Severity-based treatment for Japanese patients with MPO-ANCA-associated vasculitis: the JMAAV study

We (JMAAV [Japanese patients with MPO-ANCA-associated vasculitis] Study Group) performed a prospective, open-label, multi-center trial to evaluate the usefulness of severity-based treatment in Japanese patients with myeloperoxidase-anti-neutrophil cytoplasmic antibodies (MPO-ANCA)-associated vasculitis. Patients with MPO-ANCA-associated vasculitis received a severity-based regimen according to the appropriate protocol: low-dose corticosteroid and, if necessary, cyclophosphamide or azathioprine in patients with mild form; high-dose corticosteroid and cyclophosphamide in those with severe form; and the severe-form regimen plus plasmapheresis in those with the most severe form. We followed up the patients for 18 months. The primary end points were the induction of remission, death, and end-stage renal disease (ESRD). Fifty-two patients were registered, and 48 patients were enrolled in this study (mild form, n = 23; severe form, n = 23; most severe form, n = 2). Among the 47 patients who received the predefined therapies, 42 achieved remission within 6 months, 5 died, and 1 developed ESRD. Disease flared up in 8 of the 42 patients with remission during the 18-month follow-up period. The JMAAV trial is the first prospective trial for MPO-ANCA-associated vasculitis to be performed in Japan. The remission and death rates were comparable to those in several previous clinical trials performed in western counties. The regimen employed in this trial was tailor-made based on patients’ disease severity and disease type, and it seems that standardization can be consistent with treatment choices made according to severity

Histological heterogeneity of glomerular segmental lesions in focal segmental glomerulosclerosis

Focal segmental glomerulosclerosis (FSGS) involves considerable histological heterogeneity in terms of location and quality of the glomerular segmental lesions. The present study investigated the heterogeneity of segmental lesions in each variant of FSGS, determined by the Columbia classification, and its clinical relevance. All glomerular segmental lesions of 80 cases of primary FSGS were evaluated histologically based on location [tip (TIP), perihilar (PH), or not otherwise specified (NOS)], and quality (cellular or fibrous). Among the 1,299 glomeruli of the 80 biopsy specimens, 210 glomeruli (16.2%) had segmental lesions, comprising 57 (27%) cellular TIP, 4 (2%) fibrous TIP, 42 (20%) cellular NOS, 86 (41%) fibrous NOS, and 21 (10%) fibrous PH lesions. Each case was also classified into one of the five histological variants of the Columbia classification: collapsing (COL), TIP, cellular (CEL), PH, or NOS. Overlap of segmental lesions in different location categories was seen in the COL, TIP, and PH variants, and heterogeneity of quality was apparent in the COL and CEL variants. Histological findings of the CEL variant (endocapillary hypercellularity) were observed in nine of the 13 COL variants. Both location and quality correlated with disease duration, degree of proteinuria, and histological severity of global glomerular sclerosis and tubulo-interstitial lesions. These results demonstrated the histological heterogeneity of glomerular segmental lesions in all variants of the Columbia classification, except NOS. However, the fidelity of location and dominance of histological features were generally conserved in the TIP and PH variants. The COL and CEL variants warrant further investigation because of their overlapping histological findings and apparent histological heterogeneity in the glomerular segmental lesions

IgA腎症における接着因子とサイトカインの糸球体発現

サイトカインは生体内で複雑なネットワークを形成し,炎症の進展や組織障害,細胞外基質の産生などに重要な役割を演じているとされ,慢性糸球体腎炎でも病因,病態への関与が推測されている.今回,IgA腎症患者の腎生検組織で接着因子(intercellular adhesion molecule-1: ICAM-1, vascular cell adhesion molecule-1: VCAM-1, endothelial-leukocyte adhesion molecule-1: ELAM-1)および炎症性サイトカイン(interleukin-1β: IL-1β, tumor necrosis factor-α: TNF-α, interferon-γ: INF-γ,interleukin-5: IL-5)の糸球体内発現の検討を行った.9人のIgA腎症群の腎生検標本と5人の手術時摘出標本健常部をコントロールとして,各接着因子,サイトカインに対するモノクローナル抗体を用い,染色性の程度を定量した.またmRNAは凍結組織切片より抽出しreverse-transcription PCR (RT-PCR)法を用いて検出した. 接着因子ではICAM-1がIgA腎症の糸球体内での染色性の増加が認められた・炎症性サイトカインではTNF-αが強く染色され,mRNAの発現の亢進を伴い,その染色性は臨床所見上蛋白尿の程度と相関がみられた.IL-5の糸球体発現が染色性,mRNAともに亢進した症例が認められ,mRNAはメサンギウム細胞数と有意に相関していた.IL-5はB細胞の増殖を促進し,IgA産生の誘導作用が指摘されており,本症の特徴的所見であるIgAのメサンギウム領域への沈着のメカニズムに示唆を与えうるものと考えられた.IgA腎症の糸球体における接着因子,炎症性サイトカインの発現を免疫組織染色およびRT-PCR 法により確認した.各種サイトカインが本症の発症,進展の各時期に関与する可能性が示唆された.The present study was conducted to assess the expression of adhesion molecules and inflammatory cytokines/growth factors in the renal tissues of IgA nephropathy (IgAN) patients. Renal biopsy specimens from 9 patients and 5 control subjects were stained by the avidin-biotin immunoperoxidase complex (ABC) method using monoclonal antibodies against each of the adhesion molecules and cytokines. Tissue mRNA was detected by the reverse-transcription-polymerase chain reaction (RT-PCR) method to confirm de novo synthesis of protein. Increased intercellular adhesion molecule-1 (ICAM-1) staining was observed in the mesangial area in the IgAN specimens. Among the inflammatory cytokines, tumor necrosis factor-a (TNF-α) staining was intense and mRNA expression was increased in the glomeruli, and enhanced staining was correlated with the magnitude of proteinuria. Interleukin-5 (IL-5) expression in the glomeruli was increased in several patients with abundant mRNA, suggesting that IL-5 is involved in the immunoglobulin A modulations in the glomeruli which are prominent in this disease. Taken all together, adhesion molecules and inflammatory cytokines appear to be aberrantly expressed in the glomeruli of IgAN patients, and analysis of renal biopsy specimens for cytokine expression can provide valuable information for assessing disease activity, clinically

IgA腎症における接着因子とサイトカインの糸球体発現

サイトカインは生体内で複雑なネットワークを形成し,炎症の進展や組織障害,細胞外基質の産生などに重要な役割を演じているとされ,慢性糸球体腎炎でも病因,病態への関与が推測されている.今回,IgA腎症患者の腎生検組織で接着因子(intercellular adhesion molecule-1: ICAM-1, vascular cell adhesion molecule-1: VCAM-1, endothelial-leukocyte adhesion molecule-1: ELAM-1)および炎症性サイトカイン(interleukin-1β: IL-1β, tumor necrosis factor-α: TNF-α, interferon-γ: INF-γ,interleukin-5: IL-5)の糸球体内発現の検討を行った.9人のIgA腎症群の腎生検標本と5人の手術時摘出標本健常部をコントロールとして,各接着因子,サイトカインに対するモノクローナル抗体を用い,染色性の程度を定量した.またmRNAは凍結組織切片より抽出しreverse-transcription PCR (RT-PCR)法を用いて検出した. 接着因子ではICAM-1がIgA腎症の糸球体内での染色性の増加が認められた・炎症性サイトカインではTNF-αが強く染色され,mRNAの発現の亢進を伴い,その染色性は臨床所見上蛋白尿の程度と相関がみられた.IL-5の糸球体発現が染色性,mRNAともに亢進した症例が認められ,mRNAはメサンギウム細胞数と有意に相関していた.IL-5はB細胞の増殖を促進し,IgA産生の誘導作用が指摘されており,本症の特徴的所見であるIgAのメサンギウム領域への沈着のメカニズムに示唆を与えうるものと考えられた.IgA腎症の糸球体における接着因子,炎症性サイトカインの発現を免疫組織染色およびRT-PCR 法により確認した.各種サイトカインが本症の発症,進展の各時期に関与する可能性が示唆された.The present study was conducted to assess the expression of adhesion molecules and inflammatory cytokines/growth factors in the renal tissues of IgA nephropathy (IgAN) patients. Renal biopsy specimens from 9 patients and 5 control subjects were stained by the avidin-biotin immunoperoxidase complex (ABC) method using monoclonal antibodies against each of the adhesion molecules and cytokines. Tissue mRNA was detected by the reverse-transcription-polymerase chain reaction (RT-PCR) method to confirm de novo synthesis of protein. Increased intercellular adhesion molecule-1 (ICAM-1) staining was observed in the mesangial area in the IgAN specimens. Among the inflammatory cytokines, tumor necrosis factor-a (TNF-α) staining was intense and mRNA expression was increased in the glomeruli, and enhanced staining was correlated with the magnitude of proteinuria. Interleukin-5 (IL-5) expression in the glomeruli was increased in several patients with abundant mRNA, suggesting that IL-5 is involved in the immunoglobulin A modulations in the glomeruli which are prominent in this disease. Taken all together, adhesion molecules and inflammatory cytokines appear to be aberrantly expressed in the glomeruli of IgAN patients, and analysis of renal biopsy specimens for cytokine expression can provide valuable information for assessing disease activity, clinically

IgA腎症患者におけるシスタチンCとクレアチニンの血清濃度の比較

IgA腎症患者の糸球体濾過値(GFR)のマーカーとして,シスタチンCとクレアチニンの血清濃度(Scyst vs. Screat)を比較した.対象は,臨床的および病理学的にIgA腎症と診断された179例である.平均年齢は34.2±11.5歳で,男女比は男性:女性=67:112であった.標準GFR測定法として,イヌリン・クリアランス(Cin)を施行し,Cin値により対象を4群(I群:Cin<30ml/min/1.48m^2, II群:30<Cin<60ml/min/1.48m^2, III群:60<Cin<90ml/min/1.48m^2, IV群:90ml/min/1.48m^2<Cin)に分けた.Scystはlatex immunonephelometry法で, Screatは酵素法で測定した.他のGFR関連マーカーとして,β_2-ミクログロブリン(β_2-m)とα_1-ミクログロブリン(α_1-m)も同時に測定した.病理学的指標として,糸球体硬化率と間質線維化度を用いた. ScystおよびScreatのカットオフ値は,それぞれ 1.0mg/lと1.3mg/dlであった. Cinとの相関係数は, 1/Scyst (r=0.738), 1/Screat (r=0.582), 1/β_2-m (r=0.651)および1/α_1-m (r=0.558)で, Scystで最も相関性が高かった. Scystとの相関係数は, Screat (r=0.892),β_2-m (r=0.832)およびα_1-m(r=0.846)とほぼ同等であった. Cin値で4群に分けて, ScystとScreat濃度の変化と糸球体硬化度および間質線維化度との関係を比較したが,有意な関連性は見出せなかった. Cin=60ml/minを基準としたROC曲線による解析では, Screat曲線下面積(0.7955±0.0348)に比し, Scyst曲線下面積(0.8698±0.0286)は有意に広く(p=0.0002),診断の特異性および感受性が優れていることが判明した.これらの結果より, IgA腎症においては, ScreatよりScystがより正確にGFRを反映していると考えられた.Serum cystatin C (Scyst) has been proposed as a novel indicator of glomerular filtration rate (GFR). The present study was performed to evaluate practical use of a commercially available kit to measure Scyst as a new marker of GFR in patients with IgA nephropathy. A total of 179 patients aged 34.2 ± 11.5 years (male/female: 67/112) were enrolled in this study. We simultaneously measured the Scyst levels and other GFR markers such as inulin clearance (Cin) and serum levels of β_2 and α_1-microglobulin. A highly significant correlation was found between Scyst and serum creatinine (Screat) (r=0.892, p<0.0001), and Scyst and Cin (r=0.738, p<0.0001). No significant difference was detected in the correlation coefficient in glomerulosclerosis rate and Scyst or Screat. There were no significant changes in Scyst and Screat when the extent of interstitial fibrosis increased. The area under the receiver operating characteristics (ROC) curve was significantly greater for Scyst than for Screat (p=0.0002). This study suggests that Scyst is more sensitive than Screat for detecting a mild renal impairment and Scyst could be proposed as a confirmatory test for IgA nephropathy patients with elevated Screa

IgA腎症に対するアンギオテンシン系抑制薬の効果に影響を及ぼす組織学的因子の検討

近年,高血圧を伴う慢性腎炎において,アンギオテンシン変換酵素阻害薬(ACE-I)およびアンギオテンシン受容体拮抗薬(ARB)は,抗蛋白尿効果と腎保護作用を有すると考えられるようになってきた.本研究の目的は, IgA腎症に対するACE-IとARBの効果に影響する組織学的因子を検討することである.対象は, 1993年1月から2000年5月まで当科でIgA腎症と診断された327例のうち,生検直後より2.5年以上にわたってACE-IもしくはARB投与した26症例である.経過中にステロイド加療を受けていない症例を選別した.腎生検時と比較して尿蛋白の減少が50%以上の群を反応群(n=12), 50%未満の群を非反応群(n=14)に分けて検討した.平均観察期間は61.1±28.6 vs 65.6±24.0ヵ月,生検時の臨床所見では年齢は42.8±12.6 vs 40.4±11.3歳,男女比5:7 vs 6:8,血清クレアチニン値(S-Cr)は1.35±0.33 vs 1.25±0.23mg/dl, 24hrクレアチニンクリアランス(Ccr)は67.5±17.1 vs 70.6±20.5ml/min,尿中赤血球数は35.7±58.4 vs 39.6±53.6/HPFと両群間に有意差はなかった.両群間で生検時の尿蛋白量に有意差は認められなかったが, 1.41±0.76→0.41±0.41(p=0.0006) vs 1.50±0.90→1.53±1.28(NS)g/dayと反応群では有意に蛋白尿が減少した.最終観察時では, S-Crは1.51±0.51 vs 1.64±0.68mg/dlと有意差は認めず,血圧は両群とも低下傾向を示したが有意ではなかった.病理所見では,糸球体硬化率,半月体形成率,癒着糸球体率,メサンギウムの増殖性変化,間質炎症細胞浸潤,間質線維化において有意差は認められなかった.しかし,「grade 0:なし, grade 1:軽度,grade 2:中等度, grade 3:高度」とgradingした動脈硬化の評価では,細動脈(0.92±0.52 vs 1.91±1.08, p=0.043)および小葉間動脈硬化(1.08±0.79 vs 1.78±0.97, p=0.033)は反応群において有意に軽い傾向を示し,細動脈の硝子様硬化部の面積率は有意に非反応群で高く(7.17±9.99 vs 21.0±17.5, p=0.01),内腔の面積率は有意に反応群で高かった(17.8±8.45 vs 13.6±6.73, p=0.02).これらの結果から,腎生検所見で動脈硬化が軽度なIgA腎症の症例に対して, ACE-IあるいはARBの抗蛋白尿効果がより期待できると考えられた.Recent studies have shown that inhibitors of the renin-angiotensin system (I-RAS) such as angiotensin converting enzyme inhibitor (ACE-I) and angiotensin II receptor blocker (ARE) are effective for IgA nephropathy (IgAN). However, the precise mechanism of the effects remains unknown. The present study was conducted to elucidate the pathological factors affecting the therapeutic benefits of I-RAS in IgAN. Twenty-six IgAN patients were studied retrospectively. The patients were divided into two groups according to the grade of reduction of urinary protein excretion: the responder group (n=12) and the non-responder group (n=14). The modality of treatment was determined by the clinical and histological findings of each patient. No significant difference before treatment was observed between the responder and non-responder groups. In the evaluation of the outcome after treatment, the amounts of urinary protein excretion one year after treatment and at the final observation significantly decreased in the responder group but remained unchanged in the non-responder group. However, the levels of serum-creatinine, urinary red blood cell sediment, and mean blood pressure were not significantly different between both groups. Histologically, the rate of glomerular obsolescence, interstitial inflammatory cell infiltration and interstitial fibrosis tended to be higher in the non-responder group than in the responder group, and the rate of crescent formation tended to be higher in the responder group than in the non-responder group, but did not reach statistical significance. The grades of mesangial cell proliferation and mesangial matrix increase were not significantly different between both groups. The grade of arterio- and arteriolo-sclerosis was significantly higher in the non-responder group than in the responder group (0.92±0.52 vs 1.91±1.08, p=0.043, 1.08±0.79 vs 1.78±0.97, p=0.033). These findings suggest that arterio- and arteriolo-sclerosis could be a predictor for the effectiveness of I-RAS in IgAN patients

IgA腎症における可溶性L-セレクチンの血清濃度と腎間質病変

本研究の目的は,IgA腎症患者における腎組織におけるL-セレクチン発現および可溶性L-セレクチンの血清濃度と腎間質病変との関連性を検討することである.対象は,腎生検の結果と臨床所見からIgA腎症と診断された37例(男性18例,女性19例)で,平均年齢は38.4±2.2歳である.可溶性L-セレクチンの血清濃度は,市販のELISAキットを用いて測定した.腎生検組織におけるL-セレクチンの発現は,凍結切片を用いてLSAB法で免疫染色して確認した.IgA腎症患者における可溶性L-セレクチンの血清濃度(1.2±0.2μg/ml)は,年齢および性別を一致させた健常者のそれ(0.8±0.1μg/ml)に比し有意に高値を示した.腎生検組織におけるL-セレクチンは,間質における浸潤細胞に多量に発現していた.血清L-セレクチン濃度は,間質における細胞浸潤の程度と正の相関を示したが,腎機能や蛋白尿量との間には有意な相関性は認められなかった.これらの結果から,IgA腎症患者において,L-セレクチンは間質への細胞浸潤に関与していると推測された.また,可溶性L-セレクチンの血清濃度の測定は,腎間質病変の存在を予想するための指標になると考えられた.The purpose of the present study was to assess the correlations among expression of L-selectin in renal tissues, serum levels of soluble L-selectin, and renal injuries in patients with IgA nephropathy (IgAN). The serum levels of soluble L-selectin from 37 IgAN patients and 30 healthy controls were measured by the human soluble L-selectin immunoassay. To examine the localization of L-selectin, we immunohistochemically stained three serial sections from all biopsy specimens of 37 IgAN patients. The expression of L-selectin in renal tissues was detected by L-strepto-avidin biotin method. We observed marked expression of L-selectin in the cells infiltrated into interstitium, but not in those without interstitial cell infiltration. The serum levels of soluble L-selectin in IgAN patient (1.2 ± 0.2 μg/ml) was significantly higher than those in healthy controls (0.8 ± 0.1 μg/ml). There was a significant positive correlations between grade of interstitial cell infiltration and serum levels of L-selectin (r=0.44, p<0.1). However, there was no significant correlation between serum levels of soluble L-selectin and clinical parameters such as extent of proteinuria, creatinine clearance and serum IgA levels. These findings suggest that L-selectin may play some roles in the interstitial changes and measurement of serum soluble L-selectin may be useful to evaluate the extent of interstitial cell infiltration in IgAN patients