Skeletal Muscle Electrical Stimulation Prevents Progression of Disuse Muscle Atrophy via Forkhead Box O Dynamics Mediated by Phosphorylated Protein Kinase B and Peroxisome Proliferator-Activated Receptor gamma Coactivator-1alpha

Although electrical muscle stimulation (EMS) of skeletal muscle effectively prevents muscle atrophy, its effect on the breakdown of muscle component proteins is unknown. In this study, we investigated the biological mechanisms by which EMS-induced muscle contraction inhibits disuse muscle atrophy progression. Experimental animals were divided into a control group and three experimental groups: immobilized (Im; immobilization treatment), low-frequency (LF; immobilization treatment and low-frequency muscle contraction exercise), and high-frequency (HF; immobilization treatment and high-frequency muscle contraction exercise). Following the experimental period, bilateral soleus muscles were collected and analyzed. Atrogin-1 and Muscle RING finger 1 (MuRF-1) mRNA expression levels were significantly higher for the experimental groups than for the control group but were significantly lower for the HF group than for the Im group. Peroxisome proliferator-activated receptor gamma coactivator-1alpha (PGC-1alpha) mRNA and protein expression levels in the HF group were significantly higher than those in the Im group, with no significant differences compared to the Con group. Both the Forkhead box O (FoxO)/phosphorylated FoxO and protein kinase B (AKT)/phosphorylated AKT ratios were significantly lower for the Im group than for the control group and significantly higher for the HF group than for the Im group. These results, the suppression of atrogin-1 and MuRF-1 expression for the HF group may be due to decreased nuclear expression of FoxO by AKT phosphorylation and suppression of FoxO transcriptional activity by PGC-1alpha. Furthermore, the number of muscle contractions might be important for effective EMS.

PLA2R-positive membranous nephropathy in IgG4-related disease

BACKGROUND

IgG4-related disease (IgG4-RD) is a fibroinflammatory disease that affects multiple organs, including the pancreas, lacrimal glands, salivary glands, periaortic/retroperitoneum, and kidney. Interstitial nephritis is a typical renal disorder associated with IgG4-RD, but membranous nephropathy is also seen in some cases.

CASE PRESENTATION

Herein we report on the case of a 77-year-old male patient with nephrotic syndrome and IgG4-related lung disease. His serum phospholipase A2 receptor (PLA2R) antibody was positive. His renal biopsy specimen was also positive for PLA2R. The renal biopsy specimen showed membranous nephropathy with equal IgG3 and IgG4 immunofluorescence staining and no interstitial nephritis, suggesting IgG4-RD manifesting as membranous nephropathy.

CONCLUSIONS

Nephrotic syndrome caused by membranous nephropathy is sometimes associated with IgG4-RD. In such cases, even if serum PLA2R antibody is positive, it should be considered that the membranous nephropathy may be secondary to IgG4-RD.

Daily light exposure profiles and the association with objective sleep quality in patients with Parkinson's disease: The PHASE study

STUDY OBJECTIVES

Light information crucially influences the sleep initiation and continuity. The purpose of this study was to compare daily light exposure between patients with Parkinson's disease (PD) and non-PD older adults and evaluate the association of daily light exposure with objective sleep measures in patients with PD.

METHODS

In this cross-sectional study of 189 outpatients with PD and 1101 community dwelling older adults (controls), daily light exposure was measured using wrist light meters during the daytime and light meters set in the bedrooms during the nighttime, and objective sleep quality was measured by wrist actigraphy.

RESULTS

The median duration of exposure to ≥1000 lux light was significantly shorter in patients with PD than in controls. The median nighttime light intensity was higher in patients with PD than in controls. Among patients with PD, multivariable analysis suggested that the highest quartile of exposure to ≥1000 lux light during the daytime was linked to significantly higher sleep efficiency by 8.0% and shorter wake after sleep onset (WASO) by 36.9 min than the lowest quartile. During the nighttime, the highest quartile of mean light intensity had significantly lower sleep efficiency by 6.8%, longer WASO by 24.1 min, longer sleep onset latency, and higher fragmentation index, than the lowest quartile. Importantly, daytime and nighttime light levels were independently associated with objective sleep measures.

CONCLUSION

The present study illustrated that greater daytime light exposure and lower nighttime light exposure are significantly associated with better objective sleep measures in patients with PD.

Factors associated with early-onset intracranial aneurysms in patients with autosomal dominant polycystic kidney disease

BACKGROUND

Recently, the importance of attribute-based medicine has been emphasized. The effects of early-onset intracranial aneurysms on patients can be significant and long-lasting. Herein, we compared the factors associated with intracranial aneurysms in patients with autosomal dominant polycystic kidney disease (ADPKD) according to age categories (≥ 50 years, < 50 years).

METHODS

We included 519 ADPKD patients, with a median age of 44 years, estimated glomerular filtration rate of 54.5 mL/min/1.73 m2, and total follow-up duration of 3104 patient-years. Logistic regression analyses were performed to determine factors associated with intracranial aneurysms.

RESULTS

Regarding the presence of intracranial aneurysm, significant interactions were identified between the age category (age ≥ 50 years), female sex (P = 0.0027 for the interaction) and hypertension (P = 0.0074 for the interaction). Female sex and hypertension were associated with intracranial aneurysm risk factors only in patients aged ≥ 50 years. The presence of intracranial aneurysm was significantly associated with chronic kidney disease (CKD) stages 4-5 (odds ratio [OR] = 3.87, P = 0.0007) and family history of intracranial aneurysm or subarachnoid hemorrhage (OR = 2.30, P = 0.0217) in patients aged < 50 years. For patients aged ≥ 50 years, in addition to the abovementioned factors [OR = 2.38, P = 0.0355 for CKD stages 4-5; OR = 3.49, P = 0.0094 for family history of intracranial aneurysm or subarachnoid hemorrhage], female sex (OR = 4.51, P = 0.0005), and hypertension (OR = 5.89, P = 0.0012) were also associated with intracranial aneurysm.

CONCLUSION

Kidney dysfunction and family history of intracranial aneurysm or subarachnoid hemorrhage are risk factors for early-onset intracranial aneurysm. Patients aged < 50 years with a family history of intracranial aneurysm or subarachnoid hemorrhage or with CKD stages 4-5 may be at an increased risk of early-onset intracranial aneurysm.

Role of LL-37 in Oral Bacterial DNA Accumulation in Dental Plaque

Dental plaque, a highly structured polymicrobial biofilm, persistently forms in the oral cavity and is a common problem affecting oral health. The role of oral defense factors in either collaborating or disrupting host-microbiome interactions remains insufficiently elucidated. This study aims to explore the role of LL-37, a critical antimicrobial peptide in the oral cavity, in dental plaque formation. Through immunostaining dental plaque specimens, we observed that LL-37 and DNA colocalized in the samples, appearing as condensed clusters. In vitro experiments revealed that LL-37 binds rapidly to oral bacterial DNA, forming high molecular weight, DNase-resistant complexes. This interaction results in LL-37 losing its inherent antibacterial activity. Further, upon the addition of LL-37, we observed a visible increase in the precipitation of bacterial DNA. We also discovered a significant correlation between the levels of the DNA-LL-37 complex and LL-37 within dental plaque specimens, demonstrating the ubiquity of the complex within the biofilm. By using immunostaining on dental plaque specimens, we could determine that the DNA-LL-37 complex was present as condensed clusters and small bacterial cell-like structures. This suggests that LL-37 immediately associates with the released bacterial DNA to form complexes that subsequently diffuse. We also demonstrated that the complexes exhibited similar Toll-like receptor 9-stimulating activities across different bacterial species, including Porphyromonas gingivalis, Fusobacterium nucleatum, Prevotella intermedia, and Streptococcus salivarius. However, these complexes prompted dissimilar activities, such as the production of IL-1β in monocytic cells via both NLRP3 pathway-dependent and pathway-independent mechanisms. This study, therefore, reveals the adverse role of LL-37 in dental plaque, where it binds bacterial DNA to form complexes that may precipitate to behave like an extracellular matrix. Furthermore, the unveiled stimulating properties and species-dependent activities of the oral bacterial DNA-LL-37 complexes enrich our understanding of dental plaque pathogenicity and periodontal innate immune responses.

Immediate drop of urine osmolality upon tolvaptan initiation predicts impact on renal prognosis in patients with ADPKD

BACKGROUND AND HYPOTHESIS

Tolvaptan, a vasopressin V2 receptor antagonist, is used for treating autosomal dominant polycystic kidney disease (ADPKD). We focused on changes in urinary osmolality (U-Osm) after tolvaptan initiation to determine whether they were associated with the therapeutic response to tolvaptan.

METHODS

This was a single-centre, prospective, observational cohort study. Seventy-two patients with ADPKD who received tolvaptan were recruited. We analysed the relationship between changes in U-Osm and annual estimated glomerular filtration rate (eGFR) in terms of renal prognostic value using univariable and multivariable linear regression analyses.

RESULTS

The mean value of U-Osm immediately before tolvaptan initiation was 351.8 ± 142.2 mosm/kg H2O, which decreased to 97.6 ± 23.8 mosm/kg H2O in the evening. The decrease in U-Osm was maintained in the outpatient clinic 1 month later. However, the values of U-Osm showed higher variability (160.2 ± 83.8 mosm/kg H2O) than did those in the first evening of tolvaptan administration. Multivariate analysis revealed that the baseline eGFR, baseline urinary protein, and U-Osm change in the evening of the day of admission (initial U-Osm drop) were significantly correlated with the subsequent annual change in eGFR.

CONCLUSIONS

U-Osm can be measured easily and rapidly, and U-Osm change within a short time after tolvaptan initiation may be a useful index for the renal prognosis in actual clinical practice.

Public support for patients with intractable diseases in Japan: impact on clinical indicators from nationwide registries in patients with autosomal dominant polycystic kidney disease

BACKGROUND

Clinical practice guidelines recommend antihypertensive and tolvaptan therapies for patients with autosomal dominant polycystic kidney disease (ADPKD) in Japan. However, tolvaptan therapy may pose an economic burden. The Japanese Ministry of Health, Labour and Welfare supports patients with intractable diseases. This study aimed to confirm the impact of the intractable disease system in Japan on the clinical treatment of ADPKD.

METHODS

We analyzed the data of 3768 patients with ADPKD having a medical subsidy certificate from the Japanese Ministry of Health, Labour and Welfare in 2015-2016. The following quality indicators were use: the adherence rate to the 2014 clinical practice guideline for polycystic kidney disease (prescription rates of antihypertensive agents and tolvaptan in this cohort) and the number of Japanese patients with ADPKD nationwide started on renal replacement therapy in 2014 and 2020.

RESULTS

Compared with new applications from 2015 to 2016, the prescription rates of antihypertensives and tolvaptan for the indicated patients at the 2017 renewal application increased by 2.0% (odds ratio = 1.41, p = 0.008) and 47.4% (odds ratio = 10.1, p > 0.001), respectively. These quality indicators improved with antihypertensive treatment, especially in patients with chronic kidney disease stages 1-2 (odds ratio = 1.79, p = 0.013) and in those aged < 50 years (odds ratio = 1.70, p = 0.003). The number of patients with ADPKD who were started on renal replacement therapy in Japan decreased from 999 in 2014 to 884 in 2020 in the nationwide database (odds ratio = 0.83, p < 0.001).

CONCLUSIONS

The Japanese public intractable disease support system contributes to improvement of ADPKD treatment.

Lidocaine as a potential therapeutic option for super-refractory status epilepticus: A case report

New-onset refractory status epilepticus (NORSE) is a rare and devastating condition and the prognosis is often poor, with half to two-thirds of survivors experiencing drug-resistant epilepsy, residual cognitive impairment, or functional disability, and the mortality rate is 16% to 27% for adults. We describe a patient with cryptogenic NORSE and favorable recovery from drug-resistant super-refractory SE after the use of intravenous lidocaine. The patient experienced fever and presented with refractory generalized tonic-clonic seizures. The cause was not found by performing extensive examinations, including cell surface autoantibodies and rat brain immunohistochemistry evaluations. The refractory SE with unresponsiveness to multiple anti-epileptic and prolonged sedative medications, which are necessary for prolonged mechanical ventilation, were ameliorated by additive treatment with intravenous lidocaine initiating at 1 mg/kg/h and maintaining at 2 mg/kg/h for 40 days, which led to freedom from intravenous sedative medication and mechanical ventilation. The patient was able to return to school. Lidocaine may be an optional treatment for cryptogenic NORSE.

Glomerular hyperfiltration and hypertrophy: an evaluation of maximum values in pathological indicators to discriminate "diseased" from "normal"

The success of sodium-glucose cotransporter 2 inhibitors and bariatric surgery in patients with chronic kidney disease has highlighted the importance of glomerular hyperfiltration and hypertrophy in the progression of kidney disease. Sustained glomerular hyperfiltration and hypertrophy can lead to glomerular injury and progressive kidney damage. This article explores the relationship between obesity and chronic kidney disease, focusing on the roles of glomerular hyperfiltration and hypertrophy as hallmarks of obesity-related kidney disease. The pathological mechanisms underlying this association include adipose tissue inflammation, dyslipidemia, insulin resistance, chronic systemic inflammation, oxidative stress, and overactivation of the sympathetic nervous system, as well as the renin-angiotensin aldosterone system. This article explains how glomerular hyperfiltration results from increased renal blood flow and intraglomerular hypertension, inducing mechanical stress on the filtration barrier and post-filtration structures. Injured glomeruli increase in size before sclerosing and collapsing. Therefore, using extreme values, such as the maximal glomerular diameter, could improve the understanding of the data distribution and allow for better kidney failure predictions. This review provides important insights into the mechanisms underlying glomerular hyperfiltration and hypertrophy and highlights the need for further research using glomerular size, including maximum glomerular profile, calculated using needle biopsy specimens.

Risk factors associated with relapse after methotrexate dose reduction in patients with rheumatoid arthritis receiving golimumab and methotrexate combination therapy

AIM

To identify risk factors for relapse after methotrexate (MTX) dose reduction in rheumatoid arthritis (RA) patients receiving golimumab (GLM)/MTX combination therapy.

METHOD

Data on RA patients ≥20 years old receiving GLM (50 mg) + MTX for ≥6 months were retrospectively collected. MTX dose reduction was defined as a reduction of ≥12 mg from the total dose within 12 weeks of the maximum dose (≥1 mg/wk average). Relapse was defined as Disease Activity Score in 28 joints using C-reactive protein level (DAS28-CRP) score ≥3.2 or sustained (≥ twice) increase of ≥0.6 from baseline.

RESULTS

A total of 304 eligible patients were included. Among the MTX-reduction group (n = 125), 16.8% of patients relapsed. Age, duration from diagnosis to the initiation of GLM, baseline MTX dose, and DAS28-CRP were comparable between relapse and no-relapse groups. The adjusted odds ratio (aOR) of relapse after MTX reduction was 4.37 (95% CI 1.16-16.38, P = 0.03) for prior use of non-steroidal anti-inflammatory drugs (NSAIDs), and the aORs for cardiovascular disease (CVD), gastrointestinal disease and liver disease were 2.36, 2.28, and 3.03, respectively. Compared to the non-reduction group, the MTX-reduction group had a higher proportion of patients with CVD (17.6% vs 7.3%, P = 0.02) and a lower proportion of prior use of biologic disease-modifying antirheumatic drugs (11.2% vs. 24.0%, P = 0.0076).

CONCLUSION

Attention should be given to RA patients with history of CVD, gastrointestinal disease, liver disease, or prior NSAIDs-use when considering MTX dose reduction to ensure benefits outweigh the risks of relapse.

Gradual Increase of Avacopan Dose with Concomitant Ursodeoxycholic Acid Use May Help Avoid the Risk of C5a Receptor Inhibitor-induced Liver Injury in Antineutrophil Cytoplasmic Antibody-associated Vasculitis

Microscopic polyangiitis (MPA) is a necrotizing vasculitis characterized by anti-neutrophil cytoplasmic antibody against myeloperoxidase. The C5 receptor inhibitor avacopan effectively sustains remission in MPA with a reduction in prednisolone dosage. Liver damage is a safety concern for this drug. However, when it occurs and how to treat it remains unknown. A 75-year-old man developed MPA and presented with hearing impairment and proteinuria. Methylprednisolone pulse therapy followed by 30 mg/day prednisolone and two doses of weekly rituximab were administered. Avacopan was initiated to taper prednisolone for sustained remission. After nine weeks, liver dysfunction and sparse skin eruptions developed. Cessation of avacopan and initiation of ursodeoxycholic acid (UDCA) improved liver function without discontinuation of prednisolone and other concomitant drugs. After three weeks, avacopan was rechallenged with a small dose which was gradual increased; UDCA was continued. Full-dose avacopan did not induce recurrence of liver injury. Therefore, gradually increasing the dose of avacopan with concomitant UDCA use may help avoid possible avacopan-induced liver injury.

Increased depressive symptoms in Parkinson’s disease during the COVID‐19 pandemic: preliminary findings from longitudinal analysis of the PHASE study

Introduction

The cumulative number of patients has increased through the four waves of the pandemic in Japan. Many people experienced mental stress due to the fear of infection, and restrictions of leaving the house and leisure activities. No longitudinal study has assessed the fluctuation of neuropsychiatric symptoms during the COVID-19 pandemic using the same scale. We examined changes in non-motor symptoms, and the scores of a Parkinson’s Disease (PD)-specific questionnaire between the early and later periods during the COVID-19 pandemic.

Methods

We conducted a questionnaire survey during the first wave (from February to April 2020) and the fourth wave of the COVID-19 pandemic (from March to April 2021). We compared the number of symptoms from the two periods.

Results

Compared with the first wave, the Geriatric Depression Scale score was significantly higher in the fourth wave of the pandemic (median score of GDS: 4.00 vs. 5.50, p = 0.022). Consistently, the scores of symptoms on MDS-UPDRS part 1 in the fourth wave were significantly higher in hygiene (p = 0.033), handwriting (p = 0.033), performing hobbies and other activities (p = 0.035), and turning in bed (p = 0.046) than in the first wave.

Conclusions

Our observation over a year between the early and later phases of the COVID-19 pandemic showed an increase in the severity of depression in patients with PD.

Radiation-Induced Changes Associated with Obliteration of Brain AVMs after Repeat Radiosurgery

BACKGROUND AND PURPOSE

Radiation-induced changes can occur after stereotactic radiosurgery for brain AVMs, potentially causing symptomatic complications. We evaluated the incidence of such changes and the efficacy of repeat gamma knife radiosurgery for incompletely obliterated AVMs.

MATERIALS AND METHODS

We retrospectively evaluated 150 patients who underwent gamma knife radiosurgery for AVMs between 2002 and 2020; twenty-five underwent further radiosurgical procedures for incompletely obliterated AVMs. We recorded the median margin doses at the first (median, 20 Gy; range, 12-23 Gy; AVM volume, 0.026-31.3 mL) and subsequent procedures (median, 18 Gy; range, 12-23 Gy; AVM volume, 0.048-9.2 mL).

RESULTS

After the first treatment, radiologic radiation-induced changes developed in 48 (32%) patients, eight of whom had symptomatic changes. After repeat gamma knife radiosurgery, 16 of 25 patients achieved complete AVM obliteration (64%). The development of radiation-induced changes after the first treatment was significantly associated with successful obliteration by subsequent radiosurgery (OR = 24.0, 95% CI 1.20-483, P  = .007). Radiation-induced changes occurred in only 5 (20%) patients who underwent a second gamma knife radiosurgery, one of whom experienced transient neurologic deficits. Between the first and repeat gamma knife radiosurgery procedures, there was no significant difference in radiologic and symptomatic radiation-induced changes (P  = .35 and P  = 1.0, respectively).

CONCLUSIONS

Radiation-induced changes after the first gamma knife radiosurgery were associated with AVM obliteration after a repeat procedure. The risk of symptomatic radiation-induced changes did not increase with retreatment. When the first procedure fails to achieve complete AVM obliteration, a favorable outcome can be achieved by a repeat gamma knife radiosurgery, even if radiation-induced changes occur after the first treatment.

Visceral fat and attribute-based medicine in chronic kidney disease

Visceral adipose tissue plays a central role in obesity and metabolic syndrome and is an independent risk factor for both cardiovascular and metabolic disorders. Increased visceral adipose tissue promotes adipokine dysregulation and insulin resistance, leading to several health issues, including systemic inflammation, oxidative stress, and activation of the renin-angiotensin-aldosterone system. Moreover, an increase in adipose tissue directly and indirectly affects the kidneys by increasing renal sodium reabsorption, causing glomerular hyperfiltration and hypertrophy, which leads to increased proteinuria and kidney fibrosis/dysfunction. Although the interest in the adverse effects of obesity on renal diseases has grown exponentially in recent years, the relationship between obesity and renal prognosis remains controversial. This may be attributed to the long clinical course of obesity, numerous obesity-related metabolic complications, and patients' attributes. Multiple individual attributes influencing the pathophysiology of fat accumulation make it difficult to understand obesity. In such cases, it may be effective to elucidate the pathophysiology by conducting research tailored to individual attributes from the perspective of attribute-based medicine/personalized medicine. We consider the appropriate use of clinical indicators necessary, according to attributes such as chronic kidney disease stage, level of visceral adipose tissue accumulation, age, and sex. Selecting treatments and clinical indicators based on individual attributes will allow for advancements in the clinical management of patients with obesity and chronic kidney disease. In the clinical setting of obesity-related nephropathy, it is first necessary to accumulate attribute-based studies resulting from the accurate evaluation of visceral fat accumulation to establish evidence for promoting personalized medicine.

High-dose steroid-responsive COVID-19-related encephalopathy with a sudden onset of dysarthria mimicking stroke: a case report

There has been limited research on encephalitis/encephalopathy, which is a less common coronavirus disease 2019 (COVID-19) neurological complication. The differentiation between stroke and encephalopathy with stroke mimickers is challenging in patients with COVID-19. Here, we describe a case of COVID-19-related encephalopathy mimicking stroke that was successfully treated with high-dose steroid pulse therapy. The patient suddenly experienced language disturbance with a left facial droop and symmetric numbness in his upper limbs. Magnetic resonance imaging (MRI) scans revealed hyperintensities in both the white matter and splenium. No pneumonia was observed. MRI abnormalities and neurological symptoms resolved after steroid pulse therapy and administration of remdesivir. High-dose steroid pulse treatment (for 3 days) might alleviate COVID-19-related encephalopathy.

Persistent intolerable abdominal pain in patients with Parkinson's disease

OBJECTIVES

In Parkinson's disease (PD), pain is common, increases motor disability, and makes daily life unpleasant. Few patients reportedly have a low prevalence of abdominal pain. The pathophysiology of such abdominal pain has not been confirmed. We clinically studied patients with PD and persistent intolerable abdominal pain to determine the pathophysiology and effective therapy.

MATERIALS AND METHODS

We obtained detailed clinical information from medical records, including the disease course before and after the onset of abdominal pain. The maximal thickness of the rectus muscle at the L4 and L5 corpus vertebral level of the abdomen on axial computed tomography was calculated, and the relative muscle thickness ratio was calculated by dividing the maximal thickness by the distance from the fascia between the bilateral rectus muscles of the abdomen and the dorsal part of the corpus vertebrae.

RESULTS

In six patients with PD (three men, age range 71-85 years), the Hoehn-Yahr stage, disease duration, and daily levodopa equivalent dose were 3.1 ± 0.7, 107 ± 44 months, and 636.7 ± 451.4 mg/day, respectively. The pain occurred daily and often during the night and was not related to the timing of food intake. The pain in two patients was related to wearing-off. One patient showed constant hypertonic activity in the rectus abdominis on surface electromyography. The rectus abdominis showed that the maximal thickness and relative muscle thickness ratio of patients with abdominal pain were significantly higher than those of patients without pain. Therapeutic usefulness of antiparkinsonian medications was short and limited.

CONCLUSIONS

Although intolerable abdominal pain is likely to be infrequent, it alleviates the quality of life of patients with PD. The pathophysiology seems to vary, and our observations found wearing-off of related pain and muscle contraction, suggesting dystonia. Among persistent abdominal pain, organic abnormalities, such as the precursor state of megacolon, may be lurking.

Machine learning for morbid glomerular hypertrophy

A practical research method integrating data-driven machine learning with conventional model-driven statistics is sought after in medicine. Although glomerular hypertrophy (or a large renal corpuscle) on renal biopsy has pathophysiological implications, it is often misdiagnosed as adaptive/compensatory hypertrophy. Using a generative machine learning method, we aimed to explore the factors associated with a maximal glomerular diameter of ≥ 242.3 μm. Using the frequency-of-usage variable ranking in generative models, we defined the machine learning scores with symbolic regression via genetic programming (SR via GP). We compared important variables selected by SR with those selected by a point-biserial correlation coefficient using multivariable logistic and linear regressions to validate discriminatory ability, goodness-of-fit, and collinearity. Body mass index, complement component C3, serum total protein, arteriolosclerosis, C-reactive protein, and the Oxford E1 score were ranked among the top 10 variables with high machine learning scores using SR via GP, while the estimated glomerular filtration rate was ranked 46 among the 60 variables. In multivariable analyses, the R² value was higher (0.61 vs. 0.45), and the corrected Akaike Information Criterion value was lower (402.7 vs. 417.2) with variables selected with SR than those selected with point-biserial r. There were two variables with variance inflation factors higher than 5 in those using point-biserial r and none in SR. Data-driven machine learning models may be useful in identifying significant and insignificant correlated factors. Our method may be generalized to other medical research due to the procedural simplicity of using top-ranked variables selected by machine learning.

Cystic Kidney Diseases That Require a Differential Diagnosis from Autosomal Dominant Polycystic Kidney Disease (ADPKD)

Autosomal dominant polycystic kidney disease (ADPKD) is the most common hereditary cystic kidney disease, with patients often having a positive family history that is characterized by a similar phenotype. However, in atypical cases, particularly those in which family history is unclear, a differential diagnosis between ADPKD and other cystic kidney diseases is important. When diagnosing ADPKD, cystic kidney diseases that can easily be excluded using clinical information include: multiple simple renal cysts, acquired cystic kidney disease (ACKD), multilocular renal cyst/multilocular cystic nephroma/polycystic nephroma, multicystic kidney/multicystic dysplastic kidney (MCDK), and unilateral renal cystic disease (URCD). However, there are other cystic kidney diseases that usually require genetic testing, or another means of supplementing clinical information to enable a differential diagnosis of ADPKD. These include autosomal recessive polycystic kidney disease (ARPKD), autosomal dominant tubulointerstitial kidney disease (ADTKD), nephronophthisis (NPH), oral-facial-digital (OFD) syndrome type 1, and neoplastic cystic kidney disease, such as tuberous sclerosis (TSC) and Von Hippel-Lindau (VHL) syndrome. To help physicians evaluate cystic kidney diseases, this article provides a review of cystic kidney diseases for which a differential diagnosis is required for ADPKD.

Larger Posterior Revascularization Associated with Reduction of Choroidal Anastomosis in Moyamoya Disease: A Quantitative Angiographic Analysis

BACKGROUND AND PURPOSE

Choroidal anastomosis, a hemorrhage-prone periventricular collateral manifestation in Moyamoya disease, outflows to the cortex posterior to the central sulcus. The objective of the present study was to test whether the angiographic extent of revascularization posterior to the central sulcus contributes to the postoperative reduction of choroidal anastomosis.

MATERIALS AND METHODS

This retrospective cohort study included choroidal anastomosis-positive hemispheres before direct bypass surgery. The postoperative reduction of choroidal anastomosis was determined by a consensus of 2 raters according to the previous research. An imaging software automatically traced the angiographic revascularization area, which was subsequently divided into anterior and posterior parts by an anatomic line corresponding to the central sulcus. Each area was quantitatively measured as a percentage relative to the whole supratentorial area.

RESULTS

Postoperative reduction of choroidal anastomosis was achieved in 68 (85.0%) of the 80 included hemispheres. The revascularization area posterior to the central sulcus was significantly larger in the hemispheres with reduction than in those with no reduction (mean, 15.2% [SD, 7.1%] versus 4.2% [SD, 3.4%], P < .001), whereas no significant difference was observed in the revascularization area anterior to the central sulcus. Multivariate analysis revealed that the revascularization area posterior to the central sulcus was the only significant factor associated with reduction (OR, 1.57; 95% CI, 1.21-2.03, for every 1% increase).

CONCLUSIONS

The results suggest that a larger revascularization posterior to the central sulcus is associated with postoperative reduction of choroidal anastomosis regardless of the extent of anterior revascularization. It might facilitate optimal selection of the revascularization site for preventing hemorrhage.

Successful immunomodulation in kidney transplant recipients with cytokine release syndrome after coronavirus disease

Introduction

Patients with coronavirus disease, especially solid organ transplant recipients, are more susceptible to developing cytokine release syndrome than those with other viral infections. However, currently, treatment methods for such patients have not been established. Here, we describe two cases of successful immunomodulation in Japanese kidney transplant recipients with cytokine release syndrome following coronavirus disease.

Case presentation

Two patients who had been receiving long‐term immunosuppressant therapy developed coronavirus disease‐associated pneumonia caused by cytokine release syndrome, following immunosuppressant dosage reduction. However, they recovered immediately after administration of tocilizumab with or without dexamethasone.

Conclusion

The immunosuppressant dosage should be reduced to restore host immunity; however, immunomodulation should be considered in cases of suspected cytokine release syndrome.

Characterization and functional analysis of BmSR-B1 for phytosterol uptake

Insects cannot synthesize sterols, such as cholesterol, and require sterols in their diet. Phytophagous insects use dietary phytosterols as a source of cholesterol. Sterols are transported from the midgut by the insect lipoprotein, lipophorin (Lp), although mechanisms for uptake of phytosterols into tissues are unclear. This study characterizes Scavenger Receptor class B type1 (SR-B1) from Bombyx mori (BmSR-B1) as molecules related to phytosterol uptake. According to sterol quantification using LC-MS/MS analysis, the midgut and fat body were phytosterol-rich relative to cholesterol-rich brain and prothoracic glands. Gene expression analysis of Bmsr-b1 in silkworm tissues showed that the genes Bmsr-b1_2, 3, 4, 6, and 10 were expressed in the midgut and fat body. To characterize the function of BmSR-B1, 11 BmSR-B1 homologs expressed in Bombyx ovary-derived BmN cells and Drosophila melanogaster embryo-derived Schneider 2 (S2) cells were incubated with purified Lp. Our analysis showed that BmSR-B1_3 induced the accumulation of campesterol and BmSR-B1_4 induced the accumulation of β-sitosterol and campesterol in culture cells. BmSR-B1 incorporated specific phytosterols into insect cells by selective uptake across the cell membrane where BmSR-B1 was localized. In conclusion, our study demonstrated that one function of BmSR-B1 is the uptake of phytosterols into silkworm tissues.

Prognostic Factor for Subacute Encephalitis with First-Episode Psychosis

<b><i>Introduction:</i></b> Although symptomatic manifestations in encephalitis vary, they typically include seizures, memory deficit(s), and altered consciousness. Psychosis also occurs as an initial manifestation. In clinical practice, clinicians often encounter the question of whether first-episode psychosis (FEP) originates from encephalitis itself or if encephalitis presenting with FEP develops concurrently. The prognosis of FEP among patients with overall encephalitis, including autoimmune encephalitis, remains uncertain. <b><i>Methods:</i></b> We examined a prognostic factor in patients with encephalitis who had both FEP and CSF pleocytosis. A total of 36 patients who presented with FEP were enrolled. A score of ≥3 and ≤2 on the modified Rankin scale were defined as poor and good outcomes, respectively. A total of 13 independent variables were analyzed by the multivariate logistic regression analysis. <b><i>Results:</i></b> Significant variables on univariate logistic regression analysis included female sex (OR 5.571, 95% CI: 1.297–23.934; <i>p</i> = 0.021) and the use of mechanical ventilation during the acute stage (OR 7.286, 95% CI: 1.508–35.211; <i>p</i> = 0.013). On multivariate logistic regression analysis, the use of mechanical ventilation during the acute stage (OR 5.446, 95% CI: 1.044–28.615; <i>p</i> = 0.044) was significantly associated with poor outcomes. <b><i>Conclusions:</i></b> The use of mechanical ventilation is a poor prognostic factor of subacute encephalitis with FEP, and female sex may be a risk factor for unfavorable development of the disease.

Slowly Progressive Male Alport Syndrome Evaluated by Serial Biopsy: Importance of Type IV Collagen Staining

A slowly progressive middle-aged man initially diagnosed with thin basement membrane nephropathy based on extensive thinning of the glomerular basement membrane (GBM) was subsequently diagnosed with Alport syndrome (AS) by a serial renal biopsy eight years later. The ultrastructural analysis of the second biopsy indicated thickening and wrinkling with mild reticulation in the GBM, consistent with AS. However, a retrospective analysis of the first biopsy revealed mild attenuation of type IV collagen α5 chain staining, suggesting a potential diagnosis of AS, despite the lack of ultrastructural features of AS. We herein report the clinical usefulness of type IV collagen staining in the early diagnosis of AS.

Neural synchronization analysis of electroencephalography coherence in patients with Parkinson's disease-related mild cognitive impairment

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We studied brain functional connectivity in 20 patients with PD-MCI and 10 MCI patients without Parkinsonism.

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Cognitive impairment was related to decreased coherence in the alpha range [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19].

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Regional coherence in left FP had a higher correlation with cognitive function.

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Differences in EEG coherence may reflect a compensatory response to PD-MCI.

Introduction

The underlying pathophysiology of slight cognitive dysfunction in Parkinson’s disease-related mild cognitive impairment (PD-MCI) is yet to be elucidated. Our study aimed to evaluate the association between cognitive function and brain functional connectivity (FC) in patients with PD-MCI.

Methods

Twenty patients with sporadic PD-MCI were evaluated for FC in the brain network. Further, electroencephalography (EEG) coherence analysis in the whole-brain and quantified regional coherence using phase coupling were performed for each frequency, and motor and cognitive function were assessed in the whole-brain.

Results

The degree of cognitive impairment was related to a decrease in the coherence in the alpha ranges. The regional coherence in the left frontal-left parietal region rather than the right frontal-right parietal region showed a higher correlation with the cognitive function scores.

Conclusion

The differences in EEG coherence across different types of cognitive dysfunction reflect a compensatory response to the heterogeneous and complex clinical presentation of PD-MCI. Our findings indicate decreased brain efficiency and impaired neural synchronization in PD-MCI; these results may be crucial in elucidating the pathological exacerbation of PD-MCI.

Effect of galvanic vestibular stimulation on axial symptoms in Parkinson’s disease

Postural imbalance, abnormal axial posture, and axial rigidity are the characteristic features of Parkinson’s disease (PD), and they are referred to as axial symptoms. The symptoms are difficult to manage since they are often resistant to both L-DOPA and deep brain stimulation. Hence, other treatments that can improve Parkinsonian axial symptoms without adverse effects are required. Vestibular dysfunction occurs in PD since neuropathological changes and reflex abnormalities are involved in the vestibular nucleus complex. Galvanic vestibular stimulation (GVS), which activates the vestibular system, is a noninvasive method. This review aimed to assess the clinical effect of GVS on axial symptoms in PD. To date, studies on the effects of GVS on postural instability, anterior bending posture, lateral bending posture, and trunk rigidity and akinesia in PD had yielded interesting data, and none of the patients presented with severe adverse events, and the others had mild reactions. GVS indicated a possible novel therapy. However, most included a small number of patients, and the sample sizes were not similar in some studies that included controls. In addition, there was only one randomized controlled clinical trial, and it did not perform an objective evaluation of axial symptoms. In this type of research, vestibular contributions to balance should be distinguished from others such as proprioceptive inputs or nonmotor symptoms of PD.

Initial decline in eGFR to predict tolvaptan response in autosomal-dominant polycystic kidney disease

BACKGROUND

Tolvaptan, a vasopressin V2 receptor antagonist, is used to treat autosomal-dominant polycystic kidney disease (ADPKD). Although tolvaptan curbs disease progression, a few reports have examined factors related to treatment response. The estimated glomerular filtration rate (eGFR) decreases soon after tolvaptan is initiated. We investigated whether initial eGFR decline affects renal prognosis of patients.

METHODS

This was a single-center, retrospective observational cohort study. Eighty-three patients with ADPKD who initiated tolvaptan were selected. We analyzed the relationship of the initial eGFR change with clinical parameters and analyzed the annual eGFR change in terms of renal prognostic value using univariable and multivariable linear regression analyses.

RESULTS

The initial eGFR change was - 4.6 ± 8.0%/month. The initial eGFR change correlated significantly with the annual eGFR change in multivariable analysis, suggesting that the larger decline in the initial eGFR change, the better the renal prognosis. Furthermore, the change in fractional excretion (FE) of free water (FEH₂O) correlated positively with initial eGFR change. FEH₂O and urea nitrogen FE (FEUN) increased significantly; however, sodium FE (FENa) level remained unchanged. In approximately half of the patients, FENa unexpectedly decreased.

CONCLUSIONS

The initial eGFR decline might be caused by suppressing glomerular hyperfiltration, due to the pharmacological effect of tolvaptan, and/or by reducing renal plasma flow, due to potential volume depletion. The initial eGFR change reflects the tolvaptan effect, can be easily evaluated in clinical practice, and may be useful as one of the clinical indicator for predicting renal prognosis in patients under tolvaptan.

Pain-Related Abnormal Neuronal Synchronization of the Nucleus Accumbens in Parkinson’s Disease

Patients with Parkinson’s disease (PD) often experience pain, which fluctuates in “on” and “off” states, but the underlying mechanism is unclear. The nucleus accumbens (NAc) is a central component of the mesolimbic dopaminergic pathway involved in pain processing. We conducted resting-state functional magnetic resonance imaging (rsfMRI) analysis to explore the relationship between the neuronal synchronization of NAc with pain-related brain regions and pain intensity in “on” and “off” states. We assessed 23 patients with sporadic PD based on rsfMRI and pain intensity using the revised Short-Form McGill Pain Questionnaire. Patients with PD displayed higher pain intensity scores in the “off” state than in the “on” state. The pain intensity in the “off” state was substantially correlated with the functional connectivity (FC) between the NAc and primary motor/sensory cortices and contralateral NAc. Changes in pain intensity from the “on” to “off” state displayed correlations with those between the right (rNA) and left NAc (lNAc) and the right precentral gyrus (rPreCG) /right insular cortex (rIC) from the “off” to “on” state. Aberrant bilateral NAc and rNAc–rPreCG/rIC FC in the “off” state were closely related to pain symptoms developed from the “on” to “off” states. These results suggest that the NAc in the mesolimbic pathway is related to pain in PD and may help understand the mechanism of pain development in patients with PD.

Zonisamide for the Efficacy of Sleep Abnormality in Parkinson's Disease (ZEAL Study): A Protocol for Randomized Controlled Trials

Background: Sleep disorders are one of the most frequent non-motor symptoms of Parkinson's disease (PD), and the efficacy of dopaminergic agents remains controversial. Clinical randomized control trials for the treatment of sleep disorders in PD are limited. Zonisamide (1,2-benzisoxazole-3-methanesulfonamide) improved motor symptoms and wearing-off in patients with PD. Patients with PD were reported to have dream-enacting behavior that was resolved after treatment with zonisamide. This study aimed to verify the safety and efficacy of zonisamide for sleep disorders and rapid eye movement (REM) sleep behavioral disorders using a mobile two-channel electroencephalography (EEG)/electrooculography (EOG) recording system.

Methods and Analysis: The present study is a randomized placebo-controlled trial to determine the efficacy of zonisamide for sleep disorders in patients with PD. This study was designed to be single-blind, but the subject allocation is randomized by an independent allocation manager via computer-generated block randomization. The subjects in the treatment group took zonisamide (25 mg per day) before bedtime for 28 days. The sleep index is analyzed using a portable EEG/EOG recording system collected on two consecutive nights within 7 days prior to the intervention and reobtained on one night within 2 days after the 28-day administration of zonisamide. The amount of change in sleep efficiency before and after the 28-day administration will be compared between the zonisamide treatment group and placebo group concerning the primary endpoint. As for the secondary endpoint, the change in the ratio of other sleep parameters, including REM sleep without atonia, or sleep architecture will be evaluated.

Ethics and Dissemination: The protocol was approved by the Nara Medical University Certified Review Board (CRB5200002). The trial was notified and registered with the Japan Registry of Clinical Trials (jRCTs051200160). Written informed consent will be obtained from every participant using informed consent approved by the CRB. The results of this trial will be disseminated through peer-reviewed scientific journals.

The plant-derived triterpenoid, cucurbitacin B, but not cucurbitacin E, inhibits the developmental transition associated with ecdysone biosynthesis in Drosophila melanogaster

In insects, some sterols are essential not only for cell membrane homeostasis, but for biosynthesis of the steroid hormone ecdysone. Dietary sterols are required for insect development because insects cannot synthesize sterols de novo. Therefore, sterol-like compounds that can compete with essential sterols are good candidates for insect growth regulators. In this study, we investigated the effects of the plant-derived triterpenoids, cucurbitacin B and E (CucB and CucE) on the development of the fruit fly, Drosophila melanogaster. To reduce the effects of supply with an excess of sterols contained in food, we reared D. melanogaster larvae on low sterol food (LSF) with or without cucurbitacins. Most larvae raised on LSF without supplementation or with CucE died at the second or third larval instar (L2 or L3) stages, whereas CucB-administered larvae mostly died without molting. The developmental arrest caused by CucB was partially rescued by ecdysone supplementation. Furthermore, we examined the effects of CucB on larval-prepupal transition by transferring larvae from LSF supplemented with cholesterol to that with CucB just after the L2/L3 molt. L3 larvae raised on LSF with CucB failed to pupariate, with a remarkable developmental delay. Ecdysone supplementation rescued the developmental delay but did not rescue the pupariation defect. Furthermore, we cultured the steroidogenic organ, the prothoracic gland (PG) of the silkworm Bombyx mori, with or without cucurbitacin. Ecdysone production in the PG was reduced by incubation with CucB, but not with CucE. These results suggest that CucB acts not only as an antagonist of the ecdysone receptor as previously reported, but also acts as an inhibitor of ecdysone biosynthesis.

Anti-programmed cell death-1 (PD-1) monoclonal antibodies involve reversible cranial dura matter

This case is the first document to describe a patient receiving anti-programmed cell death 1 (PD-1) antibodies which showed cranial dura matter involvement. According to the increasing use of anti-PD-1 monoclonal antibodies, adverse effects can occur in several organs since its ligand PD-L1 and PD-L2 are expressed in a wide variety of tissues. The estimated rate of neurological complications is 1–4.2% of patients, and neuromuscular disorders are the most common. Adverse effects on the central nervous system including encephalitis are less frequent. Here, a patient receiving anti-PD-1 antibodies showed cranial dura matter involvement, and the dura enhancement on MRI was resolved by withdrawal of the treatment with anti-PD-1 antibodies only.

Health-Related Quality of Life May Predict Disease Staging in 10 Years in Parkinson Disease With Hoehn-Yahr Stage III

Background

Ten years ago, we examined 30 patients with Hoehn-Yahr stage III Parkinson disease (PD) to determine predictors related to falling, including walking speed, step number, and step time by using the originally designed narrowed paths. We verified the increased number of steps as greater risk for an upgrade of Hoehn-Yahr stage in a 6-year period. We further prospectively studied the same patients whether the step number on a sudden narrow path persists as a predictor of the severity of PD.

Methods

The follow-up patients were divided into 2 groups-patients with and without an increase in Hoehn-Yahr stage. Variables with a significant relation to the development of Hoehn-Yahr stage on a single variable logistic regression analysis (p < 0.05) were entered into multiple logistic regression analysis, adjusting both age and disease duration.

Results

The significant variables between patients with and without an increase in Hoehn-Yahr stage were 36-item Short-Form Health Survey (SF-36) scores at 2, 4, 6, and 8 years. Multiple logistic regression analyses after adjusting both age and disease duration showed the SF-36 score at 2, 4, 6, and 8 years. The domain in social functioning significantly differed between patients with and without deterioration of Hoehn-Yahr stage in 10 years.

Conclusions

This study demonstrated the capacity of low health-related quality of life (HR-QOL) to predict future developments of PD staging in 10 years. The lower HR-QOL, particularly in social functioning, may reflect the severity of both motor and nonmotor symptoms.

Circadian activity rhythm in Parkinson's disease: findings from the PHASE study

OBJECTIVE

Circadian disruptions in Parkinson's disease (PD) are characterized as amplitude reduction rather than as phase shift; however, large-scale studies evaluating circadian rhythms between PD patients and non-PD older adults have not been performed. The present study aimed to compare the circadian activity rhythm (CAR) between PD patients and non-PD older adults.

METHODS

In this cross-sectional study on 157 PD outpatients and 1111 community-dwelling older adults (controls), physical activity was measured using actigraphy at 1-min intervals over 6 days in PD patients and 2 days in non-PD older adults. Data were base-10 log-transformed and regretted to the sigmoidally transformed cosine curve.

RESULTS

The mean amplitude (log counts/min) and acrophase were 1.85 (SD, 0.52) and 14:19 (SD, 1:15), respectively, in the controls (n = 1111); 1.42 (0.48) and 14:24 (1:20), respectively, in the early-stage (Hoehn-Yahr I and II) PD patients (n = 95); and 1.23 (0.54) and 13:41 (1:56), respectively, in the late-stage (Hoehn-Yahr III-V) PD patients (n = 62). Multivariable analysis revealed significantly lower amplitude in the early-stage and late-stage PD groups than in the controls. The acrophase significantly advanced in the late-stage PD group than in the controls. With the advancement of PD stage, amplitude and peak significantly decreased; trough increased; acrophase and active offset advanced; and robustness weakened.

CONCLUSIONS

Compared with non-PD older adults, PD patients exhibited a phase advance in CAR, along with amplitude reduction. With an advanced stage of PD, a phase advance in CAR also occurred, along with amplitude reduction and weakened robustness.

Gene Expression Profiles of Human Cerebral Organoids Identify PPAR Pathway and PKM2 as Key Markers for Oxygen-Glucose Deprivation and Reoxygenation

Ischemic stroke is one of the most common neurological diseases. However, the impact of ischemic stroke on human cerebral tissue remains largely unknown due to a lack of ischemic human brain samples. In this study, we applied cerebral organoids derived from human induced pluripotent stem cells to evaluate the effect of oxygen-glucose deprivation/reoxygenation (OGD/R). Pathway analysis showed the relationships between vitamin digestion and absorption, fat digestion and absorption, peroxisome proliferator-activated receptor (PPAR) signaling pathway, and complement and coagulation cascades. Combinational verification with transcriptome and gene expression analysis of different cell types revealed fatty acids-related PPAR signaling pathway and pyruvate kinase isoform M2 (PKM2) as key markers of neuronal cells in response to OGD/R. These findings suggest that, although there remain some limitations to be improved, our ischemic stroke model using human cerebral organoids would be a potentially useful tool when combined with other conventional two-dimensional (2D) mono-culture systems.

Association between Fatigue and Hoehn-Yahr Staging in Parkinson's Disease: Eight-Year Follow-Up Study

The severity of Parkinson's disease (PD) is developed by multifactorial factors. Falls can worsen disease severity. We previously found that frontal assessment battery (FAB) score was associated with a higher risk of future falls. This eight-year follow-up study aimed to verify whether factors including low FAB score can be the risk of PD progression based on the Hoehn and Yahr scale. In total, 95 patients were initially enrolled in this research and 45 were included in the final follow-up. Then, the cohort was classified into patients with and without disease progression, defined by upgrade of Hoehn-Yahr stage. Differences in clinical characteristics between patients with disease progression and those without were evaluated using the Mann-Whitney U test. Eighteen independent variables were evaluated via a univariate logistic regression analysis. Of the 45 patients enrolled, 32 had disease progression and 13 had no progression. Age (p = 0.033), BFI score (p = 0.003), Zung self-rating depression (p = 0.011), and anxiety scale (p = 0.026) were significantly increased in patients who had disease progression than those with no disease progression. On multivariate logistic regression analysis, brief fatigue inventory (BFI) score (OR = 1.048, p = 0.045, 95% CI = 1.001-1.098) was significantly related to disease progression. All BFI subscores related to general fatigue. Fatigue could predict the progression of motor dysfunction severity over a longitudinal duration in patients with PD with disease progression, having declining physical and mental fatigue.

Dose-Dependent Effect of Tolvaptan on Renal Prognosis in Patients with Autosomal Dominant Polycystic Kidney Disease

This is the first report to describe dose dependency in the effects of tolvaptan treatment for autosomal dominant polycystic kidney disease.The weight-adjusted average daily dose of tolvaptan was found to be a factor that significantly affected the change in eGFR.If a patient shows tolerance, increasing the tolvaptan dose to the maximum should be considered.

Autopsy of a case of rheumatoid arthritis with severe bicytopoenia due to gelatinous transformation of the bone marrow

We present the case of an elderly female patient with rheumatoid arthritis (RA) treated with methotrexate. She was referred to our hospital with severe malaise. She was emaciated and had massive pleural effusion that induced atelectasis. Her blood tests revealed elevated CRP, leukopenia, and severe anaemia. She lost consciousness on the third day of hospital stay and passed away the following day. Her autopsy showed gelatinous transformation of the bone marrow that gave rise to bicytopoenia, whereas there were no other causes for severe anaemia. Bone marrow gelatinous transformation can cause impaired haematopoiesis in elderly RA patients.

Factors predicting decline in renal function and kidney volume growth in autosomal dominant polycystic kidney disease: a prospective cohort study (Japanese Polycystic Kidney Disease registry: J-PKD)

BACKGROUND

Factors affecting decline in renal function and cyst growth in patients with autosomal polycystic kidney disease (ADPKD) are not fully described, particularly in Japan.

METHODS

This was the first multi-facility, prospective, observational cohort study conducted in ADPKD patients at 14 centers in Japan. Patients in the J-PKD registry were assessed from December 2009 to June 2012 (follow-up until June 2017). Patients' data including estimated glomerular filtration rate (eGFR) and total kidney volume (TKV) were assessed initially and a maximum of five times annually. Contributing factors to eGFR decline and TKV growth were identified using multiple linear regression analysis.

RESULTS

Of the 340 patients in the J-PKD registry, data analysis was performed for 192 patients in whom serial changes for both eGFR and TKV were obtained. eGFR slope, eGFR change, and TKV change values were as follows: - 2.7 (- 4.2 to - 1.5) (ml/min/1.73 m²/year), - 5.0 (- 9.6 to - 2.3) (%/year), and 4.78 (0.86-8.22) (%/year), respectively. Lower high-density lipoprotein (HDL) cholesterol was an independent predictor of eGFR decline, using both eGFR slope and change (P = 0.04, P = 0.02, respectively), whereas lower hemoglobin and higher uric acid were significantly associated with greater eGFR change only (P = 0.02, P = 0.002, respectively). Younger age and higher fasting blood sugar were independent predictors of greater TKV change (P = 0.01, P = 0.02, respectively).

CONCLUSIONS

This real-world study in Japan identified risk factors for renal function decline in ADPKD patients. These included lower HDL cholesterol, lower hemoglobin and higher uric acid for eGFR decline, and youth and higher blood sugar levels for TKV growth.

Predicting liver cyst severity by mutations in patients with autosomal-dominant polycystic kidney disease

BACKGROUND

Most patients with autosomal-dominant polycystic kidney disease (ADPKD) develop liver cysts and polycystic liver disease as they age. To date, no simple clinical indicator has been confirmed to predict polycystic liver disease exacerbation. Furthermore, the effect of the type and location of mutation on disease progression of polycystic liver disease remains unclear. Here, we aimed to establish a simple liver cyst indicator for clinical practice and investigate whether gene mutations determined liver phenotype in patients with autosomal-dominant polycystic kidney disease.

METHODS

In total, 129 patients with ADPKD were enrolled and liver cyst indicators were assessed based on mutation type (truncating mutation: nonsense, frameshift, and splicing mutation; non-truncating mutation: substitution) and mutation position. Liver cyst severity was determined using Gigot and Drenth classifications, based on their number, maximum diameter, and area ratio with the liver.

RESULTS

We observed an overall prevalence of 62.8% for polycystic liver disease. Patients with PKD1 nonsense mutations, a type of PKD1 truncating mutation, exhibited more severe liver disease phenotypes than those without the mutation. We identified maximum diameter as a potential liver cyst indicator. Moreover, a subgroup analysis that included a PKD1 nonsense mutation cohort revealed that genetic mutations located closer to the 5' end of PKD1 were associated with a maximum diameter index value ≥ 6 cm.

CONCLUSION

PKD1 nonsense mutations were associated with liver cyst severity, which along with maximum diameter index as a simple clinical indicator for liver cysts, may improve the treatment of polycystic liver disease associated with ADPKD.

Lupus Nephritis and Hydroxychloroquine-Associated Zebra Bodies: Not Just in Fabry Disease

Zebra bodies in kidney biopsy specimens are widely accepted as a specific feature of Fabry disease but they can also be present in a drug-induced mimic of Fabry disease, phospholipidosis. Chloroquine and hydroxychloroquine may both induce zebra body formation and kidney phospholipidosis. However, the frequency and clinical significance of such changes remain unknown. We report 5 serial kidney biopsy cases diagnosed as lupus nephritis during hydroxychloroquine administration. All 5 patients exhibited a few, but varying amounts, of zebra bodies in glomerular intrinsic cells, that is, podocytes, parietal epithelial cells, mesangial cells, and endothelial cells. Most of the zebra bodies detected were subtle, though certainly recognizable; these zebra bodies were much smaller than those observed in Fabry disease. Zebra bodies were not observed in patients with lupus nephritis in the absence of chloroquine or hydroxychloroquine administration. All patients with lupus nephritis who received hydroxychloroquine achieved complete remission during continuous use of hydroxychloroquine, though kidney toxicity of drug-induced phospholipidosis might be masked by immunosuppression. Based on this small series of cases, we speculate that the hydroxychloroquine-associated manifestation of zebra bodies and phospholipidosis in the kidney may be frequent phenomena and may have only a subclinical influence on kidney function, at least in the short term.

Impact of visceral fat area in patients with chronic kidney disease

Longitudinal studies evaluating the association between visceral fat area (VFA) and kidney function decline in patients with chronic kidney disease (CKD) are limited, and little is known about VFA interactions contributing to the kidney prognosis (e.g. interactions between VFA ≥ 100 cm² and age, sex, and CKD category). In this study, we stratified patients with CKD according to VFA category, as well as age, sex, CKD category, hyperglycemia, and diabetes mellitus, and determined the ability of obesity-related indicators (body mass index, waist circumference, subcutaneous fat area, visceral-to-subcutaneous fat ratio) to predict the renal prognosis. Kidney outcomes (≥ 50% estimated glomerular filtration rate decline or end-stage kidney disease) were examined in 200 patients with CKD (median follow-up, 12.3 years). On multivariable Cox analysis, an increase in VFA (10-cm² increase) was significantly associated with kidney outcomes in the entire cohort, and VFA was significantly associated with kidney disease progression even in the VFA < 100 cm² sub-cohort. Interestingly, the hazard ratio (HR) was higher for VFA (10-cm² increase) than for the VFA ≥ 100 cm² sub-cohort (HR 1.33 vs. 1.07). Overall, VFA was found to be the most versatile obesity-related indicator associated with kidney disease progression. VFA was associated with the primary outcome in the sub-cohorts of CKD stages 1-2, hyperglycemia, and diabetes mellitus. A high VFA was a significant kidney prognostic factor in the entire CKD cohort, with greater significance in patients with VFA < 100 cm² than in patients with VFA ≥ 100 cm². Our results may provide new insights into strategies for treating CKD.

Immediate Amelioration of Severe Respiratory Distress in Sjögren's Syndrome with COVID-19 Treated with a Single Dose of Off-label Tocilizumab

The coronavirus disease 2019 (COVID-19) pandemic has become an urgent global health issue. An older age and underlying conditions, such as diabetes, have been reported as risk factors, but whether or not autoimmune diseases increase the risk remains unknown. An 85-year-old man with Sjögren's syndrome developed a severe COVID-19 infection that required oxygen supplementation. After discussing the goals of care with him and his wife, off-label tocilizumab was given concomitantly, resulting in a rapid improvement in his symptoms and respiratory failure. This patient represents a supplementary case confirming the efficacy and safety of tocilizumab for COVID-19 in elderly patients with autoimmune diseases.