Long-term outcome of children treated with rituximab for idiopathic nephrotic syndrome

Background

Rituximab (RTX) has recently showed promising results in the treatment of steroid-dependent idiopathic nephrotic syndrome (SDNS).

Methods

This was a retrospective multicenter study of 18 children treated with RTX for SDNS, with a mean follow-up of 3.2 years. RTX was introduced because of side effects or relapses during therapy with immunosuppressive agents. The children received one to four infusions of RTX during the first course of treatment, and subsequent infusions were given due to CD19-cell recovery (CD19?>1 %; 54 % of children) or relapse (41 %), as well as systematically (5 %).

Results

Treatment with RTX maintained sustained remission without relapse in 22 % of patients and increased the duration of remission in all other patients. The time between two successive relapses was 9 months in the absence of re-treatment and 24.5 months when infusions were performed at the time of CD19-cell recovery. At the last follow-up, 44.5 % of patients were free of oral drug therapy. Of those still receiving oral drugs, all doses had been decreased. No serious adverse events occurred.

Conclusion

The results of this retrospective study confirm the efficacy and very good safety of RTX in the treatment of SDNS. The optimal therapeutic protocol seems to be a repeated single infusion at the time of CD19-cell recovery.     

SPAK Differentially Mediates Vasopressin Effects on Sodium Cotransporters

Activation of the Na⁺-K⁺-2Cl⁻-cotransporter (NKCC2) and the Na⁺-Cl⁻-cotransporter (NCC) by vasopressin includes their phosphorylation at defined, conserved N-terminal threonine and serine residues, but the kinase pathways that mediate this action of vasopressin are not well understood. Two homologous Ste20-like kinases, SPS-related proline/alanine-rich kinase (SPAK) and oxidative stress responsive kinase (OSR1), can phosphorylate the cotransporters directly. In this process, a full-length SPAK variant and OSR1 interact with a truncated SPAK variant, which has inhibitory effects. Here, we tested whether SPAK is an essential component of the vasopressin stimulatory pathway. We administered desmopressin, a V2 receptor–specific agonist, to wild-type mice, SPAK-deficient mice, and vasopressin-deficient rats. Desmopressin induced regulatory changes in SPAK variants, but not in OSR1 to the same degree, and activated NKCC2 and NCC. Furthermore, desmopressin modulated both the full-length and truncated SPAK variants to interact with and phosphorylate NKCC2, whereas only full-length SPAK promoted the activation of NCC. In summary, these results suggest that SPAK mediates the effect of vasopressin on sodium reabsorption along the distal nephron.The furosemide-sensitive Na⁺-K⁺-2Cl⁻-cotransporter (NKCC2) of the thick ascending limb (TAL) and the thiazide-sensitive Na⁺-Cl⁻-cotransporter (NCC) of the distal convoluted tubule (DCT) are key regulators of renal salt handling and therefore participate importantly in BP and extracellular fluid volume homeostasis.¹ Loss-of-function mutants in the SLC12A1/ A3 genes encoding NKCC2 and NCC cause salt-losing hypotension and hypokalemic alkalosis in Bartter’s and Gitelman’s syndromes,^2,3 whereas their overactivity may contribute to essential hypertension.^4,5 Recently, attention has been focused on the two closely related STE20-like kinases, SPS-related proline/alanine-rich kinase (SPAK) and oxidative stress responsive kinase 1 (OSR1), which can phosphorylate NKCC2 and NCC at their N-terminal conserved threonine or serine residues (T96, T101, and T114 of mouse NKCC2 and T53, T58, and S71 of mouse NCC) and thereby activate the transporters.^6–8 Despite the high homology between SPAK and OSR1 and their overlapping renal expression patterns, distinct roles along the nephron have been suggested based on data from SPAK-deficient and kidney-specific OSR1-deficient mice: deletion of SPAK primarily impairs the function of NCC, whereas deletion of OSR1 negatively affects NKCC2.^9–11 The complex functional properties of a WNK-SPAK/OSR1-N(K)CC interaction cascade are currently being defined.¹² Recently, arginine vasopressin (AVP), signaling via the V2 receptor (V2R), has been identified as an efficient activator of both cotransporters, affecting their luminal trafficking and phosphorylation.^13–18 Because plasma AVP levels may vary not only with the sleep-wake cycle or long-term physiologic challenges, but also with pulsatile changes over the short term, distinct, time-dependent responses may occur.¹⁹ SPAK and OSR1 are well placed to regulate distal NaCl reabsorption in response to AVP. Here we tested the role of SPAK in AVP-induced activation of NKCC2 and NCC, acutely and during long-term treatment. The results suggest that SPAK is an essential kinase that modulates distal nephron function in response to AVP stimulation.     

Routine single-port sleeve gastrectomy: a study of 60 consecutive patients

BackgroundSingle-port surgery has been developed for many digestive procedures, such as cholecystectomy and colectomy. Our objective was to present our preliminary results for laparoscopic single-port sleeve gastrectomy (SPSG), performed in our department for the treatment of morbid obesity, at Antoine Beclere Hospital and Paris XI University.MethodsFrom July 2010 to February 2011, all patients evaluated by our multidisciplinary team for morbid obesity and eligible for sleeve gastrectomy underwent SPSG. The data were collected prospectively.ResultsSixty consecutive patients underwent SPSG. The median age was 40.1 years; 6 patients were men and 48 were white. The median body mass index was 46.5 kg/m². The co-morbidities included diabetes in 12, essential hypertension in 31, sleep apnea in 39, dyslipidemia in 33, and coronary artery disease in 9. Of the 60 patients, 9 had previously undergone laparotomy and 5 had undergone bariatric surgery. The median operating time was 86 minutes. All procedures were achieved laparoscopically, with 10 patients requiring a second trocar and 3 patients 2 additional trocars. No conversion to open surgery was required. One leak was reported, and 1 patient experienced cubital nerve compression. The median hospital stay was 4 days. During a median follow-up of 8 months, most preoperative co-morbidities resolved, and the Bariatric Analysis and Reporting Outcome System score for care efficacy was 6.8 of 9.ConclusionSPSG is feasible in routine bariatric surgery. The results for weight loss and co-morbidity resolution seem to be equivalent to those with “multiple port” laparoscopy. New instruments and specific training are required. We believe that this technique is a natural evolution of minimally invasive surgery requiring additional investigation in prospective studies.     

Balance control and adaptation of kinematic synergy in aging adults during forward trunk bending

The present study focuses on the organization of kinematic synergy and its adaptation to an unstable support surface during upper trunk movements in aging adults. Seven healthy aging adults (49-66 years old) were instructed to bend the trunk forward (the head and the trunk together) by about 40 degrees and to stabilize their final position, in the standard condition (both feet on the ground), and on a seesaw swinging in the sagittal plane. Kinematic synergy was quantified by performing a principal components analysis on the hip, knee and ankle angle changes during the movement. The results indicate that trunk bending was represented by a single component (PC1) in both conditions, indicating a strong coupling between the angle changes during the movement. The results also show a reorganization of the contribution of PC1 to the three angles when the balance constraints are increased in the seesaw condition. It is concluded that kinematic synergy is preserved during trunk bending in aging adults, regardless of the support conditions. It can also be adapted when the balance constraints are increased by changing the ratio between the angles, indicating a modification of interjoint coordination without modifying the movement's trajectory.     

Insight into siderophore-carrying peptide biosynthesis: enterobactin is a precursor for microcin E492 posttranslational modification

Microcin E492-producing bacteria secrete both unmodified and posttranslationally modified microcins. The modification consists of a C-glucosylated linear trimer of N-(2,3-dihydroxybenzoyl)-l-serine, a catecholate siderophore related to salmochelins and enterobactin. We show here that repression of enterobactin biosynthesis inhibits the acquisition of microcin E492 posttranslational modification, as monitored by high-performance liquid chromatography and mass spectrometry. Furthermore, exogenous enterobactin restored the production of posttranslationally modified microcin in a bacterial strain deficient in enterobactin synthesis. We thus concluded that enterobactin serves as a precursor for the synthesis of the posttranslationally modified microcin and that the unmodified microcin is an incompletely processed form of mature microcin E492. Gene disruption experiments showed that MceC and MceD, two enzymes encoded by the mceABCDEFGHIJ gene cluster, are involved in the synthesis of the microcin E492 posttranslational modification, as followed by mass spectrometry. Genes homologous to iroB and iroD, required for the conversion (linearization and C-glycosylation) of enterobactin into salmochelins, efficiently complemented mceC and mceD, respectively. Based on our results, a model is proposed for the biosynthesis of the mature siderophore-carrying peptide.