The challenges of renal replacement therapy and renal palliative care in the elderly.

The main aim of this review is to let general practitioners and physicians understand what happens to older patients after referral to the renal service. Usually, most patients will be managed completely by the renal team, either because the patient requires dialysis or because conservative but specialised care is appropriate. The recent increase in dialysis rate can mostly be accounted for by older patients for whom such demanding treatment was previously thought to be contraindicated. The decision to dialyse the elderly still remains difficult, with recent data suggesting that if there are significant comorbidities the survival advantage of dialysis in patients over 75 years of age is unlikely to be more than four months. Towards the end of life, conservative treatment is not simply a decision not to dialyse, but comprises active disease management, including treatment of anaemia and other supportive care, which may become increasingly complex, e.g. pain relief with fentanyl and alfentanyl. Older patients who decide to accept dialysis treatment contend with all the usual end of life issues of older people. They have an additional option, denied to the rest of us, of dialysis withdrawal; this effectively allows them to die at a time of their choosing.

Rhabdomyolysis following co-prescription of fusidic acid and atorvastatin.

The placebo-corrected incidence of rhabdomyolysis in a systematic review of 20 statin trials was 1.6/100,000 per year. It is likely to be higher than this in everyday clinical practice when statins are knowingly or inadvertently co-prescribed with drugs that interfere with their metabolism. We report a case of rhabdomyolysis causing muscle weakness and prolonging an episode of dialysis-dependent acute kidney injury, which occurred when fusidic acid was co-prescribed with atorvastatin. Renal function and muscle power recovered when both drugs were withdrawn. We found four other cases of rhabdomyolysis with fusidic acid and atorvastatin and three with fusidic acid and simvastatin in the literature, a review of which suggests that the risks of rhabdomyolysis vary with the extent to which an individual statin is dependent for its metabolism on the cytochrome P450 3A4 isoenzyme and the degree to which this isoenzyme's activity is inhibited by a particular antimicrobial. Of note, the interaction between statins and fusidic acid did not feature in seven of eight recent reviews of statin toxicity. Our case report highlights the importance of close monitoring of patients on statins, especially when new drugs are started or if patients become unwell, by checking creatine kinase and liver function tests and by examining for new muscle weakness. Our review of statin-antimicrobial drug interactions suggests that fusidic acid is another CYP450 3A4 enzyme inhibitor with the potential to cause rhabdomyolysis when co-prescribed with simvastatin and atorvastatin.

Comparison of combined urea and creatinine clearance and prediction equations as measures of residual renal function when GFR is low.

BACKGROUND: UK, US and European guidelines recommend the decision to initiate dialysis should be based on a combination of measurements of kidney function, nutritional status and clinical symptoms. Such recommendations assume an accurate and reproducible measure of glomerular filtration rate (GFR). METHODS: Prospective study of 97 patients with chronic kidney disease (CKD) and serum creatinine >200 micromol/l (2.26 mg/dl) who between them contributed 388 24 h urine collections. Our main outcome measure was the number of patients with low residual renal function identified by different tests, using widely accepted thresholds. We calculated sensitivity, specificity, positive and negative predictive values and receiver operating characteristic curves for each comparison using a combined urea and creatinine clearance of <15 ml/min to indicate the likely presence of end stage renal disease (CKD stage 5). RESULTS: Seventy five patients had a combined urea and creatinine clearance <15 ml/min during the study. Using the highest measurement of serum creatinine for each patient, the best of the prediction equations was the 4-variable modification of diet in renal disease (MDRD) equation (area under ROC curve 0.93). This was followed by Kt/V (AUC 0.91) and Cockroft Gault with and without correction for ideal body weight (AUC 0.89). Further analyses showed that the 4-variable MDRD equation had higher NPV (64%) but lower PPV (89%) than the other tests (NPV 40-49%, PPV 92-100%), for identifying patients whose combined clearance was <15 ml/min. CONCLUSION: The 4-variable MDRD formula is currently the best available prediction equation for GFR, but will nevertheless over estimate residual renal function when this is significantly impaired in up to 36% cases. Collection of 24 h urine samples may still have a role in the assessment of patients with stages 4 and 5 CKD.

Hyaluronan.

The polysaccharide hyaluronan is an essential component of the vertebrate extracellular matrix and also produced by viruses, bacteria and fungi. Although the hyaluronan polymer is simply a disaccharide that repeats many thousands of times, it has an amazing array of biological functions and medical uses. For example, it is an efficient space filler that maintains hydration, serves as a substrate for assembly of proteoglycans and cellular locomotion, regulates cellular function and development, and is involved in tumor progression, inflammation and wound healing. Its physical properties and biocompatibility also make it of considerable importance in the development of engineered tissue, biomaterials and in clinical applications.

Quantitative conformational analysis of the core region of N-glycans using residual dipolar couplings, aqueous molecular dynamics, and steric alignment.

A method is described for quantitatively investigating the dynamic conformation of small oligosaccharides containing an alpha(1 --> 6) linkage. It was applied to the oligosaccharide Man-alpha(1 --> 3) [Man-alpha(1 --> 6)] Man-alpha-O-Me, which is a core region frequently observed in N-linked glycans. The approach tests an aqueous molecular dynamics simulation, capable of predicting microscopic dynamics, against experimental residual dipolar couplings, by assuming that alignment is caused purely by steric hindrance. The experimental constraints were heteronuclear and homonuclear residual dipolar couplings, and in particular those within the alpha(1 --> 6) linkage itself. Powerful spin-state-selective pulse sequences and editing schemes were used to obtain the most relevant couplings for testing the model. Molecular dynamics simulations in water over a period of 50 ns were not able to predict the correct rotamer population at the alpha(1 --> 6) linkage to agree with the experimental data. However, this sampling problem could be corrected using a simple maximum likelihood optimisation, indicating that the simulation was modelling local dynamics correctly. The maximum likelihood prediction of the residual dipolar couplings was found to be an almost equal population of the gg and gt rotamer conformations at the alpha(1--> 6) linkage, and the tg conformation was predicted to be unstable and unpopulated in aqueous solution. In this case all twelve measured residual dipolar couplings could be satisfied. This conformer population could also be used to make predictions of scalar couplings with the use of a previously derived empirical equation, and is qualitatively in agreement with previous predictions based on NMR, X-ray crystallography and optical data.

Comparison of aqueous molecular dynamics with NMR relaxation and residual dipolar couplings favors internal motion in a mannose oligosaccharide.

An investigation has been performed to assess how aqueous dynamical simulations of flexible molecules can be compared against NMR data. The methodology compares state-of-the-art NMR data (residual dipolar coupling, NOESY, and (13)C relaxation) to molecular dynamics simulations in water over several nanoseconds. In contrast to many previous applications of residual dipolar coupling in structure investigations of biomolecules, the approach described here uses molecular dynamics simulations to provide a dynamic representation of the molecule. A mannose pentasaccharide, alpha-D-Manp-(1-->3)-alpha-D-Manp-(1-->3)-alpha-D-Manp-(1-->3)-alpha-D-Manp-(1-->2)-D-Manp, was chosen as the model compound for this study. The presence of alpha-linked mannan is common to many glycopeptides, and therefore an understanding of the structure and the dynamics of this molecule is of both chemical and biological importance. This paper sets out to address the following questions. (1) Are the single structures which have been used to interpret residual dipolar couplings a useful representation of this molecule? (2) If dynamic flexibility is included in a representation of the molecule, can relaxation and residual dipolar coupling data then be simultaneously satisfied? (3) Do aqueous molecular dynamics simulations provide a reasonable representation of the dynamics present in the molecule and its interaction with water? In summary, two aqueous molecular dynamics simulations, each of 20 ns, were computed. They were started from two distant conformations and both converged to one flexible ensemble. The measured residual dipolar couplings were in agreement with predictions made by averaging the whole ensemble and from a specific single structure selected from the ensemble. However, the inclusion of internal motion was necessary to rationalize the relaxation data. Therefore, it is proposed that although residual dipolar couplings can be interpreted as a single-structure, this may not be a correct interpretation of molecular conformation in light of other experimental data. Second, the methodology described here shows that the ensembles from aqueous molecular dynamics can be effectively tested against experimental data sets. In the simulation, significant conformational motion was observed at each of the linkages, and no evidence for intramolecular hydrogen bonds at either alpha(1-->2) or alpha(1-->3) linkages was found. This is in contrast to simulations of other linkages, such as beta(1-->4), which are often predicted to maintain intramolecular hydrogen bonds and are coincidentally predicted to have less conformational freedom in solution.

Glycosaminoglycan conformation: do aqueous molecular dynamics simulations agree with x-ray fiber diffraction?

Glycosaminoglycan-protein interactions are biologically important and require an appreciation of glycan molecular shape in solution, which is presently unavailable. In previous studies we found strong similarity between aqueous molecular dynamics (MD) simulations and published x-ray diffraction refinements of hyaluronan. We have applied a similar approach here to chondroitin and dermatan, attempting to clarify some of the issues raised by the x-ray diffraction literature relating to chondroitin and dermatan sulfate. We predict that chondroitin has the same beta(1-->4) linkage conformation as hyaluronan, and that their average beta(1-->3) conformations differ. This is explained by changes in hydrogen-bonding across this linkage, resulting from its axial hydroxyl, causing a different sampling of left-handed helices in chondroitin (2.5- to 3.5-fold) as compared with hyaluronan (3.0- to 4.0-fold). Few right-handed helices, which lack intramolecular hydrogen-bonds, were sampled during our MD simulations. Thus, we propose that the 8-fold helix observed in chondroitin-6-sulfate, represented in the literature as an 8(3) helix (right-handed), though it has never been refined, is more likely to be 8(5) (left-handed) helix. Molecular dynamics simulations implied that (4)C(1) and (2)S(O), but not (1)C(4), forms of iduronate could be used in refinements of dermatan x-ray fiber diffraction patterns. Current models of 8-fold dermatan sulfate chains containing (4)C(1) iduronate refine to right-handed helices, which possess no intramolecular hydrogen-bonds. However, MD simulations predict that models containing (2)S(O) iduronate could provide better (8(5) helix) starting structures for refinement. Thus, the 8-fold dermatan sulfate refinement (8(3) helix) could be in error.

Dynamic exchange between stabilized conformations predicted for hyaluronan tetrasaccharides: comparison of molecular dynamics simulations with available NMR data.

Studies of the hyaluronan (HA) tetrasaccharides are important for understanding hydrogen-bonding in the HA polymer, as they are probably the smallest oligomers in which characteristics of the constituent monosaccharides and the polymer are simultaneously exhibited. Here we present extensive molecular dynamics simulations of the two tetrasaccharides of HA in dilute aqueous solution. These simulations have confirmed the existence of intramolecular hydrogen-bonds between the neighboring sugar residues of HA in solution, as proposed by Scott (1989). However, our simulations predict that these intramolecular hydrogen-bonds are not static as previously proposed, but are in constant dynamic exchange on the sub-nanosecond time-scale. This process results in discrete internal motion of the HA tetrasaccharides where they rapidly move between low energy conformations. Specific interactions between water and intramolecular hydrogen-bonds involving the hydroxymethyl group were found to result in differing conformations and dynamics for the two alternative tetrasaccharides of HA. This new observation suggests that this residue may play a key role in the entropy and stability of HA in solution, allowing it to stay soluble up to high concentration. The vicinal coupling constants3 J NHCH of the acetamido groups have been calculated from our aqueous simulations of HA. We found that high values of 3J NHCH approximately 8 Hz, as experimentally measured for HA, are consistent with mixtures of both trans and cis conformations, and thus3 J NHCH cannot be used to imply a purely trans conformation of the acetamido. The rapid exchange of intramolecular hydrogen-bonds indicates that although the structure is at any moment stabilized by these hydrogen-bonds, no one hydrogen-bond exists for an extended period of time. This could explain why NMR often fails to provide evidence for intramolecular hydrogen-bonds in HA and other aqueous carbohydrate structures.

Deducing polymeric structure from aqueous molecular dynamics simulations of oligosaccharides: predictions from simulations of hyaluronan tetrasaccharides compared with hydrodynamic and X-ray fibre diffraction data.

Molecular dynamics simulations of the two hyaluronan tetrasaccharides in water predict that over a period of 500 ps, their central linkages populate a single primary minima. Over the same period the peripheral linkages explore this minima, but also a secondary minima. Structures constructed using the primary minima were found to be extended left-handed helices of axial rise per disaccharide (h) 0.8 to 1.0 nm and 2.8 to 4.5 disaccharides per turn (n), in good agreement with n=3 and n=4 helices found by X-ray fibre diffraction studies. We have used the predicted average conformation from molecular dynamics to calculate the translational diffusion coefficients of the oligosaccharide series up to decasaccharide, and compared these with experimental measurements obtained using the method of capillary dispersion. Our calculated values are found to be in good agreement with experiment beyond the size of a tetrasaccharide. A partial digest of hyaluronan in the molecular mass range 10 to 100 kDa was fractionated by gel chromatography. Molecular weights were determined by in-line laser light-scattering measurements, and the translational diffusion coefficients of selected fractions were determined by dynamic laser light-scattering. A similar experiment was performed on hyaluronan with a molecular mass greater than 1MDa. The data suggest a change from rod-like to stiff coil behaviour beyond a molecular weight of 10 kDa. We have also examined the conformations available using the secondary minima, found at the peripheral linkages. In contrast to the extended structures previously described we have found left and right-handed helices with high values of n (5-10) and low values of h. Although there is no experimental evidence for these structures, they are of interest as, over short stretches, they would introduce folds, loops, and turns into the hyaluronan molecule. Such shapes may play an important role in the hydrodynamics of hyaluronan and its interaction with lipids and proteins.

Molecular dynamics simulations of the two disaccharides of hyaluronan in aqueous solution.

Hyaluronan is an unusually stiff polymer when in aqueous solution, which has important consequences for its biological function. Molecular dynamics simulations of hyaluronan disaccharides have been performed, with explicit inclusion of water, to determine the molecular basis of this stiffness, and to investigate the dynamics of the glycosidic linkages. Our simulations reveal that stable sets of hydrogen bonds frequently connect the neighboring residues of hyaluronan. Water caging around the glycosidic linkage was observed to increase the connectivity between sugars, and further constrain them. This, we propose, explains the unusual stiffness of polymeric hyaluronan. It would allow the polysaccharide to maintain local secondary structure, and occupy large solution domains consistent with the visco-elastic nature of hyaluronan. Simulations in water showed no significant changes on inclusion of the exoanomeric effect. This, we deduced, was due to hyaluronan disaccharides ordering first shell water molecules. In some cases these waters were observed to transiently induce conformational change, by breaking intramolecular hydrogen bonds.

Structural characterisation of two forms of procyclic acidic repetitive protein expressed by procyclic forms of Trypanosoma brucei.

A procyclic acidic repetitive protein (PARP) fraction was purified from long-term cultures of Trypanosoma brucei procyclic forms by a solvent-extraction and reverse phase chromatography procedure. The PARP fraction yielded small quantities of a single N-linked oligosaccharide with the structure Man alpha1-6(Man alpha1-3)Man alpha1-6(Man alpha1-3)Manbeta1-4GlcNAcbeta1-4GlcNAc (Man5GlcNAc2). Fractionation of PARP on Con A-Sepharose revealed that the majority (80 to 90%) of the PARP fraction did not bind to Con A and was composed of the parpA alpha gene product that contains repeats of -Glu-Pro-Pro-Thr- (GPEET-PARP) and that lacks an N-glycosylation site. This form of PARP has not been previously identified at the protein-level. The minor Con-A-binding fraction was shown to be rich in the previously described form of PARP, encoded by the parpAbeta and/or parpB alpha genes, that contains a -Glu-Pro- repeat domain (EP-PARP) and an N-glycosylation site. Analysis of longer and shorter-term cultures suggested that procyclic cells initially express predominantly EP-PARP that is gradually replaced by GPEET-PARP. Both forms of PARP were shown to contain indistinguishable glycosylphosphatidylinositol (GPI) membrane anchors, where the conserved GPI core structure is substituted by heterogeneous sialylated branched polylactosamine-like structures that are predicted to form a dense surface glycocalyx above which the polyanionic -Glu-Pro-Pro-Thr- and -Glu-Pro- repeat domains are displayed. The phosphatidylinositol (PI) component of the GPI anchor was shown to be a mixture of 2-O-acyl-myo-inositol-1-HPO4-(sn-1-stearoyl-2-lyso-glycerol) and 2-O-acyl-myo-inositol-1-HPO4-(sn-1-octadecyl-2-lyso-glycerol), where the acyl chain substituting the inositol ring showed considerable heterogeneity. Mass spectrometric and light scattering experiments both suggested an average mass of approximately 15 kDa for GPEET-PARP, with individual glycoforms ranging from about 12 kDa to 20 kDa, that is consistent with its amino acid and carbohydrate composition. A measured translational diffusion coefficient of 3.9 x 10(7) cm2 s(-1) indicates that this molecule has a highly elongated shape. The possible functions of these unusual glycoproteins are discussed.