Resistance to intercompartmental mass transfer limits beta2-microglobulin removal by post-dilution hemodiafiltration.

Although clearance of beta(2)-microglobulin is greater with hemodiafiltration than with high-flux hemodialysis, beta(2)-microglobulin concentrations after long-term hemodiafiltration are only slightly less than those obtained with high-flux hemodialysis. Resistance to beta(2)-microglobulin transfer between body compartments could explain this observation. beta(2)-Microglobulin kinetics were determined in patients receiving on-line post-dilution hemodiafiltration for 4 h with 18 l of filtration. Plasma beta(2)-microglobulin concentrations were measured during and for 2 h following hemodiafiltration and immediately before the next treatment. The filter clearance of beta(2)-microglobulin was determined from arterial and venous concentrations. The beta(2)-microglobulin generation rate was calculated from the change in the plasma concentration between treatments. The intercompartmental clearance was obtained by fitting the observed concentrations to a two-compartment, variable volume model. The plasma clearance of beta(2)-microglobulin by the filter was 73 +/- 2 ml/min. Plasma beta(2)-microglobulin concentrations decreased by 68 +/- 2% from pre- to post-treatment (27.1 +/- 2.2-8.5 +/- 0.7 mg/l), but rebounded by 32+/-3% over the next 90 min. The generation rate of beta(2)-microglobulin was 0.136 +/- 0.008 mg/min. The model fit yielded an intercompartmental clearance of 82 +/- 7 ml/min and a volume of distribution of 10.2 +/- 0.6 l, corresponding to 14.3 +/- 0.7% of body weight. Hemodiafiltration provides a beta(2)-microglobulin clearance of similar magnitude to the intercompartmental clearance within the body. As a result, intercompartmental mass transfer limits beta(2)-microglobulin removal by hemodiafiltration. This finding suggests that alternative strategies, such as increased treatment times or frequency of treatment, are needed to further reduce plasma beta(2)-microglobulin concentrations.

Increasing dialysate flow rate increases dialyzer urea mass transfer-area coefficients during clinical use.

Dialyzer clearance depends on blood and dialysate flow rates and the product of the membrane surface area and mass transfer coefficient for the solute of interest, K(o)A. K(o)A is usually assumed to be constant for a given dialyzer and solute. Results of two recent studies challenge this assumption. Therefore, we examined the hypothesis that K(o)A depends on blood and dialysate flow rates during clinical dialysis. Urea clearances were measured for two different dialyzers at all four combinations of two blood flow rates (300 and 400 mL/min) and two dialysate flow rates (500 and 800 mL/min). Urea K(o)A was calculated by using standard equations for mass transfer in dialyzers operated with countercurrent flows. The impact of blood and dialysate flow rates on K(o)A was assessed by analysis of variance. Increasing dialysate flow rate from 500 to 800 mL/min significantly increased K(o)A (P = 0.018). Increasing blood flow rate from 300 to 400 mL/min did not significantly increase K(o)A (P = 0.083). Also, K(o)A decreased significantly with increasing hematocrit (P = 0.022). The results of this study extend previous in vitro findings by showing that increasing the dialysate flow rate increases urea K(o)A during clinical dialysis. However, the increase in K(o)A observed during clinical dialysis (5.7%) is less than that previously reported in vitro (14.7%), possibly because of the impact of blood cells and proteins on blood-side mass transfer resistance.

Ultrapure dialysate: a desirable and achievable goal for routine hemodialysis.

United States standards for the microbiologic quality of dialysate are not very stringent and have remained unchanged for more than 20 years, despite significant changes in the patient population and in the technology of hemodialysis. Numerous studies have demonstrated that bacterial products can cross dialysis membranes and stimulate an inflammatory response in the patient. Inflammation has been implicated in several complications associated with long-term hemodialysis therapy, and the use of ultrapure dialysate has been shown to reduce the incidence of one of these complications, beta2-microglobulin amyloidosis. Since technological innovations in water treatment and improvements in dialysis machine design allow the routine production of ultrapure dialysate, its use should now become standard.

Priming of the neutrophil respiratory burst involves p38 mitogen-activated protein kinase-dependent exocytosis of flavocytochrome b558-containing granules.

The respiratory burst of human neutrophils is primed by a number of pro-inflammatory stimuli, including tumor necrosis factor-alpha (TNFalpha) and lipopolysaccharide (LPS); however, the mechanism of priming remains unknown. LPS has been shown previously to increase membrane expression of flavocytochrome b(558), a component of the NADPH oxidase. This study shows that TNFalpha also increases membrane expression of flavocytochrome b(558). Mitogen-activated protein kinase (MAPK) modules have been implicated in the action of priming agents. Pharmacologic inhibitors of MAPKs, SB203580 and PD098059, revealed that priming of the respiratory burst and up-regulation of flavocytochrome b(558) are dependent on p38 MAPK but not on extracellular-signal regulated kinase (ERK). TNFalpha and LPS primed respiratory burst activity and increased membrane expression of CD35 and CD66b, specific markers of secretory vesicles and specific granules that contain flavocytochrome b(558), with similar time courses and concentration dependences. These processes also required p38 MAPK but were independent of ERK. TNFalpha failed to prime respiratory burst activity or to increase membrane CD35 expression in enucleated neutrophil cytoplasts. These data suggest that one mechanism by which TNFalpha and LPS prime neutrophil respiratory burst activity is by increasing membrane expression of flavocytochrome b(558) through exocytosis of intracellular granules in a process regulated by p38 MAPK.

Deficient homologous desensitization of formyl peptide receptors stably expressed in undifferentiated HL-60 cells.

The ability of formyl peptide receptors (FPRs) stably expressed in undifferentiated HL-60 cells to undergo ligand-induced desensitization was compared with their ability in normal and vector-transfected HL-60 cells following granulocyte differentiation with DMSO. fMet-Leu-Phe failed to induce uncoupling of FPRs from G-proteins in FPR-transfected cells, whereas uncoupling was induced in differentiated HL-60 cells and differentiated vector-transfected HL-60 cells, as determined by ligand-stimulated guanosine 5'-(gamma-thio)triphosphate (GTPgammaS) binding and GTPgammaS inhibition of fMet-Leu-Phe binding to isolated membranes. Immunoprecipitation of Galpha(i2) from solubilized, azidoanalide (AA-gammaGTP) photolabeled membranes showed that receptors in desensitized FPR-transfected HL-60 cells remained coupled to Galpha(i2), whereas desensitized receptors in differentiated HL-60 cell membranes were uncoupled from Galpha(i2). As determined by immunoblotting, Galpha(i2) expression was similar in undifferentiated and differentiated HL-60 cells and FPR-transfected cells. Ligand-stimulated receptor internalization and desensitization of calcium redistribution were similar in all three groups of cells. Immunoblotting also indicated that G-protein-coupled receptor kinases (GRKs) 2 and 4 were present in undifferentiated FPR-transfected HL-60 cells at 50% of the level seen in differentiated HL-60 cells. However, differentiation did not increase GRK2 or GRK4 expression, indicating that differences in GRK expression do not explain deficient desensitization. The data indicated that undifferentiated HL-60 cells are unable to induce homologous desensitization of FPRs.

Summary of new distribution records for mosquito species in the United States and Canada for the period 1981-99.

In order to elucidate the recent spread of mosquito species in the United States and Canada, a summary of new records for states and provinces has been prepared to include those reported mostly from 1981 to 1998, although some records before 1989 are also given. We are reporting 132 new records for 58 species of mosquitoes.

Improved dialyzer reuse after use of a population pharmacodynamic model to determine heparin doses.

Anticoagulation with heparin is performed to prevent clotting during dialysis. However, heparin doses are usually determined empirically, and dialyzer clotting is a common reason for discarding reused dialyzers. We hypothesized that using a population pharmacodynamic model to determine individual heparin doses would improve dialyzer reuse rates. A previously published model was used to determine the loading dose and infusion rate of heparin needed to increase the intradialytic whole-blood clotting time to 150% of the predialysis value. The effectiveness of the model was assessed by comparing dialyzer reuse rates and delivered Kt/V(urea) before and after implementation of the model in 22 chronic hemodialysis patients. As an additional control, a similar group of 22 patients were followed up during the same period without adjustment of their heparin doses. Implementation of the model resulted in no change in the average loading dose (2,382 +/- 628 versus 2,425 +/- 908 IU; P = not significant) or average infusion rate (1,398 +/- 367 versus 1,393 +/- 532 IU/h; P = not significant) of heparin. However, individual patients required changes in loading dose or infusion rate. Dialyzer reuse rates increased significantly over time in the treatment group but remained unchanged in the control group (P < 0.003). Kt/V(urea) remained unchanged throughout the study period in both patient groups. From these data, we conclude that the use of a heparin model can improve dialyzer reuse rates without compromising the delivered dose of dialysis.

Cruciate injury patterns in knee hyperextension: a cadaveric model.

We created an experimental model to evaluate the effects of strain rate on the mechanism of combined cruciate ligament injuries in knee hyperextension. Using straight knee hyperextension to rupture the anterior and posterior cruciates, two strain rates (approximately 100% per second and 5400% per second) were applied to reproduce two clinical injury patterns of the knee: low energy (sporting) and high energy (pedestrian-motor vehicle accident). Ten pairs of fresh-frozen cadaveric knees were injured to 45 degrees of hyperextension. Strain rate sensitivity of the posterior cruciate ligament was shown in this model, with midsubstance tears occuring in specimens tested at a low rate and avulsion "stripping" injuries from the femoral side occuring at a high rate. A variable pattern of anterior cruciate ligament tears at both high and low rates suggests that the specific injury mechanism may also involve other factors including notch morphology. We present a simplified mathematic model used to estimate posterior cruciate ligament strain during knee hyperextension.

Transplantation, not dialysis, corrects azotemia-dependent priming of the neutrophil oxidative burst.

The oxidative burst of neutrophils from patients with renal failure before the initiation of dialysis is primed for an enhanced response after stimulation by phagocytosis or chemoattractants. This study shows that phagocytosis-stimulated oxidative burst activity remains primed in patients treated with both high-efficiency hemodialysis and continuous ambulatory peritoneal dialysis (CAPD), but it is normal in patients with a functioning renal transplant. Incubation of normal neutrophils or HL-60 granulocytes in azotemic plasma results in increased resting and phagocytosis-stimulated H2O2 production, which is rapidly reversible on removal of the plasma. Priming of the oxidative burst by azotemic plasma is independent of changes in opsonization and phagocytosis and does not require protein synthesis. These results suggest that azotemic plasma contains a substance or substances capable of reversibly priming oxidative burst activity in neutrophils and neutrophil-like cell lines. The Inability of high-efficiency hemodialysis and CAPD to normalize oxidative burst activity suggests that this substance is of higher molecular weight.

Blood flow rate: an important determinant of urea clearance and delivered Kt/V.

Implementation of the Dialysis Outcomes Quality Initiative (DOQI) Guidelines for hemodialysis adequacy will necessitate an increase in delivered Kt/V for many patients. Before increasing Kt/V by prolonging the patient's treatment time, it is important to verify that the prescribed dialyzer urea clearance is being achieved. The principal determinant of dialyzer urea clearance is blood flow rate. Actual blood flow rates are frequently less than the nominal blood flow rate displayed by the dialysis machine, particularly at higher flow rates, leading to lower than expected urea clearances. The major reason for the reduction in blood flow rate is a low pressure in the arterial blood line proximal to the blood pump. This effect can be mitigated by the use of large bore access needles. For quality assurance purposes, actual blood flow rates should be determined by correcting nominal blood flow rates for pressure effects using empirical relationships or by using an ultrasonic flow meter. Because a poorly functioning blood access may further reduce the effective blood flow rate, blood access performance should also be monitored regularly.

Bacterial phagocytosis activates extracellular signal-regulated kinase and p38 mitogen-activated protein kinase cascades in human neutrophils.

The hypothesis that bacterial phagocytosis by human polymorphonuclear neutrophils (PMNs) stimulates MAPK cascades that regulate respiratory burst activation was tested. Extracellular response kinase (ERK) and p38 kinase, but not c-Jun NH2-terminal kinase, activities were increased within 5 min of phagocytosis of plasma-opsonized Staphylococcus aureus (S-SA), reached maximum at 20-30 min, and remained elevated through 60 min. The role of Fcy receptors was examined using gamma globulin-opsonized SA (IgG-SA), whereas CR3 receptors were activated by particulate beta-glucan. IgG-SA stimulated a maximal ERK activity at 30 min, whereas p38 activity was maximal at 5 min. Beta-glucan stimulated maximal ERK activity at 5 min and maximal p38 activity at 2 min. Non-opsonized bacteria were ingested at 10% of the level of S-SA and stimulated a minimal increase in ERK and p38 activity at 60 min. S-SA stimulation of ERK was inhibited by wortmannin, LY294002, and genistein, but not calphostin C; whereas p38 stimulation was inhibited by calphostin C and genistein, but not wortmannin and LY294002. Simultaneous measurement of phagocytosis and H2O2 production by flow cytometry was used to assess the role of ERKs and p38 kinase in phagocytosis. The MEK inhibitor PD098059 had no significant effect on phagocytosis or H2O2 production. The p38 kinase inhibitor SB203580 significantly attenuated H2O2 production, whereas phagocytosis was unaffected. In conclusion, bacterial phagocytosis stimulates ERK and p38 activation by distinct signal transduction pathways. Phagocytosis-stimulated p38 kinase activity is necessary for optimal H2O2 production.

Prediction of anticoagulation during hemodialysis by population kinetics and an artificial neural network.

All systems currently used for routine hemodialysis require heparin administration to prevent blood clotting in the extracorporeal circuit. We tested the hypothesis that population-based statistical techniques can be used to predict heparin concentrations during routine hemodialysis. Two predictive models were developed, one based on nonlinear mixed effects modeling (NONMEM) and the other on a multilayer perceptron neural network. Serial clotting time data were obtained from forty-nine patients and used to develop the models. The models were used to predict the clotting times of 70 patients in a prospective test. We determined that the neural network provided greater precision, had fewer outliers in its predictions, and did not have the model misspecification in bolus administration that the NONMEM predictions demonstrated. A final NONMEM model was developed using all data from 119 patients to identify important covariates for predicting the heparin pharmacodynamic parameters, volume of distribution, and clearance. Both the volume of distribution and clearance increased following the initiation of dialysis and as the patient's baseline clotting time increased. The volume of distribution also increased as the patient's weight increased but was decreased by smoking and diabetes. Population-based statistical techniques may provide a useful alternative to existing methods for prescribing heparin.

Activation of mitogen-activated protein kinase cascades during priming of human neutrophils by TNF-alpha and GM-CSF.

The signal transduction pathways activated by tumor necrosis factor alpha (TNF-alpha) and granulocyte-macrophage colony-stimulating factor (GM-CSF) that lead to priming of polymorphonuclear leukocytes (PMNs) are unknown. The hypotheses that these cytokines stimulate multiple mitogen-activated protein kinase (MAPK) cascades, including extracellular signal-regulated kinases (ERKs), c-Jun amino-terminal kinases (JNKs), and p38 MAPK, and that these MAPKs participate in priming of human PMNs were examined. TNF-alpha stimulated a dose-dependent increase in ERK and p38 MAPK activities that was maximal at 10 min. JNKs were not stimulated by TNF-alpha or GM-CSF. GM-CSF stimulated ERK activity comparable to that of TNF-alpha, but GM-CSF was a less potent stimulus of p38 MAPK activity. The tyrosine kinase inhibitor, genistein, inhibited ERK and p38 MAPK stimulation by both cytokines. The phosphatidylinositol 3-kinase inhibitor, wortmannin, attenuated stimulation of ERKs and p38 MAPK by GM-CSF, but not TNF-alpha. GM-CSF, but not TNF-alpha, stimulated wortmannin-sensitive activation of Raf-1. TNF-alpha and GM-CSF priming of superoxide release stimulated by N-formyl-methionyl-leucyl-phenylalanine was significantly attenuated by the MEK inhibitor, PD098059, and the p38 MAPK inhibitor, SB203580. Incubation with both MAPK inhibitors produced an additive effect. Our data suggest that TNF-alpha and GM-CSF activate ERKs and p38 MAPK by different signal transduction pathways. Both ERK and p38 MAPK cascades contribute to the ability of TNF-alpha and GM-CSF to prime the respiratory burst response in human PMNs.

Quality of life during and between hemodialysis treatments: role of L-carnitine supplementation.

End-stage renal disease affects every aspect of a patient's life, including perception of health and quality of life. It is likely that a hemodialysis patient's perceptions of health-related quality of life directly influence compliance with medical, nursing, and nutritional prescriptions. Because L-carnitine supplementation is known to enhance muscle strength and energy in hemodialysis patients, we hypothesized that L-carnitine supplementation would enhance a hemodialysis patient's perception of health-related quality of life. To test this hypothesis, 1 g L-carnitine or placebo was administered orally to 101 patients immediately before and after every hemodialysis treatment for 6 months. To assess health-related quality of life from the patient's perspective, the Medical Outcomes Study Short Form 36 instrument was administered before the study and at 1.5-month intervals for the duration of the study. In addition, a 10-item questionnaire designed to assess common intradialytic symptoms was administered at the end of each dialysis treatment. Other parameters analyzed included Kt/V(urea) and level of nutrition. In the 6-month group, oral L-carnitine supplementation had an early positive effect on general health (P < 0.02) and physical function (P < 0.03), but the perceived effect was not sustained throughout the 6 months of the study. In the 3-month group, L-carnitine supplementation improved vitality (P < 0.02) and general health (P < 0.01). There was no association between Kt/V(urea) and perceived health-related quality of life. Serum albumin concentration was directly correlated to how patients perceived the quality of their lives.

Natural habitats of Aedes Aegypti in the Caribbean--a review.

Natural breeding habitats of Aedes aegypti in the Caribbean region were reviewed by conducting larval surveys in Trinidad. Puerto Rico, and the U.S. Virgin Islands and referring to records from the Mosquitoes of Middle America project. Twelve types of natural habitats were recorded: rock holes (9.7%), calabashes (2.4%), tree holes (19.5%), leaf axils (4.8%), bamboo joints (14.9%), papaya stumps (7.3%), coconut shells (4.8%), bromeliads (7.3%), ground pools (14.9%), coral rock holes (9.7%), crab holes (2.4%), and conch shells (7.3%), of which the coconut shell and calabash habitats were new to the Caribbean. The countries having the highest prevalence of natural habitats were Trinidad. Puerto Rico, and Jamaica, with 9 types (22.0%), 7 types (17.0%), and 6 types (14.6%), respectively. The distribution of natural habitats of Ae. aegypti in the Caribbean region is discussed in relation to vector control measures.

Maintaining blood compartment volume in dialyzers reprocessed with peracetic acid maintains Kt/V but not beta2-microglobulin removal.

A dialyzer is reused if its blood compartment volume is 80% of its initial value, a condition believed to ensure that the urea clearance remains at 90% of its initial value. This criterion was developed for dialyzers containing low permeability cellulose membranes reprocessed with formaldehyde. We tested the hypothesis that the criterion is also valid for more permeable membranes when dialyzers are reprocessed with peracetic acid/hydrogen peroxide. Kt/V for urea and reduction in beta2-microglobulin concentration were measured for up to 15 uses in dialyzers containing polysulfone or cellulose membranes. Kt/V for urea did not change for either dialyzer provided blood compartment volumes remained 80% of their initial value. The reduction in plasma beta2-microglobulin concentration from predialysis to postdialysis was 30% for the first use of the dialyzer containing polysulfone membranes, but decreased significantly (P = 0.042) following reuse to 12% for the tenth use. For the dialyzers containing cellulose membranes, the reduction in plasma beta2-microglobulin concentration was 18% for the first use and decreased to 12% by the twelfth use; however, this change was not significant. We conclude that removal of urea is maintained during reuse with peracetic acid/hydrogen peroxide provided the blood compartment volume remains 80% of its initial value. However, removal of beta2-microglobulin may not be maintained, even though blood compartment volumes remain at 80% of their initial value.

A comparison of dialysers with low-flux membranes: significant differences in spite of many similarities.

The solute removal characteristics and haemocompatibility of low-flux dialysers containing Cuprophan, cellulose acetate, polymethylmethacrylate (PMMA), and polycarbonate-polyether (Gambrane) membranes were compared in a multicentre cross-over clinical trial. While all four dialysers provided comparable removal of urea and creatinine, the dialyser containing PMMA membrane showed a reduced ability to remove phosphate compared to that containing Cuprophan membrane. Significant beta 2-microglobulin removal was obtained with the dialyser containing Gambrane membrane, whereas the other three dialysers had no impact on plasma beta 2-microglobulin concentrations. The ability to activate complement, measured as changes in the plasma concentrations of C3a des Arg and the terminal complement complex, and to produce leukopenia was greater for the dialyser containing Cuprophan membrane than for the other three. The ability to activate complement and cause leukopenia was not consistent among the remaining three dialysers and the degree of leukopenia could not be predicted from the level of complement activation. Neutrophil degranulation, as indicated by the release of elastase-alpha 1-proteinase inhibitor, occurred to a greater extent with the dialysers containing Cuprophan and Gambrane membranes. None of the dialysers was overtly thrombogenic as judged by changes in platelet count and plasma concentrations of the thrombin-antithrombin III complex. Our results demonstrate that although there are many similarities between dialysers containing low-flux membranes, there are also significant differences. These differences may enable improvements in therapy, while allowing continued use of low-flux dialysers.