Generation of a novel decay accelerating factor (DAF) knock-out rat model using clustered regularly-interspaced short palindromic repeats, (CRISPR)/associated protein 9 (Cas9), genome editing.

Decay accelerating factor (DAF), a key complement activation control protein, is a 70 kDa membrane bound glycoprotein which controls extent of formation of the C3 and C5 convertases by accelerating their decay. Using clustered regularly-interspaced short palindromic repeats, (CRISPR)/associated protein 9 (Cas9) genome editing we generated a novel DAF deficient (Daf-/-) rat model. The present study describes the renal and extrarenal phenotype of this model and assesses renal response to complement-dependent injury induced by administration of a complement-fixing antibody (anti-Fx1A) against the glomerular epithelial cell (podocyte). Rats generated were healthy, viable and able to reproduce normally. Complete absence of DAF was documented in renal as well as extra-renal tissues at both protein and mRNA level compared to Daf+/+ rats. Renal histology in Daf-/- rats showed no differences regarding glomerular or tubulointerstitial pathology compared to Daf+/+ rats. Moreover, there was no difference in urine protein excretion (ratio of urine albumin to creatinine) or in serum creatinine and urea levels. In Daf-/- rats, proteinuria was significantly increased following binding of anti-Fx1A antibody to podocytes while increased C3b deposition was observed. The DAF knock-out rat model developed validates the role of this complement cascade regulator in immune-mediated podocyte injury. Given the increasing role of dysregulated complement activation in various forms of kidney disease and the fact that the rat is the preferred animal for renal pathophysiology studies, the rat DAF deficient model may serve as a useful tool to study the role of this complement activation regulator in complement-dependent forms of kidney injury.

Management of anxiety and depression in haemodialysis patients: the role of non-pharmacological methods.

Anxiety and depression in patients undergoing haemodialysis can be reduced by a variety of treatment methods, including pharmacological therapy, cognitive-behavioural therapy, regular exercise and relaxation techniques, such as Benson's relaxation method and acupressure treatment. Additionally, intradialytic exercise training programmes have a positive effect on patients' physical and psychological functioning. Moreover, social support from family and social environment, spirituality and religiosity, tele- nursing programmes and participation in network support groups frequently lead to a reduction of anxiety and depressive symptoms in these people. Finally, the provision of education and information to dialysis patients by renal professionals and a systematic psychiatric evaluation of these individuals can lead to early diagnosis and treatment of depressive symptoms.

The role of socio-demographic factors in depression and anxiety of patients on hemodialysis: an observational cross-sectional study.

PURPOSE: Depression and anxiety have high prevalence in patients on hemodialysis and are strongly associated with socio-economic factors. The aim of this study was to evaluate the prevalence of depression and anxiety in hemodialyzed patients in Greece and its association with socio-demographic factors. METHODS: Four hundred and fourteen (414) patients on hemodialysis (262 males and 152 females) from 24 dialysis centers in Greece participated in this observational cross-sectional study. Mean age was 63.54 (54.06-72.41), and mean time of dialysis treatment was 36 (16-72) months. Depression and anxiety were assessed by the state-trait anxiety inventory (STAI), the beck depression inventory (BDI) and the hospital anxiety and depression scale (HADS). Multinomial logistic regression was performed to estimate the factors being independently associated with anxiety and depression levels (HADS scale). Multiple linear regression was performed to estimate the factors being independently associated with BDI and STAI. RESULTS: From a total of 414 participants, (29.4%, n = 122) had depression and 35.9% (n = 149) had anxiety. Depression and anxiety were significantly associated with females, low level of education, increased patients' age, retirement, poor financial situation, marital status and co-morbidities. CONCLUSION: The overall study findings indicated a significant correlation between the levels of anxiety and depression in patients on hemodialysis. Patients with high levels of anxiety had higher levels of depression and those with high depression scores had higher anxiety scores.

Specific adsorbents for myasthenia gravis autoantibodies using mutants of the muscle nicotinic acetylcholine receptor extracellular domains.

Myasthenia gravis (MG) is usually caused by antibodies against the muscle acetylcholine receptor (AChR). Plasmapheresis and immunoadsorption are often used to treat non-responsive patients. Antigen-specific immunoadsorption would remove only the pathogenic autoantibodies reducing side-effects. We expressed AChR extracellular domain mutants for use as specific adsorbents, and characterized them. Antigenicity and capacity for autoantibody binding were improved compared to the wild-type proteins. Adsorption appeared to be fast, as high plasma flow-rates could be applied. The bound autoantibodies were eluted repeatedly, allowing column reuse, without compromise in efficiency. Overall, the adsorbents were specific, efficient and suitable for use in therapy.

Defected red blood cell membranes and direct correlation with the uraemic milieu: the connection with the decreased red blood cell lifespan observed in haemodialysis patients.

Together with impaired production of erythropoietin and iron deficiency, the decreased lifespan of red blood cells (RBCs) is a main factor contributing to the chronic anaemia observed in haemodialysis (HD) patients. Atomic force microscopy is employed in this work to thoroughly survey the membrane of intact RBCs (iRBCs) of HD patients in comparison to those of healthy donors, aiming to obtain direct information on the structural status of RBCs that can be related to their decreased lifespan. We observed that the iRBC membrane of the HD patients is overpopulated with extended circular defects, termed 'orifices', that have typical dimension ranging between 0.2 and 1.0 µm. The 'orifice' index-that is, the mean population of 'orifices' per top membrane surface-exhibits a pronounced relative increase of order 54 ± 12% for the HD patients as compared to healthy donors. Interestingly, for the HD patients, the 'orifice' index, which relates to the structural status of the RBC membrane, correlates strongly with urea concentration, which is a basic index of the uraemic milieu. Thus, these results indicate that the uraemic milieu downgrades the structural status of the RBC membrane, possibly triggering biochemical processes that result in their premature elimination from the circulation. This process could decrease the lifespan of RBCs, as observed in HD patients.

Bone mineral density and bone metabolism in hemodialysis patients. Correlation with PTH, 25OHD3 and leptin

Background: Bone metabolism disorders in hemodialysed patients (HD) involve several humoral factors, of which PTH plays the central role. Leptin is usually found increased in renal failure and its link with bone metabolism has not been elucidated. We investigated the BMD and bone metabolism in association with serum PTH, 25OHD3 and leptin in HD patients. Methods: We measured bone alkaline phosphatase (bSAP), cross linked N telopeptide of type 1 collagen (NTx), PTH, 25OHD3 and leptin in 37 HD patients. We also evaluated BMI and BMD in lumbar spine (LS) and in femoral neck (FN) by DXA. Statistical evaluations were based on simple regression analysis. Results: 1) Osteopenia was found in 32,1% in LS and 50% in FN and osteoporosis in 14.3% and 21.4% of our patients, respectively. LS or FN Z score was not related to HD duration. 2) Bone markers, PTH, phosphorus and leptin levels were increased. 3) 25OHD3 was low and was not related to NTx, bSAP or PTH. 4) PTH correlated with bone markers and Z score in LS and FN. 5) Leptin had no correlation with bone markers or Z score (except BMI). Conclusions: In our hemodialysed patients bone metabolism markers were increased in relation with high serum PTH levels. The observed high serum leptin was not associated with bone metabolism. Additionally the duration of hemodialysis did not appear to affect bone density (AU)

Antecedentes: Los trastornos del metabolismo óseo en pacientes en hemodiálisis (HD) implican varios factores humorales, de los cuales la función central recae sobre la hormona paratiroidea. Cuando hay insuficiencia renal normalmente se detectan niveles elevados de leptina y su relación con el metabolismo óseo está aún por esclarecer. Investigamos la densidad mineral ósea (DMO) y el metabolismo óseo en relación con la hormona paratiroidea sérica, el 25(OH)D3 y la leptina en pacientes en HD. Métodos: Medimos la fosfatasa alcalina ósea (FAO), el telopéptido N, la hormona paratiroidea, el 25(OH)D3 y la leptina en 37 pacientes en HD. Asimismo, evaluamos el IMC y la DMO en la columna lumbar (CL) y en el cuello femoral (CF) mediante DXA. Las evaluaciones estadísticas se basaron en análisis de regresión simples. Entrecruzamiento del telopéptido N del colágeno óseo tipo I. Resultados: 1) De nuestros pacientes, el 32,1% presentaba osteopenia en CL y 50% en CF y el 14,3% y el 21,4% osteoporosis, respectivamente. El puntaje Z en CL o CF no estaba relacionado con la duración de la HD. 2) Los marcadores óseos, la hormona paratiroidea, y los niveles de fósforo y leptina se vieron incrementados. 3) El 25(OH)D3 era bajo y no estaba relacionado con el telopéptido N, la FAO o la hormona paratiroidea. 4) La hormona paratiroidea estaba correlacionada con los marcadores óseos y con el puntaje Z en CL y CF. 5) La leptina no presentaba correlación con los marcadores óseos o con el puntaje Z (con excepción del IMC). Conclusiones: En nuestros pacientes en hemodiálisis, los marcadores del metabolismo óseo se vieron incrementados en relación con los niveles elevados de hormona paratiroidea sérica. La elevada leptina sérica observada no estaba asociada al metabolismo óseo. Además, la duración de la hemodiálisis no pareció afectar a la densidad ósea (AU)

Bone mineral density and bone metabolism in hemodialysis patients. Correlation with PTH, 25OHD3 and leptin.

BACKGROUND: Bone metabolism disorders in hemodialysed patients (HD) involve several humoral factors, of which PTH plays the central role. Leptin is usually found increased in renal failure and its link with bone metabolism has not been elucidated. We investigated the BMD and bone metabolism in association with serum PTH, 25OHD3 and leptin in HD patients. METHODS: We measured bone alkaline phosphatase (bSAP), cross linked N telopeptide of type 1 collagen (NTx), PTH, 25OHD3 and leptin in 37 HD patients. We also evaluated BMI and BMD in lumbar spine (LS) and in femoral neck (FN) by DXA. Statistical evaluations were based on simple regression analysis. RESULTS: 1) Osteopenia was found in 32,1% in LS and 50% in FN and osteoporosis in 14.3% and 21.4% of our patients, respectively. LS or FN Z score was not related to HD duration. 2) Bone markers, PTH, phosphorus and leptin levels were increased. 3) 25OHD3 was low and was not related to NTx, bSAP or PTH. 4) PTH correlated with bone markers and Z score in LS and FN. 5) Leptin had no correlation with bone markers or Z score (except BMI). CONCLUSIONS: In our hemodialysed patients bone metabolism markers were increased in relation with high serum PTH levels. The observed high serum leptin was not associated with bone metabolism. Additionally the duration of hemodialysis did not appear to affect bone density.

Is the underutilization of peritoneal dialysis in relation to hemodialysis, as renal replacement therapy, justifiable worldwide? Yes or No.

Peritoneal dialysis is the most important home dialysis treatment for end stage renal diseases and needs personal involvement, and support from the family . Peritoneal dialysis presented a number of discouraging technical problems and led to the belief that PD was not an appropriate renal replacement therapy, for patients with end stage renal disease. Despite the improvement of the method its rate remain low (11%) worldwide. The factors affecting the choice of PD are multiple and explain the disparity in the use of peritoneal dialysis in different countries and different parts of the same country. Dialysis costs and reimbursement structures are significant in decisions about the rates and modalities of renal replacement therapy. Late referral and the health care system seems to be very important factors that influence the dialysis modality choice. After the initiation of peritoneal dialysis we can see other factors that influence the survival of the method. The rate of peritonitis and the peritoneum function seems to be important issues.

Correlation of depressive symptoms and olfactory dysfunction in patients on hemodialysis.

BACKGROUND AND AIM: A possible link between depression and olfactory dysfunction has been suggested in the literature, in research projects using the olfactory bulbectomy model. In human studies using a syndrome-oriented approach, such an association has not been reported consistently. The aim of the study was to test the association of olfactory dysfunction with depression using a symptom-oriented approach.Paients and methods: Twenty eight end-stage renal failure patients took part in this project. The patients olfactory identification ability was tested with the University of Pennsylvania Smell Identification Test (UPSIT). Immediately before olfactory testing, the subjects completed the Zung self-rating scale, which provides data on symptoms of depression in this group of patients. RESULTS: The mean value of the number of mistakes made in the olfactory identification ability (UPSIT test) by the total sample was 14.0±4.5, with a range 6-22. Half of the symptoms seem to bear an influence on the olfactory identification performance. Patients experiencing decreased libido and dissatisfaction exhibited significantly reduced olfactory function, as contrasted to those not experiencing these symptoms. The above results remain practically unaltered even after taking into account such probable confounding factors as age, sex, olfactory detection threshold and duration of illness. CONCLUSION: These findings support previous evidence indicating that olfactory dysfunction may be related to specific depressive symptoms in humans. The present findings also suggest that the symptom-oriented approach is an effective research tool for the elucidation of such clinical issues. The need for further research in this field is pointed out.

Peritoneal dialysis without a physical peritoneal dialysis unit.

UNLABELLED: Under certain circumstances when patients need peritoneal dialysis (PD) but no physical unit or official staff are available, one has to improvise ways to serve such patients. In this study we describe our experience with such patients without a physical peritoneal dialysis unit. PATIENTS AND METHODS: Since 1997 we trained 33 patients, mean age 61.7 +/- 12.8 years old. Catheter implantation was done in another hospital on them as out-patients. We used trained nurses made available by the company that supplies the PD solution. After 2004 the whole training was done at patients' home, after having been accepted by the patients. RESULTS: Catheter implantation was successful in all 33 patients. Catheter was removed from 2 patients (one and 4 years after implantation) because of relapsing peritonitis in the first and fungal infection in the second. The overall peritonitis rate was 0.18 episodes/patient year or one episode every 63.5 patient months. Actuarial patient survival was 90%, at one year, 83% at second year and 55% at third year. First and second year technique survival were 96%, and 90% respectively. CONCLUSION: Our results, should encourage those who want to provide peritoneal dialysis to their patients even when a physical peritoneal dialysis unit is not available.

Serum oxidized LDL is inversely associated with HDL2-cholesterol subclass in renal failure patients on hemodialysis.

BACKGROUND: Dyslipoproteinemia and oxidative modification of LDL (oxLDL) are common symptoms in patients suffering from chronic renal failure on hemodialysis (HD), and contribute to the development of oxidative stress. High-density lipoprotein cholesterol (HDL-C) protects against atherosclerosis by inhibiting the oxidation of lipoproteins and by supporting reverse cholesterol transport. This study intends to examine the association of oxLDL with HDL2 and HDL3 subclasses of HDL-C in HD patients, in order to elucidate whether oxidative stress influences HDL-C composition. METHODS: Thirty-four patients on HD and 21 age- and sex-matched controls were studied. HDL2 and HDL3-C subclasses were isolated from serum according to a single-step precipitation method following a homogenous HDL-C assay. oxLDL was measured by ELISA. RESULTS: In HD patients, oxLDL concentration was higher compared to the controls (1.40 +/- 0.47 vs. 0.21 +/- 0.05 mg/l, p = 0.017) and was significantly associated to total cholesterol (r = 0.480, p = 0.044), LDL-C (r = 0.544, p = 0.019), HDL-C (r = -0.589, p = 0.027) and C-reactive protein (r = 0.578, p = 0.024). Comparing HDL-C subclasses, only HDL2-C was negatively correlated to oxLDL levels (r = -0.565, p = 0.035). CONCLUSIONS: In HD patients, high serum levels of oxLDL are associated with low HDL2-C subclass levels. This might suggest that oxidative stress affects the HDL subclass more related to the protecting activity of HDL-C, contributing to atherosclerosis development.

Reactive oxygen metabolites: a link between oxidative stress and inflammation in patients on hemodialysis.

Oxidative stress plays a significant role in the development of inflammation in patients undergoing hemodialysis (HD). This study intends to evaluate the relationship between C-reactive protein (CRP) and the newly established marker of lipid peroxidation, d-ROMs (reactive oxygen metabolites), in comparison with different indicators of oxidative stress. Plasma total antioxidant capacity (TAC), lipid peroxidation products malonaldehyde (MDA) and 4-hydroxyalkenals, as well as d-ROMs, were determined in 24 patients before HD and in 21 normal controls (NC). It was found that HD patients had higher levels of d-ROMs than NC (p = 0.033). A highly significant positive correlation was observed between logCRP and d-ROMs concentrations (p < 0.0001, r = 0.85) in patients, but not in NC. The concentrations of TAC and MDA were not associated with CRP in HD or in NC individuals. It is concluded that d-ROMs concentration is a potent marker of oxidative injury that is strongly indicative of the inflammatory status in HD patients.

Effect of dialysis on plasma total antioxidant capacity and lipid peroxidation products in patients with end-stage renal failure.

Dialysis is associated with an impairment of antioxidant defense and an overproduction of oxidative stress markers. This study focuses on the comparison of plasma total antioxidant capacity (TAC) and lipid peroxidation products in patients on hemodialysis (HD) before and after treatment and in peritoneal dialysis (PD) patients. Plasma TAC, malonaldehyde (MDA), and 4-hydroxyalkenal concentrations were measured in 31 HD patients, in 24 PD patients, and in 17 normal controls (NC). It was found that before HD, TAC and MDA levels were higher than those in the NC (p < 0.001). After HD, these levels decreased significantly but were higher than in NC and lower than in PD patients (p < 0.001). The levels of 4-hydroxyalkenals were elevated in patients as compared with NC, but did not differ between HD and PD patients. The MDA concentrations correlated positively with the TAC in the patients. It is concluded that the oxidative status of patients on HD is similar to that of patients on PD and that the susceptibility to oxidative stress is strongly related to the levels of MDA produced in plasma.

Association of serum nitric oxide levels with depressive symptoms: a study with end-stage renal failure patients.

BACKGROUND: Nitric oxide (NO) is a soluble gas produced by the activity of an enzyme found in neurons. It has been implicated in a great number of normal physiological functions (such as noradrenaline and dopamine release, memory and learning, regulation of the cerebrovascular system, modulation of wakefulness, modulation of nociception, olfaction, food intake and drinking) as well as pathologies (Alzheimer's, Huntington's disease, cerebral ischemia, stroke). Two reports have addressed the involvement of NO in depression. METHODS: The objective of the study was to examine the association between NO and specific depressive symptoms. For this purpose, in a sample of 28 end-stage renal failure patients (who have increased NO levels), we tested the hypothesis that the subgroup of patients with these specific depressive symptoms was differentiated from the patients without these symptoms with regard to serum levels of NO metabolites. The depressive symptoms were assessed using the Zung self-rating scale. RESULTS: Our study revealed an association of NO with the following depressive symptoms: sexual dysfunction, weight loss, psychomotor retardation, indecisiveness and irritability. CONCLUSION: The association between NO system and symptoms of depression does not necessarily imply a pathogenetic association between NO and depressive disorder. Further research is needed to verify these findings and study their possible pathogenetic implications.

Complications of vascular access in hemodialysis (HD)--aged vs adult patients.

Reports on the success of permanent vascular access in elderly HD patients vary considerably. We reviewed the records of 149 patients [62F and 87M] aged 20-89 years old (median 59) who were on hemodialysis for 6-242 (49 median) months, and had undergone 202 vascular access procedures (177 Cimmino-Brescia fistulae and 25 PTFE grafts). Patients were divided into two groups according to the age they started HD. Group A: 48 patients, over 60 years old (range 60-83; median 70) on HD for 43.5, (6-140) months. Group B: 101 patients, under 60 years old, range (15-59) median 46, on HD for 54 (6-242) months. There were no differences between the two groups in terms of gender, primary renal disease, (except polycystic kidney disease), Hct and EPO administration. The initial choice of vascular access, the complications and the technique survival were examined in both groups. Cimmino-Brescia fistulae were used as the first choice of vascular access in all patients except one in group B. PTFE-grafts were the second or third choice in 7/48 (group A) and 15/101 (group B) (p: NS). The only reason for technique failure was vascular thrombosis in both groups (11/48 group A and 31/101 group B p: NS). Other complications were: aneurysms (10/48 and 14/101, p: NS), infections (0/48 and 2/101 p: NS) and edema (0/48 and 6/101, p: NS). Five-year technique survival of the first AV fistula in the two groups was 35% and 45% respectively (log-rank test, p: NS). These findings suggest that: a) A.V. fistula is the first choice of vascular access in aged HD patients; b) There is no difference in vascular access complications across age groups; c) Survival of the first A.V. fistula is independent of age.