A new form of amyloid protein associated with chronic hemodialysis was identified as beta 2-microglobulin

The Early Phase of β2-Microglobulin Aggregation: Perspectives From Molecular Simulations

Protein β2-microglobulin is the causing agent of two amyloidosis, dialysis related amyloidosis (DRA), affecting the bones and cartilages of individuals with chronic renal failure undergoing long-term hemodialysis, and a systemic amyloidosis, found in one French family, which impairs visceral organs. The protein’s small size and its biomedical significance attracted the attention of theoretical scientists, and there are now several studies addressing its aggregation mechanism in the context of molecular simulations. Here, we review the early phase of β2-microglobulin aggregation, by focusing on the identification and structural characterization of monomers with the ability to trigger aggregation, and initial small oligomers (dimers, tetramers, hexamers etc.) formed in the so-called nucleation phase. We focus our analysis on results from molecular simulations and integrate our views with those coming from in vitro experiments to provide a broader perspective of this interesting field of research. We also outline directions for future computer simulation studies.

Conformational Stability and Dynamics in Crystals Recapitulate Protein Behavior in Solution

A growing body of evidences has established that in many cases proteins may preserve most of their function and flexibility in a crystalline environment, and several techniques are today capable to characterize molecular properties of proteins in tightly packed lattices. Intriguingly, in the case of amyloidogenic precursors, the presence of transiently populated states (hidden to conventional crystallographic studies) can be correlated to the pathological fate of the native fold; the low fold stability of the native state is a hallmark of aggregation propensity. It remains unclear, however, to which extent biophysical properties of proteins such as the presence of transient conformations or protein stability characterized in crystallo reflect the protein behavior that is more commonly studied in solution. Here, we address this question by investigating some biophysical properties of a prototypical amyloidogenic system, β2-microglobulin in solution and in microcrystalline state. By combining NMR chemical shifts with molecular dynamics simulations, we confirmed that conformational dynamics of β2-microglobulin native state in the crystal lattice is in keeping with what observed in solution. A comparative study of protein stability in solution and in crystallo is then carried out, monitoring the change in protein secondary structure at increasing temperature by Fourier transform infrared spectroscopy. The increased structural order of the crystalline state contributes to provide better resolved spectral components compared to those collected in solution and crucially, the crystalline samples display thermal stabilities in good agreement with the trend observed in solution. Overall, this work shows that protein stability and occurrence of pathological hidden states in crystals parallel their solution counterpart, confirming the interest of crystals as a platform for the biophysical characterization of processes such as unfolding and aggregation.

Hip hemiarthroplasty for femoral neck fractures in end-stage renal disease patients on dialysis compared to patients with late-stage chronic kidney disease

INTRODUCTION

Hip fractures in patients with end-stage renal disease (ESRD) are associated with frequent complications and poorer outcomes. Patients on chronic dialysis are at additional risk of dialysis-related complications such as myocardial infarction and early osteolysis. We analysed the complications and implant survivorship of hemiarthroplasty in patients with femoral neck fractures with late-stage chronic kidney disease with and without pre-existing dialysis.

METHODS

We conducted a retrospective case-control study of 28 patients with ESRD and 31 patients with chronic kidney disease (CKD) Stages 3-5, who had a total of 62 fractures treated with hemiarthroplasty between 2005 and 2015. The mean age of the patients was 68.33 (50.21-86.45) years. The mean follow-up time of the group was 39 months. Patient demographics, complications, outcomes and follow-up radiographs were analysed for differences.

RESULTS

Patient in both groups had statistically similar demographics and comorbidity scores except for a higher incidence of hyperparathyroidism in ESRD patients on chronic dialysis (nine patients vs. zero patients; p = 0.001). These patients were more likely to develop cardiopulmonary complications in the perioperative period (odds ratio [OR] 5.04; p = 0.04) and implant loosening on radiographic analysis (OR 8.75; p = 0.02). The incidence of loosening was higher in patients with hyperparathyroidism (OR 9.80; p = 0.002). Cemented techniques, however, did not appear to be significantly associated with intraoperative fractures or loosening.

CONCLUSION

Patients with ESRD on chronic dialysis were more likely to develop cardiopulmonary complications and implant loosening after hemiarthroplasty for femoral neck fractures. Hyperparathyroidism should be optimised, as it may prevent loosening. Our study did not show any difference in complications or outcomes for cemented fixation.

Mass spectrometry of urinary β2 microglobulin oligomer in patients with proteinuria

Urinary β2 microglobulin (β2-m) is a marker of renal tubule dysfunction; however, β2-m might become degraded under acidic conditions. To confirm the degradation and consequent deactivation of β2-m under acidic conditions, we used matrix-assisted laser desorption ionization-time-of-flight mass spectrometry (MALDI-TOF MS) to detect the levels and forms of β2-m in the urine samples of patients with high proteinuria (n = 21) and healthy subjects (n = 6). β2-m was purified in crude form using immunoprecipitation. A signal of 11.74 kDa, corresponding to the molecular weight of β2-m, was detected in all samples. In addition, several high-molecular-weight proteins were detected in a patient as integrals of the intensity at 11.74 kDa. These results indicate that posttranslational modifications of β2-m might be involved in the pathological process of proteinuria. Therefore, MS can be used for monitoring proteinuria and predicting the risk of progression.

Exploring exchange processes in proteins by paramagnetic perturbation of NMR spectra

The effect of extrinsic paramagnetic probes on NMR relaxation rates for surface mapping of proteins and other biopolymers is a widely investigated and powerful NMR technique. Here we describe a new application of those probes. It relies on the setting of the relaxation delay to generate magnetization equilibrium and off-equilibrium conditions, in order to tailor the extent of steady state signal recovery with and without the water-soluble nitroxide Tempol. With this approach it is possible to identify signals whose relaxation is affected by exchange processes and, from the relative assignments, to map the protein residues involved in association or conformational interconversion processes on a micro-to-millisecond time scale. This finding is confirmed by the comparison with the results obtained from relaxation dispersion measurements. This simple and convenient method allows preliminary inspection to highlight regions where structural or chemical exchange events are operative, in order to focus on quantitative subsequent determinations by transverse relaxation dispersion experiments or analogous NMR relaxation studies, and/or to gain insights into the predictions of calculations.

High Peritoneal Clearance of Small Molecules Did Not Provide Low Serum β2–Microglobulin Concentrations in Peritoneal Dialysis Patients

Objective

Although early reports demonstrated that serum β2-microglobulin (s-β2m) concentrations in patients on peritoneal dialysis (PD) were lower than those in patients on hemodialysis (HD), more recent studies demonstrated lower s-β2m concentrations in HD patients treated mainly with high-flux synthetic membranes. We therefore compared s-β2m concentrations between patients on PD and on HD, and also analyzed the relationship between s-β2m concentrations and other parameters in patients on PD.

Patients and Methods

We investigated 24 patients who had been undergoing PD [11 on continuous ambulatory peritoneal dialysis, 13 on continuous cycling peritoneal dialysis] for 4.3 ± 2.7 years, and 24 patients who had been undergoing HD with high-flux synthetic membranes for 6.1 ± 3.2 years. Concentrations of s-β2m in the PD patients were compared to concentrations in the HD patients. In patients on PD, we also analyzed the relationship between s-β2m concentration and other parameters, including residual renal function, total weekly Kt/V urea, total weekly creatinine clearance (CCr), and dialysis schedules.

Results

We found no significant difference in s-β2m concentrations between the PD and HD patients (33.6 ± 10.4 mg/L vs 30.3 ± 10.5 mg/L respectively). Concentrations of s-β2m in PD patients rose with PD duration and were significantly inversely correlated with residual renal function ( r = –0.71, p < 0.0001). Unexpectedly, concentrations of s-β2m in anuric PD patients rose as peritoneal CCr increased. And most of the patients with high s-β2m levels fell into the high or high-average transport categories according to a peritoneal equilibration test.

Conclusions

Concentrations of s-β2m in patients on PD did not differ significantly from concentrations in HD patients who were using high-flux synthetic membranes. The contribution of residual renal function to removal of β2m was more important than the contribution of peritoneal clearance. High peritoneal clearance of small molecules did not result in low s-β2m concentrations, especially in anuric patients with accelerated peritoneal permeability.

Destructive Spondyloarthropathy in a Patient on Continuous Ambulatory Peritoneal Dialysis for 13 Years

Since 1984 there have been reports of a destructive spondyloarthropathy occurring in patients on long-term hemodialysis. The primary abnormality appears to be an accumulation of β2-microglobulin, which is not adequately removed by dialysis, and forms amyloid deposits in articular and periarticular tissues. We report a case of this disease in a patient treated only by peritoneal dialysis. While this form of treatment may delay the development of arthropathy, as compared to hemodialysis, it does not prevent it. An increasing incidence of this disorder may be expected, since increasing numbers of patients have been on long-term peritoneal dialysis.

Beta-2 Microglobulin in Peritoneal Dialysis Patients: Serum Levels and Peritoneal Clearances

Beta-2 microglobulin (B2M) is amyloidogenic in long-term hemodialysis patients, with amyloid deposition manifesting as lytic bone lesions, carpal tunnel syndrome, destructive arthropathies, tenosynovitis, and pathologic fractures. To study the behavior of this protein in the peritoneal dialysis population, serum levels of B2M from 14 chronic peritoneal dialysis (CPD) patients (4IPD, 10 CAPD) were compared to those of 15 chronic hemodialysis patients, and peritoneal clearances were measured in 9 CAPD patients. Standard cuprophan dialyzers were used for hemodialysis.

Serum B2M levels were significantly lower in the peritoneal dialysis group (mean ± SD 73.2 ± 20.9 mg/L) than in the hemodialysis group (100.3 ± 24.7 mg/L, p < .004). When CAPD patients alone were compared to the hemodialysis patients, lower serum B2M levels were again apparent, with mean 68.7 ± 16.4 mg/L (p ≤ .002). Mean serum B2M in IPD patients (84.6 ± 28.9 mg/L) did not differ statistically from either the CAPD or the hemodialysis group.

Peritoneal clearance of B2M, urea nitrogen, and creatinine over a 6 h exchange were obtained in 9 CAPD patients without peritonitis. Mean clearance (±SD) of B2M was 0.9 ± 0.4 ml/min/1.73 m2, urea nitrogen 5.3 ± 0.3 ml/min/1.73 m2, and creatinine 4.2 ± 0.8 ml/min/1.73 m2. Mean loss of B2M via the peritoneal cavity was 19.9 ± 6.6 mg/2 L-exchange/1.73 m2 (range 7.7 to 26.2 mg/2 L-exchange/1.73 m2).

Decreased serum B2M in peritoneal dialysis patients is consistent with increased clearance by the peritoneal membrane versus standard cellulosic hemodialysis membranes. Whether use of CPD rather than hemodialysis can prevent or even treat dialysis-associated amyloidosis (AB2M) remains speculative.

β2-Microglobulin Serum Levels in Patients on Long Term Dialysis

Recently several workers have described a β2-microglobulin-containing amyloid in patients on chronic hemodialysis. We have demonstrated that, in terms of the degree of elevation and the absence of correlation with duration of dialysis, the β2-microglobulin serum levels of CAPD patients are comparable to those on hemodialysis. Thus all dialysis patients seem to bear an increasing risk of tissue deposition of β2-microglobulin in the form of the newly-described amyloid, and this risk appears to be independent of the mode and duration of dialysis.

β2-Microglobulin and Renal Bone Disease

Dialysis-related amyloidosis (DRA) is characterized by amyloid deposition mainly in bone and joint structures, presenting as carpal tunnel syndrome, destructive arthropathy, and subchondral bone erosions and cysts. β2-microglobulin has been demonstrated to be a major constituent of amyloid fibrils. DRA occurs not only in patients undergoing long-term hemodialysis, but also in patients undergoing continuous ambulatory peritoneal dialysis. The incidence of this complication increases with the duration of dialytic therapy and the age of the patient. While a definitive diagnosis of DRA can be made only by histological findings, various imaging techniques often support diagnosis. The molecular pathogenesis of this complication remains unknown. Recent studies have, however, suggested a pathogenic role of a new modification of β2-microglobulin in amyloid fibrils -that is, the advanced glycation end-products (AGEs) formed with carbonyl compounds derived from autoxidation of both carbohydrates and lipids (“carbonyl stress”). Therapy for DRA is limited to symptomatic approaches and surgical removal of amyloid deposits. High-flux biocompatible dialysis membranes could be used to delay DRA development.

Beta-2 Microglobulin Removal during Continuous Ambulatory Peritoneal Dialysis (CAPD)

Beta-2 microglobulin (B2M) handling in continuous ambulatory peritoneal dialysis (CAPD) was characterized in acute and chronic clinical studies. Average clearance rate was 0.7 mLlmin and mean mass transfer coefficient, KoA, was calculated to be 0.95 cm2lmin; these values are in the range expected from extrapolation of published data for other large solutes. In chronic studies with both anuric and oliguric populations, CAPD was shown to be much more effective than conventional hemodialysis in removing B2M and, in fact, CAPD removal rates were equivalent to those reported for high flux dialysis therapies. However, this greater extraction was not associated with any clinically significant reduction in circulating plasma concentrations. These trends remained valid in both the anuric and oliguric subsets of the study population.

Revisiting renal amyloidosis with clinicopathological characteristics, grading, and scoring: A single-institutional experience

INTRODUCTION:

Kidney involvement is a major cause of mortality in systemic amyloidosis. Glomerulus is the most common site of deposition in renal amyloidosis, and nephrotic syndrome is the most common presentation. Distinction between AA and AL is done using immunofluorescence (IF) and immunohistochemistry (IHC). Renal biopsy helps in diagnosis and also predicting the clinical course by applying scoring and grading to the biopsy findings.

MATERIALS AND METHODS:

The study includes all cases of biopsy-proven renal amyloidosis from January 2008 to May 2017. Light microscopic analysis; Congo red with polarization; IF; IHC for Amyloid A, kappa, and lambda; and bone marrow evaluation were done. Classification of glomerular amyloid deposition and scoring and grading are done as per the guidelines of Sen S et al.

RESULTS:

There are 40 cases of biopsy-proven renal amyloidosis with 12 primary and 23 secondary cases. Mean age at presentation was 42.5 years. Edema was the most common presenting feature. Secondary amyloidosis cases were predominant. Tuberculosis was the most common secondary cause. Multiple myeloma was detected in four primary cases. Grading of renal biopsy features showed a good correlation with the class of glomerular involvement.

CONCLUSION:

Clinical history, IF, and IHC are essential in amyloid typing. Grading helps provide a subtle guide regarding the severity of disease in the background of a wide range of morphological features and biochemical values. Typing of amyloid is also essential for choosing the appropriate treatment.

Collagen I Weakly Interacts with the β-Sheets of β2-Microglobulin and Enhances Conformational Exchange To Induce Amyloid Formation

Amyloidogenesis is significant in both protein function and pathology. Amyloid formation of folded, globular proteins is commonly initiated by partial or complete unfolding. However, how this unfolding event is triggered for proteins that are otherwise stable in their native environments is not well understood. The accumulation of the immunoglobulin protein β₂-microglobulin (β₂m) into amyloid plaques in the joints of long-term hemodialysis patients is the hallmark of dialysis-related amyloidosis (DRA). While β₂m does not form amyloid unassisted near neutral pH in vitro, the localization of β₂m deposits to joint spaces suggests a role for the local extracellular matrix (ECM) proteins, specifically collagens, in promoting amyloid formation. Indeed, collagen and other ECM components have been observed to facilitate β₂m amyloid formation, but the large size and anisotropy of the complex, combined with the low affinity of these interactions, have limited atomic-level elucidation of the amyloid-promoting mechanism(s) by these molecules. Using solution NMR approaches that uniquely probe weak interactions in large molecular weight complexes, we are able to map the binding interfaces on β₂m for collagen I and detect collagen I-induced μs–ms time-scale dynamics in the β₂m backbone. By combining solution NMR relaxation methods and ¹⁵N-dark-state exchange saturation transfer experiments, we propose a model in which weak, multimodal collagen I−β₂m interactions promote exchange with a minor population of amyloid-competent species to induce fibrillogenesis. The results portray the intimate role of the environment in switching an innocuous protein into an amyloid-competent state, rationalizing the localization of amyloid deposits in DRA.

Severe hand pain as an extracardiac manifestation of transthyretin amyloidosis

Transthyretin amyloidosis is a multisystemic disease caused by the aggregation of amyloid fibrils, resulting in high morbidity and mortality in the presence of cardiac involvement. Patients often experience vague symptoms that make amyloidosis difficult to diagnose. Differential diagnosis for hand pain in a patient with systemic amyloidosis is broad. We present a patient with severe hand cramping and inability to perform activities of daily living. This preceded a new diagnosis of familial amyloid cardiomyopathy. The patient was a poor responder to systemic corticosteroids, anti-inflammatories and anticonvulsant therapy. Her unique presentation gives insight into a rare but debilitating disorder and the potential link between amyloidosis and other disease processes.

Structural mapping of oligomeric intermediates in an amyloid assembly pathway

Transient oligomers are commonly formed in the early stages of amyloid assembly. Determining the structure(s) of these species and defining their role(s) in assembly is key to devising new routes to control disease. Here, using a combination of chemical kinetics, NMR spectroscopy and other biophysical methods, we identify and structurally characterize the oligomers required for amyloid assembly of the protein ΔN6, a truncation variant of human β2-microglobulin (β2m) found in amyloid deposits in the joints of patients with dialysis-related amyloidosis. The results reveal an assembly pathway which is initiated by the formation of head-to-head non-toxic dimers and hexamers en route to amyloid fibrils. Comparison with inhibitory dimers shows that precise subunit organization determines amyloid assembly, while dynamics in the C-terminal strand hint to the initiation of cross-β structure formation. The results provide a detailed structural view of early amyloid assembly involving structured species that are not cytotoxic.

Loosening of Side-Chain Packing Associated with Perturbations in Peripheral Dynamics Induced by the D76N Mutation of β2-Microglobulin Revealed by Pressure-NMR and Molecular Dynamic Simulations

β₂-Microglobulin (β₂m) is the causative protein of dialysis-related amyloidosis, and its D76N variant is less stable and more prone to aggregation. Since their crystal structures are indistinguishable from each other, enhanced amyloidogenicity induced by the mutation may be attributed to changes in the structural dynamics of the molecule. We examined pressure and mutation effects on the β₂m molecule by NMR and MD simulations, and found that the mutation induced the loosening of the inter-sheet packing of β₂m, which is relevant to destabilization and subsequent amyloidogenicity. On the other hand, this loosening was coupled with perturbed dynamics at some peripheral regions. The key result for this conclusion was that both the mutation and pressure induced similar reductions in the mobility of these residues, suggesting that there is a common mechanism underlying the suppression of inherent fluctuations in the β₂m molecule. Analyses of data obtained under high pressure conditions suggested that the network of dynamically correlated residues included not only the mutation site, but also distal residues, such as those of the C- and D-strands. Reductions in these local dynamics correlated with the loosening of inter-sheet packing.

Biochemical and biophysical comparison of human and mouse beta-2 microglobulin reveals the molecular determinants of low amyloid propensity

The molecular bases of amyloid aggregation propensity are still poorly understood, especially for proteins that display a stable folded native structure. A prototypic example is human beta-2 microglobulin (β2m), which, when accumulated in patients, gives rise to dialysis-related amyloidosis. Interestingly, although the physiologic concentration of β2m in mice is five times higher than that found in human patients, no amyloid deposits are observed in mice. Moreover, murine β2m (mβ2m) not only displays a lower amyloid propensity both in vivo and in vitro but also inhibits the aggregation of human β2m in vitro. Here, we compared human and mβ2m for their aggregation propensity, ability to form soluble oligomers, stability, three-dimensional structure and dynamics. Our results indicate that mβ2m low-aggregation propensity is due to two concomitant aspects: the low-aggregation propensity of its primary sequence combined with the absence of high-energy amyloid-competent conformations under native conditions. The identification of the specific properties determining the low-aggregation propensity of mouse β2m will help delineate the molecular risk factors which cause a folded protein to aggregate.

High Expression Achievement of Active and Robust Anti-β2 microglobulin Nanobodies via E.coli Hosts Selection

Nanobodies (VHHs) overcome many of the drawbacks of conventional antibodies, and the related technologies represent state-of-the-art and advanced applications in scientific research, pharmaceuticals, and therapies. In terms of productivity and economic cost, the cytoplasmic expression of VHHs in Escherichia coli (E. coli) is a good process for their recombinant production. The cytoplasmic environment of the host is critical to the affinity and stability of the recombinant VHHs in soluble form, yet the effects have not been studied. For this purpose, recombinant anti-β2 microglobulin VHHs were constructed and expressed in four commercialized E. coli hosts, including BL21 (DE3), Rosetta-gami B (DE3) pLysS, Origami 2 (DE3) and SHuffle T7 Express. The results showed that anti-β2 microglobulin (β2MG) VHHs expressed in different hosts exhibited distinctive differences in the affinity and structural characteristics. The VHHs expressed in Rosetta-gami B (DE3) pLysS possessed not only the greatest affinity of (equilibrium dissociation constant) K_D = 4.68 × 10⁻⁸ M but also the highest yields compared with the VHHs expressed in BL21 (DE3), Origami 2 (DE3) and SHuffle T7 Express. In addition, the VHHs expressed in Rosetta-gami B (DE3) pLysS were more stable than the VHHs expressed in the rest three hosts. Thus far, we have successfully realized the high expression of the active and robust anti-β2MG VHHs in Rosetta-gami B (DE3) pLysS. The underlying principle of our study is able to guide the expression strategies of nanobodies on the context of industrial large-scale production.

Extracellular matrix components modulate different stages in β2-microglobulin amyloid formation

Amyloid deposition of WT human β2-microglobulin (WT-hβ2m) in the joints of long-term hemodialysis patients is the hallmark of dialysis-related amyloidosis. In vitro, WT-hβ2m does not form amyloid fibrils at physiological pH and temperature unless co-solvents or other reagents are added. Therefore, understanding how fibril formation is initiated and maintained in the joint space is important for elucidating WT-hβ2m aggregation and dialysis-related amyloidosis onset. Here, we investigated the roles of collagen I and the commonly administered anticoagulant, low-molecular-weight (LMW) heparin, in the initiation and subsequent aggregation phases of WT-hβ2m in physiologically relevant conditions. Using thioflavin T fluorescence to study the kinetics of amyloid formation, we analyzed how these two agents affect specific stages of WT-hβ2m assembly. Our results revealed that LMW-heparin strongly promotes WT-hβ2m fibrillogenesis during all stages of aggregation. However, collagen I affected WT-hβ2m amyloid formation in contrasting ways: decreasing the lag time of fibril formation in the presence of LMW-heparin and slowing the rate at higher concentrations. We found that in self-seeded reactions, interaction of collagen I with WT-hβ2m amyloid fibrils attenuates surface-mediated growth of WT-hβ2m fibrils, demonstrating a key role of secondary nucleation in WT-hβ2m amyloid formation. Interestingly, collagen I fibrils did not suppress surface-mediated assembly of WT-hβ2m monomers when cross-seeded with fibrils formed from the N-terminally truncated variant ΔN6-hβ2m. Together, these results provide detailed insights into how collagen I and LMW-heparin impact different stages in the aggregation of WT-hβ2m into amyloid, which lead to dramatic effects on the time course of assembly.

One-step Preparation of a VHH-based Immunoadsorbent for the Extracorporeal Removal of β2-microglobulin

Dialysis-related amyloidosis (DRA), which has been widely recognized to be associated with the accumulation of β2-microglobulin (β2-m) in blood, is one of the most common complications in patients receiving long-term dialysis treatment. The most significant side-effect of existing hemodialysis sorbents for the removal of β2-m from blood is the loss of vital proteins due to non-specific adsorptions. Although the traditional antibodies have the capability to specifically remove β2-m from blood, high cost limits their applications in clinics. Single domain antibodies derived from the Camelidae species serve as a superior choice in the preparation of immunoadsorbents due to their small size, high stability, amenability, simplicity of expression in microbes, and high affinity to recognize and interact with β2-m. In this study, we modified the anti-β2-m VHH by the formylglycine-generating enzyme (FGE), and then directly immobilized the aldehyde-modified VHH to the amino-activated beads. Notably, the fabrication is cost- and time-effective, since all the preparation steps were performed in the crude cell extract without rigorous purification. The accordingly prepared immunoadsorbent with VHHs as ligands exhibited the high capacity of β2-m (0.75 mg/mL). In conclusion, the VHH antibodies were successfully used as affinity ligands in the preparation of novel immunoadsorbents by the site-specific immobilization, and effectively adsorbed β2-m from blood, therefore opening a new avenue for efficient hemodialysis.

Posttranslational modifications and proteinopathies: how guardians of the proteome are defeated

Protein folding is one of the fundamental processes in life and therefore needs to be tightly regulated. Many cellular quality control systems are in place to ensure that proteostasis is optimally adjusted for a changing environment, facilitating protein folding, translocation and degradation. These systems include the molecular chaperones and the major protein degradation systems, namely the ubiquitin proteasome system and autophagy. However, the capacity of the quality control systems can be exhausted and protein misfolding and aggregation, including the formation of amyloids, can occur as a result of ageing, mutations or exogenous influences. There are many known diseases in which protein misfolding and aggregation can be the underlying cause of the pathological condition; these are referred to as proteinopathies. Over the last decade, it has become clear that posttranslational modifications can govern and modulate protein folding, and that aberrant posttranslational modifications can cause or contribute to proteinopathies. This review provides an overview of protein folding and misfolding and the role of the major protein quality control systems. It focusses on different posttranslational modifications and gives examples of how these posttranslational modifications can alter protein folding and cause or accompany proteinopathies.

Investigating the Molecular Basis of the Aggregation Propensity of the Pathological D76N Mutant of Beta-2 Microglobulin: Role of the Denatured State

Beta-2 microglobulin (β2m) is a protein responsible for a pathologic condition, known as dialysis-related amyloidosis (DRA), caused by its aggregation and subsequent amyloid formation. A naturally occurring mutation of β2m, D76N, presents a higher amyloidogenic propensity compared to the wild type counterpart. Since the three-dimensional structure of the protein is essentially unaffected by the mutation, the increased aggregation propensity of D76N has been generally ascribed to its lower thermodynamic stability and increased dynamics. In this study we compare the equilibrium unfolding and the aggregation propensity of wild type β2m and D76N variant at different experimental conditions. Our data revealed a surprising effect of the D76N mutation in the residual structure of the denatured state, which appears less compact than that of the wild type protein. A careful investigation of the structural malleability of the denatured state of wild type β2m and D76N pinpoint a clear role of the denatured state in triggering the amyloidogenic propensity of the protein. The experimental results are discussed in the light of the previous work on β2m and its role in disease.

Conformational Properties Relevant to the Amyloidogenicity of β2-Microglobulin Analyzed Using Pressure- and Salt-Dependent Chemical Shift Data

β₂-Microglobulin (β₂m) is associated with dialysis-related amyloidosis. In vitro experiments have shown that β₂m forms amyloid fibrils at acidic pHs in the presence of moderate concentrations of salt. Previous studies suggested that acid-denatured β₂m has a hydrophobic residual structure, and the exposure of the hydrophobic residues enhances the association with seeds or other β₂m monomers. However, the nature of the residual structure relevant to its amyloidogenicity remains to be investigated. To understand the structural properties of acid-denatured β₂m and the role of salt, we investigated pressure- and salt concentration-dependent conformational changes by nuclear magnetic resonance spectroscopy and other methods. Here, pressure was utilized to characterize the conformers existing in a conformational equilibrium at ambient pressure. The obtained pressure- and salt concentration-dependent chemical shift data were simultaneously subjected to principal component analysis to characterize individual conformational change events. Unexpectedly, the addition of salt induced an expansion of the β₂m molecule, which likely resulted from the exclusion of the N-terminal region from the hydrophobic cluster region. The dissected chemical shift patterns for the salt-induced conformational change and other experimental data indicated that this conformational change caused a rigidification in the intrinsic hydrophobic cluster, leading to the observed amyloidogenicity.

The Effect of Renal Transplantation in End-Stage Renal Failure Patients Undergoing Total Hip Replacement

BACKGROUND

Patients with end-stage renal failure (ESRF) undergoing elective orthopedic surgery generally have higher postoperative morbidity and mortality compared to the general population. Studies on the outcome of ESRF patients undergoing total hip replacement (THR), especially those with a functioning renal transplant, are conflicting. We aim to evaluate the impact of renal transplantation on functional outcome and postoperative complications in patients with ESRF undergoing THR.

MATERIALS AND METHODS

A total of 29 primary THRs were performed in 25 patients with ESRF between 1999 and 2013. There were 12 patients with 14 THRs who had a functioning renal transplant at the time of surgery (transplant group), and 13 patients with 15 THRs who were dialysis dependent with either no or failed prior transplant (nontransplant group). Functional outcome was evaluated with the Oxford Hip Score (OHS) and Western Ontario and McMaster Universities Osteoarthritis Index. Clinical records and followup radiographs were used to evaluate postoperative complications.

RESULTS

There is lower mortality rate (P = 0.02) and lower overall complication rate in the transplant group compared to the nontransplant group (relative risk 0.60, 95% confidence interval 0.40-0.91, P = 0.008). The mean increase in OHS postoperatively was greater in the nontransplant group (nontransplant-24.7; transplant-18.7) and trended toward statistical significance (P = 0.06).

CONCLUSION

ESRF patients who undergo THR experience improvements in functional outcome regardless of transplant status. There was no significant difference in postoperative functional outcomes between the two groups of patients, but patients with renal transplants are less likely to experience postoperative complications and have better survival.

The yeast GRASP Grh1 displays a high polypeptide backbone mobility along with an amyloidogenic behavior

GRASPs are proteins involved in cell processes that seem paradoxical: responsible for shaping the Golgi cisternae and involved in unconventional secretion mechanisms that bypass the Golgi. Despite its physiological relevance, there is still a considerable lack of studies on full-length GRASPs. Our group has previously reported an unexpected behavior of the full-length GRASP from the fungus C. neoformans: its intrinsically-disordered characteristic. Here, we generalize this finding by showing that it is also observed in the GRASP from S. cerevisae (Grh1), which strongly suggests it might be a general property within the GRASP family. Furthermore, Grh1 is also able to form amyloid-like fibrils either upon heating or when submitted to changes in the dielectric constant of its surroundings, a condition that is experienced by the protein when in close contact with membranes of cell compartments, such as the Golgi apparatus. Intrinsic disorder and fibril formation can thus be two structural properties exploited by GRASP during its functional cycle.

Transmembranous Transport and Adsorption of Beta-2-microglobulin during Hemodialysis using Polysulfone, polyacrylonitrile, polymethylmethacrylate and Cuprammonium Rayon Membranes

Beta-2-microglobulin (b2M) was identified as a causative agent of amyloidosis associated with long-term hemodialysis (HD). Therefore, we examined handling of b2M during a 4-hour hemodialysis session. We compared b2M adsoprtion and diffusive/convective elimination between high-flux membranes such as polysulfone (PS; F 60®, Fresenius), polyacrylonitrile (AN 69; FiltralR, Hospal) and polyacrylonitrile (PAN, PAN 12CX2R, Asahi) and less permeable membranes such as cuprammonium rayon (CR; AM 160 HR, Asahi) and polymethylmethacrylate (PMMA; BK-1.6 UR, Toray). To calculate total elimination, arterio-venous differences of b2M were measured at 0, 5, 20, 60 and 240 minutes; dialysate concentration was analyzed to evaluate diffusive/convective transport. Differences between recovery in dialysate and total removal were regarded as amount removed by adsorption. Total elimination per 4-hour hemodialysis session and per m2 membrane surface was 154.7 ± 12.3 mg for the PS, 137.8 ± 28.4 mg for the AN 69, 179.8 ± 47.5 mg for the PAN, 130.8 ± 11.8 mg for the PMMA and 14.4 ± 16.0 mg for the CR membrane. Diffusive/convective transport was 128.0 ± 18.1 mg for PS, 54.7 ± 8.1 mg for AN 69 and 106.5 ± 20.8 mg for PAN and insignificant for PMMA and CR. Adsorption was 26.7 ± 4.3 mg for PS, 83.1 ± 29.0 mg for AN 69 and 59.8 ± 17.2 mg for PAN. Besides transmembranous transport sorption is an important mode of elimination. Weekly endogenous generation rate is about twice as high as b2M elimination

Current approaches to middle molecule removal: room for innovation

Aggressive removal of middle molecules or larger low-molecular-weight proteins (LMWPs) has been a growing concern following studies on their harmful effects on the mortality and morbidity of chronic dialysis patients. To remove larger LMWPs and some protein-bound uremic toxins (PBUTs), high- and medium-cutoff (HCOs and MCOs, respectively) membranes, convective therapy and protein adsorptive membranes are available. When we use HCO or MCO membranes for convective therapy, we have to take care to avoid massive albumin leakage during a dialysis session. Convection volume is an important element to increase middle molecule removal; however, a larger convection volume has a risk of larger leakage of albumin. Predilution hemodiafiltration is a useful measurement to increase larger LMWPs without massive albumin leakage. β2-microglobulin (B2M), α1-microglobulin (A1M) and albumin leakage during a dialysis session are useful parameters for assessing middle-molecule removal. Reduction ratios of B2M >80% and of A1M >35% are favorable to improve severe dialysis-related symptoms. The efficacy of middle molecule removal should be evaluated in comparison with clinical outcomes, mortality, morbidity and the improvement of dialysis-related symptoms. Recently some dialysis-related symptoms such as sleep disturbance, skin itchiness and dialysis hypotension have been recognized as good surrogate makers for mortality. Further studies to evaluate the relationship between middle molecule or PBUTs removal and the improvement of patient symptoms should be performed in well-designed randomized controlled trials.

HIV-1-Associated Neurocognitive Disorders: Is HLA-C Binding Stability to β2-Microglobulin a Missing Piece of the Pathogenetic Puzzle?

AIDS dementia complex (ADC) and HIV-associated neurocognitive disorders (HAND) are complications of HIV-1 infection. Viral infections are risk factors for the development of neurodegenerative disorders. Aging is associated with low-grade inflammation in the brain, i.e., the inflammaging. The molecular mechanisms linking immunosenescence, inflammaging and the pathogenesis of neurodegenerative disorders, such as Alzheimer's disease (AD) and Parkinson's disease, are largely unknown. ADC and HAND share some pathological features with AD and may offer some hints on the relationship between viral infections, neuroinflammation, and neurodegeneration. β2-microglobulin (β2m) is an important pro-aging factor that interferes with neurogenesis and worsens cognitive functions. Several studies published in the 80-90s reported high levels of β2m in the cerebrospinal fluid of patients with ADC. High levels of β2m have also been detected in AD. Inflammatory diseases in elderly people are associated with polymorphisms of the MHC-I locus encoding HLA molecules that, by associating with β2m, contribute to cellular immunity. We recently reported that HLA-C, no longer associated with β2m, is incorporated into HIV-1 virions, determining an increase in viral infectivity. We also documented the presence of HLA-C variants more or less stably linked to β2m. These observations led us to hypothesize that some variants of HLA-C, in the presence of viral infections, could determine a greater release and accumulation of β2m, which in turn, may be involved in triggering and/or sustaining neuroinflammation. ADC is the most severe form of HAND. To explore the role of HLA-C in ADC pathogenesis, we analyzed the frequency of HLA-C variants with unstable binding to β2m in a group of patients with ADC. We found a higher frequency of unstable HLA-C alleles in ADC patients, and none of them was harboring stable HLA-C alleles in homozygosis. Our data suggest that the role of HLA-C variants in ADC/HAND pathogenesis deserves further studies. If confirmed in a larger number of samples, this finding may have practical implication for a personalized medicine approach and for developing new therapies to prevent HAND. The exploration of HLA-C variants as risk factors for AD and other neurodegenerative disorders may be a promising field of study.

Structural Features of Amyloid Fibrils Formed from the Full-Length and Truncated Forms of Beta-2-Microglobulin Probed by Fluorescent Dye Thioflavin T

The persistence of high concentrations of beta-2-microglobulin (β2M) in the blood of patients with acute renal failure leads to the development of the dialysis-related amyloidosis. This disease manifests in the deposition of amyloid fibrils formed from the various forms of β2M in the tissues and biological fluids of patients. In this paper, the amyloid fibrils formed from the full-length β2M (β2m) and its variants that lack the 6 and 10 N-terminal amino acids of the protein polypeptide chain (ΔN6β2m and ΔN10β2m, respectively) were probed by using the fluorescent dye thioflavin T (ThT). For this aim, the tested solutions were prepared via the equilibrium microdialysis approach. Spectroscopic analysis of the obtained samples allowed us to detect one binding mode (type) of ThT interaction with all the studied variants of β2M amyloid fibrils with affinity ~10⁴ M-1. This interaction can be explained by the dye molecules incorporation into the grooves that were formed by the amino acids side chains of amyloid protofibrils along the long axis of the fibrils. The decrease in the affinity and stoichiometry of the dye interaction with β2M fibrils, as well as in the fluorescence quantum yield and lifetime of the bound dye upon the shortening of the protein amino acid sequence were shown. The observed differences in the ThT-β2M fibrils binding parameters and characteristics of the bound dye allowed to prove not only the difference of the ΔN10β2m fibrils from other β2M fibrils (that can be detected visually, for example, by transmission electron microscopy (TEM), but also the differences between β2m and ΔN6β2m fibrils (that can not be unequivocally confirmed by other approaches). These results prove an essential role of N-terminal amino acids of the protein in the formation of the β2M amyloid fibrils. Information about amyloidogenic protein sequences can be claimed in the development of ways to inhibit β2M fibrillogenesis for the treatment of dialysis-related amyloidosis.

Molecular dynamics simulations of β2-microglobulin interaction with hydrophobic surfaces

Hydrophobic surfaces are known to adsorb and unfold proteins, a process that has been studied only for a few proteins. Here we address the interaction of β2-microglobulin, a paradigmatic protein for the study of amyloidogenesis, with hydrophobic surfaces. A system with 27 copies of the protein surrounded by a model cubic hydrophobic box is studied by implicit solvent molecular dynamics simulations. Most proteins adsorb on the walls of the box without major distortions in local geometry, whereas free molecules maintain proper structures and fluctuations as observed in explicit solvent molecular dynamics simulations. The major conclusions from the simulations are as follows: (i) the adopted implicit solvent model is adequate to describe protein dynamics and thermodynamics; (ii) adsorption occurs readily and is irreversible on the simulated timescale; (iii) the regions most involved in molecular encounters and stable interactions with the walls are the same as those that are important in protein-protein and protein-nanoparticle interactions; (iv) unfolding following adsorption occurs at regions found to be flexible by both experiments and simulations; (v) thermodynamic analysis suggests a very large contribution from van der Waals interactions, whereas unfavorable electrostatic interactions are not found to contribute much to adsorption energy. Surfaces with different degrees of hydrophobicity may occur in vivo. Our simulations show that adsorption is a fast and irreversible process which is accompanied by partial unfolding. The results and the thermodynamic analysis presented here are consistent with and rationalize previous experimental work.

Molecular mechanisms underlying uremic toxin-related systemic disorders in chronic kidney disease: focused on β2-microglobulin-related amyloidosis and indoxyl sulfate-induced atherosclerosis-Oshima Award Address 2016

Uremic toxins are linked to chronic kidney disease (CKD)-related systemic diseases. β₂-Microglobulin (β₂-m), a water-soluble, middle-sized molecule, is associated with mortality and dialysis-related amyloidosis (DRA). DRA occurs in long-term dialysis patients, with β₂-m amyloid deposited mainly in osteoarticular tissues. We investigated a model of β₂-m amyloid fibril extension at neutral pH in the presence of trifluoroethanol or sodium dodecyl sulfate. Using this model, some biological molecules, including glycosaminoglycans and lysophospholipids, were found to be chaperones for β₂-m amyloid fibril extension. Several protein-bound solutes, such as indoxyl sulfate (IS) and p-cresyl sulfate, are independent risk factors for cardiovascular disease in CKD patients, especially those undergoing dialysis. We investigated kidney injury-induced acceleration of atherosclerosis in association with macrophage phenotypic change to a proinflammatory state as well as increased IS deposition in lesions in an animal model. IS directly induced macrophage inflammation and impaired cholesterol efflux to high-density lipoprotein (HDL) in vitro. In addition, a clinical study showed that HDL isolated from CKD patients induced proinflammatory reactions and impaired cholesterol efflux to macrophages. These findings suggest that protein-bound solutes, including IS, will induce dysfunction of both macrophages and HDL in atherosclerotic lesions. To remove uremic toxins efficiently, we demonstrated the potential efficacy of oral charcoal adsorbent and hexadecyl-immobilized cellulose beads in hemodialysis patients. These findings suggest that uremic toxins induce various CKD-related systemic disorders, and further therapeutic strategies will be needed to reduce uremic toxins enough and improve life expectancy in CKD patients.

Beta-2-Microglobulin Adsorption and Release in-Vitro: Influence of Membrane Material, Osmolality and Heparin

We studied the effects of cuprammonium rayon (CR), polyacrylonitrile (PAN), polysulfone (PS), changes in osmolality, and heparin dosage on beta-2-microglobulin (b2M) handling in an in-vitro model that excluded convective transport and minimized diffusive transport. Both PAN and PS exhibited high adsorption capacity for b2M. Osmolality changes had no effect on b2M adsorption or release. CR membrane adsorption was minimal but increased slightly when higher heparin doses were used. In experiments with CR and high heparin doses (4 U/ml) b2M release occurred during the first 15 minutes of in-vitro dialysis, but this increase was inhibited by removing the leukocytes from the blood, indicating that b2M is released from leukocytes.

Radiological Features of Dialysis Amyloid Spondyloarthropathy

Nine patients undergoing regular dialytic treatment (RDT) for more than 60 months (mean 125± 33 months) showed clinical and radiological evidence of non-infective destructive spondyloarthropathy (DSA). The cervical spine was the skeletal segment most affected (100% of cases). Three patients were found also to be suffering from discal and bone alterations of the dorsal column, and in two other patients the vertebral bodies L4-L5 were changed. Typical radiological pictures showed a narrowing of intervertebral spaces with the destruction or sclerosis of adjacent subchondral bones, erosions of vertebral body plates and cavitations. CT studies of the altered spines confirmed discal lesions and osteolytic areas with bone condensation at each level. Ligamentous lesions resulting in severe disorders of spinal statics were discovered during autopsy of three patients. Histological study of disc and peridiscal ligaments indicated the presence of large amyloid deposits containing beta-2-microglobulin (B2-m). It is possible that the minor biocompatibility of the cuprophan membrane of dialyzers is the most significant factor responsible for the hyperproduction of B2-m and thus of the osteo-articular deposition of a new type of amyloidosis.

Adsorption of ß2-Microglobulin on Dialysis Membranes: Comparison of Different Dialyzers and Effects of Reuse Procedures

In order to measure ß2-microglobulin adsorption on dialysis membranes, uremic plasma was passed through different dialyzers in a simulated hemodialysis circuit in which both plasma and dialysate compartments were organized as closed loops, the ultrafiltration pressure being adjusted to minimize water shifts. Under these conditions, comparison of the amounts of ß2-m in the plasma and dialysate compartments allowed us to calculate the binding of ß2-m to the membrane at different times of the procedure. Whereas cuprophane membrane (Gambro gf 180m, 1.8m2) did not bind ß2-m, AN69 (Filtral, 1.1 m2), high flux polysulfone (F60, 1.2m2) and modified polyamide (Polyflux 130, Gambro, 1.3m2) were found to adsorb 49 ± 8 mg (mean ± SEM), 17 ± 5 mg and 38 ± 4 mg of 82-m, respectively. These data were confirmed in trace labeling experiments with 125I-ß2-m. Adsorption was a saturable phenomenon occurring during the first 90 min of in vitro dialysis. After reuse with peracetic acid, the adsorption capacity of AN69 membrane was lowered to 20 ± 4 mg of ß2-m, contrasting with the unchanged adsorption after reuse with sodium hypochlorite. These data indicate that adsorption significantly contributes to ß2-m removal during hemodialysis with certain dialyzers and that reuse procedures may affect the propensity of dialysis membranes to bind 82-m.

Factors Affecting β2-Microglobulin Plasma Concentration during Hemodialysis

We studied ten patients on hemodialysis (HD) treated in sequence with cuprophan (CU), ethylenevinylalcohol (EVAL), polyacrylonitrile (A-69) and polysulphone (PSP) membrane dialyzers. ß2-microglobulin (ß2m) was measured by radioimmunoassay in plasma and dialysate samples. Plasma concentrations were corrected for changes in extracellular volume (ECV). We also studied adsorption in vitro by incubating the above membranes with I-125-labelled ß2m. There were no changes in ß2m plasma concentration after HD with CU dialyzers, but a significant decrease was observed with the other membranes tested. Filtration of ß2m across the dialyzer was absent with CU and minimal with EVAL. However, large amounts were recovered from dialysate with the high-permeability dialyzers, AN-69 and PSP. In vitro studies showed that maximal adsorption capacity was obtained with AN-69 (73%) compared to 9% with CU, 4% with EVAL and 7% with PSP. In summary, ß2m clearance with PSP is achieved through greater removal of this protein by mass transport across the membrane. The mechanism by which ß2m is removed from blood during AN-69 dialysis seems to include both adsorption to and filtration by the membrane itself.

Clinical Evaluation of a New High-Flux Cellulose Acetate Membrane

One major goal of dialysis therapy has become the removal of ß2-microglobulin (ß2-m). The interdialytic elimination of ß2-m was studied using a newly developed high-flux cellulose acetate (CA) membrane.

The results show that high-flux CA dialyzers offer better biocompatibility than classical Cuprophan or high-flux Cuprophan devices, with regard to leukopenia, C3a desarg generation, and elastase release from polymorphonuclear (PMN) leukocytes. Compared to high-flux CA membranes, high-flux PMMA membranes induce less C3a desarg formation but comparable leukopenia. High-flux PMMA membranes, however cause greater leukocyte stimulation than CA as demonstrated by more PMN elastase release during hemodialysis.

Using high-flux CA or high-flux PMMA membranes, serum ß2-m levels decreased 32% during dialysis. Serum ß2-m dropped 10% with high-flux Cuprophan membranes, but remained unchanged with conventional Cuprophan dialyzers.

Sieving coefficients for ß2-microglobulin (ß2-m) were virtually zero with classical Cuprophan and 0.66 with high-flux cellulose acetate membranes. High-flux membranes made of Cuprophan and PMMA gave coefficients of 0.25 and 0.45, respectively. This indicates the high removal capacity of the new CA-membrane for substances with high molecular weight.

This high-flux CA membrane thus appears to combine a good degree of biocompatibility with a high capacity for ß2-m removal.

Does Immunodeficiency in Uremic Patients Promote Dialysis-Related Amyloidosis?

The present study was undertaken to evaluate the immune function of 5 hemodialysis patients with dialysis-related amyloidosis as compared to 6 without, both groups having a dialytic age from 7 to 21 years, and 5 healthy controls. We investigated serum levels of immunoglobulins (IgG, IgA, IgM), made skin tests and measured peripheral lymphocyte subsets using monoclonal antibodies.

1) The absolute numbers of T3, T4 and T8 cells were significantly lower in hemodialysis patients than controls and T3, T4 cells were lower in patients with amyloidosis than in those without: T3 (m ± SD/μl), 387 ± 253 vs 744 ± 207 (p = 0.03); T4, 262 ± 115 vs 589 ± 297 (p = 0.04).

2) Serum levels of IgG and IgM were significantly lower in patients with amyloidosis than in the others: IgG (m ± SD, g/l), 10.2 ± 1.4 vs 15.4 ± 3.2 (p < 0.001); IgM, 0.65 ± 0.28 vs 1.65 ± 0.37 (p < 0.001).

3) Delayed hypersensitivity studied by skin tests showed less than 3 positive antigens in 4/5 patients with amyloidosis against 1/6 patients without. These data suggest there is a marked defect of T-cell help in uremic patients with dialysis-related amyloidosis.

Hemodialysis-Related Induction of β2-Microglobulin Synthesis and Release by Mononuclear Phagocytes

We have investigated β2-microglobulin (β2M) synthesis and release by blood leukocytes and isolated mononuclear phagocytes. Since β2M was discovered to form amyloid fibrils in patients undergoing long term, chronic hemodialysis and monomeric β2M levels in plasma of these patients are highly elevated, and since hemodialysis-related factors that increase β2M production are unknown, we evaluated β2M production by mononuclear phagocytes under a variety of conditions. We utilized a novel enzyme-lined immunoabsorbant assay to quantitate β2M release. Adherence of macrophages onto polystyrene or Cuprophan membranes does not induce β2M synthesis or release. In contrast, interaction of macrophages with lipopolysaccharide, gamma-interferon, tumor necrosis factor, or interleukin 1 induces synthesis or release. In contrast, interaction of macrophages with lipopolysaccharide, gamma-interferon, tumor necrosis factor, or interleukin 1 induces synthesis and release of β2M, indicating that β2M synthesis is increased during macrophage activation. Exposing leukocytes or macrophages to changes in osmotic or oncotic pressure induces a rapid release of β2M and interleukin 1 into the cellular medium. These results suggest that during hemodialysis, β2M production is more likely to result from endotoxin contamination, or osmotic and oncotic changes, rather than direct interaction of mononuclear phagocytes with cellulosic membranes.

Red Blood Cell Function and β2 Microglobulin Kinetics during Cuprophan Hemodialysis: A Hypothesis

The exact role of β2microglobulin (β2m) in dialysis amyloidosis is yet not known. Local release of β2m from the endothelial cells of the lung and other tissues as a consequence of acute-phase activation due to the contact of blood with membranes has still to be considered a possible pathogenetic factor in this syndrome. β2m kinetics and decrease of glutathione content in RBC were studied in 41 chronic hemodialysis patients during cuprophan dialysis. The latter test reflects the RBC scavenger function for free oxygen radicals. Only 30% of patients showed a clinically significant increase in β2m. The change in β2m in this group between the start and 180 minutes, corrected for plasma volume, was 23.1±3.6% and the change in gluthathione content between the start and 15 minutes was 4.5±3.4%. In these patients there was a significant correlation between β2m production and decrease of gluthathione (R= -0.61, p= 0.0299). It is possible that the production of free oxygen radicals during bioincompatible dialysis leads to cellular toxicity with release ofβ2m which may be prevented to some extent by the scavenger role of RBC.

Granulocyte Elastase, β-Thromboglobulin, and C3D during Acetate or Bicarbonate Hemodialysis with Hemophan® Compared to a Cellulose Acetate Membrane

Twenty-two patients were dialysed in a cross-over design using Hemophan® or cellulose acetate membranes. The dialysate buffer was acetate (n = 12) or bicarbonate (n = 10). Blood was sampled at 0, 15, 60 and 180 min and mean values were adjusted for changes in total protein in each sample. At 15 min during dialysis a decrease in leukocytes and platelets occurred with both membranes, irrespective of the buffer (Wilcoxon, p < 0.006). During dialysis, increases were found in granulocyte elastase inhibitor complex (E-α1-PI), β-thromboglobulin and C3d. β2-microgrobulin was not significantly changed in blood after dialysis with Hemophan® or cellulose acetate membranes with bicarbonate buffer. Side effects were more pronounced at 180 min during dialysis with bicarbonate in patients using cellulose acetate than with Hemophan® (p = 0.021, n = 8). Hemophan® seemed to be more favourable than cellulose acetate membranes in regard to leukopenia and E- α1-PI. The dialysate buffer may also alter membrane biocompatibility.

In Vivo Clearance and Elimination of Nine Marker Substances during Hemofiltration with Different Membranes

The handling of low, middle and high molecular weight markers was examined in seven stable dialysis patients during hemofiltration with different membranes. Four membranes were examined in a randomized, crossover order (polysulfone, polyamide, AN69 polyacrylonitrile, Asahi polyacrylonitrile) by measuring plasma and dialysate concentrations of phosphate, creatinine, vitamin B12, β2-microglobulin, furanic acid, hippuric acid, retinolbinding protein, alpha-1-antitrypsin, and albumin. Sieving coefficients and plasma clearances of β-microglobulin or retinol-binding protein were markedly or slightly lower during hemofiltration with the Asahi polyacrylonitrile membrane than with the other membranes (highest removal with polysulfone/AN69 polyacrylonitrile membranes). No differences of obvious clinical relevance could be seen between the four membranes. A high β2-microglobulin removal rate might be important to prevent dialysis-associated amyloidosis.

Beta 2-Microglobulin Synthesis of Mononuclear Cells in Chronic Dialysis Patients

Beta 2 microglobulin (B2M) has been identified as a major component of amyloid deposits. This study was designed to determine whether changes occur in the synthesis of B2M in dialysis patients. Mononuclear cells (MNC) were isolated in peripheral blood from healthy volunteers, patients on hemodialysis (HD) and on continuous ambulatory peritoneal dialysis (CAPD). MNC were cultured in a medium of RPMI 1640 with or without interleukins IL-1, IL-2 or interferon INF-r. B2M in the cultured cells and supernatant was measured by enzyme immunoassay. IL-2 or INF-r stimulated B2M synthesis 'was significantly lower (25%) in patients on HD than in normal controls regardless of the type of dialysis membranes used, with no change in basal B2M synthesis. No differences were detected between healthy volunteers and CAPD patients. Preincubation of MNC with complement - activating or non-complement - activating membrane had no influence on B2M synthesis. The basal B2M synthesis of MNC significantly increased after a 4-hour HD regardless of the membranes used, and IL-2 and IFN-r stimulated synthesis were both essentially the same before and after HD. It was thus concluded that maximum capacity for B2M synthesis of MNC decreases in hemodialysis patients. This low responsiveness of MNC may be partially the cause for the reduction in cell-mediated immune response in HD patients.