Background: Metformin-associated lactic acidosis (MALA) is a rare event but underrecognition may lead to unfavorable outcomes in type 2 diabetes patients. While many risk factors of MALA have been identified, how to reduce mortality from MALA is a matter of debate. This study aimed to explore the factors associated with 30-day mortality amongst MALA patients. Methods: An observational study enrolled patients diagnosed with MALA between January 2014 and December 2017. MALA was defined by a history of metformin administration, metabolic acidosis (arterial blood gas pH <7.35 or HCO₃ 5 mmol/L). We examined risk factors including age, sex, underlying diseases, current medications, blood tests, disease severity, and dialysis data. Mortality status was identified from medical records or report on telephone. Results: We included 105 MALA patients. Most patients (95.2%) were diagnosed acute kidney injury stage 3 according to KDIGO 2012 definition. The 30-day mortality rate was 36.2% and dialysis rate was 85.7%. The survivors had higher proportions of underlying chronic kidney disease, presence of metabolic acidosis, receiving renal replacement therapy within 6 hours, and haemodialysis, whereas the non-survivors had higher percentage of hypertension and disease severity. Lower APACHE II score (HR = 0.95; 95%CI, 0.91–0.99; p = 0.038), time to dialysis < 6 hours (0.31; 0.14–0.69; 0.004), and haemodialysis (0.20;0.06–0.67; 0.010) were associated with lower 30-day mortality, using multivariate Cox-regression analysis. Conclusions: Mortality rate amongst patients with MALA was high. Early dialysis treatment within 6 hours after admission and haemodialysis were independently associated with lower 30-day mortality. The large scale, well-designed studies need to confirm these encouraging results.

Backgrounds: In critically ill patients with COVID-19, secondary infections are potentially life-threatening complications. This study aimed to determine the prevalence, clinical characteristics, and risk factors of CMV reactivation among critically ill immunocompetent patients with COVID-19 pneumonia. Methods: A retrospective cohort study was conducted among adult patients who were admitted to ICU and screened for quantitative real-time PCR for CMV viral load in a tertiary-care hospital during the third wave of the COVID-19 outbreak in Thailand. Cox regression models were used to identify significant risk factors for developing CMV reactivation. Results: A total of 185 patients were studied; 133 patients (71.9%) in the non-CMV group and 52 patients (28.1%) in the CMV group. Of all, the mean age was 64.7±13.3 years and 101 patients (54.6%) were males. The CMV group had received a significantly higher median cumulative dose of corticosteroids than the non-CMV group (301 vs 177 mg of dexamethasone, p0.05). The 90-day mortality rate for all patients was 29.1%, with a significant difference between the CMV group and the non-CMV group (42.3% vs. 24.1%, p = 0.014). Median length of stay was longer in the CMV group than non-CMV group (43 vs 24 days, p<0.001). The CMV group has detectable CMV DNA load with a median [IQR] of 4,977 [1,365–14,742] IU/mL and 24,570 [3,703–106,642] in plasma and bronchoalveolar fluid, respectively. In multivariate analysis, only a cumulative corticosteroids dose of dexamethasone ≥250 mg (HR = 2.042; 95%CI, 1.130–3.688; p = 0.018) was associated with developing CMV reactivation. Conclusion: In critically ill COVID-19 patients, CMV reactivation is frequent and a high cumulative corticosteroids dose is a significant risk factor for CMV reactivation, which is associated with poor outcomes. Further prospective studies are warranted to determine optimal management.

Thrombosis in COVID‐19 is increasingly recognized and is generally associated with high mortality rate. The key clinical question of this report was whether COVID‐19 could be complicated with cardiac thrombus and pulmonary embolism in Asian population. We demonstrated the case series of thrombosis in Thai patients with confirmed SARS‐CoV‐2 infection. One case was the first case of large left ventricular thrombus and three other cases had pulmonary embolism. All patients were male and they had low absolute lymphocyte count while lactate dehydrogenase level and D‐dimer were markedly elevated, especially at the time when the thrombosis was diagnosed. All cases had severe COVID‐19 with pneumonia. Two cases who needed mechanical ventilation were successfully extubated. After hospitalization for 13 to 49 days, pneumonia and thrombosis improved and all of them could be discharged from the hospital. Thrombosis is common in COVID‐19 and could present in both arterial and venous sites even in Asian population. D‐dimer is a strong marker to predict thrombosis and could be a prognostic predictor for severity of COVID‐19.

Background: Indecision regarding the start of peritoneal dialysis (PD) is a challenging problem in chronic kidney disease (CKD) stage 5 patients who receive conventional video counseling. This study aimed to evaluate the effect of video counseling customized to the local context versus conventional video counseling on PD decision-making in CKD stage 5 patients under PD-first policy. Methods: We enrolled 120 patients with stage 5 CKD in Thailand who initiate PD between May 2016 to January 2017 in a randomized, open-label, controlled study. Patients were randomized to either a customized or conventional video counseling group. The primary outcome was PD acceptance rate with complete PD catheter insertion on schedule. The secondary outcomes were change in patient knowledge and confidence in PD and reasons for indecision PD. Results: We analyzed 120 patients (customized, n = 60 vs. conventional, n = 60). The two groups were similar for age (55 vs. 56 years), blood urea nitrogen (89 vs. 86 mg/dL), creatinine (10.37 vs. 11.29 mg/dL), and eGFR (4.7 vs. 5.6 mL/min/1.73 m(2)). The PD acceptance rate along with PD catheter insertion on schedule in the customized video counseling group was not significantly different from that in the conventional video counseling group (66.6% vs. 63.3%, relative risk: 0.97, 95% confidence interval: 0.73 to 1.29; P= 0.86). Patient knowledge of and confidence in PD increased after counseling, but the difference was not significant. Conclusion: Among stage 5 CKD patients, counseling content customized to a local context did not differ in a rate of acceptance for beginning PD with PD catheter insertion on schedule compared with conventional video counseling.

Decreased urinary output developed in a 42-year-old man who was receiving trimethoprim–sulfamethoxazole for Pneumocystis jirovecii pneumonia. Urine microscopy revealed fan-shaped crystals. A diagnosis of sulfonamide-crystal–induced acute kidney injury was made.