Plasma lipids are not oxidized during hemodialysis

Oxidative Stress in Hemodialysis Patients: A Review of the Literature

Hemodialysis (HD) patients are at high risk for all-cause mortality and cardiovascular events. In addition to traditional risk factors, excessive oxidative stress (OS) and chronic inflammation emerge as novel and major contributors to accelerated atherosclerosis and elevated mortality. OS is defined as the imbalance between antioxidant defense mechanisms and oxidant products, the latter overwhelming the former. OS appears in early stages of chronic kidney disease (CKD), advances along with worsening of renal failure, and is further exacerbated by the HD process per se. HD patients manifest excessive OS status due to retention of a plethora of toxins, subsidized under uremia, nutrition lacking antioxidants and turn-over of antioxidants, loss of antioxidants during renal replacement therapy, and leukocyte activation that leads to accumulation of oxidative products. Duration of dialysis therapy, iron infusion, anemia, presence of central venous catheter, and bioincompatible dialyzers are several factors triggering the development of OS. Antioxidant supplementation may take an overall protective role, even at early stages of CKD, to halt the deterioration of kidney function and antagonize systemic inflammation. Unfortunately, clinical studies have not yielded unequivocal positive outcomes when antioxidants have been administered to hemodialysis patients, likely due to their heterogeneous clinical conditions and underlying risk profile.

Hepato-renal protective effects of hydroethanolic extract of Senna alata on enzymatic and nonenzymatic antioxidant systems in streptozotocin induced diabetic rats

BACKGROUND

Oxidative stress induced tissue damage might be the major cause for diabetes mellitus and its associated complications. The management of such oxidative stress is the biggest challenge over the decade. The main objective was to analyze the protective effect of ethanolic extract of Senna alata L leaves on enzymatic and nonenzymatic antioxidant systems of hepatic and renal tissues in Streptozotocin-induced diabetes in rats.

METHODS

The use of streptozotocin diabetes was induced in the experimental rats and the subsequent therapeutic effects of standard drug glibenclamide and Senna alata L were compared. The levels of plasma insulin, glucose, urea, uric acid, creatinine, vitamin C, vitamin E, reduced glutathione, superoxide dismutase, catalase, glutathione peroxidase, and glutathione-s-tranferase were assayed in control and experimental groups of rats.

RESULTS

These alterations were detected throughout the study duration after the treatment with Senna alata L and glibenclamide. A significant raise followed by the treatment with Senna alata leaves in vitamin E, catalase, glutathione peroxidase and glutathione-s-tranferase was observed. It has been found that notable decline in the levels of vitamin C, reduced glutathione were observed in diabetic rats. The liver and kidney based antioxidant enzyme activities were significantly responsive to the treatment in diabetic rats. Apart from these antioxidant system, some vital changes were detected in the typical biochemical parameters such as level of protein, urea, uric acid, and creatinine from abnormal into normal in both the control and induced rats.

CONCLUSION

From the above said observations, it was very clear that, Senna alata has helped to manage the oxidative tension in diabetic rats, which in turn may greatly support the hypoglycaemic potency of Senna alata L.

Effects of Nigella sativa and thymoquinone on biochemical and subcellular changes in pancreatic β-cells of streptozotocin-induced diabetic rats

BACKGROUND

The present study investigated the effects of Nigella sativa aqueous extract and oil, as well as thymoquinone, on serum insulin and glucose concentrations in streptozotocin (STZ) diabetic rats.

METHODS

Rats were divided into five experimental groups (control, untreated STZ-diabetic, and aqueous extract-, oil-, or thymoquinone-treated diabetic rats). Treated rats received 2 mL/kg, i.p., 5%N. sativa extract, 0.2 mL/kg, i.p., N. sativa oil, or 3 mg/mL, i.p., thymoquinone 6 days/week for 30 days. Serum insulin and glucose concentrations, superoxide dismutase (SOD) levels, and pancreatic tissue malondialdehyde (MDA) were determined. Electron microscopy was used to identify any subcellular changes.

RESULTS

Diabetes increased tissue MDA and serum glucose levels and decreased insulin and SOD levels. Treatment of rats with N. sativa extract and oil, as well as thymoquinone, significantly decreased the diabetes-induced increases in tissue MDA and serum glucose and significantly increased serum insulin and tissue SOD. Ultrastructurally, thymoquinone ameliorated most of the toxic effects of STZ, including segregated nucleoli, heterochromatin aggregates (indicating DNA damage), and mitochondrial vacuolization and fragmentation. The aqueous extract of N. sativa also reversed these effects of STZ, but to a lesser extent. The N. sativa oil restored normal insulin levels, but failed to decrease serum glucose concentrations to normal.

CONCLUSIONS

The biochemical and ultrastructural findings suggest that N. sativa extract and thymoquinone have therapeutic and protect against STZ-diabetes by decreasing oxidative stress, thus preserving pancreatic β-cell integrity. The hypoglycemic effect observed could be due to amelioration of β-cell ultrastructure, thus leading to increased insulin levels. Consequently, N. sativa and thymoquinone may prove clinically useful in the treatment of diabetics and in the protection of β-cells against oxidative stress.

Reactive Oxygen Metabolites: A Link between Oxidative Stress and Inflammation in Patients on Hemodialysis

Oxidative stress plays a significant role in the development of inflammation in patients undergoing hemodialysis (HD). This study intends to evaluate the relationship between C-reactive protein (CRP) and the newly established marker of lipid peroxidation, d-ROMs (reactive oxygen metabolites), in comparison with different indicators of oxidative stress. Plasma total antioxidant capacity (TAC), lipid peroxidation products malonaldehyde (MDA) and 4-hydroxyalkenals, as well as d-ROMs, were determined in 24 patients before HD and in 21 normal controls (NC). It was found that HD patients had higher levels of d-ROMs than NC (p = 0.033). A highly significant positive correlation was observed between logCRP and d-ROMs concentrations (p < 0.0001, r = 0.85) in patients, but not in NC. The concentrations of TAC and MDA were not associated with CRP in HD or in NC individuals. It is concluded that d-ROMs concentration is a potent marker of oxidative injury that is strongly indicative of the inflammatory status in HD patients.

Beneficial effects of Murraya koenigii leaves on antioxidant defense system and ultra structural changes of pancreatic β-cells in experimental diabetes in rats

Oxidative stress and oxidative damage to tissues are common end points of chronic diseases such as atherosclerosis, diabetes, and rheumatoid arthritis. Oxidative stress in diabetes coexists with a reduction in the antioxidant status, which can further increase the deleterious effects of free radicals. The aim of the present study was to evaluate the possible protective effects of Murraya koenigii leaves extract against beta-cell damage and antioxidant defense systems of plasma and pancreas in streptozotocin induced diabetes in rats. The levels of glucose and glycosylated hemoglobin in blood and insulin, Vitamin C, Vitamin E, ceruloplasmin, reduced glutathione and TBARS were estimated in plasma of control and experimental groups of rats. To assess the changes in the cellular antioxidant defense system such as the level of reduced glutathione and activities of superoxide dismutase, catalase and glutathione peroxidase were assayed in pancreatic tissue homogenate. The levels of glucose, glycosylated hemoglobin, insulin, TBARS, enzymatic and non-enzymatic antioxidants were altered in diabetic rats. These alterations were reverted back to near control levels after the treatment of M. koenigii leaves extract. Transmission electron microscopic studies also revealed the protective nature of M. koenigii leaves on pancreatic beta-cells. These findings suggest that M. koenigii treatment exerts a therapeutic protective nature in diabetes by decreasing oxidative stress and pancreatic beta-cell damage. The antioxidant effect of the M. koenigii extract was compared with glibenclamide, a well-known hypoglycemic drug.

Skeletal muscle, cytokines, and oxidative stress in end-stage renal disease

BACKGROUND

End-stage renal disease (ESRD) is a state of microinflammation, with increased activation of cytokines and augmented oxidative stress. While peripheral blood mononuclear cells are an established source of reactive oxygen species and inflammatory cytokines during hemodialysis (HD), skeletal muscle is also capable of generating these biomolecules.

METHODS

Femoral arterio-venous (A-V) balance of interleukin-1 (IL-1), IL-6, IL-10, tumor necrosis factor-alpha (TNF-alpha), malonyldialdehyde (MDA), and carbonyl protein (CP) were measured in 17 ESRD patients and 9 healthy volunteers. ESRD patients were studied before (pre-HD) and during HD. mRNA levels of cytokines, heme oxygenase-1 (HO-1), and suppressors of cytokine signaling-2 (SOCS-2) were quantitated in the skeletal muscle by real-time polymerase chain reaction (PCR).

RESULTS

Arterial concentration of MDA (pmol/mL) was higher pre-HD (325.5 +/- 19.6) compared to controls (267.7 +/- 14.7), but decreased intradialysis (248.8 +/- 16.1) (P < 0.01). Dialysis clearance of MDA was 16.9 +/- 3.1 mL/min. CP concentration (nmol/mg protein) in the artery was significantly higher pre-HD (2.29 +/- 0.09) than in controls (1.92 +/- 0.05), and remained stable during HD (2.23 +/- 0.07). Plasma cytokines increased to a variable degree in the artery and vein during HD. A-V balance studies demonstrated that the MDA (17.8%) and CP (5.1%) concentrations increased significantly in the vein intradialysis. Venous concentration of IL-6 was higher than that in the artery during dialysis (16.27 +/- 2.42 vs. 11.29 +/- 2.17 pg/dL, P < 0.01). mRNA levels of IL-6 (0.028 +/- 0.02 vs. 6.69 +/- 0.21), HO-1 (0.96 +/- 0.01 vs. 5.08 +/- 1.11), and SOCS-2 (0.63 +/- 0.12 vs. 0.82 +/- 0.14) in the muscle increased during HD (P < 0.01). Immunohistochemical studies confirmed the increase in IL-6 protein in the skeletal muscle during HD. The intradialytic increase in IL-1, IL-10, and TNF-alpha gene expression was not significant.

CONCLUSION

Skeletal muscle may also contribute to the circulating plasma IL-6 and increased oxidative stress during HD.

Effects of Nigella sativa on oxidative stress and beta-cell damage in streptozotocin-induced diabetic rats

The aim of the present study was to evaluate the possible protective effects of Nigella sativa L. (NS) against beta-cell damage from streptozotocin (STZ)-induced diabetes in rats. STZ was injected intraperitoneally at a single dose of 50 mg/kg to induce diabetes. NS (0.2 ml/kg/day, i.p.) was injected for 3 days prior to STZ administration, and these injections were continued throughout the 4-week study. Oxidative stress is believed to play a role in the pathogenesis of diabetes mellitus (DM). To assess changes in the cellular antioxidant defense system, we measured the activities of antioxidant enzymes (such as glutathione peroxidase (GSHPx), superoxide dismutase (SOD), and catalase (CAT)) in pancreatic homogenates. We also measured serum nitric oxide (NO) and erythrocyte and pancreatic tissue malondialdehyde (MDA) levels, a marker of lipid peroxidation, to determine whether there is an imbalance between oxidant and antioxidant status. Pancreatic beta-cells were examined by immunohistochemical methods. STZ induced a significant increase in lipid peroxidation and serum NO concentrations, and decreased antioxidant enzyme activity. NS treatment has been shown to provide a protective effect by decreasing lipid peroxidation and serum NO, and increasing antioxidant enzyme activity. Islet cell degeneration and weak insulin immunohistochemical staining was observed in rats with STZ-induced diabetes. Increased intensity of staining for insulin, and preservation of beta-cell numbers were apparent in the NS-treated diabetic rats. These findings suggest that NS treatment exerts a therapeutic protective effect in diabetes by decreasing oxidative stress and preserving pancreatic beta-cell integrity. Consequently, NS may be clinically useful for protecting beta-cells against oxidative stress.

The effect of different dialysis membranes on oxidative stress and selenium status

BACKGROUND

Oxidative stress is an important risk factor for the development and progression of several complications in hemodialysis patients. The aim of this study was to evaluate the effects of two different dialysis membranes on oxidative stress and selenium status.

METHODS

Forty long-term dialysis patients and 20 age-matched healthy controls were enrolled into our study. Serum malondialdehyde (MDA) and selenium (Se) concentrations, and glutathione peroxidase (GSH-Px) activities were determined before and after hemodialysis (HD) using a hemophan (H) or a polysulfone (PS) membrane.

RESULTS

MDA levels in the HD patients were significantly higher than those in the control group (p < 0.001). GSH-Px activity and selenium concentrations were significantly lower in HD patients compared to the control group (p < 0.001). MDA levels were significantly increased (p < 0.05); GSH-Px activity and selenium concentrations were significantly reduced (p < 0.001) in the PS membrane group compared to H membrane group after HD.

CONCLUSIONS

Comparing with H membrane, PS membrane caused more oxidative stress and lower levels of Se in HD patients.

No acute impact of haemodialysis treatment on free radical scavenging enzyme gene expression in white blood cells

OBJECTIVE

Oxidative stress has been implicated in the side-effects caused by haemodialysis (HD) treatment.

DESIGN

In the present study we have investigated whether gene expression of the enzymatic defence system provided by cellular glutathione peroxidase (GPx-1), phospholipid glutathione peroxidase (GPx-4), glutathione reductase (GSSG-R), glutathione synthethase (GSH-S), Cu/Zn-superoxide dismutase (SOD-1) and catalase (CAT) is affected by HD. The GPx-1, GPx-4, GSSG-R, GSH-S, SOD-1 and CAT mRNA were determined in white blood cells by quantitative reverse transcriptase-polymerase chain reaction with the LightCycler instrument and transcription elongation factor-2 as reference gene at the start (SD) and immediately after (ED) dialysis treatment (n = 36). In a subgroup (n = 10), messenger RNA (mRNA) expression was determined hourly during a 5 h HD.

RESULTS

The expression of GPx-1, GPx-4, GSSG-R, GSH-S, SOD-1 and CAT mRNA was not affected by a single HD treatment. All mRNAs were significantly (P < 0.05) increased in HD patients [median (16. percentiles (perc.); 84. perc.)]: GPx-1: 2.18 (0.89; 3.23); GPx-4: 0.41 (0.26; 0.74); GSSG-R: 0.04 (0.02; 0.10); GSH-S: 0.04 (0.02; 0.08); SOD-1: 0.32 (0.20; 0.62); CAT: 0.12 (0.06; 0.18) when compared with healthy blood donors (GPx-1: 0.91 (0.60; 1.44); GPx-4: 0.27 (0.16; 0.43); GSSG-R: 0.02 (0.01; 0.02); GSH-S: 0.02 (0.02; 0.04); SOD-1: 0.15 (0.10; 0.18); CAT: 0.07 (0.04; 0.16).

CONCLUSIONS

These results show that the HD procedure does not acutely affect the antioxidant defence system on the gene level but suggest that the chronic stress caused by uraemia and/or HD may cause gene induction of the enzymatic defence system.

Oxidative stress in haemodialysis--intradialytic changes

Oxidative stress is likely to be involved in the development of complications due to haemodialysis. Though there is evidence for production of oxygen free radicals during haemodialysis, reports on net oxidative imbalance due to a single dialysis session are conflicting. Hence, a time-course analysis of changes in lipid peroxides (LPO) along with antioxidant enzymes and vitamins was carried out. Hourly changes in LPO and antioxidants were studied during a first-use cuprophan membrane and acetate dialysis in 20 patients on regular haemodialysis treatment. Data were corrected for haemoconcentration and standardised to measure the rate of change before statistical evaluation using analysis of variance for repeated measures. The results of the study showed a net oxidative stress due to a single dialysis session in the form of increased plasma and erythrocyte lipid peroxidation, decrease in plasma vitamin E, slight increase in plasma superoxide dismutase and erythrocyte glutathione peroxidase and no change in plasma glutathione peroxidase. erythrocyte superoxide dismutase and plasma vitamin A levels. The oxygen radical production was found to be maximum in the first hour of dialysis.

Effect of Nigella sativa on glucose concentration, lipid peroxidation, anti-oxidant defence system and liver damage in experimentally-induced diabetic rabbits

This study was carried out to investigate whether Nigella sativa could decrease the lipid peroxidation, increase the anti-oxidant defence system and also prevent the lipid-peroxidation-induced liver damage in experimentally induced diabetic rabbits. Fifteen New Zealand male rabbits were divided into three experimental groups: control, diabetic and diabetic and N. sativa-treated. The diabetes mellitus (DMI) was induced in the rabbits using 150 mg/kg of 10% alloxan. The diabetic + N. sativa-treated group was given extract of N. sativa seeds orally every day for 2 months after induction of DM. At the end of the 2-month experiment, blood samples were collected to measure malondialdehyde (MDA), glutathione (GSH), ceruloplasmin and glucose concentration, and livers were harvested for histopathological analysis. Treatment with N. sativa decreased the elevated glucose and MDA concentrations, increased the lowered GSH and ceruloplasmin concentrations, and prevented lipid-peroxidation-induced liver damage in diabetic rabbits. It was concluded that N. sativa might be used in diabetic patients to prevent lipid peroxidation, increase anti-oxidant defence system activity and also prevent liver damage.

Hemolipodialysis attenuates oxidative stress and removes hydrophobic toxins

Uremic patients undergoing hemodialysis often have increased oxidant stress and accumulation of uremic toxins. Hemodialysis, per se, often can exacerbate oxidant stress and may be inefficient at removing hydrophobic or protein bound toxins. We describe a new hemodialytic method that incorporates liposomes and antioxidants to remove hydrophobic/uremic toxins and minimize free radical mediated damage. In vitro experiments measured advanced oxidation protein products (AOPP), malonaldehyde, reactive carbonyls, and the removal of platelet activating factor (PAF) and bilirubin during extracorporeal circulation with or without liposomes. We observed a significant reduction of oxidation products as well as a significant removal of PAF and bilirubin compared to normal hemodialysis.

Haemolysis in haemodialysis patients: evidence for impaired defence mechanisms against oxidative stress

BACKGROUND

Uraemic patients have a decreased ability to withstand oxidative stress. It is postulated that their antioxidant capacity is reduced, yet the mechanism remains unclear. Recently 33 haemodialysis (HD) patients were exposed to chloramine contamination in the water supply. This led to haemolysis in 24 patients, while nine were unaffected. In the former group haemoglobin decreased from 11.7+/-1.1 to 8.5+/- 1.4 g/dl (P<0.0001) and returned to 11.4+/-0.9 g/dl (P<0.0001) following recovery. During haemolysis, haptoglobin was 38.4+/-10.6 vs 138.1+/-8.3 ng/dl (P<0.0001) following recovery.

METHODS

To explore the factors affecting the severity of haemolysis we studied extracellular and intracellular anti-oxidant defence mechanisms 3 months after recovery. In 29 patients and 20 controls we determined plasma glutathione (GSH), and the erythrocyte enzymes glutathione peroxidase (GSH-Px), glutathione reductase (GSH-Rx), and superoxide dismutase (SOD). Serum malondialdehyde (MDA) was measured as a marker of oxidative stress.

RESULTS

Plasma GSH was lower in patients as compared to controls (5.49+/-0.26 vs 7.4+/-0.5 micromol/l, P<0.005). There was an inverse correlation between GSH and the degree of haemolysis (r=-0.42, P<0.02). Patients had higher GSH-Rx (4.64+/-0.15 vs 3.97+/-0.12 U/gHb, P<0.02), lower GSH-Px (29. 7+/-1.85 vs 35.5+/-1.62 U/gHb, P<0.001), and similar SOD (0.63+/-0. 02 vs 0.51+/-0.02 U/mgHb) as compared to controls. There was no correlation between the enzyme levels and the degree of haemolysis. MDA was higher in patients (2.37+/-0.07 vs 0.97+/-0.1 nmol/ml, P<0. 0001). There was a correlation between MDA and the years patients were on HD (r=0.43, P<0.02).

CONCLUSIONS

These data indicate that HD patients have an impaired anti-oxidant response, which may be attributed in part, to plasma GSH deficiency. Patients with the lowest plasma GSH levels are more susceptible to oxidative stress and consequent haemolysis.

Acute effect of H.E.L.P. treatment on radical scavenging enzyme activities, total glutathione concentrations in granulocytes, and selenium in plasma

BACKGROUND

It has been suggested that granulocytes are activated on artificial surfaces such as dialyzer membranes or by plasma separation procedures resulting in the generation of free radicals. We reported recently that free radical scavenging enzyme (FRSE) activities of red blood cells obtained from patients undergoing hemodialysis and LDL-apheresis (LA) do not reflect an acute oxidative stress. However, because mature red cells are free of DNA and RNA, enzymes cannot be regulated on the gene level. In contrast, granulocytes are nucleated cells in which genes can be regulated, e. g. by redox sensitive transcription factors activated by extracellular oxidative stress. Therefore, granulocyte FRSE may better reflect acute oxidative stress caused by extracorporeal treatment.

MATERIALS AND METHODS

Hyperlipidemic patients (n = 18) with coronary heart disease (CHD) were treated with the Heparin-induced-Extracorporeal-LDL-Precipitation (H.E.L.P.) system. Glutathione peroxidase (GSH-Px), glutathione reductase (GSSG-R), superoxide dismutase (SOD) activities, and total glutathione were determined in granulocytes before and immediately after a single LA treatment. Selenium (Se) concentrations were assessed in plasma.

RESULTS

As a result of the H.E.L.P. treatment GSSG-R activity was significantly induced (+ 20%) and the GSH concentration increased (+ 41%) in granulocytes. GSH-Px activity in granulocytes (- 19%) and Se in plasma (- 27%) were significantly reduced whereas SOD activity in granulocytes was not affected by the H.E.L.P. procedure.

CONCLUSION

These results show that the defence against oxygen radicals in granulocytes is affected but not severely compromised in patients undergoing regular H.E.L.P-LDL-apheresis treatment, which points to the safety of this system with respect to oxidative stress.

Serum malondialdehyde and prevalent cardiovascular disease in hemodialysis

BACKGROUND

Oxidative stress has been proposed as a mechanism by which the accelerated rate of cardiovascular disease (CVD) observed in maintenance hemodialysis (HD) patients may be explained. This study examined the effects of HD and CVD on serum malondialdehyde (MDA) levels as a marker of oxidative stress in HD patients with and without prevalent CVD. Serum MDA levels and CVD prevalence in HD were modeled.

METHODS

Serum MDA was determined using spectrophotometry in HD patients (N = 76, 53 men and 23 women, mean age 63.8 years) immediately prior to and at the conclusion of one midweek HD treatment. Traditional CVD risk factors, including serum lipids, lipoproteins, apolipoproteins, and fibrinogen, were also measured, as were serum chemistry and dialysis adequacy.

RESULTS

Mean serum MDA levels were significantly elevated in HD patients with prevalent CVD compared with those without, whereas serum lipoprotein and plasma fibrinogen levels did not differ between the two groups. Patients in the highest compared with the lowest tertile of postdialysis MDA were nearly four times as likely to have prevalent CVD, and serum MDA was the single strongest predictor of prevalent CVD in this patient population.

CONCLUSIONS

These findings indicate the presence of oxidative stress in HD patients, and are consistent with the theory of oxidative stress as a factor in accelerated CVD in this population.

Comparison of hemostatic factors and serum malondialdehyde as predictive factors for cardiovascular disease in hemodialysis patients

Hemodialysis (HD) patients have accelerated cardiovascular morbidity and mortality rates compared with the general population. Identifying the factors that predict major coronary events in this population can direct the focus on prevention. This cross-sectional study compares known and suspected cardiovascular risk factors in HD patients with and without prevalent cardiovascular disease (CVD). In 76 HD patients (prevalent CVD, 44 of 76 patients), serum lipid, lipoprotein, apolipoprotein (Apo), plasma fibrinogen, tissue plasminogen activator (TPA), plasminogen activator inhibitor (PAI-1), and factor VII levels were measured using standard kits. Serum malondialdehyde (MDA; a marker of oxidative stress) was measured using spectrophotometry. Predictor variables were compared using analysis of variance and chi-squared tests, as appropriate. CVD prevalence was modeled using multiple logistic regression analysis, and odds ratios (OR) were calculated. Serum lipid, lipoprotein, Apo, plasma TPA, PAI-1, and factor VII values did not differ significantly from laboratory norms or discriminate for prevalent CVD in HD patients. Plasma fibrinogen levels were significantly elevated in HD patients compared with laboratory norms (369.4 +/- 130.02 v 276.7 +/- 77.7 mg/dL; P < 0.0001) but were not significantly different in HD patients with and without prevalent CVD. Serum MDA levels, both before and after the midweek HD treatment, were significantly elevated in all HD patients compared with laboratory norms (pretreatment, 2.6 +/- 0.8 nmol/mL; posttreatment, 2.1 +/- 0.3 v 0.91 +/- 0.09 nmol/mL; P < 0.01) and were significantly elevated in HD patients with prevalent CVD versus those without (pretreatment, 2.8 +/- 0.6 v 2.4 +/- 0.4 nmol/mL; P < 0.01; posttreatment, 2.3 +/- 0.4 v 1.94 +/- 0.2 nmol/mL; P < 0.01). Only serum MDA levels, both before and after the midweek treatment, contributed to the explanation of variation in CVD prevalence. OR for CVD in the highest versus lowest tertile of pretreatment MDA level was 2.71 (95% confidence interval [CI], 1.42 to 5.19). ORs for CVD in the highest versus lowest tertile of posttreatment MDA level was 3.65 (95% CI, 1.6 to 8.32).

Activity of free radical scavenging enzymes in red cells and plasma of patients undergoing extracorporeal low-density lipoprotein apheresis

There is evidence that reactive oxygen species (ROSs) are generated in extracorporeal circuits. Free radical scavenging enzymes (FRSEs) such as glutathione reductase (GSSG-R), glutathione peroxidase (GSH-Px), and superoxide dismutase (SOD) protect against the damaging effect of ROSs. The influence of extracorporeal treatment on FRSE activity was investigated in the plasma and red blood cells (RBCs) of 21 patients undergoing regular low-density lipoprotein (LDL) apheresis. The FRSEs GSSG-R, GSH-Px, and SOD were measured. Determinations were made before and after a single treatment. Because all apheresis patients suffered from coronary heart disease (CHD), 201 CHD patients and 90 individuals without CHD, neither group undergoing apheresis, served as controls. In apheresis patients, GSH-Px (33.9+/-8.2 U/g Hb) and GSSG-R (7.6+/-0.9 U/g Hb) activities were increased whereas SOD activity (5.4+/-1.5 U/g Hb) was decreased in RBCs before a single treatment compared to controls. Plasma FRSEs of apheresis patients were not different from those of controls. There was no effect of a single treatment on FRSEs in RBCs. However, a significant decrease in plasma GSH-Px activity (209.9+/-24.9 U/ml) due to the extracorporeal treatment was observed. These data show that long-term extracorporeal therapy with LDL apheresis modulates the activity of antioxidant enzymes in RBCs whereas a single treatment was without major effect on FRSE activity in RBCs and plasma, except for plasma GSH-Px.

Decreased total antioxidant capacity but normal lipid hydroperoxide concentrations in sera of critically ill patients

Oxidative stress (when free radical generation exceeds antioxidant defense) occurs in many human diseases and makes significant contributions to their pathogenesis. We automated assays estimating the antioxidant status of serum, and lipid hydroperoxide concentrations using the Monarch analyzer. In this assay, the antioxidant status of serum is measured by its ability to inhibit generation of free radicals from 2,2'-amino-di-[3-ethylbenzthiazole sulphonate] by metmyoglobin and hydrogen peroxide. The assay for measuring lipid peroxidation products in serum utilizes the ability of lipid hydroperoxides to generate methylene blue from 10N-methylcarbamyl 3,7-dimethylamino 10H-phenothiazine. We detected no lipid hydroperoxide in sera obtained from 24 controls. The mean antioxidant status was 1.69 mmol/l (SD; 0.20 mmol/l) in controls. The antioxidant capacity of serum was significantly reduced in sera of critically ill patients in the medical intensive care unit (mean = 1.05, SD = 0.26 mmol/l) with p value less than 0.05 by independent t-test, two tailed. Lipid peroxidation products were not significantly elevated in critically ill patients, however lipid peroxidation products were significantly elevated in hemodialysis patients (mean = 1.40, SD = 0.47 mumol/l) and in some kidney transplant recipients. We conclude that antioxidant capacity of sera in critically ill patients is significantly reduced.

Protein oxidation in hemodialysis and kidney transplantation

Oxidative damage of plasma proteins determined with the markers carbonyl group (CG) content and thiobarbituric acid-reactive substances (TBARS) was studied in 13 hemodialyzed and eight kidney-transplanted patients. The level of CGs was 38% higher in hemodialysis (HD) patients (1.49 +/- 0.05 nmol/mg protein) than in the healthy subjects (1.08 +/- 0.03 nmol/mg protein); the TBARS level was also higher in HD patients than in the control group (2.64 +/- 0.15 v 1.81 +/- 0.09 nmol/mL, P < .001). These data confirm that in end-stage renal failure, an increased oxidative stress is present and is able to induce protein damage. After transplantation, the CG content in protein was reduced (1.34 +/- 0.08 nmol/mg protein), but it was not significantly different from the level in the HD group. The failure to return to the normal range suggests that an impaired redox status is maintained, resulting in a sustained elevation of CG. Conversely, the level of TBARS in transplanted patients (1.99 +/- 0.22 nmol/mL) was not significantly different from that in the control group (1.81 +/- 0.09), suggesting that lipoperoxidation may be inhibited. These results may be explained by the different turnover rates of the molecules and by the distinct origin of the two markers, resulting from the damage of proteins or lipids. Thus, lipoperoxidation would produce rapidly removable molecules, whereas protein oxidation damage would tend to accumulate. However, the significant correlation found between CGs and TBARS indicates that a common cause (oxidative stress) binds the two markers of damage.

Influence of dialysis on plasma lipid peroxidation products and antioxidant levels

In patients with end-stage renal failure (ESRF), the incidence of atherosclerosis and cancer is increased. The importance of lipid peroxidation (LPO) products in the pathogenesis of these complications has recently been emphasized. The LPO products malondialdehyde (MDA) and hexanal, lipophilic antioxidants and erythrocyte glutathione (GSH) were estimated in 10 pediatric hemodialysis (HD) patients before and after HD and in 11 peritoneal dialysis (CPD) patients. Before HD, MDA was elevated [median (interquartile range): 384.5 (110 to 501) nM; normal < 150 nM], whereas plasma hexanal levels were normal in all patients [130.5 (88 to 222) nM; < 320 nM]. HD decreased MDA concentrations on average by 88% but did not change hexanal levels. CPD patients exhibited high plasma MDA concentrations [371 (287 to 468) nM], whereas hexanal was in the low normal range [56 (51 to 81) nM]. Antioxidants were normal in both groups and unchanged during HD. GSH decreased slightly during HD. We hypothesize that MDA may accumulate in ESRF due to reduced plasma clearance. Our results argue against a general increase of LPO in uremia.

On the pathogenesis of atherosclerosis: enzymatic transformation of human low density lipoprotein to an atherogenic moiety

Combined treatment with trypsin, cholesterol esterase, and neuraminidase transforms LDL, but not HDL or VLDL, to particles with properties akin to those of lipid extracted from atherosclerotic lesions. Single or double enzyme modifications, or treatment with phospholipase C, or simple vortexing are ineffective. Triple enzyme treatment disrupts the ordered and uniform structure of LDL particles, and gives rise to the formation of inhomogeneous lipid droplets 10-200 nm in diameter with a pronounced net negative charge, but lacking significant amounts of oxidized lipid. Enzymatically modified LDL (E-LDL), but not oxidatively modified LDL (ox-LDL), is endowed with potent complement-activating capacity. As previously found for lipid isolated from atherosclerotic lesions, complement activation occurs to completion via the alternative pathway and is independent of antibody. E-LDL is rapidly taken up by human macrophages to an extent exceeding the uptake of acetylated LDL (ac-LDL) or oxidatively modified LDL. After 16 h, cholesteryl oleate ester formation induced by E-LDL (50 micrograms/ml cholesterol) was in the range of 6-10 nmol/mg protein compared with 3-6 nmol/mg induced by an equivalent amount of acetylated LDL. At this concentration, E-LDL was essentially devoid of direct cytotoxic effects. Competition experiments indicated that uptake of E-LDL was mediated in part by ox-LDL receptor(s). Thus, approximately 90% of 125I-ox-LDL degradation was inhibited by a 2-fold excess of unlabeled E-LDL. Uptake of 125I-LDL was not inhibited by E-LDL. We hypothesize that extracellular enzymatic modification may represent an important step linking subendothelial deposition of LDL to the initiation of atherosclerosis.

Lack of plasma lipid peroxidation during LDL-apheresis by heparin-induced extracorporeal LDL-precipitation

The heparin-induced extracorporeal precipitation of low density lipoproteins (HELP) is a well established clinical apheresis procedure to markedly reduce cholesterol levels. The biocompatibility of this filter system was investigated by the determination of lipid peroxidation products. Both lipid hydroperoxides and thiobarbituric acid reactive substances (TBARS) were determined before, during and after 38 aphereses in 21 patients undergoing regular HELP treatment. Although HELP patients had significantly elevated TBARS compared to 93 healthy controls (3.13 +/- 0.64 vs. 1.66 +/- 0.50 mumol L-1; P < 0.01), no significant differences were observed compared to either 104 patients suffering from angiographically confirmed coronary heart disease (3.42 +/- 0.81 mumol L-1; P > 0.05 vs. HELP patients) or 38 aged-matched hyperlipidaemic patients (3.30 +/- 0.75 mumol L-1; P > 0.05 vs. HELP patients), neither of which were included in the HELP programme. No lipid hydroperoxides were detected in the plasma of HELP patients either before or after the extracorporeal treatment. After the LDL-apheresis TBARS were significantly decreased (2.60 +/- 0.52 mumol L-1) compared to the values before the treatment (P < 0.01). There was no evidence for the formation of lipid hydroperoxides within the HELP circuit. It is suggested, therefore, that plasma lipids are not oxidized by the HELP procedure.

Decreased clearance of low-density lipoprotein in uremic patients under dialysis treatment

The clearance of low-density lipoprotein (LDL) was studied in eleven patients on hemodialysis (HD) treatment and nine patients on continuous ambulatory peritoneal dialysis (CAPD) treatment and compared with the clearance of LDL in nine control subjects. The clearance rates for LDL (fractional catabolic rate, FCR) in all the uremic patients (FCR for LDL 0.305 +/- 0.075 pools/day, mean +/- SD) were significantly lower than the clearance of LDL in the control subjects (FCR for LDL 0.376 +/- 0.045 pools/day; P = 0.01). The clearance of LDL in the HD patients (FCR for LDL 0.334 +/- 0.066 pools/day) was only mildly decreased in comparison to the control subjects (P = 0.122), but the clearance of LDL in the CAPD patients was markedly decreased (FCR for LDL 0.268 +/- 0.072 pools/day) in comparison to the control subjects (P = 0.001). The FCR for LDL among all the patients was negatively related to the plasma total cholesterol (r = -0.56, P = 0.01) and LDL cholesterol concentration (r = -0.76, P = 0.0002) and LDL apolipoprotein B concentration (r = -0.48, P = 0.03). In conclusion, the clearance of LDL is decreased in uremic patients on dialysis treatment. This alteration in the LDL metabolism of the uremic patients may contribute to their accelerated atherosclerosis.