Changes in the peritoneal equilibration test in selected chronic peritoneal dialysis patients

Fifty-five patients on chronic peritoneal dialysis with two or more peritoneal equilibration tests (PET) performed between 1983 and 1992 with a mean interval of 21.9 +/- 22.7 months were studied retrospectively. Repeated PET were performed when transport changes were suspected rather than routinely. According to the initial PET, there were 16 high (HI), 17 high-average (HA), 15 low-average (LA), and 7 low (LO) transporters. There was a significant decrease in the mean creatinine dialysate to plasma ratio (D/P creatinine) in the HI transporters and an increase in the LA and LO transporters. The mean dialysate to instilled glucose ratio (D/Do) significantly increased in the HI transporters. The change in both the D/P creatinine and the D/Do of an individual strongly and inversely correlated to their respective initial values. The change in D/P creatinine and D/Do were significantly and inversely correlated to each other, indicating an actual transport change. No correlation was found between the change in transport with peritonitis episodes or frequencies. The centripetal [corrected] change of transport toward average described here may explain why low clearances or low ultrafiltration rates due to rapid transport are infrequent causes of peritoneal dialysis technique failure, and why patients who have been dialyzed for a long period are usually HA transporters.

Multiple structural types of gap junctions in mouse lens

Gap junctions in the epithelium and superficial fiber cells from young mice were examined in lenses prepared by rapid-freezing, and processed for freeze-substitution and freeze-fracture electron microscopy. There appeared to be three structural types of gap junction: one type between epithelial cells and two types between fiber cells. Epithelial gap junctions seen by freeze-substitution were approximately 20 nm thick and consistently associated with layers of dense material lying along both cytoplasmic surfaces. Fiber gap junctions, in contrast, were 15–16 nm (type 1) or 17–18 nm thick (type 2), and had little associated cytoplasmic material. Type 1 fiber gap junctions were extensive in flat expanses of cell membrane and had a thin, discontinuous central lamina, whereas type 2 fiber gap junctions were associated with the ball-and-socket domains and exhibited a dense, continuous central lamina. Both types of fiber gap junction had a diffuse arrangement of junctional intramembrane particles, whereas particles and pits of epithelial gap junctions were in a tight, hexagonal configuration. The type 2 fiber gap junctions, however, had a larger particle size (approximately 9 nm) than the type 1 (approximately 7.5 nm). In addition, a large number of junctional particles typified the E-faces of both fiber types but not the epithelial type of gap junction. Gap junctions between fiber and epithelial cells had structural features of type 1 fiber gap junctions.(ABSTRACT TRUNCATED AT 250 WORDS)

The requirement of low calcium dialysate in patients on continuous ambulatory peritoneal dialysis receiving calcium carbonate as a phosphate binder

In the present study we investigated the requirement of low calcium dialysate in 35 patients on continuous ambulatory peritoneal dialysis (CAPD) receiving calcium carbonate as the sole phosphate binder over a 12-month period. Patients with corrected serum calcium > or = 2.85 mmol/L after switching to oral calcium carbonate were given 1 to 3 2-litre exchanges of 2.5 mEq/L calcium dialysate. Serum phosphate level dropped from the pretreatment value of 2.95 +/- 0.62 to a level of between 1.70 +/- 0.41 to 2.03 +/- 0.44 mmol/L 2 weeks after therapy. Corrected serum calcium level increased significantly from 2 weeks onwards. Serum alkaline phosphatase rose initially at 2 and 6 weeks and decreased from 3 months onwards. Serum parathyroid hormone level dropped significantly from a mean pretreatment level of 569 to 320 pg/ml after 12 months (p < 0.001). Serum aluminum decreased significantly from a mean of 1.04 to 0.65 umol/L (p < 0.01). Daily calcium carbonate requirement fluctuated but tended to increase till 8 months and plateaued and ranged from 2.61 +/- 0.57 to 3.98 +/- 2.11 gm. The daily requirement of low calcium dialysate followed a similar trend with approximately three-quarters of patients ultimately requiring at least 1 bag of low calcium dialysate. Eight patients did not require low calcium dialysate. Patients who required low calcium dialysate were significantly older, had a significantly lower pretreatment serum parathyroid hormone and higher serum aluminum levels than those who did not.(ABSTRACT TRUNCATED AT 250 WORDS)

Primary sternal osteomyelitis presenting as a pleural-based mass

Osteomyelitis in uncommon locations can present unusual diagnostic difficulties. A patient with primary sternal osteomyelitis who presented with pain over the right supraclavicular area and a radiologic picture of a pleural-based right upper lung mass is discussed. A triple-phase bone scan was consistent with the diagnosis, and a needle aspiration of the mass revealed a staphylococcal abscess. Percutaneous drainage of the contiguous abscess and a prolonged course of antibiotic therapy cured the infection.

Ciprofloxacin-induced nephrotoxicity in patients with cancer

Nephrotoxicity associated with ciprofloxacin is uncommon. Five patients with cancer who developed acute renal failure that followed treatment with ciprofloxacin are described and an additional 15 cases reported in the literature are reviewed. Other than elevation of serum creatinine levels, characteristic clinical manifestations and abnormal laboratory findings are not frequently present. Allergic interstitial nephritis is believed to be the underlying pathological-process. Definitive diagnosis requires performance of renal biopsy, although this is not always feasible. An improvement in renal function that followed the discontinuation of the offending antibiotic supports the presumptive diagnosis of ciprofloxacin-induced acute renal failure.

Leptomeningeal toxoplasmosis after allogeneic marrow transplantation. Case report and review of the literature

A 37-year-old woman with chronic myelogenous leukemia underwent allogeneic bone marrow transplantation with CD8-depleted marrow from an HLA-identical sister. On day 43 post-transplant, the patient developed a headache and became lethargic and tremulous. Magnetic resonance imaging (MRI) of the brain showed abnormal meningeal and superficial parenchymal enhancement anteriorly. The spinal fluid had an elevated protein level with normal glucose and a neutrophilic pleocytosis. At autopsy, Toxoplasma meningoencephalitis was seen. On review of the literature, headache and confusion at 1-2 months post-transplant are common presenting signs of central nervous system toxoplasmosis. The predominance of neutrophils in the spinal fluid in this patient probably reflects the meningeal component of the infection and is an unusual finding. The presentation of toxoplasmosis in marrow transplant recipients is quite pleomorphic, and a definite diagnosis is difficult to obtain antemortem. Empiric therapy with pyrimethamine and sulfadiazine should be considered for marrow transplant recipients with neurologic deficits for which there is no other apparent etiology.

Isoniazid induced encephalopathy in dialysis patients

Three dialysis patients with extrapulmonary tuberculosis developed confusion 4-14 days after commencement of treatment with anti-tuberculosis drugs, despite the use of prophylactic pyridoxine. Full recovery of conscious state resulted within 1 week in all patients after stopping isoniazid. In 2 patients confusion recurred on rechallenge of the drug. The risk factors of isoniazid induced encephalopathy and the dosage of isoniazid in uraemic patients were discussed.

Characterization of murine Caraparu Bunyavirus liver infection and immunomodulator-mediated antiviral protection

A rapid, peripheral disease model utilizing the Bunyavirus, Caraparu, was established in mice for the evaluation of antiviral therapy with immunomodulators. 4-6-week-old B6C3F1 female mice, inoculated intraperitoneally with virus, developed coagulative liver necrosis and died between 4-6 days after infection. This Caraparu disease model was relatively resistant to treatment with immunomodulators, such as ABMP, Ampligen, alpha-interferon (IFN-alpha) or beta-interferon (IFN-beta). However, a significant increase in median survival time (MST) was consistently observed upon treatment with gamma-interferon (IFN-gamma). The nucleoside analog--ribavirin--was highly effective against Caraparu virus in repeated treatment schedules begun on either day -1, day 0, or day +1 of infection. Ribavirin gave little protection when initiation of treatment was delayed until day +2. However, combined treatment with IFN-gamma, starting on day 0 and ribavirin starting on day +2, significantly reduced mortality.

The altricial pigeon is born blind with a transient glycogen cataract

The lens nucleus of altricial birds contains a large amount of glycogen. It is not known why glycogen in such concentration does not cause a trace of lens opalescence. Here we report that the altricial pigeon is born with a dense nuclear opacity; this opacity has practically disappeared by 4 weeks of age. Thin-section electron microscopy revealed that the opacity was specifically associated with an enormous number of large glycogen aggregates in nuclear fiber cells. These aggregates of various sizes (up to approximately 5 microns) were composed of smaller individual 35-nm beta glycogen particles. In contrast, glycogen aggregates were not seen in nuclear fiber cells of all transparent older lenses. The glycogen aggregates have gradually dissociated into a homogeneous distribution of individual beta particles in the entire cytoplasm of nuclear fibers which accompanies the development of lens transparency. This study suggests that an extensive accumulation of glycogen aggregates in the lens nucleus is the cause of light scattering and opacification. The transparency of the altricial pigeon lens during normal development is therefore regulated by two different forms of glycogen. Precocial birds such as chick have no lens glycogen, therefore never develop a glycogen cataract and have excellent visual acuity upon hatching.

Nature and localization of avian lens glycogen by electron microscopy and Raman spectroscopy

Electron microscopy confirms the presence of a high concentration of glycogen particles in the lens nuclear region of birds of flying habit such as the ring-neck dove and pigeon. This observation is consistent with Raman spectroscopy. The glycogen particles in the dove lens, which are approximately 35 nm in diameter, are classified as beta type particles. Although this type has been previously characterized by high rates of glycogen turnover in other tissues, its localization in the lens nucleus indicates that it may serve a structural function rather than as a storage depot of carbohydrate in the lens. In a comparative electron microscopy study, glycogen particles were not observed in the chicken lens.

Polarized distribution of coated pits and coated vesicles in the rat lens: an electron microscopy and WGA-HRP tracer study

The presence and distribution of coated pits (CPs) and coated vesicles (CVs) in the rat lens were studied by thin-section electron microscopy (TEM) and wheat germ agglutinin-horseradish peroxidase (WGA-HRP) as a tracer. TEM revealed that CPs and CVs were approximately 150 nm in diameter, of which the characteristic clathrin coat was approximately 20 nm thick. CPs and CVs were found in both epithelium and superficial fiber cells of the entire lens, and were distributed preferentially along the basal membrane facing the lens capsule. It was estimated that more than 80% of CPs and CVs in the entire epithelium were seen along the basal membrane. The number of CPs and CVs along the basal membrane in the equatorial epithelium (4.4 per 10 microns membrane) was similar to that at the central zone (3.8 per 10 microns membrane), but there was a significant increase along the apical and lateral surfaces of the equatorial epithelium compared to that of the central epithelium, although the overall number was considerably smaller. In the lens fibers, CPs and CVs were usually found within 2-3 superficial layers of fiber cells. The number of CPs and CVs along the basal membrane of young fibers at the post-equatorial region (3.1 per 10 microns membrane) was 3-fold greater than that of the mature fibers at the posterior polar area (1 per 10 microns membrane). Thus, CPs and CVs along the entire basal membrane showed a gradual decrease in number from the anterior (and equatorial) regions to the posterior polar surface of the lens. WGA-HRP experiments showed that approximately 80% of tracer-carrying pits and vesicles were also found along the basal surface of the equatorial epithelium. This study suggests that a polarized distribution of CPs and CVs along the basal surface of epithelium and superficial fiber cells may facilitate receptor-mediated endocytosis of important macromolecules directly from the aqueous humor and vitreous body into metabolically active lens cells.

Alterations of urea-insoluble membrane fraction, MP26, of Emory mouse lenses in aging and cataractogenesis

Purified lens fiber membrane fractions from Emory mouse lenses and cataract-resistant control lenses were compared by SDS-PAGE. The differences in polypeptide patterns were determined for three ages. There was a striking alteration in MP24/MP26 ratio during aging and cataractogenesis which appears to be due to a normal age-dependent conversion of MP26 to MP24, and which is accelerated during cataractogenesis.

Visualization of crystallin droplets associated with cold cataract formation in young intact rat lens

The structure, distribution, and nature of scattering elements associated with cold cataract formation in the young rat lens were studied in situ using light and electron microscopy and ImmunoGold electron microscopy. A large accumulation of spherical droplets, ranging from approximately 1.5 microns to 10 microns in diameter, were found in the lens nucleus in cold cataracts induced at 22 degrees C or 4 degrees C in TC-199 culture medium. Many droplets of all sizes were associated with the cell membranes. A cooled and then rewarmed lens was found to lose its opacity and subsequently no droplets were observed, indicating that there was a good correlation between the onset of opacification and the formation of droplets. Electron microscopy showed that droplets were composed of homogeneous electron-dense aggregates without limiting membranes. ImmunoGold study revealed that alpha-, beta-, and gamma-crystallins were all present within each droplet. This study demonstrates that extensive accumulation of the crystallin droplets in the lens nucleus is the contributing factor for the light scattering and opacification of the cold cataract in the young intact rat lens.

Adherens junctions in the ocular lens of various species: ultrastructural analysis with an improved fixation

The ultrastructure and distribution of adherens junctions in the intact adult lens of human, chicken, dove, rat, and rainbow trout were studied with thin-section electron microscopy, using an improved fixation containing a mixture of glutaraldehyde, lysine, and tannic acid. The nature of adherens junctions in the fiber-cells of the lens was also verified by immunofluorescence and rhodamine-phalloidin labelings for vinculin and actin. Electron microscopy revealed that adherens junctions of the lens were different ultrastructurally from the desmosomes found only between the lateral epithelial cells of the lens. The adherens junctions had the same structural characteristics as the zonulae adherentes, except that they were macular contacts, not belts. However, cross bridges were evident within the interspace of the junctions. Adherens junctions were located between the fiber-cells, between the epithelial cells and fiber-cells, and between the epithelial cells. They had a characteristic distribution in the "intersections" where three hexagonal fiber-cells met, as seen in cross-sections in all species studied. In addition, adherens junctions and associated actin were found distributed randomly along the entire cell membranes of both wide and narrow sides of cortical fiber-cells in the human, chicken, and dove lenses which have good accomodating capability. However, in the poorly-accomodating lenses of rat and fish, these junctions were seen predominantly on the narrow sides and at the regions of the wide sides that were very close to the "intersections". It is suggested that adherens junctions and associated actin microfilaments are involved in stabilizing the structural integrity of lens cells during accomodation and in preserving a specific lens shape.

In vivo and in vitro observations on permeability and diffusion pathways of tracers in rat and frog lenses

Two tracers [horseradish peroxidase (HRP) and lanthanum] with different properties were injected separately into eyes of the rat and frog to determine the diffusion pathways of tracers in the lens. HRP can diffuse rapidly into lens tissue and can also be washed out, whereas lanthanum has opposite properties. In a short (2-5 min) in vivo intravitreal injection of HRP into the rat eye using an automated micro syringe, tracer reached the entire intercellular space between lens epithelium and fiber cells, and between epithelial cells primarily at the peripheral region; however, it reached the central zone in a longer period (10-20 min) of injection, as examined with light microscope and transmission electron microscope. HRP in epithelial intercellular spaces basal to the tight junctions was washed away upon 5-15 min washing with TC-199, but was retained in the spaces apical to the junctions and between epithelium and fiber cells. Lanthanum studies in both rat and frog lenses showed that within 3-4-hr incubation, tracer was seen in epithelial intercellular spaces only basal to the tight junctions at the central epithelium. At the peripheral zone, however, tracer was visualized in the entire intercellular spaces between epithelial cells, and between epithelium and fiber cells. These studies strongly suggest that both tracers seen in the intercellular space between epithelium and fiber cells are derived from the most equatorial region of the lens, and they may not leak out to the anterior lens surface through tight junctions between epithelial cells in the rat and frog. This leads us to conclude that the equatorial region of the lens is the major site of efflux and influx of substances for the anterior lens region.

Alterations in fiber cell membranes of Emory mouse cataract: a morphologic study

Morphologic alterations in cortical fiber cell membranes of the developing Emory mouse cataract were studied with scanning, transmission and freeze-fracture electron microscopy. Scanning electron microscopy revealed the extensive formation of prominent ridges on the surfaces of normal-appearing fibers, greatly enlarged degenerating fibers and globular structures in the relatively superficial cortical regions of the cataractous lenses where such a surface pattern was not found in the normal controls. Transmission electron microscopy showed undulating 13 nm pentalamellar structures, which were thinner than 17 nm heptalamellar (or pentalamellar) structures of gap junctions, were distributed within the cell membranes having ridge patterns. Some globular structures were encircled by repeated undulating 13 nm pentalamellar structures and multilamallar membranes. Freeze-fracture studies demonstrated that 13 nm pentalamellar structures consisted of square crystalline arrays of 6 nm intramembrane particles whereas 17 nm heptalamellar profiles showed randomly-packed 9 nm intramembrane particles of typical lens fiber gap junctions. It is suggested that the extensive formation of ridges in the relatively superficial cortical regions of the Emory mouse lenses may be associated with a degenerative process of lens fiber cell membranes during cataractogenesis.

Structure and distribution of gap junctions in lens epithelium and fiber cells

We report a comparative study of gap junctions in lens epithelia of frog, rabbit, rat and human, using a "double mounting" method for freeze-fracture electron microscopy. The gap junctions on the narrow sides of hexagonal cortical fiber cells of various species were also studied with the same technique. Gap junctions were commonly present between epithelial cells of the entire undifferentiated epithelium, between fiber cells on both wide and narrow sides, and between epithelial cells and fiber cells. Structural diversity of gap junctions, based on connexon arrangements, was evident in lens epithelia among the four species studied. Gap junctions with random arrays of connexons were found predominantly in frog lens epithelium, while the crystalline and striated configurations were mainly observed in the epithelia of human and rat, and of rabbit, respectively. On the other hand, there was no structural variation of gap junctions observed on either wide or narrow sides of lens fiber cells from any species studied. Only the random-type gap junction was found. However, the distribution of gap junctions was unique on the narrow sides. There was a single row of junctional plaques along the middle of the narrow sides, whereas the wide sides showed an uneven distribution pattern. The gap junctions between epithelial cells and fiber cells had a random packing of connexons.

Square arrays and their role in ridge formation in human lens fibers

Square arrays in human lens fibers were studied with freeze-fracture and thin-section TEM. In superficial fibers a number of patches of square array particles in the P face and pits in the E face are found in the smooth membrane. In the deeper cortex and the nucleus, fiber cells have undulating membranes and many ridges. Numerous patches of the particles (P face) are distributed in the concave regions, and the pits (E face) in the convex areas of the bumpy membrane. In most ridges, patches of the particles occur at regular intervals in the "valley" portion, while the pits are on the "crest" portion of ridges. Also, continuous square arrays having the same "valley" location as the regularly arranged patches are found in areas with extensive ridge patterns. The overlapping of the outer portions of two adjacent square arrays is found on the sides between the "crest" and the "valley" of the ridges. Structurally, square arrays are located in a nonjunctional part of the membrane; in an orthogonal crystalline arrangement; and with a particle size of about 6 nm and center-center spacing about 6.4 nm. They are structurally different from gap junctions found in the lens fibers. Thin-section studies reveal two types of cellular contacts: thin pentalamellar structures (about 12-13 nm in overall thickness) associated with the ridge patterns are believed to be square arrays; thick heptalamellar structures (about 16-17 nm in overall thickness) with a narrow gap in between the two central laminae are believed to be gap junctions. This study strongly suggests that square arrays are specifically involved in ridge formation in human lens fibers.

Calcium-containing opacities in the human lens

Cooperative Cataract Research Group (CCRG) photographic procedures developed by Chylack have made it possible to localize and analyze specific lens opacities for their ultrastructural and chemical characteristics. One group of human lens opacities has been shown to have a high phosphorus/sulfur ratio (as compared to normal lens fiber cells) and an accumulation of unit membranes. The present paper describes another variety of human lens opacity with the following characteristics: (1) high calcium, low sulfur, undetectable phosphorus, as determined by Energy Dispersive X-ray Analysis (EDXA) of bulk specimens in the scanning electron microscope (SEM), or "thick" sections with the transmission mode of the SEM; (2) spheroidal shape; (3) up to approximately 300 microns in size; and (4) birefringence. Microchemical analysis of these opacities shows that the calcium is in the form of calcium oxalate. These calcium-containing opacities, which have been detected in 14 out of 406 human cataractous lenses, have a characteristic morphology, as seen in the CCRG stereo photographs. Therefore, the presence of these calcium opacities, if not obscured by other kinds of opacities, can be detected with a high degree of accuracy in the fresh lens from the CCRG photographs alone.

Tight junctions in the lens epithelia of human and frog: freeze-fracture and protein tracer studies

For the first time, the existence of zonulae occludentes in the lens epithelia of human and frog has been demonstrated, using a "double mounting" method in freeze-fracture transmission electron microscope (TEM). The physiologic barrier function of zonulae occludentes in frog lens epithelium is determined by a "wash out" procedure in the protein tracer studies. It was found that within various time intervals of washing, horseradish peroxidase (HRP) was consistently restricted to the location of membrane fusions (zonulae occludentes), as seen with thin-section TEM. This corresponds to the location of zonulae occludentes found in the freeze-fracture studies. Thus, these data strongly suggest that there are zonulae occludentes in the frog lens epithelium and that these structures do provide a barrier function for the transepithelial diffusion of HRP with a molecular weight of 40,000 daltons.