Background: With the aging population and advancements in medical care worldwide, the number of older patients with end-stage kidney disease continues to rise. This study aimed to identify factors associated with osteoporosis and osteopenia in older patients undergoing incident hemodialysis and assess their impact on mortality. Methods: We analyzed a large multicenter retrospective cohort of patients aged ≥70 years undergoing incident hemodialysis to identify factors associated with osteoporosis using logistic regression analysis and to assess the association of death with osteoporosis and osteopenia using Cox multivariable analysis. Results: Among 710 patients, 39.0% and 19.6% had osteoporosis and osteopenia, respectively. Osteoporosis was significantly associated with female sex, a history of fractures, and the absence of phosphate binder use. During a median follow-up of 36.8 months, 348 participants (58.8%) died. Mortality rates were the highest in the osteoporosis group (79.8%), followed by the osteopenia (77.2%) and normal bone mineral density (BMD) groups (35.2%). Cox regression analysis revealed that even after adjusting for covariates, the osteoporosis group was significantly associated with a higher mortality risk than the normal BMD group. Osteoporosis at the start of hemodialysis was significantly associated with higher mortality. Conclusion We should consider the importance of bone health in patients undergoing incident hemodialysis and pay attention to the use of phosphate binders and fracture prevention.

Background: Obesity is a well-known risk factor for chronic kidney disease and its progression. However, the impact of obesity on the renal function of the elderly population is uncertain. We investigated the association between obesity and renal outcomes in the elderly. Methods: We analyzed 130,504 participants from the Korean National Health Insurance Service-Senior cohort. Obesity was classified according to body mass index (BMI), sex-specific waist circumference (WC), and the presence of metabolic syndrome. The primary outcome was renal function decline, defined as a decline in the estimated glomerular filtration rate (eGFR) of at least 50% from baseline or new-onset end-stage renal disease. Results: During a follow-up period of 559,531.1 person-years (median, 4.3 years), 2,486 participants (19.0%; incidence rate of 4.44 per 1,000 person-years) showed renal function decline. A multivariate Cox proportional hazards model revealed that BMI/WC was not associated with renal function decline. However, the group with metabolic syndrome had a significantly increased risk of renal function decline compared to the group without metabolic syndrome (adjusted hazard ratio [HR], 1.24; 95% confidence interval [CI], 1.13–1.36). Compared with the non-metabolic syndrome group, the adjusted HRs (95% CI) for participants with one through five components were 0.96 (0.84–1.11), 1.10 (0.96–1.27), 1.24 (1.06–1.45), 1.37 (1.12–1.66), and 1.99 (1.42–2.79), respectively (p for trend < 0.001). Conclusion In elderly Korean adults, metabolic syndrome and the number of its components were associated with a higher risk of renal function decline, but BMI or WC was not significant.

Early mortality following hemodialysis initiation hinders survival improvement in older patients. This study aimed to develop a clinical risk model for predicting 6-month mortality after dialysis initiation in older Korean hemodialysis patients. Methods: We analyzed data from incident hemodialysis patients aged >70 years from the Korean Society of Geriatric Nephrology (KSGN) database. A prediction model was developed using multivariate logistic regression analysis and externally validated with independent datasets. Results: Among 1,751 incident hemodialysis patients, the 6-month mortality rate was 15.5%. Using multivariate logistic analysis, we constructed the KSGN score as an independent risk factor for 6-month mortality, and its components and score are as follows: old age at dialysis initiation (≥85 years, score 2); hypertension and renovascular disease as a primary etiology of end-stage kidney disease (ESKD) (score 1); malignancy history (yes, score 1); low serum albumin (<3.5 g/dL, score 1); hypertension treatment (yes, score –1); prepared vascular access on maintenance dialysis (arteriovenous fistula/arteriovenous graft, score –3). In the development cohort, the area under the curve (AUC) for the KSGN score was significantly higher than the Alberta Wick’s score (0.707 vs. 0.683, p = 0.001). In the validation cohort, the KSGN score’s performance was comparable to existing models. Conclusion: The KSGN score may be a valuable tool for predicting early mortality after dialysis initiation in older patients with ESKD, aiding in decision-making and management regarding dialysis initiation.

The prevalence of dementia is 2- to 7-fold higher among patients with end-stage kidney disease (ESKD) than among the general population; however, its clinical implications in this population remain unclear. Therefore, this study aimed to determine whether comorbid dementia increases mortality among older patients with ESKD undergoing newly initiated hemodialysis. Methods: We analyzed data from the Korean Society of Geriatric Nephrology retrospective cohort, which included 2,736 older ESKD patients (≥70 years old) who started hemodialysis between 2010 and 2017. Kaplan-Meier survival and Cox regression analyses were used to examine all-cause mortality between the patients with and without dementia in this cohort. Results: Of the 2,406 included patients, 8.3% had dementia at the initiation of dialysis; these patients were older (79.6 ± 6.0 years) than patients without dementia (77.7 ± 5.5 years) and included more women (male:female, 89:111). Pre-ESKD diagnosis of dementia was associated with an increased risk of overall mortality (hazard ratio, 1.503; p < 0.001), and this association remained consistent after multivariate adjustment (hazard ratio, 1.268; p = 0.009). In subgroup analysis, prevalent dementia was associated with mortality following dialysis initiation in female patients, those aged <85 years, those with no history of cerebrovascular accidents or severe behavioral disorders, those not residing in nursing facilities, and those with no or short-term hospitalization. Conclusion: A pre-ESKD diagnosis of dementia is associated with mortality following dialysis initiation in older Korean population. In older patients with ESKD, cognitive assessment at dialysis initiation is necessary.

Evidence of the ethical appropriateness and clinical benefits of shared decision-making (SDM) are accumulating. This study aimed to not only identify physicians’ perspectives on SDM, and practices related to end-of-life care in particular, but also to gauge the effect of SDM education on physicians in Korea. Methods: A 14-item questionnaire survey using a modified Delphi process was delivered to nephrologists and internal medicine trainees at 17 university hospitals. Results: A total of 309 physicians completed the survey. Although respondents reported that 69.9% of their practical decisions were made using SDM, 59.9% reported that it is not being applied appropriately. Only 12.3% of respondents had received education on SDM as part of their training. The main obstacles to appropriate SDM were identified as lack of time (46.0%), educational materials and tools (29.4%), and education on SDM (24.3%). Although only a few respondents had received training on SDM, the proportion of those who thought they were using SDM appropriately in actual practice was high; the proportion of those who chose lack of time and education as factors that hindered the proper application of SDM was low. Conclusion: The majority of respondents believed that SDM was not being implemented properly in Korea, despite its use in actual practice. To improve the effectiveness of SDM in the Korean medical system, appropriate training programs and supplemental policies that guarantee sufficient application time are required.

BACKGROUND AND PURPOSE: Measuring the extent of the collateral blood vessels using computed tomography (CT) angiography source images may promote tissue survival and functional gain in acute ischemic stroke patients who are candidates for endovascular recanalization treatment. METHODS: Of 5,558 acute stroke patients registered in a prospective clinical stroke registry, 104 met the selection criteria of endovascular recanalization treatment for internal cerebral artery or middle cerebral artery main-stem (M1) occlusions and presented for treatment ≤4 hours after the event. Using CT angiography source images, two independent and blinded reviewers measured the extent of collateral circulations at four regions, with good interrater reliability. The functional recovery at 3 months after stroke was used as an outcome variable. RESULTS: Cases with a sufficient collateral circulation at the Sylvian fissure showed significantly increased likelihood of having a modified Rankin Scale score of ≤2 at 3 months after stroke (adjusted odds ratio=3.03, 95% confidence interval=1.19–7.73, p=0.02), but the association became nonsignificant after adding the infarct volume to the model (p=0.65). The association between leptomeningeal convexity collaterals and functional recovery was no longer significant after adjusting for the infarct volume (p=0.28). The natural indirect effect of infarct volume on functional recovery was significant for both the Sylvian fissure (p=0.03) and leptomeningeal convexity (p=0.02) collaterals. CONCLUSIONS: The extent of collateral circulation at the Sylvian fissure was significantly associated with functional recovery, which may be mediated via the volume of the final infarction.
Angiography* ; Blood Vessels ; Cerebral Arteries ; Collateral Circulation ; Humans ; Infarction ; Middle Cerebral Artery ; Mortality ; Patient Selection ; Prospective Studies ; Stroke* ; Tissue Survival

BACKGROUND: A ground-glass nodule (GGN) represents early-stage lung adenocarcinoma. However, there is still no consensus for preoperative staging of GGNs. Therefore, we evaluated the need for the routine use of positron emission tomography/computed tomography (PET)/computed tomography (CT) scans and brain magnetic resonance imaging (MRI) during staging. METHODS: A retrospective analysis was undertaken in 72 patients with 74 GGNs of less than 3 cm in diameter, which were confirmed via surgery as malignancy, at the Samsung Medical Center between May 2010 and December 2011. RESULTS: The median age of the patients was 59 years. The median GGN diameter was 18 mm. Pure and part-solid GGNs were identified in 35 (47.3%) and 39 (52.7%) cases, respectively. No mediastinal or distant metastasis was observed in these patients. In preoperative staging, all of the 74 GGNs were categorized as stage IA via chest CT scans. Additional PET/CT scans and brain MRIs classified 71 GGNs as stage IA, one as stage IIIA, and two as stage IV. However, surgery and additional diagnostic work-ups for abnormal findings from PET/CT scans classified 70 GGNs as stage IA, three as stage IB, and one as stage IIA. The chest CT scans did not differ from the combined modality of PET/CT scans and brain MRIs for the determination of the overall stage (94.6% vs. 90.5%; kappa value, 0.712). CONCLUSION: PET/CT scans in combination with brain MRIs have no additional benefit for the staging of patients with GGN lung adenocarcinoma before surgery.
Adenocarcinoma ; Brain* ; Consensus ; Electrons* ; Humans ; Lung ; Magnetic Resonance Imaging* ; Neoplasm Metastasis ; Neoplasm Staging ; Positron-Emission Tomography and Computed Tomography ; Retrospective Studies ; Solitary Pulmonary Nodule ; Tomography, X-Ray Computed

Hansen's disease(HD) is a chronic infectious disorder acquired by inoculation of Mycobacterium leprae. With the establishment of complex multidrug therapy, the incidence rate of leprosy patients has continually shown to decline by 90% compared to the incidence rate in the 1990s. However, the prevalence of the disease still remains high in southeast asian countries. Due to the rarity and diverse nature of cutaneous presentation, HD is often misdiagnosed with other dermatoses or infectious conditions. Especially, when a patient presents with unusual presentation with leprosy reaction with no classical feature such as sensory disorders and skin lesion, the diagnosis is further delayed with misguided treatments. Herein we present a 27-year-old Indonesian immigrant who displayed clinical features mimicking that of orbital cellulitis who was later diagnosed with borderline lepromatous leprosy through histologic and PCR confirmation, in light of alerting the probability of leprosy in immigrants with intractable skin presentations.
Adult ; Asian Continental Ancestry Group ; Diagnosis ; Emigrants and Immigrants ; Humans ; Incidence ; Leprosy ; Leprosy, Borderline ; Leprosy, Multibacillary ; Mycobacterium leprae ; Orbit ; Orbital Cellulitis ; Polymerase Chain Reaction ; Prevalence ; Sensation Disorders ; Skin ; Skin Diseases

BACKGROUND: Recent developments in surgical techniques and hospital care have led to improved outcomes following total anomalous pulmonary venous return (TAPVR) repair. However, the surgical repair of TAPVR remains associated with a high risk of mortality and need for reoperation. We conducted this retrospective study to evaluate mid-term outcomes following in situ TAPVR repair without total circulatory arrest (TCA), and to identify the risk factors associated with surgical outcomes. METHODS: We retrospectively reviewed 29 cases of surgical intervention for TAPVR conducted between April 2000 and July 2015. All patients were newborns or infants who underwent in situ TAPVR repair without TCA. RESULTS: Four anatomic subtypes of TAPVR were included in this study: supracardiac (20 cases, 69.0%), cardiac (4 cases, 13.8%), infracardiac (4 cases, 13.8%), and mixed (1 case, 3.4%). The median follow-up period for all patients was 42.9 months. Two (6.9%) early mortalities occurred, as well as 2 (6.9%) cases of postoperative pulmonary venous obstruction (PVO). Preoperative ventilator care (p=0.027) and preoperative PVO (p=0.002) were found to be independent risk factors for mortality. CONCLUSION: In situ repair of TAPVR without TCA was associated with encouraging mid-term outcomes. Preoperative ventilator care and preoperative PVO were found to be independent risk factors for mortality associated with TAPVR repair.
Follow-Up Studies ; Humans ; Infant ; Infant, Newborn ; Mortality ; Reoperation ; Retrospective Studies ; Risk Factors ; Scimitar Syndrome* ; Ventilators, Mechanical

OBJECTIVE: We evaluated the effect of endovascular treatment (EVT) for acute ischemic stroke in patients over 80 years of age. MATERIALS AND METHODS: The records of 156 acute stroke patients aged over 80 years who were considered as candidates for EVT were analyzed. Fifty-six patients (35.9%, EVT group) underwent EVT and 100 patients (64.1%, non-EVT group) did not. Outcomes, in terms of functional outcomes and rates of symptomatic hemorrhage, in-hospital morbidity and mortality, were compared between groups. Each comparison was adjusted for age, time from onset, initial National Institute of Health Stroke Scale, and pre-stroke modified Rankin Scale (mRS). RESULTS: More patients in the EVT group achieved good outcomes (mRS score of 0-2) at 3 months (35.7% vs. 11.0%, adjusted odds ratio [OR] 4.779 [95% confidence interval 1.972-11.579], p = 0.001) and 12 months (35.7% vs. 14.0%, adjusted OR 3.705 [1.574-8.722], p = 0.003) after stroke. During admission, rates of hospital-acquired infection including pneumonia (12.5% vs. 29.0%, adjusted OR 0.262 [0.098-0.703], p = 0.008) and urinary tract infection (16.0% vs. 34.0%, adjusted OR 0.256 [0.099-0.657], p = 0.005) were significantly lower in the EVT group. More symptomatic hemorrhages (10.7% vs. 2.0%, adjusted OR 6.859 [1.139-41.317], p = 0.036) occurred in the EVT group, but no significant difference was observed in in-hospital mortality rate (12.5% vs. 8.0%, adjusted OR 1.380 [0.408-4.664], p = 0.604). CONCLUSION: EVT improved functional outcome and reduced the risk of hospital-acquired infections in acute stroke patients over 80 years of age without increasing the risk of in-hospital mortality, although symptomatic hemorrhage occurred more frequently after EVT.
Hemorrhage ; Hospital Mortality ; Humans ; Mortality ; Odds Ratio ; Pneumonia ; Stroke* ; Thrombolytic Therapy ; Urinary Tract Infections