The observation indicator induced from gastrointestinal stromal tumor under long-term monitoring by endoscopic ultrasonography.

INTRODUCTION: We report a case of low-risk stomach gastrointestinal stromal tumor (GIST) which has been under a long-term observation, obtaining from this experience knowledge useful in determining the treatment formula for this disease. RESULTS: During the observation for 6 years, no such change as ulcer formation was observed in the appearance of the tumor. The measurement of tumor diameter, however, showed gradual growth of maximum tumor diameter from 2.7 to 5.0 cm. When the changes in the diameter of tumor during this period is plotted, taking the timeon the horizontal axis and the tumor diameter on the vertical axis, the growth of the tumor can be approximated with a secondary function, making it possible to estimate the developmental period of the GIST concerned from the approximated secondary function. Thus, the developmental period in this case was estimated to go back 19 years before the time when it was discovered for the 1(st) time. Further, it was considered that the coefficient of the secondary function represents the rate of tumor growth, and that comparison with this coefficient contributed to the evaluation of malignancy stage of the GIST concerned. CONCLUSION: The growth curve predicting the growth of tumor could be depicted by measuring the diameter of the tumor in GIST twice or more at an interval of 6-12 months with EUS, and it was thought that this was utilizable for determining treatment formula for GISTs.

A case of gastric aberrant pancreas with bleeding and diagnosed by endoscopic ultrasonography.

Aberrant pancreas is used to describe ectopic pancreatic tissue lying outside its normal location with no anatomic or vascular connection to the pancreas proper. Patients with aberrant pancreas are usually asymptomatic, so aberrant pancreas are typically discovered incidentally during endoscopy, surgery, or autopsy. This time, we report a case of gastric aberrant pancreas bleeding was repeated and endoscopic hemostasis was difficult. A 22-year-old man was admitted to a hospital with a complaint of epigastric pain and melena. Upper gastrointestinal endoscopy and endoscopic ultrasonography (EUS) revealed a submucosal tumor with a bleeding ulcer at the anterior wall of the antrum in the stomach, and diagnosed it as an aberrant pancreas. It was hard to stop bleeding by in total 7 times endoscopic hemostasis and anemia was gradually progressed, so partial gastrectomy was performed. This gastric tumor measured 40 mm × 30 mm × 20 mm and had a severe ulcerative change. The pathological diagnosis was aberrant pancreas with Langerhans islet, acinous cells and excretory duct. (Heinrich type) Until December 2013 in Japan, 13 cases of gastric aberrant pancreas with bleeding have been reported and in these, a surgery was done in 11 cases. In gastric aberrant pancreas cases with ulcer formation like this case, endoscopic hemostasis is expected to be difficult, and surgery is necessary. Hence, early accurate diagnosis by EUS is a very important to decide better treatment plan.

Type B insulin resistance syndrome with systemic lupus erythematosus.

Type B insulin resistance syndrome is a rare disease. Auto-antibodies to the insulin receptor frequently appear in the case of systemic lupus erythematosus (SLE). We report herein a case of a 56-year-old man who had presented discoid skin lesions since 1990. He was admitted to the hospital because of unconsciousness and severe hypoglycemia in 2006, and was diagnosed as having Type B insulin resistance syndrome with the presence of insulin receptor antibody. He had frequently repeated hypoglycemic and hyperglycemic episodes in spite of treatment with prednisolone (5 - 10 mg/day), and mild proteinuria of 1.5 g/day was observed. His laboratory findings on admission revealed pancytopenia and positive titer for antinuclear antibody (ANA). From these findings and his past history of skin lesions, we diagnosed him as SLE. We performed renal biopsy and his histological diagnosis was lupus nephritis Class 5 with the findings of podocytic shedding. Prednisolone dosage was increased from 10 to 60 mg/day. Thereafter, his glucose metabolism improved and proteinuria disappeared. The dose of prednisolone was tapered to 30 mg/day without recurrence of hypoglycemia and proteinuria. Early treatment with prednisolone might ameliorate proteinuria and insulin resistance. We experienced a rare case of Type B insulin resistance syndrome with increased activity of SLE, complicated with lupus nephritis. It appears that Type B insulin resistance syndrome should be suspected in differential diagnosis of hypoglycemia in SLE patients.

Tubular epithelial cells have the capacity to transdifferentiate into CD68-positive macrophage-like cells by oxidative stress.

OBJECTIVE: The present study was intended to assess transdifferentiation from tubular epithelial cells to macrophage- like cells. METHODS: Puromycin aminonucleoside nephrotic rats were sacrificed at days 4, 8, 24 and 112. We immunohistochemically evaluated CD68, CD163, and cytokeratin AE1/AE3, known as markers for macrophages and tubular epithelial cells. Nitrotyrosine, gp91(phox) and Rac 1 expressions was also analyzed. CD68 expression in cultured murine proximal tubular epithelial cells (mProx) stimulated by crude and pure BSA was examined by flow cytometry and immunofluorescence. RESULTS: The tubular CD68-positive cells were observed on day 112. Immunoelectronmicroscopy revealed that some CD68-positive cells showed brush borders on the cell membrane and some of cytokeratin-positive tubular cells also expressed CD163 in mirror sections. The tubular CD68-positive cells were also positive for nitrotyrosine, gp91 (phox) and Rac 1. They contained lipid in their cytoplasm. Crude BSA, containing free fatty acid, induced CD68 expression in a dose- and time-dependent manner in mProx, but not pure BSA. The surface expression of CD68 was increased by high dose and long term stimulation with crude BSA as shown by immunofluorescence. CONCLUSIONS: We confirmed that tubular epithelial cells have the capacity to transdifferentiate to CD68-positive macrophage-like cells, which may be linked to oxidative stress.

An (CA)n dinucleotide repeat polymorphism of the interleukin-6 (IL-6) gene is associated with metacarpal bone mineral density in hemodialysis patients.

Genetic factors may play an important role in the pathogenesis of reduced bone mineral density (BMD). IL-6 is a multifunctional cytokine and a candidate gene for regulation of bone mineral density (BMD). The relationship between a microsatellite polymorphism of the IL-6 gene and metacarpal BMD in Japanese hemodialysis patients was examined. We selected 165 patients (96 males and 69 females) with a mean age of 62.0 +/- 13.7 years (mean +/- standard deviation (SD) in this study. They were dialyzed for an average of 75.8 +/- 60.8 months (mean +/- SD). The microsatellite polymorphism in the IL-6 gene was examined. According to the number of cytosine-adenine repeats, varying from 13 to 18, 6 alleles could be distinguished. Patients were categorized based on the presence or absence of the allele with 126 bp (i.e. 14 CA repeats) (allele A, all others allele O). The frequencies of IL-6 gene genotypes in hemodialysis patients were 16.4% for OO, 52.1% for AO and 31.5% for AA. The BMD score adjusted for age and body weight (Z score) in the AA genotype group (-0.93 +/- 1.17) was significantly lower than that in the OO (-0.09 +/- 1.42, mean +/- SD, p < 0.005) or AO group (-0.48 +/- 1.15, mean +/- SD, p < 0.01). Serum intact PTH in the OO genotype group (79.3 +/- 84.6) was lower than that in the AA (120.8 +/- 113.6, mean +/- SD, p 0.10) or AO group (132.1 +/- 106.5, mean +/- SD, p < 0.05). These results suggest that polymorphism of the IL-6 gene may be a useful marker for reduced BMD.

Relationship between mast cells in the tubulointerstitium and prognosis of patients with IgA nephropathy.

There have been a few reports suggesting that mast cells may play an important role in the development of fibrosis and/or the degradation of extracellular matrix. We examined the relationship between the number of distribution of mast cells in tubulointerstitium and prognosis of patients with IgA nephropathy. Renal biopsy specimens were stained with mouse monoclonal antihuman mast cell tryptase antibody and then with aniline blue. Specimens from 45 patients with IgA nephropathy and from 5 patients with minimal-change nephrotic syndrome were used. There was a significant correlation between the number of mast cells per unit area of the whole tubulointerstitium and the degree of tubulointerstitial fibrosis or renal function. Patients with IgA nephropathy were divided into two groups (group 1: 'minimal' and 'slight'; group 2: 'moderate' and 'advanced') according to the classification by a previously reported method. Mast cells were mainly observed in the fibrotic areas in group 1. In group 2, many mast cells were detected not only in the fibrotic but also in the nonfibrotic areas. It appears that the number of mast cells in the nonfibrotic areas may be one of the predictive factors for the prognosis of patients with IgA nephropathy.

Protein localization and mRNA expression of epimorphin in mouse and human kidneys.

Epimorphin is a mesenchymal cell surface protein which induces epithelial branching morphogenesis. However, the role of epimorphin in the kidney has not been addressed. In the present study, the localization of epimorphin protein and the expression of its mRNA were investigated in the developing mouse and adult human kidneys using immunohistochemistry and semiquantitative RT-PCR. The in vitro expression of epimorphin protein and its mRNA was also explored in cultured mouse and human mesangial cells. Epimorphin protein was expressed in the renal interstitium and the circumference of the comma-shaped body at day 16 of gestation. The intensity and distribution of epimorphin were gradually increased during kidney differentiation and maturation. Epimorphin was first observed in glomeruli at 1 week of age. The localization of epimorphin in glomerular mesangial cells and interstitial fibroblasts was confirmed by immunoelectron microscopy of 2-week-old mouse kidneys. The highest mRNA expression of epimorphin was observed at day 16 of gestation, thereafter it diminished with the maturation of the kidney. A similar localization of epimorphin was observed in a normal adult human kidney. Cultured human mesangial cells expressed epimorphin mRNA 150-kD protein. These results suggest that epimorphin may play a role in the development of the kidney and in the differentiation of fibroblast and mesangial cells.

Podocyte injury predicts prognosis in patients with iga nephropathy using a small amount of renal biopsy tissue.

To predict the progression in patients with IgA nephropathy, we analyzed glomerular lesions except for sclerosis, adhesion and/or crescents in 34 patients with this disease by morphometric analysis. Levels of urinary protein excretion (UP), creatinine clearance (Ccr), serum creatinine (sCr) and mean blood pressure (MBP) at the time of renal biopsy were used as the clinical parameters. The slope of 1/sCr was also used as a prognostic parameter. Renal specimens were obtained by echo-guided biopsy. In PAS-stained light microscopic renal sections, three mid sections of open glomeruli were selected and photographed. Stereologic estimation was performed as follows: absolute values of glomerular volume (V(G)), glomerular surface area (S(G)), podocyte and nonpodocyte cell number per glomerulus (N(G(pod)) and N(G(Non-pod))), glomerular surface area covered by one podocyte S(G)/N(G(pod))) and glomerular volume occupied by one nonpodocyte cell (V(G)/N(G(Non-pod))). There was a significant correlation between the levels of UP and the change of podocyte injury parameters (N(G(pod)) and S(G)/N(G(pod))) or N(G(Non-pod)). N(G(pod)) was negatively but S(G)/N(G(pod)) and N(G(Non-pod)) were positively correlated with UP. S(G)/N(G(pod)) or N(G(Non-pod)) was correlated with MBP. N(G(pod)), S(G)/N(G(pod)), N(G(Non-pod)), UP or MBP was significantly correlated with the slope of 1/sCr. High specificity was observed for N(G(pod)), S(G)/N(G(pod)) and MBP. High sensitivity was also observed for N(G(Non-pod)) and UP. It appears that podocyte injury might provide additional prognostic information in patients with IgA nephropathy.

Identification of cellular origin of type I collagen in glomeruli of rats with crescentic glomerulonephritis induced by anti-glomerular basement membrane antibody.

BACKGROUND: Type I collagen is an interstitial collagen, which is not present in normal glomeruli. As type I collagen was observed in advanced glomerular lesions, it appears to be associated with deterioration of renal function. However, the origins of cells expressing type I collagen mRNA in glomeruli of diseased kidneys remains controversial. METHODS: We examined the expression of type I collagen in glomeruli at protein and mRNA levels in rat crescentic glomerulonephritis induced by anti-glomerular basement membrane (GBM) antibody. In addition, in situ hybridization and immunohistochemical staining of serial sections were performed to identify the cellular origin of type I collagen in glomeruli. RESULTS: Semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR) in isolated glomeruli showed that mRNA expression of type I collagen was remarkably increased on days 7, 14, and 28 after anti-GBM antibody injection (12.2+/-1.4, 20.2+/-2.1 and 14.6+/-1.0-fold over day 0, respectively). Immunofluorescence for type I collagen demonstrated marked staining in the fibrocellular and fibrous crescents, and weak staining within glomerular mesangial areas. In close association with mRNA levels analysed by RT-PCR, in situ hybridization revealed predominant presence of alpha1(I) collagen mRNA in cells within crescentic areas and Bowman's capsules. Serial section analysis for immunostaining and in situ hybridization showed that some alpha1(I) collagen mRNA-positive cells were also positive for cytokeratin. In contrast, no alpha1(I) collagen mRNA-positive cells were stained by ED-1 and podocalyxin. CONCLUSIONS: It appears that increased expression of type I collagen at the protein and mRNA levels in glomeruli is involved in the progression of glomerulonephritis. At least in this crescentic model, parietal epithelial cells (PECs) may partially contribute to the dysregulated production of type I collagen, which leads to glomerulosclerosis.

[A case of gastric antral vascular ectasia (GAVE) with chronic renal failure].

A 76-year-old woman was admitted to our hospital complaining of tarry stool, general fatigue and marked anemia(Hb 5.2 g/dl). Gastric endoscopic findings showed longitudinal red stripes and diffuse erythematous spots, indicating dilated vascular vessels. They resembled the stripes of a watermelon at the gastric antrum. The marked anemia was caused by chronic blood loss from the abnormally dilated mucosal and submucosal capillary veins in the gastric antrum. She was diagnosed as having gastric antral vascular ectasia(GAVE) with chronic renal failure(CRF). The association of GAVE and CRF is considered to be rare according to previous reports in Japan. Endoscopic argon plasma coagulation therapy was performed three times. After therapy, capillary dilatation disappeared, and the marked anemia was greatly improved. Argon plasma coagulation therapy was found to be a safe and effective procedure for this disease. Although GAVE is essentially a benign gastric disease, endoscopic therapy should be the treatment of first choice for this disease.

Dilazep hydrochloride, an antiplatelet drug, inhibits lipopolysaccharide-induced mouse mesangial cell IL-6 secretion and proliferation.

BACKGROUND: Antiplatelet agents have been widely used to reduce proteinuria and to prevent the progression of chronic glomerulonephritis or diabetic nephropathy to end-stage renal failure. Dipyridamole, one type of antiplatelet drug, inhibits the proliferation of glomerular mesangial cells (MCs). The effect of dilazep hydrochloride (dilazep) on these cells is still obscure. The effects of dilazep on cultured MC IL-6 secretion and proliferation were investigated in the present study. METHODS: IL-6 secretion from MC induced by bacterial lipopolysaccharide (LPS) were assessed using sandwich ELISA. LPS-induced MC proliferation was detected by 3H-thymidine incorporation and WST-1 assay (similar to MTT assay). RESULTS: Incubation of MCs with various dosages of LPS (0, 1, 10, 50 and 100 ng/ml) induced IL-6 secretion in a dose-dependent manner. However, dilazep significantly inhibited this LPS-induced IL-6 secretion from MCs in a dose- and time-dependent manner. Dilazep also significantly inhibited MC proliferation in a dose-dependent manner. CONCLUSION: It appears that these effects of dilazep may prevent progression of mesangial proliferative glomerulonephritis.

Urinary levels of interleukin-8 (IL-8) and disease activity in patients with IgA nephropathy.

Using quantitative sandwich ELISA, we studied 27 patients with IgA nephropathy to determine whether the levels of urinary IL-8 might reflect the disease activity. The levels of urinary IL-8 in patients with advanced stage IgA nephropathy were significantly higher than those in the patients with the mild stage of this disease, or in the healthy controls. The results showed a positive significant correlation between the levels of IL-8 and disease activity, i.e., between levels of urinary protein and urinary casts. A significant correlation between levels of urinary IL-8 and tubular function damage was also found. It was thus suggested that measurement of urinary IL-8 might be useful in evaluating the degree of renal injuries and/or prognosis in patients with IgA nephropathy.

Blockade of TGF-beta signaling in T cells prevents the development of experimental glomerulonephritis.

Anti-glomerular basement membrane (GBM) Ab-induced glomerulonephritis (GN) at late stage is thought to be mediated by T cells. However, signaling pathways of T cells that are involved in the development of anti-GBM Ab-induced GN are unclear. We have recently established transgenic mice expressing Smad7, an inhibitor of TGF-beta signaling, in mature T cells, where signaling by TGF-beta was blocked specifically in T cells. In this study, we showed that anti-GBM Ab-induced GN was suppressed in several measures in the transgenic mice including the severity of glomerular changes, proteinuria, renal function, and CD4 T cell infiltration into the glomeruli without down-regulation of CD62 ligand (CD62L) (L-selectin) expression on CD4 T cells. Furthermore, treatment with the soluble fusion protein of CD62L and IgG enhanced anti-GBM Ab-induced GN. These findings indicated that blockade of TGF-beta signaling in T cells prevented the development of anti-GBM Ab-induced GN. Because CD62L on T cells appears to be inhibitory for the development of anti-GBM Ab-induced GN, persistent expression of CD62L on CD4 T cells may explain, at least in part, the suppression of anti-GBM Ab-induced GN in the transgenic mice. Our findings suggest that the development of anti-GBM Ab-induced GN requires TGF-beta/Smad signaling in T cells.

[Immunohistochemical analysis of protein gene product 9.5, a new marker for parietal epithelial cells of Bowman's capsules, in anti-glomerular basement membrane(GBM) antibody induced glomerulonephritis of WKY rats].

Protein gene product 9.5(PGP 9.5) is expressed specifically in neuroendocrine cells and considered to be one of the neuroendocrine markers. Recently, we reported that PGP 9.5 is localized in the parietal epithelial cells(PECs) of Bowman's capsules as well as in neural tissues. In the present study, immunohistochemical analysis of PGP 9.5 as a specific marker of the PECs of Bowman's capsules, synaptopodin as a podocyte-specific marker, and ED-1 as a specific marker of monocytes/macrophages was performed in the cellular crescents in anti-GBM antibody induced glomerulonephritis of WKY rats using serial renal sections. In the acute phase of anti-GBM antibody induced glomerulonephritis, and the expression of PGP 9.5 and ED-1 was observed diffusely in proliferating cells of cellular crescents. However, in most part of cellular crescents, PGP 9.5 positive areas did not overlap with the ED-1 positive areas. Synaptopodin was constantly detected along the glomerular tufts compressed by the crescents. In the chronic phase of this disease, PGP 9.5 was observed in the cells covering the surface of fibrous crescents or scattered within fibrocellular crescents. Synaptopodin was partially detected in such cells. It appears that cellular crescents are composed mainly of proliferating PECs and macrophages in rat anti-GBM antibody-induced glomerulonephritis.

Effect of dilazep hydrochlorideon the Im munohistopathology of IgA nephropathy in ddY mice.

We determined the clinical and immunopathological effects of dilazep hydrochloride (dilazep) on IgA nephropathy of ddY mice. Group I (early-treatment group, n = 10) was orally treated with 300 mg/kg body weight of this drug from 12 weeks of age until 60 weeks of age, and group II (late-treatment group, n = 10) was also treated with the same dosage of this drug from 20 weeks of age until 60 weeks of age. Group III (control group, n = 10) received drinking water. On immunofluorescence, distribution and intensity of IgA and C3 depositions in glomeruli of group I and group II animals were significantly decreased as compared with those in group III. The expression of fibronectin, laminin, or type IV collagen in glomeruli was basically similar in the three groups treated with or without dilazep. On light microscopy, the expansion of glomerular mesangial areas and the average number of intraglomerular cells were markedly decreased as compared with those in group III. The levels of urinary protein excretion in groups I and II were significantly lower than those in group III (p < 0.01 and p < 0.05). These findings suggest that treatment with dilazep might improve the clinical and immunopathological findings in IgA nephropathy of ddY mice.

Effects of the new hydroxy-3-methylglutaryl coenzyme a reductase inhibitor fluvastatin on anti-oxidant enzyme activities and renal function in streptozotocin-induced diabetic rats.

1. The effects of 11 week treatments with the new hydroxy3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitor fluvastatin on renal intrinsic anti-oxidant enzyme (AOE) activities and renal function were evaluated in streptozotocin (STZ)-induced diabetic rats. 2. Renal intrinsic AOE activities, creatinine clearance and urinary albumin excretion were examined in STZ-induced diabetic rats. The levels of total cholesterol (TC), triglyceride (TG) and phospholipid (PL) were also examined. 3. In general, renal AOE activities and function were lower in diabetic rats than in non-diabetic Sprague-Dawley rats. 4. Decreases in TC, TG and PL levels and urinary albumin excretion by the HMG-CoA reductase inhibitor fluvastatin improved renal function and produced a non-uniform alteration in renal AOE; only glutathione peroxidase (GSH-Px) activity increased significantly with fluvastatin treatment. 5. It appears that the improvement in renal function and albuminuria may be related to increases in GSH-Px activity, but there was no correlation between changes in renal function and changes in the activity of Mn-superoxide dismutase or catalase.

Macrophage-derived MT1-MMP and increased MMP-2 activity are associated with glomerular damage in crescentic glomerulonephritis.

Membrane-type matrix metalloproteinases (MT-MMPs) have been shown to activate pro-MMP-2 on the cell surface and are suggested to be key enzymes in tissue remodelling under various physiological and pathological conditions. To investigate the role of MT-MMP in progressive renal injury, the gene expression and enzymatic activity of MT-MMP were examined in crescentic glomerulonephritis induced by anti-glomerular basement membrane (GBM) antibody in WKY rats. Isolated glomeruli were subjected to RNA and protein extraction 0, 1, 3, 7, 14, and 28 days after intravenous injection of rabbit anti-GBM antibody. Semiquantitative RT-PCR analysis revealed that among the three members of the MT-MMP family, mRNA expression of MT2-MMP remained unchanged and that of MT3-MMP was not observed in glomeruli during the development of nephritis. However, MT1-MMP gene expression increased from day 3 and reached maximum levels at day 7 (5.5+/-0.7-fold increase over day 0), closely associated with macrophage accumulation, crescent formation, and increased proteinuria. Gelatin zymography showed that the active from of MMP-2 emerged from day 7 and remained during the experimental period accompanied by increased proMMP-2, while no active form of MMP-2 was found in control rats. Using an antisense cRNA probe, intense signals of MT1-MMP mRNA were observed mostly in cells within the crescent and in some cells in the mesangial areas. Most of these cells were ED-1-positive macrophages, based on immunostaining of sequential sections. These results suggested that in the MT-MMP family, MT1-MMP was induced in infiltrating macrophages during the development of crescentic glomerulonephritis and possibly contributed to pathological degradation of glomerular extracellular matrices through the activation of proMMP-2.