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Alessandria C, Ozdogan O, Guevara M, Restuccia T, Jiménez W, Arroyo V, Rodés J, Ginès P. MELD score and clinical type predict prognosis in hepatorenal syndrome: relevance to liver transplantation. Hepatology 2005; 41:1282-9. [PMID: 15834937 DOI: 10.1002/hep.20687] [Citation(s) in RCA: 225] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Important progress has been made recently regarding the pathogenesis and treatment of hepatorenal syndrome (HRS). However, scant information exists about factors predicting outcome in patients with cirrhosis and HRS. Moreover, the prognostic value of the model of end-stage liver disease (MELD) score has not been validated in the setting of HRS. The current study was designed to assess the prognostic factors and outcome of patients with cirrhosis and HRS. The study included 105 consecutive patients with HRS. Forty-one patients had type 1 HRS, while 64 patients had type 2 HRS. Patients with type 1 HRS not only had more severe liver and renal failure than type 2 patients, they also had greater impairment of circulatory function, as indicated by lower arterial pressure and higher activation of vasoconstrictor factors. In the whole series, the median survival was 3.3 months. In a multivariate analysis of survival, only HRS type and MELD score were associated with an independent prognostic value. All patients with type 1 HRS had a high MELD score (> or =20) and showed an extremely poor outcome (median survival: 1 mo). By contrast, the survival of patients with type 2 HRS was longer and dependent on MELD score (> or =20, median survival 3 mo; <20, median survival 11 mo; P < .002). In conclusion, the outcome of patients with cirrhosis and HRS can be estimated by using two easily available variables, HRS type and MELD score. These data can be useful in the management of patients with HRS, particularly for patients who are candidates for liver transplantation.
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Affiliation(s)
- Carlo Alessandria
- Liver Unit, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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102
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Alvelos M, Ferreira A, Bettencourt P, Pimenta J, Azevedo A, Serrão P, Rocha-Gonçalves F, Soares-da-Silva P. Effect of Saline Load and Metoclopramide on the Renal Dopaminergic System in Patients with Heart Failure and Healthy Controls. J Cardiovasc Pharmacol 2005; 45:197-203. [PMID: 15725943 DOI: 10.1097/01.fjc.0000152032.46373.e7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Dopamine of renal origin has natriuretic/diuretic actions by activating D1-like receptors of the nephron. Saline load increases renal dopamine production and natriuresis in healthy subjects, and, under these conditions, the activation of D2-like receptors also produces natriuresis/diuresis. Metoclopramide is a D2-like receptor antagonist. Patients with heart failure (HF) have an increased renal dopamine-synthesizing efficiency. However, the effect of salt loading was not explored in HF. We hypothesized that HF patients respond to salt loading with increased production of renal dopamine and that metoclopramide antagonizes this response. This was a randomized, controlled, crossover study exploring the effect of NaCl and metoclopramide on renal dopaminergic, sympathetic, renin-angiotensin-aldosterone, and arginine-vasopressin (AVP) systems activity on sodium handling in 9 HF patients and 9 controls. NaCl markedly increased renal dopamine production and natriuresis in both groups. Metoclopramide blunted these responses in HF patients but not in controls. NaCl decreased renin and aldosterone plasma levels in controls but not in HF patients. In these patients B-type natriuretic peptide (BNP) levels increased, but AVP was not affected. HF patients respond to salt loading with increased natriuresis. However, the mechanisms for this response are different from those found in healthy subjects. Metoclopramide has antinatriuretic effects only in HF patients.
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Affiliation(s)
- Margarida Alvelos
- Unit of Cardiovascular Research and Development, University of Porto Medical School, Porto, Portugal.
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103
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Funayama H, Nakamura T, Saito T, Yoshimura A, Saito M, Kawakami M, Ishikawa SE. Urinary excretion of aquaporin-2 water channel exaggerated dependent upon vasopressin in congestive heart failure. Kidney Int 2005; 66:1387-92. [PMID: 15458431 DOI: 10.1111/j.1523-1755.2004.00902.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Impaired water excretion occurs in patients with congestive heart failure. The present study was undertaken to determine whether urinary excretion of aquaporin-2 (AQP-2) water channel is exaggerated in patients with congestive heart failure dependent upon arginine vasopressin (AVP). METHODS Sixty-five patients with congestive heart failure and eight age- and gender-matched control subjects were examined. The patients were divided into four groups according to the criteria of New York Heart Association (NYHA). Plasma AVP levels, urinary excretion of AQP-2, and cardiac index were determined. RESULTS Plasma AVP levels were progressively increased following the severity of NYHA class in the patients with congestive heart failure. Cardiac index was inversely decreased, and there was a negative correlation between plasma AVP levels and cardiac index (r=-0.430, P < 0.02). Urinary excretion of AQP-2 was 187.3 +/- 50.2 fmol/mg creatinine in the control subjects. It was markedly increased in the patients. Urinary excretion of AQP-2 was elevated to 1144.4 +/- 257.5 and 990.5 +/- 176.0 fmol/mg creatinine in the patients with NYHA class III and class IV, respectively, values significantly greater than the control subjects (P < 0.05). Urinary excretion of AQP-2 had a positive correlation with plasma AVP levels (r= 0.280, P < 0.02). CONCLUSION The present study indicates that exaggerated urinary excretion of AQP-2 is dependent on baroreceptor-mediated release of AVP in patients with congestive heart failure.
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Affiliation(s)
- Hiroshi Funayama
- Department of Medicine, Jichi Medical School, Omiya Medical Center, Saitama, Japan
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104
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Kamath SA, Laskar SR, Yancy CW. Novel Therapies for Heart Failure: Vasopressin and Selective Aldosterone Antagonists. ACTA ACUST UNITED AC 2005; 11:21-9. [PMID: 15722667 DOI: 10.1111/j.1527-5299.2005.03912.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Despite favorable improvements in mortality, heart failure (HF) remains a problematic illness due to the ever-present burden of hospitalization. Clearly, novel treatment strategies are needed. This review focuses on two newer pharmacologic targets: arginine vasopressin and aldosterone. Arginine vasopressin receptor antagonists will most likely serve as an adjunct to or replacement of standard diuretic therapy in selected patients. The safety and efficacy of chronic therapy with oral arginine vasopressin receptor antagonists in large groups of congestive HF patients is currently under investigation. Aldosterone antagonism is emerging as a treatment of severe congestive HF. Recent large-scale clinical trials using aldosterone antagonists have proven that those with HF or left ventricular dysfunction postmyocardial infarction derive a survival benefit from aldosterone antagonism. Whether aldosterone antagonism should be prescribed in all patients with HF is unclear; however, in carefully selected and managed patients, aldosterone antagonism is helpful.
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Affiliation(s)
- Sandeep A Kamath
- Department of Internal Medicine/Cardiology, University of Texas Southwestern Medical Center, Dallas, TX 75390-9047, USA
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105
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Alvelos M, Ferreira A, Bettencourt P, Serrão P, Pestana M, Cerqueira-Gomes M, Soares-Da-Silva P. The effect of dietary sodium restriction on neurohumoral activity and renal dopaminergic response in patients with heart failure. Eur J Heart Fail 2004; 6:593-9. [PMID: 15302007 DOI: 10.1016/j.ejheart.2003.11.020] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2003] [Revised: 11/11/2003] [Accepted: 11/19/2003] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND This work evaluates the effect of a low-sodium diet on clinical and neurohumoral parameters and on renal dopaminergic system activity in heart failure (HF) patients. METHODS We included 24 patients with mild-to-moderate stable HF with left ventricle ejection fraction <40%. Twelve patients were studied before and after a 15-day low-sodium diet; 12 maintained their usual diet. Serum sodium and creatinine, plasma l-DOPA, dopamine, its metabolites, BNP and aldosterone, and 24-h urinary sodium, creatinine, l-DOPA, dopamine and metabolites were measured. RESULTS The two groups were matched respecting to demographic and clinical parameters. Low-sodium diet caused significant reductions in weight, 24-h urinary volume and sodium and sodium fractional excretion. Renal delivery of l-DOPA and urinary excretion of l-DOPA significantly decreased while dopamine and metabolites were not affected. Urinary dopamine/l-DOPA and urinary dopamine/renal delivery of l-DOPA ratios increased, plasma l-DOPA decreased and plasma dopamine increased. Plasma aldosterone slightly rose, BNP decreased and noradrenaline and adrenaline increased. NYHA functional class was not affected by sodium restriction. Controls showed no differences. CONCLUSIONS These results suggest that sodium restriction leads to activation of antinatriuretic antidiuretic systems in HF patients. However, renal ability to synthesize dopamine is increased in this condition, probably as a counter-regulatory mechanism.
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Affiliation(s)
- Margarida Alvelos
- Unit of Cardiovascular Research and Development, Piso 9, Porto, Portugal.
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106
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Schrier RW, Chen YC, Cadnapaphornchai MA. From finch to fish to man: Role of aquaporins in body fluid and brain water regulation. Neuroscience 2004; 129:897-904. [PMID: 15561406 DOI: 10.1016/j.neuroscience.2004.06.043] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2004] [Indexed: 11/28/2022]
Abstract
Charles Darwin, in his Origin of the Species, noted that different species of finches on the Galapagos Islands had adapted their beak size based on where they sought their food. Homer Smith, in his book From Fish to Philosopher, discussed the evolution of the nephron from a single conduit in salt water vertebrates, to nephrons with large glomerular capillaries and proximal and distal tubules in fresh water vertebrates, to smaller glomerular capillaries in amphibians, to nephrons with loops of Henle to allow for urinary concentration and dilution in mammals. The kidney with its million nephrons has emerged as the vital organ for regulating body fluid composition and volume. With the recent discovery of aquaporin water channels, our understanding of volume regulation has been greatly enhanced. This article reviews current knowledge regarding: 1) the unifying hypothesis of body fluid volume regulation; 2) brain aquaporins and their role in pathophysiologic states; and 3) function and regulation of renal aquaporins in the syndrome of inappropriate antidiuretic hormone secretion (SIADH).
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Affiliation(s)
- R W Schrier
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Health Sciences Center, 4200 East 9th Avenue, Box B173, Denver, CO 80262, USA.
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107
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Abstract
Disorders of body fluids are among the most commonly encountered problems in the practice of clinical medicine. This is in large part because many different disease states can potentially disrupt the finely balanced mechanisms that control the intake and output of water and solute. It therefore behoves clinicians treating such patients to have a good understanding of the pathophysiology, the differential diagnosis and the management of these disorders. Because body water is the primary determinant of the osmolality of the extracellular fluid, disorders of body water homeostasis can be divided into hypo-osmolar disorders, in which there is an excess of body water relative to body solute, and hyperosmolar disorders, in which there is a deficiency of body water relative to body solute. The classical hyperosmolar disorder is diabetes insipidus (DI), and the classical hypo-osmolar disorder is the syndrome of inappropriate antidiuretic hormone secretion (SIADH). This chapter first reviews the regulatory mechanisms underlying water and sodium metabolism, the two major determinants of body fluid homeostasis. The major disorders of water metabolism causing hyperosmolality and hypo-osmolality, DI and SIADH, are then discussed in detail, including the pathogenesis, differential diagnosis and treatment of these disorders.
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Affiliation(s)
- Joseph G Verbalis
- Department of Medicine and Physiology, Division of Endocrinology and Metabolism, Georgetown University School of Medicine, 232 Building D, 4000 Reservoir Road NW, Washington, DC 20007, USA
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108
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Schnackenberg CG, Merz E, Brooks DP. An orally active adenosine A1 receptor antagonist, FK838, increases renal excretion and maintains glomerular filtration rate in furosemide-resistant rats. Br J Pharmacol 2003; 139:1383-8. [PMID: 12922924 PMCID: PMC1573969 DOI: 10.1038/sj.bjp.0705370] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
1. Loop and thiazide diuretics are common therapeutic agents for the treatment of sodium retention and oedema. However, resistance to diuretics and decreases in renal function can develop during diuretic therapy. Adenosine causes renal vasoconstriction, sodium reabsorption, and participates in the tubuloglomerular feedback mechanism for the regulation of glomerular filtration rate. 2. We tested the hypothesis that the selective adenosine A(1) receptor antagonist FK838 is orally active and causes diuresis and natriuresis, but maintains glomerular filtration rate in normal rats or in rats with furosemide resistance. 3. In normal male Sprague - Dawley rats, FK838 dose-dependently increased urine flow and sodium and chloride excretion while sparing potassium. In combination with furosemide, FK838 enhanced the diuretic and natriuretic actions of furosemide to the same extent as hydrochlorothiazide and did not increase the potassium loss in normal rats. In furosemide-resistant rats, FK838 increased urine flow and electrolyte excretion to a greater extent than hydrochlorothiazide. In addition, hydrochlorothiazide significantly decreased glomerular filtration rate, whereas FK838 maintained glomerular filtration rate in furosemide-resistant rats. 4. This study shows that the adenosine A(1) receptor antagonist FK838 is orally active and causes potent diuresis and natriuresis and maintains glomerular filtration rate in normal or furosemide-resistant rats. Adenosine A(1) receptor antagonists may be novel therapeutics for the treatment of oedema in normal or otherwise diuretic-resistant patients.
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Affiliation(s)
- Christine G Schnackenberg
- Department of Renal Biology, UW 2521, GlaxoSmithKline Pharmaceuticals, Box 1539, 709 Swedeland Road, King of Prussia, PA 19406, U.S.A.
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109
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Castellani S, Paniccia R, Di Serio C, La Cava G, Poggesi L, Fumagalli S, Gensini GF, Neri Serneri GG. Thromboxane inhibition improves renal perfusion and excretory function in severe congestive heart failure. J Am Coll Cardiol 2003; 42:133-9. [PMID: 12849673 DOI: 10.1016/s0735-1097(03)00511-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The aim of this study was to evaluate whether thromboxane inhibition can favorably affect renal perfusion and clinical conditions in patients affected by severe heart failure. BACKGROUND The renal formation of the vasoconstrictor thromboxane A(2) (TxA(2)) is increased during cardiac failure. METHODS By oral administration of picotamide (a renal TxA(2) synthase and TxA(2)/prostaglandin H(2) receptor inhibitor), we blocked renal TxA(2). Fourteen patients in New York Heart Association functional class IV were studied according to a randomized, double-blinded, cross-over design. Each of the two eight-day periods of testing was preceded by a three-day period during which certain vasoactive medications were stopped. RESULTS Daily 24-h total urinary thromboxane B(2) (TxB(2)), the stable metabolite of TxA(2), dropped at the end of picotamide treatment (p < 0.01 vs. baseline). Compared with placebo, effective renal plasma flow and the glomerular filtration rate increased (p < 0.01 and p < 0.05, respectively), thus leading to a significant decrease in the filtration fraction (p < 0.01). Renal vascular resistance decreased consistently (p < 0.01). In all patients, picotamide treatment was associated with an increase in diuresis and natriuresis (p < 0.001 vs. baseline). Plasma creatinine decreased (p < 0.05 vs. baseline). Patients also showed improvement in several clinical parameters, including a significant decrease in both pulmonary and venous pressure (p < 0.01 vs. baseline). CONCLUSIONS These results indicate that renal thromboxane formation plays an important role in renal vascular resistance in patients with severe heart failure, such as those described in the present study. Inhibition of TxA(2) improves renal hemodynamics and kidney function and favorably affects indexes of cardiac performance.
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Affiliation(s)
- Sergio Castellani
- Sezione Clinica Medica Generale e Cardiologia, Universita degli Studi di Firenze, Viale Morgagni 85, 50134 Florence, Italy.
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110
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Abstract
Ascites accumulation is the product of a complex process involving hepatic, renal, systemic, hemodynamic, and neurohormonal factors. The main pathophysiologic theories of ascites formation include the "underfill," "overflow," and peripheral arterial vasodilation hypotheses. These theories are not necessarily mutually exclusive and are linked at some level by a common pathophysiologic thread: The body senses a decreased effective arterial blood volume, leading to stimulation of the sympathetic nervous system, arginine-vasopressin feedback loops, and the renin-angiotensin-aldosterone system. Cornerstones of ascites management include dietary sodium restriction and diuretics. Spironolactone is generally tried initially, with furosemide added if clinical response is suboptimal. More refractory patients require large-volume paracentesis (LVP) accompanied by volume expansion with albumin. Placement of a transjugular intrahepatic portosystemic shunt is reserved for individuals with compensated liver function who require very frequent sessions of LVP. Peritoneovenous shunts are not used in contemporary ascites management. Liver transplantation remains the definitive therapy for refractory ascites. Although treatment of ascites fails to improve survival, it benefits quality of life and limits the development of such complications as spontaneous bacterial peritonitis.
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Affiliation(s)
- Mahmoud Sabri
- Division of Pediatric Gastroenterology, Children's Hospital of Pittsburgh, 3705 Fifth Avenue, Pittsburgh, PA 15213, USA.
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111
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Gurevich AK, Falk SA, Nemenoff RA, Weinberger HD, Summer SN, Rizeq M, Gengaro PE, Bedigian MP, Schrier RW. Effects of angiotensin receptor blockade on haemodynamics and gene expression after myocardial infarction. Drugs R D 2003; 3:239-49. [PMID: 12455200 DOI: 10.2165/00126839-200203040-00004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
INTRODUCTION Despite the fact that congestive heart failure (CHF) remains the most common disease in the developed world and has been extensively studied, there is little known about the molecular and cellular mechanisms of cardiac dysfunction. Angiotensin has been implicated as a mediator of cardiac injury; however, the mechanisms of its action have not been delineated. The objective of this study was to examine the relationship between the haemodynamic and molecular events during cardiac dysfunction and the role of the angiotensin system. STUDY DESIGN We examined the effects of the angiotensin receptor blocker, valsartan, on changes in the haemodynamic and gene expression patterns in a postmyocardial infarction model in the rat. METHODS Myocardial infarction (MI) was induced in rats by coronary artery ligation. Cardiac haemodynamics were monitored using echocardiography. Gene expression profiles after myocardial infarction were identified using Affymetrix Genechip oligonucleotide arrays. RESULTS Myocardial contractility, as assessed by cardiac output and left ventricle (LV) fraction of shortening, was reduced in untreated animals by week 3 after MI (p < 0.05 versus baseline), and preserved with valsartan treatment as observed by the nonsignificant changes versus baseline. LV dilatation, as demonstrated by increases in LV systolic and diastolic diameters, developed by week 3 in untreated animals (p < 0.05 versus baseline) while valsartan-treated animals were protected and showed no significant increases in diameter size compared with baseline. LV hypertrophy, as shown by LV posterior wall thickness, was more profound in untreated animals (p < 0.05 versus baseline) than in those treated with valsartan at weeks 3 and 4. Changes in gene expression at 4 weeks after MI included those encoding muscle-specific genes, fibrous tissue proliferation, immune response and various others. Treatment with valsartan reversed these changes in 67% of overexpressed genes and 83% of underexpressed genes. CONCLUSION Angiotensin receptor blockade with valsartan was found to protect cardiac function, and this beneficial effect was accompanied by a reversal of changes in gene expression induced by MI.
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Affiliation(s)
- Andrey K Gurevich
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Colorado Health Sciences Center, Denver, Colorado, USA
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112
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Laskar SR, Dries DL. The prognostic significance of renal dysfunction in patients with chronic systolic heart failure. Curr Cardiol Rep 2003; 5:205-10. [PMID: 12691637 DOI: 10.1007/s11886-003-0050-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Renal insufficiency is an independent powerful predictor of morbidity and mortality in a number of cardiovascular disorders. A number of retrospective analyses of large heart failure trials have shown that even mild renal insufficiency has powerful negative predictive power in patients with both mild and severe heart failure. We discuss the available data on the prognostic value of mild renal insufficiency in heart failure, as well as possible mechanisms of this phenomenon. Future research should focus on its possible pathophysiology.
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Affiliation(s)
- S Raja Laskar
- The University of Texas Southwestern Medical Center, Heart Failure Research Unit, Division of Cardiology, 6000 Harry Hines Boulevard, NB11.200, Dallas, TX 75235-8573, USA
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113
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Ishikawa SE, Schrier RW. Pathophysiological roles of arginine vasopressin and aquaporin-2 in impaired water excretion. Clin Endocrinol (Oxf) 2003; 58:1-17. [PMID: 12519405 DOI: 10.1046/j.1365-2265.2003.01647.x] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- San-E Ishikawa
- Department of Medicine, Jichi Medical School Omiya Medical Center, Saitama, Japan.
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114
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Wong F, Blei AT, Blendis LM, Thuluvath PJ. A vasopressin receptor antagonist (VPA-985) improves serum sodium concentration in patients with hyponatremia: a multicenter, randomized, placebo-controlled trial. Hepatology 2003; 37:182-91. [PMID: 12500203 DOI: 10.1053/jhep.2003.50021] [Citation(s) in RCA: 227] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Hyponatremia in advanced cirrhosis and ascites or congestive heart failure (CHF) is the result of an inappropriate increase in vasopressin secretion, which acts through activation of specific V(2) receptors in the distal renal nephron to increase water reabsorption. This study investigates the efficacy and safety of 3 different doses of the V(2) receptor antagonist, VPA-985, in correcting hyponatremia over a 7-day inpatient study period. Forty-four hospitalized patients (33 patients with cirrhosis, 6 with CHF, and 5 with syndrome of inappropriate antidiuretic hormone (SIADH) were studied on a constant sodium intake, with VPA doses of 25, 125, and 250 mg twice daily or placebo. Serum sodium measurements were repeated after every daily dose, and the next dose withheld for excessive serum sodium rises. Fluid intake was adjusted according to previous 24-hour urinary outputs. Adverse events were based on clinical signs of dehydration or encephalopathy. VPA-985 produced a significant overall aquaretic response compared with placebo, with significant dose related increases in free water clearance (P <.05) and serum sodium (P <.05), without significant changes in orthostatic blood pressure or serum creatinine levels. Five patients (50%) on 250 mg twice daily had to have medication withheld on multiple occasions. End-of-study plasma vasopressin levels increased significantly in the 2 larger dose groups. In conclusion, VPA-985 appears effective and safe in appropriate doses in correcting abnormal renal water handling and hyponatremia in conditions associated with water retention. Higher doses of VPA-985 may produce significant dehydration and will require close monitoring with their use.
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Affiliation(s)
- Florence Wong
- Department of Medicine, Toronto General Hospital, University of Toronto, Canada.
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115
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Abstract
Vasodilatory edema, a common adverse effect of antihypertensive therapy with vasodilators, is related to several mechanisms, including arteriolar dilatation (causing an increase in intracapillary pressure), stimulation of the renin-angiotensin-aldosterone system, and fluid volume retention. Vasodilatory edema is dose-dependent and most common with direct arteriolar dilators such as minoxidil or hydralazine, and in decreasing order of frequency with the dihydropyridine calcium antagonists, a-blockers, antiadrenergic drugs, and nondihydropyridine calcium antagonists. Not all dihydropyridine calcium antagonists are created equal with regard to vasodilatory edema. At an equal antihypertensive efficacy, lercanidipine and lacidipine are associated with less vasodilatory edema than amlodipine and nifedipine. The addition of an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin receptor blocker (ARB) to a dihydropyridine calcium antagonist significantly reduces vasodilatory edema. In contrast, the addition of a diuretic has little effect on vasodilatory edema. Thus, low-dose combination therapy (of a dihydropyridine calcium antagonist with either an ACE inhibitor or an ARB) may be preferred over high-dose monotherapy.
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Affiliation(s)
- Franz H Messerli
- Department of Internal Medicine, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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116
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Marenzi G, Lauri G, Assanelli E, Grazi M, Campodonico J, Famoso G, Agostoni P. Serum to urinary sodium concentration ratio is an estimate of plasma renin activity in congestive heart failure. Eur J Heart Fail 2002; 4:597-603. [PMID: 12413503 DOI: 10.1016/s1388-9842(02)00097-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We investigated the relationship between plasma renin activity (PRA) and serum ([sNa(+)]) and urinary ([uNa(+)]) sodium concentrations in 124 congestive heart failure (CHF) patients (II-IV NYHA class) and 20 healthy subjects. According to PRA (> or <3 ng ml(-1) h(-1)) and [sNa(+)] (> or <135 mEq l(-1)), patients were classified as Group A (normal PRA and normal [sNa(+)], n=39), Group B (increased PRA and normal [sNa(+)], n=62) and Group C (low [sNa(+)], n=23). Measurements were performed at rest and, in 26 cases, after extracorporeal ultrafiltration (UF). At rest, [sNa(+)] and [uNa(+)], and their difference ([sNa(+)]-[uNa(+)]), were linearly correlated with PRA, but the values did not allow differentiation of control subjects from patients or differentiation of patients with from those without renin-angiotensin system (RAS) activation. Conversely, the [sNa(+)]/[uNa(+)] ratio showed the best correlation with PRA (r=0.79, P<0.0001). UF-induced PRA changes were linearly correlated with [sNa(+)]/[uNa(+)] ratio changes (r=0.67, P=0.002), but not with those of [sNa(+)], [uNa(+)] and [sNa(+)]-[uNa(+)]. In CHF, the [sNa(+)]/[uNa(+)] ratio best correlates with PRA and reflects the basal activity as well as the rapid changes (as those induced by UF) of the RAS. Therefore, it can be considered a strong and easily available marker of PRA.
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Affiliation(s)
- GianCarlo Marenzi
- Centro Cardiologico Monzino, IRCCS, Institute of Cardiology, University of Milan, via Parea 4, 20138 Milan, Italy.
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117
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Linke A, Li W, Huang H, Wang Z, Hintze TH. Role of cardiac eNOS expression during pregnancy in the coupling of myocardial oxygen consumption to cardiac work. Am J Physiol Heart Circ Physiol 2002; 283:H1208-14. [PMID: 12181152 DOI: 10.1152/ajpheart.00108.2002] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
We assessed whether pregnancy results in enhanced nitric oxide (NO)-mediated control of myocardial oxygen consumption. Rats were studied before (C), at 1 wk (1w) or 2 wk (2w) of pregnancy, and at 4 days after giving birth (-4d). Left ventricular endothelial NO synthase (eNOS) protein expression was determined by immunoblotting. Oxygen consumption of left ventricular tissue samples was measured in vitro in response to increasing doses of bradykinin with or without addition of the NOS inhibitor N(G)-nitro-L-arginine methyl ester (L-NAME). Echocardiography indicated an increased cardiac output during pregnancy. Myocardial eNOS protein expression significantly increased by 46 +/- 9 and 39 +/- 8% at 1w and 2w, respectively, and returned to control levels at -4d. Bradykinin (10(-4) M) decreased cardiac oxygen consumption in a NO-dependent manner by 17 +/- 2% at C, by 21 +/- 2% at 1w, by 24 +/- 2% at 2w (P < 0.05 vs. C and -4d), and by 18 +/- 1% at -4d. Myocardial eNOS protein expression is transiently increased during pregnancy in rats, and this increase is associated with enhanced NO-dependent control of myocardial oxygen consumption at a time when cardiac output is increased.
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Affiliation(s)
- Axel Linke
- New York Medical College, Department of Physiology, Valhalla, New York 10595, USA
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118
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Kalra PR, Anagnostopoulos C, Bolger AP, Coats AJS, Anker SD. The regulation and measurement of plasma volume in heart failure. J Am Coll Cardiol 2002; 39:1901-8. [PMID: 12084586 DOI: 10.1016/s0735-1097(02)01903-4] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Plasma volume, the intravascular portion of the extracellular fluid volume, can be measured using standard dilution techniques with radiolabeled tracer molecules. In healthy persons, plasma volume remains relatively constant as a result of tight regulation by the complex interaction between neurohormonal systems involved in sodium and water homeostasis. Although chronic heart failure (CHF) is characterized by activation of many of these neurohormonal systems, few studies have evaluated plasma volume in this condition under treatment. Untreated edematous decompensated heart failure (HF) is associated with a significant expansion of plasma volume. Patients with stable CHF, receiving conventional therapy, appear to have a contracted plasma volume, a concept that is in contrast to the widely held belief that CHF is associated with long-term hypervolemia. It is likely that significant changes in plasma volume occur during intensification of medical therapy or during transition from the edematous to the stable state. Clinical assessment of plasma volume may be of particular value during treatment in patients with decompensated HF, in whom the plasma volume is contracted despite an increase in total extracellular fluid volume. Under these circumstances, treatment with inotropes or renal vasodilators may be more appropriate than intravenous diuretics alone. Further studies evaluating plasma volume in HF may help to improve our understanding of the pathophysiologic mechanisms occurring in the development and progression of this complex condition.
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Affiliation(s)
- Paul R Kalra
- Clinical Cardiology, National Heart and Lung Institute, London, United Kingdom.
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119
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Carducci MA, Nelson JB, Bowling MK, Rogers T, Eisenberger MA, Sinibaldi V, Donehower R, Leahy TL, Carr RA, Isaacson JD, Janus TJ, Andre A, Hosmane BS, Padley RJ. Atrasentan, an endothelin-receptor antagonist for refractory adenocarcinomas: safety and pharmacokinetics. J Clin Oncol 2002; 20:2171-80. [PMID: 11956279 DOI: 10.1200/jco.2002.08.028] [Citation(s) in RCA: 126] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Endothelin receptors, particularly the ET(A) receptor, have been shown to participate in the pathophysiology of prostate and other cancers. Atrasentan, an endothelin antagonist, binds selectively to the ET(A) receptor. This study evaluated the safety, pharmacokinetics, and maximum-tolerated dose of atrasentan in cancer patients. PATIENTS AND METHODS Patients who were 18 years or older and had histologically confirmed adenocarcinoma refractory to therapy enrolled in this 28-day, open-label, phase I study. Enrollment was planned for cohorts of three patients at doses escalating from 10 to 140 mg/d. When any patient had dose-limiting toxicity, that cohort was expanded. The primary outcome variable was safety; secondary outcome variables were pharmacokinetics, tumor response, and pain relief. RESULTS Thirty-one cancer patients (14 prostate) were treated at daily atrasentan doses of 10, 20, 30, 45, 60, and 75 mg (n = 3 to 8 per cohort). The most common adverse events, such as rhinitis, headache, asthenia, and peripheral edema, were reversible on drug discontinuation and responded to symptom-specific treatment. Reversible hemodilution was apparent in laboratory findings and weight gain. Clinically significant headache was the dose-limiting adverse event; the maximum-tolerated dose was 60 mg/d. Pharmacokinetics were dose-proportional across the 10- to 75-mg dose range. Atrasentan was rapidly absorbed; the time to maximum observed concentration was approximately 1.5 hours. The terminal elimination half-life was approximately 24 hours, and steady-state plasma concentrations were achieved within 7 days. Decreases in prostate-specific antigen and pain relief were noted in a patient subset. CONCLUSION Adverse events were consistent with atrasentan's pharmacologic vasodilatory effect. Linear, dose-proportional pharmacokinetics suggest that atrasentan can be easily and consistently dosed.
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Affiliation(s)
- Michael A Carducci
- Division of Medical Oncology, The Johns Hopkins Oncology Center, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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120
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Wong LL, Verbalis JG. Systemic diseases associated with disorders of water homeostasis. Endocrinol Metab Clin North Am 2002; 31:121-40. [PMID: 12055984 DOI: 10.1016/s0889-8529(01)00007-x] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Disorders of AVP secretion and action sometimes present as the first manifestation of a variety of different systemic diseases. It is prudent for the clinician to consider these causes in the differential diagnosis of hypoosmolar hyponatremia, polyuria and polydipsia, since recognizing the underlying disorder may affect treatment decisions, and intervention directed at the primary disorder often can reverse the abnormal water metabolism in these patients. Although much of the pathophysiology of these disorders is not understood completely, great progress has been made toward appreciating the complex and precise system involving thirst, AVP secretion, and renal responsiveness to AVP. Further investigation in this field likely will allow physicians to offer more effective and potent treatments in the future, such as the development of AVP V2 receptor antagonists for the treatment of SIADH [81] and edema-forming states [18, 109].
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Affiliation(s)
- Lisa L Wong
- Georgetown University School of Medicine, 232 Building D, Georgetown University Medical Center, 4000 Reservoir Rd. NW, Washington, DC 20007, USA
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121
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Ravnan SL, Ravnan MC, Deedwania PC. Pharmacotherapy in congestive heart failure: diuretic resistance and strategies to overcome resistance in patients with congestive heart failure. CONGESTIVE HEART FAILURE (GREENWICH, CONN.) 2002; 8:80-5. [PMID: 11927781 DOI: 10.1111/j.1527-5299.2002.0758.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Congestive heart failure is a complex clinical hemodynamic disorder characterized by chronic and progressive pump failure and fluid accumulation. Although the overall impact of diuretic therapy on congestive heart failure mortality remains unknown, diuretics remain a vital component of symptomatic congestive heart failure management. Over time, sodium and water excretion are equalized before adequate fluid elimination occurs. This phenomenon is thought to occur in one out of three patients with congestive heart failure on diuretic therapy and is termed diuretic resistance. In congestive heart failure, both pharmacokinetic and pharmacodynamic alterations are thought to be responsible for diuretic resistance. Due to disease chronicity, symptomatic management is vital to improved quality of life and enhancing diuretic response is therefore pivotal.
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Affiliation(s)
- Susan L Ravnan
- University of the Pacific, Thomas J. Long School of Pharmacy and Health Sciences, Stockton, CA, USA
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122
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Abstract
Disorders of body fluids, notably central diabetes insipidus (CDI) and the syndrome of inappropriate antidiuretic hormone secretion (SIADH), are relatively uncommon as a presenting symptom of sellar and suprasellar masses, but quite common following surgical resection of such lesions. It therefore behooves clinicians treating such patients to have a good understanding of the pathophysiology, the differential diagnosis and the management of these disorders. This review discusses some general issues concerning the pathogenesis, differential diagnosis, clinical manifestations and therapy of hyperosmolar and hypoosmolar syndromes, including CDI and SIADH, and then more specifically addresses the evaluation and treatment of pre- and postoperative disorders of water metabolism in patients with pituitary adenomas.
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Affiliation(s)
- Joseph G Verbalis
- Division of Endocrinology and Metabolism, Georgetown University School of Medicine, Washington, DC 20007, USA.
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123
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Saito T, Higashiyama M, Nagasaka S, Sasaki S, Saito T, Ishikawa SE. Role of aquaporin-2 gene expression in hyponatremic rats with chronic vasopressin-induced antidiuresis. Kidney Int 2001; 60:1266-76. [PMID: 11576341 DOI: 10.1046/j.1523-1755.2001.00965.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND In a state of chronic arginine vasopressin (AVP) excess, the action of antidiuresis has been attenuated, resulting in some water diuresis. This state has been termed an "AVP escape" phenomenon. The present study was designed to determine what mechanisms underlie this attenuation in renal concentrating ability, which is found in chronic AVP excess, both in the presence and absence of volume expansion. METHODS Two groups of experimental rats were established. One group received solid chow with water ad libitum. The second group received chow, which was offered as a liquid diet. Both groups received subcutaneous administration of 1-deamino-8-D-arginine vasopressin (dDAVP) at 5 ng/h for the entire observation period of one week. Over the course of the observation period, tissue levels of aquaporin-2 (AQP-2) mRNA and protein were measured. Levels of AVP V2 receptor were monitored, both by measuring mRNA levels and by ligand-binding studies using [3H]AVP. Tissue levels of cAMP also were determined. RESULTS Experimental rats with the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) had severe hyponatremia below 120 mmol/L, and impaired urinary concentrating ability, during the seven-day observation period. In contrast, the dDAVP-excess rats, given solid chow, maintained maximally concentrated urine and normal levels of serum sodium. The down-regulation of AVP V2 receptor function was comparable in the two groups. The maximal binding capacity (Bmax) fell to the nadir on day 2 and was thereafter suppressed at approximately 60% of control rats during the experiment. Up-regulation of AQP-2 mRNA expression was found, but this up-regulation was significantly less in the SIADH rats compared with the dDAVP-excess rats (153.5 +/- 29.8% vs. 323.7 +/- 23.8% on day 7, P < 0.05). This differential response between these two groups was affirmed by measured differences in AQP-2 protein levels, both in tissue and in urinary excretion. CONCLUSIONS These results indicate that the attenuated regulation of the AQP-2 gene leads to the decrease in urinary concentrating ability in the experimental SIADH rats, suffering from hypervolemic state, compared with the normonatremic rats receiving AVP. Either hypervolemia or hypotonicity may diminish the post-receptor signaling of AVP in renal collecting duct cells, under the chronic AVP excess state found in SIADH.
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Affiliation(s)
- T Saito
- Division of Endocrinology and Metabolism, Department of Medicine, Jichi Medical School, Tochigi, Japan
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124
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Ferreira A, Bettencourt P, Pestana M, Correia F, Serrão P, Martins L, Cerqueira-Gomes M, Soares-Da-Silva P. Heart failure, aging, and renal synthesis of dopamine. Am J Kidney Dis 2001; 38:502-9. [PMID: 11532681 DOI: 10.1053/ajkd.2001.26834] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The present study evaluates renal dopaminergic activity in 23 patients with heart failure (HF), 10 age-matched controls, and 10 young subjects during normal-salt (NS) intake and after 8 days of low-salt (LS) intake (patients with HF and age-matched controls only). LS intake produced a marked reduction in urine volume in patients with HF but failed to affect urine volume in age-matched controls. Urinary sodium and fractional excretion of sodium were markedly reduced by LS intake in patients with HF and age-matched controls. Daily urinary excretion of L-3,4-dihydroxyphenylalanine (L-dopa) and dopamine was lower in patients with HF than in age-matched controls. LS intake failed to alter L-dopa and dopamine urinary excretion in control subjects. In patients with HF, LS intake produced a significant decrease in urinary L-dopa excretion, but failed to alter the urinary excretion of dopamine. No significant differences were observed in urinary L-dopa, dopamine, and dopamine metabolite levels between aged controls and young healthy subjects. Urinary dopamine-L-dopa ratios in patients with HF on LS intake (24.5 +/- 7.1) were significantly greater than those with NS intake (11.6 +/- 1.3). Urinary dopamine-L-dopa ratios in old control subjects (LS, 9.7 +/- 1.3; NS, 9.3 +/- 1.1) did not differ from those in young healthy subjects (9.2 +/- 0.8). LS intake produced a marked increase in plasma aldosterone levels in both patients with HF (84.6 +/- 14.4 to 148.2 +/- 20.4 pg/mL; P = 0.0008) and controls (102.1 +/- 13.4 to 151.6 +/- 15.7 pg/mL; P < 0.04). Plasma norepinephrine levels were not significantly affected by LS intake in controls (5.1 +/- 1.62 to 6.3 +/- 1.6 pmol/mL; P = 0.22), but were significantly increased in patients with HF (5.8 +/- 0.8 to 7.1 +/- 0.9 pmol/mL; P = 0.04). In conclusion, patients with HF are endowed with an enhanced ability to take up (or decarboxylate) filtered L-dopa, which might counterbalance the reduced renal delivery of L-dopa, contributing to a relative preservation of dopamine synthesis. This may result as a compensatory mechanism, activated by stimuli leading to sodium reabsorption. Age seems to have no influence on renal dopamine production.
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Affiliation(s)
- A Ferreira
- Unidade de Investigação e Desenvolvimento Cardiovascular do Porto, Portugal.
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125
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Saito T, Higashiyama M, Nakamura T, Kusaka I, Nagasaka S, Saito T, Ishikawa S. Urinary excretion of the aquaporin-2 water channel exaggerated in pathological states of impaired water excretion. Clin Endocrinol (Oxf) 2001; 55:217-21. [PMID: 11531928 DOI: 10.1046/j.1365-2265.2001.01336.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The present study was undertaken to determine whether the hydro-osmotic action of arginine vasopressin (AVP) is exaggerated in pathological states of impaired water excretion by measuring urinary excretion of the aquaporin-2 (AQP-2) water channel. PATIENTS AND MEASUREMENTS Eighteen hyponatraemic patients with impaired water excretion and 12 control subjects were studied during an acute oral water load (20 ml/kg body weight). RESULTS In the patient group plasma AVP levels were 1.6 pmol/l, relatively high compared to plasma osmolality of 279.8 mmol/kg. Urinary excretion of AQP-2 under ad libitum water drinking was 41.1 fmol/micromol creatinine in the patient group, a value significantly greater than that of 21.7 fmol/micromol creatinine in the control subjects. The acute water load verified the impairment in water excretion in the patient group, as the excretion of the water load was only 28.2% (control, 77.3%, P < 0.001) and the minimum urinary osmolality was as high as 437.3 mmol/kg (control, 122.9 mmol/kg, P < 0.001). Also, the minimum urinary excretion of AQP-2 was significantly greater in the patient group than that in the control. There was a positive correlation between plasma AVP levels and urinary excretion of AQP-2 in the control subjects (r = 0.56, P < 0.01). In contrast, the urinary excretion of AQP-2 was exaggerated compared to the respective plasma AVP levels in the patient group, and thus the positive correlation disappeared. CONCLUSION These results indicate that hydroosmotic action of AVP is exaggerated more than that expected from plasma AVP levels in pathological states of impaired water excretion, with non-suppressible, but normal, arginine vasopressin levels in spite of the hypo-osmotic condition.
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Affiliation(s)
- T Saito
- Division of Endocrinology and Metabolism, Department of Medicine, Jichi Medical School, Tochigi, Japan
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126
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Abstract
Patients with cancer are at risk for developing a variety of fluid and electrolyte disturbances caused by the disease process or by complications from therapy. An understanding of the pathophysiology of these potential abnormalities allows the clinician to manage patients expectantly and to avoid severe metabolic disarray by correcting imbalances promptly.
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Affiliation(s)
- M Kapoor
- Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, USA
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127
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Marenzi G, Lauri G, Guazzi M, Assanelli E, Grazi M, Famoso G, Agostoni P. Cardiac and renal dysfunction in chronic heart failure: relation to neurohumoral activation and prognosis. Am J Med Sci 2001; 321:359-66. [PMID: 11417750 DOI: 10.1097/00000441-200106000-00001] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND In chronic heart failure (CHF), cardiac dysfunction is considered the major determinant of neurohumoral activation but the role of renal impairment has not been defined. We investigated the relationship between both cardiac and renal dysfunction and neurohumoral activation, and their possible influence on prognosis. METHODS Hemodynamics, renal function, plasma neurohormones, and long-term follow-up were evaluated in 148 CHF patients, grouped according to systolic volume index (SVI) and serum creatinine (CRE) values: SVI > 28 mL/m2 and CRE < 1.5 mg/dL (group I, n = 55), SVI < 28 mL/m2 and CRE < 1.5 mg/dL (group II, n = 37), SVI > 28 mL/m2 and CRE > 1.5 mg/dL (group III, n = 25), SVI < 28 mL/m2 and CRE > 1.5 mg/dL (group IV, n = 31). RESULTS Neurohormones progressively increased from Group I through IV and correlated with both cardiac and renal function. The hemodynamic pattern was similar in patients with normal or abnormal renal function, whereas neurohormones were only moderately increased in the former group and markedly increased in the latter group. Long-term survival progressively decreased from Group I through IV and was significantly poorer in patients with renal dysfunction. CONCLUSIONS Our study confirms that, in CHF, neurohumoral activation is strictly related to long-term survival and that many factors contribute to its development and progression; among these, cardiac and renal dysfunction seem to play a major role.
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Affiliation(s)
- G Marenzi
- IRCCS, Institute of Cardiology, University of Milan, Italy.
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128
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Schrier RW, Cadnapaphornchai MA, Ohara M. Water retention and aquaporins in heart failure, liver disease and pregnancy. J R Soc Med 2001; 94:265-9. [PMID: 11387413 PMCID: PMC1281519 DOI: 10.1177/014107680109400603] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- R W Schrier
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado 80262, USA.
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129
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Nara T, Yoshikawa D, Saito S, Kadoi Y, Morita T, Goto F. Perioperative management of biventricular failure after closure of a long-standing massive arteriovenous fistula. Can J Anaesth 2001; 48:588-91. [PMID: 11444455 DOI: 10.1007/bf03016837] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To report the perioperative management of arteriovenous fistula (AVF) closure in a patient with high-output heart failure and pulmonary hypertension. CLINICAL FEATURES In a 71-yr-old man, closure of a long-standing massive AVF between the right femoral artery and vein was performed. After closure of the AVF, his pulmonary artery pressure (PAP) increased from 52/21 mmHg to 68/26 mmHg, his cardiac index decreased from 5.27 L.min(-1).m(-2) to 3.18 L.min(-1).m(-2), and his pulmonary wedge pressure increased from 15 mmHg to 32 mmHg due to an acute increase in afterload. Co-administration of prostaglandin E and a phosphodiesterase III inhibitor improved the cardiac index and the PAP. CONCLUSIONS Surgical closure of the fistula may not always lead to resolution of the high output cardiac failure. In this case, afterload management using arterial dilators (prostaglandin E1, phosphodiesterase III inhibitor), use of inotropic drugs (phosphodiesterase III inhibitor), and close attention to volume status was crucial for a successful outcome after surgical AVF closure.
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Affiliation(s)
- T Nara
- Department of Anesthesiology and Reanimatology, Gunma University School of Medicine, Maebashi, Japan.
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130
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Abstract
The evaluation of ascites includes a directed history, focused physical examination, and diagnostic paracentesis with ascitic fluid analysis. Dietary sodium restriction and oral diuretics are the mainstay of therapy for the majority of patients with cirrhotic ascites. Transjugular intrahepatic portocaval shunt has emerged as the treatment of choice for selected patients with refractory ascites, although serial large-volume paracenteses should be attempted first. Early diagnosis, broad-spectrum antibiotics, and albumin infusion contribute to the successful management of spontaneous bacterial peritonitis (SBP). Referral for liver transplant evaluation should be considered at the first sign of decompensation and should not be delayed until development of ominous clinical features, such as refractory ascites and SBP.
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Affiliation(s)
- A S Yu
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, and Liver Transplant Program, Stanford University Medical Center, Stanford, USA.
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131
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Schrier RW, Cadnapaphornchai MA, Umenishi F. Water-losing and water-retaining states: role of water channels and vasopressin receptor antagonists. HEART DISEASE (HAGERSTOWN, MD.) 2001; 3:210-4. [PMID: 11975794 DOI: 10.1097/00132580-200105000-00014] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Alterations in water metabolism are present in conditions such as diabetes insipidus, syndrome of inappropriate antidiuretic hormone secretion, cardiac failure, cirrhosis, and pregnancy. Recent advances in molecular biology have enhanced our understanding of disordered water metabolism in these conditions. This review examines the roles of central vasopressin synthesis and release and collecting duct vasopressin V2 receptor and aquaporin-2 water channel regulation in water-losing and water-retaining states.
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Affiliation(s)
- R W Schrier
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado Health Sciences Center, Denver 80262, USA.
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132
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Cadnapaphornchai MA, Ohara M, Morris KG, Knotek M, Rogachev B, Ladtkow T, Carter EP, Schrier RW. Chronic NOS inhibition reverses systemic vasodilation and glomerular hyperfiltration in pregnancy. Am J Physiol Renal Physiol 2001; 280:F592-8. [PMID: 11249850 DOI: 10.1152/ajprenal.2001.280.4.f592] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The chronic role of nitric oxide (NO), independent of prostaglandin synthesis, in the primary peripheral vasodilation, increased glomerular filtration rate (GFR), and renal plasma flow (RPF) in normal pregnancy remains to be defined. The purpose of the present study was to chronically inhibit NOS to return systemic vascular resistance (SVR), cardiac output (CO), GFR, and RPF to nonpregnant values. Pregnant rats received the nitric oxide synthase (NOS) inhibitor, nitro-L-arginine methyl ester (L-NAME), orally from gestational days 7 through 14. Results were compared with nonpregnant and untreated pregnant rats. At 14 days gestation, CO significantly increased in pregnant vs. nonpregnant rats (187 +/- 17 vs. 125 +/- 10 ml/min, P < 0.05) as SVR decreased (0.64 +/- 0.08 vs. 1.08 +/- 0.08 mmHg. ml(-1). min, P < 0.05) and mean arterial pressure was unchanged (117 +/- 5 vs. 125 +/- 2 mmHg, not significant). Pregnant rats also demonstrated increased GFR (3,015 +/- 33 vs. 2,165 +/- 136 microl/min, P < 0.01) and RPF (7,869 +/- 967 vs. 5,507 +/- 290 microl/min, P < 0.05) vs. nonpregnant rats. L-NAME-treated pregnant rats had values for CO (118 +/- 7 ml/min), SVR (1.09 +/- 0.07 mmHg. ml(-1). min), GFR (2,264 +/- 150 microl/min), and RPF (5,777 +/- 498 microl/min), which were no different than nonpregnant animals. In summary, similar to human pregnancy, primary peripheral vasodilation occurs early in rat pregnancy. Furthermore, the hyperdynamic circulation and glomerular hyperfiltration of normal rat midterm pregnancy can be chronically reversed by NOS inhibition. These findings suggest a role for endothelial damage and decreased NO in the pathogenesis of preeclampsia.
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Affiliation(s)
- M A Cadnapaphornchai
- Division of Renal Diseases and Hypertension, Department of Medicine, University of Colorado School of Medicine, Denver, Colorado 80262, USA
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133
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Abstract
Congestive heart failure describes a syndrome with complex and variable symptoms and signs, including dyspnea, increased fatigability, tachypnea, tachycardia, pulmonary rales, and peripheral edema. Although this syndrome usually is associated with low cardiac output, it may occur in a number of so-called high output states, when the cardiac output is normal or greater than normal. A high output state may occur in chronic severe anemia, large arteriovenous fistula or multiple small arteriovenous shunts as in Paget's bone disease, some forms of severe hepatic or renal disorders, and acutely in septic shock. The syndrome of systemic congestion in a high output state is traditionally referred to as high output heart failure. However, the term is a misnomer because the heart in these conditions is normal, capable of generating very high cardiac output. The underlying problem in high output failure is a decrease in the systemic vascular resistance that threatens the arterial blood pressure and causes activation of neurohormones, resulting in an increase in salt and water retention by the kidney. Many of the high output states are curable conditions, and because they are associated with decreased peripheral vascular resistance, the use of vasodilator therapy for treatment of congestion may aggravate the problem. There are other clinically important issues in high output failure that have received little attention in the current medical literature. This article reviews the available data on high output cardiac failure with particular emphasis on the underlying mechanisms and treatment.
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Affiliation(s)
- Inder S. Anand
- Department of Cardiology, Veterans Administration Medical Center, One Veterans Drive 111-C, Minneapolis, MN 55417, USA.
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134
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Saito T, Fukagawa A, Higashiyama M, Nakamura T, Kusaka I, Nagasaka S, Honda K, Saito T. Close association of urinary excretion of aquaporin-2 with appropriate and inappropriate arginine vasopressin-dependent antidiuresis in hyponatremia in elderly subjects. J Clin Endocrinol Metab 2001; 86:1665-71. [PMID: 11297601 DOI: 10.1210/jcem.86.4.7426] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The present study was undertaken to determine whether urinary excretion of aquaporin-2 (AQP-2) participates in the involvement of arginine vasopressin (AVP) in hyponatremia less than 130 mmol/L in 33 elderly subjects (> or =65 yr old) during the last 5-yr period. Subjects were separated into euvolemic hyponatremia groups: 13 with hypopituitarism, 8 with syndrome of inappropriate secretion of antidiuretic hormone (SIADH), 8 with mineralocorticoid-responsive hyponatremia of the elderly, and 4 with miscellaneous diseases. Approximately 40% of those with hyponatremia was derived from hypopituitarism, but severe hyponatremia was found in the patients with SIADH and mineralocorticoid-responsive hyponatremia of the elderly. Plasma AVP levels remained relatively high despite hypoosmolality and were tightly linked with exaggerated urinary excretion of AQP-2 and antidiuresis in the 3 groups of patients, except for one miscellaneous one. An acute water load test verified the impairment in water excretion, because the percent excretion of the water load was less than 42% and the minimal urinary osmolality was not sufficiently diluted. Also, plasma AVP and urinary excretion of AQP-2 were not reduced after the water load. The inappropriate secretion of AVP was evident in the patients with SIADH and hypopituitarism, and hydrocortisone replacement normalized urinary excretion of AQP-2 and renal water excretion in those with hypopituitarism. In contrast, the appropriate antidiuresis seemed to compensate loss of body fluid in the patients with mineralocorticoid-responsive hyponatremia of the elderly, who lost circulatory blood volume by 7.3% (mean). Fludrocortisone acetate increased renal sodium handling and body fluid, resulting in the reduction in AVP release and urinary excretion of AQP-2 in mineralocorticoid-responsive hyponatremia of the elderly. These findings indicate that urinary excretion of AQP-2 may be a more sensitive measure of AVP effect on renal collecting duct cells than are plasma AVP levels, and that increased urinary excretion of AQP-2 shows exaggerated AVP-induced antidiuresis in hyponatremic subjects in the elderly. In addition, mineralocorticoid-responsive hyponatremia of the elderly has to be carefully differentiated from SIADH in elderly subjects.
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Leung AK, Robson WL. Oedema in childhood. THE JOURNAL OF THE ROYAL SOCIETY FOR THE PROMOTION OF HEALTH 2000; 120:212-9. [PMID: 11197447 DOI: 10.1177/146642400012000407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Oedema is a common childhood problem with important public health implications. It is an abnormal accumulation of fluid in the interstitial space which might result from a decrease in intravascular oncotic pressure, an increase in intravascular hydrostatic pressure, an increase in capillary permeability or impaired lymphatic drainage. Renal sodium retention is an important factor in generalised oedema. This article reviews the pathophysiology and aetiology of oedema in children and suggests an approach to evaluation, diagnosis and management of the problem.
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Affiliation(s)
- A K Leung
- University of Calgary, Alberta Children's Hospital, 1820 Richmond Road SW, Calgary, Alberta T2T 5C7, Canada
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Abstract
The incidence and prevalence of heart failure is on the rise. It has become the single most expensive health care item in the United States and the number one discharge diagnosis in the elderly. The goals of therapy include both prevention and treatment of heart failure. In recent years research studies and randomized clinical trials have revolutionized the understanding of the pathophysiology and treatment of this disease. This article focuses on the medical management of chronic systolic heart failure based on the pathophysiology of the disease. Systolic heart failure is characterized by a decrease in left ventricular function and cardiac output, which results in activation of several neurohormonal compensatory systems. The long term effects of this neurohormonal activation leads to further deterioration of cardiac function. The use of hydralazine and nitrates to reduce the systemic vascular resistance was the first to show an improvement in mortality and morbidity. Then angiotensin converting enzyme inhibitors, by inhibiting the renin angiotensin system, demonstrated a greater improvement in mortality and morbidity. More recently the inhibition of the sympathetic stimulation with beta-blockers has been shown to have an additive effect on morbidity and mortality in combination with angiotensin-converting enzyme inhibitors. Digoxin and diuretics remain important for improving symptoms and decreasing hospitalizations but have not been shown to decrease mortality. The most recent advance in the treatment of cardiac failure is the demonstration that the aldosterone antagonists, spironolactone decreases morbidity and mortality.
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Affiliation(s)
- R W Schrier
- Department of Medicine, University of Colorado School of Medicine, Denver, CO 80262 USA
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Abstract
Hyponatraemia is a frequent electrolyte disorder. It is primarily attributable to vasopressin excess plus sustained fluid intake. Hyponatraemia causes CNS symptoms, especially during the first 2-4 days; these symptoms are related to brain swelling. Hyponatraemia occurs in the setting of liver cirrhosis and congestive cardiac failure, in which it is related to stimulation by low arterial blood pressure acting through baroreceptors. Hyponatraemia also occurs in the syndrome of inappropriate antidiuretic hormone secretion, usually from neoplasms releasing vasopressin. The conventional treatment of hyponatraemia used to be fluid restriction and treatment of the underlying disorder. This kind of treatment has been unreliable, cumbersome and difficult to comply with for the patient. In the future, effective vasopressin V2 antagonists will become available for clinical use in the treatment of hyponatraemia, and are expected to improve the management of hyponatraemia. Pharmacological characteristics and observations of biological effects of three antagonists are reported in the present article.
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Affiliation(s)
- P Gross
- Department of Medicine, Universitätsklinikum C.G. Carus, Dresden, Germany.
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141
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Abstract
There are five problem schemas presented in this article that indicate potential contradictions in therapeutic goals: (1) shock and edema presenting upon premature birth; (2) the hyperosmolar state, problematic in patients less than 750 g birth weight; (3) the respiratory distress syndrome and respiratory failure, often complicated by patent ductus arteriosus; (4) bronchopulmonary dysplasia, resulting from prematurity and mechanical ventilation; and (5) late onset of hyponatremia, sometimes accompanied by growth failure in the recovering premature. These five problems considered together comprise a developmental continuum of illness and recovery, where appropriate fluid management has recently been demonstrated to benefit outcomes greatly. Clinicians over the past decade have encountered all of the fluid and electrolyte nightmares. Although there are many different formulations for treating each of these scenarios, recommending one approach for all patients is likely to be incorrect much of the time.
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Affiliation(s)
- S Baumgart
- Department of Pediatrics, State University of New York at Stony Brook, USA
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Abstract
Aquaporin-2 (AQP-2) is an arginine vasopressin (AVP)-regulated water channel in renal collecting duct cells. Approximately 3 % of AQP-2 in collecting duct cells is excreted into urine. Urinary excretion of AQP-2 varies widely in different physiological conditions, and it has a positive correlation with plasma AVP levels. Urinary excretion of AQP-2 was significantly increased by the single injection of AVP in patients with central diabetes insipidus. The urinary excretion of AQP-2 was one-eighth over in patients with central diabetes insipidus and three times greater in patients with impaired water excretion than that in normal subjects. In a hypertonic saline test, the urinary excretion of AQP-2 promptly increased 6-12-fold in normal subjects, but remained low in patients with central diabetes insipidus. In addition, exaggerated urinary excretion of AQP-2 persisted after an acute water load in patients with impaired water excretion. These results indicate that urinary excretion of AQP-2 is a potent marker for the diagnosis of water metabolism disorders dependent on AVP.
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Abstract
Generalized edema results from alterations in renal sodium homeostasis that ultimately result in an expansion of extracellular fluid volume and accumulation of interstitial fluid. The common edematous disorders include congestive heart failure, cirrhosis, nephrotic syndrome, and renal insufficiency. The abnormalities of sodium homeostasis contributing to edema formation in each condition are discussed. Management of volume homeostasis, with an emphasis on the role of diuretic therapy, is reviewed.
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Affiliation(s)
- A Rasool
- Department of Medicine, University of Pittsburgh School of Medicine, Pennsylvania, USA
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Palm C, Gross P. V2-vasopressin receptor antagonists-mechanism of effect and clinical implications in hyponatraemia. Nephrol Dial Transplant 1999; 14:2559-62. [PMID: 10534484 DOI: 10.1093/ndt/14.11.2559] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Affiliation(s)
- R W Schrier
- Department of Medicine, University of Colorado School of Medicine, Denver 80262, USA.
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Yatsu T, Tomura Y, Tahara A, Wada K, Kusayama T, Tsukada J, Tokioka T, Uchida W, Inagaki O, Iizumi Y, Tanaka A, Honda K. Cardiovascular and renal effects of conivaptan hydrochloride (YM087), a vasopressin V1A and V2 receptor antagonist, in dogs with pacing-induced congestive heart failure. Eur J Pharmacol 1999; 376:239-46. [PMID: 10448882 DOI: 10.1016/s0014-2999(99)00379-9] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The systemic hemodynamic and renal responses to conivaptan hydrochloride (YM087; 4'-(2-methyl-1,4,5,6-tetrahydroimidazo[4,5-d][1]benzoazepine -6-carbonyl)-2-phenylbenzanilide monohydrochloride), a vasopressin V1A and V2 receptor antagonist, were determined in pentobarbital-anesthetized dogs after 2 to 3 weeks of rapid right ventricular pacing. Congestive heart failure, characterized by decreases in first derivative of left ventricular pressure (left ventricular d P/dt(max)) and cardiac output, and increases in left ventricular end-diastolic pressure and total peripheral vascular resistance, was induced by chronic rapid right ventricular pacing at 260-280 beats/min. Intravenous administration of conivaptan (0.1 mg/kg) significantly increased left ventricular dP/dt(max) and cardiac output and significantly decreased left ventricular end-diastolic pressure and total peripheral vascular resistance. Conivaptan also increased urine flow and reduced urine osmolality by markedly increasing free water clearance. These results indicate that conivaptan produced hemodynamic improvement and marked aquaresis in dogs with congestive heart failure. Therefore, conivaptan may find clinical use in treating patients with congestive heart failure.
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Affiliation(s)
- T Yatsu
- Cardiovascular Diseases Research, Pharmacology Laboratories, Institute for Drug Discovery Research, Yamanouchi Pharmaceutical, Tsukuba, Ibaraki, Japan.
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Bernardi M, Blendis L, Burroughs AK, Laffi G, Rodes J, Gentilini P. Hepatorenal syndrome and ascites--questions and answers. LIVER 1999; 19:15-74. [PMID: 10227000 DOI: 10.1111/j.1478-3231.1999.tb00092.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
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149
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Fábregues F, Balasch J, Ginès P, Manau D, Jiménez W, Arroyo V, Creus M, Vanrell JA. Ascites and liver test abnormalities during severe ovarian hyperstimulation syndrome. Am J Gastroenterol 1999; 94:994-9. [PMID: 10201472 DOI: 10.1111/j.1572-0241.1999.01002.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Severe ovarian hyperstimulation syndrome is an uncommon cause of ascites that is being increasingly recognized because of the high number of women undergoing assisted reproductive techniques, mainly in vitro fertilization. This prospective study investigates the clinical and biochemical characteristics of a large series of patients with this syndrome and ascites, including renal and electrolyte abnormalities, activity of neurohormonal systems participating in the regulation of extracellular fluid volume, and liver function tests. METHODS This was a prospective longitudinal study including 50 consecutive patients with ascites due to severe ovarian hyperstimulation syndrome. Renal function, serum electrolytes, body weight, mean arterial pressure, pulse rate, plasma renin activity, plasma concentration of aldosterone, norepinephrine, antidiuretic hormone and atrial natriuretic peptide, and standard liver function tests were measured during the syndrome and 4-5 wk after recovery. A sample of ascitic fluid was obtained from eight patients for protein measurement and cell count. RESULTS At diagnosis, patients had ascites associated with low urinary sodium excretion, oliguria, and hyponatremia. They had also markedly low arterial pressure and increased pulse rate in association with marked activation of vasoconstrictor and antinatriuretic factors. The ascitic fluid was characterized by a high protein concentration, low leukocyte count, and relatively high number of red blood cells. Fifteen (30%) patients had abnormal liver tests characterized by mild to moderate increases in AST (mean 103 +/- 17.1 IU/L) and ALT (76 +/- 8.3 IU/L), which were associated in some cases with increases in gamma-glutamyl transpeptidase or alkaline phosphatase. All abnormalities reverted to normal after the resolution of the syndrome. CONCLUSIONS With the increasing use of assisted reproductive techniques, physicians should be aware of severe ovarian hyperstimulation syndrome as a cause of ascites. The syndrome is associated with sodium retention, hyponatremia, arterial hypotension, and marked activation of vasoconstrictor and antinatriuretic systems. In one third of patients, liver tests abnormalities are present.
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Affiliation(s)
- F Fábregues
- Department of Obstetrics and Gynecology, Faculty of Medicine-University of Barcelona, Hospital Clínic-Institut d'Investigaciones Biomèdiques August Pi i Sunyer, Spain
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Ishikawa S, Saito T, Sasaki S, Saito T. Prompt and sustained regulation of aquaporin-2 by arginine vasopressin in collecting duct cells and clinical implication of urinary excretion of aquaporin-2. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 1999; 449:407-14. [PMID: 10026832 DOI: 10.1007/978-1-4615-4871-3_52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Affiliation(s)
- S Ishikawa
- Department of Medicine, Jichi Medical School, Tochigi, Japan.
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