Stimulation of mononuclear cells by contact with cuprophan membranes: further increase of beta 2-microglobulin synthesis by activated late complement components

Rediscovering Beta-2 Microglobulin As a Biomarker across the Spectrum of Kidney Diseases

There is currently an unmet need for better biomarkers across the spectrum of renal diseases. In this paper, we revisit the role of beta-2 microglobulin (β₂M) as a biomarker in patients with chronic kidney disease and end-stage renal disease. Prior to reviewing the numerous clinical studies in the area, we describe the basic biology of β₂M, focusing in particular on its role in maintaining the serum albumin levels and reclaiming the albumin in tubular fluid through the actions of the neonatal Fc receptor. Disorders of abnormal β₂M function arise as a result of altered binding of β₂M to its protein cofactors and the clinical manifestations are exemplified by rare human genetic conditions and mice knockouts. We highlight the utility of β₂M as a predictor of renal function and clinical outcomes in recent large database studies against predictions made by recently developed whole body population kinetic models. Furthermore, we discuss recent animal data suggesting that contrary to textbook dogma urinary β₂M may be a marker for glomerular rather than tubular pathology. We review the existing literature about β₂M as a biomarker in patients receiving renal replacement therapy, with particular emphasis on large outcome trials. We note emerging proteomic data suggesting that β₂M is a promising marker of chronic allograft nephropathy. Finally, we present data about the role of β₂M as a biomarker in a number of non-renal diseases. The goal of this comprehensive review is to direct attention to the multifaceted role of β₂M as a biomarker, and its exciting biology in order to propose the next steps required to bring this recently rediscovered biomarker into the twenty-first century.

Revisiting the Middle Molecule Hypothesis of Uremic Toxicity: A Systematic Review of Beta 2 Microglobulin Population Kinetics and Large Scale Modeling of Hemodialysis Trials In Silico

Background

Beta-2 Microglobulin (β2M) is a prototypical “middle molecule” uremic toxin that has been associated with a higher risk of death in hemodialysis patients. A quantitative description of the relative importance of factors determining β2M concentrations among patients with impaired kidney function is currently lacking.

Methods

Herein we undertook a systematic review of existing studies reporting patient level data concerning generation, elimination and distribution of β₂M in order to develop a population model of β₂M kinetics. We used this model and previously determined relationships between predialysis β₂M concentration and survival, to simulate the population distribution of predialysis β₂M and the associated relative risk (RR) of death in patients receiving conventional thrice-weekly hemodialysis with low flux (LF) and high flux (HF) dialyzers, short (SD) and long daily (LD) HF hemodialysis sessions and on-line hemodiafiltration at different levels of residual renal function (RRF).

Results

We identified 9 studies of 106 individuals and 156 evaluations of or more compartmental kinetic parameters of β₂M. These studies used a variety of experimental methods to determine β₂M kinetics ranging from isotopic dilution to profiling of intra/inter dialytic concentration changes. Most of the patients (74/106) were on dialysis with minimal RRF, thus facilitating the estimation of non-renal elimination kinetics of β₂M. In large scale (N = 10000) simulations of individuals drawn from the population of β₂M kinetic parameters, we found that, higher dialytic removal materially affects β₂M exposures only when RRF (renal clearance of β₂M) was below 2 ml/min. In patients initiating conventional HF hemodialysis, total loss of RRF was predicted to be associated with a RR of death of more than 20%. Hemodiafiltration and daily dialysis may decrease the high risk of death of anuric patients by 10% relative to conventional, thrice weekly HF dialysis. Only daily long sessions of hemodialysis consistently reduced mortality risk between 7–19% across the range of β₂M generation rate.

Conclusions

Preservation of RRF should be considered one of the therapeutic goals of hemodialysis practice. Randomized controlled trials of novel dialysis modalities may require large sample sizes to detect an effect on clinical outcomes even if they enroll anuric patients. The developed population model for β₂M may allow personalization of hemodialysis prescription and/or facilitate the design of such studies by identifying patients with higher β₂M generation rate.

Review Article: is it time to embrace haemodiafiltration for centre-based haemodialysis?

Improvements in survival in dialysis patients over the past few decades have been disappointing. Recent prospective trials such the haemodialysis study have not shown conclusive improvements. Two recent observational studies have found a striking survival advantage for haemodiafiltration (HDF). This review covers the differences between HDF and conventional haemodialysis (HD) and the history of the technological advances in the HDF technique. In addition, it explores the putative benefits of HDF over HD. While the observational studies provide a basis for optimism that HDF will provide benefit to dialysis patients, definitive conclusions cannot be drawn until the results of randomized controlled trials are available. While the evidence in favour of HDF at this stage is observational only, there are no studies suggesting that the treatment is detrimental. The use of HDF should probably be increased, particularly in centres where an increase in the frequency and duration of dialysis cannot be readily achieved.

Dialysis-related amyloidosis: late finding or hidden epidemic?

Dialysis-related amyloidosis is a complication of end-stage renal disease (ESRD) that results from retention of beta2-microglobulin (beta2M) and its deposition as amyloid fibrils into osteoarticular tissue. The clinical manifestations usually develop after several years of dialysis dependence and include carpal tunnel syndrome, destructive arthropathy, and bone cysts and fractures. High-flux membranes, daily dialysis, and hemofiltration all would be expected to delay the onset of dialysis-related amyloidosis because, to varying degrees, each increases the clearance of beta2M from the plasma. Thus what is currently a late complication of ESRD might become an even later complication as dialysis practices change. The significance of histologically evident but clinically silent beta2M amyloid, detectable not only in osteoarticular tissue but also in blood vessels, is unclear. Accumulating evidence that amyloidogenic proteins have direct and specific effects on cell processes irrespective of the extent of amyloid deposition raises the possibility that early, clinically silent beta2M amyloid deposits have unrecognized importance.

Unfolding, Aggregation, and Seeded Amyloid Formation of Lysine-58-Cleaved β2-Microglobulin†

Beta(2)-microglobulin (beta(2)m) is the amyloidogenic protein in dialysis-related amyloidosis, but the mechanisms underlying beta(2)m fibrillogenesis in vivo are largely unknown. We study a structural variant of beta(2)m that has been linked to cancer and inflammation and may be present in the circulation of dialysis patients. This beta(2)m variant, DeltaK58-beta(2)m, is a disulfide-linked two-chain molecule consisting of amino acid residues 1-57 and 59-99 of intact beta(2)m, and we here demonstrate and characterize its decreased conformational stability as compared to wild-type (wt) beta(2)m. Using amide hydrogen/deuterium exchange monitored by mass spectrometry, we show that DeltaK58-beta(2)m has increased unfolding rates compared to wt-beta(2)m and that unfolding is highly temperature dependent. The unfolding rate is 1 order of magnitude faster in DeltaK58-beta(2)m than in wt-beta(2)m, and at 37 degrees C the half-time for unfolding is more than 170-fold faster than at 15 degrees C. Conformational changes are also reflected by a very prominent Congo red binding of DeltaK58-beta(2)m at 37 degrees C, by the evolution of thioflavin T fluorescence, and by changes in intrinsic fluorescence. After a few days at 37 degrees C, in contrast to wt-beta(2)m, DeltaK58-beta(2)m forms well-defined high molecular weight aggregates that are detected by size-exclusion chromatography. Atomic force microscopy after seeding with amyloid-beta(2)m fibrils under conditions that induce minimal fibrillation in wt-beta(2)m shows extensive amyloid fibrillation in DeltaK58-beta(2)m samples. The results highlight the instability and amyloidogenicity under near physiological conditions of a slightly modified beta(2)m variant generated by limited proteolysis and illustrate stages of amyloid formation from early conformational variants to overt fibrillation.

Ex vivo biocompatibility of a new beta2-microglobulin hemoperfusion polymer

Beta2-microglobulin (beta2-m) is an 11.8 kD protein that is excreted by the kidneys. In renal insufficiency, it accumulates in the body and can result in AB amyloidosis with bone and joint destruction. Four modifications of a new beta2-m adsorbent material were tested for biocompatibility with human whole blood. 500 ml of heparinized blood from healthy human donors was perfused ex vivo through minicolumns (adsorber beads: divinylbenzene with different biocompatible coatings) in the single-pass mode. Blood samples were taken from the antecubital vein before and at the column outlet during the 50 min test runs. Red and white cell counts remained virtually constant. No signs of hemolysis could be detected. Thrombogenicity of the columns was low as shown by the insignificant platelet loss, only slight platelet activation and moderate thrombin-antithrombin formation. There was no activation of leukocytes nor monocytes. Complement and bradykinin activation was minimal. Electrolyte concentrations and pH remained essentially constant. In conclusion, this new beta2-m adsorbent material exhibited favorable biocompatibility features in our ex vivo model and is thus a promising candidate for future clinical beta2-m hemoperfusion studies in patients.

Lipopolysaccharide concentrations during superflux dialysis using unfiltered bicarbonate dialysate

In the present report, the design of a new dialysate delivery system to produce low to moderately contaminated dialysate is described. In addition, the first data on bacterial counts and lipopolysaccharide (LPS) concentrations in both the dialysate and the blood during hemodialysis (HD) with superflux dialyzers are presented. In this prospective study, 37 patients were randomized into two consecutive periods of 12 weeks to HD with a high flux polysulfon (PS), a superflux PS, a superflux cellulosic tri-acetate (CTA) or a superflux CTA dialyzer with filtered dialysate (CTAf), resulting in 74 periods in which measurements were obtained. Filtered dialysate showed significantly lower bacterial counts, if compared with nonfiltered dialysate (p < 0.001). As for LPS, marked differences were not observed between filtered and nonfiltered dialysate, whereas mean plasma LPS concentrations were below the value of the dialysate at all time points (p < 0.001). Plasma LPS concentrations decreased significantly during HD with all four modalities (F 60: t0 0.032+/-0.005, t180 0.026+/-0.009 endotoxin units (EU)/ml, p = 0.001; F 500S, t0 0.031+/-0.004, t180 0.027+/-0.005 EU/ml, p = 0.001; Tricea 150G: t0 0.032+/-0.004, t180 0.025+/-0.005 EU/ml, p < 0.001; and Tricea 150Gf: t0 0.034+/-0.007, t180 0.025+/-0.006 EU/ml, p < 0.001). During HD with highly permeable dialyzers and moderately contaminated dialysate, plasma LPS concentrations decreased significantly, irrespective of the material used (PS or CTA), the flux characteristics of the devices (high flux or superflux), or the presence of a bacterial filter.

Effect of hemodialysis membranes on beta 2-microglobulin amyloidosis

Early after the identification of beta(2)-microglobulin amyloidosis (A beta(2)M) as the cause of carpal tunnel syndrome, it was thought that hemodialysis was a major cause in the development of the disease. It was subsequently shown that hemodialysis was not necessary for the development of dialysis-related amyloidosis; however, it was believed that the different dialysis membranes did modulate the progression of the disease. Current data demonstrate that hemodialysis fails to prevent or reverse the disease, but there is substantial evidence that high-flux, high-efficiency dialyzers slow its progression. Many factors related to hemodialysis have been evaluated in relation to A beta(2)M, including the effect of the bioincompatibility of the membrane, the capacity of the different membranes to remove beta(2)M, and the effect of reuse on beta(2)M levels. Moreover, there have been intensive efforts to evaluate, explore, and improve the different mechanisms in beta(2)M removal, with adsorption as a promising prospect. With the available evidence, it seems that the removal of beta(2)M by the membrane plays the most important role in modulating the disease outcome and rate of progression, although a large, long-term, multicentered and randomized study is still lacking to prove this relationship. However, it is possible that with the continuing advances in optimizing the beta(2)M removal efficiency of the different membranes, the frequency and severity of the disease can be substantially decreased.

Expression of beta2-microglobulin and c-fos mRNA: is there an influence of high- or low-flux dialyzer membranes?

BACKGROUND

Dialysis-related amyloidosis is an important complication of long-term hemodialysis (HD) therapy with several pathogenetic factors. One of them is the influence of the dialyzer membrane type on the synthesis of beta2-microglobulin (beta2m). In vitro results are controversial. Thus, the hypothesis of whether in vivo beta2m generation is induced by the HD procedure and whether this induction depends on the type of the used dialyzer membrane should be tested. The aim of the present study was to investigate the influence of "biocompatible" high-flux versus "bioincompatible" low-flux HD on in vivo beta2m generation as well as the induction of the early activation gene c-fos in peripheral blood cells.

METHODS

Six nondiabetic HD patients [mean age 46 (21 to 69) years; Kt/V> 1.2] were included in a randomized crossover study using either a low-flux (cellulosic/cuprophan) or a high-flux (polyamide) dialyzer membrane. At the end of a four-week run-in period for each membrane, whole blood samples were taken before, immediately at, and four hours after the end of the dialysis session. MRNA was extracted, and after transcription to cDNA, quantitative polymerase chain reaction was performed for the beta2m gene, the early response gene c-fos, and the GAP-DH housekeeping gene.

RESULTS

Based on the applied method for detection of specific mRNA, the results were given as ratio of beta2m or c-fos cDNA per GAP-DH cDNA. General cell activation during HD was indicated by increasing mRNA expression of c-fos related to the time course of the dialysis session, whereas beta2m did not change significantly. However, no difference was found when comparing the low-flux and the high-flux dialyzer membranes. Despite the evidence for activation of peripheral blood cells, as indicated by increasing c-fos message, no sign of beta2m mRNA induction during HD procedure with different dialyzer membranes was seen.

CONCLUSIONS

Our results suggest that there is post-transcriptional regulation of beta2m generation and/or release as well as the influence of the dialyzer membrane type on post-translational processes, that is, advance glycation end products (AGE) or conformational modification of the beta2m protein. Furthermore, our data demonstrate that gene expression patterns during dialysis and/or uremia are not homogenous and need to be investigated further, especially with respect to the proinflammatory role of early leukocyte activation signals.

Activation of the cyclic AMP pathway in cells adhering to biomaterials: regulation by vitronectin- and fibronectin-integrin binding

Our previous studies have shown that cells adhering to biomaterials in serum-free conditions increase their content of cyclic AMP (cAMP) and become aggregated. In cells on an acrylonitrile membrane (AN69), these biochemical and morphological changes are prevented by adding 10% foetal calf serum (FCS) to the medium; cells on the cellulose membrane Cuprophan (CU) remain unaffected. The present study examines the roles of vitronectin (VN)- and/or fibronectin (FN)-integrin binding in this inhibition. Competitively blocking VN- and FN-receptors with echistatin increased intracellular cAMP significantly and caused cells on AN69 to aggregate, but did not modify cAMP-dependent cell aggregation on CU. VN or FN adsorbed onto CU also inhibited cAMP production by attached cells and prevented their aggregation, whereas adsorbed BSA had no effect. Therefore, the binding of VN or FN to cell-surface integrins seems to limit the activation of the cAMP pathway initiated by the substratum itself.

beta(2)-microglobulin kinetics in nocturnal haemodialysis

BACKGROUND

beta(2)-Microglobulin (beta(2)m) is a major component of dialysis-related amyloidosis. The available therapeutic options do not permit normalization of the serum beta(2)m level. In a cross-over trial, we studied the kinetics of beta(2)m during two different dialytic techniques.

METHODS

Ten stable, anuric end-stage renal disease patients were studied during two consecutive weeks of three conventional (CHD) and six nocturnal haemodialysis (NHD) sessions. CHD was performed for 4 h three times weekly using a polysulfone dialyser (F80, surface area of 1.8 m(2)) with a mean blood and dialysate flow rate of 401+/-91.6 and 514+/-10.9 ml/min, respectively. The NHD was done with a smaller dialyser (F40, surface area of 0.7 m(2)) and lower blood (281+/-17 ml/min) and dialysate flow rates (99+/-1.2 ml/min) for 8 h, six nights a week.

RESULTS

Weekly removal of urea (51.6+/-24.6 vs 43.1+/-20.5 g) and creatinine (8501+/-5204 vs 6319+/-4134 mg) were comparable with the two modalities of dialysis but the mass of beta(2)m removed was significantly higher with NHD (127+/-48 vs 585+/-309 mg, P<0.001), with a percentage reduction in serum level of 20.5+/-5.8 vs 38.8+/-7. 1% (P<0.0001) and a Kt/V(beta2m) of 0.21+/-0.09 vs 0.56+/-0.17 (P<0. 0006). The mean post-dialysis beta(2)m (20.8+/-6.3 vs 14.0+/-3.8 mg/dl, P=0.02), Tac(beta2m) (26.2+/-5.2 vs 19.8+/-3.8 mg/dl, P=0.02) and pre-dialysis beta(2)m (beta(2)m(pre)) at the end of 1 week of therapy (24.4+/-7.6 vs 19.0+/-3.4 mg/dl, P=0.02) were lower with NHD. Long-term follow-up data were available in 13 and seven patients at the end of 1 and 2 years, respectively. Serum beta(2)m(pre) levels progressively declined from 27.2+/-11.7 mg/dl at initiation of NHD to 13.7+/-4.4 mg/dl by 9 months, and they remained stable thereafter.

CONCLUSIONS

NHD provides a much higher clearance of beta(2)m than CHD, leading to a long-term decrease in the pre-dialysis concentration of beta(2)m.

Extraskeletal problems and amyloid

The major clinical manifestations of dialysis-associated A beta 2M amyloidosis are chronic arthralgias, destructive arthropathy and the carpal tunnel syndrome. For dialysis patients who have been maintained on renal replacement therapy for more than 10-15 years, this complication may become a major physical handicap. It may even be life-threatening in some instances due to cervical cord compression. Amyloid deposits in joint areas precede clinical symptoms and signs by several years. Systemic deposits may also occur but their clinical manifestations are infrequent. The diagnosis of dialysis arthropathy associated with beta 2-microglobulin-associated (A beta 2M) amyloidosis mostly relies on indirect clinical and radiological evidence. Histologic proof is rarely obtained in vivo. The pathogenesis of the disease is complex. It includes reduced elimination of beta 2M and potentially also as impaired degradation of A beta 2M as well as enhanced production of A beta 2M amyloid fibrils. Non enzymatic modifications of beta 2M probably play a role, including beta 2M protein modification with advanced glycation end-products (AGE) and advanced oxidation protein products. Modified beta 2M, collagen and proteoglycans appear actively involved in the induction of a local inflammatory response and beta 2M amyloid formation. There is also evidence in favor of treatment-related factors such as the type of hemodialysis membrane and the purity of dialysis water. Hopefully, the translation of our improving knowledge of all the factors involved will lead to a better treatment and eventually to the prevention of this dramatic complication of dialysis.

Cyclic AMP in cells adhering to bioincompatible (Cuprophan) and biocompatible (AN69) substrates

The processing of signals produced when cells contact biomaterials was examined. Of the several possible pathways, this study focuses on the amount of cAMP that accumulated in NIH 3T3 cells during the first 45 min after the cells contacted the bioincompatible membrane Cuprophan (CU) and the biocompatible membrane AN69. The cells that adhered to CU contained more cAMP than those that attached to AN69. This might be because the cells did not spread but remained rounded up under scanning electron microscopy. There was no increase in cAMP in the cells that did not adhere to CU. The cAMP-modulating agents, forskolin and isoproterenol, were used to assess the cAMP-generating capacity of adenylylcyclase in cells adhering to CU and AN69. This capacity was not affected by a high concentration (100 microM) of forskolin. Isoproterenol had no effect on the cAMP content of the cells, demonstrating that beta adrenergic receptors are not implicated in the activation of cAMP production by membranes. The bioincompatibility of CU seems to be responsible for the greater amount of cAMP in adherent cells, and this parameter could provide an index for assessing biocompatibility.

L-fucose residues on cellulose-based dialysis membranes: quantification of membrane-associated L-fucose and analysis of specific lectin binding

Contact of mononuclear human leukocytes with cellulose dialysis membranes may result in complement-independent cell activation, i.e. enhanced synthesis of cytokines, prostaglandins and an increase in beta 2-micro-globulin synthesis. Cellular contact activation is specifically inhibited by the monosaccharide L-fucose suggesting that dialysis membrane associated L-fucose residues are involved in leukocyte activation. In this study we have detected and quantitated L-fucose on commercially-available cellulose dialysis membranes using two approaches. A sensitive enzymatic fluorescence assay detected L-fucose after acid hydrolysis of flat sheet membranes. Values ranged from 79.3 +/- 3.6 to 90.2 +/- 5.0 pmol cm-2 for Hemophan or Cuprophan respectively. Enzymatic cleavage of terminal alpha-L-fucopyranoses with alpha-L-fucosidase yielded 7.7 +/- 3.3 pmol L-fucose per cm2 for Cuprophan. Enzymatic hydrolysis of the synthetic polymer membranes AN-69 and PC-PE did not yield detectable amounts of L-fucose. In a second approach, binding of the fucose specific lectins of Lotus tetragonolobus and Ulex europaeus (UEAI) demonstrated the presence of biologically accessible L-fucose on the surface of cellulose membranes. Specific binding was observed with Cuprophan, and up to 2.6 +/- 0.3 pmol L-fucose per cm2 was calculated to be present from Langmuir-type adsorption isotherms. The data presented are in line with the hypothesis that surface-associated L-fucose residues on cellulose dialysis membranes participate in leukocyte contact activation.