Breath ethane in dialysis patients and control subjects

Significance of Exhaled Breath Test in Clinical Diagnosis: A Special Focus on the Detection of Diabetes Mellitus

Analysis of volatile organic compounds (VOCs) emanating from human exhaled breath can provide deep insight into the status of various biochemical processes in the human body. VOCs can serve as potential biomarkers of physiological and pathophysiological conditions related to several diseases. Breath VOC analysis, a noninvasive and quick biomonitoring approach, also has potential for the early detection and progress monitoring of several diseases. This paper gives an overview of the major VOCs present in human exhaled breath, possible biochemical pathways of breath VOC generation, diagnostic importance of their analysis, and analytical techniques used in the breath test. Breath analysis relating to diabetes mellitus and its characteristic breath biomarkers is focused on. Finally, some challenges and limitations of the breath test are discussed.

Technologies for Clinical Diagnosis Using Expired Human Breath Analysis

This review elucidates the technologies in the field of exhaled breath analysis. Exhaled breath gas analysis offers an inexpensive, noninvasive and rapid method for detecting a large number of compounds under various conditions for health and disease states. There are various techniques to analyze some exhaled breath gases, including spectrometry, gas chromatography and spectroscopy. This review places emphasis on some of the critical biomarkers present in exhaled human breath, and its related effects. Additionally, various medical monitoring techniques used for breath analysis have been discussed. It also includes the current scenario of breath analysis with nanotechnology-oriented techniques.

Blood and breath profiles of volatile organic compounds in patients with end-stage renal disease

Background

Monitoring of volatile organic compounds (VOCs) in exhaled breath shows great potential as a non-invasive method for assessing hemodialysis efficiency. In this work we aim at identifying and quantifying of a wide range of VOCs characterizing uremic breath and blood, with a particular focus on species responding to the dialysis treatment.

Methods

Gas chromatography with mass spectrometric detection coupled with solid-phase microextraction as pre-concentration method.

Results

A total of 60 VOCs were reliably identified and quantified in blood and breath of CKD patients. Excluding contaminants, six compounds (isoprene, dimethyl sulfide, methyl propyl sulfide, allyl methyl sulfide, thiophene and benzene) changed their blood and breath levels during the hemodialysis treatment.

Conclusions

Uremic breath and blood patterns were found to be notably affected by the contaminants from the extracorporeal circuits and hospital room air. Consequently, patient exposure to a wide spectrum of volatile species (hydrocarbons, aldehydes, ketones, aromatics, heterocyclic compounds) is expected during hemodialysis. Whereas highly volatile pollutants were relatively quickly removed from blood by exhalation, more soluble ones were retained and contributed to the uremic syndrome. At least two of the species observed (cyclohexanone and 2-propenal) are uremic toxins. Perhaps other volatile substances reported within this study may be toxic and have negative impact on human body functions. Further studies are required to investigate if VOCs responding to HD treatment could be used as markers for monitoring hemodialysis efficiency.

Volatile breath biomarkers for patient monitoring during haemodialysis

Patients with end-stage renal disease (ESRD) are at risk for a numerous complications. This study was intended to evaluate breath analysis for monitoring and therapy initiation under haemodialysis (HD). Exhaled alveolar air from 30 ESRD patients during 4 h thrice-weekly HD was analysed by means of HS-SPME-GC-MS. Venous blood samples were taken for determination of conventional serum parameters. Exhaled concentrations of isoprene (10-589 ppbV) were dropped at initiation of HD and increased at the end of HD. Isoprene concentration changes were similar to changes of serum LDH activities. Variation of exhaled acetone concentrations (59 to 8509 ppbV) was significantly lower in diabetic patients when compared to non-diabetics. Exhaled pentane (0.3 to 12 ppbV) increased at onset of HD and returned to baseline levels afterwards. Benzene concentrations showed typical washout characteristics. Ethanol and DMS concentrations remained constant during HD. Breath analysis can be used to recognize oxidative stress, metabolic conditions and haemolysis during HD. Hence, non-invasive breath testing could be used to monitor ESRD patients under HD and prevent them from being affected by well-known detrimental side effects of renal replacement therapy.

Exposure to potentially toxic hydrocarbons and halocarbons released from the dialyzer and tubing set during hemodialysis

BACKGROUND

Although much is known about the effect of chronic kidney failure and dialysis on the composition of solutes in plasma, little is known about their impact on the composition of gaseous compounds in exhaled breath. This study was designed to explore the effect of uremia and the hemodialysis (HD) procedure on the composition of exhaled breath. Breath samples were collected from 10 dialysis patients immediately before, during, and after a dialysis session. To determine the potential introduction of gaseous compounds from dialysis components, gasses emitted from dialyzers, tubing set, dialysate, and water supplies were collected.

STUDY DESIGN

Prospective cohort study.

PARTICIPANTS

10 HD patients and 10 age-matched healthy individuals.

PREDICTOR

Predictors include the dialyzers, tubing set, dialysate, and water supplies before, during, and after dialysis.

OUTCOMES

Changes in the composition of exhaled breath.

MEASUREMENTS

A 5-column/detector gas chromatography system was used to measure hydrocarbon, halocarbon, oxygenate, and alkyl nitrate compounds.

RESULTS

Concentrations of 14 hydrocarbons and halocarbons in patients' breath rapidly increased after the onset of the HD treatment. All 14 compounds and 5 others not found in patients' breath were emitted from the dialyzers and tubing sets. Contrary to earlier reports, exhaled breath ethane concentrations in our dialysis patients were virtually unchanged during the HD treatment.

LIMITATIONS

Single-center study with a small sample size may limit the generalizability of the findings.

CONCLUSIONS

The study documented the release of several potentially toxic hydrocarbons and halocarbons to patients from the dialyzer and tubing sets during the HD procedure. Because long-term exposure to these compounds may contribute to the morbidity and mortality in dialysis population, this issue should be considered in the manufacturing of the new generation of dialyzers and dialysis tubing sets.

Human exhaled air analytics: biomarkers of diseases

Over the last few years, breath analysis for the routine monitoring of metabolic disorders has attracted a considerable amount of scientific interest, especially since breath sampling is a non-invasive technique, totally painless and agreeable to patients. The investigation of human breath samples with various analytical methods has shown a correlation between the concentration patterns of volatile organic compounds (VOCs) and the occurrence of certain diseases. It has been demonstrated that modern analytical instruments allow the determination of many compounds found in human breath both in normal and anomalous concentrations. The composition of exhaled breath in patients with, for example, lung cancer, inflammatory lung disease, hepatic or renal dysfunction and diabetes contains valuable information. Furthermore, the detection and quantification of oxidative stress, and its monitoring during surgery based on composition of exhaled breath, have made considerable progress. This paper gives an overview of the analytical techniques used for sample collection, preconcentration and analysis of human breath composition. The diagnostic potential of different disease-marking substances in human breath for a selection of diseases and the clinical applications of breath analysis are discussed.

Overproduction of reactive oxygen species in end-stage renal disease patients: a potential component of hemodialysis-associated inflammation

During the past decade, hemodialysis (HD)-induced inflammation has been linked to the development of long-term morbidity in end-stage renal disease (ESRD) patients on regular renal replacement therapy. Because interleukins and anaphylatoxins produced during HD sessions are potent activators for nicotinamide adenine dinucleotide phosphate (NADPH) oxidase, an example of an enzyme that is responsible for overproduction of reactive oxygen species (ROS), this may constitute a link between leukocyte activation and cell or organ toxicity. Oxidative stress, which results from an imbalance between oxidant production and antioxidant defense mechanisms, has been documented in ESRD patients using lipid and/or protein oxidative markers. Characterization of HD-induced oxidative stress has included identification of potential activators for NADPH oxidase. Uremia per se could prime phagocyte oxidative burst. HD, far from improving the oxidative status, results in an enhancement of ROS owing to hemoincompatibility of the dialysis system, hemoreactivity of the membrane, and trace amounts of endotoxins in the dialysate. In addition, the HD process is associated with an impairment in antioxidant mechanisms. The resulting oxidative stress has been implicated in long-term complications including anemia, amyloidosis, accelerated atherosclerosis, and malnutrition. Prevention of oxidative stress in HD might focus on improving the hemocompatibility of the dialysis system, supplementation of deficient patients with antioxidants, and modulation of NADPH oxidase by pharmacologic approaches.

Relevance of Oxidative Pathways in the Pathophysiology of Chronic Kidney Disease

Patients with uremia (whether requiring renal replacement therapy or not) have a greatly increased cardiovascular risk that cannot be explained entirely by traditional cardiovascular risk factors. An increase in oxidative stress has been proposed as a nontraditional cardiovascular risk factor in this patient population. Using a wide variety of different biomarkers of increased oxidative stress status, numerous laboratories around the world have now unequivocally demonstrated that uremia is a state of increased oxidative stress. Recent data also suggest linkages between oxidative stress inflammation, endothelial dysfunction, and malnutrition in the uremic population. These factors are probably synergistic in their effects on atherogenecity and risk of a cardiovascular event. The pathophysiology of increased oxidative stress in uremia is multifactorial, but the retention of oxidized solute by the loss of kidney function is probably a major contributor. Uremic oxidative stress can be characterized biologically by an increase in lipid per oxidation products and reactive aldehyde groups as well as by increased retention of oxidized thiols. Two recently published studies have suggested that antioxidative therapy may be particularly promising in reducing cardiovascular events in this patient population.Further definitive studies of antioxidant use are greatly needed.

Oxidative stress in uremia

PURPOSE OF REVIEW

Oxidative stress has been described as 'a disturbance in the prooxidant-antioxidant balance in favor of the former, leading to potential damage. In uremic patients, an increase in oxidative stress may occur because of the loss of residual renal function, and may be exacerbated by dialysis. This review will focus on the emerging biochemical evidence of an increase in oxidative stress in uremic patients, the relationship with renal replacement therapy, and the potential linkages to acute-phase inflammation, malnutrition, and adverse cardiovascular outcomes in uremic patients.

RECENT FINDINGS

Many studies from multiple research laboratories around the world have recently utilized in-vivo biomarkers to describe increased oxidative stress in uremic patients. An emerging literature suggests that there are links between an increase in oxidative stress, endothelial dysfunction, an increase in acute-phase inflammation, and an accelerated risk of cardiovascular complications in dialysis patients. Additional uremia-associated metabolic abnormalities, including hyperhomocysteinemia, intravenous iron exposure, and biocompatibility changes related to dialysis, may contribute to an increase in oxidative stress. Finally, two well-conducted pilot clinical randomized trials have suggested that antioxidant therapy may have efficacy in reducing cardiovascular events in uremic patients.

SUMMARY

The implications of the findings of a generalized increase in oxidative stress associated with uremia have led to the suggestion that antioxidative therapy may be efficacious in reducing cardiovascular complications. Pilot studies have suggested potential efficacy for this approach. However, further large-scale randomized clinical trials will be required to establish a compelling, evidence-based approach to the use of antioxidants in patients with uremia.

Pulse wave velocity as an indicator of arteriosclerosis in hemodialysis patients

Studies were performed to examine whether pulse wave velocity (PWV) is a useful indicator of arteriosclerosis in hemodialysis (HD) patients. In total, 72 patients were enrolled. Annual changes in PWV were compared to clinical parameters and therapeutic maneuvers. PWV increased in diabetic patients faster than non-diabetics (35 +/- 10 cm/s/month versus 10 +/- 4 cm/s/month, P < 0.05). Changes in PWV showed strong correlations to triglyceride level exposed during observation period (r = 0.50, P < 0.05) and HD duration (r = 0.46, P < 0.05). In addition, we found that PWV of some patients decreased (regressors), while the others increased (non-regressors). Regressors more frequently received combined treatment with angiotensin blockade and lipid-lowering drugs or vitamin E-coated dialyzers than non-regressors (P < 0.05). Our data demonstrate that PWV is useful as a marker of arteriosclerosis in HD patients. Furthermore, the present results suggest that combined treatment with both angiotensin inhibition and lipid-lowering drugs or vitamin E-coated membrane would slow the progression of arteriosclerosis in HD patients.

Diagnostic potential of breath analysis--focus on volatile organic compounds

Breath analysis has attracted a considerable amount of scientific and clinical interest during the last decade. In contrast to NO, which is predominantly generated in the bronchial system, volatile organic compounds (VOCs) are mainly blood borne and therefore enable monitoring of different processes in the body. Exhaled ethane and pentane concentrations were elevated in inflammatory diseases. Acetone was linked to dextrose metabolism and lipolysis. Exhaled isoprene concentrations showed correlations with cholesterol biosynthesis. Exhaled levels of sulphur-containing compounds were elevated in liver failure and allograft rejection. Looking at a set of volatile markers may enable recognition and diagnosis of complex diseases such as lung or breast cancer. Due to technical problems of sampling and analysis and a lack of normalization and standardization, huge variations exist between results of different studies. This is among the main reasons why breath analysis could not yet been introduced into clinical practice. This review addresses the basic principles of breath analysis and the diagnostic potential of different volatile breath markers. Analytical procedures, issues concerning biochemistry and exhalation mechanisms of volatile substances, and future developments will be discussed.

Reactions of 4-hydroxynonenal with proteins and cellular targets

Peroxidative degradation of lipids yields the aldehyde 4-hydroxy-2-nonenal (4HNE) as a major product. The lipid aldehyde is an electrophile, and reactivity of 4HNE toward protein nucleophiles (i.e., Cys, His, and Lys) has been characterized. Through the use of purified enzymes and isolated cells, various pathways for biotransformation of the lipid aldehyde have been identified and include enzyme-mediated oxidation, reduction, and glutathione conjugation. Uncontrolled oxidative stress can yield excessive lipid peroxidation and 4HNE generation, however, and overwhelm these cellular defenses. Indeed, in vitro and in vivo production of 4HNE in response to pro-oxidant exposure has been demonstrated using antibodies to protein adducts of the lipid aldehyde. Recent evidence suggests a role for protein modification by 4HNE in the pathogenesis of several diseases (e.g., alcohol-induced liver disease); however, the precise mechanism(s) is currently unknown but likely results from adduction of proteins involved in cellular homeostasis or biological signaling.

Tyrosine nitration in plasma proteins from patients undergoing hemodialysis

BACKGROUND

A growing body of evidence suggesting that oxidative stress might be one of the most important complications occurring during hemodialysis (HD) has accumulated. However, although the role of reactive oxygen species has been investigated extensively, little is known about the involvement of reactive nitrogen species. In the present investigation, levels of protein modifications in the form of tyrosine nitration in patients undergoing long-term HD therapy were evaluated.

METHODS

Tyrosine nitration of plasma proteins was detected by means of Western blotting using a specific nitrotyrosine-recognizing monoclonal antibody, and band intensity was evaluated by using image analysis software. Immunoprecipitation of plasma proteins by antinitrotyrosine-agarose--conjugated antibodies, followed by Western blotting, was used in an attempt to identify the nitrated proteins.

RESULTS

Although several proteins with nitrated tyrosine residues were observed in plasma of healthy individuals, increased nitration levels were observed in some specific proteins in all patients tested (n = 25) compared with controls (n = 6). At least 6 apparent bands appeared to be more nitrated than their counterparts in plasma from controls. Ceruloplasmin was identified as 1 of the proteins with significantly increased nitration in patients.

CONCLUSION

Results of the present investigation show that specific plasma proteins of HD patients are post-translationally modified by nitration of their tyrosine residues. The nature of these proteins, as well as the exact molecular mechanisms and consequences of these modifications, warrant additional investigation.

RENAL RESEARCH INSTITUTE SYMPOSIUM: Efforts to Determine the Role of Oxidant Stress in Dialysis Outcomes

The role of elevated markers of oxidant stress needs to be established in longitudinal studies. Oxidant stress markers such as malonaldehyde (MDA), isoprostanes, and breath hydrocarbons warrant rigorous application to outcomes, if they are to be used as clinical parameters. For example, investigations of C-reactive protein (CRP), parathyroid hormone (PTH), and several other clinical indicators have shown that these markers can be used to predict outcomes such as morbidity and mortality. Long-term followup is needed for intervention studies with antioxidants, since effects with short-term studies may be focused on critically-ill individuals where intervention would not be expected to be effective. Oxidant stress studies in this population especially need a long-term approach to test the hypothesis that antioxidant intervention is beneficial.