Josef Zimmermann

Role of L-Arginine-Derived NO in Ischemic Acute Renal Failure in the Rat

Nitric oxide (NO) is involved in the regulation of renal perfusion and glomerular hemodynamics under basal conditions. We examined the hypothesis that L-arginine-derived NO modifies ischemic acute renal failure (ARF) in the rat. After a basal period ischemia was induced by clamping of both renal arteries (40 min). Thereafter, in the reperfusion period, we intravenously infused L-arginine (Arg, 300 mg/kg/60 min), or L-monomethylarginine (MeArg, 30 mg/kg/60 min), or Arg + MeArg (300 mg/kg/60 min, 30 mg/kg/60 min, resp.). Besides monitoring of urinary flow rate and arterial blood pressure, and determination of sodium excretion, glomerular filtration rate (GFR, mL/min/100 g) was estimated at the end of the infusion period and again after another 30 and 120 min by inulin clearance (fluorescence-marked inulin). In the basal period GFR showed no differences between the groups (Arg: 0.86 +/- 0.07, MeArg: 0.92 +/- 0.06, Arg + MeArg: 0.89 +/- 0.08, control: 0.84 +/- 0.07). At 180 min after the beginning of the reperfusion period, GFR was 0.13-0.02 in the control group. After administration of Arg, a remarkable and persistent increase in GFR was observed (0.28 +/- 0.03), whereas infusion of MeArg showed no significant effects (0.13 +/- 0.04). Combined administration of Arg + MeArg revealed a moderate increase of GFR (0.19 +/- 0.05), ranging between the Arg and the control group. Also, 60 and 90 min after the beginning of the reperfusion period, the highest values for GFR were obtained in the Arg group. We conclude that in this model of ischemic ARF in the rat, L-arginine-derived NO is capable of improving renal function. These data underline the regulatory role of the L-Arg-NO pathway for renal function, not only under normal conditions, but also in ARF.

Endogenous Erythropoietin and the Association with Inflammation and Mortality in Diabetic Chronic Kidney Disease

BACKGROUND AND OBJECTIVES Anemia and inflammation are prevalent in diabetic patients with chronic kidney disease (CKD). The role of endogenous erythropoietin (EPO) in the pathophysiology of anemia in chronic diseases and its relationship to clinical outcomes remain uncertain. In this cohort study, we aimed to identify factors associated with endogenous EPO levels and investigate their relation to all-cause mortality. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Between 2004 and 2005, 215 patients with type 2 diabetes were enrolled. Exclusion criteria included stage renal disease ESRD and any form of anemia therapy. The association of EPO levels with clinical and laboratory variables was investigated by linear regression modeling. Predictors of all-cause mortality were evaluated by Cox proportional hazards analyses. RESULTS Patients (median age, 67 years; 52% men; median duration of diabetes, 10 years; median estimated GFR, 49 ml/min per 1.73 m²) were followed for up to 7.0 years. Forty-one patients died. Elevated EPO levels were independently associated with elevated C-reactive protein, low ferritin, and hypertension, in a multivariate model that also included age, cardiovascular disease, kidney function, albumin, cholesterol, and hemoglobin. Higher EPO levels were independently predictive for mortality, as were age, low levels of albumin, and cardiovascular disease. CONCLUSIONS In diabetic patients with CKD, elevated endogenous EPO levels were predictive for mortality and were related mainly to markers of inflammation, independent of kidney function, and despite low hemoglobin levels. Understanding the phenomenon of EPO resistance and iron dysregulation caused by inflammation is crucial for effective and safe treatment of anemia in patients with CKD.

Toxic Acute Renal Failure in the Rat: Effects of Diltiazem and Urodilatin on Renal Function

Beneficial effects of natriuretic peptides have been reported in different models of acute renal failure (ARF). Calcium antagonists can also improve renal function, especially in ischemic models of ARF. The aim of our study was to investigate the effects of urodilatin and diltiazem alone and in combination in uranyl nitrate-induced toxic ARF in the rat. Three hours after induction of ARF glomerular filtration rate (GFR) was clearly diminished to about 50% compared to basal values. Intravenous infusion of diltiazem and urodilatin revealed a significant increase of GFR that even continued after cessation of drug delivery. Combined administration of urodilatin and diltiazem had no additional effect, probably due to a more pronounced fall in blood pressure in this group. Besides their vasorelaxing and blood pressure lowering effects both drugs also revealed diuretic activity. In conclusion both urodilatin and diltiazem are able to elevate GFR in the early phase of toxic ARF in the rat.

Hepcidin-25 in diabetic chronic kidney disease is predictive for mortality and progression to end stage renal disease.

Background Anemia is common and is associated with impaired clinical outcomes in diabetic chronic kidney disease (CKD). It may be explained by reduced erythropoietin (EPO) synthesis, but recent data suggest that EPO-resistance and diminished iron availability due to inflammation contribute significantly. In this cohort study, we evaluated the impact of hepcidin-25—the key hormone of iron-metabolism—on clinical outcomes in diabetic patients with CKD along with endogenous EPO levels. Methods 249 diabetic patients with CKD of any stage, excluding end-stage renal disease (ESRD), were enrolled (2003–2005), if they were not on EPO-stimulating agent and iron therapy. Hepcidin-25 levels were measured by radioimmunoassay. The association of hepcidin-25 at baseline with clinical variables was investigated using linear regression models. All-cause mortality and a composite endpoint of CKD progression (ESRD or doubling of serum creatinine) were analyzed by Cox proportional hazards models. Results Patients (age 67 yrs, 53% male, GFR 51 ml/min, hemoglobin 131 g/L, EPO 13.5 U/L, hepcidin-25 62.0 ng/ml) were followed for a median time of 4.2 yrs. Forty-nine patients died (19.7%) and forty (16.1%) patients reached the composite endpoint. Elevated hepcidin levels were independently associated with higher ferritin-levels, lower EPO-levels and impaired kidney function (all p<0.05). Hepcidin was related to mortality, along with its interaction with EPO, older age, greater proteinuria and elevated CRP (all p<0.05). Hepcidin was also predictive for progression of CKD, aside from baseline GFR, proteinuria, low albumin- and hemoglobin-levels and a history of CVD (all p<0.05). Conclusions We found hepcidin-25 to be associated with EPO and impaired kidney function in diabetic CKD. Elevated hepcidin-25 and EPO-levels were independent predictors of mortality, while hepcidin-25 was also predictive for progression of CKD. Both hepcidin-25 and EPO may represent important prognostic factors of clinical outcome and have the potential to further define “high risk” populations in CKD.

Kardiovaskuläre Risikofaktoren bei diabetischer Nephropathie

ZusammenfassungHintergrundDie Manifestation einer Nephropathie ist bei Typ-1-Diabetespatienten mit einem Anstieg der kardiovaskulären Mortalität assoziiert. Pathophysiologisch stehen Veränderungen des Lipidstoffwechsels und des Plasmafibrinogenspiegels in der Diskussion. Wenig Aufmerksamkeit wird bisher Veränderungen der Fließeigenschaften des Blutes und der Verschlechterung der peripheren und autonomen kardialen Nervenfunktion geschenkt. Insbesondere das Auftreten einer autonomen kardialen Neuropathie ist bekanntlich mit einem erhöhten Risiko eines plötzlichen Herztodes verbunden.Patienten und MethodenWir untersuchten bei Typ-1-Diabetespatienten ohne, mit beginnender (Mikroalbuminurie) und klinisch manifester Nephropathie (Proteinurie, Kreatinin<3 mg/dl) die Plasmalipide, das Fibrinogen, die hämorheologischen Parameter Plasmaviskosität, Erythrozytenaggregation und Erythrozytendeformabilität und darüber hinaus die periphere und autonome kardiale Nervenfunktion.ErgebnisseBei den Diabetespatienten mit klinisch manifester Nephropathie waren im Vergleich zu denjenigen mit unauffälliger Nierenfunktion LDL-Cholesterin, Triglyceride, Fibrinogen, Erythrozytenaggregation, Plasmaviskosität und Erythrozytenrigidität signifikant erhöht, HDL-Cholesterin signifikant erniedrigt. Die Parameter der peripheren Nervenfunktion (Vibrationsempfinden, motorische Nervenleitgeschwindigkeit) und der autonomen kardialen Nervenfunktion (Herzfrequenzvariabilität in Ruhe und unter forcierter Respiration, Valsalva-Quotient, 30:15-Quotient) waren ebenfalls signifikant niedriger. Bei den Diabetespatienten mit Mikroalbuminurie waren die Erythrozytenaggregation und die Erythrozytenrigidität signifikant höher und die Herzfrequenzvariabilität in Ruhe signifikant niedriger als bei den Patienten ohne Nephropathie.SchlußfolgerungBei Patienten mit manifester diabetischer Nephropathie findet man eine Koinzidenz verschiedener kardiovaskulärer Risikofaktoren. Neben Veränderungen der Plasmalipide sind erhöhte Fibrinogenspiegel und eine Verschlechterung der Fließeigenschaften des Blutes evident. Darüber hinaus ist sowohl die periphere als auch die autonome kardiale Nervenfunktion deutlich verschlechtert. Für die beobachtete eingeschränkte Herzfrequenzvariabilität ist gezeigt worden, daß sie das Risiko eines plötzlichen Herztodes erhöht und so einen Teil zum erhöhten kardiovaskulären Risiko dieser Patientengruppe beiträgt.SummaryBackgroundDiabetic nephropathy is associated with increased cardiovascular mortality. This may be contributed to by changes in plasma lipids, fibrinogen and hemorheology. Cardiovascular autonomic dysfunction, which is related to an increased incidence of arrhythmic death, may also play a role.Patients and MethodsTherefore, we investigated in 58 IDDM-patients with none (n=28), incipient (albuminuria 30 to 300 mg/day, n=11) and overt clinical nephropathy (albuminuria >300 mg/day, n=19) plasma concentrations of lipoproteins and fibrinogen, plasma viscosity, erythrocyte aggregation and erythrocyte rigidity. Assessments of neuropathy included tibial nerve motor conduction velocity, perception of vibration, beat-to-beat variation during rest and during forced respiration, heart-rate response to Valsalva maneuver and heart-rate response to standing (30:15).ResultsPatients with clinical overt nephropathy had, compared to those without nephropathy, significantly higher concentrations of LDL-cholesterol, triglycerides and fibrinogen, significantly lower concentrations of HDL-cholesterol and significantly higher plasma viscosity, erythrocyte aggregability and erythrocyte rigidity. Regarding the assessments of neuropathy we found in patients with nephropathy, compared to those without nephropathy, significantly reduced tibial nerve motor conduction velocity, reduced perception of vibration thresholds and reduced heart rate variability during rest, during forced respiration, in response to Valsalva maneuver and in response to standing. In diabetic patients with microalbuminuria erythrocyte aggregability and erythrocyte rigidity were significantly higher and heart rate variability during rest was significantly lower than in patients without nephropathy.ConclusionIn clinical overt nephropathy there is an aggregation of different cardiovascular risk factors, namely, disturbances in lipoprotein concentrations, increased fibrinogen concentration and disturbances in hemorheology. Furthermore marked deterioration in peripheral and autonomic cardial nerve function in these patients is evident accounting for a part of the greatly increased cardiovascular mortality of these patients.

Effects of Urodilatin and Diltiazem on Renal Function in Ischemic Acute Renal Failure in the Rat

In humans as well as in experimental models the hallmark of ischemic acute renal failure (ARF) is a profound diminution in glomerular filtration rate (GFR) and renal blood flow. Both calcium antagonists and a-ANP have been reported to exert beneficial effects in ischemic ARF. No data, however, exist about combined administration of the natriuretic peptide urodilatin and calcium channel blockers. We therefore investigated the effects of urodilatin (URO, 40 micrograms/kg/h, i.v.) and diltiazem (DIL, 300 micrograms/kg/h, i.v.) in the rat given immediately after clamping of both renal arteries for 40 min. Compared to controls (0.07 +/- 0.01) depressed GFR (ml/min/100 g) was clearly elevated with URO (0.16 +/- 0.03), DIL (0.13 +/- 0.03) and URO + DIL (0.14 +/- 0.02) after the ischemic lesion. After cessation of drug delivery the beneficial effects were blunted in the URO group, in contrast to the DIL and URO + DIL group, where GFR was significantly elevated compared to controls even 3 h after starting reperfusion. Besides that also urine flow, sodium excretion and blood pressure were examined. In conclusion both URO and DIL exert beneficial effects in ischemic ARF in the rat while infused. In contrast to URO DIL showed prolonged beneficial effects even after cessation of drug delivery. An additional effect of both drugs could not be observed.

Atrial natriuretic peptide and verapamil can prevent gentamicin induced acute renal failure in the rat

Summary: Calcium channel blockers are able to improve renal function in acute renal failure (ARF) and natriuretic peptides can also exert beneficial effects. At present it is unknown whether administration of atrial natriuretic peptide (ANP) and a calcium channel blocker given before a toxic lesion can prevent gentamicin induced ARF. the mechanisms of action of natriuretic peptides and calcium channel blockers are different and, as yet, it has not been clarified if combined administration can augment the effects on renal function. After a basal period we investigated the effects of verapamil (VER, 0.66 mg/kg), ANP, (30 μg/kg) and a combination of both (identical doses as described individually). the drugs were given intravenously for a period of 40 min (infusion period) before gentamicin (15 mg/kg, i.v.) was administered for induction of ARF. Basal values for glomerular filtration rate (GFR, mL/min) were around 1.8 with no differences between the groups. At the end of the infusion period (before application of gentamicin) GFR was significantly elevated with VER + ANP (3.13 ± 0.51), ANP (2.70 ± 0.59) and VER (2.34 ± 0.47) compared to controls (saline, 1.7 ± 0.48). After application of gentamicin GFR significantly dropped in the control group (0.77 ± 0.21, 0.75 ± 0.19, respectively), indicating development of ARF. In contrast with VER + ANP, ANP and VER GFR could be maintained for 30 min (2.47 ± 0.39, 2.28 ± 0.33, 2.22 ± 0.43, respectively) and 130 min (2.11 ± 0.32, 1.86 ± 0.29, 2.11 ± 0.28, respectively) after gentamicin. Moreover ANP and VER revealed natriuretic activity and, due to their vasorelaxing potency, also influenced arterial blood pressure. We conclude that both VER and ANP are able to prevent early gentamicin induced ARF when given before the toxic lesion. Both drugs induce hyperfiltration while infused, in particular when administered in combination.