Under-recognized renal insufficiency in hospitalized patients: implications for care

BACKGROUND

The consequences of undetected low glomerular filtration rate (GFR) are important in hospitalized patients who receive potentially nephrotoxic drugs or undergo major surgery. This study estimated the prevalence of estimated GFR (eGFR) <60mL/min/1.73m(2) in hospitalized patients.

METHODS

This cross-sectional descriptive study included 14,658 adults hospitalized at 10 centers in Spain. Serum samples were analyzed for hemoglobin, creatinine, albumin and urea nitrogen. eGFR was estimated using Modification of Diet in Renal Disease (MDRD) 4 or MDRD IDMS, and MDRD 6 when serum albumin and BUN were included (n=8611). Individuals were classified as having GFR>or=60mL/min/1.73m(2), stages 3, 4 and 5 (GFR 30-59, 15-29 and <15mL/min/1.73m(2), respectively). Additionally, stages 3a and 3b (GFR 45-59 and 30-44mL/min/1.73m(2), respectively) were assessed.

RESULTS

MDRD 4 eGFR showed that 28.3% of patients had renal insufficiency stages 3-5 and 14.2% had stages 3b, 4 or 5, which represents important-severe renal deterioration. Forty-three percent of patients with stages 3-5 had hemoglobin <or=11g/dL, compared with 27.9% of patients with eGFR>or=60mL/min/1.73m(2). A good correlation was observed between eGFR MDRD 4 and MDRD 6.

CONCLUSIONS

A high percentage of hospitalized patients in Spain have deteriorated renal function stages 3-5. Using eGFR equations to assess eGFR could identify more hospitalized patients with renal insufficiency, potentially leading to improved care.

[Analysis of evaluation process of research projects submitted to the Fondo de Investigación Sanitaria, Spain]

BACKGROUND

At the present time it seems very clear that research improvement is both an unquestionable fact and the right way to develop technological innovation, services and patents. However, such improvement and corresponding finances needs to be done under fine and rigorous evaluation process as an assessment tool under which all the research projects applying to a public or private call for proposals should be submitted to assure a coherence point according to the investment to be made. At this end, the main target of this work has been focused to analysis and study the evaluation process traditionally made by Fondo de Investigación Sanitaria (FIS) as well as to propose most adequate modifications.

MATERIAL AND METHOD

A sample of 431 research projects corresponding to year 1998 proposal was analysed. The evaluation from FIS and ANEP (National Evaluation and Prospective Agency) was evaluated and scored (evaluation quality) in its main contents by 3 independent evaluators, the showed results submitted to a comparative frame between these agencies at indoor (FIS) and outdoor (FIS/ANEP) level.

RESULTS

FIS evaluation had 20 commissions or areas of knowledge. The analysis indoor (FIS) clearly showed that evaluation quality was correlated to the assigned commission (F = 3.71; p < 0.001) and to the time last of the researched proposal (F = 3.42; p < 0.05) but no related to the evaluator. On the other hand, the quality of ANEP evaluation showed a correlated dependency of the three mentioned facts. In all terms, the ANEP evaluation was better than FIS for the three years time projects, but in did not show significant differences in one or two years time projects. In all cases, the evaluation with final results as negative (financing denied) showed an average quality higher than positive evaluation.

CONCLUSIONS

The obtained results advice about the convenience of making some changes in the evaluative structure and to review the sort of FIS technical commissions focusing an improvement of the evaluation process.

Red wine intake prevents nuclear factor-kappaB activation in peripheral blood mononuclear cells of healthy volunteers during postprandial lipemia

BACKGROUND

Several epidemiological studies have demonstrated the beneficial effect of red wine intake in reducing total and cardiovascular mortality. This effect has been attributed in part to its antioxidant properties. Because the monocytes/macrophages and the nuclear transcription factor kappaB (NF-kappaB) are implicated in the pathogenesis of atherosclerotic lesions, we examined the effect of red wine intake on the activation of NF-kappaB in peripheral blood mononuclear cells.

METHODS AND RESULTS

Sixteen healthy volunteers were studied 3 times each: after a moderate dose, a low dose, and no wine with a fat-enriched breakfast. Lipid profile and NF-kappaB activation (electrophoretic mobility shift assay) were examined in blood samples taken before and 3, 6, and 9 hours after wine intake. In addition, mononuclear cells were incubated with VLDL in the presence of some antioxidants (quercetin and alpha-tocopherol succinate) contained in red wine to study their effects on NF-kappaB activation. Subjects receiving a fat-enriched breakfast had increased NF-kappaB activation in peripheral blood mononuclear cells coinciding with the augmentation in total triglycerides and chylomicrons. Red wine intake prevented NF-kappaB activity even though it induced a certain increase in serum lipids, particularly VLDL, that did not increase after the fat ingestion alone. However, another form of alcohol intake (vodka) did not modify the NF-kappaB activation provided by postprandial lipemia. In cultured mononuclear cells, isolated human VLDL caused NF-kappaB activation in a time-dependent manner that did not occur in the presence of the red wine antioxidants quercetin and alpha-tocopherol.

CONCLUSIONS

Our results provide a new potential mechanism to explain the beneficial effects of red wine intake in the reduction of cardiovascular mortality.

Lipoprotein abnormalities in patients with asymptomatic acute porphyria

There have been discrepancies in reports of total cholesterol and low density lipoprotein (LDL)-cholesterol levels in patients with acute porphyria. Some studies have found that acute porphyria patients have increased levels while others do not. The aim of this study has been to evaluate the lipid profile in a series of patients with acute porphyria, in order to help clarify these differences. Serum lipoprotein levels were studied in 30 patients (25 women and five men; age:38+/-10 years) with asymptomatic acute porphyria. Controls were 30 healthy volunteers matched for age and gender. For 13 patients and 15 controls, lipoprotein lipase and hepatic lipase activities were determined. Patients exhibited increased levels of total-cholesterol, LDL-cholesterol, high density lipoprotein (HDL)-cholesterol and apolipoprotein (apo)-A1 compared with controls (P4 mmol/l in 15 patients (50%). Levels of total triglycerides, very low density lipoprotein (VLDL)-triglycerides, VLDL-cholesterol, apo-B and lipoprotein(a) were similar in patients and controls. The hepatic lipase activity tended to be lower in patients than controls (33.8+/-17.7 vs. 50.4+/-23.0 pkat/ml; P=0.05). In conclusion, in patients with asymptomatic acute porphyria an increase of total and LDL-cholesterol was found. The cardiovascular risk conferred by this factor may be attenuated by increased HDL-cholesterol and apo-A1.

Changes in phenotypes of apolipoprotein E and apolipoprotein(a) in liver transplant recipients

The aim of this study has been to confirm that liver is the main site of apolipoprotein (apo) E and apo(a) synthesis, based in the changes of their phenotypes after transplantation. Apo E phenotypes were studied in 34 patients and apo(a) phenotypes in 27 of them before and after liver transplant. Thirteen patients changed the apo E phenotype after transplantation. Eight patients with E3/3 phenotype changed to the others with 2 or 4 alleles. Three patients with E4/3 phenotype changed to E3/3, one changed from E3/2 to E3/3 and another one changed from E4/2 to E3/2 phenotype after transplantation. Twenty one of the 27 patients changed the apo(a) phenotype. Thirteen of them also changed lipoprotein (Lp)(a) serum concentration at least twofold, showing in 11 an increase and in 2 a decrease, in relation with the change to phenotype associated with high and low Lp(a) concentration, respectively. Changes in apo E and apo(a) phenotypes in liver transplant recipients studied show that most of these apolipoproteins are synthesized by the liver.

Lipoprotein compositional abnormalities in type I diabetes: effect of improved glycaemic control

Major lipoprotein mass and composition were assessed in 45 subjects with insulin dependent diabetes mellitus (IDDM), before and after 2 months of intensive insulin therapy (IIT) and in 40 healthy control subjects. As compared to the control group, diabetic subjects at baseline had higher low density lipoprotein (LDL) and lower high density lipoprotein (HDL) masses. Expressing each lipoprotein constituent as a percent of total lipoprotein mass, very low density lipoprotein (VLDL) of diabetic patients was enriched in cholesterol and phospholipid and depleted in triglyceride and protein; IDL had higher triglyceride and phospholipid and lower cholesterol and protein proportion; LDL was depleted in protein and enriched in triglyceride; HDL was depleted in protein and enriched in triglyceride, cholesterol and phospholipid. After 2 months of IIT, HbA1c fell from 10.3 +/- 2 to 7.5 +/- 2% (P < 0.0001) and so did VLDL mass, which was lower than in control subjects. In addition, LDL and HDL masses, as well as triglyceride and cholesterol proportion in IDL particles normalized. The other compositional abnormalities improved without complete normalization. Thus, intensive insulin therapy in IDDM subjects brought quantitative lipoprotein alterations to normal even subnormal range, while most of the composition abnormalities improved without reaching complete normalization.

LDL binding sites on platelets differ from the "classical" receptor of nucleated cells

Washed human platelets bound radioiodinated low density lipoprotein (125I-LDL) to a class of saturable binding sites; they numbered 1,348 +/- 126 per platelet, and the dissociation constant (KD) was 50.7 +/- 9 nM. 125I-LDL binding to platelets was reversible, and apparent equilibrium was attained within 25 minutes at 22 degrees C and was characterized by forward and reverse rate constants of 1.47 x 10(4) x sec-1 x M-1 and 8 x 10(-4) x sec-1 x M-1, respectively. Such binding was largely unaltered by temperature, divalent ions, and chelating agents. In addition, neither did receptor regulation (up or down) occur when platelets were loaded with cholesterol, nor did prostaglandin E1 (PGE1) increase the binding of 125I-LDL to platelets. On the other hand, the specificity of LDL binding was not typical of the LDL receptor of nucleated cells. Lipoproteins competed for the occupancy of LDL binding sites in platelets with the following order of potency: very low density >> intermediate density > high density subfraction 2. High density lipoprotein subfraction 3, heparin, and PGE1 had no effect on this binding. 125I-LDL binding to lymphocytes and fibroblasts and proteolytic degradation of 125I-LDL by lymphocytes was inhibited by the monoclonal antibody IgG-C7 directed against the LDL receptor to 88%, 85%, and 85% (p < 0.001), respectively. However, with this monoclonal antibody, a blocking effect on neither 125I-LDL binding to platelets nor on LDL-enhanced platelet aggregation induced by ADP and collagen was found. Moreover, we confirmed the existence of LDL binding in platelets from patients with familial hypercholesterolemia. Our results indicate that human platelets bind LDL by saturable sites, which clearly differ from the "classical" LDL receptor in their binding properties, absence of receptor regulation, presence in platelets of familial hypercholesterolemia patients, and the lack of a blocking effect of IgG-C7 on LDL binding and LDL biological activity.