Plasma Renin Activity and Blood Pressure in 89 Patients Receiving Maintenance Haemodialysis Therapy

Blood pressure, plasma renin activity, plasma sodium concentration, plasma potassium concentration, dietary sodium intake, and duration of dialysis have been measured under standard conditions in 89 patients on maintenance haemodialysis. No significant relation was found between plasma renin activity and blood pressure. Statistically significant correlations were found between plasma renin activity and plasma sodium concentration and between plasma renin activity and dietary sodium intake.Only one patient was found to have uncontrollable hypertension associated with a markedly raised plasma renin activity. Reasons are given for not performing bilateral nephrectomy in this patient. We believe the low incidence of uncontrollable hypertension and hyperreninaemia in our patients to be due to their slow introduction to haemodialysis, thus preventing violent swings in body weight, blood pressure, and renin secretion.Although plasma renin activity did fall with duration of dialysis, all 15 patients who have been on maintenance dialysis for longer than five years have normal levels.     

Nonsteroidal substances that affect serum free testosterone

Several steroid hormones affect free testosterone (FT) levels in blood by competing with testosterone for binding sites on testosterone-binding globulin (TeBG). However, the effect of endogenous nonsteroidal substances in serum has not been reported. Some of these potential modifiers of FT were studied using equilibrium dialysis. Nonesterified fatty acids at 0.9 mM elevated FT approx 10% at pH 7.4. Investigation of the curvilinear relationship of percent FT (pFT) vs pH showed that pH-dependent changes of testosterone binding to albumin were responsible for a small linear increase in pFT with decreasing pH. The greater portion of the curvilinear increase of pFT with decreasing pH was due to fatty acids competing with testosterone for TeBG binding sites. Ketone bodies significantly affected FT (7.5% elevation) only at levels found in diabetic ketoacidosis. Sodium ions improved binding 11% when 7 mM was compared to 157 mM sodium, but physiological changes in sodium would result in only +/- 1% changes in FT. Very low levels (0.03 mM) of calcium may be essential for normal testosterone binding to TeBG since 1.0 mM EGTA raised FT by 75%. This study shows that dialysis at 37 degrees C should not be performed overnight, that thimerosol should not be used as a preservative, and that the dialysis buffer should contain physiological concentrations of sodium and calcium.     

"Benign" monoclonal IgE gammopathy.

So far IgE monoclonal paraproteins have been found only in patients with malignant diseases, though there are benign monoclonal paraproteins of other immunoglobulin classes. A patient with osteoporosis first seen in Paris in 1965 was found to have a paraprotein type lambda. In 1977 immunoelectrophoresis identified this as IgE lambda paraprotein, and immunodiffusion studies showed precipitin bands identical with those in patients with IgE myeloma. This patient seemed to have a benign monoclonal IgE gammopathy which had existed for 14 years. Though the possibility of transition into multiple myeloma cannot be excluded, this case suggests that a monoclonal expansion of IgE lymphocytes need not produce malignant change.     

Glycosylation of IgG B cell receptor (IgG BCR) in multiple myeloma: relationship between sialylation and the signal activity of IgG BCR

Little is known about the glycosylation of the isotype switched B cell receptor (BCR) in multiple myeloma, and the way it might affect receptor function. In this work IgG BCRs isolated from the individual lysates of peripheral blood lymphocytes (PBL) of 32 patients with IgG multiple myeloma and healthy controls were investigated for the expression of sialic acid (SA), galactose (Gal) and N-acetylglucosamine (GlcNAc), the sugars known to specify the glycoforms of human serum IgG. The degree of glycosylation and signaling status of all 32 isolated myeloma IgG BCRs were correlated and compared with the glycosylation of the IgG paraproteins isolated from sera of the same patients. It was shown that BCR IgG in myeloma is more heavily sialylated when compared with normal controls, that the increased sialylation of IgG BCR is associated with higher levels of tyrosine phosphorylation (signaling activity) of the IgG BCR supramolecular complex and that BCR IgG and serum IgG paraprotein from the same patient differed in all cases in the levels of terminal sugar expression. The results suggest that the development of the malignant clone in MM from post-switch B cells expressing IgG BCR at their surfaces to plasma cells secreting IgG paraprotein may be followed by permanent glycosylation changes in the IgG molecules.     

Analysis of paraprotein transport into the saliva by using anti-idiotype antibodies

To determine the extent of clonal involvement of the secretory immune system and the origin of salivary immunoglobulins (Ig) in monoclonal gammopathy patients, saliva and serum samples were collected from five affected individuals (two IgA myelomas, one IgG myeloma, one IgG benign monoclonal gammopathy, and one IgM lymphoma) and were assayed for the presence of monoclonal Ig. Purified polyclonal or monoclonal anti-idiotype (Id) antibodies were prepared against each of the isolated serum paraproteins. In all five individuals, the patient saliva samples inhibited the binding of 125I-labeled homologous Ig to the corresponding anti-Id antibodies, but normal saliva did not. The concentration of Id in patients' saliva varied from 1 to 400 micrograms/ml; i.e., 0.004 to 1.0% of the corresponding serum values. Saliva of a lymphoma patient whose IgM kappa protein exhibited rheumatoid factor (RF) activity also contained RF. The salivary Id-bearing molecules were found to have the same Ig isotype as the serum paraproteins. The myeloma IgA represented a minor component (0.4 and 3.9%) of the total salivary IgA. The salivary IgA myeloma proteins were associated at least in part with secretory component, but the salivary IgG paraproteins were not. In an IgA myeloma patient, a minority (17%) of the IgA+ plasma cells found in the lacrymal gland biopsy specimen were Id+, whereas the great majority (98%) of bone marrow IgA plasma cells were Id+. The results suggest active transport rather than passive transudation of myeloma IgA into the patients' saliva, and the integrity of the secretory immune system was not compromised by the neoplastic process.     

Purification, microheterogeneity, and stability of human lipid transfer protein

A method for the purification of lipid transfer protein (LTP) from human plasma was developed with the aid of succinylated low density lipoprotein-Sepharose affinity column chromatography. The purified LTP exhibited a single main band on sodium dodecyl sulfate-polyacrylamide gel electrophoresis. However, upon isoelectric focusing on polyacrylamide gel, the preparations consistently showed nine bands with isoelectric points ranging from 4.6 to 5.4. The treatment of LTP with Clostridium perfringens neuraminidase shifted these multiple bands toward higher pH regions due to the release of sialic acid. Extensive treatment with neuraminidase resulted in the appearance of a major band with the isoelectric point of 5.6. The purified LTP was rapidly inactivated upon incubation at 37 degrees C due to the denaturation at the "air"-water interface. Various factors promoting or preventing this interfacial denaturation were elucidated. When purified LTP was stored at 4 degrees C, plasma neuraminidase co-purified with LTP became activated, resulting in the gradual desialylation of LTP. It seemed that the LTP preparations of apparent homogeneity are associated with a trace amount of an inactive form of plasma neuraminidase. The inclusion of 4 mM 2-mercaptoethanol or 0.2% EDTA in the storage media completely prevented the activation of plasma neuraminidase. These agents, however, did not significantly inhibit the already activated neuraminidase. When LTP was stored at -20 degrees C in very low ionic strength media, such as 0.001% EDTA (pH 7.4) and at high protein concentrations, the loss of the activity was minimal even after prolonged storage.     

Plasma cell tumours: cytomorphological features in a series of 12 cases diagnosed on fine needle aspiration cytology

U. Handa, S. Chhabra and H. Mohan
Plasma cell tumours: cytomorphological features in a series of 12 cases diagnosed on fine needle aspiration cytology Objective: Plasma cell tumours represent autonomous proliferation of plasma cells and can manifest as multiple myeloma, monoclonal gammopathy of undetermined significance, variants of plasma cell myeloma or plasmacytoma. Methods: We report 12 cases of plasma cell tumours, which were initially diagnosed as plasmacytoma on fine needle aspiration cytology (FNAC). The patients were further subjected to bone marrow examination, serum electrophoresis, urine examination for Bence–Jones proteins, and x‐ray examination of the skeleton. Results: The cytological smears from all cases were cellular and showed numerous plasma cells in varying degrees of maturity. Subsequent to investigations, five cases were labelled as multiple myeloma with secondary extramedullary plasmacytoma, three as solitary bone plasmacytoma and two as primary extramedullary plasmacytoma. In the remaining two cases, bone marrow and urine examination findings were not available, so a conclusive diagnosis of multiple myeloma or solitary plasmacytoma could not be made. Conclusion: The study highlights the role of FNAC in the diagnosis of plasma cell tumours. Subsequent work‐up and follow‐up of these patients is important to rule out the presence of multiple myeloma.     

Tamm-Horsfall protein antibody in patients with end-stage kidney disease.

Circulating antibody to Tamm-Horstall protein (THP) was measured using a radioimmunoassay in forty-five patients on maintenance hemodialysis and compared to levels of antibody titers measured in sera from ten healthy controls. The etiology of the end-stage kidney disease in the patient population was polycystic kidney disease in thirteen, glomerulonephritis in fourteen, diabetic nephropathy in nine, interstial nephritis and chronic pyelonephritis in three each, multiple myeloma in two, and urinary tract obstruction in one. Four patients had significantly elevated titers of antibody to THP but shared no other unifying characteristics. The results also indicate that none of the groups studied had mean antibody titers significantly different from controls. Furthermore, no general trend was apparent between levels of antibody to THP and number of months on dialysis. Observations made during the study revealed that heparinized samples of blood had lower titers of antibody to THP than did non-heparinized samples from the same patient. This finding was repeated when other anti-coagulants, i.e., ethylenediaminetetraacetate (EDTA) and sodium citrate, were used. Titers returned toward normal when CaCl2 was added back to samples anticoagulated with EDTA and sodium citrate. This suggests that clotting factors, probably fibrinogen, interfered with the measurement of antibody titers. Therefore, only serum should be used in further investigations of THP antibody using this assay.     

A histochemical study of anionic sites in the intermediate layer of rat femoral cartilage using polyethyleneimine at different pH levels

Anionic sites in the intermediate layer of young rat hyaline cartilages were examined using a cationic dye, polyethyleneimine (PEI), at different pH levels. Femoral heads were resected and fixed in 2.5% glutaraldehyde and treated with 0.5% PEI at pH 7.4, pH 2.5 or pH 1.0. Some cartilage samples were first digested with chondroitinase ABC or hyaluronidase. The PEI deposits at pH 7.4 appeared to be irregular shapes. Their sizes seemed to be larger than those at pH 2.5 or pH 1.0. The PEI deposits were also found on the surface of collagen fibrils at both pH 7.4 and pH 2.5 even after the chondroitinase ABC digestion, but were not found at pH 1.0. Moreover, they disappeared after hyaluronidase digestion. Accordingly, it is suggested that PEI-positive structures varied depending on pH levels. In addition, hyaluronan may be localized near collagen fibrils, but most sulphated proteoglycans may not. This revised version was published online in November 2006 with corrections to the Cover Date.     

Dissociation of low density lipoprotein-antibody precipitates at alkaline pH

The effect of alkaline pH on the dissociation of immunoprecipitates of low density lipoproteins (LDL) of the S(f) 0-10 class was studied by immunological and ultracentrifugal methods. The precipitates prepared at the equivalence point were dissolved and centrifuged in sodium chloride solutions of density 1.063 and pH's between 10.25 and 11.5. Analytical centrifugation of the top fraction, which floated at density 1.063, after dialysis against 0.9% sodium chloride of pH 7.4 revealed the presence of LDL and of soluble LDL-antibody complex. The amount of soluble complex was greater for the preparations obtained at lower pH than those obtained at higher pH and was undetectable at pH 11.5. The yield of immunoglobulin from the bottom fractions was maximal when the pH of the centrifugation medium was 11.0. Below pH 11.0, the greatly reduced yield of immunoglobulin was due partly to incomplete dissociation and partly to aggregation of soluble complex, while above pH 11.0 the decreased yield was possibly due to alkaline denaturation of the globulin. The immunoglobulin separated at pH 11.0 and dialyzed to pH 7.4 was reprecipitatable by LDL, and the reactivity did not seem to be appreciably influenced by the alkaline treatment.     

IgD Plasma Cell Neoplasia: Clinical Manifestations and Characteristic Features

Three patients, one with plasma cell leukemia and clinically asymptomatic hypernephroma and meningioma, and two others with multiple myeloma, had M-components of IgD/λ type. In the first case, IgD globulin was found in the serum, ascitic and pleural fluids. Including our patients, 50 cases of IgD myeloma have been reported in the literature. A review of this group showed some significant differences from the other classes of multiple myeloma. IgD myeloma seems to involve a larger proportion of younger people, 66% being less than 59 years of age. The involvement of internal organs and renal damage were more frequent in IgD myeloma than in other classes. Serum total protein was frequently not increased, the relative concentration of M-component was often low and in 12% there was no spike in electrophoresis. The diagnosis therefore was sometimes difficult. In a quarter of the cases Bence Jones proteinemia was found and in 15% there were multiple spikes, both these manifestations being rare in IgG or IgA classes of myeloma. In 89%, IgD globulin had lambda type light chain, clearly contrasting with the figure of approximately 30% in other classes. Bence Jones protein was found in the urine in 91%. The survival time seemed to be shorter than in other myelomas.     

Immunofluorescence analysis of IgA binding by human mononuclear cells in blood and lymphoid tissue

The nature of IgA-binding cells and their tissue distribution was examined by an indirect immunofluorescence assay with the use of IgA1 and IgA2 paraproteins and fluorochrome- or biotin-labeled F(ab')2 fragments of idiotype-specific antibodies. The frequency of IgA-binding mononuclear cells was approximately 13% in blood and spleen samples but less than 1% in tonsil samples. IgA binding could be visualized by flow immunocytometry on monocyte/macrophages, but not on T and B cells. IgA polymers were bound better than IgA dimers and monomers. Nonhomologous IgA myelomas of both IgA1 and IgA2 subclasses inhibited the IgA-binding to monocytes, whereas aggregated normal serum IgG, IgM paraproteins, and an IgG myeloma did not. IgA binding was relatively insensitive to changes in temperature or cation concentration. IgA-binding monocytes were found in IgA-deficient patients at the same frequency as in normal individuals. The results indicate that monocytes constitutively express class-specific binding sites for both IgA1 and IgA2 molecules.     

The effects of pH on amphetamine-induced dopamine release as measured by in vivo dialysis

The release of endogenous dopamine (DA) from the rat corpus striatum before and after the administration of d-amphetamine sulphate (AMPH) was monitored by in vivo dialysis to compare the effects of perfusion media at pH 6.0 and at pH 7.4. Basal release of DA did not differ significantly at pH 6.0 (61.25 +/- 5.34 pg/sample, n = 4) or pH 7.4 (58.02 +/- 14.17 pg/sample, n = 4). The basal value of homovanillic acid (HVA) was not significantly reduced at pH 7.4 as compared with pH 6.0; while there was a significant reduction in 3,4-dihydroxyphenylacetic acid (DOPAC) at pH 7.4 as compared to pH 6.0. Intraperitoneal injection of 2.5 mg/kg AMPH resulted in a 21 fold increase in the concentration of DA appearing in subsequent dialysis samples. This increase in DA release was not significantly affected by the pH. Equally the decrease in DOPAC and HVA content following AMPH were also not altered by the pH. These present results differ from experiments using push-pull cannulae and suggest that responses observed with the two techniques may not be equivalent.     

The interaction of bovine plasma albumin with cationic detergents at pH9

The interaction of bovine plasma albumin (BPA) with tetradecyltri-methylammonium bromide (TTAB) was studied at pH 9.0. When the system BPA-TTAB was analyzed by the gel electrophoresis, the pattern changed with the molar mixing ratio (TTAB/BPA). At molar mixing ratio 12, for example, zones 1, 2, 3, 4, and 5 were observed. Component 1 is a monomer and component 2 is a dimer of BPA. Components 3–5 are further aggregates of BPA. Thus, the intermolecular SH - SS exchange reaction occurs between BPA molecules unfolded by cationic detergent, leading to the formation of a series of lower aggregates of BPA. Under some conditions, partial precipitation of BPA occurred. Components 1′ and 1″, which are modified monomeis, were observed at certain concentrations of detergent.Studies were also made using a series of cationic detergents differing in the length of hydrocarbon chain C₆C₁₂. Including TTAB, the longer the hydrocarbon chain, the more remarkable was the effect on BPA.The effect of cationic detergent on BPA resembles that of urea insofar as gel electrophoresis is concerned. Furthermore the denatureation of BPA by cationic detergent resembles that by heat and by high pressure. These four agents are initiators of SH - SS exchange reaction for the protein.The effect of cationic detergent differs entirely from that of the anionic detergent such as sodium dodecyl sulfate (SDS). The anionic detergent does not initiate the intermolecular exchange reaction at pH 9.0 even when the molar mixing ratio SDS/BPA is high enough to make BPA unfold.     

Automated on-like dialysis, trace enrichment and high-performance liquid chromatography Inhibition of interaction with the dialysis membrane and disruption of protein binding in the determination of clozapine in human plasma

Problems related to interaction of drugs with the dialysis membrane and to protein binding must be overcome in order to develop automated methods for drug analysis based on on-line dialysis, trace enrichment and HPLC. In order to study these problems, clozapine and its active metabolite N-desmethylclozapine were chosen as model compounds because they were found to interact with the dialysis membrane, and clozapine is highly protein bound. Addition of a cationic surfactant, dodecylethyldimethyl ammonium bromide, to the donor solution and to the plasma samples was found to inhibit interaction of the drugs with surfaces. The protein binding in plasma was disrupted prior to dialysis by lowering the pH with hydrochloric acid and the plasma proteins were solubilised with glycerol. The results obtained were used to develop a fully automated method for the determination of clozapine and N-desmethylclozapine in human plasma. More than 100 samples could be analysed within 24 h. The limit of detection in human plasma was 0.050 μmol/1 for clozapine and 0.055 μmol/1 for N-desmethylclozapine. Linearity was found for drug concentrations between 0.25–3 μmol/1. The relative standard deviations were between 1.2–6.7% and the method was applicable for therapeutic drug monitoring.     

Cryocrystalglobulinemia: pH-dependent precipitation of a monoclonal IgG-kappa-immunoglobulin

Cryoglobulinemia is seen in a minority of patients with plasma cell dyscrasias and can be of clinical relevance if intravascular gelling or precipitate formation occurs at low temperatures. We observed a patient suffering from IgG-kappa multiple myeloma which was complicated by instability of the immunoglobulin forming crystalline precipitates at low pH and low temperature. Short exposure to extreme cooling initiated an unusual course terminating in disseminated vascular occlusion and fatal outcome which was connected with an adverse effect of blood exchange. Crystal formation was noticed in anticoagulated blood samples even at 37 degrees C. In vitro studies showed a critical pH dependency of solubility of the immunoglobulin close to the physiological pH of the blood. These observations suggest that the fatal outcome was due to a vicious circle of ischemia, metabolic acidosis and intravascular precipitations, initiated not only by low acral temperatures but by cold-induced ischemic tissue acidosis as well. Serum of patients with monoclonal gammopathy and cryoglobulinemia should be tested for pH dependent immunoglobulin insolubility.     

Erythrocyte 2,3-DPG,ATP and oxygen affinity in hemodialysis patients

Patients on a chronic hemodialysis regimen were studied with respect to their erythrocyte adaptation to anemia. Erythrocyte 2,3-diphosphoglycerate (DPG) concentration was suboptimal compared with that of anemic patients who were not uremic. In uremic patients erythrocyte 2,3-DPG correlated poorly with hemoglobin level but more strongly with plasma pH. Differences between observed levels of erythrocyte 2,3-DPG and the values predicted using data from other anemic patients also correlated with pH. Gradual correction of plasma pH with oral sodium bicarbonate resulted in a substantial increase in erythrocyte 2,3-DPG and a decrease in oxygen affinity. Therefore, maintenance of normal pH in uremic subjects may improve tissue oxygenation. On the other hand, the rapid correction of acidosis during dialysis resulted in increased oxygen affinity. This response was due to the direct effect of pH on oxygen affinity in the absence of a significant change in erythrocyte 2,3-DPG or adenosine triphosphate (ATP) during hemodialysis. Erythrocyte ATP but not 2,3-DPG correlated with serum inorganic phosphate in uremic subjects. A 21% reduction of serum phosphate produced by ingestion of aluminum hydroxide gel had no significant effect on these variables.     

Effect of sodium intake on fasting and postprandial levels of atrial natriuretic factor in humans

The effect of chronic dietary sodium intake on fasting and postprandial plasma atrial natriuretic factor (ANF) levels was examined in 2 studies of normal humans. In Study I, 3 separate groups of normals (n = 8 for each) received diets of either low (L), normal (N) or high (H) daily sodium intake for 7 days. Twenty-four h urines for sodium were obtained on days 6 and 7. Urine sodium excretion for each group was (L) 13.1 +/- 3.7, (N) 150.1 +/- 19.4 and (H) 271.3 +/- 33.6 mEq/day. On the completion of day 7, fasting plasma ANF showed no change with alteration in sodium intake. In contrast, when blood samples were obtained postprandially, significant increases in plasma ANF were observed in the group maintained on high sodium diet. In Study II, a continuous group of normals (n = 8) received the 3 sodium controlled diets for 7 days sequentially (L/N/H). No significant changes in fasting levels of ANF were detected between L/N/H sodium diets. In conclusion, these studies show that the maintenance of sodium balance during chronic changes in sodium intake can occur despite no significant increase in plasma ANF under normal steady state conditions. However, plasma ANF is significantly elevated during chronic high sodium intake, when measured postprandially.     

Identification of extracellular lipases/esterases produced by Thermus thermophilus HB27: partial purification and preliminary biochemical characterisation

Thermus thermophilus HB27 produces important levels of extracellular lipolytic activity when grown for 30 h at 70 degrees C in a complex medium. A method to detect esterase activity in these samples after non-reducing SDS-polyacrylamide electrophoresis was developed. The method, that implies the renaturalisation of the enzymes in the SDS-gels by washing with Triton X-100 at high temperatures, allowed detecting three esterases with different molecular weights (108, 62 and 34 kDa, respectively). The electrophoretic mobility determined under different experimental conditions suggested that the 34- and 108 kDa-esterases might correspond with two oligomeric states of a sole enzyme (monomer and trimer). Dissociation of the trimer into the monomer started when the samples were heated at temperatures higher than 60 degrees C in the presence of sodium dodecyl sulphate. Evidences were found that indicated the independent nature of the 62 kDa-esterase. A method to purify these enzymes from postincubates of T. thermophilus HB27 was developed following three steps: sodium cholate treatment, ethanol/ether precipitation and hydrophobic chromatography. In this way, an enzyme solution was obtained that contained the identified esterases/lipases. The partially purified enzymes showed an optimum of activity for the hydrolysis of p-nitrophenyl laurate at alkaline pH values and 80 degrees C, a high thermal stability and were very stable in the presence of high concentrations of isopropanol.     

Idiotypical identity of IgG myeloma protein with monoclonal IgM, Bence Jones protein, and Fv derived from one patient.

Serum from a patient (KK) with IgG2-lambda myeloma was shown to contain multiple paraproteins corresponding to an IgM-lambda monoclonal protein (MMP), a lambda-type Bence Jones protein (BJP), and a 30 kDa component in addition to the IgG2 myeloma protein (GMP). These proteins possessed common idiotypic determinants, as judged by their monoclonal reactivity with rabbit anti-GMP idiotype antibody (aId) in the immunofixation electrophoresis. Analysis with aId absorbed with either H or L chain of GMP revealed that the 30 kDa component shared both VH and VL with GMP and MMP, while BJP carried only the VL idiotype. The 30 kDa component, however, failed to react with antibody to either the mu, gamma, alpha, kappa, or lambda isotype, indicating that it had an Fv-like molecular composition. These results suggest that myeloma cells of KK had diverged from the same precursor B cell clone to produce MPs of different isotypes and altered molecular constructions.