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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

Boehringer Ingelheim and Eli Lilly.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

Abstract PD4-08: Relationship between FDG-uptake and expression level of PD-L1 in primary ER positive/HER2 negative breast cancer

Background: 18F-Fluorodeoxyglucose-positron emission tomography (FDG-PET) is used to evaluate the glucose metabolic rates of cancers. Several studies have reported that high FDG uptake is predictive of poor prognosis and aggressive features in patients with breast cancer (BC). FDG-uptake is influenced by many factors including inflammation. In this study, we investigated the relationship between FDG uptake and immunological factors, including degrees of stromal tumor-infiltrating lymphocytes (TILs), CD8 and programmed cell death ligand 1 (PD-L1) in ER positive/HER2 negative (ER+/HER2-) BC. No published study, to our knowledge, has assessed the association between FDG uptake and PD-L1 in BC cases, even though both represent prognosis. Methods: Invasive carcinoma tissues of 79 ER+/HER2- BC patients who underwent surgery without preoperative therapy were examined. PD-L1, CD8 and TILs expression were evaluated by immunohistochemically (IHC) method. The evaluation of PET was determined by standardized uptake value max (SUVmax). Multivariate linear regression analysis, including expression of PD-L1, CD8 and TILs, was performed to identify independent variable correlation with SUVmax. Results: Among the 79 ER+/HER2- BC (T1-4, N0-2, M0) patients, the analysis revealed that PD-L1 (P=0.005), lymphovascular invasion (P=0.011), large tumor size (p=0.001), lymph node meatstasis (P=0.010), and high nuclear grade (P=0.011) and premenopasal status (P=0.014) were significantly associated with high SUVmax in the primary tumor. To define predictive value for the expression of PD-L1, SUVmax cut offwas determined using receiver operating characteristic (ROC) analysis; low (&lt;3.0) and high (≥3.0). Among the 30 cases with high SUVmax, 10 cases (33.3%) had PD-L1 positive expression in the primary tumor, while only 2 (4.1%) of the 49 cases with low SUVmax had PD-L1 positive expression in the primary tumor. Conclusions: The present study demonstrated that the finding of preoperative FDG uptake is associated with the expression of PD-L1 in ER+/HER2- BC. In light of our results, FDG uptake may be predictive of the expression of PD-L1 and may be reflective of immunological features as well as prognostic features among patients with ER+/HER2- BC.

Citation Format: Hirakata T, Fijii T, Kaira K, Kurozumi S, Katayama A, Yajima R, Obayashi S, NaKazawa Y, Tokuda S, Yanai K, Shirabe K. Relationship between FDG-uptake and expression level of PD-L1 in primary ER positive/HER2 negative breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr PD4-08.

Surgical Techniques and Procedures for Kidney Transplant Recipients With Severe Atherosclerosis

OBJECTIVES

Atherosclerosis is becoming a more common problem for dialysis patients. Therefore, transplant surgeons are faced with the need to develop surgical techniques and procedures for severe atherosclerosis. This study aimed to clarify the clinical features, the usefulness of examinations, and operative procedures for kidney transplant recipients with the complication of severe atherosclerosis.

MATERIALS AND METHODS

Among 220 kidney transplant candidates, 13 patients (severe atherosclerosis group) were predicted complications due to arterial calcification in the bilateral iliac arterial system using a computed tomographic scan. They were compared with the remaining 207 patients (mild atherosclerosis group) based on patient characteristics. The severe atherosclerosis group was evaluated by additional examination, anastomosis procedure of the graft artery, and patient outcome.

RESULTS

The severe atherosclerosis group had significantly higher rates of mean recipient age, glycosylated hemoglobin A1c, past smoking, and administration of antithrombotics. Past vascular surgery related to atherosclerosis in the aortoiliac region had been performed in 8 patients from the severe atherosclerosis group. A three-dimensional computed tomography angiography and an intraoperative periarterial echography were useful to determine the kidney transplant site. A balloon catheter effectively blocked blood flow. A polytetrafluoroethylene vascular graft was used for bypass between the graft artery and abdominal aorta. All kidney grafts of the severe atherosclerosis group were functioning well.

CONCLUSIONS

Kidney transplant for patients with severe atherosclerosis can be achieved successfully by additional examinations and vascular surgical techniques.

De Novo Anti-HLA DSA Characteristics and Subclinical Antibody-Mediated Kidney Allograft Injury

BACKGROUND

It is unclear whether all donor-specific antibodies (DSA) can cause chronic antibody-mediated rejection (AMR). Subclinical stage before manifestation of renal dysfunction may be a critical period for reversing AMR. The aim of our study was to identify factors related to the development of subclinical AMR and to clarify the characteristics of de novo DSA.

METHODS

Eight hundred ninety-nine renal transplants were screened for HLA antibody. De novo DSA were detected in 95 patients. Forty-three patients without renal dysfunction who underwent renal biopsies were enrolled in this study. Eighteen patients (41.9%) were diagnosed with biopsy-proven subclinical AMR and treated with plasmapheresis and rituximab-based therapy, whereas 25 showed no findings of AMR.

RESULTS

Significant subclinical AMR-related factors were younger recipients, history of acute T cell-mediated rejection and DSA class II, especially DR-associated DSA. Mean fluorescence intensity (MFI) values of DR-DSA were significantly higher, whereas DQ-DSA was not different between subclinical AMR and no AMR. The ΔMFI (>50%), DSA-MFI values greater than 3000, and C1q binding DSA were also significant subclinical AMR-related factors (P < 0.05). Among 18 patients treated for subclinical AMR, 8 patients (44.4%) obtained over 50% reduction of DSA-MFI and/or improvement or no deterioration of pathological findings. In contrast, 25 patients without subclinical AMR did not show renal dysfunction clinically. Moreover, all of the 8 patients with rebiopsy after 2 years continued to demonstrate no AMR.

CONCLUSIONS

About 40% of patients with de novo DSA demonstrated biopsy-proven subclinical AMR, leading to progressive graft injury. To validate the intervention and treatment for de novo DSA-positive patients without renal dysfunction, further study is necessary.

Occlusal Force and Condylar Motion in Patients with Anterior Open Bite

Patients with open bite often show a weak occlusal force and temporomandibular disorders (TMDs). If these are the main cause of open bite, it may be hypothesized that both pre-pubertal and adult open-bite patients would show a weak occlusal force and abnormal condylar motion. The purpose of this study was to test this hypothesis. Test group subjects consisted of 13 consecutive pre-pubertal and 13 adult patients with anterior open bite. They were compared with age-matched normal subjects. The adult open-bite group showed a weaker occlusal force and a shorter range of condylar motion compared with the control subjects. In the pre-pubertal subjects, however, there were no significant differences in the occlusal force and range of condylar motion between the open-bite and control groups. Therefore, these results suggest that a weak occlusal force or TMDs may not be the main cause of open bite.

MiR-142-5p and miR-486-5p as biomarkers for early detection of chronic antibody-mediated rejection in kidney transplantation

De novo donor-specific HLA antibody (DSA) would not necessarily contribute to chronic antibody-mediated rejection (CAMR) in kidney transplantation. Here, we investigated whether PBMC miRNAs could be predictable biomarkers for CAMR. Microarray profiling of 435 mature miRNAs in pooled samples was conducted. Individual analysis revealed that miR-142-5p was significantly (p < 0.01) underexpressed in patients with DSA. After DSA production, miR-486-5p and its target PTEN/foxO3 mRNA were significantly overexpressed (p < 0.01) and underexpressed (p < 0.01), respectively, in patients with biopsy-proven CAMR, compared with non-CAMR. Our studies suggest that miRNA expression patterns may serve as noninvasive diagnostic biomarkers to evaluate immune response and kidney allograft status.

Association of Dialysis Duration with Outcomes after Transplantation in a Japanese Cohort

BACKGROUND AND OBJECTIVES

Evidence regarding the differences in clinical outcomes after preemptive kidney transplantation (PKT) and non-PKT in Japan is lacking.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We conducted a retrospective cohort study at a single center in Japan. Consecutive patients ages >18 years old who had received a kidney transplant from a living donor between November of 2001 and December of 2013 at our institution (n=786) were enrolled. The primary study outcome was the occurrence of clinical events before the end of 2014. Clinical events were defined as any of the following: death with functioning graft (DWFG), graft loss, or post-transplant cardiovascular disease (CVD).

RESULTS

The median follow-up period was 61.0 (35.3-94.0) months. PKT was performed in 239 patients (30.4%). Clinical events occurred in 78 (9.9%). In the Cox proportional hazard model for univariate analysis, factors found to be associated with higher risk of clinical events included older age, men, ABO incompatibility, longer dialysis duration, diabetes, pretransplant CVD, and large ventricular mass index. PKT was associated with lower risk. Clinical event rate in patients who received a PKT was 3.3% compared with 10.8%, 11.1%, 10.4%, 10.2%, 16.7%, and 16.2% among patients who were on dialysis for <1, 1 to <2, 2 to <3, 3 to <4, 4 to <5, and ≥5 years before transplant, respectively (P=0.002). The multivariate analysis showed that ABO incompatibility (hazard ratio [HR], 2.98; 95% confidence interval [95% CI], 1.89 to 4.71), duration of dialysis per year (HR, 1.07; 95% CI, 1.03 to 1.11), and diabetes (HR, 3.54; 95% CI, 2.05 to 6.12) were only three independent risk factors for the incidence of clinical events.

CONCLUSIONS

Even in Japan, where the long-term outcomes of patients on hemodialysis are excellent, PKT could be beneficial to reduce DWFG, graft loss, and post-transplant CVD.

Application of three-dimensional digital models for the morphometric analysis of predentition plasters: accuracy and precision

AIM

This study aimed to test the accuracy and precision of measurements of three-dimensional (3D) digital models from the pre-dentition period using a noncontact 3D measurement system (3D scanner) versus the gold standard method of direct measurements using a digital caliper on plaster models.

MATERIALS AND METHODS

Ten pairs of plaster models were obtained from children during the predentition period. Linear measurements were performed using both methods. Three operators were trained in the use of both methods for this study. Measurements were performed with a minimum 2-week interval between measurements in a randomly chosen order.

RESULTS

The mean difference between the measured values using the two methods was <0.2 mm for each measurement. There was no linearity in the measurements using pre-dentition digital models. An ANOVA Gage R&R analysis revealed that there was no significant operator difference (P < 0.307). The rate of variation of the 3D scanner over the total variation was 2.8%. The ICC was 0.982 (P< 0.001), suggesting excellent interoperator agreement.

CONCLUSION

The results suggest that measurements of digital 3D pre-dentition models are highly accurate and precise, and also comparable to measurements using the gold standard method.

Encephalitis caused by human herpesvirus-6B in pancreas-after-kidney transplantation

Human herpesvirus-6 (HHV-6) is a common pathogen among children, classically presenting with fever and rash that resolves without specific therapy. HHV-6 can be reactivated in the immunosuppressed patient. After bone marrow and solid organ transplantation, HHV-6 has been linked to various clinical syndromes, including undifferentiated febrile illness, encephalitis, myelitis, hepatitis, pneumonitis, and bone marrow suppression. However, HHV-6 encephalitis after pancreatic transplant has rarely been reported. Early diagnosis and treatment of HHV-6 encephalitis may be important for affected patients. We report the case of a 53-year-old pancreas-after-kidney transplant recipient who initially presented with high fever and confusion 3 weeks after operation. We managed to save the patient's life and preserve the pancreas graft function. We also review previously reported cases of HHV-6B encephalitis in solid organ transplant recipients.

Comparative analyses of paediatric dental measurements using plaster and three-dimensional digital models

AIM

Recent advances in three-dimensional imaging have led to an increased interest in the application of computer-models in paediatric dentistry. However, in evidence-based paediatric dentistry the accuracy of new methods must be validated before they are introduced to clinical practice. We aimed to compare the accuracy of measurements of digital models obtained using a non-contact 3D measuring system, with direct measurements made on plaster models (gold standard) from children.

MATERIALS AND METHODS

Twelve pairs of plaster models were obtained from children with deciduous dentition; tooth size, arch width, and arch length were examined. The same parts on each cast were measured twice with at least a 2-week interval between measurements with each method by four examiners. Linear mixed-effects model analyses were performed for comparison of values from the 2 different measurement methods.

RESULTS

The average difference between the 2 methods in measured values, derived from the final model, was <0.2 mm. Random effect of examiners was always the smallest component of variance, and frequently negligible.

STATISTICS

Intraclass correlation coefficients were typically >90%.

CONCLUSION

These results suggest that primary dentition analysis of digital models has a high accuracy level, comparable to that of direct measurement of plaster models by digital calipers.

Beneficial effects of preemptive kidney transplantation on calcium and phosphorus disorders in early post-transplant recipients

BACKGROUND

Recently, preemptive kidney transplantation (PKT) has increased in Japan; however, the effects of PKT on calcium (Ca) and phosphorus (Pi) metabolism are poorly understood.

METHODS

Thirty-two consecutive patients were enrolled in this study at Nagoya Daini Red Cross Hospital. Fifteen patients were in the PKT group and 17 patients were in the non-PKT group. Parameters of Ca and Pi metabolism, including fibroblast growth factor (FGF) 23 and intact parathyroid hormone, were measured before transplantation and 1, 3, and 24 weeks after transplantation.

RESULTS

FGF 23 decreased dramatically in both groups after transplantation; however, FGF 23 before transplantation and at 1 and 3 weeks after transplantation was significantly lower in the PKT group than in the non-PKT group (p < 0.05). Although iPTH levels were higher in the PKT group than in the non-PKT group before transplantation, these levels were lower in the PKT group at 24 weeks after transplantation (p < 0.05). Corrected Ca was lower at 24 weeks in the PKT group (p < 0.05), whereas Pi was lower in the non-PKT group at 1 and 3 weeks (p < 0.05), but not significantly different at 24 weeks. Multivariate linear regression analysis revealed that FGF 23 before transplantation was the strongest predictor of Ca and Pi disorders in early post-transplant recipients.

CONCLUSIONS

This study suggests that PKT has beneficial effects on Ca and Pi metabolism and pre-transplant FGF 23 levels are a good marker of post-transplant Ca and Pi metabolism disorders.

Strongly spin-orbit coupled two-dimensional electron gas emerging near the surface of polar semiconductors

We investigate the two-dimensional highly spin-polarized electron accumulation layers commonly appearing near the surface of n-type polar semiconductors BiTeX (X=I, Br, and Cl) by angular-resolved photoemission spectroscopy. Because of the polarity and the strong spin-orbit interaction built in the bulk atomic configurations, the quantized conduction-band subbands show giant Rashba-type spin splitting. The characteristic 2D confinement effect is clearly observed also in the valence bands down to the binding energy of 4 eV. The X-dependent Rashba spin-orbit coupling is directly estimated from the observed spin-split subbands, which roughly scales with the inverse of the band-gap size in BiTeX.

Potent immunosuppression for ABO-incompatible renal transplantation may not be a risk factor for malignancy

ABO-incompatible (ABOi) renal transplantation has been increasing, but malignant tumor is a troubling complication of kidney transplantation due to potent immunosuppression. Few previous studies, however, have demonstrated that potent immunosuppression for ABOi living-donor renal transplantation (LDRT) is a risk factor for malignancy. In the present research, data on 252 LDRT patients ftom 2003 to 2008 were retrospectively analyzed to clarify whether ABOi LDRT was associated with malignancy. A potent immunosuppressive regimen for ABOiLDRT consisted of splenectomy, cyclophosphamide, and double-filtration plasmapheresis to minimize the risk of antibody-mediated rejection, in addition to conventional immunosuppresssants including calcineurin inhibitor, prednisolone, and anti-CD25 monoclonal antibody. A total of 11 incidences of malignancy were observed during a median follow-up of 48 months. The incidence rates in ABO-compatible (ABOc; n = 189) and ABOi (n = 63) LDRT groups were 4.2 % (8/189) and 4.8 % (3/63), respectively. Kaplan-Meier survival analysis showed no statistical difference in event-free survival for malignancy between ABOc and ABOiLDRT groups (log-rank P = .73). Multivariable Cox regression analyses identified no associations of malignancy with ABOi LDRT or any immunosuppressant use. In conclusion, our investigation suggested that potent immunosuppression with splenectomy and cyclophosphamide for ABOi LDRT may not be a risk factor for malignancy.

Tumour suppressive microRNA-874 regulates novel cancer networks in maxillary sinus squamous cell carcinoma

BACKGROUND

On the basis of the microRNA (miRNA) expression signature of maxillary sinus squamous cell carcinoma (MSSCC), we found that miR-874 was significantly reduced in cancer cells. We focused on the functional significance of miR-874 in cancer cells and identification of miR-874-regulated novel cancer networks in MSSCC.

METHODS

We used PCR-based methods to investigate the downregulated miRNAs in clinical specimens of MSSCC. Our signature analyses identified 23 miRNAs that were significantly reduced in cancer cells, such as miR-874, miR-133a, miR-375, miR-204, and miR-1. We focused on miR-874 as the most downregulated novel miRNA in our analysis.

RESULTS

We found potential tumour suppressive functions such as inhibition of cancer cell proliferation and invasion. A molecular target search of miR-874 revealed that PPP1CA was directly regulated by miR-874. Overexpression of PPP1CA was observed in MSSCC clinical specimens. Silencing of the PPP1CA gene significantly inhibited cancer cell proliferation and invasion.

CONCLUSION

The downregulation of miR-874 was a frequent event in MSSCC, which suggests that miR-874 functions as a tumour suppressive miRNA, directly regulating PPP1CA that has a potential role of an oncogene. The identification of novel miR-874-regulated cancer pathways could provide new insights into potential molecular mechanisms of MSSCC oncogenesis.

[Delayed traumatic diaphragmatic hernia with strangulated stomach; report of a case]

A 30-year-old male who had suffered from the left hemopneumothorax due to the traffic accident 13 years before was admitted to our hospital suffering from abdominal pain. Computed tomography revealed the stomach was incarcerated through the left central tendon of the left diaphragm. He was diagnosed as delayed traumatic diaphragmatic hernia and emergency operation was performed via thoracic approach. Stomach and omentum, densely adhered to the lung and the chest wall, were strangulated in the left pleural cavity and hardly reducible. Stomach and omentum were reduced through the enlarged hernia and necrotized stomach was totally resected under the subsequent laparotomy. Hernia was closed directly via thoracic approach. A prompt diagnosis is necessary for a case highly suspicious of delayed traumatic diaphragmatic hernias presenting with strangulation.

Clinical features and hyperplastic patterns of parathyroid glands in hemodialysis patients with advanced secondary hyperparathyroidism refractory to maxacalcitol treatment and required parathyroidectomy

We have previously suggested that when parathyroid glands progress to nodular hyperplasia, secondary hyperparathyroidism (2HPT) may be refractory to medical treatments, including treatment with Maxacalcitol (OCT). In the present study we evaluated the clinical features and hyperplastic patterns of parathyroid glands in patients who underwent parathyroidectomy (PTx) after being withdrawn from OCT. One hundred and eighty-seven advanced 2HPT patients who had been withdrawn from OCT and required PTx were enrolled. At the start of OCT treatment, the patients had a mean age of 55.3 years and had been receiving hemodialysis (HD) for a mean period of 149 months. At the start of OCT treatment and at PTx, the mean intact PTH (i-PTH) levels were 772.8 +/- 446.0 and 855.5 +/- 420.5 pg/mL, respectively. The main reasons for withdrawal of OCT treatment were persistently high PTH (n = 148), hypercalcemia (n = 79), hyperphosphatemia (n = 65), and progressive symptoms (n = 60). We classified the parathyroid glands by hyperplastic pattern into four categories: diffuse hyperplastic gland (D), early nodularity in diffuse hyperplastic gland (EN), nodular hyperplastic gland (N), and single nodular gland (SN). The mean total excised gland weight was 2592.6 mg. Out of a total of 706 glands, 118 were classified as D, 66 as EN, 436 as N, and 86 as SN. All patients had at least one nodular hyperplastic gland or single nodular gland. The mean number of nodular hyperplastic glands and/or single nodular glands was 2.9. All hemodialysis patients with advanced OCT-refractory 2HPT who underwent PTx had at least one nodular hyperplastic gland or single nodular gland.

Hair cell regeneration: the identities of progenitor cells, potential triggers and instructive cues

Hair cells are produced and accumulate in the ears of fish and amphibians as they grow during postembryonic life; hair cell regeneration occurs in lateral line organs in those groups and in the cochlea in birds. Continuous time-lapse microscopy has directly demonstrated that supporting cells divide to give rise to hair cells during regeneration in lateral line neuromasts. Supporting cells also appear to give rise to hair cells during regeneration in the avian ear, but additional cell types have been proposed as hair cell progenitors. Alternative interpretations of current evidence are discussed in relation to the possibility that supporting cells may be the common progenitor in all cases of hair cell regeneration. The regenerative proliferation of hair cells in birds occurs in populations of cells that are mitotically quiescent in undamaged ears. Evidence suggests that the extrusion of damaged hair cells and the breaking of intercellular junctional adhesions may be a trigger for regenerative proliferation. The potential triggering influence of phagocytes is also discussed. The differentiation of replacement cells during regeneration in the cochlea may be regulated by surface interactions between cells. A model that could account for the reconstitution of the mosaic pattern of hair cells and supporting cells is proposed.

QuiCk-IntraOperative Bio-Intact PTH assay at parathyroidectomy for secondary hyperparathyroidism

BACKGROUND

In uremic patients, metabolism of 1-84 parathyroid hormone (PTH) and fragments are delayed, and in these patients, the usefulness of intraoperative PTH assay may be problematic. We evaluated the usefulness of the QuiCk-IntraOperative Bio-Intact PTH (QPTH) assay for uremic patients with secondary hyperparathyroidism who required total parathyroidectomy (PTx) with forearm autograft. The purpose of our study was to recognize whether QPTH in uremic patients was useful to determine during operation whether complete PTx had been achieved.

METHODS

Forty-four patients who underwent initial PTx were enrolled in this study. Blood samples were drawn just after induction of general anesthesia (basal samples), immediately after removal of the last gland, and at 5, 10, 15, and 30 minutes, and at the first morning after PTx. The assay was performed immediately after sample collection. Reductions of PTH levels were evaluated and expressed in percentage of basal levels.

RESULTS

The mean PTH levels in 41 patients, excluding 3 in whom the PTH level did not drop significantly (>60 pg/ml), measured by QPTH at anesthesia, 0, 5, 10, 15, and 30 minutes were 734.3, 104.7, 58.8, 37.4, 27.0, 16.3 pg/ml, corresponding to 100%, 17.1%, 9.3%, 5.8%, 4.1%, 2.4% of the preexcision values, respectively. If the cutoff value was defined as 10.8% at 10 minutes, the sensitivity was 100% and specificity 90%. When the QPTH level dropped to under 10.8% at 10 minutes, we could consider that all glands were removed.

CONCLUSIONS

QPTH in uremic patients is very useful to determine whether complete PTx is achieved during operation.