Successful treatment of severe crescentic lupus nephritis by multi-target therapy using tacrolimus and mycophenolate mofetil.

Treatment of severe lupus nephritis (LN) has been controversial, and according to recent guidelines and recommendations, cyclophosphamide still remains a first-line therapy. Herein, we present the case of a 37-year-old female patient who developed rapidly progressive glomerulonephritis, which was histologically diagnosed as class IV + V LN, with a large number of cellular to fibrocellular crescents (62 % of glomeruli). Although the patient was considered to have the most severe form of LN, complete remission was achieved within 6 months by multi-target therapy using tacrolimus and mycophenolate mofetil combined with methylprednisolone pulse therapy. Our experience suggests that multi-target therapy could be a potential treatment option for patients with severe crescentic LN.

Study of mizoribine therapy in elderly patients with membranous nephropathy: comparison with patients not receiving mizoribine.

BACKGROUND: We have previously reported the results of mizoribine (MZR) treatment for elderly patients with membranous nephropathy (MN). Here, we retrospectively compared these patients with those who had been initially treated with prednisolone (PSL) alone. METHODS: The subjects were patients with MN aged ≥65 years who were examined between April 2007 and September 2010 and followed for at least 1 year. RESULTS: The median period until the start of treatment in the MZR group (MZR-G) was 60 days. The urinary protein level at the start of MZR treatment was 3.89±2.3 g/gCr. Urinary protein in the group not treated with MZR (N-MZR-G) was 1.0±1.1 g/gCr, showing a tendency to improve in patients with nephrotic syndrome relative to the MZR-G (p=0.055). The PSL dose in the MZR-G versus N-MZR-G at 1 year was 5.7±3.0 versus 6.25±2.5 mg/day, the urinary protein level was 0.19±0.2 versus 0.13±0.1 g/gCr, and the remission rate was 80 versus 75%. In the MZR-G, the total PSL dose at 1 year after the start of MZR treatment was 5,058±1,904 versus 6,649±875 mg in the N-MZR-G. Adverse events occurred in 3/5 patients (60%) in the MZR-G and in 3/4 patients (75%) in the N-MZR-G. CONCLUSION: Elderly patients with MN who respond poorly to PSL treatment may be treated successfully with MZR.

A case of diffuse axonal injury in violent death.

A 59-year-old man was carried to the hospital by three men. The deceased was unconscious at admission and his face was severely swollen with many subcutaneous hemorrhages and extensive edema. His death was confirmed 17 min after resuscitation. A judicial autopsy was performed the next day. Findings showed that the victim's face and head were reddish and swollen, and that subscalp bleeding was ubiquitous, but no skull fracture, epi- and subdural hematoma or subarachnoidal bleeding was observed. The brain itself was severely edematous but no bleeding was found. Although small hemorrhages were seen in the limbs and back, there were no marked wounds except to the head. To determine the cause of death, we performed a microscopic histochemical examination. Conventional H.E. staining disclosed eosinophilic change, concentration of nuclei, edema, gliosis, and oozing at the corpus callosum. To identify further details of the cause of death, we used Bodian staining, Kluver-Barrera staining, anti-beta amyloid immunostaining, and anti-neurofilament immunostaining. We found sinusoidal swelling of axons and waving axons, which are typical findings of Diffuse Axonal Injury (DAI), but no positive staining of beta amyloid. Focal lesions of the corpus callosum and of the dorsolateral quadrant of the rostral brain stem, and diffuse damage to axons are considered to constitute the DAI triad. We therefore diagnosed the cause of death as DAI. Our experience shows that it is important to use several staining methods for diagnosis of a variety of neuronal degenerative disorders. Several days later, we were informed by the police that several men had hit and kicked the victim in an attempt to lynch him. To compare with this case, we also report two other cases in which DAI was observed.

Association between the GST genetic polymorphisms and methamphetamine abusers in the Japanese population.

Glutathione S-transferase (GST) plays a major role in the detoxification of many compounds by conjugation with glutathione. GSTM1 and T1, which are important members of the GST multigene family, are polymorphic in humans. Complete deletion of the gene results in the null genotype and loss of function. However, it is not clear whether deletion of this gene is associated with a vulnerability to methamphetamine (MAP) abuse. To clarify the potential role and mechanisms of genetic polymorphisms of GSTM1 and T1 in susceptibility to MAP abuse in the Japanese population, we investigated GSTM1 and T1 polymorphisms in subjects with diagnosed MAP-related disorders and in control groups. The risk of MAP abuse associated with GSTM1 null genotype was significantly higher only in females than in subjects with the GSTM1 genotype. GSTM1 and GSTT1 null genotype combined conferred increased risk for MAP abuse compared with GSTM1 and GSTT1 genotype combined. In conclusion, we found that GSTM1 gene deletion may contribute to a vulnerability to MAP abuse in female subjects. Moreover, we identified an association between GSTM1 and GSTT1 null genotype combined and risk of MAP abuse in the Japanese population.

Phenotypic differences in PFIC2 and BRIC2 correlate with protein stability of mutant Bsep and impaired taurocholate secretion in MDCK II cells.

Progressive familial cholestasis (PFIC) 2 and benign recurrent intrahepatic cholestasis (BRIC) 2 are caused by mutations in the bile salt export pump (BSEP, ABCB11) gene; however, their prognosis differs. PFIC2 progresses to cirrhosis and requires liver transplantation, whereas BRIC2 is clinically benign. To identify the molecular mechanism(s) responsible for the phenotypic differences, eight PFIC2 and two BRIC2 mutations were introduced in rat Bsep, which was transfected in MDCK II cells. Taurocholate transport activity, protein expression, and subcellular distribution of these mutant proteins were studied in a polarized MDCK II monolayer. The taurocholate transport activity was approximately half of the wild-type (WT) in BRIC2 mutants (A570T and R1050C), was substantially less in two PFIC2 mutants (D482G and E297G), and was almost abolished in six other PFIC2 mutants (K461E, G982R, R1153C, R1268Q, 3767-3768insC, and R1057X). Bsep protein expression levels correlated closely with transport activity, except for R1057X. The half-life of the D482G mutant was shorter than that of the WT (1.35 h vs. 3.49 h in the mature form). BRIC2 mutants and three PFIC mutants (D482G, E297G, and R1057X) were predominantly distributed in the apical membrane. The other PFIC2 mutants remained intracellular. The R1057X mutant protein was stably expressed and trafficked to the apical membrane, suggesting that the COOH-terminal tail is required for transport activity but not for correct targeting. In conclusion, taurocholate transport function was impaired in proportion to rapid degradation of Bsep protein in the mutants, which were aligned in the following order: A570T and R1050C > D482G > E297G > K461E, G982R, R1153C, R1268Q, 3767-3768insC, and R1057X. These results may explain the phenotypic difference between BRIC2 and PFIC2.

Eight-week oral administration of meloxicam, a non-steroidal anti-inflammatory drug, prevents dose reduction of pegylated interferon alpha-2a in the treatment of chronic hepatitis C.

AIM: We conducted a trial to evaluate whether eight-week oral administration of meloxicam, a non-steroidal anti-inflammatory drug, would decrease the rate of the patients who required dose reduction of pegylated interferon alpha-2a in the treatment of chronic hepatitis C. METHODS: Sixty patients given weekly subcutaneous administration of pegylated interferon alpha-2a at a dose of 180 mug for 48 weeks were allocated into the meloxicam group (n = 22) and the control group (n = 38) before interferon treatment. Meloxicam was given orally at a dose of 10 mg once a day for eight weeks from the start of interferon treatment. RESULTS: The cumulative rate of dose-reduction-free patients was significantly higher in the meloxicam group (P < 0.05). Until week eight, 44.7% of the control group and 9.1% of the meloxicam group required dose reduction. Dose was modified by neutropenia in 31.6% and 18.2% of the control and meloxicam groups, respectively. Meloxicam relieved a declineof neutrophil count within the first eight weeks from 54.2% to 44.2% (P < 0.05). Multivariate analysis revealed that greater pretreatment neutrophil count and the use of meloxicam were independent factors associated with avoiding dose reduction. Sustained virological response was obtained in 52.6% of the patients. The multivariate logistic analysis revealed that viral serotype and viral load were the only independent factors associated with sustained virological response. CONCLUSION: Eight-week administration of meloxicam prevented dose reduction of pegylated interferon by relieving a decline of neutrophil count in the treatment of chronic hepatitis C.

Two N-linked glycans are required to maintain the transport activity of the bile salt export pump (ABCB11) in MDCK II cells.

The aim of this study was to determine the role of N-linked glycosylation in protein stability, intracellular trafficking, and bile acid transport activity of the bile salt export pump [Bsep (ATP-binding cassette B11)]. Rat Bsep was fused with yellow fluorescent protein, and the following mutants, in which Asn residues of putative glycosylation sites (Asn(109), Asn(116), Asn(122), and Asn(125)) were sequentially replaced with Gln, were constructed by site-directed mutagenesis: single N109Q, double N109Q + N116Q, triple N109Q + N116Q + N122Q, and quadruple N109Q + N116Q + N122Q + N125Q. Immunoblot and glycosidase cleavage analysis demonstrated that each site was glycosylated. Removal of glycans decreased taurocholate transport activity as determined in polarized MDCK II cells. This decrease resulted from rapid decay of the mutant Bsep protein; biochemical half-lives were 3.76, 3.65, 3.24, 1.35, and 0.52 h in wild-type, single-mutant, double-mutant, triple-mutant, and quadruple-mutant cells, respectively. Wild-type and single- and double-mutant proteins were distributed exclusively along the apical membranes, whereas triple- and quadruple-mutant proteins remained intracellular. MG-132 but not bafilomycin A(1) extended the half-life, suggesting a role for the proteasome in Bsep degradation. To determine whether a specific glycosylation site or the number of glycans was critical for protein stability, we studied the protein expression of combinations of N-glycan-deficient mutants and observed that Bsep with one glycan was considerably unstable compared with Bsep harboring two or more glycans. In conclusion, at least two N-linked glycans are required for Bsep protein stability, intracellular trafficking, and function in the apical membrane.

Effect of in vitro interferon-beta administration on hepatitis C virus in peripheral blood mononuclear cells as a predictive marker of clinical response to interferon treatment for chronic hepatitis C.

AIM: To test whether in vitro incubation of peripheral blood mononuclear cells (PBMC) with interferon (IFN) could efficiently decrease hepatitis C virus-RNA (HCV-RNA) amount and to analyze whether this effect was associated with clinical response to IFN. METHODS: Twenty-seven patients with histologically proven chronic hepatitis C were given intravenous administration of 6 million units (MU) IFN-beta daily for 6 weeks followed by three times weekly for 20 weeks. PBMC collected before IFN therapy were incubated with IFN-beta and HCV-RNA in PMBC was semi-quantitatively determined. RESULTS: Twenty-five patients completed IFN therapy. Eight patients (32%) had sustained loss of serum HCV-RNA with normal serum ALT levels after IFN therapy (complete responders). HCV-RNA in PBMC was detected in all patients, whereas it was not detected in PBMC from healthy subjects. In vitro administration of IFN-beta decreased the amount of HCV-RNA in PMBC in 18 patients (72%). Eight of these patients obtained complete response. On the other hand, none of the patients whose HCV-RNA in PBMC did not decrease by IFN-beta was complete responders. Multiple logistic regression analysis revealed that the decrease of HCV-RNA amount in PBMC by IFN-beta was the only independent predictor for complete response (P<0.05). CONCLUSION: The effect of in vitro IFN-beta on HCV in PBMC reflects clinical response and would be taken into account as a predictive marker of IFN therapy for chronic hepatitis C.