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Baseline and follow-up DECTs were performed under a standard ULT protocol. Monthly dissolution rates were calculated by simple and compound methods. Correlations with average SU were compared and analyzed. Best-fit regression model was identified. MSU dissolution times were plotted against SU at different endpoints.In 29 tophaceous gout patients, MSU volume reduced from baseline 10.94 ± 10.59 cmMSU dissolution is better described as a logarithmic function of SU, which explains, predicts, and facilitates understanding of the dissolution process.

Hepatitis E virus (HEV) genotype 4 (HEV-4) is an emerging cause of acute hepatitis in China. Less is known about the clinical characteristics and natural history of HEV-4 than HEV genotype 3 infections in immunocompromised patients. We report transmission of HEV-4 from a deceased organ donor to 5 transplant recipients. The donor had been viremic but HEV IgM and IgG seronegative, and liver function test results were within reference ranges. After a mean of 52 days after transplantation, hepatitis developed in all 5 recipients; in the liver graft recipient, disease was severe and with progressive portal hypertension. Despite reduced immunosuppression, all HEV-4 infections progressed to persistent hepatitis. Four patients received ribavirin and showed evidence of response after 2 months. This study highlights the role of organ donation in HEV transmission, provides additional data on the natural history of HEV-4 infection, and points out differences between genotype 3 and 4 infections in immunocompromised patients.

Aim Family members of patients with end-stage renal disease (ESRD) have higher risk for chronic kidney disease (CKD). Limited study has examined the risk of developing CKD in relatives of patients in earlier stages of CKD. Methods From January 2008 to June 2009, the Hong Kong Society of Nephrology studied first-degree relatives of stage 1-5 CKD patients from 11 local hospitals. A total of 844 relatives of 466 index CKD patients (stages 1-2: 29.6%; stage 3: 16.7%; stage 4: 10.9%; stage 5: 42.7%) were reviewed for various risk factors of CKD. We also defined a composite marker of kidney damage by the presence of one or more following features: (i) positive urine protein, (ii) spot urine protein-to-creatinine ratio ≥0.15 mg/mg, (iii) hypertension and (iv) estimated glomerular filtration rate (eGFR) ≤60 mL/min per 1.73 m2 and determine its association with participant and index patient factors. Results Among these 844 relatives, 23.1%, 25.9% and 4.4% of them had proteinuria (urine protein ≥1+), haematuria (urine red blood cell ≥1+) and glycosuria (urine glucose ≥1+), respectively. Proteinuria (P = 0.10) or glycosuria (P = 0.43), however, was not associated with stages of CKD of index patients. Smoking participants had a significantly lower eGFR (102.7 vs. 107.1 mL/min per 1.73 m2 ) and a higher prevalence of proteinuria (33.6% vs. 21.4%). Multivariate analysis showed that older age, male gender, obesity, being parents of index patients and being the relatives of a female index patient were independently associated with a positive composite marker. Conclusion First-degree relatives of all stages of CKD are at risk of developing CKD and deserve screening. Parents, the elderly, obese and male relatives were more likely to develop markers of kidney damage.

Two local studies were performed in Hong Kong for early detection and prevention of chronic kidney disease (CKD) which demonstrated the efficacy for screening asymptomatic individuals in the population for silent kidney disease while first degree relatives of known CKD patients should have a higher priority on future screening in view of their higher prevalence of silent CKD. Simple measures like urine dipstick tests and blood pressure measurement would suffice for screening. Regular health education programs are useful for conveying the key messages of kidney protection to the general public.

Summary This report examined the characteristics and trends of dialysis and renal transplant patients among the resident population of Hong Kong who were managed by hospitals or dialysis centers of the Hospital Authority, and accounted for approximately 95% of all patients receiving renal replacement therapies (RRTs) in the territory. Patients receiving RRTs solely in the private sector were not included in this report. Data trends from 1996 to 2011 are presented. In 2011, 1115 new patients were accepted into RRT programs, and the incident rate was 157 patients per million populations (pmp). An increasing trend was noted. The incident rate was 95.1 pmp at the commencement of the annual report in 1996. The point prevalence on December 31, 2012 was 8197 with a prevalence rate of 1152.5 pmp. Overall, there were 3573 patients (43.6%) on peritoneal dialysis (PD) and 1246 patients (15.2%) on hemodialysis (HD), and 3378 patients (41.2%) were living with a functioning renal transplant. The PD/HD ratio was 74.2:25.8. The “PD First” policy was continued. The overall mortality rate among RRT patients was 9.95 patients per 100 patient-years exposed. There was a decreasing trend in mortality among PD patients. Infection and cardiovascular complications were the most common causes of death. Renal transplant was the modality with the best survival rates. The 5 years cumulative patient survival rate for patients on transplant treatment was 89.6%, whereas the corresponding patient survival rates for PD and HD patients were 50.7% and 55.7%, respectively. More than 70% of RRT patients with reports on rehabilitation were active and had normal daily activities.

This report examines the characteristics and trends of dialysis and renal transplant patients among the resident population of Hong Kong who were managed by hospitals or dialysis centers of the Hospital Authority of Hong Kong, and who accounted for approximately 95% of all patients who received renal replacement therapy (RRT) in the territory. Patients who received RRT solely in the private sector were not included in this report. Data trends from 1996 to 2009 are presented. In 2009, 930 new patients were accepted into RRT programs and the incident rate was 132.4 patients per million population (pmp). This is lower than the incident rate in 2008, which was 148.2 pmp. The point prevalence as of December 31, 2009 was 7,580, with a prevalence rate of 1,078.8 pmp. There were 3,401 patients on peritoneal dialysis (PD, 44.9%), 945 patients on hemodialysis (HD, 12.5%), and 3,234 patients living with a functioning renal transplant. The PD to HD ratio was 81.5:18.5 for patients on dialysis treatment at Hospital Authority centers. PD-first policy continued. The overall mortality rate among RRT patients was 10.7 patients per 100 patient-years exposed. There was a decreasing trend in mortality among PD patients. Infection and cardiovascular complications were the most common causes of death. Renal transplant was the modality with the best survival. The 5-year cumulative patient survival rate for patients on transplant treatment was 88%, whereas the corresponding patient survival rates for PD and HD patients were 37% and 34.2%, respectively. More than 80% of RRT patients with reports on rehabilitation were active and had normal activities.

This report is based on data (up to 31 March 2004) from the Renal Registry of the Hospital Authority of Hong Kong, and accounts for 90-95% of all patients receiving renal replacement therapy (RRT) in the territory. Patients receiving RRT in the private sector are not included in this report. The number of patients receiving RRT was 6,054 (889 per million population [pmp]), of whom 51.6% (3,123, 451 pmp) were receiving peritoneal dialysis (PD), 10.9% (662, 97 pmp) hemodialysis (HD), and 37.5% (2,269, 334 pmp) had functioning kidney transplants. The net increase from the previous year in the number of patients receiving RRT was 3.1%. The incidence of end-stage renal failure in patients undergoing RRT was 954 (140 pmp). The median ages of existing and new patients receiving RRT were 55 and 56 years, respectively. There was a trend towards an increasing number of elderly dialysis patients. Diabetes was the third major cause of renal failure among existing RRT patients and the most common cause of renal failure in new cases. The rate of serologic positivity for hepatitis B infection in RRT patients was 9.68%, while that for hepatitis C infection was 3.28%. In Hong Kong, most patients were put on PD when RRT was required. Of all patients on dialysis, 83% were on PD, of whom 94.8% were on continuous ambulatory peritoneal dialysis (CAPD). Most CAPD patients were on disconnect systems. HD was used in 17.5% of all patients on dialysis. Of the 2,269 patients with functioning kidney transplants, 836 (36.8%) were transplanted in Hong Kong. Of these, 495 (59.2%) had undergone cadaveric kidney transplantation. Of all patients receiving RRT, 30% were receiving erythropoietin. For the year ending 31 March 2004, the annual crude mortality rate for all RRT was 10% (15.3% for PD, 13% for HD, and 1.9% for transplantation). The major causes of death were infection, cardiovascular disease, and cerebrovascular accident. The 1- and 5-year survival rates for patients with kidney transplantation performed in Hong Kong between 1 April 1997 and 31 March 2003 were 98.6% and 96.5%, respectively, for living related kidney transplants, and 96.1% and 91.2%, respectively, for cadaveric kidney transplants. The 1- and 5- year graft survival rates were 91.1% and 86.1% (death censored) and 90.5% and 85.6% (death not censored) for living related kidney transplants, and 89% and 83% (death censored) and 86% and 79% (death not censored) for cadaveric kidney transplants. The overall peritonitis rate for all chronic PD systems for the year ending 31 March 2004 was one episode per 27.7 months.

As the number of patients with end-stage renal disease continues to grow in Hong Kong, many are opting to be managed conservatively without dialysis. A new service was initiated in Tuen Mun Hospital in 2004 aimed at offering palliative care to dying patients with renal failure. This paper presents retrospective data reflecting our dealings with patients who decided not to initiate or considered discontinuation of dialysis. In total, 107 patients received palliative care from the inception of the new service in August 2004 until July 2006. The findings illustrate that decisions related to initiation or withdrawal of dialysis are often related to personal beliefs and sentiments. Further exploration using qualitative methodology is recommended. The case history expounds a situation in which the patient cannot participate in decision-making concerning treatment options and offers some exploration of the ethical intricacies involved in treating very sick patients with dialysis therapy.

● Background: Hyperuricemia is associated strongly with the development of hypertension, renal disease, and progression. Allopurinol decreases serum uric acid levels by inhibiting the enzyme xanthine oxidase. We hypothesized that administrating allopurinol to decrease serum uric acid levels to the normal range in hyperuricemic patients with chronic kidney disease may be of benefit in decreasing blood pressure and slowing the rate of renal disease progression in these patients. Methods: We conducted a prospective, randomized, controlled trial of 54 hyperuricemic patients with chronic kidney disease. Patients were randomly assigned to treatment with allopurinol, 100 to 300 mg/d, or to continue the usual therapy for 12 months. Clinical, hematologic, and biochemical parameters were measured at baseline and 3, 6, and 12 months of treatment. We define our study end points as: (1) stable kidney function with less than 40% increase in serum creatinine level, (2) impaired renal function with creatinine level increase greater than 40% of baseline value, (3) initiation of dialysis therapy, and (4) death.Results: One patient in the treatment group dropped out because of skin allergy to allopurinol. Serum uric acid levels were significantly decreased in subjects treated with allopurinol, from 9.75 1.18 mg/dL (0.58 0.07 mmol/L) to 5.88 1.01 mg/dL (0.35 0.06 mmol/L; P < 0.001). There were no significant differences in systolic or diastolic blood pressure at the end of the study comparing the 2 groups. There was a trend toward a lower serum creatinine level in the treatment group compared with controls after 12 months of therapy, although it did not reach statistical significance (P 0.08). Overall, 4 of 25 patients (16%) in the allopurinol group reached the combined end points of significant deterioration in renal function and dialysis dependence compared with 12 of 26 patients (46.1%) in the control group (P 0.015). Conclusion: Allopurinol therapy significantly decreases serum uric acid levels in hyperuricemic patients with mild to moderate chronic kidney disease. Its use is safe and helps preserve kidney function during 12 months of therapy compared with controls. Results of this study need to be confirmed with an additional prospective trial involving a larger cohort of patients to determine the long-term efficacy of allopurinol therapy and in specific chronic kidney disease subpopulations. Am J Kidney Dis 47:51-59. © 2005 by the National Kidney Foundation, Inc.

Background Cordyceps sinensis (Cordyceps, Dong Chong Xia Cao), a herbal medicine also known as Chinese caterpillar fungus, is one of the most commonly used ingredients in traditional Chinese medicine for the treatment of people with chronic kidney disease (CKD). Objectives This review aimed to evaluate the therapeutic effects and potential adverse effects of Cordyceps sinensis for the treatment of people with CKD. Search methods We searched the Cochrane Renal Group's Specialised Register to 14 April 2014 through contact with the Trials' Search Co-ordinator using search terms relevant to this review. We also searched CINAHL, AMED, Current Controlled Trials, OpenSIGLE, and Chinese databases including CBM, CMCC, TCMLARS, Chinese Dissertation Database, CMAC and Index to Chinese Periodical Literature. Selection criteria Randomised and quasi-randomised trials comparing Cordyceps or its products with placebo, no treatment, or conventional treatment were considered for inclusion in the review. Data collection and analysis Two authors independently assessed data quality and extracted data. Statistical analyses were performed using the random-effects model and the results expressed as risk ratio (RR) for dichotomous outcomes or mean difference (MD) for continuous data with 95% confidence intervals (CI). Main results We included 22 studies that involved 1746 participants. Among people with CKD who were not receiving dialysis, Cordyceps preparations were found to significantly decrease serum creatinine (14 studies, 987 participants): MD -60.76 μmol/L, 95% CI -85.82 to -35.71); increase creatinine clearance (6 studies, 362 participants): MD 9.22 mL/min, 95% CI 3.10 to 15.34) and reduce 24 hour proteinuria (4 studies, 211 participants: MD -0.15 g/24 h, 95% CI -0.24 to -0.05). However, suboptimal reporting and flawed methodological approaches meant that risk of bias was assessed as high in four studies and unclear in 18 studies, and hence, these results need to be interpreted with caution. Authors' conclusions We found that Cordyceps preparation, as an adjuvant therapy to conventional medicine, showed potential promise to decrease serum creatinine, increase creatine clearance, reduce proteinuria and alleviate CKD-associated complications, such as increased haemoglobin and serum albumin. However, definitive conclusions could not be made because of the low quality of evidence.

Objective Superior patient survival on continuous ambulatory peritoneal dialysis (CAPD) with 3 x 2-L exchanges has been reported from Hong Kong. This study examined the relationship between indices of dialysis adequacy and nutrition and patient survival on CAPD in Hong Kong. Design A cross-sectional study on prevalent CAPD patients. Patients were assessed for indices of dialysis adequacy and nutritional status with a composite nutritional index (CNI). Patients were then followed for 24 months. Survival data were analyzed according to adequacy indices and nutritional status. Setting All prevalent CAPD patients in nine dialysis centers in Hong Kong as of 1 April 1996. Main Outcome Measure Mortality. Results 937 patients were assessed: 68.2% were using 3 x 2-L exchanges per day; mean age was 54.6 ± 13 years. Mean total Kt/V was 1.83 ± 0.42 and total creatinine clearance was 55.6 ± 19.5 L/week/1.73 m2. 19% of patients were moderately to severely malnourished according to the CNI. There was no significant correlation between indices of adequacy and serum albumin or CNI. The 1- and 2-year patient survival from the time of assessment was 90.9% and 79.8%. There was a trend toward better survival in patients with Kt/V greater than 2.0, but it was not statistically significant. Peritoneal Kt/V did not impact survival in anuric patients. Malnourished patients had poorer survival than patients who were better nourished ( p = 0.0259). After adjusting for age and diabetes, CNI was predictive of mortality but Kt/V and creatinine clearance were not. Conclusions This study demonstrates the importance of nutritional status over adequacy indices in predicting patient survival. There was a lack of correlation between nutritional status and conventional indices of dialysis adequacy.

Water treatment plays a vital role in the delivery of safe and effective hemodialysis (HD). Ensuring that water quality meets the American Association for the Advancement of Medical Instrumentation standards and recommendations (or equivalent) is necessary to reduce the incidence of chemical hazards and endotoxemia associated with the use of water for HD. This review will discuss the principles of water treatment for HD, the essential components of water purification, the recommended system monitoring and maintenance procedures, and some of the historical incidents of adverse reactions that resulted from the use of contaminated dialysis water.

When told of their need for dialysis, patients often cannot accept it and are fearful toward dialysis. Pre-dialysis counseling programs help patients to face dialysis, to make the right choice of dialysis modality, and to prepare themselves for life on dialysis. Clear explanations of peritoneal dialysis (PD) help patients choosing PD. Patients should be referred to pre-dialysis programs at least 4 – 6 months before commencement of dialysis or when their glomerular filtration rate is around 15 mL/min/1.73 m2. The pre-dialysis program is best conducted by experienced staff such as renal nurses and multidisciplinary staff including nephrologists, dietitians, physiotherapists, psychologists, social workers, or even dialysis patient representatives depending on availability. The program should be designed according to the culture, settings, staff availability, and patient load in individual hospitals. Pre-dialysis home visits may be needed in some cases to assess suitability and prepare the home for PD.

The Hong Kong Renal Registry (HKRR) is an electronic paperless registry that services as database for patients on various renal replacement therapies in the territory. The database consists of demographic data, dialysis and transplant treatments, complications, and inquiries and reports. The HKRR can be helpful for individual patient's management, for renal center management, and for territory-wide management.

The toxicity of melamine caught the attention of physicians as a result of a recent spate of renal injury after exposure to melamine-tainted milk in China. Melamine is an organic nitrogenous compound used in the production of plastics, dyes, fertilizers, and fabrics. In the current incident, melamine was added to milk to elevate falsely assay results for protein content. A variety of toxic effects from melamine, including nephrolithiasis, chronic kidney inflammation, and bladder carcinoma, all have been studied in animals. We review here the epidemiology, clinical features, and investigative findings concerning the only outbreak of melamine poisoning in humans. We also examine the renal toxicities of melamine and cyanuric acid--a by-product of its synthesis--and the associated risk factors on exposure and provide guidance on levels in foods.

We report on the successful treatment of 5 consecutive adult patients with steroid-dependent or frequently relapsing minimal change disease (MCD), using a regimen of enteric-coated mycophenolate sodium (E-MPS) and prednisolone. E-MPS was used for induction therapy in 3 patients, and maintenance therapy in 2, all in conjunction with steroid treatment in tapering doses. Eventually 4 patients managed to discontinue steroid treatment, and 2 of them were also withdrawn from E-MPS. This combination therapy resulted in sustained remission and was well tolerated by our patients, with no signs of gastrointestinal upset, marrow suppression or increased incidence of infections. Our preliminary experience suggests that E-MPS is a promising new alternative in the management of steroid-dependent and relapsing MCD with a possibility of improving gastrointestinal tolerance.

Background. Tuberculosis (TB) is an uncommon opportunistic infection in immunocompromised patients. Extrapulmonary infection involving the intestine is rare and poses diagnostic difficulties. Case report. A 49-year-old man with IgA nephropathy underwent a kidney transplantation in 1996 and was put on cyclosporine, azathioprine, and steroid. He suffered from a recurrence of his primary kidney disease and had a gradual deterioration of renal function since 1998. By 2005, he presented with an unusual gastrointestinal (GI) symptom with alternating signs of upper GI bleeding – melena – as well as lower GI bleeding with fresh rectal bleeding, resulting in severe anemia with hemoglobin level down to 5.0 g/dL. At the same time, his renal function further deteriorated and necessitated the initiation of dialysis while he was maintained on low-dose immunosuppressive drugs. Repeated upper and lower GI endoscopies were either unremarkable or revealed non-specific lesions. Symptoms persisted and exploratory laparotomy finally showed a 1 cm submucosal mass at the proximal jejunum and multiple inflammatory lesions at the terminal ileum. Segmental resection of the lesions was performed and confirmed TB infection. However, despite the initiation of anti-tuberculous treatment, the patient eventually died of complications. Conclusion. Diagnosing TB intestinal infection is a clinical challenge. A high index of suspicion in susceptible subjects is necessary, and early surgical intervention should always be considered when facing diagnostic uncertainties.

Tacrolimus has a narrow therapeutic window and a wide interindividual variation in its pharmacokinetics. The cytochrome P450 3A (CYP3A) and the ATP-binding cassette B1 (ABCB1) genes play an important role in the tacrolimus disposition. Therefore, the aim of this study was to evaluate whether CYP3A and ABCB1 polymorphisms are associated with the area under the time concentration curve (AUC0–12) calculated using a two time point sample strategy. The CYP3A and ABCB1 genotypes were determined by real-time polymerase chain reaction (RT-PCR) fluorescence resonance energy transfer (FRET) assays in 103 Chinese renal transplant recipients and consequently related to their dose-normalized (dn)AUC0–12. A significant allele-dependent effect (Kruskal–Wallis; p 0–12. Multiple regression analysis showed that the CYP3A5*3 polymorphism is the most significant independent variable and explained 35% of the dose requirement variability in relation to tacrolimus use. Regarding the ABCB1 G2677T/A and C3435T polymorphisms, a trend was observed between the different genotypes and the dnAUC0–12. In conclusion, the CYP3A5*3 polymorphism may be an important factor in determining the dose requirement for tacrolimus and genotyping can help determine the initial daily dose required by individual patients for adequate immunosuppression.

Objectives. The purpose of this study was to evaluatethe outcome of systemic lupus erythematosus (SLE)patients on continuous ambulatory peritoneal dialysis(CAPD).Methods. Eighteen SLE patients who had been under-going CAPD for at least 3 months in our unit werecompared with 36 other age- and gender-matched non-diabetic CAPD patients with an underlying primarychronic glomerulonephritis (CGn). The clinical out-come, infective complications, lupus activities, bio-chemical parameters, haemoglobin level and the use oferythropoietin were reviewed.Results. The duration of dialysis of the two studiedgroups was not different, with a mean of 35.4 monthsfor the SLE group and 36.7 months for the CGn group.Before dialysis, SLE patients had a significantly loweralbumin level (30.4±6.6 vs 35.4±5.59g/dl, P

Intraperitoneal (IP) urokinase is a fibrinolytic agent that has been used in the adjunctive treatment of continuous ambulatory peritoneal dialysis (CAPD) and resistant and relapsing peritonitis. However, its efficacy and role in treating resistant CAPD bacterial peritonitis remain unclear and results from previous prospective studies have been conflicting. We prospectively randomized 88 CAPD patients with bacterial peritonitis resistant to initial empirical IP antibiotics into two groups: IP urokinase 60,000 IU and a placebo group. Patients were treated concomitantly with susceptible antibiotics according to culture results. Peritoneal dialysate grew pseudomonas aeruginosa in 13 patients (14.8%), non-pseudomonas bacteria in 63 patients (71.6%) and negative cultures in 12 patients (13.6%). For the clinical outcomes, there were no significant differences in the primary response rates (61.4 vs. 50%), relapse rates (9.1 vs. 13.6%), Tenckhoff catheter removal rates (22.7 vs. 29.5%) and mortality rates (6.8 and 6.8%) between the urokinase group and the controls (p=ns). Subgroup analysis of culture negative patients (n=12) also demonstrated no sgnificant benefit for urokinase treatment. No significant adverse effects were encountered with the IP urokinase instillation. Total median peritonitis-related length of hospitalization for the urokinase group and controls were 7 and 11 days, respectively (p=0.32). We concluded that IP urokinse plays no significant role as an adjuvant therapy in the treatment of bacterial CAPD peritonitis resistant to initial IP antibiotic therapy.

Prevalence of silent kidney disease in Hong Kong: The Screening for Hong Kong Asymptomatic Renal Population and Evaluation (SHARE) program. Background End-stage renal disease (ESRD) is epidemic worldwide. In Hong Kong, the annual incidence of ESRD has risen from 100 pmp (per million population) in 1996 to 140 pmp in 2003. SHARE (Screening for Hong Kong Asymptomatic Renal Population and Evaluation program) is a population-based screening program aimed at identifying the prevalence of unrecognized renal disease in asymptomatic individuals, allowing further evaluation and disease-modifying interventions. Methods From November to December 2003, SHARE was conducted in several large residential communities in Hong Kong. The screening tool included a questionnaire documenting demographics and history or family history of diabetes mellitus (DM), hypertension (HT), and chronic kidney disease (CKD), together with on-site measurements of blood pressure (BP) and urine dipstick for protein, blood, and glucose. Results There were a total of 1811 participants. One thousand two hundred and one subjects were entered into the final analysis. Among the 1201 who were apparently "healthy" (asymptomatic and without history of DM, HT, or CKD), the prevalence of positive (≥1+) urine dipstick for protein, glucose, blood, protein or blood, any urine abnormality, and HT (BP≥140/90) was 3.2%, 1.7%, 13.8%, 16%, 17.4%, and 8.7%, respectively. Thirty three percent of the age over 60 years old group had either hypertension or urine abnormalities, compared with 24.0% in the 41- to 60-year-old group and 9.7% in the 20- to 40-year-old group. Having a family history of diabetes or hypertension increases the risk of having urine abnormalities, while a family history of hypertension also increases the risk of high blood pressure. Conclusion It is concluded that subclinical abnormalities in urinalysis or BP readings are prevalent across all age groups in the adult population. An effective screening program at the primary care level that identifies these subjects for further evaluation is warranted, and the public in Hong Kong should be educated toward the significance of such findings in order to have regular health check for asymptomatic renal diseases.

In patients with end-stage renal disease, temporary placement of venous catheters for haemodialysis (HD) is often necessary, and the right internal jugular (RIJ) vein is the usual preferred site of HD catheter placement. We report here a patient who experienced complications because of the development of a pseudoaneurysm of the transverse cervical artery following an apparently uneventful RIJ vein cannulation for temporary HD, using the blind landmark-guided technique. This is a rare complication of RIJ vein cannulation and HD catheter placement. The pseudoaneurysm presented 3 weeks after the procedure and was diagnosed by using colour-Doppler ultrasound, followed by an angiogram, and it was successfully occluded using endovascular coil embolization.

To assess the efficacy of using ultrasonography (USG) in monitoring the progress of exit site infection (ESI) in patients undergoing continuous ambulatory peritoneal dialysis (CAPD).Twenty-two cases of newly diagnosed ESI and 20 cases with normal exit sites as controls were assessed by using USG. The exit sites were reassessed by using USG after finishing a course of antibiotic therapy, and the sonographic findings were correlated with the clinical outcome.Out of the 22 cases of ESI, 21 cases had definite sonolucent zones around the external cuffs, while one case had normal sonographic findings. Of the 20 control cases of normal exit sites, 16 had normal sonographic findings, and four had sonolucent zones around the external cuffs. Exit site infections correlated with positive sonographic findings as compared to normal exits (P0.0001). The 21 cases of ultrasonic-positive ESI were re-examined after antibiotic therapy, and 10 of these had a post-treatment sonolucent rim around the distal cuffor =1 mm thick, while 11 cases were persistentlymm thick. The former group was shown to have a more favourable outcome (P=0.013). And despite variable USG findings, all eight patients with Pseudomonas aeruginosa-related ESI had an unfavourable clinical outcome.Ultrasonography of the exit sites in CAPD patients is a useful adjunctive tool in the management of ESI. A sonolucent zone around the external cuff1 mm thick following a course of antibiotic treatment and the involvement of the proximal cuff are associated with poor clinical outcome. In ESI caused by Pseudomonas aeruginosa, the clinical outcome was uniformly poor irrespective of the sonographic findings.

Chronic strongyloidiasis is a mild disease and has never been reported to be associated with nephrotic syndrome. Disseminated strongyloidiasis is known to have high mortality, but it frequently is not diagnosed until autopsy. We report a patient with nephrotic syndrome developing disseminated strongyloidiasis after steroid therapy. The findings in renal biopsy, the time course of the development, and resolution of nephrotic syndrome after thiabendazole treatment suggested a possible causal relationship between chronic strongyloidiasis and nephrotic syndrome. The case also demonstrated the importance of early diagnosis in disseminated strongyloidiasis and the good clinical outcome of early treatment before the development of organ failure.

Sir, Penicillins are b-lactam antimicrobial agents. They act by binding to penicillin-binding proteins on the bacterial cytoplasmic membrane and then interfere with the cell wall physiology. Piperacillin belongs to the group of acylaminopenicillin which has additional coverage for Pseudomonas aeruginosa and other Gram-negative bacilli. However, antimicrobial degradation can occur with b-lactamaseproducing bacteria, causing drug resistance. With the addition of the b-lactamase inhibitor tazobactum, Tazocin (piperacillin/tazobactum) is active against b-lactamaseproducing bacteria that are resistant to acylamino-penicillin. We present a case of hallucinations and mental confusion in a continuous ambulatory peritoneal dialysis (CAPD) patient after receiving piperacillin/tazobactam for 7 days for the treatment of pneumonia. The drug-induced encephalopathy resolved with the discontinuation of the drug and continued peritoneal dialysis. Case. A 47-year-old end-stage renal disease male patient, who had been on CAPD for 1 year, was admitted to hospital for cough, right pleuritic chest pain and fever for 2 days. The clinical picture was suggestive of lobar pneumonia, with chest X-ray showing consolidation of the right lower lobe. Laboratory results showed leukocytosis with white cell count 19.2 10 9 /l. He had a residual renal creatinine clearance of 3 ml/min, and empirical intravenous (i.v.) piperacillin/tazobactam was started at a dose of 4 g/500 mg every 12 h. Meanwhile, he continued CAPD with four 2 l exchanges per day. His fever came down on day 7 and piperacillin/tazobactam was continued. However, on the following evening, he began to experience auditory hallucinations and insomnia. This was followed by visual hallucinations, progressive mental confusion and abnormal behaviour. Electrolyte disturbances were excluded with normal sodium, potassium, calcium and magnesium levels. Computed tomography of the brain and electroencephalogram were unremarkable. Lumbar puncture yielded cerebrospinal fluid with normal biochemistry and cell counts. Drug-induced encephalopathy was suspected and piperacillin/tazobactam was stopped, 2 days after the onset of symptoms. His mental state gradually improved over the next 3 days and his pneumonia was resolving as well. He remained stable and was discharged 4 days later.

We investigated the relationship between the result of technetium-99m-methoxyisobutylisonitrile (MIBI) parathyroid scanning and the subsequent biochemical outcome following calcitriol treatment. Twenty-two patients on dialysis with serum intact parathyroid hormone (PTH) level (iPTH) more than 500 pg/mL on annual checkup were selected. Around 20 weeks later, baseline iPTH were repeated at the time of performing MIBI scan and assayed again another 20 weeks later, while patients had intensification of treatment with oral calcitriol. Ten had positive MIBI parathyroid scans (MIBI+) while 12 had negative MIBI parathyroid scans (MIBI-). Although there was no statistically significant difference between both groups concerning baseline iPTH, phosphate, calcium × phosphate product and aluminum level, the MIBI+ group had higher serum calcium level and a tendency toward longer duration of dialysis. At 20 weeks, the MIBI- group showed a significantly lower iPTH of 413.2 ±335.7 pg/mL as compared to the MIBI+ group of 884.6 ±706.6 pg/mL (p = 0.03). The MIBI-group also had a higher proportion of patients showing decrease in iPTH (p = 0.05). Despite more profound iPTH suppression, the MIBI- group was actually given a lower mean maximum weekly calcitriol dosage of 2.20 ±1.82 μg as compared to 4.33 ±2.15 μg in the MIBI+ group (p = 0.025). Excessive suppression of iPTH below 100 pg/mL was evident in two patients of the MIBI- group and none in the MIBI+ group. We concluded that for patients on dialysis with grossly elevated baseline iPTH, the biochemical response to calcitriol is more profound in the MIBI- group. MIBI parathyroid scan may provide supplementary hints concerning the outcome of the medical treatment for uremic hyperparathyroidism.

Uremia and dialysis are notorious to have adverse effect on the sexual life of renal patients. To assess the magnitude of this impact in patients on continuous ambulatory peritoneal dialysis (CAPD), married couples with one of the partner on CAPD aged less than 50 years old were studied by questionnaires. Fifty-six questionnaires returned from 28 spouses. Out of 28 patients, 53.6% indicated a decrease in satisfaction to sexual life, 71.4% had decrease in libido and 78.6% had decrease in frequency of sexual intercourse upon commencement of CAPD. Out of 11 male patients, 10 had perceived deterioration in sexual potency, seven indicated a decrease in the ease of achieving orgasm and three had complete loss of morning erection. Up to 50% of patients attributed the decrease in their libido to the fear of pulling the peritoneal dialysis (PD) catheters. Of all couples, 21.4% and 14.3% agreed to the notion that normal sexual life jeopardizes the health of male and female CAPD patients respectively; 28.6% agreed that sexual life could accelerate the deterioration of residual renal function; 14.3% felt that having sex with renal patients would be deleterious to the health of spouse. Another 16.1% thought that patients on CAPD should not have sexual life while 30.4% believed that end-staged renal failure (ESRF) would inevitably lead to loss of sexual function. Couples with complete cessation of sexual activities after CAPD tend to agree with or being uncertain about the above-mentioned notions. In conclusion, we confirmed that CAPD patients were adversely affected in various aspects of their sexual life. Misconception concerning the negative impact of sexual activities on the health of renal patients is common. Education and counseling should have definite role in the removal of myths and improvement of sexual rehabilitation amongst patients on CAPD.