European Journal of Heart Failure (2010) 12, 3237 doi:10.

1093/eurjhf/hfp169

Acute kidney injury and outcomes in acute decompensated heart failure: evaluation of the RIFLE criteria in an acutely ill heart failure population
Noritake Hata*, Shinya Yokoyama, Takuro Shinada, Nobuaki Kobayashi, Akihiro Shirakabe, Kazunori Tomita, Mitsunobu Kitamura, Osamu Kurihara, and Yasuhiro Takahashi
Division of Intensive Care Unit, Chiba Hokusoh Hospital, Nippon Medical School, 1715 Kamagari, Inbamura, Inbagun, Chiba 270-1694, Japan Received 11 June 2009; revised 16 September 2009; accepted 9 October 2009

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Aims

The clinical course including the outcome of acute decompensated heart failure (ADHF) correlates with renal dysfunction, but the evaluation of renal function has not yet been standardized. We therefore investigated the relationship between the prognosis of ADHF and acute kidney injury (AKI) evaluated using the risk, injury, failure, loss, end stage (RIFLE) criteria. ..................................................................................................................................................................................... Methods This study assessed 376 consecutive patients with ADHF admitted to the intensive care unit (ICU) (mean age 71.6 and results years; 238 male). The underlying aetiology was ischaemic heart disease, hypertensive heart disease, cardiomyopathy, valvular diseases, and other in 124, 70, 60, 107, and 15 patients, respectively. We dened AKI according to the RIFLE criteria, and the most severe RIFLE classications during hospitalization were adopted to assess patient outcomes. The in-hospital mortality was signicantly higher among patients with AKI (29 of 275; 10.5%) than in those without AKI (1 of 101; 1.0%, P 0.0010). Both ICU and hospital stays were longer for patients with AKI (8.8 + 15.4 vs. 48.6 + 47.6 days), than for patients without (5.0 + 2.8 vs. 25.7 + 16.8 days, P , 0.05 and P , 0.001). ..................................................................................................................................................................................... Conclusion Acute kidney injury evaluated by the RIFLE criteria was associated with a poorer outcome for patients with ADHF.

----------------------------------------------------------------------------------------------------------------------------------------------------------Keywords
Cardiovascular disease Renal damage Prognosis

Introduction
Acute kidney injury (AKI) affects the outcome of patients admitted to intensive care unit (ICU).1 3 In addition, the outcomes of acute decompensated heart failure (ADHF) correlate with renal dysfunction,4,5 however, to date a consensus regarding the most appropriate methods for evaluating renal function and AKI has not been reached. The RIFLE criteria have recently been established as the standard method for evaluating AKI in critically ill patients including those with neurological, cardiovascular, pulmonary, malignant, and gastrointestinal diseases,6,7 but the clinical signicance of such evaluations has not been determined in patients with heart failure. In this study, we therefore investigated the

association between ADHF outcomes and AKI evaluated by this method.

Methods
Study population
We investigated the clinical course of 376 consecutive patients with ADHF who were admitted to the ICU in Chiba Hokusoh Hospital, Nippon Medical School, Japan, between April 2000 and June 2008. Heart failure was diagnosed based on the Framingham criteria.8 Patients with acute cardiovascular disease such as acute myocardial infarction (AMI), myocarditis, pericarditis, and Takotsubo cardiomyopathy were excluded from the study. In addition, only the rst

* Corresponding author. Tel: 81 476 99 1111, Fax: 81 476 99 1911, Email: hata-n@nms.ac.jp
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2010. For permissions please email: journals.permissions@oxfordjournals.org.

AKI and outcomes in ADHF

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admission was considered for patients who were readmitted to the ICU during the study period (n 80). Patients who had undergone renal replacement therapy before admission were also excluded (n 15).

Statistical analysis
All continuous data are expressed as means + standard deviation and the mean differences between groups were analysed using Students t-test or analysis of variance (ANOVA). Proportional differences were analysed using the Fisher exact analysis. Categorical variables were analysed using the x2 test. A P-value of less than 0.05 was considered statistically signicant. All data were analysed using StatView 5 software for Windows (SAS Institute, Cary, NC, USA), and SPSS 14.0 J for Windows (SPSS Japan Institute, Tokyo, Japan).

Data collection
Data were retrospectively retrieved from hospital medical records. Laboratory data included serum creatinine, daily urine output, and brain-type natriuretic peptide (BNP) levels during hospitalization. Age, sex, history of chronic renal insufciency, and haemodialysis, aetiology of heart failure, Killip classication of heart failure severity, and left ventricular ejection fraction measured by cardiac ultrasonography (Teichholz method) were recorded. Furthermore, medications administered in the ICU, use of acute blood purication therapy, any heart surgery, duration of ICU and hospital stays, and in-hospital mortality were also evaluated.

Results
Presence of acute kidney injury during admission
In the 227 patients without chronic renal insufciency, baseline creatinine levels were based on the lowest creatinine values in 75 patients and on CrMDRD in 152 patients. We identied AKI in 125 patients (33%) with ADHF upon admission, but this increased to 275 patients (73%) during the hospital stay. Acute kidney injury developed while hospitalized in 150 of the 251 patients (60%) who were free of AKI upon admission (Figure 1). The RIFLEadm values of the 151 patients with RIFLEmax Class R were no AKI and RIFLEmax Class R in 104 and 47 patients, respectively. The 70 patients with RIFLEmax Class I were classied upon admission as having no AKI (n 23), Class R (n 29), and Class I (n 18). Moreover, of the 54 patients with RIFLEmax Class F, 23, 14, 7, and 10 were evaluated upon admission as having no AKI, Class R, Class I, and Class F, respectively. Thirty patients received renal replacement therapy and were evaluated as having AKI (Class F). Patients were assigned to the AKI (n 275) and non-AKI (n 101) groups based on their RIFLEmax values.

Evaluation of acute kidney injury

In view of the fact that the majority of patients with ADHF receive treatment with diuretics which inuence urine output, and since urine output could not be precisely measured in the general wards; AKI was investigated based only on the creatinine criteria of the RIFLE classication.9,10 Patients were classied as having: no AKI, Class R (risk), Class I (injury), and Class F (failure). Patients were classied twice according to the RIFLE criteria: upon admission (RIFLEadm) and the most severe classication recorded while in hospital (RIFLEmax). The RIFLEmax in patients who received renal replacement therapy was Class F.11 Furthermore, RIFLEmax was evaluated before heart surgery in surgical patients. Serum creatinine levels in patients without chronic renal insufciency according to their medical history were calculated using the Modication of Diet in Renal Disease (MDRD) equation as recommended by the Acute Dialysis Quality Initiative, by solving the MDRD equation for serum creatinine (CrMDRD) assuming a glomerular ltration rate of 75 mL/min/ 1.73 m2.12,13 The baseline level of creatinine was the lowest value recorded during admission for patients with chronic renal insufciency. The lower of the lowest creatinine value during hospitalization or CrMDRD creatinine served as the baseline value for patients without chronic renal insufciency. The RIFLE classication was based on the ratio of the maximum serum creatinine value to the baseline creatinine value (Table 1). Patients were separated into two groups based on the presence of AKI (RIFLEmax Class R, I, and F) during hospitalization. The duration of ICU and hospital stays, and death while in hospital were considered as outcomes. The relationship between RIFLEmax and outcomes was evaluated. The Institutional Ethics Review Board approved the study protocol.

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Characteristics of patients and acute kidney injury

The relationship between baseline characteristics upon admission and the presence of AKI during hospitalization is shown in Table 2. Patients in the AKI group were older (72.5 + 11.5 years; P 0.0087), more likely to be female (43%; P , 0.0001), and less likely to have a history of chronic renal insufciency (18%; P , 0.0001) than those in the non-AKI group (69.0 + 12.3 years, female 19%; 57% chronic renal insufciency). However, the aetiology of heart failure was similar in both groups (Table 2). Clinical

Table 1 Denition of RIFLE classication

Category Non-AKI AKI Risk (Class R) Injury (Class I) Failure (Class F) Maximal increase in serum creatinine !1.5 baseline Maximal increase in serum creatinine !2.0 baseline Maximal increase in serum creatinine !3.0 baseline or !4 mg/dL with an acute rise .0.5 mg/dL ,0.5 mL/kg/h for !6 h ,0.5 mL/kg/h for !12 h ,0.3 mL/kg/h for !24 h or anuria for 12 h

...............................................................................................................................................................................
Maximal increase in serum creatinine ,1.5 baseline

Serum creatinine criteria

Urine output criteria

AKI, acute kidney injury.

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Figure 1 Acute kidney injury (AKI) was evident in 125 of the 376 patients (33%) with acute exacerbation of heart failure upon admission (RIFLEadm, upper bar). Acute kidney injury developed during hospitalization in 150 of the 251 patients (60%) without acute kidney injury on admission. (RIFLEmax, bottom bar).

Table 2 Characteristics of patients according to the presence of acute kidney injury ...............................................................................................................................................................................
Age (years) Gender (male/female) Chronic renal insufciency (no/yes) Aetiology Ischaemic heart disease Valvular heart disease Hypertensive heart disease Cardiomyopathy Other
AKI, acute kidney injury.

Non-AKI (n 5 101) 69.0 + 12.3 82/19 44/57

AKI (n 5 275)

P-value

72.5 + 11.5 156/119 183/92 89 89 48 37 12

0.0087 ,0.0001 ,0.0001 0.7110 0.1278 0.7593 0.0382 0.7677

35 24 16 23 3

characteristics upon admission are shown in Table 3; serum creatinine levels, haemodynamics, cardiac rhythm, severity of heart failure (NYHA and Killip classication), left ventricular ejection fraction, and serum BNP levels were not signicantly different between the groups.

the non-AKI group, but no other differences in treatment methods were evident.

Acute kidney injury and outcomes

The duration of ICU and hospital stays, and the in-hospital mortality of both groups are shown in Table 5. The ICU and hospital stays were signicantly longer for the AKI than for the non-AKI group (8.8 + 15.4 vs. 5.0 + 2.8 days, P , 0.05 and 48.6 + 47.6 vs. 25.7 + 16.8 days, P , 0.0001, respectively). Twenty-nine of the 275 patients with AKI died in hospital, whereas only one

Acute kidney injury and treatment

The medications and surgical treatments used during hospitalization are shown in Table 4. The administration of inotropic agents and heart surgery were more frequent in the AKI, than in

AKI and outcomes in ADHF

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Table 3 Clinical ndings on admission ...............................................................................................................................................................................

Serum creatinine (mg/dL) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Heart rate (b.p.m.) Cardiac rhythm Sinus rhythm Atrial brillation Ventricular brillation Other NYHA classication II III IV Killip classication I II III IV No record LVEF upon admission (%) BNP upon admission (ng/mL) 17 66 18 13 41 40 0 7 34.3 + 15.3 1001 + 837 29 172 74 32 111 106 9 7 36.2 + 16.4 1110 + 1203 0.1109 0.6317 0.0788 1.29 + 0.54 163.1 + 40.0 88.8 + 22.0 116.7 + 29.4 67 30 0 4 1.33 + 0.79 155.7 + 44.9 84.7 + 24.8 113.7 + 32.3 188 71 3 13 0.6082 0.1472 0.1542 0.4086 0.7104 0.5117 0.5671 .0.9999 non-AKI (n 5 101) AKI (n 5 275) P-value

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0.7230 .0.9999 0.9051 0.1203 0.8132 0.3343 0.4895

AKI, acute kidney injury; NYHA, New York Heart Association; LVEF, left ventricular ejection fraction; BNP, brain-type natriuretic peptide.

Table 4 Medication and other treatment methods in acute kidney injury and non-acute kidney injury groups
Total (n 5 376) 360 (95.7) 350 (93.1) 271 (72.1) 12 (3.2) 125 (33.2) 10 (2.7) 1 (0.2) 22 (5.9) non-AKI (n 5 101) AKI (n 5 275) P-value

Discussion
Denition of acute kidney injury
Several epidemiological studies and clinical trials have used either simple absolute or relative changes in serum creatinine level as surrogates for changes in kidney function to dene acute renal failure. However, the applicability of serum creatinine levels or other biochemical markers alone is limited.1,14,15 The RIFLE criteria are now considered the standard method for evaluating AKI in critically ill patients including those with neurological, cardiovascular, pulmonary, malignant, and gastrointestinal diseases.6,7 In this study, we evaluated the methodology of the RIFLE criteria in an acutely ill heart failure population. However, only the creatinine criteria of the RIFLE classication were evaluated in the present study, because urine output was inuenced by the diuretic therapy administered to the majority of our ADHF patients, and also because urine output could not be measured in the general wards. Lopes et al.16 reported that serum creatinine seemed to be a better predictor of mortality than urine output because the former led to a worse RIFLE class. Patients who had undergone renal replacement therapy were regarded as RIFLEmax Class F, as described by Mehta et al.11

................................................................................
Diureticsa Vasodilatorsb Inotropic agentsc Temporary pacing Ventilator IABP PCPS Heart surgery 97 (96.0) 91 (90.1) 55 (54.5) 2 (2.0) 22 (21.8) 0 0 1 (1.0) 263 (95.6) 259 (94.2) 178 (64.7) 10 (3.6) 103 (37.5) 10 (3.6) 1 (0.4) 21 (7.6) .0.9999 0.1736 0.0733 0.5267 0.0044 0.0682 .0.9999 0.0120

Number of patients with % in parentheses. AKI, acute kidney injury; IABP, intra-aortic balloon pump; PCPS, percutaneous cardio-pulmonary support. a Included furosemide, canrenoate, and carperitide (recombinant form of human atrial natriuretic peptide). b Included nitrates, nicorandil, and phosphodiesterase inhibitors. c Included catecholamines, digitalis, and phosphodiesterase inhibitors.

patient without AKI died. The in-hospital mortality rate was signicantly higher in the AKI than in the non-AKI group (10.5 vs. 1.0%. P 0.0010). These outcomes correlated with the RIFLE criteria and were most signicant among Class F of the AKI group.

Acute kidney injury and critically ill patients

Acute kidney injury in critically ill patients has been investigated over the past decade. Donnahoo reported that AKI itself could

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N. Hata et al.

Table 5 Acute kidney injury and outcome ...............................................................................................................................................................................

Non-AKI group AKI group RIFLEmax Class R RIFLEmax class I RIFLEmax Class F 101 275 151 70 54 5.0 + 2.8 8.8 + 15.4* 6.3 + 4.2 6.4 + 3.4 19.1 + 32.5 25.7 + 16.8 48.6 + 47.6 37.5 + 20.4 49.1 + 33.1 79.7 + 88.9 1 29 0 3 26 1.0 10.5 0.0 4.3 49.1 Cases ICU stay (days) Hospital stay (days) In-hospital death (cases) Mortality (%)

ICU, intensive care unit; AKI, acute kidney injury; R, risk; I, injury; F, failure. *P , 0.05. P , 0.0001. P 0.0010 or P , 0.01.

lead to a non-infectious, proinammatory response with leucocyte activation, proinammatory cytokine secretion and the recruitment of neutrophils and macrophages with resultant lung injury, as has been demonstrated in animal models of ischaemia reperfusion-induced acute renal failure.17 Acute kidney injury is frequently encountered in critically ill patients and characteristically leads to an increase in morbidity and mortality. Acute renal failure severe enough to require renal replacement therapy develops in 5% of general ICU patients.2 Although Hoste et al.3 reported that AKI evaluated by the RIFLE criteria is associated with outcomes in critically ill patients, the relationship between AKI dened according to the RIFLE criteria and outcomes of patients with heart failure have not previously been evaluated in detail. Bagshaw et al.18 investigated the clinical applicability of the RIFLE criteria in a large heterogeneous cohort of critically ill patients admitted to the ICU and found that these criteria represent a simple tool for the detection and classication of AKI and for correlation with clinical outcomes. They considered that 72% of patients with acute exacerbation of heart failure had AKI during hospitalization and concluded that the RIFLE classication is signicantly related to outcomes including ICU stay, hospital stay, and in-hospital mortality. Other investigators have reported a relationship between AKI and outcome following sepsis,19 stroke,20 and cardiothoracic surgery.21 Uchino et al.22 reported that the RIFLE criteria for acute renal failure classied 20% of study patients admitted to general wards and the ICU as having some degree of acute impaired renal function and that such classication was useful in predicting hospital mortality.

heart failure syndromes. Silverberg reported that about half of all patients with congestive heart failure have chronic kidney disease, whereas congestive heart failure is 15 times more frequent in patients with chronic kidney disease than in those with normal renal function.25 He also stated that congestive heart failure exacerbates nephropathy, whereas chronic kidney disease is associated with accelerated atherosclerosis, microvessel disease, endothelial dysfunction, increased sympathetic activity, and cardiac pathology.25 Lassnigg et al.21 reported that small changes in serum creatinine are associated with a worse outcome for patients after cardiothoracic surgery. However, the denition of AKI was not standardized in these studies, and therefore the present study investigated the clinical applicability of the RIFLE criteria to the evaluation of AKI in patients with ADHF. Acute kidney injury evaluated by the RIFLE criteria correlated with poor ADHF outcomes. This is the rst report to describe the clinical value of the RIFLE criteria, in terms of the relationship between AKI evaluated by the RIFLE criteria and outcomes in patients with ADHF. The incidence of mortality and adverse events after AMI is high in patients with severe and end-stage renal disease.26,27 We therefore excluded patients with heart failure after acute cardiac diseases such as AMI and acute myocarditis from this study, because contrast-induced nephropathy frequently arises in such patients and it is also associated with prolonged hospitalization and adverse clinical outcomes after coronary angiography and/or percutaneous coronary intervention.28,29

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Acute kidney injury and cardiovascular diseases

Lee et al.23 found that a higher BUN and lower SBP were signicant and independent predictors of both 30-day and 1-year mortality rates in the Enhanced Feedback for Effective Cardiac Treatment (EFFECT) study. De Luca et al.24 found that the assessment of blood pressure and renal function are essential for stratifying patients presenting with acute heart failure. Fonarow et al.4 reported that BUN, SBP, and creatinine levels were the three variables most predictive of in-hospital mortality in the Acute Decompensated Heart Failure National Registry (ADHERE) and Gheorghiade et al.5 found that multiple evaluations demonstrated the prognostic value of SBP and indices of renal function in acute

Study limitations
The ratio of the maximum serum creatinine to baseline creatinine was underestimated in patients with chronic renal insufciency due to high baseline creatinine values. The time course of changes in the occurrence of AKI was not precisely evaluated. A multi-centre study should be performed to evaluate the inuence of medications administered during the hospital admission. The RIFLE classication could not be evaluated quickly in our study, therefore further studies should investigate its ability to predict AKI occurrence at an earlier stage of hospitalization. Although, the RIFLE criteria are clear and easy to understand, they are nevertheless complex and labour-intensive to calculate and are therefore mostly used in retrospective evaluations. Colpaert et al.30 stated that using an electronic alert based on the RIFLE criteria, which

AKI and outcomes in ADHF

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11. Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, Levin A. Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care 2007;11:R31. 12. Mathew TH, Johnson DW, Jones GR. Chronic kidney disease and automatic reporting of estimated glomerular ltration rate: revised recommendations. Med J Aust 2007;187:459463. 13. Levey AS, Bosch JP, Lewis JB, Greene T, Rogers N, Roth D. A more accurate method to estimate glomerular ltration rate from serum creatinine: a new prediction equation. Modication of Diet in Renal Disease Study Group. Ann Intern Med 1999;130:461 470. 14. Bellomo R, Chapman M, Finfer S, Hickling K, Myburgh J. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group. Lancet 2000;356:2139 2143. 15. Van Biesen W, Yegenaga I, Vanholder R, Verbeke F, Hoste E, Colardyn F, Lameire N. Relationship between uid status and its management on acute renal failure (ARF) in intensive care unit (ICU) patients with sepsis: a prospective analysis. J Nephrol 2005;18:5460. 16. Lopes JA, Fernandes P, Jorge S, Goncalves S, Alvarez A, Costa e Silva, Franca C, Prata MM. Acute kidney injury in intensive care unit patients: a comparison between the RIFLE and the Acute Kidney Injury Network classications. Crit Care 2008;12:R110. 17. Donnahoo KK, Shames BD, Harken AH, Meldrum DR. Review article: the role of tumor necrosis factor in renal ischemia-reperfusion injury. J Urol 1999;162: 196 203. 18. Bagshaw SM, George C, Dinu I, Bellomo R. A multi-centre evaluation of the RIFLE criteria for early acute kidney injury in critically ill patients. Nephrol Dial Transplant 2008;23:1203 1210. 19. Bagshaw SM, George C, Bellomo R. Early acute kidney injury and sepsis: a multicentre evaluation. Crit Care 2008;12:R47. 20. Covic A, Schiller A, Mardare NG, Petrica L, Petrica M, Mihaescu A, Posta N. The impact of acute kidney injury on short-term survival in an Eastern European population with stroke. Nephrol Dial Transplant 2008;23:2228 2234. 21. Lassnigg A, Schmidlin D, Mouhieddine M, Bachmann LM, Druml W, Bauer P, Hiesmayr M. Minimal changes of serum creatinine predict prognosis in patients after cardiothoracic surgery: a prospective cohort study. J Am Soc Nephrol 2004;15:1597 1605. 22. Uchino S, Bellomo R, Goldsmith D, Bates S, Ronco C. An assessment of the RIFLE criteria for acute renal failure in hospitalized patients. Crit Care Med 2006;34: 1913 1917. 23. Lee DS, Austin PC, Rouleau JL, Liu PP, Naimark D, Tu JV. Predicting mortality among patients hospitalized for heart failure: derivation and validation of a clinical model. J Am Med Assoc 2003;290:2581 2587. 24. De Luca L, Fonarow GC, Adams KF Jr, Mebazaa A, Tavazzi L, Swedberg K, Gheorghiade M. Acute heart failure syndromes: clinical scenarios and pathophysiologic targets for therapy. Heart Fail Rev 2007;12:97 104. 25. Silverberg D, Wexler D, Blum M, Schwartz D, Iaina A. The association between congestive heart failure and chronic renal disease. Curr Opin Nephrol Hypertens 2004;13:163 170. 26. Landray MJ, Thambyrajah J, McGlynn FJ, Jones HJ, Baigent C, Kendall MJ, Townend JN, Wheeler DC. Epidemiological evaluation of known and suspected cardiovascular risk factors in chronic renal impairment. Am J Kidney Dis 2001; 38:537546. 27. Henry RM, Kostense PJ, Bos G, Dekker JM, Nijpels G, Heine RJ, Bouter LM, Stehouwer CD. Mild renal insufciency is associated with increased cardiovascular mortality: The Hoorn Study. Kidney Int 2002;62:1402 1407. 28. Parfrey PS, Grifths SM, Barrett BJ, Paul MD, Genge M, Withers J, Farid N, McManamon PJ. Contrast material-induced renal failure in patients with diabetes mellitus, renal insufciency, or both. A prospective controlled study. N Engl J Med 1989;320:143 149. 29. Rihal CS, Textor SC, Grill DE, Berger PB, Ting HH, Best PJ, Singh M, Bell MR, Barsness GW, Mathew V, Garratt KN, Holmes DR Jr. Incidence and prognostic importance of acute renal failure after percutaneous coronary intervention. Circulation 2002;105:2259 2264. 30. Colpaert K, Hoste E, Van Hoecke S, Vandijck D, Danneels C, Steurbaut K, De Turck F, Decruyenaere J. Implementation of a real-time electronic alert based on the RIFLE criteria for acute kidney injury in ICU patients. Acta Clin Belg Suppl 2007;(2):322 325.

warned the physician in real-time when kidney function is deteriorating, could help to implement these criteria in routine clinical practice. These authors are currently investigating whether the implementation of real-time electronic RIFLE alerts can induce faster therapeutic intervention and are also evaluating the impact of more timely interventions on the preservation of kidney function and patient outcome. Although no precise resolution of poor outcomes in ADHF patients with AKI was identied from this study, use of cardio-renal protective medicines and early initiation of renal replacement therapy should be recommended for these patients. In conclusion, a third of patients with ADHF had AKI upon admission, but AKI also occurred in 60% of ADHF patients during hospitalization who did not have AKI at the time of admission. The presence of AKI during hospitalization was associated with poor outcomes in patients with ADHF, as has been reported in patients with other critical illnesses. The RIFLE criteria should be developed into a clinically available and standardized method for evaluating AKI.

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Acknowledgements
We are grateful to the staff of the intensive care unit and the medical records ofce in Chiba Hokusoh Hospital, Nippon Medical School, for collecting the medical data. Conict of interest: none declared.

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