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Exocytotic stimulation promotes association of the ADP-ribosylation factor with PC12 cell membranes.

ADP-ribosylation factors (ARFs) are a family of small molecular, monomeric GTP-binding (G) proteins, initially identified by their ability to enhance cholera toxin (CTX) ADP-ribosyltransferase activity. ARFs have been implicated in protein transport and vesicle and endosome fusion. Although several reports show that synthetic peptides of the N-terminus of ARF inhibited Ca(2+)-dependent exocytosis in permeabilized adrenal chromaffin cells, the role of ARFs in exocytosis has not been established. In this study, we investigated the translocation of ARFs to the membrane fraction from the cytosol fraction in PC12 cells after exocytotic stimulation by measuring the immunoreactivity of ARFs (with anti-ARF anti-serum and with anti-ARF3 antibodies) and enzymatic ARF activity, which enhances the CTX effect. Both the immunoreactivity and the enzymatic activity of ARF in the membrane fraction increased about twofold, significantly, after exocytotic stimulation with ATP and KCl. The translocation of ARF and noradrenaline release was observed in the presence of extracellular CaCl2, but not in the absence of CaCl2. The ARF translocated to the membrane fraction after stimulation in intact cells seemed to be an inactive, perhaps is the GDP form, because ARF did not activate CTX in the absence of guanosine 5'-O-(thiotriphosphate) (GTP gamma S). As previously reported, ARF in the active, GTP gamma S-bound state bound to the membrane fractions. Thus ARF may have been active during translocation and inactivated later. The immunoreactivity of Gs alpha, one of the trimeric G proteins, was not changed before or after stimulation. These findings suggest that ARFs translocate to membranes from the cytosolic fraction after exocytotic stimulation in PC12 cells, and raise the possibility that ARFs regulate exocytosis.

ADP-Ribosylation Factors↗

Energy metabolism in exertional heat stroke with acute renal failure.

BACKGROUND: Heat stroke is the clinical syndrome produced when the body overheats. It can develop in the army and in healthy civilian populations who physically exert themselves in a hot and humid environment during the summer, and may result in a significant number of heat-related deaths. Since strenuous exercise is one of the major exacerbating and precipitating factors, the incidence of exertional heat stroke (ExHS) is high among military personnel undergoing military training. Furthermore, acute renal failure (ARF) may occur in 25% of patients with ExHS and it can cause metabolic alterations that affect amino acid, carbohydrate, and lipid metabolism. Adequate nutritional support is essential for the treatment of ARF. The most important determinant of nutrient requirement in ARF is the degree of hypercatabolism caused by disease associated with renal function impairment. Indirect calorimetry (IDCM) is the method by which metabolic rate is estimated from measurements of oxygen consumption and carbon dioxide production. It can also provide information about the type and rate of substrate utilization in vivo (protein, carbohydrate, and fat). METHOD: The present clinical study is a comprehensive analysis of metabolic changes which includes energy expenditure (EE) and substrate utilization in 10 patients with ExHS with ARF and 10 patients with exertional heat exhaustion (ExHE) by the use of IDCM. RESULTS: Serum urea nitrogen, creatinine, peak creatine phosphokinase levels and heart rate were significantly increased in ExHS patients during ARF stage. Serum albumin levels were significantly decreased in ExHS patients with ARF. Resting energy expenditure (REE) was increased in patients with ExHS induced ARF and was not correlated with body temperature (r = 0.421). The average increase in EE during ARF stage was about 24%. The respiratory quotient in patients with ExHS induced ARF was lower than that in normal subjects and also in patients with ExHE. Urea nitrogen appearance rate increased in patients with ExHS induced ARF and in patients with ExHE without ARF. The percentage of total REE derived from fat in ExHS induced ARF and ExHE increased, while in patients with ExHS induced ARF and ExHE, the percentages of total REE derived from carbohydrate and protein were lower than those in control subjects. CONCLUSIONS: The present results suggest that patients with exertional heat injury (both ExHS and ExHE) have hypermetabolism during the acute stage. Furthermore, patients with exertional heat-induced rhabdomyolysis and ARF have a moderately higher hypermetabolism than those without ARF during the acute stage. We believe that this mainly reflects a more pronounced reduction of the vital cell mass (muscle) in relation to body weight, and/or a compromised substrate oxidation in ExHS with ARF. Whether or not this subgroup of patients will require a higher energy/caloric support merits further investigation.

Acute Kidney Injury↗

Molecular aspects of the cellular activities of ADP-ribosylation factors.

Adenosine diphosphate-ribosylation factor (Arf) proteins are members of the Arf arm of the Ras superfamily of guanosine triphosphate (GTP)-binding proteins. Arfs are named for their activity as cofactors for cholera toxin-catalyzed adenosine diphosphate-ribosylation of the heterotrimeric G protein Gs. Physiologically, Arfs regulate membrane traffic and the actin cytoskeleton. Arfs function both constitutively within the secretory pathway and as targets of signal transduction in the cell periphery. In each case, the controlled binding and hydrolysis of GTP is critical to Arf function. The activities of some guanine nucleotide exchange factors (GEFs) and guanosine triphosphatase (GTPase)-activating proteins (GAPs) are stimulated by phosphoinositides, including phosphatidylinositol 3,4,5-trisphosphate (PIP3) and phosphatidylinositol 4,5-bisphosphate (PIP2), and phosphatidic acid (PA), likely providing both a means to respond to regulatory signals and a mechanism to coordinate GTP binding and hydrolysis. Arfs affect membrane traffic in part by recruiting coat proteins, including COPI and clathrin adaptor complexes, to membranes. However, Arf function likely involves many additional biochemical activities. Arf activates phospholipase D and phosphatidylinositol 4-phosphate 5-kinase with the consequent production of PA and PIP2, respectively. In addition to mediating Arf's effects on membrane traffic and the actin cytoskeleton, PA and PIP2 are involved in the regulation of Arf. Arf also works with Rho family proteins to affect the actin cytoskeleton. Several Arf-binding proteins suspected to be effectors have been identified in two-hybrid screens. Arf-dependent biochemical activities, actin cytoskeleton changes, and membrane trafficking may be integrally related. Understanding Arf's role in complex cellular functions such as protein secretion or cell movement will involve a description of the temporal and spatial coordination of these multiple Arf-dependent events.

ADP-Ribosylation Factors↗

Declining mortality in patients with acute renal failure, 1988 to 2002.

Despite improvements in intensive care and dialysis, some experts have concluded that outcomes associated with acute renal failure (ARF) have not improved significantly over time. ARF was studied in hospitalized patients between 1988 and 2002 using the Nationwide Inpatient Sample, a nationally representative sample of discharges from acute-care, nonfederal hospitals. During a 15-yr period, 5,563,381 discharges with ARF and 598,768 with ARF that required dialysis (ARF-D) were identified. Between 1988 and 2002, the incidence of ARF rose from 61 to 288 per 100,000 population; the incidence of ARF-D increased from 4 to 27 per 100,000 population. Between 1988 and 2002, in-hospital mortality declined steadily in patients with ARF (40.4 to 20.3%; P < 0.001) and in those with ARF-D (41.3 to 28.1%; P < 0.001). Compared with 1988 to 1992, the multivariable-adjusted odds ratio (OR) of death was lower in 1993 to 1997 (ARF: OR 0.62, 95% confidence interval [CI] 0.61 to 0.64; ARF-D: OR 0.63, 95% CI 0.59 to 0.66) and 1998 to 2002 (ARF: OR 0.40, 95% CI 0.39 to 0.41; ARF-D: OR 0.47, 95% CI 0.45 to 0.50). The percentage of patients who had ARF with a Deyo-Charlson comorbidity index of 3 or more increased from 16.4% in 1988 to 26.6% in 2002 (P < 0.001). This study provides evidence from an administrative database that the incidence of ARF and ARF-D is rising. Despite an increase in the degree of comorbidity, in-hospital mortality has declined.

Acute Kidney Injury↗

[Characteristics of acute renal failure in elderly patients admitted to a small town hospital].

We studied the features of acute renal failure (ARF) in elderly patients treated in a hospital, without an intensive care unit, to identify etiological factors and establish adequate preventive measures and treatment. During twelve consecutive months we studied prospectively 99 patients with ARF diagnosed by conventional criteria, an incidence of 1,238 cases per million per year. ARF affected 1.78% of patients admitted to hospital. We analyzed age, sex, serum creatinine, diuresis, etiology, type of ARF, preexisting chronic diseases, treatment, complications and outcome. Preexisting chronic diseases were common, the most frequent being hypertension (54%) and diabetes (39%). Previous treatments for cardiovascular diseases were frequent (angiotensin-renin system blockade 35.4%, diuretics 50.5%). 79% of ARF arose in hospital, 21% outside hospital. ARF was pre-renal in 60%, renal in 31% and post-renal in 9%. 34.7% were caused by volume depletion, 23.4% by low cardiac output and 23.4% by infection. 44.4% of ARF patients had oliguria or anuria latrogenic factors contributed to the ethiology of ARF in 35.3% of patients. Hospital stay was doubled by ARF the presence of ARF and the mortality was 36.4%. The rate was higher in ARF arising in hospital than in ARF acquired before admission. Factors that had a significant influence on the mortality rate were comorbid conditions, oliguroanuria, ARF of renal origin and serum albumin. We conclude that ARF has a high incidence, morbidity and mortality in this elderly population. Volume depletion, associated cardiovascular pathology and pharmacological treatment are important etiological factors in those with ARF outside hospital. Adequate treatment of ARF and avoidance of nephrotoxic medications are necessary in hospital.

Acute Kidney Injury↗

GTP hydrolysis by ADP-ribosylation factor is dependent on both an ADP-ribosylation factor GTPase-activating protein and acid phospholipids.

ADP-ribosylation factor (ARF) is a 21-kDa GTP binding protein that regulates eukaryotic membrane traffic. Both the binding and hydrolysis of GTP by ARF have been shown to be necessary for this function. However, purified mammalian ARF lacks intrinsic GTPase activity (< 0.0015 min-1). We document the presence, in bovine brain extracts, of a protein with the predicted properties for an ARF GTPase-activating protein (ARF GAP). This activity was highly dependent on phospholipids. An acid phospholipid fraction from bovine brain (containing primarily phosphatidylinositol 4,5-bisphosphate (PIP2), phosphatidylinositol 4-phosphate, phosphatidylinositol, and phosphatidylserine) had no effect on intrinsic GTPase activity of purified ARF but increased the ARF GAP activity of bovine brain homogenates about 8-fold. This dependence on acid phospholipids was retained after > 100-fold purification of ARF GAP, making it, likely, an inherent property of this reaction. PIP2 alone stimulated ARF GAP activity up to 30-fold with a half-maximal effect at 100-300 microM but had no effect on the GTPase rate of ARF alone. Phosphatidylinositol 4-phosphate was also active but had only 50% of the maximal effect and twice the EC50 of PIP2. Phosphatidylserine, phosphatidylethanolamine, phosphatidylcholine, phosphatidylinositol, and diacylglycerol either alone or in the presence of ARF GAP do not stimulate ARF GTPase activity. ARF proteins have been identified recently as regulators of phospholipase D. The product of the phospholipase D reaction, phosphatidic acid, stimulated ARF GAP approximately 5-fold and reduced the PIP2 concentration needed for GAP stimulation about 6-fold. The substrate of phospholipase D, phosphatidylcholine, inhibited ARF GAP activity, but this inhibition seen with phosphatidylcholine was partially reversed by phosphatidic acid. A feedback loop for the coordinate regulation of phospholipase D and ARF activities is proposed.

ADP-Ribosylation Factors↗

Differences in vascular reactivity in models of ischemic acute renal failure.

To determine the mechanism of observed differences in vasoreactivity in norepinephrine-induced (NE) and renal artery clamp (RAC) models of ischemic acute renal failure (ARF), induction renal blood flow (RBF) was measured and vascular reactivity examined one week thereafter in NE- and RAC-ARF rat kidneys that had identical levels of renal dysfunction. Morphology also was compared at 48 hours and one week. In NE-ARF, RBF was 14% during 90 minutes of induction and by 60 minutes post-NE infusion was only 18% of baseline. In contrast, in RAC-ARF RBF was effectively 0 for 75 minutes but returned to 95% of baseline by 60 minutes after clamp release. At one week there was a paradoxical increase in renovascular resistance (RVR) to renal perfusion pressure (RPP) reduction in the autoregulatory range and an augmented vasoconstriction to renal nerve stimulation (RNS) in NE-ARF, but no change in RVR and minimal reduction in RBF to these same respective stimuli in RAC-ARF (both different at P less than 0.001). NE-ARF were more sensitive to intrarenal norepinephrine than RAC-ARF kidneys (P less than 0.001). Neither NE- nor RAC-ARF kidneys responded to endothelium-dependent acetylcholine (ACh). Vasodilation to endothelium-independent prostacyclin (PGI2) in NE- was similar to sham-ARF, but there was an attenuated response in RAC-ARF kidneys (P less than 0.001). Morphology at 48 hours showed smooth muscle necrosis in half of the resistance vessels in RAC- but in less than 10% of those in NE-ARF. Except for a slightly greater frequency of tubular casts at 48 hours in RAC-ARF, tubular injury was indistinguishable. It is concluded that NE-ARF has evidence of a predominant functional endothelial vascular injury while RAC-ARF has both morphologic and functional evidence of a predominant smooth muscle injury. Differences in vascular injury between the two models, at least in part, may be the consequence of differences in severity of initial ischemia and/or the rates of recovery of RBF; however, an additional or separate toxic effect of infused NE cannot be excluded.

Acetylcholine↗

Guanine nucleotide exchange on ADP-ribosylation factors catalyzed by cytohesin-1 and its Sec7 domain.

ADP-ribosylation factors (ARFs) are 20-kDa guanine nucleotide-binding proteins that require specific guanine nucleotide-exchange proteins (GEPs) to accelerate the conversion of inactive ARF-GDP to active ARF-GTP. Cytohesin-1, a 46-kDa ARF GEP, contains a central Sec7 domain of 188 amino acids similar in sequence to a region of the yeast Sec7 protein. Cytohesin-1 and its 22-kDa Sec7 domain (C-1 Sec7), synthesized in Escherichia coli, were assayed with recombinant non-myristoylated ARFs and related proteins to compare their GEP activities. Both were effective with native mammalian ARFs 1 and 3. Cytohesin-1 accelerated GTPgammaS (guanosine 5'-3-O-(thio)triphosphate) binding to recombinant human ARF1 (rARF1), yeast ARF3, and ARD1 (a 64-kDa guanine nucleotide-binding protein containing a C-terminal ARF domain). In contrast, C-1 Sec7 enhanced GTPgammaS binding to recombinant human ARFs 1, 5, and 6; yeast ARFs 1, 2, and 3; ARD1; two ARD1 mutants that contain the ARF domain; and Delta13ARF1, which lacks the N-terminal alpha-helix. Neither C-1 Sec7 nor cytohesin-1 increased GTPgammaS binding to human ARF-like ARL proteins 1, 2, and 3. Thus, ARLs, initially differentiated from ARFs because of their inability to activate cholera toxin, differ also in their failure to interact functionally with C-1 Sec7 or cytohesin-1. As C-1 Sec7 was much less substrate-specific than cytohesin-1, it appears that structure outside of the Sec7 domain is important for ARF specificity. Data obtained with mutant ARF constructs are all consistent with the conclusion that the ARF N terminus is an important determinant of cytohesin-1 specificity.

ADP-Ribosylation Factor 1↗

L-arginine reduces tubular cell injury in acute post-ischaemic renal failure.

BACKGROUND: The pathophysiology of renal ischaemia, resulting in tubular cell injury and leading to acute renal failure (ARF), remains unclear. An ever-increasing number of investigations focus on a possible role of nitric oxide (NO) in regulating circulation during ARF. In this context, we investigated the influence of chronic stimulation or inhibition of NO synthesis, or both, on haemodynamic parameters, histology and plasma renin activity (PRA) after ischaemia-reperfusion injury of rat kidneys. METHODS: Experiments were performed on adult, male Wistar rats. Before induction of ARF, a group of animals was treated with a NO synthesis inhibitor (L-NAME) and another group was treated with a precursor of NO synthesis (L-arginine). The animals received those substances for 4 weeks. Control groups received the same amount of tap water for 4 or 8 weeks and were divided into groups with ARF (4 weeks--ARF group and 8 weeks ARF group) and a sham-operated group. Another group of rats was treated first with L-NAME and then with L-arginine in their drinking water, for 4 weeks for each of these two substances. All parameters were evaluated 24 h after the induction of ischaemic ARF or the sham operation. RESULTS: Our results show that such long-term stimulation of NO release by L-arginine improved renal haemodynamics in the ischaemic form of ARF. Renal blood flow (RBF) increased by 96% in the L-arginine-treated rats with ARF compared with the group with ARF alone. Inhibition of NO synthesis worsens renal haemodynamics after ARF. However, this aggravation can be reversed by L-arginine. The rate of water reabsorption was reduced in all groups with ARF, but this reduction was least in the group treated with L-arginine. The rate of Na+ reabsorption was reduced in all groups 24 h after renal ischaemia, but a significant decrease was observed after the inhibition of NO synthesis. Histological examination of the kidney specimens showed that morphological changes were least in the rats treated with L-arginine, when compared with all other groups with ARF. Nevertheless, the lesions were most prominent in the L-NAME+ARF group. In this group, the areas of corticomedullar necrosis were more widespread in comparison with other groups, especially the L-arginine group where only swelling of the proximal tubular cells was observed. Treatment with L-NAME was not accompanied by any significant alteration in the plasma concentration of angiotensin I (ANG I), while in the group treated with L-arginine ANG I had a tendency to decrease. CONCLUSIONS: Acute post-ischaemic renal failure may be alleviated by administering the NO substrate (L-arginine). NO acts cytoprotectively on tubular epithelial cells in ischaemia--reperfusion injury of rat kidney. Evidence of this comes from both histopathological findings and increased tubular water and sodium reabsorption. However, inhibition of NO synthesis (provoked by L-NAME) worsens renal haemodynamics and aggravates morphological changes after ARF. These aggravations can, however, be reversed by L-arginine.

Acute Kidney Injury↗

Acute renal failure in bone marrow transplant patients admitted to the intensive care unit.

BACKGROUND/AIMS: Review of bone marrow transplant (BMT) cases admitted to our intensive care unit (ICU) and to compare co-morbidity and outcome of BMT patients developing or not developing acute renal failure (ARF). METHODS: A case review of BMT patients admitted to the ICU (a 16-bed medico-surgical ICU in a tertiary care teaching institution) over a 4-year period. RESULTS: Between January 1994 and December 1998, 57 among 441 BMT patients (12.9%) were admitted to the ICU, mainly for respiratory distress (58%) and hypotension (32%). Forty-two patients (73.7%) presented ARF as defined as a doubling of serum creatinine. Compared to the 15 other patients, ARF patients had a higher APACHE II score (30 +/- 8 vs. 25 +/- 7, p < 0.05). For ARF vs. non-ARF patients, there was no difference in age (43.8 +/- 10.8 vs. 44.3 +/- 11.1 years), in requirement for mechanical ventilation (76 vs. 73%) and vasopressors (69 vs. 60%), and in prevalence of graft-versus-host disease (19 vs. 13%) or neutropenia (69 vs. 67%), but the prevalence of sepsis (83 vs. 60%) and liver failure (69 vs. 40%) was higher. Maximum serum bilirubin was markedly increased in ARF compared to non-ARF patients (p < 0.005). For both subgroups, no difference in the administration of potential nephrotoxic agents was identified. Usually, ARF was considered multifactorial by clinicians, with ATN being the most frequent diagnosis (55%). Maximum serum creatinine reached a mean of 330 +/- 130 micromol/l. In 74% of cases, ARF occurred concomitantly or after admission to the ICU. Oligoanuria was present in 38%, whereas polyuria was observed in 17%. Fourteen ARF patients (33%) required dialytic support. Mortality rates were significantly different in ARF vs. non-ARF patients (88 vs. 60%, p < 0.05). Predictive factors for the development of ARF were liver failure (odds ratio (OR) 5.9), low serum albumin (OR 1.2) and APACHE II score (OR 1.1), whereas variables predictive of mortality were mechanical ventilation (OR 14.8), ARF (OR 5.8), liver failure (OR 3.7), and APACHE II score (OR 1.2). CONCLUSIONS: This study confirms that ARF in BMT patients admitted to the ICU is frequent, multifactorial, related to liver failure, and that its development has a negative impact on outcome.

Acute Kidney Injury↗

New experimental model of acute renal failure and sepsis in rats.

BACKGROUND: A rat model of acute renal failure (ARF) with sepsis (ARF+S) was developed to simulate the clinical syndrome of hypercatabolic illness in patients with ARF. METHODS: Sepsis was created by ligation and needle puncture of the cecum; ARF was created by left renal artery clamping and contralateral nephrectomy. RESULTS: Two studies were performed. In study 1, rats with sham surgery, sepsis, ARF, and ARF+S were examined for 48 hours. During the first 24 hours after surgery, ARF and ARF+S rats displayed increased urea and ammonia nitrogen appearances and abnormal plasma amino acid levels. These abnormalities were exaggerated in ARF+S rats. In study 2, sham, ARF, and ARF+S rats were injected with sodium bicarbonate or normal saline. During the first 24 hours after surgery, the ARF and ARF+S rats showed an increase in urea nitrogen appearance to 210% and 293%, respectively, of sham values, which was greater than the levels that have been previously reported. Sodium bicarbonate treatment did not influence nitrogen output. CONCLUSIONS: Rats with ARF+S may be a useful model for studying catabolic patients with ARF. The lack of effect of sodium bicarbonate on nitrogen balance merits additional study.

Acute Kidney Injury↗

Incidence and factors predictive of acute renal failure in patients with advanced liver cirrhosis.

BACKGROUND: Acute renal failure (ARF) is a life-threatening entity that frequently complicates advanced liver disease. This study documents a number of factors that may predispose to or precipitate ARF and influence outcomes in patients with advanced liver disease. Comparisons are also made between subgroups of patients with viral and alcohol-induced liver cirrhosis in those with ARF. PATIENTS AND METHODS: We conducted a retrospective chart review over one year of 127 consecutive hospital admissions in 82 patients who were diagnosed with advanced liver cirrhosis (Child-Pugh Class C) in a tertiary care center. A diagnosis of ARF was made in 29 admissions and another 98 admissions not complicated by ARF served as controls. This study evaluated different etiologies of ARF and developed a database which included clinical features, biochemical parameters, the etiology of cirrhosis, possible predisposing factors, and precipitating events. Version II of the Acute Physiology and Chronic Health Physiology Scoring system (APACHE II) was applied to predict short-term hospital mortality rates. RESULTS: ARF occurred in 29 admissions over the one-year study period (23%). The mean age of these patients was 56.8 +/- 12.0 years, and 73% were men. The patients with ARF had significant hyponatremia and higher levels of serum bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and white cell counts on admission than the controls. Patients who developed ARF were more likely to have had infection, especially septicemia, and gastrointestinal (GI) bleeding. Mortality rate in the patients with ARF was much higher than in those patients without ARF (72% vs. 13%, p < 0.001). The patients with viral cirrhosis and ARF were found to have higher leukocyte counts, serum bilirubin levels, and more frequent incidence of infection, septicemia and GI bleeding compared to the patients with alcoholic liver cirrhosis and ARF. Those with viral hepatitis were also significantly older and had more frequent incidence of ascites, but had lower levels of gamma-glutamyl transpeptidase and less frequent incidence of encephalopathy. CONCLUSIONS: The risk of ARF is significantly increased in patients with advanced liver cirrhosis presenting with marked hyperbilirubinemia, hyponatremia, elevated liver enzymes, infection, and GI bleeding. The presence of ARF leads to higher mortality rates in both viral and alcohol-induced liver cirrhosis.

Acute Kidney Injury↗

[Acute renal failure in patients undergoing cardiac surgery].

UNLABELLED: Acute renal failure (ARF) is an unusual and severe complication which may occur in patients following cardiac surgery. The incidence of ARF is from 1% to 15% (according to some authors up to 40%). The ARF, occurring in the postoperative period and requiring dialysis is an important risk factor for early mortality, while the overall mortality due to this complication is as high as 40% (40% to 90%). AIM: The aim of this study was to assess the incidence of ARF in patients undergoing cardiac surgery at our hospital from January 1, 2001 to June 1, 2002 and to compare it with the data obtained at the same institution and published 17 years ago. METHODS: A total of 290 patients undergoing cardiac surgery were analyzed, 71 (24.5%) female and 219 (75.5%) male, mean age 61.1 (range 17-81) years. Exclusion criteria were death within a few hours of surgery and need of chronic hemodialysis prior to surgery. ARF was defined as doubling of serum creatinine (sCr) concentration with preoperative sCr concentration below 130 micromol/L, or sCr increase by 100 or more micromol/L after cardiac surgery. Age, sex, type of surgery, preoperative sCr and preoperative risk factors (hypertension, diabetes mellitus, hyperproteinemia, pulmonary disease, peripheral vascular disease, central vascular disease) as well as complications occurring during the operation and their influence on ARF were analyzed. The incidence of ARF, therapy and mortality were also analyzed. RESULTS: Ischemic cardiac disease was present in 236 (81%) and valvular disease in 41 (14%), ventricular or atrial septal defect in 6 (2%), thoracic aortic aneurysm in 3 (1%), patent ductus arteriosus in 2 (0.7%) patients, and pericardial tumor and penetrant pericardial injury in 1 (0.36%) patient each. Arterial hypertension was present in 199 (68.6%), hyperlipoproteinemia in 194 (66.8%), diabetes mellitus in 76 (26.2%), cardiac arrhythmias in 39 (13.45%), cerebrovascular diseases in 32 (11.0%) previous, renal diseases in 25 (8.6%), chronic obstructive lung disease in 23 (7.9%) patients, peripheral vascular disease by 19 (6.6%) patients, thyroid disease by 8 (3.1%), and malignant disease in 5 (7.1%) patients. Renal function according to sCr was as follows: <79 micromol/L in 90 (31.0%), 80 to 99 micromol/L in 124 (42.7%), and 100-129 micromol/L in 58 (20%), 130-159 in 10 (3.4%), and >160 micromol/L in 4 (1.4%) patients. ARF developed in 8 (2.1%) patients who had undergone cardiac surgery. Among them, only one (0.3%) patient needed dialysis treatment (hemodialysis and continuous venovenous hemofiltration). There were no differences in sex distribution between the patients who developed ARF and those who did not. The patients who developed ARF were older, mean age 65.7 years. Most of the patients with ARF suffered from hypertension, diabetes mellitus and hyperlipoproteinemia. Seventy-five percent of patients who developed ARF had some kind of "surgical" complications: postoperative bleeding with developing hemorrhagic shock, myocardial infarction during the operation, or acute abdomen after the operation. CONCLUSION: The incidence of ARF in patients undergoing cardiac surgery was low (2.1%). The incidence of severe ARF (which must be treated with dialysis) was 0.3%. We compared the data obtained at our hospital with those obtained 17 years ago and found a reduction in the incidence of severe ARF after cardiac surgery (0.3% vs. 4%).

Acute Kidney Injury↗

Acute renal failure in patients with severe acute respiratory syndrome.

BACKGROUND AND PURPOSE: Severe acute respiratory syndrome (SARS) is caused by a new coronavirus, and results in respiratory failure. Acute renal failure (ARF) may also occur and/or complicate the disease course, however, its incidence, causes and impact in SARS patients are not known. METHODS: ARF patients were identified from a total of 78 (33 men and 45 women) probable SARS cases admitted to a single hospital. The clinical features of patients with ARF were characterized, and the etiologies analyzed. RESULTS: Patients were assigned to ARF (n = 13; 17%) and non-ARF groups (n = 65). Patients with ARF were older than their non-ARF counterparts. ARF developed 7.2 +/- 4.3 days after admission. The incidence of ARF was higher in males (77% vs 35%; p < 0.05). Comorbidities of diabetes and heart failure were more common in patients who developed ARF (38% vs 6%, p < 0.01 and 38% vs 2%, p < 0.001, respectively) and the incidence of respiratory failure (85% vs 26%, p < 0.001) and mortality (77% vs 8%, p < 0.001) were also higher. Multiple organ system failure usually accompanied ARF. Hypotension (77%) caused by nosocomial infections, gastrointestinal bleeding, or SARS per se, and rhabdomyolysis (43%) was associated with ARF in addition to pre-renal factors. Five patients in the ARF group and 1 female patient with end-stage renal failure underwent renal replacement therapy during hospitalization; however, both eventually died. Of the 16 medical staff performing renal replacement therapy, none was subsequently infected with SARS coronavirus. CONCLUSIONS: Development of ARF during the disease course in SARS patients is associated with catastrophic outcome. The cause of ARF in SARS patients is often associated with pre-renal factors, hypotension, rhabdomyolysis, and previous comorbidities including diabetes and old age. Universal precautions to prevent viral transmission are mandatory for medical staff performing renal replacement therapy.

Acute Kidney Injury↗

Acute renal failure in the ICU: risk factors and outcome evaluated by the SOFA score.

OBJECTIVES: To describe risk factors for the development of acute renal failure (ARF) in a population of intensive care unit (ICU) patients, and the association of ARF with multiple organ failure (MOF) and outcome using the sequential organ failure assessment (SOFA) score. DESIGN: Prospective, multicenter, observational cohort analysis. SETTING: Forty ICUs in 16 countries. PATIENTS: All patients admitted to one of the participating ICUs in May 1995, except those who stayed in the ICU for less than 48 h after uncomplicated surgery, were included. After the exclusion of 38 patients with a history of chronic renal failure requiring renal replacement therapy, a total of 1411 patients were studied. MEASUREMENTS AND RESULTS: Of the patients, 348 (24.7%) developed ARF, as diagnosed by a serum creatinine of 300 micromol/l (3.5 mg/dl) or more and/or a urine output of less than 500 ml/day. The most important risk factors for the development of ARF present on admission were acute circulatory or respiratory failure; age more than 65 years, presence of infection, past history of chronic heart failure (CHF), lymphoma or leukemia, or cirrhosis. ARF patients developed MOF earlier than non-ARF patients (median 24 vs 48 h after ICU admission, p < 0.05). ARF patients older than 65 years with a past history of CHF or with any organ failure on admission were most likely to develop MOF. ICU mortality was 3 times higher in ARF than in other patients (42.8% vs 14.0%, p < 0.01). Oliguric ARF was an independent risk factor for overall mortality as determined by a multivariate regression analysis (OR = 1.59 [CI 95%: 1.23-2.06], p < 0.01). Infection increased the risk of death associated with all factors. Factors that increased the ICU mortality of ARF patients were a past history of hematologic malignancy, age more than 65 years, the number of failing organs on admission and the presence of acute cardiovascular failure. CONCLUSION: In ICU patients, the most important risk factors for ARF or mortality from ARF are often present on admission. During the ICU stay, other organ failures (especially cardiovascular) are important risk factors. Oliguric ARF was an independent risk factor for ICU mortality, and infection increased the contribution to mortality by other factors. The severity of circulatory shock was the most important factor influencing outcome in ARF patients.

Acute Kidney Injury↗

Molecular characterization of a conserved, guanine nucleotide-dependent ADP-ribosylation factor in Drosophila melanogaster.

ADP-Ribosylation factors (ARFs) are ubiquitous approximately 20-kDa guanine nucleotide-binding proteins that stimulate cholera toxin-catalyzed ADP-ribosylation in vitro. Because the functional role(s) of ARF in mammalian systems is (are) elusive, we looked for ARF in Drosophila melanogaster, and report the partial purification and molecular cloning of an ARF from Drosophila. We cloned the Drosophila ARF 1 gene without library screening by a combination of 5 polymerase chain reactions (PCRs), yielding a 546-base open reading frame encoding 182 amino acids, which are > 93% identical to those of mammalian class I ARFs. This ARF gene maps to 79F3-6 in the proximal region of the left arm of Drosophila chromosome 3. The Drosophila ARF1 gene structure, including placement of introns, is highly conserved relative to mammalian class 1 ARF genes. A single ARF mRNA species of 1.8 kb was abundant in all Drosophila body segments. Recombinant Drosophila ARF 1 synthesized in Escherichia coli had biochemical and immunochemical activities similar to those of mammalian ARF. The similarities of sequence and biochemical properties between Drosophila and mammalian ARFs contrast with their differences from Drosophila arl (ARF-like protein), which does not stimulate cholera toxin-catalyzed ADP-ribosylation, and is only approximately 52-56% identical in amino acid sequence to mammalian ARFs.

ADP-Ribosylation Factor 1↗

Characterization of recombinant and endogenous ADP-ribosylation factors synthesized in Sf9 insect cells.

ADP-ribosylation factors (ARFs) are a family of highly conserved, 20-kDa guanine nucleotide-binding proteins that participate in protein trafficking and enhance cholera toxin-catalyzed ADP-ribosylation. ARF 2 from bovine retinal cDNA was expressed in Sf9 insect cells using recombinant baculovirus and compared to the major insect cell ARF (Sf9 ARF) and to recombinant ARF 2 expressed in Escherichia coli (E. coli rARF 2). The 150000g supernatant and particulate fractions of freeze-thawed, recombinant ARF 2 baculovirus-infected cells contained immunoreactive proteins of 20 and 21 kDa at significantly higher levels than were found in uninfected cells. Infected Sf9 cells incorporated [3H]myristate only into the 20-kDa protein. Sf9 cell recombinant ARF 2 (Sf9 rARF 2) and Sf9 ARF were separated by isoelectric focusing or ion-exchange chromatography and identified by microsequencing of HPLC-purified tryptic peptides. Sf9 ARF displayed considerable sequence identity to mammalian class I ARFs. Both Sf9 ARF and Sf9 rARF 2 stimulated in a GTP-dependent manner cholera toxin-catalyzed ADP-ribosylation. The Ka for GTP of Sf9 ARF was, however, significantly lower than that of Sf9 rARF 2 or E. coli rARF 2. Myristoylation did not significantly affect the ability of ARF 2 to enhance cholera toxin-catalyzed ADP-ribosylation or the Ka for GTP. Despite the sequence identities and the fact that both were synthesized in insect cells, the endogenous Sf9 ARF was functionally different from Sf9 rARF 2.

ADP-Ribosylation Factors↗

Impact of acute renal failure on mortality in end-stage liver disease with or without transplantation.

BACKGROUND: Acute renal failure (ARF) is traditionally considered a poor prognostic factor in end-stage liver disease and is associated with a mortality approaching 90%. While the increased use of orthotopic liver transplantation (OLTX) has changed the outcome for patients with end-stage liver disease (ESLD), it is not clear whether this has affected the outcome of patients with ESLD and ARF. METHODS: We prospectively followed the course of ARF in 177 patients with ESLD being evaluated for OLTX. Of these patients 111 received OLTX. In-hospital mortality was compared to that of 316 ESLD patients without ARF, of these 196 received OLTX. Variables include severity of illness as assessed by APACHE II, co-morbid conditions, oliguria, need for renal replacement therapy, and etiologies of ESLD and ARF. These variables were evaluated with respect to the outcome in-hospital mortality by multiple regression analysis for patients with ARF. RESULTS: Mortality was significantly higher in oliguric versus non-oliguric patients and in patients who required renal replacement therapy. Mortality correlated strongly with the number of co-morbid conditions, especially sepsis, encephalopathy, respiratory failure, and DIC. For OLTX recipients who developed ARF, no significant difference in survival occurred whether the ARF was pre-OLTX or post-OLTX. CONCLUSION: ARF was associated with an increased mortality consistent with the known adverse prognostic effect of ARF in ESLD. However, the effect of ARF on mortality was remarkably reduced in patients who received a functioning OLTX. Since expected mortality generated from APACHE II scores was higher in the ARF groups, it is not clear that there is an additional effect of ARF beyond the physiologic derangements captured by APACHE II. ARF per se should not necessarily be a contraindication to liver transplant.

Acute Kidney Injury↗