The Ministry of Health (MOH) has updated the Clinical Practice Guidelines on Lipids to provide doctors and patients in Singapore with evidence-based treatment for lipids. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH Clinical Practice Guidelines on Lipids, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: http://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html.
Adult ; Cardiovascular Diseases ; complications ; therapy ; Child ; Coronary Artery Disease ; complications ; therapy ; Decision Support Systems, Clinical ; Dyslipidemias ; blood ; complications ; therapy ; Evidence-Based Medicine ; Female ; Humans ; Kidney Failure, Chronic ; complications ; therapy ; Life Style ; Lipids ; blood ; Lipoproteins, LDL ; blood ; Male ; Practice Guidelines as Topic ; Pregnancy ; Pregnancy Complications ; Risk Assessment ; Risk Factors ; Singapore

PURPOSE: Copeptin has been considered as a useful marker for diagnosis and prediction of prognosis in heart diseases. However, copeptin has not been investigated sufficiently in hemodialysis patients. This study aimed to investigate the general features of copeptin in hemodialysis and to examine the usefulness of copeptin in hemodialysis patients with left ventricular dysfunction (LV dysfunction). MATERIALS AND METHODS: This study included 41 patients on regular hemodialysis. Routine laboratory data and peptides such as the N-terminal of the prohormone brain natriuretic peptide and copeptin were measured on the day of hemodialysis. Body fluid volume was estimated by bioimpedance spectroscopy, and the E/Ea ratio was estimated by echocardiography. RESULTS: Copeptin increased to 171.4 pg/mL before hemodialysis. The copeptin had a positive correlation with pre-dialysis body fluid volume (r=0.314; p=0.04). The copeptin level decreased along with body fluid volume and plasma osmolality during hemodialysis. The copeptin increased in the patients with LV dysfunction more than in those with normal LV function (218.7 pg/mL vs. 77.6 pg/mL; p=0.01). Receiver operating characteristic curve analysis showed that copeptin had a diagnostic value in the hemodialysis patients with LV dysfunction (area under curve 0.737; p=0.02) and that the cut-off value was 125.48 pg/mL (sensitivity 0.7, specificity 0.8, positive predictive value 0.9, negative predictive value 0.6). CONCLUSION: Copeptin increases in hemodialysis patients and is higher in patients with LV dysfunction. We believe that copeptin can be a useful marker for the diagnosis of LV dysfunction in hemodialysis patients.
Adult ; Aged ; Biomarkers/blood ; Echocardiography ; Female ; Glycopeptides/*blood ; Humans ; Kidney Failure, Chronic/*blood/complications/therapy ; Male ; Middle Aged ; Natriuretic Peptide, Brain/blood ; Predictive Value of Tests ; Prognosis ; ROC Curve ; Renal Dialysis/*adverse effects ; Sensitivity and Specificity ; Ventricular Dysfunction, Left/*blood/complications/*physiopathology

A 39-year-old woman with end-stage renal disease, which was maintained on haemodialysis, developed secondary haemochromatosis after receiving blood transfusions and intravenous iron supplementation without sufficient serum ferritin concentration monitoring. The patient received intravenous deferoxamine three times a week, combined with high-dose recombinant human erythropoietin therapy and haemodialysis. After three months, improvements in biochemical indicators and iron overload were noted.
Adult ; Chelating Agents ; chemistry ; Erythropoietin ; therapeutic use ; Female ; Ferritins ; blood ; Hemochromatosis ; complications ; Hemoglobins ; analysis ; Humans ; Kidney Failure, Chronic ; complications ; therapy ; Recombinant Proteins ; therapeutic use ; Renal Dialysis ; adverse effects ; Sequence Analysis, DNA ; Tomography, X-Ray Computed ; Transferrin ; chemistry ; Transfusion Reaction ; Treatment Outcome

BACKGROUND/AIMS: Serum procalcitonin (PCT) levels are low in healthy individuals but are elevated in patients with a serious bacterial infection or sepsis. In this study, we examined the ability of serum PCT concentration to diagnose infections in end-stage renal disease (ESRD) patients, and sought to determine an appropriate threshold level. METHODS: Serum PCT levels were measured in ESRD patients on antibiotic therapy for a suspected bacterial infection (ESRD infection [iESRD] group, n = 21), and compared with those of ESRD patients on hemodialysis with no sign of infection (ESRD control [cESRD] group, n = 20). RESULTS: The mean serum PCT concentration of the iESRD group was significantly higher than in the cESRD group (2.95 +/- 3.67 ng/mL vs. 0.50 +/- 0.49 ng/mL, p = 0.006), but serum PCT concentrations did not correlate with severity of infection. The optimized threshold level derived for serum PCT was 0.75 ng/mL, rather than the currently used 0.5 ng/mL; this threshold demonstrated a sensitivity and specificity of 76.2% and 80.0% for infection and 100% and 60.6% for systemic inflammatory response syndrome, respectively, compared with the cutoff of 0.5 ng/mL. CONCLUSIONS: This study suggests that serum PCT at a cutoff value of 0.75 ng/mL is an appropriate indicator of infection in ESRD patients.
Adult ; Aged ; Area Under Curve ; Bacterial Infections/*blood/complications/*diagnosis/microbiology ; Biomarkers/blood ; Calcitonin/*blood ; Case-Control Studies ; Female ; Humans ; Inflammation Mediators/*blood ; Kidney Failure, Chronic/*complications/diagnosis/therapy ; Male ; Middle Aged ; Peritoneal Dialysis ; Predictive Value of Tests ; Protein Precursors/*blood ; ROC Curve ; Renal Dialysis ; Reproducibility of Results ; Up-Regulation

INTRODUCTIONSevelamer hydrochloride (Renagel) is frequently used as a second-line phosphate binder in patients on renal replacement therapy. Many studies have shown that sevelamer can improve vascular calcification, serum uric acid and low-density lipoprotein (LDL) cholesterol levels. The main objectives of this study were to assess the efficacy of sevelamer against calcium-based phosphate binders, as well as its tolerability and side-effect profile.

METHODSThis was a retrospective study that included all patients on renal replacement therapy (between 2008 and 2011) who had previously received calcium-based binders for ≥ 6 months and were subsequently switched to sevelamer. Data collected from the patients' medical records included demographics, as well as renal parameters three months prior to sevelamer treatment, and at three and six months post treatment. The study excluded patients on multiple, concomitant phosphate binders or with functioning renal transplants, and those who were noncompliant or had inadequate follow-up blood investigations.

RESULTSA total of 39 patients were included in the study. No major side effects were reported by any of the patients. There were improvements in calcium, phosphate, uric acid and LDL cholesterol levels at three and six months post-sevelamer treatment.

CONCLUSIONWe found sevelamer to be superior to calcium-based phosphate binders in reducing serum calcium, phosphate, uric acid and LDL cholesterol levels in our patient population with advanced renal bone disease. Sevelamer also appears to be well tolerated with no significant side effects.

Adult ; Bone Diseases ; complications ; Chelating Agents ; therapeutic use ; Female ; Humans ; Hypercalcemia ; drug therapy ; Hyperphosphatemia ; drug therapy ; Kidney Failure, Chronic ; drug therapy ; Male ; Middle Aged ; Phosphates ; chemistry ; Polyamines ; therapeutic use ; Renal Replacement Therapy ; methods ; Retrospective Studies ; Sevelamer ; Treatment Outcome ; Uric Acid ; blood

OBJECTIVETo evaluate the clinical efficacy and safety of sequential treatment with alprostadil and beraprost sodium for chronic renal failure caused by chronic glomerulonephritis.

METHODSSixty-three patients with chronic renal failure due to chronic glomerulonephritis, after receiving a 2-week-long conventional treatment, were randomly divided into alprostadil group (n=20, with alprostadil injection at 10 µg/d for 2 weeks), sequential treatment group (n=21, with alprostadil injection at 10 µg/d for 2 weeks and oral beraprost sodium at 20 µg three times a day for 12 weeks), and strengthened sequential treatment group (n=22, with alprostadil injection at 20 µg/d for 2 weeks and a double dose of oral beraprost sodium for 12 weeks). Urinary albumin excretion rate (UAER), cystatin C (Cys C), blood urea nitrogen, creatinine, fibrinogen, D-dimer, prothrombin time (PT), and platelets were tested before and after the treatment, and the changes in urinary albumin discharge rate, serum creatinine, and glomerular filtration rate were determined.

RESULTSThe patients in strengthened sequential treatment group showed a significantly decreased change rate of urinary albumin discharge rate (P<0.01) than those in the other two groups. In the two sequential treatment groups, especially the strengthened treatment group, the change rate of glomerular filtration rate increased significantly compared with that in alprostadil group (P<0.01). Strengthened sequential treatment resulted also in significantly decreased increment of serum creatinine compared that in the other 2 groups (P<0.01). After 14 weeks of treatment, fibrinogen and D-dimer were decreased in all the 3 groups (P<0.05) to a comparable level between the 3 groups (P>0.05), and prothrombin time (PT) or platelet showed no significant changes (P>0.05).

CONCLUSIONSequential treatment with alprostadil and beraprost sodium can improve the glomerular filtration rate and decrease urine albumin excretion rate, serum creatinine increase rate, and lower blood fibrinogen and D-dimer levels, thus delaying the progression of chronic renal failure caused by chronic glomerulonephritis. This therapy shows a dose-related effect with good clinical safety.

Adolescent ; Adult ; Aged ; Alprostadil ; therapeutic use ; Blood Urea Nitrogen ; Chronic Disease ; Creatinine ; blood ; Drug Therapy, Combination ; Epoprostenol ; analogs & derivatives ; therapeutic use ; Female ; Fibrin Fibrinogen Degradation Products ; metabolism ; Fibrinogen ; metabolism ; Glomerular Filtration Rate ; Glomerulonephritis ; complications ; Humans ; Kidney Failure, Chronic ; blood ; drug therapy ; etiology ; Male ; Middle Aged ; Platelet Aggregation Inhibitors ; therapeutic use ; Platelet Count ; Prothrombin Time ; Urological Agents ; therapeutic use ; Young Adult

A 94-year-old female with end-stage renal disease presents with fever, fatigue, and hematochezia. She had previously resided in Hunan Province, China, and Myanmar, and she immigrated to Taiwan 30 years ago. Colonoscopy revealed a colonic ulcer. Biopsy of the colonic ulcer showed ulceration of the colonic mucosa, and many Paragonimus westermani-like eggs were noted. Serum IgG antibody levels showed strong reactivity with P. westermani excretory-secretory antigens by ELISA. Intestinal paragonimiasis was thus diagnosed according to the morphology of the eggs and serologic finding. After treatment with praziquantel, hematochezia resolved. The present case illustrates the extreme manifestations encountered in severe intestinal paragonimiasis.
Aged, 80 and over ; Animals ; Anthelmintics/therapeutic use ; Antibodies, Helminth/blood ; Antigens, Helminth/immunology ; Colonic Diseases/complications/drug therapy/*pathology ; Colonoscopy ; Enzyme-Linked Immunosorbent Assay ; Female ; Gastrointestinal Hemorrhage/complications/drug therapy/*pathology ; Humans ; Intestinal Diseases, Parasitic/complications/drug therapy/parasitology/*pathology ; Kidney Failure, Chronic/complications ; Paragonimiasis/complications/drug therapy/parasitology/*pathology ; Paragonimus westermani/*immunology ; Praziquantel/therapeutic use ; Taiwan ; Ulcer/complications/drug therapy/*pathology

This study was designed to identify the causes of the development of carpal tunnel syndrome (CTS) associated with end stage kidney disease (ESKD). A total of 112 patients with ESKD, 64 on hemodialysis (HD) and 48 on peritoneal dialysis (PD), were enrolled. The duration of ESKD and dialysis, the site of the arteriovenous (A-V) fistula for HD, laboratory data such as blood urea nitrogen, creatinine, and beta-2-microglobulin were determined. Clinical evaluation of CTS and electrophysiological studies for the diagnosis of CTS and peripheral neuropathy were performed. The electrophysiological studies showed that the frequency of CTS was not different in the HD and PD groups (P = 0.823) and the frequency of CTS was not different in the limb with the A-V fistula compared to the contralateral limb (P = 0.816). The frequency of HD and PD were not related to beta-2-microglobulin levels, an indicator of amyloidosis. The frequency of CTS did not increase as the severity of the peripheral neuropathy and the duration of ESKD and dialysis increased (P = 0.307). The results of this study do not support that microglobulin induced amyloidosis or placement of an A-V fistula are associated with an increase in CTS.
Adult ; Aged ; Amyloidosis/complications ; Arteriovenous Fistula/complications ; Blood Urea Nitrogen ; Carpal Tunnel Syndrome/*complications/*diagnosis ; Creatinine/blood ; Electrophysiological Phenomena ; Female ; Humans ; Kidney Failure, Chronic/*complications/*therapy ; Male ; Middle Aged ; Peritoneal Dialysis/adverse effects ; Polyneuropathies/*complications/*diagnosis ; Renal Dialysis/adverse effects ; beta 2-Microglobulin/blood

Anti-erythropoietin antibodies usually cross-react with all kinds of recombinant erythropoietins; therefore, erythropoiesis-stimulating agent (ESA)-induced pure red-cell aplasia (PRCA) is not rescued by different ESAs. Here, we present a case of ESA-induced PRCA in a 36-yr-old woman with chronic kidney disease, whose anemic condition improved following reintroduction of darbepoetin-alpha. The patient developed progressive, severe anemia after the use of erythropoietin-alpha. As the anemia did not improve after the administration of either other erythropoietin-alpha products or erythropoietin-beta, all ESAs were discontinued. Oxymetholone therapy failed to improve the transfusion-dependent anemia and a rechallenge with ESAs continuously failed to obtain a sustained response. However, her anemia improved following reintroduction of darbepoetin-alpha at 3 yr after the initial diagnosis. Interestingly, anti-erythropoietin antibodies were still detectable, although their concentration was too low for titration. In conclusion, darbepoetin-alpha can improve ESA-induced PRCA when the anti-erythropoietin antibody titer declines and its neutralizing capacity is lost.
Adult ; Anemia/drug therapy/etiology ; Antibodies/*blood/immunology ; Bone Marrow Cells/pathology ; Drug Hypersensitivity/immunology ; Erythropoietin/*analogs & derivatives/therapeutic use ; Erythropoietin, Recombinant/adverse effects/*immunology/therapeutic use ; Female ; Glomerulonephritis, IGA/complications ; Hematinics/adverse effects/immunology/*therapeutic use ; Humans ; Kidney Failure, Chronic/complications ; Oxymetholone/therapeutic use ; Red-Cell Aplasia, Pure/chemically induced/*drug therapy/immunology

OBJECTIVE: The purpose of this study was to evaluate the fistulographic features of malfunctioning axillary loop-configured arteriovenous grafts and the efficacy of percutaneous interventions in failed axillary loop-configured arteriovenous grafts. MATERIALS AND METHODS: Ten patients with axillary loop-configured arteriovenous grafts were referred for evaluation of graft patency or upper arm swelling. Fistulography and percutaneous intervention, including thrombolysis, percutaneous transluminal angioplasty and stent placement, were performed. Statistical analysis of the procedure success rate and the primary and secondary patency rates was done. RESULTS: Four patients had graft related and subclavian venous stenosis, two patients had graft related stenosis and another four patients had subclavian venous stenosis only. Sixteen sessions of interventional procedures were performed in eight patients (average: 2 sessions / patient) until the end of follow-up. An interventional procedure was not done in two patients with central venous stenosis. The overall procedure success rate was 69% (11 of 16 sessions). The post-intervention primary and secondary patency rates were 50% and 63% at three months, 38% and 63% at six months and 25% and 63% at one year, respectively. CONCLUSION: Dysfunctional axillary loop-configured arteriovenous grafts almost always had subclavian venous and graft-related stenosis. Interventional treatments are helpful to overcome this and these treatments are expected to play a major role in restoring and maintaining the axillary loop-configured arteriovenous loop grafts.
Adult ; Aged ; Angioplasty, Balloon/*methods ; Arteriovenous Shunt, Surgical/*methods ; Blood Vessel Prosthesis Implantation/*methods ; Chronic Disease ; Constriction, Pathologic/therapy/ultrasonography ; Female ; Follow-Up Studies ; Graft Occlusion, Vascular/*therapy/ultrasonography ; Humans ; Kidney Failure, Chronic/*complications/therapy ; Male ; Middle Aged ; *Renal Dialysis ; Subclavian Vein/ultrasonography ; Survival Analysis ; Treatment Outcome ; Vascular Patency