Kazuhito Fukuoka

Alteration of redox state of human serum albumin before and after hemodialysis.

Background:Persistent hypoalbuminemia is a predictor of death in long-term maintenance hemodialysis patients, although cardiovascular diseases remain the leading cause of death. A decreased serum antioxidant activity in maintenance hemodialysis patients may contribute to increased oxidative damage, and may be associated with accelerated atherosclerotic changes. Methods:The aim of this study was to examine the redox state of human serum albumin in maintenance hemodialysis patients by high-performance liquid chromatography (HPLC) using a fluorescence detector. Results: HPLC of human serum albumin on a Shodex-Asahipak ES-502N column at pH 4.85 showed a clear resolution of human mercaptalbumin (HMA) and nonmercaptalbumin (HNA), which are the reduced and oxidized forms of human serum albumin, respectively. The mean ± SD percentage of the HMA fraction of human serum albumin was significantly lower in maintenance hemodialysis patients than in age-matched normal subjects. The percentage of HMA increased 3–5 h after starting the hemodialysis and then decreased to subnormal levels. Conclusion: This suggests that serum albumin may be a major extracellular antioxidant in maintenance hemodialysis patients, and that hemodialysis may rescue serum albumin reduction by inducing intermolecular sulfhydryl-disulfide exchange reaction.

Distinct interleukin-1β-converting enzyme family proteases mediate cisplatin- and staurosporine-induced apoptosis of mouse proximal tubule cells

Interleukin-1beta converting enzyme (ICE) family proteases (caspases) are known to be implicated as important effectors of apoptotic pathways. The purpose of this study was to elucidate the role of ICE family proteases in apoptosis of mouse cells derived from the terminal proximal tubule (S3) treated with cisplatin, an anti-tumor drug, or staurosporine, a protein kinase C inhibitor. For this purpose, we measured the activities of ICE family proteases and examined the effects of tetrapeptide and viral ICE family protease inhibitors on the activities of ICE family proteases in and the degree of apoptosis of S3 cells treated with cisplatin and staurosporine. RT-PCR analysis revealed that S3 cells as well as mouse kidney express mRNA for ICE and CPP32, an ICE family protease. Results of enzymatic analysis, determination the degree of DNA fragmentation and cytotoxicity test suggest that CPP32 mediates cisplatin-induced apoptosis of S3 cells, whereas ICE family proteases other than CPP32 mediate staurosporine-induced apoptosis of S3 cells. In conclusion, distinct ICE family proteases mediate apoptosis of mouse proximal tubule cells depending on the stimuli to which the cells are exposed.

Multiple aortic aneurysms complicated by a rupture in the systemic lupus erythematosus: A case report

We report the case of a 61-year-old female who suffered from systemic lupus erythematosus (SLE) and died of a ruptured abdominal aortic aneurysm (AA). She was diagnosed to have SLE at 39 years of age, and was administrated steroids and prostaglandin E(2). From 52 years of age, AA, peripheral arterial occlusion, and multiple organ infarctions appeared repeatedly. At 59 years of age, she was found to be affected by antiphospholipid antibody syndrome (APS). In the following year, expansion of an abdominal AA was identified, but she was given only conservative treatment. In the next year, sudden epigastralgia and dyspnea occurred, and she died. An autopsy revealed multiple AAs up to 11 cm in diameter, one of which showed ruptures, forming a retroperitoneal hematoma. Marked atherosclerosis of the aorta was noted, and she also had aortic dissection accompanied by cystic medial necrosis (CMN). An old myocardial infarction and brain infarction were also confirmed. Although SLE with APS is common, a complication of the disease by CMN, multiple AAs, or ruptured AA has been described in several cases to date. Regarding the etiology of this complicated presentation, we presume synergistic involvement of various factors, such as atherosclerosis and CMN associated with SLE, thrombosis due to APS, and prolonged steroid therapy.

Simultaneous Inhibition of Renal Phospholipase A2 and Glutathione Synthesis by Manoalide and DL-Buthionine Sulfoximine Induces Acute Tubular Dysfunction in Rats

We have previously demonstrated that gentamicin-induced acute renal failure is mediated by the consumption of renal glutathione (GSH) and accumulation of oxidized phospholipids in tubular epithelial cells as a result of inhibition of phospholipase A2 (PLA2) activity. Based on these results, we tested the hypothesis that the simultaneous inhibition of PLA2 and GSH synthesis induces acute renal failure similar in characteristics to gentamicin-induced acute renal failure. Male Sprague-Dawley rats kept under standard laboratory conditions were administered 3 mmol/kg of DL-buthionine sulfoximine (BSO; γ-glutamylcysteine synthetase inhibitor) and 30 μg/kg of manoalide (PLA2 inhibitor), following which significant elevations in serum creatinine and urinary lysosomal enzyme levels (elevation of N-acetyl-β-D-glucosaminidase activity) were observed. The renal tissue GSH content was reduced in the group that received both BSO and manoalide as compared with the group that received manoalide alone. The renal tissue GSH content was also reduced in the group that received BSO alone. The renal tissue concentration of 2-thiobarbituric-acid-reactive substances increased rapidly, followed by an increase in renal tissue total phospholipid concentration in the group that received both BSO and manoalide. In contrast, the activity of PLA2 in renal tissue decreased in the group that received both BSO and manoalide as compared with the groups that received BSO alone or physiological saline. In conclusion, concomitant administration of BSO and manoalide induces renal tubular damage and acute renal failure in rats, similar in characteristics to gentamicin-induced nephrotoxicity, whereas administration of BSO or manoalide alone did not. These results suggest that both inhibition of PLA2 and GSH depletion are necessary for the induction of acute renal failure.

Biochemical Renal Manifestations Induced by Consecutive Administration of Gentamicin in Rats

In the present study, we investigated the generation of lipid peroxides and changes in total phospholipid levels in the kidney tissue of rats with acquired resistance to gentamicin (GM). GM resistance was induced in Sprague-Dawley male rats by subcutaneously administering each rat a dose of 80 mg/kg/day of GM for 40 consecutive days. Twelve days after the GM administration, serum urea nitrogen peaked at 35 mg/dl. The urinary creatinine excretion progressively decreased, beginning 4 days after the start of GM administration. The fractional excretion of sodium progressively increased, beginning 4 days after the start of GM administration, peaking on the 10th day. However, despite the continuation of GM administration, the urinary creatinine excretion gradually increased, and the serum urea nitrogen concentrations recovered to previous levels after 21 days. We also analyzed the relationship between the acquired resistance to GM and changes in the reduced glutathione content and glutathione peroxidase activity. Simultaneously, we investigated sequential changes in the activities of phospholipase A2 and phospholipase C, which release peroxidized membrane phospholipids into the cytoplasm via hydrolysis, as well as the relationship between changes in the kidney tissue phospholipid composition (sphingomyelin/phosphatidylcholine ratio) and renal function. We found that (1) the kidney tissue glutathione content rapidly decreased after GM administration before subsequently increasing and being maintained at a higher level; (2) the glutathione peroxidase activity showed a persistent decrease after GM administration; (3) the kidney tissue phospholipase A2 activity decreased after GM administration, while the phospholipase C activity exhibited a sustained increase from 21 days, and (4) the spingomyelin/phosphatidylcholine ratio decreased on the 4th day before stabilizing when acquired resistance was obtained. Based on these findings, we conclude that an increased supply of reduced glutathione and the induction of an antioxidase, substituting for glutathione peroxidase, may play a significant role in the acquisition of resistance to acute renal failure which occurs with continuous GM administration. Improved membrane fluidity, achieved by maintenance of the membrane phospholipid composition by increased phospholipase C activity, may be an additional factor contributing to the recovery of the renal function.

Clinical Characterization of Acute Renal Failure in Multiple Organ Dysfunction Syndrome

BackgroundAcute renal failure frequently occurs as a complication of multiple organ dysfunction syndrome (MODS). Various forms of therapy for MODS, including endotoxin absorption and anticytokine therapy, have been attempted.MethodsWe retrospectively studied the pathophysiologic characteristics of acute renal failure in 152 MODS patients examined in our department over the past 5 years. The diagnosis of MODS was based on the criteria of the Japanese Association for Critical Care Medicine. The diagnosis of systemic inflammatory response syndrome (SIRS) and sepsis was conducted in accordance with the definition proposed at the 1992 Consensus Conference of the American College of Chest Physicians/ Society of Critical Care Medicine.ResultsAcute renal failure occurred as a complication of secondary MODS with a high frequency of 76.3% (116/152 patients). Significant associations have been found between the respective frequencies of acute renal failure and disseminated intravascular coagulation occurring as complications of SIRS. An increase in the number of cases undergoing continuous hemodiafiltration was noted, in an attempt to improve the survival rate of MODS complicated with acute renal failure.ConclusionAcute renal failure seen in secondary MODS is thought to be derived from a pathogenesis differing from that of conventional intrinsic acute renal failure, such as ischemic and nephrotoxic forms. Acute renal failure associated with secondary MODS appears to be a disease entity that arises as a sequela of SIRS, similar to disseminated intravascular coagulation.

Adult-onset Still’s disease-like manifestation accompanied by the cancer recurrence after long-term resting state

Abstract A 72-year-old woman presented 9 months ago with skin rash on her bilateral forearms, which was followed by intermittent high fever, and stiffness and swelling of her bilateral fingers. She was diagnosed with seronegative rheumatoid arthritis (RA). She had a past history of breast cancer and had undergone breast preservation surgery 13 years previously. During admission in our hospital, she developed high fever and leukocytosis with a relapsing skin rash, sore throat, polyarthralgia and increased levels of serum ALT/AST and ferritin, all of which fulfilled Yamaguchi’s criteria for adult-onset Still’s disease (AOSD). While we tried to exclude other diseases that may show AOSD-like manifestations, pancytopenia rapidly developed and bone marrow biopsy strongly suggested the diagnosis of macrophage activating syndrome (MAS). Accordingly, steroid pulse therapy was begun, followed by oral glucocorticoid therapy. Thereafter, all of her symptoms improved, but systemic rash, inflammatory signs and pancytopenia gradually progressed. The results of bone marrow pathology, which returned 2 weeks after the beginning of treatment, revealed hemophagocytosis with CK7-positive/CK20-negative atypical cells that suggested recurrence of breast cancer in the bone marrow, thus all of her AOSD-like symptoms were considered to be paraneoplastic manifestations of late-onset metastatic breast cancer. She was treated successfully with chemotherapy. When we see the patients showing AOSD-like symptoms with a history of malignancy, we should consider the possibility of paraneoplastic syndrome due to cancer recurrence.

SAT0516 Two distinct subsets of low density granulocytes in anca associated vasculitis

Background Low density granulocyte (LDG), a proinflammatory population of neutrophils, was first described in systemic lupus erythematosus (SLE) and has been shown to contribute to lupus pathogenesis. It has been suggested that LDGs have a pathogenic role in ANCA associated vasculitis (AAV) based on the data of gene expression signature in AAV and the ability of excessive neutrophil extracellular traps (NETs) formation by LDGs in AAV. However, more detailed analysis of LDG in AAV patients has not been reported. Objectives In this study we investigated the characteristics of LDG in AAV patients using flow cytometry and proteomics approach and examined the correlations with disease activity. Methods We examined the presence of LDGs in peripheral blood of 10 AAV patients before treatment and followed them for 4 months with immunosuppressive therapy. Normal-density granulocytes (NDGs) were isolated by dextran sedimentation and PBMCs were isolated by Ficoll gradient. LDGs were assessed using cell surface expression of CD14 and CD15 by flow cytometry and isolated by magnetic bead procedure from PBMCs. We performed comparative proteomic analysis among LDGs and autologous NDGs and healthy controls (HC)-NDGs. Results LDG frequencies were 9.8-fold higher in AAV patients before treatment relative to HC. There were two distinct populations of LDGs showing different cell surface expressions of CD10, CD14, and CD15 in AAV patients. One population of LDGs was mainly CD10 positive and another one was CD10 negative. Although the frequency of CD10 positive-LDG decreased along with decrease of disease activity, the frequency of CD10 negative-LDG increased in 4 months (17.9-fold higher than before treatment). Comparative proteomic analysis revealed these two populations of LDGs were distinct from each other and had common differences from autologous NDGs and HC-NDGs. LDG frequencies were 9.8-fold higher in AAV patients before treatment relative to HC. There were two distinct populations of LDGs showing different cell surface expressions of CD10, CD14, and CD15 in AAV patients. One population of LDGs was mainly CD10 positive and another one was CD10 negative. Although the frequency of CD10 positive-LDG decreased along with decrease of disease activity, the frequency of CD10 negative-LDG increased in 4 months (17.9-fold higher than before treatment). Comparative proteomic analysis revealed these two populations of LDGs were distinct from each other and had common differences from autologous NDGs and HC-NDGs. Conclusions We identified two distinct subsets of LDGs in AAV. It is possible that they play different roles in the pathogenesis of AAV. References [1] Denny MF, et al. A distinct subset of proinflammatory neutrophils isolated from patients with systemic lupus erythematosus induces vascular damage and synthesizes type I Interferons. J Immunol2010;184(6):3284–3297. [2] Grayson, et al. Neutrophil-Related Gene Expression And Low-Density Granulocytes Associated with Disease Activity and Response to Treatment in ANCA-Associated Vasculitis. Arthritis Rheumatol2015;67:1922–1932. Disclosure of Interest None declared

A missense mutation of the plasminogen gene in hereditary angioedema with normal C1 inhibitor in Japan

more toxic drugs in case of relapse. The study was approved by the Internal Review Board of the Clinic. The baseline features of the study patients along with the clinical response to the treatment are shown in Table 1. Seven of 14 patients (50%) showed an ongoing complete control of the disease (UAS7 < 6) despite halving the monthly dose of omalizumab. In the remaining seven patients, the dose reduction was associated with a worsening of the disease (UAS7 score between 7 and 21), although in no case, it returned to the baseline severity. The partial loss of response to the drug did not depend on disease duration, the presence of thyroid autoimmunity, or baseline ESR, CRP, or D‐dimer, whereas it was associated with the baseline severity of the disease (P < 0.05). Also, a history of angioedema was much more frequent among those who worsened following the reduction in omalizumab dosage (6/7, 86%) than in patients who maintained the control of the disease (2/7; 29%), but due to the small number of patients, the difference did not reach the statistical significance. Although studies on larger number of patients are needed to confirm these observations and despite the limitation of being nonrandomized, the present real‐life study suggests that it is possible to halve the costs of omalizumab maintenance treatment in about one half of patients with severe CSU showing a prompt response to the drug at the dose of 300 mg/mo without any loss of clinical efficacy. Patients who worsen with a reduced dosage of omalizumab are in general those showing a more severe diseases at baseline as well as those with a history of angioedema associated with the wheals. This is in keeping with previous observations that in patients with angioedema, only the dosage of 300 mg/month seems to be effective 2 Whether the reduction in omalizumab dosage as a maintenance therapy will work also in patients showing a delayed response to the drug remains to be established. In conclusion, this study confirms previous observations in a very small number of patients 10 that a maintenance monthly dose of 150 mg of omalizumab may be sufficient to guarantee an ongoing control of the disease in a large proportion of patients with CSU showing an early response to the drug.

A Dialysis Patient With Hyperphosphatemia, Hyperkalemia, and Azotemia Without an Excessive Intake

INTRODUCTION I t is well known that the strict control of serum inorganic phosphorus (IP) and potassium (K) concentrations is important for the prevention of various complications and improving the prognosis of patients with chronic kidney disease (CKD). Hyperkalemia is associated with sudden cardiac death in hemodialysis (HD) patients and hyperphosphatemia is associated with an increase in cardiovascular events and mortality in CKD patients. It is a common practice to restrict IP and K intake when HD patients present with these electrolyte abnormalities. However, these abnormalities are not always caused by an excessive intake. We evaluated and treated a CKD case with hyperphosphatemia, hyperkalemia, and azotemia, likely caused by poor carbohydrate intake.