Effects of conventional peritoneal dialysates on leukocyte adhesion and CD11b, CD18 and CD14 expression.

Bacterial peritonitis is the most important complication of peritoneal dialysis (PD), limiting its widespread application. Conventional glucose-based peritoneal dialysates (G-PDS) depress oxygen consumption, chemiluminescence, superoxide production, phagocytosis, bacterial killing and actin polymerization in neutrophils (PMN) in vitro. Expression of adhesion receptors is critical to leukocyte activation, adhesion, migration and phagocytosis. The effects of G-PDS on basal and stimulated leukocyte adhesion molecule expression and leukocyte adhering capacity is unknown. We examined the effect of a five minutes incubation of whole blood in either HEPES-buffered saline or G-PDS containing 1.5% (83 mM), 2.5% (139 mM) or 4.25% (236 mM) glucose, at pH = 5.2, and pH = 7.4. PMN intracellular pH was measured spectrofluorometrically. Leukocyte CD11b, CD18 and CD14 were measured by flow cytometry using monoclonal antibodies in otherwise unstimulated cells or 60 minutes after lipopolysaccharide (LPS) stimulation. In addition, leukocyte adhering capacity to nylon wool was tested. In an attempt to dissect the effect of high glucose concentrations from that of the attendant hyperosmolality, the experiments were repeated with dialysates in which glucose was substituted by sodium chloride (NaCl-PDS) to attain identical osmolalities. G-PDS, as well as the mixtures of spent and fresh G-PDS, significantly depressed the basal PMN expression of adhesion receptors CD11b and CD18 and monocyte expression of CD14, and substantially mitigated the LPS-mediated up-regulation of CD11b and CD18. Likewise, G-PDS significantly inhibited leukocyte adhering capacity without affecting cell viability. Similar results were observed with NaCl-PDS. The observed abnormalities were primarily osmolality-dependent, and largely intra- and extracellular pH-independent. Impaired adhesion receptor expression and cell adhesion capacity shown here reveal another dimension of the G-PDS-induced leukocyte abnormalities.

The safety of intravenous iron dextran in hemodialysis patients.

The treatment of anemia in hemodialysis patients is frequently hindered by the presence of suboptimal iron stores. Intravenous iron dextran is in common use to maintain iron stores in this population, but there are little published data regarding the incidence and type of adverse events. The purpose of this study was to evaluate the safety of this medication. Charts from four hemodialysis centers of all 573 patients treated with intravenous iron dextran (INFeD; Schein Pharmaceutical, Inc, Florham Park, NJ) between July 1, 1993, and June 30, 1995, were studied. Twenty-seven patients (4.7%) had adverse reactions that were related to iron dextran. Four patients (0.7%) had reactions classified as serious (one cardiac arrest; three others required hospitalization). Ten patients (1.7%) had reactions classified as anaphylactoid. No patients died or developed permanent disability as a result of reactions. The most common adverse reactions included itching (1.5% of patients) and dyspnea or wheezing (1.5%); others included chest pain (1.0%), nausea (0.5%), hypotension (0.5%), swelling (0.5%), dyspepsia (0.5%), diarrhea (0.5%), skin flushing (0.3%), headache (0.3%), cardiac arrest (0.2%), and myalgias (0.2%). Five of all the reactions occurred during a test dose; four of these were anaphylactoid. Several factors were studied as possible predictors of adverse reactions. A positive history of drug allergy (odds ratio, 2.4; P = 0.03) and history of multiple drug allergy (odds ratio, 5.5; P = 0.0004) were significant predictors of reactions. In summary, we found serious adverse reactions to be uncommon in hemodialysis patients treated with intravenous iron dextran. Future prospective studies will help confirm this finding.

Childhood AIDS nephropathy: a 10-year experience.

The objective of this study was to define the demographic, immunologic, and clinical characteristics of children with acquired immunodeficiency syndrome (AIDS) and AIDS nephropathy, and contrast this with the existing adult data. Data from 62 pediatric patients with AIDS who were treated at SUNY Health Science Center, Brooklyn, New York, between 1983 and 1993 were analyzed. Human immunodeficiency virus (HIV) infection was acquired during the neonatal period by vertical transmission (n = 60) or blood transfusion (n = 2). All children with AIDS who exhibited clinical nephropathy died (n = 16), with mean survival of 55.3 months. In contrast, 32 of 56 AIDS patients (70%) who did not manifest nephropathy were alive at the end of the study period. Patients with nephropathy were noted to have significantly lower CD4+ lymphocyte counts than those without nephropathy. These observations suggest that the predominant renal lesion in pediatric patients who acquired HIV infection during the perinatal period is focal segmental glomerulosclerosis, although a variety of other histological lesions were present. As in adults, the survival in children is dismal following the onset of clinical renal disease. In contrast to the adult population in whom multiple risk factors can potentially contribute to AIDS-associated nephropathy, occurrence of nephropathy in children with vertical HIV transmission provides convincing evidence for the pathogenetic role of HIV infection.

Effect of hemodialysis on leukocyte adhesion receptor expression.

Hemodialysis with complement-activating membranes such as cuprophane is known to transiently activate leukocytes, leading to increased cellular adhesiveness, pulmonary leukostasis, and reduced functional capacity of monocytes and neutrophils. Clinically, this repetitive cell activation may contribute to the increased morbidity and mortality associated with chronic hemodialysis. To examine the effect of cuprophane hemodialysis on expression of cell-surface proteins involved in leukocyte adhesiveness, we monitored CD11b, CD18, CD14, CD54, and plasma-soluble CD54 in 10 patients during hemodialysis with cuprophan dialyzers. To test the effect of local blood recirculation, in two patients, arterial supply to the dialyzer was accessed from the peripheral arteriovenous fistula and was returned via an indwelling central venous catheter. In an attempt to examine the possible role of membrane-induced complement activation, the results were compared with those seen after incubation with C5a in vitro. Finally, the leukocyte responses to C5a and lipopolysaccharide were measured before and after hemodialysis. Leukocyte expression of CD11b and CD18 increased and CD14 decreased with hemodialysis, while CD54 remained unaltered. Plasma CD54 was markedly elevated before and remained unchanged during hemodialysis. Data obtained with C5a activation in vitro revealed identical changes in CD11b expression as that seen with hemodialysis, suggesting the role of membrane-induced complement activation. Preliminary data obtained using remote arterial and venous access sites showed only a slight increase in CD11b expression in the arterial blood, suggesting that the apparent systemic activation seen with arteriovenous access may be due to recirculation and local activation within the blood access. Finally, dialysis procedure did not impair lipopolysaccharide- or C5a-mediated upregulation of CD11b expression.

Effects of trauma on leukocyte intercellular adhesion molecule-1, CD11b, and CD18 expressions.

BACKGROUND: During traumatic injury, a multitude of events, including ischemia, may cause leukocyte adhesion and margination. In this study, alterations of surface receptors involved in leukocyte adhesion were studied in traumatized patients. In an attempt to discern the role of hypoxia, additional experiments were conducted in which normal human leukocytes were subjected to hypoxic stress in vitro. METHODS: Venous blood was obtained from 10 trauma patients within 2 hours of blunt injury (mean Injury Severity Score of 17 +/- 8) and from 8 normal volunteers (controls). Leukocytes were isolated from patients and controls. To assess the effect of hypoxia, normal leukocytes were placed in hermetically sealed environments containing 100% nitrogen. All leukocytes were labeled with phycoerythrin- or fluorescein-bound monoclonal antibodies to intercellular adhesion molecule-1 (ICAM-1), or to integrins CD18 and CD11b. Receptor concentration was measured by flow cytometry. Results were expressed as percentage of receptor-positive cells (%) and mean fluorescence channel units, which directly correlate with monoclonal antibody cell surface density. Significance of differences was tested by analysis of variance/Kruskal-Wallis test. RESULTS: Compared with the normal controls, circulating leukocytes obtained from traumatized patients showed decreased expression of ICAM-1, CD11b, and CD18 2 hours after injury. In contrast, normal leukocytes exposed to hypoxic stress in vitro exhibited a marked increase in CD11b and CD18 expression and no change in ICAM-1 expression. CONCLUSIONS: Leukocytes obtained from traumatized patients showed a significant decrease in cell surface expression of adhesion receptors. This phenomenon is unlikely to be a direct consequence of hypoxia alone, because exposure to isolated hypoxia in vitro actually increased expression of CD11b and CD18.

Hypoxia-induced alterations of neutrophil membrane receptors.

Extravasation of leukocytes at sites of ischemia may mediate tissue injury. To determine how leukocyte accumulation may be induced by ischemia, effects of hypoxia on basal neutrophil expression of adhesion and activation receptors were examined. Effects of hypoxia upon preactivated cells were also studied. To determine whether regulation of expression is dependent on oxygen availability or on mitochondrial respiration, the effects of physical hypoxia (substitution of O2 by nitrogen) were compared with those of chemical hypoxia with sodium cyanide (NaCN). Leukocytes in whole blood (eight volunteers) were exposed either to hypoxia alone or to priming concentrations of lipopolysaccharide (LPS, 1 microgram/ml) followed by chemical hypoxia (NaCN, 1 mM) or physical hypoxia (PO2 of 1-10 torr) for various time intervals. Room air was controlled and hypoxic cells were labeled with fluorescent monoclonal antibodies to integrins CD18 and CD11b or to the 55-kDa TNF alpha cell surface receptor (TNFR). Receptor concentrations were measured by flow cytometry. Data were analyzed by ANOVA/Student's t test. Physical hypoxia increased expression of both CD11b and CD18 over time and augmented their LPS-induced up-regulation. Isolated chemical hypoxia did not change neutrophil expression of CD11b or CD18, but partially inhibited neutrophil CD11b and CD18 up-regulation by LPS. LPS-induced TNFR down-regulation was not affected by physical hypoxia, which failed to alter TNFR expression in this model.(ABSTRACT TRUNCATED AT 250 WORDS)

Physiologic effects of long-term hypertension control.

Various antihypertensive agents may reduce blood pressure to a similar degree, yet they produce different outcomes with respect to long-term end-organ damage. Effective antihypertensive therapy can prevent or even reverse established left ventricular hypertrophy. The most rapid and extensive regression occurs with agents that block the reninangiotensin system or reduce entry of calcium into the cells. Other classes of drugs that reliably reverse left ventricular hypertrophy are centrally acting adrenergic inhibitors and beta blockers. The effect of antihypertensive agents on atherosclerosis appears to differ widely with regard to lipid metabolism, insulin sensitivity, and the biology of endothelium and vascular smooth muscle. Hypertension and chronic renal failure (diabetic and nondiabetic) are closely allied, but available antihypertensive agents are not equally potent in reducing intraglomerular pressure.

Lack of a fast-acting effect of erythropoietin on arterial blood pressure and endothelin level.

Recombinant erythropoietin (EPO) has been shown to induce vascular smooth muscle contraction in vitro suggesting a rapid acting pressor effect. In addition its chronic administration has been shown to raise plasma endothelin. This study was designed to explore the presence, if any, of fast-acting effects of EPO on the arterial blood pressure and endothelin level in vivo. Nine stable patients with end-stage renal disease (ESRD) were included in a double-blind, crossover, placebo-controlled study using IV bolus injections of either EPO or saline solution administered to patients while they were comfortably seated in reclining chairs and undisturbed in individual climate-controlled rooms. After a 15-min resting period, the bolus injection was given, and blood pressure (BP) and heart rate were measured and recorded automatically every 5 min for 60 min using an electronic device to avoid operator bias/error. In addition, blood samples were obtained for plasma endothelin determination at time 0 and at 5, 30, and 60 min after injection. Patients were studied approximately 2 h before their regularly scheduled dialysis session. The EPO dosage given (50-60 U/kg) was equal to the maintenance dose, routinely administered during dialysis. No significant change was observed in arterial BP, heart rate, or plasma endothelin concentration relative to the baseline values after either EPO or placebo administration. Thus, the results have excluded a rapid effect on BP, heart rate, and endothelin concentration of EPO at therapeutic doses which, when chronically administered, can clearly raise arterial blood pressure in ESRD patients.

Flow cytometric investigation of neutrophil activation pathways by n-formyl-Met-Leu-Phe and phorbol myristate acetate.

Recent evidence suggests that multiple pathways exist in PMN activation and that specific leukocyte response may be due to the activation of a particular signaling pathway. Using flow cytometry, PMN activation pathways were studied through the parallel comparison of n-formyl-Met-Leu-Phe (fMLP)- and phorbol-12-myristate-13-acetate (PMA)-induced stimulation and by simultaneous assays for CD11b expression and morphology. The maximal CD11b expression was higher with PMA than with fMLP, suggesting different activation pathways. Under these experimental conditions, a morphological response to fMLP was not observed. However, significant shape change was detected in PMA treated samples and was suppressed by either the removal of extracellular calcium or staurosporine at the concentrations above 14.5 microM. Calcium ionophore induced a similar light scattering pattern to that by PMA and enhanced CD11b expression, both of which were not inhibitable by staurosporine. These observations, for the first time, indicated that Ca2+ was a mediator in activation processes and that the treatment of PMN with PMA resulted in Ca2+ influx.

Radiodetoxified endotoxin-induced tolerance alters monocyte but not neutrophil CD11b and CD18 expression in response to lipopolysaccharide.

OBJECTIVES: To test the hypothesis that pretreatment with radiodetoxified endotoxin (RDE) may mitigate the deleterious effects of subsequent infection, in part by modifying leukocyte adhesion receptor expression, and to investigate the cellular mechanisms of endotoxin tolerance induced by RDE. DESIGN: To assess the effect of RDE pretreatment on mortality from bacterial peritonitis, rats were implanted with an intraperitoneal, barium-fecal inoculum at intervals of 0, 1, 3, and 5 days after RDE injection. Experiments were then conducted to test the effect on leukocyte adhesion receptor expression. Two groups of mice received saline solution, and one group, RDE. After 72 hours, one group received saline solution (saline/saline group), the others, lipopolysaccharide (LPS) (saline/LPS and RDE/LPS groups). Peripheral leukocytes were obtained 1 hour after injection and were analyzed for CD11b and CD18 expression by flow cytometry. SETTING: Laboratory animal study. RESULTS: Survival rates were not improved in rats that were pretreated with RDE 0 and 24 hours before inoculum (0% and 7%, respectively). In rats that were pretreated 72 hours and 120 hours before inoculum, 47% (P < .01) and 60% (P < .01) survived, respectively. CD18 expression on polymorphonuclear leukocytes increased twofold in the RDE/LPS (mean +/- SEM, 300.3 +/- 32.9) and the saline/LPS (mean +/- SEM, 360.4 +/- 59.9) groups compared with controls (mean +/- SEM, 176.4 +/- 18.9) (P < .05). CD11b expression on polymorphonuclear leukocytes increased threefold in the RDE/LPS (mean +/- SEM, 91.3 +/- 8.1) and the saline/LPS (mean +/- SEM, 89.8 +/- 11.4) groups compared with controls (mean +/- SEM, 32.1 +/- 1.8) (P < .05). CD18 expression on monocytes decreased in the saline/LPS group (mean +/- SEM, 134.2 +/- 14.2) and was unchanged in the RDE/LPS group (mean +/- SEM, 200.2 +/- 17.2) compared with controls (mean +/- SEM, 217.6 +/- 16.5) (P < .05). CD11b expression on monocytes decreased in the saline/LPS group (mean +/- SEM, 25.8 +/- 2.2) and was unchanged in the RDE/LPS group (mean +/- SEM, 36.4 +/- 0.9) compared with controls (mean +/- SEM, 39.7 +/- 3.9) (P < .05). CONCLUSIONS: Radiodetoxified endotoxin reduces mortality rates from bacterial peritonitis when given at least 72 hours prior to a bacterial inoculum. Tolerance to subsequent LPS challenge is associated with an abrogation of the reduced peripheral monocyte CD11b and CD18 expression observed in native LPS-stimulated mice but is not associated with changes in polymorphonuclear leukocyte CD11b and CD18 expression. The mechanism of the observed RDE-induced monocyte hyporesponsiveness to LPS and its possible protective effect is uncertain and requires further investigation.

Leukocyte CD11b and CD18 expression are increased in blood salvaged for autotransfusion.

To investigate whether activated leukocytes are present in salvaged blood, we measured complete blood counts and quantified the surface expression of the leukocyte adhesion receptors CD11b and CD18 in salvaged blood and arterial blood from six male patients undergoing elective abdominal aortic aneurysm repair. Salvaged blood contained 5,450 +/- 1010 leukocytes/microL and 7600 +/- 6200 platelets/microL and had a hematocrit of 50.6 +/- 3.7%. CD 11b expression was 3.3 +/- 0.5 fold higher on neutrophils and 3.8 +/- 1.0 fold higher on monocytes from salvaged blood compared with arterial blood (P < 0.05 for both). CD18 expression was increased 3.2 +/- 0.2 fold on neutrophils and 2.5 +/- 0.4 fold on lymphocytes (P < 0.05) in salvaged compared to arterial blood (P < .05). Monocyte expression of CD18 was increased 4.50 +/- 1.1 fold in salvaged blood, but this difference was not statistically significant. We conclude that a substantial number of activated leukocytes are present in salvaged blood. Because activated leukocytes could potentially be detrimental to the recipient, our findings raise theoretical concerns about the use of salvaged blood and emphasize the need for further refinement of the procedure.

Effect of erythrocyte mass on arterial blood pressure in dialysis patients receiving maintenance erythropoietin therapy.

Treatment of renal anemia with recombinant human erythropoietin (rEPO) frequently raises arterial blood pressure. The objective of this study was to determine whether this is a direct effect of rEPO or a consequence of the expansion of erythrocyte mass. Twenty-three chronic hemodialysis patients receiving maintenance rEPO therapy who had uncontrolled anemia due to iron deficiency were studied. It was anticipated that repletion of iron stores with iv iron dextran would restore rEPO responsiveness, leading to a gradual rise in hematocrit to the target values (0.30 to 0.33). The effect of the increase in hematocrit on arterial blood pressure could then be dissected from the direct effect of rEPO in patients receiving constant doses of rEPO throughout the study period. To this end, arterial blood pressure, iron indices, hematocrit, and measures of fluid balance were monitored at baseline and for a 10-wk period after iron repletion. In eight patients, the hematocrit transiently rose above 0.33, triggering a reduction in rEPO dosage. In the remaining 15 patients, rEPO dosage was held constant during the study period. In this subgroup, repletion of iron stores led to a rise in hematocrit from 0.25 +/- 0.04 to 0.32 +/- 0.04 (P < 0.001) within 4 wk. Despite the significant rise in hematocrit, both systolic and diastolic blood pressure values remained virtually unchanged. Likewise, body weight and interdialytic fluid gain were unaltered.(ABSTRACT TRUNCATED AT 250 WORDS)

Cytosolic ionized magnesium concentration in end-stage renal disease. Effect of hemodialysis.

Chronic renal failure is known to raise serum magnesium concentration. However, its effect on intracellular free cytosolic magnesium concentration ([Mg2+]i) has not been clearly delineated. Likewise, whereas hemodialysis (HD) lowers serum magnesium concentration, its effect on [Mg2+]i is unknown. It should be noted that, based on other studies, [Mg2+]i is inversely related to arterial blood pressure in the general population. Given the high prevalence of hypertension in end-stage renal disease (ESRD), the study of [Mg2+]i in this population is of interest. We measured platelet [Mg2+]i in nine ESRD patients, six of whom were hypertensive. Samples were obtained from arterial and venous lines at the start of an HD session, and from the arterial line at the end of an HD session. Five normal volunteers served as controls. [Mg2+]i was measured by spectrofluorometry using Mag-fura-2-AM. Serum magnesium and calcium concentrations were determined by atomic absorption. Compared with the normal control group, the ESRD patients exhibited significantly lower [Mg2+]i but higher serum magnesium concentrations. As expected, HD lowered the serum magnesium concentration. However, platelet [Mg2+]i was unaffected by either a single passage through the dialyzer or the entire dialysis procedure. [Mg2+]i did not correlate with serum magnesium or calcium concentrations, nor with the presence or absence of hypertension.

Tumor necrosis factor and monocytes are released during hemorrhagic shock.

Tumor necrosis factor (TNF) is a key mediator involved in many physiologic processes including immunity, inflammation, and metabolism. A relationship between TNF and hemorrhagic shock has not been clearly demonstrated. To help understand the role of TNF in hemorrhagic shock we developed a hemorrhagic shock model to measure TNF and monocyte levels during hemorrhage and resuscitation. Male Sprague-Dawley rats were anesthetized and subjected to a 50% blood loss (30 ml/kg) over 2 min and left in shock for 58 min. The animals were then resuscitated with two times blood loss (60 ml/kg) using lactated Ringers over 1 h. This model results in 75% mortality within 3 days (LD 75). Blood samples (2 ml) were obtained at intervals during shock and resuscitation, and assayed for TNF concentrations and white blood cell counts. Despite a marked fall in total leukocytes (24,600 pre-hemorrhage to 11,300 post-hemorrhage, P < 0.005), monocytes increased in percentage and in total count. Blood levels of TNF were initially undetectable but rose within 10 min after hemorrhage, peaked at 30 min after hemorrhage, and then became undetectable during resuscitation. In this model, macrophages and TNF are released into the circulation after hemorrhagic shock. TNF may play a role as a mediator in the pathophysiology of hemorrhagic shock.

Effects of chronic renal failure and hemodialysis on plasma glomerulopressin.

UNLABELLED: Glomerulopressin (GP) is a small molecular weight hepatic hormone which increases glomerular capillary pressure and enhances glomerular filtration rate (GFR) in experimental animals. Protein ingestion, glucagon secretion and volume expansion raise plasma GP activity. Effects of end-stage renal disease (ESRD) and hemodialysis (HD) on GP activity are unknown. We measured plasma levels and HD clearance of GP in eight ESRD patients and four normals. Predialysis plasma GP in the ESRD group was significantly higher than in the control group (p < 0.01). Plasma GP activity was significantly lowered by HD (p < 0.01). GP activity of hemofiltrate averaged 38.1% of that in the predialysis plasma. Single passage through the dialyzer resulted in a significant fall in plasma GP activity (p < 0.001). Dialyzer clearance of GP was 143.8 +/- 73.4 ml/min, representing 75.4% of that of urea. CONCLUSIONS: a) plasma GP activity is elevated in ESRD, due probably to increased production (volume expansion) and reduced renal elimination, b) GP is readily removed by HD and c) the fall in plasma GP postdialysis is due to removal by dialysis and possibly reduced hepatic release with the correction of hypervolemia.

Effect of recombinant human erythropoietin on platelet production in dialysis patients.

Two hundred forty-four anemic hemodialysis patients were randomized into recombinant erythropoietin and placebo-treated groups during a 12-wk double-blind phase, followed by a 24-wk open-label period. Mean platelet count rose from the baseline value of 242 x 10(9)/L to 264 x 10(9)/L on day 5 of epoetin therapy (P < 0.001, paired t test). Mean platelet count peaked at 290 x 10(9)/L on day 40 and remained at a significantly elevated level below the peak thereafter. The peak platelet count did not exceed the normal range in a majority of cases. Platelet count was unaffected by placebo. Patients without an erythropoietic response during the first few weeks of therapy exhibited a rise in platelet count comparable to that in patients with a satisfactory erythropoiesis. Patients with low initial serum ferritin concentrations had baseline platelet counts comparable to those with normal or high ferritin values and showed a similar rise in platelet count during therapy. As a group, patients with baseline platelet counts above 400 x 10(9)/L showed no rise in platelet count, whereas those with normal or reduced platelet counts showed a marked thrombopoietic response to epoetin. Erythropoietin therapy did not significantly alter the incidence of blood access thrombosis when compared with placebo treatment.

Cardiac pathology in patients with end-stage renal disease maintained on hemodialysis.

We report the spectrum of cardiovascular pathology found on autopsy examination in 106 consecutive patients with end-stage renal disease. Cardiovascular pathology was present in nearly all patients, and was the most frequent cause of death (36%), with acute myocardial infarction accounting for 15%. Particularly frequent pathologic findings were left ventricular hypertrophy, coronary and aortic atherosclerosis, pericarditis with effusion, myocardial fibrosis, and valvular dilatation. Cardiovascular death rate was higher during the first year than after the fifth year of dialysis. Nearly all patients had a history of hypertension. The nature of the underlying cause of renal failure and pre-existing cardiovascular disease, specifically diabetes mellitus and hypertension, were the principal predictors of cardiovascular mortality rather than maintenance hemodialysis therapy per se.

Perforation of the superior vena cava by a subclavian hemodialysis catheter: early detection by angiography.

A dual-lumen subclavian catheter was placed for temporary dialysis access in a 36-year-old woman. Clinical suspicion for a possible vena caval perforation by the catheter tip was confirmed by injection of contrast through the catheter. This technique allowed rapid diagnosis and prevented further potential complications related to catheter malposition.