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Background Urinary tract infections (UTIs) caused by uropathogenic Escherichia coli (UPEC) are one of the most common outpatient bacterial infections. Although bacterial and host factors are reported to be associated with UTI pathogenesis, little is known about the host age-related differences in bacterial virulence factors and antimicrobial susceptibility. Methods PCRs were carried out to detect K1 capsule antigen, 15 virulence factors, and phylogenetic groups in E. coli isolates. Antimicrobial susceptibility of selected agents was determined by the disk diffusion method. Isolates were divided into 6 groups based on their host age. Results The results showed that virulence factors PapGII, PapGIII, Cnf1, Aer, Usp, Iha, OmpT, HlyA, and Sat, had highest frequencies in the host age group 0–3. Phylogenetic group B2 dominated in our isolates (59.6%) followed by group D (20.7%). In addition, 77.4% of strains isolated from 0 to 3 age group belonged to phylogenetic group B2. Antimicrobial susceptibility tests showed that E. coli strains isolated were significantly more resistant to antimicrobial agents as host age increased. Phylogenetic group B2 isolates were more susceptible to antimicrobial agents, compared to A, B1, and D isolates. Conclusion We found E. coli isolated from elders were more resistant to antimicrobial agents and had less virulence factors.

To identify whether urolithiasis with or without hydronephrosis has an impact on acute kidney injury (AKI) in patients with urinary tract infection (UTI). This study aimed to identify whether urolithiasis with or without hydronephrosis has an impact on AKI in patients with UTI. This retrospective study enrolled hospitalized UTI patients who underwent imaging in an acute care setting from January 2006 to April 2019. Of the 1113 participants enrolled, 191 (17.2%) had urolithiasis and 76 (6.8%) had ureteral stone complicated with hydronephrosis. Multivariate logistic regression analysis showed that in UTI patients with urolithiasis, the presence of ureteral stone with concomitant hydronephrosis was an independent risk factor for AKI (odds ratio [OR] 2.299, 95% confidence interval [CI] 1.112–4.755, P = 0.025). In addition, urolithiasis was associated with an increased risk for AKI (OR 2.451, 95% CI 1.369–4.389, P = 0.003) in UTI patients without hydronephrosis. The presence of ureteral stone with hydronephrosis increases the risk for AKI of UTI patients with urolithiasis, and urolithiasis remains a risk factor of AKI in UTI patients without hydronephrosis.

This study aimed to assess the impact of diabetic retinopathy (DR) severity on the incidence of major adverse cardiac events (MACE) and end-stage renal disease (ESRD) in T1D patients. Patients diagnosed with T1D between 1999 and 2013 were identified from patient-level data of Taiwan’s National Health Insurance Research database. A total of 1135 patients were included and classified into mild DR (n = 454), severe DR (n = 227), or non-DR (n = 454) by using propensity score matching. Multi-state model analyses, an extension of competing risk models with adjustment for transition-specific covariates for prediction of subsequent MACE and ESRD, were performed. MACE and ESRD risks were significantly higher in the severe DR patients; a 2.97-fold (1.73, 5.07) and 12.29-fold (6.50, 23.23) increase in the MACE risk among the severe DR patients compared to the mild DR and DR-free patients, respectively; and, a 5.91-fold (3.50, 9.99) and 82.31-fold (29.07, 233.04) greater ESRD risk of severe DR patients than that of the mild DR and DR-free groups, respectively (p

Gut microbiota have been targeted by alternative therapies for non-communicable diseases. We examined the gut microbiota of a healthy Taiwanese population, identified various bacterial drivers in different demographics, and compared them with dialysis patients to associate kidney disease progression with changes in gut microbiota.This was a cross-sectional cohort study.Fecal samples were obtained from 119 healthy Taiwanese volunteers, and 16S rRNA sequencing was done on the V3-V4 regions to identify the bacterial enterotypes. Twenty-six samples from the above cohort were compared with fecal samples from 22 peritoneal dialysis and 16 hemodialysis patients to identify species-level bacterial biomarkers in the dysbiotic gut of chronic kidney disease (CKD) patients.Specific bacterial species were identified pertaining to different demographics such as gender, age, BMI, physical activity, and sleeping habits. Dialysis patients had a significant difference in gut microbiome composition compared to healthy controls. The most abundant genus identified in CKD patients wasThis study characterizes the healthy gut microbiome of a Taiwanese population in terms of various demographics. In a case-control examination, the results showed the alteration in gut microbiota in CKD patients corresponding to different dialysis treatments. Also, this study identified the bacterial species abundant in CKD patients and their possible role in complicating the patients' condition.

Peritonitis is a serious complication and major cause of treatment failure in patients undergoing peritoneal dialysis (PD). Escherichia coli is the major pathogen in extraintestinal Gram-negative infections, including PD-related peritonitis. The outcomes of E. coli peritonitis in PD varied from relatively favorable outcomes to a higher incidence of treatment failure. The aim of this study was to investigate the impact of bacterial virulence and host characteristics on the outcomes of PD-related peritonitis caused by E. coli. From January 2000 to June 2016, a total of 47 episodes of monomicrobial and 10 episodes of polymicrobial E. coli PD-related peritonitis, as well as 89 episodes of monomicrobial Gram-positive (56 Staphylococcus spp. and 33 Streptococcus spp.) PD-related peritonitis cases, were retrospectively enrolled. Clinical features, E. coli bacterial virulence, and outcomes were analyzed. Compared to Streptococcus spp. peritonitis, E. coli peritonitis had a higher peritoneal catheter removal rate (38 versus 12%; P = 0.0115). Compared to the monomicrobial group, patients in polymicrobial group were older and had higher peritoneal catheter removal rate (80 versus 38%; P = 0.0324). Treatment failure of E. coli peritonitis was associated with more polymicrobial peritonitis and immunocompromised comorbidity, longer duration of PD therapy, and more antimicrobial resistance. E. coli isolates with more iron-related genes had higher prevalence of phylogenetic group B2 and papG II, iha, ompT, and usp genes. This study demonstrates the important roles of clinical and bacterial characteristics in the outcomes of monomicrobial and polymicrobial E. coli PD-related peritonitis.

Nonalcoholic fatty liver disease (NAFLD) is associated with increased arterial stiffness. Although chronic hepatitis C virus (HCV) infection was shown to be associated with metabolic disorder and chronic inflammation, the effects of chronic HCV infection on arterial stiffness remain unclear. This study recruited 221 patients including 32 normal controls, 72 NAFLD patients, and 117 subjects with HCV infection. Arterial stiffness was assessed by peripheral arterial stiffness index, Compliance Index (CI), and central arterial stiffness index, Stiffness Index derived from digital volume pulse by photoplethysmography. Levels of oxidative stress marker and inflammatory markers were also measured. The HCV group had significantly lower CI (4.8 ± 3.1 units vs. 3.9 ± 2.1 units vs. 3.0 ± 1.7 units; P for trend.001) and higher Stiffness Index (7.0 ± 1.6 m/s vs. 8.3 ± 2.3 m/s vs. 8.4 ± 2.3 m/s; P for trend = .001) compared with the normal controls and NAFLD groups. Multivariate linear regression analysis showed that CI was independently correlated with systolic blood pressure (beta = -0.202, P = .013) and HCV infection (beta = -0.216, P = .036). Chronic HCV infection was independently associated with peripheral arterial stiffness. Peripheral arterial stiffness in chronic HCV infection was not associated with a marker of general inflammation (high-sensitivity C-reactive protein); however, a role for more specific markers of inflammation cannot be ruled out.

The dairy products remain as the largest reservoir for isolation of probiotic microorganisms. While probiotics have been immensely reported to exert various health benefits, it is also a common notion that these health potentials are strain and host dependent, leading to the need of more human evidence based on specific strains, health targets, and populations. This randomized, single-blind, and placebo-controlled human study aimed to evaluate the potential benefits of putative probiotic strains isolated from kefir on gastrointestinal parameters in fifty-six healthy adults. The consumption of AB-kefir (Bifidobacterium longum, Lactobacillus acidophilus, L. fermentum, L. helveticus, L. paracasei, L. rhamnosus, and Streptococcus thermophiles; total 10 log CFU/sachet) daily for 3 week reduced symptoms of abdominal pain, bloating (P = 0.014), and appetite (P = 0.041) in male subjects as compared to the control. Gut microbiota distribution profiles were shifted upon consumption of AB-kefir compared to baseline, where the abundance of bifidobacteria was increased in male subjects and maintained upon cessation of AB-kefir consumption. The consumption of AB-kefir also increased gastrointestinal abundance of total anaerobes (P = 0.038) and total bacterial (P = 0.049) in female subjects compared to the control after 3 weeks. Our results indicated that AB-kefir could potentially be developed as a natural strategy to improve gastrointestinal functions in adults.

Background Hemodialysis patients have a high risk of mortality. The most common causes of death are cardiovascular disease and infection. The potential hazard or benefit associated with vitamin D use and cardiovascular or infection outcome is poorly characterized. Methods We conducted a retrospective observational cohort study by recruiting 52,757 patients older than 20 years from Taiwan National Health Insurance Research Database (NHIRD) who initiated maintenance hemodialysis between 2001 and 2009. Patients who were prescribed activated vitamin D before the 360th day from hemodialysis initiation were defined as vitamin D users. The primary outcome of interest includes occurrence of acute myocardial infarction (AMI), ischemic stroke, lower limb amputation, and hospitalization for infection, respectively, while death events are treated as competing events. We conducted competing risk analysis using subdistribution hazard regression model to estimate subdistribution hazard ratios (SHRs) in relation to various outcomes. Results During the median follow-up of 1019 days, the vitamin D users had a lower crude mortality rate, lower incidences of AMI, ischemic stroke, amputation, and hospitalization for infection compared with non-users. Taking into consideration competing events of death, vitamin D users were associated with a lower hazard of lower limb amputation (SHR 0.84 [95% CI, 0.74–0.96]) and hospitalization for infection (SHR 0.90 [95% CI, 0.87–0.94]), but not AMI or ischemic stroke, after adjustment for potential confounders. Subgroup analyses and dose response evaluation both showed a consistent association of activated vitamin D treatment with decreased risk of amputation and infection. Conclusion The findings suggest that therapeutic activated vitamin D use in hemodialysis patients may be beneficial for decreasing infection events and amputation, of which the latter is a complication of peripheral vascular disease, rather than reducing major atherosclerotic cardiovascular events such as AMI or ischemic stroke.

It remains unclear how different uses of angiotensin-converting inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) influence the progression of chronic kidney disease (CKD). This study explored CKD progression in a multicentre, longitudinal cohort study that included 2639 patients with CKD stage 1–5 and hypertension. Patients treated with ACEI or ARB for ≥90 days during a 6-mo period comprised the study group, or no treatment, comprised the control group. The study group was subdivided on the basis of treatment: ACEI monotherapy or ARB monotherapy. Progression of renal deterioration was defined by an average eGFR decline of more than 5 mL/min/1.73 m2/yr or the commencement of dialysis. With at least 1-year follow up, a progression of renal deterioration was demonstrated in 29.70% of the control group and 25.09% of the study group. Patients in the study group had significantly reduced progression of CKD with adjusted odds ratio 0.79 (95% confidence interval: 0.63–0.99). However, when ACEI monotherapy and ARB monotherapy were analyzed separately, none of their associations with CKD progression was statistically significant. In conclusion, ACEI or ARB monotherapy may retard the deterioration of renal function among patients with CKD and hypertension.

Background Sclerostin, an antagonist of the Wingless-type mouse mammary tumor virus integration site (Wnt) pathway that regulates bone metabolism, is a potential contributor of chronic kidney disease (CKD)–mineral and bone disorder (MBD), which has various forms of presentation, from osteoporosis to vascular calcification. The positive association of sclerostin with bone mineral density (BMD) has been demonstrated in CKD and hemodialysis (HD) patients but not in peritoneal dialysis (PD) patients. This study assessed the association between sclerostin and BMD in PD patients. Methods Eighty-nine PD patients were enrolled; their sera were collected for measurement of sclerostin and other CKD–MBD-related markers. BMD was also assessed simultaneously. We examined the relationship between sclerostin and each parameter through Spearman correlation analysis and by comparing group data between patients with above- and below-median sclerostin levels. Univariate and multiple logistic regression models were employed to define the most predictive of sclerostin levels in the above-median category. Results Bivariate analysis revealed that sclerostin was correlated with spine BMD (r = 0.271, P = 0.011), spine BMD T-score (r = 0.274, P = 0.010), spine BMD Z-score (r = 0.237, P = 0.027), and intact parathyroid hormone (PTH; r = − 0.357, P

Aim To assess the relationship between acarbose and hepatotoxicity, cardiovascular disease (CVD), and mortality among type 2 diabetes (T2D) patients with end-stage renal disease (ESRD). Methods 32,531 T2D patients with ESRD were identified from Taiwan’s National Health Insurance Research Database in 2000~∼2012 and followed up until 2013. 19.3% of subjects were newly initiated with acarbose during the follow-up. The use of acarbose was quantified as the numbers of the 30-day drug’s supplies and dosages (measured by defined daily doses; DDDs), respectively. Time-varying Cox models were applied to evaluate the association of acarbose use with hepatic, cardiovascular and mortality outcomes, with adjustment for patients’ demographics, comorbidities, diabetes severity, and co-medications. Results For each 30-day supply increase in acarbose exposure, the risks of hepatic injury, composite CVD events, and all-cause mortality were significantly lowered by 9% (95% confidence interval: 6–12%), 7% (6–7%) and 7% (7–8%), respectively, while for each 30-day DDD increase in acarbose exposure, the risks for three aforementioned outcomes were significantly reduced by 45% (33–54%), 33% (29–36%) and 35% (32–39%), respectively. In subgroup analyses, the favorable study outcomes of acarbose use were more apparent among patients with more severe diabetes, a longer diabetes duration, or absence of established CVD at baseline. Conclusion Acarbose used in real-world T2D patients with ESRD may have hepatic and cardiovascular safety.

The Kidney Disease Quality of Life–36 Questionnaire (KDQOL-36™), modified by RAND, has been widely used for measurement of quality of life among hemodialysis or peritoneal dialysis patients. The purpose of this study was to refine and evaluate, by using confirmatory factor analysis, the structure of the KDQOL-36™ when the questionnaire was used to evaluate chronic kidney disease patients in Stages 1 to 5 in Taiwan. The psychometric properties of the translated version were determined among Mandarin-speaking adults ( N = 428). Because the sample data did not fit the hypothetical model, one item was deleted and nine error terms were estimated. After improving the model fit, the modified model was presented as follows: χ2 = 1390.903, χ2/ df = 2.711, p < .001, goodness-of-fit index = .833, adjusted goodness-of-fit index = .806, root mean square error of approximation = .063. According to the study results, the researchers suggest that because of content overlap, some items may be deducted from the KDQOL-36™.

This study investigated the characteristics of patients with different chronic kidney disease (CKD) stages according to various body mass index (BMI) categories and determined the influence of BMI in renal function deterioration. We conducted a multicenter, longitudinal cohort study based on the Epidemiology and Risk Factors Surveillance of CKD project (2008-2013) and National Health Insurance Research Database (2001-2013). A total of 7357 patients with CKD aged 20-85 years from 14 hospitals were included in the study. A higher male sex, diabetes mellitus (DM) and hypertension were noted among overweight and obese CKD patients, while more cancer prevalence was noted among underweight CKD patients. Charlson comorbidity index was significantly higher and correlated with BMI among late CKD patients. Patients with BMI 18.5 kg/m

Background Patients with end stage renal disease have a high all-cause and cardiovascular mortality. Secondary hyperparathyroidism and vitamin D deficiency are considered part of the mechanism for the excess mortality observed. We aimed to evaluate the relationship between vitamin D use and all-cause mortality. Methods In this retrospective cohort study, we included all incident patients who started hemodialysis in Taiwan between 2001 and 2009. Patients were followed from landmark time, i.e., the 360th day from hemodialysis initiation, through the end of 2010 or death. We evaluated the association between activated vitamin D use or not before landmark time and all-cause mortality using conditional landmark analysis with Cox regression. We used group-based trajectory model to categorize high-dose versus average-dose users to evaluate dose-response relationships. Results During the median follow-up of 1019 days from landmark time, vitamin D users had a lower crude mortality rate than non-users (8.98 versus 12.93 per 100 person-years). Compared with non-users, vitamin D users was associated with a lower risk of death in multivariate Cox model (HR 0.91 [95% CI, 0.87–0.95]) and after propensity score matching (HR 0.94 [95% CI, 0.90–0.98]). High-dose vitamin D users had a lower risk of death than conventional-dose users, HR 0.75 [95% CI, 0.63–0.89]. The association of vitamin D treatment with reduced mortality did not alter when we re-defined landmark time as the 180th day or repeated analyses in patients who underwent hemodialysis in the hospital setting. Conclusions Our findings supported the survival benefits of activated vitamin D among incident hemodialysis patients. Electronic supplementary material The online version of this article (10.1186/s12882-018-1111-2) contains supplementary material, which is available to authorized users.

Background/Purpose(s) Gram-negative peritonitis is a frequent and serious complication of peritoneal dialysis (PD). No previous reports have focused on Klebsiella pneumoniae infection. The aim of this study was to investigate the host and bacterial factors associated with K. pneumoniae PD-related peritonitis. Methods We retrospectively studied K. pneumoniae PD-peritonitis cases treated at a university hospital in southern Taiwan during 1990–2011, and analyzed the clinical features and outcomes and bacterial characteristics of serotypes, hypermucoviscosity (HV), and virulence-associated genes such as wabG, uge, and rmpA in K. pneumoniae PD-related peritonitis. Fifty-four isolates of K. pneumoniae -related community-acquired urinary tract infection (UTI) and 76 morphologically different nonpathogenic K. pneumoniae isolates from healthy adults were used as controls. Results K. pneumoniae was the second most common monomicrobial pathogen causing Gram-negative PD-related peritonitis ( n = 13, 2.7%), and the most common pathogen involved in polymicrobial peritonitis (16/43, 37.2%) and associated with high catheter removal rate (7/16, 43.8%). Compared with Escherichia coli peritonitis cases, patients with monomicrobial K. pneumoniae peritonitis also had insignificantly higher incidence of sepsis/bacteremia [ n = 5 (38%), p = 0.11] and a higher mortality rate [ n = 3 (23%), p = 0.36]. The prevalence of K1/K2 ( n = 1, 7.7%) serotypes was low, but there was a higher prevalence of serotype K20 ( n = 3, 23.1%) in K. pneumoniae isolates derived from monomicrobial PD-related peritonitis compared with control groups. HV phenotype ( p rmpA genotype ( p = 0.007) were absent in the peritonitis group. Conclusion This is the first study focused on clinical and microbiological characteristics of K. pneumoniae PD-related peritonitis. K. pneumoniae was a common Gram-negative pathogen causing monomicrobial and polymicrobial PD-related peritonitis in southern Taiwan. The bacterial characteristics with low percentage of capsular serotype K1/K2, no significant HV, and absence of rmpA suggest a different pathogenesis in K. pneumoniae PD-related peritonitis compared with that in UTI and liver abscess.

Background: Compliance index derived from digital volume pulse (CI-DVP), measuring the relationship between volume and pressure changes in fingertip, is a surrogate marker of peripheral arterial stiffness. This study investigated if CI-DVP can predict renal function deterioration, cardiovascular events and mortality in patients with chronic kidney disease (CKD). Methods: In this prospective observational study, 149 CKD patients were included for final analysis. CI-DVP and brachial-ankle pulse wave velocity (baPWV) were measured, decline in renal function was assessed by the estimated glomerular filtration rate (eGFR) slope. Composite renal and cardiovascular outcomes were evaluated, including ≥50% eGFR decline, start of renal replacement therapy, and major adverse events. Results: Patients in CKD stages 3b to 5 had higher baPWV and lower CI-DVP values than those in patients with CKD stages 1 to 3a. Stepwise multivariate linear regression analysis showed that lower CI-DVP (p =0.0001) and greater proteinuria (p =0.0023) were independent determinants of higher eGFR decline rate. Multivariate Cox regression analysis revealed that CI-DVP (HR 0.68, 95% CI 0.46-1.00), baseline eGFR (HR 0.96, 95% CI 0.94-0.98) and serum albumin (HR 0.17, 95% CI 0.07-0.42) were independent predictors for composite renal and cardiovascular outcomes. Conclusions: Compliance index, CI-DVP, was significantly associated with renal function decline in patients with CKD. A higher CI-DVP may have independent prognostic value in slower renal function decline and better composite renal and cardiovascular outcomes in CKD patients.

Understanding the pathogenesis of recurrent urinary tract infection (RUTI) and whether it is attributable to reinfection with a new strain or relapse with the primary infecting strain is of considerable importance. Because previous studies regarding community-acquired Klebsiella pneumoniae RUTI are inconclusive, we undertook this study to evaluate the characteristics of the host and the bacterial agent K. pneumoniae in RUTI. A prospective study was designed, using consecutive patients diagnosed with community-acquired K. pneumoniae-related UTI from January 2007 to December 2009. Of the total 468 consecutive episodes, we found 7 patients with RUTI. All the patients with RUTI were elderly (median, 74 years), with diabetes (100 %, 7 out of 7). Clinical K. pneumoniae isolates derived from the same patients with RUTI revealed identical genomic fingerprints, indicating that K. pneumoniae UTI relapsed despite appropriate antibiotic therapy. The antimicrobial resistance, growth curve and biofilm formation of the recurrent isolates did not change. K. pneumoniae strains causing RUTI had more adhesion and invasiveness than the colonization strains (p < 0.01). When we compared the recurrent strains with the community-acquired UTI strains, the prevalence of diabetes mellitus was significant (100 % vs 53.7 %, p = 0.03) in the RUTI group. Our data suggest that K. pneumoniae strains might be able to persist within the urinary tract despite appropriate antibiotic treatment, and the greater adhesion and invasiveness in the recurrent strains may play an important role in recurrent infections.

Aim End-stage renal disease (ESRD) is a common finding in systemic lupus erythematosus (SLE) and may contribute to mortality. The purpose of the study was to investigate the incidence of ESRD and all-cause mortality and their risk factors in patients newly diagnosed with SLE in Taiwan. Methods This nationwide cohort study used data from the National Health Insurance Research Database. We identified 4130 newly diagnosed SLE patients at risk for ESRD during 2000–2002; among them, 103 developed ESRD by the end of 2008. Additional 412 age- and sex-matched incident ESRD non-SLE patients served as controls for the survival analysis. Results Of the newly diagnosed SLE patients, 2.5% developed ESRD. Age (adjusted hazards ratio [HR] 0.66 for each 1-year increase; 95% confidence interval [CI] 0.47–0.94) and male gender (adjusted HR 2.24; 95% CI 1.4–3.6) were significantly associated with ESRD development. Survival analysis conducted after ESRD development revealed a higher mortality risk among the older patients (HR 1.04; 95% CI 1.02–1.05). Survival analysis in the younger population (age

Objective Malnutrition is common in patients with chronic kidney disease (CKD) who are on low-protein diets and is a powerful predictor of morbidity and mortality in CKD. Studies have shown that patients on low-protein diets often have difficulty meeting nutritional energy requirements. Our study evaluated the effects of a nonprotein calorie (NPC) supplement on renal function and nutritional status in patients on a low-protein diet. Design This was a prospective, randomized, open-label, controlled clinical trial. Subjects A total of 109 patients with CKD (men, 67%; mean age, 54.5 ± 13 years) with stage 3 to 4 disease were randomly assigned to the intervention group (n = 55) or the control group (n = 54). Intervention All participants received individualized dietary counseling aimed at achieving a daily protein intake of 0.6 to 0.8 g and a daily energy intake of 30 to 35 kcal/kg. The intervention group consumed a 200-kcal NPC supplement daily. The control group received dietary counseling only. Main Outcome Measure The estimated glomerular filtration rate (eGFR) was calculated using the 4-variable Modification of Diet in Renal Disease (MDRD) Study equation. Urine protein excretion, dietary protein and energy intake, and serum levels of creatinine, urea nitrogen, cholesterol, triglycerides, and albumin were assessed at baseline, at 12 weeks, and at 24 weeks. Results Dietary protein intake and urine protein excretion levels decreased significantly in the intervention group and were significantly lower than those of the control group. In addition, serum levels of creatinine and urea nitrogen decreased significantly, and eGFR increased significantly in the intervention group compared with baseline assessments. No significant differences were observed in the control group. Conclusions The NPC supplement improved patient adherence to the low-protein diet and reduced urine protein excretion in patients with CKD.

Premature arteriosclerosis may be one of the mechanisms linking pre-diabetes mellitus (pre-DM) and cardiovascular disease. We sought to characterize premature arteriosclerosis in pre-DM using different arterial stiffness indices and to find the independent contributors of this process. We recruited 33 patients without DM, 53 patients with pre-DM, and 34 subjects with DM. Both the compliance index (CI) and stiffness index (SI) were measured. Patients with pre-DM and DM had lower CI (3.8 ± 2.1 versus 5.2 ± 3.0 units; P < 0.05 and 3.6 ± 1.8 versus 5.2 ± 3.0 units; P < 0.05, respectively) and higher SI (8.0 ± 2.0 versus 6.7 ± 1.6 m/s; P < 0.01 and 9.4 ± 2.3 versus 6.7 ± 1.6 m/s; P < 0.001, respectively) than patients without DM. Using multivariate linear regression analysis, age, heart rate, and HOMA index were independent determinants for SI (whole model: R(2) = 0.47, P < 0.001), whereas male gender, hsCRP, and HOMA index were independent determinants for CI (whole model: R(2) = 0.34, P < 0.01). The HOMA index was an independent determinant for arterial stiffness. Increased insulin resistance may associate with increased arterial stiffness at peripheral arteries in pre-DM patients.

OBJECTIVE Because of the increasing incidence and prevalence of diabetes as a leading cause of end-stage renal disease (ESRD) in the aging population, we estimated the expected life-years (LYs) saved from successful prevention of ESRD in elderly patients with diabetes. RESEARCH DESIGN AND METHODS We conducted a population-based cohort study using the National Health Insurance Research Database. We identified all incidences of ESRD in the individuals >65 years of age who were receiving maintenance hemodialysis (N = 24,243) from the registry files of catastrophic illnesses in Taiwan from 1 July 1997 to 31 December 2005. We then retrospectively searched the database to determine whether there had been a diagnosis of diabetes in these cases. After the exclusion of individuals with malignancy (n = 3,423), we extrapolated the survival rates through the end of 2006 using the Monte Carlo method. Using the data of preventable ESRD cases due to diabetes and expected years of life lost (EYLL) in each age stratum, we further estimated the expected LYs saved from successful prevention of ESRD in elderly patients with diabetes. RESULTS The estimated average EYLL was 10.6–5.8 and 12.3–7.3 years for diabetic males and females, respectively, aged 65–79 years. In total, 5,430.1 LYs and 10,177 LYs could be saved by the successful prevention of ESRD in male and female elderly patients with diabetes, respectively, in a single year. CONCLUSIONS The LYs saved by successful prevention of ESRD in elderly patients with diabetes in a single year are substantial and deserve special attention, especially in elderly females.

A retrospective study was conducted at a Taiwanese medical center to characterize bloodstream infections caused by IMP-8 metallo-β-lactamase (MBL)-producing Enterobacteriaceae isolates and to assess the need for laboratory detection of IMP producers. We analyzed 37 patients infected with IMP-8 producers (two Escherichia coli, nine Klebsiella pneumoniae, 25 Enterobacter cloacae, and one Citrobacter freundii) and 107 patients infected with non-IMP-8 producers (eight E. coli, 26 K. pneumoniae, 70 E. cloacae, and three C. freundii) that were interpreted as carbapenem-nonsusceptible based on the updated Clinical and Laboratory Standards Institute (CLSI) 2010 guidelines. Only 18 (48.6 %) of the IMP-8 producers were regarded as potential carbapenemase producers based on the CLSI 2012 guidelines. The production of extended-spectrum β-lactamases (ESBLs) was more common in the MBL group (73.0 %) than in the non-MBL group (41.1 %). There were no significant differences in carbapenem susceptibilities, clinical characteristics, carbapenem use for empirical and definitive treatment, and mortality rates between the two groups. Eighteen IMP-8 producers could be deemed as resistant to all carbapenems [minimum inhibitory concentration (MIC) of any carbapenem ≥2 μg/mL]; patients with these isolates had a lower, but non-significant, 28-day mortality rate (27.8 %) than patients infected with non-MBL producers having similar carbapenem MICs (39.0 %) (p = 0.41). A multivariate analysis revealed severity of acute illness as the single independent variable associated with both 7-day and 28-day mortality rates (p < 0.01) for infections caused by Enterobacteriaceae with decreased carbapenem susceptibilities. Our findings suggest that the clinical detection of IMP-producing Enterobacteriaceae is not required even when the “old” CLSI criteria are used.

Nonalcoholic fatty liver disease (NAFLD) is associated with increasing arterial stiffness. We studied the effects of inflammation on different measurements of arterial stiffness in NAFLD. We recruited 80 patients with NAFLD and 40 control subjects. Both compliance index (CI) and stiffness index (SI) were measured. Patients with NAFLD had significantly lower CI (3.8 ± 2.1 vs 4.9 ± 2.9 units; P.05) and higher SI (8.5 ± 2.4 vs 7.1 ± 1.5 m/s; P.05) than the controls. Patients with NAFLD were further divided into 2 groups according to the median level of high-sensitivity C-reactive protein (hs-CRP). The CI was significantly lower in patients with NAFLD with high hs-CRP than in those with low hs-CRP (3.2 ± 1.7 vs 4.4 ± 2.5 units; P.05); however, SI was not statistically different. We further found that waist circumference (odds ratio, 1.06; 95% confidence interval, 1.01-1.13; P.05) was the only independent factor that predicted low CI (median value) in patients with NAFLD. Central obesity was an important determinant both for increased arterial stiffness and hs-CRP in Patients with NAFLD.

Matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) and conventional standard methods were compared for time to pathogen identification and impact on clinical outcomes in peritoneal dialysis-related peritonitis patients. The MALDI-TOF MS method identified the causative microorganisms earlier (average time saved, 64 h for all pathogens), and patients had a shorter hospital stay (mean ± standard deviation, 5.2 ± 4.8 days versus 8.2 ± 4.5 days, P = 0.001).

Background. In dialysis patients, protein-energy wasting (PEW) is associated with high mortality, and some indicators of PEW, such as serum albumin value, subjective global assessment (SGA) score and handgrip strength (HGS), may predict mortality. However, whether PEW is associated with poor renal outcomes and whether the indicators of PEW can predict renal outcomes in patients with non-dialysis-dependent chronic kidney disease (CKD-ND) is still unclear.Methods. We enrolled 128 clinically stable patients with CKD-ND and followed up for 33.8 +/- 9.2 months. Baseline characteristics, echocardiographic information, laboratory data, HGS, SGA scores, anthropometric parameters, bio-impedance analyses and other indicators of PEW were examined in relation to the risk of reaching renal composite end points of pre-dialysis mortality or dialysis-dependent end-stage renal disease.Results. Twenty-six patients reached composite renal end points. Multivariate Cox regression analyses showed that HGS was an independent predictor of renal outcome in patients with CKD-ND of Stages 1-5 [CKD(1-5), hazard ratio (HR) = 0.90, P = 0.004] or advanced CKD-ND of Stages 3b [defined as estimated glomerular filtration rate (eGFR) of 30-44 mL/min/1.73m(2)] to 5 (CKD(3b-5), HR 0.91, P = 0.031), but not serum albumin, SGA score or other indicators of PEW. When the cutoffs were set at 24.65 kg in men with CKD(1-5), 20.15 kg in men with CKD(3b-5) and 10.15 kg in women with CKD(1-5) or CKD(3b-5), which were deduced from receiver-operating characteristics analyses, patients with lower HGS had significantly poor renal outcomes in Kaplan-Meier survival analyses in all subgroups and higher HR for reaching renal end points in multivariate Cox regression analyses in all subgroups except for women with CKD(3b-5), whose HR had marginal significance (HR = 3.78, P = 0.068) after adjusting for age and eGFR.Conclusions. This is the first study demonstrating that HGS is an independent predictor of composite renal outcomes in CKD-ND patients. HGS can be incorporated to clinical practice for assessing nutrition status and renal prognosis in patients with CKD-ND.

Objective Auditory evoked potential (AEP) index is one of the several physiological parameters for assessing the depth of anesthesia. The purpose of this study was to investigate whether the AEP monitoring could provide a better information for assessment of anesthesia level in classic laryngeal mask airway (C-LMA) insertion than the use of clinical signs in general anesthesia with single standard dose of intravenous propofol and fentanyl. Methods One hundred and seventy adult patients requiring general anesthesia for minor surgery were recruited and randomized to receive AEP monitoring (group A) or judgment of clinical signs (group B) for assessment of anesthesia depth and optimal condition to insert the C-LMA. The insertion conditions, including jaw relaxation, movements, presence of airway trauma and airway reflex, successful insertion rate and induction time were recorded and compared. Results The two groups were demographically similar. In group A, baseline heart rate was slower than group B (74 ± 14 vs. 78 ± 14 beats/min, p = 0.0267) and persisted throughout the whole study period. There was no significant difference in the change of heart rate during induction of general anesthesia between both groups. The incidence of movement was reduced in group A patients with AEP monitoring in comparison with group B patients (2.4% vs. 28.2%, p p = 0.0126; laryngospasm was 0% versus 4.7%, p = 0.0430 and emergence of airway reflex was 1.2% versus 11.8%, p = 0.0050; the successful insertion rate was 100% versus 94.1%, p = 0.0232; and jaw relaxation was 83.5% versus 70.6%, p = 0.0448. There were no differences between both groups in trauma and induction time. Conclusion This study demonstrated that AEP index provided better information for C-LMA insertion with higher successful rate, less emergence of airway reflex and lower incidence of movement during induction of general anesthesia with single dose of intravenous propofol and fentanyl.

PCR coupled with electrospray ionization mass spectrometry (PCR/ESI-MS) was compared with culture for pathogen detection in peritoneal dialysis (PD)-related peritonitis. Of 21 samples of PD effluent, PCR/ESI-MS identified microorganisms in 18 (86%) samples, including Mycobacterium tuberculosis in 1 culture-negative sample. Of 15 double-positive samples, PCR/ESI-MS and culture reached levels of agreement of 100% (15/15) and 87.5% (7/8) at the genus and species levels, respectively. PCR/ESI-MS can be used for rapid pathogen detection in PD-related peritonitis.

BACKGROUND Glomerular hyperfiltration is closely related to diabetes and may lead to subsequent nephropathy, but the association between glomerular hyperfiltration and prediabetic state is unclear. We examined the relationship of different glycemic statuses, including normal glucose tolerance (NGT), isolated impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and newly diagnosed diabetes (NDD), with glomerular hyperfiltration. METHODS This study included 12 833 subjects ≥20 years of age without a history of renal disease, cancer, moderate/severe anemia or diabetes and taking medications for hypertension, diabetes, hyperlipidemia or cardiovascular disease from National Cheng Kung University Hospital between January 2000 and August 2009. Hyperfiltration was defined as an estimated GFR (eGFR) above the age- and gender-specific 95th percentile for apparently healthy subjects, while hypofiltration was defined as an eGFR below the 5th percentile. eGFR was assessed using the Chronic Kidney Disease Epidemiology Collaboration equation. RESULTS After further excluding hypofiltration and adjusting for available confounders, fasting plasma glucose (FPG), 2-hour postload glucose (2hPG), 2hPG-FPG (fluctuating blood glucose), HbA1c (average blood glucose), NDD and IGT but not isolated IFG were significantly associated with increased eGFR and a higher risk of hyperfiltration {NDD: odds ratio [OR] 1.97 [95% confidence interval (CI), 1.48-2.64], P < 0.001; IGT: OR 1.34 (95% CI 1.07-1.66), P = 0.009}. CONCLUSIONS High glucose states increase hyperfiltration risk. In addition to newly diagnosed diabetes, excessively high GFR also deserves attention in subjects with IGT.

Background Chronic kidney disease (CKD) is highly prevalent in Taiwan. More than two-thirds of end-stage renal disease is associated with diabetes mellitus (DM) or hypertension (HTN). Therefore, the formulation of a special preventative policy of CKD in these patients is essential. This study surveyed 14 traditional risk factors and identified their effects on CKD in patients with HTN/DM and compared these with their effects in the general population. Methods This study included 5328 cases and 5135 controls in the CKD/HTN/DM outpatient and health centres of 10 hospitals from 2008 to 2010. Fourteen common effect factors were surveyed (four demographic, five disease and five lifestyle), and their effects on CKD were tested. Significance tests were adjusted by the Bonferroni method. Results of the stratified analyses in the variables were presented with significant heterogeneity between patients with different comorbidities. Results Male, ageing, low income, hyperuricemia and lack of exercise habits were risk factors for CKD, and their effects in people with different comorbidities were identical. Anaemia was a risk factor, and there was an additive effect between anaemia and HTN on CKD. Patients with anaemia had a higher risk when associated with HTN [odds ratio (OR) = 6.75, 95 % confidence limit (95 % CI) 4.76–9.68] but had a smaller effect in people without HTN (OR 2.83, 95 % CI 2.16–3.67). The association between hyperlipidaemia-related factors and CKD was also moderated by HTN. It was a significant risk factor in people without HTN (OR = 1.67, 95 % CI 1.38–2.01) but not in patients with HTN (OR =1.03, 95 % CI 0.89–1.19). Hepatitis B, hepatitis C, betel nut chewing, smoking, alcohol intake and groundwater use were not associated with CKD in multivariate analysis. Conclusions We considered that patients with HTN and anaemia were a high CKD risk population. Physicians with anaemic patients in outpatient clinics need to recognise that patients who also have HTN might be latent CKD cases. Electronic supplementary material The online version of this article (doi:10.1186/s12882-015-0065-x) contains supplementary material, which is available to authorized users.

● Background: Emphysematous pyelonephritis (EPN) is a rare, severe, gas-forming infection of the kidney, and its precise pathogenesis remains obscure. Methods: To investigate the roles of host and bacterial virulence factors in the pathogenesis of EPN, we compared: (1) host factors in patients with EPN (n 47) with those in patients with acute renal infections without gas formation (non-EPN; n 79), (2) the prevalence of virulence gene in causative Escherichia coli strains from 16 of the 47 EPN cases with all 79 non-EPN cases by means of polymerase chain reaction analysis, and (3) gas volumes produced by EPN and non-EPN strains cultured in broths at 3 glucose concentrations (100, 180, and 250 mg/dL [5.6, 10.0, and 13.9 mmol/L]). Results: Diabetes mellitus (DM) with poor glycemic control (ie, hemoglobin A1c level > 11%) and urinary tract obstruction were more prevalent in the EPN group. However, DM with poor glycemic control was the only host factor independently associated with EPN (odds ratio, 4.9; P 0.018). EPN strains had a greater prevalence of the uropathogenic-specific protein (usp) genes. Multivariate analyses also showed the association between usp and EPN with borderline significance (odds ratio, 8.4; P 0.057). There was no significant difference in gas production by E coli isolated from patients with or without EPN. Conclusion: DM with poor glycemic control and urinary tract obstruction are host factors predisposing to EPN. There was no difference in gas production between EPN and non-EPN E coli strains. The distribution of E coli virulence genes was remarkably similar between the 2 groups. However, the PapG II adhesin (papG II) gene is significantly decreased and the usp gene is increased with borderline significance in EPN E coli strains. Am J Kidney Dis 46:432-439. © 2005 by the National Kidney Foundation, Inc.

Objective To investigate the effects of integrated therapy on the functional status of patients with knee osteoarthritis (OA). Methods A total of 140 subjects with bilateral knee OA (Altman grade II) were randomized sequentially into 4 groups (groups I–IV). Group I received isokinetic exercises; group II received isokinetic exercise and pulse ultrasound for periarticular soft tissue pain; group III received isokinetic exercise, pulse ultrasound, and intraarticular hyaluronan therapy; and group IV acted as the control group. The therapeutic effects of the interventions were evaluated by changes in Lequesne's index, knee range of motion, peak muscle torques of knee flexion and extension, and ambulation speed after 8 weeks of treatment and at followup 1 year later. In addition, changes in visual analog scale pain and rates of attrition in each group were also recorded. Results Patients in groups I–III exhibited increased muscle peak torques and significantly reduced pain and disability after treatment and at followup. Groups II and III showed significant improvements in range of motion and ambulation speed after treatment. Group III also showed the greatest increase in walking speed and decrease in disability after treatment and at followup. Both group II and group III had significant gains in muscular strength after treatment and at followup; group III showed the greatest gains. Conclusion An integrated therapy deals with the extra- and intraarticular progressive pathologic changes, and kinesiologic management of OA is suggested for the management of knee OA.

Objectives : To study the variations of aetiology in the patients with acute pyogenic iliopsoas abscess and identify the appropriate diagnostic modalities as well as therapeutic alternatives (e.g. extraperitoneal or retrofascial percutaneous catheter drainage, PCD) other than surgery. Methods : We carried out a retrospective review and analysis of 25 patients with acute pyogenic iliopsoas abscess in our institution from August 1988 to July 1998. Blood and urine cultures, imaging studies of the plain films of the abdomen (KUB), ultrasonography (echo) and computed tomography (CT scan) were performed in all patients. The therapeutic regimens included antibiotics only, PCD or aspiration, and surgery. Results : The male to female ratio was 7:18. The mean age was 64 years old. Diabetes mellitus (64%) was the dominant predisposing or associated factor. The most common aetiological source was urinary tract infection (52%) with enteric micro-organisms ( Escherichia coli : 44% and Klebsiella spp.: 24%). Nineteen patients (76%) had pain in the abdomen, flank or back. Six cases (24%) were classified as ‘primary' abscess, and only two patients survived. Nine cases were treated with antibiotics alone, only four responded and the others expired. Of the 15 cases receiving PCD or aspiration, five cases received subsequent surgical drainage or nephrectomy and survived. Another one case of Clostridia gas gangrene received emergency fasciotomy and expired. The total mortality was extremely high (11/25, 44%). Conclusions: We concluded that: (i) the aetiology of iliopsoas abscess may vary with the country of origin, with apreponderance of urinary tract infection in our Taiwanese series; (ii) a high index of suspicion is mandatory to enable early diagnosis of acute pyogenic iliopsoas abscess, particularly for older diabetic patients with fever, pain in the abdomen or flank, limp or flexion of the ipsilateral hip; (iii) CT scan can confirm the diagnosis and define the extent of the abscess; (iv) effective management should include appropriate antibiotic therapy and drainage of the abscess; (v) image-guided PCD should be tried first because of its low morbidity. However, should it fail, subsequent surgical drainage should be performed.

Fibrosis is the final disorder of end-stage renal disease. Activation of fibroblast growth factor (FGF) 23-klotho axis could suppress renal fibrosis in mice. Also, a marked decrease of klotho expression was observed in the kidney of streptozotocin-induced diabetic rats (STZ rats). However, relation of FGF in renal fibrosis remained unclear. This study was aimed to screen the effect of hyperglycemia on FGF receptor (FGFR) and fibrosis in kidney of rats with diabetic nephropathy and investigate this potential mechanism in cultured Madin-Darby Canine Kidney (MDCK) epithelial cells. STZ rats were used to treat with insulin or phloridzin at the dose sufficient to correct hyperglycemia for understanding the changes of renal dysfunction. The cultured MDCK cells were also used to treat with high glucose, hydrogen peroxide, or tiron in addition to transfection of siRNA to silence the klotho. Both insulin and phloridzin reversed fibrosis and FGFR expressions in kidney of STZ rats. It was confirmed in high glucose-exposed MDCK cells. However, klotho failed to modify the level of FGFR in MDCK cells. Meanwhile, FGFR was restored by tiron in MDCK cells and in diabetic rats without changing blood glucose. In conclusion, interstitial fibrosis and decreased FGFR expression are observed in the kidney of diabetic rats. This change is reversed by tiron without the correction of blood glucose. Also, klotho has no effect on expression of FGFR. Thus, decrease of oxidative stress is useful for the recovery of FGFR expression and improvement of renal fibrosis in type-1 like diabetic rats.

Spontaneous bacterial peritonitis (SBP) is one of the most serious complications in patients with cirrhosis. This study aimed to investigate the prevalence of SBP caused by Escherichia coli isolates with or without the K1 capsule antigen in cirrhotic patients and the outcome. From January 2004 to January 2012, a total of 54 and 41 E. coli strains derived from patients with SBP and intestinal perforation (IP), respectively, were included for comparison in this study. Bacterial characteristics including phylogenetic groups, K1 capsule antigen, and 14 virulence factor genetic determinants, as well as data regarding patient characteristics, clinical manifestations, and in-hospital deaths, were collected and analyzed. The prevalence of the K1 capsule antigen gene neuA was more common in SBP isolates compared to IP isolates (28 % vs. 10 %, p = 0.0385). Phylogenetic groups B2 and group D were dominant in E. coli isolates with and without the K1 capsule antigen, respectively. The prevalence of virulence factors genes papG II, ompT, and usp was higher in E. coli K1 strains. There were 26 deaths (48 %) during hospitalization. Presence of the K1 capsule antigen in E. coli isolates was significantly associated with in-hospital death in cirrhotic patients with SBP (42 % vs. 14 %, p = 0.0331). This study demonstrates a higher prevalence of the K1 capsule antigen in E. coli SBP compared to E. coli peritonitis caused by IP. There were significant associations between the K1 capsule antigen and in-hospital mortality and bacterial virulence in cirrhotic patients with E. coli SBP.

Background Patients with diabetes mellitus have an increased risk of infection. The roles of bacterial characteristics and glycemic control in diabetic patients with Escherichia coli infection have not been well investigated. The aims of this study were to examine the bacterial characteristics and glycemic control in diabetic patients with E. coli infections arising in the urinary tract. Methods A total of 271 E. coli isolates were collected from urine and bloodstream. Phylogenetic groups, the presence of virulence genes, and antimicrobial susceptibility of E. coli isolates were determined. Results There were few differences in E. coli bacterial characteristics between 190 diabetic and 81 nondiabetic patients. In diabetic patients with urosepsis, there was a higher hemoglobin A 1C level, and the related E. coli strains had more neuA , papG II , afa and hlyA genes, and a lower prevalence of antimicrobial resistance to cephalosporins and fluoroquinolones than those with asymptomatic bacteriuria and urinary tract infection. Multivariate logistic regression analysis revealed that increased hemoglobin A 1C and presence of papG II and afa genes were independent factors associated with development of urosepsis in diabetic patients. Conclusion This study demonstrated that more virulent E. coli isolates, especially with papG II and afa genes, and poorer glycemic control were important determinants for development of urosepsis in diabetic patients.

BACKGROUND Progression of atherosclerosis with increased arterial stiffness is associated with increased cardiovascular morbidity and mortality in patients with chronic kidney disease (CKD). Compliance index (CI) derived from digital volume pulse (DVP), measuring the relationship between volume and pressure changes in fingertip, can evaluate the local arterial stiffness. The purpose of this study was to measure the stiffness of different arteries and determine the relationships of CI-DVP with clinical characteristics and renal function in CKD patients. METHODS This cross-sectional pilot study included 186 CKD and 46 healthy subjects. Evaluation of different arterial stiffness was performed by DVP using dual-channel photoplethysmography and measured as CI (CI-DVP) and pulse wave velocity (PWV)-DVP. RESULTS CKD patients had lower CI-DVP and higher PWV-DVP than that in the healthy group. There was a trend of stepwise decrease in CI-DVP and increase in PWV-DVP related to the advance of CKD from early to late stage. Decrease of CI-DVP was associated with the increase in number of cardiovascular risk factors. Multivariate linear regression analysis revealed that CI-DVP (B = 4.59, P < 0.01) was independently associated with estimated glomerular filtration rate (eGFR). Male gender, eGFR, and systolic blood pressure (BP) were independent determinants for CI-DVP (B = -0.25, P = 0.01; B = 0.007, P = 0.03; and B = -0.03, P < 0.0001; whole model R(2) = 0.28, P < 0.0001). CONCLUSIONS Our data demonstrate a significant association between CI-DVP, a new surrogate marker of arterial stiffness different from PWV, and renal function and cardiovascular risk factors in CKD patients.

Klebsiella pneumoniae is the second most common species causing urinary tract infections (UTI). However, the host factors and virulence genes of K. pneumoniae related to UTI are poorly understood. The aim of this study was to analyze the capsular phenotype and virulence genes of K. pneumoniae isolates and host factors potentially relevant to community-acquired UTI. Fifty-four K. pneumoniae isolates from patients with community-acquired UTI, 76 isolates from healthy adults, and 29 from patients with community-acquired pneumonia were compared. The virulence genes (rmpA, magA, uge, and wabG) and serotype (K1, K2, K5, K20, K54, or K57) were characterized by polymerase chain reaction (PCR). The modified string test was used to determine the hypermucoviscosity. Diabetes mellitus was the most frequent underlying disease among UTI patients (53.7%, 29/54). No predominant K serotype was found in UTI strains. The hypermucoviscosity phenotype and rmpA gene were more often found in UTI isolates than in those from healthy adults (27.8 vs. 2.6%, P

SUMMARY: Background: It is well known that both pressure and volume overloads contribute to left ventricular hypertrophy (LVH) and left ventricular dilatation in patients with chronic kidney disease (CKD). Few studies have evaluated the association between increased pulse wave velocity (PWV) and LVH in CKD patients not yet receiving dialysis. The purpose of this study was to assess the relationship between arterial stiffness and cardiac remodelling in patients with CKD, and to determine the independent factors associated with increased left ventricular mass index (LVMI) and left ventricular volume index (LVVI). Methods: This cross-sectional study included 96 patients with CKD. Echocardiography and measurement of arterial stiffness by PWV were performed. Clinical and echocardiographic parameters were compared and analysed. Results: Associated with the increase of PWV, there were significant trends for progressive increase in LVMI, LVH, LVVI, left ventricular dilatation and left atrium in CKD patients. Multivariate regression analysis revealed that decreased PWV, in addition to increased haemoglobin and the use of β-blocker, was an independent determinant associated with decrease in LVMI and LVVI. Conclusion: Our study demonstrated the progressive structural remodelling of left ventricle and left atrium in CKD patients associated with increased severity of arterial stiffness. PWV was an important determinant of LVMI and LVVI in CKD patients.

Acute kidney injury (AKI) is associated with high morbidity and mortality. Urinary tract infection (UTI) may be associated with sepsis or septic shock, and cause sudden deterioration of renal function. This study investigated the clinical characteristics and change of renal function to identify the risk factors for development of AKI in UTI patients. This retrospective study was conducted in a tertiary referral center. From January 2006 to January 2013, a total of 790 UTI patients necessitating hospital admission were included for final analysis. Their demographic and clinical characteristics and comorbidities were collected and compared. Multivariate logistic regression analysis was performed to evaluate the risk factors for AKI in UTI patients. There were 97 (12.3%) patients developing AKI during hospitalization. Multivariate logistic regression analysis showed that patients with older age (OR 1.02, 95% CI 1.00-1.04, P = 0.04), diabetes mellitus (DM) (OR 2.23, 95% CI 1.35-3.68, P = 0002), upper UTI (OR 2.63, 95% CI 1.53-4.56, P = 0001), afebrile during hospitalization (OR 1.71, 95% CI 1.04-2.83, P = 0036) and lower baseline eGFR [baseline eGFR 45-59 mL/min/1.73 m2 (OR 2.12, 95% CI 1.12-4.04, P = 0.022), baseline eGFR 30-44 mL/min/1.73 m2 (OR 4.44, 95% CI 2.30-8.60 P < 0.001) baseline eGFR < 30 mL/min/1.73 m2 (OR 4.72, 95% CI 2.13-10.45, P

Supplemental Digital Content is available in the text, The aim of our study was to estimate the risk of end-stage renal disease (ESRD) in type 1 diabetes mellitus (T1DM) in Taiwanese people; in addition, our goal was to determine how the age, year, and sex at registration of T1DM affects the risk. Population-based cohort study. A nationwide cohort study of 7203 Taiwanese patients with T1DM registered in 1999 to 2010 was followed up until ESRD, death, or the end of follow-up on December 31, 2010. Annual age-, sex-, and calendar year-specific incidence rates of ESRD of the general population were used to calculate the standardized incidence ratio (SIR) of ESRD in relation to T1DM. The SIR of ESRD for male and female patients with T1DM was significantly increased at 25.85 (95% CI 23.40–28.29) and 28.08 (95% 25.45–30.71), respectively; the peak was at age 15 to 29 years for both genders. The cumulative incidence of ESRD was similar in male and female patients but was significantly higher in patients ≥ 30 years old than in patients

Soft tissue calcification is a frequent complication in end-stage renal disease (ESRD) patients with a high serum calcium-phosphate product, but systemic involvement of both the visceral organs and skin is rarely seen. We report on a newly diagnosed ESRD patient with gouty nephropathy who had initial presentations of extensive intradermal tophi, diffuse calcinosis, and hypercalcemia. He received maintenance hemodialysis (HD) with low-calcium dialysate (1.25 mEq/l) for 11 months. Although the above complications diminished, serum calcium remained elevated. Thereafter, unexpected cervical lymphadenitis from a Mycobacterium tuberculosis (TB) infection with high extra-renal production of calcitriol was found. Serum calcium levels normalized only after anti-TB treatment for 2 months. We thought that this patient might have had occult TB infection before the start of HD, which resulted in calcitriol production and hypercalcemia. In addition, concomitant hyperphosphatemia in chronic renal failure contributed to severe diffuse calcinosis. After the initiation of HD therapy, both the elevated serum calcitriol levels and accelerated resolution and mobilization of diffuse calcinosis from low-calcium HD contributed to persistent hypercalcemia.

We studied the pathogenic role of host and Escherichia coli virulence factors in the development of E. coli bacteremia in patients with acute cholangitis (AC) or upper urinary tract infection (UTI). Isolates recovered from 75 adult patients consecutively admitted to the hospital with E. coli bacteremia caused by AC (n=24) or upper UTI (n=51) were evaluated, as were 30 fecal strains isolated from healthy control individuals. Virulence genes of E. coli were detected by polymerase chain reaction analysis, including papG genes (classes I-III), sfa/foc, fimH, afa, hlyA, cnf1, and iutA. Our results show that biliary tract obstruction and urinary tract obstruction are important host factors for the development of E. coli bacteremia in patients with AC and upper UTI, respectively. With regard to E. coli virulence factors, the papG class II gene might play a more important role in the development of E. coli bacteremia in patients with upper UTI than in those with AC.

OBJECTIVE: To evaluate the secular trend in incidence of and mortality from Type 1 diabetes mellitus (T1DM) in Taiwan, 1999-2010. METHODS: All 7,225 incident cases of T1DM were retrospectively retrieved from Taiwan's National Health Insurance Research Database from 1999 to 2010. Trend of bi-annual age- and sex-specific incidence rates of T1DM was calculated and tested with Poisson regression model. Standardized mortality ratios (SMRs) were calculated, using age-, sex-, and calendar years-specific mortality rates of the general population as the reference, to estimate the relative mortality risk of T1DM. RESULTS: The number of male and female T1DM was 3,471 (48%) and 3,754 (52%), respectively. The annual number of incident T1DM increased from 543 in 1999 to 737 in 2010. The overall bi-annual incidence rate rose from 1999-00 to 2003-04 and mildly declined thereafter rose to 2009-10, with an insignificant trend (P = 0.489) over the study period. Regardless of gender, the higher age-specific incidence rate was noted in the younger groups (

A high prevalence of hepatitis G virus (HGV) infection has been noted in patients receiving chronic hemodialysis (HD) therapy, yet the incidence rate and transmission route have rarely been reported. Serum samples from 160 chronically uremic patients in a HD unit were initially collected at the time chronic HD therapy was begun, and thereafter annually in July and, finally, in November 1999. Serum HGV RNA was detected using nested reverse transcription polymerase chain reaction, and HGV E2 antibody was determined using an enzyme immunoassay. Nucleotide sequences of the 5'-noncoding region were studied in the HD patients with HGV viremia. Forty healthy staff members were also enrolled as control subjects. Three of the 40 (7.5%) healthy staff members were positive for HGV RNA or HGV E2 antibodies, in contrast to 40 of the 160 (25%) HD patients, including 14 (8.8%) who were positive for HGV RNA only, 25 (15.6%) who were positive for HGV E2 antibody only, and 1 (0.6%) who had both markers. HGV exposure did not correlate with gender, age, duration of HD therapy, or history of blood transfusions. At least 20 of the 40 (50%) patients with HGV exposure had been infected before the start of chronic HD therapy. Nevertheless, at least nine (22.5%) patients acquired new HGV infections after starting chronic HD therapy, with an incidence rate ofor = 2.6% per year. Three patients with newly acquired HGV viremia after HD therapy was started and two with pre-existing HGV viremia before HD therapy was started had the same nucleotide sequences. HGV and HCV infections (with a prevalence of 14.4%) might have been transmitted independently in HD patients. In addition, HGV infection was not found to cause significant elevation of alanine aminotransferase levels in the group exposed to HGV. To conclude, the incidence of new HGV infections was at least 2.6% per year. In addition to transmission through blood transfusion, HGV may have been transmitted nosocomially patient-to-patient within the HD unit. The compliance with standard universal precautions should be carefully re-examined, but it is not necessary to routinely screen for HGV infection among patients on chronic HD.

Silver can be absorbed through ingestion, topical administration, or inhalation. Generalized argyria results from deposition of silver in the skin, nails, mucous membranes, and internal organs and is characterized by a diffuse bluish-gray discoloration in sun-exposed areas. We report two cases of generalized argyria in patients on maintenance hemodialysis (HD) therapy for more than 15 years. They presented with diffuse hyperpigmentation of the face that was mistaken to be related to uremia and bluish-gray discoloration of all nails believed to be cyanosis. Histopathologic examination of skin biopsy specimens showed characteristic findings of argyria, which was further confirmed by radiograph microanalysis. Their serum silver levels were also elevated. No definite silver source could be determined. However, their argyria might be related to their long-term HD therapy because (1) they had been on HD therapy for more than 15 years and the discoloration appeared several years afterward, and (2) the water used for HD was not well processed in the early 1980s in TAIWAN: Argyria should be suspected in chronic HD patients presenting with a diffuse bluish-gray discoloration of the skin and nails and evaluated carefully by skin biopsy.

Metabolic alkalosis (MA), defined as a primary increment in plasma bicarbonate concentration, is a common complication in hospitalized patients and is associated with high morbidity and mortality in severe cases. One of the major routes of compensation for MA (ie, the secretion of an alkaline urine) is lost in renal failure patients. We report three cases involving four episodes of extreme MA with an arterial pH value greater than 7.60, serum bicarbonate concentration greater than 55 mmol/L, and stupor or seizure. Profound vomiting or massive gastric drainage combined with concurrent oliguric renal failure was the underlying mechanism for severe MA. Hydration and normal central venous pressure failed to improve the MA. The extreme MA was reversed quickly and safely by conventional hemodialysis with normal bicarbonate dialysate of 25 to 28 mmol/L. To our knowledge, this is the first reported successful use of normal bicarbonate dialysate in the treatment of severe MA. We also found that either H(2) blockers or proton-pump inhibitors have a prophylactic effect on the formation of MA.

Emphysematous pyelonephritis and double cancers of the kidney and urinary tract are rare. We describe here a case of a diabetic man who had simultaneous renal cell carcinoma of the right kidney and transitional cell carcinoma of the right ureter complicated with emphysematous pyelonephritis within the tumour parenchyma of renal cell carcinoma. Imaging and pathology are demonstrated.