The effect of renin-angiotensin-aldosterone system blockade on contrast-induced acute kidney injury: a propensity-matched study.

BACKGROUND: The role of the angiotensin-converting enzyme (ACE) inhibitor and angiotensin receptor blocker (ARB) in the pathophysiology of contrast-induced acute kidney injury (AKI) is controversial, and the available literature is contradictory. STUDY DESIGN: A retrospective propensity score-matched study to analyze the effect of ACE-inhibitor/ARB therapy on the development of contrast-induced AKI. SETTING & PARTICIPANTS: Using propensity score matching, 1,322 ACE-inhibitor/ARB recipients and nonrecipients were paired for analysis from 5,299 patients and fulfilled the inclusion criteria among 11,447 patients receiving coronary angiography (CAG) or percutaneous coronary intervention. PREDICTORS: ACE-inhibitor/ARB use based on prescription and risk factors for contrast-induced AKI. OUTCOMES: The incidence of contrast-induced AKI defined by AKI Network (AKIN) criteria: an absolute increase in serum creatinine levels ≥0.3 mg/dL or a relative increase ≥50% from baseline values within 48 hours after exposure to the contrast medium. MEASUREMENTS: Baseline serum creatinine, hemoglobin, and albumin levels; volume of contrast agents; preprocedural medication; and post-CAG serum creatinine levels. RESULTS: An ACE inhibitor/ARB was prescribed for 64.0% of patients receiving CAG. ACE-inhibitor/ARB users showed an increased incidence of contrast-induced AKI after propensity score matching (11.4% vs 6.3%; P < 0.001). In multivariable analysis, use of ACE inhibitors/ARBs remained an independent and significant predictor of contrast-induced AKI in an unmatched cohort (OR, 1.39; 95% CI, 1.10-1.76; P = 0.06). In the matched cohort, use of ACE inhibitors/ARBs also was associated with a higher adjusted OR of contrast-induced AKI (OR, 1.43; 95% CI, 1.06-1.94; P = 0.02). LIMITATIONS: A retrospective study at a single center. CONCLUSIONS: Use of ACE inhibitors/ARBs during CAG has a possible influence to increase the incidence of contrast-induced AKI. Further randomized clinical trials are warranted to confirm the effect of ACE-inhibitor/ARB therapy on the development of contrast-induced AKI.

Early start of dialysis has no survival benefit in end-stage renal disease patients.

The timing for dialysis initiationis still debated. The aim of this study was to compare mortality rates, using a propensity-score approach, in dialysis patients with early or late starts. From January 2000 to June 2009, incident adult patients (n = 836) starting dialysis for end-stage renal disease (ESRD) were enrolled. The patients were assigned to either an early- or late-start group depending on the initiation time of the dialysis. After propensity-score-basedmatching, 450 patients remained. At the initiation of dialysis, the mean estimated glomerular filtration rate (eGFR) was 11.1 mL/min/1.73 m(2) in the early-start group compared with 6.1 mL/min/1.73 m(2) in the late-start group. There were no significant differences in survival between the patients in the early- and late-start groups (Log rank tests P = 0.172). A higher overall mortality risk was observed in the early-start group than in the late-start group for the patients aged ≥ 70 yr (hazard ratio [HR]: 3.29; P = 0.048) and/or who had albumin levels ≥ 3.5 g/dL (HR: 2.53; P = 0.046). The survival of the ESRD patients was comparable between the patients in the early and late-start groups. The time to initiate dialysis should be determined based on clinical findings as well as the eGFR.

[Clinical features of non-alcoholic fatty liver disease in cryptogenic hepatocellular carcinoma].

BACKGROUND/AIMS: Nonalcoholic fatty liver disease (NAFLD) may be one of the important causes of cryptogenic hepatocellular carcinoma (HCC). The aim of this study was to evaluate whether patients with cryptogenic HCC share clinical features similar to that of NAFLD. METHODS: Cryptogenic HCC was defined as HCC that occurs in patients with the following conditions: HBsAg(-), anti-HCV(-), and alcohol ingestion of less than 20 g/day. All patients diagnosed with cryptogenic HCC from 2005 to 2012 (cryptogenic HCC group), and all patients diagnosed with HBV associated HCC between 2008 and 2012 (HBV-HCC group) were enrolled in the present study. Clinical features, BMI, lipid profiles, presence of diabetes mellitus, hypertension, and metabolic syndrome were compared between the two groups. RESULTS: Cryptogenic HCC group was composed of 35 patients (19 males and 16 females) with a mean age of 70 ± 11 years. HBV-HCC group was composed of 406 patients (318 males and 88 females) with a mean age of 56 ± 7 years. Patients in the cryptogenic HCC group were older (p=0.001) and female dominant (p=0.042) than those in the HBV-HCC group. There were no differences in the laboratory test results including lipid profiles and Child-Turcotte-Pugh class between the two groups. Patients in the cryptogenic HCC group had higher prevalence of diabetes (37% vs. 17%, p=0.015), hypertension (49% vs.27%, p=0.051), metabolic syndrome (37% vs. 16%, p=0.001), and higher BMI (25.3 kg/m(2) vs. 24.1 kg/m(2), p=0.042) than those in the HBV- HCC group. The tumor stage was more advanced (stage III and IV) at diagnosis in the cryptogenic HCC group than in the HBV-HCC group (60% vs. 37%, p=0.007). CONCLUSIONS: Cryptogenic HCC has clinical features similar to that of NAFLD and is diagnosed at a more advanced tumor stage.

Huge liposarcoma of esophagus resected by endoscopic submucosal dissection: case report with video.

Liposarcoma is one of the most common soft tissue sarcomas occurring in adults, but it rarely occurs in the gastrointestinal tract and more uncommonly in the esophagus. To the best of our knowledge, there are only 19 reported cases of esophageal liposarcoma in the literature published in English language up to the year 2008, and they were all treated by surgical methods. Here, we report a case of primary liposarcoma of the esophagus which was treated with endoscopic submucosal dissection (ESD). ESD was well tolerated in this patient, suggesting that it may be a therapeutic option for primary esophageal sarcomas.

A feasible modified biopsy method for tissue diagnosis of gastric subepithelial tumors.

AIM: To evaluate the diagnostic yield and safety of a modified technique for the histological diagnosis of subepithelial tumors (SETs). METHODS: A retrospective review of patients who underwent a modified technique for the histological diagnosis of gastric SETs, consisting of a mucosal incision with a fixed flexible snare (MIF) and deep-tissue biopsy under conventional endoscopic view, from January 2012 to January 2013 was performed. Eleven patients with gastric SETs 10-30 mm in diameter and originating from the third or fourth layer on endoscopic ultrasonography were included. RESULTS: The mean age was 59.8 (range, 45-76) years, and 5 patients were male. The mean size of the SETs was 21.8 (range, 11-30) mm. The number of biopsy specimens was 6.3 (range 5-8). The mean procedure time was 9.0 min (range, 4-17 min). The diagnostic yield of MIF biopsies was 90.9% (10/11). The histological diagnoses were leiomyoma (4/11, 36.4%), aberrant pancreas (3/11, 27.3%), gastrointestinal stromal tumors (2/11, 18.2%), an inflammatory fibrinoid tumor (1/11, 9.1%); one result was non-diagnostic (1/11, 9.1%). There were six mesenchymal tumors; the specimens obtained in each case were sufficient for an immunohistochemical diagnosis. There was no major bleeding, but one perforation occurred that was successfully controlled by endoscopic clipping. CONCLUSION: The MIF biopsy was simple to perform, safe, and required a shorter procedure time, with a high diagnostic yield for small SETs.

Mycobacterium intracellulare Pulmonary Disease with Endobronchial Caseation in a Patient Treated with Methotrexate.

Methotrexate (MTX) has been established as a standard disease-modifying anti-rheumatic drug. If adequate disease control is achieved for a reasonable period of time, tapering the MTX dosage is recommended because the chronic use of MTX can result in opportunistic infection. We present here a case of a woman with rheumatoid arthritis taking MTX, and the woman developed actively caseating endobronchial Mycobacterium intracellulare disease with pulmonary infiltrations. After discontinuing the MTX, the patient was able to tolerate 18 months of antimycobacterial treatment without flare ups of rheumatoid arthritis, and she completely recovered from nontuberculous mycobacterial respiratory disease.

A case of rectal mucosa-associated lymphoid tissue lymphoma diagnosed by endoscopic unroofing technique.

Mucosa-associated lymphoid tissue (MALT) lymphoma is a typical primary gastrointestinal lymphoma, particularly in the stomach. Although primary rectal lymphoma is rare, it may present as a subepithelial tumor. Several techniques have been proposed for a tissue diagnosis in subepithelial tumor, including endoscopic ultrasonography (EUS)-guided fine needle aspiration (EUS-FNA), EUS-guided trucut biopsy (EUS-TCB), and tacked biopsy. However the diagnostic efficacy of these techniques appears to be limited. The unroofing technique involves removal of the overlying mucosa, thereby exposing the subepithelial lesion. It was originally reported as a method for endoscopic treatment of colorectal lymphangioma. In this case, a subepithelial tumor of the rectum was diagnosed using the endoscopic unroofing technique. This is a useful modality for the diagnosis of subepithelial tumor, because it provides histologic results in a safe and rapid manner.

Cervical lymphadenopathy mimicking angioimmunoblastic T-cell lymphoma after dapsone-induced hypersensitivity syndrome.

A 36-year-old woman presented with erythematous confluent macules on her whole body with fever and chills associated with jaundice after 8 months of dapsone therapy. Her symptoms had developed progressively, and a physical examination revealed bilateral cervical lymphadenopathy and splenomegaly. Excisional biopsy of a cervical lymph node showed effacement of the normal architecture with atypical lymphoid hyperplasia and proliferation of high endothelial venules compatible with angioimmunoblastic T-cell lymphoma. However, it was assumed that the cervical lymphadenopathy was a clinical manifestation of a systemic hypersensitivity reaction because her clinical course was reminiscent of dapsone-induced hypersensitivity syndrome. A liver biopsy revealed drug-induced hepatitis with no evidence of lymphomatous involvement. Intravenous glucocorticoid was immediately initiated and her symptoms and clinical disease dramatically improved. The authors present an unusual case of cervical lymphadenopathy mimicking angioimmunoblastic T-cell lymphoma as an adverse reaction to dapsone.

[Efficacy of peginterferon and ribavirin combination therapy of chronic hepatitis C: a pooled analysis].

BACKGROUND/AIMS: A combination of peginterferon and ribavirin is the standard therapy for chronic hepatitis C (CHC). However, the respective study has not been carried out in a large scale in Korea. The purpose of this study was to collect the studies that have been reported in Korea in order to analyze the therapeutic effect of combination therapy and compare to find racial difference. METHODS: Twenty-eight papers related to the therapeutic effect of combination therapy in CHC patients were analyzed based on pooled analysis. RESULTS: Based on the analysis for genotype 1 in Korea, early virologic response (EVR), end of treatment response (ETR), and sustained virologic response (SVR) were 79.6% (125/157), 80.1% (166/207), and 62.7% (341/543). The EVR, ETR, and SVR for genotype 2 and 3 were 89.4% (119/133), 92.2% (203/220), and 84.1% (434/516). Data from other Asians showed that EVR and SVR for genotype 1 were 88.9% (290/326) and 64.4% (491/762) respectively and 88.8% (135/152), and 79.4% (151/190) for genotype 2 and 3 respectively. In Western, EVR and SVR for genotype 1 were 51.3% (1,981/3,860) and 42.4% (1,798/4,231) respectively, and for genotype 2 and 3 were 87.7% (350/399) and 77.8% (533/685) respectively. Based on the comparative analysis, no statistical difference in SVR between Koreans and other Asians (p=0.955) was observed; However, the SVR of Koreans was higher with significance than that of Westerns (p<0.001) On the other hand, there was no difference what so ever, in SVR for genotype 2 amongst the different races. CONCLUSIONS: The SVR of combination therapy for the Korean chronic hepatitis C patients was similar to other Asians but higher than Westerns.

Evaluation of prognostic values of clinical and histopathologic characteristics in diffuse large B-cell lymphoma treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone therapy.

The relationship between histopathologic characteristics and treatment outcomes in patients with diffuse large B-cell lymphoma (DLBCL) treated with rituximab-based immunochemotherapy needs re-evaluation. Patients with newly diagnosed DLBCL treated with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) were evaluated with respect to clinical characteristics, treatment efficacy, and survival. Immunohistochemistry of bcl-2, CD10, bcl-6, and MUM-1 was performed and patients were sub-classified as germinal center B-cell-like (GCB) or non-GCB type according to the Hans algorithm. There was no significant difference in overall survival (OS) between patients with GCB and those with non-GCB. Although there was no significant difference in OS between high-intermediate and high risk groups as classified by the standard International Prognostic Index (IPI; p = 0.50), all three groups with the revised IPI had a clear-cut separation for event-free survival and OS. The revised IPI better predicted survival than did the standard IPI in patients with DLBCL treated with R-CHOP. The Hans classification had no prognostic value.