梅田 良祐

INTRODUCTION: Urinary microcholesterol (U-mCHO) may reflect tubular or glomerular injury through impaired lipid handling; nonetheless, its prognostic value in chronic kidney disease (CKD) remains unclear. We examined whether U-mCHO is associated with adverse kidney outcomes. METHODS: We conducted a cohort study of patients with CKD (baseline eGFR ≥ 15 ml/min per 1.73 m2), among whom baseline U-mCHO was measured between April 2022 and July 2022 and who were followed until December 2025. The primary outcome was major adverse kidney events (MAKE) with a 50% estimated glomerular filtration rate (eGFR) decline (MAKE50), defined as a composite of a ≥ 50% reduction in eGFR, initiation of kidney replacement therapy (KRT), or kidney-related death. Associations were evaluated using multivariable Cox models. Subgroup analyses focused on patients with low proteinuria (urinary protein-to-creatinine ratio [UPCR] < 0.5 g/g) using an alternative composite outcome (MAKE30) based on a 30% decline in eGFR. RESULTS: A total of 1562 patients were included. The mean U-mCHO level was 3.0 ± 5.8 mg/g creatinine. Higher U-mCHO levels were associated with greater MAKE50 risk (adjusted hazard ratio [HR] for highest vs. lowest quartile: 7.30; 95% confidence interval [CI]: 2.74-19.49). This association was consistent when U-mCHO was modeled as a log-transformed continuous variable. The association remained consistent across subgroups and persisted in patients with low proteinuria (HR for MAKE30: 3.06; 95% CI: 1.37-6.85), with no interaction by proteinuria level (P = 0.89). CONCLUSION: U-mCHO is independently associated with MAKE50 in CKD. The association with MAKE30 was also observed in patients with low proteinuria, supporting U-mCHO as a potential noninvasive biomarker of kidney lipid injury.

Tryptophan (TRP) metabolism through the kynurenine pathway generates multiple biologically active metabolites with diverse immunomodulatory effects, but their roles in glomerulonephritis (GN), particularly in innate immunity, remain poorly understood. Using a nephrotoxic serum-induced GN (NTS-GN) model, we first analyzed mice deficient in key TRP-metabolizing enzymes of the kynurenine pathway: Indoleamine 2,3-dioxygenase 1 and 2 (IDO1 and IDO2), and kynurenine 3-monooxygenase (KMO), and found that Ido1-deficient mice exhibited exacerbated kidney injury and glomerular neutrophil infiltration, whereas Ido2 deficiency had no significant impact. In contrast, Kmo-deficient mice showed reduced crescent formation. Unexpectedly, the concentration of kynurenic acid (KYNA), a downstream metabolite of IDO1, was elevated in the kidney cortex of Ido1-deficient mice. Exogenous KYNA administration improved survival, ameliorated renal injury, and reduced neutrophil infiltration in Ido1-deficient mice, indicating its protective effect against antibody-mediated injury. Moreover, KYNA suppressed immune complex-mediated neutrophil spreading, attenuated FcγR-dependent Syk phosphorylation, and reduced VEGF secretion in vitro. Our results position KYNA as a key modulator of neutrophil-driven inflammation in antibody-mediated GN. This study uncovers distinct roles for kynurenine pathway enzymes and highlights the TRP-KYNA pathway as a promising immunometabolic target for controlling innate immune responses in GN.

An 81-year-old man was treated with prednisolone, avacopan, and rituximab for microscopic polyangiitis and sulfamethoxazole/trimethoprim (SMX/TMP) and vonoprazan for prophylaxis. The liver enzyme levels were elevated 42 days after avacopan administration. Avacopan, SMX/TMP, and vonoprazan treatment were discontinued. A liver biopsy revealed vanishing bile duct syndrome. The patient was subsequently treated with ursodeoxycholic acid and glucocorticoid. Although vasculitis remained in remission, the patient ultimately died. Autopsy revealed persistent bile ductopenia and progressive liver cell injury confirmed by cytokeratin 7 positivity, severe cholestasis, and portal fibrosis. Further studies are required to elucidate associated mechanisms and risk factors.

BACKGROUND: Despite the widespread use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in the management of chronic kidney disease, their role in autosomal dominant polycystic kidney disease (ADPKD) remains unclear. METHODS: This observational study evaluated the efficacy of the SGLT2i dapagliflozin in patients with ADPKD receiving tolvaptan. The primary outcome was the chronic estimated glomerular filtration rate (eGFR) slope, modeled using a multivariable linear mixed-effect model; a within-group analysis was also performed using an interrupted time series approach. RESULTS: A total of 48 patients receiving tolvaptan were analyzed (24 patients in the control group vs 24 patients in the dapagliflozin group). The mean follow-up duration was 649 ± 363 days across all patients. The chronic eGFR slope was -2.30 [95% confidence interval (CI) -3.47, -1.13] in the control group and -1.72 (95% CI -3.48, -0.03) mL/min/1.73 m2 per year in the dapagliflozin group (P = .595). In within-group analysis using an interrupted time series approach, the chronic eGFR slope changed from -2.34 (95% CI -3.39, -1.30) to -1.14 (95% CI -2.68, 0.40) mL/min/1.73 m2 per year following dapagliflozin initiation (P = .191). No serious adverse events were observed during the follow-up period. CONCLUSIONS: Although no statistically significant differences were observed, both between- and within-group analyses showed a numerically slower decline in eGFR with dapagliflozin. Importantly, no evidence of harm was observed. These findings may contribute to ongoing discussions regarding the potential role of SGLT2i in ADPKD.

BACKGROUND: Although the 2018 revised International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification was proposed recently, until now, no reports have been made comparing the association of renal prognosis between the 2018 revised ISN/RPS classification and the 2003 ISN/RPS classification. The present study aimed to assess the usefulness, especially of activity and chronicity assessment, of the 2018 revised ISN/RPS classification for lupus nephritis (LN) in terms of renal prognosis compared to the classification in 2003. METHODS: We retrospectively collected medical records of 170 LN patients from the database of renal biopsy at Fujita Health University from January 2003 to April 2019. Each renal biopsy specimen was reevaluated according to both the 2003 ISN/RPS classification and the 2018 revised ISN/RPS classification. Renal endpoint was defined as a 30% decline of estimated glomerular filtration rate (eGFR). RESULTS: A total of 129 patients were class III/IV±V (class III, 44 patients; class IV, 35 patients; class III/IV+V, 50 patients). The mean age was 42 years, 88% were female, and the median observation period was 50.5 months. Renal prognosis was significantly different among the classes and significantly poor in the patients with higher modified National Institute of Health (mNIH) chronicity index (C index, ≥ 4) by a log-rank test (p = 0.05 and p = 0.02, respectively). By Cox proportional hazard models, only the C index was significantly associated with renal outcome (hazard ratio 1.32, 95% CI 1.11-1.56, p ≤ 0.01), while the classes, the 2003 activity and chronicity subdivision, and the mNIH activity index had no significant association with renal outcome. Each component of the C index was significantly associated with renal outcome in different models. CONCLUSION: This study demonstrates that the 2018 revised ISN/RPS classification was more useful in terms of association with renal prognosis compared to the 2003 ISN/RPS classification.