Cardiovascular adverse events and prognosis in patients with haematologic malignancies and breast cancer receiving anticancer agents: Kurume-CREO Registry insights

AIMS

Cancer treatment-related cardiovascular toxicity (CTR-CVT) is a growing concern in patients undergoing anticancer therapy. The Heart Failure Association (HFA) and International Cardio-Oncology Society (ICOS) risk assessment tools have been proposed for the baseline cardiovascular (CV) risk stratification of patients with cancer. This study investigated the incidence of CV adverse events in clinical practice, also using the HFA-ICOS risk tool.

METHODS AND RESULTS

This single-centre, prospective, observational study was conducted at Kurume University Hospital from October 2016 to August 2021, including patients aged ≥20 years with haematologic malignancies or breast cancer who were receiving anticancer agents. Cardiovascular assessments were performed at enrolment and every 6 months until August 2021, with additional assessments for suspected CV adverse events. The primary endpoint was common terminology criteria for adverse events v4.0 Grade ≥2, and the secondary endpoints were all-cause and CV deaths. Of the enrolled 486 patients, CV adverse events occurred in 24.5, 15.8, 38.1, and 18.0% of patients with leukaemia, malignant lymphoma, multiple myeloma, and breast cancer, respectively. Patients at high or very high risk had a significantly higher incidence of CV events, according to the HFA-ICOS risk tool. Cardiovascular death occurred in 4 (0.8%) patients during follow-up.

CONCLUSION

This study revealed that 16-38% of patients with haematologic malignancies and breast cancer developed CTR-CVT during follow-up, in which patients with high/very high risk were well predicted by the HFA-ICOS risk assessment tool. Monitoring and managing CV risk factors are essential for safe cancer therapy.

Negative Effects of Diffuse Idiopathic Skeletal Hyperostosis on Bone Fusion after Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

This study adopted a retrospective cohort study design.

PURPOSE

This study aimed to clarify the influence of diffuse idiopathic skeletal hyperostosis (DISH) on bone fusion after transforaminal lumbar interbody fusion (TLIF).

OVERVIEW OF LITERATURE

The negative effects of DISH on lumbar degenerative diseases have been reported, and DISH may be involved in the onset and severity of lumbar spinal canal stenosis. Patients with DISH have significantly more reoperations after posterior lumbar fusion, including TLIF. However, the effects of DISH on bone fusion after TLIF have not been reported.

METHODS

The medical records of patients with intervertebral TLIF from 2012 to 2018 were retrospectively examined. The patients were divided into those with fusion and those with pseudoarthrosis, and the following data were compared: age, sex, DISH, diabetes mellitus, smoking, drinking, albumin levels, body mass index ≥30 kg/m2, and L5/S fixation. Statistical analyses were performed using regression models.

RESULTS

In this study, 180 patients (78.6%) had fusion and 49 patients (21.4%) had pseudoarthrosis. The number of patients with DISH was significantly higher in the pseudoarthrosis group than in the fusion group (36.7% and 21.7%, respectively; univariate p=0.031, multivariate p =0.019). No significant differences in age, sex, diabetes mellitus, smoking, drinking, albumin levels, body mass index ≥30 kg/m2, and L5/S fixation were observed between the two groups. The risk factors for bone fusion were statistically analyzed in 57 patients with DISH. DISH with a caudal end below Th11 was an independent risk factor for pseudoarthrosis (univariate p=0.011, multivariate p=0.033).

CONCLUSIONS

DISH is an independent risk factor for pseudoarthrosis after one intervertebral TLIF, and DISH with a caudal end below Th11 is associated with a higher risk of pseudoarthrosis than DISH without a caudal end below Th11.

Post-immunobiotics increase resistance to primary respiratory syncytial virus infection and secondary pneumococcal pneumonia

Previously, we demonstrated that post-immunobiotics derived from Lactobacillus gasseri TMT36, TMT39, and TMT40 strains (HK36, HK39 and HK40, respectively) differentially regulated Toll-like receptor 3 (TLR3)-mediated antiviral respiratory immunity in infant mice. In this work, we investigated whether the HK36, HK39 and HK40 nasal treatments were able to improve the resistance against primary respiratory syncytial virus (RSV) infection and secondary pneumococcal pneumonia. Our results demonstrated that the three treatments increased the resistance to primary viral infection by reducing variations in body weight, RSV titers and lung damage of infected infant mice. Post-immunobiotics significantly enhanced the expressions of interferon (IFN)-λ, IFN-β, IFN-γ, interleukin(IL) - 1β, IL-6, IL-27, Mx1, RNAseL and 2'-5'-oligoadenylate synthetase 1 (OAS1) genes and decreased tumour necrosis factor (TNF)-α in alveolar macrophages of RSV-challenged mice. In addition, the studies in the model of RSV-Streptococcus pneumoniae superinfection showed that the HK39 and HK40 treatments were capable of reducing lung damage, lung bacterial cell counts, and the dissemination of S. pneumoniae into the blood of infant mice. The protective effect was associated with increases in IFN-β, IFN-γ, IL-10, and IL-27 in the respiratory tract. This study demonstrates that the nasal application of the post-immunobiotics HK39 and HK40 stimulates innate respiratory immunity and enhances the defences against primary RSV infection and secondary pneumococcal pneumonia offering an alternative to combat respiratory superinfections in children, which can be fatal.

Discontinuation of Intravenous Catecholamine by Oral Ivabradine in a Patient with Decompensated Heart Failure with Low Cardiac Output Syndrome

Ivabradine has been shown to improve heart failure with sinus tachycardia by reducing the heart rate without affecting left ventricular systolic function or blood pressure. Here we report a case of a catecholaminedependent patient, New York Heart Association (NYHA) class IV, LVEF of 18%, and low cardiac output, who was able to discontinue intravenous catecholamine by oral administration of ivabradine.

Rapidly Moving Vanishing Tumor of the Lung After Open-heart Surgery

Vanishing tumor of the lung, also known as phantom tumor, is uncommonly observed in congestive heart failure. We report a case of a vanishing tumor that rapidly disappeared and reappeared in just a few minutes due to repositioning in a patient after open-heart surgery.

Effect of dapagliflozin on the initial estimated glomerular filtration rate dip in chronic kidney disease patients without diabetes mellitus

BACKGROUND

Dapagliflozin (DAPA), a sodium-glucose transporter 2 inhibitor (SGLT2i), attenuates kidney outcomes in patients with not only diabetes mellitus (DM) but also chronic kidney disease (CKD). SGLT2i-derived initial dip in estimated glomerular filtration rate (eGFR) has been considered to reduce excess glomerular pressure, followed by renal protection in patients with DM. However, whether DAPA confers the eGFR dip and its independent determinants for CKD patients without DM are unclear.

METHODS

A total of 126 patients with CKD treated with 10 mg DAPA daily was retrospectively registered. After participants with missing data and DM were excluded, 51 participants were enrolled.

RESULTS

An initial eGFR dip was observed 1 month after initiation of DAPA, which was sustained until 2 months. DAPA did not affect urinary protein excretion; however, serum uric acid was decreased, while hemoglobin level was increased. Multiple regression analysis revealed that eGFR at baseline was the only independent determinant of the initial dip of eGFR. The patients currently showing exacerbation of glomerular hyperfiltration exhibited the larger initial eGFR dip rather than those showing progressive renal dysfunction. The patients meeting exclusion criteria of DAPA-CKD trial exhibited same degree of the initial eGFR dip as others.

CONCLUSIONS

DAPA causes an initial dip of eGFR in CKD patients without DM at 1 month after starting DAPA treatment. A higher eGFR at baseline predicts a large initial eGFR dip, which might be linked to the subsequent recovery in eGFR in CKD patients without DM.

The role of cellular senescence in aortic dissection

Background

Aortic dissection (AD) is a catastrophic disease that occurs suddenly. The acute mortality is high and those who survived frequently suffer from serious complications such as aneurysm formation and distal ischemia due to progressive destruction of the aortic walls. Currently, no predictor of AD onset is available nor therapeutic intervention to specifically prevent the progressive destruction in AD, because the molecular pathogenesis is largely unknown. Clinical and experimental studies highlighted the importance of inflammation in AD, although the regulatory mechanism of inflammation remains unclear. Recently, we found that cell proliferation precedes the inflammatory response in AD. Because cell proliferation causes cellular senescence that can induce inflammatory response, we hypothesized that cellular senescence participates in AD pathogenesis.

Objective

We investigated if cellular senescence contributes to AD development and progression in mouse AD model.

Methods and results

A mouse AD model was created by continuous infusion of beta-aminopropionitrile and angiotensin II (BAPN+AngII), where AD starts to develop in 3 days and occurs to most of the mice in 14 days accompanied by frequent AD rupture and death. Infusion of BAPN+AngII resulted in the induction of senescence markers Ink4a from day 3 before AD onset and persisted for the 14 days of the observational period.

Cellular senescence, as demonstrated by the expression of senescence-associated beta-galactosidase, was evident in intimal endothelial cells, medial smooth muscle cells, adventitial macrophages and fibroblasts. We examined the role of cellular senescence in AD pathogenesis by oral administration of ABT263 which is known as “senolytics” that eliminates senescent cells. ABT263 treatment reduced the expression of the senescence marker, prevented the death by AD rupture, and ameliorated the severity of AD lesion compared to the vehicle treatment. Transcriptome analysis revealed that ABT treatment suppressed the immune and inflammatory response in AD. Quantitative RT-PCR confirmed that ABT treatment prevented the induction of p21Cip1, interleukin-6, several chemokines and their receptors by 3-day infusion of BAPN+AngII.

Conclusions

These findings demonstrated that senescence of multiple cell types precedes AD development, which is likely to induce the inflammatory response. Elimination of senescent cells effectively prevented AD progression and death. Therefore, cellular senescence represents a potential predictor and a therapeutic target for AD.

Funding Acknowledgement

Type of funding sources: None.

Screening of Fabry disease in patients with chronic kidney disease in Japan

BACKGROUND

Fabry disease (FD), an X-linked lysosomal storage disorder caused by a deficiency in alfa-galactosidase A (α-Gal A) activity due to mutations in the GLA gene, has a prevalence of 0-1.69% in patients undergoing haemodialysis; however, its prevalence in patients with chronic kidney disease (CKD) Stages 1-5 is unknown.

METHODS

Serum α-Gal A activity analysis and direct sequencing of GLA were used to screen for FD in 2122 male patients with CKD, including 1703 patients with CKD Stage 5D and 419 with CKD Stages 1-5. The correlation between serum α-Gal A activity and confounding factors in patients with CKD Stages 1-5 was evaluated.

RESULTS

FD prevalence rates in patients with CKD Stage 5D and CKD Stages 1-5 were 0.06% (1/1703) and 0.48% (2/419), respectively. A patient with CKD Stage 5D exhibited a novel GLA mutation, p.Met208Arg, whereas two patients with CKD Stages 1-5 had c.370delG and p.Met296Ile. p. Met208Arg caused moderate structural changes in the molecular surface region near the substituted amino acid residue but did not affect the catalytic residues Asp170 and Asp231 in α-Gal A. Serum α-Gal A activity in patients with CKD Stages 1-5 was inversely correlated with age (P < 0.0001) but directly correlated with estimated glomerular filtration rate (P < 0.0001).

CONCLUSIONS

FD prevalence was much higher in male patients with CKD Stages 1-5 than in those with CKD Stage 5D. FD screening in patients with CKD Stages 1-5 may improve patient survival, decreasing the number of patients with CKD Stage 5D.

The role of cellular senescence in aortic dissection

Background

Aortic dissection (AD) is a catastrophic disease that occurs suddenly. The acute mortality is high and those who survived frequently suffer from serious complications such as aneurysm formation and distal ischemia due to progressive destruction of the aortic walls. Currently, no reliable predictor is available for AD development and surgical intervention is the only therapeutic option to prevent the fatal events after AD development, because the pathogenesis of AD is largely unknown.

Clinical and experimental studies highlighted the importance of inflammation in AD pathogenesis, although the trigger of inflammation remains unclear. Recently, we found that cell proliferation precedes the inflammatory response in AD. Because cell proliferation triggers cellular senescence and senescent cells secrete of proinflammatory cytokines and matrix metalloproteinases, we hypothesized that cellular senescence may participate in AD pathogenesis.

Objective

We investigated if cellular senescence contributes to AD development and progression in a mouse model of AD.

Methods and results

A mouse AD model was created by continuous infusion of beta-aminopropionitrile and angiotensin II (BAPN+AngII), where AD starts to develop in 3 days and occurs to most of the mice in 14 days accompanied by frequent AD rupture and death. Infusion of BAPN+AngII resulted in the appearance of senescent cells that are positive for senescence-associated beta-galactosidase, and expression of senescence markers Arf and Ink4a in the aortic walls. Appearance of cellular senescence occurred in one day of BAPN+AngII infusion and continued throughout the observational period of 14 days. We examined the role of cellular senescence in AD pathogenesis by oral administration of ABT263 which is known as “senolytics” that eliminates senescent cells. ABT263 treatment reduced the expression of the senescence markers. In the vehicle-treated group, the mortality was 66.7% (12/18), whereas that of ABT263-treated group was 35% (14/20, P&lt;0.05 by log-rank test). The severity of AD, as assessed by the lesion length in vehicle group was33.2±3.1 mm, whereas that in ABT263 group was 24.6±1.8 mm (P&lt;0.05).

Conclusions

These findings demonstrated that cellular senescence precedes AD development, and ABT263 effectively prevented AD progression and death, indicating the involvement of cellular senescence in AD pathogenesis. Therefore, cellular senescence represents a potential predictor and a therapeutic target for AD.

Funding Acknowledgement

Type of funding sources: None.

Involvement of FAK in aortic dissection: potential role in aortic interstitial cells

Background

Aortic dissection (AD) is a fatal disease where the intimomedial layer of the aorta suddenly fail. Although it is widely accepted that hemodynamic stress on the aortic wall triggers its destruction that is further promoted by inflammatory response as exemplified by the infiltration of neutrophils and macrophages, molecular mechanism is unknown for the link of aortic wall stress, inflammation and tissue destruction. In general, mechanical stress to the tissue is converted to the cellular response through the cell adhesion molecules and the activation of focal adhesion kinase (Fak). Although it has been reported that Fak is involved in pathogenesis of aortic aneurysm by promoting migration and activation of macrophages, its role in AD is unknown. We hypothesized that Fak may be involved in AD pathogenesis.

Purpose

We investigated the involvement of Fak in AD pathogenesis, focusing on its role in inflammatory cells.

Methods and results

We created a mouse model of AD by continuous infusion of beta-aminopropionitrile, a collagen crosslink inhibitor, and angiotensin II (BAPN + Ang II). Immunostaining for activated Fak revealed that Fak was not activated in normal aorta, but was activated in the infiltrating inflammatory cells and in interstitial cells of the aortic wall after AD development. We examined the role of Fak by oral administration of PND-1186, a specific Fak inhibitor, in mouse AD model. Vehicle-treated group showed 63.6% mortality, whereas PND-1186-treated group showed 20% mortality (P&lt;0.01, n=20 for each group) in 14 days of the observational period. The aortic arch lesion, the most critical part in AD, was improved from 1.96±0.41 mm in vehicle group to 0.66±0.29 mm in PND group (P&lt;0.05). We next examined the cell type-specific role of Fak in AD by creating macrophage and granulocyte-specific deletion of Fak driven by LysM-Cre and floxed Fak system. Unexpectedly, the genetic deletion of Fak in macrophages and granulocytes had no impact on the mortality nor the severity of AD.

Conclusions

These findings proved that Fak plays a critical role in AD progression and death. Because Fak is dispensable for macrophages and granulocytes, other cell types, possibly aortic wall interstitial cells, may be regulated by Fak in AD pathogenesis. Deciphering the role of Fak would provide the fundamental understanding of AD pathogenesis.

Funding Acknowledgement

Type of funding sources: None.

Effects of Reducing L-Carnitine Supplementation on Carnitine Kinetics and Cardiac Function in Hemodialysis Patients: A Multicenter, Single-Blind, Placebo-Controlled, Randomized Clinical Trial

L-carnitine (LC) supplementation improves cardiac function in hemodialysis (HD) patients. However, whether reducing LC supplementation affects carnitine kinetics and cardiac function in HD patients treated with LC remains unclear. Fifty-nine HD patients previously treated with intravenous LC 1000 mg per HD session (three times weekly) were allocated to three groups: LC injection three times weekly, once weekly, and placebo, and prospectively followed up for six months. Carnitine fractions were assessed by enzyme cycling methods. Plasma and red blood cell (RBC) acylcarnitines were profiled using tandem mass spectrometry. Cardiac function was evaluated using echocardiography and plasma B-type natriuretic peptide (BNP) levels. Reducing LC administration to once weekly significantly decreased plasma carnitine fractions and RBC-free carnitine levels during the study period, which were further decreased in the placebo group (p < 0.001). Plasma BNP levels were significantly elevated in the placebo group (p = 0.03). Furthermore, changes in RBC (C16 + C18:1)/C2 acylcarnitine ratio were positively correlated with changes in plasma BNP levels (β = 0.389, p = 0.005). Reducing LC administration for six months significantly decreased both plasma and RBC carnitine levels, while the full termination of LC increased plasma BNP levels; however, it did not influence cardiac function in HD patients.

Drop foot due to lumbar degenerative disease: Painless drop foot is difficult to recover

OBJECTIVE

To evaluate the improvement of drop foot following lumbar decompression surgery and determine the prognostic factors that might influence the recovery of drop foot.

SUMMARY AND BACKGROUND DATE

Drop foot is a common but serious problem that can lead to deteriorate patient's daily activities. There are numerous studied regarding the prognostic factors for the recovery of drop foot. However a few reports have been described the pathophysiological etiology of not only drop foot but also Trendelenburg's sign due to the L5 nerve root palsy. Therefore, there is a possibility drop foot caused by peroneal nerve palsy is included. In addition, none have evaluated the presence or absence of radicular leg pain with drop foot patients. The purpose of this study was to evaluate the improvement of paretic leg muscles and determine the prognostic factors that might influence the recovery of drop foot.

METHODS

Fifty-five drop foot patients were included in the study. Prognostic factors were retrospectively studied.Patients were assessed in terms of 10 items: 1) age, 2) sex, 3) diagnosis (LDH or LSS), 4) muscle strength of tibialis anterior, 5) muscle strength of extensor halluces longus, 6) muscle strength of gluteus medius, 7) presence or absence of radicular leg pain, 8) duration before surgery, 9) surgical treatment (spinal fusion or not), 10) anamnesis of diabetes mellitus.

RESULTS

Thirty-two (58.2%) of 55 patients recovered from their drop foot (manual muscle test of tibialis anterior ≥ 4 at final follow-up), while 23 (41.8%) did not (manual muscle test of tibialis anterior ≤ 3 at final follow-up). The strength of all muscles that were innervated and controlled by the L5 nerve root had recovered at the final follow-up when evaluated as averages. Multivariate logistic regression analysis revealed significant differences in terms of 2 items: "duration before surgery" and "presence or absence of radicular leg pain".

CONCLUSIONS

"Duration before surgery" and "presence or absence of radicular leg pain" are important to predict the recovery of drop foot. Painless drop foot patients with lumbar degenerative disease are difficult to recover their paralysis.

Effective Use of Keishibukuryogan in Subcutaneous Hematoma after Implantable Cardiac Device Surgery in Two Cases

Keishibukuryogan is a Kampo medicine that induces vasodilation and improves the blood flow velocity in subcutaneous blood vessels. We herein report two cases in which keishibukuryogan completely diminished subcutaneous hematoma after cardiac resynchronization therapy pacemaker implantation and defibrillator battery replacement within a month. Keishibukuryogan can be a good option for treating or preventing subcutaneous hematoma after surgical procedures for devices.

Automated heart segmentation using a convolutional neural network accelerates 3D model creation for cardiac surgery

Funding Acknowledgements

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Japan Organization of Occupational Health and Safety

onbehalf

J3D

Introduction

Improvements in cardiovascular imaging have contributed to the accurate diagnosis and treatment of cardiovascular diseases. In recent years, we can find a new demand from surgical departments, i.e., 3D heart models of patients for preoperative simulations. However, a 3D surgical model needs a detailed segmentation of heart structures from clinical images because these details are essential for achieving accurate polygon data of an exact 3D model. Thus, in most cases, manual segmentation is required for complicated heart shapes such as the chamber wall, valves, and papillary muscles, which causes a prolonged duration time.

Purpose

We aim to achieve an automated heart segmentation using a convolutional neural network (CNN) trained using deep learning techniques for the rapid creation of 3D surgical heart models of individual patients.

Methods

We constructed our original CNN program based on the latest artificial intelligence techniques and trained it to extract shapes of the heart from cardiac computed tomography (CT) images. The training data was 361 slices selected from CT scans of 10 patients. We used data augmentation to increase the amount and diversity of the data into 24,052 slices. The training result with the best Intersection over Union (IoU), one of the evaluation metrics used in deep learning, was saved. Finally, we used the best-trained CNN to construct 3D polygon data of two surgical cases of hypertrophic obstructive cardiomyopathy (HOCM) for preoperative assessments.

Results

The IoU attained 0.85 after deep learning. The time required to complete the 3D polygon data for the first HOCM case was 5 minutes for segmentation by the trained CNN and 3 hours for data correction by a human operator. Similarly, the time required for the second case was 5 minutes for segmentation without manual correction. We had to correct the segmentation for the first case because we needed an exact 3D model for the preoperative assessment (Fig. 1). According to our records of the other eight 3D heart models in the lab, the work for a 3D polygon shape from CT images needs a median 30 hours (quartiles 23-50 hours) when the procedure is fully manual and non-continuous with breaks in between.

Conclusion

The CNN-based segmentation aided the constructing heart shapes from cardiac CT images of preoperative patients. Although the performance, reaching IoU of 0.85, was insufficient for fully automatic segmentation, the methodology can shorten the process duration from several hours to several minutes for detailed segmentation of heart structures.

We previously applied the CNN-based segmentation to the aorta, aortic stenosis valves, and atheromatous plaque in clinical images, demonstrating adequate segmentation performance. The proposed methodology can be applied as a fundamental technology of cardiovascular imaging for obtaining the actual structures of a target object as 3D coordinate values or a 3D model within a reasonable duration time.

Abstract Figure 1

Effect of switching from cinacalcet to etelcalcetide on secondary hyperparathyroidism in patients undergoing hemodialysis: an ESCORT trial

Background

Etelcalcetide is the first intravenously administered calcimimetic agent used to manage secondary hyperparathyroidism (SHPT) in hemodialysis (HD) patients. We evaluated the safety and efficacy of replacing cinacalcet with etelcalcetide in HD patients.

Methods

One hundred and thirty-three patients HD on cinacalcet were screened, and 93 patients with serum-intact parathyroid hormone (iPTH) level of ≥ 60 pg/mL and serum albumin-corrected calcium (cCa) level of ≥ 8.4 mg/dL were enrolled. The patients were divided into three groups based on the dose of cinacalcet (i.e., 25, 50, and ≥ 75 mg) and switched to etelcalcetide. Etelcalcetide was administered three times per week for 24 weeks. The primary and secondary endpoints were etelcalcetide conversion dose and etelcalcetide effectiveness for iPTH levels (target range: 60–240 pg/mL), respectively.

Results

Of the 68 patients whose iPTH level was within the management target at screening, 60 patients maintained the target level at the end of the study. Among patients whose iPTH level exceeded 240 pg/mL at screening, it decreased from 401 ± 246 pg/mL to 220 ± 209 pg/mL (p < 0.001) at the end of the study. Among 22 patients with the iPTH level of ≥ 240 pg/mL, 17 achieved the target level. The mean dose of cinacalcet was 41.4 ± 22.2 mg/day and that of etelcalcetide at the end of the study was 6.4 ± 3.7 mg/session in all patients. In 45 patients whose iPTH level was within the management target throughout the study and active vitamin D agent and calcium-based phosphate binder doses were constant, the mean dose of cinacalcet was 45.0 ± 22.4 mg/day and that of etelcalcetide at the end of the study was 6.1 ± 3.1 mg/session. The spKt/V might affect the ratio of etelcalcetide per session to oral cinacalcet per day (45 patients, p = 0.087; 90 patients, p < 0.05) in the generalized linear model. Etelcalcetide-induced severe adverse events were not observed.

Conclusions

This study reports the conversion dose of etelcalcetide and demonstrates its safety and efficacy in HD patients with SHPT previously treated with cinacalcet.

Trial registration

UMIN, UMIN000027637; Registered on June 5, 2017.

Effect of tolvaptan on renal involvement in patients with autosomal dominant polycystic kidney disease according to different gene mutations

BACKGROUND

Autosomal dominant polycystic kidney disease (ADPKD) is an inherited disorder caused by mutations in the polycystic kidney disease (PKD) gene. Although tolvaptan has benefits for renal involvement, the different effects depending on the gene mutation type are unknown. Thus, we explore the different effects of tolvaptan on the annual changes in total kidney volume (%TKV) and estimated glomerular filtration rate (eGFR) according to the gene mutation type in ADPKD patients.

METHODS

In total, 135 ADPKD patients were screened, and 22 patients taking tolvaptan for at least a year were retrospectively studied at the Kurume University Hospital. We examined the decline in renal function and %TKV by computed tomography and analyzed the gene mutation. Patients were classified into the following four groups according to gene mutation type: PKD1-truncated, PKD1-non-truncated, PKD2, and mutation not found. Patients were treated with tolvaptan, and the effects of tolvaptan were analyzed according to the gene mutation type.

RESULTS

Patients (age: 52.3 ± 11.2 years) were administered tolvaptan at a dose of 45 or 60 mg. No variation was observed in the annual changes in eGFR (%eGFR) (before: - 10.5% ± 13.9%, after: - 14.4% ± 8.1%, P = 0.139), whereas %TKV was significantly improved after the tolvaptan treatment (before: 14.9% ± 8.0%, after: - 5.4% ± 7.6%, P < 0.001). Unlike %eGFR, tolvaptan treatment significantly improved %TKV, regardless of the type of gene mutation.

CONCLUSIONS

A year treatment with tolvaptan significantly improved %TKV in patients with ADPKD, regardless of the gene mutation type.

l-carnitine supplementation vs cycle ergometer exercise for physical activity and muscle status in hemodialysis patients: A randomized clinical trial

Serum carnitine is decreased in hemodialysis patients, which induces muscle atrophy. Thus, we examined the different effects of l-carnitine and exercise on exercise activity and muscle status in hemodialysis patients. Twenty patients were divided into l-carnitine and cycle ergometer groups and were followed for 3 months. Muscle and fat mass, physical activities, and muscle status were evaluated by an impedance, physical function test, and magnetic resonance imaging, respectively. The l-carnitine significantly increased muscle mass (P = .023) and thigh circumference (P = .027), decreased fat mass (P = .007), and shortened chair stand-up time (P = .002) and 10-m walk test (P = .037). The fat fraction was improved by the l-carnitine (P = .047). Compared with the exercise group, l-carnitine improved the changes in 10-m walk test (P = .026), chair stand-up time (P = .014), and thigh circumference (P = .022). Baseline fibroblast growth factor-21 and myostatin levels predicted the l-carnitine-associated changes in exercise activities. l-carnitine, rather than exercise, improved physical activity and muscle status in hemodialysis patients.

Single Needle Granulocyte and Monocyte Apheresis for Ulcerative Colitis: A Retrospective Safety Analysis

INTRODUCTION

Granulocyte and monocyte apheresis (GMA) is an effective treatment strategy for active ulcerative colitis (UC) in Japan. Single needle (SN) apheresis reduces needle puncture pain in patients because it requires only one puncture site. We evaluated whether single-needle apheresis could be a safe and effective means of reducing patient burden.

METHOD

We performed a retrospective study of active UC patients who were treated with either SN apheresis or conventional double-needle (DN) apheresis at the Kurume university hospital from April 2014 to March 2018. All the patients treated with GMA after September 2016 underwent SN apheresis. Thus, the two groups predominantly belonged to different time periods. We assessed the safety of SN apheresis.

RESULT

Six patients underwent SN apheresis, and 6 underwent DN apheresis. The average time to the start of apheresis was significantly reduced from 23.1 minutes in the case of DN apheresis to 12.6 minutes for SN apheresis. In addition, the number of difficult punctures was significantly reduced with SN apheresis. There were no differences in adverse events between SN and DN apheresis. Treatment benefits, remission rate and disease activity were similar between SN and DN apheresis.

CONCLUSION

SN apheresis reduced both the time to treatment initiation and pain during puncture, and there was no difference in the number of blood clotting episodes as compared with DN. Although further comparative studies are needed, SN apheresis may be a safe alternative for patients to reduce the strain of treatment.

Effectiveness of cryofiltration and mizoribine combination with oral steroid therapy in a patient with membranoproliferative glomerulonephritis due to essential cryoglobulinemia

A 65-year-old male patient with nephrotic syndrome was admitted to our hospital due to worsening systemic edema and purpura on the limbs. He had an impaired renal function, low serum complement level, and elevated rheumatoid factor level. He was positive for cryoglobulin (monoclonal IgM-κ and polyclonal mixed-type IgG), and the results of his kidney biopsy showed a tissue profile of membranoproliferative glomerulonephritis (MPGN). Due to the fact that the secondary cause was unclear, he was diagnosed with MPGN due to essential mixed cryoglobulinemia. On hospital day 20, he was initiated on 50 mg/day prednisolone (PSL). On hospital day 43, oral mizoribine (MZR) at a dose of 150 mg/day was prescribed. On hospital day 49, cryofiltration was performed because the disease was steroid resistant. The treatment promptly decreased urine protein levels. Serum albumin and serum complement levels increased, and complete remission was achieved approximately three months after the initiation of treatment. The PSL and MZR doses were gradually reduced to 2 mg/day and 100 mg/day, respectively, without any reemergence of the symptoms of cryoglobulinemia or relapse of the nephrotic syndrome for three years. Here, we report this case with essential mixed cryoglobulinemia in whom we could achieve complete remission of the disease by adding cryofiltration to the oral corticosteroid and immunosuppressant therapy with mizoribine and could maintain for a long time.

AGEs-RAGE overexpression in a patient with smoking-related idiopathic nodular glomerulosclerosis

We report a case of smoking-related idiopathic nodular glomerulosclerosis (ING) with overexpression of glomerular advanced glycation end products (AGEs) and their receptor (RAGE). A 59-year-old Japanese man with nephrotic syndrome, who had a smoking history of one pack of cigarettes per day for approximately 40 years, presented with a 3-year history of urinalysis abnormalities without clinical evidence of diabetic mellitus. The patient's leg edema progressively worsened over the previous 2 years, and he was admitted to our hospital. Renal biopsy showed mesangial expansion with diabetic Kimmelstiel-Wilson-like nodular lesions, glomerular basement thickening, and arteriosclerosis. No electron-dense deposits, fibrils, or microtubule deposits were seen in the glomeruli on electron microscopy. Skin AGE level measured using AGE reader was higher in this case than the average level in age-matched Caucasians. In addition, immunohistochemical analysis revealed that N-carboxymethyl lysine, one of the major AGEs, and RAGE were overexpressed and podocin expression was decreased in the peripheral area of the glomerular nodular lesions. These observations suggest that AGEs-RAGE system may be activated in smoking-related ING, possibly leading to the progression of renal dysfunction.

A retrospective study of radiographic abnormalities in the repositories for Thoroughbreds at yearling sales in Japan

This study aimed to evaluate whether radiographic abnormalities at yearling sales were associated with the failure to start racing at 2–3 years of age. Radiographic abnormalities in the carpal (n=852), tarsal (n=976), metacarpophalangeal (n=1,055), and metatarsophalangeal joints (n=1,031) from 1,082 horses, recorded at yearling sale, were reviewed. Eighty-two horses (7.6%) failed to start racing. Radiographic abnormalities such as wedged or collapsed tarsal bones, irregular lucency of a sagittal ridge at the distal aspect of the distal third metatarsal bone, and proximal dorsal fragmentation of the first phalanx in metatarsophalangeal joints were associated with failure to start racing in these horses. In the follow-up survey of 12 horses with one or more these radiographic abnormalities, the horses failed to start racing due to reasons unrelated to these radiographic abnormalities such as pelvic fractures (2 horses), fracture of a distal phalanx (1 horse), cervical stenotic myelopathy and proximal sesamoid fracture (1 horse), superficial digital flexor tendonitis (2 horses), laryngeal hemiplegia (1 horse), economic problems (2 horses) and unknown causes (3 horses). Although radiographic abnormalities at yearling sales can be associated with failure to start racing at 2–3 years of age, these radiographically detected abnormalities might not necessarily cause that failure.

A retrospective study of radiographic abnormalities in the repositories of 2-year-old Thoroughbred in-training sales in Japan

This study aimed to evaluate the influence of radiographic abnormalities of 2-year-old Thoroughbred horses that were listed at in-training sales in Japan, on whether they started to race or not at 2–3 years of age. Radiographs of 850 2-year-old Thoroughbreds in the in-training sales repository from 2007 to 2010 were reviewed, and 26 categories of radiographic abnormalities were found. Forty-three horses (5.1%, 43/850) did not start a race at 2–3 years of age. In accordance with the racing results for this age category, as determined by Fisher’s exact test and multiple logistic regression analysis, none of the radiographic abnormalities were significantly related to failure to start a race. At 2 years of age, 198 horses (23.3%, 198/850) did not start a race. Horses with enlargement of the proximal sesamoid bones in the fore (9 of 19 horses) and hind limbs (5 of 9 horses) did not start a race at the age of 2 years, and fewer of these horses (fore, P=0.021; hind, P=0.030) started a race at the age of 2 years compared with the population of horses without these radiographic abnormalities. These results suggest that identification of radiographic enlargement of the proximal sesamoid bones during training sales could derail the racing debut of horses at the age of 2 years. However, this might not necessarily indicate a poor prognosis and resulting in retirement from racing at 2–3 years of age.

Serum albumin-adjusted glycated albumin reflects glycemic excursion in diabetic patients with severe chronic kidney disease not treated with dialysis

OBJECTIVE

Diabetic patients with severe chronic kidney disease (CKD) not treated with dialysis falsely show low levels of HbA1c and GA due to renal anemia and proteinuria, respectively. Recently, we reported that serum albumin-adjusted GA (adjGA) accurately reflects mean plasma glucose (PG) in these patients. It is considered that GA reflects not only mean PG but also glycemic excursion; therefore, in the present study we investigated whether adjGA reflects glycemic excursion in these patients.

METHODS

Thirty type 2 diabetic patients with severe CKD not treated with dialysis were enrolled in the present study. PG was monitored by seven times a day, and indicators of glycemic excursion [SD, max PG, ΔPG, M value, J index, and mean amplitude of glucose excursion (MAGE)] were calculated. The correlations between HbA1c, GA or adjGA and indicators of glycemic excursion were investigated.

RESULTS

HbA1c showed no significant correlation with indicators of glycemic excursion. GA was significantly correlated with them except for ΔPG. adjGA was significantly and strongly associated with them except for MAGE. GA, but not adjGA, showed a significant positive correlation with serum albumin.

CONCLUSION

adjGA was not influenced by serum albumin and showed a significant correlation with indicators of glycemic excursion in diabetic patients with severe CKD not treated with dialysis. These results suggest that adjGA could be useful for indicating glycemic control in diabetic patients with severe CKD not treated with dialysis.

Serum albumin-adjusted glycated albumin is a better indicator of glycaemic control in diabetic patients with end-stage renal disease not on haemodialysis

Backgrounds

Diabetic patients with end-stage renal disease who are not on haemodialysis show low concentrations of HbA1c and glycated albumin due to renal anaemia and proteinuria, respectively. In the present study, we examined whether serum albumin-adjusted glycated albumin could accurately reflect glycaemic control in these patients.

Methods

To examine the correlation between glycated albumin and serum albumin (Study 1), 49 diabetic patients with end-stage renal disease not on haemodialysis were used. To evaluate the association between the glycaemic control indicators and the glycaemic control state (Study 2), 30 diabetic patients with end-stage renal disease were enrolled. The estimated HbA1c and the estimated glycated albumin concentrations were calculated based on the mean blood glucose concentrations obtained from the diurnal variation. The adjusted glycated albumin concentrations were calculated from the regression formula between the serum albumin and glycated albumin obtained from Study 1.

Results

No significant correlation was found between the measured HbA1c and estimated HbA1c concentrations. The estimated HbA1c (inversely) and measured HbA1c/estimated HbA1c ratio (positively), but not measured HbA1c, showed a significant correlation with Hb concentrations. The estimated glycated albumin was positively associated with the measured glycated albumin and adjusted glycated albumin concentrations. Although measured glycated albumin/estimated glycated albumin ratio was positively correlated with serum albumin, there was no significant association between the adjusted glycated albumin/estimated glycated albumin ratio and serum albumin, Hb and estimated glomerular filtration rate.

Conclusions

We found for the first time that the adjustment of glycated albumin by serum albumin could be useful to determine glycaemic control in diabetic patients with end-stage renal disease not on haemodialysis. These findings suggest that adjusted glycated albumin might be a better indicator of glycaemic control than measured HbA1c and measured glycated albumin in these patients.

Rupture of the gastrocnemius muscle in neonatal thoroughbred foals: a report of three cases

Rupture of the gastrocnemius muscle is occasionally found in neonatal foals associated with dystocia and assisted delivery. In this report, 3 cases of gastrocnemius muscle disruption in newborn Thoroughbred foals (6, 5 and 2 days old) are reported. In all cases, the foals were presented with inability to rise unassisted postpartum, a dropped tarsus and swelling in the caudal aspect of the thigh accompanied by a hematoma. Ultrasonography, radiography, computerized tomography (CT) and subsequent autopsy were performed to confirm the clinical and pathological features of these cases.

Is the prognostic impact of tumor location in patients with surgically resected esophageal squamous cell carcinoma affected by surgical approach?

AIM

The aim of the present study was to clarify differences in node metastasis mode and clinical outcomes based on tumor location in patients with esophageal squamous cell carcinoma (ESCC).

PATIENTS AND METHODS

Participants comprised 228 patients with ESCC who underwent radical esophagectomy without preoperative supplement therapies. Lymph nodes were harvested from three fields: the neck, thorax, and abdomen. Patients were divided into three groups depending on tumor location [upper esophagus (UE), middle esophagus, or lower esophagus (LE)] and analyzed clinicopathologically.

RESULTS

The LE group showed significantly more progressive ESCC in terms of tumor invasion (p = 0.025), node metastasis (p = 0.0071), and TNM stage (p = 0.0043). The LE group revealed a tendency to metastasize to extrathoracic (especially abdominal) nodes (p = 0.0008). Recurrent laryngeal node metastasis was increased in the UE group (p = 0.016). However, no prognostic differences were detected between groups according to tumor location. Likewise, subgroup analyses by surgical approach (open thoracotomy vs. thoracoscopy) and cancer stage (stage I/II, III, and IV) did not reveal any significant prognostic impact of tumor location.

CONCLUSION

Lymphatic spread varied by tumor location, but no prognostic impact of tumor location could be detected in patients with ESCC in spite of surgical approach or cancer stage.

Involvement of asymmetric dimethylarginine (ADMA) in tubulointerstitial ischaemia in the early phase of diabetic nephropathy

BACKGROUND

Decreased peritubular capillary (PTC) flow due to impaired endothelial function elicits tubulointerstitial ischaemia, thereby enhancing renal damage in chronic kidney disease, including diabetic nephropathy. Since nitric oxide (NO) is a vasodilator and known to play an important role in the maintenance of PTC flow, it is conceivable that asymmetric dimethylarginine (ADMA), an endogenous inhibitor of NO synthase, may cause tubulointerstitial ischaemia, thus being involved in the progression of diabetic nephropathy. In this study, we investigated whether overexpression of dimethylarginine dimethylaminohydrolase (DDAH), an enzyme that degrades ADMA, could improve tubulointerstitial ischaemia in streptozotocin (STZ)-induced diabetic rats.

METHODS

Recombinant adenovirus vector encoding DDAH-I (Adv-DDAH) or control vector expressing bacterial beta-galactosidase (Adv-LZ) was intravenously administrated to diabetic rats. Three days after the treatment, effects of DDAH overexpression on plasma or urinary levels of ADMA or NO metabolites (NOx), tubulointerstitial ischaemia and renal expression of transforming growth factor-beta (TGF-beta) were evaluated.

RESULTS

Renal DDAH expression and activity were reduced in diabetic rats. Urinary levels of ADMA and TGF-beta were increased, while NOx levels were decreased in diabetic rats. Compared with control rats, pimonidazole-detected hypoxic areas were larger in the kidney of diabetic rats, although the number of capillaries in tubulointerstitial regions was not different between the two groups. In addition, renal expression levels of hypoxia-inducible factor-1alpha (HIF-1alpha) and TGF-beta were also increased in diabetic rats. DDAH overexpression significantly inhibited the increase of ADMA and the decrease of NOx and subsequently decreased urinary albumin excretion levels and ameliorated tubulointerstitial hypoxia and HIF-1alpha as well as TGF-beta expression in diabetic rats.

CONCLUSION

The present study demonstrated for the first time that the suppression of ADMA by DDAH overexpression could improve tubulointerstitial ischaemia and subsequent renal damage in experimental diabetic nephropathy. Substitution of DDAH protein or enhancement of its activity may become a novel therapeutic strategy for the treatment of early diabetic nephropathy.