19^th Annual Conference on
Nephrology

During past decades, the epidemiology of chronic kidney disease (CKD) has changed from infectious disease to metabolic disorders. The aim of this study was to investigate prevalence and risk factors of CKD.

Patients with end-stage renal disease (ESRD) have an increased risk of tuberculosis (TB). Approximately, 10–20% of patients with extrapulmonary TB are skeletal involvement. In addition, spinal TB accounts more than half of skeletal TB cases. Aim of this study was to determine the rate, risks and outcome of spine TB in ESRD patient. We examined records of ESRD patients who initiated dialysis between 1999 and 2007. Patients were followed from the initiation of dialysis to spinal TB, death, end of dialysis, or December 31, 2008. The cumulative proportion of patients with spinal TB and of survivors after spinal TB were calculated using the Kaplan-Meier method. Cox proportional hazards models were used to identify the risk factors for spinal TB. A total of 67,993 incident ESRD dialysis patients were examined in this study. During the follow-up period, 89 patients had a spinal TB. The overall incidence of spinal TB in ESRD dialysis patient was 32.43 / 10,000 patient-years. Being female was associated with 85% higher risk (HR 1.85, 95% CI: 1.19-2.90). Patients ≥ 65 years old had more than 2 times the risk than did those 18-44 years old (HR 2.35, 95% CI: 1.04-5.34). The most strong predictor of spinal TB after dialysis was prior TB history (HR 3.86, 95% CI: 1.56-9.55).Overall in-hospital mortality was 19.1 %. The cumulative survival rates after spinal TB was only 65.5% at one year. In conclusion, being female, elderly and prior TB history were independent risk factors for spinal TB in dialysis group. The mortality was high after spinal TB. Clinicians should be aware of back pain in ESRD patients, especially in TB endemic areas such as Taiwan, because of high mortality rate of this disease.

The worldwide elderly dialysis population has grown significantly and is expected to have more comorbid conditions and shorter life expectancies than the general elderly population. Predicting outcomes for this population is important for decision-making. Our study is to examine the comorbidity index for outcome predictability in elderly dialysis patients. In this population-based cohort study, we enrolled elderly patients who started maintenance dialysis in Taiwan. Further analyses of all-cause mortality and life expectancy in these groups with different comorbidity index score were performed. As results, a total of 21,043 incident dialysis patients divided into 4 groups by the comorbidity index score (intervals ≤ 3, 4-6, 7-9, ≥ 10) were analyzed. During a 10-year follow-up, 11272 (53.55%) patients died. Kaplan-Meier curves showed significant survival differences between groups (log-rank: P < 0.001). After stratification by age, life expectancy was significantly longer in groups with lower the comorbidity index scores. In conclusion, the comorbidity index is a strong predictor of mortality in elderly dialysis patients.

End-stage renal disease (ESRD) and chronic liver disease (CLD) both increase the risk for upper gastrointestinal (UGI) bleeding. The prevalence of ESRD and CLD are high in Taiwan. The aim of this study was to evaluate the incidence, risk factors, and categories of UGI bleeding in ESRD dialysis patients. We enrolled 42,457 incident ESRD incident dialysis patients. These patients were followed until death, dialysis cessation, or end of database. Cumulative incidence of UGI bleeding after initiation of dialysis was calculated using Kaplan-Meier methods. Predictors for UGI bleeding were determined using Cox models. During the follow-up period, 5,528 patients had a UGI bleeding. Male, elderly, receiving hemodialysis (HD) and patient with comorbidites had a higher rate of UGI bleeding. The 1-, 3-, 5- and 7-year cumulative incidence rate of UGI bleeding were 9.8%, 21%, 25.3% and 28% in patients with liver cirrhosis (LC) on HD, 5.8%, 16.2%, 22.2% and 24.4% in patients with LC on PD, 3.7%, 9.2%, 13.2% and 16.4% in patients without LC on HD, and 2.1%, 5.5%, 8.2% and 10.4% in patients without LC on PD (log-rank: p <0.001). After multivariate adjustment, prior gastrointestinal bleeding (HR 1.731, 95% CI, 1.635-1.834), LC (1.682, 95% CI, 1.524-1.856), alcoholism liver disease (1.536, 95% CI, 1.635-1.834), and receiving HD (1.316, 95% CI, 1.153-1.502) were independently risks for UGI bleeding in ESRD dialysis patient. Gastric ulcers were found to be the most common source of bleeding (50.3%), while bleeding resulting from a gastrojejunal ulcer was least frequent. In conclusion, ESRD dialysis patients had a higher risk for UGI bleeding, especially those with prior gastrointestinal bleeding, LC, and alcoholism liver disease. In addition, receiving HD is a strong predictor for UGI bleeding. More attention should be paid to select dialysis modality, especially in high risk patients.

HIV-associated nephropathy (HIVAN) in sub-Saharan Africa is a significant cause of morbidity and mortality in children. Early detection of kidney injury is essential to avert permanent damage and delay progression of kidney injury. Kidney biopsy is presently the gold standard for the diagnosis of focal segmental glomerulosclerosis (FSGS) however, it is invasive with attendant complications, and may not be representative due to sampling error. Also, serum creatinine is an insensitive and non-specific marker for the diagnosis of various kidney diseases, particularly in HIV-infected patients. Therefore the need for a non-invasive approach using additional urinary biomarkers such as KIM-1, IL-18 and GST (π) for the early detection of FSGS, particularly in paediatric HIVAN, is urgently warranted. The study group comprised of 34 children; 13 with HIVAN and 21 with idiopathic FSGS. The control groups were 19 HIV positive and 16 HIV negative children with no kidney disease. Urine samples collected from these 69 children were stored at -80ºC. Urinary concentrations of KIM-1, IL-18 and GST (π) were quantified using Pro RBM Kidney Toxicity Assay (Panel 1), a Bio-Plex® Multiplex Immunoassay system which utilizes Luminex xMAP technology using a bead-based flow cytometric platform dedicated to multiplex analysis. The data of each sample was collected and analysed using a BioPlex 200 instrument equipped with Bio-Plex Manager™ analysis software. A significant increase in urinary KIM-1 levels were observed in the HIVAN group compared to the control groups viz., HIV positive (p=0.0039) and HIV negative (p=0.0438). There was no significant increase in KIM-1 levels between the idiopathic FSGS group and the control group (p= 0.0737and p=0.1757) respectively. No statistical significant differences were noted in urinary IL-18 and GST-π levels across all study groups. Urinary KIM-1 levels are significantly elevated in children with HIVAN and may be a useful biomarker to detect kidney disease in HIV-1 infected children.

Sepsis is known worldwide as a clinical syndrome with high considerable rate of mortality and morbidity. Over the past decades, studies conducted on this life-threatening disease have discovered that septic shock, which causes organ failure and injury as a consequence of responding to infection, may lead to certain changes in the bodys hemodynamic response. Consequently, about 30% of patients with sepsis develop a multiple organ dysfunction syndrome. A 20% mortality rate has been observed in sepsis patients which further increases to 60% to 80% mortality rate, among septic shock patients. Refractory septic shock has also been observed to increase the 28-day mortality rate despite aggressive therapy. Patients with persistent hypotension and end-organ dysfunction, often require high doses of vasopressor support.

Neutrophil-to-lymphocyte ratio (NLR) has recently been investigated as a new inflammatory marker used in the assessment of systemic inflammation in many diseases. The purpose of the study was to evaluate their relation with inflammatory response and disease activity in newly diagnosed SLE patients.

Sapna Chandgadkar is a Masters Student at Goa Engineering College. She is working with Dr Virani, HoD Electronics Engineering and Dr Mahaldar, HoD, Nephrology, Manipal Hospital. Their research focuses on improving the quality of life of patient on hemodialysis, in emerging markets. The objective is to develop a Markov Model of the interventions that could help patients on Hemodialysis to improve their fitness levels a step at a time.

People with End Stage Kidney Disease(ESKD) on Hemodialysis(HD) experience multiple catabolic processes, including loss of albumin and amino acids during dialysis, metabolic derangements, and changes in skeletal muscle associated with conditions of muscle disuse. These changes result in muscle atrophy (loss of lean muscle mass). The presence of neurogenic (muscle atrophy or loss associated with nerve disorder), myogenic (damage intrinsic to the muscle), and mixed (neurogenic and myogenic) changes intrinsic to the skeletal muscle in people with ESKD on HD may further compromise the integrity of the motor-unit complex and contribute to muscle atrophy. The paper is a systematic review of the interventions to improve fitness levels of patients on maintenance HD.