Enhancement of Convection and Molecular Transport into Film Stacked Structures by Introduction of Notch Shape for Micro-Immunoassay.

A 3D-stack microfluidic device that can be used in combination with 96-well plates for micro-immunoassay was developed by the authors. ELISA for detecting IgA by the 3D-stack can be performed in one-ninth of the time of the conventional method by using only 96-well plates. In this study, a notched-shape film was designed and utilized for the 3D-stack to promote circulation by enhancing and utilizing the axial flow and circumferential flow in order to further reduce the reaction time. A finite element analysis was performed to evaluate the axial flow and circumferential flow while using the 3D-stack in a well and design the optimal shape. The 3D-stack with the notched-shape film was fabricated and utilized for the binding rate test of the antibody and antigen and ELISA. As a result, by promoting circulation using 3D-stack with notched-shape film, the reaction time for each process of ELISA was reduced to 1 min, which is 1/60 for 96 wells at low concentrations.

Enhancement of Molecular Transport into Film Stacked Structures for Micro-Immunoassay by Unsteady Rotation.

A film-stacked structure consisting of polyethylene terephthalate (PET) films stacked in a gap of 20 µm that can be combined with 96-well microplates used in biochemical analysis has been developed by the authors. When this structure is inserted into a well and rotated, convection flow is generated in the narrow gaps between the films to enhance the chemical/bio reaction between the molecules. However, since the main component of the flow is a swirling flow, only a part of the solution circulates into the gaps, and reaction efficiency is not achieved as designed. In this study, an unsteady rotation is applied to promote the analyte transport into the gaps using the secondary flow generated on the surface of the rotating disk. Finite element analysis is used to evaluate the changes in flow and concentration distribution for each rotation operation and to optimize the rotation conditions. In addition, the molecular binding ratio for each rotation condition is evaluated. It is shown that the unsteady rotation accelerates the binding reaction of proteins in an ELISA (Enzyme Linked Immunosorbent Assay), a type of immunoassay.

Performance Status Modifies the Association Between Vitamin D Receptor Activator and Mortality or Fracture: A Prospective Cohort Study on the Japanese Society for Dialysis Therapy (JSDT) Renal Data Registry.

Immobilization osteoporosis is characterized by excess bone resorption. Vitamin D receptor activators (VDRA) might have adverse effects in immobilized patients. The objective of this study was to elucidate the impact of performance status (PS) on the associations between VDRA use and outcomes among hemodialysis patients. This is a prospective cohort study. Adults on hemodialysis in the Japanese Society for Dialysis Therapy (JSDT) Renal Data Registry were included. Exposure of interest was the use of VDRA. Outcomes were all-cause mortality and hip fracture. Associations between VDRA use and mortality or hip fractures were examined by Cox and Poisson regression analyses, respectively. Among 208,512 subjects, 128,535 were on VDRA. Poor PS was associated with higher calcium (Ca), lower parathyroid hormone, and higher alkaline phosphatase levels. The association between higher Ca levels and VDRA use was stronger among those with poor PS (p interaction 0.007). Adjusted hazard ratio (HR) (95% confidence interval [CI]) for mortality and incidence rate ratio (IRR) for hip fracture was 1.02 (95% CI, 0.99-1.05) and 0.93 (0.86-1.00) among users of VDRA, respectively. The VDRA use was associated with lower mortality and incidence of hip fractures among subjects with good PS but not among subjects with poor PS (p interaction 0.03 and 0.05). Effect modification by PS was observed for cardiovascular (CV) mortality but not for non-CV mortality. In conclusion, VDRA use was associated with better outcomes only among those with good PS. These results suggest that bone and mineral disorders among hemodialysis patients should be treated differently, depending on their performance status. © 2022 American Society for Bone and Mineral Research (ASBMR).

Seasonal variations in cause-specific mortality and transition to renal replacement therapy among patients with end-stage renal disease.

Despite some studies showing seasonal variations in mortality and the transition to renal replacement therapy in patients with end-stage renal disease, detailed evidence is still scarce. We investigated seasonal variations in patients with end-stage renal disease using a large Japanese database for dialysis patients. We compared the fractions of all-cause and cause-specific mortality and the transition to renal replacement therapy among seasons and performed a mixed-effects Poisson regression analysis to compare the mortality among seasons after adjustment for some variables. The initiation of hemodialysis was highest in winter and lowest in summer. Seasonality in the initiation of peritoneal dialysis and transition to kidney transplantation differed from hemodialysis. All-cause mortality was highest in the winter and lowest in the summer. Death from coronary artery disease, heart failure, cerebral hemorrhage, and infectious pneumonia had similar seasonality, but death from cerebral infarction, septicemia, or malignant tumor did not have similar seasonality. In conclusion, the initiation of hemodialysis, all-cause mortality, and mortality from coronary heart disease, heart failure, cerebral hemorrhage, and infectious pneumonia were significantly highest in winter and lowest in summer. However, the initiation of peritoneal dialysis, transition to kidney transplantation, or mortality from cerebral infarction, septicemia, or malignant tumor did not have similar seasonal variations.

Synergic Impact of Body Mass Index, Diabetes, and Age on Long-Term Mortality in Japanese Incident Hemodialysis Patients: A Cohort Study on a Large National Dialysis Registry.

OBJECTIVES: The relationships among body mass index (BMI), diabetes, age, and all-cause mortality in hemodialysis patients remain unclear. We examined BMI-stratified relationships between diabetes, age, and the risk of long-term mortality in incident hemodialysis patients. METHODS: This is a cohort study. Data were obtained from the national dialysis registry in Japan 2007 that included 35,415 incident hemodialysis patients and 6,061 patients aged ≥20 years with BMI data. Patients were divided into 6 categories according to baseline BMI (low: <18.5, normal: 18.5-25, Obesity: ≥25) and the presence or absence of diabetes. The primary outcome was all-cause mortality during a 5-year follow-up. Hazard ratios were estimated using Cox's model for the relationships among diabetes, BMI categories, and all-cause mortality, and adjusted for potential confounders. Patients with a normal BMI and non-diabetic were the reference category. We also examined the effects of age on these relationships. RESULTS: A total of 6,061 patients, including 3,239 with diabetes, were enrolled. During the follow-up, 31.0% and 30.7% of all and diabetic patients, respectively, died. Cox's regression analysis showed that low BMI, but not obesity, was independently associated with an increased risk of all-cause death in patients with and without diabetes. When patients were divided into 2 groups-younger and older than 60 years-the risk of mortality in both groups was increased in low BMI with diabetes. CONCLUSIONS: Among Japanese incident hemodialysis patients, low BMI increases the risk of all-cause mortality. The markedly high mortality rate in diabetic patients with low BMI regardless of age warrants attention.

Current status of hepatopulmonary syndrome in liver transplantation in Japan: a Japanese multicenter analysis.

BACKGROUND: Hepatopulmonary syndrome (HPS) negatively affects the outcomes of deceased donor liver transplantation (LT). METHODS: We retrospectively reviewed the clinical records of patients with HPS who underwent LT and studied the impact of risk factors on clinical outcomes to determine strategies to overcome complications. Patients with symptoms of hypo-oxygenemia and a shunt ratio >15% on 99mTc-MAA lung perfusion scintigraphy were defined as having HPS. RESULTS: Forty-eight patients in 10 centers were enrolled. Diseases included biliary atresia, liver cirrhosis, non-alcoholic steatohepatitis, congenital hepatic fibrosis, and others. The length of ICU stay was 2-170 days. The respirator was used for 41.6% of patients on post-operative day (POD) 3 and 20.8% on POD 14. The patient survival rate was 87% at 1 year and 82% at 5 years. The causes of hospital mortality were sepsis, thrombotic microangiopathy, intracranial bleeding, pulmonary fibrosis, and transplant rejection. An amount of shunt ratio prior to LT was a significant risk factor for hospital mortality. Hypoxia from POD 3 to POD 14 was a risk factor for biliary stenosis. The shunt ratio of all surviving patients significantly improved. CONCLUSION: Although LT is feasible for patients with HPS, early transplantation and avoiding hypo-oxygenemia immediately after transplantation are important.

Author Correction: Higher dialysate calcium concentration is associated with incident myocardial infarction among diabetic patients with low bone turnover: a longitudinal study.

A correction to this article has been published and is linked from the HTML and PDF versions of this paper. The error has not been fixed in the paper.

Salt Intake and All-Cause Mortality in Hemodialysis Patients.

BACKGROUND: Although some clinical practice guidelines regarding hemodialysis recommend salt restriction, few studies have examined the association between salt intake and clinical outcomes in hemodialysis patients. This study aimed to clarify the association between salt intake and mortality in hemodialysis patients. METHODS: This retrospective cohort study was based on the Japanese Society for Dialysis Therapy renal data registry database (2008) and included 88,115 adult patients who had received hemodialysis for at least 2 years. Estimated salt intake was the main predictor and was calculated from intra-dialytic weight loss and pre- and post-dialysis serum sodium levels. Nonlinear logistic regression was used to determine the association between salt intake and mortality, adjusting for potential confounders. The outcomes considered were all-cause mortality and cardiovascular death at 1 year. RESULTS: The median (25-75th percentile) salt intake at baseline was 6.4 (4.6-8.3) g/day. At 1 year, all-cause mortality occurred in 1,845 (2.1%) patients, including 807 cardiovascular deaths. The low salt intake group (< 6 g/day) demonstrated the highest all-cause mortality and cardiovascular deaths. No association was observed between high salt intake, all-cause mortality and cardiovascular deaths. The lowest risk for all-cause mortality and cardiovascular death occurred among patients with an estimated salt intake of 9 g/day. CONCLUSION: Low salt intake, but not high salt intake, was associated with all-cause and cardiovascular mortality in Japanese hemodialysis patients. Further studies to justify including a lower limit of salt intake for hemodialysis patients are suggested.

Higher dialysate calcium concentration is associated with incident myocardial infarction among diabetic patients with low bone turnover: a longitudinal study.

This is a longitudinal study on 53,560 hemodialysis patients from the Japan Renal Data Registry. Predictor was D[Ca] ≥3.0 vs 2.5 mEq/L. Outcomes were the first CV events during 1-year observation period. Association of D[Ca] with CV events and effect modifications were tested using multivariate logistic regression analyses. Diabetes mellitus (DM) was a significant effect modifier for association of higher D[Ca] and myocardial infarction (MI) (OR: 1.26 (1.03-1.55) among DM and 0.86 (0.72-1.03) among non-DM, p for interaction <0.01). The effect size was not affected by further adjustment for serum albumin-corrected Ca or intact parathyroid hormone (iPTH) levels, but was attenuated by adjustment for intradialytic change in serum Ca concentration (ΔCa) (1.16 [0.89-1.51]). Among DM, D[Ca] ≥3.0 mEq/L was significantly associated with MI in the first tertile of corrected Ca or iPTH ≤60 pg/ml (p for interaction 0.03 and 0.03, respectively). In conclusion, higher D[Ca] was associated with incident MI in DM, especially with low serum Ca or iPTH levels. Attenuation of the effect size by adjustment for ΔCa and stratified analyses suggest that larger Ca influx during dialysis with higher D[Ca] in patients suggestive of low bone turnover leads to vascular calcification and subsequent MI in DM.

Effect of herbal medicine daikenchuto on oral and enteral caloric intake after liver transplantation: A multicenter, randomized controlled trial.

OBJECTIVE: Postoperative early oral or enteral intake is a crucial element of the Enhanced Recovery After Surgery (ERAS) protocol. However, normal food intake or enteral feeding cannot be started early in the presence of coexisting bowel dysfunction in patients undergoing liver transplantation (LT). The aim of this multicenter, randomized, double-blinded, placebo-controlled trial was to determine the enhancement effects of the Japanese herbal medicine Daikenchuto (DKT) on oral/enteral caloric intake in patients undergoing LT. METHODS: A total of 112 adult patients undergoing LT at 14 Japanese centers were enrolled. The patients were randomly assigned to receive either DKT or placebo from postoperative day (POD) 1 to 14. The primary endpoints were total oral/enteral caloric intake, abdominal distension, and pain on POD 7. The secondary endpoints included sequential changes in total oral/enteral caloric intake after LT, and portal venous flow volume and velocity in the graft. RESULTS: A total of 104 patients (DKT, n = 55; placebo, n = 49) were included in the analyses. There were no significant differences between the two groups in terms of primary endpoints. However, postoperative total oral/enteral caloric intake was significantly accelerated in the DKT group compared with the placebo group (P = 0.023). Moreover, portal venous flow volume (POD 10, 14) and velocity (POD 14) were significantly higher in the DKT group than in the placebo group (P = 0.047, P = 0.025, P = 0.014, respectively). CONCLUSIONS: Postoperative administration of DKT may enhance total oral/enteral caloric intake and portal venous flow volume and velocity after LT and favorably contribute to the performance of the ERAS protocol.

Peritoneal Dialysis Registry With 2013 Survey Report.

Since 2009, the peritoneal dialysis (PD) registry has been carried out as part of the annual nationwide survey conducted by the Statistical Survey Committee of the Japanese Society for Dialysis Therapy with the cooperation of the Japanese Society for Peritoneal Dialysis. In this study, the current status of PD patients is reported on the basis of the results of the survey conducted at the end of 2013. The subjects were PD patients who lived in Japan and participated in the 2013 survey. Descriptive analysis was performed for various items including the current status of the combined use of PD and another dialysis method such as hemodialysis (HD) or hemodiafiltration (HDF), the method of exchanging dialysate, the use of an automated peritoneal dialysis (APD) machine, and the incidences of peritonitis and catheter exit-site infection. From the results of the facility survey in 2013, the number of PD patients was 9392, a decrease of 122 from that in 2012. Among the entire dialysis patient population, 3.0% were PD patients, a decrease of 0.1%. Among the studied patients, 292 had a peritoneal catheter and underwent peritoneal lavage, 174 were started on PD in 2013 but introduced to other blood purification methods in 2013, and 1920 underwent both PD and another dialysis method such as HD or HDF. The percentage of patients who underwent PD and another dialysis method increased with the number of years on PD: <1 year, 3.5%; 1 to < 2 years, 8.4%; 2 to < 4 years, 15.3%; 4 to < 6 years, 27.1%; 6 to < 8 years, 39.3%; 8 to < 10 years, 47.1%; and ≥ 10 years, 57.5%. The percentage of PD patients for whom the dialysate was completely manually exchanged was 31.6%, whereas the percentages of PD patients who used a bag-exchange device based on ultraviolet-light irradiation and that based on thermal sterile joint systems were 52.1 and 14.9%, respectively. The mean incidence of peritonitis was 0.22 per patient per year (once per 54.5 patients per month). The mean incidence of catheter exit-site infection was 0.34 per patient per year (once per 35.3 patients per month).

Institutional factors influencing regional differences in the 1-year survival of dialysis patients.

There are regional differences in the survival of incident dialysis patients, but few studies have investigated the reasons. We assessed the effect of institutional factors on factors on survival (by both cross-sectional assessment and after a 1-year investigation) in a cohort of the Japanese Society for Dialysis Therapy (JSDT). We investigated 20 institutional factors from 3958 dialysis institution data of the 47 prefectures in Japan in 2005 and the JSDT database of 102,011 patients who commenced dialysis during 2004-2006. Univariate regression analysis between 20 factors and 1-year survival rate, Kaplan-Meier method, log-rank test, and Cox's proportional hazard model between the upper 24 and the lower 23 prefectures of the significant factors were carried out. The age-adjusted 1-year survival rate was 0.832 ± 0.027. Deaths occurred in 15.0% in 24 upper survival prefectures and 18.7% in 23 lower survival prefectures (P < 0.0001, unadjusted hazard ratio [HR] of death in lower survival prefectures: 1.26, 95% confidence interval [CI]: 1.17-1.40). A total of five factors among males were significantly correlated with 1-year survival according to the univariate regression analysis. Among them, three factors (night-time center/total dialysis center ratio [males: P < 0.0001, age, genders, and presence of diabetes adjusted HR: 0.88, 95% CI: 0.81-0.93], number of full-time dialysis nurses [males: P = 0.0427, 0.94, 0.87-1.00], number of full-time dialysis dietitians [males: P = 0.0084, 0.92, 0.85-0.98], respectively) were significant in Kaplan-Meier analysis, log-rank test, and the Cox's model. Institutional factors were closely related to the survival of incident dialysis patients, and regional differences in the survival may be explained, at least partly, by these factors.

Living donor liver transplantation using a graft with periportal fibrosis.

A 57-year-old woman with familial amyloid polyneuropathy (FAP) was scheduled to undergo living donor liver transplantation (LDLT), but the operation was cancelled because the only potential donor had chronic alcohol-related liver disease. One year later, FAP-related neurological symptoms progressed rapidly, and emergency LDLT was planned. The donor's hepatic function had returned to normal range after 1 year of abstinence. The left liver graft volume was equivalent to 37.7% of the standard liver volume (SLV) of the recipient. However, a liver biopsy revealed mild fibrosis (score, F1). LDLT was successfully performed without any complications. The recipient's neurological findings returned to normal. One year after LDLT, the liver graft volume was equivalent to approximately 90% of the SLV, and the fibrosis had improved. LDLT using a graft with a fibrosis score of up to F1 may be an acceptable alternative for recipients with normal hepatic function.

Peritoneal Dialysis Registry With 2012 Survey Report.

Since 2009, the peritoneal dialysis (PD) registry survey has been carried out as part of the annual nationwide survey conducted by the Statistical Survey Committee of the Japanese Society for Dialysis Therapy with the cooperation of the Japanese Society for Peritoneal Dialysis. In this report, the current status of PD patients is presented on the basis of the results of the survey conducted at the end of 2012. The subjects were PD patients who lived in Japan and participated in the 2012 survey. Descriptive analysis of various items was performed, which included the current status of the combined use of PD and another dialysis method such as hemodialysis (HD) or hemodiafiltration (HDF), the method of exchanging dialysate, the use of an automated peritoneal dialysis (APD) machine, and the rates of peritonitis and catheter exit-site infection. From the results of the facility survey in 2012, the number of PD patients was 9514, a decrease of 128 from 2011. Among the entire dialysis patient population, 3.1% were PD patients, a decrease of 0.1%. Among the studied patients, 347 had a peritoneal catheter and underwent peritoneal lavage, 175 were started on PD in 2012 but introduced to other blood purification methods in the same year, and 1932 underwent both PD and another dialysis method such as HD or HDF. The percentage of patients who underwent PD and another dialysis method increased with PD vintage: <1 year, 4.8%; 1 to <2 years, 9.2%; 2 to <4 years, 16.3%; 4 to <8 years, 32.0%; and ≥8 years, 47.5%. The percentage of PD patients who completely manually exchanged the dialysate was 29.8%. The percentages of PD patients who used a double-bag exchange system with ultraviolet-light irradiation and those who used the same system but with a sterile connecting device were 54.7 and 13.9%, respectively. The percentage of patients on PD for <1 year using an APD machine was 43.4%, and it decreased with a PD vintage of ≥2 years. The mean rate of peritonitis was 0.22 per patient per year. The mean rate of catheter exit-site infections was 0.36 per patient per year.

An Overview of Regular Dialysis Treatment in Japan (As of 31 December 2013).

A nationwide survey of 4325 dialysis facilities was conducted at the end of 2013, among which 4268 (98.7%) responded. The number of new dialysis patients was 38,095 in 2013. Since 2008, the number of new dialysis patients has remained almost the same without any marked increase or decrease. The number of dialysis patients who died in 2013 was 30,751. The dialysis patient population has been growing every year in Japan; it was 314,438 at the end of 2013. The number of dialysis patients per million at the end of 2013 was 2470. The crude death rate of dialysis patients in 2013 was 9.8%. The mean age of new dialysis patients was 68.7 years and the mean age of the entire dialysis patient population was 67.2 years. The most common primary cause of renal failure among new dialysis patients was diabetic nephropathy (43.8%). The actual number of new dialysis patients with diabetic nephropathy has almost been unchanged for the last few years. Diabetic nephropathy was also the most common primary disease among the entire dialysis patient population (37.6%), followed by chronic glomerulonephritis (32.4%). The percentage of dialysis patients with diabetic nephropathy has been increasing continuously, whereas the percentage of dialysis patients with chronic glomerulonephritis has been decreasing. The number of patients who underwent hemodiafiltration (HDF) at the end of 2013 was 31,371, a marked increase from that in 2012. This number is more than twice that at the end of 2011 and approximately 1.5 times the number at the end of 2012. In particular, the number of patients who underwent online HDF increased approximately fivefold over the last 2 years. Among 151,426 dialysis patients with primary causes of renal failure other than diabetic nephropathy, 10.8% had a history of diabetes. Among those with a history of diabetes, 26.8% used glycoalbumin as an indicator of blood glucose level; and 33.0 and 27.6% were administered insulin and dipeptidyl peptidase (DPP)-4 inhibitor, respectively, as a medication of diabetes. The facility survey showed that 9392 patients underwent peritoneal dialysis (PD). The patient survey revealed that 1920 of these PD patients also underwent another dialysis method using extracorporeal circulation, such as hemodialysis (HD) or HDF. The number of patients who underwent HD at home at the end of 2013 was 461, a marked increase from that at the end of 2012 (393).

An overview of regular dialysis treatment in Japan (as of 31 December 2012).

A nationwide statistical survey of 4279 dialysis facilities was conducted at the end of 2012, among which 4238 responded (99.0%). The number of new dialysis patients was 38055 in 2012. Since 2008, the number of new dialysis patients has remained almost the same without any marked increase or decrease. The number of dialysis patients who died in 2012 was 30710; a slight decrease from 2011 (30743). The dialysis patient population has been growing every year in Japan; it was 310007 at the end of 2012, which exceeded 310000 for the first time. The number of dialysis patients per million at the end of 2012 was 2431.2. The crude death rate of dialysis patients in 2012 was 10.0%, a slight decrease from that in 2011 (10.2%). The mean age of new dialysis patients was 68.5 years and the mean age of the entire dialysis patient population was 66.9 years. The most common primary cause of renal failure among new dialysis patients was diabetic nephropathy (44.2%). The actual number of new dialysis patients with diabetic nephropathy has been approximately 16000 for the last few years. Diabetic nephropathy was also the most common primary disease among the entire dialysis patient population (37.1%), followed by chronic glomerulonephritis (33.6%). The percentage of dialysis patients with diabetic nephropathy has been continuously increasing, whereas not only the percentage but also the actual number of dialysis patients with chronic glomerulonephritis has decreased. The number of patients who underwent hemodiafiltration (HDF) at the end of 2012 was 21725, a marked increase from that in 2011 (14115). In particular, the number of patients who underwent on-line HDF increased threefold from 4890 in 2011 to 14069 in 2012. From the results of the facility survey, the number of patients who underwent peritoneal dialysis (PD) was 9514 and that of patients who did not undergo PD despite having a PD catheter in the abdominal cavity was 347. From the results of the patient survey, among the PD patients, 1932 also underwent another dialysis method using extracorporeal circulation, such as hemodialysis (HD) and HDF. The number of patients who underwent HD at home in 2012 was 393, a marked increase from that in 2011 (327).

Overview of regular dialysis treatment in Japan (as of 31 December 2011).

A nationwide statistical survey of 4255 dialysis facilities was conducted at the end of 2011. Responses were submitted by 4213 facilities (99.0%). The number of new patients started on dialysis was 38,613 in 2011. Although the number of new patients decreased in 2009 and 2010, it increased in 2011. The number of patients who died each year has been increasing; it was 30,743 in 2011, which exceeded 30,000 for the first time. The number of patients undergoing dialysis has also been increasing every year; it was 304,856 at the end of 2011, which exceeded 300,000 for the first time. The number of dialysis patients per million at the end of 2011 was 2385.4. The crude death rate of dialysis patients in 2011 was 10.2%, which exceeded 10% for the first time in the last 20 years. The mean age of new dialysis patients was 67.84 years and the mean age of the entire dialysis patient population was 66.55 years. The most common primary cause of renal failure among new dialysis patients was diabetic nephropathy (44.3%). Diabetic nephropathy was also the most common primary disease among the entire dialysis patient population (36.7%), exceeding chronic glomerulonephritis (34.8%) which had been the highest until last year. The survey included questions related to the Great East Japan Earthquake, which occurred on 11 March 2011. The results on items associated with the Great East Japan Earthquake were reported separately from this report. The mean uric acid levels of the male and female patients were 7.30 and 7.19 mg/dL, respectively. Certain drugs for hyperuricemia were prescribed for approximately 17% of patients. From the results of the facility survey, the number of patients who underwent peritoneal dialysis (PD) was 9642 and the number of patients who did not undergo PD despite having a peritoneal dialysis catheter was 369. A basic summary of the results on the survey items associated with PD is included in this report and the details were reported separately.

Planning of anatomical liver segmentectomy and subsegmentectomy with 3-dimensional simulation software.

BACKGROUND: The aim of this study was to evaluate whether 3-dimensional (3D) simulation software is applicable to and useful for anatomic liver segmentectomy and subsegmentectomy. METHODS: A prospective study of 83 consecutive patients who underwent anatomic segmentectomy or subsegmentectomy using the puncture method was performed. All patients underwent 3D simulation analysis (SA) preoperatively for planning operative procedures. The clinical information acquired by 3D SA and the consistency of virtual and real hepatectomy were evaluated. RESULTS: The time needed for completing 3D SA was 18.3 ± .7 minutes. Three-dimensional SA proposed resection of multiple segments or subsegments in 29 patients (35%). It also helped complement the resection line in 26 patients (31%) who lacked a bold staining area on the liver surface. The volume of segment or subsegment calculated by 3D SA was correlated with the actual resected specimen (R(2) = .9942, P < .01). The bordering hepatic veins were clearly exposed in 71 patients (86%), in accordance with completed drawings by 3D SA. CONCLUSIONS: Three-dimensional SA showed accurate completed drawings and assisted liver surgeons in planning and executing anatomic segmentectomy and subsegmentectomy.

Patient with adult-onset type II citrullinemia beginning 2 years after operation for duodenal malignant somatostatinoma: Indication for liver transplantation.

We report a 51-year-old female patient with adult-onset type II citrullinemia (CTLN2) who had a history of pancreatoduodenectomy for duodenal somatostatinoma with metastases to regional lymph nodes at age 49 years, paying special attention to indications for liver transplantation. At age 50 years, she developed hepatic encephalopathy with elevation of plasma ammonia and citrulline levels. A diagnosis of CTLN2 was made by DNA analysis of the SLC25A13 gene and treatment with conservative therapies was begun, including a low-carbohydrate diet and supplementation with arginine and sodium pyruvate. However, despite these treatments, frequent attacks of encephalopathy occurred with markedly elevated plasma ammonia levels. While we were apprehensive regarding the risk of recurrence of somatostatinoma due to immunosuppressive therapy after liver transplantation, the patient was in a critical condition with CTLN2 and it was decided to perform living-donor liver transplantation using a graft obtained from her son. Her postoperative clinical course was uneventful and she has had an active life without recurrence of somatostatinoma for 2 years. This is the first case of CTLN2 with somatostatinoma. As the condition of CTLN2 patients with rapidly progressive courses is often intractable by conservative therapies alone, liver transplantation should be considered even after surgery for malignant tumors in cases with neither metastasis nor recurrence.