Kyu-Beck Lee

Time-Dependent Association Between Metabolic Syndrome and Risk of CKD in Korean Men Without Hypertension or Diabetes

BACKGROUND The time-dependent association between metabolic syndrome and risk of chronic kidney disease (CKD) is not clear. STUDY DESIGN Prospective cohort study. SETTING & PARTICIPANTS The study cohort was composed of 10,685 healthy men without CKD, hypertension, or diabetes who participated in a health-checkup program at a large work site. PREDICTOR Metabolic syndrome. OUTCOMES & MEASUREMENTS CKD was defined as an estimated glomerular filtration rate (GFR) less than 60 mL/min/1.73 m(2). A standard Cox proportional hazards model and a time-dependent Cox model were used to calculate adjusted hazard ratios (HRs) in the CKD model. RESULTS During 40,616.8 person-years of follow-up, 291 incident cases of CKD developed; 787 patients (7.4%) had metabolic syndrome at baseline and 1,444 (14.4%) developed incident metabolic syndrome during follow-up. After adjustment for age, baseline GFR, gamma-glutamyltransferase level, and uric acid level, metabolic syndrome at baseline was associated with a significantly increased risk of CKD (HR, 1.99; 95% confidence interval, 1.46 to 2.73). Metabolic syndrome over time as a time-dependent variable also predicted the development of CKD (HR, 1.83; [corrected] 95% confidence interval, 1.34 to 2.49) [corrected] The relationship between metabolic syndrome and incident CKD remained significant, even after further adjustment for the homeostasis model assessment of insulin resistance, high-sensitivity C-reactive protein level, current smoking, alcohol consumption, or regular exercise. In addition, there were graded relationships between number of metabolic syndrome traits or quintile of homeostasis model assessment of insulin resistance over time as a time-dependent variable and risk of CKD. Both increased triglyceride and low high-density lipoprotein cholesterol levels among metabolic syndrome traits were associated with significantly increased risk of CKD. These results were effectively unchanged, even after additional adjustment for incident hypertension and incident diabetes. LIMITATIONS Estimated GFR was used instead of a directly measured GFR to define CKD. CONCLUSION Metabolic syndrome is an independent risk factor for the development of CKD in Korean men without hypertension or diabetes, even with changes in status of metabolic syndrome over time.

Prediction of mortality in patients undergoing maintenance hemodialysis by Charlson Comorbidity Index using ICD-10 database.

Background/Aims: Many patients with end-stage renal disease have additional comorbidities that are important to clinical study and impact the patient’s outcome. The Charlson Comorbidity Index (CCI) is a popular tool and a strong predictor of outcome in end-stage renal disease patients. We obtained comorbidity data from the hospital discharge database using the International Classification of Disease, 10th revision (ICD-10) and analyzed the mortality rate in incident patients undergoing maintenance hemodialysis (HD). Methods: We evaluated the medical records of a total of 456 patients on HD (58 ± 14 years of age, 56% males). We calculated CCI scores at the start of HD with information from the hospital discharge summary according to the ICD-10 code. We then analyzed patient mortality according to these CCI scores. Results: The percentages of patients that had diabetes with end-organ damage (51.1%), congestive heart failure (9.9%), coronary artery disease (8.1%) and stroke (6.8%) were identified. CCI scores were 5.09 ± 2.01 (range 2–11). Four comorbidity groups were established by quartile ranking of the CCI scores: low, moderate, high and very high. The mortality rates were: 0.83, 7.70, 14.09 and 18.69 deaths/100 patient-years, respectively (p = 0.001). Compared with the low comorbidity group, the hazard ratios for mortality were 9.22 (95% CI 3.29–25.84) for the moderate group, 16.77 (95% CI 5.97–47.11) for the high group, and 22.37 (95% CI 8.08–61.93) for the very high group. Conclusions: The CCI scores using the ICD-10 database information were significant predictors of mortality in incident patients undergoing maintenance HD.

Digital tomosynthesis of the chest: Utility for detection of lung metastasis in patients with colorectal cancer

AIM To evaluate the performance of digital tomosynthesis (DT) of the chest for detection of lung nodules in patients with colorectal cancer (CRC). MATERIALS AND METHODS The institutional review board approved this study, and all patients provided informed consent. A commercial caesium iodide/amorphous silicon (CsI/a-Si) flat-panel detector system was used to verify the performance of the DT and chest radiography (XR) methods. DT was performed in 142 patients with CRC. All 142 patients underwent chest computed tomography (CT) within a week of DT. As a reference standard, two radiologists reviewed the chest CT in consensus and recorded the presence of pulmonary nodules. Another two radiologists independently observed the DT images and recorded the presence of pulmonary nodules. The status of all lung nodules was assessed either histologically or by follow-up over a period of 1 year. The nodules were classified into metastasis, benign, and uncertain. Statistical analysis of the results was performed. RESULTS Two hundred and thirty-seven nodules from 142 patients were found at CT. These included 71 proven metastases and 126 benign nodules; 40 nodules were uncertain. Observers detected 83% of all lung nodules and 93% of proven metastases using DT. Among 237 nodules, 147 nodules were larger than 4mm in diameter on the CT images. Observers detected 87% of lung nodules that were larger than 4mm. CONCLUSION Despite a reasonably low radiation dose, DT is a sensitive method, and is comparable to chest CT for the detection of lung nodules, particularly metastatic lung nodules in patients with CRC.

Serum 1,5-Anhydroglucitol Concentrations Are a Reliable Index of Glycemic Control in Type 2 Diabetes With Mild or Moderate Renal Dysfunction

OBJECTIVE To assess the relationship between 1,5-anhydroglucitol (AG) levels, which are a marker of glycemic control, and stages of chronic kidney disease (CKD). RESEARCH DESIGN AND METHODS This was a cross-sectional study with 269 subjects with type 2 diabetes who were divided into four groups based on estimated glomerular filtration rate (eGFR) using Modification of Diet in Renal Disease (eGFRMDRD) formula: 57 in control, 111 in CKD stages 1–2, 78 in stage 3, and 23 in stages 4–5. RESULTS The study groups differed significantly with respect to 1,5-AG and fasting plasma glucose (FPG), age, duration of diabetes, blood pressure, HDL, and percentage of antihypertension or antidyslipidemia medication use. Stepwise multivariate regression analyses showed that 1,5-AG levels in the control group, the CKD stages 1–2 group, and the CKD stage 3 group could be explained by HbA1c, age, duration of diabetes, FPG, and antihypertension medication. However, eGFRMDRD was the only independent determinant of 1,5-AG levels in CKD stages 4–5. Logarithmic transformed 1,5-AG values (ln[1,5-AG]) had significant inverse correlations with HbA1c and FPG levels for CKD stages 1–2 and CKD stage 3 (all P < 0.001). However, associations between ln(1,5-AG) and HbA1c or FPG were insignificant for CKD stages 4–5 (P = 0.274 and P = 0.080, respectively). CONCLUSIONS This study demonstrated that 1,5-AG levels do not appear to be influenced by mild or moderate renal dysfunction, suggesting it is a reliable glycemic marker in type 2 diabetes with CKD stages 1–3.

The Relationship of Microalbuminuria with Metabolic Syndrome

Background/Aims: Microalbuminuria and the metabolic syndrome are risk factors for cardiovascular disease. The aim of this study is to examine the prevalence of microalbuminuira and to document the relationship of microalbuminuria with the metabolic syndrome in a large population of Korean subjects. Methods: We examined the cross-sectional association of microalbuminuria with the components of the metabolic syndrome and with other cardiovascular risk factors in 6,588 Korean adults who took part in a health examination program. Results: The prevalence of microalbuminuria was 4.2% in the non-metabolic syndrome group (n = 5,902), and 14.4% in the metabolic syndrome group (n = 686). The odds ratio of microalbuminuria in the adults with the metabolic syndrome compared with those adults without the metabolic syndrome was 1.53 (1.13–2.07 95% CI). In the multiple logistic regression analysis, as compared with the subjects without an elevated blood pressure, a low high-density lipoprotein cholesterol level, a high triglyceride level, a high plasma glucose level and a large waist circumference, the odds ratios for microalbuminuria with these components, after adjustment was made for the body mass index, the high-sensitivity C-reactive protein level and the homeostasis model assessment, were 2.17 (95% CI 1.71–2.76), 2.84 (95% CI 1.55–5.21), 1.30 (95% CI 1.03–1.65) and 2.68 (95% CI 2.04–3.51), respectively. The corresponding multivariate-adjusted odds ratios of microalbuminuria for the participants with 1, 2, 3, and 4 and 5 components of metabolic syndrome were 1.79 (95% CI 1.24–2.59), 2.35 (95% CI 1.58–3.51), 3.23 (95% CI 2.07–5.25), and 4.22 (95% CI 2.13–8.35), respectively. Conclusion: There was a significantly graded relationship between the number of metabolic syndrome components and the corresponding prevalence of microalbuminuria. These findings suggest microalbuminuria is strongly related with the components of the metabolic syndrome.

TGF-β Mediated Epithelial-Mesenchymal Transition in Autosomal Dominant Polycystic Kidney Disease

Purpose Recent studies have showed that epithelial-mesenchymal transition (EMT) is a key process of glomerular and tubulointerstitial pathology in many chronic kidney diseases. However, there are no data of EMT in humane autosomal dominant polycystic kidney disease (ADPKD). Patients and Methods ADPKD kidneys (N = 5) with end stage renal disease (ESRD) and control kidneys (N = 4) were analyzed immnunohistochemically. We evaluated α-SMA, E-cadherin, vimentin, TGF-β1 and Smad 2/3 expression in ADPKD and compared them with those in control kidney. These immunohistochemical findings were quantitatively analyzed by computer-assisted image analyzer and positive tubules (%). Results There were severe interstitial fibrosis and proliferation of α-SMA+ myofibroblasts in ADPKD. Cystic tubular epithelial cells in ADPKD lost epithelial marker (E-cadherin) and expressed mesenchymal markers (α-SMA, vimentin). There were significant increases of α-SMA (34.3 ± 11.7% vs 0.9 ± 1.5%), vimentin (19.9 ± 3.9% vs 3.3 ± 1.4%), TGF-β1 (5.42 ± 2.83% vs 0%) and Smad 2/3 (3.4 ± 1.7% vs 0.7 ± 0.6%) in ADPKD kidneys compared with control kidneys evidenced by computer-assisted image analyzer. When we analyze the positive tubules (%), the results were the same as computer-assisted image analyzer. Conclusion Our results showed that the end stage of ADPKD is associated with TGF-β, Smad 2/3 and markers of EMT. It suggests that TGF-β mediated EMT has a role in progression of ADPKD.

RELIABILITY OF MAGNETIC RESONANCE IMAGING FOR MEASURING THE VOLUMETRIC INDICES IN AUTOSOMAL-DOMINANT POLYCYSTIC KIDNEY DISEASE: CORRELATION WITH HYPERTENSION AND RENAL FUNCTION

Background: The purpose of this study was to determine if renal volumetric indices can be accurately measured using MRI, and if these volumetric indices are associated with hypertension and renal function in patients with autosomal-dominant polycystic kidney disease (ADPKD). Methods: For testing the accuracy of the MRI-based volume measurements that we proposed for clinical trial, we designed phantoms to simulate cysts within the kidney. Fifty-six patients with ADPKD were included in this study, and their respiratory compensated T2-weighted fast spin-echo images were acquired. The total kidney volume (Vt), cyst volume (Vc), and noncystic parenchymal volume (Vp) were measured and the percent cyst volume (Pc) was calculated. These volumetric indices were compared with the disease progression in the ADPKD patients. Results: The MRI measures of the phantoms were accurate. The Vt, Vc and Pc were significantly greater in the hypertensive group (n = 35) than in the normotensive group (n = 21) (p < 0.01). The Vt, Vc and Pc were significantly greater in the renal failure group (n = 23) than in the normal renal function group (n = 33) (p < 0.01). The Vt, Vc, and Pc were inversely correlated with the creatinine clearance. Conclusion: MRI is a reliable method to measure renal volumetric indices. The MRI-based volume measurements can be employed as useful markers for the progression of disease in ADPKD patients.

Cystic intrapulmonary lymphangioma: HRCT findings

We report a rare case of cystic intrapulmonary lymphangioma involving the left lung, which presented with pneumothorax and respiratory distress in a 6-month-old infant. Chest radiographs showed a multicystic lesion in the left lung mimicking the features of congenital cystic adenomatoid malformation of the lung. The lesion appeared on high-resolution CT (HRCT) as a multiseptate, air-filled cystic lesion in the left hilar area. Associated HRCT findings were thickening of interlobular septa and bronchovascular bundles in the left lung and the presence of peripheral pulmonary vessels within cystic lesions in the apex of the left lung. HRCT findings correlated well with histopathologic findings. We suggest that these associated findings may be helpful in distinguishing this condition from other cystic lung diseases and that this entity should be included in the differential diagnosis of multicystic lung lesions.

Increased cardiovascular mortality in subjects with metabolic syndrome is largely attributable to diabetes and hypertension in 159,971 Korean adults

CONTEXT Metabolic syndrome (MetS) is a risk factor for cardiovascular disease (CVD) mortality. OBJECTIVE This study aimed to evaluate the association of MetS with all-cause and cardiovascular mortality in apparently healthy young Korean subjects. DESIGN A retrospective study of 155,971 participants (mean age, 41.8 y) in a health screening program, followed up for 3.7 years (597,628.2 person-years). The risk for all-cause mortality and CVD mortality were analyzed according to the presence or absence of MetS. MAIN OUTCOMES A total of 542 subjects died during followup. Women with MetS showed a significantly increased age-adjusted hazard ratio (HR) for all-cause mortality compared with women without MetS, even after adjustment for confounding factors (HR, 1.82; 95% confidence interval [CI], 1.15-2.88). Subjects with MetS showed a significantly increased risk for CVD mortality compared with those without MetS, even after adjustment for confounding factors (HR, 1.60; 95% CI, 1.02-2.20), of which significance disappeared when subjects with diabetes or hypertension at baseline were excluded from the analysis (HR, 0.95; 95% CI, 0.29-3.12). CONCLUSIONS The presence of MetS increased the risk for all-cause mortality in women and the risk for CVD mortality in total population. These increased HR attributed to the pre-existing diabetes or hypertension in this population.

Clinical Correlates of Mass Effect in Autosomal Dominant Polycystic Kidney Disease.

Mass effect from polycystic kidney and liver enlargement can result in significant clinical complications and symptoms in autosomal dominant polycystic kidney disease (ADPKD). In this single-center study, we examined the correlation of height-adjusted total liver volume (htTLV) and total kidney volume (htTKV) by CT imaging with hepatic complications (n = 461) and abdominal symptoms (n = 253) in patients with ADPKD. “Mass-effect” complications were assessed by review of medical records and abdominal symptoms, by a standardized research questionnaire. Overall, 91.8% of patients had 4 or more liver cysts on CT scans. Polycystic liver disease (PLD) was classified as none or mild (htTLV < 1,600 mL/m); moderate (1,600 ≤ htTLV <3,200 mL/m); and severe (htTLV ≥ 3,200 mL/m). The prevalence of moderate and severe PLD in our patient cohort was 11.7% (n = 54/461) and 4.8% (n = 22/461), respectively, with a female predominance in both the moderate (61.1%) and severe (95.5%) PLD groups. Pressure-related complications such as leg edema (20.4%), ascites (16.6%), and hernia (3.6%) were common, and patients with moderate to severe PLD exhibited a 6-fold increased risk (compared to no or mild PLD) for these complications in multivariate analysis. Similarly, abdominal symptoms including back pain (58.8%), flank pain (53.1%), abdominal fullness (46.5%), and dyspnea/chest-discomfort (44.3%) were very common, and patients with moderate to severe PLD exhibited a 5-fold increased risk for these symptoms. Moderate to severe PLD is a common and clinically important problem in ~16% of patients with ADPKD who may benefit from referral to specialized centers for further management.