Serial Assessment of Coronary Artery Healing of a Biodegradable Polymer Drug-Eluting Stent at 1, 2, and 3 Months by Optical Coherence Tomography (OCT)-The REPAIR Trial

BACKGROUND

Although first-generation drug-eluting stent (DES) devices have effectively achieved their main goal of reducing restenosis, their safety has been limited by suboptimal polymer biocompatibility, delayed stent endothelialization, and local drug toxicity, which ultimately prompted the development of new-generation DES options carrying biocompatible or even biodegradable polymers.

AIMS

We sought to assess the vessel-healing pattern of the novel sirolimus-eluting Inspiron DES (Scitech Medical) using serial optical coherence tomography (OCT) and assuming the hypothesis that this thin-strut (75-μm), biodegradable-polymer DES promotes a faster healing, with very early strut coverage.

METHODS

This is a prospective, multicenter, open-label, single-arm study enrolling 68 patients who underwent percutaneous coronary intervention guided by OCT. These patients were consecutively assigned into 3 groups. The first group had its OCT imaging follow-up performed at 3 months, the second group at 2 months, and the third group at 1 month.

RESULTS

Mean age was 59.5 years, 70.6% were male, 41.2% had type 2 diabetes, and 29.4% presented with acute coronary syndrome. A total of 72 lesions were treated and 1.06 stents were implanted per patient. OCT assessment of the stents at 1, 2, and 3 months showed a strut coverage of 90.41%, 93.96%, and 97.21%, respectively (P=.04).

CONCLUSION

The Inspiron DES showed an early strut healing pattern, with >90% of the struts covered by neointima within the first month and with almost all struts covered by the third month.

Heroin addiction and renal disease

In this paper, renal involvement secondary to other medical complications of heroin addiction is discussed. We review 12 published studies totalling 102 heroin addicts with renal disease. Of these, in only 40 patients could other discernible causes of renal disease be excluded. The existence of 40 reported cases of renal disease from a population of more than half a million is insufficient data upon which to postulate the existence of a type of renal disease unique to heroin addicts.

Association of interleukin-6 gene polymorphism with angina pectoris

In this study, we investigated the role of the -174G>C polymorphism of interleukin-6 (IL-6) as a predisposing factor to angina pectoris. Patients were separated into 2 groups: angina (N = 72) and nonangina (N = 71). There were no statistical differences between groups for all cardiovascular risk factors evaluated. The GG genotype frequency was 18% lower in the angina than in the non-angina group, whereas GC + CC was 18% higher in the angina group (P = .036). The frequency of G allele was 11% lower in the angina than in the nonangina group and C allele was 11% higher in the angina group (P = .043). Patients carrying the C allele showed a 2-fold increased risk for angina pectoris (P = .036). Our study demonstrates a high incidence of the -174G>C polymorphism of the IL-6 gene in patients with angina pectoris compared with those carrying the G allele, reinforcing the contribution of genetic factors to the symptoms of angina pectoris.

Cinacalcet HCl (Sensipar/ Mimpara) is an effective chronic therapy for hemodialysis patients with secondary hyperparathyroidism

AIMS

This 1-year double-blind, placebo-controlled, multicenter study evaluated the long-term safety and efficacy of cinacalcet for the treatment of secondary hyperparathyroidism in patients receiving hemodialysis.

METHOD

Patients were randomly assigned in a 1:1 ratio to cinacalcet or control treatment groups. The initial dose of cinacalcet (or matching placebo) was 30 mg. Doses were titrated every 3 or 4 weeks based on the intact parathyroid hormone (iPTH) response and safety profile. Sequential doses included 30, 60, 90, 120 and 180 mg/d. Phosphate binders and vitamin D sterols were adjusted per protocol as needed to control levels of calcium and phosphorus. Efficacy and safety were compared between treatment groups among patients who completed the study (52 total weeks of treatment). Reasons for withdrawal are presented for patients who did not complete the study.

RESULTS

A total of 210 patients completed 52 weeks of double-blinded treatment with cinacalcet (n = 99) or placebo (n = 111). Over the last 6 months of the study, a greater proportion of patients in the cinacalcet group than the control group achieved an iPTH level < or = 250 pg/ml (61.6 vs. 9.9%, p < 0.001) or a > or = 30% decrease in iPTH from baseline (81.8 vs. 21.6%, p < 0.001). Mean iPTH levels decreased by -47.8% in the cinacalcet group and increased by +12.9% in the control group. Mean percentage changes in other laboratory values in the cinacalcet and control groups included the following: serum calcium -6.5 vs. +0.9% (p < 0.001), serum phosphorus -3.6 vs. -1.1% (p = 0.465), and Ca x P -9.9 vs. -0.3% (p = 0.006). The most commonly reported adverse events related to study drug by the investigators included nausea (13% cinacalcet, 5% control), investigator-reported hypocalcemia (11% cinacalcet, 1% control), vomiting (9% cinacalcet, 2% control), dyspepsia (5% cinacalcet, 4% control), and diarrhea (5% cinacalcet, 2% control).

CONCLUSIONS

Treatment with cinacalcet is a safe and effective therapy for long-term control of secondary hyperparathyroidism. 1-year therapy with cinacalcet was associated with sustained, clinically significant reductions in calcium, Ca x P and iPTH which allowed a greater percentage of patients to achieve NKF-KDOQI target goals for PTH and Ca x P.

Differential effects of enalapril and irbesartan in experimental papillary necrosis

This study was undertaken to determine whether angiotensin receptor blockers are as renoprotective as angiotensin-converting enzyme inhibitors in an experimental model of chronic interstitial renal disease. Groups of rats received one of the following treatments for 1 week: (1) enalapril, (2) diltiazem, (3) a cocktail of hydralazine, reserpine, and hydrochlorothiazide, or (4) irbesartan (an AT1 antagonist). The animals were injected with bromoethylamine (200 mg/kg), and antihypertensive treatment continued for 1 month. All drugs were effective in lowering the mean arterial pressure. The bromoethylamine-treated rats developed albuminuria and sustained a 40-50% decrease in creatinine clearance. Enalapril and irbesartan reduced albuminuria, but only enalapril partially prevented the decline in creatinine clearance and lowered the number of ED-1-positive cells. Diltiazem and cocktail had no effect on proteinuria, creatinine clearance, or ED-1 cells. In this experimental model, the effects of enalapril and irbesartan were not identical. Both drugs reduced proteinuria, but enalapril was more effective in protecting the renal function. The fact that the AT1 antagonist protected against albuminuria but did not affect the clearance of creatinine implies that the results seen with angiotensin-converting enzyme inhibition may be in part due to an effect on angiotensin II via AT2 receptor blockade or through an effect on bradykinin.

SFKs, Ras, and the classic MAPK pathway couple muscarinic receptor activation to increased Na-HCO(3) cotransport activity in renal epithelial cells

Cholinergic agents are known to affect the epithelial transport of H2O and electrolytes in the kidney. In proximal tubule cells, cholinergic agonists increase basolateral Na-HCO(3) cotransport activity via M(1) muscarinic receptor activation. The signaling intermediates that couple these G protein-coupled receptors to cotransporter activation, however, are not well defined. We therefore sought to identify distal effectors of muscarinic receptor activation that contribute to increased NBC activity in cultured proximal tubule cells. As demonstrated previously for acute CO2-regulated cotransport activity, we found that inhibitors of Src family kinases (SFKs) or the classic mitogen-activated protein kinase (MAPK) pathway prevented the stimulation of NBC activity by carbachol. The ability of carbachol to activate Src, as well as the proximal (Raf) and distal [extracellular signal-regulated kinases 1 and 2 (ERK1/2)] elements of the classic MAPK module, was compatible with these findings. Cholinergic stimulation of ERK1/2 activity was also completely prevented by overexpression of a dominant negative mutant of Ras (N17-Ras). Taken together, these findings suggest a requirement for the sequential activation of SFKs, Ras, and the classic MAPK pathway [Raf-->MAPK/ERK kinase (MEK)-->ERK]. These findings provide important insights into the molecular mechanisms underlying cholinergic regulation of NBC activity in renal epithelial cells. They also suggest a specific mechanism whereby cholinergic stimulation of the kidney can contribute to pH homeostasis.

Relaxin decreases renal interstitial fibrosis and slows progression of renal disease

BACKGROUND

Relaxin, a hormone of the insulin-growth factor family, promotes collagen remodeling. In rodent models of pulmonary and dermal fibrosis, relaxin reduced interstitial fibrosis. To study relaxin's effect in renal disease, we used the experimental bromoethylamine (BEA) model that leads to severe renal interstitial fibrosis, a decrease in glomerular filtration rate, and albuminuria at one month.

METHODS

Rats were injected with BEA one week prior to implantation of an osmotic pump delivering relaxin (2 microg/hour) or vehicle continuously for 28 days.

RESULTS

BEA caused a significant decrease in creatinine clearance, which was partially prevented by relaxin. In the relaxin-treated BEA rats, serum creatinine was normal, and albumin excretion was slightly decreased. By morphometric measurement, relaxin administration was associated with a significant decrease in interstitial fibrosis at the corticomedullary junction. This was accompanied by a decrease in the number of ED-1 positive cells (an index of macrophage infiltration) and in the intensity of immunohistochemical staining for transforming growth factor-beta. This antifibrotic effect of relaxin did not appear to be mediated by systemic hemodynamic changes since the mean arterial pressure was not significantly different among the groups.

CONCLUSIONS

Relaxin may have a useful application in decreasing interstitial fibrosis and thereby slowing the progression of renal disease.

Motor neuron diseases in the university hospital of Fortaleza (Northeastern Brazil): a clinico-demographic analysis of 87 cases

In this retrospective (1980-1998) study, we have analyzed clinico-demographically, from the records of the University Hospital of Fortaleza (Brazil), a group of 87 patients showing signs and symptoms of motor neuron diseases (MNDs). Their diagnosis was determined clinically and laboratorially. The WFN criteria were used for amyotrophic lateral sclerosis (ALS) diagnosis. The clinico-demographic analysis of the 87 cases of MNDs showed that 4 were diagnosed as spinal muscular atrophy (SMA), 5 cases as ALS subsets: 2 as progressive bulbar paralysis (PBP), 2 as progressive muscular atrophy (PMA) and 1 as monomelic amyotrophy (MA), and 78 cases of ALS. The latter comprised 51 males and 27 females, with a mean age of 42.02 years. They were sub-divided into 4 groups according to age: from 15 to 29 years (n= 17), 30 to 39 years (n= 18), 40 to 69 years (n= 39) and 70 to 78 years (n= 4). From the 78 ALS patients, 76 were of the classic sporadic form whilst only 2 were of the familial form. The analysis of the 87 patients with MNDs from the University Hospital of Fortaleza showed a predominance of ALS patients, with a high number of cases of juvenile and early onset adult sporadic ALS.

Can total urinary protein measurements predict microalbuminuria?

We re-addressed the question of whether routine total urinary protein determinations can be used to predict the presence of microalbuminuria by studying 61 patients who attended a diabetic clinic and tested negative or had one positive protein by dipstick. Total urinary protein was measured by the Biorad dye-binding method in undialyzed urine (UND), in dialyzed urine (DIAL), and in dialyzed urine in which albumin and globulins were separated, measured separately with albumin and globulin standards and the results added together to obtain total urinary protein (A + G). The results were compared with albumin measurements obtained by radioimmunoassay (RIA). Compared to DIAL, urinary protein measurements were 43% higher with A + G and 22% higher with UND. Microalbuminuria correlated moderately with UND (r =0.81) and better with the other methods (r=0.87 for DIAL, r=0.91 for A + G). None of the methods predicted microalbuminuria reliably. Taking a protein-to-creatinine ratio of 0.15 and an albumin-to-creatinine ratio of 0.03 as upper limits of normal, we found that UND had a 72% positive predictive value (28% false positives) and 85 % negative predictive value (15% false negatives). DIAL had 90% positive predictive value (10% false positives) and 78% negative predictive value (22% false negatives). A + G had 65% positive predictive value (35% false positives) but 91% negative predictive value (9% false negatives). A + G, which uses the correct standards, would be the most suitable method for screening, having the least number of false negatives, but has more false positives because it is more sensitive. In practice, most routine chemical laboratories find it expedient to use only UND, but physicians interpreting the results of this method should be aware of its limitations.

Epilepsia partialis continua (Koshevnikov): a preliminary case report

We report on the preliminary clinical and electrophysiological aspects of an in-patient possibly presenting epilepsia partialis continua (Koshevnikov). We discuss the different etiologies and emphasize on the possible idiopathic form in this case.

A simple method to detect an albumin permeability factor in the idiopathic nephrotic syndrome

BACKGROUND

Several investigators have detected an albumin permeability factor in the serum of patients with the idiopathic nephrotic syndrome (INS), that is, minimal change disease (MCD) or focal segmental glomerulosclerosis (FSGS), but the methods used have been complex.

METHODS

We describe here a simpler method using cultured rat glomerular epithelial cell monolayers grown to confluence on Millicell filters, which allow sampling of apical and basolateral media. 125I-labeled human serum albumin (125I-HSA) was added to the basolateral compartment, and its leakage across the epithelial cell monolayer into the apical compartment was measured.

RESULTS

In untreated cells (negative control), the albumin leakage reached 5.3% at 18 hours. Cell monolayers fixed with 95% ethanol (positive control) showed 62% leakage. Sera from three out of four patients with MCD and three out of four with FSGS resulted in considerable albumin leakage, whereas sera from nine patients with other types of nephrotic renal disease and five normal subjects caused no leakage.

CONCLUSION

This study shows that the Millicell system provides a simple and useful method to screen for permeability factors in the INS.

Evaluation of a new fluorescent dye method to measure urinary albumin in lieu of urinary total protein

Urinary total protein (UTP) determinations are notoriously inaccurate, poorly reproducible, and difficult to interpret in early renal disease, causing many investigators to measure urinary albumin instead. In this study, we compare a new nonimmunologic fluorescent dye (AB-dye) for measuring albumin with the more expensive and cumbersome radioimmunoassay. We tested 207 urine specimens from patients with variable protein concentrations and divided the results into five arbitrary ranges (0 to 20, 21 to 50, 51 to 100, 101 to 200, and 201 to 400) for chi-square analysis. There was a high degree of correlation between the two methods (chi-square = 260. 8 with 16 degrees of freedom; P < 0.001). The correlation was also high when analyzed by linear regression (R = 0.86; F < 0.01). Based on our comparison of total protein and albumin concentration in the same urine samples, we hypothesized that patients with mild proteinuria may not necessarily have microalbuminuria. Urine samples with UTP between 150 and 400 microg/mL were tested for albumin by the AB-dye. Of 41 samples in this range, 18 (44%) had normal albumin levels. We conclude that measuring urinary albumin with the AB-dye is comparable in performance to radioimmunoassay and could replace UTP determinations, especially for patients with borderline elevations of UTP, many of whom do not have microalbuminuria.

Regulation of the renal Na-HCO(3) cotransporter. XI. Signal transduction underlying CO(2) stimulation

We have previously shown that CO(2) stimulation of the renal Na-HCO(3) cotransporter (NBC) activity is abrogated by general inhibitors of protein tyrosine kinases. The more selective inhibitor herbimycin also blocked this effect at concentrations known to preferentially inhibit Src family kinases (SFKs). We therefore examined a role for SFKs in CO(2)-stimulated NBC activity. To this end, we engineered OK cells to express the COOH-terminal Src kinase (Csk), a negative regulator of SFKs. CO(2) stimulated NBC activity normally in beta-galactosidase-expressing and untransfected control cells. In contrast, Csk-expressing cells had normal baseline NBC activity that was not stimulated by CO(2). CO(2) stimulation increased both total SFK activity and specific tyrosine phosphorylation of Src. The specific MEK1/2 inhibitor PD-98059 completely inhibited the CO(2) stimulation of NBC activity as well as the accompanying phosphorylation and activation of ERK1/2. Our data suggest the involvement of both SFKs, probably Src, and the "classic" MAPK pathway in mediating CO(2)-stimulated NBC activity in renal epithelial cells.

Suppression of hyperparathyroidism by calcitriol therapy

We reviewed the charts of 160 patients on hemodialysis and identified 33 with parathyroid hormone (PTH) > 800 pg/ml at any time during the last 3 years to confirm our impression that patients with PTH elevations for short durations of time require significantly smaller doses of calcitriol than those with prolonged PTH elevations. We divided the patients into two groups: 18 with PTH > 800 pg/ml on three or fewer occasions (Group 1, short-term hyperparathyroidism) and 15 with PTH > 800 pg/ml more than three times (Group 2, long-term hyperparathyroidism). Most patients received once weekly intravenous calcitriol, but if this failed to suppress PTH, the dose was increased gradually to three times a week, PTH was measured at mid-week, calcitriol was held if serum calcium rose to >11 mg/dl, and calcitriol was started again when calcium fell to <11 mg/dl. We found that the duration of dialysis was generally shorter in Group 1, as were maximal PTH levels. Calcitriol suppressed PTH levels to <200 pg/ml in both groups. However, the weekly dose of calcitriol needed to suppress PTH was significantly lower in Group 1 (5.4 +/- 1.2 microg in Group 1 and 11.4 +/- 1.8 microg in Group 2; p < 0.001). Further follow-up of seven patients for 1 more year showed continued suppression of PTH, and the dose of calcitriol required to maintain the suppression was lower than the initial dose. Thus patients with longer histories of dialysis and prolonged hyperparathyroidism required higher doses of calcitriol to suppress PTH to the same level as patients who were new on dialysis or with transient hyperparathyroidism. A protocol of three times weekly, high dose calcitriol with strict monitoring of serum calcium will avoid parathyroidectomy in most cases.

Cocaine-induced hypertension: role of the peripheral sympathetic system

Cocaine causes hypertension at least in part by stimulating the sympathetic nervous system, but it is not clear if this effect is centrally or peripherally mediated. To address this issue we studied the vasoconstrictive effect of cocaine in vivo and in isolated artery segments. In vivo cocaine increased mean arterial blood pressure (MAP) by 40 mmHg within 1 min of administration. Pretreatment with prazosin blocked this response by 62%. With clonidine the pre-cocaine MAP was lower and the hypertensive effect of cocaine was blocked by 50%, indicating an important role for central alpha-adrenergic mechanisms. In isolated rat carotid arteries cocaine-induced vasoconstriction was completely blocked by prazosin, phentolamine, and 6-hydroxydopamine, indicating a clear role for a peripheral effect. However, the relative contribution of the central alpha-adrenergic mechanism to the total vasoconstrictive response of cocaine was not clarified. 1999 Academic Press.

Changes in collagenases and TGF-beta precede structural alterations in a model of chronic renal fibrosis

BACKGROUND

To study the role of collagenases and transforming growth factor-beta (TGF-beta) in the genesis of interstitial fibrosis, we used the model of bromoethylamine (BEA)-induced papillary necrosis, which is known to lead over a period of 1 to 12 months to interstitial fibrosis and renal insufficiency.

METHODS

Rats were injected with BEA, and urine and kidney tissue (cortex and medulla) were collected after 1, 2, 3, 7, and 30 days. One kidney was perfused and fixed for morphological studies and immunostained for collagen type I, III, and IV. The other kidney was used to prepare cortex and medulla extracts for gelatinases (by fluorometric and zymographic techniques), tissue inhibitors of metalloproteinase-1 (TIMP-1), and TIMP-2 (by enzyme-linked immunosorbent assay, ELISA) and TGF-beta1 (by ELISA).

RESULTS

Albuminuria and interstitial fibrosis were present in BEA rats by day 7, which continued until day 30. Immunocytochemical staining for collagen types showed that collagen III and IV increased in the interstitium by day 30, but collagen I remained unchanged. Gelatinase activity in the medulla decreased by 57% compared with control by day 2 and remained low until day 30. In the cortex, gelatinase activity remained unchanged between 0 and 7 days after BEA but decreased by 72% by day 30. TIMP-1 and TIMP-2 were decreased by 80% compared with day 0 in both the medulla (by day 1) and cortex (by day 2) and remained low up to day 30. TGF-beta1 immunoreactivity increased progressively until day 2 in the medulla (16-fold higher than control) and day 3 in the cortex (8-fold higher than control) and returned to control level by day 3 in the medulla and by day 30 in the cortex. Two days after BEA injection, the mRNA for TGF-beta1 was increased eightfold in the cortex and 12-fold in the medulla, and it remained high for up to 30 days.

CONCLUSIONS

The fibrosis that follows papillary necrosis is associated with both high TGF-beta1 expression and depressed gelatinolytic activity.

Evolution of experimentally induced papillary necrosis to focal segmental glomerulosclerosis and nephrotic proteinuria

Bromoethylamine (BEA)-induced papillary necrosis is a reproducible model for analgesic nephropathy. We induced this lesion in groups of male Sprague-Dawley rats and followed the functional and histological changes for 1 year. We found that by 1 month, necrosis of the papilla was complete, glomerular filtration rate was depressed, and urine albumin excretion was increased. There was an extensive interstitial fibrosis characterized by a mononuclear cell infiltrate and patchy tubular atrophy. By 6 months, there was re-epithelialization of the papillary stump accompanied by a marked increase in albuminuria and an improvement in concentrating ability. Changes seen at 9 months were more advanced. There was extensive cortical fibrosis manifested by pitting of the surface of the kidney. At 1 year, renal function remained impaired (creatinine clearance reduced by 65% to 0.26 mL/min/100 g), and the animals were now markedly nephrotic, with albuminuria of 254 mg of albumin/24 h. In the BEA rats, there was selective destruction of the deep nephrons leading to an increase in the volume-ratio of superficial to deep nephrons. Glomerular changes, affecting approximately 60% of the glomeruli, were characteristic of focal segmental glomerular sclerosis. This model of papillary necrosis/interstitial fibrosis is associated with chronic renal insufficiency and leads to the development of focal glomerular sclerosis and nephrotic proteinuria by 6 to 12 months after its induction.

Regulation of the renal Na-HCO(3) cotransporter X. Role of nitric oxide and intracellular calcium

Cholinergic agents increase the activity of the renal Na-HCO(3) cotransporter and have been shown to stimulate the production of nitric oxide (NO) in other cells. To study the role of NO in mediating the effect of carbachol on Na-HCO(3) cotransporter, we measured the activity of the cotransporter in rabbit proximal tubule cells treated with carbachol (10(-4 )M) or the NO inhibitor, L-NAME (10(-3) M), or carbachol+L-NAME. The activity of NaHCO(3) cotransporter was measured by recovery of intracellular pH (pH(i)) in cells loaded with pH-sensitive dye, BCECF. In control cells, carbachol significantly increased Na-HCO(3) cotransporter activity while L-NAME did not affect the activity of the cotransporter but completely blocked the enhancement induced by carbachol. Carbachol increased NO production by proximal tubule cells. We also studied the effect of the NO donor, SNAP (10(-3) M), on the cotransporter incubated for 1 h in cultured proximal tubule cells. SNAP caused a similar enhancement in the activity of the cotransporter suggesting that a different NO donor is capable of enhancing the activity of the cotransporter to the same extent as that observed with carbachol. Because the effect of NO is thought to involve cGMP, we examined the effect of 8-Br-cGMP (10(-3 )M) on the cotransporter. 8-Br-cGMP caused stimulation of the Na-HCO(3) cotransporter activity although to a lesser degree than carbachol. We have previously shown that carbachol increases cytosolic calcium but the role of intracellular calcium (Ca(i)) per se on the cotransporter has not been studied. We therefore studied the role of Ca(i) on the activity of Na-HCO(3) cotransporter in rabbit proximal tubule cells by utilizing the calcium ionophore, ionomycin, the microsomal Ca-ATPase inhibitor, thapsigargin, and the calcium chelator, BAPTA. Ionomycin, 5 microM, caused a significant stimulation of Na-HCO(3) cotransporter which was prevented by BAPTA. The microsomal Ca-ATPase inhibitor, thapsigargin, also increased the cotransporter activity. As expected both ionomycin and thapsigargin caused a significant increase in Ca(i). Calyculin A, an inhibitor of protein phosphatase 2A prevented the stimulation of the cotransporter by calcium (in pH units/min: control 1.8+/-0.13; Ca 2.22+/-0.07; p<0.05; Ca+calyculin A 1.9+/-0.09, p<0.025) suggesting that calcium acting through kinases/phosphatases, plays a role in the phosphorylation of the cotransporter. These results demonstrate that NO and Ca(i) modulate the activity of the cotransporter.

Carbamylated proteins activate glomerular mesangial cells and stimulate collagen deposition

Carbamylated proteins formed in renal insufficiency from the spontaneous decomposition of urea exert a variety of metabolic effects. Here we examined the effects of carbamylated proteins on glomerular mesangial cells to determine whether urea retention in early renal insufficiency may itself promote glomerular sclerosis and hasten the progression to kidney failure. To this effect we carbamylated fetal bovine serum proteins in vitro and tested their effect on mesangial cell proliferation (by tritiated thymidine uptake), de novo protein synthesis (by tritiated leucine uptake), collagen I and collagen IV accumulation (by avidin-biotin enzyme immunoassay), and gelatinase levels in the medium (by zymography and quantitative fluorescence assay). Carbamylated fetal bovine serum at concentrations present in uremia increased tritiated thymidine incorporation by 50% without altering tritiated leucine incorporation, and it increased collagens I and IV in the monolayer by 150% to 300%. Gelatinase activity was unchanged. We conclude that carbamylated proteins can activate mesangial cells to a profibrogenic phenotype. From a clinical perspective, the carbamylation of proteins by elevated urea levels may accelerate the progression to kidney failure and thus set up a vicious cycle in which the nitrogen retention itself would cause further progression of fibrosis and deterioration of kidney function.

Prevalence of hypertension in chronic cocaine users

The association of cocaine and acute hypertension is well known; however, cocaine use has not generally been linked to chronic hypertension. We hypothesized that chronic use of cocaine over time would increase the prevalence of hypertension and that cocaine induced vasoconstriction would result in urine protein leakage, manifested by microalbuminuria. Therefore, we studied a population of predominantly black male patients admitted for addiction treatment whose drug of dependence was cocaine. A urine toxicology screen was considered positive if cocaine was detected within 24 h prior to or during admission to the hospital. A total of 301 patients with normal renal function were observed over their 2 week hospitalization. The majority (62%) of the patients were normotensive regardless of the status of their initial urine toxicology screen. Twenty percent of the population had acutely elevated blood pressure that normalized within 1 day, whereas 18% had blood pressure chronically >140/90 mm Hg (chronic hypertension). Levels of systolic and diastolic blood pressures were examined at age deciles and compared to the NHANES III (Third National Health and Nutrition Examination Survey) data for a predominantly black population. There was no significant difference in blood pressure with age in the cocaine users compared to the NHANES groups. Random urine samples were screened for the presence of microalbuminuria and no significant elevation was detected in any of the samples tested. We conclude that chronic cocaine use is associated with acute but not chronic hypertension in middle-aged black males. Cocaine use does not cause microalbuminuria.

Regulation of the renal Na-HCO3 cotransporter: IX. Modulation by insulin, epidermal growth factor and carbachol

To examine the role of tyrosine kinase (TK) on basolateral membrane (BLM) transport, we looked for the presence of TK activity in these membranes and showed that the synthetic substrate for TK, poly [Glu80 Na, Tyr20] caused a three-fold increase in tyrosine phosphorylation. This effect was completely blocked by the TK inhibitors, 2-hydroxy-5(2,5-dihydroxybenzyl) aminobenzoic acid (HAC), 1 microM, and methyl 2,5-dihydroxycinnamate (DHC), 5 microM. We then examined the effect of agents that cause TK stimulation on tyrosine kinase immunocontent and on the Na-HCO3 cotransporter activity in BLM and in primary cultures of the proximal tubule. We utilized the cholinergic agent, carbachol (10(-4) M), epidermal growth factor (EGF 10(-8) M), and insulin (10(-8) M), well known activators of TK. Carbachol, insulin, and EGF caused a significant increase in TK immunoreactive protein content which was blocked by HAC and DHC. In BLM, carbachol significantly stimulated HCO3-dependent 22Na uptake and this effect was totally prevented by the monoclonal antibody against TK. In cultured proximal tubule cells, carbachol, EGF and insulin at physiologic concentration caused a significant stimulation of the cotransporter activity and this effect was completely blocked by the TK inhibitor, HAC. Increasing the dose of insulin 100-fold did not cause further stimulation of the cotransporter indicating that insulin plays a permissive role on the cotransporter. These results demonstrate the presence of TK in renal proximal tubule cells and show that activation of this kinase by dissimilar agents enhance the activity of the Na-HCO3 cotransporter.

pH-dependent fluorescence of a heterologously expressed Aequorea green fluorescent protein mutant: in situ spectral characteristics and applicability to intracellular pH estimation

The green fluorescent protein of Aequorea victoria (GFP) is a natural peptide chromophore without substrate or cofactor requirements for fluorescence. In vitro, a recombinant F64L/S65T GFP mutant (GFPmut1) exhibited pH sensitive fluorescence within the physiologic range. When heterologously expressed in BS-C-1 cells or rabbit proximal tubule cells, uniform cytosolic and nuclear fluorescence was observed. Cytosolic fluorescence constituted over 80% of the total. Excitation scanning of transfected cells revealed two GFPmut1-specific regions that were pH-sensitive over the physiologic range, and each region exhibited a unique pH "bias" in fluorescence emission. Excitation at or near the expected maximum of 488 nm (region II) uniformly resulted in fluorescence that was preferentially altered at acidic pH. In contrast, a novel "wild-type" excitation peak at 400 nm (region I) resulted in alkaline-biased fluorescence similar to that described for the wild-type chromophore in vitro, suggesting that wild-type spectral features disrupted in vitro by mutagenesis may be recovered in intact cells. Calibration of intracellular pH (pHi) with in situ fluorescence following excitation in either region revealed a semilogarithmic relationship between fluorescence intensity and pH within the physiologic range. We therefore measured pHi changes attributable to altered Na/HCO3 cotransport (NBC) activity both in GFPmut1-expressing cells and in paired untransfected cells loaded with BCECF. Basal NBC activity was the same in each group, as was the stimulation of activity by 10% CO2, thus validating the utility of GFPmut1 as a fluorescent probe for pHi and establishing a novel, useful, and practical application for GFPmut1 in monitoring pHi in real time.

Angiotensin-converting enzyme inhibition reduces the effect of bromoethylamine-induced papillary necrosis and renal fibrosis

Rats injected with a single, 50-mg dose of bromoethylamine (BEA) developed papillary necrosis accompanied by sever interstitial fibrosis. At 1 mo, the creatinine clearance decreased (control 0.66 versus BEA 0.33 ml/min per 100 g body wt, P = 0.02), and the urine albumin-to-creatinine ratio increased markedly (control 0.19 versus BEA 0.51, P = 0.02). In a group of animals given the angiotensin-converting enzyme inhibitor enalapril (Enal; 100 mg/L) in their drinking water for 4 wk, beginning 1 wk before BEA injection, creatinine clearance improved significantly (BEA 0.33 versus Enal + BEA 0.52 ml/min per 100 g body wt, P = 0.01) and albumin excretion fell to zero. Histologic examination revealed an 88% decrease in the area of papillary necrosis and a decrease in the degree of interstitial fibrosis in the corticomedullary junction. To determine whether this was due to changes in urine flow rate induced by enalapril, a group of animals was injected with BEA, and enalapril at the above dose was begun 1 wk later. After 1 mo, the enalapril-treated animals showed the same improvement in creatinine clearance (BEA 0.33 versus BEA + Enal 0.50 ml/min per 100 g body wt, P = 0.03) and suppression of albumin excretion. The area of papillary necrosis was reduced by 67%. In the BEA animals treated with enalapril, ED-1-positive cells, alpha-smooth muscle actin, and transforming growth factor-beta1 were decreased compared with BEA alone. It is concluded that in this model of papillary necrosis, enalapril protects renal function and decreases interstitial fibrosis mediated at least in part through an angiotensin II/bradykinin-dependent mechanism.

Role of nitric oxide in cocaine-induced acute hypertension

Cocaine causes acute hypertension by blocking catecholamine reuptake. There is evidence that it also impairs the peripheral endothelial nitric oxide system, which is normally vasodilatory. We further explored the role of nitric oxide in cocaine-induced vasoconstriction in anesthetized rats, and in vitro by using isolated carotid artery segments. Cocaine administered intravenously in rats increased mean arterial pressure by 30 to 40 mm Hg within 1 min. This effect was dose dependent and the maximum effect was observed at a dose of 1.25 mg/kg. The prototype catecholamine norepinephrine induced a similar increase in blood pressure. When rats were pretreated with NG-monomethyl-L-arginine (L-NMMA, a blocker of nitric oxide) and challenged with cocaine, the increase in blood pressure was blocked by 80%, whereas pretreatment with L-NMMA did not block norepinephrine-induced vasoconstriction. Both cocaine and norepinephrine also induced an immediate vasoconstriction in isolated carotid artery preparations. The in vitro vasoconstriction induced by cocaine was blocked by pretreatment with L-NMMA, whereas L-NMMA did not block the norepinephrine-induced vasoconstriction in vitro. Furthermore, carotid artery stripped of endothelium responded to norepinephrine but failed to respond to L-NMMA or cocaine. S-nitroso-N-acetyl-D,L-penicillamine (SNAP)-a precursor of nitric oxide- stimulated nitric oxide production in control coronary artery fragments. When these fragments were incubated with cocaine there was a 20% reduction in the production of nitrite oxide. These results suggest that cocaine exerts its peripheral vasoconstriction at least in part by inhibiting local vasodilator nitric oxide.

Effect of glycated proteins on the matrix of glomerular epithelial cells

In this study, cultured glomerular epithelial cells (GEC) were exposed to a diabetic milieu containing glycated proteins to determine whether such proteins cause metabolic alterations that may lead to defects seen in the extracellular matrix in diabetic nephropathy. Cultured glomerular epithelial cells were cloned and maintained in RPMI media containing 10% fetal bovine serum (FBS). The medium was changed to RPMI-1% glycated FBS (experimental) or RPMI-1% control FBS, and cells were incubated for 1 or 4 d. Mitogenicity was tested by 3H-thymidine uptake. The media were collected and analyzed for collagenase activity by a quantitative fluorescence assay and by zymography. The cell layers were processed for matrix antigen (collagen I, glomerular basement membrane antigens, laminin, and fibronectin) and for the proteins of the tight junction (cadherin, desmosomal protein) by quantitative immunoperoxidase and immunofluorescence. Cell lysates were tested for cadherin and desmosomal protein by immunoblotting. Cells were also grown on 0.2-microM filter membranes to test for permeability to 3H-inulin and 125I-albumin. Glycated FBS resulted in a 1.8-fold increase in 3H-thymidine uptake in subconfluent layers accompanied by an increase in cell number. The treatment caused accumulation of laminin (18% above control, P < 0.05) and basement membrane antigens (33% above control, P < 0.05). Collagen I and fibronectin were unchanged. Exposing cells to glycated FBS changed the distribution of cadherin from a linear to a diffuse pattern associated with a decrease in cadherin observed on immunoblots. The media of glycated FBS-treated cells contained 45% lower collagenase activity (72-, 92-, and 150-kD species). Permeability to inulin increased by 550% and to albumin by 320% in glycated FBS-treated monolayers compared with controls. It is concluded that glycated proteins increased the accumulation of matrix proteins in the GEC, associated with a concomitant depression in collagenase activity. There were qualitative and quantitative changes in the tight junction protein cadherin. These matrix changes resulted in a functional defect in the permselective properties of the GEC tight junctions and manifested as increased leakage of inulin and albumin. Thus, the GEC are metabolically sensitive to the presence of glycated proteins, and this could play a role in the pathogenesis of diabetic nephropathy.

Regulation of renal Na-HCO3 cotransporter: VIII. Mechanism Of stimulatory effect of respiratory acidosis

We examined the effect of respiratory acidosis on the Na-HCO3 cotransporter activity in primary cultures of the proximal tubule of the rabbit exposed to 10% CO2 for 5 min, 2, 4, 24 and 48 hr. Cells exposed to 10% CO2 showed a significant increase in Na-HCO3 cotransporter activity (expressed as % of control levels, 5 min: 142 +/- 6, 2 hr: 144 +/- 13, 4 hr: 145 +/- 11, 24 hr: 150 +/- 15, 48 hr: 162 +/- 24). The increase in activity was reversible after 48 hr. The role of protein kinase C (PKC) on the stimulatory effect of respiratory acidosis on the cotransporter was examined in presence of PKC inhibitor calphostin C or in presence of PKC depletion. Both calphostin C and PKC depletion prevented the effect of 10% CO2 for 5 min or 4 hr to increase the activity of the cotransporter. 10% CO2 for 5 min or 4 hr increased total and particulate fraction PKC activity. To examine the role of phosphotyrosine kinase (PTK) on the increase in cotransporter activity we studied the effect of two different inhibitors, 2-hydroxy-5-(2,5-dihydroxylbenzyl) aminobenzoic acid (HAC) and methyl 2,5-dihydroxycinnamate (DHC) which inhibit phosphotyrosine kinase in basolateral membranes. Cells were pretreated either with vehicle or HAC or DHC and then exposed to 10% CO2 for 5 min or 4 hr. In cells treated with vehicle, 10% CO2 significantly increased cotransporter activity as compared to control cells exposed to 5% CO2. This stimulation by 10% CO2 was completely prevented by HAC or DHC at 5 min (5% CO2: 1.8 +/- 0.2, 10% CO2: 2.6 +/- 0.2, 10% CO2 + HAC: 1.6 +/- 0.2, 10% CO2: +DHC: 2.0 +/- 0.3 pH unit/min) and also at 4 hr. The protein synthesis inhibitors actinomycin D and cycloheximide appear to prevent the effect of 10% CO2 for 4 hr on the cotransporter. Our results show that early respiratory acidosis stimulates the Na-HCO3 cotransporter through PKC and PTK-dependent mechanisms and the late effect appears to be mediated through protein synthesis.

Simplified screening for microalbuminuria

BACKGROUND

Screening for microalbuminuria is increasingly advocated as a way to diagnose early renal involvement in diabetes and other diseases. It usually entails the use of a radioimmunoassay that is expensive and not always readily available.

OBJECTIVE

To assess the efficacy of three simple and inexpensive tests for ruling out microalbuminuria.

DESIGN

Cross-sectional study.

SETTING

Outpatient clinics.

PATIENTS

221 patients from primary care clinics and a diabetes clinic.

MEASUREMENTS

Random urine specimens were tested for albumin by using Micral-Test immunoassay strips (Boehringer Mannheim, Mannheim, Germany) and for protein by using sulfosalicylic acid testing and impregnated dipsticks (Chemstrips, Boehringer Mannheim). Radioimmunoassay for albumin was used for all specimens as standard for comparison.

RESULTS

When less than 20 mg/L was considered the upper limit of normal for albumin concentration, Micral-Test, sulfosalicylic acid testing, and Chemstrips had negative predictive values of 99%, 95%, and 96%, respectively. Seventy-four specimens tested negative on both sulfosalicylic acid and Chemstrips; the negative predictive value of these two tests combined was 99%.

CONCLUSIONS

The combination of sulfosalicylic acid testing and Chemistrips was as good as and less expensive than Micral-Test in ruling out microalbuminuria.

Carbamylated hemoglobin in hemodialysis patients

We have previously found that carbamylated hemoglobin (carHb) levels are increased in chronic renal failure and correlate positively with blood urea nitrogen (BUN) levels and with the duration of exposure to urea. In a fashion analogous to glycosylated hemoglobin in diabetic patients, it is possible that carHb may better reflect BUN levels before hemodialysis (preBUN) and also between hemodialysis sessions. We therefore tested the hypothesis that carHb could be a better index of adequacy of hemodialysis than the urea reduction ratio (URR). Fifty hemodialysis patients had carHb measured every 2 months for 14 months; the carHb level was compared with URR and preBUN levels, as assessed by changes in absolute numbers and trends of the BUN levels between hemodialyses. Mean URR was above 61% throughout the 14 months. Mean carHb levels did not change significantly during the study and were only weakly correlated with URR. However, there was a much better correlation between predialysis BUN and carHb, suggesting that carHb levels reflect more accurately the changes in BUN between hemodialysis sessions. To further test this hypothesis, we subdivided the patients arbitrarily, depending on the change in preBUN between two consecutive carHb measurements. We found significantly lower carHb levels when BUN decreased or remained stable than when it increased or was persistently high. In patients with decreasing or stable BUN, carHb was significantly lower than in patients with persistently high or increasing BUN (carHb 81.5 +/- 3.6 microg valine hydantoin [VH]/g Hb v 123.7 +/- 11.7 microg VH/g Hb, respectively; P < 0.001). URR was not different between groups. In addition to changes in BUN levels, carHb was correlated by multiple regression analysis with the presence of diabetes, weight, and plasma HCO3. The relationship between diabetic patients and carHb levels was complex because such patients tend to have higher preBUN levels, higher protein catabolic rate, and lower HCO3 levels. These results demonstrate that carHb reflects the changes between dialysis BUN and may serve as a more accurate index of uremia control. Clinically, it appears that well-dialyzed patients have carHb levels lower than 100 microg VH/g Hb.

The renal cortical Na+/HCO3- cotransporter VI: the effect of chemical modification in cotransporter activity

The Na+/HCO3- cotransporter is the main system that mediates bicarbonate removal out of the proximal tubule cell into the blood. We have previously partially purified this protein and showed that chemical modification of the alpha-amino groups by fluorescein isothiocyanate (FITC) inhibited the activity of the Na+/HCO3- cotransporter. The inhibition was prevented by the presence of Na and bicarbonate suggesting that this compound binds at or near the substrate transport sites of the cotransporter. We examined the effect of agents that modify the sulfhydryl group (dithiothreitol), carboxyl groups (n-n'dicyclohexyl carbodiimide) and tyrosine residues (p-nitrobenzene sulfonyl fluoride, n-acetyl imidazole and tetranitromethane) on the activity of the cotransporter to gain insight into the chemical residues which may be important for transport function. The sulfhydryl residues modifier, carboxyl group modifier, and tyrosine modifier significantly inhibited bicarbonate dependent 22Na uptake in basolateral membranes by 50-70% without altering the 22Na uptake in the presence of gluconate indicating that these agents directly affected the cotransporter without affecting diffusive sodium uptake. The effect of the tyrosine modifier n-acetylimidazole was not prevented by the presence of Na and bicarbonate suggesting that the tyrosine residues are not at the substrate binding sites. To determine the presence and role of glycosylation on the Na+/HCO3- cotransporter protein, we examined the effects of different glycosidases (endoglycosidase F and H, N-glycosidase F, O-glycanase) on the cotransporter activity. All glycosidases caused a significant 50-80% inhibition of cotransporter activity. These data demonstrate that N-glycosylation as well as O-glycosylation are important for the function of the Na+/HCO3- cotransporter protein. Taken together, these results suggest that chemical modifiers of tyrosine, carboxyl and sulfhydryl groups as well as glycosylation are important for expression of full functional activity of the cotransporter.

Regulation of the renal Na-HCO3 cotransporter: VII. Mechanism of the cholinergic stimulation

Cholinergic agents regulate proximal tubule acidification but the mechanism responsible for this effect is unclear. We examined the effect of the cholinergic agent carbachol on the activity of the Na-HCO3 cotransporter in primary cultures of the proximal tubule of the rabbit. The activity of the cotransporter was assayed either as HCO3-dependent 22Na uptake or as the recovery of intracellular pH in cells perfused continuously with Cl-free physiologic solution containing amiloride to block the Na-H antiporter. Carbachol caused a dose-dependent stimulation of the cotransporter activity with a maximum increase of 90% above control values at 10(-5) M and half maximal stimulation at 10(-7) M. The stimulation was blocked by atropine and pirenzepine indicating an effect through the M1 muscarinic receptor. Carbachol increased intracellular calcium fourfold and the rise in cytosolic calcium was prevented by the intracellular calcium chelator, BAPTA. BAPTA also blocked the effect of carbachol on the cotransporter. Because carbachol activates phospholipase C and protein kinase C, we examined the effect of carbachol in the presence of the phospholipase C inhibitor, U73122, or the PKC inhibitor, calphostin C, or PKC depletion. The phospholipase C inhibitor prevented both the effect of carbachol on the cotransporter and on the intracellular Ca. Calphostin C and PKC depletion also prevented the stimulation of the cotransporter. Carbachol increased PKC activity and caused translocation of the PKC to the particulate fraction. We also examined the effect of the phosphatase inhibitor, calyculin A or the calmodulin kinase inhibitor, W-13 on carbachol stimulation. Calyculin A and W13 likewise prevented the carbachol-induced stimulation of the cotransporter. These results demonstrate that cholinergic stimulation modulated the activity of the cotransporter through multiple pathways including phospholipase C/PKC and phosphatase systems.

Renal cortical basolateral Na+/HCO3- cotransporter: IV. Characterization and localization with polyclonal antibodies

We have previously partially purified the basolateral Na+/HCO3- cotransporter from rabbit renal cortex and this resulted in a 400-fold purification, and an SDS-PAGE analysis showed an enhancement of a protein band with a MW of approximately 56 kDa. We developed polyclonal antibodies against the Na+/HCO3- cotransporter by immunizing Dutch-belted rabbits with a partially purified protein fraction enriched in cotransporter activity. Western blot analysis of renal cortical basolateral membranes and of solubilized basolateral membrane proteins showed that the antibodies recognized a protein with a MW of approximately 56 kDa. The specificity of the purified antibodies against the Na+/ HCO3- cotransporter was tested by immunoprecipitation. Solubilized basolateral membrane proteins enriched in Na+/HCO3- cotransporter activity were incubated with the purified antibody or with the preimmune IgG and then reconstituted in proteoliposomes. The purified antibody fraction caused a concentration-dependent inhibition of the Na+/HCO3- cotransporter activity, while the preimmune IgG failed to elicit any change. The inhibitory effect of the antibody was of the same magnitude whether it was added prior to (inside) or after (outside) reconstitution in proteoliposomes. In the presence of the substrates (NaHCO3 or Na2CO3) for the cotransporter, the inhibitory effect of the antibody on cotransporter activity was significantly blunted as compared with the inhibition observed in the absence of substrates. Western blot analysis of rabbit kidneys showed that the antibodies recognized strongly a 56 kDa protein band in microsomes of the inner stripe of outer medulla and inner medulla, but not in the outer stripe of outer medulla. A 56 kDa protein band was recognized in microsomes of the stomach, liver, esophagus, and small intestine but was not detected in red blood cell membranes. Localization of the Na+/HCO3- cotransporter protein by immunogold technique revealed specific labeling of the cotransporter on the basolateral membranes of the proximal tubules, but not in the brush border membranes. These results demonstrate that the polyclonal antibodies against the 56 kDa basolateral protein inhibit the activity of the Na+/HCO3- cotransporter suggesting that the 56 kDa protein represents the cotransporter or a component thereof. These antibodies interact at or near the substrate binding sites. The Na+/HCO3- cotransporter protein is expressed in different regions of the kidneys and in other tissues.

Focal segmental glomerulosclerosis in adult African Americans

We have previously shown that idiopathic focal segmental glomerulosclerosis (FSGS) is the most common non-proliferative primary glomerulopathy in adult African Americans. In this report we present our experience with treated FSGS in 15 such patients followed over five years. They were all treated with prednisone 60 mg daily for three months, followed by a slow tapering. In addition, two patients later had cyclophosphamide, and five had enalapril. At entry hypertension was present in 73% of the patients, nephrotic syndrome in 87%, and elevated serum creatinine (> or = 1.4 mg/dl) in 40%. Five of the 15 patients (33%) developed end-stage renal failure (ESRF), one of them having a "malignant" course after the advent of pregnancy. Two patients (13%) have chronic renal insufficiency (CRI; serum creatinine > 2.5 mg/dl); three (20%) have mild renal insufficiency (serum creatinine 1.4-2.5 mg/dl), and five patients (33%) have normal renal function. The cumulative renal survival was 93% at five years, but only 26% at eight years. At last follow-up all the ten patients who did not develop ESRF were in partial remission (urinary protein of 1.3 g/day +/- 1.21), but 4 of the 5 patients who did not develop ESRF had no prolonged partial remission of nephrotic syndrome. Neither the initial clinical parameters not the use of enalapril correlated with the renal outcome (univariate analysis). However, 4 of the 5 patients who developed ESRF had elevated serum creatinine at entry, versus only 2 of the 10 not developing ESRF (p = 0.09 by two-sided, and 0.045 by one-sided Fisher's exact test). We conclude that the short-term renal outcome in nephrotic adult African Americans with treated FSGS is comparable to that of the non-African Americans, but their long-term prognosis may be poorer. Patients developing ESRF were more likely to present with elevated serum creatinine. Enalapril did not seem to modify the course of renal disease, but its utility and that of other ACE inhibitors in the treatment of FSGS must await prospective randomized studies.

Regulation of the renal Na-HCO3 cotransporter: VI. Mechanism of the stimulatory effect of protein kinase C

We have previously shown that the activity of the Na-HCO3 cotransporter is stimulated by protein kinase C (PKC) activation, but the mechanism responsible for this effect is not clear. We have shown that cultured proximal tubule cells of the rabbit have DIDS-sensitive Na-HCO3 cotransporter activity as assessed by HCO3-dependent 22Na uptake or by measurement of intracellular pH. In cells loaded with BCECF and treated with the amiloride analogue, ethylisopropyl amiloride, removal of extracellular Na was associated with a rapid decrease in pH which returned to normal with re-addition of Na. This pH recovery was inhibited by DIDS and was used to quantify the activity of the Na-HCO3 cotransporter. In the present study, we utilized primary cultures of the proximal tubule of the rabbit to examine the effect of PKC activation on the activity of the Na-HCO3 cotransporter. Short term incubation (5 min) with the active phorbol ester, phorbol 12-myristate, 13-acetate (PMA), 10(-7) M, caused a significant stimulation of the Na-HCO3 cotransporter activity as compared to controls. Incubation for two hours also caused a significant stimulation of the Na-HCO3 cotransporter activity. The inactive analogue of PMA, 4-alpha phorbol, failed to alter the cotransporter. Similar results were observed when we examined the effect of PMA on HCO3-dependent 22Na uptake. The effect of PMA to stimulate the cotransporter was mediated by PKC activation since it could be prevented by the PKC inhibitors, calphostin C or sphingosine, or by prior PKC depletion. The long term but not the short term effect of PMA to stimulate the Na-HCO3 cotransporter activity was prevented by the protein synthesis inhibitors, actinomycin D or cycloheximide. The early effect of PKC to stimulate the cotransporter appeared to be associated with increased phosphorylation of a 56 kD protein band, while the late effect appeared to be associated with an increase in immunoreactive content of a 56 kD protein which is thought to be an active component of the cotransporter. Thus PKC stimulation activates the Na-HCO3 cotransporter by two distinct mechanisms: a long term effect which is protein synthesis-dependent and a short term effect which is protein synthesis-independent and is likely mediated by phosphorylation.

The renal cortical Na-HCO3 cotransporter: V. expression in Xenopus oocytes

The Na-HCO3 cotransporter is the main system responsible for HCO3 transport from proximal tubule cells into the blood. the expression of the renal cortical basolateral Na-HCO3 cotransporter was studied in Xenopus laevis oocytes. Injection of mRNA prepared from renal cortex into oocytes enhanced HCO3-dependent 22Na uptake on average 6-fold, (range:2-44) compared with vehicle-injected oocytes, without altering 22Na uptake in presence of gluconate. These findings indicate that mRNA selectively expresses Na-HCO3 cotransporter activity without altering diffusive 22Na uptake. The expressed Na-HCO3 cotransporter activity had a Km for Na of 20 mM, was electrogenic and sensitive to disulfonic stilbenes. In presence of HCO3, the expressed Na-HCO3 cotransporter activity was like the native cotransporter, enhanced by carbonate or sulfite, a finding compatible with the existence of distinct sites for HCO3 and carbonate on the transport system. After fractionation by a sucrose density gradient, the mRNA fraction responsible for the Na-HCO3 cotransporter was found to be between 1.50 and 3.48 kb classes.

Regulation of the renal Na-HCO3 cotransporter: V. mechanism of the inhibitory effect of parathyroid hormone

PTH administration decreases proximal HCO3 reabsorption and inhibits the brush border Na-H antiporter. We studied the effect of PTH on the renal Na-HCO3 cotransporter and examined whether this effect is mediated through the adenylate cyclase/cyclic AMP system or through the phospholipase A pathway. We studied the effect of PTH [1-34] on the Na-HCO3 cotransporter activity in rabbit renal basolateral membranes incubated with 50 microM ATP by measuring the 22Na uptake in the presence of HCO3 and gluconate. Na-HCO3 cotransporter activity (expressed in nmol/mg protein/3 seconds) was taken as the difference in 22Na uptake in the presence of HCO3 and gluconate. PTH (10(-10) M) completely inhibited Na-HCO3 cotransporter activity from 1.23 +/- 0.14 to -0.58 +/- 0.23, P < 0.001. This effect of PTH to inhibit the Na-HCO3 cotransporter was prevented by the polyclonal antibody against G alpha s indicating that PTH acts through G alpha s protein. Because G alpha s stimulates adenylate cyclase/cyclic AMP system, we examined the effect of PTH in the presence and in the absence of the adenylate cyclase inhibitor, dideoxyadenosine (DDA). DDA alone (10(-4) M) stimulated the Na-HCO3 cotransporter activity. In the presence of DDA, the net inhibitory effect of PTH was the same magnitude as that of control, suggesting the existence of other pathways for the effect of PTH on the cotransporter. Calmodulin inhibition also partially prevented the effect of PTH. To determine whether the inhibitory effect of PTH is mediated at least in part, through phospholipase A, we first examined the effect of PTH on arachidonic acid release and then measured the Na-HCO3 cotransporter activity in presence and in absence of arachidonic acid or eicosatetraynoic acid (ETA), an inhibitor of arachidonic acid metabolism. PTH significantly increased the release of arachidonic acid by isolated proximal tubule cells and arachidonic acid inhibited the Na-HCO3 cotransporter in basolateral membranes. ETA (3 microM) partially prevented the inhibitory effect of PTH. In cultured proximal tubule cells, PTH inhibited the HCO3-dependent 22Na uptake and ethoxyresorufin, an inhibitor of cytochrome P-450, blocked the inhibitory effect of PTH on the cotransporter. These results demonstrate that PTH inhibits the renal Na-HCO3 cotransporter through multiple mechanisms, that are mediated through G proteins, G alpha s and GP, and CaM-KII.

Factors determining hemoglobin carbamylation in renal failure

Carbamylated hemoglobin (carhb) is formed by the reaction of hemoglobin with cyanate, a product of in vivo urea dissociation. It is found in high levels in patients with renal failure and may be useful in their clinical evaluation. Accordingly, we measured carhb by HPLC after acid hydrolysis in 73 patients with renal failure and 11 controls. Mean carhb levels (expressed as micrograms valine hydantoin/g Hb), were highest in chronic renal failure (CRF, 146 +/- 13), intermediate in end-stage renal disease on hemodialysis (ESRD, 106 +/- 7), and lowest in acute renal failure (ARF, 80 +/- 12) when compared to normal subjects (27 +/- 2). In all patients carhb was significantly correlated with BUN but not with creatinine, bicarbonate, or phosphate. For any level of BUN above 80 mg/dl, carhb was substantially higher in CRF than in ARF. Predialysis BUN and urea reduction ratio (URR) were significant predictors of carhb in ESRD. To investigate the effect of time of exposure and BUN level on the rate of carbamylation of hemoglobin, blood from normal subjects and dialysis patients was incubated in vitro with urea equivalent to BUN levels of 50, 100, 150, and 200 mg/dl and assayed for carhb at 0, 5, 9, and 14 days. Carhb increased linearly over the first nine days of urea exposure and leveled off thereafter. The rate of carbamylation increased as BUN increased and was significantly higher in hemoglobin from dialysis patients than from normal subjects. These results show that the higher the level of carhb at baseline, the higher the rate of carbamylation upon exposure to increasing urea concentrations. We conclude that carhb formation is dependent on urea concentration and length of exposure to urea. The rate of carhb formation for a given urea concentration is greater in hemoglobin already carbamylated, and this may explain why carhb is higher in CRF than in ARF at BUN levels greater than 80 mg/dl. Carhb may thus be a useful index of the duration and degree of exposure to high blood urea levels in patients with renal failure, and may potentially serve as an index of the adequacy of dialysis.

Regulation of the renal Na-HCO3 cotransporter: IV. Mechanisms of the stimulatory effect of angiotensin II

Angiotensin II stimulates proximal tubule acidification by activating both the Na-H antiporter and the Na-HCO3 cotransporter. The mechanism whereby angiotensin II stimulates the Na-HCO3 cotransporter was investigated in renal cortical basolateral membrane vesicles of the rabbit by measuring 22Na uptake in the presence of HCO3 and gluconate. Na-HCO3 cotransporter activity (expressed in nanomoles per milligram of protein per 3 s) was taken as the difference in 22Na uptake in the presence of HCO3 and gluconate. Angiotensin II stimulated Na-HCO3 cotransporter activity significantly (control, 1.5 +/- 0.4; angiotensin II, 3.3 +/- 0.6; P < 0.05), and this stimulation was prevented by the angiotensin II receptor antagonist DuP 753. Angiotensin II has been shown to stimulate both pertussis toxin-sensitive Gi protein and pertussis toxin-insensitive Gq protein. In the presence of pertussis toxin, angiotensin II (10(-11) M) failed to stimulate the Na-HCO3 cotransporter, suggesting a role of Gi protein in mediating this effect. In the presence of a polyclonal antibody against Gi protein, angiotensin II failed to stimulate the Na-HCO3 cotransporter (control, 1.6 +/- 0.4; angiotensin II, 3.9 +/- 0.9; angiotensin II + Gi, 1.2 +/- 0.7). Angiotensin II stimulated inositol triphosphate release, and this effect could be blocked by the phospholipase C inhibitor U73122, suggesting a role of phospholipase C or A2 in this effect of angiotensin II. In the presence of the protein kinase C inhibitor calphostin C (50 nM), angiotensin II also failed to stimulate the Na-HCO3 cotransporter. These results demonstrate that angiotensin II stimulates the renal Na-HCO3 cotransporter by interacting with a specific angiotensin II receptor and that this stimulation is mediated by the activation of Gi and Gq proteins.

Binding of nitrate to renal brush border membranes studied with 14N nuclear magnetic resonance (NMR)

Renal brush border membranes contain several anion exchanges that may play a role in electrolyte transport and pH regulation. To help characterize the types of exchangers present and the binding properties of these membranes, the binding of nitrate (NO3-) to highly purified rabbit kidney brush border membrane vesicles was studied. The method is based on the binding induced quadrupole relaxation of the 14N-NMR signal of nitrate [1,2]. Brush border membrane vesicles caused a relaxation of the 14N-NMR nitrate signal which could be characterized by relatively high affinity sites, KD = 6.7 +/- 1.5 mM, as well as nonspecific interactions with the membranes, KD > 150 mM. The anion transport inhibitor 4,4'-dinitrostilbene-2,2'-disulfonate (DNDS) inhibited 51 +/- 6% (n = 4) of the relaxation due to the high affinity binding sites. The DNDS inhibition could be characterized by a Ki of 10-80 microM. Both bicarbonate and formate (HCO2-) were found to partially inhibit the high affinity induced relaxation, with maximal inhibition of 37 +/- 8% (n = 3) and 30 +/- 2% (n = 3), respectively. The inhibitory effects of saturating concentrations of bicarbonate and formate were non-additive, suggesting the existence of a stilbene sensitive exchanger that can bind nitrate, as well as both bicarbonate and formate. This study indicates the usefulness of this new method for further investigation of anion exchangers on these and other membranes.

Once weekly intravenous calcitriol suppresses hyperparathyroidism in hemodialysis patients

Although thrice weekly intravenous calcitriol therapy suppresses parathyroid hormone in end-stage renal disease patients, the efficacy of once weekly administration is not known. Sixty-three patients hemodialyzed for a mean duration of 44 +/- 4 months were treated with once weekly intravenous calcitriol at a mean dose of 2.8 +/- 1 microgram/week. Parathyroid hormone was significantly suppressed from a mean baseline level of 471 +/- 38 to 342 +/- 46 at 5 months and 220 +/- 40 pg/ml at 7 months of therapy. Plasma calcium levels rose from 9.0 +/- 0.1 to 9.4 +/- 0.1 and 9.9 +/- 0.2 mg/dl, respectively. Plasma phosphate level was unchanged. No untoward side effects were observed. The same mean dose of calcitriol achieved a comparable degree of parathyroid hormone suppression regardless of whether patients were on prior thrice weekly or no prior therapy. In patients who had been treated with thrice weekly bolus injections, switching to a once weekly bolus injection achieved a comparable suppression with a 36% reduction in the cumulative dose. Thus, once weekly intravenous bolus administration of calcitriol resulted in a rapid and marked suppression of parathyroid hormone, similar in adequacy to thrice weekly boluses but at a considerably lower cumulative weekly dose. Results were particularly impressive in patients recently starting dialysis, suggesting that once weekly administration is safe, cost effective, and should become standard therapy.

Effect of acute and chronic glutathione depletion on renal function in the rat

Renal function was evaluated in normal and acid-loaded rats following acute and chronic depletion of glutathione (GSH) by buthionine sulfoximine (BSO). Creatinine clearance and fractional excretion of electrolytes were normal. There was no acidification or concentration defect detected in animals with acute or chronic GSH depletion.

Regulation of renal Na-HCO3 cotransporter: III. Presence and modulation by glucocorticoids in primary cultures of the proximal tubule

We looked for the presence of the Na-HCO3 cotransporter in primary cultures of the proximal tubule and examined the modulation of this cotransporter by glucocorticoid hormones. Primary cultures of the proximal tubule of the rabbit have Cl-independent, HCO3-dependent 22Na uptake which is DIDS-sensitive. In addition, in cells loaded with BCECF and perfused with Cl-free solution, removal of Na was associated with a decrease in intracellular pH which returned to normal with re-addition of Na. The pH recovery was not inhibited by EIPA but was sensitive to DIDS. These findings are compatible with existence of Na-HCO3 cotransporter in these cells. We examined the role of glucocorticoids on the activity of the Na-HCO3 cotransporter by culturing proximal tubule cells in the presence of hydrocortisone and when confluence was reached, hydrocortisone was deleted from the medium. In the absence of hydrocortisone, the activity of the cotransporter, measured either isotopically or fluorometrically, was significantly decreased, whereas re-addition of hydrocortisone 10(-8) M, restored the activity of the cotransporter to normal levels. The effect of hydrocortisone could not be duplicated by aldosterone, suggesting a glucocorticoid-dependent effect. Dexamethasone, a glucocorticoid without mineralocorticoid activity, stimulated the activity of the cotransporter within physiologic concentrations and this effect was blocked by progesterone. The effect of dexamethasone was time-dependent and was prevented by cycloheximide, a protein synthesis inhibitor. These results demonstrate that primary cultures of the proximal tubule have Na-HCO3 cotransporter activity which is modulated by physiological concentrations of glucocorticoids through a protein synthesis-dependent mechanism.

Renal cortical basolateral Na+/HCO3- cotransporter. III. Evidence for a regulatory protein in the inhibitory effect of protein kinase A

The activity of the Na-H antiporter is inhibited by cyclic AMP-dependent protein kinase A (cAMP-PKA). The inhibitory effect of PKA on the Na-H antiporter is mediated through a regulatory protein that can be dissociated from the antiporter by limited protein digestion. PKA also inhibits the activity of the Na+/HCO3- cotransporter. We investigated whether the activity of Na+/HCO3- cotransporter and the effect of PKA on this transporter may also be regulated by limited protein digestion. In rabbit renal cortical basolateral membranes (BLM) and in solubilized BLM reconstituted in liposomes (proteoliposomes), trypsin (100 micrograms) increased 22Na uptake in the presence of HCO3 but not in the presence of gluconate, indicating that trypsin does not alter diffusive 22Na uptake but directly stimulates the Na+/HCO3- cotransporter activity. In proteoliposomes phosphorylated with ATP, the catalytic subunit (CSU) of cAMP-PKA decreased the activity of the Na+/HCO3- cotransporter (expressed as nanomoles/mg protein/3s) from 23 +/- 10 to 14 +/- 6 (P < 0.01). In the presence of trypsin, the inhibitory effect of CSU of cAMP-PKA on the activity of Na+/HCO3- cotransporter was blunted. To identify a fraction that was responsible for the inhibitory effect of the CSU on the Na+/HCO3- cotransporter activity, solubilized proteins were separated by size exclusion chromatography. The effect of CSU of cAMP-PKA on the Na+/HCO3- cotransporter activity was assayed in proteoliposomes digested with trypsin with the addition of a fraction containing the 42 kDa protein (fraction S+) or without the 42 kDa protein (fraction S-).(ABSTRACT TRUNCATED AT 250 WORDS)

Regulation of renal cortical Na-HCO3 cotransporter. II. Role of G proteins

We examined the regulation of the renal cortical basolateral Na-HCO3 cotransporter by G proteins. Na-HCO3 cotransporter activity was measured in highly purified rabbit renal cortical basolateral membranes (BLMV) as the difference in 22Na uptake in presence of HCO3- and gluconate. HCO(3-)-dependent 22Na uptake was significantly inhibited by 10 microM guanosine 5'-O-(3-thiotriphosphate) (GTP gamma S), a G protein activator. In contrast, addition of 50 microM guanosine 5'-O-(2-thiodiphosphate) (GDP beta S), an inhibitor of G protein, prevented the inhibition of the Na-HCO3 cotransporter activity by GTP gamma S. AlF4-, another G protein activator, also inhibited the activity of the Na-HCO3 cotransporter. This inhibitory effect of G protein on the Na-HCO3 cotransporter activity was not prevented by dideoxyadenosine, an adenylate cyclase inhibitor, or by the protein kinase A inhibitor, suggesting a direct effect of G protein on the cotransporter. To identify the G proteins that mediate the regulation of the Na-HCO3 cotransporter, purified BLMV were ADP ribosylated in presence of cholera toxin or pertussis toxin. Autoradiograms of BLMV incubated with [32P]NAD showed that cholera and pertussis toxins caused ADP ribosylation of 42- and 41-kDa G proteins, respectively. To determine whether the ADP ribosylation by cholera or pertussis toxin was associated with alterations of the Na-HCO3 cotransporter activity, we measured HCO(3-)-dependent 22Na uptake in BLMV treated with 20 micrograms/ml cholera toxin or with 100 ng/ml pertussis toxin. Na-HCO3 cotransporter activity was significantly decreased by both cholera and pertussis toxins.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of cocaine in end-stage renal disease in some hypertensive African Americans

During a period of 1 year we observed 12 African American patients who had smoked or sniffed cocaine for several years and presented to inner city hospitals with accelerated hypertension and renal insufficiency. Ten required maintenance dialysis; 1 recovered partially after a brief period of dialysis, and 1 had moderate renal insufficiency. In the absence of striking proteinuria, cardiomegaly or renal shrinkage, the probable diagnosis in most of the patients was primary accelerated hypertension. The clinical history suggested that the habitual use of cocaine had worsened the hypertension, made it more difficult to control or triggered an accelerated phase resulting in renal shutdown. At a time when billions of dollars are being spent on the treatment of end-stage renal disease, the harmful role of cocaine in susceptible individuals requires due attention.

Xanthopterin-induced renal dysfunction: a reversible model of crystal nephropathy

Xanthopterin (XPT), an unconjugated pteridine compound, affects cell growth and differentiation. When injected into rats, XPT has caused changes that have been interpreted as renal growth and hypertrophy. In the present study, we investigated the effect of intraperitoneal administration of XPT on the renal function in the rat. XPT administration was associated with polyuria and a reversible form of nonoliguric acute renal failure (ARF), with renal function declining maximally after 2 days and returning to normal after 7 days. The polyuria was due, at least in part, to a concentrating defect that was vasopressin resistant. The ability of XPT to induce ARF was modulated by dietary salt intake, being enhanced by a low-sodium diet and prevented by a high sodium intake. Histological examination of the kidneys showed intratubular crystal deposition and acute tubule necrosis, suggesting that XPT induces crystal nephropathy. There was an increase in wet and dry weights of the kidney and an increased DNA/protein ratio, compatible with a hyperplastic response. Because the severity of other crystal nephropathies may be modulated by urine flow rate and pH, we studied the ability of water diuresis or alkaline diuresis to protect against XPT-induced ARF. Both water diuresis and HCO3 loading blunted the ability of XPT to decrease renal function. The change in renal function induced by XPT in the various groups was paralleled by corresponding changes in the levels of XPT-like substances in the kidney and by the amount of crystal deposition. Thus, XPT injection induces crystal nephropathy, the severity of which can be modulated by dietary salt intake, urine pH, and urine flow rate.

Renal cortical basolateral Na+/HCO3- cotransporter: II. Detection of conformational changes with fluorescein isothiocyanate labeling

Fluorescein isothiocyanate (FITC) fluorescently labels amino groups and has been useful in detecting conformational changes in transport proteins through quenching or enhancement of the fluorescence signal upon exposure of protein to substrates. Solubilized renal basolateral membrane proteins, enriched in Na+/HCO3- cotransporter activity, were reconstituted into liposomes and treated with FITC or its nonfluorescent analogue PITC (phenyl isothiocyanate). In the absence of Na+ and HCO3-, incubation of proteoliposomes with PITC or FITC significantly inhibited cotransporter activity. However, in the presence of Na+ and HCO3- during labeling both agents failed to inhibit cotransporter activity, indicating that these probes interact specifically with the cotransporter. In the presence of the substrates Na+ and HCO3-, PITC binds covalently to amino groups unprotected by substrates leaving the Na+/HCO3- cotransporter available for specific labeling with FITC. Addition of NaHCO3 to FITC-labeled proteoliposomes resulted in a concentration-dependent enhancement of the fluorescence signal which was inhibited by pretreatment with 4,4'-diisothiocyanostilbene 2',2-disulfonic acid (DIDS) prior to FITC labeling. SDS PAGE analysis of FITC-treated proteoliposomes showed the presence of two distinct fluorescent bands (approximate MW of 90 and 56 kD). In the presence of substrates, the fluorescence intensity of these bands was enhanced as confirmed by direct measurement of gel slice fluorescence. Thus, FITC detects conformational changes of the Na+/HCO3- cotransporter and labels proteins which may represent the cotransporter or components of this cotransporter.