The clinical outcome of fractional flow reserve based coronary revascularization strategy of the patients on hemodialysis

Background

The optimal coronary revascularization strategy for the patients on hemodialysis is yet to be determined. In the real-world practice, we sometimes encounter the rapid deterioration after percutaneous coronary intervention (PCI) to angiographically intermediate but functionally significant stenosis. According to the fractional flow reserve (FFR) based revascularization strategy, the clinical outcome of the deferred lesions is reported to be almost equivalent to that of the lesions received PCI. However, whether the relationship also applies to hemodialysis patients is unclear.

Purpose

To assess the clinical outcome of the lesions for which revascularization strategy was determined by FFR in patients with hemodialysis.

Methods

Consecutive 147 vessels in 120 patients with hemodialysis whose revascularization strategy was decided according to the FFR were enrolled in this study. We compared the clinical outcomes of the deferred group (FFR ≥0.80, 87 vessels, 78 patients) with the PCI group (FFR<0.80, 60 vessels, 42 patients). The primary endpoint of this study was target vessel failure (TVF) defined as a composite of TV revascularization and myocardial infarction evaluated by per-vessel analysis. The secondary endpoint was major adverse cardiovascular events (MACE) defined as all cause death, myocardial infarction, urgent revascularization evaluated by per-patient analysis.

Results

The median follow-up period was 2.3 years (interquartile range, 1.5–4.0 years). The beseline characteristics of the lesions and patients were well balanced between the 2 treatment groups except for the distribution of target vessels and FFR value. The cumulative TVF rate was not significantly different between the deferred group and PCI group (2-year event rate 26.7% vs. 17.7%; Log-rank p=0.23). The risk of MACE was also not significantly different between two groups (2-year event rate 35% vs. 30%; Log-rank p=0.48).

Conclusion

The clinical outcome of the lesions/patients for which received revascularization based on FFR was equivalent to the deferred lesions/patients even in the patients on hemodialysis (2,129/3,000).

Funding Acknowledgement

Type of funding sources: None. Table 1Figure 1

Alpelisib administration reduced lymphatic malformations in a mouse model and in patients

[Figure: see text].

Ultrasonographic evaluation of the caudal vena cava in dogs with right-sided heart disease

INTRODUCTION/OBJECTIVES

In humans with impaired right-sided cardiac function, the caudal vena cava (CVC) diameter serves as a marker of venous congestion. This study aimed to investigate whether ultrasonographic CVC variables could identify the presence of right-sided congestive heart failure (R-CHF) in dogs with right-sided heart disease (RHD).

ANIMALS

Fifty client-owned control dogs and 67 dogs with RHD were enrolled. The dogs with RHD were subdivided into the non-R-CHF (n = 43) and R-CHF (n = 24) groups.

MATERIALS AND METHODS

We measured and compared the ultrasonographic CVC variables and echocardiographic variables among the groups. Receiver operating characteristic (ROC) curve analysis was performed to calculate the sensitivity and specificity of the variables at optimal cutoff values.

RESULTS

We obtained the highest accuracies of the ratio of the shortest diameter (SD) of the minimal CVC area to the aorta diameter (Ao) during inspiration [SD(min)/Ao] and of the ratio of SD(min) to the longest diameter of the minimal CVC area during inspiration [LD(min),SD/LD(min)], with high sensitivities, specificities, and an area under the ROC curve greater than 0.925.

CONCLUSIONS

In addition to the echocardiographic assessment of right-sided cardiac function, the CVC variables in this study, especially SD(min)/Ao and SD/LD(min), would be useful diagnostic indices for identifying R-CHF in dogs with RHD.

Aggressive lipid lowering therapy with pitavastatin and ezetimibe improve cardiovascular outcomes in patients with ST segment elevation myocardial infarction: insights from the HIJ-PROPER Study

Aims

The purpose of this study was to evaluate the effect of aggressive lipid-lowering therapy with pitavastatin and ezetimibe in patients with ST-segment elevation myocardial infarction (STEMI) as compared with those with other classification of an acute coronary syndrome (ACS) including non-STEMI (NSTEMI) and unstable angina pectoris (UA).

Methods

This is a post hoc sub-analysis of the HIJ-PROPER study. In the original study, ACS patients with dyslipidemia were randomized to either pitavastatin + ezetimibe therapy or pitavastatin monotherapy. In the present analysis, we divided HIJ-PROPER participants into the STEMI group (n=880) and NSTEMI + UA group (n=841). Cardiovascular events were analyzed between the two groups. The primary endpoint was a composite of major advanced cardiovascular events (MACE; all-cause death, non-fatal myocardial infarction, non-fatal stroke, unstable angina pectoris, and ischemia-driven revascularization)

Result

During median follow-up period of 3.4 years, the cumulative incidence of the primary endpoint in STEMI group was 31.9% in the pitavastatin+ezetimibe therapy, compared with 39.7% in the pitavastatin-monotherapy (HR, 0.77; 95% CI, 0.62–0.97; p=0.02). However, there was no effect of pitavastatin+ezetimibe therapy on the primary endpoint in the NSTEMI + UA group. Concerning the individual components of the primary endpoint in STEMI group, the percentage of occurrence of all-cause death was significantly lower in the pitavastatin+ezetimibe therapy compared to pitavastatin mono-therapy (14 patients (3.2%) vs. 31 patients (6.9%), respectively; HR, 0.45; 95% CI, 0.23–1.84, p=0.01). Multivariate analysis revealed that use of ezetimibe and prevalence of diabetes mellitus at baseline were independent predictors of primary endpoints in STEMI group (HR, 0.79; 95% CI, 0.63–0.99; p=0.04 for use of ezetimibe, HR 1.54; 95% CI, 1.22–1.94, p=0.0003 for diabetes mellitus).

Conclusion

Patients with pitavastatin+ezetimibe therapy as compared with pitavastatin-monotherapy had lower cardiovascular event in patients with ST-segment elevation myocardial infarction.

Kaplan-Meier curves for primary endpoint

Funding Acknowledgement

Type of funding source: None

Impact of comprehensive management on clinical outcomes in hypertensive patients with coronary artery disease: HIJ-CREATE sub-study

Background

There are limited data on the effects of blood pressure (BP) control and lipid lowering in secondary prevention of coronary artery disease (CAD) patients. We report a secondary analysis of the effects of BP control and lipid management in participants of the HIJ-CREATE, a prospective randomized trial.

Methods

HIJ-CREATE was a multicenter, prospective, randomized, controlled trial that compared the effects of candesartan-based therapy with those of non-ARB-based standard therapy on major adverse cardiac events (MACE; a composite of cardiovascular death, non-fatal myocardial infarction, unstable angina, heart failure, stroke, and other cardiovascular events requiring hospitalization) in 2,049 hypertensive patients with angiographically documented CAD. In both groups, titration of antihypertensive agents was performed to reach the target BP of <130/85 mmHg. The primary endpoint was the time to first MACE. Incidence of endpoint events in addition to biochemistry tests and office BP was determined during the scheduled 6, 12, 24, 36, 48, and 60-month visits. Achieved systolic BP and LDL-Cholesterol (LDL-C) level were defined as the mean values of these measurements in patients who did not develop MACEs and as the mean values of them prior to MACEs in those who developed MACEs during follow-up.

Results

During a median follow-up of 4.2 years (follow-up rate of 99.6%), the primary outcome occurred in 304 patients (30.3%). Among HIJ-CREATE participants, 905 (44.2%) were prescribed statins on enrollment. Kaplan–Meier curves for the primary outcome revealed that there was no relationship between statin therapy and MACEs in hypertensive patients with CAD. The original HIJ-CREATE population was divided into 9 groups based on equal tertiles based on mean achieved BP and LDL-C during follow-up. For the analysis of subgroups, estimates of relative risk and the associated 95% CIs were generated with a Cox proportional-hazards model (Figure 1). The relation between LDL cholesterol level and hazard ratios for MACEs was nonlinear, with a significant increase of MACEs only in the patients with inadequate controlled LDL-C level even in the patients with tightly controlled BP.

Conclusions

The results of the post-hoc analysis of the HIJ-CREATE suggest that clinicians should pay careful attention to conduct comprehensive management of lipid lowering even in the contemporary BP lowering for the secondary prevention in hypertensive patients with CAD.

Figure 1

Funding Acknowledgement

Type of funding source: None

Lower levels of high-density lipoprotein cholesterol are associated with increased cardiovascular events in patients with acute coronary syndrome receiving contemporary lipid-lowering therapy

Background

This study aimed to elucidate whether high-density lipoprotein cholesterol (HDL-C) at 3-month follow-up for patients receiving contemporary lipid-lowering therapy after acute coronary syndrome (ACS) could predict cardiac events.

Methods

The HIJ-PROPER study was a multicenter, prospective, randomized trial comparing intensive lipid-lowering therapy (pitavastatin + ezetimibe) and conventional lipid-lowering therapy (pitavastatin monotherapy) after ACS. For the present analysis, the entire cohort was divided into three groups according to HDL-C levels at 3-month follow-up (Group 1, HDL-C ≤43 mg/dL; Group 2, 43–53.6 mg/dL; Group 3; HDL-C ≥53.6 mg/dL). Baseline characteristics and the incidence of the primary endpoint (a composite of all-cause death, non-fatal myocardial infarction, non-fatal stroke, unstable angina pectoris, or ischemia-driven revascularization) were compared among the three groups.

Results

The primary endpoint was reported in 34.8%, 30.1%, and 24.6% of patients in Groups 1, 2, and 3, respectively. The incidence of the primary endpoint was significantly higher in Group 1 than in Group 3 (hazard ratio [HR], 1.5; 95% confidence interval [CI], 1.19–1.9; p=0.001). Irrespective of the treatment regimen, Group 1 had a significantly higher rate of the primary endpoint than Group 3 (pitavastatin + ezetimibe therapy: HR, 1.6; 95% CI, 1.12–2.22; p=0.01 and pitavastatin monotherapy: HR, 1.4; 95% CI, 1.05–1.98; p=0.02). These trends remained even after adjustment for baseline characteristics and lipid profiles.

Conclusions

Lower levels of HDL-C at 3-month follow-up are associated with higher incidence of the cardiovascular events in patients with acute coronary syndrome receiving contemporary lipid-lowering therapy.

HDL-C levels and Cardiovascular events

Funding Acknowledgement

Type of funding source: None

Effects of PCSK9 inhibitor on adverse limb outcomes in patients with critical limb ischemia

Background

The proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9-I), evolocumab, reduced the risk of cardiovascular event in patients with peripheral artery disease in FOURIER trial. However, the effects of evolocumab on favorable limb outcomes in patients with critical limb ischemia (CLI) is still unclear.

Purpose

The aim of this study was to evaluate the impacts of evolocumab on favorable limb outcomes and lipid profile in patients with CLI.

Methods

This was a single center, prospective observational study. A total of 39 patients with CLI were enrolled between November 2016 to May 2019. The subjects were divided into 2 groups based on evolocumab administration: evolocumab-treated group: E group (mean 69.4±11.7 years, n=14) and evolocumab non-treated group: Non-E group (mean 74.0±8.8 years, n=25). Baseline characteristics were assessed at admission. Lipid profile was evaluated at admission, 1, 3, 6, 12 and 18 months. The primary outcome was defined 18-month amputation-free survival (AFS). The secondary outcomes were defined 18-month overall survival (OS) and wound-free limb salvage. Mean follow-up period was 18±11 months.

Results

The patients in E group had greater reduction in levels of LDL cholesterol and non-HDL cholesterol than those in Non-E group over time. The reduction in MDA-LDL level was maintained at 1, 3, 6, 12 months, respectively. The 18-month AFS rate in the E-group was significantly higher than those in the Non-E group (log-rank p=0.02). The patients receiving evolocumab had a lower hazard regarding AFS (hazard ratio, 0.12; 95% confidence interval, 0.02–0.94; P=0.043) and a higher proportion of wound-free limb salvage at 12 months (E group [92%] vs Non-E group [57%], P=0.034) and 18 months (92% vs 52%, P=0.03). Otherwise, evolocumab administration was not associated with 18-month OS (log-rank p=0.053).

Conclusions

Evolocumab administration may be associated with the favorable outcome of 18-month AFS in the patients with CLI. Additionally, long-term administration of evolocumab over 12 months may improve wound-free limb salvage.

Effects of evolocumab on limb outcomes

Funding Acknowledgement

Type of funding source: None

Suppression of gastric acid secretion decreased cardiovascular events independent of severe bleeding events in patients after percutaneous coronary intervention – sub-analysis from multicenter registry

Background

Suppression of gastric acid secretion by proton-pump inhibitor (PPI) or potassium-competitive acid blocker (P-CAB) has recently been developed as a standard strategy for preventing gastrointestinal bleeding for patients receiving antiplatelet therapy after percutaneous coronary intervention (PCI). However, there has been limited evidences on the association between PPI/P-CAB administration and adverse cardiovascular events in patients undergoing PCI.

Purpose

We aimed to evaluate the prognostic impact of the prescription of PPI/P-CAB on clinical outcomes in patients after PCI.

Methods

This study is a subanalysis from the TWINCRE registry that is a multicentral prospective cohort including patients who underwent PCI at 12 hospitals in Japan between 2017 and 2019. Among registered patients, we ultimately evaluated 1,428 patients who were followed-up. They were divided into two groups by the prescriptions of PPI or P-CAB at discharge for the index PCI; the PPI/P-CAB group (n=1,023), and the Non-PPI/P-CAB group (n=407). The primary endpoint was major adverse cardiovascular and cerebrovascular events (MACCE) including death, acute coronary syndrome, stent thrombosis, hospitalization due to heart failure and ischemic stroke. Secondary endpoints was major bleeding events defined BARC3, 4 and 5.

Results

The average age of the study population was 70.3 years and 80.3% were male. Baseline clinical profiles were comparable between the groups, except that the PPI/P-CAB group included significantly higher rate of patients who had history of prior PCI (28.4% vs 18.7%, P=0.02). Additionally, there was no significant difference in the duration of dual antiplatelet therapy between the PPI/P-CAB group and Non-PPI/P-CAB group (average duration; 287±8 vs. 285±8 days, P=0.66). Overall, MACCE was developed in 132 patients (9.3%), and bleeding event was observed in 24 patients (1.7%) during 574 days of median follow-up period. Kaplan-Meier analysis showed that patients in the PPI/P-CAB group had a significantly lower rate of MACCE than those in the Non-PPI/P-CAB group (Log-rank test, p=0.0003, Figure 1A). Multivariate Cox regression analysis revealed that the prescription of PPI/P-CAB still was independently associated with the primary endpoint (hazard ratio 0.532, 95% confidence interval 0.369–0.766, p=0.0007), even after the adjustment by diverse covariates. Whereas, there was no significant difference in the bleeding event (p=0.64, Figure 1B).

Conclusion

PPI or P-CAB therapy was associated with better clinical outcomes after PCI, independent of the incidences of severe bleeding events.

Figure 1

Funding Acknowledgement

Type of funding source: None

P824The clinical impact of polyunsaturated fatty acid on clinical outcomes in acute coronary syndrome with dyslipidemia: HIJ-PROPER sub-analysis

Background

Polyunsaturated fatty acids, especially omega-3 and -6 series, are key essential nutrients that play an important role in humans to maintain cell membranes and function. A recent randomized trial reported that adding eicosapentaenoic acid (EPA) to statins was beneficial to cardiovascular disease patients who had a residual risk factor. Further, several studies have reported that the low baseline value for EPA to arachidonic acid (AA) ratio is related to worse clinical outcome and plaque vulnerability in coronary artery disease patients. However, effects of baseline EPA/AA ratio on clinical outcomes in ACS patients have not been thoroughly evaluated.

Objectives

This study aimed to examine the impact of baseline eicosapentaenoic acid to arachidonic acid (EPA/AA) ratio on clinical outcomes of acute coronary syndrome (ACS) patients and how lipid-lowering therapy affects serum EPA/AA levels in these patients.

Methods

This is a sub-analysis of HIJ-PROPER assessing the effect of aggressive low-density lipoprotein cholesterol (LDL-C)-lowering treatment with pitavastatin+ezetimibe in 1,734 ACS patients with dyslipidemia. Patients were divided into two groups based on EPA/AA level on admission (cut-off: 0.34 μg/mL; median of baseline EPA/AA level) and clinical outcomes were examined.

Results

Percent reduction of LDL-C from baseline to follow-up and mean LDL-C level during follow-up were similar regardless of baseline EPA/AA ratio. In the low EPA/AA group, the Kaplan–Meier estimate for the primary endpoint at 3 years was 27.2% in the pitavastatin+ezetimibe group, compared with 36.6% in the pitavastatin-monotherapy group [hazard ratio (HR), 0.69; 95% confidence interval (CI), 0.52–0.93; P=0.015). However, in the high EPA/AA group, there was no significant reduction in the primary endpoint by pitavastatin+ezetimibe therapy (HR, 0.92; 95% CI, 0.70–1.20; P=0.52).

Conclusions

Aggressive lipid-lowering therapy with ezetimibe had a positive effect on clinical outcomes in the low EPA/AA group of ACS patients with dyslipidemia, but not in the high EPA/AA group. This effect was independent of LDL-C reduction and suggests that EPA/AA measurement on admission in ACS patients contributes to a “personalized” lipid-lowering approach.

P830Differences in the usefulness of aggressive lipid-lowering therapy among single-vessel and multi-vessel coronary artery disease patients: HIJ-PROPER sub-study

Background

Acute coronary syndrome (ACS) patients with multi-vessel disease (MVD) are at high risk of recurrent cardiovascular events. Previous study, examining stable atherosclerotic cardiac disease, reported that aggressive lipid-lowering therapy was more beneficial in MVD patients than in single-vessel disease (SVD) patients. However, no report has investigated the effects of aggressive lipid-lowering treatment according to the number of diseased coronary arteries in ACS patients.

Purpose

The purpose of the present study was to elucidate the efficacy of aggressive lipid-lowering therapy in ACS patients with MVD and SVD in modern early invasive strategy era.

Methods

The study population was derived from the HIJ-PROPER study, in which, ACS patients with dyslipidemia were randomized to pitavastatin + ezetimibe therapy (targeting LDL-C less than 70mg/dl) or pitavastatin-monotherapy (targeting LDL-C less than 90mg/dl). In the present study, the treatment efficacy was compared between patients with MVD and SVD. The primary end point was a composite of major advanced cardiovascular events (MACEs), including all-cause death, non-fatal myocardial infarction, non-fatal stroke, and ischemia driven revascularization.

Results

We identified 1702 eligible patients (mean age, 65.6 years; male, 75.6%); 869 patients (51.1%) had MVD and 833 (48.9%) patients had SVD. The rate of acute revascularization was 96.2%. The incidence of MACEs was significantly higher in MVD group compared to SVD group (43.7% vs 25.9%, hazard ratio 1.95, 95% confidence interval 1.65–2.31, p<0.001). In MVD group, there was no significant difference in MACEs between pitavastatin + ezetimibe therapy and pitavastatin-monotherapy group. (43.5% vs. 43.9%, 1.0, 0.82–1.23; p=0.95). However, in SVD group, pitavastatin + ezetimibe therapy showed significantly fewer MACEs than pitavastatin-monotherapy (34.6% vs. 47.4%, 0.72, 0.55–0.94, p=0.02). (Figure)

Conclusion

This study showed that ACS patients with SVD enjoyed significantly greater benefits from pitavastatin + ezetimibe therapy compared with pitavastatin monotherapy, whereas the patients with MVD did not. High rate of revascularization in acute phase of ACS might affect the efficacy of aggressive lipid-lowering therapy and our results in the present study suggest different treatment approach would be necessary in ACS patients with MVD in modern early invasive strategy era.

P6339Sequential organ failure assessment score on admission predicts long-time mortality of the patients with acute heart failure

Background

Despite the remarkable advances in the treatment options of acute heart failure (HF), prognosis assessment remains an ongoing challenge. Previous studies revealed only a moderate accuracy of models predicting mortality. Sequential Organ Failure Assessment (SOFA) Score are widely used in the intensive care unit (ICU) to predict outcome and predicted higher long-time mortality in unselected patients in cardiac ICU. In addition, the American Heart Association Get With the Guidelines–Heart Failure (GWTG-HF) risk score allows for risk stratification of 30-day outcome for patients hospitalized with HF. The purpose of this study was to evaluate whether SOFA score on admission is useful for long-time mortality prediction in acute HF patients and also to assess the discriminative performance as compared with GWTG-HF risk score.

Methods

This was a single-centre, retrospective cohort study. Between January 2007 and December 2016, we screened eligible 661 consecutive patients with acute HF administered at our hospital. SOFA score on admission of 294 patients was able to calculate retrospectively. We enrolled 269 patients who could complete follow up evaluation for more than 1 year. Endpoint was all-cause mortality after admission. Additive information of SOFA score was evaluated by area under the curve (AUC), net reclassification improvement (NRI), integrated discrimination improvement (IDI) and decision curve analysis (DCA).

Results

The 269 patients were included in this study (78.5±10.9 years; 136 men; left ventricular ejection fraction [EF], 49.8±16.6%) during a mean follow-up of 32.1±22.3 months. Patients with all-cause death had higher SOFA score (4.2±2.3 versus 2.8±1.8, p<0.001; AUC, 0.689) and GWTG-HF risk score (44.0±7.6 versus 38.1±7.9, P<0.001, AUC, 0.692).

Kaplan-Meier survival analysis demonstrated higher SOFA scores (P<0.001) and GWTG-HF risk scores (P<0.001) appears to be related to increase probabilities of all cause death. A multivariate Cox proportional hazard model were made with adjustment for SOFA score, GWTG-HF risk score, age, gender and ejection fraction. As a result, SOFA score (hazard ratio [HR] 1.227; 95% confidence interval [CI], 1.130 to 1.326; P<0.001), GWTG-HF (HR, 1.054; 95% CI, 1.029 to 1.078; P<0.001) and age (HR, 1.069; 95% CI 1.048 to 1.092; P<0.001) were independent predictors of all cause death and HR of SOFA score was the highest in these parameters. Incorporating SOFA score into GWTG-HF score yielded a significant NRI (0.528 (95% CI 0.291 to 0.765) and IDI (0.046 (95% CI 0.020 to 0.072). In DCA, compared with the reference model, the net benefit for SOFA score model was greater across the range of threshold probabilities.

Conclusions

The SOFA score, simple and validated mortality risk score can predict long-term all-cause mortality in patients with acute HF. Discriminative performance metrics such as NRI, IDI and DCA were improved on incorporation of the SOFA score for prediction of mortality.

P5577Preoperative transaortic pressure gradient predicts renal functional improvement after transcatheter aortic valve implantation in patients with chronic kidney disease

Introduction

Transcatheter aortic valve implantation (TAVI) theoretically increases renal blood flow through increasing cardiac output by relieving aortic valvular obstruction of blood flow from left ventricle, resulting in a renal functional recovery in patients with severe aortic valve stenosis (AS). However, procedural steps of TAVI including contrast use potentially damages renal medulla and may deteriorate renal function.

Purpose

The aim of this study was to investigate renal functional change and clarify preoperative predictors for renal functional improvement after TAVI in chronic kidney disease (CKD) patients with severe AS.

Methods

A total of 88 consecutive severe AS patients with CKD (grade >3) who underwent TAVI from 2015 to 2018 was enrolled in this observational study. They were divided into two groups depending on their renal functional improvement after TAVI that was defined as more than 10% increase in estimated glomerular filtration rate (eGFR) at discharge from their preoperative level.

Results

Among the whole candidates, 49 patients (55.7%) were improved their renal function. Patients with the lowest preoperative eGFR achieved the highest increase in eGFR after TAVI (CKD grade >4: +22.7±23.7%, Figure). Patients in the Improved group had lower hemoglobin level, higher mean transaortic pressure gradient (TAPG), and higher aortic valve gradient before TAVI, compared to those in the Non-improved group. However, contrast volume during the procedure was not significantly different between the groups. Multivariate logistic regression analysis revealed that high mean TAPG and low left ventricular ejection fraction (LVEF) before TAVI were independent predictors for the improvement of renal function (odds ratio (OR): 1.04, 95% confidence interval (CI): 1.00–1.08; OR: 0.94, 95% CI: 0.89–0.99, respectively), even after the adjustment of baseline eGFR level and hemoglobin level that were statistically significant on univariate logistic regression analysis. Receiver Operating Characteristic (ROC) curve showed the cut-off level of preoperative mean TAPG in renal functional improvement after TAVI as 47.0 mmHg (Sensitivity: 47.9%, Specificity: 79.5%, area under the curve: 0.62).

Correlation between CKDgrade and ΔeGFR

Conclusions

Preoperative high mean TAPG may predict renal functional improvement after TAVI in patients with deteriorated renal function. This non-invasive predictor may help clinicians to consider to perform TAVI in a challenging case with severe CKD.

Benign hilar bile duct strictures resected as perihilar cholangiocarcinoma

BACKGROUND

Differentiation between perihilar cholangiocarcinoma (PHCC) and benign strictures is frequently difficult. The aim of this study was to investigate the incidence and long-term outcome of patients with tumours resected because of suspicion of PHCC, which ultimately turned out to be benign (malignancy masquerade).

METHODS

Patients who underwent surgical resection with a diagnosis of PHCC between 2001 and 2016 were reviewed retrospectively.

RESULTS

Among 707 consecutive patients, 685 had PHCC and the remaining 22 (3·1 per cent) had benign biliary stricture. All patients with benign disease underwent major hepatectomy, with no deaths. Preoperative histological assessment using bile duct biopsy or aspiration cytology had a high specificity (90 per cent), low sensitivity (62 per cent) and unsatisfactory accuracy (63 per cent). Despite the increasing use of histological assessment, the incidence of benign strictures resected did not decrease over time, being 0·9 per cent in 2001-2004, 4·0 per cent in 2005-2008, 3·8 per cent in 2009-2012 and 2·9 per cent in 2013-2016. The final pathology of benign strictures included IgG4-related sclerosing cholangitis (9 patients), hepatolithiasis (4), granulomatous cholangitis (3), non-specific chronic cholangitis (3), benign strictures after cholecystectomy (2), and a benign stricture possibly caused by parasitic infection (1). The 10-year overall survival rate for the 22 patients with benign stricture was 87 per cent, without recurrence of biliary stricture.

CONCLUSION

The incidence of benign strictures resected as PHCC as a proportion of all resections was relatively low, at 3·1 per cent. Currently, unnecessary surgery for suspected PHCC is unavoidable.

Modulation of extrasynaptic GABAA alpha 5 receptors in the ventral hippocampus normalizes physiological and behavioral deficits in a circuit specific manner

Hippocampal hyperactivity is correlated with psychosis in schizophrenia patients and likely attributable to deficits in GABAergic signaling. Here we attempt to reverse this deficit by overexpression of the α5-GABAA receptor within the ventral hippocampus (vHipp). Indeed, this is sufficient to normalize vHipp activity and downstream alterations in dopamine neuron function in the MAM rodent model. This approach also attenuated behavioral deficits in cognitive flexibility. To understand the specific pathways that mediate these effects, we used chemogenetics to manipulate discrete projections from the vHipp to the nucleus accumbens (NAc) or prefrontal cortex (mPFC). We found that inhibition of the vHipp-NAc, but not the vHipp-mPFC pathway, normalized aberrant dopamine neuron activity. Conversely, inhibition of the vHipp-mPFC improved cognitive function. Taken together, these results demonstrate that restoring GABAergic signaling in the vHipp improves schizophrenia-like deficits and that distinct behavioral alterations are mediated by discrete projections from the vHipp to the NAc and mPFC.

Prepatterning of Papilio xuthus caterpillar camouflage is controlled by three homeobox genes: clawless, abdominal-A, and Abdominal-B

Color patterns often function as camouflage to protect insects from predators. In most swallowtail butterflies, younger larvae mimic bird droppings but change their pattern to mimic their host plants during their final molt. This pattern change is determined during the early fourth instar by juvenile hormone (JH-sensitive period), but it remains unclear how the prepatterning process is controlled. Using Papilio xuthus larvae, we performed transcriptome comparisons to identify three camouflage pattern-associated homeobox genes [clawless, abdominal-A, and Abdominal-B (Abd-B)] that are up-regulated during the JH-sensitive period in a region-specific manner. Electroporation-mediated knockdown of each gene at the third instar caused loss or change of original fifth instar patterns, but not the fourth instar mimetic pattern, and knockdown of Abd-B after the JH-sensitive period had no effect on fifth instar patterns. These results indicate the role of these genes during the JH-sensitive period and in the control of the prepatterning gene network.

Relationships between blood pressure lowering therapy and cardiovascular events in hypertensive patients with coronary artery disease and type 2 diabetes mellitus: The HIJ-CREATE sub-study

OBJECTIVE

The effects of intensive blood pressure (BP) lowering for hypertensive patients with coronary artery disease (CAD) and diabetes mellitus on their clinical outcomes have not been fully evaluated. The aim was to explore the optimal systolic BP target in such patients in a substudy of a prospective, randomized trial.

METHODS

Of a total of 2049 hypertensive patients with CAD who were enrolled in the HIJ-CREATE study, type 2 diabetes was diagnosed in 780 (38.1%). Titration of antihypertensive agents was performed to reach the target BP of <130/85 mmHg. The primary endpoint was the occurrence of a first major adverse cardiovascular event (MACE). Achieved BP was defined as the mean value of systolic BP in patients who did not develop MACEs and as the mean value of systolic BP prior to MACEs in those who developed MACEs during follow-up.

RESULTS

During a median follow-up of 4.2 years, the primary outcome occurred in 259 (33.2%) diabetic patients and in 293 (23.1%) non-diabetic patients (p < 0.0001). The diabetic patients were divided into quartiles based on the mean systolic BP during follow-up. The relationships between achieved BP and the incidence of MACEs did not follow a J-shaped curve. Intensive systolic BP lowering to less than 120 mmHg did not correlate with an increased risk of MACEs.

CONCLUSIONS

Our results suggest that the intensive BP lowering may not impair patients' clinical courses even in a high-risk population. The establishment of an optimal management strategy for hypertensive patients with diabetes and CAD is essential.

Major hepatectomy with or without pancreatoduodenectomy for advanced gallbladder cancer

BACKGROUND

The indications for major hepatectomy for gallbladder cancer either with or without pancreatoduodenectomy remain controversial. The clinical value of these extended procedures was evaluated in this study.

METHODS

Patients who underwent major hepatectomy for gallbladder cancer between 1996 and 2016 were identified from a prospectively compiled database. Postoperative outcomes and overall survival were compared between patients undergoing major hepatectomy alone or combined with pancreatoduodenectomy (HPD).

RESULTS

Seventy-nine patients underwent major hepatectomy alone and 38 patients had HPD. The patients who underwent HPD were more likely to have T4 disease (P < 0·001), nodal metastasis (P = 0·015) and periaortic nodal metastasis (P = 0·006), but were less likely to receive adjuvant therapy (P = 0·006). HPD was associated with a high incidence of grade III or higher complications (P = 0·002) and death (P = 0·037). Overall survival was longer in patients who underwent major hepatectomy alone than in patients who underwent HPD (median survival time 32 versus 10 months; P < 0·001). In multivariable analysis, surgery in the early period (1996-2006) (P = 0·002), pathological T4 disease (P = 0·005) and distant metastasis (P < 0·001) were associated with shorter overall survival, and cystic duct tumour (P = 0·002) with longer overall survival.

CONCLUSION

Major hepatectomy alone for gallbladder cancer contributes to favourable overall survival with low morbidity and mortality, whereas HPD is associated with poor overall survival and high morbidity and mortality rates. HPD may eradicate locally spreading gallbladder cancer; however, the indication for the procedure is questioned from an oncological viewpoint.

Targeted therapy in patients with PIK3CA-related overgrowth syndrome

CLOVES syndrome (congenital lipomatous overgrowth, vascular malformations, epidermal naevi, scoliosis/skeletal and spinal syndrome) is a genetic disorder that results from somatic, mosaic gain-of-function mutations of the PIK3CA gene, and belongs to the spectrum of PIK3CA-related overgrowth syndromes (PROS). This rare condition has no specific treatment and a poor survival rate. Here, we describe a postnatal mouse model of PROS/CLOVES that partially recapitulates the human disease, and demonstrate the efficacy of BYL719, an inhibitor of PIK3CA, in preventing and improving organ dysfunction. On the basis of these results, we used BYL719 to treat nineteen patients with PROS. The drug improved the disease symptoms in all patients. Previously intractable vascular tumours became smaller, congestive heart failure was improved, hemihypertrophy was reduced, and scoliosis was attenuated. The treatment was not associated with any substantial side effects. In conclusion, this study provides the first direct evidence supporting PIK3CA inhibition as a promising therapeutic strategy in patients with PROS.

Persistent expression of neutrophil gelatinase-associated lipocalin and M2 macrophage markers and chronic fibrosis after acute kidney injury

Recent epidemiologic studies revealed a correlation between acute kidney injury (AKI) episodes and the progression to chronic kidney disease (CKD). Although the severity and duration of the initial insult likely predict the development of CKD, information regarding tissue markers predictive of early development of renal fibrosis is limited. We investigated key markers in fibrotic kidney in rats and mice. Seven- to eight-week-old male Sprague-Dawley rats underwent bilateral ischemia-reperfusion injury (IRI). Kidney tissues were collected to determine the markers correlated with the severity of kidney fibrosis. In a separate set, a specific chemokine (C-C motif) receptor 2 (CCR2) inhibitor, RS-102895, was administered to 9-week-old male C57BL/6J mice that underwent unilateral IRI (9.2 mg/kg/day in drinking water for 17 days) to investigate whether blockade of the monocyte chemotactic protein-1 (MCP-1) signaling was sufficient to prevent fibrosis. Among candidate tissue markers, neutrophil gelatinase-associated lipocalin (NGAL) and MCP-1 mRNA expressions were correlated with kidney fibrosis. Studies on macrophage polarity showed that mRNA expression of M2, but not M1 macrophage markers, were correlated with acute-phase serum creatinine and fibrosis. Pharmacological blockade of the MCP-1-CCR2 signaling downregulated CCR2, which was insufficient to improve fibrosis in mouse unilateral IRI model, suggesting that additional, redundant pathways contribute to fibrosis. These findings suggested that tissue NGAL expression and M2 macrophage markers are promising markers that show severity of kidney fibrosis. Mechanistic involvement of these markers in CKD pathogenesis warrant additional investigation.

Ethanol ablation for refractory bile leakage after complex hepatectomy

BACKGROUND

Only a few reports exist on the use of ethanol ablation for posthepatectomy bile leakage. The aim of this study was to assess the value of ethanol ablation in refractory bile leakage.

METHODS

Medical records of consecutive patients who underwent a first hepatobiliary resection with bilioenteric anastomosis between 2007 and 2016 were reviewed retrospectively, with special attention to bile leakage and ethanol ablation therapy. Bile leakage was graded as A/B1/B2 according to the International Study Group of Liver Surgery definition. Absolute ethanol was injected into the target bile duct during fistulography.

RESULTS

Of the 609 study patients, 237 (38·9 per cent) had bile leakage, including grade A in 33, grade B1 in 18 and grade B2 in 186. Left trisectionectomy was more often associated with grade B2 bile leakage than other types of hepatectomy (P < 0·001). Of 186 patients with grade B2 bile leakage, 31 underwent ethanol ablation therapy. Ethanol ablation was started a median of 34 (range 15-122) days after hepatectomy. The median number of treatments was 3 (1-7), and the total amount of ethanol used was 15 (3-71) ml. Complications related to ethanol ablation included transient fever (27 patients) and mild pain (13). Following ethanol ablation, bile leakage resolved in all patients and drains were removed. The median interval between the first ablation and drain removal was 28 (1-154) days.

CONCLUSION

Ethanol ablation is safe and effective, and may be a treatment option for refractory bile leakage.

Vascular adhesion protein-1 enhances neutrophil infiltration by generation of hydrogen peroxide in renal ischemia/reperfusion injury

Vascular adhesion protein-1 (VAP-1) is a unique molecule since it acts as an adhesion molecule as well as an ectoenzyme catalyzing oxidative deamination of primary amines and generates hydrogen peroxide in the extracellular space. While VAP-1 is implicated in various inflammatory diseases, its role in acute kidney injury is less characterized. Here we studied VAP-1 expression in the kidney and the effect of its inhibition in a rat model of renal ischemia/reperfusion injury. VAP-1 was predominantly expressed in pericytes, which released enzymatically active enzyme. In vivo, a specific VAP-1 inhibitor, RTU-1096, significantly ameliorated rat renal ischemia/reperfusion injury and decreased neutrophil infiltration measured 12 hours after injury without altering macrophage or T lymphocyte populations. The protective effect of VAP-1 inhibition was lost in neutrophil-depleted rats, suggesting its inhibition ameliorated renal ischemia/reperfusion injury by suppressing neutrophil infiltration. To investigate whether hydrogen peroxide generated by VAP-1 enzyme reaction enhances neutrophil infiltration, we conducted an under-agarose migration assay with purified human neutrophils. Recombinant human VAP-1 significantly induced neutrophil migration, which was almost completely inhibited by RTU-1096 or catalase. Thus, VAP-1 plays a critical role in the pathophysiology of renal ischemia/reperfusion injury by enhancement of neutrophil infiltration generating a local hydrogen peroxide gradient. Hence, VAP-1 inhibition may be a novel therapy in ischemic acute kidney injury.

Identification of rare HIV-1 Group N, HBV AE, and HTLV-3 strains in rural South Cameroon

Surveillance of emerging viral variants is critical to ensuring that blood screening and diagnostic tests detect all infections regardless of strain or geographic location. In this study, we conducted serological and molecular surveillance to monitor the prevalence and diversity of HIV, HBV, and HTLV in South Cameroon. The prevalence of HIV was 8.53%, HBV was 10.45%, and HTLV was 1.04% amongst study participants. Molecular characterization of 555 HIV-1 specimens identified incredible diversity, including 7 subtypes, 12 CRFs, 6 unclassified, 24 Group O and 2 Group N infections. Amongst 401 HBV sequences were found a rare HBV AE recombinant and two emerging sub-genotype A strains. In addition to HTLV-1 and HTLV-2 strains, sequencing confirmed the fifth known HTLV-3 infection to date. Continued HIV/HBV/HTLV surveillance and vigilance for newly emerging strains in South Cameroon will be essential to ensure diagnostic tests and research stay a step ahead of these rapidly evolving viruses.

Effect of AST-120 in Chronic Kidney Disease Treatment: Still a Controversy?

AST-120 (kremezin; Kureha Chemical, Tokyo, Japan) is an oral spherical carbonaceous adsorbent, which was approved for clinical use in Japanese chronic kidney disease (CKD) patients in 1991. It adsorbs indole, the precursor of indoxyl sulfate, in the intestines and prevents indoxyl sulfate production. Indoxyl sulfate, initially identified as a major uremic toxin that causes uremic symptoms, contributes to CKD progression. Since AST-120 decreases serum indoxyl sulfate in a dose-dependent manner, multicenter prospective trials have been conducted in Japan in the 1980s; these trials were mostly in favor of the efficacy of AST-120 in delaying the initiation of dialysis in patients with advanced stage CKD. Many animal studies support the effects of AST-120 on renal outcomes as well as on cardiovascular complications. However, there are yet no reports that unequivocally demonstrate the improvement of hard renal endpoints and/or cardiovascular endpoints. This commentary briefly reviews the major outcomes of the recent clinical trials on AST-120.

Recent advances in understanding of chronic kidney disease

Chronic kidney disease (CKD) is defined as any condition that causes reduced kidney function over a period of time. Fibrosis, tubular atrophy and interstitial inflammation are the hallmark of pathological features in CKD. Regardless of initial insult, CKD has some common pathways leading CKD to end-stage kidney disease, including hypoxia in the tubulointerstitium and proteinuria. Recent advances in genome editing technologies and stem cell research give great insights to understand the pathogenesis of CKD, including identifications of the origins of renal myofibroblasts and tubular epithelial cells upon injury. Environmental factors such as hypoxia, oxidative stress, and epigenetic factors in relation to CKD are also discussed.

Changes in standing body sway of pregnant women after long-term bed rest

Pregnant women tend to fall and increased body postural instability, namely body sway, may be one of the causative factors. We had a clinical impression that pregnant women after long-term bed rest tend to fall. We hypothesised that such women may show increased body sway, which we attempted to determine. Pregnant women (n = 161) were divided into three groups: (i) women with preterm labour after 2-week bed rest, (ii) those after 4-week bed rest, and (iii) those without bed rest or preterm labour. Body sway was analysed using stabilometry, that is, computed analysis of movement of the centre of gravity. The 3 groups fundamentally showed the same stabilometric measurements. Women with oedema showed greater medial-lateral sway than those without it. Factors other than oedema yielded no differences in stabilometric parameters. Long-term bed rest fundamentally did not increase body sway to the extent that stabilometry could reveal it. It may be prudent to consider that pregnant women with oedema tend to fall.

Liver regeneration following experimental major hepatectomy with choledochojejunostomy

BACKGROUND

Surgical treatment for perihilar cholangiocarcinoma frequently involves hepatectomy and extrahepatic bile duct resection with a choledochojejunostomy (CJ). Cholangitis owing to bilioenteric anastomosis is a common complication. The impact of CJ or regurgitating cholangitis on the liver regeneration process after major hepatectomy is unknown.

METHODS

Rats underwent 70 per cent hepatectomy (Hx group) or hepatectomy with CJ (Hx + CJ group). The intrahepatic inflammatory response, hepatic regeneration rate, and expression of regeneration-associated genes in the liver and blood were compared between these two groups.

RESULTS

Levels of hepatobiliary markers in the blood were significantly higher 4 and 7 days after operation in the Hx + CJ group than the Hx group. Intrahepatic expression of inflammation-associated genes, such as interleukin 6 and tumour necrosis factor α, was also significantly higher in the Hx + CJ group on days 4 and 7. A progressive periportal inflammatory response was identified in the Hx + CJ group by histological examination. The hepatic regeneration rate was significantly lower in the Hx + CJ group than in the Hx group on day 2 (mean(s.d.) 14·2(6·3) versus 21·4(2·6) per cent; P = 0·013) and day 4 (32·4(5·3) versus 41·3(4·4) per cent; P = 0·004). Gene expression levels of hepatic regeneration-promoting factors such as hepatocyte growth factor were significantly lower in the Hx + CJ group than the Hx group on day 1.

CONCLUSION

CJ perturbs early liver regeneration after hepatectomy. An excessive inflammatory response in the liver and suppression of liver regeneration-associated factors may play a role. Surgical relevance Patients with perihilar cholangiocarcinoma may need major hepatectomy with extrahepatic bile duct resection and choledochojejunostomy. This carries a substantial risk of postoperative complications including liver failure. A rat model of partial hepatectomy with choledochojejunostomy was established. The molecular mechanisms underlying liver regeneration, and perturbation of this process by duodenobiliary reflux via the choledochojejunostomy, are described. The results give insight into the pathophysiological events following major hepatectomy with extrahepatic bile duct resection and choledochojejunostomy. This may help to develop a treatment strategy to reduce postoperative liver failure.

Inflammation and hypoxia linked to renal injury by CCAAT/enhancer-binding protein δ

Tubulointerstitial hypoxia plays a critical role in the pathogenesis of kidney injury, and hypoxia-inducible factor (HIF)-1 is a master regulator of cellular adaptation to hypoxia. Aside from oxygen molecules, factors that modify HIF-1 expression and functional operation remain obscure. Therefore, we sought to identify novel HIF-1-regulating genes in kidney. A short-hairpin RNA library consisting of 150 hypoxia-inducible genes was derived from a microarray analysis of the rat renal artery stenosis model screened for the effect on HIF-1 response. We report that CCAAT/enhancer-binding protein δ (CEBPD), a transcription factor and inflammatory response gene, is a novel HIF-1 regulator in kidney. CEBPD was induced in the nuclei of tubular epithelial cells in both acute and chronic hypoxic kidneys. In turn, CEBPD induction augmented HIF-1α expression and its transcriptional activity. Mechanistically, CEBPD directly bound to the HIF-1α promoter and enhanced its transcription. Notably, CEBPD was rapidly induced by inflammatory cytokines, such as IL-1β in a nuclear factor-κB-dependent manner, which not only increased HIF-1α expression during hypoxia, but was also indispensable for the non-hypoxic induction of HIF-1α. Thus our study provides novel insight into HIF-1 regulation in tubular epithelial cells and offers a potential hypoxia and inflammation link relevant in both acute and chronic kidney diseases.

Anti-inflammatory role of DPP-4 inhibitors in a nondiabetic model of glomerular injury

Dipeptidyl peptidase (DPP)-4 is an enzyme that cleaves and inactivates incretin hormones capable of stimulating insulin secretion from pancreatic β-cells. DPP-4 inhibitors are now widely used for the treatment of type 2 diabetes. Experimental studies have suggested a renoprotective role of DPP-4 inhibitors in various models of diabetic kidney disease, which may be independent of lowering blood glucose levels. In the present study, we examined the effect of DPP-4 inhibitors in the rat Thy-1 glomerulonephritis model, a nondiabetic glomerular injury model. Rats were injected with OX-7 (1.2 mg/kg iv) and treated with the DPP-4 inhibitor alogliptin (20 mg·kg(-1)·day(-1)) or vehicle for 7 days orally by gavage. Alogliptin significantly reduced the number of CD68-positive inflammatory macrophages in the kidney, which was associated with a nonsignificant tendency to ameliorate glomerular injury and reduce proteinuria. Another DPP-4 inhibitor, anagliptin (300 mg·kg(-1)·day(-1) mixed with food) and a glucagon-like peptide-1 receptor agonist, exendin-4 (10 mg/kg sc), similarly reduced CD68-positive macrophage infiltration to the kidney. Furthermore, ex vivo transmigration assays using peritoneal macrophages revealed that exendin-4, but not alogliptin, dose dependently reduced monocyte chemotactic protein-1-stimulated macrophage infiltration. These data suggest that DPP-4 inhibitors reduced macrophage infiltration directly via glucagon-like peptide-1-dependent signaling in the rat Thy-1 nephritis model and indicate that the control of inflammation by DPP-4 inhibitors is useful for the treatment of nondiabetic kidney disease models.

Role of uremic toxins in erythropoiesis-stimulating agent resistance in chronic kidney disease and dialysis patients

Patients with advanced chronic kidney disease are exposed to uremic toxins. In addition to causing uremic symptoms, uremic toxins accelerate the progression of renal failure. Indoxyl sulfate (IS) increases oxygen consumption in tubules, aggravating hypoxia of the kidney, and progression of the kidney disease. IS also induces endoplasmic reticulum stress and thereby contributes the progression of cellular damages in tubular epithelial cells. Hypoxia-inducible factor (HIF) is a master transcriptional regulator of adaptive responses against hypoxia and regulates expression of erythropoietin (EPO). IS suppresses EPO expression via HIF-dependent and HIF-independent manner. IS impedes the recruitment of transcriptional coactivators to HIF via upregulation of Cbp/p300-interacting transactivator with Glu/Asp-rich carboxy-terminal domain 2 through a mechanism of posttranscriptional messenger RNA stabilization. Furthermore, IS induces activating transcription factor 4 via endoplasmic reticulum stress, decreasing EPO expression. Although erythropoiesis-stimulating agent (ESA) resistance is generally defined as lack of responses to exogenous ESA administration, suppression of endogenous production of EPO under uremic conditions may aggravate ESA resistance. Uremia is associated with increased formation of advanced glycation end products (AGE). Studies of transgenic rats overexpressing glyoxalse 1 (GLO1), which detoxifies precursors of advanced glycation end products, demonstrated that glycative stress causes renal senescence and vascular endothelial dysfunction. Glycative stress also suppresses HIF activation making the kidney susceptible to hypoxia as a final common pathway to end-stage kidney disease.