RENAL RESEARCH INSTITUTE SYMPOSIUM
Longitudinal Study of Apoptosis in Chronic Uremic Patients
Vincenzo D’Intini,* Valeria Bordoni,* Antonio Fortunato,† Elisabetta Galloni,* Mariarita
Carta,† Francesco Galli,‡ Irene Bolgan,* Paola Inguaggiato,* Sonya Poulin,* Monica
Bonello,* Ciro Tetta,* Nathan Levin,§ and Claudio Ronco*
Departments of *Nephrology and †Clinical Chemistry, San Bortolo Hospital, Vicenza, Italy, ‡Department of
Clinical Biochemistry, University of Perugia, Perugia, Italy, and §Renal Research Institute, Beth Israel Medical
Center, New York, New York
ABSTRACT
Uremia is associated with a state of immune dysfunction,
increasing infection and malignancy rates. Dysregulation of
homeostasis may be directly related to abnormal apoptosis
regulation, a process which is crucial for the maintenance of the
biologic system. Abnormal apoptosis rates (ARs) have been
reported in the literature. We performed a longitudinal study
over a 10-week period in three groups of uremic sub-
jects—hemodialysis (HD), peritoneal dialysis (PD), and predi-
alysis chronic renal failure (CRF). Our results showed that ARs
were consistent over the observed period. Monocytes extracted
from HD and CRF subjects had higher ARs compared to PD
and controls (HD: 26.06 ± 8.82; CRF: 26.96 ± 12.81; PD:
14.77 ± 5.87; C: 11.42 ± 4.60) when placed in culture
medium. The plasma of HD and CRF subjects when incubated
Apoptosis is a highly regulated process used by the
body to maintain homeostasis. It is a normal physiologic
phenomenon whereby selected cells undergo active
programmed death. It is seen in developing tissues, such
as in embryogenesis, normal cell turnover, and cell
damage after insult. Apoptosis is essential and intricately
related to the development and regulation of cells.
Abnormal regulation in excessive or reduced amounts
have pathologic implications as seen in diseases such as
malignancies, acquired immunodeficiency syndrome
(AIDS), and degenerative diseases (1). Apoptosis is
characterized by several complex morphologic and
biochemical events, such as cellular shrinkage, mem-
brane blebbing, chromatin condensation, DNA frag-
mentation, and the fragmentation of cells in apoptotic
bodies, which are rapidly phagocytized and eliminated
without inflammatory response—the hallmark (2).
Induction of apoptosis is an extremely complex
process involving a mosaic of interactions of growth
factors, cytokines, and membrane proteins. A family of
Address correspondence to: Claudio Ronco, MD, Depart-
ment of Nephrology, St. Bortolo Hospital, Viale Rodolfi,
Vicenza, Italy, 36100. or e-mail: cronco@goldnet.it.
Seminars in Dialysis—Vol 16, No 6 (November–December)
2003 pp. 467–473
467
with U937 cells had a stronger apoptogenic potential compared
with PD and controls (HD: 26.08 ± 11.39; CRF:
24.87 ± 9.07; PD: 12.13 ± 4.51; C: 11.69 ± 4.02). Inflam-
matory markers (C-reactive protein [CRP], procalcitonin) and
cytokines (interleukin [IL]-1b, IL-2, IL-10) had a generally poor
correlation except for tumor necrosis factor (TNF)-a
(p < 0.001). The phagocytic ability of U937 cells when
incubated with the various plasma demonstrated impaired
response in the HD and CRF subjects (HD: 27.56 ± 6.67;
CRF: 30.24 ± 9.08; PD: 36.55 ± 9.80; C: 40.04 ± 6.98).
These results suggest continuous renal purification, such as in
continuous ambulatory peritoneal dialysis (CAPD), may have
advantages over intermittent therapies in regulating apoptosis
and maintaining biologic function and homeostasis.
cysteine proteases, the caspases, are involved in all the
pathways and are the real effectors of apoptosis. Even if
the mechanisms are not fully understood, it is clear that
the caspases are responsible for the cellular changes that
occur during apoptosis (3). Proinflammatory molecules
such as interleukin (IL)-2, IL-1b, and tumor necrosis
factor (TNF)-a have been shown to inhibit apoptosis
prolonging polymorphonuclear leukocyte (PMNL) sur-
vival. Conversely, IL-10, which has an anti-inflamma-
tory function, has been shown to promote apoptosis. The
role of various mediators in inducing apoptosis still
remains controversial, however, the role of important
regulators such as the Fas (APO-1; CD95)/Fas ligand
(FasL) system, bcl-2 gene family, and the caspase cascade
are more certain (4–6). The prevailing theory is that of a
balance between factors that contribute to cell survival
and lethality that regulate the destiny of a cell (7).
The uremic syndrome is the progressive deterioration
in biochemical and physiologic functioning of the kidney.
This process is associated with the accumulation of a
broad spectrum of molecules directly related to the
failure of the kidney to eliminate these substances. There
is a strict interaction between uremic toxins and the
biologic system. Toxins can trigger a number of cellular
responses such as phagocytosis and apoptosis, which
could be considered detrimental when it is responsible for
premature cell death (8).
 APOPTOSIS IN CHRONIC UREMIC PATIENTS
of Martin-Malo et al. (15), our PD subjects had very
similar rates of apoptosis to control. This is of great
significance, as it leads one to postulate that the
continuous purification of blood of uremic apoptotic
mediators with constant PD may have a beneficial effect
compared to the intermittent accumulation in HD
subjects and the inability to clear mediators in CRF.
Furthermore, one could deduce that apoptosis regula-
tion is less likely to be due to cell-dependent abnormal-
ities, but rather secondary to proapoptotic factors in
uremic plasma. Even though our study population was
small, the results pose an interesting result which has the
potential to expanded upon.
This study further examined cell function by phago-
cytic ability in the presence of uremic plasma. It was
demonstrated that the plasma of HD and CRF was
associated with more mononuclear cell dysfunction. PD
phagocytic function was almost similar to controls. The
correlation of increased mononuclear cell apoptosis and
decreased phagocytic function could be directly related,
as has been previously shown (10). However, many
uremic toxins have been previously identified which can
directly affect mononuclear cell function (21). The
finding that PD cell function was preserved compared
to the other uremic groups again may reflect the
continuous removal of toxins. Further study is needed
in this area. The incubation of LPS with whole blood
produced increased levels of TNF-a production, but no
statistical difference was seen between the groups.
Conclusion
Our study demonstrated that mononuclear cells and
plasma harvested from various uremic subjects have
differential apoptogenic potential. Predialysis uremic
subjects and HD subjects have a greatly elevated
apoptosis rate compared to CAPD subjects. Cell phago-
cytic ability was inversely related to apoptosis rates.
Serum TNF-a levels were the only cytokine levels to
significantly correlate with apoptosis activity. The finding
that a continuous blood purification (PD) modality has
the potential to modulate apoptosis rates in uremia which
correlates with cell function and homeostasis is exciting
and has the potential to launch further investigations.
Acknowledgments
This article was funded in part through the Renal
Research Institute–Beth Israel Medical Center–St. Bor-
tolo Hospital Sistership Program.
473
References
1. Carson DA, Ribeiro JM: Apoptosis and disease. Lancet 341(8855):1251–
1254, 1993
2. Kerr JRF, Wyllie AH, Currie AR: Apoptosis: a basic biological phenomenon
with wide-ranging implications in tissue kinetics. Br J Cancer 26:239–257,
1972
3. Thornberry A, Lazebnek Y: Caspases: enemies within. Science 281:1312–
1316, 1998
4. Kiener PA, Davis PM, Starling GC, Mehlin C, Klebanoff SJ, Ledbetter JA,
Liles WC: Differential induction of apoptosis by Fas-Fas ligand interactions
in human monocytes and macrophages. J Exp Med 185:1511–1516, 1997
5. Liles WC, Kiener PA, Ledbetter JA, Aruffo A, Klebanoff SJ: Differential
expression of Fas (CD95) and Fas ligand on normal human phagocytes:
implications for the regulation of apoptosis in neutrophils. J Exp Med
184:429–440, 1996
6. Kohler C, Orrenius S, Zhivotovsky B: Evaluation of caspase activity in
apoptotic cells. J Immunol Methods 265(1–2):97–110, 2002
7. Raff MC, Barres BA, Burne JF, Coles HS, Ishizaki Y, Jacobson MD: Pro-
grammed cell death and the control of cell survival. Philos Trans R Soc Lond
B Biol Sci 345(1313):265–268, 1994
8. Vanholder R, Argiles A, Vanholder R, Argiles A, Baurmeister U, Brunet P,
Clark W, Cohen G, De Deyn PP, Deppisch R, Descamps-Latscha B, Henle
T, Jorres A, Massy ZA, Rodriguez M, Stegmayr B, Stenvinkel P, Wratten
ML: Uremic toxicity: present state of the art. Int J Artif Organs 24:695–725,
2001
9. Pesanti EL: Immunologic defects and vaccination in patients with chronic
renal failure. Infect Dis Clin N Am 15:813–832, 2001
10. Cendoroglo M, Jaber BL, Balakrishnan VS, Perianayagam M, King AJ,
Pereira BJ: Neutrophil apoptosis and dysfunction in uremia. J Am Soc
Nephrol 10:93–100, 1999
11. Heidenreich S, Schmidt M, Bachmann J, Harrach B: Apoptosis of mono-
cytes cultured from long-term hemodialysis patients. Kidney Int 49:792–799,
1996
12. Jaber BL, Balakrishnan VS, Cendoroglo MN, Perianayagam MC, King AJ,
Pereira BJ: Modulation of neutrophil apoptosis by uremic plasma during
hemodialysis. Blood Purif 16:325–335, 1998
13. Carracedo J, Ramirez R, Madueno JA, Soriano S, Rodriguez-Benot A,
Rodriguez M, Martin-Malo A, Aljama P: Cell apoptosis and hemodialysis-
induced inflammation. Kidney Int 61(suppl 80):89–93, 2002
14. Rosenkranz AR, Peherstorfer E, Kormoczi GF, Zlabinger GJ, Mayer G,
Horl WH, Oberbauer R: Complement-dependent acceleration of apoptosis
in neutrophils by dialyzer membranes. Kidney Int Suppl 78:S216–S220, 2001
15. Martin-Malo A, Carracedo J, Ramirez R, Rodriguez-Benot A, Soriano S,
Rodriguez M, Aljama P: Effect of uremic and dialysis modality on mono-
nuclear cell apoptosis. J Am Soc Nephrol 11:936–942, 2000
16. Dini L, Coppola S, Ruzittu MT, Ghibelli L: Multiple pathways for apoptotic
nuclear fragmentation. Exp Cell Res 223:340–347, 1996
17. Thornberry NA, Rano TA, Peterson EP, Rasper DM, Timkey T, Garcia-
Calvo M, Houtzager VM, Nordstrom PA, Roy S, Vaillancourt JP, Chapman
KT, Nicholson DW: A combinatorial approach defines specificities of
members of the caspase family and granzyme B. Functional relationships
established for key mediators of apoptosis. J Biol Chem 272:17907–17911,
1997
18. Hellsing K: Influenced polymers on the antigen-antibody reaction in a con-
tinuos flow system. Colloquium on AIP, Technicon, Tarrytown, NY, May
1972
19. Ashkenazi A, Dixit VM: Death receptors. signalling and modulation. Science
281:1305, 1998
20. Varghese J, Chattopadhaya S, Sarin A: Inhibition of p38 kinase reveals a
TNF-a mediated, caspase dependent, apoptotic death pathway in a human
myelomonocyte cell line. J Immunol: 166:6570–7, 2001
21. DeSmet R, Vanholder R: Pathophysiologic effects of uremic retention sol-
utes. J Am Soc Nephrol 10:1815–1823, 1999
22. Lameire N, VanHolder R, De Smet R: Uremic toxins and peritoneal dialysis.
Kidney Int Suppl 78:292–297, 2001
23. Tarakcioglu M, Erbagci AB, Usalan C, Deveci R, Kocabas R: Acute effect of
hemodialysis on serum levels of the pro inflammatory cytokines. Mediators
Inflamm 12:9–15, 2003