Impact of Age on Prescribing Patterns of Cardiovascular Medications in Older Japanese Patients with Non-Dialysis-Dependent Chronic Kidney Disease: A Cross-Sectional Study

AIM

Older patients with chronic kidney disease (CKD) are more likely to be excluded from clinical trials. This exclusion affects the quality of cardiovascular disease (CVD) prevention in this population.

METHODS

Baseline data from the Fukuoka Kidney Disease Registry (FKR) cohort, which included 4476 adult patients with CKD stages G1-G5, were cross-sectionally analyzed to compare the use of recommended drugs for preventing CVD in each age group.

RESULTS

Different prescribing patterns were observed according to age for the cardiovascular drug classes. Older patients with CKD were less likely to receive renin-angiotensin system (RAS) inhibitors and were more likely to receive calcium channel blockers. The proportion of anticoagulation prescriptions for patients with CKD and atrial fibrillation decreased in the older age group (≥ 75 years). However, the proportion of antiplatelet therapy in patients with ischemic CVD increased linearly with age, even in the very old group aged ≥ 85 years. These findings suggest a severe cardiovascular burden in patients with CKD. Notably, RAS inhibitor use was avoided in the older group despite a severe cardiovascular burden, such as a high prevalence of CVD history and massive albuminuria ＞300 mg/g creatinine. This finding indicates that an older age independently contributed to the non-use of RAS inhibitors, even after adjusting for other covariates.

CONCLUSIONS

This study suggests that age is a potential barrier to the treatment of patients with CKD and highlights the need to establish individualized treatment strategies for cardiovascular protection in this population.

Association between Vascular Calcification and Intraplaque Hemorrhage in Coronary Atherosclerosis from Autopsy: The Hisayama Study

AIMS

Vascular calcification is observed in advanced atherosclerotic lesions. Vascular calcification is considered to increase the risk of intraplaque hemorrhage and subsequent plaque destabilization; however, there is limited pathohistoological evidence of the association between vascular calcification and intraplaque hemorrhage. The aim of this study was to investigate the association between vascular calcification and intraplaque hemorrhage in the coronary arteries.

METHODS

We examined 374 coronary arteries obtained from the autopsy samples of 126 deceased individuals. The vascular calcification levels of each artery were categorized into no calcification and quintiles of calcification area size among the arteries with calcification. Macrophage infiltration and neovascularization were also evaluated. The association of the calcification area, macrophage area, or number of vessels with the presence of intraplaque hemorrhage in the coronary arteries was estimated using a logistic regression analysis.

RESULTS

Calcification lesions were observed in 149 coronary arteries. Arteries in the fourth quintile of calcification area size had a significantly greater likelihood of intraplaque hemorrhage than the arteries without calcification, after adjusting for confounders: odds ratio 13.13 (95% confidence interval: 2.97-58.16). After evaluating the influence of macrophage infiltration, the highest odds ratio of intraplaque hemorrhage was associated with the combination of large macrophage area and moderately sized calicification areas. The odds ratio of intraplaque hemorrhage additively increased with the combination of calcification and the number of vessels.

CONCLUSIONS

The present findings suggest that vascular calcification is significantly associated with intraplaque hemorrhage. The association between vascular calcification and intraplaque hemorrhage may decrease above a certain size of the calcification area.

Relationships of Weight Change from 20 Years of Age with the Risks of All-Cause and Cardiovascular Mortality in Patients with Chronic Kidney Disease

AIMS

Weight changes from a young age are known to be associated with poor life outcomes in the general population. However, little is known about the association between weight change from a young age and life expectancy in patients with chronic kidney disease (CKD).

METHODS

Data of 2,806 nondialysis CKD patients who participated in the Fukuoka Kidney Disease Registry (FKR) Study, a multicenter observational study, were analyzed. The primary outcome was all-cause death, whereas the secondary outcome was cardiovascular mortality. The covariate of interest was weight change, defined as the difference between body weight at study enrollment and at 20 years old. Cox proportional-hazards models were used to estimate the risks of mortality for participants with weight changes of ≥ 5 or ＜5 kg compared with those with stable weights.

RESULTS

During the 5-year observation period, 243 participants died from all causes and 62 from cardiovascular disease. The risk of all-cause mortality in the weight-loss group was significantly higher than that in the stable-weight group (multivariable-adjusted hazard ratio, 2.11; 95% confidence interval [CI], 1.52-2.93). Conversely, the risk of cardiovascular mortality in the weight-loss group was significantly higher than that in the stable-weight group (multivariable-adjusted hazard ratio, 2.48; 95% CI, 1.32-4.64). However, no significant association was observed between weight gain and the risks of all-cause and cardiovascular mortalities.

CONCLUSION

Weight loss from 20 years of age was found to be associated with higher risks of all-cause and cardiovascular mortalities in patients with CKD.

Cardiovascular Risk Factor Burden and Treatment Control in Patients with Chronic Kidney Disease: A Cross-Sectional Study

AIM

Cardiovascular disease is a life-threatening chronic kidney disease (CKD) complication. Although cardiovascular risk factor management is significant in patients with CKD, there are few reports that detail the frequency of complications and the treatment of cardiovascular risk factors at different stages of CKD in clinical practice.

METHODS

There were a total of 3,407 patients with non-dialysis-dependent CKD who participated in the Fukuoka Kidney disease Registry Study, and they were cross-sectionally analyzed. The patients were classified into five groups based on their estimated glomerular filtration rate and urinary albumin to creatinine ratio according to Kidney Disease: Improving Global Outcomes 2012 guidelines, which recommend low, moderate, high, very high, and extremely high risk groups. The primary outcomes were the cardiovascular risk factor burden and the treatment status of cardiovascular risk factors. Using a logistic regression model, the association between the CKD groups and the treatment status of each risk factor was examined.

RESULTS

The proportion of patients with hypertension, diabetes mellitus, and dyslipidemia significantly increased as CKD progressed, whereas the proportion of patients who achieved cardiovascular risk factor treatment targets significantly decreased. In the multivariable analysis, the odds ratios (ORs) of uncontrolled treatment targets were significantly higher for hypertension (OR 3.68) in the extremely high risk group than in the low risk group.

CONCLUSIONS

Patients with non-dialysis-dependent CKD demonstrate an increased cardiovascular risk factor burden with greater severity of CKD. Extremely high risk CKD is associated with difficulty in managing hypertension.

Association between Serum C-Reactive Protein Concentrations and Risk of Cancer-Related Mortality in Patients Undergoing Hemodialysis: 10-Year Outcomes of the Q-Cohort Study

INTRODUCTION

Cancer constitutes a major source of morbidity and mortality among people undergoing hemodialysis (HD). A systemic inflammatory response is associated with the incidence and prognosis of cancer in the general population. However, the effect of systemic inflammation on cancer-related mortality in patients undergoing HD remains unclear.

METHODS

We analyzed 3,139 patients registered in the Q-Cohort Study, which is a multicenter, observational cohort study of patients on hemodialysis in Japan. The primary outcome was cancer-related mortality during a 10-year follow-up. The covariate of interest was serum C-reactive protein (CRP) concentrations at baseline. The patients were divided into tertiles based on their serum CRP concentrations at baseline (tertile [T] 1: ≤0.07; T2: 0.08-0.24; and T3: ≥0.25). The association between serum CRP concentrations and cancer-related mortality was calculated using the Cox proportional hazards model and the Fine-Gray subdistribution hazards model with non-cancer-related death as a competing risk.

RESULTS

During the 10-year follow-up, 216 patients died of cancer. In the multivariable analysis, the risk of cancer-related mortality in the highest tertile (T3) of serum CRP concentrations was significantly higher than that in the lowest tertile (T1) (multivariable-adjusted hazard ratio [95% confidence interval]: 1.68 [1.15-2.44]). This association remained consistent in the competing risk model, in which the subdistribution hazard ratio was 1.47 and the 95% confidence interval was 1.00-2.14 for T3 compared with T1.

CONCLUSION

Higher serum CRP concentrations are associated with an increased risk of cancer-related mortality in patients undergoing maintenance HD.

Radiation environment in high-altitude Antarctic plateau: Recent measurements and model studies

Polar regions are the most exposed to secondary particles and radiation produced by primary cosmic rays in the atmosphere, because naturally they are with marginal geomagnetic shielding. In addition, the secondary particle flux contributing to the complex radiation field is enhanced at high-mountain altitudes compared to sea level because of the reduced atmospheric attenuation. At present, there are very few systematic experimental measurements of environmental dose at high southern latitudes, specifically at high-altitude region. Here, we report a campaign of measurements with different devices, that is passive and Liulin-type dosimeters, of the radiation background at high-mountain Antarctic station Vostok (3488 m above sea level, 78° 27' S; 106° 50' E). We compare the measurements with a Monte Carlo-based model for the propagation of the cosmic rays through the atmosphere and assessment of the radiation field in the atmosphere. We employed the model to estimate the radiation dose at Vostok station during the ground-level enhancement at 28 October 2021. As in previous studies by other teams, we show that the annual dose equivalent at high-altitude Antarctic facilities can significantly exceed the limit of 1 mSv established for the general population by the ICRP.

Genome-wide association study of the risk of chronic kidney disease and kidney-related traits in the Japanese population: J-Kidney-Biobank

Chronic kidney disease (CKD) is a syndrome characterized by a gradual loss of kidney function with decreased estimated glomerular filtration rate (eGFR), which may be accompanied by an increase in the urine albumin-to-creatinine ratio (UACR). Although trans-ethnic genome-wide association studies (GWASs) have been conducted for kidney-related traits, there have been few analyses in the Japanese population, especially for the UACR trait. In this study, we conducted a GWAS to identify loci related to multiple kidney-related traits in Japanese individuals. First, to detect loci associated with CKD, eGFR, and UACR, we performed separate GWASs with the following two datasets: 475 cases of CKD diagnosed at seven university hospitals and 3471 healthy subjects (dataset 1) and 3664 cases of CKD-suspected individuals with eGFR <60 ml/min/1.73 m² or urinary protein ≥ 1+ and 5952 healthy subjects (dataset 2). Second, we performed a meta-analysis between these two datasets and detected the following associated loci: 10 loci for CKD, 9 loci for eGFR, and 22 loci for UACR. Among the loci detected, 22 have never been reported previously. Half of the significant loci for CKD were shared with those for eGFR, whereas most of the loci associated with UACR were different from those associated with CKD or eGFR. The GWAS of the Japanese population identified novel genetic components that were not previously detected. The results also suggest that the group primarily characterized by increased UACR possessed genetically different features from the group characterized by decreased eGFR.

Association between prevalence of laxative use and history of bone fractures and cardiovascular diseases in patients with chronic kidney disease: the Fukuoka Kidney disease Registry (FKR) study

BACKGROUND

Constipation is a common complication in patients with chronic kidney disease (CKD) and is involved in the pathogenesis of dysbiosis and progression of CKD. However, little is known about its association with disorders of the bone-cardiovascular axis in patients with CKD.

METHODS

We performed a cross-sectional analysis of 3878 patients with CKD using the baseline dataset of the Fukuoka Kidney disease Registry study, as a multicenter, prospective cohort study of pre-dialysis CKD patients. The main exposure of interest was constipation defined as use of at least one type of laxative. The main outcomes were the histories of bone fractures and cardiovascular diseases (CVDs) as manifestations of disorders of the bone-cardiovascular axis.

RESULTS

The prevalences of laxative use and histories of bone fractures and CVDs increased as kidney function declined. Among the 3878 patients, 532 (13.7%) patients used laxatives, 235 (6.1%) patients had prior bone fractures, and 1001 (25.8%) patients had prior CVDs. Histories of bone fractures and CVDs were significantly more prevalent among laxative users (P < 0.05). Multivariable-adjusted logistic regression analysis revealed that patients with laxatives had a significantly higher odds ratios for histories of bone fractures and CVDs than those without laxatives [adjusted odds ratios (95% confidence intervals) 1.67 (1.20-2.31) and 1.70 (1.30-2.22), respectively, P < 0.05].

CONCLUSIONS

These results suggest that constipation indicated by laxative use is associated with increased prevalences of historical bone fractures and CVDs in pre-dialysis patients with CKD.

Association between hyporesponsiveness to erythropoiesis-stimulating agents and risk of brain hemorrhage in patients undergoing hemodialysis: the Q-Cohort Study

BACKGROUND

Hyporesponsiveness to erythropoiesis-stimulating agents (ESAs) is associated with increased risks of all cause and cardiovascular mortality in patients undergoing hemodialysis (HD). However, the impact of the hematopoietic response to ESAs on the development of stroke, including brain hemorrhage and infarction, remains unclear.

METHODS

In total, 2886 patients undergoing maintenance HD registered in the Q-Cohort Study who were treated with ESAs were prospectively followed up for 4 years. The hematopoietic response to ESAs was evaluated by the erythropoietin resistance index (ERI), calculated by dividing the weekly dose of ESA by post-HD weight and hemoglobin (U/kg/week/g/dL). The primary outcomes were the incidences of brain hemorrhage and infarction. Patients were divided into quartiles based on their ERI at baseline (Q1, ≤ 4.1; Q2, 4.2-7.0; Q3, 7.1-11.2; and Q4, ≥ 11.3). The risks of brain hemorrhage and infarction were estimated using Cox proportional hazards models, adjusting for potential confounders.

RESULTS

During the 4 year follow-up period, 71 patients developed brain hemorrhage and 116 developed brain infarction. In the multivariable analysis, the incidence of brain hemorrhage in the highest quartile (Q4) was significantly higher than that in the lowest quartile (Q1) (hazard ratio [95% confidence interval], 2.18 [1.08-4.42]). However, the association between the ERI and the incidence of brain infarction was not significant.

CONCLUSIONS

A higher ERI was associated with an increased risk of brain hemorrhage, but not brain infarction, in patients undergoing maintenance HD. A high ERI is thus an important risk factor for brain hemorrhage in these patients.

Current antihypertensive treatment and treatment-resistant hypertension in Japanese patients with chronic kidney disease

BACKGROUND

Hypertension is an important prognostic predictor in patients with chronic kidney disease (CKD), and the recommended target blood pressure has been continuously revised. This study aimed to reveal the current antihypertensive practices in Japanese patients with CKD.

METHODS

In the Fukuoka Kidney disease Registry, we extracted 3664 non-dialysis-dependent patients with CKD. Apparent treatment-resistant hypertension (aTRH) was defined as a failure of blood-pressure control treated with three antihypertensive medication classes or a treatment with ≥ 4 classes regardless of blood pressure. The blood-pressure control complied with the target blood pressure recommended by the KDIGO 2012 guideline.

RESULTS

The median age of the patients was 67 years, body mass index (BMI) was 23 kg/m², and estimated glomerular filtration rate (eGFR) was 40 mL/min/1.73 m². The number of patients with unachieved blood-pressure control was 1933, of whom 26% received ≥ 3 classes of antihypertensive medications. The first choice of medication was renin-angiotensin system inhibitors, followed by calcium-channel blockers. The rate of thiazide use was low in all CKD stages (3-11%). The prevalence of aTRH was 16%, which was significantly associated with BMI (odds ratio [95% confidence interval] per 1-standard deviation change, 1.38 [1.25-1.53]), decreased eGFR (1.87 [1.57-2.23]), as well as age, diabetes mellitus, and chronic heart disease.

CONCLUSIONS

Renal dysfunction and obesity are important risk factors of aTRH. Even under nephrologist care, most patients were treated with insufficient antihypertensive medications. It is important to prescribe sufficient classes of antihypertensive medications, including diuretics, and to improve patients' lifestyle habits.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with prostate cancer

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of prostate cancer was published in 2020. It was therefore decided, by both the ESMO and the Singapore Society of Oncology (SSO), to convene a special, virtual guidelines meeting in November 2021 to adapt the ESMO 2020 guidelines to take into account the differences associated with the treatment of prostate cancer in Asia. These guidelines represent the consensus opinions reached by experts in the treatment of patients with prostate cancer representing the oncological societies of China (CSCO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence and was independent of the current treatment practices and drug access restrictions in the different Asian countries. The latter were discussed when appropriate. The aim is to provide guidance for the optimisation and harmonisation of the management of patients with prostate cancer across the different regions of Asia.

Prevalence, treatment status, and predictors of anemia and erythropoietin hyporesponsiveness in Japanese patients with non-dialysis-dependent chronic kidney disease: a cross-sectional study

BACKGROUND

Hyporesponsiveness to erythropoiesis-stimulating agents (ESAs) has been highlighted as a potential risk factor for cardiovascular disease in patients with chronic kidney disease (CKD).

METHODS

We assessed cross-sectionally the prevalence, associated factors, and treatment status of anemia and ESA hyporesponsiveness in 4460 non-dialysis-dependent CKD patients enrolled in a multicenter cohort in Japan. Anemia was defined as a hemoglobin (Hb) level of less than 11 g/dL or receiving ESA therapy. ESA hyporesponsiveness was defined by the erythropoietin-resistance index (ERI), which was the erythropoietin dose per week divided by body weight and Hb level (U/kg/week/g/dl).

RESULTS

Of the 4460 patients, 1050 (23.5%) had anemia. ESAs were administered to 626 patients, reaching a percentage of 57.5% of patients with stage G5 CKD. However, the ESA treatment rate was only 49.0% in patients with a hemoglobin level of < 11 g/dL. The proportion of patients receiving iron supplementation was lower than that of patients receiving ESAs regardless of CKD stage or hemoglobin level, and a significant proportion of patients did not receive iron supplementation, even those with iron deficiency. The ERI increased with CKD stage progression, and the multiple regression analysis showed that age, female sex, body mass index, cholesterol, glomerular filtration rate, and intact parathyroid hormone level were independent contributors.

CONCLUSIONS

Our findings demonstrate that many Japanese patients with non-dialysis-dependent CKD receiving ESAs fail to maintain adequate hemoglobin levels. These results suggest the need for interventions for ESA hyporesponsiveness factors in addition to iron supplementation.

Pan-Asian adapted ESMO Clinical Practice Guidelines for the diagnosis, treatment and follow-up of patients with renal cell carcinoma

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of renal cell carcinoma was published in 2019 with an update planned for 2021. It was therefore decided by both the ESMO and the Singapore Society of Oncology (SSO) to convene a special, virtual guidelines meeting in May 2021 to adapt the ESMO 2019 guidelines to take into account the ethnic differences associated with the treatment of renal cell carcinomas in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with renal cell carcinoma representing the oncological societies of China (CSCO), India (ISMPO), Japan (JSMO), Korea (KSMO), Malaysia (MOS), Singapore (SSO) and Taiwan (TOS). The voting was based on scientific evidence and was independent of the current treatment practices and drug access restrictions in the different Asian countries. The latter were discussed when appropriate.

Serum Alkaline Phosphatase Levels and Increased Risk of Brain Hemorrhage in Hemodialysis Patients: The Q-Cohort Study

Aim: Elevated serum alkaline phosphatase (ALP) levels have been associated with increased risks of all-cause and cardiovascular mortality in patients receiving hemodialysis. However, little is known about the impact of serum ALP levels on the development of stroke, such as brain hemorrhage and infarction.

Methods: A total of 3,497 patients receiving maintenance hemodialysis registered in the multicenter observational Q-Cohort Study were analyzed. The primary outcomes were the incidences of brain hemorrhage and infarction. The covariate of interest was serum ALP levels. Patients were divided into tertiles based on their serum ALP levels (U/L) at baseline (T1, ＜69.3; T2, 69.3–98.4; T3, ＞98.4). The risks of brain hemorrhage, brain infarction, and composite stroke were estimated using Cox proportional hazards models and competing risk models with all-cause death as a competing risk.

Results: A total of 89 patients developed brain hemorrhage and 195 patients developed brain infarction during the 4-year follow-up period. The risk of brain hemorrhage in the highest tertile (T3) was significantly higher than that in the lowest tertile (T1) (multivariable-adjusted hazard ratio [95% confidence interval], 1.93 [1.12–3.35], subdistribution hazard ratio, 1.91 [1.10–3.30]). However, there was no significant association between serum ALP levels and the risk of brain infarction or composite stroke.

Conclusions: Higher serum ALP levels are associated with an increased risk of brain hemorrhage, but not brain infarction, in patients receiving maintenance hemodialysis. High serum ALP level is thus an important risk factor for brain hemorrhage in hemodialysis patients.

Association between geriatric nutritional risk index and stroke risk in hemodialysis patients: 10-Years outcome of the Q-Cohort study

BACKGROUNDS AND AIMS

The geriatric nutritional risk index (GNRI), which is calculated using the serum albumin level and body mass index, is a nutritional marker associated with an increased risk of cardiovascular events in patients who are receiving hemodialysis. However, no studies have examined the association between the GNRI level and the incidence of stroke in this population.

METHODS

Three thousand forty-five patients were registered in the Q-Cohort Study, which is a multicenter, observational cohort of hemodialysis patients. The main outcomes were brain infarction and brain hemorrhage. The main exposure was GNRI levels at baseline. Patients were divided into quartiles on the basis of baseline GNRI levels: Q1, <90.7; Q2, 90.7-95.5; Q3, 95.6-99.8; Q4, >99.8. The risk of brain infarction or hemorrhage was estimated using the multivariable-adjusted Cox proportional hazard risk models and restricted cubic spline analyses.

RESULTS

During the 10-year follow-up period, 326 patients developed brain infarction and 149 patients developed brain hemorrhage. Cox proportional hazard risk models showed that the risk of brain infarction and hemorrhage in Q1 was significantly higher than that in Q4 group. The hazard ratios [95% confidence intervals] were 1.49 [1.05-2.12] and 1.89 [1.11-3.20], respectively. Restricted cubic spline curves showed that a lower GNRI was incrementally associated with an increased risk for both brain infarction and brain hemorrhage.

CONCLUSIONS

Our results suggest that a lower GNRI is an independent risk factor for both brain infarction and hemorrhage in patients who are receiving maintenance hemodialysis.

Nintedanib in patients with progressive fibrosing interstitial lung diseases-subgroup analyses by interstitial lung disease diagnosis in the INBUILD trial: a randomised, double-blind, placebo-controlled, parallel-group trial

BACKGROUND

The INBUILD trial investigated the efficacy and safety of nintedanib versus placebo in patients with progressive fibrosing interstitial lung diseases (ILDs) other than idiopathic pulmonary fibrosis (IPF). We aimed to establish the effects of nintedanib in subgroups based on ILD diagnosis.

METHODS

The INBUILD trial was a randomised, double-blind, placebo-controlled, parallel group trial done at 153 sites in 15 countries. Participants had an investigator-diagnosed fibrosing ILD other than IPF, with chest imaging features of fibrosis of more than 10% extent on high resolution CT (HRCT), forced vital capacity (FVC) of 45% or more predicted, and diffusing capacity of the lung for carbon monoxide (DLco) of at least 30% and less than 80% predicted. Participants fulfilled protocol-defined criteria for ILD progression in the 24 months before screening, despite management considered appropriate in clinical practice for the individual ILD. Participants were randomly assigned 1:1 by means of a pseudo-random number generator to receive nintedanib 150 mg twice daily or placebo for at least 52 weeks. Participants, investigators, and other personnel involved in the trial and analysis were masked to treatment assignment until after database lock. In this subgroup analysis, we assessed the rate of decline in FVC (mL/year) over 52 weeks in patients who received at least one dose of nintedanib or placebo in five prespecified subgroups based on the ILD diagnoses documented by the investigators: hypersensitivity pneumonitis, autoimmune ILDs, idiopathic non-specific interstitial pneumonia, unclassifiable idiopathic interstitial pneumonia, and other ILDs. The trial has been completed and is registered with ClinicalTrials.gov, number NCT02999178.

FINDINGS

Participants were recruited between Feb 23, 2017, and April 27, 2018. Of 663 participants who received at least one dose of nintedanib or placebo, 173 (26%) had chronic hypersensitivity pneumonitis, 170 (26%) an autoimmune ILD, 125 (19%) idiopathic non-specific interstitial pneumonia, 114 (17%) unclassifiable idiopathic interstitial pneumonia, and 81 (12%) other ILDs. The effect of nintedanib versus placebo on reducing the rate of FVC decline (mL/year) was consistent across the five subgroups by ILD diagnosis in the overall population (hypersensitivity pneumonitis 73·1 [95% CI -8·6 to 154·8]; autoimmune ILDs 104·0 [21·1 to 186·9]; idiopathic non-specific interstitial pneumonia 141·6 [46·0 to 237·2]; unclassifiable idiopathic interstitial pneumonia 68·3 [-31·4 to 168·1]; and other ILDs 197·1 [77·6 to 316·7]; p=0·41 for treatment by subgroup by time interaction). Adverse events reported in the subgroups were consistent with those reported in the overall population.

INTERPRETATION

The INBUILD trial was not designed or powered to provide evidence for a benefit of nintedanib in specific diagnostic subgroups. However, its results suggest that nintedanib reduces the rate of ILD progression, as measured by FVC decline, in patients who have a chronic fibrosing ILD and progressive phenotype, irrespective of the underlying ILD diagnosis.

FUNDING

Boehringer Ingelheim.

A case of ischemic osteopathy in a hemodialysis patient with advanced peripheral artery disease

Peripheral artery disease (PAD) or arteriosclerosis obliterans is a lethal complication highly prevalent in pre-dialysis CKD and dialyzed patients. PAD is driven by atherosclerotic process and causes ischemia of the affected limb. Given that normal bone metabolism is based on sufficient blood supply and PAD decreases intraosseous blood flow of the affected limb, it is probable that PAD can directly cause ischemic osteopathy or osteoporosis in affected limbs. We herein present a 69-year-old female patient receiving 18 years of maintenance hemodialysis therapy was hospitalized for the treatment of bilateral PAD. Angiography showed a diffuse stenosis of the right superficial femoral artery and total occlusion of the left superficial femoral artery. Right ankle brachial index (ABI) was 0.83, whereas left ABI was unmeasurable. Notably, T score of the bone mineral density (BMD) in the right calcaneus measured by quantitative ultrasound was - 1.4, while that in the left calcaneus was - 2.2, showing a huge difference between BMD in the bilateral calcaneus. Metal stent was inserted to the right superficial femoral artery, whereas femoropopliteal bypass surgery was performed for the left limb. After the surgery, her right and left ABI were 0.96 and 0.92, respectively. Our case typically showed the clinical significance of sufficient blood supply to the bone for the normal bone metabolism and reminds us of the potential need to conduct further research on the association between PAD and ischemic osteopathy in patients with CKD.

Impact of Prior Platinum-Based Therapy on Patients Receiving Salvage Systemic Treatment for Advanced Urothelial Carcinoma

BACKGROUND

Trials of salvage therapy for advanced urothelial carcinoma have required prior platinum-based therapy. This practice requires scrutiny because non-platinum-based first-line therapy may be offered to cisplatin-ineligible patients.

PATIENTS AND METHODS

Data of patients receiving salvage systemic chemotherapy were collected. Data on prior first-line platinum exposure were required in addition to treatment-free interval, hemoglobin, Eastern Cooperative Oncology Group performance status, albumin, and liver metastasis status. Cox proportional hazard regression was used to evaluate their association with overall survival (OS) after accounting for salvage single-agent or combination chemotherapy.

RESULTS

Data were obtained from 455 patients previously exposed to platinum-based therapy and 37 not exposed to platinum. In the group exposed to prior platinum therapy, salvage therapy consisted of a single-agent taxane (n = 184) or a taxane-containing combination chemotherapy (n = 271). In the group not exposed to prior platinum therapy, salvage therapy consisted of taxane or vinflunine (n = 20), 5-fluorouracil (n = 1), taxane-containing combination chemotherapy (n = 12), carboplatin-based combinations (n = 2), and cisplatin-based combinations (n = 2). The median OS for the prior platinum therapy group was 7.8 months (95% confidence interval, 7.0, 8.1), and for the group that had not received prior platinum therapy was 9.0 months (95% confidence interval, 6.0, 11.0; P = .50). In the multivariable analysis, prior platinum therapy versus no prior platinum exposure did not confer an independent impact on OS (hazard ratio, 1.10; 95% confidence interval, 0.75, 1.64; P = .62).

CONCLUSION

Prior platinum- versus non-platinum-based chemotherapy did not have a prognostic impact on OS after accounting for major prognostic factors in patients receiving salvage systemic chemotherapy for advanced urothelial carcinoma. Lack of prior platinum therapy should not disqualify patients from inclusion onto trials of salvage therapy.

Calibration of modified Liulin detector for cosmic radiation measurements on-board aircraft

The annual effective doses of aircrew members often exceed the limit of 1 mSv for the public due to the increased level of cosmic radiation at the flight altitudes, and thus, it is recommended to monitor them. Aircrew dosimetry is usually performed using special computer programs mostly based on results of Monte Carlo simulations. Contemporary, detectors are used mostly for validation of these computer codes, verification of effective dose calculations and for research purposes. One of such detectors is active silicon semiconductor deposited energy spectrometer Liulin. Output quantities of measurement with the Liulin detector are the absorbed dose in silicon D and the ambient dose equivalent H*(10); to determine it, two calibrations are necessary. The purpose of this work was to develop a calibration methodology that can be used to convert signal from the detector to D independently on calibration performed at Heavy Ion Medical Accelerator facility in Chiba, Japan.

Glomerular capillary regeneration and endothelial cell apoptosis in both reversible and progressive models of glomerulonephritis

In summary, angiogenetic capillary regeneration with endothelial proliferation occurred among mesangiolytic lesions in Thy-1 GN, and the damaged glomerulus recovered its normal structure with the reconstruction of the capillary network. In anti-GBM GN on WKY rats, the damaged glomerulus showed rare capillary regeneration and progressed to global sclerosis. In Thy-1 GN, endothelial cell apoptosis was found in the regenerated capillaries with endothelial cell hypercellularity. On the other hand, in anti-GBM GN on WKY rats, the number of endothelial cell apoptosis increased during the evolution of glomerular sclerosis. We have concluded that glomerular capillary regeneration plays an essential role in the recovery of damaged glomeruli. Moreover, apoptosis is indispensable in regulating the number of intrinsic endothelial cells. We also found that endothelial apoptosis is important in progression of glomerular sclerosis.

Overview of the Liulin type instruments for space radiation measurement and their scientific results

Ionizing radiation is recognized to be one of the main health concerns for humans in the space radiation environment. Estimation of space radiation effects on health requires the accurate knowledge of the accumulated absorbed dose, which depends on the global space radiation distribution, solar cycle and local shielding generated by the 3D mass distribution of the space vehicle. This paper presents an overview of the spectrometer-dosimeters of the Liulin type, which were developed in the late 1980s and have been in use since then. Two major measurement systems have been developed by our team. The first one is based on one silicon detector and is known as a Liulin-type deposited energy spectrometer (DES) (Dachev et al., 2002, 2003), while the second one is a dosimetric telescope (DT) with two or three silicon detectors. The Liulin-type instruments were calibrated using a number of radioactive sources and particle accelerators. The main results of the calibrations are presented in the paper. In the last section of the paper some of the most significant scientific results obtained in space and on aircraft, balloon and rocket flights since 1989 are presented.

Anti-IL-31 receptor antibody is shown to be a potential therapeutic option for treating itch and dermatitis in mice

BACKGROUND AND PURPOSE

IL-31, which is described as a pruritogenic cytokine, is linked to the itching that is associated with allergic and non-allergic eczema, but the precise pruritogenic mechanism of IL-31 and its potential as a therapeutic target for atopic dermatitis (AD) have not been determined.

EXPERIMENTAL APPROACH

We investigated the effects of existing drugs on the scratching behaviour induced by an i.v. injection of IL-31 to clarify whether IL-31 induced pruritus indirectly. In addition, we studied the effects of an anti-IL-31 receptor α subunit (anti-IL-31 receptor α) neutralizing antibody on chronic pruritus-inducing dermatitis in an AD-like model to determine whether IL-31 not only induces scratching behaviour, but is also the causative factor in an AD phenotype.

KEY RESULTS

The scratching behaviour induced by an i.v. injection of IL-31 was inhibited by pretreatment with an anti-IL-31 receptor α-neutralizing antibody. In contrast, it was not inhibited significantly by a non-sedative antihistamine (terfenadine), immunosuppressants (dexamethasone and tacrolimus), or a μ-opioid receptor antagonist (naloxone). The anti-IL-31 receptor α-neutralizing antibody reduced the ear swelling and dermatitis score in a chronic pruritus-inducing AD-like model. Moreover, treatment with the anti-IL-31 receptor α-neutralizing antibody showed therapeutic effects on the dermatitis even if it was injected after the disease had developed.

CONCLUSIONS AND IMPLICATIONS

Anti-IL-31 receptor α is a potential novel therapeutic approach for escaping from the itch-scratch cycle and also a treatment for dermatitis in AD.

A cohort study of toner-handling workers on inflammatory, allergic, and oxidative stress markers

Objectives:

This study examines the relationship between toner exposure and its health effects in terms of biomarkers which are known to assess the damages to humans caused by toxic material exposure.

Methods:

The subjects were 1504 male workers aged below 50 in 2003 in a Japanese toner and photocopier manufacturing company. Personal exposure measurements, pulmonary function tests, chest X-ray examinations, biomarker measurement, and a questionnaire about respiratory symptoms were conducted. We will report about biomarker measurement in this study. Cross-sectional survey studies and a longitudinal study from 2003 to 2008 were conducted.

Results:

Few significant findings were associated with the toner exposure in both the cross-sectional and the longitudinal studies. The higher toner exposure concentrations did not induce effects on increasing biomarkers.

Conclusion:

There was no evidence of excessive inflammatory, allergic, or oxidative stress reaction in toner-handling workers as compared to non-handling workers, despite some sporadically significant findings. There are no other reports of a longitudinal epidemiological study with regard to toner exposure; this report significantly contributes to toner exposure literature. Although in the current well-controlled working environment, the toner exposure concentrations are quite low; further studies are needed to completely understand the health effects toner may have, however small they may be.

A cohort study using pulmonary function tests and x-ray examination in toner-handling workers: cross-sectional and longitudinal analyses from 2003 to 2008

OBJECTIVES

This study uses pulmonary function tests and chest x-ray examinations to examine the relationship between toner-handling work and its health effects.

METHODS

The subjects were 1504 male workers in a Japanese toner and photocopier manufacturing company, in the age range from 19 to 50 years in 2003. Personal exposure measurements, pulmonary function tests, chest x-ray examinations, biomarker measurements, and a questionnaire about respiratory symptoms were conducted. The present study reports the results of pulmonary function tests and chest x-ray examinations conducted in the subjects, which includes a cross-sectional study on the toner handling and non-handling workers and a longitudinal study from 2003 to 2008.

RESULTS

Few significant findings were suspected to be caused by toner exposure found in pulmonary function indices in both the cross-sectional and longitudinal studies. Any obvious fibrotic findings in chest x-ray findings related to the toner exposure could not be found out.

CONCLUSION

No evidence of adverse effects on pulmonary function indices and chest x-rays was present in the toner-handling workers as compared to the nonspecifically exposed workers. Although the toner exposure concentration is quite low in the current well-controlled working environment, even among the toner-handling workers, we would like to continue this study in the future to verify the toner exposure health effects.

Randomised phase III study of neoadjuvant chemotherapy with methotrexate, doxorubicin, vinblastine and cisplatin followed by radical cystectomy compared with radical cystectomy alone for muscle-invasive bladder cancer: Japan Clinical Oncology Group Study JCOG0209

BACKGROUND

This study aimed to determine the clinical benefit of neoadjuvant methotrexate, doxorubicin, vinblastine, and cisplatin (MVAC) in patients with muscle-invasive bladder cancer (MIBC) treated with radical cystectomy.

PATIENTS AND METHODS

Patients with MIBC (T2-4aN0M0) were randomised to receive two cycles of neoadjuvant MVAC followed by radical cystectomy (NAC arm) or radical cystectomy alone (RC arm). The primary end point was overall survival (OS). Secondary end points were progression-free survival, surgery-related complications, adverse events during chemotherapy, proportion with no residual tumour in the cystectomy specimens, and quality of life. To detect an improvement in 5-year OS from 45% in the RC arm to 57% in the NAC arm with 80% power, 176 events were required per arm.

RESULTS

Patients (N = 130) were randomly assigned to the RC arm (N = 66) and the NAC arm (N = 64). The patient registration was terminated before reaching the initially planned number of patients because of slow accrual. At the second interim analysis just after the early stoppage of patient accrual, the Data and Safety Monitoring Committee recommended early publication of the results because the trial did not have enough power to draw a confirmatory conclusion. OS of the NAC arm was better than that of the RC arm, although the difference was not statistically significant [hazard ratio 0.65, multiplicity adjusted 99.99% confidence interval 0.19-2.18, one-sided P = 0.07]. In the NAC arm and the RC arm, 34% and 9% of the patients had pT0, respectively (P < 0.01). In subgroup analyses, OS in almost all subgroups was in favour of NAC.

CONCLUSIONS

This trial showed a significantly increased pT0 proportion and favourable OS of patients who received neoadjuvant MVAC. NAC with MVAC can still be considered promising as a standard treatment.

UMIN CLINICAL TRIALS REGISTRY IDENTIFIER

C000000093.

Medipix in space on-board the ISS

On 16 October 2012, five active radiation detectors (referred to by NASA as Radiation Environment Monitors, or REMs) employing the Timepix version of the technology developed by the CERN-based Medipix2 Collaboration were deployed on-board the International Space Station (ISS) using simple USB interfaces to the existing ISS laptops for power, control and readout [ 1– 3]. These devices successfully demonstrated the capabilities of this technology by providing reliable dose and dose-equivalent information based on a track-by-track analysis. Figure 1 shows a sample comparison of the output from all five devices with respect to the on-board tissue equivalent proportional counter (TEPC) for both absorbed dose (top) and dose-equivalent (bottom) as defined in NCRP 142. The lower graph in each set is the TEPC. Several issues were identified and solutions to adjust for them have been included in the analysis. These include items such as the need to identify nuclear interactions in the silicon sensor layer, and to separate penetrating from stopping tracks. The wide effective range in fluence and particle type of this technology was also verified through the highest rates seen during the South Atlantic Anomaly passes and the heavy ions nominally seen in the Galactic Cosmic Rays. Corrections for detector response saturation effects were also successfully implemented as verified by reference to ground-based accelerator data taken at the Heavy-Ion Medical Accelerator Center (HIMAC) facility at the National Institute for Radiological Sciences in Japan, and at the NASA Space Radiation Laboratory (NSRL) at the Brookhaven National Laboratory in New York. Flight hardware has been produced that will be flown on the first launch of the new Orion spacecraft, and flight hardware development is ongoing to accommodate the next generation of this technology as a baseline for radiation monitoring and dosimetry on future operational manned missions. Fig 1.

RISING beamline (BL28XU) for rechargeable battery analysis

The newly installed BL28XU beamline at SPring-8 is dedicated to in situ structural and electronic analysis of rechargeable batteries. It supports the time range (1 ms to 100 s) and spatial range (1 µm to 1 mm) needed for battery analysis. Electrochemical apparatus for battery charging and discharging are available in experimental hutches and in a preparation room. Battery analysis can be carried out efficiently and effectively using X-ray diffraction, X-ray absorption fine-structure analysis and hard X-ray photoelectron spectroscopy. Here, the design and performance of the beamline are described, and preliminary results are presented.

Effect of gaiters on muscle pump activity in healthy volunteers

OBJECTIVES

Exercise of the leg with external limb compression has been reported to be useful for preventing and reducing leg oedema. The aim of this study was to investigate the effects of leg gaiters on calf muscle pump activity.

METHODS

Continuous measurements of the interface pressure at the leg during exercise and determination of the femoral venous velocity at the groin during exercise were carried out in healthy volunteers with elastic stockings alone, leg gaiters alone and gaiters over the elastic stockings.

RESULTS

The greatest pressure difference between muscle contraction and relaxation during exercise was observed when gaiters were applied over the elastic stockings at the calf. Gaiters alone without elastic stockings led to a significantly greater pressure difference between muscle contraction and relaxation during exercise than elastic stockings alone (P < 0.01). A significantly higher value of the peak flow velocity of the femoral vein was observed with the combined use of gaiters and elastic stockings than the single use of elastic stockings.

CONCLUSIONS

Leg gaiters have a beneficial effect of augmenting venous femoral blood flow during calf muscle pump activity in volunteers with a normal valve function of leg veins.