Bart F.J. Heijnen

The Microcirculation and Hypertension

The role of the microcirculation is increasingly being recognized in the pathophysiology of cardiovascular disease. It is the major site of control of vascular resistance. In addition, the microcirculation is a major site of damage in most target organs of cardiovascular disease, such as the heart, brain, and kidney. In this chapter, we review the main methods used to assess the microcirculation. These methods include intravital microscopy, video capillaroscopy, Doppler flowmetry, and the use of isolated small arteries. Recently, important advances have been made in retinal microvascular imaging. These methods have led to important new insights in the role of changes in microcirculation both as a cause and a consequence of hypertension. We propose a major role for a defect in angiogenesis as a cause of microvascular rarefaction.

Renal inflammatory markers during the onset of hypertension in spontaneously hypertensive rats.

Early blockade of the renin–angiotensin system is successful in delaying the development of hypertension in spontaneously hypertensive rats (SHRs) and ameliorating organ damage by inhibition of the inflammatory response. In this study, we investigated the role of the angiotensin II type 1 receptor (AT1R) in the early renal inflammatory response in SHR. Blood pressure development and renal inflammatory markers were measured in 4-, 8- and 12-week-old SHR and age-matched Wistar Kyoto (WKY) rats. Separate groups of SHRs were transiently treated with the AT1R blocker losartan between 4 and 8 weeks of age. Urinary excretion of the renal injury markers osteopontin and neutrophil gelatinase-associated lipocalin increased in young SHR. Further, renal expression of inflammatory genes was also increased in young SHR. Losartan inhibited the increase of these inflammatory markers. In contrast, gene expression of the renal injury marker and T-cell inducer kidney injury molecule-1 (KIM-1) was reduced in 4-week-old SHR when compared with WKY. Similarly, the T-cell marker CD3 was significantly decreased in 4-week-old SHR. These effects were not antagonized by AT1R blockade. This study confirms the presence of an early renal inflammatory response in SHR that can be blocked by AT1R antagonism. In addition, it demonstrates that KIM-1 does not behave as a pure kidney injury marker in young SHR, but may reflect kidney maturation.

Phenotyping the Microcirculation

The role of the microcirculation is increasingly being recognized in the pathophysiology of cardiovascular disease.1,2 The microcirculation is a major site of damage in most target organs of cardiovascular disease, such as the heart, brain, and kidney. Both functional and structural alterations in the small arteries, arterioles, and capillaries are the basis of target organ damage. Furthermore, the microcirculation is the major site of control of vascular resistance. This makes it a central player in the etiopathogenesis of diseases characterized by an increased vascular resistance, such as hypertension. Detailed mechanistic studies in both humans and animal models of cardiovascular disease have revealed the nature of microcirculatory dysfunction. Large-scale epidemiological studies in the last 2 decades have identified the associations among deranged microvascular perfusion, structure, target organ damage, and subsequent cardiovascular disease.3 Major technological developments now allow study of the microcirculation both in mechanistic and epidemiological studies. The purpose of this Brief Review is to provide a critical appraisal of these developments and their particular impact on hypertension research. ### Assessment of the Microcirculation The Table gives an overview of the major methods to assess the microcirculation. Intravital microscopy has been used by many groups in experimental models to study microcirculatory (dys)function. It has been the primary technology underlying our present knowledge of microcirculatory function in health and disease. Intravital microscopy is the optical imaging of living organisms. The tissue to be studied is prepared by surgical techniques and microscopes, usually in combination with high quality video recorders, is used to visualize the microcirculation. Originally this technique was used in relatively transparent tissues like the bat wing, hamster cheek pouch, or rat mesentery. Later developments using trans- and epi-illumination have allowed wider access to the microcirculation of other tissues, such as skeletal muscle, the brain, and the heart. The recent introduction of …

On the Origin of Urinary Renin: A Translational Approach.

Urinary angiotensinogen excretion parallels albumin excretion, which is not the case for renin, while renin’s precursor, prorenin, is undetectable in urine. We hypothesized that renin and prorenin, given their smaller size, are filtered through the glomerulus in larger amounts than albumin and angiotensinogen, and that differences in excretion rate are because of a difference in reabsorption in the proximal tubule. To address this, we determined the glomerular sieving coefficient of renin and prorenin and measured urinary renin/prorenin 1) after inducing prorenin in Cyp1a1-Ren2 rats and 2) in patients with Dent disease or Lowe syndrome, disorders characterized by defective proximal tubular reabsorption. Glomerular sieving coefficients followed molecular size (renin>prorenin>albumin). The induction of prorenin in rats resulted in a >300-fold increase in plasma prorenin and doubling of blood pressure but did not lead to the appearance of prorenin in urine. It did cause parallel rises in urinary renin and albumin, which losartan but not hydralazine prevented. Defective proximal tubular reabsorption increased urinary renin and albumin 20- to 40-fold, and allowed prorenin detection in urine, at ≈50% of its levels in plasma. Taken together, these data indicate that circulating renin and prorenin are filtered into urine in larger amounts than albumin. All 3 proteins are subsequently reabsorbed in the proximal tubule. For prorenin, such reabsorption is ≈100%. Minimal variation in tubular reabsorption (in the order of a few %) is sufficient to explain why urinary renin and albumin excretion do not correlate. Urinary renin does not reflect prorenin that is converted to renin in tubular fluid.Urinary angiotensinogen excretion parallels albumin excretion, which is not the case for renin, while renin’s precursor, prorenin, is undetectable in urine. We hypothesized that renin and prorenin, given their smaller size, are filtered through the glomerulus in larger amounts than albumin and angiotensinogen, and that differences in excretion rate are because of a difference in reabsorption in the proximal tubule. To address this, we determined the glomerular sieving coefficient of renin and prorenin and measured urinary renin/prorenin 1) after inducing prorenin in Cyp1a1-Ren2 rats and 2) in patients with Dent disease or Lowe syndrome, disorders characterized by defective proximal tubular reabsorption. Glomerular sieving coefficients followed molecular size (renin>prorenin>albumin). The induction of prorenin in rats resulted in a >300-fold increase in plasma prorenin and doubling of blood pressure but did not lead to the appearance of prorenin in urine. It did cause parallel rises in urinary renin and albumin, which losartan but not hydralazine prevented. Defective proximal tubular reabsorption increased urinary renin and albumin 20- to 40-fold, and allowed prorenin detection in urine, at ≈50% of its levels in plasma. Taken together, these data indicate that circulating renin and prorenin are filtered into urine in larger amounts than albumin. All 3 proteins are subsequently reabsorbed in the proximal tubule. For prorenin, such reabsorption is ≈100%. Minimal variation in tubular reabsorption (in the order of a few %) is sufficient to explain why urinary renin and albumin excretion do not correlate. Urinary renin does not reflect prorenin that is converted to renin in tubular fluid.

Irreversible Renal Damage after Transient Renin-Angiotensin System Stimulation: Involvement of an AT1-Receptor Mediated Immune Response

Transient activation of the renin-angiotensin system (RAS) induces irreversible renal damage causing sustained elevation in blood pressure (BP) in Cyp1a1-Ren2 transgenic rats. In our current study we hypothesized that activation of the AT1-receptor (AT1R) leads to a T-cell response causing irreversible impairment of renal function and hypertension. Cyp1a1-Ren2 rats harbor a construct for activation of the RAS by indole-3-carbinol (I3C). Rats were fed a I3C diet between 4–8 weeks of age to induce hypertension. Next, I3C was withdrawn and rats were followed-up for another 12 weeks. Additional groups received losartan (20 mg/kg/day) or hydralazine (100 mg/kg/day) treatment between 4–8 weeks. Rats were placed for 24h in metabolic cages before determining BP at week 8, 12 and 20. At these ages, subsets of animals were sacrificed and the presence of kidney T-cell subpopulations was investigated by immunohistochemistry and molecular marker analysis. The development of sustained hypertension was completely prevented by losartan, whereas hydralazine only caused a partial decrease in BP. Markers of renal damage: KIM-1 and osteopontin were highly expressed in urine and kidney samples of I3C-treated rats, even until 20 weeks of age. Additionally, renal expression of regulatory-T cells (Tregs) was highly increased in I3C-treated rats, whereas the expression of T-helper 1 (Th1) cells demonstrated a strong decrease. Losartan prevented these effects completely, whereas hydralazine was unable to affect these changes. In young Cyp1a1-Ren2 rats AT1R activation leads to induction of an immune response, causing a shift from Th1-cells to Tregs, contributing to the development of irreversible renal damage and hypertension.

Cardiac remodeling during and after renin–angiotensin system stimulation in Cyp1a1-Ren2 transgenic rats

This study investigated renin–angiotensin system (RAS)-induced cardiac remodeling and its reversibility in the presence and absence of high blood pressure (BP) in Cyp1a1-Ren2 transgenic inducible hypertensive rats (IHR). In IHR (pro)renin levels and BP can be dose-dependently titrated by oral administration of indole-3-carbinol (I3C). Young (four-weeks old) and adult (30-weeks old) IHR were fed I3C for four weeks (leading to systolic BP >200 mmHg). RAS-stimulation was stopped and animals were followed-up for a consecutive period. Cardiac function and geometry was determined echocardiographically and the hearts were excised for molecular and immunohistochemical analyses. Echocardiographic studies revealed that four weeks of RAS-stimulation incited a cardiac remodeling process characterized by increased left ventricular (LV) wall thickness, decreased LV volumes, and shortening of the left ventricle. Hypertrophic genes were highly upregulated, whereas in substantial activation a fibrotic response was absent. Four weeks after withdrawal of I3C, (pro)renin levels were normalized in all IHR. While in adult IHR BP returned to normal, hypertension was sustained in young IHR. Despite the latter, myocardial hypertrophy was fully regressed in both young and adult IHR. We conclude that (pro)renin-induced severe hypertension in IHR causes an age-independent fully reversible myocardial concentric hypertrophic remodeling, despite a continued elevated BP in young IHR.

Transient renin-angiotensin system stimulation in an early stage of life causes sustained hypertension in rats.

Objectives Transient administration of inhibitors of the renin–angiotensin system (RAS) during the prehypertensive period in rats and humans leads to a long-lasting lowering of blood pressure (BP). Our aim was to unravel the critical period in which activation of the RAS induces chronic effects on BP and to determine the role of renal function and structure in this process. Methods Studies were performed in Cyp1a1-Ren2 rats, which harbor a construct for the production of mouse renin. This construct becomes activated when indole-3-carbinol (I3C) is added to the diet. Young (4 weeks old) and adult (30 weeks old) Cyp1a1-Ren2 rats were randomly assigned to either the I3C treatment group or the control group. Renin production was stimulated from week 4 to 8 in young and week 30 to 34 in adult rats. BP follow-up was performed via photoelectric/oscillometric tail cuff method and intra-arterial BP was determined at 4, 8, 12 and 20 weeks of age or 34 and 38 weeks of age. Additionally, renal vascular resistance, albuminuria, renal inflammation and renal pathology were determined. Results Up to 20 weeks of age, that is, 12 weeks after I3C withdrawal, mean arterial pressure (MAP) was significantly elevated in young I3C-treated rats (141 ± 7 mmHg) compared with controls (125 ± 6 mmHg). In adult rats, renin stimulation caused only a transient elevation in MAP, which returned to control values after I3C withdrawal. In young rats, the sustained pressor response was associated with increased indices of renal vascular resistance, glomerulosclerosis and tubulointerstitial damage as well as with a moderate inflammatory response. In adult rats, renal pathology and inflammation was significantly less than in young rats and was reversible. Conclusion Transient RAS stimulation causes sustained elevation in BP in young, but not in adult Cyp1a1-Ren2 transgenic rats and is associated with irreversible changes in renal structure and function and a moderate renal inflammatory response.

Early Life Microcirculation and the Development of Hypertension

See related article, pp 847–851 Research in the past decades has established a key role for the intrauterine environment, especially the maternal nutritional status, in influencing fetal growth and cardiovascular health in the offspring in later life.1 Experimental evidence suggests that the vasculature of the developing fetus may already be compromised by a suboptimal uterine environment.2 Recent data found associations between low birth weight and early vascular dysfunction, in particular in the fields of arterial wall compliance, endothelium-dependent vasodilatation, and microvascular structure. Arterial stiffness has been observed as early as on the fifth day of life in low gestational age infants.3 The alteration of the viscoelastic properties of conductance arteries has been attributed to an impaired vascular elastogenesis.4 A second mechanism considered to initiate hypertension in later life is early endothelial dysfunction. In several human studies, intrauterine growth restriction has been associated with altered endothelium-dependent vasodilatation at different ages, starting as early as in 3-month–old infants. Ligi et al4 have recently proposed that functional impairment of endothelial progenitor cells underlies the early endothelial dysfunction of low birth weight infants. The third vascular abnormality implicated has been microvascular remodeling, including reduced density of arterioles and capillaries.5 Microvascular remodeling has been …

On the Origin of Urinary ReninNovelty and Significance

Urinary angiotensinogen excretion parallels albumin excretion, which is not the case for renin, while renin’s precursor, prorenin, is undetectable in urine. We hypothesized that renin and prorenin, given their smaller size, are filtered through the glomerulus in larger amounts than albumin and angiotensinogen, and that differences in excretion rate are because of a difference in reabsorption in the proximal tubule. To address this, we determined the glomerular sieving coefficient of renin and prorenin and measured urinary renin/prorenin 1) after inducing prorenin in Cyp1a1-Ren2 rats and 2) in patients with Dent disease or Lowe syndrome, disorders characterized by defective proximal tubular reabsorption. Glomerular sieving coefficients followed molecular size (renin>prorenin>albumin). The induction of prorenin in rats resulted in a >300-fold increase in plasma prorenin and doubling of blood pressure but did not lead to the appearance of prorenin in urine. It did cause parallel rises in urinary renin and albumin, which losartan but not hydralazine prevented. Defective proximal tubular reabsorption increased urinary renin and albumin 20- to 40-fold, and allowed prorenin detection in urine, at ≈50% of its levels in plasma. Taken together, these data indicate that circulating renin and prorenin are filtered into urine in larger amounts than albumin. All 3 proteins are subsequently reabsorbed in the proximal tubule. For prorenin, such reabsorption is ≈100%. Minimal variation in tubular reabsorption (in the order of a few %) is sufficient to explain why urinary renin and albumin excretion do not correlate. Urinary renin does not reflect prorenin that is converted to renin in tubular fluid.Urinary angiotensinogen excretion parallels albumin excretion, which is not the case for renin, while renin’s precursor, prorenin, is undetectable in urine. We hypothesized that renin and prorenin, given their smaller size, are filtered through the glomerulus in larger amounts than albumin and angiotensinogen, and that differences in excretion rate are because of a difference in reabsorption in the proximal tubule. To address this, we determined the glomerular sieving coefficient of renin and prorenin and measured urinary renin/prorenin 1) after inducing prorenin in Cyp1a1-Ren2 rats and 2) in patients with Dent disease or Lowe syndrome, disorders characterized by defective proximal tubular reabsorption. Glomerular sieving coefficients followed molecular size (renin>prorenin>albumin). The induction of prorenin in rats resulted in a >300-fold increase in plasma prorenin and doubling of blood pressure but did not lead to the appearance of prorenin in urine. It did cause parallel rises in urinary renin and albumin, which losartan but not hydralazine prevented. Defective proximal tubular reabsorption increased urinary renin and albumin 20- to 40-fold, and allowed prorenin detection in urine, at ≈50% of its levels in plasma. Taken together, these data indicate that circulating renin and prorenin are filtered into urine in larger amounts than albumin. All 3 proteins are subsequently reabsorbed in the proximal tubule. For prorenin, such reabsorption is ≈100%. Minimal variation in tubular reabsorption (in the order of a few %) is sufficient to explain why urinary renin and albumin excretion do not correlate. Urinary renin does not reflect prorenin that is converted to renin in tubular fluid.

On the Origin of Urinary Renin

Urinary angiotensinogen excretion parallels albumin excretion, which is not the case for renin, while renin’s precursor, prorenin, is undetectable in urine. We hypothesized that renin and prorenin, given their smaller size, are filtered through the glomerulus in larger amounts than albumin and angiotensinogen, and that differences in excretion rate are because of a difference in reabsorption in the proximal tubule. To address this, we determined the glomerular sieving coefficient of renin and prorenin and measured urinary renin/prorenin 1) after inducing prorenin in Cyp1a1-Ren2 rats and 2) in patients with Dent disease or Lowe syndrome, disorders characterized by defective proximal tubular reabsorption. Glomerular sieving coefficients followed molecular size (renin>prorenin>albumin). The induction of prorenin in rats resulted in a >300-fold increase in plasma prorenin and doubling of blood pressure but did not lead to the appearance of prorenin in urine. It did cause parallel rises in urinary renin and albumin, which losartan but not hydralazine prevented. Defective proximal tubular reabsorption increased urinary renin and albumin 20- to 40-fold, and allowed prorenin detection in urine, at ≈50% of its levels in plasma. Taken together, these data indicate that circulating renin and prorenin are filtered into urine in larger amounts than albumin. All 3 proteins are subsequently reabsorbed in the proximal tubule. For prorenin, such reabsorption is ≈100%. Minimal variation in tubular reabsorption (in the order of a few %) is sufficient to explain why urinary renin and albumin excretion do not correlate. Urinary renin does not reflect prorenin that is converted to renin in tubular fluid.Urinary angiotensinogen excretion parallels albumin excretion, which is not the case for renin, while renin’s precursor, prorenin, is undetectable in urine. We hypothesized that renin and prorenin, given their smaller size, are filtered through the glomerulus in larger amounts than albumin and angiotensinogen, and that differences in excretion rate are because of a difference in reabsorption in the proximal tubule. To address this, we determined the glomerular sieving coefficient of renin and prorenin and measured urinary renin/prorenin 1) after inducing prorenin in Cyp1a1-Ren2 rats and 2) in patients with Dent disease or Lowe syndrome, disorders characterized by defective proximal tubular reabsorption. Glomerular sieving coefficients followed molecular size (renin>prorenin>albumin). The induction of prorenin in rats resulted in a >300-fold increase in plasma prorenin and doubling of blood pressure but did not lead to the appearance of prorenin in urine. It did cause parallel rises in urinary renin and albumin, which losartan but not hydralazine prevented. Defective proximal tubular reabsorption increased urinary renin and albumin 20- to 40-fold, and allowed prorenin detection in urine, at ≈50% of its levels in plasma. Taken together, these data indicate that circulating renin and prorenin are filtered into urine in larger amounts than albumin. All 3 proteins are subsequently reabsorbed in the proximal tubule. For prorenin, such reabsorption is ≈100%. Minimal variation in tubular reabsorption (in the order of a few %) is sufficient to explain why urinary renin and albumin excretion do not correlate. Urinary renin does not reflect prorenin that is converted to renin in tubular fluid.