Podocyte Ercc1 is indispensable for glomerular integrity

As life expectancy continues to increase, age-related kidney diseases are becoming more prevalent. Chronic kidney disease (CKD) is not only a consequence of aging but also a potential accelerator of aging process. Here we report the pivotal role of podocyte ERCC1, a DNA repair factor, in maintaining glomerular integrity and a potential effect on multiple organs. Podocyte-specific ERCC1-knockout mice developed severe proteinuria, glomerulosclerosis, and renal failure, accompanied by a significant increase in glomerular DNA single-strand breaks (SSBs) and double-strand breaks (DSBs). ERCC1 gene transfer experiment in the knockout mice attenuated proteinuria and glomerulosclerosis with reduced DNA damage. Notably, CD44+CD8+ memory T cells, indicative of T-cell senescence, were already elevated in the peripheral blood of knockout mice at 10 weeks old. Additionally, levels of senescence-associated secretory phenotype (SASP) factors were significantly increased in both the circulation and multiple organs of the knockout mice. In older mice and human patients, we observed an accumulation of DSBs and an even greater buildup of SSBs in glomeruli, despite no significant reduction in ERCC1 expression with age in mice. Collectively, our findings highlight the crucial role of ERCC1 in repairing podocyte DNA damage, with potential implications for inflammation in various organs.

Association of Inflammatory Bowel Disease with Incident Immunoglobulin A Nephropathy

BACKGROUND

There have been scarce epidemiological data on the relationship between inflammatory bowel disease and the incidence of Immunoglobulin A (IgA) nephropathy. In this study, we assessed whether inflammatory bowel disease was associated with a higher risk of developing IgA nephropathy using a large-scale epidemiological cohort.

METHODS

We retrospectively analyzed 4,311,393 adults enrolled in the JMDC Claims Database (previously known as the Japan Medical Data Center database), a nationwide epidemiological database in Japan. The definitions of IgA nephropathy and inflammatory bowel disease (ulcerative colitis or Crohn's disease) were based on International Classification of Diseases-10th Revision codes. Individuals who had a prior history of IgA nephropathy were excluded. Study participants were categorized into two groups according to the presence of inflammatory bowel disease. Clinical outcomes were collected between January 2005 and May 2022. The primary outcome was incident IgA nephropathy.

RESULTS

Median (interquartile range) age was 44 (36-53) years, and 2,497,313 (58%) were men. Inflammatory bowel disease was observed in 18,623 individuals (0.4%). Over a median follow-up of 1,089 (532-1,797) days, there were 2,631 incidences of IgA nephropathy and 22 incidences in individuals without and with inflammatory bowel disease, yielding incident ratios with 95% confidence intervals of 1.74 (1.68-1.81) and 3.43 (2.26-5.21), respectively. Kaplan-Meier curves and the log-rank test showed that a cumulative incidence of IgA was higher in individuals with inflammatory bowel disease compared to those without (log-rank p=0.003). Multivariable Cox regression analysis demonstrated that individuals with inflammatory bowel disease were at higher risk for incident IgA nephropathy (Hazard ratio 1.96, 95% confidence interval 1.29-2.99).

CONCLUSIONS

We demonstrated the potential association of inflammatory bowel disease with higher risk of developing IgA nephropathy in a general population.

Renal sinus fat is associated with intrarenal hemodynamic abnormalities independent of visceral fat in patients with chronic kidney disease

OBJECTIVE

Obesity is a risk factor of chronic kidney disease (CKD), contributing to the rising incidence of cardiometabolic diseases. Renal sinus fat (RSF) is an ectopic fat depot located at the renal cavity that could impair renal function and hemodynamic through compression of renal structures. The major purpose of this study was to explore the relationship between RSF accumulation and renal dysfunction in CKD patients.

METHODS

We evaluated the associations between computed tomography measured RSF volume and key clinical and histologic parameters involved in renal function and hemodynamics in 132 well-characterized CKD patients who underwent renal biopsy (median age: 62 years; 63.6% men).

RESULTS

RSF volume normalized by renal volume (RSF%) positively correlated with obesity-related traits such body mass index and visceral fat volume (VFV) (all P < 0.001) whereas it negatively correlated with estimated glomerular filtration rate (eGFR) (ρ = -0.42, P < 0.001) and 24-h urinary creatinine clearance (CCr) (ρ = -0.34, P < 0.001). Notably, we found robust positive correlations between RSF% and renal resistive index (RRI) measured by the Doppler ultrasound (ρ = 0.40, P < 0.001), and the histological severity of global glomerular sclerosis (ρ = 0.48, P < 0.001) and interstitial fibrosis and tubular atrophy (IFTA) (ρ = 0.35, P < 0.001). In the multivariate linear regression models, after accounting for potential confounders including VFV, RSF% remained significantly associated with CCr (β = -0.26, P < 0.001), RRI (β = 0.17, P = 0.022), global glomerular sclerosis (β = 0.21, P = 0.002), and IFTA (β = 0.17, P = 0.012).

CONCLUSION

RSF accumulation is associated with renal dysfunction and hemodynamic abnormalities independent of visceral adiposity. Our results suggest that RSF may have a potential unique role in the pathogenesis of CKD.

Comparing Various Resin Luting Cement Systems in Different Etching Modes Through Bond Durability and Morphological Features

OBJECTIVES

This study aimed to investigate bond performance of various resin luting cement (RLC) systems on enamel and dentin in different etching modes and to compare the RLC-tooth interface morphology using scanning electron microscopy (SEM).

METHODS AND MATERIALS

The self-adhesive RLC systems used in combination with universal adhesives were as follows: Scotchbond Universal Adhesive Plus + RelyX Universal (3M Oral Care) and Clearfil Universal Bond Quick ER + SA Luting Multi (Kuraray Noritake Dental). These RLC systems were also used alone as self-adhesive RLC systems without universal adhesives (self-adhesive mode). The conventional RLC systems for comparison materials were as follows: BeautiBond Xtream + ResiCem EX (Shofu) and Tooth Primer + Panavia V5 (Kuraray Noritake Dental). Twelve specimens were prepared for each group to measure shear bond strength (SBS) in different etching modes. A stainless-steel rod was used as a substitute for indirect restorations. Bonded specimens were allocated to baseline (stored for 24 hours) and artificially aged (thermocycling [TC] for 10,000 cycles) groups. Representative treated tooth surfaces and RLC-tooth interfaces were observed using SEM.

RESULTS

Three-way analysis of variance (ANOVA) revealed that all the factors (etching mode, storage period, and RLC system) had a significant influence on the enamel SBS values (p<0.05). Enamel SBS was significantly higher in etch-&-rinse (ER) mode than in self-etch (SE) mode, regardless of RLC system or storage period. Three-way ANOVA showed that all the factors had a significant influence on the dentin SBS values (p<0.001). Most RLC systems showed significantly higher dentin SBS in SE mode than in ER mode, regardless of storage period. However, the combination with Scotchbond Universal Adhesive Plus and RelyX Universal showed no significant difference in SBS values between etching modes at the baseline and showed a significantly higher SBS value in ER mode than in SE mode after TC.

CONCLUSIONS

The self-adhesive RLC systems with universal adhesives tended to show higher enamel and dentin bond performance than the self-adhesive RLC systems alone. The morphology of treated tooth surfaces and resin cement-tooth interfaces were dependent on the RLC system and etching mode used. The RLC systems with primer application showed a thin, high-density layer above the intact dentin in both etching modes, suggesting chemical interaction.

Safety and efficacy of long-term nicotinamide mononucleotide supplementation on metabolism, sleep, and nicotinamide adenine dinucleotide biosynthesis in healthy, middle-aged Japanese men

Obesity and aging are major risk factors for several life-threatening diseases. Accumulating evidence from both rodents and humans suggests that the levels of nicotinamide adenine dinucleotide (NAD+), a regulator of many biological processes, declines in multiple organs and tissues with aging and obesity. Administration of an NAD+ intermediate, nicotinamide mononucleotide (NMN), replenishes intracellular NAD+ levels and mitigates aging- and obesity-associated derangements in animal models. In this human clinical study, we aimed to investigate the safety and effects of 8-week oral administration of NMN on biochemical, metabolic, ophthalmologic, and sleep quality parameters as well as on chronological alterations in NAD+ content in peripheral tissues. An 8-week, single-center, single-arm, open-label clinical trial was conducted. Eleven healthy, middle-aged Japanese men received two 125-mg NMN capsules once daily before breakfast. The 8-week NMN supplementation regimen was well-tolerated; NAD+ levels in peripheral blood mononuclear cells increased over the course of NMN administration. In participants with insulin oversecretion after oral glucose loading, NMN modestly attenuated postprandial hyperinsulinemia, a risk factor for coronary artery disease (n = 3). In conclusion, NMN overall safely and effectively boosted NAD+ biosynthesis in healthy, middle-aged Japanese men, showing its potential for alleviating postprandial hyperinsulinemia.

Hemodialysis treatment of vancomycin-induced drug reaction with eosinophilia and systemic symptoms/drug-induced hypersensitivity syndrome in a patient undergoing peritoneal dialysis

Drug reaction with eosinophilia and systemic symptoms (DRESS), also known as drug-induced hypersensitivity syndrome (DIHS), is a severe drug-induced hypersensitivity reaction with 10% mortality. To date, there is insufficient evidence regarding the association between DRESS/DIHS and serum levels of vancomycin (VCM). Here, we report the case of a 46-year-old woman undergoing peritoneal dialysis who developed VCM-induced DRESS/DIHS. She was hospitalized for peritonitis with abdominal pain and treated with VCM. On day 10 of hospitalization, her abdominal symptoms improved; however, fever, skin rash, lymphadenopathy, eosinophilia, atypical lymphocytes, and liver and renal dysfunction developed. Based on the clinical course and laboratory findings, we diagnosed the patient with DRESS/DIHS due to VCM. Since her serum VCM concentration was high at 39.8 μg/mL, hemodialysis (HD) was performed to remove VCM, which caused her symptoms to improve. However, serum levels of VCM rebounded and the same symptoms recurred. Therefore, we re-performed HD; no further relapse occurred. This clinical course showed that increased serum VCM levels were associated with DRESS/DIHS onset and severity, suggesting that it is a blood level-dependent disease and that removal of VCM by HD is a potential therapeutic option.

Secular trends and age-specific distribution of blood pressure in Japanese adolescents aged 12-18 years in 2000-2019

Adolescent blood pressure is a predictor of future risk for hypertension and cardiovascular diseases, and therefore its status needs to be accurately determined. However, limited evidence is available regarding the secular trends and distribution of adolescent blood pressure. In the present study, we assessed the secular trends and age-specific distributions of blood pressure in Japanese adolescents aged 12-18 years by using data drawn from 20 years of annual health checkups conducted between 2000 and 2019. Participants underwent health checkups every year for three years at the same school and the data were divided into four 5-year cycles: 2000-2004, 2005-2009, 2010-2014, and 2015-2019. From a total of 124,460 records (33,496 individuals) retrieved, 3000 records (3000 individuals) from each year-cycle were randomly selected to avoid duplicating data from the same individuals. In the study period, in males systolic blood pressure showed a decreasing trend over time, whereas in females diastolic blood pressure showed an increasing trend. Subgroup analyses by school category (junior/senior high school) and by obesity category showed similar blood pressure trends as in the overall analysis. Age-specific blood pressure values in Japanese adolescents increased with age in males but not in females. Thus, different patterns of change in blood pressure values over the past 20 years were observed between males and females. Age-specific blood pressure distributions are also presented. Together, these findings will be useful for understanding blood pressure trends among adolescents.

Clinical significance of serum urea-to-creatinine ratio in patients undergoing peritoneal dialysis

INTRODUCTION

We aimed to determine the correlation between the serum urea-to-creatinine ratio and residual kidney function (RKF) in patients undergoing peritoneal dialysis (PD), as well as its predictive value for PD-related outcomes.

METHODS

This study included a cross-sectional study to assess the correlation between serum urea-to-creatinine ratio and RKF in 50 patients on PD and a retrospective cohort study to assess the association between serum urea-to-creatinine ratio and PD-related outcomes in 122 patients who initiated PD.

RESULTS

Serum urea-to-creatinine ratios had significant positive correlations with renal Kt/V and creatinine clearance values (r = 0.60, p < 0.001 and r = 0.61, p < 0.001, respectively). Additionally, serum urea-to-creatinine ratio was significantly associated with a lower risk of transfer to hemodialysis or PD/hemodialysis hybrid therapy (hazard ratio: 0.84, 95% confidence interval: 0.75-0.95).

CONCLUSION

The serum urea-to-creatinine ratio can be an indicator of RKF and a prognostic factor in patients undergoing PD.

Comparison of the effects of angiotensin receptor-neprilysin inhibitors and thiazide diuretic/renin-angiotensin system inhibitor combination therapy in hypertensive patients: a retrospective cohort study

Angiotensin receptor-neprilysin inhibitors (ARNIs) have been approved as antihypertensive agents in Japan, and thiazide diuretics (TZDs) are widely used concomitantly with renin-angiotensin system inhibitors (RASIs) for hypertension. This retrospective study included patients with hypertension who switched from RASI to ARNI therapy (ARNI group) and those who were prescribed TZDs with RASIs (TZD/RASI group). Drug-related changes in the estimated glomerular filtration rate (eGFR), blood pressure (BP), body weight (BW), serum electrolytes, uric acid (UA), and triglyceride levels were compared between the two groups. Overall, 70 participants (31 and 39 in the ARNI and TZD/RASI groups, respectively) were enrolled and observed for a median of 2 months. According to linear mixed models, compared with the TZD/RASI group, the ARNI group exhibited a significant change in mean eGFR of 3.71 mL/min/1.73 m2 [95% confidence interval (CI), 0.57-6.84; P = 0.02] from the time of switching drug to the next outpatient visit. Further, compared with the TZD/RASI group, the ARNI group exhibited significant changes in mean serum UA (-1.27; 95% CI, -1.66 to -0.88), sodium (1.22; 95% CI, 0.12 to -2.32), chloride (2.14; 95% CI, 0.75-3.52), and triglyceride (-52.1; 95% CI, -100.9 to -3.29) levels. Conversely, serum potassium levels, BW, and systolic and diastolic BP did not differ significantly between the two groups (P = 0.69, 0.44, 0.49, and 0.66, respectively). Compared with the combination therapy of TZD and RASI, ARNI therapy causes less renal dysfunction, hyperuricemia, and hypertriglyceridemia with fewer electrolyte abnormalities and no significant difference in antihypertensive effects.

Association Between Renal Sinus Fat and Cardiometabolic and Renin-Angiotensin System Parameters in Primary Aldosteronism

Context

Renal sinus fat (RSF) accumulation is associated with cardiometabolic diseases, such as obesity, diabetes, hypertension, and chronic kidney disease. However, clinical implications of RSF in primary aldosteronism (PA) remain unclear.

Objective

We aimed to investigate relationships between RSF volume and key cardiometabolic and renin-angiotensin system (RAS) parameters in PA patients and clarify the differences in these relationships between unilateral and bilateral subtypes.

Methods

We analyzed data obtained from well-characterized PA patients that involved 45 unilateral (median age: 52 years; 42.2% men) and 92 bilateral patients (51 years; 42.4% men).

Results

RSF volume normalized by renal volume (RSF%) was greater in the unilateral group than in the bilateral group (P < .05). RSF% was greater in men than in women (P < .05). RSF% positively correlated with parameters related to cardiometabolic risk, including age, body mass index, visceral fat volume, creatinine, triglycerides/high-density lipoprotein cholesterol ratio, uric acid, fasting glucose, and C-reactive protein regardless of PA subtypes (all P < .05). Intriguingly, RSF% positively correlated with plasma aldosterone concentration (PAC), aldosterone-to-renin ratio, and intact parathyroid hormone (iPTH) (all P < .05) in bilateral patients but did not correlate with RAS parameters and even showed an opposite trend in unilateral patients. In subgroup analyses by sex, these distinctions became more evident in women. After adjustment for potential confounders, RSF% remained positively correlated with PAC and iPTH in bilateral patients.

Conclusion

Our results indicate that RSF accumulation is involved in cardiometabolic dysfunction associated with PA. However, there were distinct correlations between RSF volume and RAS parameters according to sex and PA subtypes.

Phase II Clinical Trial of Hypofractionated Image-Guided Proton Therapy with 12 Fractions for Prostate Cancer

PURPOSE/OBJECTIVE(S)

Towards hypofractionated proton therapy for prostate cancer for improving convenience for patients to receive treatment and improving therapeutic efficacy, image-guided technique with hydrogel spacer solved the late gastrointestinal toxicity, but it is unclear whether acute genitourinary (GU) toxicity is acceptable. The aim of this phase II study was to evaluate the safety and efficacy of hypofractionated image-guided proton therapy (IGPT) with 12 fractions for prostate cancer.

MATERIALS/METHODS

Eligibility criteria were as follows: (1) histologically confirmed primary prostate cancer; (2) T1-T3bN0M0 staged by (UICC TNM8th); (3) ECOG-PS ≤ 2; (4) age ≥ 20 years; (5) no serious underlying disease or other cancers; (6) technically capable of proton therapy, and (7) written informed consent. Primary endpoint was the ratio of grade 2 or more acute genitourinary toxicity. We used the modified CTCAE grading of grade 2 GU toxicities, in which prescribing two and more types of drugs for dysuria within 3 months of the start of radiation was considered to indicate grade 2 GU toxicity. A phase II trial was planned based on the minimax Simon's two-stage design with a significance level of 0.05 and a power of 90%. The acceptable incidence is considered to be less than 5%, and the unacceptable incidence is considered to be more than 15%. A total of 83 patients is required for completion of the trial (7 patients or fewer). After evaluating the primary endpoint in 83 patients, 217 additional patients were registered and a total of 300 patients were registered in order to further examine the safety and efficacy. The prescribed dose to the isocenter was 51.6 GyRBE in 12 fractions (4 days a week).

RESULTS

From January 2020 to March 2021, 30, 53, and 217 patients (total 300) were enrolled. The patient characteristics were as follows: median age, 70 (48-83) years; low/intermediate/high risk, 44/132/124. Forty-nine and 38 patients had benign prostatic hyperplasia and diabetes mellitus, respectively. Grade 2 acute GU toxicities were observed in 1, 5 and 13 patients, respectively (total 6.3%). No grade 3 or higher acute GU toxicities were observed. However, urinary retention during IGPT, which was not previously observed, was observed in 3 cases, and temporary urethral catheterization was performed (Grade 2). Most of the acute GU toxicity tended to improve at 1 month after IGPT, and almost improved at 3 months. Mean score deteriorations beyond the minimum clinically important difference threshold (1/2 SD) were observed only at 1 month in the following scales: summary (-6.0), bother (-7.0), and irritative/obstructive (-6.3).

CONCLUSION

Hypofractionated IGPT with 12 fractions for prostate cancer is well tolerated in acute GU toxicities. Longer follow-up is necessary to evaluate the efficacy and late toxicities. Further investigation of hypofractionated IGPT with 12 fractions for prostate cancer is warranted. Since April 2021, an additional 1000 cases of prospective registration study have been conducted.

Targeting DNA Methylation in Podocytes to Overcome Chronic Kidney Disease

The number of patients with chronic kidney disease (CKD) is on the rise worldwide, and there is urgent need for the development of effective plans against the increasing incidence of CKD. Podocytes, glomerular epithelial cells, are an integral part of the primary filtration unit of the kidney and form a slit membrane as a barrier to prevent proteinuria. The role of podocytes in the pathogenesis and progression of CKD is now recognized. Podocyte function depends on a specialized morphology with the arranged foot processes, which is directly related to their function. Epigenetic changes responsible for the regulation of gene expression related to podocyte morphology have been shown to be important in the pathogenesis of CKD. Although epigenetic mechanisms include DNA methylation, histone modifications, and RNA-based regulation, we have focused on DNA methylation changes because they are more stable than other epigenetic modifications. This review summarizes recent literature about the role of altered DNA methylation in the kidney, especially in glomerular podocytes, focusing on transcription factors and DNA damage responses that are closely associated with the formation of DNA methylation changes.

Adipocyte NMNAT1 expression is essential for nuclear NAD+ biosynthesis but dispensable for regulating thermogenesis and whole-body energy metabolism

Nicotinamide adenine dinucleotide (NAD+) functions as an essential cofactor regulating a variety of biological processes. The purpose of the present study was to determine the role of nuclear NAD+ biosynthesis, mediated by nicotinamide mononucleotide adenylyltransferase 1 (NMNAT1), in thermogenesis and whole-body energy metabolism. We first evaluated the relationship between NMNAT1 expression and thermogenic activity in brown adipose tissue (BAT), a key organ for non-shivering thermogenesis. We found that reduced BAT NMNAT1expression was associated with inactivation of thermogenic gene program induced by obesity and thermoneutrality. Next, we generated and characterized adiponectin-Cre-driven adipocyte-specific Nmnat1 knockout (ANMT1KO) mice. Loss of NMNAT1 markedly reduced nuclear NAD+ concentration by approximately 70% in BAT. Nonetheless, adipocyte-specific Nmnat1 deletion had no impact on thermogenic (rectal temperature, BAT temperature and whole-body oxygen consumption) responses to β-adrenergic ligand norepinephrine administration and acute cold exposure, adrenergic-mediated lipolytic activity, and metabolic responses to obesogenic high-fat diet feeding. In addition, loss of NMNAT1 did not affect nuclear lysine acetylation or thermogenic gene program in BAT. These results demonstrate that adipocyte NMNAT1 expression is required for maintaining nuclear NAD+ concentration, but not for regulating BAT thermogenesis or whole-body energy homeostasis.

Longitudinal changes in pancreatic volume and pancreatic fat with weight gain in Japanese without diabetes: An analysis using health check-up data

Aims/introduction

There have been few reports about the longitudinal changes in pancreas volume (PV) or pancreatic steatosis (PS) in response to obesity. In this longitudinal analysis using health check-up data, we explored changes in PV, PS and glucose metabolic indices that occurred after weight gain in Japanese without diabetes.

Materials/methods

Clinical data on 37 Japanese subjects with a ≥1 kg/m² increase in body mass index between two health check-ups and without diabetes were collected. PV, pancreas attenuation (PA) and splenic attenuation (SA) were evaluated using computed tomography (CT) images. The pancreas area was outlined by hand in multiple images with slice thickness of 2 mm, and the PV was computed by summing these areas. PS was defined as the difference between SA and PA (SA-PA). Medical records were collected, including findings on immunoreactive insulin (IRI), homeostasis model assessment of insulin resistance (HOMA-R) and beta cell function (HOMA-β). Paired t-test and Spearman's correlation coefficient were used in the analyses.

Results

The median follow-up period was 21.1 months and the mean BMI was increased from 25.5 ± 3.3 kg/m² to 27.0 ± 3.3 kg/m². PV (53.5 ± 15.9 cm³ vs. 56.2 ± 16.4 cm³) and SA-PA (8.7 ± 9.1 HU vs. 13.6 ± 10.9 HU) increased significantly after weight gain (both, P < 0.001). There were significant increases of IRI and HOMA-R with the weight gain (both, P < 0.05), whereas HOMA-β exhibited only a nonsignificant trend of increase (55.4％ (41.5-65.5) vs. 56.8％ (46.2-83.7), P = 0.07).

Conclusions

Both PV and PS were increased longitudinally with weight gain in Japanese without diabetes.

Seasonal variation in predialysis systolic blood pressure and cardiovascular events in patients on maintenance hemodialysis

Predialysis systolic blood pressure (SBP) in patients on hemodialysis (HD) consistently followed a seasonal pattern, reaching a peak in winter and nadir in summer, similar to blood pressure in the general population. However, the relationship between seasonal variations in predialysis SBP and clinical outcomes is still under-investigated in Japanese patients on HD. This retrospective cohort study included 307 Japanese patients undergoing HD for >1 year in three dialysis clinics and evaluated the association between the standard deviation (SD) of predialysis SBP and clinical outcomes, including major adverse cardiovascular events (MACEs; cardiovascular death, nonfatal myocardial infarction or unstable angina, stroke, heart failure, and other severe cardiovascular events requiring hospitalization) with 2.5 years follow-up. The SD of predialysis SBP was 8.2 (6.4-10.9) mmHg. In the model fully adjusted for the SD of predialysis SBP, predialysis SBP, age, sex, HD vintage, Charlson comorbidity index, ultrafiltration rate, renin-angiotensin system inhibitors, corrected calcium, phosphorus, human atrial natriuretic peptide, C-reactive protein, albumin, hemoglobin, body mass index, normalized protein catabolism rate, and intradialytic SBP decline, Cox regression analyses showed that a higher SD of predialysis SBP (per 10 mmHg) was significantly associated with increased MACE risk (hazard ratio [HR], 1.89; 95% confidence interval [95% CI], 1.07-3.36) and all-cause hospitalization (HR, 1.57; 95% CI, 1.07-2.30). Therefore, greater seasonal variations in predialysis SBP were associated with worse clinical outcomes, including MACEs and all-cause hospitalization. Whether interventions to reduce seasonal variations in predialysis SBP will improve the prognosis of Japanese patients on HD must be investigated further.

Antineutrophil cytoplasmic antibody-associated vasculitis predominantly manifesting tubulointerstitial nephritis: A case report

The common histopathology of antineutrophil cytoplasmic antibody-associated vasculitis comprises pauci-immune crescentic glomerulonephritis with concomitant tubulointerstitial nephritis. Tubulointerstitial nephritis in the absence of glomerular involvement in patients with antineutrophil cytoplasmic antibody-associated vasculitis is uncommon. We report a case of antineutrophil cytoplasmic antibody-associated vasculitis-associated acute kidney injury manifesting as tubulointerstitial nephritis without glomerulonephritis. A 75-year-old woman with fever, cough, and myalgia developed kidney dysfunction with inflammatory reactions and tubular-type proteinuria, without glomerular hematuria. A kidney biopsy revealed tubulointerstitial nephritis with arteritis. We ruled out important underlying etiologies of tubulointerstitial nephritis, including infection, drug reactions, and autoimmune diseases. Since chest high-resolution computed tomography demonstrated mild interstitial pneumonia in bilateral lower lung fields, myeloperoxidase antineutrophil cytoplasmic antibody was measured and found to be positive. Therefore, we diagnosed the patient with antineutrophil cytoplasmic antibody-associated vasculitis-associated tubulointerstitial nephritis but not glomerulonephritis, and interstitial pneumonia. The patient's kidney function and symptoms markedly improved with prednisolone treatment. Clinicians should maintain high-level vigilance for antineutrophil cytoplasmic antibody-associated vasculitis as a possible underlying component of tubulointerstitial nephritis, particularly when kidney function deteriorates with tubulointerstitial injuries without glomerular features.

Amniotic fluid interleukin-6 and neutrophil gelatinase-associated lipocalin for predicting fetal inflammatory response syndrome based on histological chorioamnionitis and funisitis

OBJECTIVE

We aimed to analyze the predictive efficacy of amniotic fluid interleukin-6 (IL-6) and neutrophil gelatinase-associated lipocalin (NGAL) for fetal inflammatory response syndrome (FIRS)-related infection.

MATERIALS AND METHODS

We included singleton pregnancies classified into FIRS and non-FIRS groups. FIRS was defined as histologic chorioamnionitis and funisitis. Amniotic fluid samples were collected during vaginal delivery (VD) or cesarean section (CS). We compared amniotic fluid IL-6 and NGAL levels between the groups.

RESULTS

Forty-six pregnancies were analyzed and classified into 20 (43.5%) FIRS and 26 (56.5%) non-FIRS pregnancies. We observed significant differences in amniotic fluid IL-6 and NGAL. Amniotic fluid collection significantly influenced NGAL levels (p < 0.001). The area under the concentration-time curve (AUC), with optimal cutoff values, for amniotic fluid IL-6 and NGAL (VD and CS) levels was 0.948 (11,344 pg/mL), 0.800 (1180 ng/mL), and 0.946 (708 ng/mL), respectively.

CONCLUSION

Amniotic fluid IL-6 and NGAL levels showed equivalent predictive ability for FIRS-related infection.

DNA-damaged podocyte-CD8 T cell crosstalk exacerbates kidney injury by altering DNA methylation

Recent epigenome-wide studies suggest an association between blood DNA methylation and kidney function. However, the pathological importance remains unclear. Here, we show that the homing endonuclease I-PpoI-induced DNA double-strand breaks in kidney glomerular podocytes cause proteinuria, glomerulosclerosis, and tubulointerstitial fibrosis with DNA methylation changes in blood cells as well as in podocytes. Single-cell RNA-sequencing analysis reveals an increase in cytotoxic CD8+ T cells with the activating/costimulatory receptor NKG2D in the kidneys, which exhibit a memory precursor effector cell phenotype, and the CD44high memory CD8+ T cells are also increased in the peripheral circulation. NKG2D blockade attenuates the renal phenotype caused by podocyte DNA damage. Blood methylome shows increased DNA methylation in binding sites for STAT1, a transcription factor contributing to CD8+ T cell homeostasis. Collectively, podocyte DNA damage alters the blood methylome, leading to changes in CD8+ T cells, which contribute to sustained renal injury in chronic kidney disease.

A systematic review and meta-analysis of the clinical impact of stopping renin-angiotensin system inhibitor in patients with chronic kidney disease

Although renin-angiotensin system (RAS) inhibitors reduce the risk of cardiovascular diseases and end-stage kidney disease (ESKD) in chronic kidney disease (CKD) patients, they are often discontinued in clinical practice due to drug-related adverse events. However, limited evidence is available about the clinical impact of RAS inhibitor discontinuation in CKD patients. A comprehensive search of publications investigating the effect of discontinuing RAS inhibitors on clinical outcomes in CKD patients in PubMed, the Cochrane Library, and Web of Science was conducted (inception to November 7, 2022), and potentially relevant studies were searched by hand (through November 30, 2022). Two reviewers independently extracted data according to the PRISMA and MOOSE guidelines and assessed the quality of each study with risk-of-bias tools, RoB2 and ROBINS-I. The pooled hazard ratio (HR) for each outcome was integrated with a random-effect model. A total of 1 randomized clinical trial and 6 observational studies involving 248,963 patients were included in the systematic review. The meta-analysis of observational studies showed that discontinuation of RAS inhibitors was associated with a higher risk of all-cause mortality (HR, 1.41 [95% CI, 1.23-1.62]; I² = 97%), ESKD (1.32 [95% CI, 1.10-1.57]; I² = 94%) and MACE (1.20 [95% CI 1.15-1.25]; I² = 38%), but not with hyperkalemia (0.79 [95% CI 0.55-1.15]; I² = 90%). Overall risk of bias was moderate-to-serious, and quality of evidence (GRADE system) was low-to-very low. The present study suggests that CKD patients would benefit from continuing RAS inhibitors.

Case report: Importance of early and continuous tocilizumab therapy in nephrotic syndrome associated with idiopathic multicentric Castleman disease: A case series

Idiopathic multicentric Castleman disease (iMCD) is a systemic and polyclonal lymphoproliferative disease involving multiple organs, including the kidneys, due to the overproduction of interleukin-6 (IL-6). Recently, several reports have suggested that excessive IL-6 actions in iMCD could have a causal relationship with the development of diverse histopathological renal manifestations that cause nephrotic syndrome. However, the treatment for such cases remains unclear. We report a series of three cases of nephrotic syndrome due to iMCD that helps to delineate the importance of early and continuous therapy with the anti-interleukin-6 receptor antibody tocilizumab. First, treatment was suspended for infectious control, and the patient presented with nephrotic syndrome due to diffuse mesangial and endocapillary hypercellularity without immune deposits complicating acute kidney injury. Second, iMCD was treated with prednisolone alone. The patient suddenly developed nephrotic syndrome due to immune-complex glomerulonephritis, not otherwise specified, complicated with acute kidney injury. In the third case, nephrotic syndrome secondary to membranous glomerulonephritis was diagnosed, with a skin rash and IgE antibodies to tocilizumab, and was therefore treated with prednisolone alone. In contrast to the first two cases, the third progressed to end-stage renal disease on hemodialysis. Taken together, this series suggests that clinicians should maintain clinical vigilance for iMCD as a possible underlying component of nephrotic syndrome, since iMCD presents with a variety of renal pathologies. Prompt initiation and continuous administration of tocilizumab are likely key determinants of renal outcomes in such cases. In particular, when tocilizumab is suspended due to infection or in the perioperative period, consideration of its expeditious resumption should be made, taking into account both the withdrawal period and systemic conditions.

Correlation between acylcarnitine/free carnitine ratio and cardiopulmonary exercise test parameters in patients with incident dialysis

Objective: Diminished physical capacity is common and progressive in patients undergoing dialysis, who are also prone to deficiency in carnitine, which plays a pivotal role in maintaining skeletal muscle and cardiac function. The present study aimed to evaluate the association of carnitine profile with exercise parameters in patients with incident dialysis. Design and Methods: This was a single-center cross-sectional study including 87 consecutive patients aged 20-90 years who were initiated on dialysis in Keio University Hospital between December 2019 and December 2022 and fulfilled the eligibility criteria. Exercise parameters were evaluated via cardiopulmonary testing (CPX) using the electronically braked STRENGTH ERGO 8 ergometer, whereas the carnitine profile was assessed by determining serum free carnitine (FC), acylcarnitine (AC) levels and AC/FC ratio. Results: The mean cohort age was 62.1 ± 15.2 years, with male and hemodialysis predominance (70% and 73%, respectively). AC/FC was 0.46 ± 0.15, and CPX revealed peak oxygen consumption (VO₂) of 13.9 ± 3.7 (mL/kg/min) with percent-predicted peak VO₂ of 53.6% ± 14.7% and minute ventilation (VE)/carbon dioxide output (VCO₂) slope of 35.1 ± 8.0. Fully-adjusted multivariate linear regression analysis showed that AC/FC was significantly associated with decreased peak VO₂ (β, -5.43 [95% confidence interval (CI), -10.15 to -0.70]) and percent-predicted peak VO₂ (β, -19.98 [95% CI, -38.43 to -1.52]) and with increased VE/VCO₂ slope (β, 13.76 [95% CI, 3.78-23.75]); FC and AC did not exhibit similar associations with these parameters. Moreover, only AC/FC was associated with a decreased peak work rate (WR), percent-predicted WR, anaerobic threshold, delta VO₂/delta WR, and chronotropic index. Conclusion: In patients on incident dialysis, exercise parameters, including those related to both skeletal muscle and cardiac function, were strongly associated with AC/FC, a marker of carnitine deficiency indicating altered fatty acid metabolism. Further studies are warranted to determine whether carnitine supplementation can improve exercise capacity in patients on incident dialysis.

Compared effectiveness of sodium zirconium cyclosilicate and calcium polystyrene sulfonate on hyperkalemia in patients with chronic kidney disease

Hyperkalemia is a well-recognized electrolyte abnormality in patients with chronic kidney disease (CKD). Potassium binders are often used to prevent and treat hyperkalemia. However, few studies have evaluated the difference in serum potassium (K⁺) level-lowering effect during the post-acute phase between the novel potassium binder, sodium zirconium cyclosilicate (ZSC), and conventional agents. This retrospective study included patients who received potassium binders (either ZSC or calcium polystyrene sulfonate [CPS]) in our hospital between May 2020 and July 2022. The patients were divided into the ZSC and CPS groups. After propensity score matching, we compared changes from baseline to the first follow-up point, at least 4 weeks after initiating potassium binders, in electrolytes including K⁺ level between the two groups. Of the 132 patients, ZSC and CPS were administered in 48 and 84 patients, respectively. After matching, 38 patients were allocated to each group. The ZSC group showed greater reduction in K⁺ levels than did the CPS group (P < 0.05). Moreover, a significant increase in serum sodium minus chloride levels, a surrogate marker for metabolic acidosis, was observed in the ZSC group (P < 0.05). Our results demonstrated that ZSC could potentially improve hyperkalemia and metabolic acidosis in patients with CKD.

Prevalence and correlates of stocking up on drugs during the COVID-19 pandemic: Data from the C3PNO Consortium

BACKGROUND

Data from the COVID-19 pandemic describes increases in drug use and related harms, especially fatal overdose. However, evidence is needed to better understand the pathways from pandemic-related factors to substance use behaviours. Thus, we investigated stockpiling drugs among people who use drugs (PWUD) in five cities in the United States and Canada.

METHODS

We used data from two waves of interviews among participants in nine prospective cohorts to estimate the prevalence and correlates of stockpiling drugs in the previous month. Longitudinal correlates were identified using bivariate and multivariate generalized linear mixed-effects modeling analyses.

RESULTS

From May 2020 to February 2021, we recruited 1873 individuals who completed 2242 interviews, of whom 217 (11.6%) reported stockpiling drugs in the last month at baseline. In the multivariate model, stockpiling drugs was significantly and positively associated with reporting being greatly impacted by COVID-19 (Adjusted Odds Ratio [AOR]= 1.21, 95% CI: 1.09-1.45), and at least daily use of methamphetamine (AOR = 4.67, 95% CI: 2.75-7.94) in the past month.

CONCLUSIONS

We observed that approximately one-in-ten participants reported stocking up on drugs during the COVID-19 pandemic. This behaviour was associated with important drug-related risk factors including high-intensity methamphetamine use. While these correlations need further inquiry, it is possible that addressing the impact of COVID-19 on vulnerable PWUD could help limit drug stockpiling, which may lower rates of high-intensity stimulant use.

An attenuated vaccinia vaccine encoding the severe acute respiratory syndrome coronavirus-2 spike protein elicits broad and durable immune responses, and protects cynomolgus macaques and human angiotensin-converting enzyme 2 transgenic mice from severe acute respiratory syndrome coronavirus-2 and its variants

As long as the coronavirus disease-2019 (COVID-19) pandemic continues, new variants of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) with altered antigenicity will emerge. The development of vaccines that elicit robust, broad, and durable protection against SARS-CoV-2 variants is urgently required. We have developed a vaccine consisting of the attenuated vaccinia virus Dairen-I (DIs) strain platform carrying the SARS-CoV-2  S gene (rDIs-S). rDIs-S induced neutralizing antibody and T-lymphocyte responses in cynomolgus macaques and human angiotensin-converting enzyme 2 (hACE2) transgenic mice, and the mouse model showed broad protection against SARS-CoV-2 isolates ranging from the early-pandemic strain (WK-521) to the recent Omicron BA.1 variant (TY38-873). Using a tandem mass tag (TMT)-based quantitative proteomic analysis of lung homogenates from hACE2 transgenic mice, we found that, among mice subjected to challenge infection with WK-521, vaccination with rDIs-S prevented protein expression related to the severe pathogenic effects of SARS-CoV-2 infection (tissue destruction, inflammation, coagulation, fibrosis, and angiogenesis) and restored protein expression related to immune responses (antigen presentation and cellular response to stress). Furthermore, long-term studies in mice showed that vaccination with rDIs-S maintains S protein-specific antibody titers for at least 6 months after a first vaccination. Thus, rDIs-S appears to provide broad and durable protective immunity against SARS-CoV-2, including current variants such as Omicron BA.1 and possibly future variants.

Usefulness of echocardiographic parameters in predicting the incidence of ischemic stroke in Japanese patients with non-valvular atrial fibrillation

Background

Atrial fibrillation (AF) is a risk factor for ischemic stroke (IS). We developed a novel risk score of IS (HELT-E2S2 score) in non-valvular atrial fibrillation (NVAF) patients from the combined database of 5 major AF registries in Japan. However, this score does not include echocardiographic (Echo) parameters that have been reported to be risk factors of IS, such as left atrial diameter (LAD) enlargement or increased relative wall thickness (RWT) of left ventricle (LV).

Purpose

To investigate the predictive value of Echo parameters in Japanese patients with NVAF.

Methods

After excluding patients without the Echo data, 6,032 NVAF patients were analyzed in the present study. LAD was measured in the parasternal long axis view at the end-ventricular systole. RWT was calculated as (2x posterior wall thickness)/ LV end-diastolic dimension. We compared clinical characteristics and the incidence of IS between NVAF patients divided by LAD level (High/Low LAD group) and RWT level (High/Low RWT group). To balance the follow-up period among the registries, event data from individuals whose follow-up period exceeded 730 days were excluded from the analysis.

Results

The optimal cut-off value of LAD and RWT to predict the incidence of IS with the receiver operating characteristic analysis was 43.3 mm and 0.4167, respectively. Between the High/Low LAD groups (High LAD: n=2,640 vs. Low LAD: n=3,392), age (70.3±12.1 vs. 68.3±12.5 years; p&lt;0.001), CHA2DS2-VASc score (3.02±1.84 vs. 2.57±1.78; p&lt;0.001), HELT-E2S2 score (2.20±1.31 vs. 1.55±1.33; p&lt;0.001), the prescription of oral anticoagulants (OACs) (69.5 vs. 51.5%; p&lt;0.001), LV ejection fraction (60.4±13.4 vs. 64.4±10.7%; p&lt;0.001) and RWT (0.401±0.091 vs. 0.396±0.082; p=0.02) were significantly different. Between the High/Low RWT groups (High RWT: n=2,293 vs. Low RWT: n=3,739), percentage of female (35.6 vs. 27.8%; p&lt;0.001), age (71.2±12.1 vs. 68.0±12.4 years; p&lt;0.001), CHA2DS2-VASc score (3.08±1.82 vs. 2.58±1.79; p&lt;0.001), HELT-E2S2 score (2.10±1.39 vs. 1.67±1.31; p&lt;0.001), the prescription of OACs (62.6 vs. 57.4%; p&lt;0.001), LV ejection fraction (65.5±9.9 vs. 60.9±13.0%; p&lt;0.001) and LAD (43.0±8.1 vs. 42.4±8.3; p=0.004) were significantly different. In Kaplan-Meier analysis, the incidence of IS was different between the groups during the median follow-up period of 730 days (High LAD vs. Low LAD; 1.82 vs. 1.00 per 100 person-years; p&lt;0.001, by log-rank test, High RWT vs. Low RWT; 1.86 vs. 1.06; p&lt;0.001) (Figure). Both High LAD (hazard ratio: 1.65, 95% CI: 1.12–2.46; p=0.01) and High RWT (hazard ratio: 1.43, 95% CI: 1.01–2.04; p=0.045) were independent predictors of the incidence of IS after adjustment by the components of the HELT-E2S2 score and other clinically relevant variables including co-existing diseases, gender, and the prescription of OACs (Table).

Conclusion

Echo parameters, LAD and RWT, were independently associated with the incidence of IS among Japanese patients with NVAF.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Japan Agency for Medical Research and Development

Utility of in vivo zebrafish cardiac assay to predict the functional impact of KCNQ1 variants

Background

Genetic testing for inherited arrhythmias and discriminating pathogenic from benign variants are integral for the gene-based medicine. However, the high throughput in vivo functional analysis for the rare variants of the KCNQ1 potassium channel is scarce.

Purpose

We tested the utility of the in vivo zebrafish cardiac assay for determining the pathogenicity of the KCNQ1 variants identified in patients with long QT syndrome (LQTS) and atrial fibrillation (AF).

Methods

We generated a knock-out zebrafish with CRISPR-mediated insertions or deletions of the KCNQ1 homolog in zebrafish (kcnq1+/+). To test the utility of the cardiac assay, we used five KCNQ1 variants identified in patients with LQTS or familial AF. Human wild-type or mutant KCNQ1 cRNA (Q1) was co-injected with human KCNE1 cRNA (E1) into the F3 generation embryos with homozygous deletions. We dissected the hearts from the thorax at 72 hour-post-fertilization and measured transmembrane potential in zebrafish heart using the disrupted patch technique. Action potential duration was calculated as the time interval between the peak maximum upstroke velocity and 90% of repolarization (APD90). We compared the APD90s with patients' clinical phenotype and IKs density measured by patch-clamp technique in heterologous system.

Results

The mean APD90 of embryos with kcnq1del/del was 279±48 ms, which was restored by injecting Q1 WT and E1 (159±29 ms) to that with kcnq1+/+ (167±28 ms). We tested if the mean APD90 of embryos with kcnq1del/del was restored (shortened) by injecting the KCNQ1 variants. First we tested the dominant negative variant p.S277L and the trafficking deficient variant p.T587M. Patients with these variants showed significant prolonged QT intervals, and patch clamp study showed both variants caused the non-functional channels. Zebrafish cardiac assay showed the mean APD90 of embryos with kcnq1del/del+ Q1 S277L+E1 or Q1 T587M+E1 was significantly longer than that with kcnq1del/del+Q1 WT+E1 (Table). Next we tested in-frame variant c.1472_1473 ins GGACCT, which was identified from a patient with AF and normal QT interval. Patch clamp study showed the current density of the mutant KCNQ1 channel with KCNE1 was comparable to that of wild-type KCNQ1 channel with KCNE1. Zebrafish assay showed the mean APD90 of embryos with kcnq1del/del shortened by injecting Q1 insACCTGG +E1 (Table). Finally we tested a missense variant p.R451Q, which was identified from a patient with LQTS. Patch clamp study showed the currents in the cells transfected with R451Q+KCNE1 were similar to those with WT+KCNE1. Zebrafish assay showed the mean APD90 of embryos with kcnq1del/del+Q1 R451Q+E1 was longer than that with kcnq1del/del+Q1 WT+E1 (Table).

Conclusions

Functional analysis of in vivo zebrafish cardiac assay might be useful for determining the pathogenicity of rare variants in patients with LQTS.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Grant-in-Aid for Scientific Research (C)

High incidence of pulmonary artery thrombosis after balloon pulmonary angioplasty in CTEPH patients receiving direct oral anticoagulants

Background

Chronic thromboembolic pulmonary hypertension (CTEPH) requires life-long anticoagulant therapy, whereas limited data exist on the safety and efficacy of direct oral anticoagulants (DOACs) and vitamin K antagonists (VKAs) along with balloon pulmonary angioplasty (BPA).

Objectives

To evaluate outcomes and complications in CTEPH following BPA for individuals receiving DOACs or VKAs.

Methods

Consecutive CTEPH patients underwent BPA from September 2014 to August 2021 were included in a retrospective analysis. Complications during BPA, post-BPA hemodynamics and bleeding events were obtained from patient's medical records. Our routine follow-up “selective” pulmonary angiography, to evaluate all segmental pulmonary arteries one by one at six months and every year after final BPA session, was performed to elucidate the incidence of in-situ fresh floating thrombus.

Results

Of total 250 individuals, 104 were treated with DOACs and 146 with VKAs following BPA. Mean observation period was 905 (SD ± 660) days. Total 1278 BPA sessions were performed among the period in which 409 sessions were treated with DOACs and 869 sessions with VKAs. Significant improvements in hemodynamics and functional status were observed in both groups following BPA. There was no significant difference of hemoptysis during BPA between DOACs and VKAs (7.1% vs 10.1%, P=0.131). Major bleeding events during observation period were equivalent in those treated with DOACs and VKAs. No significant re-elevation of pulmonary artery pressure was observed in both groups after BPA. Follow-up selective pulmonary angiography identified in-situ fresh floating thrombus in pulmonary artery in 22 cases of total 769 follow-up sessions. The occurrence of fresh thrombus was significantly higher in those receiving DOACs than VKAs in therapeutic range of PT-INR &gt;1.8 (3.9% vs 1.2%, P=0.023) whereas no significant difference between DOACs and overall VKAs (3.9% vs 2.4%, P=0.177)

Conclusions

Post-BPA hemodynamic outcomes and bleeding events appear unaffected by choice of anticoagulant. However, the incidence of in-situ pulmonary thrombosis detected by selective pulmonary angiography was significantly higher in those receiving DOACs than VKAs in therapeutic range, suggesting inadequate anticoagulation under current dose of DOACs. Our study provides a rationale for further examination to evaluate the efficacy of DOACs in CTEPH.

Funding Acknowledgement

Type of funding sources: None.

Gallbladder torsion in pregnancy: a case report and literature review

Gallbladder torsion is a rare disease that requires immediate surgical intervention to avoid maternal and/or foetal sepsis and death. However, preoperative diagnosis is challenging because the disease has no specific symptoms. A 37-year-old pregnant woman at 34 weeks of gestation presented with severe epigastric pain. Ultrasonography and computed tomography scan findings showed a distended gallbladder without stones, floating from the hepatic bed, and laboratory examination demonstrated normal liver function; therefore, we made a diagnosis of gallbladder torsion and performed a caesarean section and an open cholecystectomy under general anaesthesia. This is the first report wherein gallbladder torsion in pregnancy was diagnosed preoperatively. Gallbladder torsion should be considered as a differential diagnosis in case of such imaging findings.

Fibronectin Glomerulopathy Confused with Glomerular Endothelial Injury in a Patient with Takotsubo Cardiomyopathy

A 46-year-old woman developed takotsubo cardiomyopathy and nephrotic syndrome. The first kidney biopsy suggested non-immune-complex-mediated membranoproliferative glomerulonephritis (MPGN), and she was diagnosed with glomerular endothelial injury associated with takotsubo cardiomyopathy. A second biopsy was performed two years later because of persistent proteinuria despite renin-angiotensin system inhibition. This biopsy indicated non-immune-complex-mediated MPGN, but a mesangial and subendothelial substance of a higher electron density than that in the first biopsy was detected, suggesting the possibility of glomerular disease with non-immune deposits rather than endothelial injury. Finally, she was diagnosed with fibronectin nephropathy. Although rare, fibronectin glomerulopathy should be considered in non-immune-complex-mediated MPGN.

O-294 In-vitro maturation of oocytes from ovary tissue and ovarian longevity

Study question

Is it possible to accomplish simple and robust in-vitro maturation (IVM) of oocytes from human ovarian tissue using principles of in vitro gametogenesis?

Summary answer

Many mature oocytes can be obtained from ovary tissue with simple media and no need for ovarian stimulation.

What is known already

IVM from ovarian tissue has been difficult in the past. To mature primordial follicles in vitro has become possible in mice utilizing eight ‘core genes’. It has not yet been performed in humans, and will be complicated. However, culturing germinal vesicle oocytes that have already become meiotically competent by in-vivo IVD and IVG would not be expected to be difficult. In addition, it is far easier to obtain many germinal vesicle oocytes with cortical dissection rather than with a needle.

Study design, size, duration

After the ovarian cortex has been dissected from the medulla and divided into slices for cryopreservation, the ‘spent’ medium in which the dissection took place was examined for free, loose cumulus complexes, and cultured for 24 to 48 hours. A variety of different culture media and gonadotrophin concentrations were employed, based on previously published data from in vitro gametogenesis in mice.

Participants/materials, setting, methods

A total of 119 female patients between age 2 and 35 years old underwent ovary cryopreservation (as well as in-vitro maturation of oocytes and IVM in the last 13 individuals) over a 24 year period. Up to 22 years later, 17 returned to have their ovary tissue thawed and transplanted back.

Main results and the role of chance

Every woman had return of ovarian function 5 months after transplant, similar to previous observations. As observed before, AMH concentration rose as FSH fell 4 months later. The grafts continued to work up to 8 years. Of the 17, 13 (76%) became pregnant with intercourse at least once, resulting in 19 healthy live births, including six live births from three women who had leukemia. Of the harvested germinal vesicle oocytes, 35% developed with simple culture media into mature metaphase II oocytes. Maturation of germinal vesicle to MII oocytes was detected between 24 and 48 h of exposure to the HCG-containing media. For most participants, the number of mature oocytes was what would be obtained from ovarian stimulation. Surprisingly, the success of IVM was not related to the specific media or to the concentration of gonadotrophin in the media. A variety of media and concentrations were intentionally used in light of now-established mechanisms of in-vitro oogenesis, to see if this understanding could be used for a simplification of IVM.

Limitations, reasons for caution

This is an early pilot study only, but the results are strikingly consistent with our extensive work with IVG in mice.

Wider implications of the findings

This study and the results of in-vitro gametogenesis reveal the limited role of the ovulatory cycle and ovarian stimulation in oocyte development other than for the oocyte to exit the ovary. The normal ovulation cycle is not needed for meiotic competence. Ovarian stimulation is only required for easy oocyte retrieval.

Trial registration number

Not applicable

Vaccination against connective tissue growth factor attenuates the development of renal fibrosis

There is a critical need for efficient treatment of chronic kidney disease (CKD). Renal fibrosis is a final common pathway to end-stage renal disease independent of the underlying etiology, and connective tissue growth factor (CTGF) is a well-recognized profibrotic factor in fibrosis of various organ systems. Here, we developed a novel peptide vaccine against CTGF to attenuate the development of renal fibrosis. Three inoculations with this CTGF vaccine at 2-week intervals elicited antibodies specifically binding to human full-length CTGF, and the antigen-specific serum IgG antibody titers were maintained for > 30 weeks. The efficacy of the CTGF vaccine on renal fibrosis was evaluated in adenine-induced CKD and unilateral ureteral obstruction (UUO) murine models. In adenine-induced CKD model, immunization with the CTGF vaccine attenuated renal interstitial fibrosis. Vaccinated mice showed low levels of serum creatinine and urea nitrogen and low urine albumin–creatinine ratio compared with vehicle-treated mice. In UUO model, the CTGF vaccination also suppressed the onset of renal fibrosis. In an in vitro study, CTGF vaccine-elicited IgG antibodies efficiently suppressed CTGF-induced- and transforming growth factor-β-induced α-smooth muscle actin expression in kidney fibroblasts. These results demonstrate that the CTGF vaccine is a promising strategy to attenuate the development of renal fibrosis.

POS0728 ASSOCIATION BETWEEN TREATMENT GOAL ACHIEVEMENT AND GRIT PERSONALITY CHARACTERISTICS OF ATTENDING PHYSICIAN IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: A MULTICENTER CROSS-SECTIONAL STUDY

Background

In clinical practice for systemic lupus erythematosus (SLE), the concept of “treat to target” has been introduced with an established goal of reducing glucocorticoid dose as much as possible while controlling disease activity. Although it has been shown that various personality characteristics of patients with SLE affect their disease activity and damage, it is not clear whether the personality characteristics of attending physicians affect the outcomes of patients with SLE. Grit is a personality trait characterized by perseverance and passion for achieving long-term goals.

Objectives

This study aims to evaluate the relationship between attending physicians’ grit personality characteristics and treatment goal achievements in patients with SLE.

Methods

A cross-sectional study was conducted on 386 patients with SLE in five referral hospitals in Japan. The main exposure was the “perseverance” and “consistency” (scores 1-5) of the attending physicians, as measured by the Short Grit Scale, and the primary outcome was the achievement of the Lupus Low Disease Activity Score (LLDAS). Considering the clustering of achievement of LLDAS by each attending physician, the association between attending physician’s personality and LLDAS was analyzed by logistic regression with cluster robust variance estimation. Odds ratios to assess the relationship between perseverance and consistency and LLDAS were estimated with adjustment for confounders (age, sex, disease duration, hydroxychloroquine use, immunosuppressant use, and Systemic Lupus International Collaborating Clinics-Damage Index). We used multiple imputation to handle the uncertainty caused by missing values of potential confounders on the assumption of missing at random.

Results

The median age of the patients was 45 years (interquartile range[IQR],36-56), 88% were female, and the median disease duration was 152 months(IQR, 80-240). Thirty-seven doctors were in charge of the patients (1-79 patients/each doctor). The median age of the attending physicians was 40 years (IQR, 35-43), and 19% were female. The median perseverance and consistency scores of attending physicians were 3.1 (IQR, 3.0-3.5) and 3.3 (IQR, 2.8-3.8), respectively. Of the enrolled patients, 154 (40%) had achieved LLDAS. The attending physicians with a lower consistency score of <3 were more frequent in the patients who achieved LLDAS (40% vs. 29%, p=0.026). The lower consistency score of attending physicians was still related to LLDAS independently (adjusted odds ratio 1.63, 95% confidential interval 1.17-2.27). There was no association between the achievement of LLDAS and perseverance.

Conclusion

The grit personality characteristics of the attending physician may affect the achievement of treatment goals in patients with SLE.

Disclosure of Interests

KEN-EI SADA Speakers bureau: I received speaker’s fees from Glaxo Smith Kline K.K., Grant/research support from: I received a research grant from Pfizer Inc., Yoshia Miyawaki: None declared, Kenta Shidahara: None declared, Shoichi Nawachi: None declared, Yu Katayama: None declared, Yosuke ASANO: None declared, Keigo Hayashi: None declared, Keiji Ohashi: None declared, Eri Katsuyama: None declared, Takayuki Katsuyama: None declared, Mariko Narazaki: None declared, Yoshinori Matsumoto: None declared, Nao Oguro: None declared, Yuichi Ishikawa: None declared, Natsuki Sakurai: None declared, Chiharu Hidekawa: None declared, Ryusuke Yoshimi: None declared, Takanori Ichikawa: None declared, Dai Kishida: None declared, Yasuhiro Shimojima: None declared, Noriaki Kurita: None declared, Nobuyuki Yajima: None declared

Different changes in the biomarker C-terminal telopeptides of type II collagen (CTX-II) following intra-articular injection of high molecular weight hyaluronic acid and oral non-steroidal anti-inflammatory drugs in patients with knee osteoarthritis: a multi-center randomized controlled study

OBJECTIVES

We previously reported, based on a multicenter randomized-control study, that the efficacy of intra-articular injections of hyaluronic acid (IA-HA) was not inferior to that of oral non-steroidal anti-inflammatory drugs (NSAIDs) in patients with knee osteoarthritis (OA). However, the molecular effects on the pathophysiology of knee OA remain unclear. C-terminal telopeptides of type II collagen (CTX-II) is reported to primarily originate from the interface between articular cartilage and subchondral bone, which is a site of potential remodeling in OA. We performed a predefined sub-analysis of the previous study to compare the changes of urinary CTX-II (uCTX-II) in response to IA-HA to those in response to NSAID for knee OA.

DESIGN

A total of 200 knee OA patients were registered from 20 hospitals and randomized to receive IA-HA (2,700 kDa HA, 5 times at 1-week intervals) or NSAID (loxoprofen sodium, 180 mg/day) for 5 weeks. The uCTX-II levels were measured before and after treatment.

RESULTS

The uCTX-II levels were significantly increased by IA-HA treatment (337.7 ± 193.8 to 370.7 ± 234.8 ng/μmol Cr) and were significantly reduced by NSAID treatment (423.2 ± 257.6 to 370.3 ± 250.9 ng/μmol Cr). The %changes of uCTX-II induced by IA-HA (11.6 ± 29.5%) and NSAID (-9.0 ± 26.7%) was significantly different (between-group difference: 20.6, 95% confidence intervals: 10.6 to 30.6).

CONCLUSIONS

While both IA-HA and NSAID improved symptoms of knee OA, uCTX-II levels were increased by IA-HA and reduced by NSAIDs treatment, suggesting these treatments may improve symptoms of knee OA through different modes of action.

POS1224 RHEUMATOID ARTHRITIS DISEASE ACTIVITY ASSESSED BY PATIENT-REPORTED OUTCOMES AND FLOW CYTOMETRY BEFORE AND AFTER AN ADDITIONAL DOSE OF COVID-19 VACCINE

Background

The Centers for Disease Control and Prevention recommends an additional dose (AddDose) of COVID-19 vaccine for moderately/severely immunosuppressed individuals following an initial vaccine series. The American College of Rheumatology suggests that patients interrupt use (hold) certain DMARDs around the time of COVID-19 vaccination to improve immunogenicity. Whether holding DMARDs around an AddDose of COVID-19 vaccine affects RA disease activity or affects frequencies of lymphocyte populations that may be associated with RA disease activity remains unknown.

Objectives

To test whether RA disease activity and frequencies of lymphocyte populations change pre- vs. post-AddDose of COVID-19 vaccine, overall and stratified by holding vs. continuation of DMARDs around the AddDose.

Methods

Prospective observational cohort study of patients with RA who had completed an initial COVID-19 vaccine series (2 doses of mRNA vaccine or 1 dose of adenovirus vector vaccine). Subjects enrolled July-November 2021, prior to receiving an AddDose. Subjects held or continued DMARDs around the AddDose based on discussion with their rheumatologist and/or personal decision-making. RA disease activity was assessed weekly using the validated patient-reported RA Disease Activity Index-5 (RADAI-5) from enrollment through 4 weeks post-AddDose. We compared mean RADAI-5 pre- vs. post-AddDose using generalized estimating equations to account for correlated data among individual subjects. We aimed to enroll 60 subjects to achieve 91% power to detect a 15% non-inferiority margin in mean RADAI-5 post- vs. pre-AddDose. A subset of subjects with seropositive RA provided blood for flow cytometry at enrollment and week 4 post-AddDose. Frequencies of lymphocyte populations (T peripheral helper [Tph] cells, T follicular helper [Tfh] cells, age-associated B cells [ABC], and plasmablasts) were compared pre- vs. post-AddDose using Wilcoxon paired tests with Bonferroni correction.

Results

Among 71 subjects, mean age was 62 (SD 12) years, 85% were female, and 87% had seropositive RA. Methotrexate (42%) and TNF inhibitors (38%) were the most common DMARDs; 21% were taking prednisone. One subject reported COVID-19 infection prior to the AddDose. The mean RADAI-5 was 3.20 (SD 0.23) pre-AddDose compared to 3.25 (SD 0.23) after (difference of 1.6%, p=0.51). Figure 1 displays mean RADAI-5 in 35 (49%) subjects that held at least 1 DMARD and 36 (51%) subjects that continued all DMARDs around the AddDose. Mean change in RADAI-5 between pre- vs. post-AddDose did not significantly differ based on whether subjects held vs. continued DMARDs (p for interaction = 0.16). Frequencies of Tph, Tfh, ABC, and plasmablast populations did not significantly differ between the pre- and post-AddDose timepoints in subjects that held at least 1 DMARD (n=16) or subjects that continued all DMARD (n=11) (Figure 1).

Conclusion

RA disease activity, measured weekly with a validated patient-reported outcome, is stable around the time of an AddDose of COVID-19 vaccine. Lymphocyte subsets of interest in RA were also similar before and after the AddDose, supporting the observation of stable patient-reported RA disease activity. Holding DMARDs was not associated with greater RA disease activity following the AddDose.

Disclosure of Interests

Sara Tedeschi Consultant of: NGM Biopharmaceuticals: payment to Dr. Tedeschi, Grant/research support from: Moderna: research support to institution, Jacklyn Stratton: None declared, Jack Ellrodt: None declared, Mary Grace Whelan: None declared, Keigo Hayashi: None declared, Kazuki Yoshida Consultant of: OM1, Inc: consulting fees paid to Dr. Yoshida, Lin Chen: None declared, Ifeoluwakiisi Adejoorin: None declared, Kathryne E. Marks: None declared, A. Helena Jonsson Grant/research support from: Moderna: research support to institution

Amgen: payment to institution for unrelated project, Deepak Rao Speakers bureau: Merck: honoraria lecture paid to Dr. Rao, Consultant of: Janssen: consulting fees paid to Dr. Rao

Bristol Myers Squibb: participation on scientific advisory board with compensation paid to Dr. Rao, Grant/research support from: Moderna: research funding paid to institution

Janssen: research funding paid to institution

Merck: research funding paid to institution, Daniel Solomon Grant/research support from: Moderna: payment made to institution

Amgen: payment to institution

Abbvie: payment to institution

CorEvitas: payment to institution

POS1404 SHARED DECISION MAKING AND INTERNET USE FOR GATHERING HEALTH INFORMATION IN PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: A MULTICENTER CROSS-SECTIONAL STUDY

Background

It is well known that providing appropriate health information to patients with systemic lupus erythematosus (SLE) has an advantage in the treatment decision making process. In modern information society the growing popularity of smartphones and social networking services, patients have more access to online health information. However, there are concerns that Internet use may inversely affect the shared decision making (SDM) process with their attending physicians if they receive inaccurate information.

Objectives

This study aimed to investigate how online information gathering behavior affects SDM with their attending physicians.

Methods

In this cross-sectional study, information of 386 patients with SLE, which were enrolled from five Japanese institutions between June 2020 and August 2021, were analyzed. The main exposure was time spent on the Internet per day (excluding time used for working). It was divided into four categories (none, <1 hour, 1-2 hours, > 2 hours). Patients were asked to select the source of health care information they would like to access first and were categorized into physicians, the Internet, and other media sources (family and friends, healthcare professionals other than physicians, or TV and radio, etc.). Outcome was shared decision making measured via the 9-item Shared Decision Making Questionnaire (SDM-Q-9 [scores 0-100]). To assess the relationship between the time of Internet use and SDM, we fitted general linear models adjusted for age, gender, education level, household income, marital status, history of cancer, disease duration, and disease activity. Chained equations were used to impute missing values of covariates.

Results

This study ultimately employed 334 patients whose mean age and female ratio were 45.3 years (standard deviation 13.8) and 87.7%, respectively. 68.9% of the patients indicated that they would like to access their physicians first, and 19.5% indicated that they would like to access the Internet first. Compared to patients who chose their physician as their first access to health information, there was no difference in SDM-Q-9 among patients who chose the Internet, but patients who chose other media had significantly lower SDM-Q-9 (-7.7 point, 95% confident interval [CI] -14.4 to -0.92, P=0.026). Besides, SDM-Q-9 scores were significantly lower in patients who did not use the Internet compared to those who used it for more than two hours except for their work activities (-9.6, 95%CI -18.9 to -0.26, P=0.044).

Conclusion

The present study suggests that SDM between physicians and patients is positively rather than adversely associated with online information-gathering behavior. Rheumatologists also need to be aware that how patients prefer to access health information to establish a good physician-patient relationship for SDM. In addition, rheumatologists may need to introduce their patients to websites offering appropriate health information.

Disclosure of Interests

None declared

AB0474 IMPACT OF HEALTH LITERACY ON TRUST IN PHYSICIANS AMONG PATIENTS WITH SYSTEMIC LUPUS ERYTHEMATOSUS: THE TRUMP2-SLE PROJECT

Background

Information technology has expanded the gap in patient health literacy (HL), and HL has various implications on the trust in patient-doctor relationship. Previously, only functional HL, the ability to interpret health information through reading and writing skills, has been studied in patients with SLE (1).

Objectives

We examined how trust in physicians is affected by the broader concept of HL, including communicative HL, the ability to extract health information from communication to use, and critical HL, the ability to discern and use such information (2).

Methods

This cross-sectional study enrolled 362 SLE patients at 5 sites between June 2020 and August 2021. Three domains of HL (i.e., functional HL, communicative HL, and critical HL) were assessed using the 14-item FCCHL scale (range: 1-4 points for each domain). The outcomes were patients’ trust in their physicians and physicians in general and were measured using the Japanese version of the 5-item Wake Forest Physician Trust scales (range: 0-100 points for each scale). General linear models adjusted for age, gender, education, income, SLEDAI, disease duration, depression, and hours of Internet use were conducted. Subsequently, a series of general linear models were then fit to each of the three domains of HL to examine whether or not it was associated with the aforementioned covariates.

Results

The median age of the patients was 45 (interquartile range [IQR],34-55), 88% were female. The median value of SLEDAI was 4 ([IQR], 2-8), Trust in one’s physician was 80 ([IQR], 70-95) and trust in physicians generally was 65 ([IQR], 50-80). Trust in one’s physician increased with higher functional and communicative HL (per 1-pt increase, 3.2 [95%CI 0.7 to 5.9]; 5.4 [95%CI 1.6 to 9.3]). Trust in doctors generally increased with higher communicative HL and decreased with higher critical HL (per 1-pt increase, 6.8 [95% CI 2.0 to 12]; -6.7 [95% CI -12 to -1.9]). Lower functional HL was associated with older age and depression, while higher HL was associated with higher educational level. Higher communicative HL and critical HL were each associated with longer Internet use.

Conclusion

In patients with SLE, higher trust in one’s physician was associated with both functional and communicative HL, while higher trust in physicians generally was associated with higher communicative HL and lower critical HL. Our findings suggest that trusting relationships may be fostered by the encouragement of rheumatologists to cultivate patients’ ability to share their health problems with their physicians and family members and to obtain useful health information (i.e., communicative HL), rather than to improve their ability to discern health information (i.e., critical HL).

References

[1]Maheswaranathan M, Cantrell S, Eudy AM, Rogers JL, Clowse MEB, Hastings SN, et al. Investigating Health Literacy in Systemic Lupus Erythematosus: a Descriptive Review. Curr Allergy Asthma Rep. 2020;20(12):79.

[2]Ishikawa H, Takeuchi T, Yano E. Measuring functional, communicative, and critical health literacy among diabetic patients. Diabetes Care. 2008;31(5):874-9.

Disclosure of Interests

Nao Oguro: None declared, Nobuyuki Yajima: None declared, Yoshia Miyawaki: None declared, Ryusuke Yoshimi: None declared, Yasuhiro Shimojima: None declared, KEN-EI SADA Speakers bureau: He received speaker’s fees from Glaxo Smith

Kline K.K., Grant/research support from: He received a research grant from Pfizer Inc.,, Keigo Hayashi: None declared, Kenta Shidahara: None declared, Natsuki Sakurai: None declared, Chiharu Hidekawa: None declared, Dai Kishida: None declared, Takanori Ichikawa: None declared, Yuichi Ishikawa: None declared, Noriaki Kurita: None declared

Impact of radiologic variables on item responses of ODI, SRS22 and SF-36. in adult spinal deformity patients: differential item functioning (DIF) analysis results from a multi-center database

PURPOSE

To determine if responses given to each question of the Scoliosis Research Society-22 (SRS22), Oswestry disability index (ODI) and Short Form-36 (SF-36) questionnaires are influenced by the radiological parameters.

METHODS

Patients enrolled in a multi-centre prospectively collected adult spinal deformity database who had complete SRS22, ODI and SF-36 data at baseline and at one-year follow-up were analysed. The presence of a differential item function of each question within each score in relation to radiological parameters was analysed using a mixed Rasch model with the radiological threshold value(s) determined.

RESULTS

Of those patients analysed (n = 1745; 1406 female, average age 51.0 ± 19.8 years), 944 were surgically and 801 were non-surgically treated. For the SRS22, questions (Q) 3, 5 and 18 were sensitive to almost all radiological parameters and the overall score was found sensitive to the Cobb angle. For the ODI, Q3, 6, 9 and 10 were not sensitive to any radiologic parameters whereas Q4 and 5 were sensitive to most. In contrast, only 3 of the SF-36 items were sensitive to radiological parameters.

CONCLUSIONS

78% of the SRS-22, 60% of the ODI and 8% of the questions in the SF-36 are sensitive to radiological parameters. Sagittal imbalance is independently associated with a poor overall outcome, but affects mental status and function more than pain and self-image. The assembly of questions responsive to radiological parameters may be useful in establishing a connection between changes in radiologic parameters and HRQL.