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Oberacker T, Fritz P, Schanz M, Alscher MD, Ketteler M, Schricker S. Enhanced Oxidative DNA-Damage in Peritoneal Dialysis Patients via the TXNIP/TRX Axis. Antioxidants (Basel) 2022; 11:antiox11061124. [PMID: 35740021 PMCID: PMC9220040 DOI: 10.3390/antiox11061124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/02/2022] [Accepted: 06/04/2022] [Indexed: 02/04/2023] Open
Abstract
Peritoneal dialysis (PD) is an effective method of renal replacement therapy, providing a high level of patient autonomy. Nevertheless, the long-term use of PD is limited due to deleterious effects of PD fluids to the structure and function of the peritoneal membrane leading to loss of dialysis efficacy. PD patients show excessive oxidative stress compared to controls or chronic kidney disease (CKD) patients not on dialysis. Therefore, defense systems against detrimental events play a pivotal role in the integrity of the peritoneal membrane. The thioredoxin-interacting-protein (TXNIP)/thioredoxin (TRX) system also plays a major role in maintaining the redox homeostasis. We hypothesized that the upregulation of TXNIP negatively influences TRX activity, resulting in enhanced oxidative DNA-damage in PD patients. Therefore, we collected plasma samples and human peritoneal biopsies of healthy controls and PD patients as well. Using ELISA-analysis and immunohistochemistry, we showed that PD patients had elevated TXNIP levels compared to healthy controls. Furthermore, we demonstrated that PD patients had a reduced TRX activity, thereby leading to increased oxidative DNA-damage. Hence, targeting the TXNIP/TRX system as well as the use of oxidative stress scavengers could become promising therapeutic approaches potentially applicable in clinical practice in order to sustain and improve peritoneal membrane function.
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Affiliation(s)
- Tina Oberacker
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology and University of Tuebingen, Auerbachstr. 112, 70376 Stuttgart, Germany
- Correspondence: ; Tel.: +49-711-8101-2833
| | - Peter Fritz
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Hospital, Auerbachstr. 110, 70376 Stuttgart, Germany; (P.F.); (M.S.); (M.D.A.); (M.K.); (S.S.)
| | - Moritz Schanz
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Hospital, Auerbachstr. 110, 70376 Stuttgart, Germany; (P.F.); (M.S.); (M.D.A.); (M.K.); (S.S.)
| | - Mark Dominik Alscher
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Hospital, Auerbachstr. 110, 70376 Stuttgart, Germany; (P.F.); (M.S.); (M.D.A.); (M.K.); (S.S.)
| | - Markus Ketteler
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Hospital, Auerbachstr. 110, 70376 Stuttgart, Germany; (P.F.); (M.S.); (M.D.A.); (M.K.); (S.S.)
| | - Severin Schricker
- Department of General Internal Medicine and Nephrology, Robert-Bosch-Hospital, Auerbachstr. 110, 70376 Stuttgart, Germany; (P.F.); (M.S.); (M.D.A.); (M.K.); (S.S.)
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Liu KH, Fu J, Zhou N, Yin W, Yang YY, Ouyang SX, Liang YM. 1,25-Dihydroxyvitamin D3 Prevents Epithelial-Mesenchymal Transition of HMrSV5 Human Peritoneal Mesothelial Cells by Inhibiting Histone Deacetylase 3 (HDAC3) and Increasing Vitamin D Receptor (VDR) Expression Through the Wnt/β-Catenin Signaling Pathway. Med Sci Monit 2019; 25:5892-5902. [PMID: 31391414 PMCID: PMC6698096 DOI: 10.12659/msm.916313] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background Peritoneal dialysis is the most common treatment for end-stage renal disease. However, peritoneal fibrosis resulting from long-term peritoneal dialysis restricts peritoneal ultrafiltration. Previous studies have shown a role for 1,25-dihydroxyvitamin D3 (1,25[OH]2D3) in preventing fibrosis, but the potential mechanisms remain unknown. This study aimed to investigate the role of 1,25(OH)2D3 in epithelial-mesenchymal transition (EMT) and the downstream signaling pathway in HMrSV5 human peritoneal mesothelial cells in vitro. Material/Methods An in vitro cell model of peritoneal fibrosis was established using the HMrSV5 human peritoneal mesothelial cell line. High glucose and lipopolysaccharide (LPS) culture conditions, with or without 1,25(OH)2D3, were used. Wnt agonist 1, a Wnt signaling pathway activator, was applied. Quantitative real-time polymerase chain reaction (qRT-PCR) and western blot were used to measure the vitamin D receptor (VDR) and histone deacetylase 3 (HDAC3) gene and protein expression levels, β-catenin, and EMT-associated biomarkers. Results High glucose plus LPS culture medium inhibited cell proliferation, induced cell apoptosis and promoted EMT in HMrSV5 cells, which was reversed by 1,25(OH)2D3 by down-regulation of HDAC3 and upregulation of VDR. HDAC3 inhibited VDR gene expression. The expression of EMT-associated biomarkers was increased by Wnt agonist 1 and inhibited by 1,25(OH)2D3. Conclusions In HMrSV5 human peritoneal mesothelial cells, 1,25(OH)2D3 reversed EMT by inhibiting the expression of HDAC3 and upregulating VDR gene expression via the Wnt/β-catenin signaling pathway.
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Affiliation(s)
- Kang-Han Liu
- Department of Nephrology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China (mainland)
| | - Jia Fu
- Department of Oncology, Hunan Provincial Peoples' Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China (mainland)
| | - Nan Zhou
- Department of Nephrology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China (mainland)
| | - Wei Yin
- Department of Nephrology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China (mainland)
| | - Yi-Ya Yang
- Department of Nephrology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China (mainland)
| | - Sha-Xi Ouyang
- Department of Nephrology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China (mainland)
| | - Yu-Mei Liang
- Department of Nephrology, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China (mainland)
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Zavvos V, Buxton AT, Evans C, Lambie M, Davies SJ, Topley N, Wilkie M, Summers A, Brenchley P, Goumenos DS, Johnson TS. A prospective, proteomics study identified potential biomarkers of encapsulating peritoneal sclerosis in peritoneal effluent. Kidney Int 2017; 92:988-1002. [PMID: 28673451 DOI: 10.1016/j.kint.2017.03.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 03/14/2017] [Accepted: 03/16/2017] [Indexed: 11/28/2022]
Abstract
Encapsulating peritoneal sclerosis (EPS) is a potentially devastating complication of peritoneal dialysis (PD). Diagnosis is often delayed due to the lack of effective and accurate diagnostic tools. We therefore examined peritoneal effluent for potential biomarkers that could predict or confirm the diagnosis of EPS and would be valuable in stratifying at-risk patients and driving appropriate interventions. Using prospectively collected samples from the Global Fluid Study and a cohort of Greek PD patients, we utilized 2D SDSPAGE/ MS and iTRAQ to identify changes in the peritoneal effluent proteome from patients diagnosed with EPS and controls matched for treatment exposure. We employed a combinatorial peptide ligand library to compress the dynamic range of protein concentrations to aid identification of low-abundance proteins. In patients with stable membrane function, fibrinogen γ-chain and heparan sulphate proteoglycan core protein progressively increased over time on PD. In patients who developed EPS, collagen-α1(I), γ-actin and Complement factors B and I were elevated up to five years prior to diagnosis. Orosomucoid-1 and a2-HS-glycoprotein chain-B were elevated about one year before diagnosis, while apolipoprotein A-IV and α1-antitrypsin were decreased compared to controls. Dynamic range compression resulted in an increased number of proteins detected with improved resolution of protein spots, compared to the full fluid proteome. Intelectin-1, dermatopontin, gelsolin, and retinol binding protein-4 were elevated in proteome-mined samples from patients with EPS compared to patients that had just commenced peritoneal dialysis. Thus, prospective analysis of peritoneal effluent uncovered proteins indicative of inflammatory and pro-fibrotic injury worthy of further evaluation as diagnostic/prognostic markers.
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Affiliation(s)
- Vasileios Zavvos
- Department of Nephrology, University Hospital of Patras, Patras, Greece; Academic Nephrology Unit and Sheffield Kidney Institute, University of Sheffield, Sheffield, UK
| | - Anthony T Buxton
- Academic Nephrology Unit and Sheffield Kidney Institute, University of Sheffield, Sheffield, UK
| | - Caroline Evans
- Proteomics Unit, Chemical Engineering, University of Sheffield, Sheffield, UK
| | - Mark Lambie
- Institute of Applied Clinical Sciences, Keele University, Keele, UK
| | - Simon J Davies
- Institute of Applied Clinical Sciences, Keele University, Keele, UK
| | - Nicholas Topley
- Wales Kidney Research Unit, Division of Infection and Immunity, Cardiff University School of Medicine, Cardiff, UK
| | - Martin Wilkie
- Academic Nephrology Unit and Sheffield Kidney Institute, University of Sheffield, Sheffield, UK
| | - Angela Summers
- Kidney Research Laboratories, Manchester Royal Infirmary, Manchester, UK
| | - Paul Brenchley
- Kidney Research Laboratories, Manchester Royal Infirmary, Manchester, UK
| | | | - Timothy S Johnson
- Academic Nephrology Unit and Sheffield Kidney Institute, University of Sheffield, Sheffield, UK.
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Kawanishi K, Honda K, Hamada C. Recommendations for pathological diagnosis on biopsy samples from peritoneal dialysis patients. Pleura Peritoneum 2017; 2:3-15. [PMID: 30911628 PMCID: PMC6386291 DOI: 10.1515/pp-2016-0028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 03/02/2017] [Indexed: 02/07/2023] Open
Abstract
Peritoneal dialysis (PD) has been established as an essential renal replacement therapy for patients with end stage renal disease during the past half century. Histological evaluation of the peritoneal membrane has contributed to the pathophysiological understanding of PD-related peritoneal injury such as peritonitis, fibrosis, and encapsulating peritoneal sclerosis (EPS). Hyalinizing peritoneal sclerosis (HPS), also known as simple sclerosis, is observed in almost all of PD patients. HPS is morphologically characterized by fibrosis of the submesothelial interstitium and hyalinizing vascular wall, particularly of the post-capillary venule (PCV). Two histological factors, the thickness of submesothelial compact zone (SMC) and the lumen/vessel ratio (L/V) at the PCV, have been used for the quantitative evaluation of HPS. The measuring system on SMC thickness and L/V ratio is easy and useful for evaluating the severity of HPS. On the other hand, EPS is characterized by unique encapsulation of the intestines by an "encapsulating membrane". This newly formed membranous structure covers the visceral peritoneum of the intestines, which contains fibrin deposition, angiogenesis, and proliferation of fibroblast-like cells and other inflammatory cells. This review will cover the common understandings of PD-related peritoneal alterations and provide a basic platform for clinical applications and future studies in this field.
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Affiliation(s)
- Kunio Kawanishi
- Department of Cellular and Molecular Medicine, University of California, San Diego, 9500 Gilman Drive, La Jolla, CA 92093-0687, USA
- Department of Surgical Pathology, Tokyo Women’s Medical University, 8-1, Kawada-cho, Shinjuku-ku, 162-8666, Tokyo, Japan
| | - Kazuho Honda
- Department of Anatomy, Showa University School of Medicine, Tokyo, Japan
| | - Chieko Hamada
- Division of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
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Morishita Y, Yoshizawa H, Watanabe M, Imai R, Imai T, Hirahara I, Akimoto T, Ookawara S, Muto S, Nagata D. MicroRNA expression profiling in peritoneal fibrosis. Transl Res 2016; 169:47-66. [PMID: 26616819 DOI: 10.1016/j.trsl.2015.10.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 10/28/2015] [Accepted: 10/29/2015] [Indexed: 12/22/2022]
Abstract
Peritoneal fibrosis (PF) is an intractable complication leading to peritoneal membrane failure in peritoneal dialysis (PD). The aim of this study was to identify microRNAs (miRNAs) involved in PF. Peritoneal tissue from a PF rat model was screened for miRNA expression using microarray analysis. The expression levels of differentially expressed miRNAs were evaluated in serum and drained dialysate and associated with peritoneal membrane functions, as measured by the peritoneal equilibrium test in 33 PD patients. Furthermore, an miRNA inhibitor (anti-miRNA-21-5p locked nucleic acid (LNA): anti-miRNA-21-LNA) was intraperitoneally injected to PF model mice to investigate its effects on PF. The initial profiling study of PF rat peritoneal tissue identified 6 miRNAs (miRNA-142-3p, miRNA-21-5p, miRNA-221-3p, miRNA-223-3p, miRNA-34a-5p, and miRNA-327) whose expression was increased more than 2-fold and no miRNAs whose expression was decreased more than half. Among them, serum levels of miRNA-21-5p, miRNA-221-3p, and miRNA-327 and drained dialysate levels of miRNA-221-3p and miRNA-34a-5p were significantly correlated with peritoneal membrane functions in PD patients. Anti-miRNA-21-LNA significantly inhibited miRNA-21-5p expression in the PF mouse peritoneum, inhibited peritoneal fibrous thickening, and maintained peritoneal membrane functions. These results suggest that several miRNAs are involved in PF and that they may be useful as novel diagnostic biomarkers and therapeutic targets for PF.
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Affiliation(s)
- Yoshiyuki Morishita
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Omiya, Saitama, Japan.
| | - Hiromichi Yoshizawa
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke City, Tochigi, Tochigi, Japan
| | - Minami Watanabe
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke City, Tochigi, Tochigi, Japan
| | - Reika Imai
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke City, Tochigi, Tochigi, Japan
| | - Toshimi Imai
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke City, Tochigi, Tochigi, Japan
| | - Ichiro Hirahara
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke City, Tochigi, Tochigi, Japan
| | - Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke City, Tochigi, Tochigi, Japan
| | - Susumu Ookawara
- Division of Nephrology, Department of Integrated Medicine, Saitama Medical Center, Jichi Medical University, Omiya, Saitama, Japan
| | - Shigeaki Muto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke City, Tochigi, Tochigi, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke City, Tochigi, Tochigi, Japan
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Effect of bevacizumab, a vascular endothelial growth factor inhibitor, on a rat model of peritoneal sclerosis. Int Urol Nephrol 2015; 47:2047-51. [DOI: 10.1007/s11255-015-1116-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 09/18/2015] [Indexed: 12/27/2022]
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Kitterer D, Latus J, Ulmer C, Fritz P, Biegger D, Ott G, Alscher MD, Witowski J, Kawka E, Jörres A, Seeger H, Segerer S, Braun N. Activation of nuclear factor of activated T cells 5 in the peritoneal membrane of uremic patients. Am J Physiol Renal Physiol 2015; 308:F1247-58. [DOI: 10.1152/ajprenal.00617.2014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 03/25/2015] [Indexed: 11/22/2022] Open
Abstract
Peritoneal inflammation and fibrosis are responses to the uremic milieu and exposure to hyperosmolar dialysis fluids in patients on peritoneal dialysis. Cells respond to high osmolarity via the transcription factor nuclear factor of activated T cells (NFAT5). In the present study, the response of human peritoneal fibroblasts to glucose was analyzed in vitro. Expression levels of NFAT5 and chemokine (C-C motif) ligand (CCL2) mRNA were quantified in peritoneal biopsies of five nonuremic control patients, five uremic patients before PD (pPD), and eight patients on PD (oPD) using real-time PCR. Biopsies from 5 control patients, 25 pPD patients, and 25 oPD patients were investigated using immunohistochemistry to detect the expression of NFAT5, CCL2, NF-κB p50, NF-κB p65, and CD68. High glucose concentrations led to an early, dose-dependent induction of NFAT5 mRNA in human peritoneal fibroblasts. CCL2 mRNA expression was upregulated by high concentrations of glucose after 6 h, but, most notably, a concentration-dependent induction of CCL2 was present after 96 h. In human peritoneal biopsies, NFAT5 mRNA levels were increased in uremic patients compared with nonuremic control patients. No significant difference was found between the pPD group and oPD group. CCL2 mRNA expression was higher in the oPD group. Immunohistochemistry analysis was consistent with the results of mRNA analysis. CD68-positive cells were significantly increased in the oPD group. In conclusion, uremia results in NFAT5 induction, which might promote early changes of the peritoneum. Upregulation of NFAT5 in PD patients is associated with NFκB induction, potentially resulting in the recruitment of macrophages.
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Affiliation(s)
- Daniel Kitterer
- Division of Nephrology, Department of Internal Medicine, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Joerg Latus
- Division of Nephrology, Department of Internal Medicine, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Christoph Ulmer
- Department of General, Visceral, and Trauma Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Peter Fritz
- Department of Diagnostic Medicine, Division of Pathology, Robert-Bosch Hospital, Stuttgart, Germany
| | - Dagmar Biegger
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, University of Tuebingen, Stuttgart, Germany
| | - German Ott
- Department of Diagnostic Medicine, Division of Pathology, Robert-Bosch Hospital, Stuttgart, Germany
| | - M. Dominik Alscher
- Division of Nephrology, Department of Internal Medicine, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Janusz Witowski
- Department of Pathophysiology, University of Medical Sciences, Poznan, Poland
| | - Edyta Kawka
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Achim Jörres
- Department of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Harald Seeger
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland; and
- Institute of Physiology and Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Stephan Segerer
- Division of Nephrology, University Hospital Zurich, Zurich, Switzerland; and
- Institute of Physiology and Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Niko Braun
- Division of Nephrology, Department of Internal Medicine, Robert-Bosch-Hospital, Stuttgart, Germany
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Moinuddin Z, Summers A, Van Dellen D, Augustine T, Herrick SE. Encapsulating peritoneal sclerosis-a rare but devastating peritoneal disease. Front Physiol 2015; 5:470. [PMID: 25601836 PMCID: PMC4283512 DOI: 10.3389/fphys.2014.00470] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 11/16/2014] [Indexed: 01/08/2023] Open
Abstract
Encapsulating peritoneal sclerosis (EPS) is a devastating but, fortunately, rare complication of long-term peritoneal dialysis. The disease is associated with extensive thickening and fibrosis of the peritoneum resulting in the formation of a fibrous cocoon encapsulating the bowel leading to intestinal obstruction. The incidence of EPS ranges between 0.7 and 3.3% and increases with duration of peritoneal dialysis therapy. Dialysis fluid is hyperosmotic, hyperglycemic, and acidic causing chronic injury and inflammation in the peritoneum with loss of mesothelium and extensive tissue fibrosis. The pathogenesis of EPS, however, still remains uncertain, although a widely accepted hypothesis is the "two-hit theory," where, the first hit is chronic peritoneal membrane injury from long standing peritoneal dialysis followed by a second hit such as an episode of peritonitis, genetic predisposition and/or acute cessation of peritoneal dialysis, leading to EPS. Recently, EPS has been reported in patients shortly after transplantation suggesting that this procedure may also act as a possible second insult. The process of epithelial-mesenchymal transition of mesothelial cells is proposed to play a central role in the development of peritoneal sclerosis, a common characteristic of patients on dialysis, however, its importance in EPS is less clear. There is no established treatment for EPS although evidence from small case studies suggests that corticosteroids and tamoxifen may be beneficial. Nutritional support is essential and surgical intervention (peritonectomy and enterolysis) is recommended in later stages to relieve bowel obstruction.
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Affiliation(s)
- Zia Moinuddin
- Department of Transplantation, Manchester Royal Infirmary Manchester, UK ; Faculty of Medical and Human Sciences, Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre Manchester, UK
| | - Angela Summers
- Department of Transplantation, Manchester Royal Infirmary Manchester, UK
| | - David Van Dellen
- Department of Transplantation, Manchester Royal Infirmary Manchester, UK
| | - Titus Augustine
- Department of Transplantation, Manchester Royal Infirmary Manchester, UK
| | - Sarah E Herrick
- Faculty of Medical and Human Sciences, Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Science Centre Manchester, UK
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Abrahams AC, Habib SM, Dendooven A, Riser BL, van der Veer JW, Toorop RJ, Betjes MGH, Verhaar MC, Watson CJE, Nguyen TQ, Boer WH. Patients with encapsulating peritoneal sclerosis have increased peritoneal expression of connective tissue growth factor (CCN2), transforming growth factor-β1, and vascular endothelial growth factor. PLoS One 2014; 9:e112050. [PMID: 25384022 PMCID: PMC4226475 DOI: 10.1371/journal.pone.0112050] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 07/29/2014] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Encapsulating peritoneal sclerosis (EPS) is a devastating complication of peritoneal dialysis (PD). The pathogenesis is not exactly known and no preventive strategy or targeted medical therapy is available. CCN2 has both pro-fibrotic and pro-angiogenic actions and appears an attractive target. Therefore, we studied peritoneal expression of CCN2, as well as TGFβ1 and VEGF, in different stages of peritoneal fibrosis. MATERIALS AND METHODS Sixteen PD patients were investigated and compared to 12 hemodialysis patients and four pre-emptively transplanted patients. Furthermore, expression was investigated in 12 EPS patients in comparison with 13 PD and 12 non-PD patients without EPS. Peritoneal tissue was taken during kidney transplantation procedure or during EPS surgery. In a subset of patients, CCN2 protein levels in peritoneal effluent and plasma were determined. Samples were examined by qPCR, histology, immunohistochemistry, and ELISA. RESULTS Peritoneal CCN2 expression was 5-fold higher in PD patients compared to pre-emptively transplanted patients (P < 0.05), but did not differ from hemodialysis patients. Peritoneal expression of TGFβ1 and VEGF were not different between the three groups; neither was peritoneal thickness. Peritoneum of EPS patients exhibited increased expression of CCN2 (35-fold, P < 0.001), TGFβ1 (24-fold, P < 0.05), and VEGF (77-fold, P < 0.001) compared to PD patients without EPS. In EPS patients, CCN2 protein was mainly localized in peritoneal endothelial cells and fibroblasts. CCN2 protein levels were significantly higher in peritoneal effluent of EPS patients compared to levels in dialysate of PD patients (12.0 ± 4.5 vs. 0.91 ± 0.92 ng/ml, P < 0.01), while plasma CCN2 levels were not increased. CONCLUSIONS Peritoneal expression of CCN2, TGFβ1, and VEGF are significantly increased in EPS patients. In early stages of peritoneal fibrosis, only CCN2 expression is slightly increased. Peritoneal CCN2 overexpression in EPS patients is a locally driven response. The potential of CCN2 as biomarker and target for CCN2-inhibiting agents to prevent or treat EPS warrants further study.
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Affiliation(s)
- Alferso C. Abrahams
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
- * E-mail:
| | - Sayed M. Habib
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Amélie Dendooven
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bruce L. Riser
- Department of Physiology and Biophysics, Rosalind Franklin University of Medicine and Science, IL, United States of America
| | - Jan Willem van der Veer
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Raechel J. Toorop
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Michiel G. H. Betjes
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marianne C. Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Christopher J. E. Watson
- Department of Surgery, Box 202, Addenbrooke's Hospital, and Cambridge NIHR Biomedical Research Centre, Cambridge, United Kingdom
| | - Tri Q. Nguyen
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Walther H. Boer
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
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Latus J, Habib SM, Kitterer D, Korte MR, Ulmer C, Fritz P, Davies S, Lambie M, Alscher MD, Betjes MGH, Segerer S, Braun N. Histological and clinical findings in patients with post-transplantation and classical encapsulating peritoneal sclerosis: a European multicenter study. PLoS One 2014; 9:e106511. [PMID: 25171219 PMCID: PMC4149574 DOI: 10.1371/journal.pone.0106511] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 07/30/2014] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Encapsulating peritoneal sclerosis (EPS) commonly presents after peritoneal dialysis has been stopped, either post-transplantation (PT-EPS) or after switching to hemodialysis (classical EPS, cEPS). The aim of the present study was to investigate whether PT-EPS and cEPS differ in morphology and clinical course. METHODS In this European multicenter study we included fifty-six EPS patients, retrospectively paired-matched for peritoneal dialysis (PD) duration. Twenty-eight patients developed EPS after renal transplantation, whereas the other twenty-eight patients were classical EPS patients. Demographic data, PD details, and course of disease were documented. Peritoneal biopsies of all patients were investigated using histological criteria. RESULTS Eighteen patients from the Netherlands and thirty-eight patients from Germany were included. Time on PD was 78(64-95) in the PT-EPS and 72(50-89) months in the cEPS group (p>0.05). There were no significant differences between the morphological findings of cEPS and PT-EPS. Podoplanin positive cells were a prominent feature in both groups, but with a similar distribution of the podoplanin patterns. Time between cessation of PD to the clinical diagnosis of EPS was significantly shorter in the PT-EPS group as compared to cEPS (4(2-9) months versus 23(7-24) months, p<0.001). Peritonitis rate was significantly higher in cEPS. CONCLUSIONS In peritoneal biopsies PT-EPS and cEPS are not distinguishable by histomorphology and immunohistochemistry, which argues against different entities. The critical phase for PT-EPS is during the first year after transplantation and therefore earlier after PD cessation then in cEPS.
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Affiliation(s)
- Joerg Latus
- Department of Internal Medicine, Division of Nephrology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Sayed M. Habib
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Daniel Kitterer
- Department of Internal Medicine, Division of Nephrology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Mario R. Korte
- Department of Internal Medicine, Division of Nephrology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | - Christoph Ulmer
- Department of General, Visceral and Trauma Surgery, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Peter Fritz
- Department of Diagnostic Medicine, Division of Pathology, Robert-Bosch Hospital, Stuttgart, Germany
| | - Simon Davies
- Institute for Science and Technology in Medicine, Keele University, Keele, United Kingdom
| | - Mark Lambie
- Department of Nephrology, University Hospital of North Staffordshire, Stoke-on-Trent, United Kingdom
| | - M. Dominik Alscher
- Department of Internal Medicine, Division of Nephrology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Michiel G. H. Betjes
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Stephan Segerer
- Division of Nephrology, University Hospital, Zurich, Switzerland
| | - Niko Braun
- Department of Internal Medicine, Division of Nephrology, Robert-Bosch-Hospital, Stuttgart, Germany
- * E-mail:
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11
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Braun N, Sen K, Alscher MD, Fritz P, Kimmel M, Morelle J, Goffin E, Jörres A, Wüthrich RP, Cohen CD, Segerer S. Periostin: a matricellular protein involved in peritoneal injury during peritoneal dialysis. Perit Dial Int 2013; 33:515-28. [PMID: 23378472 DOI: 10.3747/pdi.2010.00259] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Periostin is a matricellular protein involved in tissue remodeling through the promotion of adhesion, cell survival, cellular dedifferentiation, and fibrogenesis. It can be induced by transforming growth factor beta and high glucose concentrations. We hypothesized that this protein might be expressed in the peritoneal cavity of patients on peritoneal dialysis (PD) and even more in patients with signs of encapsulating peritoneal sclerosis (EPS). METHOD In this retrospective study, we included peritoneal biopsies from patients on PD with EPS (n = 7) and without signs of EPS (n = 10), and we compared them with biopsies taken during hernia repair from patients not on PD (n = 11) and during various procedures from uremic patients not on PD (n = 6). Periostin was localized by immunohistochemistry, scored semiquantitatively, and quantified by morphometry. Periostin protein concentrations were measured by ELISA in dialysates from 15 patients. Periostin messenger RNA was quantified in vitro in peritoneal fibroblasts. RESULTS In control biopsies, periostin was present in the walls of larger arteries and focally in extracellular matrix in the submesothelial zone. Patients on PD demonstrated interstitial periostin in variable amounts depending on the severity of submesothelial fibrosis. In EPS, periostin expression was very prominent in the sclerosis layer. The area of periostin was significantly larger in EPS biopsies than in control biopsies, and the percentage of periostin-positive area correlated with the thickness of the submesothelial fibrosis zone. Periostin concentrations in dialysate increased significantly with time on PD in patients without signs of EPS; in patients with EPS, periostin concentrations in dialysate were low and demonstrated the smallest increase with time. In vitro, periostin was found to be strongly expressed by peritoneal fibroblasts. CONCLUSION Periostin is strongly expressed by fibroblasts and deposited in the peritoneal cavity of patients with EPS and with simple peritoneal fibrosis on PD. This protein might play a role in the progression of peritoneal injury, and low levels of periostin after prolonged time on PD might be a marker of EPS.
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Affiliation(s)
- Niko Braun
- Department of Internal Medicine,1 Division of General Internal Medicine and Nephrology, Robert-Bosch-Hospital, and Institute of Digital Medicine,2 Stuttgart, Germany
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12
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Braun N, Fritz P, Ulmer C, Latus J, Kimmel M, Biegger D, Ott G, Reimold F, Thon KP, Dippon J, Segerer S, Alscher MD. Histological criteria for encapsulating peritoneal sclerosis - a standardized approach. PLoS One 2012; 7:e48647. [PMID: 23144917 PMCID: PMC3492493 DOI: 10.1371/journal.pone.0048647] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 09/27/2012] [Indexed: 12/11/2022] Open
Abstract
Background The two most relevant pathologies of long-term peritoneal dialysis (PD) are simple sclerosis and encapsulating peritoneal sclerosis (EPS). The histological differentiation of those two entities is difficult. The Aim of the study was to establish a method to standardize and facilitate the differentiation between simple sclerosis and EPS Methods We investigated 58 peritoneal biopsies - 31 EPS patients and 27 PD patients. Two blinded investigators analyzed 20 histological characteristics in EPS and PD patients. Results The following findings were significantly more common in EPS than in patients on PD without EPS: fibroblast like cells (FLC) (p<0.0001), mesothelial denudation (p<0.0001), decreased cellularity (p = 0.008), fibrin deposits (p<0.03), Fe deposits (p = 0.05), podoplanin vascular (p<0.0001), podoplanin avascular (p<0.0001). Using all predictor variables we trained the classification method Random Forest to categorize future cases. Podoplanin vascular and avascular were taken together (p<0.0001), FLC (p<0.0001), mesothelial denudation (p = 0.0005), calcification (p = 0.0026), acellular areas (p = 0.0094), and fibrin deposits (p = 0.0336) showed up as significantly important predictor variables. Estimated misclassification error rate when classifying new cases turned out to be 14%. Conclusion The introduced statistical method allows discriminating between simple sclerosis and EPS. The misclassification error will likely improve with every new case added to the database.
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Affiliation(s)
- Niko Braun
- Department of Internal Medicine, Division of Nephrology, Robert Bosch Hospital, Stuttgart, Germany
| | - Peter Fritz
- Margarete Fischer–Bosch Institute of Clinical Pharmacology, University of Tuebingen, Tuebingen, Germany
| | - Christoph Ulmer
- Department of Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Joerg Latus
- Department of Internal Medicine, Division of Nephrology, Robert Bosch Hospital, Stuttgart, Germany
- * E-mail:
| | - Martin Kimmel
- Department of Internal Medicine, Division of Nephrology, Robert Bosch Hospital, Stuttgart, Germany
| | - Dagmar Biegger
- Margarete Fischer–Bosch Institute of Clinical Pharmacology, University of Tuebingen, Tuebingen, Germany
| | - German Ott
- Department of Diagnostic Medicine, Division of Pathology, Robert Bosch Hospital, Stuttgart, Germany
| | - Fabian Reimold
- Department of Internal Medicine, Division of Nephrology, Robert Bosch Hospital, Stuttgart, Germany
- Department of Internal Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Klaus-Peter Thon
- Department of Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Juergen Dippon
- Department of Mathematics, University of Stuttgart, Stuttgart, Germany
| | - Stephan Segerer
- Division of Nephrology, University Hospital, Zurich, Switzerland
| | - M. Dominik Alscher
- Department of Internal Medicine, Division of Nephrology, Robert Bosch Hospital, Stuttgart, Germany
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13
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Kirov A, Duarte M, Guay J, Karolak M, Yan C, Oxburgh L, Prudovsky I. Transgenic expression of nonclassically secreted FGF suppresses kidney repair. PLoS One 2012; 7:e36485. [PMID: 22606265 PMCID: PMC3351418 DOI: 10.1371/journal.pone.0036485] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 04/06/2012] [Indexed: 11/22/2022] Open
Abstract
FGF1 is a signal peptide-less nonclassically released growth factor that is involved in angiogenesis, tissue repair, inflammation, and carcinogenesis. The effects of nonclassical FGF export in vivo are not sufficiently studied. We produced transgenic mice expressing FGF1 in endothelial cells (EC), which allowed the detection of FGF1 export to the vasculature, and studied the efficiency of postischemic kidney repair in these animals. Although FGF1 transgenic mice had a normal phenotype with unperturbed kidney structure, they showed a severely inhibited kidney repair after unilateral ischemia/reperfusion. This was manifested by a strong decrease of postischemic kidney size and weight, whereas the undamaged contralateral kidney exhibited an enhanced compensatory size increase. In addition, the postischemic kidneys of transgenic mice were characterized by hyperplasia of interstitial cells, paucity of epithelial tubular structures, increase of the areas occupied by connective tissue, and neutrophil and macrophage infiltration. The continuous treatment of transgenic mice with the cell membrane stabilizer, taurine, inhibited nonclassical FGF1 export and significantly rescued postischemic kidney repair. It was also found that similar to EC, the transgenic expression of FGF1 in monocytes and macrophages suppresses kidney repair. We suggest that nonclassical export may be used as a target for the treatment of pathologies involving signal peptide-less FGFs.
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Affiliation(s)
- Aleksandr Kirov
- Maine Medical Center Research Institute, Maine Medical Center, Scarborough, Maine, United States of America
| | - Maria Duarte
- Maine Medical Center Research Institute, Maine Medical Center, Scarborough, Maine, United States of America
| | - Justin Guay
- Maine Medical Center Research Institute, Maine Medical Center, Scarborough, Maine, United States of America
| | - Michele Karolak
- Maine Medical Center Research Institute, Maine Medical Center, Scarborough, Maine, United States of America
| | - Cong Yan
- Department of Pathology, University of Indiana, Indianapolis, Indiana, United States of America
| | - Leif Oxburgh
- Maine Medical Center Research Institute, Maine Medical Center, Scarborough, Maine, United States of America
| | - Igor Prudovsky
- Maine Medical Center Research Institute, Maine Medical Center, Scarborough, Maine, United States of America
- * E-mail:
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14
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Summers AM, Abrahams AC, Alscher MD, Betjes M, Boeschoten EW, Braun N, Brenchley PEC, Davies S, Dunn L, Engelsman L, Fieren M, Garosi G, Goffin E, Heuveling L, Korte M, Lindholm B, Rutherford P, Struijk D, Verduijn M, Verger C, Westerhuis R. A collaborative approach to understanding EPS: the European perspective. Perit Dial Int 2012; 31:245-8. [PMID: 21555409 DOI: 10.3747/pdi.2010.00086] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Angela M Summers
- Department of Renal Research, Manchester Royal Infirmary, Manchester, UK.
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15
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Braun N, Alscher MD, Kimmel M, Amann K, Büttner M. Encapsulating peritoneal sclerosis – an overview. Nephrol Ther 2011; 7:162-71. [DOI: 10.1016/j.nephro.2010.12.011] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Accepted: 12/28/2010] [Indexed: 12/21/2022]
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16
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Braun N, Fritz P, Biegger D, Kimmel M, Reimold F, Ulmer C, Alscher MD. Difference in the expression of hormone receptors and fibrotic markers in the human peritoneum--implications for therapeutic targets to prevent encapsulating peritoneal sclerosis. Perit Dial Int 2011; 31:291-300. [PMID: 21454390 DOI: 10.3747/pdi.2010.00118] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Encapsulating peritoneal sclerosis (EPS) is a rare but life-threatening complication of peritoneal dialysis (PD). The optimal management of patients with EPS is uncertain. In the present study, we investigated differences in the expression of nuclear receptors [progesterone (PR), androgen (AR), vitamin D (VDR), and glucocorticoid (GCR)] in the human peritoneum. We also investigated estrogen receptor (ER), matrix metalloproteinase 9 (MMP9), and transforming growth factor β1 (TGFβ1) in the context of their potential role in tamoxifen therapy. METHODS We analyzed clinical and histologic characteristics of 72 peritoneal biopsy specimens (22 from EPS patients, 11 from PD patients, 15 from uremic patients, and 24 from control subjects undergoing hernia repair). For immunophenotyping, we used antibodies against VDR, GCR, ER, PR, AR, MMP9, and TGFβ1. RESULTS In human peritoneum, VDR and GCR are highly expressed (98.6% and 87.3% respectively). Except in the case of VDR (p = 0.0012), we observed no significant difference in receptor expression between the groups. Expression of ER and PR was sparse (11.4% and 31% respectively), with higher expression in women, and AR was absent. Minimal MMP9 expression and moderate TGFβ1 expression were observed in all groups. The differences between the groups were nonsignificant. CONCLUSIONS Nuclear receptors are present in human peritoneum. Except in the case of VDR, the pattern for any one group is nonspecific. Glucocorticoids, vitamin D, and angiotensin converting-enzyme inhibitors or angiotensin II receptor blockers (via the vitamin D/angiotensin II pathway) might be suitable interventions for preservation of the integrity of the peritoneal membrane. The mechanism of action of tamoxifen is still not elucidated, ER expression in the peritoneum is sparse, and data about the studied pathways (MMP9, TGFβ) are inconsistent.
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Affiliation(s)
- Niko Braun
- Division of General Internal Medicine and Nephrology, Department of Internal Medicine, Robert-Bosch-Hospital, Stuttgart, Germany.
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17
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Braun N, Alscher M, Schwenger V, Amann K, Büttner M. Deutsches Peritonealbiopsieregister (DPR). ACTA ACUST UNITED AC 2010. [DOI: 10.1007/s11560-010-0484-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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18
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Braun N, Alscher DM, Fritz P, Edenhofer I, Kimmel M, Gaspert A, Reimold F, Bode-Lesniewska B, Ziegler U, Biegger D, Wüthrich RP, Segerer S. Podoplanin-positive cells are a hallmark of encapsulating peritoneal sclerosis. Nephrol Dial Transplant 2010; 26:1033-41. [PMID: 20709739 DOI: 10.1093/ndt/gfq488] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Encapsulating peritoneal sclerosis (EPS) and simple peritoneal sclerosis are important complications of long-term peritoneal dialysis (PD). Podoplanin is expressed by mesothelial cells and lymphatic vessels, which are involved in inflammatory reactions in the peritoneal cavity. METHODS We studied 69 peritoneal biopsies from patients on PD (n = 16), patients with EPS (n = 18) and control biopsies taken at the time of hernia repair (n = 15) or appendectomy (n = 20). Immunohistochemistry was performed to localize podoplanin. Additionally, markers of endothelial cells, mesothelial cells, myofibroblasts (smooth muscle actin), proliferating cells, and double labelling for smooth muscle actin/podoplanin were used on selected biopsies. RESULTS Podoplanin was present on the endothelium of lymphatic vessels in the submesothelial fibrous tissue and on mesothelial cells. In patients on PD and in biopsies with appendicitis, the mesothelial cells demonstrated a cuboidal appearance and circumferential podoplanin staining, with gaps between the cells. The number of lymphatic vessels was variable, but prominent at sites of fibrosis. In patients with EPS, a diffuse infiltration of podoplanin-positive cells with a fibroblastic appearance was present in 15 out of 18 biopsies. This pattern was focally present in 3 out of 16 on PD and none in the 35 controls. The podoplanin-positive cells did not express the endothelial marker or the mesothelial marker (calretinin). CONCLUSIONS EPS is characterized by a population of podoplanin and smooth muscle actin double-positive cells. Podoplanin might be a suitable morphological marker supporting the diagnosis and might be involved in the pathogenesis of EPS.
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Affiliation(s)
- Niko Braun
- Department of Internal Medicine, Division of General Internal Medicine and Nephrology, Robert-Bosch-Hospital, Stuttgart, Germany
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19
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Braun N, Kimmel M, Biegger D, Fritz P, Alscher MD. Angiogenesis and cellularity in encapsulating peritoneal sclerosis. Clin Kidney J 2010; 3:414-5. [PMID: 25949447 PMCID: PMC4421535 DOI: 10.1093/ndtplus/sfq089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2010] [Accepted: 04/26/2010] [Indexed: 11/16/2022] Open
Affiliation(s)
- Niko Braun
- Division of Internal Medicine and Nephrology, Department of Internal Medicine, Robert-Bosch Hospital, Auerbachstrasse 110, 70376 Stuttgart, Germany
- Institute of Digital Medicine, Auerbachstrasse 110, 70376 Stuttgart, Germany
| | - Martin Kimmel
- Division of Internal Medicine and Nephrology, Department of Internal Medicine, Robert-Bosch Hospital, Auerbachstrasse 110, 70376 Stuttgart, Germany
| | - Dagmar Biegger
- Margarete Fischer-Bosch Institute of Clinical Pharmacology, University of Tuebingen, Auerbachstrasse 110, 70376 Stuttgart, Germany
| | - Peter Fritz
- Institute of Digital Medicine, Auerbachstrasse 110, 70376 Stuttgart, Germany
| | - M. Dominik Alscher
- Division of Internal Medicine and Nephrology, Department of Internal Medicine, Robert-Bosch Hospital, Auerbachstrasse 110, 70376 Stuttgart, Germany
- Institute of Digital Medicine, Auerbachstrasse 110, 70376 Stuttgart, Germany
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