Calculation of the estimated creatinine clearance in avoiding drug dosing errors in the older patient.

BACKGROUND: The population of hospitalized older patients is increasing. We investigated whether clinicians accurately detected renal insufficiency in older patients and chose correct doses of commonly prescribed antibiotics. METHODS: We conducted a retrospective chart review of 1044 patients > 80 years admitted to the University of California Davis Medical Center between January and December 1997 with a diagnosis of infection. Inclusion criteria included data necessary to calculate creatinine clearance using the Cockroft-Gault equation and administration of any of the study antibiotics. Patients with unstable renal function, defined as an increase in creatinine of > or = 1.0 mg/dL/day were excluded. Administered dosages of each study drug were compared with the appropriate adjusted doses. We examined the variables of age, weight, serum creatinine, and sex to determine whether any were individually predictive of dosing errors. RESULTS: Dosing errors were identified in all of the antibiotics studied, and the overall dosing error rate was 34%. The factors that were predictive of dosage errors were advanced age and low body weight. Serum creatinine and sex were not statistically significant factors. CONCLUSIONS: Widespread errors in medication dosing are made in elderly hospitalized patients. The Cockroft-Gault equation reveals significant renal insufficiency requiring dose adjustments in most elderly patients studied, especially those > 85 years of age and with low body weight. Estimation of glomerular filtration rate should be performed routinely on all admitted patients older than 80 and in any patient with low lean body mass.

Hyperphagia as a mediator of renal disease initiation in obese Zucker rats.

OBJECTIVE: We sought to determine whether prevention of overeating would block the very earliest manifestations of renal injury in young obese Zucker rats (OZRs). RESEARCH METHODS AND PROCEDURES: Three groups of rats were studied, obese (fa/fa) Zucker rats and lean (Fa/Fa). Zucker controls were allowed to feed ad libitum, whereas a group of obese (fa/fa) Zucker rats was pair-fed to the lean group. Urine albumin and serum lipids were studied weekly from 6 to 10 weeks of age. Renal pathology and renal glomerular gene expression were examined when the rats were killed at 10 weeks of age. RESULTS: Obese rats fed ad libitum developed significant albuminuria by 6 weeks of age, increasing at each subsequent time-point. This increase was completely blocked by pair-feeding. Serum triglycerides were significantly increased in obese rats fed ad libitum vs. the other groups. Urine albumin correlated significantly with both body weight and serum triglyceride level. Renal histopathology was normal in all groups. Analysis of gene expression of glomerular proteins by reverse transcriptase-polymerase chain reaction revealed that pair-feeding attenuated the increased expression of glomerular desmin, fibronectin, and the 92-kDa collagenase that was seen in obese animals fed ad libitum. DISCUSSION: Prevention of overeating in young OZR normalizes albuminuria and attenuates the pathogenic alterations in glomerular gene expression seen at the initiation of renal disease in obese animals allowed to feed ad libitum. This model may be relevant for studying the early end-organ effects of obesity.

Lipoprotein-stimulated mesangial cell proliferation and gene expression are regulated by lipoprotein lipase.

BACKGROUND: Hyperlipidemia accelerates the progression of glomerular disease, and lipoproteins bind glomerular mesangial cells (MC) and induce proliferation and cytokine expression. In the vessel wall, the binding of lipoproteins to endothelial cells is markedly enhanced by lipoprotein lipase (LpL), synthesized by the underlying smooth muscle cells. While it is known that LpL is localized to the glomerulus, it is not known if and how it modulates the lipoprotein-mesangial interaction. METHODS: Very low-density lipoprotein (VLDL) was isolated from rats and was used to treat cultured primary rat MCs. Binding studies were done with and without LpL and with/without pretreatment with heparanase, which degrades cell surface heparan sulfate proteoglycan (HSPG), known to modulate the LpL-lipoprotein interaction in blood vessels. VLDL/LpL was also used to assess MC proliferation and gene expression of the cytokine platelet-derived growth factor (PDGF). RESULTS: LpL enhanced VLDL binding to MCs by as much as 200-fold, and most of this effect was blocked by pretreatment with heparanase. LpL amplified VLDL-driven MC proliferation and increased VLDL-induced PDGF expression. Heparanase pretreatment of cells eliminated both of these amplifications. LpL alone increased MC proliferation and PDGF gene expression. DISCUSSION: As in the vessel wall, LpL enhances VLDL binding to MCs. MCs respond to LpL binding by proliferating and expressing cytokines such as PDGF. LpL may be a crucial paracrine mediator of the glomerular response to circulating lipoproteins, amplifying a response that includes cytokine elaboration, influx of circulating monocytes, and eventual sclerosis.

Hypoalbuminemia and proteinuria contribute separately to reduced lipoprotein catabolism in the nephrotic syndrome.

BACKGROUND: Hypertriglyceridemia is a result of reduced triglyceride (TG)-rich lipoprotein (TRL) catabolism and occurs in rats with nephrotic syndrome (NS) and in Nagase analbuminemic rats (NARs). While the heparin-releasable lipoprotein lipase (LpL) pool in NAR and in NS is similar, TG levels are significantly greater in NS, suggesting that factors other than reduced LpL alone act in NS but not in NARs. Furthermore, clearance of chylomicrons (CM) and very low-density lipoprotein (VLDL) is normal in vivo in NAR despite low LpL levels. We tested the hypotheses that impaired binding of VLDL and impaired VLDL-high density lipoprotein (HDL) interactions contribute to hyperlipidemia in NS. METHODS: TG and apoB secretion was measured using Triton WR 1339. Clearance of CMs by perfused hearts from NS and NAR was determined. Binding of VLDL from control, NS and NAR to rat aortic endothelial cells (RAECs) was measured prior to and following incubation with HDL from NS, NARs, and control. ApoE, protein, and TG content was determined. RESULTS: TG levels were greatest in NS (516 +/- 95 mg/dL), intermediate in NAR (193 +/- 20), and least in control (97 +/- 16, P = 0.05), while in contrast, TG secretion was least in NS (178 +/- 33 mg/dL/hour) versus 212 +/- 17 in NAR and 294 +/- 15 in control (P < 0.001 vs. NS). Clearance of CMs by NS and NAR hearts was the same and significantly reduced versus control (P < 0.005). Binding of NS-VLDL to endothelial cells was reduced, while NAR-VLDL binding was increased versus control (P < 0.001). Incubation of NS-VLDL with control or NAR HDL increased VLDL binding compared with binding following incubation with NS HDL (P < 0.001). CONCLUSION: Increased TG levels in both NS and NAR are the result of decreased TRL clearance. TG levels are greater in NS because of the presence of a combined defect: (1) a decrease in endothelial-bound LpL that occurs as a consequence of reduced serum albumin concentration, and (2) a defect in VLDL binding to endothelial-bound LpL. This latter defect occurs only in the presence of proteinuria and is conferred by HDL.

Estrogen worsens incipient hypertriglyceridemic glomerular injury in the obese Zucker rat.

BACKGROUND: The obese Zucker rat (OZR) is a model of glomerulosclerosis and renal failure in the setting of hyperlipidemia, hyperinsulinemia, and obesity. Our prior work in OZRs has shown that ovariectomy attenuates glomerulosclerosis, while added estrogen worsens it. To investigate the mechanism of estrogen's effects on glomerular disease in this model, we evaluated the effects of ovariectomy and estrogen supplementation on seven-week peripubertal OZRs. At this time point, rats exhibit no overt histologic glomerular disease, but are just beginning to show elevated urinary albumin excretion. METHODS: Female OZRs fed ad libitum were ovariectomized at four weeks, with or without estrogen supplementation to raise estrogen levels to just below those of preoestral adults (mean 16.5 pg/mL). Sham-operated controls were included. RESULTS: Ovariectomy normalized albuminuria, lowered total and very low-density lipoprotein triglycerides, and reduced glomerular fibronectin expression. Estrogen supplementation worsened albuminuria and raised total/very low-density lipoprotein triglycerides and total cholesterol. Estrogen-supplemented rats exhibited enhanced glomerular deposition of apo A-IV and apo B, increased glomerular expression of desmin and type IV collagen, and increased interstitial macrophage deposition. CONCLUSION: Estrogen may be permissive for the early development of renal disease in OZRs and may act by increasing triglyceride-rich lipoproteins, which then bind to glomerular cells and initiate or accelerate glomerulosclerosis.

Hyperlipidemia and renal disease: the use of animal models in understanding pathophysiology and approaches to treatment.

Hyperlipidemia accelerates the progression of human renal disease, and its control is becoming an important component of therapy for patients with renal failure. The biologic basis for these observations remains poorly understood. This review summarizes recent data from animal models which show how lipoproteins interact with cells directly to cause renal injury. Data are presented from recent studies on the obese Zucker rat, a metabolic model of hyperlipidemia, obesity, and glomerular sclerosis, showing that triglyceride-containing lipoproteins may mediate glomerular injury. The biochemical basis for therapy is also discussed, including actions of lipid-lowering agents apart from their effect on serum lipids, and the use of polyunsaturated fatty acids as dietary therapy. Animal models are a crucial tool for the further elucidation of mechanisms of lipoprotein-mediated glomerular injury.

Serum alpha 2-macroglobulin and alpha 1-inhibitor 3 concentrations are increased in hypoalbuminemia by post-transcriptional mechanisms.

In both the nephrotic syndrome (NS) and hereditary analbuminemia in the Nagase analbuminemic rat (NAR), the plasma protein concentration is nearly normal since albumin is replaced by several high molecular weight proteins. In rats these include the protease inhibitors alpha 2-macroglobulin (alpha 2M), a 720 kDa positive acute phase protein (APP) and alpha 1-inhibitor 3 (alpha 1-I3), a 180 kDa negative APP. There is no known stimulus to increase alpha 1-I3 synthesis, but like albumin and other negative APPs its synthesis decreases during inflammation by transcriptional down-regulation. In hypoalbuminemic states gene transcription of other positive and negative APPs is increased. We report that alpha 2M was increased significantly (12-fold) in NAR and by approximately 50-fold in rats with NS compared to control. The alpha 1-I3 concentration was twice normal in NAR or NS compared to controls, providing approximately half of the total plasma protein. Infusion of human albumin into NAR to raise albumin levels > 20 mg/ml for 24 hours caused a significant decrease in alpha 1-I3 (24.8 +/- 0.6 to 18.7 +/- 0.6 mg/ml, P < 0.0001), equal in magnitude to that caused by 250 micrograms/100 g of endotoxin (23.0 +/- 1.1 to 18.6 +/- 0.6, P < 0.01). The effect of albumin was not an acute phase response since it also suppressed alpha 2M (239 +/- 10 to 205 +/- 11 micrograms/ml, P < 0.005). Turnover of 125I labeled alpha 2M and alpha 1-I3 was then measured in controls, NAR and in two models of the nephrotic syndrome in rats (Heymann nephritis, HN; adriamycin-induced, ADR), yielding fractional catabolic rates (FCR), which at steady state equals synthesis. The serum alpha 2M concentration was increased approximately equal to 50-fold and was proportional to synthesis (r = 0.91 P < 0.001). alpha 2-Macroglobulin synthesis increased by 12-fold in NAR and 50-fold in NS. In contrast, hepatic alpha 2M mRNA increased only 30% in NAR and twofold in NS, suggesting post-transcriptional regulation. Fractional catabolic rates were not decreased and played no role in increasing serum alpha 2M in NS or NAR. The alpha 1-I3 concentration and synthesis increased twofold from controls in both NAR and NS. However, hepatic alpha 1-I3 mRNA was not increased in NAR and increased only 50% in NS. Unlike alpha 2M, serum alpha 1-I3 correlated negatively with FCR (-r = 0.66, P < 0.01). In conclusion, both alpha 1-13 and alpha 2M concentration are increased in hypooncotic states by increased synthesis regulated post-transcriptionally, supporting plasma protein concentration when albumin is lost in urine or not synthesized.

Determinants of albumin concentration in hemodialysis patients.

Hypoalbuminemia predicts mortality in hemodialysis patients with end-stage renal disease and is assumed to result from malnutrition. To investigate a possible alternative cause, we evaluated the relationships between serum albumin (Salb) and serum levels of two positive acute-phase proteins: C-reactive protein (CRP) and serum amyloid A (SAA). We also examined the relationship between Salb and dialysis dose delivered (Kt/V) and normalized protein catabolic rate (PCRn) measured during 3 consecutive months in a group of 115 patients. Serum albumin was measured monthly for 5 months. SAA levels were not increased in the majority of patients, despite its low molecular weight (8 kd), and predialysis concentrations were independent of residual renal function, compatible with a nonrenal site of metabolism. Both CRP and SAA levels correlated negatively with Salb both by linear regression and by multiple regression analysis (P < 0.001). CRP correlated with fibrinogen (P < 0.005). Salb also correlated positively with PCRn (P = 0.001), but not with Kt/V. The Kt/V did not correlate with PCRn. While CRP and SAA correlated with one another, neither variable correlated with PCRn. When either SAA or CRP was high, Salb was low regardless of PCRn. Thus, there are two separate independent factors predicting Salb--markers of inflammation and protein intake--but high concentrations of acute-phase proteins have a greater impact on Salb than does low PCRn. Activity of the acute-phase response is an important predictor of low Salb in hemodialysis patients independently of nutritional factors.

The N-terminal propiece of interleukin 1 alpha is a transforming nuclear oncoprotein.

Interleukin 1 alpha (IL-1 alpha) is a pleiotropic cytokine involved in the immune response, inflammatory processes, and hematopoiesis, and acts as a mitogen for several malignant cell types, including acute leukemia and Kaposi sarcoma cells. These diverse activities have been exclusively attributed to the plasma membrane receptor-binding, 17-kDa C-terminal component (mature IL-1 alpha) that results from proteolytic processing of the 31- to 33-kDa precursor protein. No biologic function has been ascribed to the unusually large, 16-kDa N-terminal propiece formed as a result of proteolytic processing of IL-1 alpha. We report that the IL-1 alpha N-terminal propiece is concentrated by means of a nuclear localization sequence within the nuclei of both transfected and leukemic cell lines. Overexpression of this component in glomerular mesangial cells, a model perivascular myofibroblast cell type capable of IL-1 alpha synthesis and processing, results in malignant transformation to a spindle cell-type tumor. The functionally bipartite nature of the IL-1 alpha precursor represents a unique combination of the C-terminal, classical cytokine and an N-terminal nuclear oncoprotein. These findings suggest that nuclear transport of the IL-1 alpha N-terminal component may represent a critical component in the transformation of IL-1 alpha-producing cells in the bone marrow or the perivascular area to a malignant phenotype.

The 31-kDa precursor of interleukin 1 alpha is myristoylated on specific lysines within the 16-kDa N-terminal propiece.

The cytokine interleukin 1 alpha (IL-1 alpha) is a critical mediator of the immune and inflammatory responses. A unique determinant of its activity as compared with IL-1 beta may be its association with the plasma membrane. While the biologic activity of "membrane IL-1" has been extensively reported, the mechanism of membrane binding remains unclear. We report that the N terminus of the 31-kDa IL-1 alpha precursor is myristoylated on specific internal lysine residues. Immunoprecipitation of [3H]myristic acid-radiolabeled human monocyte lysates with IgG antibodies to the 31-kDa IL-1 alpha precursor recovered a protein with the physicochemical properties of the IL-1 alpha N-terminal propiece (16 kDa, pI 4.45). Glycyl N-myristoylation of this protein is precluded by the absence of a glycine residue at position 2, suggesting that the propiece is myristoylated on epsilon-amino groups of lysine. To determine which lysine(s) are acylated, a series of synthetic peptides containing all lysines found in the IL-1 alpha N-terminal propiece were used in an in vitro myristoylation assay containing peptide, myristoyl-CoA, and monocyte lysate as enzyme source. Analysis of the reaction products by reverse-phase HPLC and gas-phase sequencing demonstrated the specific myristoylation of Lys-82 and Lys-83, yielding predominantly monoacylated product. A conserved sequence in the IL-1 beta propiece was myristoylated with at least 8-fold less efficiency. Acylation of the IL-1 alpha precursor by a previously unrecognized lysyl epsilon-amino N-myristoyl-transferase activity may facilitate its specific membrane targeting.

Myristyl acylation of the tumor necrosis factor alpha precursor on specific lysine residues.

NH2-terminal glycine myristyl acylation is a cotranslational modification that affects both protein localization and function. However, several proteins that lack NH2-terminal glycine residues, including the interleukin 1 (IL-1) precursors, also contain covalently linked myristate. To date, the site(s) of acylation of these proteins has not been determined. During an evaluation of IL-1 acylation, it was observed that [3H]myristate-labeled human monocyte lysates contained a prominent 26-kD myristylated protein, which was identified as the tumor necrosis factor alpha (TNF) precursor protein on the basis of specific immune precipitation. Radioimmunoprecipitates from the supernates of labeled monocytes indicated that the processed or mature 17-kD form of TNF does not contain myristate, suggesting that the site of acylation occurs within the 76-amino acid propiece of the precursor molecule. As the TNF precursor does not contain an NH2-terminal glycine, we hypothesized that myristyl acylation occurs on the N-epsilon-NH2 groups of lysine, of which two are present in the propiece (K19K20). Synthetic peptides were designed to include all seven lysine residues present within the entire 26-kD TNF precursor, and used in an in vitro myristyl acylation assay containing peptide, myristyl-CoA, and monocyte lysate as a source of enzyme. Analysis of reaction products by reverse phase high performance liquid chromatography and gas phase sequencing demonstrated the exclusive myristyl acylation of K19 and K20, consistent with the presence in monocytes of a specific lysyl N-epsilon-NH2-myristyl transferase activity. The acylated lysine residues are located immediately downstream from a hydrophobic, probable membrane-spanning segment of the propiece. Specific myristyl acylation of the TNF propiece may facilitate membrane insertion or anchoring of this critical inflammatory mediator.

Interleukin 1: the patterns of translation and intracellular distribution support alternative secretory mechanisms.

Interleukin-1 (IL-1) is synthesized as a 31 kDa precursor protein, whose multiple extracellular activities are attributed to receptor binding of a processed, carboxy-terminal 17 kDa peptide. Unlike other secreted proteins, the IL-1 precursor lacks a hydrophobic leader sequence and is not found in organelles composing the classical secretory pathway. In order to further clarify the intracellular processing of IL-1, we studied its site of synthesis in human monocytes. Secreted and integral membrane proteins are translated on membrane-bound polyribosomes, while intracellular proteins are translated on free polyribosomes. Free and membrane-bound polysomes were isolated from Lipid A-stimulated monocyte lysates and immunoblotted using antibodies specific to the N-terminal regions of the IL-1 alpha and beta precursors. Free polysome fractions showed multiple small bands consistent with nascent peptide chains; membrane-bound polysomes yielded no detectable IL-1. Polysome fractions were then analyzed by immunoelectron microscopy; nascent IL-1 alpha and beta peptide chains were readily seen emerging from cytoskeletal-associated free polyribosomes, but not membrane-bound polyribosomes. Electron microscopic in situ hybridization revealed IL-1 mRNA chains attached to cytoskeletal-associated free, but not membrane-bound polyribosomes. The intracellular distribution of the fully synthesized IL-1 beta precursor was studied in human mesangial cells (HMC), whose cytoskeletal organization is more readily evaluated than that of monocytes. Dual immunofluorescence microscopy of these cells revealed a complex intracellular distribution of the fully synthesized 31 kDa IL-1 precursors. IL-1 was asymmetrically distributed between cytosolic, microtubule, and nuclear compartments, without association with actin or intermediate filaments. This demonstration of the sites of IL-1 synthesis and patterns of intracellular distribution provide further evidence for an extracellular release mechanism which is clearly distinct from the classical secretory pathway.