Mechanisms of the impaired diuretic and natriuretic responses to a sustained and moderate saline infusion in rats with experimental cirrhosis

Effect of extracellular volume expansion on erythrocyte cation transport in cirrhotic rats

Erythrocyte intracellular Na+ and K+, and ouabain- and bumetanide-inhibitable Na+ efflux and 86Rb uptake have been measured in control and cirrhotic rats with or without extracellular volume expansion (EVE, saline, 3% body wt., 3 h). Non-expanded, cirrhotic rats showed a lower Na+ excretion (UNaV) than controls. After EVE, control rats showed a significantly higher UNaV (90%) and urinary flow (40%), than non-expanded controls. In cirrhotics, the increases in urinary flow (10%) and UNaV (17%) were not significant. No differences in intracellular Na+ and K+ levels between control and cirrhotic rats were observed. In controls none of these values changed with volume expansion, but in cirrhotic rats intracellular Na+ was significantly higher in expanded than in non-expanded rats. No differences in 86Rb uptake between non-expanded control and cirrhotic rats were observed. In controls EVE induced a decrease of pump-mediated 86Rb influx, but in cirrhotic rats, total and pump-mediated 86Rb influxes were lower in expanded than in non-expanded animals. By contrast, EVE induced a decrease in ouabain-inhibitable 86Rb uptake. In conclusion, in spite of the limitations imposed by considering the erythrocyte as representative of the renal cells, these results do not support an alteration in the response of the ouabain-inhibitable sodium pump as responsible for the lack of natriuretic response to extracellular volume expansion in cirrhotic rats. However, modification of the cotransport system in cirrhosis could play some role in this impaired response.

Alterations in the physicochemical properties of renal cortical membranes in rats with experimental cirrhosis of the liver

Changes in the major component of renal cortical membranes as well as membrane fluidity and Na+, K+, ATPase activity have been studied in membranes from the renal cortex of rats with experimental liver cirrhosis, which show renal sodium and water retention, and in normal animals. Rats with cirrhosis of the liver show a decrease in cholesterol, phospholipid and protein content, without changes in cholesterol/phospholipid molar ratio. In addition there is a small decrease in 14:0 and 18:2 and an increase in 20:4 content, without differences in unsaturation degree. Membrane fluidity was decreased in renal membranes from cirrhotic rats when compared with normal ones. Na+, K+, ATPase activity was higher in cirrhotic than in normal renal membranes could be related with the changes in renal water and electrolyte changes shown by cirrhotic rats.

Lymphocyte function tests in cirrhotic patients under treatment with spironolactone and potassium canrenoate

This controlled study in cirrhotic patients investigated whether two antialdosteronic steroids, spironolactone (100-200 mg/day; n = 12 patient pairs) and potassium canrenoate (50-100 mg/day, n = 32 patient pairs) which are reported to bind to intracellular membranes and modify cytochrome P-450, could also produce nuclear changes. The model used was the response of peripheral lymphocytes to blastogenic agents by studying lymphocyte sub-populations. No changes occurred in the B- and T-lymphocyte sub-populations or in the helper and suppressor sub-types. The response to the blastogenic agents, phytohaemagglutinin and purified protein derived from mycobacteria, did not change significantly from before entry into the study to the follow-up (18.1 +/- 2.9 months). All control patients (n = 44 patient pairs) had slightly greater mitogenic activity compared with patients treated with spironolactone; no difference was found when control patients were compared with patients given potassium canrenoate. The difference between spironolactone and potassium canrenoate might be due to toxicity caused by the thio group of spironolactone. Overall, however, both drugs may be regarded as safe, in terms of effects on lymphatic tissue, occurring during the course of cirrhosis.

Temporal relationship between the impairment of free water excretion and antidiuretic hormone hypersecretion in rats with experimental cirrhosis

To investigate the temporal relationship between the impairment of water excretion, sodium retention, and antidiuretic hormone hypersecretion in cirrhosis, free water excretion (estimated by the minimum urinary osmolality) and urinary antidiuretic hormone excretion (which correlates with the plasma levels of this hormone) were measured weekly after an oral water load in 18 rats with carbon tetrachloride-induced cirrhosis and in 20 control animals. The onset of ascites (as an index of sodium retention) in cirrhotic rats was estimated by sequential paracentesis. Thirteen cirrhotic animals developed an impairment of water excretion 2-5 wk after the onset of ascites. The urinary excretion of antidiuretic hormone in these animals, which was normal before the impairment of water excretion, increased markedly within the week in which this abnormality was first detected and remained high thereafter. The remaining 5 cirrhotic rats did not experience an impairment of free water excretion in spite of developing ascites. The urinary excretion of antidiuretic hormone in these animals was similar to that of control rats during the entire study. In all urine samples obtained from cirrhotic rats, there was a highly significant direct linear correlation between the urinary excretion of antidiuretic hormone and the minimum urinary osmolality. Our results show the following: in rats with carbon tetrachloride-induced cirrhosis, sodium retention preceded the impairment of water excretion; and in these animals, the defect in water metabolism correlated chronologically and quantitatively with antidiuretic hormone hypersecretion. These findings are consistent with the concept that antidiuretic hormone is a major determinant of the impaired water metabolism in cirrhosis.

Influence of cardiac function on the diuretic and hemodynamic effects of the loop diuretic piretanide

The influence of cardiac function on the diuretic and hemodynamic effects of the loop diuretic piretanide was investigated in nine patients with congestive heart failure. The diuretic response to piretanide correlated significantly with the pretreatment cardiac index (r = 0.90). Furthermore, a significant correlation was found between the pretreatment fractional sodium excretion and the cardiac index (r = 0.85). The fractional sodium excretion is reciprocal to the renal sodium and water reabsorption. No change in the hemodynamics was observed prior to the onset of diuresis. At 120 minutes after administration of piretanide, the reduction of mean pulmonary capillary wedge pressure (r = 0.88) and mean right atrial pressure (r = 0.80) was significantly related to the diuretic response. We conclude that the reduced diuretic response to piretanide in patients with low cardiac index is due to increased renal sodium and water reabsorption. The hemodynamic changes following the administration of piretanide are dependent on the diuresis.

Increased levels of platelet-activating factor in blood from patients with cirrhosis of the liver

The levels of platelet-activating factor (paf-acether) were measured in blood and ascitic fluid from cirrhotic patients and in blood from a group of controls, using a recently described technique for extraction and measurement. In addition, activity of acetylhydrolase, the main catabolic enzyme for paf-acether, was also measured. The highest levels of paf-acether in blood were found in decompensated cirrhotics (1.78 +/- 0.62 ng ml-1; mean +/- SD, n = 8). Compensated cirrhotics showed lower blood values (0.79 +/- 0.21, n = 4), but higher than controls (0.20 +/- 0.04, n = 12). Paf-acether levels in ascitic fluid were similar to those of blood. Values of acetylhydrolase in serum were similar in all the groups studied (3.0 +/- 0.4 in cirrhotics vs. 2.3 +/- 0.4 nmol min-1 mg-1 of protein in controls). These data suggest an enhanced production of paf-acether in cirrhotic patients rather than a decreased catabolism. High levels of paf-acether in blood could be involved in the impaired haemodynamics of cirrhotic patients and in their renal function alterations.

Effects of the platelet-activating factor antagonist BN 52021 on the hemodynamics of rats with experimental cirrhosis of the liver

Previous studies from this laboratory have shown that rats with experimental cirrhosis of the liver induced by the combined administration of oral phenobarbital and inhaled carbon tetrachloride show an hyperdynamic status with enhanced cardiac output (CO), and decreased mean arterial pressure (MAP) and peripheral vascular resistance (PVR). Cirrhotic rats also showed an increased vascular permeability. All these phenomena are similar to some of the known effects of the systemic infusion of low doses of synthetic platelet-activating factor into the systemic circulation of normal rats. The measurement of the levels of platelet-activating factor in samples of blood demonstrated significantly higher levels in cirrhotic (2.65 +/- 0.39; n = 10) than in control rats (1.50 +/- 0.57 ng/ml; n = 10; p less than 0.05). The hemodynamic changes induced by the intravenous injection of the platelet-activating factor receptor antagonist BN 52021 (5 mg/kg body weight) have been measured in 10 control and 10 cirrhotic male Wistar rats, using a radioactive microsphere technique. BN 52021 induced no significant hemodynamic changes in control animals. However, in cirrhotic animals it induced a significant decrease in CO with increase in PVR. MAP increased slightly but not significantly. From these data it can be deduced that platelet-activating factor plays a role in the hemodynamic derangement shown by cirrhotic rats and that these derangement can be reversed by BN 52021, a highly selective antagonist of the platelet-activating factor receptor.

Effect of volume expansion on hemodynamics, capillary permeability and renal function in conscious, cirrhotic rats

General and splanchnic hemodynamics (radioactive microspheres), renal function, spontaneous and histamine-mediated vasopermeability and albumin distribution space were studied in conscious control and nonascitic cirrhotic rats, before and after a moderate and sustained saline infusion (3% of body weight per 30 min + repletion of urinary losses). In basal conditions, cirrhotic rats showed lower fractional sodium excretion than did control rats (0.09 +/- 0.01 vs. 0.15 +/- 0.01%, p less than 0.005). In addition, cirrhotic animals showed higher cardiac output (161.4 +/- 12.8 ml per min) and lower total peripheral resistance (0.63 +/- 0.05 mm Hg . min per ml) and mean arterial pressure (102.9 +/- 3.9 mm Hg) than did control rats (cardiac output: 89.0 +/- 7.6; total peripheral resistance: 1.31 +/- 0.11; mean arterial pressure: 117.5 +/- 5.11; p less than 0.005). No differences in portal-systemic shunt rate or vasopermeability between both groups were observed. After saline infusion, fractional sodium excretion increased to 4.31 +/- 0.16% in controls but only 2.11 +/- 0.02% in cirrhotic animals. In this group, cardiac output decreased by 49.6 +/- 5.1% whereas mean arterial pressure and total peripheral resistance increased by 7.1 +/- 0.6 and 112 +/- 10%, respectively. In control rats, no significant hemodynamic changes were observed. Blood gases did not change after expansion in any group. Saline infusion induced an increase in histamine-mediated vasopermeability in cirrhotic rats but not in control rats. Also albumin distribution space increased more in cirrhotic than in control animals. Heart weight was higher in cirrhotic rats.(ABSTRACT TRUNCATED AT 250 WORDS)

The pathogenesis of renal sodium retention and ascites formation in Laennec's cirrhosis

This chapter critically reviews our current understanding of the pathogenesis, clinical syndrome, and therapy of the disturbances of renal sodium handling, renal perfusion, and glomerular filtration rate that occur in patients with Laennec's cirrhosis. Avid renal sodium reabsorption, a characteristic feature of cirrhosis, occurs independent of moderate changes in renal function and precedes the onset of ascites. The initiation of sodium retention may be a direct consequence of the hepatic disease process and may also result from defective intravascular filling. In the presence of ascites the most important sodium retaining signal is a defective intravascular volume. The principal effectors of renal sodium retention and vasoconstriction are stimulation of the renin-angiotensin-aldosterone axis and augmentation of renal sympathetic nerve activity. Deficient production of natriuretic hormone(s) and endogenous renal vasodilators, such as prostaglandins and kinins, also contributes to the sodium retention and renal hypoperfusion seen in cirrhosis. The hepatorenal syndrome is an extreme imbalance in these renal vasoconstrictor and vasodilator forces. In the therapy of ascites in Laennec's cirrhosis, abstention from alcohol, sodium restriction, and cautious diuresis are the principal therapeutic measures. A grave prognosis accompanies the diagnosis of the hepatorenal syndrome although recoveries have been reported.