Therefore it is important that providers carefully familiarize th

Therefore it is important that providers carefully familiarize themselves with this technique. Indications Chest compressions are generally indicated for all patients in cardiac arrest. Unlike other medical interventions, chest compressions can be initiated by any healthcare

provider without a physician’s order. This is based on implied patient consent for emergency treatment [3]. If a patient is found unresponsive without a definite pulse or normal breathing then the responder should assume that this patient is in cardiac arrest, activate Idasanutlin solubility dmso the emergency response system and immediately start chest compressions [4]. The risk of serious injury from chest compressions to patients who are not in cardiac arrest is negligible [5], while any delay in starting chest compressions has grave implications for outcome. Due to the importance of starting chest compressions early, pulse and breathing checks were de-emphasized in the most recent CPR guidelines [4]. Thus,

healthcare providers should take no longer than 10 seconds to check for a pulse. The carotid or femoral pulses are preferred locations for pulse checks since peripheral arteries can be unreliable. Contraindications In certain LDK378 in vivo circumstances it is inappropriate to initiate chest compressions. A valid Do Not Resuscitate (DNR) order that prohibits chest compressions is an absolute contra-indication. DNR orders are considered by the attending physician on the basis of patient autonomy and treatment futility. The principle of patient autonomy dictates that competent patients have a right to refuse medical treatment [6]. Therefore a DNR order should be documented if patients do not wish to be treated with chest compressions. For patients with impaired decision-making, previous preferences should be taken into account when making decisions regarding DNR. The principle of treatment futility dictates that healthcare providers are not obliged to provide treatment if this would be futile [6]. Therefore a DNR order should be documented if chest compressions would be unlikely to confer a survival benefit or acceptable quality of life. However, few criteria

can reliably predict the futility of starting chest compressions. If there is any uncertainty selleck compound regarding DNR status then chest compressions should be started immediately while the uncertainties are addressed. Compressions may subsequently be terminated as soon as a valid DNR order is produced. Of note, patients with implantable left ventricular assist devices [7–9] or patients with total artificial hearts or biventricular assist devices [10] who suffer cardiac arrest from device failure should be resuscitated using a backup pump (e.g. ECMO [11, 12]) if this is available rather than with chest compressions. The Physiology of Chest Compressions Chest compressions generate a small but critical amount of blood flow to the heart and brain.

Our strategy based in the identification of orthologs of 14 seed

Our strategy based in the identification of orthologs of 14 seed proteins involved in copper homeostasis in 268 gamma proteobacterial genomes from 79 genera. This data was further transformed into a presence/absence matrix and optimized, preserving the phylogenetic relationships

of the organisms. It was striking to observe that only 3% of the organisms present the full copper homeostasis proteins Selumetinib clinical trial repertoire that was previously described in E.coli[7]. Interestingly, isolates presenting a large number of protein involved in copper homeostasis are pathogenic: Klebsiella pneumoniae NTUH-K2044, Klebsiella pneumoniae subsp. pneumoniae MGH 78578, Enterobacter cloacae subsp. cloacae ATCC 13047 and Escherichia coli 55989 are human pathogens; Escherichia

coli APEC O1 is a chicken pathogen and Escherichia coli ATCC 8739, Cronobacter sakazakii ATCC BAA-894 and Cronobacter turicensis TAX413502 may be opportunistic GDC-0449 molecular weight organisms. Although these organisms are well characterized, no relevant information about their biology or their lifestyles explained why these organisms present the largest repertoire of copper tolerance proteins. On the other hand, 5% of the organisms (all of them intracellular parasites) apparently lack copper homeostasis proteins. In the remaining organisms, the ensemble Rebamipide consolidated in four clusters: PcoC-CueO-YebZ-CutF-CusF, PcoE-PcoD, PcoA-PcoB and CusC-CusA-CusB-CopA, that pointed the most frequent strategies to address the necessary copper homeostasis. In this context, it is remarkable that the observed clusters were not fully consistent with evidence obtained from transcriptional co-regulation which has been fundamental for systems designation. In general, clusters distributed with phylogenetic consistency at the family level, suggesting inheritance as the main mechanism for gene transfer.

However, in some organisms harboring the full copper homeostasis repertoire, genes were organized as islands in plasmids and flanked by mobile elements, enabling them with the potential to be horizontally transferred (Additional file 2). Double optimization of the presence/absence profile exposed a tight organization of the seed proteins into nine different repertoires revealing the diversity of copper homeostasis in gamma proteobacteria. Redundancy is a common approach to improve the reliability and availability of a system. Adding redundancy increases the cost and complexity of a system design but if the cost of failure is high enough, redundancy may be an attractive option.

For example, the rs2623047 G>A showed an association with age of<

For example, the rs2623047 G>A showed an association with age of

disease onset (Table 3); the patients with the AA genotype had a mean age of selleck compound onset of 65.0 ± 9.9 years; and those with the AG genotype had 61.2 ± 10.8 years, while those with the rs2623047 GG showed 56.8 ± 10.7 year age of onset (P = 0.027 for the ANOVA test). The trend test showed a P value of 0.007 for a decreasing age with the G allele in a dose-dependent manner (Table 3). The rs13264163 AG heterozygotes also showed the youngest age of onset among all genotypes of rs13264163A>G (P = 0.016) (Table 3). We also found that the early age of disease onset was associated with the G allele of rs6990375 G>A [rs6990375 GG: 60.0 ± 10.7 years; rs6990375 GA: 61.8 ± 10.6 years; rs6990375 AA: 69.1 ± 9.0 years (P = 0.013)] (Table 3). As we noticed in the LD analysis, rs6990375 G>A had a r 2> 0.8 with

rs3802278 G>A and rs3087714 C>T; therefore, we also observed the significant trends in differences of age of disease onset among genotypes of rs3802278 G>A and rs3087714 C>T (P trend = 0.021 and 0.041, respectively), even though the differences were not significant in ANOVA tests (P = 0.069 and 0.119). Table 3 SULF1Genotype distribution and age of disease onset Genotypes Number of patients (%) Age at diagnosis (years, mean ±SD) b P-value rs2623047 G>A a     0.027    GG 16 (11.9) 56.8 ± 10.7      GA 80 (59.3) 61.2 ± 10.8      AA 39 (28.9) 65.0 ± 9.9      G allele frequency 112 (41.5)   P trend c = 0.007    A allele frequency 158 (58.5)     rs13264163 A>G     0.016    AA 70 (51.4) 63.7 ± 10.5      AG 53 (39.0) 58.6 ± 10.5      GG 13 (9.6) 64.9 ± 10.6 Tenoxicam      A allele frequency 193 (71.0)   P trend c = 0.266    G allele frequency 79 (29.0)     rs6990375 G>A  

  0.013    GG 58 (42.7) 60.0 ± 10.7      GA 63 (46.3) 61.8 ± 10.6      AA 15 (11.0) 69.1 ± 9.0      G allele frequency 179 (65.8)   P trend c = 0.009    A allele frequency 93 (34.2)     rs3802278 G>A     0.069    GG 59 (43.4) 59.7 ± 11.4      GA 65 (47.8) 62.8 ± 10.0      AA 12 (8.8) 66.7 ± 9.5      G allele frequency 183 (67.3)   P trend c = 0.021    A allele frequency 89 (32.7)     rs3087714 C>T     0.119    CC 63 (46.3) 60.1 ± 11.3      CT 62 (45.6) 62.7 ± 10.1      TT 11 (8.1) 66.6 ± 10.0      C allele frequency 188 (69.1)   P trend c = 0.041    T allele frequency 84 (30.9)     a One sample failed in this genotype b One-way ANOVA (Analysis of variance) for age differences among 3 genotypes for each SNP c P values for the trend test of age at diagnosis among 3 genotypes for each SNP from a general linear model We further evaluated the combined allele effect on age of disease onset.

Metastases were tracked using in vivo bioluminescence imaging (BL

Metastases were tracked using in vivo bioluminescence imaging (BLI) and final tumor burden was assessed by quantitative histomorphometry. In conclusion, we determined that MEK inhibitor the deletion of Ets2 in lung fibroblasts delayed the incidence of breast cancer lung metastases  ~ 4 weeks. Furthermore, metastatic tumor burden was

significantly reduced in the lung (p < 0.02). We further demonstrated that this decrease in tumor burden was not related to a decrease in endothelial cell recruitment (angiogenesis) or local macrophage infiltration (inflammation). This therefore suggests that Ets2 action in the tumor microenvironment may have a novel role in promoting lung metastases and we are currently investigating other potential mechanisms. Our overall understanding of the genetic contributions of the tumor microenvironment at the metastatic site will be essential to delay or inhibit metastasis. O159 C-reactive Protein Protects Myeloma Cells from Apoptosis via Activating ITAM-containing FcgRII Qing Yi 1 , Jing Yang1 1 Department of Lymphoma and Myeloma, MD BIBW2992 nmr Anderson Cancer Center, Houston, TX, USA It is well recognized that multiple myeloma (MM), a hematologic cancer that is still incurable, is protected by the

bone marrow microenvironment consisting of stromal cells, matrix, and cytokines such as IL-6 and IGF-1. However, our studies have also suggested that myeloma cells induce systemic changes in patients that promote myeloma cell growth and protect myeloma cell apoptosis. One of the changes is Benzatropine the presence of high levels of circulating C-reactive protein (CRP) in myeloma patients. Elevated levels of CRP are present in patients with infections, inflammatory diseases, necrosis, or malignancies including MM. Recently we made a striking discovery that CRP enhances myeloma cell proliferation under stressed

conditions and protects myeloma cells in vitro from apoptosis induced by chemotherapy drugs, IL-6 withdrawal, or serum deprivation. In vivo injections of human CRP around subcutaneous tumors protected tumor cells and significantly undermined the therapeutic effects of dexamethasone or melphalan in xenografted myeloma-SCID and SCID-hu mouse models. CRP protected tumor cells from apoptosis via binding Fcg receptors (FcgRs), preferentially the activating FcgRIIA/C, but not the inhibitory FcgRIIB, leading to PI3K/Akt, ERK, and NF-kB pathway signaling and inhibited activation of caspase cascades induced by chemotherapy drugs. CRP also enhanced myeloma cell secretion of IL-6 and synergized with IL-6 to protect myeloma cells from chemotherapy drug-induced apoptosis. These findings are clinically relevant, since we found CRP accumulating on myeloma cells from all myeloma-patient bone marrow biopsies examined; no CRP was found on marrow cells from healthy individuals (Yang et al., Cancer Cell, 2007; 12:252–265).

A – B Dendritic cells (DCs) were infected, at MOI 10 with live/d

A – B. Dendritic cells (DCs) were infected, at MOI 10 with live/dead H37Ra or live/dead H37Rv. (U = uninfected, LH37Ra = live H37Ra, sH37Ra = streptomycin-killed H37Ra, LH37Rv = live H37Rv, iH37Rv = γ-irradiated H37Rv.) Cell death was measured by propidium iodide exclusion (A) 72 h post-infection or (B) 24 h post-infection on a GE IN Cell

Analyzer 1000. (A – B) are means (± SEM) Vemurafenib datasheet of 3 pooled donors. * p < 0.05 vs. Uninfected. C. DCs were infected with live H37Ra at MOI 1, 5 or 10. Cell death was measured by propidium iodide exclusion 72 h after infection. Staurosporine was used as a positive control for cell death. * p < 0.05 vs. uninfected, ns - not significantly different from uninfected. D. DCs were infected with live H37Ra at MOI 1, 5 or 10. DNA fragmentation was measured by Cell Death ELISA 72 h after infection. * p < 0.05 vs. Uninfected, ns - not significantly different from uninfected. E. DCs were infected with live H37Ra at MOI 10 for 72 h. Nuclei were stained with Hoechst and visualised by fluorescence microscopy. Cycloheximide and staurosporine were used as positive controls for nuclear fragmentation. (C - E) are 1 representative donor of 3, showing means (± SEM) of 3 independent wells. Having established that reduced DC viability was dependent on

infection with live mycobacteria, we then investigated the mechanism of cell death in H37Ra-infected DCs. We previously noted that macrophage cell death after Palbociclib Mtb infection results in DNA fragmentation. By ELISA, we could show that DNA fragmentation

was also a feature of the DC PAK5 response to viable Mtb H37Ra infection peaking at an MOI of 5 (Figure 2D). Apoptosis results in nuclear condensation, pyknosis and, eventually, fragmentation of the nucleus into apoptotic bodies [20, 21]. To determine whether this occurred during Mtb H37Ra infection, the nuclear morphology of DCs stained with Hoechst was examined by epifluorescent microscopy. The nuclei of infected cells did not undergo pyknosis or fragmentation and were similar in appearance to those of uninfected cells at 72 h after infection, a time at which they had undergone significant cell death. DCs treated with cycloheximide and staurosporine displayed extensive nuclear fragmentation, indicating that the cells are capable of undergoing this process when treated with apoptotic stimuli (Figure 2E). Dendritic cell death after M. tuberculosis H37Ra infection is caspase-independent and proceeds without the activation of caspase 3 and 7 Activation of caspases is considered to be essential for classical apoptosis [22]. Therefore, we sought to establish if DC death following Mtb infection was caspase dependent. Cells were treated with the pan-caspase inhibitor Q-VD-OPh and infected with H37Ra, at an MOI of 10, and cell death was assessed using IN Cell fluorescent microscopy and analysed as before.

M B and V I E, respectively, and grant 089222 awarded

M.B. and V.I.E, respectively, and grant 089222 awarded Staurosporine purchase to V.I.E by the Wellcome Trust. We also thank The Wellcome Trust

for their support of the Pathogen Genomics group under grant 076964. References 1. Suzuki H, Yano H, Brown CJ, Top EM: Predicting Plasmid Promiscuity Based on Genomic Signature. J Bact 2010, 192:6045–6055.PubMedCrossRef 2. Toukdarian A: Plasmid strategies for broad-host-range replication in Gram-negative bacteria. In Plasmid Biology. Edited by: Funnell BE, Phillips GJ. Washington: ASM Press; 2004:259–270. 3. Carattoli A, Aschbacher R, March A, Larcher C, Livermore DM, Woodford N: Complete nucleotide sequence of the IncN plasmid pKOX105 encoding VIM-1, QnrS1 and SHV-12 proteins in Enterobacteriaceae find more from Bolzano, Italy compared with IncN plasmids encoding KPC enzymes in the USA. J Antimicrob Chemother 2010, 65:2070–2075.PubMedCrossRef 4. Novais A, Canton R, Valverde A, Machado E, Galan JC, Peixe L, Carattoli A, Baquero F, Coque TM: Dissemination and persistence of bl CTX-M-9 are linked to class 1 integrons containing CR1 associated with defective transposon derivatives from Tn 40 located in early antibiotic resistance plasmids of IncHI2, IncP1-alpha and IncFI groups. Antimicrob

Agents Chemother 2006, 50:2741–2750.PubMedCrossRef 5. Poirel L, Bonnin RA, Nordmann P: Analysis of the Resistome of a Multidrug-Resistant NDM-1-Producing Escherichia coli Strain by High-Throughput Genome Sequencing. Antimicrob Agents Chemother 2011, 55:4224–4229.PubMedCrossRef 6. Psichogiou M, Tassios PT, Avlamis A, Stefanou I, Kosmidis C, Platsouka E, Paniara O, Xanthaki A, Toutouza M, Daikos GL, Tzouvelekis LS: Ongoing epidemic of bl VIM-1 positive Klebsiella pneumonia in Athens, Greece: a prospective survey. J Antimicrob Chemother 2008, 61:59–63.PubMedCrossRef 7. Shen P, Jiang Y, Zhou ZH, Zhang JL, Yu YS, Li LJ: Complete nucleotide sequence of pKP96, a 67 850 bp multiresistance plasmid encoding qnrA1, aac(6′)-Ib-c and bl CTX-M-24 from Klebsiella pneumonia . J Antimicrob Chemother 2008, 62:1252–1256.PubMedCrossRef 8. Xiong JH, Hynes MF, Ye HF, Chen HL, Yang YM, M’Zali F,

Hawkey PM: bl IMP-9 and its association with large plasmids carried by pseudomonas aeruginos isolates from the People’s Republic of China. Antimicrob Agents Chemother Lck 2006, 50:355–358.PubMedCrossRef 9. Gootz TD, Lescoe MK, Dib-Hajj F, Dougherty BA, He W, Della-Latta P, Huard RC: Genetic Organization of Transposase Regions Surrounding bla(KPC) Carbapenemase Genes on Plasmids from Klebsiella Strains Isolated in a New York City Hospital. Antimicrob Agents Chemother 2009, 53:1998–2004.PubMedCrossRef 10. Austin DJ, Kristinsson KG, Anderson RM: The relationship between the volume of antimicrobial consumption in human communities and the frequency of resistance. Proc Nat Acad Sci USA 1999, 96:1152–1156.PubMedCrossRef 11.

This was not due to inefficient labeling of the DNA as demonstrat

This was not due to inefficient labeling of the DNA as demonstrated by strong hybridization of the control DNA spiked into the labeling reaction. In contrast, LSplex amplified swab DNA hybridized with probes of Enterococcus faecium and Staphylococcus epidermidis (Fig. 5). The presence of these bacterial species was confirmed by routine microbiological culture followed by biochemical characterization. It should Tanespimycin clinical trial be noted that LSplex of the DNA from swab resulted in hybridization of a few probes from other bacteria (one of from K. pneumoniae, two from P. aeruginosa, three from S. aureus and one from S. pneumoniae) which were not identified by microbiological culture. These, however were only singletons in the

redundant set of dozens of species-specific probes, allowing the correct identification of pathogens present in the specimen. In summary the results of LSplex amplification of DNA from cotton swabs followed by microarray were in concordance with the standard microbiological techniques, whilst direct microarray identification of the pathogens was not successful. Figure 5 Application of LSplex for detection of bacterial mixtures from clinical specimens. Hybridization profiles Buparlisib generated by DNA isolated from cotton swab of superficial wound. DNA

was labeled prior to hybridization without amplification (green) or after LSplex (red). Each row represents an individual capture probe of the microarray, grouped by species or genus specific regions (see Additional file 2) as indicated in the left column. The boxes represent the positive hybridization signal of bacterial DNA (in color) or absence of hybridization (in white) with individual capture probes. The presence of E. faecium and S. epidermidis on swab was verified by routine microbiological diagnostic procedures. Discussion and conclusion The applicability of fluorescence-based DNA

microarrays for the direct detection and characterization of pathogens depends on amplification of the target DNA [21]. To compensate for the low sensitivity of such a multi-capture probe detection system, microarray analysis can be preceded of pathogen isolation and clonal expansion as a source for abundant DNA. A pre-amplification of the target DNA using a single-step Large Scale multiplex PCR (LSplex) could avoid such a time-consuming procedure. Although it is generally accepted that Multiplex PCR is potentially an ideal co-adjuvant for DNA microarrays in pathogen detection [21] there is, nevertheless, a limitation in the number of distinct PCR products that can be generated. Up to date, multiplex PCR was only combined with low-density microarray formats [22] and required either several parallel multiplex PCR reactions [5, 17, 23] or subsequent PCR steps [6, 24]. The complex nature of the interference between multiple primer pairs and targets [25, 26, 21] has limited conventional multiplex PCR in solution phase to a dozen of primer pairs [27–29].

It has also been reported that

the overexpression of RhoC

It has also been reported that

the overexpression of RhoC enhances metastasis, whereas dominant-negative expression of RhoC inhibits metastasis [27]. In addition, statins have been reported to inhibit tumor cell migration and invasion phosphatase inhibitor library through the suppressing geranylgeranylation of Rho in breast and colon cancer cell lines [28, 29]. These findings suggest that statins may bring about their anti-metastatic effects by inactivating the Rho/ROCK pathway. Cell migration is known to be required for tumor metastasis. In this study, we showed that statins inhibited the migration of B16BL6 cells. It has been reported that YM529/ONO-5920 and zoledronate, nitrogen-containing bisphosphonates, inhibited hepatocellular carcinoma and osteosarcoma cell migration by suppressing

GGPP biosynthesis [30, 31]. Collectively, the findings suggest that the inhibition of GGPP biosynthesis plays an important role in the suppression of B16BL6 cell migration by statins. Matrix metalloproteinases (MMPs) and zinc-dependent endopeptidases are a family of structurally related zymogens that are capable of degrading the ECM, including the basement membrane. They are presumed to be critically involved in tumor invasion and metastasis [32]. In melanomas, higher levels of MMP-1, MMP-2, MMP-9, and MMP-14 have been observed in the more invasive and metastatic tumors [33]. Moreover, overexpression of RhoA-GTP induces MMP LY294002 mw expression and activity [34]. We observed that statins significantly inhibit the mRNA expression and enzymatic activities of MMP-1, MMP-2, MMP-9, and MMP-14 in B16BL6 cells. These results suggest that HSP90 the decrease in the activation of Rho is vital for the suppression of MMP expressions by statins in B16BL6 cells. Cell adhesion is a fundamental cellular response that is intricately involved in the physiological processes of proliferation, motility,

as well as the pathology of neoplastic transformation and metastasis. Integrins are the most important family of cell surface adhesion molecules that mediate interactions between cells and the ECM. Members of the β1 integrin subfamily are known to primarily bind to collagens, fibronectins, and laminins. We found that statins suppress cell adhesion to type I collagen, type IV collagen, fibronectin, and laminin. Furthermore, statins significantly inhibited the mRNA and protein expressions of integrin α2, integrin α4, and integrin α5. A recent study has reported that the activation of small GTPases increased cell adhesion to collagens, fibronectins, and laminins [35]. These findings indicate that the Rho/ROCK pathway may be essential for the expressions of integrin α2, integrin α4, and integrin α5. Activation of Rho could lead to the activation of LIMK and MLC [36]. These signal transduction factors are essential for cell migration, invasion, adhesion, and metastasis [37–39].

Toxin genes The CDT B gene was not detected in any of the C conc

Toxin genes The CDT B gene was not detected in any of the C. concisus isolates, but was present in C. jejuni 81-176 (Additional file 3). The zot gene was detected in 80% of C. concisus isolates from healthy humans (i.e., four of five isolates), 22% of isolates from diarrheic humans (i.e., two of nine check details isolates), and the type strain. The S-layer RTX gene was present in C. concisus CHRB3287 and CHRB2004, although amplification was weak for the latter isolate. The zot and S-layer RTX genes were not detected in C. jejuni 81-176. Discussion The observed high level of genetic diversity amongst

the isolates of C. concisus is in agreement with previous studies [1, 2, 10], and highlights the complex nature of this species. Cluster analysis of AFLP profiles indicated that the isolates examined in the current study comprised at least two distinct clusters. Similarly, Aabenhus et al. [1] denoted four AFLP clusters among 62 C. concisus isolates of which the majority (n = 56) were assigned to one of two main clusters. Results of PCR assays targeting the 23S rRNA and cpn60 genes largely corresponded with the AFLP grouping, and lend support to the suggested genetic relationship between the isolates. As C. concisus is selleck kinase inhibitor a common inhabitant of the oral cavity, it is to be expected that it may be isolated from both healthy

and diarrheic individuals. Examining isolates from healthy individuals, it was observed that the majority of isolates belonged to genomospecies A and their AFLP profiles clustered together (AFLP cluster 1) along with the type stain of oral origin. This AFLP cluster also included one genomospecies A isolate (CHRB 1609) from a Ribonuclease T1 diarrheic individual. Further studies are needed to determine whether

this group of isolates represents inhabitants of the oral cavity that have survived gastro-intestinal transit or whether they are intestinal-associated. The majority (94%) of isolates from diarrheic individuals were assigned to ALFP cluster 2. Among these isolates, 71% were assigned to genomospecies B, while only 11% of diarrheic isolates belonged to genomospecies A. Engberg et al. [2] reported a similar predominance of genomospecies B isolates among diarrheic fecal isolates, of which 33% and 67% were assigned to genomospecies A and B, respectively. Likewise, Aabenhus et al. [1] reported that 34% and 53% of fecal isolates from diarrheic patients were assigned to genomospecies A and B, respectively. Our observation that isolates from genomospecies B were exclusively obtained from diarrheic individuals suggests a potential role for these isolates in intestinal disease. A comparative molecular examination of strains belonging to genomospecies A and B may shed light on their respective pathogenic potential. Examination of the pathogenic properties amongst C. concisus isolates determined that epithelial invasion and translocation were higher for isolates assigned to AFLP cluster 2 (of which 94% were from diarrheic individuals).

The participants were then assigned to the following groups: <1 L

The participants were then assigned to the following groups: <1 L/day (14.5 %), 1–1.9 L/day (51.5 %), 2–2.9 L/day (26.3 %), and ≥3 L/day (7.7 %). As water intake increased, the percentage annual eGFR decline turned out to be 1.3, 1.0, 0.8, 0.5 %, respectively. Hebert et al. reported that high fluid intake resulted in buy ABT-888 an increased urine volume, and low urine osmolality (Uosm) was not associated with slower renal disease progression. In a randomized control trial performed by Spigt et al., one group was advised to increase their daily fluid intake by 1.5 L of water, and the other group was given placebo medication. Most subjects did not manage to increase their fluid intake by 1.5 L. The average

increase in the intervention group was approximately 1 L. Twenty-four-hour water turnover in the intervention group was

359 mL (95 % CI 171–548) higher than that of the control group at the 6-month follow-up. Blood pressure, sodium level, Hippo pathway inhibitor GFR, and QOL did not change significantly in either group during the intervention period. Increased water intake is effective for maintaining kidney function in CKD patients at stage G1 and G2, but it could be a risk factor for worsening kidney function in CKD patients at stage G3 and higher. Dehydration can exacerbate kidney function at any CKD stage. It is important to maintain an appropriate water intake based on the CKD stage. Bibliography 1. Clark WF, et al. Clin J Am Soc Nephrol. 2011;6:2634–41. (Level 4)   2. Hebert LA, et al. Am J Kidney

Dis. 2003;41:962–71. (Level 4)   3. Spigt MG, et al. J Am Geriatr Soc. 2006;54:438–43. (Level 2)   Is vaccination recommended for CKD? CKD patients have a weakened immune system and are at risk of higher morbidity and mortality rates from infections compared to healthy subjects. It is recommended that CKD patients should be given vaccinations against high risk pathogens. Pneumococcal and Influenza vaccines are inactivated, hence both have a low potential for adverse events related to the administration of the vaccination. Influenza is a common and widespread infection causing morbidity and mortality in the general population, and regular vaccinations are recommended to prevent the Fossariinae associated comorbidities. Influenza may be significantly exacerbated to pneumonia, especially in the elderly. Therefore, influenza vaccination is related to the prevention of pneumonia. The report from the United States Renal Data System (USRDS) in 2007 showed that influenza vaccination for CKD patients aged over 66 years decreased total mortality and hospitalization rates from January to March compared to that of unvaccinated patients. Pneumonia is the 4th leading cause of death in patients aged over 65 years in Japan, and 95 % of deaths from pneumonia occur in patients aged over 65 years. Pneumococcus is the most common pathogen in community-acquired pneumonia of the elderly, and it is reported that 30–50 % of Pneumococcus is drug-resistant. Viasus et al.