Sharon Silbiger

The impact of gender on the progression of chronic renal disease

Observations in experimental animals and in humans have shown that the rate of progression of renal disease is influenced by gender. Deterioration of renal function in patients with chronic renal disease is more rapid in men than in women, independent of differences in blood pressure or serum cholesterol levels. In addition to genetically determined differences between the sexes in renal structure and function, sex hormones may directly influence many of the processes implicated in the pathogenesis of renal disease progression. Potential mechanisms include receptor-mediated effects of sex hormones on glomerular hemodynamics and mesangial cell proliferation and matrix accumulation as well as effects on the synthesis and release of cytokines, vasoactive agents, and growth factors. In addition, estrogens may exert potent antioxidant actions in the mesangial microenvironment, which may contribute to the protective effect of female gender.

Glomerulosclerosis in aging humans is not influenced by gender

Aging male rats develop progressive glomerulosclerosis, proteinuria, and loss of renal function, whereas females are remarkably resistant to the development of these abnormalities. Although sex hormones appear to contribute to gender-related differences in the development of glomerulosclerosis in aging rats, it is not clear that sexual dimorphism characterizes glomerular obsolescence in aging humans. To study this question further, the glomerular histology of males and females ranging in age from infancy to 90 years was compared in 250 autopsy specimens. We found no differences between the sexes in the development of glomerulosclerosis in aging humans. These data disprove the hypothesis that testosterone is an important factor contributing to progressive glomerulosclerosis in aging men. Conversely, any renoprotective effects of estrogen would be limited by the onset of menopause because significant glomerulosclerosis did not develop until after the age of 50 years.

Estradiol suppresses mesangial cell type I collagen synthesis via activation of the MAP kinase cascade

We have previously shown that estradiol suppresses the synthesis of type I collagen by murine mesangial cells grown in the presence of serum via activation of the transcription factor activator protein-1 (AP-1). We hypothesized that estradiol upregulates AP-1 via activation of the mitogen-activated protein (MAP) kinase cascade, a signal transduction pathway that regulates AP-1 activity. Estradiol (10-10 to 10-7 M) upregulated the MAP kinase pathway in murine mesangial cells grown in the presence of serum in a dose-dependent manner. Activation was evident by 1 min, peaked at 10 min, and was completely dissipated by 2 h. In contrast, estradiol had no significant effect on total (phosphorylated + unphosphorylated) p44 extracellular signal-related protein kinase (ERK) or p42 ERK. Nuclear extracts isolated from mesangial cells treated with estradiol showed increased binding to a consensus sequence AP-1 binding oligonucleotide in gel shift assays. In contrast, nuclear extracts from cells exposed to PD-98059, a highly selective inhibitor of MAP kinase-ERK kinase 1 (MEK1) and MEK2, showed reduced binding. In addition, PD-98059 antagonizes the enhanced binding induced by estradiol. Estradiol (10-9M) suppressed mesangial cell type I collagen synthesis (37.8 ± 2.4%, expressed as a percentage of control values, P < 0.001 vs. control). In contrast, PD-98059 increased type I collagen synthesis (344.6 ± 98.8, P < 0.01) and reversed the suppression of type I collagen synthesis induced by estradiol. The effects of estradiol, PD-98059, and PD-98059 plus estradiol on type I collagen protein synthesis were closely paralleled by their effects on steady-state levels of mRNA for the α1 chain of type I collagen. These data suggest that estradiol suppresses type I collagen synthesis via upregulation of the MAP kinase cascade, leading to stimulation of AP-1 activity.We have previously shown that estradiol suppresses the synthesis of type I collagen by murine mesangial cells grown in the presence of serum via activation of the transcription factor activator protein-1 (AP-1). We hypothesized that estradiol upregulates AP-1 via activation of the mitogen-activated protein (MAP) kinase cascade, a signal transduction pathway that regulates AP-1 activity. Estradiol (10(-10) to 10(-7) M) upregulated the MAP kinase pathway in murine mesangial cells grown in the presence of serum in a dose-dependent manner. Activation was evident by 1 min, peaked at 10 min, and was completely dissipated by 2 h. In contrast, estradiol had no significant effect on total (phosphorylated + unphosphorylated) p44 extracellular signal-related protein kinase (ERK) or p42 ERK. Nuclear extracts isolated from mesangial cells treated with estradiol showed increased binding to a consensus sequence AP-1 binding oligonucleotide in gel shift assays. In contrast, nuclear extracts from cells exposed to PD-98059, a highly selective inhibitor of MAP kinase-ERK kinase 1 (MEK1) and MEK2, showed reduced binding. In addition, PD-98059 antagonizes the enhanced binding induced by estradiol. Estradiol (10(-9) M) suppressed mesangial cell type I collagen synthesis (37.8 +/- 2.4%, expressed as a percentage of control values, P < 0.001 vs. control). In contrast, PD-98059 increased type I collagen synthesis (344.6 +/- 98.8, P < 0.01) and reversed the suppression of type I collagen synthesis induced by estradiol. The effects of estradiol, PD-98059, and PD-98059 plus estradiol on type I collagen protein synthesis were closely paralleled by their effects on steady-state levels of mRNA for the alpha(1) chain of type I collagen. These data suggest that estradiol suppresses type I collagen synthesis via upregulation of the MAP kinase cascade, leading to stimulation of AP-1 activity.

Estradiol reverses TGF-β1-stimulated type IV collagen gene transcription in murine mesangial cells

We have previously shown that estradiol suppresses types I and IV collagen synthesis by mesangial cells grown in the presence of serum. In the present study, we examined the interaction between estradiol and transforming growth factor-β (TGF-β) on collagen IV synthesis. In a luciferase reporter gene construct containing the type IV collagen promoter and α1-chain regulatory sequences, we found that TGF-β1 (2 ng/ml) stimulated α1-collagen IV gene transcription in serum-free media (140.5 ± 6.2 relative luciferase units, expressed as a percent of control untreated cells, P < 0.001). Estradiol reversed the stimulatory effects of TGF-β1 on reporter gene transcription in a dose-dependent manner [for 2.5 × 10-9 M, 114.2 ± 0.2, P < 0.002 vs. TGF-β1; for 10-7 M, 89.5 ± 4.0, P < 0.001 vs. TGF-β1 and P = not significant (NS) vs. control]. Using immunoprecipitation techniques, we found that estradiol (10-7 M) reversed TGF-β1-stimulated type IV collagen synthesis (175.3 ± 14.7 vs. 111.6 ± 7.1, expressed as a percent of control untreated cells, P < 0.001) but did not affect TGF-β1-stimulated type I collagen synthesis (166.9 ± 18.8 vs. 162.2 ± 16.2, P = NS). These results were confirmed with Western blotting. Nuclear extracts from mesangial cells treated with TGF-β1 showed increased binding to a Sp1 consensus binding sequence oligonucleotide and to an Sp1 binding site in the collagen IV promoter. Estradiol reversed this enhanced binding. These data suggest that estradiol antagonizes TGF-β1-stimulated type IV collagen synthesis at a transcriptional level and that this effect may be mediated by interactions with the transcription factor Sp1.

Effects of Sex on Renal Structure

Aims: There are few data examining differences in renal structure between the sexes. Elucidation of the mechanisms responsible for the observed effects of sex on the progression of chronic renal disease requires knowledge of the effects of sex on renal structure. Results: Although we found that male kidneys weigh more than female kidneys, sex is not an independent determinant of kidney weight. The increased kidney weight seen in men is solely dependent on their greater body surface area. We found no difference in glomerular number between men and women. Although men had larger glomeruli than women, sex is not an independent determinant of glomerular volume. The occurrence of larger glomeruli in men is solely dependent on their greater body surface area. Similarly, the greater total glomerular volume seen in men as compared to women reflects increased kidney weight in men. Sex is not an independent determinant of total glomerular volume. Conclusions: These findings do not support the hypothesis that renal structural differences contribute to sex-related differences in the rate of progression of chronic renal disease.

Serum-stimulated α1 type IV collagen gene transcription is mediated by TGF-β and inhibited by estradiol

We examined the hypothesis that fetal calf serum (FCS) stimulates murine mesangial cell α1 type IV collagen ( COL4A1) gene transcription by increasing autocrine production of transforming growth factor-β (TGF-β) through a platelet-derived growth factor (PDGF)-dependent mechanism. PDGF-stimulated COL4A1 gene transcription was inhibited by neutralizing antibody to TGF-β (119.3 ± 3.6 vs. 106.0 ± 6.2 relative luciferase units, expressed as a percentage of control untreated cells, P < 0.003). FCS-stimulated gene transcription was inhibited by neutralizing antibody to PDGF (148.3 ± 4.1 vs. 136.7 ± 0.3 relative luciferase units, P < 0.002) and by neutralizing antibody to TGF-β (148.3 ± 4.1 vs. 127.1 ± 3.4 relative luciferase units, P < 0.036). The inhibitory effect of combined treatment with anti-PDGF and anti-TGF-β antibody on gene transcription was no greater than that of anti-TGF-β antibody alone [129.5 ± 0.53 vs. 127.1 ± 3.4 relative luciferase units, P = not significant (NS)]. FCS-stimulated gene transcription was also inhibited by estradiol (10-7 M) (148.4 ± 3.1 vs. 119.4 ± 8.1 relative luciferase units, P < 0.019). In the presence of estradiol, anti-TGF-β antibody failed to further reduce serum-stimulated gene transcription (119.4 ± 8.1 vs. 115.6 ± 9.8, P = NS), suggesting that estradiol reverses FCS-stimulated COL4A1 gene transcription by antagonizing the actions of TGF-β. Measurement of type IV collagen synthesis by Western blotting confirmed that the intact gene responded in a manner analogous to the promoter construct.

Effects of sex hormones on mesangial cells

Male gender is associated with a more rapid progression of chronic renal disease. In various experimental models of renal injury, manipulation of the hormonal milieu can replicate the effects of gender on the course of renal disease. These observations suggest that sex hormones per se may be important determinants of the greater susceptibility of the male kidney to progressive renal injury. Sex hormones may influence many of the processes implicated in the pathogenesis of renal disease progression, including cell proliferation and the synthesis and degradation of collagen and proteoglycans. In addition, sex hormones may indirectly influence these processes by modulating the synthesis and release of vasoactive agents, cytokines, and other growth factors, which in turn are capable of altering mesangial cell function. Finally, estrogens also exert potent antioxidant effects that may contribute to the protective effect of female gender on the course of renal disease.

Hypervitaminosis A in two hemodialysis patients

We present two cases of hemodialysis patients developing vitamin A toxicity related to excessive consumption of nutritional supplements containing large quantities of vitamin A. In one patient, severe hypercalcemia was the lone presenting sign; in the other, hypercalcemia was associated with unusual neurologic manifestations. We will discuss the reason why hemodialysis patients are at special risk for the development of hypervitaminosis A and review the mechanism leading to the associated hypercalcemia.

Raloxifene, a selective estrogen receptor modulator, is renoprotective: a post-hoc analysis

Estrogens have a protective effect on kidney fibrosis in several animal models. Here, we tested the effect of raloxifene, an estrogen receptor modulator, on the change in serum creatinine or estimated glomerular filtration rate (eGFR) and incident kidney-related adverse events. We performed a post-hoc analysis of the multiple outcomes of raloxifene evaluation trial, a double-masked, placebo-controlled randomized clinical trial encompassing 7705 post-menopausal women (aged 31-80 years) with osteoporosis. Participants were randomized to either of two doses of raloxifene, 60 or 120 mg/day, or placebo. Serum creatinine was measured at a central laboratory at baseline and annually. Adverse events were assessed every 6 months and uniformly categorized. Compared with those in the placebo group, participants on raloxifene had a slower yearly rate of increase in creatinine (significant at the low dose) and a significantly slower yearly rate of decrease in eGFR for both doses over 3 years of follow-up. Raloxifene was associated with significantly fewer kidney-related adverse events compared with placebo. Thus, treatment with raloxifene was safe and renoprotective. Clinical trials of raloxifene in post-menopausal women with kidney disease designed to look at kidney outcomes are needed to confirm these findings.

Combined antihypertensive and lipid-lowering therapy in experimental glomerulonephritis.

We examined the interrelation between systemic hypertension, hyperlipidemia, and progressive renal injury in experimental glomerulonephritis. Induction of nephrotoxic serum nephritis in Sprague-Dawley rats led to systemic hypertension and hyperlipidemia. Four groups of rats were studied over a 16-week period: (1) untreated nephritic rats; (2) nephritic rats treated with hydralazine, reserpine, and lasix (AH); (3) nephritic rats treated with lovastatin (4 mg/kg) (Lova); and (4) nephritic rats treated with combined antihypertensive/lipid-lowering therapy (AH/Lova). Systolic blood pressure rose progressively in untreated rats (152 +/- 4 mm Hg at 16 weeks). Blood pressure was reduced by antihypertensive therapy (P < .001) (108 +/- 2 mm Hg in the AH group and 111 +/- 3 mm Hg in the AH/Lova group) but remained elevated in animals treated with lovastatin alone (P > .05) (156 +/- 3 mm Hg in the Lova group). Serum cholesterol rose progressively in untreated rats (3.70 +/- 0.85 mmol/L [143 +/- 33 mg/dL] at 16 weeks). The rise in serum cholesterol was prevented by lovastatin therapy (P < .001) (2.22 +/- 0.41 mmol/L [86 +/- 16 mg/dL] in the Lova group and 2.09 +/- 0.52 mmol/L [81 +/- 2 mg/dL] in the AH/Lova group) but not antihypertensive therapy (P > .05) (2.92 +/- 0.65 mmol/L [113 +/- 25 mg/dL] in the AH group). Proteinuria was reduced by antihypertensive therapy (P < .001) and lipid-lowering therapy (P < .05) (16-week values: 1.069 +/- 0.167 g/d in untreated rats, 0.663 +/- 0.164 g/d in the Lova group, 0.392 +/- 0.051 g/d in the AH group, and 0.176 +/- 0.035 g/d in the AH/Lova group).(ABSTRACT TRUNCATED AT 250 WORDS)