[Successful use of angiotensin II receptor antagonist (losartan) in a patient with scleroderma renal crisis].

A 67-year-old man with a one-and-a half-year history of Raynaud's phenomenon was admitted to our hospital for progressive dyspnea occurring over the previous two weeks. Physical examination revealed a blood pressure of 200/124 mmHg, and slightly tight and smooth skin of the fingers, hands and forearms. Laboratory evaluation included serum creatinine of 5.42 mg/dl, plasma renin activity > 20 ng/ml/hr, and antinuclear antibody with a titer of 1 : 1,280. Renal biopsy was performed and the histopathological findings showed that some glomeruli exhibited ischemic retraction with wrinkling of the basement membranes, and that one arteriole exhibited significant intimal hyperplasia with luminal stenosis. These findings were compatible with scleroderma renal crisis (SRC). On the 5th day, serum creatinine had risen to 9.16 mg/dl, and he required temporary hemodialysis therapy. After the administration of captopril was started, his blood pressure fell to 160/86 mmHg and serum creatinine was reduced to 5.12 mg/dl. On the 9th day, he exhibited skin eruptions, and captopril was discontinued accordingly and temocapril started. Because of continued eruptions, temocapril was replaced by losartan. His blood pressure was controlled easily and his serum creatinine level reduced steadily. One year after the start of losartan, serum creatinine was 2.25 mg/dl and blood pressure was 130/82 mmHg. SRC is a life-threatening manifestation of systemic sclerosis. In the late 1970s, angiotensin converting enzyme (ACE) inhibitor was introduced and has dramatically improved the outcome in SRC patients. As ACE inhibitors act mainly on hyperreninemic renal vasoconstrictive hypertension in SRC, we would expect losartan, a selective antagonist of angiotensin receptor subtype 1, to be interchangeable with ACE inhibitors in SRC. In 1997, Caskey and colleagues reported the failure of losartan to control hypertension in a patient of SRC, and the reason has remained unclear. We report here, a case of SRC whose blood pressure was controlled successfully and his renal failure reversed by the administration of losartan.

[A case of pseudo-Bartter's syndrome with marked nephrocarcinosis].

A 38-year-old woman was admitted to our hospital on October 21, 1996 for evaluation of thirst, bilateral backache and a feeling of abdominal fullness. She had hypokalemia, normotension, hyperreninemia, hyperaldostronism and hyperplasia of the juxtaglomerular apparatus on renal biopsy. Ultrasonography, intravenous pyelography and computed tomography showed marked bilateral renal calcification. Considering her history of persistent soft stool caused by chronic laxative abuse for 15 to 16 years and past diuretic abuse for several years since 1986, we diagnosed her as pseudo-Bartter's syndrome with nephrocarcinosis. The value of urinary Ca excretion was in the normal range, and acidification disturbance in NH4Cl loading test was revealed. In addition, she had taken analgesics for 2 to 3 years and interstitial nephritis on renal biopsy was seen. It is thus suggested that the cause of nephrocarcinosis in this case was the reduction of Ca solubility in the tubular cavity induced by incomplete renal tubular acidosis associated with analgesic nephropathy or interstitial nephritis caused by hypokalemia.

Effect of pituitary microsurgery on acromegaly complicated nephrotic syndrome with focal segmental glomerulosclerosis: report of a rare clinical case.

A case of nephrotic syndrome complicated by acromegaly is presented. The first renal biopsy specimen showed minor glomerular abnormalities with glomerular hypertrophy, corresponding with minimal change nephrotic syndrome. Corticosteroid therapy led to a partial remission, followed by frequent relapses after reduction of the drug. A diagnosis of atypical focal segmental glomerulosclerosis (FSGS) was made based on the second renal biopsy results 6 months after the first. We combined steroid therapy with the administration of an anticoagulant, cytotoxic agents, angiotensin-converting enzyme inhibitor, and low-density lipoprotein adsorption. Except for the angiotensin-converting enzyme inhibitor, these medications were not effective in terms of allowing a reduction in the high dosage of steroid, which in turn threatened progressive osteoporosis and lumbar vertebrae fracture. Administering the steroid at a moderate dosage, treatment was focused on the complicating acromegaly from pituitary microadenoma. Subcutaneous injections of octreotide acetate, a somatostatin analogue, reduced proteinuria and increased urine volume. Subsequent transsphenoidal microsurgery of the adenoma resulted in the normalization of the elevated creatinine clearance and the further reduction in steroid dosage while maintaining a remission state. This is the first reported clinical case with acromegaly followed by FSGS, and it is suggested that hypersecretion of growth hormone participates in the development and progression of glomerular disease.

[Study on a predictive marker for evaluating the effectiveness of steroid therapy in IgA nephropathy-significance of extracapillary changes].

In order to obtain a useful index that can predict the effectiveness of steroid therapy in IgA nephropathy, we investigated the relationship between steroid therapy and extracapillary change. We analysed 51 cases consisting of a group of 24 cases in which steroid was administered (initial dose: prednisolone 20-60 mg/day orally, or pulse therapy), and a group of 27 cases in which steroid was not administered. First of all, we compared these two groups in terms of a clinical improvement rate over 3, 12 and 60-month-periods after the therapy, respectively. It was found that steroid therapy led to a higher improvement rate (p < 0.01-0.05), indicating that steroid is effective for IgA nephropathy. Among the group undergoing steroid therapy, the frequency of cellular crescents (C) was significantly higher (p < 0.05-0.01) in the cases in whom steroid was effective and that of fibrous crescents or adhesion (F) was significantly lower (p < 0.05-0.01). We then assessed C/F in each case of the steroid-administered group, and studied its relationship with the improvement rate. As a result, the improvement rate was below 50% in the group of C/F < 0.25, over 50% of the group of 0.25 < or = C/F < 0.75, and 100% of the group of 0.75 < or = C/F. Accordingly, we concluded that C/F could be used a parameter for predicting the effectiveness of steroid therapy in IgA nephropathy and for determining indications for steroid therapy.

[Possible role of cellular immunity against tubular basement membrane antigen (TBM) in gold nephropathy in rheumatoid arthritis patients].

Autoantibody formation and lymphocytes proliferative response to tubular basement membrane (TBM) antigen were examined to clarify the pathogenesis of gold nephropathy, in rheumatoid arthritis patients. The existence of tubulopathy was ascertained by urine protein analysis, electrophoresis and urine TBM antigen titration. Circulating antibody to human TBM antigen titrated by enzyme immunoassay was significantly elevated in patients with gold tubulopathy, and mitogenic stimulation with TBM antigen of peripheral lymphocytes specifically responded in the early stage after receiving gold, but then clearly decreased after the cessation of gold. But, when the lymphocytes had been passed through a nylon wool column, the reaction was remarkably high even in the later stage after receiving gold, suggesting that another suppressive population of lymphocytes became trapped in the nylon wool column. This evidence suggests that gold compounds definitely act as initiating and promoting agents, and the development of tubular disorders induced by gold are likely related to the cellular recognition of effector T cells to the TBM antigen, following the strong effect of gold on the cellular immune system.

[Induction of tubular basement membrane (TBM) antigen specific suppressor T cells in BALB/c mice].

Transfer of tubular basement membrane (TBM)-primed thymocytes from BALB/c mice that had been immunized with allogeneic TBM antigen without adjuvant prevented the development of interstitial nephritis (IN) in recipient BALB/c mice that had been immunized with TBM antigen with complete Freund's adjuvant (CFA) to produce IN. TBM antigen was prepared from TBM of normal ddY mice (ddY TBM antigen). BALB/c mice were highly susceptible to IN and showed a high immune response to TBM antigen when they were immunized with TBM antigen in CFA. Development of IN in high responder BALB/c mice was clearly suppressed by transfer with ddY TBM-thymocytes. The anti-TBM antibody response and the proliferative response of splenic T cells to TBM antigen were also depressed by the transfer. The cell extract of ddY TBM-thymocytes had also suppressive activity on the development of IN and on the immune response to TBM antigen. This simple system without any adjuvant for inducing the thymocytes, which has strong suppressive activity on the development of IN and on the immune response to TBM antigen, may allow us to analyse the role of suppressor T cells in negative regulation of IN.

[Study on usefulness of an aspirating biopsy needle (Vacu-Cut) and an automatic biopsy needle (Biopty-Cut) for renal biopsy--comparison with a Tru-Cut biopsy needle].

Our medical team conducted the percutaneous renal biopsy, using an aspirating biopsy needle (Vacu-Cut) in 101 cases, and an automatic biopsy needle (Biopty-Cut) in 82 cases. Thereafter, we examined the usefulness of the two types of needles in comparison with that of Tru-Cut used in 101 cases. The test confirmed that in the cases of Vacu-Cut, 7.6 glomeruli (p less than 0.01), on the average, existed in LM specimen; 9.0 glomeruli (ns), Biopty-Cut, and 10.7 glomeruli, Tru-Cut, respectively. However the incidence of cases containing more than 5 glomeruli was not significant statistically between Vacu-Cut/Biopty-Cut and Tru-Cut. The incidence that each type of needles obtained more than one glomerulus in IF specimen was as follows: 73.3%, Vacu-Cut (p less than 0.05), 81.7%, Biopty-Cut (ns), 87.1%, Tru-Cut, respectively. As for in EM specimen, 61.4%, Vacu-Cut (ns), 67.1%, Biopty-Cut (ns), and 70.3%, Tru-Cut, respectively. As for complications, in the cases of Vacu-Cut and Biopty-Cut, gross hematuria and post-biopsy pain occurred in 6.9 to 9.8% (p less than 0.01- p less than 0.05), whereas in Tru-Cut, they occurred in 20.7 to 24.8%. As for blood pressure lowering (less than 90 mmHg) and anemia (the cases in which blood transfusion was required), 0%, Vacu-Cut and Biopty-Cut, 2 to 3%, Tru-Cut, respectively. As for fever, Vacu-Cut 0%, Vacu-Cut (p less than 0.01), 3.7%, Biopty-Cut (ns), and 7.9%, Tru-Cut, respectively. The above findings lead to conclusion that both Vacu-Cut and Biopty-Cut are useful instruments for renal biopsy.

Detection of nephritogenic antigen from the Lewis rat renal tubular basement membrane.

Immunopathogenicity of trypsin-solubilized or non-solubilized renal tubular basement membrane (TBM) of the Lewis (LEW) rat was investigated. Autoimmune tubulointerstitial nephritis (TIN) was induced in BALB/c mice by immunization with trypsin-solubilized LEW rat TBM, while immunization with non-solubilized TBM did not produce the disease. Based on this preliminary experiment we studied the characterization of immunogenic and nephritogenic TBM antigen of the LEW rat. TIN was characterized by severe mononuclear cell infiltrates with multi-nucleated giant cells in the interstitium, tubular destruction and intensive IgG and C3 deposits along the TBM. Anti-TBM antisera and eluate from the nephritic mouse kidneys reacted with the TBM of normal LEW rat kidney by immunofluorescence. LEW rat TBM was also detected immunofluorescently by using antisera from BALB/c mice immunized with autologous trypsin-solubilized TBM. A competitive inhibition test revealed a higher titer of anti-TBM antibody in the eluate than in the adsorption-treated antisera per microgram IgG. Immunoblotting showed one reactive band with a molecular weight of 45,000 daltons, and the blotting patterns in tryptic TBM of the Brown Norway (BN) and LEW rats appeared similar. Amino acid analysis of nephritogenic LEW rat tryptic TBM showed that it contained no hydroxyproline and hydroxylysine, suggesting that this TBM preparation was not collagenous. These findings suggest that tryptic digestion contributes to the release of nephritogenic antigen from the LEW rat TBM and that this antigen system might participate in the immune system involved in the anti-TBM associated TIN that is well known to be induced by non-digested TBM of TBM antigen positive animals.

Adoptive transfer of experimental autoimmune hepatitis in mice--cellular interaction between donor and recipient mice.

This report extends our previous study on experimental autoimmune hepatitis in C57BL/6(B6) mice. Cellular immunity involved in the induction of liver injury in this model was studied by transfer of primed spleen cells from hepatitis donor mice to syngeneic normal recipient mice. The most prominent liver damage in recipient B6 mice was induced by transfer of nylon wool adherent spleen cells from hepatitis donor mice, and T cells in this fraction were the essential requirement for the liver damage in the recipient mice. Nylon wool adherent spleen cells from hepatitis donor mice after depletion of the suppressor T-cell function by low-dose (300 rad) irradiation induced more severe liver injury compared to the same cells without irradiation. When the recipient mice were depleted of lymphocytes by low or high dose (700 rad) whole body irradiation, transfer of primed spleen cells from hepatitis donor mice did not induce liver lesion in the lymphocyte-depleted mice. This low susceptibility of lymphocyte-depleted recipient mice to primed spleen cells of hepatitis mice was no longer demonstrated after reconstitution with normal spleen cells. In a cell-migration study using 51Cr-labelled spleen cells, it was shown that a considerable number of infiltrating cells in the liver of recipient mice were derived from recipient mice themselves. These results seem to indicate that cell-to-cell interaction between radiosensitive precursor cells of recipient mice and liver-antigen-primed T cells from hepatitis donor mice play an essential role in the induction of liver injury in the recipient mice.

Autoimmune interstitial nephritis induced in inbred mice. Analysis of mouse tubular basement membrane antigen and genetic control of immune response to it.

Purified murine tubular basement membrane (TBM) antigen (molecular weight, 32,000) induced interstitial lesions in Brown Norway (BN) rats. TBM antigen prepared from mice of 3 inbred strains--BALB/c, C3H/He, and C57BL/6--and outbred ddY mice possessed both antigenicity and nephritogenecity. Using these TBM antigens, the roles of humoral and cellular immunity in the development of interstitial nephritis (IN) and the genetic control of the induction of IN in inbred mice were investigated. BALB/c mice were highly susceptible to IN and showed a high antibody response and a high lymphocyte proliferative response to syngeneic and allogeneic TBM antigen, whereas C57BL/6 mice did not. C3H/He mice, in which minimal interstitial lesions developed, showed a high antibody response but a low proliferative response of T cells to TBM antigen. TBM antigen sensitized T cells induced interstitial lesions, but anti-TBM antisera did not do so. Thus, the development of IN seemed to be related closely to cellular immunity. Further studies with their hybrids, backcrosses, congenic mice, and recombinant mice suggested that the induction of IN and the immune response to TBM antigen are controlled by 1 or a few dominant genes, whose loci are within, or closely linked to, the H-2 complex.

Inhibitory effects of prostaglandin E1 on T-cell mediated cytotoxicity against isolated mouse liver cells.

The effects of prostaglandin E1 on cell-mediated cytotoxicity against hepatocytes were investigated using an in vitro cytotoxic assay system. Isolated liver cells from normal C57BL/6 mice were used as the target cells, and effector cells were obtained from spleens of C57BL/6 mice in which experimental hepatitis had been induced by immunization with syngeneic liver antigens. In this assay system, spleen T cells adhering to nylon wool demonstrated a high cytotoxic activity against target liver cells. The cytotoxicity was markedly reduced by prostaglandin E1 at concentrations greater than 10(-7) M. Maximum suppressive activity was obtained when prostaglandin E1 was continuously present during the assay period. By contrast, indomethacin, a specific inhibitor of prostaglandin synthesis, enhanced the cytotoxic activity of effector cells. These data seem to indicate that exogenously added prostaglandin E1 has an inhibitory effect on cell-mediated cytotoxicity of effector spleen cells against target hepatocytes.

Suppressor system in murine interstitial nephritis. Analysis of tubular basement membrane (TBM)-specific suppressor T cells and their soluble factor in C57BL/6 mice using a syngeneic system.

We induced typical interstitial nephritis with high titers of anti-tubular basement membrane (TBM) autoantibody in genetically resistant C57BL/6 mice by treating them with sodium aurothiomalate (gold) and immunizing them with syngeneic TBM antigen. When gold was not used, the T-cell fraction of nylon wool adherent splenic cells showed prominent suppressive activity against the proliferative response of nonadherent cells to TBM antigen. However, this suppressive activity was remarkably decreased by the gold treatment. TBM antigen sensitized thymocytes, a thymocyte extract, and a spleen cell extract were transferred to C57BL/6 mice which had been immunized with TBM antigen and treated with gold. This transfer clearly depressed the induction of autoimmune interstitial nephritis in an antigen-specific manner. These results indicate that TBM antigen-specific suppressor T cells and their soluble factor may play an important role in the negative regulation of interstitial nephritis in C57BL/6 mice.

Liver-specific F antigen in the serum of patients with liver diseases and the detection of early stage hepatocellular carcinoma.

Liver-specific F antigen was detected in serum using human-specific guinea pig antiserum, in 75 out of 121 patients with various liver diseases. The antigen was detectable in most of the patients (86.7%) with hepatocellular carcinoma, and the levels of F antigen were often high in these patients. There was no correlation between the levels of F antigen and alpha-fetoprotein. Temporal changes of serum F antigen level were also studied in patients with hepatocellular carcinoma. In 8 out of 13 patients with hepatocellular carcinoma, serum F antigen level remained continuously high, and in these patients, it had been significantly high for several months to one year before hepatocellular carcinoma became clinically detectable. Extracts of hepatocellular carcinomas obtained by necropsy was examined for the presence of F antigen, and it was found that most of hepatocellular carcinomas contained the human-specific determinant of F antigen, but lacked the species non-specific determinant of the antigen. The use of human-specific anti-F antiserum may facilitate early detection of hepatocellular carcinoma in some patients.

Experimental systemic amyloidosis induced by immunization with syngeneic organ extracts in mice.

Systemic amyloidosis was induced consistently in mice by intramuscular injection of syngeneic organ (liver and kidney) extracts mixed with CFA six times at weekly intervals. Syngeneic organ extract with CFA also induced amyloidosis of a lesser degree. All three strains of mice (C57BL/6, C3H/He, and BALB/c) injected with a syngeneic liver extract mixed with CFA developed systemic amyloidosis; the most prominent amyloid deposition occurred in C57BL/6 (B6) mice, followed by C3H/He and BALB/c. The amyloid substance deposited in these animals was identified as mouse amyloid A protein (AA). Furthermore, an organ specificity of the immunogen in inducing amyloidosis was suggested with liver and kidney extracts. Primed spleen cells of the immunized B6 mice were fractionated by a nylon-wool column and injected to normal recipient mice via the tail vein. Organs of the recipient mice developed systemic amyloidosis 8 wk after the transfer, and the most prominent histological changes occurred in the recipient mice given nylon-wool column adherent spleen cells. Using anti-Thy-1,2; Ly-1; Ly-2, antibody and complement, it was suggested that T cells, especially Ly-1,2,3+ T cell populations in the primed nylon-wool adherent cells, play an important role in the induction of systemic amyloidosis. It was shown further that the amyloidosis-inducing substance in liver extract was composed of unstable proteins or protein-bound substance.

Experimental gold nephropathy in guinea pigs: detection of autoantibodies to renal tubular antigens.

Renal tubular dysfunction was induced in Hartley guinea pigs by injection of sodium aurothiomalate (gold) as manifested by excretion of tubular basement membrane (TBM) antigen and renal tubular epithelial (RTE) antigen in urine and tubular proteinuria. Following the tubular dysfunction, autoimmune tubulointerstitial nephritis (TIN) and/or immune complex nephropathy (ICN) developed in a large proportion of animals. TIN was associated with anti-TBM antibodies, and the histological features were characterized by tubular lesions with interstitial mononuclear cell infiltration, destruction of tubules, and interstitial fibrosis. In ICN, the glomerular lesions consisted of partial thickening of capillary walls and mesangial cellularity, and granular immune deposits were seen in the mesangial area and on capillary walls. Furthermore, electron-dense deposits were demonstrated in the mesangial area and in the glomerular basement membrane (GBM) by electron microscopy. Anti-RTE antibodies were detected in the sera and eluates from the kidney of animals with ICN. RTE antigens were also detected in the glomerular deposits by indirect immunofluorescence using anti-guinea pig RTE antibody. These results suggest that TBM and RTE antigens released from renal tubules damaged by a direct toxic action of gold may lead to antibody formation against these antigens and induce TIN and/or ICN.

Cell-mediated cytotoxicity of sensitized spleen cells against target liver cells--in vivo and in vitro study with a mouse model of experimental autoimmune hepatitis.

Spleen cells obtained from C57BL/6 (B6) mice with an experimental autoimmune hepatitis were transferred to normal C57BL/6 recipient mice. Most prominent liver damages occurred in the recipient mice injected with sensitized nylon wool column-adherent spleen cells from the donor mice. Production of such liver damage was blocked by treatment of the sensitized adherent spleen cells with anti-Thy 1,2 monoclonal antibody and complement before injection. Based on these in vivo results, a microcytotoxicity assay was performed using isolated C57BL/6 hepatocytes as target cells and sensitized spleen cells obtained from hepatitis donor mice as effector cells. The fraction of sensitized nylon wool-adherent spleen cells demonstrated a high cytotoxic activity against isolated syngeneic hepatocytes, although the other fractions and spleen cells of control animals showed no such effect. The cytotoxic activity of sensitized-adherent spleen cells against target hepatocytes was significantly reduced after treatment with anti-Thy 1,2 antibody and complement, but it increased after depletion of B cells and Fc receptor-bearing T-cells. Although these sensitized nylon wool-adherent spleen cells showed high cytotoxic activities against syngeneic hepatocytes, their cytotoxicity against allogeneic hepatocytes was lower. They exerted no cytotoxic activity against syngeneic renal glomerular cells and EL-4 thymoma cells. These results suggest that sensitized T-cells in the nylon wool column-adherent fraction play the role of cytotoxic killer cells against target liver cells in vitro.