Biochemical assessment and clinical evaluation of a non-ionic adsorbent resin in patients with intractable jaundice

We investigated in vitro and in vivo the ability of a non-ionic adsorbing resin (styrenedivinylbenzene copolymer) to remove bilirubin and bile acids from human plasma. In preliminary experiments, human plasma from healthy donors, enriched in conjugated bile acids and bilirubin, and pooled plasma from jaundiced patients were recirculated through the resin column. The removal of bilirubin and bile acids was evaluated at two different flow rates (200 ml/min and 40 ml/min), and compared to an activated charcoal column. Four patients with severe jaundice were subsequently treated by 4-hour plasmaperfusion through the resin. The in vitro studies showed that after 1 hour the removal of bile acids was almost complete and bilirubin level decreased significantly, reaching a plateau after 4 hours. In the in vivo study, all treatments were well tolerated. After plasmaperfusion, serum bile acid levels decreased by 64.9-94.6% and total bilirubin by 35.3-57.7%. No clinical or biochemical side effects were observed. Our data suggest that plasmaperfusion through this resin is safe and efficient for removal of bilirubin and bile acids in jaundiced patients. Thus, it may serve as a method of artificial liver support in the treatment of cholestatic syndromes.     

Ultrastructural analysis of human proximal tubules and cortical interstitium in chronic renal disease (Hydronephrosis)

Summary A systematic ultrastructural analysis of proximal tubule atrophy and cortical interstitial changes was carried out in human chronic nephropathy. The investigation was based on human hydronephrotic kidneys, which had been surgically removed and subsequently perfusion-fixed for light and electron microscopy. Normal kidney tissue, which was derived from nephrectomy specimens with pathological changes confined to part of the kidney or to the renal pelvis, was used for control material. A slight degree of proximal tubule atrophy was characterized by reduction of mitochondria and basolateral membranes, enlargement of large endocytic vacuoles and increased numbers of lysosomes containing lamellar material. In moderate atrophy these changes were further accentuated, and in addition there was an increasing loss of microvilli and a reduction of endocytic invaginations and small endocytic vacuoles. In severe atrophy all types of organelles were sparse and the architecture of the tubule cells greatly simplified. A distinctive feature of atrophic tubules was the presence in the tubule cells of large bundles of actin-like filaments, which were often associated with outpouchings of basal cell parts and basement membrane. The reduction of mitochondria and basolateral cell membranes and the changes of endocytic vacuoles and lysosomes indicate that proximal tubule atrophy also in early stages may be associated with impairment of tubular transport processes. Comparisons with previous observations in various types of experimentally induced tubule cell degeneration and with the ultrastructure of regenerating proximal tubule cells provide some evidence that degenerative changes as well as imperfect regeneration of tubule cells may contribute to the alterations of ultrastructure in tubular atrophy. It is suggested that changes of the cortical interstitium may be of pathogenic importance for the progression of tubular atrophy by altering the spatial relationships between tubules and capillaries.This work was supported by grants from the Danish Medical Research Council (no 12-0528) and from the Research Foundation at the University of Aarhus.     

Effect of graded bilirubin loads on bilirubin transport by perfused rat liver.

Features of hepatic bilirubin transport were studied with the isolated perfused rat liver. Male Wistar rats weighing 350-400 g were used as liver donors. When bilirubin was constantly infused into the perfusion medium, which contained sheep erythrocytes and 3.0 g/100 ml bovine serum albumin, the maximal excretion rate for bilirubin was 14.4 +/- 1.2 mug/min per g liver. Over a wide range of constant bilirubin infusion rates which went as high as 25.9 mug/min per g liver, there was no effect on bile flow, bile acid excretion, or the pattern of bilirubin conjugates in bile. The hepatic extraction efficiency for unconjugated bilirubin from the perfusate also remained constant averaging 26%. However, when bolus injections of bilirubin were used to produce higher levels of unconjugated bilirubin in the perfusate than could be attained during constant infusion, the disappearance rate of [14C]bilirubin from the perfusate decreased with increasing bilirubin concentrations. This was consistent with saturation of the hepatic removal of unconjugated bilirubin.     

Biochemical assessment and clinical evaluation of a bilirubin adsorbent column (BR-350) in critically ill patients with intractable jaundice.

We investigated the efficacy of an anion-exchange adsorbent column (ASAHI BR-350, DIAMED) for removal of bilirubin and bile acids in five patients with intractable jaundice of various origin. Four litres of plasma were separated by membrane plasma separation (Plasmaflow OP-05) at a rate of 22.5 ml/min. The plasma was then perfused through an anion exchange adsorbent and returned to the venous blood line of the plasma separation. In some of the patients this procedure was combined with regular hemodialysis treatment. The concentration of total bilirubin was cut by 31 to 60%; total bile acids were reduced by 20 to 74%. Three patients recovered and had a favourable outcome. Two patients died despite the bilirubin adsorption treatment. The effects of the adsorbent column on specific blood parameters, including the coagulation system, were measured. Our data suggest that bilirubin adsorption should be examined further as a treatment for critically ill patients with intractable jaundice.     

Renal secretion of [35-S]furosemide and depression by albumin binding.

It was determined by use of [35-S]furosemide and an ultrafiltration procedure that furosemide is bound extensively to bovine serum albumin. When 500 muM furosemide and albumin at a concentration of 2.5 g/100 ml were used, approximately 90% of the drug was bound. With this same amount of furosemide, but with 3 times as much albumin, binding was about 98%. Using a 25-fold lower concentration of furosemide, 20 muM, binding was nearly 98% with 2.5 g albumin/100 ml, and was over 98% with 7.5 g albumin/100 ml. These same concentrations of furosemide and albumin were used to investigate the excretory and secretory rates of [35-S]furosemide in the isolated perfused rat kidney. Tubular clearance (i.e., secretion) of [35-S]furosemide was inversely related to the concentration of albumin in the perfusate. In kidneys perfused without albumin, tubular clearance of the drug was 6-20 times that found when 2.5 or 7.5 g albumin/100 ml, respectively, was used. Probenecid, with or without albumin, reduced the clearance of furosemide to that of its filtration rate. It is concluded that at physiological albumin concentrations, a very small fraction of circulating furosemide will be available for filtration, and tubular-fluid and urinary furosemide will arise predominantly from secretion. Because of extensive binding of furosemide to albumin, the renal secretory process itself is depressed, and the rate of secretion will be dependent, in part, on the concentration of unbound drug.     

Uptake of unconjugated bilirubin by isolated rat hepatocytes.

The mechanism responsible for the hepatic uptake of unconjugated bilirubin was examined in isolated rat hepatocytes from control and phenobartital-pretreated rats. The uptake was extremely rapid and the equilibrium between cell and medium was attained within 60 s with a 100-fold higher concentration in the cell than the medium. The initial velocity of uptake (Vo) exhibited a linear relationship to the bilirubin concentration in the medium. Pretreatment of cells with various metabolic inhibitors had no effect on the uptake of unconjugated bilirubin. Ouabain did significantly decrease Vo, but replacement of sodium ion with choline or lithium had no effect on bilirubin uptake. The organic acids sulfobromophthalein (112 muM) and taurocholic acid (50 (muM) and two steroidal compounds, diethylstilbestrol (50 muM) and spironolactone (50 muM), had no effect on the uptake of bilirubin. It is suggested that bilirubin gains access to the hepatocyte interior by passive diffusion into and through the lipid membrane and that intracellular binding may explain the high degree of bilirubin accumulation associated with the isolated hepatocytes.     

Artificial liver support for postoperative hepatic failure with anion exchange resin (BR-601)

An artificial liver support system for plasma exchange and plasma perfusion through BR-601 resin using a membrane separator was applied to 5 patients with postoperative liver failure. Percent absorption of total and direct bilirubin, and of bile acids were 77.1 +/- 6.4, 78.4 +/- 6.1, and 93.4 +/- 3.6%, respectively, when 250 ml of plasma was treated. Percent reductions in total and direct bilirubin, and in bile acids were 24.5 +/- 5.8, 25.5 +/- 5.8 and 30.9 +/- 8.5%, respectively. In contrast, percent reductions in total and direct bilirubin, and in bile acids by plasma exchange were 30.9 +/- 13.3, 34.5 +/- 12.5 and 24.2 +/- 8.5%, respectively. The coma grade was improved in 4 out of 5 cases, but unfortunately the patients did not recover. In conclusion, plasma perfusion through BR-601 resin is expected to play a promising role in artificial liver support systems because of its capacity to absorb bilirubin and bile acids.     

Axial heterogeneity in the handling of albumin by the rabbit proximal tubule

Morphologic and physiologic studies have established that filtered proteins are absorbed in the proximal tubule by endocytosis and transported to the lysosomes for degradation. The tubular absorption, hydrolysis and accumulation of albumin were examined in all three segments of the rabbit proximal tubule. S1, S2 and S3 segments were dissected and perfused in vitro with tritiated albumin at a physiologic concentration of 0.0364 mg/ml, and with [14C]inulin to determine fluid reabsorption. In addition, the three segments were fixed for ultrastructural examination after perfusion under conditions similar to those in the physiologic studies. The fluid reabsorption was similar in S1 and S2 but lower in S3. Albumin absorption was unexpectedly similar in the three segments. A lower percentage of absorbed albumin was hydrolyzed in the S3 segment compared with the earlier segments. The values were 70 +/- 15%, 61 +/- 11%, and 30 +/- 4% for S1, S2, and S3, respectively. The cellular accumulation of protein was highest in the S3 segment. The ultrastructure of the three segments was similar to that described in in vivo preserved kidneys, and no abnormalities were observed in the endocytic-lysosomal compartment. These results reveal axial heterogeneity in the hydrolysis of absorbed albumin by the rabbit proximal tubule and suggest that under normal physiologic conditions the S3 segment has a lower lysosomal proteolytic activity. Although the S3 segment maintains a high capacity for protein absorption, the earlier proximal segments likely have a greater role in protein degradation.     

Ultrastructure of isolated perfused proximal tubules from rabbit kidney. A comparison with proximal tubules fixed by perfusion in vivo

This study was carried out to determine whether the ultrastructure of proximal tubules isolated and perfused in vitro was comparable to the ultrastructure of tubules fixed by perfusion in vivo. The kidneys of female white rabbits were either fixed by perfusion in vivo with glutaraldehyde (controls) or removed for dissection (experimentals) of proximal convoluted tubules and late proximal straight tubules. The isolated tubules were perfused in vitro with Krebs-Ringers bicarbonate solution for 1 hour after which the tubules were fixed with glutaraldehyde. The experimental tubules and the control tubules were processed for electron microscopy, compared qualitatively, and analyzed morphometrically to evaluate the volume densities and surface densities of different cell organelles and the cell membrane. Qualitatively, there were no differences in the appearance of cell organelles in experimental tubules and control tubules, except that cells in some experimental tubules accumulated small lipid droplets which were located close to mitochondria. Only a few quantitative changes were found, the most noteworthy being a 40% decreased surface density of the brush border in experimental proximal convoluted tubules and late proximal straight tubules. Damaged experimental tubules showed an increased number of vacuoles in the inverted microscope. In the electron microscope the vacuoles corresponded to swollen and disintegrated mitochondria and enlarged endocytic vacuoles. However, small degrees of tubular damage were not observable in the inverted microscope, as very small vacuoles could only be seen in the electron microscope. The results show that proximal tubules can be dissected and perfused in vitro for 1 hour without major ultrastructural changes. It should be emphasized that tubules showing an increased vacuolization in the inverted microscope may be damaged and, thus, not function optimally, and even if the tubules appear undamaged in the light microscope they may show signs of cellular degeneration in the electron microscope.     

Renal excretion of uric acid in the rat: a micropuncture and microperfusion study.

Free-flow micropuncture experiments were done in rats of three strains infused with small amounts of urate [plasma urate (P urate) = 95 +/- 8 muM]. Urate concentrations in tubular fluid were measured by an accurate chemical fluorometric ultramicromethod. In fluid from surface glomeruli, the glomerular fluid-to-plasma urate ratio [GF/P) urate] was 0.99 +/- 0.03 (n=11), i.e., lower than expected for total ultrafiltrability of plasma urate. Along proximal convolutions, net reabsorption of 55% of filtered urate was demonstrated. Small amounts of urate may have been reabsorbed between late proximal and early distal sites. Net transepithelial movements of urate did not occur in distal tubules or collecting ducts. In microperfusion experiments on proximal tubules, both a reabsorptive flow of urate (loss of perfused [2-14C]urate) and a secretory flow (entrance of cold urate into perfusate) of the same order of magnitude were demonstrated. Neither flow was influenced by simultaneous water movements. Microperfusion of Henle's loops indicated a significant but very small net reabsorption.     

Renal proximal tubular acidification. Role of brush-border and cytoplasmic carbonic anhydrase

Carbonic anhydrase is found in the cytoplasm and brush border membranes of renal proximal tubular cells. Both the soluble and the membrane-bound enzyme have been assigned roles for the secretion of hydrogen ions into the tubular fluid and hence also for the reabsorption of bicarbonate. Attempts were made to differentiate between the roles of these enzymes for the rate of proximal tubular acidification. Proximal tubules of rats were instilled and perfused with bicarbonate solutions containing carbonic anhydrase inhibitors, especially designed to be impermeable to cell membranes. The acidification rate was measured with an antimony micro-electrode system–the only instantly responding micro-pH electrode. The membrane impermeable inhibitors had no effect on this rate in contrast to acetazolamide, which markedly inhibited the acidification rate when administered in-traluminally. It is therefore concluded that the cytoplasmic carbonic anhydrase is the important enzyme for the proximal tubular acidification rate, and hence the rate of bicarbonate reabsorption. The function of the brush border enzyme remains an outstanding problem.     

Collecting duct function in liver cirrhotic rats with early sodium retention

Liver cirrhosis is a chronic disease associated with sodium retention due to increased tubular sodium reabsorption. However, the exact tubular site of increased sodium reabsorption in uncertain. We have recently demonstrated selective hypertrophy of the inner stripe of the outer medulla (ISOM) in rats with liver cirrhosis induced by common bile duct ligation (CBL). The present study was designed in order to measure Na-K-ATPase activity in the two major tubular segments located in the ISOM: the thick ascending limb of henles (MTAL) and the collecting ducts (OMCD) in CBL rats. Sham-operated rats were used as controls. In addition, the natriuretic response to amiloride (0.2 mg kg(-1) h(-1) i.v) was examined in conscious, chronically instrumented rats during conditions where amiloride-induced volume losses were replaced continuously using a servo-controlled i.v. volume replacement system. For 4-5 weeks after CBL, cirrhotic rats showed sodium retention relative to control rats without any sign of ascites. Plasma levels of sodium and aldosterone were normal, but plasma vasopressin was increased. Effective renal plasma flow was significantly increased, whereas glomerular filtration rate (GFR) and renal lithium handling were normal. The CBL rats showed a blunted natriuretic response to amiloride (DeltaFE(Na): 1.17 +/- 0.15% vs. 1.65 +/- 0.13%; P < 0.05). In rats with CBL, Na-K-ATPase activity per mm tubular length was decreased in the OMCD and unchanged in the TAL segment. These results suggest that increased tubular sodium reabsorption in liver cirrhotic rats with early sodium retention is localized in segments proximal to the collecting ducts.     

Renal proximal tubular acidification. Role of brush-border and cytoplasmic carbonic anhydrase.

Carbonic anhydrase is found in the cytoplasm and brush border membranes of renal proximal tubular cells. Both the soluble and the membrane-bound enzyme have been assigned roles for the secretion of hydrogen ions into the tubular fluid and hence also for the reabsorption of bicarbonate. Attempts were made to differentiate between the roles of these enzymes for the rate of proximal tubular acidification. Proximal tubules of rats were instilled and perfused with bicarbonate solutions containing carbonic anhydrase inhibitors, especially designed to be impermeable to cell membranes. The acidification rate was measured with an antimony micro-electrode system--the only instantly responding micro-pH electrode. The membrane impermeable inhibitors had no effect on this rate in contrast to acetazolamide, which markedly inhibited the acidification rate when administered intraluminally. It is therefore concluded that the cytoplasmic carbonic anhydrase is the important enzyme for the proximal tubular acidification rate, and hence the rate of bicarbonate reabsorption. The function of the brush border enzyme remains an outstanding problem.     

Studies on the binding characteristics of antimycin A and albumin in relation to the inhibitor activity of the complex on rat proximal tubular sodium transport

As reported previously [11] Antimycin A is effective in inhibiting sodium transport of the proximal tubule only when applied to the luminal side and in the presence of albumin. Therefore the interaction of Antimycin A with albumin was examined with the technique of equilibrium dialysis. It was found that Antimycin A was bound to albumin at five sites with a dissociation constant of 2.5 X 10(-6) M. This finding suggests that Antimycin A is taken up by the tubular cell as an Antimycin A/albumin complex via pinocytosis. In the pinocytotic vesicle this complex probably dissociates, and free Antimycin A is released into the cytoplasm where it can reach it's sites of action in the mitochondria and at the plasma membrane. This uptake mechanism might provide a general method to incorporate substances into the cell which do not penetrate the plasma membrane.     

Quantitative ultrastructure of human proximal tubules and cortical interstitium in chronic renal disease (hydronephrosis)

Summary Surgically removed perfusion-fixed human kidneys with chronic renal disease (hydronephrosis) were studied by electron microscopy in order to determine whether there is a quantitative relationship between ultrastructural changes in proximal tubules in atrophy and changes in the surrounding cortical interstitium. Morphometric techniques were applied to montages of electron micrographs each covering several tubular profiles in the cortical labyrinth and to montages representing cross-sections of individual proximal convoluted tubules at a higher magnification. In order to enable a quantification of the spatial relations between individual tubular cross-sections and adjacent peritubular capillaries a tubulo-capillary index (TCI) was defined. This index was based on the mean distances between individual tubular cross-sections and adjacent peritubular capillaries and on the fraction of tubular circumference facing capillaries. Normal tissue from similarly fixed human nephrectomy specimens, which had been removed mainly because of neoplastic disorders, served as control material. In the hydronephrotic kidneys the relative volume of cortical interstitium (excluding capillaries) covered a range from 19.2–70.3%. Inverse correlations were demonstrated between the relative volume of cortical interstitium and various structural variables of proximal convoluted tubules, including tubular wall volume, the volume of mitochondria and the surface area of basolateral membranes. The TCI showed positive correlations with these tubular variables. No significant correlation was found between the volume fractions of cortical interstitium and capillaries. Finally, it was found that an increase in the volume fraction of the cortical interstitium from 16.2% in controls to 24.7% in cortical areas of hydronephrotic kidneys was associated with a 40–50% reduction in the volume of mitochondria and in the surface area of basolateral membranes in proximal tubules. The results are consistent with a pathogenic interrelationship between tubular and interstitial changes. An important factor in this relationship might be disturbed topographic associations between tubules and blood capillaries caused by the increase in cortical interstitium. The results further show that even slight increases in the cortical interstitial volume are associated with significant quantitative changes in tubular fine structure suggesting impaired tubular functions.This work was supported by grants from the Danish Medical Research Council (no 12-0528) and from the Research Foundation at the University of Aarhus     

Quantitative relationship of renal glucose and sodium reabsorption during ECF expansion.

To investigate the quantitative relationship between glucose and sodium reabsorption during extracellular fluid (ECF) expansion and to examine the possible contribution to glucosuria of passive diffusion of glucose from peritubular blood to tubular fluid, renal clearance studies were carried out in dogs. It was found that ECF expansion with isotonic saline or Ringer solution causes a decrease in the maximal rate of glucose reabsorption (TmGlc), which is inversely and linearly related to fractional sodium excretion (FENa) over a range from less than 1% more than 25% FENa (r equals -0.394, P less than 0.001). A continuous relationship between TmGlc and FENa could be demonstrated as the ECF was expanded in individual animals as well as in pooled data. Infusion of albumin solution to preferentially expand the plasma volume and decrease proximal tubular sodium reabsorption produced a 24% fall in TmGlc suggesting that the proximal tubule is the site of interrelated glucose and sodium reabsorption. After pulse injections into the renal artery, [14-C]glucose and insulin had the same appearance time in the urine, thus failing to demonstrate diffusion of glucose from blood into the tubule in saline-loaded dogs as well as in dogs in normal sodium balance. It is suggested that ECF expansion exerts its effect on glucose reabsorption by inhibiting the coupled transport of glucose and sodium across the epithelium of the renal proximal tubule.     

Cellular mechanism of ischemic acute renal failure: Role of Ca2+ and calcium entry blockers

Summary This presentation briefly reviews the cellular mechanism of ischemic acute renal failure (ARF) with particular emphasis on the role of Ca²⁺ and calcium entry blockers (CEB). Vascular consequences of an ischemic renal insult including vasoconstriction, diminished glomerular permeability, loss of autoregulation, and hypersensitivity to renal nerve stimulation may relate to increased cellular Ca²⁺ concentration in the renal afferent arteriole and glomerular mesangial cells. Evidence is also presented that the ischemic injury to tubular plasma membranes is associated with increased Ca²⁺ uptake. With an ischemic insult of a short duration, the renal mitochondria are able to buffer the increased cellular Ca²⁺. However, after an ischemic insult of long duration, the Ca²⁺ overloaded mitochondria deteriorate, adenosine triphosphate (ATP) synthesis decreases, and cell death follows. If a sufficient number of renal tubular cells undergo this cell death, tubular obstruction, i.e. the maintenance phase of ARF, occurs.     

The clinical importance of a protein-bound fraction of serum bilirubin in patients with hyperbilirubinemia

A directly reacting fraction of bilirubin that is probably covalently bound to albumin (albumin-bound bilirubin) has recently been described. To determine its clinical importance we used a new high-performance liquid-chromatography technique to measure it in the serum of 200 patients with hyperbilirubinemia from various causes. Albumin-bound bilirubin was an important fraction (8 to 90 per cent) of total bilirubin in patients with hepatocellular and cholestatic jaundice as well as in patients with the Dubin-Johnson syndrome. It was not detected in normal volunteers, neonates with physiologic jaundice, or patients with Gilbert's disease or hemolysis. Thus, albumin-bound bilirubin appears in serum when hepatic excretion of conjugated bilirubin is impaired. It becomes a larger component of serum bilirubin as jaundice subsides, delaying resolution of this disorder and causing bilirubin to persist in plasma after it has disappeared from the urine.     

Glomerular filtration in the isolated perfused kidney

Glomerular hemodynamics were studied of isolated perfused kidneys of 12-wk-old normotensive (NR) and spontaneously hypertensive (SHR) rats, using Pluronic F108 (BASF, Wyandotte, MI, USA) as a plasma expander. Glomerular filtration rate (GFR), proximal tubular hydrostatic pressure (PT) and glomerular capillary hydrostatic pressure (PGC) were approximately linearly related with renal perfusion pressure. PGC measured directly by micropuncture was comparable to PGC calculated from other parameters of glomerular dynamics using pore theory. We conclude that GFR in isolated kidneys perfused with Pluronic F108 is lower than in vivo, mainly as a result of an increase in PT. This rise in tubular pressure is due to an increased urine flow rate and an elevated tubular fluid viscosity. The difference in glomerular dynamics between NR and SHR kidneys is the result of an increased preglomerular vascular resistance in SHR, possibly due to an adaptive hypertrophic reaction to a sustained hypertension.     

被动型Heymann肾炎模型的建立及其发病机制的探讨

从正常大鼠肾小管刷状缘微绒毛上提取致病的小管抗原(Tub-Ag)免疫白兔可获得相应的抗血清。给大鼠被动注射此种抗血清后5分钟荧光检测即可见鼠肾小球毛细血管壁上出现兔抗体IgG。约1周后,实验鼠便产生了典型的膜性肾炎样的临床及病理学改变。应用小管抗体(Tub-Ab)进行鼠肾动脉灌注实验,结果表明:在缺乏CIC的情况下,灌注的抗体能与GBM上皮侧、裂隙孔等处结合,IC出现的部位与PHN大鼠IC的位置基本相似。上述实验均提示:PHN的发病机制乃是Tub-Ab与肾小球中固定的抗原直接结合,进而导致上皮下IC原位形成。