Prevalence and distribution of non-pulmonary vein atrial fibrillation triggers in real-world clinical settings

Background

Epidemiology of non-pulmonary vein (PV) triggers of atrial fibrillation (AF) is not fully known.

Purpose

This study aimed to clarify the prevalence and distribution of non-PV triggers in real-world clinical settings of AF catheter ablation.

Methods

One-thousand and twenty patients undergoing AF ablations were retrospectively analyzed (mean age 65 years old, 702 males (69%), 506 paroxysmal and 514 non-paroxysmal). Induction and observation of AF triggers were attempted using intravenous isoproterenol/adenosine triphosphate and repeated direct current cardioversion during AF in each session. Documentable non-PV AF triggers were characterized in the studied population. Premature atrial contractions that did not initiate AF were excluded.

Results

A hundred and twenty-six non-PV triggers were documented in 108 patients (10.6%). Non-PV trigger was documented in 6.3% of 1st session cases, whereas 30.9% of recurrent cases undergoing multiple sessions (p<0.0001). Left atrial (LA) posterior wall was the most prevalent site (N=34), followed by 30 intra-atrial septum (IAS), 29 superior vena cava (SVC), 13 crista terminalis, 7 right atrial (RA) free wall, 6 LA anterior wall, 3 coronary sinus (CS), 3 left atrial appendage, and 1 persistent left superior vena cava (LSVC). We classified those non-PV triggers into 4 groups; 43 LA, 33 thoracic veins (SVC, CS and LSVC), 30 IAS and 20 RA. Thoracic vein/RA origins were more prevalently detected in paroxysmal AF cases (57%) compared to non-paroxysmal AF (28%) (p<0.01). Conversely, LA origin was more prevalently detected in non-paroxysmal AF cases (48%) compared to paroxysmal AF (20%) (p<0.01).

Conclusions

Prevalence of non-PV trigger in cases undergoing multiple sessions is extremely high, suggesting a particular importance of non-PV trigger targeting in patients with recurrent AF undergoing 2nd or 3rd ablation sessions. Progressive nature of AF with newly generated AF triggers should be under consideration. Distributions of non-PV triggers are largely different between paroxysmal and non-paroxysmal AF. These findings may help ablation strategy regarding non-PV trigger targeting in practice.

Funding Acknowledgement

Type of funding sources: None.

Catheter ablation of persistent atrial fibrillation with heart failure improves hemodynamic status without deteriorating renal function in the elderly

Background/Introduction

Atrial fibrillation (AF) and heart failure (HF) frequently coexist in the elderly people, leading to worse clinical outcomes. HF with preserved ejection fraction (HFpEF) is the most common form of HF in the elderly, particularly in women, associated with AF. Ablation of AF in younger patients with HF with reduced EF (HFrEF) has become an established treatment option. However, clinical impact of ablation for persistent AF accompanying with HF in the elderly remains unclear.

Purpose

This study aimed to evaluate the effect of catheter ablation of persistent AF with heart failure in the elderly.

Methods

Consecutive 70 patients who underwent catheter ablation of persistent AF accompanying with HF (NYHA class> II, mean LVEF 51.7%) in our institution were retrospectively analyzed with regards to their 1-year clinical outcomes, HF markers such as BNP, renal function and transthoracic echocardiographic findings. Patients were dichotomized by age of 75-year-old (31 elderly vs 39 younger subjects) and separately analyzed.

Results

Mean age of the studied population was 70.5 year-old; 79.6±3.8 in the elderly group and 63.2±8.5 in the younger group. The elderly patients were more frequently females (45% vs 21%). Longstanding persistent AF was observed in 32% in the elderly and 28% in the younger group. Circumferential pulmonary vein isolation (PVI) was performed in all patients, with additional ablations of liner lesions and/or non-PV foci as needed. PVI alone was observed in 54.8% in the elderly and 41% in the younger group. There were no serious complications associated with the procedure. During 1 year after ablation, recurrence of AF was observed in 15 patients [6/31 (19%) in the elderly, 9/39 (23%) in the younger]. Readmission due to HF was observed in only 1 patient in the elderly and 2 patients in the younger group (3% vs. 5%, respectively). Cardiovascular events were observed in 3 patients [2/31 (6%) in the elderly, 1/39 (3%) in the younger], but there was no death. The BNP level as well as the NYHA class significantly decreased at 1-year follow-up compared to baseline in the both groups (Figure A and B). There was no change in serum creatinine level in the both groups (Figure C). The left atrial dimension and the LA volume index decreased at 1-year follow-up in the both groups (Figure D and E). The LVEF improved only in the younger group (Figure F).

Conclusions

Ablation of persistent AF in the elderly with HF (mostly with preserved EF) was associated with hemodynamic and functional improvements without deteriorating renal function in a mid-term, which was mostly comparable to the results in the younger.

Funding Acknowledgement

Type of funding sources: None.

Aggressive combined pharmacotherapy for heart failure reduces new onset atrial fibrillation

Backgrounds

Heart failure (HF) is a risk factor for new onset atrial fibrillation (AF), and the new onset AF is associated with a worse prognosis in HF patients. It has been reported that renin-angiotensin system inhibitor (RASi), β-blocker and mineral-corticoid receptor antagonist (MRA) prevent the new onset AF in HF patients. However, the effect of combined pharmacotherapy including angiotensin receptor neprilysin inhibitor (ARNI) and sodium glucose co-transporter 2 inhibitor (SGLT2i) on AF is unknown. We investigated the impact of contemporary regimen of combined pharmacotherapy for HF (RASi/ARNI+β-blocker+MRA+SGLT2i) on new onset AF.

Methods and results

We retrospectively studied rEF and mrEF patients without AF admitted to our hospital due to decompensated HF between 2015 and 2021 (n=366). Long-term (The mean follow-up was 635±421 days) incidence of new onset AF was investigated with regard to medical therapies. Patients were divided into 2 groups; patients with ≤2 HF drugs (n=181) and patients with ≥3 HF drugs (n=185). Patients with ≤2 HF drugs group were older (77.3 vs 67.0 years old, P<0.001), had a poorer renal function (Cre: 1.66 vs 1.09 mg/dl, P<0.001), and had a higher rate of ischemic heart disease (52 vs 38%, P=0.009), whereas left ventricular systolic function was better (EF: 31.9 vs 27.3%, P<0.001). There were 19 (10.5%) new onsets AF in the ≤2 HF drugs group, whereas only 7 (3.8%) had new onsets AF in the ≥3 HF drugs group (HR 0.36, 95% CI 0.15–0.85, P=0.01). All-cause death and hospitalization for HF were fewer in the ≥3 HF drugs group. A multivariate analysis revealed that ≥3 HF drugs use was an independent negative predictor of new onset AF (HR 0.37, 95% CI 0.15–0.93, P=0.03). Even after a propensity score matching of the clinical variables, the incidence of new onset AF was consistently fewer in the ≥3 HF drugs group (HR 0.36, 95% CI 0.13–0.99, P=0.04). Finally, patients with new onset AF had a higher rate of hospitalization for HF in the studied population (HR 9.68, 95% CI 5.67–16.5, P<0.01).

Conclusion

Aggressive combined pharmacotherapy for HF may be associated with fewer new onset AF in patients with HF.

Funding Acknowledgement

Type of funding sources: None.

High-Quality Transparent Conducting Oxide Films Deposited by a Novel Ion Plating Technique

A novel ion plating technique that has the attributes of both superb controllability of the high density plasma used as well as ion beam shape has been developed and applied to the deposition of transparent conducting oxides. The advantages of this technique include reduced ion damage, scale-up capability, in-plane uniformity, the use of low growth temperatures and fast deposition rates suggesting that the technique is very promising for a variety of applications such as solar cells and organic device fabrication. Gallium doped zinc oxide films have been deposited on glass substrates at 200°C. Resistivities as low as ρ∼2.7×10-4 Ω-cm with high transparency have been demonstrated. In addition, this technique has been successfully applied to large area deposition such as 65 cm × 55 cm-sized glass substrates.

Somatostatin analogue attenuates estrogen-induced augmentation of glomerular injury in spontaneous hypercholesterolemic female Imai rats

BACKGROUND

Aggravating effect of estrogen replacement therapy on glomerular injury associated with an elevation of growth hormone (GH) levels has been reported. Therefore, in the present study, to clarify an association between GH elevation and the aggravating effect of estrogen on glomerular injury, we investigated the effect of somatostatin, an inhibitor of GH secretion, on glomerular injury in estrogen-treated hypercholesterolemic female Imai rats.

METHOD

Control female rats were assigned to group 1 (Cont, n = 10). Group 2 (Cont-E, n = 10) received estrogen, and groups 3 (Cont-E-LS, n = 10) and 4 (Cont-E-HS) received estrogen and either a low dose of somatostatin analogue or a high dose of somatostatin analogue. Body weight, urinary protein, serum albumin, total cholesterol, triglycerides, blood urea nitrogen and serum creatinine were investigated every 4 weeks from 10 weeks through 30 weeks of age. At 30 weeks of age, rats were studied morphologically.

RESULTS

Estrogen administration resulted in an increase in urinary protein excretion rates and serum total cholesterol levels, and aggravated glomerular injury associated with an increase in GH. In contrast, somatostatin treatment reduced both urinary protein excretion rates and total cholesterol levels and attenuated glomerular injury to levels close to those of controls associated with a reduction of GH levels.

CONCLUSION

The results suggest that increased GH levels may contribute to an enhancing effect of estrogen administration on glomerular injury.

Cellular crescents and segmental glomerular necrosis in IgA nephropathy are indicative of the beneficial effects of corticosteroid therapy

OBJECTIVE

Recent reports have revealed that corticosteroid (PSL) therapy has a long-term beneficial effect for stabilization of renal function in progressive IgA nephropathy.

PATIENTS AND METHODS

We analyzed serum creatinine (Cr), daily proteinuria and the results of other routine laboratory examinations during a short-term course of PSL therapy in 28 cases of progressive IgA nephropathy. The cases were divided into two groups according to changes in renal function during the PSL treatment period: group I (15 cases), improved renal function; group II (13 cases), no significant change in renal function.

RESULTS

In group I, serum Cr and proteinuria were significantly decreased, with maximum effects observed at 3 months of PSL therapy, and remained low during the period of treatment. In contrast, group II showed no significant changes in serum Cr levels during the period of therapy, although proteinuria was transiently decreased after 3 months of therapy. Histologically, cellular/fibrocellular (C/F) crescents and/or segmental glomerular necrosis (SGN) occurred with a significantly higher incidence in group I (87%) than in group II (46%) (p < 0.05).

CONCLUSIONS

These results suggested that the early response to PSL in reducing serum Cr and proteinuria by 3 months of treatment may be clinically useful to predict the prognosis of IgA nephropathy and that C/F crescents and/ or SGN may be histologically indicative of the beneficial effects of PSL therapy in IgA nephropathy.

Morphogenesis of MDCK cells in a collagen gel matrix culture under stromal adipocyte-epithelial cell interaction

BACKGROUND

The stromal-epithelial cell interaction is essential for epithelial morphogenesis. Recently, the specific stromal cell type adipocytes, which abundantly exist in perirenal adipose tissue, have been suggested to affect the biological behavior of some epithelial cell types. However, adipocyte-renal epithelial cell interaction remains unclear. We thus examined the effects of adipocytes on the morphogenesis of renal epithelial cells.

METHODS

The renal epithelial cell line, Madin-Darby canine kidney (MDCK), cells were cultured in three-dimensional collagen gel matrix with or without mature unilocular adipocytes. Cultures cells were examined by histochemistry, immunohistochemistry, and electron microscopy.

RESULTS

Adipocytes extensively promoted the tubule formation of MDCK cells in two different manners. In the first type, after approximately 20% of MDCK cells actively adhered to adipocytes; they organized double-cell structured tubules between the adipocytes and the gel, contacting directly with the entire surface of the adipocytes. In the second type, approximately 70% of MDCK cells apart from adipocytes also formed tubules that had no contact with adipocytes. The component cells of both tubule types at the apical side showed microvilli and peanut agglutinin lectin-positive stain. These cells at the basal side had the basal lamina and type IV collagen-positive stain.

CONCLUSIONS

These results indicate that the specific stromal cell type adipocytes cause MDCK cells to organize the well-polarized tubular structures in two different manners according to their direct and indirect interactions, suggesting that adipocytes may be involved in the regulatory mechanism of renal epithelial morphogenesis.

Attenuating effect of a semipurified alcohol extract of soy protein on glomerular injury in spontaneous hypercholesterolemic male Imai rats

We investigated whether soy protein's alcohol-extractable components (SPEs; mainly consisting of isoflavones) have the ability to attenuate glomerular injury in male Imai rats of a spontaneous focal segmental glomerulosclerosis model. Male Imai rats were fed a casein-based diet with and without SPEs. Group 1 (Cont) was fed a standard diet without additional SPEs, and groups 2 (SPE-1) and 3 (SPE-2) were fed a standard diet supplemented with a semipurified alcohol extract of soy protein, 0.05 and 0.10 g/100 g of diet, respectively. Body weight, urinary protein level, serum constituents, and systolic blood pressure were evaluated every 4 weeks from 12 through 28 weeks of age. At 28 weeks of age, rats were studied morphologically. Growth rates were not different among the three groups throughout the experiment. SPE-supplemented diets resulted in less proteinuria and less hyperlipidemia. The decline in renal function shown by blood urea nitrogen and creatinine clearance was less marked in the animals fed the SPE-supplemented diets. Each SPE-supplemented diet equally induced less glomerular hypertrophy and less renal histological damage compared with nonsupplemented diets. The present study showed a beneficial effect of a semipurified alcohol extract of soy protein on glomerular disease.

End-stage renal failure due to crescentic glomerulonephritis in a patient with Behçet's syndrome. Review of the literature

We report a rare case of a patient with Behçet's syndrome who developed end-stage renal failure due to crescentic glomerulonephritis (GN). A 20-year-old male patient had suffered from uveitis, aphthous mouth ulcers and genital ulceration for the past 7 years. His renal function rapidly deteriorated and renal biopsy specimens obtained when his serum creatinine level was 3 mg/dl showed diffuse proliferative GN with fibrous crescent formation in 75% of glomeruli excluding totally sclerotic glomeruli. Immune complexes were identified by demonstration of complement and immunoglobulins in the glomeruli. He developed end-stage renal failure during a 1-year course and received maintenance hemodialysis. We reviewed the literature on severe forms of GN in patients with Behçet's syndrome.

A case of chronic graft-versus-host disease following living-related donor kidney transplantation

A 25-year-old man with a 2.5-year history of maintenance hemodialysis underwent a living-related donor (father) kidney transplantation. He was free from acute rejection, but 8 months after the kidney transplantation, he complained of malaise and fever which were accompanied by eruptions on the face, fingers, and hips which resembled symptoms seen in patients suffering from systemic vasculitis. Skin biopsy findings were compatible with those of chronic graft-versus-host disease (GVHD). The human leukocyte antigen (HLA) family study disclosed that the donor's HLA haplotype was homozygous and identical to one of the recipient's HLA haplotypes which indicated that the host would not resist engraftment. On the basis of these findings, a diagnosis of chronic GVHD was made, and increasing doses of immunosuppressants resulted in a resolution of these symptoms. Our report is the first describing GVHD that developed in a patient undergoing related-donor kidney transplantation.

Retroperitoneal fibrosis with perinuclear antineutrophil cytoplasmic antibodies and a longitudinally extended periaortic soft-tissue structure on CT

A 63-year-old woman showed positive perinuclear antineutrophil cytoplasmic antibodies (pANCA) and presented with an interesting CT finding of a periaortic soft-tissue structure seen as a rind of tissue surrounding the aorta, extending longitudinally from descending thoracic aorta to bilateral common iliac arteries which was compatible with an early stage of retroperitoneal fibrosis (RPF). Both pANCA titers and a periaortic mass volume were reduced following corticosteroid treatment. No cases of RPF with a periaortic mass associated with pANCA have been described. Our findings of RPF with pANCA positivity may enlarge the groups of ANCA-associated diseases.

Recurrence of rapidly progressive glomerulonephritis probably associated with two different kinds of drugs

We describe a rare case that developed a rapidly progressive glomerulonephritis twice in a 69-year-old man during a course of treatment, first with allopurinol and then with piperacillin. The cessation of each treatment was followed by spontaneous recovery in renal function. A renal biopsy showed crescentic glomerulonephritis with mild tubulointerstitial change and a skin biopsy showed leukocytoclastic vasculitis. This is, to our knowledge, a very rare case of crescentic glomerulonephritis, probably associated with vasculitis during a course of treatment with two different kinds of drugs.

Simultaneous occurrence of minimal change glomerular disease, sarcoidosis and Hashimoto's thyroiditis

We herein report a very rare case of a patient suffering from simultaneous occurrence of three immune disorders, i.e. Hashimoto's thyroiditis, sarcoidosis and minimal change glomerular disease. A 66-year-old man was admitted to our hospital for evaluation of nephrotic syndrome. Six months before admission, he was pointed out as having positive proteinuria, hypoalbuminemia and associated pretibial pitting edema. Initial laboratory data showed high gammaglobulinemia, high titers of both antimicrosomal and antithyroglobulin antibodies with normal thyroid function. Chest X-ray and CT scan revealed bilateral hilar lymphadenopathy with interstitial shadow. Ga-citrate scan disclosed positive accumulation in the thyroid glands, the mediastinum, the lungs and the kidneys. The diagnosis of minimal change nephritic syndrome and pulmonary sarcoidosis was made, based on the findings of transbronchial lung biopsy and kidney biopsy. After one and a half months of admission, thyroid function had gradually deteriorated. The histological findings of the thyroid were consistent with the features of Hashimoto's thyroiditis. Treatment with prednisolone and cyclophosphamide resulted in a decrease in urinary protein excretion, reduction in the size of mediastinal lymphadenopathy and disappearance of positive findings of Ga-citrate scan in the thyroid glands and the kidneys. Simultaneous occurrence of minimal change-glomerular disease, sarcoidosis and Hashimoto's thyroiditis in our case suggests that similar immunological abnormalities may be involved in the pathogenesis of the diseases.

Combined therapy with estrogen and testosterone eliminates the aggravating effect of estrogen replacement therapy on glomerular injury in hypercholesterolemic female Imai rats

Hypercholesterolemic Imai rats spontaneously develop proteinuria and glomerulosclerosis, especially male animals. Ovariectomy aggravates glomerular injury in female Imai rats. However, estrogen replacement therapy did not abolish this aggravating effect of ovariectomy and rather aggravated glomerular injury with an increase in serum levels of lipids and growth hormone (GH). Whereas we have already reported that treatment with testosterone in addition to estrogen reduces GH levels and attenuates glomerular injury as compared with estrogen alone in male Imai rats, in the present study, to investigate whether increased GH levels may contribute to an enhancing effect of estrogen on glomerular injury, we treated ovariectomized female Imai rats with estrogen pulse testosterone. Group 1 was sham operated and group 2 was ovariectomized at 6 weeks of age. Groups 3, 4, and 5 were ovariectomized and received estrogen, testosterone, or estrogen plus testosterone, respectively. Body weight, urinary protein, and serum constituents were investigated every 4 weeks from 12 to 24 weeks of age. At 24 weeks of age, the rats were studied morphologically. Each treatment with estrogen or testosterone equally aggravated glomerular injury with an increase in both proteinuria and serum lipids with increased serum GH levels in estrogen-treated rats but without influencing GH levels in testosterone-treated rats; combined treatment with estrogen plus testosterone resulted in a reduction of both proteinuria and serum lipids to levels of the controls and attenuated glomerular injury to levels close to those of controls with a reduction of the elevated serum GH levels. These results suggest that increased GH levels may contribute to an enhancing effect of estrogen replacement therapy on glomerular injury and that testosterone, when administered to the estrogen-treated rats, seems to exert an attenuating effect on glomerular injury by suppressing GH levels.

Efficacy of blood purification therapy for heat stroke presenting rapid progress of multiple organ dysfunction syndrome: a comparison of five cases

Five patients were admitted to our hospital because of classical heat stroke during the heat waves which attacked our country in the summers 1994 and 1995. The clinical and laboratory findings of all patients suggested the rapid progress of multiple organ dysfunction syndrome (MODS). Blood purification (BP) therapy, in addition to conventional treatment, was performed in three of the patients. Despite their disastrous general condition, all completely recovered or recovered sufficiently to be transferred to a rehabilitation hospital. Two additional patients were treated with conventional treatment only and both died in 1-3 days after admission. Clinical characteristics and laboratory findings on admission showed no differences between the cases receiving BP therapy and those not receiving BP therapy. These findings suggest that, in heat stroke patients, additional BP therapy may provide a better prognosis than conventional therapy only. These beneficial effects of BP may have been due mainly to the removal of proinflammatory cytokines related to heat stroke.

Acute renal failure due to hypokalemic rhabdomyolysis in Gitelman's syndrome

A 46-year-old-male developed acute renal failure (ARF) secondary to hypokalemic rhabdomyolysis. Potassium supplementation restored renal function following improvement of the rhabdomyolysis. After recovery from ARF, further evaluation disclosed he had hypokalemic metabolic alkalosis, normotensive hyperreninemia, hyperaldosteronism, renal hypomagnesemia, hypocalciuria and hyperplasia of the juxtaglomerular apparatus which are a diagnostic set of disorders in Gitelman's syndrome, a variant of Bartter's syndrome. This is the first reported case of ARF due to hypokalemic rhabdomyolysis associated with Gitelman's syndrome.

Estrogen replacement therapy with its physiological dose does not eliminate the aggravating effect of ovariectomy on glomerular injury in hypercholesterolemic female Imai rats

Hypercholesterolemic Imai rats spontaneously develop proteinuria and glomerulosclerosis, especially in males. Estrogen administration attenuated glomerular injury in male Imai rats, and the aggravating effect of ovariectomy in female rats is found. To clarify whether this aggravating effect of ovariectomy is due to a lack of estrogen, we administered estrogen to ovariectomized female Imai rats. At 6 weeks of age, group 1 (control) was sham-operated and group 2 was ovariectomized. Groups 3 and 4 were ovariectomized and received estrogen replacement therapy (0.1 mg in group 3 and 0.2 mg in group 4 once a month subcutaneously). Body weight, urinary protein and serum constituents were investigated every month from 3 to 6 months of age. At 6 months of age, rats were studied morphologically. Estrogen replacement therapy increased serum estrogen to levels close to those of controls when 0.1 mg was used, or higher when 0.2 mg was used. Estrogen replacement therapy with 0.1 mg did not eliminate the aggravating effect of ovariectomy on glomerular injury and rather aggravated it, but conversely therapy with 0.2 mg attenuated glomerular injury and abolished the aggravating effect of ovariectomy. Estrogen replacement therapy markedly elevated serum GH levels dose-dependently. These results suggested that other hormones as well as estrogen may play a protective role of the ovary for the development of glomerular injury, and that estrogen seems to exert a dual effect on glomerular injury.

Fibrillar crystal structure in essential monoclonal IgM kappa cryoglobulinemia

In monoclonal IgG cryoglobulinemia, two types of crystallization have been demonstrated with electron microscopy at high magnification. In contrast, little information is available on well-defined crystallization in cases of monoclonal IgM cryoglobulinemia. We present a case of pure monoclonal IgM kappa cryoglobulinemia and rapidly progressive glomerulonephritis occurring in a 75-year-old woman. We detected unequivocal formation of fibrillar crystal structure within intraglomerular macrophages on electron microscopy: the structure accords with that in a case of monoclonal IgG cyroglobulinemia described in the literature.

Different effect of estrogen administration from castration on glomerular injury in unilaterally nephrectomized male Sprague-Dawley rats

We have already reported an equally attenuating effect of castration or estrogen administration on the development of focal segmental glomerulosclerosis (FSGS) in the animal models of a short-term experimental period ended at 24 weeks. In the present study, to clarify the importance of the experimental period in studying the pathogenesis of the development of FSGS, we investigated a long-term effect of castration or estrogen administration on FSGS using an experimental model of uninephrectomized Sprague-Dawley (SD) rats ended at 54 weeks. Thirty male SD rats received unilaterally right nephrectomy at 6 weeks of age. They were divided into three groups: group 1 was control; group 2 was castrated at 6 weeks, and group 3 was administered 0.2 mg estrogen subcutaneously once a month from 6 weeks of age. Body weight, urinary protein, serum albumin and other serum constituents were investigated every 12 weeks from 18 to 54 weeks of age. Each group was studied morphologically at the end of the experiment. Castration attenuated glomerular injury to the same extent as seen in the study of a short-term experimental period, while estrogen administration failed to attenuate glomerular injury, although each treatment equally suppressed an urinary excretion of a sex-related low-molecular-weight (LMW) protein. Castration reduced significantly kidney weight (KW), glomerular volume (GV) and serum growth hormone (GH) levels, but estrogen treatment failed to reduce KW and GV, and conversely elevated GH levels. These results suggest that a sex-related LMW protein influenced by castration or estrogen treatment may not play an important role in the development of FSGS and that an increase in plasma GH levels may contribute to the failure of an attenuating effect of estrogen on glomerular injury.

Systemic lupus erythematosus in a patient with remitting minimal change nephrotic syndrome

Minimal change nephrotic syndrome (MCNS) developed in a 17-year-old female and spontaneously remitted. One month later the nephrotic syndrome relapsed. Prednisolone therapy, 60 mg/day, was started and resulted in a full remission within a week and the prednisolone dose was subsequently tapered. Seven months later, when 10 mg/day of prednisolone was being administered, she developed erythematous rash with photosensitivity and polyarthralgia without exacerbation of the nephrotic syndrome, and fulfilled four of the American College of Rheumatology criteria for classification of systemic lupus erythematosus (SLE). Avoidance of direct sunlight ameliorated the erythematous rash and the polyarthralgia disappeared even though the prednisolone dose was decreased further. This is the first reported case of SLE developed in a patient with remitting MCNS.

Attenuating effect of castration on glomerular injury is age-dependent in unilaterally nephrectomized male Sprague-Dawley rats

To clarify a role of sex hormones in greater susceptibility of young rats than adults to the development of focal and segmental glomerulosclerosis (FSGS), we castrated animals at different ages and investigated whether the attenuating effect of castration on FSGS is age-dependent in unilaterally nephrectomized male Sprague-Dawley (SD) rats. At 6 weeks of age, all groups received unilateral right nephrectomy (Nx) and group 2 was simultaneously castrated, while group 1 received a sham operation. Group 3 was castrated at 3 months of age, and group 4 at 6 months of age. Body weight, blood pressure, urinary protein and serum constituents were investigated every 2 months from 4 to 14 months of age. At 6 and 14 months of age, rats were studied morphologically. Castration at 6 weeks of age or at 3 months of age significantly inhibited the compensatory glomerular hypertrophy and hyperfunction with regard to the creatinine clearance as seen in Nx rats at 6 months of age and significantly reduced glomerular injury at the end of the experiment, while castration at 6 months produced neither an inhibitory effect on glomerular hypertrophy nor an attenuating effect on glomerular injury. Serum levels of growth hormone (GH) and somatomedin-C (SmC) were decreased by castration to a greater extent when castrated at younger age. These findings indicated that GH and SmC influenced by male sex hormone seem to play a more important role at younger age than in adults in exerting its effect on glomerular growth, leading somehow to glomerular injury in aging, unilaterally nephrectomized male SD rats.

Testosterone does not eliminate the attenuating effect of estrogen on progressive glomerular injury in estrogen-treated hypercholesterolemic male Imai rats

Hypercholesterolemic Imai rats spontaneously develop proteinuria and glomerulosclerosis, especially males. Estrogen attenuates the progressive glomerular injury in these male rats. To clarify whether this attenuating effect of estrogen depends on a reduction of testosterone and/or a reduction of the sex-related factors, we investigated whether testosterone administration eliminates the attenuating effect of estrogen on the development of glomerular injury in estrogen-treated male Imai rats. Estrogen significantly reduced sex-related low molecular weight protein excretion to undetectable levels; and treatment with estrogen and testosterone failed to increase these levels. Unexpectedly, treatment with estrogen and testosterone attenuated glomerular injury more than treatment with estrogen only. Estrogen significantly increased both levels of estrogen and growth hormone (GH), whereas it suppressed testosterone levels. Testosterone administration resulted in an increase in serum testosterone levels of about fivefold above the control levels, but reduced the elevated serum GH to the levels of the controls. These results suggest that estrogen appears to play a protective role by itself or in association with sex-related factors, independent of the levels of serum testosterone, and that testosterone does not exert its effect on augmenting glomerular injury and rather may act to attenuate glomerular injury associated with a reduction of GH levels.

The ovaries attenuate the aggravating effect of testosterone on glomerular injury in Adriamycin-induced nephropathy of female rats

To clarify whether the ovaries have a potential to attenuate the aggravating effect of testosterone (T) on glomerular injury, we investigated the effect of T in female rats with or without ovaries, using Adriamycin (ADR)-induced nephropathy in female Sprague-Dawley rats. Group 1 consisted of female control rats, group 2 received T, groups 3 and 4 were subjected to ovariectomy (OVX) at 5 weeks of age, and group 4 received further T treatment. Group 5 consisted of male control rats. T was injected subcutaneously every 4 weeks from 5 weeks of age through the end of the experiment. ADR 2 mg/kg was administered intravenously to all rats twice, at 8 weeks of age and 20 days later. Body weight, blood pressure, urinary protein and serum constituents were investigated every 4 weeks from 4 through 24 weeks after the second ADR injection. Each group was studied morphologically 24 weeks after the second ADR injection. Treatment with T or with OVX and T significantly increased the urinary protein excretion. OVX had no significant effect on the urinary protein excretion. Treatment with either T or OVX did not induce any significant effects on the renal function with regard to blood urea nitrogen (BUN), serum creatinine (Cr) and Cr clearance (Ccr) levels, but a combined treatment with OVX and T significantly lowered the serum albumin levels, increased the levels of BUN and Cr and lowered the Ccr values. The glomerulosclerosis index was significantly and markedly higher in control male rats than in control females. Treatment with T resulted in a slight but significant increase in glomerular injury to levels similar to those seen in ovariectomized rats. Combined treatment with OVX and T significantly aggravated glomerular injury in a somewhat accelerated manner, associated with a significant increase in glomerular tuft volume. Our results suggested that the ovaries could not completely suppress glomerular injury worsened by T administered at serum levels similar to those of male rats, but they had a potential to attenuate glomerular injury induced by T, and the protective effect of the ovaries on glomerular injury may be related to their attenuating effect on glomerular growth.

Ovariectomy attenuates proteinuria and glomerular injury in unilaterally nephrectomized female Sprague-Dawley rats

To determine the contribution of the ovary to the development of glomerulo-sclerosis, we investigated the effect of ovariectomy on glomerulosclerosis, using the unilaterally nephrectomized (Nx) female Sprague-Dawley rat. At 6 weeks of age, groups 2 and 3 underwent unilateral right nephrectomy and group 3 was simultaneously ovariectomized, while group 1 underwent a sham operation. Body weight, blood pressure, urinary protein, serum albumin, cholesterol, blood urea nitrogen and serum creatinine were checked every 2 months from 2 to 12 months after right nephrectomy. Control group 1, the Nx group 2 and the ovariectomized (Nx + ovariectomized) group 3 were studied morphologically at 6 and 12 months after nephrectomy. Body weight significantly increased in ovariectomized rats as compared with control and Nx rats. Nx rats became proteinuric with age. Ovariectomy significantly reduced proteinuria to the same levels in the controls. The glomerulosclerosis index was significantly higher in Nx rats than in either controls or ovariectomized rats. Ovariectomy attenuated glomerular injury in Nx rats, though not to the same levels in the control rats. Three groups showed no significant differences in either blood pressure or plasma somatomedin C. Growth hormone (GH) was significantly decreased by ovariectomy. The severity of glomerular injury and the glomerular tuft volume correlated with GH levels. Our results suggested that a decrease in plasma GH may contribute to the attenuating effect of ovariectomy on the development of glomerular injury in aging unilaterally Nx female Sprague-Dawley rats.

Renal wedge-shaped lesions on computed tomography and ultrasonography in two patients who developed acute renal failure with severe loin pain after exercise

Acute renal failure (ARF) with loin pain after exercise with development of wedge-shaped contrast enhancement on computed tomography (CT) has been described as a new disease entity. We report 2 patients who developed ARF with severe loin pain after exercise, showing wedge-shaped lesions both on CT and ultrasonography. Renal ultrasonography showed indistinct wedge-shaped lesions when performed at oliguric or recovery phase of ARF, whereas it showed distinct lesions when done between these two phases. Contrast CT performed at the recovery phase disclosed distinct wedge-shaped lesions. Our findings suggested that the best time to detect these lesions by ultrasonography is between at the beginning of diuresis and at the time of serum creatinine levels of 2 mg/dl.

Effect of ovariectomy on glomerular injury in hypercholesterolemic female Imai rats

To clarify the pathogenesis of focal and segmental glomerulosclerosis, we investigated the effect of ovariectomy in hypercholesterolemic female Imai rats. At 5 weeks of age, control female (group 1) and control male rats (group 3) were sham-operated, female rats (group 2) were ovariectomized and male rats (group 4) were castrated. Body weight, blood pressure, urinary protein and serum constituents were checked every 2 months from 2 through 12 months of age. All groups were studied morphologically at 6 months of age and further female groups (1 and 2) studied at 12 months. Both control female and control male rats developed marked proteinuria, to a significantly greater extent in the male rats. Castration reduced proteinuria, while ovariectomy did not influence it and there were no significant differences in proteinuria among the control females, the ovariectomized females and the castrated males. Control male rats had significantly lower serum albumin levels, higher cholesterol levels and a significantly greater impairment of renal function in blood urea nitrogen (BUN) levels than did the control female rats at 6 months. Castration significantly increased serum albumin levels and lowered BUN levels, while ovariectomy did not basically influence these values in the female rats. The glomerulosclerosis index at 6 months of age was significantly higher in the control males than in the control females. Castration attenuated glomerular injury, while ovariectomy aggravated glomerular injury to the same levels as found in the castrated males. This aggravating effect of ovariectomy observed at 6 months, however, disappeared at 12 months. These results suggested that sex-related factors regulated by the ovaries may play an inhibitory role in the development of glomerulosclerosis before 6 months of age, but not thereafter, in hypercholesterolemic female Imai rats.

Sex difference in progression of adriamycin-induced nephropathy in rats

To clarify the pathogenesis of focal-segmental glomerulosclerosis, we investigated the sex-related difference and the effect of castration in Adriamycin (ADR) induced nephropathy of Sprague-Dawley rats. At 5 weeks of age, group 1 female and group 2 male rats were sham operated, and group 3 male rats were castrated. ADR 2 mg/kg was intravenously administered to all rats at 8 weeks of age twice at a 20-day interval. Body weight, blood pressure, urinary protein, and serum constituents were investigated every 4 weeks, 4-20 weeks after the second ADR injection. Each group was studied morphologically 12 and 20 weeks after the second ADR injection. ADR induced massive proteinuria in male rats, whereas it induced significantly lower proteinuria in female rats, and castration significantly reduced proteinuria of male rats to an extent equal to the levels seen in female rats. Control male rats had significantly lower serum albumin levels and a significantly greater impairment of renal function (blood urea nitrogen and creatinine levels) than the female rats or the castrated male rats at 20 weeks. The glomerulosclerosis index was significantly higher in control male rats than in female rats, and castration attenuated glomerular injury of male rats to an extent close to the levels seen in female rats, though there was a significant difference in the glomerulosclerosis index between female rats and castrated male rats. The three groups did not differ in blood pressure and plasma somatomedin C and serum growth hormone levels, whereas the plasma testosterone levels were decreased to undetectable in female and castrated male rats, resulting in a reduction of sex-related low molecular weight protein in urine. These observations suggest that sex hormones such as testosterone and estrogen and/or sex-related low molecular weight protein regulated by testosterone and estrogen may play a contributory role in sex differences in the progression of glomerulosclerosis in ADR-treated rats.

Snake-strike--induced ischemic colitis with colonic stricture complicated by disseminated intravascular coagulation

A 57-year-old farmer was struck on the right thumb by a pit viper (Agkistrodon blomhoffü). Subsequently, he had acute renal failure and disseminated intravascular coagulation (DIC), associated with melanotic stools and abdominal pain. Renal failure caused by renal cortical necrosis was successfully treated with hemodialysis. A double-contrast barium enema examination revealed multiple stenoses of the colon, regional edema, and longitudinal ulcer. Histologic examination of the stenotic lesions after laparotomy revealed fibrosis of both submucosa and proper muscle layer, with fibrotic thickness in the small arteries of the colonic wall, indicating that ischemic colitis was associated with DIC. In this case, DIC from viper toxins played an etiologic role in the development of ischemic colitis with stricture, as well as acute renal failure.

Acute progressive and extensive metastatic calcifications in a nephrotic patient following chronic hemodialysis

We report on a 46-year-old female patient with a 5-year history of refractory nephrotic syndrome who rapidly developed extensive metastatic calcifications in lung, bone, blood vessels, skin, uterus and other soft tissues following maintenance hemodialysis. She was admitted for controlling anasarca. On admission, she suffered from severe nephrotic syndrome and chronic renal failure, showing 1.3 g/dl of serum albumin and 4.6 mg/dl of serum creatinine. She received bicarbonate dialysis combined with extracorporeal ultrafiltration to control anasarca. Following hemodialysis, she was treated with alfacalcidol and an increasing dose of calcium carbonate. Although anasarca was controlled, her nephrotic state remained unchanged. After 3 months of dialysis, roentgenograms of the body disclosed multiple metastatic calcifications. At this time, though the calcium-phosphorous product in serum was almost normal, the free calcium index was confirmed to have been high for 4 weeks. We considered that administration of calcium carbonate and alfacalcidol as well as an influx of free calcium from a dialysate resulted in increased serum ionized calcium which may be unable to be bound to serum protein because of lack of total protein, leading to ectopic deposition of calcium and phosphate. Our findings suggested that intensive care is needed to prevent metastatic calcification when uremic patients with severe nephrosis are treated with bicarbonate hemodialysis.

Estrogen attenuates progressive glomerular injury in hypercholesterolemic male Imai rats

Hypercholesterolemic Imai rats spontaneously develop proteinuria and glomerulosclerosis, especially in males. A sex difference in glomerular injury has been recognized, but the role of sex hormones in glomerular injury remains unclear. Therefore, we investigated whether estrogen administration influences the progressive glomerular injury in male Imai rats. Estrogen produced a significant decrease in body weight. Systolic blood pressure in estrogen-treated rats was significantly lower than that in controls. Estrogen attenuated the progression of glomerular injury by significantly reducing proteinuria and glomerular sclerosis. The glomerulosclerosis index was significantly higher in controls than in estrogen-treated rats. Estrogen suppressed serum testosterone levels, whereas it increased GH levels. Results suggest that estrogen appears to play an inhibitory role on the development of glomerular injury, by itself or in association with sex-related factors regulated by estrogen and testosterone.