Glomerular filtration rate estimated by cystatin C among different clinical presentations.

Glomerular filtration rate (GFR) estimates from serum creatinine has not been generalizable across all populations. Cystatin C has been proposed as an alternative marker for estimating GFR. The objective of this study was to compare cystatin C with serum creatinine for estimating GFR among different clinical presentations. Cystatin C and serum creatinine levels were obtained from adult patients (n=460) during an evaluation that included a GFR measurement by iothalamate clearance. Medical records were abstracted for clinical presentation (healthy, native chronic kidney disease or transplant recipient) at the time of GFR measurement. GFR was modeled using the following variables: cystatin C (or serum creatinine), age, gender and clinical presentation. The relationship between cystatin C and GFR differed across clinical presentations. At the same cystatin C level, GFR was 19% higher in transplant recipients than in patients with native kidney disease (P<0.001). The association between cystatin C and GFR was stronger among native kidney disease patients than in healthy persons (P<0.001 for statistical interaction). Thus, a cystatin C equation was derived using only patients with native kidney disease (n=204). The correlation with GFR (r(2)=0.853) was slightly higher than a serum creatinine equation using the same sample (r(2)=0.827), the Modification of Diet in Renal Disease equation (r(2)=0.825) or the Cockcroft-Gault equation (r(2)=0.796). Averaged estimates between cystatin C and serum creatinine equations further improved correlation (r(2)=0.891). Cystatin C should not be interpreted as purely a marker of GFR. Other factors, possibly inflammation or immunosuppression therapy, affect cystatin C levels. While recognizing this limitation, cystatin C may improve GFR estimates in chronic kidney disease patients.

GFR determined by nonradiolabeled iothalamate using capillary electrophoresis.

Traditional measurements of glomerular filtration rate (GFR) in clinical practice include the measurement of serum creatinine or creatinine clearance. Increasing evidence concerning the limitation of these measurements in clinical practice and clinical trials has resulted in efforts to develop technologies that improve measurement of GFR. Recent efforts in that regard have used radioisotopic labeling of markers of GFR, such as 125I-iothalamate, and 51Cr-ethylenediaminetetraacetic acid. Limitations of these technologies include radiation exposure as well as cost considerations for the management of radioisotopes, including safety, disposal, mailing, and deteriorating activity that results in short shelf life. We report a test that used 0.5 mL Conray dye injected subcutaneously and subsequent measurement of the nonisotopic (cold) iothalamate by capillary electrophoresis in blood and urine. GFR using cold iothalamate compared with standard clearance using 125I-iothalamate was 0.99. The method is cost-effective and allows for avoiding exposure to isotopes, as well as problems such as the disposal and short shelf life of isotopes. This technology could allow for replacement of 125I-iothalamate as a marker for GFR.

Development of a nonisotopic capillary electrophoresis-based method for measuring glomerular filtration rate.

The conditions for quantitative measurement of nonisotopic iothalamate meglumine (Conray) in urine and plasma by capillary zone electrophoresis (CE) have been developed. The impetus for developing this methodology was to replace the traditional [125I]iothalamate glomerular filtration rate (GFR) marker assay, a routine tool in the measurement of kidney function. This new approach for measuring kidney function is attractive since it avoids the cost of administration of radioisotopic compounds to patients, as well as the cost associated with purchase and disposal of isotopic compounds and contaminated samples. The concentration of iothalamate in urine and plasma determined by CE can be used directly to calculate GFR. The GFR in patients injected with [125I]iothalamate and nonisotopic iothalamate simultaneously showed an excellent correlation (0.998) with between-day coefficient of variation of 2.30% and a recovery of 102% and 98%, respectively, when added to urine and plasma. Interference from drugs and other urinary compounds is eliminated with this method. Collectively, this study has shown that CE is a cost-effective alternative to the current methodology for measuring GFR.

Prostaglandin synthesis by osteoid osteoma and osteoblastoma.

Osteoid osteomas are characterized clinically by a pattern of nocturnal pain which is exquisitely sensitive to salicylates. Etiology for the pain has been ascribed by previous investigators to the presence of nonmyelinated nerve fibers or to the effect of prostaglandins. In an effort to corroborate the potential role of prostaglandins in mediating the pain associated with this tumor, we have determined the concentration of prostaglandins E2, F2 alpha, 6-keto-F1 alpha, and thromboxane B2 utilizing radioimmunoassay of extracts of homogenated tumor tissue. Results were compared with similar extracts of normal bone and a variety of other osseous tumors. The increased concentrations of prostaglandin E2 found in cases of osteoid osteoma and osteoblastoma confirm studies of explants of these tumors previously recorded in the literature.

Pentosan polysulfate as an inhibitor of calcium oxalate crystal growth.

Pentosan polysulfate was studied as a calcium oxalate crystal growth inhibitor. The inhibition from pentosan polysulfate at concentrations ranging from 3.5 to 110 mg./l. was measured in simple inorganic calcium oxalate solutions at pH 5, 6 and 7. Pentosan polysulfate also was mixed with urine at concentrations from 10 to 350 mg./l. and inhibition determined. Measurement of calcium oxalate crystal growth inhibition was performed in a seeded crystal growth system. One inhibitory unit (concentration of pentosan polysulfate necessary to give a 50 per cent reduction in the rate of crystal growth) was 5.7 +/- 2 mg./l. at pH 5, 7.2 +/- 1.1 mg./l. at pH 6 and 6.0 +/- 2.1 mg./l. at pH 7. Urine-pentosan polysulfate mixtures showed more inhibitory activity than the predicted inhibition present. Addition of pentosan polysulfate to urine at a concentration of 10 mg./l. increased the inhibitory activity from 45 +/- 3 to 59 +/- 3 IU/l. Pentosan polysulfate is a potent calcium oxalate crystal growth inhibitor in urine at physiologic pH levels. If the urinary concentration of pentosan polysulfate after oral administration reaches 10 mg./l., the increase in inhibitory activity in urine that may occur might be important in the treatment of patients who form calcium oxalate calculi within the urinary tract.

Triamterene urolithiasis: solubility, pk, effect on crystal formation, and matrix binding of triamterene and its metabolites.

The commonly used diuretic Tri and its metabolites have been identified recently as major components of some kidney stones. We have carried out basic physical chemical studies to determine the mechanism of Tri incorporation into kidney stones. The solubility and pK of Tri and its major metabolites, Tri-OH and the Tri-So4, have been determined at 37 C in 0.15 M NaCl. The effect of Tri and its metabolites on crystal formation has been measured in the calcium oxalate monohydrate, hydroxyapatite, and uric acid crystal systems. Tri and its metabolites do not promote crystal nucleation, growth, or aggregation in any of these crystal systems and are not incorporated as these crystals form. We can demonstrate binding of Tri and its metabolites to the protein matrix isolated from kidney stones. These data suggest that Tri and its metabolites to the protein matrix isolated from kidney stones. These data suggest that Tri and its metabolites do not promote the formation of kidney stones but rather become incorporated into existing stones or stone nidi by binding to the protein matrix found in all kidney stones.

Urinary crystal growth: effect of inhibitor mixtures.

1. The crystal growth inhibitory activity of mixtures of known inhibitors and of mixtures of known inhibitors with normal urine was determined in calcium oxalate monohydrate and hydroxyapatite seeded crystal growth systems. 2. The inhibitory activity of the mixtures was compared with the measured activity of the individual components of the mixtures. All mixtures had inhibitory activity equal to the sum of the activities of their components, with the exception of RNA/urine mixtures in the calcium oxalate monohydrate system. 3. RNA/urine mixtures had inhibitory activity toward calcium oxalate monohydrate crystal growth which was less than would be predicted from the activity of the RNA and of the urine which were added. This reduced inhibitory activity was shown to be due probably to hydrolysis of RNA by the ribonuclease activity normally present in urine. 4. The results of these experiments make it possible to determine quantitatively the contribution of various naturally occurring urinary crystal growth inhibitors to the total measured inhibition observed in urine.

The inhibition of calcium oxalate crystal growth by multidentate organic phosphonates.

The effect of a number of structurally related multidentate organic phosphonates on the rate of crystal growth of calcium oxalate was studied as a function of pH. Rate constants were obtained at various concentrations for the phosphonates ethane-1-hydroxy-1,1-diphosphonate (EHDP), nitrilotri(methylenephosphonic acid) (NTMP), N,N,N',N'-ethylene-diaminetetra(methylenephosphonic acid) (ENTNP), and N,N,N',N'-hexamethylenediaminetetra(methylenephosphonic acid (HMTMP), at pH 5.00, 6.00, and 7.00. The effect of pH on the inhibitory activity of each of the phosphonates was considerable with effective concentrations of inhibitor decreasing two orders of magnitude, in some cases, as the pH was increased. At a given pH the potentially hexadentate ligands, ENTMP and HMTMP, were generally the most effective inhibitors. The results suggested that EHDP, at currently administered doses, provides only a moderate increase in the capacity of human urine to inhibit calcium oxalate crystal growth.

Epitaxial relationships in urolithiasis: the brushite-whewellite system.

1. Whewellite (calcium oxalate monohydrate) crystals were found to induce epitaxially the heterogeneous nucleation of brushite (calcium monohydrogen phosphate dihydrate) from its metastable supersaturated solution in approximately one-quarter of the time required for spontaneous precipitation in the absence of added nucleating agents. Scanning electron-microscope observation of the crystalline phase showed brushite crystals originating from the whewellite seed crystals. 2. Crystal growth, upon nucleation, proceeded rapidly, and the metastable solutions quickly approached saturation. 3. Brushite crystals also induced the precipitation of calcium oxalate crystals in about one-quarter of the time required for spontaneous precipitation; however, the rate of crystal growth was considerably slower. In support of the chemical data, scanning electron micrographs showed few crystals of calcium oxalate nucleated on the surface of the brushite seed. 4. The results provide some insight into the cause of stones containing calcium oxalate or calcium phosphate (or both), which form in the normally acid environment of human urine.

The epitaxially induced crystal growth of calcium oxalate by crystalline uric acid.

Seed crystals of anhydrous uric acid were shown to epitaxially induce the crystal growth of calcium oxalate monohydrate from its metastable supersaturated solution. Scanning electron microscopic examination of crystalline material isolated from the kinetic experiments supports the chemical evidence that calcium oxalate had been nucleated by uric acid. In spite of close lattice similarities between some of the faces of the two phases, the induction period required for heterogeneous nucleation by the seed material was about half of that required for precipitation in the absence of potential nucleating agents. This has created some doubt as to whether crystalline uric acid has an influence on the formation of calcium oxalate lithiasis.

Epitaxial relationships in urolithiasis: the calcium oxalate monohydrate-hydroxyapatite system.

Chemical kinetic data, complemented with scanning electron-microscope observations of the crystalline phase, show that seed crystals of hydroxyapatite have the ability to induce the growth of calcium oxalate monohydrate crystals epitaxially from a metastable supersaturated solution of calcium oxalate. The rate of growth of calcium oxalate crystals is dependent on the surface area of the seed material and follows a second-order rate law. It is suggested that there may be a causal relationship between the occurrence of apatite crystals in the urinary tract and the formation of both 'pure' and mixed urinary stones containing calcium oxalate. Under similar experimental conditions, however, seed crystals of calcium oxalate monohydrate appeared unable to induce epitaxially the growth of calcium phosphate crystals from a supersaturated calcium phosphate solution, indicating the absence of an epitaxial relationship between calcium oxalate monohydrate and the initially precipitating calcium phosphate phase(s).