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Rodieux F, Wilbaux M, van den Anker JN, Pfister M. Effect of Kidney Function on Drug Kinetics and Dosing in Neonates, Infants, and Children. Clin Pharmacokinet 2015; 54:1183-204. [PMID: 26138291 PMCID: PMC4661214 DOI: 10.1007/s40262-015-0298-7] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Neonates, infants, and children differ from adults in many aspects, not just in age, weight, and body composition. Growth, maturation and environmental factors affect drug kinetics, response and dosing in pediatric patients. Almost 80% of drugs have not been studied in children, and dosing of these drugs is derived from adult doses by adjusting for body weight/size. As developmental and maturational changes are complex processes, such simplified methods may result in subtherapeutic effects or adverse events. Kidney function is impaired during the first 2 years of life as a result of normal growth and development. Reduced kidney function during childhood has an impact not only on renal clearance but also on absorption, distribution, metabolism and nonrenal clearance of drugs. 'Omics'-based technologies, such as proteomics and metabolomics, can be leveraged to uncover novel markers for kidney function during normal development, acute kidney injury, and chronic diseases. Pharmacometric modeling and simulation can be applied to simplify the design of pediatric investigations, characterize the effects of kidney function on drug exposure and response, and fine-tune dosing in pediatric patients, especially in those with impaired kidney function. One case study of amikacin dosing in neonates with reduced kidney function is presented. Collaborative efforts between clinicians and scientists in academia, industry, and regulatory agencies are required to evaluate new renal biomarkers, collect and share prospective pharmacokinetic, genetic and clinical data, build integrated pharmacometric models for key drugs, optimize and standardize dosing strategies, develop bedside decision tools, and enhance labels of drugs utilized in neonates, infants, and children.
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Affiliation(s)
- Frederique Rodieux
- Department of Pediatric Clinical Pharmacology, Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital (UKBB), University of Basel, Spitalstrasse 33, CH-4056, Basel, Switzerland.
| | - Melanie Wilbaux
- Department of Pediatric Clinical Pharmacology, Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital (UKBB), University of Basel, Spitalstrasse 33, CH-4056, Basel, Switzerland
| | - Johannes N van den Anker
- Department of Pediatric Clinical Pharmacology, Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital (UKBB), University of Basel, Spitalstrasse 33, CH-4056, Basel, Switzerland.
- Division of Pediatric Clinical Pharmacology, Children's National Health System, Washington, DC, USA.
- Intensive Care, Erasmus Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Marc Pfister
- Department of Pediatric Clinical Pharmacology, Pediatric Pharmacology and Pharmacometrics Research Center, University Children's Hospital (UKBB), University of Basel, Spitalstrasse 33, CH-4056, Basel, Switzerland
- Quantitative Solutions LP, Menlo Park, CA, USA
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Calibration and precision of serum creatinine and plasma cystatin C measurement: impact on the estimation of glomerular filtration rate. J Nephrol 2014; 27:467-75. [PMID: 24711159 DOI: 10.1007/s40620-014-0087-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Accepted: 03/27/2014] [Indexed: 01/31/2023]
Abstract
Serum creatinine (SCr) is the main variable for estimating glomerular filtration rate (GFR). Due to inter-assay differences, the prevalence of chronic kidney disease (CKD) varies according to the assay used, and calibration standardization is necessary. For SCr, isotope dilution mass spectrometry (IDMS) is the gold standard. Systematic differences are observed between Jaffe and enzymatic methods. Manufacturers subtract 0.30 mg/dl from Jaffe results to match enzymatic results ('compensated Jaffe method'). The analytical performance of enzymatic methods is superior to that of Jaffe methods. In the original Modification of Diet in Renal Disease (MDRD) equation, SCr was measured by a Jaffe Beckman assay, which was later recalibrated. A limitation of this equation was an underestimation of GFR in the high range. The Chronic Kidney Disease Epidemiology (CKD-EPI) consortium proposed an equation using calibrated and IDMS traceable SCr. The gain in performance was due to improving the bias whereas the precision was comparable. The CKD-EPI equation performs better at high GFR levels (GFR >60 ml/min/1.73 m(2)). Analytical limitations have led to the recommendation to give a grade (>60 ml/min/1.73 m(2)) rather than an absolute value with the MDRD equation. By using both enzymatic and calibrated methods, this cutoff-grade could be increased to 90 ml/min/1.73 m(2) (with MDRD) and 120 ml/min/1.73 m(2) (with CKD-EPI). The superiority of the CKD-EPI equation over MDRD is analytical, but the precision gain is limited. IDMS traceable enzymatic methods have been used in the development of the Lund-Malmö (in CKD populations) and Berlin Initiative Study equations (in the elderly). The analytical errors for cystatin C are grossly comparable to issues found with SCr. Standardization is available since 2011. A reference method for cystatin C is still lacking. Equations based on standardized cystatin C or cystatin C and creatinine have been proposed. The better performance of these equations (especially the combined CKD-EPI equation) has been demonstrated.
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Neuman G, Nulman I, Adeli K, Koren G, Colantonio DA, Helldén A. Implications of serum creatinine measurements on GFR estimation and vancomycin dosing in children. J Clin Pharmacol 2014; 54:785-91. [PMID: 24596064 DOI: 10.1002/jcph.281] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2013] [Accepted: 02/14/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Different serum creatinine (sCr) assays may obtain different values in the same patient, causing discrepancies in estimated glomerular filtration rate (eGFR) and sCr-based vancomycin dosing calculations. OBJECTIVE To identify potential discrepancies in sCr concentrations obtained by different assays, the compensated Jaffe (sCr-Jaffe) and the enzymatic (sCr-enz), and to compare between the eGFR and vancomycin daily dose, based on these sCr values. METHOD sCr-Jaffe and, sCr-enz concentrations of 890 healthy children, aged 1-18 years, were available from the Canadian Laboratory Initiative in Pediatric Reference Intervals study in Ontario. For each subject, eGFR (eGFR-Jaffe, eGFR-enz) was calculated using the revised Schwartz equation, and vancomycin daily dose (Vdose-Jaffe, Vdose-enz) was calculated using a sCr-based pharmacokinetic model. RESULT Significant, age-related differences were found in sCr concentrations, and in subsequent eGFR and Vdose, between the two assays. In children aged 1-5 years, mean sCr-Jaffe was higher than sCr-enz (44.0 ± 5.0 vs. 27.7 ± 7.3 μmol/L, P < 0.001), leading to lower eGFR-Jaffe (83.2 ± 9.0 vs. 137.9 ± 27.1 mL/min/1.73m2, P < 0.001) and lower Vdose-Jaffe (44.7 ± 2.5 vs. 53.5 ± 5.1 mg/kg/24 h, P < 0.001). CONCLUSION Based on these findings, young children may be at risk for vancomycin under-treatment. Further research is needed to define the more accurate sCr assay in young children treated with renally excreted drugs.
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Affiliation(s)
- Gal Neuman
- Division of Clinical Pharmacology & Toxicology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Helldén A, Odar-Cederlöf I, Nilsson G, Sjöviker S, Söderström A, von Euler M, Öhlén G, Bergman U. Renal function estimations and dose recommendations for dabigatran, gabapentin and valaciclovir: a data simulation study focused on the elderly. BMJ Open 2013; 3:bmjopen-2013-002686. [PMID: 23585393 PMCID: PMC3641460 DOI: 10.1136/bmjopen-2013-002686] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES The thrombin inhibitor dabigatran is mainly excreted by the kidneys. We investigated whether the recommended method for estimation of renal function used in the clinical trials, the Cockcroft-Gault (CGold) equation and the estimated glomerular filtration rate (eGFR) modification of diet in renal disease equation 4 (MDRD4), differ in elderly participants, resulting in erroneously higher dose recommendations of dabigatran, which might explain the serious, even fatal, bleeding reported. The renally excreted drugs gabapentin and valaciclovir were also included for comparison. DESIGN A retrospective data simulation study. PARTICIPANTS Participants 65 years and older included in six different studies. MAIN OUTCOME MEASURE Estimated renal function by CG based on uncompensated ('old Jaffe' method) creatinine (CGold) or by MDRD4 based on standardised compensated P-creatinine traceable to isotope-dilution mass spectrometry, and the resulting doses. RESULTS 790 participants (432 females), mean age (±SD) 77.6±5.7 years. Mean estimated creatinine clearance (eCrCl) by the CGold equation was 44.2±14.8 ml/min, versus eGFR 59.6±20.7 ml/min/1.73 m(2) with MDRD4 (p<0.001), absolute median difference 13.5, 95% CI 12.9 to 14.2. MDRD4 gave a significantly higher mean dose (valaciclovir +21%, dabigatran +25% and gabapentin +37%) of all drugs (p<0.001). With MDRD4 58% of the women would be recommended a full dose of dabigatran compared with 18% if CGold is used. CONCLUSIONS MDRD4 would result in higher recommended doses of the three studied drugs to elderly participants compared with CG, particularly in women, and thus increased the risk of dose and concentration-dependent adverse reactions. It is important to know which method of estimation of renal function the Summary of Products Characteristics was based on, and use only that one when prescribing renally excreted drugs with narrow safety window. Doses based on recently developed methods for estimation of renal function may be associated with considerable risk of overtreatment in the elderly.
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Affiliation(s)
- Anders Helldén
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ingegerd Odar-Cederlöf
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Göran Nilsson
- Centre of Clinical Research, Uppsala University, Västerås, Sweden
| | - Susanne Sjöviker
- Department of Drug Management and Informatics, Centre for Health Care Improvement, Stockholm County Council, Stockholm, Sweden at the time of the study
| | - Anders Söderström
- Farsta home care center at the time of the study, presently at Vendelsö home care center, Stockholm, Sweden
| | - Mia von Euler
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Karolinska Institutet Stroke Research Network at Södersjukhuset, Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet
| | - Gunnar Öhlén
- Quality and Patient Safety, Karolinska University Hospital, Stockholm, Sweden, Karolinska University Hospital, Stockholm, Sweden
| | - Ulf Bergman
- Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Centre for Pharmacoepidemiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Division of Clinical Pharmacology, a partner in European Network of Centres for Pharmacoepidemiology and Pharmacovigilance (ENCePP), coordinated by the European Medicines Agency (EMA), Karolinska University Hospital, Stockholm, Sweden
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Accurate, fast, and convenient measurement of glomerular filtration rate in potential renal transplant donors. Transplantation 2010; 90:510-7. [PMID: 20595931 DOI: 10.1097/tp.0b013e3181e9139d] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Measurement of glomerular filtration rate (GFR) is essential in the risk evaluation of potential kidney donors. The optimal method of measuring GFR involves using clearance techniques. However, clearance techniques are technically complex and time consuming. The goal of this study is to evaluate a different method of measuring GFR, one that retains the accuracy of a clearance technique and adds the convenience of a plasma creatinine measurement. METHODS Fifty subjects, including both normal and patients with different degrees of renal dysfunction, were included in the initial validation study. GFR was measured simultaneously using a continuous infusion of I-iothalamate and external radioactivity measurement after a single intravenous injection of Tc-labeled diethylenetriaminepentaacetic acid (Tc-DTPA). After validation, the renal function of 80 potential renal transplant donors was measured using only external radiation detection. RESULTS External radioactivity decreases versus time with first-order kinetics. The rate of clearance of Tc-DTPA was measured as the slope (kappa) of the natural logarithm of external radioactivity corrected for radioactive decay versus time. There was an excellent correlation between kappa and simultaneous GFR measurements done with I-iothalamate. Nonlinear regression analysis of kappa GFR values obtained in potential renal transplant donors versus frequencies indicates a mean value and variance similar to normal reported values obtained with clearance techniques. Estimated GFR and 24-hr plasma creatinine clearance underestimate GFR with greater variance. CONCLUSIONS Measurements of external whole tissue radioactivity after intravenous injection of Tc-DTPA represents an accurate, fast, and convenient way to measure total and individual kidney GFR, addressing an important concern during the risk evaluation of potential renal transplant donors.
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Saenger AK, Lockwood C, Snozek CL, Milz TC, Karon BS, Scott MG, Jaffe AS. Catecholamine interference in enzymatic creatinine assays. Clin Chem 2009; 55:1732-6. [PMID: 19589845 DOI: 10.1373/clinchem.2009.127373] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Enzymatic creatinine assays are routinely used in clinical laboratories to provide more accurate estimated glomerular filtration rates and to avoid a perceived lack of analytical specificity associated with picrate (Jaffe) methods. Negative interferences with the enzymatic creatinine assay, which we noted in several patients on dopamine or dobutamine, prompted our further investigation into interference of catecholamines with enzymatic methods. METHODS Spiked solutions of dopamine, dobutamine, epinephrine, and norepinephrine were added to pooled sera at catecholamine concentrations consistent with clinically relevant dosing. Creatinine was measured enzymatically on the Roche P-Modular, Ortho Clinical Diagnostics Vitros 350, and Abbott i-STAT. Jaffe methods were performed on the Roche P-Modular and Siemens Dimension RxL. In 10 patients receiving dopamine and/or dobutamine via a venous or arterial line we evaluated and compared the extent of in vivo creatinine interference in paired serum samples obtained by venipuncture and from indwelling catheters. RESULTS All catecholamines caused significant negative interference with the Roche enzymatic creatinine assay, most pronounced for dopamine and dobutamine. The Vitros enzymatic assay demonstrated slight negative interferences, and i-STAT enzymatic and Jaffe methods were unaffected by the presence of catecholamines. Significant (P < 0.001) differences in creatinine concentrations by Roche enzymatic vs Jaffe methods were observed in venipuncture specimens compared with arterial or venous catheter specimens, suggesting dopamine and dobutamine reversibly adhere to the catheter lumen. CONCLUSIONS Negative interferences were pronounced for Roche enzymatic results in blood samples obtained from indwelling catheters, a phenomenon not observed in peripheral draws. Physicians and laboratorians should be alert to the possibility of a falsely low creatinine result and reevaluate questionable samples using a method unaffected by catecholamines.
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Affiliation(s)
- Amy K Saenger
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota 55905, USA
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Wu JZ, Ho PC. Comparing the Relative Oxidative DNA Damage Caused by Various Arsenic Species by Quantifying Urinary Levels of 8-Hydroxy-2′-Deoxyguanosine with Isotope-Dilution Liquid Chromatography/Mass Spectrometry. Pharm Res 2009; 26:1525-33. [DOI: 10.1007/s11095-009-9865-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2008] [Accepted: 02/23/2009] [Indexed: 11/28/2022]
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Srivastava T, Alon US, Althahabi R, Garg U. Impact of standardization of creatinine methodology on the assessment of glomerular filtration rate in children. Pediatr Res 2009; 65:113-6. [PMID: 18703997 DOI: 10.1203/pdr.0b013e318189a6e8] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
There is a global effort to standardize clinical laboratory serum creatinine measurements to the reference method of isotope-dilution mass spectrometry (IDMS). Creatinine values in serum and urine are frequently used in children to calculate creatinine clearance (mCrCl) or estimate glomerular filtration rate (GFR) by Schwartz's equation (eGFR). The original normative data of mCrCl and eGFR were developed using Jaffe method. To investigate what impact the differences in methodologies of creatinine analysis will have on mCrCl and eGFR, we measured creatinine in random serum and urine samples by three commercially available assays: Jaffe (J), enzymatic (E) and enzymatic method traceable to IDMS (E-IDMS). There was a significant bias in the two enzymatic methods when compared with J method. The theoretical predicted errors in overestimating mCrCl ranged from 1.10 to 1.34 by E and 1.20 to 1.54 by E-IDMS; and in calculating eGFR 1.07-1.16 by E and 1.30-1.46 by E-IDMS, which was further confirmed in children who had formal GFR evaluation. Thus, as the clinical laboratories calibrate their creatinine assays to the gold standard IDMS method, it is important for the pediatric nephrology community to develop new equations for estimation of GFR based on the new creatinine assay.
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Affiliation(s)
- Tarak Srivastava
- Section of Nephrology, University of Missouri at Kansas City, MO 64108, USA.
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Spruill WJ, Wade WE, Cobb HH. Comparison of estimated glomerular filtration rate with estimated creatinine clearance in the dosing of drugs requiring adjustments in elderly patients with declining renal function. ACTA ACUST UNITED AC 2008; 6:153-60. [DOI: 10.1016/j.amjopharm.2008.07.002] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/03/2008] [Indexed: 10/21/2022]
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Mátyus J, V Oláh A, Ujhelyi L, Kárpáti I, Balla J. [The epidemic of chronic kidney disease requires the estimation of glomerular filtration rate]. Orv Hetil 2008; 149:77-82. [PMID: 18093898 DOI: 10.1556/oh.2008.28255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Nowadays chronic kidney disease has become a major public health problem due to the great increase in atherogenic nephropathies. In the absence of classic renal symptoms, chronic kidney disease is mostly diagnosed when renal failure is already advanced, although it can be revealed by laboratory tests in the earlier stages. When diagnosis is late, the progression to end-stage renal failure is unavoidable and renal replacement therapy is needed. Even early-moderate renal failure significantly increases the risks for atherosclerosis, thereby leading to the deaths of patients from cardiovascular disease before initiation of dialysis. Therefore screening for asymptomatic chronic kidney disease is urgently needed. Estimated glomerular filtration rate has the greatest importance in the screening and in the timely intervention to slow down the progression of renal failure and cardiovascular disease. In 2005, the Hungarian Society of Nephrologists and the Hungarian Society of Laboratory Medicine suggested the automatic estimation and reporting of glomerular filtration rate, each time serum creatinine measurements were made. This practice is used more frequently by laboratories in Hungary. This article aims to help facilitate the utilization and evaluation of estimated glomerular filtration rate.
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Affiliation(s)
- János Mátyus
- Debreceni Egyetem OEC Belgyógyászati Intézet I. Belklinika, Nefrológiai Tanszék Debrecen Pf. 19. 4012.
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Spruill WJ, Wade WE, Cobb HH. Estimating glomerular filtration rate with a modification of diet in renal disease equation: Implications for pharmacy. Am J Health Syst Pharm 2007; 64:652-60. [PMID: 17353576 DOI: 10.2146/ajhp060239] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- William J Spruill
- Department of Clinical and Administrative Pharmacy, College of Pharmacy, University of Georgia, Athens, Georgia 30602, USA.
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Wu JZ, Ho PC. Evaluation of the in vitro activity and in vivo bioavailability of realgar nanoparticles prepared by cryo-grinding. Eur J Pharm Sci 2006; 29:35-44. [PMID: 16824739 DOI: 10.1016/j.ejps.2006.05.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2006] [Revised: 04/05/2006] [Accepted: 05/02/2006] [Indexed: 11/25/2022]
Abstract
Arsenic trioxide (As2O3) has been a research focus because of its promising anticancer effects especially in the treatment of leukemia. Another arsenic compound, realgar (As2S2), has long been used as a therapeutic agent to treat some diseases in ancient China and Europe, and its medicinal effects have attracted increasing attentions in recent years. However, its poor water-solubility unfortunately results in poor bioavailability and hampers it from being studied and used for possible clinical application. In this study, nanosized realgar particles were prepared by cryo-grinding with polyvinylpyrrolidone (PVP) and/or sodium dodecyl sulfate (SDS). Major physical properties of the respective nanosized realgar particles were characterized. Co-grinding realgar with PVP and/or SDS produced smaller and more monodisperse suspension of nanoparticles. The in vitro cytotoxic effects of such nanosized realgar particles on selected human ovarian (CI80-13S, OVCAR, OVCAR-3) and cervical (HeLa) cancer cell lines were investigated. Significant anti-proliferation effect of these realgar nanoparticles on these cancer cell lines was observed. CI80-13S was most sensitive to the nanosized realgar particles with IC50 values of less than 1 microM as As2S2, whereas the other cancer cell lines had IC50 values in a range of 2-4 microM as As2S2. The cytotoxic activity of the realgar nanoparticles to these human gynecological cell lines was comparable to arsenic trioxide observed previously. In these cancer cell lines, the cytotoxic effects were caused by apoptosis as confirmed by cell cycle and DNA laddering analysis. In in vivo study, a remarkable increase in urinary recovery of arsenic was observed in rats after a single oral administration of the cryo-ground realgar particle suspension. Ranging from 58.5 to 69.6% of the administered dose of arsenic was recovered in urine in the first 48 h from the PVP and/or SDS co-ground preparations; whereas the original realgar powder gave a urinary recovery of only 24.9%. The finding suggested that size reduction of realgar particles to nano levels could enhance its bioavailability substantially.
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Affiliation(s)
- Jin-Zhu Wu
- Department of Pharmacy, National University of Singapore, Singapore, Singapore
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Kong APS, So WY, Szeto CC, Chan NN, Luk A, Ma RCW, Ozaki R, Ng VWS, Ho CS, Lam CWK, Chow CC, Cockram CS, Chan JCN, Tong PCY. Assessment of glomerular filtration rate in addition to albuminuria is important in managing type II diabetes. Kidney Int 2006; 69:383-7. [PMID: 16408130 DOI: 10.1038/sj.ki.5000061] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Although much emphasis has been placed on screening for albuminuria in type II diabetic patients, less attention has been focused on the role of glomerular filtration rate (GFR) in the assessment of risk. Herein, we examined the association between GFR and vascular complications in a consecutive cohort of 5174 type II diabetic patients between 1995 and 2000. Renal function was assessed by GFR (estimated by Modification of Diet in Renal Disease equation). The frequency of chronic kidney disease (CKD) as defined by GFR <60 ml/min/1.73 m(2), micro- and macrovascular complications, and their associations were analyzed. In this study cohort, 6% had serum creatinine > or =150 micromol/l and 15.8% had CKD. After adjustment for potential confounders, including urinary albumin excretion, odds ratios [95% confidence interval (CI)] across different stages of estimated GFR (> or =90, 60-89, 30-59, 15-29, <15 ml/min/1.73 m(2)) for macrovascular disease were 1.00, 1.42 [1.12-1.80], 1.80 [1.32-2.45], 2.74 [1.64-4.56], and 4.05 [1.77-9.26], respectively (P for trend <0.001); for retinopathy were 1.00, 1.23 [1.04-1.46], 1.80 [1.40-2.30], 2.05 [1.25-3.37], and 4.12 [1.56-10.90], respectively (P for trend <0.001); for sensory neuropathy were 1.00, 1.53[1.27-1.85], 2.09 [1.58-2.76], 4.32 [2.41-7.77], and 3.16 [1.25-8.02], respectively (P for trend <0.001); and for microalbumuria (with GFR <15 ml/min/1.73 m(2) excluded from the analysis) were 1.00, 1.51 [1.30-1.75], 5.80 [4.52-7.44], and 52.5 [16.4-168.2] respectively (P for trend <0.001). Measurement of serum creatinine alone without GFR may underestimate renal impairment in type II diabetic patients. Decreasing GFR was significantly associated with increasing frequency of micro- and macrovascular complications.
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Affiliation(s)
- A P S Kong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, N.T., Hong Kong SAR
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