POS1339 FACTORS RELATED TO SERUM IgG4 ELEVATION AND DEVELOPMENT OF IgG4-RELATED DISEASE: DATA FROM RESIDENT EXAMINATION

Background

Elevated serum IgG4 levels are one of the characteristic findings in immunoglobulin G4 (IgG4)-related disease (IgG4-RD). Serum IgG4 levels have an impact to a certain extent on the diagnosis of IgG4-RD although there are some issues in their sensitivity and specificity. In the reports from Japan, China, USA, and Europe, elevated serum IgG4 levels were reported to be observed in 83-97% of patients with IgG4-RD [1-5]. In the past investigations of hospital patients, some studies reported that 10-15% of hospital patients with elevated serum IgG4 levels had IgG4-RD [6,7]. However, in general adults with no symptom, investigations of prevalence of elevated serum IgG4 levels and/or IgG4-RD have rarely been conducted.

Objectives

This study aimed to investigate the frequency of serum IgG4 elevation in the general Japanese population and its associated factors using data from resident examinations.

Methods

We measured the serum IgG4 levels in 1,204 residents who underwent a general medical examination in Ishikawa prefecture, Japan. Logistic regression analysis was used to search for factors related to elevated serum IgG4 levels. Secondary examinations were conducted for participants in whom elevation was identified.

Results

The mean serum IgG4 level was 44 mg/dL, and elevated serum IgG4 levels were observed in 42 patients (3.5%). Univariate logistic regression analyses showed that male sex, older age, lower estimated glomerular filtration rates based on cystatin C (eGFR-CysC), serum high-density lipoprotein cholesterol levels, and higher hemoglobin A1c (HbA1c) levels were associated with elevated serum IgG4 levels. Subgroup analyses in men showed that older age, lower eGFR-CysC levels, and higher serum HbA1c levels were associated with elevated serum IgG4 levels. In contrast, the analyses in women found no significant factors. One of the 10 residents who underwent secondary examinations was diagnosed with possible IgG4-related retroperitoneal fibrosis.

Conclusion

In the general population, elevated serum IgG4 levels are more common in elderly men, which is similar to the epidemiological features of IgG4-RD.

References

[1]Inoue D, et al. IgG4-related disease: dataset of 235 consecutive patients. Medicine (Baltimore). 2015;94(15):e680.

[2]Yamada K, et al. New clues to the nature of immunoglobulin G4-related disease: a retrospective Japanese multicenter study of baseline clinical features of 334 cases. Arthritis Res Ther. 2017;19(1):262

[3]Culver EL, et al. Elevated serum IgG4 levels in diagnosis, treatment response, organ involvement, and relapse in a prospective IgG4-related disease UK cohort. Am J Gastroenterol 2016;111:733–43.

[4]Lin W, et al. Clinical characteristics of immunoglobulin G4-related disease: a prospective study of 118 Chinese patients. Rheumatology (Oxford). 2015;54(11):1982–90.

[5]Carruthers MN, et al. The diagnostic utility of serum IgG4 concentrations in IgG4-related disease. Ann Rheum Dis 2015;74:14-18.

[6]James Yun, et al. Poor positive predictive value of serum immunoglobulin G4 concentrations in the diagnosis of immunoglobulin G4-related sclerosing disease. Asia Pac Allergy. 2014 Jul;4(3):172-176.

[7]Taiwo N Ngwa, et al. Sreum immunoglobulin G4 ｌevel is a poor predictor of immunoglobulin G4–related disease. Pancreas. 2014 Jul;43(5):704-7.

Disclosure of Interests

None declared

The role of increased FGF21 in VLDL-TAG secretion and thermogenic gene expression in mice under protein malnutrition

Protein malnutrition promotes hepatic lipid accumulation in growing animals. In these animals, fibroblast growth factor 21 (FGF21) rapidly increases in the liver and circulation and plays a protective role in hepatic lipid accumulation. To investigate the mechanism by which FGF21 protects against liver lipid accumulation under protein malnutrition, we determined whether upregulated FGF21 promotes the thermogenesis or secretion of very-low-density lipoprotein (VLDL)-triacylglycerol (TAG). The results showed that protein malnutrition decreased VLDL-TAG secretion, but the upregulation of FGF21 did not oppose this effect. In addition, protein malnutrition increased expression of the thermogenic gene uncoupling protein 1 in inguinal white adipose and brown adipose tissue in an FGF21-dependent manner. However, surgically removing inguinal white adipose tissue did not affect liver triglyceride levels in protein-malnourished mice. These data suggest that FGF21 stimulates thermogenesis under protein malnutrition, but this is not the causative factor underlying the protective role of FGF21 against liver lipid accumulation.

AB0760 HIGH SERUM IGA LEVELS HAVE LIMITED CLINICAL SIGNIFICANCE IN PATIENTS WITH IGG4-RELATED DISEASE DIAGNOSED BY EXPERTS

Background:

While the diagnostic and classification criteria for IgG4-related disease (IgG4-RD) have been recently developed [1-3], it is known that, without appropriate exclusions, some non-IgG4-RDs may meet these criteria. In particular, hyper IL-6 syndromes, including Castleman disease, can be misdiagnosed as IgG4-RD. Some clinical findings, including elevated serum levels of C-reactive protein (CRP) or IgA, have been suggested to be useful for differentiating hyper IL-6 syndromes from IgG4-RD [4]. However, since few clinical studies have focused on IgG4-RD with high serum IgA levels, its clinical significance has not been well known.

Objectives:

This study aimed to clarify the clinical significance of high serum IgA levels in patients with IgG4-RD.

Methods:

We retrospectively investigated the clinical features of 170 patients with IgG4-RD on the basis of the presence or absence of elevated serum IgA levels (>410 mg/dL) at the time of diagnosis. The diagnosis of IgG4-RD was made by experts on the basis of the fulfillment of the comprehensive diagnostic criteria and/or each organ-specific diagnostic criteria.

Results:

Elevated serum IgA levels were observed in 18 patients (10.6%). In the patients with elevated serum IgA levels, serum CRP levels were higher (1.14 ± 1.18 vs. 0.31 ± 0.63 mg/dL, p=0.003) and the prevalence of relapse during the clinical course was lower (5.6% vs. 27.6%, p=0.046) than in those without elevated serum IgA levels. However, there were no significant differences in the other clinical features including the number of involved organs (2.4 ± 1.3 vs. 2.8 ± 1.6, p=0.443) and inclusion scores of the ACR/EULAR classification criteria (32 ± 14 vs. 36 ± 17, p=0.374). To evaluate the influence of serum IgA elevation on relapse, we performed Cox regression analysis, which showed that the elevated serum IgA levels had no significant association with lower incidence of relapse but a tendency of it (hazard ratio 0.997, 95% confidence interval 0.994-1.000, p=0.055) during the clinical course. In addition, a prompt improvement in the IgG4-RD responder index [5] during the clinical course was seen in the patients with serum IgA elevation, suggesting a similar good response to glucocorticoids as in those without it.

Conclusion:

The findings of the present study suggest that IgG4-RD patients with high serum IgA levels can be diagnosed and treated in the same way as those without it, although they may be characterized by mild serum CRP elevation.

References:

[1]Wallace ZS et al. The 2019 American College of Rheumatology/European League Against Rheumatism classification criteria for IgG4-related disease. Ann Rheum Dis. 2020;79:77-87.

[2]Umehara H et al. The 2020 Revised Comprehensive Diagnostic (RCD) Criteria for IgG4-RD. Mod Rheumatol. 2020 Dec 4:1-14. doi: 10.1080/14397595.2020.1859710. Online ahead of print.

[3]Umehara H et al. Current approach to the diagnosis of IgG4-related disease - Combination of comprehensive diagnostic and organ - specific criteria. Mod Rheumatol. 2017;27:381-91.

[4]Sato Y et al. Systemic IgG4-related lymphadenopathy: A clinical and pathologic comparison to multicentric Castleman’s disease. Mod Pathol.2009;22:589-99.

[5]Carruthers MN et al. Development of an IgG4-RD Responder Index. Int J Rheumatol. 2012;2012:259408.

Disclosure of Interests:

None declared

POS1348 MORTALITY AND ITS RELATED FACTORS IN PATIENTS WITH IGG4-RELATED DISEASE: A JAPANESE SINGLE-CENTER STUDY

Background:

In recent years, IgG4-related disease (IgG4-RD) has become a widely recognized disorder. However, mortality and its related factors in this disease are not well known.

Objectives:

This study aimed to clarify mortality and its related factors in patients with IgG4-RD.

Methods:

We retrospectively reviewed the medical records of patients with IgG4-RD diagnosed by experts based on fulfillment of the Japanese comprehensive diagnostic criteria and/or the 2019 ACR/EULAR classification criteria for IgG4-RD at a single center in Japan. Using the collected data, we calculated the crude mortality rate and the standardized mortality ratio (SMR) using national Japan mortality statistics and investigated the cause of death. We performed Cox regression analyses to assess mortality-related factors.

Results:

A total of 179 patients with IgG4-RD were included: 124 were male (69.3%); the median age was 68 years (interquartile range [IQR] 60-75 years); and the median follow-up from diagnosis was 47 months (IQR 17-84). Ten patients (5.6%) in our cohort died during the follow-up period. Five died of malignancy, one of respiratory failure, two of infectious pneumonia, one of sudden cardiac event, and one of suspected aortic aneurysmal rupture. The crude mortality rate was 11.1 per 1,000 person-years. According to national Japan mortality statistics, 11.6 age- and sex-matched deaths were expected to occur within the follow-up period, resulting in a SMR of 0.86 (95% confidence interval [CI] 0.41-1.59). Univariate Cox regression analyses indicated that the number of affected organs at diagnosis (hazard ratio [HR] 1.45, 95% CI 1.02-2.05), serum creatinine levels at diagnosis (HR 1.82, 95% CI 1.06-3.12), and the presence of malignancy during the clinical course (HR 3.93, 95% CI 1.10-14.02) had a significant impact on the time to death, whereas the other factors including age at diagnosis and serum C-reactive protein and IgG4 levels at diagnosis did not.

Conclusion:

Our findings suggest that the mortality rate of patients with IgG4-RD does not significantly differ from that of the Japanese general population. Multi-organ involvement and renal dysfunction at diagnosis as well as malignancy during the clinical course may be associated with higher mortality. An appropriate clinical evaluation for the early detection of these risk factors is required at first diagnosis and during long-term follow-up.

Disclosure of Interests:

None declared

The utility of patent ductus arteriosus closure with hemostatic clip in dogs

This study investigated the utility of patent ductus arteriosus (PDA) closure with hemostatic clip by comparing with traditional PDA closure. Medical records of 51 dogs with surgical closure of PDA were reviewed and retrospective study was conducted. 29 dogs were treated by procedure with hemostatic clip (Group HC), and 22 dogs were treated by surgical ligation (Group SL). Data pertaining to breed, sex, age and body weight at the time of surgery, echocardiographic minimal ductal diameter, duration of surgery, hemostatic clip size, echocardiographic findings, hemor-rhage, residual ductal flow and recanalization were collected from records. The results showed that procedure with hemostatic clip had been selected in lighter dogs than traditional PDA closure. Duration of surgery performed only hemostatic clip technique was significantly shorter than that in group SL. Preoperative LVIDd, E-wave and FS were significantly lower than postoperative ones. As regard all parameters, the differences between pre- and postoperative periods were not significantly different between group HC and group SL. Hemorrhage, residual ductal flow, and recanalization were not significantly different in both groups. The present study showed that procedure with hemostatic clip is beneficial in that it is available in smaller dogs and can make shorter operation duration than traditional PDA closure. Moreover, the procedure is effective for the resolution of volume overload of the left atrium and ventricle in short-term outcome. Complications including hemorrhage, residual ductal flow and recanaliza-tion were not significantly different with both techniques.

Effect of preprocedural pharmacologic cardioversion on pulmonary vein isolation in patients with persistent atrial fibrillation

BACKGROUND

The optimal strategy for catheter ablation of persistent atrial fibrillation (PeAF) remains unknown. A preprocedural additive treatment for patients undergoing pulmonary vein isolation (PVI) alone to optimize catheter ablation should be investigated.

OBJECTIVE

The purpose of this study was to determine whether pharmacologic cardioversion with a fixed low-dose antiarrhythmic drug (AAD) before ablation could stratify the long-term outcome of a PVI-alone strategy.

METHODS

We conducted a prospective cohort study of PeAF patients who underwent PVI using contact force-sensing catheters. No substrate modification was performed. Fixed low-dose bepridil was administered before ablation for cardioversion and patients were classified into 2 groups based on obtaining sinus rhythm (SR). The rate of recurrence of atrial fibrillation (AF) and/or atrial tachycardia (AT) within 36 months was compared between the 2 groups.

RESULTS

Among the 303 PeAF patients who received the AAD, 102 returned to SR (SR group), and the other 201 had persistence of AF (non-SR group). AF persistence duration at baseline and during bepridil administration was similar between the 2 groups. The SR group had a significantly lower 36-month AF/AT recurrence rate than the non-SR group (17 [22.2%] vs 55 [34.0%], log-rank P = .022). AT-type recurrence was observed in 16 patients (2 [3.3%] in the SR group vs 14 [8.9%] in the non-SR group; log-rank P = .051). Nonresponse to AAD was an independent predictor of AF/AT recurrence after adjusting for other risk factors (hazard ratio 1.34; 95% confidence interval 1.01-1.77; P = .040).

CONCLUSION

Preprocedural pharmacologic cardioversion could be a useful determinant for patients with treatable PeAF by PVI alone.

Myelin and Axonal Damage in Normal-Appearing White Matter in Patients with Moyamoya Disease

BACKGROUND AND PURPOSE

Although chronic ischemia is known to induce myelin and axonal damage in animal models, knowledge regarding patients with Moyamoya disease is limited. We aimed to investigate the presence of myelin and axonal damage in Moyamoya disease and their relationship with cognitive performance.

MATERIALS AND METHODS

Eighteen patients with Moyamoya disease (16-55 years of age) and 18 age- and sex-matched healthy controls were evaluated with myelin-sensitive MR imaging based on magnetization transfer saturation imaging and 2-shell diffusion MR imaging. The myelin volume fraction, which reflects the amount of myelin sheath; the g-ratio, which represents the ratio of the inner (axon) to the outer (axon plus myelin) diameter of the fiber; and the axon volume fraction, which reflects axonal components, were calculated and compared between the patients and controls. In the patients with Moyamoya disease, the relationship between these parameters and cognitive task-measuring performance speed was also evaluated.

RESULTS

Compared with the healthy controls, the patients with Moyamoya disease showed a significant decrease in the myelin and axon volume fractions (P < .05) in many WM regions, while the increases in the g-ratio values were not statistically significant. Correlations with cognitive performance were most frequently observed with the axon volume fraction (r = 0.52-0.54; P < .03 in the right middle and posterior cerebral artery areas) and were the strongest with the g-ratio values in the right posterior cerebral artery region (r = 0.64; P = .004).

CONCLUSIONS

Myelin-sensitive MR imaging and diffusion MR imaging revealed that myelin and axonal damage exist in patients with Moyamoya disease. The relationship with cognitive performance might be stronger with axonal damage than with myelin damage.

FRI0188 THE CLINICOPATHOLOGICAL SIGNIFICANCE OF MODIFIED NATIONAL INSTITUTES OF HEALTH ACTIVITY AND CHRONICITY SCORING SYSTEM IN LUPUS NEPHRITIS; A MULTICENTER RETROSPECTIVE STUDY

Background:

The revised International Society of Nephrology/Renal Pathology Society (ISN/RPS) Classification of lupus nephritis (LN) 2018 defined a modified National Institutes of Health activity and chronicity scoring system for all LN classes [1]. As this was not arrived at by an evidence-based approach, its clinicopathological significance including prognostic value should be validated [1]. Furthermore, though the activity index included wire-loop lesion and hyaline deposits (WL), we previously demonstrated that WL was associated with serological immune abnormality, but not renal prognosis [2].

Objectives:

We conducted this study to clarify the relationships of modified activity score (AS) and chronicity score (CS) to clinical parameters at the time of renal biopsy and renal and life prognoses, and also to investigate the impact of AS without WL.

Methods:

We enrolled 138 Japanese LN patients subjected to renal biopsy in 11 hospitals from 2000 to 2019. We measured clinical findings at the time of renal biopsy, and determined the presence of comorbidities. We also measured serum creatinine and estimated glomerular filtration rate (eGFR) at the last patient visit, and recorded medications prescribed for LN. Renal biopsy findings were classified by the modified ISN/RPS classification 2018 including AS and CS for all LN classes. On stepwise multivariate analysis, we applied the variables with significant differences in univariate comparisons. The primary endpoint was chronic kidney disease (CKD; eGFR <60 ml/min/1.73m2) and/or death.

Results:

Of 138 patients (116 females; median 39 years old), class I, II, III, IV, and V included 2 (1.4%), 13 (9.4%), 43 (31.2%), 69 (50.0%), and 11 (8.0%), respectively. Median AS, AS without WL (AS-WL), and CS were 4, 3, and 2, respectively. AS ≥5 group (61 patients, 44.2%) had higher proteinuria, hematuria and serum anti-ds DNA antibodies levels and lower serum total protein (TP) and C3 levels than AS <5 group. CS ≥3 group (58 patients, 42%) had higher age, proteinuria, serum C3 levels, and frequency of hypertension (HT) and lower eGFR and serum anti-ds DNA antibodies and IgG levels than CS<3 group. Multiple regression analysis revealed significant associations between AS and hematuria, TP and C3 (β=0.312, -0.281, -0.213;p<0.001, 0.001, 0.009), and between CS and age (β=0.300;p=0.010). Next, patients who achieved the primary endpoint had higher age, frequencies of HT and hyperlipidemia and lower eGFR, serum TP and IgG levels than patients who did not. Observation period (median 36 vs 47 months,p=0.696) and medications for LN did not differ between these groups. Cox regression analysis revealed significant associations of prognosis with eGFR and TP clinically (β=0.955, 3.349;p=0.025, 0.008), and with CS pathologically (β=1.231,p=0.028). Neither AS nor AS-WL was included in the prognostic factors. Kaplan-Meier method with log-rank tests showed a significant difference in cumulative rate of CKD and/or death between CS ≥3 and CS <3 groups (p=0.049).

Conclusion:

AS and CS were related to different clinical parameters at the time of renal biopsy. CS was associated with renal and life prognoses, while neither AS nor AS-WL was. These results revealed that these scores have different clinicopathological significance in LN.

References:

[1]Bajema IM, et al. Kidney Int. 2018;93:789-96.

[2]Zoshima T, et al. Lupus 2019, accepted.

Disclosure of Interests:

None declared

FRI0166 HIGH FREQUENCY OF KIDNEY STONES AND/OR NEPHROCALCINOSIS IN PRIMARY SJOGREN’S SYNDROME MIGHT ACCELERATE CHRONIC RENAL DYSFUNCTION DUE TO TUBULOINTERSTITIAL DISEASE

Background:

The renal involvement of primary Sjögren’s syndrome (pSS) is characterized by distal renal tubular acidosis (RTA), tubulointerstitial nephritis (TIN), and/or glomerulonephritis [1,2]. Kidney stones and nephrocalcinosis are presumably caused by subclinical distal tubular acidosis, but its clinical significance has not been clarified.

Objectives:

This study aimed to clarify the frequency and clinical features of patients with pSS with kidney stones and/or nephrocalcinosis.

Methods:

We examined 59 patients with anti SS-A/Ro positive pSS who underwent abdominal computed tomography and/or ultrasound between 1998 and 2019 at Kanazawa University Hospital. We identified 2 groups of patients with primary Sjögren’s syndrome: 1) patients with kidney stones and/or nephrocalcinosis (group A: n=19) and 2) those without kidney stones and/or nephrocalcinosis (group B: n=40), and retrospectively analyzed their clinical features.

Results:

Kidney stones and/or nephrocalcinosis were confirmed in 19 of 59 (32%) patients with pSS. The patients comprised 4 males and 55 females with an average age of 60 years (range, 30 to 83 years) and mean observation period of 96 months (range 1 to 336 months). Estimated glomerular filtration rate (eGFR) at the time of diagnostic imaging (group A vs group B: 71.5 ml/min/1.73 m2vs 82.8 ml/min/1.73 m2; p=0.37) and eGFR at last follow up (group A vs group B: 59.3 ml/min/1.73 m2vs 74.7 ml/min/1.73 m2;p=0.03) of group A were lower than those of group B and urinary β2-microgloblin (group A vs group B: 7222 μg/mL vs 437 μg/mL; p=0.01) and urinary N-acetyl-β-D-glucosaminidase (group A vs group B: 5.8 U/L vs 3.9 U/L; p=0.22) of group A were higher than those of group B, while serum electrolytes (sodium, potassium, chloride, calcium, phosphorus), fractional excretion of calcium (group A vs group B: 1.2% vs1.5%; p=0.916), ESSDAI (group A vs group B: 7.6 vs 4.3; p=0.069), and eGFR decrease rate were not significantly different.

Conclusion:

32% patients with anti SS-A/Ro positive pSS had kidney stones and/or nephrocalcinosis in our cohort and their presence might accelerate chronic renal dysfunction due to tubulointerstitial disease (subclinical RTA or TIN).

References:

[1]Jain A et al. Renal involvement in primary Sjogren’s syndrome: a prospective cohort study. Rheumatol Int 2018; 38: 2251-62.

[2]Jasiek M et al. A multicentre study of 95 biopsy-proven cases of renal disease in primary Sjögren’s syndrome. Rheumatology 2017; 56: 362-70.

Acknowledgments:

We thank Mr. John Gelblum for critical reading of the manuscript.

Disclosure of Interests:

None declared

SAT0532 POSITIVE DISEASE-SPECIFIC AUTOANTIBODIES LOWER DIAGNOSTIC SENSITIVITY BUT HAVE LITTLE CLINICAL SIGNIFICANCE IN DIAGNOSING IgG4-RELATED DISEASE USING THE 2019 ACR/EULAR CLASSIFICATION CRITERIA IN DAILY CLINICAL PRACTICE

Background:

Recently, the 2019 ACR/EULAR classification criteria for IgG4-related disease (IgG4-RD) were published mainly to identify more homogeneous subjects for inclusion in clinical trials and observational studies [1]. However, although their high specificity is presumed to be useful to differentiate IgG4-RD from various mimickers, their value in daily clinical practice needs to be evaluated.

Objectives:

This study aimed to clarify the usefulness of the 2019 ACR/EULAR classification criteria for IgG4-RD and characteristics of false-negative patients in daily clinical practice.

Methods:

We retrospectively reviewed the medical records of 162 patients with IgG4-RD and 130 consecutive non-IgG4-RD patients (mimickers) diagnosed by experts whose serum IgG4 levels were measured at a single center in Japan. Using the collected data, we calculated sensitivity, specificity, and fulfillment rates for the entry criteria, exclusion criteria, and threshold of inclusion criteria points. In addition, to clarify the characteristics of false-negative cases in IgG4-RD, we performed an intergroup comparison of their clinical features including disease-specific autoantibodies.

Results:

Both the patients with IgG4-RD and mimickers were relatively old (66 and 65 years) with male predominance (67% and 60%). The final diagnoses of mimickers mainly consisted of cancer, lymphoma, vasculitis, sarcoidosis, multicentric Castleman’s disease, and atherosclerotic or infectious aortic aneurysm. The classification criteria had a sensitivity of 72.8% and a specificity of 100%. Of the 44 false-negative cases, one did not fulfill the entry criteria, 20 fulfilled one exclusion criterion, and 27 did not achieve sufficient inclusion criteria points. Compared with the true-positive cases, the false-negative cases had significantly fewer affected organs, lower serum IgG4 levels, higher serum CH50 levels, and lower prevalence of salivary/lacrimal gland and renal parenchymal lesions. They were also less likely to have had biopsies (61% vs 97%). Of note, positivity of disease-specific autoantibodies including SSA/Ro antibody, ANCA, ds-DNA antibody, and ACPA was the most common exclusion criterion fulfilled in 18 patients, only 2 of whom were diagnosed with a specific autoimmune disease (rheumatoid arthritis) complicated by IgG4-RD. The remaining 16 patients had no specific clinical symptoms related to such autoantibodies. In addition, compared with IgG4-RD patients without disease-specific autoantibodies, the 18 patients with them had almost equal serum IgG4 and complement levels, number of affected organs, and histopathology and immunostaining scores despite higher serum IgG and CRP levels.

Conclusion:

The present study suggests that the 2019 ACR/EULAR classification criteria for IgG4-RD has excellent diagnostic specificity and moderate sensitivity in daily clinical practice. Positive disease-specific autoantibodies alone, which lowered the sensitivity in this study, may have little clinical significance concerning the diagnosis of IgG4-RD.

References:

[1]Wallace ZS et al. The 2019 American College of Rheumatology/European League Against Rheumatism classification criteria for IgG4-related disease. Ann Rheum Dis. 2020 Jan;79(1):77-87.

Disclosure of Interests:

None declared

Wire-loop lesion is associated with serological immune abnormality, but not renal prognosis, in lupus nephritis

BACKGROUND

Wire-loop lesion (WL) is one of the active lesions of lupus nephritis (LN). However, few reports have focused on the clinicopathological relationships of WL to serological immune abnormality and renal prognosis.

METHODS

We enrolled 126 Japanese LN patients subjected to renal biopsy in 11 hospitals from 2000 to 2018. In patients with class III or IV of the International Society of Nephrology/Renal Pathology Society classification, we retrospectively compared clinicopathological findings between those with WL (WL+ group) and without WL (WL- group) to detect factors associated with WL. Chronic kidney disease (CKD) was defined as an estimated glomerular filtration rate of <60 mL/min/1.73m² for more than three months. We also compared these findings between those with CKD (CKD+ group) and without CKD (CKD- group) at the last visit to investigate factors associated with renal prognosis.

RESULTS

Of 126 patients, 100 (79.4%) were classified as class III or IV. WL was found in 36 (36.0%) of them. Although the renal function did not differ, the WL+ group had a higher titre of serum anti-dsDNA antibodies and lower serum complement 3 levels than the WL- group. Linear regression analysis revealed a significant association only between anti-dsDNA antibodies and WL (β = 0.27, 95% confidence interval (CI) 0.001-0.100, p = 0.01). Of these patients, 69 were tracked for 59.6 ± 55.1 months. Kaplan-Meier analysis showed no difference in renal prognosis between these groups. Next, the CKD+ group included 15 (22.1%) patients. They were older and had higher frequencies of hypertension and hyperuricaemia, serum creatinine (Cr) level, glomerulosclerosis, interstitial inflammation, interstitial fibrosis and tubular atrophy than the CKD- group at the time of renal biopsy. The frequency of WL was not significantly different. Cox regression analysis revealed significant associations of CKD with hypertension, hyperuricaemia, serum Cr level at the time of renal biopsy clinically and with tubular atrophy histologically.

CONCLUSIONS

WL was associated with serum anti-dsDNA antibodies but not with renal prognosis, suggesting that WL reflects immune abnormality but is not an independent factor predictive of renal prognosis in LN.

Bayesian Estimation of CBF Measured by DSC-MRI in Patients with Moyamoya Disease: Comparison with 15O-Gas PET and Singular Value Decomposition

BACKGROUND AND PURPOSE

CBF analysis of DSC perfusion using the singular value decomposition algorithm is not accurate in patients with Moyamoya disease. This study compared the Bayesian estimation of CBF against the criterion standard PET and singular value decomposition methods in patients with Moyamoya disease.

MATERIALS AND METHODS

Nineteen patients with Moyamoya disease (10 women; 22-52 years of age) were evaluated with both DSC and ¹⁵O-gas PET within 60 days. DSC-CBF maps were created using Bayesian analysis and 3 singular value decomposition analyses (standard singular value decomposition, a block-circulant deconvolution method with a fixed noise cutoff, and a block-circulant deconvolution method that adopts an occillating noise cutoff for each voxel according to the strength of noise). Qualitative and quantitative analyses of the Bayesian-CBF and singular value decomposition-CBF methods were performed against ¹⁵O-gas PET and compared with each other.

RESULTS

In qualitative assessments of DSC-CBF maps, Bayesian-CBF maps showed better visualization of decreased CBF on PET (sensitivity = 62.5%, specificity = 100%, positive predictive value = 100%, negative predictive value = 78.6%) than a block-circulant deconvolution method with a fixed noise cutoff and a block-circulant deconvolution method that adopts an oscillating noise cutoff for each voxel according to the strength of noise (P < .03 for all except for specificity). Quantitative analysis of CBF showed that the correlation between Bayesian-CBF and PET-CBF values (ρ = 0.46, P < .001) was similar among the 3 singular value decomposition methods, and Bayesian analysis overestimated true CBF (mean difference, 47.28 mL/min/100 g). However, the correlation between CBF values normalized to the cerebellum was better in Bayesian analysis (ρ = 0.56, P < .001) than in the 3 singular value decomposition methods (P < .02).

CONCLUSIONS

Compared with previously reported singular value decomposition algorithms, Bayesian analysis of DSC perfusion enabled better qualitative and quantitative assessments of CBF in patients with Moyamoya disease.

Experimental study of fast-neutron production and moderation for accelerator-based BNCT system

This work aims to study the fast-neutron production and moderation for the development of a compact accelerator-based multi-port Boron Neutron Capture Therapy (AB-mBNCT) system. An initial energy distribution and the efficiency of a test moderator assembly (TMA) for fast neutrons from a tungsten (W) target bombarded with a 53 MeV proton beam were measured using organic scintillators. The experimental results were reproduced with reasonable accuracy by simulations using the PHITS code. This paper will discuss about the experimental outcome and the related benchmark calculations by PHITS code.

Microwave oscillator using piezoelectric thin-film resonator aiming for ultraminiaturization of atomic clock

We developed a microwave oscillator and a micro electromechanical systems-based rubidium cell for the miniaturization of atomic clocks. A thin-film bulk acoustic resonator (FBAR) having a resonant frequency of the fundamental mode in the 3.5 GHz band was employed instead of a crystal resonator. It delivers a clock transition frequency of Rb atoms of 3.417 GHz without the need for a complicated frequency multiplication using a phase-locked loop. This topology considerably reduces the system scale and power consumption. For downsizing the atomic clock system toward the chip level as well as mass production, a microfabricated gas cell containing Rb and N₂ gases was also developed. These microcomponents were incorporated into an atomic clock test bench, resulting in a clock operation with a short-term frequency instability of 2.1 × 10^-11 at 1 s. To the best of our knowledge, this is the first report of a coherent population trapping clock operation using an FBAR-based microwave oscillator as well as a microfabricated gas cell.

Mechanical Strength of Synthetic Casting Tape for Application to Fracture Treatment of Farm Animals

Compressive and torsional strength of cyclindrically formed synthetic casting tape for animals (Vetcast Plus™), composed of polyurethane-impregnated glass fibres, was investigated to determine its adequate application to fracture treatment of farm animals. After the completion of curing reaction, six-layered samples of the synthetic casting tape tolerated a compressive load of 6630 N (680 kgf). The sixlayered casting tape had also a torsional strength of 64 N · m. The compressive strength increased with time after the initiation of curing reaction. The time required for practical curing (achieving more than 60% of a final strength) was only 30 min, and that for complete curing 120 min. It was demonstrated that efficacious and safe fracture treatment of farm animals could be carried out using the synthetic casting tape for animals when a layer number appropriate to the total body weight of the patient animal was employed. The information obtained in this study is thought to be very useful in clinical practice.

Mechanical strength of poly-urethane-impregnated synthetic casting tape was investigated to determine its adequate application to fracture treatment of farm animals. It was demonstrated that mechanical strength of cylindrically formed samples of the casting tape depended upon the layer number, and the six-layered sample tolerated a compressive load of 6630 N and a torsional load of 64 N · m when completely cured.

Standard Protocol for Exchange of Health-checkup Data Based on SGML: The Health-checkup Data Markup Language (HDML)

Objectives: To develop a health/medical data interchange model for efficient electronic exchange of data among health-checkup facilities.

Results: A Health-checkup Data Markup Language (HDML) was developed on the basis of the Standard Generalized Markup Language (SGML), and a feasibility study carried out, involving data exchange between two health checkup facilities. The structure of HDML is described.

Results: The transfer of numerical lab data, summary findings and health status assessment was successful.

Conclusions: HDML is an improvement to laboratory data exchange. Further work has to address the exchange of qualitative and textual data.

Ureteric entrapment in sacroiliac joint causing hydroureter and ipsilateral kidney hypertrophy

A unilateral megaureter was found in an elderly female cadaver during routine dissection. The left proximal ureter, which was thick and convolute, descended and entered into the pelvic cavity, where the distal ureter was attached to the posterior pelvic wall at the inlet level. Removal of connective tissue surrounding the attached region revealed ureteric entrapment in the sacroiliac joint. The ipsilateral kidney, from which the megaureter originated, showed no pelvicalyceal dilatation. In contrast, the left kidney was enlarged, weighing 24% more than the right kidney. Differences in the upper urinary system between the obstructed and normal sides were examined in terms of gross anatomy, measurements, and histology. Although ureteric obstruction frequently causes hydroureter and hydronephrosis, the present case is very rare as the incomplete obstruction may have stimulated ipsilateral kidney growth, instead of contralateral compensatory augmentation.

Noninvasive Evaluation of CBF and Perfusion Delay of Moyamoya Disease Using Arterial Spin-Labeling MRI with Multiple Postlabeling Delays: Comparison with 15O-Gas PET and DSC-MRI

BACKGROUND AND PURPOSE

Arterial spin-labeling MR imaging with multiple postlabeling delays has a potential to evaluate various hemodynamic parameters. To clarify whether arterial spin-labeling MR imaging can identify CBF and perfusion delay in patients with Moyamoya disease, we compared arterial spin-labeling, DSC, and ¹⁵O-gas PET in terms of their ability to identify these parameters.

MATERIALS AND METHODS

Eighteen patients with Moyamoya disease (5 men, 13 women; ages, 21-55 years) were retrospectively analyzed. CBF values of pulsed continuous arterial spin-labeling using 2 postlabeling delays (short arterial spin-labeling, 1525 ms; delayed arterial spin-labeling, 2525 ms) were compared with CBF values measured by ¹⁵O-gas PET. All plots were divided into 2 groups by the cutoff of time-based parameters (the time of the maximum observed concentration, TTP, MTT, delay of MTT to cerebellum, and disease severity [symptomatic or not]). The ratio of 2 arterial spin-labeling CBFs (delayed arterial spin-labeling CBF to short arterial spin-labeling CBF) was compared with time-based parameters: time of the maximum observed concentration, TTP, and MTT.

RESULTS

The short arterial spin-labeling-CBF values were significantly correlated with the PET-CBF values (r = 0.63; P = .01). However, the short arterial spin-labeling-CBF value dropped in the regions with severe perfusion delay. The delayed arterial spin-labeling CBF overestimated PET-CBF regardless of the degree of perfusion delay. Delayed arterial spin-labeling CBF/short arterial spin-labeling CBF was well correlated with the time of the maximum observed concentration, TTP, and MTT (ρ = 0.71, 0.64, and 0.47, respectively).

CONCLUSIONS

Arterial spin-labeling using 2 postlabeling delays may detect PET-measured true CBF and perfusion delay in patients with Moyamoya disease. Provided its theoretic basis and limitations are considered, noninvasive arterial spin-labeling could be a useful alternative for evaluating the hemodynamics of Moyamoya disease.

The effect of aprepitant and dexamethasone combination on paclitaxel-induced hypersensitivity reaction

PURPOSE OF INVESTIGATION

Dexamethasone (DEX) is often administered to prevent paclitaxel (PTX)-induced hypersensitivity reactions (HSR). The DEX dose is reduced when administered in combination with aprepitant (APR). However, the influence of that dose reduction on PTX-induced HSR has not been thoroughly studied. The present authors aimed to investigate the effects of the combined administration of APR and DEX on PTX-induced HSR.

MATERIALS AND METHODS

Fifty-one patients who received a three-week PTX regimen in combination with APR and DEX were retrospectively analysed. The authors compared the dose of DEX with the incidence of HSR and other toxicities.

RESULTS

Patients were stratified into two groups depending on the DEX dose, > 20 mg (group D, 33 patients), and < 12 mg (group reD, 26 patients). The incidence of HSR in Groups D and reD were 51.5% (17/33) and 53.8% (14/26), respectively. The frequencies of other toxicities between the groups were comparable.

CONCLUSION

The findings suggest that although a reduction in DEX dose is possible when APR is co-administered, this does not affect the PTX-induced HSR. However, adverse effect should be closely monitored.

Impact of tubulointerstitial lesions on anaemia in patients with biopsy-proven diabetic nephropathy

AIMS

To investigate the relationship between the progression of anaemia and renal pathological findings in patients with diabetic nephropathy.

METHODS

A total of 223 patients with diabetes underwent renal biopsy from 1985 to 2010 and were confirmed to have pure diabetic nephropathy according to the recent classification, of whom 113 (baseline haemoglobin ≥ 11 g/dl) were enrolled in the study. Linear regression analysis was used to estimate the changes in haemoglobin levels during the follow-up period.

RESULTS

In a multivariate model adjusted for clinical and histopathological variables, higher interstitial fibrosis and tubular atrophy scores were more strongly associated with a decrease in haemoglobin levels than were lower scores. Compared with an interstitial fibrosis and tubular atrophy score of 0, the standardized coefficients for interstitial fibrosis and tubular atrophy scores of 1, 2 and 3 were 0.20 (95% CI -0.31 to 0.93), 0.34 (95% CI -0.22 to 1.34) and 0.47 (95% CI 0.07 to 1.96), respectively, whereas a higher glomerular class, a higher vascular lesion score and the presence of exudative lesions were not strongly correlated with the decrease in haemoglobin.

CONCLUSIONS

Tubulointerstitial lesions that are more advanced are significantly associated with the progression of anaemia in patients with diabetic nephropathy after adjustment for numerous covariates. This finding suggests that tubulointerstitial lesions may be a useful prognostic indicator for anaemia in patients with diabetic nephropathy, and that decreased erythropoietin production attributable to the progression of tubulointerstitial lesions is a major cause of anaemia in these patients.

Comparison of different aspects of BMI history to identify undiagnosed diabetes in Japanese men and women: Toranomon Hospital Health Management Center Study 12 (TOPICS 12)

AIMS

To examine current BMI and various aspects of BMI history as pre-screening tools for undiagnosed diabetes in Japanese individuals.

METHODS

This cross-sectional study included 16 226 men and 7026 women aged 30-75 years without a self-reported history of clinician-diagnosed diabetes. We estimated the probability of having undiagnosed diabetes (fasting glucose ≥ 7.0 mmol/l and/or HbA1c ≥ 48 mmol⁄mol (≥ 6.5%) for the following variables: current BMI, BMI in the early 20s (BMI(20y)), lifetime maximum BMI (BMI(max)), change between BMI in the early 20s and current BMI (ΔBMI(20y-cur)), change between BMI in the early 20s and maximum BMI (ΔBMI(20y-max)), and change between lifetime maximum and current BMI (ΔBMI(max-cur)).

RESULTS

The prevalence of undiagnosed diabetes was 3.3% (771/23252) among participants. BMI(max) , ΔBMI(20y-max) and current BMI (1-sd increments) were more strongly associated with diabetes than the other factors (multivariate odds ratio 1.58 [95% CI 1.47-1.70] in men and 1.65 [95% CI 1.43-1.90] in women for BMI(max) ; multivariate odds ratio 1.47 [95% CI 1.37-1.58] in men and 1.61 [95% CI 1.41-1.84] in women for ΔBMI(20y-max) ; multivariate odds ratio 1.47 [95% CI 1.36-1.58] in men and 1.63 [95% CI 1.40-1.89] in women for current BMI). The probability of having diabetes was markedly higher in those with both the highest tertile of BMI(max) and greatest ΔBMI(20y-max) ; however, a substantially lower likelihood of diabetes was observed among individuals with the lowest and middle tertiles of current BMI (< 24.62 kg/m² in men and < 22.54 kg/m² in women).

CONCLUSIONS

Lifetime maximum BMI and BMI changes from early adulthood were strongly associated with undiagnosed diabetes. Adding BMI history to people's current BMI would improve the identification of individuals with a markedly higher probability of having undiagnosed diabetes.