Pleiotropic effects of 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors: candidate mechanisms for anti-lipid deposition in blood vessels

The 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statins) are considered first-line therapeutic agents for the prevention of coronary heart disease and atherosclerotic disorders related to hypercholesterolemia. Statins inhibit lipid deposition in the aortic endothelium. Although it has been accepted that the statins are potent inhibitors of cholesterol biosynthesis in the liver and that they lower circulating cholesterol levels, several cholesterol-independent (pleiotropic) effects have been reported. The cholesterol-independent effects of statins involve normalization of the nitric oxide (NO)-NO synthase system, anti-inflammatory effects through the inhibition of cytokine/chemokine production, inhibition of vascular smooth muscle cell proliferation and migration, and inhibition of platelet thrombus formation/reduction of the thrombotic response. Some pleiotropic effects of statins may depend on the inhibition of the biosynthesis of farnesyl- and geranylgeranyl-nonsterol compounds from mevalonate in the cells. The Rho/Rho kinase pathway and the phospatidylinositol-3 kinase/Akt pathway mediate the pleiotropic effects of statins. As variations occur in absorption, metabolism, and excretion mechanisms due to the characteristics of specific statins including their hydrophilicity and lipophilicity, there are differences in the transfer mechanisms of statins into tissues. However, the pleiotropic effects occur regardless of statin hydrophilicity and lipophilicity. This review summarizes the pleiotropic effects of statins on lipid deposition in blood vessels.

Effect of antenatal dexamethasone treatment on Ca2+-dependent nitric oxide synthase activity in rat lung

We investigated the effects of dexamethasone on nitric oxide synthase activity, nitrate/nitrite concentration, and cGMP concentration in the lungs of premature and full-term neonate rats. Dexamethasone or vehicle alone was administered to the mother (1 mg/kg/d, s.c., 2 d), and the neonate was killed 24 h after birth. Ca2+-dependent nitric oxide synthase activity and nitrate/nitrite and cGMP concentrations in lungs of dexamethasone-treated neonates, both premature and full-term, were significantly higher than those in the lungs of the control rats. Ca2+-dependent nitric oxide synthase activity, nitrate/nitrite concentration, and cGMP concentration in the lungs of control rats showed developmentally associated increases during late gestation and in the early postnatal period. The activation of the nitric oxide synthasenitric oxide-cGMP system by antenatal dexamethasone treatment may be related to the improvement of pulmonary function by antenatal glucocorticoid therapy to minimize respiratory distress syndrome.

Higher incidence of elevated body temperature or increased C-reactive protein level in asthmatic children showing transient reduction of theophylline metabolism

The authors investigated whether theophylline metabolism is decreased in asthmatic patients and what condition may be related to its reduction. Fifty-two children with asthma were given 15 mg/kg/day aminophylline intravenously at a constant rate. Blood and spot urine samples were collected at 24 hours, 48 hours, and 72 hours after beginning infusion. The ratio of plasma theophylline concentration at 72 hours to that at 24 hours (C72h/C24h) varied from 0.42 to 1.51 (average 0.894). Plasma theophylline concentration of patients with lower C72h/C24h than average reduced significantly, while the concentration of those with higher C72h/C24h remained unchanged. The urinary ratio of the sum of the metabolites to theophylline was significantly increased in the patients with the lower ratio. Among the demographic characteristics examined, significant difference was found only in the incidence of patients with C-reactive protein (CRP) of 0.5 mg/dl or greater or patients with a fever of 37.5 degrees C or greater when admitted. Acute febrile illness accompanied by increased CRP level may affect theophylline metabolism.

Developmental changes in urinary elimination of theophylline and its metabolites in pediatric patients

We investigated the developmental changes in the pattern of urinary metabolites of theophylline, a substrate for CYP1A2, to study when CYP1A2, which is absent in the perinatal period, fully develops during childhood. The urinary ratios of three metabolites (1-methyluric acid, 3-methylxanthine, and 1,3-dimethyluric acid) to theophylline in patients over 3 y of age show a much larger interindividual variation compared with those under 3 y of age, and the mean values of the ratios in patients over 3 y of age were greater than those in patients under 1 y of age. The urinary ratio of 1,3-dimethyluric acid (a metabolite generated by several cytochrome P450s) to 3-methylxanthine or 1-methyluric acid (metabolites generated by CYP1A2 exclusively) seemed to be relatively constant over 3 y of age; in patients under 3 y of age, these ratios were much higher than those in patients over 3 y of age. The urinary ratio of 1-methyluric acid to 3-methylxanthine or 3-methylxanthine to 1-methyluric acid seemed to be relatively invariable in all patients except those less than 1 y of age. These findings suggest that CYP1A2 activity may be programmed to mature by around 3 y of age and that CYP1A2 probably plays a major role in theophylline 8-hydroxylation at a therapeutic concentration after the full development of CYP1A2 activity.

A controlled trial of combined therapy for newly diagnosed severe childhood IgA nephropathy. The Japanese Pediatric IgA Nephropathy Treatment Study Group

The most appropriate treatment for patients with IgA nephropathy is controversial. Treatment with prednisolone, azathioprine, heparin-warfarin, and dipyridamole early in the course of disease may prevent immunologic renal injury in children with severe IgA nephropathy. To determine whether similar results can be obtained with a combination of just heparin-warfarin and dipyridamole, the effects of such treatment were compared to those of treatment with prednisolone, azathioprine, heparin-warfarin, and dipyridamole in 78 children with newly diagnosed IgA nephropathy showing diffuse mesangial proliferation. The patients were randomly assigned to receive either prednisolone, azathioprine, heparin-warfarin, and dipyridamole for 2 yr (group 1) or heparin-warfarin and dipyridamole for 2 yr (group 2). All of the 40 patients in group 1 and 34 of the 38 patients in group 2 completed the trial. The mean urinary protein excretion fell in group 1 patients (P < 0.0001), but remained unchanged in group 2 patients. The mean serum IgA concentration was reduced in group 1 patients (P = 0.0002), but was unchanged in group 2 patients. BP and creatinine clearance were normal at the end of the trial in all but one group 2 patient, who developed chronic renal insufficiency. The percentage of glomeruli showing sclerosis was unchanged in group 1 patients, but increased in group 2 patients (P = 0.006). The intensity of mesangial IgA deposits decreased in group 1 patients (P = 0.02), but remained unchanged in group 2 patients. In conclusion, the present study shows that treatment of children with severe IgA nephropathy with prednisolone, azathioprine, heparin-warfarin, and dipyridamole for 2 yr early in the course of disease reduces immunologic renal injury and prevents increase of sclerosed glomeruli.

A case of Guillain-Barré syndrome associated with human parvovirus B19 infection

We report a 4-year-old boy who presented with Guillain-Barré Syndrome 11 days after the onset of erythema infectiosum. The illness resolved without gamma globulin therapy.

[Clinical and bacteriological studies on panipenem/betamipron in pediatrics. Kanagawa Research Group for Infectious Diseases of Children]

Following its introduction into the market, PAPM/BP (panipenem/betamipron) was clinically studied in 188 evaluable cases out of 207 cases primarily of respiratory infectious diseases treated at the pediatric departments of 15 hospitals. In the clinical evaluation, the drug proved effective in three of three cases of sepsis; three of three cases of suppurative meningitis; nine of ten cases of laryngopharyngitis, six of seven cases of tonsillitis, 56 of 63 cases of acute bronchitis, 90 of 98 cases of pneumonia, and one of one case of phyothorax, all of which are respiratory infectious diseases; one of one case of secondary infection of a chronic respiratory disease; and two of two cases of lymphadenitis, which is a disease of the soft dermal structure. The overall efficacy rate was 91.0% (171/188 cases). In the bacteriological study, Gram-positive bacteria were eliminated in five of five strains of S. aureus, 30 of 31 strains of S. pneumoniae (96.8%), and three of three strains of S. pyogenes. Gramnegative bacteria were eliminated in 15 of 17 strains of H. influenzae (88.2%), three of four strains of M. catarrhalis, and two of two strains of K. pneumoniae. The overall elimination rate was 92.1% (70/76 strains). In the 23 strains of S. pneumoniae that were examined, penicillin-resistant strains accounted for 56.5%, showing an elimination rate of 100%. No serious adverse effects were observed, and the incidence of adverse effects was 1.45%. As for abnormalities in laboratory tests, levels of GOT and GPT increased in eight cases (3.88%), LDH increased in one case (0.48%), and neutropenia occurred in one case (0.51%). These results suggest that PAMP/BP could be considered the first choice in the treatment of infectious diseases in pediatrics, due to its effectiveness and high level of safety.

[A prospective controlled study of sairei-to in childhood IgA nephropathy with focal/minimal mesangial proliferation. Japanese Pediatric IgA Nephropathy Treatment Study Group]

To determine the effect of the Chinese herbal medicine, Sairei-to (TJ-114) in children with newly diagnosed IgA nephropathy showing focal/minimal mesangial proliferation, we undertook a prospective controlled study. One hundred and one patients were randomly assigned to receive Sairei-to for 2 years (group 1) or no drug for 2 years (group 2). Forty-six of the 50 patients in group 1 and 48 of the 51 patients in group 2 completed their trial. At entry, the two groups of patients did not differ in the clinical, laboratory and pathologic findings. At the end of the trial, urinary protein excretion and hematuria were significantly reduced in group 1, but were unchanged in group 2. Twenty-one group 1 patients (46%) had normal urine, but only 5 group 2 patients (10%) had normal urine at the end of the trial (p < 0.001). Blood pressure and creatinine clearance were normal at the end of the trial in all but one group 2 patient, who developed chronic renal failure. The present study demonstrates that 2-year Sairei-to treatment early in the course of disease is effective in children with IgA nephropathy showing focal/minimal mesangial proliferation.

Train-of-four and double burst stimulation fade at the great toe and thumb

PURPOSE

We compared probabilities of tactile detection of fade in response to train-of-four (TOF), double burst stimulation3.3 (DBS3.3), and DBS3.2 at the great toe with those at the thumb.

METHODS

One hundred and thirty adult patients anaesthetized with nitrous oxide, oxygen, isoflurane, and fentanyl were studied. At varying degrees of neuromuscular block caused by vecuronium, an observer determined the presence or absence of fade in response to TOF DBS3.3, or DBS3.2 at the great toe and that at the thumb. The relationship between T1/T0 or TOF ratio (T4/T1) measured at the great toe and that at the thumb was also examined.

RESULTS

When TOF ratios were 0-0.10, 0.11-0.20, 0.21-0.30, 0.31-0.40, 0.41-0.50, 0.51-0.60, 0.61-0.70, and 0.71-1.00, the probabilities of detection of fade in response to TOF at the great toe (thumb) were 77 (100), 66 (100), 58 (96), 52 (77), 39 (38), 26 (23), 2(4), and 0(0)%, respectively (P < 0.05 at TOF ratio 0-0.40). Similarly, the probabilities of detection of fade in response to DBS3.3 at the great toe were lower than at the thumb when TOF ratios were 0.21-0.80, and those in response to DBS3.2 at the great toe were lower than at the thumb when TOF ratios were 0.61-0.80. A dose relationship was observed between T1/T0 or TOF ratio at the great toe and that at the thumb.

CONCLUSION

This study suggests that the probability of tactile detection of fade in response to TOF, DBS3.3, or DBS3.2 at the great toe is less than that at the thumb. The present results may be because the flexor hallucis brevis muscle is more resistant to non-depolarizing neuromuscular relaxant than the adductor pollicis muscle and that the ratio of fade in response to neurostimulation at the great toe is higher than at the thumb.

Mutations in the COL4A5 gene in Alport syndrome: a possible mutation in primordial germ cells

Using a combination of gene amplification with single strand conformation polymorphisms analysis and sequencing, we examined the COL4A5 gene in 37 patients with Alport syndrome. In patient A8, a single base insertion was noted at codon 1,597 tyrosine in exon 49. The premature terminal signal appeared and 89 amino acids (approximately one-third) of the non-collagenous domain were lost. The mutation was present in the mother, hence she is heterozygous. In patient A12, the nucleotide changed from C to T at codon 1,679 glutamine in exon 51, which created a termination codon, and 7 amino acids at the carboxyl terminus were lost. Gene tracking using peripheral leukocytes revealed that the parents did not carry the mutant allele, while the sister was heterozygous. DNA samples from hair roots and skin fibroblasts of the mother were normal and immunological examination of the epidermis of the mother indicated that the alpha 5(IV) chain was normally expressed. As these results suggest that somatic cells of the mother do not carry the mutant allele, the primordial germ cells possibly carry a fresh mutation in the mother of patient A12.

[Phase III clinical trial of KRN8601 (rhG-CSF) for neutropenia in patients with human immunodeficiency virus infection]

The efficacy of KRN8601 for neutropenia associated with HIV infection was evaluated in 24 patients. KRN8601 was infused intravenously at a dosage of 200 micrograms/m2 for 14 consecutive days. Neutrophil counts recovered in 19 (90.5%) out of 21 evaluable patients by KRN8601 treatment. The concomitant myelosuppressive agents for the treatment of HIV infection and complications could be continued without dose reduction in 15 (88.2%) out of 17 patients. The clinical improvement was observed in 66.7% (12/18) of patients who were treated with anti-microbial agents for opportunistic infections which indicates that KRN8601 shows an additive effect on infections when it was given with anti-microbial agents. Adverse events and abnormal laboratory findings were observed in 3 and 7 patients, respectively, and they were reversible and tolerable. This study demonstrated that KRN8601 improved neutropenia with HIV infection, made possible to continue the full dose of myelosuppressive treatments and have additive effect on the treatment of secondary infections.

Identification of a single base insertion in the COL4A5 gene in Alport syndrome

We identified a novel mutation in the COL4A5 gene of a Japanese patient with Alport syndrome. A combination of in vitro amplification of the exons with single strand conformation polymorphisms (SSCP) analysis suggested the presence of a mutation in exon 48. Sequencing of the amplified DNA revealed a single base (T) insertion which was between nucleotides T 4750 and G 4751 within the methionine 1516. This mutation caused a shift in the reading frame of nine amino acids and introduced a premature termination signal that would be expected to lack about two-thirds of the noncollagenous (NC1) domain. This mutation may interfere with type IV collagen assembly leading to increased permeability and play a causative role in the glomerular basement membrane abnormality of this patient with typical Alport syndrome. Gene tracking by restriction enzyme NlaIII digestion revealed that the patient's mother is heterozygous whereas the patient's brother and one sister are normal, albeit they have hematuria and proteinuria. Without gene analysis, they would have been misdiagnosed. We propose that the diagnosis of Alport syndrome should be made on the basis of both clinical phenotypes and molecular defects.

[Changes in coagulation and fibrinolytic factors observed during heparin-urokinase-pulse combined therapy for nephritis resistant to conventional treatment in children]

Coagulation and fibrinolytic factors in the blood were measured during heparin-urokinase (UK)-pulse combined therapy in order to investigate the background for the availability of the therapy. Five patients with nephritis resistant to conventional treatment were treated with this combined therapy (heparin: 350-450 U/kg day, continuously i.v. during the therapy; UK: 5000 IU/kg/2 hrs, i.v., two times a day, for 3 days = 1 Kur; methylprednisolone 20 mg/kg/2hrs, d.i.v., for 3 days = 1 Kur; 3 Kurs of UK and 3 Kurs of pulse were alternately administered). 1) Blood levels of alpha 2-plasmin inhibitor (alpha 2-PI) antigen were decreased and those of alpha 2-plasmin inhibitor.plasmin complex (alpha 2-PI. PmC) were elevated during 3 Kurs of UK administration. Accordingly, activation of the fibrinolytic system was confirmed during the combined therapy, suggesting that both alpha 2-PI and alpha 2-PI.PmC were relevant in monitoring the fibrinolytic state in blood. 2) Both tissue-plasminogen activator (t-PA) and plasminogen activator inhibitor-1 (PAI-1) levels were sustained continuously in the elevated levels in the blood during both UK administration and pulse therapy. This movement of t-PA and PAI-1 was independent of that of the other fibrinolytic factors, such as alpha 2-PI,alpha 2-PI.PmC and plasminogen. 3) Inflammatory reactants such as fibrinogen, alpha 2-PI,alpha 2-macroglobulin and alpha 1-antitrypsin decreased more significantly during this heparin-urokinase-pulse combined therapy than during our previous combined therapy consisting of only heparin and urokinase. Therefore, we conclude that the anti-inflammatory effect was reinforced by adding the pulse therapy and that the combined therapy had some effect on the release of t-PA from vascular endothelial cells.

IgA nephropathy in patients with congenital C9 deficiency

The clinical, histologic, and immunopathological findings of three young Japanese males with congenital C9 deficiency and primary IgA nephropathy are reported. The C9 deficiency was discovered either through mass complement screening, or when low hemolytic activity for CH50 and normal C3 levels were detected in plasma. Hematuria and proteinuria were detected at the age of 8 or 9 years as a result of annual urinary screening tests for school children. Renal biopsy showed focal and segmental mesangial proliferation with small epithelial crescents in one patient, and mild, diffuse mesangial proliferation in two. IgA and C3 were deposited predominantly in the mesangial area, and staining for C9 was negative in these patients. Electron microscopy revealed electron dense deposits predominantly in mesangial and paramesangial zones. Immunohistochemical staining in renal biopsy tissues from two patients showed mesangial staining for C5, C8, and S-protein, but staining for C5b-9 neoantigen was completely negative. These results show that the formation of C5b-9 complex is not essential for the induction of human IgA nephropathy, and also for the proliferation of mesangial and even parietal epithelial cells.

[Analysis of the electrical charge of albumin in idiopathic nephrotic syndrome by isoelectric focusing]

The state of the electrical charge of serum and urinary albumin was investigated in both the nephrotic and remission stage of idiopathic nephrotic syndrome (INS), using isoelectric focusing (IEF). 1) Both a b2 band (a main albumin band appearing at the site of isoelectric point: pI 4.7), and a b3 band (a more anionic albumin band than the b2 band) were detected commonly in all samples of urine and serum of INS patients in nephrotic and remission stages and of healthy volunteer controls even if the applied albumin in urine and serum amounted to 20 micrograms or 100 micrograms. 2) When applied albumin amounted to 20 micrograms, b1 bands (less anionic albumin bands than the b2 band) were detected between pI 4.7 and pI 6.5 in urine and in both serum and purified albumin fractionated from serum of INS patients in the nephrotic stage. However, b1 bands were not detected at all in the urine and serum of either INS patients in remission stage and healthy volunteer controls. 3) When applied albumin amounted to 100 micrograms, b1 bands were detected also in serum of healthy volunteer controls. From these results, it was confirmed that less anionic albumin existed also in the serum of healthy volunteer controls although the amount was extremely small.(ABSTRACT TRUNCATED AT 250 WORDS)

Mesangiolysis: an important glomerular lesion in thrombotic microangiopathy

Six cases of malignancy-associated thrombotic microangiopathy and eight cases of idiopathic microangiopathy have been studied by renal biopsy. All patients of both groups had mild to severe renal impairment and microangiopathic hemolytic anemia. The renal lesions were histopathologically identical in the two groups. The most characteristic abnormalities were glomerular mesangiolysis and glomerular and arteriolar thrombosis. Subendothelial widening, presumably due to entrapment of blood components, and the formation of capillary and arteriolar thrombi may be attributed to endothelial damage. Glomerular fibrinogen was demonstrated by immunofluorescence in a majority of cases. Immunofluorescence also showed glomerular immunoglobulin M (IgM) and Clq in a majority of cases and C3 in slightly less than half. Mesangiolysis, present in every case, resulted in coalescence of capillary lumina, but mesangiolysis is a bland process, easily overlooked. The mesangial waists of the glomerular tufts seemed to unravel and come apart, with no inflammatory reaction or fibrin deposition on the luminal surface. The presence of capillary enlargement was confirmed morphometrically as an increased proportion of glomerular sectional area. In what appeared to be a late stage of mesangiolysis, the mesangium was thickened by pale fibrillary material, producing a lobulated glomerular tuft and eventual glomerular solidification. The early stages of mesangiolysis may be reflected only in glomerular capillary ectasia, whereas the late stages produce a distinctive form of glomerular sclerosis.

Inherited deficiency of the seventh component of complement: studies of C7-consuming activity

Neither the hemolytic activity nor the protein level of the seventh component of serum complement (C7) was detectable in an 8-year-old girl with nephritis, but in her parents and her brother, they were about half of the normal level. The patient was a homozygote type with a complete deficiency of C7 while her parents and brother were all heterozygote type with a partial deficiency of C7. C7-consuming activity was demonstrated in the native serum of the patient with complete C7 deficiency, and it was found that large amounts of C56 were readily generated upon incubation of the patient's serum with zymosan. It is proposed that the C7-consuming activity in the native serum of this patient is due to small amounts of C56 generated during the activation of serum complement by some kind of infection such as a common cold.

Production of C3 nephritic factor by cultured lymphocytes derived from a patient with partial lipodystrophy

C3 nephritic factor (C3 NeF) has been found mainly in the sera of patients with membranoproliferative glomerulonephritis (MPGN) and partial lipodystrophy (PLD). We examined whether peripheral blood mononuclear cells (PBMC) from a patient with PLD could produce C3 NeF. We investigated the in vitro immunoglobulin synthesis of PBMC with mitogen. We further studied the C3bBb stabilizing activity and undertook agglutination assays of the IgG obtained from the culture supernatants. The patient IgG was able to agglutinate only EAC4b3bBb cells and none of the other intermediate cells. We this demonstrated that C3 NeF could be produced in vitro by PBMC derived from a patient with PLD.