Incidence of De Novo Post-Transplant Malignancies in Thai Adult Kidney Transplant Recipients: A Single-Center, Population-Controlled, Retrospective Cohort Study at the Highest Volume Kidney Transplant Center in Thailand.

Kidney transplant recipients (KTRs) are at increased risk of developing de novo post-transplant malignancies (PTMs), with regional differences in types with excess risk compared to the general population. A single-center, population-controlled, retrospective cohort study was conducted at a tertiary care center in Thailand among all adults who underwent their first kidney transplant from 1986 to 2018. Standardized incidence ratios (SIRs) of malignancy by age, sex, and place of residence were obtained using data from the National Cancer Registry of Thailand as population control. There were 2,024 KTRs [mean age, 42.4 years (SD 11.4); female patients, 38.6%] during 16,495 person-years at risk. Of these, 125 patients (6.2%) developed 133 de novo PTMs. The SIR for all PTMs was 3.85 (95% CI 3.22, 4.56), and for pooled solid and hematologic PTMs, it was 3.32 (95% CI 2.73, 3.99). Urothelial malignancies had the largest excess risk, especially in women [female SIR 114.7 (95% CI 66.8, 183.6); male SIR 17.5 (95% CI 8.72, 31.2)]. The next two most common cancers were non-Hodgkin's lymphoma and skin cancer [SIR 20.3 (95% CI 13.6, 29.1) and 24.7 (95% CI 15.3-37.8), respectively]. Future studies are needed to identify the risk factors and assess the need for systematic screening among PTMs with excess risk in KTRs.

The impact of accessibility to non-calcium-based phosphate binders and calcimimetics on mineral outcomes in patients receiving maintenance hemodialysis: A 10-year retrospective analysis of real-world data.

INTRODUCTION: Hyperphosphatemia and hyperparathyroidism are common in end-stage kidney disease and are associated with poor outcomes. In addition to adequate dialysis, medications are usually required for optimum control of serum phosphate and parathyroid hormone (PTH) levels. The use of calcium-based phosphate binders (CBPBs) and active vitamin D is associated with an increase in serum calcium and worsening vascular calcification. To overcome these limitations, non-calcium-based phosphate binders (NCBPBs) and calcimimetics have been developed. However, the coverage for these new medications remains limited in several parts of the world due to the lack of patient-level outcome data and cost. The present study examined the differences in mineral outcomes between two main categories of healthcare programs that provided different coverage for medications used to control mineral and bone disorders (MBD). The Social Security/Universal Coverage (SS/UC) program covered only CBPBs and active vitamin D, whereas the Civil Servant/State Enterprise (CS/SE) program provided coverage of CBPBs, active vitamin D, NCBPBs, and calcimimetics. METHODS: This 10-year retrospective cohort study examined the differences in mineral outcomes between two healthcare programs in maintenance hemodialysis patients. The differences in serum calcium, phosphate, and PTH levels, as well as the aortic arch calcification score, were analyzed according to dialysis vintage by linear mixed-effects regression analyses. The difference in the composite outcome of severe hyperparathyroidism and parathyroidectomy was analyzed by the Cox-proportional hazard regression model. RESULTS: 714 patients were included in the analyses (full cohort). Of these patients, 563 required at least one type of medication to control MBD (MBD medication subgroup). Serum calcium, phosphate, and the proportions of patients with hypercalcemia and hyperphosphatemia were substantially higher in the SS/UC group compared with the CS/SE group after appropriate adjustments for confounders in both the full cohort and the MBD medication subgroup. These findings were confirmed in propensity-score matched analyses. Higher parathyroid hormone levels and a higher rate of the composite endpoint of severe hyperparathyroidism and parathyroidectomy were also observed in the SS/UC group. A more rapid progression of aortic arch calcification was suggested in the SS/UC group, but between-group changes were not significant. CONCLUSION: Patients under the healthcare program that did not cover the use of NCBPBs and calcimimetics showed higher serum calcium and phosphate levels and a more rapid progression of hyperparathyroidism. The difference in the progression of vascular calcification could not be confirmed in the present study.

Role of Parathyroid Hormone and Parathyroid Hormone-Related Protein in Protein-Energy Malnutrition.

Parathyroid hormone (PTH) is an endocrine peptide found exclusively in the parathyroid glands, whereas parathyroid hormone-related protein (PTHrP) is expressed in a wide range of tissues and organs and exerts endocrine, paracrine, and autocrine actions. PTH and PTHrP have a similar homology, sharing the initial 13 amino acid residues at the N-terminus and binding to the same type 1 PTH receptor (PTH1R), which regulates calcium homeostasis. An abnormal increase in PTH production can occur in primary and secondary hyperparathyroidism, whereas PTHrP can be produced in large quantities by malignant cancer cells from solid organs. In addition to increased bone resorption and hypercalcemia, recent evidence suggests that excess PTH and PTHrP can result in protein-energy wasting, malnutrition, and cachexia. Through binding to PTH1R and activation of cyclic adenosine monophosphate (cAMP)-dependent protein kinase A in white adipose tissue, PTH and PTHrP can stimulate the expression of thermogenic genes causing adipose tissue browning. This change results in an increase in resting energy expenditure, loss of muscle and fat mass, and weight loss. These findings provide a mechanistic link for the long-established relationship between hyperparathyroidism and myopathy, as well as cancer and cachexia. The purpose of this review is to provide a summary of the emerging evidence from both experimental and clinical studies on the role of PTH and PTHrP in protein-energy malnutrition.

Associated factors of blood pressure control and complications of hypertension in hypertensive rural Thai populations of Baan Nayao, Chachoengsao Province.

OBJECTIVE: To assess associated factors of uncontrolled blood pressure and complications of hypertension in hypertensive rural Thai populations. MATERIAL AND METHOD: A cross-sectional study was conducted in hypertensive rural Thai people aged > or =35 years-old in Baan Nayao, Chachoengsao Province, Thailand. Blood pressure (BP) was measured and questionnaires were answered. After 12-hr fasting, blood samples were taken for determining plasma glucose, lipid profiles and serum creatinine. Morning urine samples were collected for microalbuminuria testing and electrocardiography (ECG) was performed to detect left ventricular hypertrophy (LVH). RESULTS: Of the 289 participants (97 males and 192 females) mean duration of hypertension was 4.29 +/- 4.95 years and 61.5% did not achieve target BP control. Among participants who had ECG performed and urine sample investigation, 15.7% demonstrated LVH and 25.3% had microalbuminuria. In uncontrolled BP participants, 20% had LVH and 24.8% had microalbuminuria whereas in controlled BP participants, 7.8% had LVH and 26.1% had microalbuminuria. Uncontrolled BP was associated with males, dyslipidemia, diabetes, abdominal obesity, metabolic syndrome, always having salty food and salts added for seasoning. The independent risks of uncontrolled BP were hypertensive male (OR = 2.48, 95% CI = 1.07-5.76) and metabolic syndrome (OR = 2.59, 95% CI = 1.24-5.40). Males were also at risk for LVH (OR = 2.86, 95% CI = 1.31-6.23) and history of lipid disorders was a risk of microalbuminuria (OR = 3.13, 95% CI = 1.47-6.67). CONCLUSION: Males and metabolic syndrome were independently associated with uncontrolled BP in hypertensive participants. Males had more risk than females to develop LVH and having history of lipid disorders lead to microalbuminuria occurrence. Thus, life style modification may prove beneficial to these rural hypertensive participants.

Dialysate Magnesium and Coronary Artery Calcification, Bone Mineral Density, and Cramping in Maintenance Hemodialysis: A Quasi-experimental Study.

RATIONALE & OBJECTIVE: Recent evidence suggests a role for magnesium as a calcification inhibitor. Increased magnesium abundance may attenuate vascular calcification and promote bone formation. STUDY DESIGN: Parallel-group, 1:1-allocation-ratio, quasi-experimental study. SETTING & PARTICIPANTS: The study was conducted at hemodialysis centers in Bangkok, Thailand. Patients receiving maintenance hemodialysis were screened for coronary artery calcification (CAC) and bone mineral density (BMD), and those with a CAC score of ≥300 were included and matched according to the initial CAC score. The intervention and control groups consisted of 20 patients in each arm. INTERVENTIONS: A high (1.75 mEq/L) or standard (0.7 mEq/L) dialysate magnesium concentration was delivered for 26 weeks. OUTCOMES: Changes in the CAC score and BMD and the progression of CAC. The safety outcomes included occurrence of cramps recorded as per usual care. RESULTS: The median CAC score of all patients was 1,792. Serum and ionized magnesium concentrations increased substantially in the high dialysate magnesium group. At the end of the study, the CAC score increased significantly in both the groups, with no significant difference between the groups. The number of participants with CAC progression was comparable between the 2 groups. In exploratory subgroup analyses stratified by the median CAC score, a significant decline in CAC and fewer participants with CAC progression were observed in the subgroup with lower CAC scores that received the high dialysis magnesium concentration. Bone mineral density was largely unchanged in both groups. The number of participants experiencing cramps and the number of episodes of muscle cramps were markedly lower among patients who received the high dialysis magnesium concentration. LIMITATIONS: The participants had severe vascular calcification at baseline; therefore, the findings might not apply to those with less-established calcification. Moreover, cramps were not systematically ascertained. CONCLUSIONS: The high dialysis magnesium concentration did not alleviate the progression of CAC or improve BMD in patients with severe calcification receiving hemodialysis; however, muscle cramps were less frequent among those treated with high dialysate magnesium. Further study is required to determine a possible favorable effect of high dialysis magnesium concentration in individuals with mild-to-moderate calcification.

Clinical effects and factors associated with adverse clinical outcomes of hymenopteran stings treated in a Thai Poison Centre: a retrospective cross-sectional study.

OBJECTIVE: To describe clinical effects and outcomes of hymenopteran stings and to explore the non-laboratory factors associated with adverse clinical outcomes, a composite outcome including death, respiratory failure requiring intubation, acute kidney injury (AKI) requiring dialysis and hypotension requiring vasopressor use. METHODS: A retrospective cross-sectional study was performed at the Ramathibodi Poison Center, a poison centre of a tertiary care hospital in Thailand. All cases of hymenopteran sting consultations from January 2015 to June 2019 were consecutively enrolled, and charts were reviewed. Demographics, initial clinical characteristics and outcomes were collected. Factors associated with adverse clinical outcome were explored. RESULTS: One hundred and fourteen hymenopteran stings cases (wasp 48%, bee 33%, hornet 14% and carpenter bee 8.8%) were included (median age, 36.5 years (interquartile range 9-55); male 63%). The prevalence of adverse clinical outcomes was 12.3% (95%CI 6.88-12.8). At initial presentation, 100% of cases had local skin reactions, 11.4% were clinical anaphylaxis, and 8% had red urine. Adverse clinical outcomes included death (n = 10), respiratory failure requiring intubation (n = 9), AKI requiring dialysis (n = 6) and hypotension requiring vasopressor use (n = 2). None of the patients with carpenter bee or hornet stings developed adverse clinical outcomes. In univariable analysis, urticaria, wheezing, red urine, wasp sting and sting number > 10 were significantly associated with adverse clinical outcomes. In multivariable analysis, red urine (adjusted OR 11.1 (95% CI 1.57-216)), wheezing (adjusted OR 16.7 (95% CI 1.43-402)) and a number of stings > 10 (adjusted OR 21.5 (95% CI2.13-2557)) were significant. CONCLUSIONS: Adverse clinical outcomes in hymenopteran stings were not uncommon among cases inquiring to a national Thai poison centre. At initial presentation, red urine, wheezing and a number stings >10 were significantly associated with adverse clinical outcomes. Larger epidemiologic studies are required to confirm these associations.

Kidney transplant from donors with hepatitis B: A challenging treatment option.

Utilizing kidneys from donors with hepatitis B is one way to alleviate the current organ shortage situation. However, the risk of hepatitis B virus (HBV) transmission remains a challenge that undermines the chance of organs being used. This is particularly true with hepatitis B surface antigen (HBsAg) positive donors despite the comparable long-term outcomes when compared with standard donors. To reduce the risk of HBV transmission, a comprehensive approach is needed. This includes assessment of donor risk, optimal allocation to the proper recipient, appropriate immunosuppressive regimen, optimizing the prophylactic therapy, and post-transplant monitoring. This review provides an overview of current evidence of kidney transplants from donors with HBsAg positivity and outlines the challenge of this treatment. The topics include donor risk assessment by adopting the nucleic acid test coupled with HBV DNA as the HBV screening, optimal recipient selection, importance of hepatitis B immunity, role of nucleos(t)ide analogues, and hepatitis B immunoglobulin. A summary of reported long-term outcomes after kidney transplantation and proposed criteria to utilize kidneys from this group of donors was also defined and discussed.

Factors associated with unintentional weight loss among older adults in a geriatric outpatient clinic of university hospital.

BACKGROUND: Unintentional weight loss (UWL) is defined as unintentional reduction of more than 5% of baseline body weight over 6 to 12 months. UWL is a common problem in the older adults, resulting in increased rate of morbidity and mortality. With specific reference to Thailand, no information on factors associated with UWL in older adults could be traced. The aims of this research were to identify the factors associated with UWL and to assess the common causes of UWL among older adults in the geriatric outpatient clinic of university hospital. METHODS: A case-control study was conducted from June 1st, 2020 to December 31st, 2020. Eighty older adults aged 60 years or older were enrolled in the UWL group while the non-UWL group consisted of 160 participants. Data collection was performed by structural questionnaire including baseline characteristics, psychosocial factors, health information, lifestyle behaviors, and medications. The factors associated with UWL were analyzed by using univariate and multivariate logistic regression analysis. Causes of UWL were recorded from electronic medical records. RESULTS: The mean age of the 240 participants was 79.6 years (SD 7.4). Most patients were female (79.2%) and had fewer than 12 years of education (62.6%). The three common causes of UWL were reduced appetite (20.1%), dementia and behavioral and psychological symptoms of dementia (13.7%) and medications (11.0%). Multivariate logistic regression analysis showed that a Charlson Comorbidity Index (CCI) score of >1 (OR 2.55, 95% CI 1.37-4.73; P = 0.003), vitamin D deficiency (OR 4.01, 95% CI 1.62-9.97; P = 0.003), and hemoglobin level of <12 g/dL (OR 2.47, 95% CI 1.32-4.63; P = 0.005) were factors significantly associated with UWL. CONCLUSIONS: Factors associated with UWL were CCI score >1, vitamin D deficiency, and hemoglobin level of <12 g/dl. The early detection of these associated factors, reduced appetite, dementia and polypharmacy may be important in UWL prevention in older adults.

Mechanisms of Vascular Calcification in Kidney Disease.

The increase in prevalence and severity of vascular calcification in chronic kidney disease is a result of complex interactions between changes in the vascular bed, mineral metabolites, and other uremic factors. Vascular calcification can occur in the intima and the media of arterial wall. Under permissive conditions, vascular smooth muscle cells (VSMCs) can transform to osteoblast-like phenotype. The membrane-bound vesicles released from transformed VSMCs and the apoptotic bodies derived from dying VSMCs serve as nucleating structures for calcium crystal formation. Alterations in the quality and the quantity of endogenous calcification inhibitors also give rise to an environment that potentiates calcification.

Evaluation of Body Composition in Hemodialysis Thai Patients: Comparison between Two Models of Bioelectrical Impedance Analyzer and Dual-Energy X-Ray Absorptiometry.

BACKGROUND: Body composition measurement is very important for early nutritional care in hemodialysis patients. Dual-energy X-ray absorptiometry (DXA) is a gold standard test, but clinically limited. Bioelectrical impedance analysis (BIA) with multifrequency technique is a practical and reliable tool. OBJECTIVE: This cross-sectional study was aimed to compare the agreement of BIA with DXA in measurement of body composition in hemodialysis patients and to evaluate their associated factors. METHODS: Body composition was measured by 2 BIA methods (InBody S10 and InBody 720) and DXA after a hemodialysis session. A total of 69 measurements were included. Pearson's correlation and Bland and Altman analysis were used to determine the correlation of body composition between methods and to compare the methods agreement, respectively. RESULTS: The correlation coefficients of body compositions were strong between DXA and InBody S10 (fat mass index (FMI): r=0.95, fat-free mass index (FFMI): r=0.78) and also between DXA and InBody 720 (FMI: r=0.96, FFMI: r=0.81). Comparing to DXA, the means of each body composition measured by InBody S10 method were not significantly different in each gender, but differences were found in FM, %FM, and FMI measured by InBody 720. CONCLUSIONS: In maintenance hemodialysis patients, the measurement of body composition with DXA and both BIA methods had highly significant correlations; practically, BIA method could be used as an instrument to follow FM and FFM and to measure the edematous stage. Further studies with large populations are warranted.