In vivo intracellular cytokine production by leukocytes during haemodialysis

The Relationship of Residual Renal Function with Cardiovascular Morbidity in Hemodialysis Patients and the Potential Role of Monocyte Chemoattractant Protein-1

BACKGROUND

Residual renal function (RRF) provides several benefits to patients on dialysis. Monocyte chemoattractant protein-1 (MCP-1) plays an important role in atherosclerotic lesions. We considered the relationship between RRF and cardiovascular morbidity and the significant role of MCP-1 serum concentrations in hemodiafiltration (HDF) patients.

METHODS

We enrolled 76 patients on on-line HDF. RRF was defined by interdialytic urine output, and we studied the patients in two groups according to the preservation or not of urine output. MCP-1 levels were measured using enzyme-linked immunosorbent assay. χ2 tests were applied for the association between RRF and left ventricular hypertrophy (LVH), coronary artery disease (CAD), peripheral artery disease (PAD), and systolic and diastolic cardiac dysfunction. We built an adjusted model using logistic regression analysis for the factors which might impact on the loss of urine output.

RESULTS

χ2 tests showed a significant association between the loss of urine output and LVH, diastolic dysfunction, and PAD (χ2 = 7.4, p = 0.007; χ2 = 14.3, p = 0.001; χ2 = 4.2, p = 0.03, respectively), although the association with CAD and systolic dysfunction was found to be nonsignificant. The patients without RRF had significantly higher MCP-1, and the urine volume was inversely associated with MCP-1 (r = -465, p = 0.03). In the built adjusted model, the elevated MCP-1 was found to be a significant predictor for the loss of RRF.

CONCLUSION

The loss of RRF was significantly associated with LVH, diastolic dysfunction, and PAD in HDF patients. The increased MCP-1, affected by the lack of urine, may act as an additional underlying factor on this relationship, reflecting a progressive inflammation/oxidative stress condition.

Therapeutic possibilities of techniques of extracorporeal blood circulation in oncology

Malignant tumors in an advanced phase of diffusion have a very poor prognosis. However, there are conditions in the body which may impede, even if only partially, further spread of the disease. In addition to currently available treatments, other favorable conditions can help to improve the prognosis, even if only relatively, such as the presence of inhibitors of metalloproteinases, antiangiogenic factors, the absence of particular proteins that favor tumor development, and the possibility of positively activating the immune system. The authors believe that in cases where such conditions are concurrent, the addition of a new favorable condition could be very useful. On the other hand, cases of total spontaneous regression of malignancies, even if in metastatic diffusion, are well known. It was recently emphasized that the spread of metastasis of renal cell carcinoma, arising in patients on hemodialysis for a long time, is considerably reduced at the post-mortem examination compared to patients with renal cell carcinoma and not on hemodialysis. This may suggest a positive effect exerted by the dialytic membrane on metastatic spread. The authors hypothesize that extracorporeal circulation of the blood, used mainly for cardiovascular interventions and hemodialysis, could be used by applying filters suitable for cancer treatments, similar to those used in hemodialysis, even if without accomplishing the hemodialytic function, provided there are no objections to their biocompatibility. In this case, the block of metastatic cells could lead to a relative increase in the cellular elements of the immune system (NK cells and T lymphocytes) compared to cancer cells, or rather to the relative reduction in the number of cancer cells compared to NK cells and T lymphocytes. Such a block would prevent any feedback reactions, so frequent and damaging to the prognosis when using overall medical stimulation for the immune system.

The Clinical Application of Ozonetherapy

The reader may be eager to examine in which diseases ozonetherapy can be proficiently used and she/he will be amazed by the versatility of this complementary approach (Table 9 1). The fact that the medical applications are numerous exposes the ozonetherapist to medical derision because superficial observers or sarcastic sceptics consider ozonetherapy as the modern panacea. This seems so because ozone, like oxygen, is a molecule able to act simultaneously on several blood components with different functions but, as we shall discuss, ozonetherapy is not a panacea. The ozone messengers ROS and LOPs can act either locally or systemically in practically all cells of an organism. In contrast to the dogma that “ozone is always toxic”, three decades of clinical experience, although mostly acquired in private clinics in millions of patients, have shown that ozone can act as a disinfectant, an oxygen donor, an immunomodulator, a paradoxical inducer of antioxidant enzymes, a metabolic enhancer, an inducer of endothelial nitric oxide synthase and possibly an activator of stem cells with consequent neovascularization and tissue reconstruction.

Some relations among the dialysis membrane, metastatic cells and the immune system

Since results in the literature show that series of patients with kidney cancer on hemodialysis present at the postmortem examination an incidence of metastases significantly lower than such patients not on hemodialysis, the author asks what part of this favorable prognostic result is due to the dialysis membrane and what part is due to the immune system. The part due to the dialysis membrane is with every probability a blockade of metastatic cancer cells. This block, very likely consequent to phenomena of adhesion of cells to the dialysis membrane, allows a selection in that it blocks those cells that have the greatest possibility of adhesion also to the endothelium of capillaries in sites of potential colonization. The immune system would thus have, in the presence of the dialysis membrane, a greater possibility to concentrate its action on residual metastatic cells, even though uremia can have a negative influence on the clinical result. The possibility is discussed that among the various therapies of neoplasms, that for melanoma in particular may benefit from the presence of the dialysis membrane. Melanoma has demonstrated a certain sensitivity to the action of cytokines, in part also due to the presence of receptors for the latter in melanoma cells. However, the early and intense metastatic diffusion worsens the prognosis in the course of the neoplasm, and an eventual blockade, although partial, of metastatic cells could thus lead to a positive clinical result. An increase in cytokines, verified in patients on hemodialysis, does not appear to have any particular affect on the course of the disease. No signs of particular activity of the cytokines most active in an antineoplastic sense or in the sense of immune tolerance have been observed.

Nocturnal sleep related with metabolic markers in end-stage renal disease patients receiving hemodialysis

OBJECTIVE

It has been suggested that oxidative stress and inflammation are associated with the pathophysiology of sleep disorders in end-stage renal disease (ESRD) patients. We examined the relationship of the sleep variables reflecting sleep breathing disorder and limb movements during sleep with the clinical variables reflecting the metabolic abnormalities in ESRD patients receiving hemodialysis.

METHODS

Nocturnal polysomnography was conducted in 30 ESRD patients (21 men, 9 women), who were receiving hemodialysis. Blood was sampled before hemodialysis for each patient in order to measure uric acid (UA), C-reactive protein (CRP), and interleukin-6 (IL-6).

RESULTS

UA was correlated positively with the total sleep time (TST)(r=0.407) and negatively with the apnea-hypopnea index (AHI) and oxygen desaturation index (ODI)(r=-0.377, -405).

CONCLUSION

CRP was positively correlated with the limb movement index (LMI)(r=0.401). Our study showed that increased UA was related to decreased respiratory disturbance during sleep in ESRD patients receiving hemodialysis.

HCV infection in haemodialysed patients: a role for serum IL-10 and TGF-beta1 in liver damage?

BACKGROUND

Hepatitis C virus (HCV) infection is often clinically silent in haemodialysed (HD) patients and their immune response may modulate liver damage in HCV infection. IL-10 and TGF-beta1 could play a role in this setting as, IL-10 down-regulates hepatic fibrosis, while TGF-beta1 is a pro-fibrotic cytokine.

AIM

To evaluate the role of IL-10 and TGF-beta1 in HD/HCV+ patients.

PATIENTS

71 HD/HCV+ patients (58 with normal [HD/HCV-N] and 13 with high serum transaminases [HD/HCV-H]), 40 non-uremic patients with chronic hepatitis C (HCV+), 56 HD anti-HCV- patients and 20 healthy volunteers (H).

METHODS

IL-10 and TGF-beta1 serum levels were assessed using ELISA tests. Liver histology was assessed by Ishak's score.

RESULTS

IL-10 serum levels were significantly higher in HD patients, both HCV+ (3.7+/-0.4 pg/ml; p<0.01) and HCV- (3.8+/-0.8 pg/ml; p<0.05) than in non-uremic HCV patients (2.3+/-0.4 pg/ml). Among the HD/HCV+ patients, IL-10 serum levels were similar in HD/HCV-N and in HD/HCV-H patients. Among the HD/HCV+ patients, IL-10 serum levels were similar in those with moderate histological damage compared to those with mild damage. TGF-beta1 serum levels were significantly lower in HD patients, both HCV+ (4.6+/-0.9 ng/ml) and HCV- (6.0+/-0.9 ng/ml) than in non-uremic HCV+ patients (8.1+/-1.1 ng/ml; p<0.001 and p<0.01, respectively), but similar to the values found in H (5.3+/-0.9 ng/ml; p=n.s.). No correlation was seen between IL-10 and TGF-beta1 serum levels in any of the groups considered.

CONCLUSIONS

Patients on haemodialysis treatment to have high levels of IL-10, which remain high even when patients are anti-HCV+, whereas the opposite is true of TGF-beta1. The cytokine pattern observed in HD patients is compatible with the hypothesis explaining the relatively benign evolution of HCV-related liver disease in HD patients, and has a pathophysiological role.

Complement activation is involved in biological responses to leukocyte adsorptive apheresis

We examined the effects of complement activation on the biological responses of cellulose acetate (CA) beads. Peripheral blood containing the complement activation inhibitor nafamostat mesilate (NM) or heparin was incubated with CA beads in vitro. Thereafter, the fraction of adsorbed granulocytes as well as the generation of complement activation fragments (C3a and C5a) and interleukin 1 receptor antagonist (IL-1ra) were measured. Granulocyte adsorption, complement activation, and IL-1ra release were significantly inhibited in the presence of NM. Adsorption was significantly increased onto CA beads pretreated with plasma containing heparin even in the presence of NM and adding C3a or C5a enhanced IL-1ra release. These results suggested that bound complement fragment (e.g., C3b) on CA beads plays a central role in granulocyte adsorption to CA beads and that C3a and C5a augment the release of anti-inflammatory substances. We therefore conclude that complement activation is involved in these biological responses of leukocyte apheresis.

Sleep and medical disorders

Extensive evidence links cardiovascular disease and sleep disordered breathing. OSA has adverse effects on blood pressure, cardiovascular status,and mortality. Effective CPAP therapy can improve blood pressure and cardiac function in patients who have OSA. Patients who have congestive heart failure have a high prevalence of sleep-disordered breathing, with OSA occurring in 30% of such patients and Cheyne-Stokes respiration in 40%.CPAP is the preferred mode of therapy for both types of sleep-disordered breathing in patients who have coexistent congestive heart failure. Nocturnal worsening of asthma is a common manifestation of this disease that indicates increased disease severity. Therapy focuses on judicious use of long-acting bronchodilators, and the presence of OSA should also be considered. COPD is frequently associated with impaired sleep, likely because of chronic dyspnea and sleep-associated hypoxemia. Appropriate therapy again includes long-acting bronchodilators and possibly nocturnal supplemental oxygen. Gastroesophageal reflux during sleep may lead to prolonged episodes of esophageal acid exposure and may be a common sequela of OSA, perhaps triggering nocturnal worsening of asthma. Endstage renal disease and chronic dialysis are commonly associated with a host of troublesome sleep problems,including OSA, RLS, PLMD, and daytime sleepiness.

Polysomnographic measures of nocturnal sleep in patients on chronic, intermittent daytime haemodialysis vs those with chronic kidney disease

BACKGROUND

Numerous factors probably contribute to the high prevalence of sleep problems in haemodialysis (HD) patients including metabolic changes and treatment-related factors. In contrast, the sleep problems of patients with chronic kidney disease (CKD) may be more related to psychological factors rather than the metabolic changes associated with renal disease. Thus, the objective of this study was to compare polysomnographic measures of nocturnal sleep in a group of stable patients on chronic, intermittent daytime HD and an age- and gender-matched, metabolically comparable group with CKD, and evaluate the role that quality of life (including psychological factors) and the effects of treatment may play in sleep outcomes.

METHODS

The sample included 16 patients on HD and eight patients with CKD all of whom were free from other significant physical and psychological morbidity. To assess for psychological, functional, family and economic responses to the disease and treatment, all subjects took the Ferrans and Powers Quality of Life Index. HD subjects received treatment three times a week and were adequately dialysed [Kt/V >1.2, equivalent to a weekly glomerular filtration rate (GFR) of 10-15 ml/min]; CKD subjects had an estimated GFR of 14.5 (+/-7.2; range 5.4-28.8) ml/min. All subjects underwent one night of laboratory-based polysomnography. Appropriate statistical procedures were used to explore group differences in sleep variables and their relationship to quality of life dimensions and the effect of treatment.

RESULTS

The CKD patients reported significantly poorer functional and psychological quality of life; both groups had reduced total sleep time and sleep efficiency in comparison with normative data. However, HD subjects had less rapid eye movement sleep (P = 0.032). They also had a higher brief arousal index (P = 0.000), an independent predictor of which was treatment with HD, and respiratory disturbance index (P = 0.061). Less total sleep time, increased wake after sleep onset, lower sleep efficiency, higher periodic limb movement index, and longer latencies to sleep onset and rapid eye movement sleep were also noted in the HD group. Quality of life scores did not predict sleep variables in this small sample.

CONCLUSIONS

The results suggest that the sleep problems of patients with CKD and those receiving chronic, intermittent daytime HD may have different aetiologies; functional and psychological factors may play a more prominent role in the former group, while intrinsic sleep disruption (arousals, apnoeas and limb movements) secondary to the effects of chronic, intermittent daytime HD may play a more significant role in the latter. The findings suggest that further exploration is warranted and that population-specific sleep-promoting interventions may be indicated.

Lack of efficacy of tacrolimus ointment 0.1% for treatment of hemodialysis-related pruritus: A randomized, double-blind, vehicle-controlled study

Pruritus is a common and disabling symptom for patients undergoing hemodialysis. Many topical and systemic treatments have been used for uremic pruritus, mostly in anecdotal reports. A recent case series demonstrated that topical tacrolimus ointment 0.03% had a significant antipruritic effect for patients with uremia. In an attempt to confirm these findings, we conducted a randomized, double-blind, vehicle-controlled study to assess the efficacy of tacrolimus ointment 0.1% for the treatment of hemodialysis-related pruritus. The results of this study do not demonstrate that tacrolimus ointment 0.1% is more effective than vehicle in relieving uremic pruritus.

DAILY HEMODIALYSIS-SELECTED TOPICS: Sleep Apnea and Daytime Sleepiness in End-Stage Renal Disease

Sleep disorders are common in patients with end-stage renal disease (ESRD). The prevalence of sleep apnea is 10 times greater in patients with ESRD than in the general population. Although sleep apnea is not improved by conventional modes of dialysis, it is corrected by nocturnal hemodialysis, which provides a new and unique model to study its pathophysiology in this patient population. In addition to causing sleep disruption and impairment of daytime function, sleep apnea may also increase the cardiovascular morbidity and mortality that is commonly found in patients with ESRD. "Pathological" daytime sleepiness is found in 50% of patients with ESRD. Although its pathogenesis has been related both to sleep apnea and periodic limb movements, it has also been attributed to a variety of metabolic factors, including the severity of uremia. Further research is required to evaluate the impact of sleep disorders on the clinical outcome of patients with ESRD.

Sleep disturbances in dialysis patients

Sleep disturbances are extremely common in dialysis patients. Subjective sleep complaints are reported in up to 80% of those surveyed and sleep apnoea syndrome, restless legs syndrome, and periodic limb movement disorder are much more prevalent than in the general population. Excessive daytime sleepiness is also an important problem. These sleep abnormalities appear to have significant negative effects on quality of life and functional health status. Although long-term studies regarding other effects on health outcomes remain to be conducted, available data also suggest that sleep disturbances may have an important impact on morbidity and mortality. Achieving a more complete understanding of the sleep problems experienced by this group is absolutely imperative if improving health outcomes is the goal. Clinicians and researchers alike face numerous challenges in this regard, especially when considering the complex clinical presentation and treatment needs typical of these patients. Therefore, the purpose of this article is to present an up-to-date review of the literature regarding sleep disturbances in dialysis patients with special emphasis on the numerous factors potentially contributing to these problems and associated clinical and research implications.

Uremic pruritus: a clinical study of maintenance hemodialysis patients

Uremic pruritus is one of the most bothersome symptoms in patients with chronic renal failure. Its pathogenesis remains unclear. The aim of this study was to evaluate the frequency of uremic pruritus in hemodialysis patients and to correlate its presence and intensity with several clinical parameters. One hundred thirty patients on maintenance hemodialysis were included into the study. The intensity of pruritus was assessed by two methods: visual analog scale and specially adapted questionnaire scoring method. A significantly positive correlation (p < 0.00001) was demonstrated between the two methods for evaluating pruritus. Uremic pruritus was found in 40.8% of patients. An additional 36.1% of patients reported pruritus to have been present in the past during the renal disease period. Itching was generalized in 19% of patients; the remaining subjects suffered from scattered pruritus (50%) or pruritus in a single location (31%). A significant positive relationship (p < 0.02) was demonstrated between the total score of pruritus and duration of the hemodialysis period. Severity of pruritus and sleep disturbance caused by itching also significantly correlated (p < 0.05) with the duration of hemodialysis. Patients hemodialysed on polysulphone membranes more commonly suffered from pruritus than those on hemophane (p < 0.04) or cuprophane (p < 0.03) dialysis membranes. A marked relationship was demonstrated between the intensity of xerosis and prevalence of pruritus. Significantly more patients with very rough skin had pruritus compared to those with rough skin (p < 0.05) and those with slightly dry skin (p < 0.02). Itching was more common in female patients (p < 0.04), but patient age, underlying renal disease and erythropoietin intake did not correlate with the incidence or intensity of pruritus.

Low-dose theophylline does not exert its anti-inflammatory effects in mild asthma through upregulation of interleukin-10 in alveolar macrophages

BACKGROUND

There is accumulating evidence that theophylline has anti-inflammatory or immunomodulatory effects. This may be, in part, mediated via an upregulation in the production of the anti-inflammatory cytokine interleukin (IL)-10. We determined whether low-dose theophylline (LDT) would increase the production of IL-10, and attenuate the production of proinflammatory cytokines by alveolar macrophages.

METHODS

In a double-blind, placebo-controlled, crossover study involving 15 steroid-free patients with mild asthma, fiberoptic bronchoscopy and bronchoalveolar lavage (BAL) were performed at the end of the treatment and placebo periods. Alveolar macrophages were cultured in vitro, and we measured their release of IL-10, GM-CSF, and TNF-alpha. We also measured IL-10 production in whole blood together with the number of monocytes and T cells expressing intracellular IL-10 by flow cytometry.

RESULTS

LDT did not increase the production of IL-10, or attenuate the production of GM-CSF or TNF-alpha by alveolar macrophages. However, after theophylline treatment, there was a significant reduction in mean (SD) (95% CI) BAL eosinophil number from 3.4 (1.7)% (95% CI 2.4-4.4) to 1.7 (1.0)% (95% CI 1.1-2.3) compared with placebo (P<0.05). Similarly, there was no increase in whole-blood IL-10 release or in the number of monocytes and T cells expressing intracellular IL-10 after treatment.

CONCLUSIONS

LDT has an anti-inflammatory effect in asthma; however, this effect is not mediated via the production of IL-10 or the attenuation of GM-CSF or TNF-alpha. The mechanisms of theophylline activity remain to be determined.