Inter-relationship of risk factors and pathways associated with chronic kidney disease in patients with type 2 diabetes mellitus: a structural equation modelling analysis.

OBJECTIVES: Diabetes mellitus is the most common cause of chronic kidney disease (CKD); however, the inter-relationships and pathogenetic mechanisms among risk factors are still largely unknown. Structural equation modelling (SEM) was applied to test a hypothesis of causal pathways related to CKD in patients with type 2 diabetes mellitus (T2DM). STUDY DESIGN: This is a prospective observational study. METHODS: A total of 3395 patients with T2DM were enrolled in this study. A hypothesised SEM was applied to assess associations among demographic data, diabetic self-management behaviours, diabetes control, lifestyle, psycho-social, chronic inflammation factors, anthropometric and metabolic variables simultaneously and the risk of CKD. RESULTS: Demographic data (including education, marital status and mini-mental state examination score) (-0.075), white blood cell count (0.084), high blood pressure (0.144), World Health Organisation (WHO) 5 well-being index (-0.082), diabetes control (0.099), triglyceride (0.091) and uric acid (0.282) levels had direct effects on the risk of CKD. The final model could explain 26% of the variability in baseline CKD status. In addition, the same direct and specific indirect factors at baseline CKD status analysis contributed to the risk of CKD at the 12-month follow-up. The final model could explain 31% of the variability in the risk of CKD at the 12-month follow-up. CONCLUSIONS: This study investigates associations between factors obtained from real-world daily practice and CKD status simultaneously and delineates the potential pathways and inter-relationships of the risk factors that contribute to the development of CKD in patients with T2DM.

Automatic three-dimensional segmentation of mouse embryonic stem cell nuclei by utilising multiple channels of confocal fluorescence images.

Time-lapse confocal fluorescence microscopy images from mouse embryonic stem cells (ESCs) carrying reporter genes, histone H2B-mCherry and Mvh-Venus, have been used to monitor dynamic changes in cellular/differentiation characteristics of live ESCs. Accurate cell nucleus segmentation is required to analyse the ESC dynamics and differentiation at a single cell resolution. Several methods used concavities on nucleus contours to segment overlapping cell nuclei. Our proposed method evaluates not only the concavities but also the size and shape of every 2D nucleus region to determine if any of the strait, extrusion, convexity and large diameter criteria is satisfied to segment overlapping nuclei inside the region. We then use a 3D segmentation method to reconstruct simple, convex, and reasonably sized 3D nuclei along the image stacking direction using the radius and centre of every segmented region in respective microscopy images. To avoid false concavities on nucleus boundaries, fluorescence images of the H2B-mCherry reporter are used for localisation of cell nuclei and Venus fluorescence images are used for determining the cell colony ranges. We use a series of image preprocessing procedures to remove noise outside and inside cell colonies, and in respective nuclei, and to smooth nucleus boundaries based on the colony ranges.  We propose dynamic data structures to record every segmented nucleus region and solid in sets (volumes) of 3D confocal images. The experimental results show that the proposed image preprocessing method preserves the areas of mouse ESC nuclei on microscopy images and that the segmentation method effectively segment out every nucleus with a reasonable size and shape. All 3D nuclei in a set (volume) of confocal microscopy images can be accessed by the dynamic data structures for 3D reconstruction. The 3D nuclei in time-lapse confocal microscopy images can be tracked to calculate cell movement and proliferation in consecutive volumes for understanding the dynamics of the differentiation characteristics about ESCs. LAY DESCRIPTION: Embryonic stem cells (ESCs) are considered as an ideal source for basic cell biology study and producing medically useful cells in vitro. This study uses time-lapse confocal fluorescence microscopy images from mouse ESCs carrying reporter gene to monitor dynamic changes in cellular/differentiation characteristics of live ESCs. To automate analyses of ESC differentiation behaviours, accurate cell nucleus segmentation to distinguish respective cells are required. A series of image preprocessing procedures are implemented to remove noise in live-cell fluorescence images but yield overlapping cell nuclei. A segmentation method that evaluates boundary concavities and the size and shape of every nucleus is then used to determine if any of the strait, extrusion, convexity, large and local minimum diameter criteria satisfied to segment overlapping nuclei. We propose a dynamic data structure to record every newly segmented nucleus. The experimental results show that the proposed image preprocessing method preserves the areas of mouse ESC nuclei and that the segmentation method effectively detects overlapping nuclei. All segmented nuclei in confocal images can be accessed using the dynamic data structures to be visualised and manipulated for quantitative analyses of the ESC differentiation behaviours. The manipulation can be tracking of segmented 3D cell nuclei in time-lapse images to calculate their dynamics of differentiation characteristics.

Effects of treadmill running and limb immobilization on knee cartilage degeneration and locomotor joint kinematics in rats following knee meniscal transection.

OBJECTIVE: This study examined the effects of reduced and elevated weight bearing on post-traumatic osteoarthritis (PTOA) development, locomotor joint kinematics, and degree of voluntary activity in rats following medial meniscal transection (MMT). DESIGN: Twenty-one adult rats were subjected to MMT surgery of the left hindlimb and then assigned to one of three groups: (1) regular (i.e., no intervention), (2) hindlimb immobilization, or (3) treadmill running. Sham surgery was performed in four additional rats. Voluntary wheel run time/distance was measured, and 3D hindlimb kinematics were quantified during treadmill locomotion using biplanar radiography. Rats were euthanized 8 weeks after MMT or sham surgery, and the microstructure of the tibial cartilage and subchondral bone was quantified using contrast enhanced micro-CT. RESULTS: All three MMT groups showed signs of PTOA (full-thickness lesions and/or increased cartilage volume) compared to the sham group, however the regular and treadmill-running groups had greater osteophyte formation than the immobilization group. For the immobilization group, increased volume was only observed in the anterior region of the cartilage. The treadmill-running group demonstrated a greater knee varus angle at mid-stance than the sham group, while the immobilization group demonstrated greater reduction in voluntary running than all the other groups at 2 weeks post-surgery. CONCLUSIONS: Elevated weight-bearing via treadmill running at a slow/moderate speed did not accelerate PTOA in MMT rats when compared to regular weight-bearing. Reduced weight-bearing via immobilization may attenuate overall PTOA but still resulted in regional cartilage degeneration. Overall, there were minimal differences in hindlimb kinematics and voluntary running between MMT and sham rats.

Development of CuO particles onto bacterial cellulose sheets by forced hydrolysis: A synergistic approach for generating sheets with photocatalytic and antibiofouling properties.

CuO was successfully prepared on bacterial cellulose paper as a nanocomposite using the forced hydrolysis technique. The composite paper presented outstanding photocatalytic and antibacterial properties. The effect of pH from 7 to 11 on CuO formation on bacterial cellulose was tested. The structural properties of the composite were investigated by Fourier transform infrared spectroscopy and X-ray diffraction. Thermogravimetric analysis showed that the composite has a thermal resistance of up to 200 °C. Scanning electron microscopy showed that bacterial cellulose existed as a network and that CuO particles filled the spaces in the network. Energy-dispersive and mapping analysis also showed the optimal uniformity and distribution. The composite paper will act as the prototype for both photocatalyst and antibacterial properties for paper-based technology.

Edge Contrast of the FLAIR Hyperintense Region Predicts Survival in Patients with High-Grade Gliomas following Treatment with Bevacizumab.

BACKGROUND AND PURPOSE: Treatment with bevacizumab is standard of care for recurrent high-grade gliomas; however, monitoring response to treatment following bevacizumab remains a challenge. The purpose of this study was to determine whether quantifying the sharpness of the fluid-attenuated inversion recovery hyperintense border using a measure derived from texture analysis-edge contrast-improves the evaluation of response to bevacizumab in patients with high-grade gliomas. MATERIALS AND METHODS: MRIs were evaluated in 33 patients with high-grade gliomas before and after the initiation of bevacizumab. Volumes of interest within the FLAIR hyperintense region were segmented. Edge contrast magnitude for each VOI was extracted using gradients of the 3D FLAIR images. Cox proportional hazards models were generated to determine the relationship between edge contrast and progression-free survival/overall survival using age and the extent of surgical resection as covariates. RESULTS: After bevacizumab, lower edge contrast of the FLAIR hyperintense region was associated with poorer progression-free survival (P = .009) and overall survival (P = .022) among patients with high-grade gliomas. Kaplan-Meier curves revealed that edge contrast cutoff significantly stratified patients for both progression-free survival (log-rank χ2 = 8.3, P = .003) and overall survival (log-rank χ2 = 5.5, P = .019). CONCLUSIONS: Texture analysis using edge contrast of the FLAIR hyperintense region may be an important predictive indicator in patients with high-grade gliomas following treatment with bevacizumab. Specifically, low FLAIR edge contrast may partially reflect areas of early tumor infiltration. This study adds to a growing body of literature proposing that quantifying features may be important for determining outcomes in patients with high-grade gliomas.

Down-regulation of miR-329-3p is associated with worse prognosis in patients with cervical cancer.

OBJECTIVE: miR-329-3p has been reported to serve as a tumor suppressor in the progression of cervical cancer (CC). The aim of this study was to investigate the clinical significance of miR-329-3p in human CC. PATIENTS AND METHODS: Quantitative RT-PCR (qRT-PCR) was used to detect miR-329-3p expression in CC tissue samples and matched normal cervical tissues. The x2 test was used to analyze the association between miR-329-3p expression and clinical features of CC patients. Moreover, we evaluated the prognostic value of miR-329-3p by Kaplan-Meier survival curve and Cox regression model. RESULTS: We found that the mean expression level of miR-329-3p in CC tissues was significantly lower than the mean level in the adjacent normal tissues samples (p < 0.01). MiR-329-3p level was significantly associated with lymph node metastasis (p = 0.013), FIGO stage (p = 0.024) and distant metastasis (p = 0.001). Furthermore, a significant difference was found, that CC patients with low miR-329-3p expression level had distinctly shorter overall survival than patients with high miR-329-3p expression level (p = 0.001). Finally, multivariate analyses indicated that miR-329-3p represented an independent predictor for overall survival of CC (p = 0.04). CONCLUSIONS: These results indicated, for the first time, that down-regulation of miR-329-3p was associated with poor prognosis in CC patients. MiR-329-3p can be used as an independent factor to predict survival of patients with CC.

Association of hematopoietic cell transplantation-specific comorbidity index with resource utilization after allogeneic transplantation.

Comorbidities affect clinical outcomes and costs in medicine. The hematopoietic cell transplantation (HCT)-specific comorbidity index (HCT-CI) predicts mortality risk after HCT. Its association with resource utilization (RU) is unknown. In this single-center, retrospective study, we examined the association of HCT-CI with RU (readmissions, length of hospital stay (LOS) and days out of hospital alive (DOHA)) in first 100 days (n=328) and 1 year (n=226) in allogeneic HCT patients from January 2010 to June 2014. Age, disease risk, conditioning and use of antithymocyte globulin were significantly different in the four groups with HCT-CI 0 to1 (n=138), 2 (n=56), 3 (n=55) or ⩾4 (n=79). Although the readmissions were higher in the first 100 days for patients with HCT-CI >0-1 (P=0.03), they were not significantly different in patients over 1 year (P=0.13). In the multivariable analysis, patients with HCT-CI score of >0 to 1 had increased LOS and fewer DOHA in both 100 days and 1 year after HCT. In this exploratory analysis, we found that HCT-CI >0 to 1 is associated with increased RU after allogeneic HCT. Recognizing predictors of RU can identify patients at risk of high utilization and help understand what drives health-care costs.

Incidence and impact of postoperative atrial fibrillation after minimally invasive esophagectomy.

Atrial fibrillation (AF) following open esophagectomy has been associated with increased rates of pulmonary and anastomotic complications, and mortality. This study seeks to evaluate effects of AF after minimally invasive esophagectomy (MIE). A retrospective review of patients consecutively treated with MIE for esophageal carcinoma, dysplasia. and benign disease from November 2006 to November 2011 was performed. One hundred twenty-one patients underwent MIE. Median age was 65 years (range 26-88) with 85% being male. Thirty-eight (31.4%) patients developed AF postoperatively. Of these 38 patients, 7 (18.4%) had known AF preoperatively. Patients with postoperative AF were significantly older than those without postoperative AF (68.7 vs. 62.8 years, P = 0.008) and more likely to be male (94.7% vs. 80.7%, P = 0.04). Neoadjuvant chemoradiation showed a trend toward increased risk of AF (73.7% vs 56.6%, P = 0.07). Sixty-day mortality was 2 of 38 (5.3%) in patients with AF and 4 of 83 (6.0%) in the no AF cohort (P = 1.00). The group with AF had increased length of hospitalization (13.4 days vs. 10.6 days P = 0.02). No significant differences in rates of pneumonia (31.6% vs. 21.7% P = 0.24), stricture (13.2% vs. 26.5% P = 0.10), or leak requiring return to operating room (13.2% vs. 8.4% P = 0.51) were noted between groups. We did not find an increased rate of AF in our MIE cohort compared with prior reported rates in open esophagectomy populations. AF did result in an increased length of stay but was not a predictor of other short-term morbidities including anastomotic leak, pulmonary complications, stenosis, or 60-day mortality.

Diaphragmatic hernia post-minimally invasive esophagectomy: a discussion and review of literature.

BACKGROUND: Diaphragmatic hernia (DH) after esophagectomy is a known complication which can occur and the incidence may be higher after minimally invasive esophagectomy (MIE). A review of our cases involving post-MIE diaphragmatic hernias and the published literature is presented. METHODS: A retrospective review of patients who underwent MIE from November 2006 to January 2013 was performed. An Embase and Pub Med literature search on diaphragmatic hernia post-esophagectomy was conducted from 1990 to 2013 and reviewed. RESULTS: In total, 120 consecutive patients underwent MIE at our institution. Neoadjuvant chemoradiotherapy had been performed in 71.4 % of patients. The mean age was 65 ± 22 years and 85 % were male. Seven patients (5.8 %) were diagnosed with DH by radiographic imaging with 5 (71.4 %) requiring surgical intervention. Diagnosis was made at a median time of 3.4 months (range 1-45 months) after MIE. One patient recurred after repair and underwent a second repair. There were no related mortalities. In literature review, 11 publications reporting DH were reviewed documenting a total of 4669 esophagectomies, with 756 MIE. The incidence of DH observed was 121 (2.6 %) in all patients and 34 (4.5 %) in MIE. Two studies comparing open versus MIE also reported a higher incidence of DH in MIE. CONCLUSIONS: Post-esophagectomy diaphragmatic hernia can occur and may be underreported. Minimally invasive esophagectomy appears to have a higher incidence of postoperative herniation when compared to traditional, open esophagectomy.

Correlation of plasma brain-derived neurotrophic factor and metabolic profiles in drug-naïve patients with bipolar II disorder after a twelve-week pharmacological intervention.

OBJECTIVE: Brain-derived neurotrophic factor (BDNF) is thought to be involved in the pathophysiology of bipolar disorder (BD) and metabolic syndrome. We investigated the correlation between plasma BDNF with mood symptoms and metabolic indices in patients with BD-II over a 12-week pharmacological intervention. METHOD: Drug-naïve patients with BD-II (n=117) were recruited. Metabolic profiles [cholesterol, triglyceride, HbA1C, fasting serum glucose, body mass index (BMI)] and plasma BDNF wtrun "tblautotrun "tblsctrun "tbl_contere measured at baseline and 2, 8, and 12 weeks after beginning medication. To adjust within-subject dependence over repeated assessments, multiple linear regressions with generalized estimating equation methods were used. RESULTS: Seventy-six (65.0%) patients completed the intervention. Plasma BDNF levels were significantly associated with BMI (P=9.6E-5), low-density lipoprotein (P=0.034) and total (P=0.001) cholesterol, but not with the Hamilton Depression Rating Scale-17 and Young Mania Rating Scale scores over the 12-week treatment. CONCLUSION: We found initial evidence of a positive correlation between plasma BDNF levels and BMI, low-density lipoprotein and total cholesterol in drug-naïve patients with BD-II. The specific function of BDNF in regulating and maintaining peripheral metabolic health requires additional investigation.

Role of DRD2 and ALDH2 genes in bipolar II disorder with and without comorbid anxiety disorder.

The presence of comorbid anxiety disorders (AD) and bipolar II disorders (BP-II) compounds disability complicates treatment, worsens prognosis, and has been understudied. The genes involved in metabolizing dopamine and encoding dopamine receptors, such as aldehyde dehydrogenase 2 (ALDH2) and dopamine D2 receptor (DRD2) genes, may be important to the pathogenesis of BP-II comorbid with AD. We aimed to clarify ALDH2 and DRD2 genes for predisposition to BP-II comorbid with and without AD. The sample consisted of 335 subjects BP-II without AD, 127 subjects BP-II with AD and 348 healthy subjects as normal control. The genotypes of the ALDH2 and DRD2 Taq-IA polymorphisms were determined using polymerase chain reactions plus restriction fragment length polymorphism analysis. Logistic regression analysis showed a statistically significant association between DRD2 Taq-I A1/A2 genotype and BP-II with AD (OR=2.231, P=0.021). Moreover, a significant interaction of the DRD2 Taq-I A1/A1 and the ALDH2*1*1 genotypes in BP-II without AD was revealed (OR=5.623, P=0.001) compared with normal control. Our findings support the hypothesis that a unique genetic distinction between BP-II with and without AD, and suggest a novel association between DRD2 Taq-I A1/A2 genotype and BP-II with AD. Our study also provides further evidence that the ALDH2 and DRD2 genes interact in BP-II, particularly BP-II without AD.

Genetic differences in Native Americans and tacrolimus dosing after kidney transplantation.

Tacrolimus pharmacokinetics vary due to single nucleotide polymorphisms (SNPs) in metabolizing enzymes and membrane transporters that alter drug elimination. Clinically we observed that Native Americans require lower dosages of tacrolimus to attain trough levels similar to Caucasians. We previously demonstrated that Native Americans have decreased oral clearance of tacrolimus, suggesting that Native Americans may have more variant SNPs and, therefore, altered tacrolimus pharmacokinetic parameters. We conducted 12-hour pharmacokinetic studies on 24 adult Native American kidney transplant recipients on stable doses of tacrolimus for at least 1 month posttransplantation. Twenty-four Caucasian kidney transplant recipients were compared as controls. SNPs encoding the genes for the enzymes (CYP3A4, CYP3A5) and transporters (ABCB1, BCRP, and MRP1) were typed using TaqMan. The mean daily tacrolimus dose in the Native Americans was 0.03 ± 0.02 compared with the Caucasians 0.5 ± 0.3 (mg/kg/d; P = .002), with no significant differences in trough levels, (6.7 ± 3.1 vs 7.4 ± 2.1 ng/dL; P = .4). Many Native Americans, but not Caucasians, demonstrated the 3/*3 - C3435T CC and the *3/*3 -G2677T GG genotype combination previously associated with low tacrolimus dosing. Native Americans required significantly lower tacrolimus doses than Caucasians to achieve similar tacrolimus trough levels, in part due to lower tacrolimus clearance from decreased drug metabolism and excretion.

High-density lipoprotein cholesterol and the risk of nephropathy in type 2 diabetic patients.

BACKGROUND AND AIMS: To date, few studies have demonstrated the impact of variations in blood pressure, blood glucose and lipid levels on the progression of diabetic nephropathy (DN) in type 2 diabetic patients. This study aimed to assess the associations of mean values and variability in metabolic parameters with the development of DN in type 2 diabetic patients. METHODS AND RESULTS: A total of 864 patients who had participated in a comprehensive diabetic care program for at least for 3 years were studied. Patients were stratified into progressor (n = 180) and non-progressor groups (n = 684) according to the status of progression of DN during the follow-up period. By Cox regression analysis, a higher mean HDL-C level was observed to be a protective factor against the progression of DN [hazard ratio (95% CI): 0.971(0.953-0.989), P = 0.002] and a higher HDL-C variation was found to be associated with a higher risk [hazard ratio (95% CI): 1.177(1.032-1.341), P = 0.015] of DN progression. By the Kaplan-Meier survival curve, patients with a higher HDL-C level and lower HDL-C variability were found to have the lowest risk of development of nephropathy. CONCLUSIONS: Our study demonstrated for the first time that type 2 diabetic patients under a standard disease management program who have a stable and a higher mean HDL-C level were associated with a lower risk of development of DN.

Physical function mitigates the adverse effects of being thin on mortality in a free-living older Taiwanese cohort.

OBJECTIVES: To examine the significance of underweight and physical function as well as their interaction on mortality in the aged. DESIGN: Prospective cohort. SETTING: The Elderly Nutrition and Health Survey in Taiwan during 1999-2000. PARTICIPANTS: Total of 1435 representative free-living elders (739 men and 696 women). MEASUREMENTS: Body composition was assessed by various anthropometrics. Physical function score (PF, ranged 0-100) was derived from the SF-36(®). Death by December 31, 2006 was the outcome measure. RESULTS: After 7.9 (median: 7.0) years follow-up, 381 (223 men, 158 women) of 1435 eligible participants had died. Those with the lowest PF (<45) had 3.43 (hazards ratio (HR), 95% confidence interval (CI) = 2.20-5.36) times the all-cause mortality risk of the highest PF (≥58). Interactions for PF and BMI (P =0.02) and for PF and wrist circumference (P =0.09) on death were found after controlling for potential confounders. Jointly, compared to normal-BMI-highest-PF, the greatest HR for death occurred where BMI <18.5 kg/m2 was combined with the lowest-PF after covariate adjustments (HR = 8.67, 95% CI = 3.77-20.0). Similarly, the lowest arm muscle circumference (MAMC)-PF had a HR of 5.22 compared to mid-MAMC-highest-PF. However, percent and absolute body fat, estimated by bioelectrical impedance, was comparable to non-sarcopenic individuals. CONCLUSION: Thin elderly Taiwanese with sarcopenia, and less skeleton, are at the most risk of death, especially if physical function is limited.

Increased risk of severe acute pancreatitis in patients with diabetes.

AIMS: We prospectively assessed the age- and sex-specific incidence rates and relative risks of overall and severe acute pancreatitis in Taiwanese with diabetes. METHODS: The study cohort included age- and-sex-matched groups of patients with (n = 547,554) and without (n = 584,373) diabetes. Incidence rate was estimated under Poisson assumption and relative risks of acute pancreatitis and severe acute pancreatitis, based on modified Atlanta criteria, were indicated by hazard ratios estimated from Cox proportional hazard regression models. RESULTS: Over an 8-year follow-up period, the incidence of acute pancreatitis was 2.98 and 1.68 per 1000 person-years for patients with and without diabetes, respectively, representing a covariate adjusted hazard ratio of 1.53 (95% confidence interval 1.49-1.58). Diabetes was associated with a significantly elevated risk of acute pancreatitis in all sex and age stratifications, with the highest hazard ratio noted for study subjects aged < 45 years (men 2.37; women 2.95). Diabetes was also significantly associated with an increased hazard ratio of severe acute pancreatitis [1.46 (1.36-1.57)], and especially of acute pancreatitis with local complications [1.65 (1.14-2.39)]. CONCLUSIONS: Diabetes is associated with an increased risk of overall and severe acute pancreatitis, and the relation is stronger in women and young patients.

Regulation of glucose/lipid metabolism and insulin sensitivity by interleukin-4.

OBJECTIVE: Abundant evidence has demonstrated that long-term cytokine-mediated inflammation is a risk factor for obesity and type 2 diabetes mellitus (T2DM). Our previous study reveals a significant association between promoter polymorphisms of Th2-derived cytokine interleukin-4 (IL-4) and T2DM, which suggests possible roles of IL-4 in metabolism. In this study, we focused on examining the putative regulation of glucose and lipid metabolism by IL-4. METHODS: C57BL/6 mice were intraperitoneally injected with either adenovirus containing full-length IL-4 encoding gene (AdIL-4) or recombinant IL-4 for mimicking the status of transient and long-term IL-4 overexpression, respectively, and the effects of the overexpressed IL-4 to glucose/lipid metabolism and insulin sensitivity were subsequently investigated. RESULTS: Our results reveal that IL-4 improves insulin sensitivity and glucose tolerance through upregulating Akt phosphorylation while attenuating GSK-3ß activities. IL-4 is also involved in lipid metabolism by inhibiting lipid accumulation in fat tissues, which lead to decreased weight gain and fat mass. CONCLUSIONS: Our results suggest that IL-4 regulates glucose and lipid metabolism by promoting insulin sensitivity, glucose tolerance and inhibiting lipid deposits. This study uncovers the novel roles of IL-4 in metabolism and provides new insights in the interaction between cytokines/immune responses, insulin sensitivity and metabolism.

A simple renal cyst invaded by infiltrating urothelial carcinoma mimicking a Bosniak Class IV renal cyst.

We report a 79-year-old woman with a left side simple renal cyst invaded by infiltrating urothelial carcinoma mimicking a Bosniak Class IV renal cyst. Computerized tomography has high accuracy for the diagnosis of renal cysts and urothelail carcinoma. But, in this case it was still difficult to distinguish a simple renal cyst with infiltrating urothelial carcinoma invasion from a Bosniak Class IV renal cyst on CT scan. The management of a Bosniak Class IV renal cyst and urothelail carcinoma is totally different. Therefore, we performed a left side nephroureterectomy. This patient will have regular follow-up with cystoscopy every 3 months for the first 2 y, every 6 months for the next 2 y, and then annually thereafter.