Associations of multiple metal intake with all-cause and cardiovascular mortality in US adults stratified by age and sex: A prospective cohort from the NHANES database study

AIM AND OBJECTIVES

The relationship between dietary metal intake and mortality risk is controversial, and we investigated the relationship between intake of five metals (iron, copper, selenium, zinc, and magnesium) and all-cause, cardiovascular mortality in the total population, gender subgroups, and age subgroups.

MATERIALS AND METHODS

17,207 participants from the National Health and Nutrition Examination Survey (NHANES) database from 2009 to 2016 were included in this study. Kaplan-Meier survival curves, multivariate Cox proportional hazards models, and restrictive cubic spline (RCS) curves were used to explore the association between metal intake and all-cause, cardiovascular mortality.

RESULTS

In this study, the average dietary metal intake of men and older people was lower than that of women and younger people. The RCS curves found in the whole population that all-cause mortality was negative linearly associated with copper intakes, L-shaped with zinc and magnesium intakes. Further subgroup analyses of copper, zinc, and magnesium by age and gender revealed that only magnesium showed statistically significant differences in the age subgroups. In the 20-40 population, there was a non-linear increasing trend in magnesium intake and all-cause mortality, whereas there was a non-linear decreasing trend in the > 60 population.

CONCLUSION

The relationship between metal intake and mortality is more than a simple linear correlation, and differences in age can affect this correlation. In metal exposure studies, different populations can be studied to better determine the effect of metal exposure on mortality.

DATA AVAILABILITY

The dataset used for statistical analysis in this study is available on the NHANES website: https://www.cdc.gov/nchs/nhanes/index.htm.

Influence of intracranial hemorrhage on clinical outcome in acute vertebrobasilar artery occlusion undergoing endovascular treatment

BACKGROUND AND PURPOSE

The effect of intracranial hemorrhage (ICH) on the outcome of patients with large-vessel occlusion undergoing endovascular treatment (EVT) has mainly focused on the anterior circulation. Knowledge of the relationship between ICH and outcomes in patients with acute vertebrobasilar artery occlusion (VBAO) receiving EVT is limited. We aimed to assess whether ICH is a prognostic marker for acute VBAO following EVT.

METHODS

Patients who underwent EVT for acute VBAO in the acute posterior circulation ischemic stroke (PERSIST) registry were included. All patients were classified as having no or any-ICH. Any-ICH was subdivided into asymptomatic and symptomatic ICH. A multivariate regression analysis was performed to evaluate the association between ICH and functional outcomes in patients with acute VBAO after receiving EVT.

RESULTS

Five hundred and forty-seven patients, including 107 patients with ICH (19.6%): 38 (7.0%) and 69 (12.6%) with symptomatic and asymptomatic ICH, respectively. After adjustment for potential confounders, any-ICH was independently associated with reduced chance of favorable outcome (OR 0.39, 95% CI 0.21-0.72, P=0.003), functional independence (OR 0.24, 95% CI 0.16-0.52, P<0.001), and excellent outcome (OR 0.34, 95% CI 0.15-0.75, P=0.008), and increased mortality risk (OR 2.14, 95% CI 1.30-3.51, P=0.003). Symptomatic ICH had a similar association. Moreover, asymptomatic ICH was a negative predictor of functional independence (OR 0.39, 95% CI 0.17-0.88, P=0.024).

CONCLUSION

Any- and symptomatic ICH were strongly associated with worse clinical outcomes and increased mortality in patients with acute VBAO who underwent EVT. Asymptomatic ICH was an inverse predictor of functional independence.

Changes in spectrum of biopsy-proven kidney diseases within decade: an analysis based on 10 199 cases from South China

PURPOSE

To assess the regional epidemiological trends of kidney diseases over time in the South China using renal biopsy-proven cases.

METHODS

This retrospective observational cohort study was conducted at the Institute of Nephrology, Second Xiangya Hospital of Central South University, and encompasses all patients diagnosed with kidney disease via biopsy from 2012 to 2021.

RESULTS

The study sample consisted of 10 199 native kidneys, with a male-to-female ratio of 0.91:1 and an average age of 38.74 (±14.53) years. Primary glomerular nephropathy, systemic glomerular nephropathy (SGN), tubulointerstitial disease, and hereditary renal diseases accounted for 66.92 (6825)%, 24.49 (2498)%, 8.06 (822)%, and 0.53 (54)%, respectively. The leading pathologies of primary glomerular nephropathy remained the IgA nephropathy. The frequencies of IgA nephropathy and membranous nephropathy increased significantly, whereas the frequencies of minimal change disease and focal segmental glomerulosclerosis decreased (P < .001) between 2017 and 2021 than in the years 2012 and 2016. An earlier onset of membranous nephropathy was observed in the age group of 45-59 years compared to previous studies. The leading pathologies of SGN were found to be lupus nephritis (758 cases, 30.45%) and hypertension nephropathy (527 cases, 21.17%). The frequencies of hypertension nephropathy and diabetic nephropathy increased between 2017 and 2021 compared to 2012 and 2016 (P < .001), gradually becoming the leading pathological types of SGN. In elderly patients diagnosed with nephrotic syndrome, the frequencies of amyloidosis significantly increased (P < .01).

CONCLUSION

Our study may provide insights for kidney disease prevention and public health strategies. What is already known on this topic The pathological spectrum of kidney diseases has undergone significant transformations in the past decade, driven by the escalating incidence of chronic diseases. Although there are studies exploring the renal biopsy findings from various regions in China which present both similarities and differences in epidemiology, few large-scale reports from the South China in recent decades were published. What this study adds Our findings reveal the following key observations: (i) increased proportion of middle-aged patients leading to the increasing average age at the time of biopsy；(ii) the frequencies of IgA nephropathy and membranous nephropathy (MN) increased significantly, whereas the frequencies of minimal change disease and focal segmental glomerulosclerosis decreased (P < .001) between 2017 and 2021 than in the years 2012 and 2016; (iii) earlier onset of MN in the age group of 45-59 years old was found in our study; and (iv) a higher frequency of hypertension nephropathy and DN presented over time, and frequency of amyloidosis increased in elderly patients diagnosed with NS. How this study might affect research, practice, or policy This single-center yet a large-scale study of the kidney disease spectrum in South China may provide a reference point for the diagnosis, treatment, and prevention of chronic kidney disease.

Association between dietary vitamin E intake and chronic kidney disease events in US adults: a cross-sectional study from NHANES 2009-2016

Background

The relationship between vitamin E supplementation and the prevalence of chronic kidney disease (CKD) is unclear. We discussed the relationship between vitamin E intake and CKD prevalence and further investigated the effect on different CKD risk strata.

Methods

We ultimately included 20 295 participants from the National Health and Nutrition Examination Survey (NHANES) database from 2009 to 2016. Multiple logistic regression and restricted cubic splines (RCS) were applied to explore the relationship between vitamin E intake and CKD prevalence and risk stratification. Subgroup analysis was applied to assess the stability of the association between vitamin E intake and CKD.

Results

In the CKD prevalence study, we found a negative association between high vitamin E intake and CKD prevalence through an adjusted multiple logistic regression model, the odds ratio (OR) was 0.86 [95% confidence interval (CI) 0.74-1.00; P for trend = .041] and RCS showed a nonlinear negative correlation (P-nonlinear = .0002, <.05). In the CKD risk stratification study, we found that in very high-risk patients, the OR was 0.51 (95% CI 0.32-0.84; P for trend = .006) and the RCS also showed a nonlinear negative correlation (P-nonlinear <.0001, <.05). Subgroup analysis demonstrated that the correlations were stable across populations (P-values >.01 for all interactions).

Conclusion

Dietary vitamin E intake was negatively associated with the prevalence of CKD in US adults. Increased vitamin E intake was a protective factor across CKD risk strata, and as vitamin E intake increased, there was a non-linear downward trend in the proportion progressing to very high-risk CKD.

Homoharringtonine promotes heart allograft acceptance by enhancing regulatory T cells induction in a mouse model

BACKGROUND

Homoharringtonine (HHT) is an effective anti-inflammatory, anti-viral, and anti-tumor protein synthesis inhibitor that has been applied clinically. Here, we explored the therapeutic effects of HHT in a mouse heart transplant model.

METHODS

Healthy C57BL/6 mice were used to observe the toxicity of HHT in the liver, kidney, and hematology. A mouse heart transplantation model was constructed, and the potential mechanism of HHT prolonging allograft survival was evaluated using Kaplan-Meier analysis, immunostaining, and bulk RNA sequencing analysis. The HHT-T cell crosstalk was modeled ex vivo to further verify the molecular mechanism of HHT-induced regulatory T cells (Tregs) differentiation.

RESULTS

HHT inhibited the activation and proliferation of T cells and promoted their apoptosis ex vivo. Treatment of 0.5 mg/kg HHT for 10 days significantly prolonged the mean graft survival time of the allografts from 7 days to 48 days (P <0.001) without non-immune toxicity. The allografts had long-term survival after continuous HHT treatment for 28 days. HHT significantly reduced lymphocyte infiltration in the graft, and interferon-γ-secreting CD4+ and CD8+ T cells in the spleen (P <0.01). HHT significantly increased the number of peripheral Tregs (about 20%, P <0.001) and serum interleukin (IL)-10 levels. HHT downregulated the expression of T cell receptor (TCR) signaling pathway-related genes (CD4, H2-Eb1, TRAT1, and CD74) and upregulated the expression of IL-10 and transforming growth factor (TGF)-β pathway-related genes and Treg signature genes (CTLA4, Foxp3, CD74, and ICOS). HHT increased CD4+ Foxp3+ cells and Foxp3 expression ex vivo, and it enhanced the inhibitory function of inducible Tregs.

CONCLUSIONS

HHT promotes Treg cell differentiation and enhances Treg suppressive function by attenuating the TCR signaling pathway and upregulating the expression of Treg signature genes and IL-10 levels, thereby promoting mouse heart allograft acceptance. These findings may have therapeutic implications for organ transplant recipients, particularly those with viral infections and malignancies, which require a more suitable anti-rejection medication.

Clinical and pathological features of omicron variant of SARS-CoV-2-associated kidney injury

Kidney injury is common in patients with Coronavirus Disease-19 (COVID-19), which is related to poor prognosis. We aim to summarize the clinical features, athological types, and prognosis of COVID-19 associated kidney injury caused by the Omicron strain. In this study, 46 patients with Omicron-associated kidney injury were included, 38 of whom performed renal biopsy. Patients were divided into two groups: group A for patients with onset of kidney injury after SARS-CoV-2 infection; group B for patients with pre-existing kidney disease who experienced aggravation of renal insufficiency after SARS-CoV-2 infection. The clinical, pathological, and prognostic characteristics of the patients were observed. Acute kidney injury (AKI) (35%) was the most common clinical manifestation in group A. Patients in group B mainly presented with chronic kidney disease (CKD) (55%) and nephrotic syndrome (NS) (40%). The pathological type was mainly IgA nephropathy (IgAN) (39% in group A and 45% in group B). Among all of them, one case presenting with thrombotic microangiopathy had worse kidney function at biopsy time. Mean serum C3 levels were 1.2 ± 0.5 and 1.0 ± 0.2 g/L in group A and group B, respectively. In renal tissues, C3 deposits were observed in 71.1% of patients. 11.8% (n = 2) patients experienced deterioration of renal function after treatment, but no patients developed to end-stage renal disease. In our single-center study in China, the main clinical manifestations were AKI, CKD, and NS, while the main pathological type was IgAN. Compared with previous strains of SARS-CoV-2, patients with the Omicron infection had a favorable prognosis.

DsbA-L deletion attenuates LPS-induced acute kidney injury by modulating macrophage polarization

Disulfide bond A oxidoreductase-like protein (DsbA-L) drives acute kidney injury (AKI) by directly upregulating the expression of voltage-dependent anion-selective channels in proximal tubular cells. However, the role of DsbA-L in immune cells remains unclear. In this study, we used an LPS-induced AKI mouse model to assess the hypothesis that DsbA-L deletion attenuates LPS-induced AKI and explore the potential mechanism of DsbA-L action. After 24 hours of LPS exposure, the DsbA-L knockout group exhibited lower serum creatinine levels compared to the WT group. Furthermore, peripheral levels of the inflammatory cytokine IL-6 were decreased. Transcriptomic data analysis revealed a significant down-regulation in the IL-17 and tumor necrosis factor pathways in DsbA-L knockout mice following LPS induction. Metabolomic analysis suggested that arginine metabolism was significantly different between the WT and DsbA-L knockout groups after LPS treatment. Notably, the M1 polarization of macrophages in the kidneys of DsbA-L knockout AKI mice was significantly reduced. Expression of the transcription factors NF-κB and AP-1 was downregulated after DsbA-L knockout. Our results suggest that DsbA-L regulates LPS-mediated oxidative stress, promotes M1 polarization of macrophages, and induces expression of inflammatory factors via the NF-κB/AP-1 pathway.

Hybrid Immuno-RT for Bulky Tumors: Standard Fractionation with Partial Tumor SBRT

PURPOSE/OBJECTIVE(S)

Bulky tumors remain challenging to be treated. Stereotactic body radiation therapy (SBRT) is effective against radioresistant tumor cells and can induce immunogenic cell death (ICD) that leads to T-cell-mediated antitumor effects. Low-dose radiation (LDRT) can inflame the tumor microenvironment (TME) by recruiting T cells. We designed a novel radiotherapy technique (RT, ERT) whose dose distribution map resembles the "eclipse" by concurrently delivering LDRT to the whole tumor, meanwhile SBRT to only a part of the same tumor. This study examined the safety and efficacy of ERT to bulky lesions with PD-1 inhibitors in mice and patients.

MATERIALS/METHODS

In mice with CT26 colon or LLC1 lung bulky tumors (400 - 500 cm3), the whole tumor was irradiated by LDRT (2 Gy x 3), meanwhile the tumor center was irradiated by SBRT (10 Gy x 3); αPD-1 was given weekly. The dependence of therapeutic effects on CD8+ T cells was determined using depleting antibodies. Frequencies of CD8+ T cells and M1 macrophages (Mφ) were determined by flow cytometry. Multiplex Immunohistochemistry (mIHC) was applied to analyze the number and the location of CD8+ T cells and their subpopulations, as well as the phospho-eIF2α level (the ICD marker) of tumor cells in TME. Patients with advanced lung or liver bulky tumors who failed standard treatment or with oncologic emergencies were treated. Kaplan-Meier method was applied to estimate patients' progression-free survival (PFS) and overall survival (OS).

RESULTS

ERT/αPD-1 is superior to SBRT/αPD-1 or LDRT/αPD-1 in controlling bulky tumors in both mouse models in a CD8+ T-cell dependent manner. In the CT26 model, ERT/αPD-1 resulted in complete tumor regression in 3/11 mice and induced more CD8+ T cells and M1 Mφ in TME compared to other groups. mIHC analysis showed that ERT/αPD-1 induced higher bulk, stem-like (TCF1+ TIM3- PD-1+), and more differentiated (TCF1- TIM3+ PD-1+) CD8+ T cells infiltration into the tumor center and periphery compared to other groups. Compared to untreated or LDRT-treated tumor centers, tumor centers irradiated with ERT or SBRT showed elevated phospho-eIF2α accompanied by higher dendritic cell infiltration. In total, 39 advanced cancer patients were treated with ERT/αPD-1 or plus chemotherapy. Radiation-induced pneumonitis occurred in 1 of 26 patients receiving thoracic ERT. There were two cases of grade III toxicity associated with PD-1 inhibitors. No toxicity above grade III was observed. The objective response rate was 38.5%. The median PFS was 5.6 months and median OS was not reached at a median follow-up of 11.7 months.

CONCLUSION

ERT/αPD-1 showed superior efficacy in controlling bulky tumor in two mouse models. The hybrid immuno-RT (ERT) combing PD-1 inhibitors was safe and effective in patients with bulky tumors. Further clinical trials in combination with bioimaging to identify the optimal SBRT target region for the bulky tumor are warranted.

Clinical outcomes for kidney transplantation in 81 adults with IgA nephropathy

OBJECTIVES

Immunoglobulin A nephropathy (IgAN) is one of the most common types of kidney disease, and kidney transplantation is the most effective treatment for end-stage renal disease. This study aims to analyze the clinical curative effect of renal transplantation for adults with IgAN and to discuss the efficacy and safety of kidney transplantation for IgAN at the perioperative period and medium- and long-term follow-up.

METHODS

This retrospective study included the clinical and follow-up data of 81 adult patients with IgAN who underwent kidney transplantation at the Second Xiangya Hospital, Central South University from January 2018 to January 2022. Of the 81 patients whose age at (34.1±9.9) years old, 47 (58.0%) were male. The body mass index was (20.8±3.2) kg/m2, and the human leukocyte antigen (HLA) mismatch number was 3.5±1.2. The estimated glomerular filtration rate (eGFR) and daily 24-hour urine output for the recipients on the 1st, 5th, and 7th day after kidney transplantation and when they were discharged were analyzed. The recovery of the transplanted kidney and occurrence of complications were comprehensively evaluated. The eGFR, urinary protein, and occult blood were evaluated at the 6th, 12th, 24th, 36th, and 48th month and at the last follow-up.

RESULTS

The follow-up time was (25.7±15.8) months. No primary non-function occurred in any patient during the perioperative period time. Fifty-one (63.0%) patients had immediate graft function recovery, and 16 (19.8%) patients had slow graft function recovery. Delayed recovery of graft function was observed in 14 (17.3%) patients. A total of 19 perioperative complications occurred, including 9 patients with acute rejection, 5 patients with urinary fistula, 1 thrombosis in both lower limbs, and 4 lymphatic fistula. The eGFR at 6th, 12th, 24th, 36th, and 48th month of follow-up were (65.3±22.9), (67.6±23.0), (64.3±21.8), (65.9±24.7), and (68.7±31.2) mL/(min·1.73 m2), respectively. The eGFR remained high during the medium- and long-term follow-ups. At the longest follow-up of 56 months, eGFR fluctuation was still mild, and the positive rate of urine protein and occult blood was low. IgAN recurred in 4 transplanted kidneys, accounting for 4.94% of the total patients, without severe renal insufficiency. Three patients had kidney dysfunction due to severe pneumonia, rejection, and stone in the transplanted kidney. The overall survival rate of the transplanted kidney was higher than 95%, and the survival rate of all patients was 100% till Januray 2022.

CONCLUSIONS

Renal transplantation for adults with IgAN had a remarkable short-term effect. The recipients can be beneficial significantly to favorable midium- and long-term outcomes. IgAN recurrence is infrequent and rarely causes severe renal function damage.

Hemophagocytic lymphohistiocytosis secondary to virus infection and followed by lupus nephritis recurrence in a renal transplantation pediatric recipient: a case report

BACKGROUND

Hemophagocytic lymphohistiocytosis (HLH) is a rare and life-threatening disorder characterized by systemic inflammation and organ failure as a result of dysregulated immune cell activation. HLH can be induced by a variety of factors including infection, tumours and autoimmune disease and can also occur in patients following solid organ transplantation. Occurrence of HLH and lupus nephritis (LN) successively within a short period of time after renal transplantation is uncommon.

CASE PRESENTATION

We described an 11-year-old female post-transplant patient who presented with hemocytopenia, fever, elevated serum ferritin, splenomegaly, hyperlipidemia, and hypofibrinemia, and was clinically diagnosed with HLH. After comprehensive treatment with corticosteroids, intravenous immunoglobulin (IVIG), and reducing immunosuppressants, her condition improved, but then hematuria ensued. The transplant kidney biopsy showed LN. She was treated with hydroxychloroquine and methylprednisolone while intensive immunosuppressive agents were given. She has remained in remission for two years until now.

CONCLUSIONS

The main inducing factors of HLH should be identified as early as possible, and accurate treatment plans should be taken. The long-course IVIG regimen may be one of the effective treatments for virus-induced HLH. After remission of HLH, we need to be alert to the recurrence of autoimmune diseases in patients with underlying diseases, and timely increase immunosuppressants.

Drug-induced Fanconi syndrome in patients with kidney allograft transplantation

Background

Patients after kidney transplantation need to take long-term immunosuppressive and other drugs. Some of these drug side effects are easily confused with the symptoms of Fanconi syndrome, resulting in misdiagnosis and missed diagnosis, and causing serious consequences to patients. Therefore, improving awareness, early diagnosis and treatment of Fanconi syndrome after kidney transplantation is critical.

Methods

This retrospective study analyzed 1728 cases of allogeneic kidney transplant patients admitted to the Second Xiangya Hospital of Central South University from July 2016 to January 2021. Two patients with Fanconi syndrome secondary to drugs, adefovir dipivoxil (ADV) and tacrolimus, were screened. We summarized the diagnostic process, clinical data, and prognosis.

Results

The onset of Fanconi syndrome secondary to ADV after renal transplantation was insidious, and the condition developed after long-term medication (&gt;10 years). It mainly manifested as bone pain, osteomalacia, and scoliosis in the late stage and was accompanied by obvious proximal renal tubular damage (severe hypophosphatemia, hypokalemia, hypocalcemia, hypouricemia, glycosuria, protein urine, acidosis, etc.) and renal function damage (increased creatinine and azotemia). The pathological findings included mitochondrial swelling and deformity in renal tubular epithelial cells. The above symptoms and signs were relieved after drug withdrawal, but the scoliosis was difficult to rectify. Fanconi syndrome secondary to tacrolimus has a single manifestation, increased creatinine, which can be easily confused with tacrolimus nephrotoxicity. However, it is often ineffective to reduce the dose of tacrolomus, and proximal renal failure can be found in the later stage of disease development. There was no abnormality in the bone metabolism index and imageological examination findings. The creatinine level decreased rapidly, the proximal renal tubule function returned to normal, and no severe electrolyte imbalance or urinary component loss occurred when the immunosuppression was changed from tacrolimus to cyclosporine A.

Conclusions

For the first time, drug-induced Fanconi syndrome after kidney transplantation was reported. These results confirmed that the long-term use of ADV or tacrolimus after kidney transplantation may have serious consequences, some of which are irreversible. Greater understanding of Fanconi syndrome after kidney transplantation is necessary in order to avoid incorrect and missed diagnosis.

[The effects of positive end-expiratory pressure on central venous pressure in patients with different chest wall elastic resistance]

Objective: To investigate the role of chest wall elastic resistance in determining the effects of positive end-expiratory pressure (PEEP) on central venous pressure (CVP) in patients with mechanical ventilation (MV). Methods: In this prospective study, according to the median of ratio of chest wall elastic resistance to respiratory system elastic resistance (Ers), patients were divided into high chest wall elastic resistance group (Ecw/Ers≥0.24) and low chest wall elastic resistance group [elastance of chest wall (Ecw)/Ers<0.24]. PEEP was set at 5, 10, 15 cmH₂O (1 cmH₂O=0.098 kPa) respectively. Clinical data including CVP, heart rate (HR), blood pressure (BP) and respiratory mechanics were recorded. Results: Seventy patients receiving MV were included from November 2017 to December 2018. Clinical characteristics including age, BP, HR, baseline PEEP, the ratio of arterial oxygen partial pressure to fractional inspired oxygen (P/F) and comorbidities were comparable in two groups. However, patients with high Ecw/Ers ratio presented higher body mass index (BMI) than those with low Ecw/Ers ratio[ (25.4±3.2) kg/m² vs. (23.4±3.2) kg/m², P=0.011]. As PEEP increased from 5 cmH₂O to 10 cmH₂O, CVP in high Ecw/Ers group increased significantly compared with that in low Ecw/Ers group [1.75(1.00, 2.13) mmHg (1 mmHg=0.133kPa) vs. 1.50(0.50, 2.00)mmHg,P=0.038], which was the same as PEEP increased from 10 cmH₂O to 15 cmH₂O [2.00(1.50, 3.00)mmHg vs. 1.50(1.00, 2.00)mmHg,P=0.041] or PEEP increased from 5 cmH₂O to 15 cmH₂O [ 3.75(3.00,4.63)mmHg vs. 3.00(1.63, 4.00)mmHg, P=0.012]. When PEEP increased from 5 cmH₂O to 10 cmH₂O, 10 cmH₂O to 15 cmH₂O and 10 cmH₂O to 15 cmH₂O, there were significant correlations between Ecw/Ers and CVP elevation (r=0.29, P=0.016; r=0.31, P=0.011; r=0.31, P=0.01 respectively). Conclusions: In patients receiving mechanical ventilation, elevation of PEEP leads to a synchronous change of CVP, which is corelated with patients' chest wall elastic resistances.

Comparison of Outcomes of Kidney Transplantation From Extremely Low Body Weight ≤5kg Versus Larger Body Weight Pediatric Donors

Background

Kidney transplantation from donors who weigh ≤5 kg is performed at only a few transplant centers owing to the high complication and low graft survival rates associated with this approach.

Methods

We retrospectively compared the results of kidney transplantation at our center between January 2015 and December 2019 based on the following pediatric donor criteria: donor body weight ≤5 kg (n=32), 5 kg< donor weight ≤20 kg (n=143), and donor weight >20 kg (n=110). We also perform subgroup analysis of kidney transplantation outcomes from ≤5 kg donors, using conventional (dual separate and classic en-bloc KTx)/novel (en-bloc KTx with outflow tract) surgical methods and allocating to adult/pediatric recipients.

Results

The death-censored graft survival rates from extremely low body weight ≤5kg at 1 month, and 1, 3, and 5 years were 90.6%, 80.9%, 77.5%, and 73.9%, respectively, which were significantly lower than that from larger body weight pediatric donors. However, the 3-, and 5-year post-transplantation eGFRs were not significantly different between the pediatric and adult recipient group. The thrombosis (18.8%) and urinary leakage (18.8%) rates were significantly higher in the donor weight ≤5 kg group. Compared with 5 kg< donor weight ≤20 kg group, donor weight ≤5kg group was at elevated risk of graft loss due to thrombosis (OR: 13.4) and acute rejection (OR: 6.7). No significant difference on the outcomes of extremely low body weight donor kidney transplantation was observed between adults and pediatric recipients. Urinary leakage rate is significantly lower in the novel operation (8.7%) than in the conventional operation group (44.4%).

Conclusions

Although the outcomes of donor body weight ≤5kg kidney transplantation is inferior to that from donors with large body weight, it can be improved through technical improvement. Donors with body weight ≤5 kg can be considered as an useful source to expand the donor pool.

[Comparative study of short-term efficacy,effectiveness and safety at different stages of the laparoscopic pancreaticoduodenectomy learning curve]

Objective: To compare short-term efficacy,effectiveness and safety of laparoscopic pancreaticoduodenectomy(LPD) learning curve at different stages and at the same time with open pancreaticoduodenectomy(OPD). Methods: Clinical data of 488 patients who underwent pancreaticoduodenectomy at Department of Biliary-Pancreatic Surgery,Affiliated Tongji Hospital,Tongji Medical College,Huazhong University of Science and Technology from July 2014 to December 2016 were collected. There were 40 cases at the groping stage of LPD surgery(100 cases at the same time of OPD),64 cases at the stable stage (89 cases at the same time of OPD),and 118 cases at the mature stage(77 cases at the same time of OPD).The clinical data of LPD and OPD in the same period were compared and analyzed by χ² test,t test and U test,respectively. Results: There was no significant difference in preoperative indicators between the two groups at the three stages(all P>0.05). In terms of intraoperative blood volume of the LPD group was significantly lower than that of the OPD group at three stages(M(Q_R))(111.1(150.0)ml(range:0 to 700 ml) vs. 393.9(400.0)ml(range:0 to 3 000 ml),120.8(115.0)ml(range:0 to 1 000 ml) vs. 442.9(450.0)ml(range:0 to 2 000 ml) and 150.0(200.0)ml(range:10 to 1 500 ml) vs. 364.3(400.0)ml(range:0 to 1 500 ml))(all P<0.05). And in terms of operation time of the LPD group was significantly higher than that of the OPD group at the groping stage((461.1±123.9)min(range:220 to 690 minutes) vs. (385.9±113.9)minutes(range:150 to 655 minutes))(P<0.05),and there was no significant difference between the LPD group and the OPD group at the stable and mature stage(P>0.05). The incidence of B+C level pancreatic fistula of the LPD group was higher than that of the OPD group at groping stage(17.5% vs. 3.0%)(P<0.05). There was no significant difference between the LPD group and the OPD group at the stable and mature stage(P>0.05). The incidence of postoperative rebleeding(27.5%),bile leakage(20.0%) and abdominal infection(20.0%) of the LPD group was higher than those of the OPD group(11.0%(11/100),5.0%(5/100) and 7.0%(7/100)) at groping stage. There were no significant differences between the LPD group and the OPD group at the stable and mature stage(P>0.05). There were no significant differences of incidence gastrointestinal leakage,hepatic failure,renal failure,cardiac failure,pulmonary infection and 30-day death between the LPD group and the OPD group(all P>0.05). The incidence rate of gastroplegia in the LPD group was lower than that in the OPD group at the stable and mature stage(26.5%(17/64) vs. 44.9%(40/89) and 24.5%(29/118) vs. 38.9%(30/77))(all P<0.05),there was no significant difference between the LPD group and the OPD group at the groping stage(P>0.05). In terms of other incidence of complications,there were no significant differences between the LPD group and the OPD group at three stages(all P>0.05). There were no significant differences of positive margin rate of pancreas,bile duct,retroperitoneum,vascular channel,uncinate process and rate of R0 resection between the LPD group and the OPD group at three stages(all P>0.05). In terms of numbers of lymph nodes,there was no significant difference between the LPD group and the OPD group at three stages(all P>0.05).Postoperative hospital stay of the LPD group was shorter than that of the OPD group at the stable stage((14.8±6.9)days(range:10 to 38 days) vs. (17.0±9.0)days(range:4 to 56 days)) and the mature stage((13.0±7.4)days(range:3 to 57 days) vs. (15.8±6.7)days(range:6 to 69 days)(all P<0.05). Conclusion: with the stable and mature learning curve of LPD surgery,compared with traditional OPD surgery,it has the characteristics of less intraoperative bleeding,shorter postoperative hospitalization,lower incidence of delay gastric empty,safe and effective.

The Relationship Between Blood Interleukin-10 and Cardiovascular Mortality and All-Cause Mortality After Kidney Transplantation

Background

Circulating interleukin (IL)-10 is associated with adverse cardiovascular events in chronic kidney disease (CKD). Whether IL-10 predicts cardiovascular and all-cause mortality after kidney transplantation (KT) is unknown.

Methods

The association between plasma IL-10 and cardiovascular and all-cause mortality was analyzed in a prospective cohort, which included 418 stable kidney transplant recipients, at a median of 3.6 (range=1.2–8.4) years after transplantation. Multivariate Cox regression models were performed to adjusting related confounding factors.

Results

Median level of IL-10 in KT patient was 22.3 pg/mL. Multivariate Cox regression analysis revealed that serum levels IL-10 were significantly and independently associated with cardiovascular mortality after adjusting for age, gender, BMI, current smoker, current drinker, cause of kidney disease, systolic and diastolic BP, laboratory indexes and medication (HR=1.26, 95% CI 1.19–2.08, P-trend<0.001). The multivariate Cox analysis also suggested that serum levels IL-10 were independently associated with all-cause mortality (HR=1.25, 95% CI 1.11–1.8, P-trend=0.023) after controlling these same related confounding factors. Sensitivity and stratified analysis showed that the significant association can be affected by history of acute rejection.

Conclusion

Plasma IL-10 is independently and significant associated with cardiovascular and all-cause mortality after kidney transplantation. The significant association is independent of cardiovascular risk factors and other related confounding factors.

Satisfactory usage of kidneys from pediatric donors with severe hand foot mouth disease

No studies have reported making use of kidneys from pediatric donors with severe HFMD. Here, we retrospectively analyzed the feasibility and clinical effect of six cases of kidney transplantation from four pediatric donors with severe HFMD in our center between January 2014 and December 2016. The donors' age ranged from 6 months to 3 years and 11 months. The recipients' age ranged from 18 to 41 years. Single kidney transplantation was performed in four recipients, and dual splitting kidney transplantation and en bloc kidney transplantation were performed in two recipients, respectively. During the 1.5-4 years follow-up, all recipients maintained normal kidney allograft function except for one recipient whose allograft was removed due to the allograft artery thrombosis. The survival rates of recipient and allograft were 100% and 83.3%, respectively. None of the six recipients showed any symptoms associated with HFMD. In conclusion, it is feasible to perform kidney transplantation from pediatric donors with severe HFMD to adult recipients with immunity to the pathogens. The clinical effect is satisfactory.

[Efficacy analysis of LVIS and Enterprise stent assisted coil in the treatment of vertebral artery dissection aneurysm]

Objective: To observe and evaluate the therapeutic efficacy of LVIS stent and Enterprise stent assisted coil in embolization of vertebral artery dissection aneurysm (VDA). Methods: Clinical data of 96 patients with VDAs treated by LVIS stent and Enterprise stent assisted coil were analyzed retrospectively between January, 2013 and June, 2017.Of all, the LVIS stent assisted coil was performed in 28 patients (LVIS-stent group) and Enterprise in 68 patients (Enterprise-stent group). The clinical and imaging follow-up were performed. The instant embolization rate, complications, and recurrence rate were analyzed and compared between the two groups. Results: Instant angiographic results:in the LVIS stent group, complete occlusion was achieved in 17 VDAs (60.7%), near-complete occlusion in 10VDAs (35.7%), and partial occlusion in 1 VDA (3.6%). In the Enterprise stent group, complete occlusion was achieved in 27 VDAs (39.7%), near-complete occlusion in 34VDAs(50.0%), partial occlusion in 7VDAs (10.3%). Procedure-related complications occurred in 3 patients (10.7%) in LVIS stent group and 3 patients (4.4%) in Enterprise stent group. DSA follow-up was performed during 6 to 12 months after surgery, and 10 patients with vertebral artery dissection aneurysm recurred, 2 in the LVIS group and 8 in the Enterprise stent group. The latest modified Rankin Scale score was 0 in 55 patients,1 in 13, 2 in 1, 3 in 1, and 6 in 1. Among them, all follow-up patients in the LVIS stent group had good prognosis, while in the Enterprise stent group, 50 patients (94.4%) had a good prognosis. Conclusions: The stent-assisted coils have a higher degree of embolization in the vertebral artery dissection aneurysms, a higher rate of near-total embolization, a lower incidence of neurological complications, and a good prognosis. The complete andnear-complete occlusion rates and the incidence of neurological complicationsin the LVIS group was higher than that in the Enterprise groupand the recurrence ratesin the LVIS group was lower than that in the Enterprise group,both with no statistically significant difference.

A case of pulmonary mucormycosis presented as Pancoast syndrome and bone destruction in an immunocompetent adult mimicking lung carcinoma

Pulmonary mucormycosis is a rare opportunistic infection caused by Mucormycosis. This fungal infection is uncommon in immunocompetent individuals. Because of its various clinical and imaging manifestations, it is a diagnostic challenge to distinguish pulmonary mucormycosis from other pulmonary diseases, such as carcinoma. Herein, we report a case of pulmonary mucormycosis presenting as Pancoast syndrome and bone destruction of ribs. A 46-year-old Chinese woman was admitted due to pain in chest, right neck and arm for four months and hoarseness for one week. The pre-admission diagnosis via chest CT was pulmonary carcinoma. The subsequent bronchoalveolar lavage fluid analysis and bronchoscopic biopsy were negative for malignant cells, except chronic inflammation. Imaging-guided percutaneous biopsies were carried out after admission and the final pathological diagnosis was pulmonary mucormycosis. Although the patient was started on oral posaconazole of 400mg bid, the disease condition continued to deteriorate. She finally died of respiratory failure.

A novel technique for en bloc kidney transplantation from infant donors with extremely low body weight by using the distal abdominal aorta as an outflow tract

Pediatric kidney donors remain underutilized due to the high risk of postoperative thrombosis. To address this problem, we developed a novel en bloc kidney transplantation technique using donor thoracic aorta and the distal abdominal aorta as inflow and outflow tracts, respectively. Briefly, eight kidneys from deceased infant donors under five months old and with low body weight (1.9-4.9 kg) were transplanted en bloc into four pediatric and four adult patients. The donor's common iliac artery or external iliac artery was anastomosed to the recipient's distal external iliac artery or inferior epigastric artery, respectively, as an outflow tract. Recipients received basiliximab or antithymocyte globulin as induction therapy followed by tacrolimus, mycophenolate mofetil, and prednisone but without prophylactic anticoagulation. Delayed graft function was observed in one patient but was reversed at 90 days posttransplant. Two patients had urine leakage, which was cured by conservative treatment. Two recipients developed lung infections that eventually cleared. No patients experienced posttransplant vascular thrombosis. After 1-1.5 years of follow-up, all patients are well and have normal serum creatinine levels. In conclusion, this novel en bloc kidney transplantation technique using a modified arterial inflow and outflow tract can prevent vascular thrombosis and provide adequate graft function.

[Efficacy analysis of the endovascular treatment for 175 unruptured vertebrobasilar dissecting aneurysms]

Objective: To analyze the clinical characteristics, clinical effect and follow-up outcome of the different endovascular treatment techniques in the treatment of unruptured vertebrobasilar dissecting aneurysms (VBDAs). Methods: The clinical data of 160 consecutive patients (175VBDAs) from January 2012 to December 2016 in Beijing Tiantan hospital were retrospectively analyzed.All of the 175 aneurysms were treated with endovascular embolization, including 115 stent-assisted coils, 27 simple stents, 21 blood flow diverting devices, and 12 parent arteries occlusion.The imaging and clinical follow-up were performed after the operation. Results: Headache including cervical-occipital pain(43.1%)was the most common clinical manifestation.The incidence of perioperative complications was 3.75%, no intraoperative bleeding and no deaths.The imaging findings of 113 aneurysms were followed up for (9.9±7.3) months.Of the 71 stent-assisted coils, 62 recovered well and 9 relapsed; of the 19 aneurysms treated with simple stent, 4 recovered well, 11 improved, 2 stable and 2 relapsed; of the 15 aneurysms treated by the blood flow diverting devices, 4 recovered and 11 improved; all of the 8 aneurysms with parent arteries occlusion recovered well.A total of 144 patients were follow-up (17.3±16.6) months by the Modified Rankin Scale(mRS) score: 140 patients were 0-2 score and 4 patients were 3-6 score. Conclusions: The clinical manifestations of the unruptured VBDAs are complex, and the headache is the most common clinical symptom.Endovascular treatment for the treatment of unruptured VBDAs is safe and feasible.The principle of individualization should be followed during embolization.

miR-26a suppresses autophagy in swine Sertoli cells by targeting ULK2

A large number of microRNAs (miRNAs) have been detected from porcine testicular tissues thanks to the development of high-throughput sequencing technology. However, the regulatory roles of most identified miRNAs in swine testicular development or spermatogenesis are poorly understood. In our previous study, ULK2 (uncoordinated-51-like kinase 2) was predicted as a target gene of miR-26a. In this study, we aimed to investigate the role of miR-26a in swine Sertoli cell autophagy. The relative expression of miR-26a and ULK2 levels has a significant negative correlation (R²  = .5964, p ≤ .01) in nine developmental stages of swine testicular tissue. Dual-luciferase reporter assay results show that miR-26a directly targets the 3'UTR of the ULK2 gene (position 618-624). In addition, both the mRNA and protein expression of ULK2 were downregulated by miR-26a in swine Sertoli cells. These results indicate that miR-26a targets the ULK2 gene and downregulates its expression in swine Sertoli cells. Based on the expression of marker genes (LC3, p62 and Beclin-1), overexpression of miR-26a or knock-down of ULK2 inhibits swine Sertoli cell autophagy. Taken together, these findings demonstrate that miR-26a suppresses autophagy in swine Sertoli cells by targeting ULK2.

[The mechanism of nicotine on human bronchial smooth muscle cell contraction]

Objective: To investigate the molecular mechanism of contractility dysfunction of human bronchial smooth muscle cells induced by nicotine. Methods: Primary human bronchial smooth muscle cells were cultured in vitro. The cells were divided into a control group and a nicotine group which was treated with 10(-5) mol/L nicotine for 48 h and transfected with or without α7nAChR-siRNA (The siNC group, siNC + nicotine group and siα7nAChR + nicotine group). The effects of nicotine on the cell contractile function were examined by collagen gel shrinkage assay. The expressions of α7nAChR and TRPC6 protein in nicotine-treated human bronchial smooth muscle cells were detected by Western blotting. The change of intracellular calcium concentration by nicotine was detected by calcium ion imaging system.Data were analyzed by t test or single factor analysis of variance. Results: The area of collagen gel in the nicotine group (24±8)% was significantly lower than that in the control group (59±14)% (t=3.78, P<0.05). Compared with the control group, the expression of α7nAChR protein in nicotine-induced group (173±16)% was significantly higher than that of controls 100±0)%, t=-6.848, P<0.05. Compared with the siNC group [(72±10)%, (0.79±0.07), (0.41±0.04) and (0.17±0.02) respectively], the collagen gel area of siNC + nicotine group was significantly reduced by (37±10)%. However, the basal calcium level (1.04±0.02), store operated calcium entry level (SOCE, 0.68±0.03) and receptor operated calcium entry level (ROCE, 0.36±0.02) were remarkably elevated in the nicotine treated group (all P<0.05). Furthermore, compared with siNC + nicotine group, the area of collagen gel in siα7nAChR + nicotine group was significantly increased (62±10)%, and the basal calcium level (0.78±0.06), SOCE level (0.39±0.05) and ROCE level (0.15±0.02) were significantly reduced (all P<0.05). Conclusions: Nicotine can increase the expression of TRPC6 protein, SOCE and ROCE level, and increase the intracellular calcium concentration by upregulating the expression of α7nAChR protein, thereby promoting smooth muscle cell contraction.

Efficient biocatalytic stereoselective reduction of methyl acetoacetate catalyzed by whole cells of engineered E. coli

Asymmetric synthesis of chiral β-hydroxy esters, the key building blocks for many functional materials, is currently of great interest. In this study, the biocatalytic anti-Prelog reduction of methyl acetoacetate (MAA) to methyl-(R)-3-hydroxybutyrate ((R)-HBME) was successfully carried out with high enantioselectivity using the whole cell of engineered E. coli, which harbored an AcCR (carbonyl reductase) gene from Acetobacter sp. CCTCC M209061 and a GDH (glucose dehydrogenase) gene from Bacillus subtilis 168 for the in situ regeneration of the coenzyme. Compared with the corresponding wild strain, the engineered E. coli cells were proved to be more effective for the bio-reduction of MAA, and afforded much higher productivity. Under the optimized conditions, the product e.e. was >99.9% and the maximum yield was 85.3% after a reaction time of 10 h, which were much higher than those reported previously. In addition, the production of (R)-HBME increased significantly by using a fed-batch strategy of tuning pH, with a space-time yield of approximately 265 g L-1 d-1, thus the issue in previous research of relatively low substrate concentrations appears to be solved. Besides, the established bio-catalytic system was proved to be feasible up to a 150 mL scale with a large-scale relatively high substrate concentration and selectivity. For further industrial application, these results open a way to use of whole cells of engineered E. coli for challenging higher substrate concentrations of β-ketone esters enantioselective reduction reactions.

Efficacy and safety of uninterrupted low-intensity warfarin for cryoballoon ablation of atrial fibrillation in the elderly: A pilot study

WHAT IS KNOWN AND OBJECTIVE

Uninterrupted warfarin during cryoballoon ablation (CB-A) of atrial fibrillation (AF) has been widely accepted. However, to our knowledge, no previous studies exist investigating the optimal intensity of anticoagulation with warfarin for CB-A. This study aimed to evaluate the efficacy and safety of uninterrupted low-intensity warfarin for CB-A of AF in the elderly.

METHODS

Paroxysmal AF patients (age ≥ 70 years) who underwent CB-A were enrolled prospectively. The participants were stratified into 2 groups based on international normalized ratio (INR) before ablation (INR in group A: 1.5 to 2.0; INR in group B: 2.0-2.5). Primary endpoints included periprocedural thromboembolic complications and major bleeding. Secondary endpoints were new asymptomatic cerebral emboli (ACE) and minor bleeding.

RESULTS AND DISCUSSION

A total of 144 patients were enrolled (group A: 65; group B: 79). In group A, the use of concomitant antiplatelet drugs was more common. Also, the mean HAS-BLED score was significantly higher (2.4 ± 0.8 vs 2.0 ± 0.6, P < .01) and the mean activated clotting time (ACT) during the procedure was significantly lower (302 ± 14 s vs 311 ± 11 s, P < .01). Other clinical characteristics were balanced between the 2 groups. No thromboembolic complications and major bleeding occurred in either group. The incidence of periprocedural ACE was comparable between the 2 groups (9.2% vs 6.3%, P = .74). The incidence of minor bleeding in group A and group B was 4.6% and 11.4%, respectively (P = .14).

WHAT IS NEW AND CONCLUSION

Compared with standard-intensity warfarin, uninterrupted low-intensity warfarin might not increase the incidence of thromboembolic complications and might be associated with less bleeding risk during the perioperative period of cryoballoon ablation in the elderly. Large trials are needed to confirm these results.

Impacts of serum P-selectin on blood pressure control after PCI in patients with coronary heart disease complicated with hypertension

OBJECTIVE

We analyzed the impact of potent anti-hypertension or anti-thrombotic therapy after PCI in patients with coronary heart disease complicated with hypertension, whilst to reflect the prognosis by testing P-selectin.

PATIENTS AND METHODS

A total of 177 patients with coronary heart disease (CHD) complicated with hypertension was continuously enrolled in this study and randomly divided into traditional anti-hypertension group (group A: 130/80 mm Hg ≤ BP ≤ 140/90 mm Hg; anti-hypertensive drugs: β blockers and angiotensin converting enzyme inhibitor, n=84) and potent anti-hypertension group (group B: BP <130/80 mm Hg; dosage and frequency in group B > group A, n=93). This study was approved by the Ethics Committee of Shaoxing People's Hospital. Signed written informed consents were obtained from all participants before the study. Patients who need a stent placed (CAG shows narrowed vascular diameter ≥75%) have to continuously be followed-up for one year. Standard anti-hypertension (fluctuation of BP <5 mm Hg measured for 3 successive days) was detected respectively at admission and inpatient. The blood pressure, low-density lipoprotein cholesterin (LDL-C), high-sensitivity C-reactive protein (hs-CRP) and P-selectin levels were tested 1 month and 1 year after discharge; the time of adverse events (AEs) was also recorded.

RESULTS

There were no statistical differences between the occurrence times of AEs between group A and B (p=0.946). The P-selectin [(83±21) vs. (69±16) μg/L, p=0.038], systolic pressure [(134±8) vs. (119±13) mm Hg, p<0.001] and diastolic pressure [(85±6) vs. (70±5) mm Hg] in group A were higher (p=0.001) than those of group B. Compared with P-selectin ≥50.00 μg/L, the median survival time (>12 vs. 10 months, χ2=3.621, p=0.047) of P-selectin <50.00 μg/L was longer. By comparing P-selectin in different SBP grading (<120 mm Hg, 120-130 mm Hg, 130-140 mm Hg), the difference was statistically significant (χ2=12.912, p=0.002).

CONCLUSIONS

Potent anti-hypertension may influence the occurrence time of AEs after PCI in patients with coronary heart disease complicated hypertension. P-selectin can be a sensitive indicator. SBP has an apparent "J-curve effect" and an appropriate anti-hypertensive scope (120-130 mm Hg).