Serum parameters, inflammation, renal function and patient outcome

Risk Factors for No-Reflow in Patients with ST-Elevation Myocardial Infarction Who Underwent Percutaneous Coronary Intervention: A Case-Control Study

Methods

This case-control study retrospectively reviewed the medical data of patients treated with primary percutaneous coronary intervention within 12 h after STEMI onset between January 2010 and January 2013 at the Department of Cardiology of the Beijing Anzhen Hospital.

Results

A total of 902 patients were included in the analysis. The basic characteristics between the reflow and no-reflow groups were similar, except for time-to-hospital admission, heart rate, plasma glucose, high-sensitivity C-reactive protein (hsCRP)/prealbumin (PAB), neutrophil count, intraaortic balloon pump, and aspiration thrombectomy. The multivariable analysis showed that hsCRP/PAB (OR = 1.003, 95% CI: 1.000–1.006, P=0.022), neutrophil count (OR = 1.085, 95% CI: 1.028–1.146, P=0.003), plasma glucose levels (OR = 1.086, 95% CI: 1.036–1.138, P=0.001), diabetes mellitus (OR = 0.596, 95% CI: 0.371–0.958, P=0.033), Killip classification >1 (OR = 2.002, 95% CI: 1.273–3.148, P=0.003), intraoperative intraaortic balloon pump (IABP) use (OR = 3.257, 95% CI: 1.954–5.428, P=0.001), and aspiration thrombectomy (OR = 3.412, 95% CI: 2.259–5.152, P=0.001) were independently associated with no-reflow.

Conclusion

hsCRP/PAB, neutrophil count, plasma glucose levels, diabetes mellitus, Killip classification, intraoperative IABP use, and aspiration thrombectomy were independent risk factors for no-reflow in patients with STEMI.

NF-κB and tPA Signaling in Kidney and Other Diseases

The activation of the nuclear factor-κB (NF-κB) pathway plays a central role in the initiation and progression of inflammation, which contributes to the pathogenesis and progression of various human diseases including kidney, brain, and other diseases. Tissue plasminogen activator (tPA), a serine protease regulating homeostasis of blood coagulation, fibrinolysis, and matrix degradation, has been shown to act as a cytokine to trigger profound receptor-mediated intracellular events, modulate the NF-κB pathway, and mediate organ dysfunction and injury. In this review, we focus on the current understanding of NF-κB and tPA signaling in the development and progression of kidney disease. Their roles in the nervous and cardiovascular system are also briefly discussed.

Early Initiation of Dialysis and Late Implantation of Catheters Adversely Affect Outcomes of Patients on Chronic Peritoneal Dialysis

Objectives

Predialysis nephrology care is thought to affect morbidity and mortality in hemodialysis patients. This study evaluated the impact of different patterns of predialysis care on outcomes of patients undergoing chronic peritoneal dialysis (PD).

Design

Retrospective cohort.

Setting and Participants

275 patients enrolled from January 1997 to March 2005 in a medical center in North Taiwan who recently initiated dialysis were classified according to early or late referral to nephrologists (≥ 6 or <6 months of dialysis), planned or late implantation of Tenckhoff catheters (absence or presence of preceding emergent hemodialysis), and early or late start of dialysis [glomerular filtration rate (GFR) ≥ 5 or <5 mL/minute/1.73 m2].

Main Outcome Measures

All-cause mortality and hospitalization.

Results

During a median follow-up of 2.5 years, 41 deaths, 38 transfers to hemodialysis, and 26 renal transplantations occurred. Late start of dialysis was associated with a significant survival benefit (log rank, p = 0.012) and, along with planned implantation of catheters, exhibited a reduced risk for all-cause hospitalization (log rank, p = 0.025, 0.013). The predictors of overall mortality included baseline GFR [hazard ratio (HR) 1.18, p = 0.023], age (HR 1.07, p < 0.001), and diabetes (HR 3.64, p = 0.001); whereas the risk factors for all-cause hospitalization included age (HR 1.02, p = 0.012), late implantation of catheters (HR 1.78, p = 0.011), and diabetes (HR 1.92, p = 0.005). The timing of nephrology referral did not affect either death or hospitalization.

Conclusions

Our data do not support earlier initiation of PD, but underscore the importance of planned implantation of catheters before commencement of chronic PD.

Impact of residual urine volume decline on the survival of chronic hemodialysis patients in Kinshasa

Background

Despite the multiple benefits of maintaining residual urine volume (RUV) in hemodialysis (HD), there is limited data from Sub-Saharan Africa. The aim of this study was to assess the impact of RUV decline on the survival of HD patients.

Methods

In a retrospective cohort study, 250 consecutive chronic HD patients (mean age 52.5 years; 68.8% male, median HD duration 6 months) from two hospitals in the city of Kinshasa were studied, between January 2007 and July 2013. The primary outcome was lost RUV. Preserved or lost RUV was defined as decline RUV < 25 (median decline) or ≥ 25 ml/day/month, respectively. The second endpoint was survival (time-to death). Survival curves were built using the Kaplan-Meier methods. We used Log-rank test to compare survival curves. Predictors of mortality were assessed by Cox proportional hazards regression models.

Results

The cumulative incidence of patients with RUV decline was 52, 4%. The median (IQR) decline in RUV was 25 (20.8–33.3) ml/day/month in the population studied, 56.7 (43.3–116.7) in patients deceased versus 12.9 (8.3–16.7) in survivor patients (p < 0.001). Overall mortality was 78 per 1000 patient years (17 per 1000 in preserved vs 61 per 1000 lost RUV). Forty six patients (18.4%) died from withdrawal of HD due to financial constraints. The Median survival was 17 months in the whole group while, a significant difference was shown between lost (10 months, n = 119) vs preserved RUV group (30 months, n = 131; p = 0001). Multivariate Cox proportional hazards models showed that, decreased RUV (adjusted HR 5.35, 95% CI [2.73–10.51], p < 0.001), financial status (aHR 2.23, [1.11–4.46], p = 0.024), hypervolemia (a HR 2.00, [1.17–3.40], p = 0.011), lacking ACEI (aHR 2.48, [1.40–4.40], p = 0.002) or beta blocker use (aHR 4.04, [1.42–11.54], p = 0.009), central venous catheter (aHR 6.26, [1.71–22.95], p = 0.006), serum albumin (aHR 0.93, [0.89–0.96], p < 0.001) and hemoglobin (aHR 0.73, [0.63–0.84], p < 0.001) had emerged as the independent predictors of all-cause mortality.

Conclusion

More than half of HD patients in this cohort study experienced fast RUV decline which contributed substantially to increase mortality, highlighting the need for its prevention and management.

Dynamic changes of serum cholinesterase activity after severe trauma

OBJECTIVE

The aim of the present study was to examine dynamic changes in serum cholinesterase (ChE) activity during early-stage severe trauma and the clinical significance of these changes.

METHODS

This prospective, observational study included 81 patients with severe trauma who were treated between October 2011 and April 2013 in the emergency intensive care unit (EICU) of a university-affiliated, tertiary-care, grade A general hospital in China. Serum ChE activity was measured on Days 1, 3, and 7 post-injury. The correlation of dynamic changes in serum ChE activity with trauma severity and prognosis was assessed. Correlations between changes in serum ChE activity after injury and albumin (ALB), prealbumin (PAB), transferrin (TRF), and C-reactive protein (CRP) levels were also analyzed.

RESULTS

Serum ChE activity in trauma patients was 42.3%-50.2% lower on Days 1, 3, and 7 compared with the control (P<0.001 for all time points), and it continued to decrease after Day 7 in both the survival and death subgroups. In the subgroup with an injury severity score (ISS) of ≤25, serum ChE activity initially decreased, but eventually increased. However, activity decreased continuously in the ISS>25 subgroup. ChE activity was significantly lower in both the death and the ISS>25 subgroups than in the survival and ISS≤25 subgroups on Days 1, 3, and 7 after injury. Activity was negatively correlated with ISS and acute physiology and chronic health evaluation III (APACHE III) at all time points. When comparing the receiver operating characteristic (ROC) curves for predicting prognosis, the area under the curve (AUC) in the plot of serum ChE was similar to the AUCs in plots of ISS and APACHE III, but significantly smaller than the AUC in the plot of the trauma and injury severity score (TRISS). Serum ChE activity was positively correlated with ALB, PAB, and TRF at all time points post-injury. Activity was not significantly correlated with CRP on Day 1, but was significantly and negatively correlated with CRP on Days 3 and 7.

CONCLUSIONS

There is a significant decrease in serum ChE activity after severe trauma. Serum ChE may be regarded as a negative acute phase protein (APP) and the dynamic changes in serum ChE may be useful as an auxiliary indicator for evaluating trauma severity and predicting prognosis.

Relationship between HSP70-2 A+1267G Polymorphism and Cardiovascular Events of Chinese Peritoneal Dialysis Patients

BACKGROUND

Heat shock proteins (HSPs) are expressed by cells in response to various environmental stresses. A single-nucleotide polymorphism A+1267G of the HSPA1B gene affects the expression of HSP70-2, with the A allele being protective against inflammatory conditions. We investigated the relation between the HSP A+1267G polymorphism and the clinical outcomes of Chinese peritoneal dialysis (PD) patients.

METHODS

We studied 347 new PD cases (181 males, age 56.6 ± 13.7 years). Genotyping was done by standard methods. Patients were followed for 40.5 ± 20.7 months for survival analysis.

RESULTS

For the entire cohort, there was no difference in the 5-year survival between genotype groups. However, there was a significant interaction between HSP polymorphism and diabetic status on the cardiovascular event-free survival. In patients without pre-existing diabetes, 5-year cardiovascular event-free survival of the GG/AG genotype group was significantly better than that of the AA genotype group (57.2 vs. 32.1%, p = 0.011).

CONCLUSION

The G allele of the HSP70-2 A+1267G polymorphism confers survival advantages in non-diabetic PD patients. The role of HSP in the pathogenesis of cardiovascular disease in renal failure patients needs further investigation.

Renoprotective effects of the direct renin inhibitor aliskiren on gentamicin-induced nephrotoxicity in rats

This study aimed to examine the protective effects of aliskiren on gentamicin-induced nephropathy. Rats were injected with gentamicin (100 mg/kg per day) for 14 days. Aliskiren was infused for two weeks. Human proximal tubular epithelial cell lines (HK-2) were cultured with gentamicin in the absence or presence of aliskiren. Inflammatory profibrotic and apoptotic markers were evaluated in vivo and in vitro. Aliskiren treatment attenuated the decreased creatinine clearance, increased fractional sodium excretion, glomerulosclerosis and tubulointerstitial fibrosis and counteracted the increased ED-1 expression in gentamicin-treated rats. The levels of inflammatory cytokines (TNF-α, IL-1β and IFN-γ) and adhesion molecules (MCP-1, ICAM-1 and VCAM-1) increased in the gentamicin-treated kidneys. These changes were restored by aliskiren co-treatment. Aliskiren effectively reversed transforming growth factor-β-induced fibrotic responses such as induction of α-smooth muscle actin in gentamicin-treated rat kidneys. Along with these changes, aliskiren also attenuated the increase in nuclear factor κB and phosphorylated extracellular signal-regulated kinase (pERK 1/2) levels in HK-2 cells cultured with gentamicin. In addition, aliskiren decreased the number of TUNEL-positive nuclei and reduced the expression of proapoptotic markers in gentamicin-treated HK-2 cells. These findings suggest that aliskiren attenuates gentamicin-induced nephropathy by suppression of inflammatory, profibrotic and apoptotic factors through inhibition of the nuclear factor κB, Smads and mitogen-activated protein kinase signaling pathways.

Relationship between CRP polymorphism and cardiovascular events in Chinese peritoneal dialysis patients

BACKGROUND AND OBJECTIVES

The single-nucleotide polymorphism (SNP) -717A→G substitution, rs2794521, was found in the promoter of the C-reactive protein (CRP) gene. Functional studies showed that A allele promoter has higher transcriptional activity than the G allele. This study investigated the association between this SNP and the outcome of Chinese patients undergoing peritoneal dialysis (PD).

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

The study included 441 new PD patients (232 men; mean age ± SD, 56.7±13.5 years). CRP genotyping was determined; patients were followed for 41.3±18.3 months for cardiovascular events.

RESULTS

For the entire cohort, 5-year event-free survival rates did not differ between the AA and AG/GG groups (35.7% and 31.9%, respectively; P=0.64). However, there was significant interaction between plasma cholesterol levels and CRP genotype groups on event-free survival (P=0.04 for interaction). For patients with cholesterol levels of 200 mg/dl or greater, the 5-year event-free survival rate in the AG/GG group was significantly better than that in the AA group (54.7% versus 40.0%; P=0.04), whereas there was no difference in event-free survival between genotype groups for patients with cholesterol levels less than 200 mg/dl.

CONCLUSIONS

CRP gene -717AG or GG genotypes is associated with cardiovascular benefit to Chinese PD patients with cholesterol levels of 200 mg/dl or greater. These findings suggest a complex interaction among cholesterol, CRP, and cardiovascular disease in PD patients.

Serum markers may distinguish biliary atresia from other forms of neonatal cholestasis

BACKGROUND

Biliary atresia (BA) is the most serious liver disease in infants. Diagnosis currently depends on surgical exploration of the biliary tree. Noninvasive tests that distinguish BA from other types of neonatal liver disease are not available.

PATIENTS AND METHODS

To identify potential serum biomarkers that classify children with neonatal cholestasis, we performed 2-dimensional difference gel electrophoresis, statistical analysis, and tandem mass spectrometry using serum samples from 19 infants with BA and 19 infants with non-BA neonatal cholestasis.

RESULTS

Eleven potential serum biomarkers were found that could in combination classify children with neonatal cholestasis.

CONCLUSIONS

Although no single biomarker or imaging test adequately distinguishes BA from other types of neonatal cholestasis, combinations of biomarkers, imaging tests, and noninvasive clinical criteria should be further explored as potential tests for rapid and accurate diagnosis of BA.

Renoprotective effects of paricalcitol on gentamicin-induced kidney injury in rats

Vitamin D is thought to exert a protective effect on renal disease progression, but the underlying molecular mechanism remains unclear. We investigated whether paricalcitol ameliorates tubular dysfunction and fibrosis in gentamicin (GM)-induced renal injury. Two groups of rats were treated with GM (100 mg x kg(-1) x day(-1)), one of which was cotreated with paricalcitol (0.3 microg x kg(-1) x day(-1)) for 14 days and the other was not. The control group was treated with vehicle only. HK-2 cells were cultured with GM in the absence or presence of paricalcitol. Paricalcitol restored impaired renal function and the downregulated renal sodium transporters and aquaporin-1 expression caused by GM. ED-1-expressing monocyte/macrophage accumulation induced by GM was attenuated by paricalcitol treatment. Paricalcitol prevented upregulated inflammatory cytokines (TNF-alpha, IL-1beta, INF-gamma) and adhesion molecules (monocyte chemoattractant protein-1, ICAM-1, VCAM-1) induced by GM. In addition, paricalcitol effectively reversed TGF-beta1-induced epithelial-to-mesenchymal transition (EMT) process and extracellular matrix accumulation in GM-induced nephropathy. Increased collagen deposition and fibrosis in GM-treated kidney were ameliorated by paricalcitol. Paricalcitol also attenuated the upregulated NF-kappaB and phosphorylated ERK1/2 expression in HK-2 cells cultured with GM. In conclusion, paricalcitol prevents GM-induced renal injury by inhibiting renal inflammation and fibrosis, the mechanism of which is the interruption of NF-kappaB/ERK signaling pathway and preservation of tubular epithelial integrity via inhibiting EMT process.

Bicarbonate-Based Peritoneal Dialysis Solution has Less Effect on Ingestive Behavior than Lactate-Based Peritoneal Dialysis Solution

Objective

The anorexia seen in peritoneal dialysis (PD) patients may be due partially to factors of dialysis solutions, such as pH and buffering agent. We tested the effects of different PD solutions in an experimental rat model for appetite.

Design

The intraoral intake of a sucrose solution from an implanted intraoral cannula in freely moving male Wistar rats was used to evaluate appetite at 30 minutes and 120 minutes after intraperitoneal (IP) infusion of bicarbonate (25 mmol/L)/lactate (15 mmol/L)-based PD solution (P) and conventional lactate (40 mmol/L)-based PD solution (D) with different concentrations of glucose. We also tested different buffer solutions containing lactate and bicarbonate with different pH but with no glucose.

Results

The IP infusion as such and the 30 mL volume did not inhibit appetite; however, appetite was significantly less inhibited by P than by D in the 1.36%, 2.27%, and 3.86% solutions ( p < 0.05). Furthermore, intraoral intake was significantly higher in rats receiving IP solution with bicarbonate buffer (pH 7.4) than with lactate buffer ( p < 0.05), whereas there was no significant difference in intraoral intake for lactate with pH 5.5, pH 6.6, or pH 7.4.

Conclusions

The bicarbonate/lactate solution inhibited appetite less than the lactate solution; this was due partially to the use of bicarbonate. The results show possible benefit on appetite of reducing the lactate concentration in PD solutions.

Paricalcitol inhibits renal inflammation by promoting vitamin D receptor-mediated sequestration of NF-kappaB signaling

Inflammation is a pathologic feature of a variety of chronic kidney diseases. Several lines of evidence suggest a potential anti-inflammatory role for vitamin D in chronic kidney disease, but the underlying mechanism remains unknown. Here, the effect of the synthetic vitamin D analogue paricalcitol on renal inflammation was investigated in a mouse model of obstructive nephropathy. Paricalcitol reduced infiltration of T cells and macrophages in the obstructed kidney. This inhibition of inflammatory cell infiltration was accompanied by a decreased expression of RANTES and TNF-alpha. Induction of RANTES was localized primarily to the tubular epithelium, underscoring a role for tubular cells in renal inflammation. In a human proximal tubular cell line (HKC-8), paricalcitol inhibited RANTES mRNA and protein expression and abolished the ability of tubular cells to recruit lymphocytes and monocytes after TNF-alpha stimulation. Although RANTES induction depended on NF-kappaB signaling, paricalcitol affected neither TNF-alpha-mediated IkappaB alpha phosphorylation and degradation nor p65 NF-kappaB activation and nuclear translocation. Instead, chromatin immunoprecipitation assay showed that paricalcitol abolished the binding of p65 to its cognate cis-acting element in the RANTES promoter. The vitamin D receptor (VDR) and p65 formed a complex in tubular cells after paricalcitol treatment, which inhibited the ability of p65 to trans-activate gene transcription. In vivo, paricalcitol did not block NF-kappaB nuclear translocation after obstructive injury but did increase the expression and nuclear distribution of VDR. These results suggest that paricalcitol inhibits renal inflammatory infiltration and RANTES expression by promoting VDR-mediated sequestration of NF-kappaB signaling.

Novel actions of tissue-type plasminogen activator in chronic kidney disease

Tissue-type plasminogen activator (tPA) is traditionally viewed as a simple serine protease whose main function is to convert plasminogen into biologically active plasmin. As a protease, tPA plays a crucial role in regulating blood fibrinolysis, in maintaining the homeostasis of extracellular matrix and in modulating the post-translational activation of growth factors. However, emerging evidence indicates that tPA also functions as a cytokine that transmits its signal across the cell membrane, initiates a diverse array of intracellular signaling, and dictates gene expression in the nuclei. tPA binds to the cell membrane LDL receptor-related protein 1 (LRP-1), triggers its tyrosine phosphorylation. As a cytokine, tPA plays a pivotal role in the pathogenesis of renal interstitial fibrosis through diverse mechanisms. It facilitates tubular epithelial to mesenchymal transition, potentiates myofibroblast activation, and protects renal interstitial fibroblasts/myofibroblasts from apoptosis. Together, growing evidence has implicated tPA as a fibrogenic cytokine that promotes the progression of kidney diseases. These new findings have radically changed our conception of tPA in renal fibrogenesis and represent a paradigm shift towards uncovering its cytokine function.

Cytokine dysregulation in chronic kidney disease: how can we treat it?

As the kidney is the major site for elimination of many cytokines, the delicate equilibrium of pro-inflammatory cytokines and their inhibitors is clearly dysregulated in chronic kidney disease (CKD) patients. The consequences of the altered immune response in uremia lead to a state of persistent inflammation which is highly prevalent among CKD patients and is linked to complications such as the development of protein-energy wasting and atherosclerotic vascular disease. The present review aims at reviewing this complex orchestration of uremic cytokines beyond the well-studied interleukin-6 and tumor necrosis factor-alpha. Finally, we update our current understanding on anti-inflammatory treatment strategies in CKD patients, including nutritional and lifestyle measurements, pharmacological intervention and specific anticytokine strategies targeting the dialytic procedure.