Takamichi Nakamura

Alterations in the extracellular matrix components in human glomerular diseases

We investigated the distribution of extracellular matrix components such as fibronectin, laminin, type III, IV, V, and VI collagens and heparan sulfate proteoglycan (HSPG) in normal and diseased glomeruli using the indirect immunofluorescence method. This study included 96 renal biopsies: 7 controls, 3 minimal change nephrotic syndrome (MCNS), 47 mesangial proliferative glomerulonephritis (PGN), 25 membranous nephropathy (MN) and 14 membranoproliferative glomerulonephritis (MPGN) including 3 lupus nephritis. Fibronectin was detected predominantly in the mesangium and less prominently in the glomerular basement membrane (GBM) of normal glomeruli. Laminin and type IV collagen were present in the mesangium and GBM, type III collagen in the interstitium, and type V collagen in the mesangium, interstitium and a part of GBM. Type VI collagen was observed in the mesangium, interstitium and slightly in GBM. Anti-HSPG antibody reacted with the mesangium and GBM. MCNS showed a distribution of these antigens similar to that in normal controls. The finding that staining for HSPG was not decreased in the GBM and mesangium indicated that there was no change in the core protein of HSPG. Fibronectin, laminin, type IV collagen and HSPG were increased in the thickened GBM of MN and in the expanded mesangium of PGN. In MPGN, these matrix components were increased in the mesangium and GBM with remarkable increase of type V and VI collagens. While type III collagen was not found in normal glomeruli, it became detectable in the mesangium and a part of GBM in MPGN. No significant decrease in the intensity of fluorescence for HSPG was observed in the glomeruli from nephrotic patients. These findings suggest that proteinuria might be caused by the structural alteration in the glycosaminoglycan portion of HSPG, changes in any anionic material other than HSPG, or both, and also indicate that the glomerular mesangial sclerosis is closely related to the increase of type V and VI collagens.

Increased gene expression of components of the renin-angiotensin system in glomeruli of genetically hypertensive rats

Objective The renin–angiotensin system (RAS) is implicated in the development of hypertensive glomerulosclerosis. However, no experimental evidence exists that clearly demonstrates activation of glomerular RAS in hypertensive nephropathy. We used stroke-prone spontaneously hypertensive rats (SHRSP) to examine whether RAS components are increased in glomeruli of SHRSP and whether this increase leads to an increase in mRNA levels for transforming growth factor-β1(TGF-β1). Methods We examined the sequential changes of urinary albumin excretion (UAE), morphology, and glomerular mRNA expression for TGF-β1 and fibronectin (FN) in relation to glomerular mRNA expression for angiotensinogen (ATN), angiotensin converting enzyme (ACE), angiotensin II type 1a (AT1a), and type 1b (AT1b) receptors, and intervention with angiotensin II type 1 receptor antagonist candesartan and equihypotensive hydralazine. Results In SHRSP, UAE was normal at 9 weeks of age, but became higher, beginning at 12 weeks of age, than that in the age-matched Wistar–Kyoto (WKY) rats, while SHRSP showed no glomerulosclerosis until 14 weeks of age; it was marked at 24 weeks. Plasma renin activity and plasma angiotensin II level was equivalent in the 9- and 12-week-old SHRSP and the WKY rats; both parameters, however, were elevated in 24-week-old SHRSP as compared with age-matched control. RNase protection assays showed that glomerular levels of ATN, ACE, and AT1a and AT1b receptors mRNA were significantly increased in 9-, 12-, and 14-week-old, but not in 24-week-old SHRSP, compared with age-matched WKY rats. Northern blot analysis showed that glomerular levels of TGF-β1 and FN mRNA were higher in SHRSP than in WKY rats at all time points. Candesartan reduced UAE to control levels, whereas hydralazine reduced UAE but not to control levels. Candesartan administration for 12 weeks virtually prevented the progression of glomerulosclerosis. While candesartan reduced mRNA levels for RAS components, TGF-β1, and FN to control levels, hydralazine was not effective in this respect. Conclusion Results suggest that increases in glomerular RAS components that occur independently of circulating RAS alter glomerular permselectivity and increase the glomerular expression of TGF-β1 and FN in young SHRSP. Findings in old SHRSP suggest that altered glomerular permselectivity and an increased glomerular expression of TGF-β1 and FN may be associated with the activation of systemic RAS. J Hypertens 2000, 18:1247–1255

Sclerotic Lesions in the Glomeruli of Buffalo/Mna Rats

Spontaneously developing focal and segmental glomerulosclerosis (FGS) in Buffalo/Mna rats was studied. There were no differences in the occurrence of the disease between male and female rats. Plasma macromolecules were detected in the urine samples of 2-month-old rats using sodium dodecyl sulphate polyacrylamide gel electrophoresis. All 4-month-old animals had proteinuria in excess of 30 mg/24 h. At the age of 4 months, sclerotic glomeruli were rarely observed. At the age of 6 months, all animals had a few sclerotic glomeruli in every kidney section examined. Animals which were 22 months old had sclerotic lesions in 37.8-52.1% of the glomeruli. Ultrastructural examination revealed that alterations in epithelial cells, such as effacement of foot processes, vacuolization, and a podocytic membrane-like structure, were found at the age of 2 months. The animals examined were neither uremic nor hypertensive. Our present study showed that female as well as male Buffalo/Mna rats had an earlier onset of the disease than the other strains of rats and that alterations in glomerular epithelial cells were first detected in the early stage of the disease.

Improvement of Myocardial Fatty Acid Metabolism through L-Carnitine Administration to Chronic Hemodialysis Patients

The concentration of carnitine, which is essential to fatty acid metabolism, can decrease markedly in patients on long-term hemodialysis coincident with life-threatening cardiac damage. However, administration of L-carnitine improves the myocardial function of these patients. To evaluate the underlying events of this phenomenon, we used recently developed technology, 123I-labeled β-methyl-p-iodophenyl-pentadecanoic acid (BMIPP) myocardial scintigraphy, as a test of myocardial fatty acid metabolism. Our results showed that the free carnitine concentration (19.2 ± 6.5 μmol/l) was lower in 11 chronically dialyzed patients than in 8 healthy controls (49.3 ± 7.7 μmol/l, p < 0.0001). Additionally the heart to mediastinal ratio (H/M) of BMIPP was higher for these patients than for the controls (1.91 ± 0.19 vs. 1.52 ± 0.24, p < 0.005), and the patients’ washout rate (WOR) of BMIPP was lower (17.2 ± 6.0 vs. 22.8 ± 4.2%, p < 0.05). After L-carnitine was administered orally to the patients at doses of 1 g/day for 1 month and 0.5 g/day for the following month, the concentration of free carnitine in their sera increased to 85.4 ± 27.0 μmol/l (p < 0.0001). Although the H/M ratio did not change (1.89 ± 0.20) with this treatment, their WOR increased to 21.9 ± 6.6% (p < 0.001), similar to that of controls. The left ventricular end-diastolic dimension and left ventricular fractional shortening remained unchanged, as shown by echocardiography. The results presented here denote that a carnitine deficiency in chronically hemodialyzed patients disrupts their myocardial fatty acid metabolism, which is improved by L-carnitine supplementation.

Regional myocardial sympathetic dysinnervation in patients with coronary vasospasm

The purpose of this study was to assess the presence and location of impaired myocardial sympathetic innervation by using 123I metaiodobenzylguanidine (123I MIBG) in 15 patients with coronary vasospasm induced by intracoronary acetylcholine. The results were compared with those using thallium-201 (Tl-201). We also examined 14 patients with severe coronary stenosis (> 90%) and 8 control subjects without significant coronary stenosis (< 50%) and provokable coronary vasospasm. Regional myocardial sympathetic dysinnervation was detected by 123I MIBG single-photon emission computed tomography (SPECT) in all patients with coronary vasospasm, despite normal uptake during Tl-201 SPECT. This regional uptake-mismatch between 123I MIBG and Tl-201 Spect occurred specifically in the vasospasm group (p < 0.001 vs stenosis and control groups). Moreover, regional myocardial sympathetic dysinnervation was located in the distribution of perfusion in 25 of the 27 vasospasm-induced vessels. Normal uptake of 123I MIBG was observed in the perfused areas in 16 of the 18 non-vasospasm-induced vessels. The sensitivity ans specificity of 123I MIBG for detection of coronary vasospasm were 92% and 88% respectively. In patients with coronary vasospasm, we found regional myocardial sympathetic dysinnervation to be present. Furthermore, we were able to distinguish these patients from patients with critical coronary stenosis by 123I MIBG and Tl-201 SPECT.

Genetic Regulation of the Development of Glomerular Sclerotic Lesions in the BUF/Mna Rat

BUF/Mna strain rats spontaneously develop renal glomerular sclerotic lesions (RSL) at a nearly 100% incidence, diagnosed by hyperalbuminuria (greater than 500 mg/dl) and glomerular lesions morphologically resembling one type of human focal glomerular sclerosis (FGS). Genetic segregation of RSL development was studied by crossing the BUF/Mna strain with two other rat strains, WKY/NCrj and ACI/NMs, which were free of RSL. Two autosomal recessive genes in the BUF/Mna rats were found to determine the susceptibility to RSL in both combinations of crosses.

Benidipine, a Long-Acting Calcium-Channel Blocker, Prevents the Progression to End-Stage Renal Failure in a Rat Mesangioproliferative Glomerulonephritis

Background: Although the renoprotective effect of calcium-channel blockers (CCBs) has been examined in several models of hypertensive nephropathy, it remains unclear. It also remains to be clarified whether CCBs prevent the progression to end-stage renal failure in chronic progressive glomerulonephritis (GN). A new rat model of progressive mesangioproliferative GN was used to study the effect of benidipine hydrochloride, a long-acting dihydropyridine CCB, on the clinical features and morphological lesions. Methods: This animal model of progressive GN was induced by a single intravenous injection of anti-Thy-1 monoclonal antibody (MoAb 1-22-3) two weeks after unilateral nephrectomy. After 10 weeks of treatment with benidipine (1, 3, and 5 mg/kg body weight, p.o.) or hydralazine (5 mg/kg body weight, p.o.), systolic blood pressure (SBP), urinary protein excretion, creatinine clearance, glomerulosclerosis index, tubulointerstitial lesion index, glomerular cross-sectional area, and glomerular expression of transforming growth factor-β (TGF-β) and α-smooth muscle actin (α-SMA) were measured. Results: Untreated rats developed hypertension, massive proteinuria, renal dysfunction, severe glomerular and tubulointerstitial injury, higher glomerular size, and marked glomerular staining for TGF-β and α-SMA, while uninephrectomized control rats did not. Each dose of benidipine and hydralazine equally reduced SBP to uninephrectomized control levels. Three and five mg/kg/day of benidipine increased creatinine clearance, ameliorated glomerular and tubulointerstitial injury, and reduced glomerular staining for TGF-β and α-SMA, but 1 mg/kg/day of benidipine and hydralazine failed. Only a dose of 5 mg/kg/day of benidipine reduced glomerular size, although it did not reduce the size to control levels. Conclusion: These results indicate that in a rat model of progressive mesangioproliferative GN, benidipine prevents the progression to end-stage renal failure in a dose-dependent manner. This renoprotective action is associated with the suppression of glomerular expression of TGF-β and α-SMA.

Monoclonal antibodies to human glomerular antigens: II. Using human adult kidney components as antigens

Using human kidney cortical homogenates and long-term cultured glomerular cells as antigens, the author produced three monoclonal antibodies to glomerular components; 25C reacted with the glomerular basement membrane (GBM) and the wall of blood vessels but with neither the tubular basement membrane (TBM) nor the Bowmans capsule, 33G reacted predominantly with the mesangium, and 34F reacted with glomeruli and the tubular brush border in a granular pattern. Both 25C and 33G exhibited the species-restricted property, and 34F reacted with glomeruli and tubular brush border of all the species examined. Overnight incubation of the kidney sections with 4.0 M urea revealed the reactivity of 25C to the TBM and Bowmans capsule. Dot immunobinding assay revealed that 25C did not react with the known extracellular matrices examined in this study, but rather with collagenase-digested GBM fraction. Also, 33G recognized fibronectin. Western blotting revealed the binding of 34F to the 145-kDa polypeptide solubilized from the kidney with 0.5 M NaCl, and also showed the binding of 25C to 210-kDa polypeptide of collagenase-digested GBM. These findings revealed structural variations in the basement membrane and the existence of a common antigen between the glomeruli and tubular brush border in the human kidney.

Immunolocalization of a fibronectin-binding proteoglycan (PG-P1) immunologically related to HSPG2/perlecan in normal and fibrotic human liver

Immunolocalization of a fibronectin-binding proteoglycan (PG-P1) in relation to fibronectin, type IV collagen and laminin, in normal and fibrotic human liver was investigated by light and electron microscopy. HS-42, which is a monoclonal antibody to PG-P1 and is reported to recognize a heparan sulfate proteoglycan named HSPG2/perlecan, was used for this purpose. Light microscopy in the human liver with minimal changes revealed that PG-P1 was present along the hepatic sinusoids as well as fibronectin and type IV collagen, whereas laminin was only weakly detected. In portal areas, PG-P1 was only localized on basement membranes around bile duct systems and blood vessels, as well as laminin and type IV collagen, while fibronectin was scarcely detected in basement membranes. In the fibrotic liver, fibronectin was abundant in necrotic and/or newly fibrosing areas, while PG-P1 was absent in these regions. Using immunoelectron microscopy, PG-P1 was localized in the space of Disse in nearly normal livers and was only detected on basement membranes in portal tracts. In fibrotic livers, PG-P1 in the space of Disse occasionally showed a basement-membrane-like deposition in parallel with the increased light microscopical deposition of laminin in this area, suggesting the positive participation of PG-P1 in the sinusoidal capillarization. Most capillary and sinusoidal endothelial cells, and rarely bile epithelial cells revealed the reaction products of PG-P1 in their rough endoplasmic reticulum and small vesicles. Thus, it was suggested that these cell types are mainly, if not wholly, responsible for PG-P1 production.(ABSTRACT TRUNCATED AT 250 WORDS)

Splenic Abscess in a Patient on Hemodialysis

Takamichi Nakamura, MD, The Second Department of Medicine, Yamanashi Medical School, Yamanashi 409-38 (Japan) Dear Sir, A splenic abscess is an unusual condition seen in immunocompromized patients or associated with intravenous drug abuse [1]. Several conditions including trauma, immunodeficiency, corticosteroid and/or immunosuppressive therapy and diabetes mellitus have been listed under the predisposing factors for a splenic abscess [1]. Splenic abscesses have not been reported in hemodialysis patients without any of these predisposing factors reported previously [1], although 2 hemodialysis patients with diabetes mellitus or immunosuppressive therapy were reported to develop splenic abscesses acquired through access site infection [2]. A 36-year-old man who had been on hemodialysis for 3 years was admitted with left hypochondralgia and fever. There was no history of trauma, blood access site infection, diabetes mellitus or immunosuppressive therapy. Nine years previously, he had had hematuria, proteinuria and hypertension. Renal biopsy confirmed mesangial proliferative glomerulonephritis. Over the next 6 years, he progressed to end-stage renal failure. After 3 years of maintenance hemodialysis, he had general fatigue and fever. He was treated with antibiotics (MINO, ENX, CXD, CEZ), since leukocytosis was found at the hemodialysis clinic. The symptoms did not respond to these antibiotics, and he was transferred to the renal unit in our hospital. On examination, there was tenderness in the left hypochondrium. There was no sign of hepatomegaly or ascites. There was no infected needle site related with A-V fistula. The white blood cell count was 26,300/mm3 with a severe left shift. Hb was 9.3 g/dl. ESR was 117/161 mm. CRP was 6 + . S-GOT, S-GPT, AI-P and LDH were normal. Chest X ray was normal. An ultrasound scan showed multiple hypoechoic lesions in the spleen (fig. la), and normal findings in liver, gallbladder and kidney. A computed tomography also showed multiple nonenhanced low density lesions in spleen (fig. lb), and normal findings in other intra-abdominal organs. No organism was grown from the blood. As shown in figure 2, he was treated with latamoxef (LMOX) for 8 days sequentially, and the fever resolved. Subsequently, he was treated with LMOX only after hemodialysis. An ultrasound scan examination revealed that the splenic abscess was getting smaller and finally resolved on the 30th hospital day. Antibiotic therapy was stopped when the ultrasound scan examination and