METS-IR and all-cause mortality in Korean over 60 years old: Korean genome and epidemiology study-health examinees (KoGES-HEXA) cohorts

Background

The metabolic score for insulin resistance index (METS-IR) is a novel non insulin-based marker that indicates the risk for metabolic syndrome and type 2 diabetes mellitus (T2DM). However, METS-IR has not been investigated in relation to all-cause mortality. We investigated the longitudinal effect of METS-IR on all-cause mortality in a significantly large cohort of Korean adults over 60 years old.

Methods

Data were assessed from 30,164 Korean participants over 60 years of age from the Korean Genome and Epidemiology Study-Health Examinees (KoGES-HEXA) cohort data, linked with the death certificate database of the National Statistical Office. The participants were grouped into three according to METS-IR tertiles. We used multivariate Cox proportional-hazard regression models to prospectively assess hazard ratios (HRs) for all-cause mortality with 95% confidence intervals (CIs) over an 11-year postbaseline period.

Results

During the mean 11.7 years of follow-up, 2,821 individuals expired. The HRs of mortality for METS-IR tertiles were 1.16 (95% CI, 1.01-1.34) in T3 after adjustment for metabolic parameters, but the T2 did not show statistical significance towards increases for incident mortality respectively. In subgroup analysis depending on the cause of mortality, higher METS-IR was associated with cancer mortality (HR, 1.23, 95% CI, 1.01-1.51) but not with cardiovascular mortality (HR, 1.14, 95% CI, 0.83-1.57) after adjustment for the same confounding variables.

Conclusion

The METS-IR may be a useful predictive marker for all-cause mortality and cancer mortality, but not for cardiovascular mortality in subjects over 60 years of age. This implies that early detection and intervention strategies for metabolic syndrome could potentially benefit this identified group.

Oxidative Balance Score and New-Onset Type 2 Diabetes Mellitus in Korean Adults without Non-Alcoholic Fatty Liver Disease: Korean Genome and Epidemiology Study-Health Examinees (KoGES-HEXA) Cohort

The oxidative balance score (OBS) is a novel composite of pro- and anti-oxidative markers for assessing the risk of cardiometabolic diseases and non-alcoholic fatty liver disease (NAFLD). However, it has not yet been established whether the OBS is related to type 2 diabetes mellitus (T2DM), especially in a population without NALFD. Therefore, we aimed to investigate the longitudinal effect of the OBS on T2DM in a large cohort of Korean adults without NALFD. Data were assessed from 9798 participants without NALFD from the Korean Genome and Epidemiology Study-Health Examinees (KoGES-HEXA) cohort. The participants were divided into three groups according to OBS tertiles, identified as T1-T3. We prospectively assessed the hazard ratios (HRs) with 95% confidence intervals (CIs) for new-onset T2DM using multivariable Cox proportional hazard regression models over 6 years following the baseline survey. During the mean 3.5 years of follow-up, 145 individuals (1.48%; 56 men and 89 women) developed T2DM. The HRs of T2DM for the OBS tertiles were 0.79 (95% CI, 0.53-1.18) and 0.60 (95% CI, 0.39-0.93) in the T2 and T3 groups after adjusting for metabolic parameters in subjects without NALFD, respectively; however, the T2 group did not show statistical significance toward a decrease in incident T2DM. A low OBS may be a useful predictive marker in new-onset T2DM for middle-aged and older subjects without NALFD. This implies that the OBS could be an additional valuable tool for assessing the incidence of T2DM among individuals without NAFLD.

Combined effect of serum carcinoembryonic antigen and hepatic steatosis on new-onset ischemic heart disease among middle-aged and older Korean adults: a cohort study

Background

Carcinoembryonic antigen (CEA) is a commonly used tumor marker in cancer screening. However, it has also been associated with metabolic alterations. Hepatic steatosis, the accumulation of fat in liver cells, is associated with various cardiovascular risk factors. This study investigated the risk of ischemic heart disease (IHD) in individuals with elevated CEA levels, hepatic steatosis, and their co-occurrence.

Methods

The study cohort comprised 5,580 Korean adults who underwent health examinations between November 2006 and June 2010. Data regarding baseline CEA levels, hepatic steatosis status, and development of IHD were collected. Hepatic steatosis was defined as more than two findings: deep attenuation, vascular blurring, and increased liver echogenicity on abdominal ultrasound. Participants were divided into four groups based on their CEA and hepatic steatosis status: no hepatic steatosis and low CEA (group 1), no hepatic steatosis and elevated CEA (group 2), low CEA and hepatic steatosis (group 3), and elevated CEA and hepatic steatosis (group 4).

Results

A total of 226 (4.1%) participants developed IHD during the follow-up period. Participants with elevated CEA levels and hepatic steatosis (group 4) had the highest cumulative incidence of IHD in comparison to other groups (p < 0.001). The combined effect of elevated CEA levels and hepatic steatosis showed significantly greater area under the receiver operating characteristic curve than hepatic steatosis alone (p < 0.001). Furthermore, participants with elevated CEA and hepatic steatosis (group 4) had higher risk of developing IHD compared to those with low CEA and no hepatic steatosis (group 1) (hazard ratio: 1.63, 95% confidence interval: 1.04-2.55, p = 0.034).

Conclusion

Co-occurrence of elevated CEA levels and hepatic steatosis increases the risk of IHD. Comprehensive risk assessment is crucial to guide interventions and improve cardiovascular health in individuals with both the conditions.

Sex-specific associations of γ-glutamyltransferase to HDL-cholesterol ratio and the incident risk of cardiovascular disease: three Korean longitudinal cohorts from different regions

Background

The combination of gamma-glutamyl transferase (GGT) and high-density lipoprotein cholesterol (HDL-C) (GGT/HDL-C) is a novel noninsulin-based marker for assessing the risk of nonalcoholic fatty liver disease and type 2 diabetes mellitus. However, whether the GGT/HDL-C ratio is related to the risk of incident cardiovascular disease (CVD) risk is not well known. Therefore, we aimed to investigate the longitudinal effect of GGT/HDL-C ratio on incident CVD risk in three large cohorts of Korean men and women.

Methods

Data were assessed from 27,643 participants without CVD from the Korean Genome and Epidemiology Study (KoGES), Health Risk Assessment Study (HERAS), and Korea Health Insurance Review and Assessment (HIRA) (HERAS-HIRA) datasets. The participants were divided into four groups according to the GGT/HDL-C quartiles. We prospectively assessed hazard ratios (HRs) with 95% confidence intervals (CIs) for CVD using multivariate Cox proportional-hazard regression models over a 50-month period following the baseline survey.

Results

During the follow-up period, 949 patients (3.4%; 529 men and 420 women) developed CVD. The HRs of CVD for GGT/HDL-C quartiles 2-4 were 1.36 (95% CI, 0.91-2.02), 1.54 (95% CI, 1.05-2.26), and 1.66 (95% CI, 1.12-2.47) after adjusting for metabolic parameters in women, but GGT/HDL-C did not show a trend toward increases in incident CVD in men. Regional discrepancies were evident in the results; the increase in HR in the metropolitan hospital cohort was more pronounced than that in the urban cohort, and the risk was not increased in the rural cohort.

Conclusion

GGT/HDL-C ratio may be a useful predictive marker for CVD in women. Furthermore, the prevalence of CVD was strongly correlated with the GGT/HDL-C ratio in metropolitan areas, and this correlation was more significant than that observed with GGT or HDL-C in isolation.

Longitudinal Effects of Serum Calcium and Phosphate Levels and Their Ratio on Incident Ischemic Heart Disease among Korean Adults

Serum calcium and phosphate levels are controlled by a regulatory system, but their individual concentration tendencies and interactions may affect long-term vascular health. This study aimed to assess the effects of serum calcium and phosphate levels on incident ischemic heart disease (IHD) in a large-scale community-dwelling Korean cohort. We evaluated 15,259 non-diabetic individuals (median age, 45 years; range, 30–85) without previous IHD or ischemic stroke using the Korean National Health Insurance data. The study population was classified based on the calcium, phosphate, and calcium/phosphate ratios. Using Cox proportional hazards regression models, we estimated hazard ratios (HRs) with 95% confidence intervals (CIs) for IHD over 50 months after baseline enrolment. The age- and sex-adjusted incidence of IHD gradually increased with serum calcium and phosphate quartiles and decreased with calcium/phosphate ratio quartiles, with an overall crude rate of 2.1% (315/15,259). After setting the lowest calcium, phosphate, and calcium/phosphate ratio quartiles as a reference group, the HRs (95% CIs) of the highest calcium, phosphate, and calcium/phosphate ratio quartiles for IHD were 1.77 (1.15–2.72), 1.73 (1.18–2.55), and 0.58 (0.39–0.87), respectively, after adjusting for potential confounding variables. Serum calcium and phosphate levels were positively associated with IHD incidence, while the serum calcium/phosphate ratio exhibited an inverse relationship. Serum calcium and phosphate homeostasis may merit serious consideration to understand the pathogenesis of coronary atherosclerosis as a risk modifier for IHD.

Triglyceride to HDL-Cholesterol Ratio and the Incident Risk of Ischemic Heart Disease Among Koreans Without Diabetes: A Longitudinal Study Using National Health Insurance Data

Background: Early insulin resistance without diabetes can cause cardiovascular disease, which is a public health challenge. This study aimed to investigate the effects of the triglyceride to high-density lipid (HDL)-cholesterol ratio (TG/HDL-C), which could reflect insulin resistance from the beginning, on the incident risk of ischemic heart disease (IHD).

Methods: We assessed 16,455 individuals (8,426 men and 8,029 women) without diabetes in a community-dwelling Korean cohort using National Health Insurance data. Participants were classified based on the TG/HDL-C quartiles. Using multivariate Cox proportional-hazards regression models, we prospectively examined the hazard ratios (HRs) with 95% confidence intervals (CIs) for IHD over 50 months after baseline enrolment.

Results: During the follow-up period, 321 (2.0%) participants developed IHD. After adjusting for potential confounding variables, the HRs of IHD for TG/HDL-C quartiles were 1.00, 1.61 (95% CI, 1.05–2.48), 1.85 (95% CI, 1.21–2.81), and 2.29 (95% CI, 1.50–3.51), respectively. Compared with men, women showed higher HRs for the risk of incident IHD in the fourth quartile [HR (95% CI) = 2.98 [1.50–5.88] and 1.80 [1.02–3.17], respectively). Compared with metabolic syndrome, TG/HDL-C had a more powerful predictive value for IHD.

Conclusions: In Koreans without diabetes, an increased TG/HDL-C precedes future IHD. Additionally, sex differences may merit serious consideration when interpreting TG/HDL-C for assessing cardiovascular risks in clinical practice.

Longitudinal Effect of Hemoglobin Concentration With Incident Ischemic Heart Disease According to Hepatic Steatosis Status Among Koreans

Background: An increased hemoglobin (Hb) level may have detrimental effects on hepatic steatosis (HS) as well as cardiovascular disease (CVD). We investigated Hb's effect on incident ischemic heart disease (IHD) risk in the context of hepatic steatosis (HS).

Methods: We assessed 17,521 non-diabetic participants and retrospectively screened for IHD using the Korea National Health Insurance data. High Hb was defined as Hb levels ≥16.3 g/dL in men and 13.9 g/dL in women (>75th percentile). The participants were divided into five groups: reference (group 1), mild HS only (group 2), mild HS and high Hb (group 3), severe HS only (group 4), and severe HS and high Hb (group 5). We assessed hazard ratios (HRs) with 95% confidence intervals (CIs) for IHD using multivariate Cox proportional hazards regression models over 50 months from the baseline survey.

Results: During the follow-up period, 330 (1.9%) participants developed IHD (310 angina pectoris and 20 myocardial infarction). Compared with the reference group (group 1), the HRs for IHD were 1.04 (95% CI, 0.75–1.46) in group 2, 1.14 (95% CI, 0.70–1.85) in group 3, 1.58 (95% CI, 1.08–2.32) in group 4, and 1.79 (95% CI, 1.15–2.80) in group 5, after adjusting for IHD risk factors.

Conclusions: We found the combined effect of HS and Hb levels on the incidence of IHD.

Dual-graft adult living donor liver transplantation with ABO-incompatible graft: short-term and long-term outcomes

ABO-incompatible (ABOi) dual-graft (DG) adult living donor liver transplantation (ALDLT) is not commonly performed due to its inherently intricate surgical technique and immunological complexity. Therefore, data are lacking on the short- and long-term clinical outcomes of ABOi DG ALDLT. We performed a retrospective study by reviewing the medical records of patients who underwent ABOi DG ALDLT between 2008 and 2014. Additionally, computed tomography volumetric analysis was conducted to assess the graft regeneration rate. The mean age of a total of 28 recipients was 50.2 ± 8.5 years, and the mean model for end-stage liver disease score was 12.2 ± 4.6. The 1-, 3-, and 5-year patient survival rate was 96.4% during the mean follow-up period of 57.0 ± 22.4 months. The 1-, 3-, and 5-year graft survival rate was 96.4%, 94.2%, and 92.0%, respectively, and no significant differences were observed between ABO-compatible (ABOc) and ABOi grafts (P = .145). The biliary complication rate showed no significant difference (P = .195) between ABOc and ABOi grafts. Regeneration rates of ABOi grafts were not significantly different from those of ABOc grafts. DG ALDLT with ABOi and ABOc graft combination seems to be a feasible option for expanding the donor pool without additional donor risks.

Living Donor Liver Transplantation for Patients Older Than Age 70 Years: A Single-Center Experience

Over the past two decades, the age of liver transplantation (LT) recipients has been increasing. We reviewed our experience with LT for patients aged ≥70 years (range: 70-78 years) and investigated the feasibility of performing LT, especially living donor LT (LDLT), for older patients. We retrospectively reviewed the medical records of 25 patients (15 LDLT recipients, 10 deceased donor LT recipients) aged ≥70 years who underwent LT from January 2000 to April 2016. Their perioperative morbidity rate was 28.0%, and the in-hospital mortality rate was 16.0%; these results were comparable to those of matched patients in their 60s (n = 73; morbidity, p = 0.726; mortality, p = 0.816). For patients in their 70s, the 1- and 5-year patient survival rates were 84.0% and 69.8%, and the 1- and 5-year graft survival rates were 83.5% and 75.1%, respectively. Comparisons of patient and graft survival rates between matched patients in their 60s and 70s showed no statistically significant differences (patient survival, p = 0.372; graft survival, p = 0.183). Our experience suggests that patients aged ≥70 years should not be excluded from LT, or even LDLT, based solely on age and implies that careful selection of recipients and donors as well as meticulous surgical technique are necessary for successful results.

Inverse Relationship between Hepatic Steatosis and Alanine Aminotransferase with Sex Hormone-Binding Globulin in Men

PURPOSE

Sex hormone-binding globulin (SHBG) is a serum glycoprotein produced predominantly in hepatocytes. As such, the synthesis of SHBG could be associated with liver function and metabolic syndrome. Alanine aminotransferase (ALT) levels could reflect hepatocellular injury and insulin resistance; however, the relationship between hepatic steatosis and ALT with SHBG has not been investigated in humans. The objective of this study was to investigate the associations between SHBG and hepatocyte damage among Korean male patients with hepatic steatosis enrolled in a health examination program.

MATERIALS AND METHODS

We performed a retrospective cross-sectional study with 922 participants who underwent routine health examinations. A total of 922 men with or without hepatic steatosis were divided into three groups. We analyzed the risk of lower serum SHBG levels with or without elevated serum ALT levels using odds ratios with 95% confidence intervals (CIs).

RESULTS

A significantly increased risk of lower serum SHBG level was observed in the group with hepatic steatosis and ALT elevation (95% CI 1.591-4.681).

CONCLUSION

In men with hepatic steatosis, we found that elevated serum ALT levels were associated with lower serum SHBG levels. This finding suggests that subjects with both hepatic steatosis and increased ALT should be considered to have low levels of SHBG.

Survival Benefit of Early Cancer Detection Through Regular Endoscopic Screening for De Novo Gastric and Colorectal Cancers in Korean Liver Transplant Recipients

BACKGROUND

De novo malignancy is not uncommon after liver transplantation (LT). Gastric cancer is one of the most common malignancies in both the Korean general population and LT recipients, and colorectal cancer prevalence is gradually increasing.

METHODS

Among 3690 adult recipients who underwent LT from January 1999 and December 2013, the screening patterns and prognosis of 26 cases of gastric cancer and 22 cases of colorectal cancer were analyzed.

RESULTS

For gastric cancer, the mean patient age was 54.6 ± 6.2 years at LT and 59.5 ± 6.7 years at cancer diagnosis, with a post-transplant interval of 60.2 ± 29.8 months. Patients were divided into regular (n = 18) and non-regular (n = 8) screening groups, with early cancer found in 14 and 0 patients; their 2-year survival rates after cancer diagnosis were 93.1% and 33.3% (P = .006), respectively. Endoscopic resection was successfully performed in 8 patients, all in the regular screening group. For colorectal cancer, the mean patient age was 53.3 ± 6.1 years at LT and 58.1 ± 6.7 years at cancer diagnosis, with a post-transplant interval of 54.3 ± 38.0 months. Patients were divided into regular (n = 19) and non-regular (n = 3) screening groups, with early cancer found in 12 and 0 patients; their 2-year survival rates after cancer diagnosis of 92.3% and 33.3% (P = .003), respectively. Endoscopic resection was successfully performed in 6 patients, all in the regular screening group.

CONCLUSIONS

LT recipients are strongly advised to undergo regular screening studies for various de novo malignancies, especially cancers common in the general population. Regular endoscopic screening contributes to the timely detection of gastric and colorectal cancers, improving post-treatment survival outcomes.

Donor Safety and Recipient Liver Function After Right-Lobe Liver Transplantation From Living Donors With Gilbert Syndrome

BACKGROUND

Donor safety is the most important aspect in living-donor liver transplantation (LDLT). Gilbert syndrome is an autosomal recessive condition that is a common cause of isolated unconjugated hyperbilirubinemia, and its prevalence is not negligibly low in the general population. This study intended to assess donor safety and recipient liver function after LDLT with the use of right liver grafts from living donors with Gilbert syndrome.

METHODS

Among 2,140 right liver transplantations performed from January 2002 to December 20113 at our institution, we identified 12 living donors (0.6%) who showed a preoperative serum total bilirubin level of ≥2 mg/dL. These donors were clinically diagnosed with Gilbert syndrome. The clinical outcomes of these donors and their recipients were analyzed retrospectively.

RESULTS

The mean donor age was 24.6 ± 7.1 years, and 11 donors were male. All subjects met the preoperative evaluation conditions for right liver donation except for the level of unconjugated hyperbilirubinemia. The mean serum total bilirubin level of the donors was 2.23 ± 0.20 mg/dL before and 1.79 ± 0.61 mg/dL 1 year after right liver donation. The preoperative donor direct bilirubin level was 0.43 ± 0.19 mg/dL. The preoperative indocyanine green retention rate at 15 minutes was 8.2 ± 2.8%. All donors and recipients recovered uneventfully and were alive at the time of writing. The recipient serum total bilirubin level was 1.29 ± 0.47 mg/dL 1 year after LDLT.

CONCLUSIONS

We suggest that LDLT with living donors with Gilbert syndrome can be safely performed, but that a meticulous preoperative evaluation is vital to maximize donor safety.

Self-expandable metal stents for malignant esophageal obstruction: a comparative study between extrinsic and intrinsic compression

Self-expandable metal stents (SEMSs) are effective for malignant esophageal obstruction, but usefulness of SEMSs in extrinsic lesions is yet to be elucidated. This study is aimed at evaluating the clinical usefulness of SEMSs in the extrinsic compression compared with intrinsic. A retrospective review was conducted for 105 patients (intrinsic, 85; extrinsic, 20) with malignant esophageal obstruction who underwent endoscopic SEMSs placement. Technical and clinical success rates were evaluated and clinical outcomes were compared between extrinsic and intrinsic group. Extrinsic group was mostly pulmonary origin. Overall technical and clinical success rate was 100% and 91%, respectively, without immediate complications. Extrinsic and intrinsic group did not differ significantly in clinical success rate. The median stent patency time was 131.3 ± 85.8 days in intrinsic group while that of extrinsic was 54.6 ± 45.1 due to shorter survival after stent insertion. The 4-, 8-, and 12-week patency rates were 90.5%, 78.8%, and 64.9% respectively in intrinsic group, while stents of extrinsic group remained patent until death. Uncovered, fully covered, and double-layered stent were used evenly and the types did not influence patency in both groups. In conclusion, esophageal SEMSs can safely and effectively be used for malignant extrinsic compression as well as intrinsic.

Liver transplantation in Korea: past, present, and future

PURPOSE

This study reviewed the past and present status of liver transplantation (LT) and outlooks for the future of LT in Korea.

METHOD

The first LT in Korea was successfully performed using a deceased donor graft in 1988. Pediatric and adult living donor liver transplantations (LDLTs) were initiated in 1994 and 1997, respectively. From 1988 to 2013, 10,581 LTs were performed at 40 centers, whereas LDLT accounted for 76.5% of all LTs.

RESULTS

In the early 1990s, the deceased organ donation rate was less than 1.5 per million population (PMP) per year, but it increased to 5 PMP beginning in 2008. Despite the increasing number of deceased donor liver transplantations (DDLTs), high prevalence of hepatitis B virus (HBV)-induced cirrhosis and hepatocellular carcinoma (HCC) has provoked persistent performance of adult LDLT with technical advancement including middle hepatic vein (MHV) reconstruction of right lobe graft and dual graft LDLT with 1 nationwide donor mortality.

CONCLUSION

The number of LTs in Korea in 2010 was 23.2 PMP (1042 LTs/45 million population), lower than 23.5 PMP of Spain, but higher than 20 PMP of the United States. However, future LT numbers may decrease because of lowering the HBV carrier rate (neonatal HBV universal vaccination began in 1992), new potent anti-HBV agents, and lowest birth rate (1.22 children per family) with a decrease of potential live donors.

A pilot study on the safety and efficacy of generic mycophenolate agent as conversion maintenance therapy in stable liver transplant recipients

PURPOSE

The patent covering mycophenolate mofetil (MMF) in Korea has expired and, thus, several generic MMF agents are now commercially available. The supply of Cellcept (Roche Korea) was interrupted at the end of 2011, so it was inevitable that a generic MMF would be used instead. During this period, we performed a prospective pilot study to examine the safety and efficacy of a generic mycophenolate agent (Myconol: Hanmi Pharmaceutical, Seoul Korea) for use as conversion maintenance therapy in stable liver transplantation (OLT) recipients.

METHODS

OLT recipients, who were treated with MMF on an outpatient basis from January 2012 to March 2012, attended follow-up interviews conducted. The patients had undergone OLT ≥ 2 years before the study, had tolerated Cellcept, and showed stable liver function. Fifty-three patients were followed up for more than 3 months after conversion to the same dose of Myconol.

RESULTS

After conversion to Myconol, 6 patients (11.3%) experienced new side effects, which disappeared when they reverted to Cellcept (n = 5) or stopped taking Myconol medication (n = 1). The side effects associated with Myconol included gastrointestinal symptoms (indigestion and diarrhea; n = 3), skin eruptions (n = 1), pruritus (n = 1), and insomnia (n = 1). The mean mycophenolic acid levels were 1.71 ± 0.88 μg/mL for Cellcept and 1.83 ± 0.91 μg/mL for Myconol, which showed a strong correlation (r(2) = 0.92, P < .001).

CONCLUSIONS

Myconol showed similar pharmacokinetics to those of Celcept, but a small proportion of patients experienced agent-specific side effects; therefore, patients should be closely monitored when taking Myconol. Also, further studies, with a greater number of patients, are required to identify the full spectrum of drug-associated side effects.

Toward more than 400 liver transplantations a year at a single center

BACKGROUND

For the first time at Asan Medical Center (AMC) we performed more than 400 liver transplantations (LTs) per year in 2011, despite same number of living donor liver transplantations (LDLTs).

METHODS

Our OLT program was started in 1992, but not activated well due to the scarcity of deceased donor organs. Since adult LDLTs using a left lobe and then a right lobe were successfully performed in 1997, we have developed several innovative techniques and approaches for adult LDLT, for example, modified right-lobe graft reconstructing middle hepatic branches in 1998, dual graft LDLT using 2 left lobes in 2000; new criteria for hepatocellular carcinoma (HCC); as well as ABO-incompatible LDLT, the first in the world. As a result, the number of LDLTs has increased rapidly but reached a plateau recently. Nationwide efforts to promote deceased donation increased the number of deceased donor liver transplantation (DDLT).

RESULTS

We have performed 317 LDLTs per year in 2010 and 2011, respectively. The number of LTs reached 403 in 2011. This large number was possible due to a remarkable increase of DDLTs from 50 in 2010 to 86 in 2011. Seventy-nine patients (68.1%) among 116 patients (28.8%) required an urgent LT receiving a DDLT. LT for HCC or ABO-mismatch comprised 50.3% (n = 150) or 8.7% (n = 35), respectively. In-hospital mortality rate in 2011 was 4.7%.

CONCLUSIONS

The increased LTs number at AMC was aided by the nationwide campaign.

Expression of heat shock protein 90 in the kidneys of diabetic db/db mice

OBJECTIVE

To identify novel genes regulated in diabetic nephropathy.

MATERIALS AND METHODS

Total RNA from the renal cortex of db/+ and db/db mice was isolated and DNA microarrays specific for diabetes signaling pathways were used for expression profiling. Expression of mRNA and protein was determined by RT-PCR and western blotting. The terminal deoxynucleotidyl transferase-mediated biotinylated UTP nick-end labeling (TUNEL) assay and immunohistochemical staining were assessed in renal cortex of db/db mice.

RESULTS

Microarray data revealed that 7 genes show up- or down-regulated pattern and diabetic mice specifically decreased heat shock protein (Hsp) 90α expression of genes compared to control mice (diabetic mice 0.68 vs. control mice 1 relative density). Expression of Hsp90α mRNA and Hsp90 protein was significantly decreased in the renal cortex of diabetic mice. However, Hsp70 mRNA and protein expression was not changed. Apoptosis was increased in glomeruli of diabetic mice due to increased expression of cleaved caspase-3 and Bax.

CONCLUSIONS

Our results suggest that Hsp 90 expression was decreased in diabetic glomeruli and decreased Hsp90 expression may mediate podocyte apoptosis in type 2 diabetic kidneys.

Standardization of modified right lobe grafts to minimize vascular outflow complications for adult living donor liver transplantation

BACKGROUND

After >2000 adult living donor liver transplants (LDLTs), we observed minimization of the complication rate using case-by-case modification of venous outflow reconstruction in right liver graft (RLG), standardization seeking intend to provide a hemodynamic- based, regeneration-compliant hepatic outflow reconstruction.

METHODS

We retrospectively examined 100 consecutive adult LDLT using modified RLG before and after application of RLG standardization to compare the 6-month incidences of vascular outflow complications.

RESULT

The right hepatic vein stenting rate for first 6 months was 5% in the customized group and 1% in the standardized group (P=.212). The middle hepatic vein stenting rate for first 6 months was 9% in the customized group and 4% in the standardized group (P=.373). The inferior right hepatic vein stenting rate for first 6 months was 12.8% in the customized group and 7.1% in the standardized group (P=.472). The overall 6-month patient survival rate was 94% in the customized group and 95% in the standardized group (P=.867). The overall incidence of significant RLG venous outflow complications was 19% in the customized group and 8% in the standardized group (P=.023).

CONCLUSION

Standardization as a universal graft model seemed to be more effective and feasible than conventional graft customization requiring individualized case-by-case modification.

De novo malignancies after liver transplantation: incidence comparison with the Korean cancer registry

PURPOSE

De novo malignancy is not uncommon after liver transplantation (OLT). We have compared the incidence of novo malignancy following OLT with those among the general Korean population.

METHODS

Between January 1998 and December 2008, 1952 adult OLT were performed, including 1714 living donor and 238 deceased donor grafts whose medical records were retrospectively reviewed.

RESULTS

Among the 1952 patients, 44 (2.3%) showed de novo malignancies after a mean posttransplant period of 41 months. Among the 14 types of malignancy the most frequent was stomach cancer (n = 11; 25.0%), colorectal cancer (n = 9; 20.5%), breast cancer (n = 4; 9.1%), and thyroid cancer (n = 3; 6.8%). These patients underwent aggressive treatment, including surgery, chemotherapy, and radiotherapy, except for one patient with an aggressive primary liver cancer. Over a mean follow-up of 45 months after diagnosis of de novo malignancy, 13 patients (29.5%) died; the overall 3-year patient survival rate was 67.5%. The relative risk of malignancy following OLT was 7.7-fold higher in men and 7.3-fold higher in women than the Korean general population.

CONCLUSIONS

OLT recipients must be checked periodically for de novo malignancy throughout their lives, especially for cancers common in the general population.

The association between coronary artery calcification and mean platelet volume in the general population

Patients with coronary artery calcification have an increased risk of coronary vascular events and mortality. Coronary artery calcification can be quantified using the coronary calcium score (CCS) from multi-detected row computed tomography (MDCT), and the score is proportionally related to the severity of atherosclerotic disease. Mean platelet volume (MPV) is gaining interest as a new independent cardiovascular risk factor. Accordingly, the aim of our study was to evaluate the relationship between CCS and MPV in the general population. A total of 2116 individuals were enrolled from a health promotion center between July 2007 and June 2010. Among them, 259 subjects were included in the final analysis. MDCT was used to measure CCS and CCS > 1 was defined as the presence of coronary calcification. The MPV value was significantly higher in the coronary artery calcification group than in the control group. Multivariate analyses showed that MPV was positively associated with coronary calcification (OR, 1.61; 95% CI 1.02-2.55). In summary, there was a significant association between coronary artery calcification and MPV in the general population. Therefore, the detection of elevated MPV should alert clinicians to the coexistence of multiple underlying CVD risk factors warranting early evaluation and treatment.

Comparison of open and laparoscopic live donor left lateral sectionectomy

BACKGROUND

The present study was undertaken to determine whether laparoscopic live donor left lateral sectionectomy (LLS) in paediatric liver transplantation is a feasible, safe and reproducible procedure, compared with open live donor left lateral sectionectomy (OLS).

METHODS

A retrospective review was conducted of all consecutive live donor procedures for paediatric liver transplantation performed between May 2008 and October 2009. All live donor hepatectomies were carried out by a single surgeon.

RESULTS

A total of 26 live donor procedures for paediatric liver transplantation were performed, of which 11 were LLS and 11 OLS; four left hepatectomies were excluded. The LLS group had a significantly shorter hospital stay (mean(s.d.) 6·9(0·3) versus 9·8(0·9) days; P = 0·001) and time to oral diet (2·1(0·3) versus 2·7(0·4) days; P = 0·012). Duration of operation, blood loss, warm ischaemia time and out-of-pocket medical costs were comparable between groups. There was no death in either donor group and only one complication, a wound seroma, in the OLS group.

CONCLUSION

LLS seemed to be a safe, feasible and reproducible procedure, and was associated with reduced hospital stay.

Peritransplant monitoring of immune cell function in adult living donor liver transplantation

PURPOSE

We evaluated the clinical utility of peritransplant in vitro assays of immune cell function in adult living donor liver transplant (LDLT) recipients.

METHODS

In particular, we measured immune cell function, using the ImmuKnow assay, in 107 adult LDLT recipients and 200 potential living liver donors (control group) admitted to our center between July 2008 and January 2009.

RESULTS

In the control group, the mean proportion of T-helper/inducer cells was 36.8% ± 8.2%. The degree of immune response was strong in 12%, moderate in 77%, and low in 11%. In the study group, the degree of immune response within the first month was strong in 4.6%, moderate in 38.2%, and low in 57.2%, thus significantly lower than in the control group (P < .001). ImmuKnow results and tacrolimus levels did not show a significant correlation (r(2) = .002, P = .392). Although six patients showed biopsy-proven acute cellular rejection, none showed a strong immune response. Patients with overt infection showed a lower immune response.

CONCLUSIONS

These results indicate that peritransplant assessment of immune response using the ImmuKnow assay does not reliably predict the occurrence of acute rejection. Additional studies are necessary to accurately assess the clinical utility of immune response monitoring.

Small-sized liver graft does not increase the risk of hepatocellular carcinoma recurrence after living donor liver transplantation

PURPOSE

Following implantation into adult recipients, living donor liver grafts usually undergo liver regeneration. This regeneration process may provoke the growth of occult hepatocellular carcinoma (HCC) cells in the recipient body. To assess the risk of HCC recurrence, we analyzed the influence of graft-recipient weight ratio (GRWR).

METHODS

The 181 recipients with HCC within the University of California at San Francisco (UCSF) criteria were divided into four groups according to GRWR: low GRWR (<0.8; n = 30), mid GRWR (0.8-1.0; n = 65), high GRWR (>1.0; n = 64), and whole liver graft group (>1.5; n = 22).

RESULTS

There were no differences in overall patient survival (P = .105) and recurrence-free survival (P = .406) among these four groups. GRWR <0.8 was not a significant risk factor for HCC recurrence. Similar outcomes were obtained in HCC patients who met the Milan criteria (n = 170).

CONCLUSIONS

We think that small living donor liver graft and subsequent liver regeneration do not increase the risk of posttransplant HCC recurrence when HCC is within the Milan or UCSF criteria.

Suitable whole blood levels 2 hours after neoral in liver transplant patients: experiences at a single center

Whole blood levels 2 hours after Neoral (C2) administration were observed to correlate better with area under the curve (AUC(0-4)) than trough levels (C0), suggesting that C2 may be the best single time point predictor of Neoral absorption. Owing to concerns about drug toxicity due to excessive immunosuppression, C2 adjustments to target blood levels may represent an advance. The present study measured C2 and levels to determine which correlated more closely with AUC(0-4).

METHODS

Between August 2003 and July 2004, 40 adult liver transplantations were performed in our center. All patients received Neoral twice daily. They were maintained at a C0 level of about 200 ng/mL. C0 levels were measured daily. C2 levels were estimated on postoperative days 3, 5, 7, 14, and 28. AUC(0-4) performed on postoperative days 3, 7, and 28 was calculated using the trapezoidal rule.

RESULTS

The mean AUC(0-4), C0, C1, C2, C3, and C4 were 1100.3 +/- 484.8 ng/mL, 197.1 +/- 84.7 ng/mL, 240.7 +/- 166.2 ng/mL, 307.8 +/- 162.6 ng/mL, 302.8 +/- 138.9 ng/mL, and 300.3 +/- 142.8 ng/mL, respectively. C2 correlated with AUC(0-4) (R2 = 0.868: P < .05) better than C0 (R2 = 0.245: P < .05), C1 (R2 = 0.604: P < .05), or C4 (R2 = 0.583: P < .05).

CONCLUSIONS

Neoral dose monitoring according to a mean C2 range of 307.8 +/- 162.6 ng/mL correlated better with AUC(0-4). Further studies are required to determine suitable C2 levels in liver transplant patients.

Molecular cloning and characterization of mouse cardiac triadin isoforms

Triadin is a ryanodine receptor and calsequestrin binding protein located in junctional sarcoplasmic reticulum of striated muscles. In the present study, mouse cardiac triadin cDNAs have been identified by cDNA library screening and RT-PCR. The deduced aa sequences show that the three isoforms consist of 277, 293 and 305 aa giving rise to the molecular weights of approximately 31,414, 33,066, and 34,328, respectively. The isoforms have identical 262 aa N-terminal sequences, whereas they have distinct C-terminal sequences. Northern blot analysis using a cDNA probe representing the N-terminal common region of triadin revealed that the mouse triadins were present both in heart and skeletal muscles. The estimated sizes of the transcripts were approximately 1.3, 4.3 and 5 kb in heart and 5, 5.5 and 7 kb in skeletal muscle. Endo H treatment and Western blot analysis of isolated mouse cardiac sarcoplasmic reticulum and in vitro translation products indicate that there are three distinct mouse cardiac triadin isoforms having molecular weights of 35, 35.5 and 40 kDa. We termed those three isoforms as mouse cardiac triadin 1, mouse cardiac triadin 2 and mouse cardiac triadin 3.

Formation and emission status of PCDDs/PCDFs in municipal solid waste incinerators in Korea

This study was carried out to examine the formation and the emission status of polychlorinated dibenzo-p-dioxins/polychlorinated dibenzofurans (PCDDs/PCDFs) in the flue gases of commercial-scale municipal solid waste (MSW) incinerators, and thus to provide the engineering data for the reduction of PCDDs/PCDFs emitted from MSW incinerators. The formation concentrations of the PCDDs/PCDFs generated at the outlet of waste heat boilers (WHB) were in the range of 1.18-29.61 ng-TEQ/N m3 (average 5.75 ng-TEQ/N m3), while the emission concentrations at the stacks were in the range of 0.026-4.548 ng-TEQ/N m3 (average 0.924 ng-TEQ/N m3). Two major 2,3,7,8-substituted congeners were 2,3,4,7,8-PeCDF and 2,3,4,6,7,8-HxCDF, and their concentrations were up to 50% and 64% of total TEQ values at the outlet of WHB and the stack, respectively. From the results of multi-regression analysis, the formation concentration of PCDDs/PCDFs could be predicted as follows with the correlation factor of r2 = 0.962: PCDDs/PCDFs (ng-TEQ/N m3) = 3.036 (Cl) + 0.094 (T1) - 0.472 (Combustibles) + 0.059 (CO) - 0.039 (THC) - 3.366 (H) + 22.157, where T1 (degrees C) is the temperature at the outlet of the WHB. Cl, Combustibles and H are given as percentages and the others are in parts per million.

Removal efficiencies of PCDDs/PCDFs by air pollution control devices in municipal solid waste incinerators

Removal efficiencies of polychlorinated dibenzo-p-dioxins/polychlorinated dibenzofurans (PCDDs/PCDFs) by air pollution control devices (APCDs) in the commercial-scale municipal solid waste (MSW) incinerators with a capacity of above 200 ton/day were evaluated. The removal efficiencies of PCDDs/PCDFs were up to 95% when the activated carbon (AC) was injected in front of electrostatic precipitator (EP). Spray dryer absorber/bag filter (SDA/BF) had high removal efficiency (99%)) of PCDDs/PCDFs when a mixture of lime and AC was sprayed into the SDA. When the AC was not added in scrubbing solution, the whole congeners of PCDDs/PCDFs were enriched in the wet scrubber (WS) with negative removal efficiencies of -25% to -5731%. Discharge of PCDDs/PCDFs was decreased with increasing the proportions of AC added in scrubbing solution. Selective catalytic reduction (SCR) system had the removal efficiencies of up to 93% during the test operation.

Arterial supply of the nasal tip in Asians

OBJECTIVES

The blood supply to the nasal tip and columella was examined to determine whether it could be damaged as a result of transcolumellar incision during an external rhinoplasty approach in Asians.

METHODS

The blood vessels that supply the nasal tip were examined by dissecting 51 cadavers, and their corresponding 102 nasal sections were injected with red latex before dissection. The size and distribution of the vessels were measured with the unaided eye and the primary supply vessels were determined. The subdermal layer in which the vessels lie and the course of the vessels were also investigated.

RESULTS

The main blood supply source of the nasal tip proved to be the lateral nasal artery in 78% (80/102) of the cases examined, while the remaining cases (22%) received their blood supply via the dorsal nasal artery. Columellar branches were narrow in diameter and varied in size and appearance, and were therefore appeared insufficient as a main blood supply. These arteries passed through the musculoaponeurotic layer, but they were also in close proximity to the main surgical plane in the dome of the lower lateral cartilage.

CONCLUSIONS

The authors speculate that the nasal tip blood supply in Asians is primarily derived from the lateral nasal or dorsal nasal arteries, with a variable contribution from the columella arteries. Therefore, it is important to correctly determine the surgical plane below the musculoaponeurotic layer in order to prevent skin flap necrosis or nasal tip deformity that may occur from damage to the main vessel during an external rhinoplasty approach.

Fontanelle and uncinate process in the lateral wall of the human nasal cavity

OBJECTIVES

Although a complete anatomic knowledge of the fontanelle is a prerequisite to perform a surgical antrostomy opening, little is known about the boundary, shape, and size of the fontanelle. The purpose of this paper is to determine the best site for maintaining the patency of a surgical antrostomy opening by defining the anatomic boundaries, shape, and size of the fontanelle as well as its histological structure.

MATERIALS AND METHODS

One hundred sagittally divided heads were utilized. Mucosa overlying the lateral nasal wall was carefully removed with an operating microscope under 6x magnification. In some cases, a double mucous membrane, including the posteroinferior portion of the uncinate process, was cut as a whole and embedded in paraffin. The sections were stained with H&E.

RESULTS

The boundary of the fontanelle and the location of the natural ostium were described in detail. Eight patterns of the posteroinferior portion of the uncinate process were observed. There were three major fontanelle shapes when observed from the medial aspect to the lateral: triangular, pencil-like, and oval. The triangular type was the most common. The anterior portion of the fontanelle was shorter than the posterior when observed medially and was wider than the posterior portion when observed inferiorly.

CONCLUSIONS

The anterior portion of the fontanelle is more prone to stenosis than the posterior portion. An antrostomy in the posterior fontanelle may be more ideal for a middle meatal antrostomy of the maxillary sinus.

Effects of alpha-toxin of Staphylococcus aureus on the ciliary activity and ultrastructure of human nasal ciliated epithelial cells

OBJECTIVE

The in vitro effects of staphylococcal alpha-toxin on ciliary activity were investigated at different concentrations and exposure times.

STUDY DESIGN

Ciliated epithelial cells of the sphenoid sinus were taken from patients operated on for pituitary tumors. Video-computerized analysis technique and transmission electron microscopy were used to analyze the effects of the toxin on ciliary activity.

METHODS

Ciliary beat frequency (CBF) was measured in four different concentrations of alpha-toxin including 0.1, 1, 10, and 50 microg/mL. CBF was measured at 2, 4, 6, 12, 24, and 48 hours after administration of the toxin. To observe reversibility of the reduced ciliary activity, after 24-hour incubation in the media containing 10 microg/mL of alpha-toxin, the media were replaced with alpha-toxin-free media. The tissues were also processed for transmission electron microscopy to observe ultrastructural changes of the epithelial cells.

RESULTS

CBF increased significantly at 2-hour incubation and then decreased significantly after 12-hour incubation in 10 microg/mL of alpha-toxin (P< .05, repeated-measures ANOVA). The transmission electron microscopic findings showed mitochondrial swelling and a slight protrusion of the plasma membrane of the cilia. In toxin-free media, loss of ciliary activity was not recovered.

CONCLUSIONS

CBF increased at first, but with increasing incubation time ciliary movements decreased gradually and stopped eventually. This loss of CBF may be an irreversible change associated with ultrastructural changes in the mitochondria and the plasma membrane of the cilia.

Correlation between nasal obstruction symptoms and objective parameters of acoustic rhinometry and rhinomanometry

Acoustic rhinometry and rhinomanometry have been used to assess nasal airway patency objectively. We compared nasal obstruction symptoms before and after decongestion with several parameters of these objective tests. The patients assessed their nasal obstruction using a visual analogue scale (VAS). Cross-sectional areas and nasal resistance were measured by acoustic rhinometry and rhinomanometry before and after topical application of 1% phenylephrine solution in 32 patients with nasal obstruction symptoms. There was no significant correlation between the difference in the VAS and the difference in nasal resistance. There was also no significant correlation between the difference in the VAS and minimal cross-sectional area and cross-sectional areas at 3.3 cm (CA3.3), CA4.0 and CA6.4 from the nosepiece both in the wide and narrow sides and in both nasal cavities before and after nasal decongestion. It is concluded that rhinomanometry and acoustic rhinometry may have no diagnostic value in estimating the severity of nasal obstruction symptoms.

Preparation and application of Procion Yellow starch for amylase assay

A new starch derivative for the determination of amylase activity has been synthesized by coupling Procion Yellow dye with starch. The product of this reaction is intensely yellow and is easily suspended in water, in neutral buffer solution, and also in acidic solution. Amylase from pancreatin, saliva, urine and serum readily hydrolyzes this chromogenic substrate. A method for determining amylase activity based on the use of Procion Yellow Starch substrate is described. The procedure requires 0.1 ml of sample and an incubation time of 30 min. The soluble chromogen, which is liberated by enzymatic hydrolysis, is measured at 420 nm and the amylase activity-absorbance relationship at this wavelength is linear. The normal range for this method is 50--150 Somogyi units/dl.

A new method for the determination of serum creatinine based on reaction with 3.5-dinitrobenzoyl chloride in an organic medium

A new method for the determination of serum creatine, based on its reaction with 3,5-dinitrobenzoyl chloride in an organic medium is described. Various analytical parameters are studied and comparisons are made with the routine picrate procedures, as well as the dinitrobenzoic acid methods reported in the literature. On the basis of the data submitted, the proposed method is recommended for routine clinical use.

Fractionation of serum cholesterol: a critique

A procedure for fractionation of serum cholesterol is developed by employing digitonin for the precipitation of free cholesterol in isopropanol. This method is based on the ferric acetate color reaction which is unaffected by traces of digitonin. It is influenced only negligibly by the presence of stanols in serum and is shown to be equally chromogenic with respect to both free and ester forms of cholesterol. The proposed procedure shows a three-fold improvement in precision (3.1 percent coefficient of variation [CV]) compared to that of the procedure by Leffler and McDougald (10.5 percent C.V.) which is based on the ferric chloride color reaction. The proposed free cholestrol procedure showed a mean recovery of 99.5% percent (98.1 to 102.5 percent) when cholesterol in 40 to 200 mg per dl concentrations was added to serum. The analytical performance of the proposed fractionation of serum cholesterol is critically reviewed with respect to its potential application in the diagnosis of liver diseases and in basic or experimental research.

Steroid interference in iron-cholesterol reactions: a comparative study

Interference from various physiological and non-physiological steroids in the spectrophotometric determination of cholesterol by the Zak method (ferric chloride) and the method of Parekh and Jung (ferric acetate) was quantitatively measured. Contribution of the steroids at the specific absorption maxima of the cholesterol assays was determined by employing the steroids (40 mg/dl) alone, or added to a serum pool of known cholesterol content. The results show that the method of Parekh and Jung is less influenced by the presence of steroids than the Zak method. Observations on the structural specificity of the iron-cholesterol reaction are discussed.

Urinary inorganic phosphorus determinations

The Parekh-Jung method for determination of inorganic phosphorus in serum was applied to its determination in urine. Accuracy is good. The mean percentage recovery of added phosphorus was 100.2%. Forty analyses of a sample gave a mean value of 46.71 mg/100 ml +/- 0.76 standard deviation (between-batch precision). The relative usefulness of the Parekh-Jung method compared with those other methods is discussed.

An Improved Reagent System for the Measurement of Serum Uric Acid

The reagent is modified as follows: Serum chromogens are destroyed by trisodium phosphate. The use of phosphotungstic acid eliminates the tungstate and sulfate anions, a frequent cause of turbidity. Triethanolamine, added to the carbonate—urea mixture, provides unusual stability of the color through its buffering action. Only 0.2 ml of serum is required. The method is highly reproducible and accurate; analytical results agree closely with those obtained by the uricase or cyanide—urea method.