Walter Flamenbaum

Studies on the pathophysiology of acute renal failure

SummaryAcute renal failure was induced in male rats by the subcutaneous injection of 4 mg HgCl2 per kg body weight. Changes in the proximal tubule were studied by light and electron microscopy at six time intervals from 15 min to 24 h. Renal function was monitored at 6 and 24 h.Between 15 min and 3 h changes were similar in all regions of the proximal tubule (pars convoluta and pars recta). Dispersion of cytoplasmic polysome groups was widespread and mitochondrial matrices were condensed in some cells. No changes were noted in the brush border but increased endocytotic activity occurred in some convoluted tubules at 1 and 3 h. At 6 h severe changes had occurred in the pars recta in the medullary rays. Microvilli of the brush border were focally absent, the mitochondria were swollen and the endoplasmic reticulum was dilated. At this time only subtle changes occurred in the pars recta in the outer stripe of the outer medulla. However by 24 h necrosis was widespread throughout the pars recta, yet changes in the proximal convoluted portion were minimal.A significant azotemia, decreased GFR and increased FENa+ and FEK+ occurred at 6 and 24 h after HgCl2 injection. Thus HgCl2 at 4 mg per kg body weight produced reproducible renal failure and necrosis involving the pars recta of every nephron but necrosis did not begin in the pars recta until after 6 h while acute renal failure was probably initiated much earlier.The following hypothesis is presented. HgCl2 initially interacts with the entire proximal tubule. Although injury is sublethal in the pars convoluta it is responsible for greatly diminished sodium reabsorption and is related to the pathogenesis of the renal failure through feedback mechanisms involving the macula densa and release of renin. This results in renal hemodynamic alterations, decreased GFR and other functional disturbances associated with renal failure. The development of necrosis in the pars recta appears to be a relatively late event, possibly due to further accumulation of Hg++ in this region. In any case, the necrosis appears pathogenetically dissociable from the mechanism of acute renal failure.

Micropuncture studies of proximal tubule albumin concentrations in normal and nephrotic rats.

The concentration of serum albumin in proximal tubule fluid of normal rats and animals with aminonucleoside nephrosis was studied using renal micropuncture techniques. Albumin was quantitated by an ultramicrodisc electrophoresis method capable of measuring 3 chi 10(-11) g of albumin, in 10 nl volumes. With this sensitivity, only small samples of tubule fluid were required for analysis. Collection times could be kept short, therefore decreasing the opportunity for sample contamination with extraneous serum albumin. The measured mean concentration of albumin in proximal tubule fluid (1 mg/100 ml in females and 0.7 mg/100 ml in males) was somewhat lower than values reported by others, but even these values are apt to have been artifactually high as a result of animal preparation and trace contamination of samples during micropuncture. Rats injected with aminonucleoside of puromycin 4 days earlier, showed a significant increase in tubule-fluid albumin concentration coincident with a fall in serum albumin concentration and a 43-fold increase in urine albumin concentration. Tubular absorption of albumin was small relative to that of water. Although albumin filtration was significantly increased over that in normal animals, the glomerular basement membrane still served as a highly efficient barrier to albumin transfer.

Intravenous labetalol in the treatment of severe hypertension and hypertensive emergencies

The antihypertensive effects of intravenous labetalol were evaluated in 59 patients with hypertensive crises or severe hypertension in need of rapid lowering of blood pressure in a multicenter study. Patients appearing with a supine diastolic blood pressure 125 mm Hg or greater, or a supine systolic blood pressure of more than 200 mm Hg received an initial mini-bolus injection (20 mg) of labetalol. This was followed by repeated incremental doses of 20 to 80 mg given at 10 minute intervals to achieve a supine diastolic blood pressure of less than 95 mm Hg or decrease 30 mm Hg or greater, or a satisfactory decrease in systolic blood pressure. Patients were stratified into those who had taken antihypertensive medication within 24 hours and those who had not. The initial mini-bolus injection caused rapid but not abrupt reduction in blood pressure; the baseline mean blood pressure decreased 23/14 mm Hg. Further injections were needed in the majority of patients (mean: 197 mg). The blood pressure reduction after the last dose of labetalol was 55/33 mm Hg. In pretreated patients and in those who had no medication for 24 hours prior to the intravenous labetalol, the response was similar. Heart rate decreased 10 beats per minute in the total population. In patients pretreated with beta-adrenergic blockers, blood pressure response was similar to that in the total group (59/35 versus 55/33 mm Hg), but heart rate remained essentially unchanged. The dose required to achieve the therapeutic effect was less in pretreated patients than in untreated patients, but the duration of action was shorter. No serious adverse effects were encountered even in patients with concomitant diagnoses of acute left ventricular failure, myocardial infarction, stable congestive heart failure, atrial fibrillation, angina pectoris, acute stroke, transient ischemic attack or encephalopathy. Labetalol is a safe and effective treatment for a rapid blood pressure reduction in hypertensive emergencies.

PROSTAGLANDINS AND ASPIRIN THERAPY IN BARTTER'S SYNDROME

A young patient with Bartters syndrome was treated for three months with 100 mg/kg/day of aspirin to inhibit prostaglandin synthesis. Clinical symptoms resolved and serum-potassium increased from 2-9 to 3-5 mmol/l. Urinary excretion and plasma concentration of prostaglandins E and F were significantly reduced during aspirin therapy. Plasma-renin activity declined from 85 to 20 ng/ml/h (normal 1-5-4 mg/ml/h) and hyperaldosteronism was corrected. These results suggest that overproduction of prostaglandins has a central role in the pathogenesis of Bartters syndrome.

Experimental Acute Renal Failure Induced by Uranyl Nitrate in the Dog

The diminished glomerular filtration rate observed in previous studies of acute renal failure induced by uranyl nitrate has been ascribed to backflow of glomerular filtrate through necrotic tubular epithelium, since renal blood flow was essentially normal. Renal blood flow (133xenon washout) and renal function were studied serially for 96 hours after the administration of uranyl nitrate (10 mg/kg, iv) in unanesthetized dogs with chronic renal artery catheters. Inulin clearance and total renal blood flow decreased to 25% and 52% of control, respectively, by 6 hours and remained depressed. By 3 hours, cortical flow decreased to 330±20 ml/min 100 g-1 (control 507±12 ml/min 100 g−1) and outer medullary flow increased to 147±8 ml/min 100 g−1 (control 97±18 ml/min 100 g-1), indicating intrarenal blood flow redistribution. From 6 hours on, these flow components were no longer separable. The ratio of flow in the outer two-thirds of the renal cortex to that in the whole cortex, determined using 85strontium-labeled microspheres (15μ), decreased to 0.34±0.06 and 0.40±0.04 at 6 and 96 hours, respectively (control 2.21±0.12). Plasma renin activity was 1.8±0.6 ng/ml hour−1 at 3 hours and remained elevated (control 0.6±0.2 ng/ml hour−1). Histological examination revealed minimal tubular change at 6 hours and widespread disruption at 96 hours. The decrease in renal blood flow prior to any significant tubular pathology suggests that alterations in renal hemodynamics, which may be mediated by the renin-angiotensin system, are responsible for the diminished renal function observed in this model of acute renal failure.

Studies on the pathophysiology of acute renal failure. II. A histochemical study of the proximal tubule of the rat following administration of mercuric chloride.

SummaryAcute renal failure was induced in male rats by the subcutaneous injection of 4 mg HgCl2 per kg body weight. Enzyme activities of the proximal tubule were studied histochemically at six time intervals from 15 min to 24 h. The enzymes studied were alkaline phosphatase, 5′-nucleotidase, acid phosphatase, α-glycerophosphate dehydrogenase (NAD-independent), malic dehydrogenase, succinic dehydrogenase, latic dehydrogenase, glucose-6-phosphate dehydrogenase and glucose-6-phosphatase. Decreases in activity were observed for alkaline phosphatase and 5′-nucleotidase after 15 min. Acid phosphatase was decreased after 30 min. These three enzymes returned to control levels after 3 h, but malic dehydrogenase and α-glycerophosphate dehydrogenase were decreased at this time interval. Succinic dehydrogenase was first decreased after 6 h. The earliest morphological changes detectable by light microscopy were observed in pars recta tubules in the medullary rays after 6 h, a time when all enzymes studied showed widespread decreased activity throughout the proximal tubule. After 24 h, the pars convoluta appeared morphologically normal but the pars recta was necrotic and exhibited calcification, whereas enzyme activity was decreased (absent in some cases) in both pars convoluta and pars recta.These results support the hypothesis that Hg+ +, when given in a sublethal dose, is associated with early histochemical changes in the brush border of the proximal tubule, which may be related to early changes in sodium reabsorption and to the subsequent development of acute renal failure. The observation that changes in plasma membrane-associated enzymes occur early and prior to alterations in enzymes of mitochondria and the endoplasmic reticulum suggests that Hg++ interacts initially with the plasma membrane.

Effect of Acute and Chronic Calcium Administration on Plasma Renin

To evaluate the effect of Ca(++) on renin release, plasma renin activity (PRA) was measured after acute and chronic Ca(++) administration. 1% CaCl(2) was infused into one renal artery of 10 anesthetized dogs (0.3 mg/kg/min). The excreted fraction of filtered calcium (EF(ca++)) and EF(Na+) from the infused kidney were elevated (P < 0.04) during three successive 15-min infusion periods. Serum calcium concentration was significantly elevated (P < 0.001). Creatinine clearance, systemic arterial pressure, and renal blood flow did not change (P > 0.10). Compared to control (45 ng/ml/h+/-5.2 SE), renal venous PRA was suppressed (P < 0.0001) after infusion of Ca(++) for 15, 30, and 45 min (20 ng/ml/h+/-4.6, 16 ng/ml/h+/-4.0, and 13 ng/ml/h+/-2.7, respectively). 15 and 30-min after infusion, PRA did not differ from control (P > 0.20). Chronic Ca(++) loading was achieved in Sprague-Dawley rats by replacing drinking water with 1% CaCl(2) for 17 days. At sacrifice, serum Ca(++), Na(+), and K(+) of controls (n = 12) did not differ (P > 0.60) from Ca(++)-loaded rats (n = 12). Ca(++) excretion (467 mueq/24 h+/-51) was elevated (P < 0.001) compared to controls (85 mueq/24 h+/-12). PRA (8.6 ng/ml/h+/-1.4) and renal renin content of Ca(++)-loaded rats did not differ from controls (P > 0.80). However, after 8 days of sodium deprivation, both PRA and renal renin content of calcium-loaded animals were significantly lower than the respective values in pair-fed controls (P < 0.005). During the period of sodium deprivation, calcium-drinking animals were in greater negative sodium balance than controls (P < 0.005). The data are consistent with the hypothesis that acute and chronic calcium administration inhibit renin secretion.

Comparison of propranolol or hydrochlorothiazide alone for treatment of hypertension: III. Evaluation of the renin-angiotensin system

In this study, the relation between renin activity and therapeutic response to hydrochlorothiazide or propranolol was studied. Patients with a diastolic blood pressure of 95 to 114 mm Hg were treated with propranolol (40 to 320 mg twice daily) or hydrochlorothiazide (25 to 100 mg twice daily). The initial renin profiles were: low, 56 percent (n = 300); normal, 33 percent (n = 174); high, 11 percent (n = 60). A greater incidence of low and fewer high renin profiles (p less than 0.001) were observed in blacks. After furosemide administration (40 mg intravenously), 55 percent of patients (n = 291) had a low renin response and 45 percent (n = 240) had a normal renin response. No correlation between renin profile and renin response was observed, although low renin response and low renin profile occurred more frequently in older patients. Hydrochlorothiazide administration resulted in a greater decrement in diastolic blood pressure (p less than 0.05) in the total group. Irrespective of renin activity, both hydrochlorothiazide and propranolol reduced diastolic blood pressure. When renin profile was considered, no significant variation in response to hydrochlorothiazide therapy was observed, and there was a greater reduction in diastolic blood pressure in the patients with a high renin profile receiving propranolol. In comparing therapeutic response, patients with a low renin profile had a better response to hydrochlorothiazide, and propranolol was more effective in patients with a high renin profile. The anticipated effect of therapy on plasma renin activity was observed. Although these results are consistent with a volume-vasoconstrictor analysis of hypertension, the results of therapy could not have been prejudged from renin profile or responsivity. The slight differences observed do not warrant the expense of renin determinations when a simple determination of therapeutic response is sufficient.

POSSIBLE ROLE FOR IMPAIRED RENAL PROSTAGLANDIN PRODUCTION IN PATHOGENESIS OF HYPORENINÆMIC HYPOALDOSTERONISM

A 57-year-old woman with hypertension and moderate renal insufficiency had chronic unexplained hyperkalaemia. Metabolic balance studies confirmed a diagnosis of hyporeninaemic hypoaldosteronism. Two observations suggested that impaired renal prostaglandin production contributed to the pathogenesis of the patients disorder. Baseline renal-prostaglandin synthesis (as determined by urinary excretion of P.G.E and P.G.F) was was substantially depressed when compared with that in nine normal females. Infusion of low doses of P.G.A1 produced a significant increase in serum-aldosterone and urinary potassium excretion; it also led to a dramatic fall in blood-pressure and serum-potassium. It appears from these studies that a defect in renal prostaglandin synthesis has an important role in the pathogenesis of hyporeninaemic hypoaldosteronism.

Uranyl Nitrate Induced Acute Renal Failure in the Rat: Effect of Varying Doses and Saline Loading

Summary Increasing doses of intravenous uranyl nitrate above 2.5 mg/kg of body weight result in more extensive renal tubular necrosis without increasing azotemia in the rat. Despite a uniform level of azotemia, renal tubular epithelial dysfunction tended to parallel the changes in renal tubular pathology. Saline loading, designed to suppress the renin–angiotensin system, ameliorated the azotemia but not the tubular necrosis or tubular dysfunction after uranyl nitrate. These results suggest that passive backflow of glomerular filtrate through necrotic tubular epithelium is not responsible for the azotemia after uranyl nitrate in the rat. The protection afforded by saline loading further suggests a role for the renin–angiotensin system in the development of uranyl nitrate induced acute renal failure.