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.

Prolonged Dysphagia due to a Combination of Cerebral Hemorrhage and Diffuse Idiopathic Skeletal Hyperostosis: A Case Report

A 79-year-old man was diagnosed with left thalamic hemorrhage. On admission, the Functional Independence Measure (FIM) motor score was 13 points, and the Food Intake Level Scale (FILS) was Level 2, with the patient needing enteral nutrition. Six months after stroke onset, the FIM motor score had improved to 38 points and the dysphagia to FILS Level 7. The patient was able to ingest easy-to-swallow food orally three times a day, but only after postural adjustment with rotation of the head. Seven months after stroke onset, the FIM motor score had reached 45 points but without further improvement in swallowing function. Videofluoroscopic swallowing evaluation (VF) revealed that the persistence of dysphagia was due to osteophytes on the cervical vertebrae caused by diffuse idiopathic skeletal hyperostosis. On surgical removal of the osteophytes, swallowing function improved to FILS Level 9; the patient was able to ingest normal food in a seated position without postural adjustment. One year after stroke onset, the patient was discharged with an FIM motor score of 59 points and FILS Level 9. At the 2-year follow-up, there was minimal recurrence of the osteophytes, and both motor and swallowing functions were maintained at the same level as at discharge. This case suggests that dysphagia in elderly patients may be due to multiple disorders, and that surgical intervention may occasionally be effective.

anti-tumor effect of AlkB homolog 3 knockdown in hormone- independent prostate cancer cells

Castrate resistant prostate cancer (CRPC) is a disease that is resistant to both hormone therapy and chemotherapy. At present, no curative therapy for CRPC has been established. Therefore, it is necessary to determine a novel molecular target for the development of therapeutic agents. We previously reported that AlkB homolog 3 (ALKBH3) is highly expressed in prostate cancer but not in benign prostatic hyperplasia or in normal prostate epithelium and that the expression levels of ALKBH3 protein are significantly correlated with the hormone-independent state of prostate cancer. Moreover, ALKBH3 regulates the invasion of prostate cancer cells via the regulation of matrix metalloproteinase 9. Here, we show that ALKBH3 gene silencing markedly induces apoptosis in hormone-independent prostate cancer cell line DU145 but not in the normal prostate epithelial cell line PNT2. Moreover, the in vivo tumorigenicity of DU145 cells was significantly inhibited by the administration of ALKBH3 siRNA. Furthermore, the anchorage-independent growth of DU145 cells was inhibited by ALKBH3 knockdown and promoted by ALKBH3 overexpression, significantly. ALKBH3 shRNA-expressing prostate cancer cells formed significantly smaller tumors than those of control shRNA transfectants in an in vivo xenograft model. These findings suggest that ALKBH3 is a promising target molecule for the development of CRPC therapeutic agents.

Positive effect on bone fusion by the combination of platelet-rich plasma and a gelatin β-tricalcium phosphate sponge: a study using a posterolateral fusion model of lumbar vertebrae in rats

We developed a novel method for bone fusion by combining platelet-rich plasma (PRP) and a gelatin β-tricalcium phosphate (β-TCP) sponge. The PRP is an autologous concentration of platelets that includes several growth factors. The gelatin β-TCP sponge comprises gelatin and β-TCP, thus enabling the sustained release of growth factors and osteoconduction. To evaluate this method, we generated a posterolateral fusion model of lumbar vertebrae in rats and divided it into five groups by implanting the following materials between transverse processes of vertebrae, (1) the gelatin β-TCP sponge with PRP (PRP sponge), (2) the gelatin β-TCP sponge with platelet-poor plasma, (3) gelatin hydrogel with PRP, (4) autologous iliac bone (autograft), and (5) no material was implanted as a control. The assessment of bone fusion by a radiographic assessment, a biomechanical test, microcomputed tomography, and histological evaluations demonstrated that there were no significant differences between the PRP sponge and the autograft groups regarding the osteogenic effect. Subsequent examinations revealed that no significant differences existed between the PRP sponge and the autograft groups in either biomechanical stiffness or the bone volume over time; whereas the radiographic and histological composition underwent similar changes in the fusion process. These results indicate that the PRP sponge could, therefore, be potentially useful as an attractive and less invasive method for bone fusion.

The clinical usefulness of preoperative dynamic MRI to select decompression levels for cervical spondylotic myelopathy

The study subjects included 54 patients with cervical spondylotic myelopathy who underwent a selective laminoplasty. The patients were divided into three groups according to the number of decompressed levels: two levels, three levels and four or five levels. The number of cord compressions at every intervertebral level was determined in the flexion, neutral, and extension position using a dynamic magnetic resonance imaging (MRI) scan in consideration of both static and dynamic compressions. For each group, the clinical outcomes were evaluated. Moreover, the patients were divided into two groups according to their age. Then, the appearance ratios of cord compression between the neutral and extension position were compared at each intervertebral level. The clinical outcomes were satisfactory. There were no statistical differences among the three groups, except for the age and operation time. The position of the neck influenced the number of cord compressions. The appearance ratios of cord compression, which were especially prominent at C2/3, C3/4 and C4/5, showed high scores in the aged. The preoperative dynamic MRI scan was clinically useful. In the aged, attention should be given to C2/3, C3/4 and C4/5.

In vivo segmental motion of the cervical spine in rheumatoid arthritis patients with atlantoaxial subluxation

OBJECTIVE

The dynamic mechanism underlying cervical spine involvement in rheumatoid arthritis (RA) remains unidentified. The purpose of the current study was to determine the in vivo cervical segmental motion in RA patients with atlantoaxial subluxation (AAS) using a patient-based three-dimensional magnetic resonance imaging (MRI) computer model.

METHODS

Healthy volunteers and RA patients with AAS (all females, n=10) underwent MRI examination of the cervical spine. Each vertebral body from the occipital bone (Oc) to the first thoracic vertebra (T1) was reconstructed from slices of T2-weighted sagittal MR images in the neutral, flexion, and extension positions. Using volume merge methods, each reconstructed vertebral body was virtually rotated and translated. Rotational segmental and translational segmental motions were obtained in three major planes.

RESULTS

Overall, the axial translational motions in the RA group were lower than those in the healthy volunteers; however the axial translational motion at only C1-C2 during flexion was at the same level as that in the healthy volunteers and was greater on the bottom side than that at other intervertebral levels. The frontal rotational motions at C1-C2 during extension were greater in the RA patients than those in the healthy volunteers (p<0.05).

CONCLUSION

The atlantoaxial joints in the RA patients with AAS showed great frontal rotational motion during extension and great axial translation on the bottom side during flexion. The current noninvasive MRI-based method could be useful in evaluating the 3-D dynamic mechanism underlying cervical involvement in RA in vivo.

Intervertebral Disc Regeneration Using Platelet-Rich Plasma and Biodegradable Gelatin Hydrogel Microspheres

This study evaluated the regenerative effects of platelet-rich plasma (PRP) for the degenerated intervertebral disc (IVD) in vivo. After induction of IVD degeneration in rabbits, we prepared PRP by centrifuging blood obtained from these rabbits. These PRP were injected into the nucleus pulposus (NP) of the degenerated IVDs after impregnation into gelatin hydrogel microspheres that can immobilize PRP growth factors physiochemically and release them in a sustained manner with the degradation of the microspheres. As controls, microspheres impregnated with phosphate-buffered saline (PBS) and PRP without microspheres were similarly injected. Histologically, notable progress in IVD degeneration with time courses was observed in the PBS control, PRP-only, and sham groups. In contrast, progress was remarkably suppressed over the 8-week period in the PRP group. Moreover, in immunohistochemistry, intense immunostaining for proteoglycan in the NP and inner layer of the annulus fibrosus was observed 8 weeks after administration of PRP-impregnated microspheres. Almost all microspheres were indistinct 8 weeks after the injection, and there were no apparent side effects in this study. Our results suggest that the combined administration of PRP and gelatin hydrogel microspheres into the IVD may be a promising therapeutic modality for IVD degeneration.

Risk factors for de novo acute cardiac events in patients initiating hemodialysis with no previous cardiac symptom

An initial major adverse cardiac event (MACE) is an important predictor of future cardiovascular events in patients with chronic kidney disease (CKD). We sought to identify factors influencing occurrence of initial MACE in new maintenance hemodialysis patients without previous cardiac symptoms during the predialysis phase of CKD. Among 112 participating patients with no predialysis cardiac history, 57 underwent coronary angiography, whereas the other 55 underwent stress thallium-201 single-photon emission computed tomography within 1 month of beginning hemodialysis to detect asymptomatic coronary artery disease (CAD). In subsequent follow-up for a median of 24 months, subjects experiencing an initial MACE were compared with those who did not have such an event based on several clinical parameters at the end of predialysis phase. Asymptomatic CAD was present in 47 patients (42%), who had a higher cumulative MACE rate, than subjects without CAD (49 vs 3%, P<0.001). Multivariate Cox's regression analysis showed that three variables independently predicted initial MACE: asymptomatic CAD (hazard ratio or HR, 611.31; 95% confidence interval or CI, 14.07-26549.23; P<0.001), diabetes (HR, 20.41; 95% CI, 2.07-200.00; P=0.010), and each 1 mg/l increment in C-reactive protein (CRP) (HR, 1.94; 95% CI, 1.27-2.94; P=0.002). In conclusion, detection of asymptomatic CAD, presence of diabetes, or elevated CRP at the end of the predialysis phase were significantly associated with occurrence of an initial MACE in CKD patients starting hemodialysis who had no CAD symptoms.

Radiological Grading of Cervical Destructive Spondyloarthropathy in Long-term Hemodialysis Patients

On the basis of the radiological findings of dialysis patients, we made a radiological grading and analyzed the progression of destructive spondyloarthropathy (DSA) using this grading system. In this system, the radiological features of the vertebral endplates and intervertebral disc spaces were divided into 4 grades (grade 0 to grade III). Grades II and III were defined as DSA. In this study, out of the 787 dialysis patients (447 men and 340 women, mean age: 60.0 years) examined, 133 patients (16.9%) were diagnosed with DSA. During 7 years follow-up, 108 dialysis patients were examined to investigate the clinical characteristics of DSA. Fifteen of 90 non-DSA cases progressed to DSA. Six of 18 DSA cases showed grade progression. The duration required for progression of each grade was analyzed. A new classification of DSA, namely, degenerative DSA and classical DSA, was applied in this study. The degenerative DSA showed faster grade progression than the classical DSA. Therefore, great attention should be paid in the radiological follow-up of elderly patients with grade I who start dialysis at an old age.

Atlantoaxial Subluxation in Different Intraoperative Head Positions in Patients with Rheumatoid Arthritis

Background

Disorders of the cervical spine are often observed in patients with rheumatoid arthritis (RA). However, the best head position for RA patients with atlantoaxial subluxation in the perioperative period is unknown. This study investigated head position during general anesthesia for the patients with RA and proven atlantoaxial subluxation.

Methods

During anesthesia of patients with RA and proven atlantoaxial subluxation, the authors used fluoroscopy to obtain a lateral view of the upper cervical spine in four different positions: the mask position, the intubation position, the flat pillow position, and the protrusion position. Copies of the still fluoroscopic images were used to determine the anterior atlantodental interval, the posterior atlantodental interval, and the angle of atlas and axis (C1-C2 angle).

Results

The anterior atlantodental interval was significantly smaller in the protrusion position (2.3 mm) than in the flat pillow position (5.1 mm) (P &lt; 0.05). The posterior atlantodental interval was significantly greater in the protrusion position (18.9 mm) than in the flat pillow position (16.2 mm) (P &lt; 0.05). The C1-C2 angle was, on average, 9.3 degrees greater in the protrusion position than in the flat pillow position (P &lt; 0.05).

Conclusion

This study showed that the protrusion position using a flat pillow and a donut-shaped pillow during general anesthesia reduced the anterior atlantodental interval and increased the posterior atlantodental interval in RA patients with atlantoaxial subluxation. This suggests that the protrusion position, which involves support of the upper cervical spine and extension at the craniocervical junction, might be advantageous for these patients.

Clinical Study of a Modified Brooks Technique for Atlanto-axial Subluxation Using Polyethylene Tape

Forty-four patients, 15 males and 29 females (3-71 years old; mean age, 52.9), were treated for the control of cervical instability with a modified Brooks operation using Tekmilon tape (an ultrahigh molecular weight polyethylene tape) instead of metal wires. Forty of the patients had rheumatoid arthritis (RA) with atlanto-axial subluxation (AAS), three patients had os odontoideum, and one patient had a cervical spine injury. The mean follow-up period was 8 years and 4 months. These patients were divided into three groups: 30 years or less, 31 to 60 years, and over 60 years. Atlanto-dental interval (ADI), inclination angle of atlanto-axial vertebrae (A-A angle), and bone fusion were examined on plain radiographs. The proportion of patients with reduced neck pain (Ranawat's grade 0 or grade 1) increased from 42.5% to 97.9% at the time of postoperative evaluation. Surgical complications, such as dural tear, lamina fracture, and spinal cord injury did not occur in any cases. Thirty-nine patients (88.6%) achieved bone union. ADI in the maximum flexed position improved from 10.3 to 2.5 mm. There was no statistical difference between ADI in males and females. ADI did not change in any age group both before and after surgery. A-A angle also improved from 9.4 to 24.4 degrees. The polyethylene tapes, used for internal fixation, caused no neurologic complications during sublaminar wiring and produced no MR artifacts. This modified Brooks technique using Tekmilon tape was proved to be a simple and safe treatment of AAS.

Is posterior spinal cord shifting by extensive posterior decompression clinically significant for multisegmental cervical spondylotic myelopathy?

STUDY DESIGN

Posterior cervical spinal cord shifting after selective single laminectomy associated with partial laminotomies was compared with that after bilateral open-door laminoplasty between the C3 and C7 levels in relation to the clinical results of each procedure.

OBJECTIVES

To investigate the clinical significance of posterior spinal cord shifting after extensive cervical laminoplasty.

SUMMARY OF BACKGROUND DATA

Current techniques used for cervical laminoplasty for multisegmental cervical spondylotic myelopathy (CSM) are consecutively performed between the C3 and C6 or C7 levels with expectation that the spinal cord will shift backward to keep it clear of anterior compression. However, the clinical significance of the posterior spinal cord shifting remains controversial, and there has been no report verifying it by comparing limited posterior decompression procedures with conventional extensive ones.

METHODS

Twenty-six patients with consecutive 2- to 3-level CSM who underwent selective laminoplasty (Group A) were enrolled in the study, and among 56 CSM patients who underwent bilateral open-door laminoplasty between the C3 and C7 levels, 25 who had consecutive 2- or 3- level stenosis identified by preoperative magnetic resonance imaging were used as controls (Group B). The recovery rate was calculated using preoperative and postoperative Japanese Orthopedic Association (JOA) scores for each patient, and for each patient's magnetic resonance imaging, the postoperative cervical curvature index was obtained according to Ishihara's method and the magnitude of postoperative backward shifting of the spinal cord was measured.

RESULTS

There was no significant difference between the subjects in Groups A and B with respect to the spinal curvature index, preoperative JOA scores, and recovery rate, but the magnitude of the postoperative posterior shifting of the spinal cord was greater for those in Group B than for those in Group A. There was no correlation between the recovery rate and posterior shifting of the spinal cord for each group, and no correlation was also found between the curvature index and posterior shifting of the spinal cord.

CONCLUSIONS

The outcome of posterior decompression surgery for multisegmental CSM is not correlated with the magnitude of postoperative backward shifting of the spinal cord. Extensive and consecutive decompression performed in conventional cervical laminoplasties is therefore not always necessary for multisegmental CSM.

Classification of Vertebral Compression Fractures in the Osteoporotic Spine

OBJECTIVE

The purpose of this study was to clarify the relationship between initial radiographs of osteoporotic vertebral compression fractures (VCFs) and clinical results.

METHODS

Of the 135 VCFs in the elderly, 73 consecutive patients (84 vertebrae) were reviewed retrospectively. All patients were treated without rigid immobilization. The subjects consisted of 15 men and 58 women. The mean age was 75.0 years with a range from 61 to 91 years. The early radiographic features were classified into five types based on lateral radiographs. Radiographic results during follow-up were evaluated according to the number of collapsed vertebrae and vacuum clefts. Clinical results were evaluated by Visual Analog Scale and activities of daily living.

RESULTS

Of the five types, swelled-front-type, bow-shaped-type, and projecting-type fractures had a poor prognosis with late collapse and often showing a vacuum cleft. On the other hand, concave-type and dented-type fractures had a good prognosis and almost achieved fusion. Clinical results of 28 patients with vacuum clefts were fair at the final follow-up. Nineteen patients had little back pain, and nine patients experienced moderate back pain. Regarding the activities of daily living, four patients had difficulty walking.

A correlative electrophysiologic study of nerve fiber involvement in carpal tunnel syndrome using current perception thresholds

OBJECTIVE

To relate clinical severity of idiopathic carpal tunnel syndrome (CTS) to current perception threshold (CPT).

METHODS

Subjects were 51 patients with CTS (involving 51 hands), and 50 healthy control subjects (50 hands). Involved hands were grouped into three clinical grades (mild, moderate, severe). Using a neurometer (Neurotron, Baltimore, MD), we investigated the relationship between clinical grade and CPT abnormalities.

RESULTS

In the mild CTS group, most hands showed CPT abnormalities only at 2000 Hz stimulation. The moderate group included a higher percentage of hands showing abnormalities at both 2000 and 250 Hz stimulation increased. The severe group included the highest percentage of hands with abnormal values at all frequencies tested.

CONCLUSIONS

CPT showed abnormalities appear progressively from 'higher to lower' frequency stimulations relative to the increasing severity of CTS.

SIGNIFICANCE

Sensory nerve fiber dysfunction apparently begins in larger fibers, extending stepwise to smaller fibers as the clinical grade of CTS progresses.

Diagnostic utility of waveform analysis of compound muscle action potentials for carpal tunnel syndrome

PURPOSE

To determine the diagnostic utility of waveform analysis of compound muscle action potentials (CMAP) for carpal tunnel syndrome (CTS).

METHODS

A total of 131 hands in 71 patients diagnosed with CTS (grouped according to severity) and 80 hands in 44 normal subjects were evaluated using nerve conduction test through the carpal tunnel combined with waveform analysis of CMAP.

RESULTS

Compared to normal subjects, the sensory nerve conduction velocity and mean frequency of the CMAP waveform were significantly reduced in patients with CTS. Compared with distal motor latency and sensory nerve conduction velocity, the mean frequency of the CMAP decreased significantly with increasing clinical severity.

CONCLUSION

This study suggests that waveform analysis of CMAP is of diagnostic value in CTS, and is also of value in objective evaluation of postoperative recovery of carpal median nerve dysfunction.

Evaluation of sensory function after median nerve decompression in carpal tunnel syndrome using the current perception threshold test

The recovery level for sensory function after carpal tunnel release for the treatment of idiopathic carpal tunnel syndrome (CTS) was assessed with the current perception threshold (CPT) test. Seventeen CTS patients (21 hands) were followed, and the CPTs at the index finger of each patient was measured preoperatively and at 1, 3, and 6 months postoperatively. After carpal tunnel release, there was significant recovery of CPT at all stimulation frequencies, indicating improvement of all sensory functions including sensations of temperature, pain, touch, and vibration.

Central role of mitochondria and p53 in Fas-mediated apoptosis of rheumatoid synovial fibroblasts

OBJECTIVE

Fas-mediated apoptosis is preferentially observed in synoviocytes of patients with rheumatoid arthritis (RA) and is associated with the pathophysiological process of RA. To clarify the molecular mechanisms of Fas-mediated apoptosis of RA synoviocytes, we investigated the role of the mitochondrial pathway and tumour suppressor p53 in this process.

METHODS

Cultured synovial fibroblasts were prepared from RA patients. After treatment of RA synovial fibroblasts with anti-Fas monoclonal antibody, the expression levels of activated caspase-9 and -3, Bid cleavage, cytochrome c release and phosphorylation of p53 at Ser15 were assessed using immunoblot analysis. The mitochondrial membrane potential (DeltaPsim) was evaluated with a fluorescence-based detection assay. Apoptotic cells were determined by a DNA fragmentation assay in the presence or absence of caspase inhibitors. Expression of p53-regulated apoptosis-inducing protein 1 (p53AIP1) was measured by real-time PCR. RA synovial fibroblasts stably transfected with a dominant-negative (DN) p53 were prepared in order to investigate the role of p53 during Fas-induced apoptosis.

RESULTS

Fas ligation induced Bid cleavage, loss of DeltaPsim, cytochrome c release to the cytosol and activation of caspase-9 and -3 in RA synovial fibroblasts. Treatment with a caspase-9-specific inhibitor almost completely inhibited Fas-mediated apoptosis. Moreover, p53 activation after Fas ligation was evidenced by its phosphorylation at Ser15 and up-regulation of the p53 target gene p53AIP1. Fas-mediated apoptosis was significantly suppressed by anti-sense p53 oligonucleotides and by p53DN.

CONCLUSION

Our findings strongly suggest the involvement of mitochondria and p53 in Fas-mediated apoptosis of RA synovial fibroblasts.

Objective evaluation of sensory function in patients with carpal tunnel syndrome using the current perception threshold

The purpose of this study was to determine the sensitivity and specificity for the current perception threshold (CPT) test during clinical examination of idiopathic carpal tunnel syndrome (CTS). We studied 71 patients (102 hands) with CTS; 50 healthy individuals (100 hands) served as a control group. Using a neurometer, we investigated standard CPT values to obtain the sensitivity and specificity of the CPT test in the clinical examination of CTS. In the CTS group, cases that had abnormal values in the range analysis, the ratio analysis, or both were called "true-positive CPTs"; in the control group cases that had normal values in the range and ratio analyses were called "true-negative CPTs." We defined the sensitivity as the percentage of true-positive CPTs in the CTS group and the specificity as the percentage of true-negative CPTs in the control group. The sensitivity of the CPT test using both range and ratio analyses was 73%, and its specificity was 74%. Based on these results we concluded that the CPT test is a reliable quantitative sensory function test.

Electrophysiologic Evaluation of Lumbosacral Single Nerve Roots Using Compound Muscle Action Potentials

Transcutaneous electrical stimulation applied to the vertebral column produces compound muscle action potentials (CMAPs) from the leg muscles. Using this method, we evaluated the efferent pathways of the lumbosacral nerve roots. The subjects were 26 healthy volunteers and 31 patients with lumbar disc herniation (LDH). CMAP recordings were obtained from the bilateral vastus medialis, tibialis anterior, extensor digitorum brevis, and abductor hallucis muscles using low-output-impedance stimulation. In normal subjects, the CMAP latency increased linearly with the distance between the stimulating electrode and the recording electrode, with little difference in latency between the left and the right sides in each subject. The CMAP amplitude was significantly lower in the patients with LDH, and the latency was also prolonged when the stimulating electrode was placed above the lesion. This technique may thus be a useful noninvasive method for assessing lumbosacral nerve root function in patients with LDH.

Evaluation of descending spinal cord tracts in patients with thoracic cord lesions using motor evoked potentials recorded from the paravertebral and lower limb muscles

We evaluated the function of the descending spinal cord motor tracts in patients, with and without spinal cord lesion, using motor evoked potentials. We studied 50 normal volunteers and 15 patients with thoracic lesions. The onset latency of the negative waves of motor evoked potentials for the thoracic spines was obtained, and the descending spinal cord conduction time was measured for the thoracic segments. In normal subjects, motor evoked potentials of paravertebral muscles recorded from T1-T2 to T5-T6 initially appeared as negative waveform with transcutaneous electrical stimulation over occipitocervical junction, although those from T6-T7 to T8-T9 were initially positive and those from more caudal sites were flatter. The motor evoked potential waveforms of tibialis anterior muscles evoked by electrical stimulation over the occipitocervical junction were markedly similar to those over the L1-L2. In patients with upper thoracic lesions, descending spinal cord conduction time from T2-T3 to T5-T6 was prolonged (p < 0.01). The descending spinal cord conduction time from T5-T6 to T11-T12 was also prolonged (p < 0.01) in patients with lower thoracic lesion. The descending spinal cord conduction time from T2-T3 to T11-T12 in patients with smaller motor function scores (<2) was significantly prolonged (p < 0.01) compared with normal subjects and patients with larger function scores. The methods of recording motor evoked potentials from paravertebral muscles with transcutaneous electrical stimulation over occipitocervical junction were useful for evaluating the level and motor function of thoracic cord lesions.

Evaluation of lumbosacral nerve root lesions using evoked potentials recorded by a surface electrode technique

STUDY DESIGN

Patients with lumbar disc herniation were studied with lumbosacral evoked potentials (EPs).

OBJECTIVES

To evaluate lumbosacral EPs for the functional diagnosis of nerve root lesions in patients with lumbar disc herniation.

SUMMARY OF BACKGROUND DATA

No clinical studies have been conducted using lumbosacral EPs elicited by body surface leads.

METHODS

Lumbosacral EPs elicited by stimulating the posterior tibial nerve were recorded using surface electrodes placed over the interspinous processes of T12-S1. By subtracting the waveform recorded at NT12 (T12/L1 potential) from that at NL3 (L3/L4 potential), NL3' (residual potential) potentials were clearly identified. NT12 and NL3' potentials were classified into four groups based on the degree of the reduction of amplitude and/or the prolongation of latency.

RESULTS

Significant correlations were found between the NL3' score and the straight-leg raising test score (r = 0.36, P < 0.05) and between the NT12 amplitude and sensory disturbance (r = 0.37, P < 0.02). The NL3' score was 1.2 +/- 0.5 points before surgery, and it significantly improved to 2.5 +/- 0.5 points 2 months after surgery (P < 0.05). Short-term, the NT12 amplitude did not change significantly. Twelve months after surgery, the NT12 amplitude improved significantly to 1.1 +/- 0.5 microV (P < 0.05).

CONCLUSIONS

The results of this study indicated that the NL3' score may reflect impairment of the impulse traversing the nerve root in the acute clinical stage, whereas the NT12 amplitude reflects a neurologic deficit. The postoperative clinical course can be estimated by observing recovery of the NL3' score and NT12 amplitude.

[Clinical application of PGA-tube for regeneration of intrapelvic nerves during extended surgery for intrapelvic recurrent rectal cancer]

For the regeneration of injured peripheral nerves, we have devised a PGA-tube that is composed of a tube of polyglycolic acid containing collagen sponge. This PGA-tube was applied clinically to reconstruct a peripheral nerve that had been resected during extended surgical resection of for intrapelvic recurrent rectal cancer. Four months after the surgical resection, the function of the left hip joint has improved remarkably, whereas the function had been lost just after the operation. It is suggested that the PGA-tube will be useful for regeneration of peripheral nerves that are resected during operation for intrapelvic malignancy.

Spinal reconstruction for symptomatic thoracic haemangioma using a titanium cage

Most vertebral haemangiomas are asymptomatic. A case of spinal reconstruction for symptomatic extraosseous thoracic haemangioma using a titanium cage is reported. Radiographs of the T11 vertebra demonstrated characteristic vertical striations. Magnetic resonance imaging and computed tomography showed spinal cord compression by extraosseous tumour extension. Several tumour feeding vessels were shown by angiography. Through a transpedicular biopsy, a histological diagnosis of cavernous haemangioma was made. Embolisation of feeding vessels was performed using coils before surgery. Laminectomy and subtotal vertebrectomy were performed by a single posterior approach. Rigid stabilisation of the spine was achieved with pedicle screw systems and a cage filled with an autogenous bone graft. Five months postoperatively, stabilisation of the spine was established without loosening of the cage or pedicle screws. Clinical symptoms were improved.

Independent predictors of restenosis after percutaneous coronary revascularization in haemodialysis patients

BACKGROUND

Percutaneous balloon angioplasty has become a well-established and routine procedure for coronary revascularization of haemodialysis patients with coronary artery disease. However, the incidence of restenosis after balloon angioplasty is significantly higher in haemodialysis patients than in the general population. We performed a retrospective study comparing balloon angioplasty with coronary stenting in haemodialysis patients. We evaluated the long-term clinical and angiographic outcome after successful percutaneous coronary revascularization in haemodialysis patients.

METHODS

A total of 103 consecutive haemodialysis patients (123 lesions) underwent procedurally and clinically successful percutaneous revascularization. Patients were treated with three different strategies: (i) balloon angioplasty in 55 patients (69 lesions); (ii) coronary stenting with balloon angioplasty in 23 patients (25 lesions); and (iii) coronary stenting with rotational atherectomy in 25 patients (29 lesions) who had severely calcified stenotic coronaries.

RESULTS

The rates of in-hospital mortality were similar in the three groups. The 1-year incidence of overall events and major adverse cardiac events (MACE) were significantly higher in the balloon group than in the stent with/without rotational atherectomy groups (75% vs 36 and 28%, P<0.01; 71% vs 32 and 28%, P<0.01). Use of coronary stenting (relative risk=0.006, P<0.001) and the presence of calcified coronary lesion (relative risk=68.2, P<0.001) were independent predictors of the 1-year MACE-free survival after percutaneous revascularization. The 3-year MACE-free survival rate was significantly lower in the balloon group than in the stent with/without rotational atherectomy groups (11% vs 33 and 47%, P<0.005 and P<0.001).

CONCLUSIONS

This study shows that coronary stenting reduces the incidence of MACE in haemodialysis patients with/without calcified coronary lesions. Moreover, coronary stenting reduces the restenosis rate of both complex and restenotic lesions, and rotational atherectomy prior to coronary stenting reduces the restenosis rate of the severely calcified coronary lesions. These results suggest that coronary stenting with/without rotational atherectomy has led to an improved long-term outcome in the haemodialysis patients with coronary artery disease.

Haematopoietic progenitor cells from the common marmoset as targets of gene transduction by retroviral and adenoviral vectors

To establish a new non-human primate model for human cytokine and gene therapy, we characterized lymphocytes and haematopoietic progenitor cells of the small New World monkey, the common marmoset. We first assessed the reactions of marmoset bone marrow (BM) and peripheral blood (PB) cells to mouse anti-human monoclonal antibodies (mAbs) for the purpose of isolating marmoset lymphocytes and haematopoietic progenitor cells. Both cell fractions stained with CD4 and CD8 mAbs were identified as lymphocytes by cell proliferation assay and morphological examination. Myeloid-specific mAbs such as CD14 and CD33 did not react with marmoset BM and PB cells. No available CD34 and c-kit mAbs could be used to purify the marmoset haematopoietic progenitor cells. Furthermore, we studied the in vitro transduction of the bacterial beta-galactosidase (LacZ) gene into CFU-GM derived from marmoset BM using retroviral and adenoviral vectors. The transduction efficiency was increased by using a mixed culture system consisting of marmoset BM stromal cells and retroviral producer cells. It was also possible to transduce LacZ gene into marmoset haematopoietic progenitor cells with adenoviral vectors as well as retroviral vectors. The percentage of adenovirally transduced LacZ-positive clusters was 15% at day 4 (multiplicity of infection=200), but only 1-2% at day 14. The differential use of viral vector systems is to be recommended in targeting different diseases. Our results suggested that marmoset BM progenitor cells were available to examine the transduction efficiency of various viral vectors in vitro.

Coronary artery disease as a definitive risk factor of short-term outcome after starting hemodialysis in diabetic renal failure patients

Cardiovascular disease is a major cause of morbidity and mortality in patients with diabetes who are receiving dialysis. It is known that cardiac mortality is high in the first year of hemodialysis (HD). The purpose of this study was to clarify the prevalence of coronary artery disease (CAD) in patients with diabetes at the initiation of HD, and to investigate the relationship between short-term outcomes after starting hemodialysis and CAD. We performed coronary angiography (CAG), whether or not patient had angina, within one month of initiation of maintenance HD in 17 of 34 consecutive unselected diabetic patients. We studied the two-year survival rate of those with CAD. Eleven patients (65%) were classified CAD-positive. Nine (82%) of these 11 had multivessel disease. Clinical and hematologic factors did not differ significantly between the groups with and without CAD. During the two-year follow-up period, 28 (82%) of 34 patients survived. In patients with CAD the two-year survival rate was 60%. None of the patients without CAD died within 2 years after starting HD. These results suggest that the presence of CAD at the initiation of HD may play a critical role in short-term outcomes after starting HD. We believe that an evaluation of CAD should be performed at the initiation of HD.

Estimation of cervical cord dysfunction by somatosensory evoked potentials

The purpose of this study was to examine the relationship of abnormal short-latency somatosensory evoked potentials (SSEPs) recorded by a noncephalic reference montage with clinical variables in cervical myelopathy patients and to reexamine the diagnostic utility of SSEPs in such patients. We studied cervical SSEPs elicited by stimulating the median and ulnar nerves in 87 patients. Our grade classification of spinal N13, which is based on the normal limits of latencies or amplitudes, corresponded well with the clinical variables and is of value when trying to localize the cervical lesion segmentally. The N9-P14 interpeak latency in response to ulnar nerve stimulation correlated well with lower extremity function (r = -0.440, P <0.0001). We suggest a combined assessment of N13 amplitude, and N9-N13 and N9-P14 interpeak latencies to estimate dorsal column and dorsal horn function separately in patients with cervical myelopathy.

Progress reports on immune gene therapy for stage IV renal cell cancer using lethally irradiated granulocyte-macrophage colony-stimulating factor-transduced autologous renal cancer cells

There is no effective treatment for patients with stage IV renal cell cancer (RCC), although the introduction of new therapy is imminent. Cancer gene therapy is currently considered to be one of the most promising therapeutic modalities in the field of cancer treatment. Based on the results of animal studies, vaccination using autologous granulocyte-macrophage colony-stimulating factor-transduced renal cancer cells appears promising. Before initiating a clinical study using an ex vivo gene-transduced autologous cell vaccine-based immunogene therapy for RCC in Japan, in 1992 we initially planned a Japanese version of a clinical protocol in collaboration with a US group. In 1993, the original protocol was refined. We performed five preclinical qualification studies using RCC nephrectomy specimens from patients in 1997, and the results showed that preparation of RCC cells for autologous vaccines at the Clinical Cell Technology Facility, Research Hospital of the Institute of Medical Science, University of Tokyo, was feasible. Subsequently in August 1998, the Ministry of Health and Welfare and the Ministry of Education, Science, Culture, and Sport approved our clinical protocol. We have recruited two patients with stage IV RCC to our study so far. Here we report the background to the initiation of cancer gene therapy in Japan.

TCR-Vbeta repertoire analysis with RT-PCR was useful for the early detection of pulmonary relapsed T-cell lymphoma after autologous peripheral blood stem cell transplantation

Pulmonary recurrence of malignant lymphoma is a rare event after stem cell transplantation. We report here a 45-year-old male who was successfully diagnosed with relapsed pulmonary T-cell lymphoma using an RT-PCR method. Clonal expansion of T cells expressing identical TCR V-D-J junction size (Vbeta5-Jbeta1.5) was demonstrated in lymphocyte groups obtained from both bronchoalveolar lavage fluid at relapse, and paraffin embedded lymph node samples resected when he was first diagnosed with angioimmunoblastic T-cell lymphoma. This method provided evidence to diagnose relapsed pulmonary angioimmunoblastic T-cell lymphoma in its early phase.

[Long-term outcome of coronary events in hemodialysis patients younger and older than 65 years of age]

BACKGROUND AND AIM

It has been reported that a coronary event is the leading cause of mortality in HD patients. The aim of this study was to examine and compare prospectively the effect of aging in relation to the in-hospital and the long-term outcome in HD patients with or without revascularization therapy who had experienced a coronary event. STUDY PATIENTS AND METHODS: Seventy consecutive HD patients with coronary events (9 AMI, 48 AP, and 13 CHF) were registered in this study and 69 patients underwent CAG. Patients were classified into elderly (> or = 65, n = 33) and younger (< 65, n = 37) groups based on their ages at the time of the events. Forty-six patients (21 vs 25) underwent initial coronary revascularization therapy. We followed 70 HD patients with coronary events for a mean period of 31 +/- 21 months (range: 1 day to 77 months).

RESULTS

A level of 64% of the elderly group and 41% of the younger group experienced coronary events within the first year of HD. The diseased vessels (2.2 vs 1.9 per patient) and stenotic lesions (2.8 vs 2.5 pre patients) were not significantly different between the two groups. The 70-month survival rate was significantly lower (21% vs 65%, p = 0.0423) in the elderly group than in the younger group. The complicated rate of stroke after a major event was significantly higher (14 vs 4, p = 0.0025) in the elderly group than in the younger group. Moreover 21 elderly patients (11 cardiac death, 5 stroke, 4 cancer) and 9 younger patients (8 cardiac death, 1 stroke) died during the 70-month follow-up period.

CONCLUSIONS

Coronary events were most frequent in the first year of HD. Long-term survival rate was significantly lower in elderly patients than in younger patients. Cardiac death was the most common cause of death in both groups regardless of performing coronary revascularization. Death due to stroke and cancer was also more common in elderly patients.

Vaccine effect of granulocyte-macrophage colony-stimulating factor or CD80 gene-transduced murine hematopoietic tumor cells and their cooperative enhancement of antitumor immunity

To develop immunogene therapy targeting minimal residual hematopoietic tumor cells in patients, we transduced murine GM-CSF or CD80 gene into murine WEHI 3B myelomonocytic leukemia and EL-4 thymic lymphoma cells using retroviral vectors and evaluated their effects on inducing antitumor responses in syngeneic host mice. Subcutaneously injected GM-CSF- and CD80 gene-transduced WEHI 3B (GMCSF/WEHI/3.2 or CD80/WEHI/1.8, respectively) cells lost their original tumorigenicity in immunocompetent syngeneic mice. Results from tumor inoculation experiments using athymic nude mice suggested that the rejection of GMCSF/WEHI/3.2 in immunocompetent mice depended fully on T cells and that of CD80/WEHI 1.8 depended partly on T cells and partly on NK cells. In both WEHI 3B and EL-4 models, irradiated GM-CSF gene-transduced cells provided strong immuno-protection against wild-type cells, but irradiated CD80 gene-transduced cells did not. A remarkably high cooperative effect was obtained when irradiated GMCSF/EL-4 and CD80/EL-4 were inoculated together. These results suggested that the tumor vaccine effect is efficiently enhanced by GM-CSF gene transduction and CD80 gene transduction induces some protective antitumor immunity in co-operation with GM-CSF gene transduction.

Onset of coronary artery disease prior to initiation of haemodialysis in patients with end-stage renal disease

To determine whether the onset of coronary artery disease may precede the initiation of dialysis in patients with end-stage renal disease, we performed coronary angiography within 1 month of initiation of maintenance haemodialysis in 24 patients (age range 42-78 years; mean 63.7 +/- 11). Coronary angiography was performed regardless of the absence or presence of angina. Fifteen patients had diabetic nephropathy, and nine had non-diabetic nephropathy. Significant coronary stenosis was defined as at least 75% narrowing of the reference segment. Fifteen patients (62.5%) with a total of 49 lesions were classified as the coronary artery disease present group. Eleven of those 15 (73.3%) had multivessel disease. The average number of stenotic lesions was 3.3 per patient. The most common patterns of stenosis were complex (23 lesions; 47%), and diffuse lesions over 20 mm long (14 lesions; 29%). None of the clinical or haematological factors evaluated differed significantly between the groups with and without coronary artery disease. The prevalence of coronary artery disease was 72.7% in the symptomatic patients and 53.8% in the asymptomatic patients. The diagnosis of coronary artery disease at the start of maintenance haemodialysis based only on chest symptoms and clinical factors proved to be difficult. Coronary angiography is thus essential for evaluating coronary artery disease in uraemic patients. Many patients with end-stage renal disease had coronary artery disease prior to the start of haemodialysis.