Outcome of patients with lithium poisoning at a far-east poison center

INTRODUCTION

Lithium is a popular medication for bipolar disorder, but very little work has been done to study Asian patients with lithium poisoning.

METHODS

A total of 21 out of 7140 poisoned patients were referred for management of lithium poisoning between 2000 and 2009. Patients were stratified according to blood lithium level, that is mild-to-moderate (<2.5 mEq/L) or severe (≥2.5 mEq/L) poisoning. Demographic, clinical, and laboratory data were obtained for analysis. Mortality rates were also analyzed.

RESULTS

There were no significant differences between both groups for the baseline variables such as poisoning patterns, age, sex, smoking habit, alcohol consumption, or medical history of diabetes mellitus or hypertension (p > 0.05). Patients with severe poisoning had a greater distribution of severe neurological symptoms (mild/moderate/ severe: 11.1%/44.4%/44.4% versus 58.35%/16.65%/8.3%, p < 0.05), cardiovascular symptoms (66.6% versus 16.6%, p < 0.05), and renal impairment (urea nitrogen/creatinine: 27.1 ± 17.8/ 1.9 ± 1.3 mg/dL versus 14.1 ± 7.1/ 1.3 ± 0.6 mg/dL, p < 0.05) than patients with mild-to-moderate poisoning. Most patients were treated with saline diuresis (9 patients [100%] with severe poisoning versus 9 patients [75.0%] with mild-to-moderate poisoning, p > 0.05). Hemodialysis was initiated in 2 (22.2%) of 9 and 1 (8.3%) of 12 patients with severe and mild-to-moderate poisoning, respectively (p > 0.05). The treatment was successful and all patients recovered without chronic sequelae. Thus, these favorable outcomes were comparable to the data from other international Poison Centers.

CONCLUSIONS

Given the excellent outcomes of detoxification protocols, patients undergoing lithium therapy must be closely monitored for its toxicity and treated immediately in case of poisoning.

Influence of predialysis comorbidity and damage accrual on mortality in lupus patients treated with peritoneal dialysis

Objective: Although there have been many studies on systemic lupus erythematosus (SLE) patients, there are few data about survival analysis of lupus patients receiving dialysis. Therefore, the objective of this study is to analyze risk factors predicting mortality in lupus patients treated with peritoneal dialysis (PD). In addition, we also delineate the relationship between predialysis comorbid illnesses, damage accrual, and mortality in lupus patients undergoing PD. Methods: This longitudinal cohort study included 38 lupus patients undergoing PD between 1990 and 2008. The clinical parameters, disease activity (non-renal SLEDAI, nrSLEDAI), comorbid illnesses, and damage accrual were collected. We applied the Charlson Comorbidity Index (CCI), Khan Index, and Davies Index to elucidate the impact of predialysis comorbidity on mortality. Moreover, we examined prognostic value of predialysis SDI (Systemic Lupus International Collaborating Clinics Disease Damage Index) for lupus PD patients. Results: There were 33 women and five men included for analysis. The mean age at PD entry was 32.2 ± 10.4 years and mean duration of PD was 39.7 ± 22.4 months. The nrSLEDAI score during PD significantly decreased, compared to the predialysis one (2.13 ± 2.09 vs. 4.00 ± 3.08, p < 0.001). All comorbidity indices and SDI scores were significantly and positively correlated with each other (p < 0.001). Univariate Cox regression analysis showed that serum creatinine level, date at PD entry, and the CCI were predictors for mortality. The predialysis nrSLEDAI and SDI scores did not have roles in predicting mortality of lupus PD patients. Conclusions: The predialysis CCI, instead of SDI, determines an increased risk for mortality in lupus patients treated with PD. The prognosis of lupus patients treated with PD largely depends on the severity of predialysis comorbidity, especially cardiovascular diseases.

Blood lead levels association with 18-month all-cause mortality in patients with chronic peritoneal dialysis

BACKGROUND

The clinical significance of blood lead levels (BLLs) in chronic peritoneal dialysis (CPD) patients was undetermined prior to this study.

METHODS

A total of 315 patients on CPD were included in this 18-month prospective study. BLLs measured at baseline were categorized according to a BLL tertile of high (>8.66 microg/dL), middle (5.62-8.66 microg/dL) and low (<5.62 microg/dL) for cross-sectional analyses. Mortality and cause of death were recorded for longitudinal analyses.

RESULTS

At baseline, patients with high BLLs had a trend of higher parathyroid hormone and lower residual renal function than patients in other groups. Stepwise multiple regression analysis found that parathyroid hormone positively correlated and residual renal function negatively correlated with logarithmic-transformed BLLs in CPD patients after other confounders were adjusted. At the end of follow-up, 37 (11.7%) patients had died. Kaplan-Meier analysis showed that patients with high BLLs had greater mortality than those with middle and low BLLs (P = 0.008). Cox multivariate analysis showed that, using the low BLL group as the reference, basal high BLLs (hazard ratio [HR] = 3.745, 95% confidence interval [95% CI] = 1.218-11.494, P = 0.001) and middle BLLs (HR = 1.867, 95% CI = 1.618-2.567, P = 0.001) were associated with increased HR for all-cause mortality for CPD patients. There is a significant trend (P < 0.001) of HR for mortality trend tests among the three study groups.

CONCLUSIONS

BLLs are associated with residual renal function and hyperparathyroidism and are related to increased HR for all-cause 18-month mortality in CPD patients.

Proliferation of myofibroblasts in the stroma of renal oncocytoma

OBJECTIVES

Myofibroblasts are a vital component of stroma of many malignant neoplasms, but it is not yet established whether stromal myofibroblasts also exist in benign tumours such as oncocytoma of the kidney.

MATERIALS AND METHODS

Histomorphological and immunohistochemical analysis of 16 renal oncocytomas diagnosed at Chang Gung Memorial Hospital, Taiwan, has been performed.

RESULTS

Renal oncocytomas were composed of oncocytes, large cells with granular eosinophilic cytoplasm, arranged mostly in sheets, in tubulocystic or combined pattern. Few oncocytes appeared to be undergoing proliferation or apoptosis. MIB-1 and active caspase 3 indices were low, but higher in tumour than in surrounding non-tumour parenchyma (MIB-1: 0.93 +/- 0.09 versus 0.46 +/- 0.07, P < 0.001 and active caspase 3: 0.76 +/- 0.08 versus 0.41 +/- 0.09, P < 0.001). Wnt/beta-catenin signalling was not implicated in this neoplasm, as there was no loss of E-cadherin membranous localization or expression of intranuclear beta-catenin in the cells. Clumps of oncocytes were stained with periodic acid Schiff and had collagen I-, collagen III- and fibronectin-positive, but desmin- and human caldesmon-negative stromas. Importantly, alpha-smooth muscle actin (SMA)-immunostaining established the myofibroblastic nature of many of the stromal cells. Some of the myofibroblasts were also positive for MIB-1, indicating a proliferative role for them in the stroma.

CONCLUSIONS

Renal oncocytomas were composed of two independent compartments: benign oncocytes and pronounced fibrotic stroma, which consisted of proliferating myofibroblasts (SMA- and MIB-1-positive) which were associated with excessive deposition of extracellular matrix (periodic acid Schiff-component, collagen I-, collagen III- and fibronectin-positive, and desmin- and human caldesmon-negative).

Suicide victim of paraquat poisoning make suitable corneal donor

This report addresses the possibility of expanding transplant corneal donor pool by inclusion of more patients who have suffered poisoning with paraquat pre-mortem. A 27-year-old depressed man committed suicide by ingesting 50 mL of 24% paraquat (Gramoxone, Syngenta, Taiwan). He was treated aggressively with gastric lavage, with large amounts of normal saline, followed by infusion of activated charcoal and magnesium citrate. Blood paraquat level was 1.90 μg/mL. Charcoal hemoperfusion was performed for 8 hours using a charcoal-containing dialysis machine. Furthermore, pulse therapies of cyclophosphamide (15 mg/kg/day for 2 days) and methylprednisolone (1 g/day for 3 days) were administered, followed by dexamethasone (20 mg/day for 14 days). Methylprednisolone pulse therapy was repeated since PaO(2) on the 15th day of poisoning was <60 mm Hg. Chest radiography demonstrated diffuse ground glass opacities of both lungs, with thickening of the intralobular interstitium, compatible with interstitial pneumonitis. Arterial blood gas found persistent hypoxemia and large alveolar-arterial oxygen tension differences. Respiratory failure developed on the 21st day and he was intubated for mechanical ventilatory support. As the patient expressed his wish for organ donation, the corneas were harvested after expiration on the 22nd day. His corneas were transplanted in two recipients and visual acuities of the recipients were doing well at 6 months after transplantation.

Spectrum of corrosive esophageal injury after intentional paraquat ingestion

INTRODUCTION

This is an observational study that examines the clinical features, the degrees of esophageal injury, physiological markers, and clinical outcomes after paraquat ingestion and seeks to determine what association, if any, may exist between these findings.

METHODS

The study included 16 of 1410 paraquat subjects who underwent endoscopies at Chang Gung Memorial Hospital between 1980 and 2007.

RESULTS

Corrosive esophageal injuries were classified as grade 1 in 8, 2a in 5, and 2b in 3 patients. No patients had grade 0, 3a, or 3b esophageal injuries. After paraquat ingestion, systemic toxicity occurred, with rapid development of hypoxia, hepatitis, and renal failure in many cases. Hypoxia occurred in 1 (12.5%), 5 (100%), and 3 (100%) patients with grades 1, 2a, and 2b esophageal injury, respectively. There were more hypoxic patients with grades 2a and 2b than those with grade 1 esophageal injury (P < .05). The nadir Pao(2) was lower in patients with grades 2a and 2b than those with grade 1 esophageal injury (P < .05). However, there were no significant differences in terms of acute hepatitis, peak serum alanine aminotransferase, acute renal failure, and peak serum creatinine between the 3 groups (P > .05). Kaplan-Meier analysis did not find any difference in survival between the groups (P > .05).

CONCLUSION

Paraquat, a mild caustic agent, produces only grades 1, 2a, and 2b esophageal injury. Our findings showed a potential relationship between the degree of hypoxia, mortality, and degree of esophageal injury, although such a low number of study subjects limits the conclusions that can be made by this study.

Glycated hemoglobin predicts mortality in nondiabetic patients receiving chronic peritoneal dialysis

BACKGROUND

patients with chronic peritoneal dialysis (CPD) use glucose-based dialysate to maintain their life; however, whether the glycemic status influences outcome of these patients without diabetes remains unknown.

METHODS

we conducted a cross-sectional and 18-month prospective study, and 269 nondiabetic patients with CPD were enrolled in a medical center. Glycated hemoglobin (HbA1c) levels were measured at baseline and categorized in tertiles of HbA1c: high (>5.4%), middle (5.1-5.4%) and low normal (<5.1%). Mortality and cause of death were recorded for longitudinal analyses.

RESULTS

the study results showed high HbA1c group patients had a trend of being older and having higher body mass index (BMI) than other group patients. Stepwise multiple linear regression analysis showed HbA1c was positively related to age, BMI and the peritoneal solute transport rate. After 18 months of follow-up, Cox multivariate analysis showed that HbA1c (HR: 4.114; 95% CI: 1.426-11.872; p = 0.009) was the significant risk factor for all-cause mortality after relating variables were adjusted. Moreover, high HbA1c (HR: 3.892; 95% CI: 1.273-11.959; p = 0.026) and low HbA1c (HR: 1.179; 95% CI: 1.160-1.198; p = 0.039), with middle HbA1c group as the reference, also significantly predicted for mortality in these patients.

CONCLUSIONS

HbA1c levels, or presence of low or high HbA1c, are associated with 18-month all-cause mortality in nondiabetic patients with CPD.

Peritoneal dialysis and hemodialysis in systemic lupus erythematosus patients: comparison of clinical outcomes

BACKGROUND

This study compared peritoneal dialysis (PD) and hemodialysis (HD) outcomes between female systemic lupus erythematosus (SLE) patients with end-stage renal disease (ESRD) due to lupus nephropathy.

METHODS

22 female SLE patients undergoing PD were compared with 14 female SLE patients receiving HD. Clinical outcomes and infective complications were reviewed.

RESULTS

The overall mortality rate was much higher in the PD group (6/22) than in the HD group (1/14) (p = 0.027). PD patients had higher C-reactive protein level (37.1 +/- 41.4 vs. 6.7 +/- 9.5 mg/l, p = 0.037) and numbers of infectious episode (PD vs. HD: 1 episode per 33.16 patient-months vs. 1 episode per 118.26 patient-months, respectively, p = 0.046). Before the end of the observation period, HD patients had higher serum albumin (3.8 +/- 0.2 vs. 3.3 +/- 0.6 g/dl, p = 0.01).

CONCLUSIONS

In female SLE patients with ESRD due to lupus nephropathy, clinical outcomes are better after undergoing HD than after undergoing PD.

Spontaneous rupture of adrenocortical carcinoma: a coincidence or a tendency?

We report a rare case of adrenocortical carcinoma spontaneously rupturing. To our knowledge, this is the sixth reported case in literature that is not related to any preceding traumatic incidents or predisposing disease. Upon reviewing previous cases, tumor size greater than 10 cm in adults is a predisposing factor for spontaneous rupture, while the degree of lymph node invasion or the extent of distant metastasis is not indicative. Further study is warranted to validate our finding, but we suggest that if an adrenal tumor suspicious of malignant presentation is found incidentally, the size of tumor may warrant a more aggressive approach for prevention of tumor rupture and decrease in patient morbidity and mortality.

Bifurcated Abdominal Aorta, with a Coarctation over the Right Branch of the Bifurcated Abdominal Aorta and Aberrant Renal Arteries Originating from the Left Branch of the Bifurcated Abdominal Aorta

This study describes an unusual case of secondary hypertension in a young female patient presenting with severe hypertension and abdominal bruits. Gadolinium-enhanced MRA revealed a clearly bifurcated abdominal aorta, with a coarctation over the right branch of the bifurcated abdominal aorta and aberrant renal arteries originated from the left branch of the bifurcated abdominal aorta. Of interest is conventional angiography had failed to reveal these vascular abnormalities. This study mentions both embryologic and clinical aspects of this developmentally abnormal bifurcated abdominal aorta, coarctation of abdominal aorta and aberrant renal arteries.

Renal Oncocytoma in Taiwan

BACKGROUND

Renal oncocytoma has been repeatedly reported in Western countries, but only a few cases have been reported in Eastern countries. This study aims to review the clinical course of renal oncocytoma in an Eastern country such as Taiwan.

MATERIALS AND METHODS

Sixteen cases of renal oncocytoma seen between 1987 and 2002 at Chang Gung Memorial Hospital, Taipei, Taiwan, were studied.

RESULTS

Preoperatively, all patients were diagnosed to have renal cell carcinoma, following various radiologic studies. Perioperatively, frozen sections of three patients indicated renal oncocytoma in two and renal cell carcinoma in one. Renal oncocytoma has marked similarities to renal cell carcinoma, according to various radiologic, cytologic, and pathological investigations, so an accurate diagnosis is difficult to achieve, either preoperatively or perioperatively. Therefore, rather than being treated with partial nephrectomy, all patients were treated aggressively with unilateral radical nephrectomy. Postoperatively, all 16 patients were followed up, from 12 to 189 months, with a mean of 58.7 months. Notably, all patients survived with no evidence of tumor recurrence.

CONCLUSIONS

The experience in Taiwan is generally that renal oncocytoma behaves benignly, as reported in other areas. The excellent prognosis associated with this tumor appears to indicate that partial nephrectomy may suffice for removing the tumor, while sparing other unaffected renal parenchyma.

Association of environmental cadmium exposure with inflammation and malnutrition in maintenance haemodialysis patients

BACKGROUND

Chronic inflammation and malnutrition are associated with increased risk of cardiovascular death, and may cause protein-energy wasting in individuals with chronic kidney disease. Raised blood cadmium (Cd) levels were observed in maintenance haemodialysis (HD) patients in previous studies. However, the correlation of Cd exposure with inflammation and malnutrition remains uncertain. This study examined the possible adverse effects of environmental Cd exposure in maintenance HD patients.

METHODS

A total of 954 maintenance HD patients were enrolled and divided into four equal-sized groups based on blood Cd levels. Geographic, haematological, biochemical and dialysis-related data were obtained. The analysis included values for nutritional and inflammatory markers.

RESULTS

Abnormal blood Cd levels (> or =1 microg/L) were exhibited in 26.8% (256/954) of studied subjects. More subjects in the highest quartile group were malnourished (chi- square = 23.27; P < 0.0001) and had inflammatory changes (chi-square = 13.99; P = 0.0029) than in the lowest quartile group. Stepwise multiple regression analysis revealed a significant inverse correlation between serum albumin and blood Cd levels. Notably, a 10-fold increase in blood Cd levels was associated with a 0.06 g/dL decrease in serum albumin levels (P = 0.0060). Multivariate regression analysis also demonstrated a positive correlation between inflammatory risk (high-sensitivity C-reactive protein >3 mg/L) and blood Cd levels. The risk ratio of inflammation with a 10-fold increase in blood Cd levels was 1.388 (95% CI: 1.025-1.825, P = 0.0336).

CONCLUSIONS

Environmental Cd exposure is significantly associated with malnutrition, inflammation and even protein-energy wasting in maintenance HD patients. It is important for this population to avoid diets with high Cd concentrations and smoking.

Course and outcome of dialysis pericarditis in diabetic patients treated with maintenance hemodialysis

INTRODUCTION

This observational study investigated the course and outcome of dialysis pericarditis in diabetic dialysis patients, as previous reports found that in contrast to uremic pericarditis, which responds in most cases to intensive hemodialysis, dialysis pericarditis resolves with intensification of hemodialysis in fewer cases.

METHODS

From 2002 through 2006, 88 maintenance hemodialysis patients (47 diabetic and 41 non-diabetic) were referred for management of dialysis pericarditis.

RESULTS

Dialysis pericarditis in 85.1% of diabetic and 82.9% of non-diabetic patients improved following institution of intensive hemodialysis. For the few unresponsive and critical cases, 8.5% of diabetic and 7.3% of non-diabetic patients received pericardiocentesis, whereas 6.4% of diabetic and 9.8% of non-diabetic patients received surgical drainage. In terms of outcome, 85.1, 4.3 and 10.6% of diabetic patients were alive without recurrence, alive with recurrence and deceased, respectively. There was no significant difference with their non-diabetic counterparts, for which the percentages were 87.8, 4.9 and 7.3%, respectively (p > 0.05). Kaplan-Meier analysis did not find any significant difference in survival as well (p > 0.05).

CONCLUSION

Whether used in diabetics or not, intensive hemodialysis remains the primary and most effective dialysis pericarditis treatment, whereas pericardiocentesis or surgical drainage should be reserved for the few unresponsive and critical cases.

Blood eosinophilia, corticoadrenal insufficiency and eosinophilic cystitis

Blood eosinophilia generally indicates an underlying allergic, infectious or hematologic disease. Corticoadrenal insufficiency is known to be another cause of blood eosinophilia. Eosinophilic cystitis is a rare disease in which the bladder wall is infiltrated by eosinophils; however, the etiology of eosinophilic cystitis remains unclear. We report a case of corticoadrenal insufficiency with blood eosinophilia developing gross hematuria and eosinophilic cystitis. The patient was treated with medical therapy, including oral corticosteroids, obtaining excellent results.

Blood lead levels, malnutrition, inflammation, and mortality in patients with diabetes treated by long-term hemodialysis

BACKGROUND

Blood lead levels (BLLs) are associated with mortality in the general population. The clinical significance of BLLs in long-term hemodialysis (HD) patients with diabetes is unknown.

STUDY DESIGN

A cross-sectional and 1-year prospective study.

SETTINGS & PARTICIPANTS

211 patients with diabetes on long-term HD therapy at 3 centers.

PREDICTOR

BLLs measured before HD at baseline, categorized as abnormal (>20 microg/dL), high normal (10 to 20 microg/dL), and low normal (<10 microg/dL).

OUTCOMES & MEASUREMENTS

Malnutrition, defined as serum albumin level less than 3.6 g/dL, and inflammation, defined as high-sensitivity C-reactive protein level greater than 3 mg/dL, for cross-sectional analyses. Mortality and cause of death for longitudinal analyses.

RESULTS

34, 112, and 65 patients had abnormal, high-normal, and low-normal BLLs at baseline. At baseline, patients with abnormal BLLs had a greater proportion of malnutrition (14.7% versus 1.5% and 11.6%; P = 0.01) and inflammation (76.5% versus 52.3% and 50.9%; P = 0.01) than those with low- and high-normal BLLs. Backward stepwise regression analysis found that high-sensitivity C-reactive protein level correlated positively and albumin level correlated negatively with BLLs after other confounders were adjusted. At the end of follow-up, 16 patients had died. Kaplan-Meier analysis showed that patients with an abnormal BLL had greater mortality than those with low and low-normal BLLs (P = 0.004).

LIMITATIONS

Small sample size, sparse outcomes, and limited follow-up.

CONCLUSIONS

BLL may contribute to inflammation and nutritional status in long-term HD patients with diabetes on long-term HD therapy and may relate to 1-year mortality in these patients.

The quality of hemodialysis in patients with mental retardation

BACKGROUND

Mentally retarded renal failure patients receiving hemodialysis (HD) comprise a small group of HD patients. There was no previous study describing how to manage these patients during HD and if they could achieve adequate dialysis quality.

METHODS

We reported seven cases of mentally retarded patients with renal failure among 1224 patients receiving hemodialysis. Demographic and medical data were obtained from chart reviews and hospital information system. Parameters for dialysis quality were calculated.

RESULTS

These mentally retarded patients ranged from 19 to 34 years of age (mean: 27.5 +/- 5.0 year-old), with six females and one male. The HD duration ranged from 24 to 84 months (mean: 54.6 +/- 27.2 months). The most common problem the medical stuff would encounter when they care mentally retarded dialysis patients is the maintenance of a smooth HD process due to the non-cooperation of these patients. Physical restriction or sedative agents such as diazepam, alprazolam, or chloral hydrate were prescribed in these patients for their irritability during HD session. All seven patients had good family support and care. The dialysis adequacy and nutritional parameters of these patients all met the guidelines suggested by the National Kidney Foundation Dialysis Outcome Quality Initiative (K/DOQI).

CONCLUSION

Mentally retarded uremic patients can have good dialysis quality.

Transforming growth factor-beta1 decreases epithelial sodium channel functionality in renal collecting duct cells via a Smad4-dependent pathway

BACKGROUND

Transformation growth factor-beta1 (TGF-beta1) inhibits transepithelial sodium transport and suppresses the epithelial sodium channel (ENaC) in many different types of epithelial cells; however, the molecular mechanism of this effect in the kidney is still not clear. The aim of this study was to examine the regulation of transepithelial sodium transport by TGF-beta1 in renal cells.

METHODS

We derived stable mouse cortical collecting duct cell lines that overexpressed Smad4 or N-termianl truncated Smad4, and studied the effects of TGF-beta1 on them. The equivalent electrical current (I(eq)) was taken as representing transepithelial current and the amiloride sensitive short circuit current (AmsIsc) as representing the ENaC activity. We used real-time PCR to quantify the expression of ENaC and measurement of the luciferase activity of cells transiently transfected with a mouse alpha-ENaC promoter to assess the alpha-ENaC promoter activity. Result. The administration of TGF-beta1 decreased I(eq), mainly as a result of the decrease of AmsIsc, and it correlated with inhibition of the alpha-ENaC mRNA expression. The overexpression of Smad4 led to a decrease in AmsIsc, alpha-ENaC mRNA and alpha-ENaC promoter activity, but the overexpression of the N-terminal truncated Smad4 did not induce these changes. The TGF-beta1-induced reduction of AmsIsc was alleviated in the N-terminal truncated Smad4-overexpressed cells.

CONCLUSION

It appears that the N-terminus region of Smad4 is indispensable in Smad4-mediated inhibition of the transepithelial sodium transport. TGF-beta1 may decrease the ENaC functionality via a Smad4-dependent pathway.

The gastrointestinal tract stem cell niche

The gastrointestinal epithelium is unique in that cell proliferation, differentiation, and apoptosis occur in an orderly fashion along the crypt-villus axis. The intestinal crypt is mainly a proliferative compartment, is monoclonal and is maintained by stem cells. The villus represents the differentiated compartment, and is polyclonal as it receives cells from multiple crypts. In the small intestine, cell migration begins near the base of the crypt, and cells migrate from here emerging onto the villi. The basal crypt cells at position 5 are candidate stem cells. As the function of stem cells is to maintain the integrity of the intestinal epithelium, it must self-renew, proliferate, and differentiate within a protective niche. This niche is made up of proliferating and differentiating epithelial cells and surrounding mesenchymal cells. These mesenchymal cells promote the epithelial- mesenchymal crosstalk required to maintain the niche. A stochastic model of cell division has been proposed to explain how a single common ancestral stem cell exists from which all stem cells in a niche are descended. Our group has argued that these crypts then clonally expand by crypt fission, forming two daughters' crypts, and that this is the mechanism by which mutated stem cells or even cancer stem cell clones expand in the colon and in the entire gastrointestinal tract. Until recently, the differentiation potential of stem cells into adult tissues has been thought to be limited to cell lineages in the organ from which they were derived. Bone marrow cells are rare among adult stem cells regarding their abundance and role in the continuous, lifelong, physiological replenishment of circulating cells. In human and mice experiments, we have shown that bone marrow can contribute to the regeneration of intestinal myofibroblasts and thereby after epithelium following damage, through replacing the cells, which maintain the stem cells niche. Little is known about the markers characterizing the stem and transit amplifying populations of the gastrointestinal tract, although musashi-1 and hairy and enhancer of split homolog-1 have been proposed. As the mammalian gastrointestinal tract develops from the embryonic gut, it is made up of an endodermally-derived epithelium surrounded by cells of mesoderm origin. Cell signaling between these two tissue layers plays a critical role in coordinating patterning and organogenesis of the gut and its derivatives. Many lines of evidence have revealed that Wnt signaling is the most dominant force in controlling cell proliferation, differentiation, and apoptosis along the crypt-villus axis. We have found Wnt messenger RNAs expression in intestinal subepithelial myofibroblasts and frizzled messenger RNAs expression in both myofibroblasts and crypt epithelium. Moreover, there are many other factors, for example, bone morphogenetic protein, homeobox, forkhead, hedgehog, homeodomain, and platelet-derived growth factor that are also important to stem cell signaling in the gastrointestinal tract.