Protein-Bound Uremic Toxins and Immunity

Protein-bound uremic toxins (PBUTs) are bioactive microbiota metabolites originated exclusively from protein fermentation of the bacterial community resident within the gut microbiota, whose composition and function is profoundly different in the chronic kidney disease (CKD) population. PBUTs accumulate in the later stages of CKD because they cannot be efficiently removed by conventional hemodialysis due to their high binding affinity for albumin, worsening their toxic effects, especially at the cardiovascular level. The accumulation of uremic toxins, along with oxidative stress products and pro-inflammatory cytokines, characterizes the uremic status of CKD patients which is increasingly associated to a state of immune dysfunction including both immune activation and immunodepression. Furthermore, the links between immune activation and cardiovascular disease (CVD), and between immunodepression and infection diseases, which are the two major complications of CKD, are becoming more and more evident. This review summarizes and discusses the current state of knowledge on the role of the main PBUTs, namely indoxyl sulfate and p-cresyl sulfate, as regulators of immune response in CKD, in order to understand whether a microbiota modulation may be useful in the management of its main complications, CVD, and infections. Summarizing the direct effects of PBUT on immune system we may conclude that PCS seemed to be associated to an immune deficiency status of CKD mainly related to the adaptative immune response, while IS seemed to reflect the activation of both innate and adaptative immune systems likely responsible of the CKD-associated inflammation. However, the exact role of IS and PCS on immunity modulation in physiological and pathological state still needs in-depth investigation, particularly in vivo studies.

Characteristics of Colon-Derived Uremic Solutes

BACKGROUND AND OBJECTIVES

Colon microbial metabolism produces solutes that are normally excreted in the urine and accumulate in the plasma when the kidneys fail. This study sought to further identify and characterize human colon-derived uremic solutes.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Colon-derived solutes normally excreted in the urine were identified by comparing urine from controls (n=17) and patients with total colectomies (n=12), using an established metabolomic platform. Colon-derived solutes that accumulate in kidney failure were then identified by comparing the plasma of the control patients with that of patients on dialysis (n=14).

RESULTS

Ninety-one urinary solutes were classified as colon-derived on the basis of the finding of a urine excretion rate at least four-fold higher in control patients than in patients with total colectomies. Forty-six were solutes with known chemical structure, 35 of which had not previously been identified as colon-derived. Sixty of the colon-derived solutes accumulated in the plasma of patients with ESKD to a degree greater than urea and were therefore classified as uremic. The estimated urinary clearance for 27 out of the 32 colon-derived solutes for which clearance could be calculated exceeded that of creatinine, consistent with tubular secretion. Sulfatase treatment revealed that 42 out of the 91 colon-derived solutes detected were likely conjugates.

CONCLUSIONS

Metabolomic analysis identified numerous colon-derived solutes that are normally excreted in human urine. Clearance by tubular secretion limits plasma levels of many colon-derived solutes.

Survival of Dialysis Patients with Restless Legs Syndrome: A 15-Year Follow-Up Study

BACKGROUND

Restless legs syndrome, also known as Willis/Ekbom disease (RLS/WED), is a sleep-related, sensorimotor disorder with a high prevalence among end-stage renal disease (ESRD) patients undergoing haemodialysis (HD) (about 15-40%). Whether RLS/WED in uremic patients influences cardiovascular morbidity and mortality remains a matter of controversy. The aim of this study was to evaluate the relationship of RLS/WED and mortality in a population of chronically dialyzed patients.

METHOD

In 1996, we studied 128 patients with ESRD undergoing HD; 47 subjects (36.7%) complained RLS/WED symptoms. Fifteen years later we evaluated the mortality of this population. No clinical follow-up examination of the uremic population was made. The Kaplan-Maier curves in dialysis patients with or without RLS/WED (control group matched for age) were constructed for all-cause mortality and compared using log-rank test.

RESULTS

The Kaplan-Maier curves disclosed a lower mortality rate in the uremic patients with RLS/WED than in those without RLS/WED (p = 0.04). In our analysis, the mortality rate was not influenced by RLS/WED severity (p = 0.11) or gender (p = 0.15). No difference among the causes of death was found in the 2 groups.

CONCLUSIONS

Our study suggests that mortality in ESRD patients is not influenced by concomitant RLS/WED. After a 15-year follow-up, survival rates in our cohort were significantly longer in uremic subjects with RLS/WED than in those without RLS/WED. Finally, we found no relationship between RLS/WED severity and mortality.

The Saga of Two Centuries of Urea: Nontoxic Toxin or Vice Versa?

In the early 1700s, a substance ultimately identified as urea was reported for the first time in urine. About a century later, in 1828, synthesis of this organic compound was achieved, thus giving rise to modern organic chemistry. In parallel, physicians showed that urine comes from the kidneys and contains large amounts of urea, which is produced outside of the kidneys, establishing the humoral approach of renal physiology. Urea was the first uremic retention solute to be identified and it has been used as a marker of renal disease ever since. However, progress in the knowledge of urea metabolism has shown that it is susceptible to many extrarenal variations and, therefore, it cannot be a reliable marker of renal function. It reflects protein intake in the stable patient and has been used to assess nutrition and dialysis efficacy in renal patients. Although it has been studied for almost 200 years, its toxicity has been largely debated. An indirect toxicity occurring through carbamylation of lysine residues is now well established and some evidence from recent work also supports direct toxicity of urea, offering additional rationale for interventional prevention of uremic complications.

H NMR spectroscopy-based metabolomic assessment of uremic toxicity, with toxicological outcomes, in male rats following an acute, mid-life insult from ochratoxin a

Overt response to a single 6.25 mg dose of ochratoxin A (OTA) by oral gavage to 15 months male rats was progressive loss of weight during the following four days. Lost weight was restored within one month and animals had a normal life-span without OTA-related terminal disease. Decline in plasma OTA concentration only commenced four days after dosing, while urinary excretion of OTA and ochratoxin alpha was ongoing. During a temporary period of acute polyuria, a linear relationship between urine output and creatinine concentration persisted. Elimination of other common urinary solutes relative to creatinine was generally maintained during the polyuria phase, except that phosphate excretion increased temporarily. ¹H NMR metabolomic analysis of urine revealed a progressive cyclic shift in the group principal components data cluster from before dosing, throughout the acute insult phase, and returning almost completely to normality when tested six months later. Renal insult by OTA was detected by ¹H NMR within a day of dosing, as the most sensitive early indicator. Notable biomarkers were trimethylamine N-oxide and an aromatic urinary profile dominated by phenylacetylglycine. Tolerance of such a large acute insult by OTA, assessed by rat natural lifetime outcomes, adds a new dimension to toxicology of this xenobiotic.

The fractional excretion of urea in the differential diagnosis of prerenal failure and acute tubular necrosis in neonates

BACKGROUND

Acute renal failure (ARF) in a newborn is a common problem. Fractional excretion of sodium (FENa) has been used to distinguish between the two main causes of ARF, prerenal failure and acute tubular necrosis (ATN). However, the clinical usefulness of FENa could be limited by furosemide diuretic that are commonly prescribed inARF patients. In contrast, urea is not reabsorbed significantly in the distal nephron, thus the fractional excretion of urea (FE UN) should not be affected by furosemide.

OBJECTIVE

To test the hypothesis that FE UN is not effected by furosemide and useful in differentiating between prerenal failure and ATN.

MATERIAL AND METHOD

Neonates admitted to the Department of Pediatrics, Thammasat University Hospital from August 2007-May 2009 were studies prospectively for ARF which is defined as urine output < 0.5 ml/kg/hr after the 1st day and serum creatinine > 1.5 mg/dl with normal maternal renal function. FENa and FEUN were performed on the initial time of diagnosis and were repeated on two consecutive days.

RESULTS

Neonates with ARF were classified as prerenal failure (n=38) and ATN (n=5). The prerenal failure neonates were divided into two groups: those prerenal failure without furosemide (n=27), those prerenal failure with furosemide (n=11). The FENa at the initial time of diagnosis and the two consecutive days in prerenal failure neonates (0.33 +/- 0.57, 10.1 +/- 2.73, 0.8 +/- 1.32%, respectively) were lower than ATN neonates (4.74 +/- 6.12, 5.05 +/- 4.03, 3.98 +/- 2.47%, respectively) significantly. Both FENa and FE UN were no statistical difference between the two prerenal failure groups and ATN neonates.

CONCLUSION

A FE Na in prerenal failure is significantly lower than ATN. A FE UN has no benefit in distinguishing between prerenal failure and ATN. Furosemide has no effect on both FENa and FE UN.

Blockage of the renin-angiotensin system attenuates mortality but not vascular calcification in uremic rats: sevelamer carbonate prevents vascular calcification

BACKGROUND/AIMS

Hyperphosphatemia is associated with vascular calcification and increased cardiovascular morbidity and mortality. Angiotensin-converting enzyme inhibitors are beneficial in suppressing the progression of kidney and cardiovascular disease. The present studies explore the influence of enalapril and sevelamer carbonate on renal function, vascular calcification and mortality in long-term experimental uremia.

METHODS

Normal and 5/6 nephrectomized rats were fed a high-phosphorus diet for 4 months and treated with enalapril or the combination of both enalapril and sevelamer carbonate.

RESULTS

The rats treated with enalapril alone or both enalapril and sevelamer had less deterioration in renal function compared to uremic control as seen by lower serum creatinine (1.6, 1.6 vs. 2.1 mg/dl, respectively, p < 0.05) and higher creatinine clearance. They also exhibited attenuated mortality (23.5, 12.5 vs. 75%, respectively, p < 0.01) and inhibition of myocardial hypertrophy. Enalapril alone did not suppress secondary hyperparathyroidism or vascular calcification. Combination therapy with both enalapril and sevelamer carbonate ameliorated secondary hyperparathyroidism and vascular calcification (calcium content: 854 +/- 40 vs. 1,735 +/- 479 microg/g wet tissue) compared to uremic controls.

CONCLUSION

In these experiments, animal mortality and myocardial hypertrophy were significantly reduced by both enalapril alone and enalapril in combination with sevelamer. In addition, sevelamer carbonate induced beneficial effects on renal dysfunction, secondary hyperparathyroidism and vascular calcification.

Recent progress in the analysis of uremic toxins by mass spectrometry

Mass spectrometry (MS) has been successfully applied for the identification and quantification of uremic toxins and uremia-associated modified proteins. This review focuses on recent progress in the analysis of uremic toxins by using MS. Uremic toxins include low-molecular-weight compounds (e.g., indoxyl sulfate, p-cresol sulfate, 3-carboxy-4-methyl-5-propyl-2-furanpropionic acid, asymmetric dimethylarginine), middle-molecular-weight peptides, and proteins modified with advanced glycation and oxidation. These uremic toxins are considered to be involved in a variety of symptoms which may appear in patients with stage 5 chronic kidney disease. Based on MS analysis of these uremic toxins, the pathogenesis of the uremic symptoms will be elucidated to prevent and manage the symptoms.

Role of dietary phosphorus and degree of uremia in the development of renal bone disease in rats

The remnant kidney rat model has been extensively used for the evaluation of bone changes due to uremia. The present study aimed to assess the effect of the dietary phosphorus availability and of the severity of renal failure on bone histomorphometric changes and various biochemical markers over time in this model. Chronic renal failure (CRF) was induced in male Wistar rats by 5/6th nephrectomy. Half of the number of animals received a standard rat diet (STD) (0.67% P, containing low bioavailable phosphorus of plant origin); the other animals were fed a high phosphorus diet (HPD) (0.93% P, containing inorganic phosphorus with high bioavailability). Every two weeks, blood and urine samples were collected. At sacrifice after 6 or 12 weeks, bone samples were taken for the measurement of histological and histodynamic parameters. Serum creatinine measurements indicated the development of mild to moderate renal failure in both diet groups. Phosphaturia was unexpectedly low in all animals that received the STD, indicating relative phosphorus depletion despite the normal dietary phosphorus content. In the HPD CRF group, a decrease in calcemia and a rise in phosphatemia were seen after 12 weeks of CRF, which were more pronounced in animals with higher serum creatinine. Serum iPTH levels were distinctly increased in CRF rats fed a HPD, especially those with more pronounced renal failure. Serum osteocalcin and to a lesser extend tartrate-resistant acid phosphatase and urinary pyridinoline and deoxypyridinoline crosslinks were higher in the CRF animals compared to the shams, particularly in the animals of the HPD group with more pronounced CRF. In both diet groups, the CRF animals had significantly higher amounts of osteoid compared to shams. Only the animals that received a HPD developed distinct histological signs of secondary hyperparathyroidism (sHPTH), that is, an increased bone formation rate, mineral apposition rate, osteoblast perimeter, and eroded perimeter. Again, this effect was most prominent in rats with more severe CRF. In conclusion, data of the present study indicate that in experimental studies using the remnant kidney rat model, both the dietary phosphorus bioavailability and the degree of renal failure in the development of hyperparathyroidism should be considered.

Urinary and serum silicon in normal and uraemic individuals

The urinary excretion of silicon (Si) in humans was studied in normal subjects on a low Si diet, a normal diet, and after ingestion of silicate antacid. Measurements of 24-hour urinary excretion of Si showed that urinary Si was derived mainly from dietary intake. The serum concentration of Si was determined in normal individuals and in patients with chronic renal failure. In health, serum Si is maintained within a narrow range, but a significant hypersilicaemia occurs in uraemia. The concentration of Si was measured in the water supply, dialysate and pre-dialysis and post-dialysis serum in patients on regular haemo-dialysis in three areas with low, intermediate and high concentrations of Si in the water supply. Si was removed during dialysis in the region where it was naturally low in the water or where reverse osmosis was used, but it was dialysed into patients in regions with intermediate and high concentrations in the water. Serum Si levels returned to normal after renal transplantation. Preliminary analysis of the geographical variation in the Si content of tap water suggests that uraemic hypersilicaemia may protect haemodialysed patients from the development of aluminium dementia. The kidney would appear from these studies to be the major organ for elimination of absorbed Si.

Urine proteomics--prospects for future diagnostics

This brief overview of the potential diagnostic, prognostic and pathophysiological value of studies into the urine proteome describes hypothesis-driven investigations of individual proteins and proteome-wide search for urinary biomarkers of various diseases and their progression. It is intended to illustrate the recent progress in the area of urine proteomics and proselytize for the promise of this centuries-old technique of uroscopy, yet to reveal its secrets, using modem approaches.

Iron supplementation and oxidative stress in patients with uremia

The existence of oxidative stress in uremia is well proved but the relative importance of uremic status versus the role of free iron in exacerbating oxidative stress in patients with uremia is not been clarified. Serum creatinine, free iron both in ferrous and ferric state, protein thiols, lipid hydroperoxides levels were estimated by spectrophotometric methods. The study groups comprised of patients with chronic kidney disease on conservative management, on hemodialysis with and without iron supplementation, and compared with healthy controls. Free iron levels were higher in patients with chronic kidney disease on conservative management, hemodialysis patients with and without iron supplementation. Hemodialysis cases with iron supplementation had significantly higher free iron levels as compared to hemodialysis cases without iron supplementation. The levels of lipid hydroperoxides were higher and protein thiols were lower in patient groups. Creatinine correlated positively with free iron and lipid hydroperoxides, and negatively with protein thiols. In conclusion, uremia per se may be responsible for enhanced oxidative stress in patients with chronic kidney disease.

Inhibitors of calcification in blood and urine

In bone and teeth formation, coordinated calcification is a highly desirable biological process. However, heterotopic calcification at unwanted tissue sites leads to dysfunction, disease and, potentially, to death and therefore requires prevention and treatment. With the recent discovery of calcification inhibitors we now know that biological calcification is not passive but a complex, active and highly regulated process. Calcification at vascular sites is the most threatening localization and manifests as part of atherosclerosis or arteriosclerosis. Atherosclerosis is often accompanied by intimal plaque calcification, whereas arteriosclerosis is characterized by calcification of the media. The severity of calcification of cerebral or coronary atherosclerotic plaques is associated with an increased incidence of events such as stroke or myocardial infarction. Medial calcification is the major cause of arterial stiffness, which contributes to left ventricular dysfunction and heart failure. Patients with chronic kidney disease are at especially increased risk for both intimal and medial calcification. In this context, it is currently thought that calcium-regulatory factors including fetuin-A, matrix Gla protein, osteoprotegerin, and pyrophosphates act in a local or systemic manner to prevent calcifications of the vasculature, and that dys-regulations of such calcification inhibitors may contribute to progressive calcifications. Nephrolithiasis represents another process of unwanted calcification responsible for significant morbidity. More than 80% of renal stones contain calcium. Urinary factors inhibiting calcification are citrate, glycosaminoglycans, Tamm-Horsfall protein, and osteopontin. This review summarizes current experimental and clinical data underlining the biological importance of these calcification inhibitors.

Advances in urinary proteome analysis and biomarker discovery

Noninvasive diagnosis of kidney diseases and assessment of the prognosis are still challenges in clinical nephrology. Definition of biomarkers on the basis of proteome analysis, especially of the urine, has advanced recently and may provide new tools to solve those challenges. This article highlights the most promising technological approaches toward deciphering the human proteome and applications of the knowledge in clinical nephrology, with emphasis on the urinary proteome. The data in the current literature indicate that although a thorough investigation of the entire urinary proteome is still a distant goal, clinical applications are already available. Progress in the analysis of human proteome in health and disease will depend more on the standardization of data and availability of suitable bioinformatics and software solutions than on new technological advances. It is predicted that proteomics will play an important role in clinical nephrology in the very near future and that this progress will require interactive dialogue and collaboration between clinicians and analytical specialists.

An oral adsorbent, AST-120, suppresses oxidative stress in uremic rats

BACKGROUND

The production of reactive oxygen species (ROS) has been suggested to play an important role in the progression of chronic kidney disease (CKD). An oral adsorbent, AST-120, removes uremic toxins such as indoxyl sulfate (IS) and delays the progression of CKD, but the effect on ROS production is unknown. The present study aimed to determine whether AST-120 reduces oxidative stress in uremic rat kidneys using markers of ROS production such as acrolein and 8-hydroxy-2'-deoxyguanosine (8-OHdG).

METHODS

Daily administration of AST-120 was started 6 weeks after 5/6 nephrectomy and continued for 18 weeks. The changes in metabolic data, serum and urine IS levels, urinary excretion of markers of oxidative stress, and renal histological findings were investigated in uremic rats with or without AST-120 treatment.

RESULTS

In parallel with the increase in serum and urine IS, the serum creatinine, urinary protein and acrolein levels started to increase at 6 weeks, but urinary 8-OHdG remained unchanged and significantly increased at 18 weeks in uremic rats. AST-120 markedly and significantly attenuated increases in uremic toxins and oxidative stress levels as well as the histological changes in glomerular sclerosis, interstitial fibrosis, and the tubular staining of 8-OHdG.

CONCLUSION

AST-120 suppressed the progression of CKD, at least in part, via attenuation of oxidative stress induced by uremic toxin.

The uremic solute p-cresol decreases leukocyte transendothelial migration in vitro

Chronic renal failure (CRF) patients display an immunodeficiency state, and uremic solutes that accumulate during CRF may be involved in this immunodeficiency. In this study, we examined whether the uremic solute para-cresol (p-cresol), at concentrations similar to those found in patients, alters leukocyte transmigration in vitro. We found that p-cresol significantly inhibited monocyte THP-1 cell line and PBMCs transmigration across IL-1beta-stimulated human umbilical vein endothelial cell (HUVEC) in a static two-compartment model. This inhibitory effect of p-cresol persisted in the presence of a physiologic concentration of human serum albumin. In order to investigate the mechanism involved, expression of endothelial chemokines, fractalkine, monocyte chemoattractant protein 1 (MCP-1) and IL-8 and membrane expression of junctional adhesion molecule A (JAM-A or JAM-1) were studied. We found that p-cresol decreased mRNA expression of the chemokine fractalkine in IL-1beta-stimulated HUVEC, without modifying mRNA expression of MCP-1 and IL-8. In addition, p-cresol decreased IL-1beta-induced expression of membrane-bound and soluble forms of fractalkine and impaired the membrane expression of JAM-A. Taken together, these results suggest that p-cresol, by impairing leukocyte transendothelial migration, plays a role in the immune dysfunction of uremic patients.

Renal Clearance of Endogenous Hippurate Correlates with Expression Levels of Renal Organic Anion Transporters in Uremic Rats

Hippurate (HA) is a harmful uremic toxin that accumulates during chronic renal failure, and failure of the excretion system for uremic toxins is thought to be responsible. Recently, we reported that rat organic anion transporter 1 (rOat1) is the primary mediator of HA uptake in the kidney, and so now we have studied the pharmacokinetics and tissue distribution of HA after a single i.v. dose of HA to normal and 5/6 nephrectomized rats (5/6Nx rats). In control rats, the renal and biliary clearances of HA were 18.1 and 0.1 ml/min/kg, respectively. Plasma clearance decreased as dosage increased from 0.1 to 5 mg/kg, which suggests that renal tubular secretion is the primary route for elimination of HA. The plasma clearance of HA was significantly decreased in 5/6 Nx rats compared with normal rats. In 5/6 Nx rats, renal clearance of endogenous HA correlated more closely with clearance of p-aminohippurate than with that of creatinine. Protein expression of rOat1 and rOat3, assessed by Western blot analysis, was decreased in 5/6 Nx rats. Furthermore, in 5/6 Nx rats, the renal secretory clearance of endogenous HA correlated closely with protein expression of renal rOats. Thus, HA is primarily eliminated from the plasma via the kidney by active tubular secretion. The renal clearance of endogenous HA seems to be a useful indicator of changes in renal secretion that accompany the reduced levels of OAT protein in chronic renal failure.

Separation, identification of uremic middle molecules, and preliminary study on their toxicity

BACKGROUND

Compounds accumulating in uremic serum with molecular mass from 300 to 5000 Da are called uremic middle molecules (UMMs). In our previous work, two UMM fractions A and B were obtained from uremic sera, urine, and normal urine by gel permeation chromatography (GPC), and six UMMs from subfraction A3 of uremic plasma and normal urine were purified and characterized.

METHODS

Urine and serum samples from uremic patients and healthy subjects were isolated by GPC, ion exchange chromatography (IEC), and reversed-phase high-performance liquid chromatography (RP-HPLC). Moreover, matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS) and liquid chromatography/electrospray ionization tandem mass spectrometry (LC/ESI-MS/MS) were used to characterize the compounds. The effects of subfraction A3 on renal function were studied in rabbit models with chronic renal failure (CRF).

RESULTS

A compound with molecular weight 1007.94 in subfraction A3 was determined to be an octapeptide by mass spectrometry, with an amino acid sequence of Val-Val-Arg-Gly-Cys-Thr-Trp-Trp. Two CRF rabbits injected with A3 died in 5 days, while the other two CRF rabbits (no injection) survived a few days. By multistep chromatography and MALDI-TOF MS, another 11 endogenous compounds were found not only in the subfraction B9 of uremic sera but also in that of normal urine.

CONCLUSION

Seventeen endogenous middle molecular compounds were found in fractions A and B of uremic plasma and normal urine, among them an octapeptide with M(W) 1007.94 in subfraction A3. Preliminary experimental results on rabbits indicate that subfraction A3 could accelerate the death of rabbits with CRF.

Proteomics: a novel tool to unravel the patho-physiology of uraemia

BACKGROUND

Uraemic toxicity results in the dysfunction of many organ systems, provoking an increase in morbidity and mortality. To date, only approximately 90 uraemic retention solutes have been described. To examine unknown uraemic substances thoroughly, the identification of as many compounds as possible in the ultrafiltrate and/or plasma of patients would lead to a less biased definition of the uraemic retention process compared with what is proposed today.

METHODS

We describe the application of a novel proteomic tool for the identification of a large number of molecules present in ultrafiltrate from uraemic and normal plasma obtained with high- or low-flux membranes. Separation by capillary electrophoresis was coupled on-line to a mass spectrometer, yielding identification of polypeptides based on their molecular weight.

RESULTS

Between 500 and >1000 polypeptides with a molecular weight ranging from 800 to 10,000 Da could be detected in individual samples, and were identified via their mass and their particular migration time in capillary electrophoresis. In ultrafiltrate from uraemic plasma, 1394 polypeptides were detected in the high-flux vs 1046 in the low-flux samples, while in ultrafiltrate from normal plasma, 544 polypeptides vs 490 were found in ultrafiltrate from normal plasma obtained from membranes with comparable cut-off. In addition, polypeptides >5 kDa were virtually only detected in the uraemic ultrafiltrate from the high-flux membrane (n = 28 vs n = 5 with the low-flux membrane). To demonstrate the feasibility of further characterizing the detected molecules, polypeptides present exclusively in uraemic ultrafiltrate were chosen for sequencing analyses. A 950.6 Da polypeptide was identified as a fragment of the salivary proline-rich protein. A 1291.8 Da fragment was derived from alpha-fibrinogen.

CONCLUSION

The data presented here strongly suggest that the application of proteomic approaches such as capillary electrophoresis and mass spectrometry will result in the identification of many more uraemic solutes than those known at present. This could enable the introduction of more direct elimination strategies, since it is possible to obtain an extended appreciation of the removal capacities of particular dialyser membranes.

Urinary measurement of Na+/H+ exchanger isoform 3 (NHE3) protein as new marker of tubule injury in critically ill patients with ARF

BACKGROUND

It has been shown that apical sodium transporters of the renal tubule can be detected by immunoblotting of urine membrane fraction from rats. We raised the hypothesis that protein levels of the Na+/H+ exchanger isoform 3 (NHE3), the most abundant apical sodium transporter in renal tubule, should be increased in urine of patients presenting with acute renal failure (ARF) with severe tubular cell damage and thus might be a noninvasive marker of acute tubular necrosis (ATN).

METHODS

Sixty-eight patients admitted to the intensive care unit were studied prospectively (54 patients with ARF, 14 controls without renal dysfunction). Patients with ARF were divided into 3 subgroups as follows: prerenal azotemia, ATN, and intrinsic ARF other than ATN. Urinary NHE3 protein abundance was estimated from semiquantitative immunoblots of urine membrane fraction samples collected from patients. The amount of urinary NHE3 was compared with the fractional excretion of sodium (FeNa) and urinary retinol-binding protein (RBP).

RESULTS

NHE3 was not detected in urine from controls. Levels of urinary NHE3 normalized to urinary creatinine level were increased in patients with prerenal azotemia and 6 times as much in patients with ATN, without overlap (ATN, 0.78 +/- 0.36; prerenal azotemia, 0.12 +/- 0.08; P < 0.001). Conversely, urinary NHE3 protein was not detected in patients with intrinsic ARF other than ATN. Normalized NHE3 level correlated positively with serum creatinine level in patients with tubular injury (R2 = 0.305; P = 0.0003). Values for FeNa and normalized urinary RBP did not discriminate ATN from intrinsic ARF other than ATN and prerenal azotemia, respectively.

CONCLUSION

In patients with ARF, urinary NHE3 abundance might be a novel noninvasive marker of renal tubule damage, helping to differentiate prerenal azotemia, ATN, and intrinsic ARF other than ATN.

Urinary excretion of the uraemic toxin p-cresol in the rat: contribution of glucuronidation to its metabolization

BACKGROUND

Increasing evidence indicates that lipophilic and/or protein-bound substances such as p-cresol are responsible for adverse physiological alterations in uraemic patients. To better understand the evolution of p-cresol disposition in renal failure and dialysis patients, it is necessary to determine its kinetic characteristics and biotransformation pathways.

METHODS

We studied the biotransformation of p-cresol after intravenous injection of the compound in eight rats with normal renal function. Urine was collected in four 1 h intervals. To evaluate the presence of p-cresol metabolites, beta-glucuronidase was added to urine samples and the isolated unidentified chromatographic peak observed in previous experiments was submitted to tandem mass spectrometry (MS/MS) analysis.

RESULTS

Administration of p-cresol produced a p-cresol peak and an unknown peak, suggesting biotransformation of the compound. Addition of beta-glucuronidase to urine samples and incubation at 37 degrees C resulted in a marked decrease in the unidentified peak height (P<0.001) together with an increase in p-cresol peak height (P<0.001), suggesting that the unidentified peak was composed, at least in part, of p-cresylglucuronide. Mass spectrometry (MS) and MS/MS analysis of the isolated unidentified peak confirmed the presence of p-cresylglucuronide. Linear regression between the peak height of p-cresylglucuronide before enzyme treatment and the increase in p-cresol peak height after enzyme treatment in samples incubated with beta-glucuronidase allowed us to calculate the amount of p-cresylglucuronide as its p-cresol equivalents. This revealed that 64% of the injected p-cresol was excreted as glucuronide. There was no change in peak heights when sulphatase was added to the urine. When p-cresol and p-cresylglucuronide levels were combined, approximately 85% of all administered p-cresol was recovered in the urine. In addition, the combined urinary excretion of p-cresol and p-cresylglucuronide was more than four times greater than excretion of p-cresol by itself (P<0.01).

CONCLUSIONS

In rats with normal renal function, intravenous administration of p-cresol results in immediate and extensive metabolization of the compound into p-cresylglucuronide. The elimination of p-cresol from the body depends largely on the urinary excretion of this metabolite.

The low nanomolar levels of N G-monomethylarginine in serum and urine of patients with chronic renal insufficiency are not significantly different from control levels

There are no reliable mean values of N(G)-monomethylarginine (NMMA) in blood and urine of patients with renal insufficiency available in the literature. Therefore we investigate whether the NMMA levels are changed in blood and urinary excretion of nondialysed and dialysed patients with chronic renal insufficiency to evaluate whether NMMA may reach sufficiently increased concentrations in blood of the patients to exert toxic biological activity. In nondialysed as well as in dialysed patients we find no significant difference in serum concentration of NMMA between patients and controls. In nondialysed patients (all with a residual creatinine clearance lower than 15 ml/min), we find 94.5 +/- 26.1 nM (mean +/- SD) versus 94.6 +/- 19.5 nM in controls. Similar levels are found in serum of haemodialysed patients (each with serum creatinine levels >700 micro M): 83.0 +/- 20.2 nM. The urinary excretion of NMMA in nondialysed patients is also not significantly different from the excretion of controls: 123 +/- 110 in patients versus 157 +/- 117 nmol/24 hrs in controls. Furthermore, the clearance of NMMA is much lower compared to the clearance of the dimethylarginine derivatives. Based on the literature, the low nanomolar levels of NMMA found in blood of patients with renal insufficiency do not support the statement that NMMA proper may act as a uremic toxin.

Significance of the fractional excretion of urea in the differential diagnosis of acute renal failure

BACKGROUND

Fractional excretion of sodium (FENa) has been used in the diagnosis of acute renal failure (ARF) to distinguish between the two main causes of ARF, prerenal state and acute tubular necrosis (ATN). However, many patients with prerenal disorders receive diuretics, which decrease sodium reabsorption and thus increase FENa. In contrast, the fractional excretion of urea nitrogen (FEUN) is primarily dependent on passive forces and is therefore less influenced by diuretic therapy.

METHODS

To test the hypothesis that FEUN might be more useful in evaluating ARF, we prospectively compared FEUN with FENa during 102 episodes of ARF due to either prerenal azotemia or ATN.

RESULTS

Patients were divided into three groups: those with prerenal azotemia (N = 50), those with prerenal azotemia treated with diuretics (N = 27), and those with ATN (N = 25). FENa was low only in the patients with untreated plain prerenal azotemia while it was high in both the prerenal with diuretics and the ATN groups. FEUN was essentially identical in the two pre-renal groups (27.9 +/- 2.4% vs. 24.5 +/- 2.3%), and very different from the FEUN found in ATN (58.6 +/- 3.6%, P < 0.0001). While 92% of the patients with prerenal azotemia had a FENa <1%, only 48% of those patients with prerenal and diuretic therapy had such a low FENa. By contrast 89% of this latter group had a FEUN <35%.

CONCLUSIONS

Low FEUN (</=35%) was found to be a more sensitive and specific index than FENa in differentiating between ARF due to prerenal azotemia and that due to ATN, especially if diuretics have been administered.

Early detection of cysteine rich protein 61 (CYR61, CCN1) in urine following renal ischemic reperfusion injury

BACKGROUND

Acute renal failure (ARF) has a high morbidity and mortality. Many therapies have worked in animals but were unsuccessful in clinical trials. The inability to diagnose ARF early may have impaired the success of these trials.

METHOD

We screened a subtraction library to search for potential disease markers that would be induced rapidly after renal injury. Mice and rats were subjected to 30 to 40 minutes of bilateral ischemia.

RESULTS

mRNA for Cyr61, a secreted growth factor-inducible immediate early gene, was markedly up-regulated at two hours in the kidney but not other organs following renal ischemia. In situ hybridization studies suggested Cyr61 was synthesized in the proximal straight tubule. Cyr61 protein was analyzed by capture with heparin beads followed by Western blotting. Induction of Cyr61 protein could be detected in the kidney within one hour, peaked at four to eight hours, and remained elevated for at least 24 hours following ischemia. Cyr61 protein was detected in urine at three to six hours and peaked at six to nine hours after renal injury. Cyr61 was not detected after volume depletion, which is often difficult to differentiate from ARF.

CONCLUSIONS

The secreted, cysteine-rich, heparin binding protein Cyr61 is rapidly induced in proximal straight tubules following renal ischemia, and excreted in the urine where it might serve as an early biomarker of renal injury.

Differential effects of 19-nor-1,25-(OH)(2)D(2) and 1alpha-hydroxyvitamin D(2) on calcium and phosphorus in normal and uremic rats

BACKGROUND

Calcitriol, 1,25-(OH)(2)D(3) (1,25D), the most active metabolite of vitamin D, has been used in the treatment of secondary hyperparathyroidism (SH) because it controls parathyroid gland growth and suppresses parathyroid hormone (PTH) synthesis and secretion. Due to the calcemic and phosphatemic actions of 1,25D, two analogs with potentially less side effects, 19-nor-1,25-(OH)(2)D(2) (19-nor) and 1alpha(OH)D(2) (1alphaD(2)) are currently being used in the treatment of SH.

METHODS

This study compares the effects of these two analogs on calcium (Ca) and phosphorus (P) metabolism in normal, uremic, and parathyroidectomized (PTX) rats. Using doses of 50 to 250 ng of 19-nor or 1alphaD(2), experiments were conducted in normal and uremic rats.

RESULTS

In uremic rats, 19-nor did not increase plasma Ca or P while 1alphaD2 caused a dose-dependent increase in both. In addition, while the Ca x P product remained unchanged in 19-nor-treated rats, it increased progressively with 1alphaD(2)administration. In metabolic studies in normal rats treated with vehicle, 10 ng of 1,25D, 100 ng of 19-nor or 100 ng 1alphaD(2), intestinal calcium absorption and urinary calcium excretion were significantly higher in 1alphaD(2)-treated rats compared to those receiving 19-nor. Similar results were seen for intestinal phosphorus absorption and urinary phosphorus excretion. Finally, the skeletal response to these two analogs was tested in PTX rats fed a calcium-deficient diet and treated daily with 100 ng of 19-nor or 1alphaD(2). The increase in plasma calcium in 1alphaD2-treated rats was markedly higher than in those receiving 19-nor. Similar results were seen in plasma phosphorus when these studies were repeated using a phosphorus-deficient diet.

CONCLUSIONS

These studies demonstrate that when given in large doses to rats 19-nor is less calcemic and phosphatemic than 1alphaD(2). The lower Ca x P product in 19-nor treated rats may be an important consideration in patient therapy. Further studies in patients are necessary to define the clinical applicability of these differences.

Conformational intermediate of the amyloidogenic protein beta 2-microglobulin at neutral pH

Aggregation and fibrillation of beta(2)-microglobulin are hallmarks of dialysis-related amyloidosis. We characterize perturbations of the native conformation of beta(2)-microglobulin that may precede fibril formation. For a beta(2)-microglobulin variant cleaved at lysine 58, we show using capillary electrophoresis that two conformers spontaneously exist in aqueous buffers at neutral pH. Upon treatment of wild-type beta(2)-microglobulin with acetonitrile or trifluoroethanol, two conformations were also observed. These conformations were in equilibrium dependent on the sample temperature and the percentage of organic solvent present. Circular dichroism showed a loss of beta-structures and gain of alpha-helices. Reversal to the native conformation occurred when removing the organics. Affinity capillary electrophoresis experiments showed increased specific interactions of the nonnative beta(2)-microglobulin conformation with the dyes 8-anilino-1-naphthalene sulfonic acid and Congo red. The observations may relate to early folding events prior to amyloid fibrillation and facilitate the development of methods to detect and inhibit pro-amyloid protein and peptide conformations.

Dimethylglycine accumulates in uremia and predicts elevated plasma homocysteine concentrations

BACKGROUND

Hyperhomocysteinemia is a risk factor for atherosclerosis that is common in chronic renal failure (CRF), but its cause is unknown. Homocysteine metabolism is linked to betaine-homocysteine methyl transferase (BHMT), a zinc metalloenzyme that converts glycine betaine (GB) to N,N dimethylglycine (DMG). DMG is a known feedback inhibitor of BHMT. We postulated that DMG might accumulate in CRF and contribute to hyperhomocysteinemia by inhibiting BHMT activity.

METHODS

Plasma and urine concentrations of GB and DMG were measured in 33 dialysis patients (15 continuous ambulatory peritoneal dialysis and 18 hemodialysis), 33 patients with CRF, and 33 age-matched controls. Concentrations of fasting plasma total homocysteine (tHcy), red cell and serum folate, vitamins B(6) and B(12), serum zinc, and routine biochemistry were also measured. Groups were compared, and determinants of plasma tHcy were identified by correlations and stepwise linear regression.

RESULTS

Plasma DMG increased as renal function declined and was twofold to threefold elevated in dialysis patients. Plasma GB did not differ between groups. The fractional excretion of GB (FE(GB)) was increased tenfold, and FED(MG) was doubled in CRF patients compared with controls. Plasma tHcy correlated positively with plasma DMG, the plasma DMG:GB ratio, plasma creatinine, and FE(GB) and negatively with serum folate, zinc, and plasma GB. In the multiple regression model, only plasma creatinine, plasma DMG, or the DMG:GB ratio was independent predictors of tHcy.

CONCLUSIONS

DMG accumulates in CRF and independently predicts plasma tHcy concentrations. These findings suggest that reduced BHMT activity is important in the pathogenesis of hyperhomocysteinemia in CRF.

Immunochemical detection of imidazolone in uremia and rheumatoid arthritis

The advanced glycation end-product imidazolone is formed by reaction of arginine with 3-deoxyglucosone (3-DG), a reactive intermediate of the Maillard reaction, whose formation is non-oxidative. Using an antibody specific to this 3-DG-derived AGE, we demonstrated the presence of imidazolone-modified proteins in vivo in the urine and dialysate of patients with chronic renal failure, in the synovial fluid of patients with rheumatoid arthritis, as well as in vitro in human serum and human serum albumin incubated with glucose. Furthermore, we could show that in uremic patients the dimeric form of beta(2)-microglobulin is more susceptible to imidazolone modification than the monomeric one. Thus, the immunochemical detection of imidazolone may be a good marker for 3-DG-derived AGE modification in vivo and in vitro permitting a differentiation between the oxidative and the non-oxidative pathway of AGE generation.

Detection and characterization of modified nucleosides in serum and urine of uremic patients using capillary liquid chromatography-frit-fast atom bombardment mass spectrometry

To determine RNA metabolism in uremia, capillary liquid chromatography-frit-fast atom bombardment mass spectrometry was employed for the characterization of ribonucleosides in serum and urine of uremic patients, and the profiles were compared with those of healthy subjects. We have characterized 20 nucleosides in serum and 23 nucleosides in urine from both healthy subjects and uremic patients; most of them were modified nucleosides derived from tRNA breakdown products. Four metabolites derived from allopurinol were detected as exogenous nucleosides in patients receiving allopurinol; these include allopurinol-1-riboside, oxipurinol-1-riboside, oxipurinol-7-riboside and a unknown oxipurinol riboside. The endogenous and exogenous ribonucleosides were retained at higher levels in uremic serum, and may play a contributory role as toxins responsible for clinical symptoms of uremia.

[The excretion of ascorbic acid and its metabolites in uremia and hemodialysis]

Renal excretion of ascorbic, dehydroascorbic and diketogulonic acids in uremia and relevant loss in hemodialysis are measured in comparison with those in patients with uremic syndrome (prior to hemodialysis) and in healthy subjects (control). Renal elimination of ascorbic acid was higher while of dehydroascorbic acid lower vs control. Elimination of diketogulonic acid was similar to control. In a session of hemodialysis, the organism loses 132.0 +/- 13.6 mg of ascorbic, 132.0 +/- 10.0 mg of dehydroascorbic and 204.0 +/- 9.0 mg of diketogulonic acid. 48-hour urinary losses of the patients reached 8.4 +/- 1.4, 19.6 +/- 1.1, 75.6 +/- 1.5 mg, respectively. Compared to control, hemodialysis patients lose the above acids 24.3, 2.7 and 4.6 times more.

Inhibition of neutrophil superoxide production by uremic concentrations of guanidino compounds

In uremia, diminished reactive oxygen intermediate production is an important consequence of impaired neutrophil function. The effects of guanidino compounds, which are known uremic toxins, on neutrophil reactive oxygen intermediate production in vitro were studied. Neutrophils from healthy volunteers were exposed for 3 h to individual guanidino compounds or mixed guanidino compounds (GCmix), at concentrations observed in uremic plasma. After removal of the guanidino compounds, the neutrophils were activated by adhesion, N-formylmethionylleucylphenylalanine, phorbol myristate acetate, or opsonized zymosan, and superoxide production was measured by monitoring lucigenin chemiluminescence. The direct effects of guanidino compounds on superoxide production in activated neutrophils were also measured. The energy status (ATP and creatine phosphate), antioxidant status (total glutathione), and glycolytic flux (lactate production) were measured. GCmix pretreatment decreased superoxide production in activated neutrophils (activated by N-formylmethionylleucylphenylalanine or zymosan) by 50% (P < 0.01), decreased ATP concentrations by 60% (P < 0.05), and inhibited glycolytic flux (lactate production) by 45% (P < 0.01) but did not alter glutathione concentrations. Simultaneous GCmix exposure and activation did not inhibit NADPH oxidase activity in cell lysates but inhibited superoxide formation in zymosan-activated intact neutrophils; this inhibition was reversed after removal of the guanidino compounds. Guanidinosuccinic acid, guanidinopropionic acid, and guanidinobutyric acid, when tested individually, were each as potent as GCmix. The inhibition of neutrophil superoxide generation by guanidino compounds results from decreased energy status. Micromolar concentrations of guanidino compounds significantly inhibit neutrophil metabolism, with serious implications for the functions of neutrophils in host defenses.

Urinary indoxyl sulfate is a clinical factor that affects the progression of renal failure

We recently demonstrated that indoxyl sulfate is a stimulating factor for the progression of chronic renal failure (CRF). In this study we determined whether the urine or serum levels of indoxyl sulfate are related to the progression rate of CRF in undialyzed uremic patients. Fifty-five CRF patients with a serum creatinine of >2 mg/dl who had not been treated with an oral sorbent (AST-120) were randomly enrolled in the study. We measured the serum and urine levels of indoxyl sulfate, and estimated the recent progression rate of CRF as the slope of the reciprocal serum creatinine versus time (1/S-Cr-time) plot. The mean urinary amount of indoxyl sulfate in the patients was 60 mg/day. Those with indoxyl sulfate urine levels of >60 mg/day had a significantly faster progression rate of CRF than those with <60 mg/day. Especially, those patients with indoxyl sulfate urine levels of >90 mg/day had the highest CRF progression rate and those with indoxyl sulfate urine levels of <30 mg/day had the slowest CRF progression rate. Urinary indoxyl sulfate had a significantly negative correlation with the slope of the 1/S-Cr-time plot. However, the serum level of indoxyl sulfate or the ratio of serum indoxyl sulfate to creatinine was not significantly correlated with the slope of the 1/S-Cr-time plot. In conclusion, high urine levels of indoxyl sulfate are related with a rapid progression of CRF in undialyzed uremic patients. Thus, urinary indoxyl sulfate is one of the clinical factors that affect CRF progression.

RNA metabolism in uremic patients: accumulation of modified ribonucleosides in uremic serum. Technical note

To determine the metabolism of ribonucleic acid (RNA) in uremia, serum and urine levels of ribonucleosides in uremic patients were analyzed using reversed-phase high-performance liquid chromatography. The serum levels of xanthosine and all modified ribonucleosides were increased in undialyzed patients with chronic renal failure (CRF), and patients undergoing hemodialysis (HD) and continuous ambulatory peritoneal dialysis (CAPD). The serum level of pseudouridine was markedly increased in all the uremic patients especially CAPD patients (32 times higher than normal). By contrast, the serum level of adenosine did not show any significant change in the uremic patients. Interestingly, the serum and urine levels of inosine were significantly decreased in all the uremic patients, suggesting that the production of inosine is decreased in uremic patients. The serum level of uridine was significantly elevated only in the HD patients. The serum levels of all ribonucleosides except inosine and uridine decreased significantly after HD. The urinary excretion of inosine, 1-methyladenosine, 1-methylguanosine, N2,N2-dimethylguanosine and N4-acetylcytidine was significantly decreased in the CRF patients, leading to the accumulation of these modified ribonucleosides in the uremic serum. CAPD patients showed markedly increased serum levels of modified ribonucleosides such as pseudouridine, 1-methylinosine, and N2,N2-dimethylguanosine and N4-acetylcytidine as compared with the HD patients. These results demonstrate that there was an altered metabolism of RNA in uremic patients with marked accumulation of modified ribonucleosides.

Fluid therapy in acute and chronic renal failure

Fluid therapy is one of the mainstays of treatment for renal failure, and rehydration is the primary goal. In those patients with ARF or "acute on chronic" decompensated CRF, induction of a diuresis to facilitate renal excretory function is important. Measurement of urine production in these patients helps guide fluid and electrolyte therapy. In oliguric renal failure, retention of water and electrolytes is likely, whereas in nonoliguric ARF as well as CRF, loss of water and electrolytes is the primary concern.

Impairment of methylamine clearance in uremic patients and its nephropathological implications

The urinary levels of methylamine were analyzed by an HPLC/fluorometric method following derivatization of the amine with O-phthaldialdehyde (OPA). The excretion of methylamine in the uremic patients was found to be dramatically reduced. The impairment of clearance of methylamine explains why this amine was substantially increased in the serum of uremic patients. Increased deamination of methylamine would enhance formaldehyde and oxidative stresses, i.e. in the blood vessels, and cause vascular damage. This may be related to the increased risk of angiopathy associated with renal failure, and accelerate the progression of renal failure.

Continuous venovenous hemodialysis in a neonate model: a two-pump system

OBJECTIVE

To evaluate the efficiency and tolerance of venovenous hemofiltration, hemodiafiltration, and hemodialysis with a two-pump system in a neonatal animal model of acute renal failure.

DESIGN

Prospective trial.

SETTING

Animal laboratory at a large university-affiliated medical center.

SUBJECTS

New Zealand white rabbits, weighing 3325 +/- 380 g.

INTERVENTIONS

Venovenous hemofiltration, hemodiafiltration, and hemodialysis were performed in anesthetized rabbits with previous bilateral ureteral ligation.

MEASUREMENTS AND MAIN RESULTS

At a blood flow rate of 19 +/- 0.5 mL/min, we determined hematocrit, urea, creatinine, and electrolyte values in blood, at the inlet and outlet of the hemofilter, and in ultrafiltrate at the start and after 15, 30, 60, 90, 120, and 180 mins of hemofiltration (ultrafiltrate flow rate of 1.9 +/- 0.2 mL/min), hemodiafiltration (dialysate plus ultrafiltrate flow rate of 16.9 +/- 0.8 mL/min), and hemodialysis (dialysate flow rate of 15.7 +/- 1.1 mL/min). Arterial blood pressure, heart rate, and body temperature were monitored during the procedures. Urea and creatinine instantaneous clearances were higher with hemodiafiltration (8.0 +/- 0.7 and 6.2 +/- 0.7, respectively, n = 29) and hemodialysis (6.8 +/- 1.1 and 4.8 +/- 0.9, respectively, n = 31) than with hemofiltration (1.8 +/- 0.6 and 1.9 +/- 0.4, respectively, n = 16). Initial and final weights, temperatures, and hematocrit, sodium, and protein blood concentrations of each 180-min procedure were similar.

CONCLUSIONS

Hemodiafiltration had a higher urea removal rate than hemodialysis but the management of hemodiafiltration was more cumbersome and time consuming in the absence of a flow equalizer device. As a result, we recommend continuous venovenous hemodialysis as the therapy of choice.

Evidence that urea is a better surrogate marker of uremic toxicity than creatinine

The protein equivalent of nitrogen appearance normalized to standard weight was determined from urea nitrogen appearance (nPNA U) and from total Kjeldahl nitrogen appearance (nPNA K) in dialysate and/or urine in 45 predialysis patients (pre D) and in 95 patients on continuous ambulatory peritoneal dialysis (CAPD). Correlations with weekly Kt/Vurea and creatinine clearance (Ccr, L/wk/1.73 m2) were determined; renal contributions of CCr in both populations were calculated both as total CCr (A) and as CCr by GFR (CCr [B], mean of renal CCr and Curea). Correlations with weekly Kt/Vurea were significant in individual (pre D:nPNA U 0.57, p < 0.01, and nPNA K 0.37, p < 0.01; CAPD:nPNA U 0.50, p < 0.01, and nPNA K 0.43, p < 0.01) and pooled populations (nPNA U 0.54, p < 0.01 and nPNA K 0.37, p < 0.01). Correlations with neither Ccr (A) nor Ccr (B) were significant. The data also allowed comment on mathematical coupling. Ccr vs nPNA K correlations share even more mathematical couplers than does the nPNA K vs Kt/Vurea correlation, yet the correlation of nPNA K with Ccr is quite low. The authors conclude that urea is a better surrogate marker of small molecular weight toxins that inhibit protein intake in uremia, and correlations of nPNA with Kt/Vurea represent more than simple mathematical coupling.

Renal function in stroke-prone rats fed a high-K+ diet

Renal function was assessed in prestroke and poststroke Kyoto-Wistar stroke-prone spontaneously hypertensive rats (SHRsp) fed high-K+ (2.11%) and low-K+ (0.75%) diets containing 4% NaCl and in stroke-resistant SHR (srSHR) fed a low-K+ diet. Elevations in dietary K+ retarded the onset of stroke development in SHRsp, but did not alter the life-span of SHRsp between the onset of stroke and death. At ages < 12 weeks, renal function, measured by serum urea and creatinine levels and urinary protein loss, was comparable in high and low K+ fed prestroke SHRsp, and age-matched srSHR. At ages > 12 weeks, hemorrhagic stroke rapidly developed in SHRsp. When compared with srSHR, prestroke SHRsp exhibited higher serum creatinine and urea levels, a greater excretion of protein into the urine, and lower serum albumin levels. The severity of the above indices of renal failure was amplified in similar-aged poststroke SHRsp. Poststroke SHRsp also had elevated levels of hemoglobin in the urine. Increases in dietary K+ did not significantly decrease the severity of uremia and proteinuria in age-matched prestroke or poststroke SHRsp. It was concluded that a decrease in glomerular filtration, uremia, and proteinuria preceded stroke development in SHRsp. The onset of proteinuria and uremia in SHRsp could potentiate stroke development. The latter indices of renal function were not altered by modifications in dietary K+ that retard stroke development in SHRsp.

Middle-sized molecule fractions isolated from uremic ultrafiltrate and normal urine inhibit ingestive behavior in the rat

Uremic patients with suppressed food intake may regain appetite soon after starting dialysis, presumably because of the removal of one or more toxic factors that suppress appetite. To investigate this matter, this study used a new experimental model in free-moving, unstressed male Wistar rats (300 to 350 g) with feeding catheters channeled from the top of the skull to the oral cavity. When the rats recovered from surgery, they were tested under standardized conditions by being given an intraoral infusion (1 mL/min) of a 1 M sucrose solution or a 97 g/L protein solution or a mixed solution of carbohydrate, protein, and fat (Fortimel (Nutricia Nordica AB, Stockholm, Sweden)) while the time (volume) of ingestion was recorded. Solutions to be tested for their ability to inhibit ingestion were injected intraperitoneally (lp) and the intraoral infusion was started 20 min later. Plasma ultrafiltrate was collected from end-stage renal failure patients by isolated ultrafiltration at the beginning of their first hemodialysis and pooled. Ultrafiltrate was also obtained by filtering pooled plasma from healthy volunteers in vitro, using the same type of dialyzer and cellulose acetate membranes as those used in the uremic patients. Morning urine samples from healthy volunteers were pooled and subjected to the same in vitro filtration procedure as the normal plasma. Intraperitoneal injection of 20 mL normal ultrafiltrate had no effect on sucrose ingestion, whereas injection of 20 mL uremic ultrafiltrate reduced the ingestion of sucrose solution by 23% and the ingestion of Fortimel by 17%. Ten mL of ultrafiltrate from normal urine reduced the sucrose intake by 42%. The pooled ultrafiltrates from normal and uremic plasma and normal urine were subjected to molecular filtrations using a series of membranes with known cut-off points. The filtrations yielded four concentrated fractions with molecular weight ranges of 0.1 to 0.5 kilodaltons (kd), 0.5 to 1 kd, 1 to 5 kd, and 5 to 10 kd, respectively; the plasma fractions were concentrated a factor of about 25:1 and the urine fractions by about 15:1. After an ip injection of 2 mL of each concentrated plasma fraction, only the 1 to 5 kd fraction from the uremic ultrafiltrate inhibited sucrose intake, whereas the corresponding fraction from the normal ultrafiltrate had no effect. After injection of 1, 3, and 5 mL of the concentrated fractions of uremic ultrafiltrate, a dose-dependent inhibition of sucrose intake was achieved with the 1 to 5 kd fraction and, to a lesser extent, with the 5 to 10 kd fraction. Intraperitoneal injection of 0.5, 1.0, and 2 mL of the concentrated 1 to 5 kd fraction, but not of the other fractions from normal urine, also resulted in a dose-dependent inhibition of sucrose intake. The 1 to 5 kd fractions from the uremic ultrafiltrate and the normal urine ultrafiltrate also inhibited protein intake in a dose-dependent manner. These results suggest that one or more toxic compounds in the middle-molecule weight range, which are normally excreted in the urine, accumulate in uremia and suppress food intake.

Direct quantification of pentosidine in urine and serum by HPLC with column switching

Concentrations of pentosidine, an advanced glycation end product, are increased in aging, diabetes mellitus, and uremia. Using HPLC with column switching, we developed a direct method of measuring pentosidine in urine and serum. We inject the sample directly onto a gel-filtration precolumn, select ("heart-cut") the eluate fraction containing pentosidine, and introduce this fraction into a reversed-phased column by use of a switching valve. The recovery rate of the complete method was 97.7-99.9%. The intraassay CV was 5.7%, and the interassay CV was 5.8%. The calibration curve showed significant linearity (r = 0.998, P = 0.0001). We examined urinary concentrations of pentosidine in 12 diabetic patients (mean +/- SD, 8.7 +/- 2.3 micromol/mol of creatinine), 32 patients with chronic renal failure (CRF; 36.1 +/- 39.0), 19 osteoporotic patients (7.9 +/- 5.3), and 29 healthy control subjects (5.2 +/- 2.3). In CRF, urinary pentosidine in the patients undergoing hemodialysis was significantly higher than in CRF patients not being treated by hemodialysis (mean, 58.1 vs 18.2; P <0.001). Also, concentrations of urinary and serum pentosidine were significantly correlated (r = 0.797, P = 0.0011). Because this method does not require pretreatment of samples, it is convenient and useful for measuring urinary and serum pentosidine.

Prerenal azotemia: differentiation of hyperureagenesis from renal hypoperfusion using urinary urea nitrogen data

Blood urea nitrogen (BUN) rises disproportionately to serum creatinine in patients with prerenal azotemia whether due to impaired hemodynamics or excessive ureagenesis. To determine whether urinary urea nitrogen excretion rates can distinguish between these caused of hyperuremia we performed a cross-sectional observational study to compare urinary urea nitrogen excretion rates in a highly selected group of patients with prerenal azotemia. Patients who had stable serum creatinine levels, BUN: serum creatinine ratios exceeding 20:1, and progressive azotemia were identified from the hospital laboratory data base. Using conventional clinicolaboratory criteria, 27 patients were diagnosed with either renal hypoperfusion (group I; n = 17) or hyperureagenesis ((group II; n = 10). Random urine sampling for electrolytes, osmolality, creatinine, and urea nitrogen was followed by 24 h collection for creatinine clearance and urinary urea nitrogen. There were no significant differences in age, gender, absolute levels of BUN, or BUN: serum creatinine ratios between the groups. Creatinine clearance (ml/min/1.73 m2) (ml/s/1.73 m2) was lower in group I than in group II (21 +/- 16 vs 36 +/- 13; p < 0.05) (0.35 +/- 0.27 vs 0.60 +/- 0.22; p < 0.05). Twenty-four hour urinary urea nitrogen levels were significantly different (group I, 4.8 +/- 2.9 vs. group II, 13.6 +/- 3.2 gm; p < 0.001) (group I, 171 +/- 300 vs. group II, 486 +/- 114 mmol; p < 0.001). Random urine urea excretion indices were less discriminating but nevertheless still capable of separating the groups. Timed as well as random urine urea nitrogen determinations may assist in differentiating prerenal azotemia due to renal hypoperfusion from hyperureagenesis. Differentiation of these causes of prerenal azotemia might prevent iatrogenic overhydration of patients with azotemia incorrectly attributed to hemodynamic disturbances.

Hemolytic uremic syndrome in families-an Argentinian experience

Six hundred and thirty-one patients with hemolytic uremic syndrome (HUS) were treated from 1960 to 1992; 19 (3%) were familial cases, of which 9 were classified as concomitant (including twins), 6 as non-concomitant, and 4 as recurrent. In the recurrent group there were 15 HUS episodes, 10 being concomitant in 2 patients. Prodromal diarrhea was present only in concomitant and non-concomitant cases. Patients with recurrences were sisters from a single family. Concomitant and non-concomitant cases had clinical features, course, and age similar to typical endemoepidemic forms of HUS, in which an association with verocytotoxin-producing Escherichia coli has been reported. There may be a genetic determinant in concomitant cases; these occurred outside the season during which endemoepidemic forms are typically detected. In patients with recurrent disease a genetic factor which may lead to the development of the disease when triggered by viral infections is likely.

Laser Doppler flowmeter assessment of skin microcirculation in uremic patients on hemodialysis treatment

Vascular disease is frequent in uremics and may contribute to tissue malnutrition and damage. The aim of this study was to detect whether uremic patients show also changes of microcirculation and to evaluate the effects induced by hemodialysis (HD) session. Eleven uremics on HD (7 males, 4 females, aged 25-65 years) were studied; 11 healthy subjects, age- and sex-matched, served as controls. Skin microcirculatory basal flow (BF), maximal postischemic flow (PIF-max) and flow motion index (FMI) were determined at the upper limb contralateral to arteriovenous fistula, by means of a laser Doppler flowmeter. The measurements were taken before, at 1 and 2 h after starting HD and 30 min after the end of HD. In uremics, FMI was lower than in controls (mean +/- SD: 15.2 +/- 13.6 vs. 29.1 +/- 7.4%; p < 0.005); just 1 h after the start of HD, a significant improvement (28.4 +/- 17.7%; p < 0.01) versus basal values was observed and it persisted throughout the HD session. No statistical correlation was observed between the changes of FMI and those of plasma levels of Na+, K+, HCO-3, urea, iPTH or rate of ultrafiltration. BF and PIF-max were similar in uremics and controls, and no changes were observed during HD. Our study shows that the physiological flow motion is reduced in the skin microcirculation of uremics on HD. This abnormality is rapidly corrected by HD.