We present the case of infected wet gangrene of right foot in the setting of poorly controlled type 2 diabetes in a 71-year-old woman. This patient presented with improved infection condition after intravenous piperacillin–tazobactam (PTZ) 2.25 gm every 6 hours treatment and below knee amputation surgery on day 3. However, neutropenia and thrombocytopenia developed on day 13. We consulted a haematologist and performed a series of examinations. However, no significant findings were noted thereafter. PTZ was suspected to be the most likely cause of neutropenia and thrombocytopenia and was hence terminated on day 14 (cumulative dose of PTZ: 126 g) following stabilisation of the infection condition. A transfusion was performed with two units of single donor platelets on day 14 and treated with intravenous dexamethasone 5 mg every 8 hours from day 14 to 16. Her white blood cell and platelet counts increased on day 15 and continued to recover thereafter.

Introduction: End-stage kidney disease (ESKD) patients who need renal replacement therapy need to face a dialysis modality decision: the choice between hemodialysis (HD) and peritoneal dialysis (PD). Although the global differences in HD/PD penetration are affected by health-care policies, these two modalities may exert different effects on survival in patients with ESKD. Although Taiwan did not implicate PD as first policy, we still need to compare patients’ outcomes using two modalities in a nation-wise database to determine future patients’ care and health policies. Methods: We used the nationwide Taiwan Renal Registry Data System (TWRDS) database from 2005 to 2012 and included 52,900 patients (48,371 on HD and 4529 on PD) to determine all-cause and cardiovascular mortality among ESKD patients. Results: Age-matched survival probability from all-cause mortality was significantly lower in patients on PD than in those on HD (p < 0.05). The adjusted hazard ratios of 3-year and 5-year all-cause and cardiovascular mortality were significantly higher in PD compared with HD. The presence of comorbid conditions including myocardial infarction, coronary artery disease (CAD), diabetes mellitus (DM), hypoalbuminemia, hyperferritinemia and hypophosphatemia was related with significantly higher all-cause and CV mortality in PD patients. No significant difference was noted among younger patients <45 years of age regardless of DM and/or comorbid conditions. Conclusion: Although PD did not have the survival advantage compared to HD in all dialysis populations, PD was related with superior survival in younger non-DM patients, regardless of the presence of comorbidities. Similarly, for younger ESKD patients without the risk of CV disease, both PD and HD would be suitable dialysis modalities.

Life-threatening dyskalemia, defined as an abnormal serum potassium concentration, is common in emergency settings that requires timely recognition and treatment and can be detected via AI-enabled electrocardiography. We conducted a pragmatic, open-label, randomized controlled trial with physician-level randomization to evaluate whether a real-time AI-enabled electrocardiography alert could improve physicians’ management of dyskalemia. Over a six-month period in 2022, 70 emergency physicians were randomized (35 intervention, 35 control) and provided care to 14,989 patients (7506 in the intervention group and 7483 in the control group) at an academic medical center and a community hospital (ClinicalTrials.gov NCT05118022). The trial had two primary outcomes: the rate of hyperkalemia-related treatment and hypokalemia-related treatment within three hours. The intervention consisted of a real-time pop-up alert in the electronic health records that categorized patients at risk of moderate-to-severe hyperkalemia (≥6.0 mmol/L) or hypokalemia (≤3.0 mmol/L). Physicians in the control group did not receive alerts. Overall, the rate of hyperkalemia-related treatment was not significantly greater in the intervention group (8.0%) than in the control group (7.7%) (hazard ratio 1.05; 95% CI 0.94–1.17; p = 0.420). Similarly, the rate of hypokalemia-related treatment did not differ significantly (2.1% vs. 2.4%; hazard ratio 0.91; 95% CI 0.74–1.13; p = 0.392). Among patients identified by AI-enabled electrocardiography as having hyperkalemia, however, hyperkalemia-related treatment occurred more frequently in the intervention group (69.1% vs. 41.6%; hazard ratio 2.23; 95% CI 1.44–3.46; p < 0.001). This trial demonstrates that a real-time AI-enabled electrocardiography alert facilitated earlier treatment among patients identified as high risk for hyperkalemia.

Severe lactic acidosis, a mitochondrial toxicity caused by the recommended standard dosage of linezolid (LZD), may occur in patients with impaired renal function. We describe an adult male who underwent kidney transplantation with stably impaired renal function, severe dyspnea, and abdominal discomfort. He received a standard oral dose of LZD (600 mg twice daily) and azithromycin for three weeks with a reduced immunosuppressant dose due to pulmonary non-tuberculosis mycobacterial infection. He was alert and afebrile, with a blood pressure of 140/60 mmHg. Pertinent laboratory data showed: pH 7.12, PaCO2 13.6 mmHg; HCO3- 4.3 mmol/L and serum lactate 18.4 mmol/L. His trough serum LZD concentration reached toxic levels (21.4 μg/mL). With hemodialysis, his clinical symptoms improved, with a decline in serum LZD (9.8μg/mL) and lactate (3.2 mmol/L). Chronic standard dose LZD in patients with impaired renal function can lead to life-threatening lactic acidosis, especially in coexisting conditions that reduce LZD metabolism.

Background: Severe hyperkalemia is a life-threatening emergency requiring prompt management and close surveillance. Although artificial intelligence-enabled electrocardiography (AI-ECG) has been developed to rapidly detect hyperkalemia, its application to monitor potassium (K+) levels remains unassessed. This study aimed to evaluate the effectiveness of AI-ECG for monitoring K+ levels in patients with severe hyperkalemia. Methods: This retrospective study was performed at an emergency department of a single medical center over 2.5 years. Patients with severe hyperkalemia defined as Lab-K+ ≥6.5 mmol/l with matched ECG-K+ ≥5.5 mmol/l were included. ECG-K+ was quantified by ECG12Net analysis of the AI-ECG system. The following paired ECG-K+ and Lab-K+ were measured at least twice, almost simultaneously, during and after K+-lowering therapy in 1 day. Clinical characteristics, pertinent intervention, and laboratory data were analyzed. Results: Seventy-six patients fulfilling the inclusion criteria exhibited initial Lab-K+ 7.4 ± 0.7 and ECG-K+ 6.8 ± 0.5 mmol/l. Most of them had chronic kidney disease (CKD) or were on chronic hemodialysis (HD). The followed Lab-K+ and ECG-K+ measured with a mean time difference of 11.4 ± 5.6 minutes significantly declined in parallel both in patients treated medically (n = 39) and with HD (n = 37). However, there was greater decrement in Lab-K⁺ (mean 7.3 to 4.1) than ECG-K⁺ (mean 6.6 to 5.0) shortly after HD. Three patients with persistent ECG-K+ hyperkalemia despite normalized Lab-K+ exhibited concomitant acute cardiovascular comorbidities. Conclusions: AI-ECG for K+ prediction may help monitor K+ level for severe hyperkalemia and reveal more severe cardiac disorders in the patients with persistent AI-ECG hyperkalemia.

Icodextrin is widely utilized as an osmotic agent in peritoneal dialysis (PD) prescription for clinical patients with inadequate ultrafiltration, but icodextrin induced acute generalized exanthematous pustulosis (AGEP) has not been well recognized. We described a young-aged female with IgA nephropathy under continuous automated peritoneal dialysis who developed skin erythema with exfoliation over the groin at 7^th day after first infusion of icodextrin based PD prescription. Her scaling skin lesion with pinhead-sized pustules invaded the bilateral inguinal folds at first, and then extended to general trunk accompanied by pruritus and mild tingly in rapid succession. As expansion of confluent skin lesion, she was admitted on 14^th day of icodextrin exposure and PD treatment was instantly ceased. She was afebrile with stable vital sign and physical examination was notable for widespread erythematous papules with pruritus extending over her groins, abdomen and back. Pertinent laboratory examination showed leukocytosis of 18970 cells/μL with neutrophile count of 17642 cells/μL (92.3 %), and c-reactive-protein: 3.39 mg/dl. Skin biopsy reveals multifocal subcorneal abscess with papillary dermal edema, and upper-dermal neutrophilia with perivascular accentuation, consistent with the diagnosis of AGEP. After discontinuation of PD, she underwent temporary high-flux hemodialysis and treatment of steroid and antihistamine, her dermatologic lesion resolved totally four days later and restarted peritoneal dialysis at 17^th day without any skin sequalae. This case highlighted the fact that icodextrininduced AGEP should be early recognized after first use of icodextrin to avoid misdiagnosis to other dermatoses and severe complication without appropriate management.