Acetylcysteine for the prevention of radiocontrast -induced nephropathy

Radiocontrast-induced nephropathy is the 3rd most common cause of in-hospital acute renal failure after hypotension and surgery. Radio-graphic contrast media are used at a progressive rate for several diagnostic and therapeutic applications. Prevention of radiocontrast-induced nephropathy will become more important, including risk of patient impairment and costs. Radiocontrast-induced ne-phropathy is due to vasoconstriction-mediated renal medullary ischemia and direct toxic damage to renal tubular epithelial cells. These effects may in part be mediated by generation of reactive oxygen species. Several prospective, randomized, placebo-controlled studies in patients with moderate renal insufficiency showed that the prophylactic oral administration of acetylcysteine at a dose of 600 mg twice daily along with hydration prevents the reduction in renal function after radiocontrast administration. Recently, intravenous administration of acetyl-cysteine has also been shown to be effective. Use of acetylcysteine together with hydration is the treatment of choice to prevent radiocontrast-induced nephropathy.

Identification and quantification of diadenosine polyphosphate concentrations in human plasma

OBJECTIVE

Diadenosine polyphosphates have been demonstrated to be involved in the control of vascular tone as well as the growth of vascular smooth muscle cells and hence, possibly, in atherogenesis. In this study we investigated the question of whether diadenosine polyphosphates are present in human plasma and whether a potential source can be identified that may release diadenosine polyphosphates into the circulation.

METHODS AND RESULTS

Plasma diadenosine polyphosphates (ApnA with n=3 to 6) were purified to homogeneity by affinity-, anion exchange-, and reversed phase-chromatography from deproteinized human plasma. Analysis of the homogeneous fractions with matrix-assisted laser desorption/ionization mass spectrometry (MALDI-MS) revealed molecular masses ([M+H]+) of 757, 837, 917, and 997 d. Comparison of the postsource decay matrix-assisted laser desorption/ionization mass spectrometry mass spectra of these fractions with those of authentic diadenosine polyphosphates revealed that these isolated substances were identical to Ap3A, Ap4A, Ap5A, and Ap6A. Enzymatic analysis showed an interconnection of the phosphate groups with the adenosines in the 5'-positions of the ribose moieties. The mean total plasma diadenosine polyphosphate concentrations (micromol/L; mean +/- SEM) in cubital veins of normotensive subjects amounted to 0.89+/-0.59 for Ap3A, 0.72+/-0.72 for Ap4A, 0.33+/-0.24 for Ap5A, and 0.18+/-0.18 for Ap6A. Cubital venous plasma diadenosine polyphosphate concentrations from normotensives did not differ significantly from those in the hypertensive patients studied. There was no significant difference between arterial and venous diadenosine polyphosphate plasma concentrations in 5 hemodialysis patients, making a significant degradation by capillary endothelial cells unlikely. Free plasma diadenosine polyphosphate concentrations are considerably lower than total plasma concentrations because approximately 95% of the plasma diadenosine polyphosphates were bound to proteins. There were no significant differences in the diadenosine polyphosphate plasma concentrations depending on the method of blood sampling and anticoagulation, suggesting that platelet aggregation does not artificially contribute to plasma diadenosine polyphosphate levels in significant amounts. The ApnA (with n=3 to 6) total plasma concentrations in adrenal veins were significantly higher than the plasma concentrations in both infrarenal and suprarenal vena cava: adrenal veins: Ap3A, 4.05+/-1.63; Ap4A, 6.18+/-2.08; Ap5A, 0.53+/-0.28; Ap6A, 0.59+/-0.31; infrarenal vena cava: Ap3A, 1.25+/-0.66; Ap4A, 0.91+/-0.54; Ap5A, 0.25+/-0.12; Ap6A, 0.11+/-0.06; suprarenal vena cava: Ap3A, 1.40+/-0.91; Ap4A, 1.84+/-1.20; Ap5A, 0.33+/-0.13; Ap6A, 0.11+/-0.07 (micromol/L; mean +/- SEM; each P<0.05 (concentration of adrenal veins versus infrarenal or suprarenal veins, respectively).

CONCLUSIONS

The presence of diadenosine polyphosphates in physiologically relevant concentrations in human plasma was demonstrated. Because in adrenal venous plasma significantly higher diadenosine polyphosphate concentrations were measured than in plasma from the infrarenal and suprarenal vena cava, it can be assumed that, beside platelets, the adrenal medulla may be a source of plasma diadenosine polyphosphates in humans.

Increased plasma phenylacetic acid in patients with end-stage renal failure inhibits iNOS expression

NO prevents atherogenesis and inflammation in vessel walls by inhibition of cell proliferation and cytokine-induced endothelial expression of adhesion molecules and proinflammatory cytokines. Reduced NO production due to inhibition of either eNOS or iNOS may therefore reinforce atherosclerosis. Patients with end-stage renal failure show markedly increased mortality due to atherosclerosis. In the present study we tested the hypothesis that uremic toxins are responsible for reduced iNOS expression. LPS-induced iNOS expression in mononuclear leukocytes was studied using real-time PCR. The iNOS expression was blocked by addition of plasma from patients with end-stage renal failure, whereas plasma from healthy controls had no effect. Hemofiltrate obtained from patients with end-stage renal failure was fractionated by chromatographic methods. The chromatographic procedures revealed a homogenous fraction that inhibits iNOS expression. Using gas chromatography/mass spectrometry, this inhibitor was identified as phenylacetic acid. Authentic phenylacetic acid inhibited iNOS expression in a dose-dependent manner. In healthy control subjects, plasma concentrations were below the detection level, whereas patients with end-stage renal failure had a phenylacetic acid concentration of 3.49 +/- 0.33 mmol/l (n = 41). It is concluded that accumulation of phenylacetic acid in patients with end-stage renal failure inhibits iNOS expression. That mechanism may contribute to increased atherosclerosis and cardiovascular morbidity in patients with end-stage renal failure.

Identification and characterization of adenosine 5'-tetraphosphate in human myocardial tissue

Endocrine functions of the human heart have been studied extensively. Only recently, nucleotidergic mechanisms have been studied in detail. Therefore, an isolation strategy was developed to isolate novel nucleotide compounds from human myocardium. The human myocardial tissue was fractionated by several chromatographic studies. A substance purified to homogeneity was identified as adenosine 5'-tetraphosphate (Ap(4)) by matrix-assisted laser desorption/ionization mass spectrometry (MALDI MS), post-source decay MALDI MS, and enzymatic cleavage analysis. Furthermore, Ap(4) was also identified in ventricular specific granules. In the isolated perfused rat heart, Ap(4) elicited dose-dependent vasodilations. Vasodilator responses were abolished in the presence of the P(2Y1) receptor antagonist MRS 2179 (1 microm) or the NO synthase inhibitor N(G)-nitro-l-arginine methyl ester (50 microm). After removal of the endothelium by Triton X-100, Ap(4) induced dose-dependent vasoconstrictions. Inhibition of P(2X) receptors by pyridoxal phosphate-6-azophenyl-2',4'-disulfonic acid (30 microm) or desensitization of P(2X) receptors by alpha,beta-methylene ATP (alpha,beta-meATP, 1 microm) diminished these vasoconstrictor responses completely. In the present study Ap(4) has been isolated from human tissue. Ap(4) was shown to exist in human myocardial tissue and was identified in ventricular specific granules. In coronary vasculature the nucleotide exerted vasodilation via endothelial P(2Y1) receptors and vasoconstriction via P(2X) receptors on vascular smooth muscle cells. Ap(4) acts as an endogenous extracellular mediator and might contribute to the regulation of coronary perfusion.

Endogenous glycosides in critically ill patients

OBJECTIVE

To determine the incidence of critically ill patients displaying endogenous digitalis-like-immunoreactive substances (DLIS) and to examine the relationship of these hormones to routine laboratory variables, the underlying disease, myocardial function, hemodynamic status, severity of illness, systemic inflammation, and mortality rate.

DESIGN

Sera of 401 consecutive critically ill patients, not treated with cardiac glycosides, were analyzed for DLIS (digitoxin and digoxin, TDx; Abbott Diagnostics, North Chicago, IL) and endogenous ouabain. Normal values of endogenous ouabain were determined in 62 healthy volunteers. We measured pro- and anti-inflammatory mediators (L-selectin, tumor necrosis factor-alpha, interleukin-1beta, interleukin-2, interleukin-6, interleukin-10), C-reactive protein, and serum amyloid A protein as well as patients' Acute Physiology and Chronic Health Evaluation II and Goris scores. In a subgroup of patients with a pulmonary artery catheter (n = 95), we determined cardiac output, pulmonary artery occlusion pressure, systemic and pulmonary vascular resistance, left ventricular stroke volume, and right and left stroke work.

SETTING

Two surgical intensive care units of an university hospital.

SUBJECTS

Sera of 401 consecutive critically ill patients.

INTERVENTIONS

Blood sampling.

MEASUREMENTS AND MAIN RESULTS

Of the 401 patients tested, 343 had nonmeasurable DLIS concentrations (DLIS-negative), and 58 (14.5%) had positive digoxin (n = 18) or digitoxin (n = 34) concentrations (DLIS-positive) or were positive in both tests (n = 6). Mean endogenous ouabain concentrations were nine-fold increased in DLIS-positive (3.59 +/- 1.43 nmol/L) and three-fold increased in DLIS-negative (1.34 +/-.81 nmol/L) patients compared with controls (0.38 +/- 0.31 nmol/L). DLIS and ouabain concentrations closely correlated with the Acute Physiology and Chronic Health Evaluation II and Goris score and were associated with increased concentrations of transaminases, bilirubin, aldosterone, cortisol, serum creatinine, fractional sodium excretion, proinflammatory mediators, C-reactive protein, and serum amyloid A (p <or=.009). The hospital mortality rates of DLIS-positive and DLIS-negative patients were 12% and 3.2%, respectively, and for patients with ouabain concentrations above and below 2 nmol/L 38.6% and 0.6%, respectively. In DLIS-positive patients with pulmonary artery catheter (n = 23), cardiac output, stroke volume, and left ventricular stroke work were decreased, and pulmonary artery occlusion pressure and central venous pressure were increased (p <or=.009).

CONCLUSIONS

Different types of endogenous glycosides including endogenous ouabain are elevated in a significant proportion of critically ill patients. The occurrence of these substances is associated with increased morbidity and hospital mortality rates, possibly due to systemic inflammatory processes. DLIS but not endogenous ouabain concentrations were found to be related to left ventricular function.

The antioxidant acetylcysteine reduces cardiovascular events in patients with end-stage renal failure: a randomized, controlled trial

BACKGROUND

Patients with end-stage renal failure have increased oxidative stress and show elevated cardiovascular mortality. Whether increased cardiovascular events can be prevented by the administration of antioxidants is unknown.

METHODS AND RESULTS

We evaluated the effects of acetylcysteine, a thiol-containing antioxidant, on cardiovascular events in patients undergoing hemodialysis. A prospective, randomized, placebo-controlled trial was conducted between October 1, 1999, and September 30, 2001, in 134 patients (76 male and 58 female) with a mean age of 62+/-16 years (mean+/-SD) who had been undergoing maintenance hemodialysis for a minimum of 3 months 3 times weekly in an ambulatory center. Median (range) follow-up was 14.5 (1 to 24) months. Patients were randomly assigned either to receive acetylcysteine (600 mg BID) or placebo. The primary end point was a composite variable consisting of cardiac events including fatal and nonfatal myocardial infarction, cardiovascular disease death, need for coronary angioplasty or coronary bypass surgery, ischemic stroke, peripheral vascular disease with amputation, or need for angioplasty. Secondary end points included each of the component outcomes, total mortality, and cardiovascular mortality. A total of 18 (28%) of the 64 hemodialysis patients assigned to acetylcysteine group and 33 (47%) of the 70 hemodialysis patients assigned to control group had a primary end point (relative risk, 0.60 [95% CI, 0.38 to 0.95], P=0.03). No significant differences in secondary end points or total mortality were detected.

CONCLUSIONS

In hemodialysis patients, treatment with acetylcysteine (600 mg BID) reduces composite cardiovascular end points.

Mean platelet volume and coronary heart disease in hemodialysis patients

BACKGROUND

Mean platelet volume (MPV) has been shown to be an independent risk factor for myocardial infarction in the general population.

METHODS

In the present cross-sectional study it was examined whether MPV may be associated with coronary heart disease (CHD) in patients in chronic hemodialysis treatment (n = 518). CHD was diagnosed if there was a history of myocardial infarction, coronary artery bypass grafting, or critical stenosis on coronary angiography.

RESULTS

Mean platelet volume in hemodialysis patients was 8.22 +/- 0.06 fl. As compared with hemodialysis patients with a MPV <7.168 fl (the lower quintile limit), significantly more hemodialysis patients with a MPV >9.172 fl (the upper quintile limit) had CHD (odds ratio, 1.29; 95% confidence interval, 1.02-1.64). In a stepwise multiple logistic regression analysis MPV appeared to be an independent factor of CHD together with age, smoking, predialysis systolic blood pressure and serum triglyceride concentration. In a stepwise multiple linear regression model, MPV significantly depended on platelet count, volume of ultrafiltrate removed in one hemodialysis session, white blood cell count, treatment with beta blockers, heart rate, serum sodium and serum potassium concentrations. Additional measurements in 30 patients showed that MPV after a single hemodialysis session was not significantly different compared to predialysis values.

CONCLUSION

From the present study it is concluded that MPV may be associated with CHD in hemodialysis patients.

Association of calcium channel blockers and mortality in haemodialysis patients

Patients with end-stage renal disease show disturbances of calcium metabolism, including calcification of arterial walls. Such patients show increased mortality, in particular due to increased cardiovascular-associated deaths. The association of calcium channel blockers and mortality in patients undergoing haemodialysis was investigated. A total of 188 patients who were receiving haemodialysis as of July 1998 were followed up for 30 months. Baseline characteristics, including age, sex, laboratory and clinical data, medication and dialysis prescription, were obtained. As of December 2000, 51 of the patients (27%) had died. In the deceased group, age was significantly higher, body mass index was significantly lower, and smoking was significantly more frequent compared with the survival group (each P <0.001). The percentage of patients taking calcium channel blockers was significantly higher in the survival group. Cox proportional hazard regression analysis showed that haemodialysis patients assigned calcium channel blocker therapy had a significantly lower risk of mortality [relative risk 0.33 (95% confidence interval 0.17-0.67); P <0.001]. Thus, in haemodialysis patients who were at high risk of cardiovascular events, administration of calcium channel blockers was associated with lower mortality.

Angiotensin-(1-7) inhibits angiotensin II-induced signal transduction

The inhibitory effects of angiotensin-(1-7) on angiotensin II-induced vasoconstriction, growth of vascular smooth muscle cells, stimulation of protein kinase C, extracellular signal-regulated kinases (ERK), and angiotensin subtype 1 receptor (AT1) and subtype 2 receptor (AT2) mRNA expression were investigated. The hemodynamic effects of angiotensin-(1-7) were measured in Wistar rats. Vasoconstriction was measured using aortic rings. DNA synthesis or protein synthesis was measured in cultured vascular smooth muscle cells using [3H] thymidine or [3H] leucine incorporation, respectively. Angiotensin II stimulated protein kinase C and ERK1/2 were measured by Western blot analysis using phosphospecific protein kinase C and ERK1/2 antibodies. AT1 and AT2 receptor mRNA expression was measured using reverse-transcription polymerase chain reaction. Infusion of angiotensin II significantly increased whereas infusion of angiotensin-(1-7) had no effects on mean arterial blood pressure in Wistar rats. Angiotensin-(1-7) dose-dependently showed partial antagonism on angiotensin II-induced contraction of aortic rings. Angiotensin-(1-7) showed partial antagonism on angiotensin II-induced DNA synthesis and protein synthesis. Angiotensin-(1-7) showed partial antagonism on angiotensin II-induced activation of protein kinase C and ERK1/2. The administration of angiotensin-(1-7) showed partial antagonism on angiotensin II-induced downregulation of AT1 receptor mRNA expression, whereas AT2 receptor mRNA expression was unchanged. Angiotensin-(1-7) showed partial antagonism on angiotensin II-induced intracellular signal transduction and may play a crucial role in the adaptation process of AT1 receptors to sustained stimulation of angiotensin II.

Captopril and quinapril reduce reactive oxygen species

BACKGROUND

Angiotensin-converting enzyme inhibitors may affect reactive oxygen species in humans in vitro and in vivo. In the present study we evaluated whether angiotensin-converting enzyme inhibitors may affect NAD(P)H oxidase activity.

MATERIALS AND METHODS

The production of reactive oxygen species was measured spectrophotometrically in mononuclear leukocytes using the fluorescent dye, dichlorofluorescein diacetate. The effects of quinaprilat, captopril, enalaprilat and lisinopril on phorbol myristate acetate-induced reactive oxygen species generation were investigated in vitro. The effects of quinaprilat, captopril, enalaprilat and lisinopril on the NAD(P)H oxidase activity of the mononuclear leukocytes were measured photometrically. In addition, reactive oxygen species were measured before and 4 h after oral administration of quinapril.

RESULTS

In vitro, the addition of quinaprilat (72 +/- 6% of control; mean +/- SEM; n= 19; P < 0.001) and captopril (48 +/- 2% of control; n= 19; P < 0.001) significantly reduced the phorbol-12-myristate-13-acetate-induced reactive oxygen species generation by the mononuclear leukocytes, whereas enalaprilat and lisinopril showed no effect. The effect of captopril on phorbol-12-myristate-13-acetate-induced reactive oxygen species generation in vitro was concentration-dependent. Quinaprilat and captopril significantly inhibited the NAD(P)H oxidase activity. After the oral administration of 10 mg of quinapril the phorbol-12-myristate-13-acetate-induced reactive oxygen species generation by the mononuclear leukocytes was significantly decreased from 1981 +/- 292% to 988 +/- 141% (n = 14; P < 0.01).

CONCLUSION

Quinapril and captopril decrease the production of reactive oxygen species.

Acetylcysteine and contrast media nephropathy

PURPOSE OF REVIEW

Radiographic contrast media are used at an increasing rate for several diagnostic and therapeutic applications. Therefore, contrast agent-induced nephropathy will become more important, including the risk of patient impairment and costs. The prevention of radiographic contrast-induced nephropathy is mandatory. Radiographic contrast agent-induced nephropathy is caused by vasoconstriction-mediated renal medullary ischaemia and direct toxic damage to renal tubular epithelial cells. These effects may be partly mediated by the generation of reactive oxygen species. Data from experimental studies indicate that antioxidants, e.g. acetylcysteine, may prevent radiocontrast-induced nephropathy.

RECENT FINDINGS

Two prospective, randomized, placebo-controlled studies in patients with moderate renal insufficiency confirmed that the prophylactic oral administration of acetylcysteine, at a dose of 600 mg twice a day along with hydration, prevents the reduction in renal function after radiocontrast administration.

SUMMARY

The use of acetylcysteine together with hydration is the treatment of choice to protect against radiographic contrast media-induced nephropathy.

Effects of dinucleoside polyphosphates on regulation of coronary vascular tone

The aim of the present study was to investigate the effects of Xp(5)X and Xp(6)X (X = guanosine (G) or adenosine (A); n = 5 and 6), which have been identified in human platelets, on coronary vascular tone. The activation of purinoceptors in rat coronary vasculature by Xp(5)X and Xp(6)X was evaluated by measuring their effects on perfusion pressure in the Langendorff perfused rat. Ap(5)X and Ap(6)X induced dose-dependent vasodilation that was due to P2Y(1) receptor activation, as evidenced by use of the selective P2Y(1) receptor antagonist 2'-deoxy-N(6)-methyl-adenosine 3',5'-diphosphate diammonium (MRS2179). Vasodilation was induced by NO release, as evidenced by inhibition of nitric oxide synthases (NO synthases) by N(G)-nitro-L-arginine methyl ester (L-NAME). The dose-dependent decrease in coronary perfusion pressure induced by Ap(5)X and Ap(6)X was converted to a dose-dependent increase in perfusion pressure after inhibition of NO synthases by L-NAME. After endothelium removal, the vasodilation elicited by Ap(5)X and Ap(6)X was converted to a vasoconstriction which could be inhibited by P2X receptor blockade. Ap(5)A, Ap(5)G, Ap(6)A and Ap(6)G are vasodilating or vasoconstricting nucleotides that activate P2Y(1) or P2X receptors depending on the status of the coronary vascular endothelium.

Effects of glucocorticoids on generation of reactive oxygen species in platelets

Since prednisolone and dexamethasone are known as potent anti-inflammatory agents, the effects of prednisolone and dexamethasone on production of intracellular reactive oxygen species (ROS) were investigated in human platelets. Platelet ROS were measured using the intracellular fluorescent dye dichlorofluorescein diacetate after activation of protein kinase C by phorbol-12-myristate-13-acetate (PMA) or 1-oleoyl-2-acetyl-sn-glycerol (OAG). NAD(P)H oxidase activity was measured photometrically. PMA and OAG significantly increased ROS in platelets (P<0.001). Prednisolone or dexamethasone concentration-dependently reduced the PMA-induced ROS production. The PMA-induced ROS increase was significantly reduced in the presence of 10 micromol/l prednisolone to 9+/-1% (n=31; P<0.001) or in the presence of 10 micromol/l dexamethasone to 9+/-1% (n=24; P<0.001). The inhibitory effect of prednisolone or dexamethasone could also be observed in the presence of the glucocorticoid receptor inhibitor, mifepristone (RU486). Administration of testosterone or aldosterone did not significantly reduce PMA-induced ROS increase. Prednisolone had no effect on platelet NAD(P)H oxidase activity. The inhibition of oxidative phosphorylation by sodium azide reduced platelets ROS to 8+/-1% (n=35). It is concluded that glucocorticoids, prednisolone and dexamethasone, directly inhibit production of intracellular ROS. This effect may contribute to the anti-inflammatory actions of these agents.

Sleep-related breathing disorders impair quality of life in haemodialysis recipients

BACKGROUND

It is well known that the quality of life of haemodialysis recipients is often severely compromised. So far, the influence of sleep-related breathing disorders on the quality of life of patients receiving maintenance dialysis has not been evaluated.

METHODS

Quality of life as assessed by the Medical Outcomes Study Short Form-36 (SF-36) and the Nottingham Health Profile Part 1 (NHP1) was determined in 33 patients (20 males, 13 females; median age 66 years (95% CI 22-82)) with end-stage renal disease treated with haemodialysis. Additionally, polygraphy with a validated eight-channel ambulatory recording unit was performed.

RESULTS

Twenty-one patients (63.6%) had a clinically significant sleep-related breathing disorder with a median apnoea/hypopnoea index of 13.3 (6.3-78.1)/h and a median oxygen saturation during sleep of 92.5 (88-97)%. In three out of eight subjective measures of the SF-36 (vitality, social functioning and mental health) and in one out of six subjective measures of the NHP1 (emotional reactions), patients without sleep-related breathing disorders had a higher quality of life than patients with this disorder (P<0.05 each). Furthermore, the severity of the sleep-related breathing disorder as indicated by the apnoea/hypopnoea index significantly correlated with the following quality of life measures: physical functioning, social functioning, role limitation due to physical and emotional problems, general health and vitality (SF-36), and also with pain, sleep, social isolation and emotional reactions (NHP1) (P<0.05 each).

CONCLUSIONS

We conclude that sleep-related breathing disorders independently influence the quality of life of patients receiving maintenance dialysis.

A rare cause of pulmonary-renal syndrome

Diseases affecting both the lung and the kidney have grave prognosis and serious diagnostic and therapeutic consequences. Here, 3 cases of pulmonary-renal syndrome caused by antiphospholipid syndrome are reported. The patients presented with dyspnea, renal insufficiency, pulmonary infiltrates on chest X-ray and areas of ground glass attenuation on computed tomography of the lungs. There were no signs of infectious disease, vasculitis or myocardial insufficiency. Clinical findings, antiphospholipid levels and histological findings in transbronchial and/or renal biopsy proved the diagnosis of antiphospholipid syndrome. Antiphospholipid syndrome is a comparatively rare disorder which is relevant in the differential diagnosis of diseases affecting both lung and kidney and requires specific therapeutic measures.

[Antioxidant therapy in vascular and renal diseases]

BACKGROUND

Reactive oxygen species are known to play an important role in the pathogenesis of several diseases including atherosclerosis.

CARDIOVASCULAR EFFECT

Epidemiologic studies suggested a protective effect of antioxidative vitamins on atherosclerotic vascular diseases. However, prospective randomized studies failed to detect any beneficial effect of antioxidative vitamins, including tocopherol, on cardiovascular mortality.

RENAL EFFECT

On the other hand, antioxidative therapies have been shown to prevent acute decreases of renal function induced by ischemia, contrast media or drugs. It is unknown whether antioxidative therapy also has beneficial effects in patients with chronic renal failure.

Effect of continuous positive airway pressure therapy on 24-hour blood pressure in patients with obstructive sleep apnea syndrome

BACKGROUND

Patients with obstructive sleep apnea syndrome (OSAS) are subject to an increased cardiovascular morbidity including systemic hypertension. Little is known about the effects of treatment with nasal continuous positive airway pressure (CPAP) on systemic hypertension.

METHODS

Automated ambulatory 24-h blood pressure (BP) monitoring was performed in 88 consecutive patients who were referred for evaluation of snoring or suspected OSAS. In addition, the long-term effects of CPAP therapy on 24-h BP were assessed.

RESULTS

A total of 62 patients had OSAS and 26 habitual snoring. Patients with OSAS had significantly higher mean arterial BP values than snorers (102.7 +/- 10.7 v 94.0 +/- 10.2 mm Hg; P < .01). Multiple stepwise linear regression analysis disclosed that the degree of systemic hypertension was independently associated with the severity of OSAS as determined by the apnea/hypopnea index (R = 0.43; P < .001), but not with age, body mass index, or smoking habits. Of the 62 patients with OSAS, 52 were treated with CPAP and reevaluated after 9 months. The CPAP resulted in a significant decrease in mean arterial BP (from 103.7 +/- 10.4 to 99.1 +/- 10.8 mm Hg; P < .05). For those patients with systemic hypertension whose BP improved with CPAP therapy, 24-h mean pulse pressure at baseline (r = -0.36; P < .05) as well as average heart rate during the day (r = -0.35; P < .05) turned out as predictors.

CONCLUSIONS

Obstructive sleep apnea syndrome contributes, at least in part, to the development of systemic hypertension, and CPAP may improve BP values in treated OSAS patients. Predictors of a beneficial CPAP effect on BP are a high heart rate and a high pulse pressure before treatment.

Endothelial dysfunction in cold-induced hypertensive rats

Endothelial dysfunction can be observed in preatherosclerotic conditions. However, its pathogenetic role in hypertension is still controversial. Endothelial-dependent changes of blood pressure (BP) and expression of endothelial nitric oxide synthase (eNOS) were evaluated in cold-induced hypertensive rats. Wistar rats were exposed to cold stress for 8 weeks. Exposure to cold stress significantly increased the systolic BP in rats. The infusion of acetylcholine significantly lowered mean arterial BP in control rats by 48 +/- 2% and by 32 +/- 1% in cold-induced hypertensive rats. The acetylcholine-induced reduction of mean arterial BP was significantly attenuated in cold-induced hypertensive rats (control rats, 45 +/- 2 mm Hg; cold-induced hypertensive rats, 34 +/- 3 mm Hg; P < .05). Administration of N(G)-nitro-L-arginine-methyl ester for 1 week significantly increased BP in control rats, whereas no effect could be observed in cold-induced hypertensive rats. In cold-induced hypertensive rats eNOS in aortic vessels was significantly reduced compared to control rats. In this nongenetic, nonsurgical animal model of cold-induced hypertensive rats an endothelial dysfunction can be observed due to reduced eNOS.

Acetylcysteine for radiocontrast nephropathy

Radiocontrast nephropathy may in part be mediated by generation of reactive oxygen species causing direct toxic damage to renal tubular epithelial cell and renal medullary ischemia. Data from experimental studies indicated that antioxidants, eg, acetylcysteine, may prevent radiocontrast-induced nephropathy. Recently, one prospective, randomized, placebo-controlled study in patients with moderate renal insufficiency confirmed that the prophylactic oral administration of acetylcysteine at a dose of 600 mg twice daily along with hydration prevents the reduction in renal function by a nonionic, low-osmolality radiocontrast agent.

A dynamic programming approach to de novo peptide sequencing via tandem mass spectrometry

Tandem mass spectrometry fragments a large number of molecules of the same peptide sequence into charged molecules of prefix and suffix peptide subsequences and then measures mass/charge ratios of these ions. The de novo peptide sequencing problem is to reconstruct the peptide sequence from a given tandem mass spectral data of k ions. By implicitly transforming the spectral data into an NC-spectrum graph G (V, E) where /V/ = 2k + 2, we can solve this problem in O(/V//E/) time and O(/V/2) space using dynamic programming. For an ideal noise-free spectrum with only b- and y-ions, we improve the algorithm to O(/V/ + /E/) time and O(/V/) space. Our approach can be further used to discover a modified amino acid in O(/V//E/) time. The algorithms have been implemented and tested on experimental data.

Efficacy and tolerability of angiotensin II type 1 receptor antagonists in dialysis patients using AN69 dialysis membranes

AIMS AND METHODS

Our aim was to evaluate the antihypertensive efficacy and tolerability of angiotensin II type 1 (AT1) receptor antagonists. Valsartan or candesartan cilexetil was administered to 11 dialysis patients with elevated blood pressure. The patients (6 male, 5 female; mean age +/- SD 61+/-11 years) were on regular bicarbonate hemodialysis three times weekly for more than 3 months using acrylonitrile and sodium methallyl sulfonate copolymer (AN69) dialysis membranes.

RESULTS

Within 252 days after administration of the AT1 receptor antagonists the systolic blood pressure was significantly reduced from 161+/-13 to 130+/-12 mmHg (p<0.001), whereas the diastolic blood pressure did not change significantly (76+/-8 vs. 71+/-8 mmHg; p>0.05). In addition, heart rate (75+/-7 vs. 80+/-8/min), body weight, and laboratory variables (hemoglobin, creatinine, blood urea nitrogen, serum potassium, serum sodium, serum calcium, and total protein) showed no significant changes. During 1,188 hemodialysis sessions using AN69 membranes, no hypersensitivity reactions occurred after administration of AT1 receptor antagonists.

CONCLUSION

The results indicate that once-daily administration of AT1 receptor antagonists efficiently reduces the systolic blood pressure in hemodialysis patients.