[Regional epidemiology of chronic nephropathies: referral to nephrologist and initiation of dialysis]. / Epidemiologia regionale/locale delle nefropatie croniche: profili di "referral" ambulatoriale e inizio dialisi.

BACKGROUND: The epidemiology of pre-dialysis chronic nephropathies (CN) in well-defined contexts is essential to prevent delays in delivering appropriate care. METHODS: The registration of consecutive patients in seven out-patient and four in-patient dialysis centers of Basilicata (2001) formed a retrospective study on clinical charts and dialysis registers integrated with ad hoc data. RESULTS: Newly observed outpatients (I) numbered 328; prevalent patients (P) numbered 343. The age and gender of both I and P patients was similar (males: 60%, age media: 67 yr). In 316 I patients with creatinine (mean Cr: 2.3 mg/dL), the mean filtration rate (GFR) was 40.9 mL/min/1.73 m2: 13.6% were in advanced stage (S5) of GFR (<15 mL/min), 23.4% in S4/severe (15-29), 45.6% in S3/moderate (30-59), 10.8% in S2/mild (60-89), and 6.6% in S1 (>90). When compared to I patients, P patients had a mean GFR of 35.0 mL/min; S4+S5 was 48% (vs. 37%); hypertension 68% (vs. 58%); vasculopathies 15% (vs. 10%); coronary disease 10% (vs. 4%); erythropoietin 13% (vs. 7%); and low-protein diet 34% (vs. 20%) (p<0.01). Of 316 I patients, 117 in S5+S4 ('late referral' 37%) had a (mean) GFR of 18.4 mL/min, Cr 3.7 mg/dL, and were aged 70 yrs (vs. 64 yrs for 'early referral'). Of 53 new patients on dialysis, 26 (49%) were seen for the first time <6 months prior to starting (mean age: 71 yr vs. 62; female 58% vs. 26%; complications 50% vs. 17%). CONCLUSIONS: In this population, age-related factors are associated with late referral. Although sociodemographic variables depend on local contexts, these results are consistent with similar international studies. Social and cultural factors may influence physicians to postpone referring patients to a nephrologist, independently of clinical conditions.

Lack of glutathione conjugation to adriamycin in human breast cancer MCF-7/DOX cells. Inhibition of glutathione S-transferase p1-1 by glutathione conjugates from anthracyclines.

One of the proposed mechanisms for multidrug resistance relies on the ability of resistant tumor cells to efficiently promote glutathione S-transferase (GST)-catalyzed GSH conjugation of the antitumor drug. This type of conjugation, observed in several families of drugs, has never been documented satisfactorily for anthracyclines. Adriamycin-resistant human breast cancer MCF-7/DOX cells, presenting a comparable GSH concentration, but a 14-fold increase of the GST P1-1 activity relative to the sensitive MCF-7 cells, have been treated with adriamycin in the presence of verapamil, an inhibitor of the 170 P-glycoprotein (P-gp) drug transport protein, and scrutinized for any production of GSH-adriamycin conjugates. HPLC analysis of cell content and culture broths have shown unequivocally that no GSH conjugates are present either inside the cell or in the culture broth. The only anthracycline present inside the cells after 24 hr of incubation was > 98% pure adriamycin. Confocal laser scanning microscopic observation showed that in MCF-7/DOX cells adriamycin was localized mostly in the Golgi apparatus rather than in the nucleus, the preferred site of accumulation for sensitive MCF-7 cells. These findings rule out GSH conjugation or any other significant biochemical transformation as the basis for resistance to adriamycin and as a ground for the anomalous localization of the drug in the cell. Adriamycin, daunomycin, and menogaril did not undergo meaningful conjugation to GSH in the presence of GST P1-1 at pH 7.2. Indeed, their synthetic C(7)-aglycon-GSH conjugates exerted a strong inhibitory effect on GST P1-1, with K(i) at 25 degrees in the 1-2 microM range, scarcely dependent on their stereochemistry at C(7).

Induction of apoptosis in neoplastic cells by anthracycline antitumor drugs: nuclear and cytoplasmic triggering?

In spite of extensive investigation, the mechanism for cell cytotoxicity of the anthracycline antitumor drug adriamycin (ADR) has not yet been completely understood but the nature of the cytotoxic effects of this drug is generally related to its interaction with nuclear components, such as DNA and topoisomerase II. In a previous paper, we studied, using Confocal Laser Scanning Microscopy (CLSM), the localization of ADR and its glutathione (GSH)-conjugate (ADRIGLU), obtained by the anaerobic reaction of the parent anthracycline with reduced GSH, in drug-sensitive and in multidrug resistant (MDR) cells. In all drug-sensitive lines used, ADR was mostly located in the nuclei, while its GSH-conjugate was found only in the cytoplasm, predominantly in the Golgi region. In this study we examined the morphological changes induced by ADR or its GSH-conjugated adduct (ADRIGLU) treatments in TVM-A12 (clone 2) melanoma and K562 erythroleukemia human cell lines, correlated to programmed cell death (apoptosis). We observed that ADR-induced apoptosis in both cell lines tested after 5 h treatment: CLSM and Scanning Electron Microscopy (SEM) showed cell shrinkage, fragmentation and condensation of nuclear chromatin, cell surface blebbing and cytoplasmic vacuolization. On the contrary, ADRIGLU-induced fragmentation and condensation of nuclear chromatin, typical of apoptosis, only after 48-72 h treatment. Cytoflourimetric assay by propidium iodide staining confirmed the data obtained by CLSM and SEM. Our data suggest that apoptosis activation by anthracycline antitumor drugs is induced not only by direct interaction with nuclear components but also with cytoplasmic compartments.

Cytoplasmic localization of anthracycline antitumor drugs conjugated with reduced glutathione: a possible correlation with multidrug resistance mechanisms.

The accumulation of adriamycin (ADR), daunomycin (DAUNO) and their glutathione (GSH)-conjugates, recently obtained by anaerobic reaction of the parent anthracyclines with reduced GSH, was examined in drug-sensitive and multidrug resistant (MDR) cell lines using confocal laser scanning microscopy. In all drug-sensitive lines used (TVM-A12 and TVM-A197 human melanoma cells, K562 lymphoblastoid cells and MCF-7 human breast cancer cells) ADR and DAUNO were mostly located in the nuclei, while their GSH-conjugates were found only in the cytoplasm, predominantly in the Golgi region. On the contrary, in MDR MCF-7/Dox cells, both conjugated and non conjugated anthracyclines gave fluorescence only in the cytoplasm, mostly in the Golgi region, the intensity of the fluorescence being stronger in cells pretreated with verapamil. Viability assay showed that the GSH-conjugate are significantly less cytotoxic than the parent anthracyclines in sensitive cells and showed the same scarce cytotoxicity in MDR MCF-7/Dox cells. These results demonstrate that conjugation of anthracycline antitumor drugs with GSH prevents their access to the nucleus and decreases their cytotoxicity. Furthermore, the observations on MCF-7/Dox suggest that GSH-conjugation of anthracycline might occur in resistant cells and can be in part responsible for the MDR in breast cancer cells.

A redox pathway leading to the alkylation of nucleic acids by doxorubicin and related anthracyclines: application to the design of antitumor drugs for resistant cancer.

Doxorubicin has been a constituent of antitumor drug protocols for a broad spectrum of cancers for more than two decades. Side effects and resistance continue to be important limitations. Drug targets responsible for both side effects and anti-tumor activity are cell membrane receptors, cell membrane lipids, nucleic acids and topoisomerase. Induction of oxidative stress is responsible for most if not all biological activity. An important consequence of oxidative stress is the production of formaldehyde which can subsequently be utilized by the drug for covalent bonding to nucleic acids and other targets as shown by in vitro experiments. Multidrug resistance mechanisms inhibit drug-induced DNA damage, drug uptake, and drug-induced oxidative stress. Synthetic anthracyclines conjugated to formaldehyde circumvent some if not all of the resistance mechanisms. Consequently, anthracycline-formaldehyde conjugates have potential for the treatment of resistant cancer.

Production of formaldehyde and DNA-adriamycin or DNA-daunomycin adducts, initiated through redox chemistry of dithiothreitol/iron, xanthine oxidase/NADH/iron, or glutathione/iron.

The reaction of the antitumor drugs adriamycin and daunomycin with the self-complementary DNA oligonucleotide (GC)4 to generate DNA-drug adducts was investigated as a function of redox reaction conditions. The redox systems dithiothreitol (DTT)/Fe(III) and xanthine oxidase/ NADH both gave the same distribution of four DNA-anthracycline adducts. In each of these adducts the anthracycline is bonded via a methylene linkage between the 3'-amino group of the drug and the 2-amino group of a deoxyguanosine of the DNA. The methylene linkage results from reaction of the drug and DNA with in situ-generated formaldehyde via Schiff base chemistry [Taatjes, D.J., Gaudiano, G., Resing, K., and Koch, T.H. (1997) J. Med. Chem. 40, 1276-1286]. Formaldehyde production is promoted by iron, inhibited by metal-chelating agents, and does not require drug. Iron enhances formaldehyde production by a factor of 30, EDTA inhibits its formation by a factor of 2, and Desferal inhibits its formation by a factor of more than 20. Hydrogen peroxide accumulates in significant quantities only with xanthine oxidase/NADH in the presence of Desferal. The results are explained in terms of Fenton oxidation of Tris buffer to formaldehyde. Biological reagents also cause DNA-drug adduct formation; reduction of ferric ion with glutathione in phosphate buffer in the presence of spermine produced the same DNA-drug adducts. The observations are discussed in terms of cytotoxicity resulting from iron chelated to adriamycin catalyzing in vivo production of formaldehyde which links adriamycin to DNA and tumor cell resistance resulting from factors which decrease formaldehyde.

Redox pathway leading to the alkylation of DNA by the anthracycline, antitumor drugs adriamycin and daunomycin.

Reaction of the anthracycline, antitumor drugs adriamycin and daunomycin with the self-complementary DNA oligonucleotide GCGCGCGC, (GC)4, in the presence of the reducing agent dithiothreitol, the oxidizing agent hydrogen peroxide, or the alkylating agent formaldehyde gives a similar mixture of DNA-drug adducts. Negative ion electrospray mass spectra indicate that adduct formation involves coupling of the DNA to the anthracycline via a methylene group and that the major adduct is duplex DNA containing two molecules of anthracycline, each bound to a separate strand of the DNA via a methylene group. The source of the methylene group is formaldehyde. A molecular structure with each anthracycline intercalated at a 5'-CpG-3' site and covalently bound from its 3'-amino group to a 2-amino group of a 2'-deoxyguanosine nucleotide is proposed based upon spectral data and a relevant crystal structure. The reaction of (GC)4 with the anthracyclines and formaldehyde forms an equilibrium mixture with DNA-drug adducts which is shifted toward free DNA by dilution. The results suggest a pathway to the inhibition of transcription by reductively activated adriamycin and daunomycin. Reductive activation in the presence of oxygen yields hydrogen peroxide; hydrogen peroxide oxidizes constituents in the reaction mixture to formaldehyde; and formaldehyde couples the drug to DNA. In this regard, hydrogen peroxide reacts with adriamycin via Baeyer-Villiger reactions at the 13-position to yield 2, 3, and formaldehyde. Formaldehyde also results from hydrogen peroxide oxidation of Tris [tris(hydroxymethyl)aminomethane] present in transcription buffer and spermine, a polyamine commonly associated with DNA in vivo, presumably via the Fenton reaction.

Factors affecting nPCR in hemodialysed patients.

The determination of dialysis adequacy is difficult and definitions are in a state of flux (Lindsay). In fact, after fifteen years from the introduction of urea kinetics into clinical practice, nephrologists still do not agree on recognizing the real utility of it. Gotch and Sargent in their mechanistic analysis of the NCDS indicated that the dose of small molecules removal could be defined by Kt/V urea. The results of the NCDS were depicted in a three-variable plot in which six domains could be seen. Several reports have documented malnutrition as being frequently present in patients on maintenance hemodialysis. It is generally accepted that a suboptimal nutritional status is associated with an increased morbidity and may adversely affect rehabilitation and the quality of life. In 1989 Lindsay et al showed that low levels of Kt/V corresponded with low levels of nPCR and found a direct correlation between the two parameters. On this basis, they suggested the hypothesis of nPCR dependence on Kt/V. The Authors showed a good correlation (r = 0.73) between nPCR and Kt/V in 55 patients. This work aims to evaluate the correlation between Kt/V and nPCR, real age and dialytic age in a dialytic population in Southern Italy, during a long period of observation (six years, follow up 2,692 months). One hundred and thirty-four patients were studied in six years of observation. Follow up: 2,692 months. Twenty-six patients died during the observation period. The simple regression analysis of nPCR vs. Kt/V, real age and dialytic age was performed in 63 anuric patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Redox chemistry of anthracycline antitumor drugs and use of captodative radicals as tools for its elucidation and control.

The oxomorpholinyl radicals are unique materials in organic and medicinal chemistry. Their closest parallel lies in inorganic chemistry with dithionite, which exists in equilibrium with sulfur dioxide radical anion, also a one-electron reducing agent. However, dithionite is a more powerful reducing agent and is probably more toxic. The rate of release of the oxomorpholinyl radical from its dimer is medium and is structure dependent, which provides for some level of control. The oxomorpholinyl radicals TM-3 and DHM-3 are selective one-electron reducing agents for the anthracyclines, generating sequentially semiquinone and hydroquinone redox states. Formation of the reduced states of the anthracyclines is probably relevant to their cytotoxic activity. Semiquinones and hydroquinones react rapidly with molecular oxygen to yield superoxide. Hydroquinone redox states with anaerobic conditions in protic media at pH 7-8 undergo glycosidic cleavage to form quinone methides; in aprotic media or at pH less than 4, they tautomerize to leuco forms. Quinone methides react with protons from solvent to form 7-deoxyaglycons, with some nucleophiles to form adducts, and with molecular oxygen to form semiquinone methide. The reactivity of the quinone methide is a function of substitution; nucleophilic addition is facilitated by the absence of a hydroxyl group at the 11-position and by proper location of the nucleophile. Quinone methides and semiquinone methides are both viable transients for covalently linking anthracycline aglycons to biological macromolecules. DHM-3 dimer is of possible pharmaceutical value for the detoxification of quinone antitumor drugs and for the improvement of chemotherapy through modulating the redox chemistry of the quinone antitumor drugs.

Experimental chemotherapy-induced skin necrosis in swine. Mechanistic studies of anthracycline antibiotic toxicity and protection with a radical dimer compound.

The reactivity of antitumor anthracycline and mitomycin C antibiotics with the oxomorpholinyl radical dimers, bi(3,5,5-trimethyl-2-oxomorpholin-3-yl) (TM3) and bi(3,5-dimethyl-5-hydroxymethyl-2-oxomorpholin-3-yl) (DHM3), was studied in vitro. The oxomorpholinyl radical reduced daunorubicin to a quinone methide intermediate that reacted with solvent to form 7-deoxydaunorubicinone. The solvolysis reaction followed first order kinetics, and the reactivity rate constants (k2) measured for seven anthracycline analogues ranged from 2 X 10(-2) s-1 to 8.0 X 10(-4) s-1. The chemical reactivity of each anthracycline quinone methide correlated with the total skin toxicity caused by the respective parent anthracycline following injection into swine skin. Microscopic examination of experimental lesions in swine skin resemble those observed in humans after inadvertant chemotherapy extravasation. Hydrocortisone sodium succinate was not effective for the treatment of doxorubicin-induced skin necrosis, whereas DHM3 was effective for the treatment of skin necrosis caused by all seven anthracyclines and by the quinone containing antibiotic, mitomycin C.

Doxorubicin-induced skin necrosis in the swine model: protection with a novel radical dimer.

The treatment of doxorubicin (DOX) extravasation tissue injury is poorly defined. A swine model has been developed to study DOX skin toxicity and potential pharmacologic antidotes. Intradermal injections of DOX in miniature female weanling swine produced predictable and dose-dependent ulcerations that closely resemble lesions observed in humans following extravasation of DOX. The ulcers reached maximal size at 3 weeks following DOX administration and were completely healed by 7 weeks. Bi(3,5-dimethyl-5-hydroxymethyl-2-oxomorpholin-3-yl) (DHM3) is a radical dimer that can react with DOX in vitro to produce deoxydoxorubicin aglycone, an inactive anthracycline metabolite. When DHM3 was administered into the same intradermal injection site 15 minutes after DOX, the maximum ulcer size was reduced 80%, and the healing time was reduced to 5 weeks. The protection from toxicity was highly dependent on the time interval between DOX and DHM3 injections, with no protection noted after a 60-minute interval. Our data verify the swine model as a useful tool to study DOX-induced extravasation injury. Furthermore, DHM3 is an effective antidote for DOX-induced skin necrosis and has potential for clinical use.

Radical dimer rescue of toxicity and improved therapeutic index of adriamycin in tumor-bearing mice.

The product of adriamycin (ADR) reductive glycosidic cleavage is the pharmacologically inactive 7-deoxyadriamycin aglycone. Bi(3,5-dimethyl-5-hydroxymethyl-2-oxomorpholin-3-yl) (DHM3) is a radical dimer which reacts with ADR in vitro to produce this aglycone. We utilized DHM3 to prevent ADR toxicity in mice. CD2F1 male mice were given a single dose of ADR, 25 mg/kg i.p., which was acutely lethal as indicated by a median survival time of 7 days. DHM3 administered as a single i.p. dose of 50 mg/kg 15 or 30 min following ADR provided significant protection with median survival times greater than 9 wk. Mice bearing ascitic L1210 leukemic cells were given ADR, 0, 6.6, 15, or 25 mg/kg i.p. 1 day following inoculation of tumor. DHM3 administered as a single 50 mg/kg i.p. dose 20 min after ADR had no significant effect on ADR efficacy at the lower dose range (% treated versus control = 171 and 285 for 6.6 and 15.0 mg/kg, respectively). Less than 15% of the animals in these treatment groups were long-term survivors. However, following high doses of ADR (25 mg/kg), DHM3 protected mice from ADR lethality and over 70% of animals were long-term survivors. The determination of parent ADR and ADR aglycone content in several tissues indicated that the concentration of ADR was reduced in those animals that received DHM3 15 min after ADR. Correspondingly an increase in ADR aglycone concentration in each tissue resulted from DHM3 treatment. DHM3 represents a novel class of compounds that can ameliorate ADR toxicity and has potential use as a rescue agent.