In an excellent review of measures of oxidative stress, Halliwell and colleagues

discuss more broadly the different measures of oxidative stress, including reasons leading to poor correspondence between markers, like the rapid metabolism of isoprostanes compared with the slower metabolism of oxidized proteins.51 Two major goals for controlling development of CKD are early detection and slowing progression to end-stage renal disease. Using oxidative stress biomarkers in a panel of biomarkers of processes known to impact on CKD development may allow early Nivolumab price detection. Slowing its development is more problematic. Traditionally, inhibition of the renin-angiotensin-aldosterone system has been used to slow the progression of CKD,54 with established therapies relying on pharmacologic blockade of the renin-angiotensin-aldosterone system with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers. However, decline of GFR and elevated serum creatinine have continued in treated patients,55,56 and the need for novel treatments and interventions continues. Although the prophylactic use of anti-oxidant therapies in the treatment and amelioration of CKD is still in dispute, oxidant dysregulation occurs with age and age is one of the greatest risk factors for CKD. Some modifiable pathways and anti-oxidant treatments are summarized in Figure 2. There are many anti-oxidants that might be mentioned here,

but we have selected some that have some demonstrated benefits in CKD. Vitamin E comprises a family of eight different lipid-soluble tocopherols and selleck screening library tocotrienols that scavenge free radicals by incorporating into the plasma membrane of cells, thus halting lipid peroxidation chain reactions.57 Vitamin E foodstuffs primarily consist of α-tocotrienol, which has a higher anti-oxidant efficacy; however, α-tocopherol has higher bioavailability in vivo than the other

seven compounds and so the focus has been on its usage. The basis of vitamin E supplementation is to enhance α-tocopherol levels in cell plasma membranes to prevent lipid peroxidation and resultant oxidative stress. Vitamin E is often delivered with vitamin L-gulonolactone oxidase C in an attempt to boost the anti-oxidant efficacy, as vitamin C has been shown to assist in recycling vitamin E. One drawback of α-tocopherol is that it takes several days of pretreatment to exhibit anti-oxidant effects.58 Trolox (±-6-hydroxy-2,5,7,8-tetramethylchromane-2-carboxylic acid), is an analogue of α-tocopherol that has shown far better free radical scavenging properties owing to its water solubility. The majority of in vivo studies using Trolox have reported beneficial effects in acute cases of renal injury such as ischaemia reperfusion, due to rapid solubility and increased potency.59 A combination supplement containing both α-tocopherol and Trolox may offer greater efficacy due to the fast-acting activities of Trolox combined with the sustained scavenging actions of α-tocopherol.