Nephrolithiasis and/or nephrocalcinosis is significantly related to renal dysfunction in patients with primary Sjögren's syndrome

OBJECTIVE

The present study compared the clinical features of patients with primary Sjögren's syndrome (pSS) with and without nephrolithiasis and/or nephrocalcinosis to determine factors related to renal dysfunction.

METHODS

The clinical features of 68 patients with anti-Sjogren's syndrome antigen A (SSA)/Ro-antibody-positive pSS with and without nephrolithiasis and/or nephrocalcinosis who underwent abdominal computed tomography and/or ultrasonography were retrospectively analysed.

RESULTS

Of the 68 patients with anti-SSA-antibody-positive pSS, 23 (33%) had renal nephrolithiasis and/or nephrocalcinosis, whereas 45 (67%) did not. Fourteen (20%) patients had renal dysfunction at diagnostic imaging. Among five patients who underwent renal biopsy, four patients with renal nephrolithiasis and/or nephrocalcinosis were diagnosed with tubulointerstitial nephritis, and one without nephrolithiasis and/or nephrocalcinosis was diagnosed with minimal change nephrotic syndrome. Estimated glomerular filtration rate at diagnostic imaging was significantly lower in patients with than without nephrolithiasis and/or nephrocalcinosis group (P = 0.010). In addition to nephrolithiasis and/or nephrocalcinosis (odds ratio [OR], 3.467; P = 0.045), the gap between serum sodium and chloride concentrations (OR, 10.400; P = 0.012) and increased urinary β2-microglobulin (OR, 5.444; P = 0.033) were associated with renal dysfunction at the time of diagnostic imaging.

CONCLUSION

Nephrolithiasis and/or nephrocalcinosis, normal anion gap metabolic acidosis, and tubulointerstitial damage are associated with renal dysfunction in patients with pSS.

Influence of exposure to climate-related hazards in the phenotypic expression of primary Sjögren's syndrome

OBJECTIVES

To analyse how the key components at the time of diagnosis of the Sjögren's phenotype (epidemiological profile, sicca symptoms, and systemic disease) can be influenced by the potential exposure to climate-related natural hazards.

METHODS

For the present study, the following variables were selected for harmonisation and refinement: age, sex, country, fulfilment of 2002/2016 criteria items, dry eyes, dry mouth, and overall ESSDAI score. Climate-related hazards per country were defined according to the OECD and included seven climate-related hazard types: extreme temperature, extreme precipitation, drought, wildfire, wind threats, river flooding, and coastal flooding. Climatic variables were defined as dichotomous variables according to whether each country is ranked among the ten countries with the most significant exposure.

RESULTS

After applying data-cleaning techniques and excluding people from countries not included in the OECD climate rankings, the database study analysed 16,042 patients from 23 countries. The disease was diagnosed between 1 and 3 years earlier in people living in countries included among the top 10 worst exposed to extreme precipitation, wildfire, wind threats, river flooding, and coastal flooding. A lower frequency of dry eyes was observed in people living in countries exposed to wind threats, river flooding, and coastal flooding, with a level of statistical association being classified as strong (p<0.0001 for the three variables). The frequency of dry mouth was significantly lower in people living in countries exposed to river flooding (p<0.0001) and coastal flooding (p<0.0001). People living in countries included in the worse climate scenarios for extreme temperature (p<0.0001) and river flooding (p<0.0001) showed a higher mean ESSDAI score in comparison with people living in no-risk countries. In contrast, those living in countries exposed to worse climate scenarios for wind threats (p<0.0001) and coastal flooding (p<0.0001) showed a lower mean ESSDAI score in comparison with people living in no-risk countries.

CONCLUSIONS

Local exposure to extreme climate-related hazards plays a role in modulating the presentation of Sjögren across countries concerning the age at which the disease is diagnosed, the frequency of dryness, and the degree of systemic activity.

Exposure to air pollution as an environmental determinant of how Sjögren's disease is expressed at diagnosis

OBJECTIVES

To analyse how the potential exposure to air pollutants can influence the key components at the time of diagnosis of Sjögren's phenotype (epidemiological profile, sicca symptoms, and systemic disease).

METHODS

For the present study, the following variables were selected for harmonization and refinement: age, sex, country, fulfilment of 2002/2016 criteria items, dry eyes, dry mouth, and overall ESSDAI score. Air pollution indexes per country were defined according to the OECD (1990-2021), including emission data of nitrogen and sulphur oxides (NO/SO), particulate matter (PM2.5 and 1.0), carbon monoxide (CO) and volatile organic compounds (VOC) calculated per unit of GDP, Kg per 1000 USD.

RESULTS

The results of the chi-square tests of independence for each air pollutant with the frequency of dry eyes at diagnosis showed that, except for one, all variables exhibited p-values <0.0001. The most pronounced disparities emerged in the dry eye prevalence among individuals inhabiting countries with the highest NO/SO exposure, a surge of 4.61 percentage points compared to other countries, followed by CO (3.59 points), non-methane (3.32 points), PM2.5 (3.30 points), and PM1.0 (1.60 points) exposures. Concerning dry mouth, individuals residing in countries with worse NO/SO exposures exhibited a heightened frequency of dry mouth by 2.05 percentage points (p<0.0001), followed by non-methane exposure (1.21 percentage points increase, p=0.007). Individuals inhabiting countries with the worst NO/SO, CO, and PM2.5 pollution levels had a higher mean global ESSDAI score than those in lower-risk nations (all p-values <0.0001). When systemic disease was stratified according to DAS into low, moderate, and high systemic activity levels, a heightened proportion of individuals manifesting moderate/severe systemic activity was observed in countries with worse exposures to NO/SO, CO, and PM2.5 pollutant levels.

CONCLUSIONS

For the first time, we suggest that pollution levels could influence how SjD appears at diagnosis in a large international cohort of patients. The most notable relationships were found between symptoms (dryness and general body symptoms) and NO/SO, CO, and PM2.5 levels.

A Lethal Combination: Legionnaires' Disease Complicated by Rhabdomyolysis, Acute Kidney Injury, and Non-Occlusive Mesenteric Ischemia

BACKGROUND Legionnaires' disease is one of the most common types of community-acquired pneumonia. It can cause acute kidney injury and also occasionally become severe enough to require continuous renal replacement therapy (CRRT). Non-occlusive mesenteric ischemia (NOMI) is a condition characterized by ischemia and necrosis of the intestinal tract without organic obstruction of the mesenteric vessels and is known to have a high mortality rate. CASE REPORT A 72-year-old man with fatigue and dyspnea was diagnosed with Legionnaires' disease after a positive result in the Legionella urinary antigen test pneumonia confirmed by chest radiography and computed tomography. He developed acute kidney injury, with anuria, rhabdomyolysis, septic shock, respiratory failure, and metabolic acidosis. We initiated treatment with antibiotics, catecholamines, mechanical ventilation, CRRT, steroid therapy, and endotoxin absorption therapy in the Intensive Care Unit. Despite ongoing CRRT, metabolic acidosis did not improve. The patient was unresponsive to treatment and died 5 days after admission. The autopsy revealed myoglobin nephropathy, multiple organ failure, and NOMI. CONCLUSIONS We report a fatal case of Legionnaires' disease complicated by rhabdomyolysis, acute kidney injury, myoglobin cast nephropathy, and NOMI. Legionella pneumonia complicated by acute kidney injury is associated with a high mortality rate. In the present case, this may have been further exacerbated by the complication of NOMI. In our clinical practice, CRRT is a treatment option for septic shock complicated by acute kidney injury. Thus, it is crucial to suspect the presence of NOMI when persistent metabolic acidosis is observed, despite continuous CRRT treatment.

Eosinophilic Granulomatosis with Polyangiitis Presenting as Steroid-Responsive Sclerosing Cholangitis and Cholecystitis: A Rare Case Report

BACKGROUND Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare systemic vasculitic condition characterized by bronchial asthma and eosinophilia. While biliary involvement is uncommon in EGPA, we present a unique case of EGPA presenting as steroid-responsive sclerosing cholangitis and cholecystitis. This case highlights the importance of considering EGPA in the differential diagnosis of biliary diseases, especially in patients with a history of bronchial asthma. CASE REPORT A 47-year-old man with a history of bronchial asthma presented with fatigue, weight loss, and epigastralgia. Blood tests revealed eosinophilia and elevated inflammatory markers, leading to the diagnosis of EGPA. Further imaging studies, including magnetic resonance cholangiopancreatography and contrast-enhanced computed tomography, confirmed the presence of sclerosing cholangitis and cholecystitis, a rare manifestation of EGPA. CONCLUSIONS Prompt treatment with prednisolone and azathioprine resulted in remission of symptoms and resolution of cholangitis and cholecystitis in this case. Our findings emphasize the importance of early recognition and appropriate management of EGPA-associated biliary involvement. Increased awareness of this rare manifestation may facilitate timely diagnosis and improve patient outcomes.

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

POS0527 ACUTE KIDNEY INJURY (AKI) IN PATIENTS WITH RHEUMATOID ARTHRITIS (RA)

Background:

Methotrexate has been an anchor drug for patients with rheumatoid arthritis (RA). However, it is strictly prohibited to prescribe MTX to patients with severely decreased renal function because it can induce a fatal adverse event such as pancytopenia in these patients. On the other hand, since the average age of RA patients is gradually increasing, and many of them already have mildly to moderately impaired renal function, their renal function can easily decrease to below the critical level of the estimated glomerular filtration rate. Therefore, new development of acute kidney injury (AKI) during MTX administration might induce a fatal adverse event, making the identification of patients susceptible to AKI very important.

Objectives:

To clarify the frequency of AKI and the factors involved in it in RA patients.

Methods:

Two hundred and fifty-two RA patients (211 females, 41 males, mean age 62.3 ± 12.5 years, disease duration 11.0 ± 9.5 years) diagnosed more than 3 years earlier and followed for more than 5 years, and also, others diagnosed ≥3 years earlier but followed for ≤5 years were enrolled. We measured BUN, Cr, RF and aCCP in patient serum, urinary proteins, urinary blood, and urinary casts and evaluated CDAI, SDAI, disease activity score (DAS) 28-CRP and DAS28-ESR. Steinbrocker functional classification and radiological grading were evaluated. History of diabetes mellitus, hypertension and hyperlipidemia was determined from the medical records. Medications for RA, including non-steroid anti-inflammatory drugs (NSAIDs), prednisolone, csDMARD (MTX, Tacrolimus, etc.), bDMARDs and tsDMARDs were evaluated. Estimated glomerular filtration rate (eGFR) was calculated by the new Japanese coefficient-modified Modification of Diet in Renal disease (MDRD) study equation. The criteria of AKI were that serum Cr increased by 0.3 mg /dl or increased by 1.5-fold between consecutive visits according to the KIDIGO criteria 1) and the report of Leither et al2).

Results:

Twenty (7.9%) patients developed AKI, 22 times. The causes of AKI were 10 infections, 6 dehydrations, 2 enteritis, 1 urticaria, 2 hypercalcemia due to VitD administration, and 1 ureteral stone. We divided our patients into group A (with AKI) and group B (without AKI). Group A was older (69.9±10.1 vs 61.7±12.6 years), had greater physician VAS (29.5±27.7 vs 15.7±18.3 mm), higher serum creatinine (0.79±0.19 vs 0.60±0.16 mg/dl), higher BUN (18.4±5.7 vs 15.1±4.4 mg/dl), lower eGFR(65.5±23.3 vs 86.4±22.4 ml/min), more frequent prednisolone administration (75.0% vs 41.9%), more frequent hyperlipidemia (50.0% vs 19.2%) and more frequent hypertension (60.0% vs 30.6%) than Group B by univariate analysis significantly (p<0.01). We then performed multifactorial analysis using logistic regression analysis. Greater physician VAS (OR 1.02, 1.00-1.04), lower eGFR (OR 1.04, 1.01-1.08) and prednisolone administration (OR 3.29, 1.02-10.63) were found as independent relevant factors for group A.

Conclusion:

Our study indicated that AKI developed in RA patients and suggested that renal function decline and prednisolone administration may be implicated. RA patients with impaired renal function and prednisolone administration need to be treated with special attention to the onset of AKI.

References:

[1]Kidney Disease: Improving Global Outcomes (KDIGO) Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2: 1-138, 2012

[2]Leither MD, Murphy DP, Bicknese L et al. The impact of outpatient acute kidney injury on mortality and chronic kidney disease: a retrospective cohort study. Nephrol Dial Transplant. 34:493-501, 2019

Disclosure of Interests:

None declared

Different factors underlie recurrent and de novo organ involvement in immunoglobulin G4-related disease

OBJECTIVES

In IgG4-related disease (IgG4-RD), relapse including recurrent organ involvement (ROI) and de novo organ involvement (DNOI) occurs frequently during the clinical course. This study aimed to clarify the differences between the risk factors underlying ROI and DNOI in IgG4-RD.

METHODS

We retrospectively investigated factors related to ROI and DNOI in 86 IgG4-RD patients. For assessment of factors related to ROI and DNOI, we performed uni- and multivariate Cox regression analyses. On stepwise multivariate analysis, we applied the variables with P < 0.1 in the univariate analysis and the predictors of relapse suggested in past reports.

RESULTS

During the mean follow-up period of 63.1 months, ROI was detected at 1.0-120 months after diagnosis in 20 patients, 4 of whom were not receiving glucocorticoid (GC) at the time of ROI. In contrast, DNOI was detected at 5.0-120 months after diagnosis in 15 patients, 8 of whom were not receiving GC at the time of DNOI. In the multivariate analysis, blood eosinophil counts at diagnosis [per 100/μl; hazard ratio (HR) 1.072 (95% CI 1.018, 1.129)] and continuation of GC [vs discontinuation or observation without GC; HR 0.245 (95% CI 0.076, 0.793)] had a significant impact on the time to DNOI, whereas age [HR 0.942 (95% CI 0.899, 0.986)] and ANA positivity [vs negativity; HR 6.632 (95% CI 1.892, 23.255)] had a significant impact on the time to ROI.

CONCLUSION

The present study suggests that the risk factors of ROI and DNOI are different in IgG4-RD, highlighting the need for different preventative strategies.

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

The efficacy of eribulin mesylate for patients with cutaneous angiosarcoma previously treated with taxane: a multicentre prospective observational study

BACKGROUND

Taxanes are the current first-line treatment for advanced cutaneous angiosarcoma (CAS) for patients who are considered difficult to treat with doxorubicin owing to advanced age or comorbidity. However, no effective second-line therapy for such patients has been established.

METHODS

We designed a single-arm prospective observational study of eribulin mesylate (ERB) administered at a dose of 1·4 mg m^-2 on days 1 and 8 in a 21-day cycle. Patients with advanced CAS who were previously treated with a taxane and were scheduled to begin ERB treatment were enrolled. The primary endpoint was overall survival (OS) and the secondary endpoints were response rate (RR), progression-free survival (PFS) and toxicity assessment.

RESULTS

We enrolled a total of 25 patients. The median OS and PFS were 8·6 months and 3·0 months, respectively. The best overall RR was 20% (five of 25). In total, 16 grade 3/4 severe adverse events (SAEs) occurred; however, all patients recovered. Patients who achieved partial response or stable disease as best response had longer OS than those with progressive disease (median OS not reached and 3·3 months, respectively; P < 0·001). Patients who did not experience SAEs showed longer OS than those who did (median OS 18·8 months and 7·5 months, respectively; P < 0·05). Patients with distant metastasis had shorter median OS than those with locoregional disease, but without statistically significant difference.

CONCLUSIONS

ERB showed a promising RR and is a potential candidate for second-line treatment for patients with CAS, after treatment with taxanes. However, owing to the occurrence of SAEs in over half of the participants, caution should be exercised regarding ERB use in elderly patients. What is already known about this topic? Taxanes are the current first-line treatment for patients with advanced cutaneous angiosarcoma (CAS) who are considered difficult to treat with doxorubicin owing to advanced age or comorbidity. No effective therapy for taxane-resistant CAS has been established thus far. Eribulin suppresses microtubule polymerization and elicits an antitumour effect similar to that of taxanes. What does this study add? In our single-arm prospective observational study to evaluate the efficacy of eribulin for treating patients with advanced CAS who previously received taxanes, the median overall survival and progression-free survival were 8·6 and 3·0 months, respectively. Response rates at weeks 7, 13 and 25 were 20%, 17% and 14%, respectively. Although 16 grade 3/4 severe adverse events occurred, all patients recovered. Eribulin showed a promising response rate and is a potential candidate for second-line treatment in CAS after taxane treatment. Linked Comment: Smrke and Benson. Br J Dermatol 2020; 183:797-798.

Fulminant myocarditis and pulmonary cavity lesion induced by disseminated mucormycosis in a chronic hemodialysis patient: Report of an autopsied case

Mucormycosis is a rare fungal infection occurring in the immunocompromised host. It is difficult to diagnose, and its cardiac involvement is extremely rare. Here, we report a 64-year-old Japanese man with a 5-year history of hemodialysis with disseminated mucormycosis causing fulminant myocarditis and pulmonary necrosis under glucocorticoid use. Two months before, he had received an implantable cardioverter defibrillator and started to take amiodarone for recurrent ventricular arrhythmias due to hypertensive cardiomyopathy. He developed amiodarone-induced interstitial pneumonia and then received glucocorticoid therapy. Although the interstitial pneumonia partially improved, a lung cavitary lesion developed in the upper right lobe. Antibiotics had no effect, and serologic tests, blood and sputum cultures and bronchoalveolar lavage fluid were all negative for infectious pathogens. Eventually, he died of fulminant myocarditis. Autopsy revealed disseminated mucormycosis with vascular invasion and fungal thrombi, hemorrhage and infarction in lung (cavity lesion), heart (severe myocarditis), brain, thyroid and subcutaneous tissue around the implantable cardioverter defibrillator. The lung cavitary lesion was the only clinical finding suggestive of mucormycosis before autopsy. When an immunocompromised patient shows a progressive lung cavity lesion, the possibility of mucormycosis should be considered so that a broad-spectrum antifungal agent can be empirically administered in a timely fashion.

2-mm surgical margins are adequate for most basal cell carcinomas in Japanese: a retrospective multicentre study on 1000 basal cell carcinomas

BACKGROUND

Surgery is the gold standard for basal cell carcinomas (BCC). Current recommended surgical margins for BCCs are determined from studies in Caucasian populations. However, the appropriate surgical margins for BCCs in non-white races are unclear.

OBJECTIVES

To investigate the accuracy of preoperative determination of clinical tumour borders and appropriate surgical margins in Japanese patients with BCC.

METHODS

The maximum calculated differences in distance between the preoperatively determined surgical margins and the actual histologic tumour side margins were considered as 'accuracy gaps' of clinical tumour borders. Estimated side margin positivity rates (ESMPRs) with narrower (2 and 3 mm) surgical margins were calculated on the basis of the accuracy gaps.

RESULTS

Overall, 1000 surgically excised BCCs from 980 Japanese patients were included. The most frequent histologic subtype was nodular BCC (67%). The median accuracy gap was 0.3 mm [interquartile range (IQR): -0.5 to +1 mm]. The ESMPRs with 2- and 3-mm surgical margins were 3.8% and 1.4%, respectively. Only the ESMPRs between the well-defined (n = 921) and poorly defined clinical tumour border groups (n = 79) showed statistical difference [2-mm margin: 3.1% vs. 11.7%, OR: 3.89, 95% confidential interval (CI): 1.41-10.71, P <0.01; 3-mm margin: 0.97% vs. 6.3%, OR: 6.58, 95% CI: 1.67-25.99, P <0.01]. No significant differences in ESMPRs were noted in other subgroups including risk classifications.

CONCLUSIONS

The determined clinical tumour border accuracy gaps in this Japanese cohort were negligible. Dermatologic surgeons may use narrower surgical margins with acceptable margin positivity rates. The clarity of clinical tumour borders could be an appropriate guide for selection of different surgical margins in the Japanese cohort.

Hypocomplementemia is related to elevated serum levels of IgG subclasses other than IgG4 in IgG4-related kidney disease

OBJECTIVES

This study investigated the clinical features of IgG4-RKD patients with hypocomplementemia compared with those without it, so as to clarify the factors related to hypocomplementemia.

METHODS

In this single-center retrospective study, we analyzed the clinical features of 25 patients with IgG4-RKD according to the presence/absence of hypocomplementemia. Additionally, we validated the results of a single-center study in a separate large multicenter cohort of 328 patients with IgG4-RD, and searched for factors related to hypocomplementemia.

RESULTS

Serum IgG levels (p < .001), non-IgG4 IgG levels, calculated as the total IgG minus IgG4 (p < .001), serum IgG1 levels (p = .017), and the number of involved organs (p = .018) were significantly higher in the hypocomplementemia group. At relapse of renal lesions in four patients, all had serum IgG4 re-elevation, with the three with hypocomplementemia presenting worsening of hypocomplementemia and re-elevation of non-IgG4 IgG levels. In a validation cohort of 328 patients with IgG4-RD, multivariate logistic regression analysis indicated elevation of non-IgG4 IgG levels to be an independent factor related to hypocomplementemia in the patients with IgG4-RKD.

CONCLUSION

The present study suggests that hypocomplementemia is associated with elevation of IgG subclasses other than IgG4 including IgG1 in IgG4-RKD.

Deep-learning-based, computer-aided classifier developed with a small dataset of clinical images surpasses board-certified dermatologists in skin tumour diagnosis

BACKGROUND

Application of deep-learning technology to skin cancer classification can potentially improve the sensitivity and specificity of skin cancer screening, but the number of training images required for such a system is thought to be extremely large.

OBJECTIVES

To determine whether deep-learning technology could be used to develop an efficient skin cancer classification system with a relatively small dataset of clinical images.

METHODS

A deep convolutional neural network (DCNN) was trained using a dataset of 4867 clinical images obtained from 1842 patients diagnosed with skin tumours at the University of Tsukuba Hospital from 2003 to 2016. The images consisted of 14 diagnoses, including both malignant and benign conditions. Its performance was tested against 13 board-certified dermatologists and nine dermatology trainees.

RESULTS

The overall classification accuracy of the trained DCNN was 76·5%. The DCNN achieved 96·3% sensitivity (correctly classified malignant as malignant) and 89·5% specificity (correctly classified benign as benign). Although the accuracy of malignant or benign classification by the board-certified dermatologists was statistically higher than that of the dermatology trainees (85·3% ± 3·7% and 74·4% ± 6·8%, P < 0·01), the DCNN achieved even greater accuracy, as high as 92·4% ± 2·1% (P < 0·001).

CONCLUSIONS

We have developed an efficient skin tumour classifier using a DCNN trained on a relatively small dataset. The DCNN classified images of skin tumours more accurately than board-certified dermatologists. Collectively, the current system may have capabilities for screening purposes in general medical practice, particularly because it requires only a single clinical image for classification.

New clues to the nature of immunoglobulin G4-related disease: a retrospective Japanese multicenter study of baseline clinical features of 334 cases

Background

The aim was to further characterize immunoglobulin G4-related disease (IgG4-RD) by a large-scale multicenter study of its clinical and laboratory features conducted by multidisciplinary physicians of IgG4-RD in Japan.

Methods

Various specialists retrospectively evaluated IgG4-RD patients diagnosed between 1996 and 2015 in five hospitals by analyzing their baseline clinical features, laboratory, imaging, and pathological test findings, and treatment.

Results

Of the 334 patients listed, 205 were male and median age at diagnosis was 65 years. The mean number of organs involved was 3.2 at diagnosis. The most frequently affected organs were the salivary glands, followed by the lacrimal glands, lymph nodes, pancreas, retroperitoneum/periaorta, kidneys, and lungs. The mean serum level of IgG4 was 755 mg/dl, and more than 95% of patients had elevated serum IgG4 levels. The median serum level of C-reactive protein (CRP) was 0.1 mg/dl and the level was less than 1 mg/dl in 90% of patients. A total of 34.7% of patients had low serum levels of C3. Serum levels of C3 and non-IgG4 IgG, calculated as the total IgG minus IgG4, showed an inverse correlation in patients with kidney lesions, while serum IgG4 levels were not correlated with serum C3 levels. Corticosteroid was administered in 78.0% of patients, and was effective in all.

Conclusions

The serum CRP level is generally low and the serum IgG4 level is elevated in most Japanese IgG4-RD patients, in contrast to western patients. These original findings suggest that these two parameters in IgG4-RD differ in some interesting ways from those hitherto reported in western populations. Additional studies, especially international comparative ones, are needed to elucidate the extent and significance of these differences between populations. Attention will also have to be paid to whether the existence of such differences requires consideration when devising international classification criteria.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-017-1467-x) contains supplementary material, which is available to authorized users.

Comparison of ultrasonographic joint and tendon findings in hands between early, treatment-naïve patients with systemic lupus erythematosus and rheumatoid arthritis

Although both systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA) may lead to joint deformity, SLE arthritis is typically non-erosive and often accompanied by Jaccoud's deformity. Therefore, we examined characteristics of joint and tendon lesions in patients with SLE and RA by ultrasonography. Fifteen treatment-naïve SLE patients and 40 treatment-naïve RA patients with joint symptoms were included in this study. The hand joints and related tendons were ultrasonographically examined using grey-scale (GS) and power Doppler (PD). Joint involvement was comparably observed in patients with SLE and RA (80% versus 95%, p = 0.119). However, tendon involvement was more frequent in SLE than in RA (93% versus 65%, p = 0.045), especially in the wrist joints (73% versus 40%, p = 0.037). When we investigated the intensity of US findings, the joint synovitis score (GS + PD) per affected joint was lower in SLE than RA (2.0 versus 2.6, p = 0.019), while tendon inflammation score was not significantly different (2.1 versus 2.2, p = 0.738). Finally, the examination of concordance between joint and tendon involvement in the same finger revealed that joint lesion appeared in only 49% of fingers having tendon involvement in the SLE group, which was significantly less than 74% in the RA group ( p = 0.010). Thus, as compared with RA, SLE arthropathy is characterized by the predominance of tenosynovitis/periextensor tendon inflammation, which is likely to develop independently from joint synovitis.