Dispelling myths and misconceptions about the treatment of acute hyperkalemia.

Hyperkalemia represents a widespread and potentially lethal condition that affects millions of people across their lives. Despite the prevalence and severity of the condition, there are no consensus guidelines on the treatment of hyperkalemia or even a standard definition. Herein, we provide a succinct review of what we believe to be the most significant misconceptions encountered in the emergency care of hyperkalemia, examine current available literature, and discuss practical points on several modalities of hyperkalemia treatment. Additionally, we review the pathophysiology of the electrocardiographic effects of hyperkalemia and how intravenous calcium preparations can antagonize these effects. We conclude each section with recommendations to aid emergency physicians in making safe and efficacious choices for the treatment of acute hyperkalemia.

Treatment of infant formula with patiromer dose dependently decreases potassium concentration.

BACKGROUND: Hyperkalemia is a potentially life-threatening complication of chronic kidney disease (CKD). Dietary potassium restriction is challenging in infants despite low-potassium formulas. Decreasing potassium in formula using patiromer, a new calcium-based cation exchange polymer may be one option to accomplish this; however, data confirming efficacy is lacking. METHODS: Varying doses of patiromer were added to prepared Similac Advance and Similac PM 60/40. Measurements of potassium, calcium, sodium, magnesium, and phosphorus were obtained at baseline and at 30 min, 60 min, and 24 h following patiromer administration. RESULTS: Following pre-treatment with patiromer, the potassium concentration of both formulas decreased. This effect was mild with the lowest dose but increased in a dose-dependent fashion. Treating for 60 min or 24 h did not yield substantially greater effects than treating for 30 min. Calcium levels increased in both formula groups, mostly in a dose-dependent fashion. Changes in magnesium, sodium, and phosphorus were also seen after patiromer pre-treatment. CONCLUSIONS: Pre-treatment with patiromer decreases the potassium concentration of infant formula. Calcium levels increased after treatment as expected with the majority of ion exchange occurring in 30 min. Treatment of formula with patiromer shows promise as a unique option for managing hyperkalemia.

Evaluation of the Pharmacodynamic Effects of the Potassium Binder RDX7675 in Mice.

INTRODUCTION: Hyperkalemia is a common complication in patients with heart failure or chronic kidney disease, particularly those who are taking inhibitors of the renin-angiotensin-aldosterone system. RDX7675, the calcium salt of a reengineered polystyrene sulfonate-based resin, is a potassium binder that is being investigated as a novel treatment for hyperkalemia. This study evaluated the pharmacodynamic effects of RDX7675 in mice, compared to 2 current treatments, sodium polystyrene sulfonate (SPS) and patiromer. METHODS: Seven groups of 8 male CD-1 mice were given either standard chow (controls) or standard chow containing 4.0% or 6.6% active moiety of RDX7675, patiromer, or SPS for 72 hours. Stool and urine were collected over the final 24 hours of treatment for ion excretion analyses. RESULTS: RDX7675 increased stool potassium (mean 24-hour excretion: 4.0%, 9.19 mg; 6.6%, 18.11 mg; both P < .0001) compared with controls (4.47 mg) and decreased urinary potassium (mean 24-hour excretion: 4.0%, 12.05 mg, P < .001; 6.6%, 6.68 mg, P < .0001; vs controls, 20.38 mg). The potassium-binding capacity of RDX7675 (stool potassium/gram of resin: 4.0%, 1.14 mEq/g; 6.6%, 1.32 mEq/g) was greater (all P < .0001) than for patiromer (4.0%, 0.63 mEq/g; 6.6%, 0.48 mEq/g) or SPS (4.0%, 0.73 mEq/g; 6.6% 0.55 mEq/g). RDX7675 and patiromer decreased urinary sodium (mean 24-hour excretion: 0.07-1.38 mg; all P < .001) compared to controls (5.01 mg). In contrast, SPS increased urinary sodium excretion (4.0%, 13.31 mg; 6.6%, 17.60 mg; both P < .0001) compared to controls. CONCLUSIONS: RDX7675 reduced intestinal potassium absorption and had a greater potassium-binding capacity than patiromer or SPS in mice. The calcium-based resins RDX7675 and patiromer reduced intestinal sodium absorption, unlike sodium-based SPS. These results support further studies in humans to confirm the potential of RDX7675 for the treatment of patients with hyperkalemia.

Subtherapeutic serum quetiapine concentrations after absorption inhibition by binding resins: a case report.

WHAT IS KNOWN AND OBJECTIVE: Polystyrene sulfonate and sevelamer are binding resins that are used in the treatment of, respectively, hyperkalemia and hyperphosphatemia. It is unknown whether these resins interact with the antipsychotic quetiapine. CASE SUMMARY: We report on a woman with unexplainable low serum quetiapine concentrations who also used the binding resins polystyrene sulfonate and sevelamer. An In vitro binding assay showed binding of quetiapine by these resins. Separation of the ingestion times of quetiapine and the binding resins resulted in increased serum levels in this patient. WHAT IS NEW AND CONCLUSION: Polystyrene sulfonate and sevelamer are able to bind quetiapine. Healthcare professionals should be aware of this potential drug-drug interaction as this could lead to antipsychotic treatment failure.

Dedicated removal of immunoglobulin (Ig)A, IgM, and Factor (F)XI/activated FXI from human plasma IgG.

BACKGROUND: Adverse events can be associated with treating critically ill patients with immunoglobulin (Ig)G. Some adverse events are due to contaminants like IgA and activated Factor (F)XI. Therefore, new purification strategies are needed for dedicated removal of these contaminants without impairing IgG recovery. STUDY DESIGN AND METHODS: An immunoglobulin fraction containing IgG, IgM, and IgA was prepared by caprylic acid precipitation of cryoprecipitate-poor plasma. The capacities of the cation exchangers (S HyperCel and CM Ceramic HyperD F) and anion exchangers (HyperCel STAR AX and Q HyperCel) to remove IgA, IgM, and spiked FXI were tested following a design of experiment approach using microplates and chromatographic column scale-up. FXI removal was also evaluated using Mustang S chromatographic membranes. IgG/IgG subclasses, IgA, IgM, and FXI were assessed by enzyme-linked immunosorbent assay, and caprylic acid, by gas chromatography. RESULTS: Extensive removal of IgA and IgM, but not FXI, was achieved by a two-step chromatographic process combining S HyperCel used in the IgG binding and elution mode and HyperCel STAR AX used in the IgG flow-through mode, providing high IgG and IgG subclass recovery (>85%), high purity (>99.5%), and efficient removal of IgA (<0.5%) and IgM (undetectable). Twenty-six-fold FXI removal was achieved by processing the resulting purified IgG fraction through Mustang S cation-exchanger membranes at pH 6.0 and 12.7 mS/cm. Caprylic acid was removed by S HyperCel. CONCLUSIONS: Combining S HyperCel and HyperCel STAR AX extensively removed IgA and IgM, with good IgG recovery. Mustang® S membranes can be used for dedicated removal of FXI.

Contribution of extracellular polymeric substances on representative gram negative and gram positive bacterial deposition in porous media.

The significance of extracellular polymeric substances (EPS) on cell transport and retained bacteria profiles in packed porous media (quartz sand) was examined by direct comparison of the overall deposition kinetics and retained profiles of untreated bacteria (with EPS) versus those of treated cells (without EPS) from the same cell type. Four representative cell types, Pseudomonas sp. QG6 (gram-negative, motile), mutant Escherichia coli BL21 (gram-negative, nonmotile), Bacillus subtilis (gram-positive, motile), and Rhodococcus sp. QL2 (gram-positive, nonmotile), were employed to systematically determine the influence of EPS on cell transport and deposition behavior. Packed column experiments were conducted for the untreated and treated cells in both NaCl (four ionic strength ranging from 2.5 mM to 20 mM) and CaCl(2) (5 mM) solutions at pH 6.0. The breakthrough plateaus of untreated bacteria were lower than those of treated bacteria for all four cell types under all examined conditions (in both NaCl and CaCl(2) solutions), indicating that the presence of EPS on cell surfaces enhanced cell deposition in porous media regardless of cell type and motility. Retained profiles of both untreated and treated cells for all four cell types deviated from classic filtration theory (log-linear decreases). However, the degree of deviation was greater for all four untreated cells, indicating that the presence of EPS on cell surfaces increased the deviation of retained profiles from classic filtration theory. Elution experiments demonstrated that neither untreated nor treated cells preferentially deposited in secondary energy minima. Furthermore, the release of previously deposited cells in the secondary energy minima did not change the shape of retained cell profiles, indicating that deposition in secondary energy minima did not produce the observed deviations of retained profiles from classic filtration theory.

von Willebrand factor protects the Ca2+-dependent structure of the factor VIII light chain.

We have recently reported that cation-exchange iminodiacetate resin completely inactivated factor VIII (FVIII) by direct deprivation of metal ions, predominantly Ca2+, from its molecules, and that von Willebrand factor (VWF) protected FVIII antigen from resin-induced degradation. The present study was further developed to investigate this mechanism. Western blotting analysis and enzyme-linked immunosorbent assay showed that the antigenic structure of the FVIII light chain, especially the C2 domain, was completely impaired by the resin, whilst that of the heavy chain was little affected. However, the complex formation with VWF protected the C2 domain from the resin-induced degradation. The resin-treated C2 domain failed to interact with VWF and phospholipid. Furthermore, the addition of Ca2+ competitively blocked the resin-induced impairment of the C2 domain structure. These results demonstrate that VWF protects the Ca2+-dependent conformational structure of the FVIII light chain, especially the C2 domain, and may indicate that the C2 domain contains the Ca2+-binding site(s).

Sodium polystyrene sulfonate used to reduce the potassium content of a high-protein enteral formula: a quantitative analysis.

BACKGROUND: Sodium polystyrene sulfonate (Kayexalate) commonly is used in treating hyperkalemia. As a cation exchange resin, it also can be used to reduce the potassium content of enteral nutrition formulas. This study evaluates the use of Kayexalate to reduce potassium in one high-protein enteral formula and describes the quantitative analysis of the product. METHODS: Sodium polystyrene sulfonate and enteral formula were mixed into a slurry and allowed to settle, and then the supernatant was decanted off and tested as samples. Three sample concentrations were analyzed: a control not subjected to potassium reduction, 0.5 g of Kayexalate per mEq K+ sample, and a 1 g/mEq K+ sample. Of these samples, moisture, lipid, protein, carbohydrate, ash, and mineral content were obtained. RESULTS: Compared with the control, the percentage decrease of potassium ranged from 25% to 36%, depending on the concentration of Kayexalate. A significant increase of 324% in sodium concentration was found in the 1.0 g/mEq K+ sample. Although there was no change in magnesium content, a slight increase in phosphorus, iron, and zinc was evident. CONCLUSIONS: The treatment of an enteral formula with sodium polystyrene sulfonate significantly increases its sodium content, with a modest decrease in potassium content. Clinicians using this method in clinical practice should be aware of the increase in sodium content.

When good water goes bad: how it happens, clinical consequences and possible solutions.

Dialysis fluid produced by state-of-the-art water preparation and distribution is contaminated with gram-negative bacteria and cytokine-inducing substances (CIS) derived from these microorganisms. The presence of a biofilm increases the risk of continuous contamination of dialysis fluid. Depending on the type of dialyzer membrane (cellulosic vs. synthetic) and the mode of dialysis (low flux vs. high flux with backfiltration), CIS may penetrate intact dialyzer membranes, induce cytokine production in the patient's blood and contribute to chronic inflammation associated with long-term hemodialysis therapy. Measures to improve the microbiological quality of dialysis fluid are: (1) the awareness of the problem and regular testing of dialysate samples using adequate methods; (2) disinfection of the entire water preparation and distribution system on a regular basis, replacement of biofilm-containing tubings, and (3) installation of ultrafilters in the dialysate circuit in particular when high-flux hemodialysis modalities are performed.

Efficient gene delivery to primary neuron cultures using a synthetic peptide vector system.

A bi-functional, 31 amino acid synthetic peptide (polylysine-molossin) was evaluated for gene delivery to primary cultures of rat cerebral cortex neurons. Polylysine-molossin consists of an amino terminal domain of 16 lysines for electrostatic binding of DNA, and a 15 amino acid, integrin-binding domain at the carboxyl terminal. High levels of gene delivery were obtained with 20-30 microM chloroquine, with a synthetic fusogenic peptide at an optimal DNA:polylysine-molossin:fusogenic peptide w/w ratio of 1:3:0.2, and with the addition of low concentrations of Lipofectamine 2000 at an optimal DNA:polylysine-molossin:Lipofectamine 2000 w/w ratio of 1:3:0.5. With the best combination, >30% of neurons strongly expressed the beta-galactosidase reporter gene, with no observable toxicity. DNA concentrations >2 microgram/ml were essential for efficient gene delivery. This synthetic peptide provides a safe, readily standardised and flexible DNA vector system well suited to ex vivo gene delivery to neurons for experimental and clinical applications.

Ca(2+)-dependent interaction between FKBP12 and calcineurin regulates activity of the Ca(2+) release channel in skeletal muscle.

Calcineurin is a Ca(2+) and calmodulin-dependent protein phosphatase with diverse cellular functions. Here we examined the physical and functional interactions between calcineurin and ryanodine receptor (RyR) in a C2C12 cell line derived from mouse skeletal muscle. Coimmunoprecipitation experiments revealed that the association between RyR and calcineurin exhibits a strong Ca(2+) dependence. This association involves a Ca(2+) dependent interaction between calcineurin and FK506-binding protein (FKBP12), an accessory subunit of RyR. Pretreatment with cyclosporin A, an inhibitor of calcineurin, enhanced the caffeine-induced Ca(2+) release (CICR) in C2C12 cells. This effect was similar to those of FK506 and rapamycin, two drugs known to cause dissociation of FKBP12 from RyR. Overexpression of a constitutively active form of calcineurin in C2C12 cells, DeltaCnA(391-521) (deletion of the last 131 amino acids from calcineurin), resulted in a decrease in CICR. This decrease in CICR activity was partially recovered by pretreatment with cyclosporin A. Furthermore, overexpression of an endogenous calcineurin inhibitor (cain) or an inactive form of calcineurin (DeltaCnA(H101Q)) in C2C12 cells resulted in up-regulation of CICR. Taken together, our data suggest that a trimeric-interaction among calcineurin, FKBP12, and RyR is important for the regulation of the RyR channel activity and may play an important role in the Ca(2+) signaling of muscle contraction and relaxation.

A nuclear targeting peptide, M9, improves transfection efficiency in fibroblasts.

BACKGROUND: Nonviral transfection of eukaryotic cells remains inefficient. Liposomes can transport DNA plasmid into the cytoplasm, but the nuclear membrane remains a barrier to efficient plasmid DNA transfection. But normal cells have mechanisms to transport nucleic acids across the nuclear membrane. Cells routinely utilize a transporter to carry mRNA from nucleus to cytoplasm. MATERIALS AND METHODS: We used a modified mRNA transporter, the M9 component of heterogeneous nuclear ribonucleoprotein-A1, complexed to a DNA carrier to facilitate DNA transfer into the nucleus. We examined the effect of M9 on transfection in 3T3 fibroblasts. Our hypothesis was that the M9 shuttle would increase transfection efficiency by delivering plasmid to the nucleus, after cytoplasmic entry was facilitated by Lipofectamine. Transfection was assessed using plasmids expressing beta-galactosidase and green fluorescent protein (GFP). Intracellular location of rhodamine-labeled plasmid was determined by fluoroscopic microscopy. RESULTS: In the fluorescent microscopy experiments, we found that rhodamine-labeled DNA plasmid was sequestered in the cytoplasm in the Lipofectamine-treated cells, but gained access to the nucleus with the addition of M9. At concentrations where neither M9 nor Lipofectamine individually increased plasmid mediated transfection, as evidenced by beta-galactosidase activity; their combination increased transfection dramatically by approximately 20-fold, from 2 +/- 1 to 32 +/- 5. CONCLUSIONS: As expected, based on their presumed actions, Lipofectamine and the M9 shuttle synergistically promote efficient cellular transfection. Efficient cellular transfection will be required in clinical applications of gene therapy.

Toxicity of cadmium in tobacco smoke: protection by antioxidants and chelating resins.

The effects of cadmium, an environmental toxin present in tobacco smoke, were studied in vitro in human monocytes and compared to those of tobacco smoke. Overexpression of the 72kDa heat shock/stress protein Hsp70 and cell death occurred with a similar time-course and to a similar extent in human monocytes exposed to either cadmium or tobacco smoke. Cadmium and tobacco smoke-mediated toxicity were associated with a decrease in the cellular content of glutathione and ATP and the glutathione precursor N-acetyl-L-cysteine prevented both cadmium and tobacco smoke-mediated toxicity. Furthermore, tobacco smoke-mediated toxicity was prevented by pretreatment with the cadmium chelator resin Chelex-100, supporting the conclusion that cadmium plays a major role in tobacco smoke-mediated toxicity.

Interleukin-2 gene has superior antinociceptive effects when delivered intrathecally.

The antinociceptive effect of interleukin-2 gene on rat carrageenan-induced pain was explored using different delivery methods. Intrathecal (i.t.) or plantar s.c. delivery of plasmid harbouring the interleukin-2 gene produced a marked antinociceptive effect, which was maintained up to 6 days; the administration of recombinant human interleukin-2 only had a transitory effect. The antinociceptive effect lasted longer and was more potent when the interleukin-2 gene was administered i.t. than when delivered s.c. The effect of the interleukin-2 gene was related to its protein expression, was dose dependent, and could be potentiated by liposome. The results suggest that the interleukin-2 gene has a good prospect for clinical use.

Antisense inhibition of surfactant protein A decreases tubular myelin formation in human fetal lung in vitro.

Surfactant protein A (SP-A) is the most abundant of the surfactant-associated proteins. SP-A is involved in the formation of tubular myelin, the modulation of the surface tension-reducing properties of surfactant phospholipids, the metabolism of surfactant phospholipids, and local pulmonary host defense. We hypothesized that elimination of SP-A would alter the regulation of SP-B gene expression and the formation of tubular myelin. Midtrimester human fetal lung explants were cultured for 3-5 days in the presence or absence of an antisense 18-mer phosphorothioate oligonucleotide (ON) complementary to SP-A mRNA. After 3 days in culture, SP-A mRNA was undetectable in antisense ON-treated explants. After 5 days in culture, levels of SP-A protein were also decreased by antisense treatment. SP-B mRNA levels were not affected by the antisense SP-A ON treatment. However, there was decreased tubular myelin formation in the antisense SP-A ON-treated tissue. We conclude that selective elimination of SP-A mRNA and protein results in a decrease in tubular myelin formation in human fetal lung without affecting SP-B mRNA. We speculate that SP-A is critical to the formation of tubular myelin during human lung development and that the regulation of SP-B gene expression is independent of SP-A gene expression.

Cationic liposomes with plasmid DNA influence cancer metastatic capability.

BACKGROUND: Cancer gene therapy is now being developing to provide new strategies for the treatment of human tumors. Cationic lipids represent one of the powerful mediators for DNA delivery. The liposome-plasmid DNA complex itself is known to inhibit tumor cell growth, but other effects on cancer cell behaviors have not been reported so far. MATERIALS AND METHODS: Six commercially available cationic liposomes complexed with plasmid DNA were applied to cancer cells and their metastatic potentials were measured. RESULTS: The liposome-plasmid DNA complexes affected metastatic capability in three different ways: TM-TPS:DOPE and DOTAP:DOPE had no effect on metastatic capability; a suppressive effect was observed in DOSPA:DOPE and DMRIE:cholesterol; while an augmentative effect was observed in DOTMA:DOPE and Effectene. These effects are likely to be DNA sequence independent, because different plasmids have the same effects. CONCLUSION: Liposome-plasmid DNA complexes influence cancer metastasis capability, dependent upon the cationic liposome formulations.

Quantitative analysis of synthetic gene delivery vector design properties.

As intracellular gene delivery pathways are highly complex combinations of multiple potentially rate-limiting cellular and molecular processes, approaches to the design of synthetic delivery vectors focusing on any single barrier individually will likely be suboptimal. We offer here an "integrative systems" approach to vector characterization and design, combining quantitative experiment and computational modeling studies of vector uptake and trafficking kinetics. This model is validated using data for delivery of a green fluorescent protein (GFP)-encoding plasmid by means of Lipofectamine, permitting specification of model parameter values. The model is then used to make a priori predictions on the effect of polymer length in polyplex vectors, with additional parameter values determined from previous independent experimental studies of plasmid release. Comparison with data on GFP expression via these polyplex vectors shows that the model successfully predicts an experimentally observed biphasic dependence of expression efficiency on polymer length and quantifies the contributions of competing effects yielding the optimal intermediate polymer length. Finally, we use the model to predict potential effects of incorporating nuclear localization sequences in these kinds of synthetic vectors, and find that the degree of benefit from these will depend on the values of other key system properties including the vector unpackaging rate constant. Thus, we demonstrate the usefulness of a bioengineering, integrative-systems modeling approach to improved vector design and analysis.

Copper and zinc binding modulates the aggregation and neurotoxic properties of the prion peptide PrP106-126.

The abnormal form of the prion protein (PrP) is believed to be responsible for the transmissible spongiform encephalopathies. A peptide encompassing residues 106-126 of human PrP (PrP106-126) is neurotoxic in vitro due its adoption of an amyloidogenic fibril structure. The Alzheimer's disease amyloid beta peptide (Abeta) also undergoes fibrillogenesis to become neurotoxic. Abeta aggregation and toxicity is highly sensitive to copper, zinc, or iron ions. We show that PrP106-126 aggregation, as assessed by turbidometry, is abolished in Chelex-100-treated buffer. ICP-MS analysis showed that the Chelex-100 treatment had reduced Cu(2+) and Zn(2+) levels approximately 3-fold. Restoring Cu(2+) and Zn(2+) to their original levels restored aggregation. Circular dichroism showed that the Chelex-100 treatment reduced the aggregated beta-sheet content of the peptide. Electron paramagnetic resonance spectroscopy identified a 2N1S1O coordination to the Cu(2+) atom, suggesting histidine 111 and methionine 109 or 112 are involved. Nuclear magnetic resonance confirmed Cu(2+) and Zn(2+) binding to His-111 and weaker binding to Met-112. An N-terminally acetylated PrP106-126 peptide did not bind Cu(2+), implicating the free amino group in metal binding. Mutagenesis of either His-111, Met-109, or Met-112 abolished PrP106-126 neurotoxicity and its ability to form fibrils. Therefore, Cu(2+) and/or Zn(2+) binding is critical for PrP106-126 aggregation and neurotoxicity.