Red cell metabolism in renal failure--the effect of dialysis

Comparison of plasma oxidative biomarkers and conformational modifications of hemoglobin in patients with diabetes on hemodialysis

BACKGROUND

Diabetes is associated with an increased generation of reactive oxygen species (ROS), which plays an important role in the development of oxidative stress and anemia.

OBJECTIVES

The main purpose of this study was to investigate whether patients with diabetes undergoing hemodialysis (HD) were susceptible to oxidative stress and whether resulting damages affect the structure of hemoglobin (Hb) and plasma proteins.

PATIENTS AND METHODS

Twenty patients with diabetes undergoing HD, 20 patients with diabetes and normal renal function, and 20 age- and sex-matched healthy subjects were included in this study. Methaemoglobin (Met-Hb), hemichrome and conformational changes of Hb were analyzed as oxidative markers in erythrocytes. Ferric reducing ability of plasma (FRAP) and protein carbonyl content (PCO) were determined as plasma oxidative biomarkers. Also triglyceride, cholesterol, albumin, blood urea nitrogen (BUN), creatinine, glucose and uric acid were assayed as biochemical parameters of plasma.

RESULTS

Patients with diabetes undergoing hemodialysis had significantly lower levels of PCO and albumin (P < 0.05), but significantly higher levels of FRAP, BUN, creatinine and uric acid (P < 0.05) as compared to patients with diabetes and normal renal function. Linear regression analysis showed significant negative correlations between PCO and FRAP (r = -0.53), oxy-Hb (r = -0.88) and Hb absorbance at 340 nm (r = -0.79), 420 nm (r = -0.85) and 577 nm (r = -0.68) in patients with diabetes undergoing hemodialysis. Also PCO was significantly and positively correlated with Hb absorbance at 275 nm (r = 0.63) and 560 nm (r = 0.61) which confirmed the oxidative damage to erythrocytes in control subjects.

CONCLUSIONS

Hemodialysis exacerbates oxidative stress and conformational changes of Hb in patients with diabetes on hemodialysis. The FRAP value can be used as a positive determinant, while PCO and Hb derivatives can be used as negative determinants of oxidative stress in patients with diabetes.

The association of advanced glycation end-products with glutathione status

BACKGROUND

The aim of this study was to investigate oxidative stress with regard to the concentrations of advanced oxidation protein products (AOPP), advanced glycation end-products (AGEs), pentosidine, glycated albumin, reduced glutathione (GSH) and oxidized glutathione (GSSG), glutathione redox ratios and thiobarbituric acid-reactive substances (TBARS) in non-diabetic patients undergoing continuous ambulatory peritoneal dialysis (CAPD).

METHODS

The study group consisted of 52 non-diabetic CAPD patients and 34 healthy controls. AOPP, AGEs, pentosidine and glycated albumin were measured in plasma, whereas GSH, GSSG and TBARS concentrations were measured in erythrocytes of both patients and controls.

RESULTS

All parameters were found to be significantly increased, except the glutathione redox ratio, which was found to be decreased in patients undergoing CAPD. Multiple regression analysis showed that AGEs were the only independent predictor of glutathione redox ratio, whereas AGEs, glycated albumin and TBARS were each found to be independent predictors of albumin concentration.

CONCLUSION

Our results support the hypothesis that oxidative stress and AOPPs/AGEs constitute important risk factors in CAPD patients. The negative relationship between albumin and both AGEs and TBARS suggests that the decrease in albumin may contribute to the increased advanced glycation and lipid peroxidation. The negative relationship between glutathione redox ratio and AGEs suggests that late products of glycation play an important role in the development of oxidative stress observed in patients undergoing peritoneal dialysis treatment.

Oxidative Stress in Children on Peritoneal Dialysis

Objectives

Enhanced oxidative stress has been observed in dialysis and predialysis adult patients with chronic kidney disease (CKD), which resulted in increased mortality and morbidity within this population. Not much attention in the literature has been paid to nonenzymatic antioxidant defense in children with CKD on peritoneal dialysis (PD). The aim of the present study was to describe the plasma, erythrocyte, and dialysate concentrations of oxidized (GSSG) and reduced glutathione (GSH) and vitamins A, E, and C in a pediatric PD population.

Patients

10 children on PD and 27 age-matched healthy subjects were enrolled in the study.

Results

Erythrocyte and plasma GSH concentrations were lower in PD patients, erythrocyte concentration of GSSG remained unchanged, and plasma GSSG was significantly higher in children on PD. Children on PD exhibited decreased plasma concentrations of antioxidant vitamins compared to healthy subjects. Moreover, we documented loss of vitamins A, E, and C into ultrafiltrate.

Conclusion

Such low plasma levels of vitamins A, E, and C and simultaneously decreased activity of erythrocyte GSH may be responsible for the increased oxidative stress occurring in children with CKD on PD.

Erythrocyte susceptibility to oxidative stress in chronic renal failure patients under different substitutive treatments

An increased oxidative stress is now considered one of the major risk factors in chronic renal failure (CRF) patients that may be exacerbated by dialysis. It has been postulated that this increased oxidative stress might cause an augmented red blood cell (RBC) membrane lipid peroxidation with the consequent alteration in membrane deformability. The aim of this study was to evaluate RBC susceptibility to an in vitro induced oxidative stress and RBC antioxidant potential in different groups of CRF patients undergoing different substitutive treatment modalities. Fifteen end-stage CRF patients were evaluated in conservative treatment, 23 hemodialysis (HD) patients, 15 continuous ambulatory peritoneal dialysis (CAPD) patients, 15 kidney transplanted patients, and 16 controls. Their RBCs were incubated with the oxidative stress-inducing agent tert-butylhydroperoxide both in the presence and in the absence of the catalase inhibitor sodium azide, and the level of malondialdehyde (MDA) (a product of lipid peroxidation), was measured at 0, 5, 10, 15, and 30 min of incubation. In addition, the RBC content of reduced glutathione (GSH) was measured by HPLC. As opposed to the controls, RBCs from end-stage CRF patients exhibited an increased sensitivity to oxidative stress induced in vitro, both in the absence and presence of a catalase inhibitor, as demonstrated by a significantly higher level of MDA production at all the incubation times (P < 0.05). Different substitutive treatments had different impacts on this phenomenon; CAPD and kidney transplantation were able to normalize this alteration while HD was not. GSH appeared to be related to the increase in RBC susceptibility to oxidative stress; its content being significantly elevated in end-stage CRF and HD patients as compared with CAPD and transplanted patients and controls (P < 0.05). No significant changes were observed in the RBC glutathione content during the HD session. The increase of GSH in RBCs of end-stage CRF and HD patients seems to indicate the existence of an adaptive mechanism under increased oxidative stress occurring in vivo. Unlike HD, the beneficial effect of CAPD on the anemia of dialysis patients might partly be due to a condition of lower oxidative stress that might in addition counterbalance the cardiovascular negative effects of dislipidemia of CAPD patients.

Determination of erythrocyte antioxidant capacity in haemodialysis patients using electron paramagnetic resonance

BACKGROUND

The increased oxidative stress of uraemia is caused both by an increased generation of oxygen-free radicals and a decrease of antioxidative forces. There are, however, conflicting data concerning disturbances of the radical-scavenging power of red blood cells (RBCs) in uraemic patients.

METHODS

The antioxidant capacities of the RBCs of 10 haemodialysis (HD) patients and 10 controls were examined after treatment with 0.324 mM tert-butylhydroperoxide (t-BOOH) in phosphate-buffered saline at 37 degrees C using electron paramagnetic resonance (EPR) with 5,5-dimethylpyrroline-N-oxide (DMPO) as a spin trap and glutathione (GSH) regeneration as an indicator of hexose monophosphate shunt (HMPS) activity. EPR investigations were also done after pre-incubation with N-ethylmaleimide (NEM) to inhibit the GSH system. Furthermore, we determined the RBC redox state in 15 HD patients and 15 controls.

RESULTS

There was no difference between HD patients and controls in the elimination of t-BOOH-generated free radicals in the RBCs. A more than 20-fold increase in radical concentration was observed after GSH trapping with NEM. In this case, we found a delayed decrease of the relative radical concentration in HD patients compared with controls with a significant difference after 7 min (2.2+/-0.26 vs 1.60+/-0.21; P=0.005) and after 10 min (1.82+/-0.41 vs 0.83+/-0.44; P=0.001). GSH regeneration via HMPS did not differ between the RBCs of HD patients (99.5+/-13.5 nmol/min x ml RBC) and those of the controls (94.2+/-16.9 nmol/min x ml RBC). There were no differences in the RBC concentrations of GSH, GSSG, NADP, NADPH, and in the GSH/GSSG and NADP/NADPH ratios between HD patients and controls.

CONCLUSIONS

These data suggest a strong antioxidant potential in the GSH system of erythrocytes without any evidence of a disturbance in HD patients. The HMPS pathway also appears not to be impaired in the RBCs of HD patients. However, the slower radical elimination in the RBCs of HD patients after inhibition of GSH-depending radical scavengers as compared with controls indicates a defect in the antioxidant forces outside the GSH system, and could be one reason for the reduced lifespan of RBCs in HD patients.

Increased susceptibility to erythrocyte C5b-9 deposition and complement-mediated lysis in chronic renal failure

BACKGROUND

Decreased red blood cell survival contributes to the anemia of chronic renal failure patients. Because patients on chronic dialysis therapy are frequently exposed to excessive complement activation, we investigated the susceptibility of this patient population to erythrocyte C5b-9 deposition, complement-mediated lysis, and ghost formation.

METHODS

We developed a flow cytometric assay using antibodies to both glycophorin and the C5b-9 complex to detect C5b-9 deposition on intact erythrocytes and erythrocyte ghosts. Serum C5b-9 levels and C5b-9 deposition on erythrocyte ghosts were measured by enzyme-linked immunosorbent assay.

RESULTS

A significant increase in C5b-9 deposition on intact erythrocytes was demonstrated in patients with advanced chronic renal failure (2.2 +/- 0.5%) and in patients on chronic maintenance hemodialysis (2.3 +/- 0.4%) compared with normal volunteers (0.9 +/- 0.1%, P = 0.005 vs. chronic renal failure, P < 0.001 vs. chronic hemodialysis patients). There was also a significantly higher percentage of C5b-9-positive erythrocyte ghosts in patients with advanced chronic renal failure (20.6 +/- 5%) and in chronic hemodialysis patients (15.5 +/- 3.1%) compared with normal controls (2.6 +/- 0.9%, P < or = 0.001 vs. advanced chronic renal failure and chronic hemodialysis patients). Treatment of erythrocyte preparations with cobra venom factor, which activates the complement cascade, resulted in dramatic increases in the percentages of C5b-9-positive erythrocyte ghosts in patients with chronic renal failure (49.9 +/- 6.9%) and in chronic hemodialysis patients (45.0 +/- 4.2%) compared with normal volunteers (22.3 +/- 2.7%, P < 0.001 vs. chronic renal failure and chronic hemodialysis patients). Erythrocyte membrane expression of the complement regulatory proteins CD59 and CD55 did not significantly differ between normal controls and hemodialysis patients. Plasma C5b-9 levels after cobra venom factor stimulation were higher in chronic renal failure patients (538 micrograms/ml) compared with normal controls (345 micrograms/ml, P < 0.001).

CONCLUSIONS

Patients with chronic renal failure and on hemodialysis therapy are susceptible to erythrocyte C5b-9 deposition with subsequent lysis and ghost formation. Susceptibility to complement-mediated erythrocyte injury may contribute to the anemia of chronic renal disease.