: 10 years experience.

BACKGROUND: The nature of renal damage in patients with type II diabetes remains unclear. OBJECTIVE: To analyze the renal histopathology in type II diabetes who underwent renal biopsy at Siriraj Hospital, renal unit over 10 year period. MATERIAL AND METHOD: The clinical and biochemical data in 54 patients with Type II DM, atypical cases of DN, were subjected to renal biopsy and analyzed retrospectively. RESULTS: Ten out of fifty-four type II diabetic patients (18.5%) were diagnosed non-diabetic nephropathy (NDN); there were 4 patients with membranous GN, 3 patients with crescentic GN1 patient of MPGN type I, 1 patient with renal change from hypertension and 1 patient with IgMN. The most important factor that had statistically significant was nephritis urine sediment (NDN: DN 40% vs. 4.5%), However 60% of NDN had no nephritic urine sediment. CONCLUSION: There was no strong predictor to differentiate DN from NDN by clinical or biochemical data. The only significant finding in NDN was nephritic urine sediment.