Managing erythropoietin hyporesponsiveness

The anemia of chronic kidney disease is associated with cardiovascular disease, decreased quality of life, and mortality. The introduction of recombinant human erythropoietin (rHuEPO) has transformed the management of this condition. However, a significant proportion of patients fail to respond to even high doses of rHuEPO. Several factors have been implicated in the hyporesponsiveness to rHuEPO. Iron deficiency, whether absolute or functional, is considered the most important, and maintenance of adequate iron stores reduces rHuEPO requirements among patients on hemodialysis. However, traditional indices of iron that are currently utilized may not reflect iron stores accurately, and there is also increasing concern regarding the potential long-term toxicity of parenteral iron therapy. Infection and inflammation also influence the response to rHuEPO, both by disruption of iron metabolism and by eliciting the release of cytokines that inhibit erythropoiesis. Oxidative stress may contribute to rHuEPO hyporesponsiveness directly by promoting lipid peroxidation in cell membranes, leading to increased erythrocyte fragility and reduced life span and also through its strong association with inflammation. Severe hyperparathyroidism can lead to a reduced number of erythroid progenitor cells. Inadequate dialysis dose, aluminum overload, nutritional factors such as deficiencies of carnitine, vitamin B12, folic acid, and vitamin C can also reduce the efficacy of rHuEPO therapy. Hyporesponsiveness to rHuEPO presents a challenge to both diagnosis and management in an era where optimizing response to rHuEPO is critical both in limiting the burgeoning costs of anemia management and improving clinical outcomes in the dialysis population.

Effect of aluminum consumption on the vestibulo-ocular reflex

The effects of chronic exposure (90 days) to Aluminum chloride (AlCl(3)) were analyzed in 3, 10 and 24 month old male rats (n=270) by investigating the function of the VOR (vestibulo-ocular reflex) in correlation with Aluminum (Al) concentrations in blood and brain. The VOR was chosen and tested in basal conditions (pre-exposure measures) and during the continuous administration of three different concentrations of AlCl(3) (0.5, 1, 2 g/l in drinking solution): the control animals being exposed to NaCl (0.125, 0.25 and 5 g/l in drinking solution). Results showed that LOAEL (Lowest Observed Adverse Effect Level) was 43.1+/-11.4 mg Al/kg-day. At this concentration the Al induced significant VOR impairment in all exposed rats, regardless of animal age. Neuroanatomical analysis showed that VOR impairment was not dependent on astrocyte damage nor evidences of amyloid deposits in the exposed rats was found. Significant changes of Al concentrations were observed in nervous tissue, while its concentration in whole blood was unaffected. Furthermore, results show that it is possible to identify an individual neurotoxic threshold for each animal and therefore hypothesize the clinical use of the VOR test for the evaluation of individual risk toxicity to chronic Al exposure.

Differences in ion release after ceramic-on-ceramic and metal-on-metal total hip replacement. Medium-term follow-up

Modern metal-on-metal bearings produce less wear debris and osteolysis, but have the potential adverse effect of release of ions. Improved ceramic-on-ceramic bearings have the lowest wear of all, but the corrosion process has not been analysed. Our aim was to measure the serum ion release (ng/ml) in 23 patients having stable hip prostheses with a ceramic-on-ceramic coupling (group A) and to compare it with the release in 42 patients with a metal-on-metal bearing (group B) in the medium term. Reference values were obtained from a population of 47 healthy subjects (group C). The concentrations of chromium, cobalt, aluminium and titanium were measured. There was a significant increase of cobalt, chromium and aluminium levels (p < 0.05) in group B compared with groups A and C. Group A did not differ significantly from the control group. Despite the apparent advantage of a metal-on-metal coupling, especially in younger patients with a long life expectancy, a major concern arises regarding the extent and duration of ion exposure. For this reason, the low corrosion level in a ceramic-on-ceramic coupling could be advantageous.

Biological monitoring of welders exposed to aluminium

To evaluate an adequate strategy for biological monitoring of aluminium (Al), a group of 62 Al welders (age in 1999: 23-51 years, median 35 years) was surveyed annually from 1999 to 2003 by determination of pre- and post-shift Al in urine and plasma. Biomonitoring was supplemented by personal air measurements of the total dust concentration. The welders' internal exposure was compared to the exposure of 60 non-exposed assembly workers (age in 1999: 21-51 years, median: 36 years) who were surveyed in 1999, 2001 and 2003. Having a nearly constant dust exposure, median concentrations of Al in urine (Al in plasma) of the welders decreased from 40.1 microg/g to 19.8 microg/g creatinine (8.7 to 4.6 microg/l). For the control group the median levels of Al in urine (plasma) ranged from 4.8 microg/g to 5.2 microg/g creatinine (2.4-4.3 microg/l) indicating a higher sensitivity for the marker Al in urine. No systematic differences have been found between pre- and post-shift internal exposure. This might be caused by the slow elimination kinetics and low systemic bioavailability of Al. A correlation analysis did not yield close relationships between dust exposure, Al in plasma and Al in urine underlining the importance of biomonitoring for assessment of Al exposure.

Binding affinity of aluminium to human serum transferrin and effects of carbohydrate chain modification as studied by HPLC/high-resolution ICP-MS--speciation of aluminium in human serum

Aluminium (Al) in the blood is bound to transferrin (Tf), a glycoprotein of about 80kDa that is characterized by its need for a synergistic anion. In this focused review, the binding affinity of Al to Tf is surveyed in the context of our recent studies using on-line high-performance liquid chromatography/high-resolution inductively coupled plasma mass spectrometry (HPLC/HR-ICP-MS). Al in human serum without any in vitro Al-spikes was present in a form bound to the N-lobe site of Tf. The influences of sialic acid in the carbohydrate chain of human serum Tf (hTf) were studied using asialo-hTf, obtained by treatment with sialidase. The binding affinity of Fe was similar between asialo-hTf and native-hTf, while that of Al for asialo-hTf was larger than that for native-hTf, especially in the presence of oxalate, a synergistic anion. The above findings are discussed in relation to diseases in which the serum concentrations of carbohydrate-deficient Tf and oxalate are augmented.

Study of hemorheological parameters following partial hepatectomy in rats with chronic aluminium intoxication

The aim of our work was to analyze the hemorheological parameters following partial hepatectomy in rats with chronic Al-intoxication (Al). Male Wistar rats were randomly assigned into four experimental groups (n=6 each one): Sham (rats subjected to simulated surgery); Al+Sham; Partial Hepatectomy (animals subjected to 65% liver resection) and Al+Partial Hepatectomy. Our results show that both Partial Hepatectomy and Al treatment produce a decrease of plasma cholesterol level, which showed a negative association with Rigidity Index increase (r(s)=-0.6475, p<0.05). The increase of Rigidity Index observed in Partial Hepatectomy, Al+Sham and Al+Partial Hepatectomy could be related to the increase of the proportion of non-discocytic erythrocytes, particularly stomatocytes, which determines a diminution of the Morphological Index. In the Altreated groups, greater changes in Rigidity Index and Morphological Index were observed. The relative viscosity of blood at a standard haematocrit of 40% was increased in Partial Hepatectomy, Al+Sham and Al+Partial Hepatectomy as compared to Sham, due to erythrocyte rigidity. On the other hand, we observed that the increase of plasma fibrinogen concentration correlates with augmentation of plasma viscosity (r(s)=0.689, p=0.004) for all the experimental groups studied. The results indicate that both administration of Al and Partial Hepatectomy induce microcytic hypocromic anaemia in the rats reflected by a significant decrease of haematocrit, mean corpuscular volume and mean corpuscular haemoglobin concentration. From these results, we conclude that in partially hepatectomized, Al-overloaded rats the decrease in erythrocyte deformability may be an important factor leading to the installation of anaemia.

Modeling and separation-detection methods to evaluate the speciation of metals for toxicity assessment

There is an increasing appreciation for the importance of speciation in the assessment of metal toxicity. In this review, two approaches to speciation are discussed, with an emphasis on their application to biological samples. One approach is the direct separation and detection of metal species of toxicological interest. Various "hyphenated" techniques, consisting of a chromatographic system coupled to inductively coupled plasma-mass spectrometry (ICP-MS), are discussed. The chromatographic strategies employed for separation emphasize liquid chromatography (LC), but the increasing use of gas chromatography (GC) and capillary electrophoresis (CE) in speciation analysis is discussed. The second approach to speciation is the use of computer models to calculate the speciation of a metal ion within a complex mixture of ligands. This approach is applicable to systems in which the metal cation exchanges ligands rapidly, so that the sample represents an equilibrium mixture of metal complexes. These computational models are based on the equilibrium constants for the metal complexes and a series of mass balance equations and give the distribution of metal complexes in the original sample. This approach is illustrated using the speciation of Al(III) in serum as an example.

Serum Clara Cell Protein as an Indicator of Pulmonary Impairment in Occupational Exposure at Aluminum Foundry

OBJECTIVES

Although some of the exposures in aluminum (Al) smelting have been well characterized, and respiratory disorders in aluminum production workers are well known, the relationship between internal aluminum loads and appropriate lung biomarkers have not been elucidated. The aim of our work was to carry out a comprehensive investigation in workers employed in the Aluminum Foundry Casting Department with special reference to currently existing hygiene standards, known as threshold limit values (TLV) based on aluminum effects on the respiratory system. The measurement of serum anti-inflammatory Clara cell protein (CC16) was employed as a peripheral marker of the lung epithelium function.

MATERIALS AND METHODS

A group of 50 casting smelters, 5 locksmiths, 11 sawyers and auxiliary workers exposed to dust containing 14% of aluminum, and a group of 42 controls were examined. Respiratory function tests were performed and forced volume capacity (FVC), forced expiratory volume in 1 s (FEV1), forced expiratory volume in the first percent (FEV1%), forced expiratory flows in 50% VC (FEV50), and markers of foundry workers' exposure and body burden, Al concentration in the breathing zone, blood and urine, biomarkers of the effects of exposure, concentration of CC16 and hyaluronic acid (HA) in serum were determined in all examined workers. Additional measurements comprised determinations of serum iron (Fe) levels, myeloperoxidase (MPO), eosinophil cationic protein (ECP), immunoglobulin E (IgE), glutathione S-transferase (GST), and superoxide dismutase (SOD) activity in erythrocytes.

RESULTS

The group of casting smelters was characterized by the highest levels of aluminum in urine (Al-U) (43.7 microg L(-1)), high levels of MPO, ECP and IgE, high SOD activity, low CC16 levels, and low activity of GST. Lower Al-U excretion was observed in locksmiths (35.2 microg L(-1)) and sawyers (21.7 microg L(-1)). Serum CC16 proved to be the most sensitive biomarker, showing high inverse relationship with serum Al (Al-S) concentrations in casting smelters (p = 0.006).

CONCLUSIONS

The study showed that in conditions of occupational exposure, dusts containing Al2O3 < 1 mg m(-3) cause changes in the respiratory system and biomarkers in serum, especially in CC16, connected with altered functioning of this system. Changes in concentrations of the examined biomarkers and also in respiratory parameters of the study subjects were observed when Al-U concentration was > 40 microg L (-1).

Frequency of Elevated Serum Aluminum Levels in Adult Dialysis Patients

BACKGROUND

Aluminum toxicity, a complication described in dialysis patients exposed to aluminum-containing phosphate binders or water used in dialysate preparations containing elevated levels of aluminum, can cause significant morbidity. Although physicians monitor patient aluminum levels, the frequency of abnormal aluminum levels has not been reported.

METHODS

We retrospectively examined 1,410 measurements of serum aluminum in 207 dialysis patients at the Franklin Dialysis Center (FDC; Philadelphia, PA) from January 1, 2000, through April 3, 2003. We also surveyed serum aluminum levels from a nationwide dialysis provider (DaVita) to more than 43,000 patients. Local dialysis facilities were surveyed to determine the annual frequency of aluminum testing in their patients.

RESULTS

Of 1,410 serum aluminum measurements performed at FDC, only 30 abnormal levels (2.1%) were found. DaVita measured approximately 117,000 aluminum levels annually during the last 3 years, of which 2.5% were abnormal. Frequencies of abnormal aluminum levels declined significantly each year at FDC and DaVita.

CONCLUSION

The current frequency of abnormal aluminum levels in our dialysis facility and a national dialysis provider is extremely low and has significantly declined.

Effect of aluminum exposure on pteridine metabolism

Occupational and environmental aluminum (Al) exposure cause serious health problems by interaction with biological systems. Al is one of the most documented metals because its cellular targets are unclear biochemical processes and membranes of organisms. The major aim of the present study was to investigate the alteration of serum and urine aluminum in occupational exposure and to observe whether the metal exposure could cause any changes in pteridine-pathway-related critical compounds such as urinary neopterin and biopterin and blood dihydropteridine reductase (DHPR). In this study, determination of the metal concentrations was carried out in Al-exposed workers (n=23) and healthy volunteers (n=18) by using atomic absorption spectrometer. DHPR enzyme activity and levels of neopterin and biopterin were detected by spectrophotometric and high-performance liquid chromatographic methods, respectively. It was found that occupational exposure to the metal led to a statistically significant increase in serum Al levels compared to the controls (p<0.05). At the same time, urinary neopterin and biopterin concentrations of the exposed group were higher than nonexposed subjects (both p<0.05). The correlations among Al levels and DHPR activity, magnesium concentration in serum and urine, working years, smoking status, and age were evaluated.

The efficacy of deferiprone on tissues aluminum removal and copper, zinc, manganese level in rabbits

The effect of 1,2-dimethyl-3-hydroxypyrid-4-one [deferiprone (DE)] on aluminum mobilization and elimination from tissues and serum as well as the influence on the excretion of trace elements, copper, zinc and manganese in rabbits was investigated. Sixteen New Zealand rabbits were randomly divided into three groups: control, Al-only and Al+DE. The Al-only and Al+DE animals received injections of Al2(SO43.18H2O 600 micromol Al/kg 5 days per week for 3 weeks. One week after the last Al injection the Al+DE rabbits were given deferiprone 750 micromol/kg/day intragastrically for 2 weeks. At the 42nd day the animals were sacrificed and the organs were taken and digested. Blood was taken from the ear artery three times (at the initiation of the experiment, before and after deferiprone administration). The aluminum and copper, zinc, manganese were determined by atomic absorption spectrophotometry. Our results showed that deferiprone could highly mobilize aluminum stores from tissues. At the end of experiment the aluminum contents of bone, kidney, liver and brain in Al+DE were significantly lower than that in Al-only rabbits. The copper, zinc, manganese contents were not affected by deferiprone administration.

[Portal hemodynamics in patients with different syndromes of cirrhosis]

OBJECTIVE

To explore the relationship between the portal hemodynamics or the indices of liver fibrosis and the liver function score in patients with different traditional Chinese medical syndromes of liver cirrhosis.

METHODS

One hundred and forty-seven cases of liver cirrhosis with different syndromes were included in the study. Diameters and blood flow velocities of the portal vein and splenic vein were tested by color Doppler sonarography. The indices of liver function (TBIL, ALT, AST, Alb, Glb, PTA) and the indices of hepatic fibrosis (HA, PC-III, LN, VI-C) were tested.

RESULTS

The diameters of portal vein in liver cirrhosis patients with different syndromes (internal accumulation of of damp-heat, stagnation of liver-qi, superabundance of dampness due to spleen-asthenia, asthenia of liver and kidney yin, asthenia of spleen and kidney yang, blood stasis) were not significantly different. The blood flow velocities and flow volumes of portal vein in patients with the blood stasis syndrome and the internal accumulation of damp-heat syndrome were significantly different (P < 0.05). The diameter of splenic vein in patients with the internal accumulation of damp-heat syndrome was significantly different to that of the asthenia of liver and kidney yin syndrome, or the blood stasis syndrome, or the asthenia of spleen and kidney yang syndrome, respectively (P < 0.05 or P < 0.01). The blood flow velocity of splenic vein in patients with the blood stasis syndrome or the asthenia of spleen and kidney yang syndrome was significantly different to that of the internal accumulation of damp-heat syndrome, or the stagnation of liver-qi syndrome, or the asthenia of liver and kidney yin syndrome, respectively (P < 0.01). The blood flow volume of splenic vein in patients with the internal accumulation of damp-heat syndrome was significantly different to that of the asthenia of liver and kidney yin syndrome, or the asthenia of spleen and kidney yang syndrome, or the blood stasis syndrome, respectively (P < 0.01). The liver cirrhosis indices HA and PC-III in patients with the asthenia of liver and kidney yin syndrome were significantly different to those of the internal accumulation of damp-heat syndrome (P < 0.05). In Child-Pugh classification, the incidence of Child-Pugh C was the highest in the asthenia of spleen and kidney yang syndrome, while the incidence of Child-Pugh A was the highest in the stagnation of liver qi syndrome.

CONCLUSION

The changes of portal vein dynamics in liver cirrhosis patients with the asthenia of liver and kidney yin syndrome, or the asthenia of spleen and kidney yang syndrome, or the blood stasis syndrome are significantly different to those of the internal accumulation of damp-heat syndrome and the stagnation of liver-qi syndrome.

[Determination of Pb and Al in blood and hair of child using transverse heated graphite furnace atomic absorption spectroscopy]

Pb and Al in blood and hair of child were determined by transverse heated graphite furnace atomic absorption spectrometry with NH4H2PO4 and Mg(NO3)2 as a modifier, which enhanced the temperature of ashing, eliminated the matrix interference and memorial effect. The method is rapid, simple and accurate. The characteristic mass of the method was 2.3 x 10(-11) g and 2.2 x 10(-11) g for Pb and Al respectively. The relative standard deviation of Pb and Al was 3.0% and 11.4%, respectively, and the recovery was 96%-102%.

Aluminium in Alzheimer's disease: are we still at a crossroad?

Aluminium, an environmentally abundant non-redox trivalent cation has long been implicated in the pathogenesis of Alzheimer's disease (AD). However, the definite mechanism of aluminium toxicity in AD is not known. Evidence suggests that trace metal homeostasis plays a crucial role in the normal functioning of the brain, and any disturbance in it can exacerbate events associated with AD. The present paper reviews the scientific literature linking aluminium with AD. The focus is on aluminium levels in brain, region-specific and subcellular distribution, its relation to neurofibrillary tangles, amyloid beta, and other metals. A detailed mechanism of the role of aluminium in oxidative stress and cell death is highlighted. The importance of complex speciation chemistry of aluminium in relation to biology has been emphasized. The debatable role of aluminium in AD and the cross-talk between aluminium and genetic susceptibility are also discussed. Finally, it is concluded based on extensive literature that the neurotoxic effects of aluminium are beyond any doubt, and aluminium as a factor in AD cannot be discarded. However, whether aluminium is a sole factor in AD and whether it is a factor in all AD cases still needs to be understood.

Effect of volcanic gas exposure on urine, blood, and serum chemistry

AIMS

This pilot study tested the hypothesis that aluminium (Al), rubidium (Rb), arsenic (As), lead (Pb), mercury (Hg), fluorine (F), and chlorine (Cl), which are all known to be present in volcanic emissions, may be useful biological markers for occupational gas exposure in volcanologists.

METHODS

Ten human subjects were exposed to fumarole gases on White Island, New Zealand, for approximately 20 minutes. Sulphur dioxide (SO2) exposure was recorded by personal monitoring tubes. Pre- and post-exposure urine, blood and serum samples (collected using standard protocols) were analysed in the pathology laboratory for trace element and halogen content.

RESULTS

Average personal exposure was measured at <75 ppm SO2 and calculated at approximately 25 ppm HCl, approximately 8 ppm hydrogen fluoride (HF), approximately 1 ppm Al, approximately 0.1 ppb Rb and approximately 4 ppb Pb. These concentrations almost certainly exceed those usually found in occupational exposure settings. Advanced levels of urinary Al and Rb were found following gas exposure and were statistically significant in the population at p<0.005 and p<0.001, respectively. The other chemical elements that were analysed (urinary Cl, F, and Hg; blood Pb, and serum Al) did not show such patterns.

CONCLUSIONS

It is possible that urinary Al and Rb may be useful markers for exposure, a hypothesis which should be followed up in future work.

The network of the Italian laboratories: a proficiency test on the quantification of trace elements in serum

A proficiency test on the quantification of Al, Cu, Mn, Se and Zn in serum was carried out to verify the performance of about 30 regional laboratories of the network of Italian laboratories. The exercise consisted of four runs in which the laboratories were free in choosing analytical methods to determine trace elements in freeze-dried animal serum. Laboratories performances were evaluated by the study of statistical functions as Coefficients of Variation (CV), Youden plot and Z-score value. As for Al, the results were generally characterized by good accuracy and precision, in spite of the low levels of the element (5-7 microg l(-1)). Copper determination had some problems only at low concentration (about 160 microg l(-1)--first run), in which an elevated number of anomalous data were found. Better data were achieved for Zn, for which anomalous values were mainly stragglers than outliers. Due to the low number of data for Mn (concentrations from 0.6 to 60 microg l(-1)) and Se (concentration from 45 to 106 microg l(-1)), a restricted statistical treatment was applied; for these elements high CV values were found (range from 30 to 80%). The results of this trial confirmed that participation in a proficiency test represents a benefit for all analytical laboratories. In fact, with few exceptions, most of the participants improved their performances in terms of Z-score values.

[Zinc and aluminum concentrations in blood of hemodialysis patients and its impact on the frequency of infections]

A multicenter study was performed with the aim to investigate the blood concentrations of zinc (Zn) and aluminum (Al) in hemodialysis patients and to clarify the impact of these metals level on the frequency of infections and the impact of medications on metal concentration in blood of these patients.

MATERIAL AND METHODS

265 patients with end-stage renal disease from 7 dialysis centers were enrolled in this study. All patients underwent standard hemodialysis. Venous blood samples were collected from hemodialysis patients before hemodialysis sessions. Atomic absorption spectrophotometry was applied to measure blood levels of Zn and Al.

RESULTS AND CONCLUSIONS

The hemodialysis patients with infectious complications had significantly higher mean blood Al than the patients without complications (33.1+/-38.9 and 24.5+/-45.9 microg/l, respectively; p<0.001) and lower plasma levels of Zn (821.9+/-389.5 and 905.1+/-346.6 microg/l, respectively; p<0.005). Infectious complications were associated with zinc deficiency (p<0.01). The HD patients who were taken CaCO3 had lower mean concentration of Zn (849.4+/-324.6 and 1022.1+/-507.4 microg/l, respectively; p<0.006).