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.

Glycaemic management in a child with ornithine transcarbamylase deficiency undergoing cardiac surgery with hypothermic cardiopulmonary bypass

There is a lack of evidence regarding the optimal intra-operative glycaemic level of patients with ornithine transcarbamylase deficiency to prevent cerebral oedema due to protein catabolism and hyperammonemia. We describe a case of a two-year-old girl with ornithine transcarbamylase deficiency who underwent cardiac surgery requiring cardiopulmonary bypass. A high-dose dextrose infusion to prevent protein catabolism was given throughout surgery, which caused uncontrollable hyperglycaemia unresponsive to high-dose insulin administration. Factors contributing to the hyperglycaemia may have included surgical stress, steroid administration and hypothermia. During invasive surgery, anaesthetists should carefully adjust the rates of dextrose and insulin infusions, guided by close monitoring of blood ammonia, glucose and lactate.

Integration of Single-Cell RNA- and CAGE-seq Reveals Tooth-Enriched Genes

Organ development is dictated by the regulation of genes preferentially expressed in tissues or cell types. Gene expression profiling and identification of specific genes in organs can provide insights into organogenesis. Therefore, genome-wide analysis is a powerful tool for clarifying the mechanisms of development during organogenesis as well as tooth development. Single-cell RNA sequencing (scRNA-seq) is a suitable tool for unraveling the gene expression profile of dental cells. Using scRNA-seq, we can obtain a large pool of information on gene expression; however, identification of functional genes, which are key molecules for tooth development, via this approach remains challenging. In the present study, we performed cap analysis of gene expression sequence (CAGE-seq) using mouse tooth germ to identify the genes preferentially expressed in teeth. The CAGE-seq counts short reads at the 5'-end of transcripts; therefore, this method can quantify the amount of transcripts without bias related to the transcript length. We hypothesized that this CAGE data set would be of great help for further understanding a gene expression profile through scRNA-seq. We aimed to identify the important genes involved in tooth development via bioinformatics analyses, using a combination of scRNA-seq and CAGE-seq. We obtained the scRNA-seq data set of 12,212 cells from postnatal day 1 mouse molars and the CAGE-seq data set from postnatal day 1 molars. scRNA-seq analysis revealed the spatiotemporal expression of cell type-specific genes, and CAGE-seq helped determine whether these genes are preferentially expressed in tooth or ubiquitously. Furthermore, we identified candidate genes as novel tooth-enriched and dental cell type-specific markers. Our results show that the integration of scRNA-seq and CAGE-seq highlights the genes important for tooth development among numerous gene expression profiles. These findings should contribute to resolving the mechanism of tooth development and establishing the basis for tooth regeneration in the future.

Hepatocellular uptake index obtained with gadoxetate disodium-enhanced magnetic resonance imaging in the assessment future liver remnant function after major hepatectomy for biliary malignancy

Background

Functional assessment of the future liver remnant (FLR) after major hepatectomy is essential but often difficult in patients with biliary malignancy, owing to obstructive jaundice and portal vein embolization. This study evaluated whether a novel index using gadoxetate disodium-enhanced MRI (EOB-MRI) could predict posthepatectomy liver failure (PHLF) after major hepatectomy for biliary malignancy.

Methods

The remnant hepatocellular uptake index (rHUI) was calculated in patients undergoing EOB-MRI before major hepatectomy for biliary malignancy. Receiver operating characteristic (ROC) curve analyses were used to evaluate the accuracy of rHUI for predicting PHLF grade B or C, according to International Study Group of Liver Surgery criteria. Multivariable logistic regression analyses comprised stepwise selection of parameters, including rHUI and other conventional indices.

Results

This study included 67 patients. The rHUI accurately predicted PHLF (area under the curve (AUC) 0.896). A cut-off value for rHUI of less than 0.410 predicted all patients who developed grade B or C PHLF. In multivariable analysis, only rHUI was an independent risk factor for grade B or C PHLF (odds ratio 2.0 × 10³, 95 per cent c.i. 19.6 to 3.8 × 10⁷; P < 0.001). In patients who underwent preoperative portal vein embolization, rHUI accurately predicted PHLF (AUC 0.885), whereas other conventional indices, such as the plasma disappearance rate of indocyanine green of the FLR and FLR volume, did not.

Conclusion

The rHUI is potentially a useful predictor of PHLF after major hepatectomy for biliary malignancy.

Circulating presepsin (soluble CD14 subtype) as a novel marker of mortality in patients treated at medical cardiac intensive care units

Background

Presepsin, a subtype of soluble CD14, is an inflammatory marker, which largely reflects monocyte activation. The association between presepsin levels and mortality in patients treated at medical cardiac intensive care units (CICUs) remains poorly known.

Objective

We aimed to understand the prognostic value of presepsin levels on admission to medical CICUs for mortality.

Methods

We prospectively studied 1636 heterogeneous patients (median age; 71 years) treated at medical (non-surgical) CICUs. Patients with stage 5 chronic kidney disease (estimated glomerular filtration rate [eGFR] &lt;15 mL/min/1.73 m2) were excluded. Acute coronary syndrome was present in 46% of the patients, and acute decompensated heart failure in 36%. Upon admission, baseline plasma presepsin levels were measured. The primary endpoint was all-cause death.

Results

During a mean follow-up period of 44.6 months after admission, there were 323 (19.7%) deaths. Patients who died were older (median: 75 vs. 71 years, P&lt;0.0001); had higher levels of presepsin (194 vs. 110 pg/mL, P&lt;0.0001), B-type natriuretic peptide (BNP: 520 vs. 144 pg/mL, P&lt;0.0001), high-sensitivity C-reactive protein (hsCRP: 4.7 vs. 2.0 mg/L, P&lt;0.0001), and sequential organ failure assessment (SOFA) score (3 vs. 2, P&lt;0.0001); and had lower levels of eGFR (55 vs. 69 mL/min/1.73m2, P&lt;0.0001) and left ventricular ejection fraction (46% vs. 52%, P&lt;0.0001) than those of the survivors. Multivariate Cox regression analyses revealed presepsin levels as independent predictors of all-cause deaths when assessed as either continuous variables (relative risk [RR] 3.33 per 10-fold increment; P&lt;0.0001) or variables categorized according to quartiles (RR quartile 4 vs. 1, 3.60; P&lt;0.0001). Quartiles of presepsin levels were significantly (P&lt;0.0001) associated with increased risk of mortality (Figure). Adding presepsin levels to a baseline model that included established risk factors, BNP, and hsCRP further enhanced reclassification (P=0.009) and discrimination (P=0.0008) beyond that of the baseline model alone.

Conclusions

Circulating concentration of presepsin on admission may be a potent and independent predictor of mortality, and it may improve the risk stratification of patients admitted at medical CICUs.

Presepsin quartiles and mortality

Funding Acknowledgement

Type of funding source: None

Functional Analysis of PTH1R Variants Found in Primary Failure of Eruption

Although many variants of the parathyroid hormone 1 receptor (PTH1R) gene are known to be associated with primary failure of eruption (PFE), the mechanisms underlying the link remains poorly understood. We here performed functional analyses of PTH1R variants reported in PFE patients-namely, 356C>T (P119L), 395C>T (P132L), 439C>T (R147C), and 1148G>A (R383Q)-using HeLa cells with a lentiviral vector-mediated genetic modification. Two particular variants, P119L and P132L, had severe reduction in a level of N-linked glycosylation when compared with wild-type PTH1R, whereas the other 2 showed modest alteration. PTH1R having P119L or P132L showed marked decrease in the affinity to PTH_1-34, which likely led to severely impaired cAMP accumulation upon stimulation in cells expressing these mutants, highlighting the importance of these 2 amino acid residues for ligand-mediated proper functioning of PTH1R. To further gain insights into PTH1R functions, we established the induced pluripotent stem cell (iPSC) lines from a patient with PFE and the heterozygous P132L mutation. When differentiated into osteoblastic-lineage cells, PFE-iPSCs showed no abnormality in mineralization. The mRNA expression of RUNX2, SP7, and BGLAP, the osteoblastic differentiation-related genes, and that of PTH1R were augmented in both PFE-iPSC-derived cells and control iPSC-derived cells in the presence of bone morphogenetic protein 2. Also, active vitamin D₃ induced the expression of RANKL, a major key factor for osteoclastogenesis, equally in osteoblastic cells derived from control and PFE-iPSCs. In sharp contrast, exposure to PTH_1-34 resulted in no induction of RANKL mRNA expression in the cells expressing P132L variant PTH1R, consistent with the idea that a type of heterozygous PTH1R gene mutation would spoil PTH-dependent response in osteoblasts. Collectively, this study demonstrates a link between PFE-associated genetic alteration and causative functional impairment of PTH1R, as well as a utility of iPSC-based disease modeling for future elucidation of pathogenesis in genetic disorders, including PFE.

P251 Right ventricular free wall dissection clearly detected and recorded by echocardiography: a fatal complication after inferior myocardial infarction

An 81-year-old man was transferred to our institution by ambulance because of poor feeding, general fatigue and slight disorientation lasting for a week. On arrival, he was awake and able to speak, however, his blood pressure was low at 61/43 mmHg in spite of his medical history of hypertension. His ECG showed abnormal Q waves and ST elevation in II, III, aVF leads. The echo exam detected severe hypokinesis in the left ventricular inferior wall and reduced ejection fraction at 30%. Pericardial effusion was not observed in the first echo exam. The patient was diagnosed as cardiogenic shock due to recent inferior myocardial infarction. Coronary angiography was performed, which detected total occlusion of mid right coronary artery, followed by a successful percutaneous coronary intervention (PCI) with a drug-eluting stent under the support of intra-aortic balloon pumping. Nevertheless, his blood pressure remained low and intravenous adrenaline administration was necessary during and even after PCI. To detect the cause of prolonged low blood pressure, echo was performed again immediately after PCI. The echo exam detected new findings: right ventricular posterior free wall was dissected and abnormal shunt flows were obviously observed from left ventricle to right atrium through the dissection cavity during systole. An urgent surgical repair was considered as the only option for his survival, however, his family did not accept it because the operation itself was too risky. On the next day of his admission, he passed away. Right ventricular free wall dissection is a very rare but fatal complication after inferior myocardial infarction, nevertheless, we could detect it by echocardiography with clearly recorded images.

Abstract P251 Figure.

P1512 Combination of mitral annular peak systolic and early diastolic velocities with early transmitral peak flow velocity: a new prognostic echo index in patients with acute coronary syndrome

Background

One of the novel echocardiographic indices reflecting left ventricular (LV) diastolic filling is the combination of mitral annular peak systolic (s’) and early diastolic velocities (e’) with early transmitral peak flow velocity (E); E/(e’ x s’). This index is reported to be useful to predict a prognosis of heart failure patients regardless of their LV ejection fraction (LVEF).Purpose: The aim of this study was to examine whether or not E/(e’ x s’) could predict cardiac events in patients with acute coronary syndrome (ACS).Methods: We studies consecutive ACS patients hospitalized in our institution between December 2009 and February 2012. They underwent echo examination within 7 days after admission. By use of Doppler tissue imaging, e’ and s’ were respectively calculated by averaging the peak velocities measured at both septal and lateral mitral annulus in 4-chamber view. The exclusion criteria were as follows: atrial fibrillation, significant valvular diseases and inadequate echo images. Cardiac events were defined as re-hospitalization due to recurrent ACS and/or heart failure, and cardiac mortality.Results: In total, 168 patients were eligible for this study (mean age 67 ± 11 years, mean LVEF 51.7 ± 10.3 %). Median follow-up period was 22.5 months. During the follow-up, cardiac events occurred in 27 patients (16.1%). Between the patients with cardiac events and those without, there were significant differences in LV end-systolic volume (44.2 ± 29.1 vs 33.2 ± 13.6 ml, p &lt; 0.05), LV mass index (122.4 ± 38.9 vs 107.5 ± 26.4 g/m², p &lt; 0.05), left atrial volume index (31.7 ± 9.2 vs 27.6 ± 9.4 ml/m², p &lt; 0.05), LVEF (45.7 ± 13.5 vs 52.9 ± 9.2 %, p &lt; 0.05), s’ (5.1 ± 1.6 vs 7.1 ± 1.7 cm/sec, p &lt; 0.001), e’ (4.8 ± 1.3 vs 6.0 ± 1.9 cm/sec, p &lt; 0.05), E/e’ (16.4 ± 6.6 vs 12.5 ± 4.9, p &lt; 0.05), E/(e’ x s’) (3.78 ± 2.52 vs 1.94 ± 1.08, p &lt; 0.001), and serum B-type natriuretic peptide (334.7 ± 420.1 vs 113.8 ± 177.2 pg/ml, p &lt; 0.05). While Cox proportional hazard multivariate analysis detected that E/(e’ x s’) and E/e’ were independent predictors of cardiac events, E/(e’ x s’) was more powerful than E/e’ (p = 0.0002 vs p = 0.0072). ROC analysis revealed that 2.35 of E/(e’ x s’) was the optimal cutoff values to predict cardiac events in ACS patients (AUC 0.79). Patients with E/(e’ x s’) &lt;2.35 had significantly better prognosis than the rest (p &lt; 0.0001, Log-rank; Figure)Conclusion: E/(e’ x s’) could be a useful echo marker to predict cardiac events in ACS patients.

Abstract P1512 Figure.

P1508 Left ventricular diastolic function plays a different role on mortality depending on the severity of systolic dysfunction in acute heart failure patients with reduced ejection fraction

Background

It remains to be clarified whether clinical significance of left ventricular (LV) diastolic function differs depending on the severity of LV systolic dysfunction in patients with acute heart failure (AHF). The aim of this study was to examine the prognostic role of LV diastolic function in AHF patients with various systolic dysfunction.Methods: We studied consecutive hospitalized AHF patients with LV ejection fraction (LVEF) &lt;50%. The exclusion criteria were as follows: atrial fibrillation, severe mitral regurgitation, and inadequate echo image quality. They underwent echocardiography on admission. The eligible patients (n = 289, 165 males, 76 ± 10 years) were divided into 4 groups based on LVEF and left atrial pressure (LAP) grade estimated as in the ESC guidelines: Group I (LVEF 40-49% (mildly reduced LVEF)/normal LAP, n = 28), II (mildly reduced EF/increased LAP, n = 38), III (LVEF &lt;40% (severely reduced LVEF)/normal LAP, n = 110), and IV (severely reduced LVEF/increased LAP, n = 113). Cardiac death was examined up to 60 months.Results: In total, 58 patients (20%) died because of cardiac events during the follow-up (mean 20 ± 19 months). In patients with mildly reduced LVEF, Group I showed significantly less cardiac death ratio than II (n = 1 vs 10, Group I vs II, p = 0.03). On the other hand, in patients with severely reduced LVEF, there was no significant difference in cardiac death ratio between Group III and IV (n = 23 vs 24, Group III vs IV, p = 0.80). That is, LAP grade was a prognostic marker when the patients had mild LV systolic dysfunction, whereas it did not contribute to the prediction of cardiac mortality when patients showed severely reduced LV systolic function. Group I showed significantly better prognosis than those with severe LV systolic dysfunction regardless of LAP grade (Group III, IV) (Group I vs III, p = 0.04; Group I vs IV, p = 0.04).Conclusions: LV diastolic function may have a different clinical significance depending on the severity of LV systolic dysfunction in AHF patients.

P1386 A change in left ventricular global longitudinal strain is a prognostic indicator in congestive heart failure patients with preserved ejection fraction

Purposes

We examined how changes in left ventricular (LV) global longitudinal strain (GLS) were associated with prognosis in patients with preserved LV ejection fraction (LVEF) after congestive heart failure (HF) admission.

Methods

We studied 123 consecutive patients (age 70 ± 15 years, 55% male) who had been hospitalized due to congestive HF with preserved LVEF (&gt; 50%). The exclusion criteria were atrial fibrillation and inadequate echo image quality for strain analyses. The patients underwent speckle-tracking echocardiography and measurement of plasma NT-ProBNP levels on the same day at the time of hospital admission as well as in the stable condition after discharge. Differences in GLS, LVEF and NT-ProBNP (delta GLS, LVEF and NT-ProBNP ; 2nd – 1st measurements) were calculated. The study end points were all-cause mortality and cardiac events.

Results

Mean periods of echo performance after hospitalization were 2 ±１days (1st echo) and 240 ± 289 days (2nd echo), respectively. During the follow-up (974 ± 626 days), 12 patients died and 25 patients were hospitalized because of HF worsening. In multivariate analysis, delta GLS and follow-up GLS were prognostic factors, whereas baseline and follow-up LVEF, NT-ProBNP, changes in LVEF and NT-ProBNP could not predict cardiac events. Delta GLS (p = 0.002) turned out to be the best independent prognosticator. Receiver operating characteristics analysis revealed that -0.6% of delta GLS was the optimal cut-off value to predict cardiac events and mortality (sensitivity 76%, specificity 67%, AUC 0.75). Kaplan-Meier analysis showed that patients with delta GLS more than -0.6% experienced significantly less cardiac events during the follow-up period (p &lt; 0.0001, log-rank).

Conclusion

A change in LV GLS after congestive HF admission was a predictor of the prognosis in patients with preserved LVEF. It would be useful to check the changes in GLS in those with preserved LVEF after discharge.

1043 Association of left ventricular global longitudinal strain with myocardial perfusion evaluated by 13N-ammonia positron emission tomography in hemodialysis patients with preserved ejection fraction

Background

Global longitudinal strain (GLS) is an echocardiographic marker to detect subclinical left ventricular systolic dysfunction prior to the appearance of reduced left ventricular ejection fraction (LVEF). Reduced GLS identified in patients with maintenance hemodialysis (HD) has been reported to be a predictor of their higher mortality and cardiovascular events. On the other hand, pharmacological stress 13N-ammonia positron emission tomography (13N-NH3-PET) has been an established and reliable imaging modality to evaluate myocardial perfusion expressed as coronary flow reserve (CFR) or maximal stress myocardial blood flow (MBF). CFR and MBF are powerful parameters to detect coronary artery disease and to predict cardiovascular events and mortality. However, association between GLS and those myocardial perfusion parameters are not fully understood.

Purpose：The aim of this study was to evaluate the relationship between GLS and the myocardial perfusion parameters of 13N-NH3-PET in HD patients with preserved LVEF.

Methods

We studied 24 HD patients (mean age 67 years, 67% male) who underwent ATP stress 13N-NH3-PET as well as transthoracic echocardiography including 2-dimensional speckle tracking imaging for suspected ischemic heart disease. Exclusion criteria were as follows: LVEF &lt;50%, moderate to severe valvular diseases, and atrial fibrillation. Myocardial perfusion abnormality (MPA) was defined as CFR &lt;2.0 and/or stress MBF &lt;2.0.

Results

Mean GLS in all patients was -16.2 ± 3.6%. The patients were divided into 2 groups based on GLS: patients with reduced GLS (&lt;-16%) (Group A, N = 11) and those with preserved GLS (≧-16%) (Group B, N = 14). There were no significant differences between 2 groups in age, gender, body mass index, left ventricular mass index, and average E/e’. Nevertheless, Group A had significantly lower stress MBF than Group B (1.7 ± 0.41 vs 2.0 ± 0.33, p = 0.031). In addition, Group A showed more frequent MPA compared with Group B (81.8% vs 42.9%, p = 0.043). There was a moderate correlation between GLS and stress MBF (r = 0.62, p = 0.0012), whereas no significant correlation was noted between GLS and CFR (r = 0.079, p = 0.71).

Conclusion

Reduced GLS was significantly associated MPA. MPA may be one of the major contributors to the reduction in GLS in HD patients with preserved LVEF.

P4620Circulating concentration of presepsin improves early prediction of short-term mortality in patients treated at medical cardiac intensive care units

Background

Presepsin, a subtype of soluble CD14, is an inflammatory marker, which largely reflects monocytic activation. Presepsin appears to be an accurate diagnostic marker of sepsis, but its clinical significance remains unclear in cardiovascular disease.

Purpose

This prospective study aimed to investigate the predictive value of plasma presepsin levels on admission to medical (non-surgical) cardiac intensive care units (MCICUs) for short-term mortality.

Methods

We examined 1560 patients hospitalized in MCICUs and measured the baseline plasma presepsin levels at admission.

Results

Acute coronary syndrome was present in 46% of the patients, and acute decompensated heart failure in 36%. Before MCICUs admission, emergent coronary angiography or percutaneous coronary intervention was performed in 36%, mechanical ventilation was required for respiratory insufficiency in 2.1%, and intraaortic balloon pumps were needed for hemodynamic instability in 8.9%. During 6 months after admission, there were 113 (7.2%) deaths. Patients who died were older (median: 77 vs. 71 years, P<0.0001); had higher levels of presepsin (263 vs. 119 pg/mL, P<0.0001), B-type natriuretic peptide (BNP: 696 vs. 186 pg/mL, P<0.0001), high-sensitivity troponin T (hsTnT: 81 vs. 47 pg/mL, P=0.004), and high-sensitivity C-reactive protein (13.8 vs. 2.2 mg/L, P<0.0001); and had lower levels of estimated glomerular filtration rate (50 vs. 65 mL/min/1.73m2, P<0.0001) and left ventricular ejection fraction (43% vs. 51%, P<0.0001) than those of the survivors. In the multivariate Cox regression analysis, higher levels of presepsin (P=0.0002), BNP (P=0.04), and hsTnT (P=0.009) were all independent predictors of 6-month deaths. Quartiles of presepsin levels were associated with higher mortality rates within 6 months after admission (Table). Adding presepsin levels to a baseline model that included established risk factors, BNP, and hsTnT further enhanced reclassification (P=0.004) and discrimination (P=0.003) beyond that of the baseline model.

Mortality rates according to presepsin Presepsin quartile 1st 2nd 3rd 4th P value ≤80 pg/mL 81–124 pg/mL 125–232 pg/mL >232 pg/mL 1-month mortality 0.8% 2.0% 3.3% 8.0% <0.0001 6-month mortality 0.8% 3.8% 8.2% 16.3% <0.0001

Conclusions

Presepsin levels at admission could improve the prediction of short-term mortality in patients hospitalized at MCICUs.

Abstract P1-15-12: Axillary lymph node metastasis and HER2-receptor positivity significantly associate with recurrence and worse survival in breast cancer patients who achieved pathological complete response after neoadjuvant chemotherapy

BACKGROUND

Neoadjuvant chemotherapy (NAC) has become a common practice in breast cancer care since it not only expands the opportunity for breast conservation surgery, but also allows in vivo assessment of individual cancer biology. Patients who achieved pathological complete response (pCR) after NAC are known to have significantly improved outcomes than those who did not. To date, there has been no large study of factors that associate with tumor recurrence after patients had pCR following NAC. To identify such factors, we examined a cohort of 394 patients.

METHODS

Patients diagnosed during 2007-16 with clinical stage I-III breast cancer who achieved pCR following NAC were identified from clinical records at four hospitals in urban Japan. Nearly 70% of patients received standard NAC regimen, which was a combination of anthracycline and taxane, with trastuzumab added as needed. pCR was defined as no pathological evidence of invasive cancer in the breast; residual ductal carcinoma in situ (DCIS) and residual axillary lymph node metastasis were included in this study. The median follow-up time was 63 months (range = 16-161 months). Outcomes were assessed by 5-year disease-free survival (DFS) and 5-year overall survival (OS).

RESULTS

Among the 394 patients with pCR, the breast cancer subtype was as follows: Luminal – 49 (12.4%), Luminal-HER2 – 97 (24.6%), HER2 – 117 (29.7%), and TNBC – 131 (33.2%). During follow up, 28 (7.1%) of the 394 patients had experienced tumor recurrence. In univariate Cox regression analysis, each of HER2-receptor status, pre-NAC tumor size, and pre-NAC axillary lymph node status were associated with recurrence. The hazard ratios, and their 95% confidence intervals (CI) and P values for these significant factors were as follows. HER2-receptor negative vs. positive: 2.5 (CI = 1.0-5.8; P = 0.036); cT1/2 vs. cT3/4: 2.2 (CI = 1.3-6.1; P = 0.008); cN0 vs. cN1-3: 9.5 (2.2-40.7; P = 0.002). However, age (&lt;50 vs. ≥50 y), residual DCIS, post-NAC axillary lymph node status, type of mastectomy (total vs. partial), and adjuvant radiation therapy were not associated with recurrence. Of the 28 patients with recurrence, site of first event was local for 8, and brain and visceral for 10 each. Seven of the 10 patients with brain metastasis were HER2-receptor positive. Eleven of the 28 patients with recurrence had deceased, with a median post-recurrence survival duration of 40 months (range = 2–94 months). Shorter survival was associated with HER2-receptor positivity (P = 0.003).

CONCLUSION

Axillary lymph node metastasis before rather than after NAC, and HER2-receptor positivity are associated with tumor recurrence in patients who achieved pCR in breast cancer. HER2-receptor positive patients had higher risk for brain metastasis and shorter survival. Given the extreme rarity of local recurrence after pCR, we cannot help but speculate that omitting surgical removal of pCR tissue may be permissible when pCR has been diagnosed accurately.

Citation Format: Asaoka M, Narui K, Suganuma N, Chishima T, Yamada A, Kawai S, Uenaka N, Sato E, Katsuta E, Kawaguchi T, Takabe K, Ishikawa T. Axillary lymph node metastasis and HER2-receptor positivity significantly associate with recurrence and worse survival in breast cancer patients who achieved pathological complete response after neoadjuvant chemotherapy [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 P1-15-12.

Abstract P4-06-06: Comparison of the immunological and clinical effect of personalized peptide vaccination for patients with breast cancer

Background: Selected therapeutic personalized peptide vaccines (PPV) were effective for boosting anticancer immune response that was associated with the clinical outcome as a prognostic factor for metastatic recurrent breast cancer (mrBC) 1-2. In this study, we investigated the immunological and clinical effect of PPV as the prophylactic cancer vaccine for non-recurrent but high-risk BC (nrhrBC) patients (pts), and we compared it's features to those of the mrBC pts who had active cancers or became resistant to the standard therapies(TR-mrBC). Methods: Material and Patient eligibility criteria: The peptides were selected from the 31 PPVs according to the results of HLA typing and peptide-specific IgG titers. Pts with a histological diagnosis of BC and their HLA-A molecules should be each of -A2, A3, A11, A24, A26, A31 or A33. The clinical protocols were approved by the institutional review board. (UMIN000003081and 00000184400000). Treatment schedule: A maximum of 4 peptides was administrated as weekly for initial four vaccinations and as biweekly for further inoculations. The concomitant standard endocrine therapy and the chemo-endocrine therapy were available for nrhrBC pts after finishing the standard adjuvant chemotherapy, and for mrBC pts concurrently. Immune and clinical response assessment: Specific T-cell responses, IgG titers and cytokines were evaluated using by interferon (IFN)-γ ELISPOT, Luminex assay and ELISA system in every 6-8 vaccinations. Toxicity, clinical response and correlation with the immune responses were investigated. Results: 16 pts with nrhrBC, 41 pts with mrBC and 79 pts with TR-mrBC received median 18, 16 and 14 vaccines, respectively. After PPV therapies, peptide-specific IgG and CTLs increased significantly in a total of 47 (77%) and 37(60%) in nrhrBC pts, 102 (63%) and 98 (61%) in mrBC pts, and 150(53%) and 100 (42%) in TR-mrBC pts. Pts experienced Grade 1-3 skin reaction at injection site, no other grade 3 or 4 SAEs were associated with PPV but with the disease progression or combination therapy. The median time to progression (TTP) and overall survival (OS) were not reached in nrhrBC pts, 7.8 and 29 months in mrBC pts, and were 7.5 and 15.9 months in TR-mrBC pts, respectively. The peptide specific CTL response was correlated significantly with OS in nrhrBC pts and the IgG levels were associated with the better OS in either non TR-mrBC pts or TR-mrBC pts. High levels of IL-6, GM-CSF, IFN-g, IL-2 receptor, BAFF were associated with worse prognosis for pts with TR-mrBC. And high levels of GM-CSF and BAFF were associated with worse prognosis for pts with nrhrBC and mrBC, respectively. In contrast, High levels of IL-2 were associated with the better prognosis for pts with mrBC. Conclusion: This study indicated that immunological features of these three groups were different from each other with most potent PPV-induced immune boosting for nrhrBC pts. Pts with mrBC who had lower immune-suppressive cytokine levels had the better prognosis. These results suggested the PPV therapy could be effective for postoperative prophylactic vaccination in patients with nrhrBC. References: 1. Takahashi R, Toh U, et al. Breast Cancer Res. 2014; 2. Toh U, Okabe M, et al. THE BREAST 2015.

Citation Format: Toh U, Okabe M, Takao Y, Tanaka Y, Shigaki T, Takenaka M, Iwakuma N, Sudo T, Yamada A, Shichijo S, Itoh K, Akagi Y. Comparison of the immunological and clinical effect of personalized peptide vaccination for patients with breast cancer [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 P4-06-06.

Abstract OT1-05-04: Phase 3 trial of carboplatin in triple negative breast cancer (TNBC) patients with residual invasive carcinoma after neoadjuvant chemotherapy (JONIE4:J-CAT trial)

Background: It is well known that the prognosis of non pCR TNBC patients was poor after anthracycline and taxan treatment. For such patients, capecitabine seems to be effective to reduce recurrence based on the HR 0.58 of the CREATE X trial (Masuda, N. et al. Adjuvant Capecitabine for Breast Cancer after Preoperative Chemotherapy. N Engl J Med. 376, 2147. 2017) . However, the target of capecitabine is still unclear for TNBC. We classified non pCR tumors as BRCAness and Sporadic using BRCAness test(MRC-Holland, Amsterdam, the Netherlands). The recurrence rate of the BRCAness group was about 70%. Carboplatine is expected to be effective against BRCAness tumors, as it is a DNA damaging agent. In this study BRCAness can be checked just before carboplatin treatment using surgical specimens. Then the efficacy of carboplatin will be directly known to make comparison between DFS in the carboplatin group and that of the observation group.

Trial design: This is anopen label, randomized phase III study that will enroll TNBC with residual invasive cancer after surgery with preoperative chemotherapy including both anthracycrine and taxan. Patients are randomly assigned to either the carboplatin group or observation group. The patients in the carboplatin group are treated with carboplatin at AUC 6 and those in the observation group are observed at only 3 years.

Eligibility criteria:

1) ER and PgR&lt;1%, HER2 0, 1+ or 2+ with FISH negative on core needle biopsy before the chemotherapy and surgical specimens.

2) Preoperative chemotherapy including both anthracycrine and taxan.

3) Residual invasive cancer on breast tumors or lymph node metastasis in surgical specimens.

4) 20-79 year old women.

5) No chemotherapy within 5 years.

6) Not bilateral breast cancer, without metastasis, no prior breast cancer.

7) No severe bone marrow suppression.

Specific aims:Primary objective is DFS (Disease Free Survival). Secondary objectives are overall survival and safety.

STATISTICAL METHODS:

The 3 years recurrence rate of the observation group was estimated as 40% and hazard ratio at 0.58 based on the CREATE X trial. For both groups, 135 patients are necessary. This study is powered to approximately 80% to test the superiority of carboplatin group at a 2-sided α=0.05 using a stratified log-rank test.

Activation Date:22ndMarch 2018. No patients had been enrolled till 3rd July.

Citation Format: Tanino H, Suzuki M, Kaise H, Miyashita M, Chishima T, Hayashi M, Miyoshi Y, Futamura M, Ohtani S, Nagahashi M, Ohta T, Kosaka Y, Ishikawa T, Hasegawa Y, Kubota T, Sangai T, Iwatani T, Yamada A, Akazawa K, Kohno N. Phase 3 trial of carboplatin in triple negative breast cancer (TNBC) patients with residual invasive carcinoma after neoadjuvant chemotherapy (JONIE4:J-CAT trial) [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 OT1-05-04.

Benefit-cost analysis of the policy of mandatory annual rabies vaccination of domestic dogs in rabies-free Japan

Japan is one of the few rabies-free countries/territories which implement the policy of mandatory vaccination of domestic dogs. In order to assess the economic efficiency of such policy in reducing the economic burden of a future canine rabies outbreak in Japan, a benefit-cost analysis (BCA) was performed using probabilistic decision tree modelling. Input data derived from simulation results of published mathematical model, field investigation conducted by the authors at prefectural governments, literature review, international or Japanese database and empirical data of rabies outbreaks in other countries/territories. The current study revealed that the annual costs of implementing the current vaccination policy would be US$160,472,075 (90% prediction interval [PI]: $149,268,935-171,669,974). The economic burden of a potential single canine rabies outbreak in Japan were estimated to be US$1,682,707 (90% PI: $1,180,289-2,249,283) under the current vaccination policy, while it would be US$5,019,093 (90% PI: $3,986,882-6,133,687) under hypothetical abolition of vaccination policy, which is 3-fold higher. Under a damage-avoided approach, the annual benefits of implementing the current vaccination policy in expected value were estimated to be US$85.75 (90% PI: $55.73-116.89). The benefit-cost ratio (BCR) was estimated to be 5.35 X 10(-7) (90% PI: 3.46 X 10(-7)-7.37 X 10(-7)), indicating that the implementation of the current policy is very economically inefficient for the purpose of reducing the economic burden of a potential canine rabies outbreak. In worse-case scenario analysis, the BCR would become above 1 (indicating economic efficiency) if the risk of rabies introduction increased to 0.04 corresponding to a level of risk where rabies would enter Japan in 26 years while the economic burden of a rabies outbreak under the abolition of vaccination policy increased to $7.53 billion. Best-case analysis further revealed that under relatively extreme circumstances the economic efficiency of the current policy could be improved by decreasing the vaccination price charged to dog owners, relaxing the frequency of vaccination to every two to three years and implementing the policy on a smaller scale, e.g. only in targeted prefectures instead of the whole Japan.

The genotypes of Orientia tsutsugamushi, identified in scrub typhus patients in northern Vietnam

Background

There are an estimated one million patients with scrub typhus in the Asia-Pacific region. There are few reports describing the incidence of scrub typhus in Vietnam.

Methods

Blood samples collected from 63 patients clinically diagnosed as having scrub typhus from July 2015 to September 2016 were subjected to genotyping of Orientia tsutsugamushi.

Results and Conclusions

Of these patients, 42 (67%) tested positive for O. tsutsugamushi, and the most common genotype was identified to be Karp (55%). Other genotypes, TA763, Gilliam type in Japan variant, and Kato were also found in 17%, 17% and 12% of patients, respectively. To better understand the epidemiological landscape of scrub typhus in Vietnam, a countrywide study is needed.

Accession numbers

LC110330-LC110333, LC110336-LC110351 and LC214804-LC214825.

Degradation of food-derived opioid peptides by bifidobacteria

Some food-derived opioid peptides have been reported to cause diseases, such as gastrointestinal inflammation, celiac disease, and mental disorders. Bifidobacterium is a major member of the dominant human gut microbiota, particularly in the gut of infants. In this study, we evaluated the potential of Bifidobacterium in the degradation of food-derived opioid peptides. All strains tested showed some level of dipeptidyl peptidase activity, which is thought to be involved in the degradation of food-derived opioid peptides. However, this activity was higher in bifidobacterial strains that are commonly found in the intestines of human infants, such as Bifidobacterium longum subsp. longum, B. longum subsp. infantis, Bifidobacterium breve and Bifidobacterium bifidum, than in those of other species, such as Bifidobacterium animalis and Bifidobacterium pseudolongum. In addition, some B. longum subsp. infantis and B. bifidum strains showed degradative activity in food-derived opioid peptides such as human and bovine milk-derived casomorphin-7 and wheat gluten-derived gliadorphin-7. A further screening of B. bifidum strains revealed some bifidobacterial strains that could degrade all three peptides. Our results revealed the potential of Bifidobacterium species in the degradation of food-derived opioid peptides, particularly for species commonly found in the intestine of infants. Selected strains of B. longum subsp. infantis and B. bifidum with high degradative capabilities can be used as probiotic microorganisms to eliminate food-derived opioid peptides and contribute to host health.

Preventive Equipment for Urinary Incontinence: A Device Employing Lower Abdominal Impendance Changes

The object of this work was to develop a monitoring device for measuring the volume of urine in the bladder to signal, in advance, the need to urinate and thus help prevent urinary incontinence. A high-frequency electric current of 50 KHz transmitter was applied to a pair of terminals placed on the surface of a human body. The constant current was 2mA (p-p). A pair of voltage electrodes was placed in the path of the electric current to pick up high-frequency voltage signals. The best position for current electrodes was found to be on the surface of both femoral joints. Positioning the voltage electrode above the bladder on the lower abdomen was most efficient for detecting the volume of urine. New current electrodes sutured onto underpants were fitted on the surface above the femoral joints, which did not shift in the case of movement by the subjects. The reproducibility and stability were remarkably good with this electrode. The alarm level which foretold both maximum storage volume and maximum desire to void was examined. After that, when the alarm level was set within the range of impedance charge, 60% to 70%, the possibility of prediction of urination exists.

Detection and phylogenetic analysis of phlebovirus, including severe fever with thrombocytopenia syndrome virus, in ticks collected from Tokyo, Japan

Severe fever with thrombocytopenia syndrome (SFTS) was detected for the first time in China in 2011. Since then, human cases have been reported in endemic regions, including Japan. To investigate the presence of tick-borne pathogens in Tokyo, 551 ticks (266 samples) were collected from October 2015 to October 2016. Although the SFTS virus was not detected by RT-PCR, a novel phlebovirus was detected in one sample. In a phylogenetic analysis based on the partial nucleotide sequences of the L and S segments of the virus, the virus clustered with Lesvos virus (Greece), Yongjia tick virus, and Dabieshan tick virus (China). Further studies involving virus isolation are required to characterize this novel phlebovirus and to expand the epidemiological knowledge of related pathogens.

Abstract P5-03-05: Sphingosine-1-phosphate produced by sphingosine kinase 1 and exported via ABCC1 shortens survival of mice and humans with breast cancer

Background: Sphingosine-1-phosphate (S1P), a bioactive sphingolipid mediator that is generated by sphingosine kinase 1 (SphK1) when it is phosphorylated (pSphK1) inside cells, has been implicated in regulation of many process important for breast cancer progression. Previously we have shown that S1P is exported out of human breast cancer cells by ATP-binding cassette (ABC) transporter ABCC1, but not by ABCB1, both known multidrug resistance proteins that efflux chemotherapeutic agents. However, the pathological consequences of these events to breast cancer progression and metastasis have not been elucidated. Here, we report that high expression of ABCC1, but not ABCB1, is associated with poor prognosis in breast cancer patients via exporting S1P.

Materials and methods: Microarray based gene expression data of 2509 patients associated with their survival were obtained from METABRIC database. Single gene survival analysis based on expressin of SphK1, and dual ABCC1 or ABCB1 and SphK1 survival analyses were perfomerd. For protein analyses, tissues were obrained from 275 patients with stage 1-3 breast cancers treated in Yokohama City University Medical Center in Japan between 2006 and 2008. The expression of pSphK1 was analyzed by immunohistochemistry and investigate the relationship with clinicopathological findings. For in vitro and in vivo experiments, breast cancer cell lines were transfected by ABCB1, ABCC1 or vector transiently or stably. BALB/c nu/nu mice and BALB/c mice were used for in vivo experiments. S1P was measured by LC-ESI-MS/MS.

Results: SphK1 expression significantly associate with worse overall survival (median survival of 124 months with high SphK1 expression compared to 163 months for patients with low SphK1 expression, p=0.0014). Although patients with high ABCC1 expression had only a slightly worse overall survival of 150 months, those with high levels of both SphK1 and ABCC1 had much worse prognosis with median overall survival of 114 months (p &lt; 0.0068). Such association was not observed with ABCB1 expression. The frequency of strong pSphK1 protein expression was higher in HER2 enrhiched or TNBC than in Luminal. pSphK1 was more prevalent and increased in a larger tumors and in tumors from patients with lymph node metastases. Patients with breast cancers that express both pSphK1 and ABCC1 proteins have significantly shorter disease free survival. Overexpression of ABCC1, but not ABCB1, in human MCF7 and murine 4T1 cells enhanced S1P secretion, proliferation and migration of breast cancer cells. Implantation of breast cancer cells overexpressing ABCC1, but not ABCB1, into the mammary pad markedly enhanced tumor growth, angiogenesis and lymphangiogenesis with concomitant increases in lymph node and lung metastases as well as shorter survival of mice. Interestingly, S1P exported via ABCC1 from breast cancer cells upregulated transcription of SphK1 and its own formation.

Conclusions: Our findings suggest that production and export of S1P via ABCC1, but not ABCB1, is associated with worse overall and disease free survival of breast cancer patients and that S1P axis play a role in aggressive biology of breast cancer progression and metastasis.

Citation Format: Yamada A, Nagahashi M, Aoyagi T, Huang W-C, Lima S, Miyazaki H, Narui K, Ishikawa T, Endo I, Waters MR, Milstien S, Spiegel S, Takabe K. Sphingosine-1-phosphate produced by sphingosine kinase 1 and exported via ABCC1 shortens survival of mice and humans with breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-03-05.

Abstract P3-05-09: Prognostic factors for therapeutic personalized peptide vaccines in patients with metastatic recurrent breast cancer

Background: We have previously reported the prognostic role of humoral antigen spreading response against prostate-related antigen (PRA) for metastatic recurrent breast cancer (mrBC) patients who received personalized peptide vaccine (PPV) therapy (Toh U, SABCS 2015). The prognostic effect was additionally evaluated by the clinical relevant factors including intrinsic subtype, the regimens of combined chemo-hormonal therapies in present study.

Methods:We analyzed serum IgG responses to all of the peptide candidates included PRAs (PSA, PAP and PMSA) after PPV therapy by the Luminex systemusing peripheral blood samples from 77 vaccinated mrBC patients. The clinical factors and relevant events were statistically evaluated.

Results: After 6 and 12cycles of PPV therapy, the serum IgG of anti-PSA, anti-PAP, and/or anti-PMSA increased significantly in 31 patients (PRA response group), and the median progression free survival (PFS) and median overall survival (OS) were 8.1 and 14.3 months, but were 5.1 and 10.8 months, respectively, in the remaining 46 patients with no anti-PRA IgG response (PRA non-response Group). The anti-PRA IgG level was marginally correlated withPFS (p=0.059) and OS (p=0.082) between these two groups, which was a significant prognostic factor for PFS (Log-rank: 0.009) in estrogen-positive cancer patients (ER+). The statistical analyses showed that the clinical outcome was in favor of &gt; 60 year-old patients, those with longer PPV therapies (&gt;3 months), and those who received combined standard hormonal therapies or bisphosphonate/anti-RANKL therapy.

Conclusions: This study indicated a clinical significance between the pre-and post- PPV therapy measurement of serum anti-PRA IgG in patients with mrBC, which may be a useful prognostic marker for monitoring peptide vaccine treatment outcomes, particularly for patients &gt; 60 years with ER+ breast cancer. These results also suggest that the immunotherapeutic peptide vaccine could be efficiently combined with hormonal therapy, anti-HER2 therapy, and bisphosphonate/anti-RANKL therapy in mrBC patients.

Citation Format: Toh U, Saku S, Iwakuma N, Takao Y, Okabe M, Akashi M, Yamada A, Shichijo S, Itoh K, Akagi Y. Prognostic factors for therapeutic personalized peptide vaccines in patients with metastatic recurrent breast cancer [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-05-09.

Abstract P1-01-06: Targeting the SphK1/S1P/S1PR1 axis that connects obesity, chronic inflammation, and breast cancer metastasis

Introduction: Obesity with associated inflammation is now recognized as a risk factor for breast cancer and increased incidence of distant metastases. However, the link between obesity and breast cancer progression remains poorly understood. There is growing evidence that sphingosine-1-phosphate (S1P), a pleiotropic bioactive sphingolipid metabolite enriched both in blood and lymphatic fluid is involved in inflammation, obesity, and breast cancer progression. Our hypothesis is that obesity increases levels of S1P in both tumor and its microenvironment, which play a role in obesity-induced inflammation and breast cancer metastasis. The aim of this study is to test this hypothesis in in vitro and in vivo as well as patient settings.

Methods: Levels of sphingolipids including S1P in serum from breast cancer patients were quantified. Orthotopically-implanted E0771 syngeneic breast cancer and MMTV-PyMT transgenic breast cancer mouse models were used. Mice were fed with normal or high-fat diet (HFD). FTY720 was administered orally (1 mg/kg/day). To examine pre-metastatic niche formation, a mouse model utilizing tail vein injection of E0771 cells was used. In this model, mice were treated with conditioned media from E0771 breast cancer cells overexpressing SphK1 (K1-CM) or that from E0771 cells cultured with the vector control (CT-CM), prior to tail vein injections of naive E0771 cells. S1P levels were determined by electrospray ionization-tandem mass spectrometry.

Results: We found that obesity significantly increased S1P levels in serum from breast cancer patients. In animal breast cancer models, HFD upregulated expression of sphingosine kinase 1 (SphK1), the enzyme that produces S1P, and its receptor S1PR1 in syngeneic and spontaneous breast tumors. HFD also significantly increased S1P in breast tumors and in the tumor interstitial fluid, which is a component of the tumor microenvironment and bathes cancer cells in the tumor. Targeting the SphK1/S1P/S1PR1 axis with FTY720/fingolimod attenuated obesity-induced key pro-inflammatory cytokines, macrophage infiltration, and tumor progression. In addition, S1P produced by tumor SphK1 primed lung pre-metastatic niches, increased macrophage recruitment into the lung, and induced IL-6 and signaling pathways important for lung metastatic colonization. FTY720 suppressed HFD-induced lung IL-6 and macrophage infiltration as well as S1P-mediated signaling pathways and dramatically reduced formation of metastatic foci. In tumor bearing mice, FTY720 also suppressed obesity-related inflammation, S1P signaling, pulmonary metastasis, and prolonged survival.

Conclusion: Our results highlight a critical role for circulating S1P produced by tumor and the SphK1/S1P/S1PR1 axis in obesity-related inflammation, metastatic niche formation and breast cancer metastasis and suggest that targeting the SphK1/S1P/S1PR1 axis would be a useful therapeutic for obesity promoted metastatic breast cancer.

Citation Format: Nagahashi M, Yamada A, Aoyagi T, Huang W-C, Terracina KP, Hait N, Allegood JC, Tsuchida J, Nakajima M, Katsuta E, Milstien S, Wakai T, Spiegel S, Takabe K. Targeting the SphK1/S1P/S1PR1 axis that connects obesity, chronic inflammation, and breast cancer metastasis [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P1-01-06.

Abstract P6-07-03: Long non-coding RNA H19 promotes cancer stemness and worsen breast cancer survival

Background: Cancer stem cells (CSC) are good sources of tumor initiation, heterogeneity, progression, and metastasis because of their unique characteristics. Several potential markers for CSCs have been suggested for breast cancer, including CD44+/CD24−/low, aldehyde dehydrogenase 1 (ALDH1), and epithelial cell adhesion molecule/epithelial-specific antigen. We previously reported that ALDH1 gene expression is related to aggressive phenotypes and poor prognosis in breast cancers. In this study, we conducted differential analysis of mRNA expression in ALDH1-positive breast cancer to identify genes associated with CSC. Next, we performed basic and clinical studies of one gene.

Methods: Messenger RNA was isolated from ALDH1-positive cells and ALDH1-negative cells in 5 ALDH1-positive breast cancers. Microarray analysis revealed that several genes were significantly associated with the ALDH1 gene. Among them, we examined a long non-coding RNA of H19 in this study. We evaluated the effect of H19 on CSCs using RNA interference and a sphere formation assay using two cell lines, HCC1937 and iCSCL10A cells. We also investigated H19 expression in 192 surgical specimens by in situ hybridization and analyzed the relationship between H19 expression and clinic pathological findings in breast cancer patients.

Results: Through in vitro experiments, we confirmed that suppression of H19 reduced sphere formation in both HCC1937 and iCSCL10A cells. Among surgical specimens, 48 samples (25%) expressed H19. We verified thatH19 positivity was significantly higher in ALDH1-positive cases than in ALDH1-negative cases (68% vs 9.7%, p &lt; 0.001). H19 was significantly highly expressed in triple-negative breast cancer (TNBC) (46%) compared with other subtypes: luminal (33%), luminal-HER2 (6%), and HER2-enriched subtype (15%). H19-positive patients showed significantly worse prognosis (5-year disease-free survival 75.8% vs 91.5%, p = 0.001 and 5-year overall survival 88.7% vs 97.7%, p = 0.002). The effect of H19 expression on prognosis was the most significant in TNBC compared to in other subtypes (5-year disease-free survival 63.6% vs 88.9%, p = 0.038).

Conclusions: H19 is clearly associated with CSCs and correlated with poor prognosis in breast cancer patients, particularly TNBC. Our future studies will investigate the role of H19 in maintaining the nature of CSCs and protein-coding genes associated with H19.

Citation Format: Shima H, Kida K, Yamada A, Sugae S, Narui K, Miyagi Y, Ryo A, Ichikawa Y, Ishikawa T, Endo I. Long non-coding RNA H19 promotes cancer stemness and worsen breast cancer survival [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P6-07-03.

Evaluation of Francisella tularensis ΔpdpC as a candidate live attenuated vaccine against respiratory challenge by a virulent SCHU P9 strain of Francisella tularensis in a C57BL/6J mouse model

Francisella tularensis, which causes tularemia, is an intracellular gram-negative bacterium. F. tularensis has received significant attention in recent decades because of its history as a biological weapon. Thus, development of novel vaccines against tularemia has been an important goal. The attenuated F. tularensis strain ΔpdpC, in which the pathogenicity determinant protein C gene (pdpC) has been disrupted by TargeTron mutagenesis, was investigated as a potential vaccine candidate for tularemia in the present study. C57BL/6J mice immunized s.c. with 1 × 10⁶ CFUs of ΔpdpC were challenged intranasally with 100× the median lethal dose (LD₅₀ ) of a virulent SCHU P9 strain 21 days post immunization. Protection against this challenge was achieved in 38% of immunized C57BL/6J mice administered 100 LD₅₀ of this strain. Conversely, all unimmunized mice succumbed to death 6 days post challenge. Survival rates were significantly higher in vaccinated than in unimmunized mice. In addition, ΔpdpC was passaged serially in mice to confirm its stable attenuation. Low bacterial loads persisted in mouse spleens during the first to tenth passages. No statistically significant changes in the number of CFUs were observed during in vivo passage of ΔpdpC. The inserted intron sequences for disrupting pdpC were completely maintained even after the tenth passage in mice. Considering the stable attenuation and intron sequences, it is suggested that ΔpdpC is a promising tularemia vaccine candidate.

Seroepidemiology of non-primate hepacivirus (NPHV) in Japanese native horses

Non-primate hepacivirus (NPHV) is recently identified as a closely related homologue of hepatitis C virus. The previous studies showed a high prevalence of NPHV infection among Japanese domestic horses originated from abroad. The historical distribution of NPHV among horses in Japan, therefore, is still unknown. In this study, seroepidemiological study of NPHV was conducted using 335 sera from five breeds of Japanese native horses. These horses are maintained as the pedigree and are reared apart from other horse breeds. The detection of antibodies against NPHV were conducted by western blot analysis using the recombinant protein of the NPHV core protein. The antibodies against NPHV were detected in all five breeds, 83 out of 335 (23.4%) horses. These results suggested that NPHV was circulating among Japanese native horses.

Validation of cardiac magnetic resonance tissue tracking in the rapid assessment of RV function: a comparative study to echocardiography

AIM

To investigate the accuracy of cardiac magnetic resonance (CMR) tissue tracking (CMR-TT) and speckle tracking echocardiography (STE) against CMR determined right ventricular (RV) ejection fraction (RVEF) and to identify an optimal cut-off value for STE and CMR-TT to determine RVEF <45% and compare this to other conventional methods for estimating RVEF in dilated cardiomyopathy (DCM) patients.

MATERIALS AND METHODS

Twenty-nine DCM patients were recruited prospectively. CMR and echocardiography were performed within 48 hours and four-chamber views were used for strain analysis. Contoured CMR short axis images provided RVEF. Intraclass correlation coefficient (ICC), bias, levels of agreement, and receiver operating characteristic (ROC) curve analyses were performed.

RESULTS

CMR-TT RV free-wall longitudinal strain (FLS) and STE RV global longitudinal strain (GLS) showed the best correlation with RVEF (r=-0.68, r=-0.82, p<0.001 respectively). There was moderate correlation between echocardiography RV GLS and CMR RV FLS (r=0.64, p<0.001). CMR-TT FLS showed excellent intra-observer and interobserver reliability (ICC=0.980; ICC=0.968 respectively). STE GLS correlated better with RVEF than with peak systolic annular velocity (S'; r=0.45), tricuspid annular plane systolic excursion (TAPSE; r=0.56), and fractional area change (FAC; r=0.78). CMR-TT RV FLS had better correlation with RVEF than CMR TAPSE (r=0.69 versus 0.40). ROC analysis demonstrated the optimal cut-off value for CMR-TT RV FLS and STE GLS in detection of RVEF <45% was ≥-24.4% (area under the curve=0.87, 100% sensitivity, 66.7% specificity) and ≥-20.9% (area under the curve=0.88, 100% sensitivity, 60% specificity) respectively.

CONCLUSION

CMR-TT FLS and STE GLS showed potential to provide rapid assessment of RV function and had superior correlation with RVEF compared to conventional parameters.

Meta-Analysis of the Risk of Immune-Related Adverse Events With Anticytotoxic T-Lymphocyte-Associated Antigen 4 and Antiprogrammed Death 1 Therapies

We assessed the risks of immune-related adverse events with anticytotoxic T-lymphocyte-associated antigen 4 (CTLA4) and antiprogrammed death 1 (PD1) therapies by meta-analysis. Twenty-one studies including 11,144 patients were found. Anti-CTLA4 therapy was associated with a significantly higher risk of overall immune-related adverse events: diarrhea, immune-related colitis, pruritus, and rash compared to control therapies (relative risk (RR) = 2.43, 2.10, 11.39, 3.88, 3.87, 95% confidence interval (CI) = 1.77-3.34, 1.52-2.45, 6.30-20.59, 2.37-6.37, 2.39-6.27, P < 0.001 for all outcomes). Anti-PD1 therapy was associated with a significantly higher risk of pruritus (RR = 4.01, 95% CI = 1.97 to 8.17, P < 0.001); however, it did not increase the risks of other adverse events. Anti-CTLA4 and anti-PD1 therapies have distinct features of immune-related adverse events. The results of our study would aid the surveillance and management of immune-related adverse events in patients receiving these therapies.

Probing the local structure of Prussian blue electrodes by 113Cd NMR spectroscopy

We demonstrate that ¹¹³Cd NMR is a potent technique to monitor the local electronic and structural states of the Prussian blue electrode during Li⁺ intercalation, providing an atomic-scale insight into the reaction mechanism.

Tolerance mechanisms of human-residential bifidobacteria against lysozyme

We previously reported that lysozyme present in breast milk is a selection factor for bifidobacterial colonization in infant human intestines. This study is aimed at examining their underlying mechanisms. Human-residential bifidobacteria (HRB) generally exhibited higher tolerance than non-HRB to lysozymes, except B. bifidum subspecies. To assess the involvement of enzymatic activity of lysozyme, peptidoglycan (PG) was isolated and the degree of O-acetylation (O-Ac) in 19 strains, including both HRB and non-HRB, was determined. Variety in the degree of O-Ac was observed among each of the Bifidobacterium species; however, all purified PGs were found to be tolerant to lysozyme, independent of their O-Ac degree. In addition, De-O-Ac of PGs affected the sensitivity to lysozyme of only B. longum-derived PG. To examine the non-enzymatic antibacterial activity of lysozyme on bifidobacteria, lysozyme was heat-denatured. The HRB and non-HRB strains exhibited similar patterns of susceptibility to intact lysozyme as they did to heat-denatured lysozyme. In addition, strains of B. bifidum (30 strains), which showed various tolerance of lysozyme, also exhibited similar patterns of susceptibility to intact lysozyme as they did to heat-denatured lysozyme. These results suggest that bifidobacteria are resistant to the peptidoglycan-degrading property of lysozyme, and the tolerance to lysozyme among some HRB strains is due to resistance to the non-enzymatic antibacterial activity of lysozyme.

Systematic review with meta-analysis: the efficacy and safety of CT-P13, a biosimilar of anti-tumour necrosis factor-α agent (infliximab), in inflammatory bowel diseases

BACKGROUND

Biosimilars of anti-tumour necrosis factor (TNF)-α agents have now become clinically available for the treatment of inflammatory bowel diseases (IBD).

AIM

To perform a systematic review and meta-analysis to evaluate the efficacy and safety of biosimilars of anti-TNF-α agents in patients with IBD.

METHODS

Electronic databases were searched. The outcomes were the pooled rates of clinical response or remission, sustained clinical response or remission, and adverse events in patients with IBD induced with or switched to biosimilars of anti-TNF-α agents.

RESULTS

Eleven observational studies reporting outcomes in 829 patients treated with biosimilar of infliximab (CT-P13) were identified. The pooled rates of clinical response among Crohn's disease (CD) and ulcerative colitis (UC) at 8-14 weeks were 0.79 (95% confidence interval (CI) = 0.65-0.88) and 0.74 (95% CI = 0.65-0.82), respectively, and at 24-30 weeks were 0.77 (95% CI = 0.63-0.86) and 0.77 (95% CI = 0.67-0.85) respectively. Adverse events were rare (CD, 0.08 (95% CI = 0.02-0.26); UC, 0.08 (95% CI = 0.03-0.17)). The pooled rates of sustained clinical response among CD and UC after switching from infliximab to CT-P13 at 30-32 weeks were 0.85 (95% CI = 0.71-0.93) and 0.96 (95% CI = 0.58-1.00), respectively, and at 48-63 weeks were 0.75 (95% CI = 0.44-0.92) and 0.83 (95% CI = 0.19-0.99) respectively. Adverse events were rare (CD, 0.10, 95% CI = 0.02-0.31; UC, 0.22, 95% CI = 0.04-0.63).

CONCLUSIONS

CT-P13 was associated with excellent clinical efficacy and safety profile, supporting its use in the treatment of IBD.