Publications by authors named "Ming-Yen Lin"

78 Publications

Explainable Machine Learning to Predict Successful Weaning Among Patients Requiring Prolonged Mechanical Ventilation: A Retrospective Cohort Study in Central Taiwan.

Front Med (Lausanne) 2021 23;8:663739. Epub 2021 Apr 23.

Department of Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.

The number of patients requiring prolonged mechanical ventilation (PMV) is increasing worldwide, but the weaning outcome prediction model in these patients is still lacking. We hence aimed to develop an explainable machine learning (ML) model to predict successful weaning in patients requiring PMV using a real-world dataset. This retrospective study used the electronic medical records of patients admitted to a 12-bed respiratory care center in central Taiwan between 2013 and 2018. We used three ML models, namely, extreme gradient boosting (XGBoost), random forest (RF), and logistic regression (LR), to establish the prediction model. We further illustrated the feature importance categorized by clinical domains and provided visualized interpretation by using SHapley Additive exPlanations (SHAP) as well as local interpretable model-agnostic explanations (LIME). The dataset contained data of 963 patients requiring PMV, and 56.0% (539/963) of them were successfully weaned from mechanical ventilation. The XGBoost model (area under the curve [AUC]: 0.908; 95% confidence interval [CI] 0.864-0.943) and RF model (AUC: 0.888; 95% CI 0.844-0.934) outperformed the LR model (AUC: 0.762; 95% CI 0.687-0.830) in predicting successful weaning in patients requiring PMV. To give the physician an intuitive understanding of the model, we stratified the feature importance by clinical domains. The cumulative feature importance in the ventilation domain, fluid domain, physiology domain, and laboratory data domain was 0.310, 0.201, 0.265, and 0.182, respectively. We further used the SHAP plot and partial dependence plot to illustrate associations between features and the weaning outcome at the feature level. Moreover, we used LIME plots to illustrate the prediction model at the individual level. Additionally, we addressed the weekly performance of the three ML models and found that the accuracy of XGBoost/RF was ~0.7 between weeks 4 and week 7 and slightly declined to 0.6 on weeks 8 and 9. We used an ML approach, mainly XGBoost, SHAP plot, and LIME plot to establish an explainable weaning prediction ML model in patients requiring PMV. We believe these approaches should largely mitigate the concern of the black-box issue of artificial intelligence, and future studies are warranted for the landing of the proposed model.
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http://dx.doi.org/10.3389/fmed.2021.663739DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8104124PMC
April 2021

Low serum iron is associated with anemia in CKD stage 1-4 patients with normal transferrin saturations.

Sci Rep 2021 Apr 16;11(1):8343. Epub 2021 Apr 16.

Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, 100 Tzyou First Road, San-Ming District, Kaohsiung, 807, Taiwan.

Low transferrin saturation (TSAT), calculated by serum iron divided by total iron-binding capacity (TIBC), indicates iron deficiency. Because malnutrition and inflammation are associated with low TIBC in chronic kidney disease (CKD), TSAT might not reflect iron status or risk for anemia. We examined whether low serum iron was a risk factor for anemia in CKD patients with normal TSAT. Thus we compare the risk for anemia in 2500 CKD stage 1-4 patients divided by TSAT (cutoff: 20%) and serum iron (cutoff: 70 μg/dL in men, 60 μg/dL in women). Our results confirmed low TIBC (< 200 μg/dL) was associated with hypoalbuminemia and high C-reactive protein. In fully-adjusted logistic regression, both "normal TSAT low iron" and "low TSAT low iron" groups were associated with baseline anemia (hemoglobin < 11 g/dL) (odds ratios (OR) 1.56; 95% confidence interval (CI) 1.13-2.16 and OR 2.36; 95% CI 1.76-3.18, respectively) compared with the reference group (normal TSAT normal iron). Sensitivity tests with different cutoffs for TSAT and iron also showed similar results. In patients without anemia, both groups were associated with anemia after 1 year (OR 1.69; 95% CI 1.00-2.83 and OR 1.94; 95% CI 1.11-3.40, respectively). In conclusion, CKD stage 1-4 patients with normal TSAT but low serum iron are still at risk for anemia.
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http://dx.doi.org/10.1038/s41598-021-87401-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8052429PMC
April 2021

The association of echocardiographic parameters on renal outcomes in chronic kidney disease.

Ren Fail 2021 Dec;43(1):433-444

Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.

Background: Patients with chronic kidney disease (CKD) often have structural abnormalities of the heart due to pressure and volume overload. The aim of this study was to evaluate associations between echocardiographic parameters and renal outcomes (estimated glomerular filtration rate [eGFR] slope and progression to dialysis) in patients with stage 3-5 CKD.

Methods: This longitudinal study enrolled 419 patients. Changes in renal function were assessed using the eGFR slope. Rapid renal progression was defined as an eGFR slope < -3 mL/min/1.73 m/year, and the renal endpoint was defined as commencing dialysis.

Results: Increased left atrial diameter (LAD), ratio of left ventricular mass to body surface area (LVM/BSA), ratio of LVM to height (LVM/ht), and ratio of observed to predicted LVM (o/p LVM) were associated with eGFR slope in an adjusted model, but left ventricular ejection fraction (LVEF) was not. Furthermore, LAD ≥ 4.7 cm, LVM/BSA > 115 g/m in males and > 95 g/m in females, and LVM/ht > 48 g/ht in males and > 44 g/ht in females were correlated with progression to dialysis, but o/p LVM and LVEF were not. The maximum change in χ change to predict renal outcomes was observed for LAD, followed by LVM/BSA and LVM/ht.

Conclusions: A large LAD and increased LVM, regardless of how it was measured (LVM/BSA, LVM/ht and o/p LVM), were correlated with adverse renal outcomes in patients with CKD stage 3-5. LAD had superior prognostic value to LVM and LVEF.
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http://dx.doi.org/10.1080/0886022X.2021.1885444DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7946016PMC
December 2021

Low dose ultraviolet B irradiation at 308 nm with light-emitting diode device effectively increases serum levels of 25(OH)D.

Sci Rep 2021 Jan 28;11(1):2583. Epub 2021 Jan 28.

Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, TzYou 1st Rd., Sanmin District, Kaohsiung City, 80708, Taiwan.

This animal study aimed to elucidate the relationship of low-dose, narrow-band UVB at 308 nm with vitamin D synthesis. C57BL/6 female mice, at 3 weeks-of-age, were randomly divided into the following six groups (n = 6 at each time point of vitamin D measurement), which were: (1) normal diet without UVB irradiation; (2) VDd diet without UVB irradiation; and (3)-(6) VDd diet with 308 nm-UVB irradiation of 12.5, 25, 50, and 100 μω/cm, respectively. All of the groups needing UVB irradiation received an exposure of 10 min per day, five days per week, and a duration of 3-5 weeks. The mice recovering from severe VDd (plasma total 25-hydroxyvitamin D level increasing from approximately 3 to over 30 ng/mL) only occurred in groups with a UVB irradiation dosage of either 50 or 100 μω/cm. The optimal, estimated dosage for mice to recover from severe VDd was 355 mJ/cm within 3 weeks. Low-dose, narrow-band UVB irradiation at 308 nm is effective in improving VDd in mice. The results obtained, in addition to the especially small side effects of the above UVB irradiation formula, could be further translated to treating VDd-related disorders.
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http://dx.doi.org/10.1038/s41598-021-82216-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7844009PMC
January 2021

Association of digoxin with mortality in patients with advanced chronic kidney disease: A population-based cohort study.

PLoS One 2021 15;16(1):e0245620. Epub 2021 Jan 15.

Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.

Digoxin is commonly prescribed for heart failure and atrial fibrillation, but there is limited data on its safety in patients with chronic kidney disease (CKD). We conducted a population-based cohort study using the pre-end stage renal disease (ESRD) care program registry and the National Health Insurance Research Database in Taiwan. Of advanced CKD patient cohort (N = 31,933), we identified the digoxin user group (N = 400) matched with age and sex non-user group (N = 2,220). Multivariable Cox proportional hazards and sub-distribution hazards models were used to evaluate the association between digoxin use and the risk of death, cardiovascular events (acute coronary syndrome, ischemic stroke, or hemorrhagic stroke) and renal outcomes (ESRD, rapid decline in estimated glomerular filtration rate-eGFR, or acute kidney injury). Results showed that all-cause mortality was higher in the digoxin user group than in the non-user group, after adjusting for covariates (adjusted hazard ratio, aHR 1.63; 95% CI 1.23-2.17). The risk for acute coronary syndrome (sub-distribution hazard ratio, sHR 1.18; 95% CI 0.75-1.86), ischemic stroke (sHR 1.42; 95% CI 0.85-2.37), and rapid eGFR decline (sHR 1.00 95% CI 0.78-1.27) was not significantly different between two groups. In conclusion, our study demonstrated that digoxin use was associated with increased mortality, but not cardiovascular events or renal function decline in advanced CKD patients. This finding warns the safety of prescribing digoxin in this population. Future prospective studies are needed to overcome the limitations of cohort study design.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0245620PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7810292PMC
January 2021

The applicability of non-invasive methods for assessing liver fibrosis in hemodialysis patients with chronic hepatitis C.

PLoS One 2020 20;15(11):e0242601. Epub 2020 Nov 20.

Faculty of Internal Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.

Background: The accurate assessment of liver fibrosis among hemodialysis patients with chronic hepatitis C (CHC) is important for both treatment and for follow up strategies. Applying the non-invasive methods in general population with viral hepatitis have been successful but the applicability of the aminotransferase/platelet ratio index (APRI) or the fibrosis-4 index (FIB-4) in hemodialysis patients need further evaluation.

Materials And Methods: We conducted a prospective, multi-center, uremic cohort to verify the applicability of APRI and FIB-4 in identifying liver fibrosis by reference with the standard transient elastography (TE) measures.

Results: There were 116 CHC cases with valid TE were enrolled in our analysis. 46 cases (39.6%) were classified as F1, 35 cases (30.2%) as F2, 11 cases (9.5%) as F3, and 24 cases (20.7%) as F4, respectively. The traditional APRI and FIB-4 criteria did not correctly identify liver fibrosis. The optimal cut-off value of APRI was 0.28 and of FIB-4 was 1.91 to best excluding liver cirrhosis with AUC of 76% and 77%, respectively. The subgroup analysis showed that female CHC hemodialysis patients had better diagnostic accuracy with 74.1% by APRI. And CHC hemodialysis patients without hypertension had better diagnostic accuracy with 78.6% by FIB-4.

Conclusions: This study confirmed the traditional category level of APRI and FIB-4 were unable to identify liver fibrosis of CHC hemodialysis patients. With the adjusted cut-off value, APRI and FIB-4 still showed suboptimal diagnostic accuracy. Our results suggest the necessary of TE measures for liver fibrosis in the CHC uremic population.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0242601PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7678992PMC
January 2021

The role of postprandial very-low-density lipoprotein in the development of atrial remodeling in metabolic syndrome.

Lipids Health Dis 2020 Sep 22;19(1):210. Epub 2020 Sep 22.

Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.

Background: Negatively charged very-low-density lipoprotein (VLDL-χ) in metabolic syndrome (MetS) patients exerts cytotoxic effects on endothelial cells and atrial myocytes. Atrial cardiomyopathy, manifested by atrial remodeling with a dilated diameter, contributes to atrial fibrillation pathogenesis and predicts atrial fibrillation development. The correlation of VLDL-χ with atrial remodeling is unknown. This study investigated the association between VLDL-χ and remodeling of left atrium.

Methods: Consecutively, 87 MetS and 80 non-MetS individuals between 23 and 74 years old (50.6% men) without overt cardiovascular diseases were included in the prospective cohort study. Blood samples were collected while fasting and postprandially (at 0.5, 1, 2, and 4 h after a unified meal). VLDL was isolated by ultracentrifugation; the percentile concentration of VLDL-χ (%) was determined by ultra-performance liquid chromatography. The correlations of left atrium diameter (LAD) with variables including VLDL-χ, LDL-C, HDL-C, triglycerides, glucose, and blood pressure, were analyzed by multiple linear regression models. A hierarchical linear model was conducted to test the independencies of each variable's correlation with LAD.

Results: The mean LAD was 3.4 ± 0.5 cm in non-MetS subjects and 3.9 ± 0.5 cm in MetS patients (P < 0.01). None of the fasting lipid profiles were associated with LAD. VLDL-χ, BMI, waist circumference, hip circumference, and blood pressure were positively correlated with LAD (all P < 0.05) after adjustment for age and sex. Significant interactions between VLDL-χ and blood pressure, waist circumference, and hip circumference were observed. When adjusted for obesity- and blood pressure-related variables, 2-h postprandial VLDL-χ (mean 1.30 ± 0.61%) showed a positive correlation with LAD in MetS patients. Each 1% VLDL-χ increase was estimated to increase LAD by 0.23 cm.

Conclusions: Postprandial VLDL-χ is associated with atrial remodeling particularly in the MetS group. VLDL-χ is a novel biomarker and may be a therapeutic target for atrial cardiomyopathy in MetS patients.

Trial Registration: ISRCTN 69295295 . Retrospectively registered 9 June 2020.
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http://dx.doi.org/10.1186/s12944-020-01386-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7507670PMC
September 2020

Effectiveness of antiresorptive medications in women on long-term dialysis after hip fracture: A population-based cohort study.

PLoS One 2020 2;15(9):e0238248. Epub 2020 Sep 2.

Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.

There is no clear evidence how effective the antiresorptive (AR) drugs alendronate and raloxifene are at reducing risk of second hip fracture and mortality in dialysis populations. The purpose of this study was to compare the risk of hospitalization for second hip fracture and risk of mortality between AR user and non-user groups in Taiwanese women on long-term dialysis with hip fractures. We conducted a retrospective cohort study using Taiwan National Health Insurance Research Datasets. Long-term dialysis women older than 50 years with newly diagnosed hip fractures and new to AR therapy from 2005 to 2011 were recruited. The patients were divided into AR users and non-users and matched by propensity score. We used Cox Proportional Hazards models to assess association of AR with risks of second hip fracture and mortality. Totally, 1,079 dialysis patients were included, and after matching, we were left with 74 AR users and 74 non-users. AR users did not show a significant reduction in the incidence of second hip fracture compared with non-users (adjusted Hazard Ratio (HR): 0.91, 95% CI: 0.30-2.76), and alendronate users exhibited higher risk of second hip fracture compared with raloxifene users (adjusted HR: 2.80, 95% CI: 0.42-18.79). In addition, AR users were found to have significantly lower 1- and 2-year mortality rates than the non-users (1- year: adjusted HR 0.25, 95% CI, 0.07-0.90; 2-year: 0.35, 95%CI: 0.17-0.72). AR treatment did not significantly improve the risk of second hip fracture but significantly reduce mortality in older women on dialysis. Further clinical trials on effectiveness of AR medications for dialysis populations should be warranted.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0238248PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7467303PMC
October 2020

No Obvious Impact of NSAIDs on Risk of Kidney Failure: Causal or Another Selection Bias?

Am J Kidney Dis 2020 11 31;76(5):742. Epub 2020 Jul 31.

Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.

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http://dx.doi.org/10.1053/j.ajkd.2020.05.023DOI Listing
November 2020

There is a U shaped association between non high density lipoprotein cholesterol with overall and cardiovascular mortality in chronic kidney disease stage 3-5.

Sci Rep 2020 07 29;10(1):12749. Epub 2020 Jul 29.

Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.

Dyslipidemia is common in patients with chronic kidney disease (CKD), however the relationship between dyslipidemia and mortality in patients with moderate to severe CKD remains controversial. Non-high-density lipoprotein (HDL) cholesterol has been reported to be a more accurate predictor of clinical outcomes than conventional lipid measurements. Hence, the aim of this study was to investigate associations between non-HDL cholesterol and the risk of overall and cardiovascular mortality in patients with CKD stage 3-5. We enrolled 429 pre-dialysis patients with stage 3 to 5 CKD from May 2006 to January 2010. The patients were divided into four groups according to quartiles of non-HDL cholesterol. The patients were followed until death or until January 2020. During a median 11.6 years of follow-up, there were 78 (18.2%) deaths overall and 32 (7.5%) cardiovascular deaths. In adjusted models, the patients in quartile 1 (hazard ratio [HR] 3.368; 95% confidence interval [CI] 1.388-8.176; p = 0.007), quartile 3 (HR 3.666; 95% CI 1.486-9.044; p = 0.005), and quartile 4 (HR 2.868; 95% CI 1.136-7.240; p = 0.026) of non-HDL cholesterol had a higher risk of overall mortality (vs. quartile 2). In addition, the patients in quartile 1 (HR 19.503; 95% CI 2.185-174.0925 p = 0.008), quartile 3 (HR 28.702; 95% CI 2.990-275.559; p = 0.004), and quartile 4 (HR 11.136; 95% CI 1.126-110.108; p = 0.039) had a higher risk of cardiovascular mortality (vs. quartile 2). Our study showed a U-shaped relationship between non-HDL cholesterol and the risk of overall and cardiovascular mortality in patients with CKD stage 3-5. Assessing non-HDL cholesterol may help to identify subjects at high-risk of adverse outcomes.
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http://dx.doi.org/10.1038/s41598-020-69794-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7392750PMC
July 2020

Using a machine learning approach to predict mortality in critically ill influenza patients: a cross-sectional retrospective multicentre study in Taiwan.

BMJ Open 2020 02 25;10(2):e033898. Epub 2020 Feb 25.

Division of Chest, Department of Internal Medicine, Taichung Veterans General Hospital, Taichung, Taiwan

Objectives: Current mortality prediction models used in the intensive care unit (ICU) have a limited role for specific diseases such as influenza, and we aimed to establish an explainable machine learning (ML) model for predicting mortality in critically ill influenza patients using a real-world severe influenza data set.

Study Design: A cross-sectional retrospective multicentre study in Taiwan SETTING: Eight medical centres in Taiwan.

Participants: A total of 336 patients requiring ICU-admission for virology-proven influenza at eight hospitals during an influenza epidemic between October 2015 and March 2016.

Primary And Secondary Outcome Measures: We employed extreme gradient boosting (XGBoost) to establish the prediction model, compared the performance with logistic regression (LR) and random forest (RF), demonstrated the feature importance categorised by clinical domains, and used SHapley Additive exPlanations (SHAP) for visualised interpretation.

Results: The data set contained 76 features of the 336 patients with severe influenza. The severity was apparently high, as shown by the high Acute Physiology and Chronic Health Evaluation II score (22, 17 to 29) and pneumonia severity index score (118, 88 to 151). XGBoost model (area under the curve (AUC): 0.842; 95% CI 0.749 to 0.928) outperformed RF (AUC: 0.809; 95% CI 0.629 to 0.891) and LR (AUC: 0.701; 95% CI 0.573 to 0.825) for predicting 30-day mortality. To give clinicians an intuitive understanding of feature exploitation, we stratified features by the clinical domain. The cumulative feature importance in the fluid balance domain, ventilation domain, laboratory data domain, demographic and symptom domain, management domain and severity score domain was 0.253, 0.113, 0.177, 0.140, 0.152 and 0.165, respectively. We further used SHAP plots to illustrate associations between features and 30-day mortality in critically ill influenza patients.

Conclusions: We used a real-world data set and applied an ML approach, mainly XGBoost, to establish a practical and explainable mortality prediction model in critically ill influenza patients.
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http://dx.doi.org/10.1136/bmjopen-2019-033898DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7045134PMC
February 2020

Effect of nephrology referrals and multidisciplinary care programs on renal replacement and medical costs on patients with advanced chronic kidney disease: A retrospective cohort study.

Medicine (Baltimore) 2019 Aug;98(33):e16808

Department of Internal Medicine, Division of Nephrology, Kaohsiung Medical University Hospital.

Evidence-based studies have revealed outcomes in patients with chronic kidney disease that differed depending on the design of care delivery. This study compared the effects of 3 types of nephrology care: multidisciplinary care (MDC), nephrology care, and non-nephrology care. We studied their effects on the risks of requiring dialysis and the differences between these methods had on long-term medical resource utilization and costs.We conducted a retrospective cohort study involving patients with an estimated glomerular filtration rate of (eGFR) ≤45 mL/min/1.73 m from 2005 to 2007. Patients were divided into MDC, non-MDC, and non-nephrology referral groups. Between-group differences with regard to the risk of requiring dialysis and annual medical utilization and costs were evaluated using a 5-year follow-up period.In total, 661 patients were included. After other covariates and the competing risk of death were taken into account, we observed a significant (56%) reduction in the incidence of dialysis in both the MDC and non-MDC groups relative to the non-nephrology referral group. Costs were markedly lower in the MDC group relative to the other groups (average savings: US$ 830 per year; 95% confidence interval: 367-1295; P < .001).For patients without nephrology referrals, MDC can substantially reduce their risk of developing end-stage renal disease and lower their medical costs. We therefore strongly advocate that all patients with an eGFR of ≤45 mL/min/1.73 m should be referred to a nephrologist and receive MDC.
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http://dx.doi.org/10.1097/MD.0000000000016808DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6831162PMC
August 2019

Depression amongst patients commencing maintenance dialysis is associated with increased risk of death and severe infections: A nationwide cohort study.

PLoS One 2019 13;14(6):e0218335. Epub 2019 Jun 13.

Department of Medical Epidemiology and Biostatistics (MEB), Karolinska Institutet, Stockholm, Sweden.

Background: Depression is common in dialysis patients, but the clinical impact of this condition is poorly defined.

Methods: Out of 57,703 patients starting dialysis during 2000-2007 recorded in the National Health Insurance Research Database of Taiwan, we identified 2,475 patients with a clinical diagnosis of depression, and compared them with 1:5 age- and sex-matched patients without a depression diagnosis (n = 12,375). Patients were followed up for hospitalisation due to severe infections, major adverse cardiovascular events (MACE) and death. Multivariable Cox regression and competing risk analyses (accounting for death when appropriate) were used to estimate risk associations.

Results: Patients with depression had a higher frequency of comorbidities. During a mean follow-up of 3.2 years, 1,140 severe infections, 806 MACE, and 1,121 deaths were recorded. Compared to controls, patients with depression were at increased risk of death (adjusted hazard ratio 1.24; 95%CI 1.16-1.33). Patients with depression were also at higher risk of severe (1.14; 1.06-1.22) and fatal infections (death within 30 days, 1.22; 1.09-1.35), attributed mainly to sepsis (1.19; 1.08-1.31), septic shock (1.36; 1.13-1.62) and pneumonia (1.19; 1.07-1.33). Conversely, no association was observed between depression and the MACE risk (1.04; 0.94-1.15).

Conclusion: Dialysis patients with depression are associated with increased risk of infections and death.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0218335PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6564035PMC
February 2020

Predominant global glomerulosclerosis in patients of upper urinary tract urothelial carcinoma with pre-existing renal function impairment is a predictor of poor renal outcomes.

BMC Cancer 2019 Apr 8;19(1):337. Epub 2019 Apr 8.

Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, No. 100, Tzyou 1st Road, 80708, Kaohsiung, Taiwan.

Background: Incidence of renal dysfunction and risks of progression to end-stage renal disease (ESRD) were reported higher in upper urinary tract urothelial carcinoma (UTUC) than in renal cell carcinoma (RCC) patients after unilateral nephrectomy.

Methods: Totally 193 renal cancer patients, including 132 UTUC and 61 RCC, were studied to clarify whether the pathological changes of the kidney remnant removed from nephrectomy and the clinical factors might predict the risk of ESRD. Renal tubulointerstitial (TI) score and global glomerulosclerosis (GGS) rate were examined by one pathologist and two nephrologists independently under same histopathological criteria.

Results: The glomerular filtration rates at the time of surgery were lower in UTUC than RCC groups (p < 0.001). Average GGS score and average TI rate were higher in UTUC than in RCC groups (p < 0.001; p < 0.001). Competitive risk factor analysis revealed that abnormal GGS rate not related to age, predominant in UTUC with pre-existing renal function impairment, was a histopathological predictor of poor renal outcomes (creatinine doubling or ESRD) within 5 years in UTUC patients.

Conclusion: Pre-existing renal function and pathological change of kidney remnant in both UTUC and RCC have the value for prediction of renal outcomes.
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http://dx.doi.org/10.1186/s12885-019-5414-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6454684PMC
April 2019

Long-term outcomes of lateral tunneled transposed brachiobasilic arteriovenous fistulas in elderly hemodialysis patient.

J Vasc Access 2019 Sep 24;20(5):557-562. Epub 2019 Jan 24.

4 Division of Cardiovascular Surgery, Kaohsiung Medical University Hospital and College of Medicine, Kaohsiung Medical University, Kaohsiung.

Background: Arteriovenous fistula is recommended for the general dialysis population, but its use remains controversial in the elderly population. We evaluated the long-term outcomes of lateral tunneled transposed brachiobasilic arteriovenous fistulas in older patients who underwent hemodialysis.

Methods: In this retrospective cohort study, we included patients who received a two-stage transposed brachiobasilic arteriovenous fistula in a medical center from May 2005 to January 2014. The patients were followed up from the fistula placement date until any intervention, death, failure, January 2015, or the end of the sixth year. Death and arteriovenous fistula failure during the observation period were considered as adverse outcomes, and the cause of death was identified. The cumulative patency rate was calculated using the Kaplan-Meier approach to reveal the long-term outcomes of this procedure.

Results: Among the 66 patients who underwent surgery, the average age was 65.8 ± 13.5 years and the majority were females (62.1%). After a median follow-up of 20.6 months, 19 patients died, 12 (18.2%) received vascular intervention, and 3 experienced fistula failure. No significant difference was observed in the 6-year cumulative patency rates between younger and older adults (96.3% vs 80.3%, p = 0.58). None of the deaths during the observation period were related to bloodstream infection.

Conclusion: A two-stage lateral tunneled transposed brachiobasilic arteriovenous fistula can be applied to patients undergoing hemodialysis, regardless of age.
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http://dx.doi.org/10.1177/1129729818820184DOI Listing
September 2019

Thiazide-associated hyponatremia attenuates the fracture-protective effect of thiazide: A population-based study.

PLoS One 2018 7;13(12):e0208712. Epub 2018 Dec 7.

Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.

Background: Thiazide, a first-line therapy for hypertension, lowers blood pressure, increases bone mineral density, and reduces the risk of fractures. However, hyponatremia, an adverse effect of thiazide, is associated with increased risk of osteoporosis and fractures. It is currently unclear whether thiazide-associated hyponatremia (TAH) outweighs the protective effects of thiazide.

Methods: Using data from Taiwan's National Health Insurance Research Database, we identified patients who were prescribed thiazide between 1998 and 2010. Those diagnosed with hyponatremia within three years after initiation of thiazide were selected for the TAH group. Thiazide users without hyponatremia were selected for the control group. The association between TAH and fracture risk was further evaluated using multivariable Cox regression models adjusted for comorbidities and medications. Subjects were followed up from the index date until the appearance of a fracture, death, or the end of a 3-year period.

Results: A total of 1212 patients were included in the TAH group, matched with 4848 patients in the control group. The incidence rate of fracture was higher in the TAH group than in the control group (31.4 versus 20.6 per 1000 person-years). TAH was associated with a higher risk of total fractures (adjusted hazard ratio [aHR]: 1.47, 95% confidence interval [CI] = 1.15-1.88), vertebra fractures (aHR: 1.84, 95% CI = 1.12-3.01), and hip fractures (aHR: 1.66, 95% CI = 1.12-2.46) after controlling for comorbidities and other medications.

Conclusions: Thiazide users with hyponatremia have a higher risk of fracture than thiazide users without hyponatremia. The fracture-protective effect of thiazide is attenuated by TAH.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0208712PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6285977PMC
May 2019

Association of hyperglycemia episodes on long-term mortality in type 2 diabetes mellitus with vascular dementia: A population-based cohort study.

J Diabetes Complications 2019 02 25;33(2):123-127. Epub 2018 Oct 25.

Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Family Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan. Electronic address:

Aim: This study investigated the effect of severe hyperglycemia episodes on survival and associated factors related to risk of mortality in type 2 diabetes mellitus (DM) patients with dementia.

Methods: We enrolled all type 2 DM patients newly diagnosed as having dementia in Taiwan from 1998 to 2005. These patients were categorized into those who had hyperglycemia episodes and those who did not based on whether or not they had been hospitalized for hyperglycemia after dementia diagnosis. Factors independently associated with mortality were evaluated.

Results: Of 5314 patients identified, 303 (5.7%) had at least one hyperglycemia hospitalization. Patients with at least one hyperglycemia hospitalization had a 30% greater risk of mortality than those who had no such admissions (adjusted hazard ratio: 1.30, 95% confidence interval: 1.09-1.55). Other variables, including age, sex, geographical region, insurance amount, patient with congestive heart failure, cerebrovascular disease, renal disease, use of anti-hypertensive drugs, use of anti-lipid drugs, and use of insulin were independently associated with risk of mortality.

Conclusion: Severe hyperglycemia is common in type 2 DM patients with dementia and it substantially shortens their life. The findings of this study suggest a great need to improve care in DM patients with dementia.
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http://dx.doi.org/10.1016/j.jdiacomp.2018.10.014DOI Listing
February 2019

ASO Author Reflections: Dialysis and Recurrence in Urothelial Cancer.

Ann Surg Oncol 2018 12 29;25(Suppl 3):978-979. Epub 2018 Oct 29.

Department of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.

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http://dx.doi.org/10.1245/s10434-018-6893-8DOI Listing
December 2018

Incidence, Prevalence, and Duration of Chronic Kidney Disease in Taiwan: Results from a Community-Based Screening Program of 106,094 Individuals.

Nephron 2018 23;140(3):175-184. Epub 2018 Aug 23.

Department of Renal Care, Kaohsiung Medical University, Kaohsiung, Taiwan.

Background/aims: Taiwan has the highest incidence of end-stage renal disease, which requires renal replacement therapy. Chronic kidney disease (CKD) contributes to this burden. However, the current data on the epidemiologic features of CKD in Taiwan are incomplete. Therefore, we aimed to investigate the prevalence and incidence of CKD in a population-based study and then estimate the average dwelling time (ADT) in the main clinical burden of CKD (stages 3-5).

Methods: A prospective cohort study was designed with an integrated community-based multiple screening program of 106,094 individuals aged ≥20 years in Keelung, Taiwan, in 1999-2009. Prevalence was estimated as the percentage of CKD stages among individuals attending the first screening, and incidence was expressed as the ratio of total desired events in the following period to the total observational time. Finally, ADT was estimated from the ratio of prevalence to incidence.

Results: The participants' mean age was 47.7 ± 15.4 years. The estimated prevalence was 15.46% for total CKD and 9.06% for CKD stages 3-5. The incidence was 27.21/1,000 person-years (PY) for total CKD and 16.89/1,000-PY for CKD stages 3-5. Older patients, males, and those patients with comorbidities of diabetes mellitus (DM), hypertension, and metabolic syndrome (MetS) exhibited higher prevalence and incidence rates than their opposing counterparts. Moreover, the ADT of CKD stages 3-5 was 5.37 years (95% CI 5.17-5.57). Males and those with comorbidities of DM or MetS had shorter ADTs in CKD stages 3-5 than their opposing counterparts. Interestingly, the ADT of participants with hypertension was longer than those without.

Conclusions: The prevalence and incidence of CKD in Taiwan are high. Moreover, ADT in CKD stages 3-5 varied according to sex, age, and comorbidity. Further exploration of the factors associated with the shifting of this duration will shed light on effective CKD management.
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http://dx.doi.org/10.1159/000491708DOI Listing
October 2019

Factors associated with type 2 diabetes in patients with vascular dementia: a population-based cross-sectional study.

BMC Endocr Disord 2018 Jul 4;18(1):45. Epub 2018 Jul 4.

Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, No. 100, Shih-Chuan 1st Road, Kaohsiung, 80708, Taiwan.

Background: Incidence of dementia is growing rapidly and affects many people worldwide. Type 2 diabetes mellitus (DM) might link cognitive decline and dementia, but the reasons for this association remain unclear. Our study explored the factors associated with type 2 DM in patients with dementia.

Methods: Patients (n = 40,404) with vascular dementia were identified in Taiwan's 1997 to 2008 National Health Insurance Research Database and divided into a DM group and non-DM group. Eleven comorbidities were identified and categorized into four groups: cardiovascular and cerebrovascular diseases, digestive system diseases, renal and metabolic system diseases, and cancer. The associations of these factors with type 2 DM were explored through multivaraible logistic regression.

Results: Of the patients with dementia, 22.5% had DM. Associated with a higher likelihood of DM in this population were female sex (adjusted odds ratio [OR]: 1.44, 95% confidence interval [CI]: 1.36-1.52), young age (range of adjusted OR: 0.55-1.13), low income (range of adjusted OR: 1.09-1.18), and renal and metabolic system diseases (OR: 2.81, 95% CI: 2.64-2.98).

Conclusions: The findings of this study suggest that clinicians should encourage patients with dementia to receive regular glucose impairment screening if they are female, have low socioeconomic status, or have renal or metabolic diseases.
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http://dx.doi.org/10.1186/s12902-018-0273-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6033220PMC
July 2018

Effects of physician's specialty on regular chronic kidney disease care in predialysis: A population-based cross-sectional study.

Medicine (Baltimore) 2018 Jun;97(26):e11317

Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital Department of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung Department of Health Promotion and Health Education, National Taiwan Normal University, Taipei Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung Institute of Population Health Sciences, National Health Research Institutes, Miaoli, Taiwan.

Late referral in chronic kidney disease (CKD) is associated with irregular care and poor prognosis. How the specialty of healthcare provider affect late referral and irregular CKD care remain unclear.We conducted a population-based cross-sectional study to include incident dialysis patients from 2002 to 2007 in Taiwan and observed for 1, 2, and 3 years before dialysis. The medical visits-related information was evaluated every 3 months, retrospectively. Irregular follow-up was defined as missing a follow-up during more than one interval every year.A total of 46,626 patients were included. At 1, 2, and 3 years prior to maintenance dialysis, 87%, 66%, and 50% of patients had regular medical visits; however, only 49%, 23%, and 12% had estimated glomerular filtration rate (eGFR) regularly monitored, respectively. Independent factors of less regular eGFR follow-up included age (adjusted odds ratio (OR) 0.995, 95% confidence interval 0.993-0.998), cardiac disorder (0.90, 0.82-0.99), and stroke (0.76, 0.69-0.84), as well as regular visits at some other specialties (adjusted OR range: from 0.77 to 0.88); whereas, independent factors of less regular visits at nephrology included diabetes mellitus (0.48, 0.46-0.51), cardiac disorder (0.61, 0.56-0.66), stroke (0.53, 0.48-0.58), and regular visits at any other specialty (adjusted OR range: from 0.22 to 0.78).Regular medical visits were quite common in late CKD patients, but they received regular eGFR measurement and visit at nephrology much less frequently. Physicians play a major role in the late referrals in CKD and its irregular care.
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http://dx.doi.org/10.1097/MD.0000000000011317DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6039619PMC
June 2018

Effect of national pre-ESRD care program on expenditures and mortality in incident dialysis patients: A population-based study.

PLoS One 2018 1;13(6):e0198387. Epub 2018 Jun 1.

Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.

Inadequate care of chronic kidney disease (CKD) is common and may be associated with adverse outcomes after dialysis. The nationwide pre-end-stage renal disease pay for performance program (P4P) has been implemented in Taiwan to improve quality of CKD care. However, the effectiveness of the P4P program in improving the outcomes of pre-dialysis care and dialysis is uncertain. We conducted a longitudinal cohort study. Patients who newly underwent long-term dialysis (≥3 mo) between 2007 and 2009 were identified from the Taiwan National Health Insurance Research Database. Based on the patient enrolment of the P4P program, they were categorized into P4P or non-P4P groups. We analysed pre-dialysis care, healthcare expenditures, and mortality between two groups. Among the 26 588 patients, 25.5% participated in the P4P program. The P4P group received significantly better quality of care, including a higher frequency of glomerular filtration rate measurement and CKD complications survey, a higher rate of vascular access preparation, and more frequent use of arteriovenous fistulas than the non-P4P group did. The P4P group had a 68.4% reduction of the 4-year total healthcare expenditure (excluding dialysis fee), which is equivalent to US$345.7 million, and a significant 22% reduction in three-year mortality after dialysis (hazard ratio 0.78, 95% confidence interval: 0.75-0.82, P < 0.001) compared with the non-P4P group. P4P program improves quality of pre-dialysis CKD care, and provide survival benefit and a long-term cost saving for dialysis patients.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0198387PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5983494PMC
January 2019

Dialysis Increases the Risk of Bladder Recurrence in Patients with Upper Tract Urothelial Cancer: A Population-Based Study.

Ann Surg Oncol 2018 Apr 12;25(4):1086-1093. Epub 2018 Jan 12.

Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.

Background: The relation of dialysis to tumor recurrence in patients with upper tract urothelial cancer (UTUC) is unknown; however, a limited number of small-scale studies suggest that patients with renal diseases prior to UTUC are more likely to exhibit bladder recurrence. We performed a population-based analysis to determine the effect of dialysis on bladder recurrence for patients with UTUC.

Methods: This retrospective cohort study included patients diagnosed with UTUC (2002-2007) from the Taiwan National Cancer Registry and divided them into two groups-dialysis and non-dialysis groups. These patients were followed up until bladder recurrence, death, or the end of 2010. Competing risk analyses adjusting covariates and death were applied to determine the relation of dialysis and bladder recurrence.

Results: Of the 5141 eligible patients, 548 (10.7%) were undergoing dialysis. The cumulative bladder recurrence was significantly higher in the dialysis group than in the non-dialysis group (29% vs. 21%, modified log-rank p < 0.001). In the multivariable analysis, the dialysis group exhibited a 64% increased bladder recurrence risk (cause-specific hazard ratio 1.64, 95% confidence interval 1.34-2.01, p < 0.001), which was confirmed using stratification and propensity score weighting methods. The other prognostic factors for bladder recurrence were sex, diabetes, cardiac disorder, Charlson Comorbidity Index, and tumor grade.

Conclusions: Despite unknown reasons, approximately one-tenth of patients with UTUC have experienced dialysis treatment. Patients undergoing dialysis have a higher risk of bladder recurrence. Various treatment and screening strategies should be developed for dialysis and non-dialysis patients.
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http://dx.doi.org/10.1245/s10434-017-6295-3DOI Listing
April 2018

Convex border of peripheral non-small cell lung cancer on CT images as a potential indicator of pleural invasion.

Medicine (Baltimore) 2017 Oct;96(42):e7323

Department of Radiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung Department of Pathology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Department of Respiratory Therapy, College of Medicine, Kaohsiung Medical University, Kaohsiung Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Division of Chest Medicine, Department of Internal Medicine, Kaohsiung Medical University, Kaohsiung Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Faculty of Renal Care, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.

The aim of the study is to evaluate the use of the tumor border in peripheral non-small cell lung cancer (NSCLC) as an indicator of pleural invasion.This retrospective study was performed at a single tertiary center. The analysis of 136 patients with peripheral NSCLC included 101 (74.3%) patients with pathologically proven pleural invasion and 35 (25.7%) patients without pleural invasion. The tumor borders on conventional computed tomography (CT) were classified into 5 types on lung window setting: type 1, S or reverse S border with a blunt angle; type 2, sharp angle; type 3, concave border with a blunt angle; type 4, straight border with a perpendicular angle; and type 5, convex border with a perpendicular or blunt angle. In patients with more than 1 tumor border type, the priority was type 5, 4, 3, 2, and 1. Blunt angle, pleural contact >3 cm, and adjacent pleural thickening were also recorded for comparison with pleural invasion of peripheral tumors.Tumor border types 2 and 5 significantly differed between patients with and without pleural invasion (P = .001 and P < .001, respectively). Patients with and without pleural invasion did not significantly differ in tumor border type 1, tumor border type 3, tumor border type 4, blunt angle, pleural contact >3 cm, or pleural thickening. Tumor border type 5 was a moderate indicator of pleural invasion with positive LR, 5.20; accuracy, 57%; sensitivity, 45%; specificity, 91%; PPV, 94%; and NPV, 36%. Tumor border type 2 was a weak indicator of pleural invasion with positive LR, 0.51; accuracy, 34%; sensitivity, 34%; specificity, 34%; PPV, 60%; and NPV, 15%.Tumor border type 5 has a high PPV and high specificity for predicting pleural invasion by peripheral NSCLC.
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http://dx.doi.org/10.1097/MD.0000000000007323DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5662337PMC
October 2017

Association of physical activity with cardiovascular and renal outcomes and quality of life in chronic kidney disease.

PLoS One 2017 23;12(8):e0183642. Epub 2017 Aug 23.

Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.

Patients with chronic kidney disease (CKD) are more readily prone to have impaired physical activity than the general population. The aim of this study is to examine the relationship between physical activity and adverse clinical outcomes and quality of life (QOL) in CKD. One hundred and sixty-one patients with CKD stages 1-5 was enrolled from February 2013 to September 2013 and followed up until June 2016. Physical activity was measured using high handgrip strength, 30-second chair stand, and 2-minute step. The QOL was assessed using the Taiwan version of the World Health Organization Quality of Life-BREF. Clinical outcomes included commencing dialysis, major adverse cardiovascular events (MACEs), and first hospitalization. Of all participants, 1 kgf increase in handgrip strength was significantly associated with 0.13 score increase in total scores of QOL and 0.05 score increase in physical domain of QOL in adjusted analysis. One time increase in 30-second chair stand was significantly correlated with 0.14 score increase in psychological domain of QOL. Over a mean follow-up period of 29.1±11.2 months, 37 (23.0%) reached commencing dialysis, 11(6.8%) had MACEs, and 50(31.1%) had first hospitalization. High handgrip strength (hazard ratio (HR): 0.89, 95% CI: 0.84-0.96) and high 2-minute step (HR: 0.04, 95% CI: 0.01-0.95) were significantly associated with decreased risk for commencing dialysis in multivariate analysis. Thirty-second chair-stand was negatively associated with MACEs (HR: 0.65, 95%CI: 0.47-0.89) and first hospitalization (HR: 0.84, 95%CI: 0.74-0.95). In conclusion, physical activity is a potential predictor of QOL and adverse clinical outcomes in patients with CKD.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0183642PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5568323PMC
October 2017

Economic evaluation of a pre-ESRD pay-for-performance programme in advanced chronic kidney disease patients.

Nephrol Dial Transplant 2017 Jul;32(7):1184-1194

Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.

Background: The National Health Insurance Administration in Taiwan initiated a nationwide pre-end-stage renal disease (ESRD) pay-for-performance (P4P) programme at the end of 2006 to improve quality of care for chronic kidney disease (CKD) patients. This study aimed to examine this programme's effect on patients' clinical outcomes and its cost-effectiveness among advanced CKD patients.

Methods: We conducted a longitudinal observational matched cohort study using two nationwide population-based datasets. The major outcomes of interests were incidence of dialysis, all-cause mortality, direct medical costs, life years (LYs) and incremental cost-effectiveness ratio comparing matched P4P and non-P4P advanced CKD patients. Competing-risk analysis, general linear regression and bootstrapping statistical methods were used for the analysis.

Results: Subdistribution hazard ratio (95% confidence intervals) for advanced CKD patients enrolled in the P4P programme, compared with those who did not enrol, were 0.845 (0.779-0.916) for incidence of dialysis and 0.792 (0.673-0.932) for all-cause mortality. LYs for P4P and non-P4P patients who initiated dialysis were 2.83 and 2.74, respectively. The adjusted incremental CKD-related costs and other-cause-related costs were NT$114 704 (US$3823) and NT$32 420 (US$1080) for P4P and non-P4P patients who initiated dialysis, respectively, and NT$-3434 (US$114) and NT$45 836 (US$1572) for P4P and non-P4P patients who did not initiate dialysis, respectively, during the 3-year follow-up period.

Conclusions: P4P patients had lower risks of both incidence of dialysis initiation and death. In addition, our empirical findings suggest that the P4P pre-ESRD programme in Taiwan provided a long-term cost-effective use of resources and cost savings for advanced CKD patients.
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http://dx.doi.org/10.1093/ndt/gfw372DOI Listing
July 2017

The interaction between fluid status and angiopoietin-2 in adverse renal outcomes of chronic kidney disease.

PLoS One 2017 23;12(3):e0173906. Epub 2017 Mar 23.

Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.

Background: Fluid overload is not only the characteristic but also an important complication in chronic kidney disease (CKD) patients. Angiopoietin-2 (Angpt2) disturbs endothelium and vessel permeability, which may induce fluid overload. The aim of this study is to examine the interaction between fluid status and Angpt2 in adverse renal outcomes of CKD.

Methods: This cohort study enrolled 290 patients with CKD stages 3-5 from January 2011 to December 2011 and followed up until December 2015. Fluid status was presented as overhydration (OH) value measured by body composition monitor, while OH>1.1L was defined as fluid overload. Renal outcomes were defined as commencing dialysis and rapid renal function decline (the slope of estimated glomerular filtration rate < -5 ml/min/1.73 m2/y).

Results: During a mean follow-up of 38.6±18.3 months, 125 (43.1%) patients progressed to commencing dialysis and 99(34.7%) patients presented rapid renal function decline. All patients were stratified by OH of 1.1L and the median of circulating Angpt2. These patients with both OH>1.1L and high circulating Angpt2 were more likely to reach commencing dialysis compared to other groups. The risks for commencing dialysis and rapid renal function decline were significantly higher in patients with OH>1.1L and high circulating Angpt2 level compared to those with OH≦1.1L and low circulating Angpt2 (2.14, 1.21-3.78, P = 0.009; 4.96, 1.45-16.97, P = 0.01). There was a significant interaction between OH level and circulating Angpt2 in entering dialysis (P-interaction = 0.02).

Conclusions: Fluid overload and Angpt2 might have a synergistic effect on adverse renal outcomes in CKD patients.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0173906PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5363828PMC
August 2017

The role of transthoracic ultrasonography in predicting the outcome of community-acquired pneumonia in hospitalized children.

PLoS One 2017 16;12(3):e0173343. Epub 2017 Mar 16.

Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.

Conclusion: TUS findings of fluid bronchogram, multifocal involvement, and pleural effusion were associated with adverse outcomes, including longer hospital stay, ICU admission, and tube thoracotomy in hospitalized CAP children. Therefore, TUS is a novel tool for prognostic stratifications of CAP in hospitalized children.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0173343PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5354295PMC
September 2017

Hyponatremia is Associated with Fluid Imbalance and Adverse Renal Outcome in Chronic Kidney Disease Patients Treated with Diuretics.

Sci Rep 2016 11 14;6:36817. Epub 2016 Nov 14.

Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan.

Chronic kidney disease (CKD) is frequently complicated with hyponatremia, probably because of fluid overload or diuretic usage. Hyponatremia in CKD population is associated with increased mortality, but the effect on renal outcome was unknown. We investigated whether hyponatremia is associated with fluid status and is a prognostic indicator for adverse outcomes in a CKD cohort of 4,766 patients with 1,009 diuretic users. We found that diuretic users had worse clinical outcomes compared with diuretic non-users. Hyponatremia (serum sodium <135 mEq/L) was associated with excessive volume and volume depletion, measured as total body water by bioimpedance analysis, in diuretic users, but not in diuretic non-users. Furthermore, in Cox survival analysis, hyponatremia was associated with an increased risk for renal replacement therapy (hazard ratio, 1.45; 95% CI, 1.13-1.85, P < 0.05) in diuretic users, but not in diuretic non-users (P for interaction <0.05); restricted cubic spline model also showed a similar result. Hyponatremia was not associated with all-cause mortality or cardiovascular event whereas hypernatremia (serum sodium >141 mEq/L) was associated with an increased risk for all-cause mortality. Thus, hyponatremia is an indicator of fluid imbalance and also a prognostic factor for renal replacement therapy in CKD patients treated with diuretics.
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http://dx.doi.org/10.1038/srep36817DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5108044PMC
November 2016

Association of Fluid Status and Body Composition with Physical Function in Patients with Chronic Kidney Disease.

PLoS One 2016 31;11(10):e0165400. Epub 2016 Oct 31.

Division of Nephrology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.

Background: Impairment of physical function and abnormal body composition are the major presentations in patients with chronic kidney disease (CKD). The aim of this study is to investigate the relationship between body composition and physical function in CKD patients.

Methods: This cross-sectional study enrolled 172 of CKD stages 1-5 from February 2013 to September 2013. Handgrip strength (upper extremity muscle endurance), 30-second chair-stand test (lower extremity muscle endurance) and 2-minute step test (cardiorespiratory endurance) were used as indices of physical function. Body composition, including fluid status (extracellular water/total body water, ECW/TBW), lean tissue index (LTI), and fat tissue index (FTI), was measured using a bioimpedance spectroscopy method.

Results: All patients with high ECW/TBW had lower handgrip strength and 30-second chair-stand than those with low ECW/TBW (P<0.001 and P = 0.002). CKD patients with high FTI had lower handgrip strength and 30-second chair-stand than those with low FTI (P<0.001 and P = 0.002). These patients with low LTI had lower handgrip strength than those with high LTI (P = 0.04). In multivariate analysis, high ECW/TBW was positively associated with decreased handgrip strength (β = -41.17, P = 0.03) in CKD patients. High FTI was significantly correlated with decreased times of 30-second chair-stand (β = -0.13, P = 0.01). There was no significant relationship between body composition and 2-minute step test.

Conclusions: Our results show a significant association of impaired upper and lower extremity muscle endurance with high fluid status and fat tissue. Evaluation of body composition may assist in indentifying physical dysfunction earlier in CKD patients.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0165400PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5087878PMC
June 2017