The assessment of serum nontransferrin-bound iron in chelation therapy and iron supplementation

Nontransferrin-bound iron (NTBI) appears in the serum of individuals with iron overload and in a variety of other pathologic conditions. Because NTBI constitutes a labile form of iron, it might underlie some of the biologic damage associated with iron overload. We have developed a simple method for NTBI determination, which operates in a 96-well enzyme-linked immunosorbent assay format with sensitivity comparable to that of previous assays. A weak ligand, oxalic acid, mobilizes the NTBI and mediates its transfer to the iron chelator deferoxamine (DFO) immobilized on the plate. The amount of DFO-bound iron, originating from NTBI, is quantitatively revealed in a fluorescence plate reader by the fluorescent metallosensor calcein. No NTBI is found in normal sera because transferrin-bound iron is not detected in the assay. Thalassemic sera contained NTBI in 80% of the cases (range, 0.9-12.8 micromol/L). In patients given intravenous infusions of DFO, NTBI initially became undetectable due to the presence of DFO in the sera, but reappeared in 55% of the cases within an hour of cessation of the DFO infusion. This apparent rebound was attributable to the loss of DFO from the circulation and the possibility that a major portion of NTBI was not mobilized by DFO. NTBI was also found in patients with end-stage renal disease who were treated for anemia with intravenous iron supplements and in patients with hereditary hemochromatosis, at respective frequencies of 22% and 69%. The availability of a simple assay for monitoring NTBI could provide a useful index of iron status during chelation and supplementation treatments. (Blood. 2000;95:2975-2982)

H-ferritin subunit overexpression in erythroid cells reduces the oxidative stress response and induces multidrug resistance properties

The labile iron pool (LIP) of animal cells has been implicated in cell iron regulation and as a key component of the oxidative-stress response. A major mechanism commonly implied in the downregulation of LIP has been the induced expression of ferritin (FT), particularly the heavy subunits (H-FT) that display ferroxidase activity. The effects of H-FT on LIP and other physiological parameters were studied in murine erythroleukemia (MEL) cells stably transfected with H-FT subunits. Clones expressing different levels of H-FT displayed similar concentrations of total cell iron (0.3 +/- 0.1 mmol/L) and of reduced/total glutathione. However, with increasing H-FT levels the cells expressed lower levels of LIP and reactive oxygen species (ROS) and ensuing cell death after iron loads and oxidative challenges. These results provide direct experimental support for the alleged roles of H-FT as a regulator of labile cell iron and as a possible attenuator of the oxidative cell response. H-FT overexpression was of no apparent consequence to the cellular proliferative capacity. However, concomitant with the acquisition of iron and redox regulatory capacities, the H-FT-transfectant cells commensurately acquired multidrug resistance (MDR) properties. These properties were identified as increased expression of MDR1 mRNA (by reverse transcription polymerase chain reaction [RT-PCR]), P-glycoprotein (Western immunoblotting), drug transport activity (verapamil-sensitive drug efflux), and drug cytotoxicity associated with increased MDR1 or PgP. Although enhanced MDR expression per se evoked no significant changes in either LIP levels or ROS production, it might be essential for the survival of H-FT transfectants, possibly by expediting the export of cell-generated metabolites.

The cellular labile iron pool and intracellular ferritin in K562 cells

The labile iron pool (LIP) harbors the metabolically active and regulatory forms of cellular iron. We assessed the role of intracellular ferritin in the maintenance of intracellular LIP levels. Treating K562 cells with the permeant chelator isonicotinoyl salicylaldehyde hydrazone reduced the LIP from 0.8 to 0.2 micromol/L, as monitored by the metalo-sensing probe calcein. When cells were reincubated in serum-free and chelator-free medium, the LIP partially recovered in a complex pattern. The first component of the LIP to reappear was relatively small and occurred within 1 hour, whereas the second was larger and relatively slow to occur, paralleling the decline in intracellular ferritin level (t1/2= 8 hours). Protease inhibitors such as leupeptin suppressed both the changes in ferritin levels and cellular LIP recovery after chelation. The changes in the LIP were also inversely reflected in the activity of iron regulatory protein (IRP). The 2 ferritin subunits, H and L, behaved qualitatively similarly in response to long-term treatments with the iron chelator deferoxamine, although L-ferritin declined more rapidly, resulting in a 4-fold higher H/L-ferritin ratio. The decline in L-ferritin, but not H-ferritin, was partially attenuated by the lysosomotrophic agent, chloroquine; on the other hand, antiproteases inhibited the degradation of both subunits to the same extent. These findings indicate that, after acute LIP depletion with fast-acting chelators, iron can be mobilized into the LIP from intracellular sources. The underlying mechanisms can be kinetically analyzed into components associated with fast release from accessible cellular sources and slow release from cytosolic ferritin via proteolysis. Because these iron forms are known to be redox-active, our studies are important for understanding the biological effects of cellular iron chelation.

Effects of hypotonic and hypoionic media on drug pumping by P-glycoprotein expressed in epithelial and nonepithelial cell lines

The effects of anisotonic and anisoionic media on the drug-pumping function of P-glycoprotein (Pgp) were studied in epithelial and nonepithelial cells. We used HT-29 colon cells (HT-29/Pgp-) induced to express Pgp and MDR phenotype (HT-29/Pgp+) and NIH3T3 (3T3/Pgp-) cells which were stably transfected with human MDR1 DNA (3T3/Pgp+). Intracellular concentrations of rhodamine 123 (R-123) preloaded into cells were monitored as a function of time by fluorescence imaging microscopy, while cells were superfused with media of different tonicity and/or ionic strength. Efflux was analyzed by a single exponential decay function. In all media tested efflux was considerably higher in Pgp+ than Pgp- cells. In both HT-29 and 3T3 cells loaded with dye in isotonic conditions, dye efflux was not significantly different whether it was measured in isoionic-isotonic (130 mM NaCl, 300 mOsm), hypoionic-isotonic (87 mM NaCl), or hypoionic-hypotonic (200, 150, or 100 mOsm) media throughout the entire experiment or whether the media were changed during the experiment. Similar results were obtained when cells were preincubated and preloaded with dye under hypotonic conditions. Under extreme hypotonic and hypoionic challenge (changing from 130 mM NaCl-300 mOsm to 43 mM NaCl-100 mOsm medium), 3T3 cells, but not HT-29 cells, underwent marked shape and size changes which reduced R-123 cell-associated fluorescence. The changes were most conspicuous in Pgp+ cells, possibly reflecting a Pgp effect on the osmotic or osmoregulatory properties of the cells. However, drug-pumping activity remained essentially unimpaired even under the most extreme hypotonic/hypoionic conditions.

Effects of P-glycoprotein expression on cyclic AMP and volume-activated ion fluxes and conductances in HT-29 colon adenocarcinoma cells

The tissue distribution of P-glycoprotein (Pgp) and the structurally related cystic fibrosis transmembrane conductance regulator (CFTR) is apparently mutually exclusive, particularly in epithelial; where one protein is expressed the other is not. To study the possible function(s) of Pgp and its potential effects on CFTR expression in epithelia, HT-29 colon adenocarcinoma cells, which constitutively express CFTR, were pharmacologically adapted to express the classical multidrug resistance (MDR) phenotype (Pgp+). Concomitant with the appearance of Pgp and MDR phenotype (drug resistance, reduced drug accumulation and increased drug efflux), CFTR levels and cAMP-stimulated Cl conductances were markedly decreased compared to wild-type HT-29 (Pgp-) cells (as shown using the whole cell patch clamp technique). Removal of drug pressure led to the gradual decrease in Pgp levels and MDR phenotype, as evidenced by increased rhodamine 123 accumulation (Pgp-Rev). Concomitantly, CFTR levels and cAMP-stimulated Cl- conductances increased. The cell responses of Pgp/Rev cells were heterogeneous with respect to both Pgp and CFTR functions. We also studied the possible contribution to Pgp to hypotonically activated (HCS) ion conductances. K+ and Cl- effluxes from Pgp- cells were markedly increased by HCS. This increase was twice as high as that induced by the cation ionophore gramicidin; it was blocked by the Cl- channel blocker DIDS (4,4'-disothiocyano-2,2'-disulfonic stilbene) and required extracellular Ca2+. In Pgp+ cells, the HCS-induced fluxes were not significantly different from those of Pgp- cells. Verapamil (10 microM), which caused 80% reversal of Pgp-associated drug extrusion, failed to inhibit the HCS-evoked Cl- efflux of Pgp+ cells. Similarly, HCS increased Cl- conductance to the same extent in Pgp-, Pgp+ and Pgp-Rev cells. Verapamil (100 microM), but not 1,9-dideoxyforskolin (50 and 100 microM), partially inhibited the HCS-evoked whole cell current (WCC) in all three lines. Since the inhibition by verapamil was not detected in the presence of the K+ channel blocker Ba2+ (3 mM), it is suggested that verapamil affects K+ and not Cl- conductance. We conclude that hypotonically activated Cl- and K+ conductances are similar in HT-29 cells irrespective of Pgp expression. Expression of high levels of Pgp in HT-29 cells confers no physiologically significant capacity for cell volume regulation.

Induction of multidrug resistance downregulates the expression of CFTR in colon epithelial cells

The epithelial cell line HT-29, which constitutively expresses the cystic fibrosis transmembrane conductance regulator (CFTR), was induced to become drug resistant by cultivation in the presence of colchicine. The gradual acquisition of drug resistance was associated with a corresponding increase in the expression of the multidrug resistance P-glycoprotein (P-gp) and a marked (> 80%) decrease in the constitutive levels of CFTR protein, as determined by immunoblotting. The reduction in CFTR content occurred at the onset of acquisition of drug resistance when P-gp expression was still relatively low. Reversal of drug resistance by removal of colchicine from the culture medium led to a 70% decrease in P-gp levels and a concomitant 40% increase in CFTR. The levels of other membrane proteins such as Na(+)-K(+)-ATPase and alkaline phosphatase remained relatively constant (< 26% variation). We propose that a selective downregulation of CFTR is elicited by acquisition of the multidrug resistance (MDR) phenotype and that induction of P-gp expression leads to a reversible repression of CFTR biosynthesis. These findings provide an experimental foundation for the complementary patterns of expression of the CFTR and MDR1 genes observed in vivo.

Long-term cAMP activation of Na(+)-K(+)-2Cl- cotransporter activity in HT-29 human adenocarcinoma cells

Cl- channel and Na(+)-K(+)-2Cl- cotransport activities were studied in various cystic fibrosis transmembrane conductance regulator (CFTR)-expressing cells with the aim of assessing integrative patterns of regulation of Cl- secretion. Human colonic HT-29 cells express relatively high levels of CFTR and cotransporter but relatively low Cl- channel activity. These cells showed commensurate activations of both transport systems evoked by short-term (minutes) or long-term (hours) exposures to adenosine 3',5'-cyclic monophosphate (cAMP). However, unlike in the case of CFTR and Cl- channels, long-term induction of cotransporter did not depend on de novo protein synthesis or changes in number of transporters. The patterns of activation of both transporters were also examined in CFTR-deficient cell lines (CFPAC and the viral-transfected CFPAC-PLJ) and in the viral CFTR-transfected derivative (CFPAC-4.7). All these cells displayed relatively low basal cotransport activity and a correspondingly low number of transporters, whereas only CFPAC-4.7 cells showed short-term (but not long-term) activatable Cl- channels. However, irrespective of the presence or absence of CFTR in CFPAC cells, neither short- nor long-term cAMP exposures induced significant cotransporter activation. Our studies with the various epithelial cell lines indicate that expression of CFTR activity per se is not sufficient for stimulation of cotransporter activity. Moreover, despite apparent correction of CFTR levels in CFPAC cells by gene transfer, the apparent Cl- secretory capacity might be limited by the low cotransport activity, such as that found in CFPAC cells, with obvious implications for proposed gene therapy of cystic fibrosis.

Postpartum renal failure in systemic lupus erythematosus

The present report describes an unusual association between postpartum renal failure and systemic lupus erythematosus. Two healty young women developed progressive renal failure several weeks after delivery accompanied by the presence in their serum of strongly reactive anti-nuclear antibodies and positive anti-DNA antibodies. In both cases kidney biopsy disclosed light and electron microscopy pictures typical of idiopathic postpartum renal failure, with multiple intravascular thrombi and no evidence of active lupus nephritis. Intrarenal microthrombi formation may represent a form of exacerbation of systemic lupus erythematosus after delivery. The early recognition of this syndrome may have therapeutic implications.

Na(+)-H+ exchange is stimulated by protein kinase C activation in inner medullary collecting duct cells

In this study we investigated the role of protein kinases in activation of the Na(+)-H+ exchanger in inner medullary collecting duct (IMCD) cells. Monolayers, 24-48 h after achieving confluence, were made quiescent by 24 h incubation in 0.1% serum before study. Changes in pHi were measured with 2',7'-bis(carboxyethyl)-5(6)-carboxyfluorescein. Phorbol myristate acetate (PMA), a synthetic analogue of diacylglycerol (DAG), was used to stimulate protein kinase C (PKC). In nominally HCO3(-)-free media containing 110 mM Na+ and 1 mM Ca2+, PMA addition increased pHi from 7.29 +/- 0.08 to 7.54 +/- 0.07 after 20 min. The increment in pHi was completely inhibited by 1 mM amiloride or by replacement of extracellular Na+ with choline but not inhibited by 1 mM N-ethylmaleimide, an inhibitor of active proton transport. Downregulation of PKC by overnight incubation of monolayers with PMA also prevented the rise in pHi upon subsequent challenge with PMA. Another active analogue of DAG, 1,2-dioleoyl-rac-glycerol, caused an increment in pHi similar to that produced by PMA, whereas 4 alpha-phorbol, an inactive analogue, did not stimulate Na(+)-H+ exchange. Bradykinin (10(-6) M), a phospholipase C-activating hormone, also induces alkalinization of IMCD cells similar to that produced by phorbol esters. Neither vasopressin (10(-7) M), which induces cellular accumulation of adenosine 3',5'-cyclic monophosphate (cAMP) and activation of protein kinase A (PKA), nor 8-bromo-cAMP (1 mM) changed pHi. Therefore in the IMCD cell activation of PKC but not PKA stimulates a rise in pHi via the Na(+)-H+ exchanger.

Nephrotic syndrome in temporal arteritis

Renal abnormalities are highly unusual in temporal arteritis. The association of temporal arteritis with nephrotic syndrome has been reported previously in only one patient. This report describes another case.

Effect of increases in cytosolic Ca2+ on inner medullary collecting duct cell pH

Changes in cytosolic calcium concentration (Cai2+) have been implicated in the regulation of intracellular pH (pHi) in several cell types. In the present study we investigated the mechanism by which an increase in Cai2+ stimulates H+ secretion and a rise in pHi in cultured rat inner medullary collecting duct (IMCD) cells. Confluent monolayers were made quiescent by incubation for 24 h in 0.1% serum before study. Changes in pHi and Cai2+ were measured with the fluorescent probes, 2,7-biscarboxyethyl-5(6)-carboxyfluorescein (BCECF) and fura-2. In nominally bicarbonate-free media containing 110 mM Na+ and 1 mM Ca2+, addition of the Ca2+ inophore, ionomycin (10 microM), produced a biphasic response in pHi, a transient acidification from 7.29 +/- 0.07 to 7.12 +/- 0.05 at 2 min followed by a sustained alkalinization to a steady-state value of 7.51 +/- 0.10 at 10 min. The rate of alkalinization was dose dependent. The alkalinization was not affected by 1 mM amiloride, removal of extracellular Na+, or by the proton pump inhibitor, N-ethyl maleimide (NEM). Metabolic energy was not required, but removal of extracellular Ca2+ prevented the alkalinization. By use of the fluorescent probe bisoxonol to assess membrane potential, ionomycin was shown to cause depolarization under the same experimental conditions as those for alkalinization. The Ca2+-induced alkalinization was mimicked by cell depolarization (induced by raising extracellular K+ in the presence of valinomycin 1 microM). We conclude that changes in Cai2+ are important in the regulation of pHi in the IMCD. Ca2+-induced cell alkalinization may be mediated by changes in membrane ionic conductance.

Acute renal failure in the elderly treated by one-time peritoneal dialysis

To determine the factors affecting outcome of acute renal failure (ARF) in the elderly, we retrospectively studied 44 patients over the age of 65 who had undergone acute peritoneal dialysis. Thirteen patients (29%) survived 2 months or longer after dialysis treatment ("survivors"). Thirty-one patients (71%) died within this period ("nonsurvivors"). The main factor distinguishing survivors was the frequency of sepsis (none of 13 survivors vs 17 of 31 nonsurvivors). Preexisting malignancy and total number of acute insults to renal function were significantly less frequent, and immediate clinical and biochemical outcome of dialysis significantly better in survivors. The overall complication rate of dialysis was high (31 of 44 patients), but was significantly lower in survivors. Acute peritoneal dialysis is a useful procedure in the management of ARF in the elderly. However, we suggest that elderly patients in whom sepsis is a contributory factor to the development of ARF do not benefit from peritoneal dialysis therapy.

Improved renal function following acute peritoneal dialysis in patients with intractable congestive heart failure

Nine patients, six men and three women, 40 to 73 years of age, were included in the study. All of the patients had severe heart failure refractory to aggressive therapy including digitalis, diuretics, and vasodilators. Eight patients underwent one treatment of peritoneal dialysis while the remaining patient received two dialyses. The urine output was measured by an indwelling catheter; glomerular filtration rate (GFR) was determined by creatinine and inulin clearance, and renal blood flow (RBF) was determined by sodium paraamino hippurate (PAH) clearance. Following one peritoneal dialysis, the mean fluid loss/patient was 3,995 ml (range 3,200 to 5,100 ml). Dialysis was generally well tolerated. One patient, who had underlying hepatic cirrhosis and underwent two dialyses, developed hepatic failure and died 10 days after the second dialysis. At postmortem, peritonitis was discovered. All of the patients showed a marked subjective and objective clinical improvement. The mean plasma urea decreased from 154 to 71 mg/dl (P less than 0.005), and mean plasma creatinine decreased from 1.83 to 1.13 mg/dl (P less than 0.005). Blood pH was 7.30 before dialysis and increased to 7.37 (P less than 0.0125) after treatment. Mean urine output predialysis was 955 ml and increased to 1,472 ml post dialysis (P less than 0.0005). Creatinine clearance increased from 35 to 73 ml/min (P less than 0.0005). The mean inulin clearance increased from 33 ml/min predialysis to 69 ml/min post dialysis (P less than 0.0005), and mean PAH clearance increased from 96.7 to 362.5 ml/min (P less than 0.0005). Acute peritoneal dialysis is a safe and effective means for removing large quantities of excess fluid from patients with intractable heart failure.

Prevention of scarring in experimental pyelonephritis in the rat by early antibiotic therapy

Experimental pyelonephritis was produced by either retrograde or direct infection of rat kidneys by Escherichia coli 078. Combined antibiotic therapy with amoxycillin and gentamicin, commenced within 23 h of direct infection, prevented acute suppuration and subsequent scarring. The same antibiotics combination commenced 24 h after both retrograde and direct infection did not significantly reduce acute suppuration but did reduce scarring. Treatment begun later than 24 h after infection had no effect on the outcome of pyelonephritis induced by either route. Significantly lower peak levels of serum antibody to the O antigen of E. coli 078 were obtained in rats treated at 24 h after retrograde pyelonephritis than in those in which treatment was started later. Kidney scarring could not be prevented if antibiotic therapy was commenced after the appearance of mononuclear cells in the inflammatory lesion.

Recurrent spontaneous hypothermia

A patient with recurrent attacks of hypothermia is presented. Despite intensive investigation, no other manifestation of hypothalamic or autonomic dysfunction has been found. Treatment of concurrent biochemical hypothyroidism has not altered the frequency or severity of the hypothermic attacks.

The treatment of lupus nephritis by methyl prednisolone pulse therapy

Four patients with proliferative glomerulonephritis due to systemic lupus erythematosus were treated with intravenous methyl prednisolone 'pulse' therapy. In all, eight courses of therapy were given, three for acute oliguric renal failure; and on each occasion there was a good response to the treatment. Clinical, histological and immunological details of the patients are presented. The diagnosis, treatment, and monitoring of disease activity in lupus nephritis are discussed in the light of this experience.

Acute intravascular hemolysis with minimal renal impairment in Clostridium perfringens infection

We report here a case of post-abortal clostridium prefringens infection in which there was severe intravascular hemolysis with black urine, but only minor abnormalities of the clotting mechanism and mild renal failure. The patient recovered following supportive therapy only.