Which level of cytokine production is critical in haemodialysis?

Mental health disorders in patients with end-stage renal failure

Renal failure is commonly accompanied by psychological distress compounding to mental health conditions such as anxiety and depression. Common risk factors towards the development of mental health disorders in people with renal failure include the need to attend regular hemodialysis session and the burden of related complications. A growing body of evidence has elucidated the biochemical and immunological underpinnings of mental health disorders in the context of renal failure. This knowledge calls for strengthening the existing mental health support frameworks and conducting research with the reported molecular pathways as potential therapeutic targets

Paricalcitol effects on activities and metabolism of platelet activating factor and on inflammatory cytokines in hemodialysis patients

PURPOSE

Paricalcitol improves the inflammatory status of hemodialysis patients. PAF is a strong inflammatory mediator which is produced during hemodialysis. We studied the effects of paricalcitol on PAF and other inflammatory mediators implicated in chronic kidney disease (CKD).

METHODS

We examined the in vitro effects of paricalcitol on PAF/thrombin-induced aggregation as well as on the activities of PAF-basic metabolic enzymes, lyso-PAF acetyltransferase (Lyso-PAF-AT), DTT-insensitive CDP-choline: 1-alkyl-2-acetyl-sn-glycerol cholinephospho-transferase (PAF-CPT) and PAF-acetylhydrolase (PAF-AH) in blood cells from healthy volunteers. In addition, the in vivo effects of paricalcitol on the above these enzymes were examined in plasma and blood cells of hemodialysis patients who had not received any type of vitamin D treatment during the last three months before and after receiving paricalcitol for a month. Finally, IL-12p70, IL-1β, IL-6, IL-8 and TNF-α were measured.

RESULTS

Paricalcitol inhibited in vitro PAF/thrombin-induced platelet aggregation and the inhibitory effect was comparable with that of PAF/thrombin antagonists. In addition, paricalcitol inhibited in vitro PAF-CPT activity in platelets and leukocytes and increased PAF-AH activity in leukocytes, while much higher concentrations of paricalcitol were needed to inhibit Lyso-PAF-AT activity. Similarly, in hemodialysis patients, paricalcitol treatment reduced PAF-CPT activity in platelets and leukocytes and increased PAF-AH activity in leukocytes, while it could not influence Lyso-PAF-AT activity. On the other hand, paricalcitol therapy reduced IL-8, IL-1β, and TNF-α.

CONCLUSIONS

These results further support the beneficial effects of vitamin D treatment in hemodialysis patients, since it strongly affects PAF/thrombin activities, PAF-metabolism, and IL-8, IL-1β and TNF-α circulating levels.

Relationship between depression and proinflammatory cytokine levels in hemodialysis patients

AIM

To evaluate the presence of the relationship between depression and proinflammatory cytokine levels in hemodialysis (HD) patients.

METHODS

The study included 40 HD patients and 20 healthy controls. All participants were evaluated for the presence of depression using the structured clinical interview based on criteria defined by Diagnostic and statistical manual mental disorders (Fourth Edition, Text Revision) Axis I disorders. The severity of depressive symptoms was assessed using the Beck Depression Inventory, the Hamilton Depression Rating Scale, and the Hamilton Anxiety Rating Scale. The depressive patients received antidepressants for 8 weeks. Blood samples were taken at baseline and after 8 weeks of antidepressant treatment for interleukin-1 (IL-1), IL-6, and tumor necrosis factor-α (TNF-α) levels.

RESULTS

A total of 9 (22.5%) of the 40 HD patients had depression. IL-1, IL-6, and TNF-α levels were significantly higher in HD patients compared with that in the control group, but were not significantly different between HD patients with and without depression. In the depressive patients, we observed no significant difference in proinflammatory cytokine levels after antidepressant treatment. The psychometric measurements in depressive patients decreased significantly after antidepressant treatment.

CONCLUSION

We observed that depression is a common psychiatric disorder and has no significant effect on proinflammatory cytokine levels in HD patients; no important improvement in cytokine levels was observed after antidepressant therapy.

Plasma Concentrations of Tumor Necrosis Factor Alpha May Predict the Outcome of Patients with Acute Renal Failure

BACKGROUND/AIMS

Elevated plasma tumor necrosis factor-alpha (TNFalpha) concentration is frequently found in patients with chronic renal failure on hemodialysis (HD) and correlates with their mortality. The present study aimed to analyze the relationship between plasma TNFalpha concentrations and survival of patients with nonseptic acute renal failure (ARF).

METHODS

Twenty-seven patients with ARF and 27 HD patients were examined. In ARF the patients' plasma TNFalpha concentrations were assessed 3 times: before the first HD session (phase I), 5 days later at the anuric/oliguric phase (phase II), and at the polyuric phase at discharge of the patients from the hospital (phase III). In 17 ARF patients kidney function recovered and 10 patients died in phase I.

RESULTS

In ARF patients plasma TNFalpha concentration was markedly higher [70 pg/ml (37-275)] than reference values (<5 pg/ml) but significantly lower than in HD patients [216 pg/ml (18-350)]. Moreover, also plasma TNFalpha levels at the polyuric phase remained elevated. An initial plasma TNFalpha concentration in ARF patients lower than 70 pg/ml predicted the beneficial outcome with a sensitivity of 64.7% and a specificity of 70.0%.

CONCLUSIONS

(1) Plasma TNFalpha concentration may predict the outcome in patients with ARF. (2) Plasma TNFalpha concentration remained elevated at the polyuric phase in ARF despite a marked improvement of excretory kidney function.

The effects of antidepressant treatment on serum cytokines and nutritional status in hemodialysis patients

The aim of this study was to investigate the effects of antidepressant treatment on serum cytokines and nutritional status in hemodialysis patients. Twenty-eight hemodialysis patients with a depressed mood were given 20 mg of fluoxetine for 8 weeks. The degree of depressive symptoms, the serum levels of interleukin-1beta, interleukin-2, interleukin-6, tumor necrosis factor-alpha, c-reactive protein, and markers of nutritional status were assessed at baseline and after treatment. The outcome was assessed in terms of response to treatment (>50% reduction in the score of the Hamilton depression rating scale). Antidepressant treatment decreased the serum level of interleukin-beta1 in both response and nonresponse groups, and increased the serum level of interleukin-6 only in the response group. At baseline, the level of interleukin-6 in the response group was lower than in the nonresponse group. Antidepressant treatment also increased fat distribution significantly in the response group which might have slightly improved the nutritional status. This study suggests that antidepressant treatment improve depressive symptoms and may affect immunological functions and nutritional status in chronic hemodialysis patients with depression.

Effect of membrane composition on cytokine production and clinical symptoms during hemodialysis: a crossover study

BACKGROUND

Intradialytic symptoms including hypotension have been reported during dialysis and it has been suggested that these are related to the release of cytokines like IL-1beta and TNFalpha by blood mononuclear cells when they get activated either due to contact with the dialyzer membrane or by compliment activation.

OBJECTIVE

To study the relationship between hemodialysis symptoms, cytokine production, and dialyzer membrane composition.

METHOD

In a randomized prospective crossover study, 20 ESRD patients on maintenance hemodialysis were studied over cuprophan (CU) and polysulfone (PS) low flux dialyzer membranes for three weeks each undergoing a biweekly dialysis schedule of 4 h sessions. Serial IL-1beta and TNFalpha levels were measured over 0, 15, 240 min during the first use of the dialyzer for all patients on both membranes. Intradialytic symptoms were monitored in a total of 240 dialysis sessions.

RESULTS

IL-1beta levels increased from 16.6 +/- 2.2 to 64.8 +/- 25.1 pg/mL on CU and 21.5 +/- 3.7 to 103.5 +/- 30.7 pg/mL on PS membrane over the 4-h dialysis session. Similarly TNFalpha increased from 42.8 +/- 4.5 to 354.9 +/- 80.4 pg/mL on CU and 117.1+/- 53.7 to 387.0 +/- 78.0 pg/mL on PS membrane. IL-1beta levels increased significantly with PS membrane while TNFalpha rise was significant with both the membranes. Nausea was the most common symptom occurring in 138 dialysis sessions (57.5%). Vomiting, chest pain, fever, chills, and breathlessness occurred significantly more during dialysis with CU membrane as compared with PS membrane (P < 0.01). Nausea, cramps, back pain, itching, restlessness, post dialysis fatigue, and hypotension did not differ between the two membranes. The mean rise in the cytokine levels during the first 15 min of sessions where the symptoms occurred, when compared with the mean rise in sessions where the symptoms did not occur, did not reveal any significant difference. Cytokine release did not correlate with the occurrence of intradialytic symptoms.

CONCLUSION

Both CU and PS membranes increase circulating cytokine levels. More intradialytic clinical symptoms are seen in dialysis with CU as compared with PS membrane but the rise in cytokines IL-1beta and TNFalpha does not appear to be responsible for them.

Acute effect of hemodialysis on serum levels of the proinflammatory cytokines

Chronic inflammation is a common feature of end-stage renal disease, which carries a heightened risk of atherosclerosis and other co-morbid conditions. Dialysis treatment per se can bring additional risk factors for inflammation, such as increased risk of local graft and fistula infections, impure dialysate or bio-incompatible membranes. Our study was designed to determine whether a hemodialysis session leads to an acute substantial alteration in the plasma levels of the proinflammatory cytokines interleukin (IL)-6, IL-1beta and tumor necrosis factor (TNF)-alpha, the T-lymphocyte activation factor soluble IL-2 receptor (sIL-2R), and an inflammation mediator and chemotactic granulocyte factor, IL-8, in end-stage renal disease patients receiving chronic intermittent HD. In this study, 21 (12 male/nine female) patients undergoing chronic hemodialysis were enrolled. The acute effect of a hemodialysis session on serum cytokine concentrations was assessed by comparison of pre-hemodialysis and post-hemodialysis determinations. Serum IL-1beta, sIL-2R, IL-6, IL-8 and TNF-alpha levels were determined with chemiluminescence enzyme immunometric assays. A significant difference was not observed for IL-1beta, IL-6, TNF-alpha, and sIL-2R concentrations in pre-hemodialysis and post-hemodialysis specimens (p>0.05). Serum median (25th-75th percentiles) IL-8 concentration was 69.4 (34.9-110.3) pg/ml before hemodialysis, and decreased to 31.5 (18.0-78.8) pg/ml following hemodialysis (p: 0.006). Clearance of IL-8 increased by 0.47+/-0.08 pg/ml for each unit increase in pre-dialysis IL-8 (p<0.001) and decreased by 5.63+/-2.59 pg/ml for each unit increase in pre-dialysis urea mmol/l (p<0.05). In conclusion, the results of our study demonstrate that a hemodialysis session markedly decreases IL-8 concentration, which is significantly affected by pre-dialysis concentrations, indicating that removal of IL-8 is a concentration gradient-dependent action, but does not change the serum levels of IL-1beta, sIL-2R, IL-6, and TNF-alpha, underlining importance of the structural characteristics of the molecules.