Mark L. Zeidel

A simple comorbidity scale predicts clinical outcomes and costs in dialysis patients

PURPOSE In a university-based dialysis program, we found that 25% of the patients accounted for 50% of the costs and 42% of the deaths. We determined whether the Charlson Comorbidity Index, a simple measure of comorbid conditions, could predict clinical outcomes and costs in these patients. METHODS Patients on hemodialysis or peritoneal dialysis from July 1996 to June 1998 at the University of Pittsburgh outpatient dialysis unit were studied. Comorbidity scores and outcomes were determined by reviewing the Medical Archival Retrieval System database and outpatient records. RESULTS Two hundred sixty-eight patients were observed for 293 patient-years. The Comorbidity Index strongly predicted admission rate (relative risk per each unit increase = 1.20; 95% confidence interval [CI]: 1.16 to 1.23, P = 0.0001), hospital days and inpatient costs (both P <0.0001), and mortality (relative risk per unit increase = 1.24, 95% CI: 1.11 to 1.39, P = 0.0002.). Age and diabetes, used in the Health Care Financing Administration dialysis capitation model, correlated poorly with outcomes. CONCLUSIONS The modified Charlson Comorbidity Index predicts outcomes and costs in dialysis patients. This index may be useful in determining appropriate payment for care of dialysis patients under capitated payment schemes and as a research tool to stratify dialysis patients in order to compare the outcomes of various interventions.

Structural Determinants of Water Permeability through the Lipid Membrane

Despite intense study over many years, the mechanisms by which water and small nonelectrolytes cross lipid bilayers remain unclear. While prior studies of permeability through membranes have focused on solute characteristics, such as size, polarity, and partition coefficient in hydrophobic solvent, we focus here on water permeability in seven single component bilayers composed of different lipids, five with phosphatidylcholine headgroups and different chain lengths and unsaturation, one with a phosphatidylserine headgroup, and one with a phosphatidylethanolamine headgroup. We find that water permeability correlates most strongly with the area/lipid and is poorly correlated with bilayer thickness and other previously determined structural and mechanical properties of these single component bilayers. These results suggest a new model for permeability that is developed in the accompanying theoretical paper in which the area occupied by the lipid is the major determinant and the hydrocarbon thickness is a secondary determinant. Cholesterol was also incorporated into DOPC bilayers and X-ray diffuse scattering was used to determine quantitative structure with the result that the area occupied by DOPC in the membrane decreases while bilayer thickness increases in a correlated way because lipid volume does not change. The water permeability decreases with added cholesterol and it correlates in a different way from pure lipids with area per lipid, bilayer thickness, and also with area compressibility.

No facilitator required for membrane transport of hydrogen sulfide

Hydrogen sulfide (H2S) has emerged as a new and important member in the group of gaseous signaling molecules. However, the molecular transport mechanism has not yet been identified. Because of structural similarities with H2O, it was hypothesized that aquaporins may facilitate H2S transport across cell membranes. We tested this hypothesis by reconstituting the archeal aquaporin AfAQP from sulfide reducing bacteria Archaeoglobus fulgidus into planar membranes and by monitoring the resulting facilitation of osmotic water flow and H2S flux. To measure H2O and H2S fluxes, respectively, sodium ion dilution and buffer acidification by proton release (H2S ⇆ H+ + HS−) were recorded in the immediate membrane vicinity. Both sodium ion concentration and pH were measured by scanning ion-selective microelectrodes. A lower limit of lipid bilayer permeability to H2S, PM,H2S ≥ 0.5 ± 0.4 cm/s was calculated by numerically solving the complete system of differential reaction diffusion equations and fitting the theoretical pH distribution to experimental pH profiles. Even though reconstitution of AfAQP significantly increased water permeability through planar lipid bilayers, PM,H2S remained unchanged. These results indicate that lipid membranes may well act as a barrier to water transport although they do not oppose a significant resistance to H2S diffusion. The fact that cholesterol and sphingomyelin reconstitution did not turn these membranes into an H2S barrier indicates that H2S transport through epithelial barriers, endothelial barriers, and membrane rafts also occurs by simple diffusion and does not require facilitation by membrane channels.

Functional Analysis of Nodulin 26, an Aquaporin in Soybean Root Nodule Symbiosomes

Upon infection of soybean roots, nitrogen-fixing bacteria become enclosed in a specific organelle known as the symbiosome. The symbiosome membrane (SM) is a selectively permeable barrier that controls metabolite flux between the plant cytosol and the symbiotic bacterium inside. Nodulin 26 (NOD 26), a member of the aquaporin (AQP) water channel family, is a major protein component of the SM. Expression of NOD 26 in Xenopus oocytes gave a mercury-sensitive increase in osmotic water permeability (P f). To define the biophysical properties of NOD 26 water channels in their native membranes, symbiosomes were isolated from soybean root nodules and the SM separated as vesicles from the bacteria. Permeabilities were measured using stopped-flow fluorimetry in SM vesicles with entrapped carboxyfluorescein. Osmotic water permeability (P f) of SM was high, with a value of 0.05 ± 0.003 cm/s observed at 20 °C (mean ± S.E.; n = 15). Water flow exhibited a low activation energy, was inhibited by HgCl2 (0.1 mm), and exhibited a unit conductance of 3.2 ± 1.3 × 10−15 cm3/s, a value 30-fold lower than that of AQP 1, the red blood cell water channel. Diffusive water permeability (P d) was 0.0024 ± 0.0002 cm/s, and the resulting P f toP d ratio was 18.3, indicating that water crosses the SM in single file fashion via the NOD 26 water channel. In addition to high water permeability, SM vesicles also show high mercury-sensitive permeability to glycerol and formamide, but not urea, suggesting that NOD 26 also fluxes these solutes. Overall, we conclude that NOD 26 acts as a water channel with a single channel conductance that is 30-fold lower than AQP 1. Because the solutes that permeate NOD 26 are far larger than water, and water appears to cross the channel via a single file pathway, solute flux across NOD 26 appears to occur by a pathway that is distinct from that for water.

Atrial natriuretic peptides inhibit conductive sodium uptake by rabbit inner medullary collecting duct cells.

The inner medullary collecting duct (IMCD) effects net sodium reabsorption under the control of volume regulatory hormones, including atrial natriuretic peptides (ANP). These studies examined the mechanisms of sodium transport and its regulation by ANP in fresh suspensions of IMCD cells. Sodium uptake was inhibited by amiloride but insensitive to furosemide, bu-metanide, and hydrochlorthiazide. These results are consistent with uptake mediated by a sodium channel or Na+/H+ exchange. To determine the role of sodium channels, cells were hyperpolarized by preincubation in high potassium medium followed by dilution into potassium-free medium. Membrane potential measurements using the cyanine dye, Di(S)-C3-5 verified a striking hyperpolarization of IMCD cells using this protocol. Hyperpolarization increased the apparent initial rate of sodium uptake fourfold. Amiloride and ANP inhibited potential-stimulated sodium uptake 73% and 65%, respectively; the two agents together were not additive. Addition of 5 mM sodium to hyperpolarized cells resulted in a significant amiloride-sensitive depolarization. Half-maximal inhibition of potential-driven sodium uptake occurred at 3 X 10(-7) M amiloride, and 5 X 10(-11) M ANP. We conclude that sodium enters IMCD cells via a conductive, amiloride-sensitive sodium channel, which is regulated by ANP. ANP inhibition of luminal sodium entry in the IMCD appears to contribute to the marked natriuretic effect of this hormone in vivo.

Expression and function of bradykinin B1 and B2 receptors in normal and inflamed rat urinary bladder urothelium

The bladder urothelium exhibits dynamic sensory properties that adapt to changes in the local environment. These studies investigated the localization and function of bradykinin receptor subtypes B1 and B2 in the normal and inflamed (cyclophosphamide (CYP)‐induced cystitis) bladder urothelium and their contribution to lower urinary tract function in the rat. Our findings indicate that the bradykinin 2 receptor (B2R) but not the bradykinin 1 receptor (B1R) is expressed in control bladder urothelium. B2R immunoreactivity was localized throughout the bladder, including the urothelium and detrusor smooth muscle. Bradykinin‐evoked activation of this receptor elevated intracellular calcium (EC50= 8.4 nm) in a concentration‐related manner and evoked ATP release from control cultured rat urothelial cells. In contrast, B1R mRNA was not detected in control rat urinary bladder; however, following acute (24 h) and chronic (8 day) CYP‐induced cystitis in the rat, B1R mRNA was detected throughout the bladder. Functional B1Rs were demonstrated by evoking ATP release and increases in [Ca2+]i in CYP (24 h)‐treated cultured rat urothelial cells with a selective B1 receptor agonist (des‐Arg9‐bradykinin). Cystometry performed on control anaesthetized rats revealed that intravesical instillation of bradykinin activated the micturition pathway. Attenuation of this response by the P2 receptor antagonist PPADS suggests that bradykinin‐induced micturition facilitation may be due in part to increased purinergic responsiveness. CYP (24 h)‐treated rats demonstrated bladder hyperactivity that was significantly reduced by intravesical administration of either B1 (des‐Arg10‐Hoe‐140) or B2 (Hoe‐140) receptor antagonists. These studies demonstrate that urothelial expression of bradykinin receptors is plastic and is altered by pathology.

Carbon Dioxide Transport through Membranes

Several membrane channels, like aquaporin-1 (AQP1) and the RhAG protein of the rhesus complex, were hypothesized to be of physiological relevance for CO2 transport. However, the underlying assumption that the lipid matrix imposes a significant barrier to CO2 diffusion was never confirmed experimentally. Here we have monitored transmembrane CO2 flux (JCO2) by imposing a CO2 concentration gradient across planar lipid bilayers and detecting the resulting small pH shift in the immediate membrane vicinity. An analytical model, which accounts for the presence of both carbonic anhydrase and buffer molecules, was fitted to the experimental pH profiles using inverse problems techniques. At pH 7.4, the model revealed that JCO2 was entirely rate-limited by near-membrane unstirred layers (USL), which act as diffusional barriers in series with the membrane. Membrane tightening by sphingomyelin and cholesterol did not alter JCO2 confirming that membrane resistance was comparatively small. In contrast, a pH-induced shift of the CO2 hydration-dehydration equilibrium resulted in a relative membrane contribution of about 15% to the total resistance (pH 9.6). Under these conditions, a membrane CO2 permeability (3.2 ± 1.6 cm/s) was estimated. It indicates that cellular CO2 uptake (pH 7.4) is always USL-limited, because the USL size always exceeds 1 μm. Consequently, facilitation of CO2 transport by AQP1, RhAG, or any other protein is highly unlikely. The conclusion was confirmed by the observation that CO2 permeability of epithelial cell monolayers was always the same whether AQP1 was overexpressed in both the apical and basolateral membranes or not.

Primary Uroepithelial Cultures A MODEL SYSTEM TO ANALYZE UMBRELLA CELL BARRIER FUNCTION

Despite almost 25 years of effort, the development of a highly differentiated and functionally equivalent cell culture model of uroepithelial cells has eluded investigators. We have developed a primary cell culture model of rabbit uroepithelium that consists of an underlying cell layer that interacts with a collagen substratum, an intermediate cell layer, and an upper cell layer of large (25–100 μm) superficial cells. When examined at the ultrastructural level, the superficial cells formed junctional complexes and had an asymmetric unit membrane, a hallmark of terminal differentiation in bladder umbrella cells. These cultured “umbrella” cells expressed uroplakins and a 27-kDa uroepithelial specific antigen that assembled into detergent-resistant asymmetric unit membrane particles. The cultures had low diffusive permeabilities for water (2.8 × 10−4 cm/s) and urea (3.0 × 10−7 cm/s) and high transepithelial resistance (>8000 Ω cm2) was achieved when 1 mmCaCl2 was included in the culture medium. The cell cultures expressed an amiloride-sensitive sodium transport pathway and increases in apical membrane capacitance were observed when the cultures were osmotically stretched. The described primary rabbit cell culture model mimics many of the characteristics of uroepithelium found in vivo and should serve as a useful tool to explore normal uroepithelial function as well as dysfunction as a result of disease.

Functional Analysis of Aquaporin-1 Deficient Red Cells THE COLTON-NULL PHENOTYPE

The aquaporin-1 (AQP1) water transport protein contains a polymorphism corresponding to the Colton red blood cell antigens. To define the fraction of membrane water permeability mediated by AQP1, red cells were obtained from human kindreds with the rare Colton-null phenotype. Homozygosity or heterozygosity for deletion of exon I in AQP1 correlated with total or partial deficiency of AQP1 protein. Homozygote red cell morphology appeared normal, but clinical laboratory studies revealed slightly reduced red cell life span in vivo; deformability studies revealed a slight reduction in membrane surface area. Diffusional water permeability (P) was measured under isotonic conditions by pulsed field gradient NMR. Osmotic water permeability (P) was measured by change in light scattering after rapid exposure of red cells to increased extracellular osmolality. AQP1 contributes 64% (P = 1.5 × 10 cm/s) of the total diffusional water permeability pathway, and lipid permeation apparently comprises 23%. In contrast, AQP1 contributes >85% (P = 19 × 10 cm/s) of the total osmotic water permeability pathway, and lipid permeation apparently comprises only 10%. The ratio of AQP1-mediated P to P predicts the length of the aqueous pore to be 36 Å.

Phosphorylation of Aquaporin-2 Does Not Alter the Membrane Water Permeability of Rat Papillary Water Channel-containing Vesicles

Antidiuretic hormone modulates the water permeability (P) of epithelial cells in the rat kidney by vesicle-mediated insertion and removal of the aquaporin-2 (AQP-2) water channel. AQP-2 possesses a single consensus cAMP-dependent protein kinase A (PKA) phosphorylation site (Ser-256) hypothesized to regulate channel P(Kuwahara, M., Fushimi, K., Terada, Y., Bai, L., Sasaki, S., and Marumo, F.(1995) J. Biol. Chem. 270, 10384-10387). To test whether PKA phosphorylation of AQP-2 alters channel P, we compared the P values of purified AQP-2 endosomes after incubation with either PKA or alkaline phosphatase. Studies using [-P]ATP reveal that AQP-2 endosomes contain endogenous PKA and phosphatase activities that add and remove P label from AQP-2. However, the P (0.16 ± 0.06 cm/s) of endosomes containing phosphorylated AQP-2 (0.7 ± 0.3 mol of PO/mol of protein) is not significantly different from the same AQP-2 endosomes where 95 ± 8% of the phosphate has been removed (P 0.14 ± 0.06 cm/s). These data do not support a role for PKA phosphorylation in alteration of AQP-2s P. Instead, AQP-2 phosphorylation by PKA may modulate AQP-2s distribution between plasma membrane and intracellular vesicle compartments.