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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Boehringer Ingelheim and Eli Lilly.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

Comparison of risk factors for SARS-CoV-2 infection among healthcare workers during Omicron and Delta dominance periods in Japan

BACKGROUND

The risk factors for coronavirus disease (COVID-19) among healthcare workers (HCWs) might have changed since the emergence of the highly immune evasive Omicron variant.

AIM

To compare the risk factors for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among HCWs during the Delta- and Omicron-predominant periods.

METHODS

Using data from repeated serosurveys among the staff of a medical research centre in Tokyo, two cohorts were established: Delta period cohort (N = 858) and Omicron period cohort (N = 652). The potential risk factors were assessed using a questionnaire. Acute/current or past SARS-CoV-2 infection was identified by polymerase chain reaction or anti-nucleocapsid antibody tests, respectively. Poisson regression was used to calculate the risk ratio (RR) of infection risk.

FINDINGS

The risk of SARS-CoV-2 infection during the early Omicron-predominant period was 3.4-fold higher than during the Delta-predominant period. Neither working in a COVID-19-related department nor having a higher degree of occupational exposure to SARS-CoV-2 was associated with an increased infection risk during both periods. During the Omicron-predominant period, infection risk was higher among those who spent ≥30 min in closed spaces, crowded spaces, and close-contact settings without wearing mask (≥3 times versus never: RR: 6.62; 95% confidence interval: 3.01-14.58), whereas no such association was found during the Delta period.

CONCLUSION

Occupational exposure to COVID-19-related work was not associated with the risk of SARS-CoV-2 infection in the Delta or Omicron period, whereas high-risk behaviours were associated with an increased infection risk during the Omicron period.

NIN-like protein 7 transcription factor is a plant nitrate sensor

Nitrate is an essential nutrient and signaling molecule for plant growth. Plants sense intracellular nitrate to adjust their metabolic and growth responses. Here we identify the primary nitrate sensor in plants. We found that mutation of all seven Arabidopsis NIN-like protein (NLP) transcription factors abolished plants' primary nitrate responses and developmental programs. Analyses of NIN-NLP7 chimeras and nitrate binding revealed that NLP7 is derepressed upon nitrate perception via its amino terminus. A genetically encoded fluorescent split biosensor, mCitrine-NLP7, enabled visualization of single-cell nitrate dynamics in planta. The nitrate sensor domain of NLP7 resembles the bacterial nitrate sensor NreA. Substitutions of conserved residues in the ligand-binding pocket impaired the ability of nitrate-triggered NLP7 to control transcription, transport, metabolism, development, and biomass. We propose that NLP7 represents a nitrate sensor in land plants.

POS0675 IMPACT OF PAST USE OF DISEASE MODIFYING ANTI-RHEUMATIC DRUGS ON JAK INHIBITOR TREATMENT FOR RHEUMATOID ARTHRITIS - DATA FROM THE FUKUI ISHIKAWA TOYAMA DATABASE OF RHEUMATOID ARTHRITIS

Background

Currently, five types of Janus kinase inhibitors (JAKis) are used for rheumatoid arthritis (RA) treatment. The number of cases in which multiple JAKis have been prescribed is increasing. However, the real-world efficacy and safety of JAKis and related factors require further evaluation.

Objectives

The primary objective of this study was to elucidate the impact of past use of disease-modifying anti-rheumatic drugs on RA treatment using JAKis. The secondary objective was to investigate the safety profiles of these agents in a real-world setting.

Methods

Of the 303 JAKi-treated patients in the Fukui Ishikawa Toyama Database of RA included in this study, 30 had switched from one JAKi to another (JJ group), 214 switched from a biologic agent to a JAKi (BJ group), and 47 were naïve to either biologics or JAKis (NJ group). We compared baseline factors, treatment response, and JAKi continuation rates among the three groups. Factors related to JAKi discontinuation were assessed using Cox regression analysis. Furthermore, we investigated adverse events and reported them using exposure-adjusted incidence rates (EAIR; incidence rates per 100 patient-years).

Results

Data from the 303 cases were analyzed (mean age = 63.6 years; female, 82%; mean RA duration, 176 months). Of the 303 patients, 118, 106, 50, and 29 were treated with tofacitinib, baricitinib, peficitinib, and upadacitinib, respectively, on initial observation. Rate of concomitant use with methotrexate and prednisolone was 52% and 49%, respectively.

Regarding efficacy, no significant differences were observed among the three groups in terms of treatment response and JAKi continuation rates, except for the 6-month treatment response between the JJ and NJ groups. Cox regression analysis of the 303 cases revealed that only past use of JAKis during the disease history was significantly associated with JAKi discontinuation. The Kaplan–Meier method showed that patients who previously used JAKis had significantly shorter median JAKi treatment duration than those without such a history (20.9 vs. 54.7 months; p = 0.012). Treatment response was significantly poor in patients who had previously used JAKis, especially 6 months after treatment initiation.

In terms of safety, the total exposure period for the 303 cases was 495 person-years, and the total number of adverse events was 161 (EAIR, 32.5). There were 12 cases (EAIR, 2.5) of serious infections, 23 cases (EAIR, 5.1) of herpes zoster, 7 cases (EAIR, 1.4) of malignant tumors, and 4 cases (EAIR, 0.8) of MACE. Adverse events led to JAKi discontinuation in 34 patients (EAIR, 6.9); the main causes of adverse events leading to treatment discontinuation were infectious diseases in 10 cases (EAIR, 2) and neoplasms in 4 cases (EAIR, 0.8). Within 1 year of initiating JAKi therapy, 21 patients discontinued treatment owing to adverse events, which accounted for 27% of the reasons for treatment discontinuation.

We also investigated cases of JAKi dose reduction, observed in 42 of the 303 cases. Among them, 10 patients required a re-increase in the JAKi dose, and 13 patients (56.5%) were able to maintain the reduced dose for more than 1 year. The remaining 19 patients were excluded from the analysis because the treatment duration at the lower dose had not exceeded 1 year at the time of data extraction. No difference in disease activity at the time of dose reduction was observed between those who maintained the new dose and those who did not (mean DAS28-CRP: 1.48 ± 0.26 vs. 1.89 ± 0.62).

Conclusion

Past use of JAKis may contribute to decreased response and continuation rates for JAKi treatment. In this study, conducted in Japan, development of herpes zoster was found to the most frequent adverse event among the priority survey items.

Acknowledgements

I have no acknowledgements to declare.

Disclosure of Interests

None declared

Inflammation-frailty linkage and its long-term prognostic impact in patients with acute coronary syndrome

Introduction

Chronic inflammation has been receiving considerable attention as an emerging risk factor for cardiovascular disease. In contrast, with the aging of the population, frailty has been also attracting a great deal of attention as the residual risk for cardiovascular disease. Although inflammation and frailty exacerbate each other and have an adverse effect on many diseases, the relationship between chronic inflammation and frailty and the impact of these combination on long-term prognosis in patients with acute coronary syndrome (ACS) are not elucidated.

Purpose

The aims of this study were to determine the association between chronic inflammation and frailty and its impact on long-term cardiovascular outcomes in patients with ACS.

Methods

A total of 482 consecutive ACS patients with obstructive coronary artery disease (age 66±12 years, male 81%) were enrolled in this observational study. We evaluated patients' gait speed as a measure of frailty before discharge. C-reactive protein (CRP) levels at 1 month after discharge were also evaluated as inflammation in the chronic phase. According to commonly used criteria of the residual inflammation (CRP&gt;0.2 mg/dL) and the definition of the European Working Group for Sarcopenia (gait speed ≤0.8 m/sec), patients were stratified by 4 subgroups: low/high CRP with slow/normal gait speed. The primary endpoint was composite outcomes of cardiovascular death, myocardial infarction and ischemic stroke.

Results

While there was no significant association between CRP levels and gait speed in all patients, a significant negative association between two variables was observed in the high CRP group (Spearman's ρ = −0.31, p=0.001). During the median follow-up of 6 years, primary endpoints have occurred in 82 patients. Overall, event-free rates differed significantly among the 4 groups, demonstrating the lowest event-free rate in the patients with high CRP and slow gait speed (p&lt;0.0001; Figure). In the multivariate analysis, high CRP (adjusted HR 1.99, 95% CI 1.14–3.46, p=0.02) and slow gait speed (adjusted HR 1.82, 95% CI 1.09–3.04, p=0.02) were independently and significantly associated with the primary endpoint. Moreover, the patients with both high CRP and slow gait speed had a 2.6-fold higher risk of cardiovascular events compared to others (adjusted HR 2.62, 95% CI 1.36–5.05, p=0.004).

Conclusion

In the patients with ACS, CRP levels and gait speed were negatively associated in the high CRP group. Chronic inflammation and frailty were both associated with poor prognosis in ACS and in particular, the combination of these factors was strongly associated with poor prognosis.

Funding Acknowledgement

Type of funding sources: None. Figure 1

Nitrate-responsive NIN-like protein transcription factors perform unique and redundant roles in Arabidopsis

Upon sensing nitrate, NODULE INCEPTION (NIN)-like protein (NLP) transcription factors alter gene expression to promote nitrate uptake and utilization. Of the nine NLPs in Arabidopsis, the physiological roles of only three NLPs (NLP6-NLP8) have been characterized to date. To evaluate the unique and redundant roles of Arabidopsis NLPs, we assessed the phenotypes of single and higher order nlp mutants. Unlike other nlp single mutants, nlp2 and nlp7 single mutants showed a reduction in shoot fresh weight when grown in the presence of nitrate as the sole nitrogen source, indicating that NLP2, like NLP7, plays a major role in vegetative growth. Interestingly, the growth defect of nlp7 recovered upon the supply of ammonium or glutamine, whereas that of nlp2 did not. Furthermore, complementation assays using chimeric constructs revealed that the coding sequence, but not the promoter region, of NLP genes was responsible for the differences between nlp2 and nlp7 single mutant phenotypes, suggesting differences in protein function. Importantly, nitrate utilization was almost completely abolished in the nlp septuple mutant (nlp2 nlp4 nlp5 nlp6 nlp7 nlp8 nlp9), suggesting that NLPs other than NLP2 and NLP7 also assist in the regulation of nitrate-inducible gene expression and nitrate-dependent promotion of vegetative growth in Arabidopsis.

Impact of grip strength and balance function on the exercise capacity in pulmonary hypertension

Funding Acknowledgements

Type of funding sources: None.

【Background】

Patients with pulmonary hypertension (PH) suffer from poor exercise capacity due to impaired oxygenation or reduced cardiac output. However, the relationship between exercise capacity and physical functions remains unclear.

【Purpose】

The purpose of this study is to investigate the relationship between exercise capacity and physical functions in pulmonary hypertension.

【Methods】

From February 2018 to June 2020, 94 patients (61.3 ± 14.7 years old, 69.1% females) with group 1/3/4/5 PH underwent cardiac catheterization, 6-minute walking distance (6MWD), and physical function measurements simultaneously. The physical functions was measured using muscle strength (grip strength, knee extension muscle strength), balance function (one leg standing time), and short physical performance battery (SPPB). Exercise capacity was measured by 6MWD. 

【Results】

The study cohort consists of 22/8/60/4 (23.4%/8.5%/63.8%/4.3%) patients with group 1/3/4/5 PH, respectively. The average age of each group was 50.7/64.7/63.1/66.0 years old, respectively. A total of 194 measurements of physical functions were evaluated from 94 patients and employed in multivariate logistic regression analysis using adaptive-LASSO methods with the 6MWD (476.2 ± 107.5m) as a dependent variable. WHO functional class (class II: standardized β=-0.35, 95% confidence interval (CI) [-0.54 - -0.16], p &lt; 0.001), class III: β=-0.60, 95%CI [-0.90 - -0.30], p &lt; 0.001), mixed venous oxygen saturation (SvO2: β=0.11, 95%CI [0.03 - 0.19], p = 0.008), pulmonary vascular resistance (PVR: β=-0.16, 95%CI [-0.25 - -0.07], p &lt; 0.001), grip strength (β=0.20, 95%CI [0.09 - 0.31], p &lt; 0.001), one leg standing time (β=0.10, 95%CI [0.00 - 0.20], p = 0.049) , and 4m gait speed test (β=-0.28, 95%CI [-0.36 - -0.19], p &lt; 0.001) were associated with 6MWD.

【Conclusions】

Grip strength and balance function, as well as SvO2 and PVR, were associated with the exercise capacity in pulmonary hypertension.

Temperature-dependent fasciation mutants provide a link between mitochondrial RNA processing and lateral root morphogenesis

Although mechanisms that activate organogenesis in plants are well established, much less is known about the subsequent fine-tuning of cell proliferation, which is crucial for creating properly structured and sized organs. Here we show, through analysis of temperature-dependent fasciation (TDF) mutants of Arabidopsis, root redifferentiation defective 1 (rrd1), rrd2, and root initiation defective 4 (rid4), that mitochondrial RNA processing is required for limiting cell division during early lateral root (LR) organogenesis. These mutants formed abnormally broadened (i.e. fasciated) LRs under high-temperature conditions due to extra cell division. All TDF proteins localized to mitochondria, where they were found to participate in RNA processing: RRD1 in mRNA deadenylation, and RRD2 and RID4 in mRNA editing. Further analysis suggested that LR fasciation in the TDF mutants is triggered by reactive oxygen species generation caused by defective mitochondrial respiration. Our findings provide novel clues for the physiological significance of mitochondrial activities in plant organogenesis.

Prognostic significance of 2019 Asian Working Group for Sarcopenia update on definition of sarcopenia

Background/Introduction

Sarcopenia plays a major role in the pathophysiology of frailty and is associated with worse outcome in the elderly population including patients with heart failure. A recent update of the most common definition of sarcopenia in Asia, Asian Working Group for Sarcopenia (AWGS2019), included significant changes in the diagnostic algorithm with newly dividing sarcopenia into severe and “non-severe” sarcopenia.

Purpose

The objective of this study was to evaluate the differences between AWGS2014 and AWGS2019 in patients with heart failure.

Methods

In the multicenter prospective FRAGILE-HF registry, which included elderly (≥65 years old) patients who were hospitalized with heart failure, we studied 865 patients (80±8 years old, 42% female). All-cause death in 1-year follow-up was tracked.

Results

Based on the original version of AWGS (AWGS2014), 183 patients (21%) were diagnosed with sarcopenia, which was associated with higher age, lower physical performance, less muscle mass, and greater heart failure risk (all p&lt;0.001) as well as higher rate of all-cause death (HR 1.90, p=0.004 after adjustment by multivariable regression). Those patients with sarcopenia by AWGS2014 were reclassified mainly to severe sarcopenia (155, 84.7%) by AWGS2019, and 25 (13.7%) and 2 (1.1%) were classified into sarcopenia and non-sarcopenia. Meanwhile, 24 (3.5%) and 4 (0.6%) of patients without sarcopenia by AWGS2014 were reclassified into sarcopenia and severe sarcopenia, respectively. Although severe sarcopenia by AWGS2019 was associated with higher age, lower physical performance, less muscle mass, and greater heart failure risk (all p&lt;0.001), patients with “non-severe” sarcopenia was rather younger (p&lt;0.001) and had better physical performance (p=0.021) despite less muscle mass (p&lt;0.001) than those without sarcopenia. Multivariate Cox analysis demonstrated severe sarcopenia by AWGS2019 was an independent prognostic factor (HR 1.77, p=0.014), but “non-severe” sarcopenia was not (HR 1.52, p=0.37). The prognosis of patients who were reclassified from non-sarcopenia to sarcopenia or severe sarcopenia were comparable to those remained non-sarcopenia. When added to other risk factors, the prognostic predictability of AWGS2019 was significantly lower than AWGS2014 (net reclassification improvement −0.26, p=0.025).

Conclusions

About a half of “non-severe” sarcopenia in AWGS2019 were patients without sarcopenia in AWGS2014. The prognosis of such patients who were newly diagnosed as sarcopenia was good, resulting in low overall prognostic predictability of AWGS2019. A further consideration for diagnostic algorithms of sarcopenia may be warranted in patients with heart failure.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Japan Heart Foundation

Negative impact of skeletal muscle impairment in older patients with heart failure with reduced versus preserved ejection fraction

Background/Introduction

Reduced functional capacity is an important phenotype of heart failure (HF), even though it may be considered multifactorial, especially in HF with preserved ejection fraction (HFpEF). Impairment in skeletal muscle may be one of extra-cardiac factors for reduced functional capacity and subsequent poor outcome.

Purpose

We sought to investigate the impact of the impairment in skeletal muscle, defined by the cut-offs proposed by the international consensus, on functional capacity and clinical outcome, in HF patients with preserved and reduced EF (HFrEF).

Methods

This is a multicenter prospective study including 1317 consecutive older (≥65 years) hospitalized patients with HF [HFpEF (ejection fraction ≥45%, n=675, 82±7 years, 46.4% male) and HFrEF (ejection fraction &lt;45%, n=642, 78±8 years, 68.4% male)].

Results

HFrEF patients were more likely to have low skeletal muscle mass measured by bioelectrical impedance analysis (30.9% vs 22.1%, p=0.003) whereas less likely to have low muscle strength (handgrip strength; 62.9% vs 73.8%, p&lt;0.001) than HFpEF, resulting in similar prevalence of sarcopenia between the two groups (21.6% vs 18.1%, p=0.19). In HFrEF, presence of sarcopenia was an independent predictor of reduced functional capacity assessed by a 6-minute walk distance (standardized beta=−0.093, p=0.039 in multivariate linear regression analysis) and 1-year mortality (adjusted hazard ratio (aHR) and 95% CI; 2.14 (1.22–3.70), p=0.009 in multivariate Cox-regression analysis). In patients with HFpEF, sarcopenia could predict mortality (aHR and 95% CI; 2.23 (1.23–3.91), p=0.009), though its association with reduced functional capacity was not significant after multivariate adjustment (standardized beta=−0.059, p=0.20). Kaplan-Meier survival curves in HFpEF and HFrEF are shown (Figure).

Conclusion(s)

In older patients with HF, sarcopenia was similarly contributed to mortality in HFpEF and HFrEF whereas its influence on functional capacity was pronounced in HFrEF.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Japan Heart Foundation Research Grant

Social frailty provides additive prognostic impact on one-year outcome in aged patients with congestive heart failure

Background

Frailty is associated with multisystem declines in physiologic reserve and increased vulnerability to stressors, resulting in increased risks of adverse clinical outcomes in patients with heart failure (HF). Although frailty is conceptualized as an accumulation of deficits in multiple areas, most of the studies have focused mainly on physical frailty, and the social domains is one of the least investigated area.

Objectives

We prospectively evaluated the incidence and prognostic implication of social frailty (SF) in older patients with HF.

Methods

The FRAGILE-HF is a multicenter, prospective cohort study including patients hospitalized for HF and aged ≥65 years old. We defined SF by Makizako's 5 items, which are 5 questions proposed and validated to be associated with future disability. The primary endpoint of this study was a composite of death from any cause and rehospitalization due to HF. The impact of SF on all-cause mortality alone was also evaluated.

Results

Among 1,240 hospitalized HF patients, 5 simple questions revealed that 825 (66.5%) were in SF. During 1-year observation period after the discharge, the combined endpoint was observed in 399 (32.2%) patients, and 145 (11.7%) patients died. Kaplan-Meier analysis showed that SF patients had significantly higher rates of both the combined endpoint and all-cause mortality than those without SF (Log-rank test: p&lt;0.05 for both, Figures). Moreover, SF remained independently associated with higher event rate of the combined endpoint (hazard ratio: 1.30; 95% confidence interval: 1.02 to 1.66; p=0.038) and all-cause mortality (hazard ratio: 1.53; 95% confidence interval: 1.01 to 2.30; p=0.044), even after adjusting for other covariates. Significant incremental prognostic value was shown when information on social frailty was added to known risk factors for combined endpoint (NRI: 0.189, 95% confidence interval: 0.063–0.316, p=0.003) and all-cause mortality (NRI: 0.234, 95% confidence interval: 0.073–0.395, p=0.004).

Conclusions

Among older hospitalized patients with heart failure, two-thirds of the population was with SF. Evaluating SF provides additive prognostic information in elderly patients with heart failure.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Novartis Pharma Research Grants, Japan Heart Foundation Research Grant

Low-density lipoprotein cholesterol levels on admission and long-term outcomes in statin-naive patients with acute coronary syndrome

Introduction

Dyslipidemia, especially an increase in the low-density lipoprotein cholesterol (LDL-C) has been established as one of the most important risk factors for atherosclerotic cardiovascular diseases. In contrast, some recent studies have shown that the low LDL-C level was associated with short-term poor prognosis in patients with cardiovascular disease, and this is so-called “cholesterol paradox”. However, there is few data evaluating the effects on long-term outcome of “cholesterol paradox” in patients with acute coronary syndrome (ACS).

Purpose

The purpose of this study was to examine whether the low LDL-C level on admission affect long-term prognosis in patients with ACS.

Methods

A total of 434 ACS patients who survived to hospital discharge were enrolled in this study. All patients were statin-naïve on admission, and were received statin therapy after hospitalization. Patients were divided into the low LDL-C (≤114 mg/dl) and high LDL-C (&gt;114 mg/dl) groups using the first tertile of the LDL-C level on admission. The primary endpoint was composite outcomes of all-cause death, myocardial infarction, ischemic stroke, hospitalization for congestive heart failure and unplanned revascularization.

Results

During a median follow-up period of 5.5 years, primary endpoint occurred in 117 patients. Overall, event-free rates differed significantly between the low and high LDL-C groups, demonstrating the lower event-free rate in patients with the low LDL-C group (38.9% in low LDL-C group versus 20.7% in high LDL-C group, p=0.0002; Figure). Even after adjustment for age, sex, body mass index, and various classical risk factors, the low LDL-C group was significantly at higher risk for primary composite outcomes compared to the high LDL-C group (adjusted hazard ratio 1.65, 95%-confidence interval 1.10–2.49, p=0.02).

Conclusion

In patients with ACS, the low LDL-C level on admission was significantly associated with long-term worse prognosis, regardless of statin therapy at discharge. In ACS patients with low LDL-C level, it might be necessary for elucidating the residual risk for secondary adverse event to improve their prognosis.

Funding Acknowledgement

Type of funding source: None

P5483Prognostic impact of skeletal muscle, fat, and bone mass in male patients with ST-segment elevation myocardial infarction

Introduction

Muscle, fat and bone mass may play some roles to keep physical activity and favorable outcome in patients with cardiovascular diseases. However, there is a paucity of data regarding the effects on the prognosis of skeletal muscle, fat, and bone mass in patients with ST-segment elevation myocardial infarction (STEMI).

Purpose

Our purpose was to examine whether skeletal muscle, fat, and bone mass each affect the prognosis after STEMI.

Methods

A total of 354 male patients with STEMI were enrolled in this study. Dual-energy X-ray absorptiometry scan was performed before discharge. All patients were followed up for the primary composite outcome of all-cause death, nonfatal myocardial infarction, nonfatal ischemic stroke, hospitalization for congestive heart failure, and unplanned revascularization.

Results

During a median follow-up of 32 months, 57 patients experienced primary composite outcome. Each of skeletal muscle, fat, and bone mass were indexed by height squared (kg/m2) and divided into two groups using the cut-off value obtained from the maximum Youden index to predict the primary composite outcome. The event rate was significantly higher in patients with low appendicular skeletal muscle mass index (ASMI) (29.2% vs 11.7%, p<0.001), low fat mass index (FMI) (22.9% vs 13.3%, p=0.030), and low bone mass index (23.8% vs 11.6%, p=0.002). After adjustment for age, renal function, diabetes mellitus, infarct size, Killip classification, and body mass index, low ASMI but not FMI (p=0.150) and bone mass index (p=0.159) was independently and significantly associated with the primary composite outcome (adjusted hazard ratio 2.12, 95%-confidence interval 1.05–4.31, p=0.035).

Conclusions

Index about muscle mass rather than fat and bone mass have prognostic impact in male patients with STEMI.

428In-hospital coronary angiography is associated with increased evidence based medications and better survival in patients hospitalized with acute heart failure - results from REALITY-AHF

Background

Coronary artery disease is a major cause of heart failure (HF). Urgent coronary angiography (CAG) is recommended for patients with acute HF (AHF) complicated with acute coronary syndrome (ACS); however, clinical usefulness of in-hospital CAG in AHF patients without ACS remains unknown.

Purpose

To investigate the association between in-hospital CAG and all-cause mortality at 1-year after hospital discharge and effects of medications at discharge on this association.

Methods

From the REALITY-AHF study, 1344 patients hospitalized with AHF were enrolled in this study and followed up for 1-year after hospital discharge.

Results

In-hospital CAG was undergone in 511 patients (38%). CAG group had a significantly lower 1-year mortality compared with non-CAG group (unadjusted hazard ratio [HR]; 0.30, 95%-confidence interval [CI] 0.21–0.43, P<0.001, after adjustment for MAGGIC score; HR 0.45, 95%-CI 0.29–0.70, P<0.001, in propensity-score matched 296 pairs; HR 0.60, 95%-CI 0.37–0.98, P=0.04). At discharge, aspirin, statins and beta blockers were prescribed more in CAG group compared with non-CAG group (aspirin 46% versus 30%, P<0.001, statins 51% versus 35%, P<0.001, and beta blockers 76% versus 65%, P=0.007). The prescription of aspirin or statins at discharge was associated with a better 1-year survival in patients with multivessel disease (P<0.001), but not in patients without significant stenosis or single vessel disease (P=0.95) (Figure).

CAG results, medications and mortality

Conclusions

In patients hospitalized with AHF, in-hospital CAG was associated with increased evidence based medications at discharge and a better long-term survival. Aspirin and statins at discharge might improve outcomes in AHF patients with multivessel disease.

Acknowledgement/Funding

This study was funded by The Cardiovascular Research Fund, Tokyo, Japan.

218Different impact of muscle, fat, and bone mass in heart failure with reduced and preserved ejection fraction

Background

Low muscle mass with or without fat mass is a main component of cachexia in heart failure (HF) and associated with poor prognosis. There is a paucity of data, however, regarding prognostic impact of each component of body composition (i.e., muscle, fat, and bone mass).

Purpose

We hypothesized that muscle, fat, and bone mass have different impact on prognosis in HF.

Methods

We retrospectively analyzed 418 patients admitted with a diagnosis of HF (71±13 years, 59% male, 46 and 54% with preserved/mid-range (left ventricular ejection fraction (LVEF) ≥40%) and reduced (<40%) LVEF), respectively). Dual-energy X-ray absorptiometry was performed at stable state after decongestion therapy.

Results

Mean appendicular skeletal mass index (ASMI) was 6.9±1.2 kg/m2 in men and 5.6±0.9 in women, so that 55% of patients had low muscle mass categorized by the Asian Working Group of Sarcopenia. During median follow-up of 502 days, 163 (39.0%) patients experienced primary outcome defined as death or heart failure hospitalization. Using optimal cut-off of each body component chosen on the basis of a receiver operating characteristic curve and the Youden method, we demonstrated that lower ASMI defined by the cut-off of 6.5 kg/m2 in male and 5.2 in female (adjusted hazard ratio (HR): 1.768, 95% CI: 1.210–2.581, p=0.003) and bone mass (adjusted HR: 1.498, 95% CI: 1.051–2.152, p=0.025), but not lower fat mass (p=0.34), were associated with elevated risk of primary outcome after multivariate adjustment. Kaplan-Meier curves with p value by Log-rank test were shown in figure. In subgroup analysis, negative impact of lower ASMI was significant regardless of sex and LVEF category, whereas negative impact of low bone mass was significant only in 78 female patients with reduced LVEF.

Figure 1

Conclusions

Indices about muscle and bone mass rather than fat mass had prognostic impact in HF. The impact of each body component may different according to sex and LVEF.

P2657Prognostic impact of skeletal muscle mass in upper and lower extremities in patients with ST-segment elevation myocardial infarction

Introduction

Sarcopenia, characterized by the loss of skeletal muscle mass and muscle strength, has been demonstrated the importance in cardiovascular diseases including ST-segment elevation myocardial infarction (STEMI). However, there is few data comparing the effects on the prognosis of skeletal muscle mass of upper and lower extremities in STEMI patients.

Purpose

Our purpose was to examine whether skeletal muscle mass of upper and lower extremities affect the prognosis after STEMI.

Methods

A total of 432 patients with STEMI were enrolled in this study. Dual-energy X-ray absorptiometry scan was performed before discharge. Each of upper and lower extremity skeletal muscle masses was indexed by height squared (kg/m2), and divided into two groups using the first quartile value for each sex. All patients were followed up for the primary composite outcome of all-cause death, nonfatal myocardial infarction, nonfatal ischemic stroke, hospitalization for congestive heart failure, and unplanned revascularization.

Results

During a median follow-up of 32 months, 68 patients experienced primary composite outcome. The event rate was significantly higher in patients with low-lower extremity skeletal muscle mass index (LESMI) than in those with high-LESMI (24.3% vs 12.9%, log-rank p<0.001), as well as in those with low-upper extremity muscle mass index than in those with high-upper extremity muscle mass index (UESMI) (19.6% vs 14.5%, log-rank p=0.047). However, after adjustment for age, gender, renal function, diabetes mellitus, infarct size, body mass index, and body fat percentage, only low-LESMI was independently and significantly associated with the primary composite outcome (adjusted hazard ratio for LESMI 2.11, 95%-confidence interval 1.06–4.14, p=0.034, adjusted hazard ratio for UESMI 1.04, 95%-confidence interval 0.52–2.08, p=0.906,).

Conclusions

Decreased muscle mass of lower extremity, rather than upper extremity, might have prognostic impact in patients with STEMI.

The role of protein-protein interactions mediated by the PB1 domain of NLP transcription factors in nitrate-inducible gene expression

BACKGROUND

NIN-LIKE PROTEIN (NLP) transcription factors are master regulators of nitrate-inducible gene expression in higher plants. NLP transcription factors contain a nitrate signal-responsive domain in the amino-terminal region, an RWP-RK-type DNA-binding domain in the middle, and a Phox and Bem1 (PB1) domain at the carboxy terminus. Although the PB1 domain of NLP transcription factors appears to mediate protein-protein interactions associated with nitrate-inducible gene expression in higher plants, its precise role in nitrate-inducible gene expression has not previously been characterized.

RESULTS

Yeast two-hybrid assays with the PB1 domain of the Arabidopsis transcription factor NLP7 revealed NLP-NLP interactions that required the core amino acid residues (K867, D909, D911, and E913) within the PB1 domain. Consistent with previous speculation on redundant and overlapping functions between different Arabidopsis NLP transcription factors, NLP-NLP interactions were observed between a variety of combinations of different NLP transcription factors. Furthermore, a mutated form of NLP7 that harbored amino acid substitutions at K867, D909, D911, and E913 required a far higher level of expression than wild-type NLP7 to restore nitrate-responsive gene expression and growth of nlp6 nlp7-1 double mutants. Surprisingly, however, the ability to transactivate nitrate-responsive promoters in protoplast transient expression assays was similar between wild-type and mutant forms of NLP7, suggesting that the PB1 domain was not required for transcription from naked DNA.

CONCLUSIONS

Protein-protein interactions mediated by the PB1 domain of NLP transcription factors are necessary for full induction of nitrate-dependent expression of target genes in planta. The PB1 domains of NLP transcription factors may act on gene expression from chromosomal DNA via homo- and hetero-oligomerization in the presence of nitrate.

Abstract P1-11-07: Risk analysis for chemotherapy induced nausea and vomiting (CINV) in patients receiving FEC100 treatment

BACKGROUND:

Anthracycline-containing regimens are standard treatment options in adjuvant and neoadjuvant chemotherapy in breast cancer. Chemotherapy-induced nausea and vomiting (CINV) is experienced frequently in patients receiving these regimens, but the risk factors for CINV are unknown.

OBJECTIVE:

The aim of this study was to investigate risk factors for CINV in anthracycline-containing regimens retrospectively.

METHODS:

Data were collected from the JONIE study, which was conducted in order to estimate the efficacy of zoledronic acid in a neoadjuvant setting from March 2010 to June 2012 (UMIN000003261). A total of 180 patients were recruited, and we used CINV data from the first cycle of FEC100 treatment and patient backgrounds. As the protocol regulation allowed the use of antiemetic drugs,in the first cycle of the FEC100 regimen, patients received various types of antiemetic agents, which we classified into four groups: Dexamethasone (DEX)+5-HT3 receptor antagonist (5-HT3)+neurokinin-1 receptor antagonist (NK1) (DEX+5-HT3+NK1) group; Dexamethasone (DEX)+5-HT3 receptor antagonist (5-HT3) (DEX+5HT3) group; Dexamethasone (DEX)+5-HT3 receptor antagonist (5-HT3)+dopamine receptor antagonist (DRA) (DEX+5HT3+DRA) group; and Dexamethasone (DEX)+5-HT3 receptor antagonist (5-HT3)+neurokinin-1 receptor antagonist (NK1)+ dopamine receptor antagonist (DRA) (DEX+5-HT3+NK1+DRA) group. Risk factors were selected from patient backgrounds and the combinations of antiemetic drugs. In patient backgrounds, the body mass index (BMI) was stratified into 3 categories: Less than 18.5 (underweight group); equal to or more than 18.5 but less than 25 (standard BMI group); and equal to or more than 25 (overweight group). The risks for CINV were analyzed by univariate and multivariate analyses. P values of less than 0.05 were defined as significant.

RESULTS:

In a univariate analysis of nausea, the body mass index (BMI) was the only significant factor (P&lt;0.05). On the other hand, BMI and the combination of antiemetic drugs were significant factors in vomiting. (P&lt;0.05 and 0.005, respectively). In a multivariate analysis of nausea, the P value for BMI was 0.02. The odds ratio for the underweight group was 7.745 (confidence interval: 2.171 to 27.634) compared with the standard BMI group. In a multivariate analysis of vomiting, BMI and the combination of antiemetic drugs were significant risk factors (P=0.025 and 0.023, respectively). The odds ratio for the underweight group was 3.481 (confidence interval: 1.183 to 10.241)compared with the standard BMI group. Furthermore, the odds ratios in the DEX+5-HT3+DRA and DEX+5HT3 groups were 5.005 (confidence interval: 1.543 to 16.239) and 4.178 (confidence interval: 1.428 to 12.222), respectively, compared with the DEX+5-HT3+NK1 group, which was consistent with the CINV guidelines in 2011.

CONCLUSIONS:

This study revealed that BMI was the most important risk factor for nausea, and that BMI and the combination of antiemetic drugs were risk factors for vomiting. Underweight-patients tend to have CINV in anthracycline-containing regimen. The DEX+5-HT3+NK1 group was the best antiemetic drug combination. These result show that following the CINV guideline treatment is mandatory in order to prevent CINV.

Citation Format: Hayashi M, Nakazawa K, Hasegawa Y, Horiguchi J, Miura D, Ishikawa T, Takao S, Kim SJ, Yamagami K, Miyashita M, Konishi M, Shigeoka Y, Suzuki M, Taguchi T, Kubota T, Tanino Y, Yamada K, Kimura K, Akazawa K, Kohno N. Risk analysis for chemotherapy induced nausea and vomiting (CINV) in patients receiving FEC100 treatment [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-11-07.

Randomized clinical trial of adjuvant gemcitabine chemotherapy versus observation in resected bile duct cancer

BACKGROUND

Although some retrospective studies have suggested the value of adjuvant therapy, no recommended standard exists in bile duct cancer. The aim of this study was to test the hypothesis that adjuvant gemcitabine chemotherapy would improve survival probability in resected bile duct cancer.

METHODS

This was a randomized phase III trial. Patients with resected bile duct cancer were assigned randomly to gemcitabine and observation groups, which were balanced with respect to lymph node status, residual tumour status and tumour location. Gemcitabine was given intravenously at a dose of 1000 mg/m² , administered on days 1, 8 and 15 every 4 weeks for six cycles. The primary endpoint was overall survival, and secondary endpoints were relapse-free survival, subgroup analysis and toxicity.

RESULTS

Some 225 patients were included (117 gemcitabine, 108 observation). Baseline characteristics were well balanced between the gemcitabine and observation groups. There were no significant differences in overall survival (median 62·3 versus 63·8 months respectively; hazard ratio 1·01, 95 per cent c.i. 0·70 to 1·45; P = 0·964) and relapse-free survival (median 36·0 versus 39·9 months; hazard ratio 0·93, 0·66 to 1·32; P = 0·693). There were no survival differences between the two groups in subsets stratified by lymph node status and margin status. Although haematological toxicity occurred frequently in the gemcitabine group, most toxicities were transient, and grade 3/4 non-haematological toxicity was rare.

CONCLUSION

The survival probability in patients with resected bile duct cancer was not significantly different between the gemcitabine adjuvant chemotherapy group and the observation group. Registration number: UMIN 000000820 (http://www.umin.ac.jp/).

Indications for partial parotidectomy using retrograde dissection of the marginal mandibular branch of the facial nerve for benign tumours of the parotid gland

The aims of this study were to evaluate the efficacy of partial parotidectomy using retrograde dissection of the marginal mandibular branch of the facial nerve for benign tumours of the parotid gland and to establish the indications for its use. We examined 106 consecutive patients with previously untreated benign tumours in the lower portion of the parotid gland who were treated by parotidectomy. The first group (anterograde group, n=52) consisted of those who had standard anterograde parotidectomy. The remaining patients, who underwent retrograde parotidectomy, were further divided into two groups: those in whom the upper edge of the tumour was located below the mastoid tip (below mastoid group, n=46) or those in whom it was above the mastoid tip (above mastoid group, n=8). The operating time was significantly shorter in the below mastoid group (141.2, 127.5, and 98.1minutes, respectively) as was intraoperative blood loss (41.1, 53.0, and 24.4ml, respectively), compared with the other two groups. There was a higher incidence of facial nerve dysfunction in the above mastoid group postoperatively (4/8) than in the other two groups. The results suggested that the presence of a tumour of any size located below the mastoid tip is a good indication for parotidectomy using retrograde dissection of the marginal mandibular branch of the facial nerve.

Repression of Nitrogen Starvation Responses by Members of the Arabidopsis GARP-Type Transcription Factor NIGT1/HRS1 Subfamily

Nitrogen (N) is often a limiting nutrient whose availability determines plant growth and productivity. Because its availability is often low and/or not uniform over time and space in nature, plants respond to variations in N availability by altering uptake and recycling mechanisms, but the molecular mechanisms underlying how these responses are regulated are poorly understood. Here, we show that a group of GARP G2-like transcription factors, Arabidopsis thaliana NITRATE-INDUCIBLE, GARP-TYPE TRANSCRIPTIONAL REPRESSOR1/HYPERSENSITIVE TO LOW Pi-ELICITED PRIMARY ROOT SHORTENING1 proteins (NIGT1/HRS1s), are factors that bind to the promoter of the N starvation marker NRT2.4 and repress an array of N starvation-responsive genes under conditions of high N availability. Transient assays and expression analysis demonstrated that NIGT1/HRS1s are transcriptional repressors whose expression is regulated by N availability. We identified target genes of the NIGT1/HRS1s by genome-wide transcriptome analyses and found that they are significantly enriched in N starvation response-related genes, including N acquisition, recycling, remobilization, and signaling genes. Loss of NIGT1/HRS1s resulted in deregulation of N acquisition and accumulation. We propose that NIGT1/HRS1s are major regulators of N starvation responses that play an important role in optimizing N acquisition and utilization under fluctuating N conditions.

Abstract P5-16-10: Zoledronic acid combined with neoadjuvant chemotherapy for HER2-negative early breast cancer (JONIE 1 trial): Survival outcomes of a randomized multicenter phase 2 trial

BACKGROUND and AIM:

Findings from a randomized phase 2 JONIE1 trial in women with HER2-negative early breast cancer have shown that the addition of zoledronic acid (ZOL) to neoadjuvant chemotherapy (CT) has potential anticancer benefits in postmenopausal and triple-negative breast cancer patients. We report the data for the prespecified secondary endpoint of disease-free survival (DFS).

METHODS:

We enrolled women with HER2-negative early breast cancer and randomly assigned them to receive CT or CT+ZOL (CTZ). All patients received 4 cycles of FEC100 (fluorouracil 500 mg/m2, epirubicin 100 mg/m2, and cyclophosphamide 500 mg/m2), followed by 12 cycles of paclitaxel at 80 mg/m2 weekly. ZOL (4 mg) was administered 3-4 times weekly for 7 weeks to the CTZ group patients. Definitive surgery was performed 3-4 weeks after the last paclitaxel dose. The primary endpoint was pathological complete response (pCR). The secondary endpoints were the clinical response rates, rate of breast-conserving surgery, safety, and DFS (defined as the time from randomization to disease occurrence or death). The trial is registered as UMIN000003261 (www.umin.ac.jp/english/) with ongoing follow-up.

FINDINGS:

Of the 188 patients enrolled, 95 were assigned to the CT group and 93 to the CTZ group. The mean (95% CI) DFS time of the CT group was 5.15 years (4.83-5.47) and that of the CTZ group was 5.38 years (5.11-5.66). The 3-year DFS rate was 84.6% (95% CI 77.2-92.0) in the CT group and 90.7% (84.6-96.8) in the CTZ group with no significant difference (p = 0.120). The particular benefit from ZOL for the neoadjuvant CT seen as improvement of the pCR rate was indicated in the 3-year DFS period for triple-negative cancer cases (CT vs CTZ: 70.6% vs 94.1%), but not for postmenopausal cases.

CONCLUSIONS:

ZOL slightly improved DFS when combined with CT. Although a significant difference was not found in this study, plans are underway for conducting a combined analysis of 3 neoadjuvant CT trials together with ZOL. The improvement of the pCR rate may be associated with DFS in triple-negative cases. Previous studies have shown that ZOL was more efficacious in an estrogen-suppressed condition. However, the short-term application of ZOL in this study may not be sufficient to improve the outcome in postmenopausal patients.

Citation Format: Ishikawa T, Akazawa K, Hasegawa Y, Tanino H, Horiguchi J, Miura D, Hayashi M, Takao S, Kim SJ, Yamagami K, Miyashita M, Konishi M, Shigeoka Y, Suzuki M, Taguchi T, Kubota T, Kohno N. Zoledronic acid combined with neoadjuvant chemotherapy for HER2-negative early breast cancer (JONIE 1 trial): Survival outcomes of a randomized multicenter phase 2 trial [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-16-10.

142 POSSIBLE BENEFIT OF INTRACYTOPLASMIC SPERM INJECTION ON THE EFFICIENCY OF EMBRYO PRODUCTION IN AGED COWS

Reduction in oocyte quality is a major factor responsible for declining fertility with age. The abnormal fertilization rate of oocytes from aged cows was reportedly higher than that of oocytes from young cows (Iwata et al. 2011. Reprod. Fertil. Dev. 23, 424–432). We hypothesised that assisted fertilization by intracytoplasmic sperm injection (ICSI) might improve the developmental abilities of oocytes collected from aged females. The aims of the study were (1) to determine the effect of maternal aging on the ability of bovine oocytes to undergo cytoplasmic maturation, fertilization, and further embryo development; and (2) to determine whether ICSI would improve the efficiency of embryo production in aged cows. Cows aged 30 to 50 months or >120 months were defined as young or aged, respectively. Cumulus-oocyte complexes were harvested from abattoir-derived ovaries of young (40 ± 7 months, n = 89) and aged (136 ± 12 months, n = 55) Holstein cows and matured for 23 h in TCM-199 supplemented with 5% fetal bovine serum (FBS) at 38.5°C under 5% CO2 with saturated humidity. Then, surrounding cumulus cells were removed, and cortical granules in the oocyte were stained with Lens culinaris–fluorescein isothiocyanate to evaluate the cytoplasmic maturation. Matured oocytes were inseminated by IVF or ICSI. At 15 h post-insemination, the numbers of pronuclei were determined to evaluate the fertilization rates. Presumptive IVF- or ICSI-derived zygotes were cultured for 5 days in CR1aa medium with 2% FBS and subsequently in USU6 with 5% FBS for 3 days at 38.5°C in 5% O2, 5% CO2, and 90% N2 with saturated humidity. Chromosome numbers of blastocysts were counted to evaluate the effect of maternal aging on ploidy. All experiments were performed with more than 4 independent runs, and data were analysed using chi-square tests. The distribution of matured oocytes into different cortical granule classes was affected by age, with a significantly lower (P < 0.01) proportion of class III (mature cytoplasm) oocytes from aged cows (29%) compared with those from young cows (57%). Although fertilization rates following IVF did not differ between the groups, the proportion of abnormal fertilization (more than 2 pronuclei) was 32% in the aged group: higher than in the young group (15%; P < 0.01). The rates of cleaved embryos following IVF were the same among groups, but the rate of development to the blastocyst stage of oocytes from aged cows (38%) was significantly (P < 0.05) lower than in those from young cows (52%). Moreover, the proportion of diploid blastocysts with 2 sets of chromosomes (2n = 60) was lower (47%) in the aged than in the young groups (75%; P < 0.05). However, in the ICSI embryos, the rates of development to the blastocyst stage did not differ significantly between groups (young 36%; aged 43%). Thus, maternal aging might impair the cytoplasmic maturation of bovine oocytes, which could be associated with abnormal fertilization or low developmental competence. Our results also indicate possible beneficial effects of ICSI on the efficiency of embryo production in aged cows.

Abstract P3-07-50: Early and accurate prediction of pathological response by magnetic resonance imaging and ultrasonography in patients undergoing neoadjuvant chemotherapy for operable breast cancer

Background: Neoadjuvant chemotherapy (NAC) reduces tumor size, and increases the frequency of breast-conserving surgery in operable breast cancers. Response predictions to NAC are made based on diagnostic imaging.

Although various studies have reported the optimal timing for diagnostic imaging, this still remains unclear.

Purpose: To identify the optimal timing of diagnostic imaging for the response prediction to NAC, and to evaluate the accuracy of response prediction.

Methods: We evaluated 146 cases enrolled in the JONIE-1 study (a randomized controlled trial comparing zoledronic acid plus chemotherapy with chemotherapy alone as a NAC in patients with HER2-negative primary breast cancer). The chemotherapy regimen was FEC100×4 courses followed by weekly paclitaxel 80×12 courses (± zoledronic acid). Statistical analysis of the association between the tumor reduction ratio and the histopathological response and the prediction of pathological complete response (pCR) was performed using JMP software. The maximum tumor diameter was evaluated using magnetic resonance imaging and ultrasound on each patient 3 times (before NAC, after FEC treatment, after NAC) and tumor reduction ratios were calculated.

Results: The average age of the patients was 49.8 years old. The menopause status was pre-menopause in 84 patients, and post-menopause in 58 patients. Regarding the subtype classification, 116 patients were of the luminal type (Lum) and 26 patients were triple negative (TN), and the Ki-67 labeling index had a median of 25% (1%-93%).

Pathological examination demonstrated that 16 patients had pCR(11.3%, Lum, 9;TN: 7), and 126 patients had non-pCR (88.7%, Lum:107; TN:19). Seven patients had clinical-CR (4.8%, Lum: 4; TN: 3) at post-FEC, and 26 patients (17.8%, Lum: 20; TN: 6) at post-NAC. The prediction of pCR at post-FEC and post-NAC was evaluated by single variable analysis, resulting in an AUC (0.75645) p=0.0017 at post-FEC, and AUC (0.76563) p=0.0001 at post-NAC. The sensitivity / specificity / positive predictive value / negative predictive value were 0.625 / 0.873 / 0.385 / 0.948 at post-FEC, 0.250 / 0.976 / 0.571 / 0.911 at post-NAC, respectively. In TN cases, the values were 0.714 / 0.947 / 0.833 / 0.900 in post-FEC, and 0.429 / 1.000 / 1.000 / 0.826 in post-NAC.

Conclusions: Diagnostic imaging evaluation performed after FEC treatment was useful for the prediction of pCR. Furthermore, the reliability was high in Triple Negative Sub type, but is affected by the existence of residual tumors in Luminal type.

Citation Format: Kaise H, Ishikawa T, Miura D, Hasegawa Y, Horiguchi J, Hayashi M, Takao S, Kim SJ, Tanino H, Miyashita M, Konishi M, Shigeoka Y, Yamagami K, Suzuki M, Taguchi T, Akazawa K, Kohno N. Early and accurate prediction of pathological response by magnetic resonance imaging and ultrasonography in patients undergoing neoadjuvant chemotherapy for operable breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-07-50.

235 ADMINISTRATION OF LEVOTHYROXINE IMPROVES THE PROPORTION OF TRANSFERABLE EMBRYOS FOLLOWING SUPEROVULATION IN JAPANESE BLACK CATTLE

The thyroid gland has a major impact on the human female reproductive system. However, its influence on reproductive competence in livestock is unclear. In cattle, superovulatory treatments often lead to high numbers of ova/embryos but low numbers of transferable embryos. Levothyroxine is a synthetic thyroid hormone that is chemically identical to thyroxine (T4), and binds to T4 receptors found in follicle cells. We aimed to determine whether levothyroxine treatment (LT) could improve the proportion of transferable embryos after superovulation in Japanese black cattle (Wagyu). First, we observed associations between the concentrations of T4, free triiodothyronine and thyroxine, and superovulatory responses (n = 95). Blood was collected before superovulatory treatment by jugular venipuncture, and serum was separated and stored at –20°C until being assayed for thyroid hormones. Second, Wagyu cattle showing a low proportion of transferable embryos (<30%) were assigned randomly to an LT group (n = 10) or a control group (no LT, n = 15); the LT was administered by 3 i.m. injections of 2000 mg of levothyroxine given 3 days apart; Controls received no injection. On the last day of LT, hormonal stimulation for superovulation was started as described (Ideta et al. 2007 Cloning Stem Cells 9, 571–580). The proportion of transferable embryos was compared with the same individual before/after LT. Data were analysed using Student’s t-tests. There were no significant associations between the concentrations of thyroid hormones and the superovulatory responses (no. collected oocytes/embryos, or the proportions of transferable embryos or unfertilized oocytes). However, LT dramatically increased the proportion of transferable embryos in these low-responding Wagyu cattle (Table 1). In conclusion, administration of levothyroxine improved the proportion of transferable embryos following superovulatory treatment. Further studies will be needed to investigate how LT improves the quality of bovine embryos. Table 1.Effect of levothyroxine treatment on the proportion of transferable embryos after superovulation in Wagyu cattle (means ± SE)

Transcriptional repression caused by Dof5.8 is involved in proper vein network formation in Arabidopsis thaliana leaves

Vascular plants have a network of vasculature in their leaves, which supplies water and nutrients and exports photoassimilates to other tissues. The vascular network is patterned during the development of leaf primordia through the induction of provascular differentiation by auxin. Arabidopsis thaliana Dof5.8, encoding a Dof-type transcription factor, is expressed early in provascular cells under the control of the MONOPTEROS transcription factor, also known as auxin response factor 5 (ARF5). Here, we report the effect of overexpressing Dof5.8 in provascular cells on the formation of the vascular network. Overexpression of Dof5.8 inhibited the formation of higher-order veins in cotyledons and leaves, probably through transcriptional repression by Dof5.8. The expression of auxin-associated transcription factor genes, DORNRöSCHEN and SHI-RELATED SEQUENCE 5, was downregulated in the Dof5.8 overexpressors, and overexpression of these genes partially rescued the impaired formation of higher-order veins in Dof5.8-overexpressing lines, suggesting that the overexpression of Dof5.8 modulates the auxin response and leads to impaired vein formation in A. thaliana.

MONOPTEROS directly activates the auxin-inducible promoter of the Dof5.8 transcription factor gene in Arabidopsis thaliana leaf provascular cells

MONOPTEROS (MP) is an auxin-responsive transcription factor that is required for primary root formation and vascular development, whereas Dof5.8 is a Dof-class transcription factor whose gene is expressed in embryos as well as the pre- and procambial cells in the leaf primordium in Arabidopsis thaliana. In this study, it is shown that MP directly activates the Dof5.8 promoter. Although no apparent phenotype of the single dof5.8 mutants was found, phenotypic analysis with the mp dof5.8 double mutants revealed that mutations within Dof5.8 enhanced the phenotype of a weak allele of mp, with an increase in the penetrance of the 'rootless' phenotype and a reduction in the number of cotyledons. Furthermore, interestingly, although mp mutants showed reduced vascular pattern complexity in cotyledons, the mp dof5.8 double mutants displayed both more simplex and more complex vascular patterns in individual cotyledons. These results imply that the product of Dof5.8 whose expression is regulated by MP at least in part might be involved in multiple processes controlled by MP.

Emergence of a new step towards understanding the molecular mechanisms underlying nitrate-regulated gene expression

Nitrogen is one of the primary macronutrients of plants, and nitrate is the most abundant inorganic form of nitrogen in soils. Plants take up nitrate in soils and utilize it both for nitrogen assimilation and as a signalling molecule. Thus, an essential role for nitrate in plants is triggering changes in gene expression patterns, including immediate induction of the expression of genes involved in nitrate transport and assimilation, as well as several transcription factor genes and genes related to carbon metabolism and cytokinin biosynthesis and response. Significant progress has been made in recent years towards understanding the molecular mechanisms underlying nitrate-regulated gene expression in higher plants; a new stage in our understanding of this process is emerging. A key finding is the identification of NIN-like proteins (NLPs) as transcription factors governing nitrate-inducible gene expression. NLPs bind to nitrate-responsive DNA elements (NREs) located at nitrate-inducible gene loci and activate their NRE-dependent expression. Importantly, post-translational regulation of NLP activity by nitrate signalling was strongly suggested to be a vital process in NLP-mediated transcriptional activation and subsequent nitrate responses. We present an overview of the current knowledge of the molecular mechanisms underlying nitrate-regulated gene expression in higher plants.

Nitrite transport activity of a novel HPP family protein conserved in cyanobacteria and chloroplasts

Some cyanobacterial genomes encode an integral membrane protein of the HPP family, which exhibited nitrite transport activity when expressed in the nitrite transport-less NA4 mutant of the cyanobacterium Synechococcus elongatus strain PCC 7942. AT5G62720 and AT3G47980 were found to encode Arabidopsis homologs of the cyanobacterial protein. The product of AT5G62720 was localized to the chloroplast envelope membrane and was shown to confer nitrite uptake activity on the NA4 mutant when expressed with an N-terminally truncated transit peptide or as a fusion with the N-terminal region of the cyanobacterial HPP family protein. Kinetic analyses showed that the Arabidopsis protein has much higher affinity for nitrite (K(m) = 13 µM) than the cyanobacterial protein (K(m) = 150 µM). Illuminated chloroplasts isolated from the mutant lines of AT5G62720 showed much lower activity of nitrite uptake than the chloroplasts isolated from the wild-type Col-0 plants, while the chloroplasts of the mutants of AT1G68570 (AtNPF3.1), the gene previously reported to encode a plastid nitrite transporter AtNitr1, showed wild-type levels of nitrite uptake activity. AT3G47980 was expressed in roots but not in shoots. It has a putative transit peptide similar to that of AT5G62720 and its fusion with the N-terminal region of the cyanobacterial HPP protein showed low but significant activity of nitrite transport in the cyanobacterial cell. Transcription of AT5G62720 (AtNITR2;1) and AT3G47980 (AtNITR2;2) was stimulated by nitrate under the control of the NIN-like proteins, suggesting that the HPP proteins represent nitrate-inducible components of the nitrite transport system of plastids.

Arabidopsis NIN-like transcription factors have a central role in nitrate signalling

In plants, nitrate is not only a major nitrogen source but also a signalling molecule that modulates the expression of a wide range of genes and that regulates growth and development. The critical role of nitrate as a signalling molecule has been established for several decades. However, the molecular mechanisms underlying the nitrate response have remained elusive, as the transcription factor that primarily responds to nitrate signals has not yet been identified. Here we show that Arabidopsis NIN-LIKE PROTEIN (NLP) family proteins bind the nitrate-responsive cis-element and activate nitrate-responsive cis-element-dependent and nitrate-responsive transcription. Our results also suggest that the activity of NLPs is post-translationally modulated by nitrate signalling. Furthermore, the suppression of NLP function impairs the nitrate-inducible expression of a number of genes and causes severe growth inhibition. These results indicate that NLPs are the transcription factors mediating the nitrate signal and thereby function as master regulators of the nitrate response.

The evolutionary events necessary for the emergence of symbiotic nitrogen fixation in legumes may involve a loss of nitrate responsiveness of the NIN transcription factor

NODULE INCEPTION (NIN) is a key regulator of the symbiotic nitrogen fixation pathway in legumes including Lotus japonicus. NIN-like proteins (NLPs), which are presumably present in all land plants, were recently identified as key transcription factors in nitrate signaling and responses in Arabidopsis thaliana, a non-leguminous plant. Here we show that both NIN and NLP1 of L. japonicus (LjNLP1) can bind to the nitrate-responsive cis-element (NRE) and promote transcription from an NRE-containing promoter as did the NLPs of A. thaliana (AtNLPs). However, differing from LjNLP1 and the AtNLPs that are activated by nitrate signaling through their N-terminal regions, the N-terminal region of NIN did not respond to nitrate. Thus, in the course of the evolution of NIN into a transcription factor that functions in nodulation in legumes, some mutations might arise that converted it to a nitrate-insensitive transcription factor. Because nodule formation is induced under nitrogen-deficient conditions, we speculate that the loss of the nitrate-responsiveness of NIN may be one of the evolutionary events necessary for the emergence of symbiotic nitrogen fixation in legumes.

The evolutionary events necessary for the emergence of symbiotic nitrogen fixation in legumes may involve a loss of nitrate responsiveness of the NIN transcription factor

NODULE INCEPTION (NIN) is a key regulator of the symbiotic nitrogen fixation pathway in legumes including Lotus japonicus. NIN-like proteins (NLPs), which are presumably present in all land plants, were recently identified as key transcription factors in nitrate signaling and responses in Arabidopsis thaliana, a non-leguminous plant. Here we show that both NIN and NLP1 of L. japonicus (LjNLP1) can bind to the nitrate-responsive cis-element (NRE) and promote transcription from an NRE-containing promoter as did the NLPs of A. thaliana (AtNLPs). However, differing from LjNLP1 and the AtNLPs that are activated by nitrate signaling through their N-terminal regions, the N-terminal region of NIN did not respond to nitrate. Thus, in the course of the evolution of NIN into a transcription factor that functions in nodulation in legumes, some mutations might arise that converted it to a nitrate-insensitive transcription factor. Because nodule formation is induced under nitrogen-deficient conditions, we speculate that the loss of the nitrate-responsiveness of NIN may be one of the evolutionary events necessary for the emergence of symbiotic nitrogen fixation in legumes.

A nitrate-inducible GARP family gene encodes an auto-repressible transcriptional repressor in rice

Nitrogen is the most important macronutrient in plants and its supply induces responses in gene expression, metabolism and developmental processes. However, the molecular mechanisms underlying the nitrogen responses remain poorly understood. Here we show that the supply of nitrate but not ammonium immediately induces the expression of a transcriptional repressor gene in rice, designated NIGT1 (Nitrate-Inducible, GARP-type Transcriptional Repressor 1). The results of DNA-binding site selection experiments and electrophoretic mobility shift assays indicated that NIGT1 binds to DNA containing either of two consensus sequences, GAATC or GAATATTC. In transient reporter assays, NIGT1 was found to repress transcription from the promoters containing the identified NIGT1-binding sequences in vivo. Furthermore, NIGT1 repressed the activity of its own promoter, suggesting an autorepression mechanism. Consistently, nitrate-induced NIGT1 expression was found to be down-regulated after a transient peak during nitrate treatment, and the nitrate-induced expression of NIGT1 decreased in transgenic rice plants in which this gene was constitutively overexpressed. Furthermore, the chlorophyll content that could be a marker of nitrogen utilization was found to be decreased in NIGT1 overexpressors of rice grown with nitrate medium but not with ammonium medium. Thus, we propose NIGT1 as a nitrate-inducible and autorepressible transcriptional repressor that may play a role in the nitrogen response in rice. Taken together with the fact that the NIGT1-binding sites are conserved in promoter sequences of Arabidopsis NIGT1 homologs, our findings imply the presence of a time-dependent complex system for nitrate-responsive transcriptional regulation that is conserved in both monocots and dicots.