Shinichi Nishi

2008 Japanese Society for Dialysis Therapy: guidelines for renal anemia in chronic kidney disease.

The Japanese Society for Dialysis Therapy (JSDT) guideline committee, chaired by Dr Y. Tsubakihara, presents the Japanese guidelines entitled “Guidelines for Renal Anemia in Chronic Kidney Disease.” These guidelines replace the “2004 JSDT Guidelines for Renal Anemia in Chronic Hemodialysis Patients,” and contain new, additional guidelines for peritoneal dialysis (PD), non‐dialysis (ND), and pediatric chronic kidney disease (CKD) patients.

2004 Japanese Society for Dialysis Therapy guidelines for renal anemia in chronic hemodialysis patients.

Abstract:  The guideline committee of Japanese Society for Dialysis Therapy (JSDT), chaired by Professor F. Gejyo of Niigata University, now publishes an original Japanese guideline entitled ‘Guidelines for Renal Anemia in Chronic Hemodialysis Patients’. It includes the re‐evaluation of the usage of recombinant human erythropoietin (rHuEPO) with the medical and economical arguments regarding the prognosis and the quality of life of Japanese hemodialysis patients. This guideline consists of 7 sections. The first section comprises the general definition and the differential diagnosis of anemia. The hemoglobin (Hb) level of the Japanese population seemed to be low when compared with that of the European and American populations. The second section describes the target Hb level in hemodialysis patients. Multivariate analysis of the data that were collected from dialysis institutions throughout the country showed that an Hb level of 10–11 g/dL (Ht level 30–33%) at the first dialysis session in a week is the ideal range for chronic hemodialysis patients in terms of the 3–5 year survival rate. The supine position at blood sampling and the sampling timing at the first dialysis session in a week might affect the lower setting of target Hb hematocrit (Ht), compared to that of European and American guidelines. However, we particularly recommended that an Hb level of 11–12 g/dL (Ht level from 33 to 36%) at the first dialysis session in a week is desirable in relatively young patients. In the third section, the markers of iron deficiency are discussed. The Transferin saturation test (TSAT) and serum ferritin were emphasized as the standard markers. The routes of administration of rHuEPO and its dosages are written in the fourth section. The subcutaneous route was associated with the occurrence of secondary red cell aplasia due to anti‐rHuEPO antibodies; however, secondary red cell aplasia was seldom observed in the venous injection. From this fact we recommend venous injection for chronic hemodialysis patients. We advocate an initial dosage of 1500 U three times per week. The fifth section deals with the factors refractory to treatment with rHuEPO. If the patient shows an inadequate response to the usage of 9000 U per week, this condition defines the inadequate response to rHuEPO in Japan. Blood transfusion must be avoided where possible. The reasons for this and the adverse effects are interpreted in section six. In the final section, the adverse effects of rHuEPO are listed. Among them, hypertension, thrombotic events and secondary red cell aplasia were emphasized as the major complications.

Tubulointerstitial nephritis associated with IgG4-related systemic disease

We report three patients with tubulointerstitial nephritis (TIN) with high serum IgG4 concentrations. None of the patients had notable pancreatic lesions when the TIN developed, although one had a history of autoimmune pancreatitis (AIP). Nevertheless, the clinicopathological findings were quite similar to those of AIP. They were all middle-aged to elderly men. Sialadenitis and lymphadenopathy were often evident. Serum total IgG and IgG4 concentrations were elevated and hypocomplementemia was observed. Although antinuclear antibodies were positive, anti-Ro and anti-La antibodies were negative. Renal biopsy showed dense lymphoplasmacytic infiltration with fibrosis in the renal interstitium, and the infiltrated plasma cells had strong immunoreactivity for IgG4. Furthermore, lymphoplasmacytic infiltration and abundant IgG4-positive plasma cells were observed in the salivary glands of a patient. Steroid therapy was effective for TIN in all three patients. The present findings support the recently proposed concept of IgG4-related systemic disease, and suggest that IgG4 is associated not only with AIP but also with other systemic lymphoplasmacytic diseases, including TIN. The conditions responsible for the pathogenesis of TIN need to be considered, irrespective of the presence of AIP.

New advances in renal amyloidosis

Renal amyloidosis is a rare and intractable disease that accounts for 0.2% of the original kidney diseases of dialysis patients in Japan. However, the number of patients with renal amyloidosis seems to be increasing in recent years. There have been some new concepts focusing on the mechanism of amyloidogenesis, such as molecular chaperones, seeding mechanism, and genetic polymorphisms of precursor protein. Clinical and histological features of renal amyloidosis vary according to the type. Significantly higher levels of urinary protein excretion are seen in the AL type, whereas microscopic haematuria is more prominent in the AA type. Histologically, amyloid deposition of AL type has stronger predilection for GBM than mesangium, and spicule formation is more frequently observed. In contrast, AA type has a higher affinity to TBM and interstitial area. For the histological diagnosis of renal amyloidosis, plural staining methods including Congo-red, Daylon and thioflavin-T stains are available. Combinations of these staining methods are necessary for establishing the precise diagnosis. The more recent and intensive treatments for renal amyloidosis are expected to improve patient outcome. For AL amyloidosis, high-dose melphalan plus high-dose dexamethasone or VAD, in conjunction with bone marrow stem cells transplantation, have shown a definitive effect on reducing urinary protein excretion. The biological agent, tumor necrosis factor (TNFα) blocker, improves the renal function in AA-type renal amyloidosis, as well as suppresses the inflammatory reactions in patients with rheumatoid arthritis. Clinical advances have been made in various aspects of renal amyloidosis.

Effects of low-dose cadmium exposure on biological examinations.

We conducted an epidemiological study to investigate the effects of low-dose cadmium (Cd) exposure on human health in a specific area of a town in Japan where low Cd concentration was detected in rice. We compared clinical findings, urinary and whole blood Cd concentrations, and indicators of renal dysfunction between the polluted area and the control area. The study employed 44 men and 54 women from the polluted area and 21 men and 29 women from the control area. In urine analysis, as indicators of Cd exposure and possible related renal dysfunction, Cd, beta(2)-microglobulin (beta(2)-MG), alpha(1)-microglobulin (alpha(1)-MG), N-acetyl-beta-D-glucosaminidase (NAG), total protein, inorganic phosphorus, lysozyme and creatinine were quantitatively measured. In blood analysis, serum IP and creatinine and whole blood Cd were measured. No case of renal dysfunction due to Cd exposure was confirmed. However, both the urinary and whole blood Cd of the polluted area were significantly higher than those of the control area for both sexes. Urinary beta(2)-MG did not differ between the two areas. For women, urinary alpha(1)-MG was significantly higher in the polluted area than in the control area. In correlation analysis, beta(2)-MG, alpha(1)-MG and NAG, were positively correlated with both of urinary and whole blood Cd for men and women in the polluted area except for between urinary beta(2)-MG and urinary Cd for men. In the control area, the sole positive correlation observed was between urinary beta(2)-MG and whole blood Cd for men. We then examined the determinants of variations of parameters in urinary and blood tests. Potential determinants were age, sex, body mass index, an indicator of smoking habits (cigarette index) and the index of estimated Cd intake from rice (Cd-rice-index). Cd-rice-index was expressed as the product of Cd concentrations in homegrown rice multiplied by daily frequency multiplied by duration (years) of residence in the polluted area. In multiple regression analysis, whole blood Cd was independently associated with Cd-rice-index, age and gender. Variations in whole blood Cd accounted for a substantial portion of the variations in urinary Cd, although they were less influential in older individuals. Whole blood Cd was the sole independent variable related to variations in urinary beta(2)-MG. Cd-rice-index accounted for a portion of the variance in urinary NAG, while age was a more powerful determinant. It was thus revealed that the consumption of homegrown rice polluted with Cd in low concentration resulted in an elevation of whole blood Cd level and consequent increase in urinary Cd level. However, it was not clearly elucidated that the excretion of urinary low-molecular microglobulins could increase significantly in response to slight elevation of Cd body load.

Ultrastructural characteristics of diabetic nephropathy

Diabetic nephropathy is a major cause of chronic renal failure in Japan, and the prevalence rate has markedly increased during the past decade. Diabetic nephropathy shows various specific histological changes not only in glomeruli but also in the interstitial region. Nodular, diffuse, and exudative lesions, so-called diabetic glomerulosclerosis, are well known as glomerular lesions. At first, they were historically evaluated only by light microscopy, and thus which components of the glomeruli were modified was not sufficiently clear. Subsequent electron microscopic studies clarified that the expansion of the mesangial matrix was the true form of nodular and diffuse lesions, and that insudated serum substance was the real appearance of an exudative lesion. Interstitial lesions also exhibit specific features in diabetic nephropathy. In electron microscopic studies, it was proved that the size of mitochondria and thickness of the tubular basement membrane were increased in diabetic nephropathy. In this review, we introduce typical electron microscopic findings in diabetic nephropathy and recent opinions on the progression of diabetic nephropathy.

Electron-Microscopic and Inimunohistochemical Study of Beta-2-Microglobulin-Related Amyloidosis

beta 2-Microglobulin (beta 2-MG)-related amyloidosis has been reported as a complication in long-term hemodialysis patients. We observed beta 2-MG amyloid deposits in synovial sheaths, bone cysts and gastric mucosa. They showed unique ultrastructural features, that is bundles or nodules consisting of curved or linear amyloid fibrils, associated with various cell reactions. The electron-microscopic histochemical study showed that they strongly stained with periodic acid-silver methenamine stain. A similar phenomenon was noticed in the spicules or bundles of amyloid fibrils in primary and secondary renal amyloidosis. With the cationic reagent toluidine blue 0, proteoglycan-like structures were observed around amyloid bundles and nodules, but not on each fibrils. Based on these results, we postulate that there is a close relationship between ultrastructural features and histochemical characteristics in beta 2-MG amyloid fibrils.

Pinpoint targeted immunosuppression: anti‐CD20/MMF desensitization with anti‐CD25 in successful ABO‐incompatible kidney transplantation without splenectomy

Abstract: Background: In Japan, ABO‐incompatible (ABO‐I) kidney transplantation began in 1989; these transplantations have flourished because of the lack of cadaveric donors, and more than 600 cases were performed up to 2004. Splenectomy has been considered to be necessary for successful ABO‐I kidney transplantation, and the majority of pre‐conditioning protocols include splenectomy in Japan. However, we have lost some grafts due to antibody‐mediated rejection (AMR) accompanying explosive elevation of anti‐A/B antibody (Ab) titer even though the patients had a low pre‐operative Ab titer.

Comparative Study of IgA Nephropathy with Acute and Insidious Onset

In order to clarify the difference of clinical and pathological features between the IgA nephropathy patients with acute and insidious onset, 427 patients were examined in this study. Seventy-eight patients with acute onset (group 1) were often associated with mucosal system infections at the abrupt onset. This group revealed macroscopic hematuria, more severe microscopic hematuria (more than 20/hpf), higher glomerular filtration rate (p less than 0.01) and lower serum levels of C3 (p less than 0.01). It had also a significantly higher incidence of exudative lesions (p less than 0.001). On the other hand, the onset of 349 patients (group 2) was noticed to be insidious without preceding infections. This group showed a more severe increase in mesangial cells (p less than 0.01) and a significantly higher incidence of adhesion, arterial sclerosis and tubulointerstitial changes. Deposition of Clq, C4 and IgM and detachment of visceral epithelium from the basement membrane were more frequently seen in group 2. Twenty-seven of 345 patients followed for at least 1 year after the biopsy were on maintenance hemodialysis: 1 patient was in group 1 and 26 were in group 2. These results clarified that there was a difference in clinical, laboratory and histopathological findings between the patients with IgA nephropathy with acute and insidious onset.

Hypocomplementemia of unknown etiology: an opportunity to find cases of IgG4-positive multi-organ lymphoproliferative syndrome

Recently, a new clinical entity, IgG4-positive multi-organ lymphoproliferative syndrome (IgG4+ MOLPS), characterized by hyper-IgG4 gammaglobulinemia and IgG4-positive plasma cell tissue infiltration, has been proposed. It includes autoimmune pancreatitis (AIP), Mikulicz’s disease, and many other inflammatory conditions affecting multiple organs. However, diagnosis is difficult if the disease is not suspected because serum IgG subclasses are not measured routinely and the affected organs vary. Because hypocomplementemia is often observed in this condition, we investigated the serum subclasses of IgG in patients with hypocomplementemia, especially of unknown etiology. We found 6 patients with high serum IgG4 levels among 10 patients with hypocomplementemia of unknown etiology who visited our hospital between December 2004 and September 2007. The results of additional pathological and imaging examinations in the 6 patients with high serum IgG4 levels were compatible with IgG4+ MOLPS. Our results suggest that hypocomplementemia of unknown etiology offers an opportunity to find cases of IgG4+ MOLPS.