High Ferritin Is Not Needed in Hemodialysis Patients: A Retrospective Study of Total Body Iron and Oral Iron Replacement Therapy.

In vivo iron levels can be adjusted through intestinal iron absorption to be maintained at a suitable level; however, optimal iron levels in hemodialysis (HD) patients are unclear. In this study, we investigated total body iron (TBI), calculated as the sum of red blood cell (RBC) iron and iron stores, during courses of low-dose oral iron replacement therapy, and evaluated in vivo iron sufficiency and its indicators in HD patients. We analyzed data on 105 courses of low-dose iron replacement therapy administered to 83 patients on maintenance HD over 7 months. We evaluated changes in TBI, RBC iron, and iron stores from the initiation of treatment to month 7 in two groups of patients, namely, iron-therapy responders and non-responders. TBI showed significant increases until month 4 and plateaued thereafter in iron-therapy responders, and tended to increase and then reached a similar plateau in non-responders (month 7: 1900 ± 447 vs. 1900 ± 408 mg). Steady-state TBI was strongly correlated with body surface area (y = 1628.6x - 791.91, R2 = 0.88, p < 0.001). We observed constant TBI during oral iron replacement therapy suggesting the activation of a "mucosal block". The results suggest that body surface area has utility for estimating the required TBI with regression equations.

Hypoxia-Inducible Factor Prolyl Hydroxylase Inhibitors and Iron Metabolism.

The production of erythropoietin (EPO), the main regulator of erythroid differentiation, is regulated by hypoxia-inducible factor (HIF). HIF2α seems to be the principal regulator of EPO transcription, but HIF1α and 3α also may have additional influences on erythroid maturation. HIF is also involved in the regulation of iron, an essential component in erythropoiesis. Iron is essential for the organism but is also highly toxic, so its absorption and retention are strictly controlled. HIF also induces the synthesis of proteins involved in iron regulation, thereby ensuring the availability of iron necessary for hematopoiesis. Iron is a major component of hemoglobin and is also involved in erythrocyte differentiation and proliferation and in the regulation of HIF. Renal anemia is a condition in which there is a lack of stimulation of EPO synthesis due to decreased HIF expression. HIF prolyl hydroxylase inhibitors (HIF-PHIs) stabilize HIF and thereby allow it to be potent under normoxic conditions. Therefore, unlike erythropoiesis-stimulating agents, HIF-PHI may enhance iron absorption from the intestinal tract and iron supply from reticuloendothelial macrophages and hepatocytes into the plasma, thus facilitating the availability of iron for hematopoiesis. The only HIF-PHI currently on the market worldwide is roxadustat, but in Japan, five products are available. Clinical studies to date in Japan have also shown that HIF-PHIs not only promote hematopoiesis, but also decrease hepcidin, the main regulator of iron metabolism, and increase the total iron-binding capacity (TIBC), which indicates the iron transport capacity. However, concerns about the systemic effects of HIF-PHIs have not been completely dispelled, warranting further careful monitoring.

Oral Iron Absorption of Ferric Citrate Hydrate and Hepcidin-25 in Hemodialysis Patients: A Prospective, Multicenter, Observational Riona-Oral Iron Absorption Trial.

Oral ferric citrate hydrate (FCH) is effective for iron deficiencies in hemodialysis patients; however, how iron balance in the body affects iron absorption in the intestinal tract remains unclear. This prospective observational study (Riona-Oral Iron Absorption Trial, R-OIAT, UMIN 000031406) was conducted at 42 hemodialysis centers in Japan, wherein 268 hemodialysis patients without inflammation were enrolled and treated with a fixed amount of FCH for 6 months. We assessed the predictive value of hepcidin-25 for iron absorption and iron shift between ferritin (FTN) and red blood cells (RBCs) following FCH therapy. Serum iron changes at 2 h (ΔFe2h) after FCH ingestion were evaluated as iron absorption. The primary outcome was the quantitative delineation of iron variables with respect to ΔFe2h, and the secondary outcome was the description of the predictors of the body's iron balance. Generalized estimating equations (GEEs) were used to identify the determinants of iron absorption during each phase of FCH treatment. ΔFe2h increased when hepcidin-25 and TSAT decreased (-0.459, -0.643 to -0.276, p = 0.000; -0.648, -1.099 to -0.197, p = 0.005, respectively) in GEEs. FTN increased when RBCs decreased (-1.392, -1.749 to -1.035, p = 0.000) and hepcidin-25 increased (0.297, 0.239 to 0.355, p = 0.000). Limiting erythropoiesis to maintain hemoglobin levels induces RBC reduction in hemodialysis patients, resulting in increased hepcidin-25 and FTN levels. Hepcidin-25 production may prompt an iron shift from RBC iron to FTN iron, inhibiting iron absorption even with continued FCH intake.

Threshold of Serum Ferritin to Discriminate against Those at Greater Risk of Platelet Increase during Treatment with Hypoxia-Inducible Factor Prolyl Hydroxylase Domain Inhibitor.

INTRODUCTION: Hypoxia-inducible factor prolyl hydroxylase domain inhibitors (HIF-PHI) are a new treatment for renal anemia. HIF-PHI is believed to increase iron usage to improve availability of iron for erythropoiesis. Therefore, there is concern that HIF-PHI might be prone to iron deficiency and that thrombosis might be induced by increased platelet and transferrin levels due to this iron deficiency. METHODS: Relationship of iron-related factors with platelet count (PLT) and total iron-binding capacity (TIBC; which reflects the transferrin level) were examined in 29 patients who were treated with darbepoetin alfa (DA) and then switched to roxadustat (Rox). To determine how changes in PLT and TIBC related to changes in iron-related factors, univariable and multivariable linear regression models were applied. To examine what iron-related factors on Day 0 influenced change in PLT, we used receiver operating characteristic (ROC) curves and logistic regression analysis for a rate of change in PLT ≤0% as the endpoint. Logistic regression analysis was performed with the reference group having serum ferritin (s-ft) or Transferrin saturation below the corresponding cutoff value (low vs. high). RESULTS: Multivariable analysis showed significant positive correlations between the rate of change in PLT and the change in s-ft and red blood cells (RBC) count {ß-coefficients; 0.40 [95% confidence interval (CI): 0.17-0.62], p = 0.001} (ß-coefficients; 30.45 [95% CI: 10.90-50.00], p = 0.004). The rate of change in TIBC was significantly positively correlated with only the change in RBC count. The ROC showed a significant cutoff value for s-ft of 77.2 ng/mL (sensitivity 63.6%, specificity 83.3%, area under the curve 0.76, 95% CI 0.55-0.96). Multivariable logistic regression also showed that only high s-ft was significantly elevated (9.46, 95% CI 1.42-63.30, p = 0.020). CONCLUSIONS: This study showed that changes in PLT were correlated with s-ft and amount of hematopoiesis. This suggests that an increase in PLT due to iron levels is less likely when s-ft is 77.2 ng/mL or higher at the time of switching from DA to Rox. In contrast, TIBC was only related to hematopoiesis in these patients. Control of s-ft before initiation of HIF-PHI treatment and gradual hematopoiesis might reduce the risk of thrombosis when switching from erythropoiesis-stimulating agents to HIF-PHI.

A Hypoxia-Inducible Factor Stabilizer Improves Hematopoiesis and Iron Metabolism Early after Administration to Treat Anemia in Hemodialysis Patients.

Roxadustat (Rox), a hypoxia-inducible factor (HIF) stabilizer, is now available for the treatment of anemia in hemodialysis (HD) patients. To investigate hematopoietic effect and iron metabolism, this study involved 30 HD patients who were initially treated with darbepoetin (DA), a conventional erythropoietin-stimulating agent, and then switched to Rox. We measured erythrocyte, reticulocyte indices, and iron-related factors at every HD during the first two weeks after the treatment switch (Days 0-14) and again on Days 21 and 28. We measured erythropoietin (EPO) concentration every week and examined their changes from Day-0 values. The same variables were measured in 15 HD patients who continued DA at every HD for one week. Iron-related factors were also measured on Days 14 and 28. In the Rox group, hepcidin significantly decreased from Day 2. The reticulocyte hemoglobin content (CHr) significantly increased on Day 4, but decreased with a significant increase in reticulocyte count from Day 7. Log10(serum ferritin) significantly decreased after Day 11. Log10(EPO concentration) was lower at all time points. Compared with the DA group, the Rox group showed significant differences in all variables except CHr. These results suggest that Rox improves hematopoiesis and iron metabolism early after administration independent of EPO concentration.

Significance of Content of the Reticulocyte Hemoglobin in the Management of Renal Anemia.

Optimal iron level in hemodialysis patients remains a subject of debate. The reticulocyte hemoglobin content (CHr) is believed to reflect the concentration of iron required in the most recent hematopoiesis in the bone marrow. CHr is not influenced by any factors that measure direct hemoglobin (Hb) of reticulocytes and is considered a reliable indicator. The supply of iron for Hb synthesis is regulated by hepcidin-25 (Hep-25). However, CHr and Hep-25 measurements are not covered by the Japanese medical insurance system. Serum ferritin (s-ft) and transferrin saturation (TSAT) are used mainly as indicators of internal iron status. Therefore, we examined the relationships among CHr, s-ft, TSAT, and Hep-25 to determine the optimal iron level. This report presents the clinical significance of CHr, the potential use of CHr for the diagnosis of iron deficiency, and tests for optimal iron level using CHr as performed in our hospital.

Low levels of serum ferritin lead to adequate hemoglobin levels and good survival in hemodialysis patients.

BACKGROUND: The optimal level of serum ferritin (s-ft) for anemia control and good survival in hemodialysis (HD) patients remains unclear. A 10-year survey was performed to clarify the appropriate quantities of s-ft and investigate the relationships among s-ft, transferrin saturation (TSAT), and mortality in HD patients. METHODS: HD outpatients (n = 125) treated with erythropoiesis-stimulating agents (ESA) were followed for 10 years. The ESA and low-dose iron supplement dosages were adjusted to maintain the hemoglobin (Hb) at 10-11 g/dl, according to Japanese guidelines. The Kaplan-Meier method, log-rank tests, and the Cox proportional hazards model were used for performing the statistical analyses. The interactions among the Hb, s-ft, and TSAT were analyzed using a multiple linear regression model. Patients with TSAT ≥20% were classified according to the s-ft cutoff values: group 1 (s-ft <30 ng/ml); group 2 (s-ft 30-80 ng/ml); group 3 (s-ft >80 ng/ml); TSAT <20% was a predictor of poor outcome. RESULTS: The survival rate in group 2 was significantly higher than that in other groups (p = 0.013), and the Cox proportional hazards model analysis showed a good effect of low levels of s-ft on patients' survival. The multiple linear regression model showed a strong effect of s-ft on the Hb (log [s-ft], ß-coefficient -0.45: 95% confidence interval -0.65 to -0.26, p < 0.001). CONCLUSION: This study revealed that low levels of s-ft have a beneficial effect on the outcome of HD patients receiving ESA. Thus, the optimal s-ft level might be lower than that established previously for these patients.

Low-Dose Oral Iron Replacement Therapy Is Effective for Many Japanese Hemodialysis Patients: A Retrospective Observational Study.

Western guidelines recommend the use of intravenous iron supplementation for hemodialysis patients. However, in Japanese patients with well-controlled inflammation, iron replacement may be achieved with oral iron supplementation. This study involved 108 courses in 77 outpatient hemodialysis patients who received low-dose oral iron replacement therapy. Data from baseline to week 28 of treatment were analyzed to identify factors associated with effectiveness. Changes over time in erythrocyte- and iron-related parameters and erythropoiesis-stimulating agent (ESA) dose were investigated in the effective group. A total of 84 courses (77.8%) satisfied the effectiveness criteria. Compared with the effective and ineffective groups, only C-reactive protein (CRP) was significantly different (p < 0.01). ROC curve analysis with efficacy as the endpoint showed a CRP cut point value of ≤0.1 mg/dL (area under the curve, 0.69; 95% confidence interval, 0.57−0.81). The relationship between serum ferritin and hemoglobin fluctuation by reducing the ESA dose showed a positive correlation (p < 0.001). In the ESA maintenance group, the serum ferritin gradually increased and then remained constant at about 60 ng/mL. Our data suggest that patients with CRP ≤ 0.1 mg/dL may benefit from low doses of oral iron supplementation. Approximately 60 ng/mL serum ferritin may be sufficient during stable hematopoiesis.

Hypoxia-inducible factor prolyl hydroxylase domain inhibitor may maintain hemoglobin synthesis at lower serum ferritin and transferrin saturation levels than darbepoetin alfa.

BACKGROUND: Hypoxia-inducible factor (HIF) prolyl hydroxylase domain inhibitors, which have recently become clinically available for treating renal anemia, are attracting attention for their novel mechanisms of action. METHODS: Relationships of reticulocyte hemoglobin content (CHr), which reflects recent Hb synthesis, with serum ferritin (s-ft) and transferrin saturation (TSAT) were examined in 30 patients on hemodialysis after switching from darbepoetin alfa (DA) to roxadustat (Rox). Iron deficiency was defined as CHr < 32.0 pg. Cutoff values of s-ft and TSAT were determined using receiver operating characteristic curves for the endpoint CHr ≥ 32.0 pg. Logistic analysis was performed with the reference group having s-ft or TSAT below the corresponding cutoff value (low vs high). RESULTS: With the endpoint CHr ≥ 32.0 pg on Day 0, cutoff values for s-ft and TSAT were respectively 49.7 ng/mL and 21.6% on Day 0 and 35.5 ng/mL and 16.2% on Day 28. With the endpoint CHr ≥ 32.0 pg on Day 28, cutoff values for s-ft and TSAT on Day 0 were 81.6 ng/mL and 23.9%, respectively. According to multivariable logistic analysis, the odds ratios of CHr ≥ 32.0 pg on Day 0 were significantly higher for high TSAT on Day 0 [34.7 (95% CI 2.42-131.0), p<0.003] and Day 28 [24.8 (95% CI 2.75-224.0), p = 0.004]. There were no significant differences by s-ft. Odd ratios of CHr ≥ 32.0 pg on Day 28 were also significantly higher for high s-ft on Day 0 [16.0 (95% CI 1.57-163.0), p = 0.019] and high TSAT on Day 0 [13.5 (95% CI 1.24-147.0), p<0.033]. CONCLUSIONS: Our results suggest Hb synthesis was maintained with lower TSAT and s-ft during Rox therapy compared with DA therapy. To avoid iron deficiency during the 4 weeks after switching DA to Rox, ideal s-ft and TSAT levels before the switch are 81.6 ng/mL and 23.9%, respectively.

Utilization of three-dimensional computed tomography for papillary thyroid carcinoma arising in the thyroglossal duct remnant: report of a case.

This report presents a rare and interesting case of papillary thyroid carcinoma arising in a thyroglossal duct remnant (TDR) that was diagnosed by three-dimensional computed tomography (3DCT). The patient, a 61-year-old woman, presented with a painless mass in the anterior suprahyoid region that had gradually enlarged over a 2-year period. Three-dimensional CT successfully revealed the thyroglossal duct (TD) descending from the tumor to the isthmus of the thyroid. An ultrasonography-guided fine-needle aspiration biopsy of the tumor was positive for carcinoma. A total thyroidectomy was performed in addition to the Sistrunk procedure. The histological findings indicated papillary thyroid carcinoma arising in the TDR and thyroid papillary microcarcinoma in the left thyroid lobe. The patient underwent radioactive iodine ablation and thyroid suppression therapy. This is apparently the first reported case of papillary thyroid carcinoma arising in a TDR evaluated using 3DCT. Three-dimensional CT was able to clarify the relative locations of the tumor, TD, and thyroid in the present case, and visualization of the TD allowed a definitive preoperative diagnosis that would not otherwise have been possible using conventional imaging techniques. This case suggests that 3DCT may therefore play an important role in providing definitive information on patients with anterior neck masses that are difficult to diagnose.

High serum magnesium levels are associated with favorable prognoses in diabetic hemodialysis patients, retrospective observational study.

BACKGROUND: Recent studies have found hypomagnesemia is linked to a heightened risk of cardiovascular events and mortality in hemodialysis (HD) patients; however, the level of serum magnesium (s-Mg) necessary for promoting overall health in these patients and the effects of s-Mg in diabetes HD patients remains to be clarified. METHODS: HD outpatients (n = 148 under, age ≤ 70 y) were followed over a 6-y period. They were divided into four groups according to their average s-Mg during the first year (L; low level, H; high level) and if they had DM or not (non-DM). The endpoint was mortality and hospitalization for decline of Activities of Daily Living (death/hospitalization). A receiver operating characteristics curve was used in diagnostic tests to identify s-Mg associated with this endpoint. Kaplan-Meier, log-rank test, and a Cox proportional hazards model were used to evaluate prognoses. Fisher's exact test and multiple regressions examined the causes of the endpoints between the four groups and the factors predictive of s-Mg. RESULTS: s-Mg at 2.7 mg/dL was associated with death/hospitalization. The 5-y survival rate was 38.1%, 86.7%, 73.2% and 87.5%, in the DM/Mg(L), DM/Mg(H), non-DM/Mg(L) and non-DM/Mg(H) groups, respectively (P < 0.001). The Cox proportional hazards model showed significantly lower risk in other groups compared with that in the DM/Mg(L) group [DM/Mg(H); hazard ratio (HR): 0.22, 95% confidence interval (CI): 0.05-0.97, P = 0.046, non-DM/Mg(L); HR: 0.32, 95% CI: 0.15-0.68, P = 0.003, non-DM/Mg(H); HR: 0.17, 95% CI: 0.06-0.44, P < 0.001]. The frequency of the different causes of the endpoints for each group was not significant; s-Mg only associated with age in the DM group. CONCLUSIONS: s-Mg greater than 2.7 mg/dL associated with a favorable prognosis in HD patients with DM, suggesting that s-Mg is a factor independent of diabetes.

Reticulocyte hemoglobin content.

Iron deficiency leads to the suppression of hemoglobin (Hb) synthesis and induces metabolic disorders. In contrast, iron overload not only reduces the iron utilization efficiency but also induces oxidative stress. Iron metabolism in the body is closely regulated by hepcidin, a short peptide produced by the liver. Unfortunately, conventional iron indices may not always accurately reflect the iron status. For example, Hb concentration assessed using mature erythrocytes do not accurately reflect the real-time iron status due to their long lifespan. Reticulocytes are differentiated from erythroblasts after Hb synthesis and transform into mature erythrocytes in 1-2 days upon release into peripheral blood. Thus, Hb content in reticulocytes (Hb-ret) is more reflective of real-time Hb synthesis. Moreover, Hb-ret is affected only by the amount of iron intake as long as there is no hematopoietic disorder. Reticulocyte Hb content (CHr) can be accurately and inexpensively measured as Hb-ret by commercial H*3 or ADVIA hematology analyzers. CHr has been shown to be more effective than other indices of iron metabolism for the diagnosis of iron deficiency, for early detection of the therapeutic effects of iron therapy, and for differentiation of the beta thalassemia trait.

The target hemoglobin content values of reticulocytes for efficient anemia improvement are achieved by low ferritin levels and moderate transferrin saturation: a retrospective observational study.

Objectives: The optimal iron level in hemodialysis (HD) patients remains unclear. The hemoglobin content of reticulocytes (CHr) is a sensitive indicator of iron used for hematopoiesis. To identify the optimal iron content for HD patients, we investigated the relation between CHr levels and iron status, as well as the levels of hepcidin, a main regulator of iron metabolism.Methods: This study enrolled 181 HD outpatients treated with recombinant human erythropoietin (rHuEPO). A sensitivity analysis, using a generalized linear regression model that included the interaction term, was applied to determine the correlations between levels of CHr and those of serum ferritin (s-ft), transferrin saturation (TSAT), and hepcidin.Results: The greatest changes in correlation coefficients for levels of s-ft and TSAT with CHr levels indicated optimal cut-off points of 50 ng/mL (≤50 ng/mL, r = 0.47 vs >50 ng/mL, r = 0.22) and 24% (≤24%, r = 0.58 vs >24%, r = 0.08), respectively. The correlation coefficient for levels of CHr and hepcidin showed that the optimal lower and upper cut-off points were 20 ng/mL (≤20 ng/mL, r = 0.52 vs >20 ng/mL, r = -0.01) and 70 ng/mL (≤70 ng/mL, r = 0.36 vs >70 ng/mL, r = -0.45), respectively.Discussion: This study indicates that the amount of iron in HD patients is sufficient for hematopoiesis under conditions of low s-ft and moderate TSAT levels. High levels of hepcidin could induce negative iron metabolism in hematopoiesis.Conclusion: Therefore, controlling hepcidin levels to within approximately 20-70 ng/mL may prevent iron deficiency and reduced Hb synthesis, and may thus facilitate effective iron utilization in hematopoiesis.

Follicular carcinoma arising from the pyramidal lobe of the thyroid.

We present a rare case of follicular carcinoma arising from the pyramidal lobe of the thyroid in a 21-year-old woman. Radical resection of the thyroid isthmus was performed, followed by adjuvant hormonal therapy with levothyroxine. After 15 months of follow-up, the patient remains disease-free. Thyroid carcinoma in children and adolescents is rare, and also rarely arises in the pyramidal lobe. To our knowledge, this is the first report of this type of neoplasm arising from the thyroid pyramidal lobe. We are following up this case carefully, and if recurrence or metastasis or both occur, we plan to perform total thyroidectomy and ablation with (131)I. This case suggests the importance of the differential diagnosis of midline cervical masses and the management of this type of neoplasm in adolescents.

Renal Anemia and Iron Metabolism.

Normal iron metabolism is essential for effective hemoglobin (Hb) production in the management of renal anemia. Considering that studies regarding the optimal Hb levels predated the creation of the iron management indices found in the treatment guidelines for hemodialysis (HD) patients, an increase in the Hb levels caused by intravenous iron supplementation has been used as an iron management index. However, no consideration was given to iron metabolism or the long-term safety of intravenous iron supplementation. Although iron is a vital trace element in humans, it can also be toxic, and its metabolism is carefully controlled, with several factors affecting it. Considering that the details regarding the mechanisms underlying iron metabolism have been elucidated recently, a study regarding iron management that is safe and considers iron metabolism status effective for Hb production in patients with renal anemia is warranted. This study presents information regarding iron metabolism in patients on HD, the factors that influence iron metabolism in such patients, and the problems with existing treatment guidelines in Japan, apart from discussing the optimal iron levels and optimal Hb production indices.

Low levels of serum ferritin and moderate transferrin saturation lead to adequate hemoglobin levels in hemodialysis patients, retrospective observational study.

BACKGROUND: Optimal iron levels in patients on hemodialysis are currently unknown, and a higher level than that for the healthy population is usually set for such patients considering the use of erythropoiesis-stimulating agents or the occurrence of chronic inflammation. However, excessive iron causes oxidative stress and impairment of its utilization by cells. Therefore we investigated the relationship between hemoglobin (Hb) level and iron status in hemodialysis patients to identify the optimal iron levels for patients undergoing hemodialysis. METHODS: A total of 208 outpatients on maintenance hemodialysis were followed up between July 2006 and June 2007. Men accounted for 64.9% cases [mean age, 59.3 ± 13.1 years and median dialysis history, 7.7 (3.6-13.2) years], and diabetic nephropathy accounted for 25.0% cases. Hemoglobin level was measured twice a month and serum ferritin, serum iron, and total iron-binding capacity were measured once a month. The doses of recombinant human erythropoietin and low-dose iron supplement were adjusted to maintain a hemoglobin level of 10-11 g/dL, according to the guidelines of the Japanese Society for Dialysis Therapy. Hepcidin was measured at baseline. Using the mean values for 1-year period, the relationships among hemoglobin, serum ferritin levels, and transferrin saturation levels were investigated based on a receiver operating characteristic curve and a logistic regression model. In addition, the correlations among serum ferritin, transferrin saturation, and hepcidin levels were analyzed by Pearson product-moment correlation coefficient and linear regression model. RESULTS: By receiver operating characteristic curve, the cutoff point of serum ferritin and transferrin saturation levels with a hemoglobin ≥10 g/dL showed <90 ng/mL (sensitivity: 69.1%, specificity: 72.1%, p < 0.001) and ≥20% (sensitivity: 77.6%, specificity: 48.8%, p = 0.302). Upon logistic regression model analysis with a hemoglobin ≥10 g/dL as the endpoint, the analysis of odds ratios relative to a group with serum ferritin ≥90 ng/mL and transferrin saturation <20% revealed that the group with serum ferritin <90 ng/mL and transferrin saturation ≥20% had the highest ratio: 46.75 (95% confidence interval: 10.89-200.70, p < 0.001). In Pearson product-moment correlation coefficient, hepcidin showed a strong positive correlation with serum ferritin [r = 0.78 (95% confidence interval: 0.72-0.83, p < 0.001)] and a weak positive correlation with transferrin saturation [r = 0.18 (95% confidence interval: 0.04-0.31, p = 0.010)]. In the multivariable analyses of the linear regression model, a positive relationship was shown between hepcidin and serum ferritin [ß-coefficient of 0.30 (95% confidence interval: 0.27-0.34, p < 0.001)]; however, no relationship was shown with transferrin saturation [ß-coefficient of 0.09 (95% confidence interval: -0.31-0.49, p = 0.660)]. CONCLUSIONS: In this study, the iron status of serum ferritin <90 ng/mL and transferrin saturation ≥20% was optimal in hemodialysis patients receiving recombinant human erythropoietin for anemia therapy. This result indicates that the threshold values for the optimal iron status may be lower than those currently recommended in iron-level management guideline.

Intramolecular control of protein stability, subnuclear compartmentalization, and coactivator function of peroxisome proliferator-activated receptor gamma coactivator 1alpha.

Peroxisome proliferator-activated receptor gamma coactivator (PGC)-1 is a critical transcriptional regulator of energy metabolism. Here we found that PGC-1alpha is a short lived and aggregation-prone protein. PGC-1alpha localized throughout the nucleoplasm and was rapidly destroyed via the ubiquitin-proteasome pathway. Upon proteasome inhibition, PGC-1alpha formed insoluble polyubiquitinated aggregates. Ubiquitination of PGC-1alpha depended on the integrity of the C terminus-containing arginine-serine-rich domains and an RNA recognition motif. Interestingly, ectopically expressed C-terminal fragment of PGC-1alpha was autonomously ubiquitinated and aggregated with promyelocytic leukemia protein. Cooperation of the N-terminal region containing two PEST-like motifs was required for prevention of aggregation and targeting of the polyubiquitinated PGC-1alpha for degradation. This region thereby negatively controlled the aggregation properties of the C-terminal region to regulate protein turnover and intranuclear compartmentalization of PGC-1alpha. Exogenous expression of the PGC-1alpha C-terminal fragment interfered with degradation of full-length PGC-1alpha and enhanced its coactivation properties. We concluded that PGC-1alpha function is critically regulated at multiple steps via intramolecular cooperation among several distinct structural domains of the protein.

Tissue-specific expression of renin-angiotensin system components in IgA nephropathy.

BACKGROUND: The renin-angiotensin II system (RAS) has been implicated in the development of glomerulonephritis. The aims of this study were to determine (1) the expression of RAS components, angiotensin (Ang II)-forming enzymes [angiotensin-I-converting enzyme (ACE) and chymase], and Ang II receptors, and (2) the correlation between RAS expression and severity of tissue injury in IgA nephropathy (IgAN). METHODS: The expression levels of ACE, chymase, and Ang II type 1 and type 2 receptor (AT1R and AT2R) mRNAs were determined by in situ hybridization in renal specimens from 18 patients with IgAN, 5 patients with non-IgA mesangial proliferative glomerulonephritis (non-IgAN) and 10 patients with nonmesangial proliferative glomerulonephritis (minimal change nephrotic syndrome, n = 5, and membranous nephropathy, n = 5). Normal portions of surgically resected kidney served as control. RESULTS: In normal kidney, a few mesangial cells and glomerular and tubular epithelial cells weakly expressed ACE, chymase and AT1R mRNAs. In IgAN and non-IgAN samples, ACE, chymase, AT1R and AT2R mRNAs were expressed in resident glomerular cells, including mesangial cells, glomerular epithelial cells and cells of Bowman's capsule. The glomerular expressions in IgAN were stronger than in minimal change nephrotic syndrome and membranous nephropathy. In IgAN, the expressions in glomeruli correlated with the degree of mesangial hypercellularity, whereas the expression levels were weaker at the area of mesangial expansion. IgAN with severe tubulointerstitial injury showed expression of ACE, chymase, AT1R and AT2R mRNAs in atrophic tubules and infiltrating cells and such expression correlated with the degree of tubulointerstitial damage. CONCLUSION: Our results suggest that renal cells can produce RAS components and that locally synthesized Ang II may be involved in tissue injury in IgAN through Ang II receptors in the kidney.

Identification and characterization of a novel human sphingosine-1-phosphate phosphohydrolase, hSPP2.

Sphingosine 1-phosphate (S1P) is a bioactive lipid molecule that acts as both an extracellular signaling mediator and an intracellular second messenger. S1P is synthesized from sphingosine by sphingosine kinase and is degraded either by S1P lyase or by S1P phosphohydrolase. Recently, mammalian S1P phosphohydrolase (SPP1) was identified and shown to constitute a novel lipid phosphohydrolase family, the SPP family. In this study we have identified a second human S1P phosphohydrolase, SPP2, based on sequence homology to human SPP1. SPP2 exhibited high phosphohydrolase activity against S1P and dihydrosphingosine 1-phosphate. The dihydrosphingosine-1-phosphate phosphohydrolase activity was efficiently inhibited by excess S1P but not by lysophosphatidic acid, phosphatidic acid, or glycerol 3-phosphate, indicating that SPP2 is highly specific to sphingoid base 1-phosphates. Immunofluorescence microscopic analysis demonstrated that SPP2 is localized to the endoplasmic reticulum. Although the enzymatic properties and localization of SPP2 were similar to those of SPP1, the tissue-specific expression pattern of SPP2 was different from that of SPP1. Thus, SPP2 is another member of the SPP family that may play a role in attenuating intracellular S1P signaling.

Catalog of 680 variations among eight cytochrome p450 ( CYP) genes, nine esterase genes, and two other genes in the Japanese population.

We screened DNAs from 48 Japanese individuals for single-nucleotide polymorphisms (SNPs) in eight cytochrome p450 ( CYP) genes, nine esterase genes, and two other genes by directly sequencing the relevant genomic regions in their entirety except for repetitive elements. This approach identified 607 SNPs and 73 insertion/deletion polymorphisms among the 19 genes examined. Of the 607 SNPs, 284 were identified in CYP genes, 302 in esterase genes, and 21 in the other two genes ( GGT1, and TGM1); overall, 37 SNPs were located in 5' flanking regions, 496 in introns, 55 in exons, and 19 in 3' flanking regions. These variants should contribute to studies designed to investigate possible correlations between genotypes and phenotypes of disease susceptibility or responsiveness to drug therapy.