Dynamic proteomics of individual cancer cells in response to a drug

Why do seemingly identical cells respond differently to a drug? To address this, we studied the dynamics and variability of the protein response of human cancer cells to a chemotherapy drug, camptothecin. We present a dynamic-proteomics approach that measures the levels and locations of nearly 1000 different endogenously tagged proteins in individual living cells at high temporal resolution. All cells show rapid translocation of proteins specific to the drug mechanism, including the drug target (topoisomerase-1), and slower, wide-ranging temporal waves of protein degradation and accumulation. However, the cells differ in the behavior of a subset of proteins. We identify proteins whose dynamics differ widely between cells, in a way that corresponds to the outcomes-cell death or survival. This opens the way to understanding molecular responses to drugs in individual cells.

The incoherent feed-forward loop accelerates the response-time of the gal system of Escherichia coli

Complex gene regulation networks are made of simple recurring gene circuits called network motifs. One of the most common network motifs is the incoherent type-1 feed-forward loop (I1-FFL), in which a transcription activator activates a gene directly, and also activates a repressor of the gene. Mathematical modeling suggested that the I1-FFL can show two dynamical features: a transient pulse of gene expression, and acceleration of the dynamics of the target gene. It is important to experimentally study the dynamics of this motif in living cells, to test whether it carries out these functions even when embedded within additional interactions in the cell. Here, we address this using a system with incoherent feed-forward loop connectivity, the galactose (gal) system of Escherichia coli. We measured the dynamics of this system in response to inducing signals at high temporal resolution and accuracy by means of green fluorescent protein reporters. We show that the galactose system displays accelerated turn-on dynamics. The acceleration is abolished in strains and conditions that disrupt the I1-FFL. The I1-FFL motif in the gal system works as theoretically predicted despite being embedded in several additional feedback loops. Response acceleration may be performed by the incoherent feed-forward loop modules that are found in diverse systems from bacteria to humans.

Topological generalizations of network motifs

Biological and technological networks contain patterns, termed network motifs, which occur far more often than in randomized networks. Network motifs were suggested to be elementary building blocks that carry out key functions in the network. It is of interest to understand how network motifs combine to form larger structures. To address this, we present a systematic approach to define "motif generalizations": families of motifs of different sizes that share a common architectural theme. To define motif generalizations, we first define "roles" in a subgraph according to structural equivalence. For example, the feedforward loop triad--a motif in transcription, neuronal, and some electronic networks--has three roles: an input node, an output node, and an internal node. The roles are used to define possible generalizations of the motif. The feedforward loop can have three simple generalizations, based on replicating each of the three roles and their connections. We present algorithms for efficiently detecting motif generalizations. We find that the transcription networks of bacteria and yeast display only one of the three generalizations, the multi-output feedforward generalization. In contrast, the neuronal network of C. elegans mainly displays the multi-input generalization. Forward-logic electronic circuits display a multi-input, multi-output hybrid. Thus, networks which share a common motif can have very different generalizations of that motif. Using mathematical modeling, we describe the information processing functions of the different motif generalizations in transcription, neuronal, and electronic networks.

Efficient sampling algorithm for estimating subgraph concentrations and detecting network motifs

SUMMARY

Biological and engineered networks have recently been shown to display network motifs: a small set of characteristic patterns that occur much more frequently than in randomized networks with the same degree sequence. Network motifs were demonstrated to play key information processing roles in biological regulation networks. Existing algorithms for detecting network motifs act by exhaustively enumerating all subgraphs with a given number of nodes in the network. The runtime of such algorithms increases strongly with network size. Here, we present a novel algorithm that allows estimation of subgraph concentrations and detection of network motifs at a runtime that is asymptotically independent of the network size. This algorithm is based on random sampling of subgraphs. Network motifs are detected with a surprisingly small number of samples in a wide variety of networks. Our method can be applied to estimate the concentrations of larger subgraphs in larger networks than was previously possible with exhaustive enumeration algorithms. We present results for high-order motifs in several biological networks and discuss their possible functions.

AVAILABILITY

A software tool for estimating subgraph concentrations and detecting network motifs (mfinder 1.1) and further information is available at http://www.weizmann.ac.il/mcb/UriAlon/

The coherent feedforward loop serves as a sign-sensitive delay element in transcription networks

Recent analysis of the structure of transcription regulation networks revealed several "network motifs": regulatory circuit patterns that occur much more frequently than in randomized networks. It is important to understand whether these network motifs have specific functions. One of the most significant network motifs is the coherent feedforward loop, in which transcription factor X regulates transcription factor Y, and both jointly regulate gene Z. On the basis of mathematical modeling and simulations, it was suggested that the coherent feedforward loop could serve as a sign-sensitive delay element: a circuit that responds rapidly to step-like stimuli in one direction (e.g. ON to OFF), and at a delay to steps in the opposite direction (OFF to ON). Is this function actually carried out by feedforward loops in living cells? Here, we address this experimentally, using a system with feedforward loop connectivity, the L-arabinose utilization system of Escherichia coli. We measured responses to step-like cAMP stimuli at high temporal resolution and accuracy by means of green fluorescent protein reporters. We show that the arabinose system displays sign-sensitive delay kinetics. This type of kinetics is important for making decisions based on noisy inputs by filtering out fluctuations in input stimuli, yet allowing rapid response. This information-processing function may be performed by the feedforward loop regulation modules that are found in diverse systems from bacteria to humans.

Biological networks: the tinkerer as an engineer

This viewpoint comments on recent advances in understanding the design principles of biological networks. It highlights the surprising discovery of "good-engineering" principles in biochemical circuitry that evolved by random tinkering.

Structure and function of the feed-forward loop network motif

Engineered systems are often built of recurring circuit modules that carry out key functions. Transcription networks that regulate the responses of living cells were recently found to obey similar principles: they contain several biochemical wiring patterns, termed network motifs, which recur throughout the network. One of these motifs is the feed-forward loop (FFL). The FFL, a three-gene pattern, is composed of two input transcription factors, one of which regulates the other, both jointly regulating a target gene. The FFL has eight possible structural types, because each of the three interactions in the FFL can be activating or repressing. Here, we theoretically analyze the functions of these eight structural types. We find that four of the FFL types, termed incoherent FFLs, act as sign-sensitive accelerators: they speed up the response time of the target gene expression following stimulus steps in one direction (e.g., off to on) but not in the other direction (on to off). The other four types, coherent FFLs, act as sign-sensitive delays. We find that some FFL types appear in transcription network databases much more frequently than others. In some cases, the rare FFL types have reduced functionality (responding to only one of their two input stimuli), which may partially explain why they are selected against. Additional features, such as pulse generation and cooperativity, are discussed. This study defines the function of one of the most significant recurring circuit elements in transcription networks.

Subgraphs in random networks

Understanding the subgraph distribution in random networks is important for modeling complex systems. In classic Erdos networks, which exhibit a Poissonian degree distribution, the number of appearances of a subgraph G with n nodes and g edges scales with network size as <G> approximately N(n-g). However, many natural networks have a non-Poissonian degree distribution. Here we present approximate equations for the average number of subgraphs in an ensemble of random sparse directed networks, characterized by an arbitrary degree sequence. We find scaling rules for the commonly occurring case of directed scale-free networks, in which the outgoing degree distribution scales as P(k) approximately k(-gamma). Considering the power exponent of the degree distribution, gamma, as a control parameter, we show that random networks exhibit transitions between three regimes. In each regime, the subgraph number of appearances follows a different scaling law, <G> approximately Nalpha, where alpha=n-g+s-1 for gamma<2, alpha=n-g+s+1-gamma for 2<gamma<gamma(c), and alpha=n-g for gamma>gamma(c), where s is the maximal outdegree in the subgraph, and gamma(c)=s+1. We find that certain subgraphs appear much more frequently than in Erdos networks. These results are in very good agreement with numerical simulations. This has implications for detecting network motifs, subgraphs that occur in natural networks significantly more than in their randomized counterparts.

Detailed map of a cis-regulatory input function

Most genes are regulated by multiple transcription factors that bind specific sites in DNA regulatory regions. These cis-regulatory regions perform a computation: the rate of transcription is a function of the active concentrations of each of the input transcription factors. Here, we used accurate gene expression measurements from living cell cultures, bearing GFP reporters, to map in detail the input function of the classic lacZYA operon of Escherichia coli, as a function of about a hundred combinations of its two inducers, cAMP and isopropyl beta-d-thiogalactoside (IPTG). We found an unexpectedly intricate function with four plateau levels and four thresholds. This result compares well with a mathematical model of the binding of the regulatory proteins cAMP receptor protein (CRP) and LacI to the lac regulatory region. The model is also used to demonstrate that with few mutations, the same region could encode much purer AND-like or even OR-like functions. This possibility means that the wild-type region is selected to perform an elaborate computation in setting the transcription rate. The present approach can be generally used to map the input functions of other genes.

Network motifs: simple building blocks of complex networks

Complex networks are studied across many fields of science. To uncover their structural design principles, we defined "network motifs," patterns of interconnections occurring in complex networks at numbers that are significantly higher than those in randomized networks. We found such motifs in networks from biochemistry, neurobiology, ecology, and engineering. The motifs shared by ecological food webs were distinct from the motifs shared by the genetic networks of Escherichia coli and Saccharomyces cerevisiae or from those found in the World Wide Web. Similar motifs were found in networks that perform information processing, even though they describe elements as different as biomolecules within a cell and synaptic connections between neurons in Caenorhabditis elegans. Motifs may thus define universal classes of networks. This approach may uncover the basic building blocks of most networks.

Ordering genes in a flagella pathway by analysis of expression kinetics from living bacteria

The recent advances in large-scale monitoring of gene expression raise the challenge of mapping systems on the basis of kinetic expression data in living cells. To address this, we measured promoter activity in the flagellar system of Escherichia coli at high accuracy and temporal resolution by means of reporter plasmids. The genes in the pathway were ordered by analysis algorithms without dependence on mutant strains. The observed temporal program of transcription was much more detailed than was previously thought and was associated with multiple steps of flagella assembly.

Transcriptional gene expression profiles of colorectal adenoma, adenocarcinoma, and normal tissue examined by oligonucleotide arrays

Using an oligonucleotide array containing sequences complementary to approximately 3200 full-length human cDNAs and 3400 expressed sequence tags (GeneChip, Affymetrix), mRNA expression patterns were probed in 18 colon adenocarcinomas and 4 adenomas. Paired normal tissue was available and analyzed for each of the tumors. Relatively few changes in transcript expression are associated with colon cancer. Nineteen transcripts (0.48% of those detected) had at least 4-10.5-fold higher mRNA expression in carcinoma compared with paired normal samples, whereas 47 transcripts (1.3% of those detected) had at least 4-38-fold or lower expression in the tumor tissue compared with the normal samples. Some of these differences were confirmed by reverse transcription-PCR. Many of these transcripts were already known to be abnormally expressed in neoplastic tissue in general, or colon cancer in particular, and several of these differences were also observed in premalignant adenoma samples. A two-way hierarchical clustering algorithm successfully distinguished adenoma from adenocarcinoma and normal tissue, generating a phylogenetic tree that appropriately represented the clinical relationship between the three tissue types included in the analysis. This supports the concept that genome-wide expression profiling may permit a molecular classification of solid tumors.

Generation of oscillations by the p53-Mdm2 feedback loop: a theoretical and experimental study

The intracellular activity of the p53 tumor suppressor protein is regulated through a feedback loop involving its transcriptional target, mdm2. We present a simple mathematical model suggesting that, under certain circumstances, oscillations in p53 and Mdm2 protein levels can emerge in response to a stress signal. A delay in p53-dependent induction of Mdm2 is predicted to be required, albeit not sufficient, for this oscillatory behavior. In line with the predictions of the model, oscillations of both p53 and Mdm2 indeed occur on exposure of various cell types to ionizing radiation. Such oscillations may allow cells to repair their DNA without risking the irreversible consequences of continuous excessive p53 activation.

Computerized analysis of chemotaxis at different stages of bacterial growth

Chemotactic behavior as a function of growth stage in an Escherichia coli strain commonly used for chemotaxis studies was characterized using computerized image analysis. The response and adaptation to saturating, step-like additions of the attractant L-aspartate were measured. Steady-state average tumbling frequency and adaptation time increased nearly twofold during logarithmic phase. In contrast, precision of adaptation, P, defined as the ratio between steady-state tumbling frequencies in the presence and absence of attractant, appeared to be constant throughout growth (P = 1.0 +/- 0.2). The variation of tumble duration over growth was consistent with a hydrodynamic mechanism for tumble termination.

Broad patterns of gene expression revealed by clustering analysis of tumor and normal colon tissues probed by oligonucleotide arrays

Oligonucleotide arrays can provide a broad picture of the state of the cell, by monitoring the expression level of thousands of genes at the same time. It is of interest to develop techniques for extracting useful information from the resulting data sets. Here we report the application of a two-way clustering method for analyzing a data set consisting of the expression patterns of different cell types. Gene expression in 40 tumor and 22 normal colon tissue samples was analyzed with an Affymetrix oligonucleotide array complementary to more than 6,500 human genes. An efficient two-way clustering algorithm was applied to both the genes and the tissues, revealing broad coherent patterns that suggest a high degree of organization underlying gene expression in these tissues. Coregulated families of genes clustered together, as demonstrated for the ribosomal proteins. Clustering also separated cancerous from noncancerous tissue and cell lines from in vivo tissues on the basis of subtle distributed patterns of genes even when expression of individual genes varied only slightly between the tissues. Two-way clustering thus may be of use both in classifying genes into functional groups and in classifying tissues based on gene expression.

Robustness in bacterial chemotaxis

Networks of interacting proteins orchestrate the responses of living cells to a variety of external stimuli, but how sensitive is the functioning of these protein networks to variations in their biochemical parameters? One possibility is that to achieve appropriate function, the reaction rate constants and enzyme concentrations need to be adjusted in a precise manner, and any deviation from these 'fine-tuned' values ruins the network's performance. An alternative possibility is that key properties of biochemical networks are robust; that is, they are insensitive to the precise values of the biochemical parameters. Here we address this issue in experiments using chemotaxis of Escherichia coli, one of the best-characterized sensory systems. We focus on how response and adaptation to attractant signals vary with systematic changes in the intracellular concentration of the components of the chemotaxis network. We find that some properties, such as steady-state behaviour and adaptation time, show strong variations in response to varying protein concentrations. In contrast, the precision of adaptation is robust and does not vary with the protein concentrations. This is consistent with a recently proposed molecular mechanism for exact adaptation, where robustness is a direct consequence of the network's architecture.

Response regulator output in bacterial chemotaxis

Chemotaxis responses in Escherichia coli are mediated by the phosphorylated response-regulator protein P-CheY. Biochemical and genetic studies have established the mechanisms by which the various components of the chemotaxis system, the membrane receptors and Che proteins function to modulate levels of CheY phosphorylation. Detailed models have been formulated to explain chemotaxis sensing in quantitative terms; however, the models cannot be adequately tested without knowledge of the quantitative relationship between P-CheY and bacterial swimming behavior. A computerized image analysis system was developed to collect extensive statistics on freeswimming and individual tethered cells. P-CheY levels were systematically varied by controlled expression of CheY in an E.coli strain lacking the CheY phosphatase, CheZ, and the receptor demethylating enzyme CheB. Tumbling frequency was found to vary with P-CheY concentration in a weakly sigmoidal fashion (apparent Hill coefficient approximately 2.5). This indicates that the high sensitivity of the chemotaxis system is not derived from highly cooperative interactions between P-CheY and the flagellar motor, but rather depends on nonlinear effects within the chemotaxis signal transduction network. The complex relationship between single flagella rotation and free-swimming behavior was examined; our results indicate that there is an additional level of information processing associated with interactions between the individual flagella. An allosteric model of the motor switching process is proposed which gives a good fit to the observed switching induced by P-CheY. Thus the level of intracellular P-CheY can be estimated from behavior determinations: approximately 30% of the intracellular pool of CheY appears to be phosphorylated in fully adapted wild-type cells.

Aplasia of the cerebellar vermis associated with chronic renal disease. A report of six cases and a review of the literature

We report six patients with aplasia or hypoplasia of the cerebellar vermis with early symptoms consisting of psychomotor retardation, nystagmus and severely reduced visual acuity due to congenital amaurosis. At age 5.6-12.1 years, five of these patients developed symptoms of chronic renal failure due to renal maldevelopment.

CONCLUSION

Children presenting with vermis aplasia should be monitored for associated disorders, especially renal disease.

Ultrasound findings in juvenile nephronophthisis

The ultrasound finding of renal medullary cysts associated with increased echogenicity has been suggested to be diagnostic of juvenile nephronophthisis. The lack of cysts in several of our patients with juvenile nephronophthisis lead us to review the ultrasound findings at presentation in our patient population. Of 11 children with the diagnosis of juvenile nephronophthisis, 10 demonstrated increased echogenicity with loss of corticomedullary differentiation on initial ultrasound. Only 2 children had a single cyst each. On follow-up ultrasound, 2, 4.5, and 7 years later, 3 patients developed visible renal cysts. We conclude that at presentation the ultrasound finding consistent with the diagnosis of juvenile nephronophthisis is most often that of hyperechogenic kidneys without cysts; namely the lack of cysts does not rule out the diagnosis of juvenile nephronophthisis.

Vitamin status of infants receiving long-term peritoneal dialysis

The oral vitamin intakes and blood vitamin concentrations of seven infants receiving long-term peritoneal dialysis were measured. The serum concentrations of vitamin A, vitamin B12, vitamin C and folic acid were determined. Thiamine and riboflavin were assessed by the activation of erythrocyte transketolase and erythrocyte glutathione reductase, respectively. Vitamin B6 was measured as plasma pyridoxal phosphate. All patients received a daily vitamin supplement devoid of vitamin A. Dietary vitamin intake was derived from infant formula. In all cases, the patients' blood concentrations of the water-soluble vitamins were equal to or greater than normal infant values. Serum vitamin A levels were elevated despite the lack of supplementation. The combined dietary/supplemental water-soluble vitamin intake of the patients exceeded the recommended daily allowance in all but one patient. These preliminary data emphasize the need to further evaluate the vitamin requirements of infants receiving long-term peritoneal dialysis.

Assessment and interpretation of the tubular threshold for phosphate in infants and children

Studies in the last decade demonstrated that in children tubular maximum phosphate reabsorption per glomerular filtration rate (TmP/GFR) is identical to TP/GFR; TP indicating tubular phosphate reabsorption under basal conditions, without phosphate load. TP/GFR is calculated from the formula TP/GFR = SP-UP x SCr:UCr, based on simultaneous urine and blood creatinine and phosphate concentrations, and is applicable in both the fasting and non-fasting child. These studies also demonstrated that the use of Walton and Bijvoet nomogram in children may result in overestimation of TmP/GFR compared with TP/GFR calculated from the above formula. When using the formula, one should bear in mind that creatinine is used to express GFR and as a result a significant deviation from true GFR may occur in patients with renal failure. Therefore when employing TP/GFR for the investigation of the renal handling of phosphate in children, three factors should be taken into consideration: (1) the formula in reality expresses TP/CCr; (2) only data obtained by exactly the same methodology can be used as reference values; data obtained from studies in which the nomogram was utilized or in which methods other than CCr were used to measure GFR should not be used for reference; (3) in patients with renal failure, TP/CCr will significantly overestimate TP/Cinulin.

A seven year experience with kidney transplantation for pediatric end stage renal disease

Renal transplantation for pediatric end stage renal disease (ESRD) is a preferred option in dealing with these chronically ill patients. The pediatric renal transplant program at University of Missouri-Kansas City School of Medicine was begun in 1986 at St. Luke's Hospital and subsequently shifted to the Children's Mercy Hospital as experience was accumulated. To date 35 transplants have been performed in 31 recipients. Fifty-one per cent of the patients transplanted were adolescents (older than 13 years) and 91% of the patients were older than 4 years. Sixteen of the 35 transplants were from living related donors and 19 patients received their kidneys from cadaveric donors. Immunosuppression consisted of corticosteroids, azathioprine, cyclosporine and antilymphoblast globulin. No patients died following transplantation with a functioning kidney. Allograft survival with living related transplants at one year and three years was 91% and 86% respectively. Cadaveric allograft survival at one year and three years was 78% and 46% respectively. Most kidneys were lost due to either acute or chronic rejection although there were three patients who lost their kidney due to primary nonfunction, including one child age 23 months. The growth pattern of all but the youngest children (< or = 2 years) following transplantation showed no evidence of accelerated growth. Results in this early series of pediatric renal transplant patients is encouraging from the standpoint of patient and allograft survival and even though accelerated growth is not seen in the older children, it seems to offer a better quality of life for children with end stage renal disease.

The renal clearance and infusion clearance of inulin are similar, but not identical

Thirty-eight simultaneous renal (R-Cin) and infusion (INF-Cin) clearances of inulin were done. The equilibration period preceding the clearance studies was of at least two hours duration. The R-Cin on each subject was based on two clearance periods during which the plasma inulin concentration ([P(in)]) varied by 1.0 mg/dl or less and the rate of inulin excretion by less than 10%. There was excellent correlation between the R-Cin and the INF-Cin (r = 0.976), but the INF-Cin consistently exceeded the R-Cin (mean difference = 13.8 +/- 8.8 ml/min/1.73 m2, t = 9.7163 and P = < 0.001). Complete equilibration of inulin in body fluids has been assumed when [P(in)] levels were relatively constant (variation < 10%). However, complete equilibration of inulin would not be present, even with relatively constant P(in) levels, if the rate of infusion of inulin were equal to the rate of excretion plus the rate of penetration of inulin into less permeable components of the extracellular fluid compartment (that is, dense connective tissue solids). Estimation of glomerular filtration rate using the INF-Cin requires complete equilibration of inulin in body fluids, a process probably requiring 12 to 15 hours or longer.

Neuroblastoma in a renal transplanted child

A 3-year-old boy was diagnosed with neuroblastoma 2 years after a renal transplant that was complicated by acute and chronic rejection. Extensive immunosuppressive therapy may have contributed to the development or progression of this tumor which has not been described previously following organ transplantation.

Aminoglycoside ototoxicity in pediatric patients receiving long-term peritoneal dialysis

We evaluated 14 children on long-term peritoneal dialysis for ototoxicity associated with aminoglycoside (AG) therapy. Baseline evaluation of all patients and 7 controls included pure-tone audiometry (PTA) and click-evoked auditory brain stem response (ABR). Nine patients had repeat PTA and ABR evaluations and vestibular testing 1 year after study entry. Five patients had an additional assessment following intraperitoneal AG therapy. The baseline auditory function of the patients was significantly poorer than controls at 6.0 and 8.0 kHz by PTA (P < 0.05), whereas the results of ABR testing were not different. Of the 14 patients, 4 (28%) had hearing loss, 3 of whom had a history of intravenous AG therapy. In contrast, none of the patients who received intraperitoneal AG therapy only, or without a history of AG therapy, had hearing loss (P < 0.005). There was no evidence of progressive loss of hearing acuity with time or associated with intraperitoneal AG therapy. One patient had findings of vestibular dysfunction. We conclude that children receiving peritoneal dialysis are at risk of AG ototoxicity. While intraperitoneal administration of AG may be associated with less ototoxicity than intravenous administration, further study is necessary to verify this finding and close monitoring of AG levels remains mandatory irrespective of the route of administration. PTA rather than click-evoked ABR appears to be the best indicator of abnormal hearing acuity in this population.

Cerebral vasculitis in acute post-streptococcal glomerulonephritis

Neurological complications in acute post-streptococcal glomerulonephritis (APSGN) have been traditionally attributed to hypertensive encephalopathy. A 9-year-old girl with biopsy-documented APSGN developed seizures at a time she was normotensive and biochemically well balanced. Computed tomography of her brain was consistent with vasculitis, a finding which was also clinically supported by apparent vasculitic involvement of other organ systems. All clinical, laboratory and radiological abnormalities resolved with recovery from the APSGN. We suggest that on rare occasions neurological complications in APSGN may result from involvement of the central nervous system in multiorgan transient vasculitis.

Congenital nephrosis in association with hypothyroidism and hypoadrenocorticism

Adrenal abnormalities are rarely recognized in association with the nephrotic syndrome. This report describes the hospital course of an 11-week-old child with congenital nephrotic syndrome secondary to diffuse mesangial sclerosis, in addition to hypothyroidism and hypoadrenocorticism.

Peritoneal dialysis in the neonatal period: outcome data

Scant information exists on the prognosis of infants with renal failure who receive peritoneal dialysis in the first month of life. We reviewed the outcome of 23 such patients 1 year after the onset of renal failure. Diagnoses included acute tubular necrosis (11 infants), renal dysplasia (5), obstructive uropathy (4), polycystic kidney disease (1), renal vein thrombosis (1), and renal artery thrombosis (1). Seven of the eleven patients with acute tubular necrosis had had cardiac surgery. At 1 year, eight (35%) of the patients had died, six (26%) had a full recovery, seven (30%) were receiving long-term dialysis awaiting a transplant, and two (9%) had chronic renal failure. Effective dialysis, characterized by the reversal of metabolic disturbances or attainment of fluid balance, was accomplished in all patients. The mean duration of dialysis was 4.5 months (range, 0.1 to 12 months). The most common complications of dialysis were peritonitis and catheter exit site infection. Despite the provision of supplemental calories via nasogastric tube, the majority of patients receiving long-term dialysis showed impaired growth and mild developmental abnormalities. Peritoneal dialysis is an effective means of renal replacement therapy in the neonatal period; however, the morbidity and mortality rate for this population remains high.

The kidney in systemic disease: Part II--Autoimmune and vascular disorders

The long-term outlook for the pediatric patient with lupus nephritis has improved dramatically over the past several decades. In 1968, Meislin and Rothfield compared childhood with adult SLE and found the prognosis to be worse when disease onset was at the age of 15 years or younger. Children with renal disease had only a 42% 5-year survival rate vs. an 82% survival rate in adults. Caeiro et al. found the 10-year survival rate in childhood to be only 48%. However, more recent data have demonstrated comparable results for patients of all ages. Ten-year patient survival rates have improved to 69% to 85% as a result of better immunosuppressive therapy, more effective antibiotics, and improved control of hypertension. Despite this overall improvement, severe renal disease continues to complicate the course of 20% to 35% of patients with SLE originating in childhood and demands further investigation of newer therapeutic measures.

Creatinine for estimation of glomerular filtration rate

The aim of this study was to evaluate the plasma creatinine concentration (PCr) and creatinine clearance (CCr) for estimation of glomerular filtration rate (GFR). Inulin clearance (Cin) was used as the reference standard for GFR. Thirty-nine concurrent Cin and CCr studies provided data for comparing Cin with the measured CCr and with the calculated CCr (calc-CCr). (Calc-CCr = k.L/PCr, where L = height in centimeters and k is the proportionality constant.) Thirty-one children 5.3-20.8 years of age, with Cin ranging from 2.8 to 138.8 ml/min per 1.73 m2, participated in these studies at The Children's Mercy Hospital. The measured CCr was 16.7 +/- 10.3 ml/min per 1.73 m2 (P < 0.001) greater than the Cin, and the calc-CCr overestimated Cin by a mean of 31.6 +/- 20.8 ml/min per 1.73 m2 (P < 0.001). Although there is good correlation between Cin and CCr (r = 0.96), and Cin and calc-CCr (r = 0.90), the 95% confidence intervals are quite broad. Hence, the CCr and the calc-CCr, derived using Schwartz values for k, consistently overestimate GFR. However, if the k value in the equation GFR = k.L/PCr is derived from k = Cin/L, rather than from k = CCr.PCr/L, a more accurate estimate of GFR may be obtained.

Metabolic and histologic investigation of the nature of nephrocalcinosis in children with hypophosphatemic rickets and in the Hyp mouse

To investigate the biochemical nature of nephrocalcinosis in children with hypophosphatemic rickets treated with orally administered phosphate and vitamin D, we studied five such patients, aged 3.7 to 12.3 years, during treatment and again 3 days after it had been discontinued. Treatment was associated with significant increases in mean serum phosphate concentration and urine phosphate/creatinine ratio, from 0.71 to 1.03 mmol/L and from 3.61 to 9.42 mmol/mmol, respectively. Significant correlation was found between urine phosphate/creatinine and oxalate/creatinine ratios (r = 0.670; p less than 0.01); however, the mean urine oxalate/creatinine ratio of 65.0 mumol/mmol while patients were taking phosphate orally was not significantly different from the ratio of 59.0 mumol/mmol when treatment was discontinued. Kidney biopsy specimens from three of the patients showed that the renal calcifications were located mainly intratubularly and were composed exclusively of calcium phosphate. In a further investigation of the nature of phosphate-induced nephrocalcinosis, six 6-week-old male Hyp mice, the murine analog of the human disease, received oral phosphate therapy with drinking water for 48 days; six others served as control animals. Mice in the experimental group excreted more phosphate (p less than 0.001) and less calcium (p less than 0.01) than control mice did, and medullary nephrocalcinosis, with a high kidney calcium content, developed (p less than 0.001). Histologic sections showed that the renal calcifications were located intratubularly and were composed of calcium phosphate. We conclude that, both in children with hypophosphatemic rickets and in the Hyp mouse, the development of nephrocalcinosis is associated with high oral phosphate intake and subsequent deposition of calcium phosphate precipitates in the kidney.

Kidney function in very low birth weight infants with furosemide-related renal calcifications at ages 1 to 2 years

To determine whether long-term renal sequelae follow the use of furosemide in preterm infants, we evaluated renal function in 27 former very low birth weight infants (less than 1500 gm) at 1 to 2 years of age. Patients were classified into three groups on the basis of status at the time of discharge from the hospital: group 1 (n = 7) had no furosemide treatment or renal calcifications, group 2 (n = 10) had furosemide therapy but no calcifications, and group 3 (n = 10) had furosemide therapy with renal calcifications. Renal ultrasonography at the time of the study demonstrated resolution of the calcifications in six patients in group 3. No differences in renal function were observed between groups 1 and 2. Creatinine clearance (mean +/- SEM) in group 3 (83.6 +/- 7.8 ml/min per 1.73 m2) was significantly lower than clearance in groups 1 and 2 (103.2 +/- 6.5 and 109.1 +/- 5.1, respectively; p less than 0.05). Children in group 3 had significantly higher urinary calcium/creatinine ratios and fractional excretion of sodium and lower tubular reabsorption of phosphate than children in the two other groups had. Urine-blood difference in carbon dioxide tension after oral acetazolamide load, which indicates the ability of the distal tubule to secrete hydrogen ions, was 8.4 +/- 3.4 mm Hg in group 3, significantly lower than values in groups 1 and 2 (22.6 +/- 3.1 and 28.0 +/- 4.3 mm Hg, respectively, p less than 0.05). Within group 3 the four children with persistent renal calcifications had significantly lower urine-blood carbon dioxide tension differences than did those with resolution of calcifications (p = 0.02). We conclude that furosemide-related renal calcifications in very low birth weight infants may lead to glomerular and tubular dysfunction; further long-term follow-up of this population is recommended.

Recombinant human erythropoietin therapy in pediatric patients receiving long-term peritoneal dialysis

We evaluated the impact of (s.c.) recombinant human erythropoietin (r-HuEPO) therapy on the hematological status, exercise capacity, and dietary intake of nine pediatric patients (mean age 12.4 +/- 3.2 years) receiving long-term peritoneal dialysis. Five children without medical illness served as controls for the exercise testing portion of the study. Following 7.9 +/- 2.8 weeks of twice weekly r-HuEPO (50 units/kg per dose), the hematocrit increased from 21.9 +/- 3.5% to 31.3 +/- 2.5% (P less than 0.001). A further increase to 33.2 +/- 3.0% occurred after 2 months of once weekly therapy. The blood transfusion requirement decreased from 0.5 transfusions per patient-month to 0.05 transfusions per patient-month (P less than 0.01). Graded exercise testing demonstrated an increase in peak oxygen consumption from 17.8 +/- 5.2 to 24.0 +/- 7.6 ml/kg per min (P less than 0.01). The oxygen consumption at anaerobic threshold increased from 13.1 +/- 3.9 to 17.1 +/- 3.5 ml/kg per min (P less than 0.02). Treadmill time increased from 5.3 +/- 1.2 to 7.5 +/- 1.3 min (P less than 0.001). In each case, the percentage improvement was significantly greater than the improvement seen in the control population. Dietary evaluation revealed no significant change in caloric or protein intake, despite a subjectively improved appetite. r-HuEPO, given by the s.c. route, corrects the anemia and improves the exercise capacity of pediatric patients receiving long-term peritoneal dialysis.