• Journals
• OpenAccess

Beyond the Graft: Navigating the Complex Landscape of Post-Transplant Malignancy

Kidney transplantation is the gold standard treatment for end-stage kidney disease (ESKD), significantly improving survival and quality of life. However, while short-term outcomes have advanced, long-term survival remains hindered by complications, notably post-transplant malignancy (PTM). This review explores the complex landscape of PTM, emphasizing the interplay between immune-related and non-immune risk factors. Immunosuppressive therapies, while essential for graft survival, increase cancer risk by impairing immunosurveillance and facilitating viral oncogenesis. T-cell depleting induction agents and certain maintenance drugs like calcineurin inhibitors (CNIs) are associated with higher risks of lymphoproliferative disorders and solid tumors. Conversely, mTOR inhibitors (MTORi) and mycophenolate analogues may offer antineoplastic benefits. Epidemiological data from Taiwan highlight a distinct prevalence of urothelial carcinoma, particularly in female recipients, contrasting with the high skin cancer rates seen in Western populations. Non-immune factors, including advanced recipient age, prolonged pre-transplant dialysis, and donor types, further contribute to malignancy risk. Managing PTM requires a delicate balance between reducing immunosuppression to enhance anti-tumor responses and maintaining graft function. The review concludes that personalized immunosuppressive protocols, vigilant viral monitoring (e.g., EBV, HBV, HCV), and lifelong surveillance are critical to improving long-term outcomes for kidney transplant recipients.

• Journals
• OpenAccess

Association of Metabolic Syndrome With Aortic Arch Calcification and Mortality in Non-Diabetic Peritoneal Dialysis

BACKGROUND: Vascular calcification (VC) is an important risk factor for mortality in patients undergoing dialysis. We investigated whether the presence of metabolic syndrome (MetS) increases the risk and severity of VC and the impact of individual MetS components on VC in non-diabetic patients undergoing peritoneal dialysis (PD). METHODS: We enrolled 277 non-diabetic PD patients in this study. Posteroanterior chest radiography was used for the assessment of aortic arch calcification (AoAC). Factors determining the presence and severity of AoAC were identified using multinomial logistic regression analysis. RESULTS: We found that the adjusted odds ratio (OR) for mild AoAC was 3.05 (95% confidence interval [CI]: 1.37-6.77, P < 0.01) and 7.73 (95% CI: 2.84-21.03, P < 0.001) for moderate to severe AoAC among patients with MetS, as compared with those without MetS. Body mass index (BMI) ≥ 25 and hypertriglycedemia ≥ 150 were associated with incremental risk of mild and moderate to severe AoAC, respectively (BMI ≥ 25: mild AoAC [adjusted OR: 2.98, 95% CI: 1.14 - 7.80, P < 0.01]; moderate to severe AoAC [adjusted OR: 4.9, 95% CI: 1.59-15.05, P < 0.001]; hypertriglycedemia ≥ 150: mild AoAC [adjusted OR: 2.29, 95% CI: 1.01 - 5.20, P < 0.01]; moderate to severe AoAC [adjusted OR: 4.07, 95% CI: 1.53-10.87, P < 0.001]). Furthermore, the presence of one additional MetS component was associated with an incremental risk of AoAC (mild AoAC [adjusted OR: 1.58, 95% CI: 1.14-2.18, P < 0.01]; moderate to severe AoAC [adjusted OR: 2.35, 95% CI: 1.57-3.50, P < 0.001]). MetS was associated with a non-significant trend toward higher mortality in non-diabetic patients undergoing PD (log-rank test, P = 0.133). CONCLUSION: Our study suggests MetS was independently associated with the presence and severity of AoAC in non-diabetic PD patients, especially those with obesity and hypertriglyceridemia.

• Journals
• OpenAccess

Association Between Non-Alcoholic Fatty Liver Disease or Liver Fibrosis With Risk of Kidney Disease: A Population-Based Cross-Sectional Study

BACKGROUND: Growing evidence suggests that non-alcoholic fatty liver disease (NAFLD) is a multisystem disease affecting both hepatic and extra-hepatic organs. However, the association between NAFLD and kidney diseases remains inconclusive. This study aims to evaluate the association between NAFLD or liver fibrosis and the risk of kidney disease among the non-institutional general population in the United States (U.S.). METHODS: This cross-sectional study enrolled adult participants from the 2017-2018 cycle of the National Health and Nutrition Examination Survey (NHANES) without hepatitis B or C, self-reported autoimmune hepatitis, or drinking more than a moderate amount of alcohol. Liver fibrosis was measured using FibroScan® with vibration-controlled transient elastography and divided into ≤ 7.0 (F0-F1), 7.1-10.0 (F2), 10.1-14.0 (F3), and ≥ 14.1 (F4) kilopascals. Liver steatosis was assessed by controlled attenuation parameter and divided into < 238 (S0), 238-260 (S1), 261-290 (S2), and > 290 dB/m (S3). The Fibrosis-4 (FIB-4) index was calculated and dichotomized into ≤ 2 and > 2. Kidney disease was defined by an estimated glomerular filtration rate < 60 mL/min/1.73 m^2 or urinary albumin-creatinine ratio ≥ 30 mg/g. RESULTS: The average age of the study population (n = 2,832) was 53.2 ± 18.3 years old, with 51.5% of male, of whom 583 had kidney disease. We observed a higher prevalence of liver fibrosis and steatosis among individuals with kidney disease. After adjusting for age, sex, race, body mass index, diabetes, hypertension, cardiovascular disease, triglycerides, total cholesterol, smoking, education level, marital status, and family income, we found no significant difference in the risk of kidney disease in those with F2 and F3 compared with F0-F1, but the risk was higher for those with F4 (adjusted odds ratio [aOR] = 2.17; 95% confidence interval [CI]: 1.23-3.81). An FIB-4 index > 2 was also a significant risk factor for kidney disease (aOR = 1.70; 95% CI: 1.25-2.33). There was no significant difference in the risk of kidney disease for those with S1, S2, and S3 when compared with those with S0. CONCLUSIONS: Severe liver stiffness or fibrosis, but not steatosis, was significantly associated with the risk of kidney disease in patients with NAFLD. The causal relationship and underlying mechanisms remain to be explored.

• Journals
• OpenAccess

Combined Impact of Angiotensin Receptor Blockers and Far-Infrared Therapy on Glucose Degradation Products and Peritoneal Function in Peritoneal Dialysis Patients

BACKGROUND: Patients undergoing peritoneal dialysis (PD) face challenges related to peritoneal membrane integrity, accumulation of glucose degradation products (GDPs), and dialysis adequacy. Both far-infrared (FIR) therapy and angiotensin II receptor blockers (ARBs) have shown promise in addressing individual aspects of these challenges. However, the combined effect of these treatment modalities remains underexplored. The study aims to evaluate the combined impact of FIR therapy and ARBs on peritoneal function, GDP levels, and dialysis adequacy in PD patients. METHODS: A prospective study was conducted involving 31 PD patients who underwent FIR therapy for 6 months. Patients were divided into two groups based on whether they received ARBs (n = 15) or not (n = 16). An ultra-performance liquid chromatography photodiode array method was developed to determine the levels of the seven GDPs in dialysate and serum of the patients. Peritoneal membrane function tests, GDP levels, and dialysis adequacy parameters were assessed pre- and post-therapy. RESULTS: In patients receiving ARBs, FIR therapy led to a significant decrease in methylglyoxal levels (from 2,139.71 to 1,122.10 μg/L, P = 0.04), glyoxal levels (from 7,366.56 to 4,299.84 μg/L, P = 0.04), and furfural levels (from 1,562.62 to 1,052.75 μg/L, P = 0.05), without compromising dialysis adequacy. In non-ARB users, FIR therapy resulted in significantly reduced furfural levels (from 1,182.15 to 710.50 μg/L, P = 0.02) and elevated D/D0 glucose ratio (from 0.37 to 0.41, P = 0.04). Concurrently, a significant decrease in residual renal function was observed, with Kt/V dropping from 0.27 to 0.15 (P = 0.03) and weekly creatinine clearance decreasing from 16.60 to 11.95 L/week/1.73m^2 (P = 0.04). CONCLUSION: The combined utilization of FIR therapy and ARBs holds promise for enhancing peritoneal health and dialysis outcomes in PD patients. This is achieved by reducing specific GDP (methylglyoxal and furfural) levels while maintaining dialysis adequacy.

• Journals
• OpenAccess

Relationship Between Diuretic Use and Fracture Risk in Patients With Advanced Chronic Kidney Disease: A Population-Based Study

BACKGROUND: Chronic kidney disease (CKD) is a global public health problem with an increasing prevalence and complex management challenges, particularly in its advanced stages. Patients with CKD face an elevated risk of fractures due to multiple interrelated factors, including metabolic acidosis, anemia, hyponatremia, and CKD-mineral and bone disorder (CKD-MBD). The rate of diuretic use tends to increase with CKD progression, possibly predisposing patients to bone fractures. This study aimed to investigate the potential association between diuretic use and fracture risk among patients with advanced CKD in a real-world setting. METHODS: This population-based cohort study was conducted using data from the comprehensive CKD sub-database of the National Health Insurance Research Database. The study cohort comprised 23,857 patients with advanced CKD categorized by diuretic use (n = 13,664) and nonuse (n = 10,193). Cox proportional hazards models were utilized to estimate the hazard ratio (HR) for bone fractures. RESULTS: Significant differences were found in baseline comorbidities and medication use between diuretic users and nonusers. Diuretic use was associated with an adjusted HR of 1.16 (95% confidence interval [CI], 1.06-1.26) for fracture risk. Age, sex, and specific comorbid conditions also notably influenced fracture risk. Also, higher rates of diuretic possession were correlated with slightly increased fracture risk (HR: 1.001; 95% CI, 1.00-1.002). CONCLUSION: Diuretic use in patients with advanced CKD is associated with a modest but statistically significant increase in fracture risk. This study highlights the need to develop comprehensive prevention policies and strategies to address the risk of bone fractures in this vulnerable population of patients.

• Journals
• OpenAccess

High Ambient Air Ozone Exposure is Associated With Metabolic Syndrome in a Large Taiwanese Population Study

BACKGROUND: Metabolic syndrome (MetS) is a huge health issue worldwide that increases the risk of cardiovascular disease, diabetes mellitus, stroke, cancer, and mortality. Meanwhile, the air pollution exposure precipitates stress responses as well as the alterations in glucose and lipid metabolism. However, the long-term effect of ozone (O_3) exposure on metabolism still remains unclear. The purpose of this study is to explore the relationship between the long-term exposure to O_3, with MetS and its components, in a large cohort of around 120,000 Taiwanese participants in the Taiwan biobank (TWB), correlated to O_3 concentration in Taiwan, using a fine spatial-temporal resolution ensemble mixed spatial model with Geospatial Artificial Intelligence technology. METHODS: A total of 121,364 participants were enrolled from the TWB, with a mean age of 49.9 ± 11.0 years. The definition of MetS was according to the National Cholesterol Education Program Adult Treatment Panal III guidelines and modified criteria for Asians. Individual exposure to daily average O_3 concentrations for 1, 3, and 5 years before enrollment were collected. RESULTS: After multivariable analysis, the 1-year (per 1 ppb; odds ratio [OR] = 1.012; P < 0.001), 3-year (per 1 ppb; OR = 1.012; P < 0.001), and 5-year average of O_3 (per 1 ppb; OR = 1.015; P < 0.001) were significantly associated with MetS. Furthermore, the 1-year (per 1 ppb; OR = 1.014; P < 0.001), 3-year (per 1 ppb; OR = 1.019; P < 0.001), and 5-year average of O_3 (per 1 ppb; OR = 1.023; P < 0.001) were significantly associated with abdominal obesity. The 1-year (per 1 ppb; OR = 1.021; P < 0.001), 3-year (per 1 ppb; OR = 1.016; P < 0.001), and 5-year average of O_3 (per 1 ppb; OR = 1.015; P < 0.001) were significantly associated with hypertriglyceridemia. The 5-year average of O_3 (per 1 ppb; OR = 1.009; P = 0.001) was significantly associated with low high-density lipoprotein (HDL) cholesterol. The 1-year average of O_3 (per 1 ppb; OR = 1.009; P = 0.0012) was significantly associated with hyperglycemia. However, the O_3 level were not associated with high blood pressure. CONCLUSIONS: In conclusion, our study showed that high ambient air O_3 exposure was significantly associated with MetS and its components, including abdominal obesity, low HDL-cholesterol, hyperglycemia and hypertriglyceridemia. The findings of this study have important implications for public health and environmental policy. Specifically, the results of this study may be useful in individuals and organizations to take action to reduce air pollution and promote public health.

• Journals
• OpenAccess

Ten-Year Patient Survival and Technique Survival Analysis in Incident Peritoneal Dialysis Patients

BACKGROUND: The retrospective cohort study was to investigate patient survival and technique survival in patients with incident peritoneal dialysis (PD) using recent data from a single tertiary medical center in Taiwan. METHODS: This study included incident PD patients receiving PD for at least 90 days from January 1, 2007, to December 31, 2018, at China Medical University Hospital, Taichung, Taiwan. All patients were followed until transfer to hemodialysis (HD), renal transplantation, transfer to another center, death, or December 31, 2018. The survival curve was plotted using the Kaplan-Meier method. RESULTS: A total of 725 incident PD patients were recruited during the study period. The mean duration of follow-up was 2.23 ± 1.39 years. The overall 1-, 5-, and 10-year patient survival rates were 95.0%, 68.8%, and 41.8%, respectively. The overall 1-, 5-, and 10-year technique survival rates were 90.4%, 46.6%, and 19.4%. The 1-, 5-, and 10-year patient survival rates were 91.6%, 53.8%, and 13.0% in diabetic patients, compared to 97.6%, 78.4%, and 56.8% in non-diabetic patients. The 1-, 5-, and 10-year technique survival rates were 85.4%, 29.1%, and 5.4% in diabetic patients, compared to 94.4%, 59.8%, and 29.2% in non-diabetic patients. The primary reasons for dropout from PD were death (39.0%), peritonitis (25.3%), and burnout (18.8%). Cardiovascular disease was the leading cause of death (54.1%), followed by infection (29.1%). Multivariate analysis revealed that significant risk factors for mortality and technique failure included older age (hazard ratio [HR]: 1.06 for death, 95% confidence interval [CI]: 1.04-1.07; HR: 1.036 for technique failure, 95% CI: 1.03-1.04), diabetes (HR: 1.74 for death, 95% CI: 1.24-2.45; HR: 1.85 for technique failure, 95% CI: 1.46-2.35), and cardiovascular disease (HR: 2.24 for death, 95% CI: 1.59-3.16; HR: 1.38 for technique failure, 95% CI: 1.08-1.76). Hypoalbuminemia also contributed to worse outcomes (HR: 0.59 for death, 95% CI: 0.42-0.83; HR: 0.75 for technique failure, 95% CI: 0.59-0.95). The use of icodextrin was associated with a reduced risk of both death (HR: 0.62, 95% CI: 0.42-0.91) and technique failure (HR: 0.61, 95% CI: 0.47-0.81). Patients with high or high-average peritoneal transport status had an increased risk of death (HR: 1.47, 95% CI: 1.01-2.14). Higher normalized protein nitrogen appearance was linked to a lower risk of technique failure (HR: 0.51, 95% CI: 0.31-0.85). Patients initiating dialysis more recently (2015-2018) had significantly lower risks of both death (HR: 0.13, 95% CI: 0.07-0.24) and technique failure (HR: 0.26, 95% CI: 0.17-0.38). CONCLUSION: While modern PD practices have improved outcomes, diabetes and cardiovascular disease remain major risk factors affecting survival and technique viability. Tailored strategies are needed to enhance PD survival, particularly for high-risk patients such as those with older age, diabetes, cardiovascular disease, or hypoalbuminemia.

• Journals
• OpenAccess

Outcomes of Urgent-Start Peritoneal Dialysis

BACKGROUND: In Taiwan, peritoneal dialysis (PD) utilization remains low despite its advantages, including home-based treatment and improved quality of life. Urgent-start peritoneal dialysis (USPD) offers a viable option for patients requiring unplanned dialysis initiation, potentially increasing PD adoption. This study evaluates the effectiveness, quality, and outcomes of a USPD protocol implemented at a single center and identifies factors influencing its success. METHODS: We retrospectively studied patients at Keelung Chang Gung Memorial Hospital from 2023 to April 2024. Of 154 stage 5 chronic kidney disease patients undergoing SDM, 68 chose PD and completed catheter implantation, then underwent a six-day USPD protocol. On sixth-day, patients reaching a dialysate volume of 750-1,000 mL were classified as Achievers; others were Non-Achievers. Baseline demographics and clinical outcomes were compared between groups using appropriate statistical tests (P < 0.05). RESULTS: Among the 68 USPD patients, 61.8% (n = 42) were Achievers. Achievers were younger (60.20 ± 15.87 vs. 70.00 ± 17.05 years; P = 0.020), had higher albumin levels (3.57 ± 0.65 vs. 3.19 ± 0.64 g/dL; P = 0.021), were more likely male (female proportion: 45.2% vs. 76.9%; P = 0.02), underwent laparoscopic implantation (92.9% vs. 69.8%; P = 0.042), and had fewer postoperative complications (14.3% vs. 57.7%; P < 0.001). Hemodialysis (HD) requirements during USPD did not significantly differ between groups. CONCLUSION: Implementing a USPD protocol at our single center increased PD utilization to 44%. A success rate of 61.8% was achieved in completing the six-day USPD regimen. Successful USPD was associated with younger age, male gender, higher serum albumin levels, laparoscopic catheter implantation, and fewer postoperative complications. These findings demonstrate the effectiveness of USPD in enhancing PD utilization and suggest that addressing these key factors may improve outcomes for patients with end-stage renal disease initiating dialysis.

• Journals
• OpenAccess

Povidone-Iodine Associated With Acute Kidney Injury in a 31-Year-Old Woman: A Case Report

Povidone-iodine (PI) is a broad-spectrum antiseptic which can be applied topically to extend from wound care to surgical preparation as well as for managing wound infections and burn injuries. It can also be used as a dye and antiseptic agent in the hysteroscopic conventional procedures. We report a case of severe acute kidney injury that occurred in a 31-year-old female after laparoscopic bilateral salpingoplasty, right paratubal cystectomy, and hysteroscopic polypectomy using 10% PI solution as a dye and antiseptic agent. Patient was noted with rapid progression of renal function, and the serum creatinine was 3.17 mg/dL, the day after the procedure. She was also anuric state within 2 days after the procedure. So the patient was treated with hemodialysis for 12 days until renal function recovered. It is followed by a polyuric phase and nearly recovered to the normal range of serum creatinine. Therefore, doctors need to remind themselves and be aware of the possible nephrotoxicity linked to the use of PI. Typically, discontinuing the use of PI coupled with hemodialysis proves to be an effective course of treatment.