Targeting the Renin-angiotensin System: Whats New?

The renin-angiotensin system is a key target for drugs combating cardiovascular disease. Angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor type-1 (AT1 receptor) blockers are well known. However, angiotensin peptides can be generated through a number of pathways besides the classic system. This review outlines some of these pathways, their relation to the classic system and the likely effect of inhibiting them. Renin is still the key enzyme in angiotensin peptide generation and seems to be the only route to angiotensin I formation in vivo. Renin inhibitors may have some advantages in terms of specificity. Also, by blocking angiotensin I generation, the production of downstream bioactive angiotensin I metabolites should also be blocked. Chymase, a mast cell serine protease, cleaves angiotensin I to produce angiotensin II and may be important at sites of inflammation such as atherosclerotic plaque. Angiotensin-converting enzyme 2 (ACE2), a carboxypeptidase structurally related to ACE but resistant to ACE inhibitors, has a protective effect on cardiac function. Neutral endopeptidase 24.11 breaks down both atrial natriuretic peptide and angiotensin II. Inhibiting it potentiates the action of endogenous atrial peptide but only affects circulating angiotensin II when basal levels are above normal. Dual inhibitors of ACE and endopeptidase 24.11 may be of value where there is both sodium retention and increased angiotensin II. Targeting the renin-angiotensin system by gene therapy or antibody treatment may provide a longer-term treatment for hypertension.

The action of salt and captopril on blood pressure in mice with genetic hypertension

OBJECTIVE

Does captopril lower blood pressure in genetically hypertensive, normotensive and hypotensive mice under normal and salt-loaded conditions?

DESIGN AND METHODS

Groups of inbred mice that were genetically hypertensive, normotensive or hypotensive were given one of the following treatments: (a) captopril in drinking water for 7 days; controls were given water. (b) 0.85% saline to drink for up to 14 days; controls were given water. (c) Water or saline followed by captopril/water or captopril/saline for 7 days. (d) In hypotensive mice only, 0.85% saline, 0.85% saline plus captopril, water or captopril in water. Systolic blood pressures (SBP) were measured by a computerized tail-cuff sphygmomanometer. Results were compared by analysis of variance (ANOVA).

RESULTS

Captopril lowered SBP in all strains of mice. When saline was given with captopril, the fall in SBP was slower but the final SBP level was similar to that of mice given captopril in water. Hypotensive mice showed a transient rise in SBP on saline, which was abolished by concurrent treatment with captopril.

CONCLUSION

Captopril lowers blood pressure in hypertensive, normotensive and hypotensive mice. Salt-loading retards the captopril-induced fall in SBP, but the final level of SBP achieved is similar to that in mice given captopril with water. The BPL1 strain of mouse was slightly salt-sensitive, and this was abolished by captopril.

Polymorphisms of the renin gene promoter in spontaneously hypertensive and Wistar-Kyoto rats

1. In the present study, 1.39 kb of the renin gene 5' region in spontaneously hypertensive rats (SHR) and Wistar-Kyoto (WKY) rats was amplified by polymerase chain reaction from genomic DNA and sequenced. Consistent differences in the renin gene sequence of SHR and WKY rats were found at positions -725, -727, -979 and -1126/-1129 as numbered from the transcription start site (+1). No polymorphism was specific to hypertensive rats. 2. Gel-shift assays were performed using labelled SHR renin promotor DNA and nuclear proteins extracted from rat kidneys. The regions between -1122 and -1139 and between -701 and -797 showed protein binding.

The expression of renin-binding protein and renin in the kidneys of rats with two-kidney one-clip hypertension

OBJECTIVE

To test the hypothesis that renin-binding protein (RnBP) is involved in modulating the intracellular processing or release of renin, we examined the expression of RnBP in clipped and contralateral kidneys of rats with two-kidney one-clip hypertension, and in left and right kidneys from sham-operated control rats.

DESIGN AND METHODS

Kidneys from rats with two-kidney one-clip hypertension and from control rats were either snap-frozen for extraction of mRNA or fixed for in-situ hybridization and immunochemistry. Reverse-transcription polymerase chain reaction on renal mRNA was performed using primers for renin, RnBP, glyceraldehyde-3-phosphate dehydrogenase (GAPDH) and angiotensin-converting enzyme (ACE). In addition, renal total RNA was analysed by Northern blotting for RnBP, GAPDH and angiotensin II type 1A (AT1A) receptor mRNA, and the intensity of the bands was measured by laser densitometry. In situ hybridization for renin mRNA was carried out using digoxygenin-labelled antisense oligonucleotides and for RnBP using labelled antisense oligonucleotides and an antisense riboprobe. Controls included sections treated with RNase and sections stained with sense oligonucleotides.

RESULTS

The level of expression of mRNA for RnBP is similar in clipped and contralateral kidneys of renal hypertensive rats; in contrast, renin mRNA expression is upregulated in the clipped kidney. Renin-binding protein is expressed mainly in renal tubules and collecting ducts unlike renin, which is expressed in the glomerular afferent arteriole. We did not detect lateralization of expression for ACE or the AT1A receptor between clipped and contralateral kidneys.

CONCLUSION

Renin-binding protein expression is unchanged between clipped and contralateral kidneys. Therefore, a physiological stimulus that upregulates renin gene expression in clipped kidneys does not affect RnBP expression. The main sites of RnBP expression are the renal tubules and collecting ducts; in contast renin is expressed at the glomerular pole. The results show that RnBP is not colocalized or coregulated with renin in this model of hypertension.

Reduced vas deferens contraction and male infertility in mice lacking P2X1 receptors

P2X1 receptors for ATP are ligand-gated cation channels, present on many excitable cells including vas deferens smooth muscle cells. A substantial component of the contractile response of the vas deferens to sympathetic nerve stimulation, which propels sperm into the ejaculate, is mediated through P2X receptors. Here we show that male fertility is reduced by approximately 90% in mice with a targeted deletion of the P2X1 receptor gene. Male mice copulate normally--reduced fertility results from a reduction of sperm in the ejaculate and not from sperm dysfunction. Female mice and heterozygote mice are unaffected. In P2X1-receptor-deficient mice, contraction of the vas deferens to sympathetic nerve stimulation is reduced by up to 60% and responses to P2X receptor agonists are abolished. These results show that P2X1 receptors are essential for normal male reproductive function and suggest that the development of selective P2X1 receptor antagonists may provide an effective non-hormonal male contraceptive pill. Also, agents that potentiate the actions of ATP at P2X1 receptors may be useful in the treatment of male infertility.

Potent in vivo inhibitors of rat renin: analogues of human and rat angiotensinogen sequences containing different classes of pseudodipeptides at the scissile site

Using solid-phase methodology we have synthesised peptides based on the 8-14 or 6-14 human and rat angiotensinogen sequences, containing the following different isosteric units at the P1-P1' cleavage site: Leu-psi[CH2NH]Leu; Leu-psi[CH(OH)CH2]Val; Leu-psi[CH(OH)CH2]Leu and Leu-psi[CH(NH2)CH2]Val. In vitro, peptide Piv-His-Pro-Phe-His-Leu-psi[CH(OH)CH2]Leu-Tyr-Tyr-Ser-NH2(XXI) is the most potent inhibitor of rat plasma renin reported having an IC50 of 0.21 nM; it is a much weaker inhibitor of human renin (IC50 45 nM). Peptide Boc-His-Pro-Phe-His-Leu-psi[CH(OH)CH2] Leu-Val-Ile-His-NH2 (XX) was a highly effective inhibitor of rat renin in vivo. When infused (1 mg/kg/h) into two-kidney, one-clip chronic renal hypertensive rats, it lowered blood pressure and suppressed both plasma renin and angiotensin II. When given as a bolus (1 mg/kg) there was a divergence between the rapid rebound of renin levels and blood pressure, which remained suppressed. These results indicate that potent in vivo inhibitors of rat renin could be useful not only in examining the role of circulating renin but also in elucidating the equally important involvement of extracirculatory renin pools.

New renin inhibitors containing novel analogues of statine

Solid-phase methodology has been used to synthesize a series of peptides based on the N-terminal sequence of human angiotensinogen in which statine (Sta) or the novel analogues (3S,4S)-3,4-diamino- or (3R,4S)-3,4-diamino-6-methylheptanoic acid (Ads or R-Ads) and (3S,4S)-4-amino-3-aminomethyl- or (3R,4S)-4-amino-3-aminomethyl-6-methylheptanoic acid (Amd or R-Amd) replace either residue 10 or both residues 10-11 at the P1-P1' cleavage site. The synthesis of these novel analogues of statine together with biological results on the inhibition of human and rat renin by peptides derived from them is reported. The absolute stereochemistry of the (3S,4S) Ads was determined by an X-ray crystallographic analysis of its N gamma-Boc, B beta-Z, R(+)-1-methyl benzamide derivative. Peptide Boc-His-Pro-Phe-His-Sta-Val-Ile-His-NH2 (VI) is the best inhibitor of human renin containing Sta at position 10. However, peptides containing Ads and Amd gave better rat renin inhibitors than the corresponding Sta-containing peptides. Peptides Boc-His-Pro-Phe-His-Ads-Val-Ile-His-NH2 (VII) having Ads at position 10 had an IC50 of 12 nM against rat renin. Although Sta has come to be accepted as an isosteric replacement for a dipeptide unit rather than for a single amino acid residue, in our series of inhibitors Sta is more effective when replacing only the amino acid at position 10 in the natural angiotensinogen sequence. None of the peptides gave any effect in vivo in a hypertensive rat model.

Relation between renin and prorenin in plasma from hypertensive patients and normal people: evidence for different renin:prorenin ratios

Renin and prorenin concentrations in plasma correlate closely, but the proportion of active renin to prorenin shows some variation in different forms of hypertension. The proportion of active renin to prorenin is higher in normal renin essential hypertensives and in patients with renal hypertension than in normal subjects, and it is lower in low renin essential hypertension and primary hyperaldosteronism. Plasma deficient in plasma prekallikrein shows a lower proportion of active renin than might be expected. Active renin and plasma angiotensin II concentration show a strong correlation while prorenin correlates weakly with plasma angiotensin II concentration.

Renin in Wilms' tumor: prorenin as an indicator

In a prospective study, 25 children with nephroblastoma (Wilms' tumor) had preoperative plasma prorenin and renin concentrations measured. The mean plasma renin and prorenin concentrations in the patients were raised compared with a control group of patients without nephroblastoma. Four children had recurrence of tumor and, in three, this was associated with an increase in plasma prorenin concentration. Nephroblastoma tissue contained immunoreactive renin and renin messenger RNA, and the renin protein was immunologically and biochemically similar to normal human renin. We conclude that prorenin concentrations in plasma are an indicator of nephroblastoma.

Second messengers involved in the control of renin secretion in cultured human nephroblastoma cells

We aimed to study the intracellular signaling mechanisms involved in the stimulation and suppression of renin secretion from human nephroblastoma cells. Isoproterenol and forskolin increased intracellular adenosine 3',5'-cyclic monophosphate (cAMP) concentration and stimulated renin secretion as did the addition of dibutyryl-cAMP. Atrial natriuretic peptide (ANP) suppressed basal renin secretion and increased the concentration of extracellular guanosine 3',5'-cyclic monophosphate (cGMP). When ANP was added in the presence of isoproterenol or forskolin, the increase in cGMP was reduced. ANP attenuated the cAMP response to isoproterenol but not forskolin. Nephroblastoma cell membranes contained the guanosine-binding proteins Gs and Gi2, and the isoforms were similar to those in vascular smooth muscle. A functional role for Gi was indicated because the ANP-induced suppression of basal renin secretion was blocked by pertussis toxin. We conclude that cAMP stimulates and cGMP suppresses basal renin secretion, but neither fully accounts for the suppression of stimulated renin secretion by ANP.

Renal ischaemia, transient glomerular leak and acute renal tubular damage in patients envenomed by Russell's vipers (Daboia russelii siamensis) in Myanmar

Fifty-two patients who had been bitten by Russell's vipers in Myanmar developed acute renal failure (serum creatinine exceeding 1.3 mg/dL). Thirty-four of them (65%) became oliguric, but the other 18 (35%) maintained a urine output of more than 400 mL/24 h. In oliguric patients, gastrointestinal haemorrhages, renal angle tenderness and conjunctival oedema occurred more commonly, and peak serum creatinine, blood urea nitrogen and the fractional excretion of sodium were significantly higher (P < 0.01) than in non-oliguric patients, indicating a greater degree of renal damage. Urinary concentrations of beta 2 microglobulin and retinol binding protein were raised in most of the patients indicating failure of proximal tubular reabsorption of these proteins, while high urinary N-acetyl glucosaminidase concentrations were consistent with renal tubular damage. Plasma concentrations of active renin were very high, suggesting that renal ischaemia, associated with activation of the renin-angiotensin system, was involved in the development of renal dysfunction.

Hormonal control of atrial natriuretic peptide synthesis and secretion from cultured atrial myocytes

We have established optimal culture conditions for growing well-differentiated atrial myocytes from newborn rats. These myocytes show the morphological features of myocytes in intact atria; including perinuclear endocrine storage granules, contractile apparatus and numerous mitochondria. The cells synthesise, store and secrete immunoreactive ANP. Stored ANP is of similar molecular weight to pro-ANP (1-126); secreted ANP is the active form ANP (99-126) but processing appears to take place slowly after secretion. ANP secretion is stimulated by endothelin. Synthesis and secretion of ANP are markedly reduced by the beta-adrenergic agonist isoproterenol, and by forskolin.

Dexamethasone-induced differentiation of atrial myocytes in culture

Atrial and ventricular myocytes from fetal and newborn rats were cultured in medium supplemented with fetal or newborn calf serum with and without glucocorticoid. Myocyte morphology was examined by light and electron microscopy, and the amount of stored and secreted atrial natriuretic peptide (ANP) was measured. Without dexamethasone, neonatal atrial myocytes cultured for 7 days contained myofibrils organized into sarcomeres and numerous endocrine granules containing immunostainable ANP. Secretion of immunoreactive ANP reached a peak between days 7 and 9 of culture. Myocytes from fetal rats secreted ANP but contained few endocrine granules, and myofilaments were poorly organized. By contrast, the addition of dexamethasone (1 nM-1 microM) to the culture medium of newborn myocytes promoted development of numerous endocrine storage granules, mitochondria, and myofibrils with prominent Z-bands. Dexamethasone also increased the cellular content of ANP and ANP-specific mRNA in both atrial and ventricular myocytes. In the presence of dexamethasone myocytes maintained their structural integrity for periods of at least 45 days.

Atrial natriuretic peptide suppresses isoprenaline and dibutyryl cyclic adenosine monophosphate-induced cell growth in cultured renin-secreting human nephroblastoma cells. Comparison with forskolin-induced renin secretion

OBJECTIVE

Renin secretion in response to long-term exposure to isoprenaline, dibutyryl cyclic adenosine monophosphate (dbcAMP), forskolin and atrial natriuretic peptide (ANP) was measured in cultured human nephroblastoma cells.

METHODS

Human nephroblastoma cells in culture were treated long-term (1-12 days) with isoprenaline, dbcAMP or forskolin, alone or in combination with ANP; renin release and cell growth were studied.

RESULTS

The increase in renin output caused by isoprenaline and dbcAMP could be accounted for by stimulation of cell growth. The effect of isoprenaline was blocked by propranolol. Forskolin stimulated renin secretion per cell. ANP increased extracellular cyclic guanosine monophosphate and suppressed basal renin output. Suppression of basal renin output was due to a reduced secretion rate per cell, without a change in cell growth. ANP suppressed isoprenaline-induced and dbcAMP-induced renin output by blocking increased cell growth, and forskolin-induced renin output by blocking renin secretion.

CONCLUSIONS

These results suggest that beta-receptor agonists and ANP interact within the kidney to control renin secretion, by helping to determine the number of renin-secreting cells.

High blood pressure: Hunting the genes

High blood pressure is a disease of unknown cause. Family history of the disease indicates higher risk, but it is not known which genes are involved or how they interact with environmental influences to produce the disorder. Molecular biology offers an approach to problems that have not so far been solved by classical physiology or biochemistry. By analysing polymorphic variation in chromosome markers such as minisatellite sequences, or by restriction fragment polymorphism analysis of candidate genes, attempts are being made to link genetic variations with hypertension. In genetically hypertensive rats, hypertension is associated with a polymorphism of the renin gene and with other loci on chromosomes 10 and 18. The role of these loci in human hypertension remains to be determined. Other genes such as sodium-lithium countertransport may be involved. Environmental factors such as stress or salt intake could influence the rate or timing of expression of certain genes and thus result in hypertension.

Hypertension associated with increased renin concentrations in nephroblastoma

An infant with severe hypertension who had a nephroblastoma which was secreting active renin is described. Nephroblastoma must be included in the differential diagnosis of hypertension associated with increased renin concentrations, even in the absence of an abdominal mass.

Renin gene expression in nephroblastoma

Most cases of nephroblastoma have high plasma levels of prorenin which is biologically inactive. Plasma prorenin levels fall to normal following nephrectomy. In order to ascertain whether renin synthesis occurs in nephroblastomas we decided to search for renin-specific mRNA using a cDNA probe and Northern blot analyses on total RNA purified from snap-frozen human tumour tissue obtained at nephrectomy. We demonstrated renin-specific mRNA in 5/11 (45 per cent) nephroblastomas. It was 1.6 Kb in length, similar to the mRNA detected in normal kidney tissue and in kidneys with renal artery stenosis. In one of the cases of nephroblastoma, in which we could detect no normal renin mRNA at 1.6 Kb, the cDNA probe hybridized with a higher molecular weight mRNA 3 Kb in length. We conclude that some nephroblastomas synthesize renin.

Renin production by nephroblastoma cells in culture

Nephroblastoma cells have been cultured for 19 days. During this time cell growth and active and inactive renin secretion were monitored. Inactive renin was found to be secreted in excess of active renin. The main secretory protein, precipitated with antirenin IgG was found to have a molecular mass of 52,000 daltons.

Inhibitors of rat renin and their use in experimental hypertension

Hydroxy-ethylene dipeptide analogues (Leu[CH(OH)-CH2]Leu and Leu[CH(OH)-CH2]Val) of human substrate peptides are potent in vitro inhibitors of rat renin with IC50 values as low as 0.8 nmol/l. When given to renal hypertensive rats they lower blood pressure and suppress both plasma renin and angiotensin II. There was a divergence between the rapid rebound of renin and blood pressure which remained suppressed.

Arterial hypertension as a paraneoplastic phenomenon in hepatocellular carcinoma

Three South African blacks with hepatocellular carcinoma and arterial hypertension are described. Plasma angiotensinogen (renin substrate) concentrations were increased eightfold to 10-fold in the two patients in whom these concentrations were measured. One of these two patients also showed a 34-fold rise in plasma inactive, active, and total renin concentrations, and an elevated plasma renin activity (2.73 ng.L-1.s-1 angiotensin l/mL/h). Inactive renin (prorenin) constituted 90% of the total plasma renin concentration. In the third patient only plasma renin activity was measured, and this was considerably raised (6.05 ng.L-1.s-1; angiotensin l/mL/h). Thus, the arterial hypertension that rarely complicates hepatocellular carcinoma may be caused either by a combination of eutopic synthesis of excessive quantities of angiotensinogen and ectopic production and secretion of active renin by malignant hepatocytes, or by eutopic production of angiotensinogen alone.

Arterial hypertension as a paraneoplastic phenomenon in hepatocellular carcinoma

Three South African blacks with hepatocellular carcinoma and arterial hypertension are described. Plasma angiotensinogen (renin substrate) concentrations were increased eightfold to 10-fold in the two patients in whom these concentrations were measured. One of these two patients also showed a 34-fold rise in plasma inactive, active, and total renin concentrations, and an elevated plasma renin activity (2.73 ng.L-1.s-1 angiotensin l/mL/h). Inactive renin (prorenin) constituted 90% of the total plasma renin concentration. In the third patient only plasma renin activity was measured, and this was considerably raised (6.05 ng.L-1.s-1; angiotensin l/mL/h). Thus, the arterial hypertension that rarely complicates hepatocellular carcinoma may be caused either by a combination of eutopic synthesis of excessive quantities of angiotensinogen and ectopic production and secretion of active renin by malignant hepatocytes, or by eutopic production of angiotensinogen alone.

Severe hypotension with bradycardia during renin inhibition with H142 in sodium deplete man

A healthy sodium depleted subject received, on separate occasions, intravenous infusions of the renin inhibitor H142 at doses of 1.0, 2.5 and 5.0 mg/kg/h. The two lower doses of H142 produced dose-dependent reduction of both systolic and diastolic pressure associated with an increase in heart rate. The highest dose of H142 produced profound hypotension and bradycardia, both during drug infusion in the supine position, and again later, on return to standing, after H142 was stopped. An increase in plasma adrenaline, but not noradrenaline, was associated with this dose of H142. The subject differed from others studied in a randomised controlled trial of H142 at doses of 1.0 and 2.5 mg/kg/h in having the highest basal circulating plasma angiotensin II concentrations during sodium depletion, and in developing a clear reduction in systolic as well as diastolic pressure. The profound hypotensive response at the highest dose of H142 may represent an idiosyncratic response to the drug. Alternatively, and perhaps more likely, it may be a result of a reduction of angiotensin II concentrations in plasma or other tissues, with loss of arteriolar constriction, loss of facilitation of sympathetic activity, withdrawal of vagal inhibition, dilatation of capacitance vessels, or a combination of these events. Subsequent activation of the Bezold-Jarisch reflex is a possibility. The late fall in blood pressure, after H142 was stopped, and when circulating plasma angiotensin II concentrations had returned to normal, suggests that this response may have involved an effect of the inhibitor on renin in a site other than blood.

Similarity between active and trypsin-activated inactive renin in dog plasma by means of renin inhibition: the dog as an animal model for studies of inactive renin

A method for trypsin-activation of dog plasma inactive renin is described. Liquid phase trypsin (final concentration 6.7 mg/ml) was used and the reaction was stopped after 2 min at 4 degrees C by soybean trypsin inhibitor (13 mg/ml). Renin was measured as angiotensin I (Ang I) generation in trypsin-treated and untreated plasma using the antibody-trapping method, in the presence of excess ox renin substrate. The renin-like activity after trypsin was indeed due to renin, since Ang I generation in dog plasma before and after trypsin treatment was completely inhibited by H-77 at 10(-6) mol/l, and the two IC50 values were very similar (2.7 +/- 0.7 and 2.9 +/- 0.7 at 10(-8) mol/l, respectively). Dog plasma inactive renin was effectively separated from active renin by chromatography on Affigel Blue. Like human prorenin, dog plasma inactive renin rose in response to sodium depletion (furosemide 5 mg/kg, i.v.) followed by a low-salt diet (1 mmol Na+/day) for 4 days, (from 29.6 +/- 8 to 162 +/- 22 microU/ml; P less than 0.01, n = 10). Active renin also increased as expected. Intravenous captopril (6 mg/kg per h), for 3 h, led to a sharp increase in dog plasma active renin (from 53 +/- 8 to 360 +/- 60 microU/ml; P less than 0.01, n = 6), whereas inactive renin remained unchanged.(ABSTRACT TRUNCATED AT 250 WORDS)

Atrial natriuretic peptides and renin release

The relationship between endogenous plasma concentrations of atrial natriuretic peptide and renin was examined in resting normal subjects and patients with cardiac impairment. To test the hypothesis that atrial natriuretic peptide inhibits renin secretion, intravenous infusions of atrial natriuretic peptide were administered to normal volunteers, patients with end-stage renal failure, and conscious dogs in both sodium-replete and sodium-depleted states. Plasma atrial natriuretic peptide and renin were inversely related in normal subjects (r = -0.52, n = 140, p less than 0.001), but a weak positive association between these two variables was observed in patients with cardiac impairment (r = 0.32, n = 60, p less than 0.02). Low doses of both 26- and 28-amino-acid human atrial natriuretic peptide (2 pmol/kg/minute for two hours) given to sodium-replete normal subjects halved plasma renin compared with time-matched placebo values (19 +/- 4 and 18 +/- 3 versus 36 +/- 8 microU/ml, p less than 0.001 for both). Incremental doses of synthetic atrial natriuretic peptide suppressed plasma renin below time-matched placebo values in both sodium-replete (maximal suppression 1.2 +/- 0.4 versus 8.6 +/- 1.4 microU/ml, p less than 0.001) and sodium-depleted (maximal suppression 18.9 +/- 4.9 versus 51 +/- 13 microU/ml, p less than 0.05) dogs. This effect was initially apparent at low doses of atrial natriuretic peptide (1 pmol/kg/minute), and renin suppression was maximal, in both states, with lesser doses of atrial natriuretic peptide than those at which maximal natriuresis was observed. Atrial natriuretic peptide administered to patients with end-stage renal failure (10 pmol/kg/minute for one hour) caused no change in plasma renin. These data confirm that atrial natriuretic peptide inhibits renin secretion in a dose-related manner and suggest that this action of the peptide is modified by both the baseline sodium status and renal function of the recipient.

The effect of chronic prazosin therapy on the response of the renin-angiotensin system in patients with essential hypertension

Changes in plasma active and inactive renin and angiotensin II in response to tilt and intravenous frusemide were assessed in ten patients with essential hypertension, before treatment and again during chronic therapy with the alpha 1-adrenoceptor antagonist prazosin. During prazosin treatment blood pressure in the patients fell from mean levels 172/108 mmHg to 149/88 mmHg (P less than 0.05). Both before and during prazosin, tilt and frusemide each led to significant elevation of plasma active renin (P less than 0.001) and angiotensin II (P less than 0.05). Inactive renin tended to fall with tilt, and fell significantly following frusemide (P less than 0.05). Active renin (P less than 0.05) and angiotensin II (P less than 0.01) were lower 15 hours after dosing during chronic prazosin therapy than before treatment, but changes after tilt and frusemide were not attenuated during treatment. Chronic prazosin administration does not appear substantially to affect changes in active renin or angiotensin II in response to two standard stimuli, and may be useful in controlling hypertensive patients pending investigation of their renin-angiotensin system.

Diurnal change in plasma atrial natriuretic peptide concentrations

1. Diurnal changes in plasma concentrations of atrial natriuretic peptide (ANP), renin, angiotensin II, aldosterone, cortisol and antidiuretic hormone were investigated in seven normal volunteers studied under standardized conditions of dietary sodium, posture and physical activity. After completion of the diurnal study serial measurements of these variables were continued during, and on recovery from, a 2 day period of severe sodium depletion. 2. Clear diurnal variations in plasma concentrations of renin, angiotensin II, aldosterone, cortisol and antidiuretic hormone were observed. 3. Plasma ANP concentrations also varied significantly over 24 h. Values peaked about mid-day and a distinct trough in peptide concentrations occurred in the early evening. However, variations in plasma ANP values were of relatively small amplitude and not clearly independent of modest parallel shifts in sodium balance. 4. Changes in plasma ANP concentrations both within the diurnal study period and during sodium deprivation were closely and positively correlated with concomitant changes in cumulative sodium balance. 5. No simple parallel or reciprocal relationships between plasma concentrations of ANP, on the one hand, and concurrent plasma concentrations of other hormones or in the rate of urinary sodium excretion, on the other, were observed during the 25 h of the diurnal study.

Relation of arrhythmias and electrolyte abnormalities to survival in patients with severe chronic heart failure

To investigate the determinants of mortality in patients with chronic congestive heart failure, we prospectively evaluated 84 patients with this disorder who underwent detailed biochemical, clinical, and functional tests at the time of initial evaluation and were then followed for 12 to 52 months (mean 31). During this period of follow-up, 58% of the patients died, of whom 71% died suddenly. The most important pretreatment predictor of mortality in these patients was the frequency of ventricular extrasystoles, followed by echocardiographic fractional shortening, a diagnosis of coronary artery disease, and duration of treadmill exercise. The finding of hypokalemia and hyponatremia in these patients at the time of entry into the study was associated with a poor prognosis by univariate analytical methods, but these electrolyte abnormalities did not provide independent prognostic information. The presence of ventricular arrhythmias was related to the severity of left ventricular dysfunction, exercise intolerance, and neurohormonal activation, suggesting that such arrhythmias are multifactorial in origin and may not simply be related to electrolyte abnormalities.

Radio-immunoassay for plasma alpha human atrial natriuretic peptide: a comparison of direct and pre-extracted methods

Plasma atrial natriuretic peptide (ANP) concentrations were measured by both direct radio-immunoassay and with pre-extraction of the peptide from plasma using C18 reverse phase columns. Peptide concentrations were measured in normal subjects (including a group of eight volunteers who received an intravenous infusion of 0.9% NaCl solution), patients with renal failure (including a group with end-stage disease undergoing renal dialysis) and patients with a spectrum of cardiac dysfunction. The overall correlation of results from direct and extracted assay methods was good. However, absolute values from extracted assays were significantly lower than from parallel direct assays. This discrepancy was due to interference from platelets and from another, as yet unidentified, plasma component demonstrated by gel filtration experiments. Extraction of the peptide from plasma by C18 columns largely eliminated these sources of interference and was particularly important for accurate measurement of peptide concentrations within the normal range. Plasma peptide concentrations were elevated in cardiac and renal failure, fell with renal dialysis and rose in normal subjects challenged with an intravenous isotonic fluid load. These findings suggest that ANP participates in the regulation of body fluid volumes and arterial pressure.

Inactive renin: a tumor marker in nephroblastoma

Renin-containing cells have been identified in nephroblastoma. A prospective study of eight children with nephroblastoma has demonstrated abnormally high levels of total renin. The increase in total renin was due to increased levels of inactive renin (prorenin), rather than the active renin. These high levels decreased to normal after operation. The plasma level of inactive renin could be a useful biochemical tumor marker in nephroblastoma.

Plasma atrial natriuretic peptide concentrations during exercise in sodium replete and deplete normal man

To explore the effects of exercise on plasma atrial natriuretic peptide (ANP) concentrations, eight normotensive volunteers performed maximal treadmill exercise in sodium replete and deplete states. Baseline immunoreactive plasma ANP concentrations were significantly lower during sodium depletion. During exercise plasma ANP rose in all subjects on both occasions. Plasma peptide responses were attenuated by sodium depletion with peak exercise levels only double baseline values, in contrast to the threefold increase in ANP concentrations observed when subjects were sodium replete. Plasma renin and aldosterone concentrations also rose with exercise. In contrast to changes in plasma ANP, the responses of both were enhanced by sodium depletion.

Clinical and biochemical effects of the renin inhibitor H142 in humans

The inhibitor of human renin, H142, was studied in nine male volunteers. On three occasions, in random order, volunteers were infused with 5% dextrose, or with H142 at 1.0 or 2.5 mg/kg/h, for 30 min while supine and thereafter with dextrose for 1.5 h. There was a marked reduction in plasma active renin concentration as assayed by an enzyme-kinetic method, with parallel falls in the circulating concentrations of angiotensins (ANG) I and II, all of which rebounded transiently to values above basal after H142 infusion was stopped. In contrast, total renin concentration as measured by radioimmunoassay rose while ANG I and II fell, subsiding after H142 was discontinued. There was a slight but significant increase in plasma noradrenaline as renin became inhibited: plasma adrenaline was unchanged. H142 produced a slight fall in systolic blood pressure (SBP) and a clearer, highly significant, dose-related fall in diastolic blood pressure (DBP). There was modest but significant increase in the heart rate. These studies confirm H142 as an effective inhibitor of human renin in vivo.

Renin and inactive renin (prorenin) in the plasma of patients with malignant renal tumours

Plasma active and inactive renin (porenin) concentrations were measured in 26 adults with renal carcinoma and 8 children with nephroblastoma. In patients with carcinoma, plasma total renin concentration was slightly raised in 8 patients and markedly in one, in whom the increase was due to a more than 10-fold excess of inactive renin. Total renin concentration was raised in 7 out of 8 cases of nephroblastoma, the increase being due to excess inactive renin. It is likely that this represented oversecretion of a renin precursor, as inactive renin from the plasma of a patient with renal carcinoma showed similar biochemical characteristics to pure human prorenin.

Immunocytochemistry of renin in renal tumours

We used a panel of two polyclonal antisera and two monoclonal antibodies to human renin to assess the tissue distribution of immunoreactive renin in a range of tumours and normal human tissues. The only tissue showing positive staining for renin was kidney and all four antisera stained the myoepithelioid cells in the renal cortex. In the survey of tumours we found immunoreactive renin only in renal tumours, namely, renal cell carcinoma, and nephroblastoma (Wilms' tumour). The renin-positive cells were sparse and distributed mainly along the course of the tumour blood vessels. They stained positively with all four antibodies and, in pairs of serial sections, we showed that the same cell reacted with two different antisera. This suggests that renal cell carcinoma and nephroblastoma have within them cells which contain renin.

Plasma atrial natriuretic peptide: responses to modest and severe sodium restriction

Plasma atrial natriuretic peptide (ANP), active renin and aldosterone concentrations were measured during modest and severe sodium restriction in 16 normal volunteers. Eight volunteers took, in two separate 4-day periods, diets containing 200 and 15 mmol sodium/day (plus frusemide, 40 mg, on day 1 of low sodium intake), in random order. With sodium restriction plasma ANP concentrations fell in parallel with cumulative sodium balance. Changes in plasma renin and aldosterone were reciprocal to those in plasma ANP. To assess the threshold and reproducibility of the effects of modest sodium restriction on plasma ANP concentrations, a further group of eight volunteers took identical constant sodium diets (80 mmol/day in two cases and 120 mmol/day in the remainder) for 4 days on two successive weeks. On both occasions similar individual and mean falls in plasma ANP values accompanied the small net sodium loss occurring on these regimes. Plasma active renin concentration rose significantly during both diet phases. These data suggest plasma ANP concentrations alter in response to minor changes in sodium status, and are consistent with a role for plasma ANP in physiological regulation of body fluid volumes.

Twenty-four hour changes in active and inactive renin after various oral doses of the converting enzyme inhibitor ramipril (HOE498) in normal man

Different oral doses (5, 20, 50 mg) of the new orally active nonsulfhydryl-converting enzyme inhibitor, ramipril (HOE498), were given to 12 normotensive healthy males, and the pattern of changes in plasma active and inactive renin concentration was evaluated. Active and inactive renin increased after ramipril, and the magnitude of the response was clearly dose related. Active renin rose markedly by 4 hours and tended to decrease thereafter, although remaining higher than basal at 24 hours. In contrast, inactive renin rose more slowly, and the increase was sustained throughout the 24-hour period. The pattern of these changes is consistent with the hypothesis that circulating inactive renin is a biosynthetic precursor of the active form.

Plasma alpha natriuretic peptide in cardiac impairment

Regional plasma alpha human atrial natriuretic peptide concentrations were measured, and their relation to intracardiac pressures assessed, in an unselected series of 45 patients undergoing diagnostic cardiac catheterisation. Arteriovenous gradients in plasma concentrations of alpha human atrial natriuretic peptide were consistent with its cardiac secretion and its clearance by the liver and kidneys. Plasma concentrations of the peptide in the pulmonary artery, aorta, and superior vena cava correlated closely with the mean right atrial and pulmonary arterial pressures, and similar, though weaker, positive relations were seen with the left ventricular end diastolic and pulmonary artery wedge pressures. Concentrations of both atrial natriuretic peptide and renin showed significant inverse relations with serum sodium concentrations. Plasma concentrations of alpha human atrial natriuretic peptide are an additional objective indicator of the severity of haemodynamic compromise in patients with cardiac impairment.

Factors affecting renal vein renin ratio in renal artery stenosis. Secretion of inactive renin

All four factors which theoretically may affect the renal vein renin ratio in unilateral renal artery stenosis--increased renin secretion and diminished renal plasma flow on the stenotic side; suppressed renin secretion and renin extraction on the contralateral side--have been assessed. In a series of patients with unilateral renal artery stenosis, the renal vein ratio of active renin was more closely related to the reduction of renal plasma flow than to renin secretion rate on the affected side. On the contralateral side renin secretion was suppressed while angiotensin II was extracted. During long-term treatment with the converting enzyme inhibitor enalapril, peripheral plasma angiotensin II was lowered, while active renin concentration was markedly elevated, both in arterial plasma and in renal venous plasma of the stenotic kidney; the contralateral kidney became a net extractor of active renin. Thus, all 4 factors which theoretically affect the renal vein renin ratio can operate clinically. Both before and during enalapril, the affected kidney secreted inactive renin.

A study of the renin inhibitor H142 in man

The inhibitor of human renin, H142, was studied in nine male volunteers. On three occasions, in random order, volunteers were infused with 5% dextrose or with H142 at 1.0 or 2.5 mg/kg per h for 30 min while supine and thereafter with dextrose for 1 1/2 h. There was a marked reduction in plasma active renin concentration as assayed by an enzyme-kinetic method, with parallel falls in the circulating concentrations of angiotensins (ANG) I and II, all of which rebounded transiently to values above basal after the H142 infusion was stopped. In contrast, total renin concentration as measured by radio-immunoassay rose while ANG I and II fell, subsiding when H142 was discontinued. There was a slight but significant increase in plasma noradrenaline as renin became inhibited; plasma adrenaline was unchanged. H142 produced a slight fall in systolic blood pressure (SBP) and a clearer, highly significant, dose-related fall in diastolic blood pressure (DBP). There was a modest but significant increase in the heart rate. These studies confirm H142 as an effective inhibitor of human renin in vivo.

A dose-response study of HOE 498, a new non-sulphydryl converting enzyme inhibitor, on blood pressure, pulse rate and the renin-angiotensin-aldosterone system in normal man

The effect of different oral doses of HOE 498, a new non-sulphydryl containing converting enzyme inhibitor, was investigated in a double-blind, placebo-controlled study in normotensive volunteers. Dose-related reductions in serum converting enzyme activity, plasma angiotensin II and aldosterone were seen, greater at 4 h than at 12 h after drug ingestion. Converse dose-related increases in blood angiotensin I and plasma active renin concentration occurred. Falls of angiotensin II were as great with 20 mg as with 50 mg of HOE 498, although the effect was more prolonged with 50 mg. The reductions in concentrations of plasma angiotensin II and serum converting enzyme activity and the increases in plasma renin concentration were correlated with the concentration of HOE 498 - diacid in plasma. Dose-related falls in both supine and erect blood pressure were maximal 2-3.5 h after dosing. Pulse rate increased marginally but insignificantly in the supine; slightly and significantly in the upright position, concomitantly with the blood pressure reduction at all doses of active drug. We conclude that effects of single doses of HOE 498 on the renin-angiotensin system are maximal within 4 h, but are still apparent after 24 h. Thus it is likely that once daily administration will be adequate for treatment of high blood pressure in patients.

A transition-state analogue inhibitor of human renin (H.261): test in vitro and a comparison with captopril in the anaesthetized baboon

H.261, a new transition state inhibitor of human renin with an IC50 of 6.9 X 10(-10) M, was given by intravenous infusion to six anaesthetized baboons. The inhibitor was infused first at 0.1 mumol/kg/h for 15 min, then at 1.0 mumol/kg/h for a further 15 min. After a recovery period of 2 h in which the animals received 5% dextrose, they were infused with captopril, 25 mumol/kg/h for 15 min. At both rates of infusion H.261 markedly and significantly reduced the enzymatic action of renin in plasma, the blood concentration of angiotensin I, the plasma concentration of angiotensin II and mean arterial pressure. All changes reverted towards or to control values in the subsequent control period. Captopril also lowered plasma angiotensin II concentration and mean arterial pressure markedly and significantly but, as expected for an inhibitor of the angiotensin I-converting enzyme, plasma active renin concentration and blood angiotensin I concentration increased. The changes of angiotensin II and arterial pressure were similar with captopril and H.261.

Binding of human renin to plasma proteins and comparison with plasma active and inactive renin

Inactive renin was partially purified from normal male plasma. It showed no enzymatic activity at pH 7.4, and its molecular weight by gel filtration was 53 000 compared with 45 000 for partially purified plasma active renin and 41 000 for pure renal renin. After exposure to pH 3.0 the inactive renin became enzymatically active but its molecular weight did not change. The acid-activation could be reversed when the renin was re-adjusted to pH 7.4 and warmed. Pure renal renin labelled with I125 was added to normal male plasma. It had a molecular weight of 40 000 by gel filtration. When the mixture was acidified and neutralized, some I125 label appeared in a high-molecular-weight peak, as might occur if the renin was associated with a binding protein. If the mixture of plasma and labelled renin was treated with guanidine hydrochloride, most of the label appeared in the high-molecular-weight peak. However, after both acid treatment and treatment with guanidine hydrochloride the 'high-molecular-weight' peak appeared in the void volume of the column (Mr 108 000) rather than in the position of inactive renin (Mr 53 000). Also, the I125 label in the peak was neither immunologically nor electrophoretically similar to renin. It may represent denatured renin bound to plasma proteins, e.g. alpha-2 macroglobulins. We conclude that 'inactive renin' is a prorenin-like material rather than a protein-bound form of active renin.

Renal secretion of inactive renin and extraction of angiotensin II in renal artery stenosis in man: factors determining renal vein renin ratio

Triplicate blood samples were obtained, without stimulation, simultaneously from the aorta and both renal veins in 24 untreated hypertensive patients with unilateral renal artery stenosis. Across the affected kidney the plasma concentrations of active renin, inactive renin and angiotensin II increased by 363% (P less than 0.001), 80% (P less than 0.05) and 100% (P less than 0.05) respectively. Thus the affected kidney was secreting both active and inactive renin, while appreciable quantities of angiotensin II were generated across the renal circulation on that side. Across the contralateral unaffected kidney there were no significant changes in concentration of active or inactive renin, indicating net suppression of secretion of both forms of renin. Plasma angiotensin II concentration was however markedly reduced, to 50% of the arterial value (P less than 0.001), in the contralateral renal vein, demonstrating renal extraction of angiotensin II. In 14 patients renal plasma flow was also measured. The ratio of active renin concentration between the two renal veins correlated more closely with the renal plasma flow to the affected kidney (r = -0.81; P less than 0.01) than with renin secretion rate on that side (r = +0.37; NS). Thus reduction in renal blood flow rather than increase in renin secretion appeared to be the major determinant of renal vein renin ratio.

Changes in active and inactive renin and in angiotensin II across the kidney in essential hypertension and renal artery stenosis

Investigations were performed in 26 patients with essential hypertension and 24 with unilateral renal artery stenosis. In each patient blood was drawn simultaneously and in triplicate, from both renal veins and aorta, for measurement of plasma concentrations of active and inactive renin and of angiotensin II. In 19 patients estimates of individual renal plasma flow were obtained in order to calculate secretion rates for active and inactive renin, and to assess the contribution of renin secretion rate and of renal plasma flow to the renal vein renin ratio. In patients with essential hypertension there was evidence that the kidney secreted active renin (18% mean increase in renal vein concentration above that of arterial plasma; P less than 0.001), but no evidence of secretion of inactive renin (4% mean increase; NS). There was a tendency for the kidney to extract angiotensin II (8% mean decrease in renal vein concentration below that of arterial plasma; P = 0.07). The affected kidney in patients with renal artery stenosis showed marked secretion of active renin (364% mean increase; P less than 0.001) and also secreted inactive renin (80% mean increase; P less than 0.05) with net generation of angiotensin II across the renal circulation (100% mean increase; P less than 0.05). The contralateral kidney exhibited suppressed secretion of active renin (3% mean increase; NS) with no evidence of secretion of inactive renin (2% mean increase; NS), and marked extraction of angiotensin II (50% mean decrease; P less than 0.001). The correlation between combined secretion rate of active renin by both kidneys and the arterial concentration of active renin in patients with essential and renovascular hypertension taken together was strongly positive (r = 0.82; P less than 0.01). The same correlation for inactive renin was weak (r = 0.32; NS). The correlation between the combined secretion rates of active renin by both kidneys and the circulating plasma concentration of angiotensin II (r = +0.60; P less than 0.05) was both significant and positive. By contrast, the total 'secretion' rate of angiotensin II by both kidneys was inversely related to arterial plasma angiotensin II (r = -0.92; P less than 0.001). This latter relationship suggests an important role for the kidney in clearing angiotensin II from the circulation, this being more marked the higher the arterial angiotensin II concentration.(ABSTRACT TRUNCATED AT 400 WORDS)

Enalapril in hypertension with renal artery stenosis: long-term follow-up and effects on renal function

Enalapril alone, 10-40 mg given once-daily, controlled systemic hypertension long-term (mean follow-up time 19 months) in patients with renal artery stenosis. Significant, but usually modest, increases in serum creatinine and urea were observed. No serious side-effects were seen. A highly significant reduction in peripheral plasma angiotensin II was maintained 24 h after the previous dose of enalapril. Plasma active renin concentration rose 20-fold with long-term enalapril, when the stenotic kidney showed significant secretion of inactive, as well as of active renin. With enalapril therapy, the contralateral kidney showed net extraction of active renin. In unilateral renal artery stenosis, circulation on the affected side is diminished and is mainly via the juxtamedullary nephrons, which become rich in associated renin. Important intrarenal compensatory actions of the renin-angiotensin system include support of glomerular filtration, enhancement of vasa recta-mediated counter-current exchange, sustained urea excretion and maintenance of renal artery pressure distal to the stenosis. These compensatory effects are lost with converting enzyme inhibition. Thus in patients who are candidates for operation, enalapril should usually be given for no more than one month before proceeding to corrective surgery, to allow maximum blood pressure reduction without endangering the stenotic kidney for too long. Enalapril can nevertheless be given effectively long-term in patients unsuitable for corrective surgery.