Using B isotopes and B/Ca in corals from low saturation springs to constrain calcification mechanisms.

Ocean acidification is expected to negatively impact calcifying organisms, yet we lack understanding of their acclimation potential in the natural environment. Here we measured geochemical proxies (δ11B and B/Ca) in Porites astreoides corals that have been growing for their entire life under low aragonite saturation (Ωsw: 0.77-1.85). This allowed us to assess the ability of these corals to manipulate the chemical conditions at the site of calcification (Ωcf), and hence their potential to acclimate to changing Ωsw. We show that lifelong exposure to low Ωsw did not enable the corals to acclimate and reach similar Ωcf as corals grown under ambient conditions. The lower Ωcf at the site of calcification can explain a large proportion of the decreasing P. astreoides calcification rates at low Ωsw. The naturally elevated seawater dissolved inorganic carbon concentration at this study site shed light on how different carbonate chemistry parameters affect calcification conditions in corals.

"There is power in the blood": a case discussing ethical issues of utility of resources.

The allocation of medical resources is often a great concern in the United States. This article discusses a case concerning utility of resources in a patient with a terminal disease. We assert that the goals of treatment tailored to an individual patient should be made at the bedside by a fiduciary (physician) in conjunction with the patient's preferences and values. There is great responsibility in making these decisions and it is critical that they be made at the bedside with the patient and family clearly aware of the goals of treatments and informed of treatment limitations.

Hexosamine-induced fibronectin protein synthesis in mesangial cells is associated with increases in cAMP responsive element binding (CREB) phosphorylation and nuclear CREB: the involvement of protein kinases A and C.

Hyperglycemia-induced alterations in mesangial (MES) cell function and extracellular matrix protein accumulation are seen in diabetic glomerulopathy. Recent studies have demonstrated that some of the effects of high glucose (HG) on cellular metabolism are mediated by the hexosamine biosynthesis pathway (HBP), in which fructose-6-phosphate is converted to glucosamine 6-phosphate by the rate-liming enzyme glutamine:fructose-6-phosphate amidotransferase (GFA). In this study, we investigated the role of HBP on HG-stimulated fibronectin protein synthesis, a matrix component, in SV-40-transformed rat kidney MES cells. Treatment of MES cells with 25 mmol/l glucose (HG) for 48 h increases cellular fibronectin levels by two- to threefold on Western blots when compared with low glucose (5 mmol/l). Glucosamine (GlcN; 1.5 mmol/l), which enters the hexosamine pathway distal to GFA action, also increases fibronectin synthesis. Azaserine (AZA; 0.5 micromol/l), an inhibitor of GFA, blocks the HG- but not the GlcN-induced fibronectin synthesis. Fibronectin contains cAMP responsive element (CRE) consensus sequences in its promoter and the phosphorylation of CRE-binding protein (CREB) may regulate its expression. On Western blots, HG and GlcN stimulate two- to threefold the phosphorylation of CREB at Ser 133, whereas CREB protein content was unaltered by either HG or GlcN. In addition, nuclear CREB activity was increased by HG and GlcN on gel-shift assays using (32)P-CRE oligonucleotides. AZA impeded the HG-enhanced CREB phosphorylation and CRE binding but had no effect on GlcN-mediated CREB phosphorylation and CRE binding. Pharmacologic inhibition of protein kinase C (PKC) and protein kinase A (PKA), which are involved in hexosamine-mediated matrix production, blocked the CREB phosphorylation and fibronectin synthesis seen in HG and GlcN conditions. We conclude that the effects of HG on fibronectin synthesis in the mesangium are mediated by the HBP possibly via hexosamine regulation of CREB and PKC/PKA signaling pathways. These results support the hypothesis that the HBP is a sensor and regulator of the actions of glucose in the kidney.

The effect of enalapril on advanced diabetic nephropathy in African-American females.

This paper examines the effect of enalapril in African-American (AA) females with advanced type 2 diabetic nephropathy (DN)--the leading cause of end stage renal disease (ESRD) in this group. AA females followed in our university nephrology clinic with type 2 DN and a serum creatinine level (Cr) > or = 2.5 mg/dl were eligible. Historical controls who never received an ACE inhibitor were selected (matched for age and Cr) from a database of patients reaching ESRD between 1993 and 1998, with a primary diagnosis of DN. Patients enrolled (N = 6) were started on enalapril at 5 mg per day with the dose titrated upward to a blood pressure (BP) goal of 140/90 mm Hg. The enalapril group tended to be older than controls (58.8 vs 51.5 years of age, P = ns) and had had their diabetes longer (18.5 vs 13.2 years of age, P = ns). At baseline, there were no significant differences in blood pressure, blood, urea, nitrogen (BUN), Cr, or BMI between groups. One of the 6 treated with enalapril had the agent stopped due to hyperkalemia. Five of 6 in the enalapril group reached ESRD, but there was no significant difference between the groups in the time it took to reach this stage (69.5 +/- 13.8 weeks vs 92.0 +/- 21.4 weeks, enalapril group vs control group, P = ns). In the enalapril patient who did not reach ESRD, the Cr level increased from 2.9 to 3.8 mg/dl in approximately 3 years. From this small study, we conclude that, although enalapril is tolerated in AA females with advanced DN, the agent had no significant effect on renal survival.

Renal scars masquerading as complex masses in a patient with vesicoureteral reflux nephropathy.

Vesicoureteral reflux can lead to chronic pyelonephritis, renal scarring, and renal failure. We present a case of renal scarring masquerading as bilateral, complex renal masses. A 35-year old woman who was diagnosed with vesicoureteral reflux as a child presented for evaluation of recently developed hypertension and an abnormal renal ultrasound. Her serum creatinine level was 2.5 mg/dL and she had subnephrotic-range proteinuria. A renal sonogram showed small, echogenic kidneys and bilateral complex renal masses of 3.8 (right) and 4.4 (left) cm in greatest dimensions. CT scan of the kidneys revealed slightly contrast-enhancing masses with irregular walls. Renal angiogram showed decreased blood supply to the areas coinciding with the masses consistent with renal scarring. There was no increased vascularity. This case demonstrates that renal scarring may masquerade as renal masses. A step-wise, comprehensive approach is necessary to rule out potentially malignant lesions in these patients.

Diabetic nephropathy in African Americans.

Diabetic nephropathy (DN) is the number one cause of end-stage renal disease in United States and is highly prevalent in African Americans. We have found that among African Americans in Mississippi diabetic nephropathy appears to affect females more than males, which may be related to increased rates of obesity and diabetes in African American women. Glycemic control and control of blood pressure is essential to prolong renal survival and to protect against cardiovascular events. Angiotensin-converting enzyme inhibitors reduce cardiovascular mortality in diabetics and are tolerated in advanced renal disease. The impact of glycemic control, appropriate antihypertensives, and the optimal level of blood pressure control in African Americans with advanced DN require further study. This article reviews the impact, clinical characteristics, risk factors, and treatment of diabetic nephropathy in African Americans.

Endstage renal disease owing to diabetic nephropathy in Mississippi: an examination of factors influencing renal survival in a population prone to late referral.

BACKGROUND: Diabetic nephropathy (DN) is the leading cause of endstage renal disease (ESRD) in the United States. We reviewed our experience with DN as a cause of ESRD in a predominantly poor, African American (AA) population. METHODS: Charts of patients who entered the ESRD program through the University of Mississippi Medical Center with a primary diagnosis of DN from 1993 through 1998 were reviewed for factors that may affect renal survival. Time from initial clinic visit to entry into the ESRD program, or time to ESRD (TTE), was the primary end point. RESULTS: Five hundred sixty-two patients entered the ESRD program (85% AA), and 210 of them had DN as their primary ESRD diagnosis. DN accounted for 50.5% of ESRD cases among AA females, but for less than 20% among AA males. In contrast, hypertension was the ESRD diagnosis in 48% of AA males. Patients observed in our nephrology clinic were analyzed further (n=171). At presentation, patients had advanced disease (serum creatinine [Cr]=5.92 mg/dL), were hypertensive, obese, and not likely to be on an angiotensin-converting enzyme (ACE) inhibitor. Determinants of TTE in univariate analysis were race (AA did better), initial blood urea nitrogen and plasma serum Cr levels, starting an ACE inhibitor at the University of Mississippi Medical Center, and the level of mean arterial pressure (MAP) during the course of follow-up. On multivariate analysis only initial Cr and race remained significant The 142 AA diabetics (111 female) were analyzed separately. The only significant sex difference was body mass index (female, 33.6 vs male, 28.4 kg/m2; P=0.0069), but females tended to have relatively shorter TTE and higher blood pressure (BP). Univariate and multivariate analyses revealed the same factors as above as determinants of TTE; however, among AAs, presenting on a calcium channel blocker was negatively correlated with TTE in univariate analysis. Among the entire cohort and the AAs, patients who had MAP between 100 and 110 mm Hg during the course of follow-up did better in terms of renal survival than those who fell outside of that range. CONCLUSIONS: We conclude that AA females in Mississippi are significantly more predisposed to DN as a cause of ESRD than are AA males. Patients with DN in our population had poor BP control, presented to nephrologists with advanced disease, and often were not on an ACE inhibitor. The optimal level of BP control and which BP agents are best for this population need to be determined.

Glucose-induced insulin resistance of phosphatidylinositol 3'-OH kinase and AKT/PKB is mediated by the hexosamine biosynthesis pathway.

Hyperglycemia is responsible for many of the vascular complications and metabolic derangements seen in diabetes. One potential regulator of the effects of glucose is the hexosamine biosynthesis pathway (HBP). Glutamine: fructose-6-phosphate amidotransferase (GFA), the first and rate-limiting enzyme in this pathway, catalyzes the transfer of an amino group from glutamine to fructose-6-phosphate to form glucosamine-6-phosphate. Overexpression of GFA in rat-1 fibroblasts results in insulin resistance for glycogen synthase (GS) activity, and renders these cells more sensitive to the effects of glucose. Using rat-1 cells, we examine further the mechanisms whereby hexosamines lead to insulin resistance. Insulin stimulated GS activity was found to occur via a PI-3 kinase (PI-3K)-dependent pathway as wortmannin, an inhibitor of PI-3K, blocked insulin's ability to stimulate GS activity. Subsequently, we examined the effects of hexosamines on PI-3K and Akt/PKB activity. Cells were cultured in 1 mM glucose (low glucose, LG), 20 mM glucose (high glucose, HG), or 1 mM glucose plus 3 mM glucosamine (GlcN) for 16--20 h. After treatment with insulin (100 nM) for 5 min, cell extracts were assayed for IRS-1 associated and total PI-3K activity. At LG, insulin increased PI-3K activity by 43%. There was no insulin stimulation of PI-3K activity in cells cultured in HG or GlcN. There was a trend for IRS-1 protein levels to decrease in HG but not GlcN. PI-3K protein levels were not altered by HG or GlcN. Finally PKB activity was assayed. At LG, insulin stimulated PKB activity. Again, both HG and GlcN significantly reduced insulin's ability to stimulate PKB activity. We conclude that the hexosamine-mediated insulin resistance of GS activity seen in rat-1 cells is mediated by hexosamine regulation of PI-3K and PKB.

Overexpression of glutamine: fructose-6-phosphate amidotransferase in the liver of transgenic mice results in enhanced glycogen storage, hyperlipidemia, obesity, and impaired glucose tolerance.

To examine the effect of increased hexosamine flux in liver, the rate-limiting enzyme in hexosamine biosynthesis (glutamine:fructose-6-phosphate amidotransferase [GFA]) was overexpressed in transgenic mice using the PEPCK promoter. Liver from random-fed transgenic mice had 1.6-fold higher GFA activity compared with nontransgenic control littermates (276 +/- 24 pmol x mg(-1) x min(-1) in transgenic mice vs. 176 +/- 18 pmol x mg(-1) x min(-1) in controls, P < 0.05) and higher levels of the hexosamine end product UDP-N-acetyl glucosamine (288 +/- 11 pmol/g in transgenic mice vs. 233 +/- 10 pmol/g in controls, P < 0.001). Younger transgenic mice compared with control mice had lower fasting serum glucose (4.8 +/- 0.5 mmol/l in transgenic mice vs. 6.5 +/- 0.8 mmol/l in controls, P < 0.05) without higher insulin levels (48.0 +/- 7.8 pmol/l in transgenic mice vs. 56.4 +/- 5.4 pmol/l in controls, P = NS); insulin levels were significantly lower in transgenic males (P < 0.05). At 6 months of age, transgenic animals had normal insulin sensitivity by the hyperinsulinemic clamp technique. Hepatic glycogen content was higher in the transgenic mice (108.6 +/- 5.2 pmol/g in transgenic mice vs. 32.8 +/- 1.3 micromol/g in controls, P < 0.01), associated with an inappropriate activation of glycogen synthase. Serum levels of free fatty acids (FFAs) and triglycerides were also elevated (FFAs, 0.67 +/- 0.03 mmol/l in transgenic mice vs. 0.14 +/- 0.01 in controls; triglycerides, 1.34 +/- 0.15 mmol/l in transgenic mice vs. 0.38 +/- 0.01 in controls, P < 0.01). Older transgenic mice became heavier than control mice and exhibited relative glucose intolerance and insulin resistance. The glucose disposal rate at 8 months of age was 154 +/- 5 mg x kg(-1) x min(-1) in transgenic mice vs. 191 +/- 6 mg x kg(-1) x min(-1) in controls (P < 0.05). We conclude that hexosamines are mediators of glucose sensing for the regulation of hepatic glycogen and lipid metabolism. Increased hexosamine flux in the liver signals a shift toward fuel storage, resulting ultimately in obesity and insulin resistance.

Regulation of glutamine:fructose-6-phosphate amidotransferase activity by high glucose and transforming growth factor beta in rat mesangial cells.

BACKGROUND: The hexosamine biosynthesis pathway acts as a cellular glucose sensor and mediates many of the adverse effects of glucose. Increased flux through this pathway results in insulin resistance in rat fibroblasts and transgenic mice and upregulation of transforming growth factor beta (TGF-beta) transcriptional activity in rat kidney cells. The first and rate-limiting step in this pathway, which is responsible for the metabolism of glucose to glucosamine, is catalyzed by glutamine:fructose-6-phosphate amidotransferase (GFA). METHODS: Because of the known effects of hyperglycemia on mesangial cell (MC) function and growth factor regulation, we examined the regulation of GFA by glucose and TGF-beta in cultured SV40 rat MCs. GFA activity was assayed in cytosolic extracts of MCs using high-performance liquid chromatography. RESULTS: Culturing in 10 and 25 mM of glucose for 24 hours resulted in 33.4% (P < 0.025) and 43.5% (P < 0.05) decreases in GFA activity when compared with cells cultured at 1 to 5 mM of glucose. The downregulation in GFA activity by high glucose (HG) required at least 6 hours in culture and persisted for several days. HG effects were not a result of osmolar changes or glucose-induced differences in glucose uptake. Like HG, treatment of MCs with TGF-beta (2 ng/mL) for 4 hours resulted in a 30% (P < 0.05) decrease in GFA activity in cells cultured at 1 mM glucose, but the effects of TGF-beta were not additive to those of HG. TGF-beta-mediated downregulation of GFA activity was inhibited by a TGF-beta-neutralizing antibody, but HG's effects were not. Insulin-like growth factor-1 (IGF-1) had similar effects as TGF-beta, but GFA activity was not regulated by angiotensin II. CONCLUSIONS: GFA activity is downregulated by HG, TGF-beta, and IGF-1 in rat MCs. Downregulation of this cellular glucose sensor may be a protective mechanism against the harmful effects of excess glucose as seen in diabetes.

Hexosamine regulation of glucose-mediated laminin synthesis in mesangial cells involves protein kinases A and C.

Hyperglycemia leads to alterations in mesangial cell function and extracellular matrix (ECM) protein accumulation. These adverse effects of glucose may be mediated by glucose metabolism through the hexosamine biosynthesis pathway (HBP). The HBP converts fructose-6-phosphate to glucosamine-6-phosphate via the rate-limiting enzyme, glutamine:fructose-6-phosphate amidotransferase (GFA). We have investigated the effects of high glucose (HG, 25 mM) and glucosamine (GlcN, 1.5 mM) on the synthesis of the ECM protein laminin in a SV-40-transformed rat kidney mesangial (MES) cell line. The roles of protein kinases C (PKC) and A (PKA) in mediating laminin accumulation were also investigated. Treatment of MES cells with HG or GlcN for 48 h increased laminin levels in cellular extracts more than twofold compared with 5 mM glucose (low glucose; LG). The presence of the GFA inhibitor diazo-oxo-norleucine (DON, 10 microM) blocked HG but not GlcN-induced laminin synthesis. HG resulted in a time-dependent increase in total PKC and PKA activities, 57+/-11.3 (P < 0.01 vs. LG) and 85+/-17.4% (P < 0.01 vs. LG), respectively. GlcN had no effect on the total PKC activity; however, both glucose and glucosamine increased membrane-associated PKC activity by twofold compared with LG. GlcN stimulated total PKA activity by 47+/-8.4% (P < 0.01 vs. LG). Similarly, membrane- associated PKA activity was also increased by HG and GlcN approximately 1.8 and 1.5-fold, respectively. HG and GlcN increased cellular cAMP levels 2.2- and 3. 4-fold, respectively. Pharmacological downregulation of PKC by long-term incubation of MES cells with 0.5 microM phorbol 12-myristate 13-acetate (PMA) or inhibition of PKA activity by 2 microM H-8 blocked the effects of HG and GlcN on laminin synthesis. These results demonstrate that glucose-induced laminin synthesis in MES cells is mediated by flux through the HBP and that this stimulation involves PKC and PKA signaling pathways.

The effects of glucose and the hexosamine biosynthesis pathway on glycogen synthase kinase-3 and other protein kinases that regulate glycogen synthase activity.

BACKGROUND: Glycogen synthase (GS) activity is determined by its phosphorylation state. We have previously demonstrated that high glucose (HG) downregulates both basal and insulin-stimulated GS activity in rat-1 fibroblasts and that the hexosamine biosynthesis pathway (HBP) may be involved in mediating some of the effects of glucose. In this study we investigate the influence of high glucose and glucosamine (GlcN) on the activity of several kinases that phosphorylate and inactivate GS. METHODS: Glycogen synthase kinase (GSK) 3, cAMP-dependent protein kinase (PKA), protein kinase C (PKC), casein kinase (CK) 1, and phosphorylase kinase (PhK) activities were assayed in cellular extracts from control rat-1 fibroblasts and those that overexpress human cDNA for glutamine:fructose 6-phosphate amidotransferase (GFA), the rate-limiting enzyme in the HBP. RESULTS: Culturing rat-1 fibroblasts in HG (20 mmol/L) or GlcN (3-5 mmol/L) for 16-20 hours increases GSK-3 activity by 23.9 and 50%, respectively, when compared to activity at low glucose (LG, 1 mmol/L). The effects of HG on GSK-3 activity are greater in cells overexpressing GFA (38.8% increase). Insulin (1.7 nmol/L) treatment leads to a 20-25% decrease in GSK-3 activity that is not affected by HG, GlcN, or GFA overexpression. Culturing control cells in HG increases PKA and CK-1 activities by 56 and 95%, respectively, and HG diminishes insulin action on CK-1 activity. GlcN inhibits insulin action on both PKA and CK-1 activities. HG, GlcN, and GFA overexpression blunted insulin's ability to downregulate PhK activity in LG conditions. PKC activity is not significantly altered in either cell line in the above conditions. CONCLUSIONS: These results suggest that HG alters both basal and insulin-regulated activity of several kinases that phosphorylate GS, and some of the effects of glucose may be mediated by its metabolism via the HBP.

Overexpression of glutamine:fructose-6-phosphate amidotransferase in rat-1 fibroblasts enhances glucose-mediated glycogen accumulation via suppression of glycogen phosphorylase activity.

The hexosamine biosynthesis pathway (HBP) mediates many of the adverse effects of excess glucose. We have shown previously that glucose down-regulates basal and insulin-stimulated glycogen synthase (GS) activity. Overexpression of the rate-limiting enzyme in the HBP, glutamine:fructose-6-phosphate amidotransferase (GFA), mimics these effects of high glucose and renders the cells more sensitive to glucose. Here we examine the role of the HBP in regulating cellular glycogen content. Glycogen content and glycogen phosphorylase (GP) activity were determined in Rat-1 fibroblasts that overexpress GFA. In both GFA and controls there was a dose-dependent increase in glycogen content (approximately 8-fold) in cells cultured in increasing glucose concentrations (1-20 mM). There was a shift to the left in the glucose dose-response curve for glycogen content in GFA cells (ED50 for glycogen content = 5.80+/-1.05 vs. 8.84+/-0.87 mM glucose, GFA vs. control). Inhibition of GFA reduced glycogen content by 28.4% in controls cultured in 20 mM glucose. In a dose-dependent manner, glucose resulted in a more than 35% decrease in GP activity in controls. GP activity in GFA cells was suppressed compared with that in controls, and there was no glucose-induced down-regulation of GP activity. Glucosamine and uridine mimicked the effects of glucose on glycogen content and GP activity. However, chronic overexpression of GFA is a unique model of hexosamine excess, as culturing control cells in low dose glucosamine (0.1-0.25 mM) did not suppress GP activity and did not eliminate the glucose-mediated down-regulation of GP activity. We conclude that increased flux through the HBP results in enhanced glycogen accumulation due to suppression of GP activity. These results demonstrate that the HBP is an important regulator of cellular glucose metabolism and supports its role as a cellular glucose/satiety sensor.

Focal segmental glomerulosclerosis in African Americans: effects of steroids and angiotensin converting enzyme inhibitors.

BACKGROUND: Focal segmental glomerulosclerosis (FSGS) is a common primary glomerulopathy in African Americans. In this report, we present data on 40 African American patients with FSGS from our medical center. METHODS: Patients were identified from a review of all charts seen in our conservative management renal clinic in 1996, a review of renal biopsy rolls (1994-1998), and a review of patients entering the end-stage renal disease (ESRD) program with a primary diagnosis of FSGS (1993- 1997). Charts were reviewed for demographic, biopsy, and treatment data. Patients who were observed for at least 4 months (range, 4-125 months) were included. ESRD was used as the primary endpoint (n = 12). Data were analyzed using univariate and multivariate Cox hazards and Kaplan-Meier survival analysis. Twenty-four patients were treated with angiotensin-converting enzyme (ACE) inhibitors. Similarly, 24 patients were treated with corticosteroids for a mean of 8.75 +/- 2.6 months and a total dose of 9.3 +/- 2.2 g. RESULTS: On univariate analysis, factors found to be significant determinants for reaching ESRD were the initial creatinine (P = 0.0001), interstitial fibrosis (P = 0.032), the percentage of globally sclerosed glomeruli (P = 0.0018), and the mean arterial blood pressure over the course of follow-up (P = 0.05). Neither the ACE inhibitors nor the corticosteroids had a significant impact on reaching ESRD. The patients reaching ESRD (n = 12) were analyzed separately. The mean time from biopsy to ESRD was 24.7 +/- 9.8 months. ACE inhibitors prolonged renal survival (P = 0.023), but steroids did not. Initial creatinine was the only factor found to be a significant determinant for ESRD. CONCLUSIONS: We conclude that FSGS is common in African Americans. Early diagnosis and blood pressure control are important, but the beneficial effects of steroids and ACE inhibitors in this population are still unclear.

Transcriptional regulation of transforming growth factor beta1 by glucose: investigation into the role of the hexosamine biosynthesis pathway.

BACKGROUND: The hexosamine biosynthesis pathway (HBP) is hypothesized to mediate many of the adverse effects of hyperglycemia. We have shown previously that increased flux through this pathway leads to induction of the growth factor transforming growth factor-alpha (TGF-alpha) and to insulin resistance in cultured cells and transgenic mice. TGF-beta is regulated by glucose and is involved in the development of diabetic nephropathy. We therefore hypothesized that the HBP was involved in the regulation of TGF-beta by glucose in rat vascular and kidney cells. METHODS: A plasmid containing the promoter region of TGF-beta1 cloned upstream of the firefly luciferase gene was electroporated into rat aortic smooth muscle, mesangial, and proximal tubule cells. Luciferase activity was measured in cellular extracts from cells cultured in varying concentrations of glucose and glucosamine. RESULTS: Glucose treatment of all cultured cells led to a time- and dose-dependent stimulation in TGF-beta1 transcriptional activity, with high (20 mM) glucose causing a 1.4- to 2.0-fold increase. Glucose stimulation did not occur until after 12 hours and disappeared after 72 hours of treatment. Glucosamine was more potent than glucose, with 3 mM stimulating up to a 4-fold increase in TGFbeta1-transcriptional activity. The stimulatory effect of glucosamine was also dose-dependent but was slower to develop and longer lasting than that of glucose. CONCLUSIONS: The metabolism of glucose through the HBP mediates extracellular matrix production, possibly via the stimulation of TGF-beta in kidney cells. Hexosamine metabolism therefore, may play a role in the development of diabetic nephropathy.

Dignity or denial? Decisions regarding initiation of dialysis and medical therapy in the institutionalized severely mentally retarded.

Decisions regarding health care of the severely mentally retarded can be difficult. We present 2 cases of patients with severe mental retardation who lived in long-term care facilities. Both patients had progressive loss of renal function and eventually reached end-stage renal disease. In each case, the decision was made not to initiate dialysis. We discuss issues of dialysis and medical care of the severely mentally retarded and advocate using the principles of "best respect" and "best interest" in making medical decisions in this population.

Insulin stimulation of glutamine: fructose-6-phosphate amidotransferase occurs via an insulin-like growth factor-1 pathway in rat fibroblasts.

The biosynthetic pathway for hexosamine mediates some of the adverse effects of high glucose. The rate limiting enzyme in this pathway is glutamine:fructose-6-phosphate amidotransferase (GFA). Using HPLC, the regulation of GFA activity by glucose and insulin was studied in wild type and rat-1 fibroblasts overexpressing human insulin receptors (HIRcB cells). In wild type cells only maximal doses of insulin (580 ng/ml) resulted in an increase in GFA activity (51.0 +/- 40.6%). In HIRcB cells insulin led to a dose dependent increase in GFA activity that was enhanced when compared to wild type (89 +/- 5% (p<0.001) increase at 580 ng/ml). Insulin's action was glucose dependent and required prolonged serum deprivation. HIRcB's cultured in 0 mM glucose had a 58.2% (p<0.001) decrease in insulin stimulation. However, when present the concentration of glucose (2-20 mM) did not affect insulin stimulation of GFA activity. Most of insulin's effects occur by way of the IGF-1 receptor as a two-fold stimulation of GFA activity was seen with significantly lower doses (10 ng/ml) of IGF-1. We conclude that GFA enzyme activity is upregulated by insulin and this may occur via a IGF-1 receptor mediated pathway.

Rapid respiratory deterioration and sudden death due to disseminated cryptococcosis in a patient with the acquired immunodeficiency syndrome.

We report the case of a patient with the acquired immunodeficiency syndrome (AIDS) whose death occurred within 30 hours of hospitalization due to disseminated cryptococcosis, manifested by dizziness, cough, and shortness of breath. The clinical picture was consistent with pneumocystis pneumonia, and antibiotic therapy with corticosteroids was initiated. Despite initial improvement, the patient's condition quickly worsened, resulting in cardiorespiratory arrest and death. Autopsy revealed cryptococci in several organs. Sudden, rapid deterioration and death are rare consequences of disseminated cryptococcosis, and steroids may worsen the course of the disease. On the basis of this case and review of similar cases in the literature, we recommend early consideration of disseminated cryptococcosis in AIDS patients with pneumonia. Early diagnosis and appropriate therapy are essential to reduce morbidity and mortality.

The role of hypertension, obesity, and diabetes in causing renal vascular disease.

The Jackson Heart Study will be an epidemiological study of African Americans in Jackson, Mississippi, to identify risk factors for development and progression of cardiovascular disease. One of the potential risk factors to be assessed in this study is renal vascular disease. Atherosclerotic renal vascular disease is a disease of the elderly, is predominantly seen in white people, and is strongly associated with diffuse atherosclerotic disease and high-grade hypertensive retinopathy. Patients with ischemic nephropathy may constitute up to 16% of new dialysis patients and die more quickly while on renal replacement therapy. Although often not present, hypertension is a commonly observed consequence (but probably not a cause) of renal vascular disease, and the control of blood pressure may not halt the progression of the disease. Approximately 20-25% of patients with moderate to severe renal artery stenosis will be diabetic. Diabetic patients fair less well with intervention and have a higher progression to end-stage renal disease or death. Obesity is not commonly seen in patients with renal vascular disease. The Jackson Heart Study may be able to assess the true incidence of atherosclerotic renal vascular disease in African Americans and its impact of cardiovascular morbidity and mortality.