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.

The need for a systems approach in biomaterials testing.

Many factors can affect the characterisation of biomaterials during testing. These include drugs administered prior to testing and shear stress on blood cells induced by different blood flows and specific blood donor conditions. Some of the misconceptions in testing are described here and serve to indicate that a systems approach, and not only individual test parameters, is best when testing for biocompatibility.

Magneto-electro-fusion of human erythrocytes.

In inhomogeneous (static) magnetic fields close contact between 'magnetic' human erythrocytes was established. The cells were made magnetic by incubating them in a medium containing small Fe3O4 -particles which adsorbed to the outer membrane surface. Fusion was induced by applying two electric field pulses (field strength: 8.5 kV X cm-1; duration: 60 microseconds) to the magnetically collected cells. This procedure allowed the use of electrically conductive media (3 X 10(-3) omega -1 X cm-1). Fusion of red blood cells occurred very often. If cell suspensions of high density were used fusion resulted in the formation of giant red blood cells with osmotically intact membranes.

Electro-acoustic fusion of erythrocytes and of myeloma cells.

Mammalian cells can be concentrated in a sound field. A method is introduced, which combines the reversible aggregation of cells in a sound field with the electrical breakdown of cell membranes to fuse cells, which are in contact. Human red blood cells and mouse myeloma cells are fused by means of that procedure.

An improved electrofusion technique for production of mouse hybridoma cells.

An experimental procedure is described for the reproducible production of hybridoma cells using the electrofusion technique. High yields can be obtained when fusion is performed in isotonic inositol solutions containing Ca2+ and Mg2+ in a ratio of 1:5 in the millimolar range. The hybridoma cells are transferred 10 min after the field pulse application into a balanced salt solution for 30 min at 37 degrees C.

Electrofusion of myeloma cells on the single cell level. Fusion under sterile conditions without proteolytic enzyme treatment.

A technique is presented which allows electrofusion of single cells under sterile conditions. The electrofusion chamber is placed in a Petri dish. Before a droplet of the fusion medium is pipetted between the electrodes, the chamber is completely covered with vaseline, which prevents the fusion medium evaporating. Additionally, the fusion chamber is treated with solutions containing poly(L)-lysine and pronase which results in a decreased movement of the cells on the glass between the electrodes and which allows electrofusion without any proteolytic pretreatment.

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.

Verification of the chemical composition and specifications of haemodialysis membranes by NMR and GPC-FTIR-coupled spectroscopy.

The chemical composition of a dialysis membrane is decisive towards determining its physical and biochemical properties--two fundamental determinants of the success of therapy offered to patients suffering from chronic renal failure. From the vast variety of synthetic polymers available, only a few are suitable for the manufacture of dialysis membranes that have to conform to the diverse demands of modern haemodialysis and related therapies. Recently, a membrane labelled as polyamide (Polyamide S) has caused some confusion to end-users in that the product specification for the membrane is given as 'polyarylethersulfone' or simply as Polyamide S membrane. As the chemical and physical properties of these two polymer types are distinctly different, it is unclear whether the functional characteristics of Polyamide S are to be attributed to polyamide, polyarylethersulfone, or, to both polymers. We therefore undertook investigations to ascertain the exact chemical nature of the Polyamide S membrane using a series of chemical analytical tools and an appropriate polyamide reference. The analytical techniques were conventional gel permeation chromatography (GPC), GPC-FTIR coupled spectroscopy using dimethyl acetamide and hexafluoroisopropanol as solvents and nuclear magnetic resonance spectroscopy. Glass transition temperature measurements and quantitative elemental analysis were also carried out. None of the analytical techniques used showed any traces of polyamide in Polyamide S; no aliphatic or aromatic polyamide chemical entities were detected in any of the samples tested. The Polyamide S dialysis membrane thus comprises, solely, of polyarylethersulfone, which is also known as polyethersulfone.

Biocompatibility of membranes used in the treatment of renal failure.

Haemodialysis membranes with a wide range of solute and hydraulic permeabilities are used clinically. Such membranes are manufactured from either cellulose or synthetic co-polymers and their biocompatibility is commonly characterized by the complement activation and white cell changes observed during their use. The cellobiosic unit may be modified by the partial or total replacement of the hydroxyl groups by diethylaminoethyl (Hemophan), acetate (cellulose acetate), triacetate (cellulose triacetate) or 2,5-acetate (Diaphan). We have undertaken a prospective study in which such renal membranes have been studied in terms of the complement activation and neutropenia produced with the aim of investigating the relationship between modification of the cellobiosic unit and the magnitude of neutropenia and complement activation, and the extent to which membrane base material influences these parameters, by comparing the changes observed in modified cellulose membranes with that for a synthetic membrane (polysulphone). Our findings show that, while the degree of substitution varies between < 1% and total substitution, there is no correlation between the numbers of hydroxyl groups replaced and alteration of complement activation and neutropenia. However, by modification of the cellobiosic unit it is possible to produce a membrane whose biocompatibility is similar to that of a membrane manufactured from a synthetic co-polymer such as polysulphone.

In vitro contact phase activation with haemodialysis membranes: role of pharmaceutical agents.

Contact phase activation was investigated in vitro using flat sheet type of haemodialysis membranes, Cuprophan (Akzo, Faser, Germany) and AN69S (Hospal, France), and a negatively charged polyamide Ultipor NR 14225 membrane as a control. The investigation focussed on the determination of factor XII-like activity (FXIIA) as an indicator of contact phase activation in the supernatant phase and at the membrane surface after plasma-membrane contact using an incubation test cell. The findings were compared with the observations from a plasma-free system utilizing purified unactivated factor XII. The plasma FXIIA bound to the membrane surface was significantly different between the membranes, while the supernatant phase FXIIA exhibited no significant differences. In contrast, the plasma-free system exhibited significant differences in the supernatant FXIIA and membrane-bound FXIIA for all the materials used and the magnitude of the activity was significantly greater for negatively charged materials. This finding demonstrated the strong influence of the interaction of other plasma constituents on the membrane surface and as such the binding and subsequent activation of factor XII may be altered possibly due to competitive binding and steric hindrance. On the addition of anticoagulants such as heparin, low-molecular-weight heparin, citrate and hirudin, no significant differences were observed in plasma supernatant phase FXIIA. However, each anticoagulant appears to have a distinct influence on the magnitude of plasma membrane-bound FXIIA. On the addition of aprotinin (a kallikrein inhibitor), no significant differences were observed in the plasma supernatant FXIIA. In contrast, aprotinin appears to significantly reduce membrane-bound FXIIA on Cuprophan and polyamide NR, but significantly increase the magnitude of the membrane-bound FXIIA on AN69S.

Phosphate removal and hemodialysis conditions.

Hyperphosphatemia is frequently found in hemodialysis patients, and the association with an increased risk of mortality has been demonstrated. Other authors have linked hyperphosphatemia to increased cardiovascular mortality. The normalization of phosphate plasma levels is therefore an important goal in the treatment of end-stage renal disease patients. Absorption of phosphate from the food exceeds the elimination through a hemodialysis treatment, and this leads to a chronic phosphate load for the majority of hemodialysis patients. This imbalance should be improved by either a reduction of phosphate absorption or an increased removal of phosphate. A reduction of phosphate absorption can be achieved by reducing the amount of phosphate in the diet or by the administration of phosphate binders. Unfortunately, these measures imply practical difficulties, for example, a lack of patient compliance or other side effects. When considering modifications of the hemodialysis treatment, an essential understanding of the kinetics of dialytic phosphate removal is mandatory. Phosphate is unevenly distributed in different compartments of the body. Only a very small amount of phosphate is present in the easily accessible plasma compartment. The major part of phosphate removed during hemodialysis originates from the cytoplasm of cells. A transfer from intracellular space to the plasma and further from the plasma to the dialysate is necessary. However, if we consider improvement to phosphate removal by dialysis procedures, full dialyzer clearance is effective in only the initial phase of the dialysis treatment. After this initial phase, the transfer rate for phosphate from the intracellular space to the plasma becomes the rate-limiting step for phosphate transport. Attempts to improve this transfer rate have recently been investigated by acidosis correction, but turned out not to be consistently successful. Furthermore, modifications of the treatment schedule have been described in the literature as measures to influence the phosphate balance consistently. Successful improvements of the phosphate balance can be achieved specifically through increasing the frequency of the dialysis treatments.

Erythrocytes and lymphocytes as drug carrier systems: techniques for entrapment of drugs in living cells.

Mouse thymocytes and erythrocytes are loaded electrically with drugs in isotonic solution. The loaded cells are used for targeting the drugs to specific sites in the organism in order to achieve a controlled drug release in time and space. The field technique used for the loading of the cells is based on the dielectric breakdown of the cell membrane which is observed when cell suspensions are subjected to external field pulses of 2-20 kV/cm for short time intervals (ns to microseconds). When an apparent membrane potential of about 1 V is reached in response to the external field, the membrane breaks down reversibly. The breakdown of the membrane is associated with a remarkable and reversible permeability increase of the cell membrane. The increase in permeability depends on the strength and the duration of the field pulse.

Prediction of cardiovascular risk in hemodialysis patients by data mining.

OBJECTIVES: The objective of this work was to contribute to the development, validation and application of data mining methods for prediction in decision support systems in medicine. The particular focus was on the prediction of cardiovascular risk factors in hemodialysis patients, specifically the interventricular septum (IVS) thickness of the heart of individual patients as an important quantitative indicator to diagnose left ventricular hypertrophy. The work was based on data from 63 long-term hemodialysis patients of the KfH Dialysis Centre in Jena, Germany. METHODS: The approach applied is based on data mining methods and involves four major steps: data based clustering, cluster based rule extraction, rulebase construction and cluster and rule based prediction. The methods employed include crisp and fuzzy algorithms. At each step, logical and medical validation of results was carried out. Different sets of randomly selected patient data were used to train, test and optimize the clusterbases and rulebases for prediction. RESULTS: Using the best clusterbase/rulebase combination designed, the IVS thickness cluster ('small' or 'large') was predicted correctly for 30 of the 35 patients with known IVS values in the training data set; no patient was predicted incorrectly and 5 were parity predicted. For the test data set, 4 of the 6 patients with known IVS values were predicted correctly, no patient incorrectly and 2 parity. These results did not substantially differ from those obtained using the second best clusterbase/rulebase combination which was finally recommended for use based on further performance criteria. The prediction of the IVS thickness clusters of the 22 patients with unknown IVS values also yielded good results that were (and could only be) validated by a medical individual risk assessment of these patients. CONCLUSIONS: The approach applied proved successful for the cluster and rule based prediction of a quantitative variable, such as IVS thickness, for individual patients from other variables relevant to the problem. The results obtained demonstrate the high potential of the approach and the methods developed and validated to support decision-making in hemodialysis and other fields of medicine by individual risk prediction.

Contamination of dialysis water and dialysate. A survey of 30 centers.

The concentration of bacteria and endotoxin in dialysis water and dialysate of 30 dialysis centers in western Germany was examined. Water samples were obtained after treatment by reverse osmosis or other processing methods. Collection of dialysis samples for bacterial, fungal, and endotoxin analysis was conducted before and 2 hours after start of hemodialysis. In 17.8% of all water samples analyzed, the AAMI standard was exceeded and bacterial and fungal counts greater than 200 colony forming units/ml were found. In 11.7% of all dialysate samples, higher contamination than the recommendations for dialysate of 2000 colony forming units/ml were found. The concentration of endotoxin in water and dialysate varied between 0 and 95 endotoxin units in the water samples and 0 and 487 endotoxin units/ml in the dialysate samples. In 12.2% of all water sampled, and 27.5% of all dialysate samples, values of 5 endotoxin units/ml were found. No correlation was found between the level of contamination of either water or dialysate in a specific center and the following factors: water processing method (reverse osmosis or others), type of dialysate (acetate of bicarbonate), type of dialysate machine, or method of machine disinfection. In view of these results it is suggested that endotoxin testing, especially in the dialysate, be a part of regular quality control in dialysis.

Polymers in nephrology. Characteristics and needs.

Polymers employed as biomaterials in nephrology serve for different applications: they form membranes for dialysis and plasmapheresis, are used as materials for dialyser housings and as a potting mass for capillary membranes, they make up tubing-systems for extracorporeal circuits and - in the form of beads - act as parts of adsorber columns for hemoperfusion or immunoadsorption. However, generally speaking, many polymers have not yet been designed for their final application. To date, many polymers are still taken from the chemist's shelf according to their alleged performance properties or to their sterilisability. When used in medical application, polymers must show a high purity. Uncontrolled leaching of oligomers from the polymer backbone or of additives from or during the manufacturing process must be avoided. Blood and other body fluids are extremely effective in extracting any loosely bound polymers. During long-term application, e.g. in patients suffering from chronic diseases, these effects may lead to an accumulation of these compounds in circulating blood, tissue, or joints. Consequently, polymers should show an excellent biostability and not degrade during their ageing process. The amount of extractable material should be kept low in order to avoid inflammatory reactions. Polymers must have high blood compatibility in terms of minimized cell- and complement activation. Polymers for medical application should at best be able to stand high temperatures in order to survive steam sterilisation. If this is impossible, their release kinetics for residual quantities of sterilizing agents should be fast. Finally, protein adsorption should appear under controlled conditions, otherwise a reduced performance through protein adsorption will take place. Further, the uncontrolled activation of biochemical cascades, such as the coagulation, complement or contact phase cascade, following blood/material contact must be minimized. A final aspect has been recently made responsible for adverse patients reactions, the interaction between polymers and medicinal drugs. This drug/material interaction must be low, at best zero, apart form those situations, where a controlled drug-release is wanted. The chemical variety of polymers for medical application is large. However, all typical requirements cannot be met by one single polymer. Compromises have to be found between properties and application. Polymer selection for application in nephrology has always to be made under the premise of final application.

Cellulose-ester as membrane materials for hemodialysis.

The majority of dialysis membranes are fabricated from regenerated unmodified cellulose. This standard type of cellulosic membrane is frequently under attack because of its alleged lack of biocompatibility. Recent developments, however, have proven that a chemical modification of the reactive surface groups of regenerated cellulose, the hydroxyl-groups, limits the complement-activating potential of these materials and thus improves its blood-compatibility. We extended the idea of modifying cellulose for improved blood-compatibility to a series of different cellulose esters. Special focus was directed towards the question whether a variation of the type of substituent and degree of substitution could influence the blood-compatibility pattern of these materials: the analysis of blood-compatibility profiles showed a direct dependency on the type of substituent and the degree of substitution (DS). As an example, it was found that the DS, necessary for a complete reduction of complement activation, decreases with increasing chain lengths of aliphatic substituents. Optimal degrees of substitution are characteristic of the type of substituents and enable us to tailor materials specifically for optimized blood compatibility.

Computer aided time-lapse video analysis of hepatocyte morphology during adhesion to cellulose membranes.

An investigation was performed to demonstrate that time-lapse cinematography and computer aided video analysis of cell morphology is suitable to study and compare the characteristics of hepatocytes during the adhesion process to membranes. We chose to compare ordinary cellulose Cuprophan membranes and membranes coated with collagen or fibronectin. Striking differences between uncoated cellulose and fibronectin or collagen coating were seen in the cell count per square millimeter and adhesion behaviour. On the investigated uncoated Cuprophan the hepatocytes were found to attach but not to spread whilst on collagen coated Cuprophan most of the cells spread spherically, and on fibronectin coated membranes most of the cells flattened spherically or polygonally. Time-lapse video microscopy seems to be a valuable technique for assessing the morphologic behaviour of cells in a detailed and quantitative manner in order to improve the hepatocyte culture technique in bioreactors for hybrid systems.

Validation of a two-pool model for the kinetics of beta2-microglobulin.

UNLABELLED: Secondary amyloidosis due to beta-2-microglobulin (beta2-m) is a serious long-term complication in patients on regular dialysis therapy. Beta2-m can be considered a middle-molecule marker used to facilitate the assessment of dialysis efficacy. For this purpose, a validated model that calculates characteristic efficacy parameters, such as Kt/V, TAC and generation rate, is needed. There is general agreement that beta2-m-kinetics should be described by a two-pool model, but little has been published to validate such an approach. We measured the beta2-m concentration profiles of eight stable patients during hemodialysis (HD) at the start of treatment, after 30 minutes, after 60 minutes, and every hour until the end. Thereafter they were measured at 10-minute intervals for an hour. The dialyser clearances were determined from the plasma concentrations in front of and behind the dialyser twice during each session - after 1 hour, and 4 hours from the start of treatment. The kinetic parameters of a two-pool model (e.g. the compartment volumes V1 and V2, the mass transfer coefficient K12 and the generation rate G) were determined from the optimal fit of the measured concentration profile. The table below summarises the results by giving the mean and standard deviation for each parameter: [table: see text]. Inter-individual differences in V1/V2 and K12 were high, ranging from 2.5 to 10.0 for V/V2 and from 26 to 140 for K12. Error analysis suggested that these wide ranges were due to the method and that in reality the probable range of V is 25-36% of TBW, of V1/V2 3.5-5.3, and of K12 30-80 ml/min. With standard values for these three parameters (V = 30% of TBW, V/V2 = 4.4 and K12 = 55 ml/m), equal for all patients, and their respective ranges, Kt/W can be calculated with a standard deviation of 13%. Kt/W > 1.2 secures the maximum possible beta2-m removal with three HD treatments a week. CONCLUSIONS: The parameters of a two-pool model of beta2-m kinetics can be derived from concentration profiles obtained under routine dialysis conditions, but accuracy is not completely satisfactory. Similar to the dialysis dose for urea (Kt/Vurea) the dialysis dose for beta2-m (Kt/Vbeta2-m) can be calculated from the pre- and post-dialysis concentrations of beta2-m, body weight, ultrafiltration and dialysis time. Kt/Vbeta2-m > 1.2 secures the maximum possible removal of beta2-m in HD with three sessions per week.

In vitro evaluation of the hydraulic permeability of polysulfone dialysers.

An in vitro set-up has been designed to study the hydraulic permeability of hollow fiber dialysers. Forward and reverse dialysate ultrafiltration were determined using both sterile dialysers and samples with a protein layer settled on the membrane (Fresenius F6, F8, F60 and F80). The ultrafiltration coefficient KUF (ml/h.mmHg) was calculated as the ratio of volumetrical flow (QUF) and transmembrane pressure (TMP) measurements. The protein layer on the membrane was induced either by recirculating human plasma through the dialysers (in vitro) or by a standard hemodialysis session (in vivo). KUF is largely independent of TMP up to 600mmHg (low flux) and 60mmHg (high flux) for forward and reverse flow In sterile dialysers, backfiltration yields a significantly different KUF except for the F80. An in vitro induced protein layer on the membrane decreases KUF15-30% (forward) and 4-12% (backward) in low flux and 45-70% (forward) and 65-73% (backward) in high flux dialysers.

Comparison of hollow fibre membranes for hepatocyte immobilisation in bioreactors.

Various hollow fibre membranes of polyamide, cellulose and polypropylene were investigated as potential substrata for hepatocyte immobilisation in bioreactors for hybrid liver support systems. Membranes were subjected to a cytocompatibility test in which the attachment and morphology of primary hepatocytes were evaluated. The effect of coating with collagen and fibronectin was also studied. Adequate cell immobilisation was possible on polypropylene and polyamide membranes even without coating. The flattening process of the cells was dependent on the material and the coating. The incorporation of porous polypropylene hollow fibres in hybrid liver cell bioreactors and their specific permeability properties could also offer means for cell oxygenation, metabolite distribution and immuno-isolation purposes.