Induction of chronic kidney failure in a long-term peritoneal exposure model in the rat: effects on functional and structural peritoneal alterations

Effect of Scavenging Circulating Reactive Carbonyls by Oral Pyridoxamine in Uremic Rats on Peritoneal Dialysis

Pyridoxamine, a reactive carbonyl (RCO) scavenger, can ameliorate peritoneal deterioration in uremic peritoneal dialysis (PD) rats when given via dialysate. We examined the effects of scavenging circulating RCOs by oral pyridoxamine. Rats underwent nephrectomy and 3 weeks of twice daily PD either alone or with once daily oral pyridoxamine. PD solution was supplemented with methylglyoxal, a major glucose-derived RCO, to quench intraperitoneal pyridoxamine. Oral pyridoxamine achieved comparable blood and dialysate pyridoxamine concentrations, suppressed pentosidine accumulation in the blood but not in the mesenterium or dialysate, and reduced the increases in small solute transport and mesenteric vessel densities, with no effects on submesothelial matrix layer thickening or serum creatinine. Thus, reducing circulating RCOs by giving oral pyridoxamine with PD provides limited peritoneal protection. However, orally given pyridoxamine efficiently reaches the peritoneal cavity and would eliminate intraperitoneal RCOs. Oral pyridoxamine is more clinically favorable and may be as protective as intraperitoneal administration.

Identification of Gene Transcripts Implicated in Peritoneal Membrane Alterations

♦ BACKGROUND: Permanent stimulation of the peritoneum during peritoneal dialysis (PD) is likely to result in increased expression of genes encoding proteins involved in inflammation and tissue remodeling. Peritoneal fibrosis and neoangiogenesis may develop. ♦ OBJECTIVE: To assess highly expressed genes potentially in volved in peritoneal alterations during PD treatment using an animal model. ♦ METHODS: A PD catheter was implanted in 36 male Wistar rats after 70% nephrectomy. The rats were divided into 3 groups, exposed to dialysis solution for 8 weeks, and sacrificed 2 weeks later. Group B was exposed to a buffer, group D was exposed to a 3.86% glucose-based dialysis solution, and in group D+H, a second hit of intraperitoneal blood on top of the dialysis solution was given to induce the development of peritoneal sclerosis. Before sacrifice, peritoneal function was assessed. Omental tissue was obtained for analysis of gene expression using RT-qPCR. ♦ RESULTS: Fibrosis scores, vessel counts, and peritoneal function parameters were not different between the groups. Genes involved in the transforming growth factor beta signaling pathway, cell proliferation, angiogenesis, and inflammation were more expressed (p < 0.05) in the D+H group. Almost no differences were found between the control groups. We identified 4 genes that were related to peritoneal transport. ♦ CONCLUSION: Already a mid-term peritoneal exposure, when no microscopical and functional alterations are present, provokes activation of gene pathways of cell proliferation, fibrosis, neoangiogenesis, and inflammation.

New Insights into the Effects of Chronic Kidney Failure and Dialysate Exposure on the Peritoneum

♦ INTRODUCTION: Chronic uremia and the exposure to dialysis solutions during peritoneal dialysis (PD) induce peritoneal alterations. Using a long-term peritoneal exposure model, we compared the effects of chronic kidney failure (CKD) itself and exposure to either a 'conventional' or a 'biocompatible' dialysis solution on peritoneal morphology and function. ♦ METHODS: Wistar rats (Harlan, Zeist, the Netherlands) were grouped into: normal kidney function (NKF), CKD induced by 70% nephrectomy, CKD receiving daily peritoneal infusions with 3.86% glucose Dianeal (CKDD), or Physioneal (both solutions from Baxter Healthcare, Castlebar, Ireland) (CKDP). At 16 weeks, a peritoneal function test was performed, and histology, ultrastructure, and hydroxyproline content of peritoneal tissue were assessed. ♦ RESULTS: Comparing CKD with NKF, peritoneal transport rates were higher, mesothelial cells (MC) displayed increased number of microvilli, blood and lymph vasculature expanded, vascular basal lamina appeared thicker, with limited areas of duplication, and fibrosis had developed. All alterations, except lymphangiogenesis, were enhanced by exposure to both dialysis fluids. Distinct MC alterations were observed in CKDD and CKDP, the latter displaying prominent basolateral protrusions. In addition, CKDP was associated with a trend towards less fibrosis compared to CKDD. ♦ CONCLUSIONS: Chronic kidney failure itself induced peritoneal alterations, which were in part augmented by exposure to glucose-based dialysis solutions. Overall, the conventional and biocompatible solutions had similar long-term effects on the peritoneum. Importantly, the latter may attenuate the development of fibrosis.

Evaluation of Renal-Hepatic Functional Indices and Blood Pressure Based on the Progress of Time in a Rat Model of Chronic Kidney Disease

BACKGROUND

Chronic kidney disease (CKD) is defined as either kidney damage or a decline in renal function as determined by a decreased glomerular filtration rate (GFR) for three months or longer. CKD is an important risk factor for mortality.

OBJECTIVES

The aim of this study was to evaluate the effects of CKD on renal-hepatic functional indices and blood pressure in 5/6 nephrectomized (5/6 Nx) rats over the course of nine months.

MATERIALS AND METHODS

Male Wistar rats were subjected to either 5/6 Nx or sham operations (n = 8). Members of the sham group underwent the same procedure without surgical reduction of the kidney mass. For all animals, body weight (BW), serum creatinine (Cr), blood urea nitrogen (BUN), alanine transaminase (ALT), and aspartate transaminase (AST) levels were measured before and after surgery. After two-, three-, six-, and nine-month intervals, blood was collected to assay renal and hepatic functional indices. Tail-cuff blood pressure was recorded in each month after surgery.

RESULTS

BW was lower for the 5/6 Nx group rats after the operations compared with the BW of those in the sham operation group. Furthermore, the 5/6 Nx group showed elevations in blood pressure, Cr, BUN, ALT, and AST levels compared with the sham group over the course of time.

CONCLUSIONS

In summary, CKD induced by the 5/6 Nx model caused hypertension and increased serum levels of Cr, BUN, ALT, and AST. These changes are augmented by the progress of time.

High-glucose-based peritoneal dialysis solution induces the upregulation of VEGF expression in human peritoneal mesothelial cells: The role of pleiotrophin

The aim of the present study was to investigate the effect of a high-glucose-based peritoneal dialysis solution (HGPDS) on the expression of pleiotrophin (PTN) and vascular endothelial growth factor (VEGF) in human peritoneal mesothelial cells (HPMCs) and the mechanisms through which fluvastatin (Flu) protects the peritoneal membrane in continuous ambulatory peritoneal dialysis (CAPD). HPMCs were cultured with HGPDS, Flu (10-8‑10-6 mol/l) and PTN (10‑30 nmol/l). The expression of PTN and VEGF was examined at the mRNA and protein level. To define the role of PTN in the regulation of VEGF expression, HPMCs were cultured with HGPDS in the presence or absence of the blocking peptide of PTN. The signaling pathways involved in PTN synthesis induced by HGPDS were also characterized. The phenotypic characteristics of HPMCs were observed under a light microscope. Cell viability was measured by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) colorimetry and the mRNA and protein expression of PTN, VEGF and ERK1/2 was assessed by RT‑PCR and the western blot analysis, respectively. Following incubation with HGPDS for 48 h, the morphology of the HPMCs changed from a typical cobblestone‑like appearance to a fibroblast‑like phenotype. The same alteration in the morphology of the HPMCs also occurred following incubation with 20 nmol/l PTN. Flu (10-6 mol/l), GSK650394 [a competitive inhibitor of serum/glucocorticoid-regulated kinase 1 (SGK1), 10-5 mol/l] and PD98059 (a competitive inhibitor of ERK1/2, 10-5 mol/l) improved the negative changes in cell morphology induced by HGPDS. The results of MTT assay revealed that the reduction in HPMC viability occurred in the groups treated with HGPDS and this reduction was partially restored by Flu, GSK650394 and PD98059. A significant improvement in cell viability, which had been decreased by HGPDS, was observed following treatment with Flu (10-6 mol/l), PD98059 (10-5 mol/l) or GSK650394 (10-5 mol/l) (P<0.05). Compared with the control, the mRNA and protein expression of PTN and VEGF significantly increased in the HPMCs treated with HGPDS (P<0.05). GSK650394 and PD98059 significantly decreased the high mRNA and protein expression levels of PTN and VEGF induced by HGPDS (P<0.05) and Flu had the same inhibitory effect as GSK650394 and PD98059 in a dose‑dependent manner (P<0.05). The mRNA and protein expression of VEGF increased following the incubation of HPMCs with 20 nmol/l PTN. By contrast, the mRNA and protein expression levels of VEGF in the HPMCs decreased in the presence of the blocking peptide of PTN. The results from the present study indicated that HGPDS increased the expression of PTN and VEGF in the HPMCs, and this increase was attenuated by Flu, GSK650394 and PD98059. The protein expression of phosphorylated ERK1/2 (p-ERK1/2) was decreased by GSK650394 in the HPMCs treated with HGPDS. Taken together, the protective effects of Flu in HPMCs may be partially achieved through the SGK1‑ERK1/2 signaling pathway.

Hyperbranched polyglycerol is an efficacious and biocompatible novel osmotic agent in a rodent model of peritoneal dialysis

OBJECTIVES

To enhance the effectiveness of peritoneal dialysis (PD), new biocompatible PD solutions may be needed. The present study was designed to test the efficacy and biocompatibility of hyperbranched polyglycerol (HPG)-a nontoxic, nonimmunogenic water-soluble polyether polymer-in PD.

METHODS

Adult Sprague-Dawley rats were instilled with 30 mL HPG solution (molecular weight 3 kDa; 2.5% - 15%) or control glucose PD solution (2.5% Dianeal: Baxter Healthcare Corporation, Deerfield, IL, USA), and intraperitoneal fluid was recovered after 4 hours. Peritoneal injury and cellular infiltration were determined by histologic and flow cytometric analysis. Human peritoneal mesothelial cells were assessed for viability in vitro after 3 hours of PD fluid exposure.

RESULTS

The 15% HPG solution achieved a 4-hour dose-related ultrafiltration up to 43.33 ± 5.24 mL and a dose-related urea clearance up to 39.17 ± 5.21 mL, results that were superior to those with control PD solution (p < 0.05). The dialysate-to-plasma (D/P) ratios of urea with 7.5% and 15% HPG solution were not statistically different from those with control PD solution. Compared with fluid recovered from the control group, fluid recovered from the HPG group contained proportionally fewer neutrophils (3.63% ± 0.87% vs 9.31% ± 2.89%, p < 0.0001). Detachment of mesothelial cells positive for human bone marrow endothelial protein 1 did not increase in the HPG group compared with the stain control (p = 0.1832), but it was elevated in the control PD solution group (1.62% ± 0.68% vs 0.41% ± 0.31%, p = 0.0031). Peritoneal biopsies from animals in the HPG PD group, compared with those from control PD animals, demonstrated less neutrophilic infiltration and reduced thickness. Human peritoneal mesothelial cell survival after HPG exposure was superior in vitro (p < 0.0001, 7.5% HPG vs control; p < 0.01, 15% HPG vs control). Exposure to glucose PD solution induced cytoplasmic vacuolation and caspase 3-independent necrotic cell death that was not seen with HPG solution.

CONCLUSIONS

Our novel HPG PD solution demonstrated effective ultrafiltration and waste removal with reduced peritoneal injury in a rodent model of PD.

Peritoneal changes in patients on long-term peritoneal dialysis

Long-term peritoneal dialysis can lead to morphological and functional changes in the peritoneum. Although the range of morphological alterations is known for the peritoneal dialysis population as a whole, these changes will not occur in every patient in the same sequence and to the same extent. Longitudinal studies are therefore required to help identify which patients might develop the changes. Although longitudinal studies using peritoneal biopsies are not possible, analyses of peritoneal effluent biomarkers that represent morphological alterations could provide insight. Longitudinal studies on peritoneal transport have been performed, but follow-up has often been too short and an insufficient number of parameters have been investigated. This Review will firstly describe peritoneal morphology and structure and will then focus on peritoneal effluent biomarkers and their changes over time. Net ultrafiltration will also be discussed together with the transport of small solutes. Data on the peritoneal transport of serum proteins show that serum protein levels do not increase to the same extent as levels of small solutes with long-term peritoneal dialysis. Early alterations in peritoneal transport must be distinguished from alterations that only develop with long-term peritoneal dialysis. Early alterations are related to vasoactive mediators, whereas later alterations are related to neoangiogenesis and fibrosis. Modern peritoneal dialysis should focus on the early detection of long-term membrane alterations by biomarkers--such as cancer antigen 125, interleukin-6 and plasminogen activator inhibitor 1--and the improved assessment of peritoneal transport.

Protecting the peritoneal membrane: factors beyond peritoneal dialysis solutions

Functional deterioration of the peritoneal membrane in patients on peritoneal dialysis has been described as being the result of a combination of neoangiogenesis and fibrosis. Glucose, glucose degradation products, and the unphysiological pH of the dialysate solution contribute to these changes. Although newer solutions clearly perform better in terms of their biocompatibility in an in vitro setting and in animal models, the benefit of such solutions over older solutions in the clinical setting is so far unproven. The difficulties in showing a benefit of the newer, more biocompatible solutions in the clinical setting can be explained by the fact that other factors also affect the properties of the peritoneal membrane. These factors are often neglected in clinical studies, which results in unnoticed differences in case-mix and blurs the potential impact of the novel solutions. However, many of these factors are modifiable, and attention should be paid to them in clinical practice to maintain the integrity of the peritoneal membrane. This Review focuses on factors that potentially influence the integrity of the peritoneal membrane, other than those associated with the peritoneal dialysis fluid itself.

Previous renal replacement therapy time at start of peritoneal dialysis independently impact on peritoneal membrane ultrafiltration failure

Background. Peritoneal membrane changes are induced by uraemia per se. We hypothesise that previous renal replacement therapy (RRT) time and residual renal function (RRF) at start of peritoneal dialysis impact on ultrafiltration failure (UFF). Methods. The time course of PET parameters from 123 incident patients, followed for median 26 (4-105) months, was evaluated by mixed linear model. Glucose 3.86% solutions were not used in their standard therapy. Sex, age, diabetes, previous RRT time, RRF, comorbidity score, PD modality and peritonitis episodes were investigated as possible determinants of UFF-free survival. Results. PET parameters remained stable during follow up. CA125 decreased significantly. Inherent UFF was diagnosed in 8 patients, 5 spontaneously recovering. Acquired UFF group presented type I UFF profile with compromised sodium sieving. At baseline they had lower RRF and longer previous time of RRT which remained significantly associated with UFF-free survival by Cox multivariate analysis (HR 0.648 (0.428-0.980), P = 0.04) and (HR 1.016 (1.004-1.028), P = 0.009, resp.). UFF free survival was 97%, 87% and 83% at 1, 3 and 5 years, respectively. Conclusions. Inherent UFF is often unpredictable but transitory. On the other hand baseline lower RRF and previous RRT time independently impact on ultrafiltration failure free survival. In spite of these detrimental factors generally stable long-term peritoneal transport parameters is achievable with a 5-year cumulative UFF free survival of 83%. This study adds a further argument for a PD-first policy.

Benfotiamine protects against peritoneal and kidney damage in peritoneal dialysis

Residual renal function and the integrity of the peritoneal membrane contribute to morbidity and mortality among patients treated with peritoneal dialysis. Glucose and its degradation products likely contribute to the deterioration of the remnant kidney and damage to the peritoneum. Benfotiamine decreases glucose-induced tissue damage, suggesting the potential for benefit in peritoneal dialysis. Here, in a model of peritoneal dialysis in uremic rats, treatment with benfotiamine decreased peritoneal fibrosis, markers of inflammation, and neovascularization, resulting in improved characteristics of peritoneal transport. Furthermore, rats treated with benfotiamine exhibited lower expression of advanced glycation endproducts and their receptor in the peritoneum and the kidney, reduced glomerular and tubulointerstitial damage, and less albuminuria. Increased activity of transketolase in tissue and blood contributed to the protective effects of benfotiamine. In primary human peritoneal mesothelial cells, the addition of benfotiamine led to enhanced transketolase activity and decreased expression of advanced glycation endproducts and their receptor. Taken together, these data suggest that benfotiamine protects the peritoneal membrane and remnant kidney in a rat model of peritoneal dialysis and uremia.

The effects of a dialysis solution with a combination of glycerol/amino acids/dextrose on the peritoneal membrane in chronic renal failure

BACKGROUND

Long-term peritoneal dialysis (PD) with conventional glucose based, lactate-buffered PD fluids may lead to morphological and functional alterations of the peritoneal membrane. It was hypothesized that long-term exposure to a different buffer and a mixture of osmotic agents would cause less peritoneal abnormality.

OBJECTIVES

To investigate the effects of long-term exposure to a bicarbonate/lactate-buffered dialysis solution with a mixture of osmotic agents: glycerol 1.4%, amino acids 0.5%, and dextrose 1.1% (= 1% glucose) (GLAD) in a rat model with chronic kidney failure.

METHODS

All rats underwent a peritoneal catheter implantation and a 70% nephrectomy. Thereafter, the rats were randomly divided into 3 groups: GLAD, 3.86% Dianeal (Baxter, Nivelles, Belgium), and buffer (Physioneal without glucose, Baxter). All rats were infused daily for 16 weeks with the appropriate PD fluid. Afterwards, a peritoneal permeability analysis (SPARa) was performed using 3.86% Physioneal in all groups. After the SPARa, the rats were sacrificed to obtain tissue samples for morphometric determinations. Omental tissue was stained with picro Sirius red for assessment of fibrosis and with CD31 for vessel density.

RESULTS

GLAD and Dianeal showed faster small solute transport compared to the hypotonic buffer. No differences between the groups were present in ultrafiltration. Dianeal had the lowest value for free water transport and the highest protein clearances. Total triglyceride in plasma was not different between GLAD and the buffer. Vessel density after GLAD exposure (20 V/F) was very similar to the value found for the buffer solution (17 V/F); Dianeal caused a significantly higher value (35 V/F, p < 0.01). Also, the amount of fibrosis was higher in the Dianeal-exposed rats (p < 0.01).

CONCLUSION

Both hypertonic dialysis solutions increased peritoneal solute transport. GLAD exposure was associated with the best preservation of peritoneal morphology. The results of GLAD were very similar to those of the bicarbonate/lactate-buffered solution without osmotic agents. Studies in humans are needed for further assessment of GLAD.