Details of a Researcher - Kanai, Takanori

Papers - Kanai, Takanori

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Relevance of pepsinogen, gastrin, and endoscopic atrophy in the diagnosis of autoimmune gastritis

Kishikawa H., Nakamura K., Ojiro K., Katayama T., Arahata K., Takarabe S., Sasaki A., Miura S., Hayashi Y., Hoshi H., Kanai T., Nishida J.

Scientific Reports (Scientific Reports) 12 ( 1 ) 2022.12

Simple objective modalities are required for evaluating suspected autoimmune gastritis (AIG). This cross-sectional study aimed to examine whether pepsinogen, gastrin, and endoscopic findings can predict AIG. The diagnostic performance of endoscopic findings and serology in distinguishing AIG was evaluated. AIG was diagnosed in patients (N = 31) with anti-parietal cell antibody and/or intrinsic factor antibody positivity and histological findings consistent with AIG. Non-AIG patients (N = 301) were seronegative for anti-parietal cell antibodies. Receiver operating characteristic curve analysis of the entire cohort (N = 332) identified an endoscopic atrophic grade cutoff point of O3 on the Kimura–Takemoto classification (area under the curve [AUC]: 0.909), while those of pepsinogen-I, I/II ratio, and gastrin were 20.1 ng/mL (AUC: 0.932), 1.8 (AUC: 0.913), and 355 pg/mL (AUC: 0.912), respectively. In severe atrophy cases (≥ O3, N = 58, AIG/control; 27/31), the cutoff values of pepsinogen-I, I/II ratio, and gastrin were 9.8 ng/mL (AUC: 0.895), 1.8 (AUC: 0.86), and 355 pg/mL (AUC: 0.897), respectively. In conclusion, endoscopic atrophy is a predictor of AIG. High serum gastrin and low pepsinogen-I and I/II ratio are predictors even in the case of severe atrophy, suggesting their usefulness when the diagnosis of AIG is difficult or as serological screening tests.

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Efficacy and safety of low-dose rifabutin-based 7-day triple therapy as a third- or later-line Helicobacter pylori eradication regimen

Inokuchi K., Mori H., Matsuzaki J., Hirata K., Harada Y., Saito Y., Suzuki H., Kanai T., Masaoka T.

Helicobacter (Helicobacter) 27 ( 4 ) 2022.08

ISSN 10834389

Background: Rifabutin-based regimens are used as rescue therapy for refractory Helicobacter pylori infection; however, the duration for which treatment is required and side effects are concerning. This study assessed the efficacy and safety of 7-day rifabutin, amoxicillin, and vonoprazan triple therapy as third- or later-line treatment for H. pylori infection. Materials and Methods: Patients who did not respond to second-line therapy were enrolled. After H. pylori infection was confirmed with the culture method, the patients received rifabutin-containing triple therapy (20 mg vonoprazan b.i.d., 500 mg amoxicillin q.i.d., and 150 mg rifabutin q.d.) for 7 days. Twelve weeks after the eradication therapy, successful eradication was confirmed using a 13C urea breath test or the H. pylori stool antigen test. The results obtained from our previous study that reported a 10-day or 14-day esomeprazole based rifabutin-containing triple therapy as a third- or fourth-line rescue therapy treated patients were used as historical control. We determined the minimum inhibitory concentrations of amoxicillin and rifabutin. We also evaluated whether the patients were positive for the mutation of the rpoB gene. Results: Intention-to-treat and per-protocol analyses showed that our regimen resulted in a high eradication rate (91.2%, 95% CI: 84%–99% and 92.7%, 95% CI: 86%–100%, respectively). Adverse events occurred in 31.6% of the patients, and two patients discontinued the therapy. Conclusions: This is the first study to evaluate the efficacy and safety of a 7-day low-dose rifabutin-based triple therapy with vonoprazan and amoxicillin. Our results suggest that our regimen was effective and safe as a third- or later-line H. pylori eradication regimen. To clarify what component in this regimen are critical, subsequent studies using a factorial design (comparing vonoprazan-amoxicillin dual therapy vs. vonoprazan-rifabutin triple therapy) will be needed.

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AJM300 (carotegrast methyl), an oral antagonist of α4-integrin, as induction therapy for patients with moderately active ulcerative colitis: a multicentre, randomised, double-blind, placebo-controlled, phase 3 study

Matsuoka K., Watanabe M., Ohmori T., Nakajima K., Ishida T., Ishiguro Y., Kanke K., Kobayashi K., Hirai F., Watanabe K., Mizusawa H., Kishida S., Miura Y., Ohta A., Kajioka T., Hibi T., Motoya S., Maemoto A., Fujiya M., Ashida T., Goto M., Matsumoto T., Suzuki Y., Hamahata Y., Nakagawa T., Kato N., Kato J., Endo Y., Suzuki R., Matsuda K., Ohmiya N., Katsushima S., Hosomi S., Tarumi K.i., Watanabe C., Saito M., Yokoyama Y., Inaba T., Sakata Y., Hongo H., Shibuya T., Kawakami K., Kakuta Y., Irisawa A., Yoshimura N., Fukuda K., Shirai T., Ichikawa H., Nagata J., Suzuki T., Yokoyama K., Tomidokoro T., Kojima Y., Yamada M., Yamamoto H., Yamamoto T., Horiki N., Obata H., Inoue S., Tanaka S., Toyokawa T., Kunihiro M., Hisabe T., Ogata S., Takeshima F., Matsushima K., Matsuhashi N., Sakuraba H., Iwabuchi M., Tsuchiya A., Uchiyama K., Kanai T., Nakamura M., Yokoyama T., Hida N., Mitsuyama K., Osada T., Hiraoka S., Tsuzuki T., Masuo T., Hokari R., Kobayashi T., Saruta M., Araki M., Araki H., Shimizu M., Kikuchi M., Nishikawa T., Takedatsu H., Aoyagi K., Ochiai T., Toda N., Mizokami Y., Nagahori M., Matsueda K., Kino H., Kanamori A., Suzuki T., Sakurai T., Kudo M.

The Lancet Gastroenterology and Hepatology (The Lancet Gastroenterology and Hepatology) 7 ( 7 ) 648 - 657 2022.07

ISSN 24681253

Background: AJM300 is an oral, small-molecule α4-integrin antagonist. We assessed the efficacy and safety of AJM300 in patients with moderately active ulcerative colitis. Methods: This multicentre, randomised, double-blind, placebo-controlled, phase 3 study consisted of two phases: a treatment phase and an open-label re-treatment phase. The study was done at 82 hospitals and clinics in Japan. Patients with a Mayo Clinic score of 6–10, endoscopic subscore of 2 or more, rectal bleeding subscore of 1 or more, and an inadequate response or intolerance to mesalazine were enrolled. Patients were randomly allocated (1:1) via a website to either AJM300 (960 mg) or placebo by the minimisation method, which was adjusted centrally by dynamic assignment against the Mayo Clinic score (≥6 to ≤7, ≥8 to ≤10 points), any use of corticosteroid, anti-TNFα antibody, or immunosuppressants during the disease-active period (yes vs no), duration of induction therapy until randomisation (<4 weeks vs ≥4 weeks) as the minimisation factors. Patients, investigators, site staff, assessors, and the sponsor were masked to treatment assignments. The study drug was administered orally, three times daily, for 8 weeks, and continued for up to 24 weeks if endoscopic remission was not achieved or rectal bleeding did not stop. The primary endpoint was the proportion of patients with a clinical response at week 8, and was analysed in the full analysis set. Clinical response was defined as a reduction in Mayo Clinic score of 30% or more and 3 or more, a reduction in rectal bleeding score of 1 or more or rectal bleeding subscore of 1 or less, and an endoscopic subscore of 1 or less at week 8. The study is registered with ClinicalTrials.gov, NCT03531892, and is closed to recruitment. Findings: Between June 6, 2018, and July 22, 2020, 203 patients were randomly assigned to AJM300 (n=102) or placebo (n=101). At week 8, 46 (45%) patients in the AJM300 group and 21 (21%) patients in the placebo group had a clinical response (odds ratio 3·30, 95% CI 1·73−6·29; p=0·00028). During the 8-week treatment and 16-week extension treatment periods, adverse events occurred in 39 (39%) of 101 patients in the placebo group and 39 (38%) of 102 patients in the AJM300 group. We found no difference in the incidence of adverse events between groups or after repeated administration of AJM300. The most common adverse event was nasopharyngitis (11 [11%] of 101 patients in the placebo group and ten [10%] of 102 patients in the AJM300 group). The most common treatment-related adverse event was also nasopharyngitis (four [4%] of 101 patients in the placebo group and three [3%] of 102 patients in the AJM300 group). Most adverse events were mild-to-moderate in severity. No deaths were reported. A serious adverse event was reported in the AJM300 group (one patient with anal abscess), but this was judged to be unrelated to study drug. Interpretation: AJM300 was well tolerated and induced a clinical response in patients with moderately active ulcerative colitis who had an inadequate response or intolerance to mesalazine. AJM300 could be a novel induction therapy for the treatment of patients with moderately active ulcerative colitis. Funding: EA Pharma and Kissei Pharmaceutical. Translation: For the Japanese translation of the abstract see Supplementary Materials section.

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Development of a Deep-Learning Algorithm for Small Bowel-Lesion Detection and a Study of the Improvement in the False-Positive Rate

Hosoe N., Horie T., Tojo A., Sakurai H., Hayashi Y., Kamiya K.J.L.L., Sujino T., Takabayashi K., Ogata H., Kanai T.

Journal of Clinical Medicine (Journal of Clinical Medicine) 11 ( 13 ) 2022.07

Deep learning has recently been gaining attention as a promising technology to improve the identification of lesions, and deep-learning algorithms for lesion detection have been actively developed in small-bowel capsule endoscopy (SBCE). We developed a detection algorithm for abnormal findings by deep learning (convolutional neural network) the SBCE imaging data of 30 cases with abnormal findings. To enable the detection of a wide variety of abnormal findings, the training data were balanced to include all major findings identified in SBCE (bleeding, angiodysplasia, ulceration, and neoplastic lesions). To reduce the false-positive rate, “findings that may be responsible for hemorrhage” and “findings that may require therapeutic intervention” were extracted from the images of abnormal findings and added to the training dataset. For the performance evaluation, the sensitivity and the specificity were calculated using 271 detectable findings in 35 cases. The sensitivity was calculated using 68,494 images of non-abnormal findings. The sensitivity and specificity were 93.4% and 97.8%, respectively. The average number of images detected by the algorithm as having abnormal findings was 7514. We developed an image-reading support system using deep learning for SBCE and obtained a good detection performance.

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Th17 cells in the liver: balancing autoimmunity and pathogen defense

Taniki N., Nakamoto N., Chu P.S., Ichikawa M., Teratani T., Kanai T.

Seminars in Immunopathology (Seminars in Immunopathology) 44 ( 4 ) 509 - 526 2022.07

ISSN 18632297

In addition to carcinogenesis, T helper 17 (Th17) cells (a subtype of CD4 + T lymphocytes) are involved in the acute, chronic, and cirrhotic phases of liver diseases; however, their role in the development and progression of liver diseases remains unclear. It is difficult to elucidate the role of Th17 cells in liver diseases due to their dichotomous nature, i.e., plasticity in terms of pathogenic or host protective function depending on environmental and time phase factors. Moreover, insufficient depletion of Th17 cells by inhibiting the cytokines and transcription factors involved in their production causes difficulties in analyzing their specific role in vitro and in vivo murine models, partially due to complex interaction. This review summarizes the recent progress in understanding the plasticity and function of hepatic Th17 cells and type 3 cytokines.

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Organoid screening reveals epigenetic vulnerabilities in human colorectal cancer

Toshimitsu K., Takano A., Fujii M., Togasaki K., Matano M., Takahashi S., Kanai T., Sato T.

Nature Chemical Biology (Nature Chemical Biology) 18 ( 6 ) 605 - 614 2022.06

ISSN 15524450

Precision oncology presumes an accurate prediction of drug response on the basis of the molecular profile of tumors. However, the extent to which patient-derived tumor organoids recapitulate the response of in vivo tumors to a given drug remains obscure. To gain insights into the pharmacobiology of human colorectal cancer (CRC), we here created a robust drug screening platform for patient-derived colorectal organoids. Application of suspension culture increased organoid scalability, and a refinement of the culture condition enabled incorporation of normal and precursor organoids to high-throughput drug screening. Drug screening identified bromodomain and extra-terminal (BET) bromodomain protein inhibitor as a cancer-selective growth suppressor that targets genes aberrantly activated in CRC. A multi-omics analysis identified an association between checkpoint with forkhead and ring finger domaines (CHFR) silencing and paclitaxel sensitivity, which was further validated by gene engineering of organoids and in xenografts. Our findings highlight the utility of multiparametric validation in enhancing the biological and clinical fidelity of a drug screening system. [Figure not available: see fulltext.]

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A successful case of endoscopic submucosal dissection using the water pressure method for early gastric cancer with severe fibrosis

Miyazaki K., Kato M., Kanai T., Yahagi N.

VideoGIE (VideoGIE) 7 ( 6 ) 219 - 222 2022.06

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Texture and color enhancement imaging in combination with indigo carmine dye spraying to highlight the border of flat ulcerative colitis–associated neoplasia

Takabayashi K., Kato M., Sugimoto S., Yahagi N., Kanai T.

Gastrointestinal Endoscopy (Gastrointestinal Endoscopy) 95 ( 6 ) 1273 - 1275 2022.06

ISSN 00165107

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Heterogeneity of ILC2s in the Intestine; Homeostasis and Pathology

Sunaga S., Tsunoda J., Teratani T., Mikami Y., Kanai T.

Frontiers in Immunology (Frontiers in Immunology) 13 2022.05

Group 2 innate lymphoid cells (ILC2s) were identified in 2010 as a novel lymphocyte subset lacking antigen receptors, such as T-cell or B-cell receptors. ILC2s induce local immune responses characterized by producing type 2 cytokines and play essential roles for maintaining tissue homeostasis. ILC2s are distributed across various organs, including the intestine where immune cells are continuously exposed to external antigens. Followed by luminal antigen stimulation, intestinal epithelial cells produce alarmins, such as IL-25, IL-33, and thymic stromal lymphopoietin, and activate ILC2s to expand and produce cytokines. In the context of parasite infection, the tuft cell lining in the epithelium has been revealed as a dominant source of intestinal IL-25 and possesses the capability to regulate ILC2 homeostasis. Neuronal systems also regulate ILC2s through neuropeptides and neurotransmitters, and interact with ILC2s bidirectionally, a process termed “neuro-immune crosstalk”. Activated ILC2s produce type 2 cytokines, which contribute to epithelial barrier function, clearance of luminal antigens and tissue repair, while ILC2s are also involved in chronic inflammation and tissue fibrosis. Recent studies have shed light on the contribution of ILC2s to inflammatory bowel diseases, mainly comprising ulcerative colitis and Crohn’s disease, as defined by chronic immune activation and inflammation. Modern single-cell analysis techniques provide a tissue-specific picture of ILC2s and their roles in regulating homeostasis in each organ. Particularly, single-cell analysis helps our understanding of the uniqueness and commonness of ILC2s across tissues and opens the novel research area of ILC2 heterogeneity. ILC2s are classified into different phenotypes depending on tissue and phase of inflammation, mainly inflammatory and natural ILC2 cells. ILC2s can also switch phenotype to ILC1- or ILC3-like subsets. Hence, recent studies have revealed the heterogeneity and plasticity of ILC2, which indicate dynamicity of inflammation and the immune system. In this review, we describe the regulatory mechanisms, function, and pathological roles of ILC2s in the intestine.

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Aryl hydrocarbon receptor signals in epithelial cells govern the recruitment and location of Helios+ Tregs in the gut

Yoshimatsu Y., Sujino T., Miyamoto K., Harada Y., Tanemoto S., Ono K., Umeda S., Yoshida K., Teratani T., Suzuki T., Mikami Y., Nakamoto N., Sasaki N., Takabayashi K., Hosoe N., Ogata H., Sawada K., Imamura T., Yoshimura A., Kanai T.

Cell Reports (Cell Reports) 39 ( 6 ) 2022.05

CD4+Foxp3+ regulatory T cells (Tregs) are essential for homeostasis in the colon, but the mechanism by which local environmental cues determine the localization of colonic Tregs is unclear. Here, we administer indigo naturalis (IN), a nontoxic phytochemical aryl hydrocarbon receptor (AhR) agonist used for treating patients with ulcerative colitis (UC) in Asia, and we show that IN increases Helios+ Tregs and MHC class II+ epithelial cells (ECs) in the colon. Interactions between Tregs and MHC class II+ ECs occur mainly near the crypt bottom in the steady state, whereas Tregs dramatically increase and shift toward the crypt top following IN treatment. Moreover, the number of CD25+ T cells is increased near the surface of ECs in IN-treated UC patients compared with that in patients treated with other therapies. We also highlight additional AhR-signaling mechanisms in intestinal ECs that determine the accumulation and localization of Helios+ Tregs in the colon.

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A significant risk of metabolic dysfunction-associated fatty liver disease plus diabetes on subclinical atherosclerosis

Bessho R., Kashiwagi K., Ikura A., Yamataka K., Inaishi J., Takaishi H., Kanai T.

PLoS ONE (PLoS ONE) 17 ( 5 May ) 2022.05

Background This cross-sectional study aims to investigate the association between subclinical atherosclerosis and metabolic dysfunction-associated fatty liver disease (MAFLD) or non-alcoholic fatty liver disease (NAFLD), and a synergistic effect of diabetes mellitus (DM) and MAFLD on subclinical atherosclerosis. Methods Of 977 subjects who underwent health checkups with coronary artery calcification (CAC), carotid intima-media thickness, and brachial-ankle pulse wave velocity (ba-PWV), 890 were included in this study. They were classified as MAFLD, NAFLD, or Neither-FLD, and MAFLD was further categorized into three groups by three metabolic disorders (obesity, lean with metabolic dysregulation, DM), according to its new definition: Obesity-MAFLD, Lean-MAFLD and DM-MAFLD. Results In a multivariable analysis, MAFLD and NAFLD were significantly associated with subclinical atherosclerosis, except for an association between ba-PWV and NAFLD. MAFLD had higher odds for CAC than NAFLD (for CAC score > 100, odds ratio (OR) = 2.599, 95% confidence interval (CI) = 1.625–4.157; OR = 1.795, 95%CI = 1.145–2.814, respectively). In a sub-analysis, DM-MAFLD had higher odds for CAC (for CAC score > 100, OR = 5.833, 95% CI = 3.047–11.164) than the other groups of MAFLD, when compared to Neither FLD as a reference. Moreover, DM-MAFLD had a higher level of homeostasis model assessment of insulin resistance and high sensitive C-reactive protein, compared to the other groups of MAFLD. Conclusions MAFLD was significantly associated with subclinical atherosclerosis in the general population. Additionally, DM-MAFLD could be a significant risk factor for cardiovascular disease through insulin resistance and low-grade inflammation and requires careful follow-up or appropriate intervention.

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Advanced endoscopy for the management of inflammatory digestive diseases: Review of the Japan Gastroenterological Endoscopy Society core session

Matsuura M., Matsumoto T., Naito Y., Saitoh Y., Kanai T., Suzuki Y., Tanaka S., Ogata H., Hisamatsu T.

Digestive Endoscopy (Digestive Endoscopy) 34 ( 4 ) 729 - 735 2022.05

ISSN 09155635

A series of workshops entitled “Advanced endoscopy in the management of inflammatory digestive disease” was held at the 97th to 100th biannual meeting of the Japan Gastroenterological Endoscopy Society. During these core sessions, research findings concerning various endoscopic practices in the field of inflammatory bowel disease (IBD) were presented, and meaningful discussions were shared on the evolving role and future challenges of endoscopy in IBD. This article reviews these core sessions and discusses current topics on the role of endoscopy, focusing on the diagnosis, disease monitoring, mucosal healing assessments, cancer surveillance, and therapeutic interventions in IBD.

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Intracellular metabolic adaptation of intraepithelial CD4+CD8αα+ T lymphocytes

Harada Y., Sujino T., Miyamoto K., Nomura E., Yoshimatsu Y., Tanemoto S., Umeda S., Ono K., Mikami Y., Nakamoto N., Takabayashi K., Hosoe N., Ogata H., Ikenoue T., Hirao A., Kubota Y., Kanai T.

iScience (iScience) 25 ( 4 ) 2022.04

Intestinal intraepithelial lymphocytes (IELs), the first line of defense against microbial and dietary antigens, are classified as natural or induced based on their origin and receptor expression. Induced CD4+CD8αα+TCRβ+ T cells (double positive, DPIELs) originated from CD4+CD8α−TCRβ+ T cells (single positive, SPIELs) increase with aging. However, the metabolic requirements and the metabolic-related genes in IEL development remain unclear. We determined that the intraepithelial compartment is hypoxic in the presence of microbes and DPIELs increased more than natural IELs in this location. Moreover, DPIELs consumed less oxygen and glucose and exhibited unique alterations in mitochondria. Using inhibitors and genetically modified mice, we revealed that DPIELs adapt to their surrounding oxygen-deprived environment in peripheral tissues by modulating specific genes, including hypoxia-inducible factor, mammalian target of rapamycin complexes (mTORC), phosphorylated ribosomal protein S6 (pS6), and other glycolytic factors. Our findings provide valuable insight into the metabolic properties of IELs.

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Effectiveness and Durability of Ustekinumab Therapy With or Without Immunomodulators for Ulcerative Colitis Patients in Japan

Aoki Y., Sujino T., Kawaguchi T., Sugimoto S., Shimada F., Yoshimatsu Y., Kiyohara H., Nanki K., Mikami Y., Takabayashi K., Hosoe N., Ogata H., Iwao Y., Kanai T.

Crohn's and Colitis 360 (Crohn's and Colitis 360) 4 ( 2 ) 2022.04

Background and Aims: The effectiveness and durability of ustekinumab therapy with or without thiopurine immunomodulators (IMs) for ulcerative colitis (UC) in real-world Asian, Japanese patients have not yet been elucidated. Methods: To evaluate the additive effects of IMs on ustekinumab, a retrospective cohort study of UC patients receiving ustekinumab with or without thiopurine IMs, azathioprine or 6-mercaptopurine, was conducted from March 2020 to August 2021. The primary endpoint was clinical remission or response rate at week 8. The secondary endpoints were clinical remission or response rates at weeks 24 and 52, the durability of each treatment, and adverse events. Results: Of the 50 patients with UC treated with ustekinumab, 42 were enrolled. Sixteen patients were treated with a combination of ustekinumab and an IM. The clinical response rates of all patients at weeks 8, 24, and 52 were 53.7%, 63.3%, and 42.9%, respectively. There was no significant difference in the clinical responses or remission rates between the combination therapy and monotherapy groups at weeks 8, 24, and 52. (50.0% vs. 56.0%, P =. 757; 70.0% vs. 60.0%, P =. 702; and 42.9% vs. 42.9%, P = 1.00, respectively). A Kaplan-Meier analysis showed no difference in IM use on the durability of ustekinumab treatment (log-rank test; P =. 955). Conclusions: The response rate for Japanese UC patients is similar to previous reports based on American and European UC patients. There was no significant difference between the ustekinumab monotherapy group and the ustekinumab and IM combination group in the real world.

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Organ and brain crosstalk: The liver-brain axis in gastrointestinal, liver, and pancreatic diseases

Matsubara Y., Kiyohara H., Teratani T., Mikami Y., Kanai T.

Neuropharmacology (Neuropharmacology) 205 2022.03

ISSN 00283908

The liver is the largest organ in the human body and is responsible for the metabolism and storage of the three principal nutrients: carbohydrates, fats, and proteins. In addition, the liver contributes to the breakdown and excretion of alcohol, medicinal agents, and toxic substances and the production and secretion of bile. In addition to its role as a metabolic centre, the liver has recently attracted attention for its function in the liver-brain axis, which interacts closely with the central nervous system via the autonomic nervous system, including the vagus nerve. The liver-brain axis influences the control of eating behaviour in the central nervous system through stimuli from the liver. Conversely, neural signals from the central nervous system influence glucose, lipid, and protein metabolism in the liver. The liver also receives a constant influx of nutrients and hormones from the intestinal tract and compounds of bacterial origin via the portal system. As a result, the intestinal tract and liver are involved in various immunological interactions. A good example is the co-occurrence of primary sclerosing cholangitis and ulcerative colitis. These heterogeneous roles of the liver-brain axis are mediated via the vagus nerve in an asymmetrical manner. In this review, we provide an overview of these interactions, mainly with the liver but also with the brain and gut.

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Vagus nerve-mediated intestinal immune regulation: Therapeutic implications of inflammatory bowel diseases

Mikami Y., Tsunoda J., Kiyohara H., Taniki N., Teratani T., Kanai T.

International Immunology (International Immunology) 34 ( 2 ) 97 - 106 2022.02

ISSN 09538178

The pathophysiology of inflammatory bowel diseases (IBDs) involves immunological, genetic and environmental factors. Through its ability to sense environmental stimuli, the autonomic nervous system plays a key role in the development and persistence of IBDs. The vagus nerve (VN), which contains sensory and motor neurons, travels throughout the body to innervate the gut and other visceral organs in the thoracic and abdominopelvic cavities. Recent studies show that the VN has anti-inflammatory effects via the release of acetylcholine, in what is known as the cholinergic anti-inflammatory pathway (CAIP). In the gut immune system, the CAIP is proposed to be activated directly by signals from the gut and indirectly by signals from the liver, which receives gut-derived bioactive substances via the portal vein and senses the status of the gut. The gut-brain axis and liver-brain-gut reflex arc regulate a wide variety of peripheral immune cells to maintain homeostasis in the gut. Therefore, targeting the neural reflex by methods such as VN stimulation is now under investigation for suppressing intestinal inflammation associated with IBDs. In this review, we describe the role of the VN in the regulation of intestinal immunity, and we discuss novel therapeutic approaches for IBDs that target neuroimmune interactions.

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Endoscopic resection of the rectal mucosal bridge after surgery for Hirschsprung's disease

Iwata K., Kato M., Takabayashi K., Kanai T., Yahagi N.

Gastrointestinal Endoscopy (Gastrointestinal Endoscopy) 95 ( 2 ) 392 - 393 2022.02

ISSN 00165107

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Potential benefits of immunomodulator use with vedolizumab for maintenance of remission in ulcerative colitis

Naganuma M., Watanabe K., Motoya S., Ogata H., Matsui T., Suzuki Y., Ursos L., Sakamoto S., Shikamura M., Hori T., Fernandez J., Watanabe M., Hibi T., Kanai T.

Journal of Gastroenterology and Hepatology (Australia) (Journal of Gastroenterology and Hepatology (Australia)) 37 ( 1 ) 81 - 88 2022.01

ISSN 08159319

Background and Aim: This study aimed to determine the efficacy and safety of vedolizumab treatment with or without concomitant immunomodulator use in Japanese patients with moderate-to-severe ulcerative colitis. Methods: Among enrolled patients in a phase 3 study conducted in Japan (clinicaltrials.gov, NCT02039505), data from patients allocated to 300-mg intravenous vedolizumab for induction and maintenance phases were used for this exploratory analysis. Efficacy endpoints were clinical response, clinical remission, and mucosal healing at week 10 and clinical remission and mucosal healing at week 60, and disease worsening and treatment failure during the maintenance phase. Results: At week 10, the differences in clinical response, clinical remission, and mucosal healing rates between the subgroups (those with concomitant immunomodulator use minus those without) were 0.7 (95% confidence interval: −14.3, 15.7), 3.3 (95% confidence interval: −8.5, 15.2), and 1.8 (95% confidence interval: −13.0, 16.5), respectively. At week 60, the differences in clinical remission and mucosal healing between the subgroups with and without concomitant immunomodulator use were 26.1 (95% confidence interval: −3.5, 55.6) and 29.9 (95% confidence interval: 1.4, 58.4), respectively. The proportions of patients without treatment failure at day 330 of the maintenance phase were 90.7% with concomitant immunomodulator use and 73.7% without. No marked differences in incidence of infections were observed between subgroups. Conclusions: This study suggested the possibility that concomitant immunomodulator use may be beneficial to maintain the clinical efficacy of vedolizumab.

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Endoscopic Diagnosis of Biliary Stricture Combined with Digital Cholangioscope: A Case Series

Fukuhara S., Iwasaki E., Kayashima A., Machida Y., Tamagawa H., Kawasaki S., Horibe M., Hori S., Abe Y., Kitago M., Ogata H., Kanai T.

Healthcare (Switzerland) (Healthcare (Switzerland)) 10 ( 1 ) 2022.01

The endoscopic diagnosis of biliary tract lesions is applied as a non-invasive method; however, its diagnostic accuracy is not yet high. Moreover, digital cholangioscopy is used for directly visualizing the inside of the bile duct, resulting in a more precise biopsy. We present the case series of the outcomes of diagnosis using digital cholangioscopy in patients who underwent cholangioscopy for the evaluation of biliary stenosis in our department between January 2014 and March 2021. The controls were those who underwent a biopsy for biliary stenosis with conventional endoscopic retrograde cholangiopancreatography (ERCP). Background data for each case were collected, and the clinical outcomes by biopsy were evaluated, focusing on the accuracy of the diagnosis. Cholangioscopy was performed in 15 cases, while a conventional biopsy by ERCP was performed in 172 cases. Nine of 15 cases (60.0%) were diagnosed with cholangiocarcinoma. The number of specimens obtained through conventional ERCP and cholangioscopy was 2.5 ± 1.3 and 3.3 ± 1.5, respectively (p = 0.043). The diagnostic accuracy of conventional ERCP and cholangioscopy were 65.7% (113 of 172 cases) and 100%, respectively, which was significantly higher in the group with cholangioscopy. Digital cholangioscopy is useful when the diagnosis of the biliary stricture using the conventional ERCP method is difficult.

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Red dichromatic imaging reduces bleeding and hematoma during submucosal injection in esophageal endoscopic submucosal dissection

Miyazaki K., Kato M., Sasaki M., Iwata K., Masunaga T., Kubosawa Y., Hayashi Y., Mizutani M., Kiguchi Y., Takatori Y., Mutaguchi M., Matsuura N., Nakayama A., Takabayashi K., Kanai T., Yahagi N.

Surgical Endoscopy (Surgical Endoscopy) 2022

ISSN 09302794

Background: Bleeding and hematoma formation during submucosal injection in esophageal endoscopic submucosal dissection (ESD) reduce the visibility of the submucosa. Red dichromatic imaging (RDI) is an endoscopic technique that provides better visualization of the deep submucosal blood vessels. We speculated that blood vessel injury could be avoided with RDI. This pilot study evaluated the role of RDI in preventing bleeding and hematoma formation during esophageal ESD. Methods: This was a single-center retrospective observational study. We examined 60 patients who underwent ESD with white light imaging (WLI) and RDI. A single endoscopist reviewed all of the surgical videos to document the incidence and severity of bleeding episodes. Eighteen videos provided adequate quality and detail, and the number of blood vessels traversing the mucosal incision lines of the lesions in these videos was evaluated under WLI and RDI. Results: The WLI group had a significantly higher incidence of hematomas per unit area compared to the RDI group (0.18/cm2 [range 0–0.38] vs. 0 [0–0.18]/cm2, p = 0.024). The WLI group also had a significantly higher incidence of total bleeding episodes compared to the RDI group (42.9% [range 21.7–60.4] vs 16.7% [range 13.8–22.9], p < 0.001). Significantly more blood vessels were visible under RDI compared to WLI (5 [range 4–8] vs. 2 [range 1–5], p = 0.0020). Conclusion: RDI reduced the incidence of bleeding and hematoma formation during submucosal injection in esophageal ESD. It was assumed that the improvement of blood vessel visibility by RDI might have contributed to the result.

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Feasibility and Safety of Endoscopic Ischemic Polypectomy and Clinical Outcomes in Patients with Peutz–Jeghers Syndrome (with Video)

Limpias Kamiya K.J.L., Hosoe N., Takabayashi K., Okuzawa A., Sakurai H., Hayashi Y., Miyanaga R., Sujino T., Ogata H., Kanai T.

Digestive Diseases and Sciences (Digestive Diseases and Sciences) 2022

ISSN 01632116

Objectives: Peutz–Jeghers syndrome (PJS) is a rare autosomal dominant hereditary disease with a clinical features related to gastrointestinal (GI) hamartomatous polyposis, frequently observed in the small bowel. Balloon-assisted enteroscopy (BAE) has made non-surgical treatment of GI polyps possible. Endoscopic mucosal resection (EMR) has been performed but was associated with complications and difficulties. Recently, endoscopic ischemic polypectomy (EIP) has been developed and its usefulness reported. The study evaluated the feasibility and safety of EIP and the clinical outcomes of patients with PJS. Methods: We retrospectively collected data of consecutive patients with PJS between September 2009 and March 2021. Data regarding clinical characteristics, follow-up methods, endoscopic management, and complications were collected. EIP feasibility and safety were assessed. Results: Twenty-two patients were included. The observation period was 70 months (range, 5–153). Of the 124 therapeutic endoscopy procedures performed, 68 used BAE. Of the 607 polyps treated, 329 polyps were located in the small bowel. EIP was able to treat a greater number of polyps per patient than EMR (P < 0.003), without any complications, carcinoma, or intussusception in the small bowel (P < 0.001). During the follow-up period, 3 patients developed GI cancer. Conclusion: Long-term follow-up in patients with PJS showed that EIP was a feasible and safe technique.

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Efficacy of capnographic and bispectral index monitoring on trans-oral therapeutic endoscopy: A prospective observational study

Hayashi Y., Hosoe N., Takabayashi K., Limpias Kamiya K.J.L., Tojo A., Sakurai H., Kinoshita S., Sujino T., Nakayama A., Kato M., Yahagi N., Ogata H., Kanai T.

Journal of Gastroenterology and Hepatology (Australia) (Journal of Gastroenterology and Hepatology (Australia)) 2022

ISSN 08159319

Background and Aim: Oral therapeutic and invasive endoscopy requires deep sedation to reduce patient distress due to prolonged examination and procedures. The usefulness of capnography and bispectral index (BIS) monitoring in the early hypoxia detection in oral therapeutic and invasive endoscopy has yet to be evaluated. This study aimed to investigate the clinical impact of capnography and BIS monitoring on hypoxic events during oral therapeutic and invasive endoscopic procedures. Methods: This is a prospective observational study. Trans-oral non-intubated therapeutic and/or invasive endoscopic procedures were performed with conventional monitoring (pulse oximetry, pulse, and blood pressure) as well as additional monitoring (BIS and end-tidal CO2 concentration). Hypoxia is defined as oxygen saturation of <90% that lasts >15 s. The clinical impact of capnography and BIS monitoring on hypoxic events during oral therapeutic and invasive endoscopic procedures were investigated with the risk factors for hypoxia in each patient. Results: Patients with hypoxia had significantly more apneas detected using capnography than other patients. The multivariate analysis revealed the detected apnea by capnography as an independent risk factor for hypoxia (odds ratio: 3.48[95% confidence interval: 1.24–9.78], P = 0.02). The BIS was not significantly different as a risk factor for hypoxia; however, per-event analysis revealed significantly decreased BIS values over time in 3 min before hypoxic events. Conclusions: Apnea detected by capnography was an independent predictor of hypoxia. The BIS value was not associated with hypoxia events; however, it showed a significant downward trend before hypoxia events.

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Development of plasma ghrelin level as a novel marker for gastric mucosal atrophy after Helicobacter pylori eradication

Mori H., Suzuki H., Matsuzaki J., Kameyama K., Igarashi K., Masaoka T., Kanai T.

Annals of Medicine (Annals of Medicine) 54 ( 1 ) 170 - 180 2022

ISSN 07853890

Background and aim: The severity of atrophic gastritis is significantly associated with the risk of gastric cancer. Although the current gold standard for assessing the gastric cancer risk is esophagogastroduodenoscopy with a pathological examination, the development of less-invasive biomarkers is warranted for efficient risk stratification of gastric cancer. Serum pepsinogens (PGs) are biomarkers used to predict the extent of gastric mucosal atrophy; however, they are not an accurate reflection of gastric mucosal atrophy after Helicobacter pylori eradication. The present study was conducted to investigate the usefulness of plasma ghrelin levels as a marker for gastric mucosal atrophy, and as a risk stratification marker for gastric cancer, even after H. pylori eradication. Methods: Patients who received H. pylori eradication treatment were enrolled in the study. The severity of gastric mucosal atrophy was evaluated both endoscopically and histologically. Serum pepsinogen and plasma ghrelin levels were measured before and at 1, 12, 24, and 48 weeks after treatment. The study was approved by the Research Ethics Committee of the Keio University School of Medicine (no. 20140102; 8 July 2014). Results: Eighteen patients completed the study protocol. Total and acyl plasma ghrelin levels demonstrated no significant change from before treatment to 48 weeks after eradication; however, there was a significant difference between open-type and closed-type atrophic gastritis. The PG I/II ratio increased significantly from 48 weeks after H. pylori eradication. The severity of the histological intestinal metaplasia scores correlated inversely with plasma total ghrelin levels from before to 48 weeks after H. pylori eradication. Conclusion: Plasma levels of ghrelin correlate well with the level of gastric mucosal atrophy, even after H. pylori eradication.KEY MESSAGES Ghrelin plasma levels are associated with the progression of endoscopic atrophic gastritis, even at 48 weeks after H. pylori eradication. Ghrelin plasma levels are also associated with increased severity of histological intestinal metaplasia 48 weeks after H. pylori eradication. Pepsinogen I/II ratios increased immediately after H. pylori eradication and are inappropriate for assessing atrophic gastritis after H. pylori eradication.

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Mapping the human genetic architecture of COVID-19

Niemi M.E.K., Karjalainen J., Liao R.G., Neale B.M., Daly M., Ganna A., Pathak G.A., Andrews S.J., Kanai M., Veerapen K., Fernandez-Cadenas I., Schulte E.C., Striano P., Marttila M., Minica C., Marouli E., Karim M.A., Wendt F.R., Savage J., Sloofman L., Butler-Laporte G., Kim H.N., Kanoni S., Okada Y., Byun J., Han Y., Uddin M.J., Smith G.D., Willer C.J., Buxbaum J.D., Mehtonen J., Finucane H., Cordioli M., Martin A.R., Zhou W., Pasaniuc B., Julienne H., Aschard H., Shi H., Yengo L., Polimanti R., Ghoussaini M., Schwartzentruber J., Dunham I., Chwialkowska K., Francescatto M., Trankiem A., Balaconis M.K., Davis L., Lee S., Priest J., Renieri A., Sankaran V.G., van Heel D., Deelen P., Brent Richards J., Nakanishi T., Biesecker L., Eric Kerchberger V., Kenneth Baillie J., Mari F., Bernasconi A., Ceri S., Canakoglu A., Wolford B., Faucon A., Dutta A.K., Schurmann C., Harry E., Birney E., Nguyen H., Nasir J., Kaunisto M., Solomonson M., Dueker N., Vadgama N., Limou S., Rahmouni S., Mbarek H., Darwish D., Uddin M.M., Albertos R., Pérez-Tur J., Li R., Folkersen L., Moltke I., Koelling N., Teumer A., Kousathanas A., Utrilla A., Verdugo R.A., Zárate R., Medina-Gómez C., Gómez-Cabrero D., Carnero-Montoro E., Cadilla C.L., Moreno-Estrada A., Garmendia A., Moya L., Sedaghati-Khayat B.

Nature (Nature) 600 ( 7889 ) 472 - 477 2021.12

ISSN 00280836

The genetic make-up of an individual contributes to the susceptibility and response to viral infection. Although environmental, clinical and social factors have a role in the chance of exposure to SARS-CoV-2 and the severity of COVID-191,2, host genetics may also be important. Identifying host-specific genetic factors may reveal biological mechanisms of therapeutic relevance and clarify causal relationships of modifiable environmental risk factors for SARS-CoV-2 infection and outcomes. We formed a global network of researchers to investigate the role of human genetics in SARS-CoV-2 infection and COVID-19 severity. Here we describe the results of three genome-wide association meta-analyses that consist of up to 49,562 patients with COVID-19 from 46 studies across 19 countries. We report 13 genome-wide significant loci that are associated with SARS-CoV-2 infection or severe manifestations of COVID-19. Several of these loci correspond to previously documented associations to lung or autoimmune and inflammatory diseases3–7. They also represent potentially actionable mechanisms in response to infection. Mendelian randomization analyses support a causal role for smoking and body-mass index for severe COVID-19 although not for type II diabetes. The identification of novel host genetic factors associated with COVID-19 was made possible by the community of human genetics researchers coming together to prioritize the sharing of data, results, resources and analytical frameworks. This working model of international collaboration underscores what is possible for future genetic discoveries in emerging pandemics, or indeed for any complex human disease.

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CD8+ tissue-resident memory T cells promote liver fibrosis resolution by inducing apoptosis of hepatic stellate cells

Koda Y., Teratani T., Chu P.S., Hagihara Y., Mikami Y., Harada Y., Tsujikawa H., Miyamoto K., Suzuki T., Taniki N., Sujino T., Sakamoto M., Kanai T., Nakamoto N.

Nature Communications (Nature Communications) 12 ( 1 ) 2021.12

Non-alcoholic steatohepatitis (NASH) is a leading cause of chronic liver disease that can progress to liver fibrosis. Recent clinical advance suggests a reversibility of liver fibrosis, but the cellular and molecular mechanisms underlying NASH resolution remain unclarified. Here, using a murine diet-induced NASH and the subsequent resolution model, we demonstrate direct roles of CD8+ tissue-resident memory CD8+ T (CD8+ Trm) cells in resolving liver fibrosis. Single-cell transcriptome analysis and FACS analysis revealed CD69+CD103−CD8+ Trm cell enrichment in NASH resolution livers. The reduction of liver CD8+ Trm cells, maintained by tissue IL-15, significantly delayed fibrosis resolution, while adoptive transfer of these cells protected mice from fibrosis progression. During resolution, CD8+ Trm cells attracted hepatic stellate cells (HSCs) in a CCR5-dependent manner, and predisposed activated HSCs to FasL-Fas-mediated apoptosis. Histological assessment of patients with NASH revealed CD69+CD8+ Trm abundance in fibrotic areas, further supporting their roles in humans. These results highlight the undefined role of liver CD8+ Trm in fibrosis resolution.

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Pathogenesis and management of gastrointestinal inflammation and fibrosis: from inflammatory bowel diseases to endoscopic surgery

Iwata K., Mikami Y., Kato M., Yahagi N., Kanai T.

Inflammation and Regeneration (Inflammation and Regeneration) 41 ( 1 ) 2021.12

Gastrointestinal fibrosis is a state of accumulated biological entropy caused by a dysregulated tissue repair response. Acute or chronic inflammation in the gastrointestinal tract, including inflammatory bowel disease, particularly Crohn’s disease, induces fibrosis and strictures, which often require surgical or endoscopic intervention. Recent technical advances in endoscopic surgical techniques raise the possibility of gastrointestinal stricture after an extended resection. Compared to recent progress in controlling inflammation, our understanding of the pathogenesis of gastrointestinal fibrosis is limited, which requires the development of prevention and treatment strategies. Here, we focus on gastrointestinal fibrosis in Crohn’s disease and post-endoscopic submucosal dissection (ESD) stricture, and we review the relevant literature.

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Esophageal endoscopic submucosal dissection on postendoscopic variceal ligation scars with injection under red dichromatic imaging

Miyazaki K., Kato M., Matsuura N., Kanai T., Yahagi N.

VideoGIE (VideoGIE) 6 ( 12 ) 536 - 539 2021.12

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Concordance analysis of microsatellite instability status between polymerase chain reaction based testing and next generation sequencing for solid tumors

Shimozaki K., Hayashi H., Tanishima S., Horie S., Chida A., Tsugaru K., Togasaki K., Kawasaki K., Aimono E., Hirata K., Nishihara H., Kanai T., Hamamoto Y.

Scientific Reports (Scientific Reports) 11 ( 1 ) 2021.12

Various malignancies exhibit high microsatellite instability (MSI-H) or mismatch repair deficiency (dMMR). The MSI-IVD kit, a polymerase chain reaction (PCR)-based method, was the first tumor-agnostic companion diagnostic to detect MSI status in MSI-H solid tumors. Recently, next-generation sequencing (NGS), which can also detect MSI-H/dMMR, has been made clinically available; however, its real-world concordance with PCR-based testing of MSI-H/dMMR remains to be investigated. The co-primary end points included the positive and negative predictive values of MSI-H/dMMR. A retrospective analysis of 80 patients who had undergone both MSI testing and NGS between July 2015 and March 2021 was conducted. Five patients were confirmed to have MSI-H in both examinations. Among the 75 patients diagnosed as microsatellite stable (MSS) by PCR-based testing, one with pancreatic cancer was diagnosed as having MSI-H after NGS. One patient with pancreatic cancer was diagnosed as having MSS in both tests was found to have a mutation in MLH1 by NGS, which was confirmed as dMMR by IHC staining. NGS had positive and negative predictive values of 100% (5/5) and 98.7% (74/75), respectively, for MSI-H. The concordance between NGS and PCR-based testing was 98.8% (79/80). Thus, NGS can be useful for evaluating MSI/MMR status in clinical practice and can be an important alternative method for detecting MSI-H/dMMR in the future.

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Commensal microbe-derived acetate suppresses NAFLD/NASH development via hepatic FFAR2 signalling in mice

Aoki R., Onuki M., Hattori K., Ito M., Yamada T., Kamikado K., Kim Y.G., Nakamoto N., Kimura I., Clarke J.M., Kanai T., Hase K.

Microbiome (Microbiome) 9 ( 1 ) 2021.12

Background: Non-alcoholic liver disease (NAFLD) is the hepatic manifestation of metabolic syndrome, and it can progress to non-alcoholic steatohepatitis (NASH). Alterations in the gut microbiome have been implicated in the development of NAFLD/NASH, although the underlying mechanisms remain unclear. Results: We found that the consumption of the prebiotic inulin markedly ameliorated the phenotype of NAFLD/NASH, including hepatic steatosis and fibrosis, in mice. Inulin consumption resulted in global changes in the gut microbiome, including concomitant enrichment of the genera Bacteroides and Blautia, and increased concentrations of short-chain fatty acids, particularly acetate, in the gut lumen and portal blood. The consumption of acetate-releasing resistant starch protected against NAFLD development. Colonisation by Bacteroides acidifaciens and Blautia producta in germ-free mice resulted in synergetic effects on acetate production from inulin. Furthermore, the absence of free fatty acid receptor 2 (FFAR2), an acetate receptor, abolished the protective effect of inulin, as indicated by the more severe liver hypertrophy, hypercholesterolaemia and inflammation. These effects can be attributed to an exacerbation of insulin resistance in the liver, but not in muscle or adipose tissue. Conclusion: These findings demonstrated that the commensal microbiome–acetate–FFAR2 molecular circuit improves insulin sensitivity in the liver and prevents the development of NAFLD/NASH. [MediaObject not available: see fulltext.]

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Clinical Characteristics of Patients with Coronavirus Disease (COVID-19): Preliminary Baseline Report of Japan COVID-19 Task Force, a Nationwide Consortium to Investigate Host Genetics of COVID-19

Tanaka H., Lee H., Morita A., Namkoong H., Chubachi S., Kabata H., Kamata H., Ishii M., Hasegawa N., Harada N., Ueda T., Ueda S., Ishiguro T., Arimura K., Saito F., Yoshiyama T., Nakano Y., Mutoh Y., Suzuki Y., Murakami K., Okada Y., Koike R., Kitagawa Y., Tokunaga K., Kimura A., Imoto S., Miyano S., Ogawa S., Kanai T., Fukunaga K.

International Journal of Infectious Diseases (International Journal of Infectious Diseases) 113 74 - 81 2021.12

ISSN 12019712

Background and design:: The coronavirus disease (COVID-19) pandemic is having a devastating effect worldwide. Host genome differences between populations may influence the severity of COVID-19. The Japan COVID-19 Task Force is conducting host genome analysis of hospitalized patients with COVID-19 from more than 70 institutions nationwide in Japan. This report describes the clinical characteristics of patients enrolled to date. Results:: The median (interquartile range) age of the 1674 patients included in the analysis was 59 (45–71) years, and more than half of the patients (66.2%) were male. Less than half of the patients (41.2%) had severe disease. The case fatality rate was 3.2%. Conclusions:: Since this is a hospital-based study, the number of severe cases was relatively high, but the case fatality rate was relatively low, when compared to that of other countries. In the future, we will continue to enroll patients and conduct genome analyses of patients with COVID-19.

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Acetaldehyde exposure underlies functional defects in monocytes induced by excessive alcohol consumption

Shiba S., Nakamoto N., Chu P.S., Ojiro K., Taniki N., Yamaguchi A., Morikawa R., Katayama T., Yoshida A., Aoki R., Teratani T., Suzuki T., Miyamoto T., Hara S., Yokoyama A., Kanai T.

Scientific Reports (Scientific Reports) 11 ( 1 ) 2021.12

Increased intestinal permeability and hepatic macrophage activation by endotoxins are involved in alcohol-induced liver injury pathogenesis. Long-term alcohol exposure conversely induces endotoxin immune tolerance; however, the precise mechanism and reversibility are unclear. Seventy-two alcohol-dependent patients with alcohol dehydrogenase-1B (ADH1B, rs1229984) and aldehyde dehydrogenase-2 (ALDH2, rs671) gene polymorphisms admitted for alcohol abstinence were enrolled. Blood and fecal samples were collected on admission and 4 weeks after alcohol cessation and were sequentially analyzed. Wild-type and ALDH2*2 transgenic mice were used to examine the effect of acetaldehyde exposure on liver immune responses. The productivity of inflammatory cytokines of peripheral CD14+ monocytes in response to LPS stimulation was significantly suppressed in alcohol dependent patients on admission relative to that in healthy controls, which was partially restored by alcohol abstinence with little impact on the gut microbiota composition. Notably, immune suppression was associated with ALDH2/ADH1B gene polymorphisms, and patients with a combination of ALDH2*1/*2 and ADH1B*2 genotypes, the most acetaldehyde-exposed group, demonstrated a deeply suppressed phenotype, suggesting a direct role of acetaldehyde. In vitro LPS and malondialdehyde-acetaldehyde adducted protein stimulation induced direct cytotoxicity on monocytes derived from healthy controls, and a second LPS stimulation suppressed the inflammatory cytokines production. Consistently, hepatic macrophages of ethanol-administered ALDH2*2 transgenic mice exhibited suppressed inflammatory cytokines production in response to LPS compared to that in wild-type mice, reinforcing the contribution of acetaldehyde to liver macrophage function. These results collectively provide new perspectives on the systemic influence of excessive alcohol consumption based on alcohol-metabolizing enzyme genetic polymorphisms.

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Comprehensive and long-term surveys of COVID-19 sequelae in Japan, an ambidirectional multicentre cohort study: Study protocol

Nakagawara K., Namkoong H., Terai H., Masaki K., Tanosaki T., Shimamoto K., Lee H., Tanaka H., Okamori S., Kabata H., Chubachi S., Ikemura S., Kamata H., Yasuda H., Kawada I., Ishii M., Ishibashi Y., Harada S., Fujita T., Ito D., Bun S., Tabuchi H., Kanzaki S., Shimizu E., Fukuda K., Yamagami J., Kobayashi K., Hirano T., Inoue T., Kagyo J., Shiomi T., Ohgino K., Sayama K., Otsuka K., Miyao N., Odani T., Oyamada Y., Masuzawa K., Nakayama S., Suzuki Y., Baba R., Nakachi I., Kuwahara N., Ishiguro T., Mashimo S., Minematsu N., Ueda S., Manabe T., Funatsu Y., Koh H., Yoshiyama T., Saito F., Ishioka K., Takahashi S., Nakamura M., Goto A., Harada N., Kusaka Y., Nakano Y., Nishio K., Tateno H., Edahiro R., Takeda Y., Kumanogoh A., Kodama N., Okamoto M., Umeda A., Hagimura K., Sato T., Miyazaki N., Takemura R., Sato Y., Takebayashi T., Nakahara J., Mimura M., Ogawa K., Shimmura S., Negishi K., Tsubota K., Amagai M., Goto R., Ibuka Y., Hasegawa N., Kitagawa Y., Kanai T., Fukunaga K.

BMJ Open Respiratory Research (BMJ Open Respiratory Research) 8 ( 1 ) 2021.11

Introduction The rapid spread of COVID-19 posed a global burden. Substantial number of people died of the disease in the acute phase of infection. In addition, a significant proportion of patients have been reported to suffer from post-acute phase symptoms, sequelae of COVID-19, which may negatively influence the quality of daily living and/or socioeconomic circumstances of the patients. However, no previous study has comprehensively and objectively assessed the quality of life of patients by using existing international scales. Further, evidence of socioeconomic consequences among patients with COVID-19 is scarce. To address the multidimensional issues from sequelae of COVID-19, evidence from comprehensive surveys beyond clinical perspectives is critical that investigates health, and social determinants of disease progression as well as socioeconomic consequences at a large scale. Methods and analysis In this study, we plan to conduct a nationwide and comprehensive survey for the sequelae of COVID-19 in a total of 1000 patients diagnosed at 27 hospitals throughout Japan. This study will evaluate not only the health-related status of patients from clinical perspectives but also the Health-related Quality of Life (HRQoL) scores, socioeconomic status and consequences to discuss the sequelae of the disease and the related risk factors. The primary endpoint is the frequency of long-term complications of COVID-19 infection. The secondary endpoints are risk factors for progression to sequelae of COVID-19 infection. The study will provide robust and important evidence as a resource to tackle the issues from the sequelae of COVID-19 from the multi-dimensional perspectives. Ethics and dissemination This trial was approved by the Keio University School of Medicine Ethics Committee (20200243, UMIN000042299). The results of this study will be reported at a society meeting or published in a peer-reviewed journal.

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Leucine-Rich Alpha-2 Glycoprotein May Be Predictive of the Adalimumab Trough Level and Antidrug Antibody Development for Patients with Inflammatory Bowel Disease: A Sub-Analysis of the PLANET Study

Yanai S., Shinzaki S., Matsuoka K., Mizuno S., Iijima H., Naka T., Kanai T., Matsumoto T.

Digestion (Digestion) 102 ( 6 ) 929 - 937 2021.11

ISSN 00122823

Introduction: The aim of this study was to examine whether biomarkers are predictive of the adalimumab (ADA) trough level and antidrug antibody development in patients with Crohn's disease (CD) and ulcerative colitis (UC). Methods: Using data obtained in a prospective, multicenter, observational study (PLANET), we assessed serial changes in a novel biomarker-leucine-rich alpha-2 glycoprotein (LRG)-during ADA treatment for patients with active CD and UC. We measured serum LRG, C-reactive protein (CRP), and fecal calprotectin (fCAL) at weeks 0, 12, 24, and 52. The ADA trough level and anti-ADA antibody (AAA) were also measured at weeks 12 and 52. Correlations between the ADA trough level, AAA, and biomarkers were examined. Results: In all, 34 patients with CD and 47 patients with UC were enrolled. The ADA trough level at week 12 or at the time of ADA withdrawal was 8.5 ± 3.9 in the AAA-negative group (n = 70) and 2.9 ± 2.7 μg/mL in the AAA-positive group (n = 8) (p < 0.0001). The ADA trough level at week 12 or at the time of ADA withdrawal was associated with pretreatment LRG (p = 0.0437 and r =-0.23). Conclusion: LRG, rather than CRP or fCAL, may be a marker for predicting the trough level of ADA for patients with CD and UC treated with ADA.

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Risk factors for prolonged hospital stay after endoscopy

Nishizawa T., Yoshida S., Toyoshima O., Matsuno T., Irokawa M., Arano T., Ebinuma H., Suzuki H., Kanai T., Koike K.

Clinical Endoscopy (Clinical Endoscopy) 54 ( 6 ) 851 - 856 2021.11

ISSN 22342400

Background/Aims: The recovery room used after endoscopy has limited capacity, and an efficient flow of the endoscopy unit is desired. We investigated the duration of hospital stay after endoscopy and the risk factors for prolonged hospital stay among outpatients. Methods: We retrospectively studied consecutive patients who underwent esophagogastroduodenoscopy or colonoscopy at the Toyoshima Endoscopy Clinic. We collected data on age, sex, body weight, midazolam and pethidine dosage, respiratory depression during endoscopy, and duration of hospital stay after endoscopy (scope out to check out). Risk factors for prolonged hospital stay (>100 minutes) were identified using multiple logistic regression analysis. Results: We enrolled 3,898 patients, including 3,517 (90.2%) patients tested under sedation and 381 (9.8%) patients tested without sedation. Overall, 442 (11.3%) patients had prolonged stay (>100 min). The mean time difference between sedation group and non-sedation group was 44.2 minutes for esophagogastroduodenoscopy and 39.1 minutes for colonoscopy. Age (odds ratio [OR], 1.025; 95% confidence interval [CI], 1.014−1.036), female sex (OR, 1.657; 95% CI, 1.220−2.249), and midazolam dose (OR, 1.019; 95% CI, 1.013−1.026) were independently associated with prolonged hospital stay after esophagogastroduodenoscopy, with similar results for colonoscopy. Conclusions: Old age, female sex, and midazolam dose were independent risk factors for prolonged hospital stay after endoscopy.

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Predictors of technical difficulty for complete closure of mucosal defects after duodenal endoscopic resection

Mizutani M., Kato M., Sasaki M., Masunaga T., Kubosawa Y., Hayashi Y., Kiguchi Y., Takatori Y., Mutaguchi M., Matsuura N., Nakayama A., Fukuhara S., Takabayashi K., Maehata T., Kanai T., Yahagi N.

Gastrointestinal Endoscopy (Gastrointestinal Endoscopy) 94 ( 4 ) 786 - 794 2021.10

ISSN 00165107

Background and Aims: It has been reported that the prophylactic closure of mucosal defects after duodenal endoscopic resection (ER) can reduce delayed adverse events; however, under certain circumstances, this can be technically challenging. Therefore, the aim of this study was to determine the predictors of difficulty during the complete closure of mucosal defects after duodenal ER. Methods: This was a retrospective study of duodenal lesions that underwent ER between July 2010 and May 2020. We reviewed the endoscopic images and analyzed the relationships between the degree of closure or closure time and clinical features of the lesions using univariate and multivariate analyses. Results: We analyzed 698 lesions. The multivariate analysis revealed that lesion location in the medial or anterior wall (odds ratio, 2.8; 95% confidence interval, 1.36-5.85; P < .01) and a large lesion size (odds ratio, 1.4; 95% confidence interval, 1.07-1.89; P = .03) were independent predictors of an increased risk of incomplete closure. Moreover, a large lesion size (β coefficient, .304; P < .01), an occupied circumference over 50% (β coefficient, .178; P < .01), intraoperative perforation (β coefficient, .175; P < .01), treatment period (β coefficient, .143; P < .01), and treatment with endoscopic submucosal dissection (β coefficient, .125; P < .01) were independently and positively correlated with a prolonged closure time in the multiple regression analysis. Conclusions: This study revealed that lesion location in the medial or anterior wall and lesion size affected the incomplete closure of mucosal defects after duodenal ER, and lesion size, occupied circumference, intraoperative perforation, treatment period, and treatment method affected closure time.

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Linked color imaging versus white light imaging colonoscopy for colorectal adenoma detection: A randomized controlled trial

Miyaguchi K., Takabayashi K., Saito D., Tsuzuki Y., Hirooka N., Hosoe N., Ohgo H., Ashitani K., Soma H., Miyanaga R., Kimura K., Tokunaga S., Mitsui T., Miura M., Ozaki R., Nakamoto H., Kanai T., Hisamatsu T., Ogata H., Imaeda H.

Journal of Gastroenterology and Hepatology (Australia) (Journal of Gastroenterology and Hepatology (Australia)) 36 ( 10 ) 2778 - 2784 2021.10

ISSN 08159319

Background and Aim: The adenoma detection rate is an important indicator of colonoscopy quality and colorectal cancer incidence. We compared the adenoma detection rates between white light imaging (WLI) and linked color imaging (LCI) colonoscopy. Methods: Patients undergoing colonoscopy for positive fecal immunochemical tests, follow-up of colon polyps, and abdominal symptoms at three institutions were randomly assigned to the LCI or WLI groups. Mean adenoma number per patient (including based on endoscopists' experience), adenoma detection rate, cecal intubation time, withdrawal time, mean adenoma number per location, and adenoma size were compared. Results: The LCI and WLI groups comprised 494 and 501 patients, respectively. No significant differences in the cecal intubation rate (LCI vs WLI: 99.5% vs 99.4%), cecal intubation time, and withdrawal time were noted between groups. The mean adenoma number per patient was significantly higher in the LCI group than in the WLI group (1.07 vs 0.88, P = 0.04), particularly in the descending [0.12 (58/494) vs 0.07 (35/501), P = 0.01] and sigmoid colon [0.41 (201/494) vs 0.30 (149/501), P ≤ 0.001]. However, the adenoma detection rate was 47.1% in the LCI group and 46.9% in the WLI group, with no significant difference (P = 0.93). The total number of sessile-type adenomas was significantly higher in the LCI group than in the WLI group (346/494 vs 278/501, P = 0.04). As for polyp size, small polyps (≤ 5 mm) were detected at a significantly higher rate in the LCI group (271/494 vs 336/501, P = 0.04). Conclusion: Linked color imaging is significantly superior to WLI in terms of mean adenoma number per patient.

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アルコール関連肝疾患患者に対する内科医によるセリンクロ錠投与の飲酒量低減に対する効果

堀江義則, 谷木信仁, ちょ柏松, 中本伸宏, 金井隆典

肝臓 ((一社)日本肝臓学会) 62 ( 10 ) 620 - 629 2021.10

ISSN 0451-4203

アルコール関連肝疾患患者がアルコール依存症に至っている場合,簡易介入のみでは飲酒量の低減に結び付かないケースが多い.セリンクロ錠(一般名:ナルメフェン)は,飲酒欲求を抑え飲酒量を低減させる新しい薬剤である.今回,内科外来でセリンクロ錠を処方した症例を検討し,その有用性を検討した.初回投与から24週以上経過した症例は18例で,2例はめまいのため中止し,5例は連絡なく通院を中断したため,結果として副作用もなく通院を継続し24週での評価ができた症例は11例であった.全例で飲酒量の低減と肝機能の改善を認めたが,1例はその後再度飲酒量が増え,専門医療機関に紹介入院となった.セリンクロ錠による飲酒量低減が認められ,内科外来における飲酒量低減治療の新たな選択肢となることが示唆された.一方で,中断例も認められ,めまいや嘔吐などの副作用が多いことが報告されており,十分に研修を積んだ医師が処方すべきと考えられる.(著者抄録)

Hepatic Adenosine Triphosphate Reduction Through the Short-Chain Fatty Acids–Peroxisome Proliferator-Activated Receptor γ–Uncoupling Protein 2 Axis Alleviates Immune-Mediated Acute Hepatitis in Inulin-Supplemented Mice

Yamaguchi A., Teratani T., Chu P.s., Suzuki T., Taniki N., Mikami Y., Shiba S., Morikawa R., Amiya T., Aoki R., Kanai T., Nakamoto N.

Hepatology Communications (Hepatology Communications) 5 ( 9 ) 1555 - 1570 2021.09

How liver tolerance is disrupted in immune-mediated liver injury is currently unclear. There is also insufficient information available regarding susceptibility, precipitation, escalation, and perpetuation of autoimmune hepatitis. To explore how dietary fiber influences hepatic damage, we applied the concanavalin A (ConA)-induced acute immune-mediated liver injury model in mice fed a diet supplemented with 6.8% inulin, a water-soluble fermentable fiber. Twelve hours after ConA administration, inulin-supplemented diet-fed mice demonstrated significantly alleviated hepatic damage histologically and serologically, with down-regulation of hepatic interferon-γ and tumor necrosis factor and reduced myeloperoxidase (MPO)-producing neutrophil infiltration. Preconditioning with an inulin-supplemented diet for 2 weeks significantly reduced hepatic adenosine triphosphate (ATP) content; suramin, a purinergic P2 receptor antagonist, abolished the protective effect. Of note, the portal plasma derived from mice fed the inulin-supplemented diet significantly alleviated ConA-induced immune-mediated liver injury. Mechanistically, increased portal short-chain fatty acid (SCFA) levels, such as those of acetate and butyrate, by inulin supplementation leads to up-regulation of hepatic γ-type peroxisome proliferator-activated receptor (Pparg) and uncoupling protein 2 (Ucp2), which uncouples mitochondrial ATP synthesis downstream of PPARγ. Pparg down-regulating small interfering RNA cancelled the protective effect of inulin supplementation against MPO-producing neutrophil infiltration and the subsequent immune-mediated liver injury, suggesting that the SCFA–PPARγ–UCP2 axis plays a key role in the protective effect by inulin supplementation. Moreover, significant changes in the gut microbiota, including increased operational taxonomic units in genera Akkermansia and Allobaculum, also characterized the protective effect of the inulin-supplemented diet. Conclusion: There is a possible unraveled etiopathophysiological link between the maintenance of liver tolerance and dietary fiber. The SCFA–PPARγ–UCP2 axis may provide therapeutic targets for immune-mediated liver injury in the future.

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Circadian rhythms in the tissue-specificity from metabolism to immunity: insights from omics studies

Kinouchi K., Mikami Y., Kanai T., Itoh H.

Molecular Aspects of Medicine (Molecular Aspects of Medicine) 80 2021.08

ISSN 00982997

Creatures on earth have the capacity to preserve homeostasis in response to changing environments. The circadian clock enables organisms to adapt to daily predictable rhythms in surrounding conditions. In mammals, circadian clocks constitute hierarchical network, where the central pacemaker in hypothalamic suprachiasmatic nucleus (SCN) serves as a time-keeping machinery and governs peripheral clocks in every other organ through descending neural and humoral factors. The central clock in SCN is reset by light, whilst peripheral clocks are entrained by feeding-fasting rhythms, emphasizing the point that temporal patterns of nutrient availability specifies peripheral clock functions. Indeed, emerging evidence revealed various types of diets or timing of food intake reprogram circadian rhythms in a tissue specific manner. This advancement in understanding of mechanisms underlying tissue specific responsiveness of circadian oscillators to nutrients at the genomic and epigenomic levels is largely owing to employment of state-of-the-art technologies. Specifically, high-throughput transcriptome, proteome, and metabolome have provided insights into how genes, proteins, and metabolites behave over circadian cycles in a given tissue under a certain dietary condition in an unbiased fashion. Additionally, combinations with specialized types of sequencing such as nascent-seq and ribosomal profiling allow us to dissect how circadian rhythms are generated or obliterated at each step of gene regulation. Importantly, chromatin immunoprecipitation followed by deep sequencing methods provide chromatin landscape in terms of regulatory mechanisms of circadian gene expression. In this review, we outline recent discoveries on temporal genomic and epigenomic regulation of circadian rhythms, discussing entrainment of the circadian rhythms by feeding as a fundamental new comprehension of metabolism and immune response, and as a potential therapeutic strategy of metabolic and inflammatory diseases.

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New strategy for evaluating pancreatic tissue specimens from endoscopic ultrasound-guided fine needle aspiration and surgery

Fukuhara S., Iwasaki E., Iwano T., Machida Y., Tamagawa H., Kawasaki S., Seino T., Yokose T., Endo Y., Yoshimura K., Kashiwagi K., Kitago M., Ogata H., Takeda S., Kanai T.

JGH Open (JGH Open) 5 ( 8 ) 953 - 958 2021.08

Background and Aim: Preoperative histological evaluation of pancreatic neoplasms is important for guiding the resection strategy and preventing postoperative adverse events. However, conventional endoscopic methods have technical limitations that reduce the accuracy of the histopathological examination. Probe electrospray ionization mass spectrometry (PESI-MS) may be a useful technique for rapidly evaluating small specimens. Methods: This single-center prospective study included patients with pancreatic neoplasms between October 2018 and December 2019. Pancreatic ductal adenocarcinoma (PDAC) specimens were obtained via endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) and non-neoplastic tissue was obtained via surgery. Specimens were subjected to PESI-MS and the mass spectra were analyzed using partial least squares regression-discriminant analysis. Results: The study included 40 patients with 20 nonneoplastic specimens and 19 PDAC specimens (1 case of neuroendocrine carcinoma was omitted). All nonneoplastic specimens were sufficient for PESI-MS analysis, although only 7 of 19 PDAC specimens were sufficient for PESI-MS analysis because of poor sample quality or insufficient quantity (<1 mg). Among the 27 analyzed cases, the mass spectra clearly differentiated between the PDAC and nonneoplastic specimens. Conclusions: This study revealed that PESI-MS could differentiate between PDAC and nonneoplastic specimens, even in cases where EUS-FNA produced very small specimens.

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Analysis of risk factors for immune-related adverse events in various solid tumors using real-world data

Shimozaki K., Sukawa Y., Sato Y., Horie S., Chida A., Tsugaru K., Togasaki K., Kawasaki K., Hirata K., Hayashi H., Hamamoto Y., Kanai T.

Future Oncology (Future Oncology) 17 ( 20 ) 2593 - 2603 2021.07

ISSN 14796694

The aim of this study was to determine the risk factors for immune-related adverse events (irAEs) induced by immune checkpoint inhibitors. The authors conducted a retrospective study in which patients with malignant melanoma, non-small-cell lung cancer, gastric cancer or renal cell carcinoma who received anti-PD-1/PD-L1 antibodies were included. Of 247 patients, 118 developed a total of 182 irAEs. In the multivariate Fine-Gray regression analysis, serum albumin level ≥3.6 g/dl (hazard ratio: 1.62; 95% CI: 1.10-2.39; p = 0.015) and history of Type I hypersensitivity reactions (hazard ratio: 1.48; 95% CI: 1.02-2.14; p = 0.037) were significantly associated with the development of irAEs. High serum albumin levels and history of Type I hypersensitivity reactions are risk factors for irAEs.

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Rikkunshito as a Therapeautic Agent for Functional Dyspepsia and its Prokinetic and Non-Prokinetic Effects

Inokuchi K., Masaoka T., Kanai T.

Frontiers in Pharmacology (Frontiers in Pharmacology) 12 2021.06

Prokinetics is one of the therapeutic agents for functional and motility disorders of the stomach. However, its efficacy is limited. Kampo medicine is a unique medical system that was developed in Japan. In Kampo medicine, herbal medicine is prescribed based on the patient’s condition. Therefore, even for functional and motility disorders of the stomach, some herbal medicines are considered as a therapeutic option. Recently, there has been an increase in evidence for the efficacy or the mechanism of herbal medicine for functional and motility disorders of the stomach. Among these, rikkunshito is a well-studied herbal medicine that could be used as an alternative to prokinetics. In this review, we discuss the possibilities of rikkunshito for functional dyspepsia with its prokinetic and non-prokinetic effects and provide an overview of their current use with a focus on their therapeutic mechanism.

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Leucine-rich alpha-2 glycoprotein is a potential biomarker to monitor disease activity in inflammatory bowel disease receiving adalimumab: PLANET study

Shinzaki S., Matsuoka K., Tanaka H., Takeshima F., Kato S., Torisu T., Ohta Y., Watanabe K., Nakamura S., Yoshimura N., Kobayashi T., Shiotani A., Hirai F., Hiraoka S., Watanabe M., Matsuura M., Nishimoto S., Mizuno S., Iijima H., Takehara T., Naka T., Kanai T., Matsumoto T.

Journal of Gastroenterology (Journal of Gastroenterology) 56 ( 6 ) 560 - 569 2021.06

ISSN 09441174

Background: This multicenter prospective study (UMIN000019958) aimed to evaluate the usefulness of serum leucin-rich alpha-2 glycoprotein (LRG) levels in monitoring disease activity in inflammatory bowel disease (IBD). Methods: Patients with moderate-to-severe IBD initiated on adalimumab therapy were enrolled herein. Serum LRG, C-reactive protein (CRP), and fecal calprotectin (fCal) levels were measured at week 0, 12, 24, and 52. Colonoscopy was performed at week 0, 12, and 52 for ulcerative colitis (UC), and at week 0, 24, and 52 for Crohn’s disease (CD). Endoscopic activity was assessed using the Simple Endoscopic Score for Crohn’s Disease (SES-CD) for CD and the Mayo endoscopic subscore (MES) for UC. Results: A total of 81 patients was enrolled. Serum LRG levels decreased along with improvements in clinical and endoscopic outcomes upon adalimumab treatment (27.4 ± 12.6 μg/ml at week 0, 15.5 ± 7.7 μg/ml at week 12, 15.7 ± 9.6 μg/ml at week 24, and 14.5 ± 6.8 μg/ml at week 52), being correlated with endoscopic activity at each time point (SES-CD: r = 0.391 at week 0, r = 0.563 at week 24, r = 0.697 at week 52; MES: r = 0.534 at week 0, r = 0.429 at week 12, r = 0.335 at week 52). Endoscopic activity better correlated with LRG compared to CRP and fCal on pooled analysis at all time points (SES-CD: LRG: r = 0.636, CRP: r = 0.402, fCal: r = 0.435; MES: LRG: r = 0.568, CRP: 0.389, fCal: r = 0.426). Conclusions: Serum LRG is a useful biomarker of endoscopic activity both in CD and UC during the adalimumab treatment.

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Clinical, Endoscopic, and Pathological Characteristics of Immune Checkpoint Inhibitor-Induced Gastroenterocolitis

Hayashi Y., Hosoe N., Takabayashi K., Limpias Kamiya K.J.L., Tsugaru K., Shimozaki K., Hirata K., Fukuhara K., Fukuhara S., Mutaguchi M., Sujino T., Sukawa Y., Hamamoto Y., Naganuma M., Takaishi H., Shimoda M., Ogata H., Kanai T.

Digestive Diseases and Sciences (Digestive Diseases and Sciences) 66 ( 6 ) 2129 - 2134 2021.06

ISSN 01632116

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Long-Term Observation of Cyclosporine as Second-Line Therapy in Adults for Severe Acute Autoimmune Hepatitis

Noguchi F., Chu P.s., Taniki N., Yoshida A., Morikawa R., Yamaguchi A., Ikura A., Yamataka K., Hoshi H., Usui S., Ebinuma H., Saito H., Kanai T., Nakamoto N.

Hepatology (Hepatology) 73 ( 6 ) 2594 - 2597 2021.06

ISSN 02709139

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Current status of colon capsule endoscopy

Hosoe N., Limpias Kamiya K.J.L., Hayashi Y., Sujino T., Ogata H., Kanai T.

Digestive Endoscopy (Digestive Endoscopy) 33 ( 4 ) 529 - 537 2021.05

ISSN 09155635

While both the annual incidence and mortality of colorectal cancer are slowly but steadily decreasing in the United States, the incidence of such malignancy is increasing in Japan. Thus, controlling colorectal cancer in Japan is a major concern. In 2006, colon capsule endoscopy was first introduced by Eliakim et al. First-generation colon capsule endoscopy had a moderate sensitivity for detecting polyps of more than 6 mm. Thus, second-generation colon capsule endoscopy was developed to achieve higher sensitivity. Colonoscopy is the gold standard tool for colorectal cancer surveillance. With an improvement in the imaging function, the performance of second-generation colon capsule endoscopy is almost as satisfactory as that of colonoscopy. Certain situations, such as incomplete colonoscopy and contraindication for use of sedation, can benefit from colon capsule endoscopy. Colon capsule endoscopy requires a more extensive bowel preparation than colonoscopy and computed tomography colonography because it requires laxatives not only for bowel cleansing but also for promoting the excretion of the capsule. Another problem with colon capsule endoscopy includes the burden of reading and interpretation and overlook of the lesions. Currently, the development of automatic diagnosis of colon capsule endoscopy using artificial intelligence is still under progress. Although the available guidelines do not support the use of colon capsule endoscopy for inflammatory bowel disease, the possible application of colon capsule endoscopy is ulcerative colitis. This review article summarizes and focuses on the current status of colon capsule endoscopy for colorectal cancer screening and the possibility for its applicability on inflammatory bowel disease.

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Oncogenic KRAS–expressing organoids with biliary epithelial stem cell properties give rise to biliary tract cancer in mice

Kasuga A., Semba T., Sato R., Nobusue H., Sugihara E., Takaishi H., Kanai T., Saya H., Arima Y.

Cancer Science (Cancer Science) 112 ( 5 ) 1822 - 1838 2021.05

ISSN 13479032

Biliary tract cancer (BTC) arises from biliary epithelial cells (BECs) and includes intrahepatic cholangiocarcinoma (IHCC), gallbladder cancer (GC), and extrahepatic cholangiocarcinoma (EHCC). Although frequent KRAS mutations and epigenetic changes at the INK4A/ARF locus have been identified, the molecular pathogenesis of BTC is unclear and the development of corresponding anticancer agents remains inadequate. We isolated epithelial cell adhesion molecule (EpCAM)–positive BECs from the mouse intrahepatic bile duct, gallbladder, and extrahepatic bile duct, and established organoids derived from these cells. Introduction of activated KRAS and homozygous deletion of Ink4a/Arf in the cells of each organoid type conferred the ability to form lethal metastatic adenocarcinoma with differentiated components and a pronounced desmoplastic reaction on cell transplantation into syngeneic mice, indicating that the manipulated cells correspond to BTC–initiating cells. The syngeneic mouse models recapitulate the pathological features of human IHCC, GC, and EHCC, and they should therefore prove useful for the investigation of BTC carcinogenesis and the development of new therapeutic strategies. Tumor cells isolated from primary tumors formed organoids in three-dimensional culture, and serial syngeneic transplantation of these cells revealed that their cancer stem cell properties were supported by organoid culture, but not by adherent culture. Adherent culture thus attenuated tumorigenic activity as well as the expression of both epithelial and stem cell markers, whereas the expression of epithelial-mesenchymal transition (EMT)–related transcription factor genes and mesenchymal cell markers was induced. Our data show that organoid culture is important for maintenance of epithelial cell characteristics, stemness, and tumorigenic activity of BTC–initiating cells.

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Factors predicting major complications, mortality, and recovery in percutaneous endoscopic gastrostomy

Limpias Kamiya K.J.L., Hosoe N., Takabayashi K., Hayashi Y., Fukuhara S., Mutaguchi M., Nakamura R., Kawakubo H., Kitagawa Y., Ogata H., Kanai T.

JGH Open (JGH Open) 5 ( 5 ) 590 - 598 2021.05

Background and Aim: Percutaneous endoscopic gastrostomy (PEG) has been used in patients with dysphagia and inadequate food intake via an oral route. Despite being a procedure with a high success rate, complications and death have been reported. The aim was to identify the factors related to major complications and mortality, as well as PEG removal prognostic factors due to improvement of their general condition. Methods: Patient characteristics, comorbidities, laboratory data, concomitant medication, sedation, and indication for PEG placement were collected. Major complications, mortality, and PEG removal factors were assessed. Results: A total of 388 patients were enrolled. There were 15 (3.9%) cases of major complications, with major bleeding being the most frequent in 6 (1.5%) patients. Corticosteroids were the independent variable associated with major complications (odds ratio [OR] 5.85; 95% confidence interval [CI] 1.71–20; P = <0.01). Advanced cancer (hazard ratio [HR] 0.5; 95% CI 0.3–1; P = 0.05), albumin (HR 0.6; 95% CI 0.4–0.9; P = <0.01), and C-reactive protein (CRP) (HR 1.1; CI 1–1.2; P = 0.01) were considered risk factors for mortality. Previous pneumonia (HR 0.4; CI 0.2–0.9; P = 0.02) was a factor for permanent use of a PEG; however, oncological indication (HR 8.2; CI 3.2–21; P = <0.01) was factors for PEG withdrawal. Conclusions: Chronic corticosteroid users potentially present with major complications. Low albumin levels and elevated CRP were associated with death. Previous aspiration pneumonia was a factor associated with permanent use of PEG; however, patients with oncological indication were the most benefited.

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Angiopoietin-like protein 4 deficiency augments liver fibrosis in liver diseases such as nonalcoholic steatohepatitis in mice through enhanced free cholesterol accumulation in hepatic stellate cells

Teratani T., Tomita K., Wada A., Sugihara N., Higashiyama M., Inaba K., Horiuchi K., Hanawa Y., Nishii S., Mizoguchi A., Tanemoto R., Ito S., Okada Y., Kurihara C., Akita Y., Narimatsu K., Watanabe C., Komoto S., Oike Y., Miura S., Hokari R., Kanai T.

Hepatology Research (Hepatology Research) 51 ( 5 ) 580 - 592 2021.05

ISSN 13866346

Aim: We recently reported that lipoprotein lipase (LPL)-mediated free cholesterol (FC) accumulation in hepatic stellate cells (HSCs) augmented liver fibrosis in non-alcoholic steatohepatitis (NASH). The aim of the present study was to explore the role of angiopoietin-like protein 4 (Angptl4), an LPL inhibitor, in the pathogenesis of liver fibrosis in NASH. Methods: Angptl4-deficient or wild-type mice were used to investigate the role of Angptl4 in the pathogenesis of NASH induced by feeding a methionine- and choline-deficient diet. We also examined the effect of Angptl4 on FC accumulation in HSCs, and the subsequent activation of HSCs, using Angptl4-deficient HSCs. Results: In the NASH model, Angptl4-deficient mice had significantly aggravated liver fibrosis and activated HSCs without enhancement of hepatocellular injury, liver inflammation, or liver angiogenesis. FC levels were significantly higher in HSCs from Angptl4-deficient mice than in those from wild-type mice. Treatment with Angptl4 reversed low-density lipoprotein-induced FC accumulation in HSCs through the inhibition of LPL. The Angptl4 deficiency-induced FC accumulation in HSCs suppressed HSC expression of the transforming growth factor-β (TGF-ß) pseudoreceptor, bone morphogenetic protein, and activin membrane-bound inhibitor, and sensitized HSCs to TGF-β-induced activation in vivo and in vitro. Conclusions: Angptl4 plays an important role in the pathogenesis of FC accumulation in HSCs. In addition, regulation of FC levels in HSCs by Angptl4 plays a critical role in the pathogenesis of liver fibrosis in NASH. Thus, Angptl4 could represent a novel therapeutic option for NASH.

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Endoscopic diagnosis for colorectal sessile serrated lesions

Nishizawa T., Yoshida S., Toyoshima A., Yamada T., Sakaguchi Y., Irako T., Ebinuma H., Kanai T., Koike K., Toyoshima O.

World Journal of Gastroenterology (World Journal of Gastroenterology) 27 ( 13 ) 1321 - 1329 2021.04

ISSN 10079327

BACKGROUND Hyperplastic polyps are considered non-neoplastic, whereas sessile serrated lesions (SSLs) are precursors of cancer via the ''serrated neoplastic pathway''. The clinical features of SSLs are tumor size (> 5 mm), location in the proximal colon, coverage with abundant mucus called the ''mucus cap'', indistinct borders, and a cloud-like surface. The features in magnifying narrow-band imaging are varicose microvascular vessels and expanded crypt openings. However, accurate diagnosis is often difficult. AIM To develop a diagnostic score system for SSLs. METHODS We retrospectively reviewed consecutive patients who underwent endoscopic resection during colonoscopy at the Toyoshima endoscopy clinic. We collected data on serrated polyps diagnosed by endoscopic or pathological examination. The significant factors for the diagnosis of SSLs were assessed using logistic regression analysis. Each item that was significant in multivariate analysis was assigned 1 point, with the sum of these points defined as the endoscopic SSL diagnosis score. The optimal cut-off value of the endoscopic SSL diagnosis score was determined by receiver-operating characteristic curve analysis. RESULTS Among 1288 polyps that were endoscopically removed, we analyzed 232 diagnosed as serrated polyps by endoscopic or pathological examination. In the univariate analysis, the location (proximal colon), size (> 5 mm), mucus cap, indistinct borders, cloud-like surface, and varicose microvascular vessels were significantly associated with the diagnosis of SSLs. In the multivariate analysis, size (> 5 mm; P = 0.033), mucus cap (P = 0.005), and indistinct borders (P = 0.033) were independently associated with the diagnosis of SSLs. Size > 5 mm, mucus cap, and indistinct borders were assigned 1 point each and the sum of these points was defined as the endoscopic SSL diagnosis score. The receiver-operating characteristic curve analysis showed an optimal cut-off score of 3, which predicted pathological SSLs with 75% sensitivity, 80% specificity, and 78.4% accuracy. The pathological SSL rate for an endoscopic SSL diagnosis score of 3 was significantly higher than that for an endoscopic SSL diagnosis score of 0, 1, or 2 (P < 0.001). CONCLUSION Size > 5 mm, mucus cap, and indistinct borders were significant endoscopic features for the diagnosis of SSLs. Serrated polyps with these three features should be removed during colonoscopy.

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An organoid-based organ-repurposing approach to treat short bowel syndrome

Sugimoto S., Kobayashi E., Fujii M., Ohta Y., Arai K., Matano M., Ishikawa K., Miyamoto K., Toshimitsu K., Takahashi S., Nanki K., Hakamata Y., Kanai T., Sato T.

Nature (Nature) 592 ( 7852 ) 99 - 104 2021.04

ISSN 00280836

The small intestine is the main organ for nutrient absorption, and its extensive resection leads to malabsorption and wasting conditions referred to as short bowel syndrome (SBS). Organoid technology enables an efficient expansion of intestinal epithelium tissue in vitro1, but reconstruction of the whole small intestine, including the complex lymphovascular system, has remained challenging2. Here we generate a functional small intestinalized colon (SIC) by replacing the native colonic epithelium with ileum-derived organoids. We first find that xenotransplanted human ileum organoids maintain their regional identity and form nascent villus structures in the mouse colon. In vitro culture of an organoid monolayer further reveals an essential role for luminal mechanistic flow in the formation of villi. We then develop a rat SIC model by repositioning the SIC at the ileocaecal junction, where the epithelium is exposed to a constant luminal stream of intestinal juice. This anatomical relocation provides the SIC with organ structures of the small intestine, including intact vasculature and innervation, villous structures, and the lacteal (a fat-absorbing lymphatic structure specific to the small intestine). The SIC has absorptive functions and markedly ameliorates intestinal failure in a rat model of SBS, whereas transplantation of colon organoids instead of ileum organoids invariably leads to mortality. These data provide a proof of principle for the use of intestinal organoids for regenerative purposes, and offer a feasible strategy for SBS treatment.

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A significant association of non-obese non-alcoholic fatty liver disease with osteosarcopenic obesity in females 50 years and older

Kashiwagi K., Takayama M., Ichikawa H., Takaishi H., Iwao Y., Kanai T.

Clinical Nutrition ESPEN (Clinical Nutrition ESPEN) 42 166 - 172 2021.04

ISSN 24054577

Background & aims: Osteosarcopenic obesity (OSO) encompassing obesity, sarcopenia and osteopenia, is due to redistribution or infiltration of fat into muscle and bone. This cross-sectional study evaluated the association between OSO and non-alcoholic fatty liver disease (NAFLD). Methods: Obesity, sarcopenia and osteopenia was defined using the percentage of body fat mass, reduced muscle mass, and the percentage of young adult mean < 80%, measured by dual-energy x-ray absorptiometry, respectively. Non-obese and obese NAFLD was diagnosed by ultrasound and body mass index cut-off point (25 kg/m2). A total of 619 subjects ≥ 50 years who completed health checkups were divided into obesity group including OSO and sarcopenic obesity (SO) alone phenotype, and non-obesity group that did not belong to any phenotype, including standard (St). Results: Overall osteopenia and OSO were detected in only 10% and 1% in males, compared with 45% and 9% in females, respectively. Multivariate analysis for females demonstrated a significant association of OSO with non-obese NAFLD (odds ratio = 3.737, 95% confidence interval = 1.365–10.233, P = 0.010), while the association between SO alone and non-obese NAFLD was equivocal. The OSO phenotype had a significantly higher proportion of slower walking speed and weaker grip strength, compared to the St phenotype. The proportion of OSO increased with age in contrast to constant prevalence of non-obese NAFLD. Conclusion: Non-obese NAFLD had a significant association with OSO in females, independent of plausible confounders. These results suggest that non-obese NAFLD might be an independent risk factor for OSO.

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Water pressure method for duodenal endoscopic submucosal dissection (with video)

Kato M., Takatori Y., Sasaki M., Mizutani M., Tsutsumi K., Kiguchi Y., Akimoto T., Mutaguchi M., Nakayama A., Takabayashi K., Maehata T., Kanai T., Yahagi N.

Gastrointestinal Endoscopy (Gastrointestinal Endoscopy) 93 ( 4 ) 942 - 949 2021.04

ISSN 00165107

Background and Aims: Duodenal endoscopic submucosal dissection (ESD) is considered technically challenging and has a high risk of adverse events. However, we recently made some progress with the ESD technique and device by introducing 2 features: a water pressure (WP) method and a second-generation ESD knife (DualKnife) with a water jet function (DualKnife J). The present study aimed to assess whether these changes improved the clinical outcomes of duodenal ESD. Methods: This was a retrospective observational study. Among all patients who underwent ESD for superficial duodenal epithelial tumors from June 2010 to December 2018, patients in whom a single expert performed the procedure were included in this study. Various factors, including the use of the WP method and ESD devices (DualKnife or DualKnife J) and the treatment phase (early, mid, and late), were analyzed to determine whether they were associated with intraprocedural perforation and procedure time. Treatment phase was assigned by dividing the study population equally into 3 subgroups according to the treatment phase. Results: The procedure time was significantly shorter, and the proportion of patients with intraprocedural perforations was the lowest in the late phase. Multivariate analysis of the use of the WP method revealed that it significantly decreased the intraprocedural perforation rate (odds ratio, 0.39; 95% confidence interval, 0.16-0.96), and analysis of the use of both the WP method (β coefficient, −0.40; P <.01) and the DualKnife J (β coefficient, −0.10; P =.032) revealed they were independently and negatively correlated with procedure time. Conclusion: The present study reveals that the WP method significantly reduced the intraprocedural perforation rate and that both the WP method and the DualKnife J significantly shortened procedure times for duodenal ESD.

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Vulnerability to recurrent episodes of acute decompensation/acute-on-chronic liver failure characterizes those triggered by indeterminate precipitants in patients with liver cirrhosis

Hoshi H., Chu P.S., Yoshida A., Taniki N., Morikawa R., Yamataka K., Noguchi F., Kasuga R., Tabuchi T., Ebinuma H., Saito H., Kanai T., Nakamoto N.

PLoS ONE (PLoS ONE) 16 ( 4 April ) 2021.04

Background Acute decompensation (AD) of liver cirrhosis (LC) and subsequent acute-on-chronic liver failure (ACLF) are fatal and impair quality of life. Insufficient knowledge of the highly heterogeneous natural history of LC, including decompensation, re-compensation, and possible recurrent decompensation, hinders the development and application of novel therapeutics. Approximately 10%-50% of AD/ACLF is reported to be precipitated by any indeterminate (unidentifiable, cryptogenic, or unknown) acute insults; however, its clinical characteristics are unclear. Methods We conducted a single-center observational study of 2165 consecutively admitted patients with LC from January 2012 to December 2019. A total of 466 episodes of AD/ACLF in 285 patients, including their 285 first indexed AD/ACLF, were extracted for analysis. Stratified analyses of different acute precipitants, classified as indeterminate (AD/ACLFIND), bacterial infection (AD/ACLFBAC), gastrointestinal bleeding, active alcoholism, and miscellaneous, were performed. Results AD/ACLFIND was the leading acute precipitant (28%), followed by AD/ACLFBAC (23%). AD/ ACLFIND showed better survival outcomes than AD/ACLFBAC (P = 0.03); however, hyperbilirubinemia, hyponatremia, or leukocytosis significantly and uniquely characterized subgroups of AD/ACLFIND with comparable or even worse survival outcomes than those of AD/ ACLFBAC. Patients with subsequent AD/ACLF significantly tended to suffer from AD/ACLF with any organ failure in AD/ACLFIND but not in AD/ACLFBAC (P = 0.004, for trend). In competing risk analysis, patients with AD/ACLFIND were significantly more vulnerable to suffer from recurrent episodes of AD/ACLF within 180 days, compared to those triggered by other precipitants (P = 0.04). Conclusions AD/ACLFIND, the leading acute precipitant, also plays a role in subsequent AD/ACLF. An abruptly exacerbating, remitting, and relapsing nature of systemic inflammation underlying AD/ACLF may also be useful for risk estimation.

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Monitoring of inflammatory bowel disease ―capsule endoscopy―

Hosoe N., Ogata H., Kanai T.

Journal of Japanese Society of Gastroenterology (Journal of Japanese Society of Gastroenterology) 118 ( 3 ) 221 - 228 2021.03

ISSN 04466586

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Host-microbe cross-talk governs amino acid chirality to regulate survival and differentiation of B cells

Suzuki M., Sujino T., Chiba S., Harada Y., Goto M., Takahashi R., Mita M., Hamase K., Kanai T., Ito M., Waldor M.K., Yasui M., Sasabe J.

Science Advances (Science Advances) 7 ( 10 ) 2021.03

Organisms use l-amino acids (l-aa) for most physiological processes. Unlike other organisms, bacteria chiral-convert l-aa to d-configurations as essential components of their cell walls and as signaling molecules in their ecosystems. Mammals recognize microbe-associated molecules to initiate immune responses, but roles of bacterial d-amino acids (d-aa) in mammalian immune systems remain largely unknown. Here, we report that amino acid chirality balanced by bacteria-mammal cross-talk modulates intestinal B cell fate and immunoglobulin A (IgA) production. Bacterial d-aa stimulate M1 macrophages and promote survival of intestinal naïve B cells. Mammalian intestinal d-aa catabolism limits the number of B cells and restricts growth of symbiotic bacteria that activate T cell–dependent IgA class switching of the B cells. Loss of d-aa catabolism results in excessive IgA production and dysbiosis with altered IgA coating on bacteria. Thus, chiral conversion of amino acids is linked to bacterial recognition by mammals to control symbiosis with bacteria.

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Impact of Enteral Nutrition Within 24 Hours Versus Between 24 and 48 Hours in Patients With Severe Acute Pancreatitis: A Multicenter Retrospective Study

Nakashima I., Horibe M., Sanui M., Sasaki M., Sawano H., Goto T., Ikeura T., Takeda T., Oda T., Yasuda H., Ogura Y., Miyazaki D., Kitamura K., Chiba N., Ozaki T., Yamashita T., Koinuma T., Oshima T., Yamamoto T., Hirota M., Moriya T., Shirai K., Izai J., Takeda K., Sekino M., Iwasaki E., Kanai T., Mayumi T.

Pancreas (Pancreas) 50 ( 3 ) 371 - 377 2021.03

OBJECTIVES: In patients with severe acute pancreatitis (SAP), early enteral nutrition (EN) is recommended by major clinical practice guidelines, but the exact timing for the initiation of EN is unknown. METHODS: We conducted a post hoc analysis of the database for a multicenter (44 institutions) retrospective study of patients with SAP in Japan. The patients were classified into 3 groups according to the timing of EN initiation after the diagnosis of SAP: within 24 hours, between 24 and 48 hours, and more than 48 hours. The primary outcome was in-hospital mortality. RESULTS: Of the 1094 study patients, 176, 120, and 798 patients started EN within 24 hours, between 24 and 48 hours, and more than 48 hours after SAP diagnosis, respectively. On multivariable analysis, hospital mortality was significantly better with EN within 48 hours than with more than 48 hours (adjusted odds ratio, 0.49; 95% confidence interval, 0.29-0.83; P < 0.001) but did not significantly differ between the groups with EN starting within 24 hours and between 24 and 48 hours (P = 0.29). CONCLUSIONS: Enteral nutrition within 24 hours may not confer any additional benefit on clinical outcomes compared with EN between 24 and 48 hours.

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C-C motif chemokine receptor 9 regulates obesity-induced insulin resistance via inflammation of the small intestine in mice

Amiya T., Nakamoto N., Irie J., Taniki N., Chu P.S., Koda Y., Miyamoto K., Yamaguchi A., Shiba S., Morikawa R., Itoh H., Kanai T.

Diabetologia (Diabetologia) 64 ( 3 ) 603 - 617 2021.03

ISSN 0012186X

Aims/hypothesis: Accumulation of adipose tissue macrophages is considered pivotal in the development of obesity-associated inflammation and insulin resistance. In addition, recent studies suggest an involvement of the intestine as the primary organ in inducing hyperglycaemia and insulin resistance. We have reported that the C-C motif chemokine receptor (CCR) CCR9 is associated with intestinal immunity and has a pathogenic role in various liver diseases. However, its contribution to type 2 diabetes is unknown. In the current study, we aimed to clarify the involvement of CCR9 in the pathology of type 2 diabetes and the potential underlying mechanisms. Methods: To elucidate how CCR9 affects the development of metabolic phenotypes, we examined the impact of CCR9 deficiency on the pathogenesis of type 2 diabetes using male C57BL/6J (wild-type [WT]) and CCR9-deficient (CCR9 knockout [KO]) mice fed a 60% high-fat diet (HFD) for 12 weeks. Results: WT and Ccr9KO mice fed an HFD exhibited a comparable weight gain; however, glucose tolerance and insulin resistance were significantly improved in Ccr9KO mice. Moreover, visceral adipose tissue (VAT) and the liver of Ccr9KO mice presented with less inflammation and increased expression of glucose metabolism-related genes than WT mice. Ccr9 and Ccl25 expression were specifically higher in the small intestine but was not altered by HFD feeding and type 2 diabetes development. Accumulation of IFN-γ-producing CD4+ T lymphocytes and increased intestinal permeability in the small intestine was observed in WT mice following HFD feeding, but these changes were suppressed in HFD-fed Ccr9KO mice. Adoptive transfer of gut-tropic CCR9-expressing T lymphocytes partially reversed the favourable glucose tolerance found in Ccr9KO mice via exacerbated inflammation in the small intestine and VAT. Conclusions/interpretation: CCR9 plays a central role in the pathogenesis of type 2 diabetes by inducing an inflammatory shift in the small intestine. Our findings support CCR9 as a new therapeutic target for type 2 diabetes via the gut–VAT–liver axis. Graphical abstract: [Figure not available: see fulltext.]

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Role of CC chemokine receptor 9 in the progression of murine and human non-alcoholic steatohepatitis

Morikawa R., Nakamoto N., Amiya T., Chu P.s., Koda Y., Teratani T., Suzuki T., Kurebayashi Y., Ueno A., Taniki N., Miyamoto K., Yamaguchi A., Shiba S., Katayama T., Yoshida K., Takada Y., Ishihara R., Ebinuma H., Sakamoto M., Kanai T.

Journal of Hepatology (Journal of Hepatology) 74 ( 3 ) 511 - 521 2021.03

ISSN 01688278

Background & Aims: The number of patients with non-alcoholic steatohepatitis (NASH) is increasing globally. Recently, specific chemokine receptors have garnered interest as therapeutic targets in NASH. This is the first report to examine the role of the C-C chemokine receptor 9 (CCR9)/C-C chemokine receptor ligand 25 (CCL25) axis, and to reveal its therapeutic potential in NASH. Methods: Patients with biopsy-proven non-alcoholic liver disease (NAFLD) were recruited and their serum and hepatic chemokine expression was examined. Furthermore, wild-type (WT) and Ccr9−/− mice were fed a high-fat high-cholesterol (HFHC) diet for 24 weeks to establish NASH. Results: Serum CCL25, and hepatic CCR9 and CCL25 expression levels were increased in patients with NASH compared to healthy volunteers. Furthermore, Ccr9−/− mice were protected from HFHC diet-induced NASH progression both serologically and histologically. Flow cytometry and immunohistochemistry analysis showed that CCR9+CD11b+ inflammatory macrophages accumulated in the inflamed livers of HFHC diet-fed mice, while the number was reduced in Ccr9−/− mice. Consistent with human NASH livers, CCR9 was also expressed on hepatic stellate cells (HSCs) in mice with NASH, while CCR9-deficient HSCs showed less fibrogenic potential in vitro. Administration of a CCR9 antagonist hampered further fibrosis progression in mice with NASH, supporting its potential clinical application. Finally, we showed that CCR9 blockade attenuated the development of NAFLD-related hepatocellular carcinoma in HF diet-fed mice injected with diethylnitrosamine. Conclusions: These results highlight the role of the CCR9/CCL25 axis on macrophage recruitment and fibrosis formation in a murine NASH model, providing new insights into therapeutic strategies for NASH. Lay summary: Herein, we show that a specific chemokine axis involving a receptor (CCR9) and its ligand (CCL25) contributes to the progression of non-alcoholic steatohepatitis and carcinogenesis in humans and mice. Furthermore, treatment with a CCR9 antagonist ameliorates the development of steatohepatitis and holds promise for the treatment of patients with non-alcoholic steatohepatitis.

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Endoscopic ultrasound-guided sampling for personalized pancreatic cancer treatment

Iwasaki E., Fukuhara S., Horibe M., Kawasaki S., Seino T., Takimoto Y., Tamagawa H., Machida Y., Kayashima A., Noda M., Hayashi H., Kanai T.

Diagnostics (Diagnostics) 11 ( 3 ) 2021.03

Pancreatic cancer is the most lethal solid malignancy, and the number of patients with pancreatic cancer is increasing. Systemic chemotherapies are often ineffective for such patients, and there is an urgent need for personalized medicine. Unlike other types of cancer, personalized treatments for pancreatic cancer are still in development. Consequently, pancreatic cancer is less sensitive to anticancer drugs and is often refractory to common treatments. Therefore, advances in personalized medicine for pancreatic cancer are necessary. This review examined advances in personalized medicine for pancreatic cancer, including the use of endoscopic ultrasound (EUS)-guided sampling. EUS-guided sampling is widely used for diagnosing pancreatic tumors and is expected to be applied to sampled tissues. Additionally, there has been an increase in clinical research using EUS-guided sampling. The combination of precision medicine using genomic testing and pharmacological profiles based on high-throughput drug sensitivity testing using patient-derived organoids is expected to revolutionize pancreatic cancer treatment.

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The entire intestinal tract surveillance using capsule endoscopy after immune checkpoint inhibitor administration: A prospective observational study

Shimozaki K., Hirata K., Horie S., Chida A., Tsugaru K., Hayashi Y., Kawasaki K., Miyanaga R., Hayashi H., Mizuno R., Funakoshi T., Hosoe N., Hamamoto Y., Kanai T.

Diagnostics (Diagnostics) 11 ( 3 ) 2021.03

Background: Despite the proven efficacy of immune checkpoint inhibitors (ICIs) against various types of malignancies, they have been found to induce immune-related adverse events, such as enterocolitis; however, the clinical features of ICI-induced enterocolitis remain to be sufficiently elucidated, which is significant, considering the importance of early detection in the appropriate management and treatment of ICI-induced enterocolitis. Therefore, the current study aimed to determine the utility of capsule endoscopy as a screening tool for ICI-induced enterocolitis. Methods: This single-center, prospective, observational study was conducted on patients with malignancy who received any ICI between April 2016 and July 2020 at Keio University Hospital. Next, second-generation capsule endoscopy (CCE-2) was performed on day 60 after ICI initiation to explore the entire gastrointestinal tract. Results: Among the 30 patients enrolled herein, 23 underwent CCE-2. Accordingly, a total of 23 findings were observed in 14 (60.8%) patients at any portion of the gastrointestinal tract (7 patients in the colon, 4 patients in the small intestine, 2 patients in both the colon and the small intestine, and 1 patient in the stomach). After capsule endoscopy, 2 patients (8.7%) developed ICI-induced enterocolitis: both had significantly higher Capsule Scoring of Ulcerative Colitis than those who had not developed ICI-induced enterocolitis (p = 0.0455). No adverse events related to CCE-2 were observed. Conclusions: CCE-2 might be a safe and useful entire intestinal tract screening method for the early detection of ICI-induced enterocolitis in patients with malignancies.

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Adrenomedullin for steroid-resistant ulcerative colitis: a randomized, double-blind, placebo-controlled phase-2a clinical trial

Kita T., Ashizuka S., Ohmiya N., Yamamoto T., Kanai T., Motoya S., Hirai F., Nakase H., Moriyama T., Nakamura M., Suzuki Y., Kanmura S., Kobayashi T., Ohi H., Nozaki R., Mitsuyama K., Yamamoto S., Inatsu H., Watanabe K., Hibi T., Kitamura K.

Journal of Gastroenterology (Journal of Gastroenterology) 56 ( 2 ) 147 - 157 2021.02

ISSN 09441174

Background: Adrenomedullin (AM) is a bioactive peptide having many pleiotropic effects, including mucosal healing and immunomodulation. AM has shown beneficial effects in rodent models and in preliminary study for patients with ulcerative colitis (UC). We performed a clinical trial to investigate the efficacy and safety of AM in patients with UC. Methods: This was a multi-center, double-blind, placebo-controlled phase-2a trial evaluating 28 patients in Japan with steroid-resistant UC. Patients were randomly assigned to four groups and given an infusion of 5, 10, 15 ng/kg/min of AM or placebo for 8 h per day for 14 days. The primary endpoint was the change in Mayo scores at 2 weeks. Main secondary endpoints included the change in Mayo scores and the rate of clinical remission at 8 weeks, defined as a Mayo score 0. Results: No differences in the primary or secondary endpoints were observed among the four groups at 2 weeks. Despite the insufficient tracking rate, the Mayo score at 8 weeks was only significantly decreased in the high-dose AM group (15 ng/kg/min) compared with the placebo group (− 9.3 ± 1.2 vs. − 3.0 ± 2.8, P = 0.035), with its rate of clinical remission at 8 weeks being significantly higher (3/3, 100% vs. 0/2, 0%, P = 0.025). We noted mild but no serious adverse events caused by the vasodilatory effect of AM. Conclusions: In this double-blind randomized trial, we observed the complete remission at 8 weeks in patients with steroid-resistant UC receiving a high dose of AM. Clinical trial registry: JAPIC clinical trials information; Japic CTI-205255 (200410115290). https://www.clinicaltrials.jp/cti-user/trial/Search.jsp.

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Wnt Signaling Shapes the Histologic Variation in Diffuse Gastric Cancer

Togasaki K., Sugimoto S., Ohta Y., Nanki K., Matano M., Takahashi S., Fujii M., Kanai T., Sato T.

Gastroenterology (Gastroenterology) 160 ( 3 ) 823 - 830 2021.02

ISSN 00165085

Background and Aims: Diffuse-type gastric cancer (GC) is currently subdivided into signet-ring cell carcinoma (SRCC) and non-SRCC, referred to as poorly cohesive carcinoma not otherwise specified (PCC-NOS). Although these subtypes are considered to be independent, they often coexist in the same tumors, raising a question of whether they clonally differ or not. To tackle this question, we established an experimental platform for human diffuse GC that enables accurate modeling of histologic subtypes. Methods: Seven patient-derived diffuse GC organoid lines were established, characterized by histopathologic analysis, in situ hybridization, and gene expression analysis. For genetic modeling of diffuse GC, we knocked out CDH1 and/or TP53 in human normal gastric organoids. Green fluorescent protein–labeled GC organoids were xenotransplanted into immune-deficient mice for in vivo assessment. Results: PCC-NOS organoids transformed into SRCC-like structures on removal of Wnt and R-spondin from the culture medium. This morphologic change paralleled downregulation of Wnt-target and gastric stem cell genes, including LGR5, and elevation of differentiation markers, such as KRT20 and MUCs. The association between Wnt target gene expression and histologic subtypes was confirmed in 3 patient-derived GC tissues. In vivo, single clone-derived organoids formed tumors that comprised 2 distinct histologic compartments, each corresponding to SRCC and PCC-NOS. The transition from PCC-NOS to SRCC histology reflected the abundance of surrounding R-spondin–expressing fibroblasts. Conclusions: SRCC and PCC-NOS were clonally identical, and their morphology was regulated by extracellular Wnt and R-spondin expression. Our results decoded how genetic mutations and the tumor environment shape pathohistologic and biologic phenotypes in human diffuse GCs.

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Ulcerative colitis exacerbation after the onset of immune checkpoint inhibitor related colitis

Kayashima A., Shimozaki K., Hirata K., Mutaguchi M., Takabayashi K., Hayashi Y., Hosoe N., Ogata H., Sujino T., Kanai T.

Clinical Journal of Gastroenterology (Clinical Journal of Gastroenterology) 14 ( 1 ) 152 - 158 2021.02

ISSN 18657257

Immune checkpoint inhibitors (ICPI) have been reported to be effective in various carcinomas. They excessively activate the immune system, resulting in frequent immune-related adverse events (irAEs). Colitis induced by ICPI is one of the most common and is known as immune-mediated colitis (IMC). Although IMC and inflammatory bowel disease (IBD) are similar in many respects, there are very few reports of IMC in patients with preexisting IBD such as ulcerative colitis (UC) and Crohn's disease (CD). Whether preexisting IBD is concerned with the development of the colitis is not well known. Here, we reported the case who developed severe ulcerative colitis which started from IMC. It is an important case to follow the time course of the colitis developed. Our conclusion indicated that frequent colonoscopy was important for the management of IMC in a patient who has suffered chronic inflammatory disease, such as UC.

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Significance of endoscopic deep small bowel evaluation using balloon-assisted enteroscopy for Crohn’s disease in clinical remission

Takabayashi K., Hosoe N., Kato M., Hayashi Y., Nanki K., Fukuhara K., Mikami Y., Mizuno S., Sujino T., Mutaguchi M., Naganuma M., Yahagi N., Ogata H., Kanai T.

Journal of Gastroenterology (Journal of Gastroenterology) 56 ( 1 ) 25 - 33 2021.01

ISSN 09441174

Background: Small bowel lesions of Crohn’s disease (CD) are known to be associated with a poor prognosis; however, endoscopic healing leads to favorable patients’ outcome. The aim of this study was to clarify the clinical impact of assessing deep small bowel lesions (DSB) using balloon-assisted enteroscopy (BAE) on CD patients in clinical remission. Methods: From January 2012 to July 2018, a total of 100 CD patients in clinical remission were enrolled to undergo trans-anal enteroscopy using single-balloon enteroscope. Endoscopic evaluations at the terminal ileum (TI) were performed using a partial Simple Endoscopic Score for CD (pSES-CD). Endoscopic evaluations at the DSB used a modified partial SES-CD (mpSES-CD). We evaluated the factors associated with relapse, and the correlation of endoscopic score between the TI and DSB. For this study, relapse was defined as hospitalization within a year from enteroscopy. Results: 30 patients (30.0%) relapsed within a year from enteroscopy. Multivariate logistic regression analysis revealed that the Harvey–Bradshaw Index (OR 1.77, 95% CI 1.18–2.65; p = 0.003) and an mpSES-CD at DSB (OR 3.10, 95% CI 1.86–5.15; p = 0.001) were independent predictors for relapse, whereas a SES-CD at the TI did not exhibit independence. There was a significant correlation trend between the relapse rate and greater than 5 points of an mpSES-CD at DSB; however, there was no correlation between the relapse rate and pSES-CD at the TI. Conclusion: Even when Crohn's disease is in remission, it is important to evaluate DSB using BAE to assess endoscopic mucosal healing.

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Various Endoscopic Features in Monomorphic Epitheliotropic Intestinal T-Cell Lymphoma

Aoki Y., Sujino T., Takabayashi K., Mutakuchi M., Emoto K., Hosoe N., Ogata H., Kanai T.

Case Reports in Gastroenterology (Case Reports in Gastroenterology) 15 ( 1 ) 312 - 322 2021.01

A 77-year-old female who had an acute severe abdominal pain was taken to the emergency room in the previous hospital. CT scans showed jejunum and ileum wall thickening and fatty deposits around the small intestinal tract, and gastrointestinal perforation could not be ruled out. By using single anal and oral balloon endoscopy, we observed mild edema with petechial erythema, shallow erosions with edematous mucosa and ulcers with surrounded disrupted villous structures at the jejunum and ileum. Histological analysis revealed atypical lymphocytes infiltrating the small intestinal mucosa demonstrating intraepithelial lymphocytosis. Immunohistochemical staining revealed that CD3, CD7, and CD56 staining was positive, and CD4, CD5, and CD8 staining was negative in infiltrated lymphocytes. We made the diagnosis of monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL) with the combination of HE staining and IHC. PET-CT showed abnormal uptake in irregular wall thickening of the small intestine, lymph nodes, ribs, spine and pelvic bone. She was treated with chemotherapy (etoposide, prednisolone, oncovin, cyclophosphamide, hydroxydaunorubicin) and is still alive 1 year after the diagnosis. We reported the various endoscopic findings in the same MEITL patient by using single balloon endoscopy. We also summarized endoscopic characteristics of MEITL patients.

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Underwater endoscopic mucosal resection for a sporadic adenoma located at severe longitudinal ulcer scars in ulcerative colitis

Takabayashi K., Kato M., Sasaki M., Iwao Y., Ogata H., Kanai T., Yahagi N.

Endoscopy (Endoscopy) 2021

ISSN 0013726X

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Week 2 Symptomatic Response with Vedolizumab as a Predictive Factor in Japanese Anti-TNFα-Naive Patients with Ulcerative Colitis: A post hoc Analysis of a Randomized, Placebo-Controlled Phase 3 Trial

Nagahori M., Watanabe K., Motoya S., Ogata H., Kanai T., Matsui T., Suzuki Y., Pinton P., Ursos L., Sakamoto S., Shikamura M., Hori T., Fernandez J., Hibi T., Watanabe M.

Digestion (Digestion) 2021

ISSN 00122823

Background and Aim: To evaluate the onset of symptomatic response with vedolizumab in patients with moderate-to-severe ulcerative colitis in Japan. Methods: Patients were randomized to receive vedolizumab 300 mg or placebo at Weeks 0, 2, and 6. Mayo subscores were analyzed in patients with baseline stool frequency (SF) ≥1 and rectal bleeding (RB) ≥1. In patients with baseline SF ≥2 and RB ≥1, the proportion who achieved SF ≤1 and RB = 0 was determined. Results: Patients were randomized to vedolizumab (n = 164) or placebo (n = 82). Decrease from baseline in mean SF subscore was greater with vedolizumab versus placebo from Week 2 (-6.6%; 95% confidence interval [CI], -16.2, 3.0), with a greater difference in anti-tumor necrosis factor (TNF)α-naive patients (vedolizumab vs. placebo, -13.2%; 95% CI, -29.7, 3.3). Mean percentage decrease from baseline RB subscore was numerically greater with vedolizumab versus placebo from Week 6 in anti-TNFα-naive patients (-10.7%; 95% CI, -33.0, 11.5). More patients in the anti-TNFα-naive subgroup achieved SF ≤1 and RB = 0 with vedolizumab versus placebo at Week 2 (14.8%; 95% CI, 2.5, 27.0) and Week 6 (20.3%; 95% CI, 4.4, 36.2). Patients with SF ≤1 and RB = 0 at Week 2 had higher clinical response, clinical remission, and mucosal healing rates at Week 10 than those without. Conclusions: Our results indicate that vedolizumab induces a rapid symptomatic response, particularly in anti-TNFα-naive patients, and suggest that early symptomatic improvement predicts treatment response at Week 10 (NCT02039505).

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Phase 1 study on the safety and efficacy of E6011, antifractalkine antibody, in patients with Crohn's disease

Matsuoka K., Naganuma M., Hibi T., Tsubouchi H., Oketani K., Katsurabara T., Hojo S., Takenaka O., Kawano T., Imai T., Kanai T.

Journal of Gastroenterology and Hepatology (Australia) (Journal of Gastroenterology and Hepatology (Australia)) 2021

ISSN 08159319

Background and Aim: E6011 is a humanized monoclonal antibody targeting fractalkine (FKN), a CX3C chemokine, which regulates leukocyte trafficking during inflammation. We evaluated the safety and pharmacokinetic profile of E6011 in patients with Crohn's disease (CD) and also performed preliminary pharmacodynamic (PD) and efficacy assessments. Methods: This study included a 12-week multiple ascending dose (MAD) phase (2, 5, 10, and 15 mg/kg intravenously every 2 weeks, n = 6, 8, 7, and 7, respectively) and a 40-week Extension phase (n = 12) at the same dose as the MAD phase. Serum E6011, serum total FKN (free soluble FKN and E6011-FKN complex) as a PD marker and CD activity index were evaluated. The primary outcome was safety assessment in the MAD phase. Results: Twenty-seven (96%) of 28 patients had previously been treated with anti-tumor necrosis factor α agents. During the MAD phase, adverse events (AEs) occurred in 18 (64%). The most common AE was nasopharyngitis (five patients, 18%). No severe AEs occurred. Serious AEs occurred in three patients, progression of CD in two, and anemia in one. Serum E6011 concentrations increased dose-dependently after infusion and reached a plateau around 4–6 weeks. Serum total FKN rose simultaneously. Five (18%) patients developed anti-E6011 antibodies during the study. Overall, clinical response and clinical remission were observed at Week 12 in 40% (10/25) and 16% (4/25) of active CD patients, respectively. Conclusion: E6011 was well-tolerated and might be effective in CD patients. These findings need to be clarified in a randomized controlled study.

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Predictors of necessity for endoscopic balloon dilatation in patients with Crohn’s disease-related small bowel stenosis

Hayashi Y., Takabayashi K., Hosoe N., Kiyohara H., Kinoshita S., Nanki K., Fukuhara K., Mikami Y., Sujino T., Mutaguchi M., Kawaguchi T., Kato M., Ogata H., Kanai T.

Annals of Medicine (Annals of Medicine) 53 ( 1 ) 2025 - 2033 2021

ISSN 07853890

Background and Aim: In patients with Crohn’s disease (CD) and small bowel stenosis, endoscopic balloon dilation (EBD) is considered to be useful in improving stenotic symptoms and avoiding surgery. However, it carries risks such as bleeding and perforation. The aim of this study was to identify the indications for endoscopic intervention in patients with CD and small bowel stenosis. Methods: From November 2007 to March 2020, 143 CD patients with small bowel stenosis were enrolled in this study. We identified the factors associated with not requiring endoscopic intervention during long-term follow-up of these patients. Results: Forty of the 143 patients had abdominal symptoms of stenosis and had undergone EBD, whereas the remaining 103 were asymptomatic and had not undergone endoscopic intervention. During long-term follow-up, 95 of those 103 patients never required endoscopic or surgical intervention. Multivariate logistic regression analysis revealed that not consuming an elemental diet (OR 3.18, 95% CI 1.48–6.82; p <.01) and ileocecal valve (ICV) stenosis (OR 0.30, 95% CI 0.11–0.83; p =.02) were independently associated with not requiring EBD. The cumulative emergency hospitalisation-free rate also tended to be higher in patients not consuming an elemental diet or with ICV stenosis. Conclusions: Two factors, namely not consuming an elemental diet and ICV stenosis, predict a long-term intervention-free prognosis in CD patients with small bowel stenosis.Key messages When an endoscopically impassable small bowel stenosis is found in a CD patient, long-term follow-up without endoscopic intervention may be possible if the patient is asymptomatic, is not using an elemental diet, and the stenosis is ICV.

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Effect of physician-prescribed nalmefene on alcohol intake reduction in patients with alcohol-related liver disease

Hone Y., Taniki N., Chu P.S., Nakamoto N., Kanai T.

Acta Hepatologica Japonica (Acta Hepatologica Japonica) 62 ( 10 ) 620 - 629 2021

ISSN 04514203

A brief intervention is often effective for patients with mild alcohol use disorder (AUD), but it is not effective for most patients with severe AUD or alcohol dependence to reduce alcohol intake. Nalmefene (Selincro®), an opioid receptor modulator, was approved in Japan in 2019. Nalmefene was administered to 18 outpatients with alcohol-related liver diseases. Five patients stopped coming to the hospital without notice, and two patients stopped taking medicine due to dizziness. Thus, 11 patients were noted to have reduced amount of alcohol intake at 24 weeks of using nalmefene. However, one of these patients was referred to a hospital specializing in alcohol dependence thereafter. Thus, the use of nalmefene provides a new concept for AUD treatment (i. e., alcohol intake reduction). However, some adverse events are noted, such as nausea and dizziness. Therefore, physicians with more experience with AUD treatment should use the drugma.

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Polar functional group-containing glycolipid CD1d ligands modulate cytokine-biasing responses and prevent experimental colitis

Inuki S., Hirata N., Kashiwabara E., Kishi J., Aiba T., Teratani T., Nakamura W., Kojima Y., Maruyama T., Kanai T., Fujimoto Y.

Scientific Reports (Scientific Reports) 10 ( 1 ) 2020.12

The MHC class I-like molecule CD1d is a nonpolymorphic antigen-presenting glycoprotein, and its ligands include glycolipids, such as α-GalCer. The complexes between CD1d and ligands activate natural killer T cells by T cell receptor recognition, leading to the secretion of various cytokines (IFN-γ, IL-4, IL-17A, etc.). Herein, we report structure–activity relationship studies of α-GalCer derivatives containing various functional groups in their lipid acyl chains. Several derivatives have been identified as potent CD1d ligands displaying higher cytokine induction levels and/or unique cytokine polarization. The studies also indicated that flexibility of the lipid moiety can affect the binding affinity, the total cytokine production level and/or cytokine biasing. Based on our immunological evaluation and investigation of physicochemical properties, we chose bisamide- and Bz amide-containing derivatives 2 and 3, and evaluated their in vivo efficacy in a DSS-induced model of ulcerative colitis. The derivative 3 that exhibits Th2- and Th17-biasing responses, demonstrated significant protective effects against intestinal inflammation in the DSS-induced model, after a single intraperitoneal injection.

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Late-onset acute liver failure due to Wilson’s disease managed by plasmapheresis and hemodiafiltration successfully serving as a bridge for deceased donor liver transplantation: a case report and literature review

Sukezaki A., Chu P.s., Shinoda M., Hibi T., Taniki N., Yoshida A., Kawaida M., Hori S., Morikawa R., Kurokouchi A., Wakino S., Kameyama K., Obara H., Kitagawa Y., Saito H., Kanai T., Nakamoto N.

Clinical Journal of Gastroenterology (Clinical Journal of Gastroenterology) 13 ( 6 ) 1239 - 1246 2020.12

ISSN 18657257

Late-onset acute liver failure due to Wilson’s disease (WD-ALF) is rare. A 44-year-old female patient presenting acute hepatic decompensation with extreme coagulopathy was transferred to our hospital for evaluation for liver transplantation (LT). Alveolar hemorrhage and Coombs-negative acute hemolysis occurred during workup. Mechanical ventilation, plasmapheresis, and hemodiafiltration with zinc and chelation were started immediately before placing the patient on the waitlist for deceased donor LT (DDLT), with a tentative diagnosis of WD-ALF using the Leipzig score and quick diagnostic criteria suggested by the Acute Liver Failure Study Group Registry. The peak MELD score was 40, and the revised version of King’s score for WD was 13. Serum free copper levels and the patient’s overall general condition were stabilized with artificial support systems, although triphasic wave on electroencephalogram and liver atrophy were noted. She successfully underwent emergent DDLT approximately 2 weeks after suffering from acute hemolysis and survived. The genetic tests confirmed mutations at 2 loci in the ATP7B gene and, therefore, the diagnosis of WD. This is the first and oldest patient reported in Japan to present late-onset WD-ALF that was successfully treated with emergent DDLT.

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Moderate alcohol consumption is not associated with subclinical cardiovascular damage but with hepatic fibrosis in non-alcoholic fatty liver disease

Kashiwagi K., Yamaguchi A., Shiba S., Taniki N., Inoue N., Takaishi H., Iwao Y., Kanai T.

Alcohol (Alcohol) 89 1 - 7 2020.12

ISSN 07418329

Background: Moderate alcohol consumption is believed to be associated with reduced mortality from cardiovascular disease (CVD) in the general population. This cross-sectional study aimed to comprehensively examine the association between alcohol consumption and subclinical cardiovascular damage or hepatic fibrosis in non-alcoholic fatty liver disease (NAFLD). Methods: Subjects with NAFLD without a history of heart disease were extracted from 977 consecutive examinees who completed health checkups and optional cardiovascular examinations. Subclinical cardiovascular damage was assessed by coronary artery calcification (CAC), carotid artery ultrasound, and brachial-ankle pulse wave velocity (ba-PWV). CAC scores were classified into three grades (0, ≤100, and >100) by Agatston's method. Alcohol consumption was divided into three groups [Non-drinking (G0); Light (G1), 0.1–6.9 drinks/week; Moderate (G2), 7–20.9 drinks/week for men and 7–13.9 drinks/week for women]. Noninvasive markers (FIB-4, Fibrosis-4; NFS, NAFLD fibrosis score) were calculated for assessment of hepatic fibrosis and classified into low and intermediate-high grade. Results: The overall mean age was 60.2 years and males were 200 (74.6%) among 268 subjects with NAFLD. Number (%) of G0, G1, and G2 were 102 (38.1%), 103 (38.4%), and 63 (23.5%). Binary logistic regression analysis showed no significant difference between G0 and G1, or G0 and G2 in any of the above subclinical cardiovascular damages (CAC score >0, or CAC score >100, carotid plaque +, intima-media thickness ≥1.1 mm, and ba-PWV >1400 cm/s). However, only G2 had a significant association with intermediate-high grade of FIB-4 or NFS [odds ratio (95% confidence intervals), p value: 1.871 (1.209–2.893), p = 0.005; 2.910 (1.715–4.939), p = 0.000], compared to G0. Conclusions: Non-heavy drinking might not reduce the risk of CVD in NAFLD subjects. On the contrary, even moderate drinking could promote hepatic fibrosis. Thus, NAFLD drinkers should not be recommended for even a moderate amount of alcohol.

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An Organoid Biobank of Neuroendocrine Neoplasms Enables Genotype-Phenotype Mapping

Kawasaki K., Toshimitsu K., Matano M., Fujita M., Fujii M., Togasaki K., Ebisudani T., Shimokawa M., Takano A., Takahashi S., Ohta Y., Nanki K., Igarashi R., Ishimaru K., Ishida H., Sukawa Y., Sugimoto S., Saito Y., Maejima K., Sasagawa S., Lee H., Kim H.G., Ha K., Hamamoto J., Fukunaga K., Maekawa A., Tanabe M., Ishihara S., Hamamoto Y., Yasuda H., Sekine S., Kudo A., Kitagawa Y., Kanai T., Nakagawa H., Sato T.

Cell (Cell) 183 ( 5 ) 1420 - 1435.e21 2020.11

ISSN 00928674

Gastroenteropancreatic (GEP) neuroendocrine neoplasm (NEN) that consists of neuroendocrine tumor and neuroendocrine carcinoma (NEC) is a lethal but under-investigated disease owing to its rarity. To fill the scarcity of clinically relevant models of GEP-NEN, we here established 25 lines of NEN organoids and performed their comprehensive molecular characterization. GEP-NEN organoids recapitulated pathohistological and functional phenotypes of the original tumors. Whole-genome sequencing revealed frequent genetic alterations in TP53 and RB1 in GEP-NECs, and characteristic chromosome-wide loss of heterozygosity in GEP-NENs. Transcriptome analysis identified molecular subtypes that are distinguished by the expression of distinct transcription factors. GEP-NEN organoids gained independence from the stem cell niche irrespective of genetic mutations. Compound knockout of TP53 and RB1, together with overexpression of key transcription factors, conferred on the normal colonic epithelium phenotypes that are compatible with GEP-NEN biology. Altogether, our study not only provides genetic understanding of GEP-NEN, but also connects its genetics and biological phenotypes. Gastroenteropancreatic neuroendocrine neoplasms are a rare but lethal cancer with a scarcity of clinically relevant models. Kawasaki et al. establish and characterize 25 organoid lines to identify molecular subtypes with genotype-phenotype mapping.

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Mucosal concentrations of N-acetyl-5-aminosalicylic acid related to endoscopic activity in ulcerative colitis patients with mesalamine

Fukuda T., Naganuma M., Takabayashi K., Hagihara Y., Tanemoto S., Nomura E., Yoshimatsu Y., Sugimoto S., Nanki K., Mizuno S., Mikami Y., Fukuhara K., Sujino T., Mutaguchi M., Inoue N., Ogata H., Iwao Y., Abe T., Kanai T.

Journal of Gastroenterology and Hepatology (Australia) (Journal of Gastroenterology and Hepatology (Australia)) 35 ( 11 ) 1878 - 1885 2020.11

ISSN 08159319

Background and Aim: 5-Aminosalicylic acid (5-ASA) is a fundamental treatment for mild-to-moderate ulcerative colitis (UC). 5-ASA is taken up into the colonic mucosa and metabolized to N-acetyl-5-ASA (Ac-5-ASA). Few studies have assessed whether mucosal 5-ASA and Ac-5-ASA concentrations are associated with endoscopic remission. This study aimed to investigate differences in 5-ASA and Ac-5-ASA concentrations according to endoscopic activity. Methods: This single-center, prospective, cross-sectional study was conducted between March 2018 and February 2019. UC patients who were administered with 5-ASA medication for at least 8 weeks before sigmoidoscopy were enrolled. Mucosal 5-ASA and Ac-5-ASA concentrations were measured using liquid chromatography with tandem mass spectrometry. The primary endpoint was defined as the difference in mucosal concentrations of 5-ASA and Ac-5-ASA, according to the Mayo endoscopic subscore (MES). Results: Mucosal concentrations were analyzed in 50 patients. In the sigmoid colon, the median 5-ASA concentration in patients with MES of 0 (17.3 ng/mg) was significantly higher than MES ≥ 1 (6.4 ng/mg) (P = 0.019). The median 5-ASA concentrations in patients with Ulcerative Colitis Endoscopic Index of Severity ≤ 1 (16.4 ng/mg) were also significantly higher than in patients with Ulcerative Colitis Endoscopic Index of Severity ≥ 2 (4.63 ng/mg) (P = 0.047). In the sigmoid colon, the concentration of Ac-5-ASA was higher in patients with MES of 0 (21.2 ng/mg) than in patients with MES ≥ 1 (5.81 ng/mg) (P = 0.022). Conclusions: The present study showed that mucosal Ac-5-ASA concentrations, as well as 5-ASA concentrations, are higher in UC patients with endoscopic remission. Ac-5-ASA may be useful for a biomarker of 5-ASA efficacy.

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The liver–brain–gut neural arc maintains the T<inf>reg</inf> cell niche in the gut

Teratani T., Mikami Y., Nakamoto N., Suzuki T., Harada Y., Okabayashi K., Hagihara Y., Taniki N., Kohno K., Shibata S., Miyamoto K., Ishigame H., Chu P.S., Sujino T., Suda W., Hattori M., Matsui M., Okada T., Okano H., Inoue M., Yada T., Kitagawa Y., Yoshimura A., Tanida M., Tsuda M., Iwasaki Y., Kanai T.

Nature (Nature) 585 ( 7826 ) 591 - 596 2020.09

ISSN 00280836

Recent clinical and experimental evidence has evoked the concept of the gut–brain axis to explain mutual interactions between the central nervous system and gut microbiota that are closely associated with the bidirectional effects of inflammatory bowel disease and central nervous system disorders1–4. Despite recent advances in our understanding of neuroimmune interactions, it remains unclear how the gut and brain communicate to maintain gut immune homeostasis, including in the induction and maintenance of peripheral regulatory T cells (pTreg cells), and what environmental cues prompt the host to protect itself from development of inflammatory bowel diseases. Here we report a liver–brain–gut neural arc that ensures the proper differentiation and maintenance of pTreg cells in the gut. The hepatic vagal sensory afferent nerves are responsible for indirectly sensing the gut microenvironment and relaying the sensory inputs to the nucleus tractus solitarius of the brainstem, and ultimately to the vagal parasympathetic nerves and enteric neurons. Surgical and chemical perturbation of the vagal sensory afferents at the hepatic afferent level reduced the abundance of colonic pTreg cells; this was attributed to decreased aldehyde dehydrogenase (ALDH) expression and retinoic acid synthesis by intestinal antigen-presenting cells. Activation of muscarinic acetylcholine receptors directly induced ALDH gene expression in both human and mouse colonic antigen-presenting cells, whereas genetic ablation of these receptors abolished the stimulation of antigen-presenting cells in vitro. Disruption of left vagal sensory afferents from the liver to the brainstem in mouse models of colitis reduced the colonic pTreg cell pool, resulting in increased susceptibility to colitis. These results demonstrate that the novel vago-vagal liver–brain–gut reflex arc controls the number of pTreg cells and maintains gut homeostasis. Intervention in this autonomic feedback feedforward system could help in the development of therapeutic strategies to treat or prevent immunological disorders of the gut.

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Clinical features of cardiac nodularity-like appearance induced by Helicobacter pylori infection

Nishizawa T., Sakitani K., Yoshida S., Kataoka Y., Toyoshima O., Ebinuma H., Suzuki H., Nakai Y., Koike K., Kanai T.

World Journal of Gastroenterology (World Journal of Gastroenterology) 26 ( 35 ) 5354 - 5361 2020.09

ISSN 10079327

Background: We have previously reported that Helicobacter pylori (H. pylori)-associated nodular gastritis could occur in both the antrum and the cardia. Cardiac nodularity-like appearance (hereafter, called as cardiac nodularity) had a high predictive accuracy for the diagnosis of H. pylori infection. In the previous study, we included only the patients who were evaluated for H. pylori infection for the first time, and excluded patients with a history of eradication. Therefore, the prevalence and clinical features of cardiac nodularity remains unknown. Aim: To perform this cross-sectional study to explore the characteristics of cardiac nodularity. Methods: Consecutive patients who underwent esophagogastroduodenoscopy between May, 2017 and August, 2019 in the Toyoshima Endoscopy Clinic were enrolled in this study. We included H. pylori-negative, H. pylori-positive, and H. pylorieradicated patients, and excluded patients with unclear H. pylori status and eradication failure. H. pylori infection was diagnosed according to serum anti-H. pylori antibody and the urea breath test or histology. Cardiac nodularity was defined as a miliary nodular appearance or the presence of scattered whitish circular small colorations within 2 cm of the esophagogastric junction. Nodularity was visualized as whitish in the narrow-band imaging mode. We collected data on the patients' baseline characteristics. Results: A total of 1078 patients were finally included. Among H. pylori-negative patients, cardiac nodularity and antral nodularity were recognized in 0.14% each. Among H. pylori-positive patients, cardiac nodularity and antral nodularity were recognized in 54.5% and 29.5%, respectively. Among H. pylori-eradicated patients, cardiac nodularity and antral nodularity were recognized in 4.5% and 0.6%, respectively. The frequency of cardiac nodularity was significantly higher than that of antral nodularity in H. pylori-positive and -eradicated patients. The frequencies of cardiac nodularity and antral nodularity in H. pylori-eradicated patients were significantly lower than those in H. pylori-positive patients (P < 0.001). The patients with cardiac nodularity were significantly younger than those without cardiac nodularity (P = 0.0013). Intestinal metaplasia score of the patients with cardiac nodularity were significantly lower than those without cardiac nodularity (P = 0.0216). Among H. pylori-eradicated patients, the patients with cardiac nodularity underwent eradication significantly more recently compared with those without cardiac nodularity (P < 0.0001). Conclusion: This report outlines the prevalence and clinical features of cardiac nodularity, and confirm its close association with active H. pylori infection.

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Horibe GI bleeding prediction score: a simple score for triage decision-making in patients with suspected upper GI bleeding

Horibe M., Iwasaki E., Bazerbachi F., Kaneko T., Matsuzaki J., Minami K., Masaoka T., Hosoe N., Ogura Y., Namiki S., Hosoda Y., Ogata H., Chan A.T., Kanai T.

Gastrointestinal Endoscopy (Gastrointestinal Endoscopy) 92 ( 3 ) 578 - 588.e4 2020.09

ISSN 00165107

Background and Aims: Although upper GI bleeding (UGIB) is a significant cause of inpatient admissions, no scoring method has proven to be accurate and simple as a standard for triage purposes. Therefore, we compared a previously described 3-variable score (1 point each for absence of daily proton pump inhibitor use in the week before the index presentation, shock index [heart rate/systolic blood pressure] ≥1, and blood urea nitrogen/creatinine ≥30 [urea/creatinine≥140]), the Horibe gAstRointestinal BleedING scoRe (HARBINGER), with the 8-variable Glasgow-Blatchford Score (GBS) and 5-variable AIMS65 to evaluate and validate the accuracy in predicting high-risk features that warrant admission and urgent endoscopy. Methods: Consecutive patients presenting with suspected UGIB between 2012 and 2015 were prospectively enrolled in 3 acute care Japanese hospitals. On presentation to the emergency setting, an endoscopy was performed in a timely fashion. The primary outcome was the prediction of high-risk endoscopic stigmata. Results: Of 1486 enrolled patients, 637 (43%) harbored high-risk endoscopic stigmata according to international consensus statements. The area under the receiver operating characteristic curve (AUC) for the HARBINGER was.76 (95% confidence interval [CI],.72-.79), which was significantly superior to both the GBS (AUC,.68; 95% CI,.64-.71; P <.001) and the AIMS65 (AUC,.54; 95% CI,.50-.58; P <.001). When the HARBINGER cutoff value was set at 1 to rule out patients who needed admission and urgent endoscopy, its sensitivity and specificity was 98.8% (95% CI, 97.9-99.6) and 15.5% (95% CI, 13.1-18.0), respectively. Conclusions: The HARBINGER, a simple 3-variable score, provides a more accurate method for triage of patients with suspected UGIB than both the GBS and AIMS65.

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Efficacy of novel ultrathin single-balloon enteroscopy for Crohn's disease: A propensity score-matched study

Takabayashi K., Hosoe N., Kato M., Hayashi Y., Miyanaga R., Nanki K., Fukuhara K., Mikami Y., Mizuno S., Sujino T., Mutaguchi M., Naganuma M., Yahagi N., Ogata H., Kanai T.

Gut and Liver (Gut and Liver) 14 ( 5 ) 619 - 625 2020.09

ISSN 19762283

Background/Aims: The evaluation of small bowel lesions of Crohn's disease (CD) using balloon-assisted enteroscopy (BAE) is crucial because mucosal healing is associated with a good prognosis. However, BAE procedures are invasive, requiring sedation or analgesia to reduce the patient's pain. This study evaluated the clinical usefulness of a novel ultrathin single-balloon enteroscopy (SBE) procedure for CD. Methods: This single-center retrospective study included 102 CD patients who underwent trans-anal SBE between January 2012 and May 2018. Of these patients, 82 underwent enteroscopy using conventional SBE, while 20 underwent ultrathin SBE. Patients were analyzed using propensity score matching, with 20 patients per group. The median duration of the examination, terminal ileum intubation rate, median cecum intubation time, median insertion depth, adverse events, and sedated dose in each group were compared. Results: Before propensity score matching, the conventional SBE group had a larger number of surgical history patients than the ultrathin SBE group (p=0.05). After matching, the two groups did not significantly differ clinically. There were no significant differences in the mean duration of the examination, cecum intubation time, or terminal ileal intubation rate between ultrathin SBE and conventional SBE. The mean insertion depth of ultrathin SBE tended to be deeper than that of conventional SBE (p=0.09). The use of ultrathin SBE also reduced the sedative dose during needed for enteroscopy compared with conventional SBE (p=0.005). Conclusions: Novel ultrathin SBE may be less painful for CD patients than conventional SBE.

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Redox-dependent PPARγ/Tnpo1 complex formation enhances PPARγ nuclear localization and signaling

Teratani T., Tomita K., Toma-Fukai S., Nakamura Y., Itoh T., Shimizu H., Shiraishi Y., Sugihara N., Higashiyama M., Shimizu T., Inoue I., Takenaka Y., Hokari R., Adachi T., Shimizu T., Miura S., Kanai T.

Free Radical Biology and Medicine (Free Radical Biology and Medicine) 156 45 - 56 2020.08

ISSN 08915849

The nuclear receptor peroxisome proliferator-activated receptor (PPAR)γ has been implicated in the pathogenesis of various human diseases including fatty liver. Although nuclear translocation of PPARγ plays an important role in PPARγ signaling, details of the translocation mechanisms have not been elucidated. Here we demonstrate that PPARγ2 translocates to the nucleus and activates signal transduction through H2O2-dependent formation of a PPARγ2 and transportin (Tnpo)1 complex via redox-sensitive disulfide bonds between cysteine (Cys)176 and Cys180 of the former and Cys512 of the latter. Using hepatocyte cultures and mouse models, we show that cytosolic H2O2/Tnpo1-dependent nuclear translocation enhances the amount of DNA-bound PPARγ and downstream signaling, leading to triglyceride accumulation in hepatocytes and liver. These findings expand our understanding of the mechanism underlying the nuclear translocation of PPARγ, and suggest that the PPARγ and Tnpo1 complex and surrounding redox environment are potential therapeutic targets in the treatment of PPARγ-related diseases.

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A significant association of non-obese non-alcoholic fatty liver disease with sarcopenic obesity

Kashiwagi K., Takayama M., Fukuhara K., Shimizu-Hirota R., Chu P.S., Nakamoto N., Inoue N., Iwao Y., Kanai T.

Clinical Nutrition ESPEN (Clinical Nutrition ESPEN) 38 86 - 93 2020.08

ISSN 24054577

Background & aims: Non-alcoholic fatty liver disease (NAFLD) is significantly related to sarcopenia as well as obesity and its associated comorbidities. This cross-sectional study aims to examine the association between four body composition phenotypes (standard, obesity alone, sarcopenia alone, sarcopenic obesity) and non-obese NAFLD, or obese NAFLD. Methods: Reduced muscle mass and high percentage of body fat mass was measured by dual-energy x-ray absorptiometry, and body composition phenotypes were determined, according to Asian criteria for sarcopenia. Based on body mass index (BMI) cut-off point (25 kg/m2) and hepatic steatosis on ultrasound, 748 subjects who underwent a health checkup were enrolled and divided into three groups: non-obese NAFLD, obese NAFLD, and no steatosis. Results: Of 563 subjects (64.1 ± 13.0 years) without secondary causes for steatosis, the overall prevalence of non-obese NAFLD and obese NAFLD were 17% and 16%, respectively. The former prevalence remained relatively constant at around 20% from the 50s to 80's, while the proportion of sarcopenic obesity in all subjects increased gradually with age, reaching 18% in the 80's. Multivariate analysis demonstrated a significant association between sarcopenic obesity and non-obese NAFLD after adjusting for confounders (odds ratio = 2.367, 95% confidence interval = 1.317–4.254, P = 0.004). On the other hand, no significant association was found between obesity alone and obese NAFLD, when BMI and visceral adipose tissue were added as confounders, although 91% of obese NAFLD was included in obesity alone phenotype. Conclusion: Non-obese NAFLD had a significant association with sarcopenic obesity, independent of metabolic confounders. Early treatment intervention for non-obese NAFLD could suppress the deterioration of sarcopenic obesity because non-obese NAFLD might be a risk factor for sarcopenic obesity.

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Development of a Scalable Coculture System for Gut Anaerobes and Human Colon Epithelium

Sasaki N., Miyamoto K., Maslowski K.M., Ohno H., Kanai T., Sato T.

Gastroenterology (Gastroenterology) 159 ( 1 ) 388 - 390.e5 2020.07

ISSN 00165085

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Landscape and function of multiple mutations within individual oncogenes

Saito Y., Koya J., Araki M., Kogure Y., Shingaki S., Tabata M., McClure M.B., Yoshifuji K., Matsumoto S., Isaka Y., Tanaka H., Kanai T., Miyano S., Shiraishi Y., Okuno Y., Kataoka K.

Nature (Nature) 582 ( 7810 ) 95 - 99 2020.06

ISSN 00280836

Sporadic reports have described cancer cases in which multiple driver mutations (MMs) occur in the same oncogene1,2. However, the overall landscape and relevance of MMs remain elusive. Here we carried out a pan-cancer analysis of 60,954 cancer samples, and identified 14 pan-cancer and 6 cancer-type-specific oncogenes in which MMs occur more frequently than expected: 9% of samples with at least one mutation in these genes harboured MMs. In various oncogenes, MMs are preferentially present in cis and show markedly different mutational patterns compared with single mutations in terms of type (missense mutations versus in-frame indels), position and amino-acid substitution, suggesting a cis-acting effect on mutational selection. MMs show an overrepresentation of functionally weak, infrequent mutations, which confer enhanced oncogenicity in combination. Cells with MMs in the PIK3CA and NOTCH1 genes exhibit stronger dependencies on the mutated genes themselves, enhanced downstream signalling activation and/or greater sensitivity to inhibitory drugs than those with single mutations. Together oncogenic MMs are a relatively common driver event, providing the underlying mechanism for clonal selection of suboptimal mutations that are individually rare but collectively account for a substantial proportion of oncogenic mutations.

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Efficacy and safety of immediate oral intake in patients with mild acute pancreatitis: A randomized controlled trial

Horibe M., Iwasaki E., Nakagawa A., Matsuzaki J., Minami K., Machida Y., Tamagawa H., Takimoto Y., Ueda M., Katayama T., Kawasaki S., Matsushita M., Seino T., Fukuhara S., Kanai T.

Nutrition (Nutrition) 74 2020.06

ISSN 08999007

Objectives: Early enteral nutrition is recommended for patients with severe acute pancreatitis (AP); however, nutritional management strategies for patients with mild AP have not been established. The aim of this study was to evaluate the benefits and safety of immediate oral intake of low-fat solid food in patients with mild AP who were allowed to take opioid analgesics. Methods: In this single-center randomized study, the immediate feeding (IMF) group was permitted immediate oral intake of low-fat (15 g/d) solid food. In the standard food (STF) group, patients received gradually increasing amounts of dietary fat. Twenty-six patients were randomized, with 13 allocated to each group. The primary outcome was the period between diagnosis and recovery from AP. The cost and rate of progression to severe disease were evaluated as secondary outcomes. Results: The IMF group (mean recovery days: 2 ± 1) recovered significantly earlier (mean difference in recovery days: 6.3; 95% confidence interval [CI], 4.8–7.9; P < 0.001) than the STF group (mean recovery days: 8.3 ± 2.3), with a lower overall treatment cost (mean difference in costs: −$460; 95% CI, −$880 to –$40; P = 0.034). The IMF group showed a lower rate of progression to severe AP (IMF, 0%; STF, 15.3%; P = 0.48). Conclusion: The initial treatment strategy for mild AP should be altered from the gradual introduction of oral feeding upon the absence of pain to immediate oral nutrition with opioid analgesics, to improve treatment efficacy and reduce treatment cost.

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Significance of Conducting 2 Types of Fecal Tests in Patients With Ulcerative Colitis

Naganuma M., Kobayashi T., Nasuno M., Motoya S., Kato S., Matsuoka K., Hokari R., Watanabe C., Sakamoto H., Yamamoto H., Sasaki M., Watanabe K., Iijima H., Endo Y., Ichikawa H., Ozeki K., Tanida S., Ueno N., Fujiya M., Sako M., Takeuchi K., Sugimoto S., Abe T., Hibi T., Suzuki Y., Kanai T.

Clinical Gastroenterology and Hepatology (Clinical Gastroenterology and Hepatology) 18 ( 5 ) 1102 - 1111.e5 2020.05

ISSN 15423565

Background & Aims: We compared the diagnostic accuracy of the fecal calprotectin (FCP) test vs the fecal immunochemical blood test (FIT) in determining the endoscopic severity and predicting outcomes of patients with ulcerative colitis (UC). Methods: We performed a nationwide study of 879 patients with UC, enrolled at medical centers across Japan, from March 2015 to March 2017. We collected data on fecal biomarkers, endoscopic severities, and other clinical indices from Cohort 1 (n = 427) and assessed the diagnostic accuracy of FCP measurement and FIT results in determining clinical severity, based on Mayo score, and endoscopic remission, based on Mayo endoscopic sub-score (MES) or UC endoscopic index of severity. We also followed 452 patients in clinical remission from UC (Cohort 2) for 12 months and evaluated the associations of FCP levels and FIT results with clinical recurrence. Results: The levels of FCP and FIT each correlated with the MES and UC endoscopic index of severity. There were no significant differences in the areas under the curve of FCP vs FIT in distinguishing patients with MES≤1 from those with MES≥2 (P = .394) or in distinguishing patients with MES=0 from those with MES≥1 (P = .178). Among 405 patients in clinical remission at baseline, 38 (9.4%) had UC recurrences within 3 months and 90 (22.2%) had recurrences within 12 months. FCP≥146 mg/kg (hazard ratio [HR], 4.83; 95% confidence interval [CI], 2.80-8.33) and FIT≥77 ng/mL (HR, 2.92; 95% CI, 1.76-4.83) were independently associated with clinical recurrence within 12 months. UC recurred within 12 months in 69% of patients with levels of FCP≥146 mg/kg and FIT ≥77 ng/mL; this value was significantly higher than the rate of recurrence in patients with levels of FCP≥146 mg/kg and FIT <77 ng/mL (31.5%, P < .001) or patients with levels of FCP<146 mg/kg and FIT ≥77 ng/mL (30.0%, P < .001). Conclusion: In a nationwide study of patients with UC in Japan, we found that the level of FCP and FIT could each identify patients with endoscopic markers of disease severity (MES≥2). The combination of FCP and FIT results can identify patients in remission who are at risk for disease recurrence. Clinical Trials Registry no: UMIN000017650 (http://www.umin.ac.jp/ctr/)

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ラジオ波焼灼療法により良好な病勢制御が得られたトロトラスト沈着症による肝内胆管癌の一例

谷木信仁, 中本伸宏, 吉田文, ちょ柏松, 伊倉顕彦, 山高果林, 森川麗, 志波俊輔, 山口晃弘, 碓井真吾, 尾城啓輔, 海老沼浩利, 斎藤英胤, 久保田直人, 眞杉洋平, 坂元亨宇, 金井隆典

肝臓 ((一社)日本肝臓学会) 61 ( 5 ) 262 - 269 2020.05

ISSN 0451-4203

症例は87歳男性。検診で増大する肝腫瘤を指摘され当科紹介受診となった。画像所見から肝内胆管癌を含む肝原発悪性腫瘍が疑われたが、胆管浸潤を示唆する所見はなく、高齢で基礎疾患を多数有するため、ラジオ波焼灼療法(RFA:radiofrequency ablation)を行なった。治療時に施行した腫瘍生検の結果、肝内胆管癌と診断されたが、同時に採取された背景肝に1930-50年にかけて使用された造影剤であるトロトラストの沈着が疑われた。再発病変に対して2度RFAを施行し、初回治療後約3年間病勢が制御されている。今回我々は、RFAにより良好な病勢制御が得られたトロトラスト沈着症による肝内胆管癌の一例を経験した。トロトラスト晩発障害による発癌症例は肝内多中心性の発癌様式を示すため、本症例のように高齢で耐術能の低い胆管細胞癌症例においては、RFAなどの局所療法が有用な治療選択肢となりうると考えられた。(著者抄録)

Efficacy of apheresis as maintenance therapy for patients with ulcerative colitis in an open-label prospective multicenter randomised controlled trial

Naganuma M., Yokoyama Y., Motoya S., Watanabe K., Sawada K., Hirai F., Yamamoto T., Hanai H., Omori T., Kanai T., Hibi T., Naganuma M., Sugimoto S., Nanki K., Mizuno S., Ogata H., Nagase K., Nakamura S., Tanaka H., Nasuno M., Miyagawa M., Shimoyama T., Ikeya K., Itoh A., Yokoyama K., Mitsuyama K., Yamazaki H., Sakata Y., Yoshimura N., Shirai T., Suzuki Y., Matsuura M., Tanaka S., Hayashi K., Ueno Y., Sakemi R., Ishiguro Y., Yoshida A., Endo Y., Yamagami H., Sakurai T., Iwabuchi M., Sugimura M., Iizuka M., Nagino K., Kobayashi T., Ohnishi K., Yoshino T., Ohmori T., Teramoto T.

Journal of Gastroenterology (Journal of Gastroenterology) 55 ( 4 ) 390 - 400 2020.04

ISSN 09441174

Background: Apheresis therapy involves the selective removal of leukocytes and is used to induce remission in ulcerative colitis (UC) patients. The aim of this study was to demonstrate the efficacy and safety of apheresis therapy for maintaining UC remission. Methods: We conducted a multicenter, prospective, randomised-control trial of patients with remitting UC induced by granulocyte and monocyte adsorption apheresis or leukocytapheresis. Patients were randomly assigned to the apheresis group (twice per month for 12 months) or the control group (no apheresis treatment) using a 1:1 allocation ratio. The primary endpoint was the rate of cumulative clinical remission (Mayo score ≤ 2) at 12 months. The secondary endpoints were the rates of clinical remission, endoscopic remission, and complete endoscopic remission at 12 months. Results: Between March 2013 and March 2017, 164 patients were enrolled. The cumulative remission rate at 12 months was 46.6% in the apheresis group and 36.4% in the control group (p = 0.1621). The rate of endoscopic remission at 12 months was significantly higher in the apheresis group than in the control group (42.5% vs. 25.9%) p = 0.0480). The rate of clinical remission (47.5% vs.32.1%, p = 0.0540) and complete endoscopic remission (33.8% vs.19.8%, p = 0.0513) tended to be higher in the apheresis than in the control group; however, the difference was not significant. No severe adverse events were observed in either group. Conclusions: Apheresis was well tolerated as maintenance therapy for UC although the cumulative clinical remission rate at 12 months was comparable between the apheresis and control groups.

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Etiology and mortality in severe acute pancreatitis: A multicenter study in Japan

Yasuda H., Horibe M., Sanui M., Sasaki M., Suzuki N., Sawano H., Goto T., Ikeura T., Takeda T., Oda T., Ogura Y., Miyazaki D., Kitamura K., Chiba N., Ozaki T., Yamashita T., Koinuma T., Oshima T., Yamamoto T., Hirota M., Sato M., Miyamoto K., Mine T., Misumi T., Takeda Y., Iwasaki E., Kanai T., Mayumi T.

Pancreatology (Pancreatology) 20 ( 3 ) 307 - 317 2020.04

ISSN 14243903

Background/Objectives: Severe acute pancreatitis (SAP) has a high mortality rate despite ongoing attempts to improve prognosis through a various therapeutic modalities. This study aimed to delineate etiology-based routes that may guide clinical decisions for the treatment of SAP. Methods: Using data from a recent retrospective multicenter study in Japan, we analyzed the association between clinical outcomes, mainly in-hospital mortality and pancreatic infection, and various etiologies while considering confounding factors. We performed additional multivariate analyses and built decision tree models. Results: The 1097 participating patients were classified into the following groups by etiology: alcohol (n = 436, 39.7%); cholelithiasis (n = 230, 21.0%); idiopathic (n = 227, 20.7%); and others (n = 204, 18.6%). Mortality at hospital discharge was 8.4%, 12.2%, 16.7%, and 16.2% in the alcohol, cholelithiasis, idiopathic, and others groups, respectively. According to multivariable analysis, early enteral nutrition (EN) was significantly associated with reduced in-hospital mortality only in the cholelithiasis group. However, there was a consistent association between age and the need for mechanical ventilation and increased mortality, regardless of etiology. Our decision tree models presented different contributing factors depending on the etiology and patient background. Interaction analysis showed that EN and the use of prophylactic antibiotics may influence these results differently according to etiology. Conclusions: No study has yet used comprehensive models to investigate etiology-related prognostic factors for SAP; our results can, therefore, be used as a reference for improving clinical decisions.

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Clinical implications with tolvaptan on monitored bioimpedance-defined fluid status in patients with cirrhotic ascites: An observational study

Shiba S., Chu P.S., Nakamoto N., Yamataka K., Taniki N., Ojiro K., Yamaguchi A., Morikawa R., Yoshida A., Ikura A., Ebinuma H., Saito H., Kanai T.

BMC Gastroenterology (BMC Gastroenterology) 20 ( 1 ) 2020.03

Background: Prognostic value or clinical implications of fluid status monitoring in liver cirrhosis are not fully elucidated. Tolvaptan, an orally available, selective vasopressin V2-receptor antagonist approved for hyponatremia in the United States and European Union. It is also used for cirrhotic ascites at a relatively low dose (3.75 mg to 7.5 mg) in Japan, exerts its diuretic function by excreting electrolyte-free water. We hypothesized that bioimpedance-defined dynamic changes in fluid status allow prediction of response of V2 antagonism and survival in cirrhotic patients. Methods: In this prospective observational study, 30 patients with decompensated liver cirrhosis who were unresponsive to conventional diuretics were enrolled. Detailed serial changes of body composition that were assessed by using non-invasive bioimpedance analysis (BIA) devices, along with biochemical studies, were monitored at 5 time points. Results: Sixteen patients were classified as short-term responders (53%). Rapid and early decrease of BIA-defined intracellular water, as soon as 6 h after the first dose (ΔICWBIA%-6 h), significantly discriminated responders from non-responders (AUC = 0.97, P < 0.0001). ΔICWBIA%-6 h was highly correlated with the change of BIA-derived phase angle of trunk, e.g. reduced body reactance operated at 50 kHz after 24 h of the first dose of tolvaptan. Lower baseline blood urea nitrogen and lower serum aldosterone were predictive of a rapid and early decrease of ICWBIA. A rapid and early decrease of ICWBIA in response to tolvaptan was also predictive of a better transplant-free survival. Conclusions: BIA-defined water compartment monitoring may help predict short-term efficacy and survival in decompensated cirrhotic patients treated with tolvaptan.

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Effects of vedolizumab in Japanese patients with Crohn’s disease: a prospective, multicenter, randomized, placebo-controlled Phase 3 trial with exploratory analyses

Watanabe K., Motoya S., Ogata H., Kanai T., Matsui T., Suzuki Y., Shikamura M., Sugiura K., Oda K., Hori T., Araki T., Watanabe M., Hibi T.

Journal of Gastroenterology (Journal of Gastroenterology) 55 ( 3 ) 291 - 306 2020.03

ISSN 09441174

Background: Vedolizumab is a gut-selective humanized antibody that binds the α4β7 integrin. We evaluated efficacy and safety of vedolizumab in Japanese patients with moderate-to-severe Crohn’s disease (CD). Methods: In this Phase 3, double-blind study (NCT02038920), 157 patients were randomized to receive intravenous vedolizumab 300 mg (n = 79) or placebo (n = 78) at Weeks 0, 2, and 6 (induction phase). Patients with CD activity index (CDAI)-70 response at Week 10 were randomized to receive vedolizumab 300 mg (n = 12) or placebo (n = 12) at Week 14, then every 8 weeks until Week 54 (maintenance phase). Primary endpoints were ≥ 100-point reduction in CDAI (CDAI-100 response) at Week 10 for induction, and clinical remission (CR: CDAI ≤ 150) at Week 60 for maintenance. Results: At Week 10, 26.6% of patients who received vedolizumab and 16.7% who received placebo achieved CDAI-100 response (odds ratio [OR] [95% confidence interval (CI)] 1.80 [0.82–3.96]; p = 0.145). At Week 60, 41.7% of vedolizumab-treated patients and 16.7% of placebo-treated patients achieved CR (OR [95% CI] 3.57 [0.53–23.95]; p = 0.178). The incidence of adverse events was similar in both treatment groups in both induction and maintenance phases. In patients without prior anti-TNFα exposure or with inadequate response to anti-TNFα, vedolizumab showed improved outcomes over placebo in the induction phase. Age might be a possible predictive factor of CR for future research. Conclusion: Vedolizumab showed a numerically greater efficacy versus placebo as induction therapy, but the difference was not statistically significant. Vedolizumab also showed a numerically greater efficacy in maintenance therapy, and was well tolerated.

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Giant mesocaval shunt formed by recurrent ileal intussusception

Takabayashi K., Hosoe N., Ogata H., Kanai T.

Internal Medicine (Internal Medicine) 59 ( 5 ) 747 - 748 2020.03

ISSN 09182918

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A Phase II Study of Regorafenib With a Lower Starting Dose in Patients With Metastatic Colorectal Cancer: Exposure–Toxicity Analysis of Unbound Regorafenib and Its Active Metabolites (RESET Trial)

Suzuki T., Sukawa Y., Imamura C.K., Masuishi T., Satake H., Kumekawa Y., Funakoshi S., Kotaka M., Horie Y., Kawai S., Okuda H., Terazawa T., Kondoh C., Kato K., Yoshimura K., Ishikawa H., Hamamoto Y., Boku N., Takaishi H., Kanai T.

Clinical Colorectal Cancer (Clinical Colorectal Cancer) 19 ( 1 ) 13 - 21.e3 2020.03

ISSN 15330028

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Clinical and endoscopic characteristics of pyogenic granuloma in the small intestine: A case series with literature review

Hayashi Y., Dr N.H., Takabayashi K., Limpias Kamiya K.J.L., Mutaguchi M., Miyanaga R., Hirata K., Fukuhara S., Mikami Y., Sujino T., Masugi Y., Naganuma M., Ogata H., Kanai T.

Internal Medicine (Internal Medicine) 59 ( 4 ) 501 - 505 2020.02

ISSN 09182918

Pyogenic granuloma (PG) generally appears in the skin or oral cavity, but rarely occurs in the small intestine, where it can cause bleeding. To date, only 35 cases of small intestinal PG have been reported in the English literature. We retrospectively collected information from the clinical records of seven cases of small intestinal PG that were managed in our hospital and summarized the characteristics. Further information on the clinical characteristics was obtained from the literature. Capsule endoscopy, useful for identifying the source of hemorrhage in obscure gastrointestinal bleeding, can detect PGs. Treatment can often be accomplished with endoscopic mucosal resection.

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Previous Helicobacter pylori infection–induced atrophic gastritis: A distinct disease entity in an understudied population without a history of eradication

Kishikawa H., Ojiro K., Nakamura K., Katayama T., Arahata K., Takarabe S., Miura S., Kanai T., Nishida J.

Helicobacter (Helicobacter) 25 ( 1 ) 2020.02

ISSN 10834389

Individuals with chronic atrophic gastritis who are negative for active H. pylori infection with no history of eradication therapy have been identified in clinical practice. By excluding false-negative and autoimmune gastritis cases, it can be surmised that most of these patients have experienced unintentional eradication of H. pylori after antibiotic treatment for other infectious disease, unreported successful eradication, or H. pylori that spontaneously disappeared. These patients are considered to have previous H. pylori infection–induced atrophic gastritis. In this work, we define these cases based on the following criteria: absence of previous H. pylori eradication; atrophic changes on endoscopy or histologic confirmation of glandular atrophy; negative for a current H. pylori infection diagnosed in the absence of proton-pump inhibitors or antibiotics; and absence of localized corpus atrophy, positivity for autoantibodies, or characteristic histologic findings suggestive of autoimmune gastritis. The risk of developing gastric cancer depends on the atrophic grade. The reported rate of developing gastric cancer is 0.31%-0.62% per year for successfully eradicated severely atrophic cases (pathophysiologically equal to unintentionally eradicated cases and unreported eradicated cases), and 0.53%-0.87% per year for spontaneously resolved cases due to severe atrophy. Therefore, for previous H. pylori infection–induced atrophic gastritis cases, we recommend endoscopic surveillance every 3 years for high-risk patients, including those with endoscopically severe atrophy or intestinal metaplasia. Because of the difficulty involved in the endoscopic diagnosis of gastric cancer in cases of previous infection, appropriate monitoring of the high-risk subgroup of this understudied population is especially important.

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Chromosome Engineering of Human Colon-Derived Organoids to Develop a Model of Traditional Serrated Adenoma

Kawasaki K., Fujii M., Sugimoto S., Ishikawa K., Matano M., Ohta Y., Toshimitsu K., Takahashi S., Hosoe N., Sekine S., Kanai T., Sato T.

Gastroenterology (Gastroenterology) 158 ( 3 ) 638 - 651.e8 2020.02

ISSN 00165085

Background & Aims: Traditional serrated adenomas (TSAs) are rare colorectal polyps with unique histologic features. Fusions in R-spondin genes have been found in TSAs, but it is not clear whether these are sufficient for TSA development, due to the lack of a chromosome engineering platform for human tissues. We studied the effects of fusions in R-spondin genes and other genetic alterations found in TSA using CRISPR-Cas9–mediated chromosome and genetic modification of human colonic organoids. Methods: We introduced chromosome rearrangements that involve R-spondin genes into human colonic organoids, with or without disruption of TP53, using CRISPR-Cas9 (chromosome-engineered organoids). We then knocked a mutation into BRAF encoding the V600E substitution and overexpressed the GREM1 transgene; the organoids were transplanted into colons of NOG mice and growth of xenograft tumors was measured. Colon tissues were collected and analyzed by immunohistochemistry or in situ hybridization. We also established 2 patient-derived TSA organoid lines and characterized their genetic features and phenotypes. We inserted a bicistronic cassette expressing a dimerizer-inducible suicide gene and fluorescent marker downstream of the LGR5 gene in the chromosome-engineered organoids; addition of the dimerizer eradicates LGR5+ cells. Some tumor-bearing mice were given intraperitoneal injections of the dimerizer to remove LGR5-expressing cells. Results: Chromosome engineering of organoids required disruption of TP53 or culture in medium containing IGF1 and FGF2. In colons of mice, organoids that expressed BRAFV600E and fusions in R-spondin genes formed flat serrated lesions. Patient-derived TSA organoids grew independent of exogenous R-spondin, and 1 line grew independent of Noggin. Organoids that overexpressed GREM1, in addition to BRAFV600E and fusions in R-spondin genes, formed polypoid tumors in mice that had histologic features similar to TSAs. Xenograft tumors persisted after loss of LGR5-expressing cells. Conclusions: We demonstrated efficient chromosomal engineering of human normal colon organoids. We introduced genetic and chromosome alterations into human colon organoids found in human TSAs; tumors grown from these organoids in mice had histopathology features of TSAs. This model might be used to study progression of human colorectal tumors with RSPO fusion gene and GREM1 overexpression.

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Somatic inflammatory gene mutations in human ulcerative colitis epithelium

Nanki K., Fujii M., Shimokawa M., Matano M., Nishikori S., Date S., Takano A., Toshimitsu K., Ohta Y., Takahashi S., Sugimoto S., Ishimaru K., Kawasaki K., Nagai Y., Ishii R., Yoshida K., Sasaki N., Hibi T., Ishihara S., Kanai T., Sato T.

Nature (Nature) 577 ( 7789 ) 254 - 259 2020.01

ISSN 00280836

With ageing, normal human tissues experience an expansion of somatic clones that carry cancer mutations1–7. However, whether such clonal expansion exists in the non-neoplastic intestine remains unknown. Here, using whole-exome sequencing data from 76 clonal human colon organoids, we identify a unique pattern of somatic mutagenesis in the inflamed epithelium of patients with ulcerative colitis. The affected epithelium accumulates somatic mutations in multiple genes that are related to IL-17 signalling—including NFKBIZ, ZC3H12A and PIGR, which are genes that are rarely affected in colon cancer. Targeted sequencing validates the pervasive spread of mutations that are related to IL-17 signalling. Unbiased CRISPR-based knockout screening in colon organoids reveals that the mutations confer resistance to the pro-apoptotic response that is induced by IL-17A. Some of these genetic mutations are known to exacerbate experimental colitis in mice8–11, and somatic mutagenesis in human colon epithelium may be causally linked to the inflammatory process. Our findings highlight a genetic landscape that adapts to a hostile microenvironment, and demonstrate its potential contribution to the pathogenesis of ulcerative colitis.

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Anti-MAdCAM-1 antibody (PF-00547659) for active refractory Crohn's disease in Japanese and Korean patients: The OPERA study

Saruta M., Park D.I., Kim Y.H., Yang S.K., Jang B.I., Cheon J.H., Im J.P., Kanai T., Katsuno T., Ishiguro Y., Nagaoka M., Isogawa N., Li Y., Banerjee A., Ahmad A., Hassan-Zahraee M., Clare R., Gorelick K.J., Cataldi F., Watanabe M., Hibi T.

Intestinal Research (Intestinal Research) 18 ( 1 ) 45 - 55 2020.01

ISSN 15989100

Background/Aims: PF-00547659 is a monoclonal antibody against human mucosal addressin cell adhesion molecule-1 (MAdCAM-1) that prevents the binding of α4β7+ lymphocytes to MAdCAM-expressing sites in the gastrointestinal tract with high affinity and selectivity, and is being developed for the treatment of Crohn's disease (CD). Methods: OPERA is a randomized, multicenter, double-blind, placebo-controlled study to investigate the efficacy, safety, and pharmacokinetics of PF-00547659 following subcutaneous administration in subjects with active CD, a history of failure or intolerance to anti-tumor necrosis factor and/or immunosuppressants, high-sensitivity C-reactive protein >3.0 mg/L, and ulcers on colonoscopy. The primary endpoint was Crohn's Disease Activity Index-70 response at week 8 or 12. Subpopulation analyses for Asian subjects were performed as some differences are observed in genetics and clinical phenotypes in Asian CD patients compared with Western patients. Results: In this study, 265 CD subjects were randomized, with a subpopulation of 21 subjects (8 Japanese and 13 Korean) defined as the Asian population. In the overall and Asian populations; PF-00547659 was pharmacologically active as evidenced by soluble MAdCAM and circulating β7+ central memory CD4+ T-lymphocytes, although no clear evidence of efficacy was observed in any clinical endpoints; pharmacokinetics of PF-00547659 in the Asian subpopulation was generally comparable to the overall population; and the safety profile of PF-00547659 appeared acceptable up to 12 weeks of treatment. Conclusions: In the overall and Asian populations, efficacy of PF-00547659 could not be demonstrated using any clinical endpoints compared with placebo. Pharmacokinetics and safety of PF-00547659 were generally comparable. Further studies with larger numbers of patients are required to confirm our results.

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5-Aminosalicylic acid intolerance is associated with a risk of adverse clinical outcomes and dysbiosis in patients with ulcerative colitis

Mizuno S., Ono K., Mikami Y., Naganuma M., Fukuda T., Minami K., Masaoka T., Terada S., Yoshida T., Saigusa K., Hirahara N., Miyata H., Suda W., Hattori M., Kanai T.

Intestinal Research (Intestinal Research) 18 ( 1 ) 69 - 78 2020.01

ISSN 15989100

Background/Aims: 5-Aminosalicylic acid (ASA) causes intolerance reactions in some patients. This study was performed to examine the prognosis of patients with ulcerative colitis (UC) and 5-ASA intolerance, and to evaluate the potential interaction between 5-ASA intolerance and the intestinal microbiota. Methods: We performed a retrospective cohort study of patients with UC who visited participating hospitals. The primary endpoint was to compare the incidence of hospitalization within 12 months between the 5-ASA intolerance group and the 5-ASA tolerance group. The secondary endpoint was to compare the risk of adverse clinical outcomes after the start of biologics between the 2 groups. We also assessed the correlation between 5-ASA intolerance and microbial change in an independently recruited cohort of patients with UC. Results: Of 793 patients, 59 (7.4%) were assigned to the 5-ASA intolerance group and 734 (92.5%) were assigned to the 5-ASA tolerance group. The admission rate and incidence of corticosteroid use were significantly higher in the intolerance than tolerance group (P<0.001). In 108 patients undergoing treatment with anti-tumor necrosis factor biologics, 5-ASA intolerance increased the incidence of additional induction therapy after starting biologics (P<0.001). The 5-ASA intolerance group had a greater abundance of bacteria in the genera Faecalibacterium, Streptococcus, and Clostridium than the 5-ASA tolerance group (P<0.05). Conclusions: In patients with UC, 5-ASA intolerance is associated with a risk of adverse clinical outcomes and dysbiosis. Bacterial therapeutic optimization of 5-ASA administration may be important for improving the prognosis of patients with UC.

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Clinical characteristics and outcomes of duodenal-type follicular lymphoma

Abe R., Mori T., Tanigawa T., Koda Y., Hosoe N., Sakurai M., Kikuchi T., Kato J., Shimizu T., Ogata H., Kanai T., Sasaki A., Kameyama K., Okamoto S.

Leukemia and Lymphoma (Leukemia and Lymphoma) 3266 - 3268 2020

ISSN 10428194

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Small-Bowel Lesions in Patients Taking Direct Oral Anticoagulants Detected Using Capsule Endoscopy

Yamaoka M., Imaeda H., Hosoe N., Yoneno K., Kanno R., Mitsufuji T., Sasaki T., Akiyama Y., Ohgo H., Morohoshi Y., Kanai T., Yamamoto T., Mimura T., Ogata H., Araki N., Yamamoto K., Nakamoto H.

Gastroenterology Research and Practice (Gastroenterology Research and Practice) 2020 2020

ISSN 16876121

Background and Aim. Direct oral anticoagulant- (DOAC-) induced small-bowel lesions have not been described. We evaluated small-bowel lesions related to DOAC using video capsule endoscopy (VCE). Methods. This study was a prospective, open-label, nonblinded, multicenter, and observational study. From September 2013 to March 2017, patients taking DOACs were enrolled. Patients underwent VCE. The type and location of small-bowel lesions were registered. Also, (1) the proportion of lesions detected between types of DOAC was evaluated and (2) the hemoglobin (Hb) and serum ferritin levels were compared between patients with and without small-bowel lesions. Results. 33 patients were enrolled, but 4 patients withdrew their consent, and VCE was performed on 29 patients. Eight, 13, and 8 patients received dabigatran, rivaroxaban, and apixaban, respectively. Small-bowel transit was complete in 27 of 29 patients (93.1%). Small-bowel lesions were detected in 23 (79.3%), redness in 12 (41.4%), erosions in 14 (48.3%), and angioectasia in 3 (10.3%) patients, and 6 patients (20.7%) had no abnormalities. Redness and erosions were detected in the upper, middle, or lower portions, but erosions tended to be less frequent in the middle portion (p=0.25, 0.06). Angioectasia was not detected in the lower portion. No patients had active bleeding. The findings did not differ according to the drug. The relationships between the endoscopic findings and the Hb and serum ferritin levels were not significant. Conclusion. Many patients taking DOACs had small-bowel lesions; however, most lesions were relatively mild. Observing small-bowel lesions over longer periods may be necessary in patients taking DOACs. This trial is registered with UMIN000011527.

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Of infliximab with long-term administration in Japanese patients with Crohn's disease: Analysis using population pharmacokinetics

Matsuoka K., Hamada S., Shimizu M., Nanki K., Mizuno S., Kiyohara H., Arai M., Sugimoto S., Iwao Y., Ogata H., Hisamatsu T., Nagauma M., Kanai T., Mochizuki M., Hashiguchi M.

International Journal of Clinical Pharmacology and Therapeutics (International Journal of Clinical Pharmacology and Therapeutics) 58 ( 2 ) 89 - 102 2020

ISSN 09461965

Objective: Crohn's disease (CD) is a chronic inflammatory gastrointestinal disease with repeated cycles of exacerbation and remission. Infliximab (IFX), a chimeric anti-TNF-α monoclonal antibody, has been widely used for the treatment of CD. However, no study in Japanese CD patients receiving continuous IFX for more than 1 year has been reported. To avoid therapeutic failure during long-term administration in Japanese CD patients, we evaluated the variable factors of IFX pharmacokinetics and the optimal trough IFX concentration at 8 weeks after administration. Materials and methods: Population pharmacokinetic (PPK) analysis was performed using the nonlinear mixed-effect model based on the IFX serum concentration in 832 samples from 121 patients. A one-compartment model was used to examine interindividual variability in the systemic clearance (CL) of intravenously administered IFX. Results: PPK estimates (estimated value, RSE%) were total clearance (CL: 0.018 L/h, 9.1) and volumes of distribution (Vd: 7.35 L, 12.0). Interindividual variability for CL and Vd of 0.11 and 0.16, respectively, was found. Body weight, antibody to IFX (ATI), and albumin level were factors affecting the IFX CL. IFX CL was greater in the ATI-positive than in the ATInegative group. CL was also greater in nonremission patients. There was a significant association between the predicted serum IFX trough concentration at 8 weeks and therapeutic response with long-term continuous administration (p < 0.05), with a higher concentration at 8 weeks seen in the remission group. Conclusion: Using these variables including body weight, ATI, and albumin level, the IFX dose could be calculated for individual CD patients to achieve the optimal therapeutic range.

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Multiple immune-related adverse events and anti-tumor efficacy: Real-world data on various solid tumors

Shimozaki K., Sukawa Y., Beppu N., Kurihara I., Suzuki S., Mizuno R., Funakoshi T., Ikemura S., Tsugaru K., Togasaki K., Kawasaki K., Hirata K., Hayashi H., Hamamoto Y., Takaishi H., Kanai T.

Cancer Management and Research (Cancer Management and Research) 12 4585 - 4593 2020

Purpose: Immune checkpoint inhibitors (ICIs) have been approved for various types of cancer; however, they cause a broad spectrum of immune-related adverse events (irAEs). The association between the development of irAEs and the clinical benefit remains uncertain. We aimed to evaluate the association of irAEs and the treatment efficacy in real-world practice. Patients and Methods: We conducted a retrospective study on patients with recurrent or metastatic non-small-cell lung cancer, malignant melanoma, renal cell carcinoma, or gastric cancer who received anti-PD-1/PD-L1 antibodies (nivolumab, pembrolizumab, or atezolizumab) at the Keio University Hospital between September 2014 and January 2019. We recorded treatment-related AEs from medical records and graded them using the Common Terminology Criteria for Adverse Events version 4. We performed an overall survival (OS) analysis using a Cox proportional hazards model and the shared frailty model. Results: Of 212 patients eligible for this study, 108 experienced irAEs and 42 developed multiple irAEs. The median OS was significantly longer in the irAEs than in the no-irAE group (28.1 months vs 12.7 months; hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.33–0.73; P = 0.0004). Moreover, the OS of patients with multiple irAEs was significantly longer than that of patients with a single irAE (42.3 months vs 18.8 months; HR, 0.473; 95% CI, 0.346–0.647; P < 0.0001). Conclusion: Our single-center retrospective study revealed a significant tendency associating the development of multiple irAEs with favorable prognoses.

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External drainage of bile and pancreatic juice after endoscopic submucosal dissection for duodenal neoplasm: Feasibility study (with video)

Fukuhara S., Kato M., Iwasaki E., Machida Y., Tamagawa H., Kawasaki S., Sasaki M., Kiguchi Y., Takatori Y., Matsuura N., Nakayama A., Ogata H., Kanai T., Yahagi N.

Digestive Endoscopy (Digestive Endoscopy) 2020

ISSN 09155635

Background and Aims: Endoscopic submucosal dissection (ESD) for superficial duodenal epithelial tumors (SDETs) is technically difficult and has a high risk of adverse events. Endoscopic nasobiliary and nasopancreatic duct drainage (ENBPD) may reduce the risk of delayed adverse events by preventing exposure of the post-ESD mucosal defect to bile and pancreatic juice. This study was performed to evaluate the safety and feasibility of ENBPD after duodenal ESD. Methods: Patients who underwent ESD for SDETs from July 2010 to March 2020 were included. We collected data on the success rate of ENBPD, adverse events due to insertion of a side-viewing endoscope, and pancreatitis after ENBPD. We also collected the clinical outcomes of duodenal ESD, including the incidence rate of delayed adverse events (defined as bleeding or perforation found after the endoscopic procedure). Results: Among 70 patients without complete closure of the post-ESD mucosal defect, ENBPD was successfully performed in all 25 patients including 21 cases inserted immediately after ESD and four cases inserted later. There were no adverse events associated with ENBPD procedure intraoperatively, while pancreatitis after ENBPD occurred in four patients (16.0%). No patients who underwent immediate ENBPD required intervention for an intra-abdominal abscess or delayed perforation, whereas 3 of 49 patients (6.1%) who did not undergo immediate ENBPD required surgery or drainage of an abscess. Conclusions: Endoscopic nasobiliary and nasopancreatic duct drainage is technically feasible and might provide effective prophylaxis for delayed adverse events, even if a large mucosal defect is present after ESD.

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Characteristics of the Mucosal Surface on Scanning Electron Microscopy in Patients with Remitting Ulcerative Colitis

Nomura E., Sujino T., Hosoe N., Yoshimatsu Y., Tanemoto S., Takabayashi K., Mutaguchi M., Shimoda M., Naganuma M., Ogata H., Kanai T.

Digestive Diseases and Sciences (Digestive Diseases and Sciences) 2020

ISSN 01632116

Background: Ulcerative colitis (UC) is characterized by chronic intestinal epithelial damage, and previous studies have evaluated the epithelial structure of patients with active UC using electron microscopy. Aims: This study aimed to assess the intestinal epithelial structure using scanning electron microscopy (SEM) and the features of patients with UC who are in remission. Methods: In total, eight healthy controls and 20 patients with UC were enrolled, and colonic tissue samples from the cecum and rectum were collected. Then, we compared the epithelial surface structure on SEM between patients with UC who are in clinical remission and healthy controls. Results: In healthy controls, the colonic surface comprises small lobes (termed units), with one crypt located in the middle of each unit. In patients with UC, we found irregular unit and crypt mouth size, double crypt sign (> 1 crypt per unit), and lower number of small vesicles in the intestinal epithelial cells. Compared with healthy controls, patients with UC often presented with irregular unit size, double crypt sign, and irregular crypt mouth size in the rectum. The small vesicles were observed less frequently in patients with UC than in healthy controls. Conclusions: SEM revealed a unique epithelial structure in patients with UC who are in remission.

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A case of intrahepatic cholangiocellular carcinoma due to thorotrast deposition, well-controlled by radiofrequency ablation therapy

Taniki N., Nakamoto N., Yoshida A., Chu P.S., Ikura A., Yamataka K., Morikawa R., Shiba S., Yamaguchi A., Usui S., Ojiro K., Ebinuma H., Saito H., Kubota N., Masugi Y., Sakamto M., Kanai T.

Acta Hepatologica Japonica (Acta Hepatologica Japonica) 61 ( 5 ) 262 - 269 2020

ISSN 04514203

An 87-year-old man with an enlarged hepatic tumor was referred to our institute by a medical examination center. He had been diagnosed with a malignant liver tumor through several contrast imaging studies. Because of the patient’s age, the underlying disease, and the absence of bile duct invasion on imaging, radiofrequency ablation (RFA) was selected as a treatment option. A histological examination during the RFA procedure revealed the tumor to be a cholangiocellular carcinoma. In addition, the deposition of Thorotrast, a contrast agent used in the 1930s to 1950s, was suspected in the background liver collected simultaneously. Radiofrequency ablation was performed twice for recurrent lesions, and the tumor was controlled for roughly 3 years following the initial treatment. A case of intrahepatic cholangiocellular carcinoma due to Thorotrast deposition was observed and successfully controlled by RFA. Since intrahepatic cholangiocellular carcinoma from Thorotrast deposition occurs multicentrically and intrahepatically, RFA and other local therapies may present effective options for older patients with cholangiocarcinoma who are at a higher risk of surgical resection intolerance.

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Erratum: Leucine-rich Alpha-2 Glycoprotein is a Serum Biomarker of Mucosal Healing in Ulcerative Colitis (Journal of Crohn's and Colitis DOI: 10.1093/ecco-jcc/jjw132)

Shinzaki S., Matsuoka K., Iijima H., Mizuno S., Serada S., Fujimoto M., Arai N., Koyama N., Morii E., Watanabe M., Hibi T., Kanai T., Takehara T., Naka T.

Journal of Crohn's and Colitis (Journal of Crohn's and Colitis) 13 ( 12 ) 2019.12

ISSN 18739946

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The relationship between gut microbiome, immune system, and cancer

Ichikawa M., Sujino T., Kanai T.

Japanese Journal of Cancer and Chemotherapy (Japanese Journal of Cancer and Chemotherapy) 46 ( 12 ) 1807 - 1813 2019.12

ISSN 03850684

Various microbes having been living in our intestine and forming the gut microbiome. When dysbiosis which is typically characterized by reduced microbial diversity occurs, many types of diseases are triggered in our bodies. Recently, relationship between gut microbiome and our immune function are discovered gradually. From this view point, the gut microbiome may have an influence on cancer medicine such as development, therapy (immune checkpoint blockade or chemotherapy), and therapeutic toxicity. In real clinical practice, this influence is reported in some cases such as colorectal cancer and other malignancies. In the near future, the approach from gut microbiome may be a clue to improve the existent cancer diagnosis and therapy. In addition, the modulation of gut microbiome in itself, for example fecal microbiota transplant (FMT), probiotics, and limited usage of antibiotics, is expected to be hints for cancer medicine, though this is not yet established and further studies are needed.

広範な潰瘍性病変を呈したアメーバ性大腸炎の一例

津軽開, 高林馨, 南木康作, 野田まりん, 林由紀恵, 下嵜啓太郎, 平田賢郎, 福原佳代子, 三上洋平, 水野慎大, 加藤元彦, 正岡建洋, 細江直樹, 長沼誠, 緒方晴彦, 金井隆典

Progress of Digestive Endoscopy ((一社)日本消化器内視鏡学会-関東支部) 95 ( 1 ) 126 - 128 2019.12

ISSN 1348-9844

症例は63歳男性で、2年前より自然軽快する水様性下痢を繰り返していたが、2週間前からの血性下痢が軽快せず発熱や食事摂取困難を伴ったため入院した。血液検査では炎症反応上昇、低栄養、低Ig血症を認め、下部消化管内視鏡(CS)では全大腸に渡り粘稠度の高い白苔が付着した不整形潰瘍を全周性に認め、遠位結腸は一部正常粘膜が介在し回腸末端は異常を認めなかった。入院第5病日に生検検体および便塗抹検査にてアメーバ原虫を検出し、アメーバ性大腸炎と診断した。メトロニダゾールを10日間、その後パロモマイシンを7日間投与し、入院第17病日に退院した。退院3ヵ月後のCSで潰瘍は消失したが脾彎曲に小潰瘍を伴った浮腫性狭窄が残存し、退院9ヵ月後のCSでは狭窄部以外の全大腸の治癒を確認した。狭窄箇所の生検からはアメーバ原虫は検出されなかった。

Intramucosal poorly differentiated and signet-ring cell components in patients with ulcerative colitis-associated high-grade dysplasia

Sugimoto S., Shimoda M., Iwao Y., Mutaguchi M., Nanki K., Mizuno S., Kameyama K., Ogata H., Naganuma M., Kanai T.

Digestive Endoscopy (Digestive Endoscopy) 31 ( 6 ) 706 - 711 2019.11

ISSN 09155635

© 2019 Japan Gastroenterological Endoscopy Society Despite the rarity of colorectal poorly differentiated adenocarcinoma (Por) and signet-ring cell carcinoma (Sig), they are more frequent in patients with ulcerative colitis (UC). However, little is known about these components of early colitis-associated cancer due to the difficulty of detection at an early stage. Here, we reviewed colitis-associated high-grade dysplasia/cancer with Por/Sig components within the submucosa among 103 lesions of 79 UC patients who presented between 1997 and 2017. In total, one Sig in situ, three intramucosal and two submucosal carcinomas (8.7%) were identified among 69 lesions within the submucosa. Depressed appearance, loss of crypt architecture and amorphous surface pattern suggested the presence of Por/Sig, rather than submucosal infiltration. All lesions were located in the rectosigmoid colon and included high-grade dysplasia. While the surrounding noncancerous mucosa expressed E-cadherin and MUC5AC, the expression of E-cadherin was reduced and the expression of MUC5AC was negative in all of the carcinomas except for the Sig in situ. The gastric type metaplasia associated with altered MUC5AC profiles may be a sign of the stepwise accumulation of molecular alterations, including TP53 defects and a reduced expression level of E-cadherin.

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Pancreatic fat content may increase the risk of imaging progression in low-risk branch duct intraductal papillary mucinous neoplasm

Kashiwagi K., Minami K., Seino T., Hirata K., Iwasaki E., Inoue N., Iwao Y., Kanai T.

Journal of Digestive Diseases (Journal of Digestive Diseases) 20 ( 10 ) 557 - 562 2019.10

ISSN 17512972

© 2019 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd Objective: To identify risk factors of imaging progression (increase in cyst size or main pancreatic duct size, or a new mural nodule) in low-risk branch duct intraductal papillary mucinous neoplasm (BD-IPMN), including obesity-related factors such as pancreatic fat content. Methods: Our hospital databases were searched for patients who had completed health checkup, including upper abdominal magnetic resonance imaging (MRI) over 48 months (August 2012 to July 2016). Individuals with BD-IPMN without worrisome features and high-risk stigmata who underwent surveillance with at least one follow-up MRI, irrespective of the follow-up period, were included. Pancreatic computed tomography attenuation indexes were defined as the difference between the pancreas and spleen attenuation (P - S) and the pancreas to spleen attenuation ratio (P/S). Results: Among 75 patients diagnosed as having low-risk BD-IPMN, during a median follow-up of 36 months, 11 (15%) had imaging progression in cyst size, including two with worrisome features. A multivariate logistic analysis showed that the initial cyst size and both indexes (P - S, or P/S) were significantly associated with imaging progression in IPMN, respectively (Model 1: odds ratio [OR] 1.188, 95% confidence interval [CI] 1.060-1.331, P = 0.003; OR 0.871, 95% CI 0.776-0.977, P = 0.019; Model 2: OR 1.186, 95% CI 1.064-1.322, P = 0.002; OR 0.002, 95% CI 0.000-0.970, P = 0.049). Conclusions: Pancreatic fat content and initial cyst size were significantly associated with imaging progression in low-risk BD-IPMN. Revisions of international consensus Fukuoka guidelines might be customized based on initial cyst size and pancreatic fat content.

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Concerns and Side Effects of Azathioprine During Adalimumab Induction and Maintenance Therapy for Japanese Patients With Crohn's Disease: A Subanalysis of a Prospective Randomised Clinical Trial [DIAMOND Study

Hisamatsu T., Matsumoto T., Watanabe K., Nakase H., Motoya S., Yoshimura N., Ishida T., Kato S., Nakagawa T., Esaki M., Nagahori M., Matsui T., Naito Y., Kanai T., Suzuki Y., Nojima M., Watanabe M., Hibi T.

Journal of Crohn's & colitis (Journal of Crohn's & colitis) 13 ( 9 ) 1097 - 1104 2019.09

ISSN 18739946

Copyright © 2019 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com. BACKGROUND: Combining a thiopurine with the human anti-tumour necrosis factor-α monoclonal antibody adalimumab for Crohn's disease [CD] treatment is controversial with regard to efficacy and safety. By conducting a subanalysis of a multicentre, randomised, prospective, open-label trial [the DIAMOND study, UMIN registration number 000005146], we studied the risk of discontinuation of thiopurine in combination with adalimumab. METHODS: In the preceding DIAMOND study, we analysed the: [i] timing and reasons for dropout in the monotherapy group and combination group; [ii] risk factors for dropout in the combination group. RESULTS: There was no significant difference in the dropout rate up to Week 52 between the monotherapy group and combination group [p = 0.325]. The main reason for study dropout was active CD in the monotherapy group, whereas it was adverse effects in the combination group [Fisher's exact test, p <0.001]. Kaplan-Meier analyses revealed significantly earlier dropout in the combination group [log-rank test, p = 0.001]. Multivariable analysis revealed low body weight to be a risk for dropout due to adverse effects in the combination group. CONCLUSIONS: Combination of azathioprine with adalimumab resulted in dropout in the early stage of the study due to side effects of azathioprine, in comparison with late dropout due to active CD in the adalimumab monotherapy group.

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Difference in the clinical characteristic and prognosis of colitis-associated cancer and sporadic neoplasia in ulcerative colitis patients

Mutaguchi M., Naganuma M., Sugimoto S., Fukuda T., Nanki K., Mizuno S., Hosoe N., Shimoda M., Ogata H., Iwao Y., Kanai T.

Digestive and Liver Disease (Digestive and Liver Disease) 51 ( 9 ) 1257 - 1264 2019.09

ISSN 15908658

© 2019 Editrice Gastroenterologica Italiana S.r.l. Background: Although various studies have been conducted on colitis-associated cancer (CAC), few have assessed the differences in the clinical and endoscopic features, treatment, and prognosis of CAC and sporadic neoplasia (SN) in the inflamed mucosa of ulcerative colitis (UC) patients. Aims: To compare the characteristics of CAC and SN within the previously or currently inflamed mucosa. Methods: Between 1997 and 2017, we retrospectively analyzed the endoscopic chart data of 348 colonic lesions from 266 UC patients. Non-dysplastic lesions and lesions located outside the inflamed mucosa were excluded. The diagnosis of CAC or SN was confirmed by conventional histopathological and immunohistochemical evaluation of p53 and Ki67. Results: In total, 74 patients with CAC (97 lesions) and 46 with SN (58) were enrolled. The proportions of patients with a younger age of onset of UC, with chronic persistent UC, and with severe inflamed mucosa were significantly higher in the CAC group. In the SN group, no flat lesions were found, whereas 26% of the lesions in the CAC group were flat. Sixteen patients died during a median follow-up of 6.1 years (interquartile range (IQR) 1.8–11.1)in the CAC group, whereas 1 patient died during a median follow-up 3.2 years(IQR 1.4–4.6) in the SN group. Mortality from colorectal cancer was significantly higher (P = 0.015) in the CAC group (12/68; 17.6%) than in the SN group (1/44; 2.3%). The 5-year survival rate was 100% in the SN group and 97% in the CAC group for lesions located in the mucosa or submucosa. Conclusion: Recognizing differences in the characteristics of CAC and SN within the inflamed mucosa is critical to avoid unnecessary total colectomy in patients with SN.

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Sustained virologic response to direct-acting antiviral therapy in patients with chronic hepatitis C and hepatocellular carcinoma: A systematic review and meta-analysis

Ji F., Yeo Y., Wei M., Ogawa E., Enomoto M., Lee D., Iio E., Lubel J., Wang W., Wei B., Ide T., Preda C., Conti F., Minami T., Bielen R., Sezaki H., Barone M., Kolly P., Chu P., Virlogeux V., Eurich D., Henry L., Bass M., Kanai T., Dang S., Li Z., Dufour J., Zoulim F., Andreone P., Cheung R., Tanaka Y., Furusyo N., Toyoda H., Tamori A., Nguyen M.

Journal of Hepatology (Journal of Hepatology) 71 ( 3 ) 473 - 485 2019.09

ISSN 01688278

© 2019 European Association for the Study of the Liver Background & Aims: The effect of hepatocellular carcinoma (HCC) on the response to interferon-free direct-acting antiviral (DAA) therapy in patients with chronic hepatitis C (CHC) infection remains unclear. Using a systematic review and meta-analysis approach, we aimed to investigate the effect of DAA therapy on sustained virologic response (SVR) among patients with CHC and either active, inactive or no HCC. Methods: PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials were searched from 1/1/2013 to 9/24/2018. The pooled SVR rates were computed using DerSimonian-Laird random-effects models. Results: We included 49 studies from 15 countries, comprised of 3,341 patients with HCC and 35,701 without HCC. Overall, the pooled SVR was lower in patients with HCC than in those without HCC (89.6%, 95% CI 86.8–92.1%, I2 = 79.1% vs. 93.3%, 95% CI 91.9–94.7%, I2 = 95.0%, p = 0.0012), translating to a 4.8% (95% CI 0.2–7.4%) SVR reduction by meta-regression analysis. The largest SVR reduction (18.8%) occurred in patients with active/residual HCC vs. inactive/ablated HCC (SVR 73.1% vs. 92.6%, p = 0.002). Meanwhile, patients with HCC who received a prior liver transplant had higher SVR rates than those who did not (p <0.001). Regarding specific DAA regimens, patients with HCC treated with ledipasvir/sofosbuvir had lower SVR rates than patients without HCC (92.6%, n = 884 vs. 97.8%, n = 13,141, p = 0.026), but heterogeneity was high (I2 = 84.7%, p <0.001). The SVR rate was similar in patients with/without HCC who were treated with ombitasvir/paritaprevir/ritonavir ± dasabuvir (n = 101) (97.2% vs. 94.8%, p = 0.79), or daclatasvir/asunaprevir (91.7% vs. 89.8%, p = 0.66). Conclusion: Overall, SVR rates were lower in patients with HCC, especially with active HCC, compared to those without HCC, though heterogeneity was high. Continued efforts are needed to aggressively screen, diagnose, and treat HCC to ensure higher CHC cure rates. Lay summary: There are now medications (direct-acting antivirals or “DAAs”) that can “cure” hepatitis C virus, but patients with hepatitis C and liver cancer may be less likely to achieve cure than those without liver cancer. However, patients with liver cancer are also more likely to have advanced liver disease and risk factors that can decrease cure rates, so better controlled studies are needed to confirm these findings.

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Plasmacytoid dendritic cells protect against immune-mediated acute liver injury via IL-35

Koda Y., Nakamoto N., Chu P., Ugamura A., Mikami Y., Teratani T., Tsujikawa H., Shiba S., Taniki N., Sujino T., Miyamoto K., Suzuki T., Yamaguchi A., Morikawa R., Sato K., Sakamoto M., Yoshimoto T., Kanai T.

Journal of Clinical Investigation (Journal of Clinical Investigation) 129 ( 8 ) 3201 - 3213 2019.08

ISSN 00219738

© 2019, American Society for Clinical Investigation. Acute liver failure (ALF) is a life-threatening condition, and liver transplantation is the only therapeutic option. Although immune dysregulation is central to its pathogenesis, the precise mechanism remains unclear. Here, we show that the number of peripheral and hepatic plasmacytoid DCs (pDCs) decrease during acute liver injury in both humans and mice. Selective depletion of pDCs in Siglechdtr/+ mice exacerbated concanavalin A–induced acute liver injury. In contrast, adoptively transferred BM-derived pDCs preferentially accumulated in the inflamed liver and protected against liver injury. This protective effect was independent of TLR7 and TLR9 signaling, since a similar effect occurred following transfer of MyD88-deficient pDCs. Alternatively, we found an unexpected immunosuppressive role of pDCs in an IL-35–dependent manner. Both Il12a and Ebi3, heterodimeric components of IL-35, were highly expressed in transferred pDCs and CD4+CD25+ Tregs. However, the protective effect of pDC transfer was completely lost in mice depleted of Tregs by anti-CD25 antibody. Moreover, pDCs derived from IL-35–deficient mice had less of a protective effect both in vivo and in vitro even in the presence of Tregs. These results highlight a unique aspect of pDCs in association with Tregs, serving as a guide for immunotherapeutic options in ALF.

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Pharmacological effects of TAK-828F: an orally available RORγt inverse agonist, in mouse colitis model and human blood cells of inflammatory bowel disease

Igaki K., Nakamura Y., Tanaka M., Mizuno S., Yoshimatsu Y., Komoike Y., Uga K., Shibata A., Imaichi H., Takayuki S., Ishimura Y., Yamasaki M., Kanai T., Tsukimi Y., Tsuchimori N.

Inflammation Research (Inflammation Research) 68 ( 6 ) 493 - 509 2019.06

ISSN 10233830

© 2019, Springer Nature Switzerland AG. Objective and design: To evaluate the potency of RORγt blockade for treatment of Inflammatory Bowel Disease (IBD), the efficacy of TAK-828F, a novel RORγt inverse agonist, in anti-TNF-α mAb non-responsive mouse colitis model and effect of TAK-828F on IL-17 production in peripheral mononuclear blood cells (PBMCs) of anti-TNF-α naive and treatment-failure patients of IBD was investigated. Methods and results: The colitis model showed Th17-dependent pathogenicity and response to anti-IL-12/23p40 monoclonal antibody (mAb), but no response to anti-TNF-α mAb. In the model, TAK-828F, at oral dosages of 1 and 3 mg/kg, inhibited progression of colitis and reduced the immune reaction that characterize Th17 cells. Anti-IL-17A mAb showed neither efficacy nor change in the T cell population and colonic gene expression in the model. In the normal mouse, a 4-week treatment of TAK-828F at 30 mg/kg did not severely reduce lymphocyte cell counts in peripheral and intestinal mucosa, which was observed in RORγ−/− mice. TAK-828F strongly inhibited IL-17 gene expression with IC50 values from 21.4 to 34.4 nmol/L in PBMCs from anti-TNF mAb naive and treatment-failure patients of IBD. Conclusions: These results indicate that RORγt blockade would provide an effective approach for treating refractory patients with IBD by blocking IL-23/Th17 pathway.

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The association between environmental factors and the development of Crohn's disease with focusing on passive smoking: A multicenter case-control study in Japan

Kondo K., Ohfuji S., Watanabe K., Yamagami H., Fukushima W., Ito K., Suzuki Y., Hirota Y., Motoya S., Sakuraba H., Ishiguro Y., Sasaki I., Suzuki K., Fukuda K., Saruta M., Shinozaki M., Shimizu T., You A., Nagahori M., Watanabe M., Kanai T., Iizuka B., Watanabe T., Kobayashi K., Kunisaki R., Sugita A., Ishige T., Miura S., Hokari R., Hanai H., Goto H., Ando T., Tanida S., Joh T., Mizoshita T., Sasaki M., Kitamura K., Umegae S., Fujiyama Y., Ando A., Shimizu S., Yoshioka K., Kitano A., Aomatsu K., Naito Y., Yoshida M., Ooi M., Matsumoto T., Fukunaga K., Iimuro M., Ikeuchi H., Ishihara S., Tanaka S., Ueno Y., Matsui T., Yano Y., Yamasaki H., Mitsuyama K., Yamamoto S., Tsubouchi H., Sugimura K., Tenjin T.

PLoS ONE (PLoS ONE) 14 ( 6 ) 2019.06

© 2019 Kondo et al. Background The number of patients with Crohn's disease (CD) in Japan has recently been increasing. We examined the association between environmental factors and the development of CD in Japanese focusing on passive smoking. Methods We conducted a multicenter case-control study and compared the environmental factors of 93 cases who were newly diagnosed with CD to the environmental factors of 132 controls (hospital-, age-, and sex-matched patients with other diseases). The odds ratio (OR) of each factor for the development of CD and the 95% confidence interval (CI) were calculated using a logistic regression model. The association between the details of passive smoking history and the development of CD was examined for those who had an active smoking history "no". Odds ratios of number of passively smoked cigarettes (per day), time of passive smoking (per day) and period of passive smoking (year) were calculated using "passive smoking 'No'" as a reference. Results History of appendicitis, family history of inflammatory bowel disease, and active smoking history were not significantly associated with the development of CD. Drinking history showed a decreased OR for the development of CD (0.39, 0.19-0.77). "Passive smoking Yes" showed significantly increased OR (2.49, 1.09-5.73). Regarding the association between passive smoking and the development of CD, the OR increased as the number of cigarettes per day, smoking time per day, and smoking duration increased, and there was a dose-response relationship (trend P = 0.024, 0.032, 0.038). Conclusions The association between environmental factors and the development of CD among Japanese was examined by case-control study. It was suggested that the passive smoking history may be associated to the development of CD.

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How Can We Assess "Complete Healing" Beyond Endoscopic Remission?

Fukuda T., Naganuma M., Kanai T.

Inflammatory bowel diseases (Inflammatory bowel diseases) 25 ( 6 ) 2019.05

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Risk factors associated with pseudoaldosteronism in patients with chronic hepatitis: A retrospective cohort study

Komatsu A., Yoshino T., Suzuki T., Nakamura T., Kanai T., Watanabe K.

Basic and Clinical Pharmacology and Toxicology (Basic and Clinical Pharmacology and Toxicology) 124 ( 5 ) 607 - 614 2019.05

ISSN 17427835

© 2018 Nordic Association for the Publication of BCPT (former Nordic Pharmacological Society) Glycyrrhizin is used to treat chronic hepatitis, but it also plays an important role in pseudoaldosteronism. Multidrug resistance-associated protein 2 is important for glycyrrhizin excretion. Dysfunction of this transporter increases the serum levels of direct bilirubin, glycyrrhizin and its metabolites. Hence, elevated direct-bilirubin levels could predict the risk of pseudoaldosteronism. This study aimed to evaluate the relationship between elevated direct-bilirubin levels and hypokalaemia, which is the most sensitive marker of pseudoaldosteronism. This retrospective cohort study was conducted in a Japanese university hospital. The occurrence of hypokalaemia is defined as a serum potassium level of ≤3.5 mEq/L after the administration of a glycyrrhizin-containing medication, and a further decline of ≥0.5 mEq/L or an increase of ≥0.5 mEq/L after discontinuing the glycyrrhizin-containing medication was examined in patients with chronic hepatitis between January 2009 and December 2015. This analysis involved 1392 patients, including 596 women. Hepatitis C virus infections were the most common cause of chronic hepatitis in this study. Seventy-nine patients received glycyrrhizin (exposed group; mean age: 60.5 ± 14.2) and 1313 did not receive glycyrrhizin (control group; mean age: 58.3 ± 15.8 years). Synergistic effects of glycyrrhizin-containing medications and elevated direct-bilirubin levels were associated with hypokalaemia. Elevated direct-bilirubin levels and hypoalbuminaemia were associated with hypokalaemia in the exposed group. Older age, female sex, high daily glycyrrhizin dosage, longer duration of glycyrrhizin intake, and potassium-lowering medications were not associated with hypokalaemia after the model adjustment. Elevated direct-bilirubin levels and hypoalbuminaemia may predict pseudoaldosteronism caused by glycyrrhizin.

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Recent topics in intestinal microbiota and fecal microbiota transplantation

Mizuno S., Kanai T.

Otolaryngology - Head and Neck Surgery (Japan) (Otolaryngology - Head and Neck Surgery (Japan)) 91 ( 6 ) 467 - 471 2019.05

ISSN 09143491

Impact of Antimicrobial Prophylaxis for Severe Acute Pancreatitis on the Development of Invasive Candidiasis: A Large Retrospective Multicenter Cohort Study

Horibe M., Sanui M., Sasaki M., Honda H., Ogura Y., Namiki S., Sawano H., Goto T., Ikeura T., Takeda T., Oda T., Yasuda H., Miyazaki D., Hirose K., Kitamura K., Chiba N., Ozaki T., Yamashita T., Koinuma T., Oshima T., Yamamoto T., Hirota M., Yamamoto S., Oe K., Ito T., Masuda Y., Saito N., Iwasaki E., Kanai T., Mayumi T.

Pancreas (Pancreas) 48 ( 4 ) 537 - 543 2019.04

ISSN 08853177

© 2019 Wolters Kluwer Health, Inc. All rights reserved. Objective Antimicrobial prophylaxis is not generally recommended for patients with severe acute pancreatitis (SAP) owing to the limited clinical benefits. Nonetheless, it is frequently administered in actual practice given the patients' critical condition and the lack of solid evidence showing adverse effects of antimicrobial prophylaxis. We evaluated herein an association between antimicrobial prophylaxis and invasive pancreatic candidiasis as an adverse effect in patients with SAP. Methods This is a retrospective cohort study of all consecutive patients with SAP who were admitted to the study institutions (n = 44) between January 1, 2009, and December 31, 2013. We performed multivariable logistic regression analysis adjusting for the extent of pancreatic necrosis and surgical interventions for invasive pancreatic candidiasis. Results Of the 1097 patients with SAP, 850 (77.5%) received antimicrobial prophylaxis, and 21 (1.9%) had invasive pancreatic candidiasis. In multivariable logistic regression analysis, antimicrobial prophylaxis was significantly associated with the development of invasive pancreatic candidiasis (adjusted odds ratio, 4.23; 95% confidence interval, 1.14-27.6) (P = 0.029). Conclusions The results suggest that antimicrobial prophylaxis may contribute to the development of invasive pancreatic candidiasis, and therefore, the routine use of antimicrobial prophylaxis for SAP may be discouraged.

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Correction: Vedolizumab in Japanese patients with ulcerative colitis: A Phase 3, randomized, double-blind, placebo-controlled study (PLoS ONE (2019) 14:2 (e0212989) DOI: 10.1371/journal.pone.0212989)

Motoya S., Watanabe K., Ogata H., Kanai T., Matsui T., Suzuki Y., Shikamura M., Sugiura K., Oda K., Hori T., Araki T., Watanabe M., Hibi T.

PLoS ONE (PLoS ONE) 14 ( 4 ) 2019.04

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Clinical and endoscopic findings to assist the early detection of duodenal adenoma and adenocarcinoma

Matsuzaki J., Suzuki H., Shimoda M., Mori H., Fukuhara S., Miyoshi S., Masaoka T., Iwao Y., Kanai Y., Kanai T.

United European Gastroenterology Journal (United European Gastroenterology Journal) 7 ( 2 ) 250 - 260 2019.03

ISSN 20506406

© Author(s) 2018. Background: Sporadic nonampullary duodenal adenocarcinoma is a rare malignant neoplasm in which poor prognosis is often associated with delayed diagnosis. Objective: A case-control study was designed to evaluate the clinical and endoscopic characteristics of patients with nonampullary duodenal epithelial tumours (NADETs). Methods: Patients with NADETs were chronologically divided into a discovery and a validation sets. Two age- and sex-matched control individuals for each case in the discovery set were randomly selected from individuals without NADET. A prediction model for the presence of NADET, constructed in the discovery set, was evaluated in the validation set. Results: In total, 368 adenomas, 81 adenocarcinomas, and 314 controls were analysed. Current smoking, Barrett oesophagus, fundic gland polyps, history of malignant disease, and absence of dyslipidaemia were independently associated with the presence of NADET. The combination of these five factors enabled significant discrimination for NADET in the bulb with a sensitivity of 0.81 in the validation set. We also showed that duodenal adenocarcinomas in the bulb had greater invasive potential than adenocarcinomas in the second portion. Conclusion: The presence of a duodenal tumour in the bulb could be predicted by clinical and endoscopic findings, which helps improve the prognosis and quality of life of patients.

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Gut pathobionts underlie intestinal barrier dysfunction and liver T helper 17 cell immune response in primary sclerosing cholangitis

Nakamoto N., Sasaki N., Aoki R., Miyamoto K., Suda W., Teratani T., Suzuki T., Koda Y., Chu P., Taniki N., Yamaguchi A., Kanamori M., Kamada N., Hattori M., Ashida H., Sakamoto M., Atarashi K., Narushima S., Yoshimura A., Honda K., Sato T., Kanai T.

Nature Microbiology (Nature Microbiology) 4 ( 3 ) 492 - 503 2019.03

© 2019, The Author(s), under exclusive licence to Springer Nature Limited. Primary sclerosing cholangitis (PSC) is a chronic inflammatory liver disease and its frequent complication with ulcerative colitis highlights the pathogenic role of epithelial barrier dysfunction. Intestinal barrier dysfunction has been implicated in the pathogenesis of PSC, yet its underlying mechanism remains unknown. Here, we identify Klebsiella pneumonia in the microbiota of patients with PSC and demonstrate that K. pneumoniae disrupts the epithelial barrier to initiate bacterial translocation and liver inflammatory responses. Gnotobiotic mice inoculated with PSC-derived microbiota exhibited T helper 17 (T H 17) cell responses in the liver and increased susceptibility to hepatobiliary injuries. Bacterial culture of mesenteric lymph nodes in these mice isolated K. pneumoniae, Proteus mirabilis and Enterococcus gallinarum, which were prevalently detected in patients with PSC. A bacterial-organoid co-culture system visualized the epithelial-damaging effect of PSC-derived K. pneumoniae that was associated with bacterial translocation and susceptibility to T H 17-mediated hepatobiliary injuries. We also show that antibiotic treatment ameliorated the T H 17 immune response induced by PSC-derived microbiota. These results highlight the role of pathobionts in intestinal barrier dysfunction and liver inflammation, providing insights into therapeutic strategies for PSC.

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Novel mainstream capnometer system is safe and feasible even under CO <inf>2</inf> insufflation during ERCP-related procedure: A pilot study

Takimoto Y., Iwasaki E., Masaoka T., Fukuhara S., Kawasaki S., Seino T., Katayama T., Minami K., Tamagawa H., Machida Y., Ogata H., Kanai T.

BMJ Open Gastroenterology (BMJ Open Gastroenterology) 6 ( 1 ) 2019.02

© Author(s) (or their employer(s)) 2019. Background and aims There is a need to safely achieve conscious sedation during endoscopic retrograde cholangiopancreatography (ERCP). We evaluated the safety and feasibility of a mainstream capnometer system to monitor apnoea during ERCP under CO 2 insufflation. Methods Non-intubated adult patients undergoing ERCP-related procedures with intravenous sedation were enrolled. End-tidal CO 2 (EtCO 2 ) was continuously monitored during the procedure under CO 2 insufflation using a mainstream capnometer system, comprising a capnometer and a specially designed bite block for upper gastrointestinal endoscopy and ERCP. Oxygen saturation (SpO 2) was also monitored continuously during the procedure. In this study, we evaluated the safety and feasibility of the capnometer system. Results Eleven patients were enrolled. Measurement of EtCO 2 concentration was possible from the beginning to the end of the procedure in all 11 cases. There was no measurement failure, dislocation of the bite block, or adverse event related to the bite block. Apnoea linked to hypoxaemia occurred five times (mean duration, 174.4 s). Conclusion This study confirmed that apnoea was detected earlier than when using a percutaneous oxygen monitor. Measurement of EtCO 2 concentration using the newly developed mainstream capnometer system was feasible and safe even under CO 2 insufflation.

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Vedolizumab in Japanese patients with ulcerative colitis: A Phase 3, randomized, double-blind, placebo-controlled study

Motoya S., Watanabe K., Ogata H., Kanai T., Matsui T., Suzuki Y., Shikamura M., Sugiura K., Oda K., Hori T., Araki T., Watanabe M., Hibi T.

PLoS ONE (PLoS ONE) 14 ( 2 ) 2019.02

© 2019 Motoya et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Background Vedolizumab safety and efficacy have been established in many populations all over the world, but have never been studied in Japan. We report results from a Phase 3, randomized, double-blind, placebo-controlled study of vedolizumab in Japanese patients with active ulcerative colitis (UC). Methods Patients with moderate-to-severe UC were enrolled into Cohort 1 (double-blinded) or Cohort 2 (open-label) in the induction phase. Cohort 1 was randomized 2:1 to receive 300 mg vedolizumab or placebo, while Cohort 2 received vedolizumab 300 mg only, at Weeks 0, 2, and 6. Patients from Cohorts 1 and 2 showing a clinical response to vedolizumab at Week 10 were randomized 1:1 to receive vedolizumab or placebo (double-blinded) at Week 14 and then every 8 weeks up to Week 54 as the maintenance phase. The primary endpoint was clinical response at Week 10, for the induction phase, and clinical remission at Week 60, for the maintenance phase. Results A total of 292 patients were enrolled into the induction phase (246 in Cohort 1, 46 in Cohort 2); 83 patients achieved response to vedolizumab and were subsequently enrolled into the maintenance phase. Clinical response rates at Week 10 were 39.6% (65/164) and 32.9% (27/82) in the vedolizumab and placebo groups in Cohort 1, respectively (adjusted odds ratio [AOR] = 1.37, 95% CI 0.779–2.399; p = 0.2722). In the maintenance phase, clinical remission rate at Week 60 was significantly higher in the vedolizumab group, at 56.1% (23/ 41), versus 31.0% (13/42) for placebo (AOR = 2.88, 95% CI 1.168–7.108; p = 0.0210). Most adverse events were mild to moderate in intensity, and no deaths occurred during the study period. Conclusions Vedolizumab showed numerically greater efficacy compared with placebo as induction therapy, but the difference was not statistically significant. Vedolizumab was significantly superior to placebo as maintenance therapy in Japanese patients with UC. Vedolizumab has favourable safety and tolerability in these patients.

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Current new challenges in the management of ulcerative colitis

Fukuda T., Naganuma M., Kanai T.

Intestinal Research (Intestinal Research) 17 ( 1 ) 36 - 44 2019.01

ISSN 15989100

© 2019, Korean Association for the Study of Intestinal Diseases. All rights reserved. Ulcerative colitis (UC) is a chronic inflammatory condition of the gastrointestinal tract. Although the cause of UC is postulated to be multifactorial in nature, including genetic predisposition, epithelial barrier defects, dysregulation of immune responses, and environmental factors, the specific pathogenesis of UC is still incompletely understood. In the treatment of UC so far, a method of suppressing immunity and treating it has been mainstream. Immunosuppressant drugs, including thiopurines (azathioprine or 6-mercaptopurine), anti-tumor necrosis factor-α (anti-TNF-α) antibody (infliximab and adalimumab), and calcineurin inhibitor, can be used in treat patients with corticosteroid-dependent and/or corticosteroid-refractory moderateto-severe UC. Recently, in addition to such a conventional therapeutic agent, golimumab, which is the first transgenic human monoclonal anti-TNF-α antibody to be fabricated, anti α-4/β-7 integrin antibody, and Janus kinase inhibitor have been reported to novel immunosuppressant therapy. Furthermore, other treatments with unique mechanisms different from immunosuppression, have also been suggested, including fecal microbiota transplantation and Indigo naturalis, which is a Chinese herbal medicine. We compared the features and efficacy of these new treatments. In this issue, the features and treatment options for these new treatments is reviewed.

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First report of hepatobiliary Mycobacterium avium infection developing obstructive jaundice in a patient with neutralizing anti–interferon-gamma autoantibodies

Namkoong H., Asakura T., Ishii M., Yoda S., Masaki K., Sakagami T., Iwasaki E., Yamagishi Y., Kanai T., Betsuyaku T., Hasegawa N.

New Microbes and New Infections (New Microbes and New Infections) 27 4 - 6 2019.01

ISSN 20522975

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Development of an Indigo Naturalis Suppository for Topical Induction Therapy in Patients with Ulcerative Colitis

Yoshimatsu Y., Naganuma M., Sugimoto S., Tanemoto S., Umeda S., Fukuda T., Nomura E., Yoshida K., Ono K., Mutaguchi M., Nanki K., Mizuno S., Mikami Y., Fukuhara K., Sujino T., Takabayashi K., Ogata H., Iwao Y., Kanai T.

Digestion (Digestion) 101 ( 4 ) 492 - 498 2019

ISSN 00122823

© 2019 S. Karger AG, Basel. All rights reserved. Background: Indigo naturalis (IN) consists of ligands for the aryl hydrocarbon receptor and exhibits anti-inflammatory effects. Previously, we demonstrated that an 8-week treatment with oral IN is effective in inducing a clinical response in patients with ulcerative colitis (UC). Some UC patients with proctitis are refractory to topical mesalamine or corticosteroids and therefore require an alternative topical treatment. Objectives: We aimed to prospectively evaluate the safety and efficacy of IN suppositories in UC patients. Method: We performed an open-label, single-center, prospective pilot study from February 2018 to October 2018. A total of 10 patients with active UC, who had moderate to severe inflammation from the rectum to the sigmoid colon, were enrolled. The patients received a daily dose of 50 mg IN suppository for 4 weeks. The primary endpoint was safety at week 4. Results: Although 1 patient experienced anal pain, no serious adverse events were observed. At week 4, the rates of clinical remission and mucosal healing were 30 and 40%, respectively. Mayo rectal bleeding subscores significantly improved after treatment (1.80 ± 0.13 vs. 0.90 ± 0.28; p = 0.009). Approximately 80% of the patients with a baseline Mayo endoscopic subscore in the rectum (r-MES) of 2 achieved mucosal healing, but those with a baseline r-MES of 3 did not. Conclusions: We found that 4 weeks of IN suppository can be tolerated by UC patients, but its efficacy was limited by the severity of the disease. Further investigation will be needed in order to confirm the optimum dose of IN suppository for patients with UC.

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Colonic diverticular bleeding and predictors of the length of hospitalization: An observational study

Wada M., Nishizawa T., Kato M., Hirai Y., Kinoshita S., Mori H., Nakazato Y., Fujimoto A., Kikuchi M., Uraoka T., Kanai T.

Journal of Gastroenterology and Hepatology (Australia) (Journal of Gastroenterology and Hepatology (Australia)) 34 ( 8 ) 1351 - 1356 2019

ISSN 08159319

© 2019 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd Background and Aim: A significant percentage of patients with colonic diverticular bleeding (CDB) experience bleeding that is severe enough to necessitate prolonged hospitalization. Prolonged hospitalization causes deterioration in patients' quality of life, as well as difficulties with cost-effective utilization of medical resources, and is a financial burden to the society. Therefore, we investigated the factors associated with the length of hospitalization for the optimal management of patients hospitalized with CDB. Methods: This study included patients who were hospitalized for the treatment of CDB and underwent colonoscopy between July 2008 and February 2016. Logistic regression analysis was performed to investigate the association between the length of hospitalization and the patients' baseline characteristics, in-hospital procedures performed, and the clinical outcomes. Results: The study included 223 patients. Diabetes mellitus (odds ratio [OR] 3.4, P = 0.014) and blood transfusion (OR 3.1, P = 0.0006) were identified as risk factors for prolonged hospitalization (≥ 8 days). Urgent colonoscopy (OR 0.41, P = 0.0072) predicted a shorter length of hospitalization (≤ 7 days). The study also indicated that endoscopic treatment showed a stronger association with urgent colonoscopy (OR 7.8, P < 0.0001) than with elective colonoscopy and that urgent colonoscopy was not associated with an increased rate of adverse events or re-bleeding. Conclusions: Compared with elective colonoscopy, urgent colonoscopy shortens the length of hospitalization in patients with CDB. Moreover, it is not associated with an increased rate of adverse events. Urgent colonoscopy may be impracticable in a few cases; however, if possible, aggressive urgent colonoscopy should be considered for the efficient management of the patient's hospital stay.

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Capsule endoscopy for small-intestinal disorders: Current status

Hosoe N., Takabayashi K., Ogata H., Kanai T.

Digestive Endoscopy (Digestive Endoscopy) 31 ( 5 ) 498 - 507 2019

ISSN 09155635

© 2019 Japan Gastroenterological Endoscopy Society Small-bowel capsule endoscopy (SBCE) is used widely because of its non-invasive and patient-friendly nature. SBCE can visualize entire small-intestinal mucosa and facilitate detection of small-intestinal abnormalities. In this review article, we focus on the current status of SBCE. Several platforms for SBCE are available worldwide. Third-generation SBCE (PillCam ® SB3) has a high-resolution camera equipped with an adaptive frame rate system. Several software modes have been developed to reduce the reading time for capsule endoscopy and to minimize the possibility of missing lesions. The main complication of SBCE is capsule retention. Thus, the main contraindication for SBCE is known or suspected gastrointestinal obstruction unless intestinal patency is proven. Possible indications for SBCE are obscure gastrointestinal bleeding, Crohn's disease, small-intestinal polyps and tumors, and celiac disease. Colon capsule endoscopy (CCE) can observe inflamed colonic mucosa non-invasively, and allows for the continuous and non-invasive observation of the entire intestinal tract (pan-endoscopy). Recently, application of CCE as pan-enteric endoscopy for inflammatory bowel diseases (including Crohn's disease) has been reported. In the near future, reading for CE will be assisted by artificial intelligence, and reading CE videos for long periods will not be required.

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Adverse events in patients with ulcerative colitis treated with indigo naturalis: a Japanese nationwide survey

Naganuma M., Sugimoto S., Suzuki H., Matsuno Y., Araki T., Shimizu H., Hayashi R., Fukuda T., Nakamoto N., Iijima H., Nakamura S., Kataoka M., Tamura Y., Tatsumi K., Hibi T., Suzuki Y., Kanai T., Yoshimatsu Y., Chu P., Uchino M., Watanabe K., Hirano A., Esaki M., Ueno Y., Yamamoto T., Sawada K., Kawashima K., Ishihara S., Hashimoto S., Yokoyama J., Ashizuka S., Toyokawa T., Sakuraba H., Matsueda K., Yoshimura N., Ohmiya N., Kayashima Y., Yanai S., Matsumoto T., Kobayashi H., Nakajima S., Nishida T., Takeuchi Y., Ina K., Kawamura T.

Journal of Gastroenterology (Journal of Gastroenterology) 54 ( 10 ) 891 - 896 2019

ISSN 09441174

© 2019, Japanese Society of Gastroenterology. Background: Although indigo naturalis (IN) is effective for patients with active ulcerative colitis (UC), IN was associated with adverse events (AEs), including pulmonary arterial hypertension (PAH). Our aim was to evaluate the occurrence of IN-associated AEs and to evaluate any IN dose–effect on AEs. Methods: A nationwide survey, using questionnaires, was conducted by conducted by the research group funded by the Ministry of Health, Labour and Welfare of Japan, between June 2017 and September 2018. A first questionnaire determined the occurrence of AEs associated with the therapeutic use of IN or herbal medicines containing IN in patients with UC. A second survey identified the clinical characteristics of patients who developed IN-associated critical AEs, namely, liver dysfunction, PAH, and intussusception. Results: Across 337 participating institutions, 49,320 patients with UC were identified, with IN used in 877 (1.8%). AEs were reported in 91 patients (107 events), including liver dysfunction (n = 40), gastrointestinal symptoms (n = 21), headache (n = 13), and PAH (n = 11). No dose–effect relationship between IN and AEs was identified. Liver dysfunction tended to be mild and reversible. Ten cases of intussusception were reported, with 40% of these patients requiring surgical resection. IN-induced PAH was recovered in patients who discontinued to use IN. No IN-associated deaths were reported. Conclusions: IN-associated AEs were identified among patients with UC, with liver dysfunction often being reversible, while surgical resection was required in a high proportion of patients who developed intussusception. Both healthcare workers and patients should adequately recognize the potential for AEs with the use of IN.

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Long-term effect of NUDT15 R139C on hematologic indices in inflammatory bowel disease patients treated with thiopurine

Akiyama S., Matsuoka K., Fukuda K., Hamada S., Shimizu M., Nanki K., Mizuno S., Kiyohara H., Arai M., Sugimoto S., Iwao Y., Ogata H., Hisamatsu T., Naganuma M., Motobayashi M., Suzuki K., Takenaka K., Fujii T., Saito E., Nagahori M., Ohtsuka K., Mochizuki M., Watanabe M., Hashiguchi M., Kanai T.

Journal of Gastroenterology and Hepatology (Australia) (Journal of Gastroenterology and Hepatology (Australia)) 34 ( 10 ) 1751 - 1757 2019

ISSN 08159319

© 2019 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd Background and Aim: A missense variant of the nucleoside diphosphate-linked moiety X-type motif 15 (NUDT15) gene (R139C) predisposes Asian patients with inflammatory bowel disease (IBD) to thiopurine-induced leukopenia. This study evaluates the long-term effect of NUDT15 R139C heterozygosity on hematological parameters during thiopurine administration. Methods: We enrolled 83 Japanese IBD patients who were on anti-tumor necrosis factor-α agents and had used thiopurine. NUDT15 R139C was genotyped by polymerase chain reaction. We retrospectively reviewed patient clinical charts to collect data on white blood cell (WBC) count, mean corpuscular volume (MCV), hemoglobin, and platelet count during the 24 months following thiopurine initiation. Results: The included patients had either Crohn's disease (54; 65.1%) or ulcerative colitis (29; 34.9%). Genotyping of NUDT15 R139C identified 62 patients (74.7%) of genotype C/C and 21 (25.3%) of genotype C/T. The median dose of thiopurine was lower in the C/T group than in the C/C group after starting thiopurine. At 6 months, the mean WBC count of the C/T group became significantly lower than that of the C/C group (P = 0.008) and remained lower through the 24 months. The C/T group developed grade 2–4 leukopenia by 6 months, which persisted through 12–24 months. The mean MCV in the C/T group became higher than that of the C/C group after 3 months. Conclusions: NUDT15 R139C heterozygosity affected the WBC count and MCV for 24 months after thiopurine administration. Our results indicate that careful monitoring of leukopenia and dose adjustment are necessary throughout treatment in IBD patients heterozygous for the NUDT15 R139C.

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Negative effect of fatty liver on visualization of pancreatic cystic lesions at screening transabdominal ultrasonography

Kashiwagi K., Seino T., Makino K., Shimizu-Hirota R., Takayama M., Yoshida T., Iwasaki E., Sugino Y., Inoue N., Iwao Y., Kanai T.

Journal of Evaluation in Clinical Practice (Journal of Evaluation in Clinical Practice) 26 ( 1 ) 256 - 261 2019

ISSN 13561294

© 2019 John Wiley & Sons, Ltd. Rationale, aims, and objectives: The aim of this observational study is to identify factors by which some pancreatic cystic lesions (PCLs) were undetectable at transabdominal ultrasonography (TAUS), using magnetic resonance imaging (MRI) as reference standard. Methods: The database for 781 consecutive subjects who underwent a health checkup including fat computed tomography and upper abdominal MRI as option was searched. The presence of fatty liver and fatty pancreas was diagnosed by TAUS, and atrophic pancreas was determined by reevaluating the image of the pancreas in the chest computed tomography for screening. Subjects with PCL detected and those undetected at TAUS were statistically compared in clinical characteristics. Results: The prevalence of PCL detected at MRI was 17.8% in the general population. Multivariate logistic regression analysis showed that fatty liver, body mass index, and the size of PCL were significantly associated with the factors influencing the visualization of PCL at TAUS (odds ratio [OR]: 0.337, 95% confidence interval [CI]: 0.154-0.734, P = 0.006; OR: 0.852, 95% CI: 0.737-0.985, P = 0.030; OR:1.120, 95% CI: 1.045-1.200, P =.001). Thirty-six PCLs (64.3%) in a total of 56 PCLs were undermeasured by TAUS. Additionally, nine (56%) out of 16 PCLs (≥ 15 mm) were undermeasured by 5 mm or more by TAUS, although a significantly higher detection rate was observed for PCLs (≥ 15 mm) in comparison with that for PCLs (< 15 mm) (80% vs 33.6%, P =.000). Conclusions: It should be noted that coexisting fatty liver may lower the detection of PCL, and its size may be underestimated by TAUS.

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Transient hypotension during endoscopic resection of gangliocytic paraganglioma with ampullary involvement

Katayama T., Iwasaki E., Minami K., Fukuhara S., Kanai T.

VideoGIE (VideoGIE) 5 ( 1 ) 26 - 28 2019

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The Effect of an Invasive Strategy for Treating Pancreatic Necrosis on Mortality: a Retrospective Multicenter Cohort Study

Minami K., Horibe M., Sanui M., Sasaki M., Iwasaki E., Sawano H., Goto T., Ikeura T., Takeda T., Oda T., Yasuda H., Ogura Y., Miyazaki D., Kitamura K., Chiba N., Ozaki T., Yamashita T., Koinuma T., Oshima T., Yamamoto T., Hirota M., Tokuhira N., Azumi Y., Nagata K., Takeda K., Furuya T., Lefor A., Mayumi T., Kanai T.

Journal of Gastrointestinal Surgery (Journal of Gastrointestinal Surgery) 24 ( 9 ) 2037 - 2045 2019

ISSN 1091255X

© 2019, The Society for Surgery of the Alimentary Tract. Background: Infected acute necrotic collections (ANC) and walled-off necrosis (WON) of the pancreas are associated with high mortality. The difference in mortality between open necrosectomy and minimally invasive therapies in these patients remains unclear. Methods: This retrospective multicenter cohort study was conducted among 44 institutions in Japan from 2009 to 2013. Patients who had undergone invasive treatment for suspected infected ANC/WON were enrolled and classified into open necrosectomy and minimally invasive treatment (laparoscopic, percutaneous, and endoscopic) groups. The association of each treatment with mortality was evaluated and compared. Results: Of 1159 patients with severe acute pancreatitis, 122 with suspected infected ANC or WON underwent the following treatments: open necrosectomy (33) and minimally invasive treatment (89), (laparoscopic three, percutaneous 49, endoscopic 37). Although the open necrosectomy group had a significantly higher mortality on univariate analysis (p = 0.047), multivariate analysis showed no significant associations between open necrosectomy or Charlson index and mortality (p = 0.29, p = 0.19, respectively). However, age (for each additional 10 years, p = 0.012, odds ratio [OR] 1.50, 95% confidence interval [CI] 1.09–2.06) and revised Atlanta criteria-severe (p = 0.001, OR 7.84, 95% CI 2.40–25.6) were significantly associated with mortality. Conclusions: In patients with acute pancreatitis and infected ANC/WON, age and revised Atlanta criteria-severe classification are significantly associated with mortality whereas open necrosectomy is not. The mortality risk for patients undergoing open necrosectomy and minimally invasive treatment does not differ significantly. Although minimally invasive surgery is generally preferred for patients with infected ANC/WON, open necrosectomy may be considered if clinically indicated.

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Neutrophil-activating Protein Polymorphism of Helicobacter pylori Determines the Host Risk of Dyspepsia

Matsuzaki J., Tsugawa H., Kashiwazaki Y., Mori H., Yamamoto Y., Kameyama H., Masaoka T., Kanai T., Suzuki H.

Cellular and Molecular Gastroenterology and Hepatology (Cellular and Molecular Gastroenterology and Hepatology) 8 ( 2 ) 295 - 297.e6 2019

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Middle-term prognosis in patients with ulcerative colitis who achieved clinical and endoscopic remission by budesonide rectal foam

Naganuma M., Hirai F., Kobayashi K., Watanabe K., Takeuchi K., Aoyama N., Nozawa H., Motoya S., Ohmori T., Harada A., Nagai Y., Abe T., Yamada Y., Inagaki K., Shimizu N., Kanai T., Watanabe M., Tanaka S., Arai T., Kishi M., Watanabe C., Sakata Y., Ashida T., Maemoto A., Sai S., Kitano A., Sameshima Y., Yokoyama K., Kobayashi T., Suekane T., Matsuda K., Obata H., Fujiya M., Shirai T., Tominaga K., Takedatsu H., Suzuki R.

PLoS ONE (PLoS ONE) 14 ( 8 ) 2019

© 2019 Naganuma et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Background Budesonide foam is effective in inducing clinical remission in ulcerative colitis (UC) patients with active proctosigmoiditis. The aim of this study was to evaluate the duration of remission and predictors of relapse in UC patients who achieved clinical remission and mucosal healing by 6-week treatment with topical budesonide. Methods This is a retrospective, observational, multicenter study with a 2-year follow-up period. UC patients who were treated with budesonide foam in phase 2 or phase 3 clinical trials and achieved both clinical remission and mucosal healing were enrolled. Results Among 84 patients who met the eligibility criteria, 60 participated in the study. Eighteen of the 60 patients (30.0%; 95% confidence interval [CI]: 18.9–43.2) experienced no relapse (i.e., maintenance of remission) during the 2-year follow-up period. The median relapse-free survival time was 0.82 years (95% CI: 0.51–1.52). Of 37 patients with a Mayo endoscopic subscore of 0 after inducing remission with budesonide foam, 25 (67.6%) relapsed within 2 years. Patients with a disease duration of <1 year experienced a worse clinical outcome than patients with a disease duration of >5 years, and the hazard ratio was 2.38 (95% CI: 1.04–5.45). Conclusion This is the first study to evaluate the short- to middle-term prognosis in UC patients who achieved mucosal healing with topical preparations. After inducing remission by budesonide foam, treatment for maintaining remissions and strict follow-up may be needed for patients with shorter disease duration.

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Management of perforation related to endoscopic submucosal dissection for superficial duodenal epithelial tumors

Fukuhara S., Kato M., Iwasaki E., Sasaki M., Tsutsumi K., Kiguchi Y., Akimoto T., Takatori Y., Nakayama A., Maehata T., Minami K., Ogata H., Kanai T., Yahagi N.

Gastrointestinal Endoscopy (Gastrointestinal Endoscopy) 91 ( 5 ) 1129 - 1137 2019

ISSN 00165107

© 2019 American Society for Gastrointestinal Endoscopy Background and Aims: Endoscopic submucosal dissection (ESD) is being performed more frequently as a local treatment for superficial duodenal epithelial tumors (SDETs). However, ESD for SDETs is technically difficult because of specific anatomic features that increase the risk of perforation and often require surgery. This study was performed to evaluate the management of ESD-related perforation in patients with SDETs. Methods: Patients who underwent ESD for SDETs from July 2010 to December 2018 were studied. We collected data on complete closure, insertion of endoscopic nasobiliary and pancreatic duct drainage (ENBPD) tubes, and additional interventions. We also evaluated clinical outcomes, including the fasting period, hospital stay, and maximum serum C-reactive protein level. Results: ESD was completed in 264 patients with SDETs. Perforation was observed in 36 patients, including 4 patients with delayed perforation. Among 32 patients with intraoperative perforation, complete closure was achieved in 13 patients. Compared with patients without complete closure, the fasting period and hospital stay were significantly shorter and the maximum serum C-reactive protein level was significantly lower in patients with complete closure, which were equivalent to those in patients without perforation. In patients without complete closure for mucosal defect, no additional interventions were required when an ENBPD tube was inserted, whereas 2 patients without ENBPD tube insertion underwent additional interventions such as percutaneous drainage and a surgical operation. Conclusions: Perforation associated with ESD for SDETs required complex conservative management with complete closure or insertion of an ENBPD tube.

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Late-onset visceral varicella-zoster virus infection presented as acute liver failure after allogeneic hematopoietic stem cell transplantation

Kikuchi T., Arai M., Koda Y., Kato J., Shimizu T., Katano H., Fujii-Nishimura Y., Sakamoto M., Ebinuma H., Nakamoto N., Kanai T., Okamoto S., Mori T.

Transplant Infectious Disease (Transplant Infectious Disease) 21 ( 4 ) 2019

ISSN 13982273

© 2019 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd Although much less common than localized zoster, initial presentation of varicella-zoster virus (VZV) as visceral infection can occur especially after allogeneic hematopoietic stem cell transplantation (HSCT). We herein report a case of post-transplant visceral VZV infection presenting as fatal acute liver failure. It developed 4 years after allogeneic HSCT when a long-term prophylactic anti-VZV agent administration was discontinued. VZV should be listed as a causative pathogen of acute liver failure even years after allogeneic HSCT. Indication for, and duration of anti-VZV prophylaxis should be further investigated.

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Indigo naturalis is effective even in treatment-refractory patients with ulcerative colitis: a post hoc analysis from the INDIGO study

Naganuma M., Sugimoto S., Fukuda T., Mitsuyama K., Kobayashi T., Yoshimura N., Ohi H., Tanaka S., Andoh A., Ohmiya N., Saigusa K., Yamamoto T., Morohoshi Y., Ichikawa H., Matsuoka K., Hisamatsu T., Watanabe K., Mizuno S., Abe T., Suzuki Y., Kanai T., Naganuma M., Nakazato Y., Teratani T., Ogata H., Iwao Y., Yamasaki H., Toyonaga T., Nakano M., Hibi T., Sameshima Y., Hayashi R., Ueno Y., Bamba S., Watanabe M., Nakazawa A., Koike Y., Imai J., Shimoyama T., Takeuchi K., Nagasaka M., Kitano A., Ashizuka S., Inatsu H., Onodera K., Nakase H., Kitamura K., Ikeya K., Hanai H., Watanabe C., Hokari R., Hirai F., Naito Y., Hoshi N., Kinjo F., Ishiguro Y., Sasaki M., Matsumoto T., Sano F., Roberts R., Suda W., Hattori M., Fukuda S., Hirayama A.

Journal of Gastroenterology (Journal of Gastroenterology) 55 ( 2 ) 169 - 180 2019

ISSN 09441174

© 2019, Japanese Society of Gastroenterology. Background: We recently reported the efficacy of indigo naturalis (IN) in patients with active ulcerative colitis (UC) in a randomized controlled trial (INDIGO study). However, few studies have been conducted to investigate whether IN is effective even in treatment-refractory cases, such as in those with steroid dependency and anti-TNF refractoriness. Methods: In the INDIGO study, 86 patients with active UC were randomly assigned to an IN group (0.5–2.0 g daily) or placebo group. The rate of clinical response (CR), mucosal healing (MH), and change in fecal calprotectin (FCP) levels was compared between refractory [patients with steroid-dependent disease, previous use of anti-TNF-α, and concomitant use of immunomodulators (IM)] and non-refractory patients. We also analyzed factors predicting CR and MH at week 8. Results: The rates of CR of IN group were significantly higher than placebo group, even in patients with steroid-dependent disease (p < 0.001), previous use of anti-TNF-α (p = 0.002), and concomitant use of IM (p = 0.013). The rates of MH in IN group were significantly higher than in placebo group in patients with steroid-dependent disease (p = 0.009). In the IN group, median FCP levels, at week 8, were significantly lower than baseline in patients with steroid-dependent disease and patients with the previous use of anti-TNF-α (p < 0.001, respectively). Multivariate analysis indicated that the previous use of anti-TNF-α was not a predictive factor for CR and MH at week 8. Conclusions: In a sub-analysis of data from a randomized placebo-controlled trial, we found that IN may be useful even in patients with steroid-dependent disease and patients with the previous use of anti-TNF-α.

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Impact of electrical pulse cut mode during endoscopic papillectomy: Pilot randomized clinical trial

Iwasaki E., Minami K., Itoi T., Yamamoto K., Tsuji S., Sofuni A., Tsuchiya T., Tanaka R., Tonozuka R., Machida Y., Takimoto Y., Tamagawa H., Katayama T., Kawasaki S., Seino T., Horibe M., Fukuhara S., Kitago M., Ogata H., Kanai T.

Digestive Endoscopy (Digestive Endoscopy) 32 ( 1 ) 127 - 135 2019

ISSN 09155635

© 2019 Japan Gastroenterological Endoscopy Society Objective: Endoscopic papillectomy is increasingly being used for ampullary adenoma treatment. However, it remains challenging despite increased safety with treatment advances. The ideal power output and electrosurgical current mode for mucosal resection are not established. We aimed to identify the ideal electrical pulse for use during resection. Methods: This pilot randomized, single-blind, prospective, multicenter trial, recruited patients with ampullary adenomas and conventional anatomy who were scheduled to undergo endoscopic papillectomy. Endoscopic treatment was performed using a standardized algorithm and patients were randomized for endoscopic papillectomy with Endocut or Autocut. The primary outcome was the incidence of delayed bleeding. Incidence of procedure-related pancreatitis, successful complete resection, pathological findings, and other adverse events were secondary endpoints. Results: Sixty patients were enrolled over a 2-year period. The incidences of delayed bleeding (13.3% vs. 16.7%, P = 1.00) and pancreatitis (27% vs. 30%, P = 0.77) were similar between both groups. The rate of crush artifacts was higher in the Endocut than in the Autocut group (27% vs. 3.3%, P = 0.03). Immediate bleeding when resecting tumors greater than 14 mm in diameter was more common in the Autocut than in the Endocut group (88% vs. 46%, P = 0.04). Conclusions: The Autocut and Endocut modes have similar efficacy and safety for endoscopic papillectomy. The Endocut mode may prevent immediate bleeding in cases with large tumor sizes, although it causes more frequent crush artifacts. Registry and the registration number: The Japanese UMIN Clinical Trials Registry (UMIN-CTR: 000021382).

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How I do it: Endoscopic diagnosis for superficial non-ampullary duodenal epithelial tumors

Nakayama A., Kato M., Takatori Y., Shimoda M., Mizutani M., Tsutsumi K., Kiguchi Y., Akimoto T., Sasaki M., Mutaguchi M., Takabayashi K., Maehata T., Ochiai Y., Kanai T., Yahagi N.

Digestive Endoscopy (Digestive Endoscopy) 32 ( 3 ) 417 - 424 2019

ISSN 09155635

© 2019 Japan Gastroenterological Endoscopy Society There are no reports on detailed endoscopic diagnosis of superficial non-ampullary duodenal epithelial tumors (SNADET) except for relatively small case series. Herein, we conducted a prospective observational study to investigate the relationship between endoscopic findings and histopathological diagnosis of SNADET. A total of 163 SNADET diagnosed using magnified endoscopic examination with image-enhanced endoscopy (IEE-ME) were prospectively registered in this study. We investigated location, size, macroscopic type, color, and IEE-ME findings including surface structure (closed- or open-loop) and presence of white opaque substance (WOS) in SNADET. We analyzed association between these findings and histopathological diagnosis of SNADET based on the Vienna classification (VCL) using logistic regression analysis. In univariate analysis, lesion size, superficial structure, and WOS deposition showed statistical significance, and the oral side of the lesion location showed statistical tendency for association with VCL C4/5. In multivariate analysis, lesion size (odds ratio [OR], 2.92; 95% CI, 1.94–4.39; P < 0.05) and negative WOS (OR, 5.59; 95% CI, 1.72–18.1; P < 0.05) were significantly associated with VCL C4/5 lesions. Superficial structures with a closed-loop pattern on the surface showed statistical tendency for predicting VCL C4/5 lesions (OR, 2.15; 95% CI, 0.86–5.37; P = 0.10). Based on these findings, we concluded that negative WOS by IEE-ME and lesion size were independent predictors of VCL C4/5 SNADET. These factors may help us to understand of pathophysiology of SNADET and to select appropriate therapeutic strategies.

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Feasibility study comparing underwater endoscopic mucosal resection and conventional endoscopic mucosal resection for superficial non-ampullary duodenal epithelial tumor < 20 mm

Kiguchi Y., Kato M., Nakayama A., Sasaki M., Mizutani M., Tsutsumi K., Akimoto T., Takatori Y., Mutaguchi M., Takabayashi K., Ochiai Y., Maehata T., Kanai T., Yahagi N.

Digestive Endoscopy (Digestive Endoscopy) 32 ( 5 ) 753 - 760 2019

ISSN 09155635

© 2019 Japan Gastroenterological Endoscopy Society Background and Aim: Underwater endoscopic mucosal resection (UEMR) has been reported as an alternative to conventional EMR for superficial non-ampullary duodenal epithelial tumors (SNADET). However, the detailed outcomes are unclear. This study aimed to compare the clinical outcomes between UEMR and EMR for SNADET <20 mm. Patients and methods: This is a retrospective observational study using a prospective maintained database. From November 2017 to December 2018, 104 consecutive cases of attempted UEMR for SNADET <20 mm were prospectively allocated. A total of 240 cases of attempted EMR were chosen as historical controls. We compared technical success rate, defined as the resection rate without conversion to ESD; en bloc resection rate; R0 resection rate; and adverse event rate. Next, multivariate analyses were constructed to identify predictors of conversion to ESD, piecemeal resection, and RX or R1 (RX/R1) resection. Results: Technical success rate of UEMR was significantly higher than that of EMR (87% and 70%, P < 0.01). En bloc resection and R0 resection rates of UEMR were significantly lower than those of EMR (en bloc resection: 87% vs 96%, P < 0.01; R0 resection: 67% vs 80%, P = 0.05). Concerning adverse events, there were no significant differences. In multivariate analyses, attempted EMR, lesion size and depressed type were independent predictors of conversion to ESD. Attempted UEMR was an independent predictor of piecemeal resection and RX/R1 resection. Conclusion: The present study indicated that UEMR could be a feasible endoscopic resection method for SNADET (UMIN000025442).

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Electric endocut and autocut resection for endoscopic papillectomy: A systematic review

Minami K., Iwasaki E., Fukuhara S., Horibe M., Seino T., Kawasaki S., Katayama T., Takimoto Y., Tamagawa H., MacHida Y., Kanai T., Itoi T.

Internal Medicine (Internal Medicine) 58 ( 19 ) 2767 - 2772 2019

ISSN 09182918

© 2019 The Japanese Society of Internal Medicine. Objective Risks of bleeding and pancreatitis after mucosal resection using the purecut/autocut and blendcut/ endocut modes for endoscopic papillectomy have not been fully clarified. Thus, a systematic review on electrosurgical cutting modes for endoscopic papillectomy was conducted focusing on the types and incidence of adverse events. Methods We searched the PubMed and Cochrane library for cases of endoscopic papillectomy recorded as of April 2017. Studies reporting the methods of electrically excising a tumor in the duodenal papilla and the number of adverse events were extracted. Studies were collected and examined separately based on the electrosurgical cutting mode, and the incidence rate for each adverse event was summarized. Results A total of 159 relevant articles were found; among them, 20 studies were included and 139 excluded. Five studies analyzed endoscopic papillectomy with the purecut/autocut mode and 16 with the blendcut/ endocut mode. Only one study investigated both modes (purecut and endocut). With the purecut/autocut mode, the incidence of bleeding was 2.8-50%, and that of pancreatitis was 0-50% (mean: 12.8%). With the blendcut/endocut mode, the incidence of bleeding was 0-42.3%, and that of pancreatitis was 0%-17.9% (mean: 9.5%). Conclusion Both methods had high adverse event rates for endoscopic papillectomy. Thus, a standard method of endoscopic papillectomy, including the electrosurgical cutting mode, needs to be established.

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Current knowledge of irritable bowel syndrome-treatment

Masaoka T., Kanai T.

Journal of Japanese Society of Gastroenterology (Journal of Japanese Society of Gastroenterology) 116 ( 7 ) 570 - 575 2019

ISSN 04466586

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10-Year Trends in Helicobacter pylori Eradication Rates by Sitafloxacin-Based Third-Line Rescue Therapy

Mori H., Suzuki H., Matsuzaki J., Masaoka T., Kanai T.

Digestion (Digestion) 101 ( 5 ) 644 - 650 2019

ISSN 00122823

© 2019 S. Karger AG, Basel. All rights reserved. Background/Aims: Sitafloxacin (STFX)-containing regimens were shown to be useful options for third-line Helicobacter pylori eradication therapy. It is reported that resistance to quinolone is also increasing globally. Therefore, we conducted an analysis of the current efficacy of a 10-day-STFX-containing third-line rescue therapy and the changes of antibiotic resistance to H. pylori compared to 2 historical controls. Methods: Patients in whom eradication treatment using both first-and second-line triple therapies failed were enrolled from 2014 to 2015. The minimum inhibitory concentrations of STFX, clarithromycin (CLR), amoxicillin (AMX), metronidazole (MTZ) and the gyrA mutation status of the H. pylori strains were determined before treatment. After that, the patients received a 10-day triple therapy containing esomeprazole (20 mg, b.i.d.), AMX (500 mg, q.i.d.) and STFX (100 mg, b.i.d.; 10-day EAS). The eradication rate and the rate of antibiotic resistance to H. pylori were compared with 2 previous reports about STFX-containing third-line rescue therapies in 2009-2011 and 2012-2013. To explore the association between the eradication rates of regimens containing STFX, AMX and proton pump inhibitors and the location of gyrA mutation or AMX resistance, a meta-analysis was attempted. Results: The overall eradication rates, the eradication rate for gyrA mutation negative-and positive-strains were 81.6% (31/38), 94.7% (18/19) and 68.4% (13/19) respectively. These rates were not significantly different from 2 previous reports. The resistant rates to STFX, CLR, AMX, MTZ and the rate of presence of mutation in gyrA were 50.0, 81.6, 36.8, 78.9 and 50.0%, respectively, which was also not significantly different from 2 previous reports. A meta-analysis showed that the relative risk of the eradication failure is significantly lower in gyrA mutation negative strains compared to gyrA mutation positive strains, and that the relative risk of the eradication failure is significantly lower in gyrA mutation at D91 compared to gyrA mutation at N87 (p < 0.001 and p = 0.022, respectively). Moreover, a meta-analysis showed that the relative risk of the eradication failure is significantly lower in AMX-sensitive strains compared to AMX-resistant ones. Conclusion: Changes in the rate of antibiotic resistance to H. pylori were not observed from 2009 to 2015. The status of gyrA mutation is a superior marker for predicting successful eradication in STFX/AMX-containing triple regimen as a third-line rescue therapy.

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Withdrawal of thiopurines in Crohn’s disease treated with scheduled adalimumab maintenance: a prospective randomised clinical trial (DIAMOND2)

Hisamatsu T., Kato S., Kunisaki R., Matsuura M., Nagahori M., Motoya S., Esaki M., Fukata N., Inoue S., Sugaya T., Sakuraba H., Hirai F., Watanabe K., Kanai T., Naganuma M., Nakase H., Suzuki Y., Watanabe M., Hibi T., Nojima M., Matsumoto T., Endo K., Hanai H., Kobayashi T., Hiraoka S., Hisamatsu T., Honda Y., Inoue T., Inoue S., Ishida T., Ito H., Iwakiri R., Izumi M., Kagaya T., Kamata N., Naganawa Y., Kaneto H., Kani K., Kinjyo F., Yasaka H., Kurahara K., Kyouwon L., Yano Y., Matsui T., Tanaka H., Munemoto Y., Naito Y., Nakagawa T., Yokoyama Y., Nakamura S., Okazaki K., Ouchi S., Saruta M., Sasaki M., Takeshima F., Tamaki H., Tanaka S., Tanida S., Mizoshita T., Tominaga K., Yamashita M., Yoshida A., Yoshimura N.

Journal of Gastroenterology (Journal of Gastroenterology) 54 ( 10 ) 860 - 870 2019

ISSN 09441174

© 2019, Japanese Society of Gastroenterology. Background: The risk:benefit ratio of concomitant use of thiopurines with scheduled adalimumab (ADA) maintenance therapy for Crohn’s disease is controversial. The aim of this study is to identify the influence of withdrawal of thiopurines in patients in remission with combination therapy in an open-label, randomised, controlled trial (DIAMOND2; UMIN000009596). Methods: Patients in corticosteroid-free clinical remission (CFCR) for ≥ 6 months with ADA (40 mg, s.c., every other week) scheduled maintenance combined with thiopurines were randomised into two groups, “continue” (Con) or “discontinue” (Dis) group of thiopurines, whereas all other patients kept receiving scheduled ADA maintenance therapy for 52 weeks. The primary endpoint was the proportion of patients in CFCR at week 52. Secondary endpoints were endoscopic remission (ER), trough levels of ADA in serum, and safety. Results: Fifty patients were randomised to Con or Dis groups. Characteristics of patients were not significantly different between the groups. CFCR and ER prevalence at week 52 were not significantly different between groups (log rank, P = 0.704, P = 1.000, respectively). Trough levels of ADA were not significantly different between groups (P = 0.515). The proportion of patients with AAA positivity at week 52 was not significantly different (P = 0.437). ER at week 0 was involved in ER and triple remission at week 52. No serious adverse effects were observed in either group. Conclusion: Continuation of thiopurines > 6 months offers no clear benefit over scheduled ADA monotherapy. CFCR, ER, and ADA trough level at week 52 were not significantly different between groups. ER at week 0 may be involved in better long-term clinical outcomes.

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Toll-Like Receptor 7 Agonist–Induced Dermatitis Causes Severe Dextran Sulfate Sodium Colitis by Altering the Gut Microbiome and Immune Cells

Kiyohara H., Sujino T., Teratani T., Miyamoto K., Arai M., Nomura E., Harada Y., Aoki R., Koda Y., Mikami Y., Mizuno S., Naganuma M., Hisamatsu T., Kanai T.

Cellular and Molecular Gastroenterology and Hepatology (Cellular and Molecular Gastroenterology and Hepatology) 7 ( 1 ) 135 - 156 2019

© 2018 The Authors Background & Aims: Psoriasis and inflammatory bowel disease (IBD) are both chronic inflammatory diseases occurring in the skin and gut, respectively. It is well established that psoriasis and IBD have high concordance rates, and similar changes in immune cells and microbiome composition have been reported in both conditions. To study this connection, we used a combination murine model of psoriatic dermatitis and colitis in which mice were treated topically with the Toll-like receptor 7 agonist imiquimod (IMQ) and fed dextran sulfate sodium (DSS). Methods: We applied IMQ topically to B6 mice (IMQ mice) and subsequently fed them 2% DSS in their drinking water. Disease activity and immune cell phenotypes were analyzed, and the microbial composition of fecal samples was investigated using 16S ribosomal RNA sequencing. We transplanted feces from IMQ mice to germ-free IQI/Jic (IQI) mice and fed them DSS to assess the effect of the gut microbiome on disease. Results: We first confirmed that IMQ mice showed accelerated DSS colitis. IMQ mice had decreased numbers of IgD + and IgM + B cells and increased numbers of non–cytokine-producing macrophages in the gut. Moreover, the gut microbiomes of IMQ mice were perturbed, with significant reductions of Lactobacillus johnsonii and Lactobacillus reuteri populations. Germ-free mice transplanted with feces from IMQ mice, but not with feces from untreated mice, also developed exacerbated DSS colitis. Conclusions: These results suggest that skin inflammation may contribute to pathogenic conditions in the gut via immunologic and microbiological changes. Our finding of a novel potential skin–gut interaction provides new insights into the coincidence of psoriasis and IBD.

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Inhibiting xCT improves 5-fluorouracil resistance of gastric cancer induced by CD44 variant 9 expression

Miyoshi S., Tsugawa H., Matsuzaki J., Hirata K., Mori H., Saya H., Kanai T., Suzuki H.

Anticancer Research (Anticancer Research) 38 ( 11 ) 6163 - 6170 2018.11

ISSN 02507005

© 2018 International Institute of Anticancer Research.All right reserved. Background/Aim: Cancer stem cells (CSCs) play a critical role in resistance to chemotherapy. CD44 is a cell surface marker of CSCs. CD44 variant 9 (CD44v9) interacts with a cystine-glutamate antiporter (xCT) and is an unfavorable predictive factor in gastric cancer. We investigated the impact of CD44v9 expression on 5-fluorouracil (5-FU) resistance and the efficacy of the xCT inhibitor, sulfasalazine (SASP), in improving drug resistance. Materials and Methods: The human gastric cancer cell line MKN28 was transfected with pRc/CMV plasmids encoding human CD44 or CD44v9, which were used for in vitro and in vivo experiments. Results: CD44v9 expression results in 5-FU resistance by increasing intracellular glutathione and suppressing the drug-induced production of reactive oxygen species (ROS). SASP improved the drug sensitivity of CD44v9-expressing cells. Conclusion: Inhibition of xCT improved the clinical efficacy of chemotherapy against gastric cancer. CD44v9 expression can be a novel biomarker to predict resistance against 5-FU in gastric cancer.

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Pethidine dose and female sex as risk factors for nausea after esophagogastroduodenoscopy

Nishizawa T., Suzuki H., Arita M., Kataoka Y., Fukagawa K., Ohki D., Hata K., Uraoka T., Kanai T., Yahagi N., Toyoshima O.

Journal of Clinical Biochemistry and Nutrition (Journal of Clinical Biochemistry and Nutrition) 63 ( 3 ) 230 - 232 2018.11

ISSN 09120009

© 2018 JCBN. Nausea and vomiting after esophagogastroduodenoscopy have not been studied in detail. The aim of this study was to evaluate the risk factors for post-endoscopic nausea. We performed a case-control study at the Toyoshima Endoscopy Clinic. Eighteen patients with post-endoscopic nausea and 190 controls without post-endoscopic nausea were analyzed. We conducted univariate and multivariate logistic regression analyses with respect to patient age; sex; body height; body weight; the use of psychotropic drugs as baseline medications; and the dosing amounts of midazolam, pethidine, flumazenil and naloxone. On univariate analysis, post-endoscopic nausea was significantly related with patient age (odds ratio = 0.946); female sex (odds ratio = 10.85); body weight (odds ratio = 0.975); and the dose per kg body weight of pethidine (odds ratio = 53.03), naloxone (odds ratio = 1.676), and flumazenil (odds ratio = 1.26). On multivariate analysis, the dose per kg body weight of pethidine (odds ratio = 21.67, p = 0.004) and female sex (odds ratio = 13.12, p = 0.047) were the factors independently associated with post-endoscopic nausea. The prevalence of nausea after esophagogastroduodenoscopy was 0.49% (18/3, 654). In conclusion, post-endoscopic nausea was associated with the dose of pethidine and female sex.

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5-Aminosalicylic acid aggravates colitis mimicking exacerbation of ulcerative colitis

Miyoshi J., Matsuoka K., Yoshida A., Naganuma M., Hisamatsu T., Yajima T., Inoue N., Okamoto S., Iwao Y., Ogata H., Ueno F., Hibi T., Kanai T.

Intestinal Research (Intestinal Research) 16 ( 4 ) 635 - 640 2018.10

ISSN 15989100

© 2018. Korean Association for the Study of Intestinal Diseases. Ulcerative colitis (UC) is one of the major clinical phenotypes of inflammatory bowel diseases. Although 5-aminosalicylic acid (5-ASA) is widely used for UC and its efficacy and safety have been demonstrated, a few patients paradoxically develop a severe exacerbation of colitis by 5-ASA administration. It is crucial to know clinical features including endoscopic findings in this condition for making a correct diagnosis and a prompt decision to withdraw the medication. Here, we report case series with UC exacerbated by 5-ASA. Medical records of 8 UC patients experiencing an exacerbation of colitis after induction of 5-ASA that was improved by the withdrawal of 5-ASA but also re-aggravated by dose increase or re-administration of 5-ASA were reviewed. The patients were newly diagnosed with UC, started 5-ASA and developed an exacerbation in approximately 2 to 3 weeks. They did not appear to have systemic allergic reactions. Seven of the 8 patients had a high fever. Three of 5 patients who undertook total colonoscopy showed right-side-dominant colitis. These findings suggest clinical characteristics in this condition. Further assessment of clinical and endoscopic features in more cases is necessary for establishing diagnostic criteria and understanding underlying mechanisms in those cases where 5-ASA aggravates the colitis.

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Clarithromycin expands CD11b+Gr-1+cells via the STAT3/Bv8 axis to ameliorate lethal endotoxic shock and post-influenza bacterial pneumonia

Namkoong H., Ishii M., Fujii H., Yagi K., Asami T., Asakura T., Suzuki S., Hegab A., Kamata H., Tasaka S., Atarashi K., Nakamoto N., Iwata S., Honda K., Kanai T., Hasegawa N., Koyasu S., Betsuyaku T.

PLoS Pathogens (PLoS Pathogens) 14 ( 4 ) 2018.04

ISSN 15537366

© 2018 Namkoong et al. Macrolides are used to treat various inflammatory diseases owing to their immunomodulatory properties; however, little is known about their precise mechanism of action. In this study, we investigated the functional significance of the expansion of myeloid-derived suppressor cell (MDSC)-like CD11b+Gr-1+cells in response to the macrolide antibiotic clarithromycin (CAM) in mouse models of shock and post-influenza pneumococcal pneumonia as well as in humans. Intraperitoneal administration of CAM markedly expanded splenic and lung CD11b+Gr-1+cell populations in naïve mice. Notably, CAM pretreatment enhanced survival in a mouse model of lipopolysaccharide (LPS)-induced shock. In addition, adoptive transfer of CAM-treated CD11b+Gr-1+cells protected mice against LPS-induced lethality via increased IL-10 expression. CAM also improved survival in post-influenza, CAM-resistant pneumococcal pneumonia, with improved lung pathology as well as decreased interferon (IFN)-γ and increased IL-10 levels. Adoptive transfer of CAM-treated CD11b+Gr-1+cells protected mice from post-influenza pneumococcal pneumonia. Further analysis revealed that the CAM-induced CD11b+Gr-1+cell expansion was dependent on STAT3-mediated Bv8 production and may be facilitated by the presence of gut commensal microbiota. Lastly, an analysis of peripheral blood obtained from healthy volunteers following oral CAM administration showed a trend toward the expansion of human MDSC-like cells (Lineage−HLA-DR−CD11b+CD33+) with increased arginase 1 mRNA expression. Thus, CAM promoted the expansion of a unique population of immunosuppressive CD11b+Gr-1+cells essential for the immunomodulatory properties of macrolides.

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Evidence-based clinical practice guidelines for inflammatory bowel disease

Matsuoka K., Kobayashi T., Ueno F., Matsui T., Hirai F., Inoue N., Kato J., Kobayashi K., Kobayashi K., Koganei K., Kunisaki R., Motoya S., Nagahori M., Nakase H., Omata F., Saruta M., Watanabe T., Tanaka T., Kanai T., Noguchi Y., Takahashi K., Watanabe K., Hibi T., Suzuki Y., Watanabe M., Sugano K., Shimosegawa T.

Journal of Gastroenterology (Journal of Gastroenterology) 53 ( 3 ) 305 - 353 2018.03

ISSN 09441174

© 2018, The Author(s). Inflammatory bowel disease (IBD) is a chronic disorder involving mainly the intestinal tract, but possibly other gastrointestinal and extraintestinal organs. Although etiology is still uncertain, recent knowledge in pathogenesis has accumulated, and novel diagnostic and therapeutic modalities have become available for clinical use. Therefore, the previous guidelines were urged to be updated. In 2016, the Japanese Society of Gastroenterology revised the previous versions of evidence-based clinical practice guidelines for ulcerative colitis (UC) and Crohn’s disease (CD) in Japanese. A total of 59 clinical questions for 9 categories (1. clinical features of IBD; 2. diagnosis; 3. general consideration in treatment; 4. therapeutic interventions for IBD; 5. treatment of UC; 6. treatment of CD; 7. extraintestinal complications; 8. cancer surveillance; 9. IBD in special situation) were selected, and a literature search was performed for the clinical questions with use of the MEDLINE, Cochrane, and Igaku Chuo Zasshi databases. The guidelines were developed with the basic concept of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Recommendations were made using Delphi rounds. This English version was produced and edited based on the existing updated guidelines in Japanese.

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Factors predicting the therapeutic response to infliximab during maintenance therapy in Japanese patients with Crohn's disease

KANAI Takanori

PLoS One (PLoS ONE) 13 ( 10 ) 2018

© 2018 Hsieh et al. Since anti-tumor necrosis factor (TNF)-α agents (TNF-α inhibitors) induce both clinical response and remission in patients with moderate to severe inflammatory bowel disease (IBD), the use of anti-TNF therapies has fundamentally changed the approach to treatment for patients with IBD. Infliximab (IFX) is a TNF-α inhibitor approved for the induction and remission of Crohn's disease (CD). However, even among patients who initially demonstrate a clinical response to IFX therapy, secondary loss of response occurs, although the reason remains unknown. We therefore investigated predictive factors associated with the response to IFX in long-term maintenance treatment in Japanese CD patients. Eight types of single-nucleotide polymorphisms (SNPs) were investigated using the real-time PCR method, and patient characteristics were collected from the electronic medical records. The Crohn's Disease Activity Index criteria were used as the response to IFX therapy. The observation period was 1 year after IFX had been administered for more than 1 year. Associations between the IFX response and patient characteristics were evaluated using the multivariate logistic regression model. We studied 121 unrelated adult Japanese with CD treated for more than 1 year with IFX as outpatients at Keio University Hospital from November 1, 2014 to November 30, 2015. Among them, 71 were classified as in remisson. In multivariate analysis, patients with the TNF-α 857C>T C/C genotype, shorter disease duration, without double dosing, and combination treatment with an immunomodulator had higher remisson rates than those with the C/T or T/T genotype, longer disease duration, with double dosing, and no combination treatment with an immunomodulator. The response to IFX in Japanese CD patients may therefore be predicted by these 4 characteristics in actual clinical practice.

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Future perspectives on fecal microbiota transplantation

KANAI Takanori

Nihon Shokakibyo Gakkai Zasshi (Journal of Japanese Society of Gastroenterology) 115 ( 5 ) 449 - 459 2018

ISSN 04466586

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Acquisition of double mutation in gyrA caused high resistance to sitafloxacin in Helicobacter pylori after unsuccessful eradication with sitafloxacin-containing regimens

KANAI Takanori

United European Gastroenterol J (United European Gastroenterology Journal) 6 ( 3 ) 391 - 397 2018

ISSN 20506406

© 2017, © Author(s) 2017. Background and aim: Although sitafloxacin (STFX)-containing regimens are effective rescue treatments for Helicobacter pylori infection, prevalence of fluoroquinolone resistance in H. pylori has increased rapidly worldwide. The change in resistance levels and gyrA mutations, a major cause of fluoroquinolone resistance, after unsuccessful STFX-containing treatment has not been investigated. Methods: We conducted a retrospective, non-randomized study to compare the minimum inhibitory concentrations (MICs) of STFX and the location of gyrA mutations in H. pylori before and after unsuccessful eradication with STFX-containing regimens at Keio University Hospital between December 2011 and March 2015. Results: A total of 266 patients treated with STFX-containing regimens for third-line H. pylori eradication were evaluated. Double mutations in gyrA were acquired by 20.8% of strains that exhibited seven-fold increased STFX MICs, compared to pre-treatment MICs. The STFX MICs did not increase, however, when the location of the gyrA mutations did not change after treatment. Double mutations in gyrA developed in 60.0% of the strains in which eradication failed, which exhibited a baseline mutation at position D91, and in 11.1% of strains with baseline mutations at position N87. Conclusion: Acquisition of double mutations in gyrA evoked high-level resistance to STFX in H. pylori after unsuccessful eradication with STFX-containing regimens.

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Burden of impaired sleep quality on work productivity in functional dyspepsia

KANAI Takanori

United European Gastroenterol J (United European Gastroenterology Journal) 6 ( 3 ) 398 - 406 2018

ISSN 20506406

© 2017, © Author(s) 2017. Background: Impaired sleep quality is common, and can reduce work productivity in patients with functional dyspepsia (FD). Objective: The objective of this article is to evaluate whether there is a direct association between the presence of FD and the severity of impaired sleep quality, and to calculate the economic loss due to the decreased work productivity associated with sleep quality. Methods: In Study 1, using a web-based survey completed by workers with and without FD, we evaluated impaired sleep quality, work and daily productivity, and the severity of reflux and bowel symptoms. In Study 2, the association between the presence of FD and the severity of impaired sleep quality was validated in a hospital-based cohort. Results: In both Study 1 and 2, although impaired sleep quality was more frequent in participants with FD than in those without FD, the independent association between the presence of FD and the severity of impaired sleep quality was not observed after adjustment for the severity of reflux and bowel symptoms. FD participants with impaired sleep quality reported additional economic loss of 53,500 Japanese yen/month. Conclusion: Although the association between impaired sleep quality and FD was indirect, concomitant impaired sleep quality could worsen economic loss.

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Establishment of a Novel Scoring System for Colon Capsule Endoscopy to Assess the Severity of Ulcerative Colitis-Capsule Scoring of Ulcerative Colitis

KANAI Takanori

Inflamm Bowel Dis (Inflammatory Bowel Diseases) 24 ( 12 ) 2641 - 2647 2018

ISSN 10780998

© 2018 Crohn's & Colitis Foundation. Published by Oxford University Press. All rights reserved. Background: The usefulness of second-generation colon capsule endoscopy (CCE-2) for ulcerative colitis (UC) has not been fully demonstrated. This study aimed to develop an endoscopic severity score of UC for CCE-2. Methods: Patients diagnosed with UC were enrolled prospectively and underwent colonoscopy and CCE-2 on the same day. The collected CCE-2 videos were adopted for the development of the score. These videos were scored by 4 blinded inflammatory bowel disease experts. The items validated with the Ulcerative Colitis Endoscopic Index of Severity (UCEIS) were used as the candidate items, some of which were automatically assessed using the workstation. Each item was divided into proximal and distal parts at the splenic flexure and then individually assessed. The image readers simultaneously evaluated the inflammation severity using the visual analog scale (VAS). The descriptors that contribute to this scale were evaluated, and a model to predict the VAS was constructed. The UCEIS was scored by other endoscopists using colonoscopy videos. The correlation coefficients with fecal calprotectin, blood tests, and Lichtiger index were calculated. Results: The final scoring system was fixed as "vascular pattern sum (proximal + distal) + bleeding sum + erosions and ulcers sum (minimum- maximum, 0-14)" and was named Capsule Scoring of Ulcerative Colitis (CSUC). The correlation coefficient of CSUC with biomarkers and clinical score was similar to that of the UCEIS. Conclusions: We developed a new simple score using the 3 descriptors of CCE-2.

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Safety and efficacy of ultra-tapered mechanical dilator for EUS-guided hepaticogastrostomy and pancreatic duct drainage compared with electrocautery dilator (with video)

KANAI Takanori

Endosc Ultrasound (Endoscopic Ultrasound) 7 ( 6 ) 376 - 382 2018

ISSN 23039027

© 2018 SPRING MEDIA PUBLISHING CO. LTD Background and Objectives: Successful tract dilation is one of the most important steps to accomplish EUS-guided drainage. Although mechanical dilation is safer than electrocautery dilation, no dedicated mechanical dilator (MD) is currently available. Thus, we developed a new ultra-tapered MD for EUS-guided drainage. This study aimed to evaluate the safety and usefulness of this novel MD. Patients and Methods: Consecutive patients who underwent EUS-guided hepaticogastrostomy (EUS-HGS) or EUS-guided pancreatic duct drainage (EUS-PD) at two centers were included in the study. Dilation of the needle tract was initially performed with a diathermic sheath or the ultra-tapered MD. Technical success and adverse events were assessed. Results: Sixty-four patients (mean age = 68.9 ± 13.8 years, 35 men) underwent EUS-HGS (49 patients) and EUS-PD (15 patients). Thirty-three patients were included in the cautery dilator (CD) group and 31 in the ultra-tapered MD group. Initial dilation of the puncture site was achieved in 95.3% (61/64): 97% (32/33) of the patients in the CD group and 93.3% (29/31) of the patients in the MD group (P > 0.05). Adverse events were observed in 14 patients: abdominal pain in 8 patients and bleeding in 6 patients at the puncture site. All bleedings occurred in the CD group and there was no patient in whom bleeding occurred after EUS intervention in the MD group (P = 0.04). Conclusion: The novel ultra-tapered MD designed for interventional EUS appears to be safe and useful as it reduced postprocedure bleeding with a high technical success rate compared with the conventional electrocautery dilator.

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Intestinal barrier regulates immune responses in the liver via IL-10-producing macrophages

KANAI Takanori

JCI Insight (JCI insight) 3 ( 12 ) 2018

The gut-liver axis is of clinical importance as a potential therapeutic target in a wide range of liver diseases; however, the mechanisms underlying interactions between microbial products and immune responses in the liver remain unknown. In this study, we demonstrated that IL-10-producing macrophages contribute to immune tolerance in the inflamed liver under intestinal barrier disruption in a murine tandem model of dextran sulfate sodium (DSS) colitis and concanavalin A (Con A) hepatitis. Intestinal barrier disruption protected mice from subsequent liver injury, and the severity of colitis directly affected susceptibility to such injury. The protective effect of DSS-Con A was canceled in gut-sterilized mice, suggesting that gut microbiota play a substantial role in this process. Altered gut microbiota and their metabolites, along with a disrupted intestinal barrier, directly gave rise to immunological permissiveness in the inflamed liver. We identified 1-methylnicotinamide (1-MNA) as a candidate metabolite capable of suppressing liver injury with the potential to induce IL-10-producing macrophages. Consistently, expression of nicotinamide N-methyltransferase, which converts nicotinamide to 1-MNA, was upregulated in the liver of DSS-Con A mice, and this effect was abrogated by gut sterilization. Collectively, our results provide a mechanistic insight into the regulation of immunological balance in the liver via the gut-liver axis.

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Dual effects of the Nrf2 inhibitor for inhibition of hepatitis C virus and hepatic cancer cells

KANAI Takanori

BMC Cancer (BMC Cancer) 18 ( 1 ) 2018

© 2018 The Author(s). Background: We previously showed that knockdown of nuclear factor E2-related factor 2 (Nrf2) resulted in suppression of hepatitis C virus (HCV) infection. In this study, whether brusatol, an Nrf2 inhibitor, has dual anti-HCV and anticancer effects was explored. Methods: The anti-HCV effect of brusatol was investigated by analyzing HCV RNA and proteins in a hepatic cell line persistently-infected with HCV, HPI cells, and by analyzing HCV replication in a replicon-replicating hepatic cell line, OR6 cells. Then, dual anti-HCV and anticancer effects of brusatol and enhancement of the effects by the combination of brusatol with anticancer drugs including sorafenib, which has been reported to have the dual effects, were then investigated. Results: Brusatol suppressed the persistent HCV infection at both the RNA and protein levels in association with a reduction in Nrf2 protein in the HPI cells. Analysis of the OR6 cells treated with brusatol indicated that brusatol inhibited HCV persistence by inhibiting HCV replication. Combination of brusatol with an anticancer drug not only enhanced the anticancer effect but also, in the case of the combination with sorafenib, strongly suppressed HCV infection. Conclusions: Brusatol has dual anti-HCV and anticancer effects and can enhance the comparable effects of sorafenib. There is therefore the potential for combination therapy of brusatol and sorafenib for HCV-related hepatocellular carcinoma.

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Idiopathic Thrombocytopenic Purpura Responsive to Surgery for Crohn's Disease.

KANAI Takanori

Inflamm Bowel Dis (Inflammatory bowel diseases) 25 ( 3 ) 2018

ISSN 10780998

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Review of the small intestinal mucosal lesion

KANAI Takanori

Nihon Shokakibyo Gakkai Zasshi (Journal of Japanese Society of Gastroenterology) 115 ( 7 ) 605 - 611 2018

ISSN 04466586

Pancreatic Fat Content Detected by Computed Tomography and Its Significant Relationship With Intraductal Papillary Mucinous Neoplasm.

KANAI Takanori

Pancreas (Pancreas) 47 ( 9 ) 1087 - 1092 2018

ISSN 08853177

© Wolters Kluwer Health, Inc. All rights reserved. Objectives Intraductal papillary mucinous neoplasms (IPMNs) are premalignant lesions of pancreatic ductal adenocarcinomas (PDACs). Fat accumulation in the pancreas is increasingly recognized as a cause of PDAC. We aimed to identify factors that are relevant between IPMN and metabolic-related factors, including pancreatic fat. Methods The database for 781 subjects who underwent a health checkup and upper abdominal magnetic resonance imaging was searched and computed tomography attenuation indexes (pancreatic and spleen attenuation, pancreas-to-spleen attenuation ratio) were decided by measuring the regions of interest in the pancreas and spleen on nonenhanced images, using Hounsfield units. Eighty-five subjects from each of the IPMN and noncyst groups were matched for age, sex, and glycemic status and statistically compared in clinical characteristics. Results There was no difference in metabolic-related factors except for apolipoprotein A1 and high-density lipoprotein cholesterol between the 2 groups in univariate analysis. Multivariate logistic regression analysis showed that both indexes were significantly associated with IPMN (odds ratio, 0.905 [95% confidence intervals, 0.851-0.963; P = 0.002]; odds ratio, 0.006 [95% confidence intervals, 0.000-0.152; P = 0.002]). Conclusions Pancreatic fat content measured by computed tomography was significantly associated with IPMN. These results suggest that IPMN may develop secondary to pancreatic steatosis that could be an overlapping risk factor for PDAC and IPMN.

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Immune Checkpoint Induced Colitis

KANAI Takanori

Gan To Kagaku Ryoho (Japanese Journal of Cancer and Chemotherapy) 45 ( 7 ) 1027 - 1030 2018

ISSN 03850684

© 2018 Japanese Journal of Cancer and Chemotherapy Publishers Inc. All Rights Reserved. Colitis is one of major adverse event induced by immune checkpoint inhibitor (ICPi), especially in the treatment with anti-CTLA-4 antibody. Colitis can occur anytime duringICPi therapy. The most common symptom is diarrhea. Other symptoms are abdominal pain, hematochezia, weight loss, fever and vomiting. To diagnoseICPi-induced colitis, it is important to deny infectious enterocolitis and tumor-related symptoms. Sigmoidoscopy or colonoscopy with biopsy are useful for proper diagnosis and evaluation of the severity. Patients with ulcer lesion tend to show resistance to steroid therapy. Diarrhea is an important symptom to evaluate the severity of colitis. American Society of Clinical Oncology and European Society for Medical Oncology published clinical guidelines for immune related adverse events including colitis. If patient has CTCAE Grade 2 or more severe diarrhea, both guidelines recommend stop ICPi and start corticosteroid therapy. As colitis can progress rapidly and induce perforation, the initiation of steroid therapy should not be hesitated. Some patients are resistant to steroid therapy, in which case infliximab, anti-TNF-a antibody, is recommended. ICPi-induced colitis is different from conventional adverse event induced by cytotoxic agents in terms of management with coticosteroid. Therefore, consultation to gastroenterologist is essential for proper diagnosis and corticosteroid initiation without delay.

Clinical impact of closure of the mucosal defect after duodenal endoscopic submucosal dissection

KANAI Takanori

Gastrointest Endosc (Gastrointestinal Endoscopy) 89 ( 1 ) 87 - 93 2018

ISSN 00165107

© 2019 American Society for Gastrointestinal Endoscopy Background and Aims: Delayed adverse events (bleeding or perforation) are major concerns associated with duodenal endoscopic submucosal dissection (ESD). The aim of this study was to assess the efficacy of prophylactic closure of the mucosal defect after duodenal ESD. Methods: This is a retrospective study from a university hospital. One hundred sixty-eight patients (173 lesions) who underwent duodenal ESD between July 2010 and June 2017 were included in this study. The study participants were divided into 3 subgroups according to the degree of closure: complete group, incomplete group, and unclosed group. The proportion of delayed adverse events, maximum serum level of C-reactive protein (CRP), and total length of hospital stay were compared among these subgroups. Moreover, a multivariate logistic regression model was constructed to identify the risk factors for delayed adverse events. Results: The proportion of delayed adverse events in the complete group, incomplete group, and unclosed group were 1.7%, 25%, and 15.6%, respectively. The difference between the complete group and the other groups was significant (P <.01). The maximum serum CRP level was much lower (1.51 ± 2.18 mg/dL vs 6.28 ± 10.0 mg/dL, P <.01), and the length of hospital stay was significantly shorter in the complete group than in the incomplete/unclosed group (median [range] 5 [5-14] days vs 8 [4-59] days, P <.01). Multivariate analysis revealed that complete closure had a significant decrease in delayed adverse events (odds ratio [OR], 0.055; 95% confidence interval [CI], 0.01-0.29; P <.01), and a lesion located distal from the descending part showed a statistical tendency to an increase in delayed adverse events (OR, 4.48; 95% CI, 0.85-23.6; P =.08). Conclusion: The present study revealed that complete closure of the mucosal defect after duodenal ESD significantly decreased the number of delayed adverse events and improved other outcomes.

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KANAI Takanori

Gastroenterology 2018

Clinical utility of novel ultrathin single-balloon enteroscopy: a feasibility study

KANAI Takanori

Endoscopy (Endoscopy) 51 ( 5 ) 468 - 471 2018

ISSN 0013726X

© Georg Thieme Verlag KG Stuttgart . New York. Background The advent of balloon-assisted enteroscopy (BAE) has facilitated the examination of the entire digestive tract. However, using a rigid sliding tube during the procedure reduces patient acceptance. This study evaluated the clinical application of a newly developed ultrathin single-balloon enteroscope for BAE. Methods 28 outpatients underwent enteroscopy with a novel ultrathin single-balloon enteroscope. None of the subjects required therapeutic procedures, such as balloon dilation or hemostasis. The insertability, efficacy, and safety of the ultrathin single-balloon endoscope were evaluated retrospectively. Results 7 patients underwent transoral enteroscopy and 21 patients underwent transanal enteroscopy under conscious sedation. No adverse events related to the procedure were reported in any patients. Targeted observation and/or targeted biopsy were achieved in all procedures. All transoral procedures allowed evaluation of the jejunum beyond the ligament of Treitz. All transanal procedures allowed intubation of the terminal ileum, despite several patients having severe stenosis of the colon and ileum. Conclusion A novel ultrathin single-balloon enteroscope showed adequate insertability and safety for outpatient surveillance enteroscopy under conscious sedation.

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Absence of high-risk stigmata predicts good prognosis even in severely anemic patients with suspected acute upper gastrointestinal bleeding

KANAI Takanori

United European Gastroenterol J. (United European Gastroenterology Journal) 6 ( 5 ) 684 - 690 2018

ISSN 20506406

© 2018, Author(s) 2018. Background: The need for a blood transfusion, defined as hemoglobin < 70 g/L, is the measure for assessing the risk levels in patients with upper gastrointestinal bleeding (UGIB). However, not all patients with a low hemoglobin level have a poor prognosis. Objective: We assessed the clinical predictive factors associated with poor short-term prognosis in patients with a low hemoglobin level. Methods: In this prospective cohort study, all consecutive patients with suspected acute UGIB at Tokyo Metropolitan Tama Medical Center were enrolled between 2008 and 2015. Then, we extracted those who needed a blood transfusion (hemoglobin < 70 g/L) and explored the variables associated with all-cause mortality within 28 days after presentation. Results: Among 1307 patients, 311 needed a blood transfusion and 13 (4.2%) died from all causes. The presence of high-risk stigmata requiring endoscopic treatment (peptic ulcers; Forrest scores Ia, Ib and IIa; varices with current bleeding or signs of recent bleeding; and spurting or gushing bleeding or visible vessel in other diseases), diagnosed by emergency endoscopy, was a unique factor affecting mortality (odds ratio: 8.47, 95% confidence interval: 1.45–160, P = 0.01). Patients without high-risk stigmata neither died from UGIB nor had rebleeding, irrespective of the hemoglobin levels. Conclusions: Patients without high-risk stigmata showed a good prognosis even if they needed a blood transfusion. This result could facilitate triage of patients with suspected acute UGIB who only need a blood transfusion.

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β-(1,3)-Glucan derived from Candida albicans induces inflammatory cytokines from macrophages and lamina propria mononuclear cells derived from patients with Crohn's disease.

KANAI Takanori

Intest Res 2018

Effect of elemental diet combined with infliximab dose escalation in patients with Crohn's disease with loss of response to infliximab: CERISIER trial.

KANAI Takanori

Intest Res (Intestinal Research) 16 ( 3 ) 494 - 498 2018

ISSN 15989100

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Divergent Routes toward Wnt and R-spondin Niche Independency during Human Gastric Carcinogenesis.

KANAI Takanori

Cell (Cell) 174 ( 4 ) 856 - 869.e17 2018

ISSN 00928674

© 2018 Elsevier Inc. Recent sequencing analyses have shed light on heterogeneous patterns of genomic aberrations in human gastric cancers (GCs). To explore how individual genetic events translate into cancer phenotypes, we established a biological library consisting of genetically engineered gastric organoids carrying various GC mutations and 37 patient-derived organoid lines, including rare genomically stable GCs. Phenotype analyses of GC organoids revealed divergent genetic and epigenetic routes to gain Wnt and R-spondin niche independency. An unbiased phenotype-based genetic screening identified a significant association between CDH1/TP53 compound mutations and the R-spondin independency that was functionally validated by CRISPR-based knockout. Xenografting of GC organoids further established the feasibility of Wnt-targeting therapy for Wnt-dependent GCs. Our results collectively demonstrate that multifaceted genetic abnormalities render human GCs independent of the stem cell niche and highlight the validity of the genotype-phenotype screening strategy in gaining deeper understanding of human cancers. Generation and analysis of a human gastric cancer organoid bank reveal insights into molecular features underlying diverse histopathological subtypes and tumor independence from Wnt signals.

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Innate lymphoid cells in organ fibrosis. Cytokine Growth Factor Rev

KANAI Takanori

Cytokine Growth Factor Rev 2018

Correction: Clinical utility of novel ultrathin single-balloon enteroscopy: a feasibility study

KANAI Takanori

Endoscopy 2018

Management of challenging immune-related gastrointestinal adverse events associated with immune checkpoint inhibitors.

KANAI Takanori

Future Oncol (Future Oncology) 14 ( 30 ) 3187 - 3198 2018

ISSN 14796694

© 2018 Future Medicine Ltd. Immune-related gastrointestinal toxicities (irGI) are well-known adverse events (AEs) with immune checkpoint inhibitors. The aim of this review was to present clinical data from 82 cases to provide information to clinicians who face real-world challenges among their patients with irGI AEs. The findings of this review support the use of the current management guidelines. By analyzing the treatment courses and outcomes of all cases identified, our review recommends that recurrent cases be treated carefully regardless of the grade of diarrhea at the onset of events. Earlier gastroenterology consultation and computed tomography/endoscopy diagnosis are essential, especially when an irGI AE recurs or worsens during steroid tapering. We would also suggest earlier decision to add immunosuppressant agents, particularly for recurrent cases.

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Efficacy of Therapeutic Intervention for Patients With an Ulcerative Colitis Mayo Endoscopic Score of 1.

KANAI Takanori

Inflamm Bowel Dis (Inflammatory Bowel Diseases) 25 ( 4 ) 782 - 788 2018

ISSN 10780998

© 2018 Crohn's & Colitis Foundation. Published by Oxford University Press. All rights reserved. For permissions. Background Mucosal healing (MH) is proposed as a therapeutic target for ulcerative colitis (UC). Recent studies have indicated that the rate of clinical relapse in patients with a Mayo endoscopic score (MES) of 1 is higher than that of patients with an MES of 0. However, no study has yet investigated whether therapeutic intervention prevents clinical relapse in patients with an MES of 1. Methods Patients with UC with an MES of 1 and partial Mayo score ≤2 were included in this study. All patients were followed from first colonoscopy (CS) until follow-up CS. Differences in the rate of clinical relapse (requiring additional treatment for UC) or endoscopic exacerbation (MES ≥2 and proximal extension) were compared between the therapeutic intervention (immediately after first CS) group and the nontherapeutic intervention group; risk factors for relapse were also assessed. Results Among 1523 patients with UC who underwent CS between 2013 and 2016, 220 patients were included in this study. The rate of clinical relapse (P = 0.005) and endoscopic exacerbation (P = 0.11) in patients with therapeutic intervention was lower than that in patients without therapeutic intervention. Multivariable analysis indicated that absence of therapeutic intervention (P = 0.001 for clinical relapse, P = 0.050 for endoscopic exacerbation) and a higher Ulcerative Colitis Endoscopic Index of Severity vascular pattern score immediately after first CS (P = 0.021 for clinical relapse, P = 0.019 for endoscopic exacerbation) were risk factors for both clinical relapse and endoscopic exacerbation. Conclusions Therapeutic intervention for patients with UC with an MES of 1 might prevent disease relapse.

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Large Volume Fluid Resuscitation for Severe Acute Pancreatitis is Associated With Reduced Mortality: A Multicenter Retrospective Study

KANAI Takanori

J Clin Gastroenterol (Journal of Clinical Gastroenterology) 53 ( 5 ) 385 - 391 2018

ISSN 01920790

Copyright © 2019 World Gastroenterology Organisation. All rights reserved. Background and Aims: Although fluid resuscitation is critical in acute pancreatitis, the optimal fluid volume is unknown. The aim of this study is to evaluate the association between the volume of fluid administered and clinical outcomes in patients with severe acute pancreatitis (SAP). Methods: We conducted a multicenter retrospective study at 44 institutions in Japan. Inclusion criteria were age 18 years or older, and diagnosed with SAP from 2009 to 2013. Patients were stratified into 2 groups: administered fluid volume <6000 and ≥ 6000 mL in the first 24 hours. We evaluated the association between the 2 groups and clinical outcomes using multivariable logistic regression analysis. The primary outcome was in-hospital mortality. Secondary outcomes included the incidence of pancreatic infection and the need for surgical intervention. Results: We analyzed 1097 patients, and the mean fluid volume administered was 5618±3018 mL (mean±SD), with 708 and 389 patients stratified into the fluid <6000 mL and fluid ≥6000 mL groups, respectively. Overall in-hospital mortality was 12.3%. The fluid ≥ 6000 mL group had significantly higher mortality than the fluid <6000 mL group (univariable analysis, 15.9% vs. 10.3%; P<0.05). In multivariable logistic regression analysis, administration of ≥6000 mL of fluid within the first 24 hours was significantly associated with reduced mortality (odds ratio, 0.58; P<0.05). No significant association was found between the administered fluid volume and pancreatic infection, or between the volume administered and the need for surgical intervention. Conclusions: In patients with SAP, administration of a large fluid volume within the first 24 hours is associated with decreased mortality.

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Reconstruction of the Human Colon Epithelium In Vivo.

KANAI Takanori

Cell Stem Cell (Cell Stem Cell) 22 ( 2 ) 171 - 176.e5 2018

ISSN 19345909

© 2017 Elsevier Inc. Genetic lineage tracing has revealed that Lgr5 + murine colon stem cells (CoSCs) rapidly proliferate at the crypt bottom. However, the spatiotemporal dynamics of human CoSCs in vivo have remained experimentally intractable. Here we established an orthotopic xenograft system for normal human colon organoids, enabling stable reconstruction of the human colon epithelium in vivo. Xenografted organoids were prone to displacement by the remaining murine crypts, and this could be overcome by complete removal of the mouse epithelium. Xenografted organoids formed crypt structures distinctively different from surrounding mouse crypts, reflecting their human origin. Lineage tracing using CRISPR-Cas9 to engineer an LGR5-CreER knockin allele demonstrated self-renewal and multipotency of LGR5 + CoSCs. In contrast to the rapidly cycling properties of mouse Lgr5 + CoSCs, human LGR5 + CoSCs were slow-cycling in vivo. This organoid-based orthotopic xenograft model enables investigation of the functional behaviors of human CoSCs in vivo, with potential therapeutic applications in regenerative medicine. Sugimoto et al. established an orthotopic xenotransplantation system for human normal colon organoids. Using LGR5-CreER knockin organoids for genetic lineage tracing, they demonstrated the self-renewal and multipotency of LGR5 + colon stem cells in mouse colon. Interestingly, human LGR5 + colon stem cells showed slower cycling than those of mice in vivo.

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Human Pancreatic Tumor Organoids Reveal Loss of Stem Cell Niche Factor Dependence during Disease Progression.

KANAI Takanori

Cell Stem Cell (Cell Stem Cell) 22 ( 3 ) 454 - 467.e6 2018

ISSN 19345909

© 2017 Elsevier Inc. Despite recent efforts to dissect the inter-tumor heterogeneity of pancreatic ductal adenocarcinoma (PDAC) by determining prognosis-predictive gene expression signatures for specific subtypes, their functional differences remain elusive. Here, we established a pancreatic tumor organoid library encompassing 39 patient-derived PDACs and identified 3 functional subtypes based on their stem cell niche factor dependencies on Wnt and R-spondin. A Wnt-non-producing subtype required Wnt from cancer-associated fibroblasts, whereas a Wnt-producing subtype autonomously secreted Wnt ligands and an R-spondin-independent subtype grew in the absence of Wnt and R-spondin. Transcriptome analysis of PDAC organoids revealed gene-expression signatures that associated Wnt niche subtypes with GATA6-dependent gene expression subtypes, which were functionally supported by genetic perturbation of GATA6. Furthermore, CRISPR-Cas9-based genome editing of PDAC driver genes (KRAS, CDKN2A, SMAD4, and TP53) demonstrated non-genetic acquisition of Wnt niche independence during pancreas tumorigenesis. Collectively, our results reveal functional heterogeneity of Wnt niche independency in PDAC that is non-genetically formed through tumor progression. Sato and colleagues established a library of patient-derived pancreas cancer organoids and identified heterogeneous patterns of dependency on Wnt ligands among pancreas cancers. Biological and genetic analyses highlighted GATA6 as a mediator of the Wnt niche requirement, which links pancreatic tumor progression to independence from the stem cell niche.

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Fecal microbiota transplantation for recurrent Clostridium difficile infection in a patient with ulcerative colitis.

KANAI Takanori

Intest Res (Intestinal Research) 16 ( 1 ) 142 - 146 2018

ISSN 15989100

© 2018. Korean Association for the Study of Intestinal Diseases. Fecal microbiota transplantation (FMT) has been reported as a safe and effective therapy in patients with refractory and recurrent Clostridium difficile infection (CDI). FMT has also been reported as a promising therapy in patients with ulcerative colitis (UC). Both, CDI and UC, are believed to be caused by dysbiosis, such as altered compositions or decreased diversity of the intestinal microbiota. This report describes a patient with UC in remission with a second recurrent episode of CDI, who was treated with FMT. A single FMT performed via colonoscopy completely resolved the patient's diarrhea and eradicated C. difficile bacteriologically without any severe complications. Molecular biological analysis of the patient's fecal microbiota showed that FMT could dramatically change the altered composition of intestinal microbiota and restore its diversity. Despite the restoration of the intestinal microbiota, FMT could not prevent a relapse of UC in this patient. However, it improved the intestinal symptoms of CDI and could prevent further recurrences of CDI.

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Complications and outcomes of routine endoscopy in the very elderly.

KANAI Takanori

Endosc Int Open 2018

Efficacy of Bifidobacterium breve Fermented Milk in Maintaining Remission of Ulcerative Colitis.

KANAI Takanori

Dig Dis Sci (Digestive Diseases and Sciences) 63 ( 7 ) 1910 - 1919 2018

ISSN 01632116

© 2018, The Author(s). Background: Fermented milk products containing Bifidobacterium breve strain Yakult (BFM) may improve clinical status in ulcerative colitis (UC) patients. Aims: To assess efficacy of BFM in maintaining remission in Japanese patients with quiescent UC. Methods: This double-blind study (B-FLORA) enrolled 195 patients with quiescent UC, randomized to receive one pack of BFM fermented milk per day [Bifidobacterium breve strain Yakult (10 billion bacteria) and Lactobacillus acidophilus (1 billion bacteria)] (n = 98) or matching placebo (n = 97) for 48 weeks. The primary efficacy endpoint was relapse-free survival (relapse: rectal bleeding score ≥ 2 on Sutherland disease activity index scale for 3 consecutive days and/or initiation of remission induction therapy for worsening of UC). Results: An interim analysis was conducted after inclusion and follow-up of one-third of patients for the first phase of the study (n = 195). Relapse-free survival was not significantly different between the BFM and placebo groups (P = 0.643; hazard ratio 1.16; 95% CI 0.63–2.14, log-rank test), nor was the incidence of relapse. Therefore, the study was discontinued for lack of efficacy. An exploratory analysis of fecal samples from a subgroup of patients revealed no effects of either study beverage on intestinal microbiota, but there was a significant decrease in Bifidobacterium species before relapse, regardless of treatment group. Three mild adverse events occurred for which a causal relationship with the study beverage could not be ruled out (placebo: abdominal bloating and stress in one patient; BFM: body odor in one patient). Conclusions: BFM had no effect on time to relapse in UC patients compared with placebo. Study Registration: UMIN000007593.

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Treatment strategy for inflammatory bowel disease with a focus on biologicals].

KANAI Takanori

Nihon Shokakibyo Gakkai Zasshi 2018

Aortic carboxypeptidase-like protein, a WNT ligand, exacerbates nonalcoholic steatohepatitis.

KANAI Takanori

J Clin Invest (Journal of Clinical Investigation) 128 ( 4 ) 1581 - 1596 2018

ISSN 00219738

© 2018 American Society for Clinical Investigation. All rights reserved. Incidence of nonalcoholic steatohepatitis (NASH), which is considered a hepatic manifestation of metabolic syndrome, has been increasing worldwide with the rise in obesity; however, its pathological mechanism is poorly understood. Here, we demonstrate that the hepatic expression of aortic carboxypeptidase-like protein (ACLP), a glycosylated, secreted protein, increases in NASH in humans and mice. Furthermore, we elucidate that ACLP is a ligand, unrelated to WNT proteins, that activates the canonical WNT pathway and exacerbates NASH pathology. In the liver, ACLP is specifically expressed in hepatic stellate cells (HSCs). As fatty liver disease progresses, ACLP expression is enhanced via activation of STAT3 signaling by obesity-related factors in serum. ACLP specifically binds to frizzled-8 and low-density lipoprotein-related receptor 6 to form a ternary complex that activates canonical WNT signaling. Consequently, ACLP activates HSCs by inhibiting PPARγ signals. HSC-specific ACLP deficiency inhibits fibrosis progression in NASH by inhibiting canonical WNT signaling in HSCs. The present study elucidates the role of canonical WNT pathway activation by ACLP in NASH pathology, indicating that NASH can be treated by targeting ACLP-induced canonical WNT pathway activation in HSCs.

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Post-progression survival following second-line chemotherapy in patients with advanced pancreatic cancer previously treated with gemcitabine : a meta-analysis.

KANAI Takanori

Invest New Drugs (Investigational New Drugs) 36 ( 5 ) 939 - 948 2018

ISSN 01676997

© 2018, Springer Science+Business Media, LLC, part of Springer Nature. Background Post-progression survival (PPS) could be a confounding element in interpreting data from clinical trials of second-line chemotherapy in patients with advanced pancreatic cancer (PC) previously treated with gemcitabine (GEM) because a recent meta-analysis of oxaliplatin combination therapy showed statistical heterogeneity for overall survival (OS) but not for progression-free survival (PFS). This study aimed to improve the understanding of the impact of PPS on OS in this setting. Methods Databases were searched to identify randomized controlled trials (RCTs) in the salvage setting. We evaluated relationships between OS and PFS, PPS, and other variables. Results Totally, 17 RCTs with 3253 patients were identified. Median OS was strongly and moderately associated with median PPS and PFS, respectively (r = 0.913; p < 0.001 and 0.780; p < 0.001, respectively). The proportion of patients with good performance status was significantly associated with both PPS and PFS (r = 0.574, p < 0.001 and 0.492, p < 0.001, respectively). The induction rate of subsequent chemotherapy was related to the duration of PPS and OS (r = 0.640, p < 0.001 and 0.647, p < 0.001, respectively). Median PPS and OS were significantly longer in recent trials than those in older trials (3.55 versus 2.78 months, p < 0.001 and 6.29 versus 5.02 months, p < 0.001). Conclusions Median PPS was strongly correlated with median OS. Given the recently increased opportunity for subsequent chemotherapy and supportive care, PPS may serve as an important element to clarify problems in this setting.

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Clarithromycin expands CD11b+Gr-1+ cells via the STAT3/Bv8 axis to ameliorate lethal endotoxic shock and post-influenza bacterial pneumonia.

KANAI Takanori

PLoS Pathog 2018

Initial Management of Colonic Diverticular Bleeding: Observational Study

KANAI Takanori

Digestion (Digestion) 98 ( 1 ) 41 - 47 2018

ISSN 00122823

© 2018 S. Karger AG, Basel. Background/Aims: Although colonic diverticular bleeding (CDB) often ceases spontaneously, re-bleeding occurs in about 30%. Bleeding diverticulum can be treated directly by endoscopic hemostasis; however, it is difficult to perform colonoscopy in all cases with limited medical resource and certain risks. The aim of this study was to clarify who should undergo colonoscopy as well as appropriate methods of initial management in CDB patients. Methods: A total of 285 patients who were diagnosed as CDB and underwent colonoscopy from March 2004 to October 2015 were retrospectively analyzed. First, the association between re-bleeding and various factors including patients' background and initial management were analyzed. Second, the examination conditions that influenced bleeding point identification were analyzed. Results: Of 285 patients, 187 were men and 98 were women. Median age was 75 years, and the median observation period was 17.5 months. Re-bleeding was observed in 79 patients (28%). A history of CDB (OR 2.1, p = 0.0090) and chronic kidney disease (CKD; OR 2.3, p = 0.035) were risk factors, and bleeding point identification (OR 0.20, p = 0.0037) was a preventive factor for re-bleeding. Bleeding point identification significantly reduced approximately 80% of re-bleeding. Furthermore, extravasation on CT (OR 3.7, p = 0.031) and urgent colonoscopy (OR 5.3, p < 0.001) were predictors for identification of bleeding point. Compared to bleeding point identification of 11% in all patients who underwent colonoscopy, identification rate in those who had extravasation on CT and underwent urgent colonoscopy was as high as 70%. Conclusions: Contrast-enhanced CT upon arrival is suggested, and patients with extravasation on CT would be good candidates for urgent colonoscopy, as well as patients who have a history of CDB and CKD.

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The effect of fecal microbiota transplantation on psychiatric symptoms among patients with irritable bowel syndrome, functional diarrhea and functional constipation: An open-label observational study

KANAI Takanori

J Affect Disord (Journal of Affective Disorders) 235 506 - 512 2018

ISSN 01650327

© 2018 Elsevier B.V. Backgrounds: The intestinal microbiota is considered as a potential common underpinning pathophysiology of Functional Gastrointestinal Disorders (FGIDs) and psychiatric disorders such as depression and anxiety. Fecal Microbiota Transplantation (FMT) has been reported to have therapeutic effects on diseases related to dysbiosis, but few studies have evaluated its effect on psychiatric symptoms. Methods: We followed 17 patients with either Irritable Bowel Syndrome (IBS), Functional Diarrhea (FDr) or Functional Constipation (FC) who underwent FMT for the treatment of gastrointestinal symptoms and observation of psychiatric symptoms. Changes in Hamilton Rating Scale for Depression (HAM-D) and subscale of sleep-related items, Hamilton Rating Scale for Anxiety (HAM-A) and Quick Inventory for Depressive Symptoms (QIDS) between baseline and 4 weeks after FMT, and relationship with the intestinal microbiota were measured. Results: At baseline, 12 out of 17 patients were rated with HAM-D ≥ 8. Significant improvement in HAM-D total and sleep subscale score, HAM-A and QIDS were observed (p = 0.007, p = 0.007, p = 0.01, p = 0.007, respectively). Baseline Shannon index indicated that microbiota showed lower diversity in patients with HAM-D ≥ 8 compared to those of healthy donors and patients with HAM-D < 8. There was a significant correlation between baseline Shannon index and HAM-D score, and a correlation between Shannon index change and HAM-D improvement after FMT. Limitations: The small sample size with no control group. Conclusions: Our results suggest that depression and anxiety symptoms may be improved by FMT regardless of gastrointestinal symptom change in patients with IBS, FDr and FC, and the increase of microbiota diversity may help to improve patient's mood.

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A male Korean who was diagnosed with chronic enteropathy associated with SLCO2A1 (CEAS): Case report with literature review

Sun X., Hosoe N., Miyanaga R., Kimura K., Mizuno S., Takabayashi K., Naganuma M., Niizeki H., Seki A., Ogata H., Kanai T.

BMJ Open Gastroenterology (BMJ Open Gastroenterology) 5 ( 1 ) 2018

Objective To further disseminate the nomenclature of chronic enteropathy associated with SLCO2A1 (CEAS), especially for physicians in China and Korea where the genetic feature of SLCO2A1 gene mutations related hypertrophic osteoarthropathy and pachydermia had been extensively studied. SLCO2A1 gene mutations related hypertrophic osteoarthropathy and pachydermia had been extensively studied. Design A case report with literature review of SLCO2A1 gene mutations-related disorders. Results A 38-year-old Korean presented to a tertiary hospital with dizziness, abdominal pain and melena. He had a positive faecal occult blood test on initial workup. Oesophagogastroduodenal endoscopy (OGD), colonoscopy and CT scan were unremarkable and showed no obvious cause for his melena. Capsule endoscope and roentgen barium studies were performed, revealing an erythematous mucosa with ulcers in the jejunum and stenosis to the jejunal-ileal junction. Next-generation sequencing was then performed and discovered point mutations of SLCO2A1 gene's seven exon (940+1 G>A) and 13 exon (1807 C>T) allele. This Korean patient with CEAS is the first documented case noted outside of the Japanese population. Conclusion CEAS is not uniquely found in Japanese individuals. There are lots of similarities between CEAS and primary hypertrophic osteoarthropathy, the two entity may just be the two sides of one same coin. International and multidisciplined efforts are required to further study this complicated disorder.

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Clinical efficacy of immune checkpoint inhibitors in the treatment of unresectable advanced or recurrent gastric cancer: An evidence-based review of therapies

Togasaki K., Sukawa Y., Kanai T., Takaishi H.

OncoTargets and Therapy (OncoTargets and Therapy) 11 8239 - 8250 2018

© 2018 Togasaki et al. Standard treatment options for patients with advanced gastric cancer (GC) offer limited efficacy and are associated with some toxicity, which necessitates the development of more effective therapies for improving the treatment outcomes for this disease. Immunotherapy involving immune checkpoint inhibitors (ICIs) which inhibit the programmed death 1 (PD-1)/ programmed death ligand 1 interaction has emerged as a new treatment option. Nivolumab, a human IgG4 monoclonal antibody inhibitor of PD-1, has demonstrated promising clinical activity and induced durable responses in patients with advanced GC. Nivolumab has recently been approved for treating patients with pretreated advanced GC in Japan. In the present review, we summarized current evidence of the clinical efficacy of ICIs in a variety of solid tumors and reported our experience in patients with GC who were treated with nivolumab and the interesting features that were observed in these cases. Certain ICI-specific clinical features such as pseudo-and hyper-progression of tumor and hyper-response to subsequent chemotherapy have been reported in several cancer types. Lastly, we discussed the present scenario regarding research on biomarkers for assessing the clinical benefits of ICI therapies.

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Analysis of sensitivity and cell death pathways mediated by anti-cancer drugs using three-dimensional culture system

Kinoshita T., Higuchi H., Ayano-Kabashima-Niibe, Sakai G., Hamamoto Y., Takaishi H., Kanai T.

International Journal of Cancer Research (International Journal of Cancer Research) 14 ( 1 ) 1 - 12 2018

ISSN 18119727

© 2018 Takeshi Kinoshita et al. Objective: The aim of this study was to evaluate the differences of cytotoxicity mediated by anti-cancer drugs between 2D and 3D culture conditions. Methodology: The colon cancer cell line HCT116 was cultured in 2D and 3D conditions. Anti-proliferation effects and cell death pathways of cytotoxic agents, i.e., SN-38 and multi-kinase inhibitors i.e., sorafenib were examined. Data was analyzed by Studentʼs t-test. Results: Although SN-38 induced significant apoptosis associated with caspase-3/7 activation in 2D condition, apoptosis and anti-proliferation effects of SN-38 dramatically diminished in 3D condition. In contrast, anti-proliferation effects mediated by sorafenib unchanged. Interestingly, sorafenib induced significant apoptosis in the cells locating in the center of the 3D spheroids, whereas it did not induce caspase activation in 2D condition. In addition, 2D culture with low glucose concentration, a model mimicking central condition of the spheroids, revealed the significant cell death with caspase activation by sorafenib. Conclusion: 3D culture system provide new findings regarding cytotoxicity of compounds which are not identified by the 2D culture.

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Methotrexate-associated Lymphoproliferative Disorder of the Stomach Presumed to Be Mucosa-associated Lymphoid Tissue Lymphoma

Ishigaki S., Masaoka T., Kameyama H., Kawaida M., Kameyama K., Mori T., Kanai T.

Internal medicine (Tokyo, Japan) (Internal medicine (Tokyo, Japan)) 57 ( 22 ) 3249 - 3254 2018

ISSN 09182918

The number of patients with methotrexate-associated lymphoproliferative disorder (MTX-LPD) is increasing. We describe a case of MTX-LPD of the stomach. After treatment with methotrexate for rheumatoid arthritis, the patient developed left cervical lymphadenopathy and an ulcerative lesion in the stomach, which was presumed to be a mucosa-associated lymphoid tissue (MALT) lymphoma. However, we suspected MTX-LPD, based on the clinical course and the positivity of in situ hybridization for the detection of the Epstein-Barr encoding region. After the cessation of MTX, the left cervical lymphadenopathy and the gastric lesion disappeared. This is first report of gastric MTX-LPD that was presumed to be MALT lymphoma.

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Treatment strategy for inflammatory bowel disease with a focus on biologicals

Fukuda T., Naganuma M., Kanai T.

Journal of Japanese Society of Gastroenterology (Journal of Japanese Society of Gastroenterology) 115 ( 3 ) 272 - 282 2018

ISSN 04466586

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ß-(1,3)-Glucan derived from Candida albicans induces inflammatory cytokines from macrophages and lamina propria mononuclear cells derived from patients with Crohn's disease

Mori K., Naganuma M., Mizuno S., Suzuki H., Kitazume M.T., Shimamura K., Chiba S., Sugita A., Matsuoka K., Hisamatsu T., Kanai T.

Intestinal Research (Intestinal Research) 16 ( 3 ) 384 - 392 2018

ISSN 15989100

Background/Aims: Recent research has highlighted the importance of interactions between commensal fungi and intestinal inflammation. However, there are few studies investigating whether commensal fungi contribute to inflammation in patients with Crohn's disease (CD). The aim of this study is to investigate reveal interactions between commensal fungi and host immune cells in CD. Methods: CD14-positive monocytes were isolated from peripheral blood mononuclear cells from healthy human volunteers and then differentiated in the presence of macrophage colony-stimulating factor (M-CSF) (referred to as M-macrophages, M-MΦs) or M-CSF and interferon-γ (IFN-γ) (referred to as M-gamma macrophages, Mγ-Mϕs). Cytokine production by these in vitro differentiated macrophages in response to ß-(1,3)-glucan was analyzed by flow cytometry. Expression of Dectin-1 was examined using flow cytometry, western blotting, and quantitative reverse transcription-polymerase chain reaction. Cytokine production by in vitro differentiated macrophages in response to ß-(1,3)-glucan was measured in the presence of an anti-Dectin-1 receptor antagonist, anti-Syr, or an anti-Fas-1 antibody. Cytokine production by lamina propria mononuclear cells (LPMCs) derived from CD patients in response to ß-(1,3)-glucan was also analyzed. Results: Mγ-Mϕs produced a large amount of tumor necrosis factor-α (TNF-α) and interleukin-6 in response to ß-(1,3)-glucan. Dectin-1 expression was significantly higher in Mγ-Mϕs than in M-Mϕs. The increase in TNF-a production by Mγ-Mϕs stimulated with glucan was reversed by blocking Dectin-1, Syr or Fas-1. LPMCs derived from CD patients stimulated with ß-(1,3)-glucan produced significantly higher amount of TNF-α than LPMCs derived from UC patients. Conclusions: These results suggest that commensal fungal microbiota may contribute to the pathogenesis of CD by inducing macrophages-derived pro-inflammatory cytokines.

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Commensal Lactobacillus controls immune tolerance during acute liver injury in mice

Nakamoto N, Amiya T, Aoki R, Taniki N, Koda Y, Miyamoto K, Teratani T, Suzuki T, Chiba S, Chu PS, Hayashi A, Yamaguchi A, Shiba S, Miyake R, Katayama T, Suda W, Mikami Y, Kamada N, Ebinuma H, Saito H, Hattori M, Kanai T.

(Cell Rep. ) 21(5) 1215 - 1226 2017.10

Joint Work, Accepted

Gut-derived microbial antigens trigger the innate immune system during acute liver injury. During recovery, regulatory immunity plays a role in suppressing inflammation; however, the precise mechanism underlying this process remains obscure. Here, we find that recruitment of immune-regulatory classical dendritic cells (cDCs) is crucial for liver tolerance in concanavalin A-induced acute liver injury. Acute liver injury resulted in enrichment of commensal Lactobacillus in the gut. Notably, Lactobacillus activated IL-22 production by gut innate lymphoid cells and raised systemic IL-22 levels. Gut-derived IL-22 enhanced mucosal barrier function and promoted the recruitment of regulatory cDCs to the liver. These cDCs produced IL-10 and TGF-β through TLR9 activation, preventing further liver inflammation. Collectively, our results indicate that beneficial gut microbes influence tolerogenic immune responses in the liver. Therefore, modulation of the gut microbiota might be a potential option to regulate liver tolerance.

Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

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Free cholesterol accumulation in liver sinusoidal endothelial cells exacerbates acetaminophen hepatotoxicity via TLR9 signaling.

Teratani T, Tomita K, Suzuki T, Furuhashi H, Irie R, Hida S, Okada Y, Kurihara C, Ebinuma H, Nakamoto N, Saito H, Hibi T, Miura S, Hokari R, Kanai T.

J Hepatol 67 ( 4 ) 780 - 790 2017.10

Joint Work, Accepted

BACKGROUND & AIMS:

Although obesity is a risk factor for acute liver failure, the pathogenic mechanisms are not yet fully understood. High cholesterol (HC) intake, which often underlies obesity, is suggested to play a role in the mechanism. We aimed to elucidate the effect of a HC diet on acetaminophen-induced acute liver injury, the most frequent cause of acute liver failure in the USA.

METHODS:

C57BL/6 Toll-like receptor 9 (TLR9) knockout (Tlr9-/-) mice and their Tlr9+/+ littermates were fed an HC diet for fourweeks and then treated with acetaminophen. Liver sinusoidal endothelial cells (LSECs) were isolated from the mice for in vivo and in vitro analyses.

RESULTS:

The HC diet exacerbated acetaminophen-induced acute liver injury in a TLR9/inflammasome pathway-dependent manner. LSECs played a major role in the cholesterol loading-induced exacerbation. The accumulation of free cholesterol in the endolysosomes in LSECs enhanced TLR9-mediated signaling, thereby exacerbating the pathology of acetaminophen-induced liver injury through the activation of the TLR9/inflammasome pathway. The accumulation of free cholesterol in LSEC endolysosomes induced a dysfunction of the Rab7 membrane trafficking recycling mechanism, thus disrupting the transport of TLR9 from late endosomes to the lysosomes. Consequently, the level of active TLR9 in the late endosomes increased, thereby enhancing TLR9 signaling in LSECs.

CONCLUSIONS:

HC intake exaggerated acetaminophen-induced acute liver injury via free cholesterol accumulation in LSECs, demonstrating a novel role of free cholesterol as a metabolic factor in TLR9 signal regulation and pathologies of acetaminophen-induced liver injury. Therapeutic approaches may target this pathway. Lay summary: High cholesterol intake exacerbated acetaminophen-induced acute liver injury via the accumulation of free cholesterol in the endolysosomes of liver sinusoidal endothelial cells. This accumulation enhanced Toll-like receptor 9 signaling via impairment of its membrane trafficking mechanism. Thus, free cholesterol accumulation, as an underlying metabolic factor, exacerbated the pathology of acetaminophen-induced liver injury through activation of the TLR9/inflammasome pathway.

Copyright © 2017 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

KEYWORDS:

Acetaminophen; Endosome; Free cholesterol; Inflammasome; Liver injury; Liver sinusoidal endothelial cell; Lysosome; Metabolic syndrome; Rab7; Toll-like receptor 9

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Intestinal Dysbiosis and Biotin Deprivation Induce Alopecia though Overgrowth of Lactobacillus murinus in mice.

Hayashi A, Mikami Y, Miyamoto K, Kamada N, Sato T, Mizuno S, Naganuma M, Teratani T, Aoki R, Fukuda S, Suda W, Hattori M, Amagai M, Ohyama M, Kanai T.

Cell Rep. 20 ( 7 ) 1513 - 1524 2017.08

Joint Work, Accepted

Metabolism by the gut microbiota affects host physiology beyond the gastrointestinal tract. Here, we find that antibiotic-induced dysbiosis, in particular, overgrowth of Lactobacillus murinus (L. murinus), impaired gut metabolic function and led to the development of alopecia. While deprivation of dietary biotin per se did not affect skin physiology, its simultaneous treatment with vancomycin resulted in hair loss in specific pathogen-free (SPF) mice. Vancomycin treatment induced the accumulation of L. murinus in the gut, which consumes residual biotin and depletes available biotin in the gut. Consistently, L. murinus induced alopecia when monocolonized in germ-free mice fed a biotin-deficient diet. Supplementation of biotin can reverse established alopecia symptoms in the SPF condition, indicating that L. murinus plays a central role in the induction of hair loss via a biotin-dependent manner. Collectively, our results indicate that luminal metabolic alterations associated with gut dysbiosis and dietary modifications can compromise skin physiology.

Copyright © 2017. Published by Elsevier Inc.

Visualization and targeting of LGR5+ human colon cancer stem cells.

Shimokawa M, Ohta Y, Nishikori S, Matano M, Takano A, Fujii M, Date S, Sugimoto S, Kanai T, Sato T.

Nature 545 ( 7653 ) 187 - 192 2017.05

Joint Work, Accepted

The cancer stem cell (CSC) theory highlights a self-renewing subpopulation of cancer cells that fuels tumour growth. The existence of human CSCs is mainly supported by xenotransplantation of prospectively isolated cells, but their clonal dynamics and plasticity remain unclear. Here, we show that human LGR5+ colorectal cancer cells serve as CSCs in growing cancer tissues. Lineage-tracing experiments with a tamoxifen-inducible Cre knock-in allele of LGR5 reveal the self-renewal and differentiation capacity of LGR5+ tumour cells. Selective ablation of LGR5+ CSCs in LGR5-iCaspase9 knock-in organoids leads to tumour regression, followed by tumour regrowth driven by re-emerging LGR5+ CSCs. KRT20 knock-in reporter marks differentiated cancer cells that constantly diminish in tumour tissues, while reverting to LGR5+ CSCs and contributing to tumour regrowth after LGR5+ CSC ablation. We also show that combined chemotherapy potentiates targeting of LGR5+ CSCs. These data provide insights into the plasticity of CSCs and their potential as a therapeutic target in human colorectal cancer.

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Single fecal microbiota transplantation failed to change intestinal microbiota and had limited effectiveness against ulcerative colitis in Japanese patients.

Mizuno S, Nanki K, Matsuoka K, Saigusa K, Ono K, Arai M, Sugimoto S, Kiyohara H, Nakashima M, Takeshita K, Naganuma M, Suda W, Hattori M, Kanai T.

Intest Res 1 68 - 74 2017.01

Joint Work, Accepted

BACKGROUND/AIMS:

Recent developments in analytical techniques including next-generation sequencing have clarified the correlation between intestinal microbiota and inflammatory bowel disease. Fecal microbiota transplantation (FMT) for patients with ulcerative colitis (UC) is proposed as a potential approach to resolving their dysbiosis; however, its safety and efficacy have not been confirmed. This single-arm, open-label, non-randomized study aimed to evaluate the safety and efficacy of FMT for Japanese patients with UC as the first registered clinical trial in Japan.

METHODS:

We enrolled 10 patients with active UC despite medical therapy. The donors were the patients' relatives and were carefully screened for infectious diseases. Fecal material was administered via colonoscopy, and the primary endpoint was the presence or absence of serious adverse events related to FMT. The secondary endpoint was a change in partial Mayo score at 12 weeks post-FMT. Scores ≤2 were considered a clinical response. Fecal samples were collected to follow changes in gut microbiota, while extracted complementary DNA were analyzed by a next-generation sequencer. We obtained written informed consent from all patients and donors. This study was approved by our Institutional Review Board and is registered in the University hospital Medical Information Network (UMIN) Clinical Trials Registry (UMIN 000012814).

RESULTS:

Five patients with moderate disease and five with severe disease were enrolled. No severe adverse effects were observed. One patient achieved clinical response; however, none of the patients' microbiota diversity recovered to the donor levels.

CONCLUSIONS:

The use of single FMT for UC was safe; however, we failed to show its clinical efficacy and potential to change the intestinal microbiota.

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Leucine-rich Alpha-2 Glycoprotein is a Serum Biomarker of Mucosal Healing in Ulcerative Colitis.

Shinzaki S, Matsuoka K, Iijima H, Mizuno S, Serada S, Fujimoto M, Arai N, Koyama N, Morii E, Watanabe M, Hibi T, Kanai T, Takehara T, Naka T.

J Crohns Colitis 11 ( 1 ) 84 - 91 2017.01

Joint Work, Accepted

BACKGROUND AND AIMS:

Although several noninvasive and easily accessible biomarkers for inflammatory bowel disease [IBD] are available, their sensitivity and specificity are not adequate to be used as single markers and do not overrule the need for endoscopic evaluation. We previously reported that serum leucine-rich alpha-2 glycoprotein [LRG] was a novel biomarker for rheumatoid arthritis and IBD. We herein investigated whether LRG could indicate endoscopic activity in patients with ulcerative colitis [UC].

METHODS:

Serum LRG concentrations were determined by enzyme-linked immunosorbent assay [ELISA] in consecutive 129 patients with UC in two tertiary care hospitals, and associations of LRG with clinical and endoscopic activities were evaluated. Clinical activity index [CAI] < 6 was defined as clinical remission, and mucosal healing [MH] and complete mucosal healing were defined as Matts' endoscopic grades of 1 or 2 and grade of 1, respectively.

RESULTS:

Serum LRG levels were significantly increased and correlated with clinical and endoscopic activities in patients with UC. LRG levels were associated with both clinical and endoscopic activities even in patients with normal serum C-reactive protein [CRP] levels. Furthermore, LRG levels were significantly lower in patients with complete MH and deep remission. Serial measurements of LRG levels in a subset of patients demonstrated that LRG was significantly elevated during the endoscopically active stage compared with that during the MH stage.

CONCLUSIONS:

Serum LRG is a novel biomarker for detecting MH during disease course in patients with UC and a surrogate marker of endoscopic inflammation in patients with normal CRP levels.

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Successful EUS-guided nondilated pancreatic duct stent placement in patient with refractory pancreatic fistula after pancreaticoduodenectomy.

KANAI Takanori

VideoGIE 2017

Gender Difference of Gastric Emptying in Healthy Volunteers and Patients with Functional Dyspepsia.

KANAI Takanori

Digestion 95(1):72-78 2017

Glycolysis regulates LPS-induced cytokine production in M2 polarized human macrophages

KANAI Takanori

Immunol Lett 183:17-23 2017

Evaluation of the severity of ulcerative colitis using endoscopic dual red imaging targeting deep vessels.

KANAI Takanori

Endosc Int Open 5(1):E76-E82 2017

Positive relationship between subsequent chemotherapy and overall survival in pancreatic cancer: meta-analysis of postprogression survival for first-line chemotherapy.

KANAI Takanori

Cancer Chemother Pharmacol 79(3):595-602 2017

Single fecal microbiota transplantation failed to change intestinal microbiota and had limited effectiveness against ulcerative colitis in Japanese patients

KANAI Takanori

Intest Res 15(1):68-74 2017

Polyp detection rate in transverse and sigmoid colon significantly increases with longer withdrawal time during screening colonoscopy

KANAI Takanori

PLoS One 12(3):e0174155 2017

Visualization and targeting of LGR5+ human colon cancer stem cells

KANAI Takanori

Nature 545(7653):187-192 2017

Family history is an independent risk factor for the progression of gastric atrophy among patients with Helicobacter pylori infection

KANAI Takanori

United European Gastroenterol J (1):32-36. 2017

Timing of oral refeeding in acute pancreatitis: A systematic review and meta-analysis

KANAI Takanori

United European Gastroenterol J (6):725-732 2017

Endocytoscopy can be used to assess histological healing in ulcerative colitis

KANAI Takanori

Endoscopy 49(6):560-563 2017

Validation of the efficacy of the prognostic factor score in the Japanese severity criteria for severe acute pancreatitis: A large multicenter study

KANAI Takanori

United European Gastroenterol J (3):389-397 2017

Colonic dysmotility and morphological abnormality frequently detected in Japanese patients with irritable bowel syndrome

KANAI Takanori

Intest Res (2):236-243 2017

Free cholesterol accumulation in liver sinusoidal endothelial cells exacerbates acetaminophen hepatotoxicity via TLR9 signaling

KANAI Takanori

J Hepatol pii: S0168-8278(17)32056-1 2017

Limited Identification of Dual-time-point Positron Emission Tomography/Computed Tomography in Advanced Colorectal Neoplasms

KANAI Takanori

Intern Med ;56(11):1287-1292 2017

Effects of patient age and choice of antisecretory agent on success of eradication therapy for Helicobacter pylori infection

KANAI Takanori

J Clin Biochem Nutr 60(3):208-210 2017

Neural differentiation of human embryonic stem cells induced by the transgene-mediated overexpression of single transcription factors

KANAI Takanori

Biochem Biophys Res Commun ;490(2):296-301 2017

On-treatment decrease of NKG2D correlates to early emergence of clinically evident hepatocellular carcinoma after interferon-free therapy for chronic hepatitis C

KANAI Takanori

PLoS One 12(6):e0179096 2017

Bifidobacterium-Rich Fecal Donor May Be a Positive Predictor for Successful Fecal Microbiota Transplantation in Patients with Irritable Bowel Syndrome

KANAI Takanori

Digestion 96(1):29-38 2017

The Prognosis of Severe Acute Pancreatitis Varies According to the Segment Presenting With Low Enhanced Pancreatic Parenchyma on Early Contrast-Enhanced Computed Tomography: A Multicenter Cohort Study

KANAI Takanori

Pancreas 46(7):867-873 2017

Intestinal Dysbiosis and Biotin Deprivation Induce Alopecia through Overgrowth of Lactobacillus murinus in Mice

KANAI Takanori

Cell Rep 20(7):1513-1524 2017

Benefit of rebiopsy for deciding treatment strategy in rectal cancer: A case report

KANAI Takanori

Oncol Lett (3):3697-3700 2017

Curative resectability of gastrointestinal cancer identified from iron deficiency anemia

KANAI Takanori

Oncol Lett 14(4):4301-4304 2017

Inter-evaluator heterogeneity of clinical diagnosis for locally advanced esophageal squamous cell carcinoma

KANAI Takanori

Esophagus 14(4):324-332 2017

Antibiotic resistance and gyrA mutation affect the efficacy of 10-day sitafloxacin-metronidazole-esomeprazole therapy for Helicobacter pylori in penicillin allergic patients

KANAI Takanori

United European Gastroenterol J 5(6):796-804 2017

Effect of prophylactic clipping in colorectal endoscopic resection: A meta-analysis of randomized controlled studies.

KANAI Takanori

United European Gastroenterol J 5(6):859-867 2017

Changes in the Clinical Features and Long-term Outcomes of Colonic Diverticulitis in Japanese Patients

KANAI Takanori

Intern Med 10.2169/internalmedicine.7710- 2017

Commensal Lactobacillus controls immune tolerance during acute liver injury in mice

KANAI Takanori

Cell Reports 21(5):1215-1226 2017

Detection of bacterial DNA by in situ hybridization in patients with decompensated liver cirrhosis

KANAI Takanori

BMC Gastroenterol 2017

Enteric Glial Dysfunction Evoked by Apolipoprotein E Deficiency Contributes to Delayed Gastric Emptying

KANAI Takanori

Dig Dis Sci 10.1007/s10620-017-4820-7 2017

Clinical and pharmacokinetic factors associated with adalimumab-induced mucosal healing in patients with Crohn's disease

KANAI Takanori

Clin Gastroenterol Hepatol (Clinical Gastroenterology and Hepatology) S1542-3565(17)31303-4 ( 4 ) 542 - 549.e1 2017

ISSN 15423565

© 2018 AGA Institute Background & Aims: We previously reported results from a prospective randomized controlled trial comparing the efficacy of adalimumab monotherapy versus combination with azathioprine for patients with Crohn's disease (CD) who were naive to biologics and thiopurines. We performed a subanalysis of data from this study to evaluate factors associated with endoscopic response and mucosal healing in study participants. Methods: We compared simple endoscopic scores for CD between patients with moderate to severe active CD randomly assigned groups that received adalimumab monotherapy (n = 85) or adalimumab in combination with azathioprine (n = 91), from June 2011 to June 2014 in Japan. We evaluated associations of simple endoscopic scores for CD with clinical factors and trough levels of adalimumab. Ultimately, 135 patients at Week 26 and 139 patients at Week 52 from 44 referral sites were analyzed for the present investigation. Results: The odds for endoscopic response were significantly higher in the combination group than in the monotherapy group at Week 26 (odds ratio [OR], 2.12; 95% confidence interval [CI], 1.04–4.32) but not at Week 52 (OR, 1.50; 95% CI, 0.77–2.94). The odds of mucosal healing did not differ significantly between groups at Weeks 26 or 52. Simple endoscopic scores for CD at Week 0 was significantly associated with mucosal healing at Week 26 (OR, 0.80; 95% CI, 0.72–0.90) and at Week 52 (OR, 0.91; 95% CI, 0.84–0.99). Higher adalimumab trough level at Week 26 associated with mucosal healing at Week 52 (OR, 1.34; 95% CI, 1.14–1.58; P for trend =.001) and was significantly higher in patients with endoscopic response than in patients without endoscopic response at Weeks 26 and 52 (P <.001). Conclusions: In a post hoc analysis of data from a randomized controlled trial of patients with moderate to severe CD, we found that adalimumab in combination with azathioprine increased trough levels of adalimumab. Higher trough levels of adalimumab associated with endoscopic response and mucosal healing at Weeks 26 and 52. UMIN registration No: 000005146.

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The role of colorectal endoscopic submucosal dissection in patients with ulcerative colitis.

KANAI Takanori

Gastrointest Endosc (Gastrointestinal Endoscopy) 87 ( 4 ) 1079 - 1084 2017

ISSN 00165107

© 2018 American Society for Gastrointestinal Endoscopy Background and Aim: Patients with ulcerative colitis have an increased risk of colorectal dysplasia. Endoscopic submucosal dissection (ESD) for neoplastic lesions in ulcerative colitis remains controversial. The aim of this study was to clarify the role of ESD in the treatment strategy for ulcerative colitis. Methods: We retrospectively investigated 25 patients with ulcerative colitis in clinical remission who underwent colorectal ESD at 2 referral centers. We analyzed short-term and long-term outcomes. Preoperative diagnoses based on biopsy or endoscopy were also compared with the histologic diagnoses of resected specimens. Results: The mean size of the resected specimens was 34.9 ± 17.1 mm. The mean procedure time for ESD was 71.3 minutes. En bloc resection and R0 resection rates were achieved in 100% (25/25) and 76% (19/25), respectively. Postoperative bleeding and perforation during the procedure occurred in 0% and 4%, respectively. Five patients with noncurative resection underwent additional surgery. During a median 21 months (range, 8-80 months) follow-up, local recurrence did not occur. Metachronous high-grade dysplasia occurred in 1 case (4%). The biopsy predicted a final histologic diagnosis of carcinoma with a sensitivity of 72.2% (95% confidence interval [CI], 46.5-90.3), accuracy of 78.2% (95% CI, 56.3-92.5). The endoscopic findings predicted a final histologic diagnosis of carcinoma with a sensitivity of 72.2% (95% CI, 46.5-90.3), accuracy of 76% (95% CI, 54.9-90.6). Conclusion: ESD for neoplasms in ulcerative colitis is feasible by expert endoscopists and may avoid unnecessary surgery. Because the biopsy and endoscopic findings had relatively low accuracy for the final histology, ESD could have a curative as well as a diagnostic purpose.

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Endoscopic string clip suturing method: a prospective pilot study (with video)

KANAI Takanori

Gastrointest Endosc (Gastrointestinal Endoscopy) 87 ( 4 ) 1074 - 1078 2017

ISSN 00165107

© 2018 American Society for Gastrointestinal Endoscopy Background and Aims: We developed a suturing method with string and clips for a single-channel endoscope. The feasibility of the string clip suturing method is evaluated in this prospective pilot study. Methods: This study involved 10 consecutive patients who underwent endoscopic submucosal dissection (ESD) for a duodenal tumor. Polyester string was tied to the arm of a partially out thrust clip. The clip and string can be passed through the instrument channel (3.2 mm) of a single-channel endoscope. The clip with string was placed at the distal edge of the large mucosal defect. A second clip was hooked on the string and placed on the opposite side. Both clips were gathered by pulling the free end of the string, and additional clips were placed to achieve complete closure. This method was compared with that for the previous 10 patients without mucosal closure after duodenal ESD. Results: Mean size of resected specimens was 39.1 ± 12.4 mm. The success rate of the string clip suturing method was 100% (10/10). The mean procedure time was 23.4 ± 13.8 minutes. Perforation during ESD occurred in 1 patient and was successfully closed by this method. None of the treated patients developed serious adverse events after the procedure. Compared with the no-suture group, the length of stay was significantly shorter (P =.038). Conclusion: The string clip suturing method appears to be a safe and effective method for closure of large mucosal defects. (Clinical trial registration number: UMIN000023698.)

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Efficacy of Indigo naturalis in a Multicenter Randomized Controlled Trial of Patients with Ulcerative Colitis.

KANAI Takanori

Gastroenterology (Gastroenterology) 154 ( 4 ) 935 - 947 2017

ISSN 00165085

© 2018 AGA Institute Background & Aims: Indigo naturalis (IN) is a traditional Chinese medicine that contains ligands for the aryl hydrocarbon receptor and promotes regeneration of the mucosa by inducing production of interleukin 22. IN might induce mucosal healing in patients with ulcerative colitis (UC). We performed a randomized controlled trial to investigate the safety and efficacy of IN in patients with UC. Methods: We performed a multicenter, double-blind trial evaluating the safety of 86 patients in Japan with active UC (Mayo scores of 6 or more), enrolled from March 30 through December 27, 2016. Patients were randomly assigned to groups and given a daily dose of 0.5, 1.0, or 2.0 g IN or placebo (1:1:1:1 ratio) for 8 weeks. The primary endpoint was the rate of clinical response at week 8, defined as a 3-point decrease in the Mayo score and a decrease of at least 30% from baseline, with a decrease of at least 1 point for the rectal bleeding subscore or absolute rectal bleeding score of 0–1. The main secondary endpoint was the rate of clinical remission at week 8, defined as a Mayo score or ≤2 and no subscores with a value >1. Mucosal healing was also assessed at week 8. Results: The trial was terminated because of an external reason: a report of pulmonary arterial hypertension in a patient who used self-purchased IN for 6 months. In the intent-to-treat analysis, we observed a significant, dose-dependent linear trend in proportions of patients with clinical responses (13.6% with a clinical response to placebo; 69.6% to 0.5 g IN; 75.0% to 1.0 g IN; and 81.0% to 2.0 g IN) (Cochran-Armitage trend test P <.0001 compared with placebo). Proportions of patients in clinical remission at week 8 were significantly higher in the 1.0 g IN group (55.0%, P =.0004) and the 2.0 g IN group (38.1%, (P =.0093) than in the placebo group (4.5%). Proportions of patients with mucosal healing were 13.6% in the placebo group, 56.5% in the 0.5 g IN group, 60.0% in the 1.0 g IN group, and 47.6% in the 2.0 g IN group (P =.0278 compared with placebo). Although mild liver dysfunction was observed in 10 patients who received IN, no serious adverse events were observed. Conclusions: In a randomized, placebo-controlled trial, we found 8 weeks of IN (0.5–2.0 g per day) to be effective in inducing a clinical response in patients with UC. However, IN should not yet be used because of the potential for adverse effects, including pulmonary arterial hypertension. Clinical Trials Registry no: UMIN000021439 (http://www.umin.ac.jp/ctr/).

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Reply to Gheorghe et al.

KANAI Takanori

Endoscopy 2017

Gut microbiota-mediated generation of saturated fatty acids elicits inflammation in the liver in murine high-fat diet-induced steatohepatitis.

KANAI Takanori

BMC Gastroenterol 2017

The impact of visceral adipose tissue as best predictor for difficult colonoscopy and the clinical utility of a long small-caliber scope as rescue.

KANAI Takanori

PLoS One 2017

Intestinal immune response is regulated by gut microbe.

KANAI Takanori

Nihon Rinsho Meneki Gakkai Kaishi. 2017

Increased levels of prostaglandin E-major urinary metabolite (PGE-MUM) in active mesenteric panniculitis patients: A case report.

KANAI Takanori

Medicine (Baltimore) 2017

A Colorectal Tumor Organoid Library Demonstrates Progressive Loss of Niche Factor Requirements during Tumorigenesis.

Fujii M, Shimokawa M, Date S, Takano A, Matano M, Nanki K, Ohta Y, Toshimitsu K, Nakazato Y, Kawasaki K, Uraoka T, Watanabe T, Kanai T, Sato T.

Cell Stem Cell 18 ( 6 ) 827 - 38 2016.06

Joint Work, Accepted

Colorectal tumor is a heterogeneous disease, with varying clinical presentation and prognosis in patients. To establish a platform encompassing this diversity, we generated 55 colorectal tumor organoid lines from a range of histological subtypes and clinical stages, including rare subtypes. Each line was defined by gene expression signatures and optimized for organoid culture according to niche factor requirements. In vitro and in xenografts, the organoids reproduced the histopathological grade and differentiation capacity of their parental tumors. Notably, we found that niche-independent growth is predominantly associated with the adenoma-carcinoma transition reflecting accumulation of multiple mutations. For matched pairs of primary and metastatic organoids, which had similar genetic profiles and niche factor requirements, the metastasis-derived organoids exhibited higher metastatic capacity. These observations underscore the importance of genotype-phenotype analyses at a single-patient level and the value of our resource to provide insights into colorectal tumorigenesis and patient-centered therapeutic development.

Copyright © 2016 Elsevier Inc. All rights reserved.

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Inhibition of DNA Methylation Suppresses Intestinal Tumor Organoids by Inducing an Anti-Viral Response.

Saito Y, Nakaoka T, Sakai K, Muramatsu T, Toshimitsu K, Kimura M, Kanai T, Sato T, Saito H.

Sci Rep 6 ( 25311 ) 2016.05

Joint Work, Accepted

Recent studies have proposed that the major anti-tumor effect of DNA methylation inhibitors is induction of interferon-responsive genes via dsRNAs-containing endogenous retroviruses. Recently, a 3D culture system for stem cells known as organoid culture has been developed. Lgr5-positive stem cells form organoids that closely recapitulate the properties of original tissues. To investigate the effect of DNA demethylation on tumor organoids, we have established organoids from intestinal tumors of Apc(Min/+) (Min) mice and subjected them to 5-aza-2'-deoxycytidine (5-Aza-CdR) treatment and Dnmt1 knockdown. DNA demethylation induced by 5-Aza-CdR treatment and Dnmt1 knockdown significantly reduced the cell proliferation of the tumor organoids. Microarray analyses of the tumor organoids after 5-Aza-CdR treatment and Dnmt1 knockdown revealed that interferon-responsive genes were activated by DNA demethylation. Gene ontology and pathway analyses clearly demonstrated that these genes activated by DNA demethylation are involved in the anti-viral response. These findings indicate that DNA demethylation suppresses the proliferation of intestinal tumor organoids by inducing an anti-viral response including activation of interferon-responsive genes. Treatment with DNA methylation inhibitors to activate a growth-inhibiting immune response may be an effective therapeutic approach for colon cancers.

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Colonic dysmotility and morphologic abnormality frequently detected in Japanese patients with irritable bowel syndrome

KANAI Takanori

Intestinal Research 2016

Cross-sectional small intestinal surveillance of maintenance hemodialysis patients using video capsule endoscopy:SCHEMA study.

KANAI Takanori

Endosc Int Open 4(5):E589-96. 2016

A Colorectal Tumor Organoid Library Demonstrates Progressive Loss of Niche Factor Requirements during Tumorigenesis

KANAI Takanori

Cell Stem Cell 2;18(6):827-38 2016

Glycolytic pathway affects differentiation of human monocytes to regulatory macrophages

KANAI Takanori

Immunol Lett 176:18-27 2016

The Ulcerative Colitis Endoscopic Index of Severity (UCEIS) is useful to predict medium to long-term prognosis in ulcerative colitis patients with clinical remission.

KANAI Takanori

J Crohns Colitis 10(11):1303-1309 2016

Indole compounds may be promising medicines for ulcerative colitis

KANAI Takanori

J Gastroenterol. 51(9):853-61 2016

Inhibition of DNA Methylation Suppresses Intestinal Tumor Organoids by Inducing an Anti-Viral Response

KANAI Takanori

Sci Rep 4;6:25311 2016

Fatal hemorrhage in a patient with advanced soft tissue sarcoma following radiation and pazopanib treatment: A case report

KANAI Takanori

Oncol Lett 11(4):2408-2410 2016

Ulcerative colitis endoscopic index of severity is associated with long-term prognosis in ulcerative colitis patients treated with infliximab

KANAI Takanori

Dig Endosc 28(6):665-70 2016

Broadband mid-infrared pulses from potassium titanyl arsenate/zinc germanium phosphate optical parametric amplifier pumped by Tm, Ho-fiber-seeded Ho:YAG chirped-pulse amplifier

KANAI Takanori

Opt Lett 1;41(5):930-3 2016

Effects of preoperative proton pump inhibitor administration on bleeding after gastric endoscopic submucosal dissection: A systematic review and meta-analysis

KANAI Takanori

United European Gastroenterol J 4(1):5-10 2016

Clinical Efficacy and Safety of Oral Qing-Dai in Patients with Ulcerative Colitis: A Single-Center Open-Label Prospective Study

KANAI Takanori

Digestion 93(3):193-201 2016

Up-to-date medical treatment for ulcerative colitis

KANAI Takanori

Nihon Shokakibyo Gakkai Zasshi 113(3):413-23 2016

Early tumor cavitation with regorafenib in metastatic colorectal cancer

KANAI Takanori

A case report. Oncol Lett 11(1):231-233 2016

Percutaneous endoscopic gastrostomy under steady pressure automatically controlled endoscopy: First clinical series

KANAI Takanori

World J Gastrointest Endosc 10;8(3):186-91 2016

Simeprevir/pegylated interferon/ribavirin triple therapy for recurrent hepatitis C after living donor liver transplantation

KANAI Takanori

Hepatol Res 46(11):1118-1128 2016

Endoscopic Severity Predicts Long-Term Prognosis in Crohn's Disease Patients with Clinical Remission

KANAI Takanori

Digestion 93(1):66-71 2016

Endoscopic slipknot clip suturing method: an ex vivo feasibility study (with video)

KANAI Takanori

Gastrointest Endosc 83(2):447-50 2016

Findings of ulceration and severe stricture on MRE can predict prognosis of Crohn's disease in patients treated with anti-TNF treatment

KANAI Takanori

Abdom Radiol (NY) 42(1):141-151 2016

Evaluation of performance of the Omni mode for detecting video capsule endoscopy images: A multicenter randomized controlled trial

KANAI Takanori

Endosc Int Open 4(8):E878-82 2016

The Combined Usefulness of the Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios in Predicting Intravenous Immunoglobulin Resistance with Kawasaki Disease

KANAI Takanori

J Pediatr 178:281-284 2016

A simple scoring system to assess the need for an endoscopic intervention in suspected upper gastrointestinal bleeding: A prospective cohort study

KANAI Takanori

Dig Liver Dis 48(10):1180-6. 2016

Endoscopic slip knot clip suturing method: A prospective pilot study (with video)

KANAI Takanori

Gastrointest Endosc. pii S0016-5107(16)30432-1 2016

Leucine-rich Alpha-2 Glycoprotein is a Serum Biomarker of Mucosal Healing in Ulcerative Colitis

KANAI Takanori

J Crohns Colitis 11(1):84-91 2016

Polyglycolic acid sheet for closure of esophagobronchial fistula in a patient with Behçet's disease

KANAI Takanori

Gastrointest Endosc. pii S0016-5107(16)30380-7 2016

Rifabutin-based 10-day and 14-day triple therapy as a third-line and fourth-line regimen for Helicobacter pylori eradication: A pilot study

KANAI Takanori

United European Gastroenterol J 4(3):380-7 2016

Successful Pancreatic Duct Stent Placement for Recurrent Pancreatitis in a Patient with Polysplenia with Agenesis of the Dorsal Pancreas and Peutz-Jeghers Syndrome

KANAI Takanori

Intern Med 55(13):1743-6 2016

DIAMOND study group. Adalimumab Monotherapy and a Combination with Azathioprine for Crohn's Disease: A Prospective, Randomized Trial

KANAI Takanori

J Crohns Colitis 10(11):1259-1266 2016

Endoscopic morphological features of ulcerative colitis-associated dysplasia classified according to the SCENIC consensus statement

KANAI Takanori

Gastrointestinal Endoscopy. Pii :S0016-5107(16)30751-9 2016

Characteristics of gastric cancer detected within 1 year after successful eradication of Helicobacter pylori

KANAI Takanori

J Clin Biochem Nutr 59(3):226-230 2016

Long-Term Clinical Course after Conservative and Endoscopic Treatment of Colonic Diverticular Bleeding

KANAI Takanori

Digestion 9;94(4):186-191 2016

Continuous Regional Arterial Infusion of Protease Inhibitors Has No Efficacy in the Treatment of Severe Acute Pancreatitis: A Retrospective Multicenter Cohort Study

KANAI Takanori

Pancreas 46(4):510-517. 2016

Metal stent for refractory post-ES bleeding: Is this the ultimate treatment modality?

KANAI Takanori

Endosc Int Open ;4(12):E1265-E1266 2016

Accuracy of biopsy for the preoperative diagnosis of superficial nonampullary duodenal adenocarcinoma

KANAI Takanori

Gastrointest Endosc. pii S0016-5107(16)30837-9. 2016

Nanoscale Characterization of Interaction of APOBEC3G with RNA

KANAI Takanori

Biochemistry 56(10):1473-1481 2016

Endoscopic morphologic features of ulcerative colitis-associated dysplasia classified according to the SCENIC consensus statement

KANAI Takanori

S0016- 5107(16)30751-9 2016

Ampullary adenoma treated by endoscopic double-snare retracting papillectomy

Soma Hiromitsu, Miyata Naoteru, Hozawa Shigenari, Higuchi Hajime, Yamagishi Yoshiyuki, Nakamura Yuji, Saeki Keita, Kameyama Kaori, Masugi Yohei, Yahagi Naohisa, Kanai Takanori

Gut and Liver 9 ( 5 ) 689 - 692 2015.09

ISSN 1976-2283

We report herein improved methods for the safe and successful completion of endoscopic papillectomy (EP). Between January 2008 and November 2011, 12 patients underwent double-snare retracting papillectomy for the treatment of lesions of the major duodenal papilla. The main outcomes were en bloc resection rates, pathological findings, and adverse events. All of the patients (mean age, 60.1 years; range, 38 to 80 years) were diagnosed with ampullary adenoma by endoscopic forceps biopsies prior to endoscopic snare papillectomy. En bloc resection by double-snare retracting papillectomy was successfully performed for all lesions (median size, 12.3 mm), comprising six tubular adenomas, one tubulovillous adenoma, three cases of epithelial atypia, one hamartomatous polyp, and one case of duodenitis with regenerative change. Significant hemorrhage and pancreatitis were observed in one case after EP. Adenoma recurrence occurred in three patients during follow-up (median, 28.5 months) at a mean interval of 2 months postoperatively (range, 1 to 3 months). No serious adverse events were observed. Double-snare retracting papillectomy is effective and feasible for treating lesions of the major duodenal papilla. Further treatment experience, including a single-arm phase II study, needs to be accumulated before conducting a randomized controlled study.

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New endoscopic suturing method

Nishizawa Toshihiro, Uraoka Toshio, Suzuki Hidekazu, Goto Osamu, Ochiai Yasutoshi, Fujimoto Ai, Maehata Tadateru, Kanai Takanori, Yahagi Naohisa

Gastrointestinal Endoscopy 82 ( 3 ) 570 - 571 2015.09

ISSN 0016-5107

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Focus On Helicobacter pylori感染症の治療

KANAI Takanori

Internal Medicine ((株)南江堂) 116 ( 3 ) 501 - 505 2015.09

Joint Work, ISSN 0022-1961

A breakthrough in probiotics: Clostridium butyricum regulates gut homeostasis and anti-inflammatory response in inflammatory bowel disease.

Kanai T, Mikami Y, Hayashi A

J Gastroenterol 50 ( 9 ) 928 - 39 2015.09

Joint Work, Accepted

Intestinal immune homeostasis is regulated by gut microbiota, including beneficial and pathogenic microorganisms. Imbalance in gut bacterial constituents provokes host proinflammatory responses causing diseases such as inflammatory bowel disease (IBD). The development of next-generation sequencing technology allows the identification of microbiota alterations in IBD. Several studies have shown reduced diversity in the gut microbiota of patients with IBD. Advances in gnotobiotic technology have made possible analysis of the role of specific bacterial strains in immune cells in the intestine. Using these techniques, we have shown that Clostridium butyricum as a probiotic induces interleukin-10-producing macrophages in inflamed mucosa via the Toll-like receptor 2/myeloid differentiation primary response gene 88 pathway to prevent acute experimental colitis. In this review, we focus on the new approaches for the role of specific bacterial strains in immunological responses, as well as the potential of bacterial therapy for IBD treatments.

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【生物学的製剤が拓くIBD診療の新時代】生物学的製剤は中止できるか

KANAI Takanori

Mebio 32 ( 8 ) 64 - 70 2015.08

Joint Work, ISSN 0910-0474

Association of visceral fat area, smoking, and alcohol consumption with reflux esophagitis and Barrett's esophagus in Japan

Matsuzaki Juntaro, Suzuki Hidekazu, Kobayakawa Masao, Inadomi John M., Takayama Michiyo, Makino Kanako, Iwao Yasushi, Sugino Yoshinori, Kanai Takanori

PLoS ONE 10 ( 7 ) 2015.07

Background: Central obesity has been suggested as a risk factor for gastroesophageal reflux disease. The aim of this study was to evaluate the association of visceral fat area and other lifestyle factors with reflux esophagitis or Barrett's esophagus in Japanese population. Methods: Individuals who received thorough medical examinations including the measurement of visceral fat area by abdominal computed tomography were enrolled. Factors associated with the presence of reflux esophagitis, the severity of reflux esophagitis, or the presence of Barrett's esophagus were determined using multivariable logistic regression models. Results: A total of 2608 individuals were eligible for the analyses. Visceral fat area was associated with the presence of reflux esophagitis both in men (odds ratio, 1.21 per 50 cm2; 95% confident interval, 1.01 to 1.46) and women (odds ratio, 2.31 per 50 cm2; 95% confident interval, 1.57 to 3.40). Current smoking and serum levels of triglyceride were also associated with the presence of reflux esophagitis in men. However, significant association between visceral fat area and the severity of reflux esophagitis or the presence of Barrett's esophagus was not shown. In men, excessive alcohol consumption on a drinking day, but not the frequency of alcohol drinking, was associated with both the severity of reflux esophagitis (odds ratio, 2.13; 95% confident interval, 1.03 to 4.41) and the presence of Barrett's esophagus (odds ratio, 1.71; 95% confident interval, 1.14 to 2.56). Conclusion: Visceral fat area was independently associated with the presence of reflux esophagitis, but not with the presence of Barrett's esophagus. On the other hand, quantity of alcohol consumption could play a role in the development of severe reflux esophagitis and Barrett's esophagus in Japanese population Copyright:

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Current status of alcoholic liver diseases in Japan

Horie Yoshinori, Ebinuma Hirotoshi, Kikuchi Masahiro, Nakamoto Nobuhiro, Kanai Takanori

Acta Hepatologica Japonica 56 ( 7 ) 366 - 368 2015.07

ISSN 0451-4203

A nationwide survey of liver cirrhosis (LC) was un- dertaken by asking major hospitals in Japan to provide information on the number of patients with LC admit- ted in 2012 along with information related to etiology including alcohol history. Etiological agents were as fol- lows: hepatitis B virus (10.5％), hepatitis C virus (47.1％), and alcohol (24.6％). Of LC cases, 30.6％ were alcohol- related (ethanol intake >60 g day). Among alcoholic LC (Al-LC) patients, mean age was older in the present study in 2012 compared with the data for 2007-2008. Our survey revealed that the prevalence of Al-LC has been rapidly increasing in Japan. Moreover, age was identified as risk factors for development of Al-LC.

Smad2 and Smad3 Inversely Regulate TGF-β Autoinduction in Clostridium butyricum-Activated Dendritic Cells

Kashiwagi Ikkou, Morita Rimpei, Schichita Takashi, Komai Kyoko, Saeki Keita, Matsumoto Makoto, Takeda Kiyoshi, Nomura Masatoshi, Hayashi Atsushi, Kanai Takanori, Yoshimura Akihiko

Immunity 43 ( 1 ) 65 - 80 2015.07

ISSN 1074-7613

Colonization with a mixture of Clostridium species has been shown to induce accumulation of induced regulatory T (iTreg) cells in the colon. Transforming growth factor-β (TGF-β) is an essential factor for iTreg cell induction; however, the relationship between Clostridium species and TGF-β remains to be clarified. Here we demonstrated that a gram-positive probiotic bacterial strain, Clostridium butyricum (C. butyricum), promoted iTreg cell generation in the intestine through induction of TGF-β1 from lamina propria dendritic cells (LPDCs). C. butyricum-mediated TGF-β1 induction was mainly Toll-like receptor 2 (TLR2) dependent, and the ERK-AP-1 kinase pathway played an important role. In addition, the autocrine TGF-β-Smad3 transcription factor signal was necessary for robust TGF-β expression in DCs, whereas Smad2 negatively regulated TGF-β expression. Smad2-deficient DCs expressed higher concentrations of TGF-β and were tolerogenic for colitis models. This study reveals a novel mechanism of TGF-β induction by Clostridia through a cooperation between TLR2-AP-1 and TGF-β-Smad signaling pathways.

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Crohn’s disease in which the patient developed aortitis during treatment with adalimumab

Kiyohara Hiroki, Hisamatsu Tadakazu, Matsuoka Katsuyoshi, Naganuma Makoto, Kameda Hideto, Seta Noriyuki, Takeuchi Tsutomu, Kanai Takanori

Internal Medicine 54 ( 14 ) 1725 - 1732 2015.07

ISSN 0918-2918

A 23-year-old woman developed aortitis during treatment with adalimumab (ADA) for ileocolic Crohn’s disease (CD). The patient complained of a high fever, abdominal pain, diarrhea, hematochezia and arthralgia. Although the ADA therapy resulted in immediate symptom improvement, after six weeks, she again complained of a low-grade fever and abdominal pain, whereas the CD-related symptoms did not worsen. Contrast-enhanced computed tomography revealed thoracoabdominal aortitis, and we therefore started treatment with prednisolone, which immediately improved the fever and abdominal pain. We subsequently tapered the dose of prednisolone and resumed the administration of ADA in order to maintain the CD remission. No further episodes of aortitis relapse were noted after restarting ADA, and the CD currently remains in remission. This is the first report of the onset of aortitis during ADA therapy for CD.

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本邦におけるアルコール性肝硬変の実態

KANAI Takanori

肝臓 56 ( 7 ) 366 - 368 2015.07

Joint Work, ISSN 0451-4203

Computer-aided prediction of long-term prognosis of patients with ulcerative colitis after cytoapheresis therapy

Takayama Tetsuro, Okamoto Susumu, Hisamatsu Tadakazu, Naganuma Makoto, Matsuoka Katsuyoshi, Mizuno Shinta, Bessho Rieko, Hibi Toshifumi, Kanai Takanori

PLoS ONE 10 ( 6 ) 2015.06

Cytoapheresis (CAP) therapy is widely used in ulcerative colitis (UC) patients with moderate to severe activity in Japan. The aim of this study is to predict the need of operation after CAP therapy of UC patients on an individual level using an artificial neural network system (ANN). Ninety UC patients with moderate to severe activity were treated with CAP. Data on the patients' demographics, medication, clinical activity index (CAI) and efficacy of CAP were collected. Clinical data were divided into training data group and validation data group and analyzed using ANN to predict individual outcomes. The sensitivity and specificity of predictive expression by ANN were 0.96 and 0.97, respectively. Events of admission, operation, and use of immunomodulator, and efficacy of CAP were significantly correlated to the outcome. Requirement of operation after CAP therapy was successfully predicted by using ANN. This newly established ANN strategy would be used as powerful support of physicians in the clinical practice.

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Recognition of and recent issues in hereditary diffuse gastric cancer

Sugimoto Shinya, Komatsu Hirokazu, Morohoshi Yuichi, Kanai Takanori

Journal of Gastroenterology 50 ( 8 ) 831 - 843 2015.06

ISSN 0944-1174

In East Asian countries, gastric cancer incidence is high, but detection rates for germline CDH1 mutations that cause hereditary diffuse gastric cancers (HDGCs) are low. Consequently, screens and genetic testing for HDGC are often considered unimportant. Since the first germline truncating CDH1 mutations in Japanese patients were reported, some HDGC cases have been reported, and some of these involve large germline rearrangements and de novo mutation of CDH1. New methods for mutation detection—such as multiplex ligation-dependent probe amplification, array comparative genomic hybridization, and exome sequencing—have become available, as have new experimental models, including novel gene-knockout mice and gastric organoids. Because of these advances, searches for candidate genes (e.g., CTNNA1, MAP3K6) and our understanding of HDGC pathogenesis have improved in recent years; moreover, there have been substantial changes in the field since the current HDGC consensus guidelines were released. This review focuses on recent issues and advances in the study of HDGC. For example, lobular breast cancer cases and de novo occurrences of DGC are unlikely to meet the existing criteria for genetic testing, but current evidence indicates that some such cases may be good candidates for genetic testing. It is important to recognize that HDGC is a syndrome and that lobular breast cancer can be the first manifestation of this syndrome. CDH1 testing, including analyses of large genomic rearrangements, should be recommended even in countries where few HDGC cases have been reported.

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【microbiome(腸内細菌)と肝胆膵領域の新世紀】なぜ今腸内細菌か?　ヒト腸内細菌と消化管疾患

KANAI Takanori

肝・胆・膵 70 ( 6 ) 827-833 2015.06

ISSN 0389-4991

新しい消化器疾患動物モデル(第18回)　動物モデルの問題点と工夫　炎症性腸疾患モデル

KANAI Takanori

分子消化器病 12 ( 2 ) 178 - 184 2015.06

Joint Work, ISSN 1348-995X

炎症性腸疾患(IBD)、とくに潰瘍性大腸炎(UC)、クローン病(CD)はいまだに病態の解明がなされていない。遺伝、環境、腸内細菌など複合的な要因により病態が引き起こされると考えられている。しかし、いまだに完全にヒトIBDと同様の病態を示すモデルはなく、さまざまな大腸炎動物モデルを知り、必要に応じて使い分ける必要がある。近年無菌マウスシステムが確立され、腸内細菌が宿主の免疫系を教育することが判明してきた。さらにCRISPR/Cas9を利用した新しい遺伝子改変システムが今後広範に利用されるであろう。(著者抄録)

肝星細胞遊離コレステロール代謝調節による肝線維化新規治療法開発に関する研究

KANAI Takanori

臨床薬理の進歩 ( 36 ) 32 - 43 2015.06

ISSN 0914-4366

肝星細胞遊離コレステロール(Ch)代謝調節による肝線維化新規治療法開発について検討した。C57BL/6バックグラウンドの9週齢雄性ACAT1欠損マウスおよび野生型マウスを用いた。ACAT1がマウス肝星細胞の主要なアイソザイムで、ACAT2発現はほとんど認めなかった。ACAT1欠損が肝星細胞活性化に及ぼす影響が、遊離Ch蓄積に依存することを示唆した。CCL肝線維化モデルで、TLR4シグナルが欠損した状態では、ACAT1欠損は肝線維化進展に影響を及ぼさなかった。TLR4シグナルが欠損した状態でも、ACAT1欠損により肝星細胞の遊離Ch蓄積が有意に増強したが、CE蓄積には影響しなかった。TLR4シグナルが欠損している状態では、ACAT1欠損による反応性の増強は認めなかった。遊離Ch蓄積により増強したTLR4シグナルが、ACAT1欠損による肝線維化の増悪に重要な役割を果たすことが示唆された。

【ベーチェット病の最近の知見】ベーチェット病の腸管病変

KANAI Takanori

リウマチ科 53 ( 6 ) 565 - 570 2015.06

ISSN 0915-227X

糞便微生物移植の臨床応用

KANAI Takanori

日本医事新報 ( 4756 ) 49 2015.06

ISSN 0385-9215

Genotype-associated differential NKG2D expression on CD56+CD3+ lymphocytes predicts response to pegylated-interferon/ribavirin therapy in chronic hepatitis C

Chu Po Sung, Ebinuma Hirotoshi, Nakamoto Nobuhiro, Sugiyama Kazuo, Usui Shingo, Wakayama Yuko, Taniki Nobuhito, Yamaguchi Akihiro, Shiba Shunsuke, Yamagishi Yoshiyuki, Wakita Takaji, Hibi Toshifumi, Saito Hidetsugu, Kanai Takanori

PLoS ONE 10 ( 5 ) 2015.05

Hepatitis C virus (HCV) genotype 1 infections are significantly more difficult to eradicate with PEG-IFN/ribavirin therapy, compared to HCV genotype 2. The aim of this work is to investigate the difference of immunological impairments underlying this phenomenon. Pretreatment NKG2D expression on peripheral CD56+CD3+ lymphocytes and CD56+CD3-NK cells from cases of chronic hepatitis C were analyzed and assessed by treatment effect. Two strains of HCV were used to co-incubate with immune cells in vitro. NKG2D expression on peripheral CD56+CD3+ lymphocytes, but not NK cells, was significantly impaired in genotype 1 infection, compared to genotype 2. When peripheral blood mononuclear cells from healthy donors were co-incubated with TNS2J1, a genotype 1b/2a chimera strain, or with JFH1, a genotype 2a strain, genotype-specific decrease of NKG2D on CD56+CD3+ lymphocytes, but not NK cells, was observed. Pre-treatment NKG2D expression on peripheral CD56+CD3+ lymphocytes significantly correlated with reduction in serum HCV RNA levels from week 0 to week 4, and predicted treatment response. Ex vivo stimulation of peripheral CD56+CD3+ lymphocytes showed NKG2D expression-correlated IFN-γ production. In conclusion, Decreased NKG2D expression on CD56+CD3+ lymphocytes in chronic HCV genotype 1 infection predicts inferior treatment response to PEG-IFN/ribavirin therapy compared to genotype 2.

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Combination therapy with infliximab and thiopurine compared to infliximab monotherapy in maintaining remission of postoperative crohn's disease

Sakuraba Atsushi, Okamoto Susumu, Matsuoka Katsuyoshi, Sato Toshiro, Naganuma Makoto, Hisamatsu Tadakazu, Iwao Yasushi, Ogata Haruhiko, Kanai Takanori, Hibi Toshifumi

Digestion 91 ( 3 ) 233 - 238 2015.05

ISSN 0012-2823

Background and Aims: Infliximab is an efficacious agent used for the induction and maintenance of remission in Crohn's disease (CD), and recent studies suggested that it may also prevent the recurrence of this disease after surgery. The present study was performed to assess the efficacy and safety of infliximab in the postoperative setting, and to identify whether combination treatment with thiopurines had any additional beneficial effect as compared to mono-therapy. Methods: We performed a retrospective cohort study to compare the efficacy of infliximab mono-therapy and combination treatment with a thiopurine in preventing recurrence after surgery. Results: Forty-one patients who received infliximab as maintenance treatment following surgery from May 2002 to April 2010 were identified. Twenty-four were naive to infliximab, and 17 who underwent surgery during infliximab treatment were continued on it following surgery. The median follow-up period was 27 months (range 12-66 months). All patients continued infliximab as maintenance treatment, but 10 required dose intensification due to clinical recurrence. Kaplan-Meier analysis demonstrated that the use of concomitant thiopurine was correlated with the continuation of infliximab treatment at an 8-week interval (log-rank test p = 0.018). The rate of adverse event was 9.8% with no patient experiencing severe adverse reactions. Conclusion: Infliximab appears to be safe and it prevented clinical recurrence after surgery. Concomitant thiopurine use predicted response toward continuation of therapy at an 8-week interval. Prospective controlled studies to assess the efficacy of combination treatment in the postoperative setting are warranted.

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A breakthrough in probiotics: Clostridium butyricum regulates gut homeostasis and anti-inflammatory response in inflammatory bowel disease.

KANAI Takanori,Mikami Y, Hayashi A.

J Gastroenterol 2015.05

Joint Work

A breakthrough in probiotics

Kanai Takanori, Mikami Yohei, Hayashi Atsushi

Journal of Gastroenterology 50 ( 9 ) 928 - 939 2015.05

ISSN 0944-1174

Intestinal immune homeostasis is regulated by gut microbiota, including beneficial and pathogenic microorganisms. Imbalance in gut bacterial constituents provokes host proinflammatory responses causing diseases such as inflammatory bowel disease (IBD). The development of next-generation sequencing technology allows the identification of microbiota alterations in IBD. Several studies have shown reduced diversity in the gut microbiota of patients with IBD. Advances in gnotobiotic technology have made possible analysis of the role of specific bacterial strains in immune cells in the intestine. Using these techniques, we have shown that Clostridium butyricum as a probiotic induces interleukin-10-producing macrophages in inflamed mucosa via the Toll-like receptor 2/myeloid differentiation primary response gene 88 pathway to prevent acute experimental colitis. In this review, we focus on the new approaches for the role of specific bacterial strains in immunological responses, as well as the potential of bacterial therapy for IBD treatments.

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【腸内細菌フローラと疾患】炎症性腸疾患と腸内細菌の関わり

KANAI Takanori

Medical Science Digest 41 ( 4 ) 154 - 157 2015.04

ISSN 1347-4340

ヒトの腸管内には無数の細菌が腸内細菌叢を形成しており、宿主の免疫系に多大な影響を与えている。これまでの研究で、炎症性腸疾患は遺伝的素因、免疫学的機序の異常とともに腸内細菌を含んだ環境因子が関連した多因子疾患であることが示唆されている。近年、次世代シーケンサーを用いた腸内細菌の解析により、炎症性腸疾患と腸内細菌叢の乱れ、すなわちdysbiosisが関連していることが明らかになってきた。dysbiosisが腸炎を惹起することが示唆されており、また特定の細菌が腸炎の惹起・制御に関与していることも明らかとなってきた。これらの知見から腸内細菌に着目し働きかけることで腸炎を改善させる治療に期待が集まってきている。近年、dysbiosisを強力に是正する治療として糞便微生物移植が注目されており、炎症性腸疾患の新たな治療として世界中で臨床試験が開始されている。(著者抄録)

Second-look endoscopy after endoscopic submucosal dissection for gastric neoplasms

Nishizawa Toshihiro, Suzuki Hidekazu, Kinoshita Satoshi, Goto Osamu, Kanai Takanori, Yahagi Naohisa

Digestive Endoscopy 27 ( 3 ) 279 - 284 2015.03

ISSN 0915-5635

Routine second-look endoscopy after gastric endoscopic submucosal dissection (ESD) remains controversial. The aim of the present study was to systematically evaluate the efficacy of second-look endoscopy for gastric ESD. PubMed, the Cochrane library, and the Igaku-chuo-zasshi database were searched in order to identify randomized trials eligible for inclusion in the systematic review. Data were combined to calculate a pooled odds ratio (OR) for developing post-ESD bleeding. The database search yielded three randomized trials (854 patients). Compared with second-look endoscopy, the pooled OR for post-ESD bleeding without second-look endoscopy was 0.69 (95% confidence interval [CI]: 0.38-1.26, P = 0.228), without significant heterogeneity. There were no significant differences between second-look endoscopy and no second-look endoscopy with regard to large tumor size (>20 mm). This systematic review and meta-analysis showed that second-look endoscopy had no advantage for the prevention of post-ESD bleeding in patients without a high risk of bleeding.

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Pregnant woman with non-comatose autoimmune acute liver failure in the second trimester rescued using medical therapy

Sato Hirokazu, Tomita Kengo, Yasue Chihiro, Umeda Rumiko, Ebinuma Hirotoshi, Ogata Sho, Du Wenlin, Soga Shigeyoshi, Maruta Koji, Yasutake Yuichi, Narimatsu Kazuyuki, Usui Shingo, Watanabe Chikako, Komoto Shunsuke, Teratani Toshiaki, Suzuki Takahiro, Yokoyama Hirokazu, Saito Hidetsugu, Nagao Shigeaki, Hibi Toshifumi, Miura Soichiro, Kanai Takanori, Hokari Ryota

Hepatology Research 45 ( 3 ) 349 - 355 2015.03

ISSN 1386-6346

We present the case of a 25-year-old woman at 16 weeks of gestation who presented with non-comatose autoimmune acute liver failure and was at high risk of developing fulminant hepatitis. Predictive formulas indicated a high probability of developing fulminant hepatitis. Unenhanced computed tomography showed marked hepatic atrophy and broadly heterogeneous hypoattenuating areas. The course of her illness was subacute, and the etiology of liver injury was unclear. Considering all of the above, we predicted a poor prognosis. Plasma exchange (PE) and continuous hemodiafiltration (CHDF) therapy were initiated just after admission. A few days after admission, a high titer (×80) of antinuclear antibody was noted. Because autoimmune hepatitis (AIH) was considered a cause of liver failure, treatment with moderate prednisolone (30mg/day) doses was administrated, with careful consideration of her pregnancy. Thereafter, her laboratory findings and clinical course gradually improved without the need for liver transplantation. A liver biopsy at 18 days after admission indicated a diagnosis of AIH. She continued the pregnancy and delivered a healthy baby without any complications. Eventually, prednisolone doses were decreased to 10mg, after which her liver function worsened. The second liver biopsy also indicated a diagnosis of AIH. Accordingly, low-dose prednisolone and azathioprine doses (50mg/day) were administrated to recover her liver function, after which her liver function regained normalcy. This case illustrates that a pregnant woman with non-comatose autoimmune acute liver failure in the first or second trimester of pregnancy and her fetus can be rescued by PE/CHDF therapy and safe moderate doses of prednisolone.

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Proton pump inhibitor alone vs proton pump inhibitor plus mucosal protective agents for endoscopic submucosal dissection-induced ulcer

Nishizawa Toshihiro, Suzuki Hidekazu, Kanai Takanori, Yahagi Naohisa

Journal of Clinical Biochemistry and Nutrition 56 ( 2 ) 85 - 90 2015.03

ISSN 0912-0009

Mucosal protective agents may improve healing of patients with endoscopic submucosal dissection-induced ulcers. The present study systematically evaluated published clinical trials to determine whether combined therapeutic use of mucosal protective agents and proton pump inhibitors can improve the outcome of patients with endoscopic submucosal dissection-induced ulcers compared to treatment with proton pump inhibitors alone. PubMed, the Cochrane Library, and the Igaku-Chuo-Zasshi database were searched to identify eligible randomized trials for systematic review. We identified 11 randomized trials for inclusion in our study (1,160 patients). Pooled endoscopic submucosal dissection-induced ulcer healing rates were 45.8% and 34.4% for patients with or without mucosal protective agents, respectively. The odds ratio was 2.28 (95% confidence interval, 1.57-3.31) with no significant study heterogeneity. In conclusion, the systematic review and meta-analysis showed that the combined therapeutic use of proton pump inhibitors and mucosal protective agents improved healing rates of endoscopic submucosal dissection-induced ulcers compared to treatment with proton pump inhibitor monotherapy.

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栄養指導によるアルコール性肝障害の進展予防の提案

KANAI Takanori

アルコールと医学生物学 33 27 - 31 2015.03

Research paper (scientific journal), Joint Work

栄養指導によるアルコール性肝障害(ALD)の進展予防について検討した。ALDを住民検診や定期健診で指摘された男性48例を対象とした。栄養相談を拒否した群29例は、受けた群19例より比較的若年で、BMIが高く、独身や単身赴任が多く、多忙や自分で節酒できるなど依存症の否認に近い理由で拒否する例が多かった。ALTは拒否群で高く、γGTPは受講群で高かった。管理栄養士による栄養相談を受けたALD群で、肝機能ならびにTGの改善率が高かった。中等度飲酒群、非アルコール性脂肪性肝障害(NAFLD群)における栄養相談を受けていない群では、肝機能、TGの改善はほとんどみられなかった。栄養相談を受けた中等度飲酒例群ではAST、ALT、γ-GTPとも改善を認め、非アルコール性脂肪性肝障害群ではALTのみ改善を認めたが、改善の程度はALD群より少なかった。TGの改善もALD群で最も顕著であった。

【腸内細菌と健康・疾患との関わり】腸内細菌に関する最近の知見

KANAI Takanori

機能性食品と薬理栄養 8 ( 6 ) 500-504 2015.02

Joint Work, ISSN 1348-2564

Dysbiosisと糞便移植治療、その臨床応用について

KANAI Takanori

臨床栄養 126 ( 2 ) 124 - 125 2015.02

ISSN 0485-1412

【炎症性腸疾患-病態研究から標的治療への展開-】病態研究から標的治療へ　炎症性腸疾患における腸内細菌の病態への関与と標的治療への応用

KANAI Takanori

最新医学 70 ( 2 ) 222-228 2015.02

Joint Work, ISSN 0370-8241

炎症性腸疾患の原因はいまだ不明な点が多いが,遺伝学的因子,環境因子,免疫学的な因子などの複合的な因子が関与していると考えられている.特に腸内細菌との関係については,腸内細菌叢解析の進歩によりプロバイオティクスを中心とした腸内細菌をターゲットとした治療法が注目されてきている.Bacteroides fragilis,Clostridium butyricum,Fusicatenibacter saccharivoransなどの腸内細菌は,IL-10を介して腸炎抑制効果を有することより,治療応用や疾患活動性評価に有用である可能性が期待されている.(著者抄録)

Dexmedetomidine versus midazolam for gastrointestinal endoscopy

Nishizawa Toshihiro, Suzuki Hidekazu, Sagara Seiji, Kanai Takanori, Yahagi Naohisa

Digestive Endoscopy 27 ( 1 ) 8 - 15 2015.01

ISSN 0915-5635

Background and Aim Patients who undergo gastrointestinal endoscopy often require sedatives such as midazolam and the more recently developed alpha-2 agonist, dexmedetomidine. To assess the efficacy and safety of dexmedetomidine sedation for gastrointestinal endoscopy, we conducted a systematic review and meta-analysis of randomized controlled trials comparing dexmedetomidine with midazolam. Methods We searched PubMed, the Cochrane library, and the Igaku-chuo-zasshi database in order to identify randomized trials eligible for inclusion in our meta-analysis. Data from the eligible studies were combined to calculate pooled odds ratios (OR) or weighted mean differences (WMD). Results We identified nine randomized trials from the database search. Compared to that of midazolam, the pooled OR for restlessness of dexmedetomidine was 0.078 (95% confidence interval [CI]: 0.013-0.453, P < 0.0001), and there was no significant heterogeneity among the trial results. Dexmedetomidine significantly increased Ramsay sedation score compared with midazolam (WMD: 0.401, 95% CI: 0.110-0.692, P = 0.0069), without significant heterogeneity. Compared with midazolam, the pooled OR for hypoxia, hypotension, and bradycardia with dexmedetomidine sedation were 0.454 (95% CI: 0.098-2.11), 1.370 (95% CI: 0.516-3.637), and 2.575 (95% CI: 0.978-6.785), respectively, with no significant differences detected between the groups. Conclusion This meta-analysis shows that dexmedetomidine is a safe and effective sedative agent for gastrointestinal endoscopy, especially endoscopic retrograde cholangiopancreatography and endoscopic submucosal dissection.

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間接ビリルビン優位の体質性黄疸合併慢性C型肝炎に対し、ペグインターフェロン+リバビリン+シメプレビル3剤併用療法を施行し、黄疸の増強後に回復を認めた1例

KANAI Takanori

肝臓 56 ( 1 ) 13 - 17 2015.01

Joint Work, ISSN 0451-4203

症例は42歳、男性。HCV抗体陽性を指摘され当院紹介された。体質性黄疸を指摘されていたが、肝機能異常を認めたことはなかった。一般血液検査ではTB、ALT以外に異常は認めなかった。HCVは1型でウイルス量7.1Log IU/mLのため、ペグインターフェロン+リバビリン+シメプレビル3剤併用療法を開始した。投与前血清総ビリルビン値(TB)2.5mg/dl、直接ビリルビン値(DB)0.1mg/dLであったが、3週目にTB 8.1mg/dLと上昇した。肝機能は正常化しているため薬剤は減量せず継続し、4週目にはTBも5.1mg/dLと低下し、HCV-RNAも陰性化した。24週目はTB 2.7mg/dlと投与前値に回復した。3剤併用療法では、一過性のTB上昇が報告されている。体質性黄疸合併慢性C型肝炎に対し3剤併用療法を施行し、黄疸の増強後に回復を認めた症例を経験したので報告した。間接ビリルビン優位の体質性黄疸合併慢性C型肝炎症例でも3剤併用後のTBの上昇は一過性で禁忌ではなく、DBや肝逸脱酵素の上昇などを伴わない限り中止の必要性はないと考えられた。(著者抄録)

Risk Factors for Decreased Bone Mineral Density in Japanese Patients with Inflammatory Bowel Disease: A Cross-Sectional Study.

KANAI Takanori

Clin Nutr. 34(6):1202-9. 2015

Modeling colorectal cancer using CRISPR-Cas9-mediated engineering of human intestinal organoids

Matano Mami, Date Shoichi, Shimokawa Mariko, Takano Ai, Fujii Masayuki, Ohta Yuki, Watanabe Toshiaki, Kanai Takanori, Sato Toshiro

Nature Medicine 21 ( 3 ) 256 - 262 2015

ISSN 1078-8956

Human colorectal tumors bear recurrent mutations in genes encoding proteins operative in the WNT, MAPK, TGF-β, TP53 and PI3K pathways. Although these pathways influence intestinal stem cell niche signaling, the extent to which mutations in these pathways contribute to human colorectal carcinogenesis remains unclear. Here we use the CRISPR-Cas9 genome-editing system to introduce multiple such mutations into organoids derived from normal human intestinal epithelium. By modulating the culture conditions to mimic that of the intestinal niche, we selected isogenic organoids harboring mutations in the tumor suppressor genes APC, SMAD4 and TP53, and in the oncogenes KRAS and/or PIK3CA. Organoids engineered to express all five mutations grew independently of niche factors in vitro, and they formed tumors after implantation under the kidney subcapsule in mice. Although they formed micrometastases containing dormant tumor-initiating cells after injection into the spleen of mice, they failed to colonize in the liver. In contrast, engineered organoids derived from chromosome-instable human adenomas formed macrometastatic colonies. These results suggest that 'driver' pathway mutations enable stem cell maintenance in the hostile tumor microenvironment, but that additional molecular lesions are required for invasive behavior.

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Recent trends in diagnostic techniques for inflammatory bowel disease

Naganuma Makoto, Hosoe Naoki, Kanai Takanori, Ogata Haruhiko

Korean Journal of Internal Medicine 30 ( 3 ) 271 - 278 2015

ISSN 1226-3303

Although ileocolonoscopy is the gold standard for diagnosis of inflammatory bowel disease and is useful for assessing the disease severity in the colon and terminal ileum, several alternative diagnostic techniques have been developed recently. For ulcerative colitis (UC), magnification colonoscopy, endocytoscopy, and confocal laser endomicroscopy enable assessment of histological inflammation without the need for biopsy. Capsule endoscopy is useful for detection of small intestinal and colonic lesions in both female and male patients. For UC, capsule endoscopy may be useful for evaluating colonic inflammation in patients with a previous poor colonoscopy experience, while it should be used only in Crohn’s disease (CD) patients with unexplained symptoms when other examinations are negative. Magnetic resonance enterography (MRE) is particularly useful for detecting transmural inflammation, stenosis, and extraintestinal lesions, including abscesses and fistulas. MRE is also useful when evaluating small and large intestinal lesions, even in cases with severe strictures in which full evaluation of the small bowel would be virtually impossible using other devices. Therefore, the appropriate diagnostic devices for detecting CD lesions in the small and large intestine should be used.

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A case of type C chronic hepatitis with constitutional hyperbilirubinemia treated by peginterferon-alpha + ribavirin + simeprevir

Horie Yoshinori, Ebinuma Hirotoshi, Nakamoto Nobuhiro, Kanai Takanori

Acta Hepatologica Japonica 56 ( 1 ) 13 - 17 2015

ISSN 0451-4203

We reported a case of a 42-y/o man with constitutional hyperbilirubinemia and type C chronic hepatitis treated by peginterferon-alpha + ribavirin + simeprevir. His serum TB level was increased (from 2.5 to 8.1 mg/ dL 3 w after treatment), but gradually decreased thereafter (5.1 mg/dL 4 w after treatment), and recovered (3.0 mg/dL) 4 w after stopping simeprevir. HCV-RNA has been negative and liver function has been normal after treatment. He did not have either any symptom or abnormality in laboratory data except TB level during the treatment. Simeprevir was reported to sometimes increase serum TB level. In this case, organic anion- transporting polypeptide 1B1 (OATP1B1) seems to be inhibited by simeprevir, because the increase in indirect bilirubin was dominant. This case suggests that the treatment for type C chronic hepatitis with simeprevir is possible even in patients with constitutional hyperbilirubinemia, because the increase in serum TB level was temporal and recovered after stopping simeprevir.

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The gut microbiota and inflammatory bowel disease

Matsuoka Katsuyoshi, Kanai Takanori

Seminars in Immunopathology 37 ( 1 ) 47 - 55 2015

ISSN 1863-2297

Inflammatory bowel disease (IBD) is a chronic and relapsing inflammatory disorder of the gut. Although the precise cause of IBD remains unknown, the most accepted hypothesis of IBD pathogenesis to date is that an aberrant immune response against the gut microbiota is triggered by environmental factors in a genetically susceptible host. The advancement of next-generation sequencing technology has enabled identification of various alterations of the gut microbiota composition in IBD. While some results related to dysbiosis in IBD are different between studies owing to variations of sample type, method of investigation, patient profiles, and medication, the most consistent observation in IBD is reduced bacterial diversity, a decrease of Firmicutes, and an increase of Proteobacteria. It has not yet been established how dysbiosis contributes to intestinal inflammation. Many of the known IBD susceptibility genes are associated with recognition and processing of bacteria, which is consistent with a role of the gut microbiota in the pathogenesis of IBD. A number of trials have shown that therapies correcting dysbiosis, including fecal microbiota transplantation and probiotics, are promising in IBD.

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Effect of supplementation with rebamipide for Helicobacter pylori eradication therapy

Nishizawa Toshihiro, Nishizawa Yuko, Yahagi Naohisa, Kanai Takanori, Takahashi Masahiko, Suzuki Hidekazu

Journal of Gastroenterology and Hepatology (Australia) 29 ( S4 ) 20 - 24 2014.12

ISSN 0815-9319

Background and Aim: Several studies have reported that the application of rebamipide during the eradication of Helicobacter pylori can improve the eradication rate. However, the efficacy and safety are controversial. The present study systematically evaluated whether rebamipide improves the eradication rate of H.pylori by conducting a meta-analysis based on randomized controlled trials (RCTs). Methods: Literature searches were conducted in the following database: PubMed, the Cochrane Library, and the Igaku-chuo-zasshi database in Japan. A meta-analysis of all RCTs comparing rebamipide supplementation with non-rebamipide-containing therapy was performed. Results: We identified six randomized trials (611 patients). Pooled H.pylori eradication rates by per-protocol analysis were 73.3% and 61.4% for patients with or without rebamipide, respectively. The odds ratio was 1.74 (95% confidence interval. 1.19-2.53). Conclusions: Supplementation with rebamipide might be effective in increasing the H.pylori eradication rates of proton-pump inhibitor-amoxicillin dual therapy.

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Mucosal expression of aquaporin-4 in the stomach of histamine type 2 receptor knockout mice and Helicobacter pylori-infected mice

Fukuhara Seiichiro, Matsuzaki Juntaro, Tsugawa Hitoshi, Masaoka Tatsuhiro, Miyoshi Sawako, Mori Hideki, Fukushima Yasushi, Yasui Masato, Kanai Takanori, Suzuki Hidekazu

Journal of Gastroenterology and Hepatology (Australia) 29 ( S4 ) 53 - 59 2014.12

ISSN 0815-9319

Background and Aim: Basolateral water channel, aquaporin-4 (AQP4), is known to be expressed in gastric parietal cells, especially in the basal side of gastric mucosa. However, the role of AQP4 in the stomach is still unknown. Histamine type 2 receptor (H₂R) knockout mice, which are characterized by suppressed gastric acid secretion, are known as formation of mucosal hyperplasia with cystic dilatation and spasmolytic polypeptide-expressing metaplasia (SPEM) in the stomach. The aim of the present study is to investigate whether the expression of AQP4 is changed by the condition of acid suppression and Helicobacter pylori infection. Methods: Male H₂R knockout mice and their controls (C57BL/6) were used. H.pylori was orally infected at the age of 5 weeks. The distributions of AQP4 and H⁺/K⁺-ATPase in the gastric mucosa were investigated by fluorescent immunohistochemistry. The mRNA expressions of AQP4, H⁺/K⁺- ATPase, sonic hedgehog (Shh), and trefoil factor-2 (TFF2) were investigated by quantitative reverse transcription polymerase chain reaction (RT-PCR). Results: In the H₂R knockout mice, the distribution of AQP4-positive parietal cells was extended toward the surface of the fundic glands. Although the mRNA expression levels of AQP4 and H⁺/K⁺ ATPase were elevated in H₂R knockout mice at the age of 20 weeks, the elevations were not maintained by aging or H.pylori infection. In H₂R knockout mice with H.pylori infection, the expression level of TFF2mRNA was elevated while the ratio between AQP4 and H⁺/K⁺ ATPase mRNA expression was decreased compared with the H₂R knockout mice without H.pylori infection. Conclusions: In the H₂R knockout mice, massive SPEM was induced by H.pylori colonization and the ratio between AQP4 and H⁺/K⁺ ATPase mRNA expression was decreased.

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Fecal microbiota transplantation for gastrointestinal diseases

Matsuoka Katsuyoshi, Mizuno Shinta, Hayashi Atsushi, Hisamatsu Tadakazu, Naganuma Makoto, Kanai Takanori

Keio Journal of Medicine 63 ( 4 ) 69 - 74 2014.12

ISSN 0022-9717

Fecal microbiota transplantation (FMT) is a treatment to restore the normal microbial composition of the gut by introducing fecal microbiota obtained from a healthy donor into a diseased individual. There has been a growing interest in the use of FMT as a treatment of various diseases including Clostridium difficile infection (CDI), inflammatory bowel disease, and irritable bowel syndrome. Despite the increasing application of FMT, there are no standard protocols. Many aspects of FMT procedures vary regarding donor selection, preparation of fecal materials, recipient preparation, and route of administration. FMT is most successful in treating recurrent CDI. A randomized controlled trial reported a success rate of approximaetly 90%. Ulcerative colitis (UC) is a potentially good indication for FMT, although limited evidence is available on the use of FMT for the treatment of UC. Only several small case series have been reported, and the results in terms of efficacy are inconsistent. FMT can also be used to treat diseases other than gastrointestinal disorders in which the gut microbiota is disturbed, e.g., cardiovascular diseases, autoimmune diseases, and metabolic disorders. There remain many unanswered questions with regard to FMT, and more research is required in this field.

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Control of tip deflection by right pinkie shaft grip

Nishizawa Toshihiro, Uraoka Toshio, Suzuki Hidekazu, Ochiai Yasutoshi, Goto Osamu, Fujimoto Ai, Maehata Tadateru, Kanai Takanori, Yahagi Naohisa

Gastrointestinal Endoscopy 80 ( 6 ) 1208 2014.12

ISSN 0016-5107

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Control of the treatment device for endoscopy by the left hand

Nishizawa Toshihiro, Uraoka Toshio, Suzuki Hidekazu, Ochiai Yasutoshi, Goto Osamu, Fujimoto Ai, Kanai Takanori, Yahagi Naohisa

Gastrointestinal Endoscopy 80 ( 6 ) 1206 - 1207 2014.12

ISSN 0016-5107

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Surveillance using trimodal imaging endoscopy after endoscopic submucosal dissection for superficial gastric neoplasia

Imaeda Hiroyuki, Hosoe Naoki, Kashiwagi Kazuhiro, Ida Yosuke, Nakamura Rieko, Suzuki Hidekazu, Saito Yoshimasa, Yahagi Naohisa, Iwao Yasushi, Kitagawa Yuko, Hibi Toshifumi, Ogata Haruhiko, Kanai Takanori

World Journal of Gastroenterology 20 ( 43 ) 16311 - 16317 2014.11

ISSN 1007-9327

AIM: To evaluate the effectiveness of trimodal imaging endoscopy (TME) to detect another lesion after endoscopic submucosal dissection (ESD) for superficial gastric neoplasia (SGN).METHODS: Surveillance esophagogastroduodenoscopy (EGD) using a TME was conducted in 182 patients that had undergone ESD for SGN. Autofluorescence imaging (AFI) was conducted after white-light imaging (WLI). When SGN was suspicious, magnifying endoscopy with narrow-band imaging (ME-NBI) was conducted. Final diagnoses were made by histopathologic findings of biopsy specimens. The detection rates of lesions in WLI, AFI, and NBI, and the characteristics of lesions detected by WLI and ones missed by WLI but detected by AFI were examined. The sensitivity, specificity, and accuracy of endoscopic diagnosis using WLI, AFI and ME-NBI were evaluated.RESULTS: In 242 surveillance EGDs, 27 lesions were determined pathologically to be neoplasias. Sixteen early gastric cancers and 6 gastric adenomas could be detected by WLI. Sixteen lesions were reddish and 6 were whitish. Five gastric neoplasias were missed by WLI but were detected by AFI, and all were whitish and protruded gastric adenomas. There was a significant difference in color and pathology between the two groups (P = 0.006). Sensitivity, specificity and accuracy in MENBI were higher than those in both WLI and AFI. Specificity and accuracy in AFI were lower than those in WLI.CONCLUSION: Surveillance using trimodal imaging endoscopy might be useful for detecting another lesion after endoscopic submucosal dissection for superficial gastric neoplasia.

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Early intervention with adalimumab may contribute to favorable clinical efficacy in patients with Crohn's disease

Miyoshi Jun, Hisamatsu Tadakazu, Matsuoka Katsuyoshi, Naganuma Makoto, Maruyama Yuriko, Yoneno Kazuaki, Mori Kiyoto, Kiyohara Hiroki, Nanki Kosaku, Okamoto Susumu, Yajima Tomoharu, Iwao Yasushi, Ogata Haruhiko, Hibi Toshifumi, Kanai Takanori

Digestion 90 ( 2 ) 130 - 136 2014.11

ISSN 0012-2823

Background: We evaluated the clinical efficacy of adalimumab (ADA) for Crohn's disease (CD) and analyzed predictive factors for clinical remission and long-term prognosis. Methods: We retrospectively reviewed the medical records of 45 patients treated with ADA for CD at Keio University Hospital between October 2010 and March 2014. Clinical remission was defined as a Harvey-Bradshaw index of ≤ 4. Results: Twenty-eight of 45 patients (62.2%) achieved clinical remission at week 4. Among these 28 patients, 18 patients (64.3%) maintained clinical remission at week 26, and among these, 16 patients (88.9%) maintained clinical remission at week 52. Absence of a history of bowel resection and absence of prior anti-tumor necrosis factor (anti-TNF) therapy were significant predictive factors for clinical remission at week 4 upon multivariate logistic regression analyses. Younger age and a disease duration of ≤ 3 years correlated with clinical remission at week 26 upon univariate analyses. Patients without a history of bowel resection showed significantly better long-term prognosis than those with a history of bowel resection (p = 0.01). None of the patients contracted a serious infectious disease. Conclusions: Younger age, shorter duration of disease, being naive to anti-TNF antagonists, and absence of a history of bowel resection were associated with the efficacy of ADA in CD patients.

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Propofol versus traditional sedative agents for endoscopic submucosal dissection

Nishizawa Toshihiro, Suzuki Hidekazu, Matsuzaki Juntaro, Kanai Takanori, Yahagi Naohisa

Digestive Endoscopy 26 ( 6 ) 701 - 706 2014.11

ISSN 0915-5635

Methods PubMed, the Cochrane library, and the Igaku-Chuo-Zasshi database were searched in order to identify randomized trials eligible for inclusion in the systematic review. Data from the eligible studies were combined to calculate pooled odds ratios (OR) of developing restlessness, full awakening at 1 h post-ESD, hypoxia, and hypotension.Background and Aim Propofol has been suggested to be superior to benzodiazepines when used as a sedative agent for endoscopic examination. The aim of the present study was to systematically evaluate the safety and efficacy of propofol sedation for endoscopic submucosal dissection (ESD).Results We identified three randomized trials (298 patients) from the database search. Compared with traditional sedative agents, the pooled OR of restlessness and full awakening at 1 h post-ESD with propofol sedation were 0.41 (95% confidence interval [CI]: 0.21-0.81) and 8.59 (95% CI: 4.29-17.2), respectively, without significant heterogeneity. Compared with traditional sedative agents, the pooled OR of hypoxia and hypotension with propofol sedation were 1.13 (95% CI: 0.58-2.21) and 0.92 (95% CI: 0.25-3.41), respectively, indicating no significant differences between the groups.Conclusion Propofol sedation during ESD is more effective as compared with traditional sedative agent. The risk of complications is similar.

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Obscure gastrointestinal bleeding

Hirata Kenro, Hosoe Naoki, Imaeda Hiroyuki, Naganuma Makoto, Murata Hiroko, Ueno Mari, Suzuki Hidekazu, Ogata Haruhiko, Kanai Takanori

Clinical Journal of Gastroenterology 7 ( 5 ) 397 - 401 2014.10

ISSN 1865-7257

Pyogenic granulomas usually occur on the skin or oral mucosa; however, they rarely develop in the gastrointestinal tract, particularly in the ileum. We report the case of an 82-year-old female who experienced occasional bloody stools. Initially, no significant bleeding source could be identified via conventional endoscopy; however, repeat capsule endoscopy identified a bleeding polyp (8 mm) in the ileum. Therefore, we resected the polyp via double-balloon enteroscopy. Histopathological findings showed increased, lobulated, and enlarged capillaries and desquamated epithelium indicative of epithelial erosion. In addition, neutrophil-predominant inflammatory cell infiltrate and interstitial edema were observed in the intercapillary stroma. Immunohistochemical analysis showed positive staining for vascular endothelial cell markers. Previous reports have mentioned that pyogenic granulomas in the oral cavity were associated with the female hormonal receptor, vascular endothelial growth factor, and proliferative immune markers; however, no significant staining was observed in our patient. This is the first report discussing an association between pyogenic granulomas and these markers. Pyogenic granulomas in the ileum are rare and may cause fatal anemia. Pyogenic granulomas should be considered in the differential diagnosis of obscure gastrointestinal bleeding.

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Classical Th1 cells obtain colitogenicity by co-existence of RORγt-expressing T cells in experimental colitis

Saigusa Keiichiro, Hisamatsu Tadakazu, Handa Tango, Sujino Tomohisa, Mikami Yohei, Hayashi Atsushi, Mizuno Shinta, Takeshita Kozue, Sato Toshiro, Matsuoka Katsuyoshi, Kanai Takanori

Inflammatory Bowel Diseases 20 ( 10 ) 1820 - 1827 2014.10

ISSN 1078-0998

Background: Both Th1 and Th17 cell types are involved in the pathogenesis of chronic intestinal inflammation. We recently demonstrated that retinoid-related orphan receptor gamma t (RORγt)-expressing Th17 cells are progenitor cells for alternative Th1 cells, which have the potential to induce colitis. However, the involvement of classical Th1 (cTh1) cells generated directly from naive T cells without RORγt expression in the pathogenesis of colitis remains poorly understood. Methods: We performed a series of in vivo experiments using a murine chronic colitis model induced by adoptive transfer of splenic CD4+CD45RBhigh T cells obtained from wild-type, RORγtgfp/gfp, or RORγtgfp/+ mice into RAG-2-/- mice. Results: RAG-2-/- mice receiving transfer of in vitro-manipulated RORγtgfp/gfp Th1 cells developed colitis. RAG-2-/- mice co-transferred with splenic CD4+CD45RBhigh T cells obtained from wild-type mice and RORγtgfp/gfp mice developed colitis with a significant increase in RORγtgfp/gfp cTh1 cell numbers when compared with noncolitic mice transferred with splenic CD4+CD45RBhigh T cells obtained from RORγtgfp/gfp mice. Furthermore, RAG-2-/- mice transferred with in vivo-manipulated RORγtgfp/gfp cTh1 cells developed colitis with a significant increase in RORγtgfp/gfp cTh1 cell numbers. Conclusions: These findings indicate that both alternative Th1 cells and cTh1 cells have the potential to be colitogenic in an adaptive transfer model. The development of cTh1 cells was dependent on the co-existence of RORγt-expressing T cells, suggesting a critical role for the interactions of these cell types in the development of chronic intestinal inflammation.

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Modified bowel preparation regimen for use in second-generation colon capsule endoscopy in patients with ulcerative colitis

Usui Shingo, Hosoe Naoki, Matsuoka Katsuyoshi, Kobayashi Taku, Nakano Masaru, Naganuma Makoto, Ishibashi Yuka, Kimura Kayoko, Yoneno Kazuaki, Kashiwagi Kazuhiro, Hisamatsu Tadakazu, Inoue Nagamu, Serizawa Hiroshi, Hibi Toshifumi, Ogata Haruhiko, Kanai Takanori

Digestive Endoscopy 26 ( 5 ) 665 - 672 2014.09

ISSN 0915-5635

Background and Aim We have reported that second-generation colon capsule endoscopy (CCE-2) might be feasible for assessing the severity of mucosal inflammation in ulcerative colitis (UC). However, because of the low rate (69%) of complete evaluation of the colon and owing to inadequate cleansing. We believe that the method of bowel preparation could be improved by reducing volume. In the present study, we attempted to improve the colon-cleansing regimen in order to optimize the usefulness of CCE-2 in the management of UC patients.Methods: Twenty patients with histologically confirmed UC were enrolled. Patients took a maximum 2.2 L lavage solution (polyethylene glycol solution and magnesium citrate) in two or three divided doses. To assess the effectiveness of the modified bowel preparation regimen, we evaluated the rate of total colonobservation, the effectiveness of bowel cleansing, andinterobserver agreement in assessing UC disease activity. We used a four-point grading scale (poor, fair, good, and excellent) for evaluating the quality of bowel cleansing. Matts' endoscopic score was used to evaluate disease activity.Results: The rate of total colon observation was 85%, and 15 patients (75%) excreted the CCE-2 within 8 h. The proportion of excellent plus good cleansing was approximately 60%. There was a substantial interobserver agreement (κ = 0.777) in assessment of overall cleansing, which was still substantial at the fair cleansing level (κ = 0.700).Conclusion: Using CCE-2, the modified bowel preparation regimen, with reduced volume has the potential to succeed in the evaluation of mucosal severity in UC.

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Cross-talk between RORγt+ innate lymphoid cells and intestinal macrophages induces mucosal IL-22 production in Crohn's disease.

Mizuno S, Mikami Y, Kamada N, Handa T, Hayashi A, Sato T, Matsuoka K, Matano M, Ohta Y, Sugita A, Koganei K, Sahara R, Takazoe M, Hisamatsu T, Kanai T.

Inflamm Bowel Dis 20 ( 8 ) 1426 - 34 2014.08

Joint Work, Accepted

BACKGROUND:

Interleukin (IL)-22-producing RORγt innate lymphoid cells (ILCs) play a pivotal role in intestinal immunity. Recent reports demonstrated that ILCs contribute to mucosal protection and intestinal inflammation in mice. In humans, numbers of RORγt ILCs are significantly increased in the intestine of patients with Crohn's disease (CD), suggesting that ILCs may be associated with intestinal inflammation in CD. However, the mechanism by which ILCs are regulated in the intestine of patients with CD is poorly understood. This study aimed to determine the activation mechanism of intestinal ILCs in patients with CD.

METHODS:

CD45 lineage marker ILCs were isolated from intestinal lamina propria of patients with CD. ILCs were then subdivided into 4 distinct populations based on the expression of CD56 and CD127. Purified ILC subsets were cocultured with intestinal CD14 macrophages, and IL-22 production was evaluated.

RESULTS:

CD127CD56 and CD127CD56 ILC, but not CD127CD56 or CD127CD56 ILC, subsets expressed RORγt and produced IL-22. IL-22 production by these ILC subsets was enhanced when ILCs were cocultured with intestinal macrophages. IL-23 or cell-to-cell contact was required for macrophage-mediated activation of ILCs. IL-22 production by ILCs was perturbed in inflamed mucosa compared with noninflamed mucosa. IL-22 induced the expression of Reg1α and Claudin-1 in human intestinal epithelial organoids.

CONCLUSIONS:

RORγt ILCs might enhance mucosal barrier function through the upregulation of Reg1α through production of IL-22. Although CD14 macrophages augment intestinal inflammation in patients with CD, macrophages also promote a negative feedback pathway through the activation of IL-22 production by RORγt ILCs.

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Acyl-CoA:cholesterol acyltransferase 1 mediates liver fibrosis by regulating free cholesterol accumulation in hepatic stellate cells.

Tomita K, Teratani T, Suzuki T, Shimizu M, Sato H, Narimatsu K, Usui S, Furuhashi H, Kimura A, Nishiyama K, Maejima T, Okada Y, Kurihara C, Shimamura K, Ebinuma H, Saito H, Yokoyama H, Watanabe C, Komoto S, Nagao S, Sugiyama K, Aosasa S, Hatsuse K, Yamamoto J, Hibi T, Miura S, Hokari R, Kanai T.

J Hepatol 61 ( 1 ) 98 - 106 2014.07

Joint Work, Accepted

BACKGROUND & AIMS:

Acyl-coenzyme A: cholesterol acyltransferase (ACAT) catalyzes the conversion of free cholesterol (FC) to cholesterol ester, which prevents excess accumulation of FC. We recently found that FC accumulation in hepatic stellate cells (HSCs) plays a role in progression of liver fibrosis, but the effect of ACAT1 on liver fibrosis has not been clarified. In this study, we aimed to define the role of ACAT1 in the pathogenesis of liver fibrosis.

METHODS:

ACAT1-deficient and wild-type mice, or Toll-like receptor 4 (TLR4)(-/-)ACAT1(+/+) and TLR4(-/-)ACAT1(-/-) mice were subjected to bile duct ligation (BDL) for 3 weeks or were given carbon tetrachloride (CCl4) for 4 weeks to induce liver fibrosis.

RESULTS:

ACAT1 was the major isozyme in mice and human primary HSCs, and ACAT2 was the major isozyme in mouse primary hepatocytes and Kupffer cells. ACAT1 deficiency significantly exaggerated liver fibrosis in the mouse models of liver fibrosis, without affecting the degree of hepatocellular injury or liver inflammation, including hepatocyte apoptosis or Kupffer cell activation. ACAT1 deficiency significantly increased FC levels in HSCs, augmenting TLR4 protein and downregulating expression of transforming growth factor-β (TGFβ) pseudoreceptor Bambi (bone morphogenetic protein and activin membrane-bound inhibitor), leading to sensitization of HSCs to TGFβ activation. Exacerbation of liver fibrosis by ACAT1 deficiency was dependent on FC accumulation-induced enhancement of TLR4 signaling.

CONCLUSIONS:

ACAT1 deficiency exaggerates liver fibrosis mainly through enhanced FC accumulation in HSCs. Regulation of ACAT1 activities in HSCs could be a target for treatment of liver fibrosis.

Copyright © 2014 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

KEYWORDS:

Acyl-coenzyme A:cholesterol acyltransferase; Bone morphogenetic protein and activin membrane-bound inhibitor; Free cholesterol; Hepatic stellate cell; Toll-like receptor 4; Transforming growth factor-β

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Risk factors for decreased bone mineral density in inflammatory bowel disease

Wada Yasuyo, Hisamatsu Tadakazu, Naganuma Makoto, Matsuoka Katsuyoshi, Okamoto Susumu, Inoue Nagamu, Yajima Tomoharu, Kouyama Keisuke, Iwao Yasushi, Ogata Haruhiko, Hibi Toshifumi, Abe Takayuki, Kanai Takanori

Clinical Nutrition 2014.06

ISSN 0261-5614

Background & aim: Although inflammatory bowel disease (IBD) patients are at risk for metabolic bone disease, studies analyzing this correlation have identified various risk factors, including disease phenotype, age, sex and steroid therapy. Furthermore, few studies have assessed risk factors for bone loss in Japanese IBD patients. This study analyzed risk factors for metabolic bone disease in Japanese IBD patients. Methods: This cross-sectional study assessed 388 patients with IBD aged 20-50 years, including 232 with ulcerative colitis (UC) and 156 with Crohn's disease (CD). Bone mineral density of the femoral neck, total femur and lumbar spine was quantified by dual-energy X-ray absorptiometry. The blood concentrations of bone metabolism markers were measured. History of smoking and bone fracture, and nutritional intake were assessed using questionnaires. Results: Of the 388 patients with IBD, 78 (20.1%; UC, 17.2%; CD, 24.4%) had osteopenia and 17 (4.4%; UC, 3.4%; CD, 5.8%) had osteoporosis, as assessed by T-score. Bone mineral density of the lumbar vertebrae was lower in males than in females. Multivariate regression analysis showed that risk factors for bone loss in UC patients were male sex, low body mass index (BMI), high steroid dose and disease location. Risk factors for bone loss in CD patients were male sex and low BMI. Conclusion: Among Japanese patients with IBD, male sex and low BMI were associated with increased risk for metabolic bone disease. In addition, Steroid therapy shouldn't be indiscriminate in UC patients. These findings may help identify patients at particularly high risk of metabolic bone disease and may help implement appropriate therapies in a timely manner and improve long-term quality of life.

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Prominent steatosis with hypermetabolism of the cell line permissive for years of infection with hepatitis C virus

Sugiyama Kazuo, Ebinuma Hirotoshi, Nakamoto Nobuhiro, Sakasegawa Noriko, Murakami Yuko, Chu Po Sung, Usui Shingo, Ishibashi Yuka, Wakayama Yuko, Taniki Nobuhito, Murata Hiroko, Saito Yoshimasa, Fukasawa Masayoshi, Saito Kyoko, Yamagishi Yoshiyuki, Wakita Takaji, Takaku Hiroshi, Hibi Toshifumi, Saito Hidetsugu, Kanai Takanori

PLoS ONE 9 ( 4 ) 2014.04

Most of experiments for HCV infection have been done using lytic infection systems, in which HCV-infected cells inevitably die. Here, to elucidate metabolic alteration in HCV-infected cells in a more stable condition, we established an HCV-persistently- infected cell line, designated as HPI cells. This cell line has displayed prominent steatosis and supported HCV infection for more than 2 years, which is the longest ever reported. It enabled us to analyze metabolism in the HCV-infected cells integrally combining metabolomics and expression arrays. It revealed that rate-limiting enzymes for biosynthesis of cholesterol and fatty acids were up-regulated with actual increase in cholesterol, desmosterol (cholesterol precursor) and pool of fatty acids. Notably, the pentose phosphate pathway was facilitated with marked up-regulation of glucose-6- phosphate dehydrogenase, a rete-limiting enzyme, with actual increase in NADPH. In its downstream, enzymes for purine synthesis were also up-regulated resulting in increase of purine. Contrary to common cancers, the TCA cycle was preferentially facilitated comparing to glycolysis pathway with a marked increase of most of amino acids. Interestingly, some genes controlled by nuclear factor (erythroid-derived 2)-like 2 (Nrf2), a master regulator of antioxidation and metabolism, were constitutively up-regulated in HPI cells. Knockdown of Nrf2 markedly reduced steatosis and HCV infection, indicating that Nrf2 and its target genes play important roles in metabolic alteration and HCV infection. In conclusion, HPI cell is a bona fide HCV-persistently-infected cell line supporting HCV infection for years. This cell line sustained prominent steatosis in a hypermetabolic status producing various metabolites. Therefore, HPI cell is a potent research tool not only for persistent HCV infection but also for liver metabolism, overcoming drawbacks of the lytic infection systems. © 2014 Sugiyama et al.

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Macrophages and dendritic cells emerge in the liver during intestinal inflammation and predispose the liver to inflammation

Mikami Yohei, Mizuno Shinta, Nakamoto Nobuhiro, Hayashi Atsushi, Sujino Tomohisa, Sato Toshiro, Kamada Nobuhiko, Matsuoka Katsuyoshi, Hisamatsu Tadakazu, Ebinuma Hirotoshi, Hibi Toshifumi, Yoshimura Akihiko, Kanai Takanori

PLoS ONE 9 ( 1 ) 2014.01

The liver is a physiological site of immune tolerance, the breakdown of which induces immunity. Liver antigen-presenting cells may be involved in both immune tolerance and activation. Although inflammatory diseases of the liver are frequently associated with inflammatory bowel diseases, the underlying immunological mechanisms remain to be elucidated. Here we report two murine models of inflammatory bowel disease: RAG-2^-/- mice adoptively transferred with CD4⁺CD45RB^high T cells; and IL-10 ^-/- mice, accompanied by the infiltration of mononuclear cells in the liver. Notably, CD11b^-CD11c^lowPDCA-1⁺ plasmacytoid dendritic cells (DCs) abundantly residing in the liver of normal wild-type mice disappeared in colitic CD4⁺CD45RB^high T cell-transferred RAG-2^-/- mice and IL-10^-/- mice in parallel with the emergence of macrophages (Mφs) and conventional DCs (cDCs). Furthermore, liver Mφ/cDCs emerging during intestinal inflammation not only promote the proliferation of naïve CD4⁺ T cells, but also instruct them to differentiate into IFN-γ-producing Th1 cells in vitro. The emergence of pathological Mφ/cDCs in the liver also occurred in a model of acute dextran sulfate sodium (DSS)-induced colitis under specific pathogen-free conditions, but was canceled in germ-free conditions. Last, the Mφ/cDCs that emerged in acute DSS colitis significantly exacerbated Fas-mediated hepatitis. Collectively, intestinal inflammation skews the composition of antigen-presenting cells in the liver through signaling from commensal bacteria and predisposes the liver to inflammation. © 2014 Mikami et al.

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Magnetic resonance enterography of Crohn's disease

Naganuma Makoto, Hisamatsu Tadakazu, Kanai Takanori, Ogata Haruhiko

Expert Review of Gastroenterology and Hepatology 9 ( 1 ) 37 - 45 2014.01

ISSN 1747-4124

Magnetic resonance enterography (MRE) has been reported to be a useful modality for the evaluation of luminal inflammation and extraintestinal complications in Crohn's disease (CD). A recent study indicated that the diagnostic ability of MRE was comparable to the diagnostic ability of other devices, such as ileocolonoscopy. MRE can be performed repeatedly because there is no radiation exposure. Therefore, MRE is useful as a method of follow-up for younger patients with established CD. It is useful for evaluating the efficacy of medical treatments, such as biologics. MRE can detect small intestinal lesions even if the endoscope does not pass through the stenosis. The concerns of availability of expertise and the costs associated with MRE should be addressed so MRE can be widely used for CD patients in the near future.

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Free cholesterol accumulation in hepatic stellate cells

Tomita Kengo, Teratani Toshiaki, Suzuki Takahiro, Shimizu Motonori, Sato Hirokazu, Narimatsu Kazuyuki, Okada Yoshikiyo, Kurihara Chie, Irie Rie, Yokoyama Hirokazu, Shimamura Katsuyoshi, Usui Shingo, Ebinuma Hirotoshi, Saito Hidetsugu, Watanabe Chikako, Komoto Shunsuke, Kawaguchi Atsushi, Nagao Shigeaki, Sugiyama Kazuo, Hokari Ryota, Kanai Takanori, Miura Soichiro, Hibi Toshifumi

Hepatology 59 ( 1 ) 154 - 169 2014.01

ISSN 0270-9139

Although nonalcoholic steatohepatitis (NASH) is associated with hypercholesterolemia, the underlying mechanisms of this association have not been clarified. We aimed to elucidate the precise role of cholesterol in the pathophysiology of NASH. C57BL/6 mice were fed a control, high-cholesterol (HC), methionine-choline-deficient (MCD), or MCD+HC diet for 12 weeks or a control, HC, high-fat (HF), or HF+HC diet for 24 weeks. Increased cholesterol intake accelerated liver fibrosis in both the mouse models without affecting the degree of hepatocellular injury or Kupffer cell activation. The major causes of the accelerated liver fibrosis involved free cholesterol (FC) accumulation in hepatic stellate cells (HSCs), which increased Toll-like receptor 4 protein (TLR4) levels through suppression of the endosomal-lysosomal degradation pathway of TLR4, and thereby sensitized the cells to transforming growth factor (TGF)β-induced activation by down-regulating the expression of bone morphogenetic protein and activin membrane-bound inhibitor. Mammalian-cell cholesterol levels are regulated by way of a feedback mechanism mediated by sterol regulatory element-binding protein 2 (SREBP2), maintaining cellular cholesterol homeostasis. Nevertheless, HSCs were sensitive to FC accumulation because the high intracellular expression ratio of SREBP cleavage-activating protein (Scap) to insulin-induced gene (Insig) disrupted the SREBP2-mediated feedback regulation of cholesterol homeostasis in these cells. HSC activation subsequently enhanced the disruption of the feedback system by Insig-1 down-regulation. In addition, the suppression of peroxisome proliferator-activated receptor γ signaling accompanying HSC activation enhanced both SREBP2 and microRNA-33a signaling. Consequently, FC accumulation in HSCs increased and further sensitized these cells to TGFβ-induced activation in a vicious cycle, leading to exaggerated liver fibrosis in NASH. Conclusion: These characteristic mechanisms of FC accumulation in HSCs are potential targets to treat liver fibrosis in liver diseases including NASH.

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Continuous low-dose irradiation by I-125 seeds induces apoptosis of gastric cancer cells regardless of histological origin

Takabayashi Kaoru, Kashiwagi Kazuhiro, Kawata Tetsuya, Sato Toshiro, Matsuoka Katsuyoshi, Hisamatsu Tadakazu, Takaishi Hiromasa, Hibi Toshifumi, Ogata Haruhiko, Yahagi Naohisa, Kitagawa Yuko, Shigematsu Naoyuki, Kanai Takanori

Cancer Biology and Therapy 15 ( 1 ) 81 - 88 2014.01

ISSN 1538-4047

The efficacy of conventional radiation therapy for gastric cancer is controversial. In this study, we evaluated the in vitro and in vivo effects of continuous low-dose-rate irradiation by I-125 seeds on different histological types of gastric cancer cell lines. Three human gastric cancer cell lines (MKN74, MKN45, and NUGC4) were treated with or without continuous low-dose irradiation by I-125 seeds in vitro and in vivo. Cell viability, apoptosis, caspase-3 assay, and cell-cycle distribution were examined in vitro. Body weight and tumor volumes of BALB/c nude mice bearing MKN74, MKN45, and NUGC4 gastric cancer xenografts were measured, and in vivo cell proliferation and apoptosis assays were performed by Ki67 and TUNEL staining, respectively. Continuous low-dose-rate irradiation by I-125 seeds reduced cell viability and induced cell apoptosis through the activation of caspase-3, and led to the accumulation of cells in the G2/M phase in vitro. It also suppressed the growth of gastric cancer xenografts in nude mice, while inhibiting cell proliferation and inducing apoptosis as demonstrated by Ki67 and TUNEL staining. Therefore, our data suggest that continuous low-dose-rate irradiation by I-125 seeds could be a promising new option for gastric cancer treatment, regardless of histological origin. © 2014 Landes Bioscience.

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Free cholesterol accumulation in hepatic stellate cells: mechanism of liver fibrosis aggravation in nonalcoholic steatohepatitis in mice.

Tomita K, Teratani T, Suzuki T, Shimizu M, Sato H, Narimatsu K, Okada Y, Kurihara C, Irie R, Yokoyama H, Shimamura K, Usui S, Ebinuma H, Saito H, Watanabe C, Komoto S, Kawaguchi A, Nagao S, Sugiyama K, Hokari R, Kanai T, Miura S, Hibi T.

Hepatology 59 ( 1 ) 154 - 69 2014.01

Joint Work, Accepted

Although nonalcoholic steatohepatitis (NASH) is associated with hypercholesterolemia, the underlying mechanisms of this association have not been clarified. We aimed to elucidate the precise role of cholesterol in the pathophysiology of NASH. C57BL/6 mice were fed a control, high-cholesterol (HC), methionine-choline-deficient (MCD), or MCD+HC diet for 12 weeks or a control, HC, high-fat (HF), or HF+HC diet for 24 weeks. Increased cholesterol intake accelerated liver fibrosis in both the mouse models without affecting the degree of hepatocellular injury or Kupffer cell activation. The major causes of the accelerated liver fibrosis involved free cholesterol (FC) accumulation in hepatic stellate cells (HSCs), which increased Toll-like receptor 4 protein (TLR4) levels through suppression of the endosomal-lysosomal degradation pathway of TLR4, and thereby sensitized the cells to transforming growth factor (TGF)β-induced activation by down-regulating the expression of bone morphogenetic protein and activin membrane-bound inhibitor. Mammalian-cell cholesterol levels are regulated by way of a feedback mechanism mediated by sterol regulatory element-binding protein 2 (SREBP2), maintaining cellular cholesterol homeostasis. Nevertheless, HSCs were sensitive to FC accumulation because the high intracellular expression ratio of SREBP cleavage-activating protein (Scap) to insulin-induced gene (Insig) disrupted the SREBP2-mediated feedback regulation of cholesterol homeostasis in these cells. HSC activation subsequently enhanced the disruption of the feedback system by Insig-1 down-regulation. In addition, the suppression of peroxisome proliferator-activated receptor γ signaling accompanying HSC activation enhanced both SREBP2 and microRNA-33a signaling. Consequently, FC accumulation in HSCs increased and further sensitized these cells to TGFβ-induced activation in a vicious cycle, leading to exaggerated liver fibrosis in NASH.

CONCLUSION:

These characteristic mechanisms of FC accumulation in HSCs are potential targets to treat liver fibrosis in liver diseases including NASH.

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Diet, microbiota, and inflammatory bowel disease

Kanai Takanori, Matsuoka Katsuyoshi, Naganuma Makoto, Hayashi Atsushi, Hisamatsu Tadakazu

Korean Journal of Internal Medicine 29 ( 4 ) 409 - 415 2014

ISSN 1226-3303

The incidence and prevalence of inflammatory bowel diseases (IBDs) including ulcerative colitis and Crohn disease are rapidly increasing in Western countries and in developed Asian countries. Although biologic agents targeting the immune system have been effective in patients with IBD, cessation of treatment leads to relapse in the majority of patients, suggesting that intrinsic immune dysregulation is an effect, not a cause, of IBD. Dramatic changes in the environment, resulting in the dysregulated composition of intestinal microbiota or dysbiosis, may be associated with the fundamental causes of IBD. Japan now has upgraded water supply and sewerage systems, as well as dietary habits and antibiotic overuse that are similar to such features found in developed Western countries. The purpose of this review article was to describe the association of diet, particularly Japanese food and microbiota, with IBD. © 2014 The Korean Association of Internal Medicine.

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Diagnosis and management of intestinal Behçet's diseas

Hisamatsu Tadakazu, Naganuma Makoto, Matsuoka Katsuyoshi, Kanai Takanori

Clinical Journal of Gastroenterology 7 ( 3 ) 205 - 212 2014

ISSN 1865-7257

Behçets disease (BD) is a chronic relapsing disease with multiple organ system involvement characterized clinically by oral and genital aphthae, cutaneous lesions, and ophthalmological, neurological, and/or gastrointestinal manifestations. Little clinical evidence is available regarding the management of patients with intestinal BD, despite recognition that the presence of intestinal lesions is a poor prognostic factor, causing perforation and massive bleeding. Many recent case reports have suggested that anti-tumor necrosis factor alpha (TNF)α monoclonal antibodies (mAbs) are effective in patients with intestinal BD. Adalimumab, a fully human anti-TNFα mAb, has been approved in Japan for the treatment of intestinal BD. Here, we review the pathogenesis, diagnosis and management of intestinal BD, including evidence of the efficacy of anti-TNFα mAbs. © 2014 Springer Japan.

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Acyl-CoA

Tomita Kengo, Teratani Toshiaki, Suzuki Takahiro, Shimizu Motonori, Sato Hirokazu, Narimatsu Kazuyuki, Usui Shingo, Furuhashi Hirotaka, Kimura Akifumi, Nishiyama Kiyoshi, Maejima Tadashi, Okada Yoshikiyo, Kurihara Chie, Shimamura Katsuyoshi, Ebinuma Hirotoshi, Saito Hidetsugu, Yokoyama Hirokazu, Watanabe Chikako, Komoto Shunsuke, Nagao Shigeaki, Sugiyama Kazuo, Aosasa Suefumi, Hatsuse Kazuo, Yamamoto Junji, Hibi Toshifumi, Miura Soichiro, Hokari Ryota, Kanai Takanori

Journal of Hepatology 61 ( 1 ) 98 - 106 2014

ISSN 0168-8278

Background & Aims Acyl-coenzyme A: cholesterol acyltransferase (ACAT) catalyzes the conversion of free cholesterol (FC) to cholesterol ester, which prevents excess accumulation of FC. We recently found that FC accumulation in hepatic stellate cells (HSCs) plays a role in progression of liver fibrosis, but the effect of ACAT1 on liver fibrosis has not been clarified. In this study, we aimed to define the role of ACAT1 in the pathogenesis of liver fibrosis. Methods ACAT1-deficient and wild-type mice, or Toll-like receptor 4 (TLR4) ^-/-ACAT1^+/+ and TLR4^-/-ACAT1^-/- mice were subjected to bile duct ligation (BDL) for 3 weeks or were given carbon tetrachloride (CCl₄) for 4 weeks to induce liver fibrosis. Results ACAT1 was the major isozyme in mice and human primary HSCs, and ACAT2 was the major isozyme in mouse primary hepatocytes and Kupffer cells. ACAT1 deficiency significantly exaggerated liver fibrosis in the mouse models of liver fibrosis, without affecting the degree of hepatocellular injury or liver inflammation, including hepatocyte apoptosis or Kupffer cell activation. ACAT1 deficiency significantly increased FC levels in HSCs, augmenting TLR4 protein and downregulating expression of transforming growth factor-β (TGFβ) pseudoreceptor Bambi (bone morphogenetic protein and activin membrane-bound inhibitor), leading to sensitization of HSCs to TGFβ activation. Exacerbation of liver fibrosis by ACAT1 deficiency was dependent on FC accumulation-induced enhancement of TLR4 signaling. Conclusions ACAT1 deficiency exaggerates liver fibrosis mainly through enhanced FC accumulation in HSCs. Regulation of ACAT1 activities in HSCs could be a target for treatment of liver fibrosis. © 2014 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

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Cross-talk between ROR_γt ⁺ innate lymphoid cells and intestinal macrophages induces mucosal IL-22 production In Crohn's disease

Mizuno Shinta, Mikami Yohei, Kamada Nobuhiko, Handa Tango, Hayashi Atsushi, Sato Toshiro, Matsuoka Katsuyoshi, Matano Mami, Ohta Yuki, Sugita Akira, Koganei Kazutaka, Sahara Rikisaburo, Takazoe Masakazu, Hisamatsu Tadakazu, Kanai Takanori

Inflammatory Bowel Diseases 20 ( 8 ) 1426 - 1434 2014

ISSN 1078-0998

Background: Interleukin (IL)-22-producing ROR_γt ⁺ innate lymphoid cells (ILCs) play a pivotal role in intestinal immunity. Recent reports demonstrated that ILCs contribute to mucosal protection and intestinal inflammation in mice. In humans, numbers of ROR _γt
⁺ ILCs are significantly increased in the intestine of patients with Crohn's disease (CD), suggesting that ILCs may be associated with intestinal inflammation in CD. However, the mechanism by which ILCs are regulated in the intestine of patients with CD is poorly understood. This study aimed to determine the activation mechanism of intestinal ILCs in patients with CD. Methods: CD45+ lineage marker-ILCs were isolated from intestinal lamina propria of patients with CD. ILCs were then subdivided into 4 distinct populations based on the expression of CD56 and CD127. Purified ILC subsets were cocultured with intestinal CD14+ macrophages, and IL-22 production was evaluated. Results: CD127⁺CD56^- and CD127 ⁺CD56⁺ ILC, but not CD127^-CD56⁺ or CD127^-CD56^- ILC, subsets expressed ROR_γt and produced IL-22. IL-22 production by these ILC subsets was enhanced when ILCs were cocultured with intestinal macrophages. IL-23 or cell-to-cell contact was required for macrophage-mediated activation of ILCs. IL-22 production by ILCs was perturbed in inflamed mucosa compared with noninflamed mucosa. IL-22 induced the expression of Reg1_α and Claudin-1 in human intestinal epithelial organoids. Conclusions: ROR_γt
⁺ ILCs might enhance mucosal barrier function through the upregulation of Reg1 _α through production of IL-22. Although CD14⁺ macrophages augment intestinal inflammation in patients with CD, macrophages also promote a negative feedback pathway through the activation of IL-22 production by ROR_γt
⁺ ILCs. Copyright © 2014 Crohn's & Colitis Foundation of America, Inc.

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Endoscopic and pathologic changes of the upper gastrointestinal tract in Crohn's disease

Sakuraba Atsushi, Iwao Yasushi, Matsuoka Katsuyoshi, Naganuma Makoto, Ogata Haruhiko, Kanai Takanori, Hibi Toshifumi

BioMed Research International 2014 2014

ISSN 2314-6133

Background. Crohn's disease (CD) may involve any part of the gastrointestinal tract. We assessed the prevalence and features of upper gastrointestinal (UGI) lesions in CD. Methods. This was a retrospective study that included 138 CD patients that underwent esophagogastroduodenoscopy (EGD). The rate of Crohn's specific endoscopic lesions in the esophagus, stomach, and duodenum was assessed, and immunohistochemical analysis was performed. Changes in the UGI lesions were assessed in those who had two or more EGD. Results. Of 138 patients, 51.3% had Crohn's specific UGI lesions. The rates of Crohn's specific lesion in the esophagus, upper-to-middle stomach, lower stomach, duodenal bulb, and 2nd portion of the duodenum were 6.5%, 47.8%, 24.6%, 31.9%, and 18.1%, respectively. Granulomas were detected in 6.1%, 25.0%, and 11.4% in the upper-to-middle stomach, lower stomach, and duodenal bulb, respectively, but none in the esophagus and 2nd portion of the duodenum. Thirty-seven were analyzed for Helicobacter pylori and 4 were positive (10.8%). Improvements of UGI lesions were seen in 14 out of 49 (28.5%) and were unchanged in 59.2% and worsened in 12.2%. Conclusions. The prevalence of Crohn's specific UGI lesions was common in our case series, and immunohistochemical studies suggested that the majority was unrelated to Helicobacter pylori infection. Worsening of UGI lesions over the course was rare. © 2014 Atsushi Sakuraba et al.

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Effectiveness and clinical results of endoscopic management of sigmoid volvulus using unsedated water-immersion colonoscopy

Sugimoto Shinya, Hosoe Naoki, Mizukami Takeshi, Tsunoda Yuya, Ito Tsuyoshi, Imamura Satoshi, Tamura Toshihide, Nagakubo Shuichi, Morohoshi Yuichi, Koike Yuji, Fujita Yuriko, Komatsu Hirokazu, Ogata Haruhiko, Kanai Takanori

Digestive Endoscopy 26 ( 4 ) 564 - 568 2014

ISSN 0915-5635

Background and Aim Although intestinal obstruction as a result of sigmoid volvulus (SV) may be successfully resolved using endoscopic detorsion, surgical treatment remains the main therapeutic strategy. We evaluated the endoscopic detorsion procedure using unsedated water-immersion colonoscopy for the treatment of SV. Methods A retrospective chart review was conducted on the clinical background and prognosis of 21 SV patients who underwent 71 endoscopic detorsion procedures using unsedated, water-immersion colonoscopy. Results In all, 14 (67%) male and seven (33%) female patients, with a mean age of 73 years (range, 54-95 years) were enrolled; 86% were >70 years of age. Among these patients, 90% had a background of key predisposing factors. In the 21 patients, endoscopic detorsion was successfully done using unsedated water-immersion colonoscopy. SV recurred in 10 patients at a median of 180 days. Endoscopic detorsion for recurrent SV was successfully achieved in all cases, and none of the secondary cases became severe. Only male patients were observed to experience three or more recurrent episodes of SV. Conclusions SV occurred most commonly in elderly patients with a surgical risk. Our experience suggests that conservative endoscopic treatment using unsedated water-immersion colonoscopy is a safe, reasonable, conservative endoscopic approach for elderly patients in the absence of necrotic findings. We currently use this procedure in most of our cases. © 2014 The Authors. Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society.

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Endoscopic ultrasound-guided drainage for a mediastinal pancreatic pseudocyst

Sugimoto Shinya, Yamagishi Yoshiyuki, Higuchi Hajime, Kanai Takanori

Internal Medicine 53 ( 22 ) 2651 - 2652 2014

ISSN 0918-2918

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Risk and management of intra-abdominal abscess in crohn's disease treated with infliximab

Yoneno Kazuaki, Hisamatsu Tadakazu, Matsuoka Katsuyoshi, Okamoto Susumu, Takayama Tetsuro, Ichikawa Riko, Sujino Tomohisa, Miyoshi Jun, Takabayashi Kaoru, Mikami Yohei, Mizuno Shinta, Wada Yasuyo, Yajima Tomoharu, Naganuma Makoto, Inoue Nagamu, Iwao Yasushi, Ogata Haruhiko, Hasegawa Hirotoshi, Kitagawa Yuko, Hibi Toshifumi, Kanai Takanori

Digestion 89 ( 3 ) 201 - 208 2014

ISSN 0012-2823

Background and Aims: Infliximab (IFX) is a monoclonal antibody used to treat patients with Crohn's disease (CD). Intra-abdominal abscess formation is a major complication of CD with negative effects on patient prognosis. We have analyzed risk factors for abscess formation in CD patients treated with IFX. Methods: CD patients who received IFX between January 2000 and April 2011 at Keio University Hospital were analyzed retrospectively. Risk factors for abscess formation were assessed by univariate and multivariate logistic regression analyses. Results: Intra-abdominal abscess was seen in 15 of 258 patients. Univariate analyses showed serum C-reactive protein (CRP) concentration at 14 weeks after initiation of IFX (p = 0.021), serum albumin concentration at week 0 (p = 0.022) and week 14 (p = 0.004), the presence of anal lesions (p = 0.036), progression of intestine deformation (p = 0.015) and early loss of response to IFX (p < 0.0001) to be risk factors. Multivariate analysis showed that CRP concentration at 14 weeks [odds ratio (OR) 1.361] and loss of IFX response within 6 months (OR 5.361) were independent risk factors. Conclusions: Abscess formation should be suspected in patients with symptoms of CD recurrence during IFX therapy. Uncontrolled CRP concentration and early loss of response to IFX are risk factors. © 2014 S. Karger AG, Basel.

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Japan alcoholic hepatitis score can help management of patients with alcoholic hepatitis

Horie Yoshinori, Yamagishi Yoshiyuki, Ebinuma Hirotoshi, Kanai Takanori

Acta Hepatologica Japonica 55 ( 1 ) 22 - 32 2014

ISSN 0451-4203

Ability of a new scoring system for alcoholic hepatitis (AH) (Japan Alcoholic Hepatitis Score: J AS) to predict outcome was confirmed in the data of patients with AH in 2011. Twenty six hospitals provided full demographic data on 59 patients with AH (Moderate 26, Alive 22, Dead 4; Severe 33, Alive 16, Dead 17). There was no report of death in patients with mild AH (J AS score was 7 and less). Prevalence of renal failure, DIC and gastrointestinal bleeding was higher in patients who were died. Cr and PT (INR) were higher in severe AH patients who were died. These results suggest that JAS allows the stratification of the risk of death in AH, and can help the management of patients with AH. If there is any 3 points factor, intensive care such as corticosteroids, granulocytes/monocytes apheresis, plasma exchange and haemodialysis is recommended. © 2014 The Japan Society of Hepatology.

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Mucosal healing with oral tacrolimus is associated with favorable medium- and long-term prognosis in steroid-refractory/dependent ulcerative colitis patients

Miyoshi Jun, Matsuoka Katsuyoshi, Inoue Nagamu, Hisamatsu Tadakazu, Ichikawa Riko, Yajima Tomoharu, Okamoto Susumu, Naganuma Makoto, Sato Toshiro, Kanai Takanori, Ogata Haruhiko, Iwao Yasushi, Hibi Toshifumi

Journal of Crohn's and Colitis 7 ( 12 ) 2013.12

ISSN 1873-9946

Background: Oral administration of tacrolimus is an effective remission induction therapy for steroid-refractory/dependent ulcerative colitis (UC). Aim: This study aimed to evaluate the short- as well as medium- and long-term effectiveness of tacrolimus therapy. Methods: The medical records of 51 patients treated with tacrolimus for UC at our hospital between July 2009 and December 2011 were reviewed retrospectively. Clinical remission and improvement were defined as a Lichtiger score of 4 or less and as a Lichtiger score of ≤. 10 and a reduction in the score of ≥. 3 compared with the baseline score, respectively. Endoscopic findings were evaluated based on the endoscopic activity index and Mayo endoscopic score. Results: The clinical effectiveness combining clinical remission and improvement was observed in 62.7% of the patients at 3. months. Thirty-six patients underwent colonoscopy at 3. months, and 12 (33.3%) and 10 patients (27.8%) showed Mayo endoscopic scores of 0 and 1, respectively. On Kaplan-Meier analysis, the overall percentage of event-free survivors, who did not require colectomy nor switching to other induction therapy such as infliximab, was 73.0% at 6. months, 49.9% at 1. year, and 37.8% at 2. years. Patients with a Mayo endoscopic score of 0-1 at 3. months showed significantly better medium- and long-term prognosis than those with a score of 2-3 (p<. 0.01). All adverse events, including infections in 2 patients, were reversible. Conclusions: Tacrolimus therapy was effective for inducing clinical and endoscopic remission of steroid-refractory/dependent UC. Endoscopic improvement was associated with favorable medium- and long-term prognosis. © 2013 European Crohn's and Colitis Organisation.

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Mucosal CXCR4+ IgG plasma cells contribute to the pathogenesis of human ulcerative colitis through FcγR-mediated CD14 macrophage activation.

Uo M, Hisamatsu T, Miyoshi J, Kaito D, Yoneno K, Kitazume MT, Mori M, Sugita A, Koganei K, Matsuoka K, Kanai T, Hibi T.

1734 - 1744 2013.12

Joint Work, Accepted

BACKGROUND:

Chronic inflammation characterised by IgG-producing plasma cell infiltration of colonic mucosa is a histological hallmark of ulcerative colitis (UC); however, whether its function is pathogenic or protective remains unclear.

OBJECTIVE:

To explore the contribution of intestinal IgG plasma cells to UC pathogenesis.

METHODS:

We isolated lamina propria mononuclear cells (LPMCs) from intestinal mucosa of UC patients and analysed the characteristics of intestinal plasma cells (expression profiles of differentiation molecules and chemokine receptors). We investigated the involvement of IgG-immune complex (IC)-Fc gamma receptor (FcγR) signalling in intestinal inflammation by examining the cytokine production by LPMCs in response to IgG-IC stimulation.

RESULTS:

IgG plasma cells that were markedly increased in number in the inflamed mucosa of UC patients showed a distinct expression profile (CD19(+)CD27(low), CCR10(low)CXCR4(high)) compared with IgA plasma cells (CD19(+/-)CD27(high), CCR10(high)CXCR4(-/low)). In vitro IgG-IC stimulation activated intestinal CD14 macrophages that were increased in number in the inflamed mucosa of UC patients via FcγRI and FcγRII, and induced the extensive production of pro-inflammatory cytokines such as tumour necrosis factor (TNF) and interleukin-1β (IL-1β), comparable to the effect of commensal bacteria stimulation. Co-stimulation with IgG-IC and commensal bacteria increased TNF and IL-1β production more than stimulation with the latter alone. Furthermore, IgG-IC notably up-regulated the expression of TL1A, whereas commensal bacteria specifically induced IL-23.

CONCLUSIONS:

Collectively, these results demonstrate a novel aspect of UC pathogenesis in which unique IgG plasma cells infiltrate the inflamed mucosa via CXCR4, and critically influence UC pathogenesis by exacerbating mucosal inflammation through the activation of 'pathogenic' intestinal CD14 macrophages via IgG-IC-FcγR signalling.

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Clinical strategies for the blockade of IL-18 in inflammatory bowel diseases.

Kanai Takanori, Kamada Nobuhiko, Hisamatsu Tadakazu

Current drug targets 14 ( 12 ) 1392 - 1399 2013.11

Interleukin 18 (IL-18) is an IL-1 super family cytokine that is involved in infection, inflammation and autoimmune diseases. Mounting evidence suggests that IL-18 exert a dual role in inflammation and homeostasis. IL-18 can act as a promoter of T cell immunities, such as type 1 and 17 helper T cell responses, and thus enhances T cell-mediated inflammation, whereas IL-18 increases the barrier function and regeneration of epithelial cells and protects the host from inflammatory stimuli. Although the functional role of IL-18 in regulation of inflammation remains controversial, accumulating evidence indicates the contribution of IL-18 to the pathogenesis of inflammatory bowel diseases (IBD). For example, levels of serum and/or mucosal IL-18 and IL-18 binding protein are elevated in the patients with IBD. Furthermore, polymorphisms in IL-18 and IL-18-related molecules, such as the IL-18 receptor and/or an IL-18 activator NLRP3, genes are found in the patients with IBD. Thus, these preclinical data imply that IL-18 can be a novel therapeutic target for the treatment of IBD. In this review, we focus on IL-18 biology and physiological roles in animal models and human IBD, to provide an outline for development of IL-18 blockade strategies.

IL-7 promotes long-term in vitro survival of unique long-lived memory subset generated from mucosal effector memory CD4⁺ T cells in chronic colitis mice

Takahara Masahiro, Nemoto Yasuhiro, Oshima Shigeru, Matsuzawa Yu, Kanai Takanori, Okamoto Ryuichi, Tsuchiya Kiichiro, Nakamura Tetsuya, Yamamoto Kazuhide, Watanabe Mamoru

Immunology Letters 156 ( 1-2 ) 82 - 93 2013.11

ISSN 0165-2478

Colitogenic memory CD4⁺ T cells are important in the pathogenesis of inflammatory bowel disease (IBD). Although memory stem cells with high survival and self-renewal capacity were recently identified in both mice and humans, it is unclear whether a similar subset is present in chronic colitis mice. We sought to identify and purify a long-lived subset of colitogenic memory CD4⁺ T cells, which may be targets for treatment of IBD. A long-lived subset of colitogenic memory CD4⁺ T cells was purified using a long-term culture system. The characteristics of these cells were assessed. Interleukin (IL)-7 promoted the in vitro survival for >8 weeks of lamina propria (LP) CD4⁺ T cells from colitic SCID mice previously injected with CD4⁺CD45RB^high T cells. These cells were in a quiescent state and divided a maximum of 5 times in 4 weeks. LP CD4⁺ T cells expressed higher levels of Bcl-2, integrin-α4β7, CXCR3 and CD25 after than before culture, as well as secreting high concentrations of IL-2 and low concentrations of IFN-γ and IL-17 in response to intestinal bacterial antigens. LP CD4⁺ T cells from colitic mice cultured with IL-7 for 8 weeks induced more severe colitis than LP CD4⁺ T cells cultured for 4 weeks. We developed a novel culture system to purify a long-lived, highly pathogenic memory subset from activated LP CD4⁺ T cells. IL-7 promoted long-term in vitro survival of this subset in a quiescent state. This subset will be a novel, effective target for the treatment of IBD. © 2013 Elsevier B.V.

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Establishment of novel prediction system of intestinal absorption in humans using human intestinal tissues

Miyake Masateru, Toguchi Hajime, Nishibayashi Toru, Higaki Kazutaka, Sugita Akira, Koganei Kazutaka, Kamada Nobuhiko, Kitazume Mina T., Hisamatsu Tadakazu, Sato Toshiro, Okamoto Susumu, Kanai Takanori, Hibi Toshifumi

Journal of Pharmaceutical Sciences 102 ( 8 ) 2564 - 2571 2013.08

ISSN 0022-3549

The objective of this study was to establish a novel prediction system of drug absorption in humans by utilizing human intestinal tissues. Based on the transport index (TI), a newly defined parameter, calculated by taking account of the change in drug concentrations because of precipitation on the apical side and the amounts accumulated in the tissue and transported to the basal side, the absorbability of drugs in rank order as well as the fraction of dose absorbed (Fa) in humans were estimated. Human intestinal tissues taken from ulcerative colitis or Crohn's disease patients were mounted in a mini-Ussing chamber and transport studies were performed to evaluate the permeation of drugs, including FD-4, a very low permeable marker, atenolol, a low permeable marker, and metoprolol, a high permeable marker. Although apparent permeability coefficients calculated by the conventional equation did not reflect human Fa values for FD-4, atenolol, and metoprolol, TI values were well correlated with Fa values, which are described by 100 · [1 - e ^{- f · (TI - α)}]. Based on this equation, Fa values in humans for other test drugs were predicted successfully, indicating that our new system utilizing human intestinal tissues would be valuable for predicting oral drug absorption in humans. © 2013 Wiley Periodicals, Inc. and the American Pharmacists Association.

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Gastric emptying rate in subjects with malocclusion examined by [¹³C] breath test

Koike S., Sujino T., Ohmori H., Shimazaki K., Fukuyama E., Kanai T., Hibi T., Ono T.

Journal of Oral Rehabilitation 40 ( 8 ) 574 - 581 2013.08

ISSN 0305-182X

Masticatory function is significantly lower in individuals with malocclusion than in those with normal occlusion. Although several studies suggest that masticatory function influences gastrointestinal digestive function, the relationship between malocclusion and gastrointestinal symptoms has not been studied extensively. We hypothesised that insufficient masticatory function would increase the functional burden of the stomach and have some influence on the gastrointestinal system. The purpose of this study was to investigate masticatory function and gastric emptying rate in subjects with malocclusion. Eleven healthy dentate female volunteers and eleven female patients with maloc-clusion underwent a ¹³C-acetate breath test with a liquid meal. Maximum ¹³CO₂ exhalation time (T_max) was compared statistically between both groups. Masticatory function was assessed by colour-changeable chewing gum. In addition, the frequency scale for the symptoms of gastroeso-phageal reflux disease (FSSG) and questionnaires on food intake were given to both groups. The mean T_max of the malocclusion group was significantly longer than that of the normal occlusion group (P = 0·007). Masticatory performance, measured by colour-changeable gum and questionnaires, was significantly lower in the malocclusion group than in the normal occlusion group (P = 0·023, P = 0·003). There was no significant difference in the FSSG results between the two groups (P = 0·262). This study suggested that there was a correlation between malocclusion and gastric emptying function in women. © 2013 John Wiley & Sons Ltd.

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Bone marrow-mesenchymal stem cells are a major source of interleukin-7 and sustain colitis by forming the niche for colitogenic CD4 memory T cells

Nemoto Yasuhiro, Kanai Takanori, Takahara Masahiro, Oshima Shigeru, Nakamura Tetsuya, Okamoto Ryuichi, Tsuchiya Kiichiro, Watanabe Mamoru

Gut 62 ( 8 ) 1142 - 1152 2013.08

ISSN 0017-5749

Objective Interleukin (IL)-7 is mainly produced in bone marrow (BM) that forms the niche for B cells. We previously demonstrated that BM also retains pathogenic memory CD4 T cells in murine models of inflammatory bowel disease (IBD). However, it remains unknown whether BM-derived IL-7 is sufficient for the development of IBD and which cells form the niche for colitogenic memory CD4 T cells in BM. Design To address these questions, we developed mice in which IL-7 expression was specific for BM, and identified colitis-associated IL-7-expressing mesenchymal stem cells (MSC) in the BM. Results IL-7-/-×RAG-1-/- mice injected with BM cells from IL-7+/+×RAG-1-/- mice, but not from IL-7-/-×RAG- 1-/- mice, expressed IL-7 in BM, but not in their colon, and developed colitis when injected with CD4+CD45RBhigh T cells. Cultured BM MSC stably expressed a higher level of IL-7 than that of primary BM cells. IL-7-sufficient, but not IL-7-deficient, BM MSC supported upregulation of Bcl-2 in, and homeostatic proliferation of, colitogenic memory CD4 T cells in vitro. Notably, IL-7-/-×RAG-1-/- mice transplanted with IL-7- sufficient, but not IL-7-deficient, BM MSC expressed IL-7 in BM, but not in their colon, and developed colitis when transplanted with CD4+CD45RBhigh T cells. Conclusions We demonstrate for the first time that BM MSC are a major source of IL-7 and play a pathological role in IBD by forming the niche for colitogenic CD4 memory T cells in BM.

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C-C motif chemokine receptor 9 positive macrophages activate hepatic stellate cells and promote liver fibrosis in mice

Chu Po sung, Nakamoto Nobuhiro, Ebinuma Hirotoshi, Usui Shingo, Saeki Keita, Matsumoto Atsuhiro, Mikami Yohei, Sugiyama Kazuo, Tomita Kengo, Kanai Takanori, Saito Hidetsugu, Hibi Toshifumi

Hepatology 58 ( 1 ) 337 - 350 2013.07

ISSN 0270-9139

Chemokine receptors mediate migration of immune cells into the liver, thereby promoting liver inflammation. C-C motif chemokine receptor (CCR) 9⁺ macrophages are crucial in the pathogenesis of acute liver inflammation, but the role and underlying mechanisms of this macrophage subset in chronic liver injury and subsequent liver fibrosis are not fully understood. We confirmed that tumor necrosis factor alpha (TNF-α)-producing CCR9⁺ macrophages accumulated during the initiation of carbon tetrachloride (CCl₄)-induced liver injury, and CCR9 deficiency attenuated the degree of liver damage. Accumulation of CCR9⁺ macrophages persisted prominently during the process of liver fibrosis induced by repetitive CCl₄ or thioacetamide (TAA)/leptin administration. Increased CCR9 expression was also found on activated hepatic stellate cells (HSCs). Importantly, experimental liver fibrosis was significantly ameliorated in CCR9^-/- mice compared with wild-type (WT) mice, assessed by α-smooth muscle actin (α-SMA) immunostain, Sirius red staining, and messenger RNA (mRNA) expression levels of α-SMA, collagen 1α1, transforming growth factor (TGF)-β1, and tissue inhibitor of metalloproteinase (TIMP)-1. Accumulated CD11b⁺ macrophages in CCl₄-treated WT mice showed marked increases in TNF, NO synthase-2, and TGF-β1 mRNA expression compared with CCR9^-/- mice, implying proinflammatory and profibrogenic properties. Hepatic CD11b⁺ macrophages from CCl₄-treated WT mice (i.e., CCR9⁺ macrophages), but not CD8⁺ T lymphocytes or non-CD11b⁺ cells, significantly activated HSCs in vitro compared with those from CCR9^-/- mice. TNF-α or TGF-β1 antagonism attenuated CCR9⁺ macrophage-induced HSC activation. Furthermore, C-C motif chemokine ligand (CCL) 25 mediated migration and, to a lesser extent, activation of HSCs in vitro. Conclusion: Accumulated CD11b⁺ macrophages are critical for activating HSCs through the CCR9/CCL25 axis and therefore promote liver fibrosis. CCR9 antagonism might be a novel therapeutic target for liver fibrosis. © 2013 American Association for the Study of Liver Diseases.

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Th1/Th17-mediated interstitial pneumonia in chronic colitis mice independent of intestinal microbiota

Nemoto Yasuhiro, Kanai Takanori, Takahara Masahiro, Oshima Shigeru, Okamoto Ryuichi, Tsuchiya Kiichiro, Matsumoto Satoshi, Watanabe Mamoru

Journal of Immunology 190 ( 12 ) 6616 - 6625 2013.06

ISSN 0022-1767

Although intestinal microbiota are essential for the development of T cell-mediated colitis, it remains undetermined whether they enhance or suppress the chronic extraintestinal inflammation that often complicates inflammatory bowel diseases. In this study, we investigate the role of intestinal microbiota in the development of colitis and extraintestinal manifestations in a mouse model in which colitis was induced in SCID mice by adoptive transfer of CD4 ⁺CD45RB^high T cells. Under specific pathogen-free conditions, these mice developed both colitis and extraintestinal interstitial pneumonia, whereas mice given a mixture of antibiotics did not develop colitis, but, surprisingly, developed Th1/Th17-mediated IP. Irrespective of antibiotic treatment, cotransfer of CD4⁺CD25⁺ regulatory T cells suppressed the development of pneumonitis and colitis, with all local CD4 ⁺CD45RB^high T cell-derived cells converted to CD44 ^highCD62L^-IL-7Rα^high effector-memory T cells. Retransfer of CD4⁺ effector-memory T cells from the lungs of antibiotic-treated mice with IP not only induced IP in both antibiotic-treated and -untreated recipients but also induced colitis in the untreated recipients. In summary, we have established a unique model of Th1/Th17-mediated IP in microbiota-free and antibiotic-treated mice. This model may be valuable in investigating the immunological mechanisms underlying extraintestinal disorders in patients with inflammatory bowel disease. Copyright © 2013 by The American Association of Immunologists, Inc.

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A single strain of Clostridium butyricum induces intestinal IL-10-producing macrophages to suppress acute experimental colitis in mice

Hayashi Atsushi, Sato Toshiro, Kamada Nobuhiko, Mikami Yohei, Matsuoka Katsuyoshi, Hisamatsu Tadakazu, Hibi Toshifumi, Roers Axel, Yagita Hideo, Ohteki Toshiaki, Yoshimura Akihiko, Kanai Takanori

Cell Host and Microbe 13 ( 6 ) 711 - 722 2013.06

ISSN 1931-3128

Imbalance in gut bacterial composition provokes host proinflammatory responses causing diseases such as colitis. Colonization with a mixture of Clostridium species from clusters IV and XIVa was shown to suppress colitis through the induction of IL-10-producing regulatory T (Treg) cells. We demonstrate that a distinct Clostridium strain from cluster I, Clostridium butyricum (CB), prevents acute experimental colitis in mice through induction of IL-10, an anti-inflammatory cytokine. However, while CB treatment had no effect on IL-10 production by T cells, IL-10-producing F4/80⁺CD11b ⁺CD11c^int macrophages accumulated in the inflamed mucosa after CB treatment. CB directly triggered IL-10 production by intestinal macrophages in inflamed mucosa via the TLR2/MyD88 pathway. The colitis-preventing effect of CB was negated in macrophage-specific IL-10-deficient mice, suggesting that induction of IL-10 by intestinal macrophages is crucial for the probiotic action of CB. Collectively, CB promotes IL-10 production by intestinal macrophages in inflamed mucosa, thereby preventing experimental colitis in mice. © 2013 Elsevier Inc.

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A single strain of Clostridium butyricum induces intestinal IL-10-producing macrophages to suppress acute experimental colitis in mice.

Hayashi A, Sato T, Kamada N, Mikami Y, Matsuoka K, Hisamatsu T, Hibi T, Roers A, Yagita H, Ohteki T, Yoshimura A, Kanai T.

Cell Host Microbe 13 ( 6 ) 71 - 722 2013.06

Joint Work, Accepted

Abstract

Imbalance in gut bacterial composition provokes host proinflammatory responses causing diseases such as colitis. Colonization with a mixture of Clostridium species from clusters IV and XIVa was shown to suppress colitis through the induction of IL-10-producing regulatory T (Treg) cells. We demonstrate that a distinct Clostridium strain from cluster I, Clostridium butyricum (CB), prevents acute experimental colitis in mice through induction of IL-10, an anti-inflammatory cytokine. However, while CB treatment had no effect on IL-10 production by T cells, IL-10-producing F4/80(+)CD11b(+)CD11c(int) macrophages accumulated in the inflamed mucosa after CB treatment. CB directly triggered IL-10 production by intestinal macrophages in inflamed mucosa via the TLR2/MyD88 pathway. The colitis-preventing effect of CB was negated in macrophage-specific IL-10-deficient mice, suggesting that induction of IL-10 by intestinal macrophages is crucial for the probiotic action of CB. Collectively, CB promotes IL-10 production by intestinal macrophages in inflamed mucosa, thereby preventing experimental colitis in mice.

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Activated hepatic stellate cells mediate the differentiation of macrophages

Chang Jonathan, Hisamatsu Tadakazu, Shimamura Katsuyoshi, Yoneno Kazuaki, Adachi Masayuki, Naruse Hiroshi, Igarashi Toru, Higuchi Hajime, Matsuoka Katsuyoshi, Kitazume Mina T., Ando Setsu, Kamada Nobuhiko, Kanai Takanori, Hibi Toshifumi

Hepatology Research 43 ( 6 ) 658 - 669 2013.06

ISSN 1386-6346

Aim: Liver macrophages play integral roles in both the progression and resolution of hepatic inflammation and fibrosis, comprising opposing functions that largely coincide with the activation state of nearby hepatic stellate cells (HSC). While cross-talk between HSC and macrophages may be essential at various stages of inflammation and fibrogenesis, many facets of this interaction have yet to be thoroughly explored. Here, we examine the potential roles of HSC-derived signaling molecules as mediators of liver macrophage differentiation. Methods: Human peripheral blood mononuclear cells (PBMC) were differentiated to macrophages in the presence or absence of cultured HSC-derived conditioned media. The phenotype of resulting macrophages was characterized by examination of cell surface marker expression, antigen-presenting capabilities and cytokine secretion. Results: Conditioned media from activated human HSC promoted the differentiation of a unique set of macrophages that differed in morphology and function from both classical (M1) and alternative (M2) macrophages, expressing increased levels of CD14 and CD16, as well as a distinct interleukin (IL)-6^high/IL-10^low/transforming growth factor (TGF)-β^high expression profile. These macrophages expressed high levels of CD206, CD209, CD80 and human leukocyte antigen DR, though no significant increases in antigen presentation were apparent. HSC-derived macrophages exhibited specific activation of p38 mitogen-activated protein kinase, and inhibition of this activation by p38 inhibitors during differentiation effectively reversed increases in IL-6 and TGF-β. Conclusion: The present results suggest that HSC-derived signaling molecules promote differentiation of liver macrophages with both pro-inflammatory and profibrotic functions. Furthermore, these effects appear to be mediated, at least partially, in a p38-dependent manner. © 2012 The Japan Society of Hepatology.

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A case of acute pancreatitis induced by telaprevir in the anti-HCV treatment with peginterferon and ribavirin

Matsushita Misako, Ebinuma Hirotoshi, Fukuhara Seiichirou, Minami Kazushi, Minami Kazuhiro, Nakamoto Nobuhiro, Funakoshi Shinsuke, Kanai Takanori, Saito Hidetsugu, Hibi Toshifumi

Acta Hepatologica Japonica 54 ( 5 ) 340 - 346 2013.05

ISSN 0451-4203

A 61-years-old man started the combination treatment with telaprevir, peginterferon-alfa 2b, and ribavirin against chronic hepatitis C after the cure of hepatocellular carcinoma. Telaprevir was reduced to 1500 mgday due to renal dysfunction but the serum HCV-RNA was disappeared on the 15th day. On the 18th day, he visited our hospital with severe epigastralgia and a high fever. He was diagnosed acute pancreatitis by elevation of his serum amylase (2905 IUL) and diffuse swelling of pancreas. We suspected the drug-induced pancreatitis and stopped telaprevir. Although peginterferon and ribavirin were continued for the treating acute pancreatitis, his HCV-RNA became positive again. Therefore we restarted telaprevir with plenty of informed consent after recovery of the pancreatitis. On the 10th day after the resume of telaprevir, the recurrence of the pancreatitis occurred and we stopped any anti-HCV treatment. These twice pancreatitis were immediately improved by the suspension of telaprevir and the administration of antibiotics and gabexate mesilate. We here report this case of telaprevir induced acute pancreatitis confirmed by the re-administration of telaprevir. © 2013 The Japan Society of Hepatology.

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TGR5 signalling inhibits the production of pro-inflammatory cytokines by in vitro differentiated inflammatory and intestinal macrophages in Crohn's disease

Yoneno Kazuaki, Hisamatsu Tadakazu, Shimamura Katsuyoshi, Kamada Nobuhiko, Ichikawa Riko, Kitazume Mina T., Mori Maiko, Uo Michihide, Namikawa Yuka, Matsuoka Katsuyoshi, Sato Toshiro, Koganei Kazutaka, Sugita Akira, Kanai Takanori, Hibi Toshifumi

Immunology 139 ( 1 ) 19 - 29 2013.05

ISSN 0019-2805

Bile acids (BAs) play important roles not only in lipid metabolism, but also in signal transduction. TGR5, a transmembrane receptor of BAs, is an immunomodulative factor, but its detailed mechanism remains unclear. Here, we aimed to delineate how BAs operate in immunological responses via the TGR5 pathway in human mononuclear cell lineages. We examined TGR5 expression in human peripheral blood monocytes, several types of in vitro differentiated macrophages (Mφ{symbol}s) and dendritic cells. Mφ{symbol}s differentiated with macrophage colony-stimulating factor and interferon-γ (Mγ-Mφ{symbol}s), which are similar to the human intestinal lamina propria CD14⁺ Mφ{symbol}s that contribute to Crohn's disease (CD) pathogenesis by production of pro-inflammatory cytokines, highly expressed TGR5 compared with any other type of differentiated Mφ{symbol} and dendritic cells. We also showed that a TGR5 agonist and two types of BAs, deoxycholic acid and lithocholic acid, could inhibit tumour necrosis factor-α production in Mγ-Mφ{symbol}s stimulated by commensal bacterial antigen or lipopolysaccharide. This inhibitory effect was mediated by the TGR5-cAMP pathway to induce phosphorylation of c-Fos that regulated nuclear factor-κB p65 activation. Next, we analysed TGR5 levels in lamina propria mononuclear cells (LPMCs) obtained from the intestinal mucosa of patients with CD. Compared with non-inflammatory bowel disease, inflamed CD LPMCs contained more TGR5 transcripts. Among LPMCs, isolated CD14⁺ intestinal Mφ{symbol}s from patients with CD expressed TGR5. In isolated intestinal CD14⁺ Mφ{symbol}s, a TGR5 agonist could inhibit tumour necrosis factor-α production. These results indicate that TGR5 signalling may have the potential to modulate immune responses in inflammatory bowel disease. © 2013 Blackwell Publishing Ltd.

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IL-22-Producing RORγt-Dependent Innate Lymphoid Cells Play a Novel Protective Role in Murine Acute Hepatitis

Matsumoto Atsuhiro, Kanai Takanori, Mikami Yohei, Chu Po Sung, Nakamoto Nobuhiro, Ebinuma Hirotoshi, Saito Hidetsugu, Sato Toshiro, Yagita Hideo, Hibi Toshifumi

PLoS ONE 8 ( 4 ) 2013.04

Retinoid-related orphan receptor (ROR) γt is known to be related to the development and function of various immunological compartments in the liver, such as Th17 cells, natural killer T (NKT) cells, and innate lymphoid cells (ILCs). We evaluated the roles of RORγt-expressing cells in mouse acute hepatitis model using RORγt deficient (RORγt^-/-) mice and RAG-2 and RORγt double deficient (RAG-2^-/- × RORγt^-/-) mice. Acute hepatitis was induced in mice by injection with carbon tetrachloride (CCl₄), to investigate the regulation of liver inflammation by RORγt-expressing cells. We detected RORC expression in three compartments, CD4⁺ T cells, NKT cells, and lineage marker-negative SCA-1⁺Thy1^high ILCs, of the liver of wild type (WT) mice. CCl₄-treated RORγt^-/- mice developed liver damage in spite of lack of RORγt-dependent cells, but with reduced infiltration of macrophages compared with WT mice. In this regard, ILCs were significantly decreased in RAG-2^-/- × RORγt^-/- mice that lacked T and NKT cells. Surprisingly, RAG-2^-/- × RORγt^-/- mice developed significantly severer CCl₄-induced hepatitis compared with RAG-2^-/- mice, in accordance with the fact that hepatic ILCs failed to produce IL-22. Lastly, anti-Thy1 monoclonal antibody (mAb), but not anti-NK1.1 mAb or anti-asialo GM1 Ab administration exacerbated liver damage in RAG-2^-/- mice with the depletion of liver ILCs. Collectively, hepatic RORγt-dependent ILCs play a part of protective roles in hepatic immune response in mice. © 2013 Matsumoto et al.

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Long-term prognosis of patients with ulcerative colitis treated with cytapheresis therapy

Takayama Tetsuro, Kanai Takanaori, Matsuoka Katsuyoshi, Okamoto Susumu, Sujino Tomohisa, Mikami Yohei, Hisamatsu Tadakazu, Yajima Tomoharu, Iwao Yasushi, Ogata Haruhiko, Hibi Toshifumi

Journal of Crohn's and Colitis 7 ( 2 ) 2013.03

ISSN 1873-9946

Background: Although accumulating studies in Japan show that cytapheresis (CAP) therapy is safe and effective for the induction of remission of moderate or severe ulcerative colitis (UC), the long-term prognosis of UC patients treated with CAP is unknown. The aim of this study was to determine the long-term prognosis of UC patients treated with CAP. Methods: Ninety patients treated previously with CAP and followed for more than 3. years were evaluated. The rates of operation, readmission, and use or dose-up of corticosteroid were analyzed as long-term prognosis. Results: Following the first course of CAP treatment, 64% of patients showed clinical improvement (> 4-point decrease in the clinical activity index (CAI)), and 49% of patients achieved clinical remission (CAI ≤ 4). Longer disease duration and lower age at the first CAP treatment correlated significantly with the therapeutic effects of CAP (p= 0.003 and 0.035, respectively). The rates of operation and readmission were significantly lower in patients who showed previous clinical effects of CAP than in those who did not respond to CAP. The rates of operation and readmission were also significantly lower in patients whose treatment was combined with immunomodulators after the initiation of CAP than in patients who did not use immunomodulators. Importantly, the second course of CAP was also effective in most of the patients who showed a clinical response to the first CAP. Conclusions: Patients who achieve remission after the first CAP therapy may have a good long-term prognosis and a good response to a second CAP therapy even after relapse. © 2012 European Crohn's and Colitis Organisation.

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Epstein-barr virus-associated gastritis

Sujino Tomohisa, Ebinuma Hirotoshi, Hosoe Naoki, Okamoto Susumu, Imaeda Hiroyuki, Hayashi Yuuichirou, Mukai Makio, Ogata Haruhiko, Kanai Takanori, Hibi Toshifumi

Digestive Diseases and Sciences 58 ( 3 ) 883 - 886 2013.03

ISSN 0163-2116

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Immune aspects of the pathogenesis of inflammatory bowel disease

Hisamatsu Tadakazu, Kanai Takanori, Mikami Yohei, Yoneno Kazuaki, Matsuoka Katsuyoshi, Hibi Toshifumi

Pharmacology and Therapeutics 137 ( 3 ) 283 - 297 2013.03

ISSN 0163-7258

Although the precise etiologies of inflammatory bowel disease (IBD) (ulcerative colitis and Crohn's disease) remain obscure, several reports have indicated that dysfunction of the mucosal immune system plays an important role in its pathogenesis. Recent progress with genome-wide association studies has identified many IBD susceptibility genes. In individuals with genetic risk, abnormal interactions between the host immune system and gut flora, and dysregulation of cellular responses such as autophagy and ER stress, induce an abnormal host immune response in the gut resulting in intestinal inflammation. Research progress animal models in IBD, and in human IBD, has identified several key molecules in IBD pathogenesis such as TNFα and adhesion molecules, and molecular targeting therapies based on these molecules have been developed. Here, we review immunological aspects in IBD pathogenesis and the development of immunoregulatory therapy. © 2012 Elsevier Inc.

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Dendritic cells administered intrarectally penetrate the intestinal barrier to break intestinal tolerance via Th2-medeiated colitis in mice

Handa Tango, Kanai Takanori, Sato Toshiro, Mikami Yohei, Sujino Tomohisa, Hayashi Atsushi, Mizuno Shinta, Matsumoto Atsuhiro, Hisamatsu Tadakazu, Hibi Toshifumi

Immunology Letters 150 ( 1-2 ) 123 - 129 2013.02

ISSN 0165-2478

Intestinal lamina propria dendritic cells (LPDCs) in mice are known to extend dendrites between the intestinal epithelia and the luminal side when processing luminal antigens. We conducted intrarectal cell transfer experiments of bone marrow-derived dendritic cells (BMDCs) in mice to assess dendritic cell penetration of the intestine. Intrarectally administered GFP⁺ BMDCs localized in the colonic LP within 3h and the spleen within 12h after administration. 72h after administration, recipient C57BL/6 mice showed acute diarrhea, and administration of BMDCs (once weekly for 3 weeks) induced intestinal inflammation with increased numbers of recipient macrophages and CD4⁺ T cells exhibiting a Th2-mediated immune response. These results demonstrate that DCs actively communicate across the intestinal barrier, and highlight a potential technique for controlling colonic immune tolerance. © 2013 Elsevier B.V.

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Suppression of myeloid cell leukemia-1 (Mcl-1) enhances chemotherapy-associated apoptosis in gastric cancer cells

Akagi Hideko, Higuchi Hajime, Sumimoto Hidetoshi, Igarashi Toru, Kabashima Ayano, Mizuguchi Hiroyuki, Izumiya Motoko, Sakai Gen, Adachi Masayuki, Funakoshi Shinsuke, Nakamura Shoko, Hamamoto Yasuo, Kanai Takanori, Takaishi Hiromasa, Kawakami Yutaka, Hibi Toshifumi

Gastric Cancer 16 ( 1 ) 100 - 110 2013.01

ISSN 1436-3291

Background: Myeloid cell leukemia-1 (Mcl-1) is an anti-apoptotic protein that regulates apoptosis sensitivity in a variety of cell types. Here we evaluate the roles of Mcl-1 in chemotherapy-associated apoptosis in gastric cancer cells. In addition, our study examined whether Mcl-1 contributed to apoptosis resistance in so-called cancer stem cell (CSC)-like populations in gastric cancer. Methods: Seven gastric cancer cell lines were used. The expression of Mcl-1 was assessed by either real-time polymerase chain reaction or Western blot analysis. Apoptosis was quantitated by morphological observation and caspase activity measurement. Adenovirus-mediated RNA interference (RNAi) technology was used to knockdown the expression of Mcl-1. The release of cytochrome c was evaluated by subcellular fractionation and immunoblot analysis. To identify and isolate the CSC-like populations, we used the CSC-associated cell surface marker CD44 and flow cytometry. Results: Six out of the 7 gastric cancer cell lines overexpressed Mcl-1 protein. These Mcl-1-expressing cell lines were relatively resistant to chemotherapeutic agents such as 5-fluorouracil (5-FU) and cisplatin (CDDP). Depletion of Mcl-1 protein by RNAi technology effectively sensitized the cells to anticancer drug-induced mitochondrial cytochrome c release, caspase activation, and apoptosis. In addition, vast amounts of Mcl-1 mRNA were expressed in CD44-positive CSC-like cells. Mcl-1 suppression enhanced the apoptosis in CD44-positive cells to a level equivalent to that in CD44-negative cells, suggesting that Mcl-1 mediates chemotherapy resistance in CSC-like populations. Conclusion: These results suggest that Mcl-1 mediates the resistance to apoptosis in gastric cancer cells by blocking the mitochondrial pathway of cell death. Mcl-1 depletion appears to be an attractive strategy to overcome chemotherapy resistance in gastric cancer cells. © 2012 The International Gastric Cancer Association and The Japanese Gastric Cancer Association.

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Spur cell anemia associated with alcoholic cirrhosis

Sugimoto Shinya, Yamagishi Yoshiyuki, Ebinuma Hirotoshi, Kanai Takanori

Internal Medicine 52 ( 24 ) 2831 2013

ISSN 0918-2918

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Mechanism and therapeutic strategy of secondary failure to anti-tumor necrosis factor-α monoclonal antibody treatment for crohn's disease

Matsuoka Katsuyoshi, Kanai Takanori

Digestion 88 ( 1 ) 17 - 19 2013

ISSN 0012-2823

It is not too much to say that infliximab has revolutionized the treatment of Crohn's disease. However, there is the problem of 'secondary failure' wherein the effect may diminish during treatment. This is a much-discussed topic. For example, not all patients with secondary failure can maintain remission with dose intensification to 10 mg/kg. It is also important to make the appropriate drug selection and to clarify the optimal timing of dose intensification for achieving long-term maintenance of remission, including discussion of the first priority use of adalimumab.

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Applicability of second-generation colon capsule endoscope to ulcerative colitis

Hosoe Naoki, Matsuoka Katsuyoshi, Naganuma Makoto, Ida Yosuke, Ishibashi Yuka, Kimura Kayoko, Yoneno Kazuaki, Usui Shingo, Kashiwagi Kazuhiro, Hisamatsu Tadakazu, Inoue Nagamu, Kanai Takanori, Imaeda Hiroyuki, Ogata Haruhiko, Hibi Toshifumi

Journal of Gastroenterology and Hepatology (Australia) 28 ( 7 ) 1174 - 1179 2013

ISSN 0815-9319

Background and Aim: Colon capsule endoscopy has already been used for colon visualization and detection of polyps but its applicability to inflammatory bowel disease is still unconfirmed. The aim of this study was to assess the feasibility of evaluating the severity of mucosal inflammation in patients with ulcerative colitis (UC) using a second-generation colon capsule endoscope (CCE-2). Methods: Forty patients with histological confirmed diagnosis of UC were enrolled. Low-volume (2L) polyethylene glycol solution with prokinetics (mosapride citrate and metoclopramide) regimen was used for the bowel preparation. In Phase 1, consisting of 10 patients, to confirm appropriate CCE-2 bowel preparation for UC. In Phase 2, consisting of 30 patients, CCE-2 was performed with a fixed bowel preparation regimen. CCE-2 findings were recorded for 8h starting from capsule ingestion and conventional colonoscopy was subsequently performed on the same day. CCE-2 procedure completion rate and the colon cleansing level with a 4-point grading scale (poor, fair, good, and excellent) were evaluated in Phase 2. Correlations between Matts endoscopic scores as judged by CCE-2 and conventional colonoscopy were calculated. Results: CCE-2 procedure was completed within 8h in 69% of the patients. The proportion of patients with good or excellent cleansing level was below 50%. However, Matts endoscopic scores determined by CCE-2 showed a strong correlation with scores obtained by conventional colonoscopy (average ρ=0.797). Conclusions: Although modifications in bowel preparation are needed, CCE-2 might be feasible for assessing the severity of mucosal inflammation in patients with UC. © 2013 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.

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CCR2 knockout exacerbates cerulein-induced chronic pancreatitis with hyperglycemia via decreased GLP-1 receptor expression and insulin secretion

Nakamura Yuji, Kanai Takanori, Saeki Keita, Takabe Miho, Irie Junichiro, Miyoshi Jun, Mikami Yohei, Teratani Toshiaki, Suzuki Takahiro, Miyata Naoteru, Hisamatsu Tadakazu, Nakamoto Nobuhiro, Yamagishi Yoshiyuki, Higuchi Hajime, Ebinuma Hirotoshi, Hozawa Shigenari, Saito Hidetsugu, Itoh Hiroshi, Hibi Toshifumi

American Journal of Physiology - Gastrointestinal and Liver Physiology 304 ( 8 ) 2013

ISSN 0193-1857

Glucagonlike peptide-1 (GLP-1) promotes insulin release; however, the relationship between the GLP-1 signal and chronic pancreatitis is not well understood. Here we focus on chemokine (C-C motif) ligand 2 (CCL2) and its receptor (CCR2) axis, which regulates various immune cells, including macrophages, to clarify the mechanism of GLP-1-mediated insulin secretion in chronic pancreatitis in mice. One and multiple series of repetitive cerulein administrations were used to induce acute and chronic cerulein pancreatitis, respectively. Acute cerulein-administered CCR2-knockout (KO) mice showed suppressed infiltration of CD11b⁺Gr-1^low macrophages and pancreatic inflammation and significantly upregulated insulin secretion compared with paired wild-type (WT) mice. However, chronic cerulein-administered CCR2-KO mice showed significantly increased infiltration of CD11b⁺/ Gr-1 ^-and CD11b⁺/Gr-1^high cells, but not CD11b⁺/Gr-1^low cells, in pancreas with severe inflammation and significantly decreased insulin secretion compared with their WT counterparts. Furthermore, although serum GLP-1 levels in chronic cerulein-administered WT and CCR2-KO mice were comparably upregulated after cerulein administrations, GLP-1 receptor levels in pancreases of chronic ceruleinadministered CCR2-KO mice were significantly lower than in paired WT mice. Nevertheless, a significantly higher hyperglycemia level in chronic cerulein-administered CCR2-KO mice was markedly restored by treatment with a GLP-1 analog to a level comparable to the paired WT mice. Collectively, the CCR2/CCL2 axis-mediated CD11b⁺-cell migration to the pancreas is critically involved in chronic pancreatitismediated hyperglycemia through the modulation of GLP-1 receptor expression and insulin secretion. © 2013 the American Physiological Society.

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Progressive liver failure induced by everolimus for renal cell carcinoma in a 58-year-old male hepatitis B virus carrier

Mizuno Shinta, Yamagishi Yoshiyuki, Ebinuma Hirotoshi, Nakamoto Nobuhiro, Katahira Mai, Sasaki Aya, Sakamoto Michiie, Suzuki Hidekazu, Kanai Takanori, Hibi Toshifumi

Clinical Journal of Gastroenterology 6 ( 2 ) 188 - 192 2013

ISSN 1865-7257

A 58-year-old man was diagnosed as a hepatitis B virus (HBV) carrier approximately 30 years ago. He was diagnosed with renal cell carcinoma when he was 57 years old. Radical nephrectomy was performed, and everolimus was administered to treat his lung metastasis. After beginning the everolimus, intermittent fever, general fatigue, and jaundice developed. He was admitted under a diagnosis of flare (acute exacerbation) of chronic B hepatitis due to HBV reactivation. Despite intensive care, he died of hepatic failure and fungus infection. The autopsy findings were compatible with hepatic failure due to HBV reactivation by everolimus. Antiviral prophylaxis must be taken into consideration before beginning immunosuppressive therapy such as everolimus in HBV carriers. © The Author(s) 2013.

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MyD88-dependent interleukin-10 production from regulatory CD11b+Gr-1high cells suppresses development of acute cerulein pancreatitis in mice

Koike Yuji, Kanai Takanori, Saeki Keita, Nakamura Yuji, Nakano Masaru, Mikami Yohei, Yamagishi Yoshiyuki, Nakamoto Nobuhiro, Ebinuma Hirotoshi, Hibi Toshifumi

Immunology Letters 148 ( 2 ) 172 - 177 2012.12

ISSN 0165-2478

We explored the role of the MyD88 signaling pathway. This pathway mediates the recognition of pathogen-associated molecular patterns and damage-associated molecular patterns via Toll-like receptors (TLRs) and/or IL-1/IL-18 via each cytokine receptor in a murine model of acute pancreatitis induced by cerulein administration. Our analysis revealed that: various TLRs and MyD88 molecules were constitutively expressed in the pancreas of cerulein-treated and untreated wild-type (WT) mice. MyD88^-/- mice administered cerulein developed severe pancreatitis as compared with MyD88^+/+ WT mice. The number of IL-10-expressing CD11b⁺Gr-1^high cells in cerulein-administered MyD88^-/- mice was significantly decreased. This was in accordance with a reciprocal increase in the infiltration of CD4⁺ T cells as compared with that in control MyD88^+/+ mice. WT mice pretreated with antibiotics and administered cerulein developed milder pancreatitis as compared with control cerulein-administered mice without antibiotic treatment. The MyD88 signaling pathway contributes to the induction of regulatory IL-10-producing macrophages/myeloid-derived suppressor cells, possibly in response to non-bacterial components in the damaged pancreas. These results provide a new concept for therapeutic strategies against acute pancreatitis. © 2012 Elsevier B.V.

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Anticoagulation therapy dramatically improved severe sigmoiditis with findings resembling inflammatory bowel disease, which was caused by mesenteric venous thrombosis

Mikami Yohei, Kanai Takanori, Iwasaki Eisuke, Naganuma Makoto, Yamagishi Yoshiyuki, Shimoda Masayuki, Matsuoka Katsuyoshi, Hisamatsu Tadakazu, Iwao Yasushi, Ogata Haruhiko, Nakatsuka Seishi, Mukai Makio, Hibi Toshifumi

Clinical Journal of Gastroenterology 5 ( 6 ) 377 - 382 2012.12

ISSN 1865-7257

Mesenteric venous thrombosis is an insidious disease, with a high mortality rate typically attributed to the long delay in diagnosis. Rapid diagnosis and treatment are important. Here, we present a patient with idiopathic inferior mesenteric venous (IMV) thrombosis. A 65-year-old man presented with constant abdominal pain associated with fever and bloody diarrhea. He was diagnosed with severe ulcerative colitis and was treated with mesalazine and prednisolone. The prednisolone was tapered because of liver dysfunction, and he received total parenteral nutrition for a month. His abdominal pain and bloody diarrhea worsened, and he lost 5 kg of weight. He was then transferred to our institute. Computed tomography showed thickening of the left colon. Colonoscopy showed diffuse colitis with multiple ulcers, large edematous folds, congested mucosa, and stenosis of the sigmoid colon, with sparing of the rectum, raising the possibility of IMV thrombosis. Angiography confirmed IMV thrombosis. Anticoagulation therapy was initiated with intravenous heparin followed by oral warfarin. His abdominal pain and diarrhea resolved, and he was discharged from hospital. Six months later, he remained asymptomatic with normal colonoscopic findings. © 2012 Springer Japan.

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Dysregulated balance of retinoid-related orphan receptor γt-dependent innate lymphoid cells is involved in the pathogenesis of chronic DSS-induced colitis

Kimura Kayoko, Kanai Takanori, Hayashi Atsushi, Mikami Yohei, Sujino Tomohisa, Mizuno Shinta, Handa Tango, Matsuoka Katsuyoshi, Hisamatsu Tadakazu, Sato Toshiro, Hibi Toshifumi

Biochemical and Biophysical Research Communications 427 ( 4 ) 694 - 700 2012.11

ISSN 0006-291X

Retinoid-related orphan receptor (ROR) γt-expressing and IL-22-producing NKp46⁺ innate lymphoid (ILC22) cells reside in the lamina propria of the intestine in mice, suggesting that ILC22 cells contribute to host defense during intestinal damage in models of colitis in mice. Nevertheless, another set of pathological interferon (IFN)-γ and/or IL-17A-producing innate lymphoid cells (ILC1 and ICL17) may participate in the pathogenesis in different models of colitis. We here showed that RORγt⁺IL-22⁺ ILC22 cells were localized in Thy-1^highSCA-1^high and/or Thy-1^highSCA-1^low subpopulations of the intestine in normal and dextran sodium sulfate (DSS)-induced colitic RORγt-sufficient Rag-2^-/- mice. RORγt-deficient Rag-2^-/- mice developed more severe DSS-induced colitis accompanied with lower expression of REG3β and REG3γ in the colon, but with a lower ratio and absolute number of IFN-γ-producing ILC1 cells as compared to control RORγt-sufficient Rag-2^-/- mice. Collectively, not only the presence of ILC22 cells but also the balance of protective and pathogenic ILCs may be involved in the prevention of colitis. © 2012 Elsevier Inc.

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T-helper 17 and interleukin-17-producing lymphoid tissue inducer-like cells make different contributions to colitis in mice

Ono Yuichi, Kanai Takanori, Sujino Tomohisa, Nemoto Yasuhiro, Kanai Yasumasa, Mikami Yohei, Hayashi Atsushi, Matsumoto Atsuhiro, Takaishi Hiromasa, Ogata Haruhiko, Matsuoka Katsuyoshi, Hisamatsu Tadakazu, Watanabe Mamoru, Hibi Toshifumi

Gastroenterology 143 ( 5 ) 1288 - 1297 2012.11

ISSN 0016-5085

Background & Aims: T helper (Th) 17 cells that express the retinoid-related orphan receptor (ROR) γt contribute to the development of colitis in mice, yet are found in normal and inflamed intestine. We investigated their development and functions in intestines of mice. Methods: We analyzed intestinal Th17 cells in healthy and inflamed intestinal tissues of mice. We analyzed expression of lymphotoxin (LT)α by Th17 cells and lymphoid tissue inducer-like cells. Results: LTα^-/- and RORγt^-/- mice had significantly lower percentages of naturally occurring Th17 cells in the small intestine than wild-type mice. Numbers of CD3^-CD4^+/-interleukin-7Rα⁺c-kit ⁺CCR6⁺NKp46^- lymphoid tissue inducer-like cells that produce interleukin-17A were increased in LTα^-/- and LTα^-/-×recombination activating gene (RAG)-2 ^-/- mice, compared with wild-type mice, but were absent from RORγt^-/- mice. Parabiosis of wild-type and LTα ^-/- mice and bone marrow transplant experiments revealed that LTα-dependent gut-associated lymphoid tissue structures are required for generation of naturally occurring Th17 cells. However, when wild-type or LTα^-/- CD4⁺CD45RB^high T cells were transferred to RAG-2^-/- or LTα^-/-×RAG-2 ^-/- mice, all groups, irrespective of the presence or absence of LTα on the donor or recipient cells, developed colitis and generated Th1, Th17, and Th17/Th1 cells. RAG-2^-/- mice that received a second round of transplantation, with colitogenic but not naturally occurring Th17 cells, developed intestinal inflammation. The presence of naturally occurring Th17 cells in the colons of mice inhibited development of colitis after transfer of CD4⁺CD45RB^high T cells and increased the numbers of Foxp3⁺ cells derived from CD4⁺CD45RB^high T cells. Conclusions: Gut-associated lymphoid tissue structures are required to generate naturally occurring Th17 cells that have regulatory activities in normal intestines of mice, but not for colitogenic Th17 and Th17/Th1 cells during inflammation. © 2012 AGA Institute.

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P53/p66Shc-mediated signaling contributes to the progression of non-alcoholic steatohepatitis in humans and mice

Tomita Kengo, Teratani Toshiaki, Suzuki Takahiro, Oshikawa Tetsuya, Yokoyama Hirokazu, Shimamura Katsuyoshi, Nishiyama Kiyoshi, Mataki Norikazu, Irie Rie, Minamino Tohru, Okada Yoshikiyo, Kurihara Chie, Ebinuma Hirotoshi, Saito Hidetsugu, Shimizu Ippei, Yoshida Yohko, Hokari Ryota, Sugiyama Kazuo, Hatsuse Kazuo, Yamamoto Junji, Kanai Takanori, Miura Soichiro, Hibi Toshifumi

Journal of Hepatology 57 ( 4 ) 837 - 843 2012.10

ISSN 0168-8278

Background & Aims: The tumor suppressor p53 is a primary sensor of stressful stimuli, controlling a number of biologic processes. The aim of our study was to examine the roles of p53 in non-alcoholic steatohepatitis (NASH). Methods: Male wild type and p53-deficient mice were fed a methionine- and choline-deficient diet for 8 weeks to induce nutritional steatohepatitis. mRNA expression profiles in normal liver samples and liver samples from patients with non-alcoholic liver disease (NAFLD) were also evaluated. Results: Hepatic p53 and p66Shc signaling was enhanced in the mouse NASH model. p53 deficiency suppressed the enhanced p66Shc signaling, decreased hepatic lipid peroxidation and the number of apoptotic hepatocytes, and ameliorated progression of nutritional steatohepatitis. In primary cultured hepatocytes, transforming growth factor (TGF)-β treatment increased p53 and p66Shc signaling, leading to exaggerated reactive oxygen species (ROS) accumulation and apoptosis. Deficient p53 signaling inhibited TGF-β-induced p66Shc signaling, ROS accumulation, and hepatocyte apoptosis. Furthermore, expression levels of p53, p21, and p66Shc were significantly elevated in human NAFLD liver samples, compared with results obtained with normal liver samples. Among NAFLD patients, those with NASH had significantly higher hepatic expression levels of p53, p21, and p66Shc compared with the group with simple steatosis. A significant correlation between expression levels of p53 and p66Shc was observed. Conclusions: p53 in hepatocytes regulates steatohepatitis progression by controlling p66Shc signaling, ROS levels, and apoptosis, all of which may be regulated by TGF-β. Moreover, p53/p66Shc signaling in the liver appears to be a promising target for the treatment of NASH. © 2012 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

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Disadvantages of peginterferon and ribavirin treatment in older patients with chronic hepatitis C

Ebinuma Hirotoshi, Saito Hidetsugu, Tada Shinichiro, Nakamoto Nobuhiro, Ohishi Tazuko, Tsunematsu Satoshi, Kumagai Naoki, Tsuchimoto Kanji, Tsukada Nobuhiro, Inagaki Yasutaka, Horie Yoshinori, Takahashi Masahiko, Atsukawa Kazuhiro, Okamura Yukishige, Kanai Takanori, Hibi Toshifumi

Hepatology International 6 ( 4 ) 744 - 752 2012.10

ISSN 1936-0533

Purpose Peginterferon (PEG-IFN) and ribavirin (RBV) combination treatment for patients with chronic hepatitis C (CHC), infected by genotype-1 hepatitis C virus with high viral loads, results in a sustained viral response (SVR) in 50%. However, a trend of decreasing SVR in the older patients has been reported. In the present study, we verified this trend of treatment efficacy in older patients using the propensity score (PS). Methods We conducted a survey of 327 patients with CHC (genotype 1 and high viral loads) who were treated with PEG-IFN and RBV for 48 weeks. The SVR rate was compared between patients =60 and <60 years of age. Because backgrounds of these patients differed considerably, we verified this efficacy between the older (n = 102) and younger (n = 102) patients matched for gender, body weight, platelets (PLT), and red blood cell (RBC) counts using PS. Results The total SVR rate was 42.9% (161/327); this rate decreased with increasing age and was lower in the older patients (C60 years: 41.5%, <60 years: 54.3%, P = 0.0245). Moreover, younger age was a significant factor for SVR. After correction by PS, the SVR in older patients remained significantly lower (C60 years: 43.1%, <60 years: 57.8%, P = 0.0497). In addition, RBC counts and hemoglobin (Hgb) concentrations, as well as RBV adherence in the older patients, decreased with this treatment, although there were no significant differences in pretreatment RBC and Hgb levels. Conclusions The analysis using PS indicated that RBV adherence in the older patients decreased even if they did not have lower pretreatment RBC and Hgb levels. © Asian Pacific Association for the Study of the Liver 2011.

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IgA plasma cells express the negative regulatory co-stimulatory molecule programmed cell death 1 ligand and have a potential tolerogenic role in the intestine

Doi Tomomitsu, Kanai Takanori, Mikami Yohei, Sujino Tomohisa, Jun Li, Ono Yuichi, Hayashi Atsushi, Hibi Toshifumi

Biochemical and Biophysical Research Communications 425 ( 4 ) 918 - 923 2012.09

ISSN 0006-291X

To maintain immune homeostasis in the intestine, the intestinal immune system has evolved several tolerogenic mechanisms toward intestinal microflora and food antigens. Although programmed cell death-1 (PD-1) protein has been implicated in immunological tolerance in the intestine and gut-associated lymphoid tissues (GALTs), distribution of its ligands PD-L1 and PD-L2 in the small intestine lamina propria (LP) are unknown. We investigated PD-L1 expression in intestinal LP and found that IgA plasma cells (PCs) were major PD-L1 expressing cells. PD-L1 expression levels on IgA PCs were higher than that on IgG PCs in peripheral lymphoid tissues. IgA PCs expressed antigen-presenting molecule MHC class II and co-stimulatory molecules CD80, CD86, and PD-L2. IgA PCs isolated from intestinal LP exhibited antigen presentation activity, and in the presence of TGF-β induced FoxP3⁺ regulatory T cells, but not IFN-γ⁺ Th1 cells, from naïve T cells. Thus, IgA PCs in the intestine may be involved in an immune regulatory role in the intestinal immune system. © 2012 Elsevier Inc.

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CCR9⁺ macrophages are required for eradication of peritoneal bacterial infections and prevention of polymicrobial sepsis

Mizukami Takahiro, Kanai Takanori, Mikami Yohei, Hayashi Atsushi, Doi Tomomitsu, Handa Tango, Matsumoto Atsuhiro, Jun Li, Matsuoka Katsuyoshi, Sato Toshiro, Hisamatsu Tadakazu, Hibi Toshifumi

Immunology Letters 147 ( 1-2 ) 75 - 79 2012.09

ISSN 0165-2478

Sepsis is a systemic inflammatory response to infection associated with multiple organ dysfunction syndrome and a high mortality rate. In septic shock induced by severe peritonitis, early response of peritoneal macrophages against infected microbes is vital in preventing the spread of infection. We found that the mucosal homing receptor CCR9, is induced in peritoneal macrophages in response to inflammatory stimulation. We used a cecal ligation and puncture (CLP) model of sepsis to determine the role of CCR9 with respect to peritoneal macrophages, and controlling peritoneal infection and systemic inflammation. CCR9^-/- mice showed aggravated septic shock with higher mortality rates compared with wild-type (WT) mice. Six hours after CLP, CCR9^-/- mice demonstrated a greater inflammatory response. This was associated with higher production of inflammatory cytokines, such as IL-6, TNF and IP-10 in peritoneal lavage compared with WT mice. Although the numbers of peritoneal bacteria were elevated in CCR9^-/- mice subjected to CLP compared with WT mice, this was normalized in CCR9^-/- mice subjected to CLP through the adoptive transfer of WT peritoneal macrophages. We conclude that CCR9 is required for recruitment of peritoneal macrophages in the steady state to control systemic sepsis during early phases of peritoneal infection. © 2012 Elsevier B.V.

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Colon neoplastic cells do not originate from bone marrow-derived cells after sex-mismatched bone marrow transplantation

Sakai Gen, Yajima Tomoharu, Takaishi Hiromasa, Mori Takehiko, Higuchi Hajime, Nakamura Shoko, Funakoshi Shinsuke, Adachi Masayuki, Izumiya Motoko, Akagi Hideko, Hamamoto Yasuo, Kanai Takanori, Mukai Makio, Okamoto Shinichiro, Hibi Toshifumi

Anticancer Research 32 ( 9 ) 4097 - 4103 2012.09

ISSN 0250-7005

Background: Although previous studies indicate that gastrointestinal (GI) cancer may originate from cells recruited from bone marrow (BM) in mice, whether similar phenomena occur in humans is controversial. In the current study, we evaluated two female patients who developed colonic adenocarcinoma more than 10 years after gender-mismatched BM transplantation, and followingly underwent successful endoscopic mucosal resection. Materials and Methods: Fluorescent in situ hybridization (FISH) analysis was used to determine whether the tumours contained donor-derived BM cells. Results: Approximately 1.2% of the tumour cells contained Y-chromosome-positive signals, and a comparable percentage of normal colonic epithelial cells close to the tumour also contained Y-chromosome-positive signals. Conclusion: These results do not support the concept that GI cancer can originate from BM-derived cells.

Anti-high mobility group box 1 and box 2 non-histone chromosomal proteins (HMGB1/HMGB2) antibodies and anti-Saccharomyces cerevisiae antibodies (ASCA)

Takaishi Hiromasa, Kanai Takanori, Nakazawa Atsushi, Sugata Fumihiko, Nikai Akira, Yoshizawa Shigeo, Hamamoto Yasuo, Funakoshi Shinsuke, Yajima Tomoharu, Iwao Yasushi, Takemura Masao, Ozaki Shoichi, Hibi Toshifumi

Journal of Gastroenterology 47 ( 9 ) 969 - 977 2012.09

ISSN 0944-1174

Background The development of a supportive diagnostic method has long been required to differentially diagnose ulcerative colitis (UC) and Crohn's disease (CD). Several antibodies circulate in the sera of patients with inflammatory bowel disease. We previously identified the high mobility group box 1 and box 2 non-histone chromosomal proteins (HMGB1 and HMGB2) as novel antigens of perinuclear type anti-neutrophil cytoplasmic antibodies (pANCA) and discovered anti-HMGB1/HMGB2 antibodies in sera from patients with UC. Here, we evaluated the ability of anti-HMGB1/HMGB2 antibodies combined with anti-Saccharomyces cerevisiae antibodies (ASCA) to differentially diagnose UC and CD. Methods We measured titers of anti-HMGB1/HMGB2 antibodies and ASCA in the sera of 213 patients with UC and 93 with CD, using enzyme-linked immunosorbent assays. Results Among the patients with UC, 26.8% were positive for anti-HMGB1/HMGB2 antibodies, with 85.0% specificity towards CD and a positive predictive value of 80.3%. Corticosteroids significantly suppressed the titer of anti- HMGB1/HMGB2 antibodies. Among the patients with CD, 24.7% were positive for ASCA, with 96.2% specificity towards UC and a positive predictive value of 74.2%. Interestingly, the positivity rate of anti-HMGB/HMGB2 antibodies was higher (35.7%) in patients with the ileitis type ofCDthan in patients withCDin the colon (6.2%; significant difference, P0.01). The specificity of anti-HMGB1/ HMGB2 antibodies in UC for CD in the colon was 93.8%. Conclusions CD in the colon and UC can be differentially diagnosed using anti-HMGB/HMGB2 antibodies combined with ASCA. © 2012 Springer.

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CCR9⁺ plasmacytoid dendritic cells in the small intestine suppress development of intestinal inflammation in mice

Mizuno Shinta, Kanai Takanori, Mikami Yohei, Sujino Tomohisa, Ono Yuichi, Hayashi Atsushi, Handa Tango, Matsumoto Atsuhiro, Nakamoto Nobuhiro, Matsuoka Katsuyoshi, Hisamatsu Tadakazu, Takaishi Hiromasa, Hibi Toshifumi

Immunology Letters 146 ( 1-2 ) 64 - 69 2012.08

ISSN 0165-2478

Almost all mice lacking specific molecules associated with regulatory T cells or barrier function develop intestinal inflammation in the colon, but not in the small intestine (SI). Therefore, intestinal homeostasis of the SI may be tightly controlled by other mechanisms. To determine the role of CCR9⁺ plasmacytoid dendritic cells (pDCs) in intestinal homeostasis of the SI we transferred CD4⁺CD45RB^high T cells into ccr9^-/-×rag-2^-/- mice. We showed that CCL25, a counterpart chemokine for CCR9, is constitutively expressed in the SI but not the colon and spleen of rag-2^-/- or ccr9^-/-×rag-2^-/- mice before or after transfer of CD4⁺CD45RB^high T cells. The ccr9^-/-×rag-2^-/- mice did not develop spontaneous intestinal inflammation in the SI and colon. Mice of both genotype where CD4⁺CD45RB^high T cells were transferred developed colitis. However, the ccr9^-/-×rag-2^-/- mice also developed ileitis with marked infiltration of Th1 cells. These results suggest that CCR9⁺ pDCs are possibly small, regulatory, antigen-presenting cells of the intestine that suppress intestinal inflammation. © 2012 Elsevier B.V.

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Effects of the oral administration of mosapride citrate on capsule endoscopy completion rate

Ida Yosuke, Hosoe Naoki, Imaeda Hiroyuki, Bessho Rieko, Ichikawa Riko, Naganuma Makoto, Kanai Takanori, Hibi Toshifumi, Ogata Haruhiko

Gut and Liver 6 ( 3 ) 339 - 343 2012.07

ISSN 1976-2283

Background/Aims: In capsule endoscopy (CE), the capsule does not always reach the cecum within its battery life, which may reduce its diagnostic yield. We evaluated the effect of mosapride citrate, a 5-hydroxytryptamine-4 agonist that increases gastrointestinal motility, on CE completion. Methods: In a retrospective study, we performed univariate and multivariate analyses for 232 CE procedures performed at our hospital. To identify factors that affect CE completion, the following data were systematically collected: gender, age, gastric transit time (GTT), nonsteroidal anti-inflammatory drug administration, previous abdominal surgery, hospitalization, use of a polyethylene glycol solution, use of mosapride citrate (10 mg), body mass index (BMI), and total recording time. Results: The univariate analysis showed that oral mosapride citrate, GTT, and BMI were associated with improved CE completion. Multivariate analyses showed that oral mosapride citrate (odds ratio [OR], 1.99; 95% confidence interval [CI], 1.01 to 3.91) and GTT (OR, 2.34; 95% CI, 1.13 to 4.87) were significant factors for improving the CE completion. Oral mosapride citrate significantly shortened the GTT and small bowel transit time (SBTT). Conclusions: Oral mosapride citrate reduced the GTT and SBTT during CE and improved the CE completion rate.

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Bile acids induce monocyte differentiation toward interleukin-12 hypo-producing dendritic cells via a TGR5-dependent pathway

Ichikawa Riko, Takayama Tetsuro, Yoneno Kazuaki, Kamada Nobuhiko, Kitazume Mina T., Higuchi Hajime, Matsuoka Katsuyoshi, Watanabe Mitsuhiro, Itoh Hiroshi, Kanai Takanori, Hisamatsu Tadakazu, Hibi Toshifumi

Immunology 136 ( 2 ) 153 - 162 2012.06

ISSN 0019-2805

Dendritic cells (DCs) are known as antigen-presenting cells and play a central role in both innate and acquired immunity. Peripheral blood monocytes give rise to resident and recruited DCs in lymph nodes and non-lymphoid tissues. The ligands of nuclear hormone receptors can modulate DC differentiation and so influence various biological functions of DCs. The role of bile acids (BAs) as signalling molecules has recently become apparent, but the functional role of BAs in DC differentiation has not yet been elucidated. We show that DCs derived from human peripheral blood monocytes cultured with a BA produce lower levels of interleukin-12 (IL-12) and tumour necrosis factor-α in response to stimulation with commensal bacterial antigens. Stimulation through the nuclear receptor farnesoid X (FXR) did not affect the differentiation of DCs. However, DCs differentiated with the specific agonist for TGR5, a transmembrane BA receptor, showed an IL-12 hypo-producing phenotype. Expression of TGR5 could only be identified in monocytes and was rapidly down-regulated during monocyte differentiation to DCs. Stimulation with 8-bromoadenosine-cyclic AMP (8-Br-cAMP), which acts downstream of TGR5 signalling, also promoted differentiation into IL-12 hypo-producing DCs. These results indicate that BAs induce the differentiation of IL-12 hypo-producing DCs from monocytes via the TGR5-cAMP pathway. © 2012 The Authors. Immunology © 2012 Blackwell Publishing Ltd.

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Novel technique of endoscopic submucosal dissection by using external forceps for early rectal cancer (with videos)

Imaeda Hiroyuki, Hosoe Naoki, Ida Yosuke, Nakamizo Hiromasa, Kashiwagi Kazuhiro, Kanai Takanori, Iwao Yasushi, Hibi Toshifumi, Ogata Haruhiko

Gastrointestinal Endoscopy 75 ( 6 ) 1253 - 1257 2012.06

ISSN 0016-5107

Background: Endoscopic submucosal dissection (ESD) is more difficult for rectal cancer than for gastric cancer. Objective: To evaluate the feasibility and safety of an ESD procedure by using external forceps for early rectal cancer. Design: A case series. Setting: A tertiary medical center. Patients: Thirteen patients with early-stage rectal cancer were enrolled. Twelve of the 13 lesions were granular-type laterally spreading tumors and 1 was a protruding tumor. Interventions: After circumferential incision around the lesion with a dual-knife or a flex-knife, bendable external forceps were introduced with the help of grasping forceps inserted through the accessory channel and anchored at the anal margin of the lesion. After the forceps were bent, they were locked. With gentle anal traction and bending applied with the forceps, the lesion was elevated, the submucosal layer was opened, and the submucosal layer was dissected from the grasped side, facilitating dissection of the submucosal layer under direct vision. Main Outcome Measurements: Technical success, complication rates. Results: The mean lesion size was 33.0 mm (range 20-80 mm), and the mean operating time was 60 minutes (range 20-150 minutes). All lesions could be resected en bloc with tumor-free margins. Major bleeding after ESD occurred in only 1 patient (7.7%), who did not require blood transfusion. Perforation did not occur in any patient. Limitations: Single-center experience, small number of patients. Conclusion: This ESD procedure using external forceps for early-stage rectal cancers is feasible and safe. © 2012 American Society for Gastrointestinal Endoscopy.

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RORγt-dependent IL-17A-producing cells in the pathogenesis of intestinal inflammation

Kanai T., Mikami Y., Sujino T., Hisamatsu T., Hibi T.

Mucosal Immunology 5 ( 3 ) 240 - 247 2012.05

ISSN 1933-0219

The hypothesis of helper T(T _h)1/T _h2 cytokine balance proposed by Mosmann and Coffman is often invoked to explain the development of inflammatory diseases, including inflammatory bowel diseases (IBD). Recently, however, a newly identified class of T _h cells - T _h17 cells, which produce T _h17 family cytokines - has been recognized as an essential subpopulation in the development of almost all kinds of human and animal inflammatory diseases, rather than T _h1 and T _h2 cells. A representative T _h17 family cytokine, interleukin (IL)-17A, is produced by not only T _h17 cells, but also by other types of cells, such as T-cell receptor _γδ T cells, natural killer (NK) T cells, NK cells, myeloid cells, and innate lymphoid cells, which may also be critically involved in the initiation and persistence of IBD. Here we review recent advances in the study of such IL-17A-producing cells in the pathogenesis of IBD. © 2012 Society for Mucosal Immunology.

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Role of enhanced visibility in evaluating polyposis syndromes using a newly developed contrast image capsule endoscope

Hatogai Ken, Hosoe Naoki, Imaeda Hiroyuki, Rey Jean Fraņois, Okada Sawako, Ishibashi Yuka, Kimura Kayoko, Yoneno Kazuaki, Usui Shingo, Ida Yosuke, Tsukada Nobuhiro, Kanai Takanori, Hibi Toshifumi, Ogata Haruhiko

Gut and Liver 6 ( 2 ) 218 - 222 2012.04

ISSN 1976-2283

Background/Aims: A flexible spectral imaging color enhancement system was installed in new capsule software for video capsule endoscopy. Contrast image capsule endoscopy (CICE) is a novel technology using light-emitting diodes selected for the main absorption range of hemoglobin. We assessed the feasibility and diagnostic effi cacy for small bowel surveillance in patients with polyposis syndromes. Methods: Six patients with polyposis syndromes, four with familial adenomatous polyposis and one each with Cowden syndrome (CS) and Cronkhite-Canada syndrome (CCS) were examined using CICE. We conducted three evaluations to assess the effect on the numbers of the detected polyps; compare polyp diagnostic rates between adenoma and hamartoma; and assess polyp visibility. Results: The numbers of detected polyps and diagnostic accuracy did not differ signifi cantly between pre-contrast and contrast images. However, 50% of the adenomatous polyps displayed enhanced visibility on contrast images. CICE contrast images exhibited clearly demarcated lesions and improved the visibility of minute structures of adenomatous polyps. Hamartomatous polyp micro-structures in patients with CS and CCS were more clearly visualized on contrast than pre-contrast images. Conclusions: CICE is an effective tool for enhancing the visibility of polyps in patients with polyposis syndrome.

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CCL2-induced migration and SOCS3-mediated activation of macrophages are involved in cerulein-induced pancreatitis in mice

Saeki Keita, Kanai Takanori, Nakano Masaru, Nakamura Yuji, Miyata Naoteru, Sujino Tomohisa, Yamagishi Yoshiyuki, Ebinuma Hirotoshi, Takaishi Hiromasa, Ono Yuuichi, Takeda Kazuyoshi, Hozawa Shigenari, Yoshimura Akihiko, Hibi Toshifumi

Gastroenterology 142 ( 4 ) 2012.04

ISSN 0016-5085

Background & Aims: Acute pancreatitis is a common inflammatory disease mediated by damage to acinar cells and subsequent pancreatic inflammation with recruitment of leukocytes. We investigated the pathologic roles of innate immune cells, especially macrophages, in cerulein and L-arginineinduced acute pancreatitis in mice. Methods: Acute pancreatitis was induced by sequential peritoneal administration of cerulein to mice. We determined serum concentrations of amylase and lipase, pancreatic pathology, and features of infiltrating mononuclear cells. We performed parabiosis surgery to assess the hemodynamics of pancreatic macrophages. Results: Almost all types of immune cells, except for CD11b ^highCD11c ^- cells, were detected in the pancreas of healthy mice. However, activated CD11b ^highCD11c ^- cells, including Gr-1 ^low macrophages and Gr-1 ^high cells (granulocytes and myeloid-derived suppressor cells), were detected in damaged pancreas after cerulein administration. CCL2 ^-/- mice given cerulein injections developed significantly less severe pancreatitis, with less infiltration of CD11b ^highCD11c ^-Gr-1 ^low macrophages, but comparable infiltration of myeloid-derived suppressor cells, compared with cerulein-injected wild-type mice. Parabiosis and bone marrow analyses of these mice revealed that the CD11b ^highCD11c ^-Gr-1 ^low macrophages had moved out of the bone marrow. Furthermore, mice with macrophage-specific deletion of suppressor of cytokine signaling 3 given injections of cerulein developed less severe pancreatitis and Gr-1 ^low macrophage produced less tumor necrosis factor-α than wild-type mice given cerulein, although the absolute number of CD11b ^highCD11c ^-Gr-1 ^low macrophages was comparable between strains. Induction of acute pancreatitis by L-arginine required induction of macrophage migration by CCL2, via the receptor CCR2. Conclusions: Cerulein induction of pancreatitis in mice involves migration of CD11b ^highCD11c ^-Gr-1 ^low macrophage from the bone marrow (mediated by CCL2 via CCR2) and suppressor of cytokine signaling 3dependent activation of macrophage. These findings might lead to new therapeutic strategies for acute pancreatitis. © 2012 AGA Institute.

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The development of colitogenic CD4 ⁺ T cells is regulated by IL-7 in collaboration with NK cell function in a murine model of colitis

Yamaji Osamu, Nagaishi Takashi, Totsuka Teruji, Onizawa Michio, Suzuki Masahiro, Tsuge Naoto, Hasegawa Atsuhiko, Okamoto Ryuichi, Tsuchiya Kiichiro, Nakamura Tetsuya, Arase Hisashi, Kanai Takanori, Watanabe Mamoru

Journal of Immunology 188 ( 6 ) 2524 - 2536 2012.03

ISSN 0022-1767

We previously reported that IL-7 ^-/-RAG ^-/- mice receiving naive T cells failed to induce colitis. Such abrogation of colitis may be associated with not only incomplete T cell maintenance due to the lack of IL-7, but also with the induction of colitogenic CD4 ⁺ T cell apoptosis at an early stage of colitis development. Moreover, NK cells may be associated with the suppression of pathogenic T cells in vivo, and they may induce apoptosis of CD4 ⁺ T cells. To further investigate these roles of NK cells, RAG ^-/- and IL-7 ^-/-RAG ^-/-mice that had received naive T cells were depleted of NK cells using anti-asialo GM1 and anti-NK1.1 Abs. NK cell depletion at an early stage, but not at a later stage during colitogenic effector memory T cell (T _EM) development, resulted in exacerbated colitis in recipient mice even in the absence of IL-7. Increased CD44 ⁺CD62L ^- T _EM and unique CD44 ^-CD62L ^- T cell subsets were observed in the T cell-reconstituted RAG ^-/- recipients when NK cells were depleted, although Fas, DR5, and IL-7R expressions in this subset differed from those in the CD44 ⁺CD62L ^- T _EM subset. NK cell characteristics were the same in the presence or absence of IL-7 in vitro and in vivo. These results suggest that NK cells suppress colitis severity in T cell-reconstituted RAG ^-/- and IL-7 ^-/-RAG ^-/- recipient mice through targeting of colitogenic CD4 ⁺CD44 ⁺CD62L ^- T _EM and, possibly, of the newly observed CD4 ⁺CD44 ^-CD62L ^- subset present at the early stage of T cell development. Copyright © 2012 by The American Association of Immunologists, Inc.

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Mechanism and therapeutic strategy of second failure of infliximab treatment for Crohn's disease

Kanai Takanori, Matsuoka Katsuyoshi, Hisamatsu Tadakazu, Iwao Yasushi, Ogata Haruhiko, Hibi Toshifumi

Journal of Japanese Society of Gastroenterology 109 ( 3 ) 364 - 369 2012.03

ISSN 0446-6586

CCR9 ⁺ macrophages are required for acute liver inflammation in mouse models of hepatitis

Nakamoto Nobuhiro, Ebinuma Hirotoshi, Kanai Takanori, Chu Posung, Ono Yuichi, Mikami Yohei, Ojiro Keisuke, Lipp Martin, Love Paul E., Saito Hidetsugu, Hibi Toshifumi

Gastroenterology 142 ( 2 ) 366 - 376 2012.02

ISSN 0016-5085

Background & Aims: Antigen-presenting cells (APCs) are involved in the induction of liver inflammation. We investigated the roles of specific APCs in the pathogenesis of acute liver injury in mice. Methods: We used concanavalin A (con A) or carbon tetrachloride to induce acute liver inflammation in mice and studied the roles of macrophages that express CCR9. Results: After injection of con A, we detected CCR9 ⁺CD11b ⁺CD11c macrophages that express tumor necrosis factor (TNF)-α in livers of mice, whereas CCR9 ⁺SiglecH ⁺CD11bCD11c ^low plasmacytoid DCs (pDCs), which are abundant in normal livers, disappeared. The CCR9 ⁺ macrophages were also detected in the livers of RAG-2 ^-/- mice, which lack lymphocytes and natural killer T cells, after injection of con A. Under inflammatory conditions, CCR9 ⁺ macrophages induced naive CD4 ⁺ T cells to become interferon gammaproducing Th1 cells in vivo and in vitro. CCR9 ^-/- mice injected with con A did not develop hepatitis unless they also received CCR9 ⁺ macrophages from mice that received con A; more CCR9 ⁺ macrophages accumulated in their inflamed livers than CCR9 ⁺ pDCs, CCR9 pDCs, or CCR9 macrophages isolated from mice that had received injections of con A. Levels of CCL25 messenger RNA increased in livers after injection of con A; neutralizing antibodies against CCL25 reduced the induction of hepatitis by con A by blocking the migration of CCR9 ⁺ macrophages and their production of TNF-α. Peripheral blood samples from patients with acute hepatitis had greater numbers of TNF-αproducing CCR9 ⁺CD14 ⁺CD16 ^high monocytes than controls. Conclusions: CCR9 ⁺ macrophages contribute to the induction of acute liver inflammation in mouse models of hepatitis. © 2012 AGA Institute.

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[Mechanism of pathogenesis of inflammatory bowel diseases].

Kanai Takanori

Nihon rinsho. Japanese journal of clinical medicine 70 Suppl 1 59 - 65 2012.02

ISSN 0047-1852

Evaluations of capsule endoscopy software in reducing the reading time and the rate of false negatives by inexperienced endoscopists

Hosoe Naoki, Rey Jean François, Imaeda Hiroyuki, Bessho Rieko, Ichikawa Riko, Ida Yosuke, Naganuma Makoto, Kanai Takanori, Hibi Toshifumi, Ogata Haruhiko

Clinics and Research in Hepatology and Gastroenterology 36 ( 1 ) 66 - 71 2012.02

ISSN 2210-7401

Background and objective: Capsule endoscopy (CE) is a comfortable for the patients; however, CE review is time-consuming. The aim of this study was (1) to evaluate the effectiveness of the CE software in reducing the CE reading time and the number of false negatives by beginners, and (2) to determine the learning curve for reading CE images. Methods: Capsule endoscopic images were captured by Pillcam SB (Given Imaging Ltd, Tokyo, Japan), and analyzed using the proprietary RAPID5 software. Comparison of CE reading using different software modes: manual mode, automatic mode, and QuickView (QV) mode. Three trainee endoscopists participated as CE readers. Each participant watched CE videos in which positive findings had been predefined by trained endoscopists. Each participant read the same CE record by using one of three different software modes. These were blinded on clinical history of patients. CE reading time was recorded, and the number of false negatives was counted. Each trainee endoscopist read a total of 45CE videos, in five steps divided into nine videos per step. Results: There was no significant reader associated difference between the results for the different modes. The QV software did miss some positive findings. Therefore, the total number of instances of FN by the software plus the reader in the QV mode was significantly higher than the others. The reading times in the automatic mode and the QV mode were significantly shorter than that in the manual mode. After the second step, the number of instances of false negatives significantly decreased. Conclusions: CE software is useful for reducing the reading time. Experience of approximately 20CE readings can be considered as the first step to becoming an expert. © 2011 Elsevier Masson SAS.

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Novel, objective, multivariate biomarkers composed of plasma amino acid profiles for the diagnosis and assessment of inflammatory bowel disease

Hisamatsu Tadakazu, Okamoto Susumu, Hashimoto Masaki, Muramatsu Takahiko, Andou Ayatoshi, Uo Michihide, Kitazume Mina T., Matsuoka Katsuyoshi, Yajima Tomoharu, Inoue Nagamu, Kanai Takanori, Ogata Haruhiko, Iwao Yasushi, Yamakado Minoru, Sakai Ryosei, Ono Nobukazu, Ando Toshihiko, Suzuki Manabu, Hibi Toshifumi

PLoS ONE 7 ( 1 ) 2012.01

Background: Inflammatory bowel disease (IBD) is a chronic intestinal disorder that is associated with a limited number of clinical biomarkers. In order to facilitate the diagnosis of IBD and assess its disease activity, we investigated the potential of novel multivariate indexes using statistical modeling of plasma amino acid concentrations (aminogram). Methodology and Principal Findings: We measured fasting plasma aminograms in 387 IBD patients (Crohn's disease (CD), n = 165; ulcerative colitis (UC), n = 222) and 210 healthy controls. Based on Fisher linear classifiers, multivariate indexes were developed from the aminogram in discovery samples (CD, n = 102; UC, n = 102; age and sex-matched healthy controls, n = 102) and internally validated. The indexes were used to discriminate between CD or UC patients and healthy controls, as well as between patients with active disease and those in remission. We assessed index performances using the area under the curve of the receiver operating characteristic (ROC AUC). We observed significant alterations to the plasma aminogram, including histidine and tryptophan. The multivariate indexes established from plasma aminograms were able to distinguish CD or UC patients from healthy controls with ROC AUCs of 0.940 (95% confidence interval (CI): 0.898-0.983) and 0.894 (95%CI: 0.853-0.935), respectively in validation samples (CD, n = 63; UC, n = 120; healthy controls, n = 108). In addition, other indexes appeared to be a measure of disease activity. These indexes distinguished active CD or UC patients from each remission patients with ROC AUCs of 0.894 (95%CI: 0.853-0.935) and 0.849 (95%CI: 0.770-0.928), and correlated with clinical disease activity indexes for CD (r _s = 0.592, 95%CI: 0.385-0.742, p<0.001) or UC (r _s = 0.598, 95%CI: 0.452-0.713, p<0.001), respectively. Conclusions and Significance: In this study, we demonstrated that established multivariate indexes composed of plasma amino acid profiles can serve as novel, non-invasive, objective biomarkers for the diagnosis and monitoring of IBD, providing us with new insights into the pathophysiology of the disease. © 2012 Hisamatsu et al.

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A high-cholesterol diet exacerbates liver fibrosis in mice via accumulation of free cholesterol in hepatic stellate cells

Teratani Toshiaki, Tomita Kengo, Suzuki Takahiro, Oshikawa Tetsuya, Yokoyama Hirokazu, Shimamura Katsuyoshi, Tominaga Susumu, Hiroi Sadayuki, Irie Rie, Okada Yoshikiyo, Kurihara Chie, Ebinuma Hirotoshi, Saito Hidetsugu, Hokari Ryota, Sugiyama Kazuo, Kanai Takanori, Miura Soichiro, Hibi Toshifumi

Gastroenterology 142 ( 1 ) 2012.01

ISSN 0016-5085

Some studies have indicated that dietary cholesterol has a role in the progression of liver fibrosis. We investigated the mechanisms by which dietary cholesterol might contribute to hepatic fibrogenesis. C57BL/6 mice were fed a high-cholesterol diet or a control diet for 4 weeks; liver fibrosis then was induced by bile-duct ligation or carbon tetrachloride administration. Hepatic stellate cells (HSCs) were isolated from mice fed high-cholesterol diets or from NiemannPick type C1-deficient mice, which accumulate intracellular free cholesterol. After bile-duct ligation or carbon tetrachloride administration, mice fed high-cholesterol diets had significant increases in liver fibrosis and activation of HSCs compared with mice fed control diets. There were no significant differences in the degree of hepatocellular injury or liver inflammation, including hepatocyte apoptosis or Kupffer cell activation, between mice fed high-cholesterol or control diets. Levels of free cholesterol were much higher in HSCs from mice fed high-cholesterol diets than those fed control diets. In cultured HSCs, accumulation of free cholesterol in HSCs increased levels of Toll-like receptor 4 (TLR4), leading to down-regulation of bone morphogenetic protein and activin membrane-bound inhibitor (a pseudoreceptor for transforming growth factor [TGF]β); the HSCs became sensitized to TGFβ-induced activation. Liver fibrosis was not aggravated by the high-cholesterol diet in C3H/HeJ mice, which express a mutant form of TLR4; HSCs that express mutant TLR4 were not activated by accumulation of free cholesterol. Dietary cholesterol aggravates liver fibrosis because free cholesterol accumulates in HSCs, leading to increased TLR4 signaling, down-regulation of bone morphogenetic protein and activin membrane-bound inhibitor, and sensitization of HSC to TGFβ. This pathway might be targeted by antifibrotic therapies. © 2012 AGA Institute.

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A case of intestinal Behçet's disease treated with infliximab monotherapy who successfully maintained clinical remission and complete mucosal healing for six years

Maruyama Yuriko, Hisamatsu Tadakazu, Matsuoka Katsuyoshi, Naganuma Makoto, Inoue Nagamu, Ogata Haruhiko, Iwao Yasushi, Kanai Takanori, Hibi Toshifumi

Internal Medicine 51 ( 16 ) 2125 - 2129 2012

ISSN 0918-2918

Behçet's disease is a chronic relapsing disease with multiple organ system involvement, including the gastrointestinal tract, which is known as intestinal Behçet's disease. Intestinal Behçet's disease is often resistant to empirical treatments such as 5-aminosalicylic acid, immunomodulators and steroids and often causes a perforation, requiring surgical resection. Therefore, intestinal lesions are considered to be a poor prognostic factor in Behçet's disease. Recently, several reports have demonstrated the efficacy of anti-TNFα monoclonal antibodies, such as infliximab, against intestinal Behçet's disease, however, it remains unknown whether anti- TNFα therapy can improve the prognosis of patients with intestinal Behçet's disease. We herein report the case of an adult female patient with intestinal Behçet's disease who responded well to the induction therapy with infliximab, and has been maintained in remission by scheduled administration of infliximab. Her C- reactive protein level has been sustained at a negative level, and endoscopic findings revealed complete mucosal healing. Therefore, infliximab may have the potential to induce "sustained deep remission" in patients with intestinal Behçet's disease. © 2012 The Japanese Society of Internal Medicine.

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Comparison of patient acceptance of sodium phosphate versus polyethylene glycol plus sodium picosulfate for colon cleansing in Japanese

Hosoe Naoki, Nakashita Manabu, Imaeda Hiroyuki, Sujino Tomohisa, Bessho Rieko, Ichikawa Riko, Inoue Nagamu, Kanai Takanori, Hibi Toshifumi, Ogata Haruhiko

Journal of Gastroenterology and Hepatology (Australia) 27 ( 10 ) 1617 - 1622 2012

ISSN 0815-9319

Background and Aim: In Japan, patient acceptance of bowel preparation methods before colonoscopy remains unknown. This study was conducted to evaluate the patient acceptance of sodium phosphate (NaP) tablets and polyethylene glycol solution (PEG) with sodium picosulfate. Methods: One hundred patients were randomized into one of the following two groups: the NaP tablet first-use group or the PEG with sodium picosulfate first-use group in a crossover design trial. Patient acceptance and incidence of adverse events were evaluated using a questionnaire. Colon-cleansing effectiveness was also evaluated. Results: Patients' overall impressions of the preparations were significantly different between the NaP tablet (77.9%, 67/86) and PEG with sodium picosulfate (60.5%, 52/86; P=0.001). Nausea incidence as an adverse event was significantly different between the two regimens (P=0.03). Colon-cleansing effectiveness was not significantly different between the two regimens. Conclusions: The results of this crossover study showed that patient acceptance was similar to those previously reported in a parallel-group comparison. In Japanese patients, preference for and acceptance of NaP tablets was significantly higher than that for PEG with sodium picosulfate solution. © 2012 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.

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Prediction of effect of pegylated interferon alpha-2b plus ribavirin combination therapy in patients with chronic hepatitis C infection

Takayama Tetsuro, Ebinuma Hirotoshi, Tada Shinichiro, Yamagishi Yoshiyuki, Wakabayashi Kanji, Ojiro Keisuke, Kanai Takanori, Saito Hidetsugu, Hibi Toshifumi

PLoS ONE 6 ( 12 ) 2011.12

Treatment with pegylated interferon alpha-2b (PEGIFN) plus ribavirin (RBV) is standard therapy for patients with chronic hepatitis C. Although the effectiveness, patients with high titres of group Ib hepatitis C virus (HCV) respond poorly compared to other genotypes. At present, we cannot predict the effect in an individual. Previous studies have used traditional statistical analysis by assuming a linear relationship between clinical features, but most phenomena in the clinical situation are not linearly related. The aim of this study is to predict the effect of PEG IFN plus RBV therapy on an individual patient level using an artificial neural network system (ANN). 156 patients with HCV group 1b from multiple centres were treated with PEGIFN (1.5 μg/kg) plus RBV (400-1000 mg) for 48 weeks. Data on the patients' demographics, laboratory tests, PEGIFN, and RBV doses, early viral responses (EVR), and sustained viral responses were collected. Clinical data were randomly divided into training data set and validation data set and analyzed using multiple logistic regression analysis (MLRs) and ANN to predict individual outcomes. The sensitivities of predictive expression were 0.45 for the MLRs models and 0.82 for the ANNs and specificities were 0.55 for the MLR and 0.88 for the ANN. Non-linear relation analysis showed that EVR, serum creatinine, initial dose of Ribavirin, gender and age were important predictive factors, suggesting non-linearly related to outcome. In conclusion, ANN was more accurate than MLRs in predicting the outcome of PEGIFN plus RBV therapy in patients with group 1b HCV. © 2011 Takayama et al.

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Luminal CD4 ⁺ T cells penetrate gut epithelial monolayers and egress from lamina propria to blood circulation

Nemoto Yasuhiro, Kanai Takanori, Shinohara Tamako, Ito Takashi, Nakamura Tetsuya, Okamoto Ryuichi, Tsuchiya Kiichiro, Lipp Martin, Eishi Yoshinobu, Watanabe Mamoru

Gastroenterology 141 ( 6 ) 2011.12

ISSN 0016-5085

Background & Aims: The egress of memory T cells from peripheral tissues, such as lung and skin, into the draining lymph nodes requires their expression of CC chemokine receptor 7 (CCR7). In the intestine, resident memory T cells in the intestinal lamina propria (LP) do not express CCR7, indicating that they are tissue bound and do not exit the intestine. Methods: We developed a cell transfer system, using rectal administration of lymphocytes to C57BL/6 mice. Lymphotoxin α-deficient mice were crossed with RAG-2 ^-/- (recombination-activating gene-2) mice to generate lymphotoxin α-deficient × RAG-2 ^-/- mice. Results: Severe combined immunodeficient (SCID) or RAG-2 ^-/- mice given rectal administration of splenic CD4 ⁺ T cells from normal mice developed colitis; the cells proliferated not only in the LP but also in spleen. SCID or RAG-2 ^-/- mice given rectal administrations of CD4 ⁺ T cells that expressed green fluorescent protein (GFP ⁺CD4 ⁺ T cells) localized to the LP within 6 hours but were not found in the spleen until 24 hours after administration. Immunohistochemical and electron microscopic analyses detected CD4 ⁺ T cells in the intraepithelial space just 3 hours after intrarectal administration. However, neither CCR7 deficiency nor the sphingosine-1-phosphate receptor agonist Fingolimod impaired the egress of CD4 ⁺ T cells from LP to systemic circulation. Conclusions: CD4 ⁺ T cells not only penetrate from the luminal side of the intestine to the LP but also actively egress from the LP into the circulation. We developed a rectal administration system that might be used to further investigate cell trafficking in intestinal mucosa and to develop enema-based therapeutics for intestinal diseases. © 2011 AGA Institute.

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Evaluation of liver fibrosis by transient elastography using acoustic radiation force impulse

Ebinuma Hirotoshi, Saito Hidetsugu, Komuta Mina, Ojiro Keisuke, Wakabayashi Kanji, Usui Shingo, Chu Po sung, Umeda Rumiko, Ishibashi Yuka, Takayama Tetsurou, Kikuchi Masahiro, Nakamoto Nobuhiro, Yamagishi Yoshiyuki, Kanai Takanori, Ohkuma Kiyoshi, Sakamoto Michiie, Hibi Toshifumi

Journal of Gastroenterology 46 ( 10 ) 1238 - 1248 2011.10

ISSN 0944-1174

Accurate evaluation of liver fibrosis in patients with chronic liver damage is required to determine the appropriate treatment. Various approaches, including laboratory tests and transient elastography, have been used to evaluate liver fibrosis. Recently, transient elastography with acoustic radiation force impulse (ARFI) has been developed and applied with conventional ultrasonography. The aim of this study was to evaluate the clinical utility of transient elastography with ARFI and to compare the results with this method and those of the Fibroscan(®) procedure. One hundred and thirty-one patients with liver damage, who underwent liver biopsy at our department, were enrolled prospectively in this study. Elastography with ARFI (applied with ACUSON S2000(®)), and Fibroscan(®) was performed at the same time as liver biopsy. These measurements were compared with histological findings in liver biopsy specimens, and measurement accuracy was evaluated by receiver-operating characteristic analysis. Elastography values with both procedures were significantly correlated with the stages of liver fibrosis and there was little difference in the results obtained using the 2 procedures. The accuracy of differential diagnosis between no fibrosis at F0 and more than F1 stage was insufficient with ARFI, but this procedure was sufficient for diagnosing advanced fibrosis. The accuracy of ARFI was almost equivalent to that of the Fibroscan(®) method. Moreover, both ARFI and Fibroscan(®) values increased in proportion to the severity of hepatic inflammation when fibrosis stage is low, but not in proportion to the severity of steatosis. Transient elastography with ARFI is simple, non-invasive and useful for diagnosing the stage of fibrosis in chronic liver disease. The utility of ARFI was almost equivalent to that of the Fibroscan(®) method.

Correlation between endocytoscopy and conventional histopathology in microstructural features of ulcerative colitis.

Bessho Rieko, Kanai Takanori, Hosoe Naoki, Kobayashi Taku, Takayama Tetsuro, Inoue Nagamu, Mukai Makio, Ogata Haruhiko, Hibi Toshifumi

Journal of Gastroenterology 46 ( 10 ) 1197 - 1202 2011.10

ISSN 0944-1174

Routine diagnosis of the histopathological activity of ulcerative colitis (UC) requires multiple biopsy samples, and an endocytoscopy system (ECS) provides real-time ultra-magnifying microscopic imaging in vivo. We have established an ECS score (ECSS) to determine a histopathological activity index of UC. Fifty-five UC patients (mean age 40.7 years; 67% men) were enrolled. A super-magnifying ECS with magnification 450× was used, and sample biopsies were obtained. Matts' histopathological grade was determined, to evaluate disease severity, by two pathologists, with consensus. The ECSS of UC was independently determined by at least two investigators, with consensus. In total, 76 pairs of ECSS and Matts' histopathological grades were independently acquired. To validate the ECSS, inter-observer agreement between three endoscopists, with consensus, and another endoscopist, was calculated as the kappa value. We also evaluated the correlation between the ECSS and Matts' histopathological grade, and between the conventional Matts' endoscopic grade and Matts' histopathological grade. The ECSS of UC intestinal mucosa, i.e., the sum of the indices for shape (0-3) and distance between crypts (0-2), and the visibility of superficial microvessels (0-1), showed a strong correlation with Matts' histopathological grades (ρ = 0.713, P < 0.001); as well, there was a strong correlation between the conventional Matts' endoscopic grade and Matts' histopathological grade (ρ = 0.694, P < 0.001). Furthermore, the ECSS showed high reproducibility (κ = 0.79, 95% confidence interval [CI] 0.71-0.87). Our novel ECSS has good predictive value for the histopathological activity of UC.

Transition of treatments of uncreative colitis based on the imaging studies

Kanai Takanori, Ogata Haruhiko, Hosoe Naoki, Iwao Yasushi, Hibi Toshifumi

Gastroenterological Endoscopy 53 ( 10 ) 3261 - 3271 2011.10

ISSN 0387-1207

Inflammatory bowel diseases (IBD) classified at the present time as ulcerative colitis (UC) and Crohn's disease (CD) are characterized by chronic relapsing inflammations of the gastrointestinal tract. In order to select the most appropriate treatment, patients must be assessed by determining the phenotype, disease extension, disease severity, and complicating cancer. Recent advances in endoscopic technology in addition to other modalities provide the possibility for the assessment of disease activity and the determination of the treatment for each IBD patient. Here we review the controversies in the use of diagnostic procedures for UC patients.

Regulatory T cells suppress development of colitis, blocking differentiation of T-helper 17 into alternative T-helper 1 cells

Sujino Tomohisa, Kanai Takanori, Ono Yuichi, Mikami Yohei, Hayashi Atsushi, Doi Tomomitsu, Matsuoka Katsuyoshi, Hisamatsu Tadakazu, Takaishi Hiromasa, Ogata Haruhiko, Yoshimura Akihiko, Littman Dan R., Hibi Toshifumi

Gastroenterology 141 ( 3 ) 1014 - 1023 2011.09

ISSN 0016-5085

Background & Aims: Although T-helper (Th) 17 and Th1 cells are involved in pathogenesis of intestinal inflammation, their developmental pathways and sufficiency to promote disease are not known; nor are the roles of CD4 ⁺CD25 ⁺ regulatory T (T _R) cells in their development. Methods: We performed adoptive transfer experiments to investigate the induction and suppression of colitis using nave CD4 ⁺CD45RB ^high T cells and/or CD4 ⁺CD25 ⁺ T _R cells that were obtained from retinoid-related orphan receptor gamma t (RORγt) gfp/ ⁺ or Ly5.1/Ly5.2 congenic mice. Results: We observed 3 types of colitogenic CD4 ⁺ Th1 cells (interleukin [IL]-17A ^-interferon [IFN]-γ ⁺): RORγt classical Th1 cells that differentiated directly from nave T cells; RORγt ⁺ Th1-like cells; and RORγt alternative Th1 cells that were terminally differentiated from RORγt ⁺ cells via Th17 (IL-17A ⁺IFN-γ), Th17/Th1 (IL-17A ⁺IFN- γ ⁺), or Th1-like (IL-17AIFN-γ ⁺) cells. In this pathway, CD4 ⁺CD25 ⁺ T _R cells suppress the development of not only classical Th1 cells, but also alternative Th1 cells at the transition of Th17/Th1 into alternative Th1 cells, resulting in accumulation of Th17 and Th17/Th1 cells in mice in which the development of colitis was suppressed. Furthermore, T _R cells regulated the established balance of Th17 and Th1 cells under colitic conditions to yield a high ratio of Th17 and Th17/Th1 cells to Th1 cells in noncolitic conditions. Conclusions: Th17 and Th17/Th1 cells become colitogenic alternative Th1 cells via Th17, Th17/Th1, and Th1-like cells, independently of classical Th1 cells. T _R cells suppress this pathway, resulting in accumulation of Th17 and Th17/Th1 cells. © 2011 AGA Institute.

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Ectopic expression of blood type antigens in inflamed mucosa with higher incidence of FUT2 secretor status in colonic Crohn's disease

Miyoshi Jun, Yajima Tomoharu, Okamoto Susumu, Matsuoka Katsuyoshi, Inoue Nagamu, Hisamatsu Tadakazu, Shimamura Katsuyoshi, Nakazawa Atsushi, Kanai Takanori, Ogata Haruhiko, Iwao Yasushi, Mukai Makio, Hibi Toshifumi

Journal of Gastroenterology 46 ( 9 ) 1056 - 1063 2011.09

ISSN 0944-1174

Background Host-intestinal microbial interaction plays an important role in the pathogenesis of inflammatory bowel diseases (IBDs). The surface molecules of the intestinal epithelium act as receptors for bacterial adhesion and regulate the intestinal bacteria. Some known receptors are the mucosal blood type antigens, which are regulated by the fucosyltransferase2 (FUT2) gene, and individuals who express these antigens in the gastrointestinal tract are called secretors. Recent research has revealed that the FUT2 gene is associated with Crohn's disease (CD) in western populations. Methods To clarify the contribution of mucosal blood type antigens in IBD, we determined the incidence of five previously reported single-nucleotide polymorphisms of the FUT2 gene in Japanese patients. We also used immunohistochemistry to investigate the antigen expression in mucosal specimens from IBD patients and animal models. Results Genetic analysis revealed that all of the patients with colonic CD were secretors, whereas the incidence of secretors was 80, 80, 67, and 80%, respectively, for the control, ileocolonic CD, ileal CD, and ulcerative colitis groups (P = 0.036). Abnormal expression of blood type antigens was observed only in colonic CD. Interleukin- 10 ^-/- mice, but not dextran sulfate sodium colitis mice, had enhanced colonic expression of blood type antigens, and the expression of these antigens preceded the development of colitis in the interleukin-10 ^-/- mice. Conclusions FUT2 secretor status was associated with colonic-type CD. This finding, taken together with the immunohistochemistry data, suggests that the abnormal expression of blood type antigens in the colon may be a unique and essential factor for colonic CD. © Springer 2011.

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Dramatic changes in the technology of diagnostic imaging and management of Crohn's disease

Takazoe Masakazu, Hatada Yasumasa, Kanai Takanori

Gastroenterological Endoscopy 53 ( 9 ) 3000 - 3013 2011.09

ISSN 0387-1207

The appropriate therapy for Crohn's disease (CD) cannot be achieved until the extent of disease and its anatomical importance are taken into consideration. Therefore, information from imaging tests is essential to establish a diagnosis. A single gold standard for the diagnosis of CD is not available. The diagnosis should be made by clinical evaluation and a combination of endoscopic, histological, radiological, and/or biochemical investigations. In the case of patients with suspected CD in whom stenosis is not confirmed, if ileocolonoscopy and radiological examination/cross-sectional imaging show no lesion or they are difficult to conduct, small bowel capsule endoscopy is applicable. Radiological examination, especially, double-contrast imaging of the small intestine is one of the best tools for the evaluation of mucosal and transmural lesions and this technique is thought to be necessary to understand the past and present disease status. Double balloon enteroscopy should be reserved for specific situations in which biopsy samples from suspected involved areas are important for diagnosis or in which a dilatation of stricture is reasonable.

A case of beef tapeworm (Taenia saginata) infection observed by using video capsule endoscopy and radiography (with videos)

Hosoe Naoki, Imaeda Hiroyuki, Okamoto Susumu, Bessho Rieko, Saito Riko, Ida Yosuke, Kobayashi Seiki, Kanai Takanori, Hibi Toshifumi, Ogata Haruhiko

Gastrointestinal Endoscopy 74 ( 3 ) 690 - 691 2011.09

ISSN 0016-5107

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Intracellular bacteria recognition contributes to maximal interleukin (IL)-12 production by IL-10-deficient macrophages

Naruse H., Hisamatsu T., Yamauchi Y., Chang J. E., Matsuoka K., Kitazume M. T., Arai K., Ando S., Kanai T., Kamada N., Hibi T.

Clinical and Experimental Immunology 164 ( 1 ) 137 - 144 2011.04

ISSN 0009-9104

Interleukin (IL)-12 is a key factor that induces T helper cell type 1-mediated immunity and inflammatory diseases. In some colitis models, such as IL-10 knock-out (KO) mice, IL-12 triggers intestinal inflammation. An abundant amount of IL-12 is produced by intestinal macrophages in response to stimulation by commensal bacteria in IL-10 KO mice. Intact bacteria are more potent inducers of macrophage IL-12 production than cell surface components in this model. This suggested that cell surface receptor signalling and intracellular pathogen recognition mechanisms are important for the induction of IL-12. We addressed the importance of intracellular recognition mechanisms and demonstrated that signal transducers and activator of transcription 1 (STAT1) signalling activated bacterial phagocytosis and was involved in the induction of abnormal IL-12 production. In IL-10 KO mouse bone marrow-derived (BM) macrophages, Escherichia coli stimulation induced increased IL-12p70 production compared to lipopolysaccharide combined with interferon (IFN)-γ treatment. Significant repression of IL-12 production was achieved by inhibition of phagocytosis with cytochalasin D, and inhibition of de novo protein synthesis with cycloheximide. Induction of IFN regulatory factors-1 and -8, downstream molecules of STAT1 and the key transcription factors for IK-12 transcription, following E. coli stimulation, were mediated by phagocytosis. Interestingly, STAT1 was activated after stimulation with E. coli in IL-10 KO BM macrophages, although IFN-γ could not be detected. These data suggest that molecules other than IFN-γ are involved in hyper-production mechanisms of IL-12 induced by E. coli stimulation. In conclusion, enteric bacteria stimulate excessive IL-12p70 production in IL-10 KO BM macrophages via phagocytosis-dependent signalling. © 2011 The Authors. Clinical and Experimental Immunology © 2011 British Society for Immunology.

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Upregulated IL-7 receptor a expression on colitogenic memory CD4 ⁺ T cells may participate in the development and persistence of chronic colitis

Shinohara Tamako, Nemoto Yasuhiro, Kanai Takanori, Kameyama Kaori, Okamoto Ryuichi, Tsuchiya Kiichiro, Nakamura Tetsuya, Totsuka Teruji, Ikuta Koichi, Watanabe Mamoru

Journal of Immunology 186 ( 4 ) 2623 - 2632 2011.02

ISSN 0022-1767

We have previously demonstrated that IL-7 is essential for the persistence of colitis as a survival factor of colitogenic IL-7Rα-expressing memory CD4⁺ T cells. Because IL-7Rα is broadly expressed on various immune cells, it is possible that the persistence of colitogenic CD4⁺ T cells is affected by other IL-7Rα-expressing non-T cells. To test this hypothesis, we conducted two adoptive transfer colitis experiments using IL-7Rα^-/- CD4⁺CD25^- donor cells and IL-7Rα^-/- x RAG-2^-/- recipient mice, respectively. First, IL-7Rα expression on colitic lamina propria (LP) CD4⁺ T cells was significantly higher than on normal LP CD4⁺ T cells, whereas expression on other colitic LP immune cells, (e.g., NK cells, macrophages, myeloid dendritic cells) was conversely lower than that of paired LP cells in normal mice, resulting in predominantly higher expression of IL-7Rα on colitogenic LP CD4⁺ cells, which allows them to exclusively use IL-7. Furthermore, RAG-2^-/- mice transferred with IL-7Rα^-/- CD4⁺CD25^- T cells did not develop colitis, although LP CD4⁺ T cells from mice transferred with IL-7Rα^-/- CD4⁺CD25^- T cells were differentiated to CD4⁺ CD44^highCD62L^- effector-memory T cells. Finally, IL-7Rα^-/- x RAG-2 ^-/- mice transferred with CD4⁺CD25^- T cells developed colitis similar to RAG-2^-/- mice transferred with CD4 ⁺CD25^- T cells. These results suggest that IL-7Rα expression on colitogenic CD4⁺ T cells, but not on other cells, is essential for the development of chronic colitis. Therefore, therapeutic approaches targeting the IL-7/IL-7R signaling pathway in colitogenic CD4 ⁺ T cells may be feasible for the treatment of inflammatory bowel diseases. Copyright©2011 by The American Association of Immunologists, Inc.

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Evaluation of liver fibrosis by transient elastography using acoustic radiation force impulse

Journal of Gastroenterology 1 - 11 2011

ISSN 0944-1174

Background: Accurate evaluation of liver fibrosis in patients with chronic liver damage is required to determine the appropriate treatment. Various approaches, including laboratory tests and transient elastography, have been used to evaluate liver fibrosis. Recently, transient elastography with acoustic radiation force impulse (ARFI) has been developed and applied with conventional ultrasonography. The aim of this study was to evaluate the clinical utility of transient elastography with ARFI and to compare the results with this method and those of the Fibroscan^® procedure. Methods: One hundred and thirty-one patients with liver damage, who underwent liver biopsy at our department, were enrolled prospectively in this study. Elastography with ARFI (applied with ACUSON S2000^®), and Fibroscan^® was performed at the same time as liver biopsy. These measurements were compared with histological findings in liver biopsy specimens, and measurement accuracy was evaluated by receiver-operating characteristic analysis. Results: Elastography values with both procedures were significantly correlated with the stages of liver fibrosis and there was little difference in the results obtained using the 2 procedures. The accuracy of differential diagnosis between no fibrosis at F0 and more than F1 stage was insufficient with ARFI, but this procedure was sufficient for diagnosing advanced fibrosis. The accuracy of ARFI was almost equivalent to that of the Fibroscan^® method. Moreover, both ARFI and Fibroscan^® values increased in proportion to the severity of hepatic inflammation when fibrosis stage is low, but not in proportion to the severity of steatosis. Conclusions: Transient elastography with ARFI is simple, non-invasive and useful for diagnosing the stage of fibrosis in chronic liver disease. The utility of ARFI was almost equivalent to that of the Fibroscan^® method. © 2011 Springer.

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Evaluation of small-intestinal abnormalities in adult patients with HenochSchönlein purpura using video capsule

Ichikawa R., Hosoe N., Imaeda H., Takabayashi K., Bessho R., Ida Y., Naganuma M., Hisamatsu T., Inoue N., Kanai T., Iwao Y., Mukai M., Hibi T., Ogata H.

Endoscopy 43 ( SUPPL. 2 ) 2011

ISSN 0013-726X

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Correlation between endocytoscopy and conventional histopathology in microstructural features of ulcerative colitis

Bessho Rieko, Kanai Takanori, Hosoe Naoki, Kobayashi Taku, Takayama Tetsuro, Inoue Nagamu, Mukai Makio, Ogata Haruhiko, Hibi Toshifumi

Journal of Gastroenterology 1 - 6 2011

ISSN 0944-1174

Background: Routine diagnosis of the histopathological activity of ulcerative colitis (UC) requires multiple biopsy samples, and an endocytoscopy system (ECS) provides real-time ultra-magnifying microscopic imaging in vivo. Methods: We have established an ECS score (ECSS) to determine a histopathological activity index of UC. Fifty-five UC patients (mean age 40.7 years; 67% men) were enrolled. A super-magnifying ECS with magnification 450× was used, and sample biopsies were obtained. Matts' histopathological grade was determined, to evaluate disease severity, by two pathologists, with consensus. The ECSS of UC was independently determined by at least two investigators, with consensus. In total, 76 pairs of ECSS and Matts' histopathological grades were independently acquired. To validate the ECSS, inter-observer agreement between three endoscopists, with consensus, and another endoscopist, was calculated as the kappa value. We also evaluated the correlation between the ECSS and Matts' histopathological grade, and between the conventional Matts' endoscopic grade and Matts' histopathological grade. Results: The ECSS of UC intestinal mucosa, i.e., the sum of the indices for shape (0-3) and distance between crypts (0-2), and the visibility of superficial microvessels (0-1), showed a strong correlation with Matts' histopathological grades (ρ = 0.713, P < 0.001); as well, there was a strong correlation between the conventional Matts' endoscopic grade and Matts' histopathological grade (ρ = 0.694, P < 0.001). Furthermore, the ECSS showed high reproducibility (κ = 0.79, 95% confidence interval [CI] 0.71-0.87). Conclusions: Our novel ECSS has good predictive value for the histopathological activity of UC. © 2011 Springer.

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Imbalance of NKp44⁺NKp46^- and NKp44 ^-NKp46⁺ natural killer cells in the intestinal mucosa of patients with Crohn's disease

Takayama Tetsuro, Kamada Nobuhiko, Chinen Hiroshi, Okamoto Susumu, Kitazume Mina T., Chang Jonathan, Matuzaki Yumi, Suzuki Sadafumi, Sugita Akira, Koganei Kazutaka, Hisamatsu Tadakazu, Kanai Takanori, Hibi Toshifumi

Gastroenterology 139 ( 3 ) 2010.09

ISSN 0016-5085

Background & Aims: Mucosal natural killer (NK) cells that produce interleukin (IL)-22 mediate intestinal homeostasis and inflammation in mice. However, their role in the pathogenesis of human inflammatory bowel diseases (IBDs) is not known. We investigated intestinal NK cells in intestinal mucosa samples of patients with Crohn's disease (CD). Methods: We isolated lamina propria NK cells from intestinal mucosal samples of patients with IBD and subjects without IBD (controls) and analyzed expression patterns of cell surface molecules and cytokine production. Interactions between lamina propria NK cells and intestinal macrophages were examined. Results: In intestinal mucosa samples from controls, NKp44 and NKp46 were expressed differentially on CD3 ^-CD56⁺ NK cells, NKp44⁺NKp46^- (NKp44⁺) NK cells expressed CD127 and the transcription factor retinoic acid-related orphan receptor C (RORC) and produced IL-22 whereas NKp44^-NKp46⁺ (NKp46⁺) NK cells did not express CD127 or RORC and produced interferon (IFN)-γ. NKp46⁺ NK cells were predominant in intestinal mucosa of patients with CD compared with controls or patients with ulcerative colitis. Upon interaction with intestinal inflammatory macrophages NKp46⁺, NK cells from patients with CD were activated via IL-23 and produced IFN-γ; this activation required cell-to-cell contact. Conclusions: The balance of NKp44⁺/NKp46 ⁺ NK cells is disrupted in intestinal mucosa of patients with CD. NKp46⁺ NK cells might mediate the pathogenesis of CD by producing IFN-γ. © 2010 by the AGA Institute.

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Novel endoscopic activity index is useful for choosing treatment in severe active ulcerative colitis patients

Naganuma Makoto, Ichikawa Hitoshi, Inoue Nagamu, Kobayashi Taku, Okamoto Susumu, Hisamatsu Tadakazu, Kanai Takanori, Ogata Haruhiko, Iwao Yasushi, Hibi Toshifumi

Journal of Gastroenterology 45 ( 9 ) 936 - 943 2010.09

ISSN 0944-1174

Aim: Clinical symptoms are the most important factors used by physicians to evaluate the severity and extent of ulcerative colitis (UC). In this context, colonoscopy is also a useful diagnostic tool. We have recently developed an endoscopic activity index (EAI) to assess the severity of UC. Here, we assess the correlations among the EAI, other endoscopic indices, and clinical scores. The usefulness of the EAI for choosing treatment options, such as intravenous corticosteroid or cyclosporine A (CsA), in severe UC patients was also evaluated. Methods: Clinical symptoms and endoscopic finding were evaluated in 396 patients with UC (454 colonoscopies). The EAI was scored using the following six items: ulcer size, ulcer depth, redness, bleeding, edema, and mucus exudates. The patients were also scored using Matts' grade, Rachmilewitz's endoscopic index, and the Lichtiger index. Results: Our results showed that (1) the EAI scores were closely correlated with those of the Lichtiger index, Matts' grade, and Rachmilewitz's endoscopic index; (2) the EAI scores significantly decreased in patients who responded to treatment, while Matts' grade did not change in some responders treated with intravenous CsA and steroid; (3) patients with a higher EAI (14-16) tended to be refractory to corticosteroid therapy (responders 19%) compared to CsA (77%), while steroid treatment was effective in 58% of patients with EAI scores of 11-13. Conclusions: The EAI is equivalent to other endoscopic indices and relatively more useful in choosing a treatment for patients with severe UC. © 2010 Springer.

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MyD88-dependent pathway accelerates the liver damage of Concanavalin A-induced hepatitis

Ojiro Keisuke, Ebinuma Hirotoshi, Nakamoto Nobuhiro, Wakabayashi Kanji, Mikami Yohei, Ono Yuichi, Po-Sung Chu, Usui Shingo, Umeda Rumiko, Takaishi Hiromasa, Yamagishi Yoshiyuki, Saito Hidetsugu, Kanai Takanori, Hibi Toshifumi

Biochemical and Biophysical Research Communications 399 ( 4 ) 744 - 749 2010.09

ISSN 0006-291X

We have explored the pathological role of the MyD88 signaling pathway via Toll-like receptors (TLRs) that mediate the recognition of pathogen-associated molecular patterns (PAMPs) in a murine model of autoimmune hepatitis induced by administering Concanavalin A (ConA). We first found that various TLRs and MyD88 molecules were expressed in liver of Con A-treated and untreated wild-type (WT) mice including liver macrophages. Flowcytometric analysis revealed that liver CD11b⁺CD11c^- and CD11b⁺CD11c⁺ antigen-presenting cells express TLR2, although NK and NKT cells did not. When WT and MyD88^-/- mice were intravenously administered with Con A, the severity of hepatitis was significantly lower in Con A-injected MyD88^-/- mice than in WT mice in terms of the histopathology, the levels of serum transaminase and pro-inflammatory cytokines (TNF-α, IFN-γ, and IL-6), and upregulation of CD80/CD86 and TNF-α on/in liver macrophages. The results provide evidence of a possible contribution of the TLRs-MyD88 signaling pathway in activating TLR-expressing liver macrophages in the autoimmune hepatitis model, and thus indicate that the strategy of blockade of pathological pathogens via the intestinal lumen may be feasible for the treatment of the disease. © 2010 Elsevier Inc.

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In vivo visualization of trophozoites in patients with amoebic colitis by using a newly developed endocytoscope

Hosoe Naoki, Kobayashi Taku, Kanai Takanori, Bessho Rieko, Takayama Tetsuro, Inoue Nagamu, Imaeda Hiroyuki, Iwao Yasushi, Kobayashi Seiki, Mukai Makio, Ogata Haruhiko, Hibi Toshifumi

Gastrointestinal Endoscopy 72 ( 3 ) 643 - 646 2010.09

ISSN 0016-5107

Background: The endocytoscopy system (ECS) is a new method to provide real-time super-magnifying microscopic imaging in vivo. Routine diagnosis of amebic colitis requires multiple tests that are both time consuming and costly. Objective: To determine the feasibility of ECS to directly detect the amebic parasites in vivo. Design: Prospective, single-center, pilot study. Setting: Tertiary-care university hospital. Patients: This study involved 5 patients who were suspected to have amebic colitis by conventional colonoscopy in our institute. Interventions: A super-magnifying ECS with 450 × magnification. Main Outcome Measurements: We compared ECS findings with those of conventional methodsserum antibody tests and histology of colon biopsy specimens. Results: We successfully visualized the amebic trophozoites in all 5 cases. In contrast, 3 specimens had positive results on serology, and 3 had positive histology results on hematoxylin and eosin staining. Limitations: Pilot study with a limited number of patients. Findings were compared only with serology and histology findings. Conclusions: ECS would be a useful tool for the prompt diagnosis of amebic colitis via the real-time in vivo visualization of amebic trophozoites. © 2010 American Society for Gastrointestinal Endoscopy.

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TL1A produced by lamina propria macrophages induces Th1 and Th17 immune responses in cooperation with IL-23 in patients with Crohn's disease

Kamada Nobuhiko, Hisamatsu Tadakazu, Honda Haruki, Kobayashi Taku, Chinen Hiroshi, Takayama Tetsuro, Kitazume Mina T., Okamoto Susumu, Koganei Kazutaka, Sugita Akira, Kanai Takanori, Hibi Toshifumi

Inflammatory Bowel Diseases 16 ( 4 ) 568 - 575 2010.04

ISSN 1078-0998

Background: Tumor necrosis factor (TNF)-like protein 1A (TL1A) is a member of the TNF superfamily and contributes to the pathogenesis of Crohn's disease (CD) by stimulating T-helper (Th) 1 cells. In addition to Th1, recent studies have focused on the role of Th17 cells in the pathogenesis of CD. Here we tried to clarify the role of TL1A in Th1 and Th17 immunity in CD. Methods: TL1A expression was assessed by quantitative reverse-transcription polymerase chain reaction (RT-PCR) in lamina propria (LP) macrophages (LP-Mφs) from normal controls (NC) and patients with CD or ulcerative colitis (UC). Purified LP CD4⁺ T cells were stimulated with TL1A and/or IL-23 and interferon gamma (IFN-γ) and interleukin (IL)-17 levels were analyzed. We also examined the effect of TL1A on naïve CD4⁺ Tcell differentiation. Results: We found that LP-Mφs are a major producer of TL1A. TL1A expression was markedly enhanced in LP-Mφs from CD patients compared with NC or UC patients. IL-23, in addition to TL1A, was induced in LP-Mφs by commensal bacteria stimulation. TL1A and IL-23 synergistically promoted the production of IFN-γ and IL-17 by LP T cells, while TL1A alone did not induce cytokine production. Furthermore, TL1A promoted Th17 differentiation from naïve T cells by LP-Mφs; however, IL-23 did not show any synergistic effects on Th17 differentiation. Conclusions: TL1A expressed in LP-Mφs might play an important role in the pathogenesis of CD by inducing Th1 and Th17 immunity. IL-23 differentially regulated these functions of TL1A on memory and naïve T cells. Copyright © 2009 Crohn's & Colitis Foundation of America, Inc.

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Monocyte chemoattractant protein-1 contributes to gut homeostasis and intestinal inflammation by composition of IL-10-producing regulatory macrophage subset

Takada Yasuhiro, Hisamatsu Tadakazu, Kamada Nobuhiko, Kitazume Mina T., Honda Haruki, Oshima Yosuke, Saito Riko, Takayama Tetsuro, Kobayashi Taku, Chinen Hiroshi, Mikami Yohei, Kanai Takanori, Okamoto Susumu, Hibi Toshifumi

Journal of Immunology 184 ( 5 ) 2671 - 2676 2010.03

ISSN 0022-1767

Lamina propria macrophages (LPMφs) spontaneously produce large amounts of anti-inflammatory IL-10 and play a central role in regulation of immune responses against commensal bacteria. MCP-1 is a chemokine that plays an important role in recruitment of monocytes and macrophages to inflamed tissues. We demonstrated that, in addition to IL-10, LPMφs produced large amounts of MCP-1, even in a steady state. MCP-1 deficiency caused impaired IL-10 production by LPMφs and led to exacerbation of dextran sulfate sodium-induced acute colitis. As an explanation of this impaired IL-10 production by LPMφs, we found that LPMφs could be separated into two subsets with distinct side-scattered properties, namely LPMφ1 (CD11b⁺F4/80 ⁺CD11c^-SSC^hi) and LPMf2 (CD11b ⁺F4/80⁺CD11c^-SSC^lo). Unlike LPMφ1, the LPMφ2 subset migrated in response to MCP-1 and produced a larger amount of IL-10 in response to commensal bacteria. LPMφs isolated from MCP-1-deficient mice produced less IL-10 as a consequence of the lack of the MCP-1-dependent LPMφ2 population. This imbalanced composition in LPMφ population may be involved in the susceptibility to DSS-induced colitis in MCP-1-deficient mice. Our results suggest that endogenous MCP-1 contributes to the composition of resident LPMφ subsets in the intestine. Moreover, MCP-1-dependent LPMφ2 subset may play an important role in maintenance of gut homeostasis in the steady state, and in the termination of excess inflammatory responses in the intestine, by producing IL-10. Copyright © 2010 by The American Association of Immunologists, Inc.

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Competition between colitogenic Th1 and Th17 cells contributes to the amelioration of colitis

Mikami Yohei, Kanai Takanori, Sujino Tomohisa, Ono Yuichi, Hayashi Atsushi, Okazawa Akira, Kamada Nobuhiko, Matsuoka Katsuyoshi, Hisamatsu Tadakazu, Okamoto Susumu, Takaishi Hiromasa, Inoue Nagamu, Ogata Haruhiko, Hibi Toshifumi

European Journal of Immunology 40 ( 9 ) 2409 - 2422 2010

ISSN 0014-2980

Th17 cells and Th1 cells coordinate to play a critical role in the formation of inflammatory bowel diseases. To examine how Th17 and Th1 cells are regulated at inflammatory sites, we used Th1-dominant CD4⁺CD45RB ^high T cell-transferred RAG-2^-/- and Th1/Th17-mixed IL-10^-/- mice. Interestingly, not only did colitic RAG-2 ^-/- mice that were parabiosed with WT mice show significant amelioration of colitis, but amelioration of disease was also observed in those parabiosed with colitic IL-10^-/- mice. To assess the interference between Th1 and Th17 colitogenic T cells, we co-transferred colitogenic CD4 ⁺ T cells from the lamina propria (LP) of CD4⁺CD45RB ^high T cell-transferred RAG-2^-/- mice and IL-10 ^-/- mice into RAG-2^-/- mice. Surprisingly, the co-transferred RAG-2^-/- mice showed a vast cellular infiltration of LP CD4⁺ T cells similar to that seen in RAG-2^-/- mice re-transferred with the cells from colitic RAG-2^-/- mice alone, but the co-transferred RAG-2^-/- mice did not have the wasting symptoms, which are also absent in RAG-2^-/- mice transferred with cells from colitic IL-10^-/- mice alone. Furthermore, the percentages of Th1 and Th17 cells originating from IL-10^-/- mice and those of Th1 cells originating from colitic RAG-2^-/- mice were all significantly decreased in the co-transferred mice as compared with the singly-transferred paired RAG-2^-/- mice, suggesting that Th1 and Th17 cells are in competition, and that their orchestration results in a merged clinical phenotype of the two types of murine colitis. © 2010 Wiley-VCH Verlag GmbH & Co. KGaA.

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IL-2 is positively involved in the development of colitogenic CD4 ⁺ IL-7Rα^high memory T cells in chronic colitis

Kameyama Kaori, Nemoto Yasuhiro, Kanai Takanori, Shinohara Tamako, Okamoto Ryuichi, Tsuchiya Kiichiro, Nakamura Tetsuya, Sakamoto Naoya, Totsuka Teruji, Hibi Toshifumi, Watanabe Mamoru

European Journal of Immunology 40 ( 9 ) 2423 - 2436 2010

ISSN 0014-2980

IL-2 and IL-7 share a common γ-chain receptor and are critical for T-cell homeostasis. We aimed to clarify the reciprocal roles of IL-2 and IL-7 in the development and persistence of chronic colitis. We performed a series of adoptive transfers of IL-2^-/- CD4⁺CD45RB^high T cells into RAG-2^-/- mice and assessed the role of IL-2 in the induction of IL-7Rα on colitogenic CD4⁺ T cells and the development of chronic colitis. RAG-2^-/- mice transferred with WT but not with IL-2^-/- CD4⁺CD45RB^high T cells developed Th1/Th17-mediated colitis. Consistently, re-expression of IL-7Rα was severely impaired on IL-2^-/- but not on WT CD4⁺ T cells from the transferred mice. To exclude a contribution of the preclinical autoimmunity of IL-2^-/-mice, WT Ly5.1⁺ or IL-2 ^-/- Ly5.2⁺ CD4⁺CD45RB^high T cells from GFP mice previously transplanted with the same number of WT and IL-2 ^-/- BM cells were transferred into RAG-2^-/- mice. RAG-2^-/- mice transferred with IL-2^-/--derived CD4 ⁺ CD45RB^high T cells did not develop colitis, but their splenic CD4⁺ T cells changed from effector-memory to central-memory type. These results show that IL-2 is critically involved in the establishment and maintenance of IL-7-dependent colitogenic memory CD4⁺IL- 7Rα^high T cells. © 2010 Wiley-VCH Verlag GmbH & Co. KGaA.

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A case of IgA-related enteropathy complicated with gastrointestinal bleeding and progressive IgA nephropathy

Nakamura Shoko, Hisamatsu Tadakazu, Kikuchi Jun, Adachi Masayuki, Yamagishi Yoshiyuki, Imaeda Hiroyuki, Hosoe Naoki, Naganuma Makoto, Ebinuma Hirotoshi, Okamoto Susumu, Kanai Takanori, Ogata Haruhiko, Hanaoka Hironari, Furuya Yoshiaki, Kawano Yoshinaga, Bokuda Kanako, Sasamura Hiroyuki, Uchida Hiroshi, Endo Takashi, Hashiguchi Akinori, Kameyama Kaori, Mukai Makio, Hibi Toshifumi

Internal Medicine 49 ( 16 ) 1755 - 1761 2010

ISSN 0918-2918

Here, we report an adult patient with IgA-related enteropathy complicated with massive intestinal bleeding and acute renal failure, but without skin lesions. Surgical resection of the small intestine and steroid pulse therapy was performed. Histopathology revealed significant deposition of IgA and C3 in the small vessels of the intestine and the kidney mesangium. Although skin purpura was absent, the histopathology and clinical manifestations suggested that the pathophysiology was similar to Henoch-Schönlein purpura (HSP), implying IgA-related enteropathy as a subclass of HSP. Retrospective analysis indicates that terminal ileum lesions may be a poor prognostic indicator. © 2010 The Japanese Society of Internal Medicine.

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Systemically circulating colitogenic memory CD4⁺ T cells may be an ideal target for the treatment of inflammatory bowel diseases

Kanai Takanori, Watanabe Mamoru, Hibi Toshifumi

Keio Journal of Medicine 58 ( 4 ) 203 - 209 2009.12

ISSN 0022-9717

Inflammatory bowel diseases (IBD) are thought to be caused by a complex interaction of genetic, immunological, and environmental factors. Why is it that once an IBD develops it lasts a long time? Considering this simple question, we propose that coliotogenic memory CD4⁺T cells that remember the prototype of the disease in each patient are formed in IBD at the onset, and, perceiving them as "benign T-cell leukemia"-like lifelong memory CD4⁺T cells that hematogenously spread throughout the body, we thus propose that systemic circulating colitogenic memory CD4⁺T cells would be an ideal target for the treatment of IBD. Accordingly, selective depletion of colitogenic memory CD4⁺T cells by leukocytapheresis and blockade of circulation of colitogenic memory CD4⁺T cells by a newly developed immunosuppressant, FTY720, may be associated with dramatic efficacy and a marked reduction of inflammatory cytokines produced by activated leucocytes. We here describe the immunological pathogenesis focusing on the generation of circulating colitogenic memory CD4⁺T cells and the possible logics of leukocytapheresis and FTY720 for the treatment of IBD.

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Long-lived colitogenic CD4⁺ memory T cells residing outside the intestine participate in the perpetuation of chronic colitis

Nemoto Yasuhiro, Kanai Takanori, Kameyama Kaori, Shinohara Tamako, Sakamoto Naoya, Totsuka Teruji, Okamoto Ryuichi, Tsuchiya Kiichiro, Nakamura Tetsuya, Sudo Tetsuo, Matsumoto Satoshi, Watanabe Mamoru

Journal of Immunology 183 ( 8 ) 5059 - 5068 2009.10

ISSN 0022-1767

To understand the perpetuation of inflammatory bowel disease (IBD), it is important to clarify whether the colitogenic CD4⁺ T cells are self-limited effector or long-lived memory T cells. We here investigate the latency of colitogenic CD4⁺ T cells in the remission stage of colitis under germfree (GF) conditions. We isolated splenic (SP) CD4⁺ T cells from colitic CD4⁺CD45RB^high T cell-injected SCID mice maintained under specific pathogen-free (SPF) conditions and transferred them into SPF or GF SCID mice. Donor colitic SP CD4⁺ T cells have a characteristic CD44^highCD62L^-IL-7Rα^high effector-memory T-type phenotype. Six weeks after transfer of cells to GF SCID mice, one group of mice was continued in GF conditions (GF→GF), and the other was transferred into SPF conditions (GF→SPF). GF→SPF but not GF→GF SCID mice developed colitis with elevated production of Th1 and Th17 cytokines at 4 wk after transfer. Surprisingly, a large number of CD4 ⁺ effector-memory T cells and a small but substantial number of central-memory T cells remained resident in SP and bone marrow, but not in lamina propria, of the GF→GF SCID recipients. Consistent with this, GF3SPF but not GF→GF SCID mice rapidly developed colitis. Taken together, these findings suggest that long-lived colitogenic memory CD4⁺ cells can be established even in the presence of commensal Ags, reside outside the intestine in the absence of commensal bacteria, and participate in the perpetuation of colitis. Thus, blocking a stimulus of colitogenic memory CD4⁺ cells such as IL-7 may have therapeutic benefit for treatment of inflammatory bowel disease. Copyright © 2009 by The American Association of Immunologists, Inc.

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IL-7 is essential for lymphopenia-driven turnover of colitogenic CD4+ memory T cells in chronic colitis

Tomita Takayuki, Kanai Takanori, Totsuka Teruji, Nemoto Yasuhiro, Okamoto Ryuichi, Tsuchiya Kiichiro, Sakamoto Naoya, Ohteki Toshiaki, Hibi Toshifumi, Watanabe Mamoru

European Journal of Immunology 39 ( 10 ) 2737 - 2747 2009.10

ISSN 0014-2980

We previously demonstrated that IL-7 is essential for the persistence of T-cell-mediated colitis, by showing that adoptive transfer of CD4 ⁺CD45RB^high T cells into IL-7^-/- x RAG-1 ^+/+ mice did not induce colitis; and that intestinal IL-7 is not essential for this colitis model, by showing that IL-7^-/- x RAG-1^-/- mice parabiosed with colitic CD4⁺CD45RB ^high T-cell-transferred RAG-1^-/- mice developed colitis. Here, we investigated the role of IL-7 in the maintenance of colitogenic CD4⁺ T cells by surgically separating these parabionts. Surprisingly, the separated IL-7^-/- x RAG-1^-/- mice were consistently diseased after separation, although no IL-7 mRNA was detected in the tissues of separated IL-7^-/- x RAG-1^-/- partners. CD4⁺ T cells isolated from the separated RAG-1^-/- or IL-7^-/- x RAG-1^-/- mice were then transferred into new RAG-1^-/- or IL-7^-/- x RAG-1^-/- mice. Regardless of the source of donor cells, RAG-1^-/- recipients developed colitis, whereas IL-7 ^-/- x RAG-1^-/- recipients did not. Collectively, these results demonstrate that IL-7 is essential for lymphopenia-driven turnover of colitogenic CD4⁺ T cells rather than the maintenance of those cells in established colitic mice. They also provide a basis for the timing of IL-7/IL-7R blockade for the treatment of inflammatory bowel diseases. © 2009 Wiley-VCH Verlag GmbH & Co. KGaA.

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Human CD14⁺ macrophages in intestinal lamina propria exhibit potent antigen-presenting ability

Kamada Nobuhiko, Hisamatsu Tadakazu, Honda Haruki, Kobayashi Taku, Chinen Hiroshi, Kitazume Mina Tokutake, Takayama Tetsuro, Okamoto Susumu, Koganei Kazutaka, Sugita Akira, Kanai Takanori, Hibi Toshifumi

Journal of Immunology 183 ( 3 ) 1724 - 1731 2009.08

ISSN 0022-1767

Intestinal APCs are considered critical in maintaining the balance between the response against harmful pathogens and the induction of tolerance to commensal bacteria and food Ags. Recently, several studies indicated the presence of gut-specific APC subsets, which possess both macrophage and dendritic cell (DC) markers. These unique APC subsets play important roles in gut immunity, especially for immune regulation against commensal bacteria. Herein, we examined a unique macrophage subset, which coexpressed the macrophage (Mφ) marker CD14 and the DC marker CD209 in human intestinal lamina propria (LP). The LP Mφ subset in both normal control subjects or Crohn's disease (CD) patients induced proliferation of naive CD4⁺ T cells as well as monocyte-derived DCs, and it expressed retinoic acid synthetic enzyme retinaldehyde dehydrogenase 2 and retinol dehydrogenase 10, which induced expression of gut homing receptors on T cells in a retinoic acid-dependent manner. Moreover, the LP Mφ subset strongly evoked differentiation of Th1 cells and slightly induced Th17 cells in both normal control subjects and CD patients; the inducing potential was highest in CD patients. In CD patients, Th17, but not Th1, induction by the LP Mφ subset was enhanced in the presence of commensal bacteria Ags. This enhancement was not observed in normal control subjects. The Th17 induction by the LP Mφ subset was inhibited by neutralization of IL-6 and IL-1β, but it was enhanced by blockade of retinoic acid signaling. These observations highlight a role for LPMφ in the enhanced Th1, and potentially in Th17 differentiation, at the inflammatory site of inflammatory bowel diseases. Copyright © 2009 by The American Association of Immunologists, Inc.

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Homeostatic (IL-7) and effector (IL-17) cytokines as distinct but complementary target for an optimal therapeutic strategy in inflammatory bowel disease

Kanai Takanori, Nemoto Yasuhiro, Kamada Nobuhiko, Totsuka Teruji, Hisamatsu Tadakazu, Watanabe Mamoru, Hibi Toshifumi

Current Opinion in Gastroenterology 25 ( 4 ) 306 - 313 2009.07

ISSN 0267-1379

Lippincott Williams & Wilkins.Purpose of review: This review focuses on CD4⁺ T cells involved in the mediation of inflammatory tissue damage in murine models of inflammatory bowel diseases (IBDs). In particular, we describe the distinct roles of the homeostatic cytokine IL-7, which is essential to the maintenance of colitogenic memory CD4⁺ cells, and the newly discovered effector cytokine IL-17. We also discuss the close correlation between colitogenic Th17-type CD4 ⁺ T cells and inducible CD4⁺CD25⁺Foxp3 ⁺ regulatory T cells. Recent findings: IBDs are characterized by wasting and chronic intestinal inflammation induced by many different cytokine-mediated pathways. It is clearly recognized that medical and surgical interventions do not cure Crohn's disease because relapse is the rule after remission. Until a few years ago, IBD was classified into Th1-dependent, that is, Crohn's disease, and Th2-dependent, that is, ulcerative colitis, phenotypes. However, in recent years, it has been shown that new T-cell subclasses, that is, Th17 and regulatory T cells (T_R), exist independently of Th1 and Th2 and that they play a central role in modulating IBD. Summary: The persistence of IL-7-dependent colitogenic memory CD4⁺ T cells is critical to the maintenance of experimental colitis. On the other hand, though Th1 and Th2 colitogenic memory CD4⁺ cells exist, in recent years the central role of IL-17-producing Th17-type cells in IBD has attracted renewed interest. The development of molecularly targeted therapies aimed at a variety of different Th-dependent pathogenic mechanisms may represent a novel approach to IBD therapy. © 2009 Wolters Kluwer Health

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Rank-rankl signaling pathway is critically involved in the function of CD4⁺CD25⁺ regulatory T cells in chronic colitis

Totsuka Teruji, Kanai Takanori, Nemoto Yasuhiro, Tomita Takayuki, Okamoto Ryuichi, Tsuchiya Kiichiro, Nakamura Tetsuya, Sakamoto Naoya, Akiba Hisaya, Okumura Ko, Yagita Hideo, Watanabe Mamoru

Journal of Immunology 182 ( 10 ) 6079 - 6087 2009.05

ISSN 0022-1767

It is now clear that functional CD4⁺CD25⁺ regulatory T (T_R) cells exist as part of the normal immune population and prevent the development of intestinal inflammation. We have recently shown that CD4⁺CD25⁺ T_R cells reside in the intestine and control intestinal homeostasis in humans and mice. In this study, we demonstrate that the TNF family molecule RANKL and its receptor RANK are critically involved in controlling the function of CD4⁺CD25⁺ T _R cells in the intestine. We first found that RANKL was preferentially expressed on both CD4⁺CD25⁺ T_R cells and colitogenic CD4⁺ T cells, whereas RANK was expressed on dendritic cells. Although neutralizing anti-RANKL mAb did not affect T _R activity of CD4⁺CD25⁺ T_R cells to suppress the proliferation of CD4⁺ responder cells in vitro, in vivo administration of anti-RANKL mAb abrogated CD4⁺CD25⁺ T_R cell-mediated suppression of colitis induced by adoptive transfer of CD4⁺CD45RB^high T cells into SCID mice. Interestingly, an adoptive transfer experiment using Ly5.1⁺CD4 ⁺CD45RB^high cells and Ly5.2⁺CD4 ⁺CD25⁺ T_R cells revealed that the ratio of CD4⁺CD25⁺ T_R cells in total CD4⁺ T cells in inflamed mucosa was significantly decreased by anti-RANKL mAb treatment. Consistent with this, the expression of RANK on lamina propria CD11c⁺ cells from colitic mice was significantly increased as compared with that from normal mice, and in vitro treatment with anti-RANKL mAb suppressed the expansion of CD4⁺Foxp3⁺ T_R cells in culture with colitic lamina propria CD11c⁺ cells. Together, these results suggest that the RANK-RANKL signaling pathway is critically involved in regulating the function of CD4⁺CD25⁺ T_R cells in colitis. Copyright © 2009 by The American Association of Immunologists, Inc.

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Signaling pathway via TNF-α/NF-κB in intestinal epithelial cells may be directly involved in colitis-associated carcinogenesis

Onizawa Michio, Nagaishi Takashi, Kanai Takanori, Nagano Ken Ichi, Oshima Shigeru, Nemoto Yasuhiro, Yoshioka Atsushi, Totsuka Teruji, Okamoto Ryuichi, Nakamura Tetsuya, Sakamoto Naoya, Tsuchiya Kiichiro, Aoki Kazuhiro, Ohya Keiichi, Yagita Hideo, Watanabe Mamoru

American Journal of Physiology - Gastrointestinal and Liver Physiology 296 ( 4 ) 2009.04

ISSN 0193-1857

Treatment with anti-TNF-α MAb has been accepted as a successful maintenance therapy for patients with inflammatory bowel diseases (IBD). Moreover, it has been recently reported that blockade of TNF receptor (TNFR) 1 signaling in infiltrating hematopoietic cells may prevent the development of colitis-associated cancer (CAC). However, it remains unclear whether the TNF-α signaling in epithelial cells is involved in the development of CAC. To investigate this, we studied the effects of anti-TNF-α MAb in an animal model of CAC by administration of azoxymethane (AOM) followed by sequential dextran sodium sulfate (DSS) ingestion. We observed that the NF-κB pathway is activated in colonic epithelia from DSS-administered mice in association with upregulation of TNFR2 rather than TNFR1. Immunoblot analysis also revealed that the TNFR2 upregulation accompanied by the NF-κB activation is further complicated in CAC tissues induced in AOM/DSS-administered mice compared with the nontumor area. Such NF-κB activity in the epithelial cells is significantly suppressed by the treatment of MP6-XT22, an anti-TNF-α MAb. Despite inability to reduce the severity of colitis, sequential administration of MP6-XT22 reduced the numbers and size of tumors in association with the NF-κB inactivation. Taken together, present studies suggest that the TNFR2 signaling in intestinal epithelial cells may be directly involved in the development of CAC with persistent colitis and imply that the maintenance therapy with anti-TNF-α MAb may prevent the development of CAC in patients with long-standing IBD. Copyright © 2009 the American Physiological Society.

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Pathology and pathophysiology of inflammatory bowel diseases. Development of inflammatory bowel disease due to disruption of the intestinal immuno-regulatory mechanism

Kanai Takanori, Hisamatsu Tadanori, Watanabe Mamoru, Hibi Toshifumi

Nihon Naika Gakkai zasshi. The Journal of the Japanese Society of Internal Medicine 98 ( 1 ) 12 - 17 2009.01

ISSN 0021-5384

Requirement of notch activation during regeneration of the intestinal epithelia

Okamoto Ryuichi, Tsuchiya Kiichiro, Nemoto Yasuhiro, Akiyama Junko, Nakamura Tetsuya, Kanai Takanori, Watanabe Mamoru

American Journal of Physiology - Gastrointestinal and Liver Physiology 296 ( 1 ) 2009.01

ISSN 0193-1857

Notch signaling regulates cell differentiation and proliferation, contributing to the maintenance of diverse tissues including the intestinal epithelia. However, its role in tissue regeneration is less understood. Here, we show that Notch signaling is activated in a greater number of intestinal epithelial cells in the inflamed mucosa of colitis. Inhibition of Notch activation in vivo using a γ-secretase inhibitor resulted in a severe exacerbation of the colitis attributable to the loss of the regenerative response within the epithelial layer. Activation of Notch supported epithelial regeneration by suppressing goblet cell differentiation, but it also promoted cell proliferation, as shown in in vivo and in vitro studies. By utilizing tetracycline-dependent gene expression and microarray analysis, we identified a novel group of genes that are regulated downstream of Notch1 within intestinal epithelial cells, including PLA2G2A, an antimicrobial peptide secreted by Paneth cells. Finally, we show that these functions of activated Notch1 are present in the mucosa of ulcerative colitis, mediating cell proliferation, goblet cell depletion, and ectopic expression of PLA2G2A, thereby contributing to the regeneration of the damaged epithelia. This study showed the critical involvement of Notch signaling during intestinal tissue regeneration, regulating differentiation, proliferation, and antimicrobial response of the epithelial cells. Thus Notch signaling is a key intracellular molecular pathway for the proper reconstruction of the intestinal epithelia. Copyright © 2009 the American Physiological Society.

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Musashi-1 suppresses expression of Paneth cell-specific genes in human intestinal epithelial cells

Murayama Minekazu, Okamoto Ryuichi, Tsuchiya Kiichiro, Akiyama Junko, Nakamura Tetsuya, Sakamoto Naoya, Kanai Takanori, Watanabe Mamoru

Journal of Gastroenterology 44 ( 3 ) 173 - 182 2009

ISSN 0944-1174

Background: Musashi-1 (Msi-1) is a RNA-binding protein, known as a putative marker of intestinal stem cells (ISCs). However, little is known about the function of Msi-1 within human intestinal epithelial cells (IECs). Thus, the present study aimed to clarify the role of Msi-1 in differentiation and proliferation of IECs. Methods: A human intestinal epithelial cell line stably expressing Msi-1 was established. Proliferation of the established cell lines was measured by bromodeoxyuridine incorporation, whereas differentiation were assessed by reverse transcriptase-polymerase chain reaction (RT-PCR) analysis of lineage-specific genes. Activities of the Notch and Wnt pathways were examined either by reporter assays or expression of downstream target genes. The distribution of Msi-1 and PLA2G2A expression in vivo was determined by immunohistochemistry. Results: Constitutive expression of Msi-1 in IECs had no significant effect on cell proliferation, but suppressed expression of Paneth cell-specific genes, including PLA2G2A. Msi-1 appeared to suppress expression of the PLA2G2A gene at the mRNA level. Analysis of Notch and Wnt pathway activity, however, revealed no significant change upon Msi-1 expression. The expression of Msi-1 and PLA2G2A in vivo was restricted to IECs residing at the lowest part of the human intestinal crypt, but was clearly separated to within basal columnar cells or mature Paneth cells, respectively. Conclusions: Msi-1 suppresses expression of Panethcell-specific genes in IECs, presumably through a pathway independent from Notch or Wnt. These findings suggest Msi-1 is a negative regulator of Paneth cell differentiation, an may contribute to maintain the undifferentiated phenotype of ISCs. © Springer 2009.

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Two flavonoids extracts from Glycyrrhizae radix inhibit in vitro hepatitis C virus replication

Sekine-Osajima Yuko, Sakamoto Naoya, Nakagawa Mina, Itsui Yasuhiro, Tasaka Megumi, Nishimura-Sakurai Yuki, Chen Cheng Hsin, Suda Goki, Mishima Kako, Onuki Yuko, Yamamoto Machi, Maekawa Shinya, Enomoto Nobuyuki, Kanai Takanori, Tsuchiya Kiichiro, Watanabe Mamoru

Hepatology Research 39 ( 1 ) 60 - 69 2009

ISSN 1386-6346

Aim: Traditional herbal medicines have been used for several thousand years in China and other Asian countries. In this study we screened herbal drugs and their purified compounds, using the Feo replicon system, to determine their effects on in vitro HCV replication. Methods: We screened herbal drugs and their purified extracts for the activities to suppress hepatitis C virus (HCV) replication using an HCV replicon system that expressed chimeric firefly luciferase reporter and neomycin phosphotransferase (Feo) genes. We tested extracts and 13 purified compounds from the following herbs: Glycyrrhizae radix; Rehmanniae radix; Paeoniae radix; Artemisiae capillari spica; and Rhei rhizoma. Results: The HCV replication was significantly and dose-dependently suppressed by two purified compounds, isoliquiritigenin and glycycoumarin, which were from Glycyrrhizae radix. Dose-effect analyses showed that 50% effective concentrations were 6.2 ± 1.0 μg/mL and 15.5 ± 0.8 μg/mL for isoliquiritigenin and glycycoumarin, respectively. The MTS assay did not show any effect on cell growth and viability at these effective concentrations, indicating that the effects of the two compounds were specific to HCV replication. These two compounds did not affect the HCV IRES-dependent translation nor did they show synergistic action with interferon-alpha. Conclusion: Two purified herbal extracts, isoliquiritigenin and glycycoumarin, specifically suppressed in vitro HCV replication. Further elucidation of their mechanisms of action and evaluation of in vivo effects and safety might constitute a new anti-HCV therapeutics. © 2009 The Japan Society of Hepatology.

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Persistent retention of colitogenic CD4⁺ memory T cells causes inflammatory bowel diseases to become intractable

Kanai Takanori, Nemoto Yasuhiro, Tomita Takayuki, Totsuka Teruji, Watanabe Mamoru, Hibi Toshifumi

Inflammatory Bowel Diseases 15 ( 6 ) 926 - 934 2009

ISSN 1078-0998

Despite the advent of an age when "malignant" leukemia is cured by bone marrow transplantation, "benign" inflammatory bowel diseases (IBDs) are still intractable life-long diseases. Why is it that once an IBD develops it lasts a long time? We propose that, the same as in the response to vaccination, immune memory T cells that remember the disease are formed in IBDs and, perceiving them as "benign T-cell leukemia"-like lifelong pathology that hematogenously spreads throughout the body, we here propose that the bone marrow itself, which produces large amounts of the survival factor IL-7, is the reservoir for colitogenic CD4⁺ memory T cells responsible for the intractability of IBDs. Copyright © 2008 Crohn's & Colitis Foundation of America, Inc.

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Single-operator double-balloon endoscopy (DBE) is as effective as dual-operator DBE

Araki Akihiro, Tsuchiya Kiichiro, Okada Eriko, Suzuki Shinji, Oshima Shigeru, Yoshioka Sanae, Yoshioka Atsushi, Kanai Takanori, Watanabe Mamoru

Journal of Gastroenterology and Hepatology (Australia) 24 ( 5 ) 770 - 775 2009

ISSN 0815-9319

Background and Study Aims: Double-balloon endoscopy (DBE) is a new device that allows diagnosis and treatment throughout the entire small intestine. Although the originally described method requires two operators, we have recently developed a method to perform DBE by a single operator. We here assessed the clinical usefulness of this one-person method in comparison to the conventional two-person DBE. Patients and Methods: One hundred sixty-two patients (102 men and 60 women, mean age 59 years) underwent 303 DBE procedures. Total observation time, completion rate of total intestinal and colonic observation, lesion-discovery rate, and complication rate were retrospectively compared between the one-person method and the conventional two-person method of DBE. The one-person method consists of the Grip and Pinch technique and Keep (or Hold) and Slide technique. Results: The total observation times were 95.5 ± 35.1 min and 96.7 ± 47.5 min by one-person and two-person antegrade DBE, respectively, and 103 ± 29.8 min and 111 ± 30.1 min by one-person and two-person retrograde DBE, respectively. The completion rate for examination of the entire small intestine was 74.2% in one-person DBE and 76.5% in two-person DBE, respectively. The lesion-discovery rate was 69.0% in one-person DBE and 65.5% in two-person DBE, respectively. No significant differences between two methods were found in all measures. Also, no difference was observed in complication rate of the two methods. Conclusions: The single-operator method for DBE was as efficient as the dual-operator DBE without any higher risk of complications and, therefore, could replace the conventional dual-operator method in the future. © 2009 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd.

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Single-operator method for double-balloon endoscopy

Araki A., Tsuchiya K., Okada E., Suzuki S., Oshima S., Okamoto R., Kanai T., Watanabe Mamoru

Endoscopy 40 ( 11 ) 936 - 938 2008.11

ISSN 0013-726X

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Flagellin stimulation suppresses IL-7 secretion of intestinal epithelial cells

Yoshioka Atsushi, Okamoto Ryuichi, Oshima Shigeru, Akiyama Junko, Tsuchiya Kiichiro, Nakamura Tetsuya, Kanai Takanori, Watanabe Mamoru

Cytokine 44 ( 1 ) 57 - 64 2008.10

ISSN 1043-4666

IL-7 is a cytokine, which regulates development, maintenance and proliferation of T lymphocytes within the human immune system. Production of IL-7 is observed in a sterile environment such as thymus or bone marrow. However, it is also known that intestinal epithelial cells (IECs) residing in close contact with numerous bacterial stimuli also produce IL-7. Here we show that secretion of IL-7 by IECs is significantly suppressed upon stimulation by various bacterial components, including flagellin. Analysis of the intracellular mechanism by which flagellin regulates IL-7 production revealed that flagellin down-regulates expression of the two major transcripts encoding IL-7. Surprisingly, such function of flagellin was independent from the known transcriptional regulation of the IL-7 gene, as no significant change was observed in the transcriptional activity regulated by the previously identified promoter region. As the stability of IL-7 mRNA also remained unchanged upon flagellin stimulation, results suggested the possible involvement of a yet unknown transcriptional regulation of the IL-7 gene. These results describe a novel regulation of IL-7 production by bacterial stimuli, presumably mediated via Toll-like receptors. The present system might contribute to regulate the local lymphocyte pool, in response to the gut luminal or sub-mucosal bacterial abundance. © 2008 Elsevier Ltd. All rights reserved.

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Inducible expression of microRNA-194 is regulated by HNF-1α during intestinal epithelial cell differentiation

Hino Kimihiro, Tsuchiya Kiichiro, Fukao Taro, Kiga Kotaro, Okamoto Ryuichi, Kanai Takanori, Watanabe Mamoru

RNA 14 ( 7 ) 1433 - 1442 2008.07

ISSN 1355-8382

Maintenance of the intestinal epithelium is based on well-balanced molecular mechanisms that confer the stable and continuous supply of specialized epithelial cell lineages from multipotent progenitors. Lineage commitment decisions in the intestinal epithelium system involve multiple regulatory systems that interplay with each other to establish the cellular identities. Here, we demonstrate that the microRNA system could be involved in intestinal epithelial cell differentiation, and that microRNA-194 (miR-194) is highly induced during this process. To investigate this inducible expression mechanism, we identified the genomic structure of the miR-194-2, -192 gene, one of the inducible class of miR-194 parental genes. Furthermore, we identified its transcriptional regulatory region that contains a consensus-binding motif for hepatocyte nuclear factor-1α (HNF-1α), which is well known as a transcription factor to regulate gene expression in intestinal epithelial cells. By chromatin immunoprecipitation assay and luciferase reporter analysis, we revealed that pri-miR-194-2 expression is controlled by HNF-1α, and its consensus binding region is required for the transcription of pri-miR-194-2 in vivo in an intestinal epithelial cell line, Caco-2. Our observations indicate that microRNA genes could be targets of lineage-specific transcription factors and that microRNAs are regulated by a tissue-specific manner in the intestinal epithelium. Therefore, our work suggests that induced expression of these microRNAs have important roles in intestinal epithelium maturation. Published by Cold Spring Harbor Laboratory Press. Copyright © 2008 RNA Society.

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Continuous generation of colitogenic CD4⁺ T cells in persistent colitis

Tomita Takayuki, Kanai Takanori, Fujii Toshimitsu, Nemoto Yasuhiro, Okamoto Ryuichi, Tsuchiya Kiichiro, Totsuka Teruji, Sakamoto Naoya, Watanabe Mamoru

European Journal of Immunology 38 ( 5 ) 1264 - 1274 2008.05

ISSN 0014-2980

Inflammatory bowel diseases take chronic courses due to the expansion of colitogenic CD4⁺ cells. However, it is unclear whether the persistent disease is driven by continuous reactivation of colitogenic memory CD4⁺ cells to generate effector CD4⁺ cells or by continuous generation of effector CD4⁺ cells from naïve cells. To clarify this issue, we performed a series of sequential adoptive transfers of Ly5.2⁺ and Ly5.1⁺ CD4⁺CD45RB^high cells into RAG-2^-/- mice at different time points. We show here that the secondarily transferred CD4⁺CD45RB^high cells can be converted to CD4⁺CD44^highCD62L^-IL-7Rα ^high effector-memory T cells even in the presence of pre-existing effector-memory CD4⁺ cells. Although the total cell numbers of CD4⁺ cells in established colitic mice were consistently equivalent irrespective of the number of primarily transferred cells, the ratio of primarily and secondarily transferred cells was dependent on the ratio of the transferred cell numbers, but not on the order of the transfer. Of note, we found that primarily transferred CD4⁺ cells produced significantly lower amounts of IFN-γ and IL-17 than CD4⁺ cells arising from secondary transfer. In conclusion, the continuous generation of colitogenic CD4⁺ cells that compensate for exhausted CD4⁺ cells may be one of the mechanisms involved in the persistence of colitis. © 2008 Wiley-VCH Verlag GmbH & Co. KGaA, Weinheim.

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Immunosenescent colitogenic CD4+ T cells convert to regulatory cells and suppress colitis

Totsuka Teruji, Kanai Takanori, Nemoto Yasuhiro, Tomita Takayuki, Tsuchiya Kiichiro, Sakamoto Naoya, Okamoto Ryuichi, Watanabe Mamoru

European Journal of Immunology 38 ( 5 ) 1275 - 1286 2008.05

ISSN 0014-2980

Inflammatory bowel diseases progress steadily by the expansion of colitogenic CD4⁺ cells. However, it remains unknown whether colitogenic CD4⁺ cells are long-living like memory cells or exhausted like effector cells. To assess the longevity of colitogenic lamina propria (LP) CD4⁺ cells, we performed sequential transfers of LP CD4⁺ cells from colitic CD4⁺CD45RB^high cell-transferred SCID mice into new SCID mice. Although SCID mice transferred with colitic LP CD4⁺ cells stably developed colitis until at least the sixth transfer, the interval to the development of colitis gradually lengthened as the number of transfers increased. The incidence of colitis gradually decreased after the seventh transfer. Furthermore, non-colitic LP CD4⁺ cells from mice transferred over seven times expressed significantly higher levels of PD-1 and produced significantly lower amounts of IFN-γ, TNF-α, and IL-17 than colitic LP CD4⁺ cells recovered after the first transfer. Most notably, we found that re-transfer of non-colitic LP CD4⁺ cells recovered after multiple transfers prevented the development of colitis in SCID mice co-transferred with CD4⁺CD45RB^high cells. Thus, colitogenic LP CD4⁺ cells may be exhausted over time, become non-functional, convert to regulatory cells, and finally suppress colitis in the process of immunosenescence. © 2008 Wiley-VCH Verlag GmbH & Co. KGaA, Weinheim.

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Proteasomal degradation of Atoh1 by aberrant Wnt signaling maintains the undifferentiated state of colon cancer

Aragaki Mikayo, Tsuchiya Kiichiro, Okamoto Ryuichi, Yoshioka Sanae, Nakamura Tetsuya, Sakamoto Naoya, Kanai Takanori, Watanabe Mamoru

Biochemical and Biophysical Research Communications 368 ( 4 ) 923 - 929 2008.04

ISSN 0006-291X

Atoh1 plays a crucial role in intestinal cell differentiation. We have demonstrated that its human homolog Hath1 protein is targeted by the Wnt-GSK3 axis, resulting in the proteasomal degradation in human colon cancer. However, the contribution of Hath1 degradation to the undifferentiated state of colon cancer remains unknown. In this study, we demonstrated that both constitutive expression of mutant Hath1 and stabilization of Hath1 protein by a GSK3 inhibitor in colon cancer cells increased the expression of MUC2 known as a representative function of differentiated goblet cells. This means that Hath1 protein degradation may be required for maintaining the undifferentiated state of colon cancers, and that GSK3 inhibitors have potential for use in cancer therapy. © 2008 Elsevier Inc. All rights reserved.

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MyD88-dependent pathway in T cells directly modulates the expansion of colitogenic CD4⁺ T cells in chronic colitis

Tomita Takayuki, Kanai Takanori, Fujii Toshimitsu, Nemoto Yasuhiro, Okamoto Ryuichi, Tsuchiya Kiichiro, Totsuka Teruji, Sakamoto Naoya, Akira Shizuo, Watanabe Mamoru

Journal of Immunology 180 ( 8 ) 5291 - 5299 2008.04

ISSN 0022-1767

TLRs that mediate the recognition of pathogen-associated molecular patterns are widely expressed on/in cells of the innate immune system. However, recent findings demonstrate that certain TLRs are also expressed in conventional TCRαβ⁺ T cells that are critically involved in the acquired immune system, suggesting that TLR ligands can directly modulate T cell function in addition to various innate immune cells. In this study, we report that in a murine model of chronic colitis induced in RAG-2^-/- mice by adoptive transfer of CD4⁺CD45RB^high T cells, both CD4⁺CD45RB^high donor cells and the expanding colitogenic lamina propria CD4⁺CD44^hlgh memory cells expresses a wide variety of TLRs along with MyD88, a key adaptor molecule required for signal transduction through TLRs. Although RAG-2^-/- mice transferred with MyD88^-/-CD4⁺CD45RB^high cells developed colitis, the severity was reduced with the delayed kinetics of clinical course, and the expansion of colitogenic CD4⁺ T cells was significantly impaired as compared with control mice transferred with MyD88^+/+CD4 ⁺CD45RB^high cells. When RAG-2^-/- mice were transferred with the same number of MyD88^+/+ (Ly5.1⁺) and MyDSS^-/- (Ly5.2⁺) CD4⁺CD45RB^high cells, MyD88^-/-CD4 ⁺ T cells showed significantly lower proliferative responses assessed by in vivo CFSE division assay, and also lower expression of antiapoptotic Bcl-2/Bcl-x_L molecules and less production of IFN-γ and IL-17, compared with the paired MyD88 ^+/+CD4⁺ T cells. Collectively, the MyD88-dependent pathway that controls TLR signaling in T cells may directly promote the proliferation and survival of colitogenic CD4⁺ T cells to sustain chronic colitis. The Journal of Immunology, 2008, 180: Copyright © 2008 by The American Association of Immunologists, Inc.

Development of plaque assays for hepatitis C virus-JFH1 strain and isolation of mutants with enhanced cytopathogenicity and replication capacity

Sekine-Osajima Yuko, Sakamoto Naoya, Mishima Kako, Nakagawa Mina, Itsui Yasuhiro, Tasaka Megumi, Nishimura-Sakurai Yuki, Chen Cheng Hsin, Kanai Takanori, Tsuchiya Kiichiro, Wakita Takaji, Enomoto Nobuyuki, Watanabe Mamoru

Virology 371 ( 1 ) 71 - 85 2008.02

ISSN 0042-6822

HCV culture in vitro results in massive cell death, which suggests the presence of HCV-induced cytopathic effects. Therefore, we investigated its mechanisms and viral nucleotide sequences involved in this effect using HCV-JFH1 cell culture and a newly developed HCV plaque assay technique. The plaque assay developed cytopathic plaques, depending on the titer of the inoculum. In the virus-infected cells, the ER stress markers, GRP78 and phosphorylated eIF2-alpha, were overexpressed. Cells in the plaques were strongly positive for an apoptosis marker, annexin V. Isolated virus subclones from individual plaque showed greater replication efficiency and cytopathogenicity than the parental virus. The plaque-purified virus had 9 amino acid substitutions, of which 5 were clustered in the C terminal of the NS5B region. Taken together, the cytopathic effect of HCV infection involves ER-stress-induced apoptotic cell death. Certain HCV genomic structures may determine the viral replication capacity and cytopathogenicity. © 2007 Elsevier Inc. All rights reserved.

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Systemic, but not intestinal, IL-7 is essential for the persistence of chronic colitis

Tomita Takayuki, Kanai Takanori, Nemoto Yasuhiro, Totsuka Teruji, Okamoto Ryuichi, Tsuchiya Kiichiro, Sakamoto Naoya, Watanabe Mamoru

Journal of Immunology 180 ( 1 ) 383 - 390 2008.01

ISSN 0022-1767

We previously demonstrated that IL-7 is produced by intestinal goblet cells and is essential for the persistence of colitis. It is well known, however, that goblet cells are decreased or depleted in the chronically inflamed mucosa of animal colitis models or human inflammatory bowel diseases. Thus, in this study, we assess whether intestinal IL-7 is surely required for the persistence of colitis using a RAG-1/2^-/- colitis model induced by the adoptive transfer of CD4⁺CD45RB^high T cells in combination with parabiosis system. Surprisingly, both IL-7^-/- x RAG-1^-/- and IL-7^+/+ x RAG-1^-/- host mice developed colitis 4 wk after parabiosis to a similar extent of colitic IL-7^+/+ x RAG-1 ^-/- donor mice that were previously transferred with CD4 ⁺CD45RB^high T cells. Of note, although the number of CD4⁺ T cells recovered from the spleen or the bone marrow of IL-7^-/- x RAG-1^-/- host mice was significantly decreased compared with that of IL-7^+/+ x RAG-1^-/- host mice, an equivalent number of CD4⁺ T cells was recovered from the lamina propria of both mice, indicating that the expansion of CD4⁺ T cells in the spleen or in the bone marrow is dependent on IL-7, but not in the lamina propria. Development of colitis was never observed in parabionts between IL-7^+/+ x RAG-1^-/- host and noncolitic IL-7^-/- x RAG-1^-/- donor mice that were transferred with CD4 ⁺CD45RB^high T cells. Collectively, systemic, but not intestinal, IL-7 is essential for the persistence of colitis, suggesting that therapeutic approaches targeting the systemic IL-7/IL-7R signaling pathway may be feasible in the treatment of inflammatory bowel diseases. Copyright © 2007 by The American Association of Immunologists, Inc.

Current pharmacologic therapies and emerging alternatives in the treatment of ulcerative colitis

Nakamura Tetsuya, Nagahori Masakazu, Kanai Takanori, Watanabe Mamoru

Digestion 77 ( SUPPL. 1 ) 36 - 41 2008.01

ISSN 0012-2823

Recent progress in both basic and clinical research has led us to develop sophisticated and effective medical therapy of ulcerative colitis (UC). Although classical agents such as aminosalicylates, corticosteroids and immunomodulatory drugs have remained as the gold standard for decades, their novel formulations and/or dosage regimens have changed their placements in the medical management of UC. In addition, studies have shown that a number of novel therapeutic agents, designed to target specific mechanisms involved in the inflammatory cascade, have efficacy for the treatment of UC and they will have significant clinical impacts in the near future. A clear understanding of the proven and potential benefits of both the standard and emerging therapies will be required for the optimum individual care of patients with varied clinical presentations. Copyright © 2008 S. Karger AG.

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Negative feedback regulation of colitogenic CD4⁺ T cells by increased granulopoiesis

Nemoto Yasuhiro, Kanai Takanori, Tohda Shuji, Totsuka Teruji, Okamoto Ryuichi, Tsuchiya Kiichiro, Nakamura Tetsuya, Sakamoto Naoya, Fukuda Tetsuya, Miura Osamu, Yagita Hideo, Watanabe Mamoru

Inflammatory Bowel Diseases 14 ( 11 ) 1491 - 1503 2008

ISSN 1078-0998

Background: Chronic inflammatory diseases are characterized by massive infiltration of innate and acquired immune cells in inflammatory sites. However, it remains unclear how these cells cooperate in the development of disease. Although bone marrow (BM) is a primary site for hematopoiesis of immune cells except T cells, BM recruits memory T cells from the periphery. We have recently demonstrated that colitogenic CD4⁺ memory T cells reside in BM of colitic CD4⁺CD45RB^high T-cell-transferred SCID mice. Based on this background we here investigate whether granulocytes promote or suppress the expansion of colitogenic CD4⁺ T cells. Methods: First, we show that Gr-1^highCD11b⁺ granulocytes were significantly increased in colitic BM along with a significant increase of peripheral granulocytes. Consistently, the colony-forming unit (CFU) assay revealed that granulocyte colony formation was dominantly induced by supernatants from anti-CD3-stimulated colitic BM CD4⁺ T cells. Results: Administration of granulocyte-depleting anti-Gr-1 mAb to colitic mice did not ameliorate the colitis, but exacerbated the wasting disease with an increased expansion of systemic, but not lamina propria, CD4⁺ T cells with activated phenotype. Conclusions: These results suggest that the increased granulopoiesis by colitogenic BM CD4⁺ T cells represent a negative feedback mechanism to control systemic inflammation. Copyright © 2008 Crohn's & Colitis Foundation of America, Inc.

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FTY720 suppresses the development of colitis in lymphoid-null mice by modulating the trafficking of colitogenic CD4⁺ T cells in bone marrow

Fujii Toshimitsu, Tomita Takayuki, Kanai Takanori, Nemoto Yasuhiro, Totsuka Teruji, Sakamoto Naoya, Nakamura Tetsuya, Tsuchiya Kiichiro, Okamoto Ryuichi, Watanabe Mamoru

European Journal of Immunology 38 ( 12 ) 3290 - 3303 2008

ISSN 0014-2980

2-Amino-2-(2-[4-octylphenyl]ethyl)-1,3-propanediol hydrochloride (FTY720) suppresses T-cell egress from LN, thereby preventing pathogenic T cells from migrating toward disease sites. However, little is known about whether FTY720 could control the trafficking of T cells without the presence of lymphoid tissues. Here we demonstrate that FTY720 treatment suppresses the recirculation of CD4⁺ T cells in splenectomized (SPX) lymphotoxin-α^-/- (LT-α ^-/-) mice that lack LN and spleen, as shown by peripheral blood (PB) lymphopenia in FTY720-treated SPX LT-α ^-/- mice. In a short-term transfer experiment, the cell number of transferred Ly5.1⁺CD4⁺ T cells recovered from host FTY720-treated SPX LT-α^-/- mice (Ly5.2⁺) was markedly decreased in PB, but conversely increased in BM. Notably, FTY720 treatment prevented the development of colitis that is otherwise induced in untreated SPX LT-α ^-/- x RAG-2^-/- mice upon transfer of colitic lamina propria CD4⁺ T cells. In such mice, the number of CD4⁺ T cells in PB or lamina propria of FTY720-treated SPX LT-α^-/- x RAG-2^-/- recipients was significantly reduced, but that in the BM was significantly increased as compared with untreated control mice. Altogether, the present results indicate that FTY720 treatment may offer an additional role to direct trafficking of CD4⁺ T cells in BM, resulting in the prevention of colitis. © 2008 Wiley-VCH Verlag GmbH & Co. KGaA.

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Colitogenic CD4⁺ effector-memory T cells actively recirculate in chronic colitic mice

Tomita Takayuki, Kanai Takanori, Nemoto Yasuhiro, Fujii Toshimitsu, Nozaki Kengo, Okamoto Ryuichi, Tsuchiya Kiichiro, Nakamura Tetsuya, Sakamoto Naoya, Totsuka Teruji, Watanabe Mamoru

Inflammatory Bowel Diseases 14 ( 12 ) 1630 - 1640 2008

ISSN 1078-0998

Background: Although the clinical usefulness of leukocytapheresis for patients with inflammatory bowel disease (IBD) has been reported as a selective removal therapy targeting pathogenic immune cells in blood circulation, it remains unclear whether colitogenic CD4⁺ T cells continuously recirculate in peripheral blood during the chronic phase of colitis. Methods: To resolve this question we conducted a series of in vivo experiments using a murine chronic colitis model induced by adoptive transfer of CD4⁺CD45RB^high cells into SCID mice in combination with a parabiosis system. Results: In colitic SCID recipients, first, almost all CD4⁺ CD45RB^high donor cells were converted to CD4⁺CD44^highCD62L^- IL-7Rα ^high effector-memory T (T_EM) cells at 8 weeks after transfer and were distributed throughout the whole body, including colonic lamina propria, mesenteric lymph nodes, thoracic duct, peripheral blood, spleen, and bone marrow. Second, SCID mice retransferred with the colitic peripheral blood CD4⁺ T cells developed colitis that is identical to the original colitis. Third, CD4⁺ cells in parabionts between established colitic RAG-2^-/- mice induced by adoptive transfer of Ly5.1⁺ or Ly5.2⁺ CD4⁺CD45RB^high T cells were well mixed in almost equal proportions at various sites 2 weeks after parabiosis surgery, and the redistribution of Ly5.1⁺ and Ly5.2⁺ CD4⁺ T cells was significantly suppressed in FTY720-treated parabionts. Conclusions: Together, these findings indicate that colitogenic CD4⁺ TEM cells continuously recirculate in established colitic mice, suggesting that therapeutic approaches targeting systemic CD4⁺ T_EM cells, such as bone marrow transplantation, rather than those targeting only intestinal CD4⁺ T cells, may be feasible for the treatment of IBD. Copyright © 2008 Crohn's & Colitis Foundation of America, Inc.

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Treatment of inflammatory immunologic disease 1. Leukocytapheresis for inflammatory immunologic disease (tentative)

Watanabe Mamoru, Kubota Daisuke, Nagahori Masakazu, Kanai Takanori

Internal Medicine 46 ( 16 ) 1305 - 1306 2007.08

ISSN 0918-2918

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Intestinal lamina propria retaining CD4⁺CD25⁺ regulatory T cells is a suppressive site of intestinal inflammation

Makita Shin, Kanai Takanori, Nemoto Yasuhiro, Totsuka Teruji, Okamoto Ryuichi, Tsuchiya Kiichiro, Yamamoto Masafumi, Kiyono Hiroshi, Watanabe Mamoru

Journal of Immunology 178 ( 8 ) 4937 - 4946 2007.04

ISSN 0022-1767

It is well known that immune responses in the intestine remain in a state of controlled inflammation, suggesting that not only does active suppression by regulatory T (T_REG) cells play an important role in the normal intestinal homeostasis, but also that its dysregulation of immune response leads to the development of inflammatory bowel disease. In this study, we demonstrate that murine CD4⁺CD25⁺ T cells residing in the intestinal lamina propria (LP) constitutively express CTLA-4, glucocorticoid-induced TNFR, and Foxp3 and suppress proliferation of responder CD4⁺ T cells in vitro. Furthermore, cotransfer of intestinal LP CD4₊CD25⁺ T cells prevents the development of chronic colitis induced by adoptive transfer of CD4⁺CD45RB^high T cells into SCID mice. When lymphotoxin (LT)α-deficient intercrossed Rag2 double knockout mice (LTα^-/- × Rag2^-/-), which lack mesenteric lymph nodes and Peyer's patches, are transferred with CD4⁺CD45RB ^high T cells, they develop severe wasting disease and chronic colitis despite the delayed kinetics as compared with the control LTα ^+/+ × Rag2^-/- mice transferred with CD4 ⁺CD45RB^high T cells. Of note, when a mixture of splenic CD4⁺CD25⁺ T_REG cells and CD4 ⁺CD45RB^high T cells are transferred into LTα^-/- × Rag2^-/- recipients, CD4 ⁺CD25⁺ T_REG cells migrate into the colon and prevent the development of colitis in LTα^-/- × Rag2 ^-/- recipients as well as in the control LTα^+/+ × Rag2^-/- recipients. These results suggest that the intestinal LP harboring CD4⁺CD25⁺ T_REG cells contributes to the intestinal immune suppression. Copyright © 2007 by The American Association of lmmunologists, Inc.

IL-7 is essential for the development and the persistence of chronic colitis

Totsuka Teruji, Kanai Takanori, Nemoto Yasuhiro, Makita Shin, Okamoto Ryuichi, Tsuchiya Kiichiro, Watanabe Mamoru

Journal of Immunology 178 ( 8 ) 4737 - 4748 2007.04

ISSN 0022-1767

Although IL-7 has recently emerged as a key cytokine involved in controlling the homeostatic turnover and the survival of peripheral resting memory CD4⁺ T cells, its potential to be sustained pathogenic CD4⁺ T cells in chronic immune diseases, such as inflammatory bowel diseases, still remains unclear. In this study, we demonstrate that IL-7 is essential for the development and the persistence of chronic colitis induced by adoptive transfer of normal CD4⁺CD45RB^high T cells or colitogeoic lamina propria (LP) CD4⁺ memory T cells into immunodeficient IL-7^+/+ x RAG-1^-/- and IL-7^-/- x RAG-1^-/- mice. Although EL-7^+/+ x RAG-1^-/- recipients transferred-with CD4⁺CD45RB^high splenocytes developed massive inflammation of the large intestinal mucosa concurrent with massive expansion of Th1 cells, IL-7^-/- x RAG-1^-/- recipients did not. Furthermore, IL-7^-/- x RAG-1^-/-, but not IL-7^+/+ x RAG-1^-/-, mice transferred with LP CD4 ⁺CD44^highCD62L^-IL-7Rα^high effector-memory T cells (T_EM) isolated from colitic CD4 ⁺CD45RB^high-transferred mice did not develop colitis. Although rapid proliferation of transferred colitogenic LP CD4⁺ T_EM cells was observed in the in IL-7^-/- x RAG-1 ^-/- mice to a similar extent of those in IL-7^-/- x RAG-1^-/- mice, Bcl-2 expression was significantly down-modulated in the transferred CD4⁺ T cells in IL-7^-/- x RAG-1 ^-/- mice compared with those in IL-7^+/+ x RAG-1 ^-/- mice. Taken together, IL-7 is essential for the development and the persistence of chronic colitis as a critical survival factor for colitogenic CD⁺ T_EM cells, suggesting that therapeutic approaches targeting IL-7/IL-7R signaling pathway may be feasible in the treatment of inflammatory bowel diseases. Copyright © 2007 by The American Association of Immunologists, Inc.

Extracorporeal elimination of TNF-α-producing CD14 ^dullCD16⁺ monocytes in leukocytapheresis therapy for ulcerative colitis

Kanai Takanori, Makita Shin, Kawamura Takahiro, Nemoto Yasuhiro, Kubota Daisuke, Nagayama Kazuyoshi, Totsuka Teruji, Watanabe Mamoru

Inflammatory Bowel Diseases 13 ( 3 ) 284 - 290 2007.03

ISSN 1078-0998

Background: In recent years leukocytapheresis using a leukocyte removal filter (known as lymphocytapheresis, LCAP) has been applied to the treatment of various autoimmune diseases including ulcerative colitis (UC). In the present study we aimed to clarify how LCAP therapy modifies inflammatory responses by modulating circulating TNF-α-producing monocytes. Methods: Mononuclear cells were obtained from blood before and after the first treatment, and the expression profiles of various immune cells (naive versus, memory, regulatory CD4⁺CD25^bright versus non-regulatory CD4 ⁺CD25^- T cells, and CD14⁺CD16^- versus CD14^dullCD16⁺ monocytes) were assessed. To evaluate immunological differences between CD14⁺CD16^- and CD14^dullCD16⁺ monocytes, the expression of TNF-α, IL-6, IL-12, IL-10, IL-18, surface toll-like receptor 2 (TLR2), TLR4, and other activation markers including HLA-DR, CD80 and CD86, as well as cytokine profiles, were analyzed. Results: LCAP treatment selectively removed CD14 ^dullCD16⁺ monocytes, which preferentially produce TNF-α and IL-12 and express HLA-DR, CD80, CD86, and TLR2, compared with the major fraction of CD14⁺CD16^- monocytes, which conversely produce a higher amount of IL-10. In addition, the CD4 ⁺CD45RO⁺CD62L^-/CD4⁺CD45RO ⁺CD62L⁺ ratio was significantly lower after LCAP therapy. However, the CD4⁺CD25^bright/total CD4⁺ ratio did not change. Conclusions: The present findings revealed the real target of proinflammatory CD14^dullCD16⁺ monocytes removed during LCAP treatment of UC and that LCAP might be used as an extracorporeal anti-TNF-α therapy, expanding the clinical applications of this procedure to include the treatment of Crohn's disease. Copyright © 2006 Crohn's & Colitis Foundation of America, Inc.

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A case of severe ulcerative colitis successfully with intravenous cyclosporine without high dose corticosteroid

Kubota Daisuke, Kanai Takanori, Yui Fumiro, Matsumoto Tomoko, Kawamura Takahiro, Itsui Yasuhiro, Okada Eriko, Chin Seishin, Ooka Shinya, Nagahori Masakazu, Tsuchiya Kiichiro, Araki Akihiro, Sakamoto Naoya, Miyata Tatsuya, Watanabe Mamoru

Japanese Journal of Gastroenterology 104 ( 1 ) 42 - 46 2007.01

ISSN 0446-6586

A 44-year-old women developed marked myopathy one year earlier, when she was treated with intravenous prednisolone for acute severe exacerbation of ulcerative colitis. When she was admitted to our hospital for another severe exacerbation, intravenous cyclosporine A was administered as monotherapy because she could not tolerate corticosteroid. The treatment was successful and she obtained complete remission. Cyclosporine A monotherapy is considered to be a valuable alternative to proctocolectomy for severe ulcerative colitis patients who cannot tolerate corticosteroid.

Reciprocal Targeting of Hath1 and β-Catenin by Wnt Glycogen Synthase Kinase 3β in Human Colon Cancer

Tsuchiya Kiichiro, Nakamura Tetsuya, Okamoto Ryuichi, Kanai Takanori, Watanabe Mamoru

Gastroenterology 132 ( 1 ) 208 - 220 2007.01

ISSN 0016-5085

Background & Aims: The transcription factor Hath1 plays a crucial role in the differentiation program of the human gut epithelium. The present study was conducted to investigate the molecular mechanism of Hath1 expression and its close association with β-catenin/glycogen synthase kinase 3β (GSK3β) under the Wnt pathway in human colonocytes. Methods: Tissue distribution of Hath1 messenger RNA in human tissues was examined by Northern blot. Stability of Hath1 protein was analyzed by expression of FLAG-tagged Hath1 in human cell lines. Targeting of Hath1 protein by GSK3β was determined by specific inhibition of GSK-3β function. Expression of Hath1 protein in colorectal cancers was examined by immunohistochemistry. Results: Hath1 messenger RNA expression was confined to the lower gastrointestinal tract in human adult tissues. In colon cancer cells, although Hath1 messenger RNA was also detected, Hath1 protein was positively degradated by proteasome-mediated proteolysis. Surprisingly, the GSK3β-dependent protein degradation was switched between Hath1 and β-catenin by Wnt signaling, leading to the dramatic alteration of cell status between proliferation and differentiation, respectively. Hath1 protein was detected exclusively in normal colon tissues but not in cancer tissues, where nuclear-localized β-catenin was present. Conclusions: The present study suggests a novel function of the canonical Wnt signaling in human colon cancer cells, regulating cell proliferation and differentiation by GSK3β-mediated, reciprocal degradation of β-catenin or Hath1, respectively, which further emphasizes the importance of aberrant Wnt signaling in colonocyte transformation. © 2007 AGA Institute.

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Bone Marrow Retaining Colitogenic CD4⁺ T Cells May Be a Pathogenic Reservoir for Chronic Colitis

Nemoto Yasuhiro, Kanai Takanori, Makita Shin, Okamoto Ryuichi, Totsuka Teruji, Takeda Kiyoshi, Watanabe Mamoru

Gastroenterology 132 ( 1 ) 176 - 189 2007.01

ISSN 0016-5085

Background & Aims: Although bone marrow (BM) is known as a primary lymphoid organ, it also is known to harbor memory T cells, suggesting that this compartment is a preferential site for migration and/or selective retention of memory T cells. We here report the existence and the potential ability to induce colitis of the colitogenic BM CD4⁺ memory T cells in murine colitis models. Methods: We isolated BM CD4⁺ T cells obtained from colitic severe combined immunodeficient mice induced by the adoptive transfer of CD4⁺CD45RB^high T cells and colitic interleukin (IL)-10^-/- mice that develop colitis spontaneously, and analyzed the surface phenotype, cytokine production, and potential activity to induce colitis. Furthermore, we assessed the role of IL-7 to maintain the colitogenic BM CD4⁺ T cells. Results: A high number of CD4⁺ T cells reside in the BM of colitic severe combined immunodeficient mice and diseased IL-10^-/- mice, and they retain significant potential to induce type-1 T helper-mediated colitis in an IL-7-dependent manner. These resident BM CD4⁺ T cells have an effector memory (T_EM; CD44^highCD62L^-IL-7R^high) phenotype and preferentially are attached to IL-7-producing BM cells. Furthermore, the accumulation of BM CD4⁺ T_EM cells was decreased significantly in IL-7-deficient recipients reconstituted with the colitogenic lamina propria CD4⁺ T_EM cells. Conclusions: Collectively, these findings suggest that BM-retaining colitogenic CD4⁺ memory T cells in colitic mice play a critical role as a reservoir for persisting lifelong colitis. © 2007 AGA Institute.

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Blockade of NKG2D signaling prevents the development of murine CD4 ⁺ T cell-mediated colitis

Ito Y., Kanai T., Totsuka T., Okamoto R., Tsuchiya K., Nemoto Y., Yoshioka A., Tomita T., Nagaishi T., Sakamoto N., Sakanishi T., Okumura K., Yagita H., Watanabe M.

American Journal of Physiology - Gastrointestinal and Liver Physiology 294 ( 1 ) 2007

ISSN 0193-1857

It has been recently demonstrated that NKG2D is an activating costimulatory receptor on natural killer (NK) cells, natural killer T (NKT) cells, activated CD8⁺ T cells, and γδ T cells, which respond to cellular stress, such as inflammation, transformation, and infection. Here we show that intestinal inflammation in colitic SCID mice induced by adoptive transfer of CD4⁺CD45RB^high T cells is characterized by significant increase of CD4⁺NKG2D⁺ T cells and constitutive expression of NKG2D ligands, such as H60, Mult-1, and Rae-1, by lamina propria CD11c ⁺ dendritic cells. Furthermore, treatment with nondepleting and neutralizing anti-NKG2D MAb after transfer of CD4⁺CD45RB ^high T cells into SCID mice significantly suppressed wasting disease with colitis, abrogated leukocyte infiltration, and reduced production of IFN-γ by lamina propria CD4⁺ T cells. These findings demonstrate that NKG2D signaling pathway is critically involved in CD4 ⁺ T cell-mediated disease progression and suggest a new therapeutic target for inflammatory bowel diseases. Copyright © 2008 the American Physiological Society.

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Leukocytapheresis for inflammatory immune diseases

Watanabe Mamoru, Kubota Taisuke, Nagahori Masakazu, Kanai Takanori

Nihon Naika Gakkai zasshi. The Journal of the Japanese Society of Internal Medicine 95 ( 9 ) 1775 - 1780 2006.09

ISSN 0021-5384

A case report

Kubota Daisuke, Takishima Chizuru, Ishii Ken Ichi, Kawamura Takahiro, Matsumoto Tomoko, Itsui Yasuhiro, Okada Eriko, Chin Seishin, Oooka Shinya, Tsuchiya Kiichiro, Araki Akihiro, Sakamoto Naoya, Miyata Tatsuya, Kanai Takanori, Watanabe Mamoru

Japanese Journal of Gastroenterology 103 ( 9 ) 1044 - 1049 2006.09

ISSN 0446-6586

A 23-year-old man was admitted for treatment of acute exacerbation of ileitis and perianal abscess caused by Crohn's disease. After incision and drainage of the abscess, coupled with antibiotic therapy, 6-mercaptopurine (6-MP) was commenced. His white blood cell (WBC) count on day 12 after initiation of 6-MP was not decreased. However, on day 24 he was re-admitted because of severe myelosuppression (WBC: 300/μl), which was complicated by the recurrence of the perianal abscess. Myelosuppression was prolonged and required the administration of granulocyte colony stimulating factor (G-CSF). G-CSF was continued for 17 days to achieve recovery of his WBC count to a normal level.

Naturally arising CD4⁺CD25⁺ regulatory T cells suppress the expansion of colitogenic CD4⁺CD44 ^highCD62L^- effector memory T cells

Kanai T., Tanimoto K., Nemoto Y., Fujii R., Makita S., Totsuka T., Watanabe M.

American Journal of Physiology - Gastrointestinal and Liver Physiology 290 ( 5 ) 2006.05

ISSN 0193-1857

Naturally arising CD4⁺CD25⁺ regulatory T (T _R) cells have been shown to prevent and cure murine T cell-mediated colitis. However, their exact mechanism of controlling colitogenic memory CD4⁺ T cells in in vivo systems excluding the initial process of naive T cell activation and differentiation has not been examined to date. Using the colitogenic effector memory (T_EM) CD4⁺ cell-mediated colitis model induced by adoptive transfer of colitogenic CD4 ⁺CD44^highCD62L^- lamina propria (LP) T cells obtained from colitic CD4⁺CD45RB^high T cell-transferred mice, we have shown in the present study that CD4⁺CD25⁺ T_R cells are able not only to suppress the development of colitis, Th1 cytokine production, and the expansion of colitogenic LP CD4⁺ T_EM cells but also to expand these cells by themselves extensively in vivo. An in vitro coculture assay revealed that CD4⁺CD25⁺ T_R cells proliferated in the presence of IL-2-producing colitogenic LP CD4⁺ T_EM cells at the early time point (48 h after culture), followed by the acquisition of suppressive activity at the late time point (96 h after culture). Collectively, these data suggest the distinct timing of the IL-2-dependent expansion of CD4⁺CD25⁺ T _R cells and the their suppressive activity on colitogenic LP CD4 ⁺ T_EM cells. Copyright © 2006 the American Physiological Society.

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The logics of leukocytapheresis as a natural biological therapy for inflammatory bowel disease

Kanai Takanori, Hibi Toshifumi, Watanabe Mamoru

Expert Opinion on Biological Therapy 6 ( 5 ) 453 - 466 2006.05

ISSN 1471-2598

Ulcerative colitis (UC) and Crohn's disease (CD) are debilitating idiopathic inflammatory bowel diseases (IBDs) with symptoms that impair ability to function and quality of life. The aetiology of IBD is inadequately understood and, therefore, drug therapy has been empirical instead of based on sound understanding of the disease mechanisms. This has been a major factor for poor drug efficacy and treatment-related side effects that often add to disease complications. The development of biologicals, notably infliximab, to block TNF-α reflects some progress, but there is major concern about their side effects and lack of long-term safety and efficacy profiles. However, IBD by its very nature is exacerbated and perpetuated by inflammatory cytokines, including TNF-α, IL-6 and IL-12, for which activated peripheral blood lymphocytes, monocytes/macrophages and granulocytes are major sources. Hence, activated leukocytes should be appropriate targets of therapy. At present, three strategies are available for removing excess and activated leukocytes by leukocytapheresis: centrifugation, Adacolumn® and Cellsorba™. Centrifugation can deplete lymphocytes or total leukocytes, whereas Adacolumn selectively adsorbs granulocytes and monocytes together with a smaller fraction of lymphocytes (FcγR- and complement receptor-bearing leukocytes), and Cellsorba non-selectively removes all three major leukocyte populations. Efficacy has ranged from 'none' to an impressive 93% together with excellent safety profiles and downmodulation of inflammation factors. Furthermore, leukocytapheresis has shown strong drug-sparing effects and reduced the number of patients requiring colectomy or exposure to unsafe immunosuppressants, such as cyclosporin A. Leukocytapheresis removes from the body cells that contribute to IBD and, therefore, unlike drugs, it is not expected to induce dependency or refractoriness. © 2006 Informa UK Ltd.

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Do fatty acids influence functions of intestinal dendritic cells?

Kanai Takanori, Watanabe Mamoru

Journal of Gastroenterology 41 ( 3 ) 288 - 289 2006.03

ISSN 0944-1174

T _H1/T _H2-mediated colitis induced by adoptive transfer of CD4 ⁺CD45RB ^high T lymphocytes into nude mice

Kanai Takanori, Kawamura Takahiro, Dohi Taeko, Makita Shin, Nemoto Yasuhiro, Totsuka Teruji, Watanabe Mamoru

Inflammatory Bowel Diseases 12 ( 2 ) 89 - 99 2006.02

ISSN 1078-0998

Background: Transfer of CD4 ⁺CD45RB ^high T cells from normal donors to SCID/Rag-1, 2-deficient mice, which lack T and B cells, leads to the development of a T _H1-mediated inflammatory bowel disease (IBD)-like syndrome characterized by extensive mononuclear cell infiltrates and epithelial cell hyperplasia. Because it is well known that B cells are also involved in a multitude of mechanistic pathways in human IBD, this study attempts to establish a new model of colitis in nude mice. Methods: We transferred CD4 ⁺CD45RB ^high T cells into athymic nude mice, which lack thymus-dependent T cells but retain normal B cells, to establish and investigate a B cell-involving chronic colitis model. As a control, CD4 ⁺CD25 ^- T cells were also used. Results: Mice reconstituted with CD4 ⁺CD45RB ^high but not CD4 ⁺CD25 ^- T cells developed a wasting disease, with severe infiltrates of B cell aggregates as well as T cells, macrophages, and dendritic cells into the colon and elevated levels of interferon-γ, tumor necrosis factor-α, interleukin (IL)-4, IL-5, and IL-10, by 7 weeks after T cell transfer. Furthermore, the infiltrated lamina propria B cells in colitic nude mice consisted predominantly of massive aggregated immunoglobulin (Ig) M- and scattered IgG-positive cells, but not IgA-positive cells. In contrast, mice reconstituted with CD4 ⁺CD45RB ^high and CD4 ⁺CD45RB ^low did not develop wasting disease or colitis. Conclusions: Collectively, the power of the colitis model induced by the adoptive transfer of CD4 ⁺CD45RB ^high T cells into nude mice is that one can investigate the roles of T _H2-type cells and B cells in a regulatory T cell-depleted condition. Copyright © 2006 by Lippincott Williams & Wilkins.

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FTY720 suppresses CD4⁺CD44^highCD62L^- effector memory T cell-mediated colitis

Fujii R., Kanai T., Nemoto Y., Makita S., Oshima S., Okamoto R., Tsuchiya K., Totsuka T., Watanabe M.

American Journal of Physiology - Gastrointestinal and Liver Physiology 291 ( 2 ) 2006

ISSN 0193-1857

FTY720, a sphingosine-derived immunomodulator, causes immunosuppression via enhancement of lymphocyte sequestration into secondary lymphoid organs, thereby preventing their antigen-activated T cell egress to sites of inflammation. FTY720 is highly effective in inhibiting autoimmunity in various animal models. However, there is little known about how FTY720 controls the migration property of memory T cells. Here, we demonstrated that FTY720 prevents the development of colitis induced by the adoptive transfer of lamina propria (LP) colitogenic effector memory CD4⁺ T cells (T_EM cells; CD45RB ^lowCD44^highCD62L^-) into severe combined immunodeficiency (SCID) mice and suppresses interferon-γ, interleukin-2, and tumor necrosis factor-α production by LP CD4⁺ T cells. The numbers of spleen, peripheral blood, mesenteric lymph node, and LP CD4 ⁺ T cells in FTY720-treated mice were significantly reduced compared with those in control mice. Notably, LP CD⁴ T_EM cells as well as splenic CD4⁺CD45RB^high T cells expressed several spingosine-1-phosphate receptors that are targets for FTY720. Furthermore, FTY720 also prevented the development of colitis induced by the adoptive transfer of splenic CD4⁺CD45RB^high T cells into SCID mice. Collectively, the present data indicate that FTY720 treatment may offer the potential not only to prevent the onset of disease but also to treat memory T cell-mediated autoimmune diseases including inflammatory bowel diseases. Copyright © 2006 the American Physiological Society.

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A case of sacroiliitis complicated by ulcerative colitis that was successfully treated with steroid

Kubota Daisuke, Kanai Takanori, Matsumoto Tomoko, Kawamura Takahiro, Itsui Yasuhiro, Okada Eriko, Chin Seishin, Ohoka Shinya, Tsuchiya Kiichiro, Araki Akihiro, Sakamoto Naoya, Miyata Tatsuya, Watanabe Mamoru

Japanese Journal of Gastroenterology 103 ( 8 ) 936 - 942 2006

ISSN 0446-6586

A 23-year-old woman was admitted in November, 2002, complaining pain of the left side and buttock. She had ulcerative colitis when she was 16 and received medical treatment. Based on physical examination and findings of magnetic resonance imaging and bone scintigrapy, as sacroiliitis complicated by ulcerative colitis, was diagnosed Reports on sacroiliitis and ankylosing spondylitis complicated by inflammatory bowel diseases (IBD) are relatively rare in Japan, whereas they are common complications of IBD in Western countries. The efficacy of steroids on pain relief of sacroiliitis and ankylosing spondylitis is unclear.

Ameliorating effect of saporin-conjugated anti-CD11b monoclonal antibody in a murine T-cell-mediated chronic colitis

Kanai Takanori, Uraushihara Koji, Totsuka Teruji, Nemoto Yasuhiro, Fujii Rei, Kawamura Takahiro, Makita Shin, Sawada Daisuke, Yagita Hideo, Okumura Ko, Watanabe Mamoru

Journal of Gastroenterology and Hepatology (Australia) 21 ( 7 ) 1136 - 1142 2006

ISSN 0815-9319

Background: Crohn's disease (CD) is an inflammatory bowel disease that is associated with several changes in the immune system, including an increased number of infiltrating macrophages. These macrophages release a variety of pro-inflammatory cytokines, such as tumor necrosis factor-α (TNF-α) which are critically involved in the onset and the development of CD. The present study was performed to explore the initial involvement of macrophages in the development of T-cell-mediated chronic colitis. Methods: The effects were evaluated of saporin-conjugated anti-CD11b monoclonal antibody (mAb) on the development of chronic colitis in severe combined immunodeficiency (SCID) mice induced by adoptive transfer of CD4⁺CD45RB^high T cells as an animal model of CD. Results: Significantly increased CD11b-expressing macrophages as well as CD4⁺ T cells were found in inflamed colon from colitic mice. Administration of saporin-conjugated anti-CD11b mAb markedly ameliorated the clinical and histopathological disease. In vivo treatment with saporin-conjugated anti-CD11b mAb decreased CD4⁺ T-cell infiltration in the colon and suppressed inferferon-γ (IFN-γ) and TNF-α production by lamina propria CD4⁺ T cells. Conclusions: Collectively, the present results suggest an initial role of macrophages in the pathogenesis of T-cell-mediated chronic colitis. Furthermore, the macrophage-specific targeting may be a promising strategy for therapeutic intervention in CD. © 2006 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd.

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Immunological homeostasis for understanding inflammatory bowel diseases

Kanai Takanori, Watanabe Mamoru

Japan Medical Association Journal 48 ( 12 ) 593 - 600 2005.12

ISSN 1346-8650

Inflammatory bowel diseases are thought to be caused by a complex interaction of genetic, immunological, and environmental factors. The involvement of immunological factors in the etiology of inflammatory bowel diseases is suggested by various facts, such as 1) the effectiveness of immunosuppressive agents, steroids, and anti-TNF-α antibody; 2) the presence of autoantibodies, and 3) the spontaneous development of chronic colitis in mice lacking a single immunity-related gene, e.g., IL-2 or TGF-β. In particular, the treatment of Crohn's disease using anti-TNF-α antibody has been applied to clinical practice with satisfactory clinical results all over the world. This article describes the immunological pathology of inflammatory bowel diseases as autoimmune diseases, and outlines prospective new treatment methods based on the nature of the disease.

A novel apoptosis-inducing monoclonal antibody (anti-LHK) against a cell surface antigen on colon cancer cells

Matsukawa Hidehiko, Kanai Takanori, Naganuma Makoto, Kamada Nobuhiko, Hisamatsu Tadakazu, Takaishi Hiromasa, Ogata Haruhiko, Mukai Makio, Ishii Hiromasa, Mimori Tsuneyo, Watanabe Mamoru, Hibi Toshifumi

Journal of Gastroenterology 40 ( 10 ) 945 - 955 2005.10

ISSN 0944-1174

Background. Apoptosis is a crucial element in the behavior of mammalian cells in many different situations. We here report the establishment of a novel monoclonal antibody (anti-LHK mAb) that has apoptosis-inducing activity against colon cancer Colo205 cells. Methods. The mechanism of anti-LHK mAb-induced cell death was assessed by microscopic morphology, Annexin V/Hoechst 33528 staining, and detection of DNA fragmentation. The molecular weight of LHK antigen was determined by Western blotting. Growth inhibition of Colo205 cells induced by anti-LHK mAb was determined by in vitro and in vivo studies. Results. Anti-LHK reacted with a 70-kDa antigen and completely blocked the proliferation of Colo205 cells bearing LHK in vitro in a manner characteristic of apoptosis. Strikingly, anti-LHK mAb suppressed tumor growth in a murine peritoneal dissemination model. Conclusions. LHK antigen, which is restricted to epithelial cells, may be a novel death receptor that plays a critical role in controlling the growth, invasion, and metastasis of human colon cancer cells. © Springer-Verlag Tokyo 2005.

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New concept of cell therapy using regulatory T cells for the treatment of inflammatory bowel disease

Kanai Takanori, Watanabe Mamoru

Nippon Shokakibyo Gakkai zasshi The Japanese journal of gastro-enterology. 102 ( 9 ) 1132 - 1138 2005.09

ISSN 0446-6586

Regulation of murine chronic colitis by CD4⁺CD25^- programmed death-1⁺ T cells

Totsuka Teruji, Kanai Takanori, Makita Shin, Fujii Rei, Nemoto Yasuhiro, Oshima Shigeru, Okamoto Ryuichi, Koyanagi Akemi, Akiba Hisaya, Okumura Ko, Yagita Hideo, Watanabe Mamoru

European Journal of Immunology 35 ( 6 ) 1773 - 1785 2005.06

ISSN 0014-2980

Naturally arising CD4⁺CD25⁺ regulatory T (T_R) cells are engaged in the maintenance of self tolerance and prevention of autoimmune diseases. However, accumulating evidence suggests that a fraction of peripheral CD4⁺CD25^- T cells also possesses regulatory activity. Programmed death-1 (PD-1) is a new member of the CD28/CTLA-4 family, which has been implicated in the maintenance of peripheral self tolerance. Here, we identified a subpopulation of CD4⁺CD25^-PD-1⁺ T cells in the spleen of naive mice that constitutively expressed CTLA-4 and FoxP3 and was hypoproliferative in response to anti-CD3 antibody stimulation in vitro. However, the CD4⁺CD25^-PD-1⁺ T cells uniquely produced large amounts of IL-4 and IL-10 in response to anti-CD3 and anti-CD28 mAb stimulation, unlike the CD4⁺CD25⁺ T_R cells. The CD4⁺CD25^-PD-1⁺ T cells exhibited a suppressor activity against the proliferation of anti-CD3 antibody-stimulated CD4⁺CD25^-PD-1^- T cells in vitro, which was partially abrogated by anti-CTLA-4 mAb, but not by anti-IL-10 or anti-PD-1 mAb. Remarkably, the CD4⁺CD25^-PD-1⁺ T cells inhibited the development of colitis induced by adoptive transfer of CD4⁺CD45RB^high T cells into C.B17-scid/scid mice, albeit to a lesser extent than CD4⁺CD25⁺ T_R cells, in a CTLA-4-dependent manner. These results indicate that the CD4⁺CD25^-PD-1⁺ T cells contain substantial amounts of T_R cells that are involved in the maintenance of peripheral tolerance. © 2005 Wiley-VCH Verlag GmbH & Co. KGaA, Weinheim.

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Increase of bone marrow-derived secretory lineage epithelial cells during regeneration in the human intestine

Matsumoto Tomoko, Okamoto Ryuichi, Yajima Tomoharu, Mori Takehiko, Okamoto Shinichiro, Ikeda Yasuo, Mukai Makio, Yamazaki Motomi, Oshima Shigeru, Tsuchiya Kiichiro, Nakamura Tetsuya, Kanai Takanori, Okano Hideyuki, Inazawa Johji, Hibi Toshifumi, Watanabe Mamoru

Gastroenterology 128 ( 7 ) 1851 - 1867 2005.06

ISSN 0016-5085

Background & Aims: We have previously reported that bone marrow (BM)-derived cells contribute to the regeneration of the human intestinal epithelium. To analyze further how these cells arise, proliferate, and differentiate as epithelial cells, histologic analysis was conducted using endoscopic specimens. Methods: Thirty biopsy specimens from 14 female, sex-mismatched BM-transplantation recipients were examined. BM-derived cells were identified by fluorescent in situ hybridization (FISH) for the Y chromosome and immunohistochemistry. Multicolor FISH was used to exclude cell fusion. These cells were further analyzed for various differentiation or proliferation markers. Results: No evidence of cell fusion was detected. BM-derived cells did not distribute within the crypt as stem cells and rarely expressed Musashi-1. However, BM-derived epithelial cells frequently expressed Ki-67, and some of these cells appeared as pairs of adjacent cells. These cells also expressed markers of all 4 lineages of terminally differentiated cells. During regeneration following graft-vs-host disease, the number of BM-derived cells was substantially increased within Ki-67-positive cells. Interestingly, the number of cells expressing markers for secretory lineage cells was significantly increased within BM-derived cells. This change was unique for BM-derived cells, resulting in a significantly increased proportion of BM-derived cells among secretory lineage cells. Conclusions: BM-derived epithelial cells arise via a mechanism other than cell fusion and rarely give rise to stem cells. However, a small proportion of these cells express proliferation markers, and a majority reside as terminally differentiated cells. During regeneration BM-derived cells increase as secretory lineage cells, thereby contributing to restore epithelial functions. © 2005 by the American Gastroenterological Association.

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IRF-1 mediates upregulation of LMP7 by IFN-γ and concerted expression of immunosubunits of the proteasome

Namiki Shin, Nakamura Tetsuya, Oshima Shigeru, Yamazaki Motomi, Sekine Yuko, Tsuchiya Kiichiro, Okamoto Ryuichi, Kanai Takanori, Watanabe Mamoru

FEBS Letters 579 ( 13 ) 2781 - 2787 2005.05

ISSN 0014-5793

An immunoproteasome subunit low molecular weight protein 7 (LMP7) plays critical roles in major histocompatibility complex class I antigen processing; however, the mechanism for its expression has remained unclear. We demonstrate that interferon (IFN) regulatory factor-1 (IRF-1) has a pivotal role in IFN-γ-dependent LMP7 expression, as was shown for the other two immunosubunits. A tetracycline-inducible system for IRF-1 revealed its function in the LMP7 expression, and a genomic region functionally interacting with IRF-1 was also determined. Furthermore, the role of IRF-1 in IFN-γ-inducible LMP7 transcription was confirmed by employing small interfering RNA experiments and IRF-1-/- mice. These results suggest that IRF-1 acts as a master regulator for the concerted expression of immunoproteasome components. © 2005 Federation of European Biochemical Societies. Published by Elsevier B.V. All rights reserved.

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IL-7 exacerbates chronic colitis with expansion of memory IL-7R ^high CD4⁺ mucosal T cells in mice

Okada Eriko, Yamazaki Motomi, Tanabe Masanobu, Takeuchi Tsutomu, Nanno Masanobu, Oshima Shigeru, Okamoto Ryuichi, Tsuchiya Kiichiro, Nakamura Tetsuya, Kanai Takanori, Hibi Toshifumi, Watanabe Mamoru

American Journal of Physiology - Gastrointestinal and Liver Physiology 288 ( 4 51-4 ) 2005.04

ISSN 0193-1857

We have previously demonstrated that mucosal CD4⁺ T cells expressing high levels of IL-7 receptor (IL-7R^high) are pathogenic cells responsible for chronic colitis. Here we investigate whether IL-7 is directly involved in the expansion of IL-7R^high memory CD4 ⁺ mucosal T cells and the exacerbation of colitis. We first showed that CD4⁺ lamina propria lymphocytes (LPLs) from wild-type, T cell receptor-α-deficient (TCR-α^-/-), and recombinase- activating gene (RAG)-2^-/--transferred mice with or without colitis showed phenotypes of memory cells, but only CD4⁺ LPLs from colitic mice showed IL-7R^high. In vitro stimulation by IL-7, but not by IL-15 and thymic stromal lymphopoietin, enhanced significant proliferative responses and survival of colitic CD4⁺, but not normal CD4⁺ LPLs. Importantly, in vivo administration of IL-7 mice accelerated the expansion of IL-7R^high memory CD4⁺ LPLs and thereby exacerbated chronic colitis in RAG-2^-/- mice transferred with CD4⁺ LPLs from colitic TCR-α^-/- mice. Conversely, the administration of anti-IL-7R monoclonal antibody significantly inhibited the development of TCR-α^-/- colitis with decreased expansion of CD4⁺ LPLs. Collectively, the present data indicate that IL-7 is essential for the expansion of pathogenic memory CD4⁺ T cells under pathological conditions. Therefore, therapeutic approaches targeting the IL-7R pathway may be feasible in the treatment of human inflammatory bowel disease. Copyright © 2005 the American Physiological Society.

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Clinical application of human CD4⁺CD25⁺ regulatory T cells for the treatment of inflammatory bowel diseases

Kanai Takanori, Watanabe Mamoru

Expert Opinion on Biological Therapy 5 ( 4 ) 451 - 462 2005.04

ISSN 1471-2598

As our understanding of the immunological and genetic basis of inflammatory bowel disease (IBD) grows, potential therapeutic options are being developed at a rapid pace. Nevertheless, new drugs for IBD are needed because about half of all patients with severe ulcerative colitis (UC) eventually undergo colectomy, and a significant part of Crohn's disease (CD) patients do not respond to standard medical therapies, including immunosuppressants and TNF-α neutralising antibodies, or suffer from significant side effects. Finally, recurrence of disease activity following remission is frequent in both UC and CD, and there is an unmet need for effective maintenance strategies. It is well-known that immune responses in the intestine remain in a state of controlled inflammation, suggesting that not only does active suppression by regulatory T (T_R) cells play an important role in the normal intestinal homeostasis, but also its dysregulation might lead to the development of IBD. T_R cells are functional subsets of T cells that downregulate adaptive immune responses by interfering with the activation of dendritic cells and proliferation of T cells. From experimental work it is now clear that T_R cells play a critical role in maintaining immune homeostasis, and several therapeutic approaches have been targeted at the induction of T _R cells in order to control mucosal inflammation. Before using T _R cells clinically as living immunosuppressants for the treatment of IBD, however, we have to pass many critical checkpoints, such as the in vitro expansion of T_R cells and the confirmation of their safety. This paper will discuss recently gained knowledge of human T_R cells and the possibility of their clinical usages as a new strategy for the treatment of IBD. © 2005 Ashley Publications Ltd.

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MyD88-deficient mice develop severe intestinal inflammation in dextran sodium sulfate colitis

Araki Akihiro, Kanai Takanori, Ishikura Takahiro, Makita Shin, Uraushihara Koji, Iiyama Ryoichi, Totsuka Teruji, Takeda Kiyoshi, Akira Shizuo, Watanabe Mamoru

Journal of Gastroenterology 40 ( 1 ) 16 - 23 2005.01

ISSN 0944-1174

Background: Gut commensal microbes affect the development and activation of the mucosal and systemic immune systems. However, the exact molecular mechanism of these microbes that is involved in the development of colitis remains unclear. Methods: The present study was conducted to determine the distinct role of the innate immune system in the development of a dextran sulfate sodium (DSS) colitis model in MyD88^-/- mice, because myeloid differentiation protein (MyD88) is a major adaptor molecule essential for signaling via Toll-like receptors (TLRs). To this end, MyD88^-/- and wild-type (WT) mice received sterile distilled water containing 1.2% DSS for 8 days. The survival rate, total clinical score (body weight loss, stool consistency, and rectal bleeding), colon length, and histological score were assessed. The expression of surface markers (F4/80 and CD4) on infiltrating lamina propria mononuclear cells was analyzed immunohistochemistrically. Results: MyD88^-/- mice exhibited increased susceptibility to DSS-induced colitis, as reflected by significantly higher lethality and higher clinical and histological scores, and more severe colonic shortening compared to WT mice. Immunohistochemical analysis revealed a significant increase of both F4/80⁺ macrophages and CD4⁺ T cells in the inflamed mucosa in DSS-fed MyD88^-/- mice compared to DSS-fed WT mice. Conclusions: These findings suggest that, via MyD88 signaling, the innate immune system in the gut plays an important protective role in colitis. © Springer-Verlag Tokyo 2005.

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Clinical significance of microsatellite instability in the inflamed mucosa for the prediction of colonic neoplasms in patients with ulcerative colitis

Tahara Toshiyuki, Inoue Nagamu, Hisamatsu Tadakazu, Kashiwagi Kazuhiro, Takaishi Hiromasa, Kanai Takanori, Watanabe Mamoru, Ishii Hiromasa, Hibi Toshifumi

Journal of Gastroenterology and Hepatology (Australia) 20 ( 5 ) 710 - 715 2005

ISSN 0815-9319

Background and Aim: Although molecular mechanisms underlying ulcerative colitis (UC)-associated neoplasms have been studied for years, understanding of these mechanisms remains incomplete and no good predictable marker for development of colonic neoplasms in patients with UC has been established. The aim of this study was to assess if microsatellite instability (MSI) contributes to the development of colonic neoplasms in patients with UC. Methods: We have examined MSI in chronic inflamed and neoplastic colonic mucosa of UC patients. We have also obtained serial biopsied colonic tissues retrospectively 2-12 years before the final diagnosis from patients with high level MSI (MSI-H+) UC-associated neoplasms, and analyzed MSI using them at different periods. Results: Eight of 12 UC-associated colon cancers (67%), four of six UC-associated high grade dysplasias (67%), and two of six UC-associated low grade dysplasias (33%) revealed MSI-H+ phenotypes. In contrast, 15 of 59 lesions (25%) in inflamed UC mucosa without colonic neoplasm revealed MSI-H+. Interestingly, all four patients with MSI-H+ phenotypes at the final diagnosis of UC-associated colon cancer or dysplasia had already had MSI-H+ at the stage of chronic colitis, 2-12 years before the final diagnosis. Conclusion: These results support the notion that MSI contributes to the carcinogenesis of UC-associated neoplasms, and indicate that this analysis in inflamed colonic mucosa at surveillance colonoscopy is useful for identifying UC patients who have high risk for neoplastic progression. © 2005 Blackwell Publishing Asia Pty Ltd.

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Immune responses in intestinal mucosa

Kanai Takanori, Watanabe Mamoru

Nippon rinsho. Japanese journal of clinical medicine 63 Suppl 4 459 - 467 2005

ISSN 0047-1852

CD4⁺CD25^bright T cells in human intestinal lamina propria as regulatory cells

Makita Shin, Kanai Takanori, Oshima Shigeru, Uraushihara Koji, Totsuka Teruji, Sawada Taisuke, Nakamura Tetsuya, Koganei Kazutaka, Fukushima Tsuneo, Watanabe Mamoru

Journal of Immunology 173 ( 5 ) 3119 - 3130 2004.09

ISSN 0022-1767

It is well known that immune responses in the intestine remain in a state of controlled inflammation, suggesting that not only active suppression by regulatory T cells plays an important role in the normal intestinal homeostasis, but also its dysregulation leads to the development of inflammatory bowel disease. In this study, we demonstrate that the CD4⁺CD25 ^bright T cells reside in the human intestinal lamina propria (LP) and functionally retain regulatory activities. All human LP CD4⁺ T cells regardless of CD25 expression constitutively expressed CTLA-4, glucocorticoid-induced TNFR family-related protein, and Foxp3 and proliferate poorly. Although LP CD4⁺CD25^- T cells showed an activated and anergic/memory phenotype, they did not retain regulatory activity. In LP CD4⁺CD25⁺ T cells, however, cells expressing CD25 at high levels (CD4⁺CD25^bright) suppressed the proliferation and various cytokine productions of CD4⁺CD25^- T cells. LP CD4⁺CD25^bright T cells by themselves produced fewer amounts of IL-2, IFN-γ, and IL-10. Interestingly, LP CD4 ⁺CD25^bright T cells with regulatory T activity were significantly increased in patients with active inflammatory bowel disease. These results suggest that CD4⁺CD25^bright T cells found in the normal and inflamed intestinal mucosa selectively inhibit the host immune response and therefore may contribute to the intestinal immune homeostasis.

T-bet upregulation and subsequent interleukin 12 stimulation are essential for induction or Th1 mediated immunopathology in Crohn's disease

Matsuoka K., Inoue N., Sato T., Okamoto S., Hisamatsu T., Kishi Y., Sakuraba A., Hitotsumatsu O., Ogata H., Koganei K., Fukushima T., Kanai T., Watanabe M., Ishii H., Hibi T.

Gut 53 ( 9 ) 1303 - 1308 2004.09

ISSN 0017-5749

Background and aims: Many lines of evidence suggest that T helper cell type 1 (Th1) immune responses predominate in Crohn's disease (CD). Recently, a novel transcription factor T-box expressed in T cells (T-bet) has been reported as the master regulator of Th1 development. This study was designed to investigate the role of T-bet and proinflammatory cytokines in Th1 mediated immunopathology in CD. Materials: CD4+ lamina propria mononuclear cells (LPMCs) were isolated from surgically resected specimens (CD, n = 10; ulcerative colitis (UC), n = 10; normal controls (NL), n = 5). Methods: (1) T-bet expression of CD4+ LPMCs was examined by quantitative real time polymerase chain reaction and western blotting. (2) T-bet expression of LPMCs stimulated by interleukin (IL)-12/IL-18 was analysed by western blotting. (3) Interferon γ (IFN-γ) production and T-bet expression of CD4+ peripheral blood mononuclear cells (PBMCs) were examined with or without stimulation by anti-CD3/CD28 monoclonal antibodies and/or IL-12. Results: (1) T-bet expression of CD4+ LPMCs was increased in CD compared with UC and NL. (2) Synergistically, augmentation of IFN-γ production by IL-12/IL-18 was independent of T-bet expression in LPMCs. (3) T-bet was induced by T cell receptor stimulation in CD4+ PBMCs. T-bet induction correlated with IFN-γ production and with augmentation of surface expressed IL-12 receptor β2. Conclusions: T-bet induction by antigenic stimulation and subsequent stimulation by macrophage derived IL-12/IL-18 are important for establishing Th1 mediated immunopathology in CD.

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Interferon regulatory factor 1 (IRF-1) and IRF-2 distinctively up-regulate gene expression and production of interleukin-7 in human intestinal epithelial cells

Oshima Shigeru, Nakamura Tetsuya, Namiki Shin, Okada Eriko, Tsuchiya Kiichiro, Okamoto Ryuichi, Yamazaki Motomi, Yokota Takanori, Aida Masatoshi, Yamaguchi Yuki, Kanai Takanori, Handa Hiroshi, Watanabe Mamoru

Molecular and Cellular Biology 24 ( 14 ) 6298 - 6310 2004.07

ISSN 0270-7306

Intestinal epithelial cell-derived interleukin (IL)-7 functions as a pleiotropic and nonredundant cytokine in the human intestinal mucosa; however, the molecular basis of its production has remained totally unknown. We here showed that human intestinal epithelial cells both constitutively and when induced by gamma interferon (IFN-γ) produced IL-7, while several other factors we tested had no effect. Transcriptional regulation via an IFN regulatory factor element (IRF-E) on the 5′ flanking region, which lacks canonical core promoter sequences, was pivotal for both modes of IL-7 expression. IRF-1 and IRF-2, the latter of which is generally known as a transcriptional repressor, were shown to interact with IRF-E and transactivate IL-7 gene expression in an IFN-γ-inducible and constitutive manner, respectively. Indeed, tetracycline-inducible expression experiments revealed that both of these IRF proteins up-regulated IL-7 protein production, and their exclusive roles were further confirmed by small interfering RNA-mediated gene silencing systems. Moreover, these IRFs displayed distinct properties concerning the profile of IL-7 transcripts upon activation and expression patterns within human colonic epithelial tissues. These results suggest that the functional interplay between IRF-1 and IRF-2 serves as an elaborate and cooperative mechanism for timely as well as continuous regulation of IL-7 production that is essential for local immune regulation within human intestinal mucosa.

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Hepatitis C virus infection in human liver tissue engrafted in mice with an infectious molecular clone

Maeda Norio, Watanabe Mamoru, Okamoto Susumu, Kanai Takanori, Yamada Taketo, Hata Jun Ichi, Hozumi Nobumichi, Katsume Asao, Nuriya Hideko, Sandhu Jasbir, Ishii Hiromasa, Kohara Michinori, Hibi Toshifumi

Liver International 24 ( 3 ) 259 - 267 2004.06

ISSN 1478-3223

Background/Aims: Recent advances in molecular cloning of hepatitis C virus (HCV) have enabled us to apply some available HCV molecular clones to experimental studies. However, these investigations have been restricted to chimpanzee models or 'isolated hepatocytes' from tree shrews. In this study, we engrafted 'human liver tissue' into immunodeficient mice and investigated HCV infection using an infectious molecular clone. Methods: Human liver tissues from normal (non-HCV-infected) liver were transplanted into non-obese diabetic/severe combined immunodeficiency (NOD/SCID) mice. We then inoculated the mice with sera from HCV-infected patients or an infectious HCV molecular clone. HCV RNA was assessed using nested reverse-transcription polymerase chain reaction (PCR), real-time detection PCR and in situ PCR. Results: Without any growth support, normal human liver tissues survived in NOD/SCID mice while maintaining the original viable hepatic architecture. HCV RNA was detected in the mice serum until the fourth week after the inoculation. In situ PCR and immunohistochemistry clearly demonstrated positive signals for HCV in the cytoplasm of infected hepatocytes, while the engrafted human liver tissues showed no apparent morphological changes indicative of infection. Conclusion: Engraftment of human liver tissues into NOD/SCID mice and infection with HCV molecular clones could offer a reverse genetic strategy for HCV infection. Copyright © Blackwell Munksgaard 2004.

Ectopic CD40 Ligand Expression on B Cells Triggers Intestinal Inflammation

Kawamura Takahiro, Kanai Takanori, Dohi Taeko, Uraushihara Koji, Totsuka Teruji, Iiyama Ryoichi, Taneda Chikara, Yamazaki Motomi, Nakamura Tetsuya, Higuchi Tetsuya, Aiba Yuichi, Tsubata Takeshi, Watanabe Mamoru

Journal of Immunology 172 ( 10 ) 6388 - 6397 2004.05

ISSN 0022-1767

Several studies indicate that CD4⁺ T cells, macrophages, and dendritic cells initially mediate intestinal inflammation in murine models of human inflammatory bowel disease. However, the initial role of B cells in the development of intestinal inflammation remains unclear. In this study we present evidence that B cells can trigger intestinal inflammation using transgenic (Tg) mice expressing CD40 ligand (CD40L) ectopically on B cells (CD40L/B Tg). We demonstrated that CD40L/B Tg mice spontaneously developed severe transmural intestinal inflammation in both colon and ileum at 8-15 wk of age. In contrast, CD40L/B TgxCD40^-/- double-mutant mice did not develop colitis, indicating the direct involvement of CD40-CD40L interaction in the development of intestinal inflammation. The inflammatory infiltrates consisted predominantly of massive aggregated, IgM-positive B cells. These mice were also characterized by the presence of anti-colon autoantibodies and elevated IFN-γ production. Furthermore, although mice transferred with CD4⁺ T cells alone or with both CD4⁺ T and B220 ⁺ B cells, but not B220⁺ cells alone, from diseased CD40L/B Tg mice, develop colitis, mice transferred with B220⁺ B cells from diseased CD40L/B Tg mice and CD4⁺ T cells from wild-type mice also develop colitis, indicating that the Tg B cells should be a trigger for this colitis model, whereas T cells are involved as effectors. As it has been demonstrated that CD40L is ectopically expressed on B cells in some autoimmune diseases, the present study suggests the possible contribution of B cells in triggering intestinal inflammation in human inflammatory bowel disease.

Human intestinal epithelial cell-derived interleukin (IL)-18, along with IL2, IL-7 and IL-15, is a potent synergistic factor for the proliferation of intraepithelial lymphocytes

Okazawa A., Kanai T., Nakamaru K., Sato T., Inoue N., Ogata H., Iwao Y., Ikeda M., Kawamura T., Makita S., Uraushihara K., Okamoto R., Yamazaki M., Kurimoto M., Ishii H., Watanabe M., Hibi T.

Clinical and Experimental Immunology 136 ( 2 ) 269 - 276 2004.05

ISSN 0009-9104

Intestinal epithelial cell (IEC)-derived cytokines, such as stem cell factor (SCF), interleukin (IL)-7 and IL-15 are known to be required for the development of intestinal intraepithelial lymphocytes (IELs). A newly described cytokine, IL-18, has also been shown to be produced by intestinal epithelial cells. To demonstrate the functional effects of IL-18 on human IELs, we assessed IL-18/IL-18 receptor expression in IEC/IEL and proliferation following stimulation of intestinal IELs by IL-18. IL-18 transcripts were detected both in freshly isolated human colonie epithelial cells and in various colonie epithelial cell lines. IL-18 protein was also detected by ELISA and flow cytometric analysis using antihuman IL-18-specific monoclonal antibody (MoAb). Furthermore, IELs constitutively expressed the IL-18 receptor in addition to the IL-2 and IL-7 receptors. More importantly, IL-18 augmented significant proliferative responses of IEL in combination with IL-2, IL-7 and IL-15 both in the presence and in absence of anti-CD3 MoAb. These results suggest that IL-18 might play a crucial role in the proliferation and maintenance of intestinal IELs.

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Hyperexpression of Inducible Costimulator and Its Contribution on Lamina Propria T Cells in Inflammatory Bowel Disease

Sato Toshiro, Kanai Takanori, Watanabe Mamoru, Sakuraba Atsushi, Okamoto Susumu, Nakai Takaaki, Okazawa Akira, Inoue Nagamu, Totsuka Teruji, Yamazaki Motomi, Kroczek Richard A., Fukushima Tsuneo, Ishii Hiromasa, Hibi Toshifumi

Gastroenterology 126 ( 3 ) 829 - 839 2004.03

ISSN 0016-5085

Background & Aims: To investigate the role of inducible costimulator (ICOS), a new member of the CD28 family involved in regulation of T-cell activation and chronic intestinal inflammation, we assessed its expression and functional role in patients with inflammatory bowel disease (IBD). Methods: Expression of ICOS, CD28, and cytotoxic T-lymphocyte antigen (CTLA) 4 on intestinal lamina propria mononuclear cells (LPMC) from patients with ulcerative colitis (UC), Crohn's disease (CD), and normal controls was determined using flow cytometry and immunohistochemistry. Expressions of the ICOS ligand, B7h, on lamina propria B cells, macrophages, and epithelial cells (EC) in the intestinal mucosa were also determined using flow cytometry. The functional costimulatory effect of ICOS on LPMC was assessed by the proliferative response and cytokine production. Results: CD4⁺ LPMC expressing ICOS was significantly increased in the inflamed mucosa of IBD patients but not in inflammatory or normal controls. B7h was also significantly up-regulated on B cells, macrophages, and EC in inflamed mucosa of IBD patients. Proliferative responses of anti-CD3/ICOS costimulation were significantly higher compared with those of anti-CD3 monoclonal antibody (mAb) alone. Anti-CD3/ICOS-stimulated-LPMC from UC secreted significantly increased amounts of interleukin (IL)-5 among the 3 groups. In contrast, anti-CD3/ICOS-stimulated-LPMC from CD secreted significantly increased amounts of interferon (IFN)-γ in the presence of IL-12. Conclusions: Highly expressed ICOS in activated CD4⁺ LPMC of IBD patients contributes to the dysregulated immune responses in IBD. Because ICOS hyperexpression was limited to inflammatory sites in IBD patients, ICOS would be a feasible therapeutic target for the treatment of IBD.

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Erratum

Uraushihara Koji, Kanai Takanori, Ko Kwibeom, Totsuka Teruji, Makita Shin, Iiyama Ryoichi, Nakamura Tetsuya, Watanabe Mamoru

Journal of Immunology 172 ( 1 ) 717 2004.01

ISSN 0022-1767

Regulatory T cells and inflammatory bowel diseases

Kanai Takanori, Watanabe Mamoru

Nihon Rinshō Men'eki Gakkai kaishi = Japanese journal of clinical immunology 27 ( 5 ) 302 - 308 2004

ISSN 0911-4300

Crohn's disease and ulcerative colitis are two major forms of human inflammatory bowel diseases (IBD). Their etiology is unknown, but increasing evidence indicate that immune mechanisms play an important role. It is well known that immune responses in the intestine remain in a state of controlled inflammation, suggesting that not only active suppression by regulatory T (TR) cells plays an important role in the normal intestinal homeostasis, but also its dysregulation leads to the development of IBD. This article reviews the unique aspects of TR cells and discuss how these control the intestinal homeostasis.

Hyperexpression of inducible costimulator on lamina propria mononuclear cells in rat dextran sulfate sodium colitis

Ishii Kenichi, Kanai Takanori, Totsuka Teruji, Uraushihara Koji, Ishikura Takahiro, Yamazaki Motomi, Okamoto Ryoici, Araki Akihiro, Miyata Tatsuya, Tezuka Katsuaki, Nakamura Tetsuya, Watanabe Mamoru

Journal of Gastroenterology and Hepatology (Australia) 19 ( 2 ) 174 - 181 2004

ISSN 0815-9319

Background and Aims: The authors have previously shown that a third member of the CD28 family, inducible costimulator (ICOS), was increased in the inflamed intestinal mucosa of murine experimental colitis, and that the blockade of ICOS ameliorated the development of colitis. However, the role of ICOS in rat intestinal inflammation and its expression profile remains unclear. In the present study, the authors investigated the involvement of ICOS in the development of rat dextran sulfate sodium (DSS)-induced colitis, and the therapeutic potential of anti-ICOS monoclonal antibody (mAb) in colitis. Methods: The authors first examined expression of ICOS protein in normal rat by immunohistochemistry and flow cytometry. Sprague-Dawley rats were fed 3.0% DSS. The expression of ICOS on infiltrating lamina propria mononuclear cells and splenocytes were examined. The DSS-fed rats were then administered anti-ICOS mAb to test its effect on the development of colitis. Results: Unlike mice and human, ICOS was expressed on a part of CD4⁺ T-cells from the thymus, spleen, mesenteric lymph nodes and lamina propria. Levels of ICOS on CD4 ₊ T-cells from the spleen and colonic lamina propria were significantly upregulated after Concanavalin A (Con A) stimulation. In addition, ICOS was also upregulated on CD4⁺ T-cells from DSS-fed rats compared with those from non DSS-fed rats. However, anti-ICOS mAb did not ameliorate the development of both acute and chronic DSS colitis. Conclusion: These results suggest that the different expression of ICOS in rats plays a distinct role in rat intestinal inflammation. © 2004 Blackwell Publishing Asia Pty Ltd.

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Normal Development of the Gut-Associated Lymphoid Tissue Except Peyer's Patch in MyD88-Deficient Mice

Iiyama R., Kanai T., Uraushihara K., Ishikura T., Makita S., Totsuka T., Yamazaki M., Nakamura T., Miyata T., Yoshida H., Takeuchi O., Hoshino K., Takeda K., Ishikawa H., Akirat S., Watanabe M.

Scandinavian Journal of Immunology 58 ( 6 ) 620 - 627 2003.12

ISSN 0300-9475

MyD88 is a key adaptor molecule for signalling via Toll-like receptors (TLRs) and the response to gut commensal microbes. To investigate the role of TLRs/MyD88 pathway in the development of the gut-associated lymphoid tissue (GALT), we examined the development of Peyer's patches (PPs) and cryptopatch (CP), and also one of effector compartment, intraepithelial lymphocyte (IEL) in MyD88 ^-/-, TLR2 ^-/- and TLR4 ^-/- mice. In MyD88 ^-/- mice, the organogenesis of PPs was not disturbed. However, PPs in 2-week-old MyD88 ^-/- mice were significantly smaller than those in MyD88 ^+/- mice. Also, in 2-week-old TLR4 ^-/-, but not TLR2 ^-/- mice, PPs did not develop rapidly. The development of PPs in MyD88 ^-/- and TLR4 ^-/- mice was completely recovered in 10 weeks. PP cells from MyD88 ^-/- mice showed significant decrease in proliferation when stimulated with lipopolysaccharide. The development of CP and IEL was also normal in 10-week-old MyD88 ^-/- mice. These results suggest that the TLRs/MyD88 pathway might be involved in the development of PPs only at early postnatal stage, and TLRs/MyD88-independent signalling is critically involved in the development of GALT in adult mice.

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Blockade of B7-H1 suppresses the development of chronic intestinal inflammation

Kanai Takanori, Totsuka Teruji, Uraushihara Koji, Makita Shin, Nakamura Tetsuya, Koganei Kazutaka, Fukushima Tsuneo, Akiba Hisaya, Yagita Hideo, Okumura Ko, Machida Utako, Iwai Hideyuki, Azuma Miyuki, Chen Lieping, Watanabe Mamoru

Journal of Immunology 171 ( 8 ) 4156 - 4163 2003.10

ISSN 0022-1767

A newly identified costimulatory molecule, programmed death-1 (PD-1), provides a negative signal that is essential for immune homeostasis. However, it has been suggested that its ligands, B7-H1 (PD-L1) and B7-dendritic cells (B7-DC; PD-L2), could also costimulate T cell proliferation and cytokine secretion. Here we demonstrate the involvement of PD-1/B7-H1 and B7-DC interaction in the development of colitis. We first examined the expression profiles of PD-1 and its ligands in both human inflammatory bowel disease and a murine chronic colitis model induced by adoptive transfer of CD4 ⁺CD45RB^high T cells to SCID mice. Second, we assessed the therapeutic potential of neutralizing anti-B7-H1 and/or B7-DC mAbs using this colitis model. We found significantly increased expression of PD-1 on T cells and of B7-H1 on T, B, and macrophage/DCs in inflamed colon from both inflammatory bowel disease patients and colitic mice. Unexpectedly, the administration of anti-B7-H1, but not anti-B7-DC, mAb after transfer of CD4 ⁺CD45RB^high T cells suppressed wasting disease with colitis, abrogated leukocyte infiltration, and reduced the production of IFN-γ, IL-2, and TNF-α, but not IL-4 or IL-10, by lamina propria CD4⁺ T cells. These data suggest that the interaction of PD-1/B7-H1, but not PD-1/B7-DC, might be involved in intestinal mucosal inflammation and also show a possible role of interaction between B7-H1 and an as yet unidentified receptor for B7-H1 in inducing T cell activation.

The role of cryptopatch-derived intraepithelial lymphocytes in the development of chronic ileocecitis

Makita S., Kanai T., Matsumoto S., Iiyama R., Uraushihara K., Totsuka T., Yamazaki M., Nakamura T., Ishikawa H., Watanabe M.

Scandinavian Journal of Immunology 58 ( 4 ) 428 - 435 2003.10

ISSN 0300-9475

Lympho-haemopoietic progenitors residing in murine gut cryptopatches (CPs) have been shown to generate intestinal extrathymic intraepithelial lymphocytes (IELs). However, the role of CPs in the development of intestinal inflammation remains unclear. To investigate the role of CPs in the development of intestinal inflammation, we examined SAMP1/Yit mice, which spontaneously develop a chronic intestinal inflammation localized to the terminal ileum and cecum. Here, we showed the sharp correlation between the disease onset and the decreased number of CPs, resulting in decreased number of both thymus-independent IELs including T-cell receptor γδ⁺ (TCRγδ⁺) and CD8αα⁺TCRα β⁺ cells but not thymus-dependent CD8αβ ⁺TCRαβ⁺ and CD4⁺TCRαβ ⁺ cells in SAMP1/Yit mice. These data provide the first suggestion that thymus-independent IELs derived from CP might play protective role against the onset and the development of intestinal inflammation.

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Ameliorating effect of anti-Fas ligand MAb on wasting disease in murine model of chronic colitis

Dan N., Kanai T., Totsuka T., Iiyama R., Yamazaki M., Sawada T., Miyata T., Yagita H., Okumura K., Watanabe M.

American Journal of Physiology - Gastrointestinal and Liver Physiology 285 ( 4 48-4 ) 2003.10

ISSN 0193-1857

Fas/Fas ligand (FasL) interaction has been implicated in the pathogenesis of various diseases. To clarify the involvement of Fas/FasL in the pathogenesis of intestinal inflammation, we investigated the preventive and therapeutic effects of neutralizing anti-FasL monoclonal antibody (MAb) on the development of chronic colitis induced by adaptive transfer of CD4⁺CD45RB ^high T cells to SCID mice. Administration of anti-FasL MAb from 1 day after T cell transfer (prevention study) resulted in a significant improvement of clinical manifestations such as wasting and diarrhea. However, histological examination showed that mucosal inflammation in the colon, such as infiltration of T cells and macrophages, was not improved by the anti-FasL MAb treatment. In vitro studies showed that anti-FasL MAb did not inhibit IFN-γ production by anti-CD3/CD28-stimulated lamina propria CD4 ⁺ T cells but suppressed TNF-α and IL-1β production by lamina propria mononuclear cells. Therapeutic administration of anti-FasL MAb from 3 wk after T cell transfer also improved ongoing wasting disease but not intestinal inflammation. These results suggest that the Fas/FasL interaction plays a critical role in regulating systemic wasting disease but not local intestinal inflammation.

Mucosal T cells expressing high levels of IL-7 receptor are potential targets for treatment of chronic colitis

Yamazaki Motomi, Yajima Tomoharu, Tanabe Masanobu, Fukui Kazuto, Okada Eriko, Okamoto Ryuichi, Oshima Shigeru, Nakamura Tetsuya, Kanai Takanori, Uehira Masahiro, Takeuchi Tsutomu, Ishikawa Hiromichi, Hibi Toshifumi, Watanabe Mamoru

Journal of Immunology 171 ( 3 ) 1556 - 1563 2003.08

ISSN 0022-1767

The IL-7/IL-7R-dependent signaling pathway plays a crucial role in regulating the immune response in intestinal mucosa. Here we demonstrate the pivotal role of this pathway in the development and treatment of chronic colitis. T cells expressing high levels of IL-7R were substantially infiltrated in the chronic inflamed mucosa of TCR α-chain knockout mice and IL-7 transgenic mice. Transfer of mucosai T cells expressing high levels of IL-7R, but not T cells expressing low levels of IL-7R, from these mice into recombinase-activating gene-2^-/- mice induced chronic colitis. Selective elimination of T cells expressing high levels of IL-7R by administrating small amounts of toxin-conjugated anti-IL-7R Ab completely ameliorated established, ongoing colitis. These findings provide evidence that therapeutic approaches targeting mucosal T cells expressing high levels of IL-7R are effective in the treatment of chronic intestinal inflammation and may be feasible for use in the therapy of human inflammatory bowel disease.

Contrasting action of IL-12 and IL-18 in the development of dextran sodium sulphate colitis in mice

Takagi H., Kanai T., Okazawa A., Kishi Y., Sato T., Takaishi H., Inoue N., Ogata H., Iwao Y., Hoshino K., Takeda K., Akira S., Watanabe M., Ishii H., Hibi Toshifumi

Scandinavian Journal of Gastroenterology 38 ( 8 ) 837 - 844 2003.08

ISSN 0036-5521

Background: Interleukin (IL)-12 and IL-18 are major interferon (IFN)-γ-inducing factors that collaborate with each other. The present study was conducted to determine the distinct roles of IL-12 and IL-18 in the development of dextran sulphate sodium (DSS) colitis in mice. Methods: Colitis was induced in IL-12p35^-/-, IL-18^-/-, IL-18 receptor ^-/- and control mice with DSS. Clinical and histopathological analysis was conducted using survival rate, weight loss score, diarrhoea score, bloody stool score and histological score. In addition, cytokine production by lamina propria mononuclear cells (LPMCs) was examined using the specific enzyme-linked immunoassay. Results: IL-12p35^-/- mice developed only a mild disease associated with no lethality and few histopathological abnormalities. In contrast, IL-18^-/- and IL-18R^-/- mice developed more severe colitis associated with high lethality and more histopathological abnormalities compared with control mice. LPMCs from DSS-fed IL-18^-/- mice produced significantly higher amounts of IFN-γ, while LPMCs from DSS-fed IL-12^-/- mice produced lower amounts of IFN-γ and tumour necrosis factor (TNF)-α compared with control mice. Conclusion: These results suggest that IL-18 might function with manners different from IL-12 at some pathological conditions in the development of colitis.

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Interleukin-18 overproduction exacerbates the development of colitis with markedly infiltrated macrophages in interleukin-18 transgenic mice

Ishikura Takahiro, Kanai Takanori, Uraushihara Koji, Iiyama Ryoichi, Makita Shin, Totsuka Teruji, Yamazaki Motomi, Sawada Taisuke, Nakamura Tetsuya, Miyata Tatsuya, Kitahora Tetsuji, Hibi Toshifumi, Hoshino Tomoaki, Watanabe Mamoru

Journal of Gastroenterology and Hepatology (Australia) 18 ( 8 ) 960 - 969 2003.08

ISSN 0815-9319

Background and Aim: The authors have previously shown that production of interleukin (IL)-18 was increased in the inflamed mucosa of patients with Crohn's disease (CD) and blockade of IL-18 ameliorated the murine model of CD. This demonstrated that IL-18 plays a significant role during intestinal inflammation. However, the initial role of IL-18 during intestinal inflammation was unclear; therefore the susceptibility of IL-18 transgenic (Tg) mice to acute dextran sulfate sodium (DSS)-induced colitis was examined. Methods: Interleukin-18 Tg and wild-type (WT) mice were fed 2.0% of DSS for 8 days. The total clinical scores (bodyweight loss, stool consistency, and rectal bleeding), colon length and histological scores were assessed. The expressions of surface markers and IL-18 on infiltrating lamina propria mononuclear cells were analyzed immunohistochemistrically. Mesenteric lymph node (MLN) cells were isolated and the expressions of CD4⁺ T-cell activation markers (CD69, CD25 and IL18R) were analyzed by flow cytometry. Results: The IL-18 Tg mice exhibited an increased susceptibility to DSS-induced colitis, as shown by significantly increased clinical, histological scores, and more severe colonic shortening compared with WT mice. Immunohistochemical analysis revealed a significant increase of IL-18 production and CD11b⁺ macrophages but not CD4⁺T cells in the inflamed mucosa in DSS-fed IL-18 Tg compared with DSS-fed WT mice. Furthermore, MLN cells revealed no evidence of increased CD4⁺T-cell activation in DSS-fed IL-18 Tg. Conclusions: These findings suggest that IL-18 overproduction in the mucosa plays an important role in the marked infiltration of macrophages and exacerbates colitis in IL-18 Tg mice. © 2003 Blackwell Publishing Asia Pty Ltd.

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Regulation of murine inflammatory bowel disease by CD25⁺ and CD25^- CD4⁺ glucocorticoid-induced TNF receptor family-related gene⁺ regulatory T cells

Uraushihara Koji, Kanai Takanori, Ko Kwibeom, Totsuka Teruji, Makita Shin, Iiyama Ryoichi, Nakamura Tetsuya, Watanabe Mamoru

Journal of Immunology 171 ( 2 ) 708 - 716 2003.07

ISSN 0022-1767

CD4⁺CD25⁺ regulatory T cells in normal animals are engaged in the maintenance of immunological self-tolerance and prevention of autoimmune disease. However, accumulating evidence suggests that a fraction of the peripheral CD4⁺CD25^- T cell population also possesses regulatory activity in vivo. Recently, it has been shown glucocorticoid-induced TNFR family-related gene (GITR) is predominantly expressed on CD4⁺CD25⁺ regulatory T cells. In this study, we show evidence that CD4+GITR+ T cells, regardless of the CD25 expression, regulate the mucosal immune responses and intestinal inflammation. SCID mice restored with the CD4⁺GITR^- T cell population developed wasting disease and severe chronic colitis. Cotransfer of CD4⁺GITR⁺ population prevented the development of CD4⁺CD45RB^high T cell-transferred colitis. Administration of anti-GITR mAb-induced chronic colitis in mice restored both CD45RB^high and CD45RB^low CD4⁺ T cells. Interestingly, both CD4⁺CD25⁺ and CD4⁺CD25^- GITR⁺ T cells prevented wasting disease and colitis. Furthermore, in vitro studies revealed that CD4⁺CD25^-GITR⁺ T cells as well as CD4⁺CD25⁺GITR⁺ T cells expressed CTLA-4 intracellularly, showed anergic, suppressed T cell proliferation, and produced IL-10 and TGF-β. These data suggest that GITR can be used as a specific marker for regulatory T cells controlling mucosal inflammation and also as a target for treatment of inflammatory bowel disease.

The role of inducible co-stimulator (ICOS)/B7-related protein-1 (B7RP-1) interaction in the functional development of Peyer's patches

Iiyama R., Kanai T., Uraushihara K., Totsuka T., Nakamura T., Miyata T., Yagita H., Kushi A., Suzuki K., Tezuka K., Watanabe M.

Immunology Letters 88 ( 1 ) 63 - 70 2003.07

ISSN 0165-2478

T-cell co-stimulatory molecule, inducible co-stimulator (ICOS)/B7-related protein-1 (B7RP-1) interactions play an essential role of T-cell-dependent B-cell activation in peripheral lymphoid organs such as spleen and lymph nodes. Here, we investigate the role of ICOS/B7RP-1 interactions in the development of Peyer's patches (PPs). In ICOS^-/- mice, the number of PPs was not decreased, although PPs in ICOS^-/- mice were significantly reduced in size. Phenotypic analysis showed no obvious differences between ICOS^-/- and ICOS^+/- mice in the distribution of T-cells, B-cells, macrophages and dendritic cells. However, PNA⁺ cells characteristic of intestinal germinal centers were totally absent in ICOS^-/- mice. Moreover, production of IgA and IgG, but not IgM was significantly reduced in PPs in ICOS^-/- mice. These data suggest that ICOS/B7RP-1 interactions may not affect the organogenesis, but involve in the functional development of PPs. © 2003 Elsevier Science B.V. All rights reserved.

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A specific genetic alteration on chromosome 6 in ulcerative colitis-associated colorectal cancers

Ezaki Toshihiko, Watanabe Mamoru, Inoue Nagamu, Kanai Takanori, Ogata Haruhiko, Iwao Yasushi, Ishii Hiromasa, Hibi Toshifumi

Cancer Research 63 ( 13 ) 3747 - 3749 2003.07

ISSN 0008-5472

Various genetic alterations in ulcerative colitis (UC)-associated colorectal cancers (CRCs) have been reported. However, almost all studies have shown abnormalities of the known genes that have been demonstrated in sporadic CRCs. To identify novel genetic alterations, we selected unintentionally 35 microsatellite markers, and performed allelotype study in CRCs or dysplastic lesions from UC. High frequency of loss of heterozygosity (LOH; 62.5%) was detected on chromosome 6 (D6S468) but not on other chromosomes. With four additional microsatellite markers around the D6S468 locus, we determined the commonly deleted region between two loci, D6S1543 and D6S1580, in UC-associated CRCs and dysplasia. Interestingly, there was no LOH in this region in sporadic CRCs and severely inflamed lesions of longstanding and extensive UC without cancers. These results indicated the presence of novel tumor suppressor genes on chromosome 6 related to the carcinogenesis of UC but not to sporadic CSCs.

A case of chronic graft-versus-host disease (GVHD) colitis with multiple colon ulcers

Kubota Daisuke, Tozuka Teruji, Suzuki Shinji, Tamura Michiaki, Kanai Takanori, Dan Naoaki, Kurosaki Masayuki, Enomoto Nobuyuki, Miyata Tatsuya, Takizawa Toichiro, Okusa Toshifumi, Watanabe Mamoru

Gastroenterological Endoscopy 45 ( 6 ) 1044 - 1050 2003.06

ISSN 0387-1207

A rare case of chronic GVHD enterocolitis with multiple colon ulcers was reported. A 21-year-old man was admitted on May 2000, because of progressing diarrhea and abdominal pain. He had received allogenic bone marrow transplantation in August 1999. On admission, Colonoscopy showed multiple colon ulcers and mucosal edema. He was treated with antibiotics and virucide, but had no resolution both in clinically and endoscopically. We eventually diagnosed this case as chronic GVHD enterocolitis and treated with immunosuppressant. Endoscopic appearance was remarkably improved and diarrhea was disappeared.

Macrophage-derived IL-18 targeting for the treatment of Crohn's disease.

Kanai Takanori, Uraushihara Koji, Totsuka Teruji, Okazawa Akira, Hibi Toshifumi, Oshima Shigeru, Miyata Tatsuya, Nakamura Tetsuya, Watanabe Mamoru

Current drug targets. Inflammation and allergy 2 ( 2 ) 131 - 136 2003.06

ISSN 1568-010X

Crohn's disease is an inflammatory bowel disease associated with several changes in the immune system, including an increased number of infiltrating macrophages. These macrophages release a variety of proinflammatory cytokines, such as tumor necrosis factor-alpha (TNF-alpha, macrophage infiltrating factor (MIF), interleukin (IL)-6, IL-12 and IL-18, which are critically involved in the onset and the development of Crohn's disease. We here focus on the role of macrophages, especially macrophage-derived IL-18 in both patients with Crohn's disease and a murine model of Crohn's disease.

Therapeutic approaches to chronic intestinal inflammation by specific targeting of mucosal IL-7/IL-7R signal pathway.

Watanabe Mamoru, Yamazaki Motomi, Okamoto Ryuichi, Ohoka Shinya, Araki Akihiro, Nakamura Tetsuya, Kanai Takanori

Current drug targets. Inflammation and allergy 2 ( 2 ) 119 - 123 2003.06

ISSN 1568-010X

Inflammatory bowel disease is thought to result from inappropriate activation of mucosal immune responses. Intestinal epithelial cells produce interleukin (IL)-7 that serves as a regulatory factor for IL-7 receptor (IL-7R)(+) mucosal lymphocytes. The pivotal role of mucosal IL-7/IL-7R dependent signals in the activation of mucosal immune responses that lead to the development of chronic intestinal inflammation are demonstrated. Therapeutic approaches targeting IL-7/IL-7R signal pathway may be feasible in the treatment of inflammatory bowel disease.

Therapeutic effect of anti-OX40l and anti-TNF-α MAbs in a murine model of chronic colitis

Totsuka T., Kanai T., Uraushihara K., Iiyama R., Yamazaki M., Akiba H., Yagita H., Okumura K., Watanabe M.

American Journal of Physiology - Gastrointestinal and Liver Physiology 284 ( 4 47-4 ) 2003.04

ISSN 0193-1857

Interaction of OX40 (CD134) on T cells with its ligand (OX40L) on antigen-presenting cells has been implicated in pathogenic T cell activation. This study was performed to explore the involvement of OX40/OX40L in the development of T cell-mediated chronic colitis. We evaluated both the preventive and therapeutic effects of neutralizing anti-OX40L MAb on the development of chronic colitis in SCID mice induced by adoptive transfer of CD4⁺CD45RB^high T cells as an animal model of Crohn's disease. We also assessed the combination of anti-OX40L and anti-TNF-α MAbs to improve the therapeutic effect. Administration of anti-OX40L MAb markedly ameliorated the clinical and histopathological disease in preventive and therapeutic protocols. In vivo treatment with anti-OX40L MAb decreased CD4⁺ T cell infiltration in the colon and suppressed IFN-γ IL-2, and TNF-α production by lamina propria CD4⁺ T cells. The combination with anti-TNF-α MAb further improved the therapeutic effect by abolishing IFN-γ, IL-2, and TNF-α production by lamina propria CD4⁺ T cells. Our present results suggested a pivotal role of OX40/OX40L in the pathogenesis of T cell-mediated chronic colitis. The OX40L blockade, especially in combination with the TNF-α blockade, may be a promising strategy for therapeutic intervention of Crohn's disease.

Ameliorating effect of anti-inducible costimulator monoclonal antibody in a murine model of chronic colitis

Totsuka Teruji, Kanai Takanori, Iiyama Ryoichi, Uraushihara Koji, Yamazaki Motomi, Okamoto Ryuichi, Hibi Toshifumi, Tezuka Katsunari, Azuma Miyuki, Akiba Hisaya, Yagita Hideo, Okumura Ko, Watanabe Mamoru

Gastroenterology 124 ( 2 ) 410 - 421 2003.02

ISSN 0016-5085

Background & Aims: Inducible costimulator (ICOS)/B7RP-1 represents a newly described receptor/ligand pair involved in costimulation of T cells by antigen-presenting cells. We investigated the involvement of the ICOS/B7RP-1 interaction in the pathogenesis of colitis and the therapeutic potential of anti-ICOS monoclonal antibody (mAb) in experimental colitis. Methods: We administered anti-ICOS or anti-B7RP-1 mAb to mice with experimental colitis induced by transfer of CD4⁺CD45RB^high T cells from normal mice into SCID mice. The ability of CD4⁺CD45RB^high cells derived from ICOS-/- mice to induce colitis was assessed. Th2 cytokine production and apoptosis in infiltrating T cells was examined after administration of anti-ICOS mAb. Results: ICOS was strongly induced on CD4⁺ T cells, and B7RP-1 was expressed by macrophages in the inflamed mucosa of colitic mice. Anti-ICOS mAb, but not anti-B7RP-1, ameliorated chronic colitis when administered in prevention or therapeutic protocols. Transfer of CD4⁺CD45RB^high T cells from ICOS-/- mice induced colitis. Treatment with anti-ICOS mAb did not enhance the production of Th2 cytokines, but a single dose of anti-ICOS mAb induced massive apoptosis of infiltrating ICOS-expressing T cells. Conclusions: ICOS/B7RP-1 interactions are not required for the development of colitis. However, treatment with anti-ICOS mAb can prevent and reverse intestinal inflammation by inducing apoptosis of ICOS-expressing T lymphocytes.

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Mucosal T cells as a target for treatment of IBD

Watanabe Mamoru, Yamazaki Motomi, Kanai Takanori

Journal of Gastroenterology 38 ( SUPPL. 15 ) 48 - 50 2003

ISSN 0944-1174

Interleukin-7 (IL-7) is an indispensable cytokine for the development of lymphocyte lineage cells. However, the potential role of IL-7 in peripheral nonlymphoid tissues was unclear before our study. We have demonstrated that intestinal epithelial cells produce IL-7 and that IL-7 serves as a regulatory factor for proliferation of mucosal lymphocytes expressing IL-7 receptor (IL-7R). Recent studies demonstrated that intestinal epithelial cell-derived IL-7 plays a crucial role in the organization of mucosal lymphoid tissues and regulating the normal immune response in intestinal mucosa. In a previous study, we demonstrated that IL-7 transgenic mice developed chronic colitis. Here, we have demonstrated the essential role of mucosal IL-7/IL-7R-dependent signals in the development of chronic intestinal inflammation. Our results indicate that mucosal IL-7/IL-7R-dependent signals are involved in the development of chronic intestinal inflammation in both the mouse model and human disease of the intestinal mucosa. Therefore, current studies indicate that therapeutic approaches by specific targeting of IL-7R-expressing mucosal T cells may be feasible in the treatment of human ulcerative colitis.

Th1-mediated intestinal inflammation in Crohn's disease may be induced by activation of lamina propria lymphocytes through synergistic stimulation of interleukin-12 and interleukin-18 without T cell receptor engagement

Okazawa Akira, Kanai Takanori, Watanabe Mamoru, Yamazaki Motomi, Inoue Nagamu, Ikeda Masao, Kurimoto Masashi, Ishii Hiromasa, Hibi Toshifumi

American Journal of Gastroenterology 97 ( 12 ) 3108 - 3117 2002.12

ISSN 0002-9270

OBJECTIVE: The development of T helper type 1 (Th1) CD4+ T cells in the intestinal mucosa is driven by interleukin (IL)-12 produced from activated macrophages and IL-18 produced from activated macrophages and epithelial cells. Each of these two cytokines is important for the mucosal response during intestinal inflammation, but their synergistic effect is not fully understood. To characterize the synergistic effect of IL-12 and IL-18 with respect to human intestinal inflammation, we assessed the effect of IL-12 and IL-18 on lamina propria lymphocytes from normal control subjects (LPL-NL) and patients with Crohn's disease (LPL-CD). METHODS: Expression of IL-12 receptor (IL-12R) β1, β2, and IL-18Rα in LPLs was analyzed by flow cytometry. The functional activity of IL-12 and IL-18 was assessed by the effect of recombinant IL-12 and recombinant IL-18 on interferon-γ production, the proliferative response, and the induction of IL-2R, IL-12R, and IL-18R of LPLs. RESULTS: IL-12Rβ2 expression was significantly greater in LPL-CD compared with LPL-NL. LPL-NL demonstrated a proliferative response and a significant increase in interferon-γ production and IL-2Rα expression when exposed to both IL-12 and IL-18, but neither IL-12 nor IL-18 were able to induce this response on their own. However, IL-12 and IL-18 produced this response in LPL-CD when administered alone. Moreover, a more pronounced synergistic effect of IL-12 and IL-18 was observed in LPL-CD. The response normally observed after administration of IL-12 and IL-18 was significantly inhibited by anti-IL-2 and anti-IL-2Rα monoclonal antibody. Furthermore, IL-12 was observed to upregulate IL-18Rα expression in LPL-CD. CONCLUSIONS: These findings suggest that a combination of IL-12 and IL-18 in the absence of T cell receptor engagement may serve as a potent regulatory factor for LPL and contribute to the maintenance and enhancement of chronic inflammation in CD. © 2002 by Am. Coll. of Gastroenterology.

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Role of the innate immune system in the development of chronic colitis

Kanai Takanori, Iiyama Ryoichi, Ishikura Takahiro, Uraushihara Koji, Totsuka Teruji, Yamazaki Motomi, Nakamura Tetsuya, Watanabe Mamoru

Journal of Gastroenterology 37 ( SUPPL. 14 ) 38 - 42 2002.11

ISSN 0944-1174

Based on Pasteur's work on the microbial nature of fermentation, it was widely believed that the presence of bacteria in the intestine was essential for the life of the host. It has also been known for decades that gut commensal microbes effect the activation and development of the systemic immune system through gut-associated lymphoid tissues (GALT). Recent extensive studies have shown that recognition of microbes is mediated by a set of germline-encoded receptors, Toll-like receptors (TLRs), in mammals. This article reviews the role of the innate immunity system in the development of GALT and the pathogenesis of inflammatory bowel diseases (IBD).

ICOS costimulation in inflammatory bowel disease

Kanai Takanori, Totsuka Teruji, Tezuka Katsunari, Watanabe Mamoru

Journal of Gastroenterology 37 ( SUPPL. 14 ) 78 - 81 2002.11

ISSN 0944-1174

For years, medical researchers have striven to develop selective immunotherapies that could specifically ameliorate pathogenic immune responses without immunocompromising the patient. Blockade of many known receptors on T cells can inhibit the initiation of immune responses. However, this approach is problematic in that it is not possible to predict the onset of disease in patients. Current immunotherapies are unsatisfactory for the sporadic exacerbating type of diseases such as multiple sclerosis and inflammatory bowel disease (IBD), because they require either long-term treatment or acute treatment with high-dose immunosuppressants. With regard to this issue, the inducible and inflammatory site-specific molecule, inducible costimulator (ICOS), may be particularly useful as an ideal targeting molecule for the strategy of treatment of human IBD patients.

Damaged epithelia regenerated by bone marrow-derived cells in the human gastrointestinal tract

Okamoto Ryuichi, Yajima Tomoharu, Yamazaki Motomi, Kanai Takanori, Mukai Makio, Okamoto Shinichiro, Ikeda Yasuo, Hibi Toshifumi, Inazawa Johji, Watanabe Mamoru

Nature Medicine 8 ( 9 ) 1011 - 1017 2002.09

ISSN 1078-8956

Studies have shown that bone marrow cells have the potential to differentiate into a variety of cell types. Here we show that bone marrow cells can repopulate the epithelia of the human gastrointestinal tract. Epithelial cells of male donor origin were distributed in every part of the gastrointestinal tract of female bone marrow transplant recipients. Donor-derived epithelial cells substantially repopulated the gastrointestinal tract during epithelial regeneration after graft-versus-host disease or ulcer formation. Regeneration of gastrointestinal epithelia with donor-derived cells in humans shows a potential clinical application of bone marrow-derived cells for repairing severely damaged epithelia, not only in the gastrointestinal tract but also in other tissues.

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Cytokine networks in the development of intestinal inflammation in Crohn's disease

Kanai Takanori, Watanabe Mamoru, Hibi Toshifumi

Folia Pharmacologica Japonica 120 ( 1 ) 39 - 45 2002

ISSN 0015-5691

Crohn's disease (CD) affects more than 400,000 individuals in the United States and more than 18,000 in Japan. Its incidence is CD, one of the chronic inflammatory bowel diseases (IBD), is debilitating disorder of unknown ethiology, characterized by a marked accumulation of activated T cells and monocytes/macrophages in the inflamed mucosa. Various proinflammatory cytokines, such as TNF-α, INF-γ, IL-6, IL-12, and IL-18, might be involved in its pathogenesis. In this review, we describe the role of various cytokines in the development of CD and the new therapeutic trials modulating cytokine networks for the treatment of CD.

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Characterization of structures with T-lymphocyte aggregates in ileal villi of Crohn's disease

Naganuma Makoto, Watanabe Mamoru, Kanai Takanori, Iwao Yasushi, Mukai Makio, Ishii Hiromasa, Hibi Toshifumi

American Journal of Gastroenterology 97 ( 7 ) 1741 - 1747 2002

ISSN 0002-9270

OBJECTIVES: Epithelioid granulomas with transmural inflammation are a characteristic histological feature in Crohn's disease (CD). However, these are not frequently detected by histopathological examination in the biopsy specimens. Here, we demonstrated unique structures with T-lymphocyte aggregates (TLAs) that were specifically found in ileal villi of CD. We characterized the histological and phenotypical features of these structures and assessed the diagnostic value of TLAs for CD. METHODS: Tissue samples were obtained from the inflamed and uninflamed areas of ileal and colonic mucosa of 32 patients with CD. For controls, mucosal samples were obtained from unaffected areas of 18 patients with colon cancer and inflamed and uninflamed areas of 12 patients with ulcerative colitis (UC). RESULTS: 1) In 21 of 32 cases of CD (66%), we found unique structures with lymphoid cell aggregates that were localized in villi of ileum. These structures were not detected in any normal or UC intestine. 2) These structures were composed mainly of T cells, and CD4+ CD45RO+ cells dominated. Neither B cells nor c-kit positive immature lymphocytes were found. Moreover, CD68 positive macrophages were demonstrated in these aggregates, and cells positive for interleukin 18, a pivotal cytokine for Th1 differentiation, were expressed. 3) The aggregates were detected in seven of 13 patients with CD in whom granuloma was not detected by precise histopathological examination. Furthermore, we detected TLAs even in the ilea of two of four CD patients (50%) whose affected lesions were limited to the colon. CONCLUSIONS: We demonstrated TLAs in intestinal villi that may contribute to the pathogenesis of CD. Detection of these lymphocyte aggregates is helpful for diagnosis of CD when granuloma is not found. © 2002 by Am. Coll. of Gastroenterology.

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Restricted V_H gene usage in lamina propria B cells producing anticolon antibody from patients with ulcerative colitis

Inoue Nagamu, Watanabe Mamoru, Sato Toshiro, Okazawa Akira, Yamazaki Motomi, Kanai Takanori, Ogata Haruhiko, Iwao Yasushi, Ishii Hiromasa, Hibi Toshifumi

Gastroenterology 121 ( 1 ) 15 - 23 2001

ISSN 0016-5085

Background & Aims: Autoimmune responses against colonic epithelium may play a role in the development of colonic inflammation associated with ulcerative colitis (UC). In this study, we established and characterized B-cell lines and clones that produced anticolon antibody from inflamed colonic mucosa of UC subjects. Methods: B-cell lines were generated through Epstein-Barr virus transformation of lamina propria lymphocytes (LPLs) from colonic mucosa and peripheral blood lymphocytes, and these lines were screened for the production of anticolon antibodies. B-cell lines were then cloned by limiting dilution culture, and messenger RNA expression of immunoglobulin heavy-chain variable region (V_H) was assessed. Results: V_H gene families used in B-cell lines established from LPLs of normal controls were diverse, and B-cell lines from UC LPLs expressed a restricted V_H3 family usage. All 15 clones from UC used a restricted V_H3 gene family, whereas diverse V_H gene families were used by 24 clones from normal controls. The analysis of nucleotide sequences indicated that these clones were derived from various germline gene segments. Conclusions: The restricted V_H gene usage in anticolon autoantibodies producing B-cell clones suggests that a particular antigenic stimulus contributes to the pathogenesis of UC.

Macrophage-derived IL-18-mediated intestinal inflammation in the murine model of Crohn's disease

Kanai Takanori, Watanabe Mamoru, Okazawa Akira, Sato Toshiro, Yamazaki Motomi, Okamoto Susumu, Ishii Hiromasa, Totsuka Teruji, Iiyama Ryoichi, Okamoto Ryuichi, Ikeda Masao, Kurimoto Masashi, Takeda Kiyoshi, Akira Shizuo, Hibi Toshifumi

Gastroenterology 121 ( 4 ) 875 - 888 2001

ISSN 0016-5085

Background & Aims: Crohn's disease (CD) is associated with an increased number of infiltrating macrophages, which release a variety of proinflammatory cytokines. Interleukin (IL)-18 has been implicated in the modulation of mucosal CD4 ⁺ T cells towards Th1 responses, which are implicated in the pathogenesis of CD. Here we assess the role of macrophages and of IL-18 in the murine model of intestinal inflammation that mimics the immunologic characteristics of human CD. Methods: Colitis was induced in C57BL/6 mice immunized with 2,4,6-trinitrobenzene sulfonic acid (TNBS) followed by rectal administration of TNBS in ethanol. Mice were treated with either an antibody directed against macrophages conjugated to the ribosome-inactivating protein saporin (anti-Mac-1-saporin) or with a neutralizing antibody against IL-18. In addition, we assessed whether an identical TNBS immunization/challenge protocol could induce colitis in IL-18 ^-/- mice. Results: The colonic mucosa of TNBS-treated mice was marked by infiltration of Mac-1-positive macrophages and up-regulation of IL-18. The administration of the anti-Mac-1-saporin antibody or the neutralizing anti-IL-18 antibody resulted in a dramatic attenuation of mucosal inflammation in this model. In addition, TNBS was unable to induce significant colitis in the IL-18 ^-/- mice. Conclusions: Our data underscore the pivotal role of macrophages, and the macrophage-derived IL-18, in the establishment of TNBS-induced colitis in mice. Our results highlight the potential use of therapy directed against IL-18 in the treatment of patients with CD.

Interleukin-18 and Crohn's disease

Kanai Takanori, Watanabe Mamoru, Okazawa Akira, Sato Toshiro, Hibi Toshifumi

Digestion 63 ( SUPPL. 1 ) 37 - 42 2001

ISSN 0012-2823

The etiology and pathogenesis of inflammatory bowel disease remains an area under intense investigation. Crohn's disease (CD) is characterized by a marked accumulation of activated Th1 type CD4+ T cells and macrophages in inflamed intestinal mucosa. IL-18 is a recently described cytokine that mainly exists in activated macrophages and shares biological activities with IL-12 in driving the development of Th1 type CD4+ T cells by inducing interferon-γ. To clarify the role of IL-18 in intestinal inflammation in CD, we assessed the functional role of IL-18 in regulating intestinal mucosal lymphocytes in human CD and murine CD model. Copyright © 2001 S. Karger AG, Basel.

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Circulating autoantibodies against purified colonic mucin in ulcerative colitis

Takaishi Hiromasa, Ohara Susumu, Hotta Kyoko, Yajima Tomoharu, Kanai Takanori, Inoue Nagamu, Iwao Yasushi, Watanabe Mamoru, Ishii Hiromasa, Hibi Toshifumi

Journal of Gastroenterology 35 ( 1 ) 20 - 27 2000.01

ISSN 0944-1174

To clarify the role of colonic mucin in the autoimmune process of ulcerative colitis, circulating antibodies against human colonic mucin were investigated. Purified colonic mucin, obtained from human colonic mucosa by gel filtration, using a Bio-Gel A-1.5-m column and CsCl equilibrium density gradient, was divided into soluble mucin (S-mucin) secreted extracellularly and membranous mucin (M-mucin) binding to cell membrane. Sodium dodecylsulfate polyacrylamide gel electrophoresis and Western blotting analysis showed that antibodies in the serum samples of some patients with ulcerative colitis recognized purified S- and M-mucin of >180-kD. By enzyme-linked immunosorbent assay (ELISA), anti-mucin antibodies were detected in 11 of 60 patients with ulcerative colitis (18). In contrast, the antibodies were not detected in 22 patients with Crohn's disease. The titers of anti-mucin antibodies against S-mucin and M-mucin were not different in each patient. By ELISA using mucin in which the sugar chains were destroyed by neuraminidase or NaIO₄ treatment, it was demonstrated that anti-mucin antibodies recognized the epitopes of either the sugar chain or the core protein exposed through destruction of the sugar chains. We then investigated the relationship between anti-mucin antibodies and the patients' clinical features. Anti-mucin antibodies were detected in 6 of 15 patients with chronic continuous type ulcerative colitis (40) and in 5 of 26 patients with relapsing-remitting type (19), but there was no anti-mucin antibody-positive serum in patients who had had only one attack without any relapse. These results suggest that anti-mucin antibodies could be a disease marker for ulcerative colitis and that immunological abnormalities in colonic mucin contribute to the persistence of colonic mucosal inflammation.

Regulatory effect of interleukin-4 and interleukin-13 on colon cancer cell adhesion

Kanai T., Watanabe M., Hayashi A., Nakazawa A., Yajima T., Okazawa A., Yamazaki M., Ishii H., Hibi T.

British Journal of Cancer 82 ( 10 ) 1717 - 1723 2000

ISSN 0007-0920

To assess the role of interleukin-4 (IL-4) and interleukin-13 (IL-13) in colon cancer cell-cell adhesion, we investigated the effect of both cytokines in human colon cancer cell line, colo205 cell-cell adhesion. IL-4 receptor was expressed on the cell surface of colo205, and recombinant IL-4 inhibited colo205 cell-cell adhesion in a dose-dependent fashion without inhibiting cell proliferation. Flow cytometric analysis revealed that monoclonal antibodies (mAbs) directed against E-cadherin and carcinoembryonic antigen (CEA) inhibited colo205 cell-cell adhesion and IL-4 significantly inhibited the expression of E-cadherin and CEA. IL-13 also inhibited colo205 cell-cell adhesion. These results indicated that IL-4 and IL-13 inhibited colon cancer cell-cell adhesion by down-regulation of E-cadherin and CEA molecules. We then investigated the expression of both cytokines from freshly isolated colon cancer tumour-infiltrating lymphocytes (TILs). With reverse transcription-polymerase chain reaction and flow cytometric analysis. we demonstrated that colon TILs expressed IL-4 and IL-13 mRNA and protein. These results suggest that Th 2 type cytokines IL-4 and IL-13 locally-produced from TILs may regulate colon cancer adhesion by down-regulation of adhesion molecules. (C) 2000 Cancer Research Campaign.

Analysis of clinical course and long-term prognosis of surgical and nonsurgical patients with intestinal Behcet's disease

Naganuma Makoto, Iwao Yasushi, Inoue Nagamu, Hisamatsu Tadakazu, Imaeda Hiroyuki, Ishii Hiromasa, Kanai Takanori, Watanabe Mamoru, Hibi Toshifumi

American Journal of Gastroenterology 95 ( 10 ) 2848 - 2851 2000

ISSN 0002-9270

OBJECTIVE: Much remains unknown about the pathogenesis of intestinal Behcet's disease. The majority of these patients are treated with surgical intervention, although it has been recently reported that a number of medical treatments are sometimes effective. Only few studies, however, have ever been undertaken to analyze the long-term prognosis of this disease. In this study, we analyzed the clinical course and the recurrences after initial therapy in patients with intestinal Behcet's disease. METHODS: We investigated 20 patients (surgical group, n = 8; nonsurgical group, n = 12) for whom the clinical courses were known for ≥2 yr (2-23 yr). RESULTS: The surgical group tended to have higher rates of complications such as ocular and ileal lesions than the nonsurgical group. In the surgical group, 75% of the patients recurred (and were readmitted) within 2 yr, and 37.5% of the patients required reoperation for intestinal obstruction because of ulcer at the anastomosis. The percentage of peripheral CD8 + DR + lymphocytes in the recurrent group (10.4% ± 2.5%) was significantly higher than that in the nonrecurrent group (4.3% ± 1.2%, p < 0.05). CONCLUSIONS: Our results indicate that more extensive disease involving the ileum and ocular lesions are markers of severity and progression to surgical crisis, and that patients requiring surgery suffer more frequent recurrences. Furthermore, an increased percentage of peripheral CD8 + DR + lymphocytes may be a risk factor for disease recurrence. (C) 2000 by Am. Coll. of Gastroenterology.

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Clinical usefulness of microsatellite instability for the prediction of gastric adenoma or adenocarcinoma in patients with chronic gastritis

Kashiwagi K., Watanabe M., Ezaki T., Kanai T., Ishii H., Mukai M., Hibi T.

British Journal of Cancer 82 ( 11 ) 1814 - 1818 2000

ISSN 0007-0920

To assess a role of microsatellite instability (MSI) in the development of gastric adenocarcinoma or adenoma from chronic gastritis, we analysed mutations of five microsatellite loci in gastritis, adenoma and adenocarcinoma retrospectively. Gastric mucosa was biopsied from the same area in each patient at different periods and examined for MSI. Only one of 55 patients with chronic gastritis revealed MSI-H phenotype and the other 54 patients showed microsatellite stable (MSS) phenotypes. In six of 17 patients with gastric adenoma or well-differentiated adenocarcinoma, MSI-positive phenotypes were demonstrated. Interestingly, all of six patients showing MSI, including three high-level MSI (MSI-H) cases and three low-level (MSH-L) cases, had already revealed MSI at the stage of chronic gastritis. In two of three MSI-H cases, the identical MSI patterns had been observed at the stage of gastritis 1.5-7 years before the final diagnosis of adenocarcinoma. The adjacent gastritis mucosa within 10 mm from the carcinoma demonstrated MSI as well. MSI was not found in any of 35 patients with Helicobacter pylori infection, but found in one of 30 patients without infection. Moreover, two of three cases of gastric adenoma or well-differentiated adenocarcinoma with MSI-H at the stage of chronic gastritis showed no evidence of Helicobacter pylori infection throughout the observation periods. These results indicate that MSI in biopsy specimens at the stage of chronic gastritis may predict the risk of the progression to adenoma and well-differentiated adenocarcinoma, and that Helicobacter pylori infection itself may not induce MSI directly in the gastric mucosa. (C) 2000 Cancer Research Campaign.

Interleukin 18 is a potent proliferative factor for intestinal mucosal lymphocytes in Crohn's disease

Kanai Takanori, Watanabe Mamoru, Okazawa Akira, Nakamaru Koichi, Okamoto Makiyo, Naganuma Makoto, Ishii Hiromasa, Ikeda Masao, Kurimoto Masashi, Hibi Toshifumi

Gastroenterology 119 ( 6 ) 1514 - 1523 2000

ISSN 0016-5085

Background & Aims: Crohn's disease (CD) is characterized by a marked accumulation of activated Th1 type CD4⁺ T cells and macrophages in inflamed intestinal mucosa. Interleukin (IL)-18 is a recently described cytokine that mainly exists in activated macrophages and shares biological activities with IL-12 in driving the development of Th1 type CD4⁺ T cells by inducing interferon gamma. To clarify the role of IL-18 in intestinal inflammation in CD, we assessed the functional role of IL-18 in regulating intestinal mucosal lymphocytes. Methods: Serum IL-18 concentration was measured by enzyme-linked immunosorbent assay. Expression of IL-18 and IL-18 receptor in human intestinal mucosa was determined using immunohistochemistry and flow cytometry. The functional activity of IL-18 was assessed by the use of recombinant IL-18 to stimulate both the growth of intestinal mucosal lymphocytes and IL-2 receptor induction activity. Results: The serum IL-18 concentration was significantly higher in patients with CD than normal controls. In the inflamed colonic mucosa of CD, many IL-18⁺CD68⁺ macrophages had infiltrated the lamina propria. Intestinal mucosal lymphocytes from CD expressed functional IL-18 receptors. Recombinant IL-18 induced significant proliferative responses in freshly isolated mucosal lymphocytes from CD patients, but not from normal controls. 1L-18 up-regulated IL-2 receptor expression in mucosal lymphocytes from patients with CD, but not from normal controls. Conclusions: These findings suggest that infiltrated macrophages in the inflamed intestinal mucosa in CD produce IL-18, and that macrophage-derived IL-18 may serve as a potent regulatory factor for intestinal mucosal lymphocytes, thereby contributing to chronic intestinal inflammation in CD.

The role of IL-18 on the pathogenesis of Crohn's disease

Hibi T., Kanai T., Watanabe M., Okazawa S., Sato T.

Nihon Rinshō Men'eki Gakkai kaishi = Japanese journal of clinical immunology 23 ( 6 ) 607 - 610 2000

ISSN 0911-4300

Interferon-inducible gene family 1-8U expression in colitis-associated colon cancer and severely inflamed mucosa in ulcerative colitis

Hisamatsu Tadakazu, Watanabe Mamoru, Ogata Haruhiko, Ezaki Toshihiko, Hozawa Shigenari, Ishii Hiromasa, Kanai Takanori, Hibi Toshifumi

Cancer Research 59 ( 23 ) 5927 - 5931 1999.12

ISSN 0008-5472

Persistent severe inflammation in colonic mucosa is thought to cause the development of colon cancer in patients with ulcerative colitis (UC). However, predisposing genetic abnormalities have not been identified in this sequence. Using differential display PCR, we isolated cDNA fragments corresponding to mRNAs that were differentially expressed in colitis- associated cancer tissues and mucosa with mild inflammation in the colon of five UC patients. This molecular screening approach identified 60 cDNA fragments, and we sequenced 34 fragments. One cDNA fragment, which is identical to IFN-inducible gene family 1-8U, was strongly expressed in all five UC-associated cancers. 1-8U was also expressed in sporadic colon cancer tissues and colon cancer cell lines, but not in normal mucosa. This gene was strongly expressed in severely inflamed colonic mucosa of UC without colitis- associated colon cancer, although 1-8U expression was not related to the extent and duration of the disease. However, 1-8U was expressed in the colonic mucosa of all patients with chronic, continuously severe inflammation. These results indicated that IFN-inducible gene family 1-8U expression in inflamed colonic mucosa might be used as a preferential marker of colitis-associated colon cancer in UC.

A case of well differentiated adenocarcinoma with ulcerative colitis resembling colitis cystica profunda

Naganuma Makoto, Iwao Yasushi, Miura Soichiro, Okamoto Ikuo, Ohkura Yasuo, Kanai Takanori, Watanabe Mamoru, Hibi Toshifumi, Ishii Hiromasa

Japanese Journal of Gastroenterology 96 ( 6 ) 658 - 663 1999.06

ISSN 0446-6586

Functional expression of costimulatory molecule CD86 on epithelial cells in the inflamed colonic mucosa

Nakazawa A., Watanabe M., Kanai T., Yajima T., Yamazaki M., Ogata H., Ishii H., Azuma M., Hibi T.

Gastroenterology 117 ( 3 ) 536 - 545 1999

ISSN 0016-5085

Background and Aims: Costimulatory signals are essential for T-cell activation. The aim of this study was to demonstrate expression of costimulatory molecules CD86 and CD80 in human colonic epithelial cells and assess their functional roles in the activation of T cells in inflamed colonic mucosa. Methods: CD86 and CD80 expression was assessed by immunohistochemistry of colonic mucosa, reverse-transcription polymerase chain reaction, and flow cytometric analysis of isolated colonic epithelial cells and cell lines. Costimulatory effect of CD86-expressing colonic epithelial cells on purified CD4⁺ T-cell proliferation was also assessed at suboptimal phytohemagglutinin stimulation. Results: CD86 and CD80 messenger RNA was detected in isolated colonic epithelial cells from normal and inflamed mucosa of patients with ulcerative colitis. Immunohistochemistry and flow cytometric analysis of colonic epithelial cells confirmed cell surface expression of CD86 protein in inflamed colonic mucosa. Cell surface expression of CD86 protein was increased in the colonic epithelial cell line HT29-18-N2 after interferon gamma stimulation. Purified CD4⁺ T cells proliferated in response to suboptimal phytohemagglutinin costimulated with interferon gamma-stimulated HT2918-N2, and these proliferative responses were efficiently inhibited by the addition of anti-CD86 monoclonal antibody. Costimulatory effect of CD86-expressing colonic epithelial cells isolated from inflamed mucosa of ulcerative colitis was also demonstrated at suboptimal phytohemagglutinin stimulation in CD4⁺ T cells. Conclusions: Colonic epithelial cells may act as antigen-presenting cells, and contribute to the activation of T cells through costimulatory molecule CD86 expression in inflamed colonic mucosa.

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Predictive factors of response to leukocytapheresis therapy for ulcerative colitis

Yajima Tomoharu, Takaishi Hiromasa, Kanai Takanori, Iwao Yasushi, Watanabe Mamoru, Ishii Hiromasa, Hibi Toshifumi

Therapeutic Apheresis 2 ( 2 ) 115 - 119 1998.05

ISSN 1091-6660

Leukocytapheresis (LCAP) using a leukocyte removal filter was performed for 8 patients with moderate to severe ulcerative colitis (UC). Significant clinical improvement was attained in 5 of 8 patients (62.5%). All of them had been suffering from moderately active colitis and received corticosteroid therapy. On the other hand, 3 patients with severely active disease and treated with little or no corticosteroid were resistant to LCAP. This result indicates that LCAP is an effective treatment for steroid-resistant cases of UC when combined with steroid therapy. LCAP alone, however, seems to have little efficacy for severely active UC.

Gastrointestinal endoscopy as a screening method for cytomegalovirus infection following allogeneic bone marrow transplantation

Yajima T., Iwao Y., Hisamatsu T., Okamato S., Ikeda Y., Sugiura H., Mukai M., Kanai T., Ogata H., Watanabe M., Hibi T., Ishii H.

Gastrointestinal Endoscopy 47 ( 4 ) 1998

ISSN 0016-5107

Background and Aim: Cytomegalovirus (CMV) infection is a serious complication following solid organ and bone marrow transplantation (BMT). CMV affects multiple organs and results in considerable morbidity and prolonged hospitalization. But the clinical feature of upper GI lesions in CMV infection after BMT remains unclear. Detection of CMV antigen in peripheral blood leukocytes with immunohistochemical technique (antigenemia) is the most reliable screening method for CMV infection. The antigenemia is, however, not sensitive enough in some cases. The aim of this study is to investigate the clinical significance of upper GI lesions in CMV infection. Patients and Methods: We performed endoscopic examination of the upper GI tract in 47 patients 20 to 70 days after allogeneic BMT from December 1992 to November 1997. Biopsy specimens, taken each from esophagus, stomach body and antrum, and duodenum, were assayed for CMV antigen with immunohistochemical technique. Results: CMV infection was revealed in the upper GI tract in 9 patients. The endoscopic findings of the affected lesions were characteristic erosions surrounded by redness in the stomach and duodenum, map-like redness in the duodenum, and ulcer in the esophagus. Stomach was involved in all cases (9/9, 100%), but duodenum (4/9, 44%) and esophagus (2/9, 22%) were less frequently infected. In 3 patients, CMV antigen was detected in the upper GI tract before antigenemia turned positive. Conclusion: The endoscopic examination of upper GI tract is a useful screening method for CMV infection following allogeneic BMT.

The serum factor from patients with ulcerative colitis that induces T cell proliferation in the mouse thymus is interleukin-7

Watanabe Mamoru, Watanabe Noriaki, Iwao Yasushi, Ogata Haruhiko, Kanai Takanori, Ueno Yoshitaka, Tsuchiya Masaharu, Ishii Hiromasa, Aiso Sadakazu, Habu Sonoko, Hibi Toshifumi

Journal of Clinical Immunology 17 ( 4 ) 282 - 292 1997

ISSN 0271-9142

The disturbance of immune regulatory T cells is related to the pathogenesis of ulcerative colitis. Here we demonstrated and characterized the serum factor from ulcerative colitis patients that induced proliferation of intrathymic T cells. The factor isolated from the patient sera by a combination of gel filtration and anion-exchange chromatography induced proliferation of CD4⁺CD8^- intrathymic T cells in the organ-cultured embryonic mouse thymus. Purification and amino acid sequence analysis of the serum factor demonstrated that the N-terminal 12 sequence was homologous to that of interleukin-7. SDS-PAGE and Western blot confirmed that purified serum factor was interleukin-7. Enzyme immunoassay demonstrated that the serum interleukin-7 concentration was significantly increased in the patients. PCR and Southern blot hybridization demonstrated that interleukin- 7 mRNA expression was increased in the thymus tissues from patients but decreased in the colonic mucosa. Since interleukin-7 is a crucial cytokine for proliferation and differentiation of T cells in the thymus, the present study indicates that interleukin-7 may contribute to the disturbance of immune regulatory T cells in ulcerative colitis.

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Carcinoembryonic antigen mediates in vitro cell aggregation induced by interferon-γ in a human colon cancer cell line

Kanai Takanori, Hibi Toshifumi, Hayashi Atsushi, Takashima Junya, Shiozawa Masahide, Aiso Sadakazu, Toda Kyoko, Iwao Yasushi, Watanabe Mamoru, Tsuchiya Masaharu

Cancer Letters 71 ( 1-3 ) 109 - 117 1993.07

ISSN 0304-3835

The homotypic cell aggregation of a carcinoembryonic antigen (CEA) positive colon cancer cell line (Colo 205) was induced in vitro by interferon-γ (IFN-γ) treatment. Divalent cations were required for this aggregation, as it was inhibited by EDTA. The partial inhibition by cytochalasin B and the complete inhibition by a mixture of sodium azide and 2-deoxyglucose suggests that the aggregation requires the integrity of cytoskeleton and active metabolism. The expression of CEA was increased in the cytoplasm and on the membrane of Colo 205 by IFN-γ treatment. Furthermore, this aggregation was inhibited completely by anti-CEA monoclonal antibody (mAb) and partially by mAb against intercellular adhesion molecule-1. This in vitro study suggests that CEA molecule participates in the IFN-γ induced homotypic adhesion of some CEA positive cancer cells and that IFN-γ has an important role in the regulation of cell-cell interaction mediated by CEA molecule. © 1993.

Access to Document (DOI)

Interleukin 2 and interferon-γ augment anticolon antibody dependent cellular cytotoxicity in ulcerative colitis

Hibi T., Ohara M., Watanabe M., Kanai T., Takaishi H., Hayashi A., Hosoda Y., Ogata H., Iwao Y., Aiso S., Watanabe N., Toda K., Tsuchiya M.

Gut 34 ( 6 ) 788 - 793 1993.06

ISSN 0017-5749

In vitro effects of cytokines and therapeutic drugs on antibody dependent cellular cytotoxicity (ADCC) mediated by anticolon antibody were investigated in serum samples from patients with ulcerative colitis. A ⁵¹Cr release assay was used to examine ADCC activity with the colon cancer cell line, colo 205, as the target and peripheral blood mononuclear cells as the effector. High ADCC activity was shown in 13 of 32 (41%) patients with ulcerative colitis. This ADCC activity was inhibited by protein A treatment of the serum samples. Interleukin 2 (IL2) activated effector cells could enhance ADCC activity, but interferon-γ (IFN-γ) or tumour necrosis factor-α (TNF-α) had no effect on the cytotoxic activity of effector cells. Treatment of target cells with IFN-γ increased the vulnerability of these cells to ADCC with a large increase of intercellular adhesion molecule-1 (ICAM-1) expression on their surface. Monoclonal antibodies to ICAM-1 inhibited this IFN-γ enhanced ADCC activity. Interestingly, prednisolone (PSL) reduced ADCC activity, but sulphasalazine (SASP) or 5-aminosalicylic acid (5-ASA) did not. These results suggest that IL2 and IFN-γ could enhance colonic epithelial cell injury mediated by the ADCC mechanism in ulcerative colitis and that ADCC enhanced by cytokines is restored by PSL treatment.

Burkitt's lymphoma of the stomach

Miyaguchi S., Hibi T., Kanai T., Tashiro H., Suematsu M., Guevara F. M., Tsuchiya M.

Endoscopy 25 ( 7 ) 494 - 495 1993

ISSN 0013-726X

A case of Crohn's disease which initially presented with diffuse inflammation in the rectum and sigmoid colon

Hibi T., Serizawa H., Tomita M., Suematsu M., Kanai T., Watanabe N., Tashiro Y., Sugino Y., Tsuchiya M.

Digestive Endoscopy 5 ( 2 ) 169 - 174 1993

ISSN 0915-5635

This case report describes a female patient with Crohn's disease who had diffuse proctosigmoiditis without a longitudinal ulcer or cobblestone appearance at the initial attack. She was treated with sulfasalazine on the presumptive diagnosis of ulcerative colitis. Two and a half months later, painful ulcers in the oral cavity and a deep longitudinal ulcer in the sigmoid colon were found, and a non-caseous granuloma was revealed in the biopsy specimens taken from the sigmoid colon. A definitive diagnosis of Crohn's disease was established from these findings and treatment with a corticosteroid was effective.

A case of Burkitt's lymphoma of the stomach with unusual features [3]

Miyaguchi S., Hibi T., Kanai T., Tashiro H., Suematsu M., Guevara F. M., Tsuchiya M.

Endoscopy 24 ( 6 ) 603 1992

ISSN 0013-726X

Establishment of epithelial cell lines from human and mouse thymus immortalized by the 12S adenoviral E1a gene product

Hibi T., Fujisawa T., Kanai T., Akatsuka A., Habu S., Handa H., Tsuchiya M.

Thymus 18 ( 3 ) 155 - 167 1991

ISSN 0165-6090

To understand the role of thymic epithelial cells in the development of immature thymocytes, the establishment and cloning of thymic epithelial cell lines must be required. In the present study, we established human and mouse thymic epithelial cell lines through the immortalization by the transfection of cDNA sequences of adenoviral E1a 12S mRNA. This procedure resulted in the isolation of five stable cell lines (one human cell line and four mouse cell lines). These cell lines were positive in cytokeratin demonstrated by immunohistochemistry. Electron microscopic study revealed that they had bundles of tonofilaments and desmosome-like tight junctions. These findings indicate that the cell lines immortalized by E1a gene have retained the properties of epithelial cells. MHC class II antigens were not expressed on these cell lines. When interferon-γ was added to the cultured epithelial cell lines, MHC class II antigens were induced in their cytoplasm and on their surface membrane, demonstrated by immunohistochemical and immunofluorescent studies. It is suggested that these stable cell lines from human and mouse thymus might serve a good tool for the further study of thymocytes differentiation and of unknown cytokines derived from thymus epithelium.

A case of enterocolitis with diffuse multiple aphthoid lesions in which non-caseous granulomas were demonstrated microscopically

Serizawa H., Hibi T., Niwa H., Tashiro H., Kanai T., Miura S., Sugino Y., Tashiro Y., Tsuchiya M.

Japanese Journal of Gastroenterology 87 ( 8 ) 1701 - 1705 1990.08

ISSN 0446-6586

Release of the serum immunosuppressive factor by monocytes in patients with crohn's disease

Watanabe M., Hibi T., Iwao Y., Kanai T., Ohara M., Fujisawa Ogata T. H., Watanabe N., Asakura H., Aiso S., Tsuru S., Tsuchiya M.

Journal of Clinical and Laboratory Immunology 29 ( 4 ) 161 - 166 1989

ISSN 0141-2760

We investigated the in vitro immunosuppressive effect of the sera and the culture supernatants of the peripheral blood mononuclear cells obtained from patients with Crohn's disease. Sera from Crohn's disease markedly suppressed the proliferative response of mouse spleen cells, compared with sera from ulcerative colitis, intestinal tuberculosis and normal controls. The culture supernatants of the adherent mononuclear cells from Crohn's disease showed a remarkable suppressive effect (96±1%), while the culture supernatants of the nonadherent mononuclear cells ha no suppressive activity (-10±16%). The culture supernatants of the adherent and non-adherent mononuclear cells from normal controls had no suppressive activity. The fractionization of the culture supernatants of the adherent cells from the Crohn's disease patients demonstrated that the fractions with high suppressive activity had similar or identical biochemical properties to the serum immunosuppressive fractions which has been reported previously. These results indicate that monocytes may release the serum immunosuppressive factor in Crohn's disease. This factor may contribute to the depression of the immune reactivity in the mucosal lesion and to the persistence of the stimulation of abnormal immune response in the intestinal wall.

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