Gene polymorphisms contributing to hypertension in immunoglobulin A nephropathy

BACKGROUND

Hypertension, which is affected by genetic and environmental factors, is one of the major risk factors for chronic kidney disease. Identification of the genetic factor contributing to hypertension in patients with chronic kidney disease may potentially refine a therapeutic strategy.

METHODS

In the present multicenter cross-sectional study, 240 patients were eligible (aged 15-50 years with urinary protein ≥0.25 g/day) out of 429 patients who were diagnosed as having immunoglobulin (Ig) A nephropathy (IgAN) by renal biopsy between 1990 and 2005 and enrolled in our previous study, PREDICT-IgAN. The outcome was hypertension defined as ≥140 and/or ≥90 mmHg of systolic and diastolic blood pressure and/or use of antihypertensives at renal biopsy. We assessed associations between hypertension and 28 polymorphisms with the frequency of minor genotype ≥10% among 100 atherosclerosis-related polymorphisms using the Chi-squared test in dominant and recessive models. We identified polymorphisms associated with hypertension in multivariate logistic regression models.

RESULTS

Baseline characteristics: hypertension 36.3%. Among 28 polymorphisms, the Chi-squared test revealed that CD14 (-159CC vs CT/TT, P = 0.03) and ACE (DD vs DI/II, P = 0.03) were significantly associated with hypertension after Bonferroni correction. Multivariate logistic regression models revealed that CD14 -159CC [vs CT/TT, odds ratio (OR) 3.58 (95% confidence interval (CI) 1.66-7.63)] and ACE DD [vs DI/II, OR 4.41 (95% CI 1.80-10.8), P = 0.001] were independently associated with hypertension.

CONCLUSIONS

CD14 C-159T and ACE I/D contributed to hypertension in patients with IgAN.

Self-reported sleep duration and prediction of proteinuria: a retrospective cohort study

BACKGROUND

Although multiple studies have shown that sleep duration is a predictor of cardiovascular diseases and mortality, few studies have reported an association between sleep duration and chronic kidney disease.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

6,834 employees of Osaka University aged 20-65 years who visited Osaka University Healthcare Center for their mandatory annual health examinations between April 2006 and March 2010 and did not have estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2), proteinuria, or treatment for self-reported kidney disease.

PREDICTOR

Self-reported questionnaires about life style, including sleep duration, and blood and urine testing at the first examinations during the study period. An association between sleep duration and outcome was assessed using multivariate Poisson regression models adjusting for clinically relevant factors.

OUTCOME

Time to the development of proteinuria defined as 1+ or higher by dipstick test.

RESULTS

Self-reported baseline sleep duration was 6.0 ± 0.9 hours, which reflected the mean sleep duration during a median of 2.5 (25th-75th percentile, 1.4-3.9) years of the observational period. Development of proteinuria was observed in 550 employees (8.0%). A multivariate Poisson regression model clarified that shorter sleep duration, especially 5 or fewer hours, was associated with the development of proteinuria in a stepwise fashion (vs 7 hours; incidence rate ratios of 1.07 [95% CI, 0.87-1.33; P = 0.5], 1.28 [95% CI, 1.00-1.62; P = 0.05], and 1.72 [95% CI, 1.16-2.53; P = 0.007] for 6, 5, and ≤4 hours, respectively), along with younger age, heavier current smoking, trace urinary protein by dipstick test, higher eGFR, higher serum hemoglobin A(1c) level, and current treatment for heart disease. A stepwise association between shorter sleep duration and the development of proteinuria also was verified in 4,061 employees who did not work the night shift.

LIMITATIONS

Self-reported sleep duration might be biased. Results in a single center should be confirmed in the larger cohort including different occupations.

CONCLUSION

Short sleep duration, especially 5 or fewer hours, was a predictor of proteinuria.

Microarray analysis of tonsils of IgA nephropathy patients

IgA nephropathy (IgAN) is the most common primary glomerulonephritis. Its close relation with the tonsils is well known because tonsillitis sometimes causes aggravation of urinary findings or macrohematuria. However, the genes specific to the tonsils of IgAN patients are not clarified. To clarify the specific gene expression in the tonsils of IgAN patients, we performed tonsillectomy and corticosteroid IV therapy as a treatment of IgAN, analyzed the gene expression in the tonsils by microarray and compared it with that in tonsils from chronic tonsillitis patients. The upregulated genes seem to be categorized into two groups: muscle-related genes and immunerelated genes. The downregulated genes include the polymeric Ig receptor (pIgR) which was reportedly involved in single nucleotide polymorphism (SNP) of Japanese IgAN patients.

Urinary type IV collagen in nondiabetic kidney disease

BACKGROUND

Type IV collagen is one of the major components of basement membrane. In diabetic nephropathy, it is already known that urinary excretion of type IV collagen increases with the disease progression. However, in nondiabetic kidney disease, urinary type IV collagen (u-IVc) levels have not been extensively investigated. The aim of this study was to evaluate u-IVc levels in various nephropathies except diabetic nephropathy.

METHODS

u-IVc levels were measured cross-sectionally from 527 biopsy-proven nondiabetic renal disease patients at tertiary care hospitals by one-step sandwich enzyme immunoassay.

RESULTS

On simple regression analyses, u-IVc levels had positive correlation with age, blood pressure, urinary protein (u-Prot), urinary β(2) microglobulin, urinary N-acetyl-β-D-glucosaminidase, HbA(1)c, and selectivity index (SI), while u-IVc had negative correlation with eGFR and serum albumin. Multiple regression analyses revealed that u-IVc was positively correlated with u-Prot, HbA(1)c and SI. Among biopsy-proven nondiabetic nephropathies, elevation of u-IVc was distinctively observed in membranous nephropathy and anti-neutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis.

CONCLUSION

u-IVc levels were elevated with the increase in u-Prot, HbA(1)c and SI. In addition, among nondiabetic kidney disease, elevation of u-IVc was observed in patients with membranous nephropathy and ANCA, which might reflect the thickening of basement membrane or severe kidney damage.

Cigarette smoking and progression of IgA nephropathy

BACKGROUND

Multiple community-based cohort studies of mainly middle-aged and elderly populations have shown that cigarette smoking is a risk factor for chronic kidney disease. However, little information is available about an effect of cigarette smoking on progression of primary kidney diseases, including immunoglobulin A (IgA) nephropathy.

STUDY DESIGN

Retrospective cohort study.

SETTING & PARTICIPANTS

971 of 1,001 patients with a diagnosis of IgA nephropathy in 3 major nephrology centers in Osaka, Japan, between 1992 and 2005 who enrolled in the Study of Outcome and Practice Pattern of IgA Nephropathy (STOP-IgAN).

PREDICTORS

Smoking status and number of cigarettes smoked at the time of diagnosis using kidney biopsy. Dose-dependent associations between cigarette smoking and outcomes were assessed in multivariate Cox proportional hazards models. Significantly different clinical characteristics between non-/past and current smokers were controlled for using propensity score-based adjustment, stratification, and matching.

OUTCOMES

50% increase in serum creatinine level as primary outcome. A composite outcome of a 100% increase in serum creatinine level or end-stage renal disease (ESRD) and ESRD alone as secondary outcomes.

RESULTS

During the median 5.8 years (interquartile range, 2.6-10.2) of the observational period, 117 participants progressed to a 50% increase in serum creatinine level and 47 advanced to ESRD. Multivariate Cox proportional hazards models identified current smokers (HR, 2.03 [95% CI, 1.33-3.10] for primary outcome) and number of cigarettes at kidney biopsy (HR, 1.21 [95% CI, 1.06-1.39] per 10 cigarettes per day) as significant predictors of outcomes. Propensity score-based models confirmed these results. Tests for interaction showed that the association of current smoking with adverse outcomes was stronger in those with lower compared with higher estimated glomerular filtration rates.

LIMITATION

Baseline smoking status was not verified using biochemical tests. Smoking status during the observational period was unavailable.

CONCLUSIONS

Cigarette smoking, in a dose-dependent manner, was identified as a key prognostic factor in IgA nephropathy. Smoking cessation should be encouraged as part of the treatment for IgA nephropathy.

Kidney repair using stem cells: myth or reality as a therapeutic option?

The kidney has been considered a highly terminally differentiated organ of the body, and its proliferative potential is low, with the result that it has been thought of as a most unlikely organ for regeneration. From the structural point of view, the kidney is elaborately composed of many cell types that function as a tissue unit and not as individual cells, which also makes it more difficult to regenerate. However, in clinical settings, the kidney does have regenerative potential as seen in the recovery from acute kidney injury. The role of bone marrow-derived mesenchymal stromal cells may mainly be to produce humoral factors accelerating regeneration. The origin, localization and role of kidney stem cells are under investigation. We also discuss potential applications of embryonic stem cells and induced pluripotent stem cells in kidney regeneration.

Microarray analysis of tonsils in immunoglobulin A nephropathy patients

BACKGROUND

Recently, combination of tonsillectomy and steroid pulse therapy was reported to be effective as the treatment of the immunoglobulin A nephropathy (IgAN). However, the gene expression difference between the tonsils in patients with IgAN and those in control patients is not established.

METHODS

We performed tonsillectomy combined with steroid pulse as a treatment to IgAN, analyzed the gene expression in the tonsils (N=23) using microarray, compared with those with patients suffering from chronic tonsillitis (N=22). From some candidate genes related with IgAN, we confirmed the apolipoprotein B messenger RNA-editing enzyme catalytic polypeptides 2 (APOBEC2) gene expression in the tonsil and we also analyzed its expression levels and clinical features.

RESULTS

Up-regulated genes seem to be categorized into two groups. One group belongs to the muscle related genes which might be caused by structural differences. The other group includes the immune system-related genes, such as APOBEC2, CALB2, DUSP27, and CXCL11. APOBEC2 was positively stained in the epithelium and the peripheral region of the germinal center in both tonsils. APOBEC2 expression level was negatively related with serum igg level, but did not correlate with clinical course after tonsillectomy.

CONCLUSION

We confirmed gene expression differences related with immune system and muscle structure. The APOBEC2 was confirmed to be elevated in the tonsils with IgAN patients, and the gene expression level was negatively related with serum igg level in overall patients. These results might be helpful to reveal the mechanism of IgAN.

E-cadherin and claudin-4 expression has circadian rhythm in adult rat kidney

BACKGROUND

Urinary sodium excretion varies during the day. It is unknown whether expression levels of cell-cell junctions in the kidney are dynamic and associated with urinary sodium excretion.

METHODS

Adult Sprague Dawley rats were fed ad libitum or exclusively during the day, or kept under fasting condition. We measured expression levels of Per2, E-cadherin and claudin-4 as representative molecules of the peripheral circadian clock, adherens junctions and tight junctions, respectively. We also measured sodium concentration in urine. Effects of aldosterone on expression levels of Per2 and claudin-4 were also studied. To see proliferating cells in the kidney, rats were labeled with 5-bromo-2'-deoxyuridine.

RESULTS

In rats fed ad libitum, Per2, E-cadherin and claudin-4 mRNA showed robust circadian oscillation: the correlation coefficients (R values) of the cosinor fitting curves with a 24-hour cycle were 0.928, 0.999 and 0.983, respectively. Oscillation phases of these molecules shifted in response to restricted feeding (R=0.922, R=0.815 and R=0.821, respectively). E-cadherin and claudin-4 proteins also oscillated circadianly under ad libitum feeding (R=0.851 and R=0.999, respectively), which shifted in response to the restricted feeding (R=0.811 and R=0.985, respectively). Urinary sodium excretion was low when protein levels of E-cadherin and claudin-4 were high. Aldosterone or cell division did not account for mRNA oscillation of claudin-4 or E-cadherin in the kidney.

CONCLUSIONS

Expression of E-cadherin and claudin-4 has a circadian rhythm. The dynamic change in protein levels of E-cadherin and claudin-4 seems to coincide with that in the level of sodium excretion.

Early plasma exchange for progressive liver failure in recipients of adult-to-adult living-related liver transplants

BACKGROUND/AIMS

Little information is available concerning the effectiveness of plasma exchange for progressive liver failure in liver transplant recipients. The aims of the present study were to evaluate the effectiveness of plasma exchange and discuss its indication.

METHODS

Forty-six ABO-compatible recipients of living-related liver transplants operated on in Osaka University hospital were retrospectively studied.

RESULTS

Total bilirubin was identified as the most accurate predictor of the short-term prognosis of 46 recipients (optimal cut-off point: 13.3 mg/dl). Eleven patients received 14 plasma exchange sessions. Elevation of total bilirubin was significantly suppressed after plasma exchange in the patients with total bilirubin below the median (24 mg/dl), whereas total bilirubin significantly increased even after plasma exchange in those with total bilirubin above the median.

CONCLUSION

Plasma exchange improved liver function in recipients with progressive liver failure and appears to be indicated in patients with total bilirubin levels ranging between 13 and 24 mg/dl.

Assessment of coronary stenosis by a 16-slice MDCT scanner in asymptomatic diabetic patients starting dialysis therapy

BACKGROUND

The accuracy for the detection of coronary stenosis by multidetector row computed tomography (MDCT) has been getting more recognition. However, the usefulness of MDCT in patients with chronic kidney disease (CKD) has not been confirmed.

METHODS

Weanalyzed 19 consecutive patients with asymptomatic diabetic CKD who underwent both MDCT and coronary angiography (CAG) at the initiation of dialysis. The definition of stenosis in this study was lesions with > or =50% stenosis by CAG.

RESULTS

CAG revealed stenosis in 35 of 76 branches in 19 patients. Vessel diameter could not be evaluated by MDCT in 11 (14%) major vessels because of motion artifacts, pericardial effusion, pleural effusion, and severe calcification. Almost all of such lesions were located in the right coronary (4/11; 36%) or left circumflex (5/11; 45%) artery. The sensitivity, specificity, positive and negative predictive values of MDCT for a diagnosis of stenosis in the 65 evaluable major vessels were 86, 81, 78, and 88%, respectively. The severity of vessel calcification was increased in a stepwise manner with increments in the proportion of major vessels with > or =50% stenosis (p = 0.004 for trend).

CONCLUSION

MDCT seemed to be an effective non-invasive method of screening patients with diabetic CKD for CAD.

Integrated therapies including erythropoietin decrease the incidence of dialysis: lessons from mapping the incidence of end-stage renal disease in Japan

BACKGROUND

Erythropoietin (EPO) has been reported to slow the decline of renal function in predialysis chronic kidney disease (CKD) patients. On the contrary, in the recent large-scale randomized controlled trial (RCT), CREATE and CHOIR, which aimed to keep a higher haemoglobin (Hb) level than former trials, the renoprotective effect of EPO was not observed. Today, the renoprotective effect of EPO has become controversial. In order to test the hypothesis that the usage of EPO in predialysis CKD patients may ameliorate the progression of renal disease, we conducted a macro-level observational study dealing with all Japanese predialysis CKD patients.

METHODS

Annually since 1982, the Japanese Society for Dialysis Therapy reports the number of patients that have entered maintenance dialysis in each prefecture of Japan. Based on the 2002-2004 data, we calculated the annual incidence of end-stage renal disease (ESRD) in each of the 47 prefectures. The annual amounts paid for EPO by each prefecture, presumably corresponding to the amounts used, corrected for the estimated predialysis CKD patients, were calculated. We examined the relationship between the incidence of new dialysis and the usage of EPO in each prefecture. Furthermore, the usage of EPO was compared with that of antihypertensive agents including angiotensin converting enzyme inhibitor (ACE-I), and that of statin.

RESULTS

There were prefectural differences in the annual incidence of ESRD from 2002 to 2004. We also found prefectural differences in the usage of EPO for the three consecutive years. The usage of EPO in predialysis patients was negatively correlated with the incidence of ESRD on linear and multiple regression analyses. At the same time, the usage of EPO had strong positive correlations with the usage of antihypertensive agents including ACE-I and with that of statin.

CONCLUSION

Our nationwide epidemiologic study revealed that a higher use of EPO was associated with a decreased incidence of new dialysis in daily clinical practice. In addition, there were strong correlations among the usage of EPO, antihypertensive agents and statin. These data are supportive of, but do not prove, the hypothesis that EPO may be renoprotective, when used in combination with other strategies.

Exacerbation of albuminuria and renal fibrosis in subtotal renal ablation model of adiponectin-knockout mice

OBJECTIVE

Obesity is recognized increasingly as a major risk factor for kidney disease. We reported previously that plasma adiponectin levels were decreased in obesity, and that adiponectin had defensive properties against type 2 diabetes and hypertension. In this study, we investigated the role of adiponectin for kidney disease in a subtotal nephrectomized mouse model.

METHODS AND RESULTS

Subtotal (5/6) nephrectomy was performed in adiponectin-knockout (APN-KO) and wild-type (WT) mice. The procedure resulted in significant accumulation of adiponectin in glomeruli and interstitium in the remnant kidney. Urinary albumin excretion, glomerular hypertrophy, and tubulointerstitial fibrosis were significantly worse in APN-KO mice compared with WT mice. Intraglomerular macrophage infiltration and mRNA levels of vascular cell adhesion molecule (VCAM)-1, MCP-1, tumor necrosis factor (TNF)-alpha, transforming growth factor (TGF)-beta1, collagen type I/III, and NADPH oxidase components were significantly increased in KO mice compared with WT mice. Treatment of APN-KO mice with adenovirus-mediated adiponectin resulted in amelioration of albuminuria, glomerular hypertrophy, and tubulointerstitial fibrosis and reduced the elevated levels of VCAM-1, MCP-1, TNF-alpha, TGF-beta1, collagen type I/III, and NADPH oxidase components mRNAs to the same levels as those in WT mice.

CONCLUSIONS

Adiponectin accumulates to the injured kidney, and prevents glomerular and tubulointerstitial injury through modulating inflammation and oxidative stress.

Fetal cells in mother rats contribute to the remodeling of liver and kidney after injury

Fetal microchimerism indicates a mixture of cells of maternal and fetal origin seen in maternal tissues during and after pregnancy. Controversy exists about whether persistent fetal microchimerism is related with some autoimmune disorders occurring during and after pregnancy. In the current experiment, an animal model in which EGFP positive cells were taken as fetal-origin cells was designed to detect the fetal microchimerism in various maternal organs. Ethanol drinking and gentamicin injection were adopted to induce liver and kidney injury simultaneously. EGFP positive cells were engrafted not only in the maternal circulation and bone marrow, but also in the liver and kidney as hepatocytes and tubular cells, respectively. These results indicate that fetal cells are engrafted to maternal hematopoietic system without apparent injury and they also contribute to the repairing process of maternal liver and kidney.

Hematopoietic and nonhematopoietic potentials of Hoechst(low)/side population cells isolated from adult rat kidney

BACKGROUND

Although the regenerative stem cell is expected to exist in many adult tissues, the cell contributing to the regeneration of the kidney remains unknown in its type and origin.

METHODS

In this study, we isolated cells that show low stain with a DNA-binding dye Hoechst 33342 (Hoechst(low) cells) from adult rat kidney, and investigated their differentiation potentials.

RESULTS

Hoechst(low) cells, generally termed side population cells, existed at a frequency of 0.03% to 0.1% in the cell suspension of the digested kidney. Analysis of the kidney-derived Hoechst(low) cells after bone marrow transplantation indicated that some of the cells were derived from bone marrow. When enhanced green fluorescent protein (EGFP)-labeled kidney-derived Hoechst(low) cells were intravenously transplanted into wild-type adult rats, EGFP(+) cells were not detected in the kidney, but EGFP(+) skeletal muscle, EGFP(+) hepatocytes and EGFP(+) bone marrow cells were observed. Even after the induction of the experimental glomerulonephritis and gentamicin-induced nephropathy that promote the differentiation of bone marrow-derived cells into repopulating mesangial cells and tubular component cells, respectively, EGFP(+) mesangial or tubular cells were not observed. Neither with an in vitro system, which we established to produce mesangial-like cells from crude bone marrow culture, did Hoechst(low) cells yield mesangial-like cells.

CONCLUSION

These findings implicate that Hoechst(low) cells in the kidney may have potentials for hematopoietic and nonhematopoietic lineages, but are not stem cells for renal cells, especially mesangial and tubular cells.

A case of Wegener?s granulomatosis with pulmonary bleeding successfully treated with double filtration plasmapheresis (DFPP)

We report a case of a 41-year-old Japanese man who presented with rapidly progressive glomerulonephritis, chronic sinusitis, and positive cytoplasmic-antineutrophil cytoplasmic antibody (c-ANCA). Renal biopsy showed crescentic glomerulonephritis, and he was diagnosed as having Wegener's granulomatosis. During the clinical course, he suffered from pulmonary bleeding, and combination therapy of steroid, immunosuppressant, and double filtration plasmapheresis (DFPP) was started. He rapidly entered remission after assistance through DFPP, suggesting the potential efficacy of DFPP for Wegener's granulomatosis, especially with pulmonary bleeding.

Activation of the signal transducer and activator of transcription signaling pathway in renal proximal tubular cells by albumin

Renal proximal tubular cells activated by reabsorption of protein are thought to play significant roles in the progression of kidney diseases. It was hypothesized that the signal transducer and activator of transcription (STAT) proteins may be activated by proteinuria in proximal tubular cells. To test this hypothesis, murine proximal tubular cells were treated with albumin (30 mg/ml medium) for various lengths of time. The results showed that albumin could activate Stat1 and Stat5 within 15 min in proximal tubular cells. The activation of STATs was mediated mostly by Jak2 and required no protein synthesis. In addition, activation of Stat1 occurred even after neutralization of IFN-gamma. The activation of STATs was inhibited by N-acetyl-L-cysteine, a precursor of glutathione and a reactive oxygen species (ROS) scavenger, and fluorescence-activated cell sorter analysis showed upregulation of intracellular ROS after albumin overloading, suggesting that albumin per se could generate ROS in proximal tubular cells. The activation of STATs occurred by way of the ROS generating system, and especially through the membrane-bound NADPH oxidase system. Reduced activities of glutathione peroxidase and catalase could also be responsible for the accumulation of intracellular ROS. Hence, not only the ROS generating system, but also the ROS scavenging system may contribute to the induction of ROS by albumin. These findings support the hypothesis that proximal tubular cells are activated and generate ROS by reabsorption of abundant urinary proteins filtered through the glomerular capillaries, and as a consequence, various IFN-gamma-inducible proteins are synthesized through IFN-gamma-independent activation of STAT signaling.

Platelet-derived growth factor plays a critical role to convert bone marrow cells into glomerular mesangial-like cells

BACKGROUND

Despite increasing interest in bone marrow-derived stem cells, little is known about critical factors that determine their fates both in vitro and in vivo. Recently, we have reported that bone marrow is a reservoir for glomerular mesangial cells in rats. To find a key factor responsible for the differentiation of bone marrow-derived cells into mesangial cells, we established a new culture system of rat bone marrow, which is based on serial replating and differential attachment to collagen types I and IV.

METHODS

Bone marrow cells that did not adhere to collagen type I within 24 hours were transferred to collagen type IV-coated dishes. Then, the cells attached to collagen type IV in the following 24 hours were maintained in the presence of 2% horse serum, 200 ng/mL of platelet-derived growth factor (PDGF)-BB, and 1 micromol/L of all-trans retinoic acid. In vivo effect of PDGF-B was also examined by introducing human PDGF-B gene into glomeruli.

RESULTS

After cultivation under the above condition for 7 days, approximately 14% of cells expressed Thy-1 and desmin, both of which are markers for rat mesangial cells. Thy-1++/desmin+ cells were stellate-shaped, and contracted in response to angiotensin II. When human PDGF-B gene was overexpressed in the glomeruli of chimeric rats whose bone marrow was transplanted from enhanced green florescent protein (EGFP) transgenic rats, the number of EGFP+ mesangial cells increased. This effect was canceled by prior introduction of a neutralizing molecule that is composed of PDGF receptor-beta ligand binding site and IgG-Fc.

CONCLUSION

These results indicate that PDGF-B plays a critical role to direct bone marrow-derived cells toward mesangial-like cells both in vitro and in vivo.