Effect of Influenza Vaccine in Patients With Kidney Transplant

BACKGROUND

Among infectious diseases, influenza is the most common cause of infection in Japan and worldwide. We aimed to evaluate the effect of influenza vaccination in kidney transplantation (KTx) recipients.

METHODS

We retrospectively evaluated the records of 98 participants who underwent KTx at our institution between March 2009 and May 2016. All patients received tacrolimus or cyclosporine, mycophenolate mofetil, and methylprednisolone for maintenance immunosuppression after KTx. In accordance with the criteria of our institution, everolimus was administered for the maintenance of immunosuppression after KTx. We compared the rate of influenza infection during the 2016-2017 season (8 months, from October 2016-May 2017) between KTx patients treated with 1 or 2 doses of influenza vaccine (treatment group, n = 71) and KTx patients who did not receive a vaccine (nontreatment group, n = 27).

RESULTS

Among patient characteristics, only the prevalence of diabetes mellitus differed significantly between the groups (treatment group: 9.9%, 7 of 71 patients; nontreatment group: 29.6%, 8 of 21 patients; P = .02). Influenza infection occurred at similar rates in the 2 groups (treatment group, 5.63% 4 of 71 patients; nontreatment group: 3.70%, 1 of 27 patients; P = .70).

CONCLUSIONS

Among KTx patients managed in our institution, treatment with 1 or 2 doses of influenza vaccine did not reduce the rate of influenza infection in the 2016-2017 season, suggesting that influenza vaccination may currently be ineffective in KTx patients.

Time course of osteoporotic vertebral fractures by magnetic resonance imaging using a simple classification: a multicenter prospective cohort study

This study revealed the time course of osteoporotic vertebral fracture by magnetic resonance imaging using a simple classification. Signal changes were associated with the compression degree and mobility of the fractured vertebral body. This classification showed sufficient reliability in categorizing magnetic resonance imaging findings of osteoporotic vertebral fractures.

INTRODUCTION

Magnetic resonance imaging (MRI) is useful in diagnosing osteoporotic vertebral fractures (OVFs). This study investigated the time course of OVFs by MRI using a simple classification.

METHODS

This multicenter cohort study was performed from 2012 to 2015. Consecutive patients with ≤2-week-old OVFs were enrolled in 11 institutions. MRI was performed at enrollment and at 1-, 3-, 6-, and 12-month follow-up. Signal changes on T1-weighted imaging (T1WI), T2WI, and short τ inversion recovery (STIR) were classified according to signal intensity. Height and angular motion of vertebral bodies were also measured.

RESULTS

The 6-month follow-up was completed by 153 patients. At enrollment, fractured vertebrae signal changes were 43 % diffuse and 57 % confined low on T1WI; on T2WI, 56, 24, and 5 % were confined low, high, and diffuse low, respectively; on STIR, 100 % were high. On T1WI, diffuse low remained most common (90 % at 1 month and 60 % at 3 months) until 6 and 12 months, when most were confined low (54 and 52 %, respectively). On T2WI, confined low remained most common (decreasing to 41 % at 12 months). On STIR, high signal change was shown in 98, 87, and 64 % at 3, 6, and 12 months, respectively. At 3, 6, and 12 months, diffuse low signal change was associated with significantly lower vertebral height, and high signal change was associated with significantly greater angular motion.

CONCLUSIONS

MRI signal changes were associated with the compression degree and angular motion of fractured vertebrae. This classification showed sufficient reliability in categorizing MRI findings of OVFs.

Predicting delayed union in osteoporotic vertebral fractures with consecutive magnetic resonance imaging in the acute phase: a multicenter cohort study

This study demonstrated the predictive values of radiological findings for delayed union after osteoporotic vertebral fractures (OVFs). High-signal changes on T2WI were useful findings.

INTRODUCTION

The purpose of the present study is to determine predictive radiological findings for delayed union by magnetic resonance imaging (MRI) and plain X-rays at two time points in the acute phase of OVFs.

METHODS

This multicenter cohort study was performed from 2012 to 2015. A total of 218 consecutive patients with OVFs ≤2 weeks old were enrolled. MRIs and plain X-rays were performed at the time of enrollment and at 1- and 6-month follow-ups. Signal changes on T1-weighted imaging (T1WI) were classified as diffuse low-, confined low-, or no-signal change; those on T2WI were classified as high (similar to the intensity of cerebrospinal fluid), confined low-, diffuse low-, or no-signal change. The angular motion of the fractured vertebral body was measured with X-rays.

RESULTS

A total of 153 patients completed the 6-month follow-up. A high-signal change on T2WI was most useful in predicting delayed union. Sensitivity, specificity, and positive predictive values were 53.3, 87.8, and 51.6 % at enrollment and 65.5, 84.8, and 51.4 % at the 1-month follow-up, respectively. The positive predictive value increased to 62.5 % with observation of high- or diffuse low-signal changes at both enrollment and the 1-month follow-up. The cutoff value of vertebral motion was 5 degrees. Sensitivity and specificity at enrollment were 52.4 and 74.1 %, respectively.

CONCLUSIONS

This study demonstrated the radiological factors predicting delayed union after an OVF. T2 high-signal changes showed the strongest association with delayed union. Consecutive MRIs were particularly useful as a differential tool to predict delayed union following OVFs.

Role of calcium supplementation in patients with mild renal failure

A low-protein diet has been shown to be effective in the prevention of progression of renal failure. However, the role of protein and that of phosphate intake have not been definitely separated. To determine the use of calcium (CaCO3) as a phosphate binder and a possible hypotensive agent, we performed a prospective, double-blind study of oral calcium in patients with mild-to-moderate renal failure (SCr less than 5.0 mg/dl). Thirty-six patients (20 m, 16 f) were studied. After a 2-month control period, either CaCO3 (6 g/day, 12 Cap) or placebo was given for 3 months. There was no significant difference in BUN, S-Sr, S-Ca, S-Pi, 24-hour Ccr, and blood pressure during the study period both in the genuine and the placebo group. Urine phosphate was decreased by about 50% in the CaCO3 group. Calcium carbonate is feasible as a phosphate binder for patients with mild-to-moderate renal failure.

Plasma amino acid profiles are associated with insulin, C-peptide and adiponectin levels in type 2 diabetic patients

Objectives:

Plasma-free amino acid (PFAA) profiles have been associated with a future risk of developing diabetes or cardiovascular disease in nondiabetic subjects. These PFAA alterations might predominantly result from the metabolic shift caused by insulin resistance and visceral fat deposition. The variety of PFAA profiles within diabetic subjects is not well researched. In this study, we focused on type 2 diabetic subjects and examined the association between PFAA profiles and insulin- and glucose-related variables.

Methods:

Fifty-one Japanese subjects diagnosed with type 2 diabetes were recruited from an outpatient clinic. The plasma concentrations of 21 amino acids; glucose-related markers including glucose, hemoglobin A1c (HbA1c), glycoalbumin and 1,5-anhydroglucitol; insulin-related markers including insulin, C-peptide, and the homeostasis model assessment of insulin resistance; and adipocytokines including adiponectin and leptin were determined. The association of PFAA and other metabolic profiles were analyzed, and stratified analyses of the PFAAs and clinical characteristics were performed according to the fasting plasma insulin and HbA1c levels. In addition, the PFAA indices that correlate to visceral fat obesity were evaluated.

Results:

Although strong correlations between PFAAs and glucose-related markers were not observed, several amino acids (branched-chain amino acids, tryptophan, alanine, tyrosine, glutamate and proline) and PFAA indices that evaluate visceral obesity were highly correlated with insulin-related markers and adiponectin (P<0.001). In the group of diabetic patients with hyperinsulinemia, the amino acid levels were significantly increased, which generally demonstrated good concordance with insulin-related markers and adiponectin levels.

Conclusions:

The PFAA profiles in diabetic patients were strongly associated with hyperinsulinemia and hypoadiponectinemia, which might become risk evaluation factors for the development of cardiovascular diseases.

Blood pressure control in a Japanese population with chronic kidney disease: a baseline survey of a nationwide cohort

BACKGROUND

Hypertension is a key risk factor for adverse renal outcomes in chronic kidney disease (CKD), and strict blood pressure control is recommended to halt its progression. This study assessed blood pressure control in the Japanese CKD population.

METHODS

We used a nationwide database of 250,130 subjects (aged 20-88), including 45,845 CKD subjects (18.3%), participated in an annual health check, "The Specific Health Check and Guidance in Japan," and examined the relationship between CKD status and blood pressure. Blood pressures were measured in sitting position by trained staff, and target blood pressure for CKD subjects was defined as systolic (SBP)/diastolic blood pressure (DBP) <130/80 mm Hg.

RESULTS

In total population, CKD subjects had a higher prevalence of hypertension (58.0% vs. 41.8%, P < 0.001) and a higher proportion with antihypertensive medication (42.4% vs. 26.7%, P < 0.001), compared with non-CKD subjects. The proportion of subjects achieving target blood pressure was significantly lower among total CKD subjects than among total non-CKD subjects (34.6% vs. 43.8%, P ≤ 0.001). Among CKD subjects, these proportions were especially low in those with stage 4-5 (24.3-27.5%), those on antihypertensive medication (21.6%) and those with proteinuria ≥2± (21.3%). Logistic regression analysis showed that independent factors for high-blood pressure in CKD subjects were age, male gender, alcohol consumption, nonsmoking, diabetes, dyslipidemia, obesity, proteinuria, and antihypertensive medication.

CONCLUSIONS

Blood pressure control was inadequate in the majority of Japanese CKD subjects, despite antihypertensive treatment. More aggressive efforts to achieve target blood pressures among CKD subjects are recommended.

Diffuse tract damage in the hemispheric deep white matter may correlate with global cognitive impairment and callosal atrophy in patients with extensive leukoaraiosis

BACKGROUND AND PURPOSE

Patients with extensive leukoaraiosis are at high risk for vascular dementia. However, these patients exhibit variable severity of global cognitive impairment correlating with callosal atrophy. We hypothesized that callosal atrophy may reflect the severity of HDWM tract damage, which may explain global cognitive impairment. The purpose of this study was to evaluate HDWM tract damage by DTI and to investigate whether HDWM tract damage is associated with callosal atrophy and global cognitive impairment, in patients with extensive leukoaraiosis.

MATERIALS AND METHODS

Twenty-four consecutive outpatients with extensive leukoaraiosis were enrolled prospectively. The patients underwent cognitive evaluation and 3T MR imaging. The intercorrelation between cognitive score, DA of the HDWM, callosal DA, and callosal volume was analyzed statistically. The correlation of the cognitive score with DA of the HDWM and the corpus callosum was also evaluated by voxel-based analyses by using TBSS.

RESULTS

The patients' MMSE scores varied from 10 to 30 (mean, 25.1 ± 6.0). Reduced DA of the HDWM, reduced callosal DA, and callosal atrophy intercorrelated significantly. All of these parameters showed a significant correlation with global cognitive impairment. TBSS analyses showed a significant correlation between MMSE score decline and reduced DA in the diffuse HDWM and the corpus callosum.

CONCLUSIONS

In patients with extensive leukoaraiosis, atrophy and reduced DA of the corpus callosum may indicate diffuse HDWM tract damage, which may explain global cognitive impairment and development of vascular dementia.

The pH Dependent Uptake of Enoxacin by Rat Intestinal Brush-border Membrane Vesicles

The mechanism of the intestinal transport of enoxacin, an orally active fluoroquinolone antibiotic, has been investigated using brush-border membrane vesicles isolated from rat small intestine. The initial rate and time-course of enoxacin uptake were considerably dependent upon the medium pH (pH 5·5 &gt; pH 7·5) and upon the percent ionization of the carboxyl group (pKa 6·2, anionic charge), namely, the degree of uptake of cationic form was higher than that of the zwitterionic form. There was evidence of transport into the intravesicular space as shown by the effect of extravesicular medium osmolarity on enoxacin uptake at steady state (30 min). This transport across the brush-border membrane was stimulated by the valinomycin-induced K+-diffusion potential (interior negative) and an outward H+-diffusion potential. Furthermore, changing the pH of the medium from 5·5 to 7·5 significantly decreased the effect of valinomycin-induced K+-diffusion potential on the enoxacin uptake. These results suggest that the uptake behaviour of the cationic form of enoxacin plays an important role in the intestinal absorption process of enoxacin.

Transport Characteristics of Cephalosporin Antibiotics Across Intestinal Brush-border Membrane in Man, Rat and Rabbit

The uptake of orally active cephalosporins, ceftibuten and cephradine, by intestinal brush-border membrane vesicles isolated from man, rat and rabbit was studied. In the presence of an inward H+ gradient, ceftibuten but not cephradine was taken up into intestinal brush-border membrane vesicles of man and rat against the concentration gradient (overshoot phenomenon). In rabbit jejunal brush-border membrane vesicles, the uptake of both cephalosporins in the presence of an inward H+ gradient exhibited the overshoot phenomenon. In human and rat vesicles, the initial uptake of ceftibuten was strongly inhibited by compound V, an analogue of ceftibuten, but the uptake of cephradine was not affected by any of the cephalosporins tested, whereas in the rabbit brush-border membrane vesicles, initial uptake of both ceftibuten and cephradine were markedly inhibited by all cephalosporins and dipeptides used. These results suggest that the transport characteristics of human and rat intestinal brush-border membrane for cephalosporins are comparable, and that rabbit is an inadequate animal for investigating the transport characteristics of β-lactam antibiotics.

Expression and role of SNAT3 in the placenta

Glutamine is the most versatile amino acid and its plasma concentration is the highest of all amino acid. Many transporters are therefore involved in glutamine uptake or efflux. Glutamine is actively released from the placenta into fetal circulation. In this study, we examined the alteration of transporters that transport glutamine into fetal circulation as gestation progresses. High expression levels of system A and y(+)L were found in the rat placenta in the late period of pregnancy and the expression levels of these transporters increased as gestation progressed (p<0.05). On the other hand, the expression of SNAT3, the system N transporter, was detected in the early period of pregnancy and its expression level decreased as gestation progressed (p<0.05). SNAT3 was also found to be expressed in isolated human primary cytotrophoblast cells and its expression level was decreased by their differentiation into syncytiotrophoblast cells (p<0.05). Since this regulation is closely related to glutamine synthetase expression, SNAT3 may play a key role in providing glutamine corresponding to glutamine synthetase function in the early period of gestation. This is the first report on the expression of SNAT3 in the placenta in the early stage of pregnancy.

Immature platelet fraction measurement in patients with chronic liver disease: a convenient marker for evaluating cirrhotic change

Platelet number is often used as an indicator of the severity of liver disease. Although inadequate thrombopoietin production and decreased platelet production have been proposed as major causes of cirrhotic thrombocytopenia, the underlying mechanism has not yet been fully clarified. We examined whether the measurement of the immature platelet fraction (IPF) in thrombocytopenic patients with liver dysfunction is useful as a rapid and noninvasive method for the differential diagnosis of chronic liver diseases. We examined 20 liver cirrhosis patients, 56 patients with chronic hepatitis, 9 patients with fatty liver, and 86 patients without liver disease. The percentage value of IPF (IPF%) was measured using an XE-2100 multiparameter automatic hematology analyzer. Using a receiver operating characteristic curve, we found diagnostic significance of the absolute platelet count and the absolute number of the IPF between cirrhotic patients and noncirrhotic patients, and developed a powerful multivariate discriminant analysis (MDA) function based on the platelet count and the IPF%. The diagnostic accuracy obtained by the MDA function was superior to that obtained by the absolute number of platelets and the IPF. We therefore propose our IPF% measurement for the diagnosis of liver cirrhosis.

Higher survival rates of chronic hemodialysis patients on anti-hypertensive drugs

BACKGROUND

The effects of anti-hypertensive drugs on survival have not been examined in a large cohort of hemodialysis (HD) patients.

METHODS

We examined the relationship between blood pressure, anti-hypertensive drug therapy, and survival using the nationwide HD registry of the Japanese Society for Dialysis Therapy. Outcomes were confirmed using the coded ID numbers of the 2005 and 2006 registries. Logistic analyses were performed to determine the effect of anti-hypertensive drug therapy on survival.

RESULTS

A total of 163,668 patients (50.6% men; 31.5% with diabetes mellitus; mean age 63.6 years) on HD 3 times a week in 2005 were studied. Mean (SD) levels of systolic and diastolic blood pressure were 153.4 (24.1) and 78.7 (13.7) mm Hg, respectively, before the HD session. Two-thirds of the HD patients were prescribed anti-hypertensive drugs and the numbers of anti-hypertensive medications were: 1 in 26.8%, 2 in 24.4%, and 3 or more in 14.5% of the total patients. The 1-year mortality rate was 6.6% overall: 8.5% in patients not prescribed anti-hypertensive drugs and 5.6% among those prescribed anti-hypertensive drugs. The odds ratio (95% confidence interval) for the 1-year mortality rate was 0.724 (0.681-0.770, p < 0.0001) for patients prescribed anti-hypertensive drugs, after adjusting for age, sex, diabetes mellitus, body mass index, HD duration, serum albumin, and systolic blood pressure.

CONCLUSION

Survival was better in patients prescribed anti-hypertensive drugs, particularly renin-angiotensin system inhibitors, than in those not prescribed anti-hypertensive drugs. The causality on this association remained to be determined and prospective studies on blood pressure target levels and the effects of anti-hypertensive drug class in HD patients are warranted.

A case of Evans syndrome combined with systemic lupus erythematosus successfully treated with rituximab

Evans syndrome is a rare autoimmune disorder with unknown aetiology. Although corticosteroids and/or intravenous immunoglobulin (IVIG) are commonly used in its treatment, no standard strategy has been established. We report here a 44-year-old male with refractory Evans syndrome combined with systemic lupus erythematosus (SLE) who responded well to rituximab. He was admitted to our hospital with severe bleeding caused by worsening of Evans syndrome. Despite treatment with a high-dose corticosteroid and IVIG, his thrombocytopaenia and haemolytic anaemia did not improve. We started rituximab at a dose of 375 mg/m(2) once a week for a total of two doses. There was significant improvement in his thrombocytopaenia and anaemia 1 month after administration of rituximab. Although the total immunoglobulin G (IgG) level did not change, the titres of platelet-associated IgG (PA-IgG) and of an indirect antiglobulin test (IAT) decreased under the treatment with rituximab. It is suggested that rituximab would be a powerful candidate in the treatment of refractory Evans syndrome by depleting abnormal clone-producing autoantibody.

MEFV mutation analysis of familial Mediterranean fever in Japan

BACKGROUND

Familial Mediterranean fever (FMF) is an autosomal recessive disease characterized by recurrent attacks of fever with serosal inflammation. FMF gene (MEFV) mutations have been identified primarily in patients from Mediterranean populations. Although several clinical cases have been reported in Japan, there have been few reports to date on mutation analysis. We studied FMF patients and their relatives to examine the clinical and genetic features of this disease in the Japanese population.

METHODS

Twelve Japanese FMF patients who met the Tel Hashomer criteria and a total of 17 relatives from 5 of 10 families underwent molecular genetic studies to detect MEFV mutations. The characteristics of these Japanese FMF patients and geno-phenotypical correlations were examined.

RESULTS

Almost all of our patients had been suffering for a long time from fever of unknown origin and one patient also had systemic amyloidosis. In our 12 FMF patients, we detected the substitutions E84K, L110P, E148Q, R761H and M694I. We also newly diagnosed 2 relatives as having FMF based on clinical symptoms and the existence of FMF mutations. One patient was homozygous for E148Q, the patient with systemic amyloidosis was a homozygote for M694I and 4 patients from 3 families were compound heterozygotes for E148Q and M694I. Three patients in one family were compound heterozygotes for E148Q, L110P and M694I. There were 3 patients who were heterozygous for E84K, L110P-E148Q or M694I and had no other nucleotide changes in the exons of MEFV. On the other hand, 2 relatives who had never experienced symptoms of FMF were homozygous for L110P-E148Q as well as compound heterozygous for E148Q/E148Q-R761H. E148Q and M694I were the most frequently detected substitutions in our study.

CONCLUSIONS

MEFV mutations occur in Japanese FMF patients though FMF is rare in Japan. The identification of MEFV mutations could be a reliable diagnostic test for FMF. The results of genetic analyses on 14 Japanese FMF patients in this study revealed that E148Q and M694I are frequent alleles.

Anemia as a risk factor for chronic kidney disease

Chronic kidney disease (CKD) is an important and leading cause of end-stage renal disease (ESRD) and moreover, plays a role in the morbidity and mortality due to cardiovascular disease, infection, and cancer. Anemia develops during the early stages of CKD and is common in patients with ESRD. Anemia is an important cause of left ventricular hypertrophy and congestive heart failure. Correction of anemia by erthyropoiesis-stimulating agent (ESA) has been shown to improve survival in patients with congestive heart failure. Anemia is counted as one of the non-conventional risk factors associated with CKD. Hypoxia is one of the common mechanisms of CKD progression. Treatment by ESA is expected to improve quality of life, survival, and prevent the CKD progression. Several clinical studies have shown the beneficial effects of anemia correction on renal outcomes. However, recent prospective trials both in ESRD and in CKD stages 3 and 4 failed to confirm the beneficial effects of correcting anemia on survival. Similarly, treatment of other risk factors such as hyperlipidemia by statin showed no improvement in the survival of dialysis patients. Given the high prevalence of anemia in ESRD and untoward effects of anemia in CKD stages 3 and 4, appropriate and timely intervention on renal anemia using ESA is required for practicing nephrologists and others involved in the care of high-risk population. Lessons from the recent studies are to correct renal anemia (hemoglobin <10 g/dl not hemoglobin > or =13 g/dl). Early intervention for renal anemia is a part of the treatment option in the prevention clinic. In this study, clinical significance of anemia management in patients with CKD is discussed.

Concurrence of non-myasthenic symptoms with myasthenia gravis

Myasthenia gravis (MG) is a disease that is known to be accompanied by various complications. But the relationship between these complications and MG and the treatment for these complications still partly remain unknown. We report two cases of MG with unusual complications. The first one is a case of a 72-year-old woman with lingual dyskinesia, and the second is a 28-year-old man with dysgeusia. Both symptoms improved in parallel after the treatment of MG. Here we report these cases and review similar cases in the literature.

Successful management of critical limb ischemia with intravenous sodium thiosulfate in a chronic hemodialysis patient

Vascular calcification is common among hemodialysis (HD) patients and contributes to the development of peripheral arterial disease. A 57-year-old Japanese man who had been on HD for 30 years was referred to us for severe pain with multiple ulcers on his toes and fingers. He was an ex-smoker and had no diabetes mellitus. On admission, he had ulcers on his big toes bilaterally and right 2nd - 4th fingers. Peripheral pulses were strong and his ankle-brachial pressure index was above 1.3. Laboratory data were as follows: calcium 9.9 mg/dl, albumin 3.3 g/dl, phosphate 3.0 mg/dl, Ca x P product 30, and parathyroid hormone 98 pg/ml. He had a parathyroidectomy in 1998 and 1999. X-rays of his hands and legs showed diffuse subcutaneous arteriolar calcification. Angiography revealed no local stenotic lesions. Despite intensive therapies including hyperbaric oxygen therapy, painful gangrene developed on his right big toe and the pain was so intense that he could not go to sleep in a supine position. We infused intravenous sodium thiosulfate (20 g) 3 times weekly, based on previous reports. Within 4 - 5 days, he experienced rapid and dramatic symptom relief. The score of the visual analogue pain scale improved from 10/10 - 2/10. The signs of ischemia, measured by transcutaneous partial oxygen pressure and thermography, improved significantly. During the infusion of sodium thiosulfate, the patient complained of nausea, vomiting and hyperosmia. These adverse symptoms were resolved after discontinuation of the infusion. Pain relief was sustained and he could walk after 2 weeks of infusion. Our case supports the use of sodium thiosulfate as a novel therapeutic choice for critical limb ischemia with severe vascular calcification in chronic HD patients.

Metabolic syndrome and chronic kidney disease in Okinawa, Japan

We assessed the prevalence of chronic kidney disease (CKD) in a hospital-based screening program in Okinawa, Japan. The significance of metabolic syndrome as a determinant of CKD was examined using multivariate logistic regression analysis. A total of 6980 participants, aged 30-79 years, participated in a screening program in Tomishiro Chuo Hospital. Metabolic syndrome was defined according to the criteria of the Adult Treatment Panel III (ATP III). Data were also analyzed according to the modified criteria of the National Cholesterol Education Program (NCEP) that defines abdominal obesity as a waist circumference of > oe =85 cm in men and > or =90 cm in women. CKD was defined as dipstick proteinuria (> or =1+) or a reduced glomerular filtration rate (GFR). GFR was estimated using the abbreviated Modification of Diet in Renal Disease (MDRD) formula. The prevalence of metabolic syndrome and CKD was 12.8 and 13.7%, respectively. Metabolic syndrome was a significant determinant of CKD (adjusted odds ratio (OR) 1.537 and 95% confidence interval (CI) 1.277-1.850, P<0.0001). The adjusted OR (95% CI) was 1.770 (1.215-2.579, P=0.0029) for those with four metabolic syndrome risk factors compared to those with no metabolic syndrome risk factors. Metabolic syndrome was a significant determinant for younger participants (<60 years; OR 1.686, 95% CI 1.348-2.107, P<0.0001), but not for older participants (> or =60 years; OR 1.254, 95% CI 0.906-1.735, NS). The relationship between the number of metabolic syndrome risk factors and the prevalence of CKD was linear using the modified criteria. The results suggest that metabolic syndrome is a significant determinant of CKD in men under 60 years of age, in Okinawa, Japan.

Two unusual cases of Anderson-Fabry disease in a Japanese family

A 16-year-old Japanese girl was admitted to our hospital on February 27, 2001, for acute renal failure. She had not shown proteinuria or hematuria in any school examination through 2000. The first renal biopsy specimen showed focal segmental glomerulosclerosis and tubulointerstitial change. Electron microscopy showed numerous myeloid bodies in the glomerular epithelium suggesting the diagnosis of Anderson-Fabry disease. After electron microscopy, we measured WBC alpha-galactosidase A, which was slightly decreased to 36.1 nmol/mg P/h (normal: 49.8 - 116.4). WBC alpha-galactosidase A levels for other family members were 74.3 for the mother, 4.8 for the father, 45.6 for the elder sister, and 16.3 for the younger sister. During the follow-up, she had two episodes of nephrotic syndrome, which responded well to steroid therapy. Both second and third renal biopsy showed numerous myeloid bodies by electron microscopy. A 52-year-old man, the father of the case one patient, was admitted for renal biopsy because of proteinuria and low levels of WBC alpha-galactosidase. Biopsy specimen showed typical changes under light microscopy and typical myeloid bodies by electron microscopy. Our cases underscore the importance of electron microscopy when examining the biopsy specimen and suggest that undiagnosed Anderson-Fabry disease may be present, in particular on chronic dialysis.

Angiotensin-converting enzyme (ACE) insertion/deletion polymorphism and survival in a cohort of chronic hemodialysis patients

BACKGROUND

There are conflicting reports regarding the relationship between the angiotensin-converting enzyme (ACE) insertion/deletion (I/D) polymorphism and the initiation and progression of cardiovascular disease. Moreover, there is no report regarding the relationship between the ACE I/D polymorphism and the prognosis of chronic dialysis patients.

METHODS

We examined the frequency of the ACE I/D polymorphism in 727 chronic hemodialysis patients in Okinawa, Japan, and observed the prognosis over 2 years in 407 men and 320 women with mean age (SD) of 55.5 (13.9) years with a mean duration of dialysis of 84.3 (66.6) months.

RESULTS

Genotype frequencies were 42.1% for II, 43.2% for ID, and 14.7% for DD. The relative risks of death were examined by Cox-proportional hazards analysis after adjusting for age, sex, age at the start of dialysis, presence of diabetes mellitus and hypertension and total cholesterol and serum albumin levels. The adjusted hazard ratio (95% confidence interval) was 1.03 (0.38 - 2.85) for DD genotype and 1.50 (0.83 - 2.70) for DD+ID genotype when compared to II genotype.

CONCLUSION

ACE I/D polymorphism appears to have no relation to the short-term prognosis in chronic hemodialysis patients.

Comparison of the expression patterns of two LIM-homeodomain genes, Lhx6 and L3/Lhx8, in the developing palate

OBJECTIVES

To compare and contrast the gene expression of two LIM-homeobox type transcription factors, Lhx6 and L3/Lhx8, in secondary palate formation.

METHODS

In situ hybridization histochemistry with digoxygenin (DIG) labelled cRNA probes specific for Lhx6 and L3/Lhx8.

MATERIALS

Serial cryo-sections of embryonic day (E)13.5, 14.5, and 15.5 mice (C57BL/6).

OUTCOME MEASURE

Comparison of the signal intensities of NBT/BCIP precipitate by alkaline phosphatase conjugated anti-DIG antibody.

RESULTS

From E13.5 to E15.5, Lhx6 and L3/Lhx8 signals are detected in palatal mesenchyme, but the L3/Lhx8 signal is much more intense than the Lhx6 signal. In palatal epithelium, covering the mesenchyme, Lhx6 mRNA is transiently expressed at E14.5, while L3/Lhx8 mRNA expression is never detected throughout the development.

CONCLUSION

Lhx6 and L3/Lhx8 functions may be partially redundant in the mesenchyme of the secondary palate, but not in the palatal epithelium.

Evidence for high incidence of end-stage renal disease in patients after stroke and acute myocardial infarction at age 60 or younger

The impact of stroke and acute myocardial infarction (AMI) on the incidence of end-stage renal disease (ESRD) is unknown. Two community-based registries, one of patients with stroke or AMI and another of patients with ESRD who undergo dialysis, are available in Okinawa, Japan. Whether survivors after stroke and AMI who were registered from April 1988 through March 1991 entered an ESRD dialysis program by the end of December 1999 was determined. Among 4,556 patients (3,809 patients with stroke, 747 patients with AMI) who survived at least 28 days after the event onset, 44 patients (36 patients, stroke; 8 patients, AMI) entered an ESRD dialysis program during the study period. The 10-year cumulative incidence of ESRD was approximately 2.0% in those who survived stroke or AMI. The observed-expected ratio was 4.1 in men (P < 0.01) and 5.8 in women (P < 0.01) aged 30 to 59 years and 0.8 in men (not significant) and 0.4 in women (not significant) 60 years and older. The present results confirm that survivors after stroke or AMI have a greater incidence of ESRD than those in the general population, in particular, those who had stroke or AMI at 60 years or younger.

High heart rate relates to clustering of cardiovascular risk factors in a screened cohort

Increased heart rate (HR) is a predictor of cardiovascular mortality, so the present study used a screened cohort to investigate whether the clustering of cardiovascular risk factors is associated with increased HR. Individuals who were receiving medication for hypertension or heart disease and those who did not have an ECG record or who had a record of arrhythmia were excluded. In total, 8,508 subjects (5,299 men, 3,209 women; age range, 18-89 years) were studied. Subjects were divided into 2 HR classes using the value of mean HR+ 1 SD as the cut-off point: low HR (HR < 77 beats/min, n=7,320) and high HR (HR > or = 77 beats/min, n=1,188). For logistic regression analysis, the dependent variable was HR class and the independent variables were the number of risk factors (ie, hypertension, diabetes mellitus, and hypertriglyceridemia each of which was associated positively with HR class by multivariate analysis). The odds ratios and 95% confidence intervals for the number of risk factors were 1.412 (1.216-1.640) for 1 risk factor, 2.800 (2.269-3.455) for 2, and 4.582 (2.815-7.459) for 3. Multivariate regression analyses showed that the number of risk factors from 0 to 3 correlated positively with high HR. HR increased significantly with clustering of risk factors even with low HR (regression coefficient was 1.147, p<0.0001). Modifying the risk factors may lower HR and reduce cardiovascular mortality.