[A late phase II study of CPT-11, irinotecan hydrochloride, in patients with advanced pancreatic cancer. CPT-11 Study Group on Gastrointestinal Cancer]

A late phase II study of CPT-11 was conducted to evaluate the antitumor effect and toxicity of CPT-11 in patients with advanced pancreatic cancer as a cooperative study of 19 institutions. From February 1990 to June 1992, 61 patients with advanced pancreatic cancer were enrolled in this study. Fifty-seven patients were evaluable for toxicity and 35 for response. CPT-11 was administered as a 100 mg/m2 weekly intravenous infusion (regimen A) or as a 150 mg/m2 every two weeks (regimen B). The response rate was 11.4% (4/35). The primary tumor showed a 10.3% (3/29) response and the liver metastases showed a 10.5% (2/19) response. The major toxicities were myelosuppression and gastrointestinal symptoms. The incidences (> or = Grade 2) of leukopenia, anemia, anorexia, nausea/vomiting, alopecia and diarrhea were 61.4% (35/57), 56.1% (32/57), 70.2% (40/57), 56.1% (32/57), 40.4% (23/57) and 36.8% (21/57), respectively. The incidence of diarrhea was higher with regimen A than with regimen B, but the antitumor activity was no different between the two regimens. These results suggested that CPT-11 has some antitumor activity against advanced pancreatic cancer.

Identification and structural determination of the KDN-containing N-linked glycan chains consisting of bi- and triantennary complex-type units of KDN-glycoprotein previously isolated from rainbow trout vitelline envelopes

KDN-gp, which is the unique glycoprotein of the rainbow trout egg envelope, was shown to have a small amount of N-linked oligosaccharide units in addition to a large number of O-linked glycan units. Structural analysis based on chemical analysis in combination with 400 MHz 1H NMR spectroscopy revealed the presence of fully KDNosylated bi- and triantennary complex-type oligosaccharide chains, mostly fucosylated at the innermost GlcNAc residue and bisected by the GlcNAc residue linked beta 1-->4 to the beta-Man residue. The structures thus determined represent the first demonstration of N-linked glycan unit containing the KDN residues in the KDN-containing glycoproteins (see Chart 1). The KDN-gp of the rainbow trout egg envelope is a molecule that is present in the second layer of the vitelline envelope but is exposed to the outer surface around the micropyle through which sperm can get in at fertilization. Like human hematopoietic cell surface glycoproteins such as glycophorin A and leukosialin, KDN-gp, which is now characterized to contain N-linked complex-type glycan chains as minor components, is heavily O-glycosylated with alpha 2-->8-linked oligo/polyKDN-containing glycan units attached O-glycosidically to Ser/Thr residues. Although little is known about the functional roles of these glycan chains, KDN-gp appears to form a model for further study on the function of cell surface receptor for sperm in fertilization.

Glomerular expression of type III and type IV collagens in benign nephrosclerosis: immunohistochemical and in situ hybridization study

The development of glomerular sclerosis in benign nephrosclerosis (BNS) was studied. We investigated the intraglomerular expression of type III and IV collagens and their mRNAs by immunohistochemistry and by the in situ hybridization method. Formalin-fixed paraffin sections from 28 patients with BNS and 10 control cases were stained by the avidin-biotin complex (ABC) method using monoclonal antibodies for human type III and IV collagens. In the course of the sclerotic process of the glomerulus in BNS, the glomerular staining intensity of type IV collagen increased. The strongest staining was observed in the glomerulus at the early sclerotic stage, and intensity decreased slightly at the later stages. Although type III collagen was absent in normal and nonsclerotic glomeruli, peripheral regions of the sclerotic glomeruli were positive at the early sclerotic stage. Later, type III collagen was diffusely observed in the completely hyalinized glomeruli. The expression of type III and type IV collagen mRNAs was detected in the glomeruli of BNS by the non-radioactive in situ hybridization method using thymine-thymine (T-T) dimerized synthetic oligonucleotides. The number of mRNA positive cells for type III and type IV collagens increased at the presclerotic and early sclerotic stages. But these cells gradually decreased in number as glomerular sclerosis developed. We concluded that type III collagen was presumably synthesized by the intraglomerular cells and may contribute to the development of glomerular sclerosis in BNS along with type IV collagen.

Effects of naftidrofuryl oxalate on microsphere-induced changes in acetylcholine and amino acid content of rat brain regions

Effects of naftidrofuryl oxalate (naftidrofuryl) on neurotransmitter, acetylcholine, and amino acid content of brain regions following microsphere-induced cerebral embolism were examined to elucidate its possible therapeutic effects on ischemic brain. Rats received 900 microspheres (48 microns in diameter) via the right internal carotid artery, followed by ligation of the right common carotid artery; and histological and biochemical alterations were examined on the 3rd, 5th, and 28th days after embolism. The embolism induced increases in triphenyltetrazolium chloride- (TTC)-unstained areas and decreases in acetylcholine, glutamate, aspartate, and gamma-aminobutyric acid (GABA) contents in the cerebral cortex, striatum, and hippocampus of the right hemisphere, suggesting that microsphere embolism causes severe damage to these brain regions. Hematoxylin-eosin staining of the right cortical sections after embolism showed degeneration and necrosis of nerve cells with chromatolytic nuclei and eosinophilic cytoplasm. Changes in neurotransmitters of the left hemisphere were relatively small. Treatment with naftidrofuryl of the embolized rats with stroke-like symptoms took place from postoperative day 1 to 28. Treatment resulted in a reduction in TTC-unstained areas, less morphological damage to cerebral cortex on the 3rd and 5th days, and an appreciable restoration of acetylcholine content of three brain regions of the right hemisphere throughout the experiment, but restoration of neurotransmitter amino acids was observed to a smaller degree. The results suggest that naftidrofuryl is capable of preventing the development of ischemia-induced, sustained damage to brain regions vulnerable to oxygen deficiency, particularly by improving impaired acetylcholine metabolism.

Potassium channel-opening and vasorelaxant profiles of a novel compound YM099 in rat isolated portal vein and rabbit isolated aorta

The potassium channel-opening and vasorelaxant profiles of YM099, a newly synthesized benzoxadiazol derivative K channel opener, were evaluated in vitro. In the rat isolated portal vein, YM099 and a benzopyran derivative K channel opener levcromakalim concentration-dependently inhibited the frequency of spontaneous rhythmic contractions, with IC50 values of 104 and 38 nM, respectively. In the rabbit isolated aorta, YM099 (10(-7)-3 x 10(-5) M) and levcromakalim (10(-7)-3 x 10(-5) M) also concentration-dependently relaxed the contractions induced by 20 mM KCl, but they were ineffective against the contractions induced by 50 mM KCl. These effects of YM099 and levcromakalim were competitively antagonized by a K channel blocker glibenclamide (10(-7)-3 x 10(-6) M). In the rabbit isolated aorta, YM099 (3 x 10(-8)-3 x 10(-6) M), but not the calcium antagonist nifedipine (10(-8)-3 x 10(-6) M), relaxed the contractions induced by norepinephrine (10(-6) M) or prostaglandin F2 alpha (3 x 10(-6) M). These vasorelaxant effects of YM099 were also antagonized by glibenclamide. In conclusion, YM099 is a potent vascular smooth muscle-relaxant agent and possesses a vasorelaxant effect different from that of nifedipine. These effects of YM099 may be mediated, like those of levcromakalim, by the opening of glibenclamide-sensitive K channels.

Chemo-occlusion for the treatment of liver cancer. A new technique using degradable starch microspheres

The use of particulate embolic agents combined with regional chemotherapy in the treatment of hepatocellular carcinoma and metastatic liver cancer has been widely investigated over the past decade. The rationale for the use of such agents is to provide vascular blockade, resulting in a reduced or halted blood flow. This increases the in situ time, tumour exposure and, thus, efficacy of any coadministered cytotoxic drug. Of all the embolic agents and techniques available, degradable starch microspheres (DSMs) are the agents that have been evaluated most extensively. DSMs are non-toxic, are readily degradable and provide temporary vascular occlusion. Phase II and III clinical trials have demonstrated the efficacy of DSM when coadministered with chemotherapeutic drugs (chemo-occlusion), as measured by tumour response. Indeed, compared with drug therapy alone, a significantly greater tumour response is associated with chemo-occlusion, for patients with either hepatocellular carcinoma or metastatic liver cancer. The use of combination or multi-modular therapies have, in recent years, been investigated. The therapeutic benefits associated with chemo-occlusion would suggest that this technique might have a potential application as an adjuvant, or neoadjuvant therapy, for example, in reducing tumour recurrence after surgical resection in hepatocellular carcinoma, or downstaging a tumour prior to surgical resection, respectively. Furthermore, comprehensive management of patients with liver metastases and potential extrahepatic involvement may well be achieved by a combination of DSM chemo-occlusion and systemic chemotherapy. Large, randomised trials are, however, required to access more fully the clinical benefits associated with chemo-occlusion, such as, quality of life, time to tumour progression and survival. Regionally occlusive techniques administered with cytotoxic agents have also shown potential in the treatment of alternative cancers, for example, breast and pancreatic carcinomas. However, these therapies require further evaluation.

In vivo tumor growth inhibition produced by a novel sulfonamide, E7010, against rodent and human tumors

The search for compounds active against solid tumors has led us to the discovery of a novel sulfonamide, E7010 (N-[2-[(4-hydroxyphenyl)amino]-3-pyridinyl]-4- methoxybenzenesulfonamide), which inhibits tubulin polymerization. When administered orally, E7010 showed good antitumor activity against various rodent tumors and human tumor xenografts. In tests on mouse tumor, E7010, administered in doses of 25-100 mg/kg daily for 8 days, inhibited the growth of colon 38 carcinoma inoculated s.c. in mice by 60-99%. E7010 was active against s.c. inoculated M5076 fibrosarcoma (75% tumor growth inhibition), s.c. inoculated Lewis lung carcinoma (84% increase in life span), and i.p. inoculated P388 leukemia (118% increase in life span). In a test on rat tumor, E7010 inhibited the growth of SST-2 mammary carcinoma inoculated s.c. in rats by 84%. In tests on s.c. inoculated human tumor xenografts, E7010, when administered orally, showed a broad spectrum of activity. E7010 inhibited the growth of: four kinds of gastric cancer, H-81, H-111, SC-2, and SC-6 by 60-78%; three kinds of colon cancer, H-143, COLO320DM, and WiDr by 58-83%; three kinds of lung cancer, LC-376, LC-6, and LX-1 by 63-82%; and two kinds of breast cancer, H-31 and MX-1 by 79-87%. In studies on drug-resistant P388 leukemia, E7010 was effective against vincristine-resistant P388, cisplatin-resistant P388, and 5-fluorouracil-resistant P388 sublines in mice. Because of its good activity against rodent tumors and human tumor xenografts, E7010 is currently undergoing Phase I clinical trials.

[Interleukin-2 (IL-2)]

Interleukin-2, a polypeptide lymphokine that induces proliferation of antigen- or mitogen-stimulated T cells, was first described as "T-cell growth factor" by Morgan et al. in 1976. IL-2 is one of several lymphocyte-produced messenger regulatory molecules that modulate immunocyte function. The main secretory source of IL-2 is the T-helper cell. In 1983, Taniguchi and colleagues isolated a human IL-2 complementary DNA clone from a high-producer Jurkat leukemic cell line, and established its nucleotide sequence. In 1984, Rosenberg et al. described the isolation of cDNA clones of the gene for IL-2 from the Jurkat cell line, its expression in Escherichia coli and its biological characteristics. The mature secreted protein contains 133 amino acids, constituting a calculated molecular weight of 15,420. Since the discovery of IL-2 and its T-cell growth-promoting activity, extensive research has revealed the complex nature of its immunologic effects, both in vitro and in vivo. The immunopotentiating activities, encouraging in vitro results, plus successful therapy of animal tumors in preclinical studies provided the rationale for investigation of IL-2 in patients with advanced malignancy and immunodeficiencies. The IL-2 receptor has been found to have an unexpected by unusual structure in that it is composed of two separate chains designated alpha (p75) and beta (p55). Recently, it has been discovered the 3rd gamma-chain by Sugamura et al. Clinical trials of IL-2 in patients with cancer have been done by many researchers. The clinical trials has reviewed briefly.

Structural studies of a novel type of pentaantennary large glycan unit in the fertilization-associated carbohydrate-rich glycopeptide isolated from the fertilized eggs of Oryzias latipes

In a previous report (Kitajima, K., Inoue, S., and Inoue, Y. (1989) Dev. Biol. 132, 544-553), we found the presence of a heavily glycosylated polyprotein, "H-hyosophorin," isolated from the unfertilized eggs of Oryzias latipes. We now report our detailed analysis of the structure of the N-glycan chain in L-hyosophorin, the smallest repeating unit of H-hyosophorin, which was isolated from the fertilized eggs of O. latipes and formed from H-hyosophorin upon fertilization. The N-glycan structures were defined by a combination of compositional analysis, methylation analysis, selective chemical degradation (i.e. mild methanolysis, periodate-Smith degradation, and hydrazinolysis-nitrous acid deamination), enzymatic (endo-beta-galactosidase, peptide:N-glycanase, and Newcastle disease virus sialidase) digestion, and instrumental analyses (one- and two-dimensional proton nuclear magnetic resonance spectroscopy and fast atom bombardment mass spectrometry) which revealed novel and unique features: (a) the presence of highly branched poly-N-acetylactosamino pentaantennary structures; (b) the presence of a beta-galactosylated Lewis X antigenic epitope, Gal beta 1-->4 Gal beta 1-->4 (Fuc alpha 1-->3) GlcNAc beta 1-->; (c) the presence of a beta-galactosylated sialyl Lewis X structure, Gal beta 1-->4 (Neu5Ac alpha 2-->3) Gal beta 1-->4(Fuc alpha 1-->3) GlcNAc beta 1-->; (d) the presence of Gal beta 1-->4 Gal beta 1--> and Gal beta 1--> 4Gal beta 1-->4Gal beta 1--> as the major and minor groupings, respectively; and (e) the presence of the branched Gal residues, -->4GlcNAc beta 1-->3(Gal beta 1-->4) Gal beta 1-->. This study represents the first detailed investigation regarding the nature of highly branched complex asparagine-linked pentaantennary glycans in glycoproteins. The unique expression of such bulky multiantennary glycan units on proteins could be essential during early embryogenesis.

[Antitumor activity of LY 188011, a new deoxycytidine analog, against human cancers xenografted into nude mice]

LY 188011 (gemcitabine hydrochloride) was evaluated for its antitumor effect in fifteen human tumors xenografted in nude mice from seven gastric, two colorectal, two breast, two lung and two liver cancer lines, in the latter four of which the results were compared with those obtained with mitomycin C. LY 188011 significantly reduced the volume of tumor xenografts in seven lines, including drug-resistant colorectal and lung cancer lines. The antitumor effect of LY 188011 was further confirmed by pathological observation. Moreover, LY 188011 has shown to be significantly more potent in two lung cancer models than mitomycin C. Administration of LY 188011 induced less side effect; early loss of body weight was observed in four lines out of fifteen tested. These data suggest that LY 188011 seemed to be an excellent candidate in clinical trials for the treatment of cancer.

Microcirculatory patterns in human pancreas: supplementary observations of vascular casts by scanning electron microscopy

The blood vascular bed of two human pancreata was replicated partially by arterial perfusion of intentionally reduced amounts of low viscosity methacrylate resin, to be observed with a scanning electron microscope. The findings were compared with those obtained from a pancreas replicated completely by a sufficient amount of resin. Complete replication confirmed our previous findings (MURAKAMI et al., 1992) that many exocrine lobules contained one or more endocrine islets, which preferentially issued insulo-acinar portal vessels continuous with the lobular capillaries. Incomplete replication demonstrated that the casting medium filled blood capillaries in the endocrine islets more promptly than those in the exocrine lobules and secretory ducts. Furthermore, islet-containing lobules allowed a more rapid resin flow to the exocrine tissue via the insulo-acinar portal route than did the lobules lacking an islet. Since the resin medium used had the viscosity of blood and was injected under physiological pressure, the results obtained by the incomplete arterial injections are believed to suggest the physiological state of blood flow in the pancreas.

Use of human leukocyte antigen-mismatched allogeneic lymphokine-activated killer cells and interleukin-2 in the adoptive immunotherapy of patients with malignancies

Clinical effects and side effects were studied in the adoptive immunotherapy of patients bearing malignant diseases using human leukocyte antigen (HLA)-mismatched allogeneic lymphokine-activated killer (LAK) cells. Allogeneic LAK cells were induced from peripheral blood lymphocytes (PBL) of normal donors by means of initial stimulation with pokeweed mitogen (PWM). Six of 15 patients applied in the adoptive immunotherapy showed clinical effects such as partial or complete regression of pulmonary metastasis, pleural effusion and primary tumor. All pulmonary metastatic lesions were eliminated in one case by this adoptive immunotherapy combined with chemotherapy. Generally toxic effects were chillness, fever and general fatigue which were reversible, and no allergic side effects occurred even though allogeneic LAK cells were injected frequently except one patient who showed preshock like symptom accompanied with leukocytopenia and continuous hypotension immediately after infusion but was finally rescued. In the patients who received more than 10(11) of allogeneic LAK cells, anti-HLA class I antibodies appeared without any evidence of autoantibody. However, immunological side effects were never experienced after injection of allogeneic LAK cells even when the anti-HLA class I antibodies appeared in the patients. Taken together, allogeneic LAK cells could be considered as alternative therapy for patients with malignancies who could not supply sufficient materials of autologous LAK cells.

Simultaneous dual myocardial imaging with iodine-123-beta-methyl iodophenyl-pentadecanoic acid (BMIPP) and thallium-201 in patients with coronary heart disease

To assess the clinical value of simultaneous dual myocardial imaging with iodine-123-beta-methyl-iodophenyl-pentadecanoic acid (123I-BMIPP) and thallium-201 (201Tl), myocardial imaging was performed at rest and during exercise in seven patients with coronary heart disease. When 123I-BMIPP and 201Tl images were compared, the initial exercise and resting images agreed 87% and 64%, respectively. In the initial resting images, the regional uptake of 123I-BMIPP was frequently less than that of 201Tl. The incidence of exercise-induced reversible defects by 201Tl in the Tl > BMIPP regions was significantly higher than that in the Tl = BMIPP regions (57% vs 4%, p < 0.01) and the incidence of coronary narrowing of more than 90% in the Tl > BMIPP regions was also significantly higher than that in the Tl = BMIPP regions (91% vs 38%, p < 0.01). In addition, this disparity (Tl > BMIPP) was found more frequently in regions with abnormal wall motion than in regions with normal wall motion (hypokinetic regions; 68%, severe hypokinetic or akinetic regions; 50%, vs normokinetic region; 4%, p < 0.01). In contrast, the uptake of 123I-BMIPP correlated closely with that of 201T1 in normal myocardium and the uptake of both 123I-BMIPP and 201Tl was severely reduced in myocardium with severe ischemia during exercise and prior infarction. These results indicate that dual myocardial imaging with 123I-BMIPP and 201Tl may provide a unique means of identifying patients with metabolically disturbed myocardium, such as hibernating and stunned myocardium.

[Phase I clinical study on new vinca alkaloid derivative, KW-2307 (vinorelbine). KW-2307 Study Group]

Phase I study on a new vinca alkaloid derivative, KW-2307(vinorelbine), was conducted by multiple institutions in 40 patients with a variety of malignant tumors. KW-2307 was given intravenously by single administration or by weekly repeated for 4 weeks (hereinafter as the repeated administration). The initial dose, 10 mg/m2(ln), was escalated to 35 mg/m2(3.5n) in single administration and to 30 mg/m2(3n) in the repeated administration. A total of 35 cases were eligible for evaluation, consisting of 18 cases in single administration group and 17 in the repeated group. Both of single and repeated administration caused leukopenia dose-dependently, and the dose limiting toxicity (DLT) was judged as leukopenia. The maximum tolerated dose (MTD) was 30 mg/m2 in single administration and 25 mg/m2 in the repeated administration provided that administration is made weekly for 4 consecutive weeks. As subjective and objective adverse effects, general fatigue, anorexia, constipation, phlebitis etc. were observed, but all of these symptoms were relatively mild and recoverable. Peripheral neuropathy were found in two cases and judged as Grade 1. In this phase I study, a tendency of the decrease in tumor size was seen in 3 cases; 2 of non-small cell lung cancer and 1 of breast cancer. The pharmacokinetics of KW-2307 in blood after single administration showed a triphasic disappearance pattern with half-life of about 20 to 60 hrs. The data of pharmacokinetics after repeated administration revealed no accumulation of this agent. The recommended dose for early phase II study was supposed to be 20 to 25 mg/m2/week.

[Cytokines]

The development of our understanding of the cytokines which began with a collection of barely believable activities in supernatants and extracts from various cell types and has now yielded a well-defined series of molecules with key roles in the control of immunity, infection, differentiation, embryogenesis, and growth is a remarkable and continuing story. Our current, incomplete, understanding of the cytokine network is based on the following observations; 1) Most cytokines are produced by more than one cell type. 2) Different cytokines interact with distinct receptors but can produce markedly overlapping biological effects. Some structurally different cytokines (e.g., IL-1 alpha and IL-1 beta) interact with a single receptor and therefore have identical effects. 3) Most cytokines have multiple biological actions. These actions are dependent on cell type and functional state and are modified by the other mediators to which a cell is simultaneously exposed. 4) A single agent (e.g., lipopolysaccharide or viruses) can induce several different cytokines within the same cell, suggesting the cytokine interaction is important. 5) Cytokines interact within the cytokine network by; (1) stimulating the production of other cytokines; (2) transmodulation of receptors for other cytokines; (3) enhancing or inhibiting the biological activity of other cytokines.

Abnormally shaped arteries in the intestine of children with Hirschsprung's disease: etiological considerations relating to ischemic theory

Abnormally shaped arteries were found in the intestines of 17 of 62 patients (27%) with Hirschsprung's disease. The histological characteristics of abnormal arteries included proliferation of collagen fibers and smooth muscle cells in the adventitia. The incidence of abnormal arteries in each type of aganglionosis was as follows: 25% (13 of 51) in short-segment aganglionosis; 0% (0 of 6) in long-segment aganglionosis; and 80% (4 of 5) in total-colon or extensive aganglionosis. The older the patients were at the time of resection, the higher the incidence of abnormal arteries (< 1 year old, 15%; 1-3 years old, 38%; > 3 years old, 75%). The abnormally shaped arteries were mostly located in the histological transitional zone. These findings suggest the following possibilities: (a) the craniocaudal migration of ganglion cells was interrupted by intestinal ischemia in the presence of abnormal arteries in utero; (b) an ischemic episode caused both the disappearance of neural cells and dysplasia of the artery; (c) the ganglion cells were destroyed by mild ischemia caused by the abnormal arteries; or (d) the tension caused by mechanical expansion resulted in a change in the vascular walls in the transitional zone.

Pharmacologic profiles of YM934, a novel potassium channel opener

Pharmacologic profiles of YM934, a newly synthesized 1,4-benzoxazin derivative K channel opener were evaluated in in vitro and in vivo experiments. In isolated rat portal vein, YM934 and a benzopyran derivative K channel opener lemakalim inhibited the frequency of spontaneous rhythmic contractions concentration dependently, with IC50 values of 14 and 38 nM, respectively. These inhibitory effects were competitively antagonized by glibenclamide (an ATP-sensitive K channel blocker; 10(-7)-3 x 10(-6) M). In isolated rabbit aorta, YM934 (10(-8)-10(-6) M) and lemakalim (10(-8)-10(-6) M) relaxed the contractions induced by 20 mM KCl concentration dependently but were ineffective against the contractions induced by 50 mM KCl. YM934 (10(-8)-3 x 10(-6) M) and lemakalim (3 x 10(-8)-10(-5) M), but not the calcium antagonist nifedipine, relaxed the contractions induced by norepinephrine (NE 10(-6) M) or prostaglandin F2 alpha (PGF2 alpha 3 x 10(-6) M) in the aorta. In pentobarbital-anesthetized dogs, YM934 (1-10 micrograms/kg intravenously, i.v.) dose-dependently increased coronary artery blood flow (CBF), and decreased total peripheral resistance (TPR) and mean blood pressure (MBP). YM934 selectively increased CBF, but had little effect on vertebral, carotid, mesenteric, renal and femoral artery BF. These vasodilatory effects of YM934 were antagonized by glibenclamide. YM934 is a potent K channel opener and possesses potent vasodilatory effects, with particularly pronounced effects on the coronary artery. These effects of YM934 may, like lemakalim, be mediated by opening of ATP-sensitive K channels.

Renal pathology in patients with reflux nephropathy. The turning point in irreversible renal disease

In reflux nephropathy both interstitial and glomerular damage advances with an increase in the scarring grade even in macroscopically normal regions. Based on various histologic findings, sclerosis and the enlargement of glomeruli rapidly accelerate between stages c-a and c-b, as shown by the combined Smellie's scarring grade of the bilateral kidneys. These two steep histologic changes in stage c-b are followed by a remarkable reduction in renal function (DTPA-GFR) and an increase in the amount of urinary protein. These clinicopathological changes thus suggest that hemodynamic changes or overloading in the functional remnant nephrons possibly start in stage c-a. It is also suggested that glomerular enlargement is an index of progressive disease in reflux nephropathy. Among our specimens, most cases of glomerular sclerosis were global while focal segmental glomerulosclerosis was very rare. These findings thus suggest that the global sclerosis observed in our specimens is clearly different from focal segmental glomerulosclerosis.