Biotransformation of furosemide in kidney transplant patients

Perinatal growth restriction decreases diuretic action of furosemide in adult rats

Perinatal growth restriction programs higher risk for chronic disease during adulthood via morphological and physiological changes in organ systems. Perinatal growth restriction is highly correlated with a decreased nephron number, altered renal function and subsequent hypertension. We hypothesize that such renal maladaptations result in altered pharmacologic patterns for life. Maternal protein restriction during gestation and lactation was used to induce perinatal growth restriction in the current study. The diuretic response of furosemide (2mg/kg single i.p. dose) in perinatally growth restricted rats during adulthood was investigated. Diuresis, natriuresis and renal excretion of furosemide were significantly reduced relative to controls, indicative of decreased efficacy. While a modest 12% decrease in diuresis was observed in males, females experienced 26% reduction. It is important to note that the baseline urine output and natriuresis were similar between treatment groups. The in vitro renal and hepatic metabolism of furosemide, the in vivo urinary excretion of the metabolite, and the expression of renal drug transporters were unaltered. Creatinine clearance was significantly reduced by 15% and 19% in perinatally growth restricted male and female rats, respectively. Further evidence of renal insufficiency was suggested by decreased uric acid clearance. Renal protein expression of sodium-potassium-chloride cotransporter, a pharmacodynamic target, was unaltered. In summary, perinatal growth restriction could permanently imprint pharmacokinetic processes affecting drug response.

The Metabolism and Toxicity of Furosemide in the Wistar Rat and CD-1 Mouse: a Chemical and Biochemical Definition of the Toxicophore

Furosemide, a loop diuretic, causes hepatic necrosis in mice. Previous evidence suggested hepatotoxicity arises from metabolic bioactivation to a chemically reactive metabolite that binds to hepatic proteins. To define the nature of the toxic metabolite, we examined the relationship between furosemide metabolism in CD-1 mice and Wistar rats. Furosemide (1.21 mmol/kg) was shown to cause toxicity in mice, but not rats, at 24 h, without resulting in glutathione depletion. In vivo covalent binding to hepatic protein was 6-fold higher in the mouse (1.57 +/- 0.98 nmol equivalent bound/mg protein) than rat (0.26 +/- 0.13 nmol equivalent bound/mg protein). In vivo covalent binding to mouse hepatic protein was reduced 14-fold by a predose of the cytochrome P450 (P450) inhibitor, 1-aminobenzotriazole (ABT; 0.11 +/- 0.04 nmol equivalent bound/mg protein), which also reduced hepatotoxicity. Administration of [(14)C]furosemide to bile duct-cannulated rats demonstrated turnover to glutathione conjugate (8.8 +/- 2.8%), gamma-ketocarboxylic acid metabolite (22.1 +/- 3.3%), N-dealkylated metabolite (21.1 +/- 2.9%), and furosemide glucuronide (12.8 +/- 1.8%). Furosemide-glutathione conjugate was not observed in bile from mice dosed with [(14)C]furosemide. The novel gamma-ketocarboxylic acid, identified by nuclear magnetic resonance spectroscopy, indicates bioactivation of the furan ring. Formation of gamma-ketocarboxylic acid was P450-dependent. In mouse liver microsomes, a gamma-ketoenal furosemide metabolite was trapped, forming an N-acetylcysteine/N-acetyl lysine furosemide adduct. Furosemide (1 mM, 6 h) became irreversibly bound to primary mouse and rat hepatocytes, 0.73 +/- 0.1 and 2.44 +/- 0.3 nmol equivalent bound/mg protein, respectively, which was significantly reduced in the presence of ABT, 0.11 +/- 0.03 and 0.21 +/- 0.1 nmol equivalent bound/mg protein, respectively. Furan rings are part of new chemical entities, and mechanisms underlying species differences in toxicity are important to understand to decrease the drug attrition rate.

Net secretion of furosemide is subject to indomethacin inhibition, as observed in Caco-2 monolayers and excised rat jejunum

PURPOSE

To determine if intestinal secretion occurs for the poorly bioavailable diuretic, furosemide.

METHODS

Jejunal segments of male Sprague-Dawley rats were mounted on diffusion chambers, and the permeation of furosemide was measured across the excised tissue in both directions. Studies were repeated using cultured epithelia from adenocarcinoma cells (Caco-2) grown on filter inserts mounted in 6-well plates. Temperature-dependence and chemical inhibition by indomethacin was also tested using the cell culture model.

RESULTS

Net secretion from rat intestine of over 3-fold was observed for 20 microM furosemide. Net secretion of furosemide by Caco-2 cells was over 300% greater than for intestinal segments (10-fold vs. 3-fold). For both models, a decrease in furosemide transport in the direction of secretion was observed in the presence of indomethacin (100 microM), although only results using the Caco-2 cells showed in increase in the absorptive transport. Furosemide secretion from Caco-2 cells decreased with decrease in temperature from 37 degrees C to 4 degrees C, suggesting a carrier-mediated process.

CONCLUSIONS

Furosemide appears to be secreted in the small intestine. These preliminary results indicate that furosemide bioavailability may be limited by an intestinal transporter.

Frusemide and its acyl glucuronide show a short and long phase in elimination kinetics and pharmacodynamic effect in man

The pharmacokinetics of 80 mg frusemide given orally were investigated in normal subjects using a direct HPLC method for parent drug and its acyl glucuronide conjugate. Two half-lives could be distinguished in the plasma elimination of both frusemide and its conjugate, with values of 1.25 +/- 0.75 and 30.4 +/- 11.5 h for frusemide and 1.31 +/- 0.60 and 33.2 +/- 28.0 h for the conjugate. The renal excretion rate-time profile showed two phases; the rapid elimination phase lasted from 0-15 h and the second and slow phase, from 15-96 h. During the first 15 h, 33.3 +/- 4.8% of the dosed frusemide was excreted; in the remaining period 15-96 h, 4.6 +/- 1.5% was excreted. In the same two periods the excretion of the glucuronide was 13.4 +/- 4.7 and 1.9 +/- 1.1%, respectively. The mean renal clearance of frusemide was 90.2 +/- 16.9 mL min-1 during the first period and 91.5 +/- 29.3 mL min-1 in the remaining period, during which the stimulation of urine production was absent. The renal clearance of the acyl glucuronide was 702 +/- 221 mL min-1 in the first period, but only 109 +/- 51.0 mL min-1 in the second period. The stimulated urine production in the first 6 h after administration amounted to 2260 +/- 755 mL (measured urine production minus baseline value of 1 mL min-1 (360 mL). During the second or rebound period (6-96 h after drug administration), the quantity of urine was 990 +/- 294 mL lower than what would have been expected from the baseline production of 5400 mL. This reduced production (0.82 mL min-1) is equivalent to an 18% reduction in the average urine flow rate of 1 mL min-1.

Extrahepatic metabolism of frusemide in anaesthetized rabbits

1. Frusemide is removed from the body by biotransformation and renal secretion, but since frusemide metabolism is not altered in patients with hepatic cirrhosis, the role of the liver may be questioned. The aim of the study was to investigate which organs contribute to the first-pass metabolism and systemic clearance of frusemide. 2. Groups of anaesthetized New Zealand rabbits were administered frusemide proximally (prox) and distally (dist) to different organs, and blood was sampled from the abdominal aorta. The area under frusemide plasma concentrations-time curve (AUC0-infinity) was calculated and frusemide extraction by an organ was estimated from the ratio (AUCdist-AUCprox)/AUCdist. The small intestine extracted 83% of the absorbed dose of frusemide but the first-pass uptake by the liver and lungs was negligible. 3. To assess the contribution of the intestine and the kidneys to the systemic clearance of frusemide, it was injected into the jugular vein and blood was sampled proximal and distal to each organ. The kidneys extracted 24% of frusemide circulating in the renal arteries; on the other hand, the ability of the intestine to extract frusemide from the systemic circulation could not be detected. 4. The lungs did not metabolize frusemide in vitro; the rate of metabolism of frusemide in vitro by kidneys was similar to that estimated in the intestine, and both rates were faster (P < 0.05) than that observed in the liver. 5. It is concluded that in rabbits, presystemic metabolism of frusemide is carried out by the intestine, and that systemic clearance of frusemide is mainly performed by the kidneys, although other organs, such as the intestine and the liver, must contribute to it.

Furosemide dynamics in conscious rabbits: modulation by angiotensin II

The aim of this study was to investigate the effects of an infusion of angiotensin II (50 ng/kg/min) on furosemide pharmacodynamics and kinetics in the conscious rabbit. The protocol included a 90-minute phase to estimate the glomerular filtration rate and the renal plasma flow, followed by a 60-minute phase where 5 mg/kg (n = 12) or 10 mg/kg (n = 9) of furosemide were administered. During the pre-furosemide phase, compared to control rabbits, angiotensin II increased natriuresis and diuresis. In the presence of angiotensin II, the furosemide-induced natriuresis decreased, that is, it was 174 +/- 14 versus 95 +/- 25 mumol/min (p < 0.05) and 187 +/- 17 versus 89 +/- 21 mumol/min (p < 0.05) for the 5 and the 10 mg/kg doses, respectively. The infusion of angiotensin II decreased renal plasma flow without modifying the glomerular filtration rate, thus the filtration fraction was increased. Angiotensin II increased the area under the furosemide plasma concentrations as a function of time since it decreased its systemic clearance. However, furosemide urinary excretion rate was not altered and its renal clearance decreased slightly without reaching statistical significance. It is concluded that angiotensin II decreases the response to furosemide and the mechanism underlying this effect is related to the pharmacodynamics rather than the kinetics of the diuretic.

Furosemide dynamics in conscious rabbits: modulation by arginine vasopressin

The aims of this study were to assess the influence of arginine-vasopressin (AVP) on the pharmacodynamics and kinetics of furosemide. To this purpose, the response and the kinetics of furosemide (5 mg/kg i.v.) were studied in two groups of rabbits, one control and one receiving an infusion of AVP (2.5 ng/kg/min). The infusion of AVP generated mean plasma levels of 35 pg/ml, and in these rabbits osmolal clearance was increased, free water clearance was reduced, and renal plasma flow was reduced by 25% (p < 0.05). High AVP plasma levels increased the natriuresis (p < 0.01) and the urinary excretion of prostaglandin E2 (UPgE2V; p < 0.01). The increase in UPgE2V was associated with AVP plasma concentrations (r = 0.8248; p < 0.001). AVP reduced the increment in natriuresis and diuresis elicited by furosemide from 163 +/- 20 to 87 +/- 20 mumol/min (p < 0.05) and from 1.22 +/- 0.11 to 0.83 +/- 0.13 ml/min (p < 0.05). The infusion of AVP enhanced furosemide metabolic clearance but diminished its renal clearance, resulting in a decrease in the rate of furosemide urinary secretion. It was concluded that high plasma levels of AVP reduce furosemide natriuresis, presumably because of a decrease in furosemide urinary secretion.

Effects of phenobarbital and 3-methylcholanthrene pretreatment on the pharmacokinetics and pharmacodynamics of furosemide in rats

The effects of pretreatment with the enzyme inducers phenobarbital (PB) and 3-methylcholanthrene (3-MC) on the pharmacokinetic and pharmacodynamic parameters of furosemide were examined in rats. The nonrenal clearance (4.58 versus 6.18 mL/min/kg) increased significantly in PB-treated rats. This suggested that the nonrenal metabolism of furosemide increased by pretreatment with PB. This relationship was supported by the results of a tissue homogenate study; the amounts of furosemide remaining per gram of tissue after 30 min of incubation of 50 micrograms of furosemide with the 9000 x g supernatant fraction of liver, stomach, and kidney tissue homogenates decreased significantly in PB-treated rats. The contents of hepatic cytochrome P-450 (1.29 versus 2.15 nmol/mg protein) and the weights of liver and stomach increased significantly in PB-treated rats, suggesting that the metabolizing enzymes for furosemide are induced by pretreatment with PB. The 8-h urine output per 100 g of body weight increased significantly in PB-treated rats; however, the 8-h urinary excretion of furosemide per 100 g of body weight (797 versus 635 micrograms) decreased significantly in PB-treated rats. Alterations in the urine output might be due to the hormonal alterations in the concentration-effect relationship for furosemide in PB-treated rats. In 3-MC-treated rats, pharmacokinetic and pharmacodynamic parameters of furosemide were not significantly different, indicating that the metabolizing enzymes for furosemide were not induced by pretreatment with 3-MC. However, the contents of hepatic cytochrome P-450 and the weights of liver and stomach increased significantly.

Furosemide pharmacokinetics and pharmacodynamics in health and disease--an update

The literature on furosemide pharmacokinetics and pharmacodynamics is critically reviewed, concentrating on those papers published subsequent to the 1979 reviews of this topic. Intravenous and oral data are presented for healthy volunteers and for patients with various disease states. It is the latter populations about which the majority of the studies have been published since 1979. Inter- and intraindividual variations in bioavailability are discussed, as are data on the metabolism of furosemide to its glucuronide conjugate. Published studies examining the relationship between furosemide pharmacodynamics and pharmacokinetics are also evaluated. The literature is reviewed through June 1988.

The urinary excretion of frusemide and its metabolites by kidney transplant patients

Urine from 5 renal transplant recipients treated with frusemide was analyzed for unchanged frusemide (F), glucuronidated frusemide (G) and 4-chloro-5-sulfamoylanthranilic acid (CSA) by HPLC. In 3 recipients, whose renal function recovered steadily and whose hepatic function was normal throughout, the ratio of frusemide to its metabolites, F/(F + G + CSA), increased steadily in conjunction with the recovery of renal function. In one patient, who received frusemide 200-400 mg/day i.v., the urinary CSA concentration was 64-102 micrograms X ml-1. In 2 patients who experienced shock and/or hepatic dysfunction after transplantation, the F/(F + G + CSA) ratio fluctuated.

The inducibility and ontogeny of rat liver UDP-glucuronyltransferase toward furosemide

Furosemide (F) conjugation with glucuronic acid is the main pathway of F metabolism in humans and experimental animals. In order to study rat liver microsomal UDP-glucuronyltransferase (UDP-GT) activity towards F we developed an in vitro assay in which the conjugation product, furosemide 1-0-acyl glucuronide (FG) was separated and quantitatively determined by reverse phase high pressure liquid chromatography. The optimal conditions of the reaction were established and the apparent Km for F and UDP-glucuronic acid (UDPGA) were 0.22 and 1.76 mM, respectively. Substrate inhibition of UDP-GT toward F occurred at F concentrations higher than 1.5 mM. Developmental changes in F glucuronidation were compared to the ontogeny of UDP GT activity toward two other acceptors, 1-naphthol and estrone that are known to have different patterns of maturation. F glucuronidation was 26% of adult activity at 18 days of gestation, reached 48% at birth and gradually increased to 250% of adult activity at 22 days of age. Glucuronidation of 1-naphthol and estrone attained 87% and 44% of adult activity at 22 days of gestation, 37% and 66% in six-day-old rats and 100% and 427% of adult activity in 22-day-old rats, respectively. The effect of 3-methylcholanthrene (3-MC), phenobarbital (PB) and pregnenolone-16 alpha-carbonitrile (PCN) on F UDP-GT was studied and compared to their effect on 1-naphthol and estrone glucuronidation. PB, 3-MC and PCN increased F-UDP-GT activity to 208%, 282% and 342% of vehicle-treated animals, respectively, while F pretreatment did not affect the conjugation of F. In comparison, 1-naphthol glucuronidation was preferentially induced by 3-MC (4.4-fold of control) while estrone glucuronidation was induced by PB and PCN (4.9- and 2.5-fold of control, respectively). These studies suggest that several forms of UDP-GT activities, which differ in their ontogeny and inducibility patterns, are involved in the glucuronidation of F in vitro.

The relationship between the acetylator and the sparteine hydroxylation polymorphisms

Thirty-eight healthy white British Caucasian subjects were hydroxylator phenotyped with sparteine and acetylator phenotyped with sulphadimidine. The results showed that there was no significant difference in the mean sparteine metabolic ratio between eight rapid acetylator extensive hydroxylators and 27 slow acetylator extensive hydroxylators.