Efficacy and safety of whole body vibration in maintenance hemodialysis patients - A pilot study.

OBJECTIVES: The aim of this study was to assess safety and effectiveness of Whole Body Vibration exercise (WBV) to improve physical performance and parameters of inflammation in patients on maintenance hemodialysis (MHD). METHODS: Prospective, open-label trial in n=14 patients on maintenance hemodialysis. Participants performed WBV twice weekly for 12 weeks before (n=8) or after (n=6) hemodialysis sessions. The primary endpoint was physical performance assessed by the Short-Physical-Performance-Battery (SPPB). Secondary endpoints included established parameters of musculoskeletal assessment and blood chemistry. RESULTS: As compared to baseline, physical performance (SPPB) improved significantly (p=0.035). Moderate advances were also seen for 6-Minute-Walking test, Timed-up-and-go test, jumping height and handgrip strength. Improvements were particularly pronounced in subjects with seriously impaired baseline performance. Skeletal muscle index showed a tendency to better values. Laboratory data exhibited a significant reduction of white blood cell count and a trend to lower levels of hsCRP. WBV was generally well tolerated. Two events of clinically significant blood pressure decline occurred in patients exercising after dialysis sessions. CONCLUSIONS: Results of this pilot study suggest effectiveness and safety of WBV in hemodialysis patients. Beneficial effects may affect both, parameters of physical performance and systemic inflammatory activity, which should be verified in larger scale clinical trials.

Aldosterone causes DNA strand breaks and chromosomal damage in renal cells, which are prevented by mineralocorticoid receptor antagonists.

Epidemiological studies exploring the connection between hypertension and cancer incidence find a higher cancer mortality in hypertensive patients, particularly elevated in hypertension associated with a stimulation of the renin-angiotensin-aldosterone system. Primary aldosteronism, with plasma aldosterone levels between 0.5 and 1 nM (18-36 ng/dL) and local aldosterone levels up to 500 nM (18,000 ng/dL), is now recognised as a more common cause for hypertension. We recently found angiotensin II to be genotoxic due to its induction of oxidative stress. Since aldosterone in higher concentrations also has oxidative effects, its potential genotoxic action in pig LLC-PK1 cells with properties of proximal tubules was analysed. DNA damage was evaluated by two test systems: the comet assay, and the micronucleus frequency test. The results showed that aldosterone concentrations starting from 10 nM (360 ng/dL) caused a significant increase of DNA damage monitored with the comet assay in LLC-PK1, while there was no change in cell vitality and proliferation. The micronucleus frequency test revealed that 10 nM aldosterone also leads to the formation of micronuclei. Furthermore, the formation of superoxide radicals in the cells by this aldosterone concentration could be detected with the superoxide-specific stain dihydroethidium. Further evidence for oxidative stress-induced DNA damage was its reversibility by the antioxidants tempol and catalase. Addition of the steroidal mineralocorticoid receptor antagonist spironolactone or the novel selective nonsteroidal antagonist (R)-BR-4628 reduced the DNA damage and the amount of superoxide radicals indicating a receptor-dependent process.

Neuronal activation in the CNS during different forms of acute renal failure in rats.

The effect of experimentally induced acute renal failure (ARF) on neuronal cell activation was investigated by immunohistochemistry for Fos and Fra-2 in the rat brain. ARF in rats was induced by bilateral nephrectomy (BNX), bilateral ureter ligature (BUL) and uranyl acetate injection with proper controls (sham-operation or saline injections, respectively). To follow the effect of the development of ARF, rats were killed 30 and 60 min, and 3, 12, 24 and 72 h after surgery, or 3 h to 12 days after uranyl acetate injections. In the BUL and BNX rats, urea and creatinine rose markedly in the plasma within 72 h, while in the uranyl acetate-injected rats the highest levels were observed on the 7th day, followed by a marked decline. At each time-point of the three different, experimentally induced ARF, the presence of Fos- and/or Fra-2-immunoreactive neurons was determined in 120 different brain areas and nuclei. In general, the 73 of 120 brain areas that showed time and intensity dependent activation in response to ARF can be classified into four groups: 1) biogenic amine (noradrenaline, adrenaline, histamine and 5-HT) expressing cell groups in the lower brainstem, 2) "stress-sensitive" forebrain areas, with regard to certain hypothalamic, limbic and cortical areas, 3) neuronal cell groups that participate in the central regulation of body and brain water and electrolyte homeostasis, including the circumventricular organs, and 4) central autonomic cell groups, especially visceral sensory cell groups in the brain, which are in primary, secondary or tertiary connections with renal afferents. Data presented here indicate that a wide variety of neurons in several regulatory mechanisms is affected by ARF-induced peripheral and central alterations.

High-tone external muscle stimulation in end-stage renal disease: effects on symptomatic diabetic and uremic peripheral neuropathy.

OBJECTIVE AND DESIGN: Pain and peripheral neuropathy are frequent complications of end-stage renal disease (ESRD). Because drug treatment is associated with numerous side effects and is largely ineffective in many maintenance hemodialysis (MHD) patients, nonpharmacologic strategies such as electrotherapy are a potential recourse. Among various forms of electrostimulation, high-tone external muscle stimulation (HTEMS) is a promising alternative treatment for symptomatic diabetic peripheral polyneuropathy (PPN), as demonstrated in a short-term study. Based on these novel findings, we performed a prospective, nonrandomized, pilot trial in MHD patients to determine (1) whether HTEMS is also effective in treating diabetic PPN in the uremic state, and (2) whether uremic PPN is similarly modulated. PATIENTS AND INTERVENTIONS: In total, 40 MHD patients diagnosed with symptomatic PPN (25 with diabetic and 15 with uremic PPN) were enrolled. Both lower extremities were treated intradialytically with HTEMS for 1 hour, three times a week. Initially, a subgroup of 12 patients was followed for 4 weeks, and a further 28 patients for 12 weeks. The patients' degree of neuropathy was graded at baseline before HTEMS and after 1 and 3 months, respectively. Five neuropathic symptoms (tingling, burning, pain, numbness, and numbness in painful areas) as well as sleep disturbances were measured, using the 10-point Neuropathic Pain Scale of Galer and Jensen (Neurology 48:332-338, 1997). A positive response was defined as the improvement of one symptom or more, by at least 3 points. Other parameters included blood pressure, heart rate, dry body weight, and a routine laboratory investigation. RESULTS: The HTEMS led to a significant improvement in all five neuropathic symptoms, and to a significant reduction in sleep disturbances for both diabetic and uremic PPN. The response was independent of the patient's age, with a responder rate of 73%. The improvement of neuropathy was time-dependent, with the best results achieved after 3 months of treatment. The HTEMS was well-tolerated by nearly all patients. CONCLUSIONS: This pilot study shows for the first time that HTEMS can ameliorate the discomfort and pain associated with both diabetic and uremic PPN in MHD patients, and could be a valuable supplement in the treatment of pain and neuropathic discomfort in patients who do not respond to, or are unable to participate in, exercise programs during hemodialysis treatment.

Homocysteine exerts genotoxic and antioxidative effects in vitro.

INTRODUCTION: Patients with end-stage renal disease suffer from increased genomic damage and cancer incidence. One possible reason is the accumulation of uremic toxins such as homocysteine (Hcy). Elevated Hcy levels--usually indicative of cardiovascular events--correlated with the genomic damage in cross-sectional studies. Therefore we investigated the genotoxic effects of Hcy in vitro. METHODS: To analyse the genomic damage, micronucleus tests and the comet-assay were performed in L5178Y and HL60 cells. Additionally, the influence of Hcy on cell cycle progression, DNA-cytosine-methylation, oxidative stress levels and on the cellular glutathione content were determined. RESULTS: Low millimolar concentrations of Hcy-induced micronuclei in both cell lines but did not enhance the DNA damage observed with the comet-assay. Cell cycle progression was inhibited in S-phase, while DNA-cytosine-methylation remained unchanged. Furthermore, Hcy protected cells challenged with H(2)O(2) from oxidative stress. This was accompanied by an increased cellular glutathione level. CONCLUSION: Since the genotoxic effect was limited to high Hcy concentrations, a contribution of Hcy to the enhanced genomic damage in end-stage renal disease patients would only be conceivable upon local Hcy accumulation. Whether the detected antioxidant capacity of Hcy is relevant for any situation in patients remains to be elucidated.

Pilot study for comparison of reticulocyte-micronulei with lymphocyte-micronuclei in human biomonitoring.

Biomonitoring tries to determine the consequences for humans of exposures to environmental or pharmaceutical agents. Different end points have been employed to assess the burden of genomic damage. This is the first report comparing a recently introduced new end point, the reticulocyte-micronuclei analyzed by flow cytometry with the widely used lymphocyte-micronucleus assay, applied to two exposure scenarios leading to enhanced genomic damage. Radioiodine therapy was chosen to represent a short time exposure and hemodialysis treatment in end-stage renal failure was chosen to represent a chronic exposure. The results show that iodine radiation induced measurable genomic damage in the lymphocyte-micronucleus assay as well as in the reticulocyte-micronucleus test. Of two groups of patients under hemodialysis treatment, a reduced genomic damage was found with the lymphocyte-micronucleus test, but not with the reticulocyte-micronucleus test in the group undergoing daily hemodialysis, which removes uremic toxins more efficiently as compared to conventional hemodialysis, the treatment applied in the other group. The limited life-span of reticulocytes may make them less suitable for accumulation of chronic low level damage than lymphocytes. In conclusion, the lymphocyte-micronucleus test may be applicable to more exposure situations (including low chronic exposure), but the reticulocyte-micronucleus assay may be easier to perform in a clinical setting. The latter reflects a more rapid reduction of genomic damage after an acute exposure.

Oxidative stress and non-enzymatic glycation in IgA nephropathy.

AIM: Approximately 20-50% of IgA nephropathy patients develop end-stage renal disease. We have previously found enhanced oxidative stress and decreased antioxidant capacity in red blood cells of IgA nephropathy patients. In this study we assess oxidative stress, non-enzymatic glycation, oxidative resistance of low-density lipoprotein and its alpha-tocopherol content in these patients. PATIENTS AND METHODS: Non-enzymatic glycation and oxidative stress were assessed in 88 IgA nephropathy patients by measuring advanced glycation end products, Nepsilon-carboxymethyl-lysine, thiobarbituric acid reactive substances, oxidative resistance of low-density lipoprotein and its alpha-tocopherol content. RESULTS: Advanced glycation end products (2659 +/- 958 a.u.) and Nepsilon-carboxymethyl-lysine (563 +/- 215 ng/ml) were significantly higher in IgA nephropathy patients with decreased renal function compared to those with normal renal function (p < 0.002) or controls (p < 0.001). Thiobarbituric acid-reactive substances in plasma and associated with low-density lipoprotein were significantly elevated and oxidative resistance of low-density lipoprotein was significantly reduced in all groups of IgA nephropathy patients. There was no significant difference in circulating fluorescent advanced glycation end products, Nepsilon-carboxymethyl-lysine, thiobarbituric acid-reactive substances levels, oxidative resistance of low-density lipoprotein and its alpha-tocopherol content between patients with normal vs. impaired glucose metabolism. Low alpha-tocopherol content of low-density lipoprotein was accompanied with decreased oxidative resistance, depletion in polyunsaturated fatty acids, elevated saturated fatty acids and thiobarbituric acid-reactive substances within low-density lipoprotein suggesting enhanced lipid peroxidation. CONCLUSIONS: Decreased oxidative resistance of low-density lipoprotein and enhanced oxidative stress are common features in IgA nephropathy, while increased non-enzymatic glycation occurs as renal function declines.

Is vitamin D deficiency related to accumulation of advanced glycation end products, markers of inflammation, and oxidative stress in diabetic subjects?

OBJECTIVES: In diabetes accumulated advanced glycation end products (AGEs) are involved in the striking cardiovascular morbidity/mortality. We asked whether a hypovitaminosis D associates with an increased formation and toxicity of AGEs in diabetes. METHODS: In 276 diabetics (160 M/116 F, age: 65.0 ± 13.4; 43 type 1,T1DM, and 233 type 2 patients, T2DM) and 121 nondiabetic controls (60 M/61 F; age: 58.6 ± 15.5 years) routine biochemistry, levels of 25-hydroxyvitamin D3 (25-(OH)D), skin autofluorescence (SAF), plasma AGE-associated fluorescence (AGE-FL), N (ε) -(carboxymethyl)lysine (CML), soluble receptor for AGEs (sRAGE), soluble vascular adhesion protein-1 (sVAP-1), high sensitive C-reactive protein (hs-CRP), and renal function (eGFR) were determined. RESULTS: In the diabetics SAF and AGE-Fl were higher than those of the controls and correlated with age, duration of diabetes, and degree of renal impairment. In T2DM patients but not in T1DM the age-dependent rise of SAF directly correlated with hs-CRP and sVAP-1. 25-(OH)D levels in diabetics and nondiabetics were lowered to a similar degree averaging 22.5 ng/mL. No relationship between 25-(OH)D and studied markers except for sVAP-1 was observed in the diabetics. CONCLUSION: In diabetics hypovitaminosis D does not augment accumulation of AGEs and studied markers of microinflammation and oxidative stress except for sVAP-1.

Atrial natriuretic factor in specific brain areas of spontaneously hypertensive rats.

Atrial natriuretic peptides (atrial natriuretic factor, ANF) are present in a great number of brain areas inside and outside of the blood-brain barrier. The pattern of distribution implies the involvement of ANF in different physiological functions, such as blood pressure regulation, electrolyte and fluid homeostasis, and modulation of the neuroendocrine system. To further investigate a possible involvement of central ANF in spontaneous hypertension, we measured levels of ANF in 18 selected, microdissected brain areas of prehypertensive (4-week-old) and hypertensive (12-week-old) spontaneously hypertensive rats (SHR) and their normotensive control, Wistar-Kyoto rats (WKY), by radio-immunoassay. ANF was significantly decreased in seven brain areas in SHR at both ages investigated; the most pronounced decreases were found in the subfornical organ, in the perifornical and periventricular hypothalamic nuclei, and in the medial preoptic nucleus. In addition, in young SHR ANF was significantly decreased in the organum vasculosum laminae terminalis and increased in the median eminence. After the development of hypertension, a significant decrease of ANF could be detected in four more brain areas (bed nucleus of the stria terminalis, paraventricular and arcuate nuclei, dorsal raphe nucleus) of SHR, as compared with normotensive controls, and the increase in the median eminence was no longer detectable. These results suggest a role for ANF in genetic hypertension and the specific importance of certain brain regions.

Parathyroid hormone increases thiol proteinase activity by activation of protein kinase C in cultured kidney tubule cells (OK).

Chronic exposure (24 h) to parathyroid hormone (PTH) increases the intracellular proteolytic activity in cultured opossum kidney cells 2-fold at physiological PTH concentrations (10(-12) mol/l). This increase can be blocked by E-64, an inhibitor of thiol proteinases. The phorbol ester TPA mimicks the effect of PTH, whereas the calcium ionophore A23187 reduces the intracellular proteinase activity. Forskolin and dibutyrylic cAMP do not elevate proteinase activity. The protein kinase C inhibitor staurosporine is equally effective in blocking the TPA- and PTH-induced proteinase activity increase. These data indicate that PTH increases the intracellular thiol proteinase activity by an activation of protein kinase C and not by the cAMP dependent way.

Advanced glycation endproducts stimulate the MAP-kinase pathway in tubulus cell line LLC-PK1.

Advanced glycation endproducts (AGEs) are suggested to play an important role in diabetic nephropathy. They induce specific cellular responses such as the release of cytokines in different cell lines. The effect of AGEs on signal transduction pathways was investigated in the renal tubulus cell line LLC-PK1. Using a serine-phosphate-specific antibody AGE-induced cellular responses associated with phosphorylation/dephosphorylation events were demonstrated. In particular, the p42MAP kinase and its downstream target, the AP-1 complex, are shown to be activated by AGE-BSA but not by BSA. In contrast, only partial phosphorylation is observed for the p70S6-kinase. Thus, AGEs appear to induce specific signal transduction pathways.

Enhanced proteolytic activity--cause of protein catabolism in acute renal failure.

We demonstrated pH and time dependent proteolytic digestion of bovine serum albumin by sera and of phosphorylase kinase by ultrafiltrates of sera in two of eight patients with hypercatabolic acute renal failure. Phosphorylase kinase was isolated from rabbit skeletal muscle. Ultrafiltrates of sera were prepared by ultrafiltration with an Amicon XM 50 filter. These techniques appear to be sensitive indicators of active proteases in sera of patients with hypercatabolic acute renal failure and may be superior signs of hypercatabolism than serum alpha 2-macroglobulin and alpha 1-antitrypsin. Moreover, these procedures allow one to characterize the protease and to assess, in vitro, the effectiveness of specific inhibitors of these proteases.

Effects of high doses of leucine and ketoleucine on glycogen and protein metabolism in acute uremia.

Binephrectomized rats treated with high doses of ketoleucine (0.5 g/rat per 20 hr) expired after about 45 hr. In contrast, survival time was 100% 60 hr after ureteral ligation. In comparison to animals receiving low-protein diets, addition of leucine to the diet almost doubled muscle and liver protein content whereas ketoleucine increased liver protein during the first 40 hr after operation about 1.5-fold. Skeletal muscle protein content was enhanced in the ureter-ligated rats with administration of ketoleucine. There was also about a 10-fold elevation in liver glycogen and total carbohydrate content between the 20th and 60th hr in binephrectomized rats fed leucine at 5-hr intervals. In skeletal muscle glycogen, there were no significant differences among the acutely uremic rats fed at 10-hr intervals low-protein diets alone or supplemented with leucine or ketoleucine. Leucine inhibits glycogenolysis by lowering phosphorylase alpha activity in muscle and liver, whereas ketoleucine enhances glycogenolysis in acute uremia. In rats supplemented with letoleucine, there is a progressive inactivation of glycogen synthetase I which occurs in parallel with increasing phosphorylase alpha activity. In binephrectomized rats receiving leucine supplements at 5-hr feeding intervals, the activity of liver glycogen synthetase I increases up to a maximum of 90% of total enzyme activity.

Evaluation of essential amino acids and keto acids in uremic patients on low-protein diet.

The effectiveness of a mixture of five analogues of essential amino acids and the remaining four essential amino acids as compared to a preceeding treatment period of the nine essential amino acids was evaluated in 16 chronic uremic patients fed a low-protein diet. During amino acid analogues supplementation, there was a tendency for blood urea nitrogen to fall whereas creatinine did not change. Serum phosphate decreased in most patients, whereas serum calcium rose in some subjects. Protein metabolism, as judged by serum transferrin, Clq, C3c, total complement activity, was improved. Furthermore, the concentrations of prealbumin and retinol-binding protein, which are elevated in uremia, showed a further increase that might favor a vitamin A intoxication.

Increased histidine and histamine content in the brain of chronic uremic rats. Cause of enhanced cerebral cyclic adenosine monophosphate in uremia?

In rats with experimental chronic renal insufficiency (90% nephrectomy) the histidine content in brain was increased (+ 35%) in spite of normal plasma values and decreased concentrations in the striated muscle (-23%). The finding of a raised histidine level in the brain seems to be a uremia specific disorder, probably cuased by a local disturbance in histidine metabolism. In addition an increase of the histidine decarboxylation product histamine could be observed in the brain of rats with chronic renal insufficiency, as compared to pair-fed controls. This increase was directly related to the severity of azotemia. In the pathogenesis of the histamine alteration the increased histidine content in the brain of uremic rats must be considered, since the specific histidine decarboxylase is not saturated by the normal endogenous level of the amino acid precursor. Probably the increased histamine contributes to the raised cerebral cyclic AMP in the brain of uremic rats.

Acute changes in cyclic AMP levels of certain brain areas following intraventricular injection of renin in rats.

Actions of the central angiotensin system on brain cAMP concentrations were studied after intraventricular injection of renin. Biosynthesis of endogenous brain angiotensin II was stimulated by 0.1 U renin and the blood pressure was elevated 40 min after the application. Stimulation of the brain angiotensin system affected cAMP metabolism in several brain areas, mostly expressed as decreased cAMP levels. Significant decreases in cAMP concentrations were found in the cerebral cortex, hippocampus, basal ganglia, various hypothalamic nuclei, substantia nigra, central grey matter and in the locus coeruleus. The unchanged cAMP levels in the nucleus of the solitary tract might indicate that intraventricular injection of renin induced an acute blood pressure elevation which is not associated with changes in the cAMP system in the primary baroreceptor area.

Effect of beta 2-microglobulin on immunoglobulin production.

Chronic renal failure patients display high serum levels of beta 2-microglobulin (beta 2-M) and a pronounced defect in immunoglobulin production. In this light, the present study was conducted to investigate whether beta 2-M might influence the rate of antibody synthesis. Peripheral blood mononuclear cells (PBMC) from healthy subjects were cultured in the presence of beta 2-M (80 mg/l) for 7 days. Immunoglobulin concentrations were measured by ELISA-techniques in culture supernatants. Basal IgM levels were 390 +/- 10 ng/ml and increased to 940 +/- 216 ng/ml in the presence of beta 2-M. After PWM stimulation, IgM concentrations were 2654 +/- 614 ng/ml without and 3750 +/- 914 ng/ml with beta 2-M. IgG and IgA production by PBMCs was not influenced by beta 2-M in the culture medium. Likewise, the generation of beta 2-M by PBMCs was unchanged in the presence of exogenous beta 2-M in the medium. In terms of clinical relevance, serum beta 2-M levels of 28 uremic patients were correlated with capacity of their PBMCs for immunoglobulin production in vitro. However, there was no apparent correlation between beta 2-M serum levels and immunoglobulin synthesis in vitro. Taken together, beta 2-M seems to have a stimulatory effect on IgM synthesis in vitro. Whether this has some clinical meaning in patients with chronic renal failure remains to be investigated.

Advanced glycation end products and the progressive course of renal disease.

In experimental and human diabetic nephropathy (DN), it has been shown that advanced glycation end products (AGEs), in particular, carboxymethyl-lysine and pentosidine, accumulate with malondialdehyde in glomerular lesions in relation to disease severity and in the presence of an upregulated receptor for AGE (RAGE) in podocytes. Toxic effects of AGEs result from structural and functional alterations in plasma and extracellular matrix (ECM) proteins, in particular, from cross-linking of proteins and interaction of AGEs with their receptors and/or binding proteins. In mesangial and endothelial cells, the AGE-RAGE interaction caused enhanced formation of oxygen radicals with subsequent activation of nuclear factor-kappaB and release of pro-inflammatory cytokines (interleukin-6, tumor necrosis factor-alpha), growth factors (transforming growth factor-beta1 [TGF-beta1], insulin-like growth factor-1), and adhesion molecules (vascular cell adhesion molecule-1, intercellular adhesion molecule-1). In tubular cells, incubation with AGE albumin was followed by stimulation of the mitogen-activating protein (MAP) kinase pathway and its downstream target, the activating protien-1 (AP-1) complex, TGF-beta1 overexpression, enhanced protein kinase C activity, decreased cell proliferation, and impaired protein degradation rate, in part caused by decreased cathepsin activities. The pathogenic relevance of AGEs was further verified by in vivo experiments in euglycemic rats and mice by the parenteral administration of AGE albumin, leading in the glomeruli to TGF-beta1 overproduction, enhanced gene expression of ECM proteins, and morphological lesions similar to those of DN. Evidence for the pathogenic relevance of AGEs in DN also comes from experimental studies in which the formation and/or action of AGEs was modulated by aminoguanidine, OPB-9195, pyridoxamine, soluble RAGEs, serine protease trypsin, and antioxidants, resulting in improved cell and/or renal function.

Comet-assay analysis identifies genomic damage in lymphocytes of uremic patients.

This study investigates genomic damage in peripheral lymphocytes from patients with moderate to severe chronic renal insufficiency and those on long-term maintenance hemodialysis (MHD) and hemodiafiltration therapy. As a measure for genomic damage, the comet assay (single-cell gel electrophoresis) was applied. This test detects single- and double-strand breaks and alkali labile sites through electrophoretic mobility of the resulting fragments. The average damage (percentage of DNA in the tail region of the comet) observed in cells of the control group of 21 healthy subjects was 10.5% +/- 0.8%. There was a significant increase to 14.7% +/- 3.5% in cells of 23 patients with chronic renal failure, and a further increase to 17.1% +/- 3.5% in the subgroup of 12 patients with serum creatinine values greater than 6 mg/dL. Damage was 16.7% +/- 4.2% in cells of the MHD group (26 patients) and 20.1% +/- 3.0% in the subgroup with MHD therapy longer than 10 years (8 patients). Cellular DNA damage in the group of 15 maintenance hemodiafiltration patients was 15.6% +/- 2.1%, ranging between predialysis and MHD patients, and did not seem to increase with treatment time. These results, together with previously observed elevated frequencies of micronuclei, decreased DNA repair, and increased cancer incidence described for these patient groups, emphasize the need to further optimize the current therapy for reducing the degree of genomic damage.

N(epsilon)-(carboxymethyl)lysine levels in patients with type 2 diabetes: role of renal function.

Advanced glycation end products (AGEs) such as N(epsilon)-(carboxymethyl)lysine (CML) have been implicated in the development and progression of diabetic nephropathy. The aim of the present study is to investigate AGE levels in patients with type 2 diabetes with special regard to the role of renal impairment. Serum and urine CML levels (using a newly developed enzyme-linked immunosorbent assay), as well as serum AGE-fluorescence, were measured in 109 patients with type 2 diabetes. Patients were divided into groups with normal and impaired renal function. We found elevated serum fluorescent AGE and CML levels, as well as decreased urinary CML excretion rates, in patients with diabetes with renal impairment, but not those with normal renal function. In the presence of impaired renal function, serum CML and fluorescent AGE levels showed a significant inverse relation with creatinine clearance and a significant direct correlation with each other. No relationship could be found between serum AGE levels and parameters of blood glucose control or the presence of the following clinical complications: ischemic heart disease, diabetic retinopathy, and neuropathy. We conclude that the decline in renal function leads to increased serum AGE levels in patients with type 2 diabetes.