Rajamangala Institute of kidney disease

Peritonitis is the major complication of peritoneal dialysis (PD) patients. Staphylococcus is the leading causative organism of PD-related peritonitis. However, there were more reports of unusual organisms causing peritonitis. Clinical features, management, and outcome of peritonitis from unusual organisms are important information. We reported herein a 72-year-old female patient who presented with fever, abdominal pain, and cloudy dialysate for 3 days. Upon admission, ceftazidime and vancomycin were given intraperitoneally. A preliminary report of blood and PD fluid culture showed the presence of Gram-positive bacilli. Her clinical status improved 48 hours after the commencement of the antibiotics. Subsequently, culture reports of blood and PD fluid showed Lysinibacillus sphaericus which was susceptible to vancomycin at a minimal inhibitory concentration of less than 0.25 μg/mL. The patient was given intraperitoneal vancomycin for a total of 14 days. Then, the PD effluent was clear, and its cell count was below 100 cells/mm3 in 3 days. The patient did not have a recurrence of peritonitis after antibiotic discontinuation. The possibility of this organism infection is environmental contamination related to the patient's gardening activities.

Nephrolithiasis is a common urological disease worldwide. Extracorporeal shock wave lithotripsy (ESWL) has been used for the treatment of renal stones since the 1980s, while retrograde intrarenal surgery (RIRS) and percutaneous nephrolithotomy (PCNL) are newer, more invasive treatment modalities that may have higher stone-free rates. The complications of RIRS and PCNL have decreased owing to improvement in surgical techniques and instruments. We re-evaluated the best evidence on this topic in an update of a Cochrane Review first published in 2014. To assess the effects of extracorporeal shock wave lithotripsy compared with percutaneous nephrolithotomy or retrograde intrarenal surgery for treating kidney stones. We performed a comprehensive search in CENTRAL, MEDLINE, Embase, and ClinicalTrials.gov with no restrictions on language or publication status. The latest search date was 6 December 2022. We included randomized controlled trials (RCTs) and quasi-RCTs that compared ESWL with PCNL or RIRS for kidney stone treatment. Two review authors independently classified studies, extracted data, and assessed risk of bias. Our primary outcomes were treatment success rate at three months (defined as residual fragments smaller than 4 mm, or as defined by the study authors), quality of life (QoL), and complications. Our secondary outcomes were retreatment rate, auxiliary procedures rate, and duration of hospital stay. We performed statistical analyses using a random-effects model and independently rated the certainty of evidence using the GRADE approach. We included 31 trials involving 3361 participants (3060 participants completed follow-up). Four trials were only available as an abstract. Overall mean age was 46.6 years and overall mean stone size was 13.4 mm. Most participants (93.8%) had kidney stones measuring 20 mm or less, and 68.9% had lower pole stones. ESWL versus PCNL ESWL may have a lower three-month treatment success rate than PCNL (risk ratio [RR] 0.67, 95% confidence interval [CI] 0.57 to 0.79; I2 = 87%; 12 studies, 1303 participants; low-certainty evidence). This corresponds to 304 fewer participants per 1000 (397 fewer to 194 fewer) reporting treatment success with ESWL. ESWL may have little or no effect on QoL after treatment compared with PCNL (1 study, 78 participants; low-certainty evidence). ESWL probably leads to fewer complications than PCNL (RR 0.62, 95% CI 0.47 to 0.82; I2 = 18%; 13 studies, 1385 participants; moderate-certainty evidence). This corresponds to 82 fewer participants per 1000 (115 fewer to 39 fewer) having complications after ESWL. ESWL versus RIRS ESWL may have a lower three-month treatment success rate than RIRS (RR 0.85, 95% CI 0.78 to 0.93; I2 = 63%; 13 studies, 1349 participants; low-certainty evidence). This corresponds to 127 fewer participants per 1000 (186 fewer to 59 fewer) reporting treatment success with ESWL. We are very uncertain about QoL after treatment; the evidence is based on three studies (214 participants) that we were unable to pool. We are very uncertain about the difference in complication rates between ESWL and RIRS (RR 0.93, 95% CI 0.63 to 1.36; I2 = 32%; 13 studies, 1305 participants; very low-certainty evidence). This corresponds to nine fewer participants per 1000 (49 fewer to 48 more) having complications after ESWL. ESWL compared with PCNL may have lower three-month success rates, may have a similar effect on QoL, and probably leads to fewer complications. ESWL compared with RIRS may have lower three-month success rates, but the evidence on QoL outcomes and complication rates is very uncertain. These findings should provide valuable information to aid shared decision-making between clinicians and people with kidney stones who are undecided about these three options.

Abstract BACKGROUND AND AIMS The complexity of tacrolimus pharmacokinetics results in a unique tacrolimus recommendation in transplant centers and global level [1]. Intra-patient variability (IPV) of tacrolimus has become a simple and interesting marker to predict transplant outcomes in addition to minimum concentration (Cmin) monitoring [2–4]. As differences in ethnic affecting tacrolimus pharmacokinetics and patient response, we investigated a pilot study of tacrolimus IPV in our institution. METHOD The cohort study was conducted in all new kidney transplant patients receiving twice-daily tacrolimus as a standard immunosuppressive therapy. Patients were switched from twice-daily tacrolimus to other immunosuppressive agents were excluded from the study. All patients were followed-up at an outpatient clinic with routine monitoring. A one-year follow-up period was evaluated in the study. The primary outcome was the IPV of tacrolimus during the 3–12 months after transplantation. IPV of tacrolimus Cmin was calculated by [SD/(mean tacrolimus dose-normalized Cmin)] × 100.5 We categorized the IPV of tacrolimus into three levels: low (0%–10%), intermediate (11%–30%) and high IPV (>30%). The secondary outcomes were to assess renal function by eGFR and pre-defined factors associated with the IPV of tacrolimus. The study protocol was reviewed and approved by the Thai Clinical Trial Registry (TCTR20210519005). RESULTS There were 56 patients who underwent kidney transplantation during the study period. Of these 56 patients, 12 patients experienced late conversion from twice-daily to once-daily tacrolimus or were combined with sirolimus, and 4 patients became lost to follow-up. A total of 40 patients completed the one-year study period and were included in the analysis. The mean age of patients was 50.85 ± 11.07 years. A total of 39 patients received basiliximab, and one patient received anti-thymoglobulin as an induction therapy. Baseline characteristics are shown in Table 1. At 3–12 months after transplantation, the mean IPV of tacrolimus was 23.77% ± 11.23%. When categorized patients according to %IPV of tacrolimus, we found that most patients were in the intermediate IPV. The percentage of patients in each category was 7.5%, 65% and 27.5% of patients in low, intermediate and high IPV of tacrolimus, respectively (Fig. 1). The eGFR at discharge of patients with high IPV was significantly lower than that with low to intermediate IPV (P = .0282). For pre-defined factors associated with IPV of tacrolimus, the hemoglobin level at 3 months of patients with high IPV (11.23 ± 1.72 g/dL) was significantly lower than that of patients with low to intermediate IPV (12.54 ± 1.77, P = .0425). All patients were compliant as measured by pill counts and no difference in drug interaction between groups. Renal function remained stable and was similar between groups at one year of follow-up (52.03 ± 14.74 and 57.93 ± 16.40 mL/min/1.73 m2P = .3254 for high IPV and low to intermediate IPV, respectively). CONCLUSION Our findings showed that most patients were in low to intermediate IPV of tacrolimus. A low level of eGFR at discharge and a low level of hemoglobin in the early-post transplant period were associated with high IPV of tacrolimus. Therefore, clinicians should be cautious to monitor levels and adjust the dose of tacrolimus, especially if patients at risk of tacrolimus variability. A practical calculation of IPV provides a tremendous benefit for clinicians to individualized tacrolimus therapeutic drug monitoring. This study was a starting point and would expand for our large patient population. Clinical correlation with IPV of tacrolimus and IPV-directed interventions for Asian population are needed to improve tacrolimus using for achieving transplant outcomes.

The Short-Term Assessment of Risk and Treatability (START) is deemed the most appropriate instrument for assessing violence risks and management because of its balanced approach between dynamic risk and protective factors. Although several facets of reliability and predictive validity of this tool were strong, its inter-rater reliability, construct validity, and implementation in Asian population were under-investigated. The objective of this research was to examine the inter-rater reliability and construct validity of the START: Thai version within forensic psychiatric inpatients. The participants consisted of 118 forensic psychiatric inpatients hospitalized at Galya Rajanagarindra Institute in Thailand. Trained mental health professionals (i.e., psychiatrists, forensic nurses, clinical psychologists, social workers, and occupational therapists) assessed each participant across twenty domains of the Thai START. The inter-rater reliability was examined using the intraclass correlation coefficient and a confirmatory factor analysis for ordinal data was used to test the construct validity of the scale. The main finding showed a good-to-excellent inter-rater reliability and supported two relational constructs (i.e., strength vs vulnerability subscales) of the Thai START. The Thai START is a promising tool for using in Thai forensic psychiatric setting but some items were not significant in contributing to the scale. This study also provides the guideline for implementing the tool in non-Western forensic psychiatric populations.

PurposeThis study aimed to develop the Thai gaming disorder scale (T-GDS) in children and adolescents to serve medical staff and investigate the effectiveness of the scale.Design/methodology/approachThis is a research and development study. In total, 217 participants were children and adolescents between 8–18 years, then classified into four groups according to Children's Global Assessment Scale (CGAS). The T-GDS was developed; its content validity was then investigated by three experts. Mock assessment was conducted on 15 individuals replicating the actual sample group before the assessment was tested on the sample group by two medical staff. The quality of the scale is assessed through reliability, validity and cut-off point analysis.FindingsExploratory factor analysis (EFA) extracted four components with 18 items meeting the criteria and have Cronbach's alpha of 0.95. The analysis of ROC curve, to determine the cut-off point, associated the mild game addiction group with T-GDS score = 14; moderate group score = 28; and severe group score = 42.Research limitations/implicationsInvestigation of cut-off point by practitioners is vital to compare whether it aligns with the point determined by doctors in game addiction diagnosis. Future research should select critical item in order to reduce the number of questions and construct validity should be examined using confirmatory factor analysis.Originality/valueThis paper provides a comprehensive insight regarding severity of game addiction based on related criteria. As a result, treatment appropriate for each type of severity could be enhanced.

Abstract Background and Aims Cardiovascular calcification is highly prevalent among patients with end-stage renal disease (ESRD). Low normal serum magnesium has been linked to a more severe degree of vascular calcification and a decrease in patient survival. An inhibitory effect of extracellular magnesium on osteogenic transformation of vascular smooth muscle cells and the upregulation of anti-calcification protein have been confirmed in vitro. Increased dialysate magnesium concentration has also been shown to lower calcification propensity of the serum of maintenance hemodialysis (HD) patients. Method This study is an investigator initiated, single-blinded, parallel-group, matched case-control clinical trial that investigated the effect of high dialysate magnesium concentration for 24 weeks on the progression of coronary artery calcification (CAC) in maintenance HD patients. The changes in laboratory data and bone mineral density (BMD) were also examined. Seventy-six ESRD patients underwent CAC screening by multi-slice computed tomography and BMD measurement by dual-x-ray absorptiometry. Only patients with Agatston score>300 were included. They were matched according to the initial CAC score that fell within 20% of one another. Twenty patients were assigned to high dialysate magnesium concentration of 1.75 mEq/L and the matched controls were kept on standard dialysate magnesium concentration of 0.7 mEq/L. CAC and BMD measurements were repeated after 24 weeks. Laboratory data were obtained prior to dialysis at study entry, 8-week intervals during the study and 2 weeks after the study ended. Results There were no significant differences in age, sex, BMI, underlying diseases, dialysis vintage, medications, baseline CAC scores and BMD. The median baseline CAC Agatston score (Volume score) were 1923 (720) and 1672 (785) in the standard and high dialysate groups, respectively. At the end of the study, a significant increase in the CAC score was observed in both groups. Because majority of the included patients had severe calcification burden at baseline, patients were categorized into 2 subgroups using the median baseline CAC Agatston (1600) and Volume scores (700) as cut-offs. Among patients with CAC Agatston score <=1600, CAC score increased significantly in the standard dialysate magnesium group (P<0.01) but was stable in the high dialysate magnesium group (P=0.33). Among patients with CAC Agatston score >1600, the severity of CAC worsened in both groups. The progression of CAC was analyzed by the difference between the follow-up and the baseline square root transformed Agatston and Volume scores. In subgroup of patients with less severe calcification, more patients in the standard dialysate magnesium group progressed compared to the high dialysate magnesium group (P=0.03). In subgroup of patients with more severe calcification, the number of progressors were comparable among the 2 groups. Serum and ionized magnesium levels increased substantially during the study and returned to baseline after the return to standard dialysate magnesium concentration. The highest predialysis serum magnesium was 3.8 mg/dL. Most patients who received high dialysate magnesium reported the disappearance of symptoms of muscle cramps (P=0.01) and requested the high dialysate magnesium be continued after the end of the study. There were no significant changes in serum calcium, phosphate or PTH levels. The decline in BMD was observed in both groups but the difference did not reach statistical significance. Conclusion High dialysate magnesium was well tolerated and could ameliorate the progression of CAC in maintenance HD patients with mild to moderate vascular calcification.

BackgroundOn-line hemodiafiltration (HDF) clears more azotemic toxins compared to high-flux hemodialysis (HD). The response to vaccination is impaired in dialysis patients. We wished to determine whether the immune responses to influenza vaccine in dialysis patients treated by HDF were stronger than those treated by HD.Materials and methodsWe conducted a prospective cohort study in chronic dialysis patients during the 2016 and 2017 influenza seasons. All participants received a single standard dose of trivalent influenza vaccine, and we studied the elicited humoral immune response by hemagglutination inhibition test, and cell-mediated immune response by enumeration of lymphocyte cellular markers and proliferation assays.ResultsWe immunized 60 end-stage renal disease (ESRD) patients: 42 (70%) treated with HD and 18 patients (30%) with HDF. The median (interquartile range) age was 65.0 (55.0–74.5) years. All patients developed seroprotection to at least one influenza vaccine strain at one month post-vaccination, and did not differ between groups. By logistic regression, age was the only factor independently associated with seroconversion to all vaccine strains (odds ratio 0.89, 95% confidence interval 0.80–0.98; p = 0.022). Seroprotection to all vaccine strains was sustained for longer in patients treated with HDF, and the results remained the same after age adjustment. For cellular immune response, patients who seroconverted to all vaccine strains had higher CD38+ T cell subpopulations pre-vaccination. Patients treated by HDF had higher lymphocyte proliferation to circulating influenza A strains.ConclusionsSeroconversion to all influenza vaccine strains was associated with age. Patients treated with HDF demonstrated seroprotection was sustained for longer compared to those treated by HD and greater lymphocyte proliferation to circulating influenza A strains. These encouraging results for HDF require confirmation in a larger dialysis population.Trial registrationClinicalTrial.gov, NCT04122222.