Deep neck space infections in end-stage renal disease patients: Prevalence and mortality

Deep neck space infections (DNSI) are severe infections within the layers of neck fascia that are known to be associated with underlying immunocompromised states. Although uremia associated with kidney disease is known to cause immune system dysfunction, DNSI in patients with kidney disease has been poorly studied. This study investigated the prevalence of DNSI and the associated risk of mortality within the United States end-stage renal disease (ESRD) population, using a retrospective cohort study design and the United States Renal Data System database of patients (ages 18-100) who initiated dialysis therapy between 2005 and 2019. International Classification of Disease-9 and -10 codes were used to identify the diagnosis of DNSI and comorbid conditions. Of the 705,891 included patients, 2.2% had a diagnosis of DNSI. Variables associated with increased risk of DNSI were female sex, black compared to white race, catheter, or graft compared to arteriovenous fistula (AVF) access, autoimmune disease, chronic tonsillitis, diagnoses in the Charlson Comorbidity Index (CCI), tobacco use, and alcohol dependence. DNSI diagnosis was an independent risk factor for mortality, which was also associated with other comorbidity factors such as older age, catheter or graft compared to AVF access, comorbidities in the CCI, tobacco use, and alcohol dependence. Because of the increased mortality risk of DSNI in the ESRD population, health professionals should encourage good oral hygiene practices and smoking cessation, and they should closely monitor these patients to reduce poor outcomes.

Immunological features of ESRD patients undergoing hemodialysis of various ages

AIMS

To investigate the immunological characteristics of hemodialysis (HD) patients with end-stage renal disease (ESRD) of various ages, and the impact of age-related immune alterations on these patients, with a focus on peripheral T cells.

METHODS

From September 2016 to September 2019, HD patients were enrolled and followed prospectively for 3 years. Patients were divided into three groups based on their ages: < 45, 45 to 64, and ≥ 65. The distribution of T cell subsets in different age groups was investigated and compared. The effects of altered T cell subsets on overall survival were also investigated.

RESULTS

A total of 371 HD patients were enrolled. The reduced number of naive CD8+ T cells (P < 0.001) and increased number of EMRA CD8+ T cells (P = 0.024) were independently associated with the advanced age among all T cell subsets studied. Patient survival may be affected by numerical changes in naive CD8+ T cells. However, when HD patients were < 45 or ≥ 65 years, the reduction had no significant impact on survival. Only in HD patients aged 45 to 64 years, the number of naïve CD8+ T cells found to be insufficient but not deficient, identified as an independent predictor of poor survival.

CONCLUSIONS

The most significant age-related immune change in HD patients was a decrease in peripheral naive CD8+ T cells, which was an independent predictor of 3-year overall survival in HD patients aged 45 ~ 64 years.

Clinical significance of serum glucose to lymphocyte ratio as a prognostic marker in peritoneal dialysis patients

BACKGROUND

The glucose-to-lymphocyte ratio (GLR), a glucose metabolism and systemic inflammatory response parameter, is associated with an adverse prognosis for various diseases. However, the association between serum GLR and prognosis in patients undergoing peritoneal dialysis (PD) is poorly understood.

METHODS

In this multi-center cohort study, 3236 PD patients were consecutively enrolled between 1 January 2009 and 31 December 2018. Patients were divided into four groups according to the quartiles of baseline GLR levels (Q1: GLR ≤ 2.91, Q2:2.91 < GLR ≤ 3.91, Q3:3.91 < GLR < 5.59 and Q4: GLR ≥ 5.59). The primary endpoint was all-cause and cardiovascular disease (CVD) related mortality. The correlation between GLR and mortality was examined using Kaplan-Meier and multivariable Cox proportional analyses.

RESULTS

During the follow-up period of 45.93 ± 29.01 months, 25.53% (826/3236) patients died, of whom 31% (254/826) were in Q4 (GLR ≥ 5.59). Multivariable analysis revealed that GLR was significantly associated with all-cause mortality (adjusted HR 1.02; CI 1.00 ∼ 1.04, p = .019) and CVD mortality (adjusted HR 1.02; CI 1.00 ∼ 1.04, p = .04). Compared with the Q1 (GLR ≤ 2.91), placement in Q4 was associated with an increased risk of all-cause mortality (adjusted HR: 1.26, 95% CI: 1.02 ∼ 1.56, p = .03) and CVD mortality (adjusted HR 1.76; CI 1.31 ∼ 2.38, p < .001). A nonlinear relationship was found between GLR and all-cause or CVD mortality in patients undergoing PD (p = .032).

CONCLUSION

A higher serum GLR level is an independent prognostic factor for all-cause and CVD mortality in patients undergoing PD, suggesting that more attention should be paid to GLR.

Early aging and premature vascular aging in chronic kidney disease

Aging is the progressive decline of body functions and a number of chronic conditions can lead to premature aging characterized by frailty, a diseased vasculature, osteoporosis, and muscle wasting. One of the major conditions associated with premature and accelerated aging is chronic kidney disease (CKD), which can also result in early vascular aging and the stiffening of the arteries. Premature vascular aging in CKD patients has been considered as a marker of prognosis of mortality and cardiovascular morbidity and therefore requires further attention. Oxidative stress, inflammation, advanced glycation end products, fructose, and an aberrant gut microbiota can contribute to the development of early aging in CKD patients. There are several key molecular pathways and molecules which play a role in aging and vascular aging including nuclear factor erythroid 2-related factor 2 (Nrf-2), AMP-activated protein kinase (AMPK), sirtuin 1 (SIRT1), and klotho. Potential therapeutic strategies can target these pathways. Future studies are needed to better understand the importance of premature aging and early vascular aging and to develop therapeutic alternatives for these conditions.

Mortality rate and predictors of COVID-19 inpatients in Ethiopia: a systematic review and meta-analysis

Introduction

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an extremely rare virus that devastates the economy and claims human lives. Despite countries' urgent and tenacious public health responses to the COVID-19 pandemic, the disease is killing a large number of people. The results of prior studies have not been used by policymakers and programmers due to the presence of conflicting results. As a result, this study was conducted to fill the knowledge gap and develop a research agenda.

Objective

This study aimed to assess the mortality rate and predictors of COVID-19 hospitalized patients in Ethiopia.

Methods

Electronic databases were searched to find articles that were conducted using a retrospective cohort study design and published in English up to 2022. The data were extracted using a Microsoft Excel spreadsheet and exported to StataTM version 17.0 for further analysis. The presence of heterogeneity was assessed and presented using a forest plot. The subgroup analysis, meta-regression, and publication bias were computed to identify the source of heterogeneity. The pool COVID-19 mortality rate and its predictors were calculated and identified using the random effects meta-analysis model, respectively. The significant predictors identified were reported using a relative risk ratio and 95% confidence interval (CI).

Results

Seven studies with 31,498 participants were included. The pooled mortality rate of COVID-19 was 9.13 (95% CI: 5.38, 12.88) per 1,000 person-days of mortality-free observation. Those study participants who had chronic kidney disease had 2.29 (95% CI: 1.14, 4.60) times higher chance of experiencing mortality than their corresponding counterparts, diabetics had 2.14 (95% CI: 1.22, 3.76), HIV patients had 2.98 (95% CI: 1.26, 7.03), hypertensive patients had 1.63 (95% CI: 1.43, 1.85), and smoker had 2.35 (95% CI: 1.48, 3.73).

Conclusion

COVID-19 mortality rate was high to tackle the epidemic of the disease in Ethiopia. COVID-19 patients with chronic renal disease, diabetes, hypertension, smoking, and HIV were the significant predictors of mortality among COVID-19 patients in Ethiopia. COVID-19 patients with chronic diseases and comorbidities need special attention, close follow-up, and care from all stakeholders.

Autophagy Activation in Peripheral Blood Mononuclear Cells of Peritoneal Dialysis Patients

Introduction

The complete systemic deregulated biological network in patients on peritoneal dialysis (PD) is still only partially defined. High-throughput/omics techniques may offer the possibility to analyze the main biological fingerprints associated with this clinical condition.

Methods

We applied an innovative bioinformatic analysis of gene expression microarray data (mainly based on support vector machine (SVM) learning) to compare the transcriptomic profile of peripheral blood mononuclear cells (PBMCs) of healthy subjects (HS), chronic kidney disease (CKD) patients, and patients on PD divided into a microarray group (5 HS, 9 CKD, and 10 PD) and a validation group (10 HS, 15 CKD, and 15 PD). Classical well-standardized biomolecular approaches (western blotting and flow cytometry) were used to validate the transcriptomic results.

Results

Bioinformatics revealed a distinctive PBMC transcriptomic profiling for PD versus CKD and HS (n = 419 genes). Transcripts encoding for key elements of the autophagic pathway were significantly upregulated in PD, and the autophagy related 5 (ATG5) reached the top level of discrimination [-Log10 P-value = 11.3, variable importance in projection (VIP) score = 4.8, SVM rank:1]. Protein levels of ATG5 and microtubule associated protein 1 light chain 3 beta (LC3B), an important constituent of the autophagosome, validated microarray results. In addition, the incubation of PBMCs of HS with serum of patients on PD upregulated both proteins. Autophagy in PBMCs from patients on PD was attenuated by N-acetyl-cysteine or Resatorvid treatment.

Conclusions

Our data demonstrated, for the first time, that the autophagy pathway is activated in immune-cells of patients on PD, and this may represent a novel therapeutic target.

Glomerular filtration rate is an independent prognostic factor in patients with B-large cell lymphoma

Chronic kidney dysfunction is associated with increased mortality in multiple cancer types. Preliminary evidence suggests the same to be true for B-large cell lymphomas (B-LCL). To analyze the relationship of glomerular filtration rate (GFR) and outcome of B-LCL in detail we collected data on outcomes of 285 consecutive patients with newly diagnosed B-LCL treated at our institution with standard rituximab-containing regimens who did not have preexisting kidney disease or urinary tract obstruction at presentation. Median age was 59, range 18 to 87, 145 were male and 140 females. Forty-four had GFR < 60 mL/min, 123 had 60 to 90 mL/min, and 118 > 90 mL/min. Median follow-up of surviving patients was 49 months and estimated 3-year survival 76%. In univariate analysis age (P < .001), GFR (P = .014), stage (P < .001), performance status (P = .044), chemotherapy regimen (P < .01), and international prognostic index (IPI) (P < .001) were statistically significant prognostic factors. In multivariate analysis, age and GFR remained the only independent prognostic factors. Subtracting 1 from the IPI score of patients who had GFR > 90 mL/min and IPI > 1 resulted in a prognostic index that divides patients into 3 prognostic groups (low risk = 0-1, intermediate risk = 2-3 and high risk = 4-5) with an acceptable patient distribution frequency (38%, 39%, and 23%, respectively) and improved statistical significance and separation in comparison to IPI (5-year survival rates of 92%, 74%, and 42%, respectively). GFR is an important independent prognostic factor for B-LCL that should be taken into account in clinical decision making and data analysis and probably be incorporated in prognostic indices.

Pathogen Distribution, Drug Resistance Risk Factors, and Construction of Risk Prediction Model for Drug-Resistant Bacterial Infection in Hospitalized Patients at the Respiratory Department During the COVID-19 Pandemic

Objective

To investigate the distribution and drug resistance of pathogens among hospitalized patients in the respiratory unit during the COVID-19 pandemic, analyze the risk factors of drug resistance, construct a risk prediction model.

Methods

This study isolated 791 strains from 489 patients admitted to the Affiliated Hospital of Chengdu University, who were retrospectively enrolled between December 2019 and June 2021. The patients were divided into training and validation sets based on a random number table method (8:2). The baseline information, clinical characteristics, and culture results were collected using an electronic database and WHONET 5.6 software and compared between the two groups. A risk prediction model for drug-resistant bacteria was constructed using multi-factor logistic regression.

Results

K. pneumoniae (24.78%), P. aeruginosa (17.19%), A. baumannii (10.37%), and E. coli (10.37%) were the most abundant bacterial isolates. 174 isolates of drug-resistant bacteria were collected, ie, Carbapenem-resistant organism-strains, ESBL-producing strains, methicillin-resistant S. aureus, multi-drug resistance constituting 38.51%, 50.57%, 6.32%, 4.60%, respectively. The nosocomial infection prediction model of drug-resistant bacteria was developed based on the combined use of antimicrobials, pharmacological immunosuppression, PCT>0.5 ng/mL, CKD stage 4-5, indwelling catheter, and age > 60 years. The AUC under the ROC curve of the training and validation sets were 0.768 (95% CI: 0.624-0.817) and 0.753 (95% CI: 0.657-0.785), respectively. Our model revealed an acceptable prediction demonstrated by a non-significant Hosmer-Lemeshow test (training set, p=0.54; validation set, p=0.88).

Conclusion

K. pneumoniae, P. aeruginosa, A. baumannii, and E. coli were the most abundant bacterial isolates. Antimicrobial resistance among the common isolates was high for most routinely used antimicrobials and carbapenems. COVID-19 did not increase the drug resistance pressure of the main strains. The risk prediction model of drug-resistant bacterial infection is expected to improve the prevention and control of antibacterial-resistant bacterial infection in hospital settings.

COVID-19 Vaccination in Kidney Transplant Candidates and Recipients

Kidney transplant candidates and kidney transplant recipients (KTRs) are at particular risk of severe complications of COVID-19 disease. In Western countries, mortality in affected hospitalized KTRs ranges between 19% and 50%. COVID-19 vaccination remains the most important measure to prevent the severity of infection in candidates and recipients of kidney transplant. However, the uraemic condition may affect the vaccine-induced immunity in patients with advanced chronic kidney disease (CKD) and in KTRs. Retention of uraemic toxins, dysbiosis, dysmetabolism, and dialysis can diminish the normal response to vaccination, leading to dysfunction of inflammatory and immune cells. In KTRs the efficacy of vaccines may be reduced by the immunosuppressive medications, and more than half of kidney transplant recipients are unable to build an immune response even after four administrations of anti-COVID-19 vaccines. The lack of antibody response leaves these patients at high risk for SARS-CoV-2 infection and severe COVID-19 disease. The aim of the present review is to focus on the main reasons for the impaired immunological response among candidates and kidney transplant recipients and to highlight some of the present options available to solve the problem.

Longitudinal Cluster Analysis of Hemodialysis Patients with COVID-19 in the Pre-Vaccination Era

Coronavirus disease 2019 (COVID-19) in hemodialysis patients (HD) is characterized by heterogeneity of clinical presentation and outcomes. To stratify patients, we collected clinical and laboratory data in two cohorts of HD patients at COVID-19 diagnosis and during the following 4 weeks. Baseline and longitudinal values were used to build a linear mixed effect model (LME) and define different clusters. The development of the LME model in the derivation cohort of 17 HD patients (66.7 ± 12.3 years, eight males) allowed the characterization of two clusters (cl1 and cl2). Patients in cl1 presented a prevalence of females, higher lymphocyte count, and lower levels of lactate dehydrogenase, C-reactive protein, and CD8 + T memory stem cells as a possible result of a milder inflammation. Then, this model was tested in an independent validation cohort of 30 HD patients (73.3 ± 16.3 years, 16 males) assigned to cl1 or cl2 (16 and 14 patients, respectively). The cluster comparison confirmed that cl1 presented a milder form of COVID-19 associated with reduced disease activity, hospitalization, mortality rate, and oxygen requirement. Clustering analysis on longitudinal data allowed patient stratification and identification of the patients at high risk of complications. This strategy could be suitable in different clinical settings.

Association between chronic kidney disease and mortality in patients with a confirmed COVID-19 diagnosis

Objective

To determine the association between chronic kidney disease (CKD) and mortality in persons with a confirmed coronavirus disease 2019 (COVID-19) diagnosis.

Methods

Cross-sectional secondary baseline study. The study population consisted of 243,065 patients confirmed to have COVID-19 during May-December 2020. Stata 16.0 was used for statistical analysis, Chi-square test was used for bivariate analysis, and Poisson regression with robust variances was used for multiple analysis.

Results

The prevalence of patients with a confirmed COVID-19 diagnosis who had CKD and died was 1.42 times the prevalence of mortality in those without CKD. The comorbidities combined with CKD that presented the highest probability of mortality were diabetes mellitus and hypertension.

Conclusions

CKD is associated with a high mortality rate in patients with a confirmed COVID-19 diagnosis. Patients with CKD, diabetes mellitus, and arterial hypertension have a higher prevalence of mortality than those without comorbidities.

Chronic Kidney Failure Provokes the Enrichment of Terminally Differentiated CD8+ T Cells, Impairing Cytotoxic Mechanisms After Kidney Transplantation

Chronic kidney failure (KF) provokes the development of immune senescent CD8⁺ cytotoxic T cells, affecting the occurrence of graft rejection, viral infections, and malignancies after kidney transplantation. In this study, we analyzed the impact of KF, subsequent dialysis treatment, and kidney transplantation on the differentiation of CD8⁺CD31⁺CD45RA⁺CCR7⁺ recent thymic emigrant (CCR7⁺ RTE) Tregs/Tresps into CD8⁺CD31^-CD45RA^- memory (CD31^- memory) Tregs/Tresps and its effect on the release of cytokines, Fas receptor, Fas ligand as well as cytotoxic mediators by naïve, central memory (CM), effector memory (EM), and terminally differentiated effector memory (TEMRA) Tresps. We found that normal age-dependent differentiation of CD8⁺ Tregs/Tresps generally differs in the way that TEMRA cells only arise in Tresps. Compared to healthy controls, KF patients revealed an age-independently decreased frequency of CCR7⁺ RTE Tregs/Tresps, but increased frequencies of CCR7⁺ MN Tregs/Tresps and CD31^- memory Tregs/Tresps, suggesting an increased differentiation via CD31⁺CD45RA^- memory (CD31⁺ memory) Tregs/Tresps into CD31^- memory Tregs/Tresps. Intensified differentiation via CD31⁺ memory Tresps increased the emergence of apoptosis-resistant CM Tresps with strong Fas ligand-mediated cytotoxicity. CCR7⁺ RTE Tresp proliferation generated TEMRA Tresps, secreting high levels of cytotoxic mediators. In dialysis and transplant patients, CD31⁺ TEMRA Tregs/Tresps accumulated, proposing an impaired CCR7⁺ RTE Treg/Tresp differentiation via CD31⁺ memory Tregs/Tresps into CD31^- memory Tregs/Tresps. Increased percentages of CD31^- TEMRA Tresps, but not of CD31^- TEMRA Tregs, were observed in all patient groups, indicating impaired proliferation of CCR7⁺ RTE Tresps, but not of CCR7⁺ RTE Tregs, into CD31^- memory Tregs/Tresps. In transplant patients, CCR7⁺ RTE Tregs accumulated, while frequencies of CCR7⁺ RTE Tresps were decreased, suggesting that the immunosuppressive therapy only prevented excessive CCR7⁺ RTE Treg differentiation but not that of CCR7⁺ RTE Tresps. Presumably, this caused the accumulation of TEMRA Tresps with decreased release of cytotoxic mediators, such as perforin. In conclusion, we propose that chronic KF affects both the differentiation of CD8⁺ Tregs and CD8⁺ Tresps. However, the immunosuppressive therapy after transplantation may successfully prevent excessive Treg differentiation, but not as suffciently that of Tresps. Therefore, the risk for graft rejection may be reduced, while the susceptibility for infections and malignancies may be increased in these patients.

Prognostic Factors for Contralateral Recurrence of Upper Tract Urothelial Carcinoma after Nephroureterectomy: A Large Multiregional Study

Simple Summary

Recurrence of cancer on the opposite side after the removal of primary upper tract urothelial carcinoma (UTUC) is uncommon, but the risk of subsequent deterioration of kidney function may be severe and result in the need for permanent dialysis. There is a clear correlation between inflammation and tumor development in patients with cancer. As the presence of white blood cells (WBC) in urine is an indicator of local inflammation and a biomarker for bladder recurrence of UTUC, we hypothesized that systemic inflammation is involved in the occurrence of contralateral lesions. We proved that elevated serum WBC, late chronic kidney disease, and multiple tumors are independent prognostic factors for contralateral recurrence. Moreover, in a subgroup analysis, the importance of chronic kidney disease in contralateral recurrence was demonstrated for the first time in a non-Asian population. It is recommended that high-risk patients be closely followed up to monitor the opposite upper urinary tract.

Abstract

This study aimed to examine the prognostic significance of preoperative inflammation-associated blood cell markers in the metachronous contralateral recurrence of upper tract urothelial carcinoma (UTUC). Patients with nonmetastatic UTUC treated in Taiwan and the U.S. between 1990 and 2017 were included. The Kaplan–Meier method was used to calculate the contralateral recurrence rate, and multivariate logistic regression was performed to study the association of blood cell markers and clinicopathological characteristics with contralateral recurrence. Overall, a total of 1039 patients were included in this study, 52 of whom (5.0%) developed metachronous recurrence of the contralateral side. Kaplan–Meier analysis indicated that a history of bladder cancer (p = 0.006), multiple tumors (p = 0.016), advanced chronic kidney disease (CKD; p < 0.001), elevated serum white blood cell (WBC) count (p < 0.001), and decreased hemoglobin levels (p = 0.001) significantly reduced the contralateral recurrence-free survival. Multivariate analysis showed that multiple tumors (hazard ratio (HR), 1.87; p = 0.030), advanced CKD (HR, 2.63; p = 0.002) and increased WBC count (HR, 2.60; p = 0.001) were independent risk factors for higher contralateral recurrence rate. Notably, advanced CKD was a significant factor regardless of the patient’s region. In summary, multiple tumors, advanced CKD and elevated serum WBC count are independent predictors of contralateral recurrence in patients with UTUC. It is recommended that patients with these adverse characteristics be closely followed up to monitor the opposite upper urinary tract.

Inferior survival outcomes of pancreas transplant alone in uremic patients

Theoretically, pancreas transplant alone in uremic (PTAU) patients could also be one of the options for those waiting for both pancreas and kidney grafts, but it has never been reported. There were 160 cases of pancreas transplant in this study, including 16% PTAU. The 5-year patient survival was 66.2% after PTAU, 94.5% after SPK, 95.8% after PAK, and 95.4% after PTA. Rejection of pancreas graft was significantly lower in PTAU group (3.8%), followed by 16.7% in pancreas after kidney transplant (PAK), 29.8% in simultaneous pancreas and kidney transplant (SPK) and 37.0% in pancreas transplant alone (PTA). Fasting blood sugar and serum HbA1c levels after PTAU were not significantly different from those by other subgroups. The 5-year death-censored pancreas graft survival was 100% after PTAU and PAK, and 97.0% after SPK and 77.9% after PTA. However, the 5-year death-uncensored pancreas graft survival was 67.0% after PTAU, 100% after PAK, 91.3% after SPK, and 74.0% after PTA. The superior graft survival in the PTAU group was achieved only if deaths with a functioning graft were censored. In conclusion, given the inferior patient survival outcome, PTAU is still not recommended unless SPK and PAK is not available. Although PTAU could be a treatment option for patients with diabetes complicated by end-stage renal disease (ESRD) in terms of surgical risks, endocrine function, and immunological and graft survival outcomes, modification of the organ allocation policies to prioritize SPK transplant in eligible patients should be the prime goal.

Pancreas transplant with enteric drainage at a single institute in Asia

BACKGROUND/OBJECTIVE

This study is to assess immunological and graft survival outcomes after pancreas transplant at a single institute in Asia.

METHODS

Patients undergoing pancreas transplant with enteric drainage were included. Clinical data and outcomes were evaluated and compared between each subgroup.

RESULTS

There were 165 cases of pancreas transplant, including 38 (23 %) simultaneous pancreas-kidney transplant (SPK), 24 (15 %) pancreas after kidney transplant (PAK), 75 (46 %) pancreas transplant alone (PTA), and 28 (17 %) pancreas before kidney transplant (PBK). The overall surgical complication rate was 46.1 %, with highest (62.5 %) in PAK and lowest (32.0 %) in PTA, P = 0.008. The late complications included 32.7 % infection and 3.6 % malignancy. Overall rejection of pancreas graft was 24.8 % including 18.2 % acute and 9.7 % chronic rejection. Rejection was highest in PTA group (36.0 %) and lowest in PBK (3.6 %). There were 56 cases (33.9 %) with graft loss in total, with highest graft loss rate in PTA (38.7 %). The 1-year, 5-year and 10-year pancreas graft survivals for total patients were 98.0 %, 87.7 % and 70.9 % respectively.

CONCLUSIONS

Enteric drainage in pancreas transplant could be applied safely not only in SPK but also in other subgroups. Enteric drainage itself would not compromise the immunological and graft survival outcomes.

The significance of serum levels of soluble interleukin-2 receptor in patients undergoing maintenance hemodialysis

Background

Elevated serum levels of sIL-2R are commonly observed in patients undergoing maintenance hemodialysis (MHD). However, the clinical implications in these subjects are unclear. This study is aimed to assess the significance of elevated sIL-2R levels in MHD patients.

Methods

A total of 382 MHD patients were followed-up from September 2016 to December 2019. Patients were divided into two groups: high sIL-2R, with sIL-2R levels ≥2-fold of the upper limit of normal (710 U/ml); and low sIL-2R, with sIL-2R levels < 2-fold the upper limit of normal. The relationships between sIL-2R levels and other clinical parameters, as well as patient prognosis were both assessed.

Results

The median concentration of sIL-2R was 1268 U/mL. A total of 372 (97.38%) patients exhibited sIL-2R levels higher than the upper limit of the normal range. Multiple linear regression analysis revealed that monocyte count (β = 0.1571, p = 0.01), and β₂-MG (β = 0.2635, p < 0.0001), hemoglobin (β = −0.1610, p = 0.001), SCr (β = −0.3471, p < 0.0001), and HDL-C (β = −0.1091, p = 0.029) levels were independent factors influencing serum concentrations of sIL-2R. High sIL-2R was significantly correlated with non-cardiovascular-related mortality (OR 2.97 [95% CI 1.59–5.56; p = 0.001), of which 39 (82.98%) were attributed to infection and/or cancer.

Conclusions

Elevated sIL-2R is prevalent in MHD patients and related with several unfavorable parameters. sIL-2R appears to have no ability to predict cardiovascular mortality, which accounts for approximately one-half of all deaths. However, sIL-2R may be beneficial in predicting noncardiovascular mortality.

Influence of end stage renal disease on CD28 expression and T-cell immunity

BACKGROUND

T-cell immunity is affected in end stage renal disease (ESRD). However, whether this happens at pre- or post-dialysis stage and what is the impact of different renal replacement methods, remains unclear. We investigated the alterations of T-cell subtypes in patients at pre-dialysis ESRD and their further changes during dialysis.

METHODS

CD4+, CD8+, CD4 + CD28null and CD8 + CD28null T-cells were analysed in 40 ESRD patients at two different time points, (a) the day started on dialysis (ESRD-T0) and (b) 6 months later (ESRD-T6), while being on haemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD). Twenty-five age matched healthy volunteers served as controls.

RESULTS

CD4+ and CD8+ T-cells were significantly reduced in ESRD-T0 patients compared to controls, 604 (105-3551) vs 943 (584-1867)μ/L, P = .001, and 352 (103-1561) vs 422.4 (263-1453)μ/L, P = .05, respectively. However, proportions of CD4 + CD28null and CD8 + CD28null cells were significantly increased, 6.4 (0.3-30)% vs 2.7 (0.1-7.8)%, P = .04 and 58.2 (12.8-85.4)% vs 39 (7.8-57.1)%, P = .01, respectively. Proportion of CD4 + CD28null cells showed significant correlation with serum CRP (r = .4, P = .04) and albumin levels (r = -.5, P = .007) in ERSD patients. ESRD-T0 patients with cardiovascular disease (CVD) had increased CD4 + CD28null and CD8 + CD28null proportions, 8.6 (1-30)% vs 2.1 (0.1-19.8)%, P = .04 and 62.5 (12.8-85.4)% vs 45.5 (5.7-73.7)%, P = .02, respectively, compared to those without. Six months later, both CD4 + CD28null and CD8 + CD28null T-cells were increased in HD compared to CAPD patients, by +110.11 (-27.1 to 311.4)% vs -28.1 (-100 to 30)%, P = .003 and +55.23 (-29.06 to 197.93)% vs -8.34 (-54.99 to 66.72)%, P = .05, respectively.

CONCLUSIONS

CD4 + CD28null and CD8 + CD28null T-cells are increased at pre-dialysis ESRD, and correlate with chronic inflammatory markers and the presence of CVD. Dialysis methods seem to have different impact on these subpopulations.

Tissue-resident mucosal-associated invariant T (MAIT) cells in the human kidney represent a functionally distinct subset

Mucosal‐associated invariant T (MAIT) cells are innate‐like T‐cells that recognize bacterial riboflavin metabolites. They are present in human blood but are abundant at barrier sites, including the liver, lungs, and kidneys, where they possess a CD69⁺/CD103^+/− tissue‐resident phenotype. In renal tissue, MAIT cells likely defend against the ascending uropathogens responsible for urinary tract infections (UTIs), which are common, especially among renal transplant recipients (RTRs). Nevertheless, the functional role for MAIT cells in renal tissue and the influence of renal transplantation on MAIT cells remains unclear. Using multiparameter flow cytometry and the MR1‐tetramer, we characterized MAIT cell phenotype and function in healthy renal tissue (n = 6), renal transplants explanted after allograft failure (n = 14) and in blood from healthy controls (n = 20) and RTRs before and 1‐year after transplantation (n = 21). MAIT cells in renal tissue constitute a distinct CD69⁺CD103^+/− population that displays typical phenotypic features of tissue‐resident T‐cells and is skewed toward IL‐2, GM‐CSF, and IL‐17A production upon stimulation. The circulating MAIT cell population was not decreased in number in RTRs pre‐ or post‐transplantation. Tissue‐resident MAIT cells in the kidney represent a functionally distinct population. This shows how MAIT cells in the kidney may be involved in the protection against microorganisms.

LRRK2 at the Interface Between Peripheral and Central Immune Function in Parkinson's

It is becoming increasingly accepted that there is an interplay between the peripheral immune response and neuroinflammation in the pathophysiology of Parkinson's disease (PD). Mutations in the leucine-rich-repeat kinase 2 (LRRK2) gene are associated with familial and sporadic cases of PD but are also found in immune-related disorders, such as inflammatory bowel disease (IBD) and leprosy. Furthermore, LRRK2 has been associated with bacterial infections such as Mycobacterium tuberculosis and Salmonella typhimurium. Recent evidence suggests a role of LRRK2 in the regulation of the immune system and modulation of inflammatory responses, at a systemic level, with LRRK2 functionally implicated in both the immune system of the central nervous system (CNS) and the periphery. It has therefore been suggested that peripheral immune signaling may play an important role in the regulation of neurodegeneration in LRRK2 as well as non-LRRK2-associated PD. This review will discuss the current evidence for this hypothesis and will provide compelling rationale for placing LRRK2 at the interface between peripheral immune responses and neuroinflammation.

Uremia-Associated Ageing of the Thymus and Adaptive Immune Responses

Progressive loss of renal function is associated with a series of changes of the adaptive immune system which collectively constitute premature immunological ageing. This phenomenon contributes significantly to the mortality and morbidity of end-stage renal disease (ESRD) patients. In this review, the effect of ESRD on the T cell part of the adaptive immune system is highlighted. Naïve T cell lymphopenia, in combination with the expansion of highly differentiated memory T cells, are the hallmarks of immunological ageing. The decreased production of newly formed T cells by the thymus is critically involved. This affects both the CD4 and CD8 T cell compartment and may contribute to the expansion of memory T cells. The expanding populations of memory T cells have a pro-inflammatory phenotype, add to low-grade inflammation already present in ESRD patients and destabilize atherosclerotic plaques. The effect of loss of renal function on the thymus is not reversed after restoring renal function by kidney transplantation and constitutes a long-term mortality risk factor. Promising results from animal experiments have shown that rejuvenation of the thymus is a possibility, although not yet applicable in humans.

A very low thymus function identifies patients with substantial increased risk for long-term mortality after kidney transplantation

Background

End-stage renal disease is associated with premature ageing of the T cell immune system but inter-individual variation is substantial. The hypothesis was tested that advanced immunological T cell ageing assessed by peripheral T cell differentiation increases the long-term mortality risk after renal transplantation.

Results

Circulating T cells of 211 recipients of a kidney from a living donor were analyzed before and in the first year after transplantation. The number of CD31-positive naive T cells (as a marker for recent thymic emigrants) and the differentiation status of the memory T cells was assessed. Thirty recipients died during follow-up of at least 5 years. Absolute numbers of naive CD4⁺ (living:258 cells/μl vs. deceased:101 cells/μl, p < 0.001) and naive CD8⁺ T cells (living:97 cells/μl vs. deceased:37 cells/μl, p < 0.001) were significantly lower in the deceased group prior to transplantation. In a multivariate proportional hazard analysis the number of naive CD4⁺ T cells remained associated with all-cause mortality (HR 0.98, CI 0.98–0.99, p < 0.001). The low number of naive T cells in the deceased patient group was primarily caused by a decrease in recent thymic emigrants (i.e. less CD31⁺ naive T cells) indicating a lowered thymus function. In addition, the physiological age-related compensatory increase in CD31⁻ naïve T cells was not observed. Within the first year after transplantation, the number and characteristics of naive T cells remained stable.

Conclusions

A severe reduction in circulating naïve T cells because of a decrease in recent thymic emigrants is highly associated with all-cause mortality after renal transplantation.

Immunological Effects of a Single Hemodialysis Treatment

Immune disorders, involving both innate and adaptive response, are common in patients with end-stage renal disease under chronic hemodialysis. Endogenous and exogenous factors, such as uremic toxins and the extracorporeal treatment itself, alter the immune balance, leading to chronic inflammation and higher risk of cardiovascular events. Several studies have previously described the immune effects of chronic hemodialysis and the possibility to modulate inflammation through more biocompatible dialyzers and innovative techniques. On the other hand, very limited data are available on the possible immunological effects of a single hemodialysis treatment. In spite of the lacking information about the immunological reactivity related to a single session, there is evidence to indicate that mediators of innate and adaptive response, above all complement cascade and T cells, are implicated in immune system modulation during hemodialysis treatment. Expanding our understanding of these modulations represents a necessary basis to develop pro-tolerogenic strategies in specific conditions, like hemodialysis in septic patients or the last session prior to kidney transplant in candidates for receiving a graft.

Vitamin e-loaded membrane dialyzers reduce hemodialysis inflammaging

BACKGROUND

Inflammaging is a persistent, low-grade, sterile, nonresolving inflammatory state, associated with the senescence of the immune system. Such condition downregulates both innate and adaptive immune responses during chronic disorders as type II diabetes, cancer and hemodialysis, accounting for their susceptibility to infections, malignancy and resistance to vaccination. Aim of this study was to investigate hemodialysis inflammaging, by evaluating changes of several hemodialysis treatments on indoleamine 2,3-dioxygenase-1 activity and nitric oxide formation.

METHODS

We conducted a randomized controlled observational crossover trial. Eighteen hemodialysis patients were treated with 3 different hemodialysis procedures respectively: 1) Low-flux bicarbonate hemodialysis, 2) Low-flux bicarbonate hemodialysis with vitamin E - loaded dialyzers, and 3) Hemodialfitration. The control group consisted of 14 hospital staff healthy volunteers. Blood samples were collected from all 18 hemodialysis patients just after the long interdialytic interval, at the end of each hemodialysis treatment period.

RESULTS

Hemodialysis kynurenine and kynurenine/L - tryptophan blood ratio levels were significantly higher, when compared to the control group, indicating an increased indoleamine 2,3-dioxygenase-1 activity in hemodialysis patients. At the end of the low-flux bicarbonate hemodialysis with vitamin E - loaded dialyzers period, L - tryptophan serum levels remained unchanged vs both low-flux bicarbonate hemodialysis and hemodialfitration. Kynurenine levels instead decreased, resulting in a significant reduction of kynurenine/L - tryptophan blood ratio and indoleamine 2,3-dioxygenase-1 activity, when matched to both low-flux bicarbonate hemodialysis and HDF respectively. Serum nitric oxide control group levels, were significantly lower when compared to all hemodialysis patient groups. Interestingly, low-flux bicarbonate hemodialysis with vitamin E - loaded dialyzers nitric oxide serum levels from venous line blood samples taken 60 min after starting the hemodialysis session were significantly lower vs serum taken simultaneously from the arterial blood line.

CONCLUSIONS

The treatment with more biocompatible hemodialysis procedure as low-flux bicarbonate hemodialysis with vitamin E - loaded dialyzers, reduced indoleamine 2,3-dioxygenase-1 activity and nitric oxide formation when compared to both low-flux bicarbonate hemodialysis and hemodialfitration. These data suggest that low-flux bicarbonate hemodialysis with vitamin E - loaded dialyzers lowering hemodialysis inflammaging, could be associated to changes of proinflammatory signalling a regulated molecular level.

TRIAL REGISTRATION

NCT Number: NCT02981992; Other Study ID Numbers: 20100014090. First submitted: November 26, 2016. First posted: December 5, 2016. Last Update Posted: December 5, 2016.

NK Cells Contribute to the Immune Risk Profile in Kidney Transplant Candidates

Background: A previously proposed immune risk profile (IRP), based on T cell phenotype and CMV serotype, is associated with mortality in the elderly and increased infections post-kidney transplant. To evaluate if NK cells contribute to the IRP and if the IRP can be predicted by a clinical T cell functional assays, we conducted a cross sectional study in renal transplant candidates to determine the incidence of IRP and its association with specific NK cell characteristics and ImmuKnow® value.

Material and Methods: Sixty five subjects were enrolled in 5 cohorts designated by age and dialysis status. We determined T and NK cell phenotypes by flow cytometry and analyzed multiple factors contributing to IRP.

Results: We identified 14 IRP+ [CMV seropositivity and CD4/CD8 ratio < 1 or being in the highest quintile of CD8+ senescent (28CD–/CD57+) T cells] individuals equally divided amongst the cohorts. Multivariable linear regression revealed a distinct IRP+ group. Age and dialysis status did not predict immune senescence in kidney transplant candidates. NK cell features alone could discriminate IRP– and IRP+ patients, suggesting that NK cells significantly contribute to the overall immune status in kidney transplant candidates and that a combined T and NK cell phenotyping can provide a more detailed IRP definition. ImmuKnow® value was negatively correlated to age and significantly lower in IRP+ patients and predicts IRP when used alone or in combination with NK cell features.

Conclusion: NK cells contribute to overall immune senescence in kidney transplant candidates.

The difference of T cell phenotypes in end stage renal disease patients under different dialysis modality

Background

Impaired T cell immune function exists in end-stage renal disease (ESRD) patients. Dialysis treatment may lead to changes in T cell subsets. In the present study, we aimed to identify alterations of T cell phenotypes in ESRD patients, especially in those receiving peritoneal dialysis (PD), and analyze the potential associated factors.

Methods

In the present study, 110 PD patients and 110 age/gender-matched hemodialysis (HD) patients who met the inclusion criteria were studied. Pre-dialysis blood samples were obtained and analyzed by flow cytometry to detect the expression of CD45RO and CCR7. Univariate and multivariate regression analyses were used to determine the factors associated with the alteration of T cell phenotypes.

Results

In all dialysis patients, age was associated with the frequencies of both CD4+ and CD8+ naïve T cells, effector memory (EM) T cells and effector memory RA (EMRA) T cells but not central memory (CM) T cells. Dialysis modality was also associated with T cell subsets. Compared with HD patients, PD patients showed an increase in both CD4+ and CD8+ CM T cells and a reduction in both CD4+ and CD8+ EM and EMRA T cells. However, the number of CD4+ naïve T cells was lower and the number of CD8+ naïve T cells was higher in PD patients than those in HD patients. In PD patients, further multivariate analysis revealed that the frequency of CD4+ naïve T cells was positively associated with nPCR, while the frequency of CD8+ naïve T cells was negatively associated with age.

Conclusion

In dialysis patients, the dialysis modality and age influence T cell subsets. There is a progression from naïve to effector T cells in HD patients compared with PD patients. In PD patients, different factors may influence the frequencies of CD4+ and CD8+ naïve T cells.

ESRD-associated immune phenotype depends on dialysis modality and iron status: clinical implications

BACKGROUND

End-stage renal disease (ESRD) causes premature ageing of the immune system. However, it is not known whether hemodialysis (HD) and peritoneal dialysis (PD) similarly affect the T cell system.

METHODS

The aim of our study was to analyse whether dialysis modality may mitigate ESRD-induced immune senescence. We explored a large population of patients (675 ESRD patients) and both confirmed and refined the results in a second cohort (84 patients).

RESULTS

HD patients exhibited higher inflammatory monocytes counts (44/mm3 (1-520) vs 36/mm3 (1-161); p = 0.005). Patients on HD also had higher frequency of CD8 T cells (24% (7-61) vs 22% (8-42); p = 0.003) and reduced CD4/CD8 ratio. Such results were confirmed in the second cohort. Moreover, both CD4 + CD57 + CD28- (3.25% (0-38.2) vs 1.05% (0-28.5); p = 0.068) and CD8 + CD57 + CD28- (38.5% (3.6-76.8) vs 26.1 (2.1-46.9); p = 0.039) T cells frequencies were increased in HD patients. Telomere length did not differ according to dialysis modality, but was inversely related to ferritin levels (r = - 0.33; p = 0.003). There was a trend towards higher telomerase activity in PD patients (11 ± 13 vs 6 ± 11; p = 0.053). Thymic function was not different in PD and HD patients. Patients on PD before transplantation had a higher risk of acute rejection after kidney transplantation (HR, 1.61; 95%CI, 1.02 to 2.56; p = 0.041).

CONCLUSIONS

More pronounced inflammation with hemodialysis may induce premature aging of the immune system. This observation correlates with a lower risk of acute kidney rejection in patients previously on HD. Clinical consequences in patients maintained on dialysis should be determined.

TRIAL REGISTRATION

Trial registration: NCT02843867, registered July 8, 2016.

Mortality risk after herpes zoster infection in end-stage renal disease patients

Background

End-stage renal disease (ESRD) patients have increased risk of developing herpes zoster (zoster) compared with the general population, but mortality risk is unknown. We assessed the risk of mortality in hospitalized ESRD patients with a diagnosis of zoster from the inpatient hospital files (as opposed to outpatient records) of the United States Renal Data System.

Methods

This study analyzed incident ESRD patients from 2006 to 2009. Based on an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code of zoster infection, we determined 2-year mortality following an inpatient diagnosis. Cox proportional hazards models were used to examine the association of mortality and zoster, when controlling for demographic and other clinical risk factors.

Results

Zoster was diagnosed in 2784 patients, 51% of whom died within 2 years, with a mean time to death of 8.1 months. Patients who died were more likely to be white and older, score higher on the Charlson Comorbidity Index (CCI) and have other clinical diagnoses besides CCI. Increased risk of death within 2 years was associated with older age (adjusted hazard ratio 1.03), malnutrition (1.31), bacteremia/septicemia (1.16) and increasing CCI (1.10). Zoster vaccine was administered to 27 patients, but the small number precluded analysis of its impact.

Conclusions

Mortality in ESRD patients with an inpatient zoster diagnosis is increased with older age and higher severity of clinical comorbidities. The role of zoster vaccination on mortality in this population remains to be defined.

End-stage renal disease, dialysis, kidney transplantation and their impact on CD4+ T-cell differentiation

Premature aging of both CD4⁺ regulatory T (Treg) and CD4⁺ responder-T (Tresp) cells in patients with end-stage renal disease (ESRD) is expected to affect the success of later kidney transplantation. Both T-cell populations are released from the thymus as inducible T-cell co-stimulator-positive (ICOS⁺ ) and ICOS^- recent thymic emigrant (RTE) Treg/Tresp cells, which differ primarily in their proliferative capacities. In this study, we analysed the effect of ESRD and subsequent renal replacement therapies on the differentiation of ICOS⁺ and ICOS^- RTE Treg/Tresp cells into ICOS⁺  CD31^- or ICOS^-  CD31^- memory Treg/Tresp cells and examined whether diverging pathways affected the suppressive activity of ICOS⁺ and ICOS^- Treg cells in co-culture with autologous Tresp cells. Compared with healthy controls, we found an increased differentiation of ICOS⁺ RTE Treg/Tresp cells and ICOS^- RTE Treg cells through CD31⁺ memory Treg/Tresp cells into CD31^- memory Treg/Tresp cells in ESRD and dialysis patients. In contrast, ICOS^- RTE Tresp cells showed an increased differentiation via ICOS^- mature naive (MN) Tresp cells into CD31^- memory Tresp cells. Thereby, the ratio of ICOS⁺ Treg/ICOS⁺ Tresp cells was not changed, whereas that of ICOS^- Treg/ICOS^- Tresp cells was significantly increased. This differentiation preserved the suppressive activity of both Treg populations in ESRD and partly in dialysis patients. After transplantation, the increased differentiation of ICOS⁺ and ICOS^- RTE Tresp cells proceeded, whereas that of ICOS⁺ RTE Treg cells ceased and that of ICOS^- RTE Treg cells switched to an increased differentiation via ICOS^- MN Treg cells. Consequently, the ratios of ICOS⁺ Treg/ICOS⁺ Tresp cells and of ICOS^- Treg/ICOS^- Tresp cells decreased significantly, reducing the suppressive activity of Treg cells markedly. Our data reveal that an increased tolerance-inducing differentiation of ICOS⁺ and ICOS^- Treg cells preserves the functional activity of Treg cells in ESRD patients, but this cannot be maintained during long-term renal replacement therapy.

Restrictive lung disorder is common in patients with kidney failure and associates with protein-energy wasting, inflammation and cardiovascular disease

BACKGROUND

Cardiovascular disease (CVD), protein-energy wasting (PEW), and inflammation are common interrelated features of chronic kidney disease (CKD). Less is known about lung dysfunction in CKD and its possible role in this context. We evaluated lung function and its association with estimated glomerular filtration rate (GFR), CVD, PEW, and inflammation in individuals with normal to severely reduced GFR.

METHODS

In 404 individuals with GFR category G1 (n = 31; GFR >90mL/min/1.73 m2), G2 (n = 46), G3 (n = 33), G4 (n = 49) and G5 (n = 245; GFR<15mL/min/1.73 m2), pulmonary function was assessed by spirometry. Obstructive (OLD) and restrictive (RLD) lung dysfunction was defined based on forced vital capacity (FVC), forced expiratory volume in the first second (FEV1) and peak expiratory flow (PEF), expressed as percentages of predicted values (%FEV1, %FVC and %PEF, respectively). PEW was evaluated by subjective global assessment, handgrip strength (HGS) and lean body mass index (LBMI), and inflammation by interleukin-6 and high sensitivity C-reactive protein.

RESULTS

RLD (defined as FEV1/FVC ≥ 0.70 and %FVC<80) associated with GFR and was present in 36% of G5 and 14% of G1-4 individuals. OLD (FEV1/FVC<0.70) was less common with similar prevalence among G1-4 (9%) and G5 (11%) individuals. Notably, 64% of those with concomitant presence of PEW, inflammation and clinical signs of CVD had RLD while 79% of those lacking these complications had normal lung function. In multivariate logistic regression analysis, RLD associated with CVD, PEW and inflammation, after adjusting for Framingham's CVD risk score, serum albumin, and GFR category.

CONCLUSIONS

RLD is a common complication in patients with advanced CKD, especially in those with concomitant presence of CVD, inflammation and PEW. RLD appears to be an integral albeit scarcely explored consequence of pulmonary-renal interactions in CKD patients.

Impact of end-stage renal disease on hospital outcomes among patients admitted to intensive care units: A retrospective matched-pair cohort study

AIM

We aimed to estimate the burden of end-stage renal disease (ESRD) among patients admitted to intensive care units (ICUs), by comparing hospital outcomes between patients with and without ESRD.

METHODS

Using the Japanese Diagnosis Procedure Combination database, we identified patients aged 20 years or older who were admitted to ICUs for ≥3 days (2 nights) in 2011. We created a matched cohort of patients with and without ESRD for hospital, age, sex, main diagnosis category, and ICU admission type (medical or surgical) at a maximum ratio of 1:3. For these matched patients, we compared patient characteristics, treatment regimens at ICU admission, and hospital outcomes. We also performed a multivariable logistic regression analysis for the associations between ESRD and 28-day (counting from ICU admission) and in-hospital mortality.

RESULTS

Among the 164 423 eligible patients, 7998 (4.9%) had ESRD, from which 5228 ESRD and 12 274 non-ESRD patients were matched for the aforementioned factors. Compared to non-ESRD patients, ESRD patients were on more intensive treatment regimens, including mechanical ventilation, vasoactive drugs, and blood transfusion. Patients with ESRD showed significantly higher ICU, 28-day, and in-hospital mortality and longer lengths of stay in the ICU and hospital (28-day mortality: 11.7% vs. 8.3%; P < 0.001, in-hospital mortality: 21.1% vs. 12.0%; P < 0.001). After adjusting for confounding factors, ESRD was independently associated with 28-day mortality (adjusted odds ratio: 1.36, 95% confidence interval [CI]: 1.22-1.52) and in-hospital mortality (adjusted odds ratio: 1.85, 95% CI: 1.69-2.02).

CONCLUSION

This study involving the Japanese national inpatient database, with a matched-pair cohort design, suggested that ESRD is an important burden in the critical care setting.

A Chinese herbal decoction, Jian-Pi-Yi-Shen, regulates the expressions of erythropoietin and pro-inflammatory cytokines in cultured cells

Background

A Chinese herbal formula, namely Jian-Pi-Yi-Shen (JPYS), has been clinically prescribed for patients with chronic kidney disease associated-anemia, and which can improve the patient’s immunological system. However, the mechanisms of JPYS involved in anemia and immune response have not been investigated. To study the role of JPYS in regulating hematopoietic and immunological functions, we investigated its activities on the expressions of erythropoietin and pro-inflammatory cytokines in cultured cells.

Methods

The standardized herbal extracts of JPYS (0–30 μg/ml) were applied onto cultured cells for 24–48 h. Total RNA was collected from the treated cells and subjected to real-time quantitative PCR analysis. Cultured HEK293T cells, transfected with a construct composed of hypoxia response element tagged with a luciferase gene, i.e. pHRE-Luc, were treated with JPYS extracts (1–30 μg/ml) for 24 h. The cell lysates were subjected to luciferase assay.

Results

The treatment with JPYS extract onto cultured HEK293T cells induced erythropoietin expression in a dose-dependent manner, having the highest response by ~ 50% of increase. In parallel, application of JPYS extract for 24 h stimulated expressions of interleukin (IL)-1β, IL-6, and tumor necrosis factor (TNF)-α in cultured RAW 264.7 macrophages. In contrast, the pretreatment with JPYS extract suppressed expressions of IL-1β, IL-6, and TNF-α in lipopolysaccharide-induced macrophages.

Conclusions

These results confirmed the hematopoietic function of JPYS in regulating erythropoietin expression, as well as the bidirectional immune-modulatory roles of JPYS by regulating the expression of pro-inflammatory cytokines in cultures.

Chronic kidney disease, kidney transplantation and oxidative stress: a new look to successful kidney transplantation

Oxidative stress plays a key role in the pathophysiological process of uremia and its complications, particularly in cardiovascular disease. The level of oxidative stress markers is known to increase as chronic kidney disease progresses and correlates significantly with the level of renal function. Hemodialysis and peritoneal dialysis are major modes of renal replacement therapy for end-stage renal disease patients, but unfortunately they are also accompanied by increased oxidative stress. Successful kidney transplantation, however, results in near normalization of the antioxidant status and lipid metabolism by eliminating free radicals despite the surge of oxidative stress caused by the surgical procedure and ischemic injury to the organ during the operation. This success is associated with both improved renal function, reduced cardiovascular complications and overall improved morbidity and mortality. Measuring oxidative stress markers such as malondialdehyde is promising in predicting allograft survival and delayed graft function.

Clinical and hematological data to group different chronic kidney disease patients: A practical approach to establish different groups of patients

BACKGROUND

Chronic kidney disease (CKD) is the convergent point of several pathological processes, and its evolution is insidious and characterized by a progressive and irreversible loss of kidney function. This impaired function induces the accumulation of uremic toxins and individuals with terminal CKD often have altered physiological responses, including a persistent state of immuno-suppression and development of diseases. A better characterization and stratification of these patients with CKD in different immuno-compromised groups would contribute to more effective and personalized treatments. The focus of this study was to use two parameters to stratify patients with CKD into four separate groups that are representative of different immunological status.

METHODS

Patients with CKD were chosen randomly and stratified into four separate groups according to the period of time receiving dialysis treatment and leukocyte blood counts. The amount of apoptotic CD4 T cells were measured in each group of patients, and clinical/hematological parameters were correlated by multivariate analysis with each group.

RESULTS

Observations reveal that one of the four groups of patients with CKD (group 3) had more apoptotic CD4 T cells than the other group; this group also had an increased malnutrition inflammation score (MIS), an elevated Kt/V, and a higher incidence of smoking.

CONCLUSION

A simple two-parameter-based stratification strategy could be used to design effective immunological therapies that differentiate the degrees of immuno-suppression across groups of patients with CKD.

Prevalence and mortality of chronic kidney disease in lymphoma patients: A large retrospective cohort study

In patients with lymphoma, an important issue that has been recognized is renal involvement, including glomerulonephritis, acute kidney injury, and lymphoma infiltrating the kidney. However, the prevalence and mortality of chronic kidney disease (CKD) have not been fully understood in lymphoma patients. This study aimed to evaluate the prevalence of CKD and its impact on mortality in those patients.This was a retrospective cohort study of 429 consecutive lymphoma patients who were admitted or regularly visited our hospital from January 2013 to October 2016. CKD was defined as estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m and/or proteinuria ≥ 1+ that was sustained for at least 3 months. The prevalence of CKD at enrollment was evaluated according to the modified CKD classification by Kidney Disease: Improving Global Outcomes (KDIGO) (eGFR and proteinuria category). Dipstick proteinuria was classified into 3 grades: A1 for - and ±; A2 for 1+ or 2+; and A3 for ≥3+. The eGFR (mL/min/1.73 m) was classified into 6 stages: G1 for ≥90, G2 for 60 to 89, G3a for 45 to 59, G3b for 30 to 44, G4 for 15 to 29, and G5 for <15. The cumulative mortality rate was estimated using the Kaplan-Meier method, with stratification into 2 groups based on the presence or absence of CKD. Furthermore, a multivariate Cox proportional hazards regression model was used to calculate the hazard ratio (HR) and its 95% confidence interval (CI) for all-cause mortality, after adjustments for age, sex, pathologic type, clinical stage of lymphoma, presence or absence of diabetes mellitus, hypertension, and cardiovascular disease.The mean follow-up period was 3.06 ± 0.96 years, and the prevalence of CKD at study enrollment was 34.5%. The cumulative mortality rate was 20.7%, and was significantly higher in the CKD group than in the group without CKD (36.4% vs 18.0%, P = .02). Multivariate analysis found mortality to be significantly associated with CKD (HR 1.58; 95% CI, 1.01-2.46), and this association was the most robust with very high-risk CKD (HR 6.94; 95% CI, 2.50-17.33).The prevalence of CKD in lymphoma patients was high. CKD should be considered an independent risk factor for mortality among patients with lymphoma.

Cellular senescence, senescence-associated secretory phenotype, and chronic kidney disease

Chronic kidney disease (CKD) is increasingly being accepted as a type of renal ageing. The kidney undergoes age-related alterations in both structure and function. To date, a comprehensive analysis of cellular senescence and senescence-associated secretory phenotype (SASP) in CKD is lacking. Hence, this review mainly discusses the relationship between the two phenomena to show the striking similarities between SASP and CKD-associated secretory phenotype (CASP). It has been reported that replicative senescence, stress-induced premature ageing, and epigenetic abnormalities participate in the occurrence and development of CKD. Genomic damage and external environmental stimuli cause increased levels of oxidative stress and a chronic inflammatory state as a result of irreversible cell cycle arrest and low doses of SASP. Similar to SASP, CASP factors activate tissue repair by multiple mechanisms. Once tissue repair fails, the accumulated SASP or CASP species aggravate DNA damage response (DDR) and cause the senescent cells to secrete more SASP factors, accelerating the process of cellular ageing and eventually leading to various ageing-related changes. It is concluded that cellular senescence and SASP participate in the pathological process of CKD, and correspondingly CKD accelerated the progression of cell senescence and the secretion of SASP. These results will facilitate the integration of these mechanisms into the care and management of CKD and other age-related diseases.

Preoperative chronic kidney disease predicts poor oncological outcomes after radical nephroureterectomy in patients with upper urinary tract urothelial carcinoma

Objective

To evaluate the impact of preoperative chronic kidney disease (CKD) on oncological outcomes in patients with upper tract urothelial carcinoma who underwent radical nephroureterectomy.

Methods

A total of 426 patients who underwent radical nephroureterectomy at five medical centers between February 1995 and February 2017 were retrospectively examined. Oncological outcomes, including intravesical recurrence-free, visceral recurrence-free, cancer-specific, and overall survival rates (intravesical RFS, visceral RFS, CSS, and OS, respectively) stratified by preoperative CKD status (CKD vs. non-CKD) were investigated. Cox proportional hazards regression analysis was performed using inverse probability of treatment weighting (IPTW) to evaluate the impact of preoperative CKD on prognosis and a prognostic factor-based risk stratification nomogram was developed.

Results

Of the 426 patients, 250 (59%) were diagnosed with CKD before radical nephroureterectomy. Before the background adjustment, intravesical RFS, visceral RFS, CSS, and OS after radical nephroureterectomy were significantly shorter in the CKD group than in the non-CKD group. Background-adjusted IPTW analysis demonstrated that preoperative CKD was significantly associated with poor visceral RFS, CSS, and OS after radical nephroureterectomy. Intravesical RFS was not significantly associated with preoperative CKD. The nomogram for predicting 5-year visceral RFS and CSS probability demonstrated a significant correlation with actual visceral RFS and CSS (c-index = 0.85 and 0.83, respectively).

Conclusions

Upper tract urothelial carcinoma patients with preoperative CKD had a significantly lower survival probability than those without CKD.

Factors associated with the elevated percentage of CD4CD69 T cells in maintained hemodialysis patients

Background: CD4 T-cell abnormality, influencing the outcome of the maintained hemodialysis (MHD), is common in patients on dialysis. We try to find out factors associated with the activated CD4 T cells, CD4CD69 T cells, to improve the dialysis quality.

Methods: A cross-sectional study was conducted to evaluate the change of CD4CD69 in MHD patients and healthy controls in our hospital from September 2015 to May 2016. A total of 164 MHD patients and 24 healthy controls were included according to the criteria. Univariate and multivariate logistic regression models after correlation analysis were executed to discover the related factors of CD4CD69 T-cell posterior to the division of the CD4CD69 T cell according to its median.

Results: The lymphocytes were lower, but the percentage of CD4CD69 T cells was higher in MHD patients compared with healthy controls, even after the propensity score matching based on age and sex. The percentage of CD4 T cells showed no significant difference between the two groups. Further multivariate logistic regression models revealed that CD4CD69 T cell was independently associated with serum total protein (OR 95%CI: 0.830[0.696, 0.990], p = .038), transferrin (OR 95%CI: 3.072[1.131, 8.342], p = .028) and magnesium (OR 95%CI: 16.960[1.030, 279.275], p = .048).

Conclusion: The percentage of CD4CD69 T cells, activated CD4 T cells, elevated in hemodialysis patients despite the decrease in lymphocytes. The elevated CD4CD69 T cells were independently associated with serum total protein negatively, but transferrin and magnesium positively. Strengthening nutrition, reducing the concentration of transferrin and magnesium might be beneficial to reduce the activation of CD4 T cells and improve the outcome of MHD patients.

Inflammation and premature aging in advanced chronic kidney disease

Systemic inflammation in end-stage renal disease is an established risk factor for mortality and a catalyst for other complications, which are related to a premature aging phenotype, including muscle wasting, vascular calcification, and other forms of premature vascular disease, depression, osteoporosis, and frailty. Uremic inflammation is also mechanistically related to mechanisms involved in the aging process, such as telomere shortening, mitochondrial dysfunction, and altered nutrient sensing, which can have a direct effect on cellular and tissue function. In addition to uremia-specific causes, such as abnormalities in the phosphate-Klotho axis, there are remarkable similarities between the pathophysiology of uremic inflammation and so-called "inflammaging" in the general population. Potentially relevant, but still somewhat unexplored in this respect, are abnormal or misplaced protein structures, as well as abnormalities in tissue homeostasis, which evoke danger signals through damage-associated molecular patterns, as well as the senescence-associated secretory phenotype. Systemic inflammation, in combination with the loss of kidney function, can impair the resilience of the body to external and internal stressors by reduced functional and structural tissue reserves, and by impairing normal organ crosstalk, thus providing an explanation for the greatly increased risk of homeostatic breakdown in this population. In this review, the relationship between uremic inflammation and a premature aging phenotype, as well as potential causes and consequences, are discussed.

pERK-dependent defective TCR-mediated activation of CD4+ T cells in end-stage renal disease patients

Background

Patients with end-stage renal disease (ESRD) have an impaired immune response with a prematurely aged T-cell system. Mitogen-activated protein kinases (MAPKs) including extracellular signal-regulated kinase (ERK) and p38, regulate diverse cellular programs by transferring extracellular signals into an intracellular response. T cell receptor (TCR)-induced phosphorylation of ERK (pERK) may show an age-associated decline, which can be reversed by inhibiting dual specific phosphatase (DUSP) 6, a cytoplasmic phosphatase with substrate specificity to dephosphorylate pERK. The aim of this study was to assess whether ESRD affects TCR-mediated signaling and explore possibilities for intervening in ESRD-associated defective T-cell mediated immunity.

Results

An age-associated decline in TCR-induced pERK-levels was observed in the different CD4⁺ (P < 0.05), but not CD8⁺, T-cell subsets from healthy individuals (HI). Interestingly, pERK-levels of CD4⁺ T-cell subsets from young ESRD patients were in between young and elderly HI. A differentiation-associated decline in TCR-induced ERK and p38 phosphorylation was observed in T cells, although TCR-induced p38 phosphorylation was not significantly affected by age and/or ESRD. Frequencies of TCR-induced CD69-expressing CD4⁺ T cells declined with age and were positively associated with pERK. In addition, an age-associated tendency of increased expression of DUSP6 was observed in CD4⁺ T cells of HI and DUSP6 expression in young ESRD patients was similar to old HI. Inhibition of DUSP6 significantly increased TCR-induced pERK-levels of CD4⁺ T cells in young and elderly ESRD patients, and elderly HI.

Conclusions

TCR-mediated phosphorylation of ERK is affected in young ESRD patients consistent with the concept of premature immunological T cell ageing. Inhibition of DUSP6 specific for pERK might be a potential intervention enhancing T-cell mediated immunity in ESRD patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s12979-017-0096-1) contains supplementary material, which is available to authorized users.

Pre-transplant immune factors may be associated with BK polyomavirus reactivation in kidney transplant recipients

BK polyomavirus (BKPyV) reactivation in kidney transplant recipients can lead to allograft damage and loss. The elements of the adaptive immune system that are permissive of reactivation and responsible for viral control remain incompletely described. We performed a prospective study evaluating BKPyV-specific T-cell response, humoral response and overall T-cell phenotype beginning pre-transplant through one year post-transplant in 28 patients at two centers. We performed an exploratory analysis of risk factors for the development of viremia and viruria as well as compared the immune response to BKPyV in these groups and those who remained BK negative. 6 patients developed viruria and 3 developed viremia. BKPyV-specific CD8⁺ T-cells increased post-transplant in viremic and viruric but not BK negative patients. BKPyV-specific CD4⁺ T-cells increased in viremic, but not viruric or BK negative patients. Anti-BKPyV IgG antibodies increased in viruric and viremic patients but remained unchanged in BK negative patients. Viremic patients had a greater proportion of CD8⁺ effector cells pre-transplant and at 12 months post-transplant. Viremic patients had fewer CD4⁺ effector memory cells at 3 months post-transplant. Exploratory analysis demonstrated lower CD4 and higher total CD8 proportions, higher anti-BKPyV antibody titers and the cause of renal failure were associated BKPyV reactivation. In conclusion, low CD4, high CD8 and increased effector CD8 cells were found pre-transplant in patients who became viremic, a phenotype associated with immune senescence. This pre-transplant T-cell senescence phenotype could potentially be used to identify patients at increased risk of BKPyV reactivation.

Preoperative chronic kidney disease predicts poor oncological outcomes after radical cystectomy in patients with muscle-invasive bladder cancer

OBJECTIVE

To evaluate the impact of preoperative chronic kidney disease (CKD) on oncologic outcomes in muscle-invasive bladder cancer patients who underwent radical cystectomy.

METHODS

A total of 581 patients who underwent radical cystectomy at four medical centers between January 1995 and February 2017 were examined retrospectively. We investigated oncologic outcomes, including progression-free, cancer-specific, and overall survival (PFS, CSS, and OS, respectively) stratified by preoperative CKD status (pre-CKD vs. non-CKD). We performed a Cox proportional hazards regression analysis using inverse probability of treatment weighting (IPTW) to evaluate the impact of preoperative CKD on prognosis and developed the prognostic factor-based risk stratification nomogram.

RESULTS

Of the 581 patients, 215 (37%) were diagnosed with CKD before radical cystectomy. Before the background adjustment, PFS, CSS, and OS after radical cystectomy were significantly lower in the pre-CKD group compared to the non-CKD group. Background-adjusted IPTW analysis showed that preoperative CKD was significantly associated with poor PFS, CSS, and OS after radical cystectomy. The nomogram for predicting 5-year PFS and OS probability showed significant correlation with actual PFS and OS (c-index = 0.73 and 0.77, respectively).

CONCLUSIONS

Muscle-invasive bladder cancer patients with preoperative CKD had a significantly lower survival probability than those without CKD.

Restoration of immune and renal function in aged females by re-establishment of active ovarian function

Proper immune functioning is necessary to maximize reproductive success. In addition, age-associated uremia in women is often associated with hypothalamic­–pituitary–gonadal dysfunction. In the present experiments, we tested immune and renal function to determine if exposure of postreproductive mice to young, reproductively cycling ovaries would influence non-reproductive physiological functions. Control female CBA/J mice were evaluated at 6, 13 and 16 months of age. Additional mice received new (60-day-old) ovaries at 12 months of age and were evaluated at 16 months of age. Consequently, 6-month-old control mice and 16-month-old recipient mice both possessed 6-month-old ovaries and were reproductively cycling. A significant age-related decline in immune function (T-cell subset analysis) was found in 16-month-old mice, but was improved 64% by ovarian transplantation. Renal function (blood urea nitrogen : creatinine ratio) was also decreased with aging, but ovarian transplantation restored function to levels found in 6-month-old mice. In summary, we have shown that immune and renal function, which are negatively influenced by aging, can be positively influenced or restored by re-establishment of active ovarian function in aged female mice. These findings provide a strong incentive for further investigation of the positive influence of young ovaries on restoration of health in postreproductive females.

Maintenance of Mycobacterium tuberculosis-specific T cell responses in End Stage Renal Disease (ESRD) and implications for diagnostic efficacy

End-stage renal disease (ESRD) patients exhibit elevated risk of tuberculosis (TB) reactivation, but current diagnostics, including the interferon gamma release assay (IGRA), exhibit poor sensitivity in ESRD. We tested 80 ESRD patients and found an 18.75% prevalence of IGRA positivity. A subset of patients was assessed for Mtb-specific expression of 44 cytokines/chemokines, and CD4+ T cell phenotype and function. Similar to non-ESRD IGRA+ individuals, Mtb-specific IFNγ, IL-1RA, IP-10, MCP-3 and IL-2 responses were identified in the ESRD IGRA+ group. 27% of the ESRD IGRA- group exhibited MCP-3 or IL-2 Mtb-specific responses, which may identify cases of latent TB infection in ESRD. Stimulation of PBMC with PPD demonstrated similar CD4+ T cell production of IFNγ, TNFα and GM-CSF by ESRD patients. The reported low sensitivity of the IGRA in ESRD cohorts is therefore unlikely to be due to poor T cell cytokine secretion, and may instead reflect defects in antigen presentation.

Neutrophil-Lymphocyte Ratio Is Significantly Decreased in Preemptive Renal Transplant Patients

AIM

Cardiovascular diseases and infections are the leading two causes of morbidity and mortality in end-stage renal disease (ESRD) patients. Kidney transplantation is the preferred method for renal replacement owing to better survival. There are reports of irreversibly damaged immune system in dialysis patients, which did not return to normal even after kidney transplantation. The neutrophil-lymphocyte ratio (NLR) is an easily applicable method for evaluation of inflammation. We hypothesized that preemptive kidney transplantation can improve inflammatory state compared with nonpreemptive recipients. To test our hypothesis, we retrospectively investigated pretransplant and posttransplant NLR and C-reactive protein (CRP) levels of ESRD patients and compared them with values in healthy controls.

MATERIALS AND METHODS

We retrospectively analyzed NLR, CRP, and other hematologic parameters of ESRD patients who were transplanted between January 2005 and January 2014 on the day of transplantation and at the end of first year. We grouped the patients as preemptive and nonpreemptive ones. We excluded patients with coronary artery disease, obesity, hypotension, hyperthyroidism, uncontrolled diabetes mellitus, hematologic or solid organ cancers, and active documented infection at any evaluation period.

RESULTS

We included 137 ESRD patient and 34 healthy control individual in our study. Of the 137 ESRD patients, 52 (38%) were transplanted preemptively. Of the patients, 85 were already on either hemodialysis or peritoneal dialysis therapy at the time of transplantation. The white blood cell count value of the patient and control group (7246.72 ± 1460.26 and 76661.76 ± 1286.29, respectively; P = .43), NLR of the control group was significantly lower than patient group (1.98 ± 0.94 and 3.47 ± 2.33, respectively; P = .007). The NLR of the preemptive group was decreased substantially at the end of first year posttransplantation, the NLR of the preemptive group was significantly lower than the nonpreemptive group (3.08 ± 1.32 and 3.71 ± 2.33; P = .01).

CONCLUSIONS

We showed that all ESRD patients had an increased inflammation rate according to CRP and NLR when compared with healthy controls. We also found that improvement of inflammatory state in preemptive patients is significantly better than nonpreemptive patients at the end of first year evaluation.

High Mortality of Cirrhotic Patients With End-Stage Renal Disease

Ascites, hepatic encephalopathy (HE), and esophageal variceal bleeding (EVB) are 3 major complications in patients with cirrhosis. Limited data exist with which to evaluate the long-term mortality of end-stage renal disease (ESRD) in cirrhotic patients with or without complications.The National Health Insurance Database in Taiwan was used to identify patients with cirrhosis hospitalized between January 1, 2007, and December 31, 2007. The study group consisted of 1068 cirrhotic patients with ESRD, and the control group consisted of 10,680 randomly selected cirrhotic patients without baseline renal function impairment.The overall 1-year and 3-year mortality rates were 48.5% and 73.1% in the ESRD group, and 32.9% and 55.6% in the control group, respectively. After adjusting for other comorbid disorders, the cirrhotic patients with ESRD showed a statistically significant increase in 3-year mortality (hazard ratio [HR], 1.65; P < 0.001). The HR for 3-year mortality of ESRD cirrhotic patients with recurrent complications was 1.98 (P < 0.001), compared to those with no recent or past complications. The HR of ESRD for 3-year mortality was 1.48 (P < 0.001) in cirrhotic patients with ascites, 1.67 (P < 0.001) in patients with EVB, and 1.19 (P = 0.147) in patients with HE.ESRD increases the mortality rate in patients with cirrhosis. Recurrent complications can account for a 2-fold increase in the 3-year mortality of ESRD cirrhotic patients. ESRD has a smaller impact on the 3-year mortality of cirrhotic patients with HE compared to those with ascites or EVB.

C-reactive Protein: Repeated Measurements will Improve Dialysis Patient Care

Systemic inflammation is a common feature in the uremic phenotype and associates with poor outcomes. The awareness regarding the importance of inflammation assessment in chronic kidney disease (CKD) patients has risen in recent years, and despite the development of novel biomarkers, C-reactive protein (CRP) is still the most measured inflammatory parameter. Notwithstanding, the possible weak points of CRP determination, this biomarker has demonstrated being useful both for guidance in clinical practice and for risk estimation. In addition, regular determination of CRP among dialysis patients has been associated with better outcomes in different dialysis facilities. Because persistent inflammation may be a silent reflection of various pathophysiologic alterations in CKD, it is crucial that inflammatory markers are regularly monitored and therapeutic attempts be made to target this inflammation.

Reduction or discontinuation of antibiotic prophylaxis in vascular access surgery, tendon sheath incision and PD catheter placement

PURPOSE

Immune response in dialysis patients is suppressed and these patients are susceptible to bacterial infections. Therefore, minimal use of antibiotics in dialysis patients is recommended to avoid generating drug-resistant bacteria. However, minor surgeries including vascular access surgery, tendon sheath incision and peritoneal dialysis (PD) catheter placement are inevitable in dialysis patients and evidence-based recommendations on the judicious use of antibiotics are not currently available for these procedures. In this study, the optimal antibiotic prophylaxis for minor surgeries was evaluated.

METHODS

This is a retrospective study. In dialysis patients at Kawashima Hospital, a three-step reduction of antibiotic use was performed in 651 cases of arteriovenous fistula (AVF) and tendon sheath incision surgeries from July 2009 through October 2012. Moreover, general surgical guidelines-recommended dose of preoperative antibiotics only were used in 532 cases of arteriovenous graft (AVG) and PD catheter placement from January 2010 through October 2012. The surgical site was observed for 2 weeks after the surgery.

RESULTS

In only one case of AVF surgery, redness of the skin around the stitches was noticed 5 days after the surgery, which was healed with antibiotics taken orally for 3 days. Neither AVG nor PD catheter placement demonstrated any infection at the surgical site during the 2-week observation period.

CONCLUSIONS

Even in dialysis patients, neither pre- nor postoperative antibiotics are necessary for AVF and tendon sheath incision surgeries. AVG and PD catheter placement surgeries require only a small amount of antibiotics preoperatively.