The anemia of chronic renal failure: in vitro response of bone marrow to erythropoietin.

Bone marrow cells of patients with chronic renal failure were studied in short-term in vitro cultures to determine erythropietin responsiveness. Seven normals and fourtheen patients on hemodialysis were studied. Bone marrow cells of normal subjects and of patients with chronic renal failure responded similarly to erythropoietin. Total heme synthesis was significantly lower in cultures prepared with uremic serum than normal serum. We conclude that there is a substance in the serum of uremic patients which suppresses general heme synthesis and that this "uremic toxin" may be responsible, in part, for the clinically severe anemia seen in these patients.     

Polyamines in renal failure

Summary. The levels of polyamines (putrescine, spermidine and spermine) and polyamine oxidase in plasma of patients with chronic renal failure were determined. The level of putrescine was increased but the level of spermine was decreased in the plasma of these patients. The patients also had increased plasma polyamine oxidase activity leading to increased degradation of spermine. As acrolein was a major toxic compound produced from spermine by polyamine oxidase, the levels of free and protein-conjugated acrolein in plasma were also measured. Acrolein levels were enhanced in plasma of patients with chronic renal failure. The accumulated acrolein found as protein conjugates was equivalent to 170 μM, which was about 5-fold higher than in plasma of normal subjects. It was found that acrolein is mainly produced by spermine oxidase in plasma. An increase in putrescine, spermine oxidase and acrolein in plasma was observed in all cases such as diabetic nephropathy, chronic glomerulonephritis and nephrosclerosis. After patients with chronic renal failure had undergone hemodialysis, their levels of plasma polyamines, spermine oxidase and acrolein returned towards normal. It is likely that acrolein produced from spermine accumulates in the blood due to decreased excretion into urine and may function as a uremic “toxin”.     

Contribution of polyunsaturated fatty acids to Shiga toxin cytotoxicity in human renal tubular epithelium-derived cells.

Shiga toxin (Stx) produced by enterohemorrhagic Escherichia coli is a critical factor in the onset of hemolytic uremic syndrome. The current study was designed to assess whether n-3 and (or) n-6 polyunsaturated fatty acids (PUFA) act as a valuable adjunct to prevent the cell injury of renal tubule cells in the emergence of HUS. The target cells, ACHN cells derived from human tubule epithelium, were cultured with each PUFA, then exposed to Stx-1 or Stx-2. The rank order of potency of PUFA to inhibit the cell death caused by each toxin was as follows: EPA > AA = DHA > LNA. There were dose-response relations in the efficacy of each PUFA. No prophylactic effect was found in the cultures with LA. Immunofluorescence assays revealed that both the expression of the toxin receptor on ACHN cells and binding between the toxin and cells were unaffected by the PUFA. These results suggest that EPA is the most efficacious PUFA against the renal tubule cell injury caused by Stx, which may be assigned to an alteration in the intracellular pathway leading to cell death.     

Impaired binding of low density lipoprotein to hepatic membranes from uremic guinea pigs.

Chronic renal failure is associated with abnormalities in lipoprotein metabolism that may contribute to premature atherosclerosis and early mortality in patients on dialysis. In previous studies, we found that plasma clearance of radiolabelled low density lipoprotein (LDL) was retarded in nephrectomized guinea pigs left with one-sixth of normal functioning renal mass. To elucidate potential mechanisms of delayed LDL clearance, we compared binding of LDL to hepatic membranes from both normal and uremic guinea pigs. One hundred micrograms of the 8000-100,000 X g hepatic microsomal protein was incubated with 125I-labelled normal guinea pig LDL (10-150 micrograms/mL) for 1 h at 37 degrees C, and the membrane washed and pelleted by centrifugation in a Beckman Ti 42.2 rotor. Parallel incubations with excess unlabelled LDL were done to determine specific binding. LDL specific binding to uremic hepatic membranes was significantly impaired compared with normal ones. The major abnormality, as determined by Scatchard transformation of the binding data, was a reduction of the apparent maximal binding of LDL to uremic membranes, with an average Bmax of 4.1 micrograms/mg protein compared with 6.6 micrograms/mg protein for normal hepatic microsomes. The affinity of LDL for uremic liver membranes was only slightly diminished with a mean apparent Kd of 35.2 micrograms/mL in comparison with 21.8 micrograms/mL for normal liver membranes. These results provide a biochemical explanation for the diminished LDL clearance in uremia and may account for the dyslipidemia of renal failure.     

Effect of prostaglandin inhibition on glomerular filtration rate in normal and uremic rabbits

Studies were performed to assess the effect of alterations in prostaglandin biosynthesis on glomerular filtration rate in rabbits with normal renal function and after surgical reduction of renal mass. In normal animals, the administration of either of two cyclo-oxygenase inhibitors resulted in a 53% reduction in urine prostaglandin E excretion, but no change in creatinine clearance. Creatinine clearance rates were almost 71% lower in the uremic animals when compared to the animals with normal renal function. Despite the reduction in renal mass, urine prostaglandin E excretion rates in the uremic animals were over twice that seen in normal rabbits. When factored by either glomerular filtration rate or remaining renal mass, urine prostaglandin E excretion rates in uremic rabbits when compared to normal animals were increased more than 9-times and 4-times respectively. Administration of cyclo-oxygenase inhibitors in the uremic animals resulted in a 71% decrease in urine prostaglandin E excretion and, unlike the non-uremic animals, a 53% fall in creatinine clearance. These findings suggest that intact renal prostaglandin biosynthesis is a necessary factor in the homeostatic adaptive mechanisms which maintain the glomerular filtration rate in animals with decreased renal mass.     

涤毒灌肠方对慢性肾衰竭患者肠源性尿毒症毒素的影响分析

目的:探讨涤毒灌肠方对慢性肾衰竭患者肠源性尿毒症毒素的影响。方法:选择2014年2月到2017年6月在我院肾病科门诊及住院诊治的慢性肾衰竭患者92例,按患者意愿分为研究组与对照组各46例。对照组给予常规治疗措施,研究组在对照组治疗的基础上给予涤毒灌肠方治疗,两组都治疗3个月。记录两组疗效、治疗前后肾功能的变化与肠源性尿毒症毒素的释放情况。结果:治疗后,研究组与对照组的总有效率分别为93.5%和78.3%,研究组显著高于对照组(P0.05)。两组治疗后的血肌酐与尿素氮水平都显著低于治疗前(P0.05),且研究组显著低于对照组(P0.05)。研究组治疗后的大肠杆菌、肠球菌值均显著低于对照组(P0.05),双歧杆菌、乳酸杆菌值均显著高于对照组(P0.05)。研究组与对照组治疗后的内毒素含量为0.026±0.004 EU/mL和0.030±0.006 EU/mL,研究组显著低于治疗前的,且显著低于对照组(P0.05)。结论:涤毒灌肠方用于慢性肾衰竭患者中的辅助治疗能抑制肠源性尿毒症毒素的释放,改善肠道菌群及肾功能,提高治疗效果。     

Increased plasma protein binding of propranolol in rabbits with acute renal failure

Acute renal failure was produced in rabbits either by uranyl nitrate or by glycerol. Uremia ensued in all uranyl nitrate treated animals and in the majority of glycerol treated animals. In the uremic rabbits binding of phenytoin to plasma proteins decreased with respect to treated non-uremic animals and controls. On the other hand binding of propranolol markedly increased in uremia. The increased propranolol binding was not due to the elevated creatinine and urea levels in uremic plasma. Charcoal treatment of uremic plasma did not restore normal propranolol binding. The findings indicate that the influence of renal failure on binding of drugs to plasma proteins is more complex than hitherto assumed.     

Drug dosing guidelines in patients with renal failure.

The metabolism and excretion of many drugs and their pharmacologically active metabolites depend on normal renal function. Accumulation and toxicity can develop rapidly if dosages are not adjusted in patients with impaired renal function. In addition, many drugs that are not dependent on the kidneys for elimination may exert untoward effects in the uremic milieu of advanced renal disease. A familiarity with basic pharmacologic principles and a systematic approach are necessary when adjusting drug dosages in patients with abnormal kidney function. The distinct steps involve calculating the patient''s glomerular filtration rate, choosing and administering a loading dose, determining a maintenance dose, and a decision regarding monitoring of drug concentrations. If done properly, therapy in renal patients should achieve the desired pharmacologic effects while avoiding drug toxicity. Physicians must not oversimplify the pharmacologic complexities presented by patients with renal failure by relying excessively on nomograms and "cookbook" equations. In addition to a reduced glomerular filtration rate, patients with renal disease often have alterations in pharmacokinetics such as bioavailability, protein binding, hepatic biotransformation, and volume of distribution. An awareness of biologically active or toxic metabolites of parent compounds that accumulate when the glomerular filtration rate is reduced is also necessary to avoid toxicity. The effects of dialysis on drug elimination and the need for supplemental dosing are additional considerations in patients undergoing renal replacement therapy.     

An Enlarged Profile of Uremic Solutes

Better knowledge of the uremic solutes that accumulate when the kidneys fail could lead to improved renal replacement therapy. This study employed the largest widely available metabolomic platform to identify such solutes. Plasma and plasma ultrafiltrate from 6 maintenance hemodialysis (HD) patients and 6 normal controls were first compared using a platform combining gas and liquid chromatography with mass spectrometry. Further studies compared plasma from 6 HD patients who had undergone total colectomy and 9 with intact colons. We identified 120 solutes as uremic including 48 that had not been previously reported to accumulate in renal failure. Combination of the 48 newly identified solutes with those identified in previous reports yielded an extended list of more than 270 uremic solutes. Among the solutes identified as uremic in the current study, 9 were shown to be colon-derived, including 6 not previously identified as such. Literature search revealed that many uremic phenyl and indole solutes, including most of those shown to be colon-derived, come from plant foods. Some of these compounds can be absorbed directly from plant foods and others are produced by colon microbial metabolism of plant polyphenols that escape digestion in the small intestine. A limitation of the metabolomic method was that it underestimated the elevation in concentration of uremic solutes which were measured using more quantitative assays.     

Plasma arginine and ornithine levels and selected enzyme activities in uremic rats fed various amounts of arginine

Rats weighing 100 g were made chronically uremic by partial left renal artery ligation and contralateral nephrectomy. Rats with urea clearances below 0.30 ml/min and sham-operated controls were pair-fed arginine-free diets, diets containing normal amounts of arginine or diets with high levels of arginine. After 4 to 8 weeks, rats were killed and plasma levels of arginine, ornithine and lysine were measured. In addition, activities of various urea cycle enzymes in liver and kidney and renal transamidinase were determined. Plasma amino acid levels and enzyme activities of the urea cycle remained constant in control rats fed diets differing in arginine content. However, renal transamidinase activity was elevated in control rats fed arginine-free diets. In plasma of uremic as compared with control rats, arginine levels varied with the arginine intake, and lysine levels were elevated when arginine supplements were fed. With all diets, plasma ornithine remained constant in uremic rats at slightly but not significantly increased levels. Hepatic carbamoyl phosphate synthetase activity and renal arginine synthetase activity were reduced in uremic as compared to control rats. Renal transamidinase activity, expressed per g of kidney, was elevated in uremic rats with all diets except arginine-free. When amino acid diets were fed, hepatic arginase activity was higher in uremic rats and this increase was enhanced by arginine-free diets. Other enzyme activities in uremic rats were not affected by the amount of arginine in the diet.     

Dopamine and TSH secretion in uremic male rats

The role of dopamine in the dysregulation of TSH secretion in uremic male rats was investigated using the dopamine antagonist, pimozide. In order to obviate the effect of weight loss due to uremia-induced anorexia as a cause of altered TSH secretion in uremia, we also studied a group of normal animals whose food intake was restricted and who demonstrated weight loss comparable to that of the uremic animals. Baseline TSH concentrations were not significantly different in the normal, uremic or starved animals. Pimozide administration produced no change in the baseline TSH concentrations in any of the groups of rats. The peak TSH response to TRH (5 micrograms IV) was significantly blunted in the uremic animals compared to the normal controls and the starved animals. Pimozide administration did not alter the peak TRH-stimulated TSH response in either the normal animals or the starved animals. However, the peak TRH-stimulated TSH response was significantly increased in the uremic animals and was comparable to the peak TSH response seen in the pimozide-untreated control animals. The data suggest that experimental renal failure in rats is associated with diminished sensitivity of the thyrotroph to TRH stimulation, and that this blunted sensitivity may be dopamine-dependent since it can be abolished by pharmacologic dopamine blockade.     

Effect of medial calcification on vascular function in uremia

The contribution of medial calcification to vascular dysfunction in renal failure is unknown. Vascular function was measured ex vivo in control, noncalcified uremic, and calcified uremic aortas from rats with adenine-induced renal failure. Plasma urea was 16 ± 4, 93 ± 14, and 110 ± 25 mg/dl, and aortic calcium content was 27 ± 4, 29 ± 2, and 4,946 ± 1,616 nmol/mg dry wt, respectively, in the three groups. Maximal contraction by phenylephrine (PE) or KCl was reduced 53 and 63% in uremic aortas, and sensitivity to KCl but not PE was increased. Maximal relaxation to acetylcholine was impaired in uremic aortas (30 vs. 65%), and sensitivity to nitroprusside was also reduced, indicating some impairment of endothelium-independent relaxation as well. None of these parameters differed between calcified and noncalcified uremic aortas. However, aortic compliance was reduced in calcified aortas, ranging from 17 to 61% depending on the severity of calcification. We conclude that uremic vascular calcification, even when not severe, significantly reduces arterial compliance. Vascular smooth muscle and endothelial function are altered in renal failure but are not affected by medial calcification, even when severe.     

Intestinal absorption of L-ascorbic acid in rats with renal failure

We studied L-ascorbic acid absorption in rats subjected to subtotal nephrectomy (renal failure (RF) group) and compared the results with those obtained in sham-operated normal animals and those pair-fed with their azotemic counterparts (PF group). In vivo recirculating perfusion and in vitro everted sac techniques were employed. The in vitro experiments were repeated substituting buffer within the serosal compartment with pooled sera from uremic and normal individuals. L-Ascorbic acid absorption in vivo in the RF group was significantly lower than those found in normal control and PF groups. In contrast, the in vitro mucosal to serosal transport was increased in the RF and PF groups when compared with the normal control group, suggesting increased permeability to L-ascorbic acid in the former groups. The disparity between in vivo and in vitro results in the RF animals is indicative of some inhibitory influence present in the intact uremic animals. However, experiments comparing the effect of uremic with normal sera on in vitro transport failed to reveal any suppressive effect of uremic chemical environment. In addition, serum ascorbic acid was reduced in PF and RF groups when compared with the normal control animals, thereby excluding elevated blood level as a cause of impaired absorption in intact animals with RF. In conclusion, in vivo jejunal absorption of L-ascorbic acid is impaired in rats with RF despite evidence of increased in vitro permeability. The latter appears to be mediated by reduced nutrient intake and weight loss. The inhibitory influence present in vivo could not be reproduced by incubation with uremic sera in vitro.     

Gonadotropin secretion in azotemic male rats--effect of opioid blockade

The role of endogenous opioids in the control of gonadotropin secretion in uremic male rats was investigated using the narcotic antagonist, naloxone. In order to eliminate the effect of weight loss due to uremia-induced anorexia as a cause of previously described altered gonadotropin secretion in uremia, we also studied a group of normal pair-fed control animals who exhibited a weight loss comparable to that of the uremic animals. Naloxone administration had no effect on the basal or LRH-stimulated peak concentrations of LH and FSH in the normal or the uremic rats. Basal and LRH-stimulated gonadotropin responses in the pair-fed rats were comparable to those seen in the normal rats. Similarly, opioid blockade produced no change in the basal or LRH-stimulated gonadotropin responses in the pair-fed animals. Testosterone concentrations were significantly lower in the uremic and pair-fed animals compared to the normal rats. The data suggest that experimental renal failure is not associated with altered opioidergic tone, as it relates to gonadotropin secretion, or to diminished sensitivity of the gonadotroph to LRH stimulation. The decreased testosterone concentration seen in the uremic and pair-fed rats may reflect abnormalities in gonadal hormone secretion due to primary pathology occurring at the level of the gonad. These abnormalities may be reflected as diminished Leydig cell sensitivity to LH. The inappropriately low concentrations of LH in the presence of low testosterone together with normal gonadotropin response to exogenous LRH also suggest an abnormal secretion of endogenous LRH. It is not clear whether this presumed abnormality in LRH secretion is a primary event or is related to decreased testosterone production by the testes in the uremic and pair-fed rats.     

A Novel Mechanism of Bacterial Toxin Transfer within Host Blood Cell-Derived Microvesicles

Shiga toxin (Stx) is the main virulence factor of enterohemorrhagic Escherichia coli, which are non-invasive strains that can lead to hemolytic uremic syndrome (HUS), associated with renal failure and death. Although bacteremia does not occur, bacterial virulence factors gain access to the circulation and are thereafter presumed to cause target organ damage. Stx was previously shown to circulate bound to blood cells but the mechanism by which it would potentially transfer to target organ cells has not been elucidated. Here we show that blood cell-derived microvesicles, shed during HUS, contain Stx and are found within patient renal cortical cells. The finding was reproduced in mice infected with Stx-producing Escherichia coli exhibiting Stx-containing blood cell-derived microvesicles in the circulation that reached the kidney where they were transferred into glomerular and peritubular capillary endothelial cells and further through their basement membranes followed by podocytes and tubular epithelial cells, respectively. In vitro studies demonstrated that blood cell-derived microvesicles containing Stx undergo endocytosis in glomerular endothelial cells leading to cell death secondary to inhibited protein synthesis. This study demonstrates a novel virulence mechanism whereby bacterial toxin is transferred within host blood cell-derived microvesicles in which it may evade the host immune system.     

Cell therapy in kidney failure

Current therapy for acute renal failure continues to have an exceedingly high mortality rate, exceeding 50% even with dialytic or hemofiltrative support. Current renal replacement therapy in ARF only substitutes for filtration function of the kidney but not its cellular metabolic functions. Replacing these metabolic functions may optimize current therapy for this devastating disease process. In this regard, a renal tubule assist device (RAD) has been developed to be placed in an extracorporeal continuous hemoperfusion circuit in series with a hemofilter. The RAD consists of porcine renal proximal tubule cells grown as confluent monolayers in a multifiber bioreactor with a membrane surface area from 0.4 to 1.6 m2. The cells along the inner surface of the hollow fibers are immunoprotected from the patient's blood by the hollow fiber membrane. In vitro experiments demonstrate that this device possesses differentiated renal transport, metabolic and endocrinologic properties. These properties, in fact, are responsive to normal physiological regulatory parameters. In preliminary experiments in uremic dogs, this device has also been shown to tolerate a uremic environment while providing reabsorptive, metabolic, and endocrinologic activity. Pilot human trials of the RAD are anticipated within the next year to improve current renal replacement therapy in this devastating disease process. This revised version was published online in August 2006 with corrections to the Cover Date.     

Increased serum apoA-IV concentrations in experimental uremic rats.

Normal histochemical analysis localizes apoA-IV within renal proximal tubules, which suggests that the kidney is a major catabolic site. In clinical renal failure and animal models of decreased renal function, low molecular weight proteins cannot be efficiently filtered through the glomerular basement membrane, and therefore they accumulate in plasma. In normal plasma, apoA-IV exists as both lipoprotein associated and lipoprotein-free, low molecular weight forms. To examine this further, uremic serum apolipoprotein and mRNA levels were examined in surgically 5/6 nephrectomized rats. Compared to sham-operated controls, uremic serum apoA-IV was elevated twofold and was distributed to a greater extent in the lipoprotein-free subfraction. Serum triglycerides were unchanged. Despite finding no correlation between serum apoA-IV and triglyceride levels (in either the d less than 1.006 g/ml or 1.006 less than d less than 1.019 g/ml fraction), serum apoA-IV was positively correlated with the renal function parameters of blood urea nitrogen (r = 0.949, P less than 0.001), creatinine (r = 0.952, P less than 0.001), and uric acid (r = 0.903, P less than 0.001). In addition, the concentration of apoA-IV per milligram of renal homogenate protein in uremic rats was significantly higher than that of control rats, whereas there was no difference in the content of apoA-I between the two groups. ApoA-I, apoA-IV, and apoB mRNA levels in hepatic and in intestinal tissue were undistinguishable between the uremic and surgical sham rats.(ABSTRACT TRUNCATED AT 250 WORDS)     

A Translational Murine Model of Sub-Lethal Intoxication with Shiga Toxin 2 Reveals Novel Ultrastructural Findings in the Brain Striatum

Infection by Shiga toxin-producing Escherichia coli causes hemorrhagic colitis, hemolytic uremic syndrome (HUS), acute renal failure, and also central nervous system complications in around 30% of the children affected. Besides, neurological deficits are one of the most unrepairable and untreatable outcomes of HUS. Study of the striatum is relevant because basal ganglia are one of the brain areas most commonly affected in patients that have suffered from HUS and since the deleterious effects of a sub-lethal dose of Shiga toxin have never been studied in the striatum, the purpose of this study was to attempt to simulate an infection by Shiga toxin-producing E. coli in a murine model. To this end, intravenous administration of a sub-lethal dose of Shiga toxin 2 (0.5 ηg per mouse) was used and the correlation between neurological manifestations and ultrastructural changes in striatal brain cells was studied in detail. Neurological manifestations included significant motor behavior abnormalities in spontaneous motor activity, gait, pelvic elevation and hind limb activity eight days after administration of the toxin. Transmission electron microscopy revealed that the toxin caused early perivascular edema two days after administration, as well as significant damage in astrocytes four days after administration and significant damage in neurons and oligodendrocytes eight days after administration. Interrupted synapses and mast cell extravasation were also found eight days after administration of the toxin. We thus conclude that the chronological order of events observed in the striatum could explain the neurological disorders found eight days after administration of the toxin.     

The role of oxygen free radicals in the development of chronic renal failure.

This study examined whether there is increased production of oxygen free radicals during chronic renal failure. Rats subjected to 3/4 nephrectomy and sham operated controls were killed after 3 weeks. Lipid extracts of plasma and renal tissue were examined by HPLC and kidney specimens were also analyzed by EPR spectroscopy. The redox capacity of blood was assessed using nitroblue tetrazolium and plasma ascorbate levels were measured with HPLC. There was no detectable renal production of oxygen free radicals in rats with chronic renal failure. Kidney parenchymal content of other oxidants and the oxidant:reductant ratio were similar in control and uremic animals. The plasma redox capacity and ascorbate levels were elevated in uremic rats. We conclude that early in the course of chronic renal failure, there is not excessive production of oxygen free radicals. There is accumulation of reductants, primarily ascorbate, in the plasma of uremic animals.     

Optimized Metabolomic Approach to Identify Uremic Solutes in Plasma of Stage 3–4 Chronic Kidney Disease Patients

Background

Chronic kidney disease (CKD) is characterized by the progressive accumulation of various potential toxic solutes. Furthermore, uremic plasma is a complex mixture hampering accurate determination of uremic toxin levels and the identification of novel uremic solutes.

Methods

In this study, we applied ¹H-nuclear magnetic resonance (NMR) spectroscopy, following three distinct deproteinization strategies, to determine differences in the plasma metabolic status of stage 3–4 CKD patients and healthy controls. Moreover, the human renal proximal tubule cell line (ciPTEC) was used to study the influence of newly indentified uremic solutes on renal phenotype and functionality.

Results

Protein removal via ultrafiltration and acetonitrile precipitation are complementary techniques and both are required to obtain a clear metabolome profile. This new approach, revealed that a total of 14 metabolites were elevated in uremic plasma. In addition to confirming the retention of several previously identified uremic toxins, including p-cresyl sulphate, two novel uremic retentions solutes were detected, namely dimethyl sulphone (DMSO₂) and 2-hydroxyisobutyric acid (2-HIBA). Our results show that these metabolites accumulate in non-dialysis CKD patients from 9±7 µM (control) to 51±29 µM and from 7 (0–9) µM (control) to 32±15 µM, respectively. Furthermore, exposure of ciPTEC to clinically relevant concentrations of both solutes resulted in an increased protein expression of the mesenchymal marker vimentin with more than 10% (p<0.05). Moreover, the loss of epithelial characteristics significantly correlated with a loss of glucuronidation activity (Pearson r = −0.63; p<0.05). In addition, both solutes did not affect cell viability nor mitochondrial activity.

Conclusions

This study demonstrates the importance of sample preparation techniques in the identification of uremic retention solutes using ¹H-NMR spectroscopy, and provide insight into the negative impact of DMSO₂ and 2-HIBA on ciPTEC, which could aid in understanding the progressive nature of renal disease.