Aspirin intervention before ICU admission reduced the mortality in critically ill patients with acute kidney injury: results from the MIMIC-IV

Background: Aspirin, with its pleiotropic effects such as anti-inflammatory and anti-platelet aggregation, has been widely used for anti-inflammatory, analgesic, and cardiovascular diseases. However, the association between the use of aspirin before the intensive care unit (ICU) and clinical outcomes in critically ill patients with acute kidney injury (AKI) is unknown. Methods: Patients with AKI in this retrospective observational study were selected from the Marketplace for Medical Information in Intensive Care IV (MIMIC-IV). The association between aspirin intervention and 30-day mortality was assessed using Cox proportional hazards model. Logistic regression models were used to assess the association of aspirin intervention with the risks of intracranial hemorrhage, gastrointestinal bleeding and blood transfusion. The propensity score matching (PSM) method was adopted to balance the baseline variables. Sensitivity analysis was performed to validate the results by multiple interpolations for the missing data. Results: The study included 4237 pre-ICU aspirin users and 9745 non-users. In multivariate models, we found a decreased risk of mortality in those who received aspirin before ICU compared to those who did not (30-day:hazard ratio [HR], 0.70; 95% CI, 0.62-0.79; p < 0.001; 90-day:HR, 0.70; 95% CI, 0.63-0.77, p < 0.001; 180-day:HR, 0.72; 95%CI,0.65-0.79, p < 0.001). This benefit was consistent in the post-PSM analyses, sensitivity analyses, and subgroup analyses. Moreover, aspirin intervention was associated with a reduced risk of intracranial hemorrhage and gastrointestinal bleeding (HR, 0.16; 95% CI, 0.10-0.25; p < 0.001; HR, 0.59; 95% CI, 0.38-0.88, p = 0.012) after being adjusted by relating covariates, whereas with a increased risk of blood transfusion (HR, 1.28; 95% CI, 1.16-1.46; p < 0.001). Conclusion: Patients with AKI treated with aspirin before ICU admission might have reduced 30-day, 90-day and 180-day mortality without increasing the risk of intracranial hemorrhage (ICH) or gastrointestinal bleeding, but may increase the risk of transfusion.

Effects of Mineralocorticoid Receptor Antagonists for Chronic Kidney Disease: A Systemic Review and Meta-Analysis

BACKGROUND

Mineralocorticoid receptor blockade could be a potential approach for the inhibition of chronic kidney disease (CKD) progression. The benefits and harms of different mineralocorticoid receptor antagonists (MRAs) in CKD are inconsistent.

OBJECTIVES

The aim of the study was to summarize the benefits and harms of MRAs for CKD patients.

METHODS

We searched MEDLINE, EMBASE, and the Cochrane databases for trials assessing the effects of MRAs on non-dialysis-dependent CKD populations. Treatment and adverse effects were summarized using meta-analysis.

RESULTS

Fifty-three trials with 6 different MRAs involving 22,792 participants were included. Compared with the control group, MRAs reduced urinary albumin-to-creatinine ratio (weighted mean difference [WMD], -90.90 mg/g, 95% CI, -140.17 to -41.64 mg/g), 24-h urinary protein excretion (WMD, -0.20 g, 95% CI, -0.28 to -0.12 g), estimated glomerular filtration rate (eGFR) (WMD, -1.99 mL/min/1.73 m2, 95% CI, -3.28 to -0.70 mL/min/1.73 m2), chronic renal failure events (RR, 0.86, 95% CI, 0.79-0.93), and cardiovascular events (RR, 0.84, 95% CI, 0.77-0.92). MRAs increased the incidence of hyperkalemia (RR, 2.04, 95% CI, 1.73-2.40) and hypotension (RR, 1.80, 95% CI, 1.41-2.31). MRAs reduced the incidence of peripheral edema (RR, 0.65, 95% CI, 0.56-0.75) but not the risk of acute kidney injury (RR, 0.94, 95% CI, 0.79-1.13). Nonsteroidal MRAs (RR, 0.66, 95% CI, 0.57-0.75) but not steroidal MRAs (RR, 0.20, 95% CI, 0.02-1.68) significantly reduced the risk of peripheral edema. Steroidal MRAs (RR, 5.68, 95% CI, 1.26-25.67) but not nonsteroidal MRAs (RR, 0.52, 95% CI, 0.22-1.22) increased the risk of breast disorders.

CONCLUSIONS

In the CKD patients, MRAs, particularly in combination with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, reduced albuminuria/proteinuria, eGFR, and the incidence of chronic renal failure, cardiovascular and peripheral edema events, whereas increasing the incidence of hyperkalemia and hypotension, without the augment of acute kidney injury events. Nonsteroidal MRAs were superior in the reduction of more albuminuria with fewer peripheral edema events and without the augment of breast disorder events.

Retinoic Acid-Induced Protein 14 (RAI14) Promotes mTOR-Mediated Inflammation Under Inflammatory Stress and Chemical Hypoxia in a U87 Glioblastoma Cell Line

Retinoic acid-induced 14 is a developmentally regulated gene induced by retinoic acid and is closely associated with NIK/NF-κB signaling. In the present study, we examined the effect of RAI14 on mTOR-mediated glial inflammation in response to inflammatory factors and chemical ischemia. A U87 cell model of LPS- and TNF-α-induced inflammation was used to investigate the role of RAI14 in glial inflammation. U87 cells were treated with siR-RAI14 or everolimus to detect the correlation between mTOR, RAI14, and NF-κB. CoCl₂-stimulated U87 cells were used to analyze the effect of RAI14 on mTOR-mediated NF-κB inflammatory signaling under chemical hypoxia. LPS and TNF-α stimulation resulted in the upregulation of RAI14 mRNA and protein levels in a dose- and time-dependent manner. RAI14 knockdown significantly attenuated the level of pro-inflammatory cytokine via inhibiting the IKK/NF-κB pathway. Treatment with an mTOR inhibitor (everolimus) ameliorated NF-κB activity and IKKα/β phosphorylation via RAI14 signaling. Notably, RAI14 also enhanced mTOR-mediated NF-κB activation under conditions of chemical hypoxia. These findings provide significant insight into the role of RAI14 in mTOR-induced glial inflammation, which is closely associated with infection and ischemia stimuli. Thus, RAI14 may be a potential drug target for the treatment of inflammatory diseases.

[Clinical comparison of modified laparoscopic and conventional placement of peritoneal dialysis catheters]

Objective: To explore the clinical efficacy of the modified laparoscopic placement of peritoneal dialysis catheters by nephrologists. Methods: A total of 188 patients diagnosed as end-stage renal disease (ESRD) were enrolled, who received catheter and continuous ambulatory peritoneal dialysis (CAPD) therapy from January 2011 to May 2016 in Zhejiang Provincial People's Hospital. They were divided into group A (with modified laparoscopic placement of peritoneal dialysis catheters, n=59) and group B (with conventional placement of peritoneal dialysis catheter, n=129). The demographic and clinical characteristics, past abdominal operation history, surgery time, hospital stay after operation, expenses for surgery and hospitalization, early and late complications including bleeding, pain, leakage, peritonitis and catheter displacement were observed. Results: Patients with previous abdominal surgery accounted for 11.9% in group A and 0 in group B(χ²=15.897, P<0.001). The duration of the operation was (38.9±12.8)min in group A and (64.1±12.7)min in group B(t=-6.466 6, P=0.000 0). The cost of the operation was (5 488.4±156.1) yuan in group A and (1 602.7±48.92) yuan in group B (t=257.129, P=0.000 0). Catheter displacement within one month was observed in 0 and 11.6%(χ²=7.455 3, P=0.003), pain in 15.3% and 41.9% (χ²=12.862 2, P=0.000), and catheter displacement after one month in 0 and in 16.3% (χ²=10.812 4, P=0.000) of the patients, respectively in group A and group B. The incidences of peritonitis within one month and beyond one month, leakage, bleeding and so on showed no difference between the two groups(P>0.05). Conclusions: Placement of PD catheter with laparoscope is suitable for renal failure patients with abdominal operation history and replacement PD catheter. It also has the advantages of shorter surgery time, less pain and lower incidences of catheter displacement, expanding the application of PD. However, bleeding, leakage, hernia and other complications are frequently seen.

Correlation between gastric HIF-1α expression and gastric cancer recurrence

AIM: To investigate the relationship between hypoxia inducible factor -1α (HIF-1α) expression and gastric cancer recurrence and to analyze factors affecting HIF-1α expression in gastric cancer.

METHODS: Eighty patients with gastric cancer recurrence after radical resection were included in the study, and 50 patients without recurrence after radical resection for more than 5 year were selected as a control group. The expression of HIF-1α and VEGF was compared between the two groups. Risk factors for gastric cancer were analyzed with univariate and Cox proportional hazards models. The correlation between HIF-1α and VEGF expression was investigated by Spearman correlation analysis.

RESULTS: The positive rates of HIF-1α (77.50% vs 12.00%) and VEGF (73.75% vs 10.00%) expression were higher in the recurrence group than in the control group. The degree of differentiation, depth of invasion, lymph node metastasis, vascular invasion, TNM clinical stage, VEGF expression were factors affecting HIF-1α expression in gastric tissue. There was a positive correlation between HIF-1α and VEGF expression (r = 0.458, P = 0.000). The 1-year survival rate (45.16% vs 77.77%) and average survival time (8.62 ± 2.32 vs 18.96 ± 3.14) were significantly lower in the HIF-1α-positive group than in the HIF-1α-negative group. HIF-1α and VEGF expression were independent prognostic factors for gastric cancer.

CONCLUSION: HIF-1α expression is closely related to recurrence of gastric cancer and tumor angiogenesis, and can be used as a parameter for assessing gastric cancer recurrence and prognosis.

Downregulation of caspase-10 predicting poor survival after resection of stage II colorectal cancer

PURPOSE

The aim of this study was to evaluate the prevalence and clinical significance of caspase-10 mRNA expression in stage II colorectal cancer.

METHODS

Quantitative real-time reverse transcription-polymerase chain reaction (RT-PCR) was used to analyze caspase-10 expression in cancer tissue and corresponding normal mucosa from 120 patients with stage II colorectal cancer. Variables were analyzed by Chi-square test or Fisher's exact test. Survival was evaluated with method of Kaplan-Meier. Multivariate analysis was performed with Cox's proportional hazards model.

RESULTS

The expression of caspase-10 mRNA was found to be downregulated in cancer tissue compared to normal mucosa (P = 0.001). Poorly differentiated cancer showed lower mRNA expression than cancer with greater differentiation (P = 0.031). Univariate survival curves, estimated using the method of Kaplan-Meier, defined a significant association between caspase-10 expression and both overall survival (P = 0.012) and disease-free survival (P = 0.021). A multivariate analysis, performed by Cox's proportional hazards regression model, confirmed that a low caspase-10 expression was the only significant factor to predict poor prognosis in patients with stage II colorectal cancer.

CONCLUSION

Our data indicate that caspase-10 expression, measured by quantitative real-time RT-PCR, is a possible prognostic factor in patients with stage II colorectal cancer.

Occult tumor metastasis and the prognostic value of sentinel lymph nodes in rectal cancer

The aim of the present study to evaluate the application of sentinel lymph node (SLN) pathology in rectal cancer using ex vivo mapping and to investigate the incidence and prognostic value of occult SLN metastasis in routine node-negative specimens. Specimens (n=117) of rectal cancer were examined using a combination of routine pathology and ex vivo SLN mapping. The inspected SLNs were further treated with immunohistochemical staining for occult cancer foci. The log-rank test was used to assess survival. SLNs were examined in 112 of the included specimens with a total number of 212, resulting in an identification rate of 95.7% (112/117). The status of SLNs accurately reflected N stage in 93.8% (105/112) of cases and the sensitivity was 75.6% (31/41) in detecting nodal metastasis. The accuracy of SLN pathology decreased in cancers of more advanced TNM stages (P=0.001). In 74 cases with routine node-negative (N0) disease, SLN micrometastasis (MIC) and isolated tumor cells (ITC) were examined in 9 and 4 cases, while the remaining 61 were regarded as negative (NEG). The log-rank test revealed poorer disease-free and overall survival of the MIC group compared with the NEG group. However, the findings from the ITC group were not significant compared with those from the MIC and NEG groups. In conclusion, ex vivo SLN pathology is practical and accurate in rectal cancer; however, its utility is limited in cases of advanced disease. Immunohistochemically detected SLN micrometastasis in node-negative cases is therefore a predictor of poorer outcome, and may therefore be listed as a marker for adjuvant therapy.

Mesorectal and lateral node metastasis and micrometastasis in lower rectal cancer

BACKGROUND/AIMS

To study lymph node metastasis and micrometastasis within the mesorectum and lateral pelvic area in lower rectal cancer.

METHODOLOGY

Specimens of 96 patients, who underwent total mesorectal excision (TME) and lateral lymph node dissection (LLND), were included.

RESULTS

An average of 19.4 mesorectal lymph nodes were examined. Horizontally, more than 30 percent of involved lymph nodes were located in the outer layer of the mesorectum. Longitudinally, metastasized lymph nodes were harvested from the distal, paratumoral and proximal mesorectum of 6, 42 and 29 specimens, respectively. Fourteen specimens were observed to have circumferential resection margin involvement, while another 3 had micrometastasis. The average amount of harvested lateral pelvic lymph nodes was 12.1. Most (1052/1159) of the lateral nodes were defined as negative. Fourteen and 11 specimens were examined to contain lateral node metastasis and micrometastasis, respectively. Among regions of the lateral pelvic area, middle rectal root (44%), internal iliac (28%) and obturator (20%) were more likely to be involved by cancer spread.

CONCLUSIONS

Complete excision of the mesorectum is essential for local clearance of lower rectal cancer. Mesorectal margin involvement and lateral metastasis underlined the limitation of single surgical procedure, thus suggesting the significance of neoadjuvant therapy.