The successful treatment of rapidly progressive idiopathic membranoproliferative glomerulo-nephritis Type 1 in a 4-year-old male pediatric patient.

A multivariate analysis [4] revealed that the presence of crescent formation on initial biopsy irrespective of type of membranoproliferative glomerulonephritis (MPGN) was independently associated not only with end-stage renal disease but also with post-transplantation recurrence. In this study, we reported on a 4-year-old male pediatric patient requiring hemodialysis due to rapidly progressive idiopathic MPGN Type 1 with severe nephrotic syndrome and extensive cellular crescent formation on initial biopsy. The patient had been treated intravenously (i.v.) with 9 pulses of methylprednisolone, followed by daily prednisolone, resulting in the withdrawal of dialysis within 1 month. However, since active lesions in the second renal biopsy such as cellular crescents still remained and nephrotic range proteinuria had persisted for more than 2 months, the patient received additional 3 i.v. pulses of methylprednisolone, followed by combinations of alternate-day prednisolone, mizoribine, dipyridamole and warfarin, which lead to complete remission in a short-period of time. The patient has been off the combination therapy for 10 months because the third biopsy prior to the termination of this regimen showed decreased inflammatory activity. There is currently no established protocol for children with crescentic MPGN due to a rarity of its clinicopathological presentation. This case report indicates that early treatment with multiple pulses of methylprednisolone followed by the short-term combination therapy may be of benefit for children with rapidly progressive idiopathic MPGN Type 1, even when both diffuse crescentic changes and nephrotic syndrome are present at onset.

Mycophenolate mofetil therapy for childhood-onset steroid dependent nephrotic syndrome after long-term cyclosporine: extended experience in a single center.

BACKGROUND: Mycophenolate mofetil (MMF) is being used increasingly in children with steroid-dependent nephrotic syndrome (SDNS). However, there is limited information on the optimal therapeutic range for mycophenolic acid (MPA), the active metabolite of MMF, in these patients. METHODS: 26 patients with SDNS (mean age 13.1 years, 19 with minimal change disease and 7 with focal segmental glomerulosclerosis) who had received MMF for at least 6 months after longterm cyclosporine (CsA, mean 56 months) at Saitama Children's Medical Center between September 2002 and August 2008 were analyzed. MMF was introduced at an initial dose of 250 mg/12 h, adjusted to maintain target predose MPA at greater than 2 microg/ml (maximum 1 g twice daily) gradually over 4 weeks. After the introduction of MMF, the dosages of both CsA and prednisolone (PSL) were tapered off if possible. RESULTS: The mean MMF dose required was 34 +/- 6 mg/kg, which maintained the mean predose MPA levels of 3.1 mg/ml. In 26 patients, treatment with MMF for a mean follow-up period of 19 months (range 7 - 42), resulted in a reduction of the mean PSL dose from 0.33 +/- 0.23 to 0.17 +/- 0.11 mg/kg per day (p < 0.01) and mean CsA dose from 3.2 +/- 1.7 to 1.3 +/- 1.8 mg/kg per day (p < 0.01). The mean 12-monthly relapse rates decreased from 2.5 +/- 1.4 to 0.8 +/- 1.2 episodes (p < 0.01). In 20 patients treated with MMF (77%), the dose of PSL and/or CsA was successfully tapered with a reduction in the relapse rates. In 6 patients, however, CsA therapy was reintroduced or its dose was increased because of treatment failure. The patients whose average predose MPA levels were less than 3 microg/ml were significantly likely to have treatment failure (p < 0.05). 2 patients reduced the MMF dosage because of anemia or herpes labialis. However, no severe gastrointestinal discomfort was seen in any patients. Despite long-term CsA therapy, marked tubulointerstitial fibrosis developed during MMF therapy in surveillance biopsies of only one of these five patients. CONCLUSIONS: Therapy with MMF based on the predose MPA levels can be a less toxic alternative to CsA or in some cases a useful additional medication to allow for a reduction in the CsA and/or PSL dosage.

Is single-daily low-dose cyclosporine therapy really effective in children with idiopathic frequent-relapsing nephrotic syndrome?

BACKGROUND: A recent study on renal transplant patients has shown that a single dose of cyclosporine (CsA) has added the advantage of decreasing dosages and adverse effects, while maintaining graft function. However, the efficacy of this regimen in children with idiopathic frequent-relapsing nephrotic syndrome (NS) remains controversial. METHODS: 20 children with steroid-dependent NS or CsA-dependent NS (18 with minimal change disease, MCD and 2 with focal segmental glomerulosclerosis, FSGS) were enrolled in this prospective study. CsA was commenced at 1.5 â 2 mg/kg, given as a single daily dose before breakfast, and the dose was adjusted to reach 2 hours post-dose CsA levels (C2) of 600 - 800 ng/ml. RESULTS: In 9 out of 18 patients with MCD, treatment with single-daily CsA for a median of 13 months (range 7 - 21) resulted in a reduction of mean minimum prednisolone (PSL) dose from 1.1 A+/- 0.55 to 0.04 A+/- 0.09 mg/kg on alternate days (p < 0.01), and the median relapse rate from 1.3 (1.1 - 2.5) to 0 (0 - 0.2) episodes/6 months (p < 0.01). Of them, PSL could be weaned off in 7 patients (4 of 6 with steroid-dependent NS, only 3 of 14 with CsA-dependent NS) without relapse of NS while on this therapy. However, 11 out of 20 were considered to have treatment failure: 1 with steroid-dependent NS and 10 with CsA-dependent NS. In 2 patients having FSGS, this method showed no beneficial effects. In 18 patients with MCD, relapse free ratio on single-daily CsA therapy was significantly higher in patients whose average C2 levels were greater than 700 ng/ml (p < 0.05). CONCLUSIONS: Our experience demonstrates that single-daily low-dose CsA therapy maintaining C2 levels greater than 700 ng/ml may be effective in children with steroid-dependent NS or MCD, with no relapse. In contrast, the usefulness of this regimen in children with CsA-dependent NS appears to be limited.

Phase I study on human monoclonal antibody against cytomegalovirus: pharmacokinetics and immunogenicity.

MAb C23, a human immunoglobulin G1 (IgG1) monoclonal antibody (MAb) against cytomegalovirus, was administered to 20 healthy volunteers. Sixteen of them received a single infusion of a dose ranging from 5 to 80 mg. The plasma clearance curves fit a two-compartment model, with half-lives of 31.0 +/- 23.6 h in the diffusion phase and 24.2 +/- 5.8 days in the equilibration phase. The plasma after administration had the virus neutralization activities that were equivalent to the plasma MAb C23 levels. The remaining four subjects, who received three infusions of 60, 20, and 20 mg at 1-week intervals, showed pharmacokinetics that were very consistent with those of the single infusion. No antibody response against MAb C23 was observed in any of the subjects at any time, when monitored for approximately 60 days after the single infusion or the third infusion of the three repeated doses. None of the 20 subjects showed any treatment-related clinical signs or changes. These results suggest that a human IgG MAb has the same pharmacokinetic characteristics as those of natural human serum IgG, and that it is not immunogenetic and is safe in humans.

Preparation of human monoclonal antibodies against a cytomegalovirus glycoprotein complex of 130 and 55 kDa.

Nine human monoclonal antibodies (MAbs) with neutralization activity against cytomegalovirus (CMV) were obtained by screening human MAbs using a CMV glycoprotein complex of 130 and 55 kDa (gp130/55). The gp130/55 antigen was purified by immunoaffinity chromatography and the purified antigen used to detect anti-gp130/55 MAbs in an enzyme-linked immunosorbent assay. Relatively few of the human anti-CMV MAbs were directed against gp130/55 but all showed high neutralization activities to a variety of clinical isolates with titers (ED50 values) ranging from 0.15 to 7.9 micrograms/ml. Six of the nine anti-gp130/55 MAbs required complement for virus neutralization. Such human MAbs may prove to be useful for passive immunotherapy against CMV infection.

Anti-HIV (human immunodeficiency virus) activity of sulfated paramylon.

Sulfated derivatives of paramylon, a water-insoluble (1-3)-beta-D-glucan from Euglena gracilis, significantly inhibited the cytopathic effect of human immunodeficiency virus (HIV-1, HIV-2) and the expression of HIV antigen in cultured MT-4, MOLT-4 cells and human peripheral blood mononuclear cells. Native paramylon, N,N-dimethylaminoethyl paramylon, N,N-diethylaminoethyl paramylon, 2-hydroxy-3-trimethylammoniopropyl paramylon chloride, and carboxymethyl paramylon had little or no anti-HIV activity. The anti-HIV activity of the sulfated paramylon derivatives depended on the number of sulfate groups, and the molecular weight. Paramylon sulfate significantly inhibited HIV-1 binding to MT-4 cells. The anti-coagulant activity of the sulfated paramylon derivatives also depended on the number of sulfate groups, but was generally lower than that of dextran sulfate. The results point to the potential of paramylon sulfate in the treatment of HIV infection.

Stimulation of iodination and cytokine production by dehydrogenation polymers of phenylpropenoids.

Dehydrogenation polymers of phenylpropenoids (so-called 'synthetic lignins') stimulated the iodination (incorporation of radioactive iodine into an acid-insoluble fraction) of human peripheral blood monocytes and polymorphonuclear cells (PMN). The stimulation activity of the polymers strongly depended on the amount of hydrogen peroxide used during sample preparation, and on the temperature during iodination assay. These polymers also stimulated the production of interleukin-1 and tumor necrosis factor by peripheral blood mononuclear cells. On the other hand, neither iodination nor cytokine production was significantly affected by the phenylpropenoid monomers. Although the polymers stimulated the iodination of human leukemic cell lines (HL-60, ML-1), they did not induce cytokine production in these cells. The results suggest that stimulation of iodination and cytokine production by dehydrogenation polymers of phenylpropenoids might be regulated differently.

Stimulation by PSK of interleukin-1 production by human peripheral blood mononuclear cells.

PSK (Krestin), a protein-bound polysaccharide extracted from Coriolus versicolor, stimulated the production of interleukin-1 (IL-1) by human peripheral blood mononuclear cells more efficiently than the production of tumor necrosis factor (TNF). More IL-1 alpha was accumulated in the cells than in the medium fraction, whereas IL-1 beta was distributed evenly into both fractions. PSK stimulated the production of adherent mononuclear cells, in which significantly higher amounts of IL-1 alpha/IL-1 beta were accumulated per cell than in nonadherent cells. Although IL-1 alpha mRNA synthesis (assessed by Reverse Transcriptase-Polymerase Chain Reaction) was slightly enhanced, IL-1 beta mRNA synthesis was not significantly changed by PSK treatment. This suggests that PSK might increase the efficiency of IL-1 mRNA translation or the posttranslational processing of IL-1 protein. Despite potent cytokine-inducing activity, lipopolysaccharide (LPS) did not significantly stimulate the production of adherent cells. These data suggest that PSK and LPS might stimulate mononuclear cells by different mechanisms.

Stimulation of mouse peritoneal macrophages by lignin-related substances.

Various lignified materials, including pine cone extract and a commercial lignin, stimulated the morphological change (spreading) of mouse peritoneal macrophages, and their functional maturation as judged by increase in NBT-reducing activity. When these materials were treated with NaClO2 to decompose the phenolic structure, their activity was completely eliminated, whereas the activity was rather enhanced when they were treated with H2SO4 to decompose their sugar moiety. Some monomeric phenolic compounds structurally related to lignin components and several antitumor glucan derivatives had little or no macrophage stimulating activity. The results strongly suggest the importance of lignin-structure in macrophage activation.

Effect of sodium benzylideneascorbate on chemically-induced tumors in rats.

Intravenous administration of sodium benzylideneascorbate (SBA) dose-dependently induced degeneration (vacuolar and eosinophilic degeneration and cell shrinkage and nuclear condensation, which are characteristic of apoptotic cell death) of 3'-methyl-4-dimethylaminoazobenzene-induced rat hepatocellular carcinoma. SBA did not significantly induce lymphocyte infiltration and fibrosis in the liver, nor damage the gross morphology of kidney and spleen cells. SBA failed to stimulate the production of tumor necrosis factor and interleukin-1 beta in both in vitro and in vivo systems. These results may suggest a direct antitumor action of SBA via induction of apoptosis in the tumor. However, SBA did not significantly affect the doubling time, or the extent of invasion and differentiation of dimethylhydrazine-induced colon carcinoma in rats. These data suggest that the conditions of SBA administration should be re-established for each tumor sample to produce maximum antitumor activity.

Th1/Th2 balance in childhood idiopathic nephrotic syndrome.

AIMS: In view of the conflicting evidence of helper T cell type 1 (Th1) or type 2 (Th2) pattern of cytokine synthesis in childhood idiopathic nephrotic syndrome (INS) this study examined the balance of Th1 and Th2 which are characterized by intracellular cytokine production of interferon-gamma (IFNgamma) and interleukin-4 (IL-4), respectively. SUBJECTS AND METHODS: Sixteen children with steroid-sensitive INS (mean age 9.0 years) were included in this study, together with 15 healthy normal children (mean age 7.9 years) for the control group. Intracellular production of both IFNgamma and IL-4 in helper T cell (CD4+ cell) was investigated by a 3-color flow cytometry. RESULTS: The cross-sectional data showed no significant differences of percentages of Th0 (IFNgamma+ IL-4+ CD4+ cell), Th1 (IFNgamma+ lL-4- CD4+ cell) and Th2 (IFNgamma- IL-4+ CD4+ cell) in CD4+ cells (p > 0.05). The Th1/Th2 ratio during nephrotic relapse did not differ from those during nephrotic remission and in normal healthy children (p > 0.05). CONCLUSION: We conclude that there is no significant skew of Th1/Th2 balance in childhood INS and that the cardinal immunological abnormality does not lie in helper T cells but in other cells, such as suppressor/cytotoxic T cells, natural killer cells or monocytes/macrophage. To clarify the pathogenesis of INS, comprehensive studies for these cells would be worthwhile.

Mitogenic activity of natural and synthetic lignins against cultured splenocytes.

Various natural lignified materials and synthetic dehydrogenation polymers (the so-called synthetic lignins) prepared from several phenylpropenoids were investigated for their mitogenic activity. All of these materials time- and dose-dependently stimulated the DNA synthesis of isolated mouse splenocytes. However, their stimulating activity was significantly decreased when the splenocytes were pretreated with anti-Thy-1.2 monoclonal antibody and rabbit complement. Natural and synthetic lignins demand attention as potential immunopotentiators.

[Comparison between clinical response and in vitro chemosensitivity of solid tumors in the succinic dehydrogenase inhibition test].

We describe our experience with succinic dehydrogenase inhibition (SDI) test for solid tumors as a chemosensitivity test using 3-(4, 5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide. Specimens were obtained from 76 surgical resected tumors, including 32 colon cancers, 24 stomach cancers and 16 lung cancers. Following enzymatic dissociation of scissors-minced tumors, viable cells were cultured in serum free medium (S-Clone SF-B) for 4 days with eight drug concentrations obtained by 2-fold dilution of drugs. Among 76 specimens tested, 48 specimens including 15 colon cancers, 18 stomach cancers and 15 lung cancers were successfully evaluated. For the purpose of judgement, 50% inhibitory concentration (IC50) was calculated in each case. Tumor specimen was regarded as sensitive to a given agent when the IC50 value was the same or smaller than the cut-off concentrations (1 microgram/ml for mitomycin C, 5 micrograms/ml for cisplatin, 2 micrograms/ml for adriamycin and 50 micrograms/ml for 5-fluorouracil), and was regarded as resistant when it was larger than these levels. In vitro vs in vivo drug sensitivity was successfully evaluated in 23 cases. The overall predicting accuracy rate was 78% (18/23), with one true positive, 5 false positive and 17 true negative cases. This test appeared to be useful to tailor effective agents for patients because of its relatively high successful and predictive rates.

Independent risk factors for chronic cyclosporine induced nephropathy in children with nephrotic syndrome.

BACKGROUND: Cyclosporine A (CsA) has been widely used in children with steroid dependent and steroid resistant nephrotic syndrome (NS) because of its efficacy in relieving these patients from systemic side effects of steroids. However, its long term use is controversial, since chronic CsA induced nephropathy (CsAN) may develop in a considerable number of patients. AIMS AND METHODS: In order to clarify the risk factors for the development of CsAN, the clinical characteristics of children with steroid dependent or steroid resistant NS taking CsA (target blood trough levels 50-150 ng/ml) for more than six months, managed at a single centre, were retrospectively analysed. RESULTS: Thirteen of 30 children (24 boys and 6 girls) taking CsA (mean duration 43 months, range 6-144) had CsAN defined as the presence of CsA associated arteriopathy with or without striped tubulointerstitial lesions. The multivariate analysis revealed that CsA treatment for more than 36 months and an age younger than 5 years at the start of CsA treatment were independent risk factors for the development of CsAN. The univariate analysis also showed that patients with CsAN had more frequent relapses during CsA treatment than those without CsAN. CONCLUSION: An alternative treatment should be seriously considered after a 36 month administration of CsA in order to prevent CsAN. Data also suggest that CsA treatment in children younger than 5 years should be avoided if possible.