P6405Potential for drug-drug interaction between vonoprazan and prasugrel on antiplatelet effect assessed by VerifyNow P2Y12 assay in patients with coronary artery disease

Background

Vonoprazan is a potassium-competitive acid blocker increasingly used in Japan to prevent gastrointestinal bleeding in patients under dual antiplatelet therapy (DAPT) after coronary stents implantation. Since cytochrome P450 (CYP) 3A4 is involved in the primary metabolism of vonoprazan and prasugurel, there is a possibility that CYP-mediated drug-drug interaction between them can attenuate the antiplatelet function of prasugrel.

Purpose

The aim of this study was to investigate whether antiplatelet effect of prasugrel could be attenuated upon coadministration with vonoprazan compared to conventional proton pump inhibitors (PPIs).

Method

We evaluated 72 patients (57 males, 67±11 years) with coronary artery disease who were taking either vonoprazan (n=35) or PPIs (n=37) in combination with DAPT (aspirin and prasugrel) after drug-eluting stents implantation. PPIs included 21 esomeprazole, 8 lansoprazole, and 8 rabeprazole. Antiplatelet effects of prasugrel were assessed using VerifyNow P2Y12 assay. Primary measurements were P2Y12 reaction units (PRU) and P2Y12 percent inhibition. High on-treatment platelet reactivity (HPR) on prasugrel was defined as PRU >208. Administration period of vonoprazan or PPIs in combination with DAPT ≤7 days was defined as early administration period.

Results

Median administration period of vonoprazan or PPIs in combination with DAPT was 127 days. There were no significant differences in baseline clinical characteristics between patients with vonoprazan and PPIs. In the analysis for all subjects, patients with vonoprazan showed similar PRU (166±50 vs. 167±64, p=0.93) and percent inhibition (36±18 vs. 38±23, p=0.66) compared to those with PPIs. No significant differences were observed in the prevalence of HPR between patients with vonoprazan and PPIs (17 vs. 30%, p=0.27). In the analysis for patients in early administration period [vonoprazan (n=14) vs. PPIs (n=10)], there were no significant differences in PRU (166±47 vs. 186±82, p=0.45), percent inhibition (33±17 vs. 30±26, p=0.73), and prevalence of HPR (14 vs. 50%, p=0.085) between patients with vonoprazan and PPIs. In addition, the analysis for patients over early administration period [vonoprazan (n=21) vs. PPIs (n=27)] showed that PRU (166±55 vs. 160±57, p=0.73), percent inhibition (37±19 vs. 41±21, p=0.57), and prevalence of HPR (19 vs. 22%, p=1.00) were comparable between patients with vonoprazan and PPIs.

Conclusion

Compared to PPIs, vonoprazan did not exhibit significant inhibitory effects on the antiplatelet activity of prasugrel assessed by VerifyNow assay. These findings suggest that there are possibly no clinically harmful drug-drug interactions between vonoprazan and prasugrel.

P1549Serum soluble Klotho is associated with extent of coronary artery calcification in patients with stable angina pectoris undergoing percutaneous coronary intervention

Background

Klotho, which was originally identified as an aging suppressor, is a key regulator of bone and mineral metabolism. Transmembrane and soluble forms of Klotho protein have been identified. The transmembrane form serves as an obligate co-receptor for fibroblast growth factor 23 (FGF23). However, the physiological importance of soluble form of Klotho has not been determined.

Purpose

The present study aimed to test the hypothesis that circulating soluble Klotho levels can predict the presence or extent of coronary artery calcification (CAC) in patients with coronary artery disease.

Methods

We analyzed CAC of culprit lesions in patients with 75 stable angina pectoris who were not on dialysis and were scheduled for percutaneous coronary intervention (PCI) following intravascular ultrasound (IVUS). Arc and length of each calcium within the culprit lesion was measured by IVUS. The main outcome measure was the calcium index; a volumetric IVUS-derived measure which was calculated as total calcium length/lesion length × maximal calcium arc/360°. Low calcium index was defined as calcium index <0.042 of the first quartile value. Serum Klotho and FGF23 were measured before PCI. Patients were divided into two groups according to median serum Klotho value: low-Klotho (n=37, ≤460 pg/mL) and high-Klotho group (n=38, >460 pg/mL).

Results

Compared with patients with low-Klotho, those with high-Klotho had higher estimated glomerular filtration rate (eGFR) (69±20 vs. 55±16 mL/min/1.73 m2, p<0.001), lower FGF23 levels (51±24 vs. 67±41 pg/mL, p=0.010). Patients with high-Klotho had significantly lower calcium index than those with low-Klotho (0.17±0.21 vs. 0.24±0.23, p=0.043). Serum Klotho levels correlated significantly and inversely with calcium index (r=−0.31, p=0.006). The correlation between Klotho and calcium index was pronounced at analysis in patients with eGFR <60 mL/min/1.73 m2 (r=−0.52, p<0.001). Logistic regression analysis showed that high-Klotho is a sole significant independent factor associated with low calcium index (odds ratio 7.17, p=0.004). Presence of high-Klotho had high sensitivity and negative predictive value for identifying low calcium index (83% and 92%, respectively).

Conclusions

Serum Klotho values were independently and inversely associated with the degree of CAC assessed by IVUS. These findings have important clinical implications for serum Klotho as a biomarker that reflects the extent of CAC.

Practical determination of LODP (limit of detection for microarray platform) for the evaluation of microarray platforms

The performance indicator called limit of detection for microarray platform (LODP) was defined in ISO 16578:2013. The methods to determine practical LODP were explored. In general, + 3 SD of the background is used as the signal strength of limit of detection and criteria for dividing positive and negative results. Since the negative signal had been defined differently for each microarray platform, signals obtained from Non-Probe Spots (NPS) installed on the microarrays were defined as the "background" of microarrays. LODP was determined as the lowest concentration of which the average signal exceeded Avg. + 3 SD of the background (NPS) and the signal was significantly different from those of the lower and higher adjacent concentration points measured with a diluted series of reference materials. For reliable qualitative analysis, the positive results can be defined as signals higher than those corresponding to LODP and negative results as lower signals, without determining limit of detection for all target probes. The use of LODP also enables comparisons of platform performances without checking sequence dependencies, and assists to select reliable and fitting platforms for experimental purposes.

TDP-43 pathology in multiple system atrophy: colocalization of TDP-43 and α-synuclein in glial cytoplasmic inclusions

AIMS

This study aimed to assess clinicopathologic features of transactive response DNA-binding protein of 43 kDa (TDP-43) pathology and its risk factors in multiple system atrophy (MSA).

METHODS

Paraffin-embedded sections of the amygdala and basal forebrain from 186 autopsy-confirmed MSA cases were screened with immunohistochemistry for phospho-TDP-43. In cases having TDP-43 pathology, additional brain regions were assessed. Immunohistochemical and immunofluorescence double-staining and immunogold electron microscopy (IEM) were performed to evaluate colocalization of TDP-43 and α-synuclein. Genetic risk factors for TDP-43 pathology were also analysed.

RESULTS

Immunohistochemistry showed various morphologies of TDP-43 pathology in 13 cases (7%), such as subpial astrocytic inclusions, neuronal inclusions, dystrophic neurites, perivascular inclusions and glial cytoplasmic inclusions (GCIs). Multivariable logistic regression models revealed that only advanced age, but not concurrent Alzheimer's disease, argyrophilic grain disease or hippocampal sclerosis, was an independent risk factor for TDP-43 pathology in MSA (OR: 1.11, 95% CI: 1.04-1.19, P = 0.002). TDP-43 pathology was restricted to the amygdala in eight cases and extended to the hippocampus in two cases. The remaining three cases had widespread TDP-43 pathology. Immunohistochemical and immunofluorescence double-staining and IEM revealed colocalization of α-synuclein and TDP-43 in GCIs with granule-coated filaments. Pilot genetic studies failed to show associations between risk variants of TMEM106B or GRN and TDP-43 pathology.

CONCLUSIONS

TDP-43 pathology is rare in MSA and occurs mainly in the medial temporal lobe. Advanced age is a risk factor for TDP-43 pathology in MSA. Colocalization of TDP-43 and α-synuclein in GCIs suggests possible direct interaction between the two molecules.

Influence of exercise training with thigh compression on heat-loss responses

We investigated the effect of thigh compression, which accelerates activation of central command and muscle metabo- and mechanoreceptors, on the adaptation of sweating and cutaneous vascular responses during exercise heat acclimation. Nine non-heat-acclimated male subjects were acclimated to heat (32 °C and 50% RH) while cycling [50% of maximum oxygen uptake ( V ˙ O 2 m a x )] 60 min/day for 7 days (control group). The experimental group (n = 9) conducted the same training while the proximal thighs were compressed by a cuff at 60 mmHg. V ˙ O 2 m a x , acetylcholine-induced forearm sweating rate (iontophoresis), and mean sweating and cutaneous vascular responses on the forehead, chest, and forearm (SRmean and CVCmean ) during passive heating were evaluated before and after training. Training significantly increased V ˙ O 2 m a x while did not affect acetylcholine-induced sweating rates in either group. Training significantly decreased Tb thresholds for SRmean and CVCmean during passive heating without the alternations of sensitivities in both groups. Although SRmean during passive heating at a given ΔTb was not improved in either group, CVCmean was significantly (P < 0.05) attenuated after exercise training only in experimental group. Our results indicate that thigh cuff compression during exercise heat acclimation does not influence adaptation of the sweating response but attenuate cutaneous vasodilation.

Identification and characterization of novel multiple bacteriocins produced by Lactobacillus sakei D98

AIM

To characterize novel multiple bacteriocins produced by Lactobacillus sakei D98.

METHODS AND RESULTS

Lactobacillus sakei D98 isolated from Shubo (rice malt) produced at least three bacteriocins. Using three purification steps, three novel antimicrobial peptides termed sakacin D98a, sakacin D98b and sakacin D98c were purified from the culture supernatant. Amino acid and DNA sequencing analysis revealed that the sakacins D98a, D98b and D98c are novel class IIa-like or class IId bacteriocins. In particular, sakacin D98b has a variant pediocin-box sequence, YANGVXC (with Ala instead of Gly), and a different location for the disulfide bridge (Cys(11) and Cys(18)) from that found in other class IIa bacteriocins.

CONCLUSIONS

Three novel bacteriocins were identified from Lactobacillus sakei D98. Their antimicrobial spectra and intensities indicate that these sakacins would have different modes of action. In addition, sakacin D98b showed low inhibitory activity against Listeria, probably due to the differences in amino acids and position of the disulfide bridge compared with the other class IIa bacteriocins.

SIGNIFICANCE AND IMPACT OF STUDY

Sakacins D98a and D98c are novel bacteriocins belonging to class IId bacteriocins. On the other hand, sakacin D98b, a class IIa-like bacteriocin, has a unique internal structure and activity spectrum.

Increasing temperature speeds intracellular PO2 kinetics during contractions in single Xenopus skeletal muscle fibers

Precise determination of the effect of muscle temperature (T(m)) on mitochondrial oxygen consumption kinetics has proven difficult in humans, in part due to the complexities in controlling for T(m)-related variations in blood flow, fiber recruitment, muscle metabolism, and contractile properties. To address this issue, intracellular Po(2) (P(i)(O(2))) was measured continuously by phosphorescence quenching following the onset of contractions in single Xenopus myofibers (n = 24) while controlling extracellular temperature. Fibers were subjected to two identical contraction bouts, in random order, at 15°C (cold, C) and 20°C (normal, N; n = 12), or at N and 25°C (hot, H; n = 12). Contractile properties were determined for every contraction. The time delay of the P(i)(O(2)) response was significantly greater in C (59 ± 35 s) compared with N (35 ± 26 s, P = 0.01) and H (27 ± 14 s, P = 0.01). The time constant for the decline in P(i)(O(2)) was significantly greater in C (89 ± 34 s) compared with N (52 ± 15 s; P < 0.01) and H (37 ± 10 s; P < 0.01). There was a linear relationship between the rate constant for P(i)(O(2)) kinetics and T(m) (r = 0.322, P = 0.03). Estimated ATP turnover was significantly greater in H than in C (P < 0.01), but this increased energy requirement alone with increased T(m) could not account for the differences observed in P(i)(O(2)) kinetics among conditions. These results demonstrate that P(i)(O(2)) kinetics in single contracting myofibers are dependent on T(m), likely caused by temperature-induced differences in metabolic demand and by temperature-dependent processes underlying mitochondrial activation at the start of muscle contractions.

Minimally invasive removal of a recurrent lumbar herniated nucleus pulposus by the small incised microendoscopic discectomy interlaminar approach

In this report, we introduce two cases of recurrent herniated nucleus pulposus (HNP) at L5-S1 that were successfully removed using the small incised microendoscopic discectomy (sMED) technique, proposed by Dezawa and Sairyo in 2011. sMED was performed via the interlaminar approach with a percutaneous endoscope. The patients had previously underdone microendoscopic discectomy for HNP. For the recurrent HNP, the sMED interlaminar approach was selected because the HNP occurred at the level of L5-S1; the percutaneous endoscopic transforaminal approach was not possible for anatomical reasons. To perform sMED via the interlaminar approach, we employed new, specially made devices to enable us to use this technique. In conclusion, sMED is the most minimally invasive approach available for HNP, and its limitations have been gradually eliminated with the introduction specially made devices. In the near future, percutaneous endoscopic surgery could be the gold standard for minimally invasive disc surgery.

Analysis of H atoms in a negative ion source plasma with the non-equilibrium electron energy distribution function

In negative ion sources for the neutral beam injection, it is important to calculate H atom flux onto the plasma grid (PG) surface for the evaluation of H(-) production on the PG surface. We have developed a neutral (H(2) molecules and H atoms) transport code. In the present study, the neutral transport code is applied to the analysis of the H(2) and H transport in a NIFS-R&D ion source in order to calculate the flux onto the PG surface. Taking into account non-equilibrium feature of the electron energy distribution function (EEDF), i.e., the fast electron component, we have done the neutral transport simulation. The results suggest that the precise evaluation of the EEDF, especially in the energy range 15 eV < E < 30 eV is important for the dissociation rate of H(2) molecules by the electron impact collision and the resultant H atom flux on the PG.

Effect of non-uniform electron energy distribution function on plasma production in large arc driven negative ion source

Spatially non-uniform electron energy distribution function (EEDF) in an arc driven negative ion source (JAEA 10A negative ion source: 10 A NIS) is calculated numerically by a three-dimensional Monte Carlo kinetic model for electrons to understand spatial distribution of plasma production (such as atomic and ionic hydrogen (H(0)∕H(+)) production) in source chamber. The local EEDFs were directly calculated from electron orbits including electromagnetic effects and elastic∕inelastic collision forces. From the EEDF, spatial distributions of H(0)∕H(+) production rate were obtained. The results suggest that spatial non-uniformity of H(0)∕H(+) productions is enhanced by high energy component of EEDF.

Endoscopic removal of herniated nucleus pulposus migrated dorsally to the dural sac

A herniated nucleus pulposus (HNP) migrated dorsally to the dural sac is a rare condition. Here, we present a case, in which the HNP was removed with minimally invasive spinal endoscopy. A 54-year-old man presented complaining of left leg pain and paresis. Neurologic findings and an MRI suggested an epidural tumor or a dorsally migrated HNP compressing the S1 nerve root and dural sac. With a spinal endoscope, careful laminotomy of caudal L5 and cranial S1 was made. En bloc flavectomy exposed a mass covered with a thin capsule. The mass was identified as a dorsally migrated HNP. After complete HNP fragment removal, the dural sac and S1 nerve root were decompressed. Immediately postoperative, the leg pain subsided and motor function normalized, although the patient complained of numbness at the S1 dermatome area. In summary, a large HNP that had migrated dorsally to the dural sac was successfully removed endoscopically.

[Significance of preoperative ultrasound evaluation of the forearm arteries prior to coronary artery bypass grafting]

We report the significance of preoperative ultrasound evaluation of the forearm arteries in coronary artery bypass grafting (CABG). Ultrasound evaluation was performed in 288 arms with negative Allen's test between August 2004 and July 2007. The diameter, the level of atherosclerotic changes and calcifications, and systolic velocities were evaluated in radial artery (RA) and ulnar artery (UA). The diameter of RA was 2.6 +/- 0.5 mm, and in 30 arms it was smaller than 2 mm. There were 2 occlusions, 4 stenoses, and 20 arteriosclerotic changes in RA. There were 1 occlusion, 8 stenoses, and 4 arteriosclerotic changes in UA. Since there were some overlaps in small diameter and poor qualities of RA and UA, 55 arms (19%) were considered not to qualify as candidates for RA harvest. Pre-operative ultrasound evaluation of the forearm arteries allows safer radial artery harvest and should be performed even in patients with negative Allen' s test.

Nucleoside Oxidase, a Hydrogen Peroxide-Forming Oxidase, from Flavobacterium meningosepticum

A novel enzyme which catalyzes the oxidation of nucleosides to nucleoside-5(prm1)-carboxylic acids, forming hydrogen peroxide, was purified to homogeneity from Flavobacterium meningosepticum T-2799. The enzyme has a molecular weight of about 500,000, and four nonidentical subunits (molecular weights of 81,000, 69,000, 33,000, and 16,000) were detected on sodium dodecyl sulfate-polyacrylamide gel electrophoresis. On the basis of visible absorption spectra of the purified enzyme, the enzyme is concluded to be a hemoprotein. It also contains covalently bound flavin adenine dinucleotide. The various nucleosides, such as adenosine (K(infm) = 48 (mu)M), inosine (K(infm) = 66 (mu)M), guanosine (K(infm) = 21 (mu)M), thymidine (K(infm) = 50 (mu)M), uridine (K(infm) = 80 (mu)M), and cytidine (K(infm) = 50 (mu)M), were oxidized by the enzyme, but nucleotides, bases, and ribose were not.

[Minimally invasive technique for harvesting a saphenous vein via one small incision]

We report a minimally invasive technique for harvesting a saphenous vein graft (SVG) via 1 small skin incision. The expected advantages of this technique are better cosmetic results and fewer wound complications than the conventional open technique or the bridging technique. The SVG, 10-15 cm in length, can be harvested by about 3 cm-long single small skin incision. SaphLITE Retractor System (Genzyme Srugical Products, Cambridge), SLS Hematostatic Clip System (Vitalitec International, Plymouth), and curved scissors were necessary instruments for this technique. It is feasible for cases that require a shorter length of SVG.

Development of a voxel phantom of Japanese adult male in upright posture

A Japanese voxel phantom in upright posture, JM2, has been developed on the basis of CT images of a healthy Japanese adult male. Body characteristics of JM2 were compared with those of the supine voxel phantom, JM, previously developed using CT images of the same person. Differences were found in the shapes of the spine and lower abdomen and the locations of several organs such as kidneys, liver and stomach between the two phantoms. Specific absorbed fractions (SAFs) for 24 target and 11 sources organs were calculated for monoenergetic photon ranging from 0.01 to 4 MeV. It was found that the SAFs for the kidneys as source organ and the lower large intestine wall as target organ in JM2 were significantly higher than those in JM for all photon energies. The differences of the SAFs between the two phantoms were attributed to the differences in the organ distance and organ geometry depending on the posture.

Japanese adult male voxel phantom constructed on the basis of CT images

A Japanese adult male voxel (volume pixel) phantom (hereinafter referred to as the JM phantom) was constructed on the basis of CT images of a healthy Japanese adult male volunteer. Body characteristics of the JM phantom were compared with those of a voxelised MIRD5 type phantom and a Japanese adult male voxel phantom which was previously developed. The voxel size of the JM phantom is 0.98 x 0.98 x 1 mm(3). The shapes of the organs of the JM phantom, even for small or complicated organs, such as thyroid and stomach, are more realistically reproduced as compared with the previous Japanese voxel phantom (voxel size: 0.98 x 0.98 x 10 mm(3)). Photon self-absorbed fractions (self-AFs) for brain, kidneys, spleen, pancreas, thyroid and urinary bladder wall of JM were evaluated and were compared with those of the other phantoms. In consequence, it was suggested that the mass, shape and thickness of organs are important factors for the determination of self-AFs.

Effect of skin temperature on the ion reabsorption capacity of sweat glands during exercise in humans

The effect of skin temperature on the ion reabsorption capacity of sweat glands during exercise in humans is unknown. In this study, eight healthy subjects performed a 60-min cycling exercise at a constant intensity (60% VO(2max)) under moderate (25 degrees C) and cool (15 degrees C) ambient temperatures at a constant relative humidity of 40%. The sweating rate (SR), index of sweat ion concentration (ISIC) by using sweat conductivity, esophageal temperature (Tes), mean skin temperature, and heart rate (HR) were measured continuously under both ambient temperatures. The SR and ISIC were significantly lower at the cool ambient temperature versus the moderate temperature. There were no significant differences in the changes in HR and esophageal temperature between these ambient temperature conditions, while the mean skin temperature was significantly lower at the cool ambient temperature by almost 3 degrees C (P < 0.05). The slopes of the relationships between Tes and the SR and ISIC were significantly lower and the thresholds of these relationships were significantly higher at the cool ambient temperature (P < 0.05). The ion reabsorption capacity of the sweat glands was significantly lower (P < 0.05) in a cool environment (0.21 +/- 0.04 vs. 0.52 +/- 0.06 mg/cm(2)/min at 15 and 25 degrees C, respectively) as evaluated using the relationships for SR and ISIC. The results suggest that the ion reabsorption capacity of the sweat glands is influenced by skin temperature during exercise in humans.

Surgical treatment of abdominal aortic aneurysm associated with horseshoe kidney and coagulopathy case report

The coexistence of horseshoe kidney and aortic aneurysm poses a technical challenge to the vascular surgeon during aneurysm repair. Whether to divide the renal isthmus and how to approach the aneurysm are still matters of controversy, and coagulopathy sometimes occurs in patients with nontreated abdominal aortic aneurysm (AAA). We describe the successful surgical repair of an AAA with horseshoe kidney via the transperitoneal approach and division of the renal isthmus by harmonic scalpel. Exclusion of a thrombosed aneurysm can ameliorate coagulopathy due to AAA.

Kidney transplantation from non–heart-beating donors: Analysis of organ procurement and outcome

INTRODUCTION

Most donors in Japan have been non-heart-beating donors (NHBD), so-called "marginal donors." In Western countries kidney transplants from NHBD have also been increasing. We analyzed 120 kidneys harvested from NHBD with regard to organ procurement, renal function, graft survival, and the donor factors that affected graft survival.

METHODS

Donors were moved into the operating room after cardiac arrest. A double-balloon catheter was inserted into the abdominal aorta via laparotomy. In situ cooling by Euro-Collins solution was started at 500 mL/min. We did not performed cannulation into the femoral artery or vein prior to cardiac arrest.

RESULTS

Warm ischemia time (WIT) was 18.6 minutes. Among 108 kidneys (90%) used for transplantation, 102 kidneys functioned. There were no cases of bilateral nonfunctioning kidneys. The delayed graft function (DGF) rate was 86%; however, the death-censored graft survival was 80.0% at 5 years and 62.9% at 10 years. Kidneys implanted after more than 24 hours of total ischemia time required a significantly longer period of hemodialysis. Donor risk factors that affected graft survival included WIT >/= 20 minutes, donor age >/= 50 years, and serum creatinine level at admission > 1.0 mg/dL.

CONCLUSIONS

Organ procurement without cannulation prior to cardiac arrest entailed a long WIT and a high DGF rate. However, the graft survival was good. It has been necessary to use grafts from NHBD despite the inherent risk factors. It is important to reduce kidney damage both at the organ procurement and during the posttransplant management.

Clinicopathological study of vesicoureteral reflux (VUR)-associated pyelonephritis in renal transplantation

We retrospectively studied the occurrence of vesicoureteral reflux (VUR)-associated pyelonephritis using renal biopsies obtained from the transplanted kidneys, and correlated the histological changes with clinical parameters. Out of a total of 131 renal biopsies performed between 1990 and 2001 on renal transplant patients at the department of Urology of Nagasaki University Graduate School of Biomedical Sciences, 12 patients showed pyuria more than twice in a single year. Seven of these 12 patients were available for determining VUR by voiding cystourethrography (VCUG). Cystoureterography demonstrated VUR in three of seven studied patients with pyuria. A histopathological examination revealed dilatation of both proximal and distal tubules in renal biopsies of transplant patients with VUR, compared to renal biopsies of transplant patients without VUR, or non-transplanted patients with thin membrane disease. One of the patients with VUR showed advanced features of chronic pyelonephritis in four consecutive biopsies at different time points, suggesting a late stage of reflux nephropathy in the transplanted kidney. We conclude from our study that the occurrence of VUR-related pyelonephritis may be one of the important long-term complications in the survival of renal allografts.

Different clinicopathological courses of two recipients of kidneys retrieved from the same non-heart beating donor

We report the clinicopathological courses of two recipients of kidneys retrieved from the same non-heart beating donor (NHBD). A 52-year-old man received a renal transplant from an NHBD. The donor was a 66-year-old woman who died of subarachnoid haemorrhage. The recipient was immunosuppressed by basiliximab, tacrolimus (TAC), mycophenolate mofetil (MMF), methyl prednisolone (MP), and antilymphocyte globulin (ALG). On post-operative day (POD) 21, haemodialysis therapy was withdrawn, however, their serum creatinine (s-Cr) level failed to improve. Four transplant biopsies were performed (1 h and POD 46, 74, and 114). The biopsy showed tubular degeneration but no evidence of TAC nephrotoxicity. The last biopsy after discontinuation of TAC demonstrated acute rejection of borderline grade. The s-Cr level at discharge was 5.0 mg/dL. The contra-lateral kidney was transplanted into a 31-year-old female and showed early functioning, with an s-Cr level at discharge of 1.8 mg/dL. Biopsy examination on POD 38 showed a recovery of tubular degeneration. The causes of delayed graft function and persistently high level of s-Cr in Case 1 remain unclear. Various factors, including donor-related factors, recipient-related factors, TAC nephrotoxicity, acute rejection, and urinary tract infection could all be associated with this condition.

Absence of mutations in the Wilms' tumor gene wt1 in de novo non-small cell lung cancers

We recently demonstrated that the WT1 gene was overexpressed in the majority of de novo lung cancers regardless of cancer subtypes. Here, we examined WT1 genomic DNA in 38 cases of de novo non-small cell lung cancers (NSCLC) for mutations using direct sequencing. The sequencing analysis showed no mutations of WT1 genomic DNA in any of 38 de novo non-small cell lung cancers examined. These results indicated that the non-mutated, wild-type WT1 gene played an important role in de novo NSCLC.

Influence of hemodialysis on echocardiographic Doppler indices of the left ventricle: changes in parameters of systolic and diastolic function and Tei index

AIMS

Numbers of previous studies have evaluated the influence of dialysis-induced altered loading condition on Doppler-echocardiographic indices of left ventricle in patients with chronic renal failure. It has been suggested that most of Doppler-derived indices are preload-dependent. On the other hand, there are no studies that have evaluated the influence of hemodialysis on Tei index; a new Doppler-derived index obtained by isovolumetric contraction time plus isovolumetric relaxation time divided by ejection time. The aim of this study is to evaluate whether Tei index is also influenced by dialysis-induced altered loading condition as well as other Doppler-derived indices, and to assess the possibility that Tei index is also preload-dependent.

PATIENTS AND METHODS

Thirty-two patients with chronic renal failure (21 men and 11 women, aged 48-93 years) on maintenance hemodialysis were evaluated for Doppler-derived indices before and after hemodialysis. We studied parameters of diastolic function (peak velocities of mitral inflow in early diastole (E) and late diastole from atrial filling (A), ratio of A to E (A/E), deceleration time (DT), and isovolumetric relaxation time (IRT)), parameters of systolic function (ejection time (ET), pre-ejection period (PEP), ratio of PEP to ET (PEP/ET), and isovolumetric contraction time (ICT)) and Tei index.

RESULTS

Hemodialysis resulted in significant decreases in E, increase in A/E, prolongation of IRT, no change in A and DT; significant prolongation of ICT and PEP, shortening of ET, and increase in PEP/ET and a significant increase in Tei index (0.42 +/- 0.16 vs 0.51 +/- 0.16, p < 0.0001). When patients were subdivided into 2 groups based on weight loss after hemodialysis (> or = 1.5 kg and < 1.5 kg), only the group that lost > or = 1.5 kg had significant change in Tei index before and after hemodialysis (0.40 +/- 0.15 vs 0.52 +/- 0.17, p = 0.0002).

CONCLUSION

This study demonstrates that not only most of Doppler-derived indices but also Tei index is affected by dialysis-induced altered loading condition and suggests that Tei index is possibly preload-dependent.

A case of rapid progressive glomerulonephritis with IgA deposits after renal transplantation

A 46-yr-old Japanese male who underwent a second cadaveric kidney transplantation on 31 October 1996 after suffering Type II diabetic mellitus for 25 yr was admitted to our institute on 23 January 1999, because of colicky abdominal pain and abdominal discomfort. Elevated levels of serum creatinine, severe proteinuria and microscopic haematuria were observed. The allograft biopsy specimen disclosed crescentic glomerulonephritis. Immunofluorescence showed granular deposits of mainly IgA and C3 along glomerular capillary walls and mesangial areas. Electron microscopy showed extensive subepithelial and mesangial electron dense deposits. Rapid and irreversible worsening of graft function led to resumption of haemodialysis on 31 May 1999. We speculated that this case was an atypical form of de novo Henoch-Schönlein purpura nephritis (HSPN) in transplanted kidney because of the histopathological findings of the allograft biopsy and clinical symptoms.

Relationship between serum ferritin levels and tumour status in patients with renal cell carcinoma

OBJECTIVE

To assess the relationship between serum ferritin levels (a useful marker for diagnosing and staging renal cell carcinoma, RCC) and tumour status in RCC of <or=7 cm diameter.

PATIENTS AND METHODS

Serum ferritin levels were measured using an enzyme immunoassay in 101 patients before treatment for RCC. The largest diameter of the primary tumour was measured in the pathological specimens. The correlation between serum ferritin levels and histopathological status was assessed retrospectively in all patients, and separately in the 67 patients with tumours of <or=7 cm diameter.

RESULTS

For the whole group, lymph node metastasis, distant metastasis, extracapsular invasion, vascular invasion and nuclear grade were significantly different (P < 0.001) between patients with normal and those with elevated ferritin levels. However, in patients with tumours of <or=7 cm, only the presence of distant metastasis was significantly different (P < 0.001) between the groups.

CONCLUSIONS

Elevated serum ferritin levels in patients with RCC of <or=7 cm may suggest the presence of distant metastasis.

The diagnostic value of bone scan in patients with renal cell carcinoma

PURPOSE

Bone scan is performed as part of the evaluation of bone metastasis. We assessed the diagnostic value of bone scan in patients with renal cell carcinoma.

MATERIALS AND METHODS

Bone scan was performed at presentation in 205 patients with confirmed renal cell carcinoma. Abnormal hot areas were further evaluated by x-ray, computerized tomography or surgery.

RESULTS

Of the 56 patients (27%) with an abnormal bone scan 32 (57%) had osseous metastatic lesions. Overall bone metastasis was present in 34 of the 205 patients (17%). Bone scan had 94% sensitivity and 86% specificity. Of the 124 patients with clinically localized, stages T1-2N0M0 disease exclusive of bone metastasis 6 (5%) had bone metastasis only, whereas 28 of 81 (35%) with locally advanced or metastatic disease had bone metastasis, including 12 (35%) who complained of bone pain and 19 (56%) who presented with other symptoms due to local tumor growth or metastasis at other sites. Three patients (9%) were asymptomatic. There was osseous metastasis without other metastasis, enlarged regional lymph nodes or bone pain in 7 patients, including 1 with stage T1b (2% of all with that stage), 2 with stage T2 (5%), 1 with stage T3a (4%), 1 with stage T3b (6%), 1 with stage T3c (14%) and 1 with stage T4 (6%) disease.

CONCLUSIONS

Bone scan may be omitted in patients with stages T1-3aN0M0 tumors and no bone pain because of the low proportion of missed cases with bone metastasis.

A novel treatment of human malignant gliomas in vitro and in vivo: FADD gene transfer under the control of the human telomerase reverse transcriptase gene promoter

Telomerase activity has a close relationship with malignancies in many cell types and it is tightly regulated at the transcriptional level of human telomerase reverse transcriptase (hTERT). Utilizing the hTERT promoter, the authors developed a gene delivery system of Fas associated protein with death domain (FADD) (hTERT/FADD). FADD is a protein which plays an important role in the apoptotic pathway of Fas. Over-expression of FADD induces apoptosis in the cells regardless of Fas expression on the cell surface. We hypothesized that we might be able to restrict the expression of FADD in malignant glioma cells if we use the gene transfer system under the control of hTERT promoter. This study was designed to investigate whether the hTERT/FADD construct induces apoptosis effectively in malignant glioma cells while keeping normal cells intact. First, using the reverse transcription-polymerase chain reaction (RT-PCR) technique, we confirmed that hTERT mRNA was expressed in human malignant glioma cells (U373-MG, A172 and GB-1), but not in cultured astrocytes (TEN) or fibroblasts (MRC5). After transient transfection with the hTERT/FADD construct, a significant number of FADD-positive cells and apoptotic cells were detected in hTERT-positive malignant glioma cells. In contrast, hTERT-negative astrocytes and fibroblasts remained intact. Furthermore, subcutaneously implanted U373-MG tumors treated with the hTERT/FADD construct reduced in volume significantly compared to the conrol treatment (p=0.0001). Gene transfer of FADD under the control of the hTERT promoter may be a novel and promising therapy to kill hTERT-positive malignant glioma cells while sparing normal brain cells lacking hTERT.

OK432-induced killer cell activity: potential method for monitoring immunological complications after renal transplantation

BACKGROUND

Various clinical and biochemical parameters are currently in use for monitoring allograft rejection. However, the mechanism of allograft rejection is complex and it is frequently difficult to obtain a prompt and accurate diagnosis. We examined the usefulness of OK432-induced killer cell activity as an immunological monitoring system for acute renal rejection after renal transplantation.

METHODS

Twenty-four renal transplant recipients, seven patients on haemodialysis, and 10 normal volunteers were enrolled in our study. The killer cell activity of peripheral blood mononuclear cells was induced by culturing these cells with the immunopotentiator, OK432, a heat and penicillin-treated lyophilized powder of the Su-strain of Streptococcus pyogenes.

RESULTS

The OK432-induced killer cell activity of renal transplant recipients without acute rejection (stable recipients) was significantly lower than in normal volunteers. In four renal transplant recipients with acute rejection, the killer cell activity was significantly higher than in stable recipients. In three recipients suffering from opportunistic infections, killer cell activity was significantly suppressed compared with stable recipients.

CONCLUSIONS

Our new test utilizing OK432-induced killer cell activity is potentially useful for monitoring the immunological state and complications after renal transplantation.

Simple and low-cost tele-nuclear medicine conference system with the e-mail protocol

PURPOSE

Because of the recent innovative growth in computer technology, digital imaging, and the Internet, we can take advantage of these facilities for education and clinical work in nuclear medicine. We developed a tele-nuclear medicine conference system with electronic mail (e-mail) on the Internet.

METHODS

Twenty-one physicians (20 radiologists, 1 neurologist), 6 technologists and 2 medical students in six university hospitals (Japan 5, Canada 1), 5 local hospitals in Japan participated in this project. We used digital still cameras (330 k pixels) equipped with a floppy disk drive and 10 x optical zoom to digitize images with JPEG compression (640 x 480 matrix). The images were attached to e-mail messages (containing a brief description of each case). The mail was sent simultaneously to all members on the mailing list. Scintigram and SPECT images as well as other radiological images were sent by e-mail. Reply mails about each case were sent to all members via the mailing list.

RESULTS

During a period of 6 months, 18 cases (tumor/infection: 7, bone: 6, cardiovascular: 1, neurology; 3, endocrine: 1) with 144 e-mails (average 5.6/case) were submitted to the conference. The average period of discussion was 15.6 days. The number of attached images was 1 to 9 (average, 4.2/e-mails). JPEG compression rate was 1/10 to 1/20. The quality of the images was good enough for discussion. Some cases required additional images for further discussion.

CONCLUSION

Our tele-nuclear medicine conference with an electronic mailing list and digital camera was simple and low-cost. The conference system was useful for education and clinical work.

[Clinical evaluation of renal angiomyolipoma]

Between April 1980 and December 1999, 23 kidneys in 20 patients were diagnosed as having renal angiomyolipoma at our institution. The patients were 6 males and 14 females aged 24 to 79 years, with a mean age of 55.4 years. Two patients had associated tuberous sclerosis and 3 had bilateral disease. Of all patients the main clinical symptoms were pain (45%) and palpable mass (40%); 5 patients (25%) had asymptomatic lesions. The size of the tumor ranged from 1.3 to 24 cm (mean 7.7 cm). Treatment consisted of nephrectomy in 9 patients, partial nephrectomy in 6 and selective embolization in one. Pre-operative diagnosis was renal cell carcinoma in 5 of the 9 patients who underwent nephrectomy. Six patients with 7 diseased kidneys were followed radiologically. One patient underwent percutaneous biopsy to confirm the diagnosis. We suggest that nephron-sparing surgery for patients with renal angiomyolipoma should be the first step if tumor size is 4 cm < or = or increasing rapidly. Selective embolization is also a useful method. However, we need long-term follow-up to evaluate the effectiveness of embolization.

[A case of bilateral synchronous renal cell carcinoma treated with left partial nephrectomy and laparoscopic right nephrectomy]

We describe a case of bilateral synchronous renal cell carcinoma. A 70-year-old female was admitted to our department because of further examination for bilateral renal masses. Computed tomographic scanning and ultrasound examinations revealed bilateral solid enhanced renal masses, and bilateral renal cell carcinomas were suspected. First, partial left nephrectomy was performed. On the 21th day after the first operation, we confirmed the recovery of the left kidney, and performed right nephrectomy laparoscopically. The histopathological diagnosis revealed bilateral renal cell carcinomas. The patient is alive with no metastatic lesions and no recurrence at 16 months after the operations.

Predictive values of acute phase reactants, basic fetoprotein, and immunosuppressive acidic protein for staging and survival in renal cell carcinoma

OBJECTIVES

To determine the clinical significance and predictive value of three acute phase reactants (erythrocyte sedimentation rate, C-reactive protein, and ferritin), as well as basic fetoprotein (BFP) and immunosuppressive acidic protein, in patients with renal cell carcinoma.

METHODS

Erythrocyte sedimentation rate, C-reactive protein, ferritin, BFP, and immunosuppressive acidic protein levels were measured in 92 patients with renal cell carcinoma diagnosed in 1989 to 1999. The levels were compared with the clinical stage and nuclear grade, and their predictive values of survival were evaluated statistically.

RESULTS

All markers, with the exception of BFP, correlated with each other and with the clinical stage and nuclear grade. BFP did not correlate with the acute phase reactants. The log-rank test revealed that the levels of C-reactive protein, immunosuppressive acidic protein, and ferritin significantly influenced survival. Multivariate stepwise analysis identified ferritin as the only independent and significant prognostic marker (hazard ratio = 5.624, P = 0.001). However, when age, sex, clinical stage, and nuclear grade were entered into the same analysis, only clinical stage was an independent marker of prognosis.

CONCLUSIONS

The results of our study demonstrated that serum ferritin is the most useful marker among five tested factors for staging and predicting survival, although the clinical stage is the best parameter that predicts the prognosis of patients with renal cell carcinoma accurately.

Treatment of malignant glioma cells with the transfer of constitutively active caspase-6 using the human telomerase catalytic subunit (human telomerase reverse transcriptase) gene promoter

Because the apoptotic pathway is often disrupted in tumor cells, its genetic restoration is a very attractive approach for the treatment of tumors. To treat malignant gliomas with this approach, it would be preferred to restrict induction of apoptosis to tumor cells by establishing a tumor-specific expression system. Telomerase is an attractive target because the vast majority of malignant gliomas have telomerase activity whereas normal brain cells do not. Activation of telomerase is tightly regulated at the transcriptional level of the telomerase catalytic subunit [human telomerase reverse transcriptase, (hTERT)]. Therefore, we hypothesized that using a hTERT promoter-driven vector system, an apoptosis-inducible gene may be preferentially restricted to telomerase- or hTERT-positive tumor cells. In this study, we constructed an expression vector consisting of the constitutively active caspase-6 (rev-caspase-6) under the hTERT promoter (hTERT/rev-caspase-6) and then investigated its antitumor effect on malignant glioma cells. The rationale for using the rev-caspase-6 gene is because it induces apoptosis independent of the initiator caspases. We demonstrated that the hTERT/rev-caspase-6 construct induced apoptosis in hTERT-positive malignant glioma cells, but not in hTERT-negative astrocytes, fibroblasts, and alternative lengthening of telomeres cells. In addition, the growth of s.c. tumors in nude mice was significantly suppressed by the treatment with hTERT/rev-caspase-6 construct. The present results strongly suggest that the telomerase-specific transfer of the rev-caspase-6 gene under the hTERT promoter is a novel targeting approach for the treatment of malignant gliomas.

The effectiveness of an immobilization device in conformal radiotherapy for lung tumor: reduction of respiratory tumor movement and evaluation of the daily setup accuracy

PURPOSE

To evaluate the daily setup accuracy and the reduction of respiratory tumor movement using a body frame in conformal therapy for solitary lung tumor.

METHODS AND MATERIALS

Eighteen patients with a solitary lung tumor underwent conformal therapy using a body frame. The body shell of the frame was shaped to the patient's body contour. The respiratory tumor movement was estimated using fluoroscopy, and if it was greater than 5 mm, pressure was applied to the patient's abdomen with the goal of minimizing tumor movement. CT images were then obtained, and a treatment planning was made. A total dose of 40 or 48 Gy was delivered in 4 fractions. Portal films were obtained at each treatment, and the field displacements between them and the simulation films were measured for daily setup errors. The patients were repositioned if the setup error was greater than 3 mm. Correlations were analyzed between patient characteristics and the tumor movement, or the tumor movement reduction and the daily setup errors.

RESULTS

Respiratory tumor movement ranged from 0 to 20 mm (mean 7.7 mm). The abdominal press reduced the tumor movement significantly from a range of 8 to 20 mm to a range of 2 to 11 mm (p = 0.0002). Daily setup errors were within 5 mm in 90%, 100%, and 93% of all verifications in left-right, anterior-posterior, and cranio-caudal directions, respectively. Patient repositioning was performed in 25% of all treatments. No significant correlation was detected between patient characteristics and tumor movement, tumor movement reduction, and the daily setup errors.

CONCLUSIONS

The abdominal press was successful in reducing the respiratory tumor movement. Daily setup accuracy using the body frame was acceptable. Verification should be performed at each treatment in hypofractionated conformal therapy.

[Long-term experience with renal transplantation in systemic amyloidosis: a case report]

Renal transplantation was performed on a 39-year old woman with secondary amyloidosis due to rheumatoid arthritis. She remains alive and renal function has been maintained satistfactorily with the exception of proteinuria ten years after transplantation. Recent renal biopsy showed no amyloid recurrence, but the presence of chronic rejection reaction and mild cyclosporin arteriolopathy. Symptoms related to systemic amyloidosis and rheumatoid arthritis improved after transplantation. Renal transplantation is the recommended therapy for the type AA systemic amyloidosis. This is the second report of long-term experience with renal transplantation in systemic amyloidosis in Japan.