Periodic venting of MABR lumen allows high removal rates and high gas-transfer efficiencies.

The membrane-aerated biofilm reactor (MABR) is a novel treatment technology that employs gas-supplying membranes to deliver oxygen directly to a biofilm growing on the membrane surface. When operated with closed-end membranes, the MABR provides 100-percent oxygen transfer efficiencies (OTE), resulting in significant energy savings. However, closed-end MABRs are more sensitive to back-diffusion of inert gases, such as nitrogen. Back-diffusion reduces the average oxygen transfer rates (OTR), consequently decreasing the average contaminant removal fluxes (J). We hypothesized that venting the membrane lumen periodically would increase the OTR and J. Using an experimental flow cell and mathematical modeling, we showed that back-diffusion gas profiles developed over relatively long timescales. Thus, very short ventings could re-establish uniform gas profiles for relatively long time periods. Using modeling, we systematically explored the effect of the venting interval (time between ventings). At moderate venting intervals, opening the membrane for 20 s every 30 min, the venting significantly increased the average OTR and J without substantially impacting the OTEs. When the interval was short enough, in this case shorter than 20 min, the OTR was actually higher than for continuous open-end operation. Our results show that periodic venting is a promising strategy to combine the advantages of open-end and closed end operation, maximizing both the OTR and OTE.

Human and livestock waste as a reduced carbon source contributing to the release of arsenic to shallow Bangladesh groundwater.

Recent studies have demonstrated that the supply of relatively young organic carbon stimulates the release of arsenic to groundwater in Bangladesh. This study explores the potential role of human and livestock waste as a significant source of this carbon in a densely populated rural area with limited sanitation. Profiles of aquifer sediment samples were analyzed for phytosterols and coprostanol to assess the relative contributions of plant-derived and human/livestock waste-derived organic carbon at two well-characterized sites in Araihazar. Coprostanol concentrations increased with depth from non-detection (<10m at Site B and <23m at Site F) to maxima of 1.3 and 0.5ng/g in aquifer sands recovered from 17m (Site B) and 26m (Site F), respectively. The commonly used sewage contamination index ([5ß-coprostanol]/([5α-cholestanol]+[5ß-coprostanol])) exceeds 0.7 between 12 and 19m at Site B and between 24 and 26m at Site F, indicating input of human/livestock waste to these depths. Urine/fecal input within the same depth range is supported by groundwater Cl/Br mass ratios >1000 compared to Cl/Br <500 at depths >50m. Installed tube wells in the area's study sites may act as a conduit for DOC and specifically human/livestock waste into the aquifer during flood events. The depth range of maximum input of human/livestock waste indicated by these independent markers coincides with the highest dissolved Fe (10-20mg/L) and As (200-400µg/L) concentrations in groundwater at both sites. The new findings suggest that the oxidation of human/livestock waste coupled to the reductive dissolution of iron-(oxy)-hydroxides and/or arsenate may enhance groundwater contamination with As.

Stimulation of Microbially Mediated Arsenic Release in Bangladesh Aquifers by Young Carbon Indicated by Radiocarbon Analysis of Sedimentary Bacterial Lipids.

The sources of reduced carbon driving the microbially mediated release of arsenic to shallow groundwater in Bangladesh remain poorly understood. Using radiocarbon analysis of phospholipid fatty acids (PLFAs) and potential carbon pools, the abundance and carbon sources of the active, sediment-associated, in situ bacterial communities inhabiting shallow aquifers (<30 m) at two sites in Araihazar, Bangladesh, were investigated. At both sites, sedimentary organic carbon (SOC) Δ(14)C signatures of -631 ± 54‰ (n = 12) were significantly depleted relative to dissolved inorganic carbon (DIC) of +24 ± 30‰ and dissolved organic carbon (DOC) of -230 ± 100‰. Sediment-associated PLFA Δ(14)C signatures (n = 10) at Site F (-167‰ to +20‰) and Site B (-163‰ to +21‰) were highly consistent and indicated utilization of carbon sources younger than the SOC, likely from the DOC pool. Sediment-associated PLFA Δ(14)C signatures were consistent with previously determined Δ(14)C signatures of microbial DNA sampled from groundwater at Site F indicating that the carbon source for these two components of the subsurface microbial community is consistent and is temporally stable over the two years between studies. These results demonstrate that the utilization of relatively young carbon sources by the subsurface microbial community occurs at sites with varying hydrology. Further they indicate that these young carbon sources drive the metabolism of the more abundant sediment-associated microbial communities that are presumably more capable of Fe reduction and associated release of As. This implies that an introduction of younger carbon to as of yet unaffected sediments (such as those comprising the deeper Pleistocene aquifer) could stimulate microbial communities and result in arsenic release.

Insights into the impact of online physician reviews on patients' decision making: randomized experiment.

BACKGROUND: Physician-rating websites combine public reporting with social networking and offer an attractive means by which users can provide feedback on their physician and obtain information about other patients' satisfaction and experiences. However, research on how users evaluate information on these portals is still scarce and only little knowledge is available about the potential influence of physician reviews on a patient's choice. OBJECTIVE: Starting from the perspective of prospective patients, this paper sets out to explore how certain characteristics of physician reviews affect the evaluation of the review and users' attitudes toward the rated physician. We propose a model that relates review style and review number to constructs of review acceptance and check it with a Web-based experiment. METHODS: We employed a randomized 2x2 between-subject, factorial experiment manipulating the style of a physician review (factual vs emotional) and the number of reviews for a certain physician (low vs high) to test our hypotheses. A total of 168 participants were presented with a Web-based questionnaire containing a short description of a dentist search scenario and the manipulated reviews for a fictitious dental physician. To investigate the proposed hypotheses, we carried out moderated regression analyses and a moderated mediation analysis using the PROCESS macro 2.11 for SPSS version 22. RESULTS: Our analyses indicated that a higher number of reviews resulted in a more positive attitude toward the rated physician. The results of the regression model for attitude toward the physician suggest a positive main effect of the number of reviews (mean [low] 3.73, standard error [SE] 0.13, mean [high] 4.15, SE 0.13). We also observed an interaction effect with the style of the review­if the physician received only a few reviews, fact-oriented reviews (mean 4.09, SE 0.19) induced a more favorable attitude toward the physician compared to emotional reviews (mean 3.44, SE 0.19), but there was no such effect when the physician received many reviews. Furthermore, we found that review style also affected the perceived expertise of the reviewer. Fact-oriented reviews (mean 3.90, SE 0.13) lead to a higher perception of reviewer expertise compared to emotional reviews (mean 3.19, SE 0.13). However, this did not transfer to the attitude toward the physician. A similar effect of review style and number on the perceived credibility of the review was observed. While no differences between emotional and factual style were found if the physician received many reviews, a low number of reviews received lead to a significant difference in the perceived credibility, indicating that emotional reviews were rated less positively (mean 3.52, SE 0.18) compared to fact-oriented reviews (mean 4.15, SE 0.17). Our analyses also showed that perceived credibility of the review fully mediated the observed interaction effect on attitude toward the physician. CONCLUSIONS: Physician-rating websites are an interesting new source of information about the quality of health care from the patient's perspective. This paper makes a unique contribution to an understudied area of research by providing some insights into how people evaluate online reviews of individual doctors. Information attributes, such as review style and review number, have an impact on the evaluation of the review and on the patient's attitude toward the rated doctor. Further research is necessary to improve our understanding of the influence of such rating sites on the patient's choice of a physician.

A methodology to assess the effects of biofilm roughness on substrate fluxes using image analysis, substrate profiling, and mathematical modelling.

We present a novel approach, based on image analysis and modelling, to study the impact of morphological variability (roughness) and fluid dynamics on substrate mass fluxes in biofilms. Specifically, we used this method to assess substrate fluxes in counter-diffusional autotrophic biofilms in a hydrogen-based membrane biofilm reactor. The physical structure of the biofilm was determined in situ at the meso-scale using stereomicroscopy. Image analysis was used to characterize the biofilm structure, and substrate profiles were obtained using microsensors. A two-dimensional, continuum biofilm model including microbial reactions, mass transport, and fluid dynamics was developed to compute substrate conversion in irregularly shaped counter-diffusional biofilms. Experimental biofilm structures were reproduced in the model and simulated under the prevailing substrate and hydrodynamic conditions for flow velocities varied over three orders of magnitude. Model calculations were consistent with experimental results and showed enhanced conversion rates with increased roughness at higher flow velocities. Also, modelling showed that conversion rates in counter-diffusional biofilms were typically higher than in co-diffusional biofilms. This study highlights the potential to use a simple image acquisition approach coupled to a theoretical model, to evaluate biofilm overall substrate utilization related to biofilm morphological heterogeneity.

Determination of arsenic species in edible periwinkles (Littorina littorea) by HPLC-ICPMS and XAS along a contamination gradient.

Arsenic is naturally found in the tissues of marine animals, usually as the non-toxic arsenical arsenobetaine, but exposure to elevated arsenic concentrations in the environment may alter the arsenic species distribution within tissues of the organism. This study examined the arsenic species in the tissues of the marine periwinkle (Littorina littorea) along an arsenic concentration gradient in the sediment. The arsenicals in L. littorea were examined using the complementary analytical methods high performance liquid chromatography coupled with inductively coupled plasma mass spectrometry (HPLC-ICPMS) and X-ray absorption spectroscopy (XAS). Total arsenic concentrations in the periwinkle tissues ranged from 56 to 840 mg·kg(-1) dry weight (equivalent to 13 to 190 mg·kg(-1) wet weight). Inorganic arsenicals were found to be positively correlated with total arsenic concentrations (R(2)=0.993) and reached 600 mg·kg(-1) dry weight, the highest reported to date in marine organisms. These high inorganic arsenic concentrations within this low trophic organism pose a potential toxicological risk to higher trophic consumers.

Arsenic speciation in blue mussels (Mytilus edulis) along a highly contaminated arsenic gradient.

Arsenic is naturally present in marine ecosystems, and these can become contaminated from mining activities, which may be of toxicological concern to organisms that bioaccumulate the metalloid into their tissues. The toxic properties of arsenic are dependent on the chemical form in which it is found (e.g., toxic inorganic arsenicals vs nontoxic arsenobetaine), and two analytical techniques, high performance liquid chromatography coupled with inductively coupled plasma mass spectrometry (HPLC-ICP-MS) and X-ray absorption spectroscopy (XAS), were used in the present study to examine the arsenic species distribution in blue mussels (Mytilus edulis) obtained from an area where there is a strong arsenic concentration gradient as a consequence of mining impacted sediments. A strong positive correlation was observed between the concentration of inorganic arsenic species (arsenic compounds with no As-C bonds) and total arsenic concentrations present in M. edulis tissues (R(2) = 0.983), which could result in significant toxicological consequences to the mussels and higher trophic consumers. However, concentrations of organoarsenicals, dominated by arsenobetaine, remained relatively constant regardless of the increasing As concentration in M. edulis tissue (R(2) = 0.307). XANES bulk analysis and XAS two-dimensional mapping of wet M. edulis tissue revealed the presence of predominantly arsenic-sulfur compounds. The XAS mapping revealed that the As(III)-S and/or As(III) compounds were concentrated in the digestive gland. However, arsenobetaine was found in small and similar concentrations in the digestive gland as well as the surrounding tissue suggesting arsenobetaine may being used in all of the mussel's cells in a physiological function such as an intracellular osmolyte.

Arsenic species extraction of biological marine samples (Periwinkles, Littorina littorea) from a highly contaminated site.

Arsenic is ubiquitous in the tissues of marine organisms and in uncontaminated environments it is dominantly present as the highly soluble and easily extractable non-toxic arsenical, arsenobetaine. However in contaminated environments, higher proportions of inorganic arsenic, which is much less soluble, are accumulated into the tissues of marine organisms, resulting in lower extraction efficiencies (defined as the percent extracted arsenic of the total arsenic). This study carried out a comparative analysis between three different two-step arsenic extraction methods based on Foster et al. [27] from highly contaminated tissue of the marine periwinkle, Littorina littorea. The first extraction step used 100% water, 1:1 methanol-water, or a 9:1 methanol-water as the extraction solvent and the second step consisted of a gently heated dilute nitric acid extraction. The optimized two step extraction method was 1:1 methanol-water extraction followed by a 2% HNO(3) extraction, based on maximum amounts of extracted species, including organoarsenic species.

Vitamin D supplementation in CKD.

Vitamin D deficiency is common in chronic kidney disease and is associated with increased morbidity and mortality. In addition, vitamin D deficiency in renal disease is associated with serious comorbidities including secondary hyperparathyroidism and cardiovascular disease. Several therapeutic options are available to correct vitamin D deficiency, including nutritional vitamin D, pro-hormones and active hormones. In this review we discuss clinical findings related to the effectiveness of these therapies in chronic kidney disease.

The new kidney disease: improving global outcomes (KDIGO) guidelines - expert clinical focus on bone and vascular calcification.

Chronic kidney disease-mineral and bone disorder (CKD-MBD) defines a triad of interrelated abnormalities of serum biochemistry, bone and the vasculature associated with chronic kidney disease (CKD). The new kidney disease: improving global outcomes (KDIGO) guidelines define the quality and depth of evidence supporting therapeutic intervention in CKD-MBD. They also highlight where patient management decisions lack a strong evidence base. Expert interpretation of the guidelines, along with informed opinion, where evidence is weak, may help develop effective clinical practice. The body of evidence linking poor bone health and reservoir function (the ability of bone to buffer calcium and phosphorus) with vascular calcification and cardiovascular outcomes is growing. Treating renal bone disease should be one of the primary aims of therapy for CKD. Evaluation of the biochemical parameters of CKD-MBD (primarily phosphorus, calcium, parathyroid hormone and vitamin D levels) as early as CKD Stage 3, and an assessment of bone status (by the best means available), should be used to guide treatment decisions. The adverse effects of high phosphorus intake relative to renal clearance (including stimulation of hyperparathyroidism) precede hyperphosphatemia, which presents late in CKD. Early reduction of phosphorus load may ameliorate these adverse effects. Evidence that calcium load may influence progression of vascular calcification with effects on mortality should also be considered when choosing the type and dose of phosphate binder to be used. The risks, benefits, and strength of evidence for various treatment options for the abnormalities of CKD-MBD are considered.

Quasi-steady-state displacement response of whole human cadaveric knees in a MRI scanner.

It is important to determine the three-dimensional nonuniform deformation of articular cartilage in its native environment. A new magnetic resonance imaging (MRI)-based technique (cartilage deformation by tag registration (CDTR)) has been developed, which can determine such deformations provided that the compressive load-displacement response of the knee reaches a quasi-steady state during cyclic loading. The objectives of this study were (1) to design and construct an apparatus to cyclically compress human cadaveric knees to physiological loads in a MRI scanner, (2) to determine the number of load cycles required to reach a quasi-steady-state load-displacement response for cyclic loading of human cadaveric knees, and (3) to collect sample MR images of undeformed and deformed states of tibiofemoral cartilage free of artifact while using the apparatus within a MRI scanner. An electropneumatic MRI-compatible apparatus was constructed to fit in a clinical MRI scanner, and a slope criterion was defined to indicate the point at which a quasi-steady-state load-displacement response, which would allow the use of CDTR, occurred during cyclic loading of a human knee. The average number of cycles required to reach a quasi-steady-state load-displacement response according to the slope criterion defined herein for three cadaveric knee joints was 356+/-69. This indicates that human knee joint specimens can be cyclically loaded such that deformation is repeatable according to MRI requirements of CDTR. Sample images of tibiofemoral cartilage were obtained for a single knee joint. These images demonstrate the usefulness of the apparatus in a MRI scanner. Thus the results of this study are a crucial step toward developing a MRI-based method to determine the deformations of articular cartilage in whole human cadaveric knees.

Evidence of specialized bromate-reducing bacteria in a hollow fiber membrane biofilm reactor.

Bromate is a carcinogenic disinfection by-product formed from bromide during ozonation or advanced oxidation. We previously observed bromate reduction in a hydrogen-based, denitrifying hollow fiber membrane biofilm reactor (MBfR). In this research, we investigated the potential existence of specialized bromate-reducing bacteria. Using denaturing gradient gel electrophoresis (DGGE), we compared the microbial ecology of two denitrifying MBfRs, one amended with nitrate as the electron acceptor and the other with nitrate plus bromate. The DGGE results showed that bromate exerted a selective pressure for a putative, specialized bromate-reducing bacterium, which developed a strong presence only in the reactor with bromate. To gain further insight into the capabilities of specialized, bromate-reducing bacteria, we explored bromate reduction in a control MBfR without any primary electron acceptors. A grown biofilm in the control MBfR reduced bromate without previous exposure, but the rate of reduction decreased over time, especially after perturbations resulting in biomass loss. The decrease in bromate reduction may have been the result of the toxic effects of bromate. We also used batch tests of the perchlorate-reducing pure culture, Dechloromonas sp. PC1 to test bromate reduction and growth. Bromate was reduced without measurable growth. Based on these results, we speculate bromate's selective pressure for the putative, specialized BRB observed in the DGGE was not growth related, but possibly based on resistance to bromate toxicity.

An MRI-based method to align the compressive loading axis for human cadaveric knees.

There is a need to align the mechanical axis of the tibia with the axis of loading for studies involving tibiofemoral compression to interpret results and to ensure repeatability of loading within and among specimens. Therefore, the objectives of this study were (1) to develop a magnetic resonance imaging (MRI)-based alignment method for use with apparatuses applying tibiofemoral joint compression, (2) to demonstrate the usefulness of the method by aligning cadaveric knees in an apparatus that could apply tibiofemoral joint compression, and (3) to quantify the error associated with the alignment method. A four degree-of-freedom adjustable device was constructed to allow determination and alignment of the mechanical axis of the tibia of cadaveric knee joints with the axis of loading of an apparatus applying tibiofemoral joint compression. MRI was used to determine the locations of bony landmarks in three dimensions defining the mechanical axis of the tibia relative to an initial orientation of the four degree-of-freedom device. Adjustment values of the device were then computed and applied to the device to align the mechanical axis of the tibia with the axis of a compressive loading apparatus. To demonstrate the usefulness of the method, four cadaveric knees were aligned in the compressive loading apparatus. The vectors describing the mechanical axis of the tibia and the loading axis of the apparatus before and after adjustment of the four degree-of-freedom device were computed for each cadaveric knee. After adjustment of the four degree-of-freedom device, the mechanical axis of the tibia was collinear with the loading axis of the apparatus for each cadaveric knee. The errors in the adjustment values introduced by inaccuracies in the MR images were quantified using the Monte Carlo technique. The precisions in the translational and rotational adjustments were 1.20 mm and 0.90 deg respectively. The MR-based alignment method will allow consistent interpretation of results obtained during tibiofemoral compressive studies conducted using the apparatus described in this paper by providing a well-defined loading axis. The alignment method can also be adapted for use with other apparatuses applying tibiofemoral compression.

The first human cell line-derived erythropoietin, epoetin-delta (Dynepo), in the management of anemia in patients with chronic kidney disease.

AIMS: To evaluate the efficacy and safety of the first human cell line-derived erythropoietin, epoetin-delta, in the management of anemia in patients with chronic kidney disease. METHODS: This was a multicenter, randomized, double-blind, parallel-group, active-control, Phase III study. Patients aged > or = 18 years with chronic renal disease requiring hemodialysis, with hemoglobin (Hb) levels in the range 9.6-12.4 g/dl, and who had been treated with recombinant erythropoietin for > or = 90 days before study entry were eligible. In the initial double-blind comparative study phase, patients were randomized in a 3:1 ratio to 24-week treatment with either intravenous (i.v.) epoetin-delta (ED) or epoetin-alpha (EA). Patients then entered a 28-week open-label phase, receiving i.v. ED at a dose equal to that of i.v. ED or EA which they received at the end of the blinded phase. RESULTS: In total, 752 patients were randomized, of whom 555 patients subsequently received ED and 191 patients EA, with 583 patients (77.5%) completing the double-blind phase and entering the open-label phase. There was no significant difference between groups for the primary endpoint: the average Hb level from Weeks 12-24 of the study. The adjusted mean average Hb level for the modified intent-to-treat (mITT) population was 11.57 g/dl in the ED group (n = 491, mean dose 63.5 IU/kg) and 11.56 g/dl in the EA group (n = 175, mean dose 62.8 IU/kg). Efficacy was maintained on long-term use. Data for Weeks 12-52 show that ED maintained patients' Hb levels in the target range (10-12 g/dl) with a mean Hb level of 11.31 g/dl at a mean ED dose of 63.7 IU/kg. ED therapy was well tolerated, with a similar overall incidence of adverse events (AEs) (94.4%) to the EA group (92.1%) in the double-blind phase (most common events: hypotension, upper respiratory tract infection, muscle cramps, headache). AEs occurring during the open-label phase were generally similar in type and frequency to those reported during the double-blind phase. CONCLUSIONS: The human cell line-derived erythropoietin, epoetin-delta, provides an effective, well tolerated new option for the management of anemia in patients with chronic kidney disease.

Detection of cognitive decline after coronary surgery: a comparison of computerized and conventional tests.

BACKGROUND: Postoperative cognitive decline is a common complication after coronary artery bypass graft (CABG) surgery. Postoperative cognitive decline is defined on the basis of change in cognitive function detected with repeated assessments using neuropsychological tests. Therefore improvement in neuropsychological testing instruments may increase our understanding of postoperative cognitive decline. METHODS: Fifty patients undergoing CABG surgery completed both a conventional and a computerized battery of tests before and 6 days after CABG surgery. Fifty age- and education-matched controls completed the same test batteries 6 days apart. The reliability and the sensitivity to postoperative cognitive decline were computed for each battery. RESULTS: Both test batteries detected postoperative cognitive decline 6 days after CABG surgery. For the computerized battery, the reliability of the reaction times (intraclass correlation 0.89-0.92) was greater than for any test from the conventional battery (intraclass correlation 0.56-0.71), although accuracy measures were less reliable (intraclass correlation 0.61-0.89). The computerized battery detected all the cases of POCD identified by the conventional test battery and also five cases that were classified as normal by the conventional tests. CONCLUSION: Computerized tests are suitable for measuring cognitive change after CABG surgery and may detect change in a greater proportion of patients 6 days after CABG surgery than conventional neuropsychological tests.

Soluble IL-6 receptor levels in patients on chronic hemodialysis.

Osteitis fibrosa, a part of the spectrum of renal osteodystrophy, is characterized by high bone turnover as a result of high circulating levels of parathyroid hormone (PTH). It is well accepted that the bone resorptive effects of PTH occur, at least in part, by inducing osteoblasts to secrete cytokines that stimulate both differentiation and activation of osteoclasts. One such cytokine, interleukin 6 (IL-6), exerts its actions via the IL-6 receptor (IL-6R), which has alpha and beta subunits. The alpha subunit binds IL-6 and exists in both membrane bound and soluble forms which can interact with the signal transducing components of the receptor or beta subunits and result in the same biological effect. Abnormalities in the IL-6 system have the potential to affect bone turnover and to modulate the effects of PTH. In this regard, we examined the levels of circulating soluble IL-6 receptor (sIL-6R) and plasma intact PTH in 27 patients on hemodialysis, of whom 15 were on therapy with vitamin D compounds and 12 were vitamin D naive. The results were compared to values obtained from 9 healthy controls. Blood samples were obtained pre-dialysis and sIL-6R levels were determined using a commercially available enzyme immunoassay, which measures biologically active sIL-6R. In patients on chronic hemodialysis, plasma levels of sIL-6R were 123.4 +/- 11.01 ng/ml. In healthy controls, the levels were 99.61 +/- 11.52 ng/ml, values not significantly different from those found in dialysis patients. PTH values ranged from 7-1,709 pg/ml in patients on hemodialysis; however, there was no correlation between intact PTH levels and the levels of sIL-6R. Similarly, vitamin D therapy did not influence the levels of sIL-6R. These data indicate that using an assay which is specific for biologically active sIL-6R, the levels of this receptor in patients on hemodialysis are similar to those found in normal individuals and neither the levels of PTH nor vitamin D therapy alter this aspect of IL-6 action.

Mechanism of retinoic acid induced attenuation of PTH action in UMR 106-01 cells.

Studies from our laboratory in osteoblast-like cells have shown that the increase in EGF receptor expression in response to PTH was cyclic AMP mediated and was blocked by treatment with retinoic acid (RA). The present studies investigate the mechanism for this effect of RA on PTH actions. UMR 106-01 cells were exposed to RA and were tested for cAMP response to PTH as well as for (125)I PTH binding. cAMP production in response to PTH was markedly decreased by RA (25.1 +/- 1.6% of control) whereas there was only a slight decrease in PTH binding in response to RA. For the study of adenylate cyclase activity, membranes were isolated from intact cells that had been exposed to RA. Treatment with RA decreased PTH-stimulated adenylate cyclase activity; however, forskolin-stimulated enzyme activity was unchanged. Treatment of intact cells with pertussis toxin, to inactivate Gi, did not alter the inhibitory effect of RA on PTH-stimulated adenylate cyclase activity. Addition of GppNHp, a non-hydrolyzable analogue of GTP, completely restored the response to PTH in the membranes. Therefore, we examined the activity of IMP dehydrogenase, the rate-limiting enzyme for GTP biosynthesis, and GMP reductase which counteracts the effect of the synthetic enzyme. Treatment with RA for 48 hours increased GMP reductase activity by 240.9 +/- 24.2% and decreased IMP dehydrogenase activity to 67.5 +/- 8.8% of control values. These data indicate that RA impairs the response to PTH in intact cells. This blunted response was preserved in membrane preparations but was corrected by GTP. The RA-induced alterations of enzymes involved in the GTP biosynthetic pathway in a direction that favors a decrease in GTP biosynthesis provide an explanation for the inhibitory effect of RA on PTH actions.

Strategies to minimize bone disease in renal failure.

The skeletal disorders associated with renal insufficiency result from alterations in calcium, phosphorus, and vitamin D metabolism. Each requires intervention to prevent and control the problem. Hyperparathyroidism and its treatment can also result in extraskeletal complications. To prevent the development of parathyroid hyperplasia and the skeletal complications of chronic kidney disease, it is desirable to initiate interventions early in the course of kidney disease; however, many patients present with established hyperparathyroidism and additional strategies are necessary to suppress hyperparathyroidism. Mainstays of this approach are the control of phosphorus and the use of vitamin D analogs. Phosphorus control requires the use of phosphate binders, preferably non-calcium-containing binders, to prevent intestinal phosphorus absorption. Vitamin D analogs are used to suppress hyperparathyroidism and have the potential to have lesser toxicity than calcitriol. Paricalcitol is the most widely used vitamin D analog in this country and it effectively suppresses hyperparathyroidism with only minimal effects on calcium and phosphorus. A substantial body of data in experimental animals supports the use of paricalcitol as a preferential therapeutic agent. Recently, an additional vitamin D sterol, doxercalciferol, has been introduced, which is metabolized to 1,25-dihydroxyvitamin D(2). Although initially thought to have lesser toxicity than its vitamin D(3) counterpart, recent studies have not provided support for a major difference in this regard. Doxercalciferol is also effective in lowering parathyroid hormone (PTH), though hypercalcemia in hyperphosphatemic episodes occurred relatively frequently during the clinical studies. As these therapeutic strategies are undertaken, it is important not to oversuppress PTH and decrease bone turnover to abnormally low levels because of the risk for adynamic renal bone disease. It is possible that when bone turnover is abnormally low, the extraskeletal deposition of calcium in blood vessels and other tissues is enhanced. Accordingly, constant monitoring is required during treatment, with emphasis on minimizing the calcium load, and, if monitored correctly, a satisfactory control of hyperparathyroidism may be achieved with the agents currently available.