Effects to cerebral oxygenation by arteriovenous fistula creation in patients with chronic kidney disease.

BACKGROUND: Vascular access, including arteriovenous fistula (AVF), is essential in patients undergoing hemodialysis (HD). However, the presence of AVF is non-physiological in humans and could pose a burden to the systemic circulation or tissue microcirculation, potentially affecting tissue oxygenation, including in the brain. Recently, near-infrared spectroscopy has been used to measure regional oxygen saturation (rSO2) as a marker of cerebral oxygenation in various settings, including in patients undergoing HD. Thus far, no studies have reported changes in cerebral rSO2 before and after AVF creation. This study aimed to monitor the differences in cerebral oxygenation before and after AVF creation and to clarify the clinical factors affecting the changes in cerebral rSO2. METHODS: Forty-eight patients (34 men, 14 women) with chronic kidney disease (CKD) who were not undergoing dialysis and newly created AVF were recruited. Cerebral rSO2 values before and after AVF creation were evaluated using near-infrared spectroscopy (INVOS 5100c). RESULTS: Cerebral rSO2 values were significantly changed from 60.3% ± 7.5% to 58.4% ± 6.8% before and after AVF creation in all patients (p < 0.001). Cerebral rSO2 were also lower in patients with diabetes mellitus (DM) than in those without DM (57.5 ± 7.1 vs 63.7 ± 6.5, p = 0.003) before surgery; however, no differences of changes in cerebral rSO2 were observed between the two groups after AVF creation. Additionally, multivariate regression analysis identified changes in HR (standardized coefficient: 0.436) as independent factors associated with changes in cerebral rSO2. CONCLUSION: Surgically created AVF was associated with the deterioration of cerebral rSO2 in patients with CKD not undergoing dialysis. Notably, AVF could cause cerebral hypoxia, and thus further studies are needed to clarify the clinical factors influencing changes in cerebral oxygenation after AVF creation.

No Significant Changes of Glycemic Control and Renal Function in Patients with Advanced-Stage Diabetic Kidney Disease by Switching from Linagliptin to Teneligliptin.

PURPOSE: We compared the efficacy of teneligliptin versus linagliptin for glycemic control and renoprotection in patients with advanced-stage diabetic kidney disease. PATIENTS AND METHODS: Changes in the glycated hemoglobin (HbA1c), fasting blood glucose concentration, urine albumin-to-creatinine ratio (UACR), and estimated glomerular filtration rate (eGFR) during a 12-month period were retrospectively analyzed after switching from linagliptin to teneligliptin in 13 patients with advanced-stage diabetic kidney disease (teneligliptin group). Thirteen propensity score-matched patients who were treated with linagliptin alone served as controls (linagliptin group). RESULTS: The HbA1c, fasting blood glucose concentration, and UACR did not change during the 12-month study period in either group. The annual change rate in the eGFR did not differ between before and after baseline in either group. CONCLUSION: Switching from linagliptin to teneligliptin may not improve glycemic control, reduce urinary protein excretion, or ameliorate the rate of renal function decline in patients with advanced-stage diabetic kidney disease. These results suggest that teneligliptin may not be more advantageous for glycemic control and renoprotection compared with linagliptin in patients with advanced-stage diabetic kidney disease.

Effects of Roxadustat on the Anemia and Iron Metabolism of Patients Undergoing Peritoneal Dialysis.

Background: We investigated the effects of roxadustat on the anemia, iron metabolism, peritoneal membrane function, and residual renal function; and determined the factors associated with the administration of roxadustat in patients who were undergoing peritoneal dialysis. Methods: We retrospectively analyzed the changes in hemoglobin, serum ferritin, transferrin saturation (TSAT), 4-h dialysate/plasma creatinine, and renal weekly urea clearance over the 24 weeks following the change from an erythropoiesis-stimulating agent (ESA) to roxadustat in 16 patients who were undergoing peritoneal dialysis and had anemia (Roxadustat group). Twenty-three peritoneal dialysis patients who had anemia and continued ESA served as a control group (ESA group). Results: There were no significant differences in hemoglobin, serum ferritin, TSAT, 4-h dialysate/plasma creatinine, or renal weekly urea clearance between the two groups at baseline. The hemoglobin concentration was significantly higher in the Roxadustat group than in the ESA group after 24 weeks (11.6 ± 1.0 g/dL vs. 10.3 ± 1.1 g/dL, p < 0.05), whereas the ferritin concentration and TSAT were significantly lower (139.5 ± 102.0 ng/mL vs. 209.2 ± 113.1 ng/mL, p < 0.05; and 28.1 ± 11.5% vs. 44.8 ± 10.4%, p < 0.05, respectively). The changes in 4-h dialysate/plasma creatinine and renal weekly urea clearance did not differ between the two groups. Linear regression analysis revealed that the serum potassium concentration correlated with the dose of roxadustat at 24 weeks (standard coefficient = 0.580, p = 0.019). Conclusion: Roxadustat may improve the anemia and reduce the serum ferritin and TSAT of the peritoneal dialysis patients after they were switched from an ESA, without association with peritoneal membrane function or residual renal function.

Efficacy and Cardiovascular Adverse Events of Long-term Treatment with Tyrosine Kinase Inhibitors for Chronic Myeloid Leukemia: A Report from the Nagasaki CML Study Group.

Objective The standard treatment for chronic myeloid leukemia (CML) is the continuous use of tyrosine kinase inhibitors (TKIs), which results in a favorable prognosis for the majority of patients. Recent studies have identified cardiovascular diseases (CVDs) as late adverse events (AEs) related to TKIs. In this study, we evaluated the long-term efficacy and AEs of TKIs, focusing on CVDs. Methods We performed a retrospective survey of CML patients (diagnosed from 2001 to 2016) treated with TKIs in Nagasaki Prefecture. Clinical data were obtained from their medical records. We analyzed the survival, estimated cumulative incidence of CVDs, and risk factors for CVD among CML patients treated with TKIs. Results The overall survival rate of 264 CML patients treated with TKIs (median age 58 years old) was 89.6% [95% confidence interval (CI), 84.9-92.9%], and 80.5% (95% CI, 73.4-85.9%) at 5 and 10 years after the CML diagnosis, respectively. CVD events occurred in 26 patients (9.8%, median age 67.5 years old) with a median 65.5 months of TKI treatment. The cumulative incidences at 2 and 5 years was 2.4% (95% CI, 1.0-4.8%) and 5.2% (95% CI, 2.8-8.6%), respectively. Hypertension and a high SCORE chart risk at the diagnosis of CML were associated with CVD events during TKI treatment. Conclusion TKI treatment contributed to the long-term survival of CML patients in Nagasaki Prefecture in a "real-world" setting, but the incidence of CVDs seemed to be increased in these patients. A proper approach to managing risk factors for CVD is warranted to reduce CVD events during TKI treatment.

Effects of Elobixibat on Constipation and Lipid Metabolism in Patients With Moderate to End-Stage Chronic Kidney Disease.

OBJECTIVE: The aim of this study was to investigate the effects of elobixibat on constipation and lipid metabolism; and determine the factors associated with the effect of elobixibat on constipation in patients with moderate to end-stage chronic kidney disease (CKD). METHODS: Stool frequency and serum lipid parameters were retrospectively analyzed before and after 4 weeks of elobixibat administration in 42 patients (CKD stage G3, 6; stage G4, 9; stage G5, 9; stage G5D, 18). Relationships between the change in stool frequency after initiation of elobixibat and various clinical parameters were analyzed by using linear regression analysis. RESULTS: Elobixibat increased stool frequency from 0.5 ± 0.4 per day to 1.1 ± 0.6 per day (p < 0.001) regardless of whether patients were undergoing dialysis, on concomitant laxatives, or were administered elobixibat before or after breakfast. Elobixibat reduced low-density lipoprotein cholesterol concentration (from 90.9 ± 37.2 mg/dL to 77.5 ± 34.8 mg/dL, p < 0.05) and increased high-density lipoprotein cholesterol concentration (from 44.9 ± 14.3 mg/dL to 57.0 ± 25.8 mg/dL, p < 0.05), but did not change triglyceride concentration. Adverse effects were observed in two patients (nausea and diarrhea). Only phosphate concentration was correlated with the change in stool frequency after initiation of elobixibat (standard coefficient = 0.321, p = 0.043). CONCLUSIONS: Elobixibat improved constipation and lipid metabolism in patients with moderate to end-stage CKD, without serious adverse events.

Importance of correctly interpreting magnetic resonance imaging to diagnose posterior reversible encephalopathy syndrome associated with HELLP syndrome: a case report.

BACKGROUND: Severe haemolysis, elevated liver enzyme levels, and low platelet count (HELLP) syndrome in pregnancy are possible underlying trigger factors for posterior reversible encephalopathy syndrome (PRES). Magnetic resonance imaging (MRI) shows diffuse signal abnormalities involving the subcortical white matter in the parieto-occipital lobes. Although the diagnosis of RPES was clearly established by the distinctive reversibility of clinical and radiological abnormalities, it is difficult to distinguish from differential diagnosis. Thus, it is important to correctly interpret MRI. CASE PRESENTATION: We describe a case of HELLP syndrome with PRES. A 38-year-old pregnant woman was admitted to our hospital as an emergency case with a complaint of upper abdominal pain and headache at 29 weeks of pregnancy and the development of HELLP syndrome. An emergency caesarean section was immediately performed. After the operation, the patient received intravenous corticosteroids, and her blood pressure was controlled. Thereafter, she showed an altered mental status. MRI showed hypersignal intense lesions in the cortical and subcortical white matter in the occipital lobes, basal ganglia and callosal splenium in both the fluid-attenuated inversion recovery (FLAIR) sequence and apparent diffusion coefficient (ADC), but these lesions were not recognized in diffusion-weighted imaging (DWI). These images were suggestive of PRES. The patient was kept in the hospital and received the appropriate treatment, after which the patient's level of consciousness improved and all laboratory tests and imaging examinations returned normal. CONCLUSION: The MRI findings were useful for the prompt diagnosis of PRES, characterized by hypersignals in FLAIR and ADC, but not in DWI. Additionally, there was an "atypical" MRI appearance of basal ganglial and callosal splenial involvement in this case, which may mistakenly lead clinicians to diagnose other aetiologies than typical PRES. It is considered that vasogenic oedema is the main pathology of PRES according to the MRI image findings. MRI is the gold standard for diagnosing PRES because it can provide information about cerebral involvement earlier than CT; further, it can be a useful tool in the differential diagnosis. This technique facilitated the prompt diagnosis and treatment of the said patient, ultimately resulting in a good outcome.

Impact of risk factors for perinatal events in Japan: Introduction of a newly created perinatal event score.

AIM: A cohort study was performed to clarify the influence of risk factors on perinatal events (obstetric complications and/or perinatal deaths). METHODS: This cohort study reviewed 395 785 births from 2011 to 2013. Women with singleton pregnancies delivered after 22 weeks of gestation were included. The OR were determined on multivariate analysis. The perinatal event score (PES) for risk factors, which is the product of the OR of risk factors for obstetric complications, OR of risk factors for perinatal death, and OR of obstetric complications for perinatal death, was introduced to clarify the impact of each risk combination. RESULTS: There were 20 risk factors such as maternal age and medical complications relating to the 11 obstetric complications, including pregnancy-induced hypertension and preterm labor. As a result, 77 combinations of risk factors and obstetric complications were found to be significant. Six obstetric complications such as preterm labor and cervical insufficiency were found to be related to perinatal death. Two factors were found to be directly related to perinatal death: age >40 years old (OR, 1.24; 95%CI: 1.11-1.39) and essential hypertension (OR, 1.56; 95%CI: 1.19-2.05). As a result, PES ranged from 1.07 (primipara for premature rupture of membrane) to 40.1 (essential hypertension for placental abruption), and high PES (≥8) was identified in 21 combinations of risk factors and obstetric complications. CONCLUSION: This newly created score for perinatal events, PES, can be used as an indicator of the impact of risk factors on perinatal events.

Disseminated intravascular coagulopathy caused by uterine leiomyoma with sarcoma-like findings on magnetic resonance imaging.

A leiomyoma rarely causes disseminated intravascular coagulopathy (DIC). In the present report, we describe a case of DIC caused by leiomyoma. A 36-year-old nulliparous woman presented with hypermenorrhea and a lower abdominal mass. On magnetic resonance imaging, we detected a 14 cm uterine tumor, which was suspected to be a sarcoma. Blood tests at the preoperative examination indicated platelet count of 9.6 × 10(4)/µL, fibrin degradation product level of 107.1 µg/mL (normal value, 0-5.0 µg/mL), and fibrinogen level of 54 mg/dL (normal value, 129-271 mg/dL). Based on these findings, we diagnosed the patient with DIC. The patient was treated with nafamostat mesilate and fresh frozen plasma, but the DIC did not show any improvement. Subsequently, a hysterectomy was performed, after which the DIC improved. Clinicopathological findings indicated the presence of a leiomyoma with multiple vessels containing thromboemboli, and suggested that the DIC was caused by the leiomyoma. Therefore, it is essential to consider that that a benign leiomyoma may be a cause of DIC.

Prolapse of the small intestine from the uterine perforation at dilatation and curettage.

Dilatation and curettage (D&C) sometimes causes uterine perforation, which usually does not cause a serious problem. Here, we report uterine perforation caused by D&C, in which the small intestine prolapsed from the uterus, requiring intestinal resection. D&C was performed for missed abortion at 9 weeks. After dilating the cervix, forceps grasped tissue that, upon being pulled, resulted in the intestine being prolapsed into the vagina. Laparotomy revealed a perforation at the low anterior uterine wall, through which the ileum had prolapsed. The mesentery of the prolapsed ileum was completely detached and the ileum was necrotic, which was resected. The uterus and the intestine were reconstructed. Although intestinal prolapse is considered to be caused by "unsafe" D&C performed by inexperienced persons or even by nonphysicians in developing countries, this occurred in a tertiary center of a developed country. We must be aware that adverse events such as uterine perforation with intestinal prolapse can occur even during routine D&C.

Molecular analysis of the BCR-ABL1 kinase domain in chronic-phase chronic myelogenous leukemia treated with tyrosine kinase inhibitors in practice: study by the Nagasaki CML Study Group.

An appropriate trigger for BCR-ABL1 mutation analysis has not yet been established in unselected cohorts of chronic-phase chronic myelogenous leukemia patients. We examined 92 patients after 12 months of tyrosine kinase inhibitor (TKI) treatment in Nagasaki Prefecture, Japan. Univariate analysis revealed that significant factors associated with not attaining a major molecular response (MMR) were the presence of the minor BCR-ABL1 fusion gene, a low daily dose of TKI, and the emergence of BCR-ABL1 kinase domain mutations conferring resistance to imatinib. Factors associated with the loss of sustained MMR were a low daily dose of TKI and the emergence of alternatively spliced BCR-ABL1 mRNA with a 35-nucleotide insertion. Taken together, our results suggest that the search for BCR-ABL1 mutations should be initiated if patients have not achieved MMR following 12 months of TKI treatment.

Nedaplatin and irinotecan combination therapy is equally effective and less toxic than cisplatin and irinotecan for patients with primary clear cell adenocarcinoma of the ovary and recurrent ovarian carcinoma.

This study retrospectively compared nedaplatin and irinotecan hydrochloride (NDP/CPT) combination therapy with cisplatin and irinotecan hydrochloride therapy (CDDP/CPT) for efficacy and adverse events in the treatment of clear cell adenocarcinoma of the ovary (CCC) and recurrent ovarian carcinoma. A total of 115 patients were included in the present study. NDP/CPT was administered intravenously every 4 weeks (NDP, 60 mg/m(2) on day 1; CPT, 50 mg/m(2) on days 1, 8 and 15). CDDP/CPT was also administered intravenously (CDDP, 60 mg/m(2) on day 1; CPT, 60 mg/m(2) on days 1, 8 and 15). Patients with primary CCC were treated with NDP/CPT in 29 cases and CDDP/CPT in 20 cases. Patients with recurrent ovarian carcinoma were treated with NDP/CPT and CDDP/CPT in 33 cases each. No significant difference was observed in the 5-year overall survival (OS)/progression-free survival (PFS) of patients with primary CCC, with the exception of those patients with stages Ia and Ic(b) who underwent NDP/CPT and CDDP/CPT treatments (OS: 58%, PFS: 40% and OS: 53% and PFS: 47%, respectively). No significant differences were found in the response rates to NDP/CPT and CDDP/CPT in patients with recurrent ovarian carcinoma (27 and 18%, respectively). Similarly, there were no significant differences in the 5-year OS and PFS of patients with recurrent ovarian carcinoma treated with NDP/CPT or CDDP/CPT (OS: 15%, PFS: 3% and OS: 18%, PFS: 6%, respectively). In terms of the hematological toxicity of grade 3 or above and non-hematological toxicity of grade 2 or above in patients treated with NDP/CPT and CDDP/CPT, respectively, neutropenia was 23 and 56%; anemia, 1, and 20%; thrombocytopenia, 0 and 5%; nausea, 20 and 52%; diarrhea, 14 and 25%; and fever, 2 and 11%. Accordingly, NDP/CPT indicated mild toxicity, and was therefore equally effective and less toxic than CDDP/CPT in the treatment of primary CCC and recurrent ovarian carcinoma.

Downregulation of indoleamine-2,3-dioxygenase in cervical cancer cells suppresses tumor growth by promoting natural killer cell accumulation.

This study examined the role of the immunosuppressive enzyme indoleamine-2,3-dioxygenase (IDO) in cervical cancer progression and the possible use of this enzyme for cervical cancer therapy. We analyzed IDO protein expression in 9 cervical cancer cell lines (SKG-I, -II, -IIIa, -IIIb, SiHa, CaSki, BOKU, HCS-2 and ME-180) stimulated with interferon-γ. IDO expression was observed in all cell lines except for SKG-IIIb. We transfected the human cervical cancer cell line CaSki that constitutively expresses IDO with a short hairpin RNA vector targeting IDO, and established an IDO-downregulated cell line to determine whether inhibition of IDO mediates cervical cancer progression. IDO downregulation suppressed tumor growth in vivo, without influencing cancer cell growth in vitro. Moreover, IDO downregulation enhanced the sensitivity of cervical cancer cells to natural killer (NK) cells in vitro and promoted NK cell accumulation in the tumor stroma in vivo. These findings indicate that downregulation of IDO controls cervical cancer progression by activating NK cells, suggesting IDO as a potential therapy for cervical cancer.

Indoleamine-2,3-dioxygenase, an immunosuppressive enzyme that inhibits natural killer cell function, as a useful target for ovarian cancer therapy.

This study examined the role of the immuno-suppressive enzyme indoleamine-2,3-dioxygenase (IDO) in ovarian cancer progression, and the possible application of this enzyme as a target for ovarian cancer therapy. We transfected a short hairpin RNA vector targeting IDO into the human ovarian cancer cell line SKOV-3, that constitutively expresses IDO and established an IDO downregulated cell line (SKOV-3/shIDO) to determine whether inhibition of IDO mediates the progression of ovarian cancer. IDO downregulation suppressed tumor growth and peritoneal dissemination in vivo, without influencing cancer cell growth. Moreover, IDO downregulation enhanced the sensitivity of cancer cells to natural killer (NK) cells in vitro, and promoted NK cell accumulation in the tumor stroma in vivo. These findings indicate that downregulation of IDO controls ovarian cancer progression by activating NK cells, suggesting IDO targeting as a potential therapy for ovarian cancer.

Indoleamine 2,3-dioxygenase promotes peritoneal dissemination of ovarian cancer through inhibition of natural killercell function and angiogenesis promotion.

The purpose of this study was to clarify the relationship between ovarian cancer peritoneal dissemination and indoleamine 2,3-dioxygenase (IDO) expression, and to explore the possibility of IDO-targeting molecular therapy for ovarian cancer. We transfected an IDO expression vector into the IDO-non-expressing human ovarian cancer cell line OMC-1, and established an IDO-expressing cell line (OMC-1/IDO) to examine the relationship between IDO expression and cancer cell growth in vitro and in vivo. IDO expression did not influence cancer cell growth and invasion in vitro, but promoted tumor growth and peritoneal dissemination in vivo. Immunostaining showed that IDO expression inhibited natural killer (NK) cell accumulation in tumors and promoted tumor angiogenesis. In addition, the oral administration of the IDO inhibitor 1-methly-tryptophan inhibited the growth of OMC-1/IDO-derived subcutaneous tumors in mice. These findings indicate that IDO promotes the peritoneal dissemination of ovarian cancer by inhibiting NK cell accumulation in tumors and promoting angiogenesis, supporting the applicability of IDO-targeting molecular therapy in ovarian cancer.

Long-term efficacy of imatinib in a practical setting is correlated with imatinib trough concentration that is influenced by body size: a report by the Nagasaki CML Study Group.

Imatinib has dramatically improved long-term survival of chronic myelogenous leukemia (CML) patients. To analyze its efficacy in a practical setting, we registered most of CML patients in Nagasaki Prefecture of Japan. Of these, 73 patients received imatinib as an initial therapy. The overall survival rate of these patients was 88.7% at 6 years, and the cumulative complete cytogenetic response rate was 82.5% at 18 months. These results are comparable with the data of other reports including the IRIS study; however, the administered imatinib dose was smaller in our study than that in other reports. To address these discrepancies, we measured the trough concentration of imatinib among 35 patients. Although 39% of the patients were administered less than 400 mg/day, the trough level was comparable to those of previous reports. The trough level of imatinib showed a significant relationship with its efficacy, and was clearly related to dose of imatinib administrated and dose of imatinib divided by body surface area (BSA). Considering the smaller BSA of Japanese patients as compared to those of foreign origin, the results suggest that a lower dose of imatinib could maintain enough trough level and provided excellent results for the treatment of CML in our registry.

Combination therapy of tyrosine kinase receptor inhibitor TSU-68 (SU6668) and paclitaxel inhibits subcutaneous xenografts of endometrial cancer.

TSU-68 is a small-molecular-weight synthetic inhibitor of the tyrosine kinase receptors Flk-1/KDR, PDGFRß and FGFR1, which are involved in angiogenesis. Using a mouse model in which endometrial cancer was subcutaneously implanted, we investigated the effects of TSU-68 alone or in combination with paclitaxel. We subcutaneously implanted a cell strain of endometrial cancer, HEC1A, into BALB/c nude mice. TSU-68 was orally administered every day, while paclitaxel was intraperitoneally injected once a week, and the rates of subcutaneous tumor proliferation were compared. In a group treated with high-dose (200 mg/kg/day) TSU-68 alone, subcutaneous tumor proliferation was significantly inhibited in comparison with a vehicle-treated control group (p<0.05). In groups treated with low-dose TSU-68 or paclitaxel alone (100 and 10 mg/kg/day, respectively), tumor proliferation was not significantly inhibited. In a low-dose combination therapy group (100 mg/kg/day of TSU-68 + 10 mg/kg/day of paclitaxel), tumor proliferation was significantly inhibited in comparison with the control and low-dose TSU-68 or paclitaxel therapy groups (p<0.01). High-dose monotherapy with TSU-68 inhibited the proliferation of the subcutaneously implanted tumor. Furthermore, a combination of TSU-68 and paclitaxel at a low dose, one at which respective monotherapy was not effective, inhibited tumor proliferation. Combination therapy with the two agents may therefore be useful for treating endometrial cancer.

Imatinib provides durable molecular and cytogenetic responses in a practical setting for both newly diagnosed and previously treated chronic myelogenous leukemia: a study in nagasaki prefecture, Japan.

To evaluate the efficacy of imatinib in a practical setting, we registered 43 patients with newly diagnosed chronic myelogenous leukemia (CML) (group I) and 56 patients with previously diagnosed CML (group II) at 11 hematology centers in Nagasaki prefecture, Japan, from December 2001 to July 2005 and analyzed the molecular responses. Cytopenia, fluid retention, and skin rash were major adverse events, along with elevation in creatine phosphokinase levels. With a follow-up of approximately 3.5 years, imatinib treatment led to 88.7% overall survival (OS) and 85.2% progression-free survival (PFS) rates for group I, and 79.8% OS and 76.6% PFS rates for group II; the rates were not significantly different despite a lower average imatinib dose in group II. The rates of complete cytogenetic response at 30 months and major molecular response at 24 months were 86.1% and 62.5%, respectively, in group I, and 77.9% and 58.3% in group II; the rates were not significantly different. As has been reported by other groups, these results demonstrate that imatinib treatment can provide excellent clinical and molecular effects for not only newly diagnosed but also previously treated CML patients in practical settings that cover a wider variety of patients than clinical trials.