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Suenaga A, Sawa N, Oba Y, Ikuma D, Sekine A, Yamanouchi M, Hasegawa E, Mizuno H, Suwabe T, Hayashi N, Kono K, Kinowaki K, Ohashi K, Miyazono M, Yamaguchi Y, Ubara Y. A case of bullous pemphigoid and renal disease after dipeptidyl peptidase 4 inhibitor administration. CEN Case Rep 2024; 13:264-270. [PMID: 38055184 PMCID: PMC11294501 DOI: 10.1007/s13730-023-00835-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 10/29/2023] [Indexed: 12/07/2023] Open
Abstract
A 62-year-old man with type 2 diabetes was admitted because of a decrease in estimated glomerular filtration rate from 72 to 17.5 mL/min/1.73 m2 in 10 years and development of widespread bullous skin lesions. His hemoglobin A1c level had been maintained at 6.0-7.0% for 10 years with a dipeptidyl peptidase (DPP)-4 inhibitor. Skin biopsy showed typical bullous pemphigoid, and kidney biopsy showed tubulointerstitial nephritis with eosinophilic infiltration and glomerular endothelial cell proliferation. After discontinuing the DPP-4 inhibitor, skin lesions improved, and renal decline slowed. This case indicates that DPP-4 inhibitors can cause not only skin lesions but also renal disease.
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Affiliation(s)
- Atsuhiko Suenaga
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, 1-3-1, Takatsu, Kawasaki, Kanagawa, 213-8587, Japan.
- Department of Nephrology, Saga University Internal Medicine, Saga, Japan.
| | - Naoki Sawa
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, 1-3-1, Takatsu, Kawasaki, Kanagawa, 213-8587, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Yuki Oba
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, 1-3-1, Takatsu, Kawasaki, Kanagawa, 213-8587, Japan
| | - Daisuke Ikuma
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, 1-3-1, Takatsu, Kawasaki, Kanagawa, 213-8587, Japan
| | - Akinari Sekine
- Department of Nephrology and Rheumatology, Toranomon Hospital, Tokyo, Japan
| | - Masayuki Yamanouchi
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, 1-3-1, Takatsu, Kawasaki, Kanagawa, 213-8587, Japan
| | - Eiko Hasegawa
- Department of Nephrology and Rheumatology, Toranomon Hospital, Tokyo, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Hiroki Mizuno
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, 1-3-1, Takatsu, Kawasaki, Kanagawa, 213-8587, Japan
| | - Tatsuya Suwabe
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, 1-3-1, Takatsu, Kawasaki, Kanagawa, 213-8587, Japan
| | | | - Kei Kono
- Department of Pathology, Toranomon Hospital, Tokyo, Japan
| | | | - Kenichi Ohashi
- Department of Pathology, Toranomon Hospital, Tokyo, Japan
- Department of Human Pathology, Tokyo Medical Dental University, Tokyo, Japan
| | - Motoaki Miyazono
- Department of Nephrology, Saga University Internal Medicine, Saga, Japan
| | | | - Yoshifumi Ubara
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, 1-3-1, Takatsu, Kawasaki, Kanagawa, 213-8587, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
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Kurihara S, Sawa N, Sumida K, Ikuma D, Oba Y, Mizuno H, Sekine A, Yamanouchi M, Hasegawa E, Suwabe T, Urakami S, Kono K, Kinowaki K, Ohashi K, Yamaguchi Y, Ubara Y. A case report of dipeptidyl peptidase 4 inhibitor-related kidney disease combined with renal cancer. FRONTIERS IN NEPHROLOGY 2024; 4:1409098. [PMID: 39135967 PMCID: PMC11317433 DOI: 10.3389/fneph.2024.1409098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/24/2024] [Indexed: 08/15/2024]
Abstract
A kidney biopsy was performed in a 64-year-old woman with type 2 diabetes mellitus and less than 1 g of proteinuria who rapidly progressed to end-stage renal failure after approximately 2 years of treatment with two dipeptidyl peptidase 4 (DPP-4) inhibitors for type 2 diabetes mellitus. The biopsy revealed not only a coincidental diagnosis of renal cell carcinoma, which was not evident on pre-biopsy computed tomography, but also severe thrombotic microangiopathy (TMA)-like glomerular endothelial cell damage in the noncancerous areas. These results suggest that DPP4 inhibitors may have been involved in two kidney diseases.
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Affiliation(s)
- Shigekazu Kurihara
- Nephrology Center and the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Naoki Sawa
- Nephrology Center and the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Keiichi Sumida
- Nephrology Center and the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Daisuke Ikuma
- Nephrology Center and the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Yuki Oba
- Nephrology Center and the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Hiroki Mizuno
- Nephrology Center and the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Akinari Sekine
- Nephrology Center and the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Masayuki Yamanouchi
- Nephrology Center and the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Eiko Hasegawa
- Nephrology Center and the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Tatsuya Suwabe
- Nephrology Center and the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | | | - Kei Kono
- Department of Pathology, Toranomon Hospital, Tokyo, Japan
| | | | - Kenichi Ohashi
- Department of Pathology, Toranomon Hospital, Tokyo, Japan
- Department of Human Pathology, Tokyo Medical Dental University, Tokyo, Japan
| | | | - Yoshifumi Ubara
- Nephrology Center and the Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
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Duan S, Lu F, Sun R, Chen C, Chen S, Geng L, Qian L, Pan Y, Zhang C, Zeng M, Sun B, Mao H, Zhang B, Xing C, Yuan Y. 25(OH)D level and vascular lesion scores in kidney histopathology as risk-stratification tool for predicting renal progression in people with type 2 diabetes. Diabetes Metab Syndr 2024; 18:103037. [PMID: 38744090 DOI: 10.1016/j.dsx.2024.103037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 05/02/2024] [Accepted: 05/03/2024] [Indexed: 05/16/2024]
Abstract
AIM To evaluate the potential of the combined individual vascular histopathological lesion and serum 25-hydroxy vitamin D [25(OH)D] level as predictors of outcomes in patients with diabetes and chronic kidney disease. METHODS A total of 190 patients with type 2 diabetes and kidney disease stages 1-4 were retrospectively included. Kaplan-Meier analysis and the log-rank test were performed to assess renal survival differences. And the time-dependent receiver operating characteristic analyses were used to characterize the predictive accuracy. Hazard ratios for vascular lesion scores and 25(OH)D levels with renal outcomes were estimated using Cox proportional hazards regression models with follow-up time. RESULTS Over a median follow-up of 23.78 (12.61, 37.14) months, 71 patients (37.4 %) experienced the renal outcomes. Enrolled patients with more severe vascular lesions had worse kidney function, heavier proteinuria, lower serum 25(OH)D levels, and higher prevalence of composite kidney outcomes. Baseline serum 25(OH)D was a significant independent risk factor for vascular lesion scores. The effect of serum 25(OH)D level on kidney prognosis was more pronounced in males and those with more exacerbated vascular lesions (score 2). The severity of vascular lesions and serum 25(OH)D levels were associated with unfavorable kidney outcomes. Accordingly, further time-dependent receiver operating characteristic curves confirmed that combined 25(OH)D level and vascular lesion score had a stable and reliable performance in renal outcomes prediction at short and long-term follow-up times. CONCLUSIONS 25(OH)D level and vascular lesion scores in kidney histopathology could serve as a useful risk-stratification tool for predicting renal progression in patients with type 2 diabetes.
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Affiliation(s)
- Suyan Duan
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Fang Lu
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Rui Sun
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Chen Chen
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Si Chen
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Luhan Geng
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Li Qian
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Ying Pan
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Chengning Zhang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Ming Zeng
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Bin Sun
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Huijuan Mao
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China
| | - Bo Zhang
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China.
| | - Changying Xing
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China.
| | - Yanggang Yuan
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing Medical University, Nanjing, China.
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Fukata F, Eriguchi M, Tamaki H, Uemura T, Tasaki H, Furuyama R, Nishimoto M, Kosugi T, Tanabe K, Morimoto K, Okamoto K, Matsui M, Samejima KI, Tsuruya K. Differential impact of glomerular and tubule-interstitial histological changes on kidney outcome between non-proteinuric and proteinuric diabetic nephropathy. Clin Exp Nephrol 2024; 28:282-292. [PMID: 38019364 DOI: 10.1007/s10157-023-02433-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 10/31/2023] [Indexed: 11/30/2023]
Abstract
BACKGROUND Studies on kidney function and histological findings in diabetic nephropathy (DN) with low urinary protein (UP) are few. We examined the differential impact of histological changes on kidney outcomes between non-proteinuric and proteinuric DN. METHODS Patients diagnosed with DN by renal biopsy during 1981-2014 were divided into non-proteinuric (UP ≤ 0.5 g/day) and proteinuric (UP > 0.5 g/day) DN. The Cox proportional hazard model was used to examine the association of glomerular lesions (GLs) and interstitial fibrosis and tubular atrophy (IFTA) with end-stage kidney disease (ESKD) development after adjusting for relevant confounders. RESULTS The non-proteinuric and proteinuric DN groups included 197 and 199 patients, respectively. During the 10.7-year median follow-up period, 16 and 83 patients developed ESKD in the non-proteinuric and proteinuric DN groups, respectively. In the multivariable Cox hazard model, hazard ratios (HRs) [95% confidence intervals (CIs)] of GL and IFTA for ESKD in proteinuric DN were 2.94 [1.67-5.36] and 3.82 [2.06-7.53], respectively. Meanwhile, HRs [95% CIs] of GL and IFTA in non-proteinuric DN were < 0.01 [0-2.48] and 4.98 [1.33-18.0], respectively. IFTA was consistently associated with higher incidences of ESKD regardless of proteinuria levels (P for interaction = 0.49). The prognostic impact of GLs on ESKD was significantly decreased as proteinuria levels decreased (P for interaction < 0.01). CONCLUSIONS IFTA is consistently a useful predictor of kidney prognosis in both non-proteinuric and proteinuric DN, while GLs are a significant predictor of kidney prognosis only in proteinuric DN.
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Affiliation(s)
- Fumihiro Fukata
- Department of Nephrology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Masahiro Eriguchi
- Department of Nephrology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan.
| | - Hiroyuki Tamaki
- Department of Nephrology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Takayuki Uemura
- Department of Nephrology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Hikari Tasaki
- Department of Nephrology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Riri Furuyama
- Department of Nephrology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Masatoshi Nishimoto
- Department of Nephrology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Takaaki Kosugi
- Department of Nephrology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Kaori Tanabe
- Department of Nephrology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Katsuhiko Morimoto
- Department of Nephrology, Nara Prefecture Seiwa Medical Center, Nara, Japan
| | - Keisuke Okamoto
- Department of Nephrology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Masaru Matsui
- Department of Nephrology, Nara Prefecture General Medical Center, Nara, Japan
| | - Ken-Ichi Samejima
- Department of Nephrology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Kazuhiko Tsuruya
- Department of Nephrology, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
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Kipgen D, Crosby J, Dey V, Kelly M, McQuarrie E, Geddes C. The relationship between histopathological features, immunosuppression and outcome in patients undergoing native kidney biopsies. Histopathology 2024; 84:671-682. [PMID: 38084646 DOI: 10.1111/his.15115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/22/2023] [Accepted: 11/26/2023] [Indexed: 02/07/2024]
Abstract
AIMS To assess retrospectively the association between histopathological lesions on renal biopsy and subsequent impairment of renal function across the spectrum of kidney diseases and to explore the influence of immunosuppressive therapy within the first 6 months after biopsy on this association. METHODS AND RESULTS Clinical data from 488 adult patients having a renal biopsy reported at a single centre from 2017 to 2019 were obtained during a median follow-up period of 786 days. Seventeen semi-quantitative histology parameters were recorded at the time of biopsy, 14 of which were suitable for assessment of association with loss of eGFR by multivariable Cox regression analysis, measurement of eGFR slope and measurement of eGFR 12 months after biopsy. A widely used histopathological chronicity score was also assessed. Clinical baseline variables including prescription of immunosuppression were recorded. Seven of 14 histology parameters: mesangial matrix expansion, global glomerulosclerosis, tubular atrophy, interstitial fibrosis, arteriolosclerosis, mesangial hypercellularity and acute tubular injury; and the chronicity score, predicted loss of kidney function by all three measures. Prescription of immunosuppression was more likely in patients with active inflammatory pathology and less likely in patients with chronic fibrotic pathology, and was associated with reduced risk of loss of eGFR. CONCLUSIONS This retrospective study demonstrates the prognostic significance and complex relationship with immunosuppression of routinely reported histopathological variables in patients having native kidney biopsies, across the spectrum of kidney diseases. It provides useful information for renal biopsy prognostication and design of retrospective studies, including machine learning models.
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Affiliation(s)
- David Kipgen
- Department of Pathology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Jana Crosby
- Department of Pathology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Vishal Dey
- John Lynch Renal Unit, University Hospital Crosshouse, Crosshouse, UK
| | - Michael Kelly
- Dumfries and Galloway Royal Infirmary Renal Unit, Dumfries, UK
| | - Emily McQuarrie
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Colin Geddes
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
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Uemura T, Nishimoto M, Eriguchi M, Tamaki H, Tasaki H, Furuyama R, Fukata F, Kosugi T, Morimoto K, Matsui M, Samejima KI, Tsuruya K. Utility of serum β2-microglobulin for prediction of kidney outcome among patients with biopsy-proven diabetic nephropathy. Diabetes Obes Metab 2024; 26:583-591. [PMID: 37921072 DOI: 10.1111/dom.15347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 10/05/2023] [Accepted: 10/15/2023] [Indexed: 11/04/2023]
Abstract
AIM To examine whether serum β2-microglobulin (β2-MG) could improve the prediction performance for kidney failure with replacement therapy (KFRT) among patients with diabetic nephropathy (DN). METHODS Patients with biopsy-proven DN at Nara Medical University Hospital were included. The exposure of interest was log-transformed serum β2-MG levels measured at kidney biopsy. The outcome variable was KFRT. Multivariable Cox regression models and competing-risk regression models, with all-cause mortality as a competing event, were performed. Model fit by adding serum β2-MG levels was calculated using the Akaike information criterion (AIC). The net reclassification improvement (NRI) and integrated discrimination improvement (IDI) indexes were used to evaluate the improvement of predictive performance for 5-year cumulative incidence of KFRT by serum β2-MG levels. RESULTS Among 408 patients, 99 developed KFRT during a median follow-up period of 6.7 years. A higher serum β2-MG level (1-unit increase in log-transformed serum β2-MG level) was associated with a higher incidence of KFRT, even after adjustments for previously known clinical and histological risk factors (hazard ratio [95% confidence interval {CI}]: 3.30 [1.57-6.94] and subdistribution hazard ratio [95% CI]: 3.07 [1.55-6.06]). The addition of log-transformed serum β2-MG level reduced AIC and improved the prediction of KFRT (NRI and IDI: 0.32 [0.09-0.54] and 0.03 [0.01-0.56], respectively). CONCLUSIONS Among patients with biopsy-proven DN, serum β2-MG was an independent predictor of KFRT and improved prediction performance. In addition to serum creatinine, serum β2-MG should probably be measured for DN.
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Affiliation(s)
- Takayuki Uemura
- Department of Nephrology, Nara Medical University, Nara, Japan
| | | | | | - Hiroyuki Tamaki
- Department of Nephrology, Nara Medical University, Nara, Japan
| | - Hikari Tasaki
- Department of Nephrology, Nara Medical University, Nara, Japan
| | - Riri Furuyama
- Department of Nephrology, Nara Medical University, Nara, Japan
| | - Fumihiro Fukata
- Department of Nephrology, Yamatotakada Municipal Hospital, Nara, Japan
| | - Takaaki Kosugi
- Department of Nephrology, Nara Medical University, Nara, Japan
| | - Katsuhiko Morimoto
- Department of Nephrology, Nara Prefecture Seiwa Medical Center, Nara, Japan
| | - Masaru Matsui
- Department of Nephrology, Nara Medical University, Nara, Japan
- Department of Nephrology, Nara Prefecture General Medical Center, Nara, Japan
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Suzuki A, Moriya T, Hayashi A, Matsubara M, Miyatsuka T. Arteriolar Hyalinosis Predicts the Onset of Both Macroalbuminuria and Impaired Renal Function in Patients with Type 2 Diabetes. Nephron Clin Pract 2023; 148:390-398. [PMID: 38118427 PMCID: PMC11151987 DOI: 10.1159/000535875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 11/28/2023] [Indexed: 12/22/2023] Open
Abstract
INTRODUCTION Arteriolar hyalinosis (AH) has been shown to be associated with albuminuria and GFR. In this study, we investigated whether or not index of AH (IAH) is a predictor of the onset of macroalbuminuria and impaired renal function (eGFR <60 mL/min/1.73 m2 [eGFR <60]) in type 2 diabetic patients with early diabetic nephropathy. METHODS The study population consisted of 35 patients with type 2 diabetes (25 men; age: 47 ± 9 years; eGFR: 92.7 ± 18.0 mL/min/1.73 m2) with normo- or microalbuminuria who underwent percutaneous renal biopsy. These patients were followed for at least 5 (18 ± 6, range: 6-28) years. The study endpoint was the onset of macroalbuminuria or eGFR <60. Light and electron microscopy-based morphometric analyses were performed to quantitatively evaluate glomerular and interstitial structural changes. RESULTS During the observation period, 9 out of the 35 patients progressed to macroalbuminuria, and 15 out of the 35 patients developed eGFR <60. The annual rate of eGFR decline was significantly correlated with IAH (r = -0.40, p = 0.016). Kaplan-Meier analysis demonstrated that AH was associated with a significantly higher risk of onset of macroalbuminuria and eGFR <60, and microalbuminuria is associated with the onset of macroalbuminuria but not the onset of eGFR <60. CONCLUSIONS Aggravated AH is a histological risk factor which predicts the onset of macroalbuminuria and eGFR <60 in patients with type 2 diabetes. These findings provide novel insights into the mechanism of progression of diabetic nephropathy.
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Affiliation(s)
- Akihiko Suzuki
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Sagamihara, Japan,
| | - Tatsumi Moriya
- Health Care Center, Kitasato University, Sagamihara, Japan
| | - Akinori Hayashi
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Sagamihara, Japan
| | | | - Takeshi Miyatsuka
- Department of Endocrinology, Diabetes and Metabolism, Kitasato University School of Medicine, Sagamihara, Japan
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Ataka E, Matsukuma Y, Ueki K, Tsuchimoto A, Okabe Y, Masutani K, Nakamura M, Nakano T, Kitazono T. Cumulative smoking dose is associated with subclinical renal injury: a pathological study in individuals without chronic kidney disease. Nephrol Dial Transplant 2023; 38:2799-2808. [PMID: 37355777 DOI: 10.1093/ndt/gfad124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Indexed: 06/26/2023] Open
Abstract
BACKGROUND Epidemiological studies have identified smoking as an independent risk factor for development of chronic kidney disease. However, the early renal pathological lesions have not been clearly elucidated. METHODS We investigated time-zero biopsy specimens from 547 living kidney donors and evaluated the relationships between smoking and renal histological changes, including arteriolar hyalinization, intimal thickening of small-medium arteries, global glomerulosclerosis, and interstitial fibrosis and tubular atrophy (IF/TA). RESULTS A total of 199 subjects (36.4%) had smoking history; 92 (16.8%) and 107 (19.6%) subjects had <20 pack-years and ≥20 pack-years of smoking, respectively. Cumulative smoking dose was significantly associated with prevalence of arteriolar hyalinization: the multivariable-adjusted odds ratio (OR) per 20 pack-year increase was 1.50 (95% confidence interval 1.15-1.97). The ORs for smokers with <20 pack-years and ≥20 pack-years versus never-smokers were 1.76 (1.01-3.09) and 2.56 (1.48-4.44), respectively. Smoking was also associated with prevalence of >10% global glomerulosclerosis: the OR per 20 pack-year increase was 1.24 (0.96-1.59). The ORs for smokers with <20 pack-years and ≥20 pack-years versus never-smokers were 1.50 (0.98-2.78) and 2.11 (1.18-3.79), respectively. The ORs for these pathological changes increased significantly depending on cumulative smoking dose. Intimal thickening of small-medium arteries and IF/TA were not associated with smoking status. The prevalence of arteriolar hyalinization remained higher in patients with ≥10 years since smoking cessation than in never-smokers [OR 2.23 (1.03-4.83)]. CONCLUSIONS Subclinical pathological injury caused by smoking is potentially associated with renal arteriolar hyalinization and glomerular ischaemia.
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Affiliation(s)
- Eri Ataka
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yuta Matsukuma
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kenji Ueki
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Akihiro Tsuchimoto
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Yasuhiro Okabe
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kosuke Masutani
- Department of Nephrology and Rheumatology, Department of Internal Medicine, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toshiaki Nakano
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
- Center for Cohort Studies, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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9
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Suenaga A, Sawa N, Oba Y, Ikuma D, Sekine A, Hasegawa E, Mizuno H, Suwabe T, Ikeda S, Tsujimoto T, Kono K, Shintani-Domoto Y, Kinowaki K, Ohashi K, Miyazono M, Yamaguchi Y, Ubara Y. Dipeptidyl peptidase-4 inhibitor-related renal disease. J Diabetes Complications 2023; 37:108590. [PMID: 37678056 DOI: 10.1016/j.jdiacomp.2023.108590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 07/29/2023] [Accepted: 08/19/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Dipeptidyl peptidase-4 (DPP-4) inhibitors are widely used to treat type 2 diabetes (T2D). Lowering blood glucose is expected also to reduce the progression of diabetic nephropathy. We experienced a patient with T2D who achieved good glycemic control with a DPP-4 inhibitor but experienced rapid deterioration of renal function. Therefore, we performed a retrospective study of similar patients treated at our hospital. METHODS Out of 56 patients with biopsy-proven diabetic nephropathy who underwent native kidney biopsy at Toranomon Hospital from January 2018 through December 2022, we selected 22 patients who had been receiving DPP-4 inhibitors for at least 9 months at the time of kidney biopsy. Of these patients, we evaluated 16 diagnosed with class IIa diabetic nephropathy according to Tervaert's pathologic classification. The yearly estimated glomerular filtration rate (eGFR) slope in the 16 patients was arranged from the highest to the lowest slope. Ten patients with a large eGFR slope had thrombotic microangiopathy (TMA)-like lesions characterized by glomerular endothelial cell proliferation and GBM duplication on kidney biopsy (group A), whereas the remaining 6 patients did not have TMA-like lesions (group B). RESULTS Group A had a median (interquartile range [IQR]) eGFR of 18.2 (16.2, 26.2) and a yearly median (IQR) eGFR slope of -11.2 (-17.6, -9.2) mL/min/1.73 m2 after of DPP-4 administration, whereas group B had a median (IQR) eGFR of 31.5 (21.9, 34.8) mL/min/1.73 m2 and a yearly median (IQR) eGFR slope of -1.6 (-3.1, -0.3). Renal function declined significantly more rapidly in group A than in group B, and proteinuria was higher in group A than in group B (median [IQR], 3.4 [2.6, 4.4] g/day vs 0.8 [0.4, 1.3] g/day, respectively). Five patients in group A progressed to dialysis during follow-up, but none of the patients in group B did. Median (IQR) hemoglobin A1c was 6.2 % (6.0 %, 6.6 %) in group A and 5.8 % (5.7 %, 6.6 %) in group B. CONCLUSION DPP-4 inhibitors promote vascular endothelial regeneration, but when this effect occurs in the glomerulus, glomerular endothelial cell proliferation leads to TMA-like lesions, which may cause an increase in proteinuria and rapid decline in renal function.
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Affiliation(s)
- Atsuhiko Suenaga
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, Kanagawa, Japan; Department of Nephrology, Saga University School of Medicine, Saga, Japan.
| | - Naoki Sawa
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, Kanagawa, Japan; Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Yuki Oba
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Daisuke Ikuma
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Akinari Sekine
- Department of Nephrology and Rheumatology, Toranomon Hospital, Tokyo, Japan
| | - Eiko Hasegawa
- Department of Nephrology and Rheumatology, Toranomon Hospital, Tokyo, Japan; Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Hiroki Mizuno
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Tatsuya Suwabe
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Sara Ikeda
- Department of Diabetes and Endocrinology, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Tetsuro Tsujimoto
- Department of Diabetes and Endocrinology, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Kei Kono
- Department of Pathology, Toranomon Hospital, Tokyo, Japan
| | | | | | - Kenichi Ohashi
- Department of Pathology, Toranomon Hospital, Tokyo, Japan; Department of Human Pathology, Tokyo Medical Dental University, Tokyo, Japan
| | - Motoaki Miyazono
- Department of Nephrology, Saga University School of Medicine, Saga, Japan
| | | | - Yoshifumi Ubara
- Department of Nephrology and Rheumatology, Toranomon Hospital Kajigaya, Kanagawa, Japan; Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
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10
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Wang X, Ren L, Huang Y, Feng Z, Zhang G, Dai H. The Role of Tubulointerstitial Markers in Differential Diagnosis and Prognosis in Patients with Type 2 Diabetes and Biopsy Proven Diabetic Kidney Disease. Clin Chim Acta 2023:117448. [PMID: 37331550 DOI: 10.1016/j.cca.2023.117448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 05/15/2023] [Accepted: 06/13/2023] [Indexed: 06/20/2023]
Abstract
OBJECTIVE To evaluate the potential application of tubularinterstitial biomarkers in the differential diagnosis of diabetic kidney disease (DKD) from non-diabetic kidney disease (NDKD), as well as investigate key clinical and pathological parameters to help improve the stratification of patients according to end-stage renal disease risk. METHODS 132 type 2 diabetic patients with chronic kidney disease were enrolled. Patients were categorized into 2 groups according to the renal biopsy results: DKD (n=61) and NDKD (n=71).The independent factors of the occurrence of DKD and the diagnostic implications of tubular biomarkers were explored by logistic regression and receiver-operating characteristic curve analysis. Furthermore, predictors were analyzed by least absolute shrinkage and selection operator regression, and constructed a new model for predicting the unfavorable renal outcomes through Cox proportional hazard regression analysis. RESULTS Serum neutrophil gelatinase-associated lipocalin (sNGAL) (OR= 1.007; 95%CI = [1.003, 1.012], p = 0.001) was identified as an independent risk factor for the occurrence of DKD in diabetic patients with CKD. Tubular biomarkers including sNGAL, N-acetyl-β-D-glucosaminidase and β2 microglobulin (β2-MG) could complement albuminuria for DKD detection (AUC = 0.926, specificity = 90.14%, sensitivity = 80.33%).Moreover, among of the 47 variables, 4 predictors such as sNGAL, interstitial fibrosis and tubular atrophy (IFTA)score, β2-MG and estimated glomerular filtration rate were selected to construct a new model for predicting the unfavorable renal outcomes through regression analysis. sNGAL (HR = 1.004; 95%CI = [1.001, 1.007], p = 0.013), IFTA score of 2 (HR = 4.283; 95%CI = [1.086, 16.881], p = 0.038), and IFTA score of 3 (HR = 6.855; 95%CI = [1.766, 26.610], p = 0.005) were considered to be independent risk factors for unfavorable renal outcomes. CONCLUSIONS Tubulointerstitial injury in DKD is independently associated with renal function decline and routinely detected tubular biomarkers are able to enhance the level of non-invasive diagnosis of DKD beyond traditional factors.
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Affiliation(s)
- Xijian Wang
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong Jiangsu, 226001, PR China
| | - Liang Ren
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong Jiangsu, 226001, PR China
| | - Ying Huang
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong Jiangsu, 226001, PR China
| | - Zhengang Feng
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong Jiangsu, 226001, PR China
| | - Guangdi Zhang
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong Jiangsu, 226001, PR China
| | - Houyong Dai
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong Jiangsu, 226001, PR China.
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11
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Lucarelli N, Yun D, Han D, Ginley B, Moon KC, Rosenberg AZ, Tomaszewski JE, Zee J, Jen KY, Han SS, Sarder P. Discovery of Novel Digital Biomarkers for Type 2 Diabetic Nephropathy Classification via Integration of Urinary Proteomics and Pathology. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.28.23289272. [PMID: 37205413 PMCID: PMC10187347 DOI: 10.1101/2023.04.28.23289272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Background The heterogeneous phenotype of diabetic nephropathy (DN) from type 2 diabetes complicates appropriate treatment approaches and outcome prediction. Kidney histology helps diagnose DN and predict its outcomes, and an artificial intelligence (AI)-based approach will maximize clinical utility of histopathological evaluation. Herein, we addressed whether AI-based integration of urine proteomics and image features improves DN classification and its outcome prediction, altogether augmenting and advancing pathology practice. Methods We studied whole slide images (WSIs) of periodic acid-Schiff-stained kidney biopsies from 56 DN patients with associated urinary proteomics data. We identified urinary proteins differentially expressed in patients who developed end-stage kidney disease (ESKD) within two years of biopsy. Extending our previously published human-AI-loop pipeline, six renal sub-compartments were computationally segmented from each WSI. Hand-engineered image features for glomeruli and tubules, and urinary protein measurements, were used as inputs to deep-learning frameworks to predict ESKD outcome. Differential expression was correlated with digital image features using the Spearman rank sum coefficient. Results A total of 45 urinary proteins were differentially detected in progressors, which was most predictive of ESKD (AUC=0.95), while tubular and glomerular features were less predictive (AUC=0.71 and AUC=0.63, respectively). Accordingly, a correlation map between canonical cell-type proteins, such as epidermal growth factor and secreted phosphoprotein 1, and AI-based image features was obtained, which supports previous pathobiological results. Conclusions Computational method-based integration of urinary and image biomarkers may improve the pathophysiological understanding of DN progression as well as carry clinical implications in histopathological evaluation.
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Affiliation(s)
- Nicholas Lucarelli
- J. Crayton Pruitt Family Department of Biomedical Engineering, University of Florida, Gainesville, FL, USA
| | - Donghwan Yun
- Department of Biomedical Sciences, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Dohyun Han
- Proteomics Core Facility, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Brandon Ginley
- The Janssen Pharmaceutical Companies of Johnson & Johnson, Raritan NJ, USA
| | - Kyung Chul Moon
- Department of Pathology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Avi Z. Rosenberg
- Department of Pathology, Johns Hopkins University, Baltimore, MD, USA
| | - John E. Tomaszewski
- Department of Pathology and Anatomical Sciences, University at Buffalo – The State University of New York
| | - Jarcy Zee
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania and Children’s Hospital of Philadelphia, PA, USA
| | - Kuang-Yu Jen
- Department of Pathology and Laboratory Medicine, University of California, Davis Medical Center, CA, USA
| | - Seung Seok Han
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Pinaki Sarder
- Department of Medicine-Quantitative Health, University of Florida College of Medicine, Gainesville, FL, USA
- Department of Electrical and Computer Engineering, University of Florida College of Engineering, Gainesville, FL, USA
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12
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Uemura T, Nishimoto M, Eriguchi M, Tamaki H, Tasaki H, Furuyama R, Fukata F, Kosugi T, Morimoto K, Matsui M, Samejima KI, Tsuruya K. Association of triglycerides to high-density lipoprotein cholesterol ratio with incident cardiovascular disease but not end-stage kidney disease among patients with biopsy-proven diabetic nephropathy. Hypertens Res 2023:10.1038/s41440-023-01197-y. [PMID: 36750609 DOI: 10.1038/s41440-023-01197-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 02/09/2023]
Abstract
Increased triglycerides (TG) and decreased high-density lipoprotein cholesterol (HDL-C) are dyslipidemias characteristic of diabetes. Here, we aimed to examine associations of TG/HDL-C ratio with cardiovascular disease (CVD) and kidney dysfunction among patients with diabetic nephropathy. This retrospective observational study consists of patients with biopsy-proven diabetic nephropathy at Nara Medical University Hospital. Exposure of interest was TG/HDL-C ratio measured at kidney biopsy. Outcome variables were kidney histological findings, incident CVD and end-stage kidney disease (ESKD). Multivariable logistic regression models and Cox proportional hazard models were used to examined these associations. A total of 353 subjects were divided into quartiles based on TG/HDL-C ratio: Quartile 1 (reference), <1.96; Quartile 2, 1.96-3.10; Quartile 3, 3.11-4.55; and Quartile 4, ≥4.56. TG/HDL-C ratio was not a predictor of any histological findings in fully adjusted models. During median follow-up periods of 6.2 and 7.3 years, 152 and 90 subjects developed CVD and ESKD, respectively. Higher TG/HDL-C ratio was independently associated with higher incidences of CVD even after adjustments for potential confounders (hazard ratio [95% confidence interval] for Quartile 3 vs. reference; 1.73 [1.08-2.79] and Quartile 4 vs. reference; 1.86 [1.10-3.17]). Although there was a weak association between TG/HDL-C ratio and ESKD in the univariable model, the association was not significant in fully adjusted models. In conclusion, among patients with biopsy-proven diabetic nephropathy, higher TG/HDL-C ratio was independently associated with higher incidences of CVD but not with kidney outcomes, suggesting different impact of TG/HDL-C ratio on cardiorenal outcomes.
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Affiliation(s)
- Takayuki Uemura
- Department of Nephrology, Nara Medical University, Nara, Japan
| | | | | | - Hiroyuki Tamaki
- Department of Nephrology, Nara Medical University, Nara, Japan
| | - Hikari Tasaki
- Department of Nephrology, Nara Medical University, Nara, Japan
| | - Riri Furuyama
- Department of Nephrology, Nara Medical University, Nara, Japan
| | - Fumihiro Fukata
- Department of Nephrology, Nara Medical University, Nara, Japan
| | - Takaaki Kosugi
- Department of Nephrology, Nara Medical University, Nara, Japan
| | - Katsuhiko Morimoto
- Department of Nephrology, Nara Prefecture Seiwa Medical Center, Nara, Japan
| | - Masaru Matsui
- Department of Nephrology, Nara Medical University, Nara, Japan.,Department of Nephrology, Nara Prefecture General Medical Center, Nara, Japan
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13
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Adeva-Andany MM, Adeva-Contreras L, Fernández-Fernández C, Carneiro-Freire N, Domínguez-Montero A. Histological Manifestations of Diabetic Kidney Disease and its Relationship with Insulin Resistance. Curr Diabetes Rev 2023; 19:50-70. [PMID: 35346008 DOI: 10.2174/1573399818666220328145046] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/18/2022] [Accepted: 02/08/2022] [Indexed: 11/22/2022]
Abstract
Histological manifestations of diabetic kidney disease (DKD) include mesangiolysis, mesangial matrix expansion, mesangial cell proliferation, thickening of the glomerular basement membrane, podocyte loss, foot process effacement, and hyalinosis of the glomerular arterioles, interstitial fibrosis, and tubular atrophy. Glomerulomegaly is a typical finding. Histological features of DKD may occur in the absence of clinical manifestations, having been documented in patients with normal urinary albumin excretion and normal glomerular filtration rate. Furthermore, the histological picture progresses over time, while clinical data may remain normal. Conversely, histological lesions of DKD improve with metabolic normalization following effective pancreas transplantation. Insulin resistance has been associated with the clinical manifestations of DKD (nephromegaly, glomerular hyperfiltration, albuminuria, and kidney failure). Likewise, insulin resistance may underlie the histological manifestations of DKD. Morphological changes of DKD are absent in newly diagnosed type 1 diabetes patients (with no insulin resistance) but appear afterward when insulin resistance develops. In contrast, structural lesions of DKD are typically present before the clinical diagnosis of type 2 diabetes. Several heterogeneous conditions that share the occurrence of insulin resistance, such as aging, obesity, acromegaly, lipodystrophy, cystic fibrosis, insulin receptor dysfunction, and Alström syndrome, also share both clinical and structural manifestations of kidney disease, including glomerulomegaly and other features of DKD, focal segmental glomerulosclerosis, and C3 glomerulopathy, which might be ascribed to the reduction in the synthesis of factor H binding sites (such as heparan sulfate) that leads to uncontrolled complement activation. Alström syndrome patients show systemic interstitial fibrosis markedly similar to that present in diabetes.
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Affiliation(s)
- María M Adeva-Andany
- Internal Medicine Department, Nephrology Division, Hospital General Juan Cardona c/ Pardo Bazán s/n, 15406 Ferrol, Spain
| | - Lucía Adeva-Contreras
- University of Santiago de Compostela Medical School, Santiago de Compostela, Acoruna, Spain
| | - Carlos Fernández-Fernández
- Internal Medicine Department, Nephrology Division, Hospital General Juan Cardona c/ Pardo Bazán s/n, 15406 Ferrol, Spain
| | - Natalia Carneiro-Freire
- Internal Medicine Department, Nephrology Division, Hospital General Juan Cardona c/ Pardo Bazán s/n, 15406 Ferrol, Spain
| | - Alberto Domínguez-Montero
- Internal Medicine Department, Nephrology Division, Hospital General Juan Cardona c/ Pardo Bazán s/n, 15406 Ferrol, Spain
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14
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Kidney Transplantation From a Diabetic Donor to a Nondiabetic Recipient: A Case Report. Transplant Proc 2022; 54:2748-2753. [DOI: 10.1016/j.transproceed.2022.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 09/13/2022] [Indexed: 11/24/2022]
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15
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Nakashima S, Kawada M, Sekine A, Yamanouchi M, Ikuma D, Mizuno H, Oba Y, Hasegawa E, Suwabe T, Kono K, Kinowaki K, Ohashi K, Sawa N, Hoshino J, Ubara Y. Nodular-like glomerular lesion after long-standing chronic renal infection in a patient with medullary sponge kidney and mild hyperglycemia. Endocrinol Diabetes Metab Case Rep 2022. [DOI: 10.1530/edm-22-0217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
A 63-year-old Japanese woman was admitted to our institute for the evaluation of proteinuria. The patient was diagnosed with medullary sponge kidney, distal type renal tubular acidosis, and renal infection at the age of 37. Thereafter, the patient had repeated renal infections. Urinary proteinuria appeared at around the age of 61 and gradually increased up to 1.0 g daily. In the same period, glycated hemoglobin (HbA1c) increased to 7.0%. On kidney biopsy, light microscopy showed a nodular glomerular lesion and capsular drop. Linear staining for immunoglobulin G along the glomerular basement membrane was observed by immunofluorescence. Electron microscopy showed thickening of the glomerular basement membrane to a width of 800–900 nm. A class III glomerular lesion was diagnosed according to the Tervaert classification. This case indicates that mild but prolonged hyperglycemia for more than 10 years may also contribute to the formation of nodular lesions, although long-standing repeated chronic renal infection and chronic acidosis may have been a precipitating factor in the formation of diabetic nephropathy, including nodular glomerular lesions. This hypothesis is of interest because nodular lesions specific to diabetes are currently considered to be associated with long-term severe hyperglycemia.
Learning points
Nodular glomerular lesions in diabetes mellitus are thought to be associated with long-term severe hyperglycemia.
This case shows that although mild, long-term hyperglycemia for more than 10 years may also contribute to the formation of nodular lesions and that repeated chronic kidney infections over the years and chronic acidosis may be facilitating factors in the formation of diabetic nephropathy, including nodular glomerular lesions.
This case appears to be idiopathic nodular glomerulosclerosis of the medullary sponge kidney associated with chronic urinary tract infection.
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Affiliation(s)
| | | | - Akinari Sekine
- Nephrology Center, Toranomon Hospital, Tokyo, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | | | | | | | - Yuki Oba
- Nephrology Center, Toranomon Hospital, Tokyo, Japan
| | | | | | - Kei Kono
- Department of Pathology, Toranomon Hospital, Tokyo, Japan
| | | | - Kenichi Ohashi
- Department of Pathology, Toranomon Hospital, Tokyo, Japan
- Department of Human Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Naoki Sawa
- Nephrology Center, Toranomon Hospital, Tokyo, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Junichi Hoshino
- Nephrology Center, Toranomon Hospital, Tokyo, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital, Tokyo, Japan
- Okinaka Memorial Institute for Medical Research, Toranomon Hospital, Tokyo, Japan
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16
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Jiang S, Di D, Jiao Y, Zou G, Gao H, Li W. Complement Deposition Predicts Worsening Kidney Function and Underlines the Clinical Significance of the 2010 Renal Pathology Society Classification of Diabetic Nephropathy. Front Immunol 2022; 13:868127. [PMID: 35711407 PMCID: PMC9196586 DOI: 10.3389/fimmu.2022.868127] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/28/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives Converging evidence points towards a role of the complement system in the pathogenesis of diabetic nephropathy (DN). The classification system of diabetic kidney lesions devised by the Renal Pathology Society (RPS) in 2010 are based on the pathogenic process of DN. Therefore, we investigated the correlation between glomerular C3 deposits and RPS DN classification and the combined deleterious effects thereof on kidney function. Methods The study analyzed data from 217 diabetic patients who underwent renal biopsy between 2010 and 2021 and were found to have DN as the only glomerular disease. C3 deposition was considered positive if the glomerular C3 immunofluorescence intensity was at the trace or ≥1+ level. We divided DN into five glomerular lesion classes and separately evaluated the degree of interstitial and vascular involvement. The primary outcome was the composite of a ≥50% decline from the initial estimated glomerular filtration rate, end-stage renal disease, and death. Results None of the patients were classified into class I, and few were classified into classes IIa (7.8%) and IV (9.2%). Most patients were classified as IIb (30.9%) and III (52.1%). C3 deposition was detected in 53.9% of patients. Multivariate logistic regression analysis showed that DN class was significantly correlated with C3 deposits [odds ratio, 1.59; 95% confidence interval (CI), 1.08-2.36; p = 0.02). During a median follow-up of 22 months, 123 (56.7%) patients reached the composite outcome. The endpoints occurred more frequently in patients with C3 deposition (69.2 vs. 42%) compared with those without C3 deposition. Patients with C3 deposition in either class IIb [hazards ratio (HR), 3.9 (95% CI, 1.14-13.17) vs. 2.46 (95% CI, 0.68-8.89)] or III [HR, 4.98 (95% CI, 1.53-16.23) vs. 2.63 (95% CI, 0.77-9.0)] had a higher risk of adverse kidney outcomes than those without C3 deposition. The prognostic accuracy of the combination of DN class and C3 deposits at 1 and 3 years was higher than that for DN class only. Conclusions Complement deposition together with DN class predicts more rapid deterioration of kidney function in DN, which underlines the clinical significance of the DN phenotype according to the RPS classification.
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Affiliation(s)
- Shimin Jiang
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Dingxin Di
- Graduate School of Peking Union Medical College, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yuanyuan Jiao
- Graduate School of Peking Union Medical College, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Guming Zou
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Hongmei Gao
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
| | - Wenge Li
- Department of Nephrology, China-Japan Friendship Hospital, Beijing, China
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17
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Li M, Sun Z, Chang D, Yu X, Wang S, Chen M, Zhao M. C3c deposition predicts worse renal outcomes in patients with biopsy-proven diabetic kidney disease in type 2 diabetes mellitus. J Diabetes 2022; 14:291-297. [PMID: 35322566 PMCID: PMC9060041 DOI: 10.1111/1753-0407.13264] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 01/13/2022] [Accepted: 03/04/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Although extensive efforts have been paid to identify reliable predictors for renal outcomes of diabetic kidney disease (DKD) patients in type 2 diabetes mellitus (T2DM), there are still only a limited number of predictive factors for DKD progression. Increasing evidence reported the role of the overactivated complement system in the pathogenesis of DKD. Whether renal complement depositions are associated with renal outcomes of DKD in T2DM is of interest. METHODS A total of 213 biopsy-proven DKD patients with T2DM were retrospectively recruited. Clinical and pathological data of the patients were analyzed. Kaplan-Meier analysis and Cox regression analysis were performed to explore predictors of end-stage renal disease (ESRD). RESULTS During a median follow-up of 23.0 (12.0, 39.0) months, 100/213 (46.9%) patients progressed to ESRD. C3c and C1q deposition were observed in 133/213 (62.4%) and 45/213 (21.1%) patients, respectively. Kaplan-Meier analysis revealed patients with C3c or C1q deposition had significantly worse renal outcomes compared with those without C3c or C1q deposition (p = .001 and p < .001, respectively). Univariate and multivariate Cox regression analysis demonstrated proteinuria (per 1 g/24 h increase, hazard ratio [HR] 1.134, 95% confidence interval [CI] [1.079, 1.191], p < .001), interstitial fibrosis and tubular atrophy score (score 2 and 3 vs. 0 and 1, HR 3.925, 95% CI [1.855, 8.304], p < .001), and C3c deposition (per 1+ increase, HR 1.299, 95% CI [1.073, 1.573], p = .007) were independent predictors for ESRD in DKD patients with T2DM. CONCLUSIONS C3c deposition in the kidney was associated with worse renal outcomes and was an independent predictor for ESRD in DKD patients with T2DM.
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Affiliation(s)
- Meng‐Rui Li
- Renal Division, Department of MedicinePeking University First HospitalBeijingChina
- Institute of NephrologyPeking UniversityBeijingChina
- Key Laboratory of Renal DiseaseMinistry of Health of ChinaBeijingChina
- Research Units of Diagnosis and Treatment of Immune‐mediated Kidney DiseasesChinese Academy of Medical SciencesBeijingChina
| | - Zi‐Jun Sun
- Renal Division, Department of MedicinePeking University First HospitalBeijingChina
- Institute of NephrologyPeking UniversityBeijingChina
- Key Laboratory of Renal DiseaseMinistry of Health of ChinaBeijingChina
- Research Units of Diagnosis and Treatment of Immune‐mediated Kidney DiseasesChinese Academy of Medical SciencesBeijingChina
| | - Dong‐Yuan Chang
- Renal Division, Department of MedicinePeking University First HospitalBeijingChina
- Institute of NephrologyPeking UniversityBeijingChina
- Key Laboratory of Renal DiseaseMinistry of Health of ChinaBeijingChina
- Research Units of Diagnosis and Treatment of Immune‐mediated Kidney DiseasesChinese Academy of Medical SciencesBeijingChina
| | - Xiao‐Juan Yu
- Renal Division, Department of MedicinePeking University First HospitalBeijingChina
- Institute of NephrologyPeking UniversityBeijingChina
- Key Laboratory of Renal DiseaseMinistry of Health of ChinaBeijingChina
- Research Units of Diagnosis and Treatment of Immune‐mediated Kidney DiseasesChinese Academy of Medical SciencesBeijingChina
| | - Su‐Xia Wang
- Renal Division, Department of MedicinePeking University First HospitalBeijingChina
- Institute of NephrologyPeking UniversityBeijingChina
- Key Laboratory of Renal DiseaseMinistry of Health of ChinaBeijingChina
- Research Units of Diagnosis and Treatment of Immune‐mediated Kidney DiseasesChinese Academy of Medical SciencesBeijingChina
| | - Min Chen
- Renal Division, Department of MedicinePeking University First HospitalBeijingChina
- Institute of NephrologyPeking UniversityBeijingChina
- Key Laboratory of Renal DiseaseMinistry of Health of ChinaBeijingChina
- Research Units of Diagnosis and Treatment of Immune‐mediated Kidney DiseasesChinese Academy of Medical SciencesBeijingChina
| | - Ming‐Hui Zhao
- Renal Division, Department of MedicinePeking University First HospitalBeijingChina
- Institute of NephrologyPeking UniversityBeijingChina
- Key Laboratory of Renal DiseaseMinistry of Health of ChinaBeijingChina
- Research Units of Diagnosis and Treatment of Immune‐mediated Kidney DiseasesChinese Academy of Medical SciencesBeijingChina
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18
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Association Between Diabetes and Major Bleeding Complications of Renal Biopsy. Kidney Int Rep 2022; 7:232-240. [PMID: 35155862 PMCID: PMC8821035 DOI: 10.1016/j.ekir.2021.11.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/05/2021] [Accepted: 11/08/2021] [Indexed: 12/23/2022] Open
Abstract
Introduction Nephrologists have recently recognized the heterogeneity of kidney diseases among patients with diabetes and begun to actively perform percutaneous renal biopsies (PRBs). Nevertheless, the association between diabetes and major bleeding complications of PRB remains unclear. Methods In this retrospective cohort study using the Diagnosis Procedure Combination database in Japan, we identified patients who underwent an elective PRB from July 2010 to March 2018. The primary outcome was the occurrence of major bleeding complications, defined as red blood cell transfusion within 7 days after PRB or invasive hemostasis after PRB. Multivariable regression analysis was performed to analyze the association between diabetes and major bleeding complications with adjustment for patient and hospital characteristics. Results We identified 76,302 patients, including 8245 with diabetes. The proportion of PRBs performed for patients with diabetes continuously increased over time. Major bleeding complications occurred in 678 patients (0.9%), including 622 (0.8%) with red blood cell (RBC) transfusion and 109 (0.1%) with invasive hemostasis. Diabetes was significantly associated with major bleeding complications (relative risk [RR] = 2.41; 95% CI 2.00–2.90). Among patients with diabetes, multiagent or insulin treatment had significant association with major bleeding complications (RR = 1.57; 95% CI 1.18–2.10), compared with single-agent diabetes treatment. Conclusion Diabetes is significantly associated with major bleeding complications of PRBs. Moreover, severity of diabetes has association with increases in major bleeding complications. Thus, nephrologists should carefully judge whether the anticipated benefits outweigh the relatively high risk of major bleeding complications when considering PRB for patients with diabetes.
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19
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Zhou T, Wang Y, Shen L, Li X, Jiao Q, Li Z, Jia J, He L, Zhang Q, Wang N, Fan Y. Clinical and Histological Predictors of Renal Survival in Patients with Biopsy-Proven Diabetic Nephropathy. KIDNEY DISEASES (BASEL, SWITZERLAND) 2022; 8:93-101. [PMID: 35224010 PMCID: PMC8820162 DOI: 10.1159/000518222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 06/29/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION Clinical indicators or pathological features alone cannot reliably predict renal survival in patients with biopsy-confirmed diabetic nephropathy (DN). Therefore, this analysis sought to develop and validate a predictive model incorporating both clinical and pathological markers to predict renal outcomes in patients with biopsy-confirmed DN. METHODS A predictive nomogram was developed based upon data pertaining to 194 patients with biopsy-confirmed DN. The prognostic relevance of individual clinicopathological variables was assessed through univariate and multivariate Cox regression analyses. A prognostic nomogram was then developed and validated based upon concordance (C)-index values and calibration curves. Internal validation was conducted through bootstrap resampling, while the clinical utility of this model was assessed via a decision curve analysis (DCA) approach. RESULTS Nephrotic-range 24-h proteinuria, late-stage CKD, glomerular classification III-IV, and IFTA score 2-3 were all identified as independent predictors of poor renal outcomes in DN patients and were incorporated into our final nomogram. Calibration curves revealed good agreement between predicted and actual 3- and 5-year renal survival in DN patients with the C-index value for this nomogram at 0.845 (95% CI: 0.826-0.864). DCA revealed that our nomogram was superior to models based solely upon clinical indicators. CONCLUSION A predictive nomogram incorporating clinical and pathological indicators was developed and validated for the prediction of renal survival outcomes in patients with biopsy-confirmed DN. This model will be of value to clinicians, as it can serve as an easy-to-use and reliable tool for physicians to guide patient management based on individualized risk.
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Affiliation(s)
- Ting Zhou
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yiyun Wang
- Department of Emergency, Shanghai United Family Hospital, Shanghai, China
| | - Li Shen
- Clinical Research Unit, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Xiaomei Li
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Qiong Jiao
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Ze Li
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Junjie Jia
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Li He
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Qunzi Zhang
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Niansong Wang
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Ying Fan
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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20
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Zhang Y, Jiang Q, Xie J, Qi C, Li S, Wang Y, Him YH, Chen Z, Zhang S, Li Q, Zhu Y, Li R, Liang X, Bai X, Wang W. Modified arteriosclerosis score predicts the outcomes of diabetic kidney disease. BMC Nephrol 2021; 22:281. [PMID: 34407751 PMCID: PMC8375127 DOI: 10.1186/s12882-021-02492-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 08/03/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The significance of renal arteriosclerosis in the prediction of the renal outcomes of diabetic kidney disease (DKD) remains undetermined. METHODS We enrolled 174 patients with DKD from three centres from January 2010 to July 2017. The severity and extent of arteriosclerosis were analysed on sections based on dual immunohistochemical staining of CD31 and α-smooth muscle actin. An X-tile plot was used to determine the optimal cut-off value. The primary endpoint was renal survival (RS), defined as the duration from renal biopsy to end-stage renal disease or death. RESULTS The baseline estimated glomerular filtration rate (eGFR) of 135 qualified patients was 45 (29 ~ 70) ml/min per 1.73 m2, and the average 24-h urine protein was 4.52 (2.45 ~ 7.66) g/24 h. The number of glomeruli in the biopsy specimens was 21.07 ± 9.7. The proportion of severe arteriosclerosis in the kidney positively correlated with the Renal Pathology Society glomerular classification (r = 0.28, P < 0.012), interstitial fibrosis and tubular atrophy (IFTA) (r = 0.39, P < 0.001), urine protein (r = 0.213, P = 0.013), systolic BP (r = 0.305, P = 0.000), and age (r = 0.220, P = 0.010) and significantly negatively correlated with baseline eGFR (r = - 0.285, P = 0.001). In the multivariable model, the primary outcomes were significantly correlated with glomerular class (HR: 1.72, CI: 1.15 ~ 2.57), IFTA (HR: 1.96, CI: 1.26 ~ 3.06) and the modified arteriosclerosis score (HR: 2.21, CI: 1.18 ~ 4.13). After risk adjustment, RS was independently associated with the baseline eGFR (HR: 0.97, CI: 0.96 ~ 0.98), urine proteinuria (HR: 1.10, CI: 1.04 ~ 1.17) and the modified arteriosclerosis score (HR: 2.01, CI: 1.10 ~ 3.67), and the nomogram exhibited good calibration and acceptable discrimination (C-index = 0.82, CI: 0.75 ~ 0.87). CONCLUSIONS The severity and proportion of arteriosclerosis may be helpful prognostic indicators for DKD.
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Affiliation(s)
- Yifan Zhang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Main Building, Room 1436, Guangzhou, 510080, Guangdong, China
- Division of Nephrology, Wenzhou Central Hospital, Wenzhou, 325000, China
| | - Qifeng Jiang
- Division of Renal Pathology, Guangzhou KingMed Diagnostic Laboratory LTD, Guangzhou, 510320, China
| | - Jianteng Xie
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Main Building, Room 1436, Guangzhou, 510080, Guangdong, China
- School of Medicine, South China University of Technology, Guangzhou, 510006, China
| | - Chunfang Qi
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Main Building, Room 1436, Guangzhou, 510080, Guangdong, China
- School of Medicine, South China University of Technology, Guangzhou, 510006, China
| | - Sheng Li
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Main Building, Room 1436, Guangzhou, 510080, Guangdong, China
- School of Medicine, South China University of Technology, Guangzhou, 510006, China
| | - Yanhui Wang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Main Building, Room 1436, Guangzhou, 510080, Guangdong, China
- Division of Nephrology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Yau Hok Him
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Main Building, Room 1436, Guangzhou, 510080, Guangdong, China
| | - Zujiao Chen
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Main Building, Room 1436, Guangzhou, 510080, Guangdong, China
| | - Shaogui Zhang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Main Building, Room 1436, Guangzhou, 510080, Guangdong, China
| | - Qiuling Li
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Main Building, Room 1436, Guangzhou, 510080, Guangdong, China
- Shantou University Medical College, Shantou, 515041, China
| | - Yuan Zhu
- Division of Nephrology, Wenzhou People's Hospital, Wenzhou, 325000, China
| | - Ruizhao Li
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Main Building, Room 1436, Guangzhou, 510080, Guangdong, China
| | - Xinling Liang
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Main Building, Room 1436, Guangzhou, 510080, Guangdong, China
| | - Xiaoyan Bai
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Main Building, Room 1436, Guangzhou, 510080, Guangdong, China
- School of Medicine, South China University of Technology, Guangzhou, 510006, China
| | - Wenjian Wang
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, 510515, China.
- Division of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Main Building, Room 1436, Guangzhou, 510080, Guangdong, China.
- School of Medicine, South China University of Technology, Guangzhou, 510006, China.
- Shantou University Medical College, Shantou, 515041, China.
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21
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Zhao L, Zhang J, Lei S, Ren H, Zou Y, Bai L, Zhang R, Xu H, Li L, Zhao Y, Cooper ME, Tong N, Zhang J, Liu F. Combining glomerular basement membrane and tubular basement membrane assessment improves the prediction of diabetic end-stage renal disease. J Diabetes 2021; 13:572-584. [PMID: 33352010 PMCID: PMC8246816 DOI: 10.1111/1753-0407.13150] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 11/17/2020] [Accepted: 12/20/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND To address the prognostic value of combining tubular basement membrane (TBM) and glomerular basement membrane (GBM) thickness in diabetic nephropathy (DN). METHODS This retrospective study enrolled 110 patients with type 2 diabetes and biopsy-proven DN from 2011 to 2018. The pathological findings were confirmed according to the Renal Pathology Society classifications. GBM and TBM thicknesses were determined using the Haas' direct measurement/arithmetic mean method and orthogonal intercept method, respectively. Cox proportional hazard models were used to investigate the hazard ratios (HRs) for the influence of combined GBM and TBM thickness for predicting end-stage renal disease (ESRD). RESULTS Patients were assigned to three groups according to the median GBM and TBM thickness: GBMlo TBMlo (GBM < 681 nm and TBM < 1200 nm), GBMhi TBMlo /GBMlo TBMhi (GBM ≥ 681 nm and TBM < 1200 nm, or GBM < 681 nm and TBM ≥ 1200 nm), and GBMhi TBMhi (GBM ≥ 681 nm and TBM ≥ 1200 nm). The GBMhi TBMlo /GBMlo TBMhi and GBMhi TBMhi groups displayed poorer renal function, a more severe glomerular classification and interstitial inflammation, and poorer renal survival rates than the GBMlo TBMlo group The GBMhi TBMlo /GBMlo TBMhi and GBMhi TBMhi groups had adjusted HRs of 1.49 (95% confidence interval [CI], 1.21-9.75) and 3.07 (95% CI, 2.87-12.78), respectively, compared with the GBMlo TBMlo group. CONCLUSIONS TBM thickness enhanced GBM thickness for renal prognosis in patients with type 2 diabetes.
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Affiliation(s)
- Lijun Zhao
- Division of NephrologyWest China Hospital of Sichuan UniversityChengduChina
- Division of General PracticeWest China Hospital of Sichuan UniversityChengduChina
| | - Junlin Zhang
- Division of NephrologyWest China Hospital of Sichuan UniversityChengduChina
| | - Song Lei
- Division of PathologyWest China Hospital of Sichuan UniversityChengduChina
| | - Honghong Ren
- Division of NephrologyWest China Hospital of Sichuan UniversityChengduChina
| | - Yutong Zou
- Division of NephrologyWest China Hospital of Sichuan UniversityChengduChina
| | - Lin Bai
- Histology and Imaging platform, Core Facility of West China HospitalChengduChina
| | - Rui Zhang
- Division of NephrologyWest China Hospital of Sichuan UniversityChengduChina
| | - Huan Xu
- Division of PathologyWest China Hospital of Sichuan UniversityChengduChina
| | - Lin Li
- Division of PathologyWest China Hospital of Sichuan UniversityChengduChina
| | - Yuancheng Zhao
- Division of NephrologyWest China Hospital of Sichuan UniversityChengduChina
| | - Mark E. Cooper
- Division of DiabetesCentral Clinical School, Monash UniversityMelbourneMelbourneAustralia
| | - Nanwei Tong
- Division of EndocrinologyWest China Hospital of Sichuan UniversityChengduChina
| | - Jie Zhang
- Histology and Imaging platform, Core Facility of West China HospitalChengduChina
| | - Fang Liu
- Division of NephrologyWest China Hospital of Sichuan UniversityChengduChina
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22
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Yamanouchi M, Furuichi K, Shimizu M, Toyama T, Yamamura Y, Oshima M, Kitajima S, Hara A, Iwata Y, Sakai N, Oba Y, Matsuoka S, Ikuma D, Mizuno H, Suwabe T, Hoshino J, Sawa N, Yuzawa Y, Kitamura H, Suzuki Y, Sato H, Uesugi N, Ueda Y, Nishi S, Yokoyama H, Nishino T, Samejima K, Kohagura K, Shibagaki Y, Makino H, Matsuo S, Ubara Y, Wada T. Serum hemoglobin concentration, as a reflection of renal fibrosis, and risk of renal decline in early-stages of diabetic kidney disease: a nationwide, biopsy-based cohort study. Nephrol Dial Transplant 2021; 37:489-497. [PMID: 34028524 DOI: 10.1093/ndt/gfab185] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Prognosticating disease progression in patients with diabetic kidney disease (DKD) is challenging, especially in the early stages of kidney disease. Anemia can occur in the early stages of kidney disease in diabetes. We therefore postulated that serum hemoglobin concentration, as a reflection of incipient renal tubulointerstitial impairment, can be used as a marker to predict DKD progression. METHODS Drawing on nationally representative data of patients with biopsy-proven DKD, 246 patients who had an estimated glomerular filtration rate (eGFR) ≥60 mL/min/1.73 m2 at renal biopsy were identified: aged 56 (45, 63); 62.6% men; Hb 13.3 (12.0, 14.5) g/dL; eGFR 76.2 (66.6, 88.6) mL/min/1.73 m2; urine albumin-to-creatinine ratio [UACR] 534 (100, 1480) mg/g Crea. Serum hemoglobin concentration were divided into quartiles: ≤12, 12.1-13.3, 13.4-14.5, and ≥14.6 g/dL. The association between serum hemoglobin concentration and the severity of renal pathological lesions was explored. A multivariable Cox regression model was used to estimate the risk of DKD progression (new onset of end-stage kidney disease, 50% reduction of eGFR, or doubling of serum creatinine). The incremental prognostic value of DKD progression by adding serum hemoglobin concentration to the known risk factors of DKD was assessed. RESULTS Serum hemoglobin levels negatively correlated with all renal pathological features, especially with the severity of interstitial fibrosis (ρ =-0.52; P < 0.001). During a median follow-up of 4.1 years, 95 developed DKD progression. Adjusting for known risk factors of DKD progression, the hazard ratio in the first, second, and third quartile (the fourth quartile as a reference) were 2.74 (95% CI 1.26-5.97), 2.33 (95% CI 1.07-5.75), and 1.46 (95% CI 0.71-3.64), respectively. Addition of the serum hemoglobin concentration to the known risk factors of DKD progression improved the prognostic value of DKD progression (the global chi-statistics increased from 55.1 to 60.8; P < 0.001). CONCLUSIONS Serum hemoglobin concentration, which reflects incipient renal fibrosis, can be useful for predicting DKD progression in the early stages of kidney disease.
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Affiliation(s)
- Masayuki Yamanouchi
- Nephrology Center, Toranomon Hospital, Tokyo, Japan.,Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan.,Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan.,Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Kengo Furuichi
- Department of Nephrology, Kanazawa Medical University School of Medicine, Ishikawa, Japan
| | - Miho Shimizu
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Tadashi Toyama
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Yuta Yamamura
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Megumi Oshima
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Shinji Kitajima
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Akinori Hara
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Yasunori Iwata
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan.,Division of Infection Control, Kanazawa University, Ishikawa, Japan
| | - Norihiko Sakai
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
| | - Yuki Oba
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | | | - Daisuke Ikuma
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Hiroki Mizuno
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Tatsuya Suwabe
- Nephrology Center, Toranomon Hospital, Tokyo, Japan.,Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Junichi Hoshino
- Nephrology Center, Toranomon Hospital, Tokyo, Japan.,Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Naoki Sawa
- Nephrology Center, Toranomon Hospital, Tokyo, Japan.,Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Yukio Yuzawa
- Department of Nephrology, Fujita Health University School of Medicine, Aichi, Japan
| | - Hiroshi Kitamura
- Department of Pathology, National Hospital Organization Chibahigashi National Hospital, Chiba, Japan
| | - Yoshiki Suzuki
- Health Administration Center, Niigata University, Niigata, Japan
| | - Hiroshi Sato
- Department of Internal Medicine, JR Sendai Hospital, Miyagi, Japan
| | - Noriko Uesugi
- Department of Pathology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yoshihiko Ueda
- Department of Pathology, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Shinichi Nishi
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Hitoshi Yokoyama
- Department of Nephrology, Kanazawa Medical University School of Medicine, Ishikawa, Japan
| | - Tomoya Nishino
- Department of Nephrology, Nagasaki University Hospital, Nagasaki, Japan
| | | | - Kentaro Kohagura
- Department of Cardiovascular Medicine, Nephrology and Neurology, University of the Ryukyus School of Medicine, Okinawa, Japan
| | - Yugo Shibagaki
- Division of Nephrology, Department of Internal Medicine, St. Marianna University School of Medicine, Kanagawa, Japan
| | | | - Seiichi Matsuo
- Division of Nephrology, Department of Internal Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital, Tokyo, Japan.,Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
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23
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Zhao L, Li L, Ren H, Zou Y, Zhang R, Wang S, Xu H, Zhang J, Liu F. Association between serum alkaline phosphatase and renal outcome in patients with type 2 diabetes mellitus. Ren Fail 2021; 42:818-828. [PMID: 32781868 PMCID: PMC7472471 DOI: 10.1080/0886022x.2020.1804402] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
This retrospective study included 299 patients with type 2 diabetes mellitus and biopsy-confirmed diabetic nephropathy (DN) to investigate the prognostic value of alkaline phosphatase (ALP) for renal outcome. Cox proportional hazards models were used to estimate the hazard ratios (HRs) for the serum ALP level on renal outcome, which was defined as end-stage renal disease (ESRD) or a 50% decline in estimated glomerular filtration rate (eGFR) from baseline. The median baseline ALP was 80 IU/L with an interquartile range of 64–97 IU/L. Serum ALP was negatively associated with eGFR but positively associated with proteinuria and renal interstitial fibrosis. During a median follow-up period of 23 months, ESRD or a 50% declined in the eGFR occurred in 156 (52.2%) patients. The highest quartile of ALP was significantly associated with poor renal outcome, as defined above (HR 2.38, 95% confidence interval [CI] 1.09–5.17), when adjusted for sociodemographics, baseline eGFR, proteinuria, liver function parameters, parathyroid hormone levels, and renal pathological findings. Each standard deviation higher in the natural log-transformed ALP was associated with a 25% increased risk for poor renal outcome. Additionally, there was a graded increase in the risk for poor renal outcome with higher ALP in patients with nephrotic-range proteinuria. However, no significant associations were observed between serum ALP levels and renal outcome in patients with non-nephrotic-range proteinuria. In conclusion, an elevated ALP level was independently associated with poor renal outcome in patients with type 2 diabetes mellitus and nephrotic-range proteinuria after multivariate adjustment.
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Affiliation(s)
- Lijun Zhao
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Lin Li
- Division of Pathology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Honghong Ren
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yutong Zou
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Rui Zhang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Shanshan Wang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Huan Xu
- Division of Pathology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Jie Zhang
- Key Laboratory of Transplant Engineering and Immunology, Ministry of Health, Regenerative Medicine Research Center, Chengdu, Sichuan, China
| | - Fang Liu
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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24
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Moriya T, Yamagishi T, Yoshida Y, Matsubara M, Ouchi M. Arteriolar hyalinosis is related to rapid GFR decline and long-standing GFR changes observed on renal biopsies in normo-microalbuminuric type 2 diabetic patients. J Diabetes Complications 2021; 35:107847. [PMID: 33468395 DOI: 10.1016/j.jdiacomp.2021.107847] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 12/15/2020] [Accepted: 12/27/2020] [Indexed: 12/25/2022]
Abstract
AIMS Whether or not renal structural changes, especially arteriolar hyalinosis, are related to the rate of renal functional decline and increase in urinary albumin excretion (UAE) at the early stage of diabetic nephropathy in patients with type 2 diabetes is still unknown. Our previous study determined that arteriolar hyalinosis is an independent risk factor for low GFR. We sought to determine whether arteriolar hyalinosis is also a risk factor for rapidly progressive decline in GFR. METHODS We evaluated 22 type 2 diabetic patients with normo- or microalbuminuria who took part in the previous study, to clarify which renal histological factors were associated with changes in UAE and the glomerular filtration rate (GFR) during 11.0 ± 3.0 years of follow-up. Light and electron microscopy-based morphometric analyses were performed to quantitatively evaluate the glomerular and interstitial structural changes. RESULTS In all 22 patients, the GFR was significantly decreased from baseline to follow-up, while the UAE did not change markedly between the 2 periods. After 11 ± 3 years of follow-up, the GFR was significantly lower in the rapid decliner group (annual rate of GFR decline ≥3.0%) than in the non-rapid decliner group (p = 0.017). The index of arteriolar hyalinosis (IAH) at baseline in the rapid decliners was significantly larger than in the non-rapid decliners (p = 0.015). The IAH showed a significant negative correlation with the GFR at follow-up (r = 0.50, p = 0.018) and the annual rate in the GFR decline (r = 0.47, p = 0.027) and significant positive correlations with UAE at follow-up (r = 0.46, p = 0.034) and the annual rate in the UAE increase (r = 0.57, p = 0.005). The GFR at follow-up in patients with IAH ≥2.0 was significantly decreased from baseline (p = 0.042) and significantly lower than that of the patients with IAH <2.0 (p = 0.026), which did not decrease significantly from baseline. The frequency of rapid decliners was larger in the IAH ≥2.0 than in the IAH <2.0 patients (p = 0.037). CONCLUSIONS Aggravated arteriolar hyalinosis was a risk factor for a rapid GFR decline. This finding might reflect initial changes in early diabetic nephropathy.
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Affiliation(s)
- Tatsumi Moriya
- Health Care Center, Kitasato University, Kanagawa, Japan.
| | | | - Yuki Yoshida
- Health Care Center, Kitasato University, Kanagawa, Japan
| | | | - Motoshi Ouchi
- Pharmacology and Toxicology, Dokkyo Medical University School of Medicine, Tochigi, Japan
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Solidified glomerulosclerosis, identified using single glomerular proteomics, predicts end-stage renal disease in Chinese patients with type 2 diabetes. Sci Rep 2021; 11:4658. [PMID: 33633132 PMCID: PMC7907371 DOI: 10.1038/s41598-021-83856-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 02/09/2021] [Indexed: 02/07/2023] Open
Abstract
Few histological prognostic indicators for end-stage renal disease (ESRD) have been validated in diabetic patients. This biopsy-based study aimed to identify nephropathological risk factors for ESRD in Chinese patients with type 2 diabetes. Histological features of 322 Chinese type 2 diabetic patients with biopsy-confirmed diabetic nephropathy (DN) were retrospectively analysed. Cox proportional hazards analysis was used to estimate the hazard ratio (HR) for ESRD. Single glomerular proteomics and immunohistochemistry were used to identify differentially expressed proteins and enriched pathways in glomeruli. During the median follow-up period of 24 months, 144 (45%) patients progressed to ESRD. In multivariable models, the Renal Pathology Society classification failed to predict ESRD, although the solidified glomerulosclerosis (score 1: HR 1.65, 95% confidence interval [CI] 1.04-2.60; score 2: HR 2.48, 95% CI 1.40-4.37) and extracapillary hypercellularity (HR 2.68, 95% CI 1.55-4.62) were identified as independent risk factors. Additionally, single glomerular proteomics, combined with immunohistochemistry, revealed that complement C9 and apolipoprotein E were highly expressed in solidified glomerulosclerosis. Therefore, solidified glomerulosclerosis and extracapillary hypercellularity predict diabetic ESRD in Chinese patients. Single glomerular proteomics identified solidified glomerulosclerosis as a unique pathological change that may be associated with complement overactivation and abnormal lipid metabolism.
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Morimoto K, Matsui M, Samejima K, Kanki T, Nishimoto M, Tanabe K, Murashima M, Eriguchi M, Akai Y, Iwano M, Shiiki H, Yamada H, Kanauchi M, Dohi K, Tsuruya K, Saito Y. Renal arteriolar hyalinosis, not intimal thickening in large arteries, is associated with cardiovascular events in people with biopsy-proven diabetic nephropathy. Diabet Med 2020; 37:2143-2152. [PMID: 32276289 DOI: 10.1111/dme.14301] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2020] [Indexed: 12/20/2022]
Abstract
AIMS Diabetic nephropathy, a pathologically diagnosed microvascular complication of diabetes, is a strong risk factor for cardiovascular events, which mainly involve arteries larger than those affected in diabetic nephropathy. However, the association between diabetic nephropathy pathological findings and cardiovascular events has not been well studied. We aimed to investigate whether the pathological findings in diabetic nephropathy are closely associated with cardiovascular event development. METHODS This retrospective cohort study analysed 377 people with type 2 diabetes and biopsy-proven diabetic nephropathy, with a median follow-up of 5.9 years (interquartile range 2.0 to 13.5). We investigated how cardiovascular events were impacted by two vascular diabetic nephropathy lesions, namely arteriolar hyalinosis and arterial intimal thickening, and by glomerular and interstitial lesions. RESULTS Of the 377 people with diabetic nephropathy, 331 (88%) and 295 (78%) had arteriolar hyalinosis and arterial intimal thickening, respectively. During the entire follow-up period, those with arteriolar hyalinosis had higher cardiovascular event rates in the crude Kaplan-Meier analysis than those without these lesions (P = 0.005, log-rank test). When fully adjusted for clinically relevant confounders, arteriolar hyalinosis independently predicted cardiovascular events [hazard ratio (HR) 1.99; 95% confidence interval (CI) 1.12, 3.86], but we did not find any relationship between arterial intimal thickening and cardiovascular events (HR 0.89; 95% CI 0.60, 1.37). Additionally, neither glomerular nor interstitial lesions were independently associated with cardiovascular events in the fully adjusted model. CONCLUSIONS Arteriolar hyalinosis, but not intimal thickening of large arteries, was strongly associated with cardiovascular events in people with diabetic nephropathy.
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Affiliation(s)
- K Morimoto
- Department of Nephrology, Nara Medical University, Nara, Japan
- First Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - M Matsui
- Department of Nephrology, Nara Medical University, Nara, Japan
- First Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - K Samejima
- Department of Nephrology, Nara Medical University, Nara, Japan
- First Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - T Kanki
- First Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - M Nishimoto
- Department of Nephrology, Nara Medical University, Nara, Japan
- First Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - K Tanabe
- Department of Nephrology, Nara Medical University, Nara, Japan
- First Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - M Murashima
- Department of Nephrology, Nara Medical University, Nara, Japan
- First Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - M Eriguchi
- Department of Nephrology, Nara Medical University, Nara, Japan
| | - Y Akai
- Department of Nephrology, Nara Medical University, Nara, Japan
- First Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - M Iwano
- First Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - H Shiiki
- First Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - H Yamada
- First Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - M Kanauchi
- First Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - K Dohi
- First Department of Internal Medicine, Nara Medical University, Nara, Japan
| | - K Tsuruya
- Department of Nephrology, Nara Medical University, Nara, Japan
| | - Y Saito
- First Department of Internal Medicine, Nara Medical University, Nara, Japan
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Di Paolo S, Fiorentino M, De Nicola L, Reboldi G, Gesualdo L, Barutta F, Natali A, Penno G, Fioretto P, Pugliese G. Indications for renal biopsy in patients with diabetes. Joint position statement of the Italian Society of Nephrology and the Italian Diabetes Society. Nutr Metab Cardiovasc Dis 2020; 30:2123-2132. [PMID: 33239162 DOI: 10.1016/j.numecd.2020.09.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/10/2020] [Indexed: 12/31/2022]
Abstract
AIMS This joint document of the Italian Society of Nephrology and the Italian Diabetes Society reviews the main indications to perform a renal biopsy in diabetic patients, according to the recommendations of a panel of experts based on all available scientific evidence. DATA SYNTHESIS Renal biopsy has a pivotal role in assessing the nature and severity of renal injury in patients with diabetic kidney disease (DKD). The procedure is mandatory in the presence of one of more of the following features: rapid onset or progression of albuminuria or sudden onset of nephrotic syndrome, rapid GFR decline with or without albuminuria, hematuria, active urine sediment, clinical and/or laboratory suspicion of other systemic diseases, and, in patients with type 1 diabetes, short diabetes duration and absence of retinopathy. Indeed, ~40% of diabetic individuals with kidney injury undergoing renal biopsy are affected by a non-diabetic renal disease (NDRD). Furthermore, the histological evaluation of patients with suspected classical diabetic nephropathy allows to define the extent of glomerular, tubulo-interstitial and vascular lesions, thus providing important prognostic (and potentially therapeutic) data. In the future, the indications for renal biopsy might be extended to the definition of the histological lesions underlying the "nonalbuminuric" DKD phenotypes, as well as to the evaluation of the response to treatment with the new anti-hyperglycemic drugs that provide cardiorenal protection. CONCLUSIONS In view of the heterogeneous clinical presentation and course of DKD and of the related heterogeneous histopathological patterns, a more extensive use of renal biopsy may be crucial to provide valuable information with important pathogenic, diagnostic, prognostic, and therapeutic implications.
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Affiliation(s)
| | | | - Luca De Nicola
- Nephrology and Dialysis Unit, Department of Advanced Medical and Surgical Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | | | - Loreto Gesualdo
- Department of Emergency and Organ Transplantation, "Aldo Moro" University, Bari, Italy; Nephrology, Dialysis and Transplantation Unit, "Policlinico" University Hospital, Bari, Italy
| | - Federica Barutta
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Andrea Natali
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy; Unit of Internal Medicine, University Hospital, Pisa, Italy
| | - Giuseppe Penno
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy; Diabetes Unit, University Hospital, Pisa, Italy
| | - Paola Fioretto
- Department of Medicine, University of Padua, Padua, Italy; Unit of Medical Clinic 3, Hospital of Padua, Padua, Italy
| | - Giuseppe Pugliese
- Department of Clinical and Molecular Medicine, "La Sapienza" University, Rome, Italy; Endocrine and Metabolic Unit, Sant'Andrea University Hospital, Rome, Italy
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An Y, Zhang C, Xu F, Li W, Zeng C, Xie L, Liu Z. Increased urinary miR-196a level predicts the progression of renal injury in patients with diabetic nephropathy. Nephrol Dial Transplant 2020; 35:1009-1016. [PMID: 30521014 DOI: 10.1093/ndt/gfy326] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 09/07/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Recent data suggest that miR-196a is predominantly expressed in the kidney and plays an inhibitory role in the progress of renal interstitial fibrosis (IF). However, the predictive value of miR-196a in diabetic nephropathy (DN) remains unknown. We validated the role of urinary miR-196a in the progression of renal injury in a cohort of patients with type 2 diabetes mellitus. METHODS Our study included 209 patients with biopsy-proven DN. The mean follow-up time was 54.03 ± 32.94 months. Histological lesions were assessed using the pathological classification established by the Renal Pathology Society. Percentages of IF and tubular atrophy were assessed using the Aperio ScanScope system. We measured the correlation of urinary miR-196a with clinical and pathological parameters using the Spearman's correlation test. The influence of urinary miR-196a on renal outcomes was assessed using Cox regression analysis. RESULTS Urinary miR-196a levels correlated positively with proteinuria (ρ = 0.385, P < 0.001), duration of diabetes mellitus (ρ = 0.255, P < 0.001) and systolic blood pressure (ρ = 0.267, P < 0.001). The baseline estimated glomerular filtration rate (eGFR) and hemoglobin level showed a negative correlation with urinary miR-196a (ρ = -0.247, P < 0.001 and ρ = -0.236, P = 0.001, respectively). Pathologically, urinary miR-196a levels correlated with glomerular sclerosis and IF in patients with DN. Urinary miR-196a was significantly associated with progression to end-stage renal disease [hazard ratio (HR) 2.03, P < 0.001] and a 40% reduction of baseline eGFR (HR 1.75, P = 0.001), independent of age, gender, body mass index, mean arterial pressure and hemoglobinA1c level. However, urinary miR-196a did not improve predictive power to proteinuria and eGFR in DN patients. CONCLUSIONS Increased urinary miR-196a was significantly associated with the progression of renal injury and might be a noninvasive prognostic marker of renal fibrosis in DN patients.
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Affiliation(s)
- Yu An
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Changming Zhang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Feng Xu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Wei Li
- Shanghai Center for Bioinformation Research Technology, Shanghai Academy of Science and Technology, Shanghai, China
| | - Caihong Zeng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Lu Xie
- Shanghai Center for Bioinformation Research Technology, Shanghai Academy of Science and Technology, Shanghai, China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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Zhao L, Wang X, Wang T, Fan W, Ren H, Zhang R, Zou Y, Xu H, Zhang J, Wu Y, Liu F. Associations Between High-Altitude Residence and End-Stage Kidney Disease in Chinese Patients with Type 2 Diabetes. High Alt Med Biol 2020; 21:396-405. [PMID: 33185478 DOI: 10.1089/ham.2020.0076] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Zhao, Lijun, Xi Wang, Tingli Wang, Wenxin Fan, Honghong Ren, Rui Zhang, Yutong Zou, Huan Xu, Jie Zhang, Yunhong Wu, and Fang Liu. Associations between high-altitude residence and end-stage kidney disease in Chinese patients with type 2 diabetes. High Alt Med Biol. 21:396-405, 2020. Background: This study investigated whether living at high altitude was associated with progression to end-stage kidney disease (ESKD) in Chinese patients with diabetic nephropathy (DN). Materials and Methods: This retrospective study included 369 patients with type 2 diabetes mellitus (T2DM) and biopsy-confirmed DN. Cox proportional hazards models were used to estimate hazard ratios (HRs) for the influence of living at high altitude on ESKD. Results: Patients living at ≥2,000 m above sea level were more likely to be Tibetan, and they had higher mean body mass indexes, glycosylated hemoglobin, hemoglobin concentrations, and baseline estimated glomerular filtration rates than those living at lower altitudes. During a median follow-up period of 20 months, 141 (38%) patients progressed to ESKD. In multivariable Cox analysis adjusted for age, sex, ethnicity, and clinical and pathological parameters, living at high altitude was independently associated with progression to ESKD in Chinese DN patients [HR 2.83, 95% confidence interval (CI) 1.05-7.58]. Compared with Han Chinese, Tibetans were at a lower risk of progression to ESKD (HR 0.15, 95% CI 0.04-0.59). Conclusions: Living at high altitude was independently associated with renal outcome in Han Chinese patients with T2DM and DN, but not native Tibetans.
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Affiliation(s)
- Lijun Zhao
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Xi Wang
- Department of Endocrinology, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital. C.T.), Chengdu, China
| | - Tingli Wang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Wenxin Fan
- Department of Nephrology, The First Affiliated Hospital of Kunming Medical University, Chengdu, China
| | - Honghong Ren
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Rui Zhang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Yutong Zou
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
| | - Huan Xu
- Division of Pathology, West China Hospital of Sichuan University, Chengdu, China
| | - Jie Zhang
- Key Laboratory of Transplant Engineering and Immunology, Ministry of Health, Regenerative Medicine Research Center, Chengdu, China
| | - Yunhong Wu
- Department of Endocrinology, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region (Hospital. C.T.), Chengdu, China
| | - Fang Liu
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, China
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Tanaka K, Yamanaga S, Hidaka Y, Nishida S, Kinoshita K, Kaba A, Ishizuka T, Hamanoue S, Okumura K, Kawabata C, Toyoda M, Takeda A, Miyata A, Kashima M, Yokomizo H. HbA1c and Aortic Calcification Index as Noninvasive Predictors of Pre-Existing Histopathological Damages in Living Donor Kidney Transplantation. J Clin Med 2020; 9:jcm9103266. [PMID: 33053858 PMCID: PMC7601662 DOI: 10.3390/jcm9103266] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/08/2020] [Accepted: 10/08/2020] [Indexed: 11/16/2022] Open
Abstract
We previously reported that allografts from living donors may have pre-existing histopathological damages, defined as the combination of interstitial fibrosis (ci), tubular atrophy (ct), and arteriolar hyalinosis (ah) scores of ≧1, according to the Banff classification. We examined preoperative characteristics to identify whether the degree of these damages was related to metabolic syndrome-related factors of donors. We conducted a single-center cross-sectional analysis including 183 living kidney donors. Donors were divided into two groups: chronic change (ci + ct ≧ 1 ∩ ah ≧ 1, n = 27) and control (n = 156). Preoperative characteristics, including age, sex, blood pressure, hemoglobin A1c (HbA1c), aortic calcification index (ACI), and psoas muscle index (PMI), were analyzed. Comparing the groups, the baseline estimated glomerular filtration rate was not significantly different; however, we observed a significant difference for ACI (p = 0.009). HbA1c (p = 0.016) and ACI (p = 0.006) were independent risk factors to predict pre-existing histopathological damages, whereas PMI was not. HbA1c correlated with ct scores (p = 0.035), and ACI correlated with ci (p = 0.005), ct (p = 0.021), and ah (p = 0.017). HbA1c and ACI may serve as preoperative markers for identifying pre-existing damages on the kidneys of living donors.
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Affiliation(s)
- Kosuke Tanaka
- Department of Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan; (K.T.); (Y.H.); (S.N.); (K.K.); (A.K.); (K.O.); (H.Y.)
| | - Shigeyoshi Yamanaga
- Department of Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan; (K.T.); (Y.H.); (S.N.); (K.K.); (A.K.); (K.O.); (H.Y.)
- Correspondence:
| | - Yuji Hidaka
- Department of Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan; (K.T.); (Y.H.); (S.N.); (K.K.); (A.K.); (K.O.); (H.Y.)
| | - Sho Nishida
- Department of Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan; (K.T.); (Y.H.); (S.N.); (K.K.); (A.K.); (K.O.); (H.Y.)
| | - Kohei Kinoshita
- Department of Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan; (K.T.); (Y.H.); (S.N.); (K.K.); (A.K.); (K.O.); (H.Y.)
| | - Akari Kaba
- Department of Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan; (K.T.); (Y.H.); (S.N.); (K.K.); (A.K.); (K.O.); (H.Y.)
| | - Toshinori Ishizuka
- Department of Nephrology, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan; (T.I.); (S.H.); (C.K.); (M.T.); (A.M.); (M.K.)
| | - Satoshi Hamanoue
- Department of Nephrology, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan; (T.I.); (S.H.); (C.K.); (M.T.); (A.M.); (M.K.)
| | - Kenji Okumura
- Department of Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan; (K.T.); (Y.H.); (S.N.); (K.K.); (A.K.); (K.O.); (H.Y.)
| | - Chiaki Kawabata
- Department of Nephrology, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan; (T.I.); (S.H.); (C.K.); (M.T.); (A.M.); (M.K.)
| | - Mariko Toyoda
- Department of Nephrology, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan; (T.I.); (S.H.); (C.K.); (M.T.); (A.M.); (M.K.)
| | - Asami Takeda
- Department of Nephrology, Japanese Red Cross Nagoya Daini Hospital, Aichi 466-8650, Japan;
| | - Akira Miyata
- Department of Nephrology, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan; (T.I.); (S.H.); (C.K.); (M.T.); (A.M.); (M.K.)
| | - Masayuki Kashima
- Department of Nephrology, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan; (T.I.); (S.H.); (C.K.); (M.T.); (A.M.); (M.K.)
| | - Hiroshi Yokomizo
- Department of Surgery, Japanese Red Cross Kumamoto Hospital, Kumamoto 861-8520, Japan; (K.T.); (Y.H.); (S.N.); (K.K.); (A.K.); (K.O.); (H.Y.)
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Li M, Li CM, Ye ZC, Rao JL, Peng H, Lou TQ. A retrospective cohort study on the pathology and outcomes of type 2 diabetic patients with renal involvement. Int Urol Nephrol 2020; 53:333-341. [PMID: 33021708 DOI: 10.1007/s11255-020-02657-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 09/14/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To investigate the association of clinical and histological characteristics and the development of ESRD in T2DM patients with renal involvement. METHODS We conducted a retrospective analysis of clinical and pathologic data from T2DM patients who underwent renal biopsy (n = 120). RESULTS The mean age, duration of diabetes, and eGFR were 50.9 ± 11.2 years, 92.8 ± 41.3 months, 55.1 ± 42.3 mL/min/1.73 m2, respectively. Among these patients, 57 (47.5%) were diagnosed with diabetic nephropathy (DN), and 63 (52.5%) with non-diabetic renal disease (NDRD). The most common subtype of NDRD is membranous nephropathy. Compared with the NDRD group, the DN group had a longer duration of diabetes, worse renal function, and a higher proportion of diabetic retinopathy. Kaplan-Meier analysis showed that the 5-year renal survival rate of the DN group was only 41%, whereas that of the NDRD group was 84%. ESRD was defined as eGFR below 15 mL/min/1.73 m2. After multivariate adjustment, the risk of ESRD in DN patients was 3.81 times higher than that in NDRD patients. According to Glomerular Class, the 5-year renal survival rate of type IIA, IIB, III, and IV in the DN group was 88, 56, 28, and 15%, respectively. Kaplan-Meier analysis showed that there was a significant difference in renal survival among different glomerular classes or different interstitial fibrosis and tubular atrophy (IFTA) scores. But Cox proportional hazards analysis indicated that only IFTA score (HR 2.75, 95% CI 1.37-5.51, P = 0.001), but not the glomerular class (HR 1.21, 95% CI 0.73-2.00, P = 0.465), could predict renal outcome when adjusting for multivariate. CONCLUSION The prognosis of DN patients is significantly worse than that of NDRD patients. Compared with glomerular lesions, tubulointerstitial lesions were associated with higher risk for renal death in DN patients.
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Affiliation(s)
- Ming Li
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-Sen University, Tianhe Road 600#, Guangzhou, 510630, PR China
| | - Can-Ming Li
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-Sen University, Tianhe Road 600#, Guangzhou, 510630, PR China
| | - Zeng-Chun Ye
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-Sen University, Tianhe Road 600#, Guangzhou, 510630, PR China
| | - Jia-Ling Rao
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-Sen University, Tianhe Road 600#, Guangzhou, 510630, PR China
| | - Hui Peng
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-Sen University, Tianhe Road 600#, Guangzhou, 510630, PR China.
| | - Tan-Qi Lou
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-Sen University, Tianhe Road 600#, Guangzhou, 510630, PR China.
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Misra PS, Szeto SG, Krizova A, Gilbert RE, Yuen DA. Renal histology in diabetic nephropathy predicts progression to end-stage kidney disease but not the rate of renal function decline. BMC Nephrol 2020; 21:285. [PMID: 32682403 PMCID: PMC7368674 DOI: 10.1186/s12882-020-01943-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 07/12/2020] [Indexed: 12/12/2022] Open
Abstract
Background While histopathologic changes correlate with functional impairment in cross-sectional studies of diabetic nephropathy (DN), whether these findings predict future rate of kidney function loss remains uncertain. We thus sought to examine the relationship between kidney histopathology, incidence of end-stage kidney disease (ESKD), and rate of estimated glomerular filtration rate (eGFR) loss in DN. Methods In this longitudinal cohort study, we studied 50 adults diagnosed with biopsy-proven DN. We analyzed the histopathologic parameters of each patient’s kidney biopsy, as defined by the Renal Pathology Society classification system for DN, and tracked all available eGFR measurements post-biopsy. We additionally collected baseline clinical parameters (at the time of biopsy), including eGFR, albumin-to-creatinine ratio (ACR), and hemoglobin A1c. Multivariable linear regression was used to assess the relationship between histologic and clinical parameters at the time of the biopsy and eGFR slope. Kaplan-Meier curves and Cox regression were used to evaluate the association between histologic and clinical parameters and ESKD incidence. Results Progression to ESKD was associated with worsening interstitial fibrosis score (p = 0.05), lower baseline eGFR (p = 0.02), higher ACR (p = 0.001), and faster eGFR decline (p < 0.001). The rate of eGFR decline did not associate with any histologic parameter. Baseline ACR was the only studied variable correlating with eGFR slope (rho = − 0.41). Conclusions Renal histology predicts ultimate progression to ESKD, but not the rate of progression. Future work is required to identify novel predictors of rapid functional decline in patients with diabetic nephropathy.
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Affiliation(s)
- Paraish S Misra
- Division of Nephrology, St. Michael's Hospital, Unity Health Toronto and University of Toronto, 30 Bond St, Toronto, ON, M5B 1W8, Canada
| | - Stephen G Szeto
- Division of Nephrology, St. Michael's Hospital, Unity Health Toronto and University of Toronto, 30 Bond St, Toronto, ON, M5B 1W8, Canada
| | - Adriana Krizova
- Department of Pathology and Laboratory Medicine, St. Michael's Hospital, Unity Health Toronto and University of Toronto, 30 Bond St, Toronto, ON, M5B 1W8, Canada
| | - Richard E Gilbert
- Division of Endocrinology, St. Michael's Hospital, Unity Health Toronto and University of Toronto, 30 Bond St, Toronto, ON, M5B 1W8, Canada.,Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Rm 509, 5th Floor, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada
| | - Darren A Yuen
- Division of Nephrology, St. Michael's Hospital, Unity Health Toronto and University of Toronto, 30 Bond St, Toronto, ON, M5B 1W8, Canada. .,Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Rm 509, 5th Floor, 209 Victoria Street, Toronto, ON, M5B 1T8, Canada.
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Nonomura K, Iizuka K, Kuwabara-Ohmura Y, Yabe D. SGLT2 Inhibitor and GLP-1 Receptor Agonist Combination Therapy Substantially Improved the Renal Function in a Patient with Type 2 Diabetes: Implications for Additive Renoprotective Effects of the Two Drug Classes. Intern Med 2020; 59:1535-1539. [PMID: 32188813 PMCID: PMC7364240 DOI: 10.2169/internalmedicine.4323-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
A 72-year-old man had type 2 diabetes (T2D) that had been diagnosed at 54 years old. Macroalbuminuria was first detected at age 64. While his HbA1c had been kept below 7%, his estimated glomerular filtration rate (eGFR) was declining rapidly. At 70 years old, his eGFR dropped below 50 mL/min/1.73 m2. A renal biopsy revealed diabetic nephropathy. Sodium glucose transporter 2 inhibitors (SGLT2i)/glucagon-like peptide-1 receptor agonists (GLP-1RA) combination therapy substantially improved his eGFR and urinary albumin level, and the renoprotective effect persisted for the two-year study period. These findings suggest that SGLT2i and GLP-1RA can additively improve the renal function in patients with T2D.
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Affiliation(s)
- Kenta Nonomura
- Department of Diabetes and Endocrinology, Graduate School of Medicine, Gifu University, Japan
| | - Katsumi Iizuka
- Department of Diabetes and Endocrinology, Graduate School of Medicine, Gifu University, Japan
- Center for Nutritional Support and Infection Control, Gifu University Hospital, Japan
| | - Yayoi Kuwabara-Ohmura
- Department of Diabetes and Endocrinology, Graduate School of Medicine, Gifu University, Japan
| | - Daisuke Yabe
- Department of Diabetes and Endocrinology, Graduate School of Medicine, Gifu University, Japan
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Characteristic Renal Histology of a 81-Year-Old Patient with a 30-Year History of Diabetes Mellitus: A Case Report. CEN Case Rep 2020; 9:338-343. [PMID: 32361867 PMCID: PMC7502111 DOI: 10.1007/s13730-020-00483-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 04/21/2020] [Indexed: 11/07/2022] Open
Abstract
A renal histology of an 81-year-old man with a 30-year history of diabetes mellitus (DM), as well as diabetic retinopathy and neuropathy, was examined. The patient’s blood pressure was controlled within the normal range (less than 140/75 mmHg) using antihypertensive agents including angiotensin receptor blocker. Edematous management was achieved by a strict salt diet (less than 6 g/per day). However, this patient’s glycemic control was poor with HbA1c 8–10%. Serum creatinine was 0.87 mg/dL and estimated globular filtration rate (eGFR) was 64 ml/min/1.73m2. Urinary protein excretion was 1.5 g/day. This patient’s renal biopsy showed linear staining for IgG along the GBM by immunofluorescence microscopy, but light microscopy showed almost intact glomeruli, and the GBM was not thickened as revealed by electron microscopy with a width of 288–368 nm (< 430 nm). While arteriolar hyalinosis was severe, and polar vasculosis was observed around the glomerular vascular pole. This case indicates that long-standing hyperglycemia may induce polar vasculosis by the mechanism of angiogenesis, but diabetic glomerulopathy can become minor change, only when hypertension and edematous management could be controlled strictly.
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Jia C, Ke-Hong C, Fei X, Huan-Zi D, Jie Y, Li-Ming W, Xiao-Yue W, Jian-Guo Z, Ya-Ni H. Decoy receptor 2 mediation of the senescent phenotype of tubular cells by interacting with peroxiredoxin 1 presents a novel mechanism of renal fibrosis in diabetic nephropathy. Kidney Int 2020; 98:645-662. [PMID: 32739204 DOI: 10.1016/j.kint.2020.03.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 02/20/2020] [Accepted: 03/05/2020] [Indexed: 12/14/2022]
Abstract
Premature senescence of renal tubular epithelial cell (RTEC), which is involved in kidney fibrosis, is a key event in the progression of diabetic nephropathy. However, the underlying mechanism remains unclear. Here we investigated the role and mechanism of decoy receptor 2 (DcR2) in kidney fibrosis and the senescent phenotype of RTEC. DcR2 was specifically expressed in senescent RTEC and associated with kidney fibrosis in patients with diabetic nephropathy and mice with streptozotocin-induced with diabetic nephropathy. Knockdown of DcR2 decreased the expression of α-smooth muscle actin, collagen I, fibronectin and serum creatinine levels in streptozotocin-induced mice. DcR2 knockdown also inhibited the expression of senescent markers p16, p21, senescence-associated beta-galactosidase and senescence-associated heterochromatic foci and promoted the secretion of a senescence-associated secretory phenotype including IL-6, TGF-β1, and matrix metalloproteinase 2 in vitro and in vivo. However, DcR2 overexpression showed the opposite effects. Quantitative proteomics and validation studies revealed that DcR2 interacted with peroxiredoxin 1 (PRDX1), which regulated the cell cycle and senescence. Knockdown of PRDX1 upregulated p16 and cyclin D1 while downregulating cyclin-dependent kinase 6 expression in vitro, resulting in RTEC senescence. Furthermore, PRDX1 knockdown promoted DcR2-induced p16, cyclin D1, IL-6, and TGF-β1 expression, whereas PRDX1 overexpression led to the opposite results. Subsequently, DcR2 regulated PRDX1 phosphorylation, which could be inhibited by the specific tyrosine kinase inhibitor genistein. Thus, DcR2 mediated the senescent phenotype of RTEC and kidney fibrosis by interacting with PRDX1. Hence, DcR2 may act as a potential therapeutic target for the amelioration of diabetic nephropathy progression.
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Affiliation(s)
- Chen Jia
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Chen Ke-Hong
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Xiao Fei
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Dai Huan-Zi
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Yang Jie
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Wang Li-Ming
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Wang Xiao-Yue
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - Zhang Jian-Guo
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China
| | - He Ya-Ni
- Department of Nephrology, Daping Hospital, Army Medical University, Chongqing, China.
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Hoshino J. Introduction to clinical research based on modern epidemiology. Clin Exp Nephrol 2020; 24:491-499. [PMID: 32212004 PMCID: PMC7248022 DOI: 10.1007/s10157-020-01870-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 02/28/2020] [Indexed: 11/02/2022]
Abstract
Over the past 20 years, recent advances in science technologies have dramatically changed the styles of clinical research. Currently, it has become more popular to use recent modern epidemiological techniques, such as propensity score, instrumental variable, competing risks, marginal structural modeling, mixed effects modeling, bootstrapping, and missing data analyses, than before. These advanced techniques, also known as modern epidemiology, may be strong tools for performing good clinical research, especially in large-scale observational studies, along with relevant research questions, good databases, and the passion of researchers. However, to use these methods effectively, we need to understand the basic assumptions behind them. Here, I will briefly introduce the concepts of these techniques and their implementation. In addition, I would like to emphasize that various types of clinical studies, not only large database studies but also small studies on rare and intractable diseases, are equally important because clinicians always do their best to take care of many kinds of patients who suffer from various kidney diseases and this is our most important mission.
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Affiliation(s)
- Junichi Hoshino
- Toranomon Hospital, Nephrology Center, 2-2-2, Toranomon, Minato-ku, Tokyo, 105-8470, Japan.
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38
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Wang Y, Zhou T, Zhang Q, Fei Y, Li Z, Li S, He L, Zhang Q, Dong Y, Fan Y, Wang N. Poor Renal and Cardiovascular Outcomes in Patients with Biopsy-Proven Diabetic Nephropathy. Kidney Blood Press Res 2020; 45:378-390. [PMID: 32209792 DOI: 10.1159/000505919] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 01/13/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Despite the high mortality of cardiovascular disease (CVD) in diabetic patients with renal injury, few studies have compared cardiovascular characteristics and outcomes between patients with diabetic nephropathy (DN) and non-diabetic renal disease (NDRD). METHODS A total of 326 type 2 diabetes mellitus patients with renal biopsy were assigned to DN and NDRD groups. Echocardiography and Doppler ultrasound were performed to evaluate left ventricular hypertrophy (LVH) and peripheral atherosclerosis disease (PAD). Renal and cardiovascular survival rates were compared between the DN and NDRD groups by Kaplan-Meier analysis. Risk factors for renal and cardiovascular events in DN patients were identified by a Cox proportional hazards model. RESULTS In total, 179 patients entered the DN group (54.9%) and 147 made up the NDRD group (45.1%). The presence of diabetic retinopathy, family history of diabetes, and dependence on insulin therapy were associated with the presence of DN. DN patients had more CVD with more severe LVH and PAD. Poorer renal (log-rank χ2 = 26.534, p < 0.001) and cardiovascular (log-rank χ2 = 16.257, p < 0.001) prognoses were seen in the DN group. DR (HR 1.539, 95% CI 1.332-1.842), eGFR (HR 0.943, 95% CI 0.919-0.961), and 24-h proteinuria (HR 1.211, 95% CI 1.132-1.387) were identified as risk factors for renal endpoints. Age (HR 1.672, 95% CI 1.487-1.821), HbA1C (HR 1.398, 95% CI 1.197-1.876), and 24-h proteinuria (HR 1.453, 95% CI 1.289-1.672) were associated with cardiovascular endpoints. CONCLUSION Patients with DN had more severe CVD along with poorer renal and cardiovascular prognoses than those with NDRD.
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Affiliation(s)
- Yiyun Wang
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Ting Zhou
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Qiming Zhang
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yang Fei
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Ze Li
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Shiqi Li
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Li He
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Qunzi Zhang
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Yang Dong
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Ying Fan
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China,
| | - Niansong Wang
- Department of Nephrology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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Sun L, Shang J, Xiao J, Zhao Z. Development and validation of a predictive model for end-stage renal disease risk in patients with diabetic nephropathy confirmed by renal biopsy. PeerJ 2020; 8:e8499. [PMID: 32095345 PMCID: PMC7020820 DOI: 10.7717/peerj.8499] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 12/31/2019] [Indexed: 11/20/2022] Open
Abstract
This study was performed to develop and validate a predictive model for the risk of end-stage renal disease (ESRD) inpatients with diabetic nephropathy (DN) confirmed by renal biopsy. We conducted a retrospective study with 968 patients with T2DM who underwentrenal biopsy for the pathological confirmation of DNat the First Affiliated Hospital of Zhengzhou University from February 2012 to January 2015; the patients were followed until December 2018. The outcome was defined as a fatal or nonfatal ESRD event (peritoneal dialysis or hemodialysis for ESRD, renal transplantation, or death due to chronic renal failure or ESRD). The dataset was randomly split into development (75%) and validation (25%) cohorts. We used stepwise multivariablelogistic regression to identify baseline predictors for model development. The model’s performance in the two cohorts, including discrimination and calibration, was evaluated by the C-statistic and the P value of the Hosmer-Lemeshow test. During the 3-year follow-up period, there were 225 outcome events (47.1%) during follow-up. Outcomes occurred in 187 patients (52.2%) in the derivation cohort and 38 patients (31.7%) in the validation cohort. The variables selected in the final multivariable logistic regression after backward selection were pathological grade, Log Urinary Albumin-to-creatinine ratio (Log ACR), cystatin C, estimated glomerular filtration rate (eGFR) and B-type natriuretic peptide (BNP). 4 prediction models were created in a derivation cohort of 478 patients: a clinical model that included cystatin C, eGFR, BNP, Log ACR; a clinical-pathological model and a clinical-medication model, respectively, also contained pathological grade and renin-angiotensin system blocker (RASB) use; and a full model that also contained the pathological grade, RASB use and age. Compared with the clinical model, the clinical-pathological model and the full model had better C statistics (0.865 and 0.866, respectively, vs. 0.864) in the derivation cohort and better C statistics (0.876 and 0.875, respectively, vs. 0.870) in the validation cohort. Among the four models, the clinical-pathological model had the lowest AIC of 332.53 and the best P value of 0.909 of the Hosmer-Lemeshow test. We constructed a nomogram which was a simple calculator to predict the risk ratio of progression to ESRD for patients with DN within 3 years. The clinical-pathological model using routinely available clinical measurements was shown to be accurate and validated method for predicting disease progression in patients with DN. The risk model can be used in clinical practice to improve the quality of risk management and early intervention.
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Affiliation(s)
- Lulu Sun
- Nephrology Hospital, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan province, China
| | - Jin Shang
- Nephrology Hospital, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan province, China
| | - Jing Xiao
- Nephrology Hospital, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan province, China
| | - Zhanzheng Zhao
- Nephrology Hospital, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan province, China
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Zhao L, Ren H, Zhang J, Cao Y, Wang Y, Meng D, Wu Y, Zhang R, Zou Y, Xu H, Li L, Zhang J, Cooper ME, Tong N, Liu F. DIABETIC RETINOPATHY, CLASSIFIED USING THE LESION-AWARE DEEP LEARNING SYSTEM, PREDICTS DIABETIC END-STAGE RENAL DISEASE IN CHINESE PATIENTS. Endocr Pract 2020; 26:429-443. [PMID: 31968187 DOI: 10.4158/ep-2019-0512] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Objective: To characterize the relationship between diabetic retinopathy (DR) and diabetic nephropathy (DN) in Chinese patients and to determine whether the severity of DR predicts end-stage renal disease (ESRD). Methods: Bilateral fundic photographs of 91 Chinese type 2 diabetic patients with biopsy-confirmed DN, not in ESRD stage, were obtained at the time of renal biopsy in this longitudinal study. The baseline severity of DR was determined using the Lesion-aware Deep Learning System (RetinalNET) in an open framework for deep learning and was graded using the Early Treatment Diabetic Retinopathy Study severity scale. Cox proportional hazard models were used to estimate the hazard ratio (HR) for the effect of the severity of diabetic retinopathy on ESRD. Results: During a median follow-up of 15 months, 25 patients progressed to ESRD. The severity of retinopathy at the time of biopsy was a prognostic factor for progression to ESRD (HR 2.18, 95% confidence interval 1.05 to 4.53, P = .04). At baseline, more severe retinopathy was associated with poor renal function, and more severe glomerular lesions. However, 30% of patients with mild retinopathy and severe glomerular lesions had higher low-density lipo-protein-cholesterol and more severe proteinuria than those with mild glomerular lesions. Additionally, 3% of patients with severe retinopathy and mild glomerular changes were more likely to have had diabetes a long time than those with severe glomerular lesions. Conclusion: Although the severity of DR predicted diabetic ESRD in patients with type 2 diabetes mellitus and DN, the severities of DR and DN were not always consistent, especially in patients with mild retinopathy or microalbuminuria. Abbreviations: CI = confidence interval; DM = diabetic mellitus; DN = diabetic nephropathy; DR = diabetic retinopathy; eGFR = estimated glomerular filtration rate; ESRD = end-stage renal disease; HbA1c = hemoglobin A1c; HR = hazard ratio; NPDR = nonproliferative diabetic retinopathy; PDR = proliferative diabetic retinopathy; SBP = systolic blood pressure; T2DM = type 2 diabetes mellitus; VEGF = vascular endothelial growth factor.
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41
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Zhao L, Zou Y, Zhang J, Zhang R, Ren H, Li L, Guo R, Zhang J, Liu F. Serum transferrin predicts end-stage Renal Disease in Type 2 Diabetes Mellitus patients. Int J Med Sci 2020; 17:2113-2124. [PMID: 32922172 PMCID: PMC7484672 DOI: 10.7150/ijms.46259] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 07/16/2020] [Indexed: 02/05/2023] Open
Abstract
Background: To investigate the relationship between serum iron status and renal outcome in patients with type 2 diabetes mellitus (T2DM). Methods: Chinese patients (n=111) with T2DM and biopsy-proven diabetic nephropathy (DN) were surveyed in a longitudinal, retrospective study. Serum iron, total iron-binding capacity, ferritin, and transferrin were measured at the time of renal biopsy. Iron deposition and transferrin staining were performed with renal biopsy specimens of DN patients and potential kidney donors. End-stage renal disease (ESRD) was the end-point. ESRD was defined as an estimated glomerular filtration rate <15 mL/min/1.73 m2 or the need for chronic renal replacement therapy. Cox proportional hazard models were used to estimate the hazard ratios (HRs) for the influence of serum iron metabolism on ESRD. Results: During a median follow up of 30.9 months, 66 (59.5%) patients progressed to ESRD. After adjusting for age, sex, baseline systolic blood pressure, renal functions, hemoglobin, HbA1c, and pathological findings, lower serum transferrin concentrations were significantly associated with higher ESRD in multivariate models. Compared with patients in the highest transferrin quartile (≥1.65 g/L), patients in the lowest quartile (≤1.15 g/L) had multivariable-adjusted HR (95% confidence interval) of 7.36 (1.40-38.65) for ESRD. Moreover, tubular epithelial cells in DN exhibited a higher deposition of iron and transferrin expression compared with healthy controls. Conclusions: Low serum transferrin concentration was associated with diabetic ESRD in patients with T2DM. Free iron nephrotoxicity and poor nutritional status with accumulated iron or transferrin deposition might contribute to ESRD.
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Affiliation(s)
- Lijun Zhao
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China.,Division of General Practice, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Yutong Zou
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Junlin Zhang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Rui Zhang
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Honghong Ren
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Lin Li
- Division of Pathology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Ruikun Guo
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
| | - Jie Zhang
- Key Laboratory of Transplant Engineering and Immunology, Ministry of Health, Regenerative Medicine Research Center, Chengdu China
| | - Fang Liu
- Division of Nephrology, West China Hospital of Sichuan University, Chengdu, Sichuan, China
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Bermejo S, García-Carro C, Soler MJ. Diabetes and renal disease—should we biopsy? Nephrol Dial Transplant 2019; 36:1384-1386. [DOI: 10.1093/ndt/gfz248] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 10/03/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Clara García-Carro
- Nephrology Department, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Nephrology Research Group, Vall d’Hebron Research Institute, Barcelona, Spain
- GEENDIAB (Grupo Español de Estudio de la Nefropatía Diabética, working group from the Spanish Society of Nephrology). REDINREN (Red de Investigación renal
| | - María José Soler
- Nephrology Department, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
- Nephrology Research Group, Vall d’Hebron Research Institute, Barcelona, Spain
- GEENDIAB (Grupo Español de Estudio de la Nefropatía Diabética, working group from the Spanish Society of Nephrology). REDINREN (Red de Investigación renal
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Sato K, Kumagai N, Suzuki N. Alteration of the DNA Methylation Signature of Renal Erythropoietin-Producing Cells Governs the Sensitivity to Drugs Targeting the Hypoxia-Response Pathway in Kidney Disease Progression. Front Genet 2019; 10:1134. [PMID: 31798631 PMCID: PMC6863978 DOI: 10.3389/fgene.2019.01134] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 10/18/2019] [Indexed: 12/14/2022] Open
Abstract
Chronic kidney disease (CKD) affects more than 10% of the population worldwide and burdens citizens with heavy medical expenses in many countries. Because a vital erythroid growth factor, erythropoietin (EPO), is secreted from renal interstitial fibroblasts [renal EPO-producing (REP) cells], anemia arises as a major complication of CKD. We determined that hypoxia-inducible factor 2α (HIF2α), which is inactivated by HIF-prolyl hydroxylase domain-containing proteins (PHDs) in an oxygen-dependent manner, tightly regulates EPO production in REP cells at the gene transcription level to maintain oxygen homeostasis. HIF2α-mediated disassembly of the nucleosome in the EPO gene is also involved in hypoxia-inducible EPO production. In renal anemia patients, anemic and pathological hypoxia is ineffective toward EPO induction due to the inappropriate over-activation of PHDs in REP cells transformed into myofibroblasts (MF-REP cells) due to kidney damage. Accordingly, PHD inhibitory compounds are being developed for the treatment of renal anemia. However, our studies have demonstrated that the promoter regions of the genes encoding EPO and HIF2α are highly methylated in MF-REP cells, and the expression of these genes is epigenetically silenced with CKD progression. This finding notably indicates that the efficacy of PHD inhibitors depends on the CKD stage of each patient. In addition, a strategy for harvesting renal cells, including REP cells from the urine of patients, is proposed to identify plausible biomarkers for CKD and to develop personalized precision medicine against CKD by a non-invasive strategy.
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Affiliation(s)
- Koji Sato
- Division of Oxygen Biology, United Centers for Advanced Research and Translational Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.,Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Naonori Kumagai
- Department of Pediatrics, School of Medicine, Fujita Health University, Toyoake, Japan
| | - Norio Suzuki
- Division of Oxygen Biology, United Centers for Advanced Research and Translational Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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An immortalized cell line derived from renal erythropoietin-producing (REP) cells demonstrates their potential to transform into myofibroblasts. Sci Rep 2019; 9:11254. [PMID: 31375751 PMCID: PMC6677766 DOI: 10.1038/s41598-019-47766-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 07/23/2019] [Indexed: 12/22/2022] Open
Abstract
The erythroid growth factor erythropoietin (Epo) is produced by renal interstitial fibroblasts, called REP (renal Epo-producing) cells, in a hypoxia-inducible manner. In chronic kidney disease (CKD), REP cells lose their Epo-production ability, leading to renal anaemia. Concurrently, REP cells are suggested to be transformed into myofibroblasts, which are the major player of renal fibrosis. Although establishment of cultured cell lines derived from REP cells has been a long-term challenge, we here successfully established a REP-cell-derived immortalized and cultivable cell line (Replic cells) by using a genetically modified mouse line. Replic cells exhibited myofibroblastic phenotypes and lost their Epo-production ability, reflecting the situation in renal fibrosis. Additionally, we found that cell-autonomous TGFβ signalling contributes to maintenance of the myofibroblastic features of Replic cells. Furthermore, the promoters of genes for Epo and HIF2α, a major activator of Epo gene expression, were highly methylated in Replic cells. Thus, these results strongly support our contention that REP cells are the origin of myofibroblasts in fibrotic kidneys and demonstrate that cell-autonomous TGFβ signalling and epigenetic silencing are involved in renal fibrosis and renal anaemia, respectively, in CKD. The Replic cell line is a useful tool to further investigate the molecular mechanisms underlying renal fibrosis.
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Scurt FG, Menne J, Brandt S, Bernhardt A, Mertens PR, Haller H, Chatzikyrkou C. Systemic Inflammation Precedes Microalbuminuria in Diabetes. Kidney Int Rep 2019; 4:1373-1386. [PMID: 31701047 PMCID: PMC6829192 DOI: 10.1016/j.ekir.2019.06.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/22/2019] [Accepted: 06/03/2019] [Indexed: 12/13/2022] Open
Abstract
Aim The aim of the case-control study was to investigate if serum biomarkers indicative of vascular inflammation and endothelial dysfunction can predict the development of microalbuminuria in patients with diabetes mellitus type 2. Methods Among participants enrolled in the ROADMAP (Randomized Olmesartan And Diabetes MicroAlbuminuria Prevention) and observational follow-up (OFU) studies, a panel of 15 serum biomarkers was quantified from samples obtained at initiation of the study and tested for associations with the development of new-onset microalbuminuria during follow-up. A case-control study was conducted with inclusion of 172 patients with microalbuminuria and 188 matched controls. Nonparametric inferential, nonlinear regression, mediation, and bootstrapping statistical methods were used for the analysis. Results The median follow-up time was 37 months. At baseline, mean concentrations of C-X-C motif chemokine ligand 16 (CXCL-16), transforming growth factor (TGF)–β1 and angiopoietin-2 were higher in patients with subsequent microalbuminuria. In the multivariate analysis, after adjustment for age, sex, body mass index, glycated hemoglobin, duration of diabetes, low-density lipoprotein (LDL), smoking status, blood pressure, baseline urine albumin-to-creatinine ratio (UACR), estimated glomerular filtration rate (eGFR), time of follow-up and cardiovascular disease, CXCL-16 (odds ratio [OR] 2.60, 95% confidence interval [CI] 1.71–3.96), angiopoietin-2 (OR 1.50, 95% CI 1.14–1.98) and TGF-β1 (OR 1.03, 95% CI 1.01–1.04) remained significant predictors of new-onset microalbuminuria (P < 0.001). Inclusion of these biomarkers in conventional clinical risk models for prediction of microalbuminuria increased the area under the curve (AUC) from 0.638 to 0.760 (P < 0.001). Conclusion In patients with type 2 diabetes, elevated plasma levels of CXCL-16, angiopoietin-2, and TGF-β1 are independently predictive of microalbuminuria. Thus, these serum markers improve renal risk models beyond established clinical risk factors.
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Affiliation(s)
- Florian G Scurt
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Health Campus Immunology, Infectiology, and Inflammation, Otto-von-Guericke University, Magdeburg, Germany
| | - Jan Menne
- Nephrology Section, Hanover Medical School, Hanover, Germany
| | - Sabine Brandt
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Health Campus Immunology, Infectiology, and Inflammation, Otto-von-Guericke University, Magdeburg, Germany
| | - Anja Bernhardt
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Health Campus Immunology, Infectiology, and Inflammation, Otto-von-Guericke University, Magdeburg, Germany
| | - Peter R Mertens
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Health Campus Immunology, Infectiology, and Inflammation, Otto-von-Guericke University, Magdeburg, Germany
| | - Hermann Haller
- Nephrology Section, Hanover Medical School, Hanover, Germany
| | - Christos Chatzikyrkou
- Clinic of Nephrology, Hypertension, Diabetes and Endocrinology, Health Campus Immunology, Infectiology, and Inflammation, Otto-von-Guericke University, Magdeburg, Germany.,Nephrology Section, Hanover Medical School, Hanover, Germany
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Yamanouchi M, Mori M, Hoshino J, Kinowaki K, Fujii T, Ohashi K, Furuichi K, Wada T, Ubara Y. Retinopathy progression and the risk of end-stage kidney disease: results from a longitudinal Japanese cohort of 232 patients with type 2 diabetes and biopsy-proven diabetic kidney disease. BMJ Open Diabetes Res Care 2019; 7:e000726. [PMID: 31798893 PMCID: PMC6861100 DOI: 10.1136/bmjdrc-2019-000726] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 09/02/2019] [Accepted: 09/30/2019] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE The predictive value of diabetic retinopathy on end-stage kidney disease (ESKD) has not been fully addressed in patients with type 2 diabetes and diabetic kidney disease. RESEARCH DESIGN AND METHODS We studied 232 patients with type 2 diabetes and biopsy-proven diabetic kidney disease who were screened for diabetic retinopathy during the 1 month of kidney biopsy. We examined the association between retinopathy progression and renal lesions. We used Cox regression analyses to explore the risk of ESKD adjusting for known risk demographic and clinical variables. We assessed the incremental prognostic value of ESKD by adding diabetic retinopathy to the clinical variables. RESULTS The diabetic retinopathy progression positively correlated with all scores of renal lesions, especially with the glomerular-based classification (r=0.41), scores of interstitial fibrosis (r=0.41) and diffuse lesion (r=0.48). During a median follow-up of 5.7 years, 114 patients developed ESKD. Adjusting for known risk factors of ESKD, the HR for ESKD (patients with no apparent retinopathy as a reference) were 1.96 (95% CI 0.62 to 6.17) for patients with mild non-proliferative diabetic retinopathy (NPDR), 3.10 (95% CI 1.45 to 6.65) for patients with moderate NPDR, 3.03 (95% CI 1.44 to 6.37) for patients with severe NPDR, and 3.43 (95% CI 1.68 to 7.03) for patients with proliferative diabetic retinopathy, respectively. Addition of the retinopathy grading to the clinical model alone improved the prognostic value (the global χ2 statistic increased from 155.2 to 164.5; p<0.001), which is an improvement equivalent to the addition of the renal lesion grading to the clinical model. CONCLUSIONS Retinopathy progression appeared to be associated with renal lesions and the development of ESKD. Our findings suggest that diabetic retinopathy and kidney disease share the same magnitude of disease progression, and therefore diabetic retinopathy may be useful for prognosticating the clinical course for diabetic kidney disease.
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Affiliation(s)
- Masayuki Yamanouchi
- Nephrology Center, Toranomon Hospital, Tokyo, Japan
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
- Department of Nephrology and Laboratory Medicine, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Graduate School of Medical Sciences, Kanazawa University, Ishikawa, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | - Mikiro Mori
- Department of Ophthalmology, Toranomon Hospital, Tokyo, Japan
| | - Junichi Hoshino
- Nephrology Center, Toranomon Hospital, Tokyo, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo, Japan
| | | | - Takeshi Fujii
- Department of Pathology, Toranomon Hospital, Tokyo, Japan
| | - Kenichi Ohashi
- Department of Pathology, Yokohama City University Graduate School of Medicine, Kanagawa, Japan
| | - Kengo Furuichi
- Department of Nephrology, School of Medicine, Kanazawa Medical University, Ishikawa, Japan
| | - Takashi Wada
- Department of Nephrology and Laboratory Medicine, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health Sciences, Graduate School of Medical Sciences, Kanazawa University, Ishikawa, Japan
- Division of Nephrology, Kanazawa University Hospital, Ishikawa, Japan
| | - Yoshifumi Ubara
- Nephrology Center, Toranomon Hospital, Tokyo, Japan
- Nephrology Center, Toranomon Hospital Kajigaya, Kanagawa, Japan
- Okinaka Memorial Institute for Medical Research, Tokyo, Japan
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Zajjari Y, Aatif T, Hassani K, Benbria S, El Kabbaj D. Renal Histology in Diabetic Patients. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2018; 7:22-27. [PMID: 30787853 PMCID: PMC6381850 DOI: 10.4103/sjmms.sjmms_76_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Background: The diagnosis of diabetic nephropathy is based on the course of clinical manifestations and renal biopsy. Renal biopsy is usually performed in patients with atypical presentations. Objectives: This study was performed to analyze various renal histopathological lesions in diabetic patients and to establish a clinicopathological correlation. Materials and Methods: In this retrospective study, the authors analyzed renal histology of 40 patients with type 2 diabetes mellitus who presented with atypical features of diabetic renal involvement and underwent renal biopsy at the Military Hospital Mohammed V, Rabat, Morocco, between January 2008 and December 2016. Results: About 60% of the patients had isolated diabetic nephropathy, 35% had isolated nondiabetic renal diseases and 5% had both. Patients with nondiabetic renal diseases had significantly higher hematuria (P = 0.02), shorter duration of diabetes (P = 0.009), higher mean estimated glomerular filtration rate (P = 0.04) and lower prevalence of diabetic retinopathy (P < 0.001). The most common histological lesion in patients with nondiabetic renal diseases was IgA nephropathy (25%). In patients with diabetic nephropathy, the most common histological class was Class III (42.3%). Furthermore, higher histological classes were associated with lower estimated glomerular filtration rate (P < 0.001) as well as higher prevalence of diabetic retinopathy (P = 0.009) and nephrotic proteinuria (P = 0.04). Conclusions: This study found that in Rabat, Morocco, the most common histopathological lesion in patients with diabetes was diabetic nephropathy. Hematuria, shorter duration of diabetes, higher mean estimated glomerular filtration rate and lower prevalence of diabetic retinopathy were reported among those with nondiabetic renal diseases. These findings are in accord with that of studies from other countries. However, large sample size and long-term follow-up clinical studies are needed to demonstrate the renal pathological implications and renal outcomes in type 2 diabetes mellitus patients with renal involvement.
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Affiliation(s)
- Yassir Zajjari
- Department of Nephrology-Dialysis, Military Hospital Mohammed V, Rabat, Morocco
| | - Taoufiq Aatif
- Department of Nephrology-Dialysis, Military Hospital Mohammed V, Rabat, Morocco
| | - Kawtar Hassani
- Department of Nephrology-Dialysis, Military Hospital Mohammed V, Rabat, Morocco
| | - Sanaa Benbria
- Department of Nephrology-Dialysis, Military Hospital Mohammed V, Rabat, Morocco
| | - Driss El Kabbaj
- Department of Nephrology-Dialysis, Military Hospital Mohammed V, Rabat, Morocco
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Furuichi K, Yuzawa Y, Shimizu M, Hara A, Toyama T, Kitamura H, Suzuki Y, Sato H, Uesugi N, Ubara Y, Hisano S, Ueda Y, Nishi S, Yokoyama H, Nishino T, Kohagura K, Ogawa D, Mise K, Shibagaki Y, Kimura K, Haneda M, Makino H, Matsuo S, Wada T. Nationwide multicentre kidney biopsy study of Japanese patients with type 2 diabetes. Nephrol Dial Transplant 2018; 33:138-148. [PMID: 28340221 DOI: 10.1093/ndt/gfw417] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2016] [Accepted: 09/17/2016] [Indexed: 11/13/2022] Open
Abstract
Background The clinical and pathologic manifestations of nephropathy due to type 2 diabetes are diverse, but large-scale pathologic studies with long-term observations are limited. Methods Kidney biopsies and clinical data of 600 patients with type 2 diabetes were collected retrospectively from 13 centres across Japan. Thirteen pathologic findings (nine glomerular lesions, two interstitial lesions and two vascular lesions) were clearly defined and scored. Results During the observation period, there were 304 composite kidney events [dialysis, doubling of creatinine or reduction of estimated glomerular filtration rate (eGFR) by half], 31 instances of chronic kidney disease (CKD) G5D, 76 cardiovascular events and 73 deaths. The mean observation period was 72.4 months. The distribution of CKD heat map categories for the 600 patients was 103 green or yellow, 149 orange and 348 red. Even in the cases in the green and yellow category, diffuse lesions (81.6%), polar vasculosis (42.6%) and subendothelial space widening (35.1%) were commonly detected. Cox proportional hazard analysis revealed that the presence of nodular lesions [hazard ratio (HR) 21.1, 95% confidence interval (CI) 5.3-84.6], exudative lesions (HR 5.1, 95% CI 1.3-20.3) and mesangiolysis (HR 7.6, 95% CI 2.0-28.8) in cases in the green and yellow category were associated with significantly great impact on composite kidney events after adjustment for clinical risk factors. Conclusions This nationwide study on kidney biopsy of 600 cases with type 2 diabetes revealed that pathologic findings (presence of nodular lesions, exudative lesions and mesangiolysis) were strong predictors of kidney events in low-risk patients.
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Affiliation(s)
- Kengo Furuichi
- Division of Nephrology, Kanazawa University Hospital, Ishikawa, Japan
| | - Yukio Yuzawa
- Department of Nephrology, Fujita Health University Hospital, Aichi, Japan
| | - Miho Shimizu
- Division of Nephrology, Kanazawa University Hospital, Ishikawa, Japan
| | - Akinori Hara
- Division of Nephrology, Kanazawa University Hospital, Ishikawa, Japan
| | - Tadashi Toyama
- Division of Nephrology, Kanazawa University Hospital, Ishikawa, Japan
| | - Hiroshi Kitamura
- Department of Pathology, Clinical Research Center, National Hospital Organization Chiba East National Hospital, Chiba, Japan
| | - Yoshiki Suzuki
- Health Administration Center, Niigata University, Niigata, Japan
| | - Hiroshi Sato
- Clinical Pharmacology and Therapeutics, Tohoku University Graduate School of Pharmaceutical Sciences, Sendai, Japan
| | - Noriko Uesugi
- Department of Pathology, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | | | - Satoshi Hisano
- Department of Pathology, Faculty of Medicine, Fukuoka University, Fukuoka, Japan
| | - Yoshihiko Ueda
- Department of Diagnostic Pathology, Dokkyo Medical University Koshigaya Hospital, Saitama, Japan
| | - Shinichi Nishi
- Division of Nephrology and Kidney Center, Kobe University Graduate School of Medicine, Hyogo, Japan
| | - Hitoshi Yokoyama
- Department of Nephrology, Kanazawa Medical University School of Medicine, Ishikawa, Japan
| | - Tomoya Nishino
- Second Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki, Japan
| | - Kentaro Kohagura
- Department of Cardiovascular Medicine, Nephrology and Neurology, University of the Ryukyus School of Medicine, Okinawa, Japan
| | - Daisuke Ogawa
- Department of Diabetic Nephropathy, Okayama University, Okayama, Japan
| | - Koki Mise
- Department of Diabetic Nephropathy, Okayama University, Okayama, Japan
| | - Yugo Shibagaki
- Division of Nephrology and Hypertension, Department of Internal Medicine, St Marianna University School of Medicine, Kanagawa, Japan
| | | | - Masakazu Haneda
- Division of Metabolism and Biosystemic Science, Department of Medicine, Asahikawa Medical University, Hokkaido, Japan
| | - Hirofumi Makino
- Department of Diabetic Nephropathy, Okayama University, Okayama, Japan
| | - Seiichi Matsuo
- Division of Nephrology, Department of Internal Medicine, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Takashi Wada
- Division of Nephrology, Department of Nephrology and Laboratory Medicine, Kanazawa University, Ishikawa, Japan
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Yamakawa T, Kawaguchi T, Kitamura H, Kadomura M, Nishimura M, Yokoo T, Imasawa T. Glomerular basement membrane duplication is a predictor of the prognosis of diabetic nephropathy in patients with type 2 diabetes. Clin Exp Nephrol 2018; 23:521-529. [PMID: 30467801 DOI: 10.1007/s10157-018-1674-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 11/15/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Several clinical parameters and pathological findings are known to be predictors of the deterioration of diabetic nephropathy (DN). Glomerular basement membrane duplication (GBM-DP) is a pathological feature representing endothelial injury, which is commonly observed in DN. In the present study, we investigated the association between GBM-DP and the renal prognosis in DN. METHODS The study enrolled 80 patients with renal biopsy-proven DN who were managed at Chiba-East Hospital from 2005 to 2012. We confirmed the pathological findings according to the Renal Pathology Society classifications, and we further evaluated the GBM-DP, which was defined as double contours of the GBM that expanded more than 10% of capillary loops in the most affected nonsclerotic glomerulus. We used Cox regression models to estimate hazard ratios (HRs) for end-stage renal disease (ESRD), with adjustment for age, sex, systolic blood pressure, HbA1c, estimated glomerular filtration rate (eGFR), and urinary protein excretion (UP) at baseline. RESULTS Of the 80 patients, 56 were male (70.0%) and the mean age was 59.1 years. The median eGFR and UP were 42 ml/min/1.73 m2 (IQR 30, 59) and 3.1 g/gCr (IQR 1.2, 5.2). Twenty-seven patients progressed to ESRD and one patient died during the median observational period of 2.9 years (IQR 1.5, 4.3). The multivariable analyses showed that GBM-DP was significantly associated with ESRD (HR 3.18 [95% confidence interval (CI): 1.02-9.87], p = 0.045). CONCLUSION We newly identified GBM-DP as a strong prognostic predictor in DN patients. Further study is needed to clarify the pathogenic mechanism of GBM-DP in DN.
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Affiliation(s)
- Takafumi Yamakawa
- Department of Nephrology, National Hospital Organization Chiba-East Hospital, 673, Nitona, Chuou-ku, Chiba, 260-8712, Japan. .,Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.
| | - Takehiko Kawaguchi
- Department of Nephrology, National Hospital Organization Chiba-East Hospital, 673, Nitona, Chuou-ku, Chiba, 260-8712, Japan
| | - Hiroshi Kitamura
- Department of Pathology, National Hospital Organization Chiba-East Hospital, Chiba, Japan
| | - Moritoshi Kadomura
- Department of Nephrology, National Hospital Organization Chiba-East Hospital, 673, Nitona, Chuou-ku, Chiba, 260-8712, Japan
| | - Motonobu Nishimura
- Department of Nephrology, National Hospital Organization Chiba-East Hospital, 673, Nitona, Chuou-ku, Chiba, 260-8712, Japan
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan
| | - Toshiyuki Imasawa
- Department of Nephrology, National Hospital Organization Chiba-East Hospital, 673, Nitona, Chuou-ku, Chiba, 260-8712, Japan
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Oba S, Ayuzawa N, Nishimoto M, Kawarazaki W, Ueda K, Hirohama D, Kawakami-Mori F, Shimosawa T, Marumo T, Fujita T. Aberrant DNA methylation of Tgfb1 in diabetic kidney mesangial cells. Sci Rep 2018; 8:16338. [PMID: 30397232 PMCID: PMC6218490 DOI: 10.1038/s41598-018-34612-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 10/22/2018] [Indexed: 01/19/2023] Open
Abstract
Epigenetic modulation may underlie the progression of diabetic nephropathy (DN). Involvement of TGFB1 in mesangial fibrosis of DN led us to hypothesize that Tgfb1 DNA demethylation contributes to progression of DN. In primary mesangial cells from diabetic (db/db) mouse kidneys, demethylation of Tgfb1 DNA and upregulation of Tgfb1 mRNA progressed simultaneously. USF1 binding site in Tgfb1 promoter region were demethylated, and binding of USF1 increased, with decreased binding of DNMT1 in db/db compared with control. Given downregulation of Tgfb1 expression by folic acid, antioxidant Tempol reversed DNA demethylation, with increased and decreased recruitment of DNMT1 and USF1 to the promoter, resulting in decreased Tgfb1 expression in db/db mice. Addition of H2O2 to mesangial cells induced DNA demethylation and upregulated Tgfb1 expression. Finally, Tempol attenuated mesangial fibrosis in db/db mice. We conclude that aberrant DNA methylation of Tgfb1 due to ROS overproduction play a key to mesangial fibrosis during DN progression.
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Affiliation(s)
- Shigeyoshi Oba
- Division of Clinical Epigenetics, Research Center for Advanced Science and Technology, The University of Tokyo, Tokyo, Japan.
| | - Nobuhiro Ayuzawa
- Division of Clinical Epigenetics, Research Center for Advanced Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Mitsuhiro Nishimoto
- Division of Clinical Epigenetics, Research Center for Advanced Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Wakako Kawarazaki
- Division of Clinical Epigenetics, Research Center for Advanced Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Kohei Ueda
- Division of Clinical Epigenetics, Research Center for Advanced Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Daigoro Hirohama
- Division of Clinical Epigenetics, Research Center for Advanced Science and Technology, The University of Tokyo, Tokyo, Japan
| | | | - Tatsuo Shimosawa
- Department of Clinical Laboratory, International University of Health and Welfare, School of Medicine, Mita Hospital IUHW, Tokyo, Japan
| | - Takeshi Marumo
- Division of Clinical Epigenetics, Research Center for Advanced Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Toshiro Fujita
- Division of Clinical Epigenetics, Research Center for Advanced Science and Technology, The University of Tokyo, Tokyo, Japan.
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