Current treatment status of IgA nephropathy in Japan: a questionnaire survey

BACKGROUND

In 2020, the Committee of Clinical Practical Guideline for IgA Nephropathy (IgAN) revised the clinical practice guidelines. Herein, we conducted a questionnaire survey to assess the potential discrepancies between clinical practice guidelines and real-world practice in Japan.

METHODS

A web-based survey of members of the Japanese Society of Nephrology was conducted between November 15 and December 28, 2021.

RESULTS

A total of 217 members (internal physicians: 203, pediatricians: 14) responded to the questionnaire. Of these respondents, 94.0% answered that the clinical practice guidelines were referred to "always" or "often." Approximately 66.4% respondents answered that histological grade (H-Grade) derived from the "Clinical Guidelines for IgA nephropathy in Japan, 3rd version" and the "Oxford classification" were used for pathological classification. Moreover, 73.7% respondents answered that the risk grade (R-grade) derived from the "Clinical Guidelines for IgA nephropathy in Japan, 3rd version" was referred to for risk stratification. The prescription rate of renin-angiotensin system blockers increased based on urinary protein levels (> 1.0 g/day: 88.6%, 0.5-1.0 g/day: 71.0%, < 0.5 g/day: 25.0%). Similarly, the prescription rate of corticosteroids increased according to proteinuria levels (> 1.0 g/day: 77.8%, 0.5-1.0 g/day: 52.8%, < 0.5 g/day: 11.9%). The respondents emphasized on hematuria when using corticosteroids. In cases of hematuria, the indication rate for corticosteroids was higher than in those without hematuria, even if the urinary protein level was 1 g/gCr or less. Few severe infectious diseases or serious deterioration in glycemic control were reported during corticosteroid use.

CONCLUSION

Our questionnaire survey revealed real-world aspects of IgAN treatment in Japan.

Factors affecting the total occlusion time in eyes with hyperopic anisometropic amblyopia

BACKGROUND

Amblyopia treatment by occluding the healthy eye is known to be effective during a sensitive critical period. This study aims to clarify the factors for the total occlusion time (TOT) required for the amblyopic eye to achieve a normal visual acuity (VA) level of 1.0 (0.0 logMAR equivalent). This could contribute to an efficient treatment plan for eyes with hyperopic anisometropic amblyopia.

METHODS

Subjects were 58 patients (26 boys and 32 girls; age range, 3.6-9.2, average, 5.8 ± 1.3 years) with hyperopic anisometropic amblyopia. All the subjects had initially visited and completed occlusion therapy with improved VA of 1.0 or better in the amblyopic eye at Kindai University Hospital between January 2007 and March 2017. Using the subjects' medical records, we retrospectively investigated five factors for the TOT: the age at treatment, the initial VA of the amblyopic eye, refraction of the amblyopic eye, anisometropic disparity, and the presence of microstrabismus. Patient's VA improvement at one month after treatment was also evaluated to confirm the effect of the occlusion therapy.

RESULTS

The initial VA of the amblyopic eye ranged from 0.1 to 0.9 (median, 0.4). The TOT ranged from 140 to 1795 (median, 598) hours with an average daily occlusion time of 7 hours. The initial VA of the amblyopic eye and presence of microstrabismus were the significant factors for the TOT (p < 0.01). To achieve VA of 1.0 or better, patients with an initial VA of ≤ 0.3 in the amblyopic eye required a longer TOT. Moreover, patients with concomitant microstrabismus required a 1.7-fold longer TOT compared to those without microstrabismus.

CONCLUSION

Longer daily occlusion hours and early start of the treatment will be necessary for patients with poor initial VA or microstrabismus to complete occlusion therapy within the sensitive critical period.

Measurement of Fixational Eye Movements With the Head-Mounted Perimeter Imo

Purpose

Although visual field testing is conducted with the subject gazing at a fixation target, constant minute eye movements, called fixational eye movements, do occur during fixation. We examined dynamic changes in fixational eye movements associated with stimulus presentation during visual field testing.

Methods

We used the head-mounted perimeter imo, which is capable of measurement under binocular conditions, with the frame rate of its fixation monitoring camera improved to 300 Hz, to assess fixational eye movements in 18 healthy individuals. We measured changes in fixational eye movements during testing under monocular and binocular conditions and analyzed these changes based on the bivariate contour ellipse area (BCEA). We also assessed the changes in the horizontal and vertical microsaccade rates separately.

Results

Both the BCEA and horizontal microsaccade rates were higher at 400 to 600 msec after stimulus presentation than during stimulus presentation (P < 0.01). Additionally, the BCEA and vertical microsaccade rates were significantly lower in the binocular condition than in the monocular condition (P < 0.01 and P < 0.05, respectively). We did not observe a significant correlation between the test locations and microsaccade direction during visual field testing.

Conclusions

Fixational eye movements, especially vertical microsaccade rates, were lower in the binocular condition than in the monocular condition. Visual field testing under binocular conditions is a useful method for suppressing fixational eye movements and stabilizing the fixation during testing and may improve the reliability of the test results.

Translational Relevance

Visual field testing under binocular conditions can make the fixation more stable during the testing compared with monocular conditions.

Cumulative incidence of femoral localized periosteal thickening (beaking) preceding atypical femoral fractures in patients with rheumatoid arthritis

The incidence of localized periosteal thickening (LPT, also termed beaking) of the lateral cortex that often precedes an atypical femoral fracture (AFF) was not high in patients with rheumatoid arthritis (RA) but incomplete AFFs developed in two patients. Higher-dose prednisolone was a significant risk factor for LPT in patients with RA.

INTRODUCTION

Atypical femoral fractures (AFFs) are stress fractures; bisphosphonate (BP) use is a major risk factor for the development of such fractures. Localized periosteal thickening (LPT, also termed beaking) of the lateral cortex often precedes a complete or incomplete AFF. We evaluated the incidence of latent LPT in patients with rheumatoid arthritis (RA), to evaluate LPT progression, and to define LPT risk factors.

METHODS

A total of 254 patients with RA were included; all underwent annual X-ray evaluation, dual-energy X-ray absorptiometry, and analyses of serum and bone metabolic markers for 2-3 years. LPT of the lateral cortex was sought in femoral X-rays.

RESULTS

The incidence of LPT was 2.4% (6/254). Among patients on both BP and prednisolone (PSL) at enrollment, the incidence was 2.3% (3/131). Two femurs of two patients with LPT developed incomplete AFFs; LPT was extensive and associated with endosteal thickening. One patient had been on BP and PSL and microscopic polyangiitis was comorbidity. The other was on a selective estrogen receptor modulator and PSL. A daily PSL dose >5 mg (OR 11.4; 95%CI 2.15-60.2; p = 0.004) and higher-dose methotrexate (OR 1.22; 95%CI 1.01-1.49; p = 0.043) were significant risk factors for LPT.

CONCLUSIONS

The incidence of latent LPT was not high (2.4%) but incomplete AFFs developed in two RA patients. Higher-dose PSL because of a comorbid disease requiring glucocorticoid treatment other than RA or refractory RA were risk factors for LPT; X-ray screening for latent LPT would usefully prevent complete AFFs.

THU0155 SERUM MYOSTATIN IN PATIENTS WITH RHEUMATOID ARTHRITIS AND ITS CORRELATION WITH BODY COMPOSITIONS

Background:

Altered body composition is one of common findings in rheumatoid arthritis (RA), and it is estimated that up to two-thirds of patients may be affected loss of muscle mass and strength and concomitant increase in fat mass, so-called “rheumatoid cachexia”. Despite great advances in the treatment of RA such as biologics and small molecule compounds, it appears that rheumatoid cachexia persists even after joint inflammation improves. Myostatin, a member of the transforming growth factor-beta superfamily, is a potent negative regulator of skeletal muscle growth and its inactivation can induce skeletal muscle hypertrophy, while its overexpression or systemic administration causes muscle atrophy. It enhances proteolysis and inhibits protein synthesis in skeletal muscle, and has generated increasing interest as a potential regulator of cachexic status such as patients with cancers, cardiac failure, and HIV infections.

Objectives:

In this study, we investigated the possible role of myostatin for altered body compositions in patients with RA.

Methods:

This was a cross-sectional study. Ninety-six RA patients who visited Niigata University Hospital between April to June 2017, were recruited in this study. Body composition was measured by bioelectrical impedance analysis with a tetrapolar impedance meter (InBody S-10, InBody Japan Inc, Tokyo, Japan) in each subject. The right femoral neck bone density was measured using the dual energy X-ray absorption method (DEXA). Serum myostatin level was measured by enzyme-linked immunosorbent assay with a commercially available kit (Quantikine ELISA GDF-8/ Myostatin Immunoassay, R&D systems, MN, USA). Patients’ laboratory findings and disease activities were also measured, and the correlations between the titer of serum myostatin and these factors were analyzed by Spearman’s correlation coefficient and stepwise multiple regression analysis. A p-value of <0.05 was taken to denote statistical significance.

Results:

In Spearman’s correlation coefficient analysis, serum myostatin level was positively correlated with skeletal muscle mass index and FFMI, and negatively correlated with percent body fat (%BF), fat mass index (FMI), right femoral neck bone density, swollen joint counts, ESR, and DAS28(4)-ESR. In stepwise multiple regression analysis, FFMI was selected as a positive independent variable (rho=0.3620, p=0.00019) and DAS28(4)-ESR as a negative independent variable (rho=-0.2298, p=0.0154) against serum myostatin levels, respectively. In 70 female patients in this study, %BF and FMI/FFMI ratio was significantly higher in patients with low FFMI group, compared to those with normal FFMI group.

Conclusion:

Serum myostatin level was significantly correlated with body composition and disease activity in patients with RA. Patients with lower level of myostatin showed a trend of decreased skeletal muscle and increased body fat, suggesting serum myostatin as a possible biomarker for rheumatoid cachexia.

References:

[1]Elkan A-C, et al. Arthritis Res Therapy 2009; 11: R37.

[2]Lemmey AB, et al. Rheumatology 2016; 55: 1736-45.

[3]Rodriguez J, et al. Cell Mol Life Sci 2014; 71: 4361-71.

Disclosure of Interests:

None declared

FRI0440 RISK FACTORS FOR CYTOMEGALOVIRUS INFECTION IN PATIENTS WITH AUTOIMMUNE DISEASES

Background:

The risk for opportunistic infections in patients with autoimmune diseases requiring intensive immunosuppressive therapy is high and cytomegalovirus (CMV) infection is one of the most common opportunistic infections. Since 2011, we have performed weekly CMV pp65 antigen testing for patients at risk of opportunistic infections owing to autoimmune diseases to ensure appropriate patient management.

Objectives:

To evaluate the risk factors that predict CMV infection in patients that received remission-induction therapy for autoimmune diseases.

Methods:

We enrolled 254 patients (93 male, 161 female) from our hospital with autoimmune disease and who received remission-induction therapy with prednisolone at a dose greater than 0.5 mg/kg/day between January 2011 and December 2018. We retrospectively analysed their clinical characteristics and laboratory data, including treatment regimens and CMV pp65 antigen test results. The presence of more than five CMV pp65 antigen-positive cells over two slides was considered a positive result. We conducted univariate and multivariate analyses to extract CMV risk factors.

Results:

Of the patients we evaluated, 60 suffered from systemic lupus erythematosus (SLE), 55 from anti-nucleolar cytoplasmic antibody-associated vasculitis (AAV), 31 from dermatomyositis (DM), 14 from interstitial pneumonia with anti-aminoacyl tRNA synthetase antibody, 14 from adult-onset Still’s disease (AOSD), 14 from rheumatoid arthritis (RA), 11 from mixed connective tissue disease (MCTD), 10 from Takayasu’s aortitis, and 45 suffered from other autoimmune diseases. Pulse therapy with methylprednisolone (mPSL) and immunosuppressive reagents were administered to 103 (40.6 %) and 97 (38.2 %), respectively. The median follow-up period was 61.0 days, and 66 patients became CMV pp65 antigen-positive during this period (SLE, 15; DM, 14; AAV, 9; AOSD, 8; and other, 20). Univariate analysis revealed that when compared to patients testing negative for the CMV pp65 antigen patients testing positive had lower total lymphocyte count (TLC) (825 /uL vs. 1220 /uL; p < 0.01), a lower serum albumin level (2.70 g/dL vs. 3.30 g/dL; p < 0.01), a higher HbA1c level (6.3 % vs. 5.9 %; p<0.01), and were older (66.0 vs. 59.5 year old; p < 0.01). Forty-nine of the 66 patients in the positive group received mPSL pulse therapy (p < 0.01), and 38 received immunosuppressive reagents (p < 0.01). Logistic regression analyses indicated that a higher age by decade (OR; 1.46 [95%CI 1.06 - 2.00]), a lower TLC per 100/uL (OR; 0.83 [95%CI 0.73 -0.94]), a higher HbA1c level per 1% (OR; 2.37 [95%CI 1.25-4.53]), and mPSL pulse therapy (OR; 3.92 [95%CI 1.33-11.5]) were risk factors for CMV pp65 antigen positivity.

Conclusion:

Higher age, lower TLC, higher HbA1c, and treatment with mPSL pulse therapy were risk factors for acquiring CMV infection, as measured by the presence of the CMV pp65 antigen, in patients receiving remission-induction therapy for autoimmune diseases. Careful monitoring of these, at risk, patients is necessary.

Disclosure of Interests:

None declared

AB0539 URINARY INFLAMMATORY CELL ANALYSIS REFLECTS THE RENAL HISTOPATHOLOGY IN ANTI-NEUTROPHIL CYTOPLASMIC ANTIBODY-ASSOCIATED VASCULITIS

Background:

The anti-neutrophil cytoplasmic autoantibody (ANCA)- associated vasculitides (AAVs) include microscopic polyangiitis (MPA), granulomatosis with polyangitis (GPA), and eosinophilic granulomatosis with polyangitis (EGPA). These small-vessel vasculitides are characterized by necrotizing inflammation of the vessel wall, particularly affecting small arteries, arterioles, and capillaries in systemic organs, and the kidney is one of the most frequently involved organs. Although kidney biopsy is necessary for deciding the therapeutic protocol, it is invasive and is sometimes hard to perform biopsy because of patient’s severe general condition. We have already reported that T cells and macrophages appear in the urine of patients with glomerulonephritis, accompanied by active cellular infiltration such as cellular crescent formation and diffuse interstitial cell infiltration, but not in the urine of patients with glomerulonephritis without the active inflammatory lesions.

Objectives:

In this study, we examined the utility of urinary inflammatory cell analysis for accessing kidney histopathological findings in AAVs.

Methods:

This was a cross-sectional, retrospective chart study. Thirty-six AAV patients who had been referred to Niigata University Hospital between 2002 and 2018, and performed percutaneous kidney biopsy and urinary inflammatory cell analysis, were participated in this study. Thirty-two patients had MPA, and 4 had GPA. The kidney biopsy findings were classified into Berden’s classification (a method to categorize glomerular lesions into four classes) and Neumann’s classification (a method to evaluate glomerular, tubulo-interstitial, and vascular lesions by using activity indexes and chronicity indexes). Flow-cytometric analysis of urinary inflammatory cells was performed for each subject. Numbers of urinary T cells or macrophages were determined by multiplying the number of viable cells in the gated mononuclear cell region in each sample by the percentage of urinary CD3-positive or CD14-positive cells in the population, respectively. The correlations between the results of both methods and the numbers of urinary inflammatory cells were examined using Kruskal-Wallis test and Spearmann’s rank correlation coefficient. A p-value of <0.05 was taken to denote statistical significance.

Results:

The numbers of urinary inflammatory cells showed a trend of increase in crescentic category without statistical significance in Berden’s classification. Meanwhile, activity indexes had significant positive correlations with the number of urinary CD3-positive cells (r = 0.541, p = <0.001), CD14-positive cells (r = 0.354, p = 0.034), and total inflammatory cells (r = 0.449, p = 0.006) in Neumann’s classification.

Conclusion:

The numbers of urinary inflammatory cells reflect the active lesions of kidney histopathological findings, and these results indicate the usefulness of urinary inflammatory cell analysis for assessment of kidney biopsy findings in patients with AAVs.

References:

[1]Berden AE, et al. J Am Soc Nephrol. 2010 Oct;21(10):1628-36. 2) Neumann I, et al. Nephrol Dial Transplant. 2005 Jan;20(1):96-104.

Disclosure of Interests:

None declared

AB0297 THE LONG-TERM OBSERVATION OF PATIENTS WITH RHEUMATOID ARTHRITIS WHO ACHIEVED A BIO-FREE CONDITION WITH ADALIMUMAB

Background:

Biological disease-modifying antirheumatic drugs (bDMARDs) caused a paradigm shift in the treatment of rheumatoid arthritis (RA). However, their high cost is a burden for patients and the national medical economy.

Objectives:

To analyze the long-term outcomes of patients with RA who achieved a bio-free condition (BF) with adalimumab (ADA).

Methods:

We followed 25 patients (male 6, female 19) who discontinued ADA with clinical remission (CR), and one female with a low disease activity (LDA), over 19.4 ±7.8 months of ADA treatment1). At the introduction of ADA, the average age was 51.2 ± 11.9 years old, and the average disease duration was 45.1 ± 48.4 months. The disease activity measured by disease activity score based on C-reactive protein (DAS28-CRP) was defined as follows: CR, <2.3; LDA, 2.3 - 2.7; moderate DA, 2.7 -4.1; and high DA, > 4.1, since the DAS28-CRP tends to be lower than the DAS28-based on the erythrocyte sedimentation rate in Japanese patients2).

Results:

We lost one patient with a transfer to another hospital. Four patients re-started ADA due to flare (DAS28-CRP>2.7) but achieved CR (in BF) again with the intensification of the treatment (dose increase or initiation of prednisolone [PSL] and/or conventional synthetic [cs] DMARDs such as tacrolimus or iguratimode). The DAS28-CRP significantly decreased from 3.45 ± 1.32 at base line (BL) to 1.55 ± 0.41 (p<0.0001) at BF. It remained 1.59 ± 0.59 (n=25) at 24 months after BF, 1.56 ± 0.39 (n= 20) at 48 months, 1.8 ± 0.7 (n=11) at 60 months. At the last observation, every patient remained in CR up to 84 months (n=2, Figure 1). The modified health assessment questionnaire score significantly decreased from 0.42 ± 0.46 (BL, n=19) to 0.02 ± 0.05 (p<0.002) at BF. It remained 0.03 ± 0.07 (n=19) at 24 months and 0.06 ± 0.14 (n=14) at 48 months, 0.04 ± 0.08 at 60 months (n=9). The PSL dose (mg/day) decreased from 3.2 ± 3.3 (BL) to 2.2 ± 2.8 at BF and 2.04 ± 2.13 (n=25) at 24 months, 1.73 ± 1.9 (n=20) at 48 months, and 1.6 ± 2.3 (n=11) at 60 months, but there were no significant changes. The methotrexate (MTX) dose (mg/week) increased from 10.1 ± 2.9 (BL) to 10.6 ± 2.6 (p< 0.78) at BF, 10.4 ± 3.3 (n=25) at 24 months, 10.7 ± 3.4 (n=20) at 48 months, 10.4 ± 3.1 at 60 months (not significant). The number of csDMARDs significantly increased from 0.8 ± 0.6 (BL) to 1.3 ± 0.9 (p<0.001, at BF), 2.56 ± 0.94 (n=25) at 24 months, 1.6 ± 1.01 (n=20) at 48 mnths, and 1.6 ± 2.3 at 60 months (n=11, Figure 2).

Conclusion:

BF can be sustained with an adequate dose of MTX and combination of csDMARDs.

References:

[1]Ito S, et al. An analysis of the biological disease-modifying antirheumatic drug-free condition of adalimumab-treated rheumatoid arthritis patients. Intern Med 58: 511-519, 2019

[2]Inoue E, et al. Comparison of Disease Activity Score (DAS)28-erythrocyte sedimentation rate and DAS28- C-reactive protein threshold values. Ann Rheum Dis. 66:407-409, 2007.

Disclosure of Interests:

Satoshi Ito Speakers bureau: Abbvie,Eisai, Shunsuke sakai: None declared, Yoichi Kurosawa: None declared, Daisuke Kobayashi: None declared, Ryo Okabayashi: None declared, Asami Abe: None declared, Hiroshi Otani: None declared, Kiyoshi Nakazono: None declared, Akira Murasawa: None declared, Ichiei Narita: None declared, Hajime Ishikawa: None declared

SAT0147 EFFICACY AND SAFETY OF IGURATIMOD AS FIRST-LINE DISEASE-MODIFYING ANTIRHEUMATIC DRUG THERAPY FOR PATIENTS WITH RHEUMATOID ARTHRITIS

Background:

Although methotrexate is the anchor drug, it took some days to check contraindications, such as interstitial pneumonia, hepatitis B virus infection, and latent tuberculosis infection. Therefore, we sometimes start rheumatoid arthritis (RA) treatment with other disease-modifying antirheumatic drug (DMARD) in daily clinical setting. Iguratimod (IGU) is a newly developed DMARD approved in Japan in September 2012, and the efficacy of IGU for DMARD naïve patients has not been thoroughly evaluated.

Objectives:

The aim of this prospective single-center study was to demonstrate the efficacy and safety of IGU when used as a first-line daily DMARD for patients with RA in a clinical setting.

Methods:

Enrolled patients included those diagnosed with RA according to the 2010 American College of Rheumatology/European League against Rheumatism (ACR/EULAR) classification criteria who took IGU as a first-line DMARD at Niigata Rheumatic Center between April 2016 and December 2018 (IGU group). There were no constraints regarding the addition or withdrawal of other DMARDs. Details of the patients’ background, clinical parameters, and laboratory findings were obtained, including C-reactive protein (CRP) level, erythrocyte sedimentation rate (ESR), matrix metalloprotease-3 (MMP-3), rheumatoid factor (RF), Disease Activity Score for 28-joint counts based on the erythrocyte sedimentation rate (DAS28-4[ESR]), Clinical Disease Activity Index (CDAI), and Health Assessment Questionnaire Disability Index (HAQ-DI). The efficacy of IGU was evaluated at week 24. The IGU group’s data were then compared with 64 patients who took salazosulfapyridine or bucillamine as first-line DMARD in our hospital (other DMARD group). The data were expressed as median values. Comparisons between the parameters were performed using nonparametric method.

Results:

Forty-three patients (15 males, 28 females) received IGU as a first-line DMARD for RA. The age was 69.0 years and the duration of disease was 2.0 months. Twenty patients received prednisolone (PSL) concomitantly at a median dose of 5.0 mg/day. At 24 weeks medications were utilized in patients as follows: IGU in 36 (83.7 %), methotrexate in 18 (41.2%), PSL in 17 (39.5%), BUC in 10 (23.2 %), and biological DMARD in 7 (15.2 %) patients. Although 7 patients discontinued taking IGU due to liver enzyme elevation (n=4), nausea (n=1), creatinine elevation (n=1), and skin rash (n=1) during the 24-week period, serious adverse events requiring hospitalization were not observed. Clinical parameters that improved from baseline after 24 weeks of treatment included: ESR from 42.0 mm/h to 16.0 mm/h with p < 0.001; CRP from 0.70 mg/dL to 0.10 mg/dL with p< 0.001; MMP-3 from 136 ng/mL to 91.5 ng/mL with a p value of 0.11; RF went from 18.0 IU/mL to 8.00 IU/mL with p < 0.001; DAS28(4)-ESR dropped from 5.13 to 2.73 with p< 0.001; CDAI dropped from 20.0 to 5.00 with p< 0.001, and HAQ-DI decreased from 0.55 to 0.00 with p< 0.001. Patients who achieved a good or moderate response based on EULAR response at 24 weeks, included 90.7% in the IGU group versus 70.5% in the other DMARD group (Fisher`s exact test, p=0.046). The retention rate of the IGU group was 81.4 %, roughly equivalent to the 81.2% retention rate in the other DMARD group (Log-rank test, p=0.733).

Conclusion:

Our study indicates IGU is safe and effective for DMARD naïve RA patients. Starting treatment with IGU might be a new and effective strategy for RA patients without previous use of a DMARD.

Disclosure of Interests:

Daisuke Kobayashi: None declared, Eriko Hasegawa: None declared, Yoko Wada: None declared, Satoshi Ito Speakers bureau: Abbvie,Eisai, Asami Abe: None declared, Kiyoshi Nakazono: None declared, Akira Murasawa: None declared, Ichiei Narita: None declared, Hajime Ishikawa: None declared

Characterization of patients with systemic lupus erythematosus who meet the diagnostic criteria for TAFRO syndrome

Purpose

TAFRO syndrome is a novel disorder manifesting as fever, anasarca, thrombocytopenia, renal insufficiency and organomegaly, and its etiology has not been clarified. The aim of this study was to elucidate similarities and differences between systemic lupus erythematosus (SLE) and TAFRO syndrome.

Methods

We examined 46 consecutive patients diagnosed with SLE and determined whether they meet the proposed diagnostic criteria for TAFRO syndrome (2015 version).

Results

Of the 46 patients with SLE, four (8.7%) also met the TAFRO syndrome criteria (TAFRO-like group). All patients in the TAFRO-like group were males, and their mean age was significantly higher than that of the non-TAFRO group (67.5 ± 8.7 vs. 39.3 ± 18.1 years, p = 0.004). C-reactive protein and γ-glutamyl transpeptidase levels were significantly higher, and frequencies of anti-dsDNA and anti-Sm antibodies were significantly lower in the TAFRO-like than non-TAFRO group. Elder cases (onset age ≥ 50 years) met significantly more categories of the diagnostic criteria for TAFRO syndrome than did those with younger cases.

Conclusions

Several patients with SLE, especially elder cases, showed features similar to those of TAFRO syndrome. Although exclusion of SLE is needed in the diagnostic criteria for TAFRO syndrome, TAFRO syndrome-like SLE should be considered.

High and pointed type of femoral localized reaction frequently extends to complete and incomplete atypical femoral fracture in patients with autoimmune diseases on long-term glucocorticoids and bisphosphonates

Once a localized reaction (beaking) was detected, discontinuation of bisphosphonates (BPs) and switching to vitamin D supplementation or teriparatide therapy effectively improved its shape. When the localized reaction was high, of the pointed type, and/or accompanied by prodromal pain, the risks of complete and incomplete atypical femoral fracture increased and consideration of prophylactic fixation for such patients was required.

INTRODUCTION

Femoral localized reaction (localized periosteal thickening of the lateral cortex, beaking) is reported to precede atypical femoral fractures (AFFs) and to develop in 8-10% of patients with autoimmune diseases taking BPs and glucocorticoids. The aims of the present study were to retrospectively investigate the shapes of localized reaction to consider how to manage the condition.

METHODS

Twenty femora of 12 patients with autoimmune diseases who were on BPs and glucocorticoids exhibited femoral localized reaction. The heights of localized reaction were measured and the shapes classified as pointed, arched, and other. Localized reaction changes were divided into three categories: deterioration, no change, and improvement. A severe form of localized reaction was defined; this was associated with prodromal pain, de novo complete AFF, or incomplete AFF with a fracture line at the localized reaction.

RESULTS

The mean height of localized reaction was 2.3 ± 0.8 mm (range, 1.0-3.7 mm) and the pointed type was 35%. Localized reaction was significantly higher (3.3 ± 0.8 vs. 2.1 ± 0.7 mm; p = 0.003) and the pointed type more common (78 vs. 27%; p = 0.035) in those with the severe form of localized reaction. Seven patients with localized reactions discontinued BPs just after localized reaction was detected, but five continued on BPs for 2 years. Localized reaction deterioration was more common in patients who continued than discontinued BPs (100 vs. 29%; p = 0.027). After 2 years, all patients had discontinued BPs and localized reaction did not deteriorate further in any patient.

CONCLUSIONS

Once a localized reaction was detected, discontinuation of BPs and switching to vitamin D supplementation or teriparatide therapy effectively improved it. When the localized reaction was high, of the pointed type, and/or accompanied by prodromal pain, the risks of complete and incomplete AFF increased and consideration of prophylactic fixation for such patients was required.

Acquired Downregulation of Donor-Specific Antibody Production After ABO-Incompatible Kidney Transplantation

The mechanism of long-term B cell immunity against donor blood group antigens in recipients who undergo ABO-incompatible (ABOi) living-donor kidney transplantation (LKTx) is unknown. To address this question, we evaluated serial anti-A and anti-B antibody titers in 50 adult recipients. Donor-specific antibody titers remained low (≤1:4) in 42 recipients (84%). However, antibodies against nondonor blood group antigens were continuously produced in recipients with blood type O. We stimulated recipients' peripheral blood mononuclear cells in vitro to investigate whether B cells produced antibodies against donor blood group antigens in the absence of graft adsorption in vivo. Antibodies in cell culture supernatant were measured using specific enzyme-linked immunosorbent assays (ELISAs). Thirty-five healthy volunteers and 57 recipients who underwent ABO-compatible LKTx served as controls. Antibody production in vitro against donor blood group antigens by cells from ABOi LKTx patients was lower than in the control groups. Immunoglobulin deposits were undetectable in biopsies of grafts of eight recipients with low antibody titers (≤1:4) after ABOi LKTx. One patient with blood type A1 who received a second ABOi LKTx from a type B donor did not produce B-specific antibodies. These findings suggest diminished donor-specific antibody production function in the setting of adult ABOi LKTx.

The cumulative incidence of and risk factors for latent beaking in patients with autoimmune diseases taking long-term glucocorticoids and bisphosphonates

SUMMARY

The incidence of beaking, which has been reported to precede atypical femoral fracture, was high and increased over 2 years in patients with autoimmune diseases who were taking bisphosphonates and glucocorticoids. Regular femoral X-rays are strongly recommended to screen for beaking, and bisphosphonate drug holidays should be considered.

INTRODUCTION

Atypical femoral fractures (AFFs) have been recently recognized as complications associated with bisphosphonate (BP) use. AFFs are considered to be stress fractures; localized periosteal thickening of the lateral cortex is often present at the fracture site; this thickening is termed "beaking." Beaking has been reported to precede AFF. The aims of the present study were to evaluate the incidence of latent beaking in patients with autoimmune diseases taking BPs and glucocorticoids and to identify risk factors for beaking.

METHODS

A total of 125 patients with autoimmune diseases who were taking BPs and glucocorticoids was included; 116 patients underwent X-rays and analysis of serum and urine bone metabolic markers annually for 2 years. Mean patient age was 54.5 years; there were 105 (90.5%) females and the mean duration of disease was 13.2 years. Focal lateral cortical thickening in femoral X-rays was defined as beaking.

RESULTS

Beaking was detected in 15 femora of 10 patients (8.0%) at the time of recruitment. Over the 2-year observation period, the incidence of beaking increased to 21 femora of 12 patients (10.3%), and a complete AFF at the location of beaking occurred in one patient. Beaking was associated with a longer duration of BP treatment (6.1 ± 1.0 years vs. 5.0 ± 2.9 years, p = 0.01). Age 40-60 years, BP therapy ≥4 years, and diabetes mellitus were significantly associated with beaking.

CONCLUSIONS

The incidence of beaking was high, and increased over 2 years, in patients with autoimmune diseases who were taking BPs and glucocorticoids. Regular femoral X-rays are strongly recommended to screen for beaking. Long-term BP/glucocorticoid use was a risk factor for beaking in patients with autoimmune diseases; BP drug holidays should be considered.

Specific overexpression of tumour necrosis factor-α-induced protein (TNFAIP)9 in CD14(+) CD16(-) monocytes in patients with rheumatoid arthritis: comparative analysis with TNFAIP3

The tumour necrosis factor (TNF)-α-induced proteins (TNFAIP)9 and TNFAIP3 play an important pathogenic role in murine arthritis. To clarify their pathophysiological roles in patients with rheumatoid arthritis (RA), we examined their expression and localization in peripheral blood mononuclear cells (PBMC). TNFAIP9 and TNFAIP3 mRNA expression was determined in PBMC of RA patients and healthy subjects (control). Flow cytometry was used to analyse the main TNFAIP9- and TNFAIP3-expressing cell populations. TNFAIP9 and TNFAIP3 mRNA expression levels were examined in vitro on CD14(+) cells stimulated with TNF-α and lipopolysaccharide (LPS). The expression levels of TNFAIP9 and TNFAIP3 mRNA were also measured before and 12 weeks after treatment with tocilizumab and abatacept. TNFAIP9 expression was significantly higher, while TNFAIP3 expression was lower in PBMC of RA (n=36) than the control (n=24) (each P < 0.05). TNFAIP9 was expressed on CD14(+) cells, especially in human leucocyte antigen D-related (HLA-DR)(+) CD14(bright) CD16(-) cells, while TNFAIP3 was expressed mainly on CD3(+) T cells. TNF-α and LPS induced TNFAIP9 and TNFAIP3 in human CD14(+) monocytes in vitro. Treatment with tocilizumab (n=13), but not abatacept (n=11), significantly reduced TNFAIP9 mRNA expression in PBMC, which was associated with reduction in the number of circulating CD14(bright) monocytes. The expression of TNFAIP9 in CD14(+) cells was specifically elevated in patients with RA, regulated by TNF-α and LPS, and suppressed by tocilizumab, while TNFAIP3 in PBMC showed different localization and induction patterns.

Characterization of anti-P monoclonal antibodies directed against the ribosomal protein-RNA complex antigen and produced using Murphy Roths large autoimmune-prone mice

Autoantibodies, including anti-ribosomal P proteins (anti-P), are thought to be produced by an antigen-driven immune response in systemic lupus erythematosus (SLE). To test this hypothesis, we reconstituted the ribosomal antigenic complex in vitro using human P0, phosphorylated P1 and P2 and a 28S rRNA fragment covering the P0 binding site, and immunized Murphy Roths large (MRL)/lrp lupus mice with this complex without any added adjuvant to generate anti-P antibodies. Using hybridoma technology, we subsequently obtained 34 clones, each producing an anti-P monoclonal antibody (mAb) that recognized the conserved C-terminal tail sequence common to all three P proteins. We also obtained two P0-specific monoclonal antibodies, but no antibody specific to P1, P2 or rRNA fragment. Two types of mAbs were found among these anti-P antibodies: one type (e.g. 9D5) reacted more strongly with the phosphorylated P1 and P2 than that with their non-phosphorylated forms, whereas the other type (e.g. 4H11) reacted equally with both phosphorylated and non-phosphorylated forms of P1/P2. Both 9D5 and 4H11 inhibited the ribosome/eukaryotic elongation factor-2 (eEF-2)-coupled guanosine triphosphate (GTP)ase activity. However, preincubation with a synthetic peptide corresponding to the C-terminal sequence common to all three P proteins, but not the peptide that lacked the last three C-terminal amino acids, mostly prevented the mAb-induced inhibition of GTPase activity. Thus, at least two types of anti-P were produced preferentially following the immunization of MRL mice with the reconstituted antigenic complex. Presence of multiple copies of the C-termini, particularly that of the last three C-terminal amino acid residues, in the antigenic complex appears to contribute to the immunogenic stimulus.

IL-17 eliminates therapeutic effects of oral tolerance in murine airway allergic inflammation

BACKGROUND

Oral tolerance is a classically used strategy for antigen-specific systemic immunotherapy. However, the roles of IL-17 in modification of oral tolerance are not yet understood.

OBJECTIVE

To define the effects of IL-17 on the modification of oral tolerance, the effects of transfer of Th17 cells, administration of IL-17 or anti-IL-17 antibody (αIL-17Ab) to a murine allergic airway inflammation model were investigated.

METHODS

Mice sensitized to and challenged with OVA, received OVA feeding, followed by OVA challenges. Transfer of Th17 cells, administration of IL-17 or αIL-17Ab were executed during OVA feeding. Airway hyperresponsiveness (AHR), airway inflammation, Th2 cytokine response and lung pathology were assessed.

RESULTS

Administration of IL-17 as well as transfer of Th17 cells aggravated AHR and airway allergic inflammation as compared with the findings in mice subjected to OVA feeding alone, whereas administration of αIL-17Ab ameliorated AHR and airway eosinophilia. The effects of Th17 transfer were presumably attributable to augmentation of endogenous IL-6 production in gut. The number of Foxp3-positive regulatory T (Treg) cells in lungs and Payer's patches was increased in the OVA fed mice, whereas the number of these cells was decreased in the mice subjected to OVA feeding + Th17 cell transfer. Neutralization of IL-6 by monoclonal antibody in the mice subjected to OVA feeding + transfer of Th17 cells restored the effects of oral tolerance.

CONCLUSIONS AND CLINICAL RELEVANCE

These data suggest that IL-17 may inhibit the induction of tolerance to antigen through, at least in part augmenting IL-6 production, thereby suppressing the expansion of Treg cells.

The genetic susceptibility to IgA nephropathy: A novel functional candidate gene for incomplete O-glycosylation of IgA1

Incompleteness of O-glycosylation in the IgA1 hinge has been implicated as a central mechanism in the development of IgA nephropathy. Although underglycosylation was reported to be an acquired abnormality, genes for enzymes of O-glycosylation, such as C1GALT1, may be responsible for susceptibility to IgA nephropathy.

Expression of allograft inflammatory factor-1 in kidneys: A novel molecular component of podocyte

Our comprehensive gene expression profiles of the kidneys in an anti-glomerular basement membrane (GBM) nephritis model using DNA arrays revealed that allograft inflammatory factor-1 (AIF-1) was one of the highly expressed genes. Here, we explored the pathological significance of AIF-1 expression in the kidneys. The expression pattern of AIF-1 mRNA and protein in the kidneys of normal and diseased rats, such as anti-GBM nephritis and puromycin aminonucleoside nephrosis, was investigated by in situ hybridization, immunohistochemistry, and immunoelectron microscopy. Furthermore, the expression of AIF-1 in human kidneys and urinary sediments was examined. AIF-1 was expressed at both mRNA and protein levels in podocytes of normal and diseased rats, and in infiltrating cells in anti-GBM nephritis kidneys. The expression of AIF-1 in podocytes was constitutive; positive in podocytes of both normal and diseased rats. In humans, AIF-1 was expressed in podocytes and infiltrating inflammatory cells, similarly. Moreover, it was detected in urinary podocytes from patients with immunoglobulin A nephropathy. These data document for the first time that AIF-1, a constitutively expressed protein in rat and human podocytes, is a novel molecular component of podocytes, and that the upregulation of AIF-1 in an anti-GBM nephritis model may mainly be a consequence of its expression in infiltrating cells.

Etiology and prognostic significance of severe uremic pruritus in chronic hemodialysis patients

Although uremia is well known as the most common cause of pruritus, the mechanisms of pruritus in chronic hemodialysis patients remain unclear. The purpose was to characterize uremic pruritus in more detail and to investigate whether severe pruritus is a marker for poor prognosis. A total of 1773 adult hemodialysis patients were studied. A questionnaire was given to each patient to assess the intensity and frequency, as well as pruritus-related sleep disturbance. We analyzed the relationship between clinical and laboratory data and the severity of pruritus in hemodialysis patients and followed them for 24 months prospectively. In total, 453 patients had severe pruritus with a visual analogue scale (VAS) score more than or equal to 7.0. Among them, more than 70% complained of sleep disturbance, whereas the majority of patients with a VAS score of less than 7.0 had no sleep disturbance. Male gender, high levels of blood urea nitrogen, beta2-microglobulin (beta2MG), hypercalcemia, and hyperphosphatemia were identified as independent risk factors for the development of severe pruritus, whereas a low level of calcium and intact-parathyroid hormone were associated with reduced risk. During the follow-up, 171 (9.64%) patients died. The prognosis of patients with severe pruritus was significantly worse than the others. Moreover, severe pruritus was independently associated with death even after adjusting for other clinical factors including diabetes mellitus, age, beta2MG, and albumin. Severe uremic pruritus caused by multiple factors, not only affects the quality of life but may also be associated with poor outcome in chronic hemodialysis patients.

Maxacalcitol therapy decreases circulating osteoprotegerin levels in dialysis patients with secondary hyperparathyroidism

BACKGROUND

Osteoprotegerin is a natural glycoprotein which plays a critical role in osteoclast physiology. Elevated levels of circulating osteoprotegerin may account for the development of bone and mineral metabolic abnormalities in uremia. Little is known about the effects of vitamin D therapy on the circulating osteoprotegerin levels in dialysis patients.

PATIENTS AND METHODS

Fifty chronic dialysis patients whose plasma intact PTH levels were greater than 300 pg/ml were analyzed for the study. Following a four-week washout time during which all vitamin D administration was halted, 10 microg of maxacalcitol was intravenously injected thrice a week.

RESULTS

The circulating intact PTH, bone-specific alkaline phosphatase and intact osteocalcin levels were significantly lowered, while the serum calcium levels were elevated after the therapy. The osteoprotegerin levels significantly decreased after the therapy (p < 0.0001).

CONCLUSION

Maxacalcitol therapy reduced the circulating osteoprotegerin levels and improved secondary hyperparathyroidism. The observed effects were the opposite of those expected from previous in vitro studies. Osteoprotegerin may mediate and/or modify the effect of active vitamin D therapy in dialysis patients.

Transforming growth factor-beta1 gene polymorphism modifies the histological and clinical manifestations in Japanese patients with IgA nephropathy

Transforming growth factor (TGF)-beta1, a multifunctional cytokine, which regulates proliferation and differentiation of a variety of cell types, has the central role in the development and progression of renal injury in both animal models and human. Although it has been suggested that genetic variations in the TGF-beta1 gene are associated with the activity of the gene product, their clinical significance in glomerular disease is unknown. We investigated whether the polymorphisms of C-509T and T869C in TGF-beta1 account for interindividual variation in manifestations of IgA nephropathy (IgAN) using 626 Japanese subjects including 329 patients with histologically proven IgAN and 297 healthy controls with normal urinalysis. The frequencies of genotypes, alleles, and major haplotypes were similar between the patients and controls. The C-509T and T869C polymorphisms were in tight linkage disequilibrium, and the major haplotypes were C-C and T-T, which accounted for more than 95% of the total. In patients with -509CC and in those with the 869CC, urinary protein excretion was higher than in those with other genotypes, whereas no difference in other clinical manifestations was noted. Moreover, patients with -509CC and those with 869CC genotypes presented with a significant higher score of mesangial cell proliferation than in those with other genotypes. These results suggest that TGF-beta1 gene polymorphisms are specifically associated with heavy proteinuria and mesangial cell proliferation in Japanese patients with IgAN, although they do not confer susceptibility to this disease.

Development of hungry bone syndrome after rapid lowering of PTH with intravenous maxacalcitol therapy in a patient with non-uremic secondary hyperparathyroidism

A 41 year-old woman complained of general bone pain and polyuria. She did not have Albright hereditary osteodystrophy. Laboratory examination revealed hypokalemia, hypocalcemia, and an elevation of serum intact PTH concentration. The patient was polyuric and relatively hypercalciuric, though her glomerular filtration rate (GFR) was normal. Neither urinary Pi nor cAMP excretion was remarkably promoted by an exogenous PTH load. An iliac bone biopsy revealed osteopenia, active osteoclastic bone resorption, fibrous transformation in bone marrow tissue, and severely disturbed calcification. Although the oral administration of alfacalcidol showed no effects, 3 weeks of intermittent intravenous injection of maxacalcitol therapy decreased the serum intact PTH concentration from 597 pg/ml to 40 pg/ml, and the bone pain was greatly relieved. However, plasma Ca concentration also decreased and symptoms of tetany appeared. Pseudohypoparathyroidism type Ib was the most likely diagnosis in this patient. In conclusion, maxacalcitol therapy satisfactorily suppressed parathyroid function in a patient with secondary hyperparathyroidism without uremia. Appropriate Ca supplementation was required to perform it safely.

Peroxisome proliferator-activated receptor γ C161T polymorphisms and survival of Japanese patients with immunoglobulin A nephropathy

Peroxisome proliferator-activated receptor gamma (PPAR gamma) plays an important role in lipid metabolism, insulin sensitivity, atherogenesis, and immune regulation. A genetic polymorphism (C161T) at exon 6 of PPAR gamma gene (PPARG) was reported to be associated with the onset of coronary artery disease. However, there has been no report of an association with renal disease. Genomic DNAs were isolated from 225 Japanese patients with histologically confirmed immunoglobulin A nephropathy (IgAN). The PPARG C161T genotype was determined by polymerase chain reaction-restriction fragment length polymorphism. The association of the polymorphism with renal prognosis in IgAN patients was analyzed using the Kaplan-Meier method and Cox proportional hazard regression model. The PPARG polymorphism was not associated with the renal survival rate. However, when patients were stratified into those either with or without hypertension at the time of diagnosis, the renal survival of the CT/TT genotypes was significantly better in those without hypertension than those with the CC genotype. We report that the PPARG C161T polymorphism is associated with the survival of IgAN patients without hypertension. The T allele of the polymorphism might have a protective effect on the progression of IgAN.

Successful perioperative blood purification therapy in patients with maintenance hemodialysis therapy who underwent living donor liver transplantation

Living donor liver transplantation (LDLT) is a treatment for end-stage liver failure, and was developed to overcome the distinct insufficiency of cadaveric donors. Case 1 is a 56-year-old man who had undergone maintenance hemodialysis therapy for 4 years. An LDLT was performed for the treatment of advanced liver cirrhosis and hepatocellular carcinoma. Continuous hemodiafiltration (CHDF) was performed from the 2nd to 5th days after the operation. Case 2 is a 55-year-old man with primary amyloidosis and chronic renal failure. An LDLT was performed for the treatment of severe abdominal distention caused by a large liver volume. Although CHDF was started at the 3rd day after the operation, it was discontinued within 24 hours because of an increased urinary volume. CHDF was required again from the 6th-8th days, after which the blood purification mode was switched to regular intermittent hemodialysis. Meanwhile, no major problems occurred in either case. In conclusion, CHDF was required for about 5 days from the 2nd day after the operation. The application of careful and aggressive blood purification therapy during the perioperative period is a key to successful LDLT in dialysis patients.

Genetic polymorphisms in the promoter and 5' UTR region of the Fc alpha receptor (CD89) are not associated with a risk of IgA nephropathy

The molecular mechanisms of immunoglobulin A glomerulonephritis (IgAN), the most prevalent form of primary glomerulonephritis, remain poorly understood. Recently, the essential role of soluble Fc alpha receptor (FcalphaR) in the formation of the pathogenic immune complex has been revealed. We screened genomic DNA samples from patients with IgAN and those with other glomerular diseases for polymorphisms in the promoter and the 5'-untranslated region region of the FcalphaR gene by direct nucleotide sequencing. We found three common polymorphisms in this region, T-114C, T-27C, and T+56C from the putative transcription initiation site. Each genotype was determined in 151 patients with IgAN and 163 patients with other glomerular diseases shown to have no mesangial IgA deposition by renal biopsy. The haplotype analysis revealed tight linkage disequilibrium among them. An association study for the genotype, allele, and haplotype frequencies of the polymorphisms between the patients with histologically proven IgAN and those with other glomerular diseases showed no significant difference in the genotype, allele, and haplotype distributions between the two groups. The present study indicates that the analyzed polymorphisms of the FcalphaR gene do not appear to be primarily involved in the susceptibility to IgAN.

[Indication of home oxygen therapy for terminal cancer patients--comparison with present standards--as the result from investigation of our patients and questionnaire survey to home care doctors]

As the result of the observation of our patients and a questionnaire answered by home care doctors, we think it is necessary to establish new standards for home oxygen therapy, based on the characteristics of terminal cancer patients and to put great emphasis on the QOL of patients.

[Drug consultation for a terminal cancer patient at home care-management of dyspnea and pain by morphine]

We studied on the points of that a management of dyspnea and pain by morphine for a terminal cancer patient at Home care. It was suggested that a necessary on management of symptoms for a terminal cancer patient before home drug therapy, a education to patient and his family by drug consultation before and after home drug therapy, a confirmation of dyspnea and pain for a terminal cancer patient from one drug to the next, and a importance of communication between medical staffs.

Expression, roles, receptors, and regulation of osteopontin in the kidney

Osteopontin (OPN) is a secreted glycoprotein in both phosphorylated and non-phosphorylated forms. It contains an Arg-Gly-Asp cell-binding sequence and a thrombin-cleavage site. OPN is mainly present in the loop of Henle and distal nephrons in normal kidneys in animals and humans. After renal damage, OPN expression may be significantly up-regulated in all tubule segments and glomeruli. Studies utilizing OPN gene-deficient mice, antisense-treated or anti-OPN-treated animals have demonstrated that OPN promotes accumulation of macrophages, and may play a role in macrophage-mediated renal injury, but that the effect may be mild and short-lived. On the other hand, OPN has some renoprotective actions in renal injury, such as increasing tolerance to acute ischemia, inhibiting inducible nitric oxide synthase and suppressing nitric oxide synthesis, reducing cell peroxide levels and promoting the survival of cells exposed to hypoxia, decreasing cell apoptosis and participating in the regeneration of cells. In addition, OPN is associated with renal stones, but whether it acts as a promoter or inhibitor of stone formation is controversial. It has been demonstrated that OPN receptors include two families: integrin and CD44. The OPN integrin receptors include alpha(v)beta(3), alpha(v)beta(1), alpha(v)beta(5) and alpha(9)beta(1), and alpha(4)beta(1). In normal human kidneys, standard CD44 is expressed most dominantly. Different OPN functions are mediated via distinct receptors. Parathyroid hormone, vitamin D(3), calcium, phosphate and some cytokines increase OPN expression in vitro or in vivo, whereas female sex hormones and angiotensin-converting enzyme inhibitors or angiotensin II receptor antagonists decrease OPN expression in some renal damage states.

Association of gene polymorphism of polymeric immunoglobulin receptor and IgA nephropathy

OBJECTIVE

In order to explore the possibility that genetic predisposition to dysfunction of mucosal immunity and the IgA processing pathway plays a role in the pathogenesis of mesangial IgA1 deposition in IgAN, we examined the possible association of the gene polymorphism of pIgR in the patients with and without IgAN.

SUBJECTS AND METHODS

Genomic DNA of peripheral blood cells was isolated from 372 individuals including 172 histologically confirmed IgAN patients. Segments of the pIgR gene were PCR amplified and restriction fragment length polymorphism was determined as A1 and A2 with and without Pvu II site, respectively.

RESULTS

The pIgR genotype distribution was significantly different between the patients with IgAN and those without IgAN. Allele frequency of A2 was higher in IgAN than in other renal diseases (A1 and A2; 0.516 and 0.484 in IgAN, 0.641 and 0.359 in others, chi2 = 9.84, P = 0.0017, Odds ratio = 1.71). Moreover, the subjects with A2A2 genotype were associated with a relatively low level of serum IgA only in the patients with IgAN but not in other renal diseases. The difference of allele frequencies was more remarkable in the patients with a serum IgA level of less than 300 mg/dl (A1 and A2; 0.439 and 0.561 in IgAN, 0.702 and 0.298 in others, chi2 = 12.44, P = 0.0004, Odds ratio = 3.01).

CONCLUSION

This is the first demonstration of the pIgR gene polymorphisms in IgAN which are associated with its clinical phenotype. Gene polymorphisms of pIgR may be candidate genetic markers of susceptibility to IgAN.

[The fate of dioxins during green tea manufacture]

Dioxin concentrations and homologue profiles were examined in plucked new shoots, crude tea and its hot water extracts, soils and atmosphere in tea orchards. The rate of dry provisions in crude tea has increased 4 times as that of the plucked new shoots. However, dioxin concentrations except O8CDD in crude tea have increased only 2 to 3 times as those of the plucked new shoots. O8CDD concentration increased remarkably during processing. Little dioxins were detected in hot water extracts of crude tea leaves.

The circadian blood pressure rhythm in non-diabetic hemodialysis patients

This study investigates the circadian blood pressure variation of non-diabetic chronic hemodialysis (HD) patients on both HD and non-HD days as well as the factors affecting diurnal BP variation. Forty-nine HD patients aged 61.8 +/- 12.9 years who were on daytime HD for 97 +/- 68 months were studied. No significant difference was found in every daytime and nighttime BP between the first (HD) and the second (non-HD) day. However, the ratio nighttime/daytime BP was significantly higher on the second day. Each BP diurnal variability pattern was classified as either Dipper (D: the ratio nighttime/daytime mean BP 0.8-0.9), non-dipper (0.9 < ND < 1.0), or inverted dipper (ID > 1.0). More than 75% of the cases were classified as ND (26 cases) or ID (11 cases). The ultrafiltration rate in D was significantly less than that in ND and ID. The difference of plasma renin activity between pre- and post-HD (dRen) was significantly higher in ID than in D and ND. The amount of dialysis (Kt/V) was found to be significantly correlated with nighttime BP fall. Ultrafiltration, dRen and Kt/V were independent factors for the abnormal BP diurnal variability. In conclusion, the decreased nocturnal BP fall seen in non-diabetic HD patients is associated with increased extracellular fluid even in the patients without overt overhydration, whereas relatively insufficient amount of dialysis (low Kt/V) may be another possible cause. The increased dRen observed only in ID patients may reflect occult cardiovascular damage or functional disturbances in aortic and carotid baroreflexes caused by arterial structural changes.

Determination of optimal blood pressure for patients with IgA nephropathy based on renal histology

To evaluate the optimal BP control for patients with IgA nephropathy (IgAN) based on the histologic severity of the nephropathy and the degree of renal dysfunction. We analyzed 332 consecutive renal biopsy specimens and clinical data from patients with IgAN. Patients were divided into three groups based on their BP at the time of biopsy: an optimal BP (SBP<120 mmHg and DBP<80 mmHg), a hypertensive BP (SBP > or = 140 mmHg and/or DBP > or = 90 mmHg), and an intermediate BP group. Each biopsy specimen was evaluated for mesangial proliferation, degree of sclerosis and/or hyalinosis of the arterioles and the interlobular artery using a semiquantitative method. Creatinine clearance and the percentage of sclerosed glomeruli were also determined. Both the degree of renal dysfunction and the histologic changes correlated significantly with BP, even in patients with a BP <140/90 mmHg. The patients with an optimal BP at the time of biopsy had significantly less histologic damage with respect to mesangial proliferation and vessel changes than those with an intermediate or hypertensive BP. In the patients with a hypertensive BP, the percentage of sclerotic glomeruli was significantly higher and the creatinine clearance was significantly lower. The optimal BP proposed by the WHO in 1999 prevents histologic evidence of renal damage for patients with IgAN.

Down-regulation of interferon-gamma signaling by gene transfer of Stat1 mutant in mesangial cells

BACKGROUND

Interferon-gamma (IFN-gamma) is secreted by T lymphocytes and natural killer (NK) cells in the cellular immunity-mediated inflammatory lesion, including endocapillary or extracapillary proliferative glomerulonephritis. It induces and/or enhances multiple histocompatibility complex (MHC) class I and II, intercellular adhesion molecule-1 (ICAM-1), inducible nitric oxide synthase (iNOS), and Fc receptor expression in renal resident cells, resulting in the initiation and promotion of inflammation. Recently, the signaling mechanism of IFN-gamma has been investigated, and it appears that Stat1alpha is essential for signaling. We investigated Stat1alpha activation by IFN-gamma in mesangial cells and attempted to regulate the signal transduction by gene transfer.

METHODS

Western blot with anti-Stat1 and antiphosphotyrosine after immunoprecipitation of Stat1 and Northern blot for detection of Stat1 mRNA were performed. The dominant negative form of Flag-tagged Stat1 was expressed in cultured rat mesangial cells. Flag was immunostained in transfectants, and luciferase reporter assay was carried out to measure the transcriptional activity of Stat1alpha. The expression of IFN-gamma-inducible genes such as MHC class II (Ia-Aalpha) and MHC class II transactivator (CIITA) was detected by reverse transcriptase-polymerase chain reaction (RT-PCR).

RESULTS

Stat1alpha was tyrosine phosphorylated and activated by IFN-gamma in mesangial cells, and the mRNA and protein level of Stat1alpha increased upon stimulation by IFN-gamma. Overexpression of Stat1-mutant lacking 35 C-terminal amino acids strongly suppressed the IFN-gamma-induced signal transduction and inhibited the expression of MHC class II and CIITA genes in mesangial cells.

CONCLUSIONS

Stat1alpha is a critical molecule in the signal transduction of IFN-gamma in mesangial cells. The inhibition of an endogenous function of Stat1alpha by gene transfer of the Stat1 mutant may be a new method to reduce the inflammatory effects of IFN-gamma in localized inflammation of the kidney.

Adrenocorticotropic hormone-independent bilateral adrenocortical macronodular hyperplasia treated with mitotane

We report a case of adrenocorticotropic hormone (ACTH)-independent bilateral macronodular adrenocortical hyperplasia (AIMAH), which was successfully treated with mitotane. A 71-year-old man visited our hospital because of central obesity and enlarged bilateral adrenal glands. The endocrinological studies showed elevated plasma cortisol and undetectable levels of ACTH, a lack of suppression with high-dose dexamethasone and a hyper-response to exogenous ACTH. These clinical features were compatible with the diagnosis of AIMAH. In this patient, extra-adrenal multiple tumors were also detected. After treatment with mitotane, the plasma level of cortisol was decreased while that of ACTH was increased and the signs of Cushing's syndrome were resolved.