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Nozu K, Sako M, Tanaka S, Kano Y, Ohwada Y, Morohashi T, Hamada R, Ohtsuka Y, Oka M, Kamei K, Inaba A, Ito S, Sakai T, Kaito H, Shima Y, Ishikura K, Nakamura H, Nakanishi K, Horinouchi T, Konishi A, Omori T, Iijima K. Rituximab in combination with cyclosporine and steroid pulse therapy for childhood-onset multidrug-resistant nephrotic syndrome: a multicenter single-arm clinical trial (JSKDC11 trial). Clin Exp Nephrol 2024; 28:337-348. [PMID: 38010466 PMCID: PMC10955017 DOI: 10.1007/s10157-023-02431-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/21/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Only 80% of children with idiopathic nephrotic syndrome respond well to glucocorticoid therapy. Multidrug-resistant nephrotic syndrome (MRNS) is associated with a poor kidney prognosis. Several retrospective studies have identified rituximab as an effective treatment for MRNS; however, prospective studies are required to assess its efficacy and safety. METHODS We conducted a multicenter, non-blinded, single-arm trial to investigate the efficacy and safety of rituximab in patients with childhood-onset MRNS who were resistant to cyclosporine and more than three courses of steroid pulse therapy. The enrolled patients received four 375 mg/m2 doses of rituximab in combination with baseline cyclosporine and steroid pulse therapy. The primary endpoint was a > 50% reduction in the urinary protein/creatinine ratio from baseline on day 169. Complete and partial remissions were also evaluated. RESULTS Six patients with childhood-onset MRNS were enrolled. All patients were negative for pathogenic variants of podocyte-related genes. On day 169, five patients (83.3%) showed a > 50% reduction in the urinary protein/creatinine ratio, two patients showed partial remission, and two patients showed complete remission. No deaths occurred and severe adverse events occurred in two patients (infection in one patient and acute kidney injury in one patient). Three patients needed treatment for moderate-to-severe infection. CONCLUSIONS The study treatment effectively reduced the urinary protein/creatinine ratio in patients with childhood-onset MRNS. The adverse events in this study were within the expected range; however, attention should be paid to the occurrence of infections.
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Affiliation(s)
- Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan.
| | - Mayumi Sako
- Division for Clinical Trials, Department of Clinical Research Promotion, Clinical Research Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seiji Tanaka
- Department of Pediatrics, Kurume University School of Medicine, Kurume, Japan
| | - Yuji Kano
- Department of Pediatrics, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Yoko Ohwada
- Department of Pediatrics, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Tamaki Morohashi
- Department of Pediatrics, Nihon University School of Medicine, Tokyo, Japan
| | - Riku Hamada
- Department of Nephrology, Tokyo Metropolitan Children's Medical Center, Tokyo, Japan
| | - Yasufumi Ohtsuka
- Department of Pediatrics, Saga University School of Medicine, Saga, Japan
| | - Masafumi Oka
- Department of Pediatrics, Saga University School of Medicine, Saga, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Aya Inaba
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Shuichi Ito
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | - Tomoyuki Sakai
- Department of Pediatrics, Shiga University of Medical Science, Shiga, Japan
| | - Hiroshi Kaito
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Yuko Shima
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | - Kenji Ishikura
- Department of Pediatrics, Kitasato University School of Medicine, Kanagawa, Japan
| | - Hidefumi Nakamura
- Clinical Research Center, National Center for Child Health and Development, Tokyo, Japan
| | - Koichi Nakanishi
- Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Tomoko Horinouchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
| | - Akihide Konishi
- Clinical and Translational Research Center, Kobe University Hospital, Kobe, Japan
| | - Takashi Omori
- Clinical and Translational Research Center, Kobe University Hospital, Kobe, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, 650-0017, Japan
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2
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Miyamoto T, Honda Y, Izawa K, Kanazawa N, Kadowaki S, Ohnishi H, Fujimoto M, Kambe N, Kase N, Shiba T, Nakagishi Y, Akizuki S, Murakami K, Bamba M, Nishida Y, Inui A, Fujisawa T, Nishida D, Iwata N, Otsubo Y, Ishimori S, Nishikori M, Tanizawa K, Nakamura T, Ueda T, Ohwada Y, Tsuyusaki Y, Shimizu M, Ebato T, Iwao K, Kubo A, Kawai T, Matsubayashi T, Miyazaki T, Kanayama T, Nishitani-Isa M, Nihira H, Abe J, Tanaka T, Hiejima E, Okada S, Ohara O, Saito MK, Takita J, Nishikomori R, Yasumi T. Assessment of type I interferon signatures in undifferentiated inflammatory diseases: A Japanese multicenter experience. Front Immunol 2022; 13:905960. [PMID: 36211342 PMCID: PMC9541620 DOI: 10.3389/fimmu.2022.905960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 09/01/2022] [Indexed: 11/28/2022] Open
Abstract
Purpose Upregulation of type I interferon (IFN) signaling has been increasingly detected in inflammatory diseases. Recently, upregulation of the IFN signature has been suggested as a potential biomarker of IFN-driven inflammatory diseases. Yet, it remains unclear to what extent type I IFN is involved in the pathogenesis of undifferentiated inflammatory diseases. This study aimed to quantify the type I IFN signature in clinically undiagnosed patients and assess clinical characteristics in those with a high IFN signature. Methods The type I IFN signature was measured in patients’ whole blood cells. Clinical and biological data were collected retrospectively, and an intensive genetic analysis was performed in undiagnosed patients with a high IFN signature. Results A total of 117 samples from 94 patients with inflammatory diseases, including 37 undiagnosed cases, were analyzed. Increased IFN signaling was observed in 19 undiagnosed patients, with 10 exhibiting clinical features commonly found in type I interferonopathies. Skin manifestations, observed in eight patients, were macroscopically and histologically similar to those found in proteasome-associated autoinflammatory syndrome. Genetic analysis identified novel mutations in the PSMB8 gene of one patient, and rare variants of unknown significance in genes linked to type I IFN signaling in four patients. A JAK inhibitor effectively treated the patient with the PSMB8 mutations. Patients with clinically quiescent idiopathic pulmonary hemosiderosis and A20 haploinsufficiency showed enhanced IFN signaling. Conclusions Half of the patients examined in this study, with undifferentiated inflammatory diseases, clinically quiescent A20 haploinsufficiency, or idiopathic pulmonary hemosiderosis, had an elevated type I IFN signature.
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Affiliation(s)
- Takayuki Miyamoto
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Yoshitaka Honda
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Institute for the Advanced Study of Human Biology (ASHBi), Kyoto University, Kyoto, Japan
- Department of Immunology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Kazushi Izawa
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
- *Correspondence: Kazushi Izawa,
| | - Nobuo Kanazawa
- Department of Dermatology, Hyogo Medical University, Nishinomiya, Japan
| | - Saori Kadowaki
- Department of Pediatrics, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Hidenori Ohnishi
- Department of Pediatrics, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Masakazu Fujimoto
- Department of Diagnostic Pathology, Kyoto University Hospital, Kyoto, Japan
| | - Naotomo Kambe
- Department of Dermatology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Naoya Kase
- Department of Clinical Application, Center for iPS cell (Induced pluripotent stem cell) Research and Application, Kyoto University, Kyoto, Japan
| | - Takeshi Shiba
- Department of Pediatrics, Tenri Hospital, Tenri, Japan
| | - Yasuo Nakagishi
- Department of Pediatric Rheumatology, Hyogo Prefectural Kobe Children’s Hospital, Kobe, Japan
| | - Shuji Akizuki
- Division of Clinical Immunology and Cancer Immunotherapy, Center for Cancer Immunotherapy and Immunobiology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kosaku Murakami
- Division of Clinical Immunology and Cancer Immunotherapy, Center for Cancer Immunotherapy and Immunobiology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masahiro Bamba
- Department of Pediatrics, Kawasaki Municipal Hospital, Kawasaki, Japan
| | - Yutaka Nishida
- Department of Pediatrics, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Ayano Inui
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Tomoo Fujisawa
- Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Daisuke Nishida
- Department of Infection and Immunology, Aichi Children’s Health and Medical Center, Aichi, Japan
| | - Naomi Iwata
- Department of Infection and Immunology, Aichi Children’s Health and Medical Center, Aichi, Japan
| | - Yoshikazu Otsubo
- Department of Pediatrics, Sasebo City General Hospital, Sasebo, Japan
| | - Shingo Ishimori
- Department of Pediatrics, Takatsuki General Hospital, Takatsuki, Japan
| | - Momoko Nishikori
- Department of Hematology and Oncology, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kiminobu Tanizawa
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tomoyuki Nakamura
- Department of General Medicine, Osaka City Hospital Organization Osaka City General Hospital, Osaka, Japan
| | - Takeshi Ueda
- Department of Emergency and General Internal Medicine, Rakuwakai Marutamachi Hospital, Kyoto, Japan
| | - Yoko Ohwada
- Department of Pediatrics, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Yu Tsuyusaki
- Department of Neurology, Kanagawa Children’s Medical Center, Yokohama, Japan
| | - Masaki Shimizu
- Department of Pediatrics and Developmental Biology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takasuke Ebato
- Department of Pediatrics, Kitasato University, School of Medicine, Kanagawa, Japan
| | - Kousho Iwao
- Department of Internal Medicine, Division of Rheumatology, Infectious Diseases and Laboratory Medicine, University of Miyazaki, Miyazaki, Japan
| | - Akiharu Kubo
- Department of Dermatology, Keio University School of Medicine, Tokyo, Japan
| | - Toshinao Kawai
- Division of Immunology, National Center for Child Health and Development, Tokyo, Japan
| | | | | | | | | | - Hiroshi Nihira
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Junya Abe
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Pediatrics, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Japan
| | - Takayuki Tanaka
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
- Department of Pediatrics, Otsu Red Cross Hospital, Otsu, Japan
| | - Eitaro Hiejima
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Satoshi Okada
- Department of Pediatrics, Hiroshima University Graduate School of Biomedical and Health Sciences, Hiroshima, Japan
| | - Osamu Ohara
- Department of Applied Genomics, Kazusa DNA Research Institute, Kisarazu, Japan
| | - Megumu K. Saito
- Department of Clinical Application, Center for iPS cell (Induced pluripotent stem cell) Research and Application, Kyoto University, Kyoto, Japan
| | - Junko Takita
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ryuta Nishikomori
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
| | - Takahiro Yasumi
- Department of Pediatrics, Kyoto University Graduate School of Medicine, Kyoto, Japan
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3
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Iijima K, Sako M, Oba M, Tanaka S, Hamada R, Sakai T, Ohwada Y, Ninchoji T, Yamamura T, Machida H, Shima Y, Tanaka R, Kaito H, Araki Y, Morohashi T, Kumagai N, Gotoh Y, Ikezumi Y, Kubota T, Kamei K, Fujita N, Ohtsuka Y, Okamoto T, Yamada T, Tanaka E, Shimizu M, Horinochi T, Konishi A, Omori T, Nakanishi K, Ishikura K, Ito S, Nakamura H, Nozu K. Mycophenolate Mofetil after Rituximab for Childhood-Onset Complicated Frequently-Relapsing or Steroid-Dependent Nephrotic Syndrome. J Am Soc Nephrol 2022; 33:401-419. [PMID: 34880074 PMCID: PMC8819987 DOI: 10.1681/asn.2021050643] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 11/21/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Rituximab is the standard therapy for childhood-onset complicated frequently relapsing or steroid-dependent nephrotic syndrome (FRNS/SDNS). However, most patients redevelop FRNS/SDNS after peripheral B cell recovery. METHODS We conducted a multicenter, randomized, double-blind, placebo-controlled trial to examine whether mycophenolate mofetil (MMF) administration after rituximab can prevent treatment failure (FRNS, SDNS, steroid resistance, or use of immunosuppressive agents or rituximab). In total, 39 patients (per group) were treated with rituximab, followed by either MMF or placebo until day 505 (treatment period). The primary outcome was time to treatment failure (TTF) throughout the treatment and follow-up periods (until day 505 for the last enrolled patient). RESULTS TTFs were clinically but not statistically significantly longer among patients given MMF after rituximab than among patients receiving rituximab monotherapy (median, 784.0 versus 472.5 days, hazard ratio [HR], 0.59; 95% confidence interval [95% CI], 0.34 to 1.05, log-rank test: P=0.07). Because most patients in the MMF group presented with treatment failure after MMF discontinuation, we performed a post-hoc analysis limited to the treatment period and found that MMF after rituximab prolonged the TTF and decreased the risk of treatment failure by 80% (HR, 0.20; 95% CI, 0.08 to 0.50). Moreover, MMF after rituximab reduced the relapse rate and daily steroid dose during the treatment period by 74% and 57%, respectively. The frequency and severity of adverse events were similar in both groups. CONCLUSIONS Administration of MMF after rituximab may sufficiently prevent the development of treatment failure and is well tolerated, although the relapse-preventing effect disappears after MMF discontinuation.
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Affiliation(s)
- Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan,Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Mayumi Sako
- Department of Clinical Research Promotion, National Center for Child Health and Development, Tokyo, Japan
| | - Mari Oba
- Department of Medical Statistics, Toho University, Tokyo, Japan
| | - Seiji Tanaka
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Japan
| | - Riku Hamada
- Department of Nephrology, Tokyo Metropolitan Children’s Medical Center, Fuchu, Japan
| | - Tomoyuki Sakai
- Department of Pediatrics, Shiga University of Medical Science, Otsu, Japan
| | - Yoko Ohwada
- Department of Pediatrics, Dokkyo Medical University School of Medicine, Mibu, Japan
| | - Takeshi Ninchoji
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Tomohiko Yamamura
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroyuki Machida
- Department of Pediatrics, Yokohama City University, Yokohama, Japan
| | - Yuko Shima
- Department of Pediatrics, Wakayama Medical University, Wakayama City, Japan
| | - Ryojiro Tanaka
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Hiroshi Kaito
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan,Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Yoshinori Araki
- Department of Pediatrics, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Tamaki Morohashi
- Department of Pediatrics, Nihon University School of Medicine, Tokyo, Japan
| | - Naonori Kumagai
- Department of Pediatrics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Yoshimitsu Gotoh
- Department of Pediatrics, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | - Yohei Ikezumi
- Department of Pediatrics, Fujita Health University School of Medicine, Toyoake, Japan
| | - Takuo Kubota
- Department of Pediatrics, Osaka University, Suita, Japan
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Naoya Fujita
- Department of Nephrology, Aichi Children's Health and Medical Center, Obu, Japan
| | | | - Takayuki Okamoto
- Department of Pediatrics, Hokkaido University Hospital, Sapporo, Japan
| | - Takeshi Yamada
- Department of Pediatrics, Niigata University Medical and Dental Hospital, Niigata City, Japan
| | - Eriko Tanaka
- Department of Pediatrics and Developmental Biology, Tokyo Medical and Dental University, Tokyo, Japan
| | - Masaki Shimizu
- Department of Pediatrics, Kanazawa University, Kanazawa, Japan
| | - Tomoko Horinochi
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Akihide Konishi
- Clinical and Translational Research Center, Kobe University Hospital, Kobe, Japan
| | - Takashi Omori
- Clinical and Translational Research Center, Kobe University Hospital, Kobe, Japan
| | - Koichi Nakanishi
- Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, Nishihara, Japan
| | - Kenji Ishikura
- Department of Pediatrics, Kitasato University School of Medicine, Sagamihara, Japan
| | - Shuichi Ito
- Department of Pediatrics, Yokohama City University, Yokohama, Japan
| | - Hidefumi Nakamura
- Department of Research and Development Supervision, Clinical Research Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
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4
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Hashimoto J, Hamasaki Y, Takahashi Y, Kubota M, Yanagisawa T, Itabashi Y, Muramatsu M, Kawamura T, Kumagai N, Ohwada Y, Sakai K, Shishido S. Management of patients with severe Epstein syndrome: Review of four patients who received living‐donor renal transplantation. Nephrology (Carlton) 2019. [DOI: 10.1111/nep.13253] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Junya Hashimoto
- Department of Pediatric NephrologyToho University Faculty of Medicine Tokyo Japan
| | - Yuko Hamasaki
- Department of Pediatric NephrologyToho University Faculty of Medicine Tokyo Japan
| | - Yusuke Takahashi
- Department of Pediatric NephrologyToho University Faculty of Medicine Tokyo Japan
| | - Mai Kubota
- Department of Pediatric NephrologyToho University Faculty of Medicine Tokyo Japan
| | - Taketo Yanagisawa
- Department of NephrologyToho University Faculty of Medicine Tokyo Japan
| | | | - Masaki Muramatsu
- Department of NephrologyToho University Faculty of Medicine Tokyo Japan
| | - Takeshi Kawamura
- Department of NephrologySakura Medical Center, Toho University Chiba Japan
| | - Naonori Kumagai
- Department of PediatricsTohoku University School of Medicine Miyagi Japan
| | - Yoko Ohwada
- Department of PediatricsDokkyo Medical University School of Medicine Tochigi Japan
| | - Ken Sakai
- Department of NephrologyToho University Faculty of Medicine Tokyo Japan
| | - Seiichiro Shishido
- Department of Pediatric NephrologyToho University Faculty of Medicine Tokyo Japan
- Department of NephrologyToho University Faculty of Medicine Tokyo Japan
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5
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Jia X, Horinouchi T, Hitomi Y, Shono A, Khor SS, Omae Y, Kojima K, Kawai Y, Nagasaki M, Kaku Y, Okamoto T, Ohwada Y, Ohta K, Okuda Y, Fujimaru R, Hatae K, Kumagai N, Sawanobori E, Nakazato H, Ohtsuka Y, Nakanishi K, Shima Y, Tanaka R, Ashida A, Kamei K, Ishikura K, Nozu K, Tokunaga K, Iijima K. Strong Association of the HLA-DR/DQ Locus with Childhood Steroid-Sensitive Nephrotic Syndrome in the Japanese Population. J Am Soc Nephrol 2018; 29:2189-2199. [PMID: 30012571 DOI: 10.1681/asn.2017080859] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 05/11/2018] [Indexed: 12/26/2022] Open
Abstract
Background Nephrotic syndrome is the most common cause of chronic glomerular disease in children. Most of these patients develop steroid-sensitive nephrotic syndrome (SSNS), but the loci conferring susceptibility to childhood SSNS are mainly unknown.Methods We conducted a genome-wide association study (GWAS) in the Japanese population; 224 patients with childhood SSNS and 419 adult healthy controls were genotyped using the Affymetrix Japonica Array in the discovery stage. Imputation for six HLA genes (HLA-A, -C, -B, -DRB1, -DQB1, and -DPB1) was conducted on the basis of Japanese-specific references. We performed genotyping for HLA-DRB1/-DQB1 using a sequence-specific oligonucleotide-probing method on a Luminex platform. Whole-genome imputation was conducted using a phased reference panel of 2049 healthy Japanese individuals. Replication was performed in an independent Japanese sample set including 216 patients and 719 healthy controls. We genotyped candidate single-nucleotide polymorphisms using the DigiTag2 assay.Results The most significant association was detected in the HLA-DR/DQ region and replicated (rs4642516 [minor allele G], combined Pallelic=7.84×10-23; odds ratio [OR], 0.33; 95% confidence interval [95% CI], 0.26 to 0.41; rs3134996 [minor allele A], combined Pallelic=1.72×10-25; OR, 0.29; 95% CI, 0.23 to 0.37). HLA-DRB1*08:02 (Pc=1.82×10-9; OR, 2.62; 95% CI, 1.94 to 3.54) and HLA-DQB1*06:04 (Pc=2.09×10-12; OR, 0.10; 95% CI, 0.05 to 0.21) were considered primary HLA alleles associated with childhood SSNS. HLA-DRB1*08:02-DQB1*03:02 (Pc=7.01×10-11; OR, 3.60; 95% CI, 2.46 to 5.29) was identified as the most significant genetic susceptibility factor.Conclusions The most significant association with childhood SSNS was detected in the HLA-DR/DQ region. Further HLA allele/haplotype analyses should enhance our understanding of molecular mechanisms underlying SSNS.
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Affiliation(s)
- Xiaoyuan Jia
- Department of Human Genetics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tomoko Horinouchi
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuki Hitomi
- Department of Human Genetics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akemi Shono
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Seik-Soon Khor
- Department of Human Genetics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yosuke Omae
- Department of Human Genetics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kaname Kojima
- Department of Integrative Genomics, Tohoku Medical Megabank Organization.,Graduate School of Medicine, and.,Graduate School of Information Sciences, Tohoku University, Sendai, Japan
| | - Yosuke Kawai
- Department of Human Genetics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Integrative Genomics, Tohoku Medical Megabank Organization
| | - Masao Nagasaki
- Department of Integrative Genomics, Tohoku Medical Megabank Organization.,Graduate School of Medicine, and.,Graduate School of Information Sciences, Tohoku University, Sendai, Japan
| | - Yoshitsugu Kaku
- Department of Nephrology, Fukuoka Children's Hospital, Fukuoka, Japan
| | - Takayuki Okamoto
- Department of Pediatrics, Hokkaido University Hospital, Sapporo, Japan
| | - Yoko Ohwada
- Department of Pediatrics, Dokkyo Medical University School of Medicine, Tochigi, Japan
| | - Kazuhide Ohta
- Department of Pediatrics, Kanazawa Medical Center, Kanazawa, Japan
| | - Yusuke Okuda
- Department of Pediatrics, Shiga University of Medical Science, Shiga, Japan
| | - Rika Fujimaru
- Department of Pediatrics, Osaka City General Hospital, Osaka, Japan
| | - Ken Hatae
- Department of Pediatrics, Japanese Red Cross Fukuoka Hospital, Fukuoka, Japan
| | - Naonori Kumagai
- Department of Pediatrics, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Emi Sawanobori
- Department of Pediatrics, Faculty of Medicine, University of Yamanashi, Yamanashi, Japan
| | - Hitoshi Nakazato
- Department of Pediatrics, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Yasufumi Ohtsuka
- Department of Pediatrics, Faculty of Medicine, Saga University, Saga, Japan
| | - Koichi Nakanishi
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | - Yuko Shima
- Department of Pediatrics, Wakayama Medical University, Wakayama, Japan
| | - Ryojiro Tanaka
- Department of Nephrology, Hyogo Prefectural Kobe Children's Hospital, Kobe, Japan
| | - Akira Ashida
- Department of Pediatrics, Osaka Medical College, Osaka, Japan; and
| | - Koichi Kamei
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Kenji Ishikura
- Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Kandai Nozu
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Katsushi Tokunaga
- Department of Human Genetics, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan;
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan;
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6
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Imataka G, Ohwada Y, Shimura N, Yoshihara S, Arisaka O. Del(18)(q12.2q21.1) syndrome: a case report and clinical review of the literature. Eur Rev Med Pharmacol Sci 2015; 19:3241-3245. [PMID: 26400529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
The terminal deletion of the long arm of chromosome 18 is relatively common among cytogenetic abnormalities, which occur incidentally in approximately 1 in 40,000 live births. Proximal interstitial deletions of the long arm of chromosome 18 are less frequent. The critical region on chromosome 18 of this syndrome is del(18)(q12.2q21.1) and has recently been recognized as a new clinical entity. We describe a 8-year-old boy with developmental delay, obesity, and epilepsy, with characteristic facial anomalies in whom G-banding chromosome analysis revealed a unique karyotype of 46, XY, del(18)(q12.2q21.1). The patient was diagnosed with interstitial deletion chromosome 18q-syndrome. He received weight control therapy from a medical dietitian. For his epilepsy, he was administered oral carbamazepine at 4 mg/kg/day. At age six, he entered a special needs elementary school. After entering school, he often showed hyperkinesis, and was diagnosed with attention deficit hyperactivity disorder with mild mental retardation. Because patients with only del(18)(q12.2q21.1) have no serious associated malformations, physicians should be aware that even adult patients may have 18q-syndrome. Therefore, if epilepsy occurs in patients with minor facial anomalies, psychomotor retardation, obesity, and the possibility of 18q-syndrome with del(18)(q12.2q21.1) should be kept in mind, and chromosome testing should be performed.
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Affiliation(s)
- G Imataka
- Department of Pediatrics, Dokkyo Medical University School of Medicine, Mibu, Tochigi, Japan.
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Iijima K, Sako M, Oba MS, Ito S, Hataya H, Tanaka R, Ohwada Y, Kamei K, Ishikura K, Yata N, Nozu K, Honda M, Nakamura H, Nagata M, Ohashi Y, Nakanishi K, Yoshikawa N. Cyclosporine C2 monitoring for the treatment of frequently relapsing nephrotic syndrome in children: a multicenter randomized phase II trial. Clin J Am Soc Nephrol 2014; 9:271-8. [PMID: 24262503 PMCID: PMC3913253 DOI: 10.2215/cjn.13071212] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2012] [Accepted: 09/25/2013] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES An open-label, multicenter, randomized phase II trial was conducted from July 1, 2005 to March 29, 2011 to compare two protocols for treating children with frequently relapsing nephrotic syndrome using microemulsified cyclosporine. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Ninety-three children with frequently relapsing nephrotic syndrome were randomly assigned to group A (n=46) or group B (n=47). In both groups, the 2-hour postdose cyclosporine level was monitored. For group A, the cyclosporine target was set to 600-700 ng/ml for the first 6 months and 450-550 ng/ml for the next 18 months; for group B, it was set to 450-550 ng/ml for the first 6 months and 300-400 ng/ml for the next 18 months. The primary end point was the sustained remission rate. At the end of the study, if there was no difference in safety profile between the two groups and the sustained remission rate in group A was superior to group B with a decision threshold of 8%, then the regimen for group A would be determined the better treatment. RESULTS Eight children from an ineligible institution, where cyclosporine levels were not measured, were excluded from all analyses. At 24 months, the sustained remission rate was nonsignificantly higher in group A (n=43) than group B (n=42; 64.4% versus 50.0%; hazard ratio, 0.57; 95% confidence interval, 0.29 to 1.11; P=0.09), and the progression-free survival rate was significantly higher (88.1% versus 68.4%; hazard ratio, 0.33; 95% confidence interval, 0.12 to 0.94; P=0.03). The relapse rate was significantly lower in group A than group B (0.41 versus 0.95 times/person-year; hazard ratio, 0.43; 95% confidence interval, 0.19 to 0.84; P=0.02). The rate and severity of adverse events were similar in both treatment groups. CONCLUSION The sustained remission rate was not significantly different between the two treatment groups, but the regimen with the higher 2-hour postdose cyclosporine level target improved progression-free survival and reduced the relapse rate.
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Affiliation(s)
- Kazumoto Iijima
- Due to the number of contributing authors, the affiliations are provided in the Supplemental Material
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Koyama H, Sasaki T, Ohwada Y, Saito Y. The relationship between feathering abnormalities ("nakanuke") and tumour production in chickens inoculated with reticuloendotheliosis virus. Avian Pathol 2008; 9:331-40. [PMID: 18770271 DOI: 10.1080/03079458008418417] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
High concentrations of T strain reticuloendotheliosis virus (REV), which had been maintained by passage in 1-day-old chicks, produced reticuloendotheliosis tumours and deaths 8 to 13 days after inoculation. At lower concentrations fo virus inoculum, deaths did not occur but feathering abnormalities ("nakanuke") was regularly produced. These results indicate that the oncogenic T strain of REV may also produce abnormal feathering. The oncogenic potential was decreased when REV-T strain maintained in 1-day-old chicks was passaged once in duck embryo fibroblast (DEF) cultures. After three passages in DEF cultures the same virus strain had lost oncogenicity but retained the ability to induce abnormal feathering. REV-T strains which had been maintained over long periods in chicken embryo fibroblast (CEF) cell culture also lacked oncogenic potential but produced abnormal feathering in chickens. Tumours were not produced during a 2-month observation period by either REV-T which had been passaged three times in DEF culture or by the Japanese KI strain of REV which is not known to be oncogenic, but abnormal feathering was induced in both groups of inoculated chickens. Serological differences were not detectable with the indirect fluorescent antibody test among strains of REV with and without oncogenic potential.
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Affiliation(s)
- H Koyama
- Department of Microbiology, School of Veterinary Medicine and Animal Science, Kitasato University, Towada, Aomori 034, Japan
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Ohwada Y, Sakuma F, Ma L. Method to determine temperature distribution and intrinsic emissivity of a cavity. J Opt Soc Am A Opt Image Sci Vis 2000; 17:1341-1347. [PMID: 10883988 DOI: 10.1364/josaa.17.001341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
A method is presented to determine simultaneously the temperature distribution and the intrinsic emissivities of a cavity surface when radiance distributions along the cavity wall for two wavelengths are given. The intrinsic emissivity and reflection characteristics are assumed not to depend on position on the cavity wall. The intrinsic emissivity and reflection characteristics giving the smallest difference between calculated temperature distributions for the two wavelengths are found. The values found and thus the temperature distributions are verified to be close to the true ones. The method is examined on a cylindrocone by a simulation and applied to radiance temperature distributions measured on a commercially available double cone.
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Affiliation(s)
- Y Ohwada
- National Research Laboratory of Metrology, Tsukuba, Ibaraki, Japan
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Sakuraba H, Itoh K, Shimmoto M, Utsumi K, Kase R, Hashimoto Y, Ozawa T, Ohwada Y, Imataka G, Eguchi M, Furukawa T, Schepers U, Sandhoff K. GM2 gangliosidosis AB variant: clinical and biochemical studies of a Japanese patient. Neurology 1999; 52:372-7. [PMID: 9932959 DOI: 10.1212/wnl.52.2.372] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the clinical features and biochemical basis of the first Japanese patient with the GM2 gangliosidosis AB variant. METHODS The clinical manifestations and laboratory findings in the patient were investigated. Cultured fibroblasts from the patient were analyzed by means of immunofluorescence staining with an anti-GM2 ganglioside monoclonal antibody and thin-layer chromatography and immunostaining. GM1 ganglioside catabolism in cultured cells was analyzed by pulse labeling, and the amount of GM2 activator in cells was determined by Western blot analysis. Gene analysis was performed according to standard protocols. RESULTS The patient showed progressive neurologic manifestations of quite early onset. Muscular weakness and hypotonia became evident by 1 month of age, and the patient then developed a startle reaction, severe psychomotor retardation, and myoclonic seizures. Immunocytochemical analysis clearly revealed the accumulation of GM2 ganglioside in cultured fibroblasts from the patient, and thin-layer chromatography confirmed it. Western blot and metabolic studies showed a complete deficiency of GM2 activator. Gene analysis did not reveal any mutations in the protein coding region of the GM2 activator gene. CONCLUSION The clinical features and biochemical basis of this Japanese patient with GM2 gangliosidosis AB variant were determined. Immunocytochemical analysis using cultured fibroblasts as samples is available for the diagnosis of this disease.
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Affiliation(s)
- H Sakuraba
- Department of Clinical Genetics, The Tokyo Metropolitan Institute of Medical Science, Japan
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Abstract
An 11-year-old girl developed sudden visual loss in her left eye, preceding subacute myelitis by 9 months. Multifocal lesions in the central nervous system were demonstrated by magnetic resonance imaging. Although unilateral blindness is unusual, the clinical findings predominantly involving the optic nerve and spinal cord were consistent with the diagnosis of neuromyelitis optica (NMO). This case provides additional evidence to support the view that NMO is a variant of multiple sclerosis.
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Affiliation(s)
- Y Igarashi
- Department of Ophthalmology, Sapporo Medical College, Japan
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Eguchi M, Kikushima H, Kosaku A, Iwama Y, Sugiyama S, Sakakibara H, Ohwada Y, Sugita K, Furukawa T. Ultrastructural localization of DNA in leukemic cells using osmium ammine B. Exp Mol Pathol 1993; 59:186-96. [PMID: 8137901 DOI: 10.1006/exmp.1993.1038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
In order to determine whether there were any differences in distribution of nuclear DNA between acute lymphocytic leukemia (ALL) and acute myelogenous leukemia (AML), the localization of DNA in blasts from the bone marrow or buffy coat of 30 patients with ALL and 30 patients with AML was examined ultrastructurally by staining with osmium ammine B. By the ultrastructural cytochemistry, DNA in ALL cells was clumped in the nuclei, while in AML cells, it was dispersed. DNA had accumulated around the nucleoli of some blasts, and flecks of DNA were observed in nucleoli of a majority of blasts. The perinucleolar and intranucleolar DNA distribution could be classified into four types. The types with abundant perinucleolar DNA were frequently observed in ALL blasts, while the majority of AML blasts showed scant perinucleolar DNA. The types with intranucleolar flecks of DNA were more prominent in leukemic cells than in normal immature leukocytes. In conclusion, the pattern of distribution of DNA in the nuclei of leukemic cells differs between ALL and AML.
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Affiliation(s)
- M Eguchi
- Second Department of Pediatrics, Dokkyo University School of Medicine, Tochigi-ken, Japan
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Ohwada Y, Eguchi M. Ultrastructural investigation of DNA in megakaryoblastic leukemia by using osmium-ammine-B: comparison with several types of leukemia. Med Oncol Tumor Pharmacother 1993; 10:117-24. [PMID: 8264256 DOI: 10.1007/bf02987778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Using DNA staining with highly stable osmium-ammine-B, the blasts of AMKL were observed under an electron microscope, in comparison with AML, ALL, CML-MK crisis and TMD. The DNA within the nucleus of the megakaryoblasts was observed as a high electron-density substance and tended to be uniformly dispersed within the nucleus. DNA, associated with nucleoli, could be roughly divided in four types based on the presence or absence of peri-nucleolar clumps and intra-nucleolar clumps. In cases of AMKL, we often observed a type that did not have peri-nucleolar DNA clumps but did have DNA flecks within the nucleoli. By analytical evaluation there were no differences among cells from several subtypes of megakaryocytic leukemia, such as AMKL in children with Down's syndrome, AMKL in children without Down's syndrome, AMKL in adults, and CML-MK crisis. The DNA distribution of TMD blasts, which were self-limited and not malignant, resembled that of AMKL blasts.
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MESH Headings
- Adolescent
- Adult
- Aged
- Child
- Child, Preschool
- Coloring Agents
- DNA, Neoplasm/ultrastructure
- Female
- Humans
- Infant
- Leukemia, Megakaryoblastic, Acute/genetics
- Leukemia, Megakaryoblastic, Acute/pathology
- Leukemia, Myeloid/genetics
- Leukemia, Myeloid/pathology
- Leukemia, Myeloid, Acute/genetics
- Leukemia, Myeloid, Acute/pathology
- Male
- Middle Aged
- Models, Theoretical
- Osmium Compounds
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/genetics
- Precursor Cell Lymphoblastic Leukemia-Lymphoma/pathology
- Quaternary Ammonium Compounds
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Affiliation(s)
- Y Ohwada
- Second Department of Pediatrics, Dokkyo University School of Medicine, Tochigi-ken, Japan
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Ohwada Y, Sakate H. Effective emissivity of an isothermal cylinder having a longitudinal strip opening. Appl Opt 1987; 26:3186-3187. [PMID: 20490036 DOI: 10.1364/ao.26.003186] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Abstract
Local effective spectral and total emissivities of nonisothermal cavities having diffuse surfaces are evaluated. The effective emissivity of the cavity wall around the half-depth of a cylinder is little affected by a linear decrease or increase of temperature along the cavity axis because of a compensation effect. The nonisothermal effect on the integrated cavity emissivity changes considerably with cavity geometry for a given temperature distribution.
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Affiliation(s)
- Y Ohwada
- National Research Laboratory of Metrology, 1-1-4, Umezono, Sakura-mura, Niihari-gun, Ibaraki 305, Japan
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Abstract
Effective emissivities of conical cavities having diffuse surfaces are computed by an iterative procedure and effective reflectances from series that involve powers of the reflectance of the wall material. If reflections after the nth are neglected in the computation, an upper bound for the truncation error in the effective reflectance is 1.2p(n+1)I(n+1)/(l - p) for cone half-angles between 3.75 and 60 degrees and for 5 </= n, where p is the surface reflectance and I(n+1) is the (n + l)th-order coefficient of the effective reflectance.
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Koyama H, Hodatsu T, Sasaki T, Ohwada Y, Saito Y, Saito H. Continuous cell culture from chick embryos inoculated with rev strain t. Avian Pathol 1981; 10:151-62. [DOI: 10.1080/03079458108418469] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Kimura M, Nishiyama Y, Koyama H, Ohwada Y, Saito Y. Histopathological observation of chicken inoculated with C-type virus isolated from the material infected with turkey herpesvirus. Kitasato Arch Exp Med 1976; 49:107-12. [PMID: 197292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Koyama H, Suzuki Y, Ohwada Y, Saito Y. Relationships between reticuloendothelial virus of chickens and an agent isolated from a duck embryo cell culture of turkey herpesvirus. Kitasato Arch Exp Med 1976; 49:93-105. [PMID: 197293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Koyama H, Suzuki Y, Ohwada Y, Saito Y. Reticuloendotheliosis Group Virus Pathogenic to Chicken Isolated from Material Infected with Turkey Herpesvirus (HVT). Avian Dis 1976. [DOI: 10.2307/1589286] [Citation(s) in RCA: 41] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Koyama H, Suzuki Y, Ohwada Y, Saito Y. Reticuloendotheliosis group virus pathogenic to chicken isolated from material infected with turkey herpesvirus (HVT). Avian Dis 1976; 20:429-34. [PMID: 180962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Koyama H, Nagashima T, Ohwada Y, Saito Y. Cause of "nakanuke" in chickens. II. Isolation of C-type virus from material infected with turkey herpesvirus. Kitasato Arch Exp Med 1975; 48:93-105. [PMID: 183039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Koyama H, Inoue K, Nagashima T, Ohwada Y, Saito Y. Cause of "nakanuke" in chickens. I. Occurrence of "nakanuke" in chicken inoculated with the cells showed coexistence or C-type virus and turkey herpesvirus. Kitasato Arch Exp Med 1975; 48:83-91. [PMID: 183038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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