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Background The coronavirus disease 2019 (COVID-19) pandemic has put an enormous burden on health care systems worldwide. Limited access to medical care and fear of increased infective risks due to the use of immunosuppressive medication (IM) have increased concerns about IM adherence in kidney transplant recipients (KTRs). The aim of this study was to determine the various dimensions of IM nonadherence in KTRs during the COVID-19 pandemic. Methods This was a single-center, cross-sectional study using a convenient sampling approach. KTRs with follow-up in Queen Elizabeth Hospital, Hong Kong between May 1, 2020 and September 30, 2020, were invited to complete a self-reported questionnaire on IM adherence. The sociodemographic factors associated with IM adherence were extracted from medical records. Results Overall, 210 patients completed the questionnaires. The overall IM nonadherence rate was 35.2% in the 4 weeks before survey completion. None of the patients stopped taking IMs without instructions from their health care providers. The most common pattern of IM nonadherence was timing adherence (n = 63; 30.1%), followed by dose-skipping item. Among the different sociodemographic factors studied, only marital status was an independent risk factor of IM nonadherence (odds ratio, 1.97; 95% confidence interval, 1.04-3.72; P = .03). Conclusions The impact of COVID-19 on IM adherence in KTRs was not significant. All the patients continued their IM despite of the pandemic. Good family support can have a positive influence on treatment adherence in KTRs during the COVID-19 pandemic.

Introduction: Although the association between CYP3A5 gene polymorphism and tacrolimus dosing requirements was well established, the impact on how CYP3A5 genotype affects the acute rejection and long-term renal function in patients who received kidney transplants and were treated with tacrolimus remained controversial. Design: Sixty-seven Chinese patients with kidney transplants receiving de novo tacrolimus-based immunosuppressive therapy with known CYP3A5 genotype were divided into 2 groups. Those with at least 1 CYP3A5*1 allele were CYP3A5 expressers while homozygotes for the mutant allele CYP3A5*3 were nonexpressers. Instead of trough level, our center used abbreviated area under the curve for tacrolimus monitoring. Primary outcome was the long-term renal function between both groups while secondary outcomes included the weight-adjusted daily tacrolimus dose, graft survival, incidence of biopsy-proven acute rejection (BPAR), opportunistic infection, and cancer. Results: Thirty-five (52.2%) patients were CYP3A5 expressers while 32 were nonexpressers. Mean daily tacrolimus dose in the CYP3A5 expressers and nonexpressers was 0.08 (0.03) and 0.05 (0.02) mg/kg, respectively ( P < .01). Starting from 1-month posttransplant, the renal function was comparable between both groups, which persisted up to 10-year. Ten patients experienced BPAR rejection and there was no significant difference in the rejection-free survival between both groups ( P = .87). There was also no significant difference in the death-censored graft survival between both groups ( P = .86). Finally, the incidence of opportunistic infection and posttransplant cancer was similar between them. Discussion: There was no significant difference in renal function, graft survival, and acute rejection between CYP3A5 expressers and nonexpressers.

Introduction The coronavirus disease 2019 (COVID-19) pandemic was expected to have a negative impact on organ donation. With the differences in health care systems and lockdown policies in various regions, the pandemic's effect on organ donation and transplant service may vary. Most of the deceased donor organ referrals in our hospital came from non–intensive care units (ICUs). The objective of this study is to report our experience and quantify the effects of the COVID-19 pandemic on deceased donor organ donation in our center. Methods This was a retrospective observational study comparing the deceased donor organ donation activity during the period January 23 to November 30, 2020 with the same period in 2018 in Queen Elizabeth Hospital, Hong Kong. Results There was a 26.9% reduction in deceased donor organ donor referral in 2020 compared with 2018. No significant difference in the proportion of referrals from ICU or non-ICU areas between the 2 time periods was observed. The brain death confirmation rate was significantly higher in 2020 (40.8% vs 20.2%, P = .003). Nine patients had family consent for organ donation in 2020 (vs 7 patients in the same period in 2018). There were no significant differences in consent rate and number of recovered organs between the 2 periods. Conclusions With effective measures to limit the spread of COVID-19 in a community, it is possible to support the needs of both patients with COVID-19 and deceased donor organ donation services.

Aim Direct kidney involvement in B-cell lymphoproliferative disease is a rare disorder with only a few studies reported in Caucasian patients. The clinicopathological characteristics and outcome of this entity remain poorly described. Methods We retrospectively studied all adult Chinese patients who had histology-proven renal parenchymal infiltration by malignant B-cells between 1/1/2000 and 31/12/2018 at 2 tertiary hospitals in Hong Kong. Clinical, pathological and radiological data were collected from 20 patients. Follow-up data were analyzed until 31/12/2019. Results Median follow-up duration was 22 (1-171) months. Only 7 patients (35%) had established diagnosis of hematological cancer before kidney biopsy. Diffuse large B-cell lymphoma (DLBCL) was the most common subtype in our cohort (n=5, 25%). Others included low-grade B-cell lymphoma (n=11), intravascular large B-cell lymphoma (n=1), mantle cell lymphoma (n=1) and multiple myeloma (n=2). Fourteen patients (70%) presented with AKI while 12 patients (60%) had proteinuria. Seven patients (35%) had unilateral renal mass, 1 had bilateral renal masses and 1 had bilateral diffuse nephromegaly in computed tomography. Lymphomatous tubulointerstitial infiltration was the prevalent histological finding. Nine patients (45%) had coexisting renal lesions other than direct tumor infiltration. All but 1 patient received chemotherapy. Ten patients died and renal responders had a significantly better survival than non-renal responders (P=0.03). Conclusion Direct tumor infiltration can occur in a wide variety of B-cell lymphoproliferative disorders. Coexisting immunoglobulin-related nephropathy is frequently found. Renal biopsy is required for early diagnosis which allows timely and appropriate treatment. This article is protected by copyright. All rights reserved.

IntroductionDiabetic kidney disease (DKD) is a prevalent and costly complication of diabetes with limited therapeutic options, being the leading cause of end-stage kidney disease in most developed regions. Recent big data studies showed that add-on Chinese medicine (CM) led to a reduced risk of end-stage kidney disease and mortality among patients with chronic kidney disease (CKD) and diabetes. Astragalus, commonly known as huang-qi, is the most prescribed CM or used dietary herb in China for diabetes and DKD. In vivo and in vitro studies showed that astragalus ameliorated podocyte apoptosis, foot process effacement, mesangial expansion, glomerulosclerosis and interstitial fibrosis. Nevertheless, the clinical effect of astragalus remains uncharacterised. This pragmatic clinical trial aims to evaluate the effectiveness of add-on astragalus in patients with type 2 diabetes, stage 2–3 CKD and macroalbuminuria, and to identify related response predictors.Methods and analysisThis is an add-on, assessor-blind, parallel, pragmatic randomised controlled clinical trial. 118 patients diagnosed with DKD will be recruited and randomised 1:1 to receive 48 weeks of add-on astragalus or standard medical care. Primary endpoints are the changes in estimated glomerular filtration rate and urine albumin-to-creatinine ratio between baseline and treatment endpoint. Secondary endpoints include adverse events, fasting blood glucose, glycated haemoglobin, lipids and other biomarkers. Adverse events are monitored through self-complete questionnaire and clinical visits. Outcomes will be analysed by regression models. Subgroup and sensitivity analyses will be conducted for different epidemiological subgroups and statistical analyses. Enrolment started in July 2018.Ethics and disseminationThis study was approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West/East/Kowloon Central clusters (UW 16-553/HKEC-2019-026/REC (KC/KE)-19-0049/ER-4). We will report the findings in medical journals and conferences. The dataset will be available on reasonable request.Trial registration numberNCT03535935

A 56-year-old man, who received deceased kidney transplant 20 years ago, presented with an enlarged submandibular lymph node. Histologic examination revealed nodal marginal zone lymphoma in which the neoplastic lymphoid cells showed diffuse positivity for Epstein-Barr virus early RNA by in situ hybridization. Systemic lymphoma workup showed stage I disease. The tumor was managed as a posttransplant lymphoproliferative disorder and the immunosuppression was modified. There was no evidence of lymphoma at follow-up 6 years after excision alone. This case supports the inclusion of Epstein-Barr virus–positive nodal marginal zone lymphoma as a form of monomorphic B-cell lymphoproliferative disorder, in line with the status of its extranodal mucosa-associated lymphoid tissue lymphoma counterpart.

Background Vancomycin-resistant Enterococcus (VRE) colonization is common among patients with chronic kidney disease. However, data concerning VRE colonization among patients receiving peritoneal dialysis (PD) is lacking. The aim of this study is to evaluate the risk factors and various clinical outcomes for VRE colonization among PD patients. Methods This is a retrospective cohort study of 166 PD patients who were hospitalized between 1 August 2013 and 31 July 2014. They were screened for VRE colonization status during a major VRE outbreak in Hong Kong in 2013 and were then categorized into 2 groups: VRE-positive and VRE-negative. The primary outcome was all-cause mortality while the secondary outcomes included VRE infection, PD-related peritonitis, and length of hospitalization. Results Twenty-eight patients (16.9%) belonged to the VRE-positive group. Multivariate analysis showed that previous contact with VRE-positive patients (odds ratio [OR]: 417.86; 95% confidence interval [CI]: 17.21 – 10,147.26, p < 0.01), vancomycin use in previous 3 months (OR: 130.32; 95% CI: 5.35 – 3,176.30, p < 0.01), and old age (OR: 1.13; 95% CI: 1.02 – 1.24, p = 0.02) were the independent risk factors for VRE colonization. Patients in the VRE-positive group had significantly longer length of hospitalization, but there was no significant difference in all-cause mortality and peritonitis-free survival. Conclusion Vancomycin-resistant Enterococcus colonization is important among hospitalized PD patients. Cautious use of antibiotics and infection control measures are necessary to prevent VRE spreading, especially in high-risk patients.

// Chi Yuen Cheung 1 , Maggie Kam Man Ma 2 , Ka Foon Chau 1 , Wai Leung Chak 1 and Sydney Chi Wai Tang 2 1 Renal Unit, Department of Medicine, Queen Elizabeth Hospital, Hong Kong SAR, China 2 Division of Nephrology, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China Correspondence to: Sydney Chi Wai Tang, email: scwtang@hku.hk Keywords: lymphoma, posttransplant lymphoproliferative disorders, kidney transplant Received: February 22, 2017 Accepted: June 04, 2017 Published: June 30, 2017 ABSTRACT Objective: To characterize the posttransplant lymphoproliferative disorders (PTLD) including the Epstein-Barr virus (EBV) status, histological subgroups, site of occurrence and the clinical outcome in the Chinese kidney transplant recipients. Methods: A retrospective cohort study of 1, 227 adult kidney transplant recipients who were followed up in two transplant centers in Hong Kong over two decades. Results: 23 (1.9%) patients developed PTLD. Median duration from transplant to PTLD was 104 (5-252) months. Six patients (26.1%) had early PTLD and 17 (73.9%) had late PTLD. Ten (43%) developed PTLD >10 years after transplant. All patients in early PTLD group were EBV-positive. In the late PTLD group, 60% were EBV-negative and 40% EBV-positive. More than 90% of cases were monomorphic PTLD with majority being diffuse large B cell lymphoma. Bone marrow was the most common extranodal site. The overall treatment response rate was 52.2 %. None of the patients developed rejection or relapse after PTLD. At a median follow-up of 9 (1-79) months after PTLD, 18 patients died. Patient survival was 48% at 1 year and 30% at 3 years and death-censored allograft survival was 82% at 1year and 73% at 3 years. Conclusion: Late PTLD is common. Careful adjustment of immunosuppression, close monitoring of patients, increased awareness and early detection of the disease are essential.

// Chi Yuen Cheung 1 , Maggie Kam Man Ma 2 , Wai Leung Chak 1 , Ka Foon Chau 1 and Sydney Chi Wai Tang 2 1 Department of Medicine, Renal Unit, Queen Elizabeth Hospital, Yau Ma Tei, Hong Kong SAR 2 Department of Medicine, Division of Nephrology, The University of Hong Kong, Queen Mary Hospital, Yau Ma Tei, Hong Kong SAR Correspondence to: Sydney Chi Wai Tang, email: // Keywords : cancer, everolimus, kidney transplant, sirolimus Received : December 12, 2016 Accepted : January 17, 2017 Published : January 30, 2017 Abstract Objective: To investigate the impact of mammalian target of rapamycin (mTOR) inhibitor conversion together with minimization of calcineurin inhibitor on allograft outcome and patient survival in kidney transplant recipients with post-transplant cancers. Methods: A retrospective study of all kidney transplant recipients diagnosed to have post-transplant cancers between the period 1/1/1994 and 30/6/2015. Patients were divided into 2 groups: mTOR inhibitor group and non-conversion group. Outcome included allograft function, patient survival, graft survival, acute rejection and cancer recurrence. Results: 115 patients (56 in mTOR inhibitor group and 59 in non-conversion group) were analyzed. Median follow up was 28 months (range: 1 month – 20 years). The allograft function at 1-year remained similar between both groups. There was no significant difference in the patient survival, graft survival and rejection free survival between both groups. More patients in the non-conversion group developed recurrence of cancers than mTOR inhibitor group but statistically not significant. Conclusions: Use of mTOR inhibitors together with calcineurin inhibitor minimization offer a reasonable option in kidney transplant recipients who developed post-transplant cancers in view of stable renal function, low rejection rate and low cancer recurrence rate.

Background. Although high tacrolimus (FK) intrapatient variability (IPV) was shown to be associated with poor graft outcome in kidney transplant recipients (KTRs), it is uncertain whether there is any association between the CYP3A5 genotype and IPV of FK concentrations. Instead of trough level, we use calculated abbreviated AUC(0-12) to investigate the impact of CYP3A5 genetic polymorphism on IPV of FK pharmacokinetics.Methods. We conducted a retrospective, single-center study of 86 adult Chinese KTRs with known CYP3A5 genotype. Coefficient of variation (CV) was used for the quantification of FK IPV. CV of dose-normalized FK AUC(0-12) was calculated and was compared between the CYP3A5 expresser group and nonexpresser group.Results. Forty-one patients (47.7%) were classified as CYP3A5 expressers while 45 were nonexpressers. No significant differences in the baseline characteristics were found between expressers and nonexpressers. CYP3A5 expressers required 1.8 times higher FK dose compared with the nonexpressers. There was no significant difference in the FK CV between CYP3A5 expressers (18.2 +/- 7.5%) and nonexpressers (16.7 +/- 5.7%) (P = .31).Conclusion. The IPV of FK exposure was not associated with CYP3A5 genotype in stable KTRs. Further studies should focus on other factors such as medication nonadherence, which may explain FK IPV.

Anticoagulant-related nephropathy (ARN), a significant but frequently undiagnosed problem in patients receiving anticoagulation, is found to be associated with increased renal morbidity and all-cause mortality. While ARN is mainly associated with warfarin use, recent case reports suggest that it may also occur in patients taking direct oral anticoagulants (DOAC). We report a patient who had a history of alcoholic liver cirrhosis and paroxysmal atrial fibrillation, and received dabigatran 110 mg twice daily for 1 year. He presented with gross hematuria and severe acute kidney injury with an international normalized ratio of 4.09. Dabigatran was stopped and he was put on temporary hemodialysis support. His renal function gradually improved when the hematuria subsided. Renal biopsy later confirmed the presence of red blood cell casts inside the renal tubules with features of IgA nephropathy. Finally, his renal function returned back to baseline level. As DOAC has been increasingly used nowadays for the treatment of various thromboembolic diatheses, regular monitoring of renal function is warranted, especially in patients with underlying glomerular diseases and coagulopathy such as chronic liver diseases.

Dialysis is the commonest modality of renal replacement therapy for patients suffering from end-stage kidney disease. Different registry studies showed that the risks of overall cancer occurrence were significantly higher in chronic dialysis patients than in the age-matched general population. However, the frequency and pattern of different cancers may vary among different geographical areas. Since chronic dialysis patients tend to have multiple comorbidities and a shorter life expectancy, routine cancer screening in all dialysis patients may not be cost-effective; rather screening should be personalized according to the patient's expected survival, candidacy for kidney transplant together with patient preferences.

The emergence of onconephrology in recent years highlights the importance of the interaction between kidney disease and cancer. Chronic kidney disease (CKD) and cancer are linked with each other in different ways bidirectionally: cancer can cause CKD, whereas CKD itself may be a risk factor for cancer. Kidney transplant recipients (KTRs) have a 2- to 3-fold increased cancer risk when compared with the general population. The elevated risk covers a wide range of cancers. Some are related to CKD, including cancers of the kidney, urinary tract and thyroid, whereas others are related to oncogenic viruses that include non-Hodgkin lymphoma, cervical cancer, nonmelanoma skin cancer and Kaposi's sarcoma. There is no standard protocol regarding how immunosuppressive drugs should be adjusted in patients who develop posttransplant cancers. However, any modification of immunosuppressive regimens should be balanced against the risk of allograft rejection or deterioration in kidney function. Cancer surveillance can be used as a strategy to improve the clinical outcome in KTRs. Although guidelines adopted in the general population have been used as the reference, a personalized approach based on individual cancer risk, life expectancy and concurrent comorbidities has to be adopted.

Kidney transplant recipients have increased risk of cancers when compared with the general population. Hepatocellular carcinoma (HCC) is extremely important in Asia where hepatitis B virus (HBV) infection is endemic. The aim is to study the epidemiological and clinical aspects of all de novo HCC in our kidney transplant recipients. Moreover, various preventive strategies which may help to optimize the outcome will also be discussed. A retrospective review of all patients who developed HCC after kidney transplantation between May 1972 and December 2011 in Hong Kong, based on the data from Hong Kong Renal Registry. After a follow-up period of 40,246 person-years, 20 patients (males 15: females 5) developed HCC. The annual incidence was 49.7/100,000 persons per year. Among them, 16 were HBV carriers, 2 were hepatitis C (HCV) carriers and 2 had HBV and HCV co-infection. Presence of HBV infection was associated with 78-fold higher risk for HCC development. Majority (85%) were asymptomatic when HCC was diagnosed by ultrasound or alpha-fetoprotein surveillance. All patients diagnosed by surveillance received active treatment while 2/3 of symptomatic patients could only receive symptomatic care and died rapidly. In conclusion, HBV infection is the major etiological factor for HCC development in kidney transplant recipients in HBV endemic areas. Regular HCC surveillance appeared to be able to detect early stage cancers which are amenable to treatment and offer the best hope of cure.

Heparin-induced thrombocytopenia (HIT) is a potentially fatal clinical condition which can develop after exposure to unfractionated or low-molecular-weight heparins. Even small doses of heparin such as heparin flushes in hemodialysis catheter can induce the development of HIT. However, the true incidence of heparin lock-related HIT is unknown. We report a 58-year-old woman with acute kidney injury because of obstructive uropathy who developed HIT after heparin-free hemodialysis. She was found to have severe thrombocytopenia with deep vein thrombosis of left lower limb and arterial thrombosis of the right anterior and middle cerebral arteries. The heparin-platelet factor 4 antibody was positive and she was put on plasmapharesis. However, her condition further deteriorated and succumbed shortly. Heparin lock solution in the hemodialysis catheter was believed to be the cause of HIT in our patient.

We report a patient suffering from end-stage renal disease (ESRD) because of lupus nephritis presented with exhausted vascular access after multiple arteriovenous grafts creation and hemodialysis catheters insertion. A rare percutaneous transrenal approach was finally used for the insertion of dialysis catheter. After 2 years, this hemodialysis catheter was complicated by blockage but was successfully replaced by a new catheter via the same site. Our report shows that the transrenal route of hemodialysis catheter insertion can provide a glimpse of hope for those ESRD patients with exhausted vascular access.

Background: Different studies in the past have shown that the risk of cancer development is increased in chronic dialysis patients. However, data concerning the cancer risk in Asian dialysis patients was scarce. More importantly, there was lack of information about the cancer-specific mortality in dialysis patients. Methods: A multicenter retrospective cohort study of 6,254 patients who started either chronic peritoneal dialysis or hemodialysis between 1994 and 2014 in 4 renal units in Hong Kong. Patterns of cancer incidence and mortality in our dialysis patients were compared with those of the general population using standardized incidence ratios (SIRs) and standardized mortality ratios (SMRs) respectively. Results: With 14,887 person-years of follow-up, 220 cancers were recorded. The SIR of all cancers was 1.44 (95% CI 1.26-1.65). A trend of an increased SIR was observed in young patients and within the first year of dialysis. Colorectum was the most common site of cancer (20%) while kidney cancer carried the highest risk (SIR 12.28, 95% CI 8.44-17.08). The SMR of all cancers was 0.91 (95% CI 0.72-1.13) and only kidney cancer had higher cancer mortality risk (SMR 4.92, 95% CI 1.80-10.70). SMR was highest in young patients and then decreased with age. Conclusions: The incidence of cancers in our chronic dialysis patients was elevated. Our findings of substantially increased risks in young patients, particularly in relation to kidney cancer, suggest that we can adopt a more individualized approach to cancer screening in chronic dialysis patients.

This cross-sectional and exploratory study aimed to compare motor performance and electroencephalographic (EEG) attention levels in children with developmental coordination disorder (DCD) and those with typical development, and determine the relationship between motor performance and the rea

Objectives To present and discuss the epidemiological and clinical aspects, as well as therapeutic options and outcome of de novo renal cell carcinoma (RCC) of the native kidneys in a series of Chinese renal transplant recipients. Patients and Methods A retrospective, cohort study examining all renal transplant recipients with the diagnosis of RCC of native kidney followed up in two major regional hospitals in Hong Kong between January 2000 and December 2009. Clinical data includedage, gender, cause of renal failure, symptoms at presentation, duration of transplantation, immunosuppressive therapy, and history of acquired cystic kidney disease (ACKD). Laboratory, radiographic, operative, and pathology reports were used to assess the tumor extent. Results Among the 1,003 renal transplant recipients recruited, 12 transplant recipients had a nephrectomy for a total of 13 RCC. The prevalence of de novo RCC was 1.3%. The mean age at diagnosis of RCC was 48.4 years, and the median time from transplantation to diagnosis was 6.1 years. ACKD was found in 6 (50%) of the patients. All patients except one were asymptomatic. pT1 disease was found in ten patients with a mean tumor size of 3.2 cm. All patients were treated successfully with radical nephrectomy. After a median follow-up of 38 months, two patients (16.7%) died. One died of sepsis, and the other died of metastatic carcinoma. Conclusions With increasing data showing a better prognosis if RCC is detected early by screening, it is time to consider screening all kidney transplant recipients for ACKD and RCC. © The Author(s) 2011. This article is published with open access at Springerlink.com., published_or_final_version, Springer Open Choice, 21 Feb 2012

Both lipoprotein glomerulopathy (LPG) and fibrillary glomerulonephritis (FGN) are rare causes of end-stage renal disease (ESRD), and the literature concerning the outcome of kidney transplant in patients with LPG or FGN is scarce. We report a patient who suffered from ESRD with coexisting FGN and LPG and received deceased kidney transplant >10 years ago did not reveal any clinical features of disease recurrence during follow-up. Our case shows that the prognosis of patients with LPG component who received kidney transplant can be good. Kidney transplantation remains a viable therapeutic option for patients with ESRD secondary to FGN with LPG.

Tacrolimus is an immunosuppressive agent that can show a wide variety of neurological side effects, including leukoencephalopathy. The prognosis is usually good with complete neurological recovery after dose reduction or cessation. However, differentiation from progressive multifocal leukoencephalopathy can sometimes be difficult. We describe the case of a 52-year-old gentleman with severe, irreversible tacrolimus-related leukoencephalopathy 4 months after kidney transplantation.

Background Post-transplant diabetes mellitus (PTDM) after renal transplantation is associated with adverse outcome on patient and graft survival. Fasting blood glucose alone will underestimate diabetes and also ignores diagnosis of impaired glucose tolerance (IGT). IGT has a strong correlation with diabetes and cardiovascular risk. Methods In this cross-sectional study, we estimate the prevalence of abnormal glucose metabolism (AGM) using oral glucose tolerance test (OGTT) and identify its predictive factors. Patients who received kidney transplantation in our centre without pre-transplant diabetes were recruited. OGTT was performed in patients with fasting glucose levels between 5.6 and 6.9 mmol/L for at least two occasions 6 months post-transplantation. Results Of 119 patients recruited, 31 had OGTT performed. The prevalence of PTDM, IGT and IFG was 21.8 (26/119)%, 6.7 (8/119)% and 3.4 (4/119)% respectively. Thus the overall prevalence of AGM was 31.9%. Age (P = 0.003), body mass index (P = 0.032), hepatitis B seropositivity status (P = 0.01), CMV infection (P = 0.02) and acute rejection (P = 0.002) were all associated with development of AGM. Using multivariate analysis, only older age at transplant (OR 1.09), history of acute rejection (OR 3.40) and hepatitis B seropositivity (OR 3.13) were significantly associated with the development of AGM. Conclusion AGM is common in our renal transplant recipients.

SUMMARY: Aims: To evaluate the efficacy and safety of a tacrolimus-based immunosuppressive regimen with and without induction therapy using daclizumab in first cadaveric renal transplant recipients. Methods: Since January 2001, we studied the effect of daclizumab in a non-randomized and prospective study of 36 sequential first cadaveric renal transplant recipients. They were compared with a historical control group of 21 sequential first cadaveric renal transplant recipients without induction therapy. All patients received tacrolimus, azathioprine and corticosteroids as concomitant immunosuppressive therapy. Daclizumab was given at 1 mg/kg infusion 2 h before transplantation and then every 14 days for four more doses. Outcomes measured included incidence of acute rejection, patient survival, graft survival, annualized change in creatinine clearance (CrCl), cardiovascular risk profile, infection and malignancy. Results: Fewer biopsy proven acute rejections were observed in the induction treatment group: 11.1% (4/36) versus 19% (4/21) but the rejection free survival was similar (P = 0.37). The patient survival and graft survival were comparable. The renal function was similar in both groups. There were also no significant difference in infection, malignancy and cardiovascular risk profile in both groups. Conclusion: Adding daclizumab to a tacrolimus-based therapy is safe but cannot further improve clinical efficacy.

To evaluate the prevalence of chronic kidney disease (CKD) in Chinese HIV-infected population.This was a cross-sectional point prevalence study. All Chinese HIV-infected patients who were followed up in a tertiary referral center in Hong Kong were recruited. Spot urine was saved for each patient to calculate urine protein-to-creatinine ratio (urine P/Cr). Those with urine P/Cr0.3 would have 24-h urine collection to determine the exact amount of proteinuria. Glomerular filtration rate (GFR) was estimated using MDRD formula. CKD was defined as GFR60 ml/min/1.73 m2 and/or urine P/Cr0.3. Baseline demographic and clinical data were extracted from patients' records.In total 322 patients were recruited. The mean age was 45.2 +/- 11.7 years. The duration of follow up was 6.0 +/- 4.0 years. There were 264 male and 58 female patients. The prevalence of hypertension, diabetes mellitus and CKD were 7.4%, 10.6% and 16.8%, respectively. Eighteen patients (5.6%) had GFR60 ml/min/1.73 m2 while 44 patients (13.7%) had spot urine P/Cr0.3. Among those with urine P/Cr0.3, 38 patients had 24-h urine collection. Using univariate analysis, CKD was found to be significantly (P0.05) associated with age, hypertension, diabetes, use of indinavir, lower CD4 count and peak viral load. Multivariate logistic regression revealed older age (P0.001), lower CD4 count (P = 0.02) and use of indinavir therapy (P = 0.04) were associated with development of CKD.CKD is prevalent in Chinese HIV-infected patients. Patients with CKD were more likely to be older, associated with use of indinavir and CD4 nadir less than 100 cells/mul.

Tacrolimus, an immunosuppressant used after organ transplantation, has a narrow therapeutic range and its pharmacokinetic variability complicates its daily dose assessment. P-glycoprotein (P-gp), encoded by the adenosine triphosphate-binding cassette B1 (ABCB1) and the cytochrome (CYP) 3A4 and 3A5 enzymes appears to play a role in the tacrolimus metabolism. In the present study, two different renal transplant recipient groups were used to examine the influence of ABCB1 and CYP3A polymorphisms on the daily tacrolimus dose and several pharmacokinetic parameters. In total 63 Caucasian renal transplant recipients divided into 26 early [median (range) of the days since transplantation - 16 (3-74)] and 37 late [median (range) of the days since transplantation - 1465 (453-4128)] post-transplant recipients were genotyped for ABCB1 and CYP3A polymorphisms. The pharmacokinetic parameters of tacrolimus were determined for all renal transplant recipients and correlated with their corresponding genotypes. A significant difference in allele frequencies of the CYP3A4*1B (P = 0.028) and CYP3A5*1 (P = 0.022) alleles was observed between the early and late post-transplant recipient groups. Significantly higher dose-normalized trough levels (dnC(0)), dose-normalized area under the curve (dnAUC(0-12)), and dose-normalized maximum concentration (dnC(max)) were observed for carriers of the CYP3A5*3 variant allele in both renal transplant patient groups. Except for the daily tacrolimus dose (P = 0.025) no significant differences were observed for carriers of the CYP3A4*1B variant allele. Neither the individual ABCB1 polymorphisms nor the ABCB1 haplotypes were associated with any pharmacokinetic parameter. We noticed that patients carrying a CYP3A5*1 allele require a twofold higher tacrolimus dose compared with homozygous carriers of the CYP3A5*3 variant allele to maintain the target dnAUC(0-12). Therefore, genotyping for the CYP3A5*3 variant allele can contribute to a better and more individualized immunosuppressive therapy in transplant patients.

Background: Current data concerning the relationship between renal function and clinical outcome among stroke patients treated with intravenous thrombolytic therapy are conflicting. Our aim is to analyze whether the clinical outcome of Chinese ischemic stroke patients treated with thrombolytic therapy is affected by the presence of renal dysfunction. Methods: Chinese patients who received intravenous thrombolytic therapy for acute ischemic stroke were recruited. Renal dysfunction was defined as an estimated glomerular filtration rate (eGFR) 2. The primary outcome was independent function (modified Rankin Scale, mRS, 0-2) at 3 months, while secondary outcomes included early improvement of the National Institute of Health Stroke Scale (NIHSS) score of ≥4 points at 24 h, symptomatic intracerebral hemorrhage (ICH) within 36 h of treatment and 30-day mortality. Results: A total of 199 patients were recruited, of whom 51.3% had renal dysfunction. There were no significant differences in functional independence at 3 months, NIHSS improvement at 24 h post-thrombolysis and 30-day mortality between patients with or without renal dysfunction. Multivariate analysis showed that eGFR as a continuous variable was not an independent risk factor for symptomatic ICH. Conclusion: Chinese ischemic stroke patients with renal dysfunction who received thrombolytic therapy had clinical outcomes similar to those without renal dysfunction.

Background Osteopenia and bone loss are major complications after renal transplantation. Clinical data in the Asian population are lacking. Methods We prospectively studied the changes in bone mineral density (BMD) of 31 cadaveric renal allograft recipients using dual energy X-ray absorptiometry (DEXA) within 2 weeks after transplantation and then at 1 year post transplantation. Results One year after transplantation, the mean bone mineral reduction at the lumbar spine was 6.3 ± 4.9% (osteopenia in 32.2% of patients and osteoporosis in 6.5%). For the femoral neck, there was a 4.3 ± 5.5% decrease in BMD (osteopenia in 38.7% of patients and osteoporosis in 3.2%). For total hip, there was a 4.8 ± 3.6% decrease in BMD (osteopenia in 25.8% of patients and osteoporosis in 3.2%). Decrease in BMD at the femoral neck and total hip correlated with the cumulative dosage of steroid (femoral neck: r = −0.36, p = 0.048; total hip: r = −0.4, p = 0.026). Compared with patients without rejection, patients with a history of acute rejection received higher cumulative doses of steroid, and sustained a greater decrease in BMD at the femoral neck and total hip: median percentage (interquartile range) decrease in femoral neck BMD was 7.7% (−12.8 to −6.3) versus 4.4% (−6.5 to −0.065), p = 0.016; decrease in total hip BMD was 8.2% (−11.22 to −6.7) versus 3.4% (−6.92 to −1.4), p = 0.03. There was no correlation between BMD changes and cumulative dosage of cyclosporine A, azathioprine, tacrolimus, duration of dialysis, changes in body mass index, creatinine or parathyroid hormone levels. Conclusion Reduction of BMD after renal transplantation is common. The cumulative dosage of prednisolone correlates with bone loss at the femoral neck and total hip. Patients with a history of acute rejection suffered from more bone loss after 1 year compared to patients without rejection.

We report herein two patients who presented with bilateral hydronephrosis attributed to lupus cystitis with two totally different clinical consequences. Both had systemic lupus erythematosus complicated with nephritis and nephrotic range of proteinuria. During the investigation of their proteinuria, they were noted to have a dilated collecting system. The site of obstruction was localized at the vesicoureteric obstruction by excretory urogram. The hydronephrosis resolved spontaneously in one patient before the commencement of any medical therapy, whereas in the other patient, there was no response to steroid therapy. Augmentation enterocystoplasty was thus performed. Reversible hydronephrosis caused by vesicoureteric junction obstruction in patients with systemic lupus erythematosus has been reported. Immune-mediated vasculitis involving the ureter and bladder mucosa was the postulated pathogenic mechanism. The condition usually showed good clinical response upon immunosuppressive therapy. We conclude that systemic lupus erythematosus-associated interstitial cystitis can have a spectrum of different prognoses.

Diabetic nephropathy (DN) is a leading cause of end-stage kidney disease nowadays. Certain cancers are more common in patients with diabetes mellitus. However, there are no data concerning the cancer pattern in patients with DN. The aim of this study is to investigate the site-specific cancer risk and mortality in these patients. A retrospective cohort study of 5643 DN patients between 2000 and 2015 was conducted in 2 large hospitals in Hong Kong. Incidence and mortality of various cancers were compared with those of general population using standardized incidence ratios (SIRs) and standardized mortality ratios (SMRs) respectively. With 24,726 person-years follow-up, 250 cancers were diagnosed. Overall cancer incidence was similar between DN patients and the general population (SIR 1.05, 95% confidence interval [CI] 0.92–1.19). However, certain site-specific cancers are increased in DN patients: the highest risk was observed for laryngeal cancer (SIR 3.03, 95% CI 1.11–6.60), followed by cancers of liver (SIR 1.96, 95% CI 1.35–2.76) and colorectum (SIR 1.92, 95% CI 1.53–2.37), but the risk of prostate cancer was lower (SIR 0.48, 95% CI 0.21–0.95) in the males with DN. The SMR of all cancers was 1.17 (95% CI 1.01–1.37). For individual specific site, only colorectal cancer carried a significant higher mortality risk (SMR 2.45, 95% CI 1.82–3.23). Our data suggested that DN is associated with increased incidence of cancers of colorectum, liver, and larynx but decreased incidence of prostate cancer. Moreover, there is increased mortality of colorectal cancer in patients with DN.

Summary Alcoholic ketoacidosis is an important cause of double gap metabolic acidosis. The differential diagnosis includes toxic alcohol (such as methanol and ethylene glycol) ingestion. We report a patient with alcoholic ketoacidosis. He had a history of excessive alcohol intake and presented with repeated vomiting, loss of appetite and hypovolemic shock. Laboratory results revealed high anion gap metabolic acidosis, increased serum osmolal gap, ketonemia, lactic acidosis and acute renal failure. He was successfully treated with hemodialysis, and hydration with glucose and thiamine. 酒精性代謝酮酸中毒是雙重間隙代謝性酸中毒的重要成因，其鑑別診斷為有毒酒精(如甲醇、乙二醇)的攝入。以下個案是一位酒精性代謝酮酸中毒患者，具過度攝入酒精的習慣，入院時呈現重複嘔吐、無食慾、及低血容積性休克。化驗結果顯示高陰離子間隙之代謝性酸中毒、高血清滲透間隙、酮血症、乳酸中毒、及急性腎衰竭。在接受血液透析、合併葡萄糖與硫胺素補充療法後，病人反應良好。

Danggui Buxue Tang (DBT) is one of the simplest traditional Chinese medicine (TCM) decoctions, first described in China in 1247 AD. DBT is composed of 2 herbs, Astragali Radix (AR) and Angelica Sinensis Radix (ASR), boiled together in a 5 : 1 ratio. Clinically, DBT is prescribed to women as a remedy for menopausal symptoms. Here,H-NMR metabolic profiling was conducted for DBT and the water extracts of AR or ASR, to evaluate the potential of this chemical profiling method for quality control of the herbal decoction. Principal component analysis (PCA) showed that DBT could be readily distinguished from the water extracts of its constituent herbs by the metabolic profiles. More interestingly, the metabolic profile of DBT was not a simple sum of that of AR and ASR. Asparagine was found at significantly higher concentration in DBT than that in either AR or ASR extract, contributing mainly to the discrimination of DBT sample. In addition, we employed the same method to profile a commercial DBT powder, verifying its authenticity as compared to our prepared DBT. This study is the first to employH-NMR metabolic profiling for the quality control of traditional Chinese medicine decoctions.

We report a gentleman suffering from purpuric skin rash mimicking vasculitis associated with impaired renal function. He was found to have positive cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA) in the serum, but the test for anti-proteinase 3 antibodies (PR3-ANCA) was negative. Blood culture and echocardiogram confirmed the diagnosis of Streptococcal Oralis infective endocarditis. The renal biopsy did not show any features of vasculitis or crescentic glomerulonephritis. His skin rash subsided and renal function normalized after treatment of the infective endocarditis with appropriate antibiotics. Therefore, we conclude that for those patients presenting with features of vasculitis and a positive ANCA test, other causes, such as infective endocarditis, should be considered.

The effects of pH of conventional lactate-based peritoneal dialysis solutions (LPDS) on the net ultrafiltration and solute removal in intermittent peritoneal dialysis (IPD) were studied. Conventional LPDS is rendered acidic to minimize the caramelization of glucose. Fifteen stable uremic patients were put on weekly IPD with a conventional 1.5% LPDS (hourly 2 L cycle for 60 L). pH of the LPDS was raised to around 7.4 by the addition of 1.4 mmol sodium hydroxide (1 M solution) to each litre of LPDS under an aseptic condition before the commencement of dialysis. A similar study was performed with the same 15 patients but the sodium hydroxide was replaced by a similar amount of sodium chloride. The net ultrafiltration, removal of urea, creatinine, sodium, and potassium were determined and compared. Serum levels of urea, creatinine, sodium, and potassium were also measured before and after the IPD. No peritonitis was encountered during the study. The net ultrafiltration volume in the euvolemic LPDS group was greater than the acidic LPDS group although this was not statistically significant [(mean ±SD) 2526 ±910 mL and 2186 ±750 mL, respectively, p = 0.21]. The clearances of urea, creatinine, sodium, and potassium showed no differences in both groups. We concluded that the ultrafiltration, clearances of urea, creatinine, sodium, and potassium in IPD were not affected by the pH of a LPDS from our results and a larger study is warranted to see the effect of dialysate pH on the peritoneal membrane.

Different patients receiving the same dose of a drug can exhibit a wide range of blood concentrations. This is a main concern regarding the immunosuppressive drugs because of their narrow therapeutic indices. Subtherapeutic blood concentrations are associated with an increased risk of acute rejection while overdosing may increase the risk of overimmunosuppression, with subsequent increased risk of infection and malignancies. Moreover, there are also numerous drug-specific adverse effects. At present, therapeutic drug monitoring (TDM) is used to address the issue of inter-individual variation in pharmacokinetics of immunosuppressive agents. However, TDM cannot influence drug exposure during the first 2-3 days after transplantation. Thus many patients experience a significant delay in achieving target blood concentrations, significantly increasing the risk of acute graft rejection (Clase et al., 2002; Undre et al., 1999). The narrow therapeutic index of these agents prevents use of a strategy based on a higher initial dose for all patients. As a result, there is a clear need for a strategy to allow individualized immunosuppressive drug dosing in the immediate post-transplant period. After administration, the drug is absorbed and distributed to its site of action, where it interacts with targets such as receptors and enzymes, undergoes metabolism, and is then excreted. Each of these processes might involve clinically significant genetic variations. In the general population, it is estimated that genetics accounts for 20% to 95% of the variability in drug disposition and effects (Kalow et al., 1998). Other non-genetic factors, such as hepatic or renal function, drug interactions, and nature of diseases will also influence the effects of medication. With the introduction of tools for genomic analysis, the DNA variants responsible for the differences in drug-metabolizing capacities were discovered. Subsequently, individuals can be characterized as efficient or poor metabolizers for a particular drug based on their gene polymorphisms encoding protein variants that metabolize the drug. The genetic polymorphisms in drug-metabolizing enzymes together with drug transporters and drug receptors led to the hypothesis that genetic factors may be implicated in the inter-individual variability of the pharmacokinetic or pharmacodynamic characteristics of immunosuppressive drugs, major side effects, and immunologic risks. By definition, pharmacogenetics is the study of genetic variation that gives rise to differing responses to drugs, whereas pharmacogenomics is the application of genomic technologies to drug discovery (Goldstein et al., 2003; Phillips & Van Bebber, 2005; Stoughton & Friend, 2005). Nowadays, the two terms are often used interchangeably. The promising role of pharmacogenetics and pharmacogenomics illustrates the concept of personalized medicine

We report the first case of Streptococcus gordonii-related continuous ambulatory peritoneal dialysis (CAPD) peritonitis. He is a 69-year-old man with end-stage renal failure due to chronic glomerulonephritis who had been put on CAPD for 1 year. He was successfully treated with a 2-week course of cefazolin. This case highlights the emerging threat that S. gordonii can be the source of infection in patients on CAPD.

Aim: There is limited data concerning the impact of recipient body mass index (BMI) on graft outcome in Asian renal transplant recipients. The aim of this study is to identify whether obesity (BMI 25 kg/m 2 ) and overweight (BMI 23 kg/m 2 ) can predict graft outcome. Methods: This is a single-centre retrospective study. All patients who received kidney transplantation between 1997 and 2005 were recruited. Patients were categorized according to two different designated BMI cut-off values. Results: One hundred and thirty-one patients were recruited with a median follow-up duration of 73 months. If a BMI cut-off value of 25 kg/m 2 was used, 86.3% patients were classified as non-obese and 13.7% as obese. Obesity was significantly associated with poor renal graft function and decreased patient and graft survival. On the other hand, 34.3% patients were classified as overweight and 65.7% patients as normal if a BMI cut-off value of 23 kg/m 2 was used. Overweight was significantly associated with a lower glomerular filtration rate only. Cox regression analysis showed that obesity (odds ratio (OR) = 3.09), acute rejection (OR = 5.68), pre-transplant diabetes mellitus (OR = 3.21) and age of recipient (OR = 1.06) were all significant independent risk factors associated with graft failure. Conclusion: Recipient BMI 25 kg/m 2 is a significant predictive factor for long-term renal graft outcome in the Asian population. With the introduction of new immunosuppressive agents, the risk of acute rejection in renal transplantation has been significantly reduced. Much of the focus nowadays has shifted to prolong graft survival. Obesity had been linked with an increased incidence of proteinuria, hypertension, hyperlipidaemia, diabetes mellitus (DM) and focal segmental glomerulosclerosis (FSGS) in the general population. 1 On the other hand, the impact of recipient obesity on patient and renal allograft survival is controversial. Higher body mass index (BMI) has been shown to be associated with increased risk for graft failure and patient death among white patients with end-stage renal disease who undergo renal transplantation. 2 The strong association between BMI and transplant outcome was supported in a retrospective analysis of 51 927 adult renal transplant recipients. Meier-Kriesche et al. showed that both abnormally low and abnormally high BMI are risk factors for decreased patient and graft survival, independent of most of the known

SUMMARY: nep_1155 758..763 Aim: The first prospective, randomized trial with paired kidney analysis was conducted to compare the efficacy and safety of tacrolimus with cyclosporine-based immunosuppressive therapy in renal transplant recipients. This paper reports the long-term follow-up results of the authors’ previously published study, with the main focus on graft survival and renal function. Methods: Chinese patients transplanted in our centre between June 1998 and June 2005 with their first deceased renal transplant were included. Patients were included if both kidneys were received by the authors’ centre, thus allowing a paired analysis. Patients were randomized to receive triple immunosuppressive therapy with either tacrolimus or Neoral cyclosporine, concomitantly with prednisolone and azathioprine therapy. Results: Seventy-six patients received cadaveric kidneys from 38 donors. Each pair of kidneys was randomly assigned to a separate group (38 subjects/group). The mean follow-up duration was 6.1 1 1.8 years. The mean calculated creatinine clearance was significantly higher in patients receiving tacrolimus-based therapy. The rate of biopsy-proven acute rejection was lower in the tacrolimus group (18.4% vs 42.1%, P = 0.03). The patient and graft survival were comparable in both treatment arms. Significantly fewer patients on tacrolimus-based therapy developed hypercholesterolaemia (P = 0.05). However, there was no significant difference in the development of post-transplant diabetes mellitus, hypertension, opportunistic infection and malignancy between both groups. Conclusion: Using the immunosuppressive regimen, tacrolimus-based therapy provided adequate immunosuppression with better renal function and less acute rejection, as compared with cyclosporine-based therapy.

Dried blood spot (DBS) sampling and high-performance liquid chromatography tandem-mass spectrometry have been developed in monitoring tacrolimus levels. Our center favors the use of limited sampling strategy and abbreviated formula to estimate the area under concentration-time curve (AUC(0-12)). However, it is inconvenient for patients because they have to wait in the center for blood sampling. We investigated the application of DBS method in tacrolimus level monitoring using limited sampling strategy and abbreviated AUC estimation approach. Duplicate venous samples were obtained at each time point (C(0), C(2), and C(4)). To determine the stability of blood samples, one venous sample was sent to our laboratory immediately. The other duplicate venous samples, together with simultaneous fingerprick blood samples, were sent to the University of Maastricht in the Netherlands. Thirty six patients were recruited and 108 sets of blood samples were collected. There was a highly significant relationship between AUC(0-12), estimated from venous blood samples, and fingerprick blood samples (r(2) = 0.96, P < 0.0001). Moreover, there was an excellent correlation between whole blood venous tacrolimus levels in the two centers (r(2) = 0.97; P < 0.0001). The blood samples were stable after long-distance transport. DBS sampling can be used in centers using limited sampling and abbreviated AUC(0-12) strategy as drug monitoring.

Few studies used paired kidneys for comparison between tacrolimus and cyclosporine in renal transplantation. Most of the published data used whole blood trough levels for drug monitoring. However, the use of limited sampling strategy and abbreviated formula to estimate the 12-h area under concentration-time curve (AUC(0-12)) allowed better prediction of drug exposure. Sixty-six first cadaveric renal transplant recipients receiving paired kidneys were randomized to receive either tacrolimus-based (n = 33) or cyclosporine microemulsion (Neoral)-based therapies (n = 33). Abbreviated AUC(0-12) was used for drug monitoring and dose titration. Mean follow-up duration was 2.8 +/- 2 years. The patient and graft survival were comparable. Fewer incidence of acute rejection was observed in tacrolimus group (15% vs. 27.3%) though the difference was not significant (P = 0.23). The absolute value and the rate of decline of creatinine clearance were both significantly better in tacrolimus-treated patients. Prevalence of hypertension, post-transplant diabetes mellitus, infection, and malignancy were similar in both groups. Prevalence of hypercholesterolemia (11/33 vs. 4/33) and gum hypertrophy (6/33 vs. 1/33) was more common in cyclosporine-treated patients (P = 0.04 in both parameters). This was the first prospective, randomized study with paired kidney analysis showing the renal function was significantly better in tacrolimus-treated patients than in cyclosporine-treated patients.

This report describes a patient with mixed normal anion gap hyperchloremic metabolic and respiratory acidosis associated with hypokalemia attributed to cough mixture abuse. Metabolic acidosis was likely related to an overdose of ammonium chloride, whereas respiratory acidosis was probably related to the effect of hypokalemia on respiratory muscles, causing hypoventilation. Hypokalemia was caused by a transcellular shift of potassium induced by ephedrine and pseudoephedrine. Both ammonium chloride and ephedrine were probably present in the cough mixture obtained by our patient as an over-the-counter medication. Physicians should be aware of the potential for cough mixture abuse to cause major electrolyte disturbances that may carry the risk for major cardiac arrhythmias, particularly in youth. [copy ] 2001 by the National Kidney Foundation, Inc .

Cefepime is a cephalosporin with a broad spectrum of activity against most gram-positive and gram-negative pathogens. In this study, we attempted to compare the safety and efficacy of cefepime monotherapy against the potentially more toxic combination of vancomycin and netilmicin in the treatment of continuous ambulatory peritoneal dialysis (CAPD)-associated bacterial peritonitis. Eighty-one consecutive CAPD patients who presented with peritonitis from January 1, 1998, to June 30, 2000, were recruited for study. Patients were randomized to be administered either intraperitoneal (IP) cefepime, 1 g once daily (group A), or intravenous vancomycin and netilmicin at conventional doses (group B) for 10 days. Bacterial growth was obtained in 52 episodes (66%), and pathogens identified included gram-positive organisms (30 episodes; 38%), gram-negative organisms (14 episodes; 18%), mixed organisms (2 episodes; 2.5%), and fungus (6 episodes; 8%). Eight patients were excluded after randomization for various reasons (6 patients, fungal peritonitis; 2 patients, wrong diagnoses). Because of the relatively low peritonitis rate after the use of a disconnect system, the sample size of this study was relatively small, giving a power of 0.45. There were no significant differences in primary response rates and cure rates (no relapse >28 days after completion of antibiotic therapy) between both groups of patients (group A versus group B, 82% [32 of 39 patients] versus 85% [29 of 34 patients] and 72% [28 of 39 patients] versus 76% [26 of 34 patients], respectively; P = not significant). No significant side effect was encountered in either group. Total peritonitis-related hospitalizations were 84 patient-days (1, 7, 8, 11, 20, and 37 patient-days) and 115 patient-days (3, 6, 9, 14, 21, 21, and 41 patient-days), whereas total costs per patient cure were estimated to be US $1,039 and US $1,371 in groups A and B, respectively. We conclude that once-daily 1-g IP cefepime monotherapy is a simple, safe, and cost-effective alternative to vancomycin and netilmicin therapy in the treatment of CAPD-associated bacterial peritonitis.