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

To the Editor: W e read the article by Finger and Scheinberg with great interest, which described a rare adverse effect of rituximab as well as subsequent reports. We similarly observed a case of a patient who developed serum sickness after receiving rituximab as a treatment for her Sjögren syndrome. We emphasize that the literature suggests that this reaction to rituximab appears to be more common in autoimmune disease than after use in malignancies. A 50-year-old woman with overlapping syndrome between Sjögren syndrome and systemic lupus erythematosus (SLE) presented to our institute with 2 days’ history of low-grade fever, diffuse joint pain, and pruritic rash over her torso. She received rituximab 1 week before the onset of symptoms for her painful bilateral parotid gland swelling from her Sjögren syndrome. She had also previously received rituximab for central nervous system vasculitis, lymphocytic interstitial lung disease, and inflammatory arthritis from her SLE 5 years ago. She had not been taking any immunosuppressive agent for 3 years since her SLE had been inactive. Physical examination revealed temperature of 38.6-C, blood pressure of 102/67 mm Hg, and heart rate of 130 beats/min. Head, eyes, ears, nose, and throat examination was remarkable for bilateral and painful parotid gland enlargement without any associated lymphadenopathy. Her musculoskeletal examination revealed mild warmth, tenderness, erythema, and swelling in her wrists, all metacarpalphalangeal joints, and all proximal interphalangeal joints. She had urticarial rash over her torso and her back. Her cardiovascular, respiratory, neurological, and abdominal examinations were unremarkable. Laboratory tests showed hemoglobin of 10.2 g/dL, white blood cell count of 3800/KL (neutrophil of 82% and lymphocyte of 12%), and platelet count of 72,000/KL. Blood chemistry and liver function tests were within reference range. Complements were suppressed with C3 level of 97 mg/dL (90Y207 mg/dL), C4 level of less than 6 mg/dL (17.4Y52.2 mg/dL), and CH50 of 12 U/mL (30Y75 U/mL. Microbiologic investigations, including blood culture, urine culture, and viral serology, did not reveal any evidence of infection. The diagnosis of rituximab-induced serum sickness was made in the view of classic presentation of fever, arthralgia, and rash following rituximab exposure. She was treated with intravenous methylprednisolone. She responded well to the corticosteroids, and all of her symptoms were completely resolved within 48 hours. She was discharged home with oral prednisone for 7 days. Rituximab is a chimeric monoclonal anti-CD20 antibody, containing both human and murine portion in its protein structure. It has been approved for use in a variety of autoimmune diseases as well as lymphoproliferative disorders. Rituximab is relatively safe, although mild and self-limited infusion reaction can be found in 30% to 45% of patients. Serum sickness is an immune complexY mediated or type III hypersensitivity reaction characterized by clinical triad of fever, rash, and polyarthralgia/polyarthritis after exposure to triggering agents. It is a relatively uncommon adverse effect of rituximab with approximately 40 cases reported thus far. Interestingly, it has been reported more frequently in patients with autoimmune diseases than hematologic malignancies. The reasons why serum sickness occurs more frequently in patients with autoimmune disorders remains unclear. Suppression of humoral immune response in patients with cancer who often receive concurrent chemotherapy with rituximab may be an explanation of the lower incidence of the adverse reaction in this group. Another explanation is related to the nature of autoimmune disorders that usually create pools of polyclonal immunoglobulin with high affinity to self-epitopes capable of binding to infused monoclonal protein. This could also explain why in some cases this reaction occurred after first infusion but not in subsequent ones. Serum sickness is generally self-limited, and patients usually improve rapidly after withdrawal of the culprit agent. Glucocorticoid may be indicated in patients with more severe reaction. Rapid resolution of serum sickness associated with rituximab after administration of glucocorticoid has been documented in several case reports. Our patient also responded well to glucocorticoid and had complete resolution within 48 hours. As the utility of this monoclonal antibody in autoimmune disorders expands, rheumatologists should be alert for serum sickness as a possible adverse reaction to this treatment. Prompt withdrawal of rituximab and timely administration of glucocorticoid can result in rapid improvement of symptoms and excellent clinical outcome.

Rituximab-induced serum sickness in overlapping syndrome between sjögren syndrome and systemic lupus erythematosus.

Background—Patients with rheumatoid arthritis are more likely to have reduced kidney function develop over time. The aim of this study was to assess the clinical and safety outcomes of living kidney donors with rheumatoid arthritis. Methods—A retrospective cohort study at a tertiary referral hospital to assess the outcomes of living kidney donors with rheumatoid arthritis. All 6 adults with rheumatoid arthritis who underwent nephrectomy as living kidney donors between January 2000 and September 2014 were included. Eighteen nondonors with rheumatoid arthritis (3 nondonors per donor) were randomly selected for comparison by matching the year of birth and comorbidity score. Results—None of the donors with rheumatoid arthritis had a flare-up of arthritis at a median follow-up time of 5.9 years (interquartile range [IQR], 3.1–7.5 years), while 5 (27.8%) nondonors with rheumatoid arthritis had a flare-up at a median follow-up time of 4.7 years (IQR, 3.1–6.7 years). After nephrectomy, donors' estimated glomerula...

Outcomes of living kidney donors with rheumatoid arthritis.

This study aimed to investigate the association between circulating soluble Klotho level and risk of all-cause mortality in chronic kidney disease (CKD) patients using systematic review and meta-analysis technique. Potentially eligible studies were identified from Medline and EMBASE databases from inception to March 2020 using a search strategy that consisted of terms for “Klotho” and “Mortality”. Eligible study must be a cohort study that consists of one cohort of CKD patients with higher circulating soluble Klotho level and another cohort of CKD patients with lower circulating soluble Klotho level. The study must also report relative risk (RR), incidence rate ratio, hazard risk ratio or standardized incidence ratio with 95% confidence intervals (95% CIs) comparing all-cause mortality between CKD patients with lower circulating soluble Klotho level versus CKD patients with higher circulating soluble Klotho level. If the study divides patients (per circulating soluble Klotho level) into more than two groups, a comparison between the highest and the lowest group would be extracted. Point estimates with standard errors were retrieved from each study and were combined together using the generic inverse variance method. A total of 2964 articles were retrieved. After two rounds of an independent review by two investigators, six prospective cohort studies met the eligibility criteria and were included into the meta-analysis. CKD patients with lower circulating soluble Klotho level had a significantly increased risk of all-cause mortality with the pooled risk ratio of 1.88 (95% CI 1.29–2.74; I2 0%). The funnel plot was fairly symmetric and did not reveal any suggestive evidence of publication bias. The current study found a significant association between lower circulating soluble Klotho level and increased risk of all-cause mortality in CKD patients. However, this meta-analysis carries some limitations, including relatively small sample size, lack of adjustment for potential confounders and between-study heterogeneity in baseline characteristics of the patients and cut-off values used to categorize patients into higher and lower circulating serum Klotho level group.

Lower circulating soluble Klotho level is associated with increased risk of all-cause mortality in chronic kidney disease patients: a systematic review and meta-analysis

https://onlinelibrary.wiley.com/doi/pdf/10.1002/joa3.12187

Patompong Ungprasert

Papers

Rituximab-induced serum sickness in overlapping syndrome between sjögren syndrome and systemic lupus erythematosus.

Outcomes of living kidney donors with rheumatoid arthritis.

Lower circulating soluble Klotho level is associated with increased risk of all-cause mortality in chronic kidney disease patients: a systematic review and meta-analysis

Paroxysmal supraventricular tachycardia and risk of ischemic stroke: A systematic review and meta‐analysis

Higher zinc intake is associated with decreased risk of lung cancer.