Role of hypoalbuminemia in the genesis of cardiovascular disease in dialysis patients

Our objective was to review the articles about the association between hypoalbuminemia and atherosclerotic or thrombotic cardiovascular disease (CVD) and to look for possible explanations for the role of hypoalbuminemia. Increased incidences of CVD were reported in patients with hypoalbuminemia owing to renal or other diseases. Hypoalbuminemia increases plasma levels of lipoprotein(a), fibrinogen, and arachidonic acid metabolites; it also increases platelet aggregability and blood viscosity, all of which may contribute to the development of CVD. This cause effect association is thought to be "dependent." Changes in atherogenic lipoproteins or lipids, such as LDL cholesterol, triglycerides, and apolipoprotein B, are controversial in hypoalbuminemic dialysis patients, possibly because coexistent malnutrition and volume status can affect both albumin and lipids. In our recent study, there was a negative correlation between serum albumin and C-reactive protein, D-dimer (an index of intravascular thrombogenesis), and von Willebrand factor (a marker for endothelial cell injury), but infusion of albumin did not affect the level of these parameters, which suggests that the correlations may be an effect-effect association by a confounding variable, such as inflammation. In conclusion, hypoalbuminemia is associated with cardiovascular disease via two pathways: one, a "dependent" cause-effect association; the other, an effect-effect association.

Interleukin-1beta stimulates the production of extracellular matrix in cultured human peritoneal mesothelial cells

OBJECTIVE

To investigate the effect of interleukin-1beta (IL-1beta) on the production of extracellular matrix in cultured human peritoneal mesothelial cells (HPMCs).

DESIGN

Cultured HPMCs were treated with or without IL-1beta. Cell morphology was observed. The expression of fibronectin, alpha1(I) procollagen, and transforming growth factor-beta1 (TGFbeta1) mRNAs was measured by Northern blot analysis. The cell surface expression of fibronectin and type I collagen was evaluated by immunofluorescent staining. Fibronectin and type I collagen in culture supernatant were measured by inhibition ELISA.

RESULTS

Interleukin-1beta induced morphologic change in HPMCs from a cuboidal epithelioid shape into an elongated fibroblastoid shape. The elongated cells were positive for cytokeratin although they had a fibroblastoid appearance. Treatment of HPMCs with IL-1beta resulted in increased expression of both fibronectin and alpha1(I) pro-collagen mRNA in dose- and time-dependent manners. Immunofluorescent staining showed strong and diffuse cytoplasmic expression of fibronectin and type I collagen in the cells treated with IL-1beta, whereas only weak perinuclear cytoplasmic staining was noted in the cells on media alone. The concentrations of secreted fibronectin and type I collagen in culture supernatant were significantly higher in the cells treated with IL-1beta than in the control cells. IL-1beta also stimulated the expression of TGFbeta1 mRNA. However, IL-1beta-induced fibronectin mRNA expression was only partially blocked by neutralizing anti-TGFbeta antibody.

CONCLUSION

Interleukin-1beta stimulated the production of extracellular matrix in cultured HPMCs along with the induction of morphologic changes. This may play a role in the development of peritoneal fibrosis caused by peritonitis or bioincompatible dialysate in continuous ambulatory peritoneal dialysis patients.

Inhibition of poly(ADP-ribose)polymerase binding to DNA by thymidine dimer

The ability of poly(ADP-ribose)polymerase to bind damaged DNA was assessed by electrophoretic mobility shift assay. DNA binding domain of poly(ADP-ribose)polymerase (PARPDBD) binds to synthetic deoxyribonucleotide duplex 10-mer. However, the synthetic deoxyribonucleotide duplex containing cys-syn thymidine dimer which produces the unwinding of DNA helix structure lost its affinity to PARPDBD. It was shown that the binding of PARPDBD to the synthetic deoxyribonucleotide duplex was not affected by O6-Me-dG which causes only minor distortion of DNA helix structure. This study suggests that the stabilized DNA helix structure is important for poly(ADP-ribose)polymerase binding to DNA breaks, which are known to stimulate catalytic activity of poly(ADP-ribose)polymerase.

Effect of increasing serum albumin on plasma D-dimer, von Willebrand factor, and platelet aggregation in CAPD patients

This study was performed to investigate the interrelation between blood albumin level and D-dimer (a marker of intravascular coagulation) and von Willebrand factor (vWF; a marker of endothelial injury) levels or platelet aggregation. Blood levels of albumin, D-dimer, vWF, and C-reactive protein (CRP) and the threshold aggregating concentration (TAC) of ristocetin were measured in 64 continuous ambulatory peritoneal dialysis (CAPD) patients and compared with 36 healthy controls. Twenty-two CAPD patients with albumin levels less than 3.0 g/dL were divided into experimental and disease-control groups. In the experimental group, levels were measured before and after repeated infusions of 20% albumin, 100 mL/d for 7 days. The same parameters were measured in the disease-control group that did not receive the albumin infusion. CAPD patients had higher D-dimer and vWF levels than the healthy controls. There were inverse correlations between albumin and D-dimer (r = -0.48; P < 0.001), vWF (r = -0.29; P < 0.05), or logCRP (r = -0.44; P < 0.001) in CAPD patients. There were positive correlations between logCRP and D-dimer (r = 0.38; P < 0.01) and between logCRP and vWF (r = 0.32; P = 0.01) in CAPD patients. No change was seen in D-dimer, vWF, and CRP levels in either group. The TAC of ristocetin in the 18 CAPD patients was not different from that in the 11 healthy controls (0.55 +/- 0.09 v 0.65 +/- 0.07 mg/mL). There was a correlation between albumin level and TAC in the CAPD patients (r = 0.59; P < 0.01). TAC increased from 0.50 +/- 0.09 to 0.62 +/- 0.13 mg/mL (123% +/- 17%; P < 0.05; n = 6) at the end of the repeated albumin infusions in the experimental group, whereas it did not change in the control group. CRP level did not change in either group. The results of this study indicate that hypoalbuminemia increases platelet aggregability. The observation that the albumin infusion was not associated with changes in D-dimer and vWF despite the inverse correlations suggests that these relationships may be secondary to other factors, such as inflammation.

Association of plasma fibrinogen concentration with vascular access failure in hemodialysis patients

BACKGROUND

Elevated plasma fibrinogen is an important risk factor for coronary artery disease in the general population and patients with chronic renal failure. High plasma fibrinogen may trigger thrombus formation in arteriovenous fistulas. We performed a prospective, cohort study to evaluate the association of plasma fibrinogen concentration with vascular access failure in patients undergoing long-term haemodialysis.

METHODS

Between September 1989 and October 1995, 144 patients underwent a vascular access operation. In March 1997, 102 patients (56 M, 46 F) who had been followed up for more than 18 months (median; 37 months, range; 18-102 months) were included in the study. The median age of the patients was 52 years (range; 19-78 years). In 35 patients, renal disease was secondary to diabetes mellitus. The type of vascular access was a polytetrafluoroethylene (PTFE) graft in 17 patients. Seventy-seven patients received recombinant human erythropoietin (r-HuEPO) therapy during the follow-up period. Plasma fibrinogen, albumin, total cholesterol, hematocrit, platelets and creatinine were measured at the time of operation. Vascular access failure was defined as the occurrence of complications requiring transluminal angioplasty, thrombolytic therapy or surgical repair.

RESULTS

Thirty-eight patients had at least one vascular access failure and the incidence was 0.3 (range; 0-2.4) episodes per patient-year. The survival rate of vascular access was 78% (native fistula; 80%, PTFE graft; 71%) after 12 months and 70% (native fistula; 73%, PTFE graft; 51%) after 24 months. Older age, a PTFE graft, r-HuEPO therapy, higher hematocrit, lower albumin and higher fibrinogen levels were significantly associated with vascular access failure, whereas gender, diabetes mellitus, total cholesterol and platelet count were not. Plasma fibrinogen was inversely correlated with albumin (r=-0.38, P=0.001). The cumulative vascular access survival was significantly lower in patients with high plasma fibrinogen levels (> or = 460 mg/dl) compared with patients with low levels (< 460 mg/dl) (P=0.007). Independent risk factors for vascular access failure analysed by Cox's proportional hazards model were older age (RR; 1.36 by 10-year increment), higher fibrinogen level (RR; 1.20 by 100 mg/dl increment), PTFE graft (RR; 2.28) and r-HuEPO therapy (RR; 3.79).

CONCLUSION

High plasma fibrinogen level is an independent risk factor for vascular access failure in haemodialysis patients.

Sp1 and Sp3 transactivate the human lipoprotein lipase gene promoter through binding to a CT element: synergy with the sterol regulatory element binding protein and reduced transactivation of a naturally occurring promoter variant

Lipoprotein lipase (LPL) is a key enzyme in lipoprotein and energy metabolism and, therefore, regulation of its expression could have an important bearing on these processes. We have identified an evolutionarily conserved 5'-CCTCCCCCC-3' motif (from -91 to -83, CT element) in the human LPL gene promoter, deletion or mutation of which caused approximately 70-80% decrease in promoter activity. We found that Sp1 and Sp3 in THP-1 nuclear protein extracts bind specifically to this element. Co-transfection with Sp1 and Sp3 expression plasmids transactivated the LPL promoter via the CT element in Drosophila SL2 cells devoid of Sp proteins. Sp3 moderately repressed Sp1-mediated LPL promoter activation when both were co-expressed in SL2 cells. Furthermore, co-expression of an active sterol regulatory element binding protein (SREBP-1), with Sp1, but not with Sp3, synergistically activated the LPL promoter in SL2 cells. We previously reported a naturally occurring T-->G substitution at position -93 of the human LPL promoter which reduces promoter activity by 40-50% in transient transfection assays. In this study, we showed that this substitution results in reduced binding affinity to Sp1/Sp3 and in diminished transactivation by Sp1/Sp3 alone and by the synergistic action of Spl and SREBP-1 In conclusion, recruitment of Sp1/Sp3 by the CT element may play an important role in expression of the human lipoprotein lipase gene. Synergistic transcriptional activation by Sp1 and SREBP-1 may provide a mechanism for cross-talk between cholesterol and triglyceride metabolic pathways.

Treatment of chronic hepatitis B with lamivudine in renal transplant recipients

BACKGROUND

Lamivudine is a potent inhibitor of hepatitis B virus replication. Little has been reported about the efficacy and safety of lamivudine in the treatment of chronic hepatitis B in the setting of renal transplantation.

METHODS

Two patients were treated for chronic hepatitis B with lamivudine and subsequently underwent renal transplantation. Four other patients were treated with lamivudine for reactivation of hepatitis B after renal transplantation. Chronic hepatitis B was proven histologically in all the patients. The doses of lamivudine ranged from 100 to 150 mg/day. Hepatic enzyme and viral markers were monitored.

RESULTS

Lamivudine was well tolerated for a median duration of 8 months (range, 4-14 months) without significant side effects. Viral replication was suppressed, as evidenced by negative conversion of serum hepatitis B virus DNA in all the patients. Hepatic enzyme was also normalized. Modification of doses of immunosuppressant regimen was not required in using lamivudine in all patients. One patient experienced acute rejection and responded to solumedrol pulse therapy with normalization of graft function. Normal graft function was maintained in other patients while they were treated with lamivudine.

CONCLUSION

Lamivudine was a safe and effective therapy for activated hepatitis B in renal transplant recipients in the short term.

Effect of increasing serum albumin on haemostatic factors synthesized in the liver in CAPD patients

BACKGROUND

This study was performed to evaluate the relationship between serum albumin and plasma concentration of haemostatic factors and the effect of raising serum albumin on haemostatic factors synthesized in the liver in CAPD patients.

METHODS

We measured blood levels of albumin, fibrinogen, factor II, factor VII, protein C, free protein S, plasminogen, alpha2-antiplasmin and antithrombin III in 103 CAPD patients and 30 normal controls. Twenty-two patients with albumin < 3.5 g/dl were divided into two groups. In the experimental group (n = 11), haemostatic factors and albumin were measured before, after repeated infusion of 20% albumin 100 ml three times per week for 2 weeks, and 4 weeks after withdrawal of albumin infusion. The same parameters were measured in the control group (n = 11) which did not receive albumin infusion. C-reactive protein and haematocrit were followed in both groups as an indicator of acute phase reactant and an indirect measure of volume status.

RESULTS

CAPD patients as a whole had lower albumin and higher fibrinogen and factor VII than normal controls. A significant inverse correlation was present between fibrinogen and albumin (r = -0.27, P < 0.01). Albumin in the experimental group increased from 2.7 +/- 0.4 to 3.5 +/- 0.6 g/l at the end of its repeated infusion and haematocrit decreased from 26.6 +/- 4.4 to 24.9 +/- 5.2%. Fibrinogen and factor VII decreased significantly, even after correction for haematocrit (624 +/- 96 vs 556 +/- 91 mg/dl, 160 +/- 36 vs 121 +/- 44%, P < 0.05). Four weeks after withdrawal of albumin infusion, serum albumin decreased to 2.7 +/- 0.5 g/dl, whereas fibrinogen and factor VII increased to 619 +/- 78 mg/dl and 158 +/- 32%, respectively (P < 0.05). Albumin, haematocrit and haemostatic factors in the control group did not change. CRP was stable during the study period in both groups.

CONCLUSION

These findings indicate that hypoalbuminaemia is an important trigger factor in the elevation of fibrinogen, and possibly factor VII, in CAPD patients.

Chemokines, osteopontin, ICAM-1 gene expression in cultured rat mesangial cells

To investigate whether MCP-1, CINC, RANTES, osteopontin and ICAM-1 mRNA could be induced in cultured rat mesangial cells by interleukin-1beta(IL-1beta), tumor necrosis factor-alpha (TNF-alpha) and lipopolysaccharide (LPS), and whether MCP-1 and CINC gene expression could be modulated by dexamethasone, Northern blot assays were performed. IL-1beta induced MCP-1, CINC, RANTES and ICAM-1 gene expression in a time dependent manner. IL-1beta-induced MCP-1, CINC and ICAM-1 mRNA amount were maximal at 3 hours exposure around 14.5, 15.7, 2.2 folds increase and IL-1beta-induced RANTES mRNA at 24 hours around 2.0 folds. TNF-alpha and LPS also induced MCP-1 and ICAM-1 gene expression. TNF-alpha also induced RANTES gene expression but LPS did not. On the other hand, IL-1beta, TNF-alpha and LPS had little effect on osteopontin gene expression but fetal calf serum could increase osteopontin mRNA. Dexamethasone suppressed the IL-1beta-induced MCP-1 and CINC mRNA. These results suggest that, through these gene expressions, mesangial cells are able to communicate directly or indirectly with macrophages or neutrophils, which may lead to glomerulosclerosis.

Effect of increasing serum albumin on serum lipoprotein(a) concentration in patients receiving CAPD

Lipoprotein(a) [Lp(a)], an independent risk factor for atherosclerotic cardiovascular disease in the general population, is known to be elevated in patients with renal disease accompanied by hypoalbuminemia such as nephrotic syndrome and end-stage renal disease. In this study, the role of hypoalbuminemia in the elevation of serum Lp(a) was investigated in 20 continuous ambulatory peritoneal dialysis (CAPD) patients with serum albumin below 3.5 g/dL. The patients were divided into two groups. In group 1 (n = 10), fasting serum Lp(a) and albumin were measured before, after repeated infusion of 20% albumin 100 mL three times per week for 2 weeks, and 4 weeks after withdrawal of albumin infusion. In group 2 (n = 10), serum albumin and Lp(a) were measured similarly without albumin infusion. C-reactive protein was monitored in both group as an indicator of acute-phase reactant. Serum Lp(a) was also measured in 20 age- and sex-matched normal controls. Apolipoprotein(a) [apo(a)] phenotype was determined in all the subjects. CAPD patients as a whole (n = 20; median, 70.2 mg/dL; interquartile range, 45.0 to 86.2 mg/dL) had higher serum Lp(a) than normal controls (n = 20; median, 9.9 mg/dL; interquartile range, 2.4 to 24.3 mg/dL) (P < 0.0001), although the distribution of apo(a) phenotype was similar. Serum albumin in group 1 increased from 2.6+/-0.5 g/dL to 3.5+/-0.6 g/dL (P < 0.0005) at the end of repeated infusion of albumin, whereas serum Lp(a) decreased from 73.7 mg/dL (range, 43.2 to 89.0 mg/dL) to 25.6 mg/dL (range, 10.7 to 71.7 mg/dL) (P < 0.01). Four weeks after withdrawal of albumin infusion, serum albumin decreased again to 2.9+/-0.5 g/dL (P < 0.001), whereas serum Lp(a) increased to 65.2 mg/dL (range, 43.3 to 106.0 mg/dL) (P < 0.05). Serum albumin in group 2 was 2.8+/-0.6 g/dL, 3.0+/-0.4 g/dL, and 2.9+/-0.7 g/dL, respectively. The change of serum Lp(a) was not significant (67.0 mg/dL [range, 46.8 to 84.8 mg/dL], 62.8 mg/dL [range, 45.1 to 81.0 mg/dL], and 63.0 mg/dL [range, 44.7 to 74.0 mg/dL]). C-reactive protein was stable during the study period in both groups. These findings support the hypothesis that hypoalbuminemia is one of the important trigger factors in the elevation of serum Lp(a) in CAPD patients.

Protein intake and the nutritional status in patients with pre-dialysis chronic renal failure on unrestricted diet

OBJECTIVES

Malnutrition is known to be highly associated with morbidity and mortality in dialysis patients. Malnutrition may begin to develop in patients with chronic renal failure(CRF) before they need dialysis. In this study, the nutritional status of patients with moderate to severe CRF on unrestricted diet was evaluated.

METHODS

We measured dietary protein intake (DPI, g/kg/day) in 64 patients with CRF and 42 normal controls(N). Nutritional indices such as serum albumin(SA, g/dl), transferrin(TF, mg/dl), prealbumin(PA, mg/dl) and insulin-like growth factor-1(IGF-1, ng/ml) were measured to evaluate the visceral proteins, and creatinine-height index(C-H, g/d/m) to evaluate the somatic proteins.

RESULTS

Mean DPI was 0.80 +/- 0.27(S.D) in CRF and 1.07 +/- 0.30 in N(p < 0.0001). DPI was lower than 0.6 in 15 CRF patients(23%). Serum albumin, transferrin and C-H were significantly lower in CRF patients than in N(p < 0.01). In patients with CRF, nutritional indices were significantly worse with lower DPI(< 0.6 g/kg/d, n = 15) than higher DPI(> 0.6 g/kg/d, n = 49)(SA 2.9 +/- 0.7 vs. 3.6 +/- 0.8, p < 0.005; TF 147 (134-179) vs. 220(182-264), p < 0.0005; PA 24 +/- 8 vs. 32 +/- 9, p < 0.001; IGF-1 123 (66-261) vs. 226(140-344), p < 0.05; C-H 0.52 +/- 0.15 vs. 0.87 +/- 0.23, p < 0.0001). CRF patients with nephrotic range proteinuria (> 3.5 g/d, n = 19) had lower SA (2.8 +/- 0.6 vs. 3.8 +/- 0.8, p < 0.0001) and PA(27 +/- 9 vs. 32 +/- 9, p < 0.05). CRF patients with diabetes mellitus (n = 20) showed worse nutrition than non-diabetic patients(SA 2.8 +/- 0.6 g/dl vs. 3.8 +/- 0.8 g/dl, p < 0.0001; TF 176 mg/dl(148-214) vs. 220 mg/dl(175-266), p < 0.05; PA 24 +/- 10 mg/dl vs. 33 +/- 8 mg/dl, p < 0.0005; IGF-1 138 ng/ml(69-269) vs 231 ng/ml(140-364), p < 0.05; C-H 0.66 +/- 0.23 vs. 0.85 +/- 0.5, p < 0.005).

CONCLUSION

A significant protein malnutrition prevails in patients with pre-dialysis CRF on unrestricted diet, especially with low protein intake. The effort to detect and correct malnutrition should be made in patients with CRF even before initiation of maintenance dialysis.

Lipoprotein(a) and apolipoprotein(a) phenotypes in patients with end-stage renal disease

OBJECTIVE

To evaluate the distribution pattern of apolipoprotein(a) [Apo(a)] phenotypes in Koreans and the effect of dialysis modality on serum lipoprotein(a) [Lp(a)] concentration according to apo(a) phenotype in patients with end-stage renal disease (ESRD).

DESIGN

Cross-sectional study.

SETTING

A university hospital.

PARTICIPANTS

153 normal controls, 99 hemodialysis (HD) patients and 82 continuous ambulatory peritoneal dialysis (CAPD) patients.

MAIN OUTCOME MEASURES

Fasting serum Lp(a), lipids, and apo(a) phenotypes were measured.

RESULTS

The frequencies of the subjects with apo(a) phenotypes of high-molecular weight only, including S3, S4, or S5 or null type were 95.4% of control, 100% of HD patients, and 95.1% of CAPD patients. The frequent apo(a) phenotypes in Koreans consisted of S4, S4S5, S5, and S5S5 isoforms. Significant difference was found in serum Lp(a) concentration among controls and HD and CAPD patients [median (Interquartile range): 0.05 g/L, (0.01-0.19); 0.19 g/L, (0.10-0.35); 0.63 g/L, (0.28-0.90), p < 0.001]. Lp(a) levels in CAPD patients were significantly higher than in HD patients for all four common apo(a) isoforms found in Korean subjects. CAPD patients had higher total and LDL cholesterol levels, and higher ApoB levels than HD patients. Significant differences were found in serum albumin levels between controls and HD and CAPD patients (44 +/- 3 g/L, 40 +/- 4 g/L, 32 +/- 7 g/L, respectively, p < 0.05). There were significant inverse correlations between serum albumin and Lp(a) (r = -0.33, p < 0.01), total cholesterol (r = -0.31, p < 0.01), LDL (r = -0.39, p < 0.01) or ApoB (r = -0.35, p < 0.01) in ESRD patients. A significant positive correlation was found between serum albumin and ApoA1 (r = 0.24, p < 0.01).

CONCLUSION

These findings indicate that Koreans have mainly high molecular weight apo(a) phenotypes and serum Lp(a) is elevated in CAPD patients compared to HD patients for common apo(a) phenotypes, which may contribute to the frequent cardiovascular mortality in CAPD patients.

Fibrinogen and fibrinolytic activity in CAPD patients with atherosclerosis and its correlation with serum albumin

OBJECTIVE

It has been suggested that hypoalbuminemia in dialysis patients leads to a hypercoagulable state, however, the relationship between serum albumin and fibrinogen or fibrinolytic activity has not been well-documented. The aim of this study was to investigate the changes of fibrinogen, tissue plasminogen activator (tPA), plasminogen activator inhibitor type-1 (PAI-1), and lipid levels in continuous ambulatory peritoneal dialysis (CAPD) patients with atherosclerosis, and the relationship between those factors and serum albumin.

DESIGN

A cross-sectional study.

SETTING

A university hospital.

PATIENTS

Twenty CAPD patients with atherosclerosis, 49 CAPD patients without atherosclerosis, and 33 normal controls were included. Presence of atherosclerosis was determined by positive results in a stress thallium single-photon emission computed tomography or an ankle brachial index less than 0.9. Coronary angiography and/or Doppler ultrasound of extremities were followed for the patients with positive results to confirm atherosclerotic cardiovascular disease.

MAIN OUTCOME MEASURES

tPA and PAI-1 levels were determined with ELISA method, and fibrinogen with thrombin time method. Serum albumin and lipids were also measured.

RESULTS

Serum albumin and HDL-cholesterol levels were significantly lower, and the ratio of total cholesterol/HDL was significantly higher, in CAPD patients than in normal controls. CAPD patients with atherosclerosis had significantly higher fibrinogen, tPA, and PAI-1 levels than other groups: tPA was an independent predictor of atherosclerotic vascular disease in CAPD patients in stepwise logistic regression analysis. Serum albumin level was inversely correlated with fibrinogen (r = -0.28; p < 0.05) in CAPD patients, but not with tPA or PAI-1 levels. PAI-1 level was correlated with tPA (r = 0.37; p < 0.01) and triglycerides (r = 0.32; p < 0.05).

CONCLUSIONS

Association of high levels of fibrinogen and PAI-1 with lipid disorders may be of importance in the development of atherosclerosis in CAPD patients. Hypoalbuminemia may contribute to atherosclerosis via increased synthesis of fibrinogen.

Paramyotonia congenita and hyperkalemic periodic paralysis associated with a Met 1592 Val substitution in the skeletal muscle sodium channel alpha subunit--a large kindred with a novel phenotype

Paramyotonia congenita (PC) and Hyperkalemic periodic paralysis (HyperPP) are caused by amino acid substitutions in the alpha subunit of the human skeletal muscle sodium channel. One such substitution, methionine for valine at position 1592, has been associated with HyperPP with myotonia and cold sensitivity. We report clinical, electromyographic (EMG), genetic and pathological features of a large kindred with the Met1592Val substitution. Affected members were phenotypically heterogenous and had episodic potassium-sensitive paralysis, and stiffness and weakness induced by exercise and cold, which was confirmed by EMG studies. These features indicate a combined PC-HyperPP phenotype not previously described with this mutation.

Treatment of hepatitis B virus associated glomerulonephritis with recombinant human alpha interferon

To evaluate the therapeutic effect of recombinant human alpha-interferon (alpha-IFN) on hepatitis B virus associated glomerulonephritis (HBV-GN) and the relationship between the seroconversion of viral antigens and the change of proteinuria, the hepatitis B viral markers and urinary protein were monitored during alpha-IFN treatment in 8 male adult patients who (1) were positive in serum HBsAg and HBeAg, (2) had chronic hepatitis, (3) had persistent proteinuria > 1 g/day, and (4) showed glomerulonephritis on kidney biopsy. alpha-IFN was given at a dose of 3 million units, subcutaneously, three times a week for 6 months. Kidney biopsy specimens showed membranoproliferative glomerulonephritis (MPGN) in 4 patients, mesangial proliferative glomerulonephritis (MesPGN) in 2, and membranous glomerulonephritis (MGN) in 2 patients. Seven of the 8 patients received a 6-month course of alpha-IFN therapy; 1 patient with MGN quitted therapy 2 months after the initial dose because of side effects. In 5 of the 7 patients who received a 6-month therapy, serum HBeAg disappeared, and anti-HBe appeared during the therapy. In 2 of these 5 patients, HBeAg reappeared, in 1 during alpha-IFN therapy and in 1 9 months after the last dose of alpha-IFN. The hepatitis B viral markers of the patient who received a 2-month therapy did not change. HBs antigenemia persisted in all patients. In all 4 patients with MPGN, serum HBeAg was transiently or persistently converted to negative, but the proteinuria persisted. Both patients with MesPGN showed remission of proteinuria; however, only 1 patient had seroconversion of HBeAg. In 2 patients with MGN, proteinuria persisted. In conclusion, alpha-IFN at the doses given was not effective in MPGN type of HBV-GN. Improvement of proteinuria was achieved in MesPGN patients without disappearance of HBs antigenemia which is the finding against the possible role of HBsAg in the pathogenesis of this type of HBV-GN.

Risk factors of sudden infant death in Chinese babies

The influence of social and biologic factors on sudden infant death was studied in a large Chinese population. Data from all birth certificates in Taiwan from 1988 to 1992 were merged with death certificate data for postneonatal deaths from sudden infant death syndrome and suffocation. The Cox's proportional hazard model was used to compute multivariate adjusted relative risk estimates and 95% confidence intervals. Age difference of parents of more than 10 years was associated with a relative risk (RR) of 1.8 (multivariate adjusted, 95% confidence interval (CI) 1.3-2.3). Better than elementary education for the father was protective (adjusted RR 0.8, 95% CI 0.7-1.0, p < 0.05), and college education of the mother elevated the risk (adjusted RR 1.2, 95% CI 1.0-1.4, p < 0.05). Infants born second to fourth had an adjusted RR of 1.7 (95% CI 1.5-1.9), and infants born fifth or higher had a RR of 2.3 (95% CI 1.5-3.4). The multivariate adjusted RR for low birth weight and prematurity were 2.3 (95% CI 1.9-2.8) and 1.2 (95% CI 1.0-1.5), respectively. Data from this 5-year cohort in Taiwan emphasize biologic and social variables as important risk factors of sudden infant death in Chinese babies.

Regulatory mutations in the human lipoprotein lipase gene in patients with familial combined hyperlipidemia and coronary artery disease

We previously reported a compound heterozygote [T(-39)C/T(-93)G] in the human lipoprotein lipase (LPL) gene promoter in one out of 19 patients with familial combined hyperlipidemia (FCHL) and reduced post-heparin plasma LPL levels. The T(-39)C substitution resulted in 85% decrease in LPL promoter activity. Further screening of Caucasian patients with FCHL, coronary artery disease (CAD), and of unselected Caucasian subjects revealed four additional LPL promoter variants. Among the same 19 FCHL patients with reduced LPL levels, we found one heterozygote for a G(-53)C substitution. Among 115 CAD patients, we found five heterozygotes and one homozygote for the T(-93)G substitution and one heterozygote for a CC insertion between +13 and +19 of the 5' untranslated region. In a group of 183 unselected subjects, three heterozygotes with the T(-93)G substitution were found. The G(-53)C substitution led to approximately 70-75% decrease in promoter activity as assayed by transient transfections of THP-1 (macrophage-like) and C2C12 (myotube-like) cells. The T(-93)G substitution resulted in reduction of promoter activity by approximately 40-50%. The CC insertion between +13 and +19 caused a decrease in promoter activity by 20% in THP-1 and 50% in C2C12. Substitutions at -79 and -95, which had no effect on promoter function, were also discovered in the population samples studied. The finding of two promoter mutations (-39 and -53) among 19 FCHL patients with diminished LPL, but not among the other groups of subjects, suggests a potential role of regulatory mutations of the LPL gene in the development of dyslipidemia in FCHL.

Gender differences in postneonatal infant mortality in Taiwan

Numerous studies have indicated that gender discrimination influencing child survival is widespread in Asia. Therefore, we have investigated gender and cause-specific postneonatal mortality in Taiwan. Mortality data derived from death certificates and demographic statistics in Taiwan between 1981 and 1990 were analyzed. Postneonatal mortality decreased from 9.4 per 1000 live births to 5.5 per 1000 live births for males, and from 8.3 to 5.0 for females. The trends for cause-specific mortality for male and female infants were similar during the study period. The male-to-female ratio of overall death rates was 1.11. It was slightly higher in cities and lower in rural areas, and lowest in the least developed eastern region of Taiwan. Mortality from congenital diseases had the lowest male-to-female ratio, specifically in the North, the cities and areas of indigenous people. Infectious disease mortality showed low male-to-female ratios in the rural areas and in the eastern region. The place of death from infectious diseases as a measure for the use of sophisticated medical care showed that more female than male deaths occurred at home in the rural areas, cities, and central regions. It was concluded that a high level of socio-economic development created conditions of gender equality, whereas in situations of low socio-economic development males were favoured. The tendency to discriminate according to gender is very subtle in Taiwan, much less so than in other regions of Asia, including Thailand and India.

Lipocortin-1 inhibits proliferation of cultured human mesangial cells

Lipocortin-1, a 37-kDa member of the annexin family of proteins, originally evoked interest as one of the second messengers for the anti-inflammatory actions of glucocorticoids. Studies showed that glucocorticoids inhibited the proliferation of various cell types and lipocortin-1 mediated growth inhibition of glucocorticoids in a human lung adenocarcinoma cell line. The presence of specific lipocortin-1-binding sites (receptor-like molecules) on monocytic cells has been demonstrated. This study was performed to evaluate the effects of hydrocortisone and recombinant human lipocortin-1 on cultured human mesangial cells (CHMC), and the effects of anti-lipocortin-1 antibody on the hydrocortisone-induced inhibition of CHMC proliferation. The existence of specific binding sites for lipocortin-1 was also investigated. Lipocortin-1 inhibited CHMC proliferation in a dose-dependent manner as determined by [3H]thymidine uptake and cell count. Growth of CHMC was inhibited to 18% of the control in the presence of 5 micrograms/ml of lipocortin-1. Similar growth-inhibitory activity by lipocortin-1 was observed in CHMC activated by platelet-derived growth factor. Hydrocortisone also inhibited cell proliferation in a dose-dependent manner. One to 5,000 dilution of anti-lipocortin-1 antibody reversed hydrocortisone-induced inhibition of CHMC proliferation partially, whereas concentrations over 1:1,000 reversed the inhibition completely. Flow cytometry analysis as well as indirect immunofluorescent microscopy revealed specific binding sites on the surface of CHMC. These results support the hypothesis that corticosteroids act by inducing CHMC to synthesize or secrete lipocortin-1, and that lipocortin-1 generates proliferation-suppressive signal(s) through specific binding sites on CHMC.

Prednisolone non-compliance and its related factors in patients with systemic lupus erythematosus

BACKGROUND

The combination of western medicine and traditional Chinese medicine is still exerting a pervading influence on symptom relief in Chinese society. The Medical behavior pattern may influence medication non-compliance by patients with chronic illness.

METHODS

The study was designed to investigate prednisolone non-compliance and its related factors for patients with systemic lupus erythematosus (SLE) under giving patients' health beliefs, the influence of prednisolone and Chinese culture. All patients of the SLE Mutual Aid Group (N=570) participated in this study. A questionnaire which included medical behavior and individual attitudes was sent each by mail. The response rate was 63.7% (N=363); 329 responses were useable in the study.

RESULTS

Of the 329 patients, 27.9% had taken traditional medicine or a combination of traditional medicine with western medicine within the past month; 25.4% patients were non-compliant with prescribed prednisolone during the past week. The important reasons for non-compliance were feeling better, fearing side effects and treatment by Chinese medicine. The predicting factors for prednisolone non-compliance were the effects of the prednisolone, medical feasibility, patterns of medical behavior and perceived seriousness of the disease. Physician-patient relationship served as modifying factors which influenced individual attitudes toward prednisolone non-compliance and choice of medical behavior. Traditional beliefs, influenced by Chinese culture, indirectly affected prednisolone non-compliance, but through medical behavior patterns.

CONCLUSIONS

Predisolone non-compliance is quite essential for SLE patients. Findings suggested that the attributes of prednisolone and the influences of Chinese traditional medicine should be considered as well as a health belief model, when trying to improve prednisolone compliance for SLE patients in Taiwan society.

A mutation in the promoter of the lipoprotein lipase (LPL) gene in a patient with familial combined hyperlipidemia and low LPL activity

We have identified a naturally occurring mutation in the promoter of the lipoprotein lipase (LPL) gene. One of 20 patients with familial combined hyperlipidemia (FCHL) and reduced levels of postheparin plasma LPL activity was found to be a heterozygote carrier of this mutation. The mutation, a T-->C substitution at nt -39, occurred in the binding site of the transcription factor Oct-1. As a result, the transcriptional activity of the mutant promoter was < 15% of wild type, as determined by transfection studies in the human macrophage-like cell line THP-1. This decrease in promoter activity was observed in undifferentiated as well as in phorbol ester-differentiated THP-1 cells. Furthermore, the inductive effect of elevating the levels of intracellular cAMP was equally reduced. This mutation was not present among 20 FCHL patients with normal plasma LPL levels nor has it been reported among individuals with familial LPL deficiency. Thus, heterozygosity for LPL promoter mutations may be one of several factors that contribute to the etiology of FCHL.

Inhibition of hepatitis B viral gene expression by antisense phosphorothioate oligodeoxynucleotides

The inhibitory effect of antisense phosphorothioate oligodeoxyribonucleotides (S-oligos) on the production of hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) was studied using Hep G2 cells transfected with hepatitis B virus (HBV). Synthetic antisense oligos (15-mers) directed against the cap site of mRNA transcribed from the SP II promoter and regions of the translational initiation site of the S gene showed a sequence-specific, dose-dependent inhibitory effect on HBV gene expression between concentrations of 1.0 microM-5.0 microM. Oligos directed against the middle of the S gene had little effect on HBsAg and HBeAg expression, as did non-complementary random-sequence control. The cells remained viable throughout the experiments and no morphological abnormalities were observed with antisense S-oligos at concentrations below 20.0 microM. These results suggest a therapeutic potential for antisense oligonucleotides in the treatment of patients who are chronically infected with HBV.

Urban-rural and regional differences in infant mortality in Taiwan

We analyzed data from death certificates for all infant deaths in Taiwan from 1981 to 1988. During this 8-year period, the crude infant mortality rate decreased from 8.9 to 5.3 per 1000 live births. Deaths due to infectious diseases, which constituted a major fraction of this mortality, also declined from 3.4 to 1.2 per 1000 live births. While infant deaths due to nearly all causes declined, deaths due to injury and accidents rose from 0.62 to 0.71 per 1000 live births, and the sudden infant death rate rose from 0.13 to 0.46. Notable geographic differences included a high death rate in the small islands off the coast and in the eastern mountainous counties (9.1-11.2/1000 live births); this rate was twice that in Taipei (4.5/1000 live births). In addition, the level of urbanisation was also an important determinant of death rate; urban areas had much lower rates than rural areas. The highest rate (15.4) was persistently observed in the rural areas where the aboriginal tribes reside. This differential rate between urban and rural areas was most prominent for the vaccine-preventable diseases; the aboriginal areas had rates that were 12.9 times those in the cities. Moreover, since neonatal deaths are severely under-reported in Taiwan, especially in less urbanized areas, our data presumably underestimate the urban-rural health differences. Our findings identify high risk areas for various causes of infant death, and indicate that more targeted intervention such as improving education and health care as well as environmental hygiene in some specific areas may be warranted.

[Preparation and antigenic characterization of rat monoclonal antibodies against hemorrhagic fever with renal syndrome virus]

11 hybridoma cell lines secreting monoclonal antibodies (McAbs) against hemorrhagic fever with renal syndrome virus (HFRSV) were obtained in our laboratory by immunizing LOU/C rats with HFRSV Chen strain. These rat McAbs were characterized by radio-immunoprecipitation and western blotting methods, 2 directed against glycoprotein G2, 9 against nucleocapsid protein (NP) of HFRSV. The results of neutralization (NT) and hemagglutination inhibition(HI) test showed that most of the McAbs specific for NP had neither NT nor HI activities, but 2 had obvious NT and/or HI activities. It was suggested that there may be some neutralizing and hemagglutinating determinants on NP of HFRSV. Two McAbs to G2 had HI or/and NT activities. These date indicated that distinct neutralizing and hemagglutinating epitopes were located on the G2. Comparative antigenic analysis of 20 strains of HFRSV was carried out by immune horseradish peroxidase technique using 11 anti-HFRSV rat McAbs. It was found that these McAbs can be classified into group, subgroup, apodemus type and subtype specificity to HFRSV.

Cytomegalovirus is not specifically associated with immunoglobulin A nephropathy

Cytomegalovirus (CMV) has been suspected to be involved in the pathogenesis of IgA nephropathy (IgAN). Whether CMV is present in renal tissue of IgAN, however, remains controversial. To determine the presence of CMV in IgAN, compared with other glomerulonephritis (GN) as disease control, polymerase chain reaction amplifying a 159-base-pair fragment of the immediate early gene of CMV and indirect immunofluorescence staining with anti-CMV monoclonal antibody were performed on 10 IgAN and 14 non-IgAN GN renal tissues. CMV DNA was detected in 6 of 10 IgAN tissues and 10 of 14 other GN by polymerase chain reaction, whereas no CMV antigen was detected in all renal tissues by immunofluorescence. This frequent observation of CMV DNA in various types of GN as well as in IgAN would suggest that CMV is not specifically associated with the pathogenesis of IgAN seen in endemic areas of CMV infection.

Clinical value of DMSA planar and single photon emission computed tomography as an initial diagnostic tool in adult women with recurrent acute pyelonephritis

Routine DMSA scintigraphy, ultrasound (US) of the kidney, intravenous pyelography (IVP) and voiding cystoureterography (VCU) were performed in 27 consecutive adult women with recurrent acute pyelonephritis (APN) during a 12-month follow-up. Both planar and single photon emission computed tomography (SPECT) images were obtained for DMSA scan. DMSA scans were repeated in those patients with abnormal initial scan. DMSA-SPECT showed normal findings in 2, single renal cortical detect (RCD) in 9 and multiple RCD in 16 (including nonvisualization in 2). Of the 11 kidneys with normal findings or single RCD on DMSA-SPECT, only 1 (9%) showed vesicoureteral reflux (VUR) on VCU (grade I). A large proportion of those with multiple RCDs showed abnormal findings on IVP (44%, 7/16), US (38%, 6/16) or VCU (31%, 5/16); 63% in any of these three studies. 5 of 6 patients with VUR had multiple RCDs on DMSA-SPECT, and 3 of these 5 showed no abnormality on IVP or US. 7 patients who needed other managements besides initial standard antibiotic treatment had multiple RCDs on DMSA-SPECT. 15 normal women were also studied and showed normal DMSA-SPECT, US and IVP, in all cases. Follow-up DMSA-SPECT was done in 16 patients (7 with single RCD, 9 with multiple RCD). All 7 patients with single RCD showed improvement, in those with multiple RCDs improvement was observed in 2, no change in 7 on follow-up studies. We conclude: (1) DMSA-SPECT is a useful initial diagnostic tool in adult women with recurrent APN to identify patients who need more extensive radiological studies.(ABSTRACT TRUNCATED AT 250 WORDS)

Purification and characterization of human hepatic stimulator substance

Human hepatic stimulator substance (hHSS) was purified from fetal liver with 6,000-fold decrease in protein content and 840-fold increase in specific growth stimulative activity. Purification procedures included the heating of a homogenate in 35% (W/V) Tris-HCL at 95 degrees C for 20 min, high and ultra speed centrifugation, passage over Sephadex G100 gel filtration, DEAE-cellulose ion exchange, TSK G3000 SWG high performance liquid chromatography (HPLC) and YWG C-18 reverse phase HPLC techniques. The most purified material (HP-HSS) revealed cell-specific and dose dependent increase in 3H-TdR incorporation into cellular DNA. As little as 38 ng of the HP-HSS per ml of culture medium produced a 2.5-fold increase in DNA synthesis. Further studies indicate that HP-HSS in combination with insulin and epidermal growth factor stimulate DNA synthesis 16-fold compared with serum and hormone free controls and nearly 3-fold over hepatoma growth with HP-HSS alone. Sodium dedecyl sulfate polyacrylamide gel electrophoresis with silver stain and ultrascan XL laser densitrometer quantitative scanning revealed only one band at 12,800.

Causes and consequences of increase in child survival rates: ethnoepidemiology among the Hmong of Thailand

The Hmong "hill tribe" minority in Thailand has much higher exposure to factors usually associated with risk of child mortality (high fertility, low status of women, low education, less use of modern medical care for births, exposure to warfare, economic and physical disruption, and poor hygienic conditions) than the rural ethnic Thai population. Nonetheless, infant mortality has declined from over 120 per 1000 to under 50 per 1000 live births among both these populations in the past 30 years. The reason for the rapid increase in child survival among the Hmong appears to be better access to and more use of modern curative and preventive medical care associated with road construction rather than major changes in social or hygienic conditions. Conventional wisdom suggests that high fertility is both a cause and a consequence of high infant and child mortality and that parents will not reduce fertility until they see that mortality has declined. Most Hmong parents recognize the decline in child mortality and attribute it to better access to modern medical care. Most Hmong parents also say that, if they were starting to have children now, they would want to have fewer children. Fear of child death is infrequently mentioned as a motive for having more children, and the perceived decline in child mortality is rarely mentioned as a reason for reduced fertility. Most Hmong parents explain their desired family size in terms of economic conditions rather than perceived risk of child mortality. Results of this study suggest that fertility and child mortality can vary independently of one another and that major reductions in child mortality can be accomplished without waiting for major social changes (e.g., improved education or status of women) or major reductions in fertility.

Hepatic stimulator substance from human fetal liver for treatment of experimental hepatic failure

The authors previously reported the successful reversal of lethal D-Gal induced hepatic necrosis in rats by human hepatic stimulator substance (hHSS), a liver specific growth factor partially purified from human fetal liver cells, which promoted hepatocyte proliferation. In this study, they further investigated the mechanism of hHSS in improving survival of experimental acute hepatic failure. Our results demonstrated that the level of alanine transaminase and endotoxin in the plasma and lipid peroxides in the liver of chemically poisoned rats were reduced by hHSS to different extent at different periods of observation compared with the saline control group. The apparent recovery of liver function and the increase of 3H-TdR incorporation into hepatic DNA correlated with the morphologic changes observed under light and electron microscopes, showing that the damages inflicted on the cellular and subcellular structure in the liver of hHSS-treated rats were greatly alleviated and rapidly repaired. Therefore, hHSS, which can prevent liver deterioration and promote hepatocyte regeneration, may be a new hepatic stimulator factor readily available for clinical use.

Recall of AIDS public service announcements and their impact on the ranking of AIDS as a national problem

The efficacy of two public service announcements from Phase V of the "America Responds to AIDS" (ARTA) campaign was assessed at two sites. Participants were randomly assigned to view a local news program, one with an ARTA public service announcement appearing six times and the other with no AIDS public service announcements. During telephone interviews with 907 participants 1 to 3 nights after viewing, 21% at Site A and 59% at Site B could correctly recall the ARTA public service announcements. Absolute mentions of AIDS as an important national issue increased.

Therapeutic effect of guar gum in patients with non-insulin-dependent diabetes mellitus

Diets with a high-fiber content have been shown to produce some beneficial effects on metabolic factors in subjects with NIDDM. However, some controversies still exist. In this report, the long-term effect of guar gum (Guarina) on both glycemic and blood lipid profiles was assessed in a randomized, double-blind and cross-over study on 16 (seven male and nine female) subjects with NIDDM. Each subject received placebo (P) and Guarina (G) treatment for two eight-week periods separated by a four-week period to facilitate wash-out. Fasting plasma glucose levels showed significant improvement during G treatment but not during P treatment (151.7 +/- 7.9 vs 168.6 +/- 12.2 mg/dl, p less than 0.01 by paired Student's t test). Hemoglobin Alc levels decreased significantly during G treatment but not during P treatment (6.9 +/- 0.2 vs 7.2 +/- 0.8%, p less than 0.001). Fasting insulin concentrations also showed significant lowering during G treatment but not during P treatment (18.3 +/- 2.1 vs 23.1 +/- 2.9 U/ml, p less than 0.005). Other variables, including serum total cholesterol, triglyceride, HDLc, LDLc, sodium, potassium, chloride, magnesium and calcium levels showed no significant changes during G or P treatment. Ten out of the 16 patients (62.5%) suffered from side effects; these included abdominal cramps (one case), diarrhea (seven cases) and skin itching (one case). In conclusion, guar gum effectively lowers fasting plasma glucose and HbAlc levels in subjects with NIDDM. Hyperinsulinemia could also be ameliorated. The effectiveness and side effects of guar gum treatment should be cautiously evaluated in each NIDDM subject.

Effects of Hantaan virus on human endothelial cells and their significance in pathogenesis of hemorrhagic fever with renal syndrome

The effects of Hantaan virus (HTNV) on human endothelial cells (HECs) were investigated both in vivo and in vitro. The 76-118 strain or SR-11 strain of HTNV were inoculated into HECs monolayers respectively, and the virus antigens could be detected on the seventh day of the first passage after inoculation by immunofluorescent technique. The HTNV could also be isolated through cultures of Vero E-6 cells. HTNV particles and inclusion bodies together with various changes in the organelles were observed in the infected cells by transmission electronic microscopy (TEM), and the immunoenzyme positive virus particles were seen by immunoelectronic microscopy. Samples of skin biopsy were individually obtained from 14 cases of hemorrhagic fever with renal syndrome on the second to the fifth day after the onset of the illness. It was found that HTNV antigens were widely distributed in the cytoplasm of endothelial cells of the samples from 5 out of 14 cases by avidin-biotin-peroxidase complex staining, and morphologic changes of the endothelial cells similar to those observed in vitro, were also seen by TEM. The results indicated that HEC is one of the target cells susceptible to HTNV. The virus could invade and propagate in HECs, and could induce damage to the latter.

Localization and changes of hemorrhagic fever with renal syndrome virus in lymphocyte subpopulation

Double-labeled immunocytochemistry was used for studying the localization and distribution of hemorrhagic fever with renal syndrome virus (HFRSV) antigen in the peripheral blood lymphocyte subpopulations in HFRS patients and the quantitative changes of these subpopulations. It was found that HFRSV might infect different subpopulations of lymphocytes. The infection rate of B cells (31.3%) was significantly higher than that of T cells (8.5%), and the infection rate of CD8+ subpopulation (10.5%) was significantly higher than that of CD4+ subpopulation (6.1%). The infection rates of HLA-DR+ cells and Tac+ cells were 2.5% and less than 0.5%, respectively. From febrile to oliguric stage, the number of CD8+ cells increased gradually, leading to a decrease and reverse of CD4/CD8 ratio, while the number of CD4+ cells remained almost unchanged. The appearance and disappearance of HFRSV in lymphocytes were closely associated with the dynamic changes of CD4/CD8 ratio and HLA-DR and Tac expressions. The results suggested that there were certain differences in HFRSV infectivity of different lymphocyte subpopulations, which might be due to the disorders of immunoregulation and immunopathology of HFRS.