[Chronic kidney disease and cellular calcium homeostasis]. / Chronické ochorenie obliciek a vápniková homeostáza bunky.

Free intracellular calcium represents a critical signaling mediator in a number of biological systems. Calcium cations (Ca2+) are an important ubiquitous messenger, controlling a broad range of cellular processes. Free cytosolic calcium concentration ([Ca2+]i) is controlled by mechanisms that regulate Ca2+ entry from the extracellular space and Ca2+ release from intracellular stores, and by the activity of ATP-dependent Ca2+ pumps and antiporters that move Ca2+ back into stores or out of cells. Chronic kidney disease is associated with a significant elevation in [Ca2+]i which is toxic to the cells and may be responsible for a multiple organ dysfunction. Disturbances in cellular calcium homeostasis in patients with chronic kidney disease represent a complex process. Our studies elucidate pathophysiological mechanisms of altered cellular calcium homeostasis in the peripheral blood mononuclear cells which represent the model of nonexcitable cells in patients with chronic kidney disease. The results demonstrate that [Ca2+]i is significantly increased in peripheral blood mononuclear cells already in early stages of chronic kidney disease. The calcium concentration of intracellular stores and the capacitative calcium entry into the cells of these patients are significantly higher in comparison with healthy volunteers. Also the pore-forming P2X7 receptors participate in increased [Ca2+]i in peripheral blood mononuclear cells of patients with chronic kidney disease. An altered P2X7 receptor function and increased P2X7 receptor expression may contribute to the complex disturbances in intracellular calcium homeostasis in chronic kidney disease. On the other hand, the activity of plasmatic membrane Ca2+-ATPases which is responsible for removing excessive calcium out of the cell, was found to be decreased by 25 % when compared to healthy subjects. It means that not only the mechanisms of entry, but also of the removal are impaired by the disease. All these alterations in calcium signaling are contributing very likely to the elevated [Ca2+]i from early stages of chronic kidney disease.

Mitochondria and mitochondrial nitric oxide synthase alterations participate in energetical dysbalance, aging and age-related diseases.

Nitric oxide (NO) is a unique mediator of cellular regulations synthesized by nitric oxide synthases (NOS) present in cytoplasm of various cells. An additional Ca-dependent mitochondrial NOS (mtNOS) detected just recently synthesizes also NO inhibiting oxidative phosphorylation, i.e. mitochondrial energy producing metabolic process and protects mitochondria from oxygen radicals. Mitochondrial membrane possesses electrogenic uniporter transporting Ca into mitochondria (stimulation of mtNOS), while Na+/Ca2+ exchanger removes Ca from mitochondria. Mitochondrial disorders with low mtNOS activity participate in accelerated aging and age-related diseases. The direct NO balance determination is outside of the standard clinical facilities; Indirect alternatives, such as insulin resistance determination are accessible. Pharmacotherapy exploits effective therapeutic and preventive measures (NO donors, ACEI inhibitors, etc.) and pharmaceutical approach (development of mitochondriotropic drugs). We suggest, that mitochondrial disorders participate in aging and age related diseases and propose that the early diagnostics, preventive and therapeutic measures could prevent and even correct at least partially the development of age-related diseases (Tab. 4, Ref. 81).

Nitric oxide modulation of metabolic and haemodynamic balance.

Nitric oxide (NO) belongs to signal molecules and modulates notably rapid and dynamic processes. Interests are focused on the decreased NO synthesis by endothelial and mitochondrial nitric oxide synthases with the metabolic (i.e. insulin resistance, diabetes, energetical dysbalance) and vascular (i.e. hypertension, atheroslerosis) consequences. A significant source of NO are NO-donors (i.e. organic nitrates). A number of antihypertensive drugs stimulates NO production or inhibits the production of its antagonists (angiotensin II, catecholamines), other drugs (i.e. glucocorticoids) inhibit NO production. These interferences are targets of an intensive research with the aim of NO dysbalance prevention, hypertension and metabolic dysbalances correction. While the clinical research concentrates on NO and insulin resistance, the molecular biological research concentrates on "mitochondrial medicine" with the ambition to formulate a new theory of aging, carcinoma, and other fundamental biological processes (Fig. 1, Ref. 47).

Platelet-activating effect of low-density lipoprotein and its reversal by isradipine.

The effect of the calcium antagonist isradipine on platelet aggregation (induced ex vivo by serotonin and low-density lipoprotein [LDL]) was studied in 17 nonsmoking patients with essential hypertension. Platelet aggregation was measured after a four-week placebo period, and after four and 12 weeks of treatment with isradipine. Both the serotonin-induced and the LDL plus serotonin-induced platelet aggregation were significantly decreased after four weeks of isradipine treatment compared with placebo. The amplifying effect of LDL on the serotonin-induced aggregation was significant both after placebo and after active treatment with isradipine. A further decrease in platelet aggregation induced by LDL plus serotonin was observed after 12 weeks of isradipine treatment so that no amplification of serotonin-induced aggregation by LDL could be detected. In conclusion, it appears that treatment with isradipine restores the impaired platelet response to serotonin and LDL in hypertensive patients. The inhibition of this response may represent a cellular mechanism of thrombovascular protection.

Hippurate participates in the correction of metabolic acidosis.

Hippurate (Hip), an endogenous conjugate, belongs to the group of uremic toxins. Hip stimulates P-independent glutaminase (PIG) localized at the proximal luminal membrane, desamidating glutamine with the formation of ammonia, a dominant and adaptive elimination product of H+. This appears to be important because metabolic acidosis (MAC) does not stimulate PIG. Moreover, Hip inhibits ammonia production by P-dependent mitochondrial glutaminase (PDG) that is primarily stimulated by MAC. By this mechanism, it shifts the ammonia production from mitochondria to proximal tubular lumen. MAC stimulates Hip synthesis in the liver and kidney and increases Hip plasma concentration and even fractional excretion by the kidney, which creates an effective regulatory loop of ammoniagenesis. Thus, it appears that Hip by its participation in the correction of MAC possesses the modulatory function.

DNA damage of lymphocytes in experimental chronic renal failure: beneficial effects of losartan.

BACKGROUND: Kidney diseases are associated with the accumulation of various uremic toxins increasing the oxygen free radical (OFR) activity with a number of serious consequences. One of them could be the impairment of DNA stability with the increased formation of DNA breaks. METHODS: The study was performed in 4/6 kidney ablation rat nephropathy lasting for three months. The results of sham-operated (Sham), remnant kidney (Nx), and Nx treated by losartan (NxL) were compared. RESULTS: Nx significantly increased blood pressure, plasma creatinine, urea, hippurate, malondialdehyde (MDA), lipofuscin (LF), and the number of DNA breaks of lymphocytes. Losartan decreased the rise of blood pressure and inhibited the rise of creatinine plasma concentration but not of other variables, while it markedly inhibited the number of DNA breaks (Sham 15.9 +/- 1.1, Nx 54.5 +/- 1.7, P < 0.001; Nx/Sham, NxL 23.3 +/- 2.6 P < 0.001, NxL/Sham and P < 0.001 NxL/Nx). CONCLUSIONS: The 4/6 kidney ablation nephropathy increases the susceptibility of lymphocyte DNA to breaks, and losartan inhibits the number of breaks by a mechanism independent on glomerular filtration, accumulation of MDA or LF (markers of oxidative stress), and hippurate (marker of the accumulation of middle molecular substances). An independent mechanism, probably the interference with proliferation, is suggested.

Effective long-term inhibition of thromboxane production but not of serotonin release in patients with coronary heart disease by 30 mg/d acetylsalicylic acid dosage.

Efficacy of aspirin (Acetylsalicylic acid, ASA) antiaggregatory prevention was demonstrated in a series of clinical trials. The recommended ASA doses decreased gradually and doses 50-30 mg ASA/d are intensively studied at the present time. A group of 42 patients with coronary heart disease was evaluated: (1) Basal TXB2 production during spontaneous blood clotting was 360 +/- 37.6 ng/ml; (2) Two initial doses were tested: while 200 mg ASA inhibited, during spontaneous blood clotting, median TXB2 production by 99.9% (serum TXB2 concentration 1.35 ng/ml), 30 mg ASA median inhibition was just 42.0% (serum TXB2 151 ng/ml); (3) 30 mg ASA/d maintenance dose was evaluated for 3 months. The median TXB2 production inhibition was 98.5% (serum TXB2 3.75 ng/ml, first month) and 94.0% (serum TXB2 14.2 ng/ml, third month); (4) Four patients did not respond sufficiently, because of noncompliance verified by the determination of salicyluric acid urinary excretion, the lower limit of excretion being <3 micromol/2 h; (5) Both initial and maintenance ASA dose decreased metabolic TXA2 endproducts in urine; (6) 5HT platelet release did not decrease; (7) Potential changes of 5HT metabolic elimination were excluded by the simultaneous determination of 5-hydroxyindoleacetic acid (5HIAA). In conclusion, 200 mg initial dose and 30 mg ASA/d maintenance dose are suggested to be maximally inhibitory for TXB2 production without influence on 5HT release.

Effects of ramipril in nondiabetic nephropathy: improved parameters of oxidatives stress and potential modulation of advanced glycation end products.

Enhanced oxidative stress is involved in the progression of renal disease. Since angiotensin converting enzyme inhibitors (ACEI) have been shown to improve the antioxidative defence, we investigated, in patients with nondiabetic nephropathy, the short-term effect of the ACEI ramipril on parameters of oxidative stress, such as advanced glycation end products (AGEs), advanced oxidation protein products (AOPPs), homocysteine (Hcy), and lipid peroxidation products. Ramipril (2.5-5.0 mg/day) was administered to 12 newly diagnosed patients for 2 months and data compared with a patient group under conventional therapy (diuretic/beta-blockers) and with age- and sex-matched healthy subjects (CTRL). Patients had mild to moderate renal insufficiency and showed, in the plasma, higher fluorescent AGE and carboxymethyllysine (CML) levels, as well as elevated concentrations of AOPPs, lipofuscin and Hcy when compared with CTRL. Basal data of the patients on conventional therapy did not differ significantly from the ramipril group, except for higher Hcy levels in the latter. Administration of ramipril resulted in a drop in blood pressure and proteinuria, while creatinine clearance remained the same. The fluorescent AGEs exhibited a mild but significant decline, yet CML concentration was unchanged. The AOPP and malondialdehyde concentrations decreased, while a small rise in neopterin levels was evident after treatment. The mentioned parameters were not affected significantly in the conventionally treated patients. Evidence that ramipril administration results in a mild decline of fluorescent AGEs is herein presented for the first time. The underlying mechanism may be decreased oxidative stress, as indicated by a decline in AOPPs and malondialdehyde.

Middle molecular weight substances in the cerebrospinal fluid of uremic patients.

The pathogenesis of neuropathy and encephalopathy in patients with renal failure remains unknown. Possible factors include particularly aluminium intoxication, accumulation of certain middle molecular substances (MMS) and disturbances of tryptophan metabolism. Serum and CSF taken post-mortem from 8 uremic subjects who had been treated conservatively and from 4 patients on a chronic intermittent hemodialysis program who had dialysis dementia were subjected to MMS fractionation. Although MMS could not be detected in the CSF of normal controls, these substances were found in the CSF of uremic subjects in a pattern similar to that found in serum, although their concentrations were clearly lower than in serum. Their appearance could be due to impairment of the blood-CSF barrier. Uremic patients who had been treated conservatively had significantly increased CSF tryptophan concentrations when compared to the control subjects, but the CSF tryptophan concentrations of patients with dialysis dementia were in the normal range. Thus the pathogenesis of dialysis dementia cannot be related to the accumulation of MMS or to disturbances of tryptophan metabolism in the CSF.

P-aminohippurate accumulation in kidney cortex slices: stimulation by dicarboxylates, amino acids and their oxoanalogues.

The effect of various amino acids and oxoacids on the accumulation of PAH in rat kidney cortex slices was determined. The following compounds were found to increase the PAH tissue to medium ratio (T/MPAH): a) dicarboxylic acids: glutarate, 2-oxoglutarate and oxaloacetate, b) amino acids: glutamate, isoleucine, leucine, valine, methionine, tryptophane, histidine, threonine and glycine, c) monocarboxylates: hydroxymethionine, oxovaline, oxoisoleucine and oxoleucine. There were no marked concentration/effect differences to glycine, glutamate, glutarate and oxovaline. Ouabain inhibited T/MPAH only slightly, but abolished its increase by pyruvate, 2-oxoglutarate and histidine. Oxygen hyposaturation abolished the T/MPAH increase caused by 2-oxoglutarate, pyruvate, glutamate and histidine. It is concluded that various substrates stimulating the organic anion transport system (OATS) do so namely by improving the energy supply, although the direct participation of dicarboxylates in OATS could be of relevance namely in short-lasting variations.

Participation of P-dependent and P-independent glutaminases in rat kidney ammoniagenesis and their modulation by metabolic acidosis, hippurate and insulin.

The key regulatory enzymes of kidney ammoniagenesis appear to be P-dependent (PDG) and P-independent (PIG) glutaminases. While the participation of PDG has been satisfactorily elucidated, the significance of PIG remains doubtful. Rat kidney cortex slices synthesized ammonia even under basal conditions. Metabolic acidosis, hippurate and insulin stimulated ammonia production. Under basal conditions, PDG activity in kidney homogenate, was twice as high as PIG activity. Metabolic acidosis stimulated ammonia production by the stimulation of both PDG (100%) and PIG (57%) activities. Hippurate stimulated only PIG activity both under basal conditions (90%) and in metabolic acidosis (52%), while it inhibited PDG activity only insignificantly under basal conditions and markedly (53%) in metabolic acidosis. Insulin stimulated both PIG and PDG activities under basal conditions as well as in metabolic acidosis and potentiated the PIG stimulation by hippurate while it potentiated the hippurate inhibition of PDG both under basal conditions and in acidotic rats. In conclusion, both PDG and PIG participate in ammoniagenesis and are stimulated by metabolic acidosis and insulin. Hippurate stimulates PIG, while it inhibits PDG in metabolic acidosis and even after insulin administration. The effect of hippurate appears to be of physiological interest.

Acute effect of hydrochlorothiazide on renal calcium and magnesium handling in postmenopausal women.

A single 50 mg dose of hydrochlorothiazide (HCTZ) decreases the urinary excretion of calcium (U(Ca)V), clearance (C(Ca)) and fractional excretion (FE(Ca)) of calcium. This is accompanied by an increase of total calcium and ionized calcium (Ca2+) concentrations in the serum. On the other hand, HCTZ increases fractional excretion of magnesium (FE(Mg)) and decreases serum Mg2+ concentrations. Moreover, HCTZ decreases markedly clearance of phosphate (C(Pi)) and fractional excretion of phosphate (FE(Pi)) and increases serum phosphate (Pi) concentrations in healthy postmenopausal women. It is concluded that intrinsic renal cellular control promptly uncouples calcium and magnesium tubular reabsorption even without K+ depletion.

The influence of tolbutamide on fatty acid metabolism in the liver and muscle.

Metabolism of palmitate-14C was studied in the rat liver and muscle incubated with 1 mmol.l-1 tolbutamide in vitro experiments: Tolbutamide reduces the utilization of free fatty acids in the liver by inhibiting their uptake, incorporation into total lipids, and oxidation to 14CO2. Tolbutamide stimulates the incorporation into the triacylglycerol fraction in individual liver lipid fractions and inhibits the incorporation into the free fatty acid fraction. As in the liver, tolbutamide inhibits the uptake, incorporation into total lipids, and oxidation to 14CO2 in the muscle. In individual lipid fractions, tolbutamide only inhibits the incorporation of palmitate into cholesterol esters. It can be concluded that tolbutamide directly interferes with fatty acid metabolism and thus improves glucose utilization and insulin resistance.

Serum hippurate and its excretion in conservatively treated and dialysed patients with chronic renal failure.

54 healthy volunteers or patients with normal kidney and liver function, 17 patients with decreased kidney function and 12 dialysed patients were evaluated for their serum hippurate accumulation and kidney excretion. It was found that there was an inverse relationship between serum hippurate and the clearance of endogenous creatinine (CCr) and a free relationship between fractional excretion of hippurate and CCr. The excretory capacity in residual nephrons was increased. This was caused by the greater glomerular filtration load which increased up to 25 times and tubular secretion which increased 7 times in dialysed patients. The relative contribution of glomerular filtration to hippurate excretion rose from about 20% in controls to almost 50% in dialysed patients. True kidney adaptation was localized in the organic anion transport system of proximal tubules.

Does magnesium dysbalance participate in the development of insulin resistance in early stages of renal disease?

We investigated the potential role of magnesium (Mg) dysbalance in the pathogenesis of insulin resistance (IR) in patients with mildly-to-moderately decreased renal function (creatinine: 142.8+/-11.0 mmol/l). The data were compared to those of 8 age- and sex-matched healthy controls (CTRL). The standard oral glucose tolerance test (oGTT) was performed in 61 patients. Twenty-two patients were classified as IR according to their values on fasting and after-load immunoreactive insulin concentrations. Serum and total erythrocyte Mg (tErMg) (atomic absorption spectro-photometry) and free erythrocyte Mg (fErMg) concentrations ((31) P NMR spectroscopy) were determined prior to and two hours after the glucose load. Ten out of 39 insulin-sensitive (IS) patients, but only one out of 22 insulin-resistant (IR) patients, had a low basal fErMg concentration (<162.2 micromol/l, chi2, p<0.01). IR patients had higher serum Mg, total erythrocyte Mg and bound erythrocyte Mg (bErMg) concentrations (both before and after glucose load) when compared with the IS group. Both groups responded to the glucose load with a significant decrease in serum Mg concentration (within the normal range), while the IR group also exhibited a decline in tErMg and bErMg. The mean sum of insulin needed to metabolize the same glucose load correlated positively with tErMg (r=0.545, p<0.01) and bErMg (r=0.560, p<0.01) in the IR patients. It is concluded that, at an early stage of renal dysfunction, IR is not associated with the decline in free erythrocyte Mg concentration, but the magnesium handling in red blood cells is altered.

Enalapril in subantihypertensive dosage attenuates kidney proliferation and functional recovery in normotensive ablation nephropathy of the rat.

Most studies on the antiproliferative action of angiotensin converting enzyme inhibitors (ACEI) were performed in a rat hypertensive remnant kidney model with 5/6 kidney ablation which raised objections about the antihypertensive effect of ACEI and the influence of other antihypertensive drugs administered to remnant kidney control rats. To prevent these objections, a normotensive 4/6 remnant kidney model was elaborated and a subantihypertensive dosage of enalapril was used to evaluate its antiproliferative action. Subtotally nephrectomized rats (Nx) markedly increased the remnant kidney weight during a 4-week period and this rise was prevented by the treatment with enalapril (NxE) (Nx +297+/-35 mg vs. sham-operated +145+/-32 mg, p<0.001; NxE +154+/-35 mg vs. Nx p<0.001). While collagen concentration in the kidney cortex was not increased in sham-operated rats (Sham) in comparison with the control group (Ctrl) at the beginning of the study, the subsequent increase was significant in the Nx group and enalapril did not attenuate this increase (Sham 148+/-5 mg/100 g w.w. vs. Nx 164+/-2 mg/100 g w.w., p<0.01; NxE 161+/-4 mg/100 g w.w. vs. Sham p<0.05). The tubular protein/DNA ratio increase, which was significant in the Nx group, was inhibited by enalapril (Nx 26.2+/-10.5 vs. NxE 15.3+/-2.6, p<0.05). The protein/DNA ratio was much lower in glomeruli, with no significant changes in either the Nx or NxE groups. Serum urea concentrations were slightly higher in the Nx group than in the sham-operated group, but markedly elevated in the NxE group (Nx 10.71+/-0.76 mmol/l vs. Sham 6.10+/-0.33 mmol/l, p<0.001; NxE 28.9+/-2.6 mmol/l vs. Sham p<0.001). Creatinine concentrations in the Nx group were increased in comparison with the sham-operated group and markedly increased in the NxE group (Nx 63.7+/-3.56 micromol/l vs. Sham 37.2+/-2.84 micromol/l, p<0.001; NxE 107.0+/-5.2 micromol/l vs. Sham p<0.001). The clearance of creatinine was lower in the Nx group than in the sham-operated group and was markedly reduced in the NxE group (Nx 0.89+/-0.06 ml/min.g kidney wt. vs. Sham 1.05+/-0.16 ml/min x g kidney wt., p<0.01; NxE 0.58+/-0.029 ml/min x g kidney wt. vs. Sham, p<0.001). Enalapril improved proteinuria in comparison with the Nx group (NxE 5.6+/-0.6 mg/24 h vs. Nx 16.1+/-3.4 mg/24 h, p<0.05). Thus remnant kidney proliferation is substantial even in normotensive rats. It includes both proliferation and collagen accumulation with partial recovery of kidney weight and function, but is accompanied by enhanced proteinuria. Enalapril attenuates the proliferation and decreases proteinuria but prolongs kidney function recovery.

Serum ex vivo lipoprotein oxidizability in patients with ischemic heart disease supplemented with vitamin E.

The decreased oxidizability of plasma lipoproteins is related to the increased vitamin E intake and its association with a relatively lower incidence of coronary heart disease has been proposed. We investigated the effect of the in vivo vitamin E supplementation on the oxidizability of serum lipids in patients with ischemic heart disease and a moderate hypercholesterolemia. Thirty-two patients (16 males and 16 postmenopausal women) participated in this placebo-controlled, randomized trial. They were treated with 400 mg vitamin E/day for 6 weeks. The copper-induced serum lipid oxidizability ex vivo was assessed by measuring conjugated diene formation at 245 nm. We also measured vitamin E, malondialdehyde (MDA) and uric acid concentrations in the plasma. Because of observed significant differences in parameters of serum lipid oxidizability (lag time and maximal rate of oxidation), plasma alpha-tocopherol and MDA levels between male patients and postmenopausal women supplemented with vitamin E, the results were compared between both genders. Six weeks of vitamin E supplementation significantly increased plasma vitamin E levels (by 87 %) in male patients but in postmenopausal women only by 34 %. Concomitantly with increased plasma levels of vitamin E the decrease in plasma MDA levels was observed in male patients (decrease by 20 %; p=0.008), but in postmenopausal women the decrease did not attain statistical significance. Plasma uric acid levels were not apparently changed in placebo or vitamin E supplemented groups of patients. The changes in ex vivo serum lipid oxidizability after vitamin E, supplementation have shown a significantly prolonged lag time (by 11 %; p=0.048) and lowered rate of lipid oxidation (by 21 %; p=0.004) in male patients in comparison with postmenopausal women. Linear regression analysis revealed a significant correlation between plasma vitamin E levels and the lag time (r=0.77; p=0.03) and the maximal rate of serum lipid oxidation (r=-0.70; p=0.05) in male patients. However, in postmenopausal women the correlations were not significant. We conclude that 400 mg vitamin E/day supplementation in patients with ischemic heart disease and a moderate hypercholesterolemia influenced favorably ex vivo serum lipid oxidation of male patients when compared with postmenopausal women. The observed differences between both genders could be useful in the selection of the effective vitamin E doses in the prevention of coronary heart disease.

A highly sensitive HPLC method for the simultaneous determination of acetylsalicylic, salicylic and salicyluric acids in biologic fluids: pharmacokinetic, metabolic and monitoring implications.

A number of methods have been developed for the determination of acetylsalicylic acid (ASA, aspirin). However, they are not sensitive enough for the simultaneous determination of ASA and its major metabolites salicylic (SA) and salicyluric (SUA) acids at the low dosage schedules (30-100 mg ASA/d). The HPLC method with UV detection described here fulfills these requirements. The calibration curves were linear at the range 0.18-10 mumol/l. Coefficients of variation were 3.9% for SUA, 7.89% for ASA and 5.88% for SA. The recovery of ASA, SA and SUA was between 90-105%. ASA administered in doses of 30-400 mg was rapidly absorbed from gastrointestinal tract and deacetylated, forming the dominant plasma metabolite SA. SA was eliminated to about 60% by conjugation with glycine and therefore SUA was a dominant metabolite in urine. ASA was never found in urine at the low-dose ASA treatment. For this reason, SUA, but not ASA, can be determined in urine and may be used for monitoring patient compliance.

Inhibition of glucose uptake by 5-hydroxyindoleacetic acid in the isolated rat soleus muscle.

Accumulated end-products were identified to participate in the late development of glucose intolerance and insulin resistance (IR) in patients with chronic renal insufficiency. The possible pathophysiological role of accumulated 5-hydroxy-indoleacetic acid (5HIAA) in the genesis of IR was investigated employing an in vitro animal model. 5HIAA inhibited the basal glucose uptake in isolated rat soleus muscle with intact membrane with A50 = 1.25 mumol/l, and Emax = 88.6%. 5HIAA significantly inhibited the insulin, and tolbutamide stimulated glucose uptake. In Ca and Mg depletion 5HIAA showed a partially additive inhibitory effect, while nonadditive inhibitory activity was observed in the case of K+ excess. It is concluded that 5HIAA is a metabolically active end-product interfering with glucose uptake in muscle at an insulin postreceptor level, and its effect is related to Ca modulation in the insulin regulatory cascade.

Serum and ultradiafiltrate middle molecules in hemodialysed patients.

The gel filtration technique was used for the fractionation of middle molecular substances (MMS) in plasma from conservatively treated patients, from dialysed patients with renal failure and in the ultradiafiltrate from dialysed ones. The following observations were made: 1. MMS accumulate in the plasma of conservatively treated patients in chronic renal failure. 2. The accumulation of MMS in dialysed patients is even higher. 3. The elimination of the most important MMS in the ultradiafiltrate is excellent. 4. It is concluded that hemofiltration and ultradiafiltration are indicated also for the removal of MMS, namely in the case of clinical complications which cause a further accumulation of MMS.