Subdural hematoma in diabetic patients.

BACKGROUND AND PURPOSE: Subdural hematoma (SDH) is associated with a high mortality rate. However, the risk of SDH in diabetic patients has not been well studied. The aim of the study was to examine the risk of SDH in incident diabetic patients. METHODS: From a universal insurance claims database of Taiwan, a cohort of 28,045 incident diabetic patients from 2000 to 2005 and a control cohort of 56,090 subjects without diabetes were identified. The incidence and hazard ratio of SDH were measured by the end of 2010. RESULTS: The mean follow-up years were 7.24 years in the diabetes cohort and 7.44 years in the non-diabetes cohort. The incidence of SDH was 1.57-fold higher in the diabetes cohort than in the non-diabetes cohort (2.04 vs. 1.30 per 1000 person-years), with an adjusted hazard ratio of 1.63 [95% confidence interval (CI) 1.43-1.85]. The stratified data showed that adjusted hazard ratios were 1.51 (95% CI 1.28-1.77) for traumatic SDH and 1.89 (95% CI 1.52-2.36) for non-traumatic SDH. The 30-day mortality rate for those who developed SDH in the diabetes cohort was 8.94%. CONCLUSIONS: This study demonstrates that incident diabetic patients are at higher risk of SDH than individuals without diabetes. Proper intervention for diabetic patients is necessary for preventing the devastating disorder.

Subdural hematoma in patients with end-stage renal disease receiving hemodialysis.

BACKGROUND AND PURPOSE: Hemodialysis (HD) may increase the risk of acute subdural hematoma (SDH) with high fatality, but the extent of this disease in non-western populations is unclear. The incidence of and fatality from SDH in patients with end-stage renal disease (ESRD) on HD were examined for an Asian population. METHODS: A cohort of 4709 newly diagnosed ESRD patients on HD from 1998 to 2010 and a control cohort of 18 663 subjects without any kidney disease were identified from a universal insurance claims database in Taiwan. The incidence and hazard of SDH for the two cohorts and 30-day mortality from SDH were measured by the end of 2010. RESULTS: The incidence of SDH was 4.47-fold higher in the HD cohort than in the control cohort (56.3 vs. 12.6 per 10 000 person-years) with an adjusted hazard ratio (HR) of 3.81 (95% CI 2.77-5.25). HD patients with SDH had a high odds of 30-day mortality with an adjusted odds ratio of 6.34 (95% CI 2.37-16.9). CONCLUSIONS: ESRD patients with HD were demonstrated to be at high risk of subsequent SDH and to have a high mortality risk from SDH. Proper care for HD patients is necessary to prevent the devastating disorder.

Hepatocellular carcinoma in kidney transplant recipients.

OBJECTIVE: A kidney transplant is a suitable surgical management for end-stage renal disease patients; however, posttransplantation malignancy is an unwanted outcome. In Taiwan, hepatocellular carcinoma (HCC) is a major malignancy not only among the general population but also in the post-kidney transplant group. Therefore, regular imaging studies for posttransplantation follow-up are necessary. We examined the imaging characteristics and the efficacy of radiologic diagnostic criteria and the American Joint Committee on Cancer (AJCC) staging system in post-kidney transplantation HCC. PATIENTS AND METHODS: We retrospectively reviewed 15 patients with post-transplantation HCC among 554 hospital-based kidney transplant recipients. From 1988 to 2008 we analyzed the patient profiles, imaging studies, histopathologic diagnosis, treatment methods, and outcomes. The 6th-edition AJCC radiologic staging system was applied for validation in this study. RESULTS: Using the AJCC staging system, all 15 patients with histopathologically confirmed HCC were enrolled as stage I (n=7), stage II (n=2), stage IIIA (n=5), or stage IV (n=1) cases. The 5-year survival rates were 71.4% in stage I, 50% in stage II, 20% in stage IIIA, and 0% in stage IV. Over one-half of post-kidney transplantation HCC were sized 2.5-6.0 cm in diameter with mixed echogenicity. The positive diagnostic rate for radiologic criteria was 83.3%. CONCLUSIONS: The AJCC staging system and the radiologic diagnostic criteria were validated in post-kidney transplantation HCC. Surgical resection and transcatheter arterial embolization for early-stage HCC in kidney transplant recipients showed satisfactory outcomes. A noncirrhotic liver in a kidney transplant recipient makes surgical resection the treatment of choice because of the better prognosis.

Plasma exchange therapy for thrombotic thrombocytopenic purpura in pediatric patients with liver transplantation.

PURPOSE: Sporadic cases of thrombotic thrombocytopenic purpura (TTP) have been reported in bone marrow and solid organ transplant patients receiving cyclosporine (CsA). We reported our experience with TTP using plasma exchange (PE) therapy in patients with liver transplantation (OLT). METHODS: Between March, 1993, and May, 2007, 400 patients underwent OLT, including 146 pediatric living-donor liver transplantation (LDLT). Four pediatric patients developed TTP after OLT: three were males and one female of mean age at the time of transplantation of 7.8 +/- 3.6 years. The four recipients had the following indications for OLT: two glycogen storage disease, one biliary atresia, and one fulminant hepatic failure. Four patients initially received triple drug immunosuppression consisting of CsA, azathioprine, and steroids. RESULTS: Four (1%) patients developed TTP after OLT. All four patients were pediatric in the age group. The mean age at the time of TTP diagnosis was 8.0 +/- 3.2 years, with a mean postoperative interval to TTP of 78.8 +/- 114.2 days. The mean baseline platelet count was 7.0 +/- 7.1 x 10,000. The eventual platelet count was 21.1 +/- 20.8 x 10,000 after PE. These patients received PE 6.0 +/- 4.2. The mean baseline serum creatinine was 0.8 +/- 0.8 mg/dL. The mean peak serum creatinine was 2.3 +/- 2.3 mg/dL. The mean serum CsA level was 717.5 +/- 106.0 ng/mL before TTP diagnosis. Four patients were diagnosed by blood peripheral smears. The causes of TTP were CsA-associated in three patients and venoocclusive disease (VOD) in one patient. Three patients improved their platelet counts after PE therapy. Two patient changed from CsA to FK 506, one underwent reduced CsA dosage, and one stopped CsA. Three patients died of recurrent VOD, infection, and intrapulmonary hemorrhage. Only one patient survived. CONCLUSIONS: The incidence of TTP in our series was lower. It only developed in pediatric patients. The causes of TTP were associated with CsA and/or VOD. The mortality was high after the TTP diagnosis. We concluded that TTP was a potentially fatal condition, but an early diagnosis with prompt institution of therapy with invasive PE therapy may reduce its mortal consequences.

Incidence and risk factors of new-onset diabetes mellitus after renal transplantation.

PURPOSE: New-onset diabetes mellitus (PTDM), a major metabolic complication after renal transplantation, examined for incidence and risk factors. METHODS: The records of 358 renal transplant recipients with functioning grafts, from 1986 to 2006, were categorized into two groups according to the usage of tacrolimus (FK): FK-based (n = 120 patients) and non-FK-based (n = 238). Using Kaplan-Meier survival analysis and a Cox regression model, this study analyzed the cumulative incidence of PTDM and risk factors, including gender, age, and presence of hepatitis. RESULTS: Cumulative incidences of PTDM after 1, 3, and 5 years posttransplantation in the FK-based group were 11%, 18%, and 22%, respectively. In the non-FK-based group, the cumulative incidences were 5%, 9%, and 12% (P = .01). Taking into account the risk factors, the cumulative incidence of PTDM was significant among patients 51 years or older (odds ratio, 3.965; P = .005), but not with regard to gender or presence of hepatitis B and/or C. Overall cumulative incidence of PTDM in our series was 15% (54/358), including 44% (24/54) of cases that occurred within 1 year after renal transplantation. CONCLUSION: FK is more diabetogenic than cyclosporine or sirolimus. Older age (> or =51 years) is a significant risk factor, in contrast to hepatitis and gender. About half of these cases of PTDM occurred within 1 year after transplantation. These results suggest that aggressive monitoring of blood sugar is necessary for early detection of PTDM.

Successful outpatient treatment of renal vein thrombosis by low-molecular weight heparins in 3 patients with nephrotic syndrome.

Renal vein thrombosis (RV Thromb) is a serious complication ofnephrotic syndrome. Anticoagulation is usually recommended as the treatment of choice. This study reports 3 nephrotic patients diagnosed to have RVThromb combined with thromboembolic events. Low-molecular weight heparin (LMWHep) was given subcutaneously every 12 hours following the diagnosis of RVTromb, which continued at the outpatient clinic after an average of 11 in-hospital days. The patients visited the nephrology outpatient clinic every other week and underwent magnetic resonance image (MRI) studies at 6-week intervals for follow-up of patency of the involved renal vein. LMWHep was discontinued when MRI showed this patency. The average outpatient treatment period was 74 days. There was no recurrent RVThromb in the follow-up course of 6 months after discontinuation of LMWHep. Kidney function was preserved, as indicated by image studies and serial renal function tests. LMWHep produced a more predictable anti-coagulant effect, a superior bioavailability, a longer half-life and a dose-independent effect than unfractionated heparin and coumadin. These benefits made the outpatient treatment of RVThromb possible. Our report recommends outpatient treatment of RVThromb by LMWHep because it is feasible, effective and safe.

Anticardiolipin antibodies and vascular access thrombosis in Taiwanese haemodialysis patients with chronic hepatitis C: a retrospective study.

Hepatitis C virus causes various extrahepatic immunologic abnormalities. Vascular access thrombosis (VAT) is a major cause of morbidity in chronic haemodialysis (HD) patients. Immunoglobulin-G anticardiolipin antibody (IgG-ACA) is strongly associated with venous and arterial thrombosis in patients with normal renal function. Previous investigations have reported the association of raised IgG-ACA titre recurrent with VAT in HD patient, and also few equivalent studies were reported the same in Taiwan. This study attempted to determine whether raised IgG-ACA titres are associated with increased risk of recurrent VAT in HD patients with chronic hepatitis C. This study enrolled 98 chronic hepatitis C patients undergoing HD. IgG-ACA titre and hepatitis C marker were measured for all subjects. Raised IgG-ACA titres were present in 29.6% (29/98) of patients. In both groups (raised and normal IgG-ACA), the type of shunt did not differ (p = 0.416). There was strong association between raised IgG-ACA titre and recurrent VAT (p = 0.0004). In predicting for more or one episodes of VAT using multiple logistic regression, synthetic graft (p < 0.0001), raised IgG-ACA titre (p = 0.039), presence of hepatitis B (p = 0.004) and haemodialysis duration (p = 0.039) were significant factors. The prevalence of raised IgG-ACA titres was 39.6% among chronic hepatitis C with HD patients. There was strong association between raised IgG-ACA titre and recurrent VAT, and this finding may be the consequence of pathogenetic role of raised IgG-ACA titres on the development of VAT status in HD patients with chronic hepatitis C.

Hyperhomocysteinaemia and vascular access thrombosis among chronic hemodialysis patients in Taiwan: a retrospective study.

Vascular access thrombosis (VAT) is an important cause of morbidity for chronic haemodialysis (HD) patients. Some risk factors for VAT have been well-defined for chronic HD patients from western countries. However, only a few such factors have been confirmed for Taiwanese patients. This study attempted to determine the association between hyperhomocysteinaemia and the incidence of VAT for chronic HD patients in Taiwan. We retrospectively enrolled a total of 196 patients into this study during 2003. The patients were separated into VAT (n = 142) and control (n = 54) group. The participants of the VAT group were identified as those having one or more VAT, and the participants of the control group were those with no VAT in the past. The mean follow-up period was 48 months. The mean serum homocysteine levels were 29.5 +/- 9.6 and 29.1 +/- 9.5 micromol/l for the VAT (n = 142) and the control (n = 54) group, respectively. There was no significant difference in the level of homocysteine between the VAT and the control group (p = 0.70). Female chronic HD patients had significantly greater mean total homocysteine levels than male (30.89 micromol/l, 95% CI 28.84-32.94 vs. 28.06 micromol/l, 95% CI 26.32-29.82, respectively, p = 0.038). That synthetic graft was a significant risk factor for VAT was determined using multivariate logistic regression analysis. There was no association between serum total homocysteine levels and the incidence of VAT in chronic HD patients in Taiwan.

Extraintestinal manifestations of Edwardsiella tarda infection.

Summary Edwardsiella tarda, a member of the family Enterobacteriaceae, is a rare human pathogen. Gastroenteritis is the most frequently reported manifestation of E. tarda infection. In contrast, extraintestinal infection with E. tarda has rarely been reported. This study made a retrospective case and microbiological data review of patients with extraintestinal E. tarda infections to further understand this disease. This study retrospectively reviewed the charts of all isolates of E. tarda cultures from clinical specimens other than faeces at Chang Gung Memorial Hospital, Taoyuan, Taiwan from October 1998 through December 2001. Edwardsiella tarda was isolated from 22 clinical specimens from 22 hospitalised patients (13 females and nine males). The extraintestinal manifestations of E. tarda infection included biliary tract infection, bacteraemia, skin and soft tissue infection, liver abscess, peritonitis, intra-abdominal abscess, and tubo-ovarian abscess. The major underlying diseases predisposing to E. tarda extraintestinal infection were hepatobiliary diseases, malignancy and diabetes mellitus. The overall mortality rate of E. tarda extraintestinal infection in the present series was 22.7% (5/22), and four (40%) of 10 patients with bacteraemia expired. Although rare, human E. tarda extraintestinal infections can have diverse clinical manifestations and moreover may cause severe and life-threatening infections. Consequently, E. tarda should be considered a potentially important pathogen.

Anticardiolipin antibody and Taiwanese chronic haemodialysis patients with recurrent vascular access thrombosis.

Vascular access failure is a major cause of morbidity in chronic haemodialysis (HD) patients. However, some factors (such as homocysteine levels) are known regarding the risk factors predisposing certain HD patients to vascular access thrombosis (VAT). Immunoglobulin-G anticardiolipin antibody (IgG-ACA) is strongly associated with venous and arterial thrombosis in patients with normal renal function. Previous investigations have reported the characteristics of patients with raised IgG-ACA titre and recurrent VAT of HD in Western countries, but few equivalent studies exist for Taiwan. This retrospective study attempts to determine whether raised IgG-ACA titres are associated with an increased risk of recurrent VAT in chronic HD patients. This study enrolled 483 patients undergoing HD. IgG-ACA titre and hepatitis B&C marker were measured for all patients. A history of recurrent (VAT more than one) and/or VAT was elicited by using information from the patient questionnaires and was verified by means of careful inpatient and outpatient chart review. Raised IgG-ACA titres were present in 21.7% (105/483) of patients. In both groups (raised IgG-ACA and normal IgG-ACA), the type of shunt differed significantly (p = 0.029). In predicting for more or one episodes of VAT by using multiple logistic regression with all significant factors, synthetic graft was also a significant factor (p < 0.0001). The 105 raised IgG-ACA titres and 378 normal IgG-ACA titres were associated between chronic HD patients and recurrent VAT (p = 0.034). In predicting for more or one episode of VAT by using multiple logistic regression with all significant factors, raised IgG-ACA titre was a non-significant factor (p = 0.336). The presence of hepatitis C had a higher percentage in group with raised IgG-ACA titres of HD patients (p = 0.042). In predicting for more or one episode of VAT by using multiple logistic regression with all significant factors, the presence of hepatitis C was also a significant factor (p = 0.022). In conclusion, the prevalence of raised IgG-ACA titres was 21.7% among HD patients. There was a weak association between raised IgG-ACA titre and recurrent VAT and this finding may be the consequence of pathogenetic role of raised IgG-ACA titres in the development of VAT status for chronic HD patients. The presence of hepatitis C was a cofactor.

Tuberculous peritonitis in a haemodialysis patient with elevated serum CA 125 and hypercalcaemia.

CA 125, a glycoprotein derived from coelomic epithelium, is used primarily as a marker of epithelial ovarian cancer. However, elevated levels of serum CA 125 have also been detected in other benign and malignant disorders. This study describes a haemodialysis patient who contracted tuberculous peritonitis associated with hypercalcaemia, erythropoietin-resistant anaemia and elevated CA 125, which normalised gradually following antituberculosis treatment. Tuberculous peritonitis should be considered in the differential diagnosis of ascites with elevated serum CA 125. Additionally, CA 125 is a useful marker for monitoring response to tuberculous peritonitis treatment.

Low-molecular-weight heparin successfully treating a nephrotic patient complicated by renal and ovarian vein thrombosis and pulmonary embolism.

Thromboembolic complications, frequently associated with idiopathic membranous glomerulonephritis, are frequent and serious problems associated with nephrotic syndrome. However, ovarian vein thrombosis associated with nephrotic syndrome has never been reported. This study describes the case of a 35-year-old woman with idiopathic membranous glomerulonephritis who developed left renal vein thrombosis with ovarian vein thrombosis and pulmonary embolism. The thromboembolic complications were successfully treated with low-molecular-weight heparin. Low-molecular-weight heparin thus appears safe and effective for treating thromboembolism in nephrotic patients.

Acute renal failure after cadaveric related liver transplantation.

Acute renal failure (ARF) is a frequent medical complication after liver transplantation (LT). We analyzed cadaveric related liver transplant recipients who had developed ARF early in the postoperative course. Between January 1982 and August 2003, a total of 67 patients underwent cadaveric related LT. Their mean age was 28.64 years at LT. The 67 recipients had the following indications: biliary atresia (n = 17), Wilson's disease (n = 15), hepatitis B-related liver cirrhosis (n = 14), hepatitis C-related liver cirrhosis (n = 4), primary biliary cirrhosis (n = 4), hepatitis B-related liver cirrhosis with hepatoma (n = 3), hepatitis C-related liver cirrhosis with hepatoma (n = 2), Budd-Chiari syndrome (n = 2), neonatal hepatitis (n = 1), choledochus cyst (n = 1), autoimmune cirrhosis (n = 1), neuroendocrine tumor (n = 1), and hemangioendothelioma (n = 1). Forty-nine patients received cyclosporine (CsA), azathioprine, and steroids and 18, a combination with tacrolimus (FK506). Eight (11.94%) patients developed ARF at a mean time of 17.25 days after LT. The mean peak serum creatinine was 2.24 mg%. Four of these patients had a diagnosis of hepatitis B-related liver cirrhosis; two, hepatitis C-related liver cirrhosis; one, primary biliary cirrhosis; and one, hepatitis B-related liver cirrhosis with hepatoma. The ARF etiology was multifactorial for the majority of patients. Eight ARF patients had a history of liver cirrhosis, which may be a risk factor for intraoperative ARF. ARF treatment included fluid replacement, decreased or altered immunosuppressive agents, avoiding exposure to nephrotoxic drugs, and adjusting antibiotic dosages. The majority of patients returned to normal renal function at 1 to 3 weeks after the diagnosis of ARF. No patient required dialysis and/or experienced a mortality. We conclude that the incidence of ARF is relatively low and with good outcomes. ARF etiology was multifactorial for the majority of patients, but eight patients had a history of liver cirrhosis, which may be a risk factor for intraoperative ARF. We suggest that in the early postoperative period of LT cases diagnosis and treatment of ARF are important.

Early postoperative complications in recipients of living donor liver transplantation.

PURPOSE: Complications are common in the early postoperative period after living donor liver transplantation (LDLT). The aims of this analysis were to describe and identify risk factors for early postoperative complications. METHODS: Between June 1994 and June 2003, 140 consecutive LDLT patients were divided into 3 groups: group I was small infants <9 kg (n = 30); group II, pediatric patients (n = 63); and group III, adult patients (n = 47). The complications within 3 months after operation were analyzed. RESULTS: The mortality rate was 1.4%. Surgical complications requiring relaparotomy occurred in 7.9% of patients. Intraoperative portal vein thrombosis requiring immediate thrombectomy, which occurred in 10 patients, was significantly more frequent in the small infant group (23.1% vs 3.2% vs 2.1%; P < .01). Acute hepatic artery thrombosis that occurred in 2 patients was remedied successfully using operative rearterilization. Hepatic outflow obstruction requiring radiological interventions developed in 5 subjects. Medical complications included the following: pulmonary (14.3%), renal (19.3%), bacteremia (10.7%), cytomegalovirus infection (9.3%), and drain-related infections (20.7%). The incidence of hospital-acquired renal insufficiency was significantly higher in adult patients (3.3% vs 14.3% vs 36.2%; P < .01). There was no significant difference in the incidence of acute cellular rejection between members of the 3 groups (10.0% vs 17.5% vs 17%; P = .63). CONCLUSIONS: Sophisticated postoperative care with multiple disciplinary involvements may achieve a low early mortality rate in LDLT. Small infants weighing <9 kg may carry a greater risk of intraoperative portal vein thrombosis. Pulmonary complications and renal function impairments were the most troublesome in pediatric and adult recipients, respectively.

Minimal change nephrotic syndrome associated with malignant thymoma: case report and literature review.

We report on a patient with nephrotic syndrome with myasthenia gravis and malignant thymoma status post thymectomy and radiotherapy. This 44-year-old woman underwent a thymectomy and localized radiotherapy for invasive thymoma in 1991. She also took azathioprine and pyridostigmine regularly for the control of her symptoms of myasthenia gravis following thymectomy. Neither evidence of recurrence of myasthenia gravis, nor enlargement of residual thymoma was noted following treatment in 1991. Unfortunately, this patient developed a pronounced nephrotic syndrome in 1999, a renal biopsy revealing a minimal-change glomerulonephritis as being present. The patient entered remission subsequent to steroid and cyclosporin therapy, whereas many previously-reported cases of a similar nature either died or remained with a persistent proteinuria. Herein, we review the literature pertaining to examples of nephrotic syndrome for those patients diagnosed with malignant thymoma, and discuss the possible mechanisms for this association, and emphasize the need for the aggressive treatment of the condition, recommending the early use of steroids and cyclosporins.

Acute renal failure caused by rifampicin re-exposure with 10-year of interval.

A 53-year-old woman was treated for recurrent pulmonary tuberculosis with reintroduction of rifampicin after a medication-free interval of 10 years. After taking the first dose, she developed severe hemolytic anemia and oliguric acute renal failure and required temporary hemodialysis. The fulminant clinical course was compatible with rifampicin-induced acute renal failure. The renal function of this patient completely recovered after discontinuation of rifampicin and temporary hemodialysis. Since renal biopsy and anti-rifampicin antibodies cannot offer a definite diagnosis of rifampicin-induced acute renal failure, we must emphasize the importance of a clinical diagnosis of rifampicin-induced acute renal failure and complete history taking. Re-exposure is a critical factor. In this case, the rifampicin-free interval was as long as 10 years. Because of the feasible prognosis, reintroduction of rifampicin for recurrent pulmonary tuberculosis should not be abandoned, but the infrequent and life-threatening side effects should be kept in mind.

Ischemic bowel disease in chronic dialysis patients.

BACKGROUND: Ischemic bowel disease, especially acute mesenteric ischemia, carries high morbidity and mortality rates. Any delay in diagnosis or treatment aggravates the patient's outcome. Owing to the scarcity of reports concerning ischemic bowel disease in chronic dialysis patients, we investigated the ischemic bowel disease in chronic dialysis patients. METHODS: From January 1986 through April 1997, medical records of 2416 chronic dialysis patients at our hospital were reviewed. Among them, 5 patients with surgically documented ischemic bowel disease were enrolled. The clinical manifestations, laboratory findings, operative findings, pathologic test results and prognoses of these patients are reported. RESULTS: Abdominal pain, abdominal distension and bloody stool were major initial presentations. The mean age of the patients was 62.4 years at the time of diagnosis of ischemia. All patients had hypertension, 3 patients had hyperlipidemia, three patients had diabetes mellitus and three patients had history of shunt occlusion. Four patients had leukocytosis. Image studies revealed dilatation of bowel loops in four patients. Peritonitis made exploratory laparotomy necessary. The findings during operation showed turbid ascites and variable degrees of bowel ischemia or gangrene. The methods of surgical intervention depended on the severity of the disease. Only one patient died due to extensive ischemic bowel involvement and subsequent sepsis. CONCLUSION: It is mandatory to have an index suggestive of ischemic bowel disease in chronic dialysis patients with unexplained abdominal pain or discomfort. Early diagnosis and aggressive surgical intervention is the cure modality for patients with acute ischemic bowel disease.