Control of aldosterone in 17 alpha-hydroxylase deficiency

The control mechanism of aldosterone in 3 patients with 17 alpha-hydroxylase deficiency was compared to that in a patient with a deoxycorticosterone-producing tumor. The basal levels of plasma renin activity (PRA) and plasma aldosterone (PAC) were decreased in 2 of the 3 patients with 17 alpha-hydroxylase deficiency and in the patient with a tumor. However, in the third patient with accelerated hypertension, those levels were normal. In the 3 patients with low PRA and PAC, PAC was stimulated by various procedures, although the responses were lower than those in control subjects. In the patient with accelerated hypertension, the responses were similar to those of the control subjects. After 6 months' treatment with dexamethasone, the low levels of PRA and PAC gradually returned to the lower limit of normal in 2 of the patients with 17 alpha-hydroxylase deficiency. These results suggest that the suppression of PAC in patients with 17 alpha-hydroxylase deficiency is probably due to a suppression of the renin-angiotensin system.

Effects of converting enzyme inhibitor (SQ 20881) on changes in blood pressure and plasma aldosterone induced by angiotensin I or acute hemorrhage in rabbits

The effects of angiotensin converting enzyme inhibitor (CEI) upon blood pressure and plasma aldosterone (PA) were studied in rabbits with a simultaneous infusion of angiotensin I (ANG I) or with hemorrhagic hypotension. Pretreatment with CEI (SQ 20881), 1.0 mg/Kg, inhibited the effects of infused ANG I, 30 ng/Kg/min, upon PA and blood pressure at 30 min of the infusion, but the inhibition on PA was not significant at 60 min of the infusion. The same dose of CEI was ineffective in blocking the effect of 100 ng/Kg/min of ANG I on PA and blood pressure even at 30 min of the infusion. In rabbits with hemorrhagic hypotension, injection of CEI resulted in the decrement in blood pressure, whereas no decrement in blood pressure was observed in normal control rabbits. This study suggests that CEI exerts it's effect in part by inhibiting conversion of ANG I to angiotensin II (ANG II), but this can't exclude other mechanisms.

Responses of aldosterone-producing adenomas to ACTH and angiotensins

To elucidate the control mechanism of aldosterone production in primary aldosteronism, in vivo and in vitro studies were done in 7 patients with aldosterone-producing adenomas. In the in vivo study, plasma aldosterone was stimulated more significantly by (Formula: see text), synthetic ACTH than by angiotensin II or furosemide. Diurnal variations of plasma aldosterone, which were studied in 4 patients, were similar to those seen in normal controls. In agreement with the results in the in vivo study, the in vitro study also revealed ACTH stimulated aldosterone and deoxycorticosterone (DOC) from the adenoma more markedly than angiotensin II or III. There was no adenoma which was more sensitivie to angiotenion II or III than to ACTH. From these results it is considered that changes in plasma aldosterone induced by the exogenous administration of angiotensin II or ACTH in patients with aldosterone-producing adenoma are mainly based on changes in aldosterone production in the adenoma. Furthermore, in patients with an aldosterone-producing adenoma in whom diurnal variations of plasma aldosterone similar to those in normal subjects are observed, responses of aldosterone to angiotensin II are supposed to be less than those to ACTH.

Finger print deposits of the kidney in pure monoclonal IgG kappa cryoglobulinemia

In a male patient with pure monoclonal IgG kappa cryoglobulin associated with the nephrotic syndrome, finger print deposits were observed in the subendothelial space and mesangial matrix of the kidney by electron microscopy. The structure was similar to a unique tubular crystal structure of IgGl kappa cryoglobulin which was reported by Bogaars et al. [1973] in the serum of a patient with multiple myeloma. It was therefore supposed that the finger print deposits in the kidney of this patient were the precipitation of the monoclonal IgG kappa cryoglobulin in serum.

Vasospasm assessed by angiography and computerized tomography

In 44 consecutive cases of ruptured cerebral aneurysm, vasospasm was demonstrated pre- or postoperatively. These cases were examined by bilateral carotid angiography and computerized tomography (CT), and the relationship between the angiographically visualized distribution of vasospasm, the neurological symptoms, and infarction seen on CT was evaluated. Vasospasm occurred in only some intracranial portions of the cerbral arteries that were immersed in blood-stained cerebrospinal fluid. Angiographically, diffuse vasospasm extensively involving bilateral carotid systems indicated the gravest prognosis for patients. Vasospasm affecting one carotid system and the anterior cerebral arteries on the opposite side often produced permanent neurological deficits. On the contrary, when vasospasm was restricted to one carotid system or to bilateral anterior cerebral arteries, it was usually associated with temporary neurological symptoms; however, it always produced residual neurological symptoms if it extended to the ascending branches (M3) of the middle cerebral arteries. Computerized tomography definitely demonstrated a low-density area or infarction in the territory of the spastic arteries in 25 (71%) of 35 cases with vasospasm. A low-density area was always detected when vasospasm occurred in M3 segments.

[Experimental and clinical studies on blood coagulation and lysis system after hepatic resection (author's transl)]

Blood coagulation and lysis system was studied with other biochemical serum analysis in three groups of mongrel dogs; laparotomy without hepatic resection (group I), with 50% hepatic section (group II), and 70% hepatic resection (group III). In clinical studies, six cases of hepatic tumors and one case of hepatoma with cirrhosis were selected for examinations. All the data examined in group I were restored toward normal within 48 hours. Total serum protein level was significantly decreased after hepatic resection. The protein level in group III was lower than in group II on the 4th postoperative day (P less than 0.01). In clinical studies, low serum protein levels did not reach a preoperative value even 3 weeks after extended right hepatic lobectomy. Time course of Al-P and transaminase changes in clinical studies was similar to that in experimental study with dogs. Al-P and transaminase showed an abnormally high level in the patient with hepatic cirrhosis. Serum bilirubin levels were not increased after hepatic resection. In blood coagulation and lysis system, serum fibrinogen levels were markedly decreased: 50% reduction in group III and 30% reduction in group II on the first postoperative day. The degree of decrease in the fibrinogen level was proportional to the size of resected volume of the liver. On the other hand, in clinical studies fibrinogen levels were slightly decreased. In the case of hepatic resection with cirrhosis, however, the values were markedly decreased: 40% reduction on the 4th and 25% on the 21st postoperative days. Fibrinolysis system was accelerated group II and III. The acceleration continued until 3 weeks after hepatic resection. From these results it may be concluded that analysis of blood coagulation and lysis system after hepatic resection is useful in evaluating a residual hepatic function after partial resection and in selecting a treatment suitable for hepatic insufficiency.

[Diagnosis and treatment of cerebellar hemorrhage: comparison of hypertensive hemorrhage with hemorrhage caused by small angiomas, and CT findings (author's transl)]

In spontaneous cerebellar hemorrhage emergency surgical intervention is often life-saving. Clinical features and the operative results of hypertensive cerebellar hemorrhage (18 cases) were compared with those of hemorrhage caused by small angiomas (7 cases). Hypertensive hemorrhage occured most frequently in the seventh decades. Two thirds of the patients developed brainstem compression syndrome within a week from onset. One third remained awake or drowsy throughout their clinical course. Surgical removal of a hematoma was carried out in 13 patients with four deaths. Of note, two comatose patients regained consciousness after surgery, and were discharged with residual ataxia. Rupture of a small angioma occurred in younger patients. Their clinical course was sub-acute or chronic associated with focal cerebellar dysfunction. All seven surgically treated patients subsequently regained independent function. CT findings have been found helpful not only for diagnosis but also in defining appropriate therapy. Hematomas larger than 3 cm in diameter produced signs of rapidly progressing compression of the brainstem. Thereby, regardless of the cause of bleeding, emergency removal of a clot is indicated even in awake patients. Hematomas of 2 to 3 cm produced brainstem compression or prolonged cerebellar dysfunction, and occasionally require surgical decompression. Hematomas smaller than 2 cm can be managed conservatively, since they were absorbed spontaneously in three weeks without residual functional disturbances. However, in case of a young patient exploration should be performed for a probable "cryptic" angioma.

Active and inactive renin in pregnancy and in women on estrogen-containing oral contraceptives

Total and active renin concentrations (TRC and ARC) were determined in pregnant women and in women on estrogen-containing oral contraceptives to study the variation of plasma renin forms in pregnancy. TRC was already elevated in the first trimester. After that TRC increased consistently reaching the maximum in the third trimester. The ratio of inactive renin concentrations (IRC) to TRC was between 20 and 30% throughout gestation. Therefore, it was supposed that the development of the placenta or the enlargement of the uterus do not affect the ratio of IRC to TRC too much. In women on oral contraceptives in whom plasma renin activity was increased due to elevation of renin substrate, the ratio of IRC to TRC was almost the same as that in normal controls. From these results, it was suggested that the development of the placenta and the enlargement of the uterus do not play an important role in the variation of plasma renin forms, although remarkable changes are observed in the renin substrate and total amounts of renin in pregnancy.

Effect of estrogen upon the juxtaglomerular apparatus and the renin-angiotensin system in rats

Administration of 1.5 mg/kg of estriol intramuscularly and 15 mg/kg of stilbestrol disulfate intraperitoneally daily for 15 days caused an increase in plasma renin substrate (PRS), accompanied by an increase in plasma renin activity (PRA) and a slight decrease in plasma renin concentration (PRC). Contrary to the slight suppression of PRC, juxtaglomerular granulation index (JGI) was significantly increased in rats treated by estrogen. In the rats which developed hypertension by estrogen PRA, PRC and JGI were a little higher than those in the rats which remained normotensive after the same estrogon treatment, but these differences were not statistically significant. Therefore, it seems rather difficult to attribute the development of estrogen hypertension only to the quantitative changes in the renin-angiotensin system.

Role of angiotensin III in the regulation of blood pressure, plasma aldosterone and plasma renin activity in rabbit

To evaluate the role of angiotensin III in the control of blood pressure, plasma aldosterone and plasma renin activity (PRA), the pressor, steroidogenic and PRA-suppressing effect of angiotensin III was studied in rabbits with or without simultaneous constant infusion of Ile7-angiotensin III, an analogue of angiotensin III, or Sar1Ala8-angiotensin II, an analogue of angiotensin II, and compared with the effect of angiotensin II.

Infusion of 30 ng/kg/min of angiotensin III or angiotensin II produced a twofold increase in plasma aldosterone. Pressor response to angiotensin III was approximately one tenth of that of angiotensin II. Infusion of angiotensin II suppressed the PRA significantly, while infusion of angiotensin III did not suppress it. Angiotensin II or angiotensin III induced-increase in plasma aldosterone was attenuated by the pretreatment with either Ile7-angiotensin III or Sar1Ala8-angiotensin II. Pressor or PRA-suppressing action of angiotensin II was unaffected by the pre-treatment with Ile7-angiotensin III, while it was significantly inhibited by pre-treatment with Sar1Ala8-angiotensin II.

This study indicates that angiotensin III or angiotensin III analogues affect the adrenal glands selectively and suggests that there are differences between the receptor sites for angiotensins in vascular smooth muscle, kidney and those in the adrenal cortex.

Role of renin-angiotensin system in the controls of blood pressure and aldosterone in patients with cirrhosis and ascites

In an attempt to evaluate the role of renin-angiotensin system in the contols of blood pressure and aldosterone secretion in the patients with cirrhosis and asictes, 7 patients were infused of an antagonist of angiotensin II, Sar-1 Ile-8 angiotensin II, intravenously to inhibit the action of renin-angiotensin system and to observe changes in arterial pressure and plasma aldosterone. In 1 patient with recent onset of severe ascites and high plasma renin activity, blood pressure and plasma aldosterone decreased during the infusion. In contrast, mild rise in blood pressure and various changes in plasma aldosterone were observed in the other 6 patients with normal plasma renin activity. These results suggest variable angiotensin dependency in the controls of blood pressure and plasma aldosterone in the patients with cirrhosis and ascites according to the stage of the disease, the states of sodium and water balance and/or palasma renin activity.

Serum uric acid and the renin-angiotensin system in hypertension

To study whether the renin-angiotensin system is related to hyperuricemia in hypertension, the serum concentration of uric acid was determined in 96 patients with various types of hypertension and various degrees of plasma renin activity (PRA). In malignant hypertension, both PRA and the serum uric acid level were higher than in essential hypertension; but in primary aldosteronism or desoxycorticosterone-excess hypertension, they were lower than in the essential type. In renovascular hypertension, PRA was higher than in essential hypertension, but the serum uric acid levels were similar. There were no differences in PRA and serum uric acid concentration between Cushing's syndrome and essential hypertension. The serum uric acid level in high-renin essential hypertension was higher than in either the normal-renin or the low-renin type. There was a significant correlation between serum uric acid concentration and PRA in the basal state, and between the change in PRA and the change in serum uric acid induced by administration of furosemide. Apparently the close correlation between the renin-angiotensin system and the concentration of serum uric acid is related to changes in extracellular fluid volume, although an intrarenal effect of angiotensin II cannot be excluded.

Hypertension induced by adrenocortical dysfunction--hypertension in 17 alpha-hydroxylase deficiency and metopirone-induced hypertension

Hypertension in 17 alpha-hydroxylase deficiency was studied by comparing it with hypertension in Cushing syndrome or that in primary aldosteronism. Furthermore, the role of endogenous increases of ACTH, deoxycorticosterone, and 18 alpha-hydroxy-deoxycorticosterone upon blood pressure was studied in rats by administerating metopirone. Hypertension in 17 alpha-hydroxylase deficiency was considered to be more similar to that in primary aldosteronism from the studies on renin components, pressor responses to angiotensin II and norepinephrine, and renin responses to stimulations. Plasma catecholamines were slightly decreased in 17 alpha-hydroxylase deficiency. The hypertension was alleviated by the administeration of dexamethasone in 2 of 3 patients with 17 alpha-hydroxylase deficiency. However, in the remaining one who had an accelerated hypertension and normal renin, the hypertension was not alleviated by dexamethasone. In the animal studies, hypertension induced by metopirone was accelerated by salt loading of uni-lateral nephrectomy plus salt loading. In those rats, plasma ACTH, and deoxycorticosterone were markedly increased.

Timing and indication of surgery for ruptured intracranial aneurysms with regard to cerebral vasospasm

The authors survey 443 cases of intracranial aneurysms treated in the past seven years. 403 cases were operated upon with microsurgical techniques. The operative mortality was 5.4 per cent, and 82.4 per cent of surgically treated cases are well and working, leading useful social lives. It was found that cases submitted to surgery in the first three days after subarachnoid haemorrhage (SAH) (the day of SAH being counted as the first day) showed good results, little appearance of postoperative vasospasm, and no mortality due to vasospasm. Cases operated upon after one week from the insult of SAH also showed good results, whereas fatal postoperative vasospasm was seen in cases operated upon on the 4th--7th day after SAH. Cisternal, ventricular, and epidural drainage are recommended after the clipping of aneurysms in the acute stage of SAH. There were 68 cases with preoperative vasospasm. There was no case in which vasospasm was identified during the first four days after SAH, while 66 per cent of the cases exhibited vasospasm between the sixth and ninth days after SAH. These 68 cases can be classified into four groups: 1. 8 cases died from vasospasm before surgery: 2. 8 cases had renewed bleeding mainly when vasospasm began to subside. 3. 22 cases underwent surgery after vasospasm had subsided, the duration of vasospasm ranging from 8 to 24 days, on an average 14 days; 4. 30 cases underwent surgery while vasospasm was still present; of this group, (4E) 15 cases submitted to surgery, on an average 4.5 days after the onset of vasospasm, manifested deterioration of clinical states because of aggravation or new appearance of vasospasm; (4L, 15 cases which underwent surgery, on an average 7.4 days after the onset of vasospasm, showed no such deterioration. In the follow-up, well and working cases were seen in 45.5 per cent (3.), 60 per cent (4E), and 80 per cent (4L), respectively. The authors classified vasospasm into three types: Type 1, extensive diffuse, Type 2, multi-segmental, and Type 3, local. Type 1 was prognostically worst, Type 3 good, and Type 2 was located between these two types.