The danger of using inappropriate point-of-care glucose meters in patients on icodextrin dialysis.

AIMS: Icodextrin is a glucose polymer used to maintain an osmotic gradient in peritoneal dialysis. Metabolites of icodextrin are known to cause overestimation of blood glucose in glucose meters using glucose dehydrogenase/pyrroloquinolinequinone systems. The aim of this study is to determine the extent of icodextrin interference in glucose meters using the newer glucose dehydrogenase/NAD or glucose oxidase systems. This has not been established previously. METHODS: Fasting blood samples (n = 4) were spiked with either one icodextrin metabolite (maltose, maltotriose or maltotetraose) or a combination, at various blood concentrations expected during dialysis. Samples were tested in triplicate on: five glucose-meters, a Radiometer® (glucose oxidase/hydrogen peroxide) and laboratory (hexokinase) analysers. Each meter was also tested on blood from six patients undergoing dialysis. Accuracy was evaluated as % Bias = [(meter glucose - laboratory glucose)/laboratory glucose] × 100. RESULTS: A single icodextrin metabolite affected glucose measurements and, in combination, the interferences were additive in the two Accu-Chek® and Optium® Xceed meters by > 10%. Amongst these meters, the Optium Xceed 5-s machine was less affected. Meters using glucose oxidase were least affected by interference. A similar trend in interference was observed in vivo. CONCLUSION: While meters using glucose dehydrogenase/NAD are less affected by icodextrin metabolites, interference can still be demonstrated. The degree of interference can vary in different glucose meters using this enzyme/cofactor system, as seen in the Optium Xceed machines. Icodextrin is an important source of interference that sometimes even experienced professionals are unaware of and which leads to clinically significant errors in insulin dose adjustment. Awareness of this interference and selection of the most appropriate glucose meters are crucial to minimize this hazard.

Effects of glucose on matrix metalloproteinase and plasmin activities in mesangial cells: possible role in diabetic nephropathy.

Diabetic nephropathy is characterized by an accumulation of mesangium matrix that correlates well with the loss of kidney function. High glucose concentration is known to increase the synthesis of many matrix components. Recently, we have shown that degradation of matrix also decreases in diabetes. The major enzymes responsible for matrix degradation are the matrix metalloproteinases. The physiology of these enzymes is complex and their activity is tightly regulated at many levels. At the transcriptional level matrix metalloproteinase (MMP) expression is increased by protein kinase C (PKC) agonists, and some growth factors. In contrast transforming growth factor (TGF)-beta can decrease MMP expression. Once synthesized, MMPs are secreted as inactive pro-enzymes that are activated by other MMPs or plasmin. To effect this, plasmin must be liberated from plasminogen in the pericellular environment. In turn, activated MMPs can be inhibited by binding to specific inhibitors known as tissue inhibitor of metalloproteinases (TIMP). Cell culture and animal studies have shown that high glucose (HG) decreases expression of MMPs and increases expression of TIMPs. HG can also affect MMP activation by decreasing plasmin availability and reducing expression of a membrane-bound MMP called MT1-MMP. How HG induces these changes remains to be fully elucidated. One possibility is that HG can increase TGF-beta. which may in turn alter MMP promoter activity: this area is currently being studied in our laboratory.

Healthcare systems and end-stage renal disease (ESRD) therapies--an international review: access to ESRD treatments.

Assessment of healthcare technology and economics can be used to assess the access to healthcare, its quality and efficacy as well as its cost and cost efficiency. This report addresses these issues for the provision of care for end-stage renal disease (ESRD) patients. An international comparison of access to ESRD treatment modalities was made with reference to the healthcare provider structure in a range of industrial countries. The countries were grouped into 'public' (Beveridge model), 'mixed' (Bismarck model) and 'private' (Private Insurance model). In 'public' provider countries, 20-52% of dialysis patients are treated with home therapies (haemodialysis and peritoneal dialysis), and the number of patients with renal transplants is 45-81% of all ESRD patients. In 'mixed' provider countries, only 9 17% of all dialysis patients are treated with home therapies, and 20-48% of ESRD patients have renal transplants. In 'private' provider countries, 17% of US and 6% Japanese dialysis patients are treated with home therapies. Japan has 0.3% and the US has 26% of ESRD patients who receive renal transplants. It thus seems that provider structure influences access to and choice of ESRD treatment. With a growing elderly population and longer life expectancy, there will be an increased requirement for ESRD treatments in all industrial countries. Equal access to, and quality of ESRD care in the future will require adequate funding and reimbursement strategies in a cost-constrained healthcare environment. growing elderly population, new and innovative healthcare technologies, increasing expectations of the population and the dilemma of economic constraints. Therefore, new disciplines such as health technology assessment and healthcare economics are developing to support the needs of health policy decision makers. Their main objective is to create a balance between the three key factors of a healthcare system: access to healthcare (equity for all), quality of healthcare (efficacy) and finally the cost or cost efficiency of healthcare provision [1; see also Lameire et al., this issue]. This report will assess access to healthcare in a very specific and very costly area that of end-stage renal disease (ESRD). An international comparison of access to ESRD treatment for patients from a series of industrial countries will be used as a means for evaluation of this access.

Renal chloride channel, CLCN5, mutations in Dent's disease.

Dent's disease is an X-linked renal tubular disorder characterized by low-molecular-weight proteinuria, hypercalciuria, nephrocalcinosis, nephrolithiasis, and renal failure. Patients with Dent's disease may also suffer from rickets and other features of the renal Fanconi Syndrome. Patients may have mutations in the X-linked renal chloride channel gene, CLCN5, which encodes a 746-amino-acid protein with 12-13 transmembrane domains. We have investigated the 11 coding exons of CLCN5 for mutations in eight unrelated patients with Dent's disease. Leukocyte DNA was used for the polymerase chain reaction amplification of CLCN5 and the products analyzed for single-stranded conformational polymorphisms (SSCPs). Abnormal SSCPs were sequenced and revealed eight mutations. These consisted of three nonsense mutations (Arg34Stop, Arg648Stop, Arg704Stop), four deletions involving codons 40, 86, 157, and 241, and one acceptor splice consensus sequence mutation tgcag --> tgaag. The mutations were confirmed either by restriction endonuclease or sequence-specific oligonucleotide hybridization analysis. In addition, an analysis of 110 alleles from 74 unrelated normal individuals demonstrated that the DNA sequence changes were not common polymorphisms. All of the mutations predict truncated chloride channels that are likely to result in a functional loss. Thus, our findings expand the spectrum of CLCN5 mutations associated with Dent's disease and the results will help to elucidate further the functional domains of this novel chloride channel.

The role of the mesangial cell and its matrix in the pathogenesis of diabetic nephropathy.

Mesangial cells are pericyte-like cells which are found the glomeruli of the kidney. It is well known that they have important contractile and synthetic properties regulating the function of the glomerulus. During diabetes the synthesis of various extracellular matrix (ECM) components by mesangial cells are increased. In recent years it has been recognized that degradation of ECM may also be decreased in diabetes, contributing to the process of mesangium accumulation. The major enzymes responsible for ECM degradation are a large group of enzymes collectively known as matrix metalloproteinases (MMPs). The physiology of MMPs is complex and their activity is tightly regulated at many levels. The MMPs are synthesized as proenzymes and require activation via catalytic cleavage to become fully active. In this regard it is of importance that the mesangial cell and its pericellular matrix have a very active plasminogen cascade that can liberate plasmin locally to mediate matrix degradation both directly and indirectly, by activating the MMPs. In addition, the MMPs are regulated by transforming growth factor beta (TGF-beta). There is evidence that each of these pathways regulating the matrix degradation is affected by the diabetic environment and this will be the subject of this contribution.

Effect of phospholipidic boundary lubrication in rigid and compliant hemiarthroplasty models.

Hemiarthroplasty may benefit from materials which produce lower friction and improved boundary lubrication protection during start-up conditions. The purpose of this study was to evaluate the effect of phospholipidic boundary lubrication in both rigid and compliant hemiarthroplasty. An in vitro model was designed to dissociate the relative contribution of implant material compliance and the presence of phospholipid to the overall friction of a hemiarthroplasty contact using bovine articular cartilage. Normal bovine articular cartilage was articulated against four flat materials using reciprocating motion: (a) borosilicate glass: (b) borosilicate glass coated with dipalmitoylphosphatidylcholine (DPPC); (c) polyurethane (PU) elastomer (Tecoflex SG93A, a medical-grade aliphatic thermoplastic PU, Thermedics Incorporated. Woburn, Massachusetts); and (d) surface-coated PU (Tecoflex SG93A substrate coated with lipid-attracting copolymer poly[methacryloyloxyethyl phosphorylcholine (MPC)-co-butyl methacrylate (BMA)]. Tests were conducted in physiologically simulated tribological conditions for a non-conformal point contact. Friction and lubrication analysis was performed using both static and kinetic coefficients of friction mu measured for each group as a function of time for a sliding distance of up to 60 m. Results showed that the inclusion of supplemental phospholipid, DPPC, on a rigid substrate significantly decreased mu in comparison with the control (cartilage-glass). Additionally, removal of phospholipid components from the articular cartilage surface produced a significantly greater start-up mu in comparison with normal cartilage at the test onset. The use of a material with a lower modulus resulted in lower mu for the entire duration of the test. Polyurethane elastomer coated with the lipid-attracting copolymer, poly(MPC-co-BMA), resulted in the lowest frictional response. As seen in this study, the improvement of low-modulus hemiarthroplasty may involve the optimization of chemical modification and incorporation of lipid-attracting MPC copolymers onto compliant materials. However, further tests are warranted to determine whether lipid-attracting MPC copolymers perform as well during long-time, in vivo wear studies.

Bicarbonate and bicarbonate/lactate peritoneal dialysis solutions for the treatment of infusion pain.

A randomized, double-blind, cross-over study was undertaken to determine the effects of novel bicarbonate (38 mM) and bicarbonate (25 mM)/lactate (15 mM) containing peritoneal dialysis (PD) solutions on infusion pain in patients who experienced inflow pain with conventional lactate (40 mM) solution. Pain was assessed using a verbal rating scale and the validated McGill Pain Questionnaire (MPQ). Eighteen patients were recruited to the study. Both novel solutions resulted in highly statistically significant reductions in inflow pain compared to the control lactate solution, as assessed with both the verbal rating scale and the MPQ. For all pain variables assessed, the bicarbonate/lactate solution was more effective than the bicarbonate solution in alleviating pain. In conclusion, both solutions reduced the infusion pain experienced with control solution, but the bicarbonate/lactate solution appears to be the most effective. In contrast to the most widespread current treatment, which is the manual injection of sodium bicarbonate, the bicarbonate/lactate solution does not have the associated increased risk of peritonitis.

Glycohaemoglobin: a crucial measurement in modern diabetes management. Progress towards standardisation and improved precision of measurement. Australian Diabetes Society, the Royal College of Pathologists of Australasia and the Australasian Association of Clinical Biochemists [consensus development conference].

There are currently four principal glycohaemoglobin assay techniques (ion-exchange chromatography, electrophoresis, affinity chromatography and immunoassay) and about 20 different methods that measure different glycated products and report different units. Standardisation will lead to all assays reporting results in a standard unit, the HbA1c percentage of total serum haemoglobin, and should be in place within the next one to three years. In the interim, clinicians using glycohaemoglobin assays should be aware that the ranges indicating good and poor glycaemic control can vary markedly between different assays. The reproducibility of some assays may be insufficient to provide definitive evidence of changes in glycaemic control. Some assays may be so imprecise that they are unable to separate patients with good and poor control. INTERIM RECOMMENDATIONS 1 The terminology to be used for the assay is glycohaemoglobin (GHb) assay (recommendation from the combined meetings of the International Federation of Clinical Chemistry [IFCC] Working Group on HbA1c standardisation and the American Association of Clinical Chemistry [AACC] Subcommittee on Glycohemoglobin). 2 The unit of measurement for GHb assays should be reported as %HbA1c (Diabetes Control and Complications Trial equivalent). 3 Other units, such as % total GHb or %HbA1, should not be used. Assays producing these units should be converted to %HbA1c reporting units. 4 Assays with high precision are highly desirable. The IFCC/AACC are currently recommending between-run coefficients of variation of less than 5% for manufacturers of kits and instruments. However, between-run coefficients of variation of less than 3% are far more clinically useful and therefore desirable.

Identification of common ligand binding determinants of the insulin and insulin-like growth factor 1 receptors. Insights into mechanisms of ligand binding.

Insulin and insulin-like growth factor 1 (IGF-1) are peptides that share nearly 50% sequence homology. However, although their cognate receptors also exhibit significant overall sequence homology, the affinity of each peptide for the non-cognate receptor is 2-3 orders of magnitude lower than for the cognate receptor. The molecular basis for this discrimination is unclear, as are the molecular mechanisms underlying ligand binding. We have recently identified a major ligand binding site of the insulin receptor by alanine scannning mutagenesis. These studies revealed that a number of amino acids critical for insulin binding are conserved in the IGF-1 receptor, suggesting that they may play a role in ligand binding. We therefore performed alanine mutagenesis of these amino acids to determine whether this is the case. cDNAs encoding alanine-substituted secreted recombinant IGF-1 receptors were expressed in 293 EBNA cells, and the ligand binding properties of the expressed proteins were evaluated. Mutation of Phe701 resulted in a receptor with undetectable IGF-1 binding; alanine substitution of the corresponding amino acid of the insulin receptor, Phe714, produces a 140-fold reduction in affinity for insulin. Mutation of Asp8, Asn11, Phe58, Phe692, Glu693, His697, and Asn698 produces a 3.5-6-fold reduction in affinity for IGF-1. In contrast, alanine mutation of the corresponding amino acids of the insulin receptor with the exception of Asp12 produces reductions in affinity that are 50-fold or greater. The affinity of insulin for these mutants relative to wild type receptor was similar to that of their relative affinity for IGF-1 with two exceptions; the IC50 values for insulin binding to the mutants of Arg10, which has normal affinity for IGF-1, and His697, which has a 6-fold reduction in affinity for IGF-1, were both at least 2 orders of magnitude greater than for wild type receptor. The Kd values for insulin of the corresponding alanine mutants of the insulin receptor, Arg14 and His710, are 2-3 orders of magnitude greater than for wild type receptor. However, in contrast, the relative affinity of des(25-30)[PheB25 alpha-carboxamide]insulin for these IGF-1 receptor mutants is reduced only 4- and 50-fold, respectively.

Analog binding properties of insulin receptor mutants. Identification of amino acids interacting with the COOH terminus of the B-chain of the insulin molecule.

Recent studies utilizing alanine scanning mutagenesis have identified a major ligand binding domain of the secreted recombinant insulin receptor composed of two subdomains, one between amino acids 1 and 120 and the other between amino acids 704 and 716. In order to obtain a more detailed characterization of these subdomains, we examined the binding of an insulin superanalog, des-(B25-30)-[His-A8, Asp-B10, Tyr-B25 alpha-carboxamide]insulin, to alanine mutants of the ligand binding determinants of these subdomains. cDNAs encoding mutant secreted recombinant receptors were transiently expressed in 293 EBNA cells, and the binding properties for this analog of the expressed receptors were evaluated. In general des-(B25-30)-[His-A8, Asp-B10, Tyr-B25 alpha-carboxamide]insulin binding correlated with insulin binding, suggesting that both peptides bound to the receptor in a similar manner. Alanine mutations of eight amino acids (Asn15, Phe64, Phe705, Glu706, Tyr708, Leu709, Asn711, and Phe714) of the receptor produced the most profound decreases in affinity for des-(B25-30)-[His-A8, Asp-B10, Tyr-B25 alpha-carboxamide]insulin, suggesting that interactions with these amino acids contributed the major part of the free energy of the ligand-receptor interaction. Mutation of Arg14 and His710 to Ala produced receptors with undetectable insulin binding but an affinity for des-(B25-30)-[His-A8, Asp-B10, Tyr-B25 alpha-carboxamide]insulin only 8-23-fold less than for native receptor. Further analog studies were performed to elucidate this paradox. The receptor binding potencies of His-A8 and Asp-B10 insulins for these receptor mutants appeared to parallel their relative potencies for native receptor. In contrast the receptor binding potency of des-(B25-30)-[Tyr-B25 alpha-carboxamide]insulin was disproportionately increased for these mutants when compared with its potency for native receptor.

Evaluation of the frictional properties of an elastomer with enhanced lipid-adsorbing ability.

Wear particle production in load-bearing orthopaedic implants is one of the major factors currently limiting the service life of the implant. Most of the research carried out to date in attempting to solve this problem has used the approach of finding more wear-resistant biocompatible material pairs. In contrast, other researchers have attempted to reduce wear by encouraging elastohydrodynamic film formation through the use of elastomeric bearing surfaces. Unfortunately, these elastomeric bearing surfaces have poor tribological properties when a fluid film is not present. Boundary lubrication of an elastomeric orthopaedic bearing may alleviate some of these difficulties. The purpose of this research was to fabricate and characterize an elastomeric material that had a surface capable of specifically adsorbing a naturally occurring boundary lubricant. Dipalmitoyl phosphatidylcholine (DPPC) has been previously shown to be able to act as a boundary lubricant at stresses that occur in human load-bearing joints such as the hip and knee; therefore, DPPC was chosen for use in this study. It was expected that in an aqueous liposome suspension the static coefficient of friction microseconds of such a material would be lower, and increase less quickly over time, than a similar material without an ability to adsorb specifically DPPC when articulated against a polished chrome steel ball bearing. The lipid-adsorbing elastomer did not possess the desired tribological properties. This result was attributed to the polymer adsorbing the DPPC in the liposome phase and not in the bilayer phase, and interaction among the polymeric surface, DPPC and water. This approach to lubricating orthopaedic bearings was shown to have some merit, but a great deal of work needs to be done before such an approach can be used on a clinically available material.

Peritoneal dialysis kinetic modeling: validation in a multicenter clinical study.

OBJECTIVE: To clinically validate the use of a computer-based kinetic model for peritoneal dialysis (PD) by assessing the level of agreement between measured and modeled values of urea and creatinine clearances and ultrafiltration (UF). DESIGN: An open multicenter observational study. PATIENTS: There were 111 adult continuous ambulatory peritoneal dialysis (CAPD) patients (47 female, 64 male) in four centers. All patients underwent a four-hour peritoneal equilibration test (PET) using 2.5% dextrose but with variable fill volumes (range: 1-3 L). Patients with a residual renal function greater than 10 mL/min were excluded. MAIN OUTCOME MEASURES: Correlations and limits of agreement between measured and modeled values of total weekly urea KT/V, total weekly normalized creatinine clearance (L/week/1.73 m2), daily drain volume (L), net ultrafiltration (L), daily peritoneal urea clearance (L/day), and daily peritoneal creatinine clearance (L/day). Measured values were obtained from 24-hour urine and dialysate collections while modeled values were based on results from the PET in combination with the PD ADEQUEST kinetic program. RESULTS: The results show there is excellent agreement between measured and modeled urea KT/V and creatinine clearances, with concordance correlations of 0.94 and 0.92, respectively. Given the excessive variation and limited range in ultrafiltration values, the concordance correlation between measured and modeled UF was only 0.50. In terms of daily peritoneal clearances and ultrafiltration, the level of precision (i.e., standard deviation) in the differences between modeled and measured values is +/- 1.05 L/day for urea clearance +/- 1.03 L/day for creatinine clearance, and +/- 0.919 L/day for ultrafiltration. By contrast, the level of precision (i.e., standard deviation) in the differences between two measured values is estimated to be +/- 0.979 L/day for urea clearance, +/- 0.802 L/day for creatinine clearance, and +/- 0.707 L/day for ultrafiltration. Defining the limits of clinical agreement to be +/- 2 standard deviations of the differences between two clinically measured 24-hour clearances (or ultrafiltration), we find that 94% of the modeled urea clearances, 87% of the modeled creatinine clearances, and 86% of the modeled ultrafiltration values fall within the limits of clinical agreement. CONCLUSION: Data for a carefully performed PET and overnight exchange can, in combination with a scientifically validated kinetic model, provide clinicians with a powerful mathematical tool for use in CAPD dialysis prescription management. Although not intended to replace actual measurements, kinetic modeling can prove useful as a means for predicting clearances for various alternative prescriptions and perhaps also as a means for checking certain types of noncompliance.

Fabrication and characterization of dipalmitoylphosphatidylcholine-attracting elastomeric material for joint replacements.

Wear debris associated with the polyethylene components of total joint replacements has been shown to induce bone resorption which contributes to implant loosening. In an effort to promote lubrication and reduce wear in artificial hip joints, the use of the cushion bearing concept has been proposed previously; however, an elastomeric material tested as a cushion bearing has been shown to have poor tribological properties during initiation of motion from rest. The goal of this project was to fabricate and characterize an elastomer that has the ability to attract to its surface naturally occurring boundary lubricants from an aqueous solution. The test elastomer and appropriate controls were characterized using fluorescence, electron spin resonance and X-ray photoelectron spectroscopy. The test elastomer was found to have an enhanced ability to attract dipalmitoylphosphatidylcholine, a known physiological boundary lubricant. A cushion bearing that also encourages boundary lubrication represents a potential improvement over currently existing orthopaedic implant-bearing materials.

The Miller procedure for mobile flat feet.

We studied the long-term results of the Miller operation at a mean age of 13 years in 22 patients (38 feet) with persistently symptomatic mobile flat feet associated with an isolated naviculocuneiform break. At a mean of 12 years (3 to 27) after surgery, 84% of the feet had a satisfactory clinical result. We conclude that the Miller operation is a useful procedure for adolescent patients with persistently symptomatic flat feet with an isolated break at the naviculocuneiform joint.

Mapping of an NH2-terminal ligand binding site of the insulin receptor by alanine scanning mutagenesis.

Affinity labeling studies and mutational analyses have implicated the involvement of a predicted domain of the insulin receptor (L1, amino acids 1-119) in ligand binding. In order to obtain a higher resolution localization of this ligand binding site, we have performed alanine scanning mutagenesis of this domain. Alanine mutant cDNAs encoding a secreted recombinant insulin receptor extracellular domain were expressed transiently in adenovirus transformed human embryonic kidney cells and the affinity of the expressed receptor for insulin was determined. Mutation of 14 amino acids located in four discontinuous peptide segments to alanine was disruptive of insulin binding: Segment 1, amino acids 12-15; Segment 2, amino acids 34-44; Segment 3, amino acids 64-67; and Segment 4, amino acids 89-91. The quantitative contribution of the four segments to the free energy of insulin binding was 1 > 3 > 2 > 4. Of the 14 amino acids whose mutation compromised insulin binding, 3 are charged, 3 hydrophobic, 5 aromatic, and 3 are amides.

Changes in glycogen metabolism in liver of gold thioglucose injected mice during the development of obesity.

A study of glycogen metabolism in the liver has been carried out in gold thioglucose (GTG) injected mice during the development of obesity. In GTG obese mice, overt obesity, hyperglycaemia and hyperinsulinaemia had developed by 6 weeks after the injection of GTG. Beyond 6 weeks after GTG injection, the gain of body weight and increment in serum glucose and insulin levels with age in obese mice were not obvious when compared with those of age-matched control animals. The glycogen concentration, total glycogen storage, activity of glycogen synthase R and activity of phosphorylase a in the liver from GTG obese mice were significantly greater than those in lean mice from 2-4 weeks after GTG injection and remained higher thereafter. These results demonstrate that the increased liver glycogen storage and increased activity of glycogen synthase and phosphorylase occur early in the development of obesity and at a similar time to previously reported increases in pyruvate dehydrogenase activity (Caterson et al. (1987) Biochem. J. 243, 549-553) and lipid synthesis in liver (Cooney et al. (1989) Biochem. J. 259, 651-657). The emergence of these abnormalities in glycogen metabolism early in the development of obesity may contribute to the establishment of glucose intolerance and insulin resistance in this model of obesity which became apparent at approximately the same time after GTG injection.

Insulin-resistant diabetes during growth hormone therapy in a child with SHORT syndrome.

We report the case of a 13-year-old boy with SHORT syndrome, including lipoatrophy and insulin resistance, who developed diabetes mellitus while receiving growth hormone therapy. The diabetes persisted after cessation of exogenous growth hormone but oral hypoglycaemic therapy was successful and could be discontinued eight months later.