Abolition, by dopamine blockade, of the natriuretic response produced by lower-body positive pressure

Interactions between the intrarenal dopaminergic and the renin-angiotensin systems in the control of systemic arterial pressure

Systemic arterial hypertension is one of the leading causes of morbidity and mortality in the general population, being a risk factor for many cardiovascular diseases. Although its pathogenesis is complex and still poorly understood, some systems appear to play major roles in its development. This review aims to update the current knowledge on the interaction of the intrarenal renin-angiotensin system (RAS) and dopaminergic system in the development of hypertension, focusing on recent scientific hallmarks in the field. The intrarenal RAS, composed of several peptides and receptors, has a critical role in the regulation of blood pressure (BP) and, consequently, the development of hypertension. The RAS is divided into two main intercommunicating axes: the classical axis, composed of angiotensin-converting enzyme, angiotensin II, and angiotensin type 1 receptor, and the ACE2/angiotensin-(1-7)/Mas axis, which appears to modulate the effects of the classical axis. Dopamine and its receptors are also increasingly showing an important role in the pathogenesis of hypertension, as abnormalities in the intrarenal dopaminergic system impair the regulation of renal sodium transport, regardless of the affected dopamine receptor subtype. There are five dopamine receptors, which are divided into two major subtypes: the D1-like (D1R and D5R) and D2-like (D2R, D3R, and D4R) receptors. Mice deficient in any of the five dopamine receptor subtypes have increased BP. Intrarenal RAS and the dopaminergic system have complex interactions. The balance between both systems is essential to regulate the BP homeostasis, as alterations in the control of both can lead to hypertension.

Vasopressor Therapy in the Intensive Care Unit

After fluid administration for vasodilatory shock, vasopressors are commonly infused. Causes of vasodilatory shock include septic shock, post-cardiovascular surgery, post-acute myocardial infarction, postsurgery, other causes of an intense systemic inflammatory response, and drug -associated anaphylaxis. Therapeutic vasopressors are hormones that activate receptors-adrenergic: α1, α2, β1, β2; angiotensin II: AG1, AG2; vasopressin: AVPR1a, AVPR1B, AVPR2; dopamine: DA1, DA2. Vasopressor choice and dose vary widely because of patient and physician practice heterogeneity. Vasopressor adverse effects are excessive vasoconstriction causing organ ischemia/infarction, hyperglycemia, hyperlactatemia, tachycardia, and tachyarrhythmias. To date, no randomized controlled trial (RCT) of vasopressors has shown a decreased 28-day mortality rate. There is a need for evidence regarding alternative vasopressors as first-line vasopressors. We emphasize that vasopressors should be administered simultaneously with fluid replacement to prevent and decrease duration of hypotension in shock with vasodilation. Norepinephrine is the first-choice vasopressor in septic and vasodilatory shock. Interventions that decrease norepinephrine dose (vasopressin, angiotensin II) have not decreased 28-day mortality significantly. In patients not responsive to norepinephrine, vasopressin or epinephrine may be added. Angiotensin II may be useful for rapid resuscitation of profoundly hypotensive patients. Inotropic agent(s) (e.g., dobutamine) may be needed if vasopressors decrease ventricular contractility. Dopamine has fallen to almost no-use recommendation because of adverse effects; angiotensin II is available clinically; there are potent vasopressors with scant literature (e.g., methylene blue); and the novel V1a agonist selepressin missed on its pivotal RCT primary outcome. In pediatric septic shock, vasopressors, epinephrine, and norepinephrine are recommended equally because there is no clear evidence that supports the use of one vasoactive agent. Dopamine is recommended when epinephrine or norepinephrine is not available. New strategies include perhaps patients will be started on several vasopressors with complementary mechanisms of action, patients may be selected for particular vasopressors according to predictive biomarkers, and novel vasopressors may emerge with fewer adverse effects.

Dopamine and renal function and blood pressure regulation

Dopamine is an important regulator of systemic blood pressure via multiple mechanisms. It affects fluid and electrolyte balance by its actions on renal hemodynamics and epithelial ion and water transport and by regulation of hormones and humoral agents. The kidney synthesizes dopamine from circulating or filtered L-DOPA independently from innervation. The major determinants of the renal tubular synthesis/release of dopamine are probably sodium intake and intracellular sodium. Dopamine exerts its actions via two families of cell surface receptors, D1-like receptors comprising D1R and D5R, and D2-like receptors comprising D2R, D3R, and D4R, and by interactions with other G protein-coupled receptors. D1-like receptors are linked to vasodilation, while the effect of D2-like receptors on the vasculature is variable and probably dependent upon the state of nerve activity. Dopamine secreted into the tubular lumen acts mainly via D1-like receptors in an autocrine/paracrine manner to regulate ion transport in the proximal and distal nephron. These effects are mediated mainly by tubular mechanisms and augmented by hemodynamic mechanisms. The natriuretic effect of D1-like receptors is caused by inhibition of ion transport in the apical and basolateral membranes. D2-like receptors participate in the inhibition of ion transport during conditions of euvolemia and moderate volume expansion. Dopamine also controls ion transport and blood pressure by regulating the production of reactive oxygen species and the inflammatory response. Essential hypertension is associated with abnormalities in dopamine production, receptor number, and/or posttranslational modification.

A comparison of autonomic responses in humans induced by two simulation models of weightlessness: lower body positive pressure and 6 degrees head-down tilt

Six-degree head-down tilt (HDT) is well accepted as an effective weightlessness model in humans. However, some researchers utilized lower body positive pressure (LBPP) to simulate the cardiovascular and renal effects of a decreased gravitational stress. In order to determine whether LBPP was a suitable model for simulated weightlessness, we compared the differences between these two methods. Ten healthy males, aged 21-41 years, were subjected to graded LBPP at 10, 20 and 30 mmHg, as well as 6 degrees HDT. Muscle sympathetic nerve activity (MSNA) was microneurographically recorded from the tibial nerve along with cardiovascular variables. We found that MSNA decreased by 27% to a similar extent both at low levels of LBPP (10 and 20 mmHg) and HDT. However, at a high level of LBPP (30 mmHg), MSNA tended to increase. Mean arterial pressure was elevated significantly by 11% (10 mmHg) at 30 mmHg LBPP, but remained unchanged at low levels of LBPP and HDT. Heart rate did not change during the entire LBPP and HDT procedures. Total peripheral resistance markedly increased by 36% at 30 mmHg LBPP, but decreased by 9% at HDT. Both stroke volume and cardiac output tended to decrease at 30 mmHg LBPP, but increased at HDT. These results suggest that although both LBPP and HDT induce fluid shifts from the lower body toward the thoracic compartment, autonomic responses are different, especially at LBPP greater than 20 mmHg. We note that high levels of LBPP (>20 mmHg) activate not only cardiopulmonary and arterial baroreflexes, but also intramuscular mechanoreflexes, while 6 degrees HDT only activates cardiopulmonary baroreflexes. We conclude that LBPP is not a suitable model for simulated weightlessness in humans.

Renal dopamine receptors in health and hypertension

During the past decade, it has become evident that dopamine plays an important role in the regulation of renal function and blood pressure. Dopamine exerts its actions via a class of cell-surface receptors coupled to G-proteins that belong to the rhodopsin family. Dopamine receptors have been classified into two families based on pharmacologic and molecular cloning studies. In mammals, two D1-like receptors that have been cloned, the D1 and D5 receptors (known as D1A and D1B, respectively, in rodents), are linked to stimulation of adenylyl cyclase. Three D2-like receptors that have been cloned (D2, D3, and D4) are linked to inhibition of adenylyl cyclase and Ca2+ channels and stimulation of K+ channels. All the mammalian dopamine receptors, initially cloned from the brain, have been found to be expressed outside the central nervous system, in such sites as the adrenal gland, blood vessels, carotid body, intestines, heart, parathyroid gland, and the kidney and urinary tract. Dopamine receptor subtypes are differentially expressed along the nephron, where they regulate renal hemodynamics and electrolyte and water transport, as well as renin secretion. The ability of renal proximal tubules to produce dopamine and the presence of receptors in these tubules suggest that dopamine can act in an autocrine or paracrine fashion; this action becomes most evident during extracellular fluid volume expansion. This renal autocrine/paracrine function is lost in essential hypertension and in some animal models of genetic hypertension; disruption of the D1 or D3 receptor produces hypertension in mice. In humans with essential hypertension, renal dopamine production in response to sodium loading is often impaired and may contribute to the hypertension. The molecular basis for the dopaminergic dysfunction in hypertension is not known, but may involve an abnormal post-translational modification of the dopamine receptor.

Dopamine-2 receptor blockade potentiates the renal effects of nitric oxide inhibition in humans

In eight young healthy subjects on a 240 mM Na diet mean arterial pressure (MAP), renal hemodynamics and renal handling of Na and exogenous Li were measured at baseline and during acute nitric oxide (NO) inhibition with 90-minute infusion of 3.0 microg/kg x min(-1) of N(G)-L-arginine methyl ester (L-NAME). The same experiment was repeated with infusion of 50 microg/kg x min(-1) of DA2 receptor blocker L-Sulpiride (L-SULP) alone and, finally, with simultaneous infusion of both L-NAME and L-SULP. L-SULP alone did not elicit any effect. L-NAME alone produced no changes in MAP from 0 to 45 minutes (P1) and a 6.6% increase at 45 to 90 minutes (P2) of infusion. Effective renal plasma flow (ERPF, PAH clearance) and glomerular filtration rate (GFR, inulin clearance) declined by 10.2% and 7.6%, respectively, in P1 and by 15.3% and 11.5% in P2. Filtration Fraction (FF) rose by 4.2% in P2. Calculated renal vascular resistance (RVR) increased by 13.0% to 25.6%. Fractional excretion of Na (FENa) and Li (FELi) fell by 20.0% and by 16.0%, respectively, in P1 and by 40.0% and 25.1% in P2. All these variations, except for MAP and GFR, were significantly greater during coinfusion of L-NAME and L-SULP. ERPF declined by 17.8% to 33.7%, FENa by 26.7% to 53.3%, FELi by 13.8% to 34.8%, while RVR rose by 22.5% to 59.1% and FF by 10.1% to 29.3%. The present data confirm that NO blockade with low-dose systemic infusion of L-NAME produces renal vasoconstriction, reduced GFR with slight increase in FF, and enhanced tubular Li, and Na reabsorption. Since increase in RVR and FF and decrease in FENa and FELi are markedly potentiated by the simultaneous infusion of DA2 blocker L-SULP, which exerts no effects by itself, we suggest that DA interactions between DA system at the level of DA2 receptors and basal NO production play a physiological role in the regulation of renal function in humans.

Gravitational stress and volume regulation

During the past 3 decades, groundbased experiments have been performed in order to investigate the effects of increased and decreased gravitational stress, respectively, on the renal response in humans. Experiments that simulate an increase in gravitational load (+Gz) to the subjects (centrifugation, passive head-up titlt [HUT] or lower body negative pressure [LBNP] have clearly demonstrated a decrease in renal sodium and water excretion. Simultaneously, increases in plasma levels of arginine vasopressin (AVP), renin activity (PRA), aldosterone (PA), norepinephrine (NE) and decreases in ANP have been observed. Additionally, experiments that have utilized immersion of seated subjects to simulate a decreased gravitational stress (approximately 0 Gz) have demonstrated that renal water and sodium excretion increases by 100-400% and that plasma AVP, PRA, PA, and NE concentrations are reduced and ANP levels increased. Alternative experimental models conducted to simulate the effects of weightlessness in humans such as head-down tilt (HDT) and lower body positive pressure (LBPP) have yielded less consistent results than those of water immersion (WI) with respect to renal function. However, compared to a seated control HDT clearly induces an increased rate of renal fluid and sodium excretion. The demonstration that central volume expansion during WI is accompanied by an increase in renal fluid and electrolyte excretion and that central hypovolaemia during centrifugation, HUT, and LBNP is accompanied by the opposite effects indicate that changes in central blood volume is an important determinant of the renal functional changes. Results of experiments in humans during weightlessness in space are inconsistent and difficult to interpret. However, they have indicated that a cephalad redistribution of blood and fluid occurs and that this is accompanied by a decrease in total body fluid. Experimental models that, respectively, increase and decrease the gravitational stress in humans constitute promising tools in the investigation of the physiology and pathophysiology of volume regulation.

Altered dopaminergic responses in hypertension

Biogenic amine metabolism may be altered in hypertension and thus contribute to its pathophysiology. This report describes an abnormality in dopamine excretion in hypertensive subjects in the postabsorptive state that persists despite an increase in dietary precursors for dopamine supplied by a protein meal. We studied seven normotensive and six nonmedicated hypertensive men after two different meals: 60 g protein and a noncaloric electrolyte-equivalent broth. Overall mean sodium excretion was 56% higher in the hypertensive group throughout both meal studies (p less than 0.01), implying higher chronic dietary sodium intake. Despite this, overall urinary excretion of dopamine tended to be lower in hypertensive than in normotensive subjects (p = 0.06). Hypertensive also differed from normotensive subjects in their response to protein feeding. In the normotensive subjects there was a 23% increase in urinary dopamine excretion (p less than 0.05), which was not seen after the noncaloric meal. In the hypertensive subjects, there was no change in urinary dopamine after the protein meal. In the normotensive subjects there was a 74% increase in sodium excretion (p less than 0.01) after the protein meal, but no significant change was seen in the hypertensive subjects. There were no differences in baseline renal plasma flow or glomerular filtration rate between the groups and no statistically significant differences between the groups in their renal hemodynamic responses to the meals. In summary, hypertensive subjects have less renal dopamine production for the amount of sodium ingested and a decreased renal dopamine production in response to a protein load as compared with normotensive subjects, consistent with a renal defect in conversion of DOPA to dopamine.

High urinary dopa and low urinary dopamine-to-dopa ratio in salt-sensitive hypertension

Dopamine in urine is derived substantially from renal uptake and decarboxylation of 3,4-dihydroxyphenylalanine (dopa), and increases in excretion of dopa normally parallel increases in excretion of dopamine during salt loading. Since patients with salt-sensitive hypertension may have decreased urinary excretion of dopamine during dietary salt loading, the present study was designed to evaluate the response of dopa to salt loading. Sixteen inpatients with normal-renin essential hypertension ate a constant metabolic diet containing 9 mmol/day sodium for 7 days, followed by the same diet but containing 249 mmol/day sodium for 7 days. Salt sensitivity was defined as an increase in mean arterial pressure of 8 mm Hg between the diets; on this basis, nine patients were salt-sensitive and seven, salt-resistant. The rate of urinary dopa excretion was significantly higher in the salt-sensitive patients throughout the study (mean rates 132 +/- 13 nmol/day in the salt-sensitive group and 78 +/- 9 nmol/day in the salt-resistant group for the 14 days of observation, p less than 0.01). When dietary sodium intake was increased to 249 mmol/day, urinary dopa excretion increased significantly more in salt-sensitive patients than salt-resistant patients. At the end of the high salt diet, dopamine excretion was significantly attenuated in the salt-sensitive patients, despite higher rates of dopa excretion. Thus, the urinary ratio of dopamine to dopa was decreased in salt-sensitive patients, regardless of salt intake.(ABSTRACT TRUNCATED AT 250 WORDS)

A functional role for renal dopaminergic nerves in the dog

1. Efferent renal nerve stimulation at 5 Hz causes secretion of both dopamine (DA) and noradrenaline (NA) into renal venous plasma. DA comprises about 8% of the total catecholamine overflow; by contrast, DA efflux into femoral venous plasma following stimulation of the lumbar sympathetic nerves is 1% or less of total catecholamine. 2. Intact, but not denervated, kidneys of volume-loaded dogs also secrete both dopamine (DA) and noradrenaline (NA) into renal venous blood at rest, but the DA:NA ratio is considerably higher than that evoked by nerve stimulation. 3. Acute animal treatment with 6-hydroxydopamine (6-OHDA) abolishes stimulus-evoked catecholamine overflow and the usual fall in glomerular filtration and sodium and water excretion that accompanies renal nerve activation. 4. When 6-OHDA is administered in the presence of a selective inhibitor of UptakeDA (GBR 12909), stimulus-evoked DA overflow is selectively protected against the effect of 6-OHDA. Under these circumstances, nerve stimulation increases glomerular filtration and excretion of water, but not of sodium. These effects are abolished by DA1 receptor blockade. 5. These data indicate that DA is released from intrarenal dopaminergic nerve terminals in vivo, both in response to direct nerve stimulation and tonically under conditions of volume expansion. The main effects of dopaminergic nerve activation are juxtaglomerular vasodilatation and inhibition of distal tubular water reabsorption.

Atrial natriuretic factor and central venous pressure during intermittent and continuous lower-body positive pressure in healthy humans

In eight healthy volunteers undergoing 16 experiments in a cross-over design central venous pressure (CVP) and atrial natriuretic factor (ANF) in central venous plasma were measured during a 30 min control period followed by three separated periods of 10 min lower-body positive pressure (LBPP) or 90 min continuous LBPP induced by inflation of a military anti-G suit to evaluate the effect of short repeated and of extended increases in right atrial pressure on plasma ANF levels. CVP increased significantly during each of three separate periods of intermittent LBPP, and 15 min after application of continuous LBPP (P less than 0.025 for all). Blood pressure and heart rate did not change. During intermittent LBPP plasma ANF levels increased 10 min after the first inflation of the MAGT-suit (P = 0.013), but not after the second or third inflation. During continuous LBPP plasma ANF remained unchanged until 90 min after application of LBPP where a significant rise was observed (P = 0.023). The data demonstrate that the ANF response to short-term increases in right atrial pressure, as small as 2.5 mmHg, is maximal within 10 min and that repeated pressure stimuli may decrease ANF release. Sustained increases in right atrial pressure are not associated with increases in plasma ANF until long after initiation of the pressure stimulus suggesting rapid receptor-binding of ANF and that the ANF receptors might be saturated during continuously elevated ANF levels.

Increased urinary 6-keto-PGF1 alpha excretion during water immersion is blunted by metoclopramide in normal man

Urinary excretion of 6-keto-PGF1 alpha and 2,3 dinor-6-keto-PGF1 alpha, as indices of the renal and systemic production of prostaglandins, was measured during water immersion in a group of 6 healthy volunteers both in the presence and absence of dopamine blockade by the dopamine receptor antagonist, metoclopramide. Urinary flow rate and excretion of both sodium and 6-keto-PGF1 alpha increased during water immersion, while plasma renin activity and plasma aldosterone were reduced. Urinary kallikrein and 2,3 dinor-6-keto-PGF1 alpha also tended to increase during water immersion. Administration of metoclopramide significantly reduced 6-keto-PGF1 alpha and sodium excretion during water immersion, but produced no changes in plasma renin activity or in 2,3 dinor-6-keto-PGF1 alpha. Plasma aldosterone concentrations after metoclopramide were similar to those observed in the pre-immersion period. An increased synthesis of the vasodilator and natriuretic prostacyclin in the kidney might play a role in the response to water immersion. The reduced sodium and 6-keto-PGF1 alpha excretion observed after metoclopramide administration suggests that dopamine might induce prostacyclin synthesis in the kidney during water immersion.

A comparison of head-down tilt with low-dose infusion of atrial natriuretic peptide in man

1. Procedures that increase atrial pressure, such as head-down tilt, result in an increase in plasma atrial natriuretic peptide (ANP) and a natriuresis, but a direct cause-and-effect relationship between these two responses has not been established. This study was undertaken to compare the effects of head-down tilt with exogenous ANP on renal function. 2. Eight normal sodium-replete volunteers underwent a 3 h placebo infusion, a 3 h ANP infusion at 1.2 pmol kg-1 min-1 and a 3 h period of head-down tilt. Each procedure was performed on a separate day, in random order. 3. ANP and head-down tilt produced similar increases in sodium excretion (65 +/- 24 and 68 +/- 16%, respectively). ANP did not increase urine flow significantly more than placebo. Head-down tilt increased urine flow significantly more than placebo and ANP. 4. Plasma ANP rose from 8.1 +/- 1.0 to 11.4 +/- 2.5 pg ml-1 during head-down tilt and from 6.5 +/- 1.4 to 32.3 +/- 10.7 pg ml-1 with ANP infusion. 5. ANP infusion had no significant effects on systemic haemodynamics whilst head-down tilt increased cardiac output and reduced heart rate and an index of systemic vascular resistance. 6. ANP infusion, whilst achieving a natriuretic response similar to that of tilt, was associated with a 3-fold higher mean plasma ANP level. Although plasma ANP rose during both ANP infusion and tilt, there was a lack of correlation between natriuretic response and plasma ANP. 7. The results are not compatible with a direct cause-and-effect relationship between plasma ANP and sodium excretion during head-down tilt.

Evidence that dopaminergic sympathetic axons supply the medullary arterioles of human kidney

The ability of the kidney to excrete sodium appears to depend on release of dopamine from intrarenal sources. In the present study, we have used immunohistochemistry to examine the possibility that renal dopaminergic nerves constitute one of these sources. We found that the sympathetic axons supplying cortical structures in human kidney contain tyrosine hydroxylase-like immunoreactivity but lack DOPA decarboxylase-like immunoreactivity. By contrast, the vasa recta arterioles of the renal medulla are supplied by varicose tyrosine hydroxylase-positive nerve fibres, some of which also contain DOPA decarboxylase. As DOPA decarboxylase has been demonstrated in other situations to be a selective marker for dopaminergic terminal axons, our results suggest the innervation of renal medullary blood vessels in man by both noradrenergic and dopaminergic sympathetic nerves.

Comparison of resting and stimulus-evoked catecholamine release from the femoral and renal vascular beds of the dog

Plasma levels of dopamine (DA) and noradrenaline (NA) were measured in arterial and in femoral and renal venous blood of chloralose-anaesthetised dogs at rest, and during electrical stimulation of the femoral and renal sympathetic nerve supplies. In the femoral bed, sympathetic nerve stimulation elevated venous efflux of NA, but did not reproducibly elevate DA efflux: when this was increased, it comprised less than 1% of the stimulus-evoked catecholamine efflux. By contrast, renal nerve stimulation liberated both NA and DA from the kidney, and DA comprised about 8% of the total stimulus-evoked efflux. Comparison of efflux from intact and denervated kidneys indicated substantial neurogenic release of both NA and DA at rest, with DA comprising 20% of this efflux. The results extend previous evidence for dopaminergic sympathetic innervation of the dog kidney, and suggest that both dopaminergic and noradrenergic renal nerves are tonically active in anaesthetised animals.

Endogenous renal dopamine and control of blood pressure

Activation of specific receptors for dopamine in the renal vasculature and tubules leads to increases in glomerular filtration, and to diuresis and natriuresis. There is evidence for intrarenal production and release of dopamine, which may originate from two sources: tubular decarboxylation of plasma l-DOPA and a population of dopaminergic sympathetic neurons that innervate the renal cortex. Studies of plasma and urinary catecholamine levels indicate that dopamine is released within the kidney in response to sodium loading and to activation of sensory pathways related to nociception and chemoreception. There is also evidence for deficient renal release of dopamine in patients with renovascular or essential hypertension. Collectively, the available data suggest that intrarenal dopamine has a physiological function in control of blood volume and blood pressure, and that defects in this control may be implicated in the aetiology of some hypertensive states.

Domperidone treatment in man inhibits the fall in plasma renin activity induced by intravenous gamma-L-glutamyl-L-dopa

The dopamine pro-drug gamma-L-glutamyl-L-dopa (gludopa) was administered intravenously to six normal subjects at a dose of 12.5 micrograms min-1 kg-1, either with or without the dopamine antagonist domperidone. A control was provided by the intravenous infusion of domperidone and saline on a separate occasion. Intravenous gludopa produced a significant natriuresis, whether administered alone or in combination with domperidone. After gludopa infusion, there was a significant fall in plasma renin activity, an effect which was attenuated significantly by concomitant treatment with domperidone. These observations suggest that blockade of renal DA2 dopamine receptors has little or no effect on gludopa-induced natriuresis, but that at least part of the dopaminergic inhibition of renin release is mediated by renal DA2 receptors.

Shoulder-out immersion in pregnant women

In the laboratory, water immersion or lower body positive pressure produces significant diuresis and natriuresis. Shoulder-out immersion appeared to induce significant diuresis and natriuresis in 42 pregnant women who were exercising in swimming pools. Lower body positive pressure (pressure calf sleeves) or Hubbard tanks (bathtubs) was not associated with increased renal function. In selected pregnant women with abnormal water distribution, shoulder-out immersion may prove to be effective therapy.