The Effects of SGLT2 Inhibitors on Liver Cirrhosis Patients with Refractory Ascites: A Literature Review.

Decompensated liver cirrhosis is often complicated by refractory ascites, and intractable ascites are a predictor of poor prognosis in patients with liver cirrhosis. The treatment of ascites in patients with cirrhosis is based on the use of aldosterone blockers and loop diuretics, and occasionally vasopressin receptor antagonists are also used. Recent reports suggest that sodium-glucose cotransporter 2 (SGLT2) inhibitors may be a new treatment for refractory ascites with a different mechanism with respect to conventional agents. The main mechanisms of ascites reduction with SGLT2 inhibitors appear to be natriuresis and osmotic diuresis. However, other mechanisms, including improvements in glucose metabolism and nutritional status, hepatoprotection by ketone bodies and adiponectin, amelioration of the sympathetic nervous system, and inhibition of the renin-angiotensin-aldosterone system, may also contribute to the reduction of ascites. This literature review describes previously reported cases in which SGLT2 inhibitors were used to effectively treat ascites caused by liver cirrhosis. The discussion of the mechanisms involved is expected to contribute to establishing SGLT2 therapy for ascites in the future.

Concerted actions of DnaA complexes with DNA-unwinding sequences within and flanking replication origin oriC promote DnaB helicase loading.

Unwinding of the replication origin and loading of DNA helicases underlie the initiation of chromosomal replication. In Escherichia coli, the minimal origin oriC contains a duplex unwinding element (DUE) region and three (Left, Middle, and Right) regions that bind the initiator protein DnaA. The Left/Right regions bear a set of DnaA-binding sequences, constituting the Left/Right-DnaA subcomplexes, while the Middle region has a single DnaA-binding site, which stimulates formation of the Left/Right-DnaA subcomplexes. In addition, a DUE-flanking AT-cluster element (TATTAAAAAGAA) is located just outside of the minimal oriC region. The Left-DnaA subcomplex promotes unwinding of the flanking DUE exposing TT[A/G]T(T) sequences that then bind to the Left-DnaA subcomplex, stabilizing the unwound state required for DnaB helicase loading. However, the role of the Right-DnaA subcomplex is largely unclear. Here, we show that DUE unwinding by both the Left/Right-DnaA subcomplexes, but not the Left-DnaA subcomplex only, was stimulated by a DUE-terminal subregion flanking the AT-cluster. Consistently, we found the Right-DnaA subcomplex-bound single-stranded DUE and AT-cluster regions. In addition, the Left/Right-DnaA subcomplexes bound DnaB helicase independently. For only the Left-DnaA subcomplex, we show the AT-cluster was crucial for DnaB loading. The role of unwound DNA binding of the Right-DnaA subcomplex was further supported by in vivo data. Taken together, we propose a model in which the Right-DnaA subcomplex dynamically interacts with the unwound DUE, assisting in DUE unwinding and efficient loading of DnaB helicases, while in the absence of the Right-DnaA subcomplex, the AT-cluster assists in those processes, supporting robustness of replication initiation.

Family D DNA polymerase interacts with GINS to promote CMG-helicase in the archaeal replisome.

Genomic DNA replication requires replisome assembly. We show here the molecular mechanism by which CMG (GAN-MCM-GINS)-like helicase cooperates with the family D DNA polymerase (PolD) in Thermococcus kodakarensis. The archaeal GINS contains two Gins51 subunits, the C-terminal domain of which (Gins51C) interacts with GAN. We discovered that Gins51C also interacts with the N-terminal domain of PolD's DP1 subunit (DP1N) to connect two PolDs in GINS. The two replicases in the replisome should be responsible for leading- and lagging-strand synthesis, respectively. Crystal structure analysis of the DP1N-Gins51C-GAN ternary complex was provided to understand the structural basis of the connection between the helicase and DNA polymerase. Site-directed mutagenesis analysis supported the interaction mode obtained from the crystal structure. Furthermore, the assembly of helicase and replicase identified in this study is also conserved in Eukarya. PolD enhances the parental strand unwinding via stimulation of ATPase activity of the CMG-complex. This is the first evidence of the functional connection between replicase and helicase in Archaea. These results suggest that the direct interaction of PolD with CMG-helicase is critical for synchronizing strand unwinding and nascent strand synthesis and possibly provide a functional machinery for the effective progression of the replication fork.

DNA polymerase D temporarily connects primase to the CMG-like helicase before interacting with proliferating cell nuclear antigen.

The eukaryotic replisome is comprised of three family-B DNA polymerases (Polα, δ and ϵ). Polα forms a stable complex with primase to synthesize short RNA-DNA primers, which are subsequently elongated by Polδ and Polϵ in concert with proliferating cell nuclear antigen (PCNA). In some species of archaea, family-D DNA polymerase (PolD) is the only DNA polymerase essential for cell viability, raising the question of how it alone conducts the bulk of DNA synthesis. We used a hyperthermophilic archaeon, Thermococcus kodakarensis, to demonstrate that PolD connects primase to the archaeal replisome before interacting with PCNA. Whereas PolD stably connects primase to GINS, a component of CMG helicase, cryo-EM analysis indicated a highly flexible PolD-primase complex. A conserved hydrophobic motif at the C-terminus of the DP2 subunit of PolD, a PIP (PCNA-Interacting Peptide) motif, was critical for the interaction with primase. The dissociation of primase was induced by DNA-dependent binding of PCNA to PolD. Point mutations in the alternative PIP-motif of DP2 abrogated the molecular switching that converts the archaeal replicase from de novo to processive synthesis mode.

Retrospective study of predictive factors for postoperative complications of hepatectomies lasting 12 or more hours.

OBJECTIVES: Hepatectomy is used to treat several liver diseases, although perioperative mortality and postoperative complication rates remain high. Given the lack of relevant studies to date, the present study aimed to investigate potential predictive factors for postoperative complications in patients undergoing hepatectomies lasting 12 or more hours (termed "extremely long hepatectomies"). METHODS: Adult patients undergoing treatment in the intensive care unit (ICU) after extremely long hepatectomies at Fujita Health University Hospital between 2014 and 2017 were enrolled in the study. Postoperative complications were classified as "major complications" and "non-major complications" according to the Clavien-Dindo Classification grading system. We also divided our study population into "simple hepatectomy" and "non-simple hepatectomy" subgroups for further analysis. Statistical analyses were performed using the Mann-Whitney U test, chi-squared test, and multiple logistic regression analysis. RESULTS: In total, 114 patients (Major Complications Group, n=44; Non-Major Complications Group, n=70) were enrolled. In the Simple Hepatectomy Group, there were no significant variables. In the Non-Simple Hepatectomy Group, female sex (odds ratio [OR], 13.4; 95% confidence interval [CI], 1.00-1.81×102; p=0.04) and lactate levels at ICU admission (OR, 1.6; 95% CI, 0.99-2.59; p=0.05) were independent factors associated with major postoperative complications. CONCLUSIONS: In the Simple Hepatectomy Group, there were no significant variables. In the Non-Simple Hepatectomy Group, female sex and lactate levels at ICU admission of patients who underwent extremely long hepatectomies may be independent factors associated with major postoperative complications.

Replication protein A complex in Thermococcus kodakarensis interacts with DNA polymerases and helps their effective strand synthesis.

Replication protein A (RPA) is an essential component of DNA metabolic processes. RPA binds to single-stranded DNA (ssDNA) and interacts with multiple DNA-binding proteins. In this study, we showed that two DNA polymerases, PolB and PolD, from the hyperthermophilic archaeon Thermococcus kodakarensis interact directly with RPA in vitro. RPA was expected to play a role in resolving the secondary structure, which may stop the DNA synthesis reaction, in the template ssDNA. Our in vitro DNA synthesis assay showed that the pausing was resolved by RPA for both PolB and PolD. These results supported the fact that RPA interacts with DNA polymerases as a member of the replisome and is involved in the normal progression of DNA replication forks.

In Vitro Study of Endotoxin Adsorption by a Polymyxin B-Immobilized Fiber Column.

BACKGROUND: Polymyxin B-immobilized fiber (PMX-F) columns are used as therapeutic interventions for septic shock. The clinical efficacy has been reported for 2-h applications, but their ability to adsorb endotoxin over longer treatments has not been fully elucidated. We hypothesized that PMX-F columns are capable of endotoxin removal for more than 2 h. METHOD: We designed closed circuits incorporating either a PMX-F column with an 8.5-mL priming volume (PMX-01R) or a sham-control column, and used inactivated fetal bovine serum as the circulating perfusate. Endotoxin was continuously injected at a fixed rate for 24 h, and perfusate endotoxin concentrations were measured at fixed time points. PMX-01R endotoxin adsorption was calculated from the difference in the endotoxin concentrations. RESULTS: PMX-01R endotoxin adsorption increased continuously in a virtually linear manner. CONCLUSIONS: The PMX-01R column showed sustained endotoxin adsorption for at least 24 h. This indicated that PMX-F columns would be capable of clinical endotoxin removal for 24 h.

Possible function of the second RecJ-like protein in stalled replication fork repair by interacting with Hef.

RecJ was originally identified in Escherichia coli and plays an important role in the DNA repair and recombination pathways. Thermococcus kodakarensis, a hyperthermophilic archaeon, has two RecJ-like nucleases. These proteins are designated as GAN (GINS-associated nuclease) and HAN (Hef-associated nuclease), based on the protein they interact with. GAN is probably a counterpart of Cdc45 in the eukaryotic CMG replicative helicase complex. HAN is considered mainly to function with Hef for restoration of the stalled replication fork. In this study, we characterized HAN to clarify its functions in Thermococcus cells. HAN showed single-strand specific 3' to 5' exonuclease activity, which was stimulated in the presence of Hef. A gene disruption analysis revealed that HAN was non-essential for viability, but the ΔganΔhan double mutant did not grow under optimal conditions at 85 °C. This deficiency was not fully recovered by introducing the mutant han gene, encoding the nuclease-deficient HAN protein, back into the genome. These results suggest that the unstable replicative helicase complex without GAN performs ineffective fork progression, and thus the stalled fork repair system including HAN becomes more important. The nuclease activity of HAN is required for the function of this protein in T. kodakarensis.

The Cdc45/RecJ-like protein forms a complex with GINS and MCM, and is important for DNA replication in Thermococcus kodakarensis.

The archaeal minichromosome maintenance (MCM) has DNA helicase activity, which is stimulated by GINS in several archaea. In the eukaryotic replicative helicase complex, Cdc45 forms a complex with MCM and GINS, named as CMG (Cdc45-MCM-GINS). Cdc45 shares sequence similarity with bacterial RecJ. A Cdc45/RecJ-like protein from Thermococcus kodakarensis shows a bacterial RecJ-like exonuclease activity, which is stimulated by GINS in vitro. Therefore, this archaeal Cdc45/RecJ is designated as GAN, from GINS-associated nuclease. In this study, we identified the CMG-like complex in T. kodakarensis cells. The GAN·GINS complex stimulated the MCM helicase, but MCM did not affect the nuclease activity of GAN in vitro. The gene disruption analysis showed that GAN was non-essential for its viability but the Δgan mutant did not grow at 93°C. Furthermore, the Δgan mutant showed a clear retardation in growth as compared with the parent cells under optimal conditions at 85°C. These deficiencies were recovered by introducing the gan gene encoding the nuclease deficient GAN protein back to the genome. These results suggest that the replicative helicase complex without GAN may become unstable and ineffective in replication fork progression. The nuclease activity of GAN is not related to the growth defects of the Δgan mutant cells.

Formation of modulated phases and domain rigidification in fatty acid-containing lipid membranes.

We investigated the phase behavior of lipid membranes containing fatty acids (FAs) by microscopy and differential scanning calorimetry. We used palmitic acid (saturated FA), oleic acid (cis-isomer of unsaturated FA), elaidic acid (trans-isomer of unsaturated FA), and phytanic acid (branched FA) and examined the effects of FAs on phase-separated structures in lipid bilayer membranes consisting of dioleolylphosphocholine (DOPC)/dipalmitoylphosphocholine (DPPC)/cholesterol (Chol). Palmitic acid and elaidic acid exclude Chol from the DPPC-rich phase. As a result, the liquid-ordered phase formed by DPPC and Chol transforms into a solid-ordered phase. Oleic acid and phytanic acid significantly reduce the line tension at the liquid domain boundary. This decrease in line tension leads to the formation of modulated phases, such as striped, hexagonal, and polygonal domains. We measured the line tension and the interdomain interaction in these specific domains by an image analysis. The result showed that oleic acid and phytanic acid-containing vesicles as well as palmitic acid-containing vesicles are not spherical, and this domain-induced deformation is explained theoretically.

A devised strategy for tracheal extubation for predicted difficult airway in a child with unilateral vocal cord paralysis: a case report.

BACKGROUND: Extubation is a more challenging medical practice than intubation, and countermeasures against it are similar to those described in the Difficult Intubation Guidelines, but problems cannot be overcome by completely the same methods. We predicted difficult extubation in a pediatric patient with left recurrent laryngeal nerve paralysis and devised an extubation method. CASE PRESENTATION: The patient was a 2-year-and-8-month-old boy scheduled for cleft palate repair. Concomitant cardiac anomaly and first and second branchial arch syndrome-associated facial malformations, such as mandibular micrognathia and auricular malformation, were observed. He had a past medical history of difficult intubation and respiratory arrest on a catheter test under intravenous sedation at 4 months old. Left recurrent laryngeal nerve paralysis was discovered on preoperative examination of the cleft palate, based on which difficulty in postoperative extubation was predicted. A catheter for tracheal tube exchange proposed by the extubation guidelines of the Difficult Airway Society (DAS) was placed, endoscopic examination was performed while inducing spontaneous breathing and swallowing reflex by an otolaryngologist, and the tube was removed while movement of the tissue around the glottis was visually evaluated. The patient was managed in an ICU after extubation, and both the systemic and respiratory conditions were favorable. CONCLUSIONS: Extubation and airway management could be safely performed by devising extubation while conforming to the DAS guidelines.

Atomic structure of an archaeal GAN suggests its dual roles as an exonuclease in DNA repair and a CMG component in DNA replication.

In eukaryotic DNA replication initiation, hexameric MCM (mini-chromosome maintenance) unwinds the template double-stranded DNA to form the replication fork. MCM is activated by two proteins, Cdc45 and GINS, which constitute the 'CMG' unwindosome complex together with the MCM core. The archaeal DNA replication system is quite similar to that of eukaryotes, but only limited knowledge about the DNA unwinding mechanism is available, from a structural point of view. Here, we describe the crystal structure of an archaeal GAN (GINS-associated nuclease) from Thermococcus kodakaraensis, the homolog of eukaryotic Cdc45, in both the free form and the complex with the C-terminal domain of the cognate Gins51 subunit (Gins51C). This first archaeal GAN structure exhibits a unique, 'hybrid' structure between the bacterial RecJ and the eukaryotic Cdc45. GAN possesses the conserved DHH and DHH1 domains responsible for the exonuclease activity, and an inserted CID (CMG interacting domain)-like domain structurally comparable to that in Cdc45, suggesting its dual roles as an exonuclease in DNA repair and a CMG component in DNA replication. A structural comparison of the GAN-Gins51C complex with the GINS tetramer suggests that GINS uses the mobile Gins51C as a hook to bind GAN for CMG formation.

Physical properties of the hybrid lipid POPC on micrometer-sized domains in mixed lipid membranes.

Macro-phase separation in mixed lipid membranes containing the hybrid lipid palmitoyloleoylphosphatidylcholine (POPC) was observed by fluorescent and confocal laser scanning microscopy. In a binary system consisting of the saturated lipid dipalmitoylphosphatidylcholine (DPPC) and the hybrid lipid POPC, the hybrid lipid forms a liquid-disordered (Ld) phase. In a ternary system consisting of this binary system and an unsaturated lipid dioleoylphosphatidylcholine (DOPC), three-phase coexistence is observed. The POPC-rich phase appears around DPPC-rich domains, and the hybrid lipid is expected to behave like a line-active agent (linactant). Finally, phase separation in a four-component system, composed of this ternary system and cholesterol, was examined. Domains with a size that is smaller than 1 µm are found, and domain-induced budding is also observed. To explain small domain formation and domain-induced budding, chain ordering was evaluated based on Laurdan generalized polarization measurements. Our observations revealed that the hybrid lipid acted like a linactant to solid domains and disturbed chain ordering in liquid-ordered (Lo) domains. In both cases, the hybrid lipid reduced line tension at the domain boundary.

[Usefulness of S-1/gemcitabine combination therapy for advanced pancreatic cancer].

Combination chemotherapy with S-1 and gemcitabine(GEM)was given to patients with advanced pancreatic cancer and favorable results were obtained. These patients were 77-(Stage IVa), 68-(Stage IVb), and 64-year-old males (Stage IVb). They were administered S-1 at a dose of 80-100 mg/day for 2 weeks and GEM at a dose of 1,000-1,200 mg/body on days 8 and 15 followed by a 2-week recovery period. One course consisted of a 2-week treatment period and a recovery period; this course was repeated in all of these patients. The 3 types of patients have survived for a year and five months, a year and three months, and nine months, respectively, after diagnosis. In the first patient, who was in Stage IVa, the primary cancer has been maintained in a reduced state without metastasis. In the other two patients, who were in Stage IVb, the primary cancer and hepatic metastatic lesions have been reduced remarkably. Quality of life is good in all the patients. Combination therapy with S-1 and GEM can be provided for a long-term treatment with few adverse reactions on an outpatient basis. Based on the changes in tumor markers, we observed that the inhibitory effects of this combination chemotherapy are immediate and persistent with long-term treatment. Therefore, we expect S-1/GEM combination therapy to be the chemotherapy of choice for advanced pancreatic cancer.

Computational consideration of cisplatin hydrolysis and acid dissociation in aqueous media: effect of total drug concentrations.

Cisplatin (cis-DDP) is subject to nucleophilic displacement of chloride in water, forming aquated species, subsequently liberating hydrogen ion(s) with increasing pH. This study intends to theoretically analyze the hydrolysis and polyprotic dissociation behavior of cis-DDP in various aqueous media. A mathematical model was expressed by nonlinear simultaneous equations in terms of the total drug concentration, pH and pCl based on the hydrolysis and acid dissociation constants already published. Some of the interesting simulation results include that (1) in water, cis-DDP behaves in a very complicated manner, highly depending on the total drug concentration, pH and pCl, (2) in normal saline, about 3% of the total concentration is a positively charged chloro-aqua that may be very reactive, (3) in assumed blood (pH 7.4, [Cl(-)]=0.11 mol/l, mu=0.15), the drug is stabilized at the level of 85% and the remnants are the chloro-hydroxo (11%) and the chloro-aqua (4%), (4) in assumed intracellular conditions (pH 7.1, [Cl(-)]=0.01 mol/l, mu=0.15), the drug is converted to a large extent to various species including the parent species (44%), the chloro-hydroxo (30%), hydroxo-aqua (2%), chloro-aqua (24%) diaqua (less than 1%) and dihydroxo (null). The results of this analysis may provide a useful preliminary knowledge of existing species in a system concerned and a rationale for re-evaluating the reactions between cis-DDP and various nucleophilic substances already reported while there are somewhat conflicting interpretations of some cis-DDP reactions.