Yukio Miyata

Fanconi's syndrome and distal (type 1) renal tubular acidosis in a patient with primary Sjögren's syndrome with monoclonal gammopathy of undetermined significance.

Tubulointerstitial nephritis is a well-recognized complication in primary Sjögrens syndrome. Fanconis syndrome is a far less frequent complication compared with distal tubular dysfunction. We here describe a 49-year-old woman with primary Sjögrens syndrome. In 1997, she was diagnosed with primary Sjögrens syndrome with tubulointerstitial nephritis, and was then treated with oral prednisolone for the tubulointerstitial nephritis. In 2002, she was referred to our hospital because of progressive fatigue. At that time, biclonal spike on serum protein (IgG-kappa and IgA-kappa) and Bence-Jones protein in urine were found. Bone marrow aspiration showed 1.0% plasma cell infiltration. Thus, a diagnosis of monoclonal gammopathy of undetermined significance (MGUS) was made. In 2004, she was again admitted to our hospital because of mild renal dysfunction and hypokalemia. Laboratory evaluation showed inappropriate, alkaline urine in hyperchloremic metabolic acidosis and a positive urine anion gap, indicating the presence of distal (Type 1) renal tubular acidosis (RTA). The urine concentration defect was also found. Further studies revealed proximal tubular dysfunction, including renal glycosuria, generalized aminoaciduria, phosphaturia, uricosuria and proximal RTA. The kidney biopsy represented diffuse and severe tubulointerstitial nephritis with dense infiltrates of lymphocytes and IgA and K light chain-positive plasma cells. No findings of multiple myeloma or malignant lymphoma were observed. In conclusion, our patient had Sjögrens syndrome with MGUS and exhibited dysfunction of both proximal tubule (Fanconis syndrome) and distal tubule, which may be attributed to diffuse tubulointerstitial nephritis.

Mechanisms for nongenomic and genomic effects of aldosterone on Na+/H+ exchange in vascular smooth muscle cells.

Objectives We have reported that exposure of vascular smooth muscle cells (VSMCs) to aldosterone for 3 and 24 h activated Na+/H+ exchange (NHE) via nongenomic and genomic mechanisms, respectively. The present study determined whether aldosterone-induced nongenomic and genomic NHE activation depends on the number of transporters, the turnover rate of a single transporter, and/or the change in intracellular pH (pHi) sensitivity of the transporter, and whether aldosterone-induced NHE activation is inhibited by the selective mineralocorticoid receptor (MR) antagonist (eplerenone). Methods Using a fluorescent dye, we assessed NHE activity by Na+-dependent acid extrusion rates (JH) after an acid load in the absence of CO2/HCO3− in VSMCs treated with aldosterone. Results Treatment with aldosterone for 3 and 24 h increased JH at the wide pHi range, and shifted the JH versus pHi in the alkaline direction. Without affecting the apparent Km for external Na+, the Vmax increased in VSMCs treated with aldosterone for 3 and 24 h. Both eplerenone and spironolactone inhibited only aldosterone-induced genomic NHE activation, but the IC50 of eplerenone was smaller than that of spironolactone. Conclusion We demonstrated that: (1) both nongenomic and genomic stimulatory effects of aldosterone on NHE activity in VSMCs occur by an increase in the number of NHEs and the alkaline shift in pHi sensitivity of the NHE; (2) only the aldosterone-induced genomic NHE activation occurs via MR; and (3) both eplerenone and spironolactone inhibit the aldosterone-induced genomic NHE activation, but eplerenone is more effective than spironolactone, based on the IC50 value in VSMCs.

Troglitazone stimulates basolateral rheogenic Na+/HCO-3 cotransport activity in rabbit proximal straight tubules

Thiazolidinedione derivatives, new insulin-sensitizing antidiabetic agents, are expected to have potential clinical use. Since these drugs cause edema in a variable proportion of patients, we examined whether troglitazone (Tro) has direct action on Na⁺ transport of rabbit proximal straight tubule perfused in vitro. For this purpose, we measured basolateral membrane voltage (V_B) by conventional microelectrode techniques and intracellular pH (pH_i) by microscopic fluorescence spectrophotometry with a pH-sensitive fluorescent dye, 2’, 7’-bis-2-carboxyethyl-5-carboxyfluorescein. Tro at 50 µM in the bath significantly depolarized both transepithelial voltage and V_B. To examine whether the basolateral rheogenic Na⁺/HCO^–₃ cotransport activity is affected by Tro, we observed V_B deflection upon abrupt 10-fold decrease in bath HCO^–₃ in the absence and presence of Tro. The apparent transference number of HCO^–₃ (t_HCO3), as calculated from the V_B deflection, was significantly greater in the presence of Tro (50 µM) than that seen in its absence. Tro caused cell acidification and increased the intracellular acidification rates (dpH_i/dt) upon abrupt 10-fold decreases in bath HCO^–₃ and Na⁺ concentrations. The stimulatory effects of Tro on t_HCO3 and dpH_i/dt were dose dependent between 5 and 50 µM, but they were unaffected at 0.5 µM. From these results, we conclude that Tro acts on the proximal straight tubule and stimulates the basolateral rheogenic Na⁺/HCO^–₃ cotransport activity. The stimulatory action of Tro may partly account for edema formation.

Basolateral Na+/H+ exchange maintains potassium secretion during diminished sodium transport in the rabbit cortical collecting duct.

Stimulation of the basolateral Na(+)/K(+)-ATPase in the isolated perfused rabbit cortical collecting duct by raising either bath potassium or lumen sodium increases potassium secretion, sodium absorption and their apical conductances. Here we determined the effect of stimulating Na(+)/K(+)-ATPase on potassium secretion without luminal sodium transport. Acutely raising bath potassium concentrations from 2.5 to 8.5 mM, without luminal sodium, depolarized the basolateral membrane and transepithelial voltages while increasing the transepithelial, basolateral and apical membrane conductances of principal cells. Fractional apical membrane resistance and cell pH were elevated. Net potassium secretion was maintained albeit diminished and was still enhanced by raising bath potassium, but was reduced by basolateral ethylisopropylamiloride, an inhibitor of Na(+)/H(+) exchange. Luminal iberitoxin, a specific inhibitor of the calcium-activated big-conductance potassium (BK) channel, impaired potassium secretion both in the presence and absence of luminal sodium. In contrast, iberitoxin did not affect luminal sodium transport. We conclude that basolateral Na(+)/H(+) exchange in the cortical collecting duct plays an important role in maintaining potassium secretion during compromised sodium supplies and that BK channels contribute to potassium secretion.

Complete remission of minimal-change nephrotic syndrome induced by apheresis monotherapy.

We report a case of a 17-year-old male with relapse of minimal-change nephrotic syndrome (MCNS), in whom apheresis monotherapy without steroids or immunosuppressants resulted in complete remission. The patient initially developed nephrotic syndrome in February 1998. The first renal biopsy confirmed the diagnosis of MCNS. The patient was also found to be a carrier of hepatitis B virus. Steroid therapy was started with oral prednisolone 60 mg/day. Complete remission was achieved in 3 months, and the steroid treatment was tapered off in May 2001. During the steroid tapering, temporal exacerbation of liver function was noted. In July 2002, the patient was admitted to our hospital again due to relapse of nephrotic syndrome. Second biopsy reconfirmed the diagnosis of MCNS. Since the serum titer of HBV was elevated, apheresis monotherapy was selected to avoid the risk of steroid-induced fulminant hepatitis. Four sessions of low-density lipoprotein apheresis (LDL-A) and 5 sessions of double-filtration plasmapheresis (DFPP) reduced the proteinuria from 9.2 g/day to 0.2 g/day over 38 days without any additional medication. Proteinuria remained suppressed below 0.2 g/day for more than 12 months and no exacerbation of liver function was observed up to the final follow-up in September 2003. The present case suggested the potential of apheresis monotherapy to induce and maintain complete remission of MCNS and an important role of circulating factors in the pathogenesis of MCNS.

Reversible hypocalcemic heart failure with T wave alternans and increased QTc dispersion in a patient with chronic renal failure after parathyroidectomy.

Despite the crucial role of calcium in myocardial contractility, hypocalcemia has very rarely been reported as a reversible cause of heart failure. In this article, we describe a case of a 51-year-old woman with advanced stages of chronic renal failure after parathyroidectomy who exhibited congestive heart failure, severe hypocalcemia, hypomagnesemia and hypokalemia. Severe hypocalcemia resulted from discontinuation of taking calcium supplements after parathyroidectomy and from reduced 1.25(OH)2D3 synthesis by damaged kidneys. The patient presented with reduced left ventricular ejection fraction (EF) and ECG abnormalities (T wave alternans and increased QTc dispersion), both of which improved after correction of serum calcium levels. Her serum levels of total calcium corrected for serum albumin, but not serum levels of magnesium or potassium, positively and negatively correlated with EF and QTc dispersion, respectively. In the present case, both heart failure and the ECG abnormalities are directly associated with hypocalcemia.

Combined treatment with nafamostat mesilate and aspirin prevents heparin-induced thrombocytopenia in a hemodialysis patient.

We report on the management of a 36-year-old hemodialysis patient with heparin-induced thrombocytopenia (HIT, type II) and clot formation in extracorporeal circulation. Platelet aggregation test and measurement of anti-platelet factor 4/heparin complex antibody by enzyme-linked immunosorbent assay revealed to us that our patient had developed HIT. Instead of heparin, we used nafamostat mesilate (NM) as an anticoagulant during hemodialysis, but could not completely prevent HIT-induced thrombocytopenia or clot formation in the extracorporeal circuit. Combined use of NM and aspirin completely inhibited platelet aggregation, decrease in platelet count and clot formation in the extracorporeal circuit.

A case of encapsulating peritoneal sclerosis at the clinical early stage with high concentration of matrix metalloproteinase-2 in peritoneal effluent.

In encapsulating peritoneal sclerosis (EPS), matrix metalloproteinases (MMPs) and tissue inhibitor of metalloproteinases are involved in the remodeling of peritoneal tissue. We measured the MMP-2 concentration in the peritoneal effluents of a patient with EPS who discontinued continuous ambulatory peritoneal dialysis (CAPD) therapy because of ultrafiltration failure and/or underdialysis. First, we report a 58-year-old female patient who discontinued CAPD therapy because of underdialysis. Several months after cessation of CAPD, she complained of slightly blood-colored ascites and had an elevated level of C-reactive protein (CRP) in plasma. She was diagnosed as having clinical early-stage EPS. Peritoneal effluents drained from this case, and from 11 patients who discontinued CAPD therapy because of ultrafiltration failure and/or underdialysis, and who underwent peritoneal lavage with 1.5% dextrose peritoneal dialysis fluid for several months, were analyzed by gelatin zymography. MMP-2 concentration was also measured by enzyme-linked immunosorbent assay (ELISA). MMP-2 concentration in peritoneal effluent of this patient was highest compared with that of the other patients. There was some tendency of a positive correlation between MMP-2 concentration per 1 g protein and D/Pcr, and was negative correlation between MMP-2 concentration per 1 g of protein and D/D0 glucose. We concluded that MMP-2 is involved in the peritoneal remodeling of long-term CAPD therapy and the progression of EPS.

Effect of Trimethoprim-Sulfamethoxazole on Na+ and K+ Transport Properties in the Rabbit Cortical Collecting Duct Perfused in vitro

Background: In this study, the membrane mechanisms of hyperkalemia caused by trimethoprim-sulfamethoxazole (TMP-SMX) combination antibiotics were assessed in the cortical collecting duct (CCD). Methods: We used the microelectrode technique and flux measurements, and examined the effects of TMP and SMX on electrical properties of the apical and basolateral membranes in the rabbit CCD perfused in vitro. Results: TMP in the lumen caused increases in apical membrane voltage, fractional apical membrane resistance (fRA), and transepithelial resistance (RT), all effects which were completely inhibited by luminal amiloride, but not by luminal Ba2+. The luminal TMP inhibited both net Na+ reabsorption and K+ secretion in the CCD. TMP in the bath slightly but significantly depolarized transepithelial voltage and basolateral membrane voltage without influencing fRA or RT. SMX in the lumen or bath had no effect on barrier voltages or resistances. Conclusion: TMP mainly acts on the apical membrane of the CCD, inhibits the amiloride-sensitive macroscopic Na+ conductance in this membrane, and thereby decreases the net driving force for K+ exit across the membrane, resulting in an inhibition of K+ secretion. SMX in the lumen or bath had no effect on the CCD.

Sodium Ion Specifically Modifies Plasma Ionized Calcium Concentration

Background/Aim: Recently, we observed a progressive decline in the plasma ionized calcium (iCa) concentration after ingestion of Na-free beverage. Although both plasma pH and Na significantly correlated with iCa, the correlation of the latter was stronger than that of the former. Therefore, we explored the effect of Na on plasma iCa. Methods: Pooled human plasma was diluted with normal saline, 5% glucose, 0.9% KCl, or distilled water to examine the effect of plasma dilution on iCa. Also, to evaluate the effects of an isovolemic increase in ion concentration and osmolarity on plasma iCa, NaCl, KCl, and D-glucose were added to plasma. Electrolytes (Na+, K+, Cl–, iCa, HCO–3), pH, and osmolarity were measured by using ion-selective electrodes. Results: In the plasma dilution study, although all solutions significantly decreased the iCa concentration, the decrease in iCa concentration in the normal saline treated solution was significantly lower than in others. When the plasma osmolarity was isovolemically increased, the iCa concentration significantly increased in parallel with the increase in osmolarity in the NaCl group (r = 0.604, p < 0.01, n = 50). In contrast, no significant change in the iCa concentration was seen in the other solutions. NaCl did not increase, but rather decreased the iCa concentration when added to a protein-free solution. Conclusion: The present study demonstrated that Na specifically affects plasma iCa independently of pH, presumably via modulating Ca binding to plasma proteins.