Use of a modified peritoneal equilibration test to optimize solute and water clearance

The standard peritoneal equilibration test (PET) characterizes the peritoneal transport of fluid, creatinine and urea. However, the applicability of the standard PET may be limited in patients on cycling peritoneal dialysis due to the choice of 2- and 4-h sampling times which exceed the usual dwell time of most patients on cycling peritoneal dialysis. We have performed a modified PET on seven pediatric dialysis patients in an effort to optimize dwell time to achieve maximal clearance of solutes and fluid. When compared with the standard PET, values obtained for dialysate/plasma urea and dialysate/plasma creatinine with the modified PET are significantly different. This resulted in an increased estimated creatinine clearance in five of seven and increased estimated urea clearance in six of seven patients. The modified PET is a more appropriate method for evaluation of peritoneal clearances in children as well as older patients who may require cycling peritoneal dialysis.

Impact of nutrients on cellular lipid peroxidation and antioxidant defense system

A symposium entitled Impact of Nutrients on Cellular Lipid Peroxidation and Antioxidant Defense System was held at the 33rd Annual Meeting of the Society of Toxicology (SOT) at the Loews Anatole Hotel in Dallas, Texas. The symposium was sponsored by the Food Safety Specialty Section and focused on the role of particular nutrients in cellular lipid peroxidation and antioxidant defense system. Emphasis was placed on defining underlying mechanisms for damage and protection, as well as potential ramification in human health issues. The following are extractions of some of the highlights from each presentation.

Mitochondrial dysfunction during anoxia and acute cell injury

Mitochondrial function is closely linked to the maintenance of mitochondrial integrity. During short-term anoxia, ion-transport systems in the inner membrane are inhibited to protect against loss of the promotive force and associated osmotic imbalance that can cause irreversible loss of mitochondrial integrity and function. In two models of chemically induced mitochondrial failure, a prostaglandin B1 derivative, di-calciphor, protected against mitochondrial failure and prevented cell death. Characteristics were similar to those observed in mitochondria during short-term anoxia. Thus, the results indicate that di-calciphor may represent a new type of mitochondrial protectant that inhibits ion transport and thus slows the loss of osmotic stability and delays mitochondrial dysfunction under traumatic and toxicologic conditions.

Tumor lysis syndrome: pathogenesis and management

Tumor lysis syndrome refers to the metabolic disturbances (hyperuricemia, hyperphosphatemia, hyperkalemia, and hypocalcemia) associated with lymphoproliferative malignancies which occur secondary to cell lysis. In some patients, tumor lysis results in acute renal failure. The nature and severity of the metabolic alterations are variable and may be influenced by the timing and intensity of chemotherapy, the magnitude of cell lysis, and the general condition of the patient with respect to hydration and glomerular filtration rate. Not only do hyperuricemia and hyperphosphatemia result from tumor lysis syndrome, they also contribute to oliguric acute renal failure in patients with tumor lysis. The pathogenesis of tumor lysis syndrome and current therapeutic strategies are discussed.

Renal toxicity of cancer chemotherapeutic agents in children: ifosfamide and cisplatin

Ifosfamide and cisplatin are two commonly used cancer chemotherapeutic agents associated with significant acute and chronic renal toxicity. The clinical characteristics of ifosfamide-induced renal injury are proximal tubular wasting of glucose, phosphate, bicarbonate, sodium, potassium, and amino acids; proteinuria; and decreased glomerular filtration rate. Cisplatin administration may result in a dose-dependent reduction of glomerular filtration rate, hypomagnesemia, hypokalemia, and polyuria. The characteristics of renal toxicity associated with each of these agents are discussed with attention to possible mechanisms of injury and long-term clinical outcome.

Non-invasive measurement of azygos venous blood flow using magnetic resonance

Monitoring treatment efficacy in patients with portal venous hypertension has been limited by the difficulty of direct or indirect assessment of portal vein pressure. The majority of currently available haemodynamic tests, such as hepatic vein wedge pressure or azygos vein flow measurement by thermodilution catheter, are invasive which has restricted their application. We describe a non-invasive cine phase contrast magnetic resonance technique for quantitative measurements of bulk volume flow and for demonstrating flow changes during the cardiac cycle in the azygos vein. The technique was used to analyse the azygos vein flow in seven adult volunteers and five patients with biopsy-confirmed chronic liver disease, portal hypertension and endoscopically proven oesophageal varices. In the volunteers the mean volume flow rates varied between 81 and 241 ml/min with a mean for the group of 171 ml/min. The patients had a significantly higher mean volume flow rate of 628 ml/min (p < 0.01), with a range of 339 to 945 ml/min. These preliminary results suggest that cine phase contrast magnetic resonance angiography is a practical non-invasive method for measuring absolute azygos vein flow, and may provide a non-invasive method of monitoring portal hypertension.

Effects of N-acetyl-L-cysteine on T-cell apoptosis are not mediated by increased cellular glutathione

Thiol-containing antioxidants such as N-acetyl-L-cysteine (NAC) are known to inhibit apoptosis, although it is unclear whether this effect is direct or mediated through modulation of intracellular glutathione (GSH). In the present study, NAC treatment of the murine T-cell hybridoma DO-11.10 was found to inhibit apoptosis triggered by anti-CD3 antibody but enhance the process when induced by 6-alpha- methylprednisolone. HPLC measurements showed that these effects were not correlated with the levels of GSH or glutathione disulfide (GSSG) in the cells. Similar effects on DNA fragmentation were obtained when the experiments were repeated in the presence either of a specific inhibitor of GSH biosynthesis (buthionine sulfoximine) or the isomer N-acetyl-D-cysteine which cannot be enzymatically converted into GSH. We conclude that NAC can have divergent effects on apoptosis independent of changes in either the amount or redox state of intracellular GSH.

Rickets secondary to phosphate depletion. A sequela of antacid use in infancy

Two infants presented with growth failure and were found to have generalized osteomalacia (rickets) due to phosphate depletion from prolonged administration of an aluminum-containing antacid given for the symptoms of colic. One of the infants developed bilateral proptosis due to craniosynostosis related to the underlying metabolic bone disease. The chronic use of aluminum-containing antacids in infants has potential risk for the growing skeleton and is not innocuous. Therefore, antacid therapy should be used in low doses and very cautiously, with routine monitoring of serum calcium and phosphorus in children taking medications which reduce gastrointestinal phosphate absorption.

The relative roles of external taurine concentration and medium osmolality in the regulation of taurine transport in LLC-PK1 and MDCK cells

Taurine is a beta-sulfonic amino acid that serves as a nutrient important for developing brain and retina and as an osmolyte in the medullary collecting duct. The activity of the taurine transport system is regulated by substrate supply and by the external osmolality; these two stimuli induce changes in taurine transport. Increased medium osmolality (500 mosmol) stimulates taurine uptake into MDCK cells but not LLC-PK1 cells. The enhanced taurine uptake that occurs in response to hyperosmolality is localized primarily to the basolateral surface of MDCK cells, whereas the adaptive response to medium taurine concentration is expressed on both the apical and the basolateral surfaces of both cell lines. The response of MDCK cells to medium osmolality requires protein synthesis and RNA transcription and is expressed in the presence of microtubular toxins. When cell monolayers were loaded with taurine by incubation in high-taurine medium before increasing medium osmolality, the expected increase in taurine uptake was blunted. Similarly, increased external beta-alanine (500 microM) also prevented the anticipated increase in taurine accumulation in response to hypertonicity; aminoisobutyric acid and betaine (500 microM) partially prevented the increase in taurine transport after hypertonicity, whereas L-alanine had no effect. The concentration of taurine or structurally similar analogs in the external medium might modify the response of taurine accumulation after exposure to hypertonic medium, in that taurine-replete cells behave differently than taurine-depleted cells. These studies indicate that there are at least tow distinct mechanisms involved in the regulation of taurine transport: external taurine concentration and medium osmolality, with taurine concentration seeming to be the predominant stimulus.(ABSTRACT TRUNCATED AT 250 WORDS)

Clearance of glutathione disulfide from rat mesenteric vasculature

Organs of the digestive tract, including pancreas, small intestine, and colon, have mechanisms to modulate plasma thiol-disulfide balance. Because plasma glutathione disulfide (GSSG) concentration may be elevated from < 1 microM in control rats to over 25 microM during oxidative stress, we examined whether GSSG was cleared from rat mesenteric vasculature. When 100 microM GSSG was perfused through the gut via the superior mesenteric artery, an average of 45% was lost in a single pass. Results showed that gamma-glutamyltransferase (gamma-GT)-dependent and -independent mechanisms were involved in GSSG loss. Acivicin (AT125) treatment inhibited gamma-GT activity in the mesenteric vasculature by 94% and attenuated the loss of GSSG equivalents by 44%. These results supported a role for gamma-GT in GSSG loss from the mesenteric vasculature but indicated that still other mechanisms were involved in GSSG clearance. Elevations of portal levels of glutathione (GSH) and the mixed disulfide of cysteine and GSH (CySSG) also occurred with vascular GSSG perfusion and could account for about 40% of GSSG equivalents lost. Because portal elevations of GSH and CySSG were not inhibited by AT125, they were formed by a gamma-GT-independent mechanism(s). Given that cysteine was present in the mesenteric vasculature, the most likely mechanism to explain GSH and CySSG formation was via nonenzymatic thiol-disulfide exchange between GSSG and cysteine. Uptake of vascular GSSG by pancreas, small intestine (jejunum and ileum), or colon apparently did not occur as tissue contents of GSSG or GSH were not elevated, except for a small elevation of GSH in pancreas when mesenteric gamma-GT was inhibited with AT125. Additionally, GSSG was not transported from mesenteric vasculature into the small intestinal lumen because luminal levels of GSSG or GSH were not elevated. Further, total cysteine equivalents in lumen were unchanged indicating that GSSG was not transported to lumen and degraded to cystine by gamma-GT and dipeptidases localized to the intestinal brush-border. These results indicate that GSSG present in mesenteric vasculature is metabolized in the vascular compartment by gamma-GT-dependent and -independent reactions; together, these account for over 80% of lost GSSG equivalents. They also suggest that organs of the mesentery may play a quantitatively important role in plasma GSSG clearance and modulation of vascular thiol-disulfide balance.

Refining therapeutic strategies for patients with resistant Wilm's tumor

PURPOSE

Despite the excellent prognosis for 90% of patients with Wilms' tumor, survival remains poor among those with recurrent or advanced disease or tumors of unfavorable histology. We sought to identify a chemotherapy regimen for this subset of patients that offers potential efficacy with minimal nephrotoxicity.

PATIENTS AND METHODS

Through a review of patients' medical records, we compared the efficacy and nephrotoxicity of ifosfamide, cisplatin, cisplatin/etoposide, and ifosfamide/carboplatin/etoposide (ICE) regimens in 32 patients with recurrent (n = 23), refractory (n = 1), or metastatic (n = 8) Wilms' tumor, including six with tumors having unfavorable histologic features.

RESULTS

Single-agent ifosfamide was minimally nephrotoxic and induced responses in three of 11 patients, but none have survived. Cisplatin with or without etoposide induced responses in six of 18 patients with recurrent Wilms' tumor (there is one long-term survivor). Seven of eight patients with newly diagnosed extensive metastatic disease responded to cisplatin/etoposide plus vincristine, dactinomycin, adriamycin, and radiotherapy. This regimen produced three long-term survivors, but was associated with significant nephrotoxicity. The ifosfamide, carboplatin, and etoposide regimen induced responses in four of five patients treated, and had minimal nephrotoxicity. Two remain free of disease progression 22 months after recurrence.

CONCLUSIONS

Although long-term survival remains to be determined, the ICE combination appears to be effective against recurrent Wilms' tumor without endangering the patients' single remaining kidney. Myelotoxicity can be ameliorated by administering growth factors. We suggest that ICE chemotherapy be considered for the primary treatment of high-risk patients with Wilms' tumor.

Glutathione transport by type II cells in perfused rat lung

Glutathione (GSH) is an antioxidant that protects the lung against oxidative-injury. Most cells rely on synthesis of GSH to maintain intracellular supply and only a few cell types take up intact GSH. Although isolated type II cells from rat have a Na(+)-dependent uptake system that transports GSH into the cells against a concentration gradient, it is not known whether this occurs from the vasculature in the intact lung or whether other cell types in the lung also transport GSH. Based on the knowledge that gamma-glutamyl analogues of GSH are also transported by the Na(+)-GSH transporter, a method was developed and used to study the cell specificity of GSH uptake in perfused lung. A stable, fluorescent GSH S-conjugate (GSH-I14) was synthesized and separated from the original dye as analyzed by high-performance liquid chromatography. Studies with isolated alveolar type II cells showed that uptake of GSH-I14 was Na+ dependent and inhibited by GSH. In addition, uptake of GSH by the type II cells was inhibited by GSH-I14. After perfusion of the isolated rat lung with GSH-I14, the conjugate accumulated primarily in the alveolar type II cell as observed by fluorescence microscopy. This was confirmed by isolation of type II cells and measurement of GSH-I14 content. Thus these results show that specificity of GSH transport can be studied with the fluorescent derivative, GSH-I14, and that in the isolated perfused lung type II cells can transport and concentrate GSH-I14 from the perfusate. Quantitative fluorescence microscopy will be required to further determine relative transport activities by other cell types.

Apoptosis: molecular control point in toxicity

Apoptosis is a controlled form of cell death that serves as a molecular point of regulation for biological processes. Cell selection by apoptosis occurs during normal physiological functions as well as toxicities and diseases. Apoptosis is the counterpart and counterbalance to mitosis in cell population determination. Complex patterns of cell signaling and specific gene expression are clearly involved in the control of cell fate. Exposure to an apogen, a trigger of apoptosis, can significantly increase apoptotic cell loss during homeostatic processes as well as acute or chronic toxicities. Alternately, suppression of apoptosis through, for example, interference in cell signaling can result in pathological accumulation of aberrant cells and diseases such as tumors. Investigations into the mechanisms underlying apoptosis have extended into many areas, driven by increasingly sophisticated instrumental and molecular biology techniques. This symposium summary explores related aspects of apoptosis, including control of cell population size and function, specific gene activity and regulation, chromatin condensation and scaffold detachment, oxidative stress-induced cell proliferation versus death by apoptosis or necrosis, and hepatotoxicant-induced apoptosis versus necrosis. Insights into the mechanisms governing apoptosis and increasing appreciation of the relevance of apoptotic cell death are redirecting research in toxicology and carcinogenesis and are yielding novel therapeutic approaches for the control of toxicity, disease, and ultimately perhaps senescence.

The externally rotated leg: anterior dislocation of the hip

A case report of anterior dislocation of the hip presenting as a fractured neck of femur following a minor fall in an elderly patient.

Secretion of cysteine and glutathione from mucosa to lumen in rat small intestine

Using a vascularly perfused rat intestinal preparation, we found that large quantities (i.e., 100-200 microM) of acid-soluble thiols accumulated in the jejunal lumen in 10-30 min and that the accumulation was largely unaffected by dietary food restriction for 24 or 48 h. Depending on the length of perfusion, cysteine comprised 20-40% of total luminal thiols, whereas glutathione (GSH) made up only 0-3%. To determine whether luminal cysteine accumulation resulted from mucosal secretion of GSH and subsequent degradation by brush-border gamma-glutamyltransferase (gamma-GT) and dipeptidases, acivicin or serine-borate was used to inhibit gamma-GT. Both agents inhibited gamma-GT activity by > 95%, reduced luminal cysteine by approximately 40-50%, and caused a modest elevation of luminal GSH to approximately 10-13 microM, indicating that GSH secretion does occur but cannot account for all of the luminal cysteine accumulation. Luminal thiol trapping experiments with Ellman's reagent supported this conclusion. Given that cysteine made up 15-20% of the mucosal thiol pool in jejunum, secretion of cysteine from mucosa to lumen likely accounted for the majority of luminal cysteine. Given the mucolytic nature of thiols and the role of cysteine in iron absorption, intestinal thiol secretion may be important in intestinal function.

Protection of hepatocytes against death due to mitochondrial failure: effect of di-Calciphor on antimycin A-induced toxicity

Di-Calciphor is a synthetic derivative of prostaglandin B1 that protects against cerebral and cardiac ischemia apparently by preserving mitochondrial function. To determine whether di-Calciphor specifically protects against mitochondrial failure, we studied its effects on mitochondrial functions in hepatocytes treated with the specific mitochondrial poison, antimycin A. The results show that 1 microM di-Calciphor protects against cell death at concentrations of antimycin A that inhibited mitochondrial respiration and caused cellular ATP depletion. Di-Calciphor did not protect against loss of ATP but did protect against the loss of mitochondrial delta psi and delta pH. In addition, di-Calciphor protected against antimycin A-induced loading of phosphate into mitochondria and an associated mitochondrial swelling. Thus, these results show that di-Calciphor protects against a specific mitochondrial poison and support the interpretation that di-Calciphor is a mitochondrial protective agent. In addition, the results suggest that the protection of the mitochondria involves preservation of mitochondrial ionic and osmotic stability and does not involve improved ATP supply.

Synthesis and transport of glutathione by cultured human retinal pigment epithelial cells

PURPOSE

To characterize synthesis and transport of glutathione (GSH) by cultured human retinal pigment epithelial (RPE) cells.

METHODS

Cultured human RPE cells were depleted of glutathione, then incubated with various concentrations of cysteine, glutamate, and glycine or with glutathione. High-performance liquid chromatography was used to measure intracellular glutathione with time.

RESULTS

After depletion with diethylmaleate, intracellular glutathione was resynthesized from the amino acid precursors within 60 minutes. The addition of buthionine sulfoximine, a known inhibitor of GSH synthesis, completely eliminated the observed increase. Similar incubation with exogenous GSH failed to increase the intracellular GSH concentration.

CONCLUSION

Cultured human RPE cells are able to rapidly synthesize glutathione from exogenously administered amino acids, but they are incapable of direct GSH uptake.

Acute hepatic and renal toxicity from low doses of acetaminophen in the absence of alcohol abuse or malnutrition: evidence for increased susceptibility to drug toxicity due to cardiopulmonary and renal insufficiency

A 67-yr-old man with chronic cardiopulmonary disease exhibited severe hepatic and moderately severe renal injury after short-term ingestion of therapeutic doses of acetaminophen (1 to 3 gm/day for 3 days). Drug metabolism and other studies, performed 5 mo after recovery from the acute insult, indicated that the patient had decreased rates of hepatic metabolism of acetaminophen to its primary, nontoxic metabolites and decreased kidney function that was compromised further by acetaminophen ingestion. He also had abnormally low concentrations of hepatic and plasma reduced glutathione. Alcohol abuse and malnutrition could not be implicated in the pathogenesis of injury; rather it appeared that advancing age with chronic renal, cardiac and pulmonary insufficiency contributed to acetaminophen toxicity in this patient.

Phase I study of escalating targeted doses of carboplatin combined with ifosfamide and etoposide in treatment of newly diagnosed pediatric solid tumors

BACKGROUND

The combination of carboplatin, ifosfamide, and etoposide has shown promising activity in a variety of relapsed childhood solid tumors but has not been studied in newly diagnosed patients.

PURPOSE

The tolerance for and activity of escalating targeted doses of carboplatin combined with ifosfamide and etoposide (ICE) were assessed in children with advanced germ cell tumors or other rare solid tumors for which no standard therapy exists.

METHODS

Fifteen children with newly diagnosed solid tumors received ICE chemotherapy. Individualized carboplatin doses were calculated to achieve a target area under the concentration x time curve (AUC) and adjusted for the glomerular filtration rate (estimated by 99mTc-labeled diethylene-triamine pentaacetic acid clearance). Cohorts of at least three patients received carboplatin at an initial target AUC of 6 mg.min/mL, with escalations of 2 mg.min/mL in subsequent cohorts. Carboplatin was given on day 1, followed by ifosfamide at 2 g/m2 per day and etoposide at 100 mg/m2 per day on days 2 through 4. All patients received at least two courses of therapy in the absence of progressive disease, and as many as eight courses could be given.

RESULTS

The 15 patients received a total of 46 assessable courses of ICE. Myelosuppression was the dominant toxicity; 30 courses (67%) resulted in hospitalization for febrile neutropenia. Neutropenia was dose limiting at the carboplatin target AUC of 12 mg.min/mL. One complete and eight partial responses were seen in the 14 assessable patients; two additional patients had at least partial responses documented at surgery or autopsy. Six patients are without evidence of disease at a median of 548 days after diagnosis.

CONCLUSION

ICE chemotherapy, with the carboplatin dose based on a target AUC of 10 mg.min/mL, is tolerable and has significant activity in a variety of rare malignancies, including extragonadal germ cell tumors.

IMPLICATIONS

The combination of carboplatin, etoposide, and ifosfamide holds promise in the treatment of rare pediatric malignancies.