Noninvasive continuous monitoring of digital pulse waves during hemodialysis

Intermittent hemodynamic instability during hemodialysis treatment is a frequent complication in patients with end-stage renal failure. A noninvasive method for continuous hemodynamic monitoring is needed. We used noninvasive digital photoplethysmography and an algorithm for continuous, investigator-independent, automatic analysis of digital volume pulse in 10 healthy subjects and in 20 patients with end-stage renal failure during the hemodialysis session. The reflective index was defined representing the diastolic component of the digital pulse wave. The properties of the reflective index were studied in healthy control subjects (n=10). An increased reflective index was due to increased peripheral pulse wave reflection (e.g., vasoconstriction). During a hemodialysis session, the reflective index increased significantly from 36+/-3 arbitrary units to 41+/-3 arbitrary units (n=20; p<0.05) measured using digital photoplethysmography. This increase appeared in 15 of the 20 patients with end-stage renal failure. Our data establish digital photoplethysmography as a noninvasive, reliable, and sensitive method for continuous monitoring during the hemodialysis session.

Association of angiotensin-converting enzyme 2 gene A/G polymorphism and elevated blood pressure in Chinese patients with metabolic syndrome

To establish whether angiotensin-converting enzyme 2 (ACE2) gene A/G single nucleotide polymorphism is associated with hypertension in Chinese patients with metabolic syndrome. The study was conducted in 353 patients with metabolic syndrome. The alleles of the ACE2 A/G polymorphism, which is located on the X chromosome, were detected using polymerase chain reaction and subsequent cleavage by Alu I restriction endonuclease. G allele frequencies in patients with metabolic syndrome were 36.6% in female subjects and 43.4% in male subjects, respectively. Female patients with metabolic syndrome who carry the GG genotype had a significantly higher diastolic blood pressure compared with other genotypes. Multivariate logistic regression showed that female gender (P = 0.019) and carrying only the G allele (odds ratio 2.83 [95% CI 1.36 to 5.91]; P = 0.005) were significantly associated with increased diastolic blood pressure. It is concluded that the ACE2 A/G polymorphism is associated with hypertension in patients with metabolic syndrome.

Contrast medium-induced nephropathy: The pathophysiology

A widespread, rather general, definition of contrast-induced nephropathy (CIN) is an impairment in renal function occurring within 3 days following the intravascular administration of contrast media (CM) and the absence of an alternative aetiology. In spite of the vast clinical importance of CIN, its understanding and the pathophysiology behind CIN remain incomplete. Many studies have been performed; however, they have provided no widely accepted conclusion so far. Here the possible mechanisms underlying CIN are outlined, which span from altered rheological properties, perturbation of renal haemodynamics, regional hypoxia, auto-, and paracrine factors (adenosine, endothelin, reactive oxygen species) to direct cytotoxic effects. Although these potential mediators of CIN will be discussed separately, several factors may act in concert to perturb kidney function after exposure to contrast media. From the current knowledge of the mechanisms causing CIN, it is not possible to recommend a certain class of contrast media, except to avoid large doses of CM of the first generation. From a pathophysiological perspective, volume expansion is effective in avoiding CIN, since water permeability of the collecting ducts will decrease and enhance fluid excretion. Hence, CM in the distal portions of the tubular system is diluted, which implies reduced fluid viscosity and a lower risk of obstruction.

Low density lipoproteins inhibit the Na+/H+ antiport in human platelets via activation of p38MAP kinase

Low density lipoproteins (LDL) inhibit the Na+/H+ antiport and thereby sensitize platelet towards agonist. However, mechanisms underlying the suppressing effect of LDL on Na+/H+ exchange are unclear. We here show that the lowering of intracellular pH and the suppression of the sodium propionate-induced Na+/H+ exchange in the presence of LDL are abolished by SKF86002, a selective inhibitor of p38MAP kinase (p38MAPK). The inhibitory effect of LDL on Na+/H+ exchange was mimicked by H2O2, which directly activates p38MAPK. Exposure of platelets to LDL or H2O2 led to phosphorylation of p38MAPK, its upstream regulator MAP kinase kinase 3/6 (MKK 3/6), and its downstream target heat shock protein 27 (HSP27), and this effect was abrogated in SKF86002-pretreated platelets. In addition, both LDL and H2O2 produced the SKF86002-sensitive phosphorylation of an oligopeptide encompassing p38MAPK phosphorylation sequence derived from NHE-1, a major Na+/H+ exchanger in platelets. We further show that the sensitizing effects of LDL on the thrombin-induced platelet activation, as reflected by aggregation and granule secretion, are abolished in cells pretreated with SKF86002. We conclude that activation of p38MAPK is required for the inhibitory effect of LDL on Na+/H+ antiport and thereby for LDL-dependent sensitization in human platelets.

Increased transient receptor potential channel TRPC3 expression in spontaneously hypertensive rats

BACKGROUND

Disturbances in the regulation of cytosolic calcium concentration have been attributed to primary hypertension, but the role of calcium-permeable transient receptor potential canonical channel 3 (TRPC3) has not yet been evaluated in primary hypertension.

METHODS

Expression of TRPC3 was determined using in-cell Western assay. Evaluation of RNA interference for the downregulation of a specific gene in cells by small interfering RNA was performed. Measurements of cytosolic calcium were carried out using the fluorescent dye fura2.

RESULTS

Expression of TRPC3 was significantly increased in monocytes from spontaneously hypertensive rats (SHR) compared with normotensive Wistar-Kyoto rats (WKY). Transplasmamembrane calcium influx and thapsigargin-induced sustained calcium increase were significantly higher in SHR compared with WKY. In the presence of the TRP channel blocker SKF-96365 these differences were no longer observed. Specific TRPC3-knockdown by transfection of monocytes from SHR with small interfering RNA significantly reduced TRPC3 expression, trans-plasma membrane calcium influx, and thapsigargin-induced sustained calcium increase.

CONCLUSIONS

This study shows, for the first time, increased TRPC3 channel expression and increased TRPC3-related calcium influx in SHR.

Sustained increase of extracellular calcium concentration causes arterial vasoconstriction in humans

BACKGROUND

Vascular tone is affected by extracellular electrolytes.

OBJECTIVE

To evaluate whether a sustained increase in the extracellular calcium concentration may produce vasoconstriction in humans.

DESIGN

Cross-sectional data of a cohort study of 65 patients with end-stage renal failure.

MEASUREMENTS

Arterial tone was obtained from radial artery waveforms. Intracellular stored calcium and sarcoendoplasmic reticulum Ca(2+)-ATPase activity were measured in mononuclear leukocytes using fluorescent dye techniques and oxalate-supported calcium uptake.

RESULTS

During the haemodialysis sessions the extracellular calcium concentration increased significantly from 2.28 +/- 0.03 to 2.63 +/- 0.03 mmol/l (n = 65; mean +/- SEM; P < 0.001) and arterial tone increased from 31 +/- 2 to 44 +/- 3 mmHg/ml (n = 65; P < 0.001). Multivariate analysis showed that pre and postdialysis extracellular calcium and pre and postdialysis body weight were the only independent predictors of arterial tone during haemodialysis. Intracellular stored calcium in mononuclear leukocytes significantly declined from 5.1 +/- 1.2 arbitrary units at the start to 2.3 +/- 0.6 arbitrary units at the end of haemodialysis (n = 10; P = 0.01). The activity of the sarcoendoplasmic reticulum Ca(2+)-ATPase significantly decreased from 13.6 +/- 2.6 nmol calcium/mg protein per 5 min at the start to 9.2 +/- 1.6 nmol calcium/mg protein per 5 min at the end of haemodialysis (n = 28; P = 0.01). On the other hand, when a low dialysate calcium concentration was used, the increase in artery tone and reduction in sarcoendoplasmic reticulum Ca(2+)-ATPase activity were reversed.

CONCLUSION

A sustained increase in the extracellular calcium concentration causes arterial vasoconstriction in humans. In addition, a reduction of sarcoendoplasmic reticulum Ca(2+)-ATPase activity and intracellular stored calcium in mononuclear leukocytes was observed.

GATA4-mediated cardiac hypertrophy induced by d-myo-inositol 1,4,5-tris-phosphate

We evaluated the effects of d-myo-inositol 1,4,5-tris-phosphate on cardiac hypertrophy. d-myo-inositol 1,4,5-tris-phosphate augmented cardiac hypertrophy as evidenced by its effects on DNA synthesis, protein synthesis, and expression of immediate-early genes c-myc and c-fos, beta-myosin heavy chain, and alpha-actin. The administration of d-myo-inositol 1,4,5-tris-phosphate increased the expression of nuclear factor of activated T-cells and cardiac-restricted zinc finger transcription factor (GATA4). Real-time quantitative RT-PCR showed that d-myo-inositol 1,4,5-tris-phosphate-induced GATA4 mRNA was significantly enhanced even in the presence of the calcineurin inhibitor, cyclosporine A. The effect of d-myo-inositol 1,4,5-tris-phosphate was blocked after inhibition of inositol-trisphosphate receptors but not after inhibition of c-Raf/mitogen-activated protein kinase kinase (MEK)/mitogen-activated protein kinase (ERK) or p38 mitogen-activated protein kinase pathways. The study shows that d-myo-inositol 1,4,5-tris-phosphate-induced cardiac hypertrophy is mediated by GATA4 but independent from the calcineurin pathway.

Drug therapy for hypertension in hemodialysis patients

Hypertension in chronic hemodialysis patients is very common, and associated with cardiovascular morbidity and mortality. On the other hand, normalization of blood pressure in this patient population results in improvement of survival in the long-term. Drug therapy for hypertension in hemodialysis patients includes mainly angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers, beta-blockers and diuretics, but guidelines for the use of specific classes of antihypertensive medications do not exist for end-stage renal disease (ESRD) patients on maintenance hemodialysis treatment. In survival analyses, some studies are in favour for the ACE inhibitors, other studies report reduced risk of cardiovascular mortality by using calcium channel blockers. Beta blockers seem to be ideal antihypertensive agents, since sympathetic nerve activity is inappropriately increased in ESRD patients. Most studies indicate that hypertension control is still not adequate in the majority of chronic hemodialysis patients. Randomized, controlled clinical trials are needed to determine the most advantageous antihypertensive agent(s) to use in ESRD patients on chronic hemodialysis therapy.

N-Acetylcysteine in nephrology; contrast nephropathy and beyond

PURPOSE OF REVIEW

Since the first publication appeared in 2000 showing that prophylactic oral administration of the antioxidant acetylcysteine, along with adequate hydration, can prevent the reduction in renal function induced by non-ionic, low-osmolality contrast agents, acetylcysteine has rapidly become widely used in clinical practice. Meanwhile, other applications of acetylcysteine in nephrology have been reported. This review analyses recent literature on the effects of acetylcysteine on radiocontrast-induced nephropathy, on plasma homocysteine concentrations, and on cardiovascular events in patients with end-stage renal failure.

RECENT FINDINGS

At least 19 randomized trials evaluating acetylcysteine for the prevention of radiocontrast-induced nephropathy, at least five meta-analyses, and several reviews on that topic have been published within the past 4 years. The studies on radiocontrast-induced nephropathy showed remarkably mixed results, probably as a result of study heterogeneity. One study recently indicated that the administration of acetylcysteine during a haemodialysis session significantly lowered plasma homocysteine concentrations. Another study indicated that long-term antioxidative treatment with acetylcysteine significantly reduced cardiovascular events in patients with end-stage renal failure.

SUMMARY

Although there are controversies on dosing and timing, the use of acetylcysteine together with hydration should be considered to protect patients from radiographic contrast media-induced nephropathy. Long-term antioxidative treatment with acetylcysteine in patients with end-stage renal failure may also be useful to prevent adverse cardiovascular events.

Effect of Sodium on Vasoconstriction and Angiotensin II Type 1 Receptor mRNA Expression in Cold‐induced Hypertensive Rats

Angiotensin II and sodium play an important pathogenetic role in several models of hypertension. Now, we investigated the effects of sodium on vasoconstriction and angiotensin II type 1 (AT1) and type 2 (AT2) receptor mRNA expression in aortic vessels from cold-induced hypertensive rats. Wistar rats on low sodium and high sodium diet were exposed to cold-stress for 8 weeks. The effects of angiotensin II infusion on mean arterial blood pressure were investigated in these rats. In addition, angiotensin II induced contraction was measured using aortic rings. Expression of AT1 receptor mRNA and AT2 receptor mRNA was assessed in aortic vessels by reverse transcription polymerase chain reaction. After infusion of angiotensin II mean arterial blood pressure in cold-induced hypertensive rats on high sodium diet was significantly higher compared to cold-induced hypertensive rats on low sodium diet (p < 0.05). Angiotensin II-induced contraction of aortic rings was significantly higher in cold-induced hypertensive rats on high sodium diet compared to cold-induced hypertensive rats on low sodium diet (2.39 +/- 0.03 g vs. 2.21 +/- 0.04 g, n = 12, p < 0.01). Angiotensin AT1 receptor mRNA was significantly higher in cold-induced hypertensive rats on high sodium diet compared to cold-induced hypertensive rats on low sodium diet (p < 0.05). It is concluded that in this nongenetic, nonsurgical animal model of cold-induced hypertension increased vasoconstriction and increased AT1 receptor mRNA expression in aortic vessels are dependent on sodium intake.

Characterisation of advanced glycation endproducts in saliva from patients with diabetes mellitus

Patients with diabetes mellitus are prone to develop increased advanced glycation endproducts causing local complications and increased overall morbidity and mortality. Nuclear magnetic resonance spectra were determined in saliva of 52 consecutive patients with diabetes mellitus and 47 age-matched healthy control subjects. Resonance spectra showed specific peaks at 2.3, 7.3, and 8.4 ppm in saliva from patients with diabetes mellitus. These peaks could be generated by incubation of saliva from healthy control subjects with hypochloric acid in vitro, indicating the presence of advanced glycation endproducts. The presence of advanced glycation endproducts in patients with diabetes mellitus was associated with approximal plaque index, indicating increased periodontal damage. The study indicates that increased advanced glycation endproducts are involved in the pathogenesis of diabetic complications.

Influence of treatment on leptin levels in patients with obstructive sleep apnoea

Obstructive sleep apnoea syndrome (OSAS) is a common disorder in obesity. Leptin, an adipocyte-derived signalling factor, plays an important role in metabolic control. There is growing evidence that leptin regulation is altered in OSAS. Therefore, the aim of this study was to test the hypothesis that effective treatment will influence leptin levels in OSAS patients. Serum leptin levels were determined in 86 consecutive patients (aged 57.5 +/- 11.0 yrs) with polysomnographically verified OSAS. In addition, leptin levels were reassessed and treatment efficacy was evaluated by polysomnography after 6 months of therapy. Patients were treated with continuous or bilevel positive airway pressure, a mandibular advancement device or conservatively, depending on the clinical symptoms. Mean serum leptin levels did not change with treatment in the whole study group (7.3 +/- 5.0 versus 7.5 +/- 4.8 ng.mL-1), however, leptin levels decreased in effectively treated patients (8.5 +/- 5.0 versus 7.4 +/- 5.1 ng.mL-1) while they increased in ineffectively treated patients (5.0 +/- 4.0 versus 7.7 +/- 4.1 ng.mL-1). Furthermore, not only was there a significant and independent correlation between the change in leptin levels with treatment and the change in body mass index, but also with the change in apnoea/hypopnoea index. Effective treatment of sleep-disordered breathing may have significant effects on leptin levels in obstructive sleep apnoea syndrome patients. Changes in leptin levels are related to changes in apnoea/hypopnoea index in obstructive sleep apnoea syndrome patients.

[Medical treatment of hypertension--what treatment for what patients?]

The antihypertensive agents of first choice include ACE-inhibitors, angiotensin receptor blockers, beta blockers, calcium antagonists and diuretic agents. For the selection of medicaments, the individual patient risk profile of decisive importance. In particular a metabolic syndrome, diabetes mellitus, disturbed renal function and/or a disturbed electrolyte household must be considered. For initial treatment monotherapy or a low-dose combination regime is suggested. If the response is inadequate, possible options include increasing the dose, changing the medicament, (sequential monotherapy) or, in the sense of stepped treatment, introduction of further combination drugs. Resistance to therapy should prompt consideration of a number of causes, in particular noncompliance on the part of the patient.

Differentially expressed genes in hypertensive rats developing cerebral ischemia

The molecular events occurring after cerebral ischemia in hypertension may include de novo expression of numerous genes. Receptor genes are predominantly involved in the process of cell death, neuroprotection and reconstruction after ischemic injury. Ischemic stroke was observed in the non-genetic, non-surgical model of hypertension, the cold-induced hypertensive rat. In hypertensive rats suppression subtractive hybridization analysis was used to identify differentially expressed receptor genes in stroke-tissue compared to normal rat brain. We found 76 genes predominantly expressed in hypertensive rat stroke-tissue. These predominantly expressed genes included genes involved in energy metabolism, signal transduction/cell regulation, and replication/transcription/translation. For example, the T3 receptor alpha was predominantly expressed in stroke-tissue, indicating that regeneration of nerves in stroke tissue may be facilitated by increased T3 receptor alpha expression.

Acetylcysteine Reduces Plasma Homocysteine Concentration and Improves Pulse Pressure and Endothelial Function in Patients With End-Stage Renal Failure

Background— Increased oxidative stress, elevated plasma homocysteine concentration, increased pulse pressure, and impaired endothelial function constitute risk factors for increased mortality in patients with end-stage renal failure.

Methods and Results— We investigated the metabolic and hemodynamic effects of intravenous administration of acetylcysteine, a thiol-containing antioxidant, during a hemodialysis session in a prospective, randomized, placebo-controlled crossover study in 20 patients with end-stage renal failure. Under control conditions, a hemodialysis session reduced plasma homocysteine concentration to 58±22% predialysis (mean±SD), whereas in the presence of acetylcysteine, the plasma homocysteine concentration was significantly more reduced to 12±7% predialysis ( P <0.01). The reduction of plasma homocysteine concentration was significantly correlated with a reduction of pulse pressure. A 10% decrease in plasma homocysteine concentration was associated with a decrease of pulse pressure by 2.5 mm Hg. Analysis of the second derivative of photoplethysmogram waveform showed changes of arterial wave reflectance during hemodialysis in the presence of acetylcysteine, indicating improved endothelial function.

Conclusions— Acetylcysteine-dependent increase of homocysteine removal during a hemodialysis session improves plasma homocysteine concentration, pulse pressure, and endothelial function in patients with end-stage renal failure.

Effect of sodium on blood pressure, cardiac hypertrophy, and angiotensin receptor expression in rats

BACKGROUND

Sodium-induced hypertensive cardiac hypertrophy is related to pressure and volume overload.

METHODS

Wistar rats were exposed to low and high sodium diet for 8 weeks. Angiotensin II receptor mRNA, abundance of p38 mitogen-activated protein kinase (p38MAPK), vasoconstriction of aortic rings, and angiotensin II-induced calcium increase were investigated.

RESULTS

Rats on high sodium diet showed significantly elevated blood pressure. Heart weight, AT1 receptor mRNA in cardiac and aortic tissues, and abundance of p38MAPK were significantly increased in rats on high sodium diet.

CONCLUSIONS

Increased AT1 receptor expression and angiotensin II-induced calcium increase are compensatory effects in sodium-induced hypertension.

The AN69 hemofiltration membrane has a decreasing effect on the intracellular diadenosine pentaphosphate concentration of platelets

BACKGROUND/AIM

The biocompatibility of hemodialysis membranes has a substantial impact on the mortality of patients with end-stage renal failure. In the present study, the effects of hemodialysis on the intracellular amount of diadenosine pentaphosphate (Ap(5)A), a hydrophilic, anionic substance with a low molecular weight, was investigated.

METHODS

The intracellular Ap(5)A concentrations were measured before and after hemodialysis using either polyacrylonitrile (AN69; n = 10) or polysulfone (n = 23) membranes. Ap(5)A was isolated from platelets using affinity chromatography and reversed-phase chromatography methods.

RESULTS

The Ap(5)A concentrations were quantified by ultraviolet absorption at 254 nm. The Ap(5)A concentrations were significantly higher in platelets from the patients with end-stage renal failure as compared with the 21 healthy control subjects (136 +/- 50 vs. 9 +/- 6 fg/platelet; mean +/- SEM, p < 0.01). Before hemodialysis, the intracellular Ap(5)A concentrations in platelets from 10 patients with end-stage renal failure using an AN69 membrane were not significantly different from those in platelets from 23 patients using a polysulfone membrane (93 +/- 39 vs. 155 +/- 70 fg/platelet). However, after a hemodialysis session, the intracellular Ap(5)A concentrations in platelets from patients with end-stage renal failure using an AN69 membrane were significantly lower as compared with those in platelets before hemodialysis (51 +/- 18 vs. 93 +/- 39 fg/platelet, p < 0.05) as well as compared with those in platelets from patients using a polysulfone membrane (51 +/- 18 vs. 250 +/- 59 fg/platelet, p < 0.05).

CONCLUSIONS

It was found that hemofiltration by using an AN69 membrane has a direct effect on the intracellular amount of Ap(5)A and that changes of intracellular hydrophilic substances are dependent on the hemodialysis membrane used.