Chronic and intradialytic effects of high-flux hemodialysis on tumor necrosis factor-alpha production: relationship to endotoxins

Permeability and Adsorption Capacity of Dialysis Membranes to Lipid A

Hemodialysis membranes were tested in vitro for possible penetration by low molecular weight endotoxins containing lipid A. Using lipid A from Escherichia coli as a model substance for this kind of pyrogen, different dialyzers (F4, E3, Acepal 1300, Altraflux, F 40, Polyflux 110, Filtral 12, F 60) were challenged by tangential filtration in aqueous medium. All membranes exhibited impermability to lipid A (as well as to LPS from Pseudomonas aeruginosa), which was proved by additional experiments using culture filtrates of Pseudomonas aeruginosa in bicarbonate dialysis fluid, as well as by employing miniaturized dialyzers with synthetic lipid A as a contaminant. Furthermore, the highest adsorption capacities were found for polysulfone and polyamide membranes.

High-flux dialyzers, backfiltration, and dialysis fluid quality

Currently, high-flux hemodialysis is the most common mode of dialysis therapy worldwide. Its steadily increasing use is largely based on the desire to reduce the excessively high morbidity and mortality of end-stage renal disease patients maintained on conventional dialysis (low-flux, mostly cellulosic membranes) by offering better biocompatibility and enhanced removal of uremic toxins. Two large randomized trials suggest a survival benefit for selected subgroups of high-flux dialysis patients such as diabetics, patients with hypoalbuminemia, or patients who have been on dialysis for a long period (>3.7 years). The major disadvantage of high-flux hemodialysis relates to the use of dialysis fluid, which is commonly not pure and may endanger patients treated with high-flux hemodialysis. Endotoxin fragments and other bacterial substances derived from bacteriologically contaminated dialysis fluid may, even at bacterial counts or endotoxin concentrations within the limits of accepted standards of dialysis fluid purity, enter from the dialysate into the patient's blood either by convective transfer (backfiltration) or by movement down the concentration gradient (backdiffusion). Repeated exposure of high-flux hemodialysis patients to backtransport of dialysate contaminants aggravates the uremia-associated inflammatory response syndrome and contributes to long-term morbidity. At present, the only solution to circumvent the risks of backtransport is the use of dry powder cartridges for bicarbonate concentrate and the use of bacteria- and endotoxin-retentive filters for the online production of ultrapure dialysis fluid. Use of ultrapure dialysis fluid (bacteria <0.1 CFU/ml and endotoxin <0.03 IU/ml) has been found to reduce inflammation and comorbidities in clinical investigations compared to commercial dialysis fluid. The European Renal Association and a number of national societies in Europe or in Japan strongly recommend the use of ultrapure dialysis for high-flux hemodialysis.

Systemic nitric oxide production rate during hemodialysis and its relationship with nitric oxide-related factors

BACKGROUND/AIMS

Nitric oxide (NO) plays a key role in the regulation of vascular tone and controls both local and systemic hemodynamics. Here, we estimated systemic NO production rates of hemodialysis (HD) patients, based on the time course of plasma concentration of nitrate (an oxidative end product of NO) and investigated possible roles of NO-related factors.

METHODS

We measured plasma concentrations of nitrate, L-arginine (a substrate of NO synthase: NOS), asymmetric dimethylarginine (ADMA, an endogenous NOS inhibitor), tetrahydrobiopterin (BH4, a NOS cofactor), dihydrobiopterin (BH2, an oxidized form of BH4) and oxidized low-density lipoprotein (oxyLDL; an index of oxidative stress) before and after 30-min and 4-hour HD (n = 10).

RESULTS

The time-averaged NO production rate during HD was estimated by fitting the time course of plasma nitrate concentration with a single-compartment model (4.00 +/- 0.82 micromol/min, 4.99 +/- 1.08 micromol/kg/h). The L-arginine/ADMA ratio (L-arginine availability) after 30-min HD showed a positive correlation with the NO production rate (p < 0.05).

CONCLUSION

The systemic NO production rate during HD could be estimated by the single-compartment analysis. The L-arginine/ADMA ratio seems to play an important role in the regulation of the NO production during HD.

Development of a contamination free 6 valve injector inline monitoring system for endotoxin measurement in dialysate

Use of dialysate as supplement fluid in hemodiafiltration requires controlling contamination by endotoxin of the dialysate. We thus aimed at developing an endotoxin monitoring system with complete exclusion of endotoxin contamination for simple, easy, and accurate measurement of endotoxin concentration in dialysate. In the present study, we used a 6 valve injector along with a high performance liquid chromatogram system. This new system showed a sensitivity of approximately 1 endotoxin units (EU)/L in the range of 0 to 30 EU/L endotoxin in dialysate and no trace of endotoxin contamination. In conclusion, the new endotoxin monitoring system showed high sensitivity and reproducibility, with easy operation.

Role of lipoprotein (a) and TGF-beta 1 in atherosclerosis of hemodialysis patients

Atherosclerotic vascular disease is a major cause of death for uremic patients who are on hemodialysis (HD). Recent evidence suggests that lipoprotein (a) [Lp(a)] may aggravate atherosclerosis by inhibiting activation of transforming growth factor-beta 1 (TGF-beta 1). Plasma Lp(a) and plasma TGF-beta 1 activation in HD patients (n = 51), chronic renal failure patients not subjected to hemodialysis (non-HD-CRF; n = 12), and healthy volunteers (control; n = 13) were investigated. Plasma Lp(a) was significantly higher in HD (18.75 +/- 1.62 mg/ml) and non-HD-CRF patients (25.0 +/- 8.4 mg/ml) than in control subjects (10.9 +/- 5.8 mg/ml). The degree of atherosclerosis in HD patients was assessed by measuring the intima-media thickness (IMT) and plaque score with the use of an ultrasound scanner. IMT and plaque score were higher in HD and non-HD-CRF patients than in controls. A significant positive correlation was found in HD patients between Lp(a) and IMT (r = 0. 377, P < 0.01) as well as between Lp(a) and plaque score (r = 0.43, P < 0.01). Plasma total TGF-beta 1 significantly increased in HD (119.8 +/- 53.5 ng/ml) and non-HD-CRF patients (93.2 +/- 25.0 ng/ml) compared with control subjects (17.7 +/- 6.4 ng/ml), whereas the plasma level of mature (active) TGF-beta1 did not differ among the groups. When plasma TGF-beta 1 and supernatant TGF-beta 1 from cultured peripheral mononuclear cells were compared before and after an HD session, neither total nor mature TGF-beta 1 showed a significant difference between the values before and after an HD session. There were no significant relationships between plasma total TGF-beta 1 and IMT or plaque score, between mature TGF-beta 1 and IMT or plaque score, or between mature TGF-beta 1 and Lp(a). In conclusion, Lp(a) may be an important atherogenic factor in CRF patients. However, it was not clarified whether Lp(a) exerts its effect by inhibiting TGF-beta 1 activation in CRF patients.

Experimental hypocalcemia induced by hemodialysis in goats

To evaluate whether hemodialysis with a dialysate containing no calcium (Ca-free HD) can induce hypocalcemia and restore the clinical signs and blood biochemical changes in naturally occurred hypocalcemic disorder in ruminants, the clinical signs and the changes in plasma electrolytes and minerals concentrations were observed in goats during 6-hr hemodialysis. The four goats received hemodialysis with the dialysate containing calcium (Ca HD), and 10 days later they had Ca-free HD. The plasma ionized Ca (Ca++) and total Ca (TCa) concentrations were not affected by Ca HD, whereas the levels significantly decreased during whole period of Ca-free HD. The Ca++ and TCa concentrations were 0.69+/-0.06 mmol/l and 5.9+/-0.3 mg/dl at 6 hr of Ca-free HD, respectively. The clinical signs observed during Ca-free HD seemed to resemble to those in naturally occurred hypocalcemic cases that were reported previously. Therefore, Ca-free HD was suggested to be one of the possible methods to induce experimental hypocalcemia in ruminants.

The cleaning and disinfecting of hemodialysis equipment using electrolyzed strong acid aqueous solution

In general, sodium hypochlorite, formalin, and Dialox (Teijin Gambro Medical, Ltd., Tokyo, Japan [main ingredients: H2O2, CH3CHOOOH, CH3COOH, H2O]) are used to clean and disinfect hemodialysis pipelines. In this study, the suitability of electrolyzed strong acid aqueous solution (ESAAS), which has attracted considerable interest in Japan because of its strong disinfecting properties, was examined. The crossover method was used to investigate the effectiveness of ESAAS in disinfecting the dialysis pipelines in comparison to that of sodium hypochlorite (200 ppm) used alternately with 1% acetic acid. The number of bacteria and the concentration of endotoxin (Et) were measured over an approximately 3 year period, starting in September 1994. Until then, 200 ppm sodium hypochlorite had been used alternately with 1% acetic acid, and the contamination of the pipeline had been marked. However, after switching to the ESAAS disinfection method, the dialysis pipelines very rapidly became cleaner. Therefore, the decision to develop an automated ESAAS cleaning system for long-term use was made. During the development period, the original disinfectants (200 ppm sodium hypochlorite used alternately with 1% acetic acid) were used as a stopgap. After confirmation of its performance and safety, the automated ESAAS cleaning system was introduced. To find out whether the decrease in bacteria secondarily caused a decrease in the Et concentration or whether the ESAAS directly inactivated the Et, an in vitro experiment was carried out. Highly concentrated Et, which had been left in the reverse osmosis (RO) drainage pipeline, was used as a sample to investigate the effects of ESAAS on Et at various concentrations and temperatures and on the recovery test. The results showed that ESAAS directly inactivated Et. This paper reports the results of the crossover test. The results of parallel tests carried out over an approximately 4 year period have already been reported. No significant problems occurred in the dialysis. The automated ESAAS cleaning system that was developed proved to be more economical than the conventional disinfecting method.

Monocyte production of transforming growth factor beta in long-term hemodialysis: modulation by hemodialysis membranes

Cytokines are likely involved in hemodialysis-associated complications such as immunodeficiency and beta 2 microglobulin amyloidosis. Because transforming growth factors beta (TGF beta) exert immunosuppressive effects on lymphocytes, down-modulate monocyte functions, and promote fibrosis, we hypothesize that they participate in the deleterious effects of hemodialysis. We investigated the production of TGF beta 1 and TGF beta 2 by monocytes from controls and patients dialyzed with high-flux cellulose triacetate (CT) and polyacrylonitrile (PAN) membranes. The detection of both TGF beta s required an acidification step, suggesting that they are secreted as latent complexes. The spontaneous production of TGF beta 1 and TGF beta 2 was significantly higher in patients dialyzed with CT or PAN than in controls, but the oversecretion of TGF beta 1 was more sustained in CT-treated patients than in PAN-dialyzed patients. The production of interleukin-6 (IL-6) was increased in both patient groups as compared with controls. In contrast to TGF beta 1, the increase was greater in PAN-treated patients than in CT-treated patients, and the release of tumor necrosis factor alpha (TNF alpha) was increased only in PAN-treated patients. Taken together, our results show that hemodialysis is associated with the oversecretion of monocyte cytokines. Moreover, the type of dialysis membrane specifically affects the balance between the secretion of suppressive cytokines such as TGF beta and that of inflammatory cytokines such as IL-6 and TNF alpha.

Effect of hemodialysis on leukocyte adhesion receptor expression

Hemodialysis with complement-activating membranes such as cuprophane is known to transiently activate leukocytes, leading to increased cellular adhesiveness, pulmonary leukostasis, and reduced functional capacity of monocytes and neutrophils. Clinically, this repetitive cell activation may contribute to the increased morbidity and mortality associated with chronic hemodialysis. To examine the effect of cuprophane hemodialysis on expression of cell-surface proteins involved in leukocyte adhesiveness, we monitored CD11b, CD18, CD14, CD54, and plasma-soluble CD54 in 10 patients during hemodialysis with cuprophan dialyzers. To test the effect of local blood recirculation, in two patients, arterial supply to the dialyzer was accessed from the peripheral arteriovenous fistula and was returned via an indwelling central venous catheter. In an attempt to examine the possible role of membrane-induced complement activation, the results were compared with those seen after incubation with C5a in vitro. Finally, the leukocyte responses to C5a and lipopolysaccharide were measured before and after hemodialysis. Leukocyte expression of CD11b and CD18 increased and CD14 decreased with hemodialysis, while CD54 remained unaltered. Plasma CD54 was markedly elevated before and remained unchanged during hemodialysis. Data obtained with C5a activation in vitro revealed identical changes in CD11b expression as that seen with hemodialysis, suggesting the role of membrane-induced complement activation. Preliminary data obtained using remote arterial and venous access sites showed only a slight increase in CD11b expression in the arterial blood, suggesting that the apparent systemic activation seen with arteriovenous access may be due to recirculation and local activation within the blood access. Finally, dialysis procedure did not impair lipopolysaccharide- or C5a-mediated upregulation of CD11b expression.

Monocyte cell-surface CD14 expression and soluble CD14 antigen in hemodialysis: evidence for chronic exposure to LPS

Expression of CD14 on peripheral blood monocytes and serum levels of the 53 kD soluble CD14 antigen were investigated in patients with end-stage renal failure who were undergoing chronic hemodialysis (HD) with either cuprophane/hemophane (CU/HE) low-flux (LF) or polysulfone/polyamide (PS/PA) high-flux (HF) membranes. Baseline expression of CD14 was significantly lower in HD patients compared to uremic patients and normal controls. Patients using PS/PA membranes disclosed a further decreased CD14 expression than patients with CU/HE membranes. Specific fluorescence intensity for CD14 increased 15 minutes after the start of the dialysis session and was on average 22% higher after hemodialysis. The serum levels of sCD14 were elevated about 2.5-fold in HD patients compared to healthy controls (5.4 +/- 1.3 vs. 2.2 +/- 0.5 mg/liter, P < 0.0001) and were significantly higher compared to non-dialyzed patients with chronic renal failure (3.9 +/- 1.0 mg/liter, P < 0.001). After regular dialysis with high-flux membranes, soluble CD14 serum concentrations significantly increased (P < 0.001) compared to pre-dialysis levels. Values of soluble CD8 (54 kD) were elevated only 1.5-fold in HD patients relative to healthy controls, whereas serum levels of the low molecular weight soluble CD23 (20 kD) 12 and 19-fold in patients treated with HF-HD and LF-HD, reflecting the renal impairment and filtration through HF membranes. Thus, high sCD14 values in HD patients may stem from increased release of the up-regulated membrane antigen due to monocyte activation during hemodialysis treatment. Since the CD14 antigen is involved in LPS-induced monocyte activation, the influence of lipopolysaccharide on CD14 expression and sCD14 release was investigated in vitro. Addition of 1 ng/ml or 0.01 ng/ml LPS to whole blood significantly enhanced monocyte CD14 expression after 30 or 60 minutes of incubation. The release of soluble CD14 by cultured peripheral blood monocytes significantly increased in the presence of 0.01 ng/ml LPS during a five-day incubation experiment. Our results demonstrate an enhanced expression of CD14 by monocytes after HD and increased sCD14 serum levels possibly due to chronic exposure to trace amounts of endotoxins, as supported by in vitro experiments.

Reappraisal with meta-analysis of bacteremia, endotoxemia, and mortality in gram-negative sepsis

Among patients with suspected sepsis, endotoxemia is variably present in association with gram-negative bacteremia. A total of 738 patients with suspected sepsis from 11 studies could be classified into four groups: 131 (18%) patients had both endotoxemia and gram-negative bacteremia (group 1), 87 (12%) had only gram-negative bacteremia (group 2), and 143 (19%) had only endotoxemia (group 3); in 377 (51%) patients neither could be detected (group 4). By the statistical techniques of meta-analysis, the fatality risk for patients with either endotoxemia or gram-negative bacteremia or both was estimated with group-specific case fatality rates from these studies and expressed as an odds ratio (OR; 95% confidence interval [95% CI]) versus patients with these factors absent. This risk was increased marginally when endotoxemia was detected without gram-negative bacteremia (OR, 2.3; 95% CI, 1.3 to 4.0) or the converse (OR, 2.0; 95% CI, 1.0 to 3.8), in contrast to the striking increase when both endotoxemia and gram-negative bacteremia were detected (OR, 6.3; 95% CI, 4.0 to 10.0). Alone, neither endotoxemia nor gram-negative bacteremia is a strong predictor of outcome in patients with suspected sepsis. However, in combination, the two identify a subpopulation with a substantially increased risk of mortality.

Endotoxemia: methods of detection and clinical correlates

As an assay for endotoxin, the Limulus amebocyte lysate assay has several desirable properties: sensitivity, specificity, and potential for adaptation to a quantitative format. Several modifications have been developed to enhance its potential for clinical application. The modifications that allow quantitative measurement of endotoxin and also improve its application to blood samples are described in this review. In fluids other than blood, the detection of endotoxin with the Limulus amebocyte lysate assay can be used as an aid to identify the presence of gram-negative bacteria, and the assay has established utility. With blood, however, there are a range of factors that interfere with the detection of endotoxemia and there are disparate views with respect to the diagnostic and prognostic significance of the test results. In general, the clinical significance of the finding of endotoxemia broadly parallels the frequency and importance of gram-negative sepsis in the patient groups studied and a decline in endotoxin levels accompanies clinical improvement. However, with therapies designed to reduce levels of endotoxin, or to antagonize its effects, it is unclear whether clinical improvement occurs as a consequence of changes in the levels of endotoxemia.

Diffusive and convective transfer of cytokine-inducing bacterial products across hemodialysis membranes

The widespread use of bicarbonate dialysate, and high-flux and high-efficiency dialyzers have raised concerns regarding the transmembrane passage of bacterial products from the dialysate into the blood compartment. To study the mechanisms as well as magnitude of the transmembrane transfer of bacterial products from the dialysate, we developed a computerized in vitro dialysis model which provides continuous pressure recording from the arterial, venous, dialysate inflow and outflow ports. By virtue of a computer controlled on-line infusion pump, this model permits control of ultrafiltration/backfiltration. Heparinized (10 U/ml) whole blood (150 ml) was circulated through the blood compartment for 120 minutes at 100 ml/min. Bicarbonate dialysate contaminated with Pseudomonas maltophilia filtrate was circulated through the dialysate compartment at 100 ml/min. A two-point pressure of -10 mm of Hg (ultrafiltration) was maintained for the first 60 minutes and -10 mm of Hg (backfiltration) for the next 60 minutes. Whole blood samples (10 ml) were drawn from the blood at 0, 60 and 120 minutes. Peripheral blood mononuclear cells (PBMC) harvested from these samples were incubated for 24 hours in tissue culture medium. In addition, 0.5 ml samples of dialysate were collected at 0, 60 and 120 minutes and incubated with PBMC from the same donor for 24 hours. After 24 hour incubation, total cell-associated IL-1Ra and IL-1 beta were measured by specific radioimmunoassay. Paired experiments were performed with eight high-flux synthetic membranes (polyamide) and eight low-flux cellulose membranes (hemophan). Cytokine production is expressed as pg/2.5 million PBMC.(ABSTRACT TRUNCATED AT 250 WORDS)