A novel autoregulated proliferation-controlled production process using recombinant CHO cells

Controlled proliferation bioprocesses have shown great enhancement of heterologous protein production. This novel technology has been implemented here using a multicistronic expression unit encoding the product gene and a cytostatic cell-cycle-arresting gene (p27) under control of a single tetracycline-repressible (tet(off)) promoter. The strict genetic linkage of both genes allows the dissection of the production process into a nonproductive growth phase (dicistronic expression unit repressed) followed by a proliferation-inhibited production phase (dicistronic expression unit induced) when the cells have reached an optimal cell density. Based on rapid degradation of the external repressible agents tetracycline (tet) and doxycycline (dox) in the cell culture medium, we developed a self-regulated process for transition from the growth phase to the production phase in a fashion that is dependent only on the starting cell population and the initial concentration of the tetracyclines. With this process, no change in medium is required to accomplish the transition from growth to production phase. The two-phase bioprocess achieved here by tet switch-controlled proliferation is reliable and allows a growth-arrested production phase of at least 7 days, during which cells remain in a well-defined, highly viable physiological state and show enhanced heterologous protein production. This Tet(SWITCH) process is readily adaptable to a variety of industrial processes designed for production of difficult-to-express protein pharmaceuticals.

Estimation of P-to-O ratio in Bacillus subtilis and its influence on maximum riboflavin yield

Simultaneous growth and riboflavin overproduction were investigated using a previously developed stoichiometric model of Bacillus subtilis metabolism. A fit of model predictions to experimental data was used to obtain estimates of fundamental energetic parameters of B. subtilis. Although multiple solutions describe the experimental data, evidence for a P-to-O ratio of about 1(1/3) mole of ATP produced per atom of oxygen consumed in oxidative phosphorylation was provided by genomic analysis of electron transport components, because no homologue of the proton-translocating NADH dehydrogenase I was found in the B. subtilis genome database. These results allow us to devise a rational metabolic engineering strategy to improve riboflavin production. The potential influence of increased energy coupling in oxidative phosphorylation on riboflavin yield is discussed. Higher coupling is most significant under carbon-limiting conditions in slow-growing cells, that is, in fed-batch processes of industrial interest.

Academic managed care organizations and adverse selection under Medicaid managed care in Tennessee

CONTEXT

Health plans competing in a managed care system may face serious financial consequences if they are disproportionately selected by enrollees with expensive health conditions. Academic medical centers (AMCs) have traditionally provided medical care for the sickest patients and may be at particularly high risk for adverse selection, but whether this occurs is not known.

OBJECTIVE

To determine whether managed care organizations (MCOs) representing AMCs are adversely selected by Medicaid managed care (MMC) enrollees with expensive chronic health conditions.

DESIGN AND SETTING

Observational study using state Medicaid claims data from all of 1994 and January to August 1995 for Tennessee's statewide MMC program (TennCare).

PARTICIPANTS

All 12 capitated MCOs in Tennessee, which collectively provided services for 1.2 million Medicaid enrollees from January 1994 through August 1995 following the initiation of TennCare.

MAIN OUTCOME MEASURES

Prevalence of 6 state-specified high-cost chronic conditions-acquired immunodeficiency syndrome (AIDS), coagulation defects, cystic fibrosis, pregnancy, prematurity, and organ transplantation-and 27 additional high-cost conditions compared by academic, statewide, and regional MCOs.

RESULTS

The prevalence of state-specified high-cost chronic conditions was generally higher for academic MCOs compared with other MCOs. Specifically, prevalence of AIDS was 14.1 times higher in academic MCOs than in statewide MCOs; coagulation defects, 6.4 times higher; transplantations, 4.4; pregnancy, 3.3; cystic fibrosis, 2.4; and prevalence of prematurity was equivalent. Prevalence was higher for academic than for statewide MCOs for 22 of the additional 27 high-cost conditions considered and similar for the remaining 5 conditions.

CONCLUSIONS

Our results suggest that academic MCOs in an MMC system are selected by a large percentage of the sickest patients. Adverse selection may present serious financial risks for AMCs participating in managed care.

Serum protects protein-free competent Chinese hamster ovary cells against apoptosis induced by nutrient deprivation in batch culture

The development of serum- and protein-free Chinese hamster ovary (CHO) cell cultures is a high priority for the production of biopharmaceuticals. Protein-free competent CHO cells lines have been previously constructed by two different methods-metabolic engineering with cell-cycle regulatory proteins and long-term selective adaptation. Apoptosis was present in both cell lines during protein-free, static-batch culture as a result of nutrient deprivation, and glucose deprivation alone was a potent inducer of apoptosis compared to the depletion of other nutrients such as amino acids. By adding back serum to the cultures during batch growth or nutrient deprivation, it was shown that unidentified survival factors in serum can greatly reduce apoptosis in protein-competent cell lines in all phases of the culture. Both observations contrast to previous reports for hybridoma cells, in which amino acids were the key determinants of apoptosis and serum had no additional antiapoptotic effect. Serum's protective effect against CHO cell death in batch culture was multifaceted and complex: (1) 10% FBS increased cell viability to >99% during exponential growth from roughly 75-90%, (2) 5-10% fetal bovine serum (FBS) reduced specific glucose consumption rates in both cell lines by 40%, thereby delaying the onset of apoptosis caused by glucose deprivation, and (3) 5% FBS reduced the specific cell death rate by 65% during a 3-d lactate-consumption phase characterized by substantial abortive proliferation, in which the cells both proliferated and died at a constant rate. The benefit of serum on cell production over the various phases of batch growth was combined into a single parameter by integrating the viable cell concentration vs. time profile (termed here as cumulative volumetric viable cell-time, VCTvol). Despite the ability of both cell lines to grow indefinitely without any exogenous growth factors, the addition of serum resulted in a 2. 3-fold increase in the VCTvol. Thus, it is clear that there is much room for improvement of protein-free CHO cell lines despite their adequate growth competence, and new strategies different from those successfully used for hybridomas may be necessary to combat CHO cell apoptosis.

Bioreaction network topology and metabolic flux ratio analysis by biosynthetic fractional 13C labeling and two-dimensional NMR spectroscopy

Biosynthetically directed fractional 13C labeling of the proteinogenic amino acids is achieved by feeding a mixture of uniformly 13C-labeled and unlabeled carbon source compounds into a bioreaction network. Analysis of the resulting labeling pattern enables both a comprehensive characterization of the network topology and the determination of metabolic flux ratios. Attractive features with regard to routine applications are (i) an inherently small demand for 13C-labeled source compounds and (ii) the high sensitivity of two-dimensional [13C,1H]-correlation nuclear magnetic resonance spectroscopy for analysis of 13C-labeling patterns. A user-friendly program, FCAL, is available to allow rapid data analysis. This novel approach, which recently also has been employed in conjunction with metabolic flux balancing to obtain reliable estimates of in vivo fluxes, enables efficient support of metabolic engineering and biotechnology process design.

Influence of low temperature on productivity, proteome and protein phosphorylation of CHO cells

Proliferation of mammalian cells can be controlled by low cultivation temperature. However, depending on cell type and expression system, varying effects of a temperature shift on heterologous protein production have been reported. Here, we characterize growth behavior and productivity of the Chinese hamster ovary (CHO) cell line XM111-10 engineered to synthesize the model-product-secreted alkaline phosphatase (SEAP). Shift of cultivation temperature from 37 degrees C to 30 degrees C caused a growth arrest mainly in the G1 phase of the cell cycle concomitant with an up to 1.7-fold increase of specific productivity. A low temperature cultivation provided 3.4 times higher overall product yield compared to a standard cultivation at 37 degrees C. The cellular and molecular mechanisms underlying the effects of low temperature on growth and productivity of mammalian cells are poorly understood. Separation of total protein extracts by two-dimensional gel electrophoresis showed altered expression levels of CHO-K1 proteins after decrease in cultivation temperature to 30 degrees C. These changes in the proteome suggest that mammalian cells respond actively to low temperature by synthesizing specific cold-inducible proteins. In addition, we provide the first evidence that the cold response of mammalian cells includes changes in postranslational protein modifications. Two CHO proteins were found to be phosphorylated at tyrosine residues following downshift of cultivation temperature to 30 degrees C. Elucidating cellular events during cold exposure is necessary for further optimization of host-cell lines and expression systems and can provide new strategies for metabolic engineering.

Etomidate and telazol

These two drugs, etomidate and Telazol, have different pharmacological properties. The good properties of these drugs should be employed in specific patients and procedures to be performed (Table 3). There is no ideal injectable agent available yet for clinical practice. This in itself makes practice quite interesting because of the continuous process of rationalizing and determining the best drug for a specific condition and patient.

Glucose catabolism of Escherichia coli strains with increased activity and altered regulation of key glycolytic enzymes

This study investigates the effect of overexpression of key glycolytic enzymes exhibiting either native or alternative allosteric regulation on glucose bioconversion by resting Escherichia coli cells previously engineered for ethanol production. Homologous and heterologous pyruvate kinases (Pyk) and phosphofructokinases (Pfk) were individually and simultaneously overexpressed. Overexpression of the E. coli Pfk led to a shift from ethanol to lactate formation (three-fold above the control level) while overexpression of Pyks accelerated lactate formation two-fold with less reduction in ethanol formation. Further increase in lactate formation (five-fold above the control level) resulted from overexpression of Pfk from Lactobacillus bulgaricus which, unlike the E. coli Pfk, is not allosterically regulated by either phosphoenolpyruvate or ADP. These effects on the carbon flux distribution were accompanied by significant changes in the intracellular concentrations of several glycolytic intermediates. Increased Pfk levels led primarily to reduced levels of hexose phosphates. Increased Pyk activity resulted in more complex changes which were different for overexpressed native Pyk and for overexpressed Bacillus stearothermophilus Pyk, which differs from E. coli Pyk in lacking activation by fructose 1,6-diphosphate, but is allosterically activated by AMP and ribose 5-phosphate. Simultaneous overexpression of native Pfk and Pyk caused a Pfk-overexpression-like phenotype with lower levels of hexose phosphates and further increased lactate formation (nine-fold above the control level). The flux data demonstrate that overexpression of even single enzymes early in a central pathway can increase the fluxes to a particular metabolic product, although it may not affect the glucose uptake rate.

Expression of Vitreoscilla hemoglobin in Escherichia coli enhances ribosome and tRNA levels: a flow field-flow fractionation study

Asymmetrical flow field-flow fractionation (FFF) was used to separate and quantitate 70S ribosomes, the 30S and 50S subunits, and tRNA in one single analytical procedure. The method was applied to an investigation of the effect of Vitreoscilla hemoglobin (VHb) on the translational machinery of the recombinant Escherichia coli cells. The number of active 70S ribosomes per cell increased dramatically, more than 2-fold, as did also the tRNA levels for the VHb-expressing strain relative to VHb-negative control at the end of a 30-h fed-batch cultivation. This was accompanied by a corresponding 61% increase of a cloned marker enzyme activity. The results clearly indicate that VHb promotes the level of translational components. There should be many other cases in bioengineering where it is important to relate the protein production level in a bioreactor to the ribosome and tRNA levels.

Isolation and characterization of the naphthocyclinone gene cluster from Streptomyces arenae DSM 40737 and heterologous expression of the polyketide synthase genes

Streptomyces arenae produces the aromatic polyketide naphthocyclinone, which exhibits activity against Gram-positive bacteria. A cosmid clone containing the putative naphthocyclinone gene cluster was isolated from a genomic library of S. arenae by hybridization with a conserved region from the actinorhodin PKS of S. coelicolor. Sequence analysis of a 5.5-kb DNA fragment, which hybridizes with the actI probe, revealed three open reading frames coding for the minimal polyketide synthase. A strong sequence similarity was found to several previously described ketosynthases, chain length factors and acyl carrier proteins from other polyketide gene clusters. An additional open reading frame downstream of the PKS genes of S. arenae showed 53% identity to act VII probably encoding an aromatase. Another open reading frame was identified in a region of 1.436 bp upstream of the PKS genes, which, however, had no similarity to known genes in the database. Approximately 8 kb upstream of the PKS genes, a DNA fragment was identified that hybridizes to an actVII--actIV specific probe coding for a cyclase and a putative regulatory protein, respectively. Disruption of the proposed naphthocyclinone gene cluster by insertion of a thiostrepton resistance gene completely abolished production of naphthocyclinones in the mutant strain, showing that indeed the naphthocyclinone gene cluster had been isolated. Heterologous expression of the minimal PKS genes in S. coelicolor CH999 in the presence of the act ketoreductase led to the production of mutactin and dehydromutactin, indicating that the S. arenae polyketide synthase forms a C-16 backbone that is subsequently dimerized to build naphthocyclinone. The functions of the proposed cyclase and aromatase were examined by coexpression with genes from different polyketide core producers.

Engineered glycoforms of an antineuroblastoma IgG1 with optimized antibody-dependent cellular cytotoxic activity

The glycosylation pattern of chCE7, an antineuroblastoma chimeric IgG1, was engineered in Chinese hamster ovary cells with tetracycline-regulated expression of beta(1,4)-N-acetylglucosaminyltransferase III (GnTIII), a glycosyltransferase catalyzing formation of bisected oligosaccharides that have been implicated in antibody-dependent cellular cytotoxicity (ADCC). Measurement of the ADCC activity of chCE7 produced at different tetracycline levels showed an optimal range of GnTIII expression for maximal chCE7 in vitro ADCC activity, and this activity correlated with the level of constant region-associated, bisected complex oligosaccharides determined by matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. The new optimized variants of chCE7 exhibit substantial ADCC activity and, hence, may be useful for treatment of neuroblastoma. The strategy presented here should be applicable to optimize the ADCC activity of other therapeutic IgGs.

Genetic optimization of recombinant glycoprotein production by mammalian cells

Genetically modified mammalian cells are the preferred system for the production of recombinant therapeutic glycoproteins. Other applications include engineering of cell lines for drug screening and cell-based therapies, and the construction of recombinant viruses for gene therapy. This article highlights contemporary core genetic technologies and emerging strategies for genetically engineering mammalian cells for optimal recombinant-protein expression.

The metabolic effects of native and transgenic hemoglobins on plants

The strictly aerobic bacterium Vitreoscilla expresses a hemoglobin-like protein, VHb, when subjected to oxygen stress. When expressed in plants, this has several intriguing physiological effects, such as improving the overall growth rate, speeding germination and flowering, and increasing the productivity of certain oxygen-requiring metabolic pathways. Although the mechanisms behind the effects of VHb in heterologous hosts are not yet fully characterized, it has been suggested that VHb facilitates oxygen transport and/or storage. This hypothesis is supported by the kinetic properties of VHb, which allow very rapid dissociation of oxygen from the protein.

Management of Plant-parasitic Nematodes on Peanut with Selected Nematicides in North Carolina

Field experiments were conducted to determine peanut growth and yield responses to selected fumigant and nonfumigant nemaficide treatments in 1988 and 1989. All treatments with the fumigant 1, 3-D significantly suppressed nematode reproduction (Meloidogyne arenaria, M. hapla, and Mesocriconema ornatum) and enhanced peanut yields over the other treatments in four tests in 1988. Yield increases with the fumigant ranged from about 20% to 100% over the untreated control. Test sites in 1989 had lower nematode levels than those for 1988, and fewer positive plant and nematode responses were detected. Treatments with 1,3-D improved peanut quality but not yield in one experiment with low levels of M. hapla and M. ornatum in 1988. The 1,3-D + chloropicrin treatments at another site gave higher peanut yields than 1,3-D alone.

Molecular regulation of cell-cycle progression and apoptosis in mammalian cells: implications for biotechnology

Regulation of the cell cycle and of programmed cell death (apoptosis) is essential for mammalian development and homeostasis. Furthermore, this regulation is fundamental to successful cell culture technology and tissue engineering. Therefore the molecular networks which regulate these processes are critical targets for drug development, gene therapy, and metabolic engineering. This review summarizes the genes, proteins, and interactions presently known to control apoptosis and cell-cycle progression. Knowledge of the networks summarized here and access to the component genes and proteins have already been applied successfully to guide research and development in bioprocess technology and medical treatment.

Cloning and expression of the Zymomonas mobilis pyruvate kinase gene in Escherichia coli

The homotetrameric pyruvate kinases (PK) constitute a fine example of allosteric enzymes subjected to sophisticated regulatory mechanisms. We have cloned and sequenced the Zymomonas mobilis structural gene for the first prokaryotic dimeric PK, as an initial step toward understanding the peculiar properties of this enzyme. The deduced amino acid sequence of the pyk gene consists of 475 residues with a calculated molecular mass of 51.4kDa and exhibits up to 50% sequence identity with other PKs. Heterologous expression in Escherichia coli was not obtained from the native promoter, but only when the pyk gene was under the control of a strong inducible promoter when a ribosome-binding site was present upstream of the putative TTG start codon of the pyk gene. Kinetic characterization of PK in concentrated crude cell extracts showed that the enzyme is not activated by sugar phosphates or AMP but is slightly inhibited by ATP. Thus, PK of Z. mobilis is unique among the characterized prokaryotic PKs due to its high activity in the absence of any allosteric activator. Amino acid sequence alignments revealed that glutamate 381 may play a role in ineffective binding of the usual PK activator, fructose-1,6-bisphosphate.

Higher productivity of growth-arrested Chinese hamster ovary cells expressing the cyclin-dependent kinase inhibitor p27

We constructed stable Chinese hamster ovary (CHO) cell lines which conditionally and coordinately express the model product gene secreted alkaline phosphatase (SEAP) and one of the cytostatic genes p21, p27, and p53175P, a p53 mutant deficient in apoptotic but not cell-cycle arrest function. The use of dicistronic expression technology allowed the conditional expression of the model product gene and the cytostatic gene in a coordinated fashion from a single expression unit under the control of the tetracycline-responsive promoter PhCMV-1. Due to the presence of a cytostatic gene in the multicistronic expression unit, the growth behavior of the engineered CHO cell lines could be controlled by the addition or withdrawal of the exogenous agent tetracycline to or from the cell culture medium. Withdrawal of tetracycline resulted in sustained growth arrest of the stable cell lines for a prolonged period. The growth arrest of such cell lines was found to be accompanied by a 10-15-fold increase in their production of SEAP per cell. This controlled proliferation technology allows the design of a novel two-stage production process which consists of a proliferation phase leading to the desired cell density, followed by an extended production phase during which the cells remain growth-arrested and increase cell-specific production of a heterologous protein.

A methodologic issue for ophthalmic telemedicine: image quality and its effect on diagnostic accuracy and confidence

BACKGROUND

The possibility of ophthalmic telemedicine raises questions as to the quality of images displayed on a video display terminal and its effect on a doctor's accuracy and confidence of diagnosis. This study compares diagnostic accuracy and confidence levels of subjects observing two formats of retinal imaging.

METHODS

Test images included 90 conventional 4- x 6-inch retinal fundus photographs and the same set of photographs after they had been scanned, digitized, modified in brightness and contrast, and displayed on a video display terminal. Fifty-six of the images demonstrated one or more retinal anomalies; the remaining 34 were of normal fundi. Abnormalities were selected on the basis of estimates of prevalence in the general population. Twenty optometrists affiliated with the Southern California College of Optometry participated as subjects. One group of 10 was shown the photographs; the remaining ten subjects were shown the digitized images. Both groups were asked if the pictures were "healthy" or "unhealthy," how confident they were of their decision, and, if abnormal, what was the ocular disease.

RESULT

T-tests were used to compare the results of the two groups. There was a statistically significant difference in the confidence of a specific diagnosis between the two groups (p = 0.018), as well as tendencies toward significance on other measures.

CONCLUSION

Viewing digitally reconstructed photographic images of the retina on a video display caused doctors to lose confidence in making a diagnosis before they lost accuracy.

Antisense strategies for glycosylation engineering of Chinese hamster ovary (CHO) cells

Novel glycoproteins, inaccessible by other techniques, can be obtained by metabolic engineering of the oligosaccharide biosynthesis pathway. Furthermore, alteration of cell-surface oligosaccharides can change the properties of receptors involved in cell-cell adhesion. Sialyl Lewis X (sLex) is a cell-surface oligosaccharide determinant which is specifically expressed on granulocytes and monocytes and which interacts with selectins to influence leukocyte trafficking, thrombosis, inflammation, and cancer. Antisense technology targeting fucosyltransferase VI (Fuc-TVI), an enzyme necessary for the synthesis of the sLex in engineered Chinese hamster ovary (CHO) cells, has reduced Fuc-TVI activity, sLex synthesis, and adhesion to endothelial cells. Antisense methodology to reduce targeted activity in oligosaccharide biosynthesis or other pathways is an important addition to CHO cell metabolic engineering capabilities.

An Escherichia coli host strain useful for efficient overproduction of secreted recombinant protein

Periplasmic secretion of overexpressed Bacillus stearothermophilus alpha-amylase was analyzed in batch and fed-batch cultivations of Escherichia coli MG1655:pCSS4-p and the mutant strain CWML2:pCSS4-p. Under all conditions investigated, growth and product formation of MG1655:pCSS4-p were severely impaired by heterologous protein expression and/or processing, while E. coli CWML2:pCSS4-p was found to be more robust and to accumulate 2- to 3-fold higher maximum alpha-amylase levels. While this strain is itself potentially interesting for applications, its properties also illustrate the potential of the selection procedure that was employed to obtain it from its progenitor MG1655 (Weikert, C., Sauer, U., Bailey, J. E., 1997. Microbiol. 143: 1567-1574. Application of this procedure to existing industrial strains may lead to significantly improved process organisms.

Physicians' experiences with Medicaid managed care: the Tennessee American College of physicians survey on TennCare

Despite widespread introduction of Medicaid managed care (MMC), physicians have not been surveyed regarding its impact on patient care. This study documented physician experiences with MMC in Tennessee, where a statewide experimental managed care program (TennCare) delivers services through 12 capitated managed care organizations (MCOs). Practicing Tennessee American College of Physician (ACP) members (n = 1,181) were questioned regarding recent experience with the TennCare program, assessment of the program, and suggestions for improvement. The results, derived from 306 physician respondents (response rate 26%), were as expected, based on findings of a prior administrative focus group and independent surveys. Physicians' experiences were similar regardless of practice type. Most physicians rated the TennCare program as either fair (43%) or poor (42%) overall. The majority cited administrative complexity as a major problem that frequently adversely affected patient care. Physician experience suggests that administrative procedures and medication formularies should be streamlined and standardized to improve patient care.

Metabolic capacity of Bacillus subtilis for the production of purine nucleosides, riboflavin, and folic acid

We developed a stoichiometric model of Bacillus subtilis metabolism for quantitative analysis of theoretical growth and biochemicals production capacity. This work concentrated on biochemicals that are derived from the purine biosynthesis pathway; inosine, guanosine, riboflavin, and folic acid. These are examples of commercially relevant biochemicals for which Bacillus species are commonly used production hosts. Two previously unrecognized, but highly desirable properties of good producers of purine pathway-related biochemicals have been identified for optimally engineered product biosynthesis; high capacity for reoxidation of NADPH and high bioenergetic efficiency. Reoxidation of NADPH, through the transhydrogenase or otherwise, appears to be particularly important for growth on glucose, as deduced from the corresponding optimal carbon flux distribution. The importance of cellular energetics on optimal performance was quantitatively assessed by including a bioenergetic efficiency parameter as an unrestricted, ATP dissipating flux in the simulations. An estimate for the bioenergetic efficiency was generated by fitting the model to experimentally determined growth yields. The results show that the maximum theoretical yields of all products studied are limited by pathway stoichiometry at high bioenergetic efficiencies. Simulations with the estimated bioenergetic efficiency of B. subtilis, growing under glucose-limiting conditions, indicate that the yield of these biochemicals is primarily limited by energy and thus is very sensitive to the process conditions. The maximum yields that can reasonably be expected with B. subtilis on glucose were estimated to be 0.343, 0.160, and 0.161 (mol product/mol glucose) for purine nucleosides, riboflavin, and folic acid, respectively. Potential strategies for improving these maximum yields are discussed.

Improved erythromycin production in a genetically engineered industrial strain of Saccharopolyspora erythraea

An industrial erythromycin production strain of Saccharopolyspora erythraea spp. was used to demonstrate that careful genetic engineering can significantly improve productivity. The chromosomally integrated Vitreoscilla hemoglobin gene (vhb) was shown to enhance the final titer of erythromycin by some 70% compared to the original S. erythraea spp. Overall, specific erythromycin yields were about 2.5 g of erythromycin/g of total protein for S. erythraea::vhb but <1 for the S. erythraea spp. The maximum rates of biosynthesis were 57.5 mg of erythromycin/(L/h) and 24.3 mg/(L/h) for the recombinant strain S. erythraea::vhb and S. erythraea spp., respectively. Overall space-time yield was 100% higher for the S. erythraea::vhb fermentation (1.1 g of erythromycin/(L/day)) than for the S. erythraea spp. fermentation (0. 56 g of erythromycin/(L/day)). The genetic stability of the recombinant strain was high, and no selective pressure was needed throughout the cultivations. Expression of functional Vitreoscilla hemoglobin throughout the cultivations was verified by CO difference spectrum assays.

Diuretic-based treatment and cardiovascular events in patients with mild renal dysfunction enrolled in the systolic hypertension in the elderly program

BACKGROUND

It is expected that the treatment of hypertension in patients with renal disease decreases the risk of cardiovascular events, but the evidence in these patients is lacking.

OBJECTIVE

To assess the effect of diuretic-based treatment on cardiovascular events in patients with isolated systolic hypertension and renal dysfunction.

METHODS

A total of 4336 persons aged 60 years and older with systolic blood pressures of 160 mm Hg and higher and diastolic blood pressures of less than 90 mm Hg were randomly assigned to receive either placebo or chlorthalidone (12.5-25.0 mg/d), with the addition of atenolol (25-50 mg/d) or reserpine (0.05-0.10 mg/d) if needed, and observed for 5 years. The risk of first-occurring cardiovascular events, including stroke, transient ischemic attack, myocardial infarction, heart failure, coronary artery bypass surgery, angioplasty, aneurysm, endarterectomy, sudden death, or rapid death, was stratified according to baseline serum creatinine levels (35.4-84.0, 84.1-101.6, 101.7-119.3, and 119.4-212.2 micromol/L [0.4-0.9, 1.0-1.1, 1.2-1.3, and 1.4-2.4 mg/dL]).

RESULTS

Systolic blood pressure reduction was not affected by baseline serum creatinine levels. Active treatment did not affect the risk of serum creatinine levels becoming elevated during follow-up. The risk of hypokalemia with active treatment decreased significantly with increasing baseline serum creatinine levels. In the 4 baseline serum creatinine groups, the relative risk (95% confidence interval) of cardiovascular events developing with active treatment was 0.73 (0.54-0.97), 0.63 (0.49-0.82), 0.62 (0.44-0.87), and 0.59 (0.38-0.91). The results were similar for the outcomes of stroke or coronary artery events and in analyses stratified by sex or age.

CONCLUSION

Diuretic-based treatment of patients with isolated systolic hypertension prevents the development of cardiovascular events in older persons with mild renal dysfunction.