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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
ORIGINAL ARTICLE  
Year : 2017  |  Volume : 28  |  Issue : 3  |  Page : 507-516
Effect of hemodialysis on oxidants and antioxidant factors in chronic renal failure


1 Non-Communicable Diseases Research Center, Alborz University of Medical Science, Karaj, Iran
2 Department of Internal Medicine, School of Medicine, Alborz University of Medical Science, Karaj, Iran
3 Social Determinations of Health Research Center, Alborz University of Medical Science, Karaj, Iran
4 School of Medicine, Alborz University of Medical Science, Karaj, Iran
5 Department of Biochemistry, School of Medicine, Alborz University of Medical Sciences, Karaj; Endocrinology and Metabolism Research Center, Valiasr Hospital, Tehran University of Medical Sciences, Tehran, Iran

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Date of Web Publication18-May-2017
 

   Abstract 

The current study was conducted to assess the effect of hemodialysis (HD) on the status of plasma oxidants and antioxidants among patients with end-stage renal disease (ESRD). These parameters can have an influence on the HD process and can also be useful for follow-up of these patients. The participants of this cross-sectional study comprised 91 patients with a mean age of 51.1 ± 8.2 years on chronic HD with kt/v between 1.2 and 1.4. The etiology of ESRD in these patients was as follows: diabetes mellitus in 39, hypertension in 35, and glomerulonephritis in 17 patients. All patients were on maintenance treatment with phosphate binder, 1,25 Vitamin D, iron, and erythropoietin therapy as per the K/DOQI guidelines. They were selected by random method from Shahid Bahonar Hospital, Karaj, Iran. The height, weight, waist circumference (WC), and blood pressure were measured according to standardized protocols, and blood samples were obtained before and after HD. Blood samples were checked for advanced glycation end products, advanced oxidation protein product, malondialdehyde (MDA), oxidized low-density lipoprotein (ox-LDL), and ferritin reducing ability of plasma, catalase, glutathione peroxidase (GPx), superoxide dismutase (SOD), and blood urea nitrogen (BUN). The means of MDA, BUN, advanced glycation end product (AGE), and ox-LDL plasma level postdialysis significantly decreased compared to the predialysis level. The mean of plasma catalase, GPx, and SOD increased significantly postdialysis compared to the predia- lysis level in these patients. Factors including age, body mass index, WC, and diastolic blood pressure affected changes in levels of oxidants and antioxidants after HD. Our study results revealed that the status of antioxidants and oxidants tends to improve after HD.

How to cite this article:
Tajbakhsh R, Qorbani M, Mehrpour G, Rahimzadeh M, Azimzadeh MM, Mirmiranpour H. Effect of hemodialysis on oxidants and antioxidant factors in chronic renal failure. Saudi J Kidney Dis Transpl 2017;28:507-16

How to cite this URL:
Tajbakhsh R, Qorbani M, Mehrpour G, Rahimzadeh M, Azimzadeh MM, Mirmiranpour H. Effect of hemodialysis on oxidants and antioxidant factors in chronic renal failure. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2017 Oct 18];28:507-16. Available from: http://www.sjkdt.org/text.asp?2017/28/3/507/206446

   Introduction Top


Documented studies show that oxidative stress (OS) state increases in patients with chronic renal failure (CRF).[1],[2],[3] In the presence of oxi- dative stress, DNA, lipids, and proteins are damaged by free radicals.[4] Furthermore, factors such as oxidized low-density lipoprotein (ox-LDL), methylguanidine metals, phenol indoxyl carboxyl, and malondialdehyde (MDA) increase, and antioxidant factors such as superoxide dismutase (SOD), catalase, Vitamin C, and Vitamin E decrease.[5],[6]

Mortality and morbidity increase in patients with CRF, which may be the consequence of enhancement of OS. It is likely that OS has a mediator role in the development of complications of CRF such as cardiovascular, neurology, and hypertension (HTN).[7],[8] Data reveal that atherosclerotic events are responsible for about 55% of mortalities in patients with end- stage renal disease (ESRD).[9]

Hemodialysis (HD) is effective in improving metabolic abnormalities related to OS and wastes in patients.[10] Some studies have shown that exposure of blood to dialysis membrane creates OS by producing reactive oxygen species on the surface of dialysis membranes.[11],[12] A previous study reported an increase of lipid peroxidase activity and decrease of antioxidant activity after a single HD session.[13]

Several studies have investigated factors associated with the activity of enzymatic antioxidant and production of oxidants.[14],[15] A study has shown that aging was associated with increased level of lipid peroxidation, protein damage, and reduction of antioxidant enzymes.[14] Furthermore, smoking was associated with lower activity of enzymatic antioxidants.[16] To our knowledge, no study has assessed factors associated with a change in level of antioxidants and oxidants during HD.

Thus, this study was performed to assess the effect of HD on plasma antioxidants’ status among patients with ESRD. Furthermore, the factors that might affect the change in level of oxidants and antioxidants during HD were assessed.


   Methods Top


The participants of this cross-sectional study were 91 patients with renal failure selected by random method from Shahid Bahonar Hospital, Karaj, Iran, in the years 2013–2014. Inclusion criteria were patients aged between 20 and 70 years, glomerular filtration rate (GFR) of less than 15 mL/min, having diabetes mellitus II (DM), or HTN, or glomerulonephritis, and receiving HD three times a week. Each session was of 4 h duration and all patients were on HD for more than six months. All patients had an arteriovenous fistula (AVF), but two of them were dialyzed by temporary vascular access. Dialysis filters were F- or PS- series with polysulfone fiber dialyzer. Patients with a history of acute cardiovascular disease, acute renal failure, infection, cirrhosis, and history of using antioxidant drugs were excluded from the study. This study was approved by the Ethics-in-Research Commission of Karaj University of Medical Sciences. Written informed consents were obtained from the participants after complete explanation of the study’s objective and protocol.

Measurements

Anthropometric parameters including height, weight, waist circumference (WC), and blood pressure were measured according to standardized protocols at the beginning and end of the study. Weight was measured in light clothing to the nearest 0.1 kg on a digital scale (Seca, Germany), and height was recorded without shoes to the nearest 0.1 cm. Body mass index (BMI) (kg m-2) was calculated from weight (kg) divided by square of height (m). WC was measured using a nonelastic tape to the nearest 0.1 cm, at a point midway between the lower border of the rib cage and the iliac crest at the end of normal expiration. To measure systolic and diastolic blood pressures, a standard mercury sphygmomanometer (HEM-780-E) was used. Measurement was taken from the arm without the AVF or dialysis vascular access and was taken with the subjects asked to rest in sitting position for at least 10 min in a calm environment. Two measurements, 5 min apart were carried out and the average was recorded.

Blood samples were obtained before and after the HD session. A volume of 10 mL of cubital vein blood was collected from the patients; one sample was mixed with anticoagulant ethylenediaminetetraacetic acid and the other without serum anticoagulant. The blood was centrifuged at 2500 x g for 10 min, and the serum was then separated and aliquoted into tubes. Samples were stored at –70°C until assayed.

Blood samples were checked for advanced glycation end products (AGEs), advanced oxidation protein product (AOPP), MDA, ox-LDL, ferritin reducing ability of plasma (FRAP), catalase, glutathione peroxidase (GPx), SOD, and blood urea nitrogen (BUN). The plasma concentration of catalase, GPx, and SOD was measured by enzymatic colorimetric method. MDA and ox-LDL were tested by enzymatic colorimetric and ELISA methods, respectively.

Determination of AOPPs was based on spec- trophotometric detection.[17] Two hundred microliters of plasma diluted 1:5 in 20 mM phosphate buffer, pH 7.4, containing chloramine-T standard solutions (0–100 μmol/L), was placed in each well of a 96-well microtiter plate, followed by 20 μL of 10% acetic acid. Ten microliters of 1.16 M potassium iodide was then added, followed by 20 μL of 10% acetic acid. The absorbance of the reaction mixture was immediately read at 340 nm in a micro- plate reader against a blank containing 200 μ! of phosphate-buffered saline (PBS), 10 μL of KI, and 20 μL of 10% acetic acid. The chloramine-T absorbance at 340 nm was linear within the range of 0 to 100 μmol/L. AOPP concentrations were expressed in μmol/L of chloramine-T equivalents.

Determination of FRAP was based on spec- trophotometric detection; when ferric tripy- ridyltriazine (FellI-TPTZ) complex is reduced to the ferrous (FeII) form at low pH, an intense blue color with an absorption maximum at 593 nm develops.[18]

AGEs concentration was measured by fluorescence emission. The serum samples were diluted to 1:50 by PBS, and the fluorescence intensity was measured at 440 nm after excitation at 350 nm. The fluorescence was expressed as the relative fluorescence intensity in arbitrary units. Serum BUN was determined by enzymatic colorimetric method.


   Statistical Analysis Top


Data were analyzed using the Statistical Package for the Social Sciences (SPSS) version 16.0 for Windows (SPSS Inc., Chicago, IL, USA). Normality assumption of continuous variables was assessed using Kolmogorov- Smirnov test. Continuous and categorical variables were expressed as mean ± standard deviation and frequency (%), respectively. Association of categorical and continuous variables with sex was assessed using Chi-square and independent /-test, respectively. Paired t- test was used to compare continuous variables before and after HD. Association of independent variables with change of antioxidant after HD as a dependent variable was assessed using linear regression model. Results of linear regression are presented as β (SE). P <0.05 was considered statistically significant.


   Results Top


A total of 91 patients on dialysis participated in this study with a mean age of 51.1 ± 8.2 years. Of the participants, 35 (38.5%), 39 (42.9%), and 17 (18.7%) had HTN, DM, and glomerulonephritis, respectively [Table 1].
Table 1: Demographic and clinical characteristics of the study patients.

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The mean plasma level of MDA (2.7 ± 0.3 pm/L) significantly decreased postdialysis in patients with DM compared to the predialysis level (3.2 ± 0.3 pm/L). Similar results were observed in patients with glomerulonephritis (2.7 ± 0.4pm/L) and HTN (2.6 ± 0.3 pm/L) compared to predialysis levels (3.2 ± 0.2 pm/L and 3.1 ± 0.3 pm/L, respectively). The mean plasma BUN and ox-LDL levels decreased significantly postdialysis compared to predia- lysis level in all the patients. The serum AGE level significantly decreased after HD in patients with DM and HTN, and the mean changes were 5.0 ± 10.1 and 5.2 ± 9.2, respectively. There was a significant increase in plasma catalase level postdialysis in patients with DM (2.3 ± 0.4 U/mL), glomerulonephritis (2.4 ± 0.3 U/mL), and HTN (2.4 ± 0.3 U/mL) compared to predialysis levels (2.0 ± 0.3 U/mL, 2.2 ± 0.3 U/mL, and 2.0 ± 0.2 U/mL, respectively). A significant increase was observed in GPx and SOD level after HD among the patients [Table 2].
Table 2: Mean (±SD) plasma concentration of biochemical parameters in the predialysis and postdialysis state of the patients.

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The means of MDA, BUN, AGE, and ox- LDL plasma levels decreased significantly postdialysis compared to the predialysis level. Significantly, the mean plasma catalase, GPX, and SOD increased postdialysis compared to predialysis level in these patients. In the male participants, the mean postdialysis plasma MDA level (2.7 ± 0.3 pm/L) decreased compared to the predialysis level (3.1 ± 0.2 pm/L). A similar result was observed in female patients as well (3.2 ± 0.3 pm/L). Totally, the mean BUN, ox-LDL, and AGE significantly decreased in male and female patients (mean change: 60.1 ± 109.1 mg/dL, 2.7 ± 1.2 mU/L, and 4.1 ± 9.9, respectively). The mean changes of catalase, GPx, and SOD in male and female participants were -0.3 ± 0.2 U/mL, -5.2 ± 11.1 U/mL, and -0.4± 0.2 U/mL, respectively [Table 3].
Table 3: Mean (±SD) plasma concentration of biochemical parameters in the predialysis state and the postdialysis state of the patients according to gender.

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On multivariate analysis, age and WC were associated with a change in GPx level after HD (P <0.05), i.e., one-year increase of age increased the GPx by 0.3 U/mL after HD, whereas increasing WC per centimeter decreased by 0.3 U/mL. Significantly, BMI and WC were associated with change of BUN level after HD, i.e., increase of BMI per kg/m2 and WC per cm increased the BUN level by 9.8 mg/dL and 2.7 mg/dL, respectively, after HD [Table 4].
Table 4: Mean (±SD) plasma concentration of biochemical parameters in the predialysis and the postdialysis states of the patients.

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   Discussion Top


In the current study, a significant difference was observed in antioxidant enzymes and oxidation markers between pre- and post-HD states. Antioxidant enzymes increased significantly after HD and oxidation markers decreased. The findings of studies on the effect of HD on OS are controversial. In the present study, the plasma level of SOD, GPx, and catalase, as antioxidant enzymes, increased after HD which are in agreement with the study of González Rico et al.[19] Recent data show that HD can improve antioxidant status among patients. The findings are inconsistent with some previous studies.[19],[20],[21] Meerashivashekar et al reported that plasma level of GPx and catalase significantly increased postdialysis in patients with ESRD.[20] However, in some previous studies, no statistically significant difference was observed in SOD and GPx activity in patients undergoing HD.[12],[22] Recent researches suggest that dialysis membrane affects enzymatic antioxidant activity. Eiselt et al reported that the activity of SOD and glutathione peroxidase was higher in patients dialyzed with cellulose acetete membrane compared with those dialyzed with polysulfone membrane.[23]

According to the present study, the MDA and ox-LDL levels were lower post-HD compared to pre-HD which is consistent with some previous works.[19],[24] Some reports suggest that the dialysis process can aggravate OS and lipid peroxidation markers.[25],[26] On the contrary, the current findings showed that the plasma MDA decreased, probably because of the helpful effect of HD on plasma aminothiols which are the main markers of oxidation.[27],[28]

In the current study, the enzymatic antioxidants significantly increased after a HD session. Dursun et al[29] investigated the effect of HD on oxidants and antioxidants in patients with DM and showed that the catalase activity was enhanced in diabetic HD patients (DHD) in comparison to the predialysis state. However, SOD activity as an enzymatic antioxidant did not change significantly after dialysis. The lowest antioxidant enzymes were observed in DHD patients indicating that diabetes has an additive effect on the OS status.[29] On the other hand, the level of oxidants decreased after HD among patients with DM, which is not in line with some past studies.[30],[31] In the study of Kitabayashi et al, it was found that plasma ox- LDL concentration was enhanced after a HD session in diabetic ESRD patients, but the mechanism behind this increase has not been confirmed.[30]

It is well known that HTN is associated with OS.[32],[33] Several studies indicate that the SOD activity decreases in patients with HTN.[34] In addition, it was found that the serum MDA level was higher in patients with HTN compared to normotensive patients, and catalase activity was lower in patients with HTN compared to normotensive patients.[35] In the present study, the OS status improved after HD by increasing antioxidant capacity and decreasing the level of oxidants. Furthermore, some studies suggest that antihypertensive therapy can contribute to reduction of free radical production and lipid peroxidation in patients with HTN.[36]

Furthermore, the change in the level of GPX after HD was associated with age and WC. Other studies suggest that age is associated with the activity of enzymatic antioxidants, i.e., aging is related to decrease of antioxidant enzymatic activity.[15],[37] To the best of our knowledge, the factors associated with a change in the level of antioxidants were not studied in previous research works. In our study, factors associated with a change in level of oxidants were assessed; BMI, WC, and DPB were associated with a change in level of BUN and ox-LDL as oxidants. BMI and WC were associated with increase in the level of BUN, whereas DBP was associated with a decrease in the level of ox-LDL.

The main limitation of the study is its cross- sectional design. The main strength is its novelty in assessing the factors that may affect change in level of oxidants and antioxidants during HD. In conclusion, our study suggests that antioxidant enzymes and oxidation markers improved after HD sessions.

Conflict of interest: None declared.

 
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Correspondence Address:
Hossein Mirmiranpour
Department of Biochemistry, School of Medicine, Alborz University of Medical Sciences, Karaj
Iran
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DOI: 10.4103/1319-2442.206446

PMID: 28540886

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