Elevated serum levels of 3-deoxyglucosone, a potent protein-cross-linking intermediate of the Maillard reaction, in uremic patients

Analysis of Serum Advanced Glycation Endproducts Reveals Methylglyoxal-Derived Advanced Glycation MG-H1 Free Adduct Is a Risk Marker in Non-Diabetic and Diabetic Chronic Kidney Disease

Accumulation of advanced glycation endproducts (AGEs) is linked to decline in renal function, particularly in patients with diabetes. Major forms of AGEs in serum are protein-bound AGEs and AGE free adducts. In this study, we assessed levels of AGEs in subjects with and without diabetes, with normal renal function and stages 2 to 4 chronic kidney disease (CKD), to identify which AGE has the greatest progressive change with decline in renal function and change in diabetes. We performed a cross-sectional study of patients with stages 2-4 CKD, with and without diabetes, and healthy controls (n = 135). Nine protein-bound and free adduct AGEs were quantified in serum. Most protein-bound AGEs increased moderately through stages 2-4 CKD whereas AGE free adducts increased markedly. Methylglyoxal-derived hydroimidazolone MG-H1 free adduct was the AGE most responsive to CKD status, increasing 8-fold and 30-fold in stage 4 CKD in patients without and with diabetes, respectively. MG-H1 Glomerular filtration flux was increased 5-fold in diabetes, likely reflecting increased methylglyoxal glycation status. We conclude that serum MG-H1 free adduct concentration was strongly related to stage of CKD and increased in diabetes status. Serum MG-H1 free adduct is a candidate AGE risk marker of non-diabetic and diabetic CKD.

Accumulation of plasma 3-deoxyglucosone impaired glucose regulation in Chinese seniors: implication for senile diabetes?

AIMS

To investigate the impact of increasing accumulation of 3-deoxyglucosone (3-DG) on glucose regulation in non-diabeteic seniors.

METHODS

This research is a 2-year prospective follow-up study. We conducted a HPLC assay to determine the plasma 3-DG concentrations of 132 non-diabetic retirees of Suzhou. An oral glucose tolerance test was carried out 2 years after baseline in 16 subjects with continual high plasma 3-DG and 16 control subjects randomly sampled in those with normal plasma 3-DG.

RESULTS

The median plasma 3-DG level of 132 subjects was 43.52 ng/ml (7.89-736.09 ng/ml), of which 47 subjects (36.6%) were beyond 70 ng/ml. A correlation between age and 3-DG was found among people between 50 and 66 years old (r=0.408, P<0.001). The 60-69 years group had a higher 3-DG level than 50-59 years group (P<0.001). Compared with control group, the continual high plasma 3-DG subjects had a higher level of FINs (P<0.05), FBG (P<0.01), HOMA-IR (P<0.001), and a lower level of ISI (P<0.001) and ΔI(60)/ΔG(60) (P<0.05), as well as a higher incidence of impaired glucose regulation (χ(2)=7.814, P<0.05).

CONCLUSIONS

There was abnormal elevation of plasma 3-DG in non-diabetic seniors, and the increasing accumulation of plasma 3-DG, which mainly resulted from aging, eventually lead to the impaired glucose regulation, indicating an association of 3-DG with senile diabetes.

Rapid and sensitive determination of the intermediates of advanced glycation end products in the human nail by ultra-performance liquid chromatography with electrospray ionization time-of-flight mass spectrometry

The resolution of the intermediate advanced glycation end products (AGEs) in the human nail was carried out by the combination of 4,5-dimethyl-1,2-phenylenediamine (DMPD) derivatives and ultra-performance liquid chromatography with electrospray ionization time-of-flight mass spectrometry (UPLC-ESI-TOF-MS). The reaction of the reagent with 3-deoxyglucosone (3-DG), methylglyoxal (MG), and glyoxal (GO) effectively proceeds at 60°C for 2h. The resulting derivatives were efficiently separated by a gradient program (a mixture of water and acetonitrile containing 0.1% formic acid) using a reversed-phase ACQUITY UPLC BEH C(18) column (1.7 μm, 50×2.1 mm i.d.) and sensitively detected by TOF-MS. The detection limits (signal-to-noise ratio=5) of the TOF-MS were 10 to 50 fmol. A good linearity was achieved from the calibration curve, which was obtained by plotting the peak area ratios of the analytes relative to the internal standard (IS) (i.e., 2,3-hexanedione) versus the injected amounts of 3-DG, MG, and GO (r(2)>0.999), and the intra- and interday assay precisions were less than 6.89%. The derivatives of the compounds in the human nail were successfully identified by the proposed procedure. As we know, these three kinds of dicarbonyl intermediates in the formation of AGEs-3-DG, MG, and GO-were first found in human nail samples. Using these methods, the amounts of compound in the nails of healthy volunteers and diabetic patients were determined. When comparing the index from the diabetic patients with that from healthy volunteers, there is no significant difference in the content of the MG and GO in the nails. However, a statistically significant (P<0.001) correlation was observed between the 3-DG concentrations. Because the proposed method provides a good mass accuracy and the trace detection of the dicarbonyl intermediates of AGEs in the human nail, this analytical technique could be a noninvasive technique to assist in the diagnosis and assessment of disease activity in diabetic patients. Here we present a novel, sensitive, and simple method for the simultaneous determination of dicarbonyl compounds in the human nail.

Adsorption and carbonylation of plasma proteins by dialyser membrane material: in vitro and in vivo proteomics investigations

BACKGROUND

Protein carbonylation is an irreversible and not reparable reaction which is caused by the introduction into proteins of carbonyl derivatives such as ketones and aldehydes, generated from direct oxidation processes or from secondary protein reaction with reactive carbonyl compounds. Several studies have demonstrated significantly increased levels of reactive carbonyl compounds, a general increase in plasma protein carbonyls and carbonyl formation on major plasma proteins in blood from uremic patients, particularly those undergoing chronic haemodialysis.

MATERIALS AND METHODS

In the present preliminary study, we first assessed by an in vitro filtration apparatus the possible effects of different materials used for haemodialysis membranes on protein retention and carbonylation. We employed hollow fiber minidialyzers of identical structural characteristics composed of either polymethylmethacrylate, ethylenevinyl alcohol, or cellulose diacetate materials. Protein Western Blot and SDS-PAGE coupled to mass spectrometry analysis were applied to highlight the carbonylated protein-binding characteristics of the different materials. We also investigated in vivo protein carbonylation and carboxy methyl lisine-modification in plasma obtained before and after a haemodialysis session.

RESULTS

Our data underline a different capability on protein adsorption associated with the different properties of the filter materials, highlighting the central buffering and protective role of serum albumin. In particular, polymethylmethacrylate and cellulose diacetate showed, in vitro, the highest capacity of binding plasma proteins on the surface of the hollow fiber minidialyzers.

CONCLUSIONS

The present study suggests that biomaterials used for fabrication of haemodialysis membrane may affect the carbonyl balance in chronic uremic patients.

Plasma 3-deoxyglucosone elevation in chronic renal failure is associated with increased aldose reductase in erythrocytes

BACKGROUND

Serum concentrations of 3-deoxyglucosone (3DG), a highly reactive dicarbonyl compound, are elevated in uremic patients. Aldose reductase (AR) is an enzyme involved in both the detoxification of 3DG and producing precursors of 3DG.

METHODS

We examined the relationship between plasma 3DG and erythrocyte AR content in uremic patients. Patients were divided into three groups: (1) progressive renal disease without hemodialysis (HD; chronic renal failure [CRF] group), (2) patients without diabetes mellitus (DM) treated with maintenance HD (HD group), and (3) patients with DM treated with maintenance HD (DM-HD group). High-performance liquid chromatography was used to measure 3DG, and erythrocyte AR was measured by means of enzyme-linked immunosorbent assay.

RESULTS

Both 3DG and erythrocyte AR levels were significantly greater in the CRF, HD, and DM-HD groups than in healthy controls. These results did not change after HD sessions in the HD or DM-HD groups. Serum creatinine levels correlated with 3DG and erythrocyte AR levels in the control and CRF groups (3DG: r = 0.67; P < 0.001; erythrocyte AR: r = 0.71; P < 0.001). Both erythrocyte AR and 3DG levels then increased as renal function declined. A positive correlation was seen between 3DG and erythrocyte AR levels in all groups (r = 0.65; P < 0.001), and also between plasma osmolality and erythrocyte AR level (r = 0.46; P < 0.001).

CONCLUSION

Both erythrocyte AR and 3DG levels are increased in uremic patients, and these increases could possibly contribute to the development of uremic symptoms.

Glyoxalase I deficiency is associated with an unusual level of advanced glycation end products in a hemodialysis patient

BACKGROUND

Advanced glycation of proteins and their attendant advanced glycation end products (AGEs) contribute to the complications associated with diabetes mellitus or uremia. Regulatory mechanisms of AGE formation in vivo remain an issue of particular interest. We investigated a role of the glyoxalase detoxification system of precursor reactive carbonyl compounds (RCOs) in the in vivo AGE formation.

METHODS

Plasma levels of AGEs [pentosidine and Nepsilon-carboxymethyllysine (CML)], their RCO precursors, d-lactate (the final product resulting from the glyoxalase detoxification pathway), as well as of various compounds known to generate AGE precursors and surrogate markers for oxidative stress (antioxidant enzymes and glutathione), were measured in both hemodialysis (HD) patients and normal subjects. The activity and protein expression of glyoxalase I, an enzyme essential for the detoxification of alpha-oxoaldehydes, in red blood cells (RBC) were also examined.

RESULTS

In one 69-year-old lady who had been on hemodialysis (HD) for three years and had suffered from recurrent cardiovascular complications despite the absence of significant risk factors, plasma levels of pentosidine (77.3 +/- 2.4 pmol/mg protein) and CML (330.8 +/- 8.2 pmol/mg protein) were markedly elevated as compared to other HD patients (N = 20: 26.6 +/- 11.8 pmol/mg protein for pentosidine and 224.4 +/- 51.7 pmol/mg protein for CML). The plasma level of RCO precursors for pentosidine and CML was also higher in this patient than in other HD patients. Further investigation disclosed a very low activity in RBC of glyoxalase I (1.5 +/- 0.4 mU/106 RBC), as compared to other HD patients (3.9 +/- 0.6 mU/106 RBC) or normal subjects (4.0 +/- 0.6 mU/106 RBC). The glyoxalase I protein level, assessed in RBC by immunoblot analysis with a specific antibody, was markedly lower than that observed in HD patients and normal subjects. The causes of this deficiency remain unknown. Nucleotide sequencing of the products of reverse transcription-polymerase chain reaction from the patient's mononuclear cells revealed no genetic mutation within the coding region of the glyoxalase I gene. Plasma d-lactate level was also in the lower range (0.18 +/- 0.03 mg/dL) of the values measured in the other HD patients (0.27 +/- 0.09 mg/dL) and normal subjects (0.35 +/- 0.12 mg/dL). The plasma levels of various compounds known to generate AGE precursors (glucose, lipids and ascorbic acid) were either normal or low. The surrogate markers for oxidative stress such as antioxidant enzymes (glutathione peroxidases and superoxide dismutase) and glutathione were all within the range observed in the other HD patients.

CONCLUSION

The unusually high levels of AGEs in this patient implicate a deficient glyoxalase detoxification of RCO precursors. The present clinical observation implicates, to our knowledge for the first time, the glyoxalase detoxification system and, in particular, glyoxalase in the actual level of AGEs in a uremic patient.

Continuous flow peritoneal dialysis: solution formulation and biocompatibility

When peritoneal dialysis was introduced several years ago an important alternative dialysis therapy to hemodialysis was made available for the treatment of end-stage chronic disease. However, a continuous search for new developments and technologies is necessary to find the optimal peritoneal dialysis fluid (PDF) to preserve peritoneal membrane function as long as possible. Conventional PDFs are known to compromise the functional integrity of the peritoneal membrane as a consequence of their acidic pH in combination with their high lactate content, as well as the high concentrations of glucose and glucose degradation products (GDPs) present in currently used conventional solutions. Novel solutions such as bicarbonate-buffered PDF (at neutral pH) display improved in vitro biocompatibility as compared to conventional, acidic lactate-buffered PDF. Since these novel solutions are manufactured in dual-chambered bags they also contain fewer GDPs, thus further reducing their potential toxicity and protein glycation. Clinically the novel solutions reduce inflow pain and improve peritoneal membrane transport characteristics, ultrafiltration capacity, and effluent markers of peritoneal membrane integrity. The concept of continuous flow peritoneal dialysis (CFPD) is another approach to optimize PDF. The technique of CFPD not only enables the individualization of acid-base correction by variable concentrations of HCO3- but may also help to restore peritoneal cell functions by neutral pH, reduced glucose load, diminished GDP content, and reduced advanced glycation end product (AGE) formation, thereby potentially contributing to the improved preservation of peritoneal membrane function.

Molecular heterogeneity of amyloid beta2-microglobulin and modification with advanced glycation end products

By using liquid chromatography-electrospray ionization mass spectrometry, Western blotting and N-terminal amino acid sequence analysis, we characterized the molecular heterogeneity and advanced glycation end product (AGE) modification of beta2-microglobulin (beta2m) extracted from the amyloid tissue of a hemodialysis patient. Amyloid beta2m was composed of full-length beta2m, truncated beta2m and dimer beta2m. Truncated beta2m and dimer beta2m were modified with AGEs such as imidazolone and N(e)-(carboxymethyl)lysine, and showed fluorescence characteristic of AGE. Truncated beta2m species were formed by cleavage between amino acid residues of Pro6/Ile7, Gln/Val9 and Val9/Tyr10. Heterogeneous dimer beta2m species showed the molecular masses of 22,591 and 22 675, which resulted from cross-linking between truncated beta2m.

Innovative approaches to the preservation of the peritoneal membrane: from bench to bedside

The functional integrity of the peritoneal membrane is of critical importance for the long-term success of peritoneal dialysis therapy. In addition to water and solute transport properties, the function of the membrane encompasses complex interactions with immune cells, invading microorganisms, and dialysis fluid components. During chronic peritoneal dialysis, intraperitoneal homeostasis is threatened by the repeated exposure to an unphysiologic environment that is created by the instilled solutions. Whereas their acidic pH and hyperosmolality were shown to primarily induce alterations of acute cell function, long-term peritoneal function might be affected by the repeated exposure to high concentrations of glucose and glucose degradation products. In addition to their intrinsic toxicity, these might induce or accelerate glycation processes, such as formation and deposition of advanced glycation end products in the peritoneal membrane. Presently, a new generation of dual-chambered peritoneal dialysis solutions combining the advantages of neutral pH and reduced glucose degradation products content is being introduced into clinical practice. In addition to an improved in vitro biocompatibility profile, emerging clinical trials of these novel solutions indicate that they might also improve the host defense status, membrane transport characteristics, ultrafiltration capacity, and effluent markers of peritoneal membrane integrity, while being safe and effective in correcting uremic acidosis and providing relief of inflow pain. Overall, these findings suggest that these new dialysis solutions might constitute an important step toward better preservation of long-term peritoneal membrane function during peritoneal dialysis.

Dialysis-related amyloidosis: pathogenesis focusing on AGE modification

Dialysis-related amyloidosis (DRA) is a serious complication in long-term dialysis patients, and presents with carpal tunnel syndrome, cystic bone lesions, destructive spondylarthropathy, diffuse arthritis and periarthritis, systemic organ involvement, and dialysis-related spinal canal stenosis (DSCS). Recently a new concept of DSCS has been proposed that includes both destructive spondylarthropathy and myeloradiculopathy induced by extradural thickness. beta(2)-microglobulin (beta(2)M) amyloid was demonstrated to be modified with advanced glycation end products (AGEs) such as imidazolone, N(epsilon)-(carboxymethyl)lysine (CML), and pentosidine. Imidazolone is a reaction product of arginine residue in proteins with 3-deoxyglucosone (3-DG), which is markedly accumulated in uremic serum. Imidazolone is generated under nonoxidative conditions, while CML and pentosidine are formed by oxidative processes. Immunoelectron microscopy demonstrated that AGEs were localized not only in dialysis amyloid but also in nonamyloid collagenous structures, supporting the hypothesis that AGE modification of collagen might have pathogenic relevance in the deposition of beta(2)M on collagen. Serum levels of AGEs are increased in uremic patients. The dimeric form of beta(2)M in the dialysate and urine of uremic patients is more susceptible to imidazolone modification as observed in dialysis amyloid. However, the major component of dialysis amyloid is a native form of beta(2)M, while AGE-modified beta(2)M and truncated beta(2)M are the minor components. Thus I propose that 3-DG and the other dicarbonyl compounds accumulating in uremic serum promote the modification of beta(2)M with AGEs mainly after deposition of beta(2)M as amyloid. For the prevention and treatment of DRA, beta(2)M should be efficiently eliminated from circulating blood by kidney transplantation, hemodialysis, or hemodiafiltration using high-flux membranes and an adsorbent (Lixelle) column.

3-deoxyglucosone and AGEs in uremic complications: inactivation of glutathione peroxidase by 3-deoxyglucosone

3-deoxyglucosone (3-DG) is accumulated not only in uremic serum but also in uremic erythrocytes. 3-DG rapidly reacts with protein amino groups to form advanced glycation end products (AGEs) such as imidazolone, pyrraline, and N(epsilon)-(carboxymethyl)lysine, among which imidazolone is the AGE that is most specific for 3-DG. In diabetes, hyperglycemia enhances the synthesis of 3-DG via the Maillard reaction and the polyol pathway and thereby leads to its high plasma and erythrocyte levels. In uremia, however, the decreased catabolism of 3-DG that may be due to the loss of 3-DG reductase activity in the end-stage kidneys may lead to a high plasma 3-DG level. The elevated 3-DG levels in uremic patients may promote the formation of AGEs such as imidazolone in erythrocytes, aortas, and dialysis-related amyloid deposits. Treatment with an aldose reductase inhibitor reduced the erythrocyte levels of 3-DG and AGEs such as imidazolone in diabetic uremic patients. This finding demonstrates an important role of the polyol pathway in the formation of erythrocyte 3-DG and AGEs. The erythrocyte levels of 3-DG are elevated in not only diabetic uremic but also nondiabetic uremic patients. 3-DG showed some cytotoxicities by inducing intracellular oxidative stress. In contrast, oxidative stress was demonstrated to cause accumulation of intracellular 3-DG. Recently, we have demonstrated that 3-DG inactivates intracellular enzymes such as glutathione peroxidase, a key enzyme in the detoxification of hydrogen peroxide. Thus, intracellular accumulation of 3-DG may enhance oxidative stress by inactivating the antioxidant enzymes. In conclusion, 3-DG may play a principal role in the development of uremic complications, such as dialysis-related amyloidosis, atherosclerosis, and enhanced oxidative stress.

Inflammation and advanced glycation end products in uremia: simple coexistence, potentiation or causal relationship?

The causes for the high frequency of cardiovascular disease in dialysis patients are multifactorial in origin. Disturbances in the carbohydrate and lipid metabolism, the balance between oxidants and antioxidants and the immuno-inflammatory system are thought to play a role. Chronic uremia is characterized by the accumulation of advanced glycation end products (AGEs) and advanced oxidation products (AOPP) as well as activation of the acute phase response. High serum levels of these products and acute phase reactants such as C-reactive protein (CRP), fibrinogen and serum amyloid A can be found. CRP has been shown to predict cardiovascular and overall mortality in hemodialysis patients. Whether CRP is involved causally in atherosclerosis or merely represents a marker of disease is as yet unknown. Since CRP has been detected in colocalization with modified apolipoproteins or complement components in atherosclerotic lesions, a pathophysiological role seems very likely. AGEs as well have been detected in aortas of hemodialysis patients. Incubation of endothelial cells with AGEs induced expression of adhesion molecules with consecutive attraction of monocytes to the vessel wall. Thus far, clinical studies investigating the predictive effects of AGEs on cardiovascular mortality in hemodialysis patients are lacking. There is considerable debate about what factors turn on the acute phase response in this population. Proinflammatory effects of AGEs mediated through one receptor for AGEs, RAGE, have been described. We hypothesize that there may be a link between increased hepatic CRP production and the accumulation of AGEs in uremia. AGEs may stimulate CRP production in hepatocytes either directly or indirectly via interaction with monocytes.

Reactive carbonyl compounds related uremic toxicity ("carbonyl stress")

Many studies on uremic toxins have focused on enzymatic biochemistry. Recently, attention has turned to nonenzymatic biochemistry, especially progressive and irreversible modifications of proteins. Two different approaches opened the field of irreversible nonenzymatic modifications of proteins in uremia: the advanced glycation end products (AGEs) derived from the Maillard reaction and the advanced lipoxidation end products (ALEs) derived from lipid peroxidation. They have revealed the accumulation of reactive carbonyl compounds (RCOs) derived from carbohydrates and lipids and the subsequent carbonyl modifications of proteins ("carbonyl stress"). In this article, we describe the causal role of various RCOs and AGEs/ALEs accumulating in uremia, the clinical consequences of carbonyl stress in uremia, and finally, the therapeutic perspectives. We propose carbonyl stress as a new uremic toxicity.

Relevance of oxidative and carbonyl stress to long-term uremic complications

Oxidative stress is a disturbance of balance between oxidants and antioxidant species. The existence of an increased oxidative stress in chronic renal failure is supported by evidence of increased lipid, carbohydrate, and protein oxidation products in plasma and cell membrane. Recent studies have implicated the oxidative stress in the nonenzymatic biochemistry leading to irreversible protein modifications. Reactive oxygen species may directly alter proteins with the eventual formation of oxidized amino acids. Alternatively, reactive carbonyl compounds formed by the oxidation of carbohydrates and lipids may indirectly lead to advanced glycation or lipoxidation of proteins. Chronic uremia is associated with increased modification of protein caused by reactive carbonyl compounds derived from both carbohydrates and lipids. Increased carbonyl modification of proteins subsequently results in the rise of plasma and tissue contents of advanced glycation end products and advanced lipoxidation end products, in which the deleterious biological effects have been revealed. This article focuses on the irreversible nonenzymatic modification of proteins, which might, at least in part, contribute to the development of complications associated with chronic renal failure and long-term dialysis, such as atherosclerosis and dialysis-related amyloidosis.

Mechanisms for the formation of glycoxidation products in end-stage renal disease

BACKGROUND

Advanced glycation end products (AGEs) accumulate on tissue and plasma proteins in patients with renal failure far in excess of normal aging or diabetes. The aim of these studies was to elucidate the nature of the precursors and the pathways that lead to an accelerated formation of two structurally identified AGEs [pentosidine and Nepsilon(carboxymethyl)lysine (CML)] in the uremic milieu.

METHODS

Serum levels of the glycoxidation products, pentosidine and CML, were quantitated by high-performance liquid chromatography in uremic patients treated by dialysis. The formation of early glycation products (as furosine) and late glycoxidation products was modeled in uremic serum and in spent peritoneal dialysate.

RESULTS

Clinical factors that affect circulating levels of AGEs included dialysis clearance and dialyzer membrane pore size, but not the presence or absence of diabetes. Both pentosidine and CML form at an accelerated rate in serum from uremic patients. Chelating agents most effectively slow the formation in vitro. In uremic fluids, the primary mechanism of formation of pentosidine is through the Amadori pathway. The primary mechanism of formation of CML is through metal-chelated autoxidation of reducing sugars generating reactive carbonyl precursors. In uremic serum, the presence of an unidentified reactive low molecular weight precursor accelerates the formation of pentosidine.

CONCLUSIONS

The formation of the two glycoxidation products, pentosidine and CML, proceeds by different pathways and is enhanced by different precursors in the uremic milieu. The formation of both AGEs is markedly enhanced by metal-catalyzed reactions, evidence for the presence of increased metal-ion mediated oxidant stress in uremia.

Effect of glucose degradation products on human peritoneal mesothelial cell function

Bioincompatibility of conventional glucose-based peritoneal dialysis fluids (PDF) has been partially attributed to the presence of glucose degradation products (GDP) generated during heat sterilization of PDF. Most previous studies on GDP toxicity were performed on animal and/or transformed cell lines, and the impact of GDP on peritoneal cells remains obscure. The short-term effects of six identified GDP on human peritoneal mesothelial cell (HPMC) functions were examined in comparison to murine L929 fibroblasts. Exposure of HPMC to acetaldehyde, formaldehyde, glyoxal, methylglyoxal, furaldehyde, but not to 5-hydroxymethyl-furfural, resulted in dose-dependent inhibition of cell growth, viability, and interleukin-1beta (IL-1beta)-stimulated IL-6 release; for several GDP, this suppression was significantly greater compared with L929 cells. Although the addition of GDP to culture medium at concentrations found in PDF had no major impact on HPMC function, the exposure of HPMC to filter-sterilized PDF led to a significantly smaller suppression of HPMC proliferation compared to that induced by heat-sterilized PDF. The growth inhibition mediated by filter-sterilized PDF could be increased after the addition of clinically relevant doses of GDP. These effects were equally evident in L929 cells. In conclusion, GDP reveal a significant cytotoxic potential toward HPMC that may be underestimated in test systems using L929 cells. GDP-related toxicity appears to be particularly evident in experimental systems using proliferating cells and the milieu of dialysis fluids. Thus, these observations may bear biologic relevance in vivo where HPMC are repeatedly exposed to GDP-containing PDF for extended periods of time.

3-Deoxyglucosone: metabolism, analysis, biological activity, and clinical implication

3-Deoxyglucosone (3-DG) is synthesized via the Maillard reaction and the polyol pathway, and is detoxified to 3-deoxyfructose and 2-keto-3-deoxygluconic acid. 3-DG rapidly reacts with protein amino groups to form advanced glycation end products (AGEs) such as imidazolone, pyrraline, N'-(carboxymethyl)lysine and pentosidine, among which imidazolone is the AGE most specific for 3-DG. As demonstrated by using gas chromatography-mass spectrometry or high-performance liquid chromatography, plasma 3-DG levels are markedly increased in diabetes and uremia. Although the plasma 3-DG levels had been controversial, it was clearly demonstrated that its plasma level depends on the deproteinization method by which either free or total 3-DG, presumably bound to proteins, is measured. In diabetes, hyperglycemia enhances the synthesis of 3-DG via the Maillard reaction and the polyol pathway, and thereby leads to its high plasma and erythrocyte levels. In uremia, however, the decreased catabolism of 3-DG, which may be due to the loss of 3-DG reductase activity in the end-stage kidneys, may lead to high plasma 3-DG level. The elevated 3-DG levels in plasma and erythrocytes may promote the formation of AGEs such as imidazolone, as demonstrated by immunohistochemistry and immunochemistry using an anti-imidazolone antibody. Although AGE-modified proteins prepared in vitro exhibit a variety of biological activities, known AGE structures have not yet been demonstrated to show any biological activities. Because 3-DG is potent in the formation of AGEs and has some biological activities, such as cellular toxicity, it may be more important in the development of diabetic and uremic complications than the known AGE structures. By demonstrating that treatment with an aldose reductase inhibitor reduces the erythrocyte levels of 3-DG and AGEs, such as imidazolone, light is shed on the mystery of how aldose reductase inhibitors may prove beneficial in diabetic complications. These evidences suggest that 3-DG plays a principal role in the development of diabetic and uremic complications.

Gas chromatographic-mass spectrometric analysis of erythrocyte 3-deoxyglucosone in hemodialysis patients

The erythrocyte levels of 3-deoxyglucosone (3-DG) were measured by a selected ion monitoring method of gas chromatography-chemical ionization mass spectrometry using [13C6]-3-DG as an internal standard. Because the erythrocyte levels of 3-DG measured after deproteinization using ethanol were 18 times higher than those using ultrafiltration, we used ethanol deproteinization for measurement of total 3-DG in the erythrocytes. The concentration of 3-DG was significantly elevated in hemodialysis (HD) patients compared with healthy subjects. Although HD treatment could remove the erythrocyte 3-DG efficiently, its post-HD levels were still elevated compared with the healthy subjects.

Increased erythrocyte 3-DG and AGEs in diabetic hemodialysis patients: role of the polyol pathway

BACKGROUND

3-Deoxyglucosone (3-DG) accumulating in uremic serum plays an important role in the formation of advanced glycation end products (AGEs). To determine if 3-DG is involved in the formation of intracellular AGEs, we measured the erythrocyte levels of 3-DG and AGEs such as imidazolone and N epsilon-carboxymethyllysine (CML) in hemodialysis (HD) patients with diabetes. Further, to determine if the polyol pathway is involved in the formation of erythrocyte 3-DG and AGEs, an aldose reductase inhibitor (ARI) was administered to these patients.

METHODS

The erythrocyte levels of sorbitol, 3-DG, imidazolone, and CML were measured in ten diabetic HD patients before and after treatment with ARI (epalrestat) for eight weeks, and were compared with those in eleven healthy subjects. 3-DG was incubated in vitro with hemoglobin for two weeks to determine if imidazolone and CML are formed by reacting 3-DG with hemoglobin.

RESULTS

The erythrocyte levels of sorbitol, 3-DG, imidazolone, and CML were significantly elevated in diabetic HD patients as compared with healthy subjects. The erythrocyte levels of 3-DG significantly decreased after HD, but sorbitol, imidazolone or CML did not. The administration of ARI significantly decreased the erythrocyte levels of sorbitol, 3-DG and imidazolone, and tended to decrease the CML level. Imidazolone was rapidly produced in vitro by incubating 3-DG with hemoglobin, and CML was also produced, but less markedly as compared with imidazolone.

CONCLUSION

The erythrocyte levels of 3-DG and AGEs are elevated in diabetic HD patients. The administration of ARI reduces the erythrocyte levels of 3-DG and AGEs, especially imidazolone, as well as sorbitol. Thus, 3-DG and AGEs, especially imidazolone, in the erythrocytes are produced mainly via the polyol pathway. ARI may prevent diabetic and uremic complications associated with AGEs.

Increase in three alpha,beta-dicarbonyl compound levels in human uremic plasma: specific in vivo determination of intermediates in advanced Maillard reaction

Methylglyoxal (MGO), glypxal (GO) and 3-deoxyglucosone (3-DG) are reactive alpha,beta-dicarbonyl intermediates in advanced Maillard reaction, which form advanced glycation and oxidation end products (AGEs) by reaction with both lysine and arginine residues in protein. We measured these three dicarbonyl compound levels in human plasma to estimate the relationship between accumulation of alpha, beta-dicarbonyl compounds and AGE formation reactions in uremia and diabetes in human plasma by a highly selective and specific assay, electrospray ionization liquid chromatography mass spectrometry (ESI/LC/MS). We show that 3-DG and MGO levels are significantly higher in uremia and diabetes compared with age-matched healthy controls. Only the GO level in uremic plasma is significantly higher compared to diabetes and healthy controls. In both diabetic and uremic patients, these dicarbonyl compounds promote AGE accumulation in vivo, and especially in uremic patients, increased accumulation of GO could result from accelerating oxidative stress.

N epsilon-(carboxymethyl)lysine in blood from maintenance hemodialysis patients may contribute to dialysis-related amyloidosis

BACKGROUND

Recent studies demonstrated not only that advanced glycation end product could be found in amyloid tissue from patient with dialysis related amyloidosis, but also that amyloid beta2-microglobulin was modified with N(epsilon)-(carboxymethyl)lysine (CML). We wanted to determine if CML could be a biomarker in these patients.

METHODS

To raise polyclonal anti-carboxymethyllysine antibody, human serum albumin was carboxymethylated by glyoxylic acid and was immunized to rabbits as antigen. Carboxymethyllysine-hemoglobin (CML-Hb) levels were measured by the dot blotting method using this antibody.

RESULTS

The levels of CML-Hb were 6.68 +/- 3.10 nmol CML/mg Hb in nondiabetic hemodialysis patients (N = 70), 6.39 +/- 3.43 nmol CML/mg Hb in diabetic hemodialysis patient (N = 21), and 3.13 +/- 0.88 nmol CML/mg Hb in 47 healthy volunteers. For clinical signs of dialysis-related amyloidosis, 70 nondiabetic hemodialysis patients were scored according Gejyo's criteria. The CML-Hb levels in patients with a high amyloid score as well as a low amyloid score were significantly higher than in patients with negative amyloid score (8.89 +/- 3.53 nmol CMLmg Hb, 7.28 +/- 2.32 nmol CML/mg Hb vs. 5.11 +/- 2.09 nmol CML/mg Hb, P < 0.001, P < 0.05). Furthermore, the CML-Hb levels correlated significantly with serum values of the methylguanidine over creatinine ratio and hyaluronate.

CONCLUSIONS

We suggest that CML-Hb is increased in blood from patients on maintenance hemodialysis and is thus a potential biomarker of oxidative damage in these patients. Moreover, CML-modification of protein may play a pathogenic role in the development of dialysis related amyloidosis.

Mass spectrometry in the search for uremic toxins

This article reviews the literature on the mass spectrometry (MS) that has been used in the research of uremic toxins. Gas chromatography/mass spectrometry (GC/MS) has been most often used for the analysis of low-molecular-weight compounds in uremic blood such as organic acids, phenols, and polyols. However, it cannot be used for the analysis of middle- to high-molecular-weight substances or for involatile compounds. The development of fast atom bombardment (FAB) and liquid secondary ion mass spectrometry (LSIMS) has made possible the analysis of middle-molecules and involatile low-molecular-weight substances such as peptides and nucleosides. The development of atmospheric pressure chemical ionization (APCI) has also lead to the analysis of involatile low-molecular-weight substances. The recent advances in ionization methods, such as electrospray ionization (ESI) and matrix-assisted laser desorption ionization (MALDI), have permitted the MS analysis of high-molecular-weight substances such as beta 2-microglobulin, a major component of dialysis amyloid. Liquid chromatography/mass spectrometry (LC/MS), using ESI, APCI, or FAB as an ionization method, is currently the preferred method for the analysis of low- to high-molecular-weight substances in uremic blood. ESI-LC/MS and matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOFMS) are useful for elucidating the structure of post-translationally modified proteins obtained from the blood and tissues of uremic patients. Post-translational modification such as the formation of advanced glycation end-products and carbamoylation is enhanced in uremic patients, and is considered to be responsible for some uremic symptoms. Laser microprobe MS is unique in its capability for the two-dimensional detection of atoms such as aluminum in a tissue section obtained from uremic patients. This review focuses on the mainstream research for discovering uremic toxins, specific uremic toxins identified or quantified using MS, and the MS analysis of post-translationally modified proteins in uremia. These studies have provided ample evidence that MS has played an important role in the search for uremic toxins.

Quantitation of 3-deoxyglucosone levels in human plasma

3-Deoxyglucosone (3DG), a reactive dicarbonyl, is an important intermediate in the formation of advanced glycation end products (AGEs). The AGEs are particularly important in diabetes since they have been correlated with the development of diabetic complications. Consequently, measurements of 3DG are likely to provide valuable insights into the role of this metabolite in the etiology of diabetic complications. While several methods of 3DG quantitation in human plasma have been previously published, a significant discrepancy (over 30-fold) exists in the reported values. Knecht et al. (Arch. Biochem. Biophys. 294, 130-137, 1992) have reported the levels of plasma 3DG in normoglycemics to be 61 nM, using a GC/MS procedure. In contrast to this, Niwa et al. (Biochem. Biophys. Res. Commun. 196, 837-843, 1993) reported 3DG levels to be 1800 nM in normoglycemics, using a totally independent GC/MS method. To resolve this disagreement and fill the need for a robust assay for this dicarbonyl, suitable for absolute quantitation, a GC/MS procedure was devised for its measurement. Plasma samples were deproteinized either by ultrafiltration or by addition of ethanol as described by Niwa et al. (Biochem. Biophys. Res. Commun. 196, 837-843, 1993). 3DG in the ultrafiltrate or the supernatant was conjugated with 2,3-diamino-naphthalene to produce a stable adduct which was then converted to a silyl ether and analyzed by GC/MS. The analyte was monitored by selected ion monitoring at an m/z of 295 and 306 and quantitated using an internal standard of [U-13C]3DG. Using this approach, 3DG levels in plasma deproteinized by ultrafiltration were found to be significantly elevated from 58.5 +/- 14 (SD) nM in normoglycemics to 98.5 +/- 34 (SD) nM in type I diabetics. When deproteinization of the plasma was carried out using ethanol, the levels of 3DG from normoglycemic plasma were similar to those reported by Niwa et al. (1710 +/- 750 (SD) nM). These results suggest that 3DG levels measured by ultrafiltration may represent the free circulating 3DG and those obtained by ethanol extraction may represent aform of 3DG bound to a macromolecule (presumbaly protein).

Imidazolone, a novel advanced glycation end product, is present at high levels in kidneys of rats with streptozotocin-induced diabetes

We produced a monoclonal antibody to imidazolones A and B, novel advanced glycation end products formed from the reaction of 3-deoxyglucosone (3-DG) with the guanidino group of arginine. Liquid chromatography/mass spectrometry demonstrated that the formation of imidazolone A by incubating 3-DG with arginine is very rapid, reaching a maximum concentration within 24 h, but the formation of imidazolone B is very slow and low in quantity even after 2 weeks. Thus, at physiological conditions the formation of imidazolone A is dominant, while that of imidazolone B is negligible. Immunochemistry demonstrated that the imidazolone content in the kidneys of streptozotocin-induced diabetic rats was significantly higher than in the control rats. Serum levels of 3-DG in the diabetic rats were also significantly higher than in control rats. 3-DG attacks the arginine residues of the tissue proteins, producing imidazolone at high levels in the kidneys affected by diabetic nephropathy.

Immunohistochemical detection of imidazolone, a novel advanced glycation end product, in kidneys and aortas of diabetic patients

To investigate the role of the Maillard reaction in the pathogenesis of diabetic complications, we produced several clones of monoclonal antibodies against advanced glycation end products (AGEs) by immunizing mice with AGE-modified keyhole limpet hemocyanin, and found that one clone (AG-1) of the anti-AGE antibodies reacted specifically with imidazolones A and B, novel AGEs. Thus, the imidazolones, which are the reaction products of the guanidino group of arginine with 3-deoxyglucosone (3-DG), a reactive intermediate of the Maillard reaction, were found to be common epitopes of AGE-modified proteins produced in vitro. We determined the erythrocyte levels of imidazolone in diabetic patients using ELISA with the monoclonal anti-imidazolone antibody. The imidazolone levels in the erythrocytes of diabetic patients were found to be significantly increased as compared with those of healthy subjects. Then we studied the localization of imidazolone in the kidneys and aortas obtained from diabetic patients by immunohistochemistry using the antibody. Specific imidazolone immunoreactivity was detected in nodular lesions and expanded mesangial matrix of glomeruli, and renal arteries in an advanced stage of diabetic nephropathy, as well as in atherosclerotic lesions of aortas. This study first demonstrates the localization of imidazolone in the characteristic lesions of diabetic nephropathy and atherosclerosis. These results, taken together with a recent demonstration of increased serum 3-DG levels in diabetes, strongly suggest that imidazolone produced by 3-DG may contribute to the progression of long-term diabetic complications such as nephropathy and atherosclerosis.

Amyloid beta 2-microglobulin is modified with imidazolone, a novel advanced glycation end product, in dialysis-related amyloidosis

We have recently demonstrated by immunohistochemistry that amyloid beta 2-microglobulin (beta 2m) is modified with advanced glycation end products (AGEs) in dialysis-related amyloidosis (DRA). To further investigate the role of the Maillard reaction in the pathogenesis of DRA, we produced a monoclonal antibody to imidazolone, a novel AGE, and a reaction product of arginine and 3-deoxyglucosone (3-DG) which was accumulated in uremic serum. Then we determined the localization of imidazolone in the amyloid tissues by immunohistochemistry using the antibody. The connective tissues in carpal tunnel and ligamentum flavum were obtained from six patients with carpal tunnel syndrome and two patients with destructive spondyloarthropathy. Imidazolone was localized to all the beta 2m-positive amyloid deposits in these patients. Western blotting using the antibody demonstrated that beta 2m extracted from the synovium amyloid of hemodialysis patients was modified with imidazolone. Further, beta 2m isolated from the blood ultrafiltrate of hemodialyzed patients was also modified with imidazolone. In vitro incubation of beta 2m with 3-DG produced imidazolone-modified beta 2m. In conclusion, amyloid tissue beta2m is modified with imidazolone in patients with DRA. 3-DG accumulating in uremic serum may be involved in the modification of beta 2m with imidazolone.

Amyloid beta 2-microglobulin is modified with N epsilon-(carboxymethyl)lysine in dialysis-related amyloidosis

Recent work from this laboratory revealed that advanced glycation end product was localized to amyloid deposits in patients with dialysis-related amyloidosis by immunohistochemistry using a monoclonal antibody to advanced glycation end product. To elucidate the epitope of the antibody, N alpha-p-tosyl-L-lysine-methyl ester was incubated with glucose in vitro, and then a compound reactive to the antibody was purified from the incubate by buthanol extraction, XAD-2 column chromatography, and high-performance liquid chromatography while the reactivity was examined by enzyme linked immunosorbent assay. The purified compound was identified as N epsilon-(carboxymethyl)-N alpha-p-tosyl-L-lysine-methyl ester by using secondary ion mass spectrometry, and 1H- and 13C-nuclear magnetic resonance spectroscopy. The epitope of the antibody was identified as -CH2-NH-CH2-COOH by enzyme-linked immunosorbent assay of compounds with structures similar to N epsilon-(carboxymethyl)lysine. Immunochemical study using the antibody demonstrated the presence of N epsilon-(carboxymethyl)lysine in the beta 2-microglobulin dimer (molecular weight 23929) isolated from the synovium amyloid of a hemodialysis patient with dialysis-related amyloidosis. In conclusion, amyloid beta 2-microglobulin is modified with N epsilon-(carboxymethyl)lysine in dialysis-related amyloidosis.

Modification of beta 2m with advanced glycation end products as observed in dialysis-related amyloidosis by 3-DG accumulating in uremic serum

beta 2microglobulin (beta 2m) isolated from the amyloid deposits in patients with dialysis-related amyloidosis (DRA) has been demonstrated to be modified with advanced glycation end products (AGEs). We demonstrated that AGE was localized to amyloid deposits in patients with DRA by immunohistochemistry using a monoclonal anti-AGE antibody. To clarify the mechanism of AGE modification of beta 2m-amyloid, we studied the effects of 3-deoxyglucosone (3-DG), a potent protein crosslinking the intermediate of the Maillard reaction, on the AGE modification of beta 2m, and quantified the serum levels of 3-DG in patients undergoing hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD), and undialyzed patients. The serum levels of 3-DG were markedly increased in the dialyzed and undialyzed uremic patients. Although the serum level of 3-DG decreased after HD with a mean reduction rate of 67%, it was still significantly higher than in normal serum. Incubation of beta 2m with 3-DG at 37 degrees C emitted fluorescence characteristic for AGE, and caused AGE modification and dimer formation of beta 2m as demonstrated by Western blotting using the same monoclonal anti-AGE antibody used for immunohistochemical demonstration of AGE in DRA. The AGE-modified dimer of beta 2m could be extracted from the amyloid tissue of a patient with DRA. 3-DG showed more intense and faster reactivity with beta 2m to form AGE and dimer as compared with glucose, and aminoguanidine suppressed the AGE and dimer formation of beta 2m by 3-DG. In conclusion, 3-DG accumulating in uremic serum may be involved in the AGE modification of beta 2m-amyloid.