Thesis (Ph.D.) -- University of Texas Southwestern Medical Center at Dallas, 2005. / Embargoed. Vita. Bibliography: 222-278.

Orientador: Marilda Mazzali / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-08T15:27:17Z (GMT). No. of bitstreams: 1 Mazali_FernandaCristina_M.pdf: 3384913 bytes, checksum: 0d3a47a884265f3d5949b9aff82161a6 (MD5) Previous issue date: 2006 / Resumo: Objetivo: Hiperuricemia é uma complicação freqüente da terapêutica com ciclosporina (CsA). Estudos anteriores demonstraram que a hiperuricemia exacerba a lesão intersticial e vascular no modelo experimental de nefrotoxicidade por CsA (CsA ntx). O presente estudo tem como hipótese que a normalização da uricemia preveniria o desenvolvimento da nefropatia crônica por CsA. Metodologia: A nefropatia crônica por CsA foi induzida em ratos machos, Sprague Dawley, através da injeção subcutânea diária de CsA (15mg/kg/dia), por um período de 7 semanas, em associação com dieta hipossódica (CSA). O efeito do controle da hiperuricemia foi determinado através do tratamento concomitante com um inibidor de xantina oxidase (alopurinol, 15mg/Kg/dia ? CSA/ALP) ou com um agente uricosúrico (benzbromarona, 15mg/Kg/dia, CSA/BENZ), em bebedouro. O grupo-controle incluiu ratos tratados com veículo (VEH, injeções SC diárias de óleo de oliva). Ao sacrifício foram realizadas análises funcionais e histológicas. Resultados: Os animais do grupo CSA desenvolveram hiperuricemia leve (ácido úrico 4.36 vs 2.49 mg/dl, CSA vs VEH, p<0.05), com hialinose arteriolar, atrofia tubular, fibrose intersticial em faixa, aumento de proliferação celular e redução da expressão de VEGF. O tratamento com alopurinol ou benzbromarona reduziu a lesão renal, assim como os níveis de ácido úrico e creatinina sérica (ácido úrico 2.03 CSA/ALP e 2.93 mg/dl, CSA/BENZ, p<0.05 vs VEH e CSA). Ambos os tratamentos reduziram a fibrose intersticial, a proliferação celular, infiltrado de macrófagos, expressão de osteopontina e hialinose arteriolar, em associação com restauro da expressão de VEGF, com proteção comparável entre as duas drogas. Conclusão: A hiperuricemia exacerba a nefropatia pela CsA em ratos. Tratamento concomitante com alopurinol ou benzbromarone reduz a severidade da lesão. Como ambas as drogas promovem proteção semelhante, concluímos que o efeito protetor é associado ao controle da hiperuricemia, mais importante que o efeito antioxidante do alopurinol / Abstract: Aim: Hyperuricemia frequently complicates cyclosporine (CSA) therapy. Previous studies have shown that hyperuricemia increases the interstitial and vascular lesions in the cyclosporine model. We therefore tested the hypothesis that normalization of uric acid could prevent the development of cyclosporine toxicity. Material and Methods: CSA nephropathy was induced by the administration of CSA (15 mg/kg/day) for 7 weeks to rats on a low salt diet (CSA group). The effect of preventing hyperuricemia on CSA nephropathy was determined by concomitant treatment with the xanthine oxidase inhibitor, allopurinol (CSA-ALP), or with the uricosuric, benzbromarone (CSA-BENZ), in the drinking water. Control groups included rats treated with vehicle (VEH). Histological and functional studies were determined at sacrifice. Results:. CSA treated rats developed mild hyperuricemia with arteriolar hyalinosis, tubular atrophy, striped interstitial fibrosis, increased cell proliferation and decreased VEGF expression. Treatment with either allopurinol (CSA-ALP) or benzbromarone (CSA-BENZ) reduced renal injury. Both treatments reduced interstitial fibrosis, cell proliferation, macrophage infiltration, osteopontin expression and arteriolar hyalinosis in association with restoration of VEGF expression. Both drugs provided comparable protection. Conclusions: An increase in uric acid exacerbates CSA nephropathy in the rat. Concomitant treatment with allopurinol or benzbromarone reduced the severity of renal disease. As both drugs promoted similar protection, we can conclude that the protective effect is associated with lowering uric acid levels, more than the antioxidant effect of allopurinol / Mestrado / Ciencias Basicas / Mestre em Clinica Medica

Introduction Acute interstitial nephritis (AIN), also called tubulointerstitial nephritis, is a renal pathology that can cause a significant decline in kidney function. Drug-induced AIN accounts for 70% of all cases and is often due to non-steroidal anti-inflammatory drugs (NSAIDs), antimicrobials, and proton pump inhibitors. However, there have been isolated reports of other drugs being responsible for AIN. We hereby report a case of furosemide-induced AIN. Case Presentation A 68-year-old caucasian male with a medical history significant for chronic kidney disease (CKD) stage 3 due to hypertensive nephrosclerosis with a baseline serum creatinine (Cr) of 1.3-1.5, hypertension, hyperlipidemia, atrial fibrillation, heart failure with preserved ejection fraction (HFpEF), and hypogonadism was admitted for evaluation of worsening renal failure. At initial evaluation, the patient had nonspecific symptoms like malaise, nausea, and vomiting but denied any other complaints. Physical examination was unremarkable, without any rashes or abdominal bruit. The patient’s creatinine progressively trended up from his baseline to 3.5 over three months. Pre-renal pathology was suspected initially, and the patient's furosemide was held on admission with concurrent fluid resuscitation. However, this did not improve his kidney function as repeat lab work showed a worsening Cr level of 4.4, along with a blood urea nitrogen (BUN) of 72. Further evaluation showed a complete blood count significant for mild eosinophilia with urinalysis revealing hematuria, pyuria with eosinophiluria but no protein, WBC casts, or RBC casts. Renal ultrasound and abdominal CT scan were unremarkable. The patient had no known drug allergies until that point and was on a stable medication regimen for his chronic conditions for several years, except for a daily dose of furosemide started three months ago for fluid retention and elevated BNP. Ultrasound-guided renal biopsy revealed findings consistent with acute interstitial nephritis on top of chronic tubulointerstitial fibrosis plus underlying moderate arterial sclerosis from hypertension. Other extensive workup was negative for any autoimmune process, IgG4 related disease, sarcoidosis, or infection, thus favoring the diagnosis of drug-induced acute interstitial nephritis. Given the temporal relationship between the initiation of furosemide in this patient and his worsening kidney function makes it the likely offending agent. He was observed off furosemide without any immunosuppressant treatment. The patient’s creatinine level gradually trended down and ultimately returned to his baseline at a one-month follow-up. Discussion Furosemide is a loop diuretic, often used in patients to prevent volume overload. Therefore, furosemide is often implicated as a cause of pre-renal acute kidney injury (AKI) secondary to volume depletion. However, interstitial inflammation as a mechanism of furosemide-induced kidney injury is uncommon and can often be overlooked as a potential cause, especially in patients with long medication lists. In such patients, a causal link can be established by correlating the onset of decline in kidney function with the time of initiation of a new drug and resolution of AKI after discontinuation of the drug.

Immunoglobulin G4–related disease (IgG4-RD) is a chronic fibrosing inflammatory systemic disorder that has been recognized relatively recently in the medical literature. Little is known about the exact disease pathogenesis and epidemiology. IgG4-RD may be asymptomatic or may have minimal symptoms or involve multiple organs with overt symptoms. The different phenotypes of IgG4-RD can lead to delayed or incorrect diagnosis. We report the case of a 66-year-old male with coal worker’s pneumoconiosis who presented with progressive kidney disease and was diagnosed with tubulointerstitial nephritis due to IgG4-RD. The patient was noted to have progressive kidney disease, skin involvement, worsening interstitial lung disease, complete vision loss in the left eye, and retroperitoneal fibrosis. Serologic workup revealed elevated inflammatory markers, IgG4 and IgG1 levels, and hypocomplementemia. A tissue biopsy helped us establish a definitive diagnosis of IgG4-RD and initiate treatment with glucocorticoids to prevent further progression of kidney disease and other end-organ damage.

No description available.

Hyperacute renal failure is rarely the initial presentation of systemic lupus erythematosus (SLE). Pregnancy can predispose untreated lupus nephritis to acute renal failure. Collapsing glomerulopathy (CG) type of renal failure is not a new clinicopathological entity. There have been documented cases prior to 1979. It is thought that detection bias coupled with the predilection for HIV has caused this form of glomerulopathy to be incorrectly named or diagnosed as 'malignant focal segmental glomerulosclerosis (FSGS)'. This is a case of CG described in lupus nephritis. We present a case of untreated lupus in a female in whom pregnancy triggered the exacerbation of lupus nephritis that presented as collapsing glomerulopathy.

Feline morbillivirus (FeMV) is a recently discovered virus belonging to the genus Morbillivirus of the virus family Paramyxoviridae. Often, the virus has been detected in urine of cats with a history of urinary disease and has a worldwide distribution. Currently, it is unclear which receptor the virus uses to enter the target cells. Furthermore, many aspects of FeMV biology in vivo, including tissue tropism, pathogenesis, and virus excretion in the natural host remain unclear. In this study we analyzed the replication of FeMV in various cell lines. Secondly, we tested if the presence of feline SLAMF1 (Signaling Lymphocytic Activation Molecule family 1/CD150, principal entry receptor for other members of the Morbillivirus genus) improved FeMV replication efficiency in vitro. Finally, to elucidate in vivo biology in cats, as a natural host for FeMV, we experimentally infected a group of cats and monitored clinical symptoms, viremia, and excretion of the virus during the course of 56 days. Our study showed that FeMV shares some features with other morbilliviruses like the use of the SLAMF1 receptor. For the first time, experimental infection of SPF cats showed that FeMV does not induce an acute clinical disease like other morbilliviruses but can induce lesions in the kidneys, including tubulointerstitial nephritis. Further investigations are needed to confirm the site and dynamics of replication of FeMV in the urinary tract and the longer-term impact of FeMV-induced lesions on the renal function. Whether FeMV infection can result in chronic kidney disease will require the monitoring of cats over a longer period.

京都大学 / 新制・課程博士 / 博士(医学) / 甲第24994号 / 医博第5028号 / 新制||医||1069(附属図書館) / 京都大学大学院医学研究科医学専攻 / (主査)教授 上野 英樹, 教授 椛島 健治, 教授 濵﨑 洋子 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DFAM

Systemic lupus erythematosus (SLE) is a chronic multifactorial inflammatory autoimmune disease with heterogeneous clinical manifestations. Among different manifestations, lupus nephritis (LN) remains a major cause of morbidity and mortality. There are few FDA approved treatments for LN. In general, they are non-selective and lead to global immunosuppression with significant side effects including an increased risk of infection. In the past 60 years, only one new drug, belimumab was approved for lupus disease with modest efficacy in clinic and not approved for patients suffering for nephritis. Therefore, it is urgent to develop new treatments to replace or reduce the use of current ones. Histone deacetylase 6 (HDAC6) plays a variety of biologic functions in a number of important molecular pathways in diverse immune cells. Both innate and adaptive immune cells contribute to pathogenesis of lupus. Among those cells, B cells play a central role in pathogenesis of lupus nephritis in an anti-body dependent manner through differentiation into plasma cells (PCs). As a result, HDAC6 inhibitors represent an entirely new class of agents that could have potent effects in SLE. Importantly, the available toxicity profile suggests that HDAC6 inhibitors could be advanced into SLE safely. We have demonstrated previously that histone deacetylase (HDAC6) expression is increased in animal models of systemic lupus erythematosus (SLE) and that inhibition of HDAC6 decreased disease. ACY-738 is a hydroxamic acid HDAC6 inhibitor that is highly selective for HDAC6. In our current studies, we tested if an orally selective HDAC6 inhibitor, ACY-738, would decrease disease pathogenesis in a lupus mouse model with established early disease. Moreover, we sought to delineate the cellular and molecular mechanism(s) of action of a selective HDAC6 inhibitor in SLE. In order to define the mechanism by which HDAC6 inhibition decreases disease pathogenesis in NZB/W mice by using RNAseq to evaluate the transcriptomic signatures of splenocytes from treated and untreated mice coupled with applied computational cellular and pathway analysis. In addition, we sought to bridge between the transcriptomic data obtained from the HDAC6 treated mice and human gene expression information to determine the relevance to this target in possibly controlling human lupus. We treated 20-week-old (early-disease) NZB/W F1 female mice with two different doses of the selective HDAC6 inhibitor (ACY-738) for 4~5 weeks. As the mice aged, we determined autoantibody production and cytokine levels by ELISA, and renal function by measuring proteinuria. At the termination of the study, we performed a comprehensive analysis on B cells, T cells, and innate immune cells using flow cytometry and examined renal tissue for immune-mediated pathogenesis using immunohistochemistry and immunofluorescence. We then used RNAseq to determine the genomic signatures of splenocytes from treated and untreated mice and applied computational cellular and pathway analysis to reveal multiple signaling events associated with B cell activation and differentiation in SLE that were modulated by HDAC6 inhibition. Our results showed a reduced germinal center B cell response, decreased T follicular helper cells and diminished interferon (IFN)-γ production from T helper cells in splenic tissue. Additionally, we found the IFN-α-producing ability of plasmacytoid dendritic cells was decreased along with immunoglobulin isotype switching and the generation of pathogenic autoantibodies. Renal tissue showed decreased immunoglobulin deposition and reduced inflammation as judged by glomerular and interstitial inflammation. The molecular pathways by which B cells become pathogenic PC secreting autoantibodies in SLE are incompletely characterized. RNA sequence data showed that PC development was abrogated and germinal center (GC) formation was greatly reduced. When the HDAC6 inhibitor-treated lupus mouse gene signatures were compared to human lupus patient gene signatures, the results showed numerous immune and inflammatory pathways increased in active human lupus were significantly decreased in the HDAC6 inhibitor treated animals. Pathway analysis suggested alterations in cellular metabolism might contribute to the normalization of lupus mouse spleen genomic signatures, and this was confirmed by direct measurement of the impact of the HDAC6 inhibitor on metabolic activities of murine spleen cells. Taken together, these studies show selective HDAC6 inhibition decreased several parameters of disease pathogenesis in lupus-prone mice. The decrease was in part due to inhibition of B cell development and response. RNA sequence data analysis show HDAC6 inhibition decreases B cell activation signaling pathways and reduces PC differentiation in SLE and suggests that a critical event might be modulation of cellular metabolism. / Doctor of Philosophy / Systemic lupus erythematosus (SLE) is a chronic inflammatory autoimmune disease by which immune cells mistakenly attacks healthy self-cells in different organs. Kidney inflammation occurs in nearly 50% of patients with lupus resulting in kidney damage leading to end stage renal disease. Lupus nephritis (LN) is major cause of morbidity and mortality associated with SLE. Current treatments for LN consist primarily of immunosuppressants that block the immune response and leave the patients with unwanted side effects including an increased risk of infection. To circumvent the unwanted side effects, we explored a novel mechanism to target the immune response. My project was to determine whether histone deacetylase 6 (HDAC6) inhibition would suppress the autoimmune inflammatory response in lupus. We found that inhibition of HDAC6 was effective at attenuating early LN, probably by down-regulating innate immune response, which suppressed subsequent adaptive immune responses downstream. HDAC6 inhibition affected the innate immune response by inhibiting type I interferon production by plasmacytoid dendritic cells. HDAC6 inhibition affected the cell mediated immune response by decreasing T helper cell and B cell activation. To determine the mechanism by which HDAC6 inhibits immune cells activation, we used RNAseq to reveal HDAC6 inhibition on multiple signaling events associated with the induction of lupus disease. These results suggest that HDAC6 could be a potential therapeutic target in the early stage of LN.

Systemic lupus erythematosus (SLE) is an autoimmune disease involving the inflammatory damages of multiple organs. Lupus nephritis (LN) as the manifestation in the kidney occurs in more than 50% of SLE patients and is a major cause of morbidity and mortality. Current treatments consist of immunosuppressants that always lead to compromised immune responses with increased risks of infections as the major side effect. To minimize this side effect, it is crucial to develop new treatments that are more natural and specific. Vitamin A, particularly in the form of its functional metabolite, retinoic acid, has shown some beneficial effects against LN in both lupus-prone mouse models and clinical cases. However, a more systemic evaluation of vitamin A treatment in lupus had not been investigated. In our study, we found paradoxical effects of all-trans-retinoic acid (tRA) on lupus-like disease in MRL/lpr lupus-prone mice. Starting at 6 weeks old when the inflammatory environment had been established in MRL/lpr mice, tRA administration reduced immune cell numbers in the secondary lymphoid organs and improved glomerulonephritis. However, circulating autoantibodies and inflammation in renal tubulointerstitium and other organs were increased. The detrimental effects of tRA were not present in MRL control mice, which didn't have an established inflammatory environment at 6 weeks old as shown in MRL/lpr mice, suggesting that the pro-inflammatory effects of tRA are dependent on the pre-existing inflammatory environment. Therefore, to successfully apply vitamin A-based treatment, it is important to avoid the detrimental effects of tRA on lupus by identifying and then specifically eliminating the critical pro-inflammatory immune cell types in lupus. As treatments usually start after the onset of apparent symptoms in patients at the effector stage of autoimmune responses, targeting the inflammatory contributors at this stage appears to be more practical and critical. Among different types of leukocytes, we chose to focus on dendritic cells (DCs), because they are highly diverse and critical in the immune responses as a bridge between the innate and adaptive immune systems. Plasmacytoid DCs (pDCs) as a candidate target have been demonstrated to be crucial for the initiation of lupus development by producing IFNα. However, we demonstrated that although pDCs produced a large amount of IFNα during disease initiation, those from late-stage lupus mice were found to be defective in producing IFNα, suggesting that pDC-targeted treatments should be performed at the initiation stage. This will depend on the progress in early diagnosis in the future. Besides pDCs, we identified a CD11c+ cell population absent at the early-stage but gradually accumulating at the late-stage in the kidneys of lupus mice. These cells have a phenotype of mature monocyte-derived DCs, with particularly high CX3CR1 expression on the surface. Consistent with their pathogenic cytokine profile, in vivo administration of anti-CX3CR1-saporin conjugates to dysfunction these cells in MRL/lpr mice significantly reduced proteinuria scores. Ex vivo activation of renal-infiltrating CD4+ T cells showed increased survival rate, proliferation and IFN-γ production of activated CD4+ T cells when they were cultured with these renal-infiltrating CD11c+ cells. These results suggest that the renal-infiltrating CD11c+ cells are pathogenic and promote inflammation in the kidney at the later effector stage of lupus by interacting with renal-infiltrating CD4+ T cells. In conclusion, although vitamin A showed anti-inflammatory effects on reducing glomerulonephritis, its use in lupus treatment should be guarded due to the other potential pro-inflammatory effects induced by the pre-existing inflammatory environment. IFNα-producing pDCs and CX3CR1highCD11c+ monocyte-derived DCs could be specific therapeutic targets to reduce the established inflammation at the early stage and late stage of LN, respectively. Therefore, it is worthwhile to further investigate the comprehensive effects of combination therapy on lupus, with vitamin A administration and pDCs-specific depletion at the early stage, and CX3CR1highCD11c+ monocyte-derived DCs-specific depletion at the late stage. / Ph. D.