Pontus B. Persson

Contrast-induced kidney injury: mechanisms, risk factors, and prevention

In general, iodinated contrast media (CM) are tolerated well, and CM use is steadily increasing. Acute kidney injury is the leading life-threatening side effect of CM. Here, we highlight endpoints used to assess CM-induced acute kidney injury (CIAKI), CM types, risk factors, and CIAKI prevention. Moreover, we put forward a unifying theory as to how CIAKI comes about; the kidney medullas unique hyperosmolar environment concentrates CM in the tubules and vasculature. Highly concentrated CM in the tubules and vessels increases fluid viscosity. Thus, flow through medullary tubules and vessels decreases. Reducing the flow rate will increase the contact time of cytotoxic CM with the tubular epithelial cells and vascular endothelium, and thereby damage cells and generate oxygen radicals. As a result, medullary vasoconstriction takes place, causing hypoxia. Moreover, the glomerular filtration rate declines due to congestion of highly viscous tubular fluid. Effective prevention aims at reducing the medullary concentration of CM, thereby diminishing fluid viscosity. This is achieved by generous hydration using isotonic electrolyte solutions. Even forced diuresis may prove efficient if accompanied by adequate volume supplementation. Limiting the CM dose is the most effective measure to diminish fluid viscosity and to reduce cytotoxic effects.

Viscosity of contrast media perturbs renal hemodynamics.

Contrast-induced nephropathy is a common cause of acute renal failure, and the mechanisms underlying this injury are not completely understood. We sought to determine how physicochemical properties of contrast media may contribute to kidney damage in rats. We administered contrast media of equivalent iodine concentrations but differing physiocochemical properties: the high-osmolality iopromide was compared to the high-viscosity iodixanol. In addition, the non-iodinated substances mannitol (equivalent osmolality to iopromide) and dextran (equivalent viscosity to iodixanol) were also studied. Both types of contrast media transiently increased renal and hindquarter blood flow. The high-osmolality agents iopromide and mannitol markedly increased urine production whereas iodixanol, which caused less diuresis, significantly enhanced urine viscosity. Only the high-viscosity agents iodixanol and dextran decreased renal medullary blood flux, erythrocyte concentration, and pO2. Moreover, iodixanol prolonged the tubuloglomerular feedback response and increased plasma creatinine levels to a greater extent than iopromide or dextran. Therefore, the viscosity of contrast media may play a significant role in contrast-induced nephropathy.

Phorbol-ester mediated suppression of hASH1 synthesis: multiple ways to keep the level down

Human achaete-scute homolog-1 (hASH1), encoded by the human ASCL1 gene, belongs to the family of basic helix-loop-helix transcription factors. hASH1 and its mammalian homolog Mash1 are expressed in the central and peripheral nervous system during development, and promote early neuronal differentiation. Furthermore, hASH1 is involved in the specification of neuronal subtype identities. Misexpression of the transcription factor is correlated with a variety of tumors, including lung cancer and neuroendocrine tumors. To gain insights into the molecular mechanisms of hASH1 regulation, we screened for conditions causing changes in hASH1 gene expression rate. We found that treatment of human neuroblastoma-derived Kelly cells with phorbol 12-myristate 13-acetate (PMA) resulted in a fast, strong and long-lasting suppression of hASH1 synthesis. Reporter gene assays with constructs, in which the luciferase activity was controlled either by the ASCL1 promoter or by the hASH1 mRNA untranslated regions (UTRs), revealed a mainly UTR-dependent mechanism. The hASH1 promoter activity was decreased only after 48 h of PMA administration. Our data indicate that different mechanisms acting consecutively at the transcriptional and post-transcriptional level are responsible for hASH1 suppression after PMA treatment. We provide evidence that short term inhibition of hASH1 synthesis is attributed to hASH1 mRNA destabilization, which seems to depend mainly on protein kinase C activity. Under prolonged conditions (48 h), hASH1 suppression is mediated by decreased promoter activity and inhibition of mRNA translation.

Time versus frequency domain techniques for assessing baroreflex sensitivity.

Background Newer techniques to evaluate baroreflex sensitivity (BRS) are based on the analysis of blood pressure (BP) and heart rate (HR) time series in the time or frequency domain. These novel approaches are steadily gaining popularity, since they do not require injection of vasoactive substances, nor do they rely on a complex experimental set-up. Aim This review outlines and compares some basic features of the latest methods to assess spontaneous baroreflex function. Results Modern techniques for the estimation of spontaneous BRS are based on a variety of signal processing schemes and derive information on the baroreflex function from different perspectives. Thus factors such as respiration and other non-stationary agents may have different influences on the estimates provided by each of these approaches. Notwithstanding such individual specificity, however, it has been observed that in several physiological and pathophysiological conditions these techniques often provide comparable information on BRS changes over time, particularly when the estimates are averaged over time windows of a few minutes. Conclusions Due to the general agreement in the pattern of BRS among most modern methods, it seems reasonable to employ the most validated of these techniques, for which data obtained in several studies are already available.

Iodixanol, Constriction of Medullary Descending Vasa Recta, and Risk for Contrast Medium–induced Nephropathy

PURPOSE To determine whether a type of contrast medium (CM), iodixanol, modifies outer medullary descending vasa recta (DVR) vasoreactivity and nitric oxide (NO) production in isolated microperfused DVR. MATERIALS AND METHODS Animal handling conformed to the Animal Care Committee Guidelines of all participating institutions. Single specimens of DVR were isolated from rats and perfused with a buffered solution containing iodixanol. A concentration of 23 mg of iodine per milliliter was chosen to mimic that expected to be used in usual examinations in humans. Luminal diameter was determined by using video microscopy, and NO was measured by using fluorescent techniques. RESULTS Iodixanol led to 52% reduction of DVR luminal diameter, a narrowing that might interfere with passage of erythrocytes in vivo. Vasoconstriction induced by angiotensin II was enhanced by iodixanol. Moreover, iodixanol decreased NO bioavailability by more than 82%. Use of 4-hydroxy-2,2,6,6-tetramethylpiperidine 1-oxyl (a superoxide dismutase mimetic) prevented both vasoconstriction with iodixanol alone and increased constriction with angiotensin II caused by CM. CONCLUSION Iodixanol in doses typically used for coronary interventions constricts DVR, intensifies angiotensin II-induced constriction, and reduces bioavailability of NO. CM-induced nephropathy may be related to these events and scavenging of reactive oxygen species might exert a therapeutic benefit by preventing the adverse effects that a CM has on medullary perfusion.

Does low frequency power of arterial blood pressure reflect sympathetic tone

We tested whether power spectral analysis of arterial blood pressure (ABP) is a feasible tool to detect differences in peripheral sympathetic nerve activity in normotensive and hypertensive rats with differing basal sympathetic tones. Nine Wistar Kyoto rats (WKY), 10 Sprague-Dawley rats (SD), 10 spontaneously hypertensive rats (SHR) and 9 hypertensive transgenic rats harbouring the mouse Ren-2 gene (TGR) were chronically instrumented with femoral artery catheters and nerve electrodes around the sympathetic major splanchnic nerve. Two days after surgery ABP and splanchnic nerve activity (SpNA) were recorded in the conscious state during basal conditions as well as during alpha 1-adrenergic receptor blockade. Power spectra and squared coherence in the low (LF, 0.02-0.20 Hz), mid (MF, 0.20-0.80 Hz) and high (HF, respiration peak +/- 0.3 Hz) frequency bands were calculated for ABP and SpNA. Mean blood pressure in SHR (133 +/- 8 mmHg) and TGR (142 +/- 8 mmHg) was significantly higher (P < 0.05) than in WKY (115 +/- 3 mmHg) and SD (95 +/- 4 mmHg). SpNA in SHR was higher than in WKY (23.4 +/- 6.4 microV vs. 11.6 +/- 0.8 microV, P < 0.05) while SpNA in TGR was lower than in SD (20.1 +/- 3.9 microV vs. 28.8 +/- 4.2 microV, P < 0.05). LF and MF components of ABP variability were not significantly higher in those rats with high sympathetic tones. However, alpha 1-adrenergic receptor blockade reduced LF and MF components of ABP and SpNA in all strains except SHR. LF and MF coherence was not greater in rats with high sympathetic tones than in those with low sympathetic tones. The reduction of LF and MF components of ABP variability by alpha 1-adrenergic receptor blockade indicates an important contribution of peripheral sympathetic nerve activity to LF and MF blood pressure variability on an acute basis. However, the lack of higher LF and MF power in the ABP spectra of those rats with high SpNA together with the finding that LF and MF coherence was not higher in those rats with high SpNA led to the conclusion that LF and MF spectral components of ABP do not appear to be suitable markers for the prevailing sympathetic nerve activity.

Renin: origin, secretion and synthesis

Renin is a central hormone in the control of blood pressure and various other physiological functions. In spite of the very early discovery of renin over 100 years ago, we have only recently gained a deeper understanding of the origin of renin‐producing cells and of the mechanisms responsible for renin synthesis and secretion. The main source of renin is the juxtaglomerular cells (JGCs), which release renin from storage granules. Besides the renin‐angiotensin system (RAS) in the JGCs, there exist local RASs in various tissues. JGCs originate in situ within the metanephric kidney from mesenchymal cells that are not related to smooth muscle lineages, as hitherto assumed. The previous notion that JGCs stem from vascular smooth muscle cells may be explained by JGC differentiation: they acquire smooth muscle markers that are maintained throughout adulthood. It has become clear that increasing intracellular free [Ca2+] inhibits renin secretion in JGCs. In contrast, cAMP stimulates renin release. Over the last decade, numerous studies on isolated JGCs and intact animals have provided contradictory results as to whether cGMP has a stimulatory or inhibitory action on renin release. More recent results strongly suggest that the effects of cGMP on renin release from JGCs involve the degradation of cAMP, which is modulated by cGMP. Finally, it has been found that not only is the production of renin modulated by enhancing or attenuating renin transcription, but renin mRNA stability is controlled by various proteins present in renin‐producing cells.

The neurovascular unit – concept review

The cerebral hyperaemia is one of the fundamental mechanisms for the central nervous system homeostasis. Due also to this mechanism, oxygen and nutrients are maintained in satisfactory levels, through vasodilation and vasoconstriction. The brain hyperaemia, or coupling, is accomplished by a group of cells, closely related to each other; called neurovascular unit (NVU). The neurovascular unit is composed by neurones, astrocytes, endothelial cells of blood–brain barrier (BBB), myocytes, pericytes and extracellular matrix components. These cells, through their intimate anatomical and chemical relationship, detect the needs of neuronal supply and trigger necessary responses (vasodilation or vasoconstriction) for such demands. Here, we review the concepts of NVU, the coupling mechanisms and research strategies.

Activation of the bumetanide-sensitive NA+,K+,2CL--cotransporter NKCC2 is facilitated by Tamm-Horsfall protein in a chloride-sensitive manner

Active transport of NaCl across thick ascending limb (TAL) epithelium is accomplished by Na+,K+,2Cl− cotransporter (NKCC2). The activity of NKCC2 is determined by vasopressin (AVP) or intracellular chloride concentration and includes its amino-terminal phosphorylation. Co-expressed Tamm-Horsfall protein (THP) has been proposed to interact with NKCC2. We hypothesized that THP modulates NKCC2 activity in TAL. THP-deficient mice (THP−/−) showed an increased abundance of intracellular NKCC2 located in subapical vesicles (+47% compared with wild type (WT) mice), whereas base-line phosphorylation of NKCC2 was significantly decreased (−49% compared with WT mice), suggesting reduced activity of the transporter in the absence of THP. Cultured TAL cells with low endogenous THP levels and low base-line phosphorylation of NKCC2 displayed sharp increases in NKCC2 phosphorylation (+38%) along with a significant change of intracellular chloride concentration upon transfection with THP. In NKCC2-expressing frog oocytes, co-injection with THP cRNA significantly enhanced the activation of NKCC2 under low chloride hypotonic stress (+112% versus +235%). Short term (30 min) stimulation of the vasopressin V2 receptor pathway by V2 receptor agonist (deamino-cis-d-Arg vasopressin) resulted in enhanced NKCC2 phosphorylation in WT mice and cultured TAL cells transfected with THP, whereas in the absence of THP, NKCC2 phosphorylation upon deamino-cis-d-Arg vasopressin was blunted in both systems. Attenuated effects of furosemide along with functional and structural adaptation of the distal convoluted tubule in THP−/− mice supported the notion that NaCl reabsorption was impaired in TAL lacking THP. In summary, these results are compatible with a permissive role for THP in the modulation of NKCC2-dependent TAL salt reabsorptive function.

Up to 50-fold Increase in Urine Viscosity with Iso-osmolar Contrast Media in the Rat

PURPOSE To compare changes in urinary viscosity in the renal tubules following administration of a high-viscosity iso-osmolar contrast agent (iodixanol) to that observed following administration of a less viscous, higher osmolar contrast agent (iopromide) in anesthetized rats. MATERIALS AND METHODS A total of 43 rats were studied. Experiments were approved by the Berlin, Germany, animal protection administration. A viscometer was developed to measure viscosity in minute samples (7 microL). Urine was collected, viscosity was measured (at 37 degrees C), and glomerular filtration rate (GFR) was determined by means of creatinine clearance. Boluses of 1.5 mL of iodixanol (320 mg iodine per milliliter, iso-osmolar to plasma, high viscosity) or iopromide (370 mg iodine per milliliter, higher osmolality and lower viscosity than iodixanol) were injected into the thoracic aorta. There were five groups (seven rats per group). Groups 1 (iodixanol) and 2 (iopromide) had free access to water prior to the experiment; groups 3 (iodixanol) and 4 (iopromide) received an additional infusion of isotonic saline (4 mL/kg/h). Group 5 was treated as group 1 but received only 0.75 mL of iodixanol. The observation period was 100 minutes. Statistical comparisons were made by means of nonparametric procedures (Friedman test, Kruskal-Wallis test). RESULTS Iodixanol increased urine viscosity from 0.69 to 36.7 mm(2)/sec; thus, urine became threefold more viscous than native iodixanol solution. The increase in urine viscosity after injection of iopromide was from 0.73 to 2.3 mm(2)/sec. While GFR was not significantly affected by iopromide, GFR transiently decreased by 50% after administration of iodixanol. Iopromide had a diuretic effect twofold greater than that of iodixanol. Saline infusion blunted the viscosity rise and transient decline in GFR caused by iodixanol, as did reducing the iodixanol dose by 50%. CONCLUSION Contrast media, in particular iodixanol, increase urine viscosity (which is equal to tubular fluid viscosity in the collecting ducts); in response to iodixanol, GFR markedly decreases. Saline infusion attenuates this response, thus potentially explaining the protective effects of volume expansion in contrast medium-induced nephropathy.