Cardiac arrhythmia during early-week and mid-week dialysis in hemodialysis patients.

Data on cardiac arrhythmia and electrolyte changes during the dialysis cycle have been limited. Fifty-two hemodialysis (HD) patients underwent 48-h Holter monitoring during early-week and mid-week HD sessions. Pre-HD and post-HD blood samples were collected in both HD sessions. The 48-h Holter data were divided into five phases: (1) 4-h during the early-week HD (HD1), (2) 12-h post-HD1, (3) 16-h period between Phases 2 and 4 (used as the patient's baseline electrocardiography [ECG]), (4) 12-h pre-HD2 phase, and (5) 4-h during the mid-week HD (HD2). The patients' mean age was 68.54 ± 13.37 years. We found that the dialysate-to-serum[K] gradient and changes of S[K] were significantly higher in HD1 than in HD2, as well as changes of S[Mg]. There were no significant ECG changes during the 4-h HD1 and HD2 when compared with the baseline ECG. Phase 2 of Holter ECG was the most common phase that showed significant changes (increased QT interval dispersion (QTD), increased ventricular events, increased number of premature ventricular contractions, ST elevation and ST depression), which was contributed from the dialysate[K] 2 mmol/L subgroup, but not the dialysate[K] 3 mmol/L subgroup. In the subgroup of patients with a high ultrafiltration rate (UFR; mean UFR ≥10 mL/kg/h), there were significantly increased ventricular events and ST-segment changes in Phase 2. In conclusion, ECG changes were associated with the dialysis cycle, significantly in the 12-h after early-week HD sessions. These may be associated with low dialysate[K] or high dialysate-to-S[K] gradient, high ultrafiltration rate and duration of the interdialytic interval.

Prevalence and Factors Associated with Left Ventricular Systolic Dysfunction in End-Stage Renal Disease Patients on Dialysis.

Background: Heart failure is a major cause of morbidity and mortality in patients with end-stage renal disease (ESRD). Previous studies reported various factors associated with left ventricular systolic dysfunction (LVSD) in patients with ESRD. Objective: To investigate the prevalence and factors associated with LVSD in patients with ESRD on dialysis. Material and Method: Patients with ESRD on dialysis who underwent comprehensive transthoracic echocardiography at Siriraj Hospital between 2003 and 2014 were enrolled. LVSD was defined as left ventricular ejection fraction less than 40%. Results: One hundred sixty one patients with a mean age of 56.5±15.4 years were included and 46% were female. Regarding mode of dialysis, 25% and 75% of patients were on peritoneal dialysis and hemodialysis, respectively. Median duration of dialysis was three years. Smoking, diabetes, dyslipidemia, and hypertension were reported in 30%, 40%, 57%, and 94% of patients, respectively. History of heart failure and coronary artery disease (CAD) were reported in 23% and 24% of cases, respectively. Prevalence of LVSD was 5%. History of heart failure, known CAD, and left ventricular diastolic dimension (LVDd) were found to be univariately associated with LVSD. Multivariate factors associated with LVSD were known CAD (OR 23.67, 95% CI 1.23-456.54, p-value = 0.036) and LVDd (OR 1.56, 95% CI 1.15-2.11, p-value = 0.004). Conclusion: Prevalence of LVSD in patients with ESRD on dialysis in the present study was 5%. Known CAD and LVDd were independent predictors of LVSD in this population.

Glomerular macrophage is an indicator of early treatment response in diffuse proliferative lupus nephritis.

BACKGROUND: Patients with diffuse proliferative lupus nephritis (class IV) who responded to treatment within 6 months had better renal outcome than those who did not. Glomerular macrophage is known to be associated with poor renal outcome in glomerular diseases. OBJECTIVE: To evaluate association between glomerular macrophage number and early treatment response in lupus nephritis class IV patients. MATERIAL AND METHOD: Renal biopsies (n = 90, 86 females) diagnosed with lupus nephritis class IV were included in the study. The patients were divided into 2 groups (n = 45 each) according to response to treatment within 6 months. The treatment response group was defined as having decreased serum creatinine at least 25% from baseline and 24 hr urine protein or UPCR (urine protein creatinine ratio) < 1. The non-response group was defined as stable or increased serum creatinine and 24 hr urine protein or UPCR > or = 1. Immunohistochemistry for macrophage marker (CD68) was performed and the glomerular macrophages were counted on each biopsy. The relevant clinicopathologic data were collected. RESULTS: The glomerular macrophage number in response and non-response group was 4.5 +/- 2.5 and 6.2 +/- 4.5 respectively (p = 0.029). The glomerular macrophage number was conversely and inversely correlated with activity (r = 0.281, p = 0.007) and chronicity (r = -0.358, p < 0.001) index, respectively CONCLUSION: Lupus nephritis class IV patients who responded to treatment within 6 months had lower glomerular macrophages than those who did not. The glomerular macrophage number may be used to determine treatment response in lupus nephritis class IV patients.

Buttonhole technique better than area puncture technique on hemostasis and pain associated with needle cannulation.

BACKGROUND: The buttonhole (constant site) arteriovenous fistulae cannulation technique, in which the inserted needle utilizes exactly the same site and the same angle every dialysis session, offers the advantage of an easier cannulation procedure, less pain associated with cannulation, and fewer complications when compared with the traditional method. OBJECTIVE: To compare buttonhole arteriovenous fistula (AVF) cannulation technique with area puncture method on the effect of hemostasis after needle withdrawal and pain during needle puncture. MATERIAL AND METHOD: The duration of hemostasis after needle withdrawal and pain during needle puncture of AVF were prospectively recorded in 21 chronic hemodialysis patients at Siriraj Hospital. The data that were collected while using area puncture with sharp needle and while using buttonhole with blunt needle were compared by using Paired t-test. RESULTS: Compared with area puncture method, the duration of hemostasis after needle withdrawal in patients using buttonhole method was significantly shorter in both arterial (4.19 +/- 1.66 mins vs. 9.12 +/- 2.36 mins, p < 0.0001) and venous site (3.92 +/- 1.37 mins vs. 9.12 +/- 2.36 mins, p < 0.0001). The pain score during needle puncture of AVF in patients using buttonhole method was also significantly less than area puncture method in both arterial (1.20 +/- 0.90 vs. 6.03 +/- 0.90, p < 0.0001) and venous site (1.38 +/- 0.75 vs. 5.88 +/- 0.82, p < 0.0001). CONCLUSION: Buttonhole AVF puncture method is a useful technique to reduce both the time for hemostasis after needle withdrawal and pain during needle puncture.

Late onset lupus nephritis: analysis of clinical manifestations and renal pathological features in Siriraj Hospital.

BACKGROUND: Lupus nephritis (LN) is uncommon after the age of 50 years and studies of elderly patients with LN are rare. The authors conducted the current study to determine the clinical manifestations, pathological features and prognosis of 30 Thai patients with late onset LN in Siriraj hospital in Bangkok from 1989 to 2006. MATERIAL AND METHOD: Thirty LN patients with a disease onset beyond the age of 50 years from 1989 to 2006 were enrolled in this retrospective study. All of them received renal biopsy. The histological classifications were categorized according to 2003 International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification. RESULTS: Clinical and pathologic records were collected from 30 patients (23 female and 7 men) who were followed-up for a mean period of 25.8 months (range, 6 to 96 months). The mean age was 56.6 +/- 4 years. Hypertension was diagnosed in 66.7% of patients and 41.3% had serum creatinine greater than 1.5 mg/dL. Nephrotic-range proteinuria was found in 63.3% of patients and creatinine clearance less than 50 ml/min was found in 70%. Of the 30 patients, the most common renal histologic finding was diffuse proliferative glomerulonephritis (63.30%). The overall probability of patient survival was 94.1% at 12 months, 68.6% at 36 months and 34.3% at 60 months. During the follow-up period (25.8 months; range, 6 to 96 months), 4 patients died. Infection was the leading cause of death (75%). CONCLUSION: Lupus nephritis in the elderly patients is not uncommon. Prompt diagnosis should be made for appropriate management and optimal outcome.

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.

Evaluation of atherosclerosis, arterial stiffness and related risk factors in chronic hemodialysis patients in Siriraj Hospital.

BACKGROUND: Additional to traditional risk factors for cardiovascular disease (CVD), recent evidence demonstrates that nontraditional risk factors such as high-sensitive C-reactive protein (hsCRP), hyperhomocysteinemia and vascular calcification may cause progressive atherosclerosis in hemodialysis patients. OBJECTIVE: We aim to determine the prevalence of atherosclerosis and assess the arterial stiffness and related risk factors. MATERIAL AND METHOD: Common carotid artery intima-media thicknesses (CIMT), atherosclerotic plaque occurrence were determined by B-mode ultrasonography in 105 hemodialysis patients (mean age, 53 +/- 15.5 years; mean dialysis duration 82 +/- 59.5 months). A history of clinically significant atherosclerotic vascular disease was elicited by patient questionnaire and verified by careful patient chart review and physical examination. Cardiovascular ankle index (CAVI) was use to assess arterial stiffness. Serum biochemical marker for traditional risk factors, hsCRP and homocysteine were measured by standard method. RESULTS: Atherosclerotic vascular disease (defined by a history of CVD or presence of atherosclerotic plaque) was present in 79% of patients. Compared to non-atherosclerotic group, the mean CIMT and serum hsCRP in atherosclerotic group was higher (1.9 +/- 0.8 mm vs. 0.8 +/- 0.6 mm, p < 0.001; 6.5 +/- 8.8 mg/L vs. 3.3 +/- 3.5 mg/L, p = 0.03, respectively), while other biochemical markers were not significantly different, as well as the percentage of abnormal CAVI (69% vs. 54.5%, p = 0.28). CAVI was positively correlated with maximum carotid intima-meida thickness (r = 0.44, p < 0.001). CAVI was also significantly greater in patients with carotid plaque (soft plaque (p < 0.05) and calcified plaque (p < 0.05)) compared with patients without carotid plaque. CONCLUSION: A high prevalence of atherosclerosis and arterial stiffness was observed in hemodialysis patients. Carotid atherosclerosis is associated with an increased inflammatory marker (hsCRP). CAVI may be a useful index to assess arterial stiffness and associated with arterial intima-media thickness.

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.

Malnutrition-inflammation score associated with atherosclerosis, inflammation and short-term outcome in hemodialysis patients.

BACKGROUND: Malnutrition-Inflammation Score (MIS) has been proposed as a new quantitative system for assessment of malnutrition and inflammation, which are common important risk factors for increased morbidity and mortality in maintenance hemodialysis (MHD) patients. OBJECTIVE: To determine the MIS and related it to the presence of atherosclerosis, and the morbidity and mortality rate. MATERIAL AND METHOD: The inflammatory and nutritional status in 100 MHD patients was evaluated by serum high-sensitivity C-reactive protein (hs-CRP), Subjective Global Assessment (SGA), and MIS. Atherosclerosis was defined by a history of cardiovascular disease or presence of carotid plaque by B-mode ultrasonography. Twelve-month prospective hospitalization and mortality rates were recorded. RESULTS: The MIS score was significantly higher in patients with atherosclerosis (5.5 +/- 2.3 vs. 3.0 +/- 1.7, p = 0.003) and modestly correlated with serum ferritin level (r = 0.304, p = 0.03), but did not correlated with hs-CRP. The SGA was not associated with hs-CRP level and atherosclerosis. Over a 12-month follow-up period, 4 patients died and 28 were hospitalized at least once. Compared to the survivor group, MIS in the deceased group was significantly higher (8.0 +/- 1.4 vs. 5.1 +/- 2.3, p = 0.01) while SGA, hs-CRP and other biochemical markers were not significantly different. The Receiver Operating Characteristics Curves for the prediction of 1-year mortality from the MIS score identified the optimal cut-off value of 7.5 with sensitivity of 75% and specificity of 88%. There was no association between MIS or SGA and hospitalization. CONCLUSION: MIS is a useful tool for the assessment of malnutrition and inflammatory status. It is superior to the conventional SGA as a predictor of short-term outcome in MHD patients.

Arterial occlusion in nephrotic syndrome: report of four cases in Siriraj Hospital.

Venous thrombosis is commonly found in nephrotic syndrome, but arterial occlusion is never report in Thailand. Four cases with cerebral and femoral arteries occlusion were demonstrated. The early diagnosis and appropriate intervention can improve outcomes, reduce mortality and morbidity significantly.

Efficacy of intradermal hepatitis B vaccination compared to intramuscular vaccination in hemodialysis patients.

BACKGROUND: Hepatitis B virus infection remains an important problem in hemodialysis patients. Only 50 to 60% of the patients develop seroconversion (anti-HBs Ab titer > 10 IU/L) after intramuscular hepatitis B vaccination. Small dose intradermal inoculation method of hepatitis B vaccine has been reported to be effective as well as economical, and could provide rapid seroconvesion of immunity. The aim of the present study was to compare the efficacy of intradermal hepatitis B vaccination with intramuscular vaccination in hemodialysis patients. MATERIAL AND METHOD: Fifty one hemodialysis patients were randomly assigned to two groups, 25 patients received a total 7 doses of 10 mmicrog of recombinant hepatitis B vaccine (Engerix B) intradermally every 2 weeks (ID group), whereas 26 patients received 40 microg intramuscularly at 0, 1, 2 and 6 months (IM group). Anti-HBs Ab titer was measured at 2, 3, 4 and 7 months after the first vaccination in both groups. Vaccination responses were classified into 3 subgroups according to anti-HBs Ab titer and these included excellent response (> 1,000 IU/L), good response (10-999 IU/L) and non-response (< 10 IU/L). RESULTS: The seroconversion rates at 2, 3, 4, and 7 months in the ID group were 56%, 76%, 88%, and 92% compared with 31%, 42%, 65%, and 69% in the IM group, respectively. Only the seroconversion rates at 3 months were significantly higher in the ID group (76% versus 42%, p = 0.03). At 7 months after the first vaccination, good and excellent responders in the ID group were 72% (18/25) and 20% (5/25) compared with 34.5% (9/26) and 34.5% (9/26), respectively (p > 0.05). Only minor side effects were observed. CONCLUSION: Seven doses of 10 mg intradermal vaccination induced a high seroconversion rate and were comparable with intramuscular regimen. Intradermal vaccination may be helpful for the rapid induction of protective level of antibodies and may be a cost-saving alternative to intramuscular vaccination in hemodilaysis patients.

An analysis of 3,555 cases of renal biopsy in Thailand.

BACKGROUND: The knowledge of the epidemiology of biopsied renal diseases provides useful information in clinical practice. There are several epidemiologic population-based studies of biopsy-proven nephropathies with detailed clinicopathologic correlations that could be different according to the country analyzed. OBJECTIVE: To identify the prevalence of primary and secondary glomerular diseases and to study the trend of the pattern changes of the glomerulopathy in Thailand. MATERIAL AND METHOD: A retrospective study of percutaneous renal biopsies during a 23-year period of 1982 to 2005 was performed. A total of 3,555 consecutive native kidney biopsies in adult patients between 12 and 84 years of age were analyzed for the prevalence and changes in the 5-year interval over the two decades. RESULTS: From the clinical trial of 3,275 patients, the ratio between primary and secondary glomerular diseases was 2:1 (2154:1121). The most common primary glomerular disease (2154 patients) were IgM nephropathy (n = 986, 45.8%) followed by IgA nephropathy (n = 386, 17.9%); membranous nephropathy (n = 341, 15.8%); diffuse endocapillary proliferative glomerulonephritis (n = 114, 5.3%) and diffuse crescentic glomerulonephritis (n = 71, 3.3%). Lupus nephritis was the most prevalent cause of secondary glomerulonephritis in the present study (n = 992, 88.5%). Examination of the 5-year interval along the study period revealed a significant increase in the prevalence of IgA nephropathy and diabetic nephropathy. Prevalence of focal and segmental glomerulosclerosis rose by five times over the last two decades in contrast to IgM nephropathy, which prevalence is decreasing. CONCLUSION: There is high prevalence of IgM nephropathy, IgA nephropathy, and lupus nephritis in Thailand which is different from other countries. It could be due to various races and altered environments. The information obtained from these results is an important contribution for the understanding of the prevalence in renal diseases in Thailand. It can be used as the baseline data for making efficient research into the appropriate and beneficial way of management in the future.

Effect of short-term folate and vitamin B supplementation on blood homocysteine level and carotid artery wall thickness in chronic hemodialysis patients.

OBJECTIVE: Hyperhomocysteinemia is an independent risk factor for atherosclerotic vascular disease in chronic hemodialysis patients. This stratified randomized controlled trial was designed to measure the effect of high dose oral vitamin B6, vitamin B12, and folic acid on homocysteine levels, and to evaluate the effect on atherosclerosis as measured by Intima-Media Thickness (IMT) of carotid arteries. MATERIAL AND METHOD: Fifty-four chronic hemodialysis patients with hyperhomocysteinemia were randomized to receive oral 15 mg folic acid, 50 mg vitamin B6, and 1 mg vitamin B12 daily (treatment group) or oral 5 mg folic acid alone (control group) for 6 months. Homocysteine level and IMT were measured in both groups. RESULTS: At 6 months, homocysteine levels in the treatment group were significantly reduced from 27.94 +/- 8.54 to 22.71 +/- 3.68 mmol/l (p = 0.009) and were not significantly increased from 26.81 +/- 7.10 to 30.82 +/- 8.76 mmol/l in control group (p = 0.08). Mean difference between both groups was statistically significant (p = 0.002). There was no significant difference of IMT of carotid arteries, however, a tendency that the treatment group would have less thickness was observed (0.69 +/- 0.29 mm and 0.62 +/- 0.16 mm, p = 0.99). CONCLUSION: Treatment of hyperhomocysteinemia in chronic hemodialysis patients with daily oral 15 mg folic acid, 50 mg vitamin B6, and 1 mg vitamin B12 for 6 months decreases homocysteine levels and tends to reduce IMT of carotid arteries. A long term study for the prevention of atherosclerosis is warranted.

Relationship between hyperhomocysteinemia and atherosclerosis in chronic hemodialysis patients.

BACKGROUND: Hyperhomocysteinemia is an independent risk factor of coronary artery heart disease (CAHD) and atherosclerosis in a normal population. However, it is still controversial in end-stage kidney disease patients who underwent long-term dialysis. Carotid intima-media thickness (IMT) is the standard non-invasive measurement of atherosclerosis. The aims of the present study were to determine the homocysteine (Hcy) level, and to evaluate its role as a risk factor of atherosclerosis in hemodialysis (HD) patients. MATERIAL AND METHOD: Clinical data and blood chemistries were assayed in 62 HD patients. Atherosclerosis was defined by clinical presentations of CAHD, cerebrovascular or peripheral vascular diseases, or carotid plaque by ultrasound. IMT was also measured by ultrasound RESULTS: Plasma Hcy level in HD patients was significantly higher in HD patients than normal controls (28.3 +/- 8.3 vs 9.7 +/- 2.9 micromol/l, p < 0.001). Older age (p < 0.001), male sex (p = 0.05), longer duration of HD (p = 0.05), and higher plasma Hcy level (p = 0.01) correlated with atherosclerosis by univariate analysis, but plasma Hcy did not show significant correlation by multivariable analysis. There was also correlation between IMT and atherosclerosis in HD patients (p < 0.001) but no correlation was observed between plasma Hcy level and lMT. CONCLUSION: Hyperhomocysteinemia is not an independent factor in the genesis of atherosclerosis in HD patients. Advanced age plays a major role of hyperhomocysteinemia and IMT is a useful marker of atherosclerosis in these patients.

Prednisone metabolism in recipients of kidney or liver transplants and in lung recipients receiving ketoconazole.

BACKGROUND: Actual prednisone exposure in low-dose prednisone regimens, in part determined by cytochrome P450 metabolism, has been shown to be important for allograft survival. METHODS: Prednisolone (the principal active metabolite of prednisone) metabolism was determined in eight nontransplant patients and in transplant recipients receiving oral prednisone maintenance therapy (20 kidney and 6 liver recipients receiving cyclosporine [CsA] and eight lung recipients receiving ketoconazole and CsA or tacrolimus [FK506]). RESULTS: Prednisolone area under the curve (AUC)-dose-normalized (PNAUCn) to 1 mg/kg was 8,288+/-1,513 ng.hr/mL in kidney recipients, versus 4,826+/-999 ng/mL per hr in healthy subjects (P<0.001); it was also increased in liver recipients versus healthy subjects (11,456+/-1,214 ng.hr/mL, P<0.001). Liver recipients also metabolized prednisolone more slowly than kidney recipients (P<0.001). PNAUCn in lung recipients was similar in kidney recipients despite the effect of ketoconazole to slow CsA metabolism. In kidney transplant recipients, the rate of CsA metabolism was correlated with the rate of prednisolone metabolism (r=0.54, P=.026). Basal cortisol levels in all transplant recipients were lower than in healthy subjects, suggesting more prednisolone exposure in transplant patients. CONCLUSIONS: Prednisolone metabolism is slower in solid-organ transplant recipients than in healthy subjects. The slower metabolism of prednisolone, particularly in liver recipients, may help explain the immunologic effectiveness of low-dose prednisone regimens in these patients.

Proteinuria in "normal" cadaver kidney donors.

BACKGROUND: More information is needed about cadaver organ donor pathophysiology. METHODS: We quantitated preprocurement, timed urine protein excretion in 23 "normal" cadaver kidney donors, and correlated results with urine protein dipstick readings and multiple other parameters. We also attempted to measure microalbuminia in 10 subjects. RESULTS: Seventeen of 23 cadaver donors did not have detectable proteinuria (albuminuria) by urine dipstick testing but had 1,704+/-2,900 mg (mean+/-SD) of quantitated daily urine protein, which did not correlate with creatinine clearance or urine volume. Donors with head trauma had numerically more quantitated proteinuria (3,000+/-5,160 vs. 970+/-670 mg/day, P=0.13). Microalbumin varied from 3 to 34% of the total urine protein concentration. CONCLUSIONS: Significant proteinuria as measured by quantitative collection techniques is often present in excellent cadaver kidney donors and is not detected by dipstick testing. It may be a marker of important terminal pathophysiologic events and deserves further study.