Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Quasicontinuous Exhaust Scenario for a Fusion Reactor: The Renaissance of Small Edge Localized Modes

Tokamak operational regimes with small edge localized modes (ELMs) could be a solution to the problem of large transient heat loads in fusion reactors. A ballooning mode near the last closed flux surface governed by the pressure gradient and the magnetic shear there has been proposed for small ELMs. In this Letter, we experimentally investigate several stabilizing effects near the last closed flux surface and present linear ideal simulations that indeed develop ballooninglike fluctuations there and connect them with nonlinear resistive simulations. The dimensionless parameters of the small ELM regime in the region of interest are very similar to those in a reactor, making this regime the ideal exhaust scenario for a future device.

Monobody adapter for functional antibody display on nanoparticles for adaptable targeted delivery applications

Vascular endothelial cells (ECs) play a central role in the pathophysiology of many diseases. The use of targeted nanoparticles (NPs) to deliver therapeutics to ECs could dramatically improve efficacy by providing elevated and sustained intracellular drug levels. However, achieving sufficient levels of NP targeting in human settings remains elusive. Here, we overcome this barrier by engineering a monobody adapter that presents antibodies on the NP surface in a manner that fully preserves their antigen-binding function. This system improves targeting efficacy in cultured ECs under flow by >1000-fold over conventional antibody immobilization using amine coupling and enables robust delivery of NPs to the ECs of human kidneys undergoing ex vivo perfusion, a clinical setting used for organ transplant. Our monobody adapter also enables a simple plug-and-play capacity that facilitates the evaluation of a diverse array of targeted NPs. This technology has the potential to simplify and possibly accelerate both the development and clinical translation of EC-targeted nanomedicines.

IMMU-09. Interim analysis from BrainChild-03: Seattle Children’s Locoregional B7-H3 CAR T Cell Trial for Children with Recurrent Central Nervous System Tumors and DIPG

BrainChild-03 is a phase 1 clinical trial delivering repeated locoregional 2nd generation B7-H3 CAR T cells with 4-1BB co-stimulation to children with central nervous system (CNS) tumors without lymphodepleting chemotherapy. The primary endpoints are feasibility and safety, with secondary endpoints of disease response and correlatives of CAR T cell activity. There are 3 arms: (A) – weekly delivery into the tumor cavity, (B) – weekly delivery into the lateral ventricle for metastatic disease, (C) – biweekly delivery into the lateral ventricle for diffuse intrinsic pontine glioma (DIPG). In total, 23/24 (96%) enrolled patients have had successful CAR T manufacturing. 16/24 patients are evaluable and have received a total of 141 intracranial CAR T cell doses. Unevaluable patients include 5 never treated and 3 who progressed prior to receiving the minimum doses to become evaluable. The most common adverse events have been headache (16/16, 100%), nausea/vomiting (12/16, 75%), and fever (10/16, 63%). There has been 1 DLT for an intratumoral hemorrhage and no cytokine release syndrome (CRS). 7 evaluable patients with DIPG (Arm C) have received a cumulative 50 infusions. 5/7 DIPG patients enrolled after progression and have a median survival of 246.5 days post-initial CAR T cell infusion, with 4/5 still alive. The 2 DIPG patients enrolled prior to progression had radiographic improvement, including 1 with improvement of a cranial nerve 6 palsy who self-withdrew from protocol therapy after 18 infusions over 12 months and 1 still on protocol therapy after 11 infusions over 6 months. DIPG patients have had increased CSF levels of proinflammatory mediators (e.g. CXCL10, CCL2, IFNg, GM-CSF, IL-12) without systemic cytokine changes. 5/7 DIPG patients had detectable CAR T cells in their CSF post-infusion. Ultimately, the preliminary experience suggests locoregional delivery of B7-H3 CAR T cells may be feasible and tolerable in children with CNS tumors, including DIPG.

CTIM-27. LOCOREGIONAL B7-H3-SPECIFIC CAR T CELLS FOR CHILDREN AND YOUNG ADULTS WITH DIPG: INTERIM REPORT OF BRAINCHILD-03 ARM C

Following preclinical optimization of B7-H3-specific CAR T cells against pediatric brain tumor models, we opened BrainChild-03 (NCT04185038), a phase 1 clinical trial of repeatedly dosed, outpatient, locoregional B7-H3-specific CAR T cells for children with recurrent/refractory central nervous system (CNS) tumors or diffuse intrinsic pontine glioma (DIPG). Here, we report the interim findings from patients enrolled on Arm C, dedicated to DIPG. The primary endpoints are feasibility and safety, with secondary endpoints of disease response. We utilize second-generation CAR T cells with a 4-1BB costimulatory domain and a methotrexate-resistant human DHFR mutein (huDHFRFS; L22F,F31S), allowing for methotrexate selection. We do not deliver conditioning chemotherapy. The first three evaluable patients with DIPG all met feasibility for generating a balanced CD4:CD8 CAR T cell product, with 3.85x109 CAR T cells generated for S005, 4.29x109 for S008, and 2.45x109 for S012, allowing for greater than 6 months of biweekly dosing for each patient. All subjects were treated at Dose Level 1 (1x107 CAR T cells). S005 received 10 doses before clinical progression greater than 2 years from diagnosis, S008 has received 10 doses and continues on therapy with decreased tumor volume, and S012 has received 5 doses and continues on study with stable disease. There have been no dose limiting toxicities (DLT). 3/3 patients exhibited post infusion fever, headache, and elevated serum CRP but no evidence of cytokine release syndrome (CRS) or systemic CAR T cells. 0/3 patients required PICU admissions. In the cerebrospinal fluid (CSF), 2/3 patients have had elevations of cytokines such as CXCL10 and CCL2, as well as circulating CSF CAR T cells. Advanced serial patient CSF proteomic and transcriptomic profiling are underway. Ultimately, this report provides preliminary evidence that outpatient locoregional B7-H3 CAR T cells for children with DIPG may be feasible and tolerable.

O-214 Undisturbed embryo culture under High Humidity atmosphere in a time-lapse system increases pregnancy rates

Study question

Does culture in high relative humidity conditions (HC) improve pregnancy rates when using a time-lapse system (TLS) and single-step (SS) culture medium?

Summary answer

Using an integrated-TLS and SS medium, culture under HC increases the likelihood of embryos to achieve a pregnancy with respect to those cultured in DC.

What is known already

Many variables affect embryo development, and need to be precisely tuned in every IVF laboratory, especially inside the incubators. TLS provide stability during embryo culture, which is a well-known key factor for a proper embryo development. The humidity content of culture atmosphere is especially relevant in order to avoid oscillations in culture media osmolality. It has been previously reported that culture under HC has a significant effect on embryo quality and morphokinetics. However, studies assessing the effect of HC in clinical outcome are rare and inconclusive, mostly due to the variability in the incubator device used and insufficient sample size.

Study design, size, duration

The present is a retrospective study performed over 1624 ICSI treatments from 3 fertility clinics from December 2017 to October 2020. Zygote cohorts were randomly assigned to dry (N = 794) or humid conditions (N = 830). It includes autologous treatments with (N = 555) and without (N = 368) pre-implantation genetic testing (PGT) and egg donation treatments (N = 701). Following selection by combining morphological and morphokinetic criteria, 1611 mostly single embryo transfers (92%) were performed, 779 from DC and 832 from HC.

Participants/materials, setting, methods

Stimulation, oocyte pickup and fertilization were performed according to the standard procedures of the clinic. We used a GERI incubator (Genea Biomedx), with 6 separated chambers for individual patients, 3 of them configured to work in DC, and 3 in HC. Embryos were cultured in specific 16-well GERI trays with single-step Gems® culture medium (Genea Biomedx). The effect of HC in pregnancy rate was assessed by multivariate logistic regression and Pearson Chi Square Test.

Main results and the role of chance

Types of treatment and patient demographics were homogeneously distributed in the two study groups. Mean patient age was 39.88±4.47 years, BMI: 23.54±4.21 Kg/m2 and number of correctly fertilized oocytes: 7.86±3.87. A logistic regression was performed, including other possible affecting factors: ovum age and origin, transfer day, fresh or frozen-warmed embryo transfer, number of transferred embryos and the use of PGT. Said analysis revealed that embryos cultured in HC are more likely to achieve a pregnancy than those cultured in DC (OR = 1.30, 95% CI (1.05-1.59), p=0.014). Pregnancy rate was significantly higher in HC (66.7%) than in DC (60.9%) in the total embryo transfers (p = 0.017). Pregnancy rate was also higher in HC in fresh embryo transfers (68.6% in HC vs 63.2% in DC; p = 0.133) and frozen-thawed transfers (65.2% in HC vs 59.1% in DC; p = 0.062), although differences were not statistically significant due to the reduced sample size. Stratifying the results, the significant difference remained in transfers belonging to autologous cycles (68.4% HC vs 56.5% in DC; p = 0.030) and in treatments in which PGT was performed (67.1% HC vs 56.0% in DC; p = 0.023), but the difference in egg donation procedures was not statistically significant (66.4% in HC vs 64.7% in DC, p = 0.577).

Limitations, reasons for caution

This is a retrospective analysis performed over the clinics’ treatments, so it might be compromised by some bias, although multivariable analysis may overcome them. For further assessing the effect of HC in clinical results a prospective controlled study, with a larger sample size could be performed, also comparing life-birth rates.

Wider implications of the findings

These results, alongside our previous findings (Valera et al. 2020, Albert et al. 2020), support that HC contributes to optimize embryo development and clinical results in undisturbed culture in TLS with single-step medium. To our knowledge, this is the largest study on the matter and the first performing multivariable analysis.

Trial registration number

Not applicable

IMMU-11. CLINICAL UPDATES AND CORRELATIVE FINDINGS FROM THE FIRST PATIENT WITH DIPG TREATED WITH INTRACRANIAL CAR T CELLS

We report preliminary data for the first subject with diffuse intrinsic pontine glioma (DIPG) treated with intracranial CAR T cells. BrainChild-03 (NCT04185038) is a phase 1 trial of repetitively-dosed locoregional B7-H3-specific CAR T cells for children with recurrent/refractory central nervous system (CNS) tumors or DIPG. DIPG patients enroll on Arm C, on which B7H3CARs are delivered into the ventricular system via a CNS reservoir catheter. This study does not use lymphodepletion. Primary endpoints are feasibility and safety, with second endpoints of disease response. This 18-year-old female (BrainChild-03 S005) with radiographically-classic DIPG and biopsy-confirmed H3 K27M mutation enrolled on Arm C after progression 552 days from diagnosis following focal radiation and temozolomide, irinotecan, and bevacizumab. Apheresis and manufacturing produced 4.2x10⁹ second-generation B7H3CARs with a methotrexate-resistant human DHFR mutein (huDHFR^FS; L22F,F31S) in a single transcript in combination with the B7-H3-specific CAR and EGFRt, each separated by a T2A linker, allowing methotrexate selection and enrichment. At time of submission, she has received 10 every-other-week outpatient infusions of 1x10⁷ B7H3CARs (first dose on October 2, 2020). She has had no DLTs, but has experienced grade 2 fever and grade 2–3 headache peaking ~12–48 hours after each infusion. Following the 8^th CAR T cell infusion, she experienced increased focal weakness and dysarthria at ~72 hours with resolution after 48 hours. She has not experienced cytokine release syndrome (CRS). She has stable disease 138 days post-initial CAR T cell infusion. Frequently collected correlative studies have detected viable B7H3CARs in the CSF post-infusion via flow cytometry. CSF cytokine analysis has revealed elevations of CXCL10, GM-CSF, and G-CSF following B7H3CAR infusions, without correlation in the serum. A second evaluable subject with DIPG has also received 4 locoregional doses of 1x10⁷ B7H3CARs without a DLT. She also has stable disease and detectable viable B7H3CARs in the CSF.

IMMU-03. UPDATES ON BRAINCHILD-01, -02, AND -03: PHASE 1 LOCOREGIONAL CAR T CELL TRIALS TARGETING HER2, EGFR, AND B7-H3 FOR CHILDREN WITH RECURRENT CNS TUMORS AND DIPG

We report preliminary results of three Phase 1 trials of repetitively dosed locoregional CAR T cells for children with recurrent/refractory CNS tumors, targeting HER2 (BrainChild-01), EGFR (BrainChild-02), and B7-H3 (BrainChild-03). Cells are delivered into the tumor cavity (Arm A) or ventricular system (Arm B and BrainChild-03’s DIPG-specific Arm C). Primary endpoints are feasibility and safety. Successful CAR T cell manufacture occurred in 2/2 subjects (BrainChild-01) and 2/3 (BrainChild-02). All subjects tolerated intra-patient dose escalation from 1x107 to 2.5x107 cells/dose without DLTs. Two subjects were evaluable on BrainChild-01 (S-001: glioblastoma, Arm A, survival 173 days post-first infusion, received 6 infusions; S-002: ependymoma, Arm B, survival 111 days, 9 infusions). One subject was evaluable on BrainChild-02 (glioblastoma, Arm A, withdrew from trial at 49 days, 5 infusions). One enrolled patient on BrainChild-03 has not begun treatment. None of the subjects developed new neurologic toxicities, although transient worsening of baseline tumor-related signs and symptoms were seen. Secondary endpoints are efficacy and disease response. No objective radiographic responses have been observed. Both BrainChild-01 subjects had transient systemic CRP elevations following infusions (S-001: peak of 3.9 post Course 1 Week 1; S-002: peak of 2.3 post Course 2 Week 1), possibly indicating an inflammatory response. Both subjects had post-infusion CSF cytokine elevations (CXCL10, GCSF, GM-CSF, IFNa2, IFNg, IL-10, IL12-p40, IL12-p70, IL-15, IL-1a, IL-3, IL-6, IL-7, TNFa, VEGF) without concurrent systemic changes. In summary, we provide preliminary evidence of safety and feasibility of intracranial delivery of CAR T cells for pediatric CNS tumors.

FRI0095 SARILUMAB IMPROVED PATIENT-PERCEIVED IMPACT OF RHEUMATOID ARTHRITIS WHATEVER THE BASELINE DISEASE ACTIVITY: FIRST RESULTS FROM AN INTERVENTIONAL NON CONTROLLED STUDY: SARIPRO, IN MODERATE AND SEVERE RHEUMATOID ARTHRITIS PATIENTS

Background:

Sarilumab, an anti-IL-6R antibody, is approved for the treatment of moderate to severe RA and shown efficacy on disease activity and patient-reported outcomes (PROs). Detailed analyses of drug efficacy from the patient point of view is important. SariPRO is a pragmatic interventional study close to the daily practice.

Objectives:

To assess the effectiveness of sarilumab on several PROs using the RAID (Rheumatoid Arthritis Impact of Disease) score.

Methods:

The SariPRO study (NCT 03449758) was a French multicenter interventional study assessing the effects of sarilumab 200 mg on PROs in patients with moderately to severely active RA with an inadequate response or intolerance to conventional synthetic or biologic DMARDs. The primary endpoint was change in total RAID score from baseline to week 24 (RAID ranges 0-10 where 10 is maximal impact). Changes from baseline for RAID, DAS28-ESR and CDAI according to baseline disease activity were analyzed as secondary outcomes. Safety was assessed by monitoring adverse events (AE). All statistical analyses were descriptive, 95% CI was given when appropriate.

Results:

84 patients were included in 31 centers and 62 were evaluable and analyzed for effectiveness. They had similar characteristics to the 84 patients at baseline and were as expected for an RA population initiating a biologic: mean (SD) age: 59.9 (12.4) years, 71.0% female, disease duration 9.7 (10.3) years, rheumatoid factor positivity 82.5%, ACPA positivity 86.4%, and DAS28=4.9 (11). Total RAID score decreased significantly from 5.7 (2.0) at baseline to 3.3 (2.5) at W24; mean change was -2.4 [95% CI: -3.0; -1.8]. Furthermore, this improvement was noted both for highly and less active patients at baseline: for patients with DAS28-ESR < 5.1 (n=31), mean change was -1.56 [-2.28; -0.83] and for patients with DAS28-ESR≥5.1 (n=27), mean change was -1.98 [-2.91; -1.05]. Changes in DAS28-ESR and CDAI were significant (-2.8 [-3.2; -2.4] and -15.2 [-18.5; -11.8], respectively). AEs were consistent with the safety profile of anti-IL-6R antibodies and with results from RCTs (data not shown).

Conclusion:

In this real world study, treatment with sarilumab during 24 weeks in RA patients led to an improvement in the total RAID score irrespective of baseline levels of disease activity. This is the first time RAID score is used as the primary endpoint in a study.

References:

[1]Study was sponsored by Sanofi Genzyme

Disclosure of Interests:

Laure Gossec Grant/research support from: Lilly, Mylan, Pfizer, Sandoz, Consultant of: AbbVie, Amgen, Biogen, Celgene, Janssen, Lilly, Novartis, Pfizer, Sandoz, Sanofi-Aventis, UCB, René-Marc Flipo Consultant of: Johnson and Johnson, MSD France, Novartis, Sanofi, Speakers bureau: Johnson and Johnson, MSD France, Novartis, Sanofi, Thierry Schaeverbeke: None declared, Christine Albert: None declared, Athan Baillet Consultant of: Athan BAILLET has received honorarium fees from Abbvie for his participation as the coordinator of the systematic literature review, marie-Christophe Boissier: None declared, Cyrille Confavreux: None declared, Gregoire CORMIER: None declared, Emmanuelle Dernis Speakers bureau: Lilly, Novartis, Elisabeth Gervais Solau: None declared, Sophie Godot: None declared, Jacques-Eric Gottenberg Grant/research support from: BMS, Pfizer, Consultant of: BMS, Sanofi-Genzyme, UCB, Speakers bureau: Abbvie, Eli Lilly and Co., Roche, Sanofi-Genzyme, UCB, Philippe Goupille Grant/research support from: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Consultant of: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Speakers bureau: AbbVie, Amgen, Biogen, BMS, Celgene, Chugai, Lilly, Janssen, Medac, MSD France, Nordic Pharma, Novartis, Pfizer, Sanofi and UCB, Slim Lassoued: None declared, Thierry Lequerre: None declared, Frederic Lioté Consultant of: CME: Nordic Pharma, Christian Marcelli: None declared, Yves Maugars: None declared, Minh Nguyen: None declared, Aleth Perdriger: None declared, Yves-Marie Pers: None declared, Edouard Pertuiset: None declared, Lucile Poiroux: None declared, Carole Rosenberg: None declared, Christian Roux: None declared, Adeline Ruyssen-Witrand Grant/research support from: Abbvie, Pfizer, Consultant of: Abbvie, BMS, Lilly, Mylan, Novartis, Pfizer, Sandoz, Sanofi-Genzyme, Martin SOUBRIER: None declared, Pascale Vergne-Salle: None declared, Charles Zarnitsky: None declared, Eric Fakra Consultant of: Janssen, Lundbeck, Otsuka, Sanofi, Hubert MAROTTE Grant/research support from: Bristol Myers Sqibb, Lilly France, MSD, Novartis, Nordic Pharma, Pfizer, SanofiAventis, Consultant of: AbbVie, Amgen, Bristol Myers Sqibb, Lilly France, MSD, Novartis, Nordic Pharma, Pfizer, SanofiAventis, Paid instructor for: Sanofi-Aventis, Speakers bureau: Sanofi-Aventis, Florence E Lévy-Weil Employee of: Sanofi Genzyme employee

Clinicopathologic features of infection-related glomerulonephritis with IgA deposits: a French Nationwide study

Background

Infection-related glomerulonephritis with IgA deposits (IRGN-IgA) is a rare disease but it is increasingly reported in the literature. Data regarding epidemiology and outcome are lacking, especially in Europe. We aimed to assess the clinical, pathologic and outcome data of IRGN-IgA.

Methods

Clinical and outcome data from patients from 11 French centers over the 2007–2017 period were collected retrospectively. We reviewed pathologic patterns and immunofluorescence of renal biopsies and evaluated C4d expression in IRGN-IgA. We analyzed the correlation between histological presentation and outcome.

Results

Twenty-seven patients (23 men, mean age: 62 ± 15 years) were included. Twenty-one (78%) had Staphylococcus aureus infection and twelve (44%) were diabetic. At the time of biopsy, 95.2% had haematuria, 48.1% had a serum creatinine level of > 4 mg/dL, and 16% had hypocomplementemia. The most common pathologic presentation included mesangial (88.9%) and endocapillary proliferative glomerulonephritis (88.9%) with interstitial fibrosis and tubular atrophy (IF/TA) (85.1%). Diffuse and global glomerular C4d expression was found in 17.8%, mostly in biopsies with acute or subacute patterns, and was associated with a short delay between infection and renal biopsy compared to segmental and focal staining. After median follow-up of 13.2 months, 23.1% died, 46.2% had persistent renal dysfunction and 15.4% reached end-stage renal disease. Renal outcome was correlated to IF/TA severity.

Conclusions

Infection-related glomerulonephritis with IgA deposits is usually associated with Staphylococcus infections and mainly affects adult men. This entity has a poor prognosis which is correlated to interstitial fibrosis and tubular atrophy severity.

Ultrasonographic assessment of the internal jugular vein for the estimation of central venous pressure in hemodialysis patients: A preliminary study

PURPOSE

To investigate a new noninvasive method to assess central venous pressure (CVP) in hemodialysis patients, based on the ultrasonographic measurement of the collapsing point of the internal jugular vein (CVPni).

MATERIALS AND METHODS

In this preliminary, noninterventional, single center study, we enrolled 22 dialyzed patients with an indwelling jugular catheter. CVPni was compared to the gold-standard invasive measurement of CVP using the central venous catheter (CVPi). Agreement between CVPi and CVPni was assessed by Bland and Altman Method. Correlation was assessed by linear regression.

RESULTS

A strong correlation was observed between CVPi and CVPni (OR = 3.47 [2.96; 4.07], P < .0001). For overloaded patients, the area under the curve for the operating characteristic curve was 0.971 (IC95: 0.915; 1.000). For under-loaded patients, area under the curve was 0.971 (IC95: 0.917; 1.000). The mean bias between intra-individual CVPi and CVPni measures was 0.57 cm H₂ O (SD: 3.1 cm H₂ O).

CONCLUSION

CVPni appears as a noninvasive and reliable technique. Further studies are required to confirm these results and to assess the direct clinical impact of this new method.

Application of genomics to identify therapeutic targets in recurrent pediatric papillary thyroid carcinoma

Children with papillary thyroid carcinoma (PTC) may relapse despite response to radioactive iodine (RAI). Two children with multiply relapsed PTC underwent whole-genome and transcriptome sequencing. A TPM3-NTRK1 fusion was identified in one tumor, with outlier NTRK1 expression compared to the TCGA thyroid cancer compendium and to Illumina BodyMap normal thyroid. This patient demonstrated resolution of multiple pulmonary nodules without toxicity on oral TRK inhibitor therapy. A RET fusion was identified in the second tumor, another potentially actionable finding. Identification of oncogenic drivers in recurrent pediatric PTC may facilitate targeted therapy while avoiding repeated RAI.

Serum levels for midkine, a heparin-binding growth factor, inversely correlate with angiotensin and endothelin receptor autoantibody titers in patients with macroangiopathy

AIM

Peripheral artery disease results in impaired blood flow to the extremities, most often as a consequence of atherosclerotic disease. The hallmark of atherosclerosis is chronic inflammation in the vessel wall. The renin-angiotensin and endothelin systems are considered important pathophysiological effectors. Midkine, a multifunctional cytokine, fulfils different roles in inflammation and promotion of neoangiogenesis. The aim of this study was to assess whether circulating midkine serum levels in patients with peripheral artery disease correlate with established atherosclerosis risk factors, as well as titers of functional autoantibodies directed against receptors of the renin-angiotensin and endothelin system.

METHODS

Clinical data, laboratory values and serum samples from 118 patients operated on for severe peripheral artery disease, and from 100 healthy blood donors were collected. Serum samples were analysed for midkine concentrations as well as autoantibody titers against angiotensin II type 1 and endothelin-1 type A receptors.

RESULTS

Midkine values were significantly higher in the study population than in healthy controls (P<0.001). Circulating midkine levels did not correlate with neither of the traditional risk factors age, sex, obesity, smoking, hypertension, high cholesterol levels, or diabetes mellitus. An unexpected inverse correlation was found with the autoantibodies against angiotensin II type 1 receptor (P<0.05) and endothelin-1 type A receptor (P<0.01).

CONCLUSION

The high levels of midkine in severe peripheral artery disease patients introduce this cytokine as a possible novel effector in the advanced atherosclerotic process. These results also suggest a functional link between vascular receptor autoantibody formation and down-regulated midkine serum levels, that may be relevant in the pathogenesis of clinically relevant peripheral artery occlusive disease.

Mechanical characterization of fourth generation composite humerus

Mechanical data on upper extremity surrogate bones, supporting use as biomechanical tools, is limited. The objective of this study was to characterize the structural behaviour of the fourth-generation composite humerus under simulated physiologic bending, specifically, stiffness, rigidity, and mid-diaphysial surface strains. Three humeri were tested in four-point bending, in anatomically defined anteroposterior (AP) and mediolateral (ML) planes. Stiffness and rigidity were derived using load–displacement data. Principal strains were determined at the anterior, posterior, medial, and lateral surfaces in the humeral mid-diaphysial transverse plane of one specimen using stacked rosettes. Linear structural behaviour was observed within the test range. Average stiffness and rigidity were greater in the ML (918 ± 18 N/mm; 98.4 ± 1.9 Nm2) than the AP plane (833 ± 16 N/mm; 89.3 ± 1.6 Nm2), with little inter-specimen variability. The ML/AP rigidity ratio was 1.1. Surface principal strains were similar at the anterior (5.41 µε/N) and posterior (5.43 µε/N) gauges for AP bending, and comparatively less for ML bending, i.e. 5.1 and 4.5 µε/N, at the medial and lateral gauges, respectively. This study provides novel strain and stiffness data for the fourth-generation composite humerus and also adds to published construct rigidity data. The presented results support the use of this composite bone as a tool for modelling and experimentation.

Non-Randall proliferative glomerulonephritis with humps and monotypic IgG deposits in primary Sjögren's syndrome: a first case report

Renal involvement is frequent in patients suffering from primary Sjögren's syndrome (pSS). Tubulointerstitial infiltration is the most common renal lesion, while glomerular involvement is rare. We report the case of a 50-year-old woman with pSS who developed renal failure due to an unusual proliferative glomerulonephritis with humps and monotypic IgG1-kappa deposits. Searches for cryoglobulinaemia, anti-double-stranded DNA and anti-neutrophil cytoplasmic antibodies were negative. Serum protein electrophoresis and immunofixation revealed no monoclonal immunoglobulin. Extensive work-up excluded associated infectious, collagen or lymphoproliferative disease. This case adds to the spectrum of pSS-related glomerular disease which is reviewed in depth.

Regional discrepancies in peritoneal dialysis utilization in France: the role of the nephrologist's opinion about peritoneal dialysis

BACKGROUND

Peritoneal dialysis (PD) is underused in France compared with other countries. In addition, there are tremendous regional discrepancies concerning the utilization rate of PD. This study was carried out to evaluate the opinion of French nephrologists regarding the optimal rate of PD utilization and to determine which factors limit PD development in France.

METHODS

Of the 22 French regions, 2 regions with a high rate of PD utilization (prevalence >15%) and 3 regions with a low rate of PD utilization (prevalence <10%) were selected. In June 2007, nephrologists from the five regions were surveyed by questionnaire. Responses were compared between 'low-prevalence' and 'high-prevalence' groups.

RESULTS

The response rate was 70% and there was no significant difference between the two groups regarding the response rate. In the two groups, a majority of nephrologists were in charge of PD patients (30/34 in 'high-prevalence' group versus 61/80 in 'low-prevalence' group, P = 0.14). Information about PD in the predialysis clinics was provided by nephrologists from high- and low-prevalence regions (32/34 versus 65/80, P = 0.08). Opinions on the optimal rate of PD for prevalent and incident dialysis patients were significantly different between 'high-prevalence' and 'low-prevalence' groups [31 +/- 15% versus 25 +/- 14% (P < 0.03) and 25 +/- 14% versus 19 +/- 9% (P < 0.02)]. There was a significant difference concerning the optimal rate of PD in incident dialysis patients between nephrologists working in public centres (29 +/- 15%), those working in non- profit clinics (27 +/- 12%) and nephrologists working in the private sector (14 +/- 8%). Lack of nurses available for the patient care (48%), low reimbursement of PD (25%), limited training (23%) and hospital care facilities (23%) were the main barriers limiting PD utilization.

CONCLUSIONS

In France, like in other countries, there are factors limiting PD development; however, regional discrepancies regarding PD utilization seem to be linked to the nephrologist's opinion.

Plant response traits mediate the effects of subalpine grasslands on soil moisture

* In subalpine grasslands, changes in abiotic conditions with decreased management intensity alter the functional composition of plant communities, leading to modifications of ecosystem properties. Here, it is hypothesized that the nature of plant feedbacks on soil moisture is determined by the values of key traits at the community level. * As community functional parameters of grasslands change along a gradient of land uses, those traits that respond most to differences in abiotic conditions produced by land use changes were identified. A vegetation removal experiment was then conducted to determine how each plant community affected soil moisture. * Soil moisture was negatively correlated with community root length and positively correlated with canopy height, whereas average leaf area was associated with productivity. These traits were successfully used to predict the effects on soil moisture of each plant community in the removal experiment. This result was validated using data from an additional set of fields. * These findings demonstrate that the modification of soil moisture following land use change in subalpine grasslands can be mediated through those plant functional traits that respond to water availability.

Cement penetration and primary stability of the femoral component after impaction allografting

This study explored the relationship between the initial stability of the femoral component and penetration of cement into the graft bed following impaction allografting.

Impaction allografting was carried out in human cadaveric femurs. In one group the cement was pressurised conventionally but in the other it was not pressurised. Migration and micromotion of the implant were measured under simulated walking loads. The specimens were then cross-sectioned and penetration of the cement measured.

Around the distal half of the implant we found approximately 70% and 40% of contact of the cement with the endosteum in the pressure and no-pressure groups, respectively. The distal migration/micromotion, and valgus/varus migration were significantly higher in the no-pressure group than in that subjected to pressure. These motion components correlated negatively with the mean area of cement and its contact with the endosteum.

The presence of cement at the endosteum appears to play an important role in the initial stability of the implant following impaction allografting.