Protective Role of Apelin Against Cyclosporine-Induced Renal Tubular Injury in Rats.

BACKGROUND: Cyclosporine (CsA) usually reduces glomerular filtration rate (GFR) but also can induce tubular injury without resulting in GFR reduction. Apelin is an endogenous ligand for the apelin receptor and has diverse physiologic roles related to hemodynamic or metabolic processes. We investigated the renoprotective role of apelin against CsA-induced tubular toxicity in rats. METHODS: Rats were given CsA (15 mg/kg/day) and/or apelin-13 (15 µg/kg/day) for 7 days via subcutaneous injection. We performed serum and urinary assays of creatinine and neutrophil gelatinase-associated lipocalin (NGAL) to estimate renal injury and performed Western blotting for endothelial nitric oxide synthase and nuclear factor of activated T-cell cytoplasmic 1 (NFATc1) to document the underlying mechanism. RESULTS: The CsA-treated group showed increased urinary creatinine excretion, polyuria, and renal glycosuria without GFR reduction, suggesting adequate CsA-induced renal tubular injury. Urinary NGAL excretion also increased significantly in the CsA group. Conversely, apelin attenuated CsA-induced tubular injury and had no effect on urinary NGAL excretion. In histopathologic examination, the apelin-treated group had lower tubulo-interstitial injury scores compared with those in the CsA group. Regarding the effects of apelin, our results indicate that apelin provides protection against CsA-induced tubular injury by activating nitric oxide and/or the NFATc1 pathway. Notably, we also found that CsA inhibits renal glucose reabsorption by reducing Na+-K+ ATPase expression and that apelin reverses reduced renal glucose reabsorption by CsA in tubular cells. CONCLUSIONS: Our study demonstrates the renoprotective effect of apelin against CsA-induced renal tubular toxicity and provides novel insights into the effects of CsA and apelin on renal tubular cells.

Decision Making by Young Transplant Surgeons Regarding Expanded-Criteria Donors With Acute Kidney Injury or Allocation Failure.

BACKGROUND: The utilization of expanded-criteria donors (ECDs) has increased to overcome donor shortages. Unfortunately, the discard rate has also increased, especially in ECDs with acute kidney injury (AKI). We evaluated the outcomes of kidney transplantation in ECDs and standard-criteria donors (SCDs) with and without AKI. METHODS: We reviewed the medical records of patients who underwent kidney transplantation. We used the AKI definition published by the Kidney Disease: Improving Global Outcomes group and reviewed the demographic characteristics of donors and recipients. We analyzed transplantation outcomes. RESULTS: Twenty-seven patients underwent kidney transplantation from ECDs with AKI (n = 6) or without AKI (n = 5) and SCDs with AKI (n = 6) or without AKI (n = 10). Initial creatinine and estimated glomerular filtration rate (eGFR) were not significantly different between the groups. The incidence of delayed graft function was highest in ECDs with AKI (n = 3; 36.4%), but this was not a significantly difference. There was no difference in the last creatinine and eGFR in ECDs with AKI (1.32 mg/dL, 58.7 mL/min/1.73 m(2)), ECDs without AKI (1.67 mg/dL, 44.2 mL/min/1.73 m(2)), SCDs with AKI (0.94 mg/dL, 81.5 mL/min/1.73 m(2)) and SCDs without AKI (0.97 mg/dL, 81.8 mL/min/1.73 m(2)). CONCLUSIONS: As the donor pool is extended to ECDs, young transplant surgeons may increasingly face decisions regarding ECDs with AKI or allocation failure. There is no consensus regarding discard criteria. However, if the donor showed initially normal creatinine levels or if dual-kidney transplantation can be performed, young transplant surgeons should not hesitate to use ECDs with AKI or allocation failure.

Gastrointestinal phytobezoars in childhood.

We reviewed 33 children under the age of 15 with gastrointestinal phytobezoars. Twenty were boys and 13 were girls. Nearly all patients were observed in late fall and winter. In 22 patients, symptoms developed following ingestion of several ripe or dried persimmons with seeds but none had a history of unripe persimmon ingestion. All patients but three underwent enterotomy, gastrotomy, or enterotomy combined with gastrotomy for bezoar removal. The remaining three had small bowel resection due to strangulation. There was a single location of the bezoar in 85% and multiple locations in 15% at operation. Emergency laparotomy was performed on 25 patients who had typical mechanical intestinal obstruction revealed the plain abdominal films. It is not surprising that persimmon is the most common cause of bezoar formation in Korea, because it is a favorite fruit among Koreans, either in hard, soft, or dried variety.

Preduodenal portal vein: a cause of prenatally diagnosed duodenal obstruction.

Preduodenal portal vein is a rare congenital anomaly that causes high intestinal obstruction. The authors report on a newborn who was diagnosed as having duodenal obstruction at 30 weeks' gestation. During surgery the patient was found to have duodenal obstruction caused by a preduodenal portal vein. Malrotation was an associated finding. Treatment consisted of Ladd's procedure and a diamond-shaped duodenoduodenostomy performed anterior to the portal vein.

Purulent umbilical drainage from infection of left umbilical artery associated with open umbilicoperitoneal communication.

This is a case report of a 20-day-old girl with persistent umbilical drainage due to infection of the left umbilical artery that ruptured at the base of the umbilicus and formed an open umbilicoperitoneal communication.

Ultrasound-guided water enema: an alternative method of nonoperative treatment for childhood intussusception.

Ultrasound-guided water enema (USWE) reduction was performed in 115 patients with intussusception, which was diagnosed by ultrasound between April 1988 and August 1992 at Keimyung University Dongsan Medical Center. The overall rate of successful reduction was 80.9%. The rate was 91.0% for patients with symptoms of < or = 24 hours' duration, and 61.1% for patients with symptoms of more than 24 hours' duration (P < .001). Six patients had recurrence during the study period (recurrence rate, 5.2%). There was no perforation or other complications during and after the water enema reduction. The authors conclude that (1) USWE reduction for childhood intussusception has a higher rate of successful reduction and a lower rate of recurrence than does barium enema and (2) USWE is safe and may be an alternative method in the nonoperative treatment of intussusception.

The ultrasonographic 'triangular cord' coupled with gallbladder images in the diagnostic prediction of biliary atresia from infantile intrahepatic cholestasis.

PURPOSE: The aim of this study was to evaluate the importance of the ultrasonographic "triangular cord" (TC) coupled with gallbladder images in the diagnostic prediction of biliary atresia (BA) from infantile intrahepatic cholestasis. METHODS: Seventy-nine infants with cholestatic jaundice underwent ultrasound examinations, focusing on the TC and gallbladder images. The TC was defined as visualization of a triangular or bandlike periportal echogenicity (3 mm or greater in thickness), which represents a cone-shaped fibrotic mass cranial to the portal vein in infants with BA. An abnormal gallbladder (nonvisualized or small) was thought to be more suggestive of BA than infantile intrahepatic cholestasis. RESULTS: Among 25 infants with BA, 21 showed TC, whereas 4 had no TC. Fifty-three of 54 infants with infantile intrahepatic cholestasis had no TC, showing a diagnostic accuracy of 94% with 84% sensitivity and 98% specificity. As for positive predictive value in the diagnosis of BA by the TC coupled with gallbladder images, it was 100% when a positive TC was coupled with an abnormal gallbladder and 88% when a positive TC was coupled with a normal gallbladder. It decreased to 25% when a negative TC was coupled with an abnormal gallbladder. CONCLUSIONS: The TC appears to be a very specific and definite ultrasonographic finding in the early diagnosis of BA. Positive TC regardless of gallbladder images is highly suggestive of BA, showing a 95% positive predictive value, but BA cannot be ruled out when negative TC is coupled with an abnormal gallbladder, requiring further diagnostic modalities such as liver needle biopsy or hepatobiliary scintigraphy.

'Triangular cord': a sonographic finding applicable in the diagnosis of biliary atresia.

Biliary atresia (BA) is characterized by luminal obstruction of the extrahepatic bile duct with fibrous remnants. The authors reviewed ultrasonographic examinations of the fibrous tissue in the bifurcation of the portal vein at the porta hepatis and identified the triangular- or tubular-shaped echogenic density, the so-called "triangular cord" (TC), in the vicinity of the portal vein on a transverse or longitudinal scan. In this prospective study, the authors investigated whether TC was useful in the noninvasive diagnosis of biliary atresia in 18 infants who had persistent neonatal jaundice. This was done by comparing the ultrasonographic examination with the histopathologic examination (HPE) of liver specimens obtained from a needle biopsy. The TC was identified in nine patients, all of whom were confirmed to have BA by HPE. The TC was not observed in the other nine patients, who had neonatal hepatitis (NH). The mean size of the TC was 13 mm (wide) x 6 mm (thick) (width range, 5 to 21 mm; thickness range, 4 to 12 mm). The diagnosis of BA was confirmed at the time of Kasai hepatoportojejunostomy in eight of the nine patients whose TC was noted by ultrasonography (US). The other patient was discharged because his parents refused the operation; he died of liver failure at 15 months of age. The nine patients with absent TC were treated medically for NH. Eight of them improved clinically. The other, diagnosed to have NH by needle and wedge liver biopsies, was reexamined 40 days after the initial examination because of worsening jaundice. A 18 x 12-mm TC was visualized ultrasonographically. Additionally, a percutaneous liver biopsy specimen showed BA with severe portal fibrosis and ductal proliferation. The patient underwent a Kasai hepatoportoenterostomy. On the basis of these results, the authors conclude that TC is a very specific ultrasonographic finding, representing the fibrous cone at the porta hepatis, and is a useful tool in the noninvasive diagnosis of BA. However, early exploration or close US follow-up is recommended for any patient suspected of having BA clinically, even if a liver biopsy confirms the NH.

Appendicoumbilical fistula as a sequela of perforated appendicitis.

This is the first report, we believe, of a 5-year-old boy who developed appendicoumbilical fistula as a sequela of perforated appendicitis. We discuss a proposed explanation of the mechanism in its formation.

Ectopic umbilical liver in conjunction with biliary atresia: uncommon association.

The case of a neonate with an ectopic liver in the umbilicus in conjunction with biliary atresia in the liver proper and an ectopic pancreas in the jejunum is reported. Following excision of the ectopic umbilical liver and Kasai type 1 hepatic portoenterostomy, bile fistula originating in the anterior inferior area of the right lobe of the liver was a complication, and it was successfully treated by construction of hepaticojejunostomy. No similar case has been reported in English language literature. It is of particular interest that the pathological features of the ectopic liver and the liver proper are quite similar.