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Ruwanpathirana P, Chang T. Uraemic brainstem encephalopathy mimicking ocular myasthenia: a case report. BMC Neurol 2024; 24:121. [PMID: 38609854 PMCID: PMC11010437 DOI: 10.1186/s12883-024-03626-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 04/08/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Uraemia causes a generalised encephalopathy as its most common neurological complication. Isolated brainstem uraemic encephalopathy is rare. We report a case of fatigable ptosis and complex ophthalmoplegia in brainstem uraemic encephalopathy. CASE PRESENTATION A 22-year-old Sri Lankan man with end stage renal failure presented with acute onset diplopia and drooping of eyelids progressively worsening over one week. The patient had not complied with the prescribed renal replacement therapy which was planned to be initiated 5 months previously. On examination, his Glasgow coma scale score was 15/15, He had a fatigable asymmetrical bilateral ptosis. The ice-pack test was negative. There was a complex ophthalmoplegia with bilateral abduction failure and elevation failure of the right eye. The diplopia did not worsen with prolonged stare. The rest of the neurological examination was normal. Serum creatinine on admission was 21.81 mg/dl. The repetitive nerve stimulation did not show a decremental pattern. Magnetic resonance imaging (MRI) of the brain demonstrated diffuse midbrain and pontine oedema with T2 weighted/FLAIR hyperintensities. The patient was haemodialyzed on alternate days and his neurological deficits completely resolved by the end of the second week of dialysis. The follow up brain MRI done two weeks later demonstrated marked improvement of the brainstem oedema with residual T2 weighted/FLAIR hyperintensities in the midbrain. CONCLUSIONS Uraemia may rarely cause an isolated brainstem encephalopathy mimicking ocular myasthenia, which resolves with correction of the uraemia.
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Affiliation(s)
- Pramith Ruwanpathirana
- Professorial Unit in Medicine, National Hospital of Sri Lanka, Colombo, 01000, Sri Lanka.
| | - Thashi Chang
- Professorial Unit in Medicine, National Hospital of Sri Lanka, Colombo, 01000, Sri Lanka
- Department of Clinical Medicine, University of Colombo, 25, Kynsey Road, Colombo, 00800, Sri Lanka
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Sethi SK, Luyckx V, Bunchman T, Nair A, Bansal SB, Pember B, Soni K, Savita, Yadav DK, Sharma V, Alhasan K, Raina R. Prevention of dialysis disequilibrium syndrome in children with advanced uremia with a structured hemodialysis protocol: A quality improvement initiative study. Hemodial Int 2024; 28:216-224. [PMID: 38504636 DOI: 10.1111/hdi.13147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 02/29/2024] [Accepted: 03/04/2024] [Indexed: 03/21/2024]
Abstract
BACKGROUND Dialysis disequilibrium syndrome (DDS) is a rare but significant concern in adult and pediatric patients undergoing dialysis initiation with advanced uremia or if done after an interval. It is imperative to gain insights into the epidemiological patterns, pathophysiological mechanisms, and preventive strategies aimed at averting the onset of this ailment. DESIGN Prospective observational quality improvement initiative cohort study. SETTING AND PARTICIPANTS A prospective single-center study involving 50 pediatric patients under 18 years recently diagnosed with chronic kidney disease stage V with blood urea ≥200 mg/dL, admitted to our tertiary care center for dialysis initiation from January 2017 to October 2023. QUALITY IMPROVEMENT PLAN A standardized protocol was developed and followed for hemodialysis in pediatric patients with advanced uremia. This protocol included measures such as lower urea reduction ratios (targeted at 20%-30%) with shorter dialysis sessions and linear dialysate sodium profiling. Prophylactic administration of mannitol and 25% dextrose was also done to prevent the incidence of dialysis disequilibrium syndrome. MEASURES Incidence of dialysis disequilibrium syndrome and severe dialysis disequilibrium syndrome, mortality, urea reduction ratios (URRs), neurological outcome at discharge, and development of complications such as infection and hypotension. Long-term outcomes were assessed at the 1-year follow-up including adherence to dialysis, renal transplantation, death, and loss to follow-up. RESULTS The median serum creatinine and urea levels at presentation were 7.93 and 224 mg/dL, respectively. A total of 20% of patients had neurological symptoms attributable to advanced uremia at the time of presentation. The incidence of dialysis disequilibrium syndrome was 4% (n = 2) with severe dialysis disequilibrium syndrome only 2% (n = 1). Overall mortality was 8% (n = 4) but none of the deaths were attributed to dialysis disequilibrium syndrome. The mean urea reduction ratios for the first, second, and third dialysis sessions were 23.45%, 34.56%, and 33.50%, respectively. The patients with dialysis disequilibrium syndrome were discharged with normal neurological status. Long-term outcomes showed 88% adherence to dialysis and 38% renal transplantation. LIMITATIONS This study is characterized by a single-center design, nonrandomized approach, and limited sample size. CONCLUSIONS Our structured protocol served as a framework for standardizing procedures contributing to low incidence rates of dialysis disequilibrium syndrome.
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Affiliation(s)
- Sidharth Kumar Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Valerie Luyckx
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- Department of Public and Global Health, Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Timothy Bunchman
- Pediatric Nephrology, Children's Hospital of Richmond at VCU, Richmond, Virginia, USA
| | - Aishwarya Nair
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | | | - Bryce Pember
- Northeast Ohio Medical University, Rootstown, Ohio, USA
| | - Kritika Soni
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Savita
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | | | - Vivek Sharma
- Department of Radiology, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Khalid Alhasan
- Pediatric Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Rupesh Raina
- Pediatric Nephrology, Akron Children's Hospital, Cleveland, Ohio, USA
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Chow CM, Persad AH, Karnik R. Effect of Membrane Permeance and System Parameters on the Removal of Protein-Bound Uremic Toxins in Hemodialysis. Ann Biomed Eng 2024; 52:526-541. [PMID: 37993752 PMCID: PMC10859350 DOI: 10.1007/s10439-023-03397-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 10/25/2023] [Indexed: 11/24/2023]
Abstract
Inadequate clearance of protein-bound uremic toxins (PBUTs) during dialysis is associated with morbidities in chronic kidney disease patients. The development of high-permeance membranes made from materials such as graphene raises the question whether they could enable the design of dialyzers with improved PBUT clearance. Here, we develop device-level and multi-compartment (body) system-level models that account for PBUT-albumin binding (specifically indoxyl sulfate and p-cresyl sulfate) and diffusive and convective transport of toxins to investigate how the overall membrane permeance (or area) and system parameters including flow rates and ultrafiltration affect PBUT clearance in hemodialysis. Our simulation results indicate that, in contrast to urea clearance, PBUT clearance in current dialyzers is mass-transfer limited: Assuming that the membrane resistance is dominant, raising PBUT permeance from 3 × 10-6 to 10-5 m s-1 (or equivalently, 3.3 × increase in membrane area from ~ 2 to ~ 6 m2) increases PBUT removal by 48% (from 22 to 33%, i.e., ~ 0.15 to ~ 0.22 g per session), whereas increasing dialysate flow rates or adding adsorptive species have no substantial impact on PBUT removal unless permeance is above ~ 10-5 m s-1. Our results guide the future development of membranes, dialyzers, and operational parameters that could enhance PBUT clearance and improve patient outcomes.
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Affiliation(s)
- Chun Man Chow
- Department of Chemical Engineering, Massachusetts Institute of Technology, 25 Ames St, Cambridge, MA, 02142, USA
| | - Aaron H Persad
- Department of Mechanical Engineering, Massachusetts Institute of Technology, 77 Massachusetts Ave, Cambridge, MA, 02139, USA
| | - Rohit Karnik
- Department of Mechanical Engineering, Massachusetts Institute of Technology, 77 Massachusetts Ave, Cambridge, MA, 02139, USA.
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Huang CY, Chen CJ, Lin JN, Shih YY, Chen CF. Symptom perception and self-care practice for uraemic pruritus in patients receiving haemodialysis. J Ren Care 2024; 50:36-46. [PMID: 36451513 DOI: 10.1111/jorc.12452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 10/10/2022] [Accepted: 11/15/2022] [Indexed: 02/09/2024]
Abstract
BACKGROUND Due to the recurrent nature of uraemic pruritus among patients receiving haemodialysis, self-care can offer patients a means to ameliorate this symptom. Qualitative data on self-care of uraemic pruritus are limited. OBJECTIVE To explore how patients on haemodialysis perceive uraemic pruritus, implement self-care practice, and appraise the outcome of self-caring uraemic pruritus. DESIGN The Common Sense Model of Self-Regulation guided the study design. PARTICIPANTS AND APPROACHES Data were collected through face-to-face interviews with 30 patients receiving haemodialysis who were aged from 50 to 89 years and had had uraemic pruritus for more than 6 weeks. Interviews were audio recorded, and verbatim transcriptions of interviews were analysed. FINDINGS Our participants generally used life-related analogies to describe uraemic pruritus, which they reviewed as a momentarily controllable symptom with an endless timeline. Most participants reported limited knowledge of the aetiology and multifaceted impacts of uraemic pruritus on their daily life and emotional status. The impacts on daily life included decreased zest for activities and sleep disturbances. Physical management of uraemic pruritus involved daily substance use and interventions employed during pruritic episodes. Psychological managements involved preferences for indoor activities and a fatalistic outlook. Unsatisfactory outcomes and psychological burdens from self-care practice were reported. CONCLUSIONS Life experiences shape symptom presentation and self-care practice in patients on haemodialysis. The modalities for self-caring for uraemic pruritus are diverse but not remarkably effective. Performing self-care tasks places a substantial burden on patients. Individualised educational programs should be developed to improve the outcome of self-care practice.
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Affiliation(s)
- Chih-Yuan Huang
- Division of Nephrology, Department of Internal Medicine, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan
- Department of Sport Management, College of Recreation and Health Management, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Ching-Ju Chen
- School of Nursing, Fooyin University, Kaohsiung City, Taiwan
| | - Jong-Ni Lin
- College of Nursing and Health Sciences, Dayeh University, Changhua, Dacun, Taiwan
| | | | - Chiu-Feng Chen
- Department of Nursing, Ditmanson Medical Foundation Chia-Yi Christian Hospital, Chia-Yi, Taiwan
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Akiyama H. [Neurological Complications Associated with Kidney Disease]. Brain Nerve 2024; 76:231-238. [PMID: 38514104 DOI: 10.11477/mf.1416202593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
The kidneys filter the blood to excrete waste products and excess salt from the body as urine, while reabsorbing what the body needs and keeping it in the body. For this reason, when the function of the kidneys deteriorates, urine cannot be produced, and homeostasis of electrolytes and acid-bases cannot be maintained. As a result, waste products accumulate in the body, resulting in uremia and the need for dialysis induction or kidney transplant. This paper provides an overview of the neurological complications that appear in kidney disease and their treatment.
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Affiliation(s)
- Hisanao Akiyama
- Department of Neurology, St. Marianna University School of Medicine
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Jiang X, Sun F, Huang H. Clinical Efficacy and Long-term Prognosis of High Flux Hemodialysis Combined with Different Frequency Hemodiafiltration in the Treatment of Middle-Aged and Elderly Patients with Uremia. Iran J Kidney Dis 2024; 1:36-44. [PMID: 38308549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/14/2023] [Accepted: 10/01/2023] [Indexed: 02/04/2024]
Abstract
INTRODUCTION To analyze the clinical efficacy and long-term prognosis of high flux hemodialysis (HFHD) combined with different frequency hemodiafiltration (HDF) in uremic patients. METHODS 86 middle-aged and elderly patients with uremia were divided into the HF group (HFHD combined with high-frequency HDF) and the LF group (HFHD combined with low-frequency HDF). The changes between the two groups in various indicators after 12 months of dialysis and the survival rate at 5 years of follow-up were compared. We used SPSS 25.0 software for data analysis. RESULTS The differences of the levels of serum albumin, hemoglobin and transferrin in HF Group was significantly higher than LF Group before and after treatment (P < .05). The differences of the levels and clearance rate of calcium, phosphorus, parathyroid hormone, β2-microglobulin and cysteine protease inhibitor C in the patients' blood after dialysis were significantly higher in HF Group than in LF Group (P < .05). The all-cause mortality rate, new cardiovascular event rate, new cerebrovascular event rate, and new infection event rate of HF Group were significantly lower than those of LFHD group, respectively (P < .05). The LF Group had a significantly higher risk of all-cause mortality events, new cardiovascular cerebrovascular and infectious events than the HF Group (P < .05). CONCLUSION 1 week/time HDF combined with HFHD can more effectively eliminate the vascular related toxins in middle-aged and elderly patients with uremia, improve their nutritional status, treatment effect, and long-term prognosis. DOI: 10.52547/ijkd.7864.
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Affiliation(s)
| | | | - Haiyan Huang
- Geriatrics Department (Health Department), Yantai Yuhuangding Hospital, Yantai 264000, China.
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Zhang JJ, Yang LF, Zhang YZ, Xie XH. Clinical value of ultrasound in adult Wilms' tumor patient with uremia: A case report and literature review. Medicine (Baltimore) 2023; 102:e36381. [PMID: 38065912 PMCID: PMC10713150 DOI: 10.1097/md.0000000000036381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/09/2023] [Indexed: 12/18/2023] Open
Abstract
RATIONALE Wilms' tumor (WT) is the most common pediatric kidney malignancy and is rarely found in adults. Nonspecific clinical symptoms and imaging features often lead to delayed diagnosis or misdiagnosis of adult WT, resulting in poor clinical outcomes. Ultrasound (US), as an efficient and noninvasive examination method, has been widely used in clinical diagnosis and treatment. Therefore, various US evidence is meaningful to improve understanding of adult WT characteristics in ultrasound. PATIENT CONCERNS A 45-year-old female patient with uremia (regular hemodialysis for 13 years) with painless gross hematuria was diagnosed with a right kidney tumor penetrating to the lung. Preoperatively, B-mode ultrasonography showed an ill-defined hyperechoic mass in the right kidney, which revealed an unclear border, uneven internal echoes, and calcification. Besides, the internal blood flow signal of the tumor was detected. Contrast-enhanced ultrasound (CEUS) showed an uneven hyper-enhancement in the tumor ("fast in and slow out"). Contrast-enhanced computed tomography of the kidney indicated a similar result as the CEUS. Moreover, the chest CT identified multiple pulmonary metastatic nodules. DIAGNOSES An ultrasound-guided percutaneous core needle biopsy of the tumor proceeded to make a definite diagnosis of adult WT (epithelial type). INTERVENTIONS The patient was treated with tislelizumab. OUTCOMES No progress was found to date. LESSONS We report the first case in which CEUS was performed in an adult WT patient with uremia and multiple pulmonary metastases. The features obtained by the US can help in the diagnosis of adult WT and direct further diagnostic procedures.
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Affiliation(s)
- Jing-Jing Zhang
- Ultrasonic Department, Ningbo Yinzhou No. 2 Hospital, Ningbo, Zhengjiang, China
| | - Li-Fei Yang
- Ultrasonic Department, Ningbo Yinzhou No. 2 Hospital, Ningbo, Zhengjiang, China
| | - Yi-Zhen Zhang
- Ultrasonic Department, Ningbo Yinzhou No. 2 Hospital, Ningbo, Zhengjiang, China
| | - Xiao-Hong Xie
- Ultrasonic Department, Ningbo Yinzhou No. 2 Hospital, Ningbo, Zhengjiang, China
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Xu F, Zhuang B, Wang Z, Wu H, Hui X, Peng H, Bian X, Ye H. Knowledge, attitude, and practice of patients receiving maintenance hemodialysis regarding hemodialysis and its complications: a single-center, cross-sectional study in Nanjing. BMC Nephrol 2023; 24:275. [PMID: 37730535 PMCID: PMC10510168 DOI: 10.1186/s12882-023-03320-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 09/04/2023] [Indexed: 09/22/2023] Open
Abstract
BACKGROUND Good knowledge of and attitudes toward hemodialysis and its complications might be expected to promote good practices and improve adherence. This study investigated, the knowledge, attitude, and practice of patients receiving hemodialysis regarding hemodialysis and its complications. METHODS This cross-sectional study enrolled patients with uremia who were receiving hemodialysis at the Second Affiliated Hospital of Nanjing Medical University (China) between January 9, 2023, and January 16, 2023. A questionnaire was designed that included the following dimensions: demographic/clinical information, knowledge, attitude, and practice. Correlations between knowledge, attitude, and practice scores were evaluated by Pearson correlation analysis. RESULTS The analysis included 493 patients (305 males, 61.87%). The average knowledge, attitude, and practice score was 19.33 ± 7.07 (possible range, 0-31), 28.77 ± 3.58 (possible range, 8-40), and 43.57 ± 6.53 (possible range, 11-55) points, respectively. A higher knowledge score was associated with younger age (P < 0.001), a higher education level (P < 0.001), and not living alone (P < 0.001), while a higher practice score was associated with a shorter history of hemodialysis (P < 0.001). There were positive correlations between the knowledge and practice scores (r = 0.220, P < 0.001) and between the attitude and practice scores (r = 0.453, P < 0.001), although the knowledge and attitude scores were not significantly correlated. CONCLUSIONS The results provide important insights into the knowledge, attitudes, and practices of patients with uremia in Nanjing (China) regarding hemodialysis and its complications. These findings may facilitate education programs to improve self-care practices in patients receiving maintenance hemodialysis in Nanjing (China).
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Affiliation(s)
- Fangfang Xu
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210000, China
| | - Bing Zhuang
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210000, China
| | - Zhongxia Wang
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210000, China
| | - Hao Wu
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210000, China
| | - Xin Hui
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210000, China
| | - Hongyan Peng
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210000, China
| | - Xueqin Bian
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210000, China.
| | - Hong Ye
- Center for Kidney Disease, The Second Affiliated Hospital of Nanjing Medical University, Nanjing, 210000, China.
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Zhao H, Wu D, Gyamfi MA, Wang P, Luecht C, Pfefferkorn AM, Ashraf MI, Kamhieh-Milz J, Witowski J, Dragun D, Budde K, Schindler R, Zickler D, Moll G, Catar R. Expanded Hemodialysis ameliorates uremia-induced impairment of vasculoprotective KLF2 and concomitant proinflammatory priming of endothelial cells through an ERK/AP1/cFOS-dependent mechanism. Front Immunol 2023; 14:1209464. [PMID: 37795100 PMCID: PMC10546407 DOI: 10.3389/fimmu.2023.1209464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 08/31/2023] [Indexed: 10/06/2023] Open
Abstract
Aims Expanded hemodialysis (HDx) therapy with improved molecular cut-off dialyzers exerts beneficial effects on lowering uremia-associated chronic systemic microinflammation, a driver of endothelial dysfunction and cardiovascular disease (CVD) in hemodialysis (HD) patients with end-stage renal disease (ESRD). However, studies on the underlying molecular mechanisms are still at an early stage. Here, we identify the (endothelial) transcription factor Krüppel-like factor 2 (KLF2) and its associated molecular signalling pathways as key targets and regulators of uremia-induced endothelial micro-inflammation in the HD/ESRD setting, which is crucial for vascular homeostasis and controlling detrimental vascular inflammation. Methods and results First, we found that human microvascular endothelial cells (HMECs) and other typical endothelial and kidney model cell lines (e.g. HUVECs, HREC, and HEK) exposed to uremic serum from patients treated with two different hemodialysis regimens in the Permeability Enhancement to Reduce Chronic Inflammation II (PERCI-II) crossover clinical trial - comparing High-Flux (HF) and Medium Cut-Off (MCO) membranes - exhibited strongly reduced expression of vasculoprotective KLF2 with HF dialyzers, while dialysis with MCO dialyzers led to the maintenance and restoration of physiological KLF2 levels in HMECs. Mechanistic follow-up revealed that the strong downmodulation of KLF2 in HMECs exposed to uremic serum was mediated by a dominant engagement of detrimental ERK instead of beneficial AKT signalling, with subsequent AP1-/c-FOS binding in the KLF2 promoter region, followed by the detrimental triggering of pleiotropic inflammatory mediators, while the introduction of a KLF2 overexpression plasmid could restore physiological KLF2 levels and downmodulate the detrimental vascular inflammation in a mechanistic rescue approach. Conclusion Uremia downmodulates vasculoprotective KLF2 in endothelium, leading to detrimental vascular inflammation, while MCO dialysis with the novel improved HDx therapy approach can maintain physiological levels of vasculoprotective KLF2.
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Affiliation(s)
- Hongfan Zhao
- Department of Nephrology and Internal Intensive Care Medicine, at Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Dashan Wu
- Department of Nephrology and Internal Intensive Care Medicine, at Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Michael Adu Gyamfi
- Department of Nephrology and Internal Intensive Care Medicine, at Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Pinchao Wang
- Department of Nephrology and Internal Intensive Care Medicine, at Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Christian Luecht
- Department of Nephrology and Internal Intensive Care Medicine, at Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | | | | | - Julian Kamhieh-Milz
- Institute of Transfusion Medicine, at Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Janusz Witowski
- Department of Pathophysiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Duska Dragun
- Department of Nephrology and Internal Intensive Care Medicine, at Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Klemens Budde
- Department of Nephrology and Internal Intensive Care Medicine, at Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Ralf Schindler
- Department of Nephrology and Internal Intensive Care Medicine, at Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Daniel Zickler
- Department of Nephrology and Internal Intensive Care Medicine, at Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Guido Moll
- Department of Nephrology and Internal Intensive Care Medicine, at Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
- BIH Center for Regenerative Therapies (BCRT) and Berlin-Brandenburg School for Regenerative Therapies (BSRT), at Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Rusan Catar
- Department of Nephrology and Internal Intensive Care Medicine, at Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
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Rahman WK, Rabea IS, Meizel MM. Protective effect of activated charcoal against progression of chronic kidney disease: A randomized clinical study. J Med Life 2023; 16:1310-1315. [PMID: 38107705 PMCID: PMC10719797 DOI: 10.25122/jml-2023-0128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 06/13/2023] [Indexed: 12/19/2023] Open
Abstract
Chronic kidney disease (CKD) is a non-reversible and progressive disease affecting the kidneys, significantly impacting global public health. One of the complications of chronic kidney disease is impaired intestinal barrier function, which may allow harmful products such as urea to enter the bloodstream and cause systemic inflammation. This study aimed to investigate whether supplementation with activated charcoal could reduce uremic toxins in patients with end-stage renal disease (ESRD). The study was a randomized clinical trial conducted at the Dialysis Center of al Diwaniyah Medical Hospital in the Diwaniyah Governorate. Eighty-two patients with ESRD on regular hemodialysis were enrolled, with 15 patients receiving oral supplementation with activated charcoal in addition to standard care and 13 patients receiving only standard care. Blood samples were collected at baseline and after eight weeks, and several biomarkers were measured, including estimated glomerular filtration rate (eGFR), creatinine, urea, phosphorus, albumin, and indoxyl sulfate. The results showed a significant reduction in both serum urea and serum phosphorus levels after eight weeks of oral-activated charcoal treatment. However, the other biomarkers were not affected by the treatment. In conclusion, the use of oral-activated charcoal for eight weeks in Iraqi patients undergoing maintenance hemodialysis improved urea and phosphorus levels.
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Affiliation(s)
- Waleed Khaild Rahman
- Al-Diwaniyah Health Office, Ministry of Health and Environment, Al-Diwaniyah, Iraq
| | - Ihsan Salah Rabea
- Department of Clinical Pharmacy, Faculty of Pharmacy, University of Kufa, Al-Najaf, Iraq
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Zha F, Li W, Shi C, Deng Y, Shen J. Early clinical observation of supra-hemodiafiltration with endogenous reinfusion in the treatment of uremic pruritus. Artif Organs 2023; 47:1503-1513. [PMID: 37083002 DOI: 10.1111/aor.14552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 03/31/2023] [Accepted: 04/14/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND To evaluate the clinical efficacy of supra-hemodiafiltration with endogenous reinfusion (Supra-HFR) for pruritus in uremic maintenance hemodialysis (HD) patients and explore the possible mechanism. METHODS This study prospectively included 60 patients with uremia who underwent maintenance hemodialysis and developed pruritus. Patients were randomly divided into a study group (30 cases) and a control group (30 cases). Patients in the study group underwent dialysis once a week with Supra-HFR and twice a week with HD. The group received HD dialysis 3 times a week. Visual analog scales (VAS) scores, 5-D itch scale scores, and 12-Item Pruritus Severity Scale (12-PSS) were used to evaluate the itching degree of patients. Quality of life was assessed using KDTA and SF-36 scores. Blood levels of hypersensitive C-reactive protein, calcium ion (Ca2+), phosphorus ion (P3+ ), free parathyroid hormone (iPTH), and β2-microglobulin (β2-MG) were compared between the two groups before treatment and at follow-up 24 weeks after treatment. RESULTS Before treatment, there was no significant difference in VAS, 5-D itch scale, and 12-PSS score between the study group and the control group (all p > 0.05). After 24 weeks of treatment, the VAS score of the study group (2.82 ± 0.91) was significantly lower than that of the control group (7.47 ± 1.32, p < 0.001), the 5-D itch scale score of the study group (9.47 ± 2.34) was significantly lower than that of the control group (18.53 ± 4.02, p < 0.001), the 12-PSS score of the study group (11.20 ± 1.81) was significantly lower than that of the control group (16.47 ± 2.09, p < 0.001). KDTA of the study group (64.17 ± 8.07 vs. 47.83 ± 13.46, p < 0.001) and SF-36 scores (65.37 ± 6.28 vs. 55.90 ± 14.28, p = 0.002) were significantly higher than that in the control group. The levels of hs-CRP, P3+ , iPTH, and β2-MG in the study group after treatment were lower than those before treatment, and lower than those in the control group after treatment (all p < 0.05). CONCLUSIONS The Supra-HFR can effectively reduce the itching symptoms of uremia patients and improve their quality of life.
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Affiliation(s)
- Fei Zha
- Department of Nephrology, Renmin Hospital, Hubei University of Medicine, Shiyan, China
| | - Wenwen Li
- Department of Nephrology, Renmin Hospital, Hubei University of Medicine, Shiyan, China
| | - Chunhua Shi
- Department of Nephrology, Renmin Hospital, Hubei University of Medicine, Shiyan, China
| | - Yanyan Deng
- Department of Nephrology, Renmin Hospital, Hubei University of Medicine, Shiyan, China
| | - Jianming Shen
- Department of Nephrology, Renmin Hospital, Hubei University of Medicine, Shiyan, China
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12
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Reis T, Reis F, Fagundes A, da Hora Passos R, Neves FDAR. Rationale for Adsorption in Extracorporeal Blood Purification. Contrib Nephrol 2023; 200:107-117. [PMID: 37263243 DOI: 10.1159/000527707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 10/23/2022] [Indexed: 06/03/2023]
Abstract
A strong rationale supports the development of adsorption-based extracorporeal blood purification in conditions such as sepsis, acute kidney disease, uremia, and acute liver failure. The retention of compounds as a consequence of acute or chronic organ dysfunction might have detrimental effects. When a causative effect of an accumulated compound in a pathogenic condition is demonstrated, a rationale for the removal of this solute is also established. Adsorption is a mass transfer mechanism in which a solute chemically interacts with the surface of a solid structure (sorbent) and is removed from its solvent (i.e., blood or plasma). Traditional extracorporeal blood purification techniques utilize semipermeable membranes and depend mainly on diffusion and convection as mechanisms of mass transfer. Protein-bound solutes and water-soluble compounds with molecular weight above 25 kDa are scantly removed by either diffusive or convective clearances. In contrast, recently developed resins have demonstrated safety aligned with notable adsorptive capability, which enables the extraction of endotoxins, inflammatory mediators, and uremic toxins. The understanding of the kinetics of these elements and the improvement in patient selection are key factors to propel exploratory and confirmatory trials that ultimately will lead to the expected changes in clinical practice.
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Affiliation(s)
- Thiago Reis
- D'Or Institute for Research and Education (IDOR), São Luiz Itaim Hospital, São Paulo, Brazil
- Laboratory of Molecular Pharmacology, Faculty of Health Sciences, University of Brasília, Brasília, Brazil
| | - Fábio Reis
- D'Or Institute for Research and Education (IDOR), DF Star Hospital, Brasília, Brazil
| | - Antônio Fagundes
- D'Or Institute for Research and Education (IDOR), DF Star Hospital, Brasília, Brazil
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13
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Zanganeh M, Abbasi A, Khosravi A, Amerian M, Ebrahimi H. Effects of Increased Blood Flow Rate and Oral Activated Charcoal on the Severity of Uremic Pruritus: A Randomized Crossover Clinical Trial. Saudi J Kidney Dis Transpl 2023; 34:125-133. [PMID: 38146721 DOI: 10.4103/1319-2442.391890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2023] Open
Abstract
The aim of this study was to compare the effect of increased blood flow rate and the administration of an activated charcoal suspension on the severity of uremic pruritus in hemodialysis patients in a crossover clinical trial. Each group (n = 20) received three 2-week interventions, including increased pumping speed, daily administration of a charcoal suspension (6 g), and the concurrent use of increased pumping speed and oral administration of the charcoal suspension. After each intervention, they had a 2-week washout period. The severity and quality of pruritus were measured using the Yosipovitch's pruritus questionnaire. The results showed that the mean severity, highest pruritus score, and lowest pruritus score decreased after all three interventions, but the highest decrease was related to the third intervention. Considering the results of this study, simultaneous use of increased pumping speed and oral administration of a charcoal suspension is recommended to reduce uremic pruritus in hemodialysis patients.
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Affiliation(s)
- Mahmoud Zanganeh
- Department of Nursing, Imam Hossein Hospital, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Ali Abbasi
- Department of Nursing, School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Ahmad Khosravi
- Center for Health Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Monireh Amerian
- Clinical Research Development Unit, Imam Hossein Hospital, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Hossein Ebrahimi
- Center for Health Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran
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14
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Molina P, Ojeda R, Blanco A, Alcalde G, Prieto-Velasco M, Aresté N, Buades JM, Simó VE, Goicoechea M, Pérez-Morales RE, Sánchez-Álvarez E, Sánchez-Villanueva R, Montesa M, Arenas MD. Etiopathogenesis of chronic kidney disease-associated pruritus: putting the pieces of the puzzle together. Nefrologia 2023; 43:48-62. [PMID: 37173258 DOI: 10.1016/j.nefroe.2023.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 06/28/2022] [Indexed: 05/15/2023] Open
Abstract
Defined as the unpleasant sensation that causes the desire to scratch, pruritus is the most common skin symptom associated with uremia and appears in almost half of patients with advanced chronic kidney disease (CKD). Beyond its direct impact on quality of life, CKD-associated pruritus (CKD-aP) is an independent predictor of mortality that also has a synergistic effect with other quality of life-related symptoms, such as insomnia, depression, and anxiety. Although different mechanisms have been proposed to explain the origin of Pa-ERC, its etiopathogenesis is still not fully understood. Since new therapeutic targets have been identified and several clinical trials have recently shown promising results, our current understanding of the interrelationships has expanded significantly and the pathophysiological mechanisms underlying CKD-aP are now considered to be multifactorial. The potential triggers of pruritus in patients with CKD are discussed in this review, including hypotheses about skin xerosis, accumulation of uremic toxins, dysregulation of the immune system and systemic inflammation, uremic neuropathy, and imbalances in the endogenous opioid system. Other non-uremic causes of pruritus are also discussed, with the aim of guiding the physicians to apply an adequate aetiopathogenic approach to CKD-aP in their day-to-day clinical practice.
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Affiliation(s)
- Pablo Molina
- Servicio de Nefrología, FISABIO, Hospital Universitari Dr Peset, Departamento de Medicina, Universitat de València, Valencia, Spain.
| | - Raquel Ojeda
- Servicio de Nefrología, Hospital Universitario Renia Sofía, Córdoba, Spain
| | - Ana Blanco
- Fresenius Medical Care, Centro de Diálisis Alcobendas, Madrid, Spain; Servicio de Nefrología, Hospital Quirón Ruber Juan Bravo, Madrid, Spain
| | - Guillermo Alcalde
- Servicio de Nefrología, BIOARABA, Hospital Universitario Araba, Osakidetza, Universidad del País Vasco, Vitoria-Gasteiz, Álava, Spain
| | | | - Nuria Aresté
- Servicio de Nefrología, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Juan Manuel Buades
- Servicio de Nefrología, Hospital Universitario Son Llàtzer, Institut d'Investigació Sanitària de les Illes Balears (IdISBa), Palma, Spain
| | - Vicent Esteve Simó
- Servicio de Nefrologia, Hospital Terrassa, Consorci Sanitari Terrassa (CST), Terrassa, Barcelona, Spain
| | - Marian Goicoechea
- Servicio de Nefrología, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Rosa Elena Pérez-Morales
- Servicio de Nefrología. Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Emilio Sánchez-Álvarez
- Servicio de Nefrología, Hospital Universitario de Cabueñes, Red de Investigación Renal (REDINREN), Gijón, Asturias, Spain
| | | | - María Montesa
- Servicio de Nefrología, FISABIO, Hospital Universitari Dr Peset, Departamento de Medicina, Universitat de València, Valencia, Spain
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15
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Kashani K, Cozzolino MG, Massy ZA, Blankestijn PJ, Stenvinkel P, Rosner MH, Ronco C. Proposal for a New Classification of Solutes of Interest in Uremia and Hemodialysis. Blood Purif 2022; 52:233-241. [PMID: 36502799 DOI: 10.1159/000528040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 11/04/2022] [Indexed: 12/14/2022]
Abstract
Uremic toxins contribute to clinical manifestations of kidney dysfunction. These toxins include organic and inorganic elements or compounds. While the kidney typically clears uremic toxins, gut dysbiosis, and tissue inflammation could lead to increased production of substances that can further the clinical manifestations of uremia. The uremic toxins are quantitatively measurable in biological fluids and have an established relationship with azotemia signs and symptoms. Their elimination is associated with mitigated uremic manifestations, while their administration to the uremic levels leads to uremic signs in animal or human models or in vitro studies. Besides, the uremic toxins have an established and plausible pathophysiologic relationship with uremic manifestations. The previous classification of uremic toxins was mainly focused on the physicochemical characteristics of these substances to divide them into three categories, (1) free water-soluble low-molecular-weight (<500 Da) solutes, (2) protein-bound, water-soluble, low molecular weight (<500 Da), (3) middle molecular weight (>500 Da and <12,000 Da), and (4) high molecular weight (>12,000 Da). Unfortunately, the classification named above was not centered around patient outcomes and quality of life among those with severe kidney failure. Therefore, a panel of experts convened virtually to provide additional insights into the current state and propose a new uremic toxin classification. This article describes the group’s consensus recommendations regarding the new classification of uremic toxins into more clinically oriented categories.
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Affiliation(s)
- Kianoush Kashani
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Mario G Cozzolino
- Renal Division, Department of Health Sciences, ASST Santi Paolo e Carlo, Università degli Studi di Milano, Milan, Italy
| | - Ziad A Massy
- INSERM U1018, Équipe 5, Centre de Recherche en Epidémiologie et Santé des Populations (CESP), Université Paris Saclay et Université Versailles Saint Quentin en Yvelines (UVSQ), Villejuif, France
- Service de Néphrologie et Dialyse, Assistance Publique-Hopitaux de Paris (APHP), Hôpital Universitaire Ambroise Paré, Boulogne-Billancourt, France
| | - Peter J Blankestijn
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Peter Stenvinkel
- Department of Renal Medicine, M99, Karolinska University Hospital, Stockholm, Sweden
| | - Mitchell H Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padova, Italy
- Department of Nephrology, Dialysis, and Transplantation, San Bortolo Hospital, International Renal Research Institute of Vicenza, Vicenza, Italy
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16
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Rosner MH, Ronco C. Uremic Toxins: Toward a Greater Understanding and Classification. Blood Purif 2022; 52:219-220. [PMID: 36423596 DOI: 10.1159/000527682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 09/12/2022] [Indexed: 11/27/2022]
Affiliation(s)
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padova, Italy
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy
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17
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Zhu L, Tong G, Yang F, Zhao Y, Chen G. The role of neuroimmune and inflammation in pediatric uremia-induced neuropathy. Front Immunol 2022; 13:1013562. [PMID: 36189322 PMCID: PMC9520989 DOI: 10.3389/fimmu.2022.1013562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 09/01/2022] [Indexed: 11/13/2022] Open
Abstract
Uremic neuropathy in children encompasses a wide range of central nervous system (CNS), peripheral nervous system (PNS), autonomic nervous system (ANS), and psychological abnormalities, which is associated with progressive renal dysfunction. Clinically, the diagnosis of uremic neuropathy in children is often made retrospectively when symptoms improve after dialysis or transplantation, due to there is no defining signs or laboratory and imaging findings. These neurological disorders consequently result in increased morbidity and mortality among children population, making uremia an urgent public health problem worldwide. In this review, we discuss the epidemiology, potential mechanisms, possible treatments, and the shortcomings of current research of uremic neuropathy in children. Mechanistically, the uremic neuropathy may be caused by retention of uremic solutes, increased oxidative stress, neurotransmitter imbalance, and disturbance of the blood-brain barrier (BBB). Neuroimmune, including the change of inflammatory factors and immune cells, may also play a crucial role in the progression of uremic neuropathy. Different from the invasive treatment of dialysis and kidney transplantation, intervention in neuroimmune and targeted anti-inflammatory therapy may provide a new insight for the treatment of uremia.
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Affiliation(s)
- Linfeng Zhu
- Department of Urology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Guoqin Tong
- Department of Neurology, The First People’s Hospital of XiaoShan District, Hangzhou, China
| | - Fan Yang
- Department of Urology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Yijun Zhao
- Department of Urology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Guangjie Chen
- Department of Urology, The Children’s Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
- *Correspondence: Guangjie Chen,
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18
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de Vries JC, van Gelder MK, Monninkhof AS, Ahmed S, Hazenbrink DHM, Nguyen TQ, de Kort GAP, Vonken EJPA, Vaessen KRD, Joles JA, Verhaar MC, Gerritsen KGF. A Uremic Pig Model for Peritoneal Dialysis. Toxins (Basel) 2022; 14:toxins14090635. [PMID: 36136573 PMCID: PMC9503030 DOI: 10.3390/toxins14090635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 08/31/2022] [Accepted: 09/08/2022] [Indexed: 11/16/2022] Open
Abstract
With increasing interest in home dialysis, there is a need for a translational uremic large animal model to evaluate technical innovations in peritoneal dialysis (PD). To this end, we developed a porcine model with kidney failure. Stable chronic kidney injury was induced by bilateral subtotal renal artery embolization. Before applying PD, temporary aggravation of uremia was induced by administration of gentamicin (10 mg/kg i.v. twice daily for 7 days), to obtain uremic solute levels within the range of those of dialysis patients. Peritoneal transport was assessed using a standard peritoneal permeability assessment (SPA). After embolization, urea and creatinine concentrations transiently increased from 1.6 ± 0.3 to 7.5 ± 1.2 mM and from 103 ± 14 to 338 ± 67 µM, respectively, followed by stabilization within 1–2 weeks to 2.5 ± 1.1 mM and 174 ± 28 µM, respectively. Gentamicin induced temporary acute-on-chronic kidney injury with peak urea and creatinine concentrations of 16.7 ± 5.3 mM and 932 ± 470 µM respectively. PD was successfully applied, although frequently complicated by peritonitis. SPA showed a low transport status (D/P creatinine at 4 h of 0.41 (0.36–0.53)) with a mass transfer area coefficient of 9.6 ± 3.1, 4.6 ± 2.6, 3.4 ± 2.3 mL/min for urea, creatinine, and phosphate respectively. In conclusion, this porcine model with on-demand aggravation of uremia is suitable for PD albeit with peritoneal transport characterized by a low transport status.
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Affiliation(s)
- Joost C. de Vries
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, 3508 GA Utrecht, The Netherlands
| | - Maaike K. van Gelder
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, 3508 GA Utrecht, The Netherlands
| | - Anneke S. Monninkhof
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, 3508 GA Utrecht, The Netherlands
| | - Sabbir Ahmed
- Department of Pharmaceutical Sciences, Utrecht University, 3584 CG Utrecht, The Netherlands
| | - Diënty H. M. Hazenbrink
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, 3508 GA Utrecht, The Netherlands
| | - Tri Q. Nguyen
- Department of Pathology, University Medical Centre Utrecht, 3508 GA Utrecht, The Netherlands
| | - Gèrard A. P. de Kort
- Department of Radiology, University Medical Centre Utrecht, 3508 GA Utrecht, The Netherlands
| | - Evert-Jan P. A. Vonken
- Department of Radiology, University Medical Centre Utrecht, 3508 GA Utrecht, The Netherlands
| | - Koen R. D. Vaessen
- Central Laboratory Animal Research Facility, Utrecht University, 3584 CJ Utrecht, The Netherlands
| | - Jaap A. Joles
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, 3508 GA Utrecht, The Netherlands
| | - Marianne C. Verhaar
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, 3508 GA Utrecht, The Netherlands
| | - Karin G. F. Gerritsen
- Department of Nephrology and Hypertension, University Medical Centre Utrecht, 3508 GA Utrecht, The Netherlands
- Correspondence: ; Tel.: +31-88-755-7329
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Ebersolt M, Santana Machado T, Mallmann C, Mc-Kay N, Dou L, Bouchouareb D, Brunet P, Burtey S, Sallée M. Protein/Fiber Index Modulates Uremic Toxin Concentrations in Hemodialysis Patients. Toxins (Basel) 2022; 14:toxins14090589. [PMID: 36136527 PMCID: PMC9502511 DOI: 10.3390/toxins14090589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/09/2022] [Accepted: 08/25/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Indoxyl sulfate (IS) and p-cresyl sulfate (PCS), two uremic toxins (UTs), are associated with increased mortality in patients with chronic kidney disease (CKD). These toxins are produced by the microbiota from the diet and excreted by the kidney. The purpose of this study was to analyze the effect of diet on IS and PCS concentration in hemodialysis (HD) patients. Methods: We performed a prospective monocentric study using a seven-day diet record and determination of serum IS and PCS levels in HD patients. We tested the association between toxin concentrations and nutritional data. Results: A total of 58/75 patients (77%) completed the diet record. Mean caloric intake was 22 ± 9.2 kcal/kg/day. The protein/fiber index was 4.9 ± 1.8. No correlation between IS or PCS concentration and protein/fiber index was highlighted. In the 18 anuric patients (31%) in whom residual renal function could not affect toxin concentrations, IS and PCS concentrations were negatively correlated with fiber intake and positively correlated with the protein/fiber index. In a multivariate analysis, IS serum concentration was positively associated with the protein/fiber index (p = 0.03). Conclusions: A low protein/fiber index is associated with low concentrations of uremic toxins in anuric HD patients. Diets with an increased fiber intake must be tested to determine whether they reduce PCS and IS serum concentrations.
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Affiliation(s)
- Manon Ebersolt
- Centre de Néphrologie et Transplantation Rénale, AP-HM, Hôpital de la Conception, 147 Bd Baille, 13005 Marseille, France
| | | | - Cecilia Mallmann
- Centre D’investigation Clinique, Hôpital de la Conception, 13005 Marseille, France
| | - Nathalie Mc-Kay
- Aix Marseille Univ, INSERM, INRAE, C2VN, 13005 Marseille, France
| | - Laetitia Dou
- Aix Marseille Univ, INSERM, INRAE, C2VN, 13005 Marseille, France
| | - Dammar Bouchouareb
- Centre de Néphrologie et Transplantation Rénale, AP-HM, Hôpital de la Conception, 147 Bd Baille, 13005 Marseille, France
| | - Philippe Brunet
- Centre de Néphrologie et Transplantation Rénale, AP-HM, Hôpital de la Conception, 147 Bd Baille, 13005 Marseille, France
- Aix Marseille Univ, INSERM, INRAE, C2VN, 13005 Marseille, France
| | - Stéphane Burtey
- Centre de Néphrologie et Transplantation Rénale, AP-HM, Hôpital de la Conception, 147 Bd Baille, 13005 Marseille, France
- Aix Marseille Univ, INSERM, INRAE, C2VN, 13005 Marseille, France
- Correspondence:
| | - Marion Sallée
- Centre de Néphrologie et Transplantation Rénale, AP-HM, Hôpital de la Conception, 147 Bd Baille, 13005 Marseille, France
- Aix Marseille Univ, INSERM, INRAE, C2VN, 13005 Marseille, France
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20
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Abstract
Chronic kidney disease (CKD) leads to cognitive impairment and emotional changes. However, the precise mechanism underlying the crosstalk between the kidneys and the nervous system is not fully understood. Inflammation and cerebrovascular disease can influence the development of depression in CKD. CKD is one of the strongest risk factors for cognitive impairment. Moreover, cognitive impairment occurs in CKD as patients experience the dysregulation of several brain functional domains due to damage caused to multiple cortical regions and to subcortical modulatory neurons. The differences in structural brain changes between CKD and non-CKD dementia may be attributable to the different mechanisms that occur in CKD. The kidney and brain have similar anatomical vascular systems, which may be susceptible to traditional risk factors. Vascular factors are assumed to be involved in the development of cognitive impairment in patients with CKD. Vascular injury induces white matter lesions, silent infarction, and microbleeds. Uremic toxins may also be directly related to cognitive impairment in CKD. Many uremic toxins, such as indoxyl sulfate, are likely to have an impact on the central nervous system. Further studies are required to identify therapeutic targets to prevent changes in the brain in patients with CKD.
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Affiliation(s)
- Duk-Soo Kim
- Department of Anatomy, Soonchunhyang University College of Medicine, Cheonan,
Korea
| | - Seong-Wook Kim
- Graduate School of New Drug Discovery & Development, Chungnam National University, Daejeon,
Korea
| | - Hyo-Wook Gil
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Cheonan,
Korea
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21
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Changa AR, Rucker JC, Drummond PS. Opsoclonus in Uremia With Resolution After Hemodialysis. J Neuroophthalmol 2022; 42:e448-e449. [PMID: 34270515 DOI: 10.1097/wno.0000000000001327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT A 78-year-old man was evaluated for altered mentation in the setting of significant uremia. On examination, he was found to be encephalopathic with generalized myoclonus and spontaneous opsoclonus. He had no known risk factors for the development of opsoclonus and upon undergoing hemodialysis, experienced near resolution of his eye movement abnormalities, thus highlighting a possible link between the uremic state and opsoclonus.
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Affiliation(s)
- Abhinav R Changa
- Departments of Neurology (ARC, JCR, PSD) and Ophthalmology (JCR), NYU Langone Health, New York, New York; and Department of Neurology, Fresco Institute for Parkinson's and Movement Disorders (PSD); NYU Langone Health, New York, New York
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22
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Luo W, Zhang R, He D, Sun Z, Zhou Y, Cheng L, Li H. The Value of CT Angiography Based on Intelligent Segmentation Algorithm for Survival of Hemodialysis Patients. Comput Math Methods Med 2022; 2022:6470576. [PMID: 35096133 PMCID: PMC8791739 DOI: 10.1155/2022/6470576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/10/2021] [Accepted: 12/22/2021] [Indexed: 11/21/2022]
Abstract
This study was to explore the application value for central venous stenosis and occlusion in hemodialysis patients under the CT angiography based on intelligent segmentation algorithm, so that patients can survive better. Spiral CT was used to examine upper limb swelling in 62 uremic hemodialysis patients at a speed of 3.8 mL/s. Nonionic iodine contrast agent was injected around the contralateral limb. The total dosage of 90-102 mL, it was scanned by intelligent trigger technology. The trigger scanning threshold was set. The monitoring point was located in the superior vena cava. CT with convolutional neural network intelligent segmentation algorithm was used to process image data. Finally, the quality of life and related biochemical levels of patients before and after hemodialysis were detected. Under the CT angiography of intelligent segmentation algorithm, 77 stenoses were found in 62 uremic patients, including 48 stenoses of the brachial vein and 17 stenoses of the superior vena cava. The correlation coefficient between CT angiography and digital subtraction angiography (DSA) imaging results of intelligent segmentation algorithm was 0.411. Segmentation effect of the algorithm in this study: automatic segmentation accuracy was greater than 79%. After hemodialysis treatment, the scores of physical fitness, pain, social function, and energy status of patients were significantly increased compared with those before treatment, and the levels of albumin, serum phosphorus, and parathyroid hormone were significantly decreased (P < 0.05). In summary, CT angiography with intelligent segmentation algorithm can obtain clear, intuitive, and complete vascular walking images, and better display subclavian vein, brachiocephalic vein, and superior vena cava. It can provide more valuable support for surgical intervention and has certain application value for better survival of hemodialysis patients.
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Affiliation(s)
- Wei Luo
- Second Department of Orthopaedics, Longkou Hospital of Traditional Chinese Medicine, Longkou, 265700 Shandong Province, China
| | - Ruidong Zhang
- Second Department of Orthopaedics, Longkou Hospital of Traditional Chinese Medicine, Longkou, 265700 Shandong Province, China
| | - Da He
- Department of Nephrology, Wuhan No. 1 Hospital, Wuhan, 430022 Hubei Province, China
| | - Zhenyi Sun
- Second Department of Orthopaedics, Longkou Hospital of Traditional Chinese Medicine, Longkou, 265700 Shandong Province, China
| | - Yunlong Zhou
- Department of Medicine, Longkou Hospital of Traditional Chinese Medicine, Longkou, 265700 Shandong Province, China
| | - Li Cheng
- Department of Nephrology, Wuhan No. 1 Hospital, Wuhan, 430022 Hubei Province, China
| | - Hongbo Li
- Department of Nephrology, Wuhan No. 1 Hospital, Wuhan, 430022 Hubei Province, China
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Santos-Alonso C, Maldonado Martín M, Sánchez Villanueva R, Álvarez García L, Vaca Gallardo MA, Bajo Rubio MA, Del Peso Gilsanz G, Ossorio González M, Selgas Gutiérrez R. Pruritus in dialysis patients. Review and new perspectives. Nefrologia 2022; 42:15-21. [PMID: 36153894 DOI: 10.1016/j.nefroe.2022.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/29/2020] [Accepted: 12/02/2020] [Indexed: 06/16/2023] Open
Abstract
Uremic pruritus (UP) is one of the most uncomfortable symptoms for patients in dialysis. UP has a great impact on dialysis patients' quality of life and has a great prevalence between those (28-70%). Physiopathology of UP is unknown and usually is unnoticed for most nephrologists (in more than 65% of centers is underdiagnosed). This lack of awareness drives to the unsuccessful treatment of this symptom. Moreover, the fact that most studies have been carried out on small populations and the difficulty assessing UP complicates a correct therapeutical approach. For this reason, we have designed treatment algorithms based on the efficacy of the drugs but also its safeness to avoid adverse effects.
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Ishizaki Y, Nishizono R, Kikuchi M, Inagaki H, Sato Y, Fujimoto S. Case Report: A Case of Encephalopathy Presenting the Lentiform Fork Sign on MRI in a Diabetic Dialysis Patient. F1000Res 2021; 9:969. [PMID: 34868569 PMCID: PMC8602957 DOI: 10.12688/f1000research.25597.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 11/20/2022] Open
Abstract
Basal ganglia lesions showing an expansile high signal intensity on T2-weighted MRI are termed the lentiform fork sign. This specific finding is mainly observed in diabetic patients with uremic encephalopathy with metabolic acidosis, although there are also reports in patients with ketoacidosis, dialysis disequilibrium syndrome, intoxication, and following drug treatment (e.g., metformin). A 57-year-old Japanese man on chronic hemodialysis for 4 years because of diabetic nephropathy was admitted to our hospital for relatively rapid-onset gait disturbance, severe dysarthria, and consciousness disturbance. Brain T2-weighted MRI showed the lentiform fork sign. Hemodialysis was performed the day before admission, and laboratory tests showed mild metabolic (lactic) acidosis, but no uremia. Surprisingly, metformin, which is contraindicated for patients with end-stage kidney disease, had been prescribed for 6 months in his medication record, and his sluggish speaking and dysarthria appeared gradually after metformin treatment was started. Thus, the encephalopathy was considered to be related to metformin treatment. He received hemodialysis treatment for 6 consecutive days, and his consciousness disturbance and dysarthria improved in 1 week. At the 8-month follow-up, the size of the hyperintensity area on MRI had decreased, while the mild gait disturbance remained. Considering the rapid onset of gait and consciousness disturbance immediately before admission, diabetic uremic syndrome may also have occurred with metformin-related encephalopathy, and resulted in the lentiform fork sign, despite the patient showing no evidence of severe uremia on laboratory data.
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Affiliation(s)
- Yuri Ishizaki
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Ryuzoh Nishizono
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Masao Kikuchi
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Hiroko Inagaki
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yuji Sato
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Shouichi Fujimoto
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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25
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Catar R, Moll G, Kamhieh-Milz J, Luecht C, Chen L, Zhao H, Ernst L, Willy K, Girndt M, Fiedler R, Witowski J, Morawietz H, Ringdén O, Dragun D, Eckardt KU, Schindler R, Zickler D. Expanded Hemodialysis Therapy Ameliorates Uremia-Induced Systemic Microinflammation and Endothelial Dysfunction by Modulating VEGF, TNF-α and AP-1 Signaling. Front Immunol 2021; 12:774052. [PMID: 34858433 PMCID: PMC8632537 DOI: 10.3389/fimmu.2021.774052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 10/20/2021] [Indexed: 12/15/2022] Open
Abstract
Abstract Systemic chronic microinflammation and altered cytokine signaling, with adjunct cardiovascular disease (CVD), endothelial maladaptation and dysfunction is common in dialysis patients suffering from end-stage renal disease and associated with increased morbidity and mortality. New hemodialysis filters might offer improvements. We here studied the impact of novel improved molecular cut-off hemodialysis filters on systemic microinflammation, uremia and endothelial dysfunction. Human endothelial cells (ECs) were incubated with uremic serum obtained from patients treated with two different hemodialysis regimens in the Permeability Enhancement to Reduce Chronic Inflammation (PERCI-II) crossover clinical trial, comparing High-Flux (HF) and Medium Cut-Off (MCO) membranes, and then assessed for their vascular endothelial growth factor (VEGF) production and angiogenesis. Compared to HF membranes, dialysis with MCO membranes lead to a reduction in proinflammatory mediators and reduced endothelial VEGF production and angiogenesis. Cytokine multiplex screening identified tumor necrosis factor (TNF) superfamily members as promising targets. The influence of TNF-α and its soluble receptors (sTNF-R1 and sTNF-R2) on endothelial VEGF promoter activation, protein release, and the involved signaling pathways was analyzed, revealing that this detrimental signaling was indeed induced by TNF-α and mediated by AP-1/c-FOS signaling. In conclusion, uremic toxins, in particular TNF-signaling, promote endothelial maladaptation, VEGF expression and aberrant angiogenesis, which can be positively modulated by dialysis with novel MCO membranes. Translational Perspective and Graphical Abstract Systemic microinflammation, altered cytokine signaling, cardiovascular disease, and endothelial maladaptation/dysfunction are common clinical complications in dialysis patients suffering from end-stage renal disease. We studied the impact of novel improved medium-cut-off hemodialysis filters on uremia and endothelial dysfunction. We can show that uremic toxins, especially TNF-signaling, promote endothelial maladaptation, VEGF expression and aberrant angiogenesis, which can be positively modulated by dialysis with novel improved medium-cut-off membranes.
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Affiliation(s)
- Rusan Catar
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Guido Moll
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
- BIH Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
- Berlin-Brandenburg School for Regenerative Therapies (BSRT), Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Julian Kamhieh-Milz
- Institute of Transfusion Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Christian Luecht
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Lei Chen
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Hongfan Zhao
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Lucas Ernst
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Kevin Willy
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
- Department of Cardiology, University Hospital Münster, Münster, Germany
| | - Matthias Girndt
- Department of Internal Medicine II, Martin-Luther-University Halle, Halle, Germany
| | - Roman Fiedler
- Department of Internal Medicine II, Martin-Luther-University Halle, Halle, Germany
| | - Janusz Witowski
- Department of Pathophysiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Henning Morawietz
- Division of Vascular Endothelium and Microcirculation, Department of Medicine III, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Olle Ringdén
- Division of Therapeutic Immunology (TIM), Department of Laboratory Medicine (LABMED), Karolinska Institutet, Stockholm, Sweden
| | - Duska Dragun
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Kai-Uwe Eckardt
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Ralf Schindler
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
| | - Daniel Zickler
- Department of Nephrology and Internal Intensive Care Medicine, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Berlin, Germany
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Bakre A, Aradhey P, Acharya S, Kumar S. The relationship of electrophysiological parameters of uremic polyneuropathy and uremic toxins in patients with chronic kidney disease. Saudi J Kidney Dis Transpl 2021; 32:1264-1272. [PMID: 35532695 DOI: 10.4103/1319-2442.344745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Abstract
We aimed to study the correlation of measurable uremic toxins with electrophysiological parameters of uremic polyneuropathy in chronic kidney disease (CKD) patients. This study was conducted between January 2018 and December 2018, 40 CKD patients on hemodialysis (HD) and 40 controls were included in the present study. Prevalence of peripheral neuropathy in CKD patients was 50% clinically and 65% of patients found to have neuropathy by electrophysiological study. The mean age of patients was 36.9 ± 12 years in which, 26 (65%) were male and 14 (35%) were female. All patients were recently diagnosed CKD on HD since <1 year duration. In the present study 16 (40%) patients had mild-to-moderate neuropathy and 4 (10%) had severe neuropathy according to modified NDS score. The most common pattern of neuropathy was axonal and mixed sensorimotor. On correlation of serum creatinine (Cr) and blood urea nitrogen (BUN) with nerve conduction study parameters, statistically significant association was present but other uremic toxins including serum potassium, calcium, phosphorus, uric acid, and parathyroid hormone did not correlate with neuropathy indices. Peripheral neuropathy is common in CKD patients causing significant morbidity at very early stage and though BUN and Cr are dialyzable toxins, they correlate significantly with neuropathy severity and can be guiding markers for optimization of dialysis therapy.
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Affiliation(s)
- Anand Bakre
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India
| | - Parag Aradhey
- Department of Neurology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India
| | - Sourya Acharya
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India
| | - Sunil Kumar
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (Meghe), Wardha, Maharashtra, India
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Lu PH, Yu MC, Wei MJ, Kuo KL. The Therapeutic Strategies for Uremic Toxins Control in Chronic Kidney Disease. Toxins (Basel) 2021; 13:573. [PMID: 34437444 PMCID: PMC8402511 DOI: 10.3390/toxins13080573] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 08/04/2021] [Accepted: 08/16/2021] [Indexed: 12/27/2022] Open
Abstract
Uremic toxins (UTs) are mainly produced by protein metabolized by the intestinal microbiota and converted in the liver or by mitochondria or other enzymes. The accumulation of UTs can damage the intestinal barrier integrity and cause vascular damage and progressive kidney damage. Together, these factors lead to metabolic imbalances, which in turn increase oxidative stress and inflammation and then produce uremia that affects many organs and causes diseases including renal fibrosis, vascular disease, and renal osteodystrophy. This article is based on the theory of the intestinal-renal axis, from bench to bedside, and it discusses nonextracorporeal therapies for UTs, which are classified into three categories: medication, diet and supplement therapy, and complementary and alternative medicine (CAM) and other therapies. The effects of medications such as AST-120 and meclofenamate are described. Diet and supplement therapies include plant-based diet, very low-protein diet, probiotics, prebiotics, synbiotics, and nutraceuticals. The research status of Chinese herbal medicine is discussed for CAM and other therapies. This review can provide some treatment recommendations for the reduction of UTs in patients with chronic kidney disease.
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Affiliation(s)
- Ping-Hsun Lu
- Department of Chinese Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 23142, Taiwan; (P.-H.L.); (M.-C.Y.); (M.-J.W.)
- School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien 97048, Taiwan
| | - Min-Chien Yu
- Department of Chinese Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 23142, Taiwan; (P.-H.L.); (M.-C.Y.); (M.-J.W.)
- School of Post-Baccalaureate Chinese Medicine, Tzu Chi University, Hualien 97048, Taiwan
| | - Meng-Jiun Wei
- Department of Chinese Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 23142, Taiwan; (P.-H.L.); (M.-C.Y.); (M.-J.W.)
| | - Ko-Lin Kuo
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 23142, Taiwan
- School of Medicine, Buddhist Tzu Chi University, Hualien 97048, Taiwan
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Khanh VC, Fukushige M, Chang YH, Hoang NN, Yamashita T, Obata-Yasuoka M, Hamada H, Osaka M, Hiramatsu Y, Ohneda O. Wharton's Jelly Mesenchymal Stem Cell-Derived Extracellular Vesicles Reduce SARS-CoV2-Induced Inflammatory Cytokines Under High Glucose and Uremic Toxin Conditions. Stem Cells Dev 2021; 30:758-772. [PMID: 34074129 PMCID: PMC8356045 DOI: 10.1089/scd.2021.0065] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/31/2021] [Indexed: 01/08/2023] Open
Abstract
Cytokine storm is recognized as one of the factors contributing to organ failures and mortality in patients with COVID-19. Due to chronic inflammation, COVID-19 patients with diabetes mellitus (DM) or renal disease (RD) have more severe symptoms and higher mortality. However, the factors that contribute to severe outcomes of COVID-19 patients with DM and RD have received little attention. In an effort to investigate potential treatments for COVID-19, recent research has focused on the immunomodulation functions of mesenchymal stem cells (MSCs). In this study, the correlation between DM and RD and the severity of COVID-19 was examined by a combined approach with a meta-analysis and experimental research. The results of a systematic review and meta-analysis suggested that the odd of mortality in patients with both DM and RD was increased in comparison to those with a single comorbidity. In addition, in the experimental research, the data showed that high glucose and uremic toxins contributed to the induction of cytokine storm in human lung adenocarcinoma epithelial cells (Calu-3 cells) in response to SARS-CoV Peptide Pools. Of note, the incorporation of Wharton's jelly MSC-derived extracellular vesicles (WJ-EVs) into SARS-CoV peptide-induced Calu-3 resulted in a significant decrease in nuclear NF-κB p65 and the downregulation of the cytokine storm under high concentrations of glucose and uremic toxins. This clearly suggests the potential for WJ-EVs to reduce cytokine storm reactions in patients with both chronic inflammation diseases and viral infection.
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Affiliation(s)
- Vuong Cat Khanh
- Laboratory of Regenerative Medicine and Stem Cell Biology, Departments of University of Tsukuba, Tsukuba, Japan
| | - Mizuho Fukushige
- Laboratory of Regenerative Medicine and Stem Cell Biology, Departments of University of Tsukuba, Tsukuba, Japan
| | - Yun Hsuan Chang
- Laboratory of Regenerative Medicine and Stem Cell Biology, Departments of University of Tsukuba, Tsukuba, Japan
| | - Ngo Nhat Hoang
- Laboratory of Regenerative Medicine and Stem Cell Biology, Departments of University of Tsukuba, Tsukuba, Japan
| | - Toshiharu Yamashita
- Laboratory of Regenerative Medicine and Stem Cell Biology, Departments of University of Tsukuba, Tsukuba, Japan
| | | | - Hiromi Hamada
- Obstetrics and Gynecology, University of Tsukuba, Tsukuba, Japan
| | - Motoo Osaka
- Cardiovascular Surgery, University of Tsukuba, Tsukuba, Japan
| | - Yuji Hiramatsu
- Cardiovascular Surgery, University of Tsukuba, Tsukuba, Japan
| | - Osamu Ohneda
- Laboratory of Regenerative Medicine and Stem Cell Biology, Departments of University of Tsukuba, Tsukuba, Japan
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Bai YF, Wang CL, Xu MZ, Pan MJ, Sun QY, Chen RM. The clinical effectiveness and safety of traditional Chinese medicine uremic clearance granule combined with high-flux hemodialysis in the treatment of uremic pruritus: A protocol for systematic review and meta analysis. Medicine (Baltimore) 2021; 100:e26423. [PMID: 34160430 PMCID: PMC8238327 DOI: 10.1097/md.0000000000026423] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 06/03/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Skin pruritus is a common complication in patients with uremia. When the hemodialysis time of patients is extended, and the probability of skin pruritus is greater. Patients often have the symptoms of skin pruritus intolerable, affecting the normal sleep and normal life of patients. The patients with uremic pruritus often constant scratching and pruritus skin, resulting in broken skin, and further symptoms such as infection, and subsequent skin shedding, prurigo nodularis, and other adverse complications, aggravating the patient's condition. Some patients will experience symptoms such as depression and insomnia due to skin pruritus, and simply scratching the skin lead to infection. Severely affected patients may even show suicidal tendency, endangering the physical and mental health of patients, and it is needed to give the effective treatment to patients. Hemodialysis is a common treatment for uremic pruritus, which can effectively relieve the pruritus symptoms of patients. The drugs can also relieve the symptoms and improve the degree of pruritus in patients. And some studies show that traditional Chinese medicine UCG combined with HFH in the treatment of uremic pruritus has a very good effect, Therefore, this study will systematically evaluate the clinical efficacy and safety of UCG combined with HFH and HFH alone in the treatment of uremic pruritus. METHODS Use computer to search English and Chinese databases, English databases include: PubMed, Web of Science, EMbase, The Cochrane Library. Chinese databases include: CNKI, CBM, WanFang Data and VIP databases, collecting the RCT on the clinical effectiveness and safety of UCG combined with HFH and HFH alone in the treatment of uremic pruritus. The retrieval time is from the beginning of each database to May 1, 2021. In order to improve the retrieval rate of the literature, the references cited in the included research are also collected and screened. Set Chinese and English as the search language. Two members of the research group independently collected, included and excluded the literatures. In case of disagreement, consulting the third party to assist in the judgment. For the literature with missing data, the original author should be contacted as far as possible to obtain complete data. Two evaluators evaluate the bias risk of included studies according to the Cochrane Handbook bias risk assessment tool for RCT. RevMan 5.3 software is used for statistical analysis and the forest plot is drawn to show the outcome indicators and funnel plot is drawn to show the publication bias. RESULTS This study evaluates the advantages and disadvantages of traditional Chinese medicine UCG combined with HFH and HFH alone in the treatment of uremic pruritus through the clinical effectiveness and safety-related indicators. CONCLUSION This study will give a positive conclusion on the efficacy and safety of uremic clearance granule in the treatment of uremic pruritus, and the research results will be published in professional journals in the form of academic papers, thus benefiting more patients. ETHICS AND DISSEMINATION This study belongs to meta-analysis and all data comes from academic papers published publicly in formal academic journals, so there are no ethical issues involved in this study and no ethical review or approval is required. OSF REGISTRATION NUMBER DOI 10.17605/OSF.IO/W8P5G.
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Cupisti A, Bolasco P, D’Alessandro C, Giannese D, Sabatino A, Fiaccadori E. Protection of Residual Renal Function and Nutritional Treatment: First Step Strategy for Reduction of Uremic Toxins in End-Stage Kidney Disease Patients. Toxins (Basel) 2021; 13:toxins13040289. [PMID: 33921862 PMCID: PMC8073165 DOI: 10.3390/toxins13040289] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 02/06/2023] Open
Abstract
The retention of uremic toxins and their pathological effects occurs in the advanced phases of chronic kidney disease (CKD), mainly in stage 5, when the implementation of conventional thrice-weekly hemodialysis is the prevalent and life-saving treatment. However, the start of hemodialysis is associated with both an acceleration of the loss of residual kidney function (RKF) and the shift to an increased intake of proteins, which are precursors of uremic toxins. In this phase, hemodialysis treatment is the only way to remove toxins from the body, but it can be largely inefficient in the case of high molecular weight and/or protein-bound molecules. Instead, even very low levels of RKF are crucial for uremic toxins excretion, which in most cases are protein-derived waste products generated by the intestinal microbiota. Protection of RKF can be obtained even in patients with end-stage kidney disease (ESKD) by a gradual and soft shift to kidney replacement therapy (KRT), for example by combining a once-a-week hemodialysis program with a low or very low-protein diet on the extra-dialysis days. This approach could represent a tailored strategy aimed at limiting the retention of both inorganic and organic toxins. In this paper, we discuss the combination of upstream (i.e., reduced production) and downstream (i.e., increased removal) strategies to reduce the concentration of uremic toxins in patients with ESKD during the transition phase from pure conservative management to full hemodialysis treatment.
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Affiliation(s)
- Adamasco Cupisti
- Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy; (C.D.); (D.G.)
- “Conservative Treatment of Chronic Kidney Disease” Project Group of the Italian Society of Nephrology, 00185 Rome, Italy;
- Correspondence:
| | - Piergiorgio Bolasco
- “Conservative Treatment of Chronic Kidney Disease” Project Group of the Italian Society of Nephrology, 00185 Rome, Italy;
| | - Claudia D’Alessandro
- Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy; (C.D.); (D.G.)
- “Conservative Treatment of Chronic Kidney Disease” Project Group of the Italian Society of Nephrology, 00185 Rome, Italy;
| | - Domenico Giannese
- Department of Clinical and Experimental Medicine, University of Pisa, 56121 Pisa, Italy; (C.D.); (D.G.)
| | - Alice Sabatino
- Department of Medicine and Surgery, University of Parma, Nephrology Unit, Parma University Hospital, 43121 Parma, Italy; (A.S.); (E.F.)
| | - Enrico Fiaccadori
- Department of Medicine and Surgery, University of Parma, Nephrology Unit, Parma University Hospital, 43121 Parma, Italy; (A.S.); (E.F.)
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Paats J, Adoberg A, Arund J, Fridolin I, Lauri K, Leis L, Luman M, Tanner R. Optical Method and Biochemical Source for the Assessment of the Middle-Molecule Uremic Toxin β2-Microglobulin in Spent Dialysate. Toxins (Basel) 2021; 13:toxins13040255. [PMID: 33807387 PMCID: PMC8067283 DOI: 10.3390/toxins13040255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 03/23/2021] [Accepted: 03/29/2021] [Indexed: 02/07/2023] Open
Abstract
Optical monitoring of spent dialysate has been used to estimate the removal of water-soluble low molecular weight as well as protein-bound uremic toxins from the blood of end stage kidney disease (ESKD) patients. The aim of this work was to develop an optical method to estimate the removal of β2-microglobulin (β2M), a marker of middle molecule (MM) uremic toxins, during hemodialysis (HD) treatment. Ultraviolet (UV) and fluorescence spectra of dialysate samples were recorded from 88 dialysis sessions of 22 ESKD patients, receiving four different settings of dialysis treatments. Stepwise regression was used to obtain the best model for the assessment of β2M concentration in the spent dialysate. The correlation coefficient 0.958 and an accuracy of 0.000 ± 0.304 mg/L was achieved between laboratory and optically estimated β2M concentrations in spent dialysate for the entire cohort. Optically and laboratory estimated reduction ratio (RR) and total removed solute (TRS) of β2M were not statistically different (p > 0.35). Dialytic elimination of MM uremic toxin β2M can be followed optically during dialysis treatment of ESKD patients. The main contributors to the optical signal of the MM fraction in the spent dialysate were provisionally identified as tryptophan (Trp) in small peptides and proteins, and advanced glycation end-products.
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Affiliation(s)
- Joosep Paats
- Department of Health Technologies, Tallinn University of Technology, 19086 Tallinn, Estonia; (J.A.); (I.F.); (K.L.); (M.L.); (R.T.)
- Correspondence:
| | - Annika Adoberg
- Centre of Nephrology, North Estonia Medical Centre, 13419 Tallinn, Estonia; (A.A.); (L.L.)
| | - Jürgen Arund
- Department of Health Technologies, Tallinn University of Technology, 19086 Tallinn, Estonia; (J.A.); (I.F.); (K.L.); (M.L.); (R.T.)
| | - Ivo Fridolin
- Department of Health Technologies, Tallinn University of Technology, 19086 Tallinn, Estonia; (J.A.); (I.F.); (K.L.); (M.L.); (R.T.)
| | - Kai Lauri
- Department of Health Technologies, Tallinn University of Technology, 19086 Tallinn, Estonia; (J.A.); (I.F.); (K.L.); (M.L.); (R.T.)
- SYNLAB Eesti OÜ, 10138 Tallinn, Estonia
| | - Liisi Leis
- Centre of Nephrology, North Estonia Medical Centre, 13419 Tallinn, Estonia; (A.A.); (L.L.)
| | - Merike Luman
- Department of Health Technologies, Tallinn University of Technology, 19086 Tallinn, Estonia; (J.A.); (I.F.); (K.L.); (M.L.); (R.T.)
- Centre of Nephrology, North Estonia Medical Centre, 13419 Tallinn, Estonia; (A.A.); (L.L.)
| | - Risto Tanner
- Department of Health Technologies, Tallinn University of Technology, 19086 Tallinn, Estonia; (J.A.); (I.F.); (K.L.); (M.L.); (R.T.)
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Gomez M, Bañon-Maneus E, Arias-Guillén M, Fontseré N, Broseta JJ, Ojeda R, Maduell F. Distinct Solute Removal Patterns by Similar Surface High-Flux Membranes in Haemodiafiltration: The Adsorption Point of View. Blood Purif 2021; 51:38-46. [PMID: 33789268 DOI: 10.1159/000514936] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 02/01/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Haemodialysis (HD) allow depuration of uraemic toxins by diffusion, convection, and adsorption. Online haemodiafiltration (HDF) treatments add high convection to enhance removal. There are no prior studies on the relationship between convection and adsorption in HD membranes. The possible benefits conferred by intrinsic adsorption on protein-bound uraemic toxins (PBUTs) removal are unknown. METHODS Twenty-two patients underwent their second 3-days per week HD sessions with randomly selected haemodialysers (polysulfone, polymethylmethacrylate, cellulose triacetate, and polyamide copolymer) in high-flux HD and HDF. Blood samples were taken at the beginning and at the end of the treatment to assess the reduction ratio (RR) in a wide range of molecular weight uraemic toxins. A mid-range removal score (GRS) was also calculated. An elution protocol was implemented to quantify the amount of adsorbed mass (Mads) for each molecule in every dialyser. RESULTS All synthetic membranes achieved higher RR for all toxins when used in HDF, specially the polysulfone haemodialyser, resulting in a GRS = 0.66 ± 0.06 (p < 0.001 vs. cellulose triacetate and polyamide membranes). Adsorption was slightly enhanced by convection for all membranes. The polymethylmethacrylate membrane showed expected substantial adsorption of β2-microglobulin (MadsHDF = 3.5 ± 2.1 mg vs. MadsHD = 2.1 ± 0.9 mg, p = 0.511), whereas total protein adsorption was pronounced in the cellulose triacetate membrane (MadsHDF = 427.2 ± 207.9 mg vs. MadsHD = 274.7 ± 138.3 mg, p = 0.586) without enhanced PBUT removal. DISCUSSION/CONCLUSION Convection improves removal and slightly increases adsorption. Adsorbed proteins do not lead to enhanced PBUTs depuration and limit membrane efficiency due to fouling. Selection of the correct membrane for convective therapies is mandatory to optimize removal efficiency.
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Affiliation(s)
- Miquel Gomez
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundacio Clínic per la Recerca Biomedica (FCRB), Hospital Clínic de Barcelona, Barcelona, Spain
| | - Elisenda Bañon-Maneus
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundacio Clínic per la Recerca Biomedica (FCRB), Hospital Clínic de Barcelona, Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | | | - Néstor Fontseré
- Department of Nephrology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - José Jesús Broseta
- Department of Nephrology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Raquel Ojeda
- Department of Nephrology, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Francisco Maduell
- Department of Nephrology, Hospital Clinic de Barcelona, Barcelona, Spain
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Rysz J, Franczyk B, Ławiński J, Olszewski R, Ciałkowska-Rysz A, Gluba-Brzózka A. The Impact of CKD on Uremic Toxins and Gut Microbiota. Toxins (Basel) 2021; 13:toxins13040252. [PMID: 33807343 PMCID: PMC8067083 DOI: 10.3390/toxins13040252] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/23/2021] [Accepted: 03/28/2021] [Indexed: 12/11/2022] Open
Abstract
Numerous studies have indicated that the progression of chronic kidney disease (CKD) to end-stage renal disease (ESRD) is strictly associated with the accumulation of toxic metabolites in blood and other metabolic compartments. This accumulation was suggested to be related to enhanced generation of toxins from the dysbiotic microbiome accompanied by their reduced elimination by impaired kidneys. Intestinal microbiota play a key role in the accumulation of uremic toxins due to the fact that numerous uremic solutes are generated in the process of protein fermentation by colonic microbiota. Some disease states, including CKD, are associated with the presence of dysbiosis, which can be defined as an "imbalanced intestinal microbial community with quantitative and qualitative changes in the composition and metabolic activities of the gut microbiota". The results of studies have confirmed the altered composition and functions of gut microbial community in chronic kidney disease. In the course of CKD protein-bound uremic toxins, including indoxyl sulfate, p-cresyl glucuronide, p-cresyl sulfate and indole-3-acetic acid are progressively accumulated. The presence of chronic kidney disease may be accompanied by the development of intestinal inflammation and epithelial barrier impairment leading to hastened systemic translocation of bacterial-derived uremic toxins and consequent oxidative stress injury to the kidney, cardiovascular and endocrine systems. These findings offer new therapeutic possibilities for the management of uremia, inflammation and kidney disease progression and the prevention of adverse outcomes in CKD patients. It seems that dietary interventions comprising prebiotics, probiotics, and synbiotics could pose a promising strategy in the management of uremic toxins in CKD.
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Affiliation(s)
- Jacek Rysz
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-549 Lodz, Poland; (J.R.); (B.F.)
| | - Beata Franczyk
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-549 Lodz, Poland; (J.R.); (B.F.)
| | - Janusz Ławiński
- Department of Urology, Institute of Medical Sciences, Medical College of Rzeszow University, 35-055 Rzeszow, Poland;
| | - Robert Olszewski
- Department of Gerontology, Public Health and Didactics, Rheumatology and Rehabilitation, National Institute of Geriatrics, 02-637 Warsaw, Poland;
- Department of Ultrasound, Institute of Fundamental Technological Research, Polish Academy of Sciences, 02-637 Warsaw, Poland
| | | | - Anna Gluba-Brzózka
- Department of Nephrology, Hypertension and Family Medicine, Medical University of Lodz, 90-549 Lodz, Poland; (J.R.); (B.F.)
- Correspondence: ; Tel.: +48-42-6393750
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Magnani S, Atti M. Uremic Toxins and Blood Purification: A Review of Current Evidence and Future Perspectives. Toxins (Basel) 2021; 13:toxins13040246. [PMID: 33808345 PMCID: PMC8066023 DOI: 10.3390/toxins13040246] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 12/15/2022] Open
Abstract
Accumulation of uremic toxins represents one of the major contributors to the rapid progression of chronic kidney disease (CKD), especially in patients with end-stage renal disease that are undergoing dialysis treatment. In particular, protein-bound uremic toxins (PBUTs) seem to have an important key pathophysiologic role in CKD, inducing various cardiovascular complications. The removal of uremic toxins from the blood with dialytic techniques represents a proved approach to limit the CKD-related complications. However, conventional dialysis mainly focuses on the removal of water-soluble compounds of low and middle molecular weight, whereas PBTUs are strongly protein-bound, thus not efficiently eliminated. Therefore, over the years, dialysis techniques have been adapted by improving membranes structures or using combined strategies to maximize PBTUs removal and eventually prevent CKD-related complications. Recent findings showed that adsorption-based extracorporeal techniques, in addition to conventional dialysis treatment, may effectively adsorb a significant amount of PBTUs during the course of the sessions. This review is focused on the analysis of the current state of the art for blood purification strategies in order to highlight their potentialities and limits and identify the most feasible solution to improve toxins removal effectiveness, exploring possible future strategies and applications, such as the study of a synergic approach by reducing PBTUs production and increasing their blood clearance.
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Herič T, Vivoda T, Bogataj Š, Pajek J. Medium Cut-Off Dialysis Membrane and Dietary Fiber Effects on Inflammation and Protein-Bound Uremic Toxins: A Systematic Review and Protocol for an Interventional Study. Toxins (Basel) 2021; 13:toxins13040244. [PMID: 33805509 PMCID: PMC8066258 DOI: 10.3390/toxins13040244] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/22/2021] [Accepted: 03/25/2021] [Indexed: 02/07/2023] Open
Abstract
The aim of this systematic review is to investigate the effects of the use of a medium cut-off membrane (MCO) and dietary fiber on the concentration of protein-bound uremic toxins (PBUTs) and inflammatory markers in hemodialysis (HD) patients. Of 11,397 papers originally found, eight met the criteria of randomized controlled trial design. No study examined the effects of MCO membranes on PBUTs. Three studies examined the reduction in inflammatory markers with MCO membranes compared to high-flux HD membranes and showed no significant differences. Five studies of dietary fiber supplementation showed an inconclusive positive effect on PBUT levels and a significant positive effect on the reduction in inflammatory markers (interleukin-6 reduction: standardized difference in means −1.18; 95% confidence interval −1.45 to −0.9 for dietary fiber supplementation vs. control; p < 0.001). To date, no study has combined the use of an MCO membrane and fiber supplementation to reduce PBUT levels and inflammation with online hemodiafiltration as a comparator. A rationale and protocol for an interventional trial using a combination of MCO membrane dialysis and fiber supplementation to lower inflammatory markers and PBUT concentrations are presented.
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Affiliation(s)
- Tjaša Herič
- Department of Nephrology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (T.H.); (T.V.); (Š.B.)
| | - Tjaša Vivoda
- Department of Nephrology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (T.H.); (T.V.); (Š.B.)
| | - Špela Bogataj
- Department of Nephrology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (T.H.); (T.V.); (Š.B.)
| | - Jernej Pajek
- Department of Nephrology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia; (T.H.); (T.V.); (Š.B.)
- Department of Internal Medicine, Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
- Correspondence:
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Cohen G. Effect of High-Density Lipoprotein from Healthy Subjects and Chronic Kidney Disease Patients on the CD14 Expression on Polymorphonuclear Leukocytes. Int J Mol Sci 2021; 22:ijms22062830. [PMID: 33799511 PMCID: PMC7998954 DOI: 10.3390/ijms22062830] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/26/2021] [Accepted: 03/08/2021] [Indexed: 01/22/2023] Open
Abstract
In uremic patients, high-density lipoprotein (HDL) loses its anti-inflammatory features and can even become pro-inflammatory due to an altered protein composition. In chronic kidney disease (CKD), impaired functions of polymorphonuclear leukocytes (PMNLs) contribute to inflammation and an increased risk of cardiovascular disease. This study investigated the effect of HDL from CKD and hemodialysis (HD) patients on the CD14 expression on PMNLs. HDL was isolated using a one-step density gradient centrifugation. Isolation of PMNLs was carried out by discontinuous Ficoll-Hypaque density gradient centrifugation. CD14 surface expression was quantified by flow cytometry. The activity of the small GTPase Rac1 was determined by means of an activation pull-down assay. HDL increased the CD14 surface expression on PMNLs. This effect was more pronounced for HDL isolated from uremic patients. The acute phase protein serum amyloid A (SAA) caused higher CD14 expression, while SAA as part of an HDL particle did not. Lipid raft disruption with methyl-β-cyclodextrin led to a reduced CD14 expression in the absence and presence of HDL. HDL from healthy subjects but not from HD patients decreased the activity of Rac1. Considering the known anti-inflammatory effects of HDL, the finding that even HDL from healthy subjects increased the CD14 expression was unexpected. The pathophysiological relevance of this result needs further investigation.
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Affiliation(s)
- Gerald Cohen
- Department of Nephrology and Dialysis, Medical University of Vienna, A-1090 Vienna, Austria
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Abstract
Chronic kidney disease and seizures often co-exist. When seizures are provoked in patients with kidney disease, their treatment poses a particular challenge. Seizures may be provoked in the context of uremia, and toxic substances associated with uremic encephalopathy. In that case, the mainstay of therapy is to treat the uremia before consideration for anticonvulsant therapy. Treatment of seizures in the setting of chronic kidney disease requires special attention to selection of anticonvulsant medications and knowledge of the altered pharmacokinetics of these medications, which may require special titration schedule in that setting. The purpose of this review is to summarize the current knowledge about inter-relation of seizures and kidney disease. The review will also help practitioners who treat patients with renal failure and coexisting seizures in choosing the best treatment options.
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Affiliation(s)
- Mona Sazgar
- Clinical Professor, Department of Neurology/ UC Irvine Health, Comprehensive Epilepsy Program, 101 The City Drive South/ Pavilion I/ Suite 123, Orange, CA 92868-3201, USA.
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Yamamoto S, Sasahara K, Domon M, Yamaguchi K, Ito T, Goto S, Goto Y, Narita I. pH-Dependent Protein Binding Properties of Uremic Toxins In Vitro. Toxins (Basel) 2021; 13:toxins13020116. [PMID: 33557434 PMCID: PMC7914709 DOI: 10.3390/toxins13020116] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/30/2021] [Accepted: 02/01/2021] [Indexed: 12/22/2022] Open
Abstract
Protein-bound uremic toxins (PBUTs) are difficult to remove using conventional dialysis treatment owing to their high protein-binding affinity. As pH changes the conformation of proteins, it may be associated with the binding of uremic toxins. Albumin conformation at pH 2 to 13 was analyzed using circular dichroism. The protein binding behavior between indoxyl sulfate (IS) and albumin was examined using isothermal titration calorimetry. Albumin with IS, and serum with IS, p-cresyl sulfate, indole acetic acid or phenyl sulfate, as well as serum from hemodialysis patients, were adjusted pH of 3 to 11, and the concentration of the free PBUTs was measured using mass spectrometry. Albumin was unfolded at pH < 4 or >12, and weakened interaction with IS occurred at pH < 5 or >10. The concentration of free IS in the albumin solution was increased at pH 4.0 and pH 11.0. Addition of human serum to each toxin resulted in increased free forms at acidic and alkaline pH. The pH values of serums from patients undergoing hemodialysis adjusted to 3.4 and 11.3 resulted in increased concentrations of the free forms of PBUTs. In conclusion, acidic and alkaline pH conditions changed the albumin conformation and weakened the protein binding property of PBUTs in vitro.
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Affiliation(s)
- Suguru Yamamoto
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata 951-8510, Japan; (M.D.); (T.I.); (S.G.); (I.N.)
- Correspondence: ; Tel.: +81-25-227-2200
| | - Kenichi Sasahara
- Institute for Protein Research, Osaka University, Yamadaoka 3-2, Suita, Osaka 565-0871, Japan; (K.S.); (K.Y.); (Y.G.)
| | - Mio Domon
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata 951-8510, Japan; (M.D.); (T.I.); (S.G.); (I.N.)
| | - Keiichi Yamaguchi
- Institute for Protein Research, Osaka University, Yamadaoka 3-2, Suita, Osaka 565-0871, Japan; (K.S.); (K.Y.); (Y.G.)
| | - Toru Ito
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata 951-8510, Japan; (M.D.); (T.I.); (S.G.); (I.N.)
| | - Shin Goto
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata 951-8510, Japan; (M.D.); (T.I.); (S.G.); (I.N.)
| | - Yuji Goto
- Institute for Protein Research, Osaka University, Yamadaoka 3-2, Suita, Osaka 565-0871, Japan; (K.S.); (K.Y.); (Y.G.)
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata 951-8510, Japan; (M.D.); (T.I.); (S.G.); (I.N.)
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Tantisattamo E, Kalantar-Zadeh K. Editorial: Novel therapeutic approaches in chronic kidney disease, uremia and kidney transplantation: past, present and future. Curr Opin Nephrol Hypertens 2021; 30:1-4. [PMID: 33186225 DOI: 10.1097/mnh.0000000000000677] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Ekamol Tantisattamo
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, University of California Irvine School of Medicine, Orange, California
- Nephrology Section, Department of Medicine, Veterans Affairs Long Beach Healthcare System, Long Beach, California
- Multi-Organ Transplant Center, Section of Nephrology, Department of Internal Medicine, William Beaumont Hospital, Oakland University William Beaumont School of Medicine, Royal Oak, Michigan
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Kidney Disease Research and Epidemiology, Division of Nephrology, Hypertension and Kidney Transplantation, Department of Medicine, University of California Irvine School of Medicine, Orange, California
- Nephrology Section, Department of Medicine, Veterans Affairs Long Beach Healthcare System, Long Beach, California
- Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center, Torrance, California, USA
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Sumida K, Lau WL, Kovesdy CP, Kalantar-Zadeh K, Kalantar-Zadeh K. Microbiome modulation as a novel therapeutic approach in chronic kidney disease. Curr Opin Nephrol Hypertens 2021; 30:75-84. [PMID: 33148949 DOI: 10.1097/mnh.0000000000000661] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Gut dysbiosis has been implicated in the pathogenesis of chronic kidney disease (CKD). Interventions aimed at restoring gut microbiota have emerged as a potential therapeutic option in CKD. This review summarizes the current evidence on gut microbiota-targeted strategies in patients with CKD. RECENT FINDINGS A growing number of studies have shown that plant-based diets, low-protein diets, prebiotic, probiotic, and synbiotic supplementation, and constipation treatment may lead to favorable alterations in the gut microbiota. Current evidence suggests that the implementation of both plant-based and low-protein diets has potential benefits for the primary prevention of CKD, and for slowing CKD progression, with minimal risk of hyperkalemia and/or cachexia. The use of prebiotics, probiotics, and synbiotics and laxatives may have beneficial effects on uremic toxin generation, but their evidence is limited for the prevention and treatment of CKD. Recent advances in diagnostic technologies (e.g., high-throughput sequencing and nanotechnology) could enhance rapid diagnosis, monitoring, and design of effective therapeutic strategies for mitigating gut dysbiosis in CKD. SUMMARY Plant-based and low-protein diets, prebiotic, probiotic, and synbiotic supplementation, and constipation treatment represent novel gut microbiota-targeted strategies in the conservative management of CKD, which could improve clinical outcomes in CKD.
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Affiliation(s)
- Keiichi Sumida
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Wei Ling Lau
- Division of Nephrology and Hypertension, Department of Medicine, University of California Irvine, Orange, California
| | - Csaba P Kovesdy
- Division of Nephrology, Department of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
- Nephrology Section, Memphis VA Medical Center, Memphis, Tennessee, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology and Hypertension, Department of Medicine, University of California Irvine, Orange, California
| | - Kourosh Kalantar-Zadeh
- School of Chemical Engineering, University of New South Wales, Kensington, New South Wales, Australia
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Zarantonello D, Rhee CM, Kalantar-Zadeh K, Brunori G. Novel conservative management of chronic kidney disease via dialysis-free interventions. Curr Opin Nephrol Hypertens 2021; 30:97-107. [PMID: 33186220 DOI: 10.1097/mnh.0000000000000670] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW In advanced chronic kidney disease (CKD) patients with progressive uremia, dialysis has traditionally been the dominant treatment paradigm. However, there is increasing interest in conservative and preservative management of kidney function as alternative patient-centered treatment approaches in this population. RECENT FINDINGS The primary objectives of conservative nondialytic management include optimization of quality of life and treating symptoms of end-stage renal disease (ESRD). Dietetic-nutritional therapy can be a cornerstone in the conservative management of CKD by reducing glomerular hyperfiltration, uremic toxin generation, metabolic acidosis, and phosphorus burden. Given the high symptom burden of advanced CKD patients, routine symptom assessment using validated tools should be an integral component of their treatment. As dialysis has variable effects in ameliorating symptoms, palliative care may be needed to manage symptoms such as pain, fatigue/lethargy, anorexia, and anxiety/depression. There are also emerging treatments that utilize intestinal (e.g., diarrhea induction, colonic dialysis, oral sorbents, gut microbiota modulation) and dermatologic pathways (e.g., perspiration reduction) to reduce uremic toxin burden. SUMMARY As dialysis may not confer better survival nor improved patient-centered outcomes in certain patients, conservative management is a viable treatment option in the advanced CKD population.
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Affiliation(s)
| | - Connie M Rhee
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange
| | - Kamyar Kalantar-Zadeh
- Harold Simmons Center for Chronic Disease Research and Epidemiology, University of California Irvine School of Medicine, Orange
- Tibor Rubin Veterans Affairs Medical Center, Long Beach, California, USA
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Barba C, Soulage CO, Caggiano G, Glorieux G, Fouque D, Koppe L. Effects of Fecal Microbiota Transplantation on Composition in Mice with CKD. Toxins (Basel) 2020; 12:toxins12120741. [PMID: 33255454 PMCID: PMC7761367 DOI: 10.3390/toxins12120741] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 11/07/2020] [Accepted: 11/12/2020] [Indexed: 12/18/2022] Open
Abstract
Background: Chronic kidney disease (CKD) is a renal disorder characterized by the accumulation of uremic toxins with limited strategies to reduce their concentrations. A large amount of data supports the pivotal role of intestinal microbiota in CKD complications and as a major source of uremic toxins production. Here, we explored whether fecal microbiota transplantation (FMT) could be attenuated in metabolic complication and uremic toxin accumulation in mice with CKD. Methods: Kidney failure was chemically induced by a diet containing 0.25% (w/w) of adenine for four weeks. Mice were randomized into three groups: control, CKD and CKD + FMT groups. After four weeks, CKD mice underwent fecal microbiota transplantation (FMT) from healthy mice or phosphate buffered saline as control. The gut microbiota structure, uremic toxins plasmatic concentrations, and metabolic profiles were explored three weeks after transplantation. Results: Associated with the increase of alpha diversity, we observed a noticeable improvement of gut microbiota disturbance, after FMT treatment. FMT further decreased p-cresyl sulfate accumulation and improved glucose tolerance. There was no change in kidney function. Conclusions: These data indicate that FMT limited the accumulation of uremic toxins issued from intestinal cresol pathway by a beneficial effect on gut microbiota diversity. Further studies are needed to investigate the FMT efficiency, the timing and feces amount for the transplantation before, to become a therapeutic option in CKD patients.
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Affiliation(s)
- Christophe Barba
- CarMeN Lab, INSA-Lyon, INSERM U1060, INRA, University Claude Bernard Lyon 1, 69100 Villeurbanne, France; (C.B.); (C.O.S.); (D.F.)
- Department of Nephrology, Hospices Civils de Lyon, Lyon Sud Hospital, 69310 Pierre Bénite, France
| | - Christophe O. Soulage
- CarMeN Lab, INSA-Lyon, INSERM U1060, INRA, University Claude Bernard Lyon 1, 69100 Villeurbanne, France; (C.B.); (C.O.S.); (D.F.)
| | - Gianvito Caggiano
- Nephrology, Dialysis and Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, 70124 Bari, Italy;
| | - Griet Glorieux
- Nephrology Section, Department of Internal Medicine and Pediatrics, Ghent University Hospital, 9000 Gent, Belgium;
| | - Denis Fouque
- CarMeN Lab, INSA-Lyon, INSERM U1060, INRA, University Claude Bernard Lyon 1, 69100 Villeurbanne, France; (C.B.); (C.O.S.); (D.F.)
- Department of Nephrology, Hospices Civils de Lyon, Lyon Sud Hospital, 69310 Pierre Bénite, France
| | - Laetitia Koppe
- CarMeN Lab, INSA-Lyon, INSERM U1060, INRA, University Claude Bernard Lyon 1, 69100 Villeurbanne, France; (C.B.); (C.O.S.); (D.F.)
- Department of Nephrology, Hospices Civils de Lyon, Lyon Sud Hospital, 69310 Pierre Bénite, France
- Correspondence:
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Gomez M, Bañon-Maneus E, Arias-Guillén M, Maduell F. Assessment of removal and adsorption enhancement of high-flux hemodialyzers in convective therapies by a novel in vitro uremic matrix. Sci Rep 2020; 10:17403. [PMID: 33060805 PMCID: PMC7562951 DOI: 10.1038/s41598-020-74528-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 09/24/2020] [Indexed: 11/08/2022] Open
Abstract
Adsorption properties of hemodialyzers are traditionally retrieved from diffusive treatments and mainly focused on inflammatory markers and plasma proteins. The possible depurative enhancement of middle and high molecular weight solutes, as well as protein-bound uremic toxins by adsorption in convective treatments, is not yet reported. We used discarded plasma exchanges from uremic patients and out-of-date erythrocytes as a novel in vitro uremic precursor matrix to assess removal and adsorption patterns of distinct material and structure but similar surface hemodialyzers in hemodialysis and on-line hemodiafiltration treatments. We further related the obtained results to the possible underlying membrane pore blocking mechanisms. Convection improved removal but slightly enhanced adsorption in the cellulosic and synthetic dialyzers tested. The polymethylmethacrylate hemodialyzer obtained the highest extracted ([Formula: see text]) and adsorbed ([Formula: see text]) mass values when submitted to hemodiafiltration for all molecules analyzed including albumin ([Formula: see text] g, [Formula: see text] mg), whereas the polyamide membrane obtained substantial lower results even for this molecule ([Formula: see text] g, [Formula: see text] mg) under the same treatment parameters. Hemodiafiltration in symmetric and enlarged pore hemodialyzers enhances removal and adsorption by internal pore deposition (intermediate pore-blocking) for middle and high molecular weight toxins but leads to substantial and deleterious albumin depuration.
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Affiliation(s)
- Miquel Gomez
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació Clínic per la Recerca Biomédica (FCRB), Hospital Clínic de Barcelona, Barcelona, Spain.
| | - Elisenda Bañon-Maneus
- Laboratori Experimental de Nefrologia i Trasplantament (LENIT), Fundació Clínic per la Recerca Biomédica (FCRB), Hospital Clínic de Barcelona, Barcelona, Spain
- Red de Investigación Renal (REDINREN), Madrid, Spain
| | | | - Francisco Maduell
- Department of Nephrology, Hospital Clínic de Barcelona, Barcelona, Spain
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Arai Y, Shioji S, Tanaka H, Katagiri D, Hinoshita F. A Novel Uremic Score Reflecting Accumulation of Specific Uremic Toxins More Precisely Predicts One-Year Mortality after Hemodialysis Commencement: A Retrospective Cohort Study. Toxins (Basel) 2020; 12:toxins12100634. [PMID: 33019590 PMCID: PMC7601006 DOI: 10.3390/toxins12100634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/24/2020] [Accepted: 09/30/2020] [Indexed: 11/16/2022] Open
Abstract
Uremic toxins (UTs) generally accumulate in patients developing end-stage renal disease (ESRD). Although some kinds of UTs cause early death after starting hemodialysis (HD), it remains unknown whether the degree of excessive accumulation of various UTs is associated with worsening of prognosis. We retrospectively conducted this cohort study consisting of adult patients developing ESRD who initiated HD at the National Center for Global Health and Medicine from 2010 to 2019. We created a new uremic score, which was defined as the aggregate score of the following variables reflecting uremic state: elevated blood urea nitrogen, β2-microglobulin, and anion gap before starting HD. The primary outcome was early mortality within 1-year after HD commencement. The hazard ratio (HR) and 95% confidence interval (CI) for a one-point increase in uremic score was calculated with Cox proportional hazard models adjusted by baseline conditions. We included 230 participants, 16 of whom experienced the primary outcome of early mortality after HD commencement. Uremic score was significantly associated with the primary outcome (crude HR: 1.91, 95% CI 1.16–3.14; adjusted HR: 4.19, 95% CI 1.79–9.78). Our novel uremic score, reflecting accumulation of specific UTs, more precisely predicts early mortality after HD commencement.
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Affiliation(s)
- Yohei Arai
- Department of Nephrology, National Center for Global Health and Medicine, Tokyo 162-8655, Japan; (D.K.); (F.H.)
- Department of Nephrology, Tokyo Medical and Dental University, Tokyo 113-8510, Japan
- Correspondence: ; Tel.: +81-3-3202-7181
| | - Shingo Shioji
- Department of Nephrology, Yokosuka Kyosai Hospital, Kanagawa 238-8558, Japan; (S.S.); (H.T.)
| | - Hiroyuki Tanaka
- Department of Nephrology, Yokosuka Kyosai Hospital, Kanagawa 238-8558, Japan; (S.S.); (H.T.)
| | - Daisuke Katagiri
- Department of Nephrology, National Center for Global Health and Medicine, Tokyo 162-8655, Japan; (D.K.); (F.H.)
| | - Fumihiko Hinoshita
- Department of Nephrology, National Center for Global Health and Medicine, Tokyo 162-8655, Japan; (D.K.); (F.H.)
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Rapp N, Evenepoel P, Stenvinkel P, Schurgers L. Uremic Toxins and Vascular Calcification-Missing the Forest for All the Trees. Toxins (Basel) 2020; 12:E624. [PMID: 33003628 PMCID: PMC7599869 DOI: 10.3390/toxins12100624] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 09/22/2020] [Accepted: 09/25/2020] [Indexed: 12/23/2022] Open
Abstract
The cardiorenal syndrome relates to the detrimental interplay between the vascular system and the kidney. The uremic milieu induced by reduced kidney function alters the phenotype of vascular smooth muscle cells (VSMC) and promotes vascular calcification, a condition which is strongly linked to cardiovascular morbidity and mortality. Biological mechanisms involved include generation of reactive oxygen species, inflammation and accelerated senescence. A better understanding of the vasotoxic effects of uremic retention molecules may reveal novel avenues to reduce vascular calcification in CKD. The present review aims to present a state of the art on the role of uremic toxins in pathogenesis of vascular calcification. Evidence, so far, is fragmentary and limited with only a few uremic toxins being investigated, often by a single group of investigators. Experimental heterogeneity furthermore hampers comparison. There is a clear need for a concerted action harmonizing and standardizing experimental protocols and combining efforts of basic and clinical researchers to solve the complex puzzle of uremic vascular calcification.
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MESH Headings
- Animals
- Cardio-Renal Syndrome/metabolism
- Cardio-Renal Syndrome/pathology
- Cardio-Renal Syndrome/physiopathology
- Cardio-Renal Syndrome/therapy
- Humans
- Kidney/metabolism
- Kidney/pathology
- Kidney/physiopathology
- Muscle, Smooth, Vascular/metabolism
- Muscle, Smooth, Vascular/pathology
- Muscle, Smooth, Vascular/physiopathology
- Prognosis
- Renal Insufficiency, Chronic/metabolism
- Renal Insufficiency, Chronic/pathology
- Renal Insufficiency, Chronic/physiopathology
- Renal Insufficiency, Chronic/therapy
- Toxins, Biological/metabolism
- Uremia/metabolism
- Uremia/pathology
- Uremia/physiopathology
- Uremia/therapy
- Vascular Calcification/metabolism
- Vascular Calcification/pathology
- Vascular Calcification/physiopathology
- Vascular Calcification/therapy
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Affiliation(s)
- Nikolas Rapp
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 ER Maastricht, The Netherlands;
| | - Pieter Evenepoel
- Laboratory of Nephrology, KU Leuven Department of Microbiology and Immunology, University Hospitals Leuven, 3000 Leuven, Belgium;
| | - Peter Stenvinkel
- Karolinska Institute, Department of Clinical Science, Intervention and Technology, Division of Renal Medicine, 141 86 Stockholm, Sweden;
| | - Leon Schurgers
- Department of Biochemistry, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, 6229 ER Maastricht, The Netherlands;
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Abstract
Chronic kidney disease (CKD) afflicts more than 500 million people worldwide and is one of the fastest growing global causes of mortality. When glomerular filtration rate begins to fall, uremic toxins accumulate in the serum and significantly increase the risk of death from cardiovascular disease and other causes. Several of the most harmful uremic toxins are produced by the gut microbiota. Furthermore, many such toxins are protein-bound and are therefore recalcitrant to removal by dialysis. We review the derivation and pathological mechanisms of gut-derived, protein-bound uremic toxins (PBUTs). We further outline the emerging relationship between kidney disease and gut dysbiosis, including the bacterial taxa altered, the regulation of microbial uremic toxin-producing genes, and their downstream physiological and neurological consequences. Finally, we discuss gut-targeted therapeutic strategies employed to reduce PBUTs. We conclude that targeting the gut microbiota is a promising approach for the treatment of CKD by blocking the serum accumulation of PBUTs that cannot be eliminated by dialysis.
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Affiliation(s)
- Amanda L. Graboski
- Department of Pharmacology, University of North Carolina, Chapel Hill, NC 27599-7365, USA;
| | - Matthew R. Redinbo
- Departments of Chemistry, Biochemistry, Microbiology and Genomics, University of North Carolina, Chapel Hill, NC 27599-3290, USA
- Correspondence:
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Ishizaki Y, Nishizono R, Kikuchi M, Inagaki H, Sato Y, Fujimoto S. Case Report: A Case of Encephalopathy Presenting the Lentiform Fork Sign on MRI in a Diabetic Dialysis Patient. F1000Res 2020; 9:969. [PMID: 34868569 PMCID: PMC8602957 DOI: 10.12688/f1000research.25597.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2021] [Indexed: 12/01/2023] Open
Abstract
Basal ganglia lesions showing an expansile high signal intensity on T2-weighted MRI are termed the lentiform fork sign. This specific finding is mainly observed in diabetic patients with uremic encephalopathy with metabolic acidosis, although there are also reports in patients with ketoacidosis, dialysis disequilibrium syndrome, intoxication, and following drug treatment (e.g., metformin). A 57-year-old Japanese man on chronic hemodialysis for 4 years because of diabetic nephropathy was admitted to our hospital for relatively rapid-onset gait disturbance, severe dysarthria, and consciousness disturbance. Brain T2-weighted MRI showed the lentiform fork sign. Hemodialysis was performed the day before admission, and laboratory tests showed mild metabolic (lactic) acidosis, but no uremia. Surprisingly, metformin, which is contraindicated for patients with end-stage kidney disease, had been prescribed for 6 months in his medication record, and his sluggish speaking and dysarthria appeared gradually after metformin treatment was started. Thus, the encephalopathy was considered to be related to metformin treatment. He received hemodialysis treatment for 6 consecutive days, and his consciousness disturbance and dysarthria improved in 1 week. At the 8-month follow-up, the size of the hyperintensity area on MRI had decreased, while the mild gait disturbance remained. Considering the rapid onset of gait and consciousness disturbance immediately before admission, diabetic uremic syndrome may also have occurred with metformin-related encephalopathy, and resulted in the lentiform fork sign, despite the patient showing no evidence of severe uremia on laboratory data.
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Affiliation(s)
- Yuri Ishizaki
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Ryuzoh Nishizono
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Masao Kikuchi
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
| | - Hiroko Inagaki
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Yuji Sato
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Shouichi Fujimoto
- Department of Nephrology, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, 5200 Kihara, Kiyotake, Miyazaki, 889-1692, Japan
- Dialysis Division, University of Miyazaki Hospital, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
- Department of Hemovascular Medicine and Artificial Organs, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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Wang Y, Hu M, Ye G, Zhao Y, Yin Q, Pi P, Luo D. Clinical characteristics of patients with uremia undergoing maintenance hemodialysis complicated with COVID-19. Medicine (Baltimore) 2020; 99:e21547. [PMID: 32769892 PMCID: PMC7593003 DOI: 10.1097/md.0000000000021547] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/01/2020] [Accepted: 07/06/2020] [Indexed: 12/15/2022] Open
Abstract
This study aimed to evaluate the onset characteristics of patients with uremia undergoing maintenance hemodialysis complicated with COVID-19, so as to improve the understanding, diagnosis, and treatment.26 cases were confirmed cases of COVID-19. Confirmed patients with COVID-19 undergoing maintenance hemodialysis in the blood purification center were recruited. The general data of patients, including age, sex, duration of dialysis, and basic diseases, were analyzed. The clinical features included fever, respiratory symptoms, and gastrointestinal symptoms. The items for laboratory tests included blood routine examination, liver function, C-reactive protein, procalcitonin, creatine kinase, creatine kinase-MB, markers of myocardial injury, B-type natriuretic peptide, D-dimer, and so forth. The imaging examinations referred mainly to computed tomography imaging findings of the lungs.Twenty-one cases were complicated with chronic basic diseases, such as hypertension or diabetes. In terms of clinical manifestations, 13 cases had fever, which was close to the number of cases without fever (13 cases). The respiratory symptoms included dry cough (19 cases), shortness of breath (9 cases), fatigue (11 cases), and so forth. Further, 15 patients had hypoxemia, indicating more severe patients. Sore throat (2 cases) was not significant, and a few patients reported gastrointestinal symptoms (3 cases). The results of blood routine examination showed decreased absolute lymphocyte count (0.7 ± 0.4 × 10∼9/L), lower hemoglobin level (105.2 ± 20 g/L), and normal absolute neutrophil count 4.2 (3.0, 5.9) × 10∼9/L. Of the inflammatory indexes, procalcitonin was 0.69 (0.24, 2.73) ng/mL; C reactive protein was 17.2 (5.2, 181.6) mg/L, which was higher than normal. Blood biochemistry revealed lower albumin level (38.0 ± 4.0 g/L) and higher troponin 0.11(0.035, 6.658) ng/mL and myoglobin levels (538.5 ± 240.5 ng/mL), suggesting myocardial injury.The patients with uremia and confirmed COVID-19 undergoing maintenance hemodialysis are more common in males. Although the proportion of fever patients is 50%, the proportion of hypoxemia patients is high (58%). With poor cardiac function. They were prone to respiratory failure complicated with heart failure. According to the onset characteristics of this population, early diagnosis and treatment could help reduce the risk of developing a critical illness and control the spread of the COVID-19 epidemic.
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Abstract
BACKGROUND To investigate the effect of hemodialysis on microbiota in uremic patients. OBJECTIVE To investigate the effect of hemodialysis on microbiota in uremic patients. METHODS This study included 85 adult patients who have received hemodialysis since August 2014, and the treatment plan has not changed for more than 12 months. These patients were divided into hemodialysis group (group A), hemodialysis+hemodialysis filtration group (group B), and hemodialysis+hemodialysis filtration+blood perfusion group (group C). Twenty-four adult ESRD patients (CK group) were enrolled. Serum biochemical indexes were measured, glomerular filtration rate (EGFR) was estimated, dialysis adequacy (kt/V) was calculated, and fresh feces were collected. At the same time, the feces of 30 health workers were selected as the control. 16S rRNA sequence was used to determine the intestinal flora of all fecal specimens. First of all, we analyzed the difference of the whole flora distribution between dialysis and nondialysis ESRD patients; then, we selected the most representative content of bifidobacteria, Lactobacillus acidophilus, Escherichia coli, and Enterococcus faecalis to analyze the influence of different blood purification methods on the intestinal flora. RESULTS (1) The level of C-reactive protein (CRP) in dialysis patients was lower than that in nondialysis ESRD patients, and CRP in group C was lower than that in groups A and B. There was no significant difference in kt/V between group A, group B, and group C. There was no significant difference in EGFR between the four groups. (2) The species diversity of ESRD patients without dialysis (CK group) was significantly lower than that of ESRD patients with dialysis; there was no significant difference between group A and group B; the species diversity of group C was significantly higher than that of group A and group B. (3) Compared with the control group, the levels of bifidobacteria and Lactobacillus acidophilus in ESRD patients were significantly lower, while the levels of Escherichia coli and Enterococcus faecalis were significantly higher. (4) The levels of bifidobacteria and Lactobacillus acidophilus in hemodialysis patients were significantly higher than those in nonblood purification treatment group, and the levels of Escherichia coli and Enterococcus faecalis were significantly lower than those in nonblood purification treatment group. (5) The level of Lactobacillus acidophilus in group C was significantly higher than that in groups A and B, and the level of Escherichia coli was significantly lower than that in groups A and B. CONCLUSION ESRD patients have microbiota disorder. Hemodialysis can improve microbiota disorder in uremic patients. Compared with ordinary hemodialysis, combined hemoperfusion dialysis can further improve microbiota disorder.
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Affiliation(s)
- Haidong He
- Department of Geriatrics, First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, 215006 Suzhou, China
- Minhang Hospital, Fudan University, Shanghai, China
| | - Yan Xie
- Department of Geriatrics, First Affiliated Hospital of Soochow University, No. 899, Pinghai Road, 215006 Suzhou, China
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Six I, Flissi N, Lenglet G, Louvet L, Kamel S, Gallet M, Massy ZA, Liabeuf S. Uremic Toxins and Vascular Dysfunction. Toxins (Basel) 2020; 12:toxins12060404. [PMID: 32570781 PMCID: PMC7354618 DOI: 10.3390/toxins12060404] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/15/2020] [Accepted: 06/17/2020] [Indexed: 02/07/2023] Open
Abstract
Vascular dysfunction is an essential element found in many cardiovascular pathologies and in pathologies that have a cardiovascular impact such as chronic kidney disease (CKD). Alteration of vasomotricity is due to an imbalance between the production of relaxing and contracting factors. In addition to becoming a determining factor in pathophysiological alterations, vascular dysfunction constitutes the first step in the development of atherosclerosis plaques or vascular calcifications. In patients with CKD, alteration of vasomotricity tends to emerge as being a new, less conventional, risk factor. CKD is characterized by the accumulation of uremic toxins (UTs) such as phosphate, para-cresyl sulfate, indoxyl sulfate, and FGF23 and, consequently, the deleterious role of UTs on vascular dysfunction has been explored. This accumulation of UTs is associated with systemic alterations including inflammation, oxidative stress, and the decrease of nitric oxide production. The present review proposes to summarize our current knowledge of the mechanisms by which UTs induce vascular dysfunction.
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Affiliation(s)
- Isabelle Six
- UR 7517 UPJV, Pathophysiological Mechanisms and Consequences of Cardiovascular Calcifications (MP3CV), Picardie Jules Verne University, 80025 Amiens, France; (N.F.); (G.L.); (L.L.); (S.K.); (M.G.); (S.L.)
- Correspondence: ; Tel./Fax: +03-22-82-54-25
| | - Nadia Flissi
- UR 7517 UPJV, Pathophysiological Mechanisms and Consequences of Cardiovascular Calcifications (MP3CV), Picardie Jules Verne University, 80025 Amiens, France; (N.F.); (G.L.); (L.L.); (S.K.); (M.G.); (S.L.)
| | - Gaëlle Lenglet
- UR 7517 UPJV, Pathophysiological Mechanisms and Consequences of Cardiovascular Calcifications (MP3CV), Picardie Jules Verne University, 80025 Amiens, France; (N.F.); (G.L.); (L.L.); (S.K.); (M.G.); (S.L.)
| | - Loïc Louvet
- UR 7517 UPJV, Pathophysiological Mechanisms and Consequences of Cardiovascular Calcifications (MP3CV), Picardie Jules Verne University, 80025 Amiens, France; (N.F.); (G.L.); (L.L.); (S.K.); (M.G.); (S.L.)
| | - Said Kamel
- UR 7517 UPJV, Pathophysiological Mechanisms and Consequences of Cardiovascular Calcifications (MP3CV), Picardie Jules Verne University, 80025 Amiens, France; (N.F.); (G.L.); (L.L.); (S.K.); (M.G.); (S.L.)
- Amiens-Picardie University Hospital, Human Biology Center, 80054 Amiens, France
| | - Marlène Gallet
- UR 7517 UPJV, Pathophysiological Mechanisms and Consequences of Cardiovascular Calcifications (MP3CV), Picardie Jules Verne University, 80025 Amiens, France; (N.F.); (G.L.); (L.L.); (S.K.); (M.G.); (S.L.)
| | - Ziad A. Massy
- Service de Néphrologie et Dialyse, Assistance Publique—Hôpitaux de Paris (APHP), Hôpital Universitaire Ambroise Paré, 92100 Boulogne Billancourt, France;
- INSERM U1018, Equipe 5, CESP (Centre de Recherche en Épidémiologie et Santé des Populations), Université Paris Saclay et Université Versailles Saint Quentin en Yvelines, 94800 Villejuif, France
| | - Sophie Liabeuf
- UR 7517 UPJV, Pathophysiological Mechanisms and Consequences of Cardiovascular Calcifications (MP3CV), Picardie Jules Verne University, 80025 Amiens, France; (N.F.); (G.L.); (L.L.); (S.K.); (M.G.); (S.L.)
- Pharmacology Department, Amiens University Hospital, 80025 Amiens, France
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