Maturation of proximal tubular acidification

Transfusion strategies for neonates: current perspectives

Background

Blood transfusion intervention has been proven to be a crucial therapeutic aid for preterm infants with serious morbidities such as sepsis, intraventricular hemorrhage, and cardiopulmonary insufficiencies. However, blood transfusion practices have also been shown to cause significant adverse outcomes, which may negate the therapeutic effect of the intervention. To address the varying policies regarding the administration of blood products, healthcare professionals have adopted a consensus-based approach. The absence of a standard protocol has resulted in conflicting outcomes in previous clinical studies.

Objective

This study aimed to evaluate the effectiveness of blood transfusion practices in preterm infants by analyzing past clinical research and identifying the current trends that have emerged as a result of recent trials.

Results

Recent trials have demonstrated comparable trends in mortality rates and other primary outcomes, including retinopathy of prematurity, intraventricular hemorrhage, bronchopulmonary dysplasia, and brain injury, following transfusion of blood products in both groups. Nevertheless, employing restrictive thresholds rather than adopting a liberal approach can reduce these outcomes.

Conclusion

The current literature does not provide clear support for either technique as opposing and contradictory results are evident. However, there is a slight inclination toward the restrictive transfusion threshold due to recent trials, which warrants further in-depth investigation into this issue.

Uses and misuses of sodium bicarbonate in the neonatal intensive care unit

Over the past several decades, bicarbonate therapy continues to be used routinely in the treatment of acute metabolic acidosis in critically ill neonates despite the lack of evidence for its effectiveness in the treatment of acid-base imbalance, and evidence indicating that it may be detrimental. Clinicians often feel compelled to use bicarbonate since acidosis implies a need for such therapy and thus the justification for its use is based on hearsay rather than science. This review summarizes the evidence and refutes the clinical practice of administering sodium bicarbonate to treat metabolic acidosis associated with several specific clinical syndromes in neonates.

Glucocorticoids Reduce Renal NHE8 Expression

The proximal tubule reabsorbs most of the filtered bicarbonate which is mediated in large part by Na⁺/H⁺ exchange (NHE). We have previously demonstrated that there is an isoform switch during postnatal maturation from NHE8 to NHE3 that is concordant with the postnatal increase in serum glucocorticoid levels. To examine if glucocorticoids may be responsible for this isoform switch, we administered dexamethasone daily to mice at 7–10 days of age, a time prior to the normal isoform switch. We show that compared to vehicle-treated controls, dexamethasone caused a premature increase in renal NHE3 and decrease in NHE8 mRNA, total protein, and brush border membrane protein abundance. To examine if there was a direct epithelial action of dexamethasone on NHE8, we studied normal rat kidney (NRK) cells in vitro which express NHE8 on their apical membrane. Dexamethasone decreased NHE8 mRNA, total protein, and apical protein abundance. Dexamethasone also decreased Na⁺/H⁺ exchanger activity. These studies provide evidence that glucocorticoids may play a role in the developmental isoform switch from NHE8 to NHE3 and cause a decrease in NHE8 expression and activity.

Developmental changes in proximal tubule NaCl transport

The proximal tubule reabsorbs two thirds of the filtered NaCl in an isoosmotic fashion. In the adult proximal tubule, active NaCl transport is mediated by the parallel operation of Na(+)/H(+) and Cl(-)/base exchangers, and a substantive amount of chloride transport occurs passively across the paracellular pathway. Studies in the neonatal proximal tubule have resulted in unexpected results. The isoform of the Na(+)/H(+) exchanger mediating proximal tubule sodium absorption, NHE3, is virtually absent in the neonatal rat kidney. NHE8, an isoform of the Na(+)/H(+) exchange, in low abundance on the apical membrane of the adult proximal tubule, is present in high abundance in the neonatal segment. Whereas chloride permeability is high in the adult, favoring passive paracellular chloride flux, the neonatal proximal tubule is virtually impermeable to chloride ions. This is again due to a developmental change in isoforms of proteins forming the tight junction. The permeability properties of epithelia are due to a family of tight junction proteins called claudins. Claudins 6 and 9 are expressed in the neonatal proximal tubule at a time when chloride permeability is low, but these claudin isoforms are virtually absent in the adult segment. The causes for these postnatal changes in proximal tubular transport and developmental isoform changes are also discussed in this review.

Ontogeny of renal sodium transport

One of the main functions of the adult kidney is to maintain a constant extracellular fluid balance. The adult kidney does this, by and large, by filtering a massive quantity of fluid and reabsorbing the solutes needed to maintain volume and electrolyte homeostasis, while leaving the waste products to be excreted in the urine. One of the most precisely regulated functions of the adult kidney is to maintain sodium balance. The challenge of the neonatal kidney is even greater. It must maintain a positive salt balance for growth while the neonate is fed a diet that is very low in sodium. This review focuses on how the neonatal kidney reabsorbs NaCl with a special emphasis on the differences between the neonatal and adult kidney.

Neonatal acid base balance and disturbances

Maintaining acid base balance presents a considerable challenge to the growing neonate. The infant must ingest protein for growth and development. The metabolism of sulfur containing amino acids leads to the production of protons that must be secreted by the kidney. In addition, the formation of hydroxyapatite for the mineralization of growing bone also leads to acid production. Thus, the growing infant must excrete approximately 2 to 3 mEq of acid per kilogram of body weight per day to avoid becoming acidotic. The mechanisms for excreting acid undergo complex maturational changes that predispose the neonate, and the premature neonate in particular, to a great risk for the development of acidosis. In addition, infants are susceptible to gastrointestinal disturbances that can lead to acidosis due to acute loss of bicarbonate in the stool. The kidney is then responsible for the production of new bicarbonate to restore the body's acid base balance. There are also a number of inherited disorders in the kidney that affect acid secretion and lead to acid base disturbances in neonates. This review discusses the mechanisms by which the kidney is capable of excreting acid as well as the developmental regulation of these processes and the basis of inherited disorders of acidification.

Maturational changes in rabbit renal brush border membrane vesicle urea permeability

Urea transport in the proximal tubule is thought to occur by passive diffusion through the lipid bilayers of the cell membranes. The lipid composition of cell membranes changes during maturation and may directly affect urea permeability of proximal tubule membranes. The present study examined the maturation of urea transport in rabbit renal brush border membrane vesicles (BBMV). BBMV from adult and neonatal (9- to 11-d-old) New Zealand white rabbits were loaded with 500 mM urea and mixed with an iso-osmotic mannitol solution using a stop-flow instrument. Vesicle shrinkage, due to efflux of urea, was followed with light scattering and urea permeability was calculated from an exponential fit of the data. Urea permeability was significantly lower in the neonatal BBMV than the adult at 25 degrees C (0.34+/-0.04 x 10(-6) versus 0.56+/-0.03 x 10(-6) cm/sec;p < 0.001, n=7) and 37 degrees C (0.45+/-0.04 x 10(-6) versus 0.66+/-0.03 x 10(-6) cm/sec; p=0.001, n=7). There was no effect of 250 microM phloretin on urea permeability in either adult or neonatal BBMV at either temperature. The activation energy for urea diffusion was higher in the neonatal than the adult BBMV. Because the maturational increase in urea permeability could potentially be due to a sodium-dependent urea transporter in the adult BBMV, the sodium dependence of urea uptake in adult BBMV was examined. There was no difference in urea permeability in the presence or absence of 20 mM NaCl. Permeability of the lipid-soluble molecule, glycerol, was also found to be the same in the neonatal and adult BBMV. Urea transport in the apical membrane of neonatal and adult proximal tubules is not phloretin sensitive, a finding consistent with diffusion of urea via the lipid bilayer. The rate of urea diffusion is lower in neonatal membranes and may be an important factor in overall urea excretion. This may also play a role in developing and maintaining a high medullary urea concentration and thus the ability to concentrate the urine during renal maturation.

Maturational changes in rabbit renal cortical phospholipase A2 activity

Several studies have demonstrated that the neonatal kidney has a markedly attenuated response to parathyroid hormone (PTH); however, the cause for this blunted response is unknown. PTH stimulated cAMP production by 215 +/- 18% in neonatal proximal tubule suspensions compared to a 35 +/- 7% increase in adult proximal tubules. Thus, neonatal proximal tubules have functioning PTH receptors and a greater adenylate cyclase response than the adult segment. In adult proximal tubules, PTH stimulates phospholipase A2 (PLA2) activity and the inhibition of Na,K-ATPase activity by PTH is blocked by inhibitors of PLA2. We examined whether maturational changes in renal cortical activity could play a role in the attenuated response to PTH in the neonatal proximal tubule. Compared to adults, neonates had a lower renal cortical cytosolic PLA2 (cPLA2) activity, assessed as the release of 14C-arachidonic acid (AA) from labeled phosphatidyl choline (0.44 +/- 0.10 vs. 0.74 +/- 0.06% 14C-AA released/min/mg protein, P < 0.05) and microsomal PLA2 activity (0.32 +/- 0.03 vs. 1.20 +/- 0.13% 14C-AA released/min/mg protein, P < 0.001). The protein abundance of cPLA2 was not different between the neonatal and adult renal cortex as assessed by immunoblot assay. Thus, the difference in activities must be due to a difference in regulation of cPLA2. Annexin 1 (lipocortin 1) has been shown to inhibit PLA2 activity by binding to phospholipid substrate. Annexin 1 protein abundance was higher in neonatal than in adult renal cortex (P < 0.001). Thus, the lower activity of PLA2 in the neonatal tubules may be due in part to higher expression of annexin 1. PLA2 activation by PTH, -8-bromo-cAMP and PMA was assessed as 3H-AA release from prelabeled suspensions of neonatal and adult proximal tubules. PTH (10(-7) M), 8-bromo-cAMP (10(-4) M) and PMA (5 x 10(-8) M) significantly increased 3H-AA release from adult tubules (P < 0.05) but had no effect on neonatal tubules (P = NS). Thus, PTH, 8-bromo-cAMP and PMA stimulated PLA2 in adult but not neonatal proximal tubules. In conclusion, the maturational changes in renal cortical PLA2 activity may be a factor in the blunted response of neonatal proximal tubules to PTH.