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Sakairi T, Hiromura K, Kaneko Y, Maeshima A, Hirato J, Nojima Y. Histological findings in the spleen affected by adult-onset Still's disease: a report of three cases. Clin Exp Rheumatol 2016; 34:566-567. [PMID: 26841850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 10/05/2015] [Indexed: 06/05/2023]
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Ikeuchi H, Hiromura K, Kayakabe K, Tshilela KA, Uchiyama K, Hamatani H, Sakairi T, Kaneko Y, Maeshima A, Nojima Y. Renal outcomes in mixed proliferative and membranous lupus nephritis (Class III/IV + V): A long-term observational study. Mod Rheumatol 2016; 26:908-913. [DOI: 10.3109/14397595.2016.1158896] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Hara R, Miyazawa H, Nishimura K, Momoi T, Nozawa T, Kikuchi M, Sakurai N, Kizawa T, Shimamura S, Yasuda S, Hiromura K, Sada KE, Kawaguchi Y, Tamura N, Takei S, Takasaki Y, Atsumi T, Mori M. A national survey on current use of mycophenolate mofetil for childhood-onset systemic lupus erythematosus in Japan. Mod Rheumatol 2015. [PMID: 26215483 DOI: 10.3109/14397595.2015.1077555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To conduct a national survey of systemic lupus erythematosus (SLE) patients treated with mycophenolate mofetil (MMF). Based on current information on the use of MMF, we aimed to evaluate its efficacy and safety for childhood-onset (c-) SLE. TARGET We evaluated 115 patients by questionnaire on MMF use for c-SLE in medical facilities specializing in pediatric rheumatic and renal diseases. RESULTS Average age at SLE onset was 10.6 (range, 2-15) years; average age at the time of starting MMF was 12.3 (range, 2-15) years. Average dose per body surface area was 1,059.3 mg/m(2)/day. Corticosteroid dosing was 20.9 mg/day before treatment but 7.7 mg/day after treatment. Laboratory values before and after MMF treatment were as follows: C3 increased from 67.0 to 84.9 mg/dl (p < 0.001), C4 increased from 10.2 to 15.1 mg/dl (p < 0.001), and anti-DNA antibody decreased from 154.2 to 18.4 IU/ml (p < 0.001). 24 adverse events in 21 cases were reported, but MMF was not discontinued in any. CONCLUSIONS The amount of MMF for c-SLE in Japan is similar to the standard dose in other countries. Reduction of corticosteroid dose and improvement of laboratory values represent efficacy of MMF. The side effects recorded here indicated tolerability of the drug.
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Nakasatomi M, Maeshima A, Mishima K, Ikeuchi H, Sakairi T, Kaneko Y, Hiromura K, Nojima Y. Novel approach for the detection of tubular cell migration into the interstitium during renal fibrosis in rats. FIBROGENESIS & TISSUE REPAIR 2015; 8:12. [PMID: 26161140 PMCID: PMC4496823 DOI: 10.1186/s13069-015-0030-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 06/30/2015] [Indexed: 01/10/2023]
Abstract
Background The process of epithelial-mesenchymal transition (EMT), which is generally defined by phenotypic changes of injured tubules such as loss of epithelial markers or acquisition of mesenchymal markers, implies various activating steps, including proliferation, migration, and ability to produce extracellular matrix proteins. We established here a novel approach for the detection of tubular cell migration into the interstitium during renal fibrosis in vivo. Results Using an osmotic pump, bromodeoxyuridine (BrdU) was continuously given to 7-week-old Wistar rats for 4 weeks, and BrdU-positive cells were detected by immunostaining. BrdU-positive cells were present in aquaporin-1-positive proximal tubules, but not in the interstitium of BrdU-treated rat kidneys. After unilateral ureteral obstruction (UUO), some BrdU-positive tubular cells protruded from the basement membrane and migrated into the interstitium. Interstitial BrdU-positive cells were co-localized with alpha-smooth muscle actin, fibroblast specific protein-1, vimentin, and type I collagen, but not with CD68 or CD3. No BrdU-positive cells were observed in the interstitium of sham-operated kidneys. The number of BrdU-positive cells migrating into the interstitium significantly increased and peaked at 8 days after UUO. Conclusions Long-term BrdU labeling marked some of the proximal tubular cells and enabled us to detect tubular cell migration into the interstitium after UUO. This simple method might be useful to detect EMT in vivo.
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Tshilela KA, Ikeuchi H, Matsumoto T, Kuroiwa T, Sakurai N, Sakairi T, Kaneko Y, Maeshima A, Hiromura K, Nojima Y. Glomerular cytokine expression in murine lupus nephritis. Clin Exp Nephrol 2015; 20:23-9. [PMID: 25985839 DOI: 10.1007/s10157-015-1123-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2015] [Accepted: 05/07/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Aberrant expression of T helper cell (Th) cytokines is believed to play a central role in the pathogenesis of systemic lupus erythematosus (SLE). While the glomerulus is one of the major targets of lupus inflammation, little is known about the cytokine expression in glomeruli. The current study aimed to explore the profiles of Th cytokine gene expressions in isolated glomeruli of lupus-prone mice. METHODS Glomeruli were purified from lupus-prone MRL/lpr mice using the magnetic microbead method. Expressions of cytokine genes representing the Th subset and FoxP3 were examined using real-time polymerase chain reaction. Serum levels of these cytokines were also measured by enzyme-linked immunosorbent assay. MRL/n mice were used as controls. Histologic glomerular damages were scored semiquantitatively. To examine the role of TNF-α in glomerular damage, we administered etanercept, a TNF-α antagonist, into the subjects. RESULTS Glomerular gene expressions of TNF-α in lpr mice increased with week postpartum and reached statistically significant levels at 16 weeks compared with those of the glomeruli from control mice. Expressions of IFN-γ, IL-4 and FoxP3 also increased, but the difference was not significant. There was a significant increase in serum levels of TNF-α, IFN-γ, and IL-17 and decrease in those of IL-4. Among the genes examined, TNF-α significantly correlated with glomerular damage score. Administration of etanercept did not affect glomerular cytokine expressions or proteinuria and failed to ameliorate histologic glomerular damages. CONCLUSION Our data suggest that Th1 cytokines, especially TNF-α, are dominantly expressed in the glomeruli of lupus-prone mice, but its pathophysiological role remains unclear.
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Yasuda S, Atsumi T, Shimamura S, Ono K, Hiromura K, Sada K, Mori M, Takei S, Kawaguchi Y, Tamura N, Takasaki Y. Surveillance for the use of mycophenolate mofetil for adult patients with lupus nephritis in Japan. Mod Rheumatol 2015; 25:854-7. [DOI: 10.3109/14397595.2015.1031444] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Motohashi R, Ikeuchi H, Hiromura K, Ohishi Y, Sakurai N, Sakairi T, Kaneko Y, Maeshima A, Nojima Y. Two cases of ulcerative colitis developing in rheumatoid arthritis patients during abatacept therapy. Scand J Gastroenterol 2014; 49:1270-1. [PMID: 25115461 DOI: 10.3109/00365521.2014.946087] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Hamatani H, Hiromura K, Sakairi T, Takahashi S, Watanabe M, Maeshima A, Ohse T, Pippin JW, Shankland SJ, Nojima Y. Expression of a novel stress-inducible protein, sestrin 2, in rat glomerular parietal epithelial cells. Am J Physiol Renal Physiol 2014; 307:F708-17. [PMID: 25056347 DOI: 10.1152/ajprenal.00625.2013] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Sestrin 2, initially identified as a p53 target protein, accumulates in cells exposed to stress and inhibits mammalian target of rapamycin (mTOR) signaling. In normal rat kidneys, sestrin 2 was selectively expressed in parietal epithelial cells (PECs), identified by the marker protein gene product 9.5. In adriamycin nephropathy, sestrin 2 expression decreased in PECs on day 14, together with increased expression of phosphorylated S6 ribosomal protein (P-S6RP), a downstream target of mTOR. Sestrin 2 expression was markedly decreased on day 42, coinciding with glomerulosclerosis and severe periglomerular fibrosis. In puromycin aminonucleoside nephropathy, decreased sestrin 2 expression, increased P-S6RP expression, and periglomerular fibrosis were observed on day 9, when massive proteinuria developed. These changes were transient and nearly normalized by day 28. In crescentic glomerulonephritis, sestrin 2 expression was not detected in cellular crescents, whereas P-S6RP increased. In conditionally immortalized cultured PECs, the forced downregulation of sestrin 2 by short hairpin RNA resulted in increased expression of P-S6RP and increased apoptosis. These data suggest that sestrin 2 is involved in PEC homeostasis by regulating the activity of mTOR. In addition, sestrin 2 could be a novel marker of PECs, and decreased expression of sestrin 2 might be a marker of PEC injury.
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Tshilela K, Ikeuchi H, Hiromura K, Moxhizuki K, Kayakabe K, Sakurai N, Sakairi T, Kaneko Y, Maeshima A, Nojima Y. AB0521 Repeat Biopsy in Lupus Nephritis: A Single Center Analysis in Japan:. Ann Rheum Dis 2014. [DOI: 10.1136/annrheumdis-2014-eular.4586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Sakairi T, Okabe S, Ohishi Y, Sakurai N, Ikeuchi H, Kaneko Y, Maeshima A, Hiromura K, Nojima Y. THU0406 Histological Findings of Spleen Affected by Adult Onset Still's Disease: an Analysis of 3 Cases. Ann Rheum Dis 2014. [DOI: 10.1136/annrheumdis-2014-eular.1443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Motohashi R, Ikeuchi H, Kayakabe K, Sakurai N, Kaneko Y, Maeshima A, Hiromura K, Nojima Y. AB0934 Clinical Features and Prognosis of Adult-Onset Still's Disease: S Single Center Study in Japan: Table 1. Ann Rheum Dis 2014. [DOI: 10.1136/annrheumdis-2014-eular.4939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Sakairi T, Okabe S, Hiromura K, Motegi S, Sakurai N, Ikeuchi H, Kaneko Y, Maeshima A, Hirato J, Nojima Y. A case of ANCA-negative renal small-vessel vasculitis with tubulointerstitial infiltration of IgG4-positive plasma cells. Mod Rheumatol 2014; 26:780-3. [PMID: 24842479 DOI: 10.3109/14397595.2014.915510] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
A 62-year-old male patient presented with progressive renal dysfunction for 2 months. He had elevated serum C-reactive protein and IgG4 levels with absence of anti-neutrophil cytoplasmic antibodies. A renal biopsy showed severe tubulointerstitial nephritis (TIN) with extensive infiltration of IgG4-positive plasma cells, suggesting a diagnosis of IgG4-related kidney disease (IgG4-RKD). However, the identification of a few crescentic glomeruli and necrotizing vasculitis of an interlobular artery lead to a diagnosis of renal small-vessel vasculitis. This case indicates that a careful examination is required to distinguish between IgG4-RKD and TIN caused by renal small-vessel vasculitis.
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Takahashi S, Hiromura K, Sakurai N, Matsumoto T, Ikeuchi H, Maeshima A, Kaneko Y, Kuroiwa T, Nojima Y. Efficacy and safety of tacrolimus for induction therapy in patients with active lupus nephritis. Mod Rheumatol 2014. [DOI: 10.3109/s10165-010-0398-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Umemoto A, Ikeuchi H, Hiromura K, Hamatani H, Sakurai N, Sakairi T, Matsumoto T, Maeshima A, Kuroiwa T, Nojima Y. Hydronephrosis caused by a relapse of granulomatosis with polyangiitis (Wegener’s). Mod Rheumatol 2014. [DOI: 10.3109/s10165-011-0554-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Hiromura K, Ikeuchi H, Kayakabe K, Nojima Y. [Lupus nephritis and nephrotic syndrome: diagnosis and treatment]. NIHON JINZO GAKKAI SHI 2014; 56:510-517. [PMID: 24956883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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Ikeuchi H, Hiromura K, Takahashi S, Mishima K, Sakurai N, Sakairi T, Kaneko Y, Maeshima A, Kuroiwa T, Nojima Y. Efficacy and safety of multi-target therapy using a combination of tacrolimus, mycophenolate mofetil and a steroid in patients with active lupus nephritis. Mod Rheumatol 2013; 24:618-25. [DOI: 10.3109/14397595.2013.844397] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Hiromura K. [Serious organ damage and intractable clinical conditions in rheumatic and connective tissue disease--progress in pathophysiology and treatment. Topics: I. Damage to important organs whose early treatment makes a big difference; 4. Kidney]. ACTA ACUST UNITED AC 2013; 102:2558-66. [PMID: 24400535 DOI: 10.2169/naika.102.2558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Takahashi S, Tomioka M, Hiromura K, Sakairi T, Hamatani H, Watanabe M, Ikeuchi H, Kaneko Y, Maeshima A, Aoki T, Ohnishi H, Matozaki T, Nojima Y. SIRPα signaling regulates podocyte structure and function. Am J Physiol Renal Physiol 2013; 305:F861-70. [PMID: 23842779 DOI: 10.1152/ajprenal.00597.2012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Signal-regulatory protein-α (SIRPα) is a transmembrane protein that contains tyrosine phosphorylation sites in its cytoplasmic region; two tyrosine phosphatases, SHP-1 and SHP-2, bind to these sites in a phosphorylation-dependent manner and transduce multiple intracellular signals. Recently, SIRPα was identified as one of the major tyrosine-phosphorylated proteins in the glomeruli and found to be expressed in podocytes. In the present study, we examined the role of SIRPα expression in podocytes using knockin mice (C57BL/6 background) expressing mutant SIRPα that lacks a cytoplasmic region (SIRPα-mutant mice). Light microscopic examination revealed no apparent morphological abnormalities in the kidneys of the SIRPα-mutant mice. On the other hand, electron microscopic examination revealed abnormal podocytes with irregular major processes and wider and flattened foot processes in the SIRPα-mutant mice compared with their wild-type counterparts. Significantly impaired renal functions and slight albuminuria were demonstrated in the SIRPα-mutant mice. In addition, adriamycin injection induced massive albuminuria together with focal glomerulosclerosis in the SIRPα-mutant mice, while their wild-type counterparts were resistant to adriamycin-induced nephropathy. These data demonstrate that SIRPα is involved in the regulation of podocyte structure and function as a filtration barrier under both physiological and pathological conditions.
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Kayakabe K, Ikeuchi H, Hiromura K, Kadiombo AT, Sakurai N, Sakairi T, Kaneko Y, Maeshima A, Nojima Y. FRI0278 Risk factors for mortality in patients with lupus nephritis: a long-term study at a single center in japan. Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2013-eular.1405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Sakurai N, Hidekazu I, Kayakabe K, Sakairi T, Kaneko Y, Maeshima A, Hiromura K, Nojima Y. SAT0072 Frequency of interferon-gamma-positive TH17 (TH17-1) cells is up-regulated in synovial fluids in patients with rheumatoid arthritis. Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2012-eular.3019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Takahashi S, Hiromura K, Tsukida M, Ohishi Y, Hamatani H, Sakurai N, Sakairi T, Ikeuchi H, Kaneko Y, Maeshima A, Kuroiwa T, Yokoo H, Aoki T, Nagata M, Nojima Y. Nephrotic syndrome caused by immune-mediated acquired LCAT deficiency. J Am Soc Nephrol 2013; 24:1305-12. [PMID: 23620397 DOI: 10.1681/asn.2012090913] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Lecithin-cholesterol acyltransferase (LCAT) is an enzyme involved in maintaining cholesterol homeostasis. In familial LCAT deficiency (FLD), abnormal lipid deposition causes renal injury and nephrotic syndrome, frequently progressing to ESRD. Here, we describe a 63-year-old Japanese woman with no family history of renal disease who presented with nephrotic syndrome. The laboratory data revealed an extremely low level of serum HDL and undetectable serum LCAT activity. Renal biopsy showed glomerular lipid deposition with prominent accumulation of foam cells, similar to the histologic findings of FLD. In addition, she had subepithelial electron-dense deposits compatible with membranous nephropathy, which are not typical of FLD. A mixing test and coimmunoprecipitation study demonstrated the presence of an inhibitory anti-LCAT antibody in the patient's serum. Immunohistochemistry and immunofluorescence detected LCAT along parts of the glomerular capillary walls, suggesting that LCAT was an antigen responsible for the membranous nephropathy. Treatment with steroids resulted in complete remission of the nephrotic syndrome, normalization of serum LCAT activity and HDL level, and disappearance of foam cell accumulation in renal tissue. In summary, inhibitory anti-LCAT antibody can lead to glomerular lesions similar to those observed in FLD.
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Mishima K, Maeshima A, Miya M, Sakurai N, Ikeuchi H, Hiromura K, Nojima Y. Involvement of N-type Ca(2+) channels in the fibrotic process of the kidney in rats. Am J Physiol Renal Physiol 2013; 304:F665-73. [PMID: 23324177 DOI: 10.1152/ajprenal.00561.2012] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
N-type Ca(2+) channels are densely distributed in sympathetic nerves that innervate renal tubules. However, the role of N-type Ca(2+) channels in renal fibrosis remains unknown. To address this issue, we examined the difference between the effects of amlodipine (an L-type Ca(2+) channel blocker) and cilnidipine (a dual L/N-type Ca(2+) channel blocker) on fibrotic changes using a rat unilateral ureteral obstruction (UUO) model. The expression of both L-type and N-type Ca(2+) channels was significantly upregulated in UUO kidneys compared with that in contralateral kidneys. There were no significant differences in mean blood pressure among the rats tested. Both amlodipine and cilnidipine significantly attenuated fibrotic changes in UUO kidneys. The antifibrotic effect of cilnidipine was more potent than that of amlodipine. Amlodipine as well as cilnidipine reduced type III collagen deposition, α-smooth muscle actin (α-SMA) expression, and interstitial cell proliferation. In addition, cilnidipine significantly reduced deposition of type I collagen and macrophage infiltration in UUO kidneys. With the use of in vivo bromodeoxyuridine labeling, label-retaining cells (LRCs) were identified as a population of tubular cells that participate in epithelial-mesenchymal transition after UUO. Some LRCs migrated into the interstitium, expressed α-SMA and vimentin, and produced several extracellular matrixes in UUO kidneys. The number of interstitial LRCs was significantly decreased by cilnidipine but not amlodipine. These data suggest that N-type Ca(2+) channels contribute to multiple steps of renal fibrosis, and its blockade may thus be a useful therapeutic approach for prevention of renal fibrosis.
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Nagamine A, Takenaka M, Aomori T, Okada Y, Hiromura K, Nojima Y, Araki T, Nakamura T, Yamamoto K. Effect of genetic polymorphisms on effectiveness of low-dose azathioprine in Japanese patients with systemic lupus erythematosus. Am J Health Syst Pharm 2012; 69:2072-8. [DOI: 10.2146/ajhp120179] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
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Matsui A, Ikeuchi H, Shimizu A, Takahashi S, Mishima K, Sakurai N, Sakairi T, Kaneko Y, Maeshima A, Hiromura K, Nojima Y. [Case report: posterior reversible encephalopathy syndrome and scleroderma renal crisis developed in a patient with overlap syndrome after treatment with high-dose steroids and tacrolimus]. ACTA ACUST UNITED AC 2012; 101:2051-4. [PMID: 22897011 DOI: 10.2169/naika.101.2051] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Fujita Y, Araki T, Okada Y, Aomori T, Shimizu R, Tomizawa T, Hiromura K, Nojima Y, Nakamura T, Yamamoto K. Analysis of cytochrome P450 gene polymorphism in a lupus nephritis patient in whom tacrolimus blood concentration was markedly elevated after administration of azole antifungal agents. J Clin Pharm Ther 2012; 38:74-6. [PMID: 22971159 DOI: 10.1111/jcpt.12004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Both itraconazole (ITCZ) and voriconazole (VCZ) are potent inhibitors of cytochrome P450 (CYP) 3A, and their effects have been reported to be equal. However, ITCZ is metabolized by CYP3A, whereas VCZ is mainly metabolized by CYP2C9 and CYP2C19 and only partially by CYP3A. We experienced the case of a patient who showed a 5-fold increase in trough levels of tacrolimus (FK) level after switching from ITCZ to VCZ. Our objective is to discuss the mechanism of the increase drug-drug interaction in terms of serum concentration of the azole drugs and patient pharmacogenomics. CASE SUMMARY A 53-year-old woman was treated with FK (1 mg/day) for lupus nephritis. Because fungal infection was suspected, she received ITCZ (100 mg/day). When ITCZ was replaced with VCZ (400 mg/day), the blood concentration of FK increased markedly from 6·1 to 34·2 ng/mL. During coadministration with FK, the levels of ITCZ and VCZ were 135·5 ng/mL and 5·5 μg/mL, respectively, with the VCZ level around 3-fold higher than the previously reported level (1·4-1·8 μg/mL). Her CYP genotypes were CYP2C19*1/*2, CYP3A4*1/*1 and CYP3A5*3/*3. WHAT IS NEW AND CONCLUSION The patient was a CYP2C19 intermediate metabolizer (IM) and deficient in CYP3A5. The increase in plasma VCZ level appears to have been at least in part, associated with the CYP2C19 IM phenotype. One possible explanation for the marked increase in blood FK concentration was increased inhibition of CYP3A because of the impaired metabolism and subsequent increased plasma concentration of VCZ. This case shows that the severity of drug interactions may be influenced by metabolic gene polymorphism.
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