Sex Difference in the Associations among Hyperuricemia with New-Onset Chronic Kidney Disease in a Large Taiwanese Population Follow-Up Study.

The global prevalence and incidence of chronic kidney disease (CKD) continue to increase. Whether hyperuricemia is an independent risk factor for renal progression and whether there are sex differences in the relationships between serum uric acid (UA) and a decline in renal function are unclear. Therefore, in this longitudinal study, we aimed to explore these relationships in a large cohort of around 27,000 Taiwanese participants in the Taiwan Biobank (TWB), and also to identify serum UA cutoff levels in men and women to predict new-onset CKD. A total of 26,942 participants with a median 4 years of complete follow-up data were enrolled from the TWB. We excluded those with CKD (estimated glomerular filtration rate <60 mL/min/1.73 m2) at baseline (n = 297), and the remaining 26,645 participants (males: 9356; females: 17,289) were analyzed. The participants who developed CKD during follow-up were defined as having incident new-onset CKD, and those with a serum UA level >7 mg/dL in males and >6 mg/dL in females were classified as having hyperuricemia. After multivariable analysis, hyperuricemia (odds ratio [OR], 2.541; 95% confidence interval [CI], 1.970−3.276; p < 0.001) was significantly associated with new-onset CKD. Furthermore, in the male participants (n = 9356), hyperuricemia (OR, 1.989; 95% CI, 1.440−2.747; p < 0.001), and quartile 4 of UA (vs. quartile 1; OR, 2.279; 95% CI, 1.464−3.547; p < 0.001) were significantly associated with new-onset CKD, while in the female participants (n = 17,289), hyperuricemia (OR, 3.813; 95% CI, 2.500−5.815; p < 0.001), quartile 3 of UA (vs. quartile 1; OR, 3.741; 95% CI, 1.250−11.915; p = 0.018), and quartile 4 of UA (vs. quartile 1; OR, 12.114; 95% CI, 14.278−34.305; p < 0.001) were significantly associated with new-onset CKD. There were significant interactions between hyperuricemia and sex (p = 0.024), and quartiles of serum UA and sex (p = 0.010) on new-onset CKD. Hyperuricemia was associated with new-onset CKD in the enrolled participants, and the interactions between hyperuricemia and sex were statistically significant. Hyperuricemia was more strongly associated with new-onset CKD in the women than in the men.

Effect of nephrology referrals and multidisciplinary care programs on renal replacement and medical costs on patients with advanced chronic kidney disease: A retrospective cohort study.

Evidence-based studies have revealed outcomes in patients with chronic kidney disease that differed depending on the design of care delivery. This study compared the effects of 3 types of nephrology care: multidisciplinary care (MDC), nephrology care, and non-nephrology care. We studied their effects on the risks of requiring dialysis and the differences between these methods had on long-term medical resource utilization and costs.We conducted a retrospective cohort study involving patients with an estimated glomerular filtration rate of (eGFR) ≤45 mL/min/1.73 m from 2005 to 2007. Patients were divided into MDC, non-MDC, and non-nephrology referral groups. Between-group differences with regard to the risk of requiring dialysis and annual medical utilization and costs were evaluated using a 5-year follow-up period.In total, 661 patients were included. After other covariates and the competing risk of death were taken into account, we observed a significant (56%) reduction in the incidence of dialysis in both the MDC and non-MDC groups relative to the non-nephrology referral group. Costs were markedly lower in the MDC group relative to the other groups (average savings: US$ 830 per year; 95% confidence interval: 367-1295; P < .001).For patients without nephrology referrals, MDC can substantially reduce their risk of developing end-stage renal disease and lower their medical costs. We therefore strongly advocate that all patients with an eGFR of ≤45 mL/min/1.73 m should be referred to a nephrologist and receive MDC.

Association of Brachial-Ankle Pulse Wave Velocity and Cardiomegaly With Aortic Arch Calcification in Patients on Hemodialysis.

Aortic arch calcification (AoAC) is associated with cardiovascular and all-cause mortality in end-stage renal disease population. AoAC can be simply estimated with an AoAC score using plain chest radiography. The objective of this study is to evaluate the association of AoAC with brachial-ankle pulse wave velocity (baPWV) and cardiomegaly in patients who have undergoing hemodialysis (HD).We retrospectively determined AoAC and cardiothoracic ratio (CTR) by chest x-ray in 220 HD patients who underwent the measurement of baPWV. The values of baPWV were measured by an ankle-brachial index-form device. Multiple stepwise logistic regression analysis was used to identify the factors associated with AoAC score >4.Compared patients with AoAC score ≦4, patients with AoAC score >4 had older age, higher prevalence of diabetes and cerebrovascular disease, lower diastolic blood pressure, higher baPWV, higher CTR, higher prevalence of CTR ≧50%, lower total cholesterol, and lower creatinine level. After the multivariate stepwise logistic analysis, old age, cerebrovascular disease, high baPWV (per 100 cm/s, odds ratio [OR] 1.065, 95% confidence interval [CI] 1.003-1.129, P = 0.038), CTR (per 1%, OR 1.116, 95% CI 1.046-1.191, P = 0.001), and low total cholesterol level were independently associated with AoAC score >4.Our study demonstrated AoAC severity was associated with high baPWV and high CTR in patients with HD. Therefore, we suggest that evaluating AoAC on plain chest radiography may be a simple and inexpensive method for detecting arterial stiffness in HD patients.

Link between Peripheral Artery Disease and Heart Rate Variability in Hemodialysis Patients.

Peripheral artery disease (PAD) and low heart rate variability (HRV) are highly prevalent in hemodialysis patients, and both are associated with increased cardiovascular morbidity and mortality. This study aims to examine the suggested relationship between PAD and HRV, and the relationship of parameters before and after hemodialysis. This study enrolled 161 maintenance hemodialysis patients. PAD was defined as ABI < 0.9 in either leg. HRV was performed to assess changes before and after hemodialysis. The change in HRV (△HRV) was defined as post-hemodialysis HRV minus pre-hemodialysis HRV. Patients' clinical parameters were collected from the dialysis records. All HRV parameters except high frequency (HF) % were lower in patients with PAD than patients without PAD, though not achieving significant level. In patients without PAD, HF (P = 0.013), low frequency (LF) % (P = 0.028) and LF/HF (P = 0.034) were significantly elevated after hemodialysis, whereas no significant HRV parameters change was noted in patients with PAD. Serum intact parathyroid hormone was independently associated with △HF (ß = -0.970, P = 0.032) and △LF% (ß = -12.609, P = 0.049). Uric acid level (ß = -0.154, P = 0.027) was negatively associated with △LF/HF in patients without PAD. Our results demonstrated that some of the HRV parameters were significantly increased after hemodialysis in patients without PAD, but not in patients with PAD, reflecting a state of impaired sympatho-vagal equilibrium. Severity of secondary hyperparathyroidism and hyperuricemia contributed to lesser HRV parameters increase after hemodialysis in patients without PAD.

Mediastinal hematoma caused by central venous catheterization: a rare cause of obscure blood loss.

Gastrointestinal hemorrhage, internal bleeding beyond the gastrointestinal tract and hemolysis are common causes of blood loss in intensive care unit patients. However, mediastinal hematoma is a rare cause of blood loss and is not usually detected. Here, we report a patient who developed a mediastinal hematoma resulting from central venous catheterization who presented with obscure blood loss refractory to blood transfusion. A mediastinal hematoma should be considered in the presence of obscure blood loss in patients with catheter placement.

Determinants of peripheral arterial stiffness in patients with chronic kidney disease in southern Taiwan.

High prevalences of peripheral artery occlusive disease (PAOD) and increased arterial stiffness have been reported in patients with chronic kidney disease (CKD). However, these have not been assessed in Taiwan where the prevalence of CKD is high. The aim of this study was to investigate the determinants of PAOD and arterial stiffness in patients with CKD in southern Taiwan. We enrolled 169 patients with stage 3-5 CKD in one regional hospital. Ankle-brachial index (ABI) and brachial-ankle pulse wave velocity were measured using an ABI-form device (Colin VP1000). In multivariate analysis, ABI<0.9 was positively correlated with the presence of diabetes mellitus (p=0.014) and negatively correlated with the estimated glomerular filtration rate (eGFR) (p=0.049), and increased brachial-ankle pulse wave velocity was correlated with increased age, diabetes mellitus, increased systolic blood pressure, decreased pulse pressure and decreased eGFR. This study identified determinants of PAOD and arterial stiffness in patients with CKD in one hospital in southern Taiwan. In addition to the traditional atherosclerotic risk factors, decreased eGFR was also correlated with PAOD and increased arterial stiffness in these patients.

Comparison of ankle-brachial index and brachial-ankle pulse wave velocity between patients with chronic kidney disease and hemodialysis.

BACKGROUND/AIMS: Patients with chronic renal failure are highly predisposed to atherosclerosis. However, there is limited data about the direct comparison of atherosclerosis between patients with chronic kidney disease (CKD) and hemodialysis. The aim of this study was to compare ankle-brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) between patients with CKD and hemodialysis and thus examined the status of peripheral artery occlusive disease (PAOD) and arterial stiffness between them. METHODS: We enrolled 169 patients with CKD stage 3-5 and 225 hemodialysis patients in one regional hospital. ABI and baPWV were measured by using an ABI-form device (VP1000, Colin). RESULTS: A higher prevalence of ABI <0.9 was found in hemodialysis patients than in CKD patients (15.6 vs. 8.3%, p = 0.030). After a multivariate analysis, ABI <0.9 was associated with increased age, diabetes mellitus (DM), increased pulse pressure, decreased serum albumin level, and hemodialysis treatment. The baPWV was positively associated with age, DM, systolic and diastolic blood pressures, and negatively with body mass index. However, after adjusting for other variables, baPWV was comparable between patients with CKD and hemodialysis. CONCLUSIONS: The study revealed that PAOD might be more prevalent in patients with hemodialysis than in patients with CKD, but arterial stiffness might be comparable between them.

Associated risk factors for abnormal ankle-brachial index in hemodialysis patients in a hospital.

Ankle-brachial index (ABI) is a marker for peripheral artery disease and can predict mortality in hemodialysis patients. However, it is seldom studied in southern Taiwan, an area with high prevalence of end-stage renal disease (ESRD). The aim of this study was to investigate the prevalence and associated risk factors for peripheral artery disease in the ESRD population in a hospital. All routine hemodialysis patients in one regional hospital were included except for six patients who refused ABI examinations and four patients with atrial fibrillation. Finally, 225 patients formed our study group. ABI was measured using an ABI-form device (Colin VP1000). The prevalence of ABI < 0.9 and > or = 1.3 was 15.6% and 5.8%, respectively. ABI < 0.9 was independently associated with advanced age (p = 0.027), increased pulse pressure (p = 0.005), increased hematocrit (p = 0.008) and decreased serum albumin level (p = 0.009). In addition, ABI > or = 1.3 was significantly associated with diabetes mellitus (p = 0.019). This study demonstrated the associated risk factors of peripheral artery disease in patients with hemodialysis in a hospital. ESRD patients of advanced age and with increased pulse pressure, increased hematocrit and decreased serum albumin level had a relatively high risk for ABI < 0.9 and patients with diabetes had a relatively high risk for ABI > or = 1.3.

Slowing renal function decline in chronic kidney disease patients after nephrology referral.

AIM: Late referral of chronic kidney disease (CKD) patients to nephrologists is associated with increased morbidity and mortality and is still quite common and seldom studied in Taiwan because of unique sociocultural factors. We aimed to study the decline in renal function and factors related to the change in renal function before and after referral. METHODS: We retrospectively reviewed the changes of estimated glomerular filtration rate (eGFR) in 213 new referrals of patients with CKD stages 3-5 to the nephrology divisions of one medical centre and one regional hospital from 2001-2006. Data on demographics and laboratory investigations were collected for study. RESULTS: The rates of annual eGFR decline slowed significantly from -7.38 +/- 0.84 before referral to -1.02 +/- 0.45 mL/min per 1.73 m(2)/year after referral (mean +/- standard error of the mean, P < 0.001). The nephrology referral was the most significant factor associated with the slowing of renal function progression, as was younger age and female sex. After nephrology referral, patients with diabetes had an increase in eGFR compared to those without diabetes (P = 0.034). Patients had better control of diastolic blood pressure, sugar and lipid, more frequent use of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers and statins, less frequent use of non-steroidal anti-inflammatory drugs, and more serum creatinine measurements after nephrology referral. CONCLUSION: Slowing renal functional decline in CKD patients after referral addresses the importance of nephrology referral for CKD care, which should be strongly promoted in CKD prevention projects in Taiwan.