Diabetic kidney disease is a microvascular complication of diabetes mellitus and the leading cause of end-stage renal disease resulting in renal replacement therapy. Approximately 30% to 40% of diabetic patients have diabetic kidney disease, which contributes to a significant increase in morbidity and mortality. Microalbuminuria is considered the gold standard for diabetic kidney disease diagnosis; however, its predictive value is restricted. Although blood glucose control, blood pressure control, and angiotensin converting enzyme inhibitors have been the primary treatment strategies, there are no definitive treatment modalities capable of inhibiting the progression of kidney dysfunction in these patients. This study was undertaken to answer seven questions regarding the various aspects of diabetic kidney disease. Why does it develop? what kind of factors affect its development? How is it diagnosed? What are its possible biomarkers? When is a kidney biopsy necessary? What are the preventive and therapeutic options? And what are the novel treatments?
Angiotensin-Converting Enzyme Inhibitors ; Biomarkers ; Biopsy ; Blood Glucose ; Blood Pressure ; Diabetes Mellitus ; Diabetic Nephropathies ; Diagnosis ; Humans ; Kidney ; Kidney Failure, Chronic ; Mortality ; Renal Replacement Therapy

BACKGROUND/AIMS: It has been suggested that chronic kidney disease (CKD) is a risk factor for Clostridium difficile infection (CDI) and is associated with increased mortality among patients infected with C. difficile. However, recent studies of the clinical impact of CKD on CDI in Asians are still insufficient. We sought to determine the relationship between CKD and CDI in a Korean population. METHODS: This was a single-center, retrospective case-control study. In total, 171 patients with CDI were included as cases and 342 age- and gender-matched patients without CDI were used as controls. We compared the prevalence of CKD in the study sample and identified independent risk factors that could predict the development or prognosis of CDI. RESULTS: Independent risk factors for CDI included stage IV to V CKD not requiring dialysis (odds ratio [OR], 2.90) and end-stage renal disease requiring dialysis (OR, 3.34). Patients with more advanced CKD (estimated glomerular filtration rate < 30) and CDI showed higher in-hospital mortality and poorer responses to the initial metronidazole therapy. CONCLUSIONS: More advanced CKD is an independent risk factor for CDI and is associated with higher in-hospital mortality and poor treatment responses in CDI patients. Thus, in CKD patients, careful attention should be paid to the occurrence of CDI and its management to improve the outcome of CDI.
Aged ; Anti-Infective Agents/therapeutic use ; Chi-Square Distribution ; Clostridium difficile/*pathogenicity ; Enterocolitis, Pseudomembranous/diagnosis/drug therapy/*microbiology/mortality ; Female ; Hospital Mortality ; Humans ; Kidney Failure, Chronic/*complications/diagnosis/therapy ; Logistic Models ; Male ; Metronidazole/therapeutic use ; Middle Aged ; Multivariate Analysis ; Odds Ratio ; Prevalence ; Renal Dialysis ; Renal Insufficiency, Chronic/*complications/diagnosis/mortality/therapy ; Republic of Korea/epidemiology ; Retrospective Studies ; Risk Factors ; Treatment Outcome

BACKGROUND/AIMS: This study analyzed the risk factors for technique survival in dialysis patients and compared technique survival rates between hemodialysis (HD) and peritoneal dialysis (PD) in a prospective cohort of Korean patients. METHODS: A total of 1,042 patients undergoing dialysis from September 2008 to June 2011 were analyzed. The dialysis modality was defined as that used 90 days after commencing dialysis. Technique survival was compared between the two dialysis modalities, and the predictive risk factors were evaluated. RESULTS: The dialysis modality was an independent risk factor predictive of technique survival. PD had a higher risk for technique failure than HD (hazard ratio [HR], 10.8; 95% confidence interval [CI], 1.9 to 62.0; p = 0.008) during a median follow-up of 11.0 months. In the PD group, a high body mass index (BMI) was an independent risk factor for technique failure (HR, 1.3; 95% CI, 1.0 to 1.8; p = 0.036). Peritonitis was the most common cause of PD technique failure. The difference in technique survival between PD and HD was more prominent in diabetic patients with a good nutritional status and in non-diabetic patients with a poor nutritional status. CONCLUSIONS: In a prospective cohort of Korean patients with end-stage renal disease, PD was associated with a higher risk of technique failure than HD. Diabetic patients with a good nutritional status and non-diabetic patients with a poor nutritional status, as well as patients with a higher BMI, had an inferior technique survival rate with PD compared to HD.
Adult ; Aged ; Body Mass Index ; Humans ; Kidney Failure, Chronic/diagnosis/mortality/*therapy ; Male ; Middle Aged ; Nutritional Status ; Peritoneal Dialysis/adverse effects/mortality ; Prospective Studies ; *Renal Dialysis/adverse effects/mortality ; Republic of Korea ; Risk Factors ; Time Factors ; Treatment Outcome

The Korean Society of Nephrology (KSN) launched a nationwide end-stage renal disease (ESRD) patient registry in 1985 called the Insan Prof. Byung-Suk Min Memorial ESRD Patient Registry. KSN members voluntarily participate in this registry, which has been collecting data through the Internet since 2000. The KSN ESRD patient registry data were reviewed to elucidate the major changes and improvements in dialysis therapy in Korea. The data review revealed: a rapid increase in the number of patients with ESRD; an increase in the number of patients with diabetic nephropathy; a decrease in the proportion of patients undergoing peritoneal dialysis; an increase in the role of private dialysis clinics; an increase in the number of elderly patients undergoing dialysis and the number of patients undergoing long-term dialysis; a decrease in mean blood pressure and an increase in pulse pressure; improvement in anemia treatment; improvement in dialysis adequacy; and improvement in the survival of patients undergoing dialysis. In conclusion, improvements have been made in blood pressure control, anemia treatment, and dialysis adequacy despite increases in the number of elderly patients, diabetic patients, and patients on long-term dialysis during the last two decades in Korea.
Diabetic Retinopathy/diagnosis/mortality/*therapy ; Humans ; Kidney Failure, Chronic/diagnosis/mortality/*therapy ; Peritoneal Dialysis/trends ; Private Sector/trends ; Quality Improvement/trends ; Quality Indicators, Health Care/trends ; Registries ; Renal Dialysis/adverse effects/mortality/standards/*trends ; Republic of Korea/epidemiology ; Risk Factors ; Time Factors ; Treatment Outcome

BACKGROUND/AIMS: To compare the clinical characteristics and outcomes of systemic lupus erythematosus between male and female Korean patients. METHODS: A retrospective analysis was performed at a single tertiary hospital from August 1994 to May 2010. Male patients were matched with two to three female patients based on age and disease duration. Organ damage was assessed using the Systemic Lupus International Collaborating Clinics/American College of Rheumatology damage index (SLICC/ACR DI). RESULTS: Fifty-three male patients were compared with 150 female patients. Renal disorders were found more frequently in male patients at disease onset (p < 0.001); the adjusted odds ratio (OR) demonstrated a significant sex preponderance for renal manifestations (OR, 3.26; 95% confidence interval [CI], 1.62 to 6.57). Diffuse proliferative lupus nephritis and end-stage renal disease requiring dialysis during the disease course were more prevalent in male patients (p = 0.025 and p < 0.001, respectively). The risk for requiring long-term dialysis was significantly higher in male than in female patients (OR, 4.02; 95% CI, 1.07 to 15.06), as was the mean SLICC/ACR DI (1.55 +/- 1.35 vs. 1.02 +/- 1.57, respectively; p = 0.028). CONCLUSIONS: Our data demonstrate that Korean patients with lupus have characteristics similar to those of cohorts reported previously. Male patients had significantly higher incidences of renal manifestations and organ damage.
Adult ; *Asian Continental Ancestry Group ; Female ; Humans ; Immunosuppressive Agents/therapeutic use ; Incidence ; Kaplan-Meier Estimate ; Kidney Failure, Chronic/diagnosis/ethnology/therapy ; Lupus Erythematosus, Systemic/diagnosis/*ethnology/mortality/therapy ; Lupus Nephritis/diagnosis/ethnology/therapy ; Male ; Middle Aged ; Multivariate Analysis ; Odds Ratio ; Prevalence ; Prognosis ; Renal Dialysis ; Republic of Korea/epidemiology ; Retrospective Studies ; Risk Factors ; Sex Distribution ; Sex Factors ; Tertiary Care Centers ; Time Factors ; Young Adult

Echocardiographic parameters can predict cardiovascular events in several clinical settings. However, which echocardiographic parameter is most predictive of each cardiovascular or non-cardiovascular event in patients starting hemodialysis remains unresolved. Echocardiography was used in 189 patients at the time of starting hemodialysis. We established primary outcomes as follows: cardiovascular events (ischemic heart disease, cerebrovascular disease, peripheral artery disease, and acute heart failure), fatal non-cardiovascular events, all-cause mortality, and all combined events. The most predictable echocardiographic parameter was determined in the Cox hazard ratio model with a backward selection after the adjustment of multiple covariates. Among several echocardiographic parameters, the E/e' ratio and the left ventricular end-diastolic volume (LVEDV) were the strongest predictors of cardiovascular and non-cardiovascular events, respectively. After the adjustment of clinical and biochemical covariates, the predictability of E/e' remained consistent, but LVEDV did not. When clinical events were further analyzed, the significant echocardiographic parameters were as follows: s' for ischemic heart disease and peripheral artery disease, LVEDV and E/e' for acute heart failure, and E/e' for all-cause mortality and all combined events. However, no echocardiographic parameter independently predicted cerebrovascular disease or non-cardiovascular events. In conclusion, E/e', s', and LVEDV have independent predictive values for several cardiovascular and mortality events.
*Echocardiography ; Female ; Heart Failure/*diagnosis/mortality ; Humans ; Kidney Failure, Chronic/mortality/*therapy ; Male ; Middle Aged ; Predictive Value of Tests ; Prognosis ; *Renal Dialysis ; Risk Factors ; Ventricular Function, Left/*physiology

BACKGROUND/AIMS: The effect of high-flux (HF) dialysis on mortality rates could vary with the duration of dialysis. We evaluated the effects of HF dialysis on mortality rates in incident and prevalent hemodialysis (HD) patients. METHODS: Incident and prevalent HD patients were selected from the Clinical Research Center registry for end-stage renal disease (ESRD), a Korean prospective observational cohort study. Incident HD patients were defined as newly diagnosed ESRD patients initiating HD. Prevalent HD patients were defined as patients who had been receiving HD for > 3 months. The primary outcome measure was all-cause mortality. RESULTS: This study included 1,165 incident and 1,641 prevalent HD patients. Following a median 24 months of follow-up, the mortality rates of the HF and low-flux (LF) groups did not significantly differ in the incident patients (hazard ratio [HR], 1.046; 95% confidence interval [CI], 0.592 to 1.847; p = 0.878). In the prevalent patients, HF dialysis was associated with decreased mortality compared with LF dialysis (HR, 0.606; 95% CI, 0.416 to 0.885; p = 0.009). CONCLUSIONS: HF dialysis was associated with a decreased mortality rate in prevalent HD patients, but not in incident HD patients.
Aged ; Chi-Square Distribution ; Female ; Humans ; Incidence ; Kaplan-Meier Estimate ; Kidney Failure, Chronic/diagnosis/*mortality/*therapy ; Male ; Middle Aged ; Multivariate Analysis ; Prevalence ; Proportional Hazards Models ; Prospective Studies ; Registries ; Renal Dialysis/adverse effects/methods/*mortality ; Republic of Korea/epidemiology ; Risk Factors ; Time Factors ; Treatment Outcome

The prevalence of antibiotic resistance is higher in patients undergoing renal replacement therapy (RRT) than in patients who did not undergo RRT. We investigated the presence of KP (Klebsiella pneumoniae) in patients who underwent RRT. All data were collected retrospectively by accessing patient medical records from 2004 to 2011 for the culture results of all patients who were positive for KP. We grouped the patients by the presence of extended-spectrum beta-lactamase (ESBL) into a KP ESBL(-) group (KP[-]) and a KP ESBL(+) group (KP[+]). In total, 292 patients (23.1%) were in the KP(+) group, and 974 patients (76.9%) were in the KP(-) group. A greater percentage of KP(+) was found in patients who underwent RRT (7.5%) than in patients who did not undergo RRT (3.2%) (OR, 2.479; 95% CI,1.412-4.352). A Cox's hazard proportional model analysis was performed, and for patients with pneumonia, the risk of KP(+) was 0.663 times higher in patients who had lower albumin levels, 2.796 times higher in patients who had an inserted Levin tube, and 4.551 times higher in patients who underwent RRT. In conclusion, RRT can be a risk factor for KP(+) in patients with pneumonia.
Adult ; Aged ; Aged, 80 and over ; Female ; Humans ; Kaplan-Meier Estimate ; Kidney Failure, Chronic/*microbiology/therapy ; Klebsiella Infections/*epidemiology/microbiology/mortality ; Klebsiella pneumoniae/*enzymology/isolation & purification ; Male ; Middle Aged ; Odds Ratio ; Pneumonia/diagnosis/*epidemiology/microbiology ; Prevalence ; Proportional Hazards Models ; Renal Replacement Therapy ; Retrospective Studies ; Risk Factors ; Serum Albumin/analysis ; beta-Lactamases/*metabolism

BACKGROUND/AIMS: Nonselective beta-blockers (NSBBs), such as propranolol, reportedly exert a pleiotropic effect in liver cirrhosis. A previous report suggested that survival was higher in patients receiving adjusted doses of NSBBs than in ligation patients. This study investigated whether low-dose NSBB medication has beneficial effects in patients with liver cirrhosis, especially in terms of overall survival. METHODS: We retrospectively studied 273 cirrhotic patients (199 males; age 53.6+/-10.2 years, mean+/-SD) who visited our institution between March 2003 and December 2007; follow-up data were collected until June 2011. Among them, 138 patients were given a low-dose NSBB (BB group: propranolol, 20-60 mg/day), and the remaining 135 patients were not given an NSBB (NBB group). Both groups were stratified randomly according to Child-Turcotte-Pugh (CTP) classification and age. RESULTS: The causes of liver cirrhosis were alcohol (n=109, 39.9%), hepatitis B virus (n=125, 45.8%), hepatitis C virus (n=20, 7.3%), and cryptogenic (n=19, 7.0%). The CTP classes were distributed as follows: A, n=116, 42.5%; B, n=126, 46.2%; and C, n=31, 11.4%. Neither the overall survival (P=0.133) nor the hepatocellular carcinoma (HCC)-free survival (P=0.910) differed significantly between the BB and NBB groups [probability of overall survival at 4 years: 75.1% (95% CI=67.7-82.5%) and 81.2% (95% CI=74.4-88.0%), respectively; P=0.236]. In addition, the delta CTP score did not differ significantly between the two groups. CONCLUSIONS: Use of low-dose NSBB medication in patients with liver cirrhosis is not indicated in terms of overall and HCC-free survival.
Adrenergic beta-Antagonists/*therapeutic use ; Adult ; Aged ; Alcohol Drinking ; Carcinoma, Hepatocellular/complications/diagnosis ; Female ; Follow-Up Studies ; Humans ; Kaplan-Meier Estimate ; Kidney Failure, Chronic/complications/diagnosis ; Liver Cirrhosis/complications/*drug therapy/mortality ; Liver Neoplasms/complications/diagnosis ; Male ; Middle Aged ; Predictive Value of Tests ; Proportional Hazards Models ; Propranolol/*therapeutic use ; Retrospective Studies ; Severity of Illness Index

OBJECTIVETo analyze the clinical features of hemodialysis patients complicated by infective endo carditis.

METHODSThe clinical features of six such patients admitted to Peking Union Medical College Hospital during the year 1990 to 2009 were analyzed. All of them were diagnosed based on Chinese Children Diagnostic Criteria for Infective Endocarditis.

RESULTSThe average age of the six patients was 52.3 +/- 19.3 years old. Four were males. Vascular accesses at the onset of infective endocarditis were as follows: permanent catheters in three, temporary catheters in two, and arteriovenous fistula in one. Three were found with mitral valve involvement, two with aortic valve involvement, and one with both. Five vegetations were found by transthoracic echocardiography, and one by transesophageal echocardiography. Four had positive blood culture results. The catheters were all removed. Four of the patients were improved by antibiotics treatment, in which two were still on hemodialysis in the following 14-24 months and the other two were lost to follow-up. One patient received surgery, but died of heart failure after further hemodialysis for three months. One was well on maintenance hemodialysis for three months after surgery.

CONCLUSIONSInfective endocarditis should be suspected when hemodialysis patients suffer from long-term fever, for which prompt blood culture and transthoracic echocardiography confirmation could be performed. Transesophageal echocardiography could be considered even when transthoracic echocardiography produces negative findings. With catheters removed, full course of appropriate sensitive antibiotics and surgery if indicated could improve the outcome of chronic hemodialysis patients complicated by infective endocarditis.

Adult ; Aged ; Aged, 80 and over ; Anti-Bacterial Agents ; therapeutic use ; Echocardiography, Transesophageal ; Endocarditis ; diagnosis ; drug therapy ; mortality ; Female ; Humans ; Kidney Failure, Chronic ; therapy ; Male ; Middle Aged ; Renal Dialysis ; adverse effects ; Risk Factors