Lower Creatinine Levels Research Articles

P.10.15 Clinical aspects on estimation of renal function in patients with primary neuromuscular disease

Estimated renal function based on serum creatinine can be falsely low and reduced renal function thus go undetected in patients with neuromuscular disorders. Cystatin C, another marker of renal function, could be a better marker of renal function in this patient population since it is not to the same extent afflicted by the patients muscle mass. To investigate the association between measured glomerular filtration rate (mGFR) assessed by iohexolclearence, and estimated glomerular filtration rate (eGFR) with two creatinine-based formulas MDRD (eGFRMDRD) and CKD-EPI (eGFRCKD-EPI) and one cystatin C-based formula (eGFRcysC) in patients with primary neuromuscular disease. Fifty patients (19 M, 31 W, age mean (sd) 46(14) years, BMI 26(6) kg/m 2 ) with DM1, LGMD, FSHD, Duchenne or Becker muscular dystrophy were included. GFR was measured by iohexolclearence and blood samples for analysis of serum creatinine and cystatin C were drawn simultaneously. GFR (mGFR) was mean (sd) 75(16), range 38–117 ml/min/1.73 m 2 (normal > 60) Serum creatinine ranged between 7 and 144 μ mol/l (normal 60–95). Serum cystatin C was 0.98(0.17) in men and 0.88(0.16) mg/l in women, respectively (normal 2 , respectively. Cystatin C-based eGFR was significantly correlated to mGFR ( r = 0.74, p 2 . This overestimation was independent of mGFR in the interval 50–100 ml/min/1.73 m 2 . However creatinine-based eGFR overestimated the kidney function even more. Both creatinine- and cystatin C-based eGFR overestimated renal function in patients with muscular dystrophy. Estimation of renal function using cystatin C-based formulas was somewhat more reliable than creatinine-based formulas, especially in patients with very low muscle mass and extremely low levels of creatinine.

Renal failure in myocardial infarction with cardiogenic shock - comparison of established and novel biomarkers - a biomarker substudy of the IABP-SHOCK II-trial

Background: Impairment of renal function is an important prognostic factor in acute coronary syndromes. In cardiogenic shock loss of renal function is one important sign of inadequate end-organ perfusion. The role of the novel biomarkers Neutrophil Gelatinase-Associated Lipocalin (NGAL), Kidney Injury Molecule 1 (KIM1) and Cystatin C for renal injury in comparison to established serum creatinine has never been investigated before. Methods: In the randomized Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II)-trial 600 patients with Cardiogenic Shock (CS) complicating acute myocardial infarction undergoing early revascularization were assigned to therapy with IABP or no IABP. In 190 patients blood samples were collected directly during primary primary coronary intervention, on day one, and day two after randomization. Blood was centrifuged immediately after sample drawing and serum frozen at -87° C. NGAL, KIM1 and Cystatin C were measured with standard ELISA-Kits, Creatinine was assessed with routine laboratory measurement. All-cause mortality at 30 days was used for outcome assessment. Results: Survivors had lower levels of creatinine (109 [IQR 90; 141] vs. 138 [IQR 102; 186] μmol/L; p<0.001) and NGAL (915 [IQR 568; 1415] vs. 1091 [IQR 769; 2229] ng/mL; p=0.01) than non-survivors at baseline, whereas there was no significant difference for KIM1 (134 [IQR 119; 164] vs. 123 [IQR 108; 178] pg/mL; p=0.82) and Cystatin C (3084 [IQR 2510; 3596] vs. 3366 [IQR 2626; 3778] ng/mL; p=0.16). In repeated measures analysis of variance over all three measurements creatinine (p=0.04) and NGAL (p=0.04) showed significant differences in contrast to KIM1 (p=0.21) and Cystatin C (p=0.42). Receiver operator characteristics (ROC) showed highest values for the area under the curve (AUC) in prediction of 30 day mortality for creatinine at all three time points (AUC baseline 0.65; day one 0.75; day two 0.78), NGAL showed the second best performance (AUC baseline 0.62; day one 0.60; day two 0.66). In c-statistics creatinine showed significant higher AUC over NGAL on day one and day two (p=0.003; p=0.03; respectively) and significant higher AUC at all time points in comparison to KIM1 and Cystatin C. Conclusion: Renal failure has significant impact on outcome in cardiogenic shock. Of novel markers of renal injury NGAL showed the best performance in prediction of 30 day mortality, but was inferior to established serum creatinine measurements.

Impact of donor–recipient gender on kidney graft and patient survival: short- and long-term outcomes

Donor and recipient gender influence on post-transplant kidney and patient survival is still controversial, and the literature data do not present unanimous conclusions. The aim of this study was to evaluate the effect of gender disparities between donor and recipient in 963 kidney transplants performed at our center from January 2000 to December 2010. The patients were subdivided into four groups according to recipient and donor gender: male donor-to-male recipient (MDMR; n = 305), male donor-to-female recipient (MDFR; n = 203), female donor-to-female recipient (FDFR; n = 206), and female donor-to-male recipient (FDMR; n = 249). Independent sample's t test and one-way ANOVA were used for statistical analyses. Graft and patient survival were calculated by the Kaplan-Meier method and compared using the log rank test. There were no statistically significant differences between the groups with regard to age, cold ischemia time, delayed graft function, primary non-function, and episodes of acute and chronic rejection. Moreover, no difference in either graft (p = 0.92) or patient (p = 0.41) survival at 1, 3, and 5 years was observed. However, female recipients had significantly lower serum creatinine values and higher estimated GFR, particularly if they received a male donor kidney, and these findings were stable up to 3-year post-transplantation. No impact of gender on short- or long-term graft and patient survival was observed in deceased kidney transplantation. However, we report a lower creatinine level in the male donors to female recipients group as compared with other recipient-donor gender combinations, although this difference loses statistical significance after the third-year post-transplantation.

Impact of creatinine values on MELD scores in male and female candidates for liver transplantation

Introduction. A systematic bias against women, resulting from the use of creatinine as a measure of renal function, has been identified in Model for End-stage Liver Disease (MELD)-based liver allocation. Correction of this bias by calculation of female creatinine levels using the Modification of Diet in Renal Disease (MDRD) formula has been suggested.Material and methods. A cohort of 639 cirrhotic candidates for first-time liver transplantation was studied. Creatinine levels were corrected for gender using the MDRD formula. The accuracy of MELD, with or without creatinine correction, to predict 3- and 6-month mortality after inclusion in a transplant waiting list was estimated.Results. Women exhibited significantly lower creatinine levels, glomerular filtration rate, and MELD scores than men. After creatinine correction, female MELD scores had a mean increase of 1.1 points. Creatinine correction yielded an increase of 3 points in the MELD score in 15.2% of patients, 2 points in 22.4%, and 1 point in 17.6% of patients. The likelihood of death at 3 and 6 months after enrollment in the transplant waiting list was similar in males and females and the likelihood of receiving a transplant, as assessed by Kaplan-Meier survival curves, was also similar in males and females.Conclusion. The survival or the likelihood of receiving a transplant while on the waiting list were similar in men and women in both pre- and post-MELD eras and creatinine correction did not increase the accuracy of the MELD score in estimating 3- and 6-month mortality in female candidates for liver transplantation.

Celastrol, an NF-κB inhibitor, improves insulin resistance and attenuates renal injury in db/db mice.

The NF-κB pathway plays an important role in chronic inflammatory and autoimmune diseases. Recently, NF-κB has also been suggested as an important mechanism linking obesity, inflammation, and metabolic disorders. However, there is no current evidence regarding the mechanism of action of NF-κB inhibition in insulin resistance and diabetic nephropathy in type 2 diabetic animal models. We investigated the effects of the NF-κB inhibitor celastrol in db/db mice. The treatment with celastrol for 2 months significantly lowered fasting plasma glucose (FPG), HbA1C and homeostasis model assessment index (HOMA-IR) levels. Celastrol also exhibited significant decreases in body weight, kidney/body weight and adiposity. Celastrol reduced insulin resistance and lipid abnormalities and led to higher plasma adiponectin levels. Celastrol treatment also significantly mitigated lipid accumulation and oxidative stress in organs including the kidney, liver and adipose tissue. The treated group also exhibited significantly lower creatinine levels and urinary albumin excretion was markedly reduced. Celastrol treatment significantly lowered mesangial expansion and suppressed type IV collagen, PAI-1 and TGFβ1 expressions in renal tissues. Celastrol also improved abnormal lipid metabolism, oxidative stress and proinflammatory cytokine activity in the kidney. In cultured podocytes, celastrol treatment abolished saturated fatty acid-induced proinflammatory cytokine synthesis. Taken together, celastrol treatment not only improved insulin resistance, glycemic control and oxidative stress, but also improved renal functional and structural changes through both metabolic and anti-inflammatory effects in the kidney. These results suggest that targeted therapy for NF-κB may be a useful new therapeutic approach for the management of type II diabetes and diabetic nephropathy.

Adolescent CF Lung Transplant Recipients Have Decreased Survival When Compared to CF Lung Transplant Recipients in Other Age Groups

Purpose Lung transplant (LTRX) is a treatment for end-stage cystic fibrosis (CF) lung disease. CF is the leading indication for LTRX in children (6-11) and adolescents (12-17) accounting for 56% and 72% of all transplants, respectively. The half-life of adult recipients was 5.4 years compared with 5.5 years in pediatric recipients. We hypothesize that there is a difference in survival of patients with CF based on age of recipient. Methods and Materials This study was a retrospective analysis of the UNOS Database for all LTRX recipients with CF performed in the United States from October 1999 to June 2011. Patients were grouped on the basis of age into 4 groups [children (age 6-12), adolescents (age 13-18), young adults (age 19-30), and older adults (age 31-50)]. The primary outcome of interest was patient survival. Results There were 3,302 LTRX performed in CF patients ages of 6-50 years; 143 (4%) in children, 461 (14%) in adolescents, 1,568 (48%) in young adults, and 1130 (34%) in older adults with follow-up data available for 99%. Adolescents were more likely to be female, have lower creatinine level, have shorter wait list time and donor ischemic time compared to adults (p Conclusions Adolescents comprise a minority of CF patients that undergo LTRX in the United States and have the lowest overall survival. Older adults have graft survival and patient survival that is over twice as long as adolescents. The decreased survival observed in adolescents is independent of some donor and recipient characteristics. Further study is needed to improve outcomes in this high risk group of patients.

Clostridium difficileInfection and Limitations of Markers for Severity in Patients with Hematologic Malignancy

To describe characteristics of Clostridium difficile infection (CDI) and markers of severe CDI among patients with hematologic malignancies. Case-control study. Tertiary care teaching hospital. Inpatients with hematologic malignancies and CDI were age and time matched with 2 control inpatients without hematologic malignancies. Chart reviews were performed, and C. difficile isolates were strain typed. Case patients (n = 41) and control patients (n = 82) patients were different in respect to receipt of immunosuppressive agents within 2 months (92.7% vs 25.6%; P < .0001); neutropenia within 2 months (75.6% vs 3.7%; P < .0001) and mean (± standard deviation) white blood cell (WBC) count at diagnosis (vs 4.9 ± 14.1 vs 11.8 ± 6.8 x 10(3) cells/mL; P <.0001); baseline mean creatinine level (0.89 ± 0.1 vs 1.6 ± 2.4 mg/dL; P = .003), mean creatinine level at diagnosis (0.83 ± 0.4 vs 1.85 ± 1.9 mg/dL; P = .004), and creatinine increases of 1.5 times over baseline (2.4% vs 15.1%; P = .02). Immunosuppressive agents and creatinine level remained significant in multivariable analysis (P = .03 for both variables). Severity correlated with mortality when measured by alternate severity criteria but not when measured by the Society for Healthcare Epidemiology of America/Infectious Diseases Society of America criteria, which are based solely on WBC count and creatinine elevation. The prevalence of the epidemic BI/NAP1/027 strain was similar in both groups. Patients with hematologic malignancies had lower creatinine levels at the time of CDI diagnosis compared with control patients. WBC counts also tended to be lower in case patients. CDI severity criteria based on WBC count and creatinine level may not be applicable to patients with hematologic malignancies.

Serum Creatinine and Weaning in Patients with Chronic Obstructive Pulmonary Disease: Multicenter Pilot Study

Background: Serum creatinine can provide indirect information on body muscle mass. The role of respiratory muscle is very important during the weaning process in patients with chronic obstructive pulmonary disease (COPD). We aimed to assess whether low creatinine levels are a predictor of unsuccessful weaning or prolonged ventilation in COPD patients receiving mechanical ventilation (MV) in the intensive care unit (ICU). Methods: A multicenter, retrospective cohort study was conducted in three ICUs between July 1 st , 2007 and June 30th, 2008. All consecutive COPD patients receiving MV were enrolled. Patients with acute or chronic renal failure were excluded. Patient demographics, ICU severity score (APACHE II), body mass index (BMI), and serum creatinine and blood urea nitrogen (BUN) levels, were recorded on the first day in ICU, and the first and seventh day of weaning. Successful weaning was defined as successful extubation after the first T-piece trial. Unsuccessful weaning was failed extubation after more than one T-piece trial. Prolonged ventilation was MV duration more than seven days. The chi- square, Fischer's exact test, or t-test (where appropriate) were used to compare the simple weaning group, (SWG, successful weaning) and the prolonged weaning group (PWG, unsuccessful weaning or prolonged ventilation). Results: Eighty-five patients were enrolled (SWG, 36 PWG, 49). No significant difference was found between the groups with respect to age, gender, APACHE II score, and BMI. Patients with low creatinine (less than 0.5 mg/dL) on the first day of ICU, and first day of the weaning trial in SWG and PWG were 4/36, 12/49, and 4/36, 19/49, respectively (p>0.16 and p<0.006). Mortality was detected in only PWG (n=7, 8.2%). Conclusion: Low creatinine levels at the start of weaning trial appear to be a predictor of unsuccessful weaning or prolonged ventilation in COPD patients in the ICU.

Antidiabetic and Hypolipidemic Activities of Curculigo latifolia Fruit:Root Extract in High Fat Fed Diet and Low Dose STZ Induced Diabetic Rats.

Curculigo latifolia fruit is used as alternative sweetener while root is used as alternative treatment for diuretic and urinary problems. The antidiabetic and hypolipidemic activities of C. latifolia fruit:root aqueous extract in high fat diet (HFD) and 40 mg streptozotocin (STZ) induced diabetic rats through expression of genes involved in glucose and lipid metabolisms were investigated. Diabetic rats were treated with C. latifolia fruit:root extract for 4 weeks. Plasma glucose, insulin, adiponectin, lipid profiles, alanine aminotransferase (ALT), gamma glutamyltransferase (GGT), urea, and creatinine levels were measured before and after treatments. Regulations of selected genes involved in glucose and lipid metabolisms were determined. Results showed the significant (P < 0.05) increase in body weight, high density lipoprotein (HDL), insulin, and adiponectin levels and decreased glucose, total cholesterol (TC), triglycerides (TG), low density lipoprotein (LDL), urea, creatinine, ALT, and GGT levels in diabetic rats after 4 weeks treatment. Furthermore, C. latifolia fruit:root extract significantly increased the expression of IRS-1, IGF-1, GLUT4, PPARα, PPARγ, AdipoR1, AdipoR2, leptin, LPL, and lipase genes in adipose and muscle tissues in diabetic rats. These results suggest that C. latifolia fruit:root extract exerts antidiabetic and hypolipidemic effects through altering regulation genes in glucose and lipid metabolisms in diabetic rats.

Encefalopatía perdedora de sal en romboencefalitis por listeria

Hyponatremia is common in patients with severe neurological diseases and is often secondary to a syndrome of inappropriate antidiuretic hormone secretion (SIADH). However, in some patients, hyponatremia is due to cerebral salt wasting syndrome (CSWS). SIADH and CSWS treatments are opposite and misdiagnosis can lead to increased morbidity and mortality. We report a 52 years old female with a rhom-boencephalitis caused by Listeria Monocytogenes (LM), ventriculitis and abscesses in cerebellum and brainstem. It was associated with hyponatremia, hypotension, increased natriuresis, hypouricemia, and low creatinine and blood urea nitrogen levels. Large amounts of sodium were needed and the condition persisted after hospital discharge. Hyponatremia is common in central nervous system involvement by LM, however we are not aware of CSWS reports of this condition.

Coronary Disease Risk Curve of Serum Creatinine Is Linear in Turkish Men, U-Shaped in Women

ObjectivesThe highest levels of glomerular filtration rate are associated with increased coronary heart disease (CHD) risk, an issue we investigated in separate sexes in a population prone to metabolic syndrome.Research...

Prevalence and Risk Factors for Age-Related Macular Degeneration in Indians: A Comparative Study in Singapore and India

To compare the prevalence and risk factors for age-related macular degeneration (AMD) in 2 Indian populations, 1 living in urban Singapore and 1 in rural central India. Population-based, cross-sectional studies of Indians aged 40+ years. Our analysis included 3337 Singapore-residing participants and 3422 India-residing participants. All participants underwent comprehensive systemic and ocular examinations and retinal photography. AMD was graded from retinal photographs according to the Wisconsin Age-Related Maculopathy Grading System. Systemic and ocular risk factors were assessed for association with AMD. Singapore-residing participants were older (mean age 57.8 years vs 53.8 years) and, after adjusting for age and sex, were more likely to have previous cataract surgery, higher body mass index, hypertension, diabetes, previous myocardial infarction, higher cholesterol, and lower creatinine levels, but less likely to be current smokers, than India-residing participants. The age-standardized prevalence of early and late AMD was 4.45% and 0.34%, respectively, in Singapore and 5.80% and 0.16%, respectively, in India. Shorter axial length was associated with early AMD in both Singapore and India, whereas previous cataract surgery, higher body mass index, hypertension, and lower cholesterol were associated with early AMD in Singapore but not in India. The prevalence of AMD was similar among Indian adults living in urban Singapore and rural India, despite differences in cardiovascular risk factor profile and demographics.

Identifying Differential Responders and Their Characteristics in Clinical Trials: Innovative Methods for Analyzing Longitudinal Data

ObjectivesTo present a step-by-step example of the examination of heterogeneity within clinical trial data by using a growth mixture modeling (GMM) approach. MethodsSecondary data from a longitudinal double-blind clinical drug study were used. Patients received enalapril or placebo and were followed for 2 years during the drug component, followed by a 3-year postdrug component. Primary variables of interest were creatinine levels during the drug component and number of hospitalizations in the postdrug component. Latent growth modeling (LGM) methods were used to examine the treatment response variability in the data. GMM methods were applied where substantial variability was found to identify latent (unobserved) subsets of differential responders, using treatment groups as known classes. Post hoc analyses were applied to characterize emergent subgroups. ResultsLGM methods demonstrated a large variability in creatinine levels. GMM methods identified two subsets of patients for each treatment group. Placebo class 2 (7.0% of the total sample) and enalapril class 2 (8.5%) include individuals whose creatinine levels start at 1.114 mg/dl and 1.108 mg/dl, respectively, and show worsening (slopes: 0.023 and 0.017, respectively). Placebo class 1 (43.1%) and enalapril class 1 (41.4%) individuals start with lower creatinine levels (1.082 and 1.083 mg/dl, respectively) and show very minimal change (0.008 and 0.003, respectively). Post hoc analyses revealed significant differences between placebo/enalapril class 1 and placebo/enalapril class 2 in terms of New York Heart Association functional ability, depression, functional impairment, creatinine levels, mortality, and hospitalizations. ConclusionsGMM methods can identify subsets of differential responders in clinical trial data. This can result in a more accurate understanding of treatment effects.

Pathogenesis and Assessment of Renal Function in Patients With Liver Cirrhosis

In liver cirrhosis patients awaiting liver transplantation, it is prognostically equally important to assess the renal function before and after transplantation. This is evidenced by the inclusion of serum creatinine in the Model for End-Stage Liver Disease (MELD) score. Most of the causes of renal failure in liver cirrhosis are functional, the acute kidney damage including prerenal azotemia, acute tubular necrosis and hepatorenal syndrome. A major index of the renal function, the glomerular filtration rate (GFR) is determined in a specific way in patients with liver cirrhosis. Clinically, serum creatinine is considered the best indicator of kidney function, although it is rather unreliable when it comes to early assessment of renal dysfunction. Most of the patients with liver cirrhosis have several concomitant conditions, which are the reason for the false low creatinine levels, even in the presence of moderate to severe kidney damage. This also holds for the creatinine clearance and creatinine-based estimation equations for assessment of the glomerular filtration rate (the Cockroft-Gault and MDRD formulas), which overestimate the real glomerular filtration. Clearance of exogenous markers is considered a gold standard, but the methods for their determination are rather costly and hard to apply. Alternative serum markers (e.g., cystatin C) have been used, but they should be better studied in cases of liver cirrhosis assessment.

Low plasma DHEA-S increases mortality risk among male hemodialysis patients

ObjectiveThe incidence of chronic kidney disease (CKD) is on the rise. CKD patients are at high risk of cardiovascular (CVD) and all-cause mortality. CKD patients have several endocrine disorders, including low levels of dehydroepiandrosterone sulfate (DHEA-S). In the general population, low levels of DHEA-S are associated with high CVD and all-cause mortality. The aim of this study was to analyze the prognostic value of plasma DHEA-S on the survival of CKD patients on hemodialysis. MethodThis was a single-center prospective cohort study on two hundred CKD patients on hemodialysis, which assessed the prognostic value of plasma DHEA-S on their survival. ResultWe found that plasma DHEA-S levels were negatively associated with age, and positively associated with dialysis duration and plasma creatinine, albumin, and phosphate levels in hemodialysis men. Elderly patients with co-morbidities (i.e. diabetes mellitus, congestive heart failure, and chronic obstructive pulmonary disease), poorer fluid control which was evaluated by higher cardiothoracic ratio, and low plasma creatinine and albumin levels seemed to have poor prognosis in hemodialysis men. Furthermore, low plasma DHEA-S levels were significantly associated with CVD-related [hazard ratio (HR)=3.877; P=0.021], non-CVD-related (HR=3.522; P=0.016), and all-cause mortality (HR=3.667; P=0.001) in hemodialysis men. But low plasma DHEA-S levels were not significantly associated with CVD-related, non-CVD-related, and all-cause mortality in hemodialysis women. Multivariate Cox regression analysis suggested that low plasma DHEA-S levels are significantly and independently associated with all-cause mortality in hemodialysis men (HR=2.933; P=0.033). ConclusionThe study suggested that low plasma DHEA-S was independently and significantly associated with all-cause mortality in CKD hemodialysis men.

Analytical evaluation of two enzymatic methods for the measurement of total bile acid in intrahepatic cholestasis of pregnancy

The aim of this study was to estimate bilirubin interference and accuracy of six routine methods for measuring creatinine compared with isotope dilution–liquid chromatography mass spectrometry (ID–LC/MS).A total of 40 clinical serum samples from 31 patients with serum total bilirubin concentration > 68.4 μmol/L were collected. Serum creatinine was measured using two enzymatic reagents and four Jaffe reagents as well as ID–LC/MS. Correlations between bilirubin concentration and percent difference in creatinine compared with ID–LC/MS were analyzed to investigate bilirubin interference. Bias estimations between the six reagents and ID–LC/MS were performed. Recovery tests using National Institute of Standards and Technology (NIST) Standard Reference Material (SRM) 967a were also performed.Both the enzymatic methods showed no bilirubin interference. However, three of the four Jaffe methods demonstrated significant bilirubin concentration-dependent interference in samples with creatinine levels < 53 μmol/L, and two of them showed significant bilirubin interference in samples with creatinine levels ranging from 53.0 to 97.2 μmol/L. Comparison of these methods with ID–LC/MS using patients' samples with elevated bilirubin revealed that the tested methods failed to achieve the bias goal at especially low levels of creatinine. In addition, recovery test using NIST SRM 967a showed that bias in one Jaffe method and two enzymatic methods did not achieve the bias goal at either low or high level of creatinine, indicating they had calibration bias. One enzymatic method failed to achieve all the bias goals in both comparison experiment and recovery test.It is important to understand that both bilirubin interference and calibration traceability to ID–LC/MS should be considered to improve the accuracy of creatinine measurement.

Associative factors of existing fragility fractures among elderly medical inpatients: A hospital-based study

BackgroundFragility fractures are important in public health because of the increase of morbidity, mortality and cost worldwide. Most fragility fractures occur in patients who have no osteoporosis, but the association with frailty syndrome and cerebrovascular disease is stronger. The main purpose of this study was to evaluate comorbid conditions associated with elderly medical inpatients admitted to the Geriatric Evaluation and Management Unit with existing fragility fractures. MethodsThis was a retrospective study screening all medical records of patients admitted to the Geriatric Evaluation and Management Unit of a tertiary medical center from March, 2010 to April, 2011. Patients who had bone mineral density examinations of the hips in the past 5 years were enrolled. Pathological fractures or fractures caused by major trauma were excluded. Demographic characteristics, such as age, sex, height, weight, body mass index, bone mineral density, underlying comorbidity, blood biochemistry, and fracture sites were carefully recorded. ResultsOverall, 169 patients (mean age: 84 years, range: 66–96 years; 62.1% male) were enrolled, and fragility fractures were identified in 130 patients, including 115 vertebral fractures, 12 hip fractures and three pelvic fractures. Patients with existing fragility fractures were significantly lower in T score (−2.33 ± 1.10 vs. −1.87 ± 1.23, p = 0.030), serum albumin (3.6 ± 0.4 mg/dL vs. 3.9 ± 0.4 mg/dL, p = 0.003), total protein (6.4 ± 0.9 mg/dL vs. 6.9 ± 0.7 mg/dL, p = 0.007), blood urea nitrogen (20.4 ± 11.6 mg/dL vs. 26.3 ± 13.9 mg/dL, p = 0.014), and creatinine (1.0 ± 0.6 mg/dL vs. 1.4 ± 0.7 mg/dL, p < 0.001), but not in bone mineral density (0.59 ± 0.25 g/cm3 vs. 0.66 ± 0.16 g/cm3, p = 0.120) and diagnosis of osteoporosis (41.5% vs. 25.6%, p = 0.073). A multivariate logistic regression model showed that serum levels of albumin<3.5 mg/dL (odds ratio: 4.6, 95% confidence interval: 1.1–18.2, p = 0.032) and creatinine <0.8 mg/dL (odds ratio: 10.8, 95% confidence interval: 1.2–97.3, p = 0.033) were significantly associated with existing fragility fractures. ConclusionFor medical patients, fragility fractures were significantly associated with low serum levels of albumin and creatinine, which may be suggestive of malnutrition and low muscle mass. A further prospective study is needed to clarify the sequential effect of fragility fracture, malnutrition and sarcopenia.

Amelioration of renal damage by administration of anti-thymocyte globulin to potential donors in a brain death rat model

Brain death (BD), a non-immunological factor of renal injury, triggers an inflammatory process causing pathological signs of cell death in the kidney, such as necrosis and apoptosis. Kidneys from brain dead donors show lower success rates than kidneys from living donors and one strategy to improve transplantation outcome is to precondition the donors. For the first time, anti-rat thymoglobulin (rATG) was administered in an experimental brain death animal model to evaluate if it could ameliorate histopathological damage and improve organ function. Animals were divided into three groups: V (n=5) ventilated for 2h; BD (n=5) brain death and ventilated for 2h; and BD+rATG (n=5) brain death, ventilated for 2h, rATG was administered during brain death (10mg/kg). We observed lower creatinine levels in treatment groups (means): V, 0·88±0·22 mg/dl; BD, 1·37±0·07 mg/dl; and BD+rATG, 0·64±0·02 mg/dl (BD versus BD+rATG, P<0·001). In the BD group there appeared to be a marked increase of ATN, whereas ATN was decreased significantly in the rATG group (V, 2·25±0·5 versus BD, 4·75±0·5, P<0·01; BD+rATG, 2·75±0·5 versus BD 4·75±0·5 P<0·01). Gene expression was evaluated with reverse transcription-polymerase chain reaction; tumour necrosis factor (TNF)-α, interleukin (IL)-6, C3, CD86 showed no significant difference between groups. Increased IL-10 and decreased CCL2 in BD+rATG compared to BD (both cases P<0·01). Myeloperoxidase was increased significantly after the brain death setting (V: 32±7·5 versus BD: 129±18). Findings suggest that rATG administered to potential donors may ameliorate renal damage caused by BD. These findings could contribute in the search for specific cytoprotective interventions to improve the quality and viability of transplanted organs.

Restless legs syndrome, sleep impairment, and fatigue in chronic obstructive pulmonary disease

To investigate the frequency of factors associated with restless legs syndrome (RLS) in patients with chronic obstructive pulmonary disease (COPD). RLS diagnosis was investigated (International RLS Study Group, IRLSSG) and severity was assessed (IRLS rating scale) in 104 consecutive COPD patients (age 69.1±8). Other measures were dyspnea severity (Modified Medical Research Council, MMRC), sleep quality (Pittsburgh Sleep Quality Index, PSQI), daytime somnolence (Epworth Sleepiness Scale, ESS), depressive symptoms (Beck Depression Inventory, BDI-II), and fatigue (Fatigue Severity Scale, FSS). Laboratory values included hemoglobin, ferritin, creatinine, and fibrinogen. Thirty-two patients (30.8%) were diagnosed with RLS (65.6% women), which was moderate/severe (IRLS >11) in 26 (81.3%). RLS symptoms started after age 40 in most patients (93.3%). RLS patients had poorer sleep quality (PSQI >5=59.6%; p=0.002), worse fatigue (FSS >27=51%; p=0.005), and more depressive symptoms (BDI-II >10=14.4%; p=0.005). Patients with RLS also presented more severe dyspnea (p=0.009) and lower creatinine levels (p=0.005). Overall, fatigue severity was correlated with older age (p=0.001); level of dyspnea was positively correlated with PSQI and FSS (p<0.005) and negatively correlated with ferritin (p=0.03) and creatinine (p=0.005), and PSQI scores correlated positively with FSS (p<0.005) and negatively with ferritin (p=0.005) and creatinine (p=0.02). Quality of sleep was independently predicted by dyspnea severity and creatinine and fatigue by age and depression. RLS is common in COPD. Patients with RLS have low creatinine, poorer quality of sleep, and more fatigue and depressive symptoms. RLS symptom severity is correlated to lower ferritin and severity of dyspnea.

Transcatheter arterial chemoembolization confers survival benefit in patients with a spontaneously ruptured hepatocellular carcinoma

Spontaneous rupture causing a hemoperitoneum is a life-threatening complication of hepatocellular carcinoma (HCC). The aim of this study was to document clinical features and prognostic factors in patients with a ruptured HCC. The medical records of 1412 patients with HCC admitted to a single tertiary medical center from January 2000 to August 2010 were reviewed. The clinical features, treatment modalities, and outcomes were collected. Univariate and multivariate analyses were carried out to analyze the factors affecting survival. Thirty-five of 1412 patients diagnosed with a ruptured HCC were included. The median survival time was 59 days. Transcatheter arterial chemoembolization (TACE) was performed in 24 patients and 11 patients were managed conservatively. The 24 patients who received TACE achieved hemostasis without complications. The 30-day survival was related to better Child-Pugh class, higher hemoglobin level, lower creatinine level, and TACE in patients with a ruptured HCC. Multivariate analysis showed that patients who received TACE [odds ratio (OR), 0.076; P=0.020] or those with higher hemoglobin level (OR, 0.626; P=0.011) had a better chance of survival. The 30-day survival rate in a patient who received TACE was 83.3%. In the TACE group, the 30-day survival was independently associated with a higher hemoglobin level (OR, 0.609; P=0.036). TACE is a minimally invasive treatment that has a high success rate for hemostasis. TACE increased the 30-day survival in patients with a ruptured HCC. However, survival rates in patients with lower hemoglobin levels, resulting in a large amount of bleeding, remained poor regardless of successful TACE.