Hong Kong Journal of Nephrology

Palliative Care of Renal Failure Patient

Cheuk Chun Szeto — 2009-10-01

Complement Activation and Progression of Chronic Kidney Disease

Ziyong Tang, Neil Sheerin — 2009-10-01

Proteinuria is a strong predictor of progression in chronic kidney disease. Complement proteins are a major constituent of the urine of proteinuric patients. Complement is activated in the tubular lumen through the alternative pathway, and complement activation products are deposited on the apical surface of tubular epithelial cells. Recent animal studies have suggested that complement activation in the tubular compartment plays an important role in proteinuria-associated tubulointerstitial injury. Complement deficiency, depletion or inhibition all reduce the tubular cell damage and interstitial fibrosis that develops in proteinuric animals. In particular, inhibition of anaphylatoxin receptors protects the kidneys from proteinuria-associated damage. In this review, we discuss the evidence for a role of complement activation in the progression of chronic kidney disease.

Nephrology After the Wenchuan Earthquake

Li Wang, Guisen Li, Qiang He, Xiuchuan Yang — 2009-10-01

The Wenchuan earthquake on May 12, 2008 was a catastrophic natural disaster and resulted in a massive number of deaths and casualties. After the earthquake, nephrologists played critical roles not only in the restoration of dialysis facilities for regular renal replacement therapy but also in the prevention and treatment of crush syndrome and crush-related acute kidney injury. Brief guidelines, functional action plans and good training were significant factors in nephrologists being able to fulfill their critical roles, but the national network of renal disaster relief was also extremely important.

Experience of a Renal Palliative Care Program in a Hong Kong Center: Characteristics of Patients Who Prefer Palliative Care to Dialysis

Doris Man-Wah Tse — 2009-10-01

Background: A renal palliative care (RPC) program was developed in a local center as an option for patients with end-stage renal disease (ESRD) who may not benefit from dialysis or who do not prefer dialysis. The model involved collaboration between the palliative care and renal teams, and the RPC program was introduced as an option in the advance care planning (ACP) interview during which treatment benefits, burdens, predicted prognosis and the patient's preferences were discussed. Patients who preferred palliative care to dialysis were recruited into the RPC program. An interdisciplinary team approach was adopted and the Renal Palliative Clinic comprised the core component among the full spectrum of services. Methods: This was a retrospective study of the characteristics of ESRD patients who were interviewed for ACP between August 2007 and the end of 2008 and who preferred palliative care to dialysis. Results: A total of 96 ESRD patients were interviewed for ACP during this period, among which 36 patients opted for dialysis while 60 patients chose RPC. In both groups, around 97% of patients were mentally competent and involved in ACP. The patients who chose RPC, as compared with the patients who opted for dialysis, were older (74.1 ± 8.7 years vs. 56.3 ± 10.0 years, p< 0.001), included more widowers (40.0% vs. 2.8%, p<0.001), were more financially dependent on their family (65.0% vs. 36.1%, p< 0.001), had a higher incidence of diabetes mellitus (73.4% vs. 41.6%, p= 0.002), and had a higher modified Charlson Comorbidity Index (9.5 ± 1.9 vs. 6.9 ± 3.1, p< 0.001). More RPC patients relied on assistance to walk and had a constant caregiver at home. The decision for RPC was primarily the patient's in 41.7%, while it was a shared family decision in 56.5%. The reasons given for declining dialysis were perceived undue physical burden in 60.1%, social burden in 53.4%, and psychological burden in 56.8%, while 35.1% of patients cited all of the above reasons for their decision. By the end of 2008, 30 (50.0%) RPC patients had died, after receiving palliative care for a median duration of 132.5 days (range, 3–437 days; interquartile range, 115.0). They all lived with their choice of RPC until death. Conclusion: The RPC program, introduced as an option in ACP, was appropriate in meeting the preferences and needs of a significant proportion of ESRD patients and their families.

Cardiac Damage Induced by Renal Ischemia/Reperfusion Injury in Hyperlipidemic Rats: Role of PPAR-α Agonist

Yagnik Bhalodia, Navin Sheth, Jitendra Vaghasiya, Nurudin Jivani — 2009-10-01

Background: In view of the reported efficacy of peroxisome proliferator-activated receptor-α in renal ischemia/reperfusion (I/R) injury, the present study was designed to investigate the effect of fenofibrate on cardiac damage induced by renal I/R in hyperlipidemic rats. Methods: Male Wistar rats were divided into five groups: Group 1, normal control; Group 2, hyperlipidemic control; Group 3, renal I/R injury; Group 4, hyperlipidemic + renal I/R injury; and Group 5, hyperlipidemic +renal I/R injury + fenofibrate. Hyperlipidemia was induced by feeding the rats with cholesterol (500 mg/kg per oral) in hydrogenated ground nut oil (as a vehicle) for 4 weeks. At the end of the fourth week, renal I/R injury was induced by occlusion of both renal vascular pedicles for 60 minutes, followed by 24-hour reperfusion. In the treatment group, fenofibrate (100 mg/kg per oral, dissolved in water containing 0.2% methyl cellulose) was given 2 weeks before I/R injury. At the end of the experiment, blood and heart were isolated for biochemical analysis. Results: Hyperlipidemic I/R rats have significantly higher levels of cardiac lipid peroxidation, xanthine oxidase, nitric oxide and myeloperoxidase, and lower levels of antioxidant enzymes (reduced glutathione, superoxide dismutase and catalase) compared to non-hyperlipidemic I/R rats, the levels of which were restored after treatment with fenofibrate. Cardiac functional enzymes were normalized after the administration of fenofibrate. Conclusion: This study elucidated the oxidative role of cardiac damage induced by renal I/R via inflammatory mediators, which was attenuated by fenofibrate.

Non-healing Skin Ulcers Secondary to Calciphylaxis with Candida tropicalis Fungemia in an End-stage Renal Disease Patient

2009-10-01

Calciphylaxis is an uncommon necrotizing skin condition characterized by excessive calcification of soft tissue and small arteries, leading to ischemic ulceration of the skin. It mainly affects patients with chronic renal failure and often leads to fatal consequences. Chronic renal failure, hyperparathyroidism, hypercalcemia, and hyper-phosphatemia often trigger the precipitation of calcium-phosphate crystals in the arterioles of the dermis and soft tissues, leading to ischemia and skin ulcerations. The diagnosis of calciphylaxis is mainly clinical and skin biopsy is infrequently done because of the risk of poor healing and secondary infections. Despite aggressive treatment regimens, mortality is high. Here, we report the case of a 44-year-old female end-stage renal disease patient with multiple non-healing skin ulcers secondary to calciphylaxis complicated with refractory infections including Candida tropicalis fungemia, vancomycin-resistant enterococcus and Acinetobacter baumannii wound infections.