Ferroptosis is a form of programmed cell death involved in various types of acute kidney injury (AKI). It is characterized by inactivation of the selenoprotein, glutathione peroxidase 4 (GPX4), and upregulation of acyl-CoA synthetase long-chain family member 4 (ACSL4). Since urinary selenium binding protein 1 (SBP1/SELENBP1) is a potential biomarker for AKI, this study investigated whether SBP1 plays a role in AKI. First, we showed that SBP1 is expressed in proximal tubular cells in normal human kidney, but is significant downregulated in cases of AKI in association with reduced GPX4 expression and increased ACSL4 expression. In mouse renal ischemia-reperfusion injury (I/R), the rapid downregulation of SBP1 protein levels preceded downregulation of GPX4 and the onset of necrosis. In vitro, hypoxia/reoxygenation (H/R) stimulation in human proximal tubular epithelial (HK-2) cells induced ferroptotic cell death in associated with an acute reduction in SBP1 and GPX4 expression, and increased oxidative stress. Knockdown of SBP1 reduced GPX4 expression and increased the susceptibility of HK-2 cells to H/R-induced cell death, whereas overexpression of SBP1 reduced oxidative stress, maintained GPX4 expression, reduced mitochondrial damage, and reduced H/R-induced cell death. Finally, selenium deficiency reduced GPX4 expression and promoted H/R-induced cell death, whereas addition of selenium was protective against H/R-induced oxidative stress. In conclusion, SBP1 plays a functional role in hypoxia-induced tubular cell death. Enhancing SBP1 expression is a potential therapeutic approach for the treatment of AKI.

ABSTRACT Background: Primary membranous nephropathy (pMN) is the most common pathological type of nephrotic syndrome in adults. Therefore, it is imperative to find a better combination therapy with fewer adverse effects for patients with pMN. Methods: This study enrolled 84 patients with biopsy-proven pMN and nephrotic syndrome. Thirty patients in the low-dose multitarget regimen (LDMT) group received low-dose glucocorticoids along with tacrolimus and mycophenolate mofetil, and 54 patients in the prednisone plus intravenous cyclophosphamide regimen (PC) group received corticosteroids plus intravenous cyclophosphamide. The clinical efficacy and safety of the LDMT and PC regimens in treating pMN in adults were analyzed and compared. Results: The cumulative complete remission rate was 6.67%, 56.30%, and 83.14% at the 6 th , 12 th , and 24 th month after treatment in the LDMT group, and 16.67%, 60.84%, and 81.02% in the PC group, respectively ( P = 0.620). The generalized estimating equation analysis showed that the longer the treatment duration, the better the improvements in serum albumin and urinary protein levels, and hyperlipidemia ( P = 0.0001). However, the serum creatinine levels in both groups remained stable during the treatment period. Meanwhile, the relapse rates were comparable between the two groups (21.43% vs. 22.00%, P = 0.953). Moreover, patients in the LDMT group showed fewer adverse events than those in the PC group (46.67% vs. 72.22%, P = 0.020). Conclusions: These data indicated that the low-dose multitarget regimen, which might be an alternative treatment choice for patients with pMN, had a more favorable safety profile and non-inferior efficacy compared with prednisone plus intravenous cyclophosphamide.

End-stage renal disease（ESRD） patients undergoing outpatient hemodialysis（HD） and home peritoneal dialysis（PD） are high risk population of severe and critical types caused by SARS-CoV-2 infection. In order to improve the quality of diagnosis and treatment in dialysis patients with SARS-CoV-2 infection, we wrote this recommendation for primary care clinicians. During the epidemic period of SARS-CoV-2 infection, all patients should be instructed to strengthen self-management. Once the SARS-CoV-2 infection was found in dialysis patients, early stratified management should be carried out within 72 hours after the first positive nucleic acid or antigen test results, which includes early antiviral therapy, early recognition, and transferring severe patients from community or primary hospital to a referral hospital promptly. Guidance for dietary and sports rehabilitation after SARS-CoV-2 infection should also be started as soon as possible.

目的 探讨舒血宁注射液联合用药治疗糖尿病肾病(DN)的疗效及对氧化应激和炎症因子的影响.方法 选取DN患者140例,分为对照组和实验组,各70例.对照组采用常规对症治疗,实验组在对照组的用药基础上增加舒血宁注射液治疗,比较两组治疗效果.结果 实验组治疗有效率高于对照组(P＜0.05);实验组治疗后IL-6、TNF-α、hs-CRP均低于对照组(P＜0.05);实验组SOD水平高于对照组,MDA、LPO水平低于对照组(P＜0.05).结论 采用舒血宁注射液联合用药可提高DN的治疗效果,其作用机制可能与该药能够降低炎性因子、提高抗氧化指标水平等有关,具有较高的临床应用价值.

Full-dose prednisone (FP) regimen in the treatment of high-risk immunoglobulin A nephropathy (IgAN) patients, is still controversial. The pulsed intravenous methylprednisolone combined with alternative low-dose prednisone (MCALP) might have a more favorable safety profile, which has not been fully investigated. Eighty-seven biopsy-proven IgAN adult patients and proteinuria between 1 and 3.5 g/24 h after ACEI/ARB for at least 90 days were randomly assigned to 6-month therapy: (1) MCALP group: 0.5 g of methylprednisolone intravenously for three consecutive days at the beginning of the course and 3rd month respectively, oral prednisone at a dose of 15 mg every other day for 6 months. (2) FP group: 0.8–1.0 mg/kg/days of prednisone (maximum 70 mg/day) for 2 months, then tapered by 5 mg every 10 days for the next 4 months. All patients were followed up for another 12 months. The primary outcome was complete remission (CR) of proteinuria at 12 months. The percentage of CR at 12th and 18th month were similar in the MCALP and FP groups (51% vs 58%, P = 0.490, at 12th month; 60% vs 56%, P = 0.714, at 18th month). The cumulative dosages of glucocorticoid were less in the MCALP group than FP group (4.31 ± 0.26 g vs 7.34 ± 1.21 g, P < 0.001). The analysis of the correlation between kidney biopsy Oxford MEST-C scores with clinical outcomes indicated the percentages of total remission was similar between two groups with or without M1, E1, S1, T1/T2, and C1/C2. More patients in the FP group presented infections (8% in MCALP vs 21% in FP), weight gain (4% in MCALP vs 19% in FP) and Cushing syndrome (3% in MCALP vs 18% in FP). These data indicated that MCALP maybe one of the choices for IgAN patients with a high risk for progression into ESKD. Trial registration: The study approved by the Chinese Clinical Trial Registry (registration date 13/01/2018, approval number ChiCTR1800014442, https://www.chictr.org.cn/ ).

Background/Aims: The imbalance of T helper 17 (Th17) and regulatory T (Treg) cells exists in the occurrence and development of various diseases. Endoplasmic reticulum stress (ERS) is an important self-protective cellular response to harmful stimuli, such as uremic environment. The objective of this study was to investigate the Th17/Treg cell balance and ERS in a uremic environment and analyze the relationship between them. Methods: (1) The rat spleen lymphocytes were extracted and treated with thapsigargin (inducer of ERS) and sodium citrate. The proportion of Th17 and Treg cells were then detected. (2) The uremic serum-cultured lymphocytes were used and divided into three groups: non-uremic serum group, uremic serum group, and uremic serum + sodium citrate group. Afterward, the proportion of Th17/Treg cells and the expression of ERS-related proteins (GRP78 and CHOP) were detected. Results: Thapsigargin had no significant effect on the proportion of Th17 cells within a limited concentration range, but it could reduce the proportion of Treg cells, sodium citrate had a negative influence on the deviation of Th17/Treg cells treated with thapsigargin. Uremic serum treatment reduced the proportion of Treg cells, resulting in an increase of the Th17/Treg ratio. However, sodium citrate had no influence on the deviation of Th17/Treg cells treated by uremic serum. Sodium citrate reduced the elevation of ERS-related proteins induced by uremic serum. Conclusions: Uremic serum can lead to the imbalance of Th17/Treg cells as well as ERS, suggesting that ERS is one of the mechanisms of the imbalance of Th17/Treg cells induced by uremic serum. Sodium citrate can inhibit ERS induced by uremic serum.

[目的]探讨慢性肾炎患者尿N-乙酰-β-D-葡萄糖苷酶(NAG)、β2-微球蛋白(β2-MG)水平及临床意义.[方法]比较慢性肾炎患者和同期体检的健康成年人(对照组)尿NAG、β2-MG、血炎症因子超敏C反应蛋白(hs-CRP)、肿瘤坏死因子-α(TNF-α)、肾功能指标血肌酐(SCr)、尿素氮(BUN)和营养指标白蛋白(ALB)、血红蛋白(HGB)、红细胞计数(RBC)的差异,并分析慢性肾炎患者尿NAG、β2-MG与相关指标的相关性.[结果]慢性肾炎组患者的NAG、β2-MG水平高于对照组(P＜0.01);慢性肾炎组患者的hs-CRP、TNF-α和SCr、BUN水平高于时照组(P＜0.01),RBC、HGB和ALB水平均低于对照组(P＜0.01);慢性肾炎患者NAG、β2-MG与hs-CRP、TNF-a、SCr、BUN呈正相关,与RBC、HGB和ALB呈负相关.[结论]慢性肾炎患者NAG、β2-MG水平较高,且与炎症因子、肾功能等指标相关.

提高住院医师的规范化培训质量是临床医学人才培养的关键,本文评价了微信学习互动群在肾病内科住院医师规范化培训中的积极作用.通过建立微信群,加入肾病内科规培的学员103人,定期在群中学习讨论.学员出科时通过考核和问卷调查评价微信群的作用,并与往年非微信群学员的成绩进行比较.发现参与微信群学习讨论的学员成绩高于非参与组差异有统计学意义,问卷调查结果规培学员及带教教师对微信学习群满意度高.我们得出结论:微信群是一种快捷、高效、实用的住院医师规范化培训和管理方式.

Objective To investigate the clinical effect and safety of sofosbuvir-based regimens in the treatment of hepatitis C virus (HCV)-associated glomerulonephritis (HCV-GN). Methods A retrospective analysis was performed for the clinical data of 5 patients with HCV-GN who were given sofosbuvir-based antiviral therapy in The Second Affiliated Hospital of Xi’an Jiaotong University from April 2015 to October 2018, and their clinical outcome and safety were analyzed. The patients were evaluated in terms of sustained virologic response at 12 weeks after treatment ended (SVR12), changes in liver/renal function and urinary protein during and after treatment, and safety. Results Five patients were enrolled, with an age of 27-81 years. There were 4 male patients, among whom 2 had liver cirrhosis. Of all patients, 4 had genotype 1b and 1 had genotype 2a. Renal biopsy was performed for 2 patients, who were diagnosed with membranoproliferative glomerulonephritis and mesangial proliferative glomerulonephritis, respectively. Of all patients, 2 received sofosbuvir+ribavirin, 2 received ledipasvir/sofosbuvir, and 1 received sofosbuvir/velpatasvir for 12 or 24 weeks. All 5 patients achieved SVR12. There were significant reductions in alanine aminotransferase and 24-hour urinary protein excretion from baseline to the end of treatment and 12 weeks of follow-up, with a slight increase in serum albumin. Blood urea nitrogen and serum creatinine were improved or showed no change. Only 1 patient experienced adverse gastrointestinal events associated with ribavirin. Conclusion Sofosbuvir-based regimens have good clinical effect and tolerability in patients with HCV-GN. Long-term follow-up should be performed to evaluate the long-term prognosis of renal disease after HCV clearance.

Macrophages in the kidney play different roles in renal interstitial fibrosis (RIF) depending on their phenotypes. M2 phenotype macrophages are believed to protect the kidney against RIF. Free fatty acid receptor GPR120 is expressed in macrophages, and its activation induces macrophage transition to M2 phenotype. In this study, the effects of GPR120 agonist-programmed macrophages on RIF were investigated. The peritoneal macrophages collected from rats were incubated with GPR120 agonist TUG891 in vitro for 24 h, and then they were transplanted autologously to the kidney with ureteral obstruction by intrarenal injection for 7 days on the same day following unilateral ureteral obstruction (UUO) operation. RIF was identified by Masson trichrome histological staining, and the expression of RIF-related proteins was analyzed by immunohistochemistry and western blot. It was observed that TUG891-programmed macrophages up-regulated the expression of CD206 and arginase-1 while the expression of interleukin-6 and tumor necrosis factor-α were down-regulated. RIF in rats was significantly increased following UUO, which was markedly alleviated by TUG891-programmed macrophages but not untreated macrophages. TUG891-programmed macrophages inhibited the abnormal expression of TGF-β1 and SMAD2. The abnormal expression of epithelial-mesenchymal transition (EMT)-related proteins including vimentin, α-SMA and β-catenin was also significantly decreased in rats with transplantation of TUG891-programmed macrophages as compared to UUO rats. This study suggests that autologous administration of peritoneal macrophages programmed in vitro by GPR120 agonist to kidney has a protective effect against RIF following UUO.

目的 探讨PBL联合CBL教学法应用于肾内科临床见习的教学效果.方法 研究对象选取在我院肾内科见习的64名学生,随机分为实验组和对照组,每组各32人,对照组采用传统的教学法即讲授法,实验组采用PBL联合CBL教学法,见习任务结束后进行随堂测试和问卷调查评估教学效果.结果 PBL联合CBL教学法组在学习成绩及教学方式满意度等方面显著高于传统教学法组,实验组学生考核成绩为(89.6±5.1)分,对照组学生(83.4±4.2)分,差异具有统计学意义(P＜0.05).结论 PBL联合CBL教学法相较传统教学法,能有效提高学生的学习成绩和主观能动性,有利于培养其临床思维能力,值得推广.

目的 研究血清成纤维细胞生长因子23(FGF23)、胎球蛋白A(FA)水平与维持性血液透析患者冠状动脉钙化的关系.方法 选择2016年4月～2017年4月西安交通大学第二附属医院收治的维持性血液透析患者97例,所有患者行冠状动脉多层螺旋CT检查,并根据冠状动脉Agaston评分(CACs)将患者分为无钙化组(CACs＜10分)21例,轻度钙化组(11分≤CACs＜ 100分)33例,中度钙化组(100分≤CACs＜400分)24例,重度钙化组(CACs≥400分)19例.比较各组患者基本资料,各项生化指标水平,并进行相关性分析.结果 重度钙化组患者年龄显著高于无钙化组、轻度钙化组、中度钙化组,透析时间长于无钙化组、轻度钙化组、中度钙化组,中度钙化组患者透析时间长于无钙化组,差异均有统计学意义(均P＜ 0.05).各组糖尿病患病率、高血压患病率和性别构成比较,差异无统计学意义(P＞0.05).无钙化组、轻度钙化组、中度钙化组、重度钙化组血磷、血清FGF23水平呈逐渐升高趋势,而血清FA水平呈逐渐降低趋势,各组间比较差异均有统计学意义(均P＜0.05),各组尿素氮、血肌酐、肾小球滤过率、空腹血糖、总胆固醇、三酰甘油、血钙比较,差异无统计学意义(P＞0.05).经Pearson相关性分析可得:维持性血液透析患者冠状动脉钙化程度与年龄、透析时间、血磷、血清FGF23水平均呈正相关,而与血清FA水平呈负相关(均P＜ 0.05).结论 血清FGF23、FA水平与维持性血液透析患者冠状动脉钙化存在密切相关,且随着血清FGF23水平的升高以及FA水平的降低,维持性血液透析患者冠状动脉钙化程度越严重.

Recent work in a murine model of ascending urinary tract infection has suggested that C5a/C5aR1 interactions play a pathogenic role in the development of renal infection through enhancement of bacterial adhesion/colonization to renal tubular epithelial cells (RTECs). In the present study, we extended these observations to human. We show that renal tubular epithelial C5aR1 signaling is involved in promoting uropathogenic Escherichia coli (UPEC) adhesion/invasion of host cells. Stimulation of primary cultures of RTEC with C5a resulted in significant increases in UPEC adhesion/invasion of the RTEC. This was associated with enhanced expression of terminal α-mannosyl residues (Man) (a ligand for type 1 fimbriae of E. coli) in the RTEC following C5a stimulation. Mechanism studies revealed that C5aR1-mediated activation of ERK1/2/NF-κB and upregulation of proinflammatory cytokine production (i.e., TNF-α) is at least partly responsible for the upregulation of Man expression and bacterial adhesion. Clinical sample studies showed that C5aR1 and Man were clearly detected in the renal tubular epithelium of normal human kidney biopsies, and UPEC bound to the epithelium in a d-mannose-dependent manner. Additionally, C5a levels were significantly increased in urine of urinary tract infection patients compared with healthy controls. Our data therefore demonstrate that, in agreement with observations in mice, human renal tubular epithelial C5aR1 signaling can upregulate Man expression in RTEC, which enhances UPEC adhesion to and invasion of RTEC. It also suggests the in vivo relevance of upregulation of Man expression in renal tubular epithelium by C5a/C5aR1 interactions and its potential impact on renal infection.

目的 探讨血清sclerostin水平与慢性肾衰竭(chronic renal failure,CRF)血液透析患者血管钙化(vascular calcification,VC)的关系.方法 选取2017年3月至5月于我院行维持性血液透析的94例CRF患者,收集相关临床资料,采用酶联免疫吸附法测定血清sclerostin水平,采用胸部计算机断层扫描(computed tomography,CT)明确血管钙化(包括主动脉钙化和冠状动脉钙化)情况,分析血清sclerostin水平与血管钙化的关系.结果钙化组患者与非钙化组患者相比,血清sclerostin水平显著升高[(121.23±53.13) vs.(81.84±30.20) pmol/L,P＜0.05].多因素Logistic回归分析显示血清sclerostin(OR=1.038,P＜0.01)与透析患者VC发生相关.当sclerostin水平为91.27pmol/L时,灵敏度和特异度均为0.71,此时灵敏度和特异度之和最大,因此,预测VC的最佳截断值为91.27 pmol/L;联合年龄、糖尿病、钙和全段甲状旁腺激素时预测VC的灵敏度为0.91,特异度为0.74.结论 血清sclerostin水平在透析患者中显著升高,并与透析患者VC发生相关,对VC有一定的预测价值.

目的:探讨病例教学法在肾病科临床见习教学中的效果.方法:将92名五年制临床医学本科大三见习学生随机分为对照组和实验组,分别采用了传统教学法和病例教学法对见习学生进行教学,通过对学生医学理论知识考核和学生对两种教学法的满意率两方面来的比较两种教学方法的效果.结果:实验组见习学生在医学理论知识掌握度及学生对教学满意率两方面均优于对照组.结论:在肾病科的临床见习教学中,病例教学法优于传统教学法.

住院医师规范化培训是医学生毕业后医学教育的重要组成部分,总结自2015年以来西安交通大学第二附属医院的住院医师规范化培训工作,发现其中存在一些问题,最突出的是培训学员在受教育程度、临床水平、科研和教学能力上存在着极大差异,造成目前“一刀切”式培训模式的培训效果不理想.我们采取了“分层分段式教学”模式,将学员合理分层,同时将培训过程分为四个阶段,采用循序渐进、分段考核的方式进行培训,取得了良好的培训效果.

To investigate the relationship between the regulatory immune network and endoplasmic reticulum stress (ERS) in patients with different stages of chronic kidney disease (CKD).A total of 91 patients diagnosed with CKD were divided into different groups according to the stage of disease and treatment with hemodialysis (HD) or peritoneal dialysis (PD). Routine blood and biochemical tests were performed in patients in the different CKD groups and in healthy controls (n=20). The frequencies of T helper type 17 (Th17) and regulatory T (Treg) cells in the overall T cell population were measured by flow cytometric analysis. Levels of Th17 cell (IL-17) and Treg cell (IL-10) cytokines and the ERS markers CCAAT-enhancer-binding protein homologous protein (CHOP) and glucose-regulated protein 78 (GRP78) were measured by enzyme-linked immunosorbent assay in serum samples collected from controls and patients. Correlations between each parameter and serum creatinine were analyzed by Spearman rank correlation and regression test.CKD stage showed a positive correlation with serum creatinine level, and increased and decreased percentages of Th17 and Treg cells, respectively, reflected in an increased Th17/Treg cell ratio. Consistent with this, CKD stage was positively correlated with serum concentrations of IL-17 and negatively correlated with serum IL-10 levels. Moreover, serum levels of CHOP and GRP78 increased with advancing CKD stage. These correlations were most pronounced in patients in the CKD5 group, who also had the poorest response to HD and PD treatment, compared with CKD5 patients in the nondialysis group. Correlation analysis showed that serum levels of CHOP and GRP78 were independently and positively correlated with the ratio of Th17/Treg cells.We have found that an increased Th17/Treg cell ratio and increased serum levels of ERS markers correlate with the progression of CKD. Our results indicate that the interplay between regulation of the immune network and management of ERS is closely associated with the pathogenesis of CKD. Although HD and PD treatment manage chronic kidney conditions and prevent further deterioration of renal function, they have limited effects on improving the immune disorder and relieving ERS. Our study suggests a potential new direction for development of therapeutic strategies in CKD.

目的 探讨BOPPPS和思维导图相结合的教学模式在内科学临床实践教学中的应用及教学效果.方法 以西安交通大学2012级临床医学本科生为研究对象,将其分为新教学模式组和传统教学模式组,分别应用BOPPPS结合思维导图的新教学模式和教师授课的传统教学模式开展教学,对学生学习效果进行评价及总结分析.结果 应用BOPPPS与思维导图相结合的新教学模式组的学生基础理论考试成绩与传统教学模式组无差异(P＞0.05),总成绩与病例分析部分成绩明显高于传统教学模式组(P＜0.05).结论 BOPPPS和思维导图相结合的教学模式有助于临床医学学生专业知识的掌握和临床思维的培养,值得推广.

Vascular calcification (VC) is a major contributor of cardiovascular dysfunction in chronic renal failure (CRF). Citrate binds calcium and inhibits the growth of calcium crystals. This present study intends to evaluate the effect of citrate on VC in adenine-induced CRF rats. The rats were randomly divided into five groups: the control group, the citrate control group, model group, model rats with low-dose treatment of citrate (216 mg/kg) and model rats with high-dose treatment of citrate (746 mg/kg). The rats were euthanized at 5 weeks with their blood and aorta in detection. The results showed that serum level of blood urea nitrogen, serum creatinine, phosphorus, calcium, and related renal failure function marker were elevated in the model group. Furthermore, the aortic calcium accumulation and alkaline phosphatase activity were significantly increased in the model group compared with control groups. Additionally, hematoxylin- eosin staining results demonstrated that the vascular calcification in aorta is significantly increased in the model group. Finally, the expression of VC-related proteins including bone morphogenetic protein and osteocalcin were increased in the model group, whereas alpha-smooth muscle actin was decreased in the model group compared with the control group. However, treatment with citrate caused a reversal effect of all the above events in a dose-dependent manner. In conclusion, citrate may attenuate vascular calcification in adenine-induced CRF rats.

Suppressor of cytokine signaling 1 (SOCS1) participates in renal fibrosis by downregulating Janus kinase 2 (JAK2)/signal transducer and activator of transcription 1 (STAT1)-mediated cytokine signaling. Recently, it was found that anti-double-stranded DNA (dsDNA) IgG induces the synthesis of profibrotic cytokines by renal cells. To explore the potential effect of anti-dsDNA IgG on SOCS1-mediated renal fibrosis, kidney tissues were collected from patients with lupus nephritis (LN) as well as MRL/lpr lupus-prone mice. The SOCS1 expression was evaluated in tissue samples. In addition, SCID mice were injected with anti-dsDNA IgG, followed by evaluation of SOCS1 levels. Renal resident cells were cultured in vitro, receiving the stimulation of anti-dsDNA IgG and then the measurement of SOCS1, JAK2, STAT1α, and profibrotic cytokines. Moreover, the binding of anti-dsDNA IgG to SOCS1 kinase inhibitory region (KIR) peptide was analyzed by surface plasmon resonance. We found that SOCS1 expression was inhibited, but JAK2/STAT1 activation was prominent in the kidney tissues of patients with LN, MRL/lpr mice, or anti-dsDNA IgG-injected SCID mice. The cultured renal cells also showed SOCS1 downregulation, JAK2/STAT1 activation, and profibrotic cytokine promotion upon anti-dsDNA IgG stimulation. Surprisingly, anti-dsDNA IgG showed high affinity to KIR peptide and competed with JAK2 loop for KIR. Additionally, a DNA-mimicking peptide (ALW) blocked the binding of anti-dsDNA IgG to KIR, and even partially abrogated the activation of JAK2/STAT1α signals and the expression of profibrotic cytokines in SCID mice. In conclusion, anti-dsDNA IgG downregulates SOCS1 expression, activates JAK2/STAT1 signals, and contributes to renal fibrosis; its peptide blockade may restore the SOCS1 inhibitory effect on the production of profibrotic cytokine, and finally ameliorate renal fibrosis in LN.