Korean Journal of Internal Medicine最新文献

This review provides a comprehensive examination of the recent research findings concerning the pathophysiology and clinical implications of adipose tissue fibrosis in obesity and metabolic diseases. Recent large-scale studies, including a longitudinal study spanning 24 years (Swedish Obese Subjects), have demonstrated that weight loss in obese patients is directly correlated with reduced metabolic complications and mortality. Nonetheless, instances of weight regain and subsequent loss of metabolic improvements have been observed in some patients, with adipose tissue dysfunction and fibrosis identified as significant contributing factors. Adipose tissue fibrosis is increasingly recognized as a critical pathological mechanism that influences weight loss responsiveness and long-term prognosis, extending beyond the previously predominant focus on inflammatory responses. Recent advancements in spatial transcriptomics and single-cell omics have elucidated the interactions and molecular networks among various cell types (e.g., fibroblasts and macrophages), revealing the involvement of miRNAs, among other factors, in metabolic plasticity and weight maintenance. Anti-diabetic therapies (such as GLP-1 receptor agonists, SGLT2 inhibitors, and thiazolidinediones) and bariatric surgery have been shown to contribute to tissue remodeling and the mitigation of fibrosis. However, the issue of weight regain upon drug discontinuation persists, underscoring the necessity for integrated strategies that simultaneously target adipose tissue set-point regulation and fibrosis improvement. In conclusion, adipose tissue fibrosis is proposed as a novel predictive and therapeutic target for metabolic health prognosis and treatment selection in patients with obesity. This study is anticipated to lay the groundwork for personalized management from a precision medicine perspective.

Atrial fibrillation (AF) is the most common sustained tachyarrhythmia and its increasing prevalence has resulted in a growing healthcare burden. Catheter ablation is indicated for patients with AF who are either refractory or intolerant to antiarrhythmic drugs or who exhibit decreased left ventricular systolic function. Catheter ablation can be categorized based on the energy source used, including radiofrequency ablation (RFA), cryoablation, laser ablation, and the recently emerging pulsed field ablation (PFA). PFA is anticipated to be promising owing to its tissue specificity, resulting in less collateral damage than thermal energy catheter ablations, such as RFA and cryoablation. In this review, we summarize the biophysical principles and clinical applications of PFA, highlighting its safety and efficacy profile compared to that with conventional thermal ablation.

Inflammatory bowel diseases (IBD), such as ulcerative colitis and Crohn's disease, are distinct chronic immune-mediated intestinal inflammatory disorders. The pathogenesis of IBD is complex and involves a combination of genetic and environmental factors, the gut microbiome, and the host immune system. Despite significant progress in identifying the genetic factors of IBD, the increasing IBD incidence in recent decades, along with findings from immigrant and twin studies, suggest the involvement of environmental factors on IBD susceptibility. In this review, we summarize various up-to-date environmental factors, including early-life influences; diet, food, and nutritional exposures; urbanization and air pollution; smoking; appendectomy; medications; psychological stress; sleep; and latitude and geography.

Background/aims: Assessing the risk of colorectal cancer (CRC) after kidney transplantation (KT) in patients with endstage renal disease (ESRD) receiving dialysis is crucial to determine KT's risks and benefits. In Korea, the study results remain unclear. Therefore, using a nationwide health screening and claims database, this longitudinal study aimed to investigate CRC risk in KT recipients versus patients with ESRD receiving hemodialysis.

Methods: This research recruited 65,154 participants (60,202 on dialysis vs. 4,955 with KT) from the database of the Korean National Health Insurance Service, which provides mandatory health insurance to all Korean citizens. These participants were followed up from the baseline to CRC development, loss of follow-up, or study completion. The landmark method was used to effectively control the immortal time bias.

Results: During the follow-up period, the incidence of CRC was 2.9 per 1,000 person-years in the dialysis group and 1.2 per 1,000 person-years in the KT group (p < 0.001). The mean time for CRC development in the dialysis and KT groups was 4.5 and 4.8 years, respectively. Compared with dialysis patients, the KT group obtained an adjusted hazard ratio of 0.54 for CRC (95% confidence interval, 0.42-0.71; p < 0.001). Landmark analysis showed that the 15-year cumulative CRC incidence was significantly higher in the dialysis group than in the KT group after landmark time points of 3 and 5 years (p < 0.0001).

Conclusion: The risk of CRC after KT remained significantly lower than that of patients undergoing dialysis, even after landmark analysis.

Global population aging has substantially increased in the number of older adults who undergo kidney replacement therapy (KRT). Age-related physiological changes and functional dependence in this population lead to the multifaceted clinical and ethical challenges associated with KRT. Geriatric syndromes, including functional impairment, frailty, malnutrition, and multimorbidity, can influence the choice of dialysis modality and modify dialysis prescriptions, often resulting in patients requiring assistance with dialysis implementation. Although dialysis remains a key life-sustaining therapy, the limited life expectancy and multiple comorbidities of older adults increase the risk of adverse outcomes, supporting the consideration of conservative kidney management as an alternative. Furthermore, because many older adults prioritize quality of life and reduced treatment burdens over longevity and biochemical targets, dialysis-related decisions should be tailored to individual preferences and goals. Shared decision-making involving older patients, their caregivers, healthcare professionals, and nephrologists is essential for determining the most appropriate treatment approach. This review addresses the clinical considerations in decision- making regarding dialysis and proposes optimal treatment strategies tailored to the unique needs of older patients with chronic kidney disease.

Background/aims: Cardiovascular-kidney-metabolic (CKM) syndrome is a continuum of metabolic, cardiovascular, and kidney dysfunctions. This study aimed to evaluate the association between CKM stages and the risk of adverse composite clinical outcomes.

Methods: This retrospective cohort study used data from the Korean National Health Insurance Database and included 1,497,913 individuals who underwent at least two health checkups between 2009 and 2012. The participants were classified into CKM stages (0-4), and the primary outcome was a composite of all-cause death, myocardial infarction, ischemic stroke, hemorrhagic stroke, and hospitalization for heart failure.

Results: The distribution of CKM stages was 17.4% (stage 0), 15.7% (stage 1), 57.6% (stage 2), 6.3% (stage 3), and 3.1% (stage 4). The incidence rate of primary outcomes increased progressively across the CKM stages, from 2.07 per 1,000 person- years in stage 0 to 40.70 per 1,000 person-years in stage 4. Compared with stage 0, the adjusted hazard ratios (HRs) for the primary outcome were significantly elevated: stage 1 (HR 1.09; 95% confidence interval [CI] 1.06-1.13; p < 0.001), stage 2 (HR 1.36; 95% CI 1.32-1.39; p < 0.001), stage 3 (HR 1.72; 95% CI 1.67-1.77; p < 0.001), and stage 4 (HR 2.70; 95% CI 2.62-2.79; p < 0.001).

Conclusion: A higher CKM stage was associated with a progressive increase in the risk of all-cause mortality and major cardiovascular events. Clinicians may benefit from prioritizing the early identification of high-risk individuals and implementing targeted management strategies based on CKM staging to improve long-term adverse outcomes.

Background/aims: Circulating exosomal microRNAs (miRNAs) can serve as diagnostic and prognostic biomarkers for cancer. This study aimed to identify specific miRNAs in serum exosomes of patients with hepatocellular carcinoma (HCC) and validate their biological functions as novel diagnostic and predictive biomarkers.

Methods: Serum exosomal miRNAs in patients with HCC (n = 241) and without HCC (n = 45) were measured by qRT-PCR. The role of exosomal miRNAs in HCC was investigated through in vitro tests and verified in a clinical cohort of patients.

Results: In vitro, we observed delivery of exosomal miRNA-720 (miR-720) to recipient cells. Exosome-mediated miR-720 promoted proliferation and inhibited apoptosis of recipient HCC cells. Exosomal miR-720 inhibited tumor suppressor StarD13 expression in recipient cells. Additionally, exosomal miR-720 promoted stemness in recipient cells by increasing protein expression of stemness-associated markers such as OCT4 and c-MYC. In our cohort, serum exosomal miR-720 was significantly upregulated in HCC patients than in non-HCC patients, showing an excellent diagnostic performance for HCC. Particularly, exosomal miR-720 exhibited superior performance in diagnosing small HCC (< 2 cm) compared to AFP or DCP. Exosomal miR-720 levels positively correlated with advancing tumor stage and size. Patients with high expression of exosomal miR-720 had significantly shorter time to progression than those with low expression of exosomal miR-720 during transarterial chemoembolization (TACE).

Conclusion: Our results demonstrate that exosomal miR-720 plays an oncogenic role in HCC by targeting StarD13. Circulating exosomal miR-720 could be used as a novel diagnostic and therapeutic biomarker and serve as a guide for selecting treatment options including TACE for HCC.

Background/aims: We evaluated the efficacy and safety of tacrolimus as maintenance therapy in Korean patients with lupus nephritis (LN).

Methods: A total of 179 patients with biopsy-proven LN were included, of whom 92 received tacrolimus and 87 did not. Clinical parameters were assessed at six months and at one, two, three, and five years. Complete renal response (CR) and partial response (PR) were defined based on established criteria. Adverse events, renal flares, and poor outcomes have been reported.

Results: Baseline characteristics were similar, except for a higher prevalence of class V LN in the tacrolimus group. At six months, the CR rate was 49.5% in the tacrolimus group and 56.6% in the non-tacrolimus group (p = 0.308), with PR rates of 33.0% and 24.1% (p = 0.213). At one year, the non-tacrolimus group had a significantly higher CR rate (73.1% vs. 52.3%, p = 0.006), whereas the overall response rates were similar (p = 0.15). By two years, the CR rates were 71.8% in the non-tacrolimus group and 58.2% in the tacrolimus group (p = 0.031). At three years, the overall response was found 75.4% with tacrolimus and 83.1% without (p = 0.252); and at five years, these rates were 72.9% and 87.3% (p = 0.1). No significant differences in renal flares, poor outcomes, or adverse events were observed.

Conclusion: This study has demonstrated that tacrolimus is an effective and safe maintenance therapy for achieving renal response and slowing disease progression in patients with LN who have not achieved remission.

Background/aims: Despite some evidence supporting its utility, the role of adjunctive dobutamine in the management of septic shock remains unclear.

Methods: The nationwide prospective sepsis cohort of the Korean Sepsis Alliance was analyzed. Adult patients with septic shock receiving norepinephrine were enrolled over a 29-month period. Patients given a dobutamine infusion within 3 days of intensive care unit (ICU) admission were compared with patients who received no infusion. To balance baseline characteristics, propensity score matching (PSM) was used.

Results: Of 11,981 patients with sepsis, 1,827 patients with septic shock receiving norepinephrine were included (108 dobutamine vs. 1,719 no dobutamine; mean age 71.4 ± 13.2 years, 59.4% male). After PSM (ratio of 1:2; 105 dobutamine patients and 209 no-dobutamine patients), Sequential Organ Failure Assessment scores and lactate levels on ICU day 3 did not significantly differ between groups. Additionally, in-hospital and ICU mortality rates did not differ between groups (54.3% vs. 48.3%, p = 0.319; 46.7% vs. 39.2%, p = 0.208, respectively). A Cox proportional model revealed that dobutamine use was not associated with in-hospital mortality (HR 1.13, 95% CI 0.81-1.58). However, subgroup analysis indicated that dobutamine use was associated with an increased risk of in-hospital mortality among patients in the lowest quintile of early fluid balance (p = 0.0286 for interaction).

Conclusion: Adjunctive dobutamine administration did not improve short-term organ function or hospital outcomes in septic shock patients. However, early fluid balance may influence the impact of dobutamine, highlighting the importance of a more tailored approach.