A simple method to detect an albumin permeability factor in the idiopathic nephrotic syndrome

BACKGROUND

Several investigators have detected an albumin permeability factor in the serum of patients with the idiopathic nephrotic syndrome (INS), that is, minimal change disease (MCD) or focal segmental glomerulosclerosis (FSGS), but the methods used have been complex.

METHODS

We describe here a simpler method using cultured rat glomerular epithelial cell monolayers grown to confluence on Millicell filters, which allow sampling of apical and basolateral media. 125I-labeled human serum albumin (125I-HSA) was added to the basolateral compartment, and its leakage across the epithelial cell monolayer into the apical compartment was measured.

RESULTS

In untreated cells (negative control), the albumin leakage reached 5.3% at 18 hours. Cell monolayers fixed with 95% ethanol (positive control) showed 62% leakage. Sera from three out of four patients with MCD and three out of four with FSGS resulted in considerable albumin leakage, whereas sera from nine patients with other types of nephrotic renal disease and five normal subjects caused no leakage.

CONCLUSION

This study shows that the Millicell system provides a simple and useful method to screen for permeability factors in the INS.

Evaluation of a new fluorescent dye method to measure urinary albumin in lieu of urinary total protein

Urinary total protein (UTP) determinations are notoriously inaccurate, poorly reproducible, and difficult to interpret in early renal disease, causing many investigators to measure urinary albumin instead. In this study, we compare a new nonimmunologic fluorescent dye (AB-dye) for measuring albumin with the more expensive and cumbersome radioimmunoassay. We tested 207 urine specimens from patients with variable protein concentrations and divided the results into five arbitrary ranges (0 to 20, 21 to 50, 51 to 100, 101 to 200, and 201 to 400) for chi-square analysis. There was a high degree of correlation between the two methods (chi-square = 260. 8 with 16 degrees of freedom; P < 0.001). The correlation was also high when analyzed by linear regression (R = 0.86; F < 0.01). Based on our comparison of total protein and albumin concentration in the same urine samples, we hypothesized that patients with mild proteinuria may not necessarily have microalbuminuria. Urine samples with UTP between 150 and 400 microg/mL were tested for albumin by the AB-dye. Of 41 samples in this range, 18 (44%) had normal albumin levels. We conclude that measuring urinary albumin with the AB-dye is comparable in performance to radioimmunoassay and could replace UTP determinations, especially for patients with borderline elevations of UTP, many of whom do not have microalbuminuria.

Suppression of hyperparathyroidism by calcitriol therapy

We reviewed the charts of 160 patients on hemodialysis and identified 33 with parathyroid hormone (PTH) > 800 pg/ml at any time during the last 3 years to confirm our impression that patients with PTH elevations for short durations of time require significantly smaller doses of calcitriol than those with prolonged PTH elevations. We divided the patients into two groups: 18 with PTH > 800 pg/ml on three or fewer occasions (Group 1, short-term hyperparathyroidism) and 15 with PTH > 800 pg/ml more than three times (Group 2, long-term hyperparathyroidism). Most patients received once weekly intravenous calcitriol, but if this failed to suppress PTH, the dose was increased gradually to three times a week, PTH was measured at mid-week, calcitriol was held if serum calcium rose to >11 mg/dl, and calcitriol was started again when calcium fell to <11 mg/dl. We found that the duration of dialysis was generally shorter in Group 1, as were maximal PTH levels. Calcitriol suppressed PTH levels to <200 pg/ml in both groups. However, the weekly dose of calcitriol needed to suppress PTH was significantly lower in Group 1 (5.4 +/- 1.2 microg in Group 1 and 11.4 +/- 1.8 microg in Group 2; p < 0.001). Further follow-up of seven patients for 1 more year showed continued suppression of PTH, and the dose of calcitriol required to maintain the suppression was lower than the initial dose. Thus patients with longer histories of dialysis and prolonged hyperparathyroidism required higher doses of calcitriol to suppress PTH to the same level as patients who were new on dialysis or with transient hyperparathyroidism. A protocol of three times weekly, high dose calcitriol with strict monitoring of serum calcium will avoid parathyroidectomy in most cases.

Dialysis-associated renal cystic disease resembling autosomal dominant polycystic kidney disease: a report of two cases

Acquired renal cystic disease is common in patients receiving dialysis. Characteristically, the kidneys are small or, less often, normal in size, and the cysts are usually less than 0.6 cm in diameter. We present here 2 patients who, after 5 and 7 years on hemodialysis, developed marked renal enlargement, with large cysts in the kidneys and, in 1 patient, in the liver as well; the appearance on ultrasonography and computed tomography was indistinguishable from autosomal dominant polycystic kidney disease. Before starting dialysis the first patient was a 19-year-old man who developed renal shutdown from crescentic glomerulonephritis, and the second patient was a 33-year-old man who developed end-stage renal failure from malignant hypertension. Neither patient had renal cysts at the onset of end-stage renal failure.

Cocaine-induced hypertension: role of the peripheral sympathetic system

Cocaine causes hypertension at least in part by stimulating the sympathetic nervous system, but it is not clear if this effect is centrally or peripherally mediated. To address this issue we studied the vasoconstrictive effect of cocaine in vivo and in isolated artery segments. In vivo cocaine increased mean arterial blood pressure (MAP) by 40 mmHg within 1 min of administration. Pretreatment with prazosin blocked this response by 62%. With clonidine the pre-cocaine MAP was lower and the hypertensive effect of cocaine was blocked by 50%, indicating an important role for central alpha-adrenergic mechanisms. In isolated rat carotid arteries cocaine-induced vasoconstriction was completely blocked by prazosin, phentolamine, and 6-hydroxydopamine, indicating a clear role for a peripheral effect. However, the relative contribution of the central alpha-adrenergic mechanism to the total vasoconstrictive response of cocaine was not clarified. 1999 Academic Press.

Changes in collagenases and TGF-beta precede structural alterations in a model of chronic renal fibrosis

BACKGROUND

To study the role of collagenases and transforming growth factor-beta (TGF-beta) in the genesis of interstitial fibrosis, we used the model of bromoethylamine (BEA)-induced papillary necrosis, which is known to lead over a period of 1 to 12 months to interstitial fibrosis and renal insufficiency.

METHODS

Rats were injected with BEA, and urine and kidney tissue (cortex and medulla) were collected after 1, 2, 3, 7, and 30 days. One kidney was perfused and fixed for morphological studies and immunostained for collagen type I, III, and IV. The other kidney was used to prepare cortex and medulla extracts for gelatinases (by fluorometric and zymographic techniques), tissue inhibitors of metalloproteinase-1 (TIMP-1), and TIMP-2 (by enzyme-linked immunosorbent assay, ELISA) and TGF-beta1 (by ELISA).

RESULTS

Albuminuria and interstitial fibrosis were present in BEA rats by day 7, which continued until day 30. Immunocytochemical staining for collagen types showed that collagen III and IV increased in the interstitium by day 30, but collagen I remained unchanged. Gelatinase activity in the medulla decreased by 57% compared with control by day 2 and remained low until day 30. In the cortex, gelatinase activity remained unchanged between 0 and 7 days after BEA but decreased by 72% by day 30. TIMP-1 and TIMP-2 were decreased by 80% compared with day 0 in both the medulla (by day 1) and cortex (by day 2) and remained low up to day 30. TGF-beta1 immunoreactivity increased progressively until day 2 in the medulla (16-fold higher than control) and day 3 in the cortex (8-fold higher than control) and returned to control level by day 3 in the medulla and by day 30 in the cortex. Two days after BEA injection, the mRNA for TGF-beta1 was increased eightfold in the cortex and 12-fold in the medulla, and it remained high for up to 30 days.

CONCLUSIONS

The fibrosis that follows papillary necrosis is associated with both high TGF-beta1 expression and depressed gelatinolytic activity.

Evolution of experimentally induced papillary necrosis to focal segmental glomerulosclerosis and nephrotic proteinuria

Bromoethylamine (BEA)-induced papillary necrosis is a reproducible model for analgesic nephropathy. We induced this lesion in groups of male Sprague-Dawley rats and followed the functional and histological changes for 1 year. We found that by 1 month, necrosis of the papilla was complete, glomerular filtration rate was depressed, and urine albumin excretion was increased. There was an extensive interstitial fibrosis characterized by a mononuclear cell infiltrate and patchy tubular atrophy. By 6 months, there was re-epithelialization of the papillary stump accompanied by a marked increase in albuminuria and an improvement in concentrating ability. Changes seen at 9 months were more advanced. There was extensive cortical fibrosis manifested by pitting of the surface of the kidney. At 1 year, renal function remained impaired (creatinine clearance reduced by 65% to 0.26 mL/min/100 g), and the animals were now markedly nephrotic, with albuminuria of 254 mg of albumin/24 h. In the BEA rats, there was selective destruction of the deep nephrons leading to an increase in the volume-ratio of superficial to deep nephrons. Glomerular changes, affecting approximately 60% of the glomeruli, were characteristic of focal segmental glomerular sclerosis. This model of papillary necrosis/interstitial fibrosis is associated with chronic renal insufficiency and leads to the development of focal glomerular sclerosis and nephrotic proteinuria by 6 to 12 months after its induction.

Carbamylated proteins activate glomerular mesangial cells and stimulate collagen deposition

Carbamylated proteins formed in renal insufficiency from the spontaneous decomposition of urea exert a variety of metabolic effects. Here we examined the effects of carbamylated proteins on glomerular mesangial cells to determine whether urea retention in early renal insufficiency may itself promote glomerular sclerosis and hasten the progression to kidney failure. To this effect we carbamylated fetal bovine serum proteins in vitro and tested their effect on mesangial cell proliferation (by tritiated thymidine uptake), de novo protein synthesis (by tritiated leucine uptake), collagen I and collagen IV accumulation (by avidin-biotin enzyme immunoassay), and gelatinase levels in the medium (by zymography and quantitative fluorescence assay). Carbamylated fetal bovine serum at concentrations present in uremia increased tritiated thymidine incorporation by 50% without altering tritiated leucine incorporation, and it increased collagens I and IV in the monolayer by 150% to 300%. Gelatinase activity was unchanged. We conclude that carbamylated proteins can activate mesangial cells to a profibrogenic phenotype. From a clinical perspective, the carbamylation of proteins by elevated urea levels may accelerate the progression to kidney failure and thus set up a vicious cycle in which the nitrogen retention itself would cause further progression of fibrosis and deterioration of kidney function.

Prevalence of hypertension in chronic cocaine users

The association of cocaine and acute hypertension is well known; however, cocaine use has not generally been linked to chronic hypertension. We hypothesized that chronic use of cocaine over time would increase the prevalence of hypertension and that cocaine induced vasoconstriction would result in urine protein leakage, manifested by microalbuminuria. Therefore, we studied a population of predominantly black male patients admitted for addiction treatment whose drug of dependence was cocaine. A urine toxicology screen was considered positive if cocaine was detected within 24 h prior to or during admission to the hospital. A total of 301 patients with normal renal function were observed over their 2 week hospitalization. The majority (62%) of the patients were normotensive regardless of the status of their initial urine toxicology screen. Twenty percent of the population had acutely elevated blood pressure that normalized within 1 day, whereas 18% had blood pressure chronically >140/90 mm Hg (chronic hypertension). Levels of systolic and diastolic blood pressures were examined at age deciles and compared to the NHANES III (Third National Health and Nutrition Examination Survey) data for a predominantly black population. There was no significant difference in blood pressure with age in the cocaine users compared to the NHANES groups. Random urine samples were screened for the presence of microalbuminuria and no significant elevation was detected in any of the samples tested. We conclude that chronic cocaine use is associated with acute but not chronic hypertension in middle-aged black males. Cocaine use does not cause microalbuminuria.