[Diabetic nephropathies: therapeutic aspects]

The incidence of diabetic nephropathy has declined these last decades, but diabetes mellitus still remains the commonest cause of end-stage renal failure, due to an increased prevalence of diabetes mellitus and a longer life expectancy for diabetic patients. The aim of this review is to describe the natural history of diabetic nephropathy and discuss the influence of many factors such as genetic and non-genetic progression promoters, hypertension, hyperglycemia, dyslipidemia, proteinuria and tobacco. Because only a comprehensive treatment strategy of these promoters will reduce the risk of end-stage renal failure, the inclusion of cardiovascular risk factors management and the screening of cardiovascular disease will further contribute to reduce the very high mortality of diabetic patients suffering of diabetic nephropathy.

[Diabetic foot: a public health problem too often underestimated. Consequences and therapeutic possibilities]

The clinical screening of diabetic patients at risk for foot ulcer should be regularly performed by all physicians and health professionals in charge of these patients. In addition, the high risk patient should be also educated to detect high risk foot lesions. This step represents the first strategy in order to prevent this too frequent complication of diabetes mellitus. The amputation which represents the most dramatic evolution of foot ulcer, has profound psychosocial, economic and functional effects on diabetic patients. For these reasons a global strategy should be developed in order to reduce the incidence of diabetic foot ulcer. A systematic follow-up strategy in high risk patients is highly recommended. The patient education is one of the most important step for the success of this strategy.

[Adrenal insufficiency caused by treatment with levothyroxine]

Primary adrenal insufficiency is a rare disease. Its diagnosis remains a clinical challenge since the signs and symptoms of the disease are insidious in onset and non specific in nature. A case report of Addison's crisis induced by levothyroxine substitution therapy is described. This clinical case is discussed in details with a special emphasis to the published literature regarding the strategy of diagnosis and the specific therapy of primary adrenal insufficiency.

Suppression of specific and bystander IgE responses in a mouse model of oral sensitization to beta-lactoglobulin

BACKGROUND

Mechanisms of systemic IgE suppression by oral tolerance have been extensively studied, but less is known about oral tolerance induction in mice challenged at mucosal sites. We have previously shown in systemically challenged mice that high-dose tolerance suppressed specific but not bystander IgE. In an attempt to mimic oral tolerance in food-allergic patients, we have investigated how IgE suppression could be induced in mice sensitized orally against beta-lactoglobulin (BLG).

METHODS

Mice were immunized orally against BLG using cholera toxin as adjuvant. Before oral sensitization, mice were administered milk whey proteins, either in the form of a single high-dose gavage, or by prolonged ad libitum administration of various doses.

RESULTS

Orally sensitized mice mounted a BLG-specific IgE response. In contrast to systemically challenged mice, a single high-dose gavage of whey protein given prior to the onset of oral sensitization resulted in the suppression of both specific and bystander IgE. When mice were fed moderate to low doses of milk whey proteins daily ad libitum in the drinking water during 3 weeks prior to oral sensitization, all doses effectively suppressed antigen-specific IgE. However, bystander IgE suppression was observed only at the lowest doses. When mice were tolerized during 4 days instead of 3 weeks, IgE titers remained unchanged.

CONCLUSIONS

In orally sensitized mice, bystander IgE suppression depended on the dose of tolerogen, but also on its mode of administration. Mucosally induced IgE responses were suppressed by a mechanism that was distinct from that operating in the periphery.

Induction by a lactic acid bacterium of a population of CD4(+) T cells with low proliferative capacity that produce transforming growth factor beta and interleukin-10

We investigated whether certain strains of lactic acid bacteria (LAB) could antagonize specific T-helper functions in vitro and thus have the potential to prevent inflammatory intestinal immunopathologies. All strains tested induced various levels of both interleukin-12 (IL-12) and IL-10 in murine splenocytes. In particular, Lactobacillus paracasei (strain NCC2461) induced the highest levels of these cytokines. Since IL-12 and IL-10 have the potential to induce and suppress Th1 functions, respectively, we addressed the impact of this bacterium on the outcome of CD4(+) T-cell differentiation. For this purpose, bacteria were added to mixed lymphocyte cultures where CD4(+) T-cells from naive BALB/c mice were stimulated weekly in the presence of irradiated allogeneic splenocytes. In these cultures, L. paracasei NCC2461 strongly inhibited the proliferative activity of CD4(+) T cells in a dose-dependent fashion. This was accompanied by a marked decrease of both Th1 and Th2 effector cytokines, including gamma interferon, IL-4, and IL-5. In contrast, IL-10 was maintained and transforming growth factor beta (TGF-beta) was markedly induced in a dose-dependent manner. The bacteria were not cytotoxic, because cell viability was not affected after two rounds of stimulation. Thus, unidentified bacterial components from L. paracasei NCC2461 induced the development of a population of CD4(+) T cells with low proliferative capacity that produced TGF-beta and IL-10, reminiscent of previously described subsets of regulatory cells implicated in oral tolerance and gut homeostasis.

[Kinetics of potassium transfer during hemodialysis]

INTRODUCTION

In order to study whether the removal of potassium in haemodialysis patients could be increased, we analyzed the kinetics of potassium transfer in the dialyzer.

METHOD

40 patients were included in the study. We studied: a) in vitro potassium exchanges between erythrocytes and plasma; b) plasma and erythrocyte potassium concentrations at dialyzer input and output; c) potassium transfers into the dialysate, using plasma clearance and direct measurement in the collected dialysate and d) erythrocyte potassium concentrations at the beginning and the end of dialysis.

RESULTS

In vitro, there is virtually no potassium transfer between erythrocytes and plasma. In vivo, erythrocyte potassium concentration is not affected by the dialyzer (98.7 +/- 6.4 mmol/l to 97.7 +/- 7.5 mmol/l, p = NS). Potassium transfer levels determined by calculated plasma clearance were similar to values obtained by measuring potassium in dialysate (0.71 +/- 0.10 mmol/min vs 0.68 +/- 0.10 mmol/min, p = NS). These results suggest that erythrocytes do not participate in potassium exchange in the dialyzer. This was confirmed by measured erythrocyte potassium concentrations, which were the same at the beginning and the end of dialysis (104.0 +/- 5.6 mmol/l vs 104.2 +/- 5.0 mmol/l, p = NS).

Case complexity and clinical outcome in diabetes mellitus. A prospective study using the INTERMED

The aim of this study was to assess a population of patients with diabetes mellitus by means of the INTERMED, a classification system for case complexity integrating biological, psychosocial and health care related aspects of disease. The main hypothesis was that the INTERMED would identify distinct clusters of patients with different degrees of case complexity and different clinical outcomes. Patients (n=61) referred to a tertiary reference care centre were evaluated with the INTERMED and followed 9 months for HbA1c values and 6 months for health care utilisation. Cluster analysis revealed two clusters: cluster 1 (62%) consisting of complex patients with high INTERMED scores and cluster 2 (38%) consisting of less complex patients with lower INTERMED. Cluster 1 patients showed significantly higher HbA1c values and a tendency for increased health care utilisation. Total INTERMED scores were significantly related to HbA1c and explained 21% of its variance. In conclusion, different clusters of patients with different degrees of case complexity were identified by the INTERMED, allowing the detection of highly complex patients at risk for poor diabetes control. The INTERMED therefore provides an objective basis for clinical and scientific progress in diabetes mellitus. Ongoing intervention studies will have to confirm these preliminary data and to evaluate if management strategies based on the INTERMED profiles will improve outcomes.

Kinetics and extent of protein tyrosine kinase activation in individual T cells upon antigenic stimulation

Using human CD4+ T-cell clones and peptide-pulsed antigen-presenting cells (APC) we measured, at the single cell level, different steps in the T-cell activation cascade. Simultaneous analysis of T-cell antigen receptor (TCR) down-regulation and interferon-gamma (IFN-gamma) production shows that both the level of TCR occupancy and the amount of IFN-gamma produced by single T cells increase in an antigen dose-dependent fashion. Conversely, commitment of T cells to IFN-gamma production does not occur as soon as a defined number of TCR have been engaged, but requires the same duration of sustained signalling at low as well as at high antigen concentrations. Measurement of phosphotyrosine levels by flow cytometry reveals that, upon conjugation with APC, individual T cells undergo an antigen dose-dependent activation of protein tyrosine kinases (PTK), which parallels the level of TCR occupancy. In antigen-stimulated T cells the increased phosphotyrosine staining is localized in the area of contact with APC, as shown by confocal microscopy. PTK activation is sustained for at least 2 hr after conjugation, and is required to maintain a sustained increase in intracellular Ca2+ concentration. Our results show, for the first time, a direct correlation between the level of TCR occupancy and the activation of PTK in individual T cells and offer an explanation for how the number of triggered TCR can be 'counted' and integrated in a corresponding biological response.

Purification of a dichlorophenol-indophenol oxidoreductase from rat and bovine synaptic membranes: tight complex association of a glyceraldehyde-3-phosphate dehydrogenase isoform, TOAD64, enolase-gamma and aldolase C

NADH-dichlorophenol-indophenol oxidoreductases (PMOs) were purified from synaptic plasma membranes or synaptic vesicles (small recycling vesicles) from both bovine and rat brains and from a neuroblastoma cell line, NB41A3. Several isoforms could be identified in purified plasma membranes and vesicles. Purification of the enzyme activity involved protein extraction with detergents, (NH4)2SO4 precipitation, chromatography under stringent conditions and native PAGE. PMO activity could be attributed to a very tight complex of several proteins that could not be separated except by SDS/PAGE. SDS/PAGE resolved the purified complex into at least five proteins, which could be micro-sequenced and identified unambiguously as hsc70, TOAD64 and glyceraldehyde-3-phosphate dehydrogenase tightly associated with the brain-specific proteins aldolase C and enolase-gamma. Enzyme activity could be purified from both synaptic plasma membranes and recycling vesicles, yields being much greater from the latter source. Highly purified plasma membranes (prepared from a neuroblastoma cell line NB41A3 by iminobiotinylation of intact cells and affinity purification with avidin and anti-avidin antibodies under very stringent conditions) also displayed PMO activity tightly associated with TOAD64. The association of PMO in a tight complex was confirmed by its immunoprecipitation from cellular and membrane extracts of NB41A3 using antibodies directed against any component protein of the complex followed by immunodetection with antibodies directed against the other members. Antibodies also inhibited the enzyme activity synergistically. In addition, induction of the different components of the complex during dichlorophenol-indophenol stress was demonstrated by the S1 RNase-protection assay in synchronized NB41A3 cells. The role of the complex in membrane fusion and cellular response to extracellular oxidative stress during growth and development is discussed.

Effects of plasma membrane oxidoreductases on Ca2+ mobilization and protein phosphorylation in rat brain synaptosomes

We have investigated the possible role of plasma membrane oxidoreductases in the Ca2+ export mechanisms in rat brain synaptic membranes. Ca2+ efflux in nerve terminals is controlled both by a high-affinity/low capacity Mg-dependent ATP-stimulated Ca2+ pump and by a low affinity/high capacity ATP-independent Na(+)-Ca2+ exchanger. Both Ca2+ efflux mechanisms were strongly inhibited by pyridine nucleotides, in the order NADP greater than NAD greater than NADPH greater than NADH with IC50 values of ca. 10 mM for NADP and ca. 3 mM for the other agents in the case of the ATP-driven Ca2+ pump and with IC50 values between 8 and 10 mM for the Na(+)-Ca2+ exchanger. Oxidizing agents such as DCIP3 and ferricyanide inhibited the ATP-driven Ca2+ efflux mechanism but not the Na(+)-Ca2+ exchanger. In addition, full activation of plasma membrane oxidoreductases requires both an acceptor and an electron donor; therefore the combined effects of both substrates added together were also studied. When plasma membrane oxidoreductases of the synaptic plasma membrane were activated in the presence of both NADH (or NADPH) and DCIP or ferricyanide, the inhibition of the ATP-driven Ca2+ pump was optimal; by contrast, the pyridine nucleotide-mediated inhibition of the Na(+)-Ca2+ exchanger was partially released when both substrates of the plasma membrane oxidoreductases were present together. Furthermore, the activation of plasma membrane oxidoreductases also strongly inhibited intracellular protein phosphorylation in intact synaptosomes, mediated by either cAMP-dependent protein kinase, Ca2+ calmodulin-dependent protein kinases, or protein kinase C.