Charge selective function in childhood glomerular diseases

The charge selectivity (CS) function in human renal disease has not been unequivocally demonstrated to date. However, the clearance ratio of IgA to IgG may be theoretically useful in estimating CS in humans, since IgA and IgG have similar sizes and tertiary structures, but distinct isoelectric points (3.5-5.5 [IgA] and 4.5-9.0 [IgG]), and Stokes-Einstein radius: 61 A (IgA) and 49-60 A (IgG). Two-dimensional electrophoresis with the following immunoblotting revealed that the considerably anionic portion (isoelectric points [pI] <4.0) of IgA, visible in serum, was absent in the urine in steroid-sensitive nephrotic syndrome (SSNS) but present in the same during IgA nephropathy (IgAN) and membranoproliferative glomerulonephritis (MPGN). A latex assay revealed the CS index (CSI) was significantly low in patients with podocyte disease (group A), including SSNS, focal and segmental glomerulosclerosis (FSGS) and Finnish-type congenital nephrotic syndrome (FCNS), but high in those with Alport syndrome (AS), IgAN, Henoch-Schönlein purpura nephritis (HSPN), and MPGN (group B). The linear regression analysis of the IgA size selectivity index (IgA SSI; clearance ratio of IgA to transferrin) and SSI (clearance ratio of IgG to transferrin), which represents the clearance ratio of IgA to IgG referring to the transferrin clearance, revealed the influence of the charge more accurately. Indeed, the slope of the regression lines of IgA SSI (y) to SSI (x) were concluded to be y = 0.39x (group A) and y = 1.05x (group B), respectively. These results suggested that the charge selective barrier among podocyte diseases (group A) is preserved to some degree, but lost in cases of nephritis and AS (group B).

Predictors of tumour involvement in remaining axillary lymph nodes of breast cancer patients with positive sentinel lymph node

AIMS

To characterize the various clinicopathologic features in cases of breast cancer with positive sentinel lymph nodes (SLNs), in order to determine factors that might help in predicting the involvement of the non-SLNs.

METHODS

A retrospective database review was performed of 726 breast cancer patients with stage 0-II, in whom SLNs were successfully identified. One hundred eighty-five of these patients showed positive SLNs, and subsequently underwent axillary lymph node dissection (ALND). These cases were divided into two groups based on the presence or absence of metastases in the non-SLNs, i.e. positive non-SLNs (NSLN+; 81 cases) and negative non-SLNs (NSLN-; 104 cases).

RESULTS

Multivariate analysis revealed that a larger size of the primary tumour (>2.0cm), presence of lymphatic invasion, larger size of the largest SLN metastasis (>2mm), and a 100% metastatic rate in the SLNs (number of positive SLNs/number of harvested SLNs) were significantly associated with NSLN+. Among the cases in which all the four factors were present, 73% (30/41) were found to have NSLN+.

CONCLUSION

We found four independent predictors in relation to non-SLN metastasis. Although these factors might be useful for determining the need of additional ALND, it would seem that even the presence of all of these four factors in combination may be insufficient to safely omit ALND. Thus, until further evidence is accumulated from the results of large clinical trials, ALND would still be recommended for patients with SLN metastasis.

[Sequential combined liver-kidney transplantation for a one-year-old boy with infantile primary hyperoxaluria type 1]

We present the case of a one-year-old male patient with infantile primary hyperoxaluria type 1 (PH1). The patient visited hospital because of growth delay and poor feeding when he was six months old, and was diagnosed as PH1 with chronic renal failure. He underwent peritoneal dialysis until receiving a living-related liver transplantation when he was seventeen months old, and after the operation, underwent hemodialysis or hemodiafiltration four times per week. Six months after the liver transplantation, his serum oxalate level decreased to around 20 micromol/l and a living-related kidney transplantation was successfully performed. Nine months have passed since the kidney transplantation, and the patient's liver and kidney functions have been good and his growth and development much better than before the sequential liver and kidney transplantation. However, his serum and urine oxalate levels remained high and he has required high dose hydration to prevent deposition of calcium oxalate crystals in his grafted kidney. The key-points for treating infantile PHI patients are summarized as follows; 1) make a precise diagnosis as soon as possible, 2) perform a combined liver-kidney transplantation successfully, 3) conduct careful monitoring of the serum and urine oxalate levels and continue adequate hydration after kidney transplantation until the serum and urine oxalate levels normalize. Furthermore, cooperation between the medical staff and the patient's family seems to be essential.

Analysis of NPHS1, NPHS2, ACTN4, and WT1 in Japanese patients with congenital nephrotic syndrome

BACKGROUND

Congenital nephrotic syndrome (CNS) causes significant renal failure, and is classified into two types: (1) Finnish type; and (2) other, including diffuse mesangial sclerosis. Mutations of NPHS1 and NPHS2, which encode the slit diaphragm components nephrin and podocin, cause CNS and autosomal-recessive familial steroid-resistant nephrotic syndrome, respectively. Most patients with Finnish-type CNS in Europe and the United States have NPHS1 mutations. However, NPHS2 mutations have been detected in some cases. Mutations in ACTN4, encoding alpha-actinin-4, cause an autosomal-dominant focal segmental glomerulosclerosis. alpha-actinin-4 stabilizes the podocyte cytoskeleton structure, connecting with actin filaments. WT1 mutations, causing Wilm's tumor, have been demonstrated in some CNS patients with diffuse mesangial sclerosis. Systematic investigation of genes for CNS in Japan has never been performed.

METHODS

To clarify the role of mutations in these four genes, we used polymerase chain reaction (PCR) and direct sequencing to investigate all exons and exon-intron boundaries for these genes in 13 unrelated CNS patients from regional pediatric kidney disease centers in Japan.

RESULTS

A novel homozygous nonsense mutation of NPHS1, E246X in exon 7, and a novel homozygous deletion mutation of NPHS1, 2156_2163del in exon 16 were detected in one patient each. A novel homozygous nonsense mutation of NPHS2, R196X in exon 5, was found in one patient, and the same heterozygous nonsense mutation was detected in another. No ACTN4 or WT1 mutations were detected.

CONCLUSION

These studies demonstrate that mutation of NPHS1 is not a major cause of CNS in Japanese patients, and that mutation of NPHS2 can be responsible for CNS in this population.

Epitope analysis of myeloperoxidase-specific antineutrophil cytoplasmic autoantibodies (MPO-ANCA) in childhood onset Graves’ disease treated with propylthiouracil

AIM

This study aimed to elucidate the relationship between epitope profiles and clinical manifestations of patients with myeloperoxidase antineutrophil cytoplasmic autoantibodies-(MPO-ANCA) positive childhood onset Graves' disease treated with propylthiouracil (PTU).

METHODS

Sixteen patients were studied. The patients were grouped into ten without clinical vasculitis and nephritis (non-vasculitis group) and six with biopsy-proven pauci-immune necrotizing crescentic glomerulonephritis (vasculitis group). Epitope analysis was performed on serum samples by an enzyme-linked immunosorbent assay (ELISA) using a panel of recombinant deletion mutants of MPO.

RESULTS

The high frequency sites were region upstream of Met341 (Ha region) near the N-terminus of the heavy chain, and regions downstream of Gly598 (Hf and Hg regions) near the C-terminus. Most patients in the non-vasculitis group had polyclonal MPO-ANCA recognizing both the above linear sites and other epitope sites of the heavy chain of MPO. Only one of ten patients in the non-vasculitis group, and four of six patients in the vasculitis group had MPO-ANCA recognizing only the linear sites of the heavy chain of the MPO molecule (Ha, Hf and/or Hg). Of the four patients in the vasculitis group, two had nephritis, like rapidly progressive glomerulonephritis and one had alveolar hemorrhage.

CONCLUSION

These findings suggest that most patients with childhood onset Graves' disease treated with PTU who manifest no vasculitis have polyclonal MPO-ANCA recognizing both the linear and other epitope sites of the heavy chain of MPO. However, some patients who develop nephritis have MPO-ANCA recognizing only the linear sites of the heavy chain of MPO. This clonality of MPO-ANCA may be a risk factor that induces clinical vasculitis and nephritis in patients treated with PTU. Therefore, patients exposed to PTU should be monitored for MPO-ANCA level and epitopes.

Primary tumour-vessel tumour-nodal tumour classification for patients with invasive ductal carcinoma of the breast

There are many studies that show biological differences between invasive ductal carcinoma (IDC) with and without nodal metastasis, but no prognostic classification taking into consideration any biological differences between them is currently available. We previously investigated the histological characteristics that play an important role in tumour progression of IDCs according to their nodal status, and a new prognostic histological classification, the primary tumour–vessel tumour–nodal tumour (PVN) classification, was devised based on the histological characteristics of IDCs with and without nodal metastasis. Multivariate analyses using the Cox proportional hazard regression models were used to compare the ability of the PVN classification to predict tumour recurrence and death in 393 IDC patients based on the following histological classifications: (1) the pTNM classification, (2) the Nottingham Prognostic Index, (3) the modified Nottingham Prognostic Index, and (4) the histologic grade. In IDCs without nodal metastasis, only the PVN classification significantly increased the hazard rates (HRs) of tumour recurrence and death (P<0.05), independent of the hormone receptor status. Similarly, in IDCs with nodal metastases, only the PVN classification significantly increased the HRs of tumour recurrence and death (P<0.05), independent of the hormone receptor status. We conclude that the PVN prognostic histological classification is the best classification available for IDC of the breast.

Two cases of schwannoma with marked cystic changes

We report two cases of schwannoma displaying marked cystic changes; one in the temporalis muscle and one in the submandibular space. The first patient, a 44-year-old male, presented after complaining of a swelling rapidly increasing in size in the left temporal region. Computed tomography (CT) indicated a low-density area surrounded by soft tissue. Magnetic resonance imaging (MRI) revealed signal hypointensity on T1 weighted imaging and strong signal hyperintensity on T2 weighted imaging. The extirpated tumour specimen measured 58 mm x 58 mm x 30 mm. Histopathological examination identified schwannoma, comprising spindle cell proliferation in a palisading pattern with obvious cystic changes. The second case involved a 46-year-old female who presented with swelling of the right submandibular region. Panoramic radiography and lateral oblique mandible projection, which were used together with conventional sialography of the submandibular gland, revealed the so-called "ball in hand" appearance of the submandibular gland, and contrast-enhanced CT identified a lesion of 30 mm diameter with a well-defined annular margin and homogeneous low-density near the tumour centre. Benign pleomorphic adenoma was suspected, but histopathological examination identified schwannoma, predominantly comprising Antoni B type tissue.

A boy with Japanese Dent's disease exhibiting abnormal calcium metabolism and osseous disorder of the spine: defective megalin expression at the brushborder of renal proximal tubules

We encountered a 16-year-old boy with Japanese Dent's disease who exhibited renal insufficiency and an osseous disorder of the spine. Proteinuria first was noted at the age of 2 years. At 13 years, the patient underwent analysis of the CLCN5 gene, which identified missense mutation (I524K) in exon 10. During follow-up, a marked increase in urinary beta2-microglobulin was associated with mild deterioration of renal function. At the age of 15 years, hypocalcemia (7.5 mg/dl) accompanied by an increased plasma concentration of alkaline phosphatase was first detected. At that time, plasma concentration of 25(OH)D3 and 1'alpha25(OH)2D3 were low accompanied by a high plasma parathyroid hormone concentration. A renal biopsy specimen revealed tubulointerstitial alterations including mononuclear cell infiltration, partial fibrosis and focal glomerular sclerosis. Immunofluorescence revealed weak, discontinuous staining of megalin along the brushborder of renal proximal tubules. Western blotting demonstrated decreased urinary excretion of megalin. Thus, clinical manifestations and prognosis may vary in Japanese Dent's disease. Reduced megalin expression may have disturbed calcium homeostasis, leading to osseous disorder in our patient.

The diagnostic value of serum concentrations of 2-(alpha-mannopyranosyl)-L-tryptophan for normal renal function

BACKGROUND

We have previously reported that the serum concentration of 2-(alpha-mannopyranosyl)-L-tryptophan (MPT), tryptophan glycoconjugate, is a more accurate measure of renal function than that of serum creatinine concentration. The aim of the present study was to compare the diagnostic value of serum concentrations of MPT and creatinine as a measure of normal renal function.

METHODS

A total of 156 subjects with serum creatinine concentration < or =1.60 mg/dL aged 0 to 88 years were recruited. Serum concentrations of MPT and creatinine, and creatinine clearance calculated by Cockcroft-Galt formula were determined. A diagnostic accuracy of serum concentrations of MPT and creatinine for normal renal function was analyzed by using receiver-operating characteristics (ROC) curves. In 82 subjects with normal renal function defined as calculated creatinine clearance > or =80 mL/min (aged 6 to 68 years), the correlations between age and/or urinary creatinine excretion, which is related to muscle mass, and serum concentrations of MPT or creatinine, were determined.

RESULTS

In the ROC curve, the area under the curve (AUC) in serum MPT concentration was significantly greater than that of creatinine (0.855 versus 0.800, respectively, P < 0.001) and the cut-off levels associated with the greatest diagnostic accuracy were 90 ng/mL for serum MPT concentration and 0.70 mg/dL for serum creatinine concentration. The sensitivity, specificity, and positive and negative predictive values were 69.5%, 85.1%, 83.8%, and 71.6% for serum MPT concentration, and 53.7%, 81.1%, 75.9%, and 61.2% for serum creatinine concentration. A close correlation existed between serum creatinine concentration and age (r= 0.798, P < 0.0001) in 23 subjects aged 20 years or younger. Conversely, serum MPT concentration remained unchanged regardless of age (r=-0.135, P= 0.228). Furthermore, a close correlation existed between serum creatinine concentration and urinary creatinine excretion (r= 0.817, P < 0.0001), but not between serum MPT concentration and urinary creatinine excretion (r= 0.082, P= 0.461).

CONCLUSION

The concentration of serum MPT is a more reliable diagnostic parameter than that of serum creatinine as a measure of normal renal function, and renal function can be compared in subjects independently of age and muscle mass when serum MPT concentration is measured.

Cationic charge-preferential IgG reabsorption in the renal proximal tubules

BACKGROUND

The brush border of the renal proximal tubules has a polyanionic charge. Since immunoglobulin G (IgG) molecules have a wide range of charge diversity, reabsorption of urinary IgG molecules are supposed to be influenced by the electrostatic interaction.

METHODS

Charge diversity of serum and urinary IgG molecules in patients with various renal diseases (N= 12) and premature neonates (N= 3) were analyzed by isoelectric focusing and Immunoblotting.

RESULTS

In patients with glomerular diseases, urinary IgG was solely composed of neutral and anionic IgG, whereas that of the cationic part (isoelectric point >8) was not observed. By contrast, in patients with proximal tubular diseases (Dent's disease and idiopathic Fanconi syndrome), the proportion of the cationic IgG was similar to that of serum IgG. In addition, the cationic part of IgG in the urine was found in the neonates with a gestational age of 28 and 31 weeks, but not found in those of 35 weeks.

CONCLUSION

The results suggest that renal proximal tubules reabsorb the urinary IgG in a cationic preferential way, and this mechanism requires renal maturation.

[Lung metastasis with a 12 years disease free interval from the first surgery of synovial sarcoma; report of a case]

A 48-year-old woman was admitted for surgery on a lung tumor found incidentally. Her medical history showed a synovial sarcoma of left inguinal region which was resected 12 years ago. We performed segmentectomy of left S4 + 5 to removed the metastatic tumor. Histological examination revealed that the tumor was metastatic synovial sarcoma. Synovial sarcoma can metastasize to lung frequently but such a long disease free interval as 12 years is quite uncommon.

Sentinel node biopsy for breast cancer patients in Japan

Sentinel node biopsy may become a standard procedure to detect lymph node metastases in early breast cancer. Numerous studies have confirmed and demonstrated the reliability of the hypothesis of sentinel node biopsy, with a high identification rate and overall accuracy connected with dye-guided and radio-guided sentinel node biopsy. To assess the benefit of sentinel node biopsy, randomized clinical trials are underway in Western countries comparing sentinel node biopsy with conventional axillary lymph node dissection. In Japan, feasibility studies on sentinel node biopsy started in the mid-1990s. The dye and radiopharmaceuticals associated with sentinel node biopsy commonly used in Western countries are not available in Japan. Japanese investigators have attempted to perform sentinel node biopsy using other dyes and radiopharmaceuticals. The results from feasibility studies have been similar to those reported previously. In conclusion, sentinel node biopsy for breast cancer patients is successful in Japan. The current status and the problems are discussed.

NPHS2 mutations in sporadic steroid-resistant nephrotic syndrome in Japanese children

Podocin is an integral membrane protein encoded by NPHS2, which is mapped to 1q25-31 and is exclusively expressed in glomerular podocytes. NPHS2 mutations are responsible for autosomal recessive familial steroid-resistant nephrotic syndrome (SRNS) with minor glomerular abnormalities or focal segmental glomerulosclerosis (FSGS), which is characterized by early childhood onset (age less than 6 years) and rapid progression to chronic renal insufficiency. This gene mutation is also responsible for an adolescent/adult onset form of autosomal recessive familial FSGS with heavy proteinuria. It has been demonstrated that sporadic SRNS and heavy proteinuria are also due to NPHS2 gene mutations. We isolated genomic DNA from 36 Japanese children with chronic renal insufficiency caused by SRNS or heavy proteinuria, and analyzed all eight exons and exon-intron boundaries of NPHS2 using the polymerase chain reaction and direct sequencing. The age at onset of disease was 3.9+/-0.5 years. There were 29 patients with SRNS and 7 with heavy proteinuria without nephrotic syndrome at the onset, but all patients developed chronic renal insufficiency 4.6+/-0.8 years after the onset. A new homozygous missense variant of NPHS2, G34E (G101A) in exon 1, was detected in 1 of 36 patients. However, this homozygous variant was also found in 1 of 44 normal controls, suggesting that the mutation is a polymorphism. Two silent variants (T954C and A1038G) in exon 8 of this gene were also identified in some of the patients and normal controls, indicating that the silent variants are also polymorphisms. There was no significant difference in the genotypic and allelic frequencies of T954C and A1038G polymorphisms between the patients and normal controls. In conclusion, NPHS2 gene mutations are not a major cause of chronic renal insufficiency caused by sporadic SRNS or heavy proteinuria in Japanese children.

Multicentre study comparing aggressive behaviour of familial non-medullary thyroid carcinoma and sporadic thyroid cancer

Background

Familial non-medullary thyroid cancer represents about 5 per cent of all thyroid cancers of follicular cell origin. Whether familial non-medullary thyroid cancer is more aggressive than sporadic thyroid cancer is controversial.

Methods

Each patient with familial non-medullary thyroid cancer was matched with three controls for age, sex and tumour node metastasis (TNM) stage of disease. Possible prognostic factors were compared in relation to recurrence, metastases and mortality rate in both groups. Univariate analysis was performed using contingency table analysis and McNemar's χ2 test for paired measurements. Multivariate analysis was used to evaluate factors significant in univariate analysis.

Results

Forty-eight cases (ten men) and 144 matched controls (30 men) were analysed with a mean follow-up of 102 and 94 months respectively. The mean age was 39 years for cases and 46 years for controls. Some 29 per cent of the cases and 12 per cent of the controls had history of prior or coexistent benign thyroid disease (P &lt; 0·05). Ninety-four per cent of cases and 90 per cent of controls had papillary cancers; the remainder were Hurthle cell cancers. Based on TNM staging, there were 66 per cent stage I, 21 per cent stage II and 13 per cent stage III tumours in the familial non-medullary thyroid cancer group; the distribution was similar in the control group. Modified radical neck dissection was performed in 42 per cent of cases and 22 per cent of controls. Multifocal or bilateral disease was seen in 75 per cent of cases and 41 per cent of controls (P &lt; 0·05); 35 per cent of cases and 16 per cent of controls had at least one recurrence (P &lt; 0·05). Ten per cent of cases and 2 per cent of controls developed distant metastases (P &lt; 0·05). Six per cent of cases but no controls died from thyroid cancer (P &lt; 0·05). In patients with familial non-medullary thyroid cancer aged over 45 years (n = 14), distant metastases affected four, of whom three died. In multivariate analysis, age was the only significant variable that affected the disease outcome (P &lt; 0·01).

Conclusion

Familial non-medullary thyroid cancer is more aggressive than sporadic thyroid cancer and is associated with increased recurrence, metastasis and death, especially in patients over 45 years of age.

Coexistence of beta2 microglobulin and lambda light chain in amyloid fibrils of dialysis-unrelated plasma cell dyscrasia-associated systemic amyloidosis

BACKGROUND

Systemic amyloidosis occurs as a result of amyloid deposition in various tissues. The amyloid fibrils in systemic amyloidosis have been reported to originate from immunoglobulin light chains.

OBJECTIVE

We studied the composition of amyloid fibrils from two patients with plasma cell-associated systemic amyloidosis (PASA).

METHODS

A double immunofluorescence study of the lesional skin of PASA was undertaken. Amyloid proteins were extracted with distilled water from one case of PASA.

RESULTS

The double immunofluorescence study showed that anti-lambda light chain and anti-beta2 microglobulin antibodies mostly reacted with the same area of amyloid deposit. Amyloid deposits from two patients with PASA who had never undergone haemodialysis showed a positive reaction with the antibodies for beta2 microglobulin as well as immunoglobulin lambda light chain. By the use of immunoblot assay of amyloid fibril proteins, polypeptides immunoreactive with antigamma light chain antibody (29 kDa) and with anti-beta2 microglobulin antibody (12 kDa) were detected.

CONCLUSIONS

These results indicate that beta2 microglobulin is a component of amyloid fibrils in PASA.

Quantitative electroencephalography of medetomidine, medetomidine-midazolam and medetomidine-midazolam-butorphanol in dogs

The purpose of this study was to evaluate the effects of the administration of an alpha2-adrenoceptor agonist alone and in combination with other derivatives on brain wave activity. In addition, the diagnostic values of the electroencephalogram (EEG) for judging the depth of the balanced anaesthesia with an alpha2-adrenoceptor agonist was evaluated. The treatments comprised 20 microg/kg medetomidine (Me-20), 80 microg/kg medetomidine (Me-80), 20 microg/kg medetomidine and 0.5 mg/kg midazolam (Me-Mi) administered intramuscularly, and 20 microg/kg medetomidine with 0.5 mg/kg midazolam and 0.1 mg/kg butorphanol (Me-Mi-Bu). The EEG was recorded continuously at pre-administration, and at 7, 10, 20, 30, 45 and 60 min after administration. The recorded data were analysed by separating the power spectrum into 1-3, 4-7, 8-13 and 14-30 Hz bands. Spectral-edge analysis was used to calculate the spectral edge frequency 90 (SEF90) and the median edge frequency (MEF). Time-related changes in power spectrum analysis showed a significant increase in the Me-80 group in the 1-3 Hz band. The power for 1-3 Hz in the Me-80 group was significantly higher than in all the other groups. In the 14-30 Hz band, there was a significant reduction of power in all groups following administration of the agents. The SEF90 frequencies were significantly reduced in all groups except for the Me-20 group after administration of the agents. The SEF90 frequencies in the Me-20, Me-Mi and Me-Mi-Bu were all significantly higher than those in the Me-80 group. However, there was no significant difference between the Me-20, Me-Mi and Me-Mi-Bu groups in any analyses. Our results demonstrated that the changes in quantitative EEG made by the Me-Mi-Bu and Me-Mi groups were similar to those made by Me-20 groups. Present results suggest that the EEG should be interpreted with caution in assessing the anaesthetic level in balanced anaesthesia in dogs.

The citrus flavonoid, nobiletin, inhibits peritoneal dissemination of human gastric carcinoma in SCID mice

The flavonoid nobiletin (5,6,7,8,3',4'-hexamethoxyflavone), found in Citrus depressa Rutaceae, a popular citrus fruit in Okinawa, Japan, reportedly inhibits the production of pro-matrix metalloproteinase (proMMP)-1, 3, and 9 in rabbit synovial fibroblasts in vitro. In the present study, we demonstrated the inhibitory effects of nobiletin on the proliferation of the cancer cell line, TMK- 1, and its production of MMPs. In the SCID mouse model, we found that nobiletin inhibited the formation of peritoneal dissemination nodules from TMK-1. The enzymatic activity of MMP-9 expressed in culture medium obtained from a co-culture of TMK-1 and mouse fibroblastic cells was inhibited by nobiletin in a concentration-dependent manner. In the SCID mouse model, total weight of dissemination nodules was significantly lower in the treated group compared with the vehicle control group (0.07 g vs. 0.78 g, P = 0.0059). The total number of dissemination nodules was also significantly lower than in the vehicle control group (7.5 vs. 69.3 / body, P = 0.0001). These results suggest that nobiletin may be a candidate anti-metastatic drug for prevention of peritoneal dissemination of gastric cancer.