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Summary of the 2024 Annual Report on Kidney Disease in Taiwan

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Strategies to Address the Global Kidney Disease Burden: Summary Report from the 40th Anniversary Policy Forum of the Taiwan Society of Nephrology

Chronic kidney disease (CKD) is a global health crisis affecting 9.1% of the population, with progression to End-Stage Kidney Disease (ESKD) linked to high mortality and healthcare burdens. Despite preventive measures such as early interventions, multidisciplinary care, and reno-protective therapies, CKD prevalence continues to rise, particularly in the Asia-Pacific region. To address this, the Taiwan Society of Nephrology (TSN) marked its 40th anniversary by hosting a Policy Forum titled "Strategies to Reduce Kidney Disease Burden," featuring contributions from prominent nephrology associations across the Asia-Pacific. Efforts to enhance kidney care through education, advocacy, and implementation of standards of care were highlighted by the International Society of Nephrology's (ISN) and the Asian Pacific Society of Nephrology (APSN). Perspectives on kidney disease prevention from Korea, Japan, Malaysia, Australian and New Zealand were also addressed together with the commitment of TSN to combat the burden of kidney disease.

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An Association Between Variability of Serum Potassium Levels and Clinical Outcomes Among Patients on Hemodialysis

BACKGROUND: Serum potassium levels are associated with clinical events in patients undergoing hemodialysis (HD). This study aimed to assess the relationship between the trajectory of serum potassium levels and clinical outcomes, including all-cause mortality, cardiovascular (CV) mortality, and hospital readmission rates, in patients undergoing HD. METHODS: A cohort of patients on regular HD (n = 280) was followed up from the day they started HD (mean follow-up duration, 600 days). The association between the quarter-yearly predialytic serum potassium trajectory measurements and relevant clinical parameters was assessed using binomial logistic regression analysis. The Kaplan-Meier estimator was used to assess the survival rates. A Cox proportional model was used to determine the association between hospital readmission events, serum potassium trajectory, and related factors in the study population, and the generalized method of moments was used to improve the Cox proportional model. RESULTS: There were no statistically significant differences in all-cause and CV mortality rates between the low and high potassium trajectory groups. Patients with low potassium trajectory (n = 129; mean, 4.1 mEq/L) demonstrated significantly increased risk of all-cause hospital readmissions compared to those with high potassium trajectory (n = 151; mean, 4.9 mEq/L). A higher serum albumin level was associated with a lower risk of low potassium trajectory. Significant aggregated effects on hospital readmissions were derived from the potassium trajectory and comorbidities of coronary artery disease and malignancy. CONCLUSION: Patients with end-stage kidney disease demonstrated a higher risk of all-cause hospital readmissions in a low than in a high potassium trajectory after HD initiation. The serum potassium levels were combined with other clinical parameters and aggregated into all-cause hospital readmissions.

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A Retrospective Cohort Study on the Association Between Dialysate Calcium Concentration and Clinical Outcomes in Hemodialysis Patients: Comparing Medium-Low and Extremely Low Calcium Concentrations

BACKGROUND: Hemodialysis (HD) patients have a higher mortality rate than the non-dialysis population. Apart from the hyperphosphatemia and elevated calcium-phosphorus (Ca × P) product, elevated serum calcium is also linked to increased mortality. Lowering hypercalcemia while reducing serum phosphorus is crucial. As dialysate calcium (DCa) concentration is related to the calcium balance, this study aims to clarify whether an extremely-low dialysate calcium (EL-DCa) concentration enhances the clinical prognosis of HD patients. METHODS: A total of 633 patients who underwent HD were studied. The patients were divided into the medium-low dialysate calcium (2.5 and 3.0 mEq/L, ML-DCa) group and the EL-DCa (2.0 mEq/L) group. We compared the overall survival rate between the two groups by Kaplan-Meier survival analysis. Multivariate Cox hazard regression analysis was used for adjusting potential confounding factors. RESULTS: The overall survival rates between the EL-DCa group and the ML-DCa group were 75.9% and 47.3%, respectively, with a log-rank test, χ^2 = 12.840, P < 0.001. Multivariate Cox hazard regression analysis revealed that DCa, age, hemodialysis duration, albumin, creatinine, Ca × P product, and hypertension were independent risk factors for the overall survival. After adjusting confounding factors by multivariate Cox hazard regression, the EL-DCa group still exhibited a statistically significant better survival rate, with a P-value of 0.039. CONCLUSION: HD of EL-DCa, compared with ML-DCa, have better overall survival. Even after undergoing multivariate adjustment, such advantages persist.

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Prevalence of Peripheral Artery Disease and Its Risk Factors in Patients Undergoing Hemodialysis

BACKGROUND: Peripheral artery disease (PAD) is common and contributes to an increased risk of morbidity and mortality in patients with end-stage kidney disease (ESKD). Early detection of PAD is important, but it remains underdiagnosed and undertreated in dialysis patients. The aim of this study was to investigate the prevalence of PAD and its risk factors in patients undergoing hemodialysis (HD). We also assessed risk factors for bilateral lower extremities PAD, as opposed to unilateral lower extremity PAD, among patients with PAD. METHODS: In a quality improvement program, a hospital-based survey of PAD was conducted in patients with ESKD who underwent maintenance HD therapy. A total of 288 patients were assessed for ankle-brachial index (ABI) measurements during HD therapy. PAD was defined by an ABI value less than or equal to 0.9. Demographic, clinical, and laboratory parameters were also collected. Multivariate logistic regression analyses were performed to assess risk factors related to PAD and bilateral lower extremities PAD. RESULTS: The mean age of the study participants was 67 ± 10 years. In total, 183 patients (64%) had diabetes and 60 (21%) had heart failure. Among the participants, 36% met the PAD criteria and only 2% had an ABI value ≥ 1.3. In a univariate analysis, factors associated with PAD were older age, shorter vintage, history of heart failure, left ventricular hypertrophy, stroke, diabetes mellitus, poorer Karnofsky performance scale, antiplatelet agent use, lesser use of arteriovenous fistula, lower blood pressure (BP) level, larger cardiothoracic ratio, higher white blood cell count, and higher glucose level. Multivariate logistic regression analyses showed that patients with a history of heart failure (odds ratio [OR]: 3.0, 95% confidence interval [CI]: 1.4-6.3, P < 0.01), stroke (OR: 2.5, 95% CI: 1.1-6.0, P = 0.03), diabetes mellitus (OR: 3.6, 95% CI: 1.7-7.6, P < 0.01), or poorer Karnofsky performance scale (OR: 3.5, 95% CI: 1.8-6.9, P < 0.01) had an increased risk, and those with higher pre-dialysis diastolic BP (OR: 0.7, 95% CI: 0.6-0.9, P < 0.01) had a decreased risk for PAD. Among those with PAD, those with a history of diabetes mellitus (OR: 7.6, 95% CI: 1.6-35.7, P = 0.01) and antiplatelet agent use (OR: 7.9, 95% CI: 2.2-28.1, P < 0.01) had an increased risk, and those with higher serum creatinine level (OR: 0.7, 95% CI: 0.5-0.9, P = 0.02) had a decreased risk for bilateral lower extremities PAD. CONCLUSION: PAD is common in HD patients, and those with heart failure, stroke, diabetes mellitus, or poorer functional status are more likely to have PAD. In contrast, those with higher diastolic BP are less likely to have PAD. Among those with PAD, diabetes mellitus and antiplatelet agent use are associated with a higher risk, and higher serum creatinine level is associated with a lower risk for bilateral lower extremities PAD. Detection of PAD by means of ABI measurements during HD therapy is a simple and effective method to overcome the underdiagnosis of PAD in this population.

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High Muscle Mass is Associated With Better Survival and Probably With Worse Renal Outcome in CKD Stage 4-5 Patients

BACKGROUND: Muscle wasting is a manifestation of protein-energy wasting (PEW) and is increasing the prevalence as renal function worsening. However, the independent effect of muscle mass to predict the mortality and renal outcomes is still questioned in patients with advanced chronic kidney disease (CKD). So, we use malnutrition-inflammation score (MIS) to evaluate PEW and hypothesize that muscle mass has a role of prediction for all-cause mortality and renal outcomes, even after the consideration of PEW, in CKD stage 4-5 patients. METHODS: We included 744 patients with stage 4-5 CKD. To study the impact of muscle mass on mortality and renal outcomes, the included patients were divided into four muscle mass groups (cutoff: 13.2%, 14.5%, and 15.7% in men; 11.8%, 13.0%, and 14.1% in women). Linear regression analysis was used to evaluate the factors associated with muscle mass. Cox proportional hazards analysis was used to investigate the relationship of muscle mass percentage (MMP%) and lean body mass percentage (LBM%) with all-cause mortality and renal outcomes. RESULTS: We reported the hazard ratio for mortality with the fully adjusted Cox regression model grouped by MMP% with adjustment for malnutrition-inflammation score (MIS). The reference groups were MMP% Q1. Mortality was significantly decreased in MMP% Q2 (HR: 0.51; 95% CI: 0.32-0.83), Q3 (HR: 0.53; 95% CI: 0.31-0.88), and Q4 (HR: 0.41; 95% CI: 0.23-0.73). Renal outcomes were non-significant increase in MMP% Q2 (HR: 0.99; 95% CI: 0.72-1.30), Q3 (HR: 1.00; 95% CI: 0.70-0.50), and Q4 (HR: 1.3; 95% CI: 0.88-1.90). The reference groups were LBM% Q1. Mortality was significantly decreased in LBM% Q2 (HR: 0.51; 95% CI: 0.32-0.83), Q3 (HR: 0.53; 95% CI: 0.31-0.88), and Q4 (HR: 0.41; 95% CI: 0.23-0.73). Renal outcomes were non-significant increase in MMP% Q2 (HR: 0.99; 95% CI: 0.72-1.30), Q3 (HR: 1.00; 95% CI: 0.70-0.50), and Q4 (HR: 1.3; 95% CI: 0.88-1.90). Adjustment for MIS had no effect on the association of MMP% and LBM% with all-cause mortality and renal outcomes. CONCLUSIONS: In our study, we found that muscle mass is associated with better survival and probably with worsened renal outcomes in CKD stage 4-5 patients. Moreover, we elucidate the muscle mass still has the independent prediction function for all-cause mortality and probably renal outcomes after considering protein-energy wasting by MIS.

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Double-Positive Anti-Glomerular Basement Membrane Antibody and Myeloperoxidase Antineutrophil Cytoplasmic Autoantibody-Associated Glomerulonephritis After the First Dose of Oxford-AstraZeneca COVID-19 Vaccine: A Case Report

Emerging evidence suggests a potential association between COVID-19 vaccination and de novo glomerulonephritis, predominantly with mRNA vaccines. Post-vaccination double-positive anti-glomerular basement membrane (anti-GBM) and antineutrophil cytoplasmic autoantibody (ANCA)-associated glomerulonephritis are exceptionally rare. We reported a case with insidious presentation of lower limb numbness and pain one week after Oxford-AstraZeneca COVID-19 vaccination. The patient developed the rapid progressive glomerulonephritis and received plasmapheresis, cyclophosphamide, and steroids. Both anti- GBM and myeloperoxidase antineutrophil cytoplasmic antibodies (MPO-ANCA) turned seronegative after treatment. There was no sign of relapse during a long-term period of 18 months.