Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial

BACKGROUND

Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001).

INTERPRETATION

Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor.

FUNDING

Boehringer Ingelheim and Eli Lilly.

Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial

BACKGROUND

The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population.

METHODS

EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110.

FINDINGS

Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1).

INTERPRETATION

In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease.

FUNDING

Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.

Formate-producing capacity provided by reducing ability of Streptococcus thermophilus nicotinamide adenine dinucleotide oxidase determines yogurt acidification rate

Yogurt is made by fermenting milk with 2 lactic acid bacteria, Lactobacillus delbrueckii ssp. bulgaricus and Streptococcus thermophilus. To comprehensively understand the protocooperation mechanism between S. thermophilus and L. bulgaricus in yogurt fermentation, we examined 24 combinations of cocultures comprising 7 fast- or slow-acidifying S. thermophilus strains with 6 fast- or slow-acidifying L. bulgaricus strains. Furthermore, 3 NADH oxidase (Nox)-deficient mutants (Δnox) and one pyruvate formate-lyase deficient mutant (ΔpflB) of S. thermophilus were used to evaluate the factor that determines the acidification rate of S. thermophilus. The results revealed that the acidification rate of S. thermophilus monoculture determined the yogurt fermentation rates, despite the coexistence of L. bulgaricus, whose acidification rate was either fast or slow. Significant correlation was found between the acidification rate of S. thermophilus monoculture and the amount of formate production. Result using ΔpflB showed that the formate was indispensable for the acidification of S. thermophilus. Moreover, results of the Δnox experiments revealed that formate production required Nox activity, which not only regulated dissolved oxygen, but also the redox potential. The Nox provided the large decrease in redox potential required by pyruvate formate-lyase to produce formate. A highly significant correlation was found between formate accumulation and Nox activity in S. thermophilus. In conclusion, the formate production ability provided by the action of Nox activity determines the acidification rate of S. thermophilus, and consequently, regulates yogurt coculture fermentation.

Preoperative protocol for right flank laparotomy affects postoperative serum cortisol concentrations in dairy cows

OBJECTIVE

To evaluate analgesic efficacy of 3 different preoperative protocols in cows undergoing right flank laparotomy for displaced abomasum.

ANIMALS

40 cows diagnosed with displaced abomasum.

PROCEDURES

The cows were assigned by block randomization to 1 of 3 preoperative protocols: inverted L-block using 50 mL of 2% lidocaine (ILB; n = 13), ILB plus preoperative flunixin meglumine (2 mg/kg, IV; ILB-F; 13), and dorsolumbar epidural anesthesia using 2% xylazine (0.8 mL) and 2% lidocaine (4 mL; EPI; 14). Venous blood samples were collected for CBC, serum biochemistry, and cortisol preoperatively and at 0 (immediately after), 3, 17, and 48 hours postoperatively.

RESULTS

The mean (95% CI) of the serum cortisol in ILB, ILB-F, and EPI were 108.7 (66.7 to 150.7), 150.7 (116.4 to 185.0), and 139.8 (93.4 to 186.3), respectively. The serum cortisol concentrations decreased over time in all groups (ILB, P = .001; ILB-F and EPI, P < .001). In the ILB group, the cortisol concentration at 17 and 48 hours postoperatively decreased (P = .026 and P = .009, respectively), compared with that preoperatively. In the ILB-F and EPI groups, the preoperative cortisol concentration was the highest and then decreased at 0, 3, 17, and 48 hours postoperatively (ILB-F, 0 hours [P = .001] and 3, 17, and 48 hours [P < .001]; EPI, all [P < .001]).

CLINICAL RELEVANCE

ILB-F and EPI improved intraoperative and immediate postoperative indicators of pain-related stress when compared to standard ILB. EPI requires less anesthetic, which may be beneficial when in short supply.

mRNA expression of immune factors by milk somatic cells from healthy Holstein lactating cows

This study investigated the mRNA of immune factors expressed by milk somatic cells from 72 healthy lactating Holstein cows on 1 farm. Milk samples were collected aseptically from the right front mammary gland before milking. The milk samples that had a negative reaction to the California mastitis test were used to analyze the mRNA of immune factors. Cows were divided into 2 groups based on the detection of bacteria in milk samples: positive group (n = 22 cows), which showed bacteria in cultures, and negative group (n = 50 cows), which did not show bacteria in cultures. There were significant positive correlations among the relative mRNA levels of interleukin (IL)-6, IL-8, arginase 1, chemokine (C-C motif) ligand (CCL) 1, and chemokine (C-X-C motif) ligand (CXCL) 13, as well as among the relative mRNA levels of IL-10, pentraxin 3, CCL5, and CCL14. Significantly high levels of IL-1β, IL-6, IL-8, arginase 1, Batf, CCL1, CXCL14, and toll-like receptor 4 in the positive group were discovered compared to the negative group. These results suggest that the presence of bacteria in lactating healthy dairy cows may affect mRNA levels of inflammatory mediators expressed by somatic cells.

Oxidative Stress Inhibits Endotoxin Tolerance and May Affect Periodontitis

Periodontal disease is caused by dysbiosis of the dental biofilm and the host inflammatory response. Various pathogenic factors, such as proteases and lipopolysaccharides (LPSs) produced by bacteria, are involved in disease progression. Endotoxin tolerance is a function of myeloid cells, which sustain inflammation and promote tissue regeneration upon prolonged stimulation by endotoxins such as LPS. The role of endotoxin tolerance is gaining attention in various chronic inflammatory diseases, but its role in periodontal disease remains elusive. Oxidative stress, one of the major risk factors for periodontal disease, promotes disease progression through various mechanisms, of which only some are known. The effect of oxidative stress on endotoxin tolerance has not yet been studied, and we postulated that endotoxin tolerance regulation may be an additional mechanism through which oxidative stress influences periodontal disease. This study aimed to reveal the effect of oxidative stress on endotoxin tolerance and that of endotoxin tolerance on periodontitis progression. The effect of oxidative stress on endotoxin tolerance was analyzed in vitro using peritoneal macrophages of mice and hydrogen peroxide (H₂O₂). The results showed that oxidative stress inhibits endotoxin tolerance induced by Porphyromonas gingivalis LPS in macrophages, at least partially, by downregulating LPS-elicited negative regulators of Toll-like receptor (TLR) signaling. A novel oxidative stress mouse model was established using SMP30KO mice incapable of ascorbate biosynthesis. Using this model, we revealed that oxidative stress impairs endotoxin tolerance potential in macrophages in vivo. Furthermore, gingival expression of endotoxin tolerance-related genes and TLR signaling negative regulators was decreased, and symptoms of ligature-induced periodontitis were aggravated in the oxidative stress mouse model. Our findings suggest that oxidative stress may contribute to periodontitis progression through endotoxin tolerance inhibition.

Real world research on transcranial magnetic stimulation treatment strategies for neuropsychiatric symptoms with long-COVID in Japan

The number of patients suffering from long-COVID is currently increasing rapidly, even after the acute symptoms of COVID-19 have improved. The objective of this study was to investigate the effects of a pilot transcranial magnetic stimulation (TMS) treatment on neuropsychiatric symptoms caused by long-COVID. In this study, we examined the efficacy of the TMS treatment protocol, which has been established to be effective in refractory depression, by applying it to patients who sought TMS treatment for neuropsychiatric symptoms caused by long-COVID at TMS clinics in Tokyo, Japan in the context of the real world TMS registry study in Japan. Of the 23 patients (13 females) with long-COVID included in this case series, the main neuropsychiatric symptoms were chronic fatigue (n = 12) and cognitive dysfunction (n = 11), but most patients also showed mild depressive symptoms. The mean score on the Montgomery-Åsberg Depression Rating Scale before TMS treatment was 21.2, which improved to 9.8 after treatment. Similarly, the score on the Performance Status, which assesses the degree of fatigue, improved from 5.4 to 4.2, and the score on the Perceived Deficits Questionnaire-Depression 5-item, which reflects cognitive function, improved from 10.0 to 6.3. Although a few patients complained of pain at the stimulation site during the TMS as a side effect, there were no serious adverse events. Despite the limitations of this open-label pilot study, the TMS protocol implemented in this study may have beneficial effects on neuropsychiatric symptoms caused by long-COVID, including depressive symptoms, chronic fatigue, and cognitive impairment. These preliminary findings warrant further validation in randomized controlled trials.

Association Between Nonadherence and Transient Hyperuricemia in Pediatric Kidney Transplantation

BACKGROUND

Nonadherence among pediatric transplant recipients is a significant problem that reduces graft survival and leads to poor kidney graft outcomes. It is, however, extremely difficult to detect during a regular follow-up. This study, therefore, aimed to investigate the risk factors involved in nonadherence, focusing on unexplained transient hyperuricemia in pediatric kidney transplant (KTx) recipients at a single pediatric center.

METHODS

This retrospective study included 167 patients who underwent KTx at our pediatric center. A Cox proportional hazards analysis was performed to evaluate the risk of nonadherence using the following factors: age, sex, body mass index SD score, transient hyperuricemia, hypertension, and follow-up period.

RESULTS

Nonadherence was identified in 19 patients (11%), with the average (SD) age and post-KTx duration at diagnosis being 17.21 (4.73) years and 79.21 (38.77) months, respectively. Thirty-four patients (20%) were diagnosed with transient hyperuricemia at a median of 14 months after KTx. On multivariate Cox regression analysis, transient hyperuricemia was the only independent risk factor for nonadherence after KTx.

CONCLUSIONS

Transient hyperuricemia was identified as one of the risk factors for nonadherence after KTx; therefore, careful monitoring for transient hyperuricemia may allow early detection of nonadherence.

Melanogenic effect of dersimelagon (MT-7117), a novel oral melanocortin 1 receptor agonist

Background

The activation of melanocortin 1 receptor (MC1R) on melanocytes stimulates the production of eumelanin. A tridecapeptide α melanocyte‐stimulating hormone (αMSH) is known to induce skin pigmentation.

Objectives

We characterised the properties of a novel oral MC1R agonist dersimelagon (MT‐7117) with respect to its specific binding to MC1R, downstream signalling and eumelanin production in experimental models.

Methods

The competitive binding and production of intracellular cyclic adenosine 3′, 5′‐monophosphate in cells expressing recombinant melanocortin receptors were examined. A mouse melanoma cell line B16F1 was used for the evaluation of in vitro melanin production. The in vitro activity of MT‐7117 was determined with αMSH and [Nle⁴, D‐Phe⁷]‐αMSH (NDP‐αMSH) as reference comparators. The change of coat colour and skin pigmentation were evaluated after repeat administration of MT‐7117 by oral gavage to C57BL/6J‐A^y/+ mice and cynomolgus monkeys, respectively.

Results

MT‐7117 showed the highest affinity for human MC1R compared to the other melanocortin receptors evaluated and agonistic activity for human, cynomolgus monkey and mouse MC1R, with EC₅₀ values in the nanomolar range. In B16F1 cells, MT‐7117 increased melanin production in a concentration‐dependent manner. In vivo, MT‐7117 (≥0.3 mg/kg/day p.o.) significantly induced coat colour darkening in mice. MT‐7117 (≥1 mg/kg/day p.o.) induced significant skin pigmentation in monkeys and complete reversibility was observed after cessation of its administration.

Conclusions

MT‐7117 is a novel oral MC1R agonist that induces melanogenesis in vitro and in vivo, suggesting its potential application for the prevention of phototoxic reactions in patients with photodermatoses, such as erythropoietic protoporphyria and X‐linked protoporphyria.

Effects of intra-articular inoculation with Mycoplasma bovis on immunological responses in calf joints

Mycoplasma arthritis that caused by Mycoplasma bovis exhibit severe lameness. This disease is difficult to cure with antibiotics, but the detailed pathological mechanisms have not been fully clarified. In this study, we examined the effects of intra-articular inoculation with M. bovis on immunological responses in calf joints. We inoculated three calves each with M. bovis or phosphate buffer saline (control) into the right stifle joint and dissected them at 15 days postinoculation. Mycoplasma bovis-inoculated calves exhibited swelling of the stifle joint, increases in synovial fluid, fibrin deposition, and cartilage thinning. Intracellular M. bovis was detected in synovial tissues analyzed by immunohistochemistry and transmission electron microscopy. Messenger RNA expressions of interleukin (IL)-1β, IL-6, IL-8, IL-12p40, and IL-17A in synovial fluid cells and synovial tissues from M. bovis-inoculated calves were significantly higher than those from control calves. Protein levels of these cytokines in synovial fluid from M. bovis-inoculated calves were markedly higher than those from control calves. Our study clarified that inoculation with M. bovis into the stifle joint induced the production of inflammatory cytokines by synovial fluid cells and synovial tissues, causing a severe inflammatory response in joints. Additionally, M. bovis could invade cells in synovial tissues, which may have aided it in evading antibiotics and host immune surveillance.

Comparison of distal forelimb conformations between Japanese Black and Holstein-Friesian newborn calves

Flexural and hyperextension deformities are congenital problems in calves. We, therefore, aimed to investigate the distal limb conformation in 1 day- and 28-day-old female Holstein-Friesian (HF) calves (n=21), male Japanese Black (JB) calves (n=15), and female JB calves (n=15). The claw angle of the forelimb dorsal claw wall in a standing position and recorded other parameters, including body weight, withers height, circumference of forelimbs, and flexor tendon thickness in the forelimbs, were measured and compared these between the three groups. At 1 day old, the mean claw angles were 51.1° in female HF calves, 47.0° in male JB calves, and 41.8° in female JB calves; the 95% confidence intervals (CIs) of the claw angles showed large distributions in all three groups. One female HF and one male JB calves showed mild flexural deformity, whereas four JB calves showed hyperextension deformity. At 28 days old, the mean claw angles were 51.7° in female HF calves, 51.2° in male JB calves, and 48.4° in female JB calves; the 95% CIs of the claw angles showed smaller distributions than those at 1 day old in all groups. For all groups, the limb deformities had improved without treatment at 28 days old. As a feature of the breed, female JB calves were apt to show hyperextended deformities inversely proportional to the body weight. These limb deformities healed spontaneously and were thought to be physiological.

Sesame lignans suppress age-related disorders of the kidney in mice

OBJECTIVE

Sesamin is a functional ingredient in sesame (Sesamum indicum) seeds and has many physiological effects. This study investigated whether sesame lignans, sesamin and episesamin (1:1), can suppress age-related disorders of the kidney.

MATERIALS AND METHODS

Twenty-month-old mice were divided into three groups, and each group received a regular diet (O-C), diet containing sesame lignans (O-SE), and diet containing sesame lignans and α-tocopherol (VE; O-SE+VE), respectively, for 5 months. Six-month-old young mice (Y-C) were compared to the older mice.

RESULTS

Renal lipofuscin deposition was increased in the O-C group compared to that in the Y-C group and its deposition with aging was significantly decreased in both O-SE and O-SE+VE groups. Plasma blood urea nitrogen levels in the O-C group increased compared to those in the Y-C group; however, those in both O-SE and O-SE+VE groups did not differ from those in the Y-C group. The number of podocytes in the O-C group decreased compared to that in the Y-C group and this effect was attenuated in the O-SE and O-SE+VE groups. The effect was strongest in the O-SE+VE group. Histological examinations showed that glomerular hypertrophy accompanied by mesangial hyperplasia and renal tubular degeneration was less severe in the O-SE and O-SE+VE groups than in the O-C group. Moreover, age-related increases in the mRNA expression of NADPH oxidase- and inflammation-related genes, including p67phox, p40phox, TNFα, and IL-6, in the kidney were suppressed in the O-SE and O-SE+VE groups.

CONCLUSIONS

Sesame lignans might be useful to suppress age-related kidney disorders, and these effects could be enhanced with VE.

Inflammatory cytokine mRNA and protein levels in the synovial fluid of Mycoplasma arthritis calves

Bovine Mycoplasma arthritis (MA) is caused by Mycoplasma bovis and exhibits severe clinical symptoms. However, the pathophysiology of bovine MA is incompletely understood. In this study, we examined the cytokine mRNA expression of synovial fluid (SF) cells and cytokine concentrations in the SF of MA calves. The SF was isolated from five clinically healthy (control) and seven MA calves. mRNA and protein levels of interleukin (IL)-1β, IL-6, IL-8, IL-12, and IL-17 in the SF from MA calves were significantly higher than those from control calves. Our results indicate that SF cells produce inflammatory cytokines, which mainly contribute to the severe inflammatory response in the joints of the MA calves.

Efficacy of cardiac rehabilitation with motion assistance from wearable cyborg hybrid assistive limb in patients with chronic heart failure: a randomized controlled trial

Background

Recent Cochrane Systematic Review suggested that the participation in cardiac rehabilitation is associated with approximately 20% lower cardiovascular mortality and morbidity. Exercise therapy is the key component of cardiac rehabilitation programs. In recent years, innovative technologies have been introduced into the field of rehabilitation, and a typical example is the wearable cyborg Hybrid Assistive Limb (HAL). The wearable cyborg HAL provides motion assistance based on detection of bioelectrical signals on the skin surface when muscle forces are generated. The lumbar-type HAL is expected to expand the therapeutic options for severe cardiac patients who have difficulty in performing usual cardiac rehabilitation programs, such as bicycle pedaling or walking.

Purpose

We aim to compare the efficacy of exercise therapy performed with motion assistance from a lumbar-type HAL versus conventional training (sit-to-stand exercise without HAL) in patients with chronic heart failure.

Methods

This clinical trial is a randomized, non-blinded, and controlled study. Twenty-eight heart failure patients (73.1±13.8 years) who have difficulty in walking at the usual walking speed of healthy subjects were randomly assigned to 2 groups (HAL group or control group) with a 1:1 allocation ratio and performed sit-to stand exercise either with HAL or without HAL for 5 to 30 minutes once a day, and 6 to 10 days during the study period. The brain natriuretic peptide (BNP), isometric knee extensor strength, standing ability (30-seconds chair-stand test: CS-30), short physical performance battery (SPPB) and 6-minute walking distance (6MWD) were measured before and after the completion of cardiac rehabilitation. Cardiac events such as death, re-hospitalization, myocardial infarction and worsening of angina pectoris and heart failure during 1 year after discharge were evaluated.

Results

There was no significant difference in the number of days of exercise therapy between the two groups. BNP, SPPB and 6MWD were improved in both groups. In the HAL group, the isometric knee extensor strength (0.29±0.11 vs 0.35±0.11 kgf/kg, p=0.003) significantly improved and CS-30 (5.5±5.1 vs 8.2±5.3, p=0.054) tended to improve. However, in the control group, either the isometric knee extensor strength (0.35±0.11 vs 0.36±0.14 kgf/kg, p=0.424) or CS-30 (6.0±4.3 vs 9.2±6.2, p=0.075) did not significantly change. HAL group showed significantly more improvement in the isometric knee extensor strength than control group (p=0.045). Cardiac events occurred in 20% in the HAL group and 43% in the control group.

Conclusion

The improvement in isometric knee extensor strength with the assistance from lumbar-type HAL suggests that exercise therapy using this device may be useful in chronic heart failure patients with flail or sarcopenia, a strong poor prognostic factor in these patients.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This work was supported in part by a grant-in-aid for Scientific Research from the Ministry of Education, Science, and Culture of Japan (JSPS KAKENHI grant number JP17K09485) and funded by the ImPACT Program of the Council for Science, Technology and Innovation (Cabinet Office, Government of Japan) (grant number 2017-PM05-03-01).

Impact of coronary plaque characteristics on periprocedural myocardial injury after elective percutaneous coronary intervention -MDCT and CMR analysis-

Background

Percutaneous coronary intervention (PCI) is often complicated by periprocedural myocardial injury (PMI) manifested by elevated cardiac biomarkers. The occurrence of PMI has been shown to be associated with worse clinical outcome over short- and long-term.

Purpose

We performed multidetector computed tomography (MDCT) and cardiac magnetic resonance imaging (CMR) to evaluate the relationship between culprit plaque characteristics and PMI.

Methods

A total of 90 patients who underwent elective PCI were underwent CMR and multidetector coronary tomography before PCI. The high intensity plaque (HIP) on CMR was defined as a coronary plaque to myocardium signal intensity ratio (PMR) of &gt;1.4. The plaque characteristics and the presence of napkin-ring sign (NRS) were analyzed on MDCT. PMI was defined as an increase in cardiac Troponin T levels to more than 5 times the upper limit of normal at 24 h after PCI. Patients were divided into 2 groups according to the presence (Group I, n=26) or absence (Group II, n=64) of PMI.

Results

Spotty calcification, positive remodeling, low attenuation plaque and NRS on MDCT were significantly more observed in Group I than in Group II. HIP on CMR was significantly more observed in Group I than in Group II. In the multivariable logistic regression analysis, the presence of NRS and HIP were significantly independent predictors of PMI (odds ratio (OR) 4.82, 95% confidence interval 1.13–20.60, P=0.034 and OR 3.66, 95% CI 1.09–12.30, P=0.036, respectively). Moreover, for prediction of PMI, NRS and HIP showed a high positive predictive value of 81%, and their absence showed a high negative predictive value of 91%.

Conclusions

MDCT and CMR may play an important role in detecting which lesions are high risks for myocardial necrosis after PCI in elective coronary stenting.

Funding Acknowledgement

Type of funding source: None

Association of coronary high-intensity plaque on T1-weighted magnetic resonance imaging and circulating malondialdehyde-modified low-density lipoprotein levels with cardiac events

Background

Although elevated oxidized low-density lipoprotein could play critical roles in vulnerable plaque, there are no studies that compared coronary high-intensity plaque (HIP) on non-contrast T1-weighted magnetic resonance imaging (T1WI_MRI) and circulating malondialdehyde-modified low-density lipoprotein (MDA-LDL) levels for the prediction of cardiac events.

Methods and results

A total of 139 patients with coronary artery stenosis (&gt;70%) were examined with non-contrast T1WI using a 1.5-T MRI (HIP: n=63, non-HIP: n=76). Scheduled percutaneous coronary intervention (PCI) for culprit lesions was performed within 48 h after MRI. HIP was defined as a signal intensity of coronary plaque to cardiac muscle ratio (PMR) of ≥1.4. At admission, circulating levels of MDA-LDL and other lipid-related markers were measured. We evaluated the subsequent cardiac events, which were defined as major adverse cardiac events (MACE; cardiac death, myocardial infarction, and/or ischemia-driven PCI) during follow-up periods (5.6±1.3 years). Circulating MDA-LDL levels were significantly higher in patients with HIP than in those without HIP (p&lt;0.0001). MDA-LDL levels were significantly correlated with PMR (r=0.490, p&lt;0.0001). In multivariable logistic regression analysis, MDA-LDL levels were independently associated with the presence of HIP (OR 1.05; 95% CI, 1.02–1.08, p&lt;0.0001). The incidence of MACE was significantly higher in patients with HIP (27%) than in those without HIP (5%; p=0.011 by the log-rank test). In the multivariable Cox proportional hazard analysis, the MDA-LDL levels (HR 1.03; 95% CI:1.01–1.05, p=0.007) and PMR (HR 2.39; 95% CI:1.19–4.65, p=0.016) were significantly associated with MACE. For MACE prediction, the C-statistic values for MDA-LDL, PMR, and PMR+MDA-LDL were 0.724, 0.791, and 0.800, respectively. Compared with MDA-LDL alone, the addition of PMR to MDA-LDL increased the net reclassification improvement by 0.78 (p=0.012).

Conclusions

MDA-LDL levels might be associated with the presence of HIP in patients with coronary artery disease. Furthermore, adding PMR to MDA-LDL levels markedly improved MACE prediction.

Funding Acknowledgement

Type of funding source: None

Pulmonary vein isolation for atrial fibrillation patients with reduced left ventricular ejection fraction

 

Background/Introduction Pulmonary vein isolation (PVI) is a cornerstone of curable treatment for atrial fibrillation (AF). Left ventricular (LV) ejection fraction (EF) occasionally improves after PVI in AF patients with reduced LVEF (rEF), the mechanism of which is not fully understood. CASTLE-AF trial have demonstrated that PVI with radiofrequency (RF) catheter for AF patients with rEF can reduce their mortality and heart failure. Nevertheless there are limited data about the clinical outcome of the PVI for patients with impaired LV function.

Purpose

This study was to evaluate the efficacy of PVI and improvement of LVEF after the procedure in AF patients with rEF.

Methods

A total of 2709 consecutive AF patients (age 65±39 y/o, male 67%) underwent their first PVI with cryoballoon or RF catheter in our facility from April 2014 to March 2019, and retrospectively analyzed. All the patients underwent echocardiogram before and half to one year after the procedure. Patients with LVEF under 40% before the PVI were selected (n=111) and divided into two groups based on whether there were specific etiologies of LV function impairment (group A) or not (group B).

Results

There were no significant difference in mean LVEF between group A (n=40) and group B (n=71) (32±6% vs 33±6%, p=0.12). The major etiology of rEF in group A were old myocardial infarction (n=20, 18%), hypertensive heart disease (n=6, 5.4%), and dilated cardiomyopathy (n=5, 4.5%). After mean follow-up of 2.7 years, there were no significant difference in clinical outcome after the procedure between two groups (1-year Kaplan–Meier event rate estimates; 72.2% vs 72.9%; p=0.85). The change amounts of LVEF after the PVI were significantly higher in group B (20±14%) compared to group A (2±10%) (p&lt;0.001). Multivariable Cox regression analysis revealed that age was the independent significant predictors of EF improvement over 10% in group B (p=0.048).

Conclusions

In AF patients with reduced LVEF, there were no significant difference in efficacy of PVI between those who have specific etiologies of LV function impairment other than AF and who have not. The improvement of LVEF after PVI was significantly larger in patients without specific etiologies compared to those with.

Funding Acknowledgement

Type of funding source: None

Flexor tendon transection and post-surgical external fixation in calves affected by severe metacarpophalangeal flexural deformity

This study aimed to evaluate the transection of superficial digital flexor tendon (SDFT) and deep digital flexor tendon (DDFT) in calves with severe metacarpophalangeal flexural deformities (MPFD). The study comprised 17 forelimbs of 10 calves that were diagnosed at the Animal Medical Centre, Rakuno Gakuen University. The calves were treated via transection of the SDFT and DDFT with retention of the suspensory ligament, followed by external fixation according to a post-surgical gait test. The post-procedural prognosis was determined at 14 days post-surgery. Of the 17 limbs, 14 (82%) achieved non-lameness and a good prognosis. Surgical complications were not observed in any treated calves. The transection of SDFT and DDFT is an effective first-line surgical option for calves with severe MPFD.

P3098Association with coronary high-intensity plaque on T1-weighted magnetic resonance imaging and circulating levels of malondialdehyde-modified low-density lipoprotein

Objectives

This study aimed to evaluate the association with coronary high-intensity plaque (HIP) on non-contrast T1-weighted magnetic resonance imaging (T1WI) and circulating levels of malondialdehyde-modified low-density lipoprotein (MDA-LDL).

Methods

A total of 139 patients with coronary artery stenosis (>70%) were imaged with non-contrast T1WI by using a 1.5-T magnetic resonance system (HIP: n=60, non-HIP: n=79). HIP was defined as a signal intensity of coronary plaque to cardiac muscle ratio (PMR) of ≥1.4. At admission, circulating levels of MDA-LDL and other lipid-related markers (triglyceride, HDL, LDL, Lp(a), RLP-C, and EPA/AA) were measured.

Results

Circulating levels of MDA-LDL (p=0.001) and LDL (p=0.041) were significantly higher in patients with HIP than those without, whereas the other lipid-related markers were not significantly different between both groups. In multivariable logistic regression analysis, MDA-LDL levels were independently associated with the presence of HIP (OR 1.03; 95% CI, 1.00–1.06, p=0.015) after adjusting for cofounding factors (age, sex, triglyceride, LDL, Lp(a), RLP-C, and EPA/AA). The optimal MDA-LDL threshold for predicting coronary HIP was 90.4 U/L, identified by the receiver operating characteristic curve.

Conclusion

MDA-LDL levels might be associated with the presence of HIP in patients with coronary artery disease.

P737Endothelial ERK2/thromboxane receptor pathway induces endothelial dysfunction, insulin resistance and steatohepatosis through superoxide with high fat high sucrose diet

Introduction

Metabolic syndrome (MetS) is well known as the risk of cardiovascular diseases associated with endothelial dysfunction and induces steatohepatosis. Insulin resistance is a major character of MetS, which affects intracellular signaling pathways and endothelial function. Extracellular signal-regulated kinase (ERK) is a major component of insulin signal and many of vasoactive peptides, which were released in MetS, can activate it in endothelium. However, the role of endothelial ERK in nitric oxide (NO) bioactivity in MetS in in vivo has been unknown.

Purpose

The aim of this study is to clarify the role of endothelial ERK2 on NO bioactivity in mice model of MetS.

Methods and results

We created endothelial specific ERK2 knock out mice (EE2KO) crossing Tie2-Cre mice and ERK2 flox mice and fed them with normal or high-fat/high-sucrose diet (HFHSD) for 24 weeks. Serum glucose and insulin levels and HOMA-IR were lowered in EE2KO with HFHSD without changing body weight. In wild type mice (WT) with HFHSD, nonalcoholic fatty liver disease (NAFLD) activity score, fibrosis score and serum ALT level were increased, all of which were blunted in EE2KO. EE2KO with HFHSD lowered systolic blood pressure (WT: 123.7±5.83 mmHg, EE2KO: 101.4±3.66 mmHg, P<0.01, N=8) without changing heart rate, which was increased to the same levels with L-NAME, an endothelial NO synthase inhibitor, in both groups. Serum NO levels measured with serum nitrite/nitrate concentrations were increased in EE2KO with HFHSD (WT: 23.10±3.74 μmol/l, EE2KO: 41.71±6.73 μmol/l, P<0.05, N=12). Endothelial function was assessed with the isometric tension measurement of aortic rings with acetylcholine (ACh). ACh-induced relaxation was improved in EE2KO with HFHSD. Superoxide production of aorta from EE2KO was lowered than WT with HFHSD in dihydroethidium (DHE) staining. S18886, an antagonist of the thromboxane A2-prostanoid (TP) receptor, decreased superoxide production of aorta in DHE staining resulting in improving endothelial function in the isometric tension measurement of aortic rings. Oral administrations of S18886 decreased systolic blood pressure, serum fasting glucose and insulin levels, and surprisingly improved steatohepatosis by decreasing NAFLD activity score and fibrosis score.

Relaxation of aortic rings with ACh

Conclusions

Endothelial ERK2/TP receptor pathway increases superoxide production and decreased NO bioactivity, resulting in deteriorating endothelial function, insulin resistance and steatohepatosis, which were improved by antagonist of the TP receptor in mice model of MetS. The present study indicates that ERK2/TP pathway could be a therapeutic target for complications of MetS.

P1918Comparison of the clinical outcome of pulmonary vein isolation with cryoballoon and radiofrequency ablation for atrial fibrillation with pulmonary vein triggers

Background

Pulmonary vein isolation (PVI) using radiofrequency (RF) or cryoballoon (CB) has been an established treatment for atrial fibrillation. PVI using RF is the most common method with a rather complex technique of a point-by-point tissue heating and navigation of electro-anatomical-guided mapping system, and PVI with CB is also the common method with a relatively simple technique of freezing balloon occlusion. These 2 types of ablation are comparable in terms of the efficacy of the PVI procedure.

Purpose

The data on the clinical outcome of each AF type with PV triggers has been limited. We compared the outcome of success rate between RF and CB group with respect to each AF type, and further assessed the efficacy of pulmonary vein isolation for AF patients with the origin of only PV.

Methods

A total of 3402 AF patients (age 64±11; 2463 males) underwent initial PVI from May 2009 to July 2018 (PAF: 67%, non-PAF: 37%). Radiofrequency using irrigation-tip catheter was employed to 1796 patients since May 2009 (RF-PAF: 55%, RF-non-PAF: 45%). Second-generation cryoballoon was employed to other 1606 patients since September 2014 (CB-PAF: 81%, CB-non-PAF: 19%). In CB group, PV touch-up ablation with RF was needed for 113 patients (7%) (CB-PAF: 6%, CB-non-PAF: 13%; p<0.001). After PVI, additional ablation for non-PV foci was undergone after the induction by using isoproterenol infusion and rapid atrial pacing (RF-AF: 34%, CB-AF: 32%; p=0.107).

Results

In all PAF patients, AF free survival rate was significantly superior in CB group (2-years Kaplan-Meir event rate, CB 83.2%, RF 75.2%; log-rank p<0.001). The percentage of patients with non-PV foci was almost equivalent in both group (CB 30%, RF 31%, p=0.644). And in PAF patients with only PV-foci, AF free survival rate was significantly superior in CB group (2-years Kaplan-Meir event rate, CB 85.0%, RF 78.8%; log-rank p<0.001). On the other hand, in all non-PAF patients, AF free survival rate was almost equivalent in both non-PAF group (2-years Kaplan-Meir event rate, CB 65.5%, RF-non-PAF 70.0%; log-rank p=0.9). The percentage of patients with non-PV foci was almost equivalent in both group (CB 40%, RF 39%, p=0.731), And in non-PAF patients with only PV-foci, AF free survival rate was almost equivalent in both non-PAF group (2-years Kaplan-Meir event rate, CB 69.7%, RF 73.0%; log-rank p=0.376).

Conclusions

Our study showed better outcome of PVI with CB for PAF patients with PV triggers, and indicated the non-inferiority of PVI with CB for non-PAF patients with PV triggers to PVI with RF.

P6380The impact of coronary artery disease to predict mortality and neurological outcome in post-cardiac arrest patients

Background

Some studies reported that performing coronary angiography (CAG) for patients with out-of-hospital cardiac arrest (OHCA) is effective for the prognosis and neurological outcome. However, the impact of complexity of coronary artery disease (CAD) on CAG findings has not been evaluated sufficiently.

Purpose

We sought to investigate the complexity of CAD to predict the prognosis and neurological outcome in patients with OHCA.

Methods

A total of 1382 out-of-hospital cardiac arrest patients were transferred to our critical care center, of which 252 cardiovascular arrest patients achieving the return of spontaneous circulation (ROSC) were extracted from the institutional consecutive database between January 2015 and December 2018. Among those patients, we performed CAG for 160 patients. To predict mortality in hospital and neurological outcome at 30 days, we investigated basic patients' characteristics, pre-hospital information, coronary anatomical angiographical findings.

Results

Ventricular fibrillation (VF) (P=0.001), younger age (P=0.007), pre-hospital ROSC (P<0.001) and normal coronary artery on CAG findings (P=0.014) were associated with low 30-days mortality in hospital. VF (P=0.003), younger age (P=0.004), pre-hospital ROSC (P<0.001), bystander cardiopulmonary resuscitation (CPR) (P=0.043) and normal coronary artery (P=0.001) were associated with good neurological outcome (cerebral-performance-category (CPC) =1 or 2) at 30 days. We further investigated 100 patients who had any coronary artery stenosis on CAG findings. Among these patients, 55 patients (55.0%) had multi-vessel coronary artery disease and 29 patients (29.0%) had at least a chronic total occlusion lesion. VF survivor (P=0.035), without previous history of CAD (P=0.008), pre-hospital ROSC (P=0.013), and Syntax score (P=0.002) were associated with low 30-days mortality. In multivariate analysis, Syntax score (OR 0.94; 95% confidence interval (CI) 0.88–0.99; P=0.042) was independent predictor of mortality. Bystander CPR (P=0.001), pre-hospital ROSC (P<0.001) were associated with good neurological outcome at 30 days. Bystander CPR (OR 5.92; 95% CI 2.01–17.5; P<0.001) and pre-hospital ROSC (OR 9.22; 95% CI 3.34–25.5; P<0.001) were predictive for good neurological outcome.

Conclusions

OHCA patients with any coronary stenosis had high mortality and bad neurological outcome in comparison with those who had normal coronary arteries. OHCA patients with CAD had complex lesions such as multi-vessel disease or chronic total occlusion lesions. The coronary complexity in patients with OHCA was a predictor of in-hospital 30-days mortality. However, pre-hospital care such as bystander CPR and pre-hospital ROSC were the most important to achieve good neurological outcome at 30 days in the present study.

P2266The predictor of mortality and neurological outcome in out-of-hospital cardiac arrest patients with non-ST-segment elevation

Background

The prognosis of patients with out-of-hospital cardiac arrest (OHCA) remains poor. Coronary artery disease (CAD) is the most frequent cause of OHCA. The prompt evaluation and revascularization for coronary artery in OHCA patients with ST-segment elevation are recommended because they often have CAD. However, OHCA patients without ST-segment elevation also have any coronary stenosis in the non-negligible proportion. The predictor of mortality and neurological outcome in OHCA patients with no ST-segment elevation has not been sufficiently elucidated.

Purpose

We sought to investigate the predictor of mortality and neurological outcome at 30 days in OHCA patients without ST-segment elevation.

Methods

A total of 1382 out-of-hospital cardiac arrest patients were transferred to our critical care center, of which 252 cardiovascular arrest patients achieving the return of spontaneous circulation (ROSC) were extracted from the institutional consecutive database between January 2015 and December 2018. Among those patients, 183 patients' electrocardiogram after ROSC were without ST-segment elevation. We performed coronary angiography (CAG) for 103 patients, who were eligible for final analysis. To predict mortality in hospital and neurological outcome at 30 days, we investigated basic patients' characteristics, pre-hospital information, post-hospital care.

Results

Any coronary stenosis was founded in 50 patients (48.5%). Male (P=0.007), older age (P<0.001), past history of coronary artery disease (CAD) (P=0.037) and diabetes mellitus (P=0.087) were associated with coronary artery stenosis on CAG findings. Age (OR 1.05; 95% confidence interval (CI) 1.02–1.08; P<0.001), male (OR 5.33; 95% CI 1.37–20.7; P<0.001) were independent predictors of coronary artery stenosis. Among those who had stenosis, 34 patients (68.0%) survived and 27 patients (54.0%) achieved good neurological outcome (cerebral-performance-category (CPC) =1 or 2) at 30 days. Successful revascularization by percutaneous coronary intervention (PCI) was not associated with low mortality (P=0.77). Past history of CAD (P=0.014) and high Syntax score (P=0.030) were associated with mortality. Bystander cardiopulmonary resuscitation (CPR) (P-0.021), pre-hospital ROSC (P<0.001) was more frequent in patients with good neurological outcome. Pre-hospital ROSC (OR 14.7; 95% CI 3.1–69.3; P<0.001) was independently predictive for good neurological outcome.

Conclusions

Successful PCI for OHCA patients with no ST-segment elevation was not a predictor of mortality. CAD past history and complex CAD was associated with mortality. Pre-hospital information such as pre-hospital ROSC was important to achieve good neurological outcome.

P1919The assessment of the application and the efficacy of pulmonary vein isolation with cryoballoon for non-paroxysmal atrial fibrillation

Background

Pulmonary vein isolation (PVI) using second generation cryoballoon (CB) ablation has become an established treatment for paroxysmal atrial fibrillation (PAF) patients. On the other hand, PVI with radiofrequency (RF) has been an established treatment for non-PAF patients, in addition to PAF patients.

Purpose

The data on second generation CB ablation for non-PAF patients is limited. We assessed the application of PVI with CB for non-PAF patients and compared the outcomes of success rate, radiational time, and procedural time.

Methods

A total of 2632 AF patients (age 64±10; 1873 males) underwent initial PVI from September 2014 to June 2018. Second-generation CB was employed to 1587 patients (CB-PAF: 80%, CB-non-PAF: 20%) and RF using irrigation-tip catheter was employed to other 1045 patients (RF-PAF: 40%, RF-non-PAF: 60%). In CB group, PV touch-up ablation with RF was needed for 113 patients (7%) (CB-PAF: 6%, CB-non-PAF: 13%; p<0.001). After PVI, additional ablation for non-PV foci was undergone after the induction by using ISP infusion and rapid atrial pacing.

Results

AF free survival rate was almost equivalent in both non-PAF group (2-years Kaplan-Meir event rate, CB-non-PAF 66.3%, RF-non-PAF 69.8%; log-rank p=0.297). There was significantly difference in procedural time (CB-non-PAF 132±56min, RF-non-PAF: 189±52min, p<0.001), and radiation time (CB-non-PAF: 47±40min, RF-non-PAF: 75±31min, p<0.001). The percentage of patients with non-PV foci was significantly higher in CB group (CB-non-PAF 41%, RF-non-PAF 54%, p<0.001), and after excluding the patients with non-PV foci, AF free survival rate was almost equivalent in both group (2-years Kaplan-Meier event rate, CB-non-PAF 75.4%, RF-non-PAF 78.8%; log-rank p=0.577). On the other hand, in patients in CB, AF free survival rate was significantly superior in PAF group (2-years Kaplan-Meir event rate, CB-PAF 83.3%, CB-non-PAF 65.2%; log-rank p<0.001). There was significantly difference in procedural time (CB-PAF: 117±47min, CB-non-PAF: 132±56min, p<0.001), and radiation time (CB-PAF: 38±22min, CB-non-PAF: 46±27min, p<0.001). The percentage of patients with non-PV foci was significantly higher in non-PAF group (CB-PAF 30%, CB-non-PAF 41%, p<0.001), and after excluding the patients with non-PV foci, AF free survival rate was also significantly superior in PAF group (2-years Kaplan-Meier event rate, CB-PAF 85.1%, CB-non-PAF 69.8%; log-rank p<0.001).

Conclusions

For non-PAF patients with PV triggers, PVI with CB might be non-inferior to PVI with RF. Our study showed the efficacy of CB in terms of the shortening of procedural time, and the reduction of radiational exposure. PVI with CB for non-PAF patients was inferior to that for PAF patients.

Adverse reactions associated with long-term drug administration in Mycobacterium avium complex lung disease

SETTING

The number of patients with non-tuberculous mycobacterial lung disease (NTM-LD) worldwide has been increasing. Mycobacterium avium complex lung disease (MAC-LD) accounts for 90% of NTM-LD. MAC-LD necessitates long-term treatment, but adverse reactions with long-term administration of drugs are poorly understood.

OBJECTIVE

To evaluate adverse reactions with long-term administration of drugs for MAC-LD.

DESIGN

We conducted a retrospective single-centre medical chart review of 364 patients administered two or more drugs between July 2010 and June 2015.

RESULTS

The prevalence and median time to onset of adverse reactions were as follows: hepatotoxicity 19.5%, 55 days; leucocytopaenia 20.0%, 41 days; thrombocytopaenia 28.6%, 61.5 days; cutaneous reactions 9.3%, 30 days; ocular toxicity 7.7%, 278 days; and increase in serum creatinine 12.4%, 430.5 days. Multivariate analysis showed that rifampicin use was independently associated with thrombocytopaenia, and ethambutol use was independently associated with increases in serum creatinine.

CONCLUSION

The main adverse reactions appeared within 3 months after start of treatment. Most patients were able to continue treatment with liver-supporting therapy, antihistamine agents or desensitisation therapy; however, ocular toxicity must be monitored for up to 1 year after start of treatment.

S-1 and irinotecan plus bevacizumab versus mFOLFOX6 or CapeOX plus bevacizumab as first-line treatment in patients with metastatic colorectal cancer (TRICOLORE): a randomized, open-label, phase III, noninferiority trial

Background

Combination therapy with oral fluoropyrimidine and irinotecan has not yet been established as first-line treatment of metastatic colorectal cancer (mCRC). We carried out a randomized, open-label, phase III trial to determine whether S-1 and irinotecan plus bevacizumab is noninferior to mFOLFOX6 or CapeOX plus bevacizumab in terms of progression-free survival (PFS).

Patients and methods

Patients from 53 institutions who had previously untreated mCRC were randomly assigned (1 : 1) to receive either mFOLFOX6 or CapeOX plus bevacizumab (control group) or S-1 and irinotecan plus bevacizumab (experimental group; a 3-week regimen: intravenous infusions of irinotecan 150 mg/m2 and bevacizumab 7.5 mg/kg on day 1, oral S-1 80 mg/m2 twice daily for 2 weeks, followed by a 1-week rest; or a 4-week regimen: irinotecan 100 mg/m2 and bevacizumab 5 mg/kg on days 1 and 15, S-1 80 mg/m2 twice daily for 2 weeks, followed by a 2-week rest). The primary end point was PFS. The noninferiority margin was 1.25; noninferiority would be established if the upper limit of the 95% confidence interval (CI) for the hazard ratio (HR) of the control group versus the experimental group was less than this margin.

Result

Between June 2012 and September 2014, 487 patients underwent randomization. Two hundred and forty-three patients assigned to the control group and 241 assigned to the experimental group were included in the primary analysis. Median PFS was 10.8 months (95% CI 9.6-11.6) in the control group and 14.0 months (95% CI 12.4-15.5) in the experimental group (HR 0.84, 95% CI 0.70-1.02; P < 0.0001 for noninferiority, P = 0.0815 for superiority). One hundred and fifty-seven patients (64.9%) in the control group and 140 (58.6%) in the experimental group had adverse events of grade 3 or higher.

Conclusion

S-1 and irinotecan plus bevacizumab is noninferior to mFOLFOX6 or CapeOX plus bevacizumab with respect to PFS as first-line treatment of mCRC and could be a new standard treatment.

Clinical trials number

UMIN000007834.

Abstract P5-12-17: Prognostic and predictive value of serum level of vascular endothelial growth factor-A in metastatic breast cancer patients treated with bevacizumab plus paclitaxel

Background

Several studies showed that first-line bevacizumab plus chemotherapy for HER2-negative metastatic breast cancer improves progression-free survival and tumor response rate but not overall survival. MERiDiAN trial evaluated plasma vascular endothelial growth factor-A (VEGF-A) prospectively as a predictive biomarker for bevacizumab efficacy in metastatic breast cancer. However, results of this trial do not support using baseline plasma VEGF-A to identify patients benefitting most from bevacizumab. We measured baseline serum VEGF-A level from stored blood samples of metastatic breast cancer patient with treated bevacizumab plus paclitaxel as fist-line and later line therapy, and evaluated a correlation between serum VEGF-A level and efficacy of bevacizumab and prognosis of breast cancer patients tread with bevacizumab, retrospectively.

Patients and methods

We examined blood samples from 57 metastatic breast cancer patients treated with bevacizumab and paclitaxel, after obtaining written informed consent. And, we evaluated a correlation between baseline serum VEGF-A level and time to treatment failure (TTF) and overall survival (OS). We also compared the serum VEGF-A level of response group (CR and PR) and that of non-response group (SD and PD).

Results

Baseline serum level of VEGF-A ranged from 80 to 2079 pg/ml. Cases of treatment line were as follows: first-line, 22 cases (38.6%); second line, 11 cases (19.3%) and third-line and the later line, 24 cases (42.1%). The cutoff identified by ROC curve analysis that was able to differentiate response group and non-response group in first-line setting was 360pg/ml for serum VEGF-A. And, we separated high serum VGEF-A group and low serum VEGF-A group of patients treated with bevacizumab plus paclitaxel.

In patients treated as first line therapy, median TTF was 4.0 months with high serum VGEF-A group versus 5.0 months with low serum VEGF-A group, and median OS was 12 months with high serum VGEF-A group versus 11months with low serum VEGF-A group. There were no significant differences in both TTF and OS in first line setting. In patients treated as second line and later line therapy, median TTF was 2.8 months with high serum VGEF-A group versus 7.1 months with low serum VEGF-A group, and median OS was 6.4 months with high serum VGEF-A group versus 12.7 months with low serum VEGF-A group. The prognosis of high serum VEGF-A group was significantly worse than that of low serum group in both TTF and OS.

The serum VEGF-A level of response group was tend to be higher than that of non-response group in first line setting, and was lower in second and later line setting. However, there were no significant differences.

Conclusion

In this study, serum VEGF-A cannot be a predictor for efficacy of bevacizumab plus paclitaxel as first line therapy for metastatic breast cancer patients. On the other hand, there was a possibility that high serum level of VEGF-A can be a poor prognostic factor in late line therapy setting of bevacizumab.

Citation Format: Tozuka K, Nagai SE, Matsumoto H, Hayashi Y, Kubo K, Tsuboi M, Sato A, Takai K, Wang X, Yamada Y, Inoue K. Prognostic and predictive value of serum level of vascular endothelial growth factor-A in metastatic breast cancer patients treated with bevacizumab plus paclitaxel [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P5-12-17.

Clinical and experimental studies of intraperitoneal lipolysis and the development of clinically relevant pancreatic fistula after pancreatic surgery

Background

Visceral obesity is one of the risk factors for clinically relevant pancreatic fistula after pancreatic resection. The objective of this study was to evaluate the impact of intraperitoneal lipolysis on postoperative pancreatic fistula.

Methods

The degree of intraperitoneal lipolysis was investigated by measuring the free fatty acid concentration in drain discharge in patients after pancreatic resection. An experimental pancreatic fistula model was prepared by pancreatic transection, and the impact of intraperitoneal lipolysis was evaluated by intraperitoneal administration of triolein (triglyceride) with, or without orlistat (lipase inhibitor).

Results

Thirty-three patients were included in the analysis. The free fatty acid concentration in drain discharge on postoperative day 1 was significantly associated with the development of a clinically relevant pancreatic fistula (P = 0·004). A higher free fatty acid concentration in drain discharge was associated with more visceral adipose tissue (P = 0·009). In the experimental model that included 98 rats, intraperitoneal lipolysis caused an increased amount of pancreatic juice leakage and multiple organ dysfunction. Intraperitoneal administration of a lipase inhibitor reduced lipolysis and prevented deterioration of the fistula.

Conclusion

Intraperitoneal lipolysis significantly exacerbates pancreatic fistula after pancreatic resection. Inhibition of lipolysis by intraperitoneal administration of a lipase inhibitor could be a promising therapy to reduce clinically relevant postoperative pancreatic fistula.

Phase Angle Is a Useful indicator for Muscle Function in Older Adults

AIM

Phase angle (PhA) can be determined through bioelectrical impedance analysis and is a unique variable for skeletal muscle. The objective of this study was to evaluate the relationship between PhA and muscle mass/quality in older adults. In addition, we attempted to determine the cutoff value of PhA for poor muscle function.

METHODS

Community-dwelling Japanese older men (n=285, 81.1±7.1 years) and women (n=724, 80.4±6.8 years) participated in this study and were classified into four groups based on the Asian Working Group for Sarcopenia (normal, presarcopenia, dynapenia, and sarcopenia). We measured PhA using bioelectrical impedance analysis, muscle quantity and quality indicators using ultrasonography, muscle strength, and physical performance and compared them in four groups. We also tried to determine the cutoff value of PhA for poor muscle function.

RESULTS

We found a significant difference in PhA among the four groups in men (P<0.05), and the dynapenia (3.61±0.75°) and sarcopenia groups (3.40±0.74°) showed significantly lower values than the normal group (4.50±0.86°) (P<0.05), but not the presarcopenia group (4.12±0.85°). In women, a significant difference was also observed among the four groups (P<0.05), and the dynapenia (3.41±0.65°) and sarcopenia groups (3.31±0.66°) showed significantly lower measures than the normal group (4.14±0.71°) (P<0.05), but not the presarcopenia group (4.07±0.51°). The receiver-operating characteristic curve analysis indicated the best cutoff value of PhA (men: 4.05°, women: 3.55°) to discriminate sarcopenia and dynapenia from normal and presarcopenia.

CONCLUSION

These findings suggest that PhA is a useful indicator for muscle function.