Combinatorial Effect of Prophylactic Interventions for Post-ERCP Pancreatitis among Patients with Risk Factors: A Network Meta-Analysis

Background/Aims@#The combinatorial effects of prophylactic methods for postendoscopic retrograde cholangiopancreatography pancreatitis (PEP) in patients with risk factors remain unclear. In this network meta-analysis, we compared the efficacy of various prophylactic strategies to decrease the risk of PEP among patients with risk factors. @*Methods@#A systematic review was performed to identify randomized controlled trials from PubMed, Embase, and the Cochrane Library through July 2021. We used frequentist network meta-analysis to compare the rates of PEP among patients who received prophylactic treatments as follows: class A, rectal nonsteroidal anti-inflammatory drugs; class B, prophylactic pancreatic stent; class C, aggressive hydration; or control, no prophylaxis or active control. We selected those studies that included patients with risk factors for PEP. @*Results@#We identified 19 trials, comprising 4,328 participants. Class ABC (odds ratio [OR], 0.08; 95% confidence interval [CI], 0.03 to 0.24), class AC (OR, 0.10; 95% CI, 0.02 to 0.47), class AB (OR, 0.12; 95% CI, 0.05 to 0.26), class BC (OR, 0.13; 95% CI, 0.04 to 0.41), class A (OR, 0.16; 95% CI, 0.05 to 0.50), and class B (OR, 0.26; 95% CI, 0.14 to 0.46), were associated with a reduced risk of PEP as compared to that of the control. The most effective prophylaxis was ABC (0.87), followed by AC (0.68), AB (0.65), BC (0.56), A (0.49), and B (0.24) according to P-score. @*Conclusions@#The results of this network meta-analysis suggest that the more prophylactic methods are employed, the better the outcomes. It appears that for patients with risk factors, we need to prevent PEP through the use of these well proven combination strategies.

A Case of Adenomyomatous Hyperplasia of the Distal Common Bile Duct Mimicking Malignant Stricture / 대한소화기학회지

Adenomyomatous hyperplasia is a reactive malformation or non-neoplastic tumor-like lesion frequently observed in the gallbladder, stomach, duodenum and jejunum, but rare in the extrahepatic bile duct. A 42-year-old man with epigastric discomfort had a stricture in the common bile duct on initial CT scans. Initially, it was regarded as a malignant lesion with some evidence, but histopathologic examinations of multiple biopsies obtained by multiple sessions of endoscopic retrograde cholangiopancreatography showed no evidence of malignancy. The patient had undergone the pylorus preserving pancreaticoduodenectomy because of the possibility of malignancy; however, the final diagnosis was adenomyomatous hyperplasia. It is important to distinguish a malignancy from benign biliary stricture with endoscopic biopsies. Surgery for suspected biliary malignancy often reveals benign lesions. Therefore, a correct diagnosis is important before deciding upon treatment of bile duct stricture. In conclusion, in younger patients with bile duct stricture where there is no evidence of histologic malignancy despite multiple biopsies, the possibility of benign disease such as adenomyomatous hyperplasia should be considered, to avoid unnecessary radical surgery.

A Case of Idiopathic Severe Acute Pancreatitis following Cesarean Section Delivery / 대한소화기학회지

Acute pancreatitis rarely occurs in the postpartum period. Furthermore, there are very few reports of it after cesarean section delivery. A 35-year-old woman presented with dyspnea and abdominal distension on the third day after cesarean section delivery. Under a suspicion of acute pancreatitis, she was initially managed with conservative treatment. However, she developed intra-abdominal fluid collections and gastric bleeding, which were managed with percutaneous drainage, endoscopic hemostasis, and angiographic embolization. She was discharged with good clinical recovery. Postpartum pancreatitis, especially after cesarean section, is rare; however, its management is not different from that for usual pancreatitis.

Intraductal Papillary Mucinous Neoplasm with an Associated Invasive Carcinoma Manifested by Acute Pancreatitis / 대한췌담도학회지

Idiopathic acute pancreatitis (IAP) is defined as acute pancreatitis for which the standard initial evaluation has failed to reveal the etiology. Although a tumor is a rare cause of IAP, it is important to consider it in advance, because prognosis is poor if diagnosis is delayed. We describe a case of presumed IAP at the index presentation that was finally diagnosed as intraductal papillary mucinous neoplasm with an associated invasive carcinoma in a 70-year-old woman after surgery to remove a mass identified during follow-up endoscopic ultrasonography. Therefore, this is a case in which suspicion of malignancy and follow-up endoscopic ultrasonography helped to appropriately diagnose and treat the tumor.

The Effect of Cyclosporine on P-cadherin Expression in Experimental Diabetic Nephropathy and Glucose-Stimulated Podocytes / 대한신장학회잡지

PURPOSE: We investigated whether Cyclosporin A (CsA) had the anti-proteinuric effect in diabetic rats and whether it was associated with the alteration of P-cadherin expression. METHODS: Sprague-Dawley rats were injected with diluent (C, N=16) or streptozotocin intraperitoneally (DM, N=16). Eight rats in each group were treated with 10% ethanol or with 1.5 mg/kg/day of CsA (C+CsA and DM+CsA) for 6 weeks. Immortalized mouse podocytes were cultured in media with 5.6 mM glucose (LG), LG+CsA (10-8 M), LG+TGF-beta1, 30 mM glucose (HG), or HG+CsA. Real time-PCR and Western blot were performed for P-cadherin and TGF-beta1 mRNA and protein expression, respectively, with sieved glomeruli and cell lysates. RESULTS: Urinary albumin excretion was significantly higher in DM compared with C rats, and CsA treatment inhibited the increase in albuminuria in DM rats. Glomerular P-cadherin mRNA and protein expression in DM were decreased compared with C rats, and these decreases were significantly inhibited by CsA. Glomerular TGF-beta1 mRNA and protein expression were higher in DM than C rats, and CsA treatment inhibited the increase in TGF-beta1 expression in DM. P-cadherin mRNA and protein expression in HG and LG+TGF-beta1 podocytes were lower than LG cells, and these HG-induced decrements were restored by CsA. CONCLUSION: CsA treatment reduces urinary albumin excretion in DM rats. P-cadherin expression is decreased under diabetic conditions, which is ameliorated by CsA. In addition, inhibition of the increase in glomerular TGF-beta1 expression under diabetic conditions by CsA seems to restore the P-cadherin expression, resulting in the decrease in albuminuria.

Congenital Nephrogenic Diabetes Insipidus Presented with Bilateral Hydronephrosis: Genetic Analysis of V2R Gene Mutations

Most cases of hydronephrosis are caused by urinary tract obstruction. However, excessive polyuric syndrome rarely gives rise to non-obstructive hydronephrosis, megaureter, and a distended bladder. The authors report here on two cases of congenital nephrogenic diabetes insipidus (NDI) with severe bilateral hydronephrosis and megaureter. It is Interesting that the patients were symptomless except for their polyuria, and they both presented with bilateral hydronephrosis. Fluid deprivation testing revealed the presence of AVP resistant NDI. Gene analysis for these patients showed the AVP receptor 2 (V2R) missense mutations (Q225X and S126F), which have previously been reported on in other studies. We made the diagnosis of NDI by using a physiologic test, and we confirmed it by mutation analysis of the V2R gene.

Left Ventricular Longitudinal Diastolic Function and Functional Reserve in ESRD Patients Starting Dialysis Treatment / 대한신장학회잡지

BACKGROUND: Abnormalities of the left ventricular (LV) diastolic dysfunction are common in patients with end-stage renal disease (ESRD). Recently, Doppler tissue imaging (DTI) has been introduced as a method to evaluate diastolic function or myocardial relaxation by measuring mitral annulus velocity during diastole. This study was undertaken to assess resting diastolic function and diastolic functional reserve during exercise in ESRD patients starting dialysis treatment. METHODS: Mitral inflow velocities by Doppler echocardiography and septal mitral annular velocities by DTI were measured at rest and during supine bicycle exercise in 22 new ESRD patients and 23 age- and sex-matched subjects with normal renal function as a control. RESULTS: LV end-diastolic and end-systolic dimensions, septal thickness, and left atrial volume index were significantly higher in patients with ESRD compared with those of controls (p<0.01). LV ejection fraction was significantly lower in ESRD group (p<0.05). There were no significant differences in mitral inflow velocities (E, E/A, DT) between the two groups except A velocity, which was significantly higher in ESRD group (p<0.01). However, early diastolic mitral annular velocity (E') at rest (5.3+/-1.3 cm/sec vs. 6.5+/-1.5 cm/sec, p=0.013) and augmentation of E' with exercise (deltaE') were significantly lower in ESRD group compared with controls (at 25W exercise, 1.3+/-1.6 cm/sec vs. 4.0+/-3.0 cm/sec, p=0.002; at 50W exercise, 3.3+/-2.3 cm/sec vs. 6.5+/-5.3 cm/sec, p=0.030). CONCLUSION: Unlike conventional mitral inflow parameters, longitudinal resting diastolic function and diastolic functional reserve during exercise assessed by DTI were significantly reduced in ESRD patients starting dialysis treatment.

Clinical Characteristics of Nephrotic Syndrome Associated with Malignancy / 대한신장학회잡지

BACKGROUND: Even though there have been many case reports on nephrotic syndrome in patients with malignancy, an overall study on malignancy- associated nephrotic syndrome is rare in Korea. The purpose of this study was to explore the clinical and pathologic findings and clinical course of malignancy-associated nephrotic syndrome. METHODS: From January, 1986 to December, 2003, the medical records of patients with nephrotic syndrome and concomitant malignancy were retrospectively reviewed. RESULTS: Forty-eight patients (2.3%) out of 2, 085 patients with nephrotic syndrome had concomitant malignant disease during the study period. The mean age of patients was 57.9+-1.6 years with sex ratio of 2.4: 1. The most common primary origin of malignancy was liver (8 patients, 16.7%) and lungs (8 patients, 16.7%), and adenocarcinoma (17 patients, 35.4 %) was the leading histologic type of malignancy. There was no significant difference in 24-hour urinary protein excretion among patients grouped by TNM stage. Percutaneous renal biopsy was performed in 26 patients (54.2%), renal pathology revealed membranous nephropathy and minimal change disease in 9 patients (34.6%) each, membranoproliferative glomerulonephritis in 6 (23.1%), and IgA nephropathy in 2 patients (7.7%). When the patients were divided into progression and remission group based on the clinical course of underlying malignancy, there were significantly more patients with improved nephrotic syndrome in the remission group than the progression group (55.0% vs. 0%, p<0.05). CONCLUSION: Malignancy should be considered as a cause of nephrotic syndrome in adults, and the treatment of underlying malignancy may affect the outcome of nephrotic syndrome in patients with malignancy.

Clinical Characteristics of Non-diabetic Renal Disease in Type 2 Diabetic Patients / 대한신장학회잡지

BACKGROUND: Non-diabetic renal diseases are accompanied in 9-66% of type 2 diabetic patients and some clinical and laboratory findings are known as predictors of these non-diabetic renal disease. In Korea, however, there have been few studies on the clinical and pathologic findings of non-diabetic renal disease in diabetic patients. The purpose of this study was to explore the clinical, laboratory, and pathologic features of non-diabetic renal disease and to clarify the factors that could predict non-diabetic renal disease in type 2 diabetic patients. METHODS: The medical records of type 2 diabetic patients who were over 20 years old and underwent renal biopsy between January, 1994 and December, 2003, were retrospectively reviewed. RESULTS: A total of 56 patients were enrolled. Persistent hematuria (25.0%) was the leading reason for renal biopsy in type 2 diabetic patients, followed by sudden onset of nephrotic-range proteinuria (23.2 %), short duration (<10 years) of DM (23.2%), rapid deterioration of renal function (17.9%), and absence of diabetic retinopathy (8.9%). Renal biopsy revealed diabetic nephropathy (DN) in 20 patients (35.7%), non-diabetic renal disease (NDRD) in 33 patients (58.9%), and NDRD with concomitant DN in 3 patients (5.4%). The most common NDRD was membranous nephropathy, accompanied in 9 patients (16.1 %), followed by minimal change disease (10.7%), focal segmental glomerulosclerosis (8.9%). When the patients were divided into DN (20 patients) and NDRD (36 patients) groups, NDRD group had significantly shorter duration of DM, more patients with hematuria, and less patients with DM retinopathy. In contrast, there were no differences in age, sex, blood pressure, blood urea nitrogen, serum creatinine, albumin, and total cholesterol levels, 24 hr urinary protein and albumin excretion, creatinine clearance, and proportion of patients with DM neuropathy between the two groups. CONCLUSION: There were significant differences in the duration of DM, the presence of hematuria, and the presence of retinopathy between DN and NDRD groups. Therefore, we must consider NDRD in type II DM patients with short duration of DM, hematuria or without retinopathy.

The Study on the Mechanism Regulating the Production of Extracellular Matrix in Renal Tubular Epithelial Cells Cultured in High Glucose Concentration / 대한신장학회잡지

Thickening of tubular basement membrane and progressive tubulointerstitial fibrosis has been reported as important components of diabetic nephropathy, In order to investigate the mechanisms of tubulinterstitial changes in diabetic nephropathy, we evaluated the effects of a high concentration of glucose(25mM; 450mg/dL) on glucose transporter GLUT1 level, fibronectin production and tissue inhibitors of metalloproteinases (TIMP)-1 concentration in renal tubular(LLC-PK1) cells. As the effect of high glucose-induced alteration in LLC-PK1 cells, the expression of facilitative glueose transporter, GLUT1 was decreased after longer than 24-hours exposure to 25mM glucose, compared to control(5.6mM). The administration of protein kinase C (PKC) inhibitor GF109203X(10 microM) did not show significant effect on high glucose-induced decrease of GLUT1 level. On western blot analysis of fibronectin production, The exposure of LLC-PK cells to 25mM glucose for 48 hours significantly increasc4 fibro- nectin production, dose-dependently. The addition of GF102903X at the concentration of 10pM induced the significant increase of fibronectin level in LLC-PK1cells under glucose-free condition, whereas there was no significant effect on the high glucose-induced increase of fibronectin production. The addition of anti-TGF-beta antibody at 30 microgram/mL partly inhibited the high glucose-induced increase of fibronectin production. Concerning the changes of tissue inhibitor of metallo-proteinase(TIMP)-1 levels in the presence of high glucose, the exposure to high glucose for 24 and 43 hours increased TIMP-1 levels in culture supernatant of LLC-PK1 cells, dose-dependently. The TIMP-1 levels of 48-hour exposure to 15 and 25mM glucose were also significantly higher than those of 24-hourexposure. The treatment with 10 microM GF102903X or 30 microgram/mL anti-TGF-Beta antibody had no significant effects on TIMP-1 levels measured under the high glucose culture condition. In conclusion, the expression of facilitative glucose transporter, GLUT1 is inhibited and the production of fibronectin is increased in renal tubular cells cultured in the presence of high concentration of glucose, which is partly mediated by TGF-beta. The TIMP-1 level is also increased under high glucose culture condition. The enhanced productions of fibronectin and TIMP-1 of renal tubular cells under high glucose concentration may contribute to tubulointerstitial fibrosis that occurs in diabetic nephropathy.

Clinical Outcome and Prognostic Factors of Biopsy-proven Diffuse Proliferative Lupus Nephritis / 대한신장학회잡지

Lupus nephritis is a major cause of morbidity and mortality arising from systemic lupus erythematous. It is generally acknowledged that the presence of diffuse proliferative lupus nephritis(DPLN) is highly predictive of a poor prognosis in terms of renal and patient out- come on survival. The objective of this study was to evaluate the clinicopathologic characteristics, renal out- come according to therapeutic regimen, and prognostic factors of biopsy-proven diffuse proliferative lupus nephritis. Among the biopsy-proven lupus nephritis patients who were admitted to Yonsei University Medical Center from January 1986 to June 1997, 36 patents who were diagnosed DPLN by renal biopsy and treated for at least 6 months and regularly followed-up for at least 12 months were included. We retrospec-tively reviewed the medical recorders. Patients were treated with steroid regimen with or without cyclo-phosphamide. According to the therapeutic response, patients were divided into two groups : a therapeutic response group(n=24), and a therapeutic non-response group

A case of endobronchial aspergilloma

Pulmonary aspergillosis may be classified under three categories, depending upon whether the host is atopic or immunocompromised: invasive aspergillosis, allergic bronchopulmonary aspergillosis (ABPA) or aspergilloma. However, it is not always possible to effectively categorize this disease. We experienced a case of endobronchial aspergilloma, which was difficult to categorize, in a healthy male patient. The chest X-ray and computed tomography showed an ill-defined nodule mimicking lung cancer. Fiberoptic bronchoscopy revealed an aspergilloma without cavity formation in the left lower laterobasal segmental bronchial orifice. The aspergilloma was removed and the patient's symptoms were relieved. We present this unusual case with a review of the literature.

Phase IV Study on the Antihypertensive Effect and Safety of Irbesartan in Patients with Mild to Moderate Hypertension and Renal Disease / 대한신장학회잡지

Irbesartan is a new selective angiotensin II subtype 1 receptor antagonist. We evaluated the efficacy and tolerability of irbesartan in patients with mild to moderate hypertension and renal disease. On 24 hypertensive patients, oral irbesartan 150mg a day was administered. In cases whose seated diastolic blood pressure did not decrease to 85mmHg after treatment for 4 weeks, the dose of irbesartan was increased to 300mg per day. Every 4 weeks, blood pressure, heart rates, and adverse effects were monitored. And we assessed WBC counts, hemoglobin, hematocrits, platelets, creatinine, BUN, total protein, albumin, fasting blood sugar, total cholesterol, AST, ALT, alkaline phosphatase, total bilirubin, sodium, potassium, calcium, uric acid and urine protein/creatinine ratio to evaluate the change of renal and hepatic function and other adverse effects. Seated systolic blood pressure was decreased from 157.1+/-3.1mmHg to 135.5+/-3.7mmHg, and seated diastolic blood pressure was also decreased from 99.2+/-1.7mmHg to 84.3+/-2.5mmHg. Irbesartan was effective in lowering blood pressure in 20 among 24 patients, and the effective rate of this drug was 83.3%. After treatment, a non clinically significant increase of heart rates and statistically significant decrease of total cholesterol level were noted. There was no dose-related adverse effect. We conclude that irbesartan is a safe and effective angiotensin II subtype 1 receptor antagonist for lowering blood pressure in patients with mild to moderate hypertension and renal disease.

A Case of True Hermaphroditism Masquerading as Testicular Tumor / 대한비뇨기과학회지

True hermaphroditism represents the rarest of all intersex disorders. The condition is defined by the presence of both ovarian and testicular tissue in the same individual. True hermaphroditism is usually diagnosed during the newborn period in the course of evaluating ambiguous genitalia. We present an unusual case of a 15-year-old boy with phenotypically normal male genitalia and bilaterally descended ovotestis, who was seen for evalution of intermittent scrotal swelling and pain.

A Case of Micropapillary Transitional Cell Carcinoma of the Urinary Bladder / 대한비뇨기과학회지

More than 90% of bladder cancers are transitional cell carcinomas. Transitional cell carcinoma of the urinary bladder ordinarily does not pose diagnostic difficulties and is well known its clinical behavior. However, variation from the classic histology can cause problems in recognition. Recently several variants of transitional cell carcinoma of the urinary bladder have been described to promote the recognition of, or to draw attention to, possible differences in clinical behavior. The presence of a micropapillary component in transitional cell carcinoma is associated with high-stage and high-grade transitional cell carcinoma with a tendency of vascular invasion, and with poor prognostic histologic feature. We report a case of micropapillary transitional cell carcinoma of the urinary bladder.