Renal tubular acidosis during therapy for diabetic ketoacidosis.

A young woman presented with typical diabetic ketoacidosis. Five hours after insulin had been given hyperchloremic metabolic acidosis developed. This could not be attributed to gastrointestinal loss of bacarbonate, ingestion of HCI or carbonic anhydrase inhibitor, or the administered fluids and electrolytes. The combination of hyperchloremic metabolic acidosis and a urine pH of 5.6 during acidemia prompted specific studies that established the presence of disorders of renal acidification. A transient defect of hydrogen ion secretion in the distal nephron was suggested by the decrease in urine-blood Pco-2 gradient after administration of sodium bicarbonate. Proximal renal tubular acidosis was indicated by the reduced bicarbonate threshold that persisted for approximately 7 weeks.     

Lactic acidosis complicating treatment of ketosis of labour.

Hypertonic glucose, fructose, and sorbitol solutions were given intravenously to women in the first stage of labour who had ketonuria and ketonaemia as evidenced by a raised blood acetoacetate and 3-hydrosybutyrate. There was no difference in the antiketogenic action of these, which was rapid and effective, but when compared with a control group who were given normal saline they had a high incidence of hyperlactataemia, and nine out of 28 patients developed lactic acidosis after the infusions. The "lactatogenic" effect was shared by all three substrates, and when they are used in the treatment of ketosis of labour, and the mother develops lactic acidosis, they might exacerbate pre-existing lactic acidosis and precipitate fetal distress.     

Lactic acidosis secondary to metformin overdose: a case report

ABSTRACT: INTRODUCTION: Metformin is a commonly used treatment modality in type 2 diabetes mellitus, with a welldocumented side effect of lactic acidosis. In the intensive care setting lactate and pH levelsare regularly used as a useful predictor of poor prognosis. In this article we highlight howhigh lactate levels are not an accurate predictor of mortality in deliberate metforminoverdose. CASE PRESENTATION: We present the case of a 70-year-old Caucasian man who took a deliberate metforminoverdose of unknown quantity. He had a profound lactic acidosis at presentation with a pH of6.93 and a lactate level of more than 20mmol/L. These figures would normally correspondwith a mortality of more than 80%; however, with appropriate management this patient'scondition improved. CONCLUSION: We provide evidence that the decision to treat severe lactic acidosis in deliberate metforminoverdose should not be based on arterial lactate and pH levels, as would be the case in otheroverdoses. We also demonstrate that appropriate treatment with hemodiafiltration and 8.4%sodium bicarbonate, even in patients with a very high lactate and low pH, can be successful.     

Anti-HIV-1 ADCC: clinical and therapeutic implications.

The predominant antienvelope cell-mediated cytotoxicity in HIV-1-infected patients is a direct form of antibody-dependent cellular cytotoxicity (ADCC) in which circulating NK/K cells armed with cytophilic antibodies comprise a cytolytic effector cell complex capable of destroying HIV-1-expressing targets. This non-MHC-restricted form of virus-specific cytotoxicity is present in most infected patients, with maximum activity in early disease, gradually declining with disease progression. This endogenous cytotoxicity provides a focal point in the design of interventive strategies involving immune-based therapies. In the first such attempts, the lymphokine interleukin-2 has been employed in an effort to augment these potentially beneficial cytolytic reactivities. The focus of this article is to present the rationale, early clinical results, and future direction of such therapeutic approaches and, in doing so, to illustrate how careful basic research findings can be applied to the design of rational therapeutic strategies.     

Calcium-binding proteins: basic concepts and clinical implications.

Calcium ions exert their effects in part via interactions with a wide variety of intracellular calcium-binding proteins. One class of these proteins shares a common calcium-binding motif, the EF-hand. A consensus amino acid sequence for this motif has aided the identification of new members of this family of EF-hand proteins, which now has over 200 members. A few of these proteins are present in all cells, whereas the vast majority are expressed in a tissue-specific fashion. The physiological function of a few of these proteins is known to be achieved via a calcium-dependent interaction with other proteins, thereby regulating their activity. Some members, like parvalbumin, calbindin, and calretinin, proved to be useful neuronal markers for a variety of functional brain systems and their circuitries. Their major role is assumed to be buffering, transport of Ca2+, and regulation of various enzyme systems. Since cellular degeneration is accompanied by impaired Ca2+ homeostasis, a protective role for Ca(2+)-binding proteins in certain neuron populations has been postulated. Another protein family are the annexins, members of which interact with phospholipids and cellular membranes in a calcium-dependent manner. In some cases members of the annexin family were even found to interact with EF-hand proteins. Certain annexins have been suggested to be involved in anti-inflammatory response, inhibition of blood coagulation, membrane trafficking or cytoskeletal organization, but several of these functions have been questioned recently. The elucidation of the interactions and functions of the majority of these proteins remains a challenging task for the coming years.     

Renal nucleoside transporters: physiological and clinical implications.

Renal handling of physiological and pharmacological nucleosides is a major determinant of their plasma levels and tissue availabilities. Additionally, the pharmacokinetics and normal tissue toxicities of nucleoside drugs are influenced by their handling in the kidney. Renal reabsorption or secretion of nucleosides is selective and dependent on integral membrane proteins, termed nucleoside transporters (NTs) present in renal epithelia. The 7 known human NTs (hNTs) exhibit varying permeant selectivities and are divided into 2 protein families: the solute carrier (SLC) 29 (SLC29A1, SLC29A2, SLC29A3, SLC29A4) and SLC28 (SLC28A1, SLC28A2, SLC28A3) proteins, otherwise known, respectively, as the human equilibrative NTs (hENTs, hENT1, hENT2, hENT3, hENT4) and human concentrative NTs (hCNTs, hCNT1, hCNT2, hCNT3). The well characterized hENTs (hENT1 and hENT2) are bidirectional facilitative diffusion transporters in plasma membranes; hENT3 and hENT4 are much less well known, although hENT3, found in lysosomal membranes, transports nucleosides and is pH dependent, whereas hENT4-PMAT is a H+-adenosine cotransporter as well as a monoamine-organic cation transporter. The 3 hCNTs are unidirectional secondary active Na+-nucleoside cotransporters. In renal epithelial cells, hCNT1, hCNT2, and hCNT3 at apical membranes, and hENT1 and hENT2 at basolateral membranes, apparently work in concert to mediate reabsorption of nucleosides from lumen to blood, driven by Na+ gradients. Secretion of some physiological nucleosides, therapeutic nucleoside analog drugs, and nucleotide metabolites of therapeutic nucleoside and nucleobase drugs likely occurs through various xenobiotic transporters in renal epithelia, including organic cation transporters, organic anion transporters, multidrug resistance related proteins, and multidrug resistance proteins. Mounting evidence suggests that hENT1 may have a presence at both apical and basolateral membranes of renal epithelia, and thus may participate in both selective secretory and reabsorptive fluxes of nucleosides. In this review, the renal handling of nucleosides is examined with respect to physiological and clinical implications for the regulation of human kidney NTs and adenosine signaling, intracellular nucleoside transport, and nephrotoxicities associated with some nucleoside drugs.     

Endothelial thromboxane receptors: biochemical characterization and functional implications

We have identified thromboxane specific receptors in membrane preparations of bovine pulmonary artery endothelial cells using a potent thromboxane specific antagonist, [125I]-PTA-OH in a binding assay. The binding was specific and saturable. Neither thromboxane B2, prostaglandin D2 nor prostaglandin F2 alpha displaced the ligand (0.1 nM) at concentrations up to 10 microM. However, binding was displaced by IPTA-OH greater than SQ29548 greater than U46619. In addition, we observed that thromboxane mimetic U46619 significantly lowered the basal production of prostacyclin and also markedly suppressed bradykinin-stimulated prostacyclin released by endothelial cells. We propose that an important biological effect of thromboxane on vascular endothelial cells may be the suppression of prostacyclin production.