Apoptosis and inflammation in renal reperfusion injury

Ischemia followed by reperfusion (I/R) has cardinal implications in the pathogenesis of organ transplantation and rejection. Apoptosis and inflammation are central mechanisms leading to organ damage in the course of renal I/R. General aspects of apoptosis, morphology, induction, and biochemistry are discussed. Activated caspases, the classical effector enzymes of apoptosis, are able to induce not only apoptosis but also inflammation after I/R in experimental models. This redefines the involvement of apoptosis in I/R injury toward a central and functional role in the development of organ damage. Our purpose is to assess aspects of apoptosis and inflammation in terms of involvement in the pathogenesis of I/R-induced organ damage. Moreover, the implications of recent experimental advances for diagnosis and treatment of renal I/R injury in clinical practice will be discussed.

The role of ischemia in acquired cystic kidney disease

Acquired cystic kidney disease (ACKD) is the result of cyst formation in failing noncystic kidneys. This condition occurs in patients with chronic renal failure and becomes more common with increasing time on renal replacement therapy. Its complications include hemorrhage and tumor formation, which have acquired greater significance as more patients are started on dialysis treatment. The causes of ACKD remain speculative thus far. Its occurrence in nondialyzed patients suggests that dialysis itself is not a necessary factor in its pathogenesis. Five cases of severe unilateral renovascular disease and associated cyst formation are reported. The authors conclude that ACKD may derive from primary renovascular occlusion or from the secondary arterial and arteriolar occlusions seen in the end-stage kidney.

Renal acid-base metabolism after ischemia

The response of the kidney to ischemia-induced cellular acidosis was followed over the immediate one hr post-ischemia reflow period. Clearance and extraction experiments as well as measurement of cortical intracellular pH (pHi) were performed on Inactin-anesthetized Sprague-Dawley rats. Arteriovenous concentration differences and para-aminohippurate extraction were obtained by cannulating the left renal vein. Base production was monitored as bicarbonate released into the renal vein and urine; net base production was related to the renal handling of glutamine and ammonia as well as to renal oxygen consumption and pHi. After a 15 min control period, the left renal artery was snared for one-half hr followed by release and four consecutive 15 min reflow periods. During the control period, cortical cell pHi measured by [14C]-5,5-Dimethyl-2,4-Oxazolidinedione distribution was 7.07 +/- 0.08, and Q-O2 was 14.1 +/- 2.2 micromoles/min; neither net glutamine utilization nor net bicarbonate generation occurred. After 30 min of ischemia, renal tissue pH fell to 6.6 +/- 0.15. However, within 45 min of reflow, cortical cell pH returned and exceeded the control value, 7.33 +/- 0.06 vs. 7.15 +/- 0.08. This increase in pHi was associated with a significant rise in cellular metabolic rate, Q-O2 increased to 20.3 +/- 6.4 micromoles/min. Corresponding with cellular alkalosis was a net production of bicarbonate and a net ammonia uptake and glutamine release; urinary acidification was abolished. These results are consistent with a nonexcretory renal metabolic base generating mechanism governing cellular acid base homeostasis following ischemia.

Intracellular electrolyte composition following renal ischemia

The technique of electron microprobe analysis was used to determine the intracellular electrolyte concentrations in proximal or distal tubular cells of the rat kidney during ischemia. When the exposed kidney was maintained in air during ischemia, the composition of the surface cells differed little from control, and the electrolyte disturbances were confined to the deeper lying cells. When maintained in nitrogen, all cells underwent changes in cellular electrolyte concentrations that were uniform, indicating that the surface cells can preserve their composition during ischemia by utilizing oxygen from the air. In the proximal tubular cells, after 20 or 60 min of ischemia in nitrogen, sodium increased from 20 to 93 or 112, chloride rose from 21 to 53 or 66, potassium fell from 141 to 65 or 42, phosphate decreased from 145 to 110 or 95 mmoles.kg-1 of wet wt, and the dry wt dropped from 22.6 to 20.3 or 17.5% of wet wt, respectively. In the distal tubular cells, 20 min of ischemia in nitrogen produced little effect on cellular composition, but after 60 min, sodium increased from 11 to 77, chloride rose from 15 to 48, potassium fell from 134 to 89, phosphate decreased from 168 to 145 mmoles.kg-1 of wet wt, and the dry wt dropped from 20.8 to 18.4% of wet wt. The disturbances in sodium and potassium are caused primarily by an inhibition of the sodium/potassium pump, whereas the changes in chloride, phosphate, and dry weight content result mainly from an influx of extracellular fluid. When blood flow was reintroducing, the electrolyte disturbances were rapidly reversed in all cells, restoration being virtually complete within 60 min, but returned in some proximal cells by 18 hr of reperfusion. Thus, the disturbance in electrolyte composition increases with the duration of ischemia, is less pronounced in the distal than proximal cells and, although initially completely reversible when blood flow is restored, reappeared in the proximal cells 1 days after the initial injury.

Renal chemoreceptors in the rat

There are afferent nerve fibers responsive to alterations of the kidney's chemical environment in the renal nerves of the rat. In anesthetized, artificially ventilated, male Sprague-Dawley rats, single unit recordings were prepared by dissection of the centrally cut nerves of the right kidney. The stimuli used included occlusion of the renal artery, systemic asphyxia, changes in renal arterial and venous pressures, changes in ureteral pressure, and cyanide infusion. We found a population of sensory nerve fibers whose endings are activated only during markedly impaired renal blood flow (produced by clamping the renal artery, severe hypotension below 40 mm Hg, and prolonged occlusion of the renal vein), and during systemic asphyxia. The same units are not responsive to increases and decreases in systemic arterial pressure (range: 40--190 mm Hg), to ureteral pressure (range: 0--50 mm Hg), or to changes in renal venous pressure. None of the 40 single units studied was spontaneously active; their pattern of activation during renal ischemia always was characterized by trains of impulses. These sensory units have functional properties distinctly different from those of known renal mechanoreceptors. They appear to be a homogeneous group of sensory elements, and we have termed them renal ("R") chemoreceptors. Evidence also is presented which is consistent with the concept that a chemical substance released by or accumulated within the kidney might be the agent activating these chemoreceptors during renal ischemia.