Early as compared to late initiation of twice-weekly hemodialysis and short-term survival among end-stage renal disease patients.

INTRODUCTION: The impact of timing of hemodialysis (HD) for end-stage renal disease (ESRD) patients treated with twice-weekly HD remains unclear. We aimed to determine the effects of late initiation of HD on short-term mortality and hospitalization. METHODS: A multicenter cohort study was conducted in 11 HD centers in Northeastern Thailand (HEmodialysis Network of the NorthEastern Thailand study group). We recruited adult ESRD patients who were treated with twice-weekly HD for more than 3 months and had data on eGFR at HD initiation. Clinical and laboratory values at the time of recruitment were recorded. Late and early (eGFR at start <5 and >5 ml/min/1.73 m2 ) initiations were defined. Outcomes were disease-related death (excluding any accidental deaths) and first hospitalization. Data analysis was performed by multivariable cox-regression analysis. FINDINGS: A total of 407 patients who had data on eGFR at HD initiation (303 in late group and 104 in early group) were included for analysis. There were 56.8% male with a mean age of 55 years. During the 15.1 months of follow-up, there were 27 (6.6%) disease-related deaths. The 1-year survival rate was similar among late and early initiation groups. The incidence density of first hospitalization in the late group was significantly lower than those in the early group (HR adjusted, 0.63; 95% CI, 0.40-0.99, p = 0.047). Among 303 patients who were in the late start group, patients with diabetes had a higher mortality rate (HR, 3.49; 95% CI, 1.40-8.70, p = 0.007) when compared to non-diabetic patients. DISCUSSION: Early initiation of HD at eGFR >5 ml/min/1.73 m2 had no short-term survival benefit compared to the late group in ESRD patients treated with twice-weekly HD for at least 3 months in a resource-limited setting. A survival benefit from an early start of HD was found among diabetic patients.

Can a multidisciplinary approach slow renal progression in CKD patients?

Background: Several randomized controlled trials have examined the benefits of multidisciplinary CKD care on estimated glomerular filtration rate (eGFR). But, the results are inconclusive. Purpose: This study aimed to evaluate whether or not multidisciplinary CKD care was beneficial in terms of CKD progression. Methods: This is a randomized controlled trial and conducted at community hospital, Thailand. The inclusion criteria were patients with age of 18 years or older and diagnosed with up to stage 3b CKD based on the KDIGO guidelines. Eligible patients divided into two groups: intervention and control group. The intervention group received a type of multidisciplinary treatment, while patients in the control group received the standard treatment administered at the outpatient clinic. The primary outcome was eGFR outcomes at three months after enrollment. Results: During the study period, there were 334 patients who met the study criteria. Eligible patients were divided into two groups: intervention (166 patients; 49.70%) and control (168 patients; 50.30%). There were three outcomes that differed significantly between the two groups at 3 months: mean difference of eGFR from baseline, proportion of patients with eGFR decline greater than 4 mL/min/1.73 m2, and difference in CKD stage from baseline. A significantly higher percentage of patients in the intervention group experienced CKD improvement by one stage (24.10% vs 5.95%), and a significantly lower percentage experienced decline by one stage (8.43% vs 35.12%) than in the control group. Conclusion: Slower renal progression in patients with up to stage 3b CKD was shown in patients who were treated by a multidisciplinary approach.

Survival Analysis and Associated Factors in Thai Patients on Peritoneal Dialysis Under the PD-First Policy.

BACKGROUND: The peritoneal dialysis First (PD-First) policy means that PD is the first modality of dialysis chosen for patients with end-stage renal disease (ESRD), as put forth by the Universal Health Coverage (UHC) scheme. It was initiated in Thailand in 2008. Our aim is to analyze patient survival, technique survival, and associated factors. METHODS: Data of PD patients from January 2008 to November 2016 were studied. We calculated patient and technique survival rates (censored for death and kidney transplantation). Factors associated with survival were analyzed by the Cox proportional hazard model. Patient and technique survival rates between 2008 - 2012 and 2013 - 2016 were compared. RESULTS: Our study included 11,477 patients. The mean (standard deviation [SD]) age at initiation of PD was 54.0 (14.4) years. The level of education in 85.2% of cases was illiterate or primary school. A total of 60.9% of patients developed ESRD secondary to diabetes. The 1- to 5-year patient survival rates were 82.6, 71.8, 64.0, 58.5, and 54.0%, respectively. The first-year technique survival rate was 94.8%. The patient and technique survival rates during 2013 - 2016 were better than those seen during 2008 - 2012. Factors associated with lower patient survival rates were: female gender, increased age at start of PD, coverage with civil servant medical benefit scheme, low educational levels, and a history of diabetes. CONCLUSION: Most patients had diabetes and low educational levels as seen in the outcomes in the previous literature. These factors impacted the survival of patients under the PD-First policy.

Relation of peritubular capillary features to class of lupus nephritis.

BACKGROUND: Experimental studies have linked peritubular capillary (PTC) loss with progression of chronic kidney disease. Minimal information on PTC in lupus nephritis (LN) has been reported. We therefore evaluated the PTC area in different classes of LN and determined if specific clinical characteristics correlated with PTC changes. METHODS: Renal biopsies of 253 subjects with LN (categorized using the ISN/RPS 2003 classification) and 13 normal renal donors (the controls) were retrospectively evaluated for PTC morphology by staining for CD31 with immunohistochemistry method. The percent positive area of PTC (% PTC) was correlated with serum and urinary measures of renal function and renal pathology. RESULTS: Significant PTC loss was observed in all classes of LN compared to controls. The % PTC area was highest in controls (7.64±1.48 %) with levels of 1.95±1.50, 4.16±3.85, 4.19±4.45, 5.02±1.79, and 4.45±3.75 in classes II, III, IV, IV combined with V and V, respectively (all p values < 0.05). The lowest PTC density was observed in class II LN, but this may be because some cases with worse classes of LN showed increased PTC density due to abnormally dilated capillaries associated with acute inflammation and angiogenesis. %PTC was increased in those with hematuria (5.8±5.2 vs. 3.6±3.4 %, red blood cells 3-10 vs. < 3 cells/high power field, p < 0.05) and was reduced in those with a moderately declined renal function (3.29±3.40 vs. 4.42±4.12, eGFR 15-59 vs. ≥ 60 ml/min/1.73 m2, p < 0.05). Nephrotic-range proteinuria also trended to be associated with lower PTC density although it did not reach statistical significance (3.1±2.6 vs. 4.9±4.5, p= 0.067). CONCLUSIONS: LN is associated with PTC loss and the severity correlates with reduced renal function. Further studies are needed to investigate whether a loss of PTC can predict long term renal outcomes in LN.

A prospective, multi-centre, observational study to examine kidney disease progression in adults with chronic kidney disease - CKDOD - Study design and preliminary results.

BACKGROUND: The objective of this article is to describe the organisation of an international, clinical registry, the Chronic Kidney Disease Observational Database (CKDOD), the processes of enrolling patients and entering data and preliminary results to date. DESIGN: The Chronic Kidney Disease Observational Database (CKDOD) is designed to assess the association between different factors with a known influence on chronic kidney disease (CKD) progression as well as treatment strategies such as dietary modifications, blood pressure control and pharmacological interventions in Asian countries (India, China, Malaysia and Thailand). The only inclusion criterion is the presence of CKD stage 2 or higher as defined by the KDIGO guidelines. Demographic and clinical information are collected by a standardised electronic questionnaire, available in English and Chinese. The data are transferred to the CKDOD database either by e-mail or via web access. All data are checked for consistency and missing values. Collection of data started in September 2011 and by April 2015, data on 1323 individual patients had been submitted. The mean age at inclusion was 57 ± 14 years, 67 % were male and 36 % were diabetic. The baseline estimated glomerular filtration rate was 26 ml/min/1.73 m(2). Of all enrolled patients, 324 (24 %) received ketoanalogue supplementation during at least one recorded visit. DISCUSSION: The CKDOD is a very large and comprehensive data repository, currently focused in subjects recruited from Asia. The database is expected to provide important long-term information on CKD progression, nutritional and metabolic derangements that accompany CKD progression and treatment strategies to ameliorate progression and complications of CKD. TRIAL REGISTRATION: Clinical Trial Registry - India: CTRI/2012/06/002743 ; 25th July 2012.

Immediate Effects of Traditional Thai Massage on Psychological Stress as Indicated by Salivary Alpha-Amylase Levels in Healthy Persons.

BACKGROUND Stress can cause psychological and physiological changes. Many studies revealed that massage can decrease stress. However, traditional Thai massage has not been well researched in this regard. The purpose of this study was to investigate the immediate effects of traditional Thai massage (TTM) on salivary alpha-amylase levels (sAA), heart rate variability (HRV), autonomic nervous system (ANS) function, and plasma renin activity (PRA). MATERIAL AND METHODS Twenty-nine healthy participants were randomly allocated into either a traditional Thai massage (TTM) group or Control (C) group, after which they were switched to the other group with a 2-week wash-out period. Each of them was given a 10-minute mental arithmetic test to induce psychological stress before a 1-hour session of TTM or rest. RESULTS Within-groups comparison revealed that sAA was significantly decreased (p<0.05) in the TTM group but not in the C group. HRV and ANS function were significantly increased (p<0.05) and PRA was significantly decreased (p<0.05) in both groups. However, low frequency per high frequency ratio (LF/HF ratio) and ANS balance status were not changed. Only sAA was found to be significantly different between groups (p<0.05). CONCLUSIONS We conclude that both TTM and rest can reduce psychological stress, as indicated by decreased sAA levels, increased parasympathetic activity, decreased sympathetic activity, and decreased PRA. However, TTM may have a modest effect on stress reduction as indicated by a reduced sAA.

Psychological Stress Can Be Decreased by Traditional Thai Massage.

OBJECTIVE: The purpose of this study was to investigate the immediate effects of traditional Thai massage (TTM) on psychological stress and heart rate variability (HRV). MATERIAL AND METHOD: Thirty healthy participants were randomly allocated in two groups, a TTM group (n = 15) who received a 1-hour session with moderate pressure of whole body TTM or a control group (n=15) who rested on the bedfor 1 hour All ofthem were given a 10-minute mental arithmetic test to induce psychological stress after which they received a 1-hour session of TTM or bed rest. Psychological stress and HR V were measured at baseline and immediately after mental arithmetic test, and immediately after TTM or bed rest. RESULTS: The studyfound that psychological stress was signficantly increased (p<0.05) after mental arithmetic test in both groups. Comparison on these measures between immediately after mental arithmetic test and after TTM or bed rest revealed that psychological stress was significantly decreased (p<0.05) and HR Vwas significantly increased (p<0.05) in both groups. Root mean square of successive differences (RMSSD) and low frequency were significantly increased (p<0.05) only in the TTM group. However; all of these measures were found without significant difference when groups were compared. CONCLUSION: TTM and bed rest could decrease psychological stress and HRV

Dialysis dose and risk factors for death among ESRD patients treated with twice-weekly hemodialysis: a prospective cohort study.

BACKGROUND/AIMS: We aimed to define the dosing and risk factors for death in patients undergoing twice-weekly hemodialysis. METHODS: A prospective multi-center cohort study was conducted with one-year observation. Patients treated with twice- or thrice-weekly hemodialysis were identified. Death and first admission were the outcomes. spKt/V was a factor of interest. RESULTS: We enrolled 504 twice-weekly and 169 thrice-weekly hemodialysis patients. The mean weekly values of spKt/V in the two groups were 3.4 and 5.1. The one-year survival rate and times to hospitalization were similar in both groups. The hazard ratios for death in higher spKt/V quartile was not associated with lower mortality, p = 0.70. The four significant predictors for death were serum albumin, HR = 2.6, current smoking, HR = 19.3, age, HR = 1.1, and the Index of Coexistent Disease [ICED], HR = 1.9. CONCLUSION: The effect of spKt/V on short-term mortality was not obvious in twice-weekly dialysis patients. Attention should be paid to patients who smoke, have hypoalbuminemia, are elderly, or have a high ICED.

Personalized tacrolimus doses determined by CYP3A5 genotype for induction and maintenance phases of kidney transplantation.

BACKGROUND: Cytochrome P450 (CYP) 3A4 and 3A5 are major isoforms involved in the metabolism of tacrolimus, with the CYP3A5 gene being more polymorphic. It is hypothesized that individual variation in the metabolism of tacrolimus drug may result from genetic polymorphism of CYP3A5. It has been reported that the clearance of tacrolimus in patients with the CYP3A5*1 allele was ~2.5-fold greater than that in those with the CYP3A5*3/*3 genotype. Recent data have also shown that polymorphism in exon 26 (C3435T) of the multidrug resistance gene (MDR1) was correlated with the expression level and function of P-glycoprotein in the lower duodenum, making the relationship between polymorphism of MDR1 and the effective dose of tacrolimus a source of controversy. OBJECTIVES: This study investigated the influence of genetic polymorphisms of CYP3A5 and MDR1 on the dose requirements for the induction and maintenance phases of tacrolimus therapy in kidney transplant recipients. METHODS: Sixty-eight kidney transplant recipients were enrolled, and their clinical and laboratory data were retrospectively reviewed after 6 months of tacrolimus administration. Genotypes of CYP3A5*1 and CYP3A5*3 and exon 26 of MDR1 (C3435T) were determined by the single-nucleotide polymorphism genotyping method. RESULTS: The frequencies of CYP3A5*3/*3, CYP3A5*1/*3, and CYP3A5*1/*1 were 44.1%, 35.3%, and 20.6%, respectively. The mean dose of tacrolimus required for the induction phase was significantly greater in the CYP3A5*1/*1 group (0.142 [0.050] mg/kg/d) than that required in the CYP3A5*1/*3 group (0.097 [0.040] mg/kg/d; P = 0.072) and in the CYP3A5*3/*3 group (0.077 [0.020] mg/kg/d; P = 0.005). The maintenance dose of tacrolimus required in the CYP3A5*1/*1 group (0.12 [0.03] mg/kg/d) was 1.3-fold higher than that in the CYP3A5*1/*3 group (0.09 [0.03] mg/kg/d; P = 0.018) and 2.4-fold higher than in the CYP3A5*3/*3 group (0.05 [0.02] mg/kg/d; P < 0.0001). No statistically significant relationship was observed between the doses of tacrolimus required for the induction and maintenance phases and MDR1 polymorphism. CONCLUSION: Determination of the CYP3A5 genotype would be helpful in the design of adequate immunosuppressive treatment and in lowering toxicity by predicting the doses of tacrolimus required for the induction and maintenance phases in individual kidney transplant recipients.

Experiences on bedside Tenckhoff catheter implantation.

OBJECTIVE: To clarify the outcome of a bedside technique of peritoneal dialysis (PD) catheter implantation which is practiced differently from worldwide guidelines in some points. MATERIAL AND METHOD: This retrospective study was conducted in end stage renal diseases (ESRD) patients treated with chronic ambulatory peritoneal dialysis (CAPD). Catheter placement was initiated by the authors' bedside technique comprising no antibiotic prophylaxis, dry abdomen, and routinely right sided exit site as our protocol. All events within one month postimplantation, such as tip mal-position, malfunction, infection, and bleeding were analyzed. RESULTS: One hundred and fourteen cases were participated with age, ranged from 14 to 78 yrs. Of the participating subjects, 38.5% was female and 60.52% was diabetes mellitus (DM). After 1 month, 113 out of 114 cases (99.1 %) accomplished CAPD. Of these, 79.8 % had good tip position and function after the break-in period. Early mal-position and poor flow was detected in 21 cases (18.4 %); 9 of them responded to laxative bowel stimulation while 12 cases needed surgical correction. Exit-site infection and/or wound infection were found in 7.9%. The peritonitis rate was 2.63%. All cases with infection were cured. Coagulase positive Staphylococcus aureus was the major causative organism. CONCLUSION: Bedside Tenckhoff catheter implantation without antibiotic prophylaxis in dry abdomen is a safe modality for selected ESRD patients.

The "PD First" policy in Thailand: three-years experiences (2008-2011).

Universal coverage (UC) scheme is a reformed national healthcare insurance that has been set up since the year 2002 and covers more than 80% of Thai population who are self-employed and do not work as government employees. Initially, this scheme offered only basic and comprehensive healthcare while renal replacement therapy (RRT), the financial cost of which was high, was not included. Without the support from the government healthcare insurance, the patients and their families will become insolvency. The benefit of peritoneal dialysis (PD) over hemodialysis (HD) has been shown in terms of medical expenses and cost-effectiveness. The "PD First" policy in Thailand has been implemented on January 1st 2008 as a model of initial treatment of end stage renal disease (ESRD) patients under the UC scheme. During the year 2008-2011, 12,753 cases, 6,177 were male and 6,576 were female, registered in this modality. The technical survivals at 1, 2 and 3 years were 92, 85 and 80%, respectively while the patient survivals were 79, 66 and 57% at 1, 2 and 3 years, respectively. The hematocrit level had been significantly increased from 25.9 +/- 5% in October 2009 to 28.0 +/- 5% in October 2010. The Peritonitis rate was decreased from 20.7 per patient months during the year 2009 to 25.8 per patient months at the year 2011 and the exit-site infection rate was 1 episode per 40.7 patient months. Currently, there are 111 PD centers that service for ESRD patients nationwide. There are strong supports from The National Health Security Office, The Nephrology Society of Thailand, The Dialysis Nurse Association, The Kidney Foundation of Thailand The Ministry of Public Health, The Thai Kidney Patient Association, Chulalongkorn University, Thai Red Cross Society, community, and social network, all of which are the major factors to guarantee the salutary outcomes in the future.

Prevalence and risk factors of chronic kidney disease in the Thai adult population: Thai SEEK study.

BACKGROUND: Previous reports of chronic kidney disease (CKD) prevalence in Thailand varied from 4.3% to 13.8%. However, there were methodological concerns with these reports in terms of generalization and the accuracy of estimation. This study was, therefore, conducted to determine CKD prevalence and its risk factors in Thai adult populations. METHODS: The population-based Thai Screening and Early Evaluation of Kidney Disease (SEEK) study was conducted with cross-sectional stratified-cluster sampling. Serum creatinine was analysed using the modified Jaffe method and then standardized with isotope dilution mass spectrometry. RESULTS: The study included 3,459 subjects were included in the study. The mean age was 45.2 years (SE = 0.8), and 54.5% were female. Six hundred and twenty-six subjects were identified as having CKD, which evidenced an overall CKD prevalence of 17.5% [95% confidence interval (95% CI) = 14.6-20.4%]. The CKD prevalence of Stages I, II, III and IV were 3.3% (95% CI = 2.5%, 4.1%), 5.6% (95% CI = 4.2%, 7.0%), 7.5% (95% CI = 6.2%, 8.8%) and 1.1% (95% CI = 0.7%, 1.5%), respectively. The prevalence of CKD was higher in Bangkok, the Northern and Northeastern regions than in the Central and Southern regions. Seven factors (i.e. age, gender, diabetes, hypertension, hyperuricaemia, history of kidney stones and the use of traditional medicines) were associated with CKD. Only 1.9% of the subjects were aware that they had CKD. CONCLUSIONS: CKD prevalence in the Thai population is much higher than previously known and published. Early stages of CKD seem to be as common as later stages. However, albuminuria measurement was not confirmed and adjusting for persistent positive rates resulted in the prevalence of 14.4%. Furthermore, the awareness of CKD was quite low in the Thai population.

Acute valproic acid overdose: enhance elimination with multiple-doses activated charcoal.

Multiple dose activated charcoal (MDAC) is used to enhance elimination of toxic substance in acute poisoning. However, its role in acute valproic acid (VA) overdose is controversial. The authors report a case of VA overdose that successfully recovered with MDAC treatment. The half-life of VA in the presented patient was decreased from 12 to 8 hours during MDAC administration. MDAC treatment in acute poisoning enhanced VA elimination four times than without treatment. MDAC should be considered for the treatment of acute VA intoxication.

Impact of the heterozygous TPMT*1/*3C genotype on azathioprine-induced myelosuppression in kidney transplant recipients in Thailand.

BACKGROUND: Thiopurine S-methyltransferase (TPMT) is a polymorphic enzyme associated with detoxification of azathioprine, an immunosuppressant used after renal transplantation in several Asian countries. Patients with variations of the TPMT gene may be at risk for myelosuppression after they receive a standard dosage of the drug. The frequency of TPMT*3C has been reported to be higher in the Thai population than in other Asian populations, possibly putting the Thais at higher risk for myelosuppression. OBJECTIVE: The aim of this study was to assess the impact of the heterozygous TPMT*1/*3C genotype on azathioprine-induced myelosuppression in kidney transplant recipients in Thailand. METHODS: This study was conducted at Srinagarind Hospital, Khon Kaen University, Khon Kaen, Thailand, and Chulalongkorn Hospital, Chulalongkorn University, Bangkok, Thailand. Eligible patients underwent kidney transplantation from deceased or living-related donors from 1984 to 2007. Electronic medical records were assessed retrospectively for the 6-month period after initiation of azathioprine treatment. TPMT genotyping and phenotyping were studied prospectively using real-time polymerase chain reaction and biochemical assay, respectively. The odds ratios (ORs), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were determined. RESULTS: A total of 139 patients were enrolled (89 men, 50 women; median age, 42 years [range, 17-70 years]; mean weight, 58 kg [range, 37-87 kg]). The heterozygous TPMT*1/*3C genotype was found in 9 of the 139 patients (6.47%) (95% CI, 3.00-11.94). The TPMT activity of those patients was significantly lower than that of patients with the homozygous wild-type genotype (median, 21.37 vs 37.12 nmol 6-methylthioguanine/g . Hb/h, respectively; P < 0.001). The risk for azathioprine-induced myelosuppression in the patients with the heterozygous TPMT*1/*3C genotype was significantly higher than that in patients with the wild-type genotype (adjusted OR, 14.18 [95% CI, 3.07-65.40]; P < 0.005). The sensitivity and specificity of TPMT*3C genotyping for the prediction of azathioprine-induced myelosuppression in these kidney transplant recipients were 27% and 97%, respectively. Assuming a prevalence of azathioprine-induced myelotoxicity of 7% according to previously published data, the PPV and NPV were estimated to be 50% and 95%, respectively. CONCLUSION: In these kidney transplant recipients, patients who carried the TPMT*3C allele were at a higher risk for azathioprine-induced myelosuppression than noncarriers.

Thiazide diuretics exacerbate fructose-induced metabolic syndrome.

Fructose is a commonly used sweetener associated with diets that increase the prevalence of metabolic syndrome. Thiazide diuretics are frequently used in these patients for treatment of hypertension, but they also exacerbate metabolic syndrome. Rats on high-fructose diets that are given thiazides exhibit potassium depletion and hyperuricemia. Potassium supplementation improves their insulin resistance and hypertension, whereas allopurinol reduces serum levels of uric acid and ameliorates hypertension, hypertriglyceridemia, hyperglycemia, and insulin resistance. Both potassium supplementation and treatment with allopurinol also increase urinary nitric oxide excretion. We suggest that potassium depletion and hyperuricemia in rats exacerbates endothelial dysfunction and lowers the bioavailability of nitric oxide, which blocks insulin activity and causes insulin resistance during thiazide usage. Addition of potassium supplements and allopurinol with thiazides might be helpful in the management of metabolic syndrome.

Survival and technical failure in a large cohort of Thai CAPD patients.

OBJECTIVE: To evaluate patient and technique survival, and to analyze factors influencing survival in a large Thai CAPD program. MATERIAL AND METHOD: A single center, retrospective, observational cohort study was carried out to examine the baseline factors affecting patient and technique survival. RESULTS: From January 1995 to December 2005, 322 incident CAPD patients were recruited for study. One hundred and thirteen patients (35.1%) died during the study period of 7,706 patient-months. Median patient survival time was 46.4 months. The major cause of death was related to infection. In multivariate analysis, only age at enrollment and baseline serum albumin were strong risk factors of death. Median technique survival was 41.2 months. The major cause of technique failure was peritoneal dialysis related infection. History of peritonitis, baseline serum albumin, and dialysis commencement in recent era were technique failure predictors. A neutral effect of self and caregiver performer was observed in the present study. CONCLUSION: Patient survival in the presented institute is similar to that reported in Western countries. Age and baseline serum albumin were the strongest predictors of death.

Risk factors of first peritonitis episode in Thai CAPD patients.

BACKGROUND: Peritonitis is a major complication of continuous ambulatory peritoneal dialysis (CAPD) patients. Information on the specific risk of peritonitis is important in reducing this common complication. MATERIAL AND METHOD: A single center retrospective cohort study was done to assess time to first peritonitis event and risk factors in Thai CAPD population. RESULTS: Between January 1995 and December 2005, 322 incident CAPD patients were recruited for the present study. During the study period of 4,281 patient-months, 198 episodes of first peritonitis were recorded. The median peritonitis-free time was 13.7 months. A Cox regression model showed that an increase in level of baseline albumin and hematocrit by 1 g/dL and 1% would decrease risk of peritonitis by 27% and 3%, respectively (hazard ratio (95%CI): 0.73 (0.59-0.91) and 0.97 (0.94-1.00)). A neutral effect of self and caregiver performer was observed in the present study. CONCLUSION: The present study confirmed the susceptibility of hypoalbuminemia and anemia to peritonitis. Awareness of particular risk groups should be achieved to prevent peritonitis.

The validity of A new practical quality of life measure in patients on renal replacement therapy.

OBJECTIVE: A new quality of life measure, apart of the National Health and Welfare 2003 survey, is a promising tool for outcome evaluation of clinical practice due to its brevity, validity, reliability, and providing easy interpretation against general population norm-based scores. The measure consisting of 9-items, and so called 9-item Thai Health status Assessment Instrument (9-THAI) was used to assess its validity and reliability in patients on renal replacement therapy (RRT). MATERIAL AND METHOD: Three hundred and two patients on RRT who visited Srinagarind Hospital from March to May 2005 were studied Convergent and divergent validity were assessed using SF-36 as the concurrent measure. Concurrent validity was also assessed using hematocrit level and hospitalization history in the last year as concurrent clinical measures. Test-retest reliability was studied by repeated measure within one 1 month. Responsiveness of 9-THAI was studied in patients who reported health improvement. RESULTS: Results of correlations between 9-THAI and SF-36 domains were as hypothesized 9-THAI scores were significantly correlated with hematocrit level and hospitalization history. The results confirmed the validity of 9-THAI for use as a quality of life measure. Intraclass correlation coefficients of 9-THAI scores in stable patients were satisfactory. Among patients on RRT who reported overall health improvement, 9-THAI scores significantly increased, thus adding further evidence of the responsiveness of 9-THAI. CONCLUSION: The 9-THAI is a valid and reliable generic health status measure that can be used as an ideal core in a battery of quality of life measures in clinical practice for patients on RRT.

Bone mineral density among patients undergoing continuous ambulatory peritoneal dialysis (CAPD).

Apart from the conventional risks, low bone mineral density (BMD) is one of the risk factors for bone fracture. Interestingly, the incidence of bone fracture is highest among patients with chronic renal failure, but there is little data comparing the BMD of patients undergoing continuous ambulatory peritoneal dialysis (CAPD) with normal persons. The authors, therefore, compared the BMD between sex-, age- and bodyweight-matched CAPD patients and normal persons. The femoral neck, lumbar spine and total BMD were measured by dual energy X-ray absorptiometry in 62 CAPD patients and normal persons. In unadjusted analysis, femoral neck and total BMD in CAPD patients was significantly lower than normal controls in both men and women, while there was no significant difference at lumbar spine BMD between the two groups. The results were unchanged after adjusting for age, body weight and height (0.13 and 0.29 g/cm2, p < 0.001, for femoral and total BMD, respectively and 0.001 g/cm2, p = 0.96 for lumbar spine BMD). In conclusion, low BMD is already a major risk factor for hip fracture, and this risk is exacerbated by CAPD. BMD measurement should be incorporated into the routine care of CAPD patients in order to identify incipient osteoporosis, so that it may be treated to prevent fractures.