At risk nephrons and the decline in renal function in response to treatment of hypertension

An examination of change in renal function following blood pressure lowering in more than 4,400 individuals in several clinical trials revealed that renal function declined following initiation of antihypertensive treatment in both essential hypertension and hypertensive diabetics for a period of two years before stabilizing at or near zero change. This initial decline can be related to the severity of preexisting hypertension but does not appear related to the type of antihypertensive regimen used. This phenomenon appears most readily explained by progressive obsolescence of previously damaged nephrons and not by the type of antihypertensive therapy employed. These finding raise questions about validity of interpretation of clinical trials designed to test efficacy of specific drug regimens in preserving renal function when outcome results are predominantly influenced by events during the first two years of intervention.

Mechanisms of injury in progressive renal disease

Recognition that loss of renal function is progressive has led to extensive investigation into risk factors and mechanisms of injury. Persistent activity of the underlying disease contributes, though progression may proceed in its absence. Nephrotoxic insults which pose little threat to the normal kidney may enhance progression in the diseased kidney. Functional adaptations, including glomerular hypertension and proteinuria, in themselves contribute to ongoing destruction. Structural and cellular adaptations, including tubulointerstitial fibrosis, also play a role. A large number of mediators of injury have been identified, as well as dietary and metabolic factors which act through these mediators and mechanisms. This brief overview will summarize the various mechanisms which have been proposed and which are likely to alter clinical strategies to slow the progression of renal disease.

Homeostatic efficiency of tubuloglomerular feedback is reduced in established diabetes mellitus in rats

We tested the hypothesis that the ability of the tubuloglomerular feedback (TGF) to stabilize renal function is impaired in rats with 7-8 wk of insulin-treated streptozotocin-diabetes. Proximal tubular flow was measured in free-flowing nephrons using a noninvasive optical technique. The homeostatic efficiency of TGF was determined from the fractional compensation for perturbations in ambient flow. Fractional compensation was substantially reduced in diabetic rats. To assess the roles of the proximal tubule and loop of Henle as determinants of TGF efficiency, we tested the effect of diabetes on proximal tubular reabsorption as determined by standard micropuncture and on the ionic content of early distal tubular fluid by employing a microelectrode for on-line measurement of electrical conductivity (TED). Diabetes caused glomerular hyperfiltration and increased fractional proximal tubular reabsorption (FPR), such that late proximal tubular flow (VLP) and early distal tubular flow were unaffected. The increase in FPR was a minor contributor to the overall effect on fractional compensation. Diabetes decreased the ambient TED without affecting the slope of the relationship between VLP and TED. These results demonstrate that the homeostatic, efficiency of the TGF system is reduced in diabetes and that this cannot be fully accounted for by changes in tubular reabsorption. Impaired TGF efficiency renders the diabetic glomerular microvasculature more susceptible to impact from fluctuations in systemic hemodynamics.

Single-nephron adaptations to partial renal ablation in cats

To evaluate remnant nephron hyperfiltration, cats underwent sham surgery (group 1, n = 6) or three-fourths nephrectomy (group 2, n = 6). Four to six weeks later, micropuncture studies demonstrated increases (P < 0.01) of single-nephron glomerular filtration rate (SNGFR) in group 2 (28.1 +/- 2.8 vs. 56.0 +/- 5.9 nl/min). In group 2 the mean estimated glomerular capillary pressure of 74.0 +/- 1.7 mmHg exceeded (P < 0.01) the value for group 1 (62.6 +/- 1.4 mmHg). The mean effective filtration pressure (EFPm) for group 2 (28.7 +/- 3.1 mmHg) was greater (P < 0.05) than that in group 1 (20.8 +/- 1.9 mmHg). Similarly, the mean ultrafiltration coefficient (Kf) in group 2 of 2.03 +/- 0.24 nl.min-1.mmHg-1 exceeded (P < 0.05) the corresponding value for group 1 of 1.35 +/- 0.06 nl.min-1.mmHg-1. Morphological studies demonstrated glomerular enlargement and mesangial matrix expansion in group 2 (P < 0.05). Proteinuria, as assessed by the urine protein-to-creatinine ratio, was increased (P < 0.05) after partial renal ablation. These results demonstrate that increases in SNGFR in feline remnant nephrons occur in association with glomerular hypertension, glomerular hypertrophy, expansion of mesangial matrix, and proteinuria, and furthermore, that the observed increases in SNGFR are attributable to an augmentation of EFPm and Kf.

Magnitude of TGF-initiated nephron-nephron interactions is increased in SHR

We compared the tubuloglomerular feedback (TGF)-initiated nephron-nephron interaction in spontaneously hypertensive rats (SHR) and normotensive Sprague-Dawley (SD) rats. Interaction strength was assessed by measuring stop-flow pressure (delta SFP) responses in pairs of nephrons, where only one nephron of the pair was microperfused. The vascular connection was determined from casts of the nephrons and vessels; length of arteriolar separation between the two glomeruli was measured on the casts. When microperfusion rate was increased from 5 to 50 nl/min, delta SFP in perfused nephrons was 10.6 +/- 0.6 and 10.2 +/- 0.7 mmHg [not significant (NS)] in SD and SHR, respectively. In the matched unperfused nephrons from the same cortical radial artery, delta SFP was 1.3 +/- 0.2 and 2.9 +/- 0.7 mmHg (P < 0.05) in SD and SHR. When the perfused and unperfused nephron originated from different cortical radial arteries, delta SFP in the unperfused nephrons was -0.1 +/- 0.2 and 0.0 +/- 0.3 mmHg (NS) in SD and SHR, respectively. In both strains, interaction strength varied inversely with glomerular separation. When the dependence on distance was taken into account, interaction strength was about threefold greater in SHR than in SD. We conclude that the nephron-nephron interaction is significantly greater in SHR. The dependence of interaction strength on distance separating the glomeruli suggests that the interaction is propagated along the preglomerular vasculature.

Fewer nephrons at birth: a missing link in the etiology of essential hypertension?

In 1988, Brenner et al advanced the hypothesis that the nephron endowment at birth is inversely related to the risk of developing essential hypertension in later life (Am J Hypertens 1:335-347, 1988). This novel perspective on the origins of essential hypertension was taken from the viewpoint that the development and maintenance of hypertension must involve a renal factor favoring sodium retention, thereby preventing pressure-induced natriuresis from restoring blood pressure toward normal levels. Since nephron numbers in the normal population range from 300,000 to 1,100,000 or more, it was reasoned that a congenital deficit in nephron endowment itself could be the renal risk factor for hypertension: demographic groups in whom hypertension is unusually prevalent tend to have smaller kidneys, implying fewer nephrons, and some inbred hypertensive rat strains have, on average, fewer nephrons than their respective normotensive controls. We argue that recent independent observations in humans relating low birth weight to both increased risk of hypertension in later life and the formation of fewer nephrons at birth lend strong support to the nephron number hypothesis. Moreover, independent experimental studies in rodents suggest that maternal protein intake during gestation is directly related to he numbers of nephrons formed and that when protein intake is restricted, the offspring develop hypertension in maturity. The concept that nephron numbers may be programmed during gestation, as these observations imply, is discussed in relation to the potential advantages and disadvantages of such a mechanism for the next generation; parallels are drawn with the relationship of low birth weight to pancreatic beta cell development and maturity-onset diabetes.(ABSTRACT TRUNCATED AT 250 WORDS)

A micropuncture study of the renal response to haemorrhage in rats: assessment of the role of vasopressin

The acute effects of haemorrhage (15 ml (kg body wt)-1) on renal function at whole-kidney and single-nephron levels were studied in Inactin-anaesthetized rats. In order to assess the role of vasopressin in mediating the haemodynamic effects, responses in untreated Long-Evans rats were compared with those in Brattleboro rats (which lack circulating vasopressin) and in Long-Evans rats treated with a V1 receptor antagonist. In time-control animals, there were no significant changes in mean arterial pressure (MAP), excretion rates, glomerular filtration rate (GFR), superficial-nephron GFR (SNGFR) or fluid reabsorption in the superficial proximal tubules during the course of the experiment. Following haemorrhage, the immediate reduction in MAP was followed in each group by partial recovery for 30 min; thereafter, MAP was stable. In untreated Long-Evans rats, haemorrhage was followed by a 26% reduction in GFR (P < 0.001, measured 60-150 min post-haemorrhage) and a larger reduction (45%, P < 0.001) in SNGFR, so that the SNGFR/GFR ratio fell significantly ((27.9 +/- 1.9) x 10(-6), control period; (20.2 +/- 2.2) x 10(-6) post-haemorrhage, P < 0.01). Slightly greater reductions in GFR and SNGFR were seen in Brattleboro rats and V1 antagonist-treated Long-Evans rats, which corresponded to slightly greater haemorrhage-induced reductions in blood pressure in these groups; the falls in the SNGFR/GFR ratio were similar to that in untreated Long-Evans rats. In all three groups of bled rats, fractional reabsorption by the proximal convoluted tubule increased slightly 30-60 min after haemorrhage, but during the subsequent period (60-150 min) returned to values indistinguishable from those during the control period. The results suggest that the renal haemodynamic changes that follow moderate haemorrhage include a preferential reduction in the GFR of superficial nephrons. Vasopressin appears to play no role in this response. Increases in fractional reabsorption in the proximal tubules are seen only during the immediate post-haemorrhage period.

Single nephron hemodynamics in spontaneously hypertensive rats

This study was designed to determine whether glomerular hypertension develops as a function of age in the spontaneously hypertensive rat (SHR). Male SHR and age-matched Wistar-Kyoto (WKY) normotensive controls were divided into three groups for measurements of whole kidney and single nephron hemodynamics at 5, 10, and 15 months of age. As reported previously, SHR developed significant proteinuria which was predominantly an albuminuria, after 5 months of age. There were no differences in whole kidney or single nephron glomerular filtration rates between SHR and WKY. Afferent glomerular capillary hydraulic pressure (PGC) was slightly increased in SHR compared with WKY at 10 months of age. At 15 months of age, PGC in SHR was significantly lower than WKY. Our studies indicate that increased capillary pressure is not a major factor in the development and progression of renal injury in the spontaneously hypertensive rat.

Intrarenal hemodynamics in low- and high-output cardiac failure in rats

Cardiac failure is multifactorial in causation, and the underlying physiologic mechanisms are variable, yet their renal effects have been considered more homogeneous. To investigate and compare the intrarenal hemodynamic characteristics in two experimental types (low- and high-output) of cardiac failure, renal micropuncture studies were performed in rats after myocardial infarction (MI) and arteriovenous fistula, respectively. Myocardial infarction was produced by ligation of the left main coronary artery and arteriovenous fistula by direct puncture of the aorta and inferior vena cava below the renal arteries. Pressures and interrenal and glomerular dynamics were obtained using classic micropuncture techniques. Both forms of cardiac failure were characterized by elevated left ventricular end-diastolic pressure (LVEDP), reduced mean arterial pressure, and increased cardiac mass. Left ventricular end-diastolic pressure was higher in MI rats, and effective renal plasma flow (ERPF) tended to be reduced in both forms of cardiac failure. There were no apparent differences in effective renal plasma flow between two models. In addition, single-nephron plasma flow and single-nephron glomerular filtration rate were reduced, and single-nephron filtration fraction and glomerular capillary pressure (PG) were increased in both models. These changes were associated with higher afferent and efferent arteriolar resistances and lower ultrafiltration coefficients. Despite these similarities, PG was higher in MI rats, yet LVEDP correlated directly with PG (r = 0.73; P < 0.001) and efferent arteriolar resistances (r = 0.72; P < 0.01). Therefore, although systemic arterial pressure and effective renal plasma flow were similar in both models of cardiac failure, PG was significantly higher in MI rats with higher LVEDP than in arteriovenous fistula rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Early urinary markers of target nephron segments as studied in cadmium toxicity

A number of chemicals may adversely affect one or more of the anatomical structures of the kidney, such as the glomerulus, the tubular apparatus, the medullary, or interstitial cells. To recognize subclinical renal dysfunction, a battery of new, non-invasive tests was applied in comparison to established ones. The study on cadmium exposed subjects, performed within the framework of a collaborative European research project, exemplifies the concept of target selectivity within a nephron. One hundred seventy-two subjects were classified according to urinary cadmium excretion as controls (< 1.5 micrograms/g creatinine), or subjects with moderate or high cadmium body burden (1.5 to 5 micrograms/g creatinine, > 5 micrograms/g creatinine). Twenty-six urinary analytes (such as serum derived proteins, tubular enzymes, eicosanoids) and four plasma markers, related to the function or integrity of specific nephron segments, were investigated in a cross-sectional study. The group with the moderate cadmium body burden showed alterations of proximal tubular integrity, that is, increased excretion of tubular brush-border antigens. The group with higher cadmium body burden revealed an involvement of the whole nephron. The most prominent quantitative changes were found for the glomerular markers high molecular weight proteins, and thromboxane B2 and for the proximal tubular markers retinol binding protein, alpha 1-microglobulin, N-acetyl-beta-D-glucosaminidase, and the intestinal alkaline phosphatase. A diagnostic approach to screen for nephrotoxicity due to environmental hazards like cadmium should include proximal tubular markers (alpha 1-microglobulin and tubular enzymes, that is, intestinal alkaline phosphatase) but the measurement of glomerular markers is also advisable.

Inhibition of cyclic GMP phosphodiesterases augments renal responses to atrial natriuretic factor in congestive heart failure

Atrial natriuretic factor (ANF), a cardiac peptide hormone with potent natriuretic and vasodilator actions, mediates its biologic responses via increases in intracellular cyclic guanosine monophosphate (cGMP). Recognizing that phosphodiesterases degrade cGMP and that congestive heart failure (CHF) is characterized by reduced renal responses to ANF, the authors hypothesized that cGMP phosphodiesterases limit the renal actions of exogenous and endogenous ANF in the presence of experimental CHF. In anesthetized dogs with severe CHF and avid sodium retention produced by rapid ventricular pacing, the authors explored the renal actions of M&B 22,948 (Rhône-Poulenc, Essex, UK), an inhibitor of cGMP-specific phosphodiesterases. High-dose intrarenal cGMP phosphodiesterase inhibition (PDI), with minimal effects upon systemic hemodynamics and hormones, significantly enhanced sodium excretion. This occurred primarily by decreasing distal nephron sodium reabsorption while enhancing renal cGMP generation. In separate groups of dogs, low-dose intrarenal cGMP PDI potentiated the actions of exogenous ANF on glomerular filtration and distal nephron sodium reabsorption, leading to enhanced natriuresis in the presence or absence of severe CHF. These studies support a link between ANF and the renal actions of cGMP PDI, and indicate that cGMP phosphodiesterases may contribute to sodium retention in advanced CHF by limiting the renal actions of increased endogenous ANF.

Renal function in hypertensive rats transgenic for mouse renin gene

The recent development of a transgenic rat strain carrying the mouse ren-2 renin gene [TGR(mRen2)27] has provided a new model of hypertension characterized by suppressed plasma renin levels and marked hyperproreninemia. In this long-term study, we examined the kidney function of these animals. Transgenic rats had significantly (P < 0.01) higher blood pressures than control animals at 2, 4, and 8 mo of age. However, the severity of their hypertension diminished over time (225 +/- 8 mmHg at age 2 mo vs. 169 +/- 5 mmHg at age 8 mo, P < 0.001), indicating age-dependent transgene regulation. Whole kidney and single-nephron blood flows and glomerular filtration rates did not differ between control and TGR(mRen2)27 animals studied with micropuncture techniques at 4 and 8 mo of age. Preglomerular vasoconstriction was responsible for this normal autoregulatory response. Elevated preglomerular vascular resistance of transgenic rats prevented transmission of systemic hypertension to glomeruli at 4 but not 8 mo of age leading to increased glomerular capillary pressures in these older animals (53 +/- 1 vs. 48 +/- 1 mmHg, P < 0.05). Pathological albuminuria appeared as early as 2 mo of age but did not increase over the subsequent 6 mo of follow-up. The incidence of glomerulosclerosis, assessed at 4 and 8 mo of age, was greater in TGR(mRen2)27 than control animals (6.6 +/- 1.4% vs. 0.9 +/- 0.3%, P = 0.01) but did not differ between 4- and 8-mo-old transgenic rats. Glomerular ultrafiltration coefficients were significantly elevated (P < 0.05) in transgenic rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Functional state of the nephron and diuretic dose-response--rationale for low-dose combination therapy

The functions of the different nephron segments follow changes in the effective arterial blood volume and the extracellular fluid volume. In syndromes with reduced effective arterial blood volume, for example congestive heart failure, decompensated hepatic cirrhosis and nephrotic syndrome, hyperreabsorption of sodium in the proximal tubule reduces the sodium load in the more distal segments of the nephron. As this is a major site of sodium excretion, reduction in the response to a diuretic may be predicted by a reduced fractional excretion of sodium (< 0.2%). Such diuretic resistance may be overcome with acetazolamide, which increases delivery of sodium to the distal tubule. In syndromes with increased extracellular fluid volume, such as chronic renal failure, distal tubular rejection of sodium leads to a progressive increase in its fractional excretion as the glomerular filtration rate is reduced. The remaining intact nephrons exhibit a relatively increased response to diuretics. The efficacy of loop diuretics in renal failure can be optimized by combination with thiazides. The latter prevent early distal tubular hyperreabsorption following diuretic-induced blockade of sodium transport in the loop of Henle. For these reasons, low-dose combinations of different diuretics induce 'segmental nephron blockade' and are, therefore, potentially more clinically effective and safer than high doses of single compounds.

Glomerular structure and function in proteinuric type 2 (non-insulin-dependent) diabetic patients

Glomerular ultrastructure was examined in a series of 20 Type 2 (non-insulin-dependent) diabetic patients with proteinuria. Reference was made to data previously obtained in non-diabetic kidney donors and in Type 1 (insulin-dependent) diabetic patients with similar degrees of proteinuria. The Type 2 diabetic patients demonstrated the changes which characterize the diabetic glomerulopathy seen in Type 1 diabetic patients: basement membrane thickening, and increase in the mesangium and mesangial matrix expressed as fraction of the glomerular volume. Among the Type 2 diabetic patients there was more variation than among the Type 1 diabetic patients, as this group included subjects with normal parameters. The group means and coefficients of variation (= SD/mean) of the glomerulopathy parameters combined in the glomerulopathy index = basement membrane thickness/10+ Vv(matrix/glom).100 were 81 (0.30) and 92 (0.15) in the two diabetic groups, clearly different from the non-diabetic index, 42 (0.16). All Type 2 diabetic patients who also had retinopathy had a glomerulopathy index above the normal range. Similar changes in glomerular composition were seen in the two diabetic groups: with increasing glomerulopathy the volume of matrix dominated over the peripheral basement membrane, and a shift in the ratio of interfaces was seen: mesangial surface towards capillary lumen increased relative to the urinary surface, and peripheral capillary surface comprised less of the total capillary surface. Data indicated marked glomerular hypertrophy, which correlated with the mesangial volume fraction, thus encompassing preserved filtration surface per glomerulus.(ABSTRACT TRUNCATED AT 250 WORDS)

Insulin-like growth factor-I receptor and binding proteins in rat kidney after nephron loss

Insulin-like growth factor (IGF)-binding proteins and the IGF-I receptor in rat kidney were studied to gain perspective on their potential roles in the control of renal cell mass. Thirty days after nephrectomy (UNx), membranous whole-kidney binding of IGF-I averaged 9.5 +/- 1.0 pmol/kidney, whereas binding to sham-operated controls (SNx) averaged 6.3 +/- 0.8 pmol/kidney (N = 6; P < 0.01). Scatchard analysis of IGF-I binding per milligram of protein to glomerular membranes or proximal tubule basolateral membranes (BLM) at Day 30 did not reveal significance differences in Bmax or KD between SNx and UNx; however, protein per glomerulus increased from 361 +/- 33 ng/glomerulus in SNx animals to 826 +/- 123 ng/glomerulus in UNx rats (N = 6; P < 0.002). Histomorphometrics documented an increase in proximal tubule circumference per cell and an increase in the basolateral/basement membrane ratio. IGF-I affinity labeling studies demonstrated three proteins in both glomerular membranes and proximal tubule BLM; molecular weight approximately 140,000 d, the alpha subunit of the IGF-I receptor, a protein > 200,000 d, and a protein approximately 31,000 d that was immunostained with IGF-binding protein-5 antibodies. Differences in expression between SNx and UNx were not observed at Day 30 in either glomeruli or BLM. These studies suggest that cytosolic hypertrophy of proximal nephron structures is accompanied by membrane hypertrophy with a fixed density of IGF-I receptor and IGF-binding protein-5.

Dietary protein restriction versus fish oil supplementation in the chronic remnant nephron model

Dietary protein restriction and fish oil supplementation (MaxEPA) have been reported to have favourable effects on the remnant nephron model. In the present study female Munich-Wistar rats underwent 5/6 renal ablation (60 rats) or sham surgery (20 rats). The renal ablation rats were randomized one week post-surgery to receive a diet that contained either regular laboratory diet (RLD), 6% low protein diet (LPD) or 24% fish oil diet (FOD) supplementation. Mortality rates at 10 and 20 weeks post-surgery were not different amongst the RLD, LPD or FOD renal ablation cohorts. However the G.F.R. was significantly preserved in the FOD and LPD versus the RLD renal ablation rat groups. Both the LPD and FOD decreased albuminuria and gammaglobulinuria but LPD was more effective. Both dietary interventions prevented glomerulosclerosis but only LPD significantly reduced mesangial expansion. The FOD diet prevented intraglomerular fibrin formation and the LPD had no effect. The dyslipidemia noted at 20 weeks in the renal ablation group was significantly abrogated by both FOD and LPD, although only LPD prevented the heavy proteinuria. The LPD rats gained significantly less weight than the FOD and RLD cohorts. FOD exerted a significantly greater effect on blood pressure reduction than the LPD and also produced significant changes in the renal tissue phospholipids. These results indicate that protein restriction and fish oil supplementation preserve renal structure and function in the remnant nephron model but have different effects on mechanisms known to be co-factors in the progressive renal injury.

Autosomal dominant polycystic kidney disease (ADPKD)--mechanisms of cyst formation and renal failure

None of the hypotheses proposed so far to explain cyst formation in autosomal dominant polycystic kidney disease (ADPKD) is entirely satisfactory, e.g. the theory of tubular obstruction by intraluminal polyps or dilatation of nephron segments as a consequence of abnormal compliance of the basement membrane. Recent in vitro studies show that (i) synthesis of basement membrane material is abnormal and that (ii) the direction of transepithelial resorptive flux into a secretory mode is reversed as a consequence of faulty insertion of Na, K-ATP'ase into the luminal membrane. It remains unclear why cystic transformation of a few percent of nephrons should cause endstage renal failure. Our clinical and experimental studies do not provide evidence to support some hypotheses proposed in the past, i.e. that renal parenchyma is compressed by expanding cysts and that glomeruli are overperfused. Our histological studies show that progression to endstage renal failure is associated with (i) progressive arteriolar lesions (out of proportion to the vascular lesions seen in extrarenal vascular beds; and (ii) progressive interstitial fibrosis. It appears that fibroblasts in ADPKD are particularly sensitive to platelet derived growth factor (PDGF) which is secreted by epithelial cells of the cyst wall in a paracrine fashion. In contrast to previous opinion, which was presumably skewed by ascertainment bias, it appears that not all, and perhaps not even a majority, of ADPKD patients progress to endstage renal failure. Factors related to progression are gender, family history and hypertension. Both abnormal sodium excretion and inappropriate renin secretion play a role in the genesis of hypertension. Elevated blood pressure, albeit within the normotensive range, is demonstrable even in prepubertal children. The involvement of renin in renal vasoconstriction of normotensive ADPKD patients suggests a particular role of ACE inhibitors in the management of these patients.

Assessment of atrial natriuretic peptide resistance in cirrhosis with head-out water immersion and atrial natriuretic peptide infusion

The nature of sodium retention in cirrhosis complicated by ascites has been studied for the last 30 years. Resistance to the natriuretic action of atrial natriuretic peptide (ANP) may play a potential role in this sodium retention. To further evaluate this possibility, we studied 12 patients with biopsy-proven cirrhosis and ascites on 2 consecutive days after a 7-day period off diuretics while receiving a 20 mmol/day sodium restricted diet. Following a crossover design, patients underwent head-out water immersion (HWI) for 3 h and were infused with a alpha-human ANP for 2 h on 2 consecutive days. Blood and urine samples were collected hourly. Five patients displayed a natriuretic response to HWI, sufficient to achieve negative sodium balance, and these patients were termed responders. Each of these five patients also displayed a natriuretic response to ANP infusion. In contrast, the other seven patients (nonresponders) consistently failed to develop a natriuretic response to either maneuver. The two groups had similar elevations in plasma ANP concentrations, but at baseline differed in terms of plasma sodium, plasma renin activity, and serum aldosterone. Despite higher serum aldosterone concentrations, nonresponders excreted less potassium than responders during the peak effect of the interventions, suggesting greater sodium delivery to the aldosterone-sensitive nephron segment in responders. We conclude that the inability to mount an adequate sodium excretory response to HWI in patients with cirrhosis may be conveyed through increased antinatriuretic factors that decrease the sodium delivery to the medullary collecting duct and inhibit the natriuretic effect of ANP at that site.

Diuretics in the therapy of hypertension: current status

Diuretics were the first effective oral agents for treating hypertension. They have proven to be safe and effective. Recently, they have been scrutinized as possibly being responsible for certain side effects that may increase risk for cardiovascular morbidity and mortality. A careful review of the literature suggests this class of agents warrants continued use as first-line therapy of hypertension, especially in certain demographic groups. However, monitoring of potential baleful effects and a general reduction in dosage are appropriate. Furthermore, selection of other (alternative) agents for monotherapy is advised in certain clinical circumstances.

Sorbinil does not prevent hyperfiltration, elevated ultrafiltration pressure and albuminuria in streptozotocin-diabetic rats

The effects of aldose reductase inhibition on kidney function were studied in rats with streptozotocin-induced diabetes mellitus. Diabetic rats were fed sorbinil (20 and 50 mg/kg) by daily gastric gavage and were compared with untreated diabetic rats and normal rats. The rats were under daily supervision with regard to blood glucose control, insulin administration and body weight. The aim was to promote continuous body growth and to maintain the blood glucose concentration at around 22 mmol/l without large day-to-day fluctuations. The renal functional changes observed in this well-established diabetic model closely resembled those reported in human Type 1 (insulin-dependent) diabetes mellitus. Sorbinil treatment completely prevented renal cortical sorbital accumulation, but did not abolish kidney enlargement or the increase in ultrafiltration pressure and glomerular filtration rate. Albumin excretion was increased to the same extent in the sorbinil-treated and in the untreated diabetic rats. We conclude that increased metabolism of glucose to sorbitol does not cause the hyperfiltration in rats with streptozotocin-induced diabetes.