Development of osteomalacia in a post-liver transplant patient receiving adefovir dipivoxil

We report the case of a patient treated with living donor-related liver transplantation who suffered from osteomalacia during adefovir dipivoxil (ADV)-containing antiviral therapy for lamivudine-resistant hepatitis B virus infection. The patient had generalized bone pain,with severe hypophosphatemia after 20 mo of ADV therapy. Radiographic studies demonstrated the presence of osteomalacia. The peak plasma ADV level was 38 ng/mL after administration of ADV at 10mg/day. It was also found that ADV affected the metabolism of tacrolimus,a calcineurin-inhibitor,and caused an increase in the plasma levels of tacrolimus. The disability was reversed with the withdrawal of ADV and with mineral supplementation. ADV can cause an elevation of plasma tacrolimus levels,which may be associated with renal dysfunction. High levels of ADV and tacrolimus can cause nephrotoxicity and osteomalacia. This case highlights the importance of considering a diagnosis of osteomalacia in liver transplantation recipients treated with both ADV and tacrolimus.

Stratifying the risk of lymph node metastasis in undifferentiated-type early gastric cancer

AIM:To study how lymph node metastasis(LNM) risk is stratified in undifferentiated-type early gastric cancer(undiff-EGC) dependent on combinations of risk factors.METHODS:Five hundred and sixty-seven cases with undiff-EGC undergoing gastrectomy with lymphadenectomy were examined retrospectively.Using clinicopathological factors of patient age,location,size,an endoscopic macroscopic tumor form,ulceration,depth,histology,lymphatic involvement(LI) and venous involvement(VI),LNM risk was examined and stratified by conventional statistical analysis and datamining analysis.RESULTS:LNM was positive in 44 of 567 cases(7.8%).Univariate analysis revealed > 2 cm,protrusion,submucosal(sm),mixed type,LI and VI as significant prognostic factors and > 2 cm and LI-positive were independent factors by multivariate analysis.In preoperatively evaluable factors excluding LVI,sm and > 2 cm were independent factors.According to the depth and size,cases were categorized into the low-risk group [m and ≤ 2 cm,0%(LNM incidence)],the moderaterisk group(m and > 2 cm,5.6%; and sm and ≤ 2 cm,6.0%),and the high-risk group(sm and > 2 cm,19.3%).On the other hand,LNM occurred in 1.4% in all LI-negative cases,greatly lower than 28.2% in all LI-positive cases,and LNM incidence was low in LInegative cases even in the moderate- and high-risk groups.CONCLUSION:LNM-related factors in undiff-EGC were depth and size preoperatively while those were LI and size postoperatively.Among these factors,LI was the most significantly correlated factor.