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Liu CH, Fang YJ, Liu CJ, Su TH, Huang SC, Tseng TC, Wu JH, Chen PJ, Kao JH. Splenic Arterial Pulsatility Index to Predict Hepatic Fibrosis in Hemodialysis Patients with Chronic Hepatitis C Virus Infection. J Clin Med 2023; 12:jcm12052020. [PMID: 36902807 PMCID: PMC10004191 DOI: 10.3390/jcm12052020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2022] [Revised: 02/27/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
The clinical utility of the splenic arterial pulsatility index (SAPI), a duplex Doppler ultrasonographic index, to predict the stage of hepatic fibrosis in hemodialysis patients with chronic hepatitis C virus (HCV) infection remains elusive. We conducted a retrospective, cross-sectional study to include 296 hemodialysis patients with HCV who underwent SAPI assessment and liver stiffness measurements (LSMs). The levels of SAPI were significantly associated with LSMs (Pearson correlation coefficient: 0.413, p < 0.001) and different stages of hepatic fibrosis as determined using LSMs (Spearman's rank correlation coefficient: 0.529, p < 0.001). The areas under receiver operating characteristics (AUROCs) of SAPI to predict the severity of hepatic fibrosis were 0.730 (95% CI: 0.671-0.789) for ≥F1, 0.782 (95% CI: 0.730-0.834) for ≥F2, 0.838 (95% CI: 0.781-0.894) for ≥F3, and 0.851 (95% CI: 0.771-0.931) for F4. Furthermore, the AUROCs of SAPI were comparable to those of the fibrosis index based on four parameters (FIB-4) and superior to those of the aspartate transaminase (AST)-to-platelet ratio index (APRI). The positive predictive value (PPV) for ≥F1 was 79.5% when the Youden index was set at 1.04, and the negative predictive values (NPVs) for ≥F2, ≥F3, and F4 were 79.8%, 92,6%, and 96.9%, respectively, when the maximal Youden indices were set at 1.06, 1.19, and 1.30. The diagnostic accuracies of SAPI with the maximal Youden index for a fibrosis stage of ≥F1, ≥F2, ≥F3, and F4 were 69.6%, 67.2%, 75.0%, and 85.1%, respectively. In conclusion, SAPI can serve as a good noninvasive index in predicting the severity of hepatic fibrosis in hemodialysis patients with chronic HCV infection.
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Affiliation(s)
- Chen-Hua Liu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100225, Taiwan
- Hepatitis Research Center, National Taiwan University Hospital, Taipei 100225, Taiwan
- Department of Internal Medicine, National Taiwan University Hospital, Yun-Lin Branch, Douliou 640203, Taiwan
- Correspondence: (C.-H.L.); (J.-H.K.); Tel.: +886-2-23123456 (ext. 63572) (C.-H.L.); +886-2-23123456 (ext. 67307) (J.-H.K.)
| | - Yu-Jen Fang
- Department of Internal Medicine, National Taiwan University Hospital, Yun-Lin Branch, Douliou 640203, Taiwan
| | - Chun-Jen Liu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100225, Taiwan
- Hepatitis Research Center, National Taiwan University Hospital, Taipei 100225, Taiwan
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei 100233, Taiwan
| | - Tung-Hung Su
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100225, Taiwan
- Hepatitis Research Center, National Taiwan University Hospital, Taipei 100225, Taiwan
| | - Shang-Chin Huang
- Department of Internal Medicine, National Taiwan University Hospital Bei-Hu Branch, Taipei 108206, Taiwan
| | - Tai-Chung Tseng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100225, Taiwan
- Hepatitis Research Center, National Taiwan University Hospital, Taipei 100225, Taiwan
- Department of Medical Research, National Taiwan University Hospital, Taipei 100225, Taiwan
| | - Jo-Hsuan Wu
- Hamilton Glaucoma Center, Shiley Eye Institute and Viterbi Family Department of Ophthalmology, University of California, San Diego, CA 92039, USA
| | - Pei-Jer Chen
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100225, Taiwan
- Hepatitis Research Center, National Taiwan University Hospital, Taipei 100225, Taiwan
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei 100233, Taiwan
| | - Jia-Horng Kao
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100225, Taiwan
- Hepatitis Research Center, National Taiwan University Hospital, Taipei 100225, Taiwan
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei 100233, Taiwan
- Department of Medical Research, National Taiwan University Hospital, Taipei 100225, Taiwan
- Correspondence: (C.-H.L.); (J.-H.K.); Tel.: +886-2-23123456 (ext. 63572) (C.-H.L.); +886-2-23123456 (ext. 67307) (J.-H.K.)
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Bui HH, Vo VH, Nguyen CD, Phan ST, Quach PT, Nguyen DB. Diagnostic Performance of Acoustic Radiation Force Impulse Imaging in Evaluating Liver Fibrosis in Patients with Chronic Hepatitis B Infection: A Cross-Sectional Study. Indian J Radiol Imaging 2022; 32:287-293. [PMID: 36177272 PMCID: PMC9514909 DOI: 10.1055/s-0042-1755251] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Acoustic radiation force impulse point shear wave elastography (ARFI-pSWE), measuring shear-wave velocity (SWV), has been utilized to examine the liver stiffness caused by different etiologies. However, information on its reliability in staging liver fibrosis in chronic hepatitis B (CHB) patients is scarce.
Purpose
The aim of the study is to examine the diagnostic performance of ARFI-pSWE and determine the optimal SWV cut-off values to predict significant fibrosis (
F
≥2) and cirrhosis (F4) in CHB patients.
Material and Methods
All 114 adult CHB patients visiting the University Medical Center, Ho Chi Minh City, Vietnam between February 2019 and March 2021 underwent liver stiffness measurement using ARFI-pSWE and FibroScan. SWV results were tested against FibroScan for sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). The area under the receiver operating characteristic (AUROC) curve was used to identify the optimal SWV cut-off values.
Results
There was a strong agreement between ARFI-pSWE and FibroScan (
r
= 0.92,
p
<0.001). The optimal SWV cut-off value for detecting significant fibrosis was 1.37 m/s with an AUROC of 0.975, sensitivity of 83.3%, specificity of 100%, PPV of 100%, and NPV of 81%. The optimal cut-off value for predicting cirrhosis was 1.70 m/s with an AUROC of 0.986, sensitivity of 97%, specificity of 93%, PPV of 95%, and NPV of 96%.
Conclusion
ARFI-pSWE could be an effective technique for evaluating liver fibrosis in CHB patients. SWV cut-off values of 1.37 and 1.70 m/s could be used to diagnose significant fibrosis and cirrhosis, respectively.
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Affiliation(s)
- Hoang Huu Bui
- Department of Gastroenterology, University Medical Center, Ho Chi Minh City, Vietnam
- Department of Internal Medicine, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam
| | - Van Huy Vo
- Department of Gastroenterology, University Medical Center, Ho Chi Minh City, Vietnam
| | - Chuong Dinh Nguyen
- Department of Gastroenterology, University Medical Center, Ho Chi Minh City, Vietnam
| | - Sang The Phan
- Department of Gastroenterology, University Medical Center, Ho Chi Minh City, Vietnam
| | - Phong Tien Quach
- Department of Gastroenterology, University Medical Center, Ho Chi Minh City, Vietnam
| | - Dung Bich Nguyen
- Department of Gastroenterology, University Medical Center, Ho Chi Minh City, Vietnam
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Aksakal M, Oktar SO, Sendur HN, Esendaglı G, Ozenirler S, Cindoruk M, Hızel K. Diagnostic performance of 2D shear wave elastography in predicting liver fibrosis in patients with chronic hepatitis B and C: a histopathological correlation study. Abdom Radiol (NY) 2021; 46:3238-3244. [PMID: 33723676 DOI: 10.1007/s00261-021-03019-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 02/21/2021] [Accepted: 02/25/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE In this study, we investigated the diagnostic efficacy of 2D-Shear Wave Elastography (2D-SWE) in detecting stages of liver fibrosis and determining the disease-specific cut-off values in patients with chronic hepatitis B and C infection, using histopathological analysis as the reference method. METHOD Our study included 103 consecutive adult patients with chronic hepatitis B and C infection (CHB and CHC) who had liver biopsy within three months of elastography examination. A real-time 2D-SWE was performed using the LOGIQ E9 system (GE Medical Systems, Wisconsin, USA). The correlation between the liver stiffness measurements and the METAVIR scores was evaluated. The diagnostic performance of 2D-SWE was assessed, and cut-off values were set. RESULTS We found a statistically significant positive correlation between elastography values and the degree of liver fibrosis (Spearman's correlation coefficient = 0.76 and 0.83 for CHB and CHC; respectively) (p = 0.0001). The stiffness cut-off values were F ≥ 1: 5.92 kPa, F ≥ 2: 7.69 kPa, F ≥ 3: 8.97 kPa, F ≥ 4: 12.15 kPa in CHB; and F ≥ 1: 6.09 kPa, F ≥ 2: 7.81 kPa, F ≥ 3: 9.0 kPa, F ≥ 4: 12.47 kPa in CHC patients. CONCLUSION 2D-SWE is reliable and accurate for the diagnosis of liver fibrosis. In selected patients, 2D-SWE may be useful in reducing the need for liver biopsy when staging fibrosis. Further studies in larger prospective series are needed to confirm these results and determine the most appropriate cut-off values for each stage of liver fibrosis.
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Affiliation(s)
- Mehmet Aksakal
- Department of Radiology, Gazi University, 06500, Beşevler, Ankara, Turkey.
| | - Suna Ozhan Oktar
- Department of Radiology, Gazi University, 06500, Beşevler, Ankara, Turkey
| | - Halit Nahit Sendur
- Department of Radiology, Gazi University, 06500, Beşevler, Ankara, Turkey
| | - Güldal Esendaglı
- Department of Pathology, Gazi University, 06500, Beşevler, Ankara, Turkey
| | - Seren Ozenirler
- Department of Gastroenterology, Gazi University, 06500, Beşevler, Ankara, Turkey
| | - Mehmet Cindoruk
- Department of Gastroenterology, Gazi University, 06500, Beşevler, Ankara, Turkey
| | - Kenan Hızel
- Department of Infectious Diseases, Gazi University, 06500, Beşevler, Ankara, Turkey
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Nakano C, Nishimura T, Tada T, Yoshida M, Takashima T, Aizawa N, Ikeda N, Nishikawa H, Enomoto H, Hatano E, Yano H, Hirota S, Hachiya H, Iijima H. Severity of liver fibrosis using shear wave elastography is influenced by hepatic necroinflammation in chronic hepatitis patients, but not in cirrhotic patients. Hepatol Res 2021; 51:436-444. [PMID: 33462941 DOI: 10.1111/hepr.13617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/18/2020] [Accepted: 01/06/2021] [Indexed: 12/14/2022]
Abstract
AIM Shear wave elastography (SWE) in patients with chronic liver diseases is a noninvasive useful method for the diagnosis of liver fibrosis severity, which can be an alternative to liver biopsy. However, the liver stiffness measurement using SWE can be affected by various factors including hepatic inflammation, extrahepatic cholestasis, heart failure, and underlying liver diseases. The aim of this study is to clarify the correlation between liver stiffness using SWE and hepatic necroinflammation serologically and pathologically. METHODS A total of 843 patients with chronic liver disease who received liver biopsy were analyzed. Liver stiffness measurement using transient elastography (TE) and virtual touch quantification (VTQ) were carried out on the same day as the liver biopsy. The correlation between SWE and hepatic inflammation was analyzed serologically and pathologically. RESULTS The liver stiffness values increased significantly with the progression of liver fibrosis and inflammation (overall p < 0.001). In patients with F0-1, F2, and F3, TE and VTQ values of A2 or A3 were significantly higher than those of A0 or A1 (p value, all <0.05), but not in patients with F4. The median alanine aminotransferase (ALT) values increased significantly with the progression of liver inflammation (p < 0.001). Moreover, TE and VTQ in patients with ALT ≥70 IU/L were significantly higher than those in patients with ALT <70 IU/L (p < 0.01), but not in patients with F4. CONCLUSION Shear wave elastography can be affected by hepatic necroinflammation in F0-F3 fibrosis, but not in F4.
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Affiliation(s)
- Chikage Nakano
- Ultrasound Imaging Center, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Takashi Nishimura
- Ultrasound Imaging Center, Hyogo College of Medicine Hospital, Nishinomiya, Japan.,Department of Internal Medicine, Division of Gastroenterology and Hepatology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Toshifumi Tada
- Department of Internal Medicine, Japanease Red Cross Society Himeji Hospital, Himeji, Japan
| | - Masahiro Yoshida
- Ultrasound Imaging Center, Hyogo College of Medicine Hospital, Nishinomiya, Japan
| | - Tomoyuki Takashima
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Nobuhiro Aizawa
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Naoto Ikeda
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroki Nishikawa
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Hyogo College of Medicine, Nishinomiya, Japan.,Center for Clinical Research and Education, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hirayuki Enomoto
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Etsuro Hatano
- Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hirohisa Yano
- Department of Pathology, Kurume University School of Medicine, Kurume, Japan
| | - Seiichi Hirota
- Department of Pathology, Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroyuki Hachiya
- School of Engineering, Tokyo Institute of Technology, Tokyo, Japan
| | - Hiroko Iijima
- Ultrasound Imaging Center, Hyogo College of Medicine Hospital, Nishinomiya, Japan.,Department of Internal Medicine, Division of Gastroenterology and Hepatology, Hyogo College of Medicine, Nishinomiya, Japan
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Zhou X, Rao J, Wu X, Deng R, Ma Y. Comparison of 2-D Shear Wave Elastography and Point Shear Wave Elastography for Assessing Liver Fibrosis. ULTRASOUND IN MEDICINE & BIOLOGY 2021; 47:408-427. [PMID: 33342618 DOI: 10.1016/j.ultrasmedbio.2020.11.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 11/08/2020] [Accepted: 11/16/2020] [Indexed: 06/12/2023]
Abstract
Progressive liver fibrosis may result in cirrhosis, portal hypertension and increased risk of hepatocellular carcinoma. We performed a meta-analysis to compare liver fibrosis staging in chronic liver disease patients using 2-D shear wave elastography (2-D SWE) and point shear wave elastography (pSWE). The PubMed, Web of Science and Cochrane Library databases were searched until May 31, 2020 for studies evaluating the diagnostic performance of 2-D SWE and pSWE in assessing liver fibrosis. Pooled sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratios and area under receiver operating characteristic curve were estimated using the bivariate random effects model. As a result, 71 studies with 11,345 patients were included in the analysis. The pooled sensitivities of 2-D SWE and pSWE significantly differed for the detection of significant fibrosis (F ≥ 2; 0.84 vs. 0.76, p < 0.001) and advanced fibrosis (F ≥ 3; 0.90 vs. 0.83, p = 0.003), but not for detection of cirrhosis (F = 4; 0.89 vs. 0.85, p = 0.090). The pooled specificities of 2-D SWE and pSWE did not significantly differ for detection of F ≥ 2 (0.81 vs. 0.79, p = 0.753), F ≥ 3 (0.87 vs. 0.83, p = 0.163) or F = 4 (0.87 vs. 0.84, p = 0.294). Both 2-D SWE and pSWE have high sensitivity and specificity for detecting each stage of liver fibrosis. Two-dimensional SWE has higher sensitivity than pSWE for detection of significant fibrosis and advanced fibrosis.
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Affiliation(s)
- Xiaozhuan Zhou
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Jiawei Rao
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Xukun Wu
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Ronghai Deng
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yi Ma
- Organ Transplant Center, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial Key Laboratory of Organ Donation and Transplant Immunology, First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China; Guangdong Provincial International Cooperation Base of Science and Technology (Organ Transplantation), First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China.
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Tsuji Y, Namisaki T, Kaji K, Takaya H, Nakanishi K, Sato S, Saikawa S, Sawada Y, Kitagawa K, Shimozato N, Kawaratani H, Moriya K, Noguchi R, Akahane T, Mitoro A, Yoshiji H. Comparison of serum fibrosis biomarkers for diagnosing significant liver fibrosis in patients with chronic hepatitis B. Exp Ther Med 2020; 20:985-995. [PMID: 32765655 PMCID: PMC7388477 DOI: 10.3892/etm.2020.8798] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 02/04/2020] [Indexed: 12/11/2022] Open
Abstract
Chronic hepatitis B (CHB) virus continues to be a leading cause of morbidity and mortality worldwide. The diagnosis of liver fibrosis has a key role in selecting patients with CHB for antiviral treatment. However, serum biomarkers demonstrate limited diagnostic utility. The present study aimed to compare the performances of fibrosis biomarkers for diagnosing significant liver fibrosis that indicates the need for antiviral therapy in patients with CHB and to identify the most appropriate biomarker for these patients. The current study included 96 antiviral-naïve patients with CHB who underwent liver biopsy. METAVIR scoring system was used to assess liver fibrosis and necroinflammation. The diagnostic performances were evaluated of the platelet (PLT) count; the levels of hyaluronan, serum 7S domain of type 4 collagen, procollagen type III N-terminal peptide, tissue inhibitor of metalloproteinases 1, Mac-2 binding protein glycosylation isomer (M2BPGi) and N-terminal type III collagen propeptide (Pro-C3); the fibrosis index based on four factors; the aspartate aminotransferase-to-platelet ratio index; and enhanced liver fibrosis score for identifying significant liver fibrosis [≥fibrosis stage 2 (F2)]. All fibrosis biomarkers, except the Pro-C3 level, correlated with the fibrosis stage. M2BPGi was better than other biomarkers for diagnosing ≥F2, with the highest area under the curve of 0.902. M2BPGi demonstrated a higher diagnostic accuracy for significant fibrosis than mild/severe fibrosis or cirrhosis. However, no significant correlation was observed between the M2BPGi level and fibrosis stage in patients with CHB having significant liver necroinflammation defined as ≥ necroinflammatory activity 2. The M2BPGi level and PLT count were exclusively correlated with the fibrosis stage in 73 patients without significant liver necroinflammation. M2BPGi demonstrated the highest diagnostic performance for significant fibrosis in patients having significant liver fibrosis with no significant liver necroinflammation. In conclusion, the M2BPGi level can accurately diagnose significant liver fibrosis that indicates the need for antiviral therapy in patients with CHB.
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Affiliation(s)
- Yuki Tsuji
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Tadashi Namisaki
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Kosuke Kaji
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Hiroaki Takaya
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Keisuke Nakanishi
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Shinya Sato
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Soichiro Saikawa
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Yasuhiko Sawada
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Kou Kitagawa
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Naotaka Shimozato
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Hideto Kawaratani
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Kei Moriya
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Ryuichi Noguchi
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Takemi Akahane
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Akira Mitoro
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara 634-8522, Japan
| | - Hitoshi Yoshiji
- Third Department of Internal Medicine, Nara Medical University, Kashihara, Nara 634-8522, Japan
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