Everolimus-facilitated calcineurin inhibitor reduction in Asian de novo kidney transplant recipients: 2-year results from the subgroup analysis of the TRANSFORM study.

OBJECTIVE: We analyzed the efficacy and safety of an everolimus with reduced-exposure calcineurin inhibitor (EVR+rCNI) versus mycophenolic acid with standard-exposure CNI (MPA+sCNI) regimen in Asian patients from the TRANSFORM study. METHODS: In this 24-month, open-label study, de novo kidney transplant recipients (KTxRs) were randomized (1:1) to receive EVR+rCNI or MPA+sCNI, along with induction therapy and corticosteroids. RESULTS: Of the 2037 patients randomized in the TRANSFORM study, 293 were Asian (EVR+rCNI, N = 136; MPA+sCNI, N = 157). At month 24, EVR+rCNI was noninferior to MPA+sCNI for the binary endpoint of estimated glomerular filtration rate (eGFR) < 50 ml/min/1.73 m2 or treated biopsy-proven acute rejection (27.0% vs. 29.2%, P = .011 for a noninferiority margin of 10%). Graft loss and death were reported for one patient each in both arms. Mean eGFR was higher in EVR+rCNI versus MPA+sCNI (72.2 vs. 66.3 ml/min/1.73 m2 , P = .0414) even after adjusting for donor type and donor age (64.3 vs. 59.3 ml/min/1.73 m2 , P = .0582). Overall incidence of adverse events was comparable. BK virus (4.4% vs. 12.1%) and cytomegalovirus (4.4% vs. 13.4%) infections were significantly lower in the EVR+rCNI arm. CONCLUSION: This subgroup analysis in Asian de novo KTxRs demonstrated that the EVR+rCNI versus MPA+sCNI regimen provides comparable antirejection efficacy, better renal function, and reduced viral infections (NCT01950819).

Association between serum uric acid and chronic kidney disease in patients with hypertension: A multicenter nationwide cross-sectional study.

INTRODUCTION: Current data on the role of hyperuricemia as a risk factor for renal progression in patients with hypertension is inconclusive. This study aimed to assess the association of uric acid and chronic kidney disease (CKD) in hypertensive patients using a nationwide patient sample. METHODS: We conducted a nationwide cross-sectional study based on the DM/HT study of the Medical Research Network of the Consortium of Thai Medical Schools. This study evaluated adult patients with hypertension from 831 Thailand public hospitals in the year 2014. Serum uric acid (SUA) was categorized into quintiles (≤4.5, 4.6 to 5.4, 5.5 to 6.2, 6.3 to 7.4, ≥7.5 mg/dL). CKD was defined as estimated glomerular filtration rate of ≤ 60 mL/min/1.73 m2 . Multivariate logistic regression was performed to assess the association between SUA and CKD using uric acid of ≤4.5 mg/dL as the reference group. RESULTS: A total of 9776 hypertensive patients with available SUA were included in the analysis. The mean SUA was 6.1±1.8 mg/dL. The prevalence of CKD in hypertensive patients was 31.8%. SUA of 4.6 to 5.4, 5.5 to 6.2, 6.3 to 7.4, and ≥7.5 mg/dL were associated with an increased CKD with ORs of 1.57 (95% CI 1.28 to 1.92), 2.15 (95% CI 1.74 to 2.66), 3.31 (95% CI 2.72 to 4.04), and 7.11 (95% CI 5.76 to 8.78), respectively. The restricted cubic spline showed significant increased CKD prevalence when uric acid ≥4.6 mg/dL. CONCLUSION: Higher SUA was associated with increased CKD prevalence in patients with hypertension. SUA should be monitored in hypertensive patients for CKD prevention.

Associations of renal function with diabetic retinopathy and visual impairment in type 2 diabetes: A multicenter nationwide cross-sectional study.

BACKGROUND: Diabetic retinopathy (DR) separately has been noted as a major public health problem worldwide as well. Currently, many studies have demonstrated an association between diabetic nephropathy and DR in type 1 diabetes mellitus (T1DM) patients, but this association is less strong in T2DM. The evidence for an association between renal function and DR and visual impairment among T2DM patients is limited, particularly in the Asian population. AIM: To assess the association between glomerular filtration rate (GFR) and DR, severe DR, and severe visual impairment among T2DM patients in Thailand. METHODS: We conducted a nationwide cross-sectional study based on the DM/HT study of the Medical Research Network of the Consortium of Thai Medical Schools. This study evaluated adult T2DM patients from 831 public hospitals in Thailand in the year 2013. GFR was categorized into ≥ 90, 60-89, 30-59 and < 30 mL/min/1.73 m2. The association between GFR and DR, severe DR, and severe visual impairment were assessed using multivariate logistic regression. RESULTS: A total of 13192 T2DM patients with available GFR were included in the analysis. The mean GFR was 66.9 ± 25.8 mL/min/1.73 m2. The prevalence of DR, proliferative DR, diabetic macular edema, and severe visual impairment were 12.4%, 1.8%, 0.2%, and 2.1%, respectively. Patients with GFR of 60-89, 30-59 and < 30 mL/min/1.73 m2 were significantly associated with increased DR and severe DR when compared with patients with GFR of ≥ 90 mL/min/1.73 m2. In addition, increased severe visual impairment was associated with GFR 30-59 and < 30 mL/min/1.73 m2. CONCLUSION: Decreased GFR was independently associated with increased DR, severe DR, and severe visual impairment. GFR should be monitored in diabetic patients for DR awareness and prevention.

Beta Cell Function and Insulin Resistance After Conversion from Tacrolimus Twice-Daily to Extended-Release Tacrolimus Once-Daily in Stable Renal Transplant Recipients.

BACKGROUND Post-transplantation diabetes mellitus is a major metabolic adverse effect of tacrolimus (TAC). The objective of this study was to determine if the conversion from tacrolimus twice-daily (TAC-BID) to extended-release tacrolimus once-daily (TAC-OD) in stable renal transplant recipients had any effect on beta cell function (HOMA-b), insulin resistance (HOMA-IR), patient preference, and expense. MATERIAL AND METHODS Twenty-eight renal transplant recipients were recruited and converted from TAC-BID to TAC-OD at the same dose. Primary outcomes were beta cell function and insulin resistance in stable renal transplant recipients at 4, 8, and 16 weeks after conversion. Secondary outcomes were patient satisfaction and expense of medication. RESULTS No significant change in the HOMA-ß and HOMA-IR was found in any of the 28 renal transplant recipients. However, HOMA-ß increased from 60 (37.33, 109.71) to 78.5 (44.3, 108.4) (p=0.02) in 15 patients who had the conversion within 4 years after renal transplantation. In multivariate regression analysis, the conversion from TAC-BID to TAC-OD significantly increased HOMA-b at 4 months at 1.21 mIU/mmol (95%CI 0.54-1.88 mIU/mmol, p=0.01) in this subgroup. The renal transplant recipients reported the conversion was more satisfactory and cost of treatment was comparable. CONCLUSIONS In short-term follow-up, conversion from TAC-BID to TAC-OD is safe in stable renal transplant recipients and might be beneficial in term of improved beta cell function in the early years after renal transplantation. The conversion caused comparable cost and was preferred by renal transplant recipients.

The Development of Sleep Questionnaires Thai Version (ESS, SA-SDQ, and PSQI): Linguistic Validation, Reliability Analysis and Cut-Off Level to Determine Sleep Related Problems in Thai Population.

Background: The Epworth Sleepiness Scale (ESS), Sleep Apnea Scale of Sleep Disorders Questionnaire (SA-SDQ), and Pittsburgh Sleep Quality Index (PSQI) are widely used in English speaking countries for sleep problem screening. However, there is no officially validated Thai-version of sleep questionnaires available. Objective: To provide standard Thai version of three sleep questionnaires and find cut-off level to screening sleep problems in Thai population. Material and Method: We used Mapi Research Institute Methods for translation from original language to Thai questionnaire. Then, test-retest reliability analysis was performed. Finally, we collected data from patients who underwent polysomnography in Phramongkutklao Sleep Lab Centre between June and August 2011. Cut-off value to screen population at risk for sleep-related disorder was researched. Results: The questionnaires were translated with very good inter-rater agreement. Cut-off of ESS, SA-SDQ, and PSQI suggested sleep disorders would be 9, 27, and 6.5 respectively. Conclusion: Sleep disorder questionnaires including ESS, SA-SDQ, and PSQI were translated into Thai with high validity, reliability, and accuracy.

Metabolic Syndrome in Thai Renal Transplant Recipients: A Multicenter Study.

BACKGROUND Many renal transplant recipients develop complications such as obesity, posttransplantation diabetes mellitus, and dyslipidemia. There have been few studies of metabolic syndrome (MS) in Asian renal transplant recipients. MATERIAL AND METHODS This cross-sectional study was performed in 303 patients in 5 transplant centers in Bangkok, Thailand. The diagnosis of MS was based on the criteria of the modified NCEP-ATPIII, and chronic allograft dysfunction was defined as estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m^2. RESULTS Of 303 recipients, MS was diagnosed in 94 cases (31.0%) and the prevalence of MS in the first 3 years and after 3 years posttransplantation were 21.4% and 34.7% (P=0.042), respectively. There was an association between advanced age and chronic allograft dysfunction and higher prevalence of MS. Regarding non-anti-hypertensive and non-hypoglycemic medications, m-TOR inhibitor (odds ratio [OR], 2.14; 95% CI, 1.02-4.5) was associated with the prevalence of MS. Multivariate analysis revealed MS was associated with the use of beta-blockers (OR, 3.17; 95% CI, 1.88-5.32). Patients with no MS components had 26.9% prevalence of chronic allograft dysfunction and patients with higher numbers of MS components had 87.5% prevalence of chronic allograft dysfunction, which was significantly different (P=0.022). CONCLUSIONS Our study revealed that the prevalence of MS was higher in patients with higher numbers of MS components, especially after 3 years posttransplantation. Presence of more components of MS was associated with worse renal function in renal transplant recipients.

Effect of sulodexide on urinary biomarkers of kidney injury in normoalbuminuric type 2 diabetes: a randomized controlled trial.

Glycosaminoglycans or sulodexide has shown benefits in early experimental diabetic nephropathy (DN) models, but its efficacy in patients with early stage of DN is unknown. Methods. Twenty patients were randomly assigned to the placebo group and another 20 patients were randomly assigned to receive sulodexide 100 mg/day for 14 weeks. Primary outcome was a change of urinary TGF-beta1, albuminuria, and glomerular filtration rate (GFR). All patients had stable metabolic profiles for at least 90 days before randomization. Results. Urinary TGF-beta1 increased significantly in the placebo group but did not change significantly in the sulodexide group. Additionally, the mean change of urine TGF-beta1 in the placebo group was significantly higher than that in the sulodexide group (8.44 ± 9.21 versus 2.17 ± 6.96 pg/mg Cr, P = 0.02). Mean changes of urinary albumin were 15.05 ± 30.09 µg/mg Cr (P = 0.038) in the placebo group and 13.89 ± 32.25 µg/mg Cr (P = 0.069) in the sulodexide group. No consistent patterns of side effects were observed. Conclusion. In this 14-week trial, benefits of sulodexide in preventing the increase of urinary TGF-beta1 were observed in patients with normoalbuminuric type 2 diabetes. The study suggests that sulodexide treatment may provide additional renoprotection in early stage DN. This trial is registered with TCTR20140806001.

Benefits of Allopurinol Treatment on Blood Pressure and Renal Function in Patients with Early Stage of Chronic Kidney Disease.

BACKGROUND: Hyperuricemia has been associated with increased risk of endothelial dysfunction, cardiovascular, and renal disease. Allopurinol is a potent xanthine oxidase inhibitor used in hyperuricemic patients. It has been shown to decrease cardiovascular disease and hypertension. However, studies have reported conflicting evidence on its effects on blood pressure (BP) and estimated glomerular filtration rate (GFR) in chronic kidney disease (CKD) patients. OBJECTIVE: To demonstrate the effect of allopurinol on BP and estimated GFR in CKD patients. MATERIAL AND METHOD: Patients with CKD stage II-III were screened for possible study enrollment. All patients received allopurinol 50 mg once daily for 12 weeks. The main outcomes were to observe the changes of BP and GFR after given treatment. RESULTS: Forty-four patients were eligible with mean age of 70.14 ± 8.50 years and mean estimated GFR of 43.22 ± 14.44 mL/ min/1.73 m². Serum uric acid decreased significantly from 8.11 ± 2.68 to 7.05 ± 2.38 mg/dL (p = 0.012) at the end of the study. Allopurinol had also statistically significant lower systolic BP (137.72 ± 14.72 to 131.34 ± 12.10 mmHg, p = 0.019) and diastolic BP (79.63 ± 11.56 to 75.43 ± 9.80 mmHg, p = 0.037) at 12 weeks when compared to baseline. There was significant increased in GFR after treatment (43.22 ± 14.44 vs. 45.34 ± 16.09, mL/min/1.73 m², p = 0.029). No serious adverse effects were noted in any of the treated subjects. Two patients (4.5%) in the treatment group had minor skin reaction. CONCLUSION: The study results confirmed that 12 weeks of allopurinol treatment affects the values of serum uric acid, BP and GFR in early stage of CKD patients who already received standard antihypertensive agents without any significant serious adverse effects.

BIOPSY-PROVEN BK VIRUS NEPHROPATHY WITHOUT DETECTABLE BK VIREMIA IN A ONE-YEAR POST-KIDNEY TRANSPLANT RECIPIENT.

BK virus nephropathy (BKVN) is an important clinical problem in kidney transplant (KT) recipients. The sequence of disease is usually viruria, viremia and then nephropathy. Diagnosis of BK virus (BKV) infection includes checking BKV DNA in the urine, in the plasma and histology on renal biopsy. This last method is used to diagnose BKVN. We describe a KT patient with BKVN without detectable BK viremia. A 62-year-old female with hypertensive nephropathy underwent renal transplant from a living relative donor in December 2011. Fourteen months after transplantation, her serum creatinine(SCr) rose up from 1.2 to 1.6 mg/dl with biopsy-proven acute antibody-mediated and cellular rejection. After pulse methylprednisolone, plasmapheresis and intravenous immunoglobulin, her SCr decreased to baseline but she subsequently developed cytomegalovirus infection with pancytopenia and transaminitis. The SCr rose to 1.9 mg/dl despite ganciclovir treatment. Renal ultrasound and antegrade pyelogram showed partial obstruction of the proximal ureter with moderate hydronephrosis. A quantitative polymerase chain reaction (PCR) assay for BKV DNA was negative (less than 10 copies/ml). A renal biopsy was performed and the pathology revealed viral cytopathic changes in the tubular epithelium with interstitial inflammation. The renal biopsy also showed BKV nucleic acid sequences by in-situ hybridization confirming BKVN. Immunosuppression regimen was changed to cyclosporine, low-dose prednisolone and leflunomide. A temporary percutaneous nephrostomy was performed. Her renal function improved within one week. The diagnosis of BKVN should be considered in a KT recipient with a rising SCr with or without BK viremia and should be made by renal biopsy.

Intensive plasmapheresis and intravenous immunoglobulin for treatment of antibody-mediated rejection after kidney transplant.

OBJECTIVES: Acute antibody-mediated rejection is an important cause of acute and chronic kidney allograft dysfunction and graft loss. The purpose of the present study was to evaluate our experience using plasmapheresis and intravenous immunoglobulin in treating patients who had acute antibody-mediated rejection after kidney transplant. MATERIALS AND METHODS: A retrospective review of 13 patients who had biopsy proven antibody-mediated rejection was performed to determine the efficacy of plasmapheresis and intravenous immuno-globulin with or without bortezomib. RESULTS: All 13 patients were treated with plasmapheresis (5-18 sessions) with intravenous immunoglobulin (2 ± 1 g/kg) during and/or after plasmapheresis; 6 patients also received bortezomib. Mean age was 43 ± 10 years and median time from transplant to rejection was 4.5 months (interquartile range, 1.25-20 mo). Most patients (11 patients [85%]) had serum creatinine level return to within 20% baseline serum creatinine level before rejection. In all 13 patients, mean hospital length of stay was 27 ± 14 days. Frequency of recurrence of antibody-mediated rejection was 31%, and 1 patient resumed dialysis 7 months after treatment. Mean serum creatinine level was greater before (217 ± 111 µmol/L) than after treatment (141 ± 59 µ mol/L; P ≤ .03). CONCLUSIONS: The combination of intensive plasmapheresis and intravenous immunoglobulin is effective treatment for antibody-mediated rejection after kidney transplant. Long-term, prospective studies are justified to determine the effect of this regimen on graft survival.

Effect of enhanced external counterpulsation treatment on renal function in cardiac patients.

BACKGROUND: Enhanced external counterpulsation (EECP) enhances coronary perfusion and reduces left ventricular afterload. However, the role of EECP on renal function in cardiac patients is unknown. Our aim was to assess renal function determined by serum cystatin C in cardiac patients before and after EECP treatment. METHODS: A prospective observational longitudinal study was conducted in order to evaluate renal function using serum cystatin C (Cys C) and estimated glomerular filtration rate (GFR) after 35 sessions of EECP treatment in 30 patients with chronic stable angina and/or heart failure. The median (IQR) time for follow-up period after starting EECP treatment was 16 (10-24) months. RESULTS: Cys C significantly declined from 1.00 (0.78-1.31) to 0.94 (0.77-1.27) mg/L (p < 0.001) and estimated GFR increased from 70.47 (43.88-89.41) to 76.27 (49.02-91.46) mL/min/1.73 m(2) (p = 0.006) after EECP treatment. Subgroup analysis showed that patients with baseline GFR <60 mL/min/1.73 m(2) or NT-proBNP >125 pg/mL had a significant decrease in Cys C when compared to other groups (p < 0.01). CONCLUSIONS: The study demonstrated that EECP could improve long-term renal function in cardiac patients especially in cases with declined renal function or with high NT-proBNP. TRIAL REGISTRATION: The study was registered in the clinical trial as International Standard Randomized Controlled Trial Number ISRCTN11560035.

Clinical factors for severity of Plasmodium falciparum malaria in hospitalized adults in Thailand.

Plasmodium falciparum is a major cause of severe malaria in Southeast Asia, however, there is limited information regarding clinical factors associated with the severity of falciparum malaria from this region. We performed a retrospective case-control study to compare clinical factors and outcomes between patients with severe and non-severe malaria, and to identify clinical factors associated with the requirement for intensive care unit (ICU) admission of patients with severe falciparum malaria among hospitalized adults in Southeast Asia. A total of 255 patients with falciparum malaria in the Hospital for Tropical Diseases in Bangkok, Thailand between 2006 and 2012 were included. We identified 104 patients with severe malaria (cases) and 151 patients with non-severe malaria (controls). Patients with falciparum malaria with following clinical and laboratory characteristics on admission (1) referrals, (2) no prior history of malaria, (3) body temperature of >38.5°C, (4) white blood cell counts >10×10(9)/µL, (5) presence of schizonts in peripheral blood smears, and (6) albumin concentrations of <3.5 g/dL, were more likely to develop severe malaria (P<0.05). Among patients with severe malaria, patients who met ≥3 of the 2010 WHO criteria had sensitivity of 79.2% and specificity of 81.8% for requiring ICU admission. Multivariate analysis identified the following as independent associated factors for severe malaria requiring ICU admission; (1) ethnicity of Thai [odds ratio (OR) = 3.601, 95% confidence interval (CI) = 1.011-12.822] or Myanmar [OR = 3.610, 95% CI = 1.138-11.445]; (2) referrals [OR = 3.571, 95% CI = 1.306-9.762]; (3) no prior history of malaria [OR = 5.887, 95% CI = 1.354-25.594]; and (4) albumin concentrations of <3.5 g/dL [OR = 7.200, 95% CI = 1.802-28.759]. Our findings are important for the clinical management of patients with malaria because it can help early identification of patients that could develop severe malaria and require ICU admission. Early identification and the timely initiation of appropriate treatments may well improve the outcomes and reduce the mortality of these patients.

Obesity and its relation to chronic kidney disease: a population-based, cross-sectional study of a Thai army population and relatives.

AIM: Obesity represents a significant problem in patients with cardiovascular disease and chronic kidney disease (CKD). The aim of the present study was to investigate the association between body mass index (BMI) and CKD in Thai individuals. METHODS: Participants underwent general health screening. Overweight, weight at risk, obese I and obese II were defined as having a BMI ≥23 kg/m(2), 23-24.9 kg/m(2) , 25-29.9 kg/m(2) and ≥30 kg/m(2), respectively. Waist circumference ≥ 90 cm for men and > 80 cm for women were represented by abdominal obesity. CKD was defined as a glomerular filtration rate (GFR) < 60 mL/min per 1.73 m(2). An estimate of the GFR was obtained by the four-variable Modification of Diet in Renal Disease (MDRD) equation. RESULTS: The study population had 12 348 males and 3009 females. The survey population had a 7.5% prevalence of CKD. There was also a significant graded relationship between the degrees of overweight with the prevalence of CKD. Mean BMI were 25.36 ± 3.29 kg/m(2) for CKD subjects and 24.04 ± 3.13 kg/m(2) for non-CKD subjects (P < 0.001). Prevalence of overweight and abdominal obesity in the participants with CKD were found to be higher than in those without CKD (overweight, 77.6% vs. 61.6%, P < 0.001; abdominal obesity, 35.7% vs. 25.3%, P < 0.001). In a multivariate logistic regression analysis, weight at risk (adjusted odds ratio 1.29; 95% CI 1.07-1.54), obese I (adjusted odds ratio 1.58; 95% CI 1.33-1.87) and obese II (adjusted odds ratio 1.65; 95% CI 1.24-2.19) were associated with CKD. CONCLUSION: Our data showed that overweight and obesity were associated with CKD in Thai members of the army population and their relatives undergoing a general health screening, independently of age, gender, blood pressure, serum lipid, uric acid and glucose levels.

Malignancy in renal transplant recipients: a single-center experience in Thailand.

BACKGROUND: Malignancy is the second most common cause of death in renal transplant patients with functioning graft and its incidence increases with time after organ transplantation. OBJECTIVE: To present the cumulative incidence and manifestations of malignancy among renal transplant recipients in Phramongkutklao hospital between 1987 and 2009. MATERIAL AND METHOD: To retrospectively review of the transplant charts and records of 168 kidney transplant recipients from October 1, 1987 to November 15, 2009 at Phramongkutklao Hospital. The data related to malignancy were recorded. RESULTS: The cumulative incidence of malignancy was 4/168 (2.4%) recipients with a median age of 45 years (range, 8-55 years). The median time of diagnosis of malignancy after transplantation was 7.3 years (range, 0.8-10.4 years). All four patients had posttransplantation malignancy. The diagnosis was based on pathological specimens. All of them received cyclosporine, prednisolone and azathioprine or mycophenolate mofetil as immunosuppressive regimen. Two patients had native renal cell carcinoma (RCC), one had post-transplant lymphoproliferative disorder (PTLD), the other had a malignant hemangiopericytoma. Two patients (PTLD and advanced RCC cases) are alive, one patient died of malignancy (malignant hemangiopericytoma) and the other died of infection (Pseudallescheria boydii brain abscess). CONCLUSION: The incidence of malignancies in the present study was increased among renal transplant recipients compared to the general population especially renal cell carcinoma. Because of the higher risk to develop malignancy in transplant recipients, a close surveillance for early detection of malignancy is necessary in the long term follow-up.

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

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

Triple immunosuppressive therapy can accelerate the recovery of antibody-mediated pure red cell aplasia and allow successful concurrent resumption of erythropoietin.

Antibody (Ab)-mediated pure red cell aplasia (PRCA) is a rare hematologic disorder. For the first time here, the authors report the use of combination therapy which consists of mycophenolate mofetil 500-1000 mg/day, intravenous cyclophosphamide 600 mg monthly and monthly intravenous methylprednisolone 1 gm/day for 2 days followed by oral prednisolone 10 mg/day. A 62-year-old woman developed Ab-mediated PRCA after using subcutaneous erythropoietin-beta 3000 U weekly for 14 months at the predialysis stage. Ab-mediated PRCA was diagnosed based on (1) the transfusion need of more than 1 unit/wk to keep hemoglobin level stable, (2) corrected reticulocyte count 0.36% and (3) < 5% erythroblasts with normal myeloid cells and megakaryocytes in bone marrow biopsy. Serum assay confirmed the anti-erythropoietin antibody of 230 ng/mL. The patient recovered from PRCA after the triple immunosuppressive therapy for 3 months. The rapid recovery occurred despite the fact that the patient was receiving intravenous erythropoietin-alpha while having the antibody in the serum. The present case describes the acceleration of the recovery and successful resumption of erythropoietin concurrently despite the positive serum anti-erythropoietin antibody.

Isometric tubular vacuolization in renal transplant recipient: the first case report in Thailand.

Cyclosporine can cause acute and chronic nephrotoxicity. Renal biopsy is a reliable tool for the diagnosis of cyclosporine nephrotoxicity. The authors report a 56-year-old Thai female with a history of end-stage renal disease who underwent cadaveric renal transplantation. A transplanted kidney biopsy was performed on day 9 post-transplant to identify the cause of delayed graft function. Light and electron microscopic findings revealed widespread (> 50% involvement) numerous tubules filled with uniformly-sized vacuoles in cytoplasm (isometric vacuolization). Serum cyclosporine trough level was 534 ng/mL. Neither acute rejection nor acute tubular necrosis was seen. Diagnosis of acute cyclosporine nephrotoxicity was made. Isometric vacuolization in more than 50% involvement of the tubules is rare (3%) in biopsy specimens. The tubular isometric vacuolization might not have the strong impact to the long term graft outcome. This is the first case report of isometric tubular vacuolization due to cyclosporine toxicity in renal transplant recipient in Thailand.

A single-centre experience: peritoneal dialysis-related infections in patients on long-term dialysis.

OBJECTIVE: Peritoneal dialysis is a convenient way of maintaining patients with end stage renal disease (ESRD) and in the present days, the Thai government supports all payments for ESRD patients. Continuous ambulatory peritoneal dialysis-(CAPD) related infections are the major cause of morbidity and mortality. The present study was conducted to identify the incidence and epidemiological data of CAPD-related infection. MATERIAL AND METHOD: Medical records of 333 CAPD patients attending the Dialysis Unit of Phramongkutklao Hospital from January 1983 to June 2007 were reviewed. The historical cohort study was focused on the incidence of CAPD-related infections, causing pathogens, risk factors, and patient outcome. RESULTS: In total, 73.3% of episodes developed peritoneal infection. The incidences of peritonitis, exit site infection, and tunnel infection were 0.864, 0.213, and 0.034 episodes per patient per year, respectively. The most common infecting organisms were gram positive cocci (49.1%). The main pathogens were Coagulase-negative staphylococcus (15.9%), Staphylococcus aureus (15.2%) and Pseudomonas spp. (14.2%). CAPD-related infections increased in patients who had age > 60. A total of 81% of the infections responded to initial antibiotic therapy administered in the dialysis fluid. Overall, there were 10 episodes (1.9%) of the refractory group and 83 episodes (15.4%) of peritoneal catheter loss, with an overall mortality rate of 1.1%. Non-vancomycin based regimens were applied in 63.9% of peritoneal infected patients. CONCLUSION: The authors' center's CAPD-related infection rate achieved the International Society for Peritoneal Dialysis (ISPD) recommendation. A significantly enhanced incidence of CAPD-related infection occurred in advanced age. Coagulase-negative staphylococcus is still a very common organism that generally responds well to antibiotic therapy.

Insulin resistance in dialysis versus non dialysis end stage renal disease patients without diabetes.

OBJECTIVE: Insulin resistance is frequently recognized in uremic patients and is a predictor of cardiovascular mortality in end stage renal disease (ESRD) patients. However sparse data are available regarding the effects of different methods of renal dialysis on insulin resistance in ESRD without diabetes. The present study was conducted to evaluate the levels of insulin resistance in dialysis versus non dialysis ESRD patients without diabetes. MATERIAL AND METHOD: A cross-sectional study was carried out in 45 non diabetic ESRD patients including continuous ambulatory peritoneal dialysis (CAPD), hemodialysis (HD), and non dialysis ESRD patients. The value of insulin resistance was obtained by homeostasis model assessment (HOMA). Estimation of the glomerular filtration rate (GFR) was obtained by the four-variable Modification of Diet in Renal Disease equation and ESRD was defined when GFR was below 15 ml/min/1.73 m2. RESULTS: Non diabetic ESRD patients were studied: 12 patients on CAPD treatment for 67.4 months, 18 patients on HD treatment for 89.3 months, and 15 patients on conservative treatment. HOMA scores (CAPD 5.4 +/- 2.3, HD 6.0 +/- 1.9 vs. non dialysis 1.5 +/- 0.9, p < 0.05) and fasting plasma insulin levels (CAPD 21.9 +/- 7.7 microU/mL, HD 19.5 +/- 8.4 microU/mL vs. non dialysis 4.4 +/- 2.5 microU/mL, p < 0.05) of the CAPD and HD groups were significantly higher than the non dialysis ESRD group, with no significant differences observed between CAPD and HD groups. However, fasting plasma glucose was significantly lower in the HD group than the CAPD and non dialysis ESRD groups (CAPD 98.2 +/- 10.6 mg/dL, non dialysis 93.0 +/- 11.5 mg/dL vs. HD 76.2 +/- 7.8 mg/dL, p < 0.05). All groups showed no significant differences for blood pressure, body weight, body mass index, fat free mass, body fat, and serum levels of albumin, total cholesterol, LDL-cholesterol, HDL-cholesterol, and triglycerides. CONCLUSION: Impaired insulin sensitivity in both dialysis groups after long term dialysis was still higher than that of the non dialysis ESRD group. However, no significant differences were noted between CAPD and HD treatments.

C.E.R.A. once every 4 weeks corrects anaemia and maintains haemoglobin in patients with chronic kidney disease not on dialysis.

BACKGROUND: No previous randomized controlled studies have been reported examining de novo, once every 4 weeks (Q4W) administration of erythropoiesis-stimulating agents in chronic kidney disease (CKD) patients. We report results from a randomized multinational study that compared continuous erythropoietin receptor activator (C.E.R.A.) Q4W with darbepoetin alfa once weekly (QW) or every 2 weeks (Q2W) for the correction of anaemia in non-dialysis CKD patients. METHODS: Patients were randomized (1:1) to receive either 1.2 µg/kg C.E.R.A. Q4W or darbepoetin alfa QW/Q2W during a 20-week correction period and an 8-week evaluation period. Two primary end points were assessed: the haemoglobin (Hb) response rate and the change in average Hb concentration between baseline and evaluation. RESULTS: The Hb response rate for C.E.R.A. was 94.1%, significantly higher than the protocol-specified 60% response rate [95% confidence interval (CI): 89.1, 97.3; P < 0.0001] and comparable with darbepoetin alfa (93.5%; 95% CI: 88.4, 96.8; P < 0.0001). C.E.R.A. Q4W was non-inferior to darbepoetin alfa QW/Q2W, with similar mean Hb changes from baseline of 1.62 g/dL and 1.66 g/dL, respectively. Patients receiving C.E.R.A. showed a steady rise in Hb, with fewer patients above the target range during the first 8 weeks compared with darbepoetin alfa [39 patients (25.8%) versus 72 patients (47.7%); P < 0.0001]. Adverse event rates were comparable between the treatment groups. CONCLUSION: C.E.R.A. Q4W successfully corrects anaemia and maintains stable Hb levels within the recommended target range in non-dialysis CKD patients.