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Law MM, Tan SJ, Wong MC, Toussaint ND. Atrial Fibrillation in Kidney Failure: Challenges in Risk Assessment and Anticoagulation Management. Kidney Med 2023; 5:100690. [PMID: 37547561 PMCID: PMC10403723 DOI: 10.1016/j.xkme.2023.100690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/08/2023] Open
Abstract
Management of atrial fibrillation (AF) is a clinical conundrum in people with kidney failure. Stroke risk is disproportionately high, but clinicians have a limited armamentarium to improve outcomes in this population in whom there is a concurrently high bleeding risk. Direct oral anticoagulants may have a superior benefit-risk profile compared with vitamin K antagonists in people on hemodialysis. Although research has predominantly focused on identifying a safe and effective oral anticoagulation option to reduce stroke risk in people with kidney failure (and predominantly those on hemodialysis), it remains uncertain how clinicians discriminate between people who would derive net clinical benefit as opposed to net harm. The recommended CHA2DS2-VASc score cutoffs provide poor discriminatory value, and there is an urgent need to identify robust markers of thromboembolic risk in kidney failure. There is increasing data to challenge the prior dogma of risk equivalence across AF type, and the American Heart Association highlights moving beyond AF as a binary entity to consider the prognostic significance of AF burden. Implantable cardiac monitor studies reveal high rates and varied burden of subclinical and paroxysmal AF in people on hemodialysis. The association between AF burden and the proarrhythmic environment of hemodialysis with cyclical volume loading, offloading, and electrolyte changes is not well studied. We review the significance of AF burden as a contributor to thromboembolic risk, its potential as the missing link in risk assessment, and updated evidence for anticoagulation in people with kidney failure.
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Affiliation(s)
- Mandy M. Law
- Department of Nephrology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Sven-Jean Tan
- Department of Nephrology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Michael C.G. Wong
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
- Department of Cardiology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Nigel D. Toussaint
- Department of Nephrology, the Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
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2
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Bendall AC, See EJ, Toussaint ND, Fazio T, Tan SJ. Community-acquired versus hospital-acquired acute kidney injury at a large Australian metropolitan quaternary referral centre: incidence, associations and outcomes. Intern Med J 2023; 53:1366-1375. [PMID: 35491485 DOI: 10.1111/imj.15787] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/06/2022] [Accepted: 04/18/2022] [Indexed: 08/22/2023]
Abstract
BACKGROUND There is increasing global incidence of acute kidney injury (AKI) and significant short- and long-term impacts on patients. AIMS To determine incidence and outcomes of community-acquired AKI (CA-AKI) and hospital-acquired AKI (HA-AKI) among inpatients in the Australian healthcare setting using modern health information systems. METHODS A retrospective cohort study of adult patients admitted to a quaternary hospital in Melbourne, Australia, between 1 January 2018 and 31 December 2019 utilising an electronic data warehouse. Participants included adult patients admitted for >24 h who had more than one serum creatinine level recorded during admission. Kidney transplant and maintenance dialysis patients were excluded. Main outcomes measured included AKI, as classified by the Kidney Disease Improving Global Outcomes (KDIGO) criteria, hospital length of stay and 30-day mortality. RESULTS A total of 6477 AKI episodes was identified across 43 791 admissions. Of all AKI episodes, 77% (n = 5011), 15% (n = 947) and 8% (n = 519) were KDIGO stage 1, 2 and 3 respectively. HA-AKI accounted for 55.9% episodes. Patients required intensive care unit admission in 22.7% (n = 1100) of CA-AKI and 19.3% (n = 935) of HA-AKI, compared with 7.5% (n = 2815) of patients with no AKI (P = 0.001). Patients with AKI were older with more co-morbidities, particularly chronic kidney disease (CKD). Length of stay was longer in CA-AKI (8.8 days) and HA-AKI (11.8 days) compared with admissions without AKI (4.9 days; P < 0.001). Thirty-day mortality was increased with CA-AKI (10.2%) and HA-AKI (12.8%) compared with no AKI (3.7%; P < 0.001). CONCLUSION The incidence of AKI detected by the electronic data warehouse was higher than previously reported. Patients who experienced AKI had greater morbidity and mortality. CKD was an important risk factor for AKI in hospitalised patients.
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Affiliation(s)
- Anna C Bendall
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Emily J See
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine (RMH), University of Melbourne, Melbourne, Victoria, Australia
| | - Timothy Fazio
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Business Intelligence Unit, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Sven-Jean Tan
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine (RMH), University of Melbourne, Melbourne, Victoria, Australia
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3
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Martin K, Toussaint ND, Tan SJ, Hewitson TD. Skin regulation of salt and blood pressure and potential clinical implications. Hypertens Res 2023; 46:408-416. [PMID: 36434290 DOI: 10.1038/s41440-022-01096-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/12/2022] [Accepted: 10/20/2022] [Indexed: 11/27/2022]
Abstract
Sodium chloride, as salt, gives rise to hypertension. Nevertheless, individual susceptibility to the ramifications of sodium chloride is heterogeneous. The conventional nephron-centric regulation of sodium with neurohormonal inputs and responses is now expanded to include an intricate extrarenal pathway including the endothelium, skin, lymphatics, and immune cells. An overabundance of sodium is buffered and regulated by the skin interstitium. Excess sodium passes through (and damages) the vascular endothelium and can be dynamically stored in the skin, modulated by skin immune cells and lymphatics. This excess interstitially stored sodium is implicated in hypertension, cardiovascular dysfunction, metabolic disruption, and inflammatory dysregulation. This extrarenal pathway of regulating sodium represents a novel target for better blood pressure management, rebalancing disturbed inflammation, and hence addressing cardiovascular and metabolic disease.
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Affiliation(s)
- Kylie Martin
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia. .,Department of Medicine, University of Melbourne, Parkville, Victoria, Australia.
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Sven-Jean Tan
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
| | - Timothy D Hewitson
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine, University of Melbourne, Parkville, Victoria, Australia
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4
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Martin K, Venkatraman V, Agostinelli A, Thai B, Stäb D, Hewitson TD, Tan SJ, Toussaint ND, Robertson P. Magnetic Resonance Imaging (MRI) Analysis of Tissue Sodium Concentration in Chronic Kidney Disease. Methods Mol Biol 2023; 2664:161-171. [PMID: 37423989 DOI: 10.1007/978-1-0716-3179-9_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
Human body sodium is regulated by the kidneys and extrarenal mechanisms. Stored skin and muscle tissue sodium accumulation is associated with kidney function decline, hypertension, and a pro-inflammatory and cardiovascular disease profile. In this chapter, we describe the use of sodium-hydrogen magnetic resonance imaging (23Na/1H MRI) to dynamically quantify tissue sodium concentration in the lower limb of humans. Real-time quantification of tissue sodium is calibrated against known sodium chloride aqueous concentrations. This method may be useful for investigating in vivo (patho-)physiological conditions associated with tissue sodium deposition and metabolism (including in relation to water regulation) to enlighten our understanding of sodium physiology.
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Affiliation(s)
- Kylie Martin
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Melbourne, VIC, Australia.
- Department of Medicine (RMH), University of Melbourne, Melbourne, VIC, Australia.
| | - Vijay Venkatraman
- Department of Radiology, The Royal Melbourne Hospital and The University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - Angela Agostinelli
- Department of Radiology, The Royal Melbourne Hospital and The University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - Braden Thai
- Department of Radiology, The Royal Melbourne Hospital and The University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - Daniel Stäb
- MR Research Collaborations, Siemens Healthcare Pty Limited, Melbourne, VIC, Australia
| | - Tim D Hewitson
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Melbourne, VIC, Australia
- Department of Medicine (RMH), University of Melbourne, Melbourne, VIC, Australia
| | - Sven-Jean Tan
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Melbourne, VIC, Australia
- Department of Medicine (RMH), University of Melbourne, Melbourne, VIC, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Melbourne, VIC, Australia
- Department of Medicine (RMH), University of Melbourne, Parkville, Melbourne, VIC, Australia
| | - Patsy Robertson
- Department of Radiology, The Royal Melbourne Hospital and The University of Melbourne, Parkville, Melbourne, VIC, Australia
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5
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Lomax-Browne HJ, Medjeral-Thomas NR, Barbour SJ, Gisby J, Han H, Bomback AS, Fervenza FC, Cairns TH, Szydlo R, Tan SJ, Marks SD, Waters AM, Appel GB, D'Agati VD, Sethi S, Nast CC, Bajema I, Alpers CE, Fogo AB, Licht C, Fakhouri F, Cattran DC, Peters JE, Cook HT, Pickering MC. Association of Histologic Parameters with Outcome in C3 Glomerulopathy and Idiopathic Immunoglobulin-Associated Membranoproliferative Glomerulonephritis. Clin J Am Soc Nephrol 2022; 17:994-1007. [PMID: 35777834 PMCID: PMC9269630 DOI: 10.2215/cjn.16801221] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 05/16/2022] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES C3 glomerulopathy and idiopathic Ig-associated membranoproliferative GN are kidney diseases characterized by abnormal glomerular complement C3 deposition. These conditions are heterogeneous in outcome, but approximately 50% of patients develop kidney failure within 10 years. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS To improve identification of patients with poor prognosis, we performed a detailed analysis of percutaneous kidney biopsies in a large cohort of patients. Using a validated histologic scoring system, we analyzed 156 native diagnostic kidney biopsies from a retrospective cohort of 123 patients with C3 glomerulopathy and 33 patients with Ig-associated membranoproliferative GN. We used linear regression, survival analysis, and Cox proportional hazards models to assess the relationship between histologic and clinical parameters with outcome. RESULTS Frequent biopsy features were mesangial expansion and hypercellularity, glomerular basement membrane double contours, and endocapillary hypercellularity. Multivariable analysis showed negative associations between eGFR and crescents, interstitial inflammation, and interstitial fibrosis/tubular atrophy. Proteinuria positively associated with endocapillary hypercellularity and glomerular basement membrane double contours. Analysis of second native biopsies did not demonstrate associations between immunosuppression treatment and improvement in histology. Using a composite outcome, risk of progression to kidney failure associated with eGFR and proteinuria at the time of biopsy, cellular/fibrocellular crescents, segmental sclerosis, and interstitial fibrosis/tubular atrophy scores. CONCLUSIONS Our detailed assessment of kidney biopsy data indicated that cellular/fibrocellular crescents and interstitial fibrosis/tubular atrophy scores were significant determinants of deterioration in kidney function.
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Affiliation(s)
- Hannah J Lomax-Browne
- Department for Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College London, London, United Kingdom
| | - Nicholas R Medjeral-Thomas
- Department for Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College London, London, United Kingdom
| | - Sean J Barbour
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jack Gisby
- Department for Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College London, London, United Kingdom
| | - Heedeok Han
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, New York
| | - Andrew S Bomback
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, New York
| | | | - Thomas H Cairns
- West London Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Richard Szydlo
- Department for Immunology and Inflammation, Centre for Haematology, Imperial College London, London, United Kingdom
| | - Sven-Jean Tan
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Stephen D Marks
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom.,National Institute for Health Research Great Ormond Street Hospital Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Aoife M Waters
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Gerald B Appel
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, New York
| | - Vivette D D'Agati
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York
| | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Cynthia C Nast
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Ingeborg Bajema
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands
| | - Charles E Alpers
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington
| | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Christoph Licht
- Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Fadi Fakhouri
- Service of Nephrology and Hypertension, Department of Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Daniel C Cattran
- Toronto General Research Institute, Division of Nephrology, University of Toronto, Toronto, Ontario, Canada
| | - James E Peters
- Department for Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College London, London, United Kingdom
| | - H Terence Cook
- Department for Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College London, London, United Kingdom
| | - Matthew C Pickering
- Department for Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College London, London, United Kingdom
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6
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Tiong MK, Cai MMX, Toussaint ND, Tan SJ, Pasch A, Smith ER. Effect of nutritional calcium and phosphate loading on calciprotein particle kinetics in adults with normal and impaired kidney function. Sci Rep 2022; 12:7358. [PMID: 35513558 PMCID: PMC9072391 DOI: 10.1038/s41598-022-11065-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 03/31/2022] [Indexed: 12/20/2022] Open
Abstract
Plasma approaches metastability with respect to its calcium and phosphate content, with only minor perturbations in ionic activity needed to sustain crystal growth once nucleated. Physiologically, calcium and phosphate are intermittently absorbed from the diet each day, yet plasma concentrations of these ions deviate minimally post-prandially. This implies the existence of a blood-borne mineral buffer system to sequester calcium phosphates and minimise the risk of deposition in the soft tissues. Calciprotein particles (CPP), endogenous mineral-protein colloids containing the plasma protein fetuin-A, may fulfill this function but definitive evidence linking dietary mineral loading with their formation is lacking. Here we demonstrate that CPP are formed as a normal physiological response to feeding in healthy adults and that this occurs despite minimal change in conventional serum mineral markers. Further, in individuals with Chronic Kidney Disease (CKD), in whom mineral handling is impaired, we show that both fasting and post-prandial levels of CPP precursors are markedly augmented and strongly inversely correlated with kidney function. This study highlights the important, but often neglected, contribution of colloidal biochemistry to mineral homeostasis and provides novel insight into the dysregulation of mineral metabolism in CKD.
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Affiliation(s)
- Mark K Tiong
- Department of Nephrology, The Royal Melbourne Hospital, Grattan Street, Parkville, VIC, 3052, Australia. .,Department of Medicine (RMH), University of Melbourne, Parkville, Australia.
| | - Michael M X Cai
- Department of Nephrology, The Royal Melbourne Hospital, Grattan Street, Parkville, VIC, 3052, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Grattan Street, Parkville, VIC, 3052, Australia.,Department of Medicine (RMH), University of Melbourne, Parkville, Australia
| | - Sven-Jean Tan
- Department of Nephrology, The Royal Melbourne Hospital, Grattan Street, Parkville, VIC, 3052, Australia.,Department of Medicine (RMH), University of Melbourne, Parkville, Australia
| | - Andreas Pasch
- Calciscon AG, Biel, Switzerland.,Lindenhofspital Bern, Bern, Switzerland.,Department of Physiology and Pathophysiology, Johannes Kepler University, Linz, Austria
| | - Edward R Smith
- Department of Nephrology, The Royal Melbourne Hospital, Grattan Street, Parkville, VIC, 3052, Australia. .,Department of Medicine (RMH), University of Melbourne, Parkville, Australia.
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7
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Martin K, Tan SJ, Toussaint ND. Magnetic resonance imaging determination of tissue sodium in patients with chronic kidney disease. Nephrology (Carlton) 2021; 27:117-125. [PMID: 34510658 DOI: 10.1111/nep.13975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/05/2021] [Accepted: 09/06/2021] [Indexed: 11/30/2022]
Abstract
Excess sodium is a major modifiable contributor to hypertension and cardiovascular risk. Knowledge of sodium storage and metabolism has derived mainly from indirect measurements of dietary sodium intake and urinary sodium excretion, however both attempt to measure body sodium and fluid in a two-compartment model of intracellular and extracellular spaces. Our understanding of total body sodium has recently included a storage pool in tissues. In the last two decades, sodium-23 magnetic resonance imaging (23 Na MRI) has allowed dynamic quantification of tissue sodium in vivo. Tissue sodium is independently associated with cardiovascular dysfunction and inflammation. This review explores (i) The revolution of our understanding of sodium physiology, (ii) The development and potential clinical adoption of 23 Na MRI to provide improved measurement of total body sodium in CKD and (iii) How we can better understand mechanistic and clinical implications of tissue sodium in hypertension, cardiovascular disease and immune dysregulation, especially in the CKD population.
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Affiliation(s)
- Kylie Martin
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine (RMH), University of Melbourne, Parkville, Victoria, Australia
| | - Sven-Jean Tan
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine (RMH), University of Melbourne, Parkville, Victoria, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine (RMH), University of Melbourne, Parkville, Victoria, Australia
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8
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Tiong MK, Ullah S, McDonald SP, Tan SJ, Lioufas NM, Roberts MA, Toussaint ND. Serum phosphate and mortality in incident dialysis patients in Australia and New Zealand. Nephrology (Carlton) 2021; 26:814-823. [PMID: 34046973 DOI: 10.1111/nep.13904] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Revised: 04/19/2021] [Accepted: 05/21/2021] [Indexed: 12/22/2022]
Abstract
AIM Hyperphosphataemia is associated with increased adverse outcomes, including mortality. Re-examining this association using up-to-date data reflecting current and real-world practices, across different global regions and in both haemodialysis and peritoneal dialysis patients, is important. METHODS We describe the association between serum phosphate and all-cause and cardiovascular mortality in incident dialysis patients between 2008 and 2018 using the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Time-dependent Cox proportionate hazards models were used. Models were adjusted for available covariates and fitted for the overall cohort, and also each dialysis modality. RESULTS 31 989 patients were followed over 97 122 person-years at risk (mean age at first dialysis 61 years, 38% female, 67% haemodialysis). We observed a U-shaped association between serum phosphate and all-cause mortality. In the fully adjusted model, categories of serum phosphate above and below 1.25-1.99 mmol/L were associated with progressively higher risk, reaching a hazard ratio of 2.13 (95% CI 1.93-2.36, p < .001) for serum phosphate ≥2.75 mmol/L, and 1.56 (95% CI 1.44-1.69, p < .001) for serum phosphate <1.00 mmol/L. Low and high levels of serum phosphate were also associated with increased risk of cardiovascular mortality, however the association with high serum phosphate was more pronounced ("J-shaped relationship"). The associations were consistent across sub-analyses of patients receiving haemodialysis and peritoneal dialysis treatment. CONCLUSION In this large contemporary dialysis cohort, both high and low levels of serum phosphate were independently associated with increased risk of mortality. Future studies are required to determine whether treatment of abnormal serum phosphate levels improves mortality.
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Affiliation(s)
- Mark K Tiong
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine (RMH), University of Melbourne, Parkville, Australia
| | - Shahid Ullah
- Australian and New Zealand Dialysis and Transplant Registry, Adelaide, Australia
| | - Stephen P McDonald
- Australian and New Zealand Dialysis and Transplant Registry, Adelaide, Australia.,Central and Northern Renal and Transplantation Service, Central Adelaide Local Health Network, Adelaide, Australia.,Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Sven-Jean Tan
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine (RMH), University of Melbourne, Parkville, Australia
| | - Nicole M Lioufas
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine (RMH), University of Melbourne, Parkville, Australia.,Department of Nephrology, Western Health, Footscray, Australia
| | - Matthew A Roberts
- Eastern Health Clinical School, Monash University, Box Hill, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine (RMH), University of Melbourne, Parkville, Australia
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Bendall AC, Tan SJ, See EJ, Toussaint ND. Electronic alerts for early detection of acute kidney injury: considering their implementation in Australian hospitals. Med J Aust 2021; 214:347-349.e1. [PMID: 33847000 DOI: 10.5694/mja2.51024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 11/10/2020] [Accepted: 11/12/2020] [Indexed: 01/07/2023]
Affiliation(s)
| | - Sven-Jean Tan
- Royal Melbourne Hospital, Melbourne, VIC.,University of Melbourne, Melbourne, VIC
| | - Emily J See
- Royal Melbourne Hospital, Melbourne, VIC.,Austin Health, Melbourne, VIC
| | - Nigel D Toussaint
- Royal Melbourne Hospital, Melbourne, VIC.,University of Melbourne, Melbourne, VIC
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10
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Tan SJ, Zhang ZG, Wu GH. [Advances in the prevention and treatment of postoperative ileus]. Zhonghua Wai Ke Za Zhi 2020; 58:642-645. [PMID: 32727197 DOI: 10.3760/cma.j.cn112139-20200216-00090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
With the development and progress in the concepts and techniques of perioperative management, especially the latest reports of clinical trials, the prospect of prevention and treatment of postoperative ileus (POI) is promising. Proper nutritional support therapy, optimized surgical and anesthetic treatment, individualized fluid management, timely psychosocial intervention, and active anti-inflammation and traditional Chinese medicine treatment can effectively reduce occurrence of POI. Nevertheless, how to optimize and combine perioperative treatments to comprehensively prevent and treat POI still needs further study.
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Affiliation(s)
- S J Tan
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai Clinical Nutrition Research Center, Shanghai 200032, China
| | - Z G Zhang
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai Clinical Nutrition Research Center, Shanghai 200032, China
| | - G H Wu
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai Clinical Nutrition Research Center, Shanghai 200032, China
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Tan SJ, Jiang Y, Xi QL, Meng QY, Zhuang QL, Han YS, Wu GH. [Meta-analysis of laparoscopic versus open surgery for palliative resection of the primary tumor in stage IV colorectal cancer]. Zhonghua Wei Chang Wai Ke Za Zhi 2020; 23:589-596. [PMID: 32521980 DOI: 10.3760/cma.j.cn.441530-20190619-00247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To systematically evaluate the safety and efficacy of laparoscopic versus open surgery for palliative resection of the primary tumor in stage IV colorectal cancer. Methods: The databases of CNKI, Wanfang, VIP, PubMed, EMBASE and Cochrane Library were searched to retrieve randomized controlled trials (RCT) or clinical controlled trials (CCT) comparing laparoscopic surgery with open surgery for palliative resection of the primary tumor in stage IV colorectal cancer published from January 1991 to May 2019. Chinese search terms included "colorectum/colon/rectum" , "cancer/malignant tumor" , "laparoscopy" , "metastasis" , " IV" ; English search terms included "laparoscop*" , "colo*" , "rect*" , "cancer/tumor/carcinoma/neoplasm" , " IV" , "metasta*" . Inclusion criteria: (1) RCT or CCT, with or without allocation concealment or blinding; (2) patients with stage IV colorectal cancer that was diagnosed preoperatively and would receive resection of the primary tumor; (3) the primary tumor that was palliatively resected by laparoscopic or open procedure. Exclusion criteria: (1) no valid data available in the literature; (2) single study sample size ≤20; (3) subjects with colorectal benign disease; (4) metastatic resection or lymph node dissection was performed intraoperatively in an attempt to perform radical surgery; (5) duplicate publication of the literature. Two researchers independently evaluated the quality of the included studies. In case of disagreement, the evaluation was performed by discussion or a third researcher was invited to participate. The data were extracted from the included studies, and the Cochrane Collaboration RevMan 5.1.0 version software was used for this meta-analysis. Results: Four CCTs with a total of 864 patients were included in this study, including 216 patients in the laparoscopic group and 648 patients in the open group. Compared with the open group, except for longer operation time (WMD=37.60, 95% CI: 26.11 to 49.08, P<0.05), laparoscopic group had less intraoperative blood loss (WMD=-74.89, 95% CI: -144.78 to -5.00, P<0.05), earlier first flatus and food intake after surgery (WMD=-1.00, 95% CI: -1.12 to -0.87, P<0.05; WMD=-1.61, 95%CI: -2.16 to -1.06, P<0.05), shorter hospital stay (WMD=-2.01, 95% CI: -2.21 to -1.80, P<0.05) and lower morbidity of postoperative complication (OR=0.52, 95% CI: 0.35 to 0.77, P<0.05). However, no significant differences were found in time to start postoperative chemotherapy, postoperative chemotherapy rate, and mortality (P > all 0.05). Conclusion: Laparoscopic surgery for palliative resection of the primary tumor is safe and feasible to enhance recovery after surgery by promoting postoperative bowel function recovery, shortening hospital stay and reducing postoperative complication in stage IV colorectal cancer.
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Affiliation(s)
- S J Tan
- Department of General Surgery, Shanghai Clinical Nutrition Research Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Y Jiang
- Department of General Surgery, Shanghai Clinical Nutrition Research Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Q L Xi
- Department of General Surgery, Shanghai Clinical Nutrition Research Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Q Y Meng
- Department of General Surgery, Shanghai Clinical Nutrition Research Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Q L Zhuang
- Department of General Surgery, Shanghai Clinical Nutrition Research Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Y S Han
- Department of General Surgery, Shanghai Clinical Nutrition Research Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - G H Wu
- Department of General Surgery, Shanghai Clinical Nutrition Research Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
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12
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Tan SJ, Chu MM, Toussaint ND, Cai MM, Hewitson TD, Holt SG. High-intensity physical exercise increases serum α-klotho levels in healthy volunteers. J Circ Biomark 2018; 7:1849454418794582. [PMID: 30147756 PMCID: PMC6100126 DOI: 10.1177/1849454418794582] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2018] [Accepted: 07/02/2018] [Indexed: 01/16/2023] Open
Abstract
The recently discovered klotho proteins have roles in a diverse range of metabolic processes with the oldest protein, α-klotho, implicated in various cellular pathways in energy, glucose, and phosphate metabolism. Circulating soluble klotho (sKl), derived from membrane α-klotho cleavage, not only has effects on ion channels and insulin signaling pathways, but is inversely associated with mortality. Effects of physical exercise on sKl have not been well studied. The effect of a single high-intensity standardized exercise on sKl and serum phosphate (sPi) levels in healthy adults was investigated. A standard Bruce protocol treadmill exercise was undertaken by 10 fasting healthy volunteers. sKl, sPi, and blood glucose levels were measured in samples collected 1-week prior, immediately pre (Tpre), 0 (Tpost), 30 (T30), 240 (T240) min, and 1-week after exercise. Median (interquartile range) age of participants was 47.5 (44-51) years; five (50%) were male. All study participants achieved at least 90% predicted maximum heart rate (MHR). sKl increased acutely after exercise (Tpre median 448 pg/mL vs. Tpost median 576 pg/mL; p < 0.01). There was a nonsignificant sPi decline at T30 (Tpre 0.94 ± 0.12 mmol/L vs. T30 0.83 ± 0.22 mmol/L). Exercise led to a reduction in blood glucose by T240 with median glucose levels at Tpre, Tpost, T30, and T240 of 6.0, 6.5, 6.3, and 5.7 mmol/L, respectively. In conclusion, a single high-intensity exercise session is associated with a transient increase in sKl, a delayed reduction in blood glucose, and a nonsignificant decrease in sPi levels in healthy adults. The evaluation of long-term effects of cardiovascular fitness programs on sKl and sPi in healthy individuals and disease cohorts are required to identify potential lifestyle modifications to help improve chronic disease management and long-term outcomes.
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Affiliation(s)
- Sven-Jean Tan
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Melissa M Chu
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Michael Mx Cai
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Tim D Hewitson
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, The University of Melbourne, Parkville, VIC, Australia
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13
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Abstract
The current management of Chronic Kidney Disease-Mineral Bone Disorder (CKD-MBD) relies largely on clinical judgement and assessment of biochemical parameters including serum calcium, phosphate and intact parathyroid hormone concentrations. In the past two decades, there has been a leap in the understanding of the pathophysiology of CKD-MBD, leading to the discovery of novel biomarkers. The potential utility of these markers in this clinical setting is an area of intense investigation. In the absence of any guidelines aiding the clinician's understanding and application of these markers, we summarise the current available literature surrounding fibroblast growth factor-23, α-Klotho, sclerostin and serum calcification propensity testing and their respective assays in the context of CKD-MBD management.
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Affiliation(s)
- Sven-Jean Tan
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
| | - Michael Mx Cai
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Medicine, The University of Melbourne, Parkville, Victoria, Australia
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14
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Cai MMX, Smith ER, Tan SJ, Hewitson TD, Holt SG. The Role of Secondary Calciprotein Particles in the Mineralisation Paradox of Chronic Kidney Disease. Calcif Tissue Int 2017; 101:570-580. [PMID: 28861648 DOI: 10.1007/s00223-017-0313-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Accepted: 08/09/2017] [Indexed: 12/12/2022]
Abstract
Mineralisation paradox is prevalent in chronic kidney disease and ageing where increased vascular calcification is accompanied by reduced bone mineralisation and osteopenia. Secondary calciprotein particles (CPP2), colloidal nanoparticles containing hydroxyapatite crystal stabilised by a protein shell, have been implicated in vascular calcification in chronic kidney disease. Here, we describe the effect of CPP2 on osteoblasts and vascular smooth muscle cells (VSMC) mineralisation in an in vitro model system. The mineralisation paradox can be simulated in vitro by the addition of phosphate ions (Pi, 3 mM) and CPP2 (10 µg/ml of Ca equivalent). Pi alone induced osteoblast mineralisation but had no effect on VSMC mineralisation. CPP2 alone had no effect on mineralisation in either cell line, but when combined with elevated Pi, reduced osteoblast-like mineralisation (P < 0.001) whilst induced VSMC mineralisation (P < 0.001). These results suggest that in an in vitro system the synergistic interaction between Pi and CPP2 could mimic the mineralisation paradox, and may provide a potential mechanistic link to explain these clinical observations.
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Affiliation(s)
- Michael M X Cai
- Department of Nephrology, Royal Melbourne Hospital, Parkville, VIC, Australia.
- Department of Medicine (RMH), University of Melbourne, Parkville, VIC, Australia.
| | - Edward R Smith
- Department of Nephrology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine (RMH), University of Melbourne, Parkville, VIC, Australia
| | - Sven-Jean Tan
- Department of Nephrology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Timothy D Hewitson
- Department of Nephrology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine (RMH), University of Melbourne, Parkville, VIC, Australia
| | - Stephen G Holt
- Department of Nephrology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Medicine (RMH), University of Melbourne, Parkville, VIC, Australia
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15
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Krishnasamy R, Tan SJ, Hawley CM, Johnson DW, Stanton T, Lee K, Mudge DW, Campbell S, Elder GJ, Toussaint ND, Isbel NM. Progression of arterial stiffness is associated with changes in bone mineral markers in advanced CKD. BMC Nephrol 2017; 18:281. [PMID: 28870151 PMCID: PMC5584006 DOI: 10.1186/s12882-017-0705-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Accepted: 08/22/2017] [Indexed: 12/17/2022] Open
Abstract
Background Arterial stiffness is an independent predictor of all-cause and cardiovascular mortality in patients with chronic kidney disease (CKD). There are limited prospective data however on progression of arterial stiffness in CKD, including evaluating associations with bone mineral markers such as fibroblast growth factor 23 (FGF23) and soluble α-klotho (sKl). Methods In this prospective, single-center, observational study, arterial stiffness [measured by pulse wave velocity (PWV)] and hormones influencing mineral homeostasis, including serum FGF23 and sKl, were compared between non-dialysis CKD stages 4/5 and healthy controls at baseline and 12 months (12 m). Abdominal aortic calcification (AAC) was quantitated using lateral lumbar radiography at baseline. Results Forty patients with CKD [mean estimated glomerular filtration rate (eGFR) 19.5 ± 6.7 mL/min/1.73m2] and 42 controls (mean eGFR 88.6 ± 12.9 mL/min/1.73m2) completed follow-up. There were no differences in age, gender and body mass index between groups. A significant increase in FGF23 [240.6 (141.9–1129.8) to 396.8 (160.3–997.7) pg/mL, p = 0.001] was observed in the CKD group but serum phosphate, corrected calcium, parathyroid hormone and sKl did not change significantly over 12 m. At baseline, CKD subjects had higher AAC prevalence [83.8% versus (vs.) 43.6%, p = 0.002] and higher aortic PWV [9.7(7.6–11.7) vs. 8.1 (7.2–9.7) m/s, p = 0.047] compared to controls. At 12 m, aortic PWV increased by 1.3 m/s (95% confidence interval, 0.56 to 2.08, p < 0.001) in the CKD cohort, with 30% of subjects showing progression from normal aortic elasticity to stiffening (PWV > 10 m/s). Serum FGF23 was associated with AAC, abnormal PWV and progression of PWV at 12 m. Conclusions Arterial stiffness and serum FGF23, both of which are associated with increased cardiovascular risk, increased over one year in individuals with CKD. Additionally, a significant association was found between serum FGF23 and arterial calcification and stiffness. Larger clinical studies and further experimental work are warranted to delineate the temporal relationship as well as the pathological mechanisms linking FGF23 and vascular disease. Electronic supplementary material The online version of this article (10.1186/s12882-017-0705-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rathika Krishnasamy
- Department of Nephrology, Sunshine Coast University Hospital, PO Box 5340, Sunshine Coast, Birtinya, MC QLD, 4560, Australia. .,Faculty of Medicine, The University of Queensland, Brisbane, Australia.
| | - Sven-Jean Tan
- Department of Nephrology, The Royal Melbourne Hospital (RMH), Melbourne, VIC, Australia.,Department of Medicine (RMH), The University of Melbourne, Parkville, VIC, Australia
| | - Carmel M Hawley
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Translational Research Institute, Brisbane, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - David W Johnson
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Translational Research Institute, Brisbane, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Tony Stanton
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Cardiology, Sunshine Coast University Hospital, Birtinya, Australia
| | - Kevin Lee
- Department of Radiology, Princess Alexandra Hospital, Brisbane, Australia
| | - David W Mudge
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Scott Campbell
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Grahame J Elder
- Department of Renal Medicine, Westmead Hospital, Sydney, Australia.,Osteoporosis and Bone Biology Division, Garvan Institute of Medical Research, Sydney, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital (RMH), Melbourne, VIC, Australia.,Department of Medicine (RMH), The University of Melbourne, Parkville, VIC, Australia
| | - Nicole M Isbel
- Faculty of Medicine, The University of Queensland, Brisbane, Australia.,Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
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16
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Tan SJ, Smith ER, Holt SG, Hewitson TD, Toussaint ND. Soluble klotho may be a marker of phosphate reabsorption. Clin Kidney J 2017; 10:397-404. [PMID: 28616218 PMCID: PMC5466110 DOI: 10.1093/ckj/sfw146] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Accepted: 12/05/2016] [Indexed: 12/20/2022] Open
Abstract
Background: Membrane-bound α-klotho functions as a co-receptor with fibroblast growth factor receptor at the renal tubule conferring specificity to fibroblast growth factor-23 (FGF-23), allowing it to inhibit tubular phosphate reabsorption at physiological concentrations. α-klotho also exists as a soluble protein. However, the complex interrelationships between soluble α-klotho (sKl), FGF-23 and phosphate reabsorption are poorly understood, with little known about the links between sKl, FGF-23 and phosphate reabsorption in chronic kidney disease (CKD). This study addresses this issue in a cohort of patients with and without CKD. Methods: We conducted a single-centre, cross-sectional study of contemporaneously obtained samples of blood and 24-h urine biochemistry along with sKl and intact FGF-23 (iFGF-23) from non-dialysis-dependent CKD patients and healthy volunteers. Pearson's correlation coefficients were used to determine correlations between natural log-transformed (Ln) sKl and iFGF-23 with other parameters of interest. Backward multivariate analysis was undertaken to evaluate the relationship between mineral parameters. Results: One hundred and sixteen participants (77 with CKD and 39 healthy volunteers) were studied, of which 74 (63.8%) were male. The median age was 61 (interquartile range 49-71) years. Those with CKD had lower sKl (408 versus 542 pg/mL), higher iFGF-23 (94 versus 41 pg/mL), higher fractional excretion of phosphate (25.05 versus 10.98%) and lower daily urinary phosphate excretion (UPE) (24.8 versus 32.3 mmol/L) compared with healthy volunteers (all P ≤ 0.002). Age correlated inversely and estimated glomerular filtration rate (eGFR) correlated positively with phosphate reabsorption and Ln(sKl), while the opposite was seen with Ln(iFGF23). Upon multivariate analysis, eGFR, Ln(sKl) and parathyroid hormone were independently associated with phosphate reabsorption, whereas Ln(iFGF-23) was not, after adjustment for age. Conclusions: Abnormalities in phosphate regulatory pathways are disturbed early in CKD. While iFGF-23 is associated with phosphate excretion on univariate analyses, sKl demonstrates a significant association with phosphate reabsorption independent of iFGF-23, and this relationship deserves further exploration.
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Affiliation(s)
- Sven-Jean Tan
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine (RMH), University of Melbourne, Melbourne, Australia
| | - Edward R. Smith
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Australia
| | - Stephen G. Holt
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine (RMH), University of Melbourne, Melbourne, Australia
| | - Tim D. Hewitson
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine (RMH), University of Melbourne, Melbourne, Australia
| | - Nigel D. Toussaint
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Australia
- Department of Medicine (RMH), University of Melbourne, Melbourne, Australia
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17
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Hewitson TD, Holt SG, Tan SJ, Wigg B, Samuel CS, Smith ER. Epigenetic Modifications to H3K9 in Renal Tubulointerstitial Cells after Unilateral Ureteric Obstruction and TGF-β1 Stimulation. Front Pharmacol 2017; 8:307. [PMID: 28611663 PMCID: PMC5447091 DOI: 10.3389/fphar.2017.00307] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 05/11/2017] [Indexed: 02/01/2023] Open
Abstract
Introduction: Epigenetic regulation of fibrogenesis through post-translational histone modifications (marks) may be a key determinant of progression in renal disease. In this study, we examined the distribution and acquisition of histone 3 Lysine 9 (H3K9) marks after injury and stimulation with the pro-fibrotic cytokine TGF-β1. Our focus was on their presence in activated fibroblasts (myofibroblasts) and epithelial cells (epithelial-mesenchymal transition). Methods and Results: Immunofluorescent microscopy was used to examine global H3K9 acetylation (H3K9Ac) and tri-methylation (H3K9Me3) after unilateral ureteric obstruction (UUO) in mice. Confocal, super resolution microscopy and flow cytometry were used to determine the in vitro effect of TGF-β1 on structural arrangement of these marks, and their relationship with α-smooth muscle actin (αSMA) expression, a marker of myofibroblasts and early EMT. The number of individual histone marks was increased 10 days after UUO (p < 0.05 vs. control), with both marks clearly seen in various cell types including proximal tubules and myofibroblasts. Sub-nuclear microscopy in primary rat renal fibroblasts and a proximal tubule cell line (NRK-52e) showed that H3K9Ac was co-localized with phosphorylated-Ser2 RNA polymerase II (pRNAPol II), while H3K9Me3 was not, consistent with permissive and repressive effects on gene expression respectively. In both cell types H3K9Ac was diffusely distributed throughout the nucleus, while H3K9Me3 was found in compartments resembling the nucleolus, and in the case of the fibroblast, also juxtapositioned with the nuclear membrane. TGF-β1 had no effect on H3K9Ac marks in either cell, but resulted in a redistribution of H3K9Me3 within the fibroblast nucleus. This was unrelated to any change in mitogenesis, but was associated with increased αSMA expression. Conclusion: These findings highlight why it is important to consider the epigenetics of each cell individually, because whilst no overall enrichment occurred, renal myofibroblast differentiation was accompanied by distinct changes in histone mark arrangements.
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Affiliation(s)
- Timothy D Hewitson
- Department of Nephrology, The Royal Melbourne Hospital, MelbourneVIC, Australia.,Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, MelbourneVIC, Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital, MelbourneVIC, Australia.,Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, MelbourneVIC, Australia
| | - Sven-Jean Tan
- Department of Nephrology, The Royal Melbourne Hospital, MelbourneVIC, Australia
| | - Belinda Wigg
- Department of Nephrology, The Royal Melbourne Hospital, MelbourneVIC, Australia
| | - Chrishan S Samuel
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Pharmacology, Monash University, MelbourneVIC, Australia
| | - Edward R Smith
- Department of Nephrology, The Royal Melbourne Hospital, MelbourneVIC, Australia.,Department of Medicine, The Royal Melbourne Hospital, The University of Melbourne, MelbourneVIC, Australia
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18
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Tan SJ, Hewitson TD, Hughes PD, Holt SG, Toussaint ND. Changes in Markers of Mineral Metabolism After Living Kidney Donation. Transplant Direct 2017; 3:e150. [PMID: 28405606 PMCID: PMC5381743 DOI: 10.1097/txd.0000000000000660] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 01/27/2017] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Living kidney donors (LKDs) experience reduction in kidney function, however serum phosphate (sPi) levels are lower compared to patients with chronic kidney disease matched for reduced kidney function. Mineral metabolism adaptations that occur in LKDs have not been adequately investigated. To evaluate the effect of nephrectomy on markers of mineral metabolism in LKDs compared to healthy volunteers (HV) over 12 months. METHODS Mineral parameters were evaluated in twenty-one adult LKDs and twenty HVs. Parameters included sPi, intact parathyroid hormone, fibroblast growth factor-23 (FGF23), soluble Klotho (sKl) and urinary phosphate, measured prior to donation (T0), 1 month (T1), 6 months (T6) and 12 months (T12) post-kidney donation. Statistical analyses were conducted on normalized variables and changes were assessed using 2-way analysis of variance. RESULTS Mean ages of LKDs and HVs were 54.1 ± 14.7 and 52.6 ± 8.0 years, respectively. There were no baseline clinical or biochemical differences between LKDs and HVs. In LKDs at T1, serum creatinine increased (from 75 ± 12 to 114 ± 22 μmol/L), FGF23 increased (52 ± 15 to 70 ± 19 pg/mL) and sKl decreased (564 [469-662] to 424 [375-523] pg/mL), all P less than 0.001. Changes were sustained at T12. After donation, LKDs consistently demonstrated lower sPi compared with T0, with the maximal sPi change at T6 (-0.19 mmol/L difference, P < 0.001). Other markers of mineral metabolism were unchanged in LKDs. There were no mineral differences in HVs over 12 months. CONCLUSIONS Prospective evaluation of mineral metabolism parameters in LKDs provides valuable insight into compensatory mechanisms after reduction in kidney function. Further reduction of sPi at T6 despite early alterations in FGF23 and sKl suggest adaptation of mineral metabolism continues long-term in LKDs.
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Affiliation(s)
- Sven-Jean Tan
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine (RMH), The University of Melbourne, Parkville, Victoria, Australia
| | - Tim D. Hewitson
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine (RMH), The University of Melbourne, Parkville, Victoria, Australia
| | - Peter D. Hughes
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine (RMH), The University of Melbourne, Parkville, Victoria, Australia
| | - Stephen G. Holt
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine (RMH), The University of Melbourne, Parkville, Victoria, Australia
| | - Nigel D. Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine (RMH), The University of Melbourne, Parkville, Victoria, Australia
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19
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Tan SJ, Crosthwaite A, Langsford D, Obeysekere V, Ierino FL, Roberts MA, Hughes PD, Hewitson TD, Dwyer KM, Toussaint ND. Mineral adaptations following kidney transplantation. Transpl Int 2017; 30:463-473. [PMID: 28120476 DOI: 10.1111/tri.12925] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 10/28/2016] [Accepted: 01/18/2017] [Indexed: 12/30/2022]
Abstract
Klotho is predominantly expressed in the kidney and reported to have antioxidant and antifibrotic properties. Soluble Klotho (sKl), the circulating protein cleaved from membrane-bound Klotho, is reduced significantly with kidney disease and inversely associated with mortality. sKl has not been thoroughly evaluated prospectively after kidney transplantation. Incident kidney transplant recipients (KTRs) were prospectively evaluated pretransplantation, 1, 12 and 52 weeks post-transplantation. Basic biochemistry, sKl and intact FGF23 were measured. Within-subject comparisons were evaluated using repeat-measure anova or Friedman's analysis. Effects of immunosuppression and biochemical parameters on sKl and FGF-23 over time were analysed using mixed-effects modelling. Median serum creatinine (sCr) at 1 week was 116 (92-142) μmol/l, and at 52 weeks, all 29 KTRs had a functioning graft with median sCr of 111 (97-131) μmol/l. Compared with baseline, sKl was increased at 52 weeks following an initial decline at 1 week (P < 0.005 and P < 0.01, respectively), while FGF23 was considerably reduced at 52 weeks (P < 0.001). In a mixed-effects model, an increased sKl was not associated with reduction in immunosuppression or evaluated biochemical parameters. Modest increase in sKl is observed one-year postkidney transplantation with excellent early graft function suggesting factors beyond renal capacity may influence circulating sKl. FGF23 normalization was observed. Longer term evaluation in transplantation, specifically addressing the effects of immunosuppression, is required to understand the pathophysiology of the sKl/FGF23 axis and potential for modification.
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Affiliation(s)
- Sven-Jean Tan
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine, The University of Melbourne, Parkville, Vic., Australia
| | - Amy Crosthwaite
- Department of Medicine, The University of Melbourne, Parkville, Vic., Australia.,Department of Nephrology, Austin Hospital, Heidelberg, Vic., Australia
| | - David Langsford
- Department of Nephrology, Northern Hospital, Epping, Vic., Australia
| | - Varuni Obeysekere
- Department of Endocrinology, St Vincent's Hospital Melbourne, Fitzroy, Vic., Australia
| | - Frank L Ierino
- Department of Medicine, The University of Melbourne, Parkville, Vic., Australia.,Department of Nephrology, St Vincent's Hospital Melbourne, Fitzroy, Vic., Australia.,Victorian Kidney Transplantation Collaborative, Melbourne, Vic., Australia
| | - Matthew A Roberts
- Victorian Kidney Transplantation Collaborative, Melbourne, Vic., Australia.,Eastern Health Clinical School, Monash University, Box Hill, Vic., Australia
| | - Peter D Hughes
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine, The University of Melbourne, Parkville, Vic., Australia
| | - Tim D Hewitson
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine, The University of Melbourne, Parkville, Vic., Australia
| | - Karen M Dwyer
- Department of Medicine, The University of Melbourne, Parkville, Vic., Australia.,Department of Nephrology, St Vincent's Hospital Melbourne, Fitzroy, Vic., Australia.,Victorian Kidney Transplantation Collaborative, Melbourne, Vic., Australia.,School of Medicine, Deakin University, Geelong, Vic., Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Vic., Australia.,Department of Medicine, The University of Melbourne, Parkville, Vic., Australia
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20
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Sharma AK, Masterson R, Holt SG, Tan SJ, Hughes PD, Chu M, Jayadeva P, Toussaint ND. Impact of cinacalcet pre-transplantation on mineral metabolism in renal transplant recipients. Nephrology (Carlton) 2016; 21:46-54. [PMID: 26072678 DOI: 10.1111/nep.12536] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2015] [Indexed: 11/30/2022]
Abstract
AIM Cinacalcet is effective in reducing parathyroid hormone (PTH) in patients on dialysis. Reports of biochemical profiles and other clinical outcomes in patients discontinuing cinacalcet at time of renal transplantation are limited. METHODS A retrospective study assessing markers of mineral metabolism, graft and patient outcomes in renal transplant recipients to determine differences in patients discontinuing cinacalcet (C+) compared with patients not treated with cinacalcet (C-) at time of transplantation. To allow for differences between groups in pre-transplant biochemical parameters, we also analysed a matched cohort of C- with C+ recipients (2:1), matched for age, calcium and PTH levels at transplantation. RESULTS Five hundred thirty-two recipients (460 C-, 72 C+), transplanted January 2006-December 2012, were analysed, mean age 48.0 ± 12.7 years and 64.3% were men. At a median 42.9 months follow up, there were 10 deaths (1.9%), 56 allograft loss (10.6%) and 5 parathyroidectomies post-transplant (0.8%). Median PTH immediately pre-transplant was higher in C+ versus C- (50.7(25.4-75.2) versus 28.3(13.9-49.7) pmol/L, P < 0.001). Twelve-month post-transplant PTH was reduced but higher in C+ (11.7(6.9-21.2) vs 7.2(4.6-11.2) pmol/L, P < 0.001). Mean calcium was higher for C+ versus C- at 12 months (2.50 ± 0.19 vs 2.43 ± 0.17 mmol/L, P < 0.001), with differences to 4 years post-transplant. No difference was seen in renal function, graft loss, post-transplant parathyroidectomy rate and mortality. In the matched cohort (144 C- vs 72 C+), similar findings were also seen. CONCLUSION Differences in mineral metabolism post-transplant are seen with cinacalcet pre-transplant compared with no cinacalcet. Transplant recipients discontinuing cinacalcet had higher post-transplant PTH and calcium although the clinical significance is unclear.
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Affiliation(s)
- Ashish K Sharma
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Rosemary Masterson
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Sven-Jean Tan
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
| | - Peter D Hughes
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
| | - Melissa Chu
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
| | - Pavithra Jayadeva
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
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Tan SJ, Smith ER, Hewitson TD, Holt SG, Toussaint ND. The importance of klotho in phosphate metabolism and kidney disease. Nephrology (Carlton) 2016; 19:439-49. [PMID: 24750549 DOI: 10.1111/nep.12268] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2014] [Indexed: 12/19/2022]
Abstract
The discovery of fibroblast growth factor-23 (FGF23) and its co-receptor α-klotho has broadened our understanding of mineral metabolism and led to a renewed research focus on phosphate homeostatic pathways in kidney disease. Expanding knowledge of these mechanisms, both in normal physiology and in pathology, identifies targets for potential interventions designed to reduce the complications of renal disease, particularly the cardiovascular sequelae. FGF23 has emerged as a major α-klotho-dependent endocrine regulator of mineral metabolism, functioning to activate vitamin D and as a phosphatonin. However, increasingly there is an appreciation that klotho may act independently as a phosphate regulator, as well as having significant activity in other key biological processes. This review outlines our current understanding of klotho, and its potential contribution to kidney disease and cardiovascular health.
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Affiliation(s)
- Sven-Jean Tan
- Department of Nephrology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia; Department of Medicine (RMH), The University of Melbourne, Melbourne, Victoria, Australia
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22
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Tan SJ, Ducharlet K, Dwyer KM, Myers D, Langham RG, Hill PA. A case of triple pathology: seronegative anti-glomerular basement membrane antibody-mediated glomerulonephritis and membranous nephropathy in a patient with underlying diabetic kidney disease. Clin Kidney J 2015; 6:322-6. [PMID: 26064494 PMCID: PMC4400487 DOI: 10.1093/ckj/sft043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 03/19/2013] [Indexed: 01/19/2023] Open
Abstract
In diabetic patients with acute kidney injury (AKI), kidney biopsy often reveals non-diabetic kidney pathology. This case describes a patient with known Type 1 diabetes who presented with AKI, nephrotic syndrome and haematuria. Combination pathology of seronegative anti-glomerular basement membrane antibody-mediated glomerulonephritis (anti-GBM GN), membranous nephropathy (MN) and diabetic nephropathy (DN) was demonstrated. Strong linear GBM IgG-staining on biopsy with crescentic GN and clinical AKI led to a diagnosis of anti-GBM GN, although serum antibodies were not detectable. Features of DN, Kimmelstiel-Wilson nodules and albumin staining were also present, along with features of MN, such as subepithelial deposits on electron microscopy. Despite treatment with immunosuppression and plasmapheresis, there was no recovery of kidney function. Coexisting anti-GBM GN and MN is well recognized, but the concurrent diagnosis with DN has not been described.
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Affiliation(s)
- Sven-Jean Tan
- Department of Nephrology , St Vincent's Hospital , Fitzroy, VIC , Australia
| | - Kathryn Ducharlet
- Department of Nephrology , St Vincent's Hospital , Fitzroy, VIC , Australia
| | - Karen M Dwyer
- Department of Nephrology , St Vincent's Hospital , Fitzroy, VIC , Australia
| | - Damian Myers
- Department of Surgery and Orthopaedics , St Vincent's Hospital , Fitzroy, VIC , Australia
| | - Robyn G Langham
- Department of Nephrology , St Vincent's Hospital , Fitzroy, VIC , Australia ; Department of Medicine , University of Melbourne , Parkville, VIC , Australia
| | - Prue A Hill
- Department of Anatomical Pathology , St Vincent's Hospital , Fitzroy, VIC , Australia
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23
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Ducharlet K, Murphy C, Tan SJ, Dwyer KM, Goodman D, Aboltins C, Daffy JR, Langham RG. Recurrent Mycobacterium haemophilum in a renal transplant recipient. Nephrology (Carlton) 2014; 19 Suppl 1:14-7. [PMID: 24460607 DOI: 10.1111/nep.12193] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/18/2013] [Indexed: 11/29/2022]
Abstract
Mycobacterium haemophilum is a rare isolate of non-tuberculous Mycobacterium which has been reported to affect immunocompromised patients. We report a case of a 32-year-old renal transplant patient with M. haemophilum infection initially involving his left sinus which was treated with appropriate antimicrobial therapy for thirteen months. Two weeks after cessation of antibiotics the infection rapidly recurred in his skin and soft tissues of his hands and feet. This case highlights the difficult diagnostic and therapeutic implications of atypical infections in transplant patients. To our knowledge this is the first reported case of relapsed M. haemophilum infection in a renal transplant recipient.
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Affiliation(s)
- Kathryn Ducharlet
- Department of Nephrology, St Vincent's Hospital, Fitzroy, Victoria, Australia
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24
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Tan SJ, Smith ER, Hewitson TD, Holt SG, Toussaint ND. Diurnal variation and short-term pre-analytical stability of serum soluble α-klotho in healthy volunteers: a pilot study. Ann Clin Biochem 2014; 52:506-9. [PMID: 25416731 DOI: 10.1177/0004563214563415] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2014] [Indexed: 11/16/2022]
Abstract
AIM To investigate the diurnal variability and pre-analytical stability of soluble α-klotho in serum. BACKGROUND Recent evidence suggests that the cleaved extracellular domain of the α-klotho receptor, soluble α-klotho, affects phosphate homeostasis, ion channel regulation and antifibrotic/antioxidant pathways. However, soluble α-klotho measurements have yielded inconsistent results when related to renal function, markers of mineral metabolism and patient outcomes. Pre-analytical factors such as biological variation and analyte stability may affect the interpretation of soluble α-klotho results but are yet to be formally assessed. METHODS Clotted blood samples were collected from 10 healthy adult volunteers at three time-points during the day to assess diurnal change. Additional samples were collected and allowed to stand at room temperature for 30, 60 and 120 min, prior to centrifugation and analysis to evaluate analyte stability. Serum soluble α-klotho was measured using a validated commercial enzyme-linked immunosorbent assay. RESULTS Delayed processing of samples had no significant effect on serum soluble α-klotho concentrations over a 2-h period. Serum soluble α-klotho concentrations remained stable over morning, midday and afternoon time-points in this pilot study. CONCLUSION Serum soluble α-klotho demonstrates short-term pre-analytical stability and minimal diurnal variability in this pilot study. Larger studies are warranted to confirm these findings.
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Affiliation(s)
- Sven-Jean Tan
- Department of Nephrology, The Royal Melbourne Hospital (RMH), Parkville, Australia Department of Medicine (RMH), The University of Melbourne, Melbourne, Australia
| | - Edward R Smith
- Department of Nephrology, The Royal Melbourne Hospital (RMH), Parkville, Australia
| | - Tim D Hewitson
- Department of Nephrology, The Royal Melbourne Hospital (RMH), Parkville, Australia Department of Medicine (RMH), The University of Melbourne, Melbourne, Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital (RMH), Parkville, Australia Department of Medicine (RMH), The University of Melbourne, Melbourne, Australia
| | - Nigel D Toussaint
- Department of Nephrology, The Royal Melbourne Hospital (RMH), Parkville, Australia Department of Medicine (RMH), The University of Melbourne, Melbourne, Australia
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Liu X, Tan SJ, Chen YP, Liu J, Liang XL, Li CM, Shi XM, Zhao NN. Relationships between biochemical and physiological changes induced by exercise in postmyocardial infarction patients. J Sports Med Phys Fitness 2013; 53:665-670. [PMID: 24247190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
AIM AIM of the study was to examine the relationships between biochemical and physiological changes induced by exercise in postmyocardial infarction patients (PMIP) during the early stages of cardiac rehabilitation. METHODS Forty-nine male non-blockade recent PMIP, aged 63.8 ± 4.7 years, performed a graded exercise test on a motorised treadmill until volitional cessation or reaching any of the American College of Sports Medicine criteria. Blood pressure and rate-pressure product (RPP) were recorded every three minutes. A 12-lead electrocardiogram was monitored continuously and heart rate (HR) was taken from this. Blood samples were obtained by two methods; those used for testing blood lactate (BL) were taken from an already warmed finger tip before and during exercise, and the others used for enzymatic analysis based on lactate dehydrogenase (LDH), lactate dehydrogenase isoenzyme 1 (LDH-1), creatine kinase (CK) and creatine kinase polypeptide sub-unit MB (CK-MB) were collected by venipuncture from the antecubital vein pre and immediate post exercise test. RESULTS Highly significant correlations existed between exercise-induced changes in HR, RPP, BL and ST segment level with increased enzymes activity in serum, and 73.1% to 90.1% of the variance in percentage increase of the enzyme activity could be predicted from the variance in percentage increase of HR during exercise. However, the mechanism of these relationships may differ. CONCLUSION Since the rise in serum enzymes during submaximal exercise is primarily attributed to changes in membrane permeability in fatigued muscle, these relationships provide useful guidance to health professionals obtaining biochemical information about muscle fatigue.
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Affiliation(s)
- X Liu
- Department of Human Movement Science Tianjin University of Sport, Tianjin 300381, PR China -
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26
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Teng J, Hoo XN, Tan SJ, Dwyer K. Serum sickness following rabbit anti-thymocyte globulin for acute vascular renal allograft rejection. Clin Kidney J 2012; 5:334-5. [PMID: 25874092 PMCID: PMC4393471 DOI: 10.1093/ckj/sfs061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2012] [Accepted: 04/24/2012] [Indexed: 11/14/2022] Open
Abstract
A simultaneous pancreas–kidney transplant recipient developed serum sickness manifesting with severe upper limb allodynia, arthralgia and myalgia 17 days following rabbit anti-thymocyte globulin (rATG) infusion for biopsy-proven vascular rejection. Rapid resolution of symptoms followed treatment with high-dose glucocorticoids. rATG is increasingly favoured over equine ATG in solid-organ transplantation, and although rATG has a superior safety profile, it is important to maintain a high index of suspicion for serum sickness.
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Affiliation(s)
- Jessie Teng
- Correspondence and offprint requests to: Jessie Teng; E-mail:
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27
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Tehan JV, Tan SJ, Gregg W, Dwyer K. An interaction between tacrolimus and pristinamycin resulting in an elevated tacrolimus level. Clin Kidney J 2011; 4:456-7. [PMID: 25984230 PMCID: PMC4421681 DOI: 10.1093/ndtplus/sfr112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jane V Tehan
- Nephrology Unit, St Vincent's Hospital, Melbourne, Australia
| | - Sven-Jean Tan
- Nephrology Unit, St Vincent's Hospital, Melbourne, Australia
| | - Wayne Gregg
- Pharmacy Department, St Vincent's Hospital, Melbourne, Australia
| | - Karen Dwyer
- Nephrology Unit, St Vincent's Hospital, Melbourne, Australia
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Tan SJ, Juan YH, Fu PT, Yu MH, Lai HC. Chemotherapy with low-dose bevacizumab and carboplatin in the treatment of a patient with recurrent cervical cancer. EUR J GYNAECOL ONCOL 2010; 31:350-353. [PMID: 21077488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Management of patients with recurrent or advanced cervical cancer is a challenge. Concurrent chemotherapy has become the mainstay of treatment and platinum remains the most effective single agent. Combinations of other agents have not demonstrated significant advantages. The application of angiogenesis inhibitors such as bevacizumab, an antibody inhibiting vascular endothelial growth factor, in metastatic or advanced cervical cancer remains to be evaluated. We present the case of a patient with platinum-resistant recurrent cervical cancer treated with low-dose bevacizumab and carboplatin, with resultant improved disease progression and tolerable toxicity profiles.
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Affiliation(s)
- S J Tan
- Department of Obstetrics and Gynecology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
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30
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Liu YB, Tan SJ, Sun ZY, Li X, Huang BY, Hu QM. Clear lens phacoemulsification with continuous curvilinear capsulorhexis and foldable intraocular lens implantation for the treatment of a patient with bilateral anterior lenticonus due to Alport syndrome. J Int Med Res 2009; 36:1440-4. [PMID: 19094456 DOI: 10.1177/147323000803600634] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The case of a 29-year-old man is reported who presented with a gradually progressive, painless decrease in vision over 10 years. Anterior segment examination with a slit lamp revealed anterior lenticonus in both eyes. The patient had previously been diagnosed with bilateral sensorineural deafness, however investigations revealed microscopic haematuria and renal insufficiency that subsequently led to a diagnosis of classical Alport syndrome. Since the patient's quality of vision was severely affected by the bulging anterior lens capsule, surgical treatment was required. Clear lens phacoemulsification with continuous curvilinear capsulorhexis and foldable intraocular lens implantation were performed in each eye 2 days apart. One week after surgery, visual acuity was excellent in both eyes. Clear lens phacoemulsification with continuous curvilinear capsulorhexis and foldable intraocular lens implantation was a safe and effective therapeutic choice in this patient for the management of anterior lenticonus due to Alport syndrome.
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Affiliation(s)
- Y B Liu
- Department of Ophthalmology, First Affiliated Hospital of Guangxi Medical University, Nanning, China
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31
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Tan SJ, Lao IK, Ji HM, Agarwal A, Balasubramanian N, Kwong DL. Microfluidic design for bio-sample delivery to silicon nanowire biosensor - a simulation study. ACTA ACUST UNITED AC 2006. [DOI: 10.1088/1742-6596/34/1/103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
The recent demonstration of a successful zona-free manipulation technique for bovine somatic nuclear transfer (NT) that is both simpler and less labor intensive is of considerable benefit to advance the applications of this technology. Here, we describe that this method is also applicable to porcine somatic NT. Porcine cumulus oocyte complexes were matured in TCM-199 medium before sequential removal of the cumulus and zonae. Zona-free oocytes were bisected using a microknife, and the halves containing the metaphase plate (as determined by Hoechst 33342 staining) were discarded. Each half cytoplast was agglutinated to a single granulosa cell (primary cultures grown in 0.5% serum for 2-5 days prior to use) in phytohaemagglutinin-P. Subsequently, each half cytoplast-granulosa cell couplet was simultaneously electrofused together and to another half cytoplast. Reconstructed embryos were activated in calcium ionophore A23187 followed by DMAP and were then individually cultured in microwells in NCSU-23 medium. On day 7 after activation, blastocyst yield and total cell numbers were counted. Of 279 attempted reconstructed NT embryos, 85.0 +/- 2.8% (mean +/- SEM; n = 5 replicates) successfully fused and survived activation. The blastocyst rate (per successfully fused and surviving embryo) was 4.8 +/- 2.3% (11/236; range, 0-12.8%). Total blastocyst cell count was 36.0 +/- 4.5 (range, 18-58 cells). The blastocyst rate and total cell numbers of parthenogenetically activated and zona-free control oocytes propagated under the same conditions was 11.6 +/- 3.9% (35/335 embryos; n = 3 replicates) and 36.8 +/- 5.2, respectively. Developmentally halted embryos that could still be evaluated on day 7 possessed 54.4 +/- 2.3% (53/96 embryos; n = 3 replicates) anucleate blastomeres, the latter representing 53.5 +/- 6.6% of the blastomeres in such embryos. In conclusion, blastocyst yield was independent of activation efficiency and was likely reduced by insufficient nuclear remodeling, reprogramming, imprinting, or other effects. The data also suggest that fragmentation was a considerable problem that could conceivably contribute to halted development in a high proportion of embryos. The results indicate that the zona-free manipulation technique can be successfully applied to pig somatic NT. Although such zona-free early cleavage stage embryos cannot be transferred to recipients at present, this technique permits simplification of the NT technique for application in basic research, until pig nonsurgical blastocyst transfer becomes a realistic option.
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Affiliation(s)
- P J Booth
- Section for Reproductive Biology, Department of Animal Breeding and Genetics, Danish Institute of Agricultural Sciences, 8800 Tjele, Denmark.
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Booth PJ, Tan SJ, Reipurth R, Holm P, Callesen H. Simplification of bovine somatic cell nuclear transfer by application of a zona-free manipulation technique. Cloning Stem Cells 2002; 3:139-50. [PMID: 11945223 DOI: 10.1089/153623001753205098] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Contemporary nuclear transfer techniques often require the involvement of skilled personnel and extended periods of micromanipulation. Here, we present details of the development of a nuclear transfer technique for somatic cells that is both simpler and faster than traditional methods. The technique comprises the bisection of zona-free oocytes and the reconstruction of embryos comprising two half cytoplasts and a somatic cell by adherence using phytohaemagglutinin-P (PHA) followed by an electropulse and subsequent culture in microwells (termed WOWs--well of the well). The development of the system was based on results using parthenogenetic and in vitro fertilized zygotes in order to (a) select the optimal primary activation agent that induced the lowest lysis rate but highest parthenogenetic blastocyst yield, (b) evaluate the quantity and quality of zona-free blastocysts produced in WOWs, and (c) establish any potential embryotoxic effects of PHA-P. The initial data indicated that, of calcium ionophore A23187, ionomycin, and electropulse treatments as primary activation agents, the two former were equally efficient even with reduced exposure times. WOW-culture of zona-free versus zona-intact zygotes were not different in either blastocyst yield (44.6 +/- 2.4% versus 51.8 +/- 13.5% [mean +/- SEM]) or quality (126.3 +/- 48.4 versus 119.9 +/- 32.6 total cells), and exposure of zygotes to PHA-P did not reduce blastocyst yields compared to vehicle control (40.8 +/- 11.6% versus 47.1 +/- 20.8% of cultured oocytes). Subsequent application of the optimized technique for nuclear transfer using nine different granulosa cell primary cultures (cultured in 0.5% serum for 5-12 days) generated 37.6 +/- 3.9% (11 replicates; range, 16.4-58.1%) blastocysts per successfully fused and surviving reconstructed embryo (after activation), and 33.6 +/- 3.7% blastocysts per attempted reconstructed embryo. Mean day 7 total blastocyst cell numbers from 5 clone families was 128.1 +/- 15.3. The ongoing pregnancy rate of recipients each receiving two nuclear transfer blastocysts is 3/13 (23.1%) recipients pregnant at 5 months after transfer. These results suggest that the zona-free nuclear transfer technique generates blastocysts of equivalent quantity and quality compared to conventional micromanipulation methods, requires less technical expertise, is less time consuming and can double the daily output of reconstructed embryos (even after taking into consideration the rejection of the half oocytes containing the metaphase plate).
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Affiliation(s)
- P J Booth
- Section for Reproductive Biology, Department of Animal Breeding and Genetics, Danish Institute of Agricultural Sciences, Tjele, Denmark.
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Hu WX, Tan CY, Tan SJ, Jiang J. [Progress in the protective medicine against [correction of aganist] rocket propellents]. Space Med Med Eng (Beijing) 1999; 12:451-5. [PMID: 12434814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
To review the progress in the major assignment, the organization and implementation of protection against liquid rocket propellent. The safety detection methods of the rocket [correction of rocked] propellent in the launching field were also discussed. Three steps of the sanitation and protection of the liquid propellent, the toxicity and the toxicology of hydrazine on central nervous system, blood circulatory system, assimilation system, respiratory system, immune system, liver, kidney, eye, skin and its hereditary toxicology were described. In addition, the clinical types of poisoning, the current principle and the common ways of the prevention and treatment of hydrazine and nitrogen oxides poisoning were summarized.
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Affiliation(s)
- W X Hu
- Institute of Military Medical Sciences, Headquarters of General Equipment, Beijing, China
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35
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Tan SJ, Pan JY, Zhan CY, Zhu XN. [Effect of angiotensin II on c-fos expression and protein synthesis in cultured rat myocardial cells]. Sheng Li Xue Bao 1999; 51:521-6. [PMID: 11498949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
The present study was to investigate the effects of angiotensin II on c-fos mRNA expression and protein synthesis in cultured neonatal rat myocardial cells. The results showed that angiotensin II induced c-fos mRNA expression, increased protein content in a dose-dependent manner and stimulated 3H-leucine incorporation rate. All these effects were blocked by angiotensin II receptor antagonist saralasin. The angiotensin II-induced expression of c-fos gene was also blocked by Ca2+ channel antagonist nicardipine.
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Affiliation(s)
- S J Tan
- Department of Cardiology, Shanghai Sixth People's Hospital, Shanghai 200233
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36
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Drew WL, Stempien MJ, Andrews J, Shadman A, Tan SJ, Miner R, Buhles W. Cytomegalovirus (CMV) resistance in patients with CMV retinitis and AIDS treated with oral or intravenous ganciclovir. J Infect Dis 1999; 179:1352-5. [PMID: 10228054 DOI: 10.1086/314747] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Treatment of cytomegalovirus (CMV) retinitis with oral ganciclovir results in relatively low plasma concentrations of drug, which theoretically could cause more frequent viral resistance compared with intravenous (iv) ganciclovir. By use of a plaque-reduction assay to quantify phenotypic sensitivity to ganciclovir, virus isolates were studied from patients with CMV retinitis participating in four clinical trials of oral ganciclovir. Before treatment, 69% of patients were culture-positive but just 1.1% of patients yielded a resistant CMV, defined as a median inhibitory concentration (IC50) >6 microM. On treatment, the first resistant isolate was recovered at 50 days. Overall, 3.1% of patients receiving iv ganciclovir and 6. 5% of those taking oral ganciclovir shed resistant CMV (median ganciclovir exposures of 75 and 165 days, respectively). Since IC50s for clinical isolates increased proportionately with treatment duration, it is likely that viral resistance would be more frequent with longer treatment.
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Affiliation(s)
- W L Drew
- Clinical Microbiology and Infectious Diseases, University of California at San Francisco-Mt. Zion Medical Center, San Francisco, CA, USA.
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37
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Peng QT, Hu WX, Tan SJ. [New progress in separation and determination of medicinal enantiomers by HPLC]. Yao Xue Xue Bao 1998; 33:793-800. [PMID: 12016936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
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38
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Tan SJ, Lang JH. [Clinical uses of goserelin in gynecologic diseases and its safety]. Zhonghua Fu Chan Ke Za Zhi 1998; 33:58-60. [PMID: 10682460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
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39
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Wei ZY, Tan SJ, Tang EH, Pan JY, Zhan CY. [The role of G protein in Leu-enkephalin induced Ca2+ release from intracellular pool in myocytes]. Sheng Li Xue Bao 1995; 47:173-8. [PMID: 7652593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The mechanism underlying Leu-enkephalin (LEK) induced increase of the intracellular concentration of free calcium ([Ca2+]i) in rat ventricular myocytes was investigated by using fura-2 AM as a calcium indicator. The results were as follows: LEK (60 mumol/L) elevated [Ca2+]i in ventricular myocytes no matter whether extracellular calcium was removed or not. However, the effect was no longer observed when the calcium in the intracellular pool was depleted by caffeine (5 mmol/L). The LEK effect could also be blocked by naloxone (100 mumol/L), pretreatment of the cells with PTX (200 ng/L) 8-10 h or procain (2 mmol/L). The results suggest that the LEK effect is mediated by coupling of G-protein with delta-receptor that induced Ca2+ release from the intracellular pool in myocytes.
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Affiliation(s)
- Z Y Wei
- Department of Physiology, Sun Yat-Sen University of Medical Sciences, Guangzhou
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40
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Abstract
Women with a breast cancer diagnosis often are given a choice between breast conservation or mastectomy as the primary treatment for their cancer. Despite the high frequency of this cancer, there is little systemic information about the effect of surgical treatment on the quality of life or psychological adjustment of the patient. In this study, the authors prospectively evaluated quality of life, performance status, and psychological adjustment in 109 women who had primary breast cancer treatment. During the year of follow-up, no statistically significant differences in quality of life, mood disturbance, performance status, or global adjustment were found between the two surgical groups, and both groups of patients improved significantly during the year of observation (P = 0.0001). As was predicted, patients receiving mastectomy reported more difficulties with clothing and body image; however, these results apparently did not affect the assessment of mood or quality of life. The authors conclude that patients receiving breast conservation therapy do not experience significantly better quality of life or mood than patients having mastectomy; however, patients having breast conservation surgery have fewer problems with clothing and body image. Women receiving breast conservation therapy may require more intensive psychosocial intervention in the postoperative period because of the added burden of primary radiation therapy.
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Affiliation(s)
- P A Ganz
- Department of Medicine, University of California Los Angeles-San Fernando Valley Program
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41
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Abstract
The use of the Fisher exact test for comparing two independent binomial proportions has spawned an extensive controversy in the statistical literature. Many critics have faulted this test for being highly conservative. Partly in response to such criticism, some statisticians have suggested the use of a modified, non-randomized version of this test, namely the mid-P-value test. This paper examines the actual type I error rates of this test. For both one-sided and two-sided tests, and for a wide range of sample sizes, we show that the actual levels of significance of the mid-P-test tend to be closer to the nominal level as compared with various classical tests. The computational effort required for the mid-P-test is no more than that needed for the Fisher exact test. Further, the basis for its modification is a natural adjustment for discreteness; thus the test easily generalizes to r x c contingency tables and other discrete data problems.
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Affiliation(s)
- K F Hirji
- Department of Biomathematics, School of Medicine, University of California, Los Angeles 90024-1766
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Abstract
Data from the Multicenter AIDS Cohort Study (MACS) of 1637 gay men, recruited in 1984 and 1985 in Los Angeles and followed at 6-monthly intervals, are used to develop a computer simulation model of the typical pattern of CD4 T-cell number changes in HIV-infected AIDS-free subjects. The empirical model incorporates the following features: (1) within-person and between-person variability in CD4 measurements; (2) variation in the rates of decline of CD4 values; (3) variation in the level of CD4 at which clinical AIDS is diagnosed, and (4) greater absolute variation in CD4 values in men with high CD4 levels compared with men with low CD4 values. Three applications of the model to assist in the design and interpretation of clinical trials are given. Further applications to clinical trials and to estimate the current and future spectrum of HIV-mediated immunological disease in the USA, as measured by the CD4 values, are discussed.
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Liu JJ, Yang YC, Gu KM, Tan SJ. [Comparison of the cytotoxic effect of sulmazole with ouabain on cultured myocardial cells]. Zhongguo Yao Li Xue Bao 1988; 9:129-31. [PMID: 3188947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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44
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Yin M, Liao XL, Tan SJ. [Effects of 2,2'-[(4,8-bis(diethylamino)-pyrimido[5,4-d]pyrimidine-2,6-diyl) di-(2-methoxyethyl)imino]diethanol (RA 642) on experimental scald shock]. Zhongguo Yao Li Xue Bao 1987; 8:533-6. [PMID: 3451667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
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45
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Abstract
Primary cultures of newborn rat myocardial cells were treated in various extracellular calcium concentrations (0, 1.35, 2.7, 4.05, and 5.4 mM) with three different drugs; namely, ouabain, sulmazole, and chlorpromazine. Lactate dehydrogenase (LDH) release was used as an indicator of damage. The results showed 10(-3) M ouabain caused apparent damage of the cells and the damage was increased by an increased extracellular calcium concentration. Sulmazole (10(-3)M) caused damage of the cells in the absence of calcium; but it did not cause damage of the cells in the presence of calcium; it protected the cells from damage caused by high calcium concentrations (4.05 and 5.4 mM). Chlorpromazine (1.6 X 10(-4)M) caused severe damage of the cells. The various calcium concentrations had no influence on the degree of the damage. Correlation coefficients showed that correlations between the calcium concentrations and the cell damage caused by ouabain, sulmazole and chlorpromazine were positive correlation, negative correlation, and no correlation, respectively. It is suggested that influx of extracellular calcium is not a final common pathway of drug-induced myocardial cell injury, although it plays an important role in cell injury.
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