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BACKGROUND Therapeutic drug monitoring (TDM) is necessary for immunosuppressive therapy with tacrolimus and everolimus after kidney transplantation. Several studies have suggested that the concentrations of immunosuppressive agents in allografts may better reflect clinical outcomes than whole blood concentrations. This study aimed to develop a method for the simultaneous quantification of tacrolimus and everolimus concentrations in clinical biopsy samples and investigate their correlation with histopathological findings in kidney transplant recipients. METHODS Fourteen biopsy samples were obtained from kidney transplant recipients at 3 months after transplantation. Kidney allograft concentrations (Ctissue) of tacrolimus and everolimus were measured by liquid chromatography tandem mass spectrometry (LC-MS/MS), and the corresponding whole blood trough concentrations (C0) were obtained from clinical records. RESULTS The developed method was validated over a concentration range of 0.02[FIGURE DASH]2.0 ng/mL for tacrolimus and 0.04[FIGURE DASH]4.0 ng/mL for everolimus in kidney tissue homogenate. The Ctissue of tacrolimus and everolimus in kidney biopsies ranged from 21.0 to 86.7 pg/mg tissue and 33.5 to 105.0 pg/mg tissue, respectively. Dose-adjusted Ctissue of tacrolimus and everolimus was significantly correlated with the dose-adjusted C0 (P < 0.0001 and P = 0.0479, respectively). No significant association was observed between the Ctissue of tacrolimus and everolimus and the histopathologic outcomes at 3 months after transplantation. CONCLUSIONS This method could support further investigation of the clinical relevance of tacrolimus and everolimus allograft concentrations after kidney transplantation.

Nephrotoxicity is the major adverse reaction to tacrolimus; however, the underlying mechanisms remain to be fully elucidated. Although several tacrolimus-induced nephrotoxicity animal models have been reported, most renal injury rat models contain factors other than tacrolimus. Here, we report the development of a new nephrotoxicity with interstitial fibrosis rat model induced by tacrolimus administration. Thirty Wistar rats were randomly divided into four groups: sham-operated (Sham), vehicle-treated ischemia reperfusion (I/R) injury (IRI), tacrolimus treated (TAC) and tacrolimus treated I/R injury (TAC + IRI). Rats subjected to IR injury and treated with tacrolimus for 2 weeks showed higher serum creatinine (Scr), blood urea nitrogen (BUN), serum magnesium (Mg) and serum potassium (K), indicating decreased renal function. In addition, tacrolimus treatment combined with IR injury increased histological injury (tubular vacuolation, glomerulosclerosis and interstitial fibrosis), as well as α-smooth muscle actin (α-SMA), transforming growth factor-β (TGF-β), and kidney injury molecule-1 (KIM-1) expression in the renal cortex. In summary, we have developed a tacrolimus-induced kidney injury rat model with interstitial fibrosis within 2 weeks by creating conditions mimicking renal transplantation via tacrolimus administration following ischemia-reperfusion.

For many of the novel antiepileptics, immunoassays, used for routine therapeutic drug monitoring (TDM), cannot be used. We could monitor eight novel antiepileptics using an LC/MS method since July 2017. The purpose of this study was to evaluate the significant changes associated with the transition from outsourcing to in-hospital monitoring of novel antiepileptics. The number of measurements of novel antiepileptics was significantly increased during the first (p

Aims Tacrolimus—a widely used immunosuppressant to prevent allograft rejection after organ transplantation—is nephrotoxic, increasing the risk of kidney injury accompanied by kidney fibrosis. The mammalian target of rapamycin (mTOR) inhibitor, everolimus, is an immunosuppressant used together with tacrolimus. Although mTOR signaling inhibition has been demonstrated to exhibit antifibrotic effects, the efficacy of everolimus against tacrolimus-induced kidney fibrosis has not been explored. Therefore, we evaluated the protective effects of everolimus against tacrolimus-induced kidney fibrosis. Main methods To assess antifibrotic effect of everolimus against tacrolimus-induced kidney fibrosis, male Wistar rats were subcutaneously administered vehicle or tacrolimus (5 mg/kg per day) and/or everolimus (0.2 mg/kg per day) for 2 weeks after bilateral renal ischemia for 45 min. The antifibrotic effect of everolimus was also assessed using rat kidney fibroblast cell line (NRK-49F). Key findings Tacrolimus administration increased predominant profibrotic cytokine transforming growth factor-β (TGF-β) and fibroblast activation marker α-smooth muscle actin (α-SMA) expression and promoted the infiltration of macrophages in the kidney cortex, resulting in renal interstitial fibrosis in rats. Tacrolimus increased serum creatinine, blood urea nitrogen, kidney injury molecule-1 (KIM-1), and kidney injuries, such as tubular dilation, vacuolization, and glomerular atrophy. Everolimus administration attenuated tacrolimus-induced kidney fibrosis and the associated abnormalities. Everolimus strongly suppressed TGF-β-induced kidney fibroblast activation and extracellular matrix protein expression by the mTOR signaling inhibition. Significance We demonstrated that everolimus attenuates tacrolimus-induced renal interstitial fibrosis in rats. Owing to its protective effect against tacrolimus-induced kidney fibrosis, everolimus may be useful when used concomitantly with tacrolimus.

CYP3A5 gene polymorphism in recipients plays an important role in tacrolimus blood pharmacokinetics after renal transplantation. Even though CYP3A5 protein is expressed in renal tubular cells, little is known about the influence on the tacrolimus intrarenal exposure and hence graft outcome. The aim of our study was to investigate how the tacrolimus intrarenal concentration (Ctissue) could be predicted based on donor CYP3A5 gene polymorphism in renal transplant recipients. A total of 52 Japanese renal transplant patients receiving tacrolimus were enrolled in this study. Seventy-four renal biopsy specimens were obtained at 3 months and 1 year after transplantation to determine the donor CYP3A5 polymorphism and measure the Ctissue by liquid chromatography-tandem mass spectrometry (LC-MS-MS). The tacrolimus Ctissue ranged from 52 to 399 pg/mg tissue (n = 74) and was weak but significantly correlated with tacrolimus trough concentration (C0) at 3 months after transplantation (Spearman, r = 0.3560, p = 0.0096). No significant relationship was observed between the donor CYP3A5 gene polymorphism and Ctissue or Ctissue/C0. These data showed that the tacrolimus systemic level has an impact on tacrolimus renal accumulation after renal transplantation. However, donor CYP3A5 gene polymorphism alone cannot be used to predict tacrolimus intrarenal exposure. This study may be valuable for exploring tacrolimus renal metabolism and toxicology mechanism in renal transplant recipients.

CYP3A5 gene polymorphism in recipients plays an important role in tacrolimus blood pharmacokinetics after renal transplantation. Even though CYP3A5 protein is expressed in renal tubular cells, little is known about the influence on the tacrolimus intrarenal exposure and hence graft outcome. The aim of our study was to investigate how the tacrolimus intrarenal concentration (Ctissue) could be predicted based on donor CYP3A5 gene polymorphism in renal transplant recipients. A total of 52 Japanese renal transplant patients receiving tacrolimus were enrolled in this study. Seventy-four renal biopsy specimens were obtained at 3 months and 1 year after transplantation to determine the donor CYP3A5 polymorphism and measure the Ctissue by liquid chromatography-tandem mass spectrometry (LC-MS-MS). The tacrolimus Ctissue ranged from 52 to 399 pg/mg tissue (n = 74) and was weak but significantly correlated with tacrolimus trough concentration (C0) at 3 months after transplantation (Spearman, r = 0.3560, p = 0.0096). No significant relationship was observed between the donor CYP3A5 gene polymorphism and Ctissue or Ctissue/C0. These data showed that the tacrolimus systemic level has an impact on tacrolimus renal accumulation after renal transplantation. However, donor CYP3A5 gene polymorphism alone cannot be used to predict tacrolimus intrarenal exposure. This study may be valuable for exploring tacrolimus renal metabolism and toxicology mechanism in renal transplant recipients.

Kidney transplantation is the treatment of choice for patients with advanced chronic kidney disease (CKD) and end stage renal disease (ESRD). However, acute rejection (AR) is a common complication in kidney transplantation and is associated with reduced graft survival. Current diagnosis of AR relies mainly on clinical monitoring including serum creatinine, proteinuria, and confirmation by histopathologic assessment in the biopsy specimen of graft kidney. Although an early protocol biopsy is indispensable for depicting the severity of pathologic lesions in subclinical acute rejection (subAR), it is not acceptable in some cases and cannot be performed because of its invasive nature. Therefore, we examined the detection of noninvasive biomarkers that are closely related to the pathology of subAR in protocol biopsies three months after kidney transplantation. In this study, the urinary level of microtubule-associated protein 1 light chain 3 (LC3), monocyte chemotactic protein-1 (MCP-1), liver-type fatty acid-binding protein (L-FABP), neutrophil gelatinase-associated lipocalin (NGAL), and human epididymis secretory protein 4 (HE4) were measured three months after kidney transplantation. Urine samples of 80 patients undergoing kidney transplantation between August 2014 to September 2016, were prospectively collected after three months. SubAR was observed in 11 patients (13.8%) in protocol biopsy. The urinary levels of LC3, MCP-1, NGAL, and HE4 were significantly higher in patients with subAR than in those without, while those of L-FABP did not differ between the two groups. Multivariate regression models, receiver-operating characteristics (ROC), and areas under ROC curves (AUC) were used to identify predicted values of subAR. Urinary HE4 levels were able to better identify subAR (AUC = 0.808) than the other four urinary biomarkers. In conclusion, urinary HE4 is increased in kidney transplant recipients of subAR three months after kidney transplantation, suggesting that HE4 has the potential to be used as a novel clinical biomarker for predicting subAR.

Single nucleotide polymorphisms in drug-metabolizing genes may affect tacrolimus pharmacokinetics. Here, we investigated the influence of genotypes of CYP3A5, CYP2C19, and POR on the concentration/dose (C/D) ratio of tacrolimus and episodes of acute graft-versus-host disease (GVHD) in Japanese recipients of allogeneic hematopoietic stem cell transplantation (HSCT). Thirty-six patients receiving the first HSCT using tacrolimus-based GVHD prophylaxis were enrolled with written informed consent. During continuous intravenous infusion, HSCT recipients carrying the CYP3A5*1 allele, particularly those with at least one POR*28 allele, had a significantly lower tacrolimus C/D ratio throughout all three post-HSCT weeks compared to that in recipients with POR*1/*1 (p &lt, 0.05). The CYP3A5*3/*3 genotype and the concomitant use of voriconazole were independent predictors of an increased tacrolimus C/D ratio during the switch from continuous intravenous infusion to oral administration (p &lt, 0.05). In recipients receiving concomitant administration of voriconazole, our results suggest an impact of not only CYP3A5 and CYP2C19 genotypes, but also plasma voriconazole concentration. Although switching from intravenous to oral administration at a ratio of 1:5 was seemingly appropriate in recipients with CYP3A5*1, a lower conversion ratio (1:2&ndash, 3) was appropriate in recipients with CYP3A5*3/*3. Our results suggest that CYP3A5, POR, and CYP2C19 polymorphisms are useful biomarkers for individualized dosage adjustment of tacrolimus in HSCT recipients.

Mandibular movements are produced by a combination of condylar translation and rotation. The relationship between condylar translation and rotation during opening jaw movement and border movement was studied in 10 controls (4 men and 6 women), aged 20 to 26, without signs or symptoms of masticatory disorders and 61 patients (5 men and 56 women), aged 19 to 64 (average age 37.5), with closed lock of the temporomandibular joint (TMJ). The patterns of condylar movement and clinical findings were evaluated by means of multivariate analysis. Mandibular movements were recorded with an electronic jaw tracking system (JKN-1) consisting of 5000-pixel linear charge-coupled-device (CCD) cameras that register the position of six light-emitting diodes (LEDs) muted on two facebows separately attached to the upper and lower jaws. A computer produced plots of the opening angle versus the anterior condylar translation as well as the condylar path in the sagittal plane.The condylar translation/rotation patterns were analyzed visually for differences in trace patterns. The patterns on visual analysis could by classified into six types. Type I: At the begining and at the end of opening, rotation was more pronounced than translation. Type II: At the end of opening, translation was more pronounced than rotation. Type III: At the begining of opening, rotation was more pronouced than translation. Type IV: The condylar translation/rotation patterns were almost linear. Type V: At the end of opening, rotation was pronounced and translation was severely limited. Type VI: At opening, rotation was pronounced and translation was completely limited. These patterns in the patients with closed lock of the TMJ differed from those in the controls. Of the controls, 50% were found to be type I, and 30% were type II. In contrast, 44% of the patients with closed lock were found to be Type V, and 33% were Type VI.As for opening movement of patients with closed lock of the TMJ, abnomalities of condylar movement were more pronounced than those of movements at the incisive point. The results indicate that it is possible to diagnose the condition of closed lock disease. Moreover, our statistical evidence shows that it is possible to predict the patterns of condylar movement depending on age, degree of pain at opening, and deformity of the condyle.

A rare case of clear cell odontogenic carcinoma was investigated using histochemical and immunohistochemical methods. The tumor occurred in the anterior mandible of a 69-year-old Japanese man. Histologically, the tumor was composed mostly of large clear cells and squamous cells. Columnar-shaped cells with basophilic nuclei polarized away from the basement membrane were observed at the periphery of the tumor foci. The tumor cells had aggressively invaded muscle and perineural tissues. The tumor cells were positive for PAS staining. Immunohistochemically, tumor cells reacted positively to keratin, cytokeratin19, epithelial membrane antigen, and S-100 protein. The tumor was diagnosed as a clear cell odontogenic carcinoma. Its characteristics are discussed in term of its histopathological, histochemical and immunohistochemical features.

Genioplasty is a routine procedure for the improvement of profile in the correction of dentofacial deformities. Horizontal osteotomy of the inferior border of the mandible is usually performed. Osteotomized genial segment has conventionally been fixed with wire osteosyntheses. However, since this method had many disadvantages, use of rigid internal fixation with mini bone plates and screws or screws alone in genioplasty has spread. Rigid internal fixation provides a rapid and rigid means of stabilizing the inferior mandibular fragment after horizontal osteotomy, and is able to achieve the optimum bony union and the small resorption of bone. Moreover, screw fixation seems to have advantages over mini bone plates and screws, and also lag screw fixation seems to have advantages over position screw fixation.In 1989, we began using lag screw fixation after horizontal osteotomy in genioplasty by the use of only one titanium mini non self-tapping screw in the median part of the chin, and this screw is inserted through inferior approach and fixed to the lingual cortex of the mandible.So far, we have used it in 50 cases.This method has the following advantages:1. Excellent rigid osteosynthesis.2. Easy and rapid procedure.3. Easy removal.

It is very important to reposition and to keep the occlusal plane in harmonious relation to TMJ and the skull in two jaw surgery. In addition, the surgery should be performed as accurately as the presurgical planning.However, it is not always easy to satisfy the above-mentioned items in deformities indicating sagittal, transverse and vertical dysplasia or discrepancy of maxilla and mandible. For this reason, we have performed the method of intra-operative repositioning of the Le Fort I osteotomized maxilla according to the pre-operative planning by using the semi-adjustable articulator SAM or Whip-Mix facebow. We use routinely the simultaneous jaw movement by Le Fort I and sagittal splitting osteotomy for two jaw surgery.The maxillary position determined by preplanning of the cephalometric prediction tracing and model operation is recorded with the facebow. After the recording, the facebow with the bitefork is removed from the articulator, and is sterilized with gas to be ready for the intraoperative transfer.The maxilla is adequately mobilized as usual, the vertical dimensions of maxilla are reduced to the same extent as the model operation. The osteotomized maxilla is inserted into the bite fork. Then, the facebow is adjusted to the external auditory canal.In addition, intermaxillary wiring is performed after the mandible is also inserted into the bitefork. Once the facebow is fixed by the nasion locator, the facebow system is kept rigid and free from distortion.The characteristics or advantages and the indication of this facebow transfer system are as follows:1. This system using the Whip-mix or the SAM facebow guarantees precise transfer from the articulator to the patient.2. It has the possibility of obtaining intra-operatively accurate reproduction of the position of osteotomized maxilla in relation to the skull, the mandibular teeth arch, and the TMJ as preplanned.3. It has the possibility of keeping the transferred position and stabilizing maxilla with the mini-plates without freehanding.4. As this system is a “step by step” technical procedure, the laboratory workup is very important.5. The model operation in this system is for the oral surgeon operation training.6. The indication of this system seems to be facial asymmetry or long face with mandibular protrusion.We have performed this facebow transfer system on 14 patients and obtained good results. All patients currently have acceptable results.

Eosinophilic granuloma of soft tissue mainly appeares as a tumor-like nodule in the subcutanous head and neck region. Histopathologically, it is characterized oy the presence of lymphoid follicles, and marked infiltration of eosinophils, as well as fibrosis and vascular proliferation.We reported 4 cases of cosinophilic granuloma of soft tissue in the parotid-massetcr region, inferior surface of the tongue and buccal region. We obtained successful results by surgical procedures and/or radio therapy.

1. We experienced a basal cell nevus syndrome with huge multiple jaw cyst as major symptom and reported the case with other 4 experienced cases in our department.2. Ocular hyperterorism, broadened nasal root, frontal and biparietal bossing, jaw cyst, bridging of sella turcica and family appearance were observed at all cases.3. Basal cell nevi and pits were observed in cases 1, 2 and 5, but were unknown in cases 3 and 4.4. Keratocyst was the histological diagnosis of all jaw cysts.5. Treatment methods with jaw cysts were: Encleation after murspalization in case 1, presently murspalization and in the future enucleation in case 2, encleation alone in cases 3 and 4, and murspalization alone in case 5. Yet, cases 2 and 5 were recurrence by murspalization alone, therefor it was thought necessary to do complete enucleation including the surrounding healthy bone tissues.6. As jaw cysts were keratocyst, they were apt to recur, and the importance of long term progress observation is important.

The advantages are:(1) Stabilization of osteotomized bone fragment can be sure and complete.Relapse is less than with wire osteosynthesis.(2) In mandibular osteotomy, owing to monocortical osteosynthesis, damage to neurovascular bundle and root of teeth is rare.Miniplate can be used in maxilla that has thin layer of cortical bone.(3) Le Fort I osteotomy, zygomatic arch suspension wiring to stabilize bone fragments is unnecessary.(4) The period of intermaxillary fixation is shorter than wire osteosynthesis. Opening of the mouth can be possible during operation and immediate postoperation.Since 1982, we used miniplate in 63 cases of orthognathic surgical procedure with very satisfactory results.

The efficacy of Amfenac Sodium (Fenazox®), nonsteroid anti-inflammatory agent on temporomandibular joint pain was clinically evaluated in 28 temporomandibular arthrosis patients. Amfenac Sodium dosage of 200 mg was given orally in 4 times daily for two weeks.The results were as follows:1) Temporomandibular joint pain and limitation of mouth opening because of pain improved remarkedly.2) Effectiveness of Amfenac Sodium was “Excellent” in 5 cases (17.9%), “Good” in 12 cases (42.9%) and “Fair” in 10 cases (35.7%).3) Side effects were observed in 8 of the 28 cases. Most of those 3 cases had slight gastrointestinal disorders and only two cases were dropped.4) The usefulness of Amfenac Sodium was in 3 cases (10.7%) “Excellent”, 13 cases (46.4%) “Good” and 10 cases (35.7%) “Fair”.It is suggested that Amfenac Sodium is useful for relief from temporomandibular joint pain in temporomandibular arthrosis patients.

Kimura's disease, eosinophilic granuloma of soft tissues, is a chronic inflammatory condition and appears as subcutaneous tumor-like nodules in the head and neck regions. Histopathologically, it is characterized by the presence of lymphoid follicles, marked infiltration of eosinophils, fibrosis and vascular proliferation. This disease occurring in the orofacial region is relatively rare, only 14 cases having been previously reported. We describe 3 additional cases of Kimura's disease and discuss these in relation to angiolymphoid hyperplasia with eosinophilia.

In order to reconstruct the perfect shape of jaw bones, we developed the new operation procedures by using reimplantation of resected jaw portion treated by freezing and warming. The operation procedures which we developed are as follows.One is the one-stage procedure in which immediate reconstruction is performed intraorally, indicated for benign tumors and tumorlike conditions. The other is the two-stage procedure in which late reconstruction is performed extraorally, indicated for malignant tumors.We resect the affected jaw bone with the intact part included, and remove the affected parts from the resected jaw portion under direct observation, then decorticate the inner layer of the cortical bone and drill small holes on the cortical bone to prevent the cracking by deep freezing and to ensure the revascularization from the surrounding soft tissue.In order to kill the tumor cells within the resected jaw bones totally, we use two different freezing and warming treatments. The resected jaw portion is put into the freezing chamber at-85 degrees C for 45 minutes, and then immersed into physiological saline solution at+ 45 degrees C for 15 minutes. When the freezing apparatus is not available, the resected jaw portion is immersed into liquid nitrogen at-195 degrees C for 5 minutes, and then immersed into phisological saline solution at 45 degrees C for 10 minutes. These treatments are repeated three times respectively. After the treatment the cells in the lesion decreased in number and became low staining drastically.In the malignant cases the resected jaw portion is treated by the freezing and warming mentioned above, then lyophilized and stored in a vacuous bottle at the room temperature for over 18 months.The combination of resected jaw portion and fresh autogenous marrow and cancellousbone are used for reconstruction. The former is expected to play a role as an anatomical template, and the latter is used as a material capable of inducting osteogenesis.The one-stage procedure was performed in 6 cases and two-stage procedure in 2 cases. The mandibular reconstruction was performed in 7 eases and maxillary reconstruction in 1 case. No tumor recurrence was observed and satisfactory results without complication were obtained. At the postoperative biopsy of time reimplanted area, a large number of bone cells were observed in the bone that presented layers and remodelling, implying the absorption and new bone formation in the reimplanted bone.