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Introduction: More reports of thrombotic microangiopathy (TMA) in immunoglobulin A (IgA) nephropathy suggest its association with poor clinical outcomes. However, the prevalence and clinical significance of TMA in IgA nephropathy have not been widely studied in different populations., Methods: Kidney biopsies of all patients with primary IgA nephropathy from 1995 to 2015 at the King Chulalongkorn Memorial Hospital, Thailand, were retrospectively reviewed and reclassified by two pathologists following the Oxford MEST-C classification. TMA lesions were detected based solely on light microscopic findings. Associations between the presence of TMA and clinical data, other pathologic findings, and clinical outcomes were studied., Results: Among 267 patients with primary IgA nephropathy, 166 had adequate clinical data and kidney tissues for the analysis. TMA was observed in 21 patients (13%) and was associated with higher mean arterial pressure (MAP), history of malignant hypertension, higher proteinuria, and lower estimated glomerular filtration rate (eGFR) at diagnosis compared to those without TMA. According to the Oxford MEST-C classification, TMA showed a significant association with severe tubular atrophy/interstitial fibrosis (T2) but not with mesangial hypercellularity (M1), endocapillary hypercellularity (E1), segmental glomerulosclerosis (S1), or crescents (C1-2). After a median follow-up of 50 months, patients with TMA had a significantly higher risk of progression to end-stage kidney disease (ESKD) (hazard ratio [HR] 5.8, 95% confidence interval [CI]: 3.1-10.9) and all-cause mortality (HR 3.4, 95% CI: 1.3-8.8). After adjusting for baseline eGFR, MAP, proteinuria, and other pathological lesions, TMA remained an independent predictor of ESKD (adjusted HR 2.4, 95% CI: 1.1-5.4)., Conclusions: Kidney TMA in IgA nephropathy is associated with advanced disease stages, carries a poor prognosis, and thus should be considered in the pathological classification of IgA nephropathy., (© 2023 S. Karger AG, Basel.)

Sarcopenia in end-stage kidney disease patients requiring dialysis is a frequent complication but remains an under-recognized problem. This meta-analysis was conducted to determine the prevalence of sarcopenia and explored its impacts on clinical outcomes, especially cardiovascular events, and mortality in dialysis patients. The eligible studies were searched from PubMed, Scopus, and Cochrane Central Register of Controlled trials up to 31 March 2022. We included studies that reported the interested outcomes, and the random-effects model was used for analysis. Forty-one studies with 7576 patients were included. The pooled prevalence of sarcopenia in dialysis patients was 25.6% (95% CI 22.1 to 29.4%). Sarcopenia was significantly associated with higher mortality risk (adjusted OR 1.83 (95% CI 1.40 to 2.39)) and cardiovascular events (adjusted OR 3.80 (95% CI 1.79 to 8.09)). Additionally, both low muscle mass and low muscle strength were independently related to increased mortality risk in dialysis patients (OR 1.71; 95% CI (1.20 to 2.44), OR 2.15 (95% CI 1.51 to 3.07)), respectively. This meta-analysis revealed that sarcopenia was highly prevalent among dialysis patients and shown to be an important predictor of cardiovascular events and mortality. Future intervention research to alleviate this disease burden in dialysis patients is needed.

In hemodialysis (HD) patients, protein-energy wasting (PEW) is highly prevalent and firstly treated with oral nutritional supplements (ONS). The extent to which intradialytic parenteral nutrition (IDPN) contributes to improve PEW status in HD patients intolerable to ONS remains unclear. Maintenance PEW HD patients being unable to tolerate ONS adverse effects, and having spontaneous energy and protein intake of ≥ 20 kcal/kg/day and ≥ 0.8 g/kg/day, respectively were randomly assigned 1:1 into IDPN and control groups. In IDPN group, most concentrated 3-in-1, fish-oil based parenteral nutrition was infused during HD for 3 months. The control group received intensive dietary counselling once weekly for 3 months. Both groups were then followed for additional 3 months after intervention. A total of 38 patients were randomized (mean age 67.6 years). After 3 months, serum albumin was significantly higher in the IDPN (n = 18) compared with control group (from 3.5 ± 0.3 to 3.8 ± 0.2 vs from 3.6 ± 0.3 to 3.5 ± 0.3 g/dL, respectively, p = 0.01). Spontaneous dietary intake (p = 0.04), body weight (p = 0.01), and malnutrition inflammation score (MIS, p = 0.01) were improved in the IDPN, but not in the control group. Muscle mass, strength, serum prealbumin, interleukin-6, high sensitivity-c reactive protein, and acylated ghrelin were not significantly different but leptin levels increased in the control group after 3 months (p = 0.03). At 6 months, serum albumin in the IDPN group was persistently higher than baseline (p = 0.04). Neither volume overload nor uncontrolled hyperglycemia was found throughout the study. In conclusion, a 3-month IDPN supplementation demonstrated a significant increase in serum albumin, body weight, spontaneous oral intake, and MIS; and appeared to be superior to continuing intensive dietary counselling among HD patients intolerable to ONS. The impacts of IDPN therapy on clinical outcomes may require larger scale with longer period of study., (© 2022. The Author(s).)

Incremental hemodialysis (HD) has become an exciting approach according to the recognition of the importance of preserving residual kidney function (RKF). However, not all incident HD patients are suitable for this approach, particularly once-weekly HD. This is the first study which reported the effectiveness of once-weekly online-hemodiafiltration (OL-HDF) plus low protein diet (LPD) in incident HD patients. All stage 5 CKD patients who had chosen HD as their treatment modality at the HD center of King Chulalongkorn Memorial Hospital, Bangkok, Thailand, with RKF ⩾ 3 mL/min calculated by renal clearance of urea and urine output ⩾ 800 mL/day, started the treatment with once-weekly OL-HDF. Dietitians advised patients to consume LPD (0.6-0.8 g/kg/day) on non-dialysis days and a regular protein diet on the dialysis day (1.2 g/kg/day). Eleven incident HD patients were enrolled in the study. The mean RKF and urine volume at baseline were 4.56 ± 2.21 mL/min and 2,019.54 ± 743.73 mL/day, respectively. After 6 and 12 months of follow-up, the mean RKF of the patients who remained in the once-weekly OL-HDF protocol were 3.82 ± 1.68 mL/min and 3.28 ± 0.95 mL/min, respectively. The median duration of once-weekly OL-HDF before transitioning to twice- or thrice-weekly OL-HDF was 7 months (3-24 months). The most common indication for stepping prescription was too low RKF. We reported that dialysis initiation in the university-based center with once-weekly OL-HDF in carefully selected incident HD patients combined with LPD under serial monitoring is practical. Further studies on the clinical benefits of once-weekly OL-HDF are still required.

Background Non-vitamin K antagonist oral anticoagulants (NOACs) have better pharmacologic properties than warfarin and are recommended in preference to warfarin in most patients with non-valvular atrial fibrillation. Besides lower bleeding complications, other advantages of NOACs over warfarin particularly renal outcomes remain inconclusive. Methods and Results Electronic searches were conducted through Medline, Scopus, Cochrane Library databases, and ClinicalTrial.gov. Randomized controlled trials and observational cohort studies reporting incidence rates and hazard ratio (HR) of renal outcomes (including acute kidney injury, worsening renal function, doubling serum creatinine, and end-stage renal disease) were selected. The random-effects model was used to calculate pooled incidence and HR with 95% CI. Eighteen studies were included. A total of 285 201 patients were enrolled, 118 863 patients with warfarin and 166 338 patients with NOACs. The NOACs group yielded lower incidence rates of all renal outcomes when compared with the warfarin group. Patients treated with NOACs showed significantly lower HR of risk of acute kidney injury (HR, 0.70, 95% CI, 0.64-0.76; P <0.001), worsening renal function (HR, 0.83; 95% CI, 0.73-0.95; P =0.006), doubling serum creatinine (HR, 0.58; 95% CI, 0.41-0.82; P =0.002), and end-stage renal disease (HR, 0.82; 95% CI, 0.78-0.86; P <0.001). Conclusions In non-valvular atrial fibrillation, patients treated with NOACs have a lower risk of both acute kidney injury and end-stage renal disease when compared with warfarin.

Although high-volume postdilution online hemodiafiltration (ol-HDF) is superior to high-flux HD in removing all kinds of uremic toxins and improving survival, this treatment is not available in most HD centers. The present study was conducted to compare the effectiveness in removals of protein-bound (indoxyl sulfate [IS]), middle-molecule [beta-2 microglobulin (B2M) and alpha-1 microglobulin (A1MG)], and small-molecule uremic toxins between super high-flux HD (SHF-HD), HD with a novel SHF dialyzer and high-volume postdilution ol-HDF in a noninferiority fashion. Fifteen prevalent HD patients were randomly allocated into two sequences of 12-week treatment periods of SHF-HD treatment and later high-volume postdilution ol-HDF period or vice versa. Each treatment period was divided by a wash-out phase of 4-week high-flux HD. Twelve of 15 patients could complete the study. When compared with high-volume postdilution ol-HDF (convective volume of 24.4 ± 3.52 L), SHF-HD provided comparable reduction ratio values of IS, B2M, and A1MG with mean difference of 5.87 (95% confidence interval [CI] -1.63, 13.37), 1.98 (95% CI,-0.21, 4.18), and 22.96 (95% CI, -1.91, 47.83), respectively. The spKt/Vurea was not different. The predialysis levels of all uremic toxins at baseline and after 12-week treatment did not differ between both groups. Although albumin loss in dialysate in SHF-HD was greater than high-volume postdilution ol-HDF, the serum albumin levels after 12-week SHF-HD treatment were significantly higher than baseline. In conclusion, SHF-HD provides noninferior effectiveness to high-volume postdilution ol-HDF in removing various uremic toxins with significantly increased serum albumin levels despite higher albumin loss. SHF-HD might be an effectively alternative treatment when high-volume postdilution ol-HDF is not available., (© 2020 International Society for Apheresis, Japanese Society for Apheresis, and Japanese Society for Dialysis Therapy.)

Background: Although the levels of intact parathyroid hormone (iPTH) are well-controlled following the Kidney Disease Outcomes Quality Initiative guideline, the incidence of osteoporosis and fracture are still high in haemodialysis (HD) patients. This study was conducted to investigate the correlation between bone turnover markers, bone mineral density (BMD), and bone histomorphometry in HD patients., Methods: Twenty-two chronic HD patients were enrolled. Serum levels of bone turnover markers were measured. Double tetracycline-labelled iliac crest bone specimens were evaluated using specialized a computer program (Osteomeasure). The types of bone histomorphometry were classified based on turnover, mineralization and volume. BMD and coronary artery calcification were also determined., Results: Bone histomorphometry revealed osteitis fibrosa (50%), adynamic bone disease (45%) and mixed uremic osteodystrophy (5%). Serum iPTH level predicted high bone turnover with area under the receiver operating characteristic (ROC) of 0.833 (95% CI = 0.665-1.000, P = 0.008). Serum TRAP-5b also had ROC of 0.733 (95% CI = 0.517-0.950, P = 0.065). In addition, when using serum iPTH (cut-off 484.50 ng/mL) or serum TRAP-5b (cut-off 1.91 pg./mL) to predict high turnover, the sensitivity was 0.917. On the other hand, when both iPTH and TRAP-5B were above these cut-off, the specificity was 1.000. Low BMD and severe vascular calcification were commonly identified. However, there were no significant correlations between bone biomarkers and BMD or severe vascular calcification., Conclusion: Although iPTH levels were close to the target of Kidney Disease Outcomes Quality Initiative guideline, abnormal bone histomorphometry, BMD, and severe vascular calcification are still common. Bone biopsy is still crucially required as an accurate diagnostic tool in providing optimal guide for the treatment. © 2019 Asian Pacific Society of Nephrology., (© 2019 Asian Pacific Society of Nephrology.)

Background: Secondary hyperparathyroidism (SHPT) is associated with high incidences of cardiovascular disease, bone fracture, and mortality. This study was conducted to demonstrate the effectiveness of cinacalcet treatment on chronic kidney disease-mineral bone disorder (CKD-MBD) markers in chronic hemodialysis patients with severe SHPT., Methods: In phase 1, 30 adult HD patients were randomized to cinacalcet or control groups for 12 weeks to explore the achievement of >30% reduction of iPTH. In phase 2, 45 patients were participated to further explore the effect of cinacalcet on CKD-MBD parameters for 24-week follow up and 12 additional weeks after cinacalcet discontinuation., Results: In phase 1, the baseline serum iPTH levels were not different [1374 (955, 1639) pg/mL in the control group vs. 1191 (1005, 1884) pg/mL in the cinacalcet group], the percentage of patients achieving iPTH target were significantly higher in the treatment group [80% vs. 13%, p = .001]. In phase 2, the significant reductions of iPTH, FGF-23, tartrate-resistant acid phosphatase 5b, and slightly decreased size of parathyroid gland and stabilized vascular calcification were observed at 24-week follow up and markedly rebounded after discontinuation of cinacalcet., Conclusions: The effectiveness of cinacalcet were still obviously demonstrated even in chronic HD patients with severe SHPT. In addition, the improvements of bone markers and FGF-23, and stabilization of vascular calcification were observed. Therefore, cinacalcet can provide salutary effects on CKD-MBD in severe SHPT and might be an initially effective PTH-lowering therapy prior to surgical parathyroidectomy as well as an alternative treatment in the patients unsuitable for surgery., Clinical Trial Registration: ClinicalTrials.gov: NCT02056730. Date of registration: February 4, 2014.

Background: Arterial stiffness (AS) and vascular calcification are significantly related to a high cardiovascular mortality risk in hemodialysis (HD) patients. Intravenous sodium thiosulfate (IV STS) can prevent and delay the vascular calcification progression in uremic states; however, the STS effect on AS has not been assessed. This study aimed to evaluate the STS efficacy on vascular calcification and AS in HD patients., Methods: Fifty HD patients with abnormal AS, as measured via the cardio-ankle vascular index (CAVI ≥8), were prospectively randomized to open-label 12.5 g IV STS during the last HD hour twice weekly for 6 months (n = 24) or the usual care (control group; n = 26). Patients and treating physicians were not blinded. The CAVI, coronary artery calcification (CAC) score, hemodynamics, and biochemical parameters were measured at the baseline and at 3 and 6 months., Results: All the baseline parameters were comparable. The IV STS significantly reduced the CAVI when compared to the control group (mean CAVI difference = -0.53; 95% CI -1.00 to -0.06; p = 0.03). A significant CAVI improvement was seen in those patients without diabetes mellitus. The natural logarithm of the CAC volume score was significantly increased in the control group. The high sensitivity C-reactive protein level was slightly lowered in the IV STS group (not significant)., Conclusion: The intradialytic STS treatment significantly reduced the AS, as measured by the CAVI, and stabilized the vascular calcification in the HD patients. STS may be a novel therapeutic strategy for delaying and treating the structural and functional vascular wall abnormalities in HD patients., (© 2018 S. Karger AG, Basel.)

Background: Recently, in the first hemodiafiltration (HDF) experience report from South East Asia (SEA), we reported a 3-year prospective study demonstrating the various short-term benefits of high-efficiency online HDF (OL-HDF) over high-flux hemodialysis (HD). Very few long-term survival reports of high-efficiency OL-HDF are available and the data are heterogeneous and incomplete., Objectives: The present historical cohort study was conducted to determine the long-term survival and outcome of high-efficiency OL-HDF-treated patients., Methods: Sixty-six high-efficiency OL-HDF treated patients at a center in SEA were included in the study. The prescription included blood and dialysis fluid flow rates of 400 and 800 mL/min, respectively. The post- or pre-dilution substitution fluid of 100 or 200 mL/min, respectively, was prescribed., Results: Of 66 HDF patients, whose age was 57.4 ± 14.0 years, there were 38 (58%) females. The majority of comorbidity was diabetes (36%). There were 33 (50%) incident HDF cases that were prescribed OL-HDF at the dialysis initiation and 33 (50%) prevalent HDF cases that were switched from HD to OL-HDF. The 1-, 3-, 5-, and 10-year survival rate were 95.1, 83.4, 77.7, and 61.8% respectively. The mean survival time was 8.99 ± 0.64 years. There were 15 transplantations and 15 deaths during this study periods. The 2 major causes of death were cardiovascular (33.3%) and infectious diseases (20%). Serum ferritin was the only parameter that correlated with mortality (HR 1.004, p = 0.005). There was comparable survival between incident and prevalent HDF cases. The survival after transplantation of a sub-group of patients who received kidney transplantation (KT) was not different from that of the overall HDF patients (p = 0.93)., Conclusions: High-efficiency OL-HDF could provide an excellent long-term survival nearly comparable to the KT sub-group., (© 2018 S. Karger AG, Basel.)

This is the case of a 5-year-old girl diagnosed with end-stage renal disease due to bilateral renal hypoplasia who developed anemia of unknown cause.

♦ BACKGROUND: Current guidelines suggest that intraperitoneal (IP) antibiotics should be administered only in a long peritoneal dialysis (PD) dwell (≥ 6 hours). The long dwell might result in low ultrafiltration and volume overload. We aim to examine plasma and dialysate concentration of cefazolin and ceftazidime after IP administration in a short-dwell (≤ 2 hours) automated cycling exchange. ♦ METHODS: Stable PD patients without peritonitis were invited to participate in the present study. Patients underwent 5 2-liter exchanges of PD fluid over 10 hours by the PD cycling machine without last fill or additional dwell. Cefazolin and ceftazidime (20 mg/kg each) were added to the first 5-liter bag of 2.5% dextrose PD fluid that was placed on the warmer of the PD cycling machine. Plasma samples were collected at 12 time-points over 24 hours. Dialysate samples from each exchange were also collected. Antibiotic concentrations in plasma and dialysate were then determined by high-performance liquid chromatography (HPLC). ♦ RESULTS: Six stable PD patients without peritonitis participated in the study. Dialysate cefazolin and ceftazidime were consistently high throughout the PD session in all patients (26 - 360 mg/L). Plasma cefazolin and ceftazidime exceeded the minimal inhibitory concentration (MIC) for susceptible organisms (≤ 8 mg/L) within 2 hours (cefazolin 28.5 ± 8.0 and ceftazidime 12.5 ± 3.4 mg/L), peak at 10 hours (51.1 ± 14.1 and 23.0 ± 5.2 mg/L) and sustained well above the MIC at 24 hours (42.0 ± 9.6 and 17.1 ± 3.1 mg/L). ♦ CONCLUSIONS: The short-dwell cycling IP cefazolin and ceftazidime could provide adequate plasma concentration for up to 24 hours. Daily short-dwell cycling IP cefazolin and ceftazidime might be used to treat peritonitis in PD patients already using a PD cycling machine as well as selected continuous ambulatory PD (CAPD) patients who need shorter dwells during peritonitis due to increasing peritoneal solute transport., (Copyright © 2017 International Society for Peritoneal Dialysis.)

Aim: Recurrent IgA nephropathy (IgAN) is a common recurrent glomerular disease after kidney transplantation. Recurrent IgAN, in particular, with crescent formation or endocapillary proliferation might result in kidney allograft loss. However, the current treatment options of recurrent IgAN are conflicting., Methods: We have reported three kidney-transplanted recipients with biopsy-proven recurrent IgAN treated with four consecutive months of rituximab at the dose of 375 mg/1.73m 2 without corticosteroids., Results: At median follow-up 20 months following rituximab administration, all three recipients demonstrated decrease in proteinuria severity, slow disease progression with a well-tolerated condition. This therapeutic effect is most probably mediated by the B cell depletion., Conclusion: Our three case reports suggest that the disease severity of recurrent IgAN with endocapillary proliferation regardless of crescent formation can be minimized by the four doses of monthly rituximab regimen., (© 2016 Asian Pacific Society of Nephrology.)

Background: Cytomegalovirus (CMV) infection significantly causes morbidity in kidney transplant (KT) recipients. This study aims to investigate the incidence, timing, and risk factors of CMV infection in KT recipients., Methods: This is a single-center retrospective study at a tertiary referral hospital. Patients who underwent KT from January 2012 to September 2014 were included. CMV infection was defined as the presence of CMV measured by polymerase chain reaction. Logistic regression analysis was performed to assess independent risk factors of CMV infection after KT., Results: Of 121 KT patients enrolled, 120 patients had CMV D(+)/R(+) serostatus, and 1 had D-/R(+). CMV infection occurred in 33 (27.2%) of patients with a median follow-up time of 16 (IQR 4-25) months. Of those, 25 had CMV viremia and 8 had CMV disease mainly involving the gastrointestinal system. In total, 86% of CMV cases occurred within 3 months. All recipients received anti-IL-2 receptor antibody (IL-2 RA), low-dose rabbit antithymocyte globulin (rATG; total of 1.5 mg/kg), or standard-dose rATG (1.5 mg/kg/day for 3-5 days) for induction. Of those, the incidences of CMV infection were 19.6%, 50%, and 67%, respectively. Preemptive strategy was used in all but 1 patient in the IL-2 RA and low-dose rATG group, whereas universal prophylaxis was given in 67% of patients in the standard-dose rATG group. Independent risk factors of CMV infection were older recipient age (per 10-year increase, OR 1.5; 95% CI 1.04-2.23), and induction with standard (OR 8.19; 95% CI 2.29-34) and low-dose rATG (OR 3.87; 95% CI 1.06-12.23)., Conclusions: More than 25% of KT recipients developed CMV infection within 6 months after KT. The risk is increased in older recipients and induction with rATG. The level of CMV risk in low-dose rATG is 52% lower than in standard-dose rATG. In a limited-resource setting such as Thailand, deferred or preemptive strategy may be acceptable in patients who received IL-2 RA and low-dose rATG, while prophylactic therapy should be given to patients who received standard-dose rATG., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Tacrolimus pharmacokinetics prediction by CYP3A5 genotyping is not available in many Asian resource-limited settings. Therefore, an alternative technique is needed to estimate the dose of tacrolimus perioperatively. The 12-hour level after the first dose (C12-0) is an alternative technique for estimating the dose of tacrolimus. This simple and inexpensive calculation technique can be used by any transplantation center., Methods: A prospective study on a cohort of 57 incident post-kidney transplant recipients was conducted. The whole-blood tacrolimus trough level (C12-0) was measured at 12 hours after the first dose (0.1 mg/kg) of orally administered tacrolimus during transplantation. Concomitant medications with CYP3A5 inhibitors/inducers were not allowed. Genotyping for CYP3A5 expression was carried out by reverse transcription polymerase chain reaction. The dosages and trough levels of tacrolimus at postoperative day 7 and postoperative months 1 to 3 were measured and analyzed for the dose requirements for therapeutic levels (mg/kg/d)., Results: The doses of tacrolimus were widely diverse, ranging from 0.049 to 0.260 mg/kg/d and 0.031 to 0.298 mg/kg/d at day 7 and months 1 to 3, respectively. There were 9, 28, and 20 patients (15.8%, 49.1%, and 35.1%) with CYP3A5 *1/*1, *1/*3, and *3/*3, respectively. The CYP3A5 genotypes were significantly correlated with the target tacrolimus dose at day 7 (r(2) = 0.307) and the stable dose at months 1 to 3 (r(2) = 0.337). The C12-0 level also was significantly correlated with the dose of tacrolimus at day 7 (r(2) = 0.546) and the stable dose at months 1 to 3 (r(2) = 0.406)., Conclusions: There were strong correlations between the C12-0 level and the tacrolimus doses during the perioperative period at day 7 and the stable period at 1 to 3 months. Countries with limited resources for genotype testing can use the C12-0 level as an alternative to estimate the tacrolimus dose., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The outcomes of kidney transplantation (KT) from hepatitis B surface antigen-positive [HBsAg(+)] donors to HBsAg(-) recipients remain inconclusive, possibly due to substantial differences in methodological and statistical models, number of patients, follow-up duration, hepatitis B virus (HBV) prophylactic regimens and hepatitis B surface antibody (anti-HBs) levels. The present retrospective, longitudinal study (clinicaltrial.gov NCT02044588) using propensity score matching technique was conducted to compare outcomes of KT between HBsAg(-) recipients with anti-HBs titer above 100 mIU/mL undergoing KT from HBsAg(+) donors (n = 43) and HBsAg(-) donors (n = 86). During the median follow-up duration of 58.2 months (range 16.7-158.3 months), there were no significant differences in graft and patient survivals. No HBV-infective markers, including HBsAg, hepatitis B core antibody, hepatitis B extracellular antigen and HBV DNA quantitative test were detected in HBsAg(+) donor group. Renal pathology outcomes revealed comparable incidences of kidney allograft rejection while there were no incidences of HBV-associated glomerulonephritis and viral antigen staining. Recipients undergoing KT from HBsAg(+) donors with no HBV prophylaxis (n = 20) provided comparable outcomes with those treated with lamivudine alone (n = 21) or lamivudine in combination with HBV immunoglobulin (n = 2). In conclusion, KT without HBV prophylaxis from HBsAg(+) donors without hepatitis B viremia to HBsAg(-) recipients with anti-HBs titer above 100 mIU/mL provides excellent graft and patient survivals without evidence of HBV transmission., (© Copyright 2014 The American Society of Transplantation and the American Society of Transplant Surgeons.)

Mid-dilution and mixed-dilution on-line hemodiafiltration (OL-HDF) techniques are innovated to overcome the limitations of two standard techniques including predilution and postdilution. Unfortunately, the head-to-head comparisons between these two novel techniques in the same study are still limited. Moreover, the original mid-dilution and mixed-dilution OL-HDF need special dialyzers and special machines. In the present study, simple mid-dilution and simple mixed-dilution OL-HDF were settled with the aim for clinical use in general hemodialysis (HD) centers. The efficacies of uremic toxins removal between both modalities were measured and compared. This prospective randomized crossover study was conducted on 12 stable HD patients undergoing simple mixed-dilution and simple mid-dilution OL-HDF techniques. HD prescriptions were similar in both techniques. The dialysis efficacies were determined by calculating small- (urea, creatinine, and phosphate) and middle-molecule (beta-2 microglobulin [β2M]) removal. Moreover, potential complications such as high transmembrane pressure (TMP) and protein loss were also observed. Simple mixed-dilution OL-HDF provided significantly greater clearances of urea, creatinine, and β2M when compared with the simple mid-dilution OL-HDF techniques. Phosphate clearances in both techniques were comparable. In addition, TMP and dialysate albumin loss were not different. There were no intradialytic complications in both techniques. Simple mixed-dilution OL-HDF could provide greater efficacy for small- and middle-molecule clearances and acceptable potential risks, while phosphate removal is comparable., (© 2012, Copyright the Authors. Artificial Organs © 2012, International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.)

Objective: Understanding how best to measure renal function in HIV-infected patients is critical because estimated glomerular filtration rate (eGFR) in HIV-infected patients can be affected by ethnicity and body composition. We validated the available eGFR equations and compared them to the plasma Tc-diethylenetriaminepentaacetic acid (Tc-DTPA) clearance in HIV-infected patients., Design: Test of diagnostic accuracy., Methods: One hundred and ninety-six HIV-infected patients underwent measuring of Tc-DTPA plasma clearance, five creatinine-based eGFR equations, cystatin-C GFR, and 24-h urine creatinine clearance (CrCl)., Results: Mean (SD) Tc-DTPA GFR was 117.7 ± 29.2 ml/min per 1.73 m. The re-expressed Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), re-expressed MDRD formula with Thai racial correction factor, Thai eGFR equation, Cockcroft-Gault equation, cystatin-C GFR, and 24-h urine CrCl underestimated the reference GFR. The bias estimated by the mean of differences (SD) for the re-expressed MDRD equation, CKD-EPI, re-expressed MDRD formula with Thai racial correction factor, Thai eGFR, Cockcroft-Gault equation, cystatin-C, and 24-h urine CrCl can be expressed as 18.9 ± 27.3, 11.1 ± 25.5, 6.2 ± 28.8, 15.4 ± 27.0, 30.4 ± 28.0, 3.2 + 36.1, and 5.0 ± 12.1 ml/min per 1.73 m, respectively., Conclusion: The available eGFR equations underestimated GFR in HIV-infected adults. However, the eGFR by cystatin-C GFR was the most precise and accurate. Among creatinine-based eGFR equations, re-expressed MDRD formula with Thai racial correction factor was the most precise and accurate. The racial factor for each ethnicity is important and the existing eGFR equation should be validated before using it in the HIV population.

Objective: Growing evidence has demonstrated the potential survival benefit of online hemodiafiltration (HDF) over conventional hemodialysis (HD). Previous studies regarding online HDF utilized single-use dialyzer The present study was conducted to compare the long-term clinical parameters between pre- and post-dilution online HDF with the reuse dialyzer, Material and Method: This 2-year historical cohort study was conducted in 20 chronic hemodialysis patients who had undergone thrice-a-week pre-dilution online HDF for at least one year. The patients were switched to post-dilution online HDF for another year. Reuse dialyzers were utilized in both methods., Results: No pyrogenic reactions had been detected throughout the 2-year study period. The C-reactive protein (CRP) and nutritional parameters were in good normal ranges. The normalization of protein equivalent of nitrogen appearance (nPNA) was significantly higher during the post-dilution period (1.25 +/- 0.22 vs. 1.11 +/- 0.14 g/kg/d, p < 0.01). Regarding adequacy of hemodialysis, the post-dilution online HDF showed significantly better Kt/V than the pre-dilution mode (2.46 +/- 0.35 vs. 2.35 +/- 0.35, p < 0.05) whereas the predialysis beta2-microglobulin levels were not different (23.43 +/- 5.35 vs. 23.73 +/- 5.55 mg/L, NS). The numbers of reuse were comparable (17.3 +/- 2.6 vs. 16.4 +/- 2.7, NS)., Conclusion: Utilizing reuse dialyzer in online HDF could provide efficacy, safety, cost saving, and environmental benefit. The post-dilution technique yielded the better adequacy and nutritional status without causing the limitation in the reuse number and would be the standard mode-of-choice for online HDEF

Objective: Implementation of the "Peritoneal Dialysis-First (PD First)" policy, mandating PD as the first modality of renal replacement therapy for end-stage renal disease patients under universal health coverage, leads to a rapid growth of PD cases and centers in Thailand. Since PD-related infection is the Achilles' heel of PD, this retrospective study was conducted to examine the magnitude of PD-related infection in Thailand under the "PD First" policy., Material and Method: All PD centers in Thailand were included in the present study. PD nurse specialists in each center were requested to review medical records of all patients undergoing PD during October 1, 2009 to September 30, 2010 and to submit data to the main investigators., Results: Eighty-eight percent of all active PD-centers in Thailand (102 out of 116) participated in the present study. One hundred and thirty-three nephrologists and 220 PD nurse specialists served 8,201 PD prevalent patients in these centers (7,925 CAPD and 276 APD). The overall exit-site infection (ESI) rate was 1 episode/37.7 patient-month (0.32 episodes/patient-year) while the overall peritonitis rate was 1 episode/25.5 patient-month (0.47 episode/patient-year)., Conclusion: Despite the rapid growth of PD cases under the limited resource, the PD-related infection rates in Thailand are only small degree behind the goal of Asia-Pacific Key Performance Indicators (KPIs) Task Force.

Background: Currently, estimated glomerular filtration rate (eGFR) equations have been validated only in Caucasians and African-Americans and is not applicable to people of other races/ethnicities as shown in studies conducted in two Asian populations: Chinese and Japanese. Because of this, it is important that eGFR equations are validated in its prospective population before applying it in the clinical setting and in epidemiologic studies. Therefore, we examined all eGFR equations available: reexpressed isotope dilution mass spectroscopy (IDMS)-traceable Modification of Diet in Renal Disease (MDRD) equation, Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation, Chinese equation and Japanese equation., Methods: A total of 350 adult Thai CKD patients were studied. The (99m)Tc-DTPA plasma clearance was used as a reference for glomerular filtration rate (GFR). The serum creatinine was determined by IDMS reference enzymatic methods (Cr(Enz)) and Jaffe's kinetic assay (Cr(Jaffe)) as indicated in each equation., Results: The disagreement between the reference GFR and eGFR (reference GFR minus eGFR) was 9.6 mL/min/1.73 m(2) for the reexpressed IDMS-traceable MDRD equation, 8.0 mL/min/1.73 m(2) for CKD-EPI equation, 1.9 mL/min/1.73 m(2) for eGFR equation from the Chinese study and 20.9 mL/min/1.73 m(2) for the eGFR equation from the Japanese study. The Thai coefficient for the reexpressed MDRD was 1.129. The reexpressed MDRD equation for Thais is as follows: 175 × Cr(Enz) ((-1.154)) × Age ((-0.203)) × 0.742 (if female) × 1.129 (if Thai). When stepwise multiple regression analysis was used, the Thai eGFR formula is: 375.5 × Cr(Enz) ((-0.848)) × Age ((-0.364)) × 0.712 (if female)., Conclusions: Differences in race/ethnicity can significantly affect the results obtained from MDRD-based eGFR equation. It is highly recommended that each population should validate eGFR equations before applying the equation in epidemiologic studies or clinical use.

Objective: The national health insurance fund in Thailand initiated by the national health security act in November, 2002. In October 2007, the national health insurance fund launched the first renal replacement therapy (RRT) reimbursement plan by the "Peritoneal Dialysis-First" (PD First) policy. The rationale of the PD First Policy resulted from the perspective that PD for end stage renal disease (ESRD) treatment offers the most economic and efficient outcome. The present study was conducted to determine whether the increase of RRT penetration by national health policy could impact the national RRT prevalence., Material and Method: The Thailand Renal Replacement Therapy (TRT) database in 2007, 2008, and 2009 were retrieved and analyzed., Results: By TRT registry data, the total yearly prevalence of RRT increased by an average of 14.8% after the implementation of national health insurance and the "PD First" policy from 2007 to 2009. The total yearly prevalence of hemodialaysis (HD) modestly increased (14.7%) while the total yearly prevalence of PD remarkably expanded by 107.3%. The yearly incidence of all RRT modalities increased by an average of 34.8% in 2007 to 2009. The yearly incidence of HD modestly increased (8.1%) while the total yearly incidence of PD remarkably elevated by 157.8%. Civil Servants Medical Benefit Compensation (CSMBS) was the major funding source of RRT cases (34.5%) while national health insurance funding was the second major funding source (26.0%). From 2007-2009, the CSMBS funding was the majority of HD while national health insurance funding was the majority of PD. The sharing of PD by national health insurance increased from 33.9% in 2007, 58.6% in 2208, and 77.2% in 2009., Conclusion: The coverage ofESRD patients by national health insurance fund by the "PD First" policy impacted the RRT prevalence and incidence both the total prevalence and total incidence due to the universal penetration to RRT treatment of Thai population. Also, the policy altered the RRT modality predisposition. PD modality willfinally be the majority ofThaiRRT modalities if the policy can be managed successfully.

Background: In Thailand, dialysate endotoxin contamination levels vary from less than 0.001 to 2.0 EU/ml. This difference has prompted an investigation on the production of proinflammatory cytokines and counter-inflammatory mediators of peripheral blood mononuclear cells (PBMCs) after high-flux dialysis., Methods: Patients from four hemodialysis (HD) centers who met the inclusion/exclusion criteria were enrolled into the study. PBMCs were isolated by Ficoll density gradient centrifugation and cultured. Supernatants were tested for interleukin 6 (IL-6), IL-1β and IL-1 receptor antagonist (IL-1Ra) concentration by ELISA., Results: HD centers 1, 2, 3 and 4 had mean dialysate endotoxin contamination levels of 0.001, 0.026, 0.558 and 1.960 EU/ml, respectively. HD center 4 had the highest levels of IL-6 (1,052.3 ± 240.7 pg/10(6) PBMCs), IL-1β (1,297.1 ± 334.6 pg/10(6) PBMCs) and IL-1Ra (2,713.4 ± 1,255.3 pg/10(6) PBMCs). There were no significant differences in cytokine production between HD centers 1 and 2., Conclusion: Our study showed that ultrapure dialysate can minimize the risk of stimulating inflammatory cells. Ultrapure dialysate may prevent or delay endotoxin exposure-related complications., (Copyright © 2011 S. Karger AG, Basel.)

Objective: To evaluate 25 hydroxyvitamin D (25-OH-D) deficiency in a cohort ofpredialysis CKD patients and the treatment effect and safety of high dose ergocalciferol supplement in predialysis CKD., Material and Method: Fifty-six predialysis CKD patients who came for a regular visit at a single hospital with calculated glomerular filtration rate < or =60 mL/min/1.73 m2 were screened for 25-OH-D levels. Forty-four patients with 25-OH-D deficiency were recruited into this prospective observational study that examined the effect of high dose oral ergocalciferol supplementation. After eight weeks, 37 patients completed the follow-up and biochemical parameters were reevaluated and analyzed., Results: The mean 25-OH-D level of 56 patients was 25.6 +/- 8 ng/mL. Forty-four (78.5%) patients had 25-OH-D levels less than 30 ng/mL and four (7.1%) had severe deficiency with the level less than 15 ng/mL. High dose ergocalciferol supplement successively increased 25-OH-D levels in 35 (95%) patients. 25-OH-D levels increased significantly from 22 +/- 4.8 to 34.5 +/- 10.8 ng/mL after eight weeks (p < 0.001). During the study period, there were no changes in serum calcium, phosphate, and PTH. There was no other side effect associated with the treatment., Conclusion: 25-OH-D deficiency were found in this cohort of predialysis CKD patients. Ergocalciferol was a safe and effective supplement for the 25-OH-D in predialysis CKD.

Growing evidence suggests the superiority of on-line hemodiafiltration (HDF) compared with the conventional hemodialysis technique in many aspects; however, on-line HDF is still not used worldwide, including in Southeast Asia. The purpose of this study is to compare various clinical outcomes between on-line HDF and high-flux hemodialysis (HFHD). This was a single-center three-year prospective observational study that demonstrated the clinical parameters after switching from HFHD to on-line HDF in 22 HDF patients, whose average age was 58.1 +/- 13.3 years. The incidence of intradialytic undesired events, including hypotension, decreased and an apparent increase in appetite and an improvement in overall well-being were recorded by most patients after switching to on-line HDF. The data for dry weight, body mass index, and normalized protein nitrogen appearance, which represent nutritional status, showed a significant improvement while still maintaining a satisfactory albumin level. The adequacy in terms of urea reduction ratio significantly increased. The serum predialysis beta(2)-microglobulin levels were reduced by 25.7% from 31.1 +/- 3.1 to 23.1 +/- 4.8 mg/L (P < 0.05) at six months and remained constant during the three years of follow-up. The patients' lipid profile was well controlled, and the mean C-reactive protein value was still maintained in the normal range. In conclusion, our three-year experience showed that on-line HDF is a well-tolerated treatment with a lower incidence of intradialytic undesired events. The potential benefits may include the effective removal of higher molecular weight uremic toxins and an improved nutritional status, along with a low inflammatory state.

Objective: Tubulointerstitial fibrosis plays an essential role in progression to end stage renal disease (ESRD) in various chronic renal failure (CRF) models including the 5/6 nephrectomy (5/6). The present study examines the renoprotective effect of citrate in the renal ablative model that is quite similar to CRF in human., Material and Method: Male Wistar rats underwent 5/6 and were fed with tap water (5/6tap) or tap water containing 67 mEq/L citrate solution (5/6cit). Sham-operated rats (S) were divided into Stap and Scit groups. Renal function, renal histopathology, renal alpha-Smooth muscle actin (SMA), and renal transforming growth factor (TGF)-beta1 were determined immediately and at the 8th week after operation., Results: Following the surgery, the values of glomerular filtration rate (GFR) in the 5/6tap and the 5/6cit groups were 2.39 +/- 0.25 and 2.35 +/- 0.25 (mL/kg/min), respectively, both were significantly lower than sham groups (p < 0.05). At the eighth week, the 5/6tap group had progressively decreased GFR and had higher fibrosis score, increased alpha-SMA positive cells, and renal tissue TGF- beta1 when compared with the sham groups. The 5/ 6cit group, when compared with the 5/6tap group, had higher GFR (2.51 +/- 0.22 vs 1.17 +/- 0.33 mL/kg/min; p < 0.05), lower fibrosis score (1.83 +/- 0.88 vs 3.0 +/- 0.4, p < 0.001), lower alpha-SMA activity (159 +/- 2.9 vs 187 +/- 12.3 cells per 1000 interstitial cells, p < 0.05), and lower renal TGF-beta1 levels (1771.3 +/- 239.5 vs 4716.9 +/- 871.2 pg/mg protein, p < 0.005)., Conclusion: As such, in 5/6 nephrectomized rats, citrate therapy for eight weeks could decrease tubulointerstitial fibrosis mainly by reducing the heightened renal TGF-beta1 levels and additionally by attenuating the increased myofibroblast activity.

Objective: To compare beta2-microglobulin (beta2M) clearance between on-line hemodiafiltration (HDF) and high flux hemodialysis (HFHD)., Material and Method: The total, convection/diffusion, and membrane adsorption components of beta2M clearance in 10 hemodialysis patients treated with on-line HDF at the replacement fluid rates of 75 (HDF75) and 125 (HDF125) mL/min, were determined and compared with HFHD., Results: The total beta2M clearance in the HDF 125 group was significantly higher than the HDF75 group (124.5 +/- 4.4 vs 101.3 +/- 4.1 mL/min; p < 0.05); both values were much greater than the HFHD group (p < 0.01). The convection/diffusion was the major portion of total beta2M clearance in all three groups. The values of convection/diffusion and membrane adsorption in both HDF groups were about 2 and 3 times, respectively, of the HFHD group (p < 0.01). Both components of beta2M clearance in the HDF125 group did not statistically differ from the HDF75 group, however; the value of convection/diffusion clearance in HDF125 was more than in the HDF75 group. Regarding Kt/Vurea and phosphate clearance, there were no significant differences among the study groups., Conclusion: On-line HDF could provide more beta2M clearance than HFHD by increasing both the convection/ diffusion, and membrane adsorption clearances. HDF125 provided more total beta2M clearance than HDF75 from the convection/diffusion mechanism while the adsorptive mechanisms were equal.