Impact of chronic total coronary occlusion on microvascular reperfusion in patients with a first anterior ST-segment elevation myocardial infarction.

BACKGROUND: We investigated an impact of the presence of chronic total coronary occlusion (CTO) in a non-infarct related coronary artery on microvascular reperfusion in patients with a first anterior ST-segment elevation myocardial infarction (STEMI) who underwent percutaneous coronary intervention (PCI). METHODS: In accordance with the presence or absence of CTO in a non-infarct related coronary artery, we analyzed Thrombolysis in Myocardial Infarction myocardial perfusion (TMP) grade on a scale of 0 to 3, with higher scores indicating better perfusion, and ST-segment resolution in sum of lead I, aVL, and V1 through V6 to evaluate microvascular reperfusion in a total of 140 consecutive patients with a first anterior STEMI. RESULTS: We identified CTO in 15 patients (11% of total). The incidence of impaired microvascular reperfusion was greater in patients with CTO vs without CTO, defined as TMP grades 0 or 1 together with <30% ST-segment resolution (33% vs 6%, respectively; P=.0006) and the enzymatic infarct was larger (10304 ± 8060 IU/L vs 6804 ± 4959 IU/L; P=.009). Logistic regression analysis revealed that CTO is closely associated with incidental impaired microvascular reperfusion (odds ratio, 6.801; 95% confidence interval, 1.284-36.209; P=.024). CONCLUSION: The presence of CTO in a non-infarct related coronary artery might confer a considerable disadvantage upon microvascular reperfusion and result in adverse clinical outcomes of PCI for a first anterior STEMI.

[Ratio of serum levels of 1,25-dihydroxyvitamin D3 and parathyroid hormone for the diagnosis and treatment of tuberculous peritonitis in a chronic kidney disease patient: a case report].

An 80-year-old man was admitted to our hospital because of exacerbation of preexisting chronic kidney disease (CKD). On admission, he showed elevated levels of serum creatinine (6.37 mg/dL) and corrected calcium (13.7 mg/dL). Although the serum levels of intact parathyroid hormone (I-PTH) and parathyroid hormone-related peptide(PTITH-rP)were low, the serum 1,25-dihydroxyvitamin D3 (1,25 (OH)2D3)levels were high. Computed tomography (CT) revealed ascites, and the ascitic fluid was exudative and serous with predominance of lymphocytes. The levels of adenosine deaminase (ADA) in the ascitic fluid were also elevated, and the results of QuantiFERON-TB2G (QFT-2G)assay were positive, indicating tuberculous peritonitits. Ascites resolved rapidly after initiation of the antituberculosis therapy. The elevated levels of serum calcium and 1,25 (OH) 2D3 returned to below-normal levels; however, serum i-PTH levels increased from 8.9 pg/ mL to 432 pg/mL. Diagnosis of extrapulmonary tuberculosis is often difficult in CKD patients. CKD patients show abnormal vitamin D activation, so these patients usually have low levels of serum 1,25(OH)2D3. On the other hand, in our patient, 1,25(OH)2D3 was extrarenally produced from tuberculous granuloma and therefore, he showed high levels of serum 1,25(OH)2D3 and correspondingly, low levels of serum i-PTH. We observed that the ratio of 1,25 (OH) 2D3:i-PTH decreased due to antituberculosis therapy. This ratio facilitated the diagnosis and evaluation of treatment for this condition.

Long-term outcomes of idiopathic membranous nephropathy in Japanese patients treated with low-dose cyclophosphamide and prednisolone.

BACKGROUND: Treatment with cyclophosphamide and steroids for idiopathic membranous nephropathy (IMN) is effective in Caucasian patients, but the cumulative cyclophosphamide dosage exceeds 10 g and includes steroid pulse therapy. Adverse effects and difficulties with repeating treatment are major limitations. We studied the long-term outcomes of low-dose cyclophosphamide and prednisolone therapy in Japanese patients, who were thought to have relatively benign IMN compared with Caucasian patients. METHODS: This is a prospective cohort study of 103 consecutive Japanese patients with IMN and nephrotic syndrome. Patients were treated with cyclophosphamide (50 mg/day for the first 3 months and 25 mg/day for the next 3 months) and prednisolone (30 mg/day for the first week and the dosage was gradually tapered to withdraw by 2 years). Additional therapies were allowed for initial treatment failure or relapse. RESULTS: With a mean observation period of 8.5 years, 90 patients (87.4%) achieved proteinuria of <1 g/day and 78 (75.7%) achieved complete remission. A total of 27 patients did not respond to initial treatment and 30 patients had relapses after remission. Of these patients, 39 received additional therapies. At the last observation, 12 patients had developed renal insufficiency (S-Cr >1.5 mg/dL) but only 2 patients had reached renal death. Multivariate analysis revealed that the duration without remission was the strongest risk factor for renal prognosis. There were 14 deaths, and 8 patients developed cancers during the observation period. CONCLUSION: Treating nephrotic IMN in Japanese patients with low-dose cyclophosphamide and prednisolone is beneficial for long-term renal prognosis with relatively few adverse effects.