Acute kidney injury (AKI) is a complex disorder for which currently there is no accepted definition. Having a uniform standard for diagnosing and classifying AKI would enhance our ability to manage these patients. Future clinical and translational research in AKI will require collaborative networks of investigators drawn from various disciplines, dissemination of information via multidisciplinary joint conferences and publications, and improved translation of knowledge from pre-clinical research. We describe an initiative to develop uniform standards for defining and classifying AKI and to establish a forum for multidisciplinary interaction to improve care for patients with or at risk for AKI. Members representing key societies in critical care and nephrology along with additional experts in adult and pediatric AKI participated in a two day conference in Amsterdam, The Netherlands, in September 2005 and were assigned to one of three workgroups. Each group's discussions formed the basis for draft recommendations that were later refined and improved during discussion with the larger group. Dissenting opinions were also noted. The final draft recommendations were circulated to all participants and subsequently agreed upon as the consensus recommendations for this report. Participating societies endorsed the recommendations and agreed to help disseminate the results. The term AKI is proposed to represent the entire spectrum of acute renal failure. Diagnostic criteria for AKI are proposed based on acute alterations in serum creatinine or urine output. A staging system for AKI which reflects quantitative changes in serum creatinine and urine output has been developed. We describe the formation of a multidisciplinary collaborative network focused on AKI. We have proposed uniform standards for diagnosing and classifying AKI which will need to be validated in future studies. The Acute Kidney Injury Network offers a mechanism for proceeding with efforts to improve patient outcomes.

Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury

2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines

Review of recent research on hepatitis C therapy for 54th annual meeting of the American association for the study of liver diseases

结节病易误诊,据王洪武等~([1])收集国内18篇关于此病误诊的文献,误诊率高达63.2%,当然有误诊就会有误治,如孙永昌等~([2])报道26例结节病在影像学检查诊断的第一印象中拟诊结核5例,其中就有2例完成规范的抗结核治疗,为此应引起临床对本病诊治的重视。

Sarcoidosis

The latest advances in hepatology were presented in oral and poster presentations. In order to cover the varying subspecialties, the sessions were divided into various sections including 'Acute Liver Failure and Artificial Liver Support', 'Biliary Tract and Immunologic Liver Diseases', 'Cellular and Molecular Biology', 'Clinical and Experimental Hepatobiliary Surgery', 'Hepatotoxicity and Cell Death', 'Transport and Biliary Physiology', 'Viral Hepatitis', 'Evaluation and Treatment of Biliary Disease', 'Necrosis/Apoptosis', 'Portal Hypertension', 'Blood Flow and Vascular Disorders of Cirrhosis', 'Liver Transplantation', 'Fibrogenesis', 'Hepatocellular Carcinoma', 'Metabolism and Genetic Disease', and 'Public Policy, Epidemiology and Decision Analysis'. Drug therapy focused on treatments for viral hepatitis, autoimmune hepatitis, primary biliary cirrhosis and primary sclerosing cholangitis, and recurrent viral disease following liver transplant. High dose interferon therapy or various combinations of interferon/ribavirin (ICN Pharmaceuticals Inc) therapy seem to offer the best current therapy for chronic HCV. PEGylated interferon (F Hoffmann-La Roche Ltd) offers hope for treatment and histologic improvement in patients with chronic HCV. Following liver transplantation, combination interferon/ribavirin therapy may also find success, but caution with new potent immunosuppressant monoclonal antibodies is advised. For HBV, intramuscular H-BIG (NABI) appears to be effective and less costly than iv H-BIG administration following liver transplantation. Percutaneous radiofrequency ablation may hold promise over conventional ethanol injection therapy for small hepatocellular carcinoma. Autoimmune hepatitis may respond to tacrolimus therapy whereas budesonide therapy did not provide any advantage to prednisone therapy. For primary biliary cirrhosis, eicosapentate and ursodeoxycholic acid may provide benefit to some patients while silymarin from milk thistle did not provide any additional benefit. In primary sclerosing cholangitis, high dose ursodeoxycholic acid may provide benefit. Ursodeoxycholic acid may also provide benefit for mothers with intrahepatic cholestasis of pregnancy by decreasing pruritus, lowering laboratory values and allowing deliveries to occur closer to term.

Digestive disease week 2000. American Association for the Study of Liver Diseases

Dear Editor, A 61-year-old male presented with significant unintentional 50-pound weight loss associated with night sweats, arthralgias, and low-grade fever for 3 months. Complete blood count, comprehensive metabolic panel, erythrocyte sedimentation rate, and C-reactive protein were unremarkable. HIV screening, fungal serologies, QuantiFERON-TB, antineutrophil cytoplasmic antibodies, and antinuclear antibodies were negative. Vitamin D level was normal at 24 ng/mL (reference range 20–50). Computerized tomography (CT) of the chest and abdomen revealed multiple lateral pulmonary nodules and a low-attenuation lesion in the right lobe of the liver. The patient subsequently underwent CT-guided biopsy of the pulmonary nodule and liver lesion demonstrating necrotizing granulomas with negative acid-fast bacilli (AFB) and Grocott’s methenamine silver (GMS) stain. ANCA-negative granulomatosis with polyangiitis (GPA)was suspicious. However, since the potential side effects of treatment are high without confirmatory study, video-assisted thoracic surgeryguided lung biopsy, therefore, was performed. Lung biopsy revealed infiltration of lymphoid cells and histiocytes with scattered atypical mononuclear cells (Fig. 1a). There were also foci of necrosis within the central area of infiltration. Immunohistochemistry for CD3 and CD20 as well as in situ hybridization for Epstein-Barr virus (EBV)-encoded small nuclear RNA (EBER) were performed. The majority of the cells were CD3-positive small T cells (Fig. 1b) with scattered large CD20-positive large B cells (Fig. 1c) interspersed among small T cells. In situ hybridization showed scattered areas of EBER-positive cells throughout the lesions (Fig. 1d). Thus, the patient was diagnosed with lymphomatoid granulomatosis (LYG). Patient was subsequently started on rituximab cyclophosphamide, doxorubicin, vincristine, and prednisone and completed six cycles without clinical or radiologic signs of tumor recurrence or metastasis. Lymphomatoid granulomatosis is a rare angiodestructive lymphoproliferative disorder. It was first described in 1972 by Liebow et al. [1] as an uncommon multiorgan systemic disease with most commonly lung involvement. The World Health Organization classification in 2008 placed LYG under the category of Blarge B cell lymphomas^ and described it as an extranodal, angiocentric, Tcell-rich B cell lymphoma. LYG is thought to be EBV-driven process [2]. LYG is commonly seen in middle-aged adults, withmale predominance [3, 4] and associated with unfavorable prognosis, mortality was 63.5 %, and median survival was 14 months [3]. Fever, dry cough, and weight loss are the most common presentation [5]. Diagnosis of LYG can be challenging given its bewildering presentation. Thus, it may mimic many conditions [6] as in our case presentation. A biopsy is mandatory for the diagnosis and the histological triad of polymorphic lymphocytic infiltrate angiitis, and granulomatosis with central necrosis is required [3]. There is currently no officially therapeutic approach to this rare disease. In most cases, corticosteroids, in combination with chemotherapy, are the first line of treatment [4]. As with diffuse large B cell lymphomas, cyclophosphamide, * Narat Srivali srivali.narat@mayo.edu

Lymphomatoid granulomatosis mimicking vasculitis.

Background: A hallmark of sarcoidosis is lung disease. However, the prognosis and long-term outcome of pulmonary sarcoidosis are not well-defined due to the limited number of studies with long duration of follow-up. Objectives: This study was undertaken to characterize the course of pulmonary sarcoidosis in a population-based cohort. Methods: A population-based cohort of 311 incident cases of pulmonary sarcoidosis among Olmsted County, Minnesota residents in 1976-2013 were identified. Medical records of the confirmed cases were reviewed from diagnosis to last follow-up. Data on stage of pulmonary sarcoidosis at diagnosis, serial pulmonary function tests, requirement of oxygen therapy and treatment were abstracted. The cumulative incidence of chronic respiratory impairment (defined as forced vital capacity of <50%, diffuse capacity for carbon monoxide of <40% or requirement to use oxygen supplementation) adjusted for the competing risk of death was estimated. Cox models were used to assess the association of stage of pulmonary sarcoidosis and treatment on the development of chronic respiratory impairment. Results: 25 patients developed chronic respiratory impairment which corresponded to a 10-year event rate of 4.4% (95% confidence interval [CI], 1.9.-6.9). Stage of pulmonary sarcoidosis at diagnosis was a strong predictor for chronic respiratory impairment with hazard ratio compared with stage I of 5.29 (95% CI, 1.65-16.96) for stage II and 8.36 (95% CI, 26.3-26.52) for stage III and IV. Use of glucocorticoids and immunosuppressive agents was associated with a significantly increased risk of chronic respiratory impairment. Conclusion: Patients with pulmonary sarcoidosis have a good pulmonary prognosis with a low incidence of chronic respiratory impairment. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 123-128).

Outcome of pulmonary sarcoidosis: a population-based study 1976-2013.

Background: Recent studies have suggested that patients with chronic rhinosinusitis (CRS) may have a higher risk of stroke although the data are still limited. The current systematic review and meta-analysis was conducted with the aims to identify all studies that investigated this relationship and summarize their results together to better characterize the risk of stroke among patients with CRS. Methods: A comprehensive literature review was conducted by searching for published articles in MEDLINE and EMBASE databases from inception to October 2018 to identify all observational studies that compared the risk of stroke among patients with CRS to individuals without CRS. Pooled risk ratio (RR) and 95% confidence interval (CI) were calculated using random-effect, generic inverse variance method of DerSimonian and Laird. Results: A total of 5 studies with 447,065 participants met the eligibility criteria and were included into the meta-analysis. The risk of stroke among patients with CRS was significantly higher than individuals without CRS with the pooled RR of 1.79 (95% CI, 1.34-2.40, I2 = 84%). Conclusions: The current study found that CRS is associated with higher risk stroke. Whether this relationship is causal and how it should be addressed in clinical practice require further investigations.

Risk of Stroke among Patients with Chronic Rhinosinusitis: A Systematic Review and Meta-analysis.

Background Proton pump inhibitors (PPIs) are commonly prescribed for cirrhotic patients. However, the use of PPIs in these patients may increase the risk of bacterial infection. The current study aimed to investigate the risk of developing pneumonia among cirrhotic patients exposed to PPIs. Methods A literature search was independently conducted by 2 investigators using the MEDLINE and EMBASE databases up to September 2019. To be eligible, a study had to be an observational (cohort, case-control or cross-sectional) study that included one group of cirrhotic patients with PPI use and another group of cirrhotic patients without PPI use. Effect estimates of the association between PPI use and pneumonia had to be reported. Point estimates and standard errors from each eligible study were combined together using the generic inverse variance method of DerSimonian and Laird. Results Of 1947 articles identified from the 2 databases, 3 cohort and 5 cross-sectional studies with 40,295 participants met the eligibility criteria and were included in the meta-analysis. The pooled analysis found that cirrhotic patients with a history of PPI use had a significantly higher risk of developing pneumonia than those without PPI use, with a pooled risk ratio of 1.36 (95% confidence interval 1.00-1.85; I 2 47%). Conclusion A significantly increased risk of pneumonia among cirrhotic patients exposed to PPIs was demonstrated in this study.

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Use of proton pump inhibitors is associated with a higher risk of pneumonia in cirrhotic patients: a systematic review and meta-analysis.

Objective To investigate the association between allergic rhinitis (AR) and the risk of rheumatoid arthritis (RA). Methods Potentially eligible studies were identified from MEDLINE and EMBASE databases from inception to November 2019. Eligible cohort study must report relative risk with 95% confidence intervals (95% CIs) of incident RA between AR patients and comparators. Eligible case-control studies must include cases with RA and controls without RA, and must explore their history of AR. Odds ratio with 95% CIs of the association between AR and RA must be reported. Point estimates with standard errors from each study were combined using the generic inverse variance method. Results A total of 21,824 articles were identified. After two rounds of the independent review by three investigators, two cohort studies and 10 case-control studies met the eligibility criteria. The pooled analysis showed no association between AR and risk of RA (RR = 0.94; 95% CI, 0.73 to 1.20; I2 = 84%). However, when we conducted a sensitivity analysis including only studies with acceptable quality, defined as Newcastle-Ottawa score of seven or higher, we found that patients with AR had a significantly higher risk of RA (RR = 1.36; 95% CI, 1.12 to 1.65; I2 = 45%). Conclusions The current systematic review and meta-analysis could not reveal a significant association between AR and RA. However, when only studies with acceptable quality were included, a significantly higher risk of RA among patients with AR than individuals without AR was observed.

Patompong Ungprasert

Papers

Lymphomatoid granulomatosis mimicking vasculitis.

Outcome of pulmonary sarcoidosis: a population-based study 1976-2013.

Risk of Stroke among Patients with Chronic Rhinosinusitis: A Systematic Review and Meta-analysis.

Use of proton pump inhibitors is associated with a higher risk of pneumonia in cirrhotic patients: a systematic review and meta-analysis.

The association between allergic rhinitis and risk of rheumatoid arthritis: A systematic review and meta-analysis.