Hong Kong Journal of Nephrology

News about the Hong Kong Journal of Nephrology

C.C. Szeto — 2011-10-01

The Hong Kong Journal of Nephrology is entering a time of transition. For the past 9 years, Dr. Alex Yu, from the Alice Ho Miu Ling Tai Po Nethersole Hospital, has served as the Editor-in-Chief. Beginning in January 2011, Dr. C.C. Szeto, from the Chinese University of Hong Kong, assumed the duty of Editor-in-Chief, and Dr. Sydney Tang from the University of Hong Kong became the Deputy Editor. We continue to work with Elsevier as our publisher, but from this issue onwards, we have transferred our journal’s editorial production from Elsevier’s Hong Kong office to their global system.

Autoimmunity of patients with TINU syndrome

Ying Tan, Feng Yu, Ming-Hui Zhao — 2011-10-01

Summary: Tubulointerstitial nephritis and uveitis (TINU) syndrome is characterized by tubulointerstitial nephritis with bilateral sudden-onset anterior uveitis. Currently, only over 200 cases have been described in the literature. TINU syndrome might be underestimated due to lack of recognition and under-diagnosis. The pathogenesis of TINU syndrome remains unclear. It has been reported to be associated with infection, drugs or autoimmune diseases. However, TINU syndrome is mostly postulated to be the result of an autoimmune process. It may involve both humoral and cellular autoimmunity, with more evidence of the latter since obvious disturbances of cell-mediated immunity have been noted in patients with TINU syndrome. Recently, autoantibodies directed against renal tubular cells have thrown new light on the role of humoral autoimmunity in TINU syndrome. It is postulated that renal tubular and ciliary body epithelia might share cross-reactive autoantigens since the major characteristics of TINU syndrome are the involvement of the kidneys and eyes, and renal tubular and ciliary body epithelia share some similar functions. This review updates the current understanding on TINU syndrome, especially its autoimmune nature.肾小管间质性肾炎-眼色素膜炎 (TINU) 综合征是一种以肾间质损伤和眼色素膜炎为主要表现的的疾病。迄今，国内外仅有 200 例左右的病例报道。由于对 TINU 综合征的认识尚浅，临床上可能漏诊了一些病例。目前其发病机制尚不明确。有报道指出 TINU 综合征与感染、药物或自身免疫疾病有关。其发病机制可能涉及体液免疫及细胞免疫。以往研究认为细胞免疫占据主导地位。近期研究发现 TINU 综合征患者血清中存在抗肾小管上皮细胞抗体，体液免疫的作用逐渐被认识。研究认为肾小管间质性肾炎及眼色素膜炎可能存在共同的免疫发病机制，即在肾、眼组织中可能存在着共同抗原。本文主要就 TINU 综合征的发病机制的一些最新进展，尤其是与自身免疫相关的部分做一简介。

Correlation study between spot urine protein-to-creatinine ratio and 24-hour urine protein measurement in 174 patients for proteinuria assessment

2011-10-01

Summary: Background/Purpose: According to the US National Kidney Foundation K/DOQI Guidelines in 2000, under most circumstances, spot urine samples should be used to detect and monitor proteinuria in children and adults and timed collection is often unnecessary. However, its use is still not widely implemented in Hong Kong. We aimed to assess the correlation of spot urine protein-to-creatinine (Pr/Cr) ratio to 24-hour urine protein excretion in our local setting.Methods: This was a prospective study set in regional hospitals in Hong Kong. A total of 174 patients were recruited from 2007 to 2008. Spot urine Pr/Cr ratio and 24-hour urine protein measurements were determined. Linear regression model was used to fit and test the relationship between 24-hour urine protein excretion and the spot urine Pr/Cr ratio.Results: Spot urine Pr/Cr ratio correlated well with 24-hour urine protein excretion (r = 0.95, p < 0.0001).Conclusion: Spot urine Pr/Cr ratio is a convenient, user-friendly and reliable method to replace 24-hour urine protein measurement for the assessment of proteinuria.背景: 根據 2000 年美國國家腎臟基金會的 K/DOQI 指引，對於偵測及監察成人及兒童的蛋白尿，在大多數情況下採用隨機單次尿液檢體即可，毋須講究尿液收集的時間。然而，此措施在香港並未被廣泛應用。本研究之目的，是在香港的區域醫院內，測量病人隨機單次尿液之蛋白-肌酸酐 (Pr/Cr) 比例、及 24 小時之尿蛋白排泄量，並調查兩者的相關性。方法: 研究採取前瞻性的方式，在 2007 至 2008 年間共納入 174 位病人，分別測量隨機單次尿液 Pr/Cr 比例及 24 小時尿蛋白排泄量，並以線性回歸法進行數據的分析。結果: 結果顯示，隨機單次尿液 Pr/Cr 比例與 24 小時尿蛋白排泄量呈現顯著的相關性 (r = 0.95、p < 0.0001)。結論: 在蛋白尿的評估上，作為一個簡便而可靠的指標，隨機單次尿液 Pr/Cr 比例理應可取代 24 小時尿蛋白排泄量。

Prevalence of hypertension, diabetes and chronic kidney disease in participants of the 2009 World Kidney Day screening exercise in Southwest Nigeria

2011-10-01

Summary: Background/Purpose: Early detection of chronic kidney disease (CKD) and its risk factors such as hypertension (HT), diabetes (DM) and proteinuria will allow prompt medical intervention, which may impact positively on kidney outcome. We took advantage of the World Kidney Day, which is intended to raise awareness and increase the detection of CKD, to screen participants for HT, DM and CKD using dipstick-positive proteinuria as a marker of CKD.Methods: A total of 586 participants were screened for HT, DM and dipstick-positive proteinuria during the 2009 World Kidney Day at Osogbo in southwest Nigeria.Results: The overall prevalence of proteinuria, HT and DM in the unselected population was 2.5%, 25.9%, and 3.8%, respectively. Of participants with HT, there were more females (32.3% vs. 21.9%, p=0.005), a higher prevalence of family history of HT (p<0.001), older age (p<0.001), higher mean weight (p<0.001), higher mean body mass index (p<0.001) and higher mean random blood sugar (p=0.018) when compared to those without HT. However, among the 461 apparently healthy participants (asymptomatic and without history of HT, DM or CKD), the prevalence of significant dipstick-positive proteinuria, HT and DM was 2.8%, 11.1% and 2.0%, respectively. In the asymptomatic cohort, age (odds ratio, 1.1; 95% confidence interval, 1.06–1.14; p<0.001) and sex (odds ratio, 2.68; 95% confidence interval, 1.2–5.95; p=0.016) were significant risk factors associated with the presence of HT on multivariate analysis. Of participants with DM, there were more females (p=0.032), older age (p=0.019), higher mean body mass index (p=0.008), higher mean systolic blood pressure (p<0.001) and higher mean diastolic blood pressure (p=0.011) when compared to those without DM.Conclusion: Dipstick-positive proteinuria, HT and DM were common in our unselected and asymptomatic population. Public education and opportunistic screening for these risk factors of CKD will improve patient- and physician-level awareness, which in turn will ensure early detection of kidney disease.背景: 早期偵測慢性腎病 (CKD) 及其危險因子如高血壓 (HT)、糖尿病 (DM)、及蛋白尿，有助於治療的及早施行，可望對患者的預後產生正面的影響。我們為響應世界腎臟日對 CKD 認知與偵測的提倡，在相關活動當天對參加者進行了 HT、DM、及 CKD (蛋白尿試紙檢測) 的篩檢行動。方法: 該活動於尼日利亞奧索各博 (Oshogbo、Nigeria) 的 2009 年世界腎臟日進行，共有 586 位參加者接受了 HT、DM、及試紙蛋白尿的篩檢。結果: 整體上，蛋白尿、HT、及 DM 的盛行率分別為 2.5%、25.9%、及 3.8%。相比於非患者，HT 患者的特徵包括：女性比例較高 (32.3% vs. 21.9%、p=0.005)、HT 家族史比例較高 (p<0.001)、較高齡 (p<0.001)、體重較高 (p<0.001)、身體質量指數較高 (p<0.001)、及隨機血糖較高 (p=0.018)。然而，在健康無異常 (無症狀、無 HT、DM、或 CKD 病史) 的參加者 (n=461) 間，試紙蛋白尿陽性、HT、及 DM 的盛行率分別為 2.8%、11.1%、及 2.0%。多變數分析顯示，年齡 (OR、1.1；95% CI、1.06–1.14；p<0.001) 及性別 (OR、2.68；95% CI、1.2–5.95；p=0.016) 是 HT 的重大危險因子。相比於非患者，DM 患者的特徵則包括：女性比例較高 (p=0.032)、較高齡 (p=0.019)、身體質量指數較高 (p=0.008)、收縮血壓較高 (p<0.001)、及舒張血壓較高 (p=0.011)。結論: 即使在未經挑選且無症狀的人群中，試紙蛋白尿陽性、HT、及 DM 仍然頗為盛行。透過有效的衛生教育與篩檢措施，可望提升社會對 CKD 的認知，並對患者作出及早的診治。

Clinical experience of conversion from twice-daily standard-release tacrolimus to once-daily prolonged-release tacrolimus in stable renal transplant recipients

2011-10-01

Summary: Background: Conversion of standard-release tacrolimus to prolonged-release once-daily tacrolimus is often performed in a 1:1 (mg:mg) manner. We sought to determine the safety and efficacy of this conversion strategy in Chinese renal transplant recipients.Methods: In this single-center study, 16 stable renal transplant recipients were observed for 1 year after a milligram to milligram switch from standard-release to prolonged-release tacrolimus formulation. Trough blood tacrolimus level and graft function were serially monitored.Results: Mean daily dose of tacrolimus was 0.040±0.018mg/kg before conversion. After conversion, we observed a significant decrease in trough tacrolimus levels, from 4.5±2.2ng/mL to 3.4±1.1ng/mL (p=0.046) at 1 month, and from 4.5±2.2ng/mL to 3.3±1.1ng/mL (p=0.01) at 12 months. After 12 months, 44% of patients (n=7) experienced a decrease in tacrolimus blood levels of more than 20%. All patients maintained stable graft function otherwise, without acute rejection.Conclusion: Our findings confirm that trough tacrolimus blood level can decrease following a 1:1 (mg:mg) conversion from standard-release to prolonged-release tacrolimus formulation in Chinese patients. Close monitoring of the drug levels and clinical condition seems to be warranted after medication switch.背景: 從標準釋放型 tacrolimus 轉換至一天一次延長釋放型 tacrolimus 通常是按 1:1 (mg:mg) 的比例進行；以下研究以華裔腎臟移植接受者為對象，對此轉換法的功效及安全性作出調查。方法: 本研究於單一院所進行，參與者為 16 位穩定的腎臟移植接受者，從標準釋放型轉換至延長釋放型 tacrolimus (按 1:1 之 mg:mg 比例) 後接受 1 年的持續追蹤，內容包括 tacrolimus 谷底血液濃度及植入腎臟功能。結果: 轉換前，tacrolimus 之平均劑量為 0.040±0.018mg/kg；轉換後，tacrolimus 谷底濃度呈現明顯下降：1 個月時從 4.5±2.2ng/mL 至 3.4±1.1ng/mL (p=0.046)，12 個月時從 4.5±2.2ng/mL 至 3.3±1.1ng/mL (p=0.01)。在經過 12 個月後，44% 的病人 (n=7) 呈現 >20% 的 tacrolimus 血液濃度降幅。然而，所有病人的植入腎臟均維持穩定的功能，未出現急性排斥現象。結論: 本研究證實在華裔病人間，從標準釋放型 tacrolimus 按 1:1 (mg:mg) 比例轉換至延長釋放型 tacrolimus 後，tacrolimus 谷底濃度會有所下降，因此理應有需要在轉換後密切監察病人的藥物濃度及臨床狀況。

Effect of e-mail education on stress and compliance in Korean elderly on hemodialysis

Gyeong-Ju An — 2011-10-01

Summary: Background/Purpose: The number of elderly patients receiving hemodialysis for end-stage renal disease has increased such that patients aged over 60 years account for 41.4% of the hemodialysis population in Korea. Elderly hemodialysis patients feel more stressed from a social and psychological perspective than from a physical perspective. Thus, it is necessary to develop nursing interventions to decrease the level of stress in Korean elderly hemodialysis patients. The purpose of the present study was to determine the effects of e-mail education about the treatment regimen on stress and compliance in elderly hemodialysis patients.Methods: A non-equivalent pretest–posttest control experimental design was used. Forty patients were allocated to the control (n = 21) and e-mail (n = 19) groups from two hospitals. The e-mail group received an education program about the hemodialysis diet and drug administration by e-mail twice a week for 6 weeks while the control group did not.Results: Stress score (50.22 ± 8.79 vs. 45.13 ± 6.24, p = 0.043), serum cortisol (13.32 ± 3.84 vs. 10.03 ± 3.79 μg/dL, p = 0.031) and epinephrine (28.42 ± 14.50 vs. 20.36 ± 18.07 ng/dL, p = 0.019) of the e-mail group were significantly lower than in the control group. Compliance, including interdialytic weight gain (2.84 ± 0.94 vs. 2.17 ± 0.82 kg, p = 0.038), of the e-mail group was significantly improved compared to the control group.Conclusion: The e-mail education program for Korean elderly hemodialysis patients was effective in improving stress and compliance related to fluid restriction.背景: 在韓國，因末期腎病正在接受血液透析的病人之間，60 歲以上的病人數目呈現增長，並佔整體血液透析人口的 41.4%。對於年老的病人，血液透析在社會及心理層面上所構成的壓力比身體上的壓力更甚，這種需求必須被納入護理照護的考量中。本研究對年老血液透析患者，透過電郵方式，進行了療程相關的衛教，並調查了此措施對患者壓力及依從性的影響。方法: 研究採用不相等前測–後測對照組設計，對象來自兩所醫院共 40 位病人，包括對照組 21 人及電郵組 19 人，僅後者以電郵方式接受衛教，內容涵蓋血液透析的飲食與服藥方面，頻率為每週兩次達 6 週。結果: 相比於對照組，各項指標均以電郵組表現較佳，包括壓力評分 (50.22 ± 8.79 vs. 45.13 ± 6.24、p = 0.043)、血清皮質醇 (13.32 ± 3.84 vs. 10.03 ± 3.79 μg/dL、p = 0.031) 及腎上腺素水平 (28.42 ± 14.50 vs. 20.36 ± 18.07 ng/dL、p = 0.019)；此外，電郵組的依從性亦呈現明顯改善，包括較小的透析間體重增幅 (2.84 ± 0.94 vs. 2.17 ± 0.82 kg、p = 0.038)。結論: 對於韓國的年老血液透析患者，電郵衛教有效改善了患者的壓力水平及液體限制依從性。

Renal amyloidosis: A rare presenting manifestation of Hodgkin’s disease

Jai Prakash, Sanjeev Kumar Behura, Biplab Ghosh, Shivendra Singh, Usha — 2011-10-01

Summary: Renal amyloidosis leading to nephrotic syndrome is very rare in Hodgkin’s disease as compared to minimal change disease. Amyloidosis usually develops insidiously after many years of active Hodgkin’s disease, and is often a late and irreversible complication. Concomitant presentation of Hodgkin’s disease and nephrotic syndrome are rarely reported in the literature. We describe a 35-year-old female who presented simultaneously with Hodgkin’s disease and nephrotic syndrome, which was found to be secondary to renal amyloidosis on renal biopsy.相比於腎臟的微小變化疾病，類澱粉沉積所致之腎病症候群在霍杰金氏病中非常罕見。在活性的霍杰金氏病患者間，類澱粉沉積症通常潛伏多年，至後期演變成一個不可逆的併發症。至今，文獻鮮有記載霍杰金氏病及腎病症候群的共同病發現象。以下是一位35歲的女性患者，同時呈現霍杰金氏病及腎病症候群，後者經活組織檢驗證實是腎臟的類澱粉沉積症所致。

Double gap metabolic acidosis in a Chinese alcoholic

Chi Yuen Cheung, Chun Sang Li — 2011-10-01

Summary: Alcoholic ketoacidosis is an important cause of double gap metabolic acidosis. The differential diagnosis includes toxic alcohol (such as methanol and ethylene glycol) ingestion. We report a patient with alcoholic ketoacidosis. He had a history of excessive alcohol intake and presented with repeated vomiting, loss of appetite and hypovolemic shock. Laboratory results revealed high anion gap metabolic acidosis, increased serum osmolal gap, ketonemia, lactic acidosis and acute renal failure. He was successfully treated with hemodialysis, and hydration with glucose and thiamine.酒精性代謝酮酸中毒是雙重間隙代謝性酸中毒的重要成因，其鑑別診斷為有毒酒精(如甲醇、乙二醇)的攝入。以下個案是一位酒精性代謝酮酸中毒患者，具過度攝入酒精的習慣，入院時呈現重複嘔吐、無食慾、及低血容積性休克。化驗結果顯示高陰離子間隙之代謝性酸中毒、高血清滲透間隙、酮血症、乳酸中毒、及急性腎衰竭。在接受血液透析、合併葡萄糖與硫胺素補充療法後，病人反應良好。

Major depression and chronic kidney disease in Pakistan

Syed Ather Hussain, Haider Naqvi, Syed Ali Danial Jafri — 2011-10-01

Non-communicable diseases (NCDs) have a significant global impact, being responsible for 60% of all deaths and 47% of the global burden of disease. In South Asia, almost half of the adult burden of disease falls into the NCD category. In Pakistan, NCDs contribute significantly to the disease burden, ranking among the top 10 causes of mortality and morbidity. Estimates indicate that about 25% of deaths occurring in the country may be attributed to NCDs.